Hair Restoration Blog

Follicular Unit Extraction (FUE) – Advantages or disadvantages

My patients always ask about advantages and disadvantages of Follicular Unit Extraction so I thought this topic makes a good post for the blog. Before going over these points I have to say, although we at US Hair Restoration offer the most advanced techniques of FUE nationwide, most of our patients are still being transplanted by strip technique and I don’t recommend FUE to everyone and select my FUE patients very meticulously. Here are the main reasons why we do recommend FUE to some people and not to everyone.

Advantages

• FUE does not leave a linear scar, which is great for those who want to wear their hair very short on the back or the ones who may need to shave their head in the future (like actors).
• FUE has a more comfortable healing process with decreased healing time.
• No restrictions in physical activities for those who want to do strenuous exercise right after FUE procedure.
• FUE is a viable alternative for those who have tight scalp that makes strip surgery risky or impossible.
• Follicular unit extraction makes it possible to harvest hair from body, beard or almost everywhere else.
• FUE is very useful when we need limited number of grafts like for restoration of eyebrow hair.

Disadvantages

• The biggest disadvantage of follicular unit extraction is that the maximum follicular unit graft yield is lower than when it is done with strip technique due to higher rate of follicular transection compared to the strip technique.
• Although linear scar is not present after FUE, small punctuate scars will be there that may make future FUE hair transplant surgeries more difficult or impossible.
• Not everyone is a candidate for FUE and patients need to be tested with FOX before proceeding with the surgery.
• FUE procedure takes much longer to perform compared with strip FUT procedure.
• FUE is more laborious thus it cost more compared with strip technique hair transplants.
• In FUE, we have more chance of burying grafts that increases the risk of having folliculitis (tiny inflamed cysts under the skin) on the donor area.

Q:

I underwent a gastric bypass surgery about 2.5 years ago and since a few months after surgery my hair has been thinning. What do I need to do to prevent further loss?

A:

Losing hair or changing the quality and color of hair after gastric bypass surgery is commonly seen within the first few months after the gastric bypass surgery. This condition can mimic shock loss that could be seen after hair restoration surgery. Right after the gastric bypass surgery your body goes through a period of severe starvation and tries to divert nutrients toward more vital organs instead of skin and hair. Although carbohydrates, proteins, minerals and vitamins especially the family of vitamin B has been blamed for the hair loss in patients who had gastric bypass, it can happen while all of those elements are within normal range and the exact mechanism of hair loss after gastric bypass surgery is not completely known.

The great news is that the hair loss after a gastric bypass surgery is always temporary. Your hair condition should return to normal within a few months of hair loss occurrence. Patients who had gastric bypass should have serial examinations within the first few months of their gastric bypass. Your surgeon should check many elements because gastric bypass surgery could increase the incidence of iron, folic acid, vitamin B12, calcium, and vitamin D deficiency. Most people need to stay on supplementation of these minerals and vitamins. Close monitoring with regular laboratory tests for these deficiencies should be done by your surgeon or primary care physician.

Q:

Hi Doctor,

Some doctors prescribe Dutasteride (Avodart) for hair loss prevention. I know you do not recommend Dutasteride for hair loss for obvious reasons, but based on available research findings on this medication, what do you think are the most likely possible side effects from using Dutasteride if worse come to worse. Would it be like multitude of finasteride side effects? Again, I know your view of non-FDA approved drugs.

A:

Dutasteride (Avodart) is one of the selective inhibitors of the type I and II of the enzyme 5-alpha-reductase, the enzyme that converts the male hormone testosterone to 5-alpha-dihydroxytestosterone (DHT). In comparison with dutasteride, finasteride (Propecia) acts as an inhibitor of just type II of the enzyme 5-alpha-reductase, which is more specific. Studies around dutasteride mechanism of action shows that, blocking both type I and type II enzyme can be more potent that only one in reducing the levels of DHT in the body.

If you are taking dutasteride for other indications, you may get some hair growth as a good side effect. As you may guess cannot recommend dutasteride solely for prevention of male patterned hair loss; not until it is approved for hair loss treatment by FDA. Other than not being FDA approved my other reasons are:

1. The optimum dose of dutasteride for hair loss prevention is not determined.
2. The side effects of dutasteride are much more prominent comparing to finasteride.  That include the negative effect of the medication on sex drive in men.
3. If you are considering the cost effectiveness of dutasteride, with new price reduction of finasteride that should not be in the picture any more.

Q:

I have diabetes. Can I have a hair transplant procedure?

A:

Patients with diabetes can successfully have a hair transplant surgery if diabetes is under good control. Diabetes used to be a life limiting disorder and diabetic patients could not have many elective surgical procedures due to their increased risk of wound complications and infection. With the new medications and methods for controlling diabetes, patients with diabetes can safely have hair transplant surgery or any other elective procedures without significant increased risk of infection or complications with their healing phase. Here at US Hair Restoration, we need to have a clearance from the doctor who follows patient for his/her diabetes to make sure patient’s blood sugar is in normal range and diabetes is effectively controlled.

Q:

Is Hair cloning or multiplication being done anywhere yet?

A:

Hair cloning or multiplication has been in the news in the last few years. I prefer to use the term hair multiplication, rather than cloning because cloning refers to production of genetically identical organisms. Dolly the most celebrated sheep was the product of first cloning. When it comes to hair, we do not really clone the cells, but we culture them and try to get a whole organism from cultured cells. Unfortunately the process of culturing hair follicle cells has not been as simple as some other tissues in human body. The complexity of hair physiology is due to participation of many different stem cells in development of each hair follicle. In this process, we do not multiply genetic material or DNA of cells.

Hair cloning news

Hair multiplication if become a reality could bring about a great opportunity for bald people with violated donor scalp who cannot be good candidates for hair transplantation with current techniques. Despite our enthusiasm about hair multiplication, hair cloning news in last few years has not been filled with many success stories.

Hair cloning 2007

Year 2006 intercytex company announced that they are going to start phase 3 of hair multiplication study soon. Hair cloning has been in the news and many people are eagerly following that news to see when and how they can get a full head of hair using hair cloning techniques. Unfortunately, cloning hair has not been going that well and in last few years we only had limited research results on hair multiplication in animal models and in human. Here is the question that people usually ask me: Is hair cloning being done anywhere yet? And my answer usually is: Not except on experimental levels. Several investigations are in process on hair multiplication field and hair stem cell research.

Hair cloning 2008

Hair multiplication or as people call it hair cloning is a method that allows us to culture hair follicles and multiply it so we can increase the final number of hairs. So far, we know that it is doable on animals, and there are some reports of its feasibility on human volunteers. Safety has been one of the biggest questions on any research involved with stem cells. Stimulating growth of stem cells has always raised the flag for possible tumor formation. In year 2008, we should witness some results of the phase 3 studies on the procedure. During this year or in next few years, we should have a better understanding of the effectiveness and safety of hair multiplication. I know many of my patients are following hair cloning news carefully. Unfortunately, hair multiplication news has not been very fruitful in last year, but the process is complex and one way or another it will become clear in next few years that we can or cannot use hair multiplication methods in hair restoration surgeries.

Searching for the best Los Angeles hair transplant surgeon may not be an easy task, but Los Angeles has always been a referral center for most cosmetic surgeries, even though hair transplant surgery is one of the newer branches of cosmetic surgery. You can find a wide variety in style and levels of Los Angeles and Beverly Hills hair transplant surgeons. Some of the most updated hair transplant surgeons practice in Los Angeles and San Diego, California, but you can also see lousy surgeries done by some hair transplant surgeons. Overall, hair restoration surgery like any other cosmetic surgery is a buyer‚Äôs beware market, and one must be careful not to fall into the trap of signs such as “Number one Beverly Hills hair transplant surgeon” or “the most experienced Los Angeles hair transplant surgeon”. You can see similar advertisements and a lot more like Extreme make over hair transplant surgeon or doctor 90210.

The good news is that today, most hair transplant surgeons offer free initial consultation. It is importantto take advantage of this situation and shop around. It is your look and your desire to live with it for the rest of your life after all. It is not enough to visit several hair transplant doctors; you also need to educate yourself on hair transplantation process, surgical techniques and hair transplant surgeon’s background before visiting the doctor. This way, you can appreciate a good technique and knowledgeable doctor when you see one while you can find the most affordable hair transplant. US Hair Restoration – a Los Angeles hair transplant surgery center offers free physician consultation for everyone. We offer state-of-the-art hair transplant surgery with exclusive follicular unit transplants (FUT), mega sessions for people with extensive hair loss and follicular unit extractions (FUE) or noninvasive hair transplants that does not leave an scar in the donor area.

Los Angeles is Hollywood and in Hollywood “appearance” is everything. Modern hair transplant surgery with undetectable results has become a demanding field in Southern California in last few years both because of the number of people looking for hair restoration surgery and the ones looking for the best hair transplant surgeon in Los Angeles, Beverly Hills and Southern California over all. Many people travel the world to get their hair transplant surgery done in Los Angeles or Beverly Hills. Los Angeles is and will probably always be the Mecca of hair transplant surgery for people who cannot accept anything but the best.

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.

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.

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:
I am a 22 year old white male with some recession in the corners that has been bothering me in the last two years. Am I eligible for a hair transplant procedure?

Answer:
I generally don’t recommend hair transplant before the age 24 (with some exceptions). We need to have a better understanding of the pattern of your hair loss before coming up with a surgical plan. If you are destined to become a stage VII (advanced stages of hair loss) the plan should be totally different than if you are going to stop at stage III.

We can usually see the final pattern of baldness by the age of 23 or 24 with a microscopic examination of scalp. We should be able to determine whether or not you are going to stop at stage III or if you are heading to more advanced stages such as VI or VII. We can densely pack the corner areas knowing that the patient had plenty of reserve and is not going to lose much more. But if you are supposed to become severely bald, we should be more conservative in repairing your frontal corners knowing that you are going to need a good portion of your hair for the top and crown areas of your scalp in the future.

If I see the evidences of end stage hair loss at an earlier age, I can more safely plan for hair transplant at that age rather than waiting for a more advanced age since the patient is already showing the signs of sever baldness.