Hair Restoration Blog

Innovation in Chronic Wound Healing

A new study on hair transplant in chronic wound healing brings new hope for many patients who suffer from non-healing or delayed healing wounds.  The study was conducted by my friend Dr. Francisco Jiménez in Spain. In this research, Dr. Jiménez and his colleague evaluate the effect of hair transplant grafts on improved healing of chronic wounds.

Area reduction in experimental group (black line) that received hair transplant into their ulcers vs. the control group (red line)

The study is based on the fact that epidermal sheets from the hair follicle may help in re-epithelialization of the wound bed.  The investigators reported that healing of chronic wounds progresses faster in skin where healthy hair follicles exist.

This may be explained by the fact that hair follicles are full of progenitor cells (cells that can transform to other types).  In this study 10 patients with chronic wounds (ulcers) of about 36 cm².  Most wounds were present without complete healing for about 10 years. The researchers implanted 20 hair grafts in an area of 2×2 centimeter.  They also used a similar square of non grafted area as control.

After evaluation of the wound in those two areas it was readily apparent that the area receiving hair implants healed much faster at the 18-week end point.  In this particular case the transplanted area of wound (ulcer) healed significantly better than non transplanted area (27.1% vs. 6.5% ulcer area reduction).  The maximum healing has been noted to be 33.5% vs. 9.7% (transplanted vs. control group) reduction at week four.  In further microscopic evaluation, the investigators noted an increase in several wound healing elements such as epithelialization, neovascularization, and dermal reorganization.

This study demonstrates the amazing role of hair follicle grafting into wound that do not heal normally due to a variety of different causes.  The process of transplanting the wound with hair grafts can be done as an outpatient procedure. This new procedure could improve the life style of many people while reducing the financial burden of treating chronic wounds for the society.

Reference:

Jiménez F et al. A pilot clinical study of hair grafting in chronic leg ulcers, Wound Repair Regen. 2012 Nov-Dec;20(6):806-14

Q:

I had a hair transplant in past and planning to have another one. Part of the scar from the first procedure is often visible on the right side of the back of my head even when my hair is pretty long. It’s just a small section, but during the second procedure would it be possible to minimize its visibility further by transplanting a small amount of hair into that area (not sure if this is safe or not if the grafts are being removed from a nearby area) or through other means?

Stretched Hair Transplant Scar

A:

In order to minimize the visibility, we will do a double-edge trichophytic closure on the donor scar. We generally have more flexibility with our trichophytic closure during the second procedure due to the fact that we now know how aggressive we should be in bringing hair into the scar. The second time around, we know how your body scars and can anticipate what kind of stretching will occur. Going further, in the future we can place hair into the scar if needed with filling the scar with FUE transplant or even use SMP (scalp micropigmentation), which will minimize the visibility of the scar by placing pigments in it. Everything discussed above will be addressed in the future if necessary.  Whether to use FUE or SMP to minimize the visibility of hair transplant scar is discussed in another blog post.

Q:

Dear Dr Mohebi,

I had a couple of hair transplant surgeries (FUT) in the past (about 12 years ago), and would like to do another surgery now. I have a question regarding the scar line in the back of my head. I obviously have a line now, but what I need to know is if you can use my current scar line as a part of your transplanted hair area, or if you would create a new scar line if I do another surgery? In other words, does a patient like me (who had surgeries before) end up with a new scar line, or does the new line overlap and cover the old line?

A:

Thanks for your question. The old linear hair transplant donor scar should be included in the new strip. That means you should end up with only one scar after your repeat hair transplants. We also perform trichophytic closure whenever we can in strip hair transplant surgeries to help hair grow inside the donor scar. This method allows some hair appear inside the final scar and make the final donor scar blend in with the surrounding skin when the scars matures. If your previous hair transplants were done many years in the past, it is likely that you have not received trichophytic closure. That means the final scar could be even improved comparing to what you currently have. Obviously, there are more individual factors involved in the process of wound healing and scar formation and we cannot always predict the final outcome. However we attempt to minimize the visibility of the hair transplant scar in repeat hair restorations whenever possible.

Parsa Mohebi, MD 

Since the advent of hair transplant surgery, hair transplant surgeons have been challenged to address the scarring that is inevitable from the donor wound in strip hair transplants. Other types of scalp surgeries such as neurological surgeries can also leave linear type scars in the scalp.

In addition trauma to the head can leave a person with unwanted scar.  A patient’s natural hair coverage can obscure the visibility of a scar in most cases.  However, proximity to a patient’s hairline and or wearing the hair too short can make a scar more obvious.

A hair transplant surgeon can easily repair or camouflage most scalp scars.  The variations in a scar shape, location and size are key factors affecting the techniques that a surgeon will use in the revisioning of the scar. The singular and most important purpose of the scar revisioning is to obscure or minimize its appearance to the naked eye. Scar revisioning is not merely cosmetic. Disfigurement from scarring often affects a person’s sense of well being and self worth.  Do to the inherent nature of the work they do cosmetic surgeons are at the forefront of minimizing the appearance of scars. We have developed an algorithm utilized in hair restoration and other surgical cosmetic practices that effectively meets the challenge of scarring from these procedures. Many of the same techniques are also employed in addressing scalp scarring from trauma and scalp surgical procedures.

Medical excellence is predicated on examination. Physically examining the scar is essential in determining what proportion of scar visibility is due to stretching, hypertrophic reaction and or hair transaction.

A scar that is wider than expected gives evidence that some level of stretching has occurred. Skin that is stretched typically has a contrasting color to neighboring skin. Minimizing this contrast is one of the key approaches to reducing this type of scar. Hair transplant surgeon can reduce the contrast by bringing hair inside the scar by a variety of techniques to minimize the contrast between the hair bearing scalp and non-hair bearing scar. That is done through placing  follicular unit grafts with FUE procedure or by performing trichophytic closure on one or both edges of a scalp scar.  Many people may need more than one hair transplant into their scalp to improve the reduction in visibility of the scar.

Every cosmetic surgeon should be familiar and knowledgeable about the cosmetic products or non-medical methods that could be used to improve scars. When managing a scalp scar, we always consider and discuss with the patients the role of a variety of techniques that might be used solely or in conjunction with surgical procedures for further improving appearance of scars. Some of these are; microfibers, foundations, and coloring agents for skin and hair or tattooing of scalp.

If you are suffering from a scalp scar, you need to find a good hair transplant surgeon with plenty of experience with treatment of scalp scars.  A simple consultation would make the overall plan clear.  The plan may include a surgical procedure, using cosmetics for hair and scalp and hair style changes.

Often times we at US Hair Restoration receive questions about the difference between the FUT Strip Method and the FUE procedure. Some will make claims that one option is superior, while the other is inferior. Both hair transplant techniques are done in US Hair Restoration and have their own adavntages and disadvantages.  Here is a list of reasons supporting both the strengths and weaknesses of the FUT Strip Method and the FUE:

The FUT Strip Method

• Allows the hair transplant surgeon to transplant a larger number of grafts in one session. Most people who have never had a hair transplant surgery can have maximum results in only one procedure.

• Allows the surgeon(s) to process and harvest the grafts under a microscope minimizing the level of damaged hair follicles.

•  Can be achieved at a more rapid speed than the FUE.

• What can be achieved in one FUT strip procedure can take 2-3 FUE surgeries.

• The number of damaged grafts might be greater for certain patients which undergo the FUE procedure because of their unique hair characteristics. People with wavy or   curly hair may have a higher risk of transection than patients with straight hair. A FOX test may be performed on patients with curly hair or wavy hair to determine whether or not they make good candidates for an FUE procedure. A FOX test is a small FUE procedure which helps to determine the level of damage to follicular graft before proceeding with a complete FUE transplantation procedure.

• The FUE requires more tedious labor and the cost for performing an FUE is usually more than a strip hair transplant.

• FUE procedures require a highly skilled operator and create a technical challenge for less experienced technicians who don’t have good hand-eye coordination.

The majority of the patients which receive a hair transplant with the strip method are going to have a linear scar on their donor area.  This scar can be minimized with certain surgical techniques such as the trichophytic closure, but it can never completely be eliminated. FUE hair transplant procedures offer unique advantages for differing patient circumstances.

FUE Procedure

• The scar visibility is slightly noticeable to completely non-existent with the FUE.  It may leave some miniature spots because of a lack of hair in that particular area or de-pigmentation, like a small dot which is lighter when seen close up.

• Hair can be kept short after the Hair Transplant surgery in front and back.  Any types of spots or de-pigmentation are not easily detectable.

• There is minimal pain for most patients and they don’t need pain killers after their hair transplantation.

• The surgeon can get donor hair from different parts of the body which the strip method has limited areas to take from. Areas such as the temples, beard and other body hair is included in this.

• The surgeon can choose the specific type of grafts to harvest.  When a special type of follicular unit is needed, this option is very good because the surgeon can choose the exact number of specific grafts to transplant. This is great for touch up work on the frontal hairline which needs single hair grafts, or for filling an isolated crown balding spot that does not require any singles.

• The contrast between high hair density and bald areas can be decreased by the FUE. Restoring hair in a scar only needs hair added to the scar, and the FUE would help to minimize the contrast between the scar and the surrounding areas more easily.

Despite of all above advantages and disadvantages about the two methods discussing them with a good hair transplant surgeon is a good starting point to find out what it the best option for you.

Q:

Is my donor area thick enough and did I have any signs of miniaturization there? Most men I have seen that are bald on top have a much thicker back area of their hair that is not affected by mpb than I do. From your experience and knowledge is it good enough not only to be used as a donor now, but also in the future if I need to cover crown or do any other procedure. It seems to me that my hair is too thin in the back to conceal a scar and that it might possibly thin out a lot when im older. But I’m not a professional so please give me your opinion and insight. The scars all look thin enough for contentment but its when you dont have hair growing around it making it look like someone scrapped a bald line in the back of your head with a hair cutting tool.

A:

When I reviewed your microscopic exam I found it to shows you have only 10% miniaturization in that particular area.  Less than 20% hair miniaturization measurement is within normal range for someone with male pattern baldness (MPB). As we discussed before, if you keep your hair the same length as during your consultation, you should not be able to see the scar. We perform double edged trichophytic closure for most patients which minimizes the visibility of a scar even when you decide to keep your hair very short.

Laxometer II

Often times we receive inquiries at US Hair Restoration about the latest hair transplant technology, and we feel obligated to spread the news about the latest hair transplant technology.  We are excited about the new generation of Laxometer, the newest hair transplant device invented by Dr. Parsa Mohebi. The Laxometer II is a handheld device which revolutionizes the art and science of hair restoration. Being in the growing sector of the cosmetic surgery arena, progressive updates on hair transplant new technology is critical.

Applications

The revolutionary Laxometer II increases the number of hair grafts which can safely and precisely be transplanted in one surgery. A hair transplant of more than 3500 hair grafts once upon a time took two or more surgeries to complete, but with this latest technology in hair transplantation, it can be done in only one procedure.

The Laxometer II, the new technology in the hair transplant industry, is basically a measuring device which is used to calculate the laxity of one’s scalp. An accurate measurement of scalp laxity is critical when determining how large the donor strip can be. This latest breakthrough hair transplant technology gives a precise measurement which can be increased as a result of patients actively doing daily scalp exercises. The larger the available strip, the more grafts can be made available for transplantation.

At the International Society of Hair Restoration Surgery’s 19th Annual Scientific meeting in Alaska in September 2011, Dr. Mohebi unveiled his new invention for purchase to all hair transplant surgeons. This latest technology in hair transplant surgery was welcomed with anticipation and applause as it will help to continue the industry progressing forward.

Here is a video demostration of the Laxometer work: Laxometer Instructional Video

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.

Faculties: Drs. Suddleson, Mohebi and Perez in OLSW-17

Orlando Live Surgical Workshop (OLSW 17) of International society of hair restoration surgery (ISHRS) was held one more time in beautiful city of Orlando last month.  Hair transplant surgeons participated from different parts of the world.  We had many great lectures from the leaders of hair restoration surgery to cover basic information about hair restoration methods for new hair transplant surgeons and to refresh and update the more experienced ones.

We had lectures every morning and in the afternoon went to surgery center for hands on procedures to teach the techniques of hair transplant surgery.  I have to congratulate the the whole staff involved with this workshop for the great work they have done this year, coordinating a large group of doctors from all over the world and putting together a great set of lectures to cover a wide variety of subjects about modern hair restoration procedures and medical treatments.

Dr. Mohebi and Dr. Leavitt in OLSW-17

We had lectures about new methods of hair restoration surgery such as robotic hair transplant surgery.   The most updates on robotic surgery was shown to the audience.  There is a hope that the practical model of robotic hair restoration be available within a few months.

There is a woman behind every successful EVENT - Dr. Mohebi and Valarie Montalbano

I had two lectures that were both emphasizing on the techniques of removal of follicular units in hair transplants with large number of grafts using Laxometer.  I also demonstrated the applications of Laxometer in sequential strip removal techniques in live surgical workshop.

Technician training: Patrick Tafoya teaching hair transplant technicians

My second lecture was on Scalp Scars and the methods to revise them.  The lecture was focused on making surgeons more familiar with the proper techniques of scar revision and indications of each particular technique.

I went over trichophytic closure methods for a variety of different scars.  I discussed the implications of Follicular Unit Extraction (FUE) to revise scalp scars.  I presented a variety of several scalp scars treated with FUE methods.  I went over the pros and cons of FUE to revise scalp scar and provided a guideline that hair transplant surgeons can decide what method should be used for each type of scar.

Q:

I had a hair transplant back on October 31, 2009. I started getting red boils along my transplanted area (suspected to be folliculitis) in January and I have been taking Accutane for the last complete month.

My question to you is, why did it happen? Was it due to infected surgical equipment used in the surgery? I was advised to get such a heavy drug which has effected the overall tone of my face somewhat like getting severe dryness. Lastly, sir what do u think there are few patches in the infected area who are now like bald patches. Do you have any suggestions or medicine for the future?

A:

Pimple-like scalp lesions that develop after hair transplant surgery are typically folliculitis.

Folliculitis can typically be seen after hair transplant surgery in both the implanted and donor wound areas in the few weeks to month after hair transplant.

The development mechanism of folliculitis is similar to acnea.  It is usually due to blockage in the exit pores of the sebaceous gland (skin oil glands).  Following obstruction of those pores that can occur after hair transplant surgery, sebum (skin oil) cannot be emptied to the skin surface and instead begins accumulating underneath the skin surface.  The result is red or white head-like pimples.

Recovery is generally spontaneous. Although, if too many of these lesions develop, or if there was any sign of secondary infection (i.e.- redness or swelling around the area), the lesions may need to be drained by your physician and the patient may occasionally be recommended to use antibiotics.

Thanks to the generous vascular supply of scalp skin, the infection of scalp skin after hair transplant surgery is extremely rare.