Post Hair Loss Questions and Get Answers

Most balding men and women would love to restore their natural full head of hair by waving a magic wand and/or by popping a miracle pill. However, hair restoration involves careful and strategic planning with a skilled and experienced hair loss doctor. While Propecia (finasteride) and Rogaine (minoxidil) are typically good at slowing down or stopping the progression of male pattern baldness, hair transplant surgery is the only method of hair restoration proven to grow hair in completely bald areas.

Today’s state of the art hair transplants are very natural looking and undetectable by even the harshest critics. This explains its increase in popularity over the last several years. But while advancements in surgical hair restoration are indeed exciting, it’s crucial for men and women considering this procedure to develop realistic expectations. What can realistically be achieved with hair transplantation varies for each patient. Below, we’ve cited a few important tips in helping you learn what to expect from hair replacement surgery.

Supply Verses Demand: What can be realistically achieved depends on the supply of donor hair and the amount of baldness in demand of new hair. Most patients can typically only achieve an illusion of fullness even under the best circumstances. Thankfully, this is usually enough to provide patients with a cosmetically significant improvement. Those with advanced balding may have to make additional sacrifices and leave some balding areas untouched. To see what hair transplants can accomplish on patients of varying degrees of lost hair, view Hair Transplant Photos by Norwood scale.

In the past I have been told that hair density of 50 follicular unit grafts per square centimeter should not compromise graft survival.  However, I was wondering would transplanting hair at 55 FU/cm2 or 65 FU/cm2 compromise vascularity or hair growth yield? Also, is any graft survival compromised leading up to achieving natural density? Cheers.

This insightful information was posted on our hair restoration forum by Dr. Brad Limmer of San Antonio, TX who is a member of the Coalition of Independent Hair Restoration Physicians.

I agree with what has been on the hair loss forum discussion thread “Graft Survival and High Hair Densities” by various members regarding percentage yield.  As Coalition member Dr. Charles points out a very important point regarding this question, “there are countless variables that go into this equation.” Some are hair transplant patient dependant and some are hair restoration clinic/technique dependant.   Thus, the outcome can be different between patients even though they go to the same clinic.

We have typically approached the problem of yielding densities higher than 50 FU/cm2 by a 2 pass approach. While more conservative than some (who produce nice results), I feel it minimizes 3 important risks to the patient:

1. Less than optimal hair growth
2. The Potential for ridging (dermal fibrosis below the skin – which is basically scar tissue resulting from the multiple recipient sites create in such a small area)
3. Permanent neovascularization (redness that won’t go away – resulting from capillary proliferation during the healing process)

Do you have any idea as to what the average surface area is for level 5, 6, and 7 on the Norwood scale of hair loss?  I was measuring my scalp and found that even if I progress to a Norwood scale level 7, I will only have about 175 cm2 of bald area. That would only take 7,000 grafts to fill in the entire area with 40cm2, a density that I believe is more than adequate to give an illusion of fullness and hair density. I realize there are variables such as color, hair shaft diameter, texture, etc. that come into play, but shouldn’t any hair restoration physician that transplants 1,000 grafts per Norwood level fill in the entire area with good density?

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.

In my experience, the average patient’s head can be divided into two areas. 

The frontal 2/3 of the scalp on average measures 100 sq.cm. On average the crown loss is 80 to 100 sq.cm. The area of the crown will vary by how low and wide the crown loss is. On average I would say that to cover the total bald area in most men who are type 6 or 7 on the Norwood scale, I cover an area of 200 sq. cm. But there are men with very large balding scalps in which the area is more like 250 to 300 sq.cm and men with smaller areas. A total area of 170sq.cm.is in the realm of a normal area to cover.

This hair loss question was answered by Dr. Glenn Charles of Florida who is a member of the Coalition of Independent Hair Restoration Physicians.  His professional answer is below.

Do all the good doctors require you shave your head before hair transplant surgery?

There are some great hair transplant doctors who require the patients shave the hair and other excellent hair restoration doctors who do not require shaving. One thing for sure is that the surgery is easier to perform if there is no hair to work around.

The question is what is more important? Making the surgery easy for the doctor and staff or keeping the patient happy even though the surgery may take a little longer. When a hair transplant megasession of densely packed grafts are placed into an area that has existing hair, there is often the development of postoperative shock loss and significant thinning hair. This can be very upsetting to the patient. Some physicians may choose to require shaving prior to surgery to avoid the potential patient complaints. Interestingly enough I have heard that some doctors actually charge more if the patient does not shave.

Dr. Glenn Charles, D.O.

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Bill Seemiller – aka Falceros
Associate Publisher/Editor

Technorati Tags: hair loss, hair transplant, hair transplant doctors, hair restoration, hair transplant megasession, shock loss, thinning hair

This insightful information was posted on our hair restoration forum by Dr. Timothy Carman who is a member of the Coalition of Independent Hair Restoration Physicians.  His professional answer is below.

Many hair restoration doctors don’t perform hair transplant megasessions and they appear to be limited to do only 3500 grafts or maximum 4000 grafts.  The few doctors that do perform megasessions go up to 5000 grafts plus.  What’s the reason for this?  Are megasessions unsafe due to limited blood supply?  I know doctors recommended on the Hair Transplant Network do perform megasessions and their patients have great results, but why do other doctors limit themselves?

 In general, the maximum amount of donor grafts available in any one hair transplant session is dependent upon three factors:

1) The patient’s hair density in the donor area;
2) The length of the strip removed; and
3) The width of the strip removed.

Number one, the patients density (average = 100 FU/cm2), is what it is- this factor is beyond the surgeons/clinics control. If this number is 110 or 120 FU/cm2, the total amount of potential grafts available can dramatically increase.

Number two, the length of the incision, is limited by the size of one’s head and the relative hair density of the hair on the sides of the head. How far the incision is extended up the sides is an area where one needs to not only observe a patient’s density at the time of surgery, but also (especially in the younger patient) the anticipated thinning hair that may be in the future based on the patients genetic (family) history and hair loss pattern to date. This is critical, as, a cavalier approach for the sake of “getting big numbers” may backfire in ten years if the patient thins on the sides, revealing the incision scar.

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

Here are few examples of hair transplant patients in which I believe dense packing in the hairline area is appropriate. I consider planting at densities between 40- 60 follicular units per square centimeter (FU/cm2) as dense packing. There are hair restoration patients in whom I will plant at densities from 60-80 FU/cm2, but they are the rare exceptions and need to be perfect candidates for what I would call super dense packing. In order for me to feel comfortable dense packing the hairline I think the following criteria need to be met:

1) The patient must be at least 30 years of age
2) The patent should have a family history that suggest his hair loss will not progress further than a class IV on the Norwood Scale of hair loss.
3) The donor area has to have at least an average density of 80 FU/cm2
4) The donor area has to have good laxity
5) The hair behind the hairline should have no or little evidence of miniaturization.
6) The crown should have no or little evidence of hair loss or miniaturization.

This hair loss question was answered by Dr. Glenn Charles of Florida who is a member of the Coalition of Independent Hair Restoration Physicians.  His professional answer is below.

One thing I never really understood is when people say that the hairline will soften during the period 6-18 months after a hair transplant.  I thought that hairs initially grew thin and thickened up during this same period.  If hairs are getting thicker how can the hairline get softer? What does softening of the hairline actually mean?

Creating a soft and natural hairline with surgical hair restoration should be addressed by the hair replacement surgeon during the procedure.

It is critical that the thinner/finer hairs be used in the hairline. Thick/coarse hairs will most likely have a similar look and feel no matter where it is placed.  It is true that sometimes transplanted hairs will be more brittle and kinky during its first hair growth cycle. After repeated hair growth cycles and hair cuts those same hairs might begin to look and feel softer, but are probably just finally returning to their original state.

 Dr. Glenn Charles, D.O.

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Bill Seemiller – aka Falceros
Associate Publisher/Editor

Technorati Tags: hair loss, hair transplant, hair restoration, hair replacement, transplanted hairs, hair growth

This insightful article was written by Dr. Shelly Friedman of Scottsdale, Arizona who is one of our recommended hair restoration physicians.

To appreciate today’s hair transplant, one must realize how far we have travelled over the past 50 years:

When Dr. Norman Orentreich first introduced hair transplantation in the 1950s he was more interested in getting hair to grow in its new site rather than concerned with the cosmetic appearance.  The first hair transplants utilized a 4mm round punch which removed the hair and the surrounding tissue.  The “hair plugs” were removed with a cylindrical punch either manually or with an electric drill, and allowed to heal secondarily with a white scar.

This small piece of skin called a “plug” was then placed back into the scalp after a 3.5mm punch removed the bald skin.  The bald skin was discarded and the “plug” was inserted in the new recipient site.  The typical “hair plug” measured 4mm in diameter and had approximately 15-25 permanent or terminal hairs.  To accommodate the blood supply in the recipient region, the “plugs” needed to be spaced one “plug” apart.  This created the checkerboard effect which required 4 surgeries to fill in the entire transplanted area.

In 1984, Dr. Wayne Bradshaw, a hair transplant surgeon from Australia described a new approach to hair restoration whereby a 4mm “plug” is either bisected or quadrisected.  Instead of removing balding tissue in the recipient region, a blade is used to incise or create a paper cut within the tissue.  This new type of “plug” is called a minigraft.  The term “plug” was then abandoned in hair transplant circles.

One of the most important factors that make a hair transplant look natural is a hair restoration surgeon’s ability to create a soft and natural looking hairline that mimics nature. Creating a natural looking hairline involves great skill, placement, artistic design, and hair density.

During the first several months of hair regrowth, transplanted hair can grow in at different rates, thin, and can sometimes be hard to tame, making a hairline appear “hard” rather than soft and natural. At what point does a hairline actually soften, look natural, and mature?

In this hair loss forum discussion members discuss the stages of hair transplant maturation and how and at what point transplanted hair softens and blends with their natural hair. You are encouraged to join in the discussion and offer your experience and opinion.

Bill Seemiller – aka Falceros
Associate Publisher/Editor

Technorati Tags: hair transplant, hair restoration, hair density, hair regrowth, transplanted hair, hair transplant, natural hair

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.

How many follicular units per cm2 (FU/cm2) does it take in hair transplant surgery to look thick?  I am wondering if 35-40 FU/cm2 would be thick enough to meet my needs.

First of all, it should be noted that a very good recent research study by Coalition member Dr. Sharon Keene from Tucson, AZ showed that in “normal” men without male pattern baldness, the average follicular unit hair density at the front hairline was 51 FU/cm2 with a range of 38-78. The average density in the temple apex region (behind the recession) was around 44 FU/cm2 with a range of 25-64.

The biggest factor in predicting whether or not the 35-40 FU/cm2 density you mentioned would look “dense” is the diameter of the hair shaft. In a man with coarse hair, that could indeed look dense. In a man with fine hair, it would probably be “see-through.” The other factor besides just stating an FU number per cm2 is the number of hairs that the follicular units average out to. Obviously, at the very edge of the front hairline you would want all 1-hair grafts, but I think it’s important to switch to 2-hair grafts fairly quickly as soon as you get 2-3 grafts deep into the hairline zone.