Right Age for Hair Transplant

A question frequently asked by many of my hair loss patients is, " Am I right age for transplant?"


I wish, I had an easy answer to that one. Alas, the real answer is so convoluted that even doctors will find it difficult to grasp. Let us first consider the reasons or indications for hair transplant. You should plan a transplant if,

      You have Androgenetic alopecia stage III to stage VII.

      Your hairline is not appropriate for age or you wish to achieve younger looking hair line

      You have burn alopecia or traction alopecia.

      You have eyebrow, eyelash or facial hair loss.

Now, for each of the above mentioned indications, there is a stronger underlying indication. That is the first question you should ask yourself. And that question is, " How bothered am I with my hair loss?" If you are fine with a bald pate; do not let others bully you into a transplant, whatever be your age.

But if this hair loss affecting your work, your social life etc; you should consult a good plastic surgeon. Generally, men achieve their adult hairline in late twenties to early thirties. And so, transplant after this age is considered appropriate. However, this does not mean that every patient in his mid twenties should be denied a transplant, even if he is stage V or VI Norwood. 
Confused. 
Well, let me put it this way. Age is not the only deciding factor for a transplant. Present hair loss status, donor hair reserve, ongoing miniaturisation, family history and physical condition are also equally important determinants for a persons suitability for hair transplant. 

All said, as a rule of thumb you should wait if,

You are in your teens with unstable hair line.

If you have rare genetic conditions like DUPA, extensive alopecia areata etc.

If you are medically unfit for surgery (uncontrolled blood pressure, uncontrolled diabetes, heart failure etc)

Even in these conditions, it is best to consult a qualified plastic and cosmetic surgeon; because he can help you chalk out a plan for future and may offer you alternative therapies. An honest expert advice can save you lot of grief and money.

Hair and Diet

Before I start telling you about foods that help you build healthy hair, I want to tell you that food is not magic. It's not even medicine, so do not expect miracles with the food items listed below. They will help you get good hair if you take them adequately over a long period. 

As a general rule, all the food articles that are good for your body are good for your hair. That means a balanced diet rich in proteins, vitamins and minerals. Also remember to follow a healthy lifestyle. And yes, exercise is good for your hair also.

Protein 

Well, 99.9% of hair is protein. If you have low protein intake your hair will be thin, dull and unevenly pigmented. These kind of changes in hair (called " band sign") actually form a part of diagnosis in chronic protein deficiency. 

Eat Sufficient amount of good protein everyday from both plant and animal sources.

What to Eat: Pulses and legumes especially soybean is good for hair. Also, white meat like fish and chicken, eggs and dairy products. 

Iron 

Anaemia and low iron levels are a major cause of hair loss in females. This kind of hair loss is totally reversible with appropriate iron replacement therapy. But, more importantly you can avoid it altogether by including following in your dirt.

What to Eat:  Nuts like peanuts, almonds and walnuts, jaggery, green leafy vegetables like spinach. Also red meat, dried fruit and whole grains.

Vitamins

Two vitamins namely Vitamin C and Biotin are very important for hair growth. Vitamin C helps in collagen production which is the building block of hair while biotin is important for keratin production. Deficiency of either may lead to poor quality hair.

What to Eat: Citrus fruits like oranges, limes and tangerines. Whole grains, eggs and dairy products.

Trace Minerals 

It may sound strange but trace elements like Zinc and Selenium are very important for hair health. Studies show these minerals can affect levels of androgens, hormones associated with hair loss. 

What to Eat: Sea food like oysters and fish, sprout beans, beef and nuts, flaxseeds etc. 

Of Virender Sehwag, Transplants and Advertisements.

Early in the morning, when I open the news paper with my first cup of coffee, I am sure to find one cricketer or another trying to sell me something. From soft drinks to real estate, everything that can be sold is being marketed. Latest in this series is the endorsements for hair transplant surgery and medical procedures. 




In this era of consumerism, hair mills with deep pockets are enticing people with celebrity endorsements and full page advertisements. During a day's work, some patient in my clinic would surely ask me for the inside scoop on Sehwag's or Harsha Bhogle's hair transplant. All I can tell them is that they are not my patients. And of course, every one has an opinion on that. What is it about cricketers and hair transplants that has had the whole country buzzing?

First of all is the exposure that the hair transplant procedure has got. Plastic surgery procedures  in India are like sex. You may have it as much as you want, just don't talk about it. And God save you if you happen to say anything nice about it. When people are twisting their tongues over politically correct "au naturel" statements, this kind of celebrity endorsement for hair transplant comes as a surprise. It is like taking the procedure out of closet and saying; Yes! I got it done and it feels good. Such acceptance by a public figure speaks volumes about the inherent advantage of hair transplant procedure. It also helps to allay the fears and misconceptions of those who may be skeptic of the procedure and the results.

However, there is also a commercial aspect to such endorsements. With all the marketing and advertisement the hair transplant procedure is reduced to a commodity. Now, there is more emphasis on adverts and marketing rather than patient selection and good techniques. And patients, on their part, are now more worried about price per graft. In this fierce competition, somehow, the priority is getting a good deal rather than getting a good surgeon and good results. With scientific approach thrown in background and business approach reigning, the ultimate sufferer in this hair war is the naive patient and perhaps an honest surgeon.

Modern day Hair Transplant: History and Evolution

Hair transplant in modern times was probably first described by a Japanese plastic surgeon Akuda as a reconstructive procedure in his burn patients. He used to harvest hair plugs from permanent donor area which were then implanted in scarred areas of scalp. It was not used for male pattern baldness.
However, due to censorship applied during WW II, these reports and techniques were not available to the rest of the world.

 Dr. Norman Orentreich in New York City was the first to use this technique for male pattern baldness in 1950s. He laid the foundation of modern hair transplants and defined the basic principles of hair transplant. He noted that the hair coming from the permanent zone maintained the characteristics and growth pattern of the area from where it came rather than changing to the implanted area characteristics. He called it the 'principle of donor dominance' which is the fundamental feature of hair restoration surgeries.

This image is from Dr. O'Tar Norwood's textbook 'Hair Transplant Surgery' published in 1973.

During the initial period of hair transplant surgery, large punches were used to cut out hair bearing skin from permanent donor zone which were then placed in holes created by a similar punch in the front. The surgeries were usually small and 25-30 grafts were placed during one session. As the long term results started coming in the flaws in this approach became evident.

First and foremost, the look in the transplanted area was unnatural. The hair came out in tufts at an abnormal angle in the scalp and were likened to "rows of corns" and "doll's hair". Many a times the hair in the central portion of the plug did not grow due to poor oxygenation and were lost forever. There was extensive damage to the donor area. Sometimes the results were so bad that the patient was forced to cover his head, not due to baldness but, due to transplant.

Then came the era of mini and micro transplants where hair was removed as a strip and then cut to small grafts called;

1.Large Mini-grafts – Grafts containing 4-5 hairs
2. Small mini-grafts -- Grafts containing 2-3 hairs

3.Micro-grafts – tiny grafts containing 1-2 hairs. 

Although the results improved but they could not stand to close scrutiny. Since the natural follicular unit architecture of the hair was not respected the hair growth was poor and wastage high.

Modern day "Follicular Unit" grafts compared to common ball point pen.

As interest and research in procedure grew, the importance of follicular unit architecture was realised. And, today "Follicular Unit Transplant" is considered the 'gold standard' hair replacement procedure through out the world.

What is "Donor Zone" ?

In simple words donor zone is the area from where the tissue is being borrowed for placement in another location. In hair transplant this is a ribbon shaped area centered over a bony prominence in the skull called occipital protuberance. This area described as "Universal Safe Zone" forms the basis of hair restoration surgeries. It extends from the area around ear going back towards temples over to the occipital protuberance and is best seen in Norwood VII patients.

Norwood VII is the "Universal Safe Zone" for scalp hair.

The height of donor area is around 5-6 cm in midline and it is approximately 30-35 cm long. If we were to utilise all of it there would be no hair left in the donor zone of a class VII patient. However, it is possible to utilise around 50% of this hair without a visible reduction in hair density on the back. This means a total usable area of around 90-100 square cms. 


Assuming an average density of 100 FUs /cm square in caucasians and 80 FUs / cm square in east asians, this gives us a total of 10,000 FUs to 8000 FUs of movable follicular units having approximately 15 to 20, 000 permanent, DHT resistant scalp hair. Of course, if you have a higher density you will get more hair and vice versa.


Having 10,000 movable follicular units does not mean that all of them can be harvested at the same time. The number of units that can be taken out in one session depends upon your scalp laxity. Harvesting too narrow a strip will give smaller number of follicular units and harvesting too broad a strip may result in wide unsightly scar. So, it's a compromise between the two. A patient with high donor density and good scalp laxity will have significantly higher yield than one with low donor density and poor scalp laxity.


Remember, donor zone is the single most important factor in any hair restoration surgery. As a plastic surgeon I have learned to give utmost respect to donor zone but many a times under-qualified doctors do not give adequate attention donor zone.  If you look at the stage VII of Norwood class you will realise that hairline recedes not only from the front and top but also creeps up from the neck and temples. That is why follicular harvest from areas above or below this zone may result in visible scarring.Over harvesting from the donor zone may result in wide unsightly scars and thinned out see through look in the donor area. This is so unnatural that the whole exercise of hair transplant becomes futile. Although I am a strong proponent of large sessions, for the aforementioned reasons, larger sessions are not always better for you.

Example of  a bad strip scar.
This patient underwent follicular unit transplant by strip method
at a  clinic in New Delhi.  500 FUs were grafted.

 Every one is different and every hair restoration needs to be individualised. Do not rush to the doctor who is offering highest number of grafts for same area. You may end up losing precious donor hair in the bargain. Think, deliberate, consult and research before taking your decision for money can not bring these hair back.

Cheap Hair Transplants : What is the real cost?

Recently, there has been a flood of hair transplant clinics who are willing to do transplants at  ridiculously low prices. As a consumer, you think this is because of growing competition in the field. And like other commodities prices had to fall one day. You are happy that now the procedure is within your 'budget' and you quickly get a transplant before you lose this golden opportunity.

Few months pass by and you see some hair growing. You are overjoyed by this new growth and give yourself a pat on the back for a wise decision. Few more months pass by, and you don't really see the results you expected. You talk to your hair transplant physician ( who you now realise is just a general surgeon or not even that) and he reassures you of great results in few months time.

This patient received ' state of the art'  'No stitch No scar' transplant at a leading clinic in New Delhi.
Two years later his whole scalp is scarred, hairline is low and straight and donor area is depleted.

You wait with growing impatience and are then told to go for another procedure to increase the density. You pay again and get a second transplant. This time you see some improvement, but you are still looking 'kind of weird'. And you certainly cant afford a third session that was advised to you.

As time passes you lose some more hair and now the reality of your 'cost effective' transplant is there for all to see. And it is not a pleasant sight. Now you are really concerned  so you start looking for a good hair restoration surgeon. You do your homework, look at doctor's credentials and degrees, look at his results and then get an appointment. It is only now that you understand the full impact of damage done. Most of your donor zone is depleted and even the best plastic and hair transplant surgeon can not do much.

This is a story I hear at least once every day. The real tragedy is not the loss of money but the loss of hair for you and loss of repute for hair transplant procedure. Hair restoration procedure is delicate and highly skilled procedure. And once done, it can not be undone. Take your decision wisely the first time. You may never get a chance again.  Do not be blinded by the discounts and cheap pricing that many clinics are now offering online. Search and research about your surgeon for the success of transplant depends on the surgical team alone.

What is Follicular Unit Extraction and Transplant??

For contemporary hair transplants, there are two basic methods of harvesing donor hair. The conventional strip technique and follicular unit extraction. In Follicular Unit Extraction (FUE) technique donor hair are harvested one by one and is therefore more labour intensive. During this technique a small micropunch usually sized 1mm or smaller is used to isolate a group of hair from its skin attachments. These groups having one to four hair, called follicular units, are then gathered (pulled out) from the head. This leaves a pin point wound from the area of harvest.

In this way the hair are taken out one after another, until adequate number of hair required for that session have been harvested. This surgery is done at a "micro" level and requires 8X magnification and expert hand control. Since FUE procedure requires careful and delicate handling, it is possible to harvest only 1200-1500 follicular units per session. An average session may last 8 hours and may need to be repeated, if balding area or graft requirement is extensive. The donor wounds heal over the next of seven to ten days with barely visible scars. Stiches are not required

In contrast, in FUT (strip) technique all the required hair are removed in one long strip of hair bearing skin. These hair are then isolated from the strip and implanted. To close the gap after strip harvest, stiching is required.

After the grafts are harvested, micro slits are created in the bald area where these follicular units are implanted with help of fine instruments. Once they develop their blood supply they will grow into healthy growing hair. The angulation of hair, density in key areas and hair design remais different from surgeon to surgeon and depends upon his experience and expertise.

At the end of the day the difference is only in harvesting technique, but what a big difference is that.

I will try to post a video of FUE soon and may be a pictorial comparison of two techniques.

Follicular Dissection and Implantation : Video

Follicular unit Harvest as a Strip : Video

Hair Transplant Donor Harvesting & Graft Preparation Techniques Physicia...

Growth after Hair Transplant : What to Expect

What to Expect

Knowledge can prevent unnecessary distress, so it is a good idea to be familiar with natural post operative course of transplanted hair. I have given it in a table form for quick reference, followed by explanation of important points. Remember, everybody is unique and this timeline is just and indicator of average progress. If your experience is a little behind (or ahead) of this timeline, it is still alright.

POST OP DAY	TRANSPLANT AREA	SUTURED AREA (FUHT)	DONOR AREA (FUE)
DAY 1	Stubble like hair, blood and crusting. Decreased sensation	Pain and stretching sensation. Crusting.	Some discomfort. Crusting.
DAY 10	Scabs should be gone. Stubble like hair. Itching.	Some discomfort. Reduced sensation/ Numbness.	Near normal
DAY 15	No scabs. Effluvium begins. Area may feel hard to touch.	Suture removal. Area is hard to touch. May have reduced sensation and/or pain.	Near normal. May be hard to touch.
WEEK 8	All transplanted hair fall. Some redness may persist.	May have reduced sensation. Hard to touch.	Normal. Planning for second session may begin.
MONTH 2-4	Some hair fall from normal non transplant area. (Shock loss)	Near normal
MONTH 3-5	New hair growth begins. They are thin and fine at first.	Near Normal
MONTH 5-9	New hair keep coming out roughly 10-15% per month. Already sprouted hair begin to grow longer.	Near Normal
MONTH 9-10	80% of appearance. Transplant appears thin due to small caliber of new hair. Planning for second session may begin.	Planning for second session may begin. Scalp massage and scalp stretching exercises may commence.
YEAR 1	90% of appearence. Hair shaft continues to grow longer and thicker.
YEAR 2	Final appearence of transplant.

FAQs about Hair Transplant

What is Hair Transplant?

Word "Transplant" can be seen as  made of two  words, Transfer and Implant. So, hair transplant is simply transfer of living hair. These hair can be transplanted in any hairless area such as balding scalp or area of stable scar, eyebrow, moustache etc. Currently, this is the only technique that can give natural, permanent, growing hair in bald area.

Who Needs It?

Hair transplantation is used predominantly to treat the hereditary balding condition known as androgenetic alopecia ( Male pattern baldness). Patients with male pattern hair loss tend to loose hair from the front and top of their head. Since baldness is often ridiculed in society, it can undermine one's confidence and performance, especially if it comes at a young age.

Women with diffuse alopecia, selected patients with burn alopecia, eyebrow and facial hair loss patients are other candidates who can benefit from the procedure.

What Causes Hair Loss?

Although there are many causes of hair loss, the commonest cause is male pattern baldness. this is due to a combination of two factors. First, the hormonal byproduct Di Hydro Testosterone (DHT) and second your hair follicle's susceptibility to DHT, which is genetically determined. Both the factors should be present to cause hair loss.

How is Hair Transplant done?

Patients having baldness still have good density of permanent hair on the sides and back of the head. These good quality hair that naturally last a lifetime, are used to fill up the bald region. The hair are taken out from the scalp one by one (as single units called FUE)  and are implanted individually in the bald area. This highly sophisticated procedure replicates the natural hair growing pattern.

Is There Pain?

Hardly if any at all. I customise local anesthesia solution to gently numbs the area of procedure. You will not feel anything at all. even in post operative phase when anaesthesia effect wears off, only mild painkillers may be required. Some people do not require any painkiller after FUE method.

How Long Will It Take?

Hair transplant is a one day  procedure in office setting. No admission is required. An average surgery of 1500-2000 grafts takes 5-6 hours. Megasessions of 3000 or more grafts may take 8-10 hours. You can go home the same day after procedure.

Are Results Permanent?

Yes. Since transplanted hair come from permanent hair zone (the back and side of scalp) that is unaffected by DHT, these hair do not fall after implantation. They will have same texture, colour, growth and quality as your back hair and the results will last you a lifetime.

Why Shouldn't I go for Artificial Hair?

Entirely too many reasons. The biggest reason that my patients tell me is that they feel artificial. There is always that fear of losing face in public if the hair piece comes off. Then, of course, there is price for maintenance, price for replacement and price for touch ups. After some time the cost of maintaining a good hair piece crosses that of transplant and you still have nothing to show. Last but not the least is health reasons. The glue can cause allergy, the clips can cause headache,even wounds if they are too tight, weaving may pull and damage your existing hair

Can I afford it?

The initial cost of a good hair transplant may be high but it does not require any maintenance. It is a kind of investment that will keep you giving good returns for times to come. An average a transplant session costs 5-7,000 US $ for FUT and 15-20,000 US $ for FUE hair transplants, but it is much cheaper in India.

Cause of Hair Loss

There are many myths in the society regarding hair loss. Reasons from diet to dandruff and change of water to  family stress have been cited as the cause for hair loss. There also have been a lot of research on the cause of baldness. In this post I would like to tell you about real cause of hair loss. It is always an advantage to know your enemy if you want to defeat him. I hope, with this working knowledge you would be able to plan your fight against hair loss in a better way.

 On the basis of cause hair loss or alopecia can be divided into three basic groups

1. Male Pattern or Androgenic alopecia, by far the common balding.
2. Diffuse pattern alopecia usually caused by disease
3. Scarring alopecia where injury to scalp causes hair loss.
   
   
   More than 95% of hair loss in men is due to androgenic alopecia. For androgenic alopecia to occur, three conditions must be met,
   
   
   1.Genetic predisposition to balding:This is not as simple as it sounds. You may have a father with full head and brothers with some baldness but you have a clean pate. The inheritance is usually polygenic, meaning multiple genes and their expressions play a role in development of baldness.
   However, if every man in your family loses hair by thirty, there is a stronger possibility that you will follow suit. Genetic factors are non modifiable. You must live with them.

2. Androgens or Male Hormones: All men and all women (YES!) produce male hormones. These hormones are generated in different quantities in men and women and typically the levels are much higher in males. This is also the reason why patterned baldness is much much more common in males than in females.
The male sex hormone, Testosterone is converted to another product called Di Hydro Testosterone (DHT) which is presently considered the main reason for hair fall. The conversion of Testosterone to DHT is mediated by an enzyme called 5 alpha reductase. DHT progressively destroys the hair root in genetically susceptible hair by a process called “miniaturisation” which leads to baldness.

         3.Time: Time or ageing is the third factor that plays arole in balding process. Nobody           loses hair before puberty (because DHT is not present in the body) but after that, everybody loses some hair. The pace of hair fall vary amongst individuals but it takes approximately 10 hair cycles for a strong anagen hair to become velus hair.

          Although much less important let me discuss other causes of baldness as well. Diffuse thinning of hair may be caused by anemia, thyroid or other hormonal disorder, severe physical stress etc. A rare type of diffuse thinning called diffuse unpatterned alopecia may even involve permanent hair zone.

On the other hand scarring alopecia could be due to injury, burn or skin conditions. Alopecia areata is a rare autoimmune disease in which hair are lost in bunches and body hair may also be involved.I hope it is now clear that change of water, tension and helmets are not the cause of your hair loss. And repeated shaving or oiling is not going to save them either.

Top 5 Hair Loss Myths

When you are suffering from hair loss, every one will offer you an advice or two. From office boy to neighborhood auntie, each can tell you cause and remedy of your hair loss. How they became so knowledgeable is anybody’s guess but here is a list to tell you when they are right and when they are not.

Myth No.1 : Shaving the Head will Prevent Hair Loss

NO! NO! NO! Shaving does not prevent hair fall. Probably the origin of this myth lies in the fact that short stubble feels coarser and is therefore considered made of better quality hair. In fact, it only feels harder because the hair is short and not because hair quality has improved overnight.  

Another contributing factor to the popularity of this myth may be that you stop “seeing” hair loss. After shaving your head, you don’t see hair in your hands or pillow like you used to. This is again because the hair is so short that you don’t notice its fall and not because hair loss has stopped.

Remember, the hair is falling due to hair root injury and shaving can not change this process. Hair fall will continue even if you shave your head hundred times.

Myth No.2 :  Dandruff causes Hair Loss

Again not true. The origin of this myth is the fact that every time you scratch your scalp you get one or two hair in your hands. These are just weak telogen hair that were about to fall any way. Dandruff on the other hand is a surface infection or colonization by a fungus. It happens in oily scalp and is medically treatable. It does not cause any damage to hair roots. Also remember that flaking of dry scalp is different from dandruff and only requires good hair conditioner.

Myth No.3 : Tension causes Hair Loss

False.  I  don’t know where this came from. Severe prolonged stress due to injury or disease can cause telogen effluvium, but day to day stress does not exacerbate hair loss.

Myth No.4 : Helmet or Hat causes Hair Loss

Wrong. Tight helmets or hats may contribute to hair fiber damage, but it does not cause root injury. On the other hand, pulling the hair too hard while wearing a turban or cornrows, can cause permanent hair loss. This is called traction alopecia and requires surgical treatment.

Myth No.5 : Oiling Prevents Hair Loss

Not true. Adequate oil is produced by your scalp to nourish hair roots. In fact, evey hair has its own oil producing gland. If you have very long hair, then putting hair oils may improve the texture, but short hairs do not require oiling. Head massage with oils can relax you but does little for hair growth.

So, what causes hair loss? I shall discuss this in my next blog.

Hair Fall and Stem Cells

There was a very interesting news item in field of hair transplant which I would like to share. This concerns cause of male pattern alopecia.
It is a known fact that in male pattern balding (Androgenetic alopecia), hair follicles don't disappear. They become so small by a process called “miniaturization” that they are not visible to naked eye. Although, we know that DHT is responsible for this process, how exactly it causes miniaturization of hair roots is still not known.

One theory of miniaturization says that DHT causes stem cell depletion in hair follicles of bald areas. A new study, published in the Journal of Clinical Investigation, tries to shed some light on this.  The research team led by Dr. Costarelis, MD collected cell samples from bald and non bald areas from the same persons and counted the number of stem cells present. They were surprised to find that bald areas had the same number of stem cells as hair bearing areas. When they looked further, they found that another cell type, which develops from stem cell, called progenitor cell was deficient in miniaturized follicle.

Dr Costarelis says that, "This implies that there is a problem in the activation of stem cells converting to progenitor cells in bald scalp." As of now, why or what causes the arrest in progression of stem cells to progenitor cells is not known. "However, the fact that there are normal numbers of stem cells in bald scalp gives us hope for reactivating those stem cells," notes Costarelis.
The logical next step would be to identify the factors that arrest this progression and to remove them. A locally applied agent or growth factors that can help stem cells to get converted to progenitor cells would also be very useful.
I have used growth factors injections in some of my patients. The results, especially when used with PRP are good but temporary. The repeated injections overcome the cost benefit. The big break will be an agent that can grow hair permanently. Till then we have hair transplants.

Advantage Follicular Unit Transplant

As I discussed in my last blog, the scalp hair is arranged in distinct anatomical and physiologic units called Follicular units. The knowledge of existence of follicular units have revolutionised the field of hair transplant, so that modern day transplant looks absolutely natural.

These are the advantages of Follicular architecture that we use in modern hair transplant;

Maximizing  growth

The follicular unit is a family. some have only one member while some have more. These members (hairs) of a follicular unit share vital support system. If we remove hair from them, then neither of them grow well. This results in sub optimal growth and inferior result.

 Natural Appearance


Since Follicular unit is a natural phenomenon, transplant done using follicular units looks natural and easily mixes with existing hair. The unnatural clumpy appearance of mini and micrografting is avoided. Since the follicular units are small in size an even density can be provided, mimicking the nature.

Dense Packing

Follicular units are generally prepared under the microscope and therefore it is possible to create trim grafts by removing excess of fat/skin tissue. This trimmed graft takes lesser space as compared to a traditional graft, and so, more grafts can be placed in same area.

Wound Healing and Recovery

Again, since graft size is small we need to make smaller cuts in scalp (to place them). These heal faster than the bigger cuts required for traditional grafting. It also means less pain and lesser chances of nerve damage.

Correction Hair Transplant

This method can be used to correct and improve the hairline and pluggy appearance of a punch or mini/micrograft transplant.

What is a Follicular Unit?

Follicular unit is a natural grouping of one or more hairs in the scalp. Follicular units also contain sebaceous (oil) glands, arrector pili muscle, and nerves and blood vessels. This can be likened to a family of hair. If you separate a person from his/her family, he may survive but will not be happy. These Follicular units terminal (and occasionally a velus) hair are so close together that it is not feasible to separate them, without compromising the growth.

This is how a follicular unit looks like.

On the left is a two hair unit and on the right is a single hair unit.

So, what is advantage of this follicular architecture?? How does this affect your hair transplant?
I shall discuss this in my next blog.

FUE or Strip: Which is Better?

The two most commonly performed procedures for hair transplant currently are Strip method (FUT - Follicular unit transplant) and FUE (Follicular unit extraction). Although FUT is currently most performed procedure, world over, FUE is fast emerging as a method of 1st choice especially when cost is not a constraint. I offer both procedures to almost all my patients who have good donor area and even now, most patients opt for strip method since it is cheaper.

The only difference between FUT & FUE is in harvesting the hair from the donor areas. The method of placement and the final outcome is similar in both methods..

Why FUE?

1. STITCH:

Strip method will always use stitch / staples in the donor area.

Some patients, in spite of the best techniques and educated judgment by the surgeons across the world will encounter problems due to stitches such as foreign body reaction, delayed absorption, suture spitting, stitch abscess etc solely due to presence of stitches. Such complication can then give rise to wide scars. Non Absorbable stitches and staples both need to be removed by 7 to 14 days and patient needs to visit the doctor for that that may add to their expenses and time out of work

FUE does not have stitches and therefore avoids all stitch related complications

2. SCAR:

Strip method will always leave a permanent linear scar in the donor area. This scar, how so ever fine is always visible in a short hair cut and therefore does not allow patient to wear a short hairstyle. Even trichophytic closure can have its own set of problems such as misdirected and ingrown hair.  After multiple sessions, patient will usually have “tram line” scars, tightness of scalp and low hair density leading to “show” of the unsightly scar.

FUE: Although it is known that FUE does leave marks and cumulative scarring is more than that of strip scar for equal number of follicles, it is the position of scar(s) that makes all the difference. I like to call it the stars and the Moon phenomenon. If you combine the brightness of all the stars in the sky the total brightness will be more than a full Moon. But still, you will more often notice a full moon in the sky first. The multiple pin point scars when combined are more than strip but they are so scattered as to be less visible to the eye.

3. PAIN:
 Strip method is painful and patient usually require pain killers for 3-5 days. Some patients cal develop long duration pain or painful scars. . Painful scarring, long term parasthesia or reduced sensation above the linear mark is always more in strip method.

 FUE patients usually have pain free recovery. Some patients may occasionally require painkillers for a day or two. Very rarely, some FUE patient may have hypersensitivity of the donor area but it always involves smaller area as compared to strip method and lasts for a shorter duration.

4. PREVIOUS SURGERIES

Strip method is not suitable for patients having tight scalp due to previous strip procedures or scalp reductions. In such cases, there is always some difficulty in closing the wound after strip removal and there is a high chance that the scar may widen with time.

 FUE does not require donor site closure and is therefore eminently suitable for such cases. In fact, many surgeons including me prefer to do second and third sessions with FUE, especially if the first one was FUT.

 5. SHOCK LOSS
Difficult to assess at this stage. Evidence is missing. FUT is more invasive so, it may cause more shock loss. FUE involves larger area so it may cause more shock loss.

6. SHAVING

Strip method is almost always done without shaving of the entire donor area. The existing hair in the donor area can usually hide the stitch line well.

 FUE requires shaving of the donor area. Theoretically, if small no. of hair are required, one may shave a strip of hair, harvest from it and use existing hair to cover the donor area. This is usually not the case. Shaving is the price, I feel, one should be ready to pay for all other donor site advantages.

7. BODY HAIR TRANSPLANT:

Strip method can not be used for BHT. Total hair supply is restricted to 5000 to 7000 grafts. In patients with advanced stages of baldness (Norwood VI/ VII) where more hair is required, it actually delivers less.

FUE can extend the donor area to body hair. In doing so, a large pool of DHT resistant beard, chest and other hairs become accessible and therefore practically inexhaustible hair supply is available.

8. FOLLICULAR TRANSECTION RATE

Strip method probably has lower transection rate compared to FUE since it is done under vision. However, slivering and cutting which involves major part of procedure is done by trained technicians of different skills and it is not possible for surgeon to inspect and assess each graft prepared by the staff.

FUE harvest is almost always done by surgeon (hence the cost). He can maintain control on the quality of graft. In strip surgery 80% job is done by assistants and 20% by surgeon whereas in case of FUE it is vice versa.

9. HAIR QUALITY:

Strip method has no control over the quality of harvested hair. At a given time 5-15% of hairs on the head are in telogen /  exogen phase. In strip technique, what ever is harvested is grafted, whether it is a good anagen follicle or a poor telogen graft. Moreover, the exact no. of hair harvested is difficult to tell beforehand, and sometimes the surgeon may harvest more or less than the requisite number.

In FUE only good anagen hair are harvested, because every hair is chosen by transplant surgeon. These hair have more chance of robust growth in post operative phase as compared to poor telogen/ exogen hair. Also, the number of hair harvested is exactly the same as no. of hair required.

10. COST AND TIME:

Strip method is relatively faster and cheaper.

FUE usually requires more time. An average surgeon will do 1000-1500 FUEs per day depending upont the expertise of the team. However a single session can go on for 2-3 days or more, depending upon patient requirement.

The cost is usually 2-3 times more than strip method because 1.disposable items ie; FUE punches are costlier, 2. Majority of work is done by highly skilled cosmetic surgeon, 3. Only a limited no. of grafts can be transplanted in a day so operation theatre charges & maintenance cost goes up.

Hair Transplant Basics: Who is the Right Candidate?

Did you know that by the time you start noticing hair loss, approximately 50% of the hair are already gone. So, as soon as you notice hair loss, you should consult a doctor. Remember that consulting a doctor is not same as going for transplant. In early stages of baldness, medicines can help you retain your hair and may postpone the need of transplant. However, medicines can not bring back the lost hair and to grow new hair in a bald area, transplant is the only option..

You should plan a transplant if,

      You have Androgenetic alopecia stage III to stage VII.

      Your hairline is not appropriate for age or you wish to achieve younger looking hair line

      You have burn alopecia or traction alopecia.

      You have eyebrow, eyelash or facial hair loss.

You should wait if,

You are in your teens or early twenties with unstable hair line.

If you have rare genetic conditions like DUPA, extensive alopecia areata etc.

If you are medically unfit for surgery (uncontrolled blood pressure, uncontrolled diabetes, heart failure etc)

Even in these conditions, it is best to consult a qualified plastic and cosmetic surgeon; because he can help you chalk out a plan for future and may offer you alternative therapies. An honest expert advice can save you lot of grief and money.