Post Hair Loss Questions and Get Answers

This insightful article was written by a Dr. Michael Beehner of Saratoga Springs, NY who is one of our recommended hair restoration physicians.

Over the past few years Bill Seemiller (Falceros) and Pat Hennessey have asked me to share with the reading audience my rationale for using multi follicular unit grafts (MFU) grafts (multi-follicular grafts, 4-6 hairs each) in the hair transplant planning for some patients. I will try to do so here.

First of all, in order to get our terminology straight, the difference between a “minigraft” and a MFU Graft, is that the minigraft is cut with less magnification, usually with “loupes” and are “cut to size” and often have a little transection in the cutting process. A MFU graft is cut, at least in our practice, under a 10x stereoscopic microscope and the nurse in our practice who specializes in cutting them each case that we use them, under high magnification dissects out a graft that encompasses two (or sometimes three) follicular units (FUs) that are in close proximity to each other. Incidentally, MFU grafts can be placed into either a small slit (usually made in what we call a “parallel” orientation) or into a small, round hole (usually 1-1.3mm in diameter; about the size of pencil lead)

ADVANTAGES:

1) In most research studies performed on hair growth / survival in follicles within MFU grafts, the survival has been 100%. It is presumed that this is because of the fact that they are buffered and protected by the surrounding tissue around and thus are less susceptible to trauma and drying. Also, hidden “telogen” stage (hibernation) hairs are often present and grow out later, which with FU dissection might be stripped away.

This hair loss article was written by Dr. Ron Shapiro of Bloomington, MN who is a member of the Coalition of Independent Hair Restoration Physicians. 

When Hair Restoration Surgery (HRS) was first popularized by Orentreich, the primary graft used was the “standard” 4 mm round punch graft.  However, over the past 10 years we have seen the introduction of much more diversity with respect to the size and shape of grafts. Grafts used today vary significantly and can be described with respect to a number of different variables including:

• Number of hairs
• Number of follicular units (FU’s) per graft
• Graft shape (linear, rectangular, round, chubby, skinny)  
• Size and type of the recipient site used (i.e. slit, slot or punch incisions).  Although technically this last variable refers to the recipient site and not the graft, in clinical practice, grafts are often described in this manner. 
• Process of graft production (i.e. cut “to size” vs. deliberately cut to contain a specific “number of hairs (or FU’s)”.

The reality of the situation was that for a long time a great deal of inconsistency and lack of specificity existed  when grafts were  described in the literature or at conferences.   Often in the past all that was stated was  that “Micrografts” or “Minigrafts” were  used.  This lack of specificity contributed to much of the confusion that existed when trying to compare different techniques that have developed over the years. 

This insightful hair transplant article was written by Dr. Bernardino Arocha of Houston, TX - an elite member of the Coalition of Independent Hair Restoration Physicians.

Hair characteristics, caliber, presence of curl, color, angle of emergence, and sheen play a pivotal role in the outcome of hair restoration surgeries. If your hair genie offered one of two wishes:

1) To double the amount of your hair;
2) To increase the diameter of your hair from thin to coarse.

Which of the wishes would be your choice? Well wish number one is quite simple by doubling the amount of hair you increase the volume by two, but what about the other option? If we go from fine hair with a diameter of 40 microns to coarse hair with a diameter of 80 microns, the area covered increases TWELVE fold since hair shaft is a circle the area is ∏r2 hence  (3.14)(2)2= 3.14x 4≥12. 

The other characteristics have a significant influence on the cosmetic impact of the hair transplant result, but to a lesser degree. The presence of curl can have a great impact on the volume; hence very curly. African-American hair covers a greater volume and more than compensates for the lower hair density in this race. The color or rather the amount of contrast between the color of the hair and the complexion is also important. Black hair looks thinner on the fair skinned individuals, while fuller on a tanned or darker individual. Similarly, a fair skinned individual with black hair who is transplanted will appear to get thicker hair as he ages and his hair turns grey. It is all attributed to the decrease in contrast.

I’ve noticed that some hair transplant surgeons use .7mm custom blades while others use .9mm to 1mm custom blades. Is it logical to follow the intuition of “the smaller the better”?

A doctor’s skill always reigns paramount when discussing something like this, or loupes verses microscopes. But assuming the hair restoration physicians are of equal ability, is there any reason why smaller blades/incisions are not optimal? Are there actual attributes for using the larger blades I referenced, other than that it’s easier for a doctor?

This hair loss question was answered on our hair restoration forum by Dr. Paul Shapiro of Bloomington, MN who is a member of the Coalition of Independent Hair Restoration Physicians.  His professional answer is below.

The answer to your question is that sometimes smaller blades are more optimal, and sometimes not. It depends on many factors. What is more important then the size of the blade is how the follicular unit (FU) fits in the incision. The graft should fit snugly, but not too tight to cause compression. Also, the incision size should be such that the follicular unit grafts can be planted into the skin with as little trauma as possible. The texture and thickness of ones skin and the size of the graft determine what size blade should be used to make the incisions. Some patients have tough, non-forgiving skin that does not have much stretch to it.  In these hair transplant patients I would usually cut my blades a bit larger. Some patients have follicular units which splay at the bottom. I find they get squashed a bit if the incision size is too small and I have to use larger incisions for this type of follicular unit. A person who has thin blond hair will have much smaller follicular units then a person who has thick, black hair. Persons with very curly or kinky hair will have a curve to the follicular unit and will need larger incisions. Also, a FU with 4 hairs will be larger then a one hair FU and will need a larger incision to fit properly.

Have you ever wondered why so many actors have a full head of hair? Though it may appear that Hollywood is immune to male pattern baldness, many may have restored their hair with today’s revolutionary hair transplant procedures.

Thanks to the online collaboration between educated patients and quality physicians, today’s surgical hair restoration procedures can produce results so natural that even your hair stylist can’t detect them.

Ultra refined follicular unit grafting has raised the bar for physicians and their staff. Today, clinics dedicated to this revolutionary procedure can perform larger densely packed sessions when appropriate for the patient. A hair transplant surgeon must have a large and experienced enough staff to carefully trim all follicular units under microscopes and pack them closely together into tiny incisions carefully and timely. Only experienced and delicate hands can properly place grafts into small and densely packed incisions without damaging the grafts.

Thankfully, a handful of surgeons, such as members of the Coalition of Independent Hair Restoration Physicians have mastered this technique and regularly perform it with excellent results. Below we’ve provided a few recent examples provided by real patients sharing their stories and hair transplant photos with us. You are encouraged to offer your input on their hair loss blogs.

The concept of hair transplant surgeons giving varying estimates on the number of grafts needed to meet a patient’s hair restoration goals has concerned prospective patient members of our hair loss forum for years. Where one surgeon may estimate only 2500 grafts are needed, another may suggest 4000. But how many will a patient need to get a great hair transplant result?

The topic of splitting grafts has been heavily discussed on our patient hair loss forum for a long time. Where most if not all clinics will subdivide larger grafts into singles for hairline reconstruction, which clinics (if any) will cut smaller grafts and split true follicular units? What are the benefits and drawbacks to cutting smaller grafts?

Forum member “Reptile” was told by a doctor he consulted with that no hair transplant clinic can do sessions larger than 4000 grafts unless their splitting true follicular units. View this thread to read others and offer your own input on whether or not what this doctor saying has any validity.

Bill Seemiller - aka Falceros
Associate Publisher/Editor

Technorati Tags: hair transplant, hair restoration, hair loss, follicular units

This question was posed by a hair loss sufferer seeking hair loss help on our hair restoration forum and answered by Dr. Michael Beehner of Saratoga Springs, NY who is one of our recommended hair restoration physicians. His professional answer is below.

I’ve noticed that some hair transplant surgeons use .7mm custom blades while others use .9mm to 1mm custom blades. Is it logical to follow the intuition of “the smaller the better”?

A doctor’s skill always reigns paramount when discussing something like this, or loupes verses microscopes. But assuming the hair restoration physicians are of equal ability, is there any reason why smaller blades/incisions are not optimal? Are there actual attributes for using the larger blades I referenced, other than that it’s easier for a doctor?

The answers on this hair loss forum thread by Bill Seemiller (Falceros) and Dr. Paul Shapiro are excellent and I agree with everything they have said.

I just wanted to add that a very important factor in hair transplant blade size (or needle size) selection is the coarseness of the hair (the hair shaft diameter). Very fine 1-hair follicular units can be placed into 0.6mm blade incisions, whereas coarse ones require a 0.8mm one.  Same goes for 2-hair and 3-hair follicular unit. The blade width is significantly larger for these grafts when the hair is coarse.

And one more factor that is significant.  Some patients have follicular unit structures in which the hairs are very straight, parallel to each other, and situated “tightly” together. Other patients have what we term “teepee-ing” of the grafts, with the hairs curving off from each other in various directions. This affects what size blade is chosen also.

Recently, the Publishers of the Hair Transplant Network attended the 2008 16th annual ISHRS scientific meeting held in Montreal from September 3rd to the 7th.  See the formal Press Release.

Though many topics were discussed, this report will highlight topics that may be of most interest to hair loss sufferers. Many of these topics have been discussed and debated by patients for years on our hair loss forum. Topics include optimal hairline design and density, minimizing the appearance of the donor scar, using all follicular units (FUs) verses some multi follicular units (MFUs), FUE Megasessions, and complications with perpendicular (coronal/lateral) incisions and dense packing difficulties. There was a brief presentation on advances in hair biology discussing the latest research on cellular and molecular controls of follicular development and growth. However, because the Publishers of this community were not able to attend this presentation, this report won’t contain any new information on this topic.

The attention to detail at these meetings is certainly very impressive and hair transplant surgeons who regularly attend deserve to be commended for their dedication to continuing education.

Background on the ISHRS and Meetings

The primary mission of the ISHRS (International Society of Hair Restoration Surgery) is to educate hair restoration physicians from the beginner to the master. It is by far the most prominent hair restoration professional organization in the world and the host of the five day annual scientific meeting. Their website (www.ISHRS.org) provides useful information about hair restoration and profiles and contact information for its 700 worldwide physician members.

This insightful information was posted on our hair restoration forum by Dr. Timothy Carman of La Jolla, CA, who is recommended on the Hair Transplant Network.

I have noticed some hair transplant patients will have a lesser number of follicular unit grafts but a greater hair count.  Which is more important? Does the hair count matter?  Often I only hair loss patients speak about the number of grafts they received.

In my opinion, both are relevant.  Hair graft counts alone can be misleading, as follows. 

Say a hair restoration patient has 1000 follicular units available in the donor area.  When trimmed to their naturally occurring groupings (true follicular unit grafts of 1’s, 2’s, 3’s and 4’s), they will average 2 hairs per follicular unit.  This will yield 2000 hairs as per my example. Now one can cut each and every follicular unit down to one hair grafts, and if a hair restoration physician were to do that, you would have 2000 grafts.  This would be labeled as a “2000 graft case”, when, in fact, a surgeon is moving the same amount of hair mass in both instances. As Pat Hennessey, Publisher of the Hair Transplant Network says, “More slices doesn’t make the pizza bigger”.

Now, to the hair loss newbie, the 2000 grafts sounds like a “better and bigger deal”. In fact, the result obtained, were one to compare the 1000 graft case (native follicular unit grafts, original groupings) with the 2000 graft case (all follicular units cut down to 1’s), in my honest opinion, the 1000 graft case would look much more natural, due to the heterogeneity of grafts (which mimics nature).

I’ve noticed a number of hair restoration physicians like to employ a few hundred double follicular units (DFUs), particularly when working on the balding crown / vertex.  It makes sense that this would be a boon towards increased hair density.  But what are the downsides?  And if you are a proponent of selective DFUs, are virtually all cases of crown/vertex work a good fit to utilize this?

The most immediate concern I have would be “naturalness”, but I’ve seen it stated that when blending in to the crown region this concern is nullified.

I happen to be an advocate of all follicular unit grafting however, Dr. Paul Shapiro and a few others have made a compelling case on our hair loss forum with hair transplant photos that using minimal quantities of double follicular units in certain candidates might help aid the illusion of hair density.

In my opinion, DFUs must be used in small quantities in the forelock or crown area in patients with adequate surrounding hair density - either natural or transplanted hair (follicular units). Otherwise, the DFUs may appear “pluggy”.

Another concern in my opinion, is that using too many double follicular units may limit a patient’s hair length and style.  Cutting their hair too short may result in an unnatural look in these areas.

If DFUs have been placed around natural hair that later suffers from hair loss, a patient may feel more pressed to get another hair transplant not only to add more hair density, but to camouflage the double follicular units.