Q:

Hello,
I wanted to get more information like FUE transplantation vs. strip hair transplant. I have been doing a lot of reading. How do you know if one is best and using a FOX test? I like the idea of the FUE but hear many claims that it is not good. However, I am not a big fan of getting a piece of my skin taken off. There is so much different information. Also all the normal questions that come with the procedure. I hope to hear from you.

Thank you for taking the time to read this,

A:

That is a great question! I realize that there is a large amount of conflicting information on the Internet, especially relating to new technology and surgical techniques.

Follicular Unit Extraction (FUE) is a method we use to remove hair follicular units individually rather than taking a strip of the scalp and dissecting it into follicular units.

Simply looking at the facts, there are many hair restoration centers which may market one method as being supperior to the other for the cold truth they are capable of performing it. They may lean towards recommending one particular procedure over the other for money making purposes.

If performed correctly, the FUE transplantation is a great solution for some hair loss sufferers, especially those with minimum hair loss or those avoiding a scar on their scalp. We also use FUE for people who suffer from significant pain or donor complications with previous strip procedure, and those with a violated donor area for which removing more hair through strip is impossible.

With that said, most hair transplant surgeries are done through the strip method for many reasons:

• Strip hair transplantation gives liberty to the surgeon to maximize the quality and viability of the hair follicles. We anticipate some number between 1-5% as the highest for a trans-section of hair follicles (damaged follicles) in microscopic strip hair transplantation. This rate of success is because all the grafts are  harvested under 3-D magnifications using stereotactic microscopes.
• In FUE cases, patients may have a high trans-section rate and some of the transplanted hair may never grow into healthy hair. The trans-section rate might be very low in most people, with an average of 0 to 10%. However, in some people it might be significantly higher based on the hair’s characteristics. The  FOX test is a procedure that should be done for some patients with curly or wavy hair.  The FOX test can determine the patients who are not good candidates for an FUE procedure. It is basically a small FUE transplant that determines the levels of a trans-section to the hair follicles in the process of extracting them.
• In an FUE transplantation, we may harvest up to 1500  in one session. Sessions larger than that keep hair grafts outside the body for a long period of time that may jeopardize the grafts’ survival.
• Today, we have many methods, such as trichophytic closure to minimize the visibility of the hair transplant donor scar in strip methods.
• The cost of FUE is higher since it is more labor intensive and requires more specialized artistic skill.

If you are considering to have a FUE transplant, I highly recommend having an evaluation by a hair transplant surgeon who is skilled in both FUE transplantation and strip method before you decide which procedure is right for you. A qualified hair transplant surgeon can discuss all your options so you can make an informed decision about how to restore your hiar.

Turban Alopeica due to chronic use of turban and knotting hiar - Bottom: hair line design before hair transplant surgery

Turban Alopecia is a type of traction alopecia that is seen in people who wear tight turbans, such as Sikhs.  Turban Alopecia can also occur as a result of knotting and braiding long hair which results in hair being pulled continuously for long periods of time.  This can cause hair loss with the same mechanism as many other types of traction alopecia – chronic pull on hair follicles can destroy them permanently.

Prognosis of Turban Alopecia is similar to other types of traction alopecia.  It might be reversible to some degree only in some patients.  However, if re-growth is not seen after a year of stopping the use of the turban and tight hair braiding, it is unlikely that new growth will occur at all, leaving the affected areas of the scalp with permanent hair loss.

Turban Alopecia is generally seen in the frontal area of the scalp and in some cases in temple areas.  Those are the areas that are directly affected by the traction effect of the turban and hair braiding.  (This could be seen in most members of a Sikh family.)  Unlike the more common androgentic alopecia, which is a genetic predisposition to hair loss, Turban Alopecia is not genetic, but being predisposed to familial male patterned baldness is an accelerator factor and can cause occurrence of male patterned hair loss prematurely.

The risk of traction alopecia in Turban Alopecia type could be reduced by not knotting or braiding the hair and by wearing turbans more loosely. But for those who have experienced permanent hair loss due to Turban Alopecia, there is a natural and proven treatment option available through surgical hair transplantation. (It will be important to control hair braiding and tight turbans following hair transplantation to insure continued hair growth in these areas.)

Also see: Hair loss for cap

Q:

Dear Dr. Mohebi -

There is an article in the LA times about a doctor practicing in LA who treats women’s pattern hair loss by injection of progesterone into the scalp, as well as prescribing Finasteride and applying minoxidil-plus solution onto the scalp.

As an expert in the field, I appreciate your opinion about this hormonal method of hair loss treatment.

Thank you.

____________________

A:

Thank you for your question and your kind words. Although there are many practices regarding the treatment of female pattern hair loss, we try to remain evidence based in our recommendations. This means that we only use treatments and methods that are proven to work through scientific studies or peer reviewed publications.

There is no proof that the injection of progesterone to the scalp can treat typical female pattern hair loss. Minoxidil is a known hair loss medication that can help women who have significant miniaturization (thinning of hair shafts) experience some increased density (thickening of hair shafts). Candidacy of the patients needs to be determined by a doctor after microscopic evaluation of the scalp before starting on minoxidil.

Finasteride should only be prescribed to women who are not pregnant or planning on becoming pregnant, and are losing their hair in a “male pattern” due to increased levels of testosterone, due to a variety of potential factors. This needs to be tested and documented before starting a woman on finasteride. I should mention that finasteride is FDA approved under the name Propecia as a potential treatment for certain types of hair loss in men, not women.

Some doctors may use different methods of hair loss treatment. They may also promote themselves and their “innovative methods” in the media and on the internet. That does not make their case any stronger or provide a shred of evidence that their treatment methods will work. We are in an era of evidence based medicine, and the research, history, safety and potential treatment benefits are readily avilable to everyone.

I strongly encourage everyone to agree to treatment recommendations accepted and practiced by the medical society through scientific research or those through published peer reviewed journals.

Hair restoration surgery is a blending of science, skill and artistry. But there is also a mathematical component to this equation that can help us better understand what it is we’re seeing, experiencing and can expect from hair loss and hair restoration. So here’s a little information that puts numbered averages to the process.

On average, Caucasians and some African-Americans are born with around 100,000 hairs. This number may be slightly lower in Asians and Hispanics and slightly higher in those of Middle Eastern descent. The density of hair varies throughout the scalp, but in the donor area (in the back and sides) hair density averages around 2 hairs per square millimeter.

On average, people do not notice that they are losing their hair until they’ve lost around 30% of their overall hair density on any area. However, they have to lose more than 70% to look bald. The maximum hair density one should expect from a (“strip method FUT”) hair transplant procedure is about 40% of original density, which is quite good. Hair loss need, continued loss of native hairs, surgical technique, surgical skill, donor area quality and availability will all play a factor in this as well.

With a qualified surgeon and staff and good donor quality, “giga-session” procedures of 3,500 and more grafts can be transplanted in a single (“strip method”) surgery, when appropriate and warranted. These giga-sessions can translate over 10,000 hair follicles.

Follicular Unit Extraction (“FUE”) procedures are much more labor intensive and require a great deal more surgical time than strip method procedures. The maximum number of grafts, on average, per procedure utilizing FUE techniques is from 1,500 to 2,000 in each session. Patients who need larger number of grafts need to undergo more than one session of hair restoration.

Although the vast majority of men and women who undergo modern day surgical hair restoration are completely satisfied with the results, with theaesthetic and emotional benefits far exceeding their initial desires, it’s important to understand that there are limits to what hair transplantation can do. And for each patient, there are unique variables that play a major role in the outcome.

> Hair loss (androgenetic alopecia) is a progressive, ongoing genetic disorder that first manifests itself as thinning hair and ultimately results in hair loss, in those pre-determined hair follicles effected.

> You should never expect to retain the same hair density or the same hair line placement you had as a teenager, nor should you want to. Hairlines and overall hair density evolve as we age.

> You may have already lost up to 70% of your hair density before you’ve even realized your hair was thinning.

> Hair transplantation simply relocates natural hairs, it does not produce new hair.

> Hair transplantation does not stop affected native hair from thinning and future loss. The transplanted hairs are permanent, as they are genetically different from the thinning hairs, but hairs that are pre-disposed to thinning and loss will continue on that course.

> If warranted, in addition to hair transplant surgery to replace lost hairs, your physician may recommend finasteride or minoxidil in an effort to stabilize existing thinning hairs.

> Since beauty is in the eye of the beholder, and hair loss is progressive, somewhere down the road, you may elect a second hair transplant procedure to help you achieve your hair restoration goals.

Here are some factors that directly impact surgical results and should be considered when setting realistic expectations:

1) The ratio of supply (donor hair) and demand (area of hair thinning and loss). In essence, the more significant the hair loss and/or the larger area of scalp affected by hair loss, the more donor hair required. Hair density following one surgical procedure will be based on limits to donor hair extraction.

2) The caliber (diameter) of each hair shaft. Thicker hair will provide greater coverage and volume than fine hair.

3) The body of hair. Curly or wavy hair tends to create greater coverage than straight hair, resulting in greater hair density.

4) The contrast between the scalp and the hair. Hair density, or at least the perception of greater hair density, increases as the contrast (or visibility) of the scalp through the hair diminishes. For patients with dark hair and a light scalp, this contrast is greater, giving the appearance of thinner hair, or less hair density.

5) The density of the donor area. The donor area is the source of the hairs utilized in surgical hair transplantation. The greater the natural donor hair density (hairs per square millimeter), the more available donor hairs for possible future procedures.

6) Scalp elasticity. Mega-session and giga-session hair transplant procedures are becoming more common. For a surgeon to safely perform a procedure of this size (4,000 to 5,000 grafts or more), there has to be a need for it, the donor area has to have sufficient density, AND the scalp has to have enough elasticity to accommodate the donor removal, allowing the surgeon to close the area safely, leaving nothing more than an undetectable scar.

7) Future thinning and loss. Unless a patient is a Class 7, having lost most of the hairs in the affected area, it’s important to anticipate future, continued loss and recession. A secondary procedure and/or the use of finasteride or minoxidil may be recommended to achieve the hair restoration objective.

It’s important to review all available information, to make an informed decision. And when considering hair transplant surgery, or any surgery for that matter, it’s good to remember that the most critical decision is the surgeon himself… his training, his artistry, his skill, his compassion, his surgical techniques, his results.

If you are looking for answers to hair loss and are considering hair transplant surgery, we encourage you to visit a good hair transplant surgeon. In the right hands, you too can experience the life-changing benefit of hair transplantation, exceeding all of your expectations.

Hi, doctor. I’m a 38 year old man who’s been losing hair for a few years. I’ve lost a lot… to the point of balding on top and in front. I’ve asked my hairstylist for advice, and she recommended Nioxxin shampoo. It didn’t do anything. I then asked my doctor, and he referred me to a dermatologist who talked about steroid injections in my scalp! then I keep reading about hair transplant surgery. It sounds like it works. But if a hair transplant really is the right solution, why didn’t my stylist and doctor recommend it? Can you explain this or at least help me understand?

Thanks.

_____

A:

This is a very good question. Thanks for asking. First… hair restoration surgery is the only proven, permanent and natural treatment for androgenetic alopecia, the most common cause of hair loss in men. And when performed by a skilled hair restoration surgeon, the results are amazing.

Hair restoration surgery has evolved over the past twenty years, with the most dramatic changes taking place within the past five years alone. The most important advancements are in the dissection and placement of hair grafts (removing individual hair follicles utilizing state-of-the-art microscopic equipment then implanting these follicles in a perfectly natural growth pattern) and in the “size” of surgical procedures today (with “Giga-Sessions” transplanting up to 5,000 grafts or more, when safe and appropriate).

Many hair stylists and even physicians are still unaware of modern-day hair transplantation and what it can do for their clients and patients suffering from hair loss. We, at US Hair Restoration, continue to educate the public, hair stylists and physicians on the art and science of hair transplantation today. We invite hair stylists and physicians to contact us for information, to witness a live surgery and to see the life-changing results just months post-op. We encourage hair stylists and physicians to learn all they can to better serve their clients and patients.

When it comes to “hair” and hair loss, hair stylists are generally the first professional we see and ask for guidance. This summer, we are launching our most aggressive education campaign yet, reaching out to LA’s top hair stylists. We believe our message will be heard.

Thanks again for your question. And for you personally, if you are experiencing hair loss and want to know the best possible treatment option for you, I encourage you to meet with a qualified hair transplant surgeon. You’ll be glad you did.