Cutting Grafts Under the Stereoscope

As part of our dedication to excellent quality hair transplants, NHT Medical Center uses the latest state-of-the-art MANTIS stereoscopes, which provide our skilled surgical technicians with detailed visibility when cutting the grafts. This follicular removal technique provides the greatest number of grafts, as well as the least damage to the hair.

Why we don’t offer FUE procedure?

Why we don’t offer FUE procedure?

Because we don’t think it’s your best interest!

Don’t listen to what people tell you! Take sometime, do your study seriously, ask questions, use your own intelligent and make your own decision.

Differences between FUT and FUE:

The only different between FUT and FUE is donor harvesting.

FUT uses blade and FUE uses punch. The recipient site transplant are completely the same.

Different tool used produced different result!

Comparison	FUE	FUT
Is it the latest technique?	no, it is the oldest punch graft but change the size of punch
Tool	punch	blade
Donor harvesting	blind	under direct microscopy vision
Wound treatment	leave open	closed
Scar	thousand of small punch scars	one linear scar
Scar distribution (in same length)	5 to 6 times wider	one line only
Total Scar Size	10 times bigger
Scar long term effect	permanent	permanent
For keloid patient	disaster-hard to treat thousand keloids	easier- only one scar to treat
Quality of graft	defect graft (no tissue around follicle)	intact graft (come with tissue around follicle)
Growth rate of transplantation	61.40%	86%	Read Dr.Beehner's study
Impact to 2nd surgery	huge-scar tissues change the hair direction	minimum- can use different donor area
Length of hair need to cover up the scar	1 cm	2 cm
Hairstyle options such as marine cut	no	yes
Price	Double

Why most surgeons prefer FUE?

  

FUE: need only one technician

FUT: need 3-4 technicians

Some surgeons do everything by themselves without hiring any assistance to save on business costs. It is for their own best interest, not yours.

In addition to the overhead expense, the surgery fee is double for the FUE technique. The incentive using FUE for physicians are simply irresistible. Especially for new physician who’s just starting his practice with only 3 to 5 surgeries a month. It’s difficult to start a business when you need to hire 3 to 4 technicians to assist.

ISHRS Warning

Learn from one hair transplant surgeon’s own experience.

Transection at Donor Harvesting

After the microscopic hair dissection was adapted into hair transplantation, the most transection of hair follicle occurs at donor harvesting.

In our office, we have moved from multi-blade knife to double blade now to a single blade. The transection rate was cut down but not as perfect as expected. We had a paper to mention how to harvest strips years ago. But we keep improving our method.

Currently we use a completely different approach, combined with an intruder, skin hook and blade technique. The result is amazing, even curly hair has very minimal transection.

As you can see from the photos, there are many different types of hair: Caucasian hair, Asian hair, African-American hair, wavy, curly and gray hair. All have an excellent result.

After 50 years of hair transplant technique improvement, if we use the right method, the transection during the procedure is finally reduced to minimum.

Asian Hair

Caucasian Hair

Curly Hair

Edge-Most Difficult part to avoid transection

Wavy Hair

Grey Hair-Hard to see

Curly Hair-Not only curly on hair but also curly in the tissue. Almost impossible to avoid transection.

Live Patient Session of ISHRS Annual Meeting

There are always live patient sessions in the ISHRS ( International Society of Hair Restoration Surgery) annual meeting . About 20 to 30 live patients will show their hair transplant surgery results to the meeting attendants. Of course, these are the best results from doctors who presented them.

Started from 2006 San Diego meeting, I personally asked every patient if they take Finasteride to find out the relationship between surgery result and Finasteride.

The survery below shows the percentage of live patients on Finasteride:

2006 San Diego meeting- 100%
2007 Las Vegas meeting-100%
2008 Montreal meeting- 100%
2009 Amsterdam meeting- about 70%, In Europe the trend is different, but the surgery result was not as impressive as in the States.
2010 Boston meeting- only two patients didn’t take Finasteride. But both told me that after received hundreds of advices from attendant doctors, they would like to try it.
2011 Anchorage meeting- only 3 to 4 patients presented and the main target moved towards how to cover donor scar.

Conclusion from the survey:
To have the best surgery result, taking Finasteride is necessary.

No Linear Scar, New Approaches!

You don’t like to have a linear scar at the back of your head.

FUE is not the only option anymore.

We have new approaches:

1, FUT+FUE approach
We can use FUT method to transplant as many grafts as needed (at the 50% of FUE cost ). With the Tricophytics Closure technique, it will ensure a fine scar. After 6 months if you don’t like the fine scar we can transplant 100 to 200 FUE grafts onto the scar to make the scar invisible.

2, FUT+FUT approach
First step as above but instead of using FUE graft to cover up the scar, we can cut only 2-3 cm strips to use as grafts.

3, FUT+TATOO
This approach is much easier.First step as above but use tatoo to make scar invisible.

Advantages of these approaches compare to total FUE (no linear scar from all approaches)-

1, Much better result. Grafts quality is much better to cut under microscope direct vision then blind FUE extraction.
2, No extensive shave at donor site during the surgery.
3, Leave only 100-200 small punch scars compare to thousand scars left from total FUE procedure.4, Save thousand and thousand surgery fee.

Disadvantage-You may need second minor surgery. But anyway, FUE procedure always needs more than one procedure too.

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.

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.

Thirteen Years after Hair Transplant Surgery

One of my patients who had hair transplant surgery done 13 years ago (1996) came in yesterday.

He had two sessions and the total density delivered is 50% donor site density.

He is not taking Propecia.

Please see the before/after surgery photos.

Super Dense Packing-92 grafts per sq.cm.

Surgery Date: December 7, 2006


Patient designs preferred eyebrow shape.



The length of the eyebrow is about 5 cm.


The widest part is 0.6 cm.


The narrowest part is about 0.2 to 0.3 cm.
The eyebrow area is 5 cm x 0.6 cm=3 cm2 on each side.


The eyebrow outline is about 11 cm (5cm +5cm+0.6cm +0.3cm).
We made 125 slits on the outline, the distance between each graft is about 0.8 mm.


We made 277 slits on an area of 3 cm2.
(The slit number depends on graft number available.)




This photo shows same direction of transplanted hair and original eyebrow hair.
(Coarser hair is the transplanted hair and the fine hair is original eyebrow hair.)




We transplanted 277 grafts on one side of eyebrow (area=3cm2).
This is about 92 grafts in one centimeter square.



June 20, 2007
Six months after surgery- Our patient was very happy with the results. We have achieved his goal in one surgery.



Comments:
The average density on this eyebrow is 92 grafts per cm2. Should I be proud of it? No. Not at all. Every hair transplant facility should have no problem to achieve this super dense packing. As long as you make the slits very small and trim all the tissues around the hair.

Our clinic can achieve 92 % density easily, but why we do not perform super dense packing on all hair transplant procedures?

I have checked the growth rate of the eyebrow hair six months after the surgery; the total re-growth is 455 hairs. The growth rate is 82%. Our average growth rate for hair transplants on the scalp is about 96%. In other words, with the super dense packing technique, we have sacrificed 14% of hair.

The super dense packing method is not suit for all potential hair transplant patients. Factors such as skin color, contrast, hair quality, degree of baldness and the texture of someone's hair can require a different size of graft to achieve the best result. We will work with cases individually to best fit the wants and needs of the patient.

For comparison reasons, please see the following three photos:

Our regular hair transplant grafts



Grafts used for super dense packing



Grafts used in live surgery meeting


Which one do you think will have the best growth rate?

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: Do I need to come back for suture removal?

Question: Do I need to come back for suture removal?

Answer:

At NHT Medical Center we use a polyglactin 910 suture to close the donor area. I prefer using sutures to staples because they are more comfortable for the patient and result in a less noticeable scar. In addition, these absorbable sutures begin to fall off on their own 7 to 10 days after surgery as the wound heals. The patient does not have to return for suture removal saving him a trip back to the office.

This photo is of a donor incision five days after surgery. At this point you can no longer see the suture.

An article in the 1999 Journal of the Canadian Dental Association reported on the advantages of the polyglactin 910 suture compared to staples. In the survey, researchers evaluated 42 patients with scalp wounds from cosmetic surgeries. They closed half the wound with the irradiated polyglactin 910 vicryl rapide fast-absorbing suture and the other half with traditional staples. In the study of these 42 patients they found:

· No inflammatory reaction in the areas closed with the absorbable sutures compared to 1 case in the wounds closed with staples
· An average pain score of 1.82 reported by patients for the sutures compared to average pain score of 6.7 for the staples
· No patient reported suppuration, hypertrophic scarring, or alopecia with either method
· All 42 patients in the sample preferred sutures to staples

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."

Hair Can Grow Through Donor Scar

Since Dr. Mario Marzola presented Trichophytic closure in the 2005 July/Aug ISHRS Forum, (Dr. Patrick Frechet also presented a variation of the technique), the appearance of donor scars have been improved significantly. Now hair can grow through the scar.

This photo shows the scar on the donor site (shaved for purpose of picture taking). You can see that there are hairs growing on the red scar area.

If you keep the hair long, the scar is nearly invisible. (Click on photos to see enlarged images)

It is one of the most important discoveries in hair transplant history.

Previously, the hair transplant patient may have wanted to use the same donor area on the second surgery to remove the scar from the prior surgery. However, if we use the same donor area (where the scar is), we harvest 20-30 percent less donor hair. The density in that area was already reduced in the first surgery.

Now with Trichophytic closure, since the scar is not ugly, there is no point in using the same donor area anymore. If one needs a second surgery, we can use a new donor area.

Painless Hair Transplantation

We perform the NHT Anesthesia Technique. Ninety-nine percent of our patients consider the hair transplant experience almost as easy as having a hair cut.

The NHT Anesthesia Method is an art of modern anesthesia. Our facility uses minimal dosages of medication, so it is extremely safe. The patient relaxes without being put to sleep, and feels little to no discomfort throughout the entire process.

The two kinds of pain patients face are psychological and physical.

Physical Pain is not the only problem patients face. In many cases, the fear of surgery causes as much distress for the patient. Psychological fear causes patients to tense up or become pale. They start to sweat and their heartbeats slow down significantly, only to jump up with even the slightest touch. Therefore when discussing a painless procedure, we must consider both psychological and physical discomforts.

We use “Twilight Anesthesia” to reduce any psychological discomfort our patients might feel. The anesthesia relaxes our patients enough to remove the discomfort, while allowing them to follow oral commands and respond. Since Twilight Anesthesia is not a general anesthesia, patients are conscious throughout the procedure.

To reduce any physical discomfort, we use the finest needles available. We apply a vibration before the injection, warm up the local anesthesia and use nerve blocks. To further ensure the comfort of the patient, we pre-numb the skin before applying the stimulus anesthesia agent. Tumescent anesthesia is used to make the anesthesia last longer than 10-15 hours. Furthermore, to ensure our patients' comfort after surgery, we provide the latest, best oral pain reliever which can be taken once a day. Patients can now rest comfortably after the operation without disturbance by the suture on the donor site.

See one of our patient's video testimonial about our near painless anesthesia.

The gentleman had one very painful hair transplant experience in another facility. He tried to use a hairpiece because he didn't want to go through another surgery. He didn't like the hairpiece at all. Finally, he found our clinic and had the nearly painless procedure.

The Bald Truth of Hair Transplant-

The Bald Truth of Hair Transplant-
Why some surgeons can finish their job in 10 minutes in an 8-hour surgery?

There is no other cosmetic surgery similar to a hair transplant procedure.

In other surgeries, a surgeon can use different assistants without any impact to the surgery. The reason is that the surgeon is the only one who does the surgery.

But for a hair transplant procedure, it is a completely different story.

A hair transplant procedure utilizes team work and the technician’s responsibility is very significant. At times up to ninety-five percent of the work is handled by the technicians. I can say that if the technicians decide to quit then the surgery has to be cancelled. No hair transplant surgeon can finish the job alone.

Hair transplant surgery contains six steps:

1. Anesthesia
2. Donor Harvesting
3. Suturing
4. Slit making
5. Dissection
6. Implantation

Among them, anesthesia, sutures, dissection, and implantation can legally be handled by nurses. Slit making depends on which state the facility is located. Most states allow nurses to make slits (California is an exception).

The job left solely for the surgeon is donor harvesting.

Usually when we need surgery, the most important step is selecting a surgeon. When choosing a hair transplant surgeon, there are many additional factors to take into consideration.