Case Study #2 -Norwood Class 6

Case #2- Total Increased Density: 35%
One Surgery:		Hair Regrowth Medication: Yes
Coverage Area:	60 cm2
Donor Area:	23 cm2
Density:	35%
Graft Number:	1510 grafts

We added 30% density to zone 1,2,3,4.

For zone 5,6, we recommend the patient to use the FDA approved oral medication, Finasteride (Propecia) to slow down his hait loss progress and maybe grow some new hair for his vertex area.

Case Study#1 -Norwood Class 7

Case #1- Total Increased Density: 30%
One Surgery:		Hair Regrowth Medication: Yes
Coverage Area:	88 cm2
Donor Area:	28 cm2
Density:	30%
Graft Number:	1690 grafts

We added 30% density to zone 1,2,3,4.

For zone 5,6,7, we recommend the patient to use the FDA approved oral medication, Finasteride (Propecia) to slow down his hait loss progress and maybe grow some new hair for his vertex area.

The after surgery photos are taken two years after the procedure.

From 2014 ISHRS Meeting -Is a glaucoma drug the next treatment for hair loss?

ISHRS 2014 Meeting

Is a glaucoma drug the next treatment for hair loss?

Professor Valerie A. Randall, PhD, FIBMS, FSB

Professor of Biomedical Sciences, Centre for Skin Sciences, School of Life Sciences University of Bradford, Great Britain, U.K

Hair Loss causes significant negative effects on the quality of life of affected individuals. This occurs in every culture due to hair’s importance in human social and sexual communication across the world. As common as alopecia is, treatments are very limited and vary in their effectiveness. Current treatments involve cosmetic wigs or hairpieces to surgical techniques. The main medical therapies in current use include hormone action modifiers for androgen-dependent hair loss and non-hormonal treatments for other alopecias.

Glaucoma drugs are recently being researched for hair growth. They are used to reduce intraocular pressure, but seemed to stimulate eyelash growth as a side effect. Then came about Latisse (bimatoprost), previously a glaucoma drug that is now indicated for eyelash growth. Eyelash follicles differ from scalp hair as they specialize in the protection of the eyes. When bimatoprost was tested on isolated scalp follicles it showed increased human hair synthesis of organ cultures. It also stimulated hair growth in rodent pelage follicles. Bimatoprost appears to offer a new approach to stimulate scalp hair growth clinically. It is currently in phase 2 clinical trial in the US as a topically-applied treatment for androgenetic alopecia in men. Overall, increased understanding of the hair follicle function both in health and disease and careful observation of drug side-effects are leading to new approaches for therapies for alopecia.

From 2014 ISHRS Meeting -Aging Scalp and Gray Hair

Aging Scalp and Gray Hair

ISHRS 2014

Desmond J. Tobin, PhD, FSB, FRCPath.

Desmond J. Tobin is Professor of Cell Biology and Director of Centre for Skin Sciences at University of Bradford.

Although humans have over 5 million individual hair follicles on their bodies, most attention be it academic or commercial is focused on the paltry 2% of these that are distributed on our scalps. 

The hair follicle produces several different types of hair fiber during a normal lifetime. It is worth emphasizing that hair will grow up to 4 meters all  within the same single hair follicle. Hair growth rates also vary significantly during human aging and for different body sites. Indeed, when these are averaged for post-40 year old non-balding males, hair actually grows most rapidly and with greater individual fiber thickness in certain body sites in individuals during their 50-70 years of age. 

Increasing age can leave its mark on several phenotypic properties of the hair fiber. While the most visually apparent of these include hair thinning, hair loss, reduction in the rate of growth, pigmentation loss, aging can also affect change in the surface morphology of hair. The hair follicle is somewhat unusual however, in that some of its interactive cell systems appear to be non-essential for overall hair follicle survival. Indeed, strikingly gray and white hair follicles may paradoxically grow hair even more vigorously than their pigmented predecessors. 

Much of the recent research has focused on both the oxidative stress that appears to increase with aging and to which the hair follicle melanocytes appears especially sensitive, and the fate of hair follicle melanocyte stem cell capacity. This is likely to reflect significant differences in the epidermal and follicular melanocyte microenvironments.  The hair follicle may provide richer information in this context. Pre-proliferative, proliferative, differentiated, terminally-differentiated and ‘senescent‘ melanocytes all co-exist in the same growing hair follicle.

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. 

FUT Donor Scar-Videos

You can barely see the donor scar from the videos.

FUT Scars

The scar on the donor site is nearly invisible with with Trichophytic Closure.

These photos below are taken on the suture removal days (10 days after surgery)

Invisible FUE Scar?

There was one young gentleman sitting in front of me on the airport shuttle.

I was looking around, and all of a sudden, I saw thousands of small round bald spots at the back of his head. I realized immediately that they are the recently popular FUE scars.

The size of FUE punch usually range from 0.8 mm to 1 mm. It is assumed the scar would be the same size, but the fact is that the scar always grows bigger than the size of the punch. The more tension of the scalp the bigger the scar. 

People spend 2-3 times the surgery fee and transection rate is much higher just to have the option to have a short hair cut. However, they really don't have option to shave their head. If their barber cuts their hair too short then they will be bothered for weeks before hair grows long enough to cover the scars. At the same time, it is a big problem for their barber too, they don't have any idea how short they can cut without the scars showing. 

Under direct sunshine requires much longer hair to cover then indoors, which is the standard they should perform.  

Attached are two photos which I used an  Iphone to take.The shuttle was very jumpy, hard to focus on.

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.

Compare the Quality of FUE Graft and FUT Graft

FUE grafts are cut blindly using punch, basically are bare grafts, no tissue at button part. No study discuss about regrowth hair rate, quality and life time yet.



FUE Grafts:




FUT grafts are cut under microscopic direct vision, contain a lot of tissue including regrowth elements bulge and sebaceous gland.

FUT Grafts:

Which type of graft do you prefer?

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.

Wine and Hair Transplant

The top news around the world today. ONE GLASS OF WINE A DAY INCREASES
RISK OF BREAST CANCER. It shocked so many people, because not too long ago, they said to drink one glass of wine a day to protect your heart and was published on all medias, That encouraged many people to drink wine every night.
This kind of controversial report it is not the first to happen, and it happens very often. It is
like vitamins, they always have controversial reports.
It happened in hair transplant field too. To try to transplant more and more grafts in certain area, the grafts should be cut smaller and smaller, without doing any study about its impact to the quality of regrowth and hair quality. Especially a lot of FUE grafts and not even a intact graft
( like bare graft)
We all know donor hair is limited if it were wasted, we never be able to undo it.

Intruder

After microscopy dissection was introduced, the chance for hair transaction during the surgery was mainly during donor harvesting.
To reduce it, the instrument changed from a multiple blade knife to a single knife. Instead of cutting blindly, the Haber Spreader and Tykocinski intruder were invented.
So far the intruder seems the safest and has minimum transecting rate( less then 1%).
The method is to score the outline about 2mm in depth, then make multiple insertions of the intruder into the incision line going to a depth slightly below the hair bulbs. Then, using two skin hooks to separate the incision gently. This way there is almost no transection and you don’t have to worry about damaging nerves and vessels.
Tykocinski intruder is easy to use and a great break through for donor harvesting.

Compare Different FUE Methods

There are so many name and methods for FUE. I would like to organize them
in this form to make easy comparison.

	punch	motorized	unique point
2 step	sharp	no
3 step	sharp+dull	no
Safe system	dull	yes	*1
Roto core	sharp	yes	*2
Neo graft	sharp	yes	*3
Artas robotic	sharp+ dull	yes	*4

*1,Safe system
The initial rotation speed is only enough to allow the dull punch to penetrate
the skin and slow down the speed when pass deeper to separate the follicular
units from surrounding tissue. This will reduce transection rate of follicles.

*2, Roto core
Automatic rotation when downward pressure is placed. It has debris disposal
window to fasten disposal process and potential harm to the Punch tip.

*3, Neo graft
The device is used to extract follicular units and implant them in the recipient area
via a suction system. It seems a great idea, but has two major problems.
At first, suction has tendency to produce bare grafts. 2nd the contineous flows of air will dry up the delicate follicular units.

*4, Artas robotic
After initial calibration, the robot will work 100% automatic.
The quality of the grafts is excellent and transection rate is about 5-8%.
I would like to say it is the best way to have FUE procedure, if the price is
right.

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.

Sharp Punch and Dull Punch

Hair alignment is different in and out of the scalp.

Using FUE procedure to punch the grafts is a blind procedure.

There is no way to see through the skin. Therefore, two types of punch (sharp and dull punch) are used to reduce the transection rate.

	Deep Level	Advantage	Disadvantage
Sharp Punch	shallow, only cut through skin	less transection	bare graft caping
Dull Punch	deep to whole follicle	punch out whole follicle	more transection

* Sharp punch only punch through skin, need to use two forceps to pull out the grafts.Because the tissue around the follicles didn’t separate, a lot of time follicle come out without any surroundings tissue,that we call bare grafts. Sometimes during pulling, only skin pull out,follicle still stay in the scalp, that we call capping.*Dull punch method,use blunt dissection to isolate the follicular units from the surrounding tissue.Require more experience and skill to perform, even the speed of punch is very important.