Techniques to Avoid

This page is devoted to a discussion of miscellaneous techniques for treating hair loss that are not recommended by the New Hair Institute, but are important for your overall understanding of the different types of hair restoration procedures being offered today.

These include the standard practice of mini-micrografting, the use of dilators to widen the recipient sites, and transplanting plugs (large grafts). Yes, some doctors still do this. We also do not advise (but think that you should know about) laser hair transplantation, scalp reductions and flaps.

Mini-micrografting

This technique is not performed by NHI.

Mini-micrografting is a popular technique in which the donor tissue is removed with a multi-bladed knife and is then cut into smaller pieces depending upon the desired size. Those that contain 1-2 hairs are referred to as micrografts and those that have 3-6 hairs are called minigrafts. Often the minigrafts produced by this technique contain considerably more than 6 hairs. A more accurate term for the procedure is “mini-micrografts cut to size,” since the grafts are cut to a predetermined size rather than dissected the way they naturally grow.

multibladeThis photo shows a multi-bladed knife used in Mini-micrografting. In this case the knife is loaded with 8 parallel blades.
o_mini02This shows a donor strip that has been harvested from the donor area using the multi-bladed knife pictured above. Note that the strip has been divided into thin slivers as it was removed from the scalp. The problem with this “blind” harvesting technique is that although the blades are perfectly parallel, the follicular units are random in the scalp and the follicles themselves are not aligned parallel. As a result the follicular units are broken apart and the follicles themselves are often transected.
o_mini03To add insult to injury, the strip is then further cut into horizontal sections, again disregarding the follicular anatomy. This causes additional transection and a further break-up of the naturally occurring follicular units in the scalp.
o_mini04This slide shows a histologic view of how the multi-bladed knife and vertical sections break up the scalp’s natural anatomy.
o_mini05This slide is an example of a section cut with a multi-bladed knife that was originally used as an example of the “clean” incision made by this instrument. When viewed under a stereo-microscope, however, a significant amount of transection is readily apparent. In this small piece alone, 9 hair shafts have their bulbs completely cut off, with a similar amount of damage on the other side.

 

As we can see, in mini-micrografting the grafts do not necessarily correspond to the naturally occurring follicular units, so that individual follicular units may be split up or combined. In addition, the harvesting and dissecting techniques do not insure that the individual follicles are kept intact. Another problem with this technique, is that in order not to prevent excessive wasteage, all the tissue from the donor site is transplanted. If any of this tissue were trimmed, the multiple hair fragments produced by the multi-bladed knife would be lost. As a result, the intervening bald skin in the donor area is transplanted along with the hair. This results in grafts that are larger than necessary and larger recipient sites to hold them. Of course, larger recipient sites can compromise the blood supply in the area where the grafts are being placed and limit the survival of the transplant.

In sum, with Mini-micrografting, neither preserving follicular units nor even keeping hair follicles intact are felt to be that important. Rather, the speed and economics of the procedure are the important factors. Mini-micrografters use a multi-bladed knife to quickly generate thin strips of tissue and then use direct visualization (rather than microscopic control) to cut the tissue. The resulting grafts are generally larger than follicular units and have considerably more follicular transection (injury).

The following table summarizes the major differences between the technique of Mini-micrografting just described and that of New Hair Institute’s Follicular Unit Transplantation.

Follicular Unit TransplantationMini-Micrografting
THE GRAFTS
Follicular Units used exclusivelyYesNo
Graft sizeUniformly smallLarger
Number of hairs per graft1-41-6 (or more)
Hair/skin ratio in graftHighAverage
Extra skin transplantedNoYes
Wound sizeUniformly smallVariable
THE TECHNIQUE
Harvesting typeSingle-StripMulti-bladed knife
Microscopic dissection requiredYesNo
Preservation of Follicular UnitsYesNo
Follicular transectionNoYes
Maximizes donor supplyYesNo
THE RESULTS
Healing timeFastSlower
Skin surface changeNoYes
Maximum fullnessYesNo
Totally undetectableYesNo
COST & CONVENIENCE
Staff requirementsModerateSmall
Duration of individual procedureLongShort
Time for complete restorationShortLong
Cost per procedureMoreLess
Total cost for restorationSimilarSimilar

 

It should be apparent from the above comparison that Follicular Unit Transplantation is superior in producing a natural, undetectable result, in maximizing healing, and preserving the patient’s donor supply. Mini-micrografting is popular with doctors because it requires a smaller staff and each procedure is cheaper and shorter. However, in the final result it often takes more procedures and may cost the patient just as much. Not such a bargain for an inferior technique.

Dilators

This technique is not performed by NHI.

Dilators were first introduced by Dr. Emanual Marritt of Denver Colorado in 1988. As the surgical sites for smaller grafts became smaller, Dr. Marritt had difficulty locating the holes after he made them. Once he found them, he had difficulty inserting the grafts. He came up with idea that he should use a toothpick-type device, placeing them in the small holes as he made them. By doing this, the holes were stretched and became larger. This made them easier to locate and it also made the grafts easier to place. As he removed each dilator, he kept count and was sure that every hole was filled.

As Dr. Marritt built experience, he found that he did not need the dilators. He was also concerned that the stretching may have caused more damage to the scalp. The dilators also required wider spacing than he thought he could accomplish without them. Eventually he gave up using them completely.

Dilators are still used by a few doctors during a hair transplant to help them find the recipient sites once they have been made, and to stretch them open to make it easier to insert the grafts. They are also used by these doctors to help provide hemostasis.

One of the benefits of Follicular Unit Transplantation is that the “snug fit”, produced by the proper sizing of the follicular units to the recipient sites, ensures that the grafts will be held securely by the elastic tissues of the skin. This will promote rapid healing and allow the patient to resume normal activities, such as shampooing, as soon as possible. More important, it permits easier oxygen flow into the grafts and maximizes the growth of the transplant. Dilators stretch out the skin and loosen this fit; negating one of the great advantages of using properly-sized follicular units.

o_dilators

With the very small recipient sites used in Follicular Unit Transplantation, hemostasis is not a problem during, or after, the procedure. Our staff uses magnification during placing, and experienced placers can easily see even the smallest recipient sites and know which have been filled with grafts. Dilators just add an unnecessary step and slow down the procedure. A final issue is that dilators run the risk of increased pitting or delling, a problem not encountered with Follicular Unit Transplantation.

It is always surprising to us that some doctors resort to dilators rather than mastering the basic techniques of small-graft insertion. After all, an experienced placer should easily be able to find the recipient site and see if it has been filled with a graft. Dilators make it difficult, if not impossible, to place grafts closely and to produce the subtle changes in hair direction that give the transplant its most natural look.

The above photograph shows dilators in use during a hair transplant (from the text “A Color Atlas of Hair Restoration Surgery” by Swinehardt).

Plug-Type Grafts

This technique is not performed by NHI.

o_plugs01

In the early days of hair transplantation, rather large grafts were removed with a ‘punch’ instrument and transplanted to thinning areas. When transplanted, the tissue surrounding the plug constricted during the natural healing process, causing the hairs in the plug to be pushed much closer together than hairs naturally would be. The final effect is much like a doll with ‘rooted hair’. Very unfortunately, when finer methods of transplantation were developed, some physicians continued to use the old ‘plug’ method and many individuals were needlessly deformed.

New Hair Institute pioneered follicular unit transplantation, transplanting hair in naturally occurring groups to create an incredibly natural appearance. NHI’s Dr. Rassman and Dr. Bernstein have written articles for medical journals that describe the process of follicular unit transplantation in detail so that state-of-the art advances could be incorporated into every hair transplantation procedure by every physician. Change has been swift, but not swift enough.

We have, over the years, developed some surgical strategies that help camouflage plugs for many men. If you have one of these old-style transplants, a visit with one of our NHI physicians could result in a plan leading to a much more natural appearance.

o_plugs02Large punch, used to make plugs.o_plugs03Wound made in the skin by the punch.
o_plugs04Recipient area in punch-grafting.o_plugs05Donor area in punch-grafting.

Laser Hair Transplants

This technique is not performed by NHI.

In the public’s mind, no single word in medicine evokes a stronger image of “state-of the art” than the word “Laser.” The phrase “Laser Hair Transplantation” is no exception. But, when we begin to examine what lasers actually do to the skin, it is obvious that not only is the laser inappropriate for Follicular Unit Transplantation, but that it is actually detrimental in all hair transplantation surgery.

In other fields of medicine the laser’s value lies in its properties of “selective photo-thermolysis” (this is the ability to destroy a specific target without injuring the surrounding tissue). In hair transplantation, there is no selective target; rather the laser is used purely as a destructive tool. It literally burns a recipient hole in the skin. The laser companies claim that the newest lasers can make a recipient site with little or no thermal burn to the surrounding tissue, but this is missing the whole point. That point is that no matter how precise the laser is, it is still making a hole by removing tissue, and is, therefore, a throwback to the old punch technique. This technique always leaves surface change and scarring.

Just to remind our web reader, removing tissue destroys blood vessels and collagen and weakens the elastic support around the newly transplanted grafts. It also increases the coagulum (clot) around the graft which, in turn, decreases oxygen perfusion and retards healing. Essentially, the laser “loosens” the “snug fit” between the transplanted graft and recipient site, that should nourish it.

If a doctor needs to use a laser to decrease bleeding during surgery then he/she should learn better surgical techniques. When one wants to maximize the growth of a transplant, whether they are follicular units or any other type of grafts for that matter, maximizing the blood supply is of the utmost importance. Using lasers or any other device that interferes with this blood supply, will hamper healing and prevent maximum growth and should be avoided.

If a doctor promotes lasers as painless surgery then he is not telling you the truth. The lasers used in hair restoration surgery are extremely painful and must always be used in conjunction with anesthesia.

In sum, in hair restoration surgery, lasers now operate merely as non-selective, destructive instruments and we see no beneficial role for their use.

Click here to learn more

This technique is not performed by NHI.

o_reductions01

Scalp reductions, a technique to reduce the size of the bald area by essentially “cutting it out” was first described in 1977 by Dr’s. Blanchard & Blanchard. In 1978, Dr’s. Martin Unger and Walter Unger began using a combination of scalp reductions and hair transplantation to manage their balding patients and introduced scalp reductions to a large segment of the surgical community. The official term “Scalp Reduction” was first introduced by Sparkuhl that same year at the International Hair Transplant Symposium in Switzerland.

In 1979, Bosley Medical published the first large series on Male Pattern Reduction (their term for scalp reductions) and heavily marketed this procedure to the general public. In 1983, Dr. O’Tar Norwood (the creator of the famous Norwood Classification for male pattern alopecia), first warned of the potential complications of scalp reductions and the list has continued to grow longer and longer ever since.

The appearance of a person who is losing his hair is improved most by restoring the front part of the scalp. A completely natural frontal hairline (which frames the face) with good coverage on the front and top of the scalp, is the key to achieving the best aesthetic results. Since the crown is generally the least cosmetically important of the balding areas (and potentially the largest), crown coverage should not be a first priority. It should be addressed after the aesthetically more important areas have been satisfactorily transplanted and there is enough donor hair for any future needs in these regions.

In all hair restoration surgery, the potential cosmetic improvement is ultimately limited by a finite donor supply, which, in turn, is dependent upon the donor density and scalp laxity. Scalp reductions deplete this supply by simultaneously decreasing both the donor density and scalp laxity; a bad combination when the benefit is merely to reduce the size of a non-critical cosmetic area.

As a result of the scalp reduction, the donor density decreases, so that a larger donor area must now be harvested to yield the same amount of hair, but the larger strip becomes more difficult to remove due to a tighter scalp. When the strip is finally removed, some of the hair must then be placed back in the crown to cover the scar produced by the reduction, further limiting the amount of hair available for the front.

The scalp reduction scar eliminates the option of leaving the crown untreated, as well as the ability to reduplicate the normal delicate swirl of hair that characterizes this area. Since the scalp reduction scar is either linear or geometric, the hair used to cover it will necessarily be in this pattern. Although this may not produce a short-term problem, eventually, as the balding progresses, an isolated island of hair will remain in the same geometric pattern as the scar it originally served to cover. More hair will then be needed to follow this new expanding cosmetic defect.

The scarred scalp, the irregular balding pattern, and the abnormal direction of hair can preclude the crown from ever looking normal, and the decreased donor density and scalp tightness will compromise the ability to adequately cover the front and top of the scalp in any patient with significant balding.

Although scalp reductions may be performed with the best intentions, they can place patients in the precarious position of having more cosmetic problems than they started with and the lack of donor reserves to correct them. The Hippocratic oath implores physicians to “First, Do No Harm!” In light of the many new advances in hair restoration surgery, it is probably reasonable for everyone to take a more critical look at this once popular procedure for androgenetic balding.

o_reductions04o_reductions02o_reductions03

 

 

Scalp Lifts

Scalp Lifts or “Major Scalp Reductions” are just what the term implies, more extensive scalp reductions where very large amounts of tissue are advanced in a single procedure. As is to be expected, the problems encountered with these “lifts” are also increased.

Problems can occur because of risk of damage to the major blood vessels and nerves in the back of the scalp, the occipital neuro-vascular bundles and from the extensive movement of scalp tissue. Although there are some doctors very skilled in this technique, it is our opinion that, even in the best of hands, these procedures are risky and create too many cosmetic problems for the patient in the long run.

For those interested, further information on scalp reductions and lifts may be found in the texts “Hair Transplantation” by Walter P. Unger (Dekker, 1995) and “Color Atlas of Hair Restoration” by James M. Swinehart (Appleton & Lange, 1996).

Flaps

This technique is not performed by NHI.

A “Flap” is a medical term that refers to a strip of tissue that is rotated on a narrow base (pedicle) into an adjacent area. In hair restoration, a hair-bearing strip of scalp usually taken from the sides of the head is rotated into the balding area in the top or front.

A flap is freed of its attachments to the surrounding tissue on three sides but it remains attached on the fourth side, through which it receives its blood supply. Unlike free skin grafts, flaps must carry their blood supply with them.

In performing a flap, the recipient site is first prepared in the intended area by making an incision and freeing the overlying skin. The free end of the flap is then transferred from its original location to the new one. The remaining opening in the donor area is closed by sewing the skin edges together. Some flap procedures use two flaps, one from each side of the head. Other procedures use a single, long flap from one side and the back of the head.

Flap procedures are major surgery that must be performed in a hospital-level operating room. Some doctors do the operation in two, or even three stages. First, they delay the flap by making the incisions for it, but leaving the flap in place to stimulate the development of an independent blood supply. This creates a barrier of scar surrounding the flap on three sides. Once the area becomes wholly dependent upon its base artery for its entire blood supply, the flap can be rotated into its new position.

o_flaps01o_flaps01

 

The main advantage of flaps is that they offer the quickest method of putting long, dense hair into a frontal bald area. However, they have so many disadvantages that most hair restoration surgeons no longer perform them.

The main problem is that this hair is too dense. So much hair is placed in a relatively thin band across the front of the scalp that it doesn’t look natural. In addition, so much hair is used up that other parts of the scalp can’t be covered if the patient continues to bald.

The abrupt transition from a bald forehead to a band of dense, coarse hair, which is growing in the wrong direction, gives a distinctly abnormal appearance and is literally impossible to correct. In an effort to improve the appearance of a flap, some doctors remove part of the hair from the leading edge of the flap. Some doctors place small grafts of fine hair directly in front of the flaps. These techniques attempt to create a zone of finer hair oriented in the proper direction in order to hide the straight line of scar that is often visible in front of the flap. Unfortunately, they are rarely completely successful.

Another problem is that the scalp remains bald behind the flap. This area may not be too visible in patients with dense hair and limited balding, but patients whose hair is sparse, or who have highly contrasting hair and skin color, have difficulty hiding the expanse of bare scalp. Patients whose temple hair thins as they age also have problems with visibility of the bald part of the scalp. These patients typically become extremely self-conscious about their appearance. Transplanting hair into this area can improve its general appearance, but the effects of the flap procedure markedly decrease the number of available grafts, making complete correction impossible.

As mentioned above, the rotation of the flap changes the direction of hair so that the hair actually grows in the reverse of its natural direction. Because of the rotation, the corner of the flap is often distorted so that a natural looking hairline is never achieved.

A “Beetle Brow” occurs when the loose skin over the eyebrows is pushed down and forward when the flap is transposed to the forehead so that the patient develops jutting, overhanging eyebrows that give a weird, Neanderthal appearance to the face. This can be corrected by a brow lift operation in which the loose skin in front of the flap is excised. However, it is best if this problem were avoided altogether.

In addition to these problems, there are a host of complications associated with flaps. The worst of is flap necrosis (a medical term for tissue death). In one study done by an experienced plastic surgeon, more than one-third of the flaps sustained some degree of necrosis. The surgeon said that because of the frequency of this problem he would not do flap surgery any longer. When a flap dies, it often leaves a wide, ugly scar in the frontal hairline area of the scalp. Necrosis of the flap causes permanent loss of the hair in the part of the flap that dies, and this very difficult to conceal, even with further surgery.

In sum, flaps move “too much hair,” in the wrong direction, and to the wrong place. Unfortunately, this wrong place happens to be the cosmetically critical frontal hairline, where it’s the most important for the scalp to look natural.