Hair Restoration Blog

Hi Doctor,

My son has had a hair transplant years ago with old techniques and he has bad hair transplant scar now. He now wants to shave his head, but the scar of hair transplant on the back of his head may become exposed. Do you perform hair transplant scar repair or do you recommend any procedure that can help with hair transplant donor scar coverage?

Answer:

Hair transplant with strip technique can cause a linear scar that could be visible on the back of head if the patient wants to shave his/her head. A hair transplant scar is not limited to a bad hair transplant technique and it might have to do with one’s personal healing process too (some people are generally better healers compared to the others).

The good news is that we have methods to minimize the size of the scars nowadays and if you have bad hair transplant scars from bad transplants in the past, there are several new methods that can help improving the appearance of the donor scar. A hair transplant scar could be improved by repair of linear widened scars with different methods that we perform at our Los Angeles office of US Hair Restoration. Dr. Mohebi is the inventor of the axometer, a device that measure the laxity of the scalp precisely before hair transplant surgeries. Good measurement of the scalp laxity is one of the best ways to minimize development of donor wound complications and widening of donor scar and the Laxometer is the device to do these measurements.

One method is through simply excising the scar. Excision of the donor scar may be helpful for some donor scars. After removing the scar, hair transplant surgeon can close the skin with the trichophytic closure method in which a small wedge on one or both sides of the skin edge is removed and the skin is closed primarily. Trichophytic closure allows some hair follicles to grow new hair into the final scar. Presence of hair helps making the hair transplant scar become invisible.

Hair transplant donor scar coverage could also be performed by transplanting hair into the scar. Hair could be harvested from other areas using FUE or mini-strip techniques. Again, presence of the hair inside scarred area could trick the discriminating eye and the scar would become less detectable. Patients may need more than one hair transplant procedure into the donor scar for minimizing the difference between the densities of hair in scar and surrounding areas.

The last method that could be used to camouflage the linear scar is by tattooing the scar. People who plan to keep the hair very short can easily tattoo the scar with the figures of short hairs so it seems that there are some hairs present in the scar area, which can help minimizing the visibility of the scar.

Mega session hair transplant surgery has been around for almost a decade since Dr. Rassman and others started doing bigger and bigger sessions. Before 1993 all could be done was less than 1000 and occasionally 1500 grafts per each session. Using newer techniques and larger team of experienced technicians, we at US Hair Restoration are currently performing large sessions on a regular basis.

Not all physician teams are equal. If a doctor routinely performs sessions in over 2500 graft size, then it would be safe to assume that this doctor has mastered the skills required for large session. Unfortunately, not all doctors have either the teams or the skills to accomplish the feat on a routine basis. Limiting the size of the session to under 2000 grafts, it may take more surgical sessions to accomplish the same goal as when twice the number is transplanted.

Many factors should come together for a megasession hair transplant surgery. First, the surgical team must be trained in doing large sessions with fast, efficient cutting and placing. The following points must be available for the surgery to be successful. The sessions should not take more than eight to ten hours, for more than that, the grafts that are out of the body awaiting placement produces reduced graft growth. Hair transplant surgeon should keep a larger team of technicians to help reducing the time of surgery.

The surgeon must know the nuances of prolonged anesthesia without increasing the risks to the patient. The patient’s scalp laxity must be very loose so that a wide strip can be taken safely (often these strips measure greater than 2cm in width and 22cm in length). The patient’s density must be high (50% higher than normal densities). Large sessions might carry increased risk of swelling and redness after surgery, but overall are not more risky than smaller sessions, but the above criteria must be bet or the yield would not be there. At US Hair Restoration, we offer megasessions to patients with extensive baldness with good donor quality with excellent results.

hey doctor!

As I read through forums and articles, people mention that propecia works better in conjunction with something else, such as rogaine for exmaple. At the moment, the vertex area of my scalp seems emptier than than the crown and minoxidil works well with the vertex. Do you recommend me go back on minoxidil for the vertex, or should I just focus on propecia?

Answer:
I generally prescribe finasteride to most of my patients who have significant miniaturization whether they are getting hair transplants or not. There are several studies on using Rogaine (minoxidil) and Propecia (finasteride) as single therapy and in combination with each other or with other medications.

Comparing minoxidil and finasteride for treatment of male pattern baldness clearly shows that treatment with only finasteride is more effective than treatment with only minoxidil. Combination of finasteride with minoxidil and with some other medications shows improved outcome, but the rate of improvement is not significant enough that I can convince myself to prescribe combination therapy to all my patients for the rest of their lives, considering difficulty of using topical minoxidil (topical spreading of medication twice a day on the balding area of scalp).

If you want to do everything possible to prevent or slow down further hair loss and maybe grow some, you can consider combination therapy, but remember when you start minoxidil you are committed to continue it for the rest of your life or until there are better alternatives.

I just received the last issue of the Hair Transplant Forum International, the Journal of International Society of Hair Restoration Surgery (ISHRS). Our article, Psychology of Hair Transplant‚ is published as the cover article on this issue of the journal. I also have a copy of the article in our hair loss library in our website. Here is the abstract:

Psychology of Hair Transplant

Parsa Mohebi, M.D., William Rassman, M.D.

Balding and its psychological impacts has been the subject of many studies in the past. The relationship between hair loss and stress is clear to all clinicians who practice in this field. Negative psychosocial impacts of hair loss in male patterned baldness and in women with generalized thinning have also been seen. Many of us (hair transplant surgeons) have seen the negative effects of hair loss on self esteem and self-image.

We know that hair loss impacts some men sex life and their stability with regard to career choices in men of different ages. Despite the solid evidences and published literature on psychological impact of hair loss, the corrective effect of medical and surgical hair restoration has never been studied. After observing the drastic changes in patient behavior and the high level of patient satisfaction in those who had hair transplant procedure, we were motivated to look into the psychological impact of hair restoration on different aspects of a patient’s life.

We came up with a series of criteria that could have been modified by having a hair restoration procedure; we used some indexes that were previously studied comparing bald and non bald men on different psychological variables. We initially performed a pilot study and asked patients about different aspects of their lives during their post op visits. We gave our patients open ended questionnaires and probed their psychological state after their hair restoration procedure was complete. Eventually we focused in on eight major criteria that have been reported and documented as variables associated with hair loss in the literature. We collected a subset of them in our pilot study. Included were questions on the general level of happiness, energy level, feeling of youthfulness, anxiety levels, self confidence, outlook on their future and impact on their sex life.

We have chosen the patients who had their first hair transplant surgery between one to three years from the time of our study, so they had seen the final result of their hair restoration procedure. We limited the study to male patients with male pattern baldness and the ones who had surgeries less than three years ago so they still had a fresh memory of the changes they experienced. Each patient had exclusively follicular unit transplants that reflected our standard of care for that period. We sent a questionnaire with a brief description on the nature of this scientific study. We did not collect any patient identifiers and the response was totally voluntary. We sent the two hundred questionnaires with stamped return envelope.

The response rate to our questionnaire was 37 (18%). Each patient was used as his own control since we asked about the changes that they experienced after surgery in comparison to those variables before the surgery. We used T-test to compare patient’s responses. Table 1 shows the mean and standard error in eight different criteria that were asked. Patients had significant improvements in all eight criteria regardless of their stage of baldness and their ages.

In another attempt to compare psychological changes that patients experienced in different stages of baldness, we divided patients into two groups: (1) those who had Norwood IV patterns or less and (2) the ones with Norwood V patterns and above. We observed the most significant difference in two categories, (a) sex life and (b) career experience. Patients with less balding had a greater impact on their sex life and career when compared to patients who had more advanced stages of hair loss. These changes were not age related.

Hair restoration surgery can affect many aspects of a patient’s life. Hair transplant can potentially reverse psycho-social problems associated with hair loss. The positive impact of hair restoration surgery is more visible among patients who suffer from those undesirable effects the most. In early stages of hair loss, patients may have more awareness of their condition and they might be more affected than men in the later stages of hair loss.

Patients who experienced hair loss at an early age while involved in an active social life were more prone to the negative side effects of balding. That could explain why younger people with hair loss appeared more benefited by hair restoration procedures. Also it could be assumed that hair loss can have a negative impact on a patient’s outlook which seems to reverse after receiving a hair restoration procedure which improved their outlook.

Low response rate from a blind mailing has always been a drawback in questionnaire studies. We received 37 out of 200 of the questionnaires that we sent out (response rate was 18.5%). Giving incentives to responders may be a good way of increasing the participation rate of any questionnaire studies. We presented the result of this study at the annual scientific meeting of ISHRS and have been contacted by many of our colleagues who expressed interest in collaborating in a larger scale study. We are currently trying to rise funding for repeating this study to optimize our response rate and the statistical value of the study.

If you have any questions on the content of this article you can contact US Hair Restoration office at Los Angeles through email at info@ushairrestoration or phone.

Q:

Hi Dr.Mohebi,

I am wondering if the chest hair be transfer to the head?

Yours,

Name

A:

Good question and the answer is yes. Some people with limited scalp hair can be good candidates for body hair transplants. This is how it works:

Body hair can be harvested and used for hair transplants in people who have both good course body hair and are severely depleted of scalp donor hair (hair on the sides and back of the head). Body hair should not regularly be used as an alternative to scalp hair for hair transplants. This is because body hair has a short growth cycle in comparison to scalp hair, which makes body hair less desirable than scalp hair for a hair transplant.

Each scalp hair grows between 1 to 6 years and then goes to its resting phase for 4 to 6 weeks in which the hair follicle falls out before the start of another growth cycle. Body hair on the other hand has a different growth cycle, which consists of much shorter growth phase and a longer resting phase. In other words, many body hair follicles that you transplant stay in resting phase most of their lives and only a fraction of them grow and are visible at any given period of time. So you are transplanting hair follicles knowing that not many of them could be seen at any given period of time.

Having said that body hair transplants are OK for people who have no alternative ie. bad donor hair density or quality.

Question:

Dear Dr. Mohebi,

Dr., I had a question: say I would use proscar now and took it for a while, after how long based on studies is it possible to see adverse side effects, if any? The reason why I ask is because when I went and read the messages on the forums, I saw positive and negative feedbacks. One person used proscar for 7 years and saw nothing but great results. I would like to give it a shot and see if I am lucky, hopefully. Thank you! Have a great weekend,

Answer:
The side effects of finasteride (Propecia/Proscar) could be seen anytime from right after starting it to months after starting finasteride. If you read the articles on adverse effects of finasteride you can clearly see that there is a small difference between the rates of side effects from the people who took placebos to the ones taking finasteride.

Let’s face it; you are prescribing a drug to a patient telling him that it works through altering your male hormones. What do you think the chances are that the patient will have problems with his sex drive?

The good news is that the side effects of finasteride are few and the most problematic one (decreased sex drive) is only seen in one out of a hundred patients. The other good news is that even if you are in that one percent category and you decide to continue using finasteride anyway, after one year of using finasteride the rate of side effects decreases to about the rate that was shown in people who only took a placebo.

Question:

Dr. Mohebi,
Is The ProCede an alternative to hair transplant surgery?

Answer:
ProCede TM is a cosmetic hair product that can thicken your hair shafts and increase the appearance of fuller hair. ProCede is classified under hair volumizers, which increases the volume of hair shafts. ProCede does not help re-growing hair and does not have any effect on the length or diameter of actual hair. There is no medicine such as minoxidil or finasteride involved in the formulation of this product so it does not need FDA approval.

There are many claims on Procede removing toxins from skin, but this has not been proven with scientific evidence. There are reports of severe allergic reaction to ProCede and this is why the skin patch test is recommended for patients who use this product. It is recommended to repeat ProCede every 90 day to sustain its effect on thinning hair.

Above information was mostly based on what I found online on ProCede. Searching through medical literature, I could not find any published articles, nor did I see any supporting medical documents on the ProCede website. I would wait to see more documentation on the mechanism and safety of this product before recommending it to my hair loss patients.

I met an internist friend today and he asked me whether or not I do hair cloning for my patients. Obviously my answer was no. He mentioned that Dr. X does offer cloning to his patients and in fact plans on doing it for one of his current patients. My comment is this: The field of hair transplant surgery is a buyer beware market; just like any other fields in cosmetic surgery.

I have heard many doctors calling themselves a pioneer on this and that technique. If your doctor told you that he or she is the inventor of some popular method, make sure to ask for a published article from him or her on the topic in a peer reviewed medical journal. In medicine, we don’t keep secrets. When any inventions are formulated they are presented in scientific meetings or published in peer reviewed journals.

Hair cloning (as it is being called by people) or hair multiplication has been studied extensively in America and Europe over the past few years. There are some reports on the success of culturing hair and making new hairs from one in animals and human. There are also claims that phase 3 of clinical trials has started, but we do not know much about the success of this procedure since we don’t have any published articles as of yet. We don’t know anything about the possibility of mass production of hair through hair multiplication nor its feasibility and safety on human.

It is very likely that hair multiplication will be available in the future, but as of now we can not make any comments on the timing and quality of it.