Is the latest technique the best technique?

With technology, the saying has always been: the latest, the better; like smart phones and new cars. However, this does not apply with hair transplantation. The human body is a very intricate and complicated system. Pharmaceutical companies invest years, billions of dollars, and multiple phases of clinical tests to develop the newest medications. But even with extensive research, the medications still get recalled occasionally.

Basically, a hair transplant is only a relocation of hair from the back of the head to the desired area. It’s a very easy and simple procedure. However, this makes it difficult to stand out from other clinics. In order to convince potential clients, you have to create something brand new and different. Something that is very convincing and feasible.  For example, laser hair transplants were very popular twenty years ago. At that time, lasers were the the latest invention. It was the best marketing tool which is why doctors spoke so highly of the many laser hair transplant advantages. However, they did not realize that the laser sealed the blood supply as well. When people discovered that laser hair transplants held very poor yield rates and results, a few years had already passed. A lot of donor hair was wasted and a great amount of damage was done. Currently, no one mentions laser hair transplants anymore. Scalp reduction, flap, extension, expansion and ultra slim dense packing claim to transplant more than 3,000 very slim SFU to qualify as being advantageous. However, body hair transplants and eyelash transplants went through that course and all failed. Concurrently, there has been a lot of improvement on hair transplantation. But so far it is still only a relocation of the hair.

The latest techniques on hair transplantation always have a different surgical approach.

A surgical trend like FUE is very convincing and catches the interest of a lot of patients. More importantly is how profitable it is for the doctors. Doctors concentrate on how to produce the perfect grafts but they overlook the more important aspect. How efficient can FUE use the donor area? After the first surgery there will be thousands of punch scars around the donor site. This is worrisome because scar tissues will have a big impact on the hair growth direction. What will be the quality of the grafts by the second surgery? If patients keep losing hair, how will they handle the thousands of scars that will show someday? What is the maximum donor area that can be used? No one currently has the right answer and no one dares to bring up the problems either.

For patients who choose the latest technique for hair transplantation, they are taking a lot of  risks. 

When you want to have the latest hair transplant surgery, you should always be very cautious and use your own judgement. I am sure the FUE technique will be one that will cause major problems in the future.

FUE was called "punch graft" 30 years ago, the only difference is that size of punch is reduced. The scars are smaller but still stay forever. 

Asian Hair

Asian Hair



Caucasian Hair

Asian hair is much coarser, lower density and thicker skin. Caucasian hair is thinner with higher density and thinner skin.For hair transplantation, the principal is the same for both hairs, but there are a few differences.

Compared to Caucasian hair, Asian hair tends to have a lot of tissue surrounding the hair, if we trim the graft too thin, it will automatically remove 10% to 15% of hair which is still in the resting phase.

Asian skin also has a tendency to bleed more; the technique of Anesthesia needs to be adjusted.
Asian hair graft is more difficult to implant due to its thicker skin, so experienced technicians is of extreme importance.

We have offices in Taiwan, Japan, and California. We are one of the most experienced clinics in the world when it comes to dealing with Asian hair transplantation!

For more detailed info, please read Chubby vs. Skinny Graft.

Paired Graft vs. Intact Graft

From July 2009 Dr. Michael Beehner’s report ~

One intact 2- hair graft: contain two single hairs follicular unit. This can also be cut into two 1-hair follicular units (paired graft). *paired graft=combine two grafts and insert into one slit.

One intact 3-hair graft: contain one single hair follicular unit and one two-hair follicular unit. This can also be cut into one 1-hair and one 2-hair follicular unit (paired graft).

BFU=Bi-Follicular Unit

Conclusion from Dr. Michael Beehner:

Intact follicular unit’s growth rate is better than paired grafts (93% vs. 70%)
3-hair follicular unit has higher growth rate than 2-hair follicular units. (99% vs. 83% on intact 2-hair graft, 49% on paired graft 1 hair+1 hair

Comments:
Intact follicular units and 3-hair follicular units are our modified follicular units (bi-follicular unit). Paired grafts are single follicular units. This is why our modified follicular unit (bi-follicular unit) has higher growth rate.
Another reason why we opposed to the paired graft is that the goal of hair transplant is to minimize the empty spaces among the grafts. When transplant same size of donor area and hair, paired grafts will increase the empty space.

The photo below shows the scalp skin. If you paired the blue circled hair into adjacent hair, the empty area will increase almost four times.

From another point of view, the intention of hair transplant is to use lesser amount of hair to cover a bigger area. But when you pair grafts, it covers less area. That’s against the purpose of hair transplantation.

Look at the picture above and imaging that if you paired all the hairs, the empty space becomes huge and unnatural. If you want to keep same space then we have to remove 50% of empty skin. Transplant area will be reducing to 50% smaller area.

Super dense packing (92 grafts/cm2), does it benefit the patients?

Here is the abstract of another presentation that I did at the 2009 ISHRS annual meeting.

Super dense packing (92 grafts/cm2), does it benefit the patients?

I. Introduction
For past several years, mega-session with dense packing is the main trend in hair transplant surgery. The graft number and density get more and higher every year.
Does it really benefit the patient in general?

II. Technique
To precisely calculate the growth rate of the transplanted hair, we transplanted hair onto eyebrow instead of the scalp. We transplanted 544 grafts in an area of 6 cm2. The density is 92 grafts/ cm2.

Prior to this case, we usually deliver a density of 40 to 50 grafts/ cm2 on eyebrow transplantation.

We compare the result of the growth rate to find out if super dense packing benefits the patients.

III. Discussion
Six months after the 92 grafts/ cm2 eyebrow transplant surgery, we counted 455 hairs. The growth rate is 82%.

We have done about 300 eyebrow cases for the past 15 years and the average growth rate is about 96%.

With the super dense packing technique, we have sacrificed 14% of hair.

To grow 455 grafts with 40 to 50 grafts/ cm2 density, we only need to implant 474 grafts. The last 70 grafts (544-474) were wasted.

In order to achieve 92 grafts/ cm2 density, we have to cut the graft much smaller and instead of making 19G coronal slit, we have to make 20G needle coronal slit.

When we transplant hair onto the scalp, we had the same result. http://hairtransplantion.blogspot.com/2009/08/chubby-vs-skinny-graft.html

In the process of preparing the smaller graft, the technician must trim off all the tissue next to the grafts. Bare graft obviously has lower growth rate.


IV. Conclusion
So far no one knows what the best density for best growth rate is, maybe we never will.

I’m sure that depends on age, health, nutrition, etc. everyone has different limitation. Without knowing the body’s limitation, only looking for higher density is not the patient’s best interest.

Chubby vs. Skinny Graft

The more denser-packing, the more skinny grafts.

Here are the study results that I can find about chubby vs. skinny grafts.






Conclusion:

All studies show that compared to the chubby grafts, the growth rate of the skinny graft is decreased 15% to 33%.

Virtually Painless Hair Transplant Anesthesia

I just attended the International Society of Hair Restoration Surgery (ISHRS) 17th Annual Meeting at Amsterdam last week.

Here is the abstract of my a pesentation about how to use anesthesia technique to perform a virtually painless hair transplant procedure.

Title: Virtually Painless HT Anesthesia

I Introduction
The ideal Anesthesia for HT includes many factors. Safety is a main priority. Blood pressure and heart rate must be monitored. Minimal blood loss, minimum airway obstruction and minimal if no discomfort for the patient is the ultimate goal for HT anesthesia.
This discussion will revolve around delivering painless anesthesia to the patient. There are so many nerves involved, so to apply painless HT Anesthesia is never an easy job.
The method I am going to mention I have being using for the past 15 years. We have modified it during the course of time and now all our patients appreciate it and have almost no side affects. I don’t recall the last time we have encountered airway obstruction, nausea or vomiting.

II, Technique- minimum sedation and stimuli
A. minimum IV sedation
The purpose of this is to relax the patients and not to put them to sleep.
Never give too much sedation. How to give the right dose is the most difficult part. Some practitioners might be reluctant to use IV sedation. The method works with just partial knowledge of the technique that I use.

B. always pre-numb the skin
Use a 30 gauge needle with bacteriostatic sodium chloride. Never use xylocaine for pre numbing purpose. Its ph is too low and will sting.

C. Two step super orbital block
Too my knowledge, not too many practitioners use a super orbital block because it is too painful to apply. I have created a 2 step block to reduce the pain to a minimum.
I pre numb the landmark with a 30 gauge needle and bacteriostatic sodium chloride and then apply 1cc of xylocaine on each side. I only stick the needle up to the subcutaneous area. The second block occurs after I remove the donor site and close it. It usual takes me about 30 minutes. By that time, even if I stick the needle deeper to numb the nerves, the patient usually doesn’t feel any or very minimum pain.

D. Massage.
Always use the vibrator if possible to interfere with the pain transfer path.

E. Inject the medication very slowly.
The speed of injection makes a lot of difference.

III Discussion
For sedation I use midazolam and narcotics fentanyl.

To prevent N&V, I screen my patients with two questions. Have they experienced nausea after previous surgeries and if they experience any type of motion sickness. If one of the answers is positive then I don't use any narcotics it at all. My max dose of fentanyl is 2ml.

I.V. midazolam relaxes the patient fast and efficiently, it never causes N&V, minimum cardiac impact and causes some amnesia.

We don't want to put patients into deep sleep, because it might cause airway obstruction. To give the right dose is very important and difficult. Everyone needs a different dose, so we give it incrementally in 10-15 minutes. In my experience I have never had to use antidote (Romazicon). I don't remember the last time I had to hold the chin to open the air way.

An Email from a Stranger

Subject: About NHT Philosophy

I checked your website and I was amazed with your frankness and integrity. I have had 2 hair transplant with very good results. I DID NOT get the surgeries done at your place. I went with another doctor who was a friend's referral. The reason why I'm contacting you is because I saw your gallery and read your Philosophy and was pleased with the way you present yourselves. As a prior hair transplant patient I KNOW what to expect from the procedure. I want to encourage people who check your website to definitely get a consultation with you because you seem very honest and explain REASONABLE expectations and your pictures are not altered to improve the appearance of results. Your website contrasts with the competition as you present actual results that are not photoshopped. Keep up the good work!

J. C. G.

Happy Patients

Great results don't require using all single follicular units. For this fine haired gentleman, we only used 50 single follicular units (SFU's). Please listen to his testimonial.

One Surgery
Donor Size=30 sq. cm, Coverage Area=92 sq. cm.

Density=30/92 which gives 32%
Number of grafts used: 50 single follicular units &

1232 modified follicular units. Total number of grafts=1282

Date of surgery-August 9, 2007 and then eight months after one surgery (Photo taken on April 24, 2008)

Punch Graft Correction

The 4 mm size grafts were transplanted more than 20 years ago. Everyone blames the big grafts for causing the pluggy look. I think the big graft is only the indirect reason for the pluggy look. The graft is too big to place close enough to each other.

The direct reason is too big of the spaces among the grafts. If we are able to fill in all the spaces then the pluggy look will disappear. It is unnecessary to remove the big grafts. By not removing the large graft, they will help to increase the density and make the final result easier to achieve.

Please study the photos, to observe two facts.
1. Please notice the huge spaces among the grafts.

2. The large graft has the original density. Within the 4 mm graft, the distance among the hairs is kept in their original density. The hairs are appropriately spaced. The size of the graft is not the problem; the hairs are in their original form and not squeezed into a smaller space. The problem lies in the fact that the grafts (also known as plugs) are spaced too far apart from each other and the space in-between the grafts accentuate the pluggy look.

Immediately after we made the slits

The goal is to fill in all the spaces between the punch grafts.

Please see Surgical Correction of ‘Plugginess’ in Hair Transplants
Published on Hair Transplant Forum International
January/February 2006 Volume 16, Number 1

Question: Exclusive use of single follicular units (SFU) seems to be the current norm, why does NHT insist on using mixed sized grafts?

Question: Exclusive use of single follicular units (SFU) seems to be the current norm, why does NHT insist on using mixed sized grafts?

Answer:
There are a number of reasons why many surgeons today use only SFU for hair transplants. Exclusively using SFU for hair transplants provides a more even "look" and fewer scabs immediately after surgery. As an additional benefit, surgeons can pack SFU more densely than modified follicular units.

However, there are three concerns:
1. Higher telogen (resting) stage hair loss due the process of thin graft preparation

Humans typically shed 60 to 100 hairs per day. These telogen stage hairs, or resting hairs, amount to 10% to 15% of our total hair at any given time. After about three months, the hairs re-grow and start the natural process over again. Telogen stage hairs are of concern for hair transplants because they are effectively invisible. In the process of preparing an SFU, the technician must trim off the tissue next to the SFU grafts possibly discarding the invisible hair inside the tissue. 10% to 15% of hair may be lost in this trimming process.

Photo: 10% to 15% of hairs are in Telogen Stage and are invisible.

2. Poorer growth rates when using thin grafts compared to "chubby" graft
Dr. Seager, Dr. Beener, Dr. Beeher, Dr. Reed and Dr. Raposio each conducted studies to compare the results of chubby and thin grafts. These studies found that re-growth rates for chubby grafts' are 20% to 51% more than the thin grafts. So far we haven't heard any report indicating that the thin graft's growth rates are better.

Photo: Thin follicular units-almost no tissue attached

Photo: Thin Follicular Units - tissues are trimmed off

Photo: Chubby Follicular Units

Photo: Chubby Modified Follicular Units

3. Cost to patient is almost double when using SFUs only

The cost associated with a hair transplant surgery is also an important issue. We work hard to earn our incomes - why should we waste it if we have a more affordable alternative to achieve our goal.

For example, here is a cost estimate for a typical SFU-only hair transplant for a hypothetical patient.
Assumes:

• A recipient area of 80 cm2
• A donor size of 40 cm2 needed for a 50% transplanted density
• Donor area contains about 100 FUs in one cm2
• Total grafts needed are around 4000 SFUs
• Total cost is around $20,000 at $5 per graft

In reality this surgery would likely cost much more than this estimate; in this calculation we didn't take into consideration potential hair loss during surgery or the growth rate.Remember that hair loss is a life long process. A patient needs to receive touch-up hair transplants once in a while to maintain a good "look". Over the longer term, the exclusive use of SFUs adds up to quite a sum!

Why We Don't Use FUE

When Dr. William Rassman first presented the Follicular Unit Extraction (FUE) method in 2002, almost every hair transplant surgeon criticized it as it taking us back to the old punch age. The FUE punch measured 0.8mm in diameter, much smaller than the 4mm original punch, and caused more transection than the older technique.

Over time Dr. Rassman convinced some surgeons to use his method. Dr. Jim Harris then improved the FUE punch to reduce the transection rate.

Let's evaluate the pros and cons of FUE.

The advantages of FUE:
1. No linear scar/minimizes scarring
2. Can use body hair as donor hair
3. Better for smaller surgeries (i.e. eyebrows, facial hair, touch-ups, scar cover-up)
4. For limited donor hair availability
5. For persons whom would like to wear their hair short


Rebuttal to Advantages:

#1-No linear scar does not mean no scar at all, it still leaves hundreds even thousands of small, round scars, whereas with the trichophytic closure method (discussed on 1/30/07 - Hair Can Grow Through Donor Scar), the linear scar is almost invisible.(as picture below)

#2-In Dr. Rassman's New Hair News volume 12, 2007 comment on body hair transplants, he stated: “in the live patient viewing, one doctor presented two patients who had body hair transplanted into the scalp. The aesthetic impact was negligible fuzz on the top of the scalp…Based upon what I saw, the value of body hair transplants to the scalp may only have experimental value in today’s surgical practice.”

#3-A small area such as eyebrow needs 300 to 400 grafts. With the strip method, we need a linear donor skin of 1 cm in width and 5 cm in length. When the hairs are shaved, it will show a 5-cm long fine scar. With FUE, it will show 300 to 400 small punched scar. Which scar looks more natural?

#4-With limited donor hair availability the small scars are even more visible.

#5-Extremely short hair leads to the possibility of FUE scars and linear scars being visible. Patient cannot shave his head with either procedures.

Further disadvantages of FUE:
1. Price
2. Time in surgery

FUE costs 200-300 hundred percent more than the strip harvest method and requires more time in surgery. I know one surgeon in Australia who takes one week to finish one patient. Is it worth the time and money?

Further disadvantage of FUE( compare to strip method)

*Quality of grafts can't compare this strips method.
FUE is blind punch method, strips method is cutting under microscope direct vision.
Which way will produce better guality of the grafts? And better result of regrowth?
* When hair loss progress, FUE patients will be converted to strips method's patients.
* After extensive FUE procedure, because of scars and lower density. The result of strips
method will be discount.

One hair transplant physician states that, "I have practiced FUE for the past five years. Most of my cases are strip FUT, but I perform an average of two FUE cases per week. Unfortunately, there are unscrupulous practitioners who advertise FUE as a scarless surgery and, therefore, many prospective patients present requesting FUE out of this expectation. Patients must understand that there are punctate scars. Granted, they are not visible when FUE has not been extensive, but can be readily detected when harvesting has been extensive and donor hair worn very short."

Young Patients-#1

Each patient is unique.

I offer individualized treatments to all my patients, especially the younger ones. Younger patients require particular attention because their hair loss progress is often unpredictable and donor hair limited. Under these conditions, hair transplant is not always the best option for young people. I have to use hair loss pattern, size, age, hair quality, gender and other factors to give them different plans.

These recommendations may include: surgery, Propecia, Rogaine, observation and sometimes a different hair style or hair color.

In the next several weeks, I will mention them one by one.

******************
Case 1a:

A 32 year old male came for a hair transplant consultation.



His concern is his vertex area.

His vertex hair is thin and fine; the frontal hair is thinner and softer than donor hair. This is one of the first signs of hair loss.

Vertex thinning area is about 90 square centimeters.

Family History: His father is a Norwood pattern class 6.

His main concern: He is young and has the potential to lose as much hair as his father did. If we do the surgery at the vertex now, we might run out of donor hair and be unable to cover the front in the future.

Treatment Suggested: No surgery right away, instead take Propecia for six months. I always take pictures for comparison. Without the photos it is always difficult to tell the difference.


Case 1b:

Some of my patients on Propecia end up not having surgery after taking the medication.

This patient is on Propecia and never had surgery.

Before Using Propecia


After Using Propecia

Case 1c:

23 years old patient came in for consultation. I advised him to take Propecia first.

The patient took Propecia for two years. The medication helped him grow hair on the crown area and prevented further hair loss.



There was still some thinning on the frontal area and receding hairline, so I performed a hair transplant surgery and used 12 square centimeters of donor. The surgery increased density by 25%.

Conclusion:

He is very happy with the results. By taking Propecia first, he saved both a lot of donor hair for future use and the surgery fee.

What is NHT's philosophy for hairline design?

Question: What is NHT's philosophy for hairline design?

Answer:

We believe that one’s hairline should be designed in according to one’s preference. In general, a hairline design should take into consideration the shape of one’s face. For instance, most Caucasians have longer and narrower faces, therefore, longer and narrower hairlines are considered. Whereas a flatter hairline may suit a square face better, as is the case for many Asian faces.

We also recommend that the center of hairline be at least 1.5 cm higher than the highest wrinkle in the face.

But person is unique and everyone has different preferences. A few people prefer to have lower and flatter hairlines. They are mature enough to drink, vote, and to be in a jury. Why can't they decide what kind of hairline they want? In situations like this, we will offer our advice repeatedly, but also respect the patient's decision. He or she has the right to have what they want. As long as the person feels great about his hairline, why should we judge him with our standard?

An example of a low hairline requested by my patient.