The follicular unit was first defined by Headington in 1984.  He described an FU as consisting of “two to four terminal follicles, and one, or rarely two, vellus follicles, the associated sebaceous lobules, and the insertions of the arrector pili muscles… a single follicular unit is circumscribed by the investing stroma, the perifolliculum.” He went on to say that “the normal density of follicular units is about one per square millimeter.” (1)

In the first paper on follicular unit hair transplantation, published in 1995 (2), Bernstein and Rassman used this definition of Headington.  Limmer, who had been referring to these naturally occurring groups as “stereoscopically assisted micrografts”(3) and Seager, who called them “follicular bundles” (4) soon began to use the term follicular unit as well.

Limmer’s technique of using stereo-microscopic dissection, the backbone of follicular unit transplantation, required expensive equipment, special technical skills and was very labor-intensive.  Because of this and because many doctors at that time did not grasp the importance of microscopic dissection, or of even using follicular units in the hair transplant, other, more easily to perform procedures were being performed.

Surprisingly, due to the increasing power of the internet, follicular unit transplantation became a buzz word in the hair loss chat groups more quickly than it was accepted by their doctors. (5)  This put significant pressure on hair restoration surgeons to learn about the new procedure and adopt its technology.  Although many quickly adapted their practices to perform FUT, others merely changed their marketing – some advertising that they performed follicular unit transplantation, even before buying microscopes.

Partly as a response to the misrepresentation, but mainly to further the science, in 1998, a group of 21 hair transplant surgeons, that included Bob Bernstein, Bill Rassman, David Seager, Ron Shapiro, Jerry Cooley, O’Tar Norwood, Dow Stough, Mike Beehner, Jim Arnold, Bobby Limmer, Marc Avram, Bob McClellan, Paul Rose, Guillermo Blugerman, Marcelo Gandelman, Paul Cotterill, Bob Haber, Roy Jones, Jim Vogel, Ronald Moy and Walter Unger joined forces to write “Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques.” (6)

In their words, the purpose of the publication was to “provide hair restoration surgeons with guidelines to . . .  facilitate communication among physicians, stimulate research, increase the accuracy by which hair transplant procedures can be represented to our patients and, ultimately, improve the quality of the care that we offer them.

In the paper, the following definitions were agreed upon:

Follicular Unit – The follicular unit of the adult human scalp is a naturally occurring entity that consists of 1-4, and occasionally 5, terminal hair follicles, 1, or rarely 2, vellus follicles, the associated sebaceous lobules, the insertions of the arrector pili muscles, its neural and vascular plexuses, and the fine adventitial collagen which surrounds, and defines, the unit (the perifolliculum).

Follicular Unit Graft – A graft that is obtained by dissecting out the individual, naturally occurring follicular unit. This is also referred to as a follicular unit implant, a term which implies that (unlike most grafts) the ratio of hair/skin is greater in the follicular unit implant than in the original donor area, since some of the non-hair bearing tissue has been trimmed away in the dissection.

Micrograft – A 1-2 hair graft. It may consist of naturally occurring one and two-hair follicular units or be derived from larger units which are subdivided.

Minigraft – A 3-6 hair graft derived from either a single follicular unit, multiple follicular units, or multiple, partial follicular units. As suggested by Walter Unger, this may be further classified into small minigrafts of 3-4 hairs, and large minigrafts of 5-6 hairs.

Slit-graft – A 3-6 hair graft derived from either multiple follicular units, or multiple, partial follicular units where the dissection technique specifically attempts to produce a linear arrangement of follicles, or follicular units. This may be further classified into small slit-grafts of 3-4 hairs, and large slit-grafts of 5-6 hairs.

Follicular Unit Dissection – A technique in which naturally occurring, individual follicular units are dissected from donor tissue that has been removed as a single strip (rather than with a multi-bladed knife of more than two blades) in order to keep the follicular units intact. Some non-hair bearing tissue is removed to decrease the overall bulk of the implant. Stereo-microscopic dissection is required.

Mini-Micrografts or Slit-grafts Cut to Size – A dissection technique whereby the donor strip is subdivided to produce grafts of specific sizes as defined by the number of hairs they contain and/or the size of tissue that will fit into a specific recipient site. The removal of excess skin is not required. The dissection can be performed with or without magnification and the donor tissue may be removed as a single strip or with a multi-bladed knife.

Follicular Unit Transplantation – A method of hair restoration surgery where hair is transplanted exclusively in its naturally occurring, individual follicular units. Single strip harvesting and stereo-microscopic dissection are required. The grafts must be placed into small recipient incisions. 

Mini-Micrografting – A method of hair transplantation which uses grafts containing 1-6 hairs, in groups that do not necessarily correspond to the naturally occurring follicular units. The recipient sites may be either incisions, excisions (tissue removed), or both.
Two Terminology Extremes: Science vs. Marketing

Soon after the publication, Seager suggested to add another term, the “Follicular Family Unit.” (7) To paraphrase Dr. Seager:          
When dissecting follicular units, it is sometimes unclear as to which unit a seemingly “stray” hair belongs.  In other words, occasionally it is not completely obvious where one follicular unit ends, and an adjacent one begins. When one is specifically trying to create increased density, a stray hair would be included with an (unusually) close neighboring, larger follicular unit, containing possibly three hairs.  This technique would create a four-haired unit, when there may have been no four-haired units there at all.  One must find two separate units that look close enough to almost “belong together.”  If the two contiguous units are chosen correctly, the resulting unit can be very difficult, sometimes impossible, to distinguish from a naturally occurring follicular unit. 

The key to success in this endeavor is the concept of the “Follicular Family Unit.”  If any (“non-family”) two-follicular units are randomly doubled up, the resulting graft will be more the size of a minigraft, rather than a micrograft.  It would need a larger recipient site, which would preclude dense packing because of both technical planting limitations and impairment of scalp vasculature.  If, on the other hand, despite their larger size, they are forced into minute micrograft-sized recipient sites; they would be traumatized during attempts at insertion.

Although the term “follicular family unit” was introduced to account for the variability in the anatomy of the follicular unit and to take advantage of these variations in the surgery, other terms were not necessarily based on purely scientific considerations.  

A blatant misrepresentation of the term follicular unit was “Follicular Unit Coupling – The Role of Slot Grafting in Hair Transplantation.” (8)  In this case, the author attached the new term to the original slot grafting method.  This was a technique that used slit grafts harvested with a multi-bladed knife and then cut into thin pieces and placed into large slots of skin removed with a rectangular punch.  The term was new and a marketing campaign followed, but the technique was the same as the original one, with no-attempt whatsoever to use, or preserve, follicular units.

Between these extremes, is the ongoing struggle to describe what we do in a clear, precise way – in the face of ever evolving concepts and techniques, and an ever increasing number of terms.  The issue at hand is to be able to distinguish which terms are adding to the science and which are just blurring it. 
Making Sense of the FU Salad

From the opening list of acronyms, all used at the recent ISHRS meeting, it seems that we again need to step back and examine the new terms, to see which represent distinct ideas or techniques and which are, perhaps, redundant.  What follows is a first-pass attempt at sorting out the six terms that, in our opinion, are the most confusing, and have the most overlap. They come in two groups: The first is FU Coupling, FU pairing, Double FUs (DFUs) and Multiple FUs (MFUs). The second group includes FUE and FIT.

With respect to the first group, we think that there are two distinct situations that doctor’s are trying to communicate with these terms. The first is the technique of placing two separately dissected follicular unit grafts into one recipient site.  This is distinct from the commonly used term “Doubling-up” which many doctors have used to refer to placing two micrografts in one site.  Our suggestion is to use the term FU pairing to refer to the technique of placing two separately isolated follicular units into one recipient site.  We suggest discarding the term FU Coupling as it has been incorrectly associated with slit grafting procedures in past literature and its use will be confusing.

The second situation is when a doctor places two (or more) follicular units, that have not been separated in the dissection, into one hole.  In our view, this is clearly not follicular unit transplantation. The reason is that a main advantage of FUT was that in isolating FUs one would remove some of the non-hair bearing skin between FUs, to decrease the bulk of the graft. This, in turn, would allow the doctor to use a smaller recipient site, create less wounding, allow for safely transplanting a larger number of grafts in a single session etc, etc.  Using multiple non-dissected follicular units, in our view, creates a larger wound and accomplishes none of these goals.

We are not suggesting that doctors should abandon this technique. Some excellent surgeons incorporate these grafts into their procedures.  We are merely suggesting that it not be called FUT.  Well then what should one call them?  Our answer is to call them what they have always been called, namely micro-grafts, mini-grafts and slit grafts. If one argues that they are now different due to the use of the stereo-microscope, then we agree.  In this case, the grafts should be called microscopically dissected micro-grafts, mini-grafts and slit grafts, to communicate the fact that follicular transection may be avoided.  But these are still not follicular unit grafts any more than a pedicle flap is follicular unit transplantation.  To avoid confusion, we suggest eliminating the terms DFUs and MFUs.

So what should we call eyebrow transplants? According to the technique used by most hair restoration surgeons, where they divide up the donor strip into single hairs, it should be called one-hair micrografting.  If one uses the contra-lateral eyebrow for donor hair, then this can truly be referred to as FUT.   
FUE and FIT

The increased transection rate of FUE harvesting techniques that use a sharp punch (relative to single-strip harvesting and stereomicroscopic dissection) had some doctors immediately question whether this procedure should be classified as a type of follicular unit transplantation. (9)  With the introduction of the blunt dissection technique by Harris, that significantly decreased damage to follicles and increased the preservation of follicular units, the argument for classifying FUE as a type of FUT is considerably stronger – but certainly not bullet-proof – since in some cases significant transection remains and in others the entire follicular unit cannot be captured. (10)

The Follicular Isolation Technique (FIT), is a term used by Cole and Rose that refers to an FUE technique that uses a punch with a “stop” to limit the depth of penetration. Although these authors and other physicians question the need for a depth-stop in the extraction technique, FIT is possibly a better term than FUE if the entire unit is not being captured.  In our view, when the goal is just to extract hair, rather than intact follicular units, the term FIT is preferable.

Conclusion

In sum, these authors suggest that the following four terms and definitions be added to the original classification.
Follicular Family Unit  Two closely contiguous follicular units that are dissected as one graft, so that they can fit into the same size recipient site as the largest naturally occurring follicular unit normally used in the procedure.

FU pairing  The technique of placing two separately isolated follicular units into one recipient site. 
FUE  Direct donor extraction procedures where the intent is to extract the entire follicular unit. If a depth stop is used, this should be indicated.
FIT  Direct extraction procedures where the intent is to extract individual or multiple hairs smaller than the entire follicular unit. (In other words, the direct extraction of micro-grafts.) If a depth stop is used, this should be indicated.

Micro-grafts, mini-grafts and slit grafts that have been dissected microscopically to prevent follicular transection should be referred to just that, namely: microscopically dissected micro-grafts, mini-grafts and slit grafts.  These authors do not feel that these procedures should be classified as a type of follicular unit transplantation.  We also suggest that the terms FU Coupling, DFUs and MFUs are confusing and should be abandoned. 

References

1.    Headington JT: Transverse microscopic anatomy of the human scalp. Arch Dermatol 1984;120:449-456.
2.    Bernstein RM, Rassman WR, Szaniawski W, Halperin A. Follicular Transplantation.  Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.
3.    Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation. Dermatol Surg 1994;20:789-793.
4.    Seager D. Binocular stereoscopic dissecting microscopes: should we use them? Hair Transplant Forum Int 1996; 6(4): 2-5.
5.    Bernstein RM: Microscopophobia. Hair Transplant Forum International. 1998; 8(5): 23.
6.    Bernstein RM, et al.  Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatol Surg 1998; 24: 957-63.
7.    Seager D. Dense hair transplantation from sparse donor area – introducing the “follicular family unit.” Hair Transplant Forum Intl 1998; 8(1):21-23.
8.    Bernstein RM, Rassman WR, Marritt E, Seager D, et al: A slot by any other name.  Hair Transplant Forum International 1999; 9(6): 175.
9.    Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular Unit Extraction: Minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8): 720-7.
10.    Harris JA. The SAFE System: New Instrumentation and Methodology to Improve Follicular Unit Extraction (FUE). Hair Transplant Forum Intl. 2004; 14(5): 157, 163-4.

Although many technical advances have been made in the field of surgical hair restoration over the past decade, particularly with the widespread adoption of follicular transplantation, many problems remain. The majority revolve around doctors recommending surgery for patients who are not good candidates.  The most common reasons that patients should not proceed with surgery are that they are too young and that their hair loss pattern is too unpredictable.  Young persons also have expectations that are typically too high – often demanding the density and hairline of a teenager. Many people who are in the early stages of hair loss should simply be treated with medications, rather than being rushed to go under the knife.  And some patients are just not mature enough to make level-headed decisions when their problem is so emotional.

In general, the younger the patient, the more cautious the practitioner should be to operate, particularly if the patient has a family history of Norwood Class VII hair loss, or diffuse un-patterned alopecia. 

Problems also occur when the doctor fails to adequately evaluate the patient?s donor hair supply and then does not have enough hair to accomplish the patient?s goals. Careful measurement of a patient?s density and other scalp characteristics will allow the surgeon to know exactly how much hair is available for transplantation and enable him/her to design a pattern for the restoration that can be achieved within those constraints.  

In all of these situations, spending a little extra time listening to the patient?s concerns, examining the patient more carefully and then recommending a treatment plan that is consistent with what actually can be accomplished, will go a long way towards having satisfied patients.  Unfortunately, scientific advances will improve only the technical aspects of the hair restoration process and will do little to insure that the procedure will be performed with the right planning or on the appropriate patient.    

Five-year View

The improvement in surgical techniques that have enabled an ever increasing number of grafts to be placed into ever smaller recipient sites had nearly reached its limit and the limitations of the donor supply remain the major constraint for patients getting back a full head of hair.  Despite the great initial enthusiasm of follicular unit extraction, a technique where hair can be harvested directly from the donor scalp (or even the body) without a linear scar, this procedure has added relatively little towards increasing the patient?s total hair supply available for a transplant. The major breakthrough will come when the donor supply can be expanded though cloning.  Although some recent progress had been made in this area (particularly in animal models) the ability to clone human hair is at least 5 to 10 years away.      

Key Issues

1. The greatest mistake a doctor can make when treating a patient with hair loss is to perform a hair transplant on a person that is too young, as expectations are generally very high and the pattern of future hair loss unpredictable.
2. Chronic sun exposure over one?s lifetime has a much more significant negative impact on the outcome of the hair transplant than peri-operative sun exposure.
3. A bleeding diathesis, significant enough to impact the surgery, can be generally picked up in the patient?s history; however OTC medications often go unreported (such as non-steroidals) and should be asked for specifically.
4. Depression is possibly the most common psychiatric disorder encountered in patient?s seeking hair transplantation, but it is also a common symptom of those persons experiencing hair loss.  The doctor must differentiate between a reasonable emotional response to balding and a depression that requires psychiatric counseling.
5. In performing a hair transplant, the physician must balance the patient?s present and future needs for hair with the present and future availability of the donor supply.  It is well known that one?s balding pattern progresses over time. What is less appreciated is that the donor zone may change as well. 
6. The patient?s donor supply depends upon a number of factors including the physical dimensions of the permanent zone, scalp laxity, donor density, hair characteristics, and most importantly, the degree of miniaturization in the donor area – since this is a window into the future stability of the donor supply.
7. Patients with very loose scalps often heal with widened donor scars.  
8. One should never assume that a person?s hair loss is stable. Hair loss tends to progress over time.  Even patients who show a good response to finasteride will eventually lose more hair.
9. The position of the normal adult male hairline is approximately 1.5 cm above the upper brow crease. Avoid placing the newly transplanted hairline at the adolescent position, rather than one appropriate for an adult.
10. A way to avoid having a hair transplant with a look that is too thin is to limit the extent of coverage to the front and mid-scalp until an adequate donor supply and a limited balding pattern can be reasonably assured – an assurance that can only come after the patient ages.  Until that time, it is best to avoid adding coverage to the crown.

Introduction

Hair Transplantation has been available as a treatment for hair loss for over 40 years. [1]

Through a majority of that time, hair transplantation was characterized by the use of plugs, slit grafts, flaps and mini-micro grafts. Although these were the best tools available to physicians at the time, they were incapable of producing consistently natural results. 

With the introduction of Follicular Unit Transplantation (FUT) in 1995, doctors were finally able to produce these natural results. [2] But the mere capability to produce them did not necessarily ensure that these natural results would actually be achieved. The FUT procedure presented new challenges to the hair restoration surgeon and only when the procedure was properly planned and perfectly executed, would the patient truly benefit from the power of this new technique.[3]

The ability of follicular unit grafts to mimic nature soon produced results that were completely undetectable.  This is the hallmark of Follicular Unit Hair Transplantation. [4] Of equal importance, however, is hair conservation – the one to one correspondence between what is harvested from the donor area and what ultimately grows in the recipient scalp.  Since a finite donor supply is the main constraint in hair transplantation, the preservation of hair is a fundamental aspect of every technique.  However, unlike the older procedures that used large grafts, the delicate follicular units are easily traumatized and very susceptible to desiccation, making follicular unit transplantation procedures, involving thousands of grafts, particularly challenging. [5]      

As of this writing, the vast majority of hair transplants performed in the United States use Follicular Unit Transplant techniques.  Due to limited space, this review will focus on only this technique and not on the older procedures.  Nor will it focus on Follicular Unit Extraction, since this technique is still evolving and the ways to avoid the major pitfalls of this procedure are still being worked out and a subject onto itself.  As the title suggests, this paper will focus on the prevention of the various problems encountered in FUT, rather than its treatment – an equally important subject, but one that has already been covered in an extensive review. [6, 7]

For those not familiar with Follicular Unit Transplantation, there is a concise review of the topic in the dermatology text Surgery of the Skin [8].  For more detailed information, several hair transplant textbooks have sections devoted to this technique. [9, 10]  

The most common types of problems that occur in FUT procedures can be grouped into two broad categories; those involving errors in planning the hair transplant and those caused by errors in surgical technique. Of the two, errors in planning often lead to far more serious consequences for the patient and will be the subject of this paper.   

Patient Selection

Age

The single greatest mistake a doctor can make when treating a patient with hair loss is performing a hair transplant on a person that is too young.  Although, there is no specific age that can serve as a cut off (since this will vary from person to person), understanding the problems associated with performing hair restoration in young persons can help the physician in deciding when surgery may be appropriate.  Getting it wrong can literally ruin a young person?s life.

When someone is beginning to lose hair in their teens or early 20s, there is a significant chance that he (or she) may become extensively bald later in life and that the donor area may eventually thin and become see-through over time.  Although miniaturization (decreased hair shaft diameter) in the donor area is an early sign that this may occur, and can be picked up using densitometry, these changes may not be apparent when a person is still young.    

If a person were to become very bald (become a Norwood Class 6 or a Class 7) then he would often not have enough hair to cover his crown.  A transplanted scalp with a thin or balding crown is a pattern acceptable for an adult, but totally unsuitable for a person in his twenties. [11] In addition, if the donor area were to thin over time, the donor scar might become visible if the hair were worn short – a style that is much more common in people who are young. 

Expectations

This subject is very closely related to age.  For surgical hair restoration to be successful, expectations must match what can actually be accomplished.  The expectations of a young person are usually to return to the look they had as a teenager; namely to have a broad, flat hairline and to have all of the density they had only a few years before.

The problem is that a hair transplant neither creates more hair (and therefore can?t increase overall density) nor prevents further hair loss (so the pattern must be appropriate as the person ages).  But since receded temples and a thin crown is not an acceptable look for a young person, the surgery should best be postponed in a person in whom this is not acceptable. As a person ages, he often becomes more realistic and is happy with what a hair transplant can actually achieve.  And, over time, if a person?s donor area proves to be stable and his hair loss limited, more ambitious goals can be attained.
Chronic Sun Exposure

Although it is common wisdom to avoid sunburns after a hair transplant, in fact, significant chronic sun exposure over one?s lifetime has a much more significant negative impact on the outcome of the hair transplant then peri-operative sun exposure.

Actinic damage alters the collagen and elastic fibers so that the grafts are not grasped as securely and the alteration to the vasculature decreases the ability of the recipient tissue to support the transplantation of a large number of grafts.  Even with the very small recipient sites used in follicular unit transplantation, making sites too close can result in a compromised blood supply and result in poor growth.  

Another issue is that a hair transplant will cover areas of sun damage and make cancer detection more difficult.  When the actinic related growths are finally treated, the involved sections of the hair transplant will be destroyed. 

The best approach in a person with significant sun damage is to first treat the entire scalp aggressively with 5-flurouracil to remove all of the pre-cancerous lesions before hair transplant is contemplated.  One should wait at least 6-12 months after the treatment for the scalp to completely heal, as the tissue will be more friable during this period. Although this treatment can set the surgery back a year or more, it will result in better graft survival and less problems with future skin cancer detection.  

Medical Conditions and Medications

Although not necessarily an absolute contraindication to surgery, a number of medical conditions make the follicular unit hair transplant procedure more problematic and need to be taken into account.  Whenever significant medical conditions are present, it is always prudent to obtain medical clearance from the patient?s primary care physician or appropriate specialist. 

Because the scalp is quite vascular, and FUT procedures involve a large surgical team, patients that are known to have blood born pathogens, such as HIV and Hepatitis B and C, pose some increased risk to the staff, despite the fact that universal precautions are used.  It is useful if the team is aware of the medical histories of hair transplant patients so that they can proceed with a higher degree of alert when necessary. 

In an HIV positive patient, it is important to make certain that the patient?s immune status is adequate, so that the patient does not have a greater risk of infection. In patient?s with Hepatitis, it is important to assess their liver function so that the dosing of medications is appropriate.

Patients with diabetes mellitus may be at greater risk of having a peri-operative infection.  In this case the normal aseptic conditions that most hair transplants are performed under might be changed to a modified sterile technique (modified in that it is difficult to prep the scalp).  This should also be considered in patients with cardiac valvular disease, implanted devices and others in whom bacterial seeding might have more severe consequences.  Antibiotic coverage should also be administered in high risk individuals, although it is not needed in routine hair restoration procedures. [12]

A bleeding diathesis, significant enough to impact the surgery, can be generally picked up in the patient?s history; however medications often go under the radar and should be asked for specifically.  Patient?s often don?t think to report taking aspirin and this must be asked about as well as other non-steroidal anti-inflammatory medications.  Plavix, in particular can significantly increase bleeding during the procedure.  Alcohol, of course increases bleeding as well. [13] 

One should make adjustments in a patient?s anti-coagulant medication in conjunction with his/her cardiologist or regular physician.  As a general rule, one should stop anti-platelet medications one week prior to the hair transplant, but the interval will vary depending upon the specific drug, the size of the procedure, and the importance of the medication to the patient?s health. They can be resumed three days after the procedure. If the anticoagulants cannot be stopped, it may be reasonable to proceed with a smaller session.  

Since epinephrine is used in most hair restoration procedures, if a person has a history of arrhythmias or other cardiac disease that could be exacerbated by epinephrine, medical clearance from the patient?s primary care doctor, or cardiologist, should be obtained.  Epinephrine can also interact with broad-beta blocking agents such as propranolol, causing a hypertensive crisis; therefore, it is best to have the patient switch to a selective beta-blocker for the surgery. [14]

A number of manipulations can be used during the procedure to control bleeding and decrease the need for epinephrine.  Among the most useful, is to scatter the recipient sites broadly over the area to be transplanted (allowing the extrinsic pathway to begin coagulation) and then filling in the areas with additional sites when the bleeding has subsided. [15] 

If patients have a history of seizures, it is important that they do not discontinue their medication for the procedure and that medical clearance is obtained.  One should also remember that otherwise normal patients can have a vaso-vagal episode during the procedure; particularly during the administration of the local anesthetic.  This can be avoided by immediately placing the patient in Trendelenberg as soon as the patient complains of nausea or begins to sweat, or look pale. 

A patient should be monitored with a pulse oximiter if a significant amount of sedatives or other respiratory depressants are used. The patient should be monitored closely to be sure that local anesthetics are administered in safe amounts and that the warning signs of lidocaine overdose are well known to all members of the surgical team. [16] 

Finally, it is helpful to have a pre-printed summary of all the medications and their doses commonly used during the procedure. This can be given to the patient?s regular physician when seeking medical clearance.

Psychological Factors

Hair loss can take a psychological toll on a person?s self-esteem and cause considerable emotional distress.  When a person has underlying psychiatric issues, the impact can be more severe and, therefore, management of hair loss considerably more difficult.  It is important to identify these problems as well as other psychological factors that may play a role in a patient?s ability to clearly understand both the hair restoration process and its anticipated outcome.

In some cases, counseling can be done in conjunction with hair restoration, but often it should precede treatment, especially when surgery is contemplated.  It is prudent to obtain clearance for surgery from a psychiatrist or clinical psychologist when there is a history of mental illness, or when it is suspected at the time of the consultation.

A number of psychiatric conditions are particularly relevant to the successful outcome of a hair transplant.  These include Trichotillomania, Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Syndrome (BDS), and Depression.

Trichotillomania is a relatively common condition characterized by the persistent urge to pull out one?s hair.  It most commonly involves scalp hair, but can also involve the eyelashes, facial hair or other body hair.  It often results in bald patches and can be identified by short hairs in the affected area that are not long enough to grasp.  Active trichitollomania on any part of the body is an obvious contraindication to a hair transplant, but if a person has a history of this condition, the doctor should also be cautious and only consider surgery if the therapist is confident that the condition has little chance of recurring. 

Obsessive-compulsive disorder (OCD) is a condition characterized by recurrent, intrusive thoughts (obsessions) and related behaviors (compulsions) which attempt to neutralize the anxiety or stress caused by the obsessions.  In consultation, the OCD patient often asks a litany of questions and often asks the next question before listening to the answer to previous one.  OCD patients are extremely difficult to satisfy and even in a very successful hair transplant can focus on a minor imperfection seeming oblivious to the good overall result.  

Body dysmorphic disorder (BDD) is a mental disorder that involves a distorted image of one?s body. The person is extremely critical of their physical self, despite the fact there may be no actual defect.  It should be obvious that patients with BDD will not be satisfied with a hair transplant, or other forms of cosmetic procedures, and the condition is best treated by a psychiatrist rather than a surgeon.  Another note of caution is that patients with BDD have a much higher suicide rate than the general population, even greater than patients with depression. [17]   

Depression is possibly the most common psychiatric disorder encountered in patient?s seeking hair transplantation, but it is also a common symptom of those experiencing hair loss.  The doctor must differentiate between a reasonable emotional response to balding and a depression that requires psychiatric counseling.  It is important to realize that a hair transplant will be ineffective in curing a medical depression and unfulfilled expectations may lead to a worsening of the condition.
References

1. Orentreich N: Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479, 1959.
2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.
3. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84.
4. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99.
5. Gandelman M, et al: Light and electron microscopic analysis of controlled injury to follicular unit grafts. Dermatol Surg 2000; 26(1): 31.\
6. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part I: Basic repair strategies. Dermatol Surg 2002; 28(9): 783-94.
7. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part II: The tactics of repair. Dermatol Surg 2002; 28(10): 873-93.
8. Bernstein RM, Follicular Unit Hair Transplantation. In: Robinson JK, Hanke CW, Siegel DM, Sengelmann RD, editors: Surgery of the Skin, Elsevier Mosby, London UK. 2005.
9. Unger WP, Shapiro R. Hair Transplantation. New York: Marcel Dekker, Inc. 2004.
10. Bernstein RM, Rassman, WR. Follicular Unit Transplantation. In: Haber RS, Stough DB, editors: Hair Transplantation, Chapter 12. Elsevier Saunders, 2006: 91-97.
11. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365.
12. Haas AF, Grekin RC: Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol 1995; 32: 155-76.
13. Otley CC. Perioperative evaluation and management in dermatologic surgery. J Am Acad Dermatol 2006; 54: 119-27.
14. Gandelman M, Bellio R, Barretto M: Beta-blockers and local anesthetics with vasoconstrictors: A dangerous association. Intl J Aesthetic Restorative Surgery 1995; 3 (2): 143-45.
15. Bernstein RM, Rassman WR: Limiting epinephrine in large hair transplant sessions. Hair Transplant Forum International 2000; 10(2): 39-42.
16. Skidmore RA, Patterson JD, Tomsick, RS: Local anesthetics. Dermatol Surg 1996; 22:511-522.
17. Phillips KA, Menard W: Suicidality in body dysmorphic disorder: A prospective study.  Am J Psychiatry, 2006; 163:1280-82. 
18. Bernstein RM, Rassman WR. The scalp laxity paradox. Hair Transplant Forum International 2002; 12(1): 9-10.

Densitometry is a technique that analyzes the scalp under high-power magnification to give information on hair density, follicular unit composition and degree of miniaturization. It can be used to help evaluate a patient’s candidacy for hair transplantation and help predict future hair loss. More recently, video-microscopes have been developed that can project the image onto a computer screen and provide a permanent digital record. This paper describes the value of taking objective measurements, using densitometry or video-microscopy, in the hair transplant evaluation.

Background

One of the earliest methods of measuring hair density was devised by Bouhanna, who used camera attachments to create a “phototrichogram,” an ultra close-up photograph of hair exiting the scalp. This method provided the capability to document the quality and quantity of hair shafts.  However, the disadvantage of this innovation was that an assessment could not be done until after the film had been developed. [1]

In 1993, Rassman introduced a small hand-held instrument, the Hair Densitometer, to make densitometry easy to perform during a consultation. [2, 3].  The hair densitometer is a self-contained, portable, device that houses a magnifying lens and an opening of predetermined size.  The hair is clipped short (~ 1-mm) and the unit is placed directly on the scalp.  An assessment is made from a standard 10mm2 field.  Multiple measurements taken from different parts of the scalp are often helpful, particularly if there is significant variability from one location to another. [4] An advantage of the hand-held densitometer is that it is inexpensive and readily available to be used during the consultation and can provide immediate information regarding a patient’s candidacy for surgery.  

A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler. With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7]

The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10]. The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss. [10-12]

A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler.  With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] [Figure 2]

The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10].  The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss.  [10-12]   

Miniaturization

Normally, follicular units contain 1-4 terminal hairs of uniform diameter and, occasionally, fine vellous hairs, with the two hair populations being clinically distinct.   In androgenetic hair loss, the action of DHT causes individual terminal hairs in some follicular units to miniaturize, where they begin to decrease in diameter and in length until they resemble vellous hairs. Eventually, these hairs will disappear.  In androgenetic alopecia, hairs in varying stages of involution (and thus of varying diameters) cause these two distinct populations of hairs to merge into one continuum.  The changes eventually cause visible thinning in affected areas, but may initially be detectable only through densitometry.

At first, miniaturization involves only one or two hairs in select follicular units, but eventually progresses to involve all the hair follicles in genetically susceptible areas.  It has been the observation of these authors that a shift from focal to generalized miniaturization precedes the actual loss of affected hairs, so that total hair counts remain relatively constant until end-stage baldness. [8]  Said another way, the progressive thinning associated with androgenetic hair loss (particularly in the early stages) is caused by a decrease in the hair shaft diameter of an increasingly larger number of hairs, rather than by the actual loss of individual hair follicles.

Miniaturization, unfortunately, can also occur in the back and sides of the scalp.  When it affects a person’s donor area, it will have profound implications for surgery. Although miniaturization in the donor area is a relatively uncommon occurrence in men, it is quite common in women, explaining why so many more men with hair loss are candidates for surgery compared to women.  In all cases, donor miniaturization must be assessed prior to considering surgery.

Densitometry Measurements

Densitometry is extremely helpful in evaluating patients for hair transplantation. When determining which persons are candidates for hair transplantation, it can be used to measure the absolute donor hair density (i.e. # of hairs/mm2), the composition of follicular units (i.e. the number of 1-, 2-, 3- and 4-hair units), and the degree of miniaturization.

Although the precise hair density and composition of follicular units will not be known until after the donor strip has been completely dissected, at the time of the consultation, densitometry can tell the doctor the approximate hair density. This will enable him to determine how much hair will be obtained from a certain size strip or how large a strip will be needed for a required number of follicular unit grafts.  

Densitometry will also give information regarding the cosmetic impact of the hair restoration.  Other hair characteristics being equal, if a person has a high number of 3- and 4-hair grafts, he/she would be expected to have a fuller hair transplant than a person with predominately 1- and 2-hair follicular units. 

For example, a typical Caucasian would have follicular units in his/her donor area that contained, on average, 2.25 hairs each.  If there were 1 follicular unit per mm2 in the donor area (0.9 to 1.0 is normal) then one would need 2,500mm2 of donor tissue for a 2,500 graft procedure. A donor strip that was 1cm wide would need to be approximately 25cm long to contain 2,500 follicular unit grafts.  See the following table.

Stereo-microscopic dissection of the donor strip would yield approximately 14% 1-hair grafts, 53% 2-hair grafts and 33% 3- and 4-hair grafts.  The single-hair grafts would be used to create a soft, natural frontal hairline and the 3- and 4-hair grafts would be used in the forelock area to create the appearance of central density. 

Small variations in follicular unit density can have a significant impact on the procedure. A person of similar hair shaft characteristics (i.e. hair diameter, color and wave) that had 2.0 hairs per follicular unit, also spaced 1mm apart, would require exactly the same size strip for a 2,500 graft procedure.  In this case, however, the follicular units would, on average, have less cosmetic value and the person should expect a thinner look from the surgery as only 17% of the grafts contain 3- or 4- hairs.  In addition, the ability to create central density via graft sorting would be reduced.  On the other hand, with a donor density of 2.4 hairs per unit, 40% of the grafts will contain 3- or 4-hairs and the ability of the surgeon to create density in the forelock area using only naturally occurring follicular unit will be significant

If we look at the total number of hairs contained in the follicular units, we note that for a 2,500 graft procedure, a person with 2.4 hairs per follicular unit will have 1,000 more hairs than a person with a density of 2.0.

Densitometry, therefore, gives the physician information regarding the number of single hair units that can be anticipated from a given size donor strip (without having to subdivide larger units) and the degree to which the larger follicular units can create central and forward weighting to enhance the aesthetic impact of the procedure. 

Donor Miniaturization 

Normally, the donor area shows little or no miniaturization and the density counts described above are useful in predicting both the short- and long-term outcome of the procedure.  However, if genetic hair loss affects the donor area, the situation changes dramatically. Once full-thickness terminal hair begins to miniaturize, the cosmetic value of the follicular unit begins to decrease and the value of the grafts will be diminished.  In other words, just because hair is transplanted, it doesn’t make the hair transplant   permanent – the hair in the donor area must be permanent.     

Early detection of miniaturization in the donor area is a warning sign that the donor area is not stable and that the person may not be a good candidate for surgical hair restoration.   If any miniaturization is detected in a young person, i.e. under the age of 25, red flags should go up that their donor area may not be stable.  When miniaturization is noted in a teenager, the risk of developing diffuse un-patterned hair loss (see below) is significant.  In an older adult male, some miniaturization, perhaps up to 20%, is consistent with being a good surgical candidate. 

Unlike men, adult women often have significant levels of miniaturization in the donor area, so the mere presence of miniaturization is not necessarily a contraindication to surgery.  However, miniaturization does indicate an unstable donor supply and one has to make a judgment regarding the risk/reward of the procedure. The physician needs to consider the absolute number of full terminal hairs that are available for the hair transplant, the risk of further miniaturization, the area that needs to be covered, and the risk of the surgery accelerating the hair loss.  This is particularly important to consider in women, since hair is often transplanted into an area that has a considerable amount of existing hair – some of which is at risk of being shed from the surgery. 

In women, when the risk of continued miniaturization of the donor area is added to the risk of the surgery accelerating hair loss in the area to be transplanted, a far fewer percentage of women are good candidates for surgery compared to men. To think otherwise is disingenuous. 
Diffuse Patterned and Un-patterned Alopecia

The importance of donor miniaturization as a factor affecting a person’s candidacy for a hair transplant was emphasized almost a decade ago in the paper “Follicular Transplantation: Patient Evaluation and Surgical Planning.”[4] In this writing, we described two conditions; “Diffuse Patterned Alopecia” (DPA) and “Diffuse Un-patterned Alopecia” (DUPA). These were first mentioned by O’tar Norwood when he devised the classification of androgenetic alopeica that bears his name.  These two conditions, however, were not detailed in his paper and never received much attention. This was unfortunate because their understanding gives important insights into how to determine who will be a candidate for hair restoration surgery. [5]

Diffuse Patterned Alopecia (DPA) is characterized by diffuse thinning (miniaturization) in the front, top, and vertex of the scalp in conjunction with a stable permanent zone. DPA is usually associated with the persistence of the frontal hairline and, in the early stages, the thinning is relatively even across the top of the scalp. This contrasts with regular Norwood patients that have early hair loss at the temples and in the crown with balding that spares the top of the scalp. Patients with DPA can be good candidates for hair transplantation due to their stable permanent zone; however, they have an increase risk of shedding after the hair transplant, due to the diffuse miniaturization across the top of the scalp.  

In the less common Diffuse Un-patterned Alopecia (DUPA), the miniaturization process occurs over the entire scalp, so that the person lacks a stable permanent zone. People with DUPA tend to lose their hair at an early age, often beginning in their teens. In the early stages, there may be only a slight suggestion of decreased hair volume overall and actual thinning may only be noted through densitometry. Over time, the back and sides of the scalp can take on a transparent appearance, particularly when the hair is cut short. Because the donor area is not permanent, hair transplantation is contra-indicated in patients with Diffuse Un-patterned Alopecia.   

Although fully manifest diffuse un-patterned hair loss is relatively uncommon in men, there are many younger patients who have slightly increased degrees of miniaturization in the back and sides of the scalp, making the long-term stability of the donor area questionable. In these patients, the decision to recommend hair restoration surgery is particularly difficult.  As a general rule, if the decision is difficult, it is best postponed, since, over time, the stability of the donor area will become more obvious.  A mistake can leave the patient with transplanted hair that will thin over time and a donor scar(s) that may become visible.

Both Diffuse Patterned and Un-patterned alopecia also occur in women. However, in contrast to men, the DUPA pattern in women is much more common, possibly occurring 10 times as frequently as DPA.  As in men, female patients with DUPA are not good candidates for a transplant, except in the instance where the goal is solely to soften the frontal edge of a hairpiece. The high incidence of Diffuse Un-patterned Alopecia in women partly explains why many fewer women are good candidates for hair transplantation as compared to men. 

It is important to emphasize that other, non-genetic, causes of hair loss must be considered in cases where the balding pattern is diffuse.  These include anemia, thyroid disease, connective tissue disease, gynecological conditions, severe emotional events, and medications. Although the presence of miniaturization likely points toward a hereditary cause of the hair loss, with diffuse hair loss other etiologies must always be entertained.

Conclusion

Densitometry is an important tool for the evaluation of hair loss and for assessing candidacy for hair transplantation.  Measuring donor density and assessing the degree of miniaturization in the donor area should be an integral part of the evaluation of every patient in which surgical hair restoration is considered. This will enable physicians to better select those who are good candidates for a hair transplant and help identify those patients in whom the procedure is contraindicated.  For patients having a hair transplant, these measurements will enable the physician to better estimate the size of the donor strip and be better able to anticipate the aesthetic outcome of the hair restoration procedure.  

References

1. Bouhanna P: Phototrichogram: a technique for the objective evaluation of the diagnosis and course of diffuse alopecia. In W Montagna et al. (eds). Hair and Aesthetic Medicine. Roma, Salus Ed. 1983: 277-280.

2. Rassman WR, Pomerantz, MA. The art and science of mini-grafting. Int J Aesthet Rest Surg 1993; 1:27-36.

3. Rassman WR, Carson S. Micro-grafting in extensive quantities; the ideal hair restoration procedure.  Dermatol Surg 1995; 21:306-311.

4. Bernstein RM, Rassman WR, Seager D, Shapiro R, et al.  Standardizing the classification and description of follicular unit transplantation and mini-micro-grafting techniques. Dermatol Surg 1998; 24: 957-63.

5. Stough DB, Haber RS. Hair Replacement: Surgical and Medical. St. Louis: Mosby-Year Book, Inc., 1996: 139-140.

6. Van Neste D, Dumortier M, De Coster W: Phototrichogram analysis: technical aspects and problems in relation to automated quantitative evaluation of hair growth by computer assisted image analysis. In Van Neste D, Lachapelle JM, Antoine JL (eds). Trends in Human Hair Growth and Alopecia Research. Dordrecht, Kluwer Acad. Pub, 1989: 155-165.

7. Hayashi S, Hiyamoto I, Takeda K: Measurement of human hair growth by optical microscopy and image analysis. Br J Dermatol 1991; 125:123-129.

8. Bernstein RM , Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32.

9. Bernstein RM, Rassman WR: The logic of follicular unit transplantation. Dermatologic Clinics 1999; 17 (2): 277-95.

10. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84.

11. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99.

12. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365.

Most post hair transplant patients may undergo a scar revision procedure which is the correction or minimizing of the scar that was left in the donor area after a hair transplant by strip procedure. Patients are made aware prior that there will be a scar at the end of the procedure but there are options and ways to minimize its visibility. A few may include surgical techniques like trichophytic closure, follicular unit extraction, or even through Botox injectable treatment.

The most common and simplest way to correct most donor scars is by removing the scar tissue and reclosing the affected area. This alone can help minimize its visibility. On top of that, the surgeon may also opt to use trichophytic closure which is a technique used to allow hair follicles to grow into the scar area further minimizing its visibility.

Follicular unit extraction (FUE) is the process in which hair graft follicles are selectively extracted from the donor area without removing a strip of tissue. This process can also be used to fill in the donor scar. This will then further minimize its visibility or make nearly impossible to see the original scar.

In a recent study, some hair transplant surgeons have began applying Botox injections around the scar area after a procedure to help prevent excess stretching which may help prevent the scar from widening or over stretching. Not all surgeons practice this technique and there is no exact recommendation on the amount of Botox units to be used. The practicing surgeon is solely responsible for the amount of treatment that may be applied and should be kept within safe practice standards at all times.

Scars may take as long as 6 or more months to fully mature or heal. This time issue limits how soon a surgeon can begin any type of scar revision. It is recommended that patients and surgeons wait a minimum of 6 months (maturation period) after hair transplant surgery to even consider surgical scar revision.

We’ve discussed this topic in our other blogs but considering the amount of attention from a number of patients we saw it fit to talk about the subject once more. Truth of the matter is we cannot comment on who the best hair transplant surgeon is. That is a decision one has to make for themselves. Many patients confuse quality of work with cost of work and that kind of mentality may lead to a regrettable situation. Being in Southern California, it would be unfair and hard to say who the best hair transplant surgeon in Southern California is. Here are a few suggestions to help demystify the process of selecting the best hair transplant surgeon for you.

In larger metropolitan cities like Los Angeles or Orange County, searching for the right hair transplant surgeon can be a tedious job. Consider the large network of plastic and cosmetic surgeons and you soon realize the possible referral choices. Regarding hair restoration, this branch of surgery is relatively new and continues to change based on new findings and method application. This however can help predetermine who may be a more likely surgeon since you can base it on their technique and level of expertise.

Your rapport with your hair transplant surgeon is an important one. Get to know your possible surgeon prior to doing any surgical procedure so you may know and understand them better. You can truly appreciate a good technique from a knowledgeable doctor when you see one. Most surgeons offer a free initial consultation and are open to scrutinizing.

On that same note, be sure to do research on your hair transplant surgeon as well as the services and techniques applied. Most locations, like ours, specialize in state-of-the-art FUT (follicular unit transplant) procedure, mega session work for patients with extensive hair loss, and FUE (follicular unit extraction) procedure. FUE is the minimally invasive procedure designed to minimize or completely avoid an unsightly scar by selectively extracting hair grafts from the donor area.

All doctors practice differently and we’ve seen results from a variety of surgeons. Many are notable and others are regrettable. Modern hair restoration technique is in high demand and keeps growing in most major metropolitan areas like Los Angeles and Orange County. To close, we high suggest that anyone considering hair restoration surgery to get educated about hair restoration first and meet with a hair transplant surgeon with a list of questions you want answered personally. In the end you should be able to trust your surgeon and feel comfortable about your choice in the.

Patients considering hair restoration surgery will have a number of questions and concerns that they will want answered. A patient of ours considering hairline lowering brought up a few that saw noteworthy:

How do I know if I am a good hair transplant candidate? Is there any possibility the hair will fall off and affect my regular hair to fall off as well? Do I have to stay home after the surgery? Is there any adverse side effect caused by this type of surgery to the rest of my body or health?

Good hair transplant candidacy is based on the severity of their miniaturization or thinning of hair. Most female patients experience significant miniaturization of the hair shafts making them an unlikely candidate for hair restoration surgery. As long as the donor area shows minimal miniaturization of the hair shafts, hair restoration and / or hairline lowering is possible.

Patients with some degree of miniaturization may experience what is known as shock loss or loss of native hair after hair restoration surgery. This is due to the interruption of the surrounding hair during surgery but the effects are only temporary. The hairs lost will recover their normal growth cycle and will grow back in time. This statement does not always apply since not all patients even with some level of miniaturization do not lose their hair to shock loss.

This type of procedure is considered minimally invasive and patients can go back home the same day. Most patients can return to their normal daily routines and almost all patients recover at about the same rate. Medication is provided for take home treatment to speed up recovery time and to control swelling and redness. This surgical procedure can be easily concealed through practical means (change of hair style, make up, hat, etc.) and should not impede you from leaving home at all.

The only real adverse effect hair restoration has on any patient is that of temporary swelling and redness on the recipient area. Hair transplantation does not affect the rest of the body in any negative way. The only other concern would be based on any allergic reaction to the medications used during and after surgery. Be sure to inform you hair transplant surgeon of any medical condition and allergic reactions to medications prior to your surgery. Some facilities will provide a complimentary lunch the day of surgery so food allergies must be reported as well. Above all, hair restoration surgery is minimally invasive and any negative effects to the body are very unlikely to happen.

As hair loss problems are being faced by a substantial number of people, especially males, in the UK, FUE hair transplant as a therapy is fast gaining prominence. Its popularity is further boosted by the number of hair clinics that has come up in notable cities of the country providing professional help to avert and overcome this problem.

As claimed by trained professionals in the field, FUE hair transplant is the safest and the fastest way to acquire healthy hair and avoid baldness. This problem is often overlooked as shedding hair is a natural process and 100 shafts of hair are estimated to fall off naturally. If left untreated over a long period of time, the problem continues to grow, thereby, resulting in partial or complete baldness.

Since there are many reasons for hair fall like illness, side effects of drugs or chemicals used for a long period of time and hormonal changes, it is necessary to first detect the cause as FUE Hair transplant can be prescribed once the problem area is pointed out clearly.

Moreover, surgeons carry out thorough examination before they decide that a patient needs to undergo hair transplant. This is the reason why they suggest a graft calculation prior to a FUE hair transplant as the availability of grafts is crucial for the successful transplanting method.

In the hands of experienced surgeons, anyone can be assured of a satisfactory FUE hair transplant. That’s why, it’s best to avail the services of reputed hair replacement clinics in the UK. Not only they are known for their varied services and well trained staff, but they are the best places to turn to if one does not want the money to go waste or reel under the hazards of an improper hair transplant.

Usually, FUE hair transplant is safe and has no side effects. Surgeons use modern technology and surgical tools in the process, thereby, replacing the age old strip method. The follicle extraction as well as implantation is harmless and painless. The healing takes place within 7 days with absolutely no side effects. The result – new and healthy hair growth in the balding areas in a natural way.

However, care should be taken once the FUE Hair Transplant is done to maximise the benefits. Taking proper care of oneself and acting according to the suggestions provided by the surgeons is a must post the hair transplant session. Taking antibiotics or pain killers as prescribed, using medicated shampoos and keeping the scalp clean are some of the precautions that need to be taken to benefit from a FUE hair transplant.

At our Orange County Hair Transplant Clinic, we received an email from a patient who already had a hair transplant from another clinic. He writes: “I received hair restoration surgery… and my hair never grew in the area and I followed all the directions carefully.” He then asks, “Is there any other solutions to bring back my hair?”

Hair transplant surgery can seem as a simple procedure but there are certain factors that can cause suboptimal growth of newly transplanted hair. It is OK for any patient who is considering or has had a hair transplant procedure to be concerned about the survival of their newly transplanted hair. These issues can be categorized into two factors:

Technical Problems Patient Factor

Both can potentially determine what the outcome of your hair transplant procedure will be.

Technical Issues

Problems during hair graft preparation and handling: During the preparation phase of hair grafts, an inexperienced technician may unintentionally manipulate hair grafts more than what they can tolerate. The most common effect is damage to the proliferated follicle cells during graft slivering, harvesting or implanting which can or will cause the hair not to grow. Problems with graft maintenance: Once the hair is removed from the body the follicles should be kept in a physiological solution suitable for their survival until the time they are placed in their new location. The solution should be kept at 0 – 4 degrees centigrade to prolong the longevity of the follicular cells and slowdown the cell’s metabolism. Implantation phase complications: If the hair graft sites are too tight, technicians may unintentionally manipulate the hair graft’s physical attributes too much and affect the final potential of the hair cells growth.

Patient Factor

Patient factor can be attested to either intentional or unintentional damaged caused by the patient or sometimes by a hair transplant surgeon’s negligence. Certain skin conditions can result in the loss or complete damage to the newly transplanted hair grafts. Some examples include Alopecia Areata (AA) or Alopecia Cicatricial (AC) as well as others medical conditions. In some cases these conditions may have already been present prior to the transplant or became present afterward. This is why all hair transplant surgeons must raise particular questions in regards to family history of hair loss. If there is no known history of hair loss or the patient is experiencing atypical male pattern baldness a biopsy can easily determine their condition. Come conditions can be easily determined by means of microscopic and macroscopic scalp and hair evaluation. Post operative hair transplant care plays a very important role in the final results of any hair transplant procedure. Physical trauma to the newly transplanted hair and other forms of hair trauma include pulling out or scratching newly transplanted hair and may cause you to lose your newly transplanted hair. In psychological conditions like Trichotillomania in which the patient pulls out their own hair it is best to see a psychologist to help you correct these types of issues.

Results are usually more evident after about one year so we recommend having your hair reevaluated by a good hair transplant surgeon if there is any doubt. Once a reevaluation is completed your hair transplant surgeon can help you treat the disorder that caused your less than desirable growth results and even tell you what may have caused your condition.

US Hair Restoration Weblog posted the original blog titled Unsuccessful Hair Transplant