FUE : The Best Hair Transplant Technique Ever?

FUE is the latest technique in hair restoration nowadays. Many novice clinics and physicians are offering FUE as the most advanced ultimate solution for hair loss. While, there are inherent advantage of FUE, which I have discussed before, proclaiming that FUE is 'always' the best is stretching the truth too far. The procedure has its own set of disadvantages, which must be brought to prospective patient's notice, before mutually deciding upon the technique of restoration.

One problem that FUE holds is the number of grafts that can be harvested in one session of transplant. Although, a larger number of grafts can now be harvested, the number is still not comparable to strip technique. The chief reason for this is technique itself. When performed properly and carefully, FUE is labour and technique intensive, and therefore lesser number of grafts can be harvested. Some clinics have now started using power tools and robots for follicular harvest. The main drawback of such practice is injury to surrounding follicles and high wastage of hair. Contrast this with strip, where larger number of grafts are taken out in same duration, because many qualified technicians can work simultaneously.

Proper Technique of FUE. Note use of small punch, minimal bleeding  and  limited harvest.
Also not that permanent hair zone is not breached.

Scarring is also an oft repeated marketing ploy with "FUE only" clinics. It is claimed as a "No Scar" technique. Rest assured, it is NOT so. Any cut in the skin will cause some scarring. The valid question, therefore, is visibility of scars. Which technique gives less visible scars? Here I agree with FUE proponents, that scars are less visible with short hairs in FUE after one session. On shaving or close trim, these scars can be seen as white dots in the scalp. They appear light colored because of removal of melanin (Hair pigment) and reduced blood supply in that area. After multiple sessions this can cause 'moth eaten' appearance in donor area, especially in dark skinned people.

Poor scarring after FUE.
Two sessions of 2500 FUs done at another clinic using Robotic Hair Transplant.

Some clinics even call FUE as non-surgical technique. This is also a bogus claim, as anesthesia, incision by small punch and physical removal of hair roots with forceps and placement in incisions can not be non surgical. FUE maybe minimally invasive surgery in respect to punch size used but overall invasiveness is only determined by the extent of the procedure and the harvesting protocol. Multiple incisions made on skin during FUE have a ripple effect on the surrounding skin. This can result in abnormal orientation of remaining hair and difficulty in future extraction.

Another common problem with large FUE sessions is that, one has to often go beyond the safe donor zone. By doing so we expose the potentially balding area to scarring. More importantly, one can implant temporary hair in bald areas, which are prone to hair fall in future. An experienced surgeon rarely makes such mistake but a novice may offer you many more grafts than are actually safe, just to seal the deal. Remember, more is not always better in hair transplant.

To summarise, patients should be clear that both strip technique and FUE are credible hair transplant techniques and both give good results when performed properly. Branding one technique as advanced just because its new is dangerous. Both have their pros and cons; and both have their own place in hair restoration.

Finasteride: Myth and Reality

At present Finasteride 1 mg is considered 1st line therapy for androgenic alopecia, the common male pattern baldness. As a hair transplant surgeon I prescribe it to some of my patients who have sufficient amount of hair in balding zone and who do not want another session in near future.

In some of these patients, I have seen strong resistance and bias against Finasteride. This bias, mostly generated through internet 'research', is sometimes so strong that it persists even after thorough counselling. Since it is impossible to give details to every individual in person, I am writing this post.


What is Finasteride?
Finasteride is an enzyme blocker used for Benign Prostatic Hypertrophy in high doses(5mg) and for male pattern baldness in low dosage form (1mg).

How does it work?
Finasteride inhibits type II 5-alpha-reductase, the enzyme that converts testosterone into dihydrotestosterone (DHT), which is responsible for the progressive miniaturization of hair follicles seen in male pattern hair loss.

What is the evidence that it works?
Multiple clinical studies have shown that finasteride 1 mg/day slowed hair loss and
increased hair growth in men with mild to moderate pattern hair loss. Results can be seen in 4 to 6 months.
Long-term studies also revealed that the continuous use of finasteride decreases the likelihood of developing further visible hair loss. Discontinuation of the drug leads to return to pretreatment condition.

For readers who are interested in actual studies, they can be found in medical journals mentioned here.
1. Kaufman KD, Olsen EA, Whiting D, et al (1998) Finasteride in the treatment of men with
androgenetic alopecia. J Am Acad Dermatol 39:578–589
2. Leyden J, Dunlap F, Miller B, et al (1999) Finasteride in the treatment of men with frontal
male pattern hair loss. J Am Acad Dermatol 40:930–937
3. Kaufman KD, Rotonda J, Shah AK, et al (2008) Long term treatment with Finasteride 1 mg
decreases the likelihood of developing further visible hair loss in men with androgenetic
alopecia. Eur J Dermatol 18:400–406
4. Price VH, Menefee E, Sanchez M, et al (2006) Changes in hair weight in men with androgenetic
alopecia after treatment with fi nasteride (1 mg daily): 3- and 4-year results. J Am
Acad Dermatol 55:71–74



Does it work in Asians and Indians?
Among Indians, Finasteride was found to be superior on all measures of efficacy at study conducted in All India Institute of Medical sciences, New Delhi. At the end of 12 month study there was an improvement in hair count and hair growth while reducing the hair fall.
Among Asians a study done on Japanese men with pattern hair loss showed that 1 mg of finasteride taken once daily slowed hair loss and improved hair growth in Japanese men with male pattern hair loss .Similar results were seen among Taiwanese men with male pattern hair loss .

1. Prasad H, Khanna R, Pandhi (2005)   A randomized double blind study of the effect of finasteride on hair growth in male patients of androgenetic alopecia. Indian J Dermatol 2005;50:139-45 
2.Kawashima M, Hayashi N, Igarashi A, et al (2004) Finasteride in the treatment of Japanese
men with male pattern hair loss. Eur J Dermatol 14:247–254
3. Lin JH, Chen WC (2002) Finasteride in the treatment of Taiwanese men with androgenetic
alopecia: a 12-month open-label study. Kaohsiung J Med Sci 18:379–385

What are the side effects?
The only notable side effects in various studies were decreased libido, erectile dysfunction, and breast tenderness. In a long-term efficacy and safety study, 1524 patients treated with Finasteride tablets USP and 1516 patients treated with placebo were evaluated for safety over a period of 4 years. The most frequently reported adverse reactions were related to sexual function. 3.7% (57 patients) treated with Finasteride tablets USP and 2.1% (32 patients) treated with placebo  discontinued therapy as a result of adverse reactions related to sexual function, which are the most frequently reported adverse reactions.
Note: Placebo refers to a sham tablet with no medicine that looks exactly like real medicine. It is used for comparative studies to negate the psychological effects of 'taking a medicine'.

Are these side effects permanent?
 These adverse events were seen only in a very small percentage of patients and were noted to
disappear soon after finasteride was stopped .
It was also noted that side effects also disappeared on continuation of the medicine, so that at 2,3 & 4 years the side effect profile was same in Finasteride and placebo group.

1. Finasteride: Official FDA information


Whatever I have written in this post, is based on published scientific studies. I have tried to be non judgmental and just report the facts. This is in no way an authoritative monograph and, I would be grateful for further words and comments on this topic.

Hair Weaving, Bonding & Extensions

A question frequently asked by my patients is about hair weaving and bonding. Some of them think it is a variety or technique of hair transplant. In fact, it is not. These are just ways to attach artificial non growing hairs or wig to your scalp. This confusion has occurred because clever new age salesmen wanted to overcome the negative connotations that the words "wig" "hairpiece" and "toupee" conjure up in the minds of most men. Instead of calling their products wigs, we now have "hair extensions", "hair weaves" or some kind of fancy "non surgical hair restoration systems".

Listed below is a list of all the different types of wigs with an explanation of each.

Wigs & Toupees

Wigs are artificially arranged animal, human or synthetic hair traditionally used to conceal hair loss . Toupees are similar to wigs meant for a smaller area. The most popular way to attach a wig to the scalp is with tape or glue. The problem is that with perspiration and body heat, this glue melts and the grip of the wig loosens. The wig can come off easily, causing embarrassment and humiliation in public or amongst friends.

Some wigs are firmly held in place by wire loops or clips that pinch the scalp skin. In such situation the chances of wig falling off is reduced. But these clips or wire may cut through the skin causing infection. Also due to constant pressure by clips the hair in that region are destroyed permanently.

A wig is a wig.

The biggest aesthetic problem with a wig is unnatural appearing frontal hair line, which appears too full and too straight, without usual irregularities. If the wig is not color and hair texture matched, then it looks ugly. Another problem is that the sun and water can cause the wig to discolour and become frizzy thus making it stand out from the wearer’s original hair.

Wigs are highly visible and extremely delicate. To keep them looking presentable, they must be of high quality, and be maintained with scrupulous care. Ideally a person would have three wigs, one for wearing while one is being cleaned and a spare for any catastrophe that may occur. The cost of regular replacement is high and hygiene can also be a severe problem.

Hair Weaving

Hair weaving is a technique whereby the wig is attached by weaving wig’s artificial hair with remaining scalp hair. Sometimes, strands or wefts of hair are used for the weave.

The biggest problem with weaving is that the procedure itself causes more hair loss. This permanent hair loss is caused due to pulling of hair roots during retying or tightening of the wig. It also means that as your own hair grows the wig loosens. Therefore retightening needs to be done at least once a month. After about six months a person can begin to lose hair permanently along the stress point where the wig is tied. This is known as traction alopecia.

Hair loss due to weaving

The initial cost of the weave may seem very reasonable, which is a major selling point, but the real expense comes in the monthly visits to have the weave re-tightened, this will add to the cost considerably. Moreover, since these are non-growing hair wear and tear means regular replacement of the hair fibers as well.

Hair Bonding-Fusion

In this technique hair, artificial fiber or dead human hair, is bonded with a glue to your existing hair and scalp. It needs to re-tightened on a regular basis as your own hair grows. Again the initial cost may be comparatively low but you have to continually go back to the clinic to have the hair piece re-glued. Allergy to glue and pull on existing hair roots during combing and styling are other problems.

 Hair Extensions

Hair extensions are used to increase density or provide volume to existing hair. They cannot cover a bald patch and are useful for long hair only. This method is useful for females wanting long thick tresses. Re-tightening and servicing is regularly required.

To summarize, artificial hair is not a good choice health wise or aesthetically. But if one has to resort to it, a customized hair piece should be used. Scalp care should be immaculate to maintain hygiene and health of existing hair.

Stages of Hair Loss

It is a common knowledge that baldness occurs in degrees and is a gradual phenomenon. Since it is not possible to convey the extent of baldness in words, a classification system was developed by Dr. Norwood. This is the most commonly used sytem today, although other more complicated systems are also available.

Broadly speaking, Norwood classification attempts to divide baldness in seven stages with stage I  being normal adult hairline and stage VII being total possible baldness. Although, there are many flaws in this system, it still gives a basic idea regarding the extent of baldness in an individual.

Stage I

Essentially normal adult male hairline (not to be confused with 'juvenile hairline'). Temporal recessions are well defined   with frontal hairline in normal position. No miniaturisation in crown region.

Stage II

The frontal hairline shows slight recession(< 2 cm), with more pronounced recession in temporal area.
The "A" variant implies that hair line is receding uniformly and that frontal forelock is not spared. This means
exaggerated appearance of baldness and larger requirement of hair during transplant.

In this stage hair transplant should be done if the baldness is stable. Usually a single session is adequate.

Many surgeons defer operating in such patients, especially if they are young.

Stage III

This stage can be considered as watershed for transplant, because now the baldness is very obvious
and most transplant surgeons would consider performing a procedure in such patients. There is definite recession
in frontal hairline combined with deep temporal areas and usually thinned out look in most of frontal area.
Crown may also show miniaturisation and/or actual hair loss (Stage III Vertex)

State IV

This is a more advanced state of baldness, in which frontal and frontotemporal recession is deeper than in State III
and the density of hair in these areas is noticeably reduced. As the baldness moves from front to back,
and circumferentially in crown area; a bridge of healthy hair remains in the mid section of scalp.
This area called the 'bridge' is characteristic of stage IV.  Loss of bridge, is seen is considered a feature of
advanced baldness.

Stage V

Area of baldness keeps increasing and thinning of bridge segment is present.

Stage VI

In this stage there is total disappearance of the bridge segment that separates the two main areas of baldness.
The depth of the frontal and crown areas has expanded sideward and backwards.
In some individuals, frontal forelock may be spared to become 'isolated forelock'.

Stage VII

This is the most advanced stage of hair loss. In this stage only the universal safe zone remains.
Hair transplant is useful only in those individuals of stage VII who have good hair characteristics.

Hair transplant is possible from stage II through VII. Advanced stages of baldness usually require more than
one session to achieve maximum benefit.
In selected individuals mega sessions can be planned to cover large areas in one go.

Sanjay Dutt, Kaancha Cheena and Hair Transplant

For those of you who do not know, who Sanjay Dutt is, I can tell that he is a big star in Hindi film industry, has done memorable roles in many movies and has led an eventful life so far.

For those of you who do not know, who Kanch Cheena is, I can tell that I also did not know about it till a short time ago. Now, I know that Kancha Cheena is the name of  principal  negative character of a Hindi movie called Agneepath. To play the character of Kancha Cheena, Sanjay Dutt went bald.

The next logical Q would be, why am I, a cosmetic and hair transplant surgeon, blogging about this?
Well you can see the reason in picture no.1 above........
See that nice 'U' shaped scar on the back of his scalp. That's exactly how a hair transplant scar looks like, when strip method is employed.
Since this scar had piqued my curiosity, I did a little more googling and came up with this.

and this...

Mr. Dutt, Circa 2008

Mr. Dutt, Circa 2010

and..

Mr. Dutt, Circa 2011

I congratulate Mr. Dutt for having the guts to go bald in a country where cosmetic enhancement is a taboo.
 I also hope that his bold step will help to establish the fact that conventional strip procedure is safe, helpful and still in vogue.

Mr. Dutt, Nov 2011