Hair Transplant Basics and History
The Dermatologist Dr. Norman Orentreich introduced hair transplantation in the United States in the late 1950s. Although the basic concept behind hair transplantation is rather simple, self-proclaimed “experts” have shrouded the field in mystery, and these myths have been perpetuated over the years.
The hair growing on the sides and lower part of the back of the head is permanent hair in most people. It persists even in the face of the most extreme degree of male pattern baldness. This permanent hair can be redistributed to cover the areas of the head where the hair has thinned . All hair restoration procedures work through the redistribution of this permanent hair. Women often do not have such a permanent zone of hair in the back and around the sides of the head.
To learn more about the basics of hair transplantation, including what you should know before, during, and after any procedure, please view the following topics:
A Very Brief History of Hair Transplantation
The modern technique of hair transplantation was first described by a Japanese dermatologist named Okuda in 1939. Dr. Okuda, working on severely burned patients, transplanted round grafts of skin containing hair follicles from the permanent hair-bearing areas into slightly smaller round openings in scarred areas of scalp. The grafts continued to produce hair in their new location. Dr. Okuda’s findings were published in a Japanese medical journal, but he died in World War II, and his discovery was lost. Dr. Okuda limited his treatment to burn victims; he may not have realized the possibilities of using this technique to treat baldness.
Another Japanese dermatologist, Tamura, used very small 1- to 2-hair grafts to restore hair in the female pubic region. His techniques were, in many ways, similar to the techniques used today. Unfortunately, because of World War II, the articles describing these techniques were not known to the Western World until many years after Dr. Orentreich had founded the field of Hair Transplantation in the United States.
The principles and techniques of modern hair transplantation were rediscovered by Dr. Norman Orentreich in New York City in the early 1950s. He published his work in 1959 in the Annals of the New York Academy of Science. Interestingly, his original paper was rejected three times by other medical journals as the reviewing physicians did not believe that the procedure could work. Unlike those performing hair transplantation before him, Dr. Orentreich was the first to use this technique to treat male pattern baldness.
Dr. Oreintreich’s discovery was that hair maintained the characteristics of the area from where it came rather than the area to where it was transplanted. This means that hair that was transplanted from the permanent zone in the back of the scalp into the balding area in the front of the scalp would continue to grow as if it had remained in the back of the scalp. He coined the term “Donor Dominance” to explain this basic principle of hair transplantation – that grafts continue to show the characteristics of the donor site at their new location. This principle of donor dominance is due to the fact that the pathogenesis of hair loss is inherent to each individual hair follicle. This is the basic principle behind all hair transplantation.
After experimenting with a number of different size grafts, Dr. Orentreich chose to use 4mm punches (which are about the size of pencil erasers) as his “workhorse”. He chose this size because larger sizes often didn’t grow hair in the center (from oxygen not reaching the core of the graft), and smaller grafts didn’t seem to contain enough hair. At the time, only 20-30 grafts were transplanted in any one session. Over the next twenty years, the punch grafts became smaller and the numbers used per session grew slightly larger. The smaller punches looked better than the larger ones, but the small punches caused a lot of damage to the hair as they were harvested from the donor area, and the smaller the punch, the greater the problem.
The problem was partially solved by removing the donor tissue in thin strips using a multi-bladed knife, but this had its own problems with cutting hair follicles (transection) and causing damage. The era of mini-micrografting of the late 80’s and early 90’s evolved from this multiple-strip method where the thin strips were subsequently cut into different sized grafts based upon the approximate number of hairs the doctors wanted them to contain. A more accurate term for the procedure is mini-micrografts “cut to size”, since the doctor cut the grafts to the size he wanted rather than with respect to the way they grew.
Hair Transplantation Today
In 1993, Rassman introduced the Densitometer, an instrument that could directly measure hair density. He stressed the importance of accurately quantifying donor density and assessing hair supply in the surgical planning. Densitometry made hair transplantation truly “scientific”.
In 1994, Limmer published a paper describing a technique he had been using since the late 1980s. With this technique, he harvested the donor area in a single ellipse (long oval) and used a microscope to generate small micrografts while avoiding transection of hair follicles. At the International Hair Restoration meeting that year in Toronto, Dr. Rassman presented 22 live patents that popularized the Megasession (a technique using large numbers of small grafts) that was first described by Uebel in Brazil.In the 1995 publication “Follicular Transplantation”, Bernstein and Rassman proposed that the ideal hair restoration surgery should consist of performing the entire transplant with naturally occurring individual follicular units, and that these units should be used in large numbers. They detailed the advantages of this procedure and introduced the term “follicular unit” to modern hair transplantation. In 1998, the name of the procedure was changed to Follicular Unit Transplantation. Today, the majority of physicians use mini-micrografting techniques which, compared to Follicular Unit Transplantation, are faster and easier to perform. Those physicians who practice Follicular Unit Transplantation feel that this procedure offers the patient so many advantages in naturalness, indectability, and preservation of donor supply.
Besides Mini-micrografting and Follicular Unit Transplantation, some doctors still use small punches or slivers of tissue placed into long slits (slit grafting). The use of scalp reductions, scalp lifts and flaps, as well as laser hair transplantation, has fallen from popularity in recent years (with good reason), but patients can still find doctors using all of these techniques.
The newest method, NHI Medical’s FUE procedure (Follicular Unit Excision) enables the surgeon to literally extract individual follicular units, one by one, from the donor area without a linear incision.
When you arrive for your hair transplant, the NHI Medical staff will begin by going over the activities for the surgery. Your NHI Medical physician will review the goals that have been established and will answer any last minute question that you might have. The doctor will take the time to be sure that there are no outstanding issues, areas of confusion or concerns. The surgical consent forms that had been sent to you are reviewed and signed followed by the taking of pre-surgical photographs. Mild medication is given to relax you and to make you more comfortable. We also give routine antibiotics during the procedure, but not afterwards.
Length of the Procedure
Your FUT or FUE procedure may require many hours of work by a team of professionals. Some of the longest procedures (between 2000-2500+ grafts) may take hours of surgery, and during that time, many highly trained technicians and nurses will participate in the process. The work must be organized efficiently so that the total length of the procedure for the patient will be minimized. On average, a procedure of 1500 grafts would last about 6 hours.
The Surgical Experience
The procedure may be long, but for the patient, the time goes by quickly. You are lightly sedated so that you can sleep if you desire. Most patients choose to watch TV or movies for at least part of the time. We try to make your experience enjoyable so that the actual time the surgery takes is transparent. Some patients may choose to be fully awake the entire procedure.
A relaxed and informal atmosphere is encouraged so that the day stands out as one of the better, more pleasurable experiences ever encountered. The patient takes a series of breaks – to the bathroom, to eat lunch, to eat an ice cream sundae, or to just stretch and move around. Not infrequently, patients tell us that the experience of being the center focus of the day’s activities is wonderful, and they further state that watching all of those people working on them was like watching an orchestra playing beautiful music, while having people catering to their every need!
After preparatory medication is given orally, the actual anesthesia begins. We use a combination of Lidocaine (Xylocaine) which you have probably been given by your dentist, and a longer acting local anesthetic called Marcaine. Injections around the perimeter of the scalp (called a ring block) will make your entire scalp numb, and although this is uncomfortable, a little hand-holding will get you through it just fine. With this technique, there is no need to use anesthesia directly in the area that is being transplanted. Once anesthetization is complete, there is generally no pain or discomfort during the remainder of the procedure. If you do require more, it will be given before the first anesthetic wears off.
The Surgical Team
The procedures can be long, and during the initial period when the donor hair is removed, the surgical team must work without stopping. NHI Medical boasts what we consider to be the world’s most highly skilled surgical team performing FUT and FUE. The team must prepare the grafts according to the surgeon’s exacting specifications. The preparation of 2,000 or more grafts and placing them into the recipient area may take a team hours of intensive, concentrated work. Care must be taken to keep the surgical team free of stress. Just as the patient needs a break, so do team members. At NHI Medical, we focus on the needs of our staff as well as the patient to ensure that the best-trained staff in the world is always operating at peak performance.
The Donor Scalp
After a strip of donor scalp is removed, it is temporarily placed into a container with chilled Lactated Ringer’s, a solution that closely mimics the body’s own natural fluids. The area from where the donor strip is removed is sutured closed. This usually leaves a fine scar that heals in a week or two, with the sutures either self-dissolving or being removed in that time frame. Ideally, the scar may heal well enough that it is almost undetectable even when the hair is combed back by a barber or hairdresser. After the tissue has been harvested, the individual follicular units (each containing from 1 to 4 hairs) are meticulously dissected out in their naturally occurring groups under strict stereo-microscopic control. The grafts are trimmed of extraneous fatty tissue and the bald intervening skin between the groups is discarded.
The isolation of individual, naturally occurring follicular units that were obtained from the donor area is an essential part of Follicular Unit Transplantation. If this step is not done correctly, the follicles can be injured and growth can be impaired. It is important that these steps be carried out only by a highly experienced surgical team.
Grafts and Blood Supply
A number of hours may pass between the time the donor grafts are removed from the back of the scalp to the time they are placed into the recipient area. Care must be taken to preserve the viability of the grafts during this process. The procedure starts with the removal of a strip of scalp from the donor area. Once the strip is removed, it is immediately immersed into a cold bath of Lactated Ringer’s saline to lower its temperature. Once the individual follicular unit grafts are prepared, they are cooled to 38-40C and kept at this temperature while awaiting placement. The solution, in our hands, is an organ preservation solution used in many organ transplants since it has the best track record for preserving the hair grafts. We feel that, if it is good enough for your lungs, heart or kidneys, it is good enough for your hair. The solution is expensive, so most hair transplant doctors don’t use it to save a few hundred dollars.
Many people have the impression that hair transplantation is a “bloody procedure.” In our hands, it is not. At NHI Medical, we have developed surgical techniques that greatly minimize the amount of bleeding in all aspects of the procedure. Of course, we take great precautions to protect ourselves from all blood-born agents, and our patients and staff are routinely tested for HIV and hepatitis for everyone’s protection and safety.
The Surgical Suite
The surgical team wears masks, surgical gloves, and gowns, and uses instruments that are sterile. The procedure is performed while the patient sits in a comfortable, adjustable reclining chair. For added comfort, the Suites are equipped with music, TV, and an assortment of movies.
After the anesthesia is administered, the patient should feel nothing other than pressure sensations. Many patients have long, friendly conversations with the doctor and assistants during the time it takes to complete the transplant. Occasionally, a patient will speak to friends or conduct business transactions during the surgery on their cell phones. Of course, we would prefer that you just take the day off and relax.
The atmosphere in the treatment area will make the patient feel secure and relaxed. Concern and compassion on the part of the doctor and medical staff make a tremendous difference, and we will expend great effort to make sure that your experience is a pleasant one.
Making the Recipient Sites
The creating of the recipient sites determines much of the aesthetic look of the transplant. It determines the angle at which the new hair grows and determines the distribution and density of the grafts. This is a very important part of the procedure and requires considerable artistic knowledge and surgical skill. It may be the one part of the procedure where your NHI Medical physician is silent as he or she concentrates on making these sites. Don’t be concerned if they aren’t chatty during this time.
Your NHI Medical physician is accustomed to working in and around existing hair, so you need not cut your hair short for the procedure. Your existing hair may help to cover any traces of the transplant.
Placement of New Grafts
Placing is the longest part of the procedure. The placement process is exacting, and during this time you will be asked to keep your head relatively still. Watching TV or even sleeping will make the time go quickly. You can takes breaks as needed to eat and use the bathroom.
When placing is complete, photos are taken and post-op instructions are given to you verbally and in writing. A tennis bandage is placed around your head, and a baseball cap is worn home. No bandages are required on the transplanted area.
After Your Procedure
The night of the surgery (and for the next few nights after that) you are encouraged to sleep with your head elevated on pillows. You will be given medication to help you sleep if needed. The morning after surgery, you can remove the bandage and you will be instructed to shower and gently clean the transplanted area with a special shampoo. The follicular unit grafts are made to fit snugly in the recipient site and will not be dislodged in the shower provided you follow the instruction given to you. After your first shower, no further bandages are required.
If the post-operative instructions are followed carefully, the transplant is barely detectable in most patients after a few days, and practically undetectable after the first week. We will give you medication for swelling, but in spite of this, some patients experience swelling of the forehead that settles around the bridge of the nose over the course of the next several days. If this occurs, it is almost always gone in the first week and should not be a cause for concern.
Frequently, the newly transplanted grafts can be made less noticeable by minor changes in hair style and a little bit of hair spray to cover the area. Skin-colored makeup can be used to cover any redness that lasts more than a week. Makeup consultants in large drug stores and department stores can help you choose the appropriate shade and type of makeup. Any problem of visibility can also be minimized by altering the appearance of your face. If you do not shave for a while, most people will focus upon your new beard, not on your head. If you have a mustache or a beard, consider taking it off for the first few weeks and then letting it grow back.
We like you to come into the office the morning after your procedure to give you your first hair wash, teach you how to do it, and to answer questions. We also like to see if there is anything else you need. You will be given a follow-up appointment approximately two weeks after your procedure. For patients who live far from the office, we will often use absorbable sutures that don’t have to be removed so that their follow-ups can be handled by phone.
Patients often worry about the potential visibility of their new grafts. Scabbing or crusts that tend to form on the scalp surface should be washed off as they accumulate for the first few days following the surgery. With the very small sites used in Follicular Unit Transplantation, no new crusts may form after the second day unless the wash is not done properly. Other than the stubble transplanted hair and some faint redness in a few patients, or some swelling on the third day for a few patients who do not respond to the steroids we give them to reduce the swelling, the transplant should not be visible after the first week.
The following chart shows the anticipated course for the average patient undergoing Follicular Unit Transplantation, regardless of the size of the session. It is intended to serve as a general guide. It is normal for there to be significant variability between people, and even between sessions in the same person. Therefore, if you do not follow the course exactly as outlined, do not be concerned.
|TIME POST-OP||TRANSPLANTED AREA||DONOR SUTURED AREA|
|Next Day||Hair is washed thoroughly. Grafts should be clean of blood.||Some soreness, tightness and numbness.|
|2-3 Days||Scabbing is largely gone. Moderate redness may be present. Some swelling may appear on forehead.||Soreness begins to disappear. Some numbness may continue.|
|1 Week||Redness is minimal to absent. Swelling is usually gone. 1st Post-op Visit.||Soreness is generally gone. Occasionally some numbness persists.|
|2 Weeks||Looks and feels like a 4-day-old beard.||Sutures begin to absorb. Discomfort is gone. Numbness is uncommon.|
|2-8 Weeks||Transplanted hair is shed as the follicles enter a dormant phase.||Knots at the ends of the absorbable sutures fall off.|
|2-4 Months||Some original hair may be shed in the transplanted area.||Any residual numbness in the donor area is generally gone.|
|3-6 Months||Transplanted hair begins to grow first as very fine hair.|
|5-10 Months||Some or all of the original hair that was shed begins to grow.|
|8 Months||Hair is groomable, but transplant appears thin as hair continues to grow and thicken. Slight textural change in hair is occasionally present.|
|8-12 Months||Patient is evaluated for a possible second procedure.|
|1 Year||90% of the final appearance of procedure is usually present.|
|1-2 Years||There may be additional fullness during the second year. Any textural change in hair usually returns to normal.|
Assessing Hair Loss
The first step in making a rational assessment of the extent of your hair loss is to compare your present hairline with the hairline on a photograph taken a few years ago. This will give you an approximate idea of how much hair loss has occurred and the rapidity of the process. The unknown factor for most men is the extent of hair loss in the crown area. Looking in a mirror is one way to appraise the loss at the back of your head. The best way to accurately assess the hair loss in this area is to have someone take a picture of the back of your head. For an accurate reading, the picture should be taken with a flash, or in good lighting.
Knowing the hair loss patterns of your father, grandfather, and brothers will help suggest what may happen to you. You may not follow one of their patterns, but it is a reasonable way to estimate what pattern you might develop. Take a look at the patterns of hair loss below to learn more.
A visit to a physician who specializes in hair restoration is a worthwhile step. A thorough history and examination of the scalp can reveal the extent and trend of the hair loss process. With the use of the Hair Densitometer, a special magnifying apparatus invented and patented by Dr. William Rassman, and with a special instrument which can measure hair bulk (called the haircheck instrument, which measures the actual volume of hair), the physician can measure the actual degree of hair loss in various areas of the scalp.
This has the advantage of establishing a baseline from which the hair loss can be graded over time. If you decide to treat the process with a drug like Minoxidil, a repeat examination in 6-12 months may show the effectiveness of the treatment. Careful assessment of the hair loss process is critical to accurate prediction of the rate and extent of hair loss. We have seen young men who have no evidence of any hair loss, yet they are convinced that they are losing hair, and when we measure the hair bulk in different areas of the head with the haircheck instrument, we can validate or reject this premise regardless of what we see since the eye cannot tell a loss of as much as 30% or more of the hair in any particular area of the head. Because hair loss causes loss of hair bulk over time, these tests show a general direction of your hair loss and a skilled doctor can project just what hair loss pattern you might develop.
The scientific way to assess your degree of baldness is to compare your pattern with the standard patterns described by Dr. O’Tar Norwood (detailed below). They depict the most common configurations of male pattern baldness. There are seven grades of hair loss in the main series and five grades of a variation called the “A” series. Comparing your own front and back with these diagrams can tell you where you stand. Discussion with a knowledgeable physician can give you some idea of what is likely to be in your future based upon their examination of you. This will allow you to develop a Master Plan for your hair loss, both short and long term.
Norwood Classes Explained
In 1975, Dr. O’Tar Norwood developed a classification of male pattern hair loss that is widely used today.
He divided androgenetic hair loss in men into two common patterns: the Regular Type, characterized by hair loss that begins in two different areas (at the hairline and in the crown) and these two areas may gradually merge into one. The less common Type “A” patterns are characterized by “front-to-back” hair loss. In men, 99% of hair loss is genetic, and hair loss that is not genetic usually does not conform to the patterns below.
Some women also lose hair according to the pattern described by Norwood, but more commonly have a diffuse thinning process (thinning all over), rather than patterned variety. Pattern balding does occur in women, but when they do, they do not develop the patterns described by Norwood, but rather patterns described by Hamilton. The Norwood patterns shown below do not progress from 2 to 7. The hairs that are actually lost in these male patterns form a gradual process. In other words, if your father has a Class 7 pattern, he developed it most probably before the age of 30, often never going though the other patterns shown below.
Hair loss always progresses over the years, although the rate can vary dramatically from person to person, and the rate of loss can vary significantly. For example, a man may lose hair rapidly in his early 40s and then stabilize for many years, not showing a significant amount of additional hair loss until his 60s. People who become extensively bald usually show most of their hair loss in their 20s (but not always). It is the doctor’s job to help you slow this progression down with the use of medications that often work well.
In general, the pattern of one’s hair loss follows the specific type first presented. On a thorough examination by a good doctor, the bulk measurements, regardless of what can be seen with the naked eye, will show loss of bulk in the Class 5 pattern despite the reality that what you see may just be a Class 3 pattern. A Class 3a pattern may become a Class 4a and then a Class 5a pattern, but again, the bulk measurements will mostly show some early hair loss in the entire Class 5a pattern, regardless of what you see. Rarely, a Class 2 may thin diffusely and directly evolve into a Class 6 or 7 pattern. One rare but significant form of balding is a condition called Diffuse Un-Patterned Alopecia (DUPA) which will impact the entire hair baring scalp. This type of condition may be associated with one of the patterns of hair loss, but if this diagnosis is made, it should never be transplanted. A doctor should be able to find out if you have DUPA by using a hand microscope on the hair in the donor area (the hair around the sides and back of your head). DUPA will show miniaturized hairs in excess of 20% of the hairs in these areas. Unfortunately, this diagnosis is rarely made by hair transplant doctors, and these kind of patients receive hair transplants that eventually result in hair loss deformities and hair transplant failures.
Look over the following diagrams to see if you can recognize your pattern or the pattern of hair loss of any male member in your family tree. The patterns you see in your older relatives may become your pattern since heredity plays an important role in androgenetic baldness. It is important to know the age at which the family member reached a specific pattern. For example, if your father is totally bald but lost all of his hair in his 20s, and you are 35 with only a Class 4a pattern, his extensive hair loss pattern has little relevance to predicting your future loss.
Regular Norwood Classes
Type I • No recession
- “Adolescent” or “Juvenile” hairline
Type II • Temporal recession (less than an inch)
- “Mature” hairline which can be identified by lifting your eyebrows, allowing your forehead to crease, and then placing your finger on the highest crease. The mature hairline is one finger breadth above the highest crease and takes on a gentle V shape.
Type III • Further frontal recession
- Deeper recession at corners
- Earliest stage of balding
Type IIIv • Hairloss predominantly in vertex (crown)
- Frontal hairline recession may or may not be present
Type IV • Further frontal hair loss and temporal recession
- Enlargement of vertex (crown)
- Solid band of hair across top separating front from vertex (generally ear-to-ear)
Type V • Frontal and temporal areas enlarge further
- Band separating the two areas becomes narrower and sparser, often disappearing. The fringe area above the ears may remain high.
Type VI • Frontal and vertex balding areas merge into one and increase in size, and the fringe area may lower.
Type VII • Narrow horseshoe band of hair
- Low hairline in the back and sides (about a 3-inch-high band of hair)
- This hair is considered permanent lifetime hair, and the zone is called the permanent zone. This is also the area we consider the good donor area for hair transplants since these hairs almost always last the lifetime of the person.
Type A Variant Norwood Classes
- Frontal recession keeps advancing backwards
- Single area of balding
- Eventual extent of balding tends to be more limited than in Regular classes
Type IIa • Entire frontal hairline recedes
Type IIIa • Entire frontal hairline recedes further
Type IVa • Hair loss moves past this “mid-coronal” line
Type Va • Hair loss extends towards the vertex
- Back part of bald area is narrower than in the regular Norwood VI
How much hair do I need?
|Norwood Class||Follicular Units||Total Units with Crown*|
|III||1000-1500+||** –(depends upon extent of recession and thickness of hair shafts)|
|IIIv||1500-2500+||1000-1500+ (depends upon extent of recession and thickness of hair shafts)|
|IV||1100-2000+||1500-2000+ (depends upon extent of recession and thickness of hair shafts)|
|IVa||1500-2500+||– (depends upon extent of recession and thickness of hair shafts)|
|VI||2000-4000+||2800-6000+ (depends upon extent of recession and thickness of hair shafts)|
|VII||4000-8000+||– (depends upon extent of recession and thickness of hair shafts)|
Over the past few years, we have tried to put a number on the amount of hair and grafts any given person might need. We have found that our patients want more hair than we initially believed. At NHI Medical, patient procedures are planned to ensure natural-looking results after each session. However, some of our patients elect to undergo further sessions to enhance their appearance. A recurring question is how much hair does NHI Medical recommend? The number of grafts recommended is highly dependent on information our doctors gather during a private consultation with you, as well as your hair’s texture and coarseness. Your expectations are also factored in.
The total number of follicular units generally transplanted in the first session for specific Norwood classifications are listed above. In general, the higher the donor density, the greater the number of hairs each follicular unit will contain, and the more hair that can be transplanted in a single session. With low donor density, little scalp laxity, or poor hair characteristics, these numbers may not be achievable.
Hair Loss Myths
Because people are so attached to their hair, a number of myths have sprung up regarding hair. When and why it goes gray, what causes baldness, and how baldness can be prevented are just a few of topics of focus. This page turns an objective eye to hair myths so you can separate the serious from the silly when it comes to hair loss.
Myth 1: Hair loss comes from your mother’s side of the family.
The idea that you inherit a baldness gene only from your mother’s side of the family is a myth. The inheritance of common baldness appears to be found on the autosomal — the non-sex-related — chromosomes, which means that baldness can come from either parent. Moreover, the baldness gene is a dominant gene, meaning that you need only one gene on one chromosome to express the balding trait, although multiple genes appear to influence the balding process.
You can get some insight into baldness by examining balding patterns in your relatives. If you have an uncle, father, or grandfather who is bald or balding, find out when he started to lose his hair; it may be an indication as to when you may go bald. Just don’t put all the blame on Mom if you start to lose your hair. It’s not her fault!
Women also inherit the thinning or balding patterns found in their families, but the patterns that are inherited are distinctly women’s patterns, not men’s patterns. This suggests that the inheritance patterns in women do not follow the inheritance patterns in men. Women with hair loss or thinning will frequently report that they take after their mom, grandmother (either side of the family), sister, aunt, etc.
Myth 2: Wearing Hats Causes Hair Loss
More than a few people believe that hats are to blame for baldness based on the idea that hats cut off air circulation to the scalp and prevent the scalp from breathing. What they don’t know is that hair follicles get oxygen from the bloodstream, not the air, so you can’t suffocate your hair follicles just by wearing a hat. The baseball cap so often worn by men whose hair is thinning doesn’t cause baldness — it hides baldness.
WARNING: Hats that fit tightly on the head are another story. These hats may cause thinning around the sides of the head where constant traction is applied to the hair. Hats worn all the time for cultural and religious reasons (such as turbans and yarmulkes) may cause hair loss, too. In rare cases, sports helmets have been known to cause traction alopecia in athletes who wear their helmets too often, particularly if the helmet rubs repeatedly against an area of the scalp.
Myth 3: If You Don’t See Hair in the Drain, You Aren’t Balding
You don’t go bald because your hair is falling out; you go bald because your normal, thick hair is gradually being replaced by finer, thinner hair in a process called miniaturization. Yet people who are sensitive to the prospect of going bald often obsessively scrutinize the shower drain and the hairbrush for evidence of impending baldness.
Most people lose about 100 hairs daily, but grow another 100 hairs daily to replace what is lost. Some of the lost hairs wind up in your shower drain or hairbrush, or they may just fall off as you go about your normal activity, responding to whatever your environment dishes out.
Massive hair loss appearing in the shower drain should alarm you, but insidious, progressive loss may be far more subtle. If progressive loss persists over time, you may lose far more hair than you’ll ever see in the shower drain. This is particularly the case with female hair loss.
Myth 4: Excessive Use of Hair Chemicals and Hot Irons Kills Your Hair
Hair isn’t alive, so hair products or hot irons can’t “kill” hair, although they may cause hair damage to these “dead” hairs which have fatty structures that give them the fine texture we all try to improve with various products. As long as the damage caused by hair products is limited to the hair and not the growing hair follicles below the skin, hair will regrow from the follicles at a rate of a 1/2 inch per month. Some women treat their hair with chemicals to straighten their hair, and some of these chemicals work their way into the hair follicles and damage or kill them below the skin. Many straighteners and dyes can do this, so great care is critical in knowing what you can and can not get away with.
Damaging hair follicles below the skin, however, can cause baldness. When inexperienced people apply chemicals such as unsafe dyes or relaxing agents to the hair and scalp, the caustic chemicals may work their way into the growing part of the hair follicle and damage or kill the hair follicle at its root. More powerful chemicals stay on the scalp, penetrating into the pores of the skin where the hair follicles are, resulting in permanent hair loss or hair that may never look “healthy.”
Applying dyes, chemicals, or hot irons (even hair rollers that are too hot) can cause the hair to become fragile and break off as these hot irons may burn off the fatty layers in each hair shaft. Hair breakage and split ends are most common in people with long hair because the hair is around for a longer amount of time before being cut, so it’s more susceptible to damage from washing, wind, drying, and sunlight as well as chemicals such as relaxers and hair dyes.
Myth 5: Hair Loss Is Caused by Decreased Blood Flow
One hair loss myth says that standing on your head increases the flow of blood to your scalp and thereby improves hair regrowth and regeneration. Although the act may entertain the neighbors and give you a unique look on life, specialists agree that standing on your head has no impact whatsoever on hair loss. Growing hair does require a significant amount of blood flow, but after you lose hair, blood flow to your scalp decreases because you just don’t need it without the hair.
There’s a cause and effect issue here, but it’s important to remember that the hair loss occurs before the blood flow decreases. Decreased blood flow to the scalp isn’t the cause of the hair loss, but rather the result of it. The absolute proof of this is that, when good hair is placed into a bald scalp with decreased blood flow, the blood flow returns when the hair starts growing.
Myth 6: Magnets Increase Hair Growth
In the early days of electricity, magnetic devices were commonly sold in local newspapers as a cure for hair loss. Magnetic therapy, a kind of alternative medicine, holds that magnetic fields can yield health benefits by improving blood flow. Backers of the therapy claim that it can be used to treat arthritic joints, circulation problems, and erectile dysfunction.
Over the years, we’ve been asked many times whether magnets can increase hair growth. The answer is a definitive “no.” Even if magnetic fields did affect blood flow, increasing blood flow to the scalp doesn’t prevent hair loss or regenerate hair.
Myth 7: Brushing Your Hair Is Better Than Combing It
When you tug and pull a comb or brush through the tangles and knots in your hair, you may pull out a few hairs, but they’ll grow back because brushing and combing healthy hair doesn’t disturb the hair follicles below the skin surface. Brushing the hair isn’t necessarily better than combing because the real issue is how you brush or comb the particular kind of hair you have. Tugging on knotted hair isn’t good even for healthy hair, but hair that has already started being miniaturized is more susceptible to loss from any kind of rough treatment, including with a comb or brush.
TIP: You’re less likely to damage your hair using a wide-tooth plastic comb or brushes as opposed to a metal comb, or one with finer, tighter teeth; these combs tend to be rougher and more traumatic to the hair shaft. When brushing or combing, direct your motion in the direction of hair growth so that the hair shaft (the grain of the hair) is in line with your brushstrokes.
Myth 8: Cutting or Shaving Your Hair Makes It Grow Back Thicker
Getting frequent haircuts doesn’t make your hair grow more thickly, but it’s easy to see how this particular myth came about. When hair is cut short, it gets scratchy like sandpaper, and when you run your fingers through this scratchy hair, it seems thicker than it did before. But it’s not thicker — it’s just shorter. Hair grows on average at a rate of a 1/2 inch per month.
Myth 9: Hair Loss Is Caused by Clogged Pores
Many dishonest people claim that clogged pores are the cause of hair loss. Some folks build huge businesses around massaging hair and “treating” the clogged hair follicles to allow the hair to come through the skin.
If common baldness were simply due to clogged pores, you wouldn’t need anything more than rigorous shampooing to maintain a full head of hair. You have probably seen men and women who do not wash their hair often, but who don’t seem to have a problem with balding. Men in particular buy into the clogged pore myth because they feel helpless at watching their hair fall out; when someone tells them that frequent massaging and the use of special lotions will free up these clogged pores, they buy into it.
Myth 10: Frequent Shampooing Causes Hair to Fall Out
When you notice your hair starting to thin, you may blame your shampoo. You notice shed hair in the bathtub or shower and decide to shampoo less often to keep from losing hair. As a result, hair that would normally come out in the bath or shower builds up on the scalp. With the next shampoo, you see even more hair loss, confirming your original suspicion that shampooing causes baldness. Thus another hair myth gains footing.
REMEMBER: Hereditary baldness isn’t caused by hair falling out, but by normal hair which is gradually being replaced by finer, thinner hair, and eventually doesn’t get replaced. Shampoo has nothing to do with baldness.
Myth 11: Hair Loss Stops When You Get Older
This myth is partly true because hair loss slows down in men as they age. Usually, men over the age of 60 see only marginal loss, if they have any hair loss at all. For women, the exact opposite is true: With age and the loss of the protective hormone estrogen, women with genetic hair loss find that the hair loss process that starts during menopause gets progressively worse as they age. They also note a change in their hair character where the hair becomes finer.
Donor Area Harvesting
The limits of a safe donor area extraction of grafts over the lifetime of a patient depends mostly on the donor density found in that person’s donor area. There is a relationship between the donor supply and the recipient area demand for grafts. The larger the need for hair (the balder you are), the more the donor area must be harvested; however, there are limits to how many grafts the donor area can supply, particularly in the very bald patient. We are all born with different donor densities. The Caucasian has generally the highest donor density (typically 110,000 hairs total). The Asian patient often has 20% less hair than the Caucasian patient (between 88,000-90,000 hairs on their head), and the African patient has between 30-40% less total hair on their head (between 66,000-77,000 hairs). Regardless of the total hair count, the permanent zone reflects only approximately 20% of the total original hair population, so the only place that hair can be extracted is from the 20% fringe, which conforms to the balding patient shown below. Hair always remains in this zone regardless of a person’s genetic balding pattern, and it is this zone of hair that the hair transplant surgeon focuses on as a source of donor hair.
It should be evident by looking at figure 1 that the size of the bald area is much larger than the size of the permanent zone where hair still remains (five times larger), so the key to having a good hair transplant surgeon is to find a doctor who understands how to exploit this very privileged and limited donor area and not produce balding in the donor zone where the hair was taken from. The two patients in Figure 2 had too many FUE grafts removed. They both have some degree of permanent balding or thinning in the donor area, resulting from overharvesting of FUE grafts. The man on the left has not yet allowed his hair to grow out to see if he gets any “cover” from longer hair. Doctors would like you to believe that FUE is a scarless surgery, but as you look at the man on the left, it is clear that he is very scarred and will have to cover the scar somehow. The patient on the right covers the thin donor area by keeping his hair longer. Scalp MicroPigmentation (SMP) can usually provide camouflage to this balding area, especially when the hair is kept longer, but SMP is not hair – it is a cosmetic tattoo that works to mimic the fullness that hair brings. The message here is that donor site depletion reflects poor planning on the doctor’s part, and poor education on the patient’s part, because each patient must hold their surgeon responsible for any balding in the donor area, especially if it came as a surprise after the FUE was done.
The donor area contains approximately 20% of the patient total hair count, so for a typical Caucasian who often has more hair than Asians and Africans, the donor area has approximately 23,000 hairs, or 10,450 follicular units or grafts (each follicular unit contains approximately 2.2 hairs). Likewise, the Asian has approximately 8,360 grafts and the African has approximately only 6,270 grafts in this permanent zone. In modern FUE transplant surgery, the surgeon tries to move only the follicular units with more hair (2-4 hairs each) because the use of the follicular units that have more hair is what makes the hair transplant look fuller. In the Asian, the number of 3 and 4 hair grafts are few, if any, so the surgeon tries to excise the two hair grafts to get the greatest amount of hair from these patients. The permanent donor hair population is an absolute number for each patient, and that number will be lower each and every time you have an FUE performed. Sooner or later, the donor supply will run out of grafts as more and more hair is moved to the balding area, and the donor area will become thinner and thinner. Ask your doctor “(a) How many grafts can be taken from my donor area for the hair transplant procedure, and (b) how many grafts will remain after the surgery is done for future needs?” Never go forward with a hair transplant without understanding the answer to these two questions, and be sure that your surgeon understands this as well.
To answer these questions, we always measure the donor density of our patients. For a typical Caucasian with wavy, dark, brown hair and tan skin, the surgeon can safely remove approximately 6,272 follicular grafts in total, leaving behind approximately 4,180 grafts to provide the needed cover for the donor area. When the skin is very pale, or the hair is very straight or fine in character, or if the hair is black, then the limit for harvesting grafts might be less than 6,272 grafts. On the other hand, if the hair is coarser, or the hair is blonde, salt and pepper, or white in color, or the hair is very curly or kinky (typical African hair), the total number of potentially harvested grafts may be much higher as a percentage of the patient’s donor supply.
Those patients destined to develop advanced patterns of balding are caught in a conundrum: The larger the area of projected need, the more distributed the grafts must be when transplanted. The more distributed the hair is placed, the thinner will be the look of the end result. Overall harvesting numbers are altered downward in the various races (Asians and Africans), with calculations that are similar to those described in the Caucasian model illustrated above.
With strip surgery, the excision of the grafts is only performed in the center of the permanent donor area; however, with FUE, the extractions are spread throughout the donor area. For this reason, strip surgeries can often harvest more grafts than FUE. Determination of a safe extraction area in FUE must avoid extracting from areas that are likely to be affected by the genetic balding process. This usually means excluding the hair in the nape of the neck (which is not permanent hair) and the upper lateral fringe regions of the donor area. In the illustration in Figure 3 below, the donor area was harvested outside the safe permanent zone (above and below it), so we can expect that this patient will eventually lose those hairs that were not taken from the non-permanent donor zone. Unfortunately, these patients may end up with significant scars from the FUE excision, similar to those shown in Figure 2 above. The surgeon was very irresponsible when he/she pushed the harvested FUE numbers higher in this patient since the extractions were extended well outside the safe zone.
The most important number in calculating the donor supply is the donor density, which may vary widely from person to person, even in people of the same racial background. This number will tell the surgeon how many total grafts the donor area can support over the lifetime of the patient (as discussed above). Since genetic hair loss in men is not stable, and patients with genetic balding may expect further hair loss for years, your present balding pattern most probably will advance as you age. For extraction estimates, the “average” number of available grafts is higher when the donor density is higher, but it is also lower when the donor density is lower. The calculated harvested numbers are influenced by many other factors, such as the thickness of the hair shafts in the donor area; fine, medium, or coarse (coarse hair is the best of hair thicknesses), the character of the hair; straight, wavy, curly, or kinky (curly or kinky hair is the best of hair characteristics), the color-contrast between hair and skin (lower contrast allows more donor grafts, so blonde- or white-haired men are terrific candidates for larger graft harvesting sessions), and the angle the hair exits from the donor area. This is knowledge that your surgeon must know and discuss with you when estimating a specific number of grafts for a surgical session, and in assessing your overall remaining donor supply over your lifetime. The 3-dimensional properties impacting the appearance of hair volume (e.g., straight vs. wavy or curly hair, the exit angle of the hair, and planned hair length that the patient wishes to have after the FUE is completed) can influence the surgeon’s decision on the number of grafts to harvest. It is the doctor’s job to determine the safe maximum extraction density per square centimeter for each and every patient, always leaving enough residual hair in the donor area to (a) cover the extractions that were taken, and (b) to be available for a future time as needed.
If, a bright light accentuates a see-through scalp visibility, one might anticipate that the patient has fine hair. People with coarse hair, on the other hand, never have a see-through look unless they lose their hair. Longer hair covers better than shorter hair because it provides more hair bulk to create the illusion of fullness. Very short hair in the donor area (i.e., stubble) eliminates any contribution from hair length, wave, or curl, and strongly reduces the contribution of even the better, coarser hair thickness in producing coverage. Short hair also seems to accentuate the “empty spaces” left by the FUE from where each graft was taken.
An Example of Safe Total Maximal Extractions over Lifetime of the Patient
|Hairs on Head||Donor Density Hairs/mm2||Strip Grafts||FUE Grafts|
FUEs remove the anatomic follicular units (grafts). The above chart defines the graft limit based upon the original donor density. The lower your donor density, the smaller will be a safe FUE or strip extraction surgery.
Strip surgery is a good alternative or possibly a good second surgery, because the graft removals are done in the center of the donor area and are easily concealed by the surrounding hairs. The appearance of a linear scar is a risk when too many strip procedures are done, but for just 1- or-2 strip surgeries, the overall linear scarring risk may be limited to one that measures just a couple of millimeters in width for most people, certainly far less scarring than shown in the patient on the left in Figure 2.
Conclusion: Donor harvesting is as much an art as it is a science. It demands that the doctor understand the nuances of relationships between donor density, hair thickness, the color/contrast between hair and skin, hair character, and the exit angle of the donor hair. It is important for you, as a patient, to understand this as well, because if you don’t, and your surgeon does not, then you run the risk of developing balding in the donor area. The chart may help you judge the numbers offered to you by your surgeon.
Hair Loss Causes
Throughout history, man has searched for the cause of hair loss. It is only in recent years, with greater knowledge of genetics and the chemistry of sexual hormones, that we have begun to understand the causes. One thing that we do know for certain: no matter what we eat, what our lifestyles may be, or what kind of vitamins we take, we never grow more hair follicles than we were born with. The average Caucasian is born with 100,000 hairs, the average Asian with 80,000 hairs, and the average African with 60,000 hairs. The character and the thickness of each hair shaft reflect the ability of that hair to cover the scalp. Fine hair covers less than coarse hair. Curly hair covers better than straight hair (e.g., African hair, with its kinky character, covers well, especially when the hair is more coarse. Straight hair layers well, so most people with straight hair take advantage of styling to maximize the coverage that straight hair brings.
The most common type of baldness is called Male Pattern Baldness, or, more scientifically, Androgenetic Alopecia. In Androgenetic Alopecia, hair follicles that are producing healthy, terminal hairs begin to produce thinner, shorter, more brittle hairs with weaker shafts (this process is called Miniaturization, and the hairs involved are called Miniaturized hairs). Eventually, these follicles produce only fine, almost invisible, short, vellus-like hairs, or they may die out altogether. The dying process of a hair from Androgentic Alopecia is called Apotosis, and the timing of this process is ingrained in the genetics of balding. It is regional, varying in different parts of the scalp. The patterns of male pattern balding reflect the apoptosis (life cycle) of the hair, and the areas that lose their hair eventually undergo apoptosis. Fortunately, the hair around the back and sides of the head seem to be immune from Apoptosis, and these hairs live as long as most humans who, when they die, will still have this rim of hair around the side and back of the head, even in the baldest of men.
Androgenetic hair loss is caused by the effects of male hormones on genetically susceptible hair follicles. It is related to three interdependent factors:
Common baldness cannot occur without the presence of specific inherited genes. These genes can be passed on by either parent. A gene is a single bit of chemically encoded hereditary instruction that is located on a chromosome and actually represents a tiny segment of DNA. Chromosomes occur in pairs (humans have 23 pairs), and every individual gets one set of chromosomes from each parent. The genetics of androgenetic alopecia is complicated, and hair loss is now felt to involve more than one gene. When several genes govern a trait, it is called polygenic. Genes that are located on the X- or Y-chromosomes are call sex-linked. Genes on the other 22 pairs of chromosomes are called autosomal. It is felt that the genes governing common baldness are autosomal. This means that the baldness trait can be inherited from the mother’s side of the family or the father’s side. The commonly held notion that baldness comes only from the mother’s side of the family is incorrect, although, for reasons not fully understood, the predisposition inherited from an affected mother is of slightly greater importance than that inherited from an affected father.
The term “dominant” means that only one gene of a pair is needed for the trait to show up in the individual. A “recessive” gene means that both genes need to be present in order for the trait to be expressed. The genes involved in androgenetic alopecia are felt to be dominant.
Just because a person has the genes for baldness does not mean the trait will manifest itself. The ability of a gene to affect one’s characteristics is called “expressivity”. Gene expression is related to a number of factors, the major ones being hormones and age, although stress and other factors can play a role. To put it simply, a man whose father and uncles are severely bald may have minimal hair loss himself, either because the baldness genes have not been passed on or because the expression of the baldness gene that he did inherit is limited. The opposite of this is also true, as men who have balding cannot identify any one male in their family (father, grandfather, uncles, or brothers from either side of the family). We do not have an explanation for this last example.
It is of interest that, to date, none of the genes for male pattern baldness have been identified. This suggests that any kind of genetic engineering to prevent common baldness is still many years away.
Hormones are biochemical substances that are made in various glands throughout the body. These glands secrete their products directly into the bloodstream so that the chemical they make is spread throughout the body. These chemicals are very powerful; only minute amounts of them have profound effects upon the body.The major male sex hormone is called testosterone. Testosterone and other related hormones that have masculinizing effects are made primarily in the testicles. Therefore, the hormonal levels that are seen in adults do not reach significant levels until the testicles develop and enlarge during puberty. In fact, these same hormones are the cause of many of the changes that occur in puberty: change in the voice, growth of the beard and mustache, development of an adult aroma in the sweat, change in the muscular development, and change in the basic body shape.
These same hormones can cause acne, and will cause beard growth. They seem to also signal the beginning of baldness (usually past the age of 17). The presence of androgens, testosterone, and its related hormone DHT cause some follicles to regress and die. In some women, hormones with androgenic activity cause hair loss as well. In addition to the testicles, the adrenal glands located above each of our kidneys produce androgenic hormones. This would be similar in both sexes. In females, the ovaries are an additional source of hormones that can affect hair and hair loss, and there are diseases of the ovaries that can produce masculine changes in some women, resulting in facial hair and hair loss.
The specific relationship between testosterone and hormonally induced hair loss was discovered by a psychiatrist in the early part of the twentieth century. At that time, castration was commonly performed on patients with certain types of mental illness. The rationale behind this procedure was that it was believed to be a treatment for mental illness at a time when there were no other forms of real treatment. Castration seemed to have a calming effect upon many patients who were aggressive and hyperactive, and castration reduced the sex drive of patients who had no outlet for their desires. The doctor noted that the identical twin brother of one patient was profoundly bald while the mentally ill twin had a full head of hair. The doctor decided to determine the effect of treating his patient with testosterone, which had recently become available in a purified form. He injected his patient, the hairy twin, with testosterone to see what would happen. Within weeks, the hairy twin began to lose all but his wreath of permanent hair, just like his normal twin. The doctor then stopped giving the testosterone to see whether the process would be reversed, but the balding process continued, and his patient never regained his full head of hair. It was apparent to him that eliminating testosterone will slow, or stop, further hair loss once it has begun, but it will not revive any dead follicles.
The hormone felt to be directly involved in androgenetic alopecia is actually dihydrotestosterone (DHT) rather than testosterone. DHT is formed by the action of the enzyme 5-a reductase on testosterone, which is a way that testosterone is metabolized. DHT acts by binding to special receptor sites on the cells of the hair follicles to cause the specific changes associated with balding. Among other effects, DHT decreases the length of the anagen (growing) cycle and increases the telogen (resting) phase, so that, with each new cycle, the hair shaft becomes progressively smaller.
It is interesting that testosterone effects axillary and pubic hair, whereas DHT effects beard growth, patterned baldness, and the appearance of hair in the nose and ears (something that older men experience). Scalp hair growth, however, is not androgen dependent – only scalp hair loss depends on androgens.
One should keep in mind that the presence of the necessary genes and hormones are not, in themselves, sufficient to cause baldness. The reaction also requires time for exposure of susceptible hair follicles to the hormone for hair loss to begin. The time required for this to start varies from one individual to another and is related to a person’s genetic expression, and to the levels of testosterone in their bloodstream. Most men with very advanced balding will lose their hair by their mid-twenties, while others see slow hair loss that often takes decades to advance.
There is another time factor that is poorly understood. Hair loss does not occur all at once, nor in a steady, straight-line progression. Hair loss is cyclical. People who are losing their hair experience alternating periods of slow and rapid hair loss. Many of the factors that cause this rate of loss are unknown.
The presence of the necessary genes and hormones are not sufficient to cause baldness. Even after a person has reached puberty, susceptible hair follicles must continually be exposed to the hormone over a period of time for hair loss to occur. The age at which these effects finally manifest themselves varies from one individual to another and is related to a person’s genetic composition, and to the levels of testosterone in the bloodstream.
Even when there is no predisposition to genetic balding, as a patient ages, some hairs randomly begin to miniaturize (shrink in length and width) in each follicular unit. As a result, each group will contain both of full terminal hairs and miniaturized hairs (similar to the very fine hairs that occur on the rest of the body and are clinically insignificant) making the area look less full. Eventually, the miniaturized hairs are lost, and the actual follicular units are reduced in the number of hairs that they contain. In all adult people, the entire scalp undergoes any aging process so that even the donor zone is not truly permanent, but will gradually thin, to some degree, over time. Fortunately, in most people, the donor zone retains enough permanent hair that hair transplantation is a viable procedure, even for a patient well into their 70s.
Nearly half of all the hair restoration surgeries performed at NHI Medical involves some type of corrective procedure to fix hair transplants, scalp reductions, and flaps performed by other physicians.
Using Follicular Unit Transplantation, we have the ability to correct the old “pluggy” or “corn-row” look that resulted from outdated or poorly planned procedures. This can be accomplished by camouflaging the old work or, when necessary, actually removing the larger grafts and re-transplanting the hair in a more natural pattern. This is carried out with the aid of the stereo-microscope that gives us the ability to remove old plugs, separate them into individual follicular units, and re-implant them with minimal damage.
Microscopic dissection also allows the retrieval of donor hair in and around the scar tissue produced by the old transplants, significantly increasing the amount of usable hair. This latter technique is extremely important since so many patients that have had older types of surgery are left with a severely depleted donor supply. Preserving every follicle is essential in order to make the most out of repair procedures.
To learn more about corrective procedures, please view the following topics below:
Fixing Old Plugs
A “pluggy” appearance is probably the most easily recognized problem of older procedures and, unfortunately, has come to literally be synonymous with hair transplants in many people’s minds. The density within the plugs is too high, and the density in the surrounding area is too low. When one tries to “fill-in” all the gaps, one simply runs out of hair.
The “Pluggy Look” occurs when the contraction of large grafts causes the density of the grafts to increase and the space between the grafts to widen. This is shown diagrammatically below.
The following patient shows the cosmetic problems of the punch-graft technique which typically results in a “Pluggy Look”:
The real problem can be seen from a top view. In spite of the fact that almost all of the person’s donor supply has been used up, only a fraction of the scalp has actually been transplanted.
Because of its inherent inefficiencies, the more hair that has been transplanted with the old punch-graft technique, the more hair has been used up, and the less hair there is left to correct the problems it created. The photo of the donor area shows how much of the above patient’s hair has already been used up with the punch-graft technique.
Wasted Donor Hair
The patient above had large grafts in his temple area that should have contained 20-25 hairs each. Because of waste from the punch-graft technique, only very few of these grafts actually grew. Even though the results don’t look “pluggy”, a huge amount of hair has been wasted. In addition, you can see the scarring in the skin around the grafts.
The strategies to repair these problems can be divided into a number of different approaches. The first method is simply camouflage. This can be effective by itself if the old grafts are far enough back on the scalp that a zone of follicular units can be built up in front of them without having to bring the hairline down too low. In general, the pluggier the appearance, the deeper the zone of camouflage that is required.
The following patient had rows of plugs placed in his temples when he first started to lose his hair. As he continued to bald, he lost all of the hair in the central portion of the front of his scalp, creating a real cosmetic problem. Fortunately, the rows of plugs were far enough back from the hairline that a wide zone of follicular units could be created in front of them (without having to come down too low on the forehead). The correction was achieved in just one session of Follicular Unit Transplantation. Fortunately, he also was blessed with a good supply of donor hair that had been preserved.
If the larger grafts have been placed too far forward, or if the hairline is made too broad, or the hair in them grows in the wrong direction, then they should generally be removed. Removal can be accomplished either by a long excision (if the plugs are lined up) or by removing them individually. We generally prefer to remove each graft individually, as this will usually give the best cosmetic result. This decision should be made on a case-by-case basis, but, either way, the hair should be re-implanted, and must never be wasted.
At times, the larger grafts are neither too low nor in the wrong direction, but just much too dense to look natural. In these cases, reducing the number of hair per grafts can be accomplished through (a) electrolysis, (b) laser hair removal, or (c) surgical coring out of part of the grafts.
Electrolysis is not useful in large grafts since the hair follicles are so distorted from the scar tissue that the needle can’t be inserted. Electrolysis may be useful if there are isolated hairs, or very small grafts, that are either placed too low, or in the wrong direction. Electrolysis destroys the hair so that they can’t be used again, but it is often effective where there are a small number of hairs in the wrong place, and the surrounding skin is not scarred.
The latter point is very important. Any time hair is removed, the skin under it becomes more visible, so if hair removal is to be used alone, the skin under it must be relatively normal in appearance. Larger grafts universally produce skin changes such as scarring, depigmentation and cobblestoning. Hair removal alone will not suffice. In these situations, the abnormal skin can be partially removed through excision, improved through procedures such as dermabrasion, or covered with normal appearing follicular units. The latter is generally the most effective technique.
The following shows the repair of the patient that was discussed in the beginning of this section. Note how the follicular unit grafts were transplanted through the scarred area, completely camouflaging the damaged skin.
Laser hair removal is a new technology still in its infancy. It has some advantages over electrolysis in that it works well and can be performed quickly. However, it is not always permanent, doesn’t allow the hair to be reused, and doesn’t address the problems in the underlying skin.
Removing part of a large graft is generally the most effective technique and the one that we most commonly use to decrease the unnatural density of the old plugs. It is accomplished by punching, or “coring out,” part of the old graft and leaving a crescent shaped sliver of hair behind. This method has a number of advantages: 1) it preserves some of the hair in the original graft, 2) it enables the removed hair to be reused, 3) it can remove and improve the appearance of some of the scarred underlying skin, and 4) its results are immediate.
The above left photo shows plugs immediately after being sutured. The photo above at right shows the patient several months later, after the sutured holes had healed. The photos below were taken after two and three sessions of follicular unit transplantation.
Camouflaging Large Grafts
The basic concept in most repair procedures is camouflage. The easiest way to understand this is with the “picket fence” analogy. It goes like this:
To hide a picket fence, you don’t board it up and make it into a wall (that will only make it more obvious).
Instead, you should plant flowers in front of it, and do it again if you need to. Although the fence has not been moved, it is now barely noticed.
The tendency of doctors to “fill in the spaces” between plugs with more plugs, just creates a solid wall of hair and worsens the cosmetic problem. The following patient had a solid wall of hair created by large grafts. These were softened by a zone of follicular units.
The next patient had mini-grafts placed at the frontal hairline, giving an unnatural appearance. These were camouflaged by a zone of all follicular units.
The best method, if the position of the hairline to be repaired is high enough, is to create a transition zone of follicular units 1-2 cm in depth. This should be accomplished with the normal progression of 1-hair follicular units in the very front, followed by 2- and then 3-hair units behind them. In very pluggy areas, a greater proportion of the larger units should be placed immediately in front of the larger grafts to enhance the camouflage. It is important to be aware that complete camouflage can rarely be accomplished in one session.
We have found that the first session alone can often be effective in making a 60-90% improvement, with the “finishing touches” accomplished in subsequent procedures. Remember, the pluggier the older grafts are, and the further forward they had been placed, the more important removal is prior to camouflage.
A commonly encountered problem is to find grafts placed in the wrong direction that need to be camouflaged. In situations where they are not going to be removed, the doctor has the following dilemma. If the doctor matches the angle of the existing hair, the problem may be worsened, but if the new hair is placed in the proper direction, it may not relate well to the old grafts and may look unnatural. This problem is resolved by the subtle but progressive angling of implants away from the improperly placed grafts.
Working with a Limited Donor Supply
As we have discussed, the stereo-microscope allows dissection of hair from within scar tissue and maximizes the amount of hair that can be obtained in areas of low density. In spite of this technology, there are many situations in which the amount of transplantable hair is well below what would generally be required for a complete restoration.
It is especially common for patients who have had open donor harvesting (as part of the punch-graft technique), or those who have had scalp reductions or scalp lifts, to have markedly depleted donor supplies.
In situations where the donor supply is very limited, the first step is to set priorities regarding what needs to be corrected most. This should always be a joint decision between the doctor and a well-informed patient. The frontal hairline, being the cosmetically most important area, should usually be the main focus of the repair. Another reason why it is important to make the frontal hairline as “perfect” as possible, is that when it looks natural, the hair can be combed backwards, providing coverage for the top of the scalp and the crown.
An important part of this technique is the use of tacking hairs. These are individual hairs scattered in areas that would otherwise be completely bald. They serve to anchor down the frontal hairs grown long so that they can be combed backwards over the bald areas. This “tacking” helps to keep them in place during routine activities, and in the wind. Using a “Hockey Stick” distribution is another means of providing camouflage with a minimal amount of hair. In the Hockey Stick, most of the harvested hair is devoted to the frontal hairline and the side of the scalp that the hair is parted on. The hair can then be combed diagonally backward, taking advantage of both layering and coverage of the back half of the scalp with hair from the front.
The shaded area in the figure above illustrates the “Hockey Stick” distribution for left-to-right and diagonally back. The dots represent the placement of tacking hairs.
Repairing Scalp Reductions
Scalp reductions can pose such a complex array of cosmetic problems that a full discussion of their repair is way beyond the scope of this section. The most common issue is that of a diminished, or depleted, donor supply in conjunction with decreased scalp laxity, minimizing the amount of “movable hair” available for the correction.
This can be partially addressed by the “hair conserving” powers of microscopic dissection, but with multiple scalp reductions, full correction with even the best techniques are often not possible. Specific patterns of repair, such as the “Hockey Stick,” used for treating patients who have low donor supply in general, would be especially useful for patients with low donor supply as a result of scalp reductions and scalp lifts.
Another problem created by scalp reductions and lifts is the scar in the crown. This can be camouflaged, but it requires a considerable amount of hair. In addition, the scar tissue limits the amount of hair that can be used in one session, so multiple sessions are often required. When the scar is covered with hair, the patient then runs the future risk of having an abnormal pattern if the hair loss continues and the hair loss in the crown progresses.
In general, correcting scalp reductions and the associated defects can be approached similar to the way one would approach plugs and a depleted donor supply – that is, to correct the front as much as possible and allow that hair to grow and camouflage problems in the back with either light coverage or tacking hair. “Weighting” of the hair to the side will also add fullness that can be achieved when the donor supply is low and, producing a very natural look at the same time. The following figure illustrates the concepts of side weighting and layering. When the patient combs his hair to the side and diagonally backwards, it provides good frontal coverage, takes advantage of layering, and gives coverage in the back of the scalp using only a modest amount of hair.
The patient pictured below had “Y-Shaped” scalp reductions that left significant scarring. This was camouflaged with a single procedure of 1,825 follicular unit grafts. If the patient had not had the scalp reductions, more hair would have been available, and even greater fullness would have been possible. In addition, there would be no scarring (limiting how close grafts could be placed) and the hair direction in the top and back of his scalp would have been far more natural. The three photos below show a top view of the patient before, during, and after a camouflage repair of an extensive scalp reduction.
The photos below show the dramatic changes in the frontal presentation of the same patient after just one corrective session with Follicular Unit Transplantation.
Sometimes, the cosmetic problems are so significant that camouflage alone is insufficient, and a specific repair of the defect must be performed first. A “dog-ear” deformity (puckering of excess tissues in the corners) caused by a poorly planned scalp reduction can be corrected by excision, and the hair in the excised tissue can be dissected into follicular units and re-implanted. On the other hand, significantly altered hair direction from a scalp reduction is an extremely difficult problem to correct and sometimes requires further tissue movement to undo the defect.
In the above photos, the elevated dog-ear section was removed so that the area now lies flat. The hair in the excised dog-ear tissue was transplanted into the front part of the scalp in individual follicular units. In subsequent procedures, hair will be added to the area where the dog-ear was, completely camouflaging it.
Fixing The Donor Area
If there is adequate scalp laxity, the area of open donor scarring can be reduced in size or sometimes removed entirely. The patient below shows the typical scarring of the open donor technique. In his repair, a portion of the area was removed and the hair within the scar tissue was dissected out under microscopic control and re-implanted. Note the reduced size of the open donor zone. On his next procedure, this will be completely eliminated.
Covering the Scarred Scalp
Although it is illegal in most states, we occasionally see patients that have had hair systems, or artificial fibers that have been sewn directly into the skin. The body rejects these foreign materials, and this often results in extensive scarring. The patient below had worn this type of system for many years. Fortunately, he still had a moderate donor supply of thick, wavy, salt and pepper hair. The after picture was taken after two sessions of Follicular Unit Transplantation.
The History of NHI Medical
In 1989, Dr. William Rassman entered the field of hair restoration surgery as an administrator for Bosley Medical Group. After hearing numerous complaints from hair transplant patients, he became acutely aware that there were inadequacies not only in the techniques being used, but also in the surgical judgments of the physicians performing them, as well as in the way they presented the procedure to their patients.
It was standard for patients undergoing hair transplantation to get caught up in a series of procedures that extended over many years after being sold a bill of goods by overenthusiastic salesmen. They rightfully expected that the process would be completed in just a few sessions. The doctor often rushed the unwary patient to “sign up” for the first procedure before the patient had time to give it due consideration, or time to understand all of the long-term implications of the decision to undergo a hair transplant. The standard of care for these procedures is not unacceptable today, but they were unacceptable at the time they were offered. Unfortunately, true “informed consent”, in the legal sense of the phrase, was rarely given.
The catch phrase was “try a few grafts to see if you like them”, or “now is a good time to start so no one will notice.” It would have been obvious to these patients if they had time to think about what they were doing – once a few grafts were “tried”, there was no turning back. More importantly, the patient whose hair loss was so early that “no one would notice”, would hardly be a candidate for surgery. Unfortunately, it was in the best business interest of the doctor not to give the patients time to think.
Their plan was reflective of much of the hair transplant industry at the time, and it was simple enough. The patient received their plugs, and three or four months later when they began to grow in, that is exactly what the patient saw. Panicked, the patient rushed back to see the doctor who calmly pointed out how nicely the hair was growing, quickly glossing over how bad they actually looked. He explained that the first session was mainly to achieve density, and that the patient needed another procedure to make their hair look natural. Somewhat reassured, the patient signed up for the next session, but the next session was just more of the same. When questioned again, the doctor, speaking with great authority, told the patient they would need another procedure. So the patient signed up again. Eventually, after multiple procedures, the patient started to get the sinking feeling that an end wasn’t really in sight, but by now the doctor wasn’t quite as available for questions. The frustrated patient eventually went somewhere else or stopped treatment and resigned themselves to wearing a baseball cap forever.
For the patient who had plenty of hair to begin with, the story started out differently (but ended the same). The plugs initially looked OK, camouflaged by the patient’s existing hair. It wasn’t until their own hair actually started to thin that they saw the old plugs could not “stand on their own.” To make matters worse, this thinning was often accelerated by the poorly timed surgery; a non-candidate now became a candidate, and, like the last patient, once they completed their first procedure, they became committed to a long series of procedures that had no clear-cut goals or end point, which continued until they ran out of money, or hair, or both.
The price for the surgery at first seemed reasonable enough, but once the process began, the costs seemed to skyrocket. It was not unusual for a patient to spend $2,000 for their first session and end up paying tens of thousands of dollars, a figure well beyond their wildest expectations, only to be left with a partially completed transplant and a totally depleted donor supply. But the real travesty was that, in the end, the patient often looked freakish – not just a thinning look appropriate for their age. They often regretted that they ever met the doctor who was supposed to help them.
Dr. Rassman formed NHI Medical in 1992 to confront these problems head on. It was the only way he felt he could, in good conscience, practice medicine. He was committed to the plan that NHI Medical would address these issues as the foundation of its business philosophy. The seven central goals of NHI Medical would be:
- To produce hair transplants that look completely natural.
- To achieve the patient’s goals in as few sessions as possible.
- To develop and then offer state-of the-art technology to achieve the best possible results.
- To let the patient’s needs drive the procedure.
- To make transplantation affordable.
- To honestly represent the procedures that we offer.
- Never to offer a surgery to an inappropriate patient who is not a candidate for a hair transplant (young men under 25 and most women).
- To make our procedures available and affordable to as many patients as possible.
It was clear that, in order for the transplant to look natural, the grafts must be kept very small. In order to achieve a significant visual impact, large numbers of these very small grafts had to be used. The adaptation to transplantation of small grafts in large quantities was not an easy technical feat, and because it was such a new process, Dr. Rassman had to develop many of the necessary tools and techniques from scratch. The transition to larger sessions took a couple of years with many surgeries lasting well into the night. But larger procedures meant that patients could expect to complete their planned hair restorations in just a few sessions. Dr. Rassman started increasing the number of grafts per surgery with these smaller grafts. At the same time, he mastered both the preparation of the grafts and the placing of the grafts. This required him to not only develop the needed skills, but also to progressively do it faster over time. He started training medical assistants in these two techniques, and it took years before the technicians matched his skills and speed. Eventually, those who were good with their hands not only matched his skills, but exceeded them. They were always younger and more agile than he was. He had to identify those who were careful, were able to follow close supervision, and would not break his quality rules that he set up (in writing and in practice). Turn-over was high, and once they worked for him, even the bad technicians would easily be hired by all of the doctors in Los Angeles. These technicians spread the technology.
At the time, the small grafts that we used mainly consisted of micrografts and small mini-grafts that contained between 1 and 3 hairs. Although the results were never pluggy, they often didn’t have the fullness that we had expected. A major advance in Dr. Rassman’s procedure came about in 1992 when he introduced high powered magnification and back lighting to the cutting process. Finally, in 1995 when Dr. Robert Bernstein joined NHI Medical’s practice, Rassman and Bernstein worked out the technique of Follicular Unit Transplantation, the procedure that has made NHI Medical world-renowned. Follicular Unit Transplantation not only insured that the transplant looked perfectly natural, but it enabled us to achieve fullness not available with the older techniques, resulting more hairs per grafts and with smaller grafts.
At NHI Medical, we are committed to letting the needs of the patient and the quality of the process drive the procedure. What this means is that we first decide what is best for the patient. Then, we discuss it with the patient and figure out how to achieve it. This is the exact opposite of the doctor who only has one assistant to help them and only the time to transplant a small number of grafts in one sitting. This was the speech they gave the patient who came to their office at the time. Once we had established that Follicular Unit Transplantation produced the most natural results and that transplanting follicular units in large sessions was best for our patients, we set up our facilities, trained our staff, and developed instrumentation to offer it this way. We never looked back, and we never expected our patients to settle for anything less.
With experience, the procedures became progressively better, more efficient, and less expensive. It became the norm for patients to achieve their goals in one or two sessions. To achieve these milestones, NHI Medical developed new tools and technology that allowed the procedure to continually improve. We developed densitometry to help us predict the patient’s true donor supply. We assessed hair quality by predicting which patients would benefit most from surgery as opposed to medical therapies. We developed special tools to make the procedure easier on our patients and to allow them to return to normal activities more quickly. We developed automated tools to insure that the highest quality of the work we did was consistent from one procedure to the next.
To help our patients understand the hair transplant process, we arranged open house events where prospective patients could observe surgery. We gave seminars all over the United States where prospective patients could meet our surgical patients and have their questions answered directly by the people who had hair transplants. We provided extensive written material to explain our new techniques. But most importantly, the patient who came to NHI Medical would meet directly with the physicians responsible for their care and see a surgery in progress. There would be no intermediaries, no hype, and no salespeople. Each prospective patient as well as previous hair transplant patients from other clinics came to our open house events, and the comparisons made all of the difference for those being introduced into this field.
NHI Medical doctors became active in the medical community, publishing articles on technical breakthroughs and sharing each and every advance with the profession. NHI Medical presented papers at national and international medical meetings and published articles in the most prestigious medical journals. As a result of these efforts, NHI Medical’s Follicular Unit Transplantation techniques became recognized as the gold standard in the field. Then came Follicular Unit Excision (FUE), and then came Scalp Micropigmentation (SMP). Each process was managed the exact same way. We started to bring out patients to medical meetings in 1993. Then, in 1994, we brought 23 patients to the International Society of Hair Replacement Surgery (ISHRS) in Las Vegas and put them on the speaker stage where hundreds of doctors could see what a good hair transplant looks like. Nothing more needed to be said – that event was a turning point for the industry, and the new standard of care was set for the future in this industry.
It became clear that, for the patients to benefit from Follicular Unit Transplantation, we had to expand beyond the borders of our medical group. With this in mind, NHI Medical embarked on a three-pronged approach: 1) to develop technology that would allow other physicians to do the procedures we routinely perform more easily, 2) to provide educational programs that would train physicians around the globe in our special techniques and 3) to continue to provide the best possible care for our patients. This is the NHI Medical that the world knows today.
NHI Medical doctors have perfected Follicular Unit Excision with the FUE Procedure, a minimally invasive procedure that allows our physicians to remove donor hair without a linear scar. With this advance in transplanting Follicular Units, FUE allowed yet another option for patients. Scalp Micropigmentation (SMP) enlarged patient’s options. For those who do not want a surgery, cannot not afford a surgery, are not candidates for a surgery, or want previous deformities repaired, SMP is an effective alternative.
The NHI Medical Way
Since its founding in 1992, NHI Medical has been a world leader in innovating hair transplantation techniques, in performing clinical research, and in teaching these techniques and innovations to the hair transplantation community. Throughout its history, NHI Medical has trained physicians and educated patients using formal medical presentations, accredited training programs, and open house events. NHI Medical has used many vehicles to communicate new ideas, to dispel hair transplantation myths that hold little or no scientific basis, and to answer the many questions of those concerned with hair loss.
Our physicians, surgical team, innovative techniques, experience, ethics, integrity, and open door policy all comprise The NHI Medical Way.
The NHI Medical Team
It takes years to develop the skills to perfect the technique of Follicular Unit Transplantation. The FUT procedure (a) requires a large number of highly skilled staff, (b) demands the team work in an orchestrated fashion with strict quality control systems in place, and (c) necessitates strict and continuous supervision. These processes must be flawless to maximize both graft yield and survival. Keeping the grafts in a moist environment is central to the process and is not as simple as it sounds. Grafts must be dissected, sorted, stored, held, and then placed into the recipient sites. Leaving a graft open to the air for just 10 seconds as it is moved from place to place will kill the graft. In addition, they must be handled gently so that the delicate growth centers are not damaged.
Doctors are trained in medicine and surgery, but are not necessarily trained in team building, understanding process, managing process, or tedious and routine activities. Most doctors have problems with FUT because they are fundamentally poor at creating technician teams that can effectively cut and place grafts. So what do doctors do? Many work with inexperienced teams (that establish their own standards) or hire independent traveling technicians that work per diem and carry with them skills from various doctor’s offices (some good and some possibly bad). As a result, the technicians often dictate the surgery. Unfortunately, stereo-microscopic dissection is not something untrained technicians will willingly perform. Doctors who may in fact want to perform FUT or large sessions of small grafts are limited by the skills or whims of the traveling teams.
At NHI Medical, our surgical team is an essential part of the process. Our staff has as much an interest in seeing a perfect outcome as does the operating surgeon. Each member of our team is thoroughly trained in stereo-microscopic dissection and graft placing. Continual monitoring insures their techniques create a maximum transplant yield. Our extraordinary team effort produces predictable outcomes with the most exacting Follicular Unit Transplantation procedure possible. It is The NHI Medical Way, and we have taught this process to hundreds of doctors worldwide.
NHI Medical Innovations
The NHI Medical Way is highlighted by constant introspection and change. Part of this process is innovation and, often times, pushing ahead with innovation, even when those changes are momentarily unpopular. As NHI Medical has forged forward, the industry has followed.
The NHI Medical Look
In the early 1990s, there was a trend in the hair transplant community to create a central island, or tuft of hair, in the front of the scalp, often called a “frontal forelock.” This was often a necessity with older, larger graft methods since the surgeon frequently ran out of hair and had to compromise on hairline design. In 1995, NHI Medical, realizing the power of Follicular Unit Transplantation to conserve donor hair, proposed that the physician not compromise the frontal hairline. We began creating a fully framed face on the very first session, producing a natural look from the outset. Additional density in subsequent sessions was added for those patients who wanted a fuller look. Conventional thinking was challenged, and an undetectable hair transplant became the “NHI Medical look”. Now it is the standard of care worldwide.
The Ethical Practice of Medicine
From the beginning, NHI Medical has been a leading exponent of reform in hair transplantation ethics. As early as 1992, in the industry newsletter Hair Transplant Forum International, NHI Medical physicians published articles questioning the ethics of using salesmen and their high-pressure sales tactics exploited industry-wide (even today). Many patients are desperate for hair and are vulnerable to pressure tactics, especially when promises are wrapped in the guise of a doctor’s white coat. We have taken considerable flack for our stance. Today, salespeople are still used as patient educators, but their compensation reflects their successful “educational activities”. We have never employed salespeople because we feel that only our doctors can judge the patient’s state of mind, and only a doctor can set proper expectations.
In 1995, an NHI Medical Newsletter titled “For Some Doctors, It’s Money above Ethics” outraged many in the hair transplant community. Dr. Rassman took considerable flack for this stance; however, we continue to speak out against the use of salespeople, consultants, scalp reductions, laser hair transplants, automated graft dissectors, transplanting patients with diffuse hair loss, unnecessary hair transplants on most women who are too young, and other procedures or decisions that may be harmful to patients. It is The NHI Medical Way.
Openness & Integrity
At NHI Medical, we have had an “open shop” since we started. “Open Houses” and Seminars around the country have been our staple. Anyone could and still can ask questions in an open forum and hold us publicly accountable for our work. Patients continue to show off their results under direct inspection by prospective candidates. We have never employed salespeople to “sell” our procedures. Most importantly, every prospective patient always meets directly with a specially trained NHI Medical physician. It is only the doctor that evaluates the patient, and only the doctor who makes recommendations for treatment. It is The NHI Medical Way.
Judgment & Decisions
Backed by pioneering work in Follicular Unit Transplantation dating back to 1995 and Megasessions dating back to 1993, NHI Medical has amassed tremendous experience that few medical groups can match. This experience is critical in making important decisions and answering such questions as:
- What are the patient’s best non-surgical options?
- At what age should surgical hair restoration be considered?
- When should Megasessions be performed, and how large should they be?
- How much donor area should be harvested at one time?
- How close should grafts be placed?
- What are the indications for surgical hair restoration in women?
- How should the transplant be designed and planned for the long-term?
We turn down more patients than almost every hair transplant organization in the world. If we believe that the patient, for whatever reason, is not a suitable candidate, then we do not accept them. To some doctors, this means that we let “money out of our office”, but for us, money is not as important as the patient’s welfare. It is The NHI Medical Way.
Regarding Honesty in Communications
Dr. Bradley Wolfe further describes difficulties patients may have in discerning truth from fiction:
Concerning follicular unit terminology, there are those that are benefiting from the semantics of FU transplants without really doing them. A local competitor, ISHRS member, advertises that he does “follicular unit minigrafts” that average 5 to 7 hairs per graft. Of course all hair is made up of FUs as all things are made of atoms. To say you drive an “atomic car” would be theoretically correct because it is made of atoms. Semantically, and with regard to accepted ideas, one would assume that the car was powered using atomic energy. So, calling your car “atomic” would be deceptive. In my view, it is deceptive to say you use FUs if they are not separated from the FUs around them. A real FU to be used in hair transplant surgery takes an investment in time, skill, energy, and patience to create, and it doesn’t exist semantically or for practical purposes unless it is separated from those FUs around it with levels of magnification needed to entirely see all the FUs that exist in a donor strip and sliver. Naming minigrafts by the numbers of FUs in them and implying that one is performing FU hair transplants is deceptive and wrong in my opinion, unless every FU is seen and all the dissection is being done with higher powers of magnification. Simply counting how many FUs are in a graft doesn’t automatically make it FU surgery any more than my “saying” I drive an “atomic car” because the car is made of atoms.
A Sample of Published Commentary
The most important means of communicating information has been through peer reviewed medical journals. This medium allows new ideas to be disseminated to physicians throughout the world and, most importantly, be subject to a process where scientific data can be reviewed and scrutinized by experts in the field before it reaches the public domain. Information is truthful and has scientific validity. Our physicians have generated a continuous stream of medical publications documenting their work and accomplishments since NHI Medical’s inception. More recently, a body of publications was created, constituting the foundation of a new field in hair restoration surgery, Follicular Unit Transplantation, Follicular Unit Extraction, and Scalp Micropigmentation. It is The NHI Medical Way.
With mass marketing, infomercials, the internet, and other forms of communication where the quality and content of the information is literally unchecked, doctors can make claims about anything they choose. It is difficult for patients to discern truth from fiction, and nearly impossible to make the best decisions on how their hair loss should be evaluated and treated. To address these concerns, we would like to offer some published comments made by other medical professionals regarding NHI Medical’s work.
Use of Microscopes
Introduced to the field by Dr. Bobby Limmer in the 1980s, the stereo-microscope has proven critical to performing FUT. In particular, it is essential for the efficient dissection of intact follicular unit grafts from the donor area. It allows for the unit to be removed whole and without damage, and allows for the natural and maximally full appearance of the final look. The critical use of the microscope was recently summarized quite well by Dr. Brad Wolfe, who, like us, uses microscopes as an integral part of the transplant process:
“There is a relative paucity of objective studies in hair transplantation, but I do recall the studies done by Drs. Bob Bernstein and Bill Rassman that showed increased graft numbers when using microscopes. Over the years, as I increased the number of microscopes and power of magnification, I noticed the number of grafts from a strip increased. A follicular unit cut without any magnification can look as good, identical, or even better than one cut with magnification. But that’s not the criteria which should be used – an increase in the number of preserved follicles is. What is being lost isn’t being seen because it can’t be seen without higher powers of magnification, and it’s in the garbage. If one believes these studies and the experience of those who have seen the light, by not using higher powers of magnification one is committing follicular homicide. This is not in the best interest of the patient, regardless of cost to the physician and patient in money and/or time. In the past, one could argue that not using magnification didn’t really make a difference because we didn’t know. That is no longer true, so there is no excuse in my opinion. There are ways to magnify without microscopes but I found increased graft numbers going from loupes to 6X magnification, and even more from 6X to 10X magnification. I refer to cutting slivers and the grafts from the slivers with magnification, either/or doesn’t count. No assistant has 6X eyes regardless of gender or ethnicity.
Smaller recipient sites are always optimal for the transplant. Sites should match the size of the graft so that a snug fit occurs. Small recipient sites limit blood flow issues, a critical concern when dense packing. Some surgeons use nails to stretch undersized sites, while others make sites too large. Both approaches reflect what is best (or easiest) for the surgeon and staff rather than what is best for the patient. The smaller the wound size, the faster and more complete the healing. A snug fit reduces the oozing of blood and serum from around the wound and is the only way to ensure that recipient site scarring is eliminated. On the other hand, when sites are too small, the staff must force the graft in the site. The result is a damaged graft, or, as discussed above, improperly dissected units. Training is arduous, but the results are vastly better for the patient. Again, some doctors do not take the time and care to properly create small recipient sites.
Follicular Unit Excision (The FUE procedure)
The Follicular Unit Excision (FUE) procedure, where individual follicular units are extracted directly from the donor area without a traditional linear incision, was published by us in the journal Dermatologic Surgery in 2002 in the paper titled “Follicular Unit Extraction: Minimally Invasive Surgery for Hair Transplantation”. The procedure has been adapted by some doctors, yet resisted by many. The controversy of this procedure was reinforced at the 2003 ISHRS meeting in New York (our annual convention for hair doctors), where many doctors from around the world openly discussed their experience and frustration with this exacting procedure. The difficulty in performing the procedure (which is tedious and stressful for both doctor and staff) was battered about by most physicians in a series of talks on the subject after Dr. Rassman presented his paper. One attempt at a clinical demonstration of the procedure was scheduled at a local New York hair restoration facility. However, the surgeon that was scheduled to perform the procedure mysteriously left town the morning of the surgery. Many of the attendees were left wondering if this was telling of an unpredictable surgery.
The FUE procedure remains an exciting advance, and the promise of an almost scar-less surgery is enticing to both patient and surgeon. An important limitation of the procedure is that the total yield will always be lower than with traditional Follicular Unit Transplantation using the strip technique for harvesting, and for this reason we carefully review the benefits and limitations of both FUT and FUE with each patient.
Follicular Unit Transplant (FUT)
We published the first paper on Follicular Unit Transplantation in the International Journal of Aesthetic and Restorative Surgery in 1995. The concept of FUT was initially rejected by many in the hair transplant community, claiming it to be technically difficult, not significantly different from mini-micrografting, and overall just not worth the effort. We disagreed and pushed onward. We followed the 1995 paper with an extraordinarily detailed pair of articles published in Dermatologic Surgery in 1997 – “Follicular Transplantation: Patient Evaluation and Surgical Planning”, and “The Aesthetics of Follicular Unit Transplantation”. Eventually, our approach became the standard of care.
By the time of the second publication, hair transplant surgeons began to see the value of this new procedure. This sentiment is reflected in the editorial commentary by Dr. Richard Shiell that accompanied the 1997 publications in Dermatologic Surgery:
“This is a very important paper on hair transplantation, well written, and covering every important aspect of the subject. A recent advance like stereoscopic microscopy is simply an aid to obtain more accurately cut pilosebaceous units. Cloning, if it ever becomes a practical reality, will simply provide us with more raw materials. Whatever happens, we will still be using something close to the Bernstein-Rassman technique in decades to come, as it provides convincing results with nature’s own building blocks, the compound pilosebaceous units. The authors Bernstein and Rassman are well known for their contributions to this field in the past 5 years, and this paper is virtually a mini-textbook on hair restoration practice. There is no doubt that their techniques are revolutionizing hair restoration surgery, and almost every practitioner in this field has already been influenced by their past writings and very convincing case presentations at meetings.
In this paper, there is much sound advice for the beginner about case selection and donor hair availability. Experienced surgeons have learned much of this in the past by trial and error, but the authors provide objective measurements of donor site size and hair density, which makes the “learning curve” far less arduous for the newcomer to this field. Four pages are devoted to the vitally important task of assessing the degree of present and future hair loss. The authors emphasize the importance of measuring the degree of hair shaft miniaturization in both the donor and recipient areas. This is an advanced indicator of future trends and is often ignored by those looking only for gross hair loss.
The authors make many very valuable points throughout this paper. Some concepts are difficult for the beginner, but make excellent revision reading for the experienced surgeon. These are not necessarily new concepts, but, on the other hand, they are points that are rarely discussed and have been seldom, if ever, written in the past.
The authors point out the importance of counseling the patient and educating him about his condition so that his expectations can be realistic. The patient who is complaining of a recent acceleration of his hair loss is probably very anxious and keen to proceed with surgery. This is the very patient who is at the greatest risk of being unhappy with the outcome of surgery, due to difficulty in keeping up with the continuing hair loss or because of accelerated hair loss as a result of surgical intervention.”
In 1999, NHI Medical published another controversial paper, “The Logic of Follicular Unit Transplantation”, this time in Dermatologic Clinics. The editor, Dr. Stough, wrote:
“Everything you wanted to know about follicular unit transplantation, and then some. This monograph presented by Bernstein and Rassman can be thought of as a thesis on the subject of the follicular unit. This may be perhaps the most comprehensive accumulation of thoughts on the matter recorded thus far… Therefore, I believe the follicular unit is here to stay. After all, hair does emerge in follicular groupings and not as a single follicular unit.”
The ideal way to perform a hair transplant is to understand its nuances so that potential problems can be avoided. Unfortunately, this is not the way hair restoration has traditionally been performed. Repair of older type procedures has become a major part of our practice. Initially, a majority of surgeons used camouflage – placing smaller grafts in front of the larger plugs. This was a quick and simple method, but was largely ineffective. As our experience with repairs grew, it became apparent that excision of larger grafts previously camouflaged was the missing critical step.
Fortunately, the hair from these larger plugs was not wasted. Under a stereo-microscope, they can be dissected into individual follicular units and be immediately re-implanted into the scalp. Many patients later, we published a comprehensive review of our work in the summer of 2002 in the journal Dermatologic Surgery. Like all of our published works before, we laid out the logic of the repair process and believe that our documentation will become the standard for the repair process.
The concept of Megasessions, where a thousand or more very small grafts are placed in a single session, was first proposed by Dr. Uebel in Brazil in the late 1980s. However, this technique gained little attention in the United States until NHI Medical presented live patient Megasession results before physician audiences in 1993 and 1994. As a perspective, when NHI Medical was performing up to 2,000 grafts in a single session, the hair transplant community rarely went above 200-300 large grafts in a single session.
Achieving a patient’s goals in the shortest timeframe with the fewest surgeries required a paradigm shift for the doctor’s practice. Multiple sessions of large grafts were easier and more profitable than the Megasession. Doctors were reluctant to abandon their old ways.
In the past, most doctors trained their surgical staff to perform a series of two-hour surgeries. Other cosmetic procedures were performed in the same two-hour timeframe, so doctors squeezed in these small transplant sessions to fit their current schedules. Few doctors were willing to take the time, make the effort, or bear the expense of revamping their office procedures. Aggressively defending their status quo was an easier solution.
When Dr. Rassman entered the transplant field, a well-known hair transplant surgeon welcomed him with the following greeting:
“This is a wonderful business and the money is good – just don’t make waves, and you will succeed and make a very comfortable living.”
Dr. Rassman clearly did not follow the other doctor’s advice. Instead, Dr. Rassman forced the paradigm shift to encompass a lower-per-graft price, and longer, more tedious, and more stressful surgeries for both the surgeon and their staff. But the NHI Medical team quickly adapted to the demands of the new procedure. It was to become the NHI Medical Way, and still is.
As pioneers, we had to give special attention to (a) developing safe anesthesia techniques to span the longer surgical procedure, (b) the size and number of recipient wounds to reduce and control bleeding, (c) the donor strip which had to be wider and longer to yield a large number of grafts, and (d) special graft handling so that delicate follicular unit grafts would not be harmed. We developed special techniques to address each of these critical issues. In the beginning, there were days when the surgery went well into the night as we perfected the process. A step up of 500 grafts from a 500 to a 1,000 graft procedure created an exponential increase in complexity and required a new set of skills.
We initially published our articles in the industry newsletter Hair Transplant Forum. Worldwide dissension arrived as other doctors failed to replicate our results and were only met with complications. It was clear that the paradigm we developed required special skills. The Megasession was so labor intensive that it was virtually impossible for an experienced surgeon to make the major structural changes in their office. Instead of making these changes, many turned their failures into points of attack against NHI Medical during various medical meetings.
As NHI Medical patients were presented at hair transplant conventions, the enthusiasm for this approach slowly began to take hold. The initial enthusiasm came from the patients themselves. This became contagious, first for other prospective patients and eventually reaching other doctors who could not offer these techniques. In 1995, we presented 23 completed patients before an audience of over 500 doctors. The initial protests began to wane as doctors were able to see first-hand results of the technique.
It was immediately clear that using individual follicular units instead of micrografts was the ideal way to perform Megasessions, an idea we soon published. In this article, we merged Megasessions and FUT into one procedure and recommended sessions as large as 3,500 grafts for Norwood Class 6 and 7 patients.
The key to our success was to train a new group of technicians to complete a surgery in less than 10 hours and train doctors through courses offered at our offices. These courses were massively successful initially. The generally accepted time frame that hair grafts would survive out of the body as well as themaximum time frame for the use of local anesthesia was a primary focus of these teaching sessions. Patients would no longer need 4-8 surgical procedures. We called the remarkable results of these Megasessions the Fast-Track approach. Not all doctors learned this technique; one doctor, who never took our courses, had the only reported death in the United States in an office just 2 miles from ours as a result of inappropriate use of anesthetics.
Achieving as much density as possible in a single session has been the desire of most patients. Prior to 1993, it was thought that density could only be achieved with larger grafts, a falsity that resulted in an unnatural look, and often left the patient with a scarred scalp. In 1993, NHI Medical began performing dense packing using very small grafts to achieve significant density while creating a natural result. At the first meeting of the ISHRS, Dr. Rassman came under personal attack for demonstrating dense packing. Doctors claimed that placing grafts so close together would compromise the skin of the recipient area or the graft’s ability to survive. In spite of these protests, NHI Medical continued to perform and enhance the technique. All of the warnings by other doctors never amounted to any complications in Dr. Rassman’s hands.
Recently, the field has shifted focus to a literal obsession over dense packing. Doctors have forgotten, however, the caution NHI Medical discussed when we first introduced dense packing. Doctors can risk poor graft growth due to graft mishandling and poor blood supply. Inexperienced hair restoration surgeons now market and push the technique, but often lack the skills to carry it out. Some are even breaking up follicular units to make grafts smaller, allowing dense packing to technically be easier and artificially increasing the graft count. However, this shortcut technique in the hands of inexperienced surgeons actually produces a thinner look, the opposite of what the patient wants to achieve. We have seen patients, in the hands of some of these less skilled surgeons, develop complications never seen in the 15,000+ surgical cases done in Dr. Rassman’s clinics. These complications produced gangrene in the mid-portion of the scalp, and unfortunately few doctors know what to do about them.
In 2010, NHI Medical introduced Scalp Micropigmentation – SMP (a specialized scalp tattoo). SMP is a new and innovative technique that offers an alternative styling option for men and women who do not want or are not candidates for hair transplant surgery. SMP adds to the look of fullness by reducing the contrast between your scalp and your hair color. It can also camouflage scars found on the scalp, including those from strip harvesting. NHI Medical has used SMP in a variety of scalp conditions, including genetic male pattern baldness (MPB), scarring alopecias (alopecia areata, alopecia totalis), many deformities of the scalp, and scarring from neurosurgical procedures or burns. Like all of our works, this technique has been published now in two text books and three peer reviewed medical journal articles.
a. Scalp Micropigmentation. A Usefully Cosmetic Procedure for Hair and Scalp Conditions, William Rassman, Jae Pak, Jino Kim, Re: HAIR TRANSPLANTATION 6th Edition, W. Unger, R. Shapiro.(2017) In Press
b. Medicolegal Issues in Hair Replacement, William Rassman, Mike Neff and Paul T. Rose, HAIR TRANSPLANTATION 6th Edition, W. Unger, R. Shapiro. (2017) In Press
c. Rassman W, Pak J, Kim J. Scalp micropigmentation: a useful treatment for hair loss. Facial Plast Surg Clin North Am. 2013;21(3):497–503.
d. Rassman W, Pak J, Kim J. In: lam SM, ed. Scalp Micropigmentation: A Valuable Technique for Use in Hair Loss. 1st ed. Vol 3. Jaypee Brothers Medical Publishers; 2014.
f. Scalp Micropigmentaation (SMP), A concealer for Hair and Scalp Deformities, Rassman W, Pak J, Kim J., Estrin, N, , Journal of Clinical and Aesthetic Dermatology, March 2015, Volume 8, Number 3
- Rassman WR. One of our greatest Problems…Lowballing! Hair Transplant Forum Intl. 1992; 2(6): 5
- Rassman WR. Pomerantz, MA The Importance of Measuring Hair Density in the Diagnosis and Treatment of Hair Loss. Hair Transplant Forum Intl. 1993; 3(2): 8-9
- Rassman WR, Pomerantz, MA. The art and science of minigrafting. Int J Aesthet Rest Surg 1993; 1:27-36.
- Rassman WR. Megatransplants in Transition – A Pictorial Review. Hair Transp Forum Intl. 1993; 3(4): 11
- Rassman WR. Megasessions: Dense Packing. Hair Transplant Forum Intl. 1994; 4(3): 5
- Norwood, OT. William Rassman, M.D – Gearing Up for Two Thousand Grafts per Session and Dense Packing. Hair Transplant Forum Intl. 1994; 4(4): 1-4
- Rassman WR. Concern about Quality. Hair Transplant Forum Intl. 1994; 4(4): 8-9
- Rassman WR. Trouble with Megasessions and Dense Packing. Hair Transplant Forum Intl. 1995; 5(6): 4-5
- Rassman WR, Carson S. Micrografting in extensive quantities; The ideal hair restoration procedure. Dermatol Surg 1995; 21:306-311.
- Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.
- Bernstein RM: Are scalp reductions still indicated? Hair Transplant Forum Intl. 1996; 6(3): 12-13. Bernstein RM, Rassman WR: Laser hair transplantation: Is it really state of the art? Lasers in Surgery and Medicine 1996; 19: 233-5.
- Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84.
- Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermat Surg 1997; 23: 785-99.
- Norwood, OT. Notes from the Editor Emeritus: “An Idea Whose Time Has Come.” Hair Transplant Forum Intl. 1997; 7(3): 10-11
- Bernstein RM, Rassman WR: What is delayed growth? Hair Transplant Forum Intl. 1997; 7(2): 22.
- Bernstein RM. Measurements in Hair Restoration. Hair Transplant Forum Intl. 1998; 8(1): 27.
- Bernstein RM, Rassman WR. Dissecting microscope versus magnifying loupes with transillumination in the preparation of follicular unit grafts. A bilateral controlled study. Dermatol Surg 1998; 24: 875-80.
- Bernstein RM, Rassman WR, Seager D, Shapiro R, et al. Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatol Surg 1998; 24: 957-63.
- Bernstein RM: Microscopophobia. Hair Transplant Forum International. 1998; 8(5): 23.
- Rassman WR. Blind Graft Production with Cutting Grates and Multi-bladed Knives. Hair Transplant Forum Intl. 1998; 8(5): 22-23
- Bernstein RM: Blind graft production: Value at what cost? Hair Transplant Forum International 1998; 8(6): 28-29.
- Bernstein RM, Rassman WR: The logic of follicular unit transplantation. Dermatologic Clinics 1999; 17 (2): 277-95.
- Bernstein RM: Unified terminology for hair transplantation. Hair Transplant Forum International 1999; 9(4): 121-3.
- Bernstein RM, Rassman WR: Hemostasis with minimal epinephrine. Hair Transplant Forum International 1999; 9(5): 153.
- Bernstein RM: A slot by any other name. Hair Transplant Forum International 1999; 9(6): 175.
- Bernstein RM, Rassman WR, Seager D, Unger WP, et al. The Future in Hair Transplantation. Journal of Aesthetic Dermatology & Cosmetic Dermatologic Surgery 1999; 1(1): 55-89.
- Bernstein RM, Rassman WR: Limiting epinephrine in large hair transplant sessions. Hair Transplant Forum International 2000; 10(2): 39-42.
- Bernstein RM, Rassman WR, Stough D: In support of follicular unit transplantation. Dermatologic Surgery 2000; 26(2): 160-2.
- Bernstein RM, Rassman WR, Rashid N: A new suture for hair transplantation: Poliglecaprone 25. Dermatol Surg 2001; 27(1): 5-11.
- Bernstein RM, Rassman WR: Follicular unit graft yield using three different techniques. Hair Transplant Forum International 2001; 11(1): 1, 11-13.
- Bernstein RM, Rassman WR: The scalp laxity paradox. Hair Transplant Forum International 2002; 12(1): 9-10.
- Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part I: Basic repair strategies. Dermatol Surg 2002; 28(9): 783-94.
- Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part II: The tactics of repair. Dermatol Surg 2002; 28(10): 873-93.
- Rassman WR, Bernstein RM. The Automation of Hair Transplantation: Past, Present, and Future. In: Harahap M, ed. Innovative Techniques in Skin Surgery. New York, Marcel Dekker, Inc., 2002: 489-502.
- Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular Unit Extraction: Minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8): 720-7.
Men are not the only people who suffer from hair loss. While male pattern baldness is a more common and accepted condition, many practitioners perform SMP for women just as often as their male clients.
There are several reasons why women could begin losing their hair. Alopecia is an autoimmune condition that can cause hair loss all over the body, and often presents with hair falling out in chunks, leaving the patient with large bald spots all over his or her head.
Women are often under an immense amount of social pressure to look great, and one way many choose to accomplish this is to restrictively diet in order to lose those extra pounds. Unfortunately, if a diet doesn’t provide the body with the nutrients it needs, one could end up shedding hair alongside weight.
Finally, hair loss is wrapped up in genetics, and just like men, certain women may be predisposed.
Why SMP for Women is an Important Procedure
It may seem like there are few options for women who are losing their hair. After all, not every girl can pull off a short hairstyle. The situation is not so hopeless, however. Even if wigs, special shampoos, and surgeries haven’t done the job, Scalp MicroPigmentation isn’t short hair specific! Patients can choose how to fill out their visible scalp. Many of our clients have taken advantage of our SMP for women. Check out their stories:
Patient Mrs. S
I was so excited when my boyfriend finally proposed to me and couldn’t wait for our summer wedding! As the date drew nearer though, I was plagued by doubts. I always wore my thinning hair up to hide my ever-visible scalp but I knew my husband and I both wanted my hair down on the big day.
It was important that my marriage was perfect, so I investigated SMP for women, finding that it was an effective, short-recovery method for filling in a head of long hair! The treatment took no time and all and I was so happy with the results. My wedding day was perfect; I knew I looked like the bride of my husband’s dreams!
Patient Mrs. F
I’ve always been overweight, but it was only when I realized my children were taking after my unhealthy eating habits that I decided to make a change. Together with my daughter, I began a restrictive diet and we both lost a large amount of weight over the course of the summer.
We were thrilled with our weight loss, but found that whenever we showered, large swaths of hair would fall out. I tried everything to get to the bottom of this, but no doctor could figure it out. Finally I went to a hair loss specialist who suggested I try SMP for women to fill in the thinning hair. I booked three sessions for myself and couldn’t be happier with the results. My long hair looks as thick and luxurious as it did before I started dieting! Now I can feel self-confident about my weight loss without being worried about my thinning hair! I also learned the importance of having a doctor approve my diets and making sure I get all my nutrients.
Patient Mrs. R
I am a young woman in my early 20’s and I never thought that hair loss would affect me, but more and more I was able to see my scalp showing through my hair. People would comment on how obvious my parting was and I was getting really self-conscious. My doctor told me I wasn’t a good candidate for hair transplant surgery because we didn’t know when my hair would stop thinning. As a last ditch effort, I opted for SMP.
I am so happy I chose this treatment! I can still style my hair however I want but I don’t have to worry about drying it out with dry shampoo or making it look greasy with hair gel. I don’t get comments any more about my visible scalp and my confidence has returned tenfold! SMP was a way easier treatment than hair transplant and it was super effective.