What can I do to prevent my thinning hair?
Katy asked:
I’m 17 and have thinning hair, but, according to what I’ve been researching lately, this could be caused by many things but really the only things that seem to fit best to my history are: Pulling my hair up tight for years, genetics, poor nutrition, or perming and coloring. Other than that I use mousse everyday and most of the time a hot iron and blow dryer. I also shampoo my hair every day because it gets oily fast and tends to part but I don’t use conditioner. Then I take Biotin and Grapefruit Seed Extract to help promote healthy skin and hair. Could I be doing something wrong? Do I need to eliminate some things, such as the way I style my hair or using vitamins? Or do I need to just be patient and wait for it to grow back? It’s been like this for over a year now. Please anyone who can help I would gladly appreciate your feedback. Thanks!
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I’m 17 and have thinning hair, but, according to what I’ve been researching lately, this could be caused by many things but really the only things that seem to fit best to my history are: Pulling my hair up tight for years, genetics, poor nutrition, or perming and coloring. Other than that I use mousse everyday and most of the time a hot iron and blow dryer. I also shampoo my hair every day because it gets oily fast and tends to part but I don’t use conditioner. Then I take Biotin and Grapefruit Seed Extract to help promote healthy skin and hair. Could I be doing something wrong? Do I need to eliminate some things, such as the way I style my hair or using vitamins? Or do I need to just be patient and wait for it to grow back? It’s been like this for over a year now. Please anyone who can help I would gladly appreciate your feedback. Thanks!
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Before You Undergo Hair Restoration Surgery
Legacy Hair Center asked:
For years, you have endured raised eyebrows and scrutinizing stares when people see your balding head. You may have resorted to wearing all sorts of ball caps or scarves, just to keep people from noticing your progressive loss of hair. The stuff you bought from the infomercial didn’t grow any hair either, and your confidence is shattered.
Today, things will change. You have finally decided to consider a hair restoration procedure as a solution to your hair loss problem. The decision to undergo hair restoration is a life-changing one. You must think over your options carefully. Also, you need be guided by a hair loss specialist who has the expertise and experience to help you make the right decision. Ultimately, this will determine your level of satisfaction after the procedure.
Here are the questions you should ask before undergoing hair restoration surgery:
Are your expectations realistic?
While the techniques of hair transplantation are nearing perfection, you should realize that hair transplantation is not for everybody. You don’t actually grow new hair when you undergo the procedure. Instead, hair from healthy regions of your scalp (the donor site) is transplanted to your scalp’s balding areas (the recipient site). You have to wait 2 months for the transplanted hair to grow normally, and 6 months for it to look natural.
Hence, the amount and quality of your remaining hair and your age will determine the results that you may expect from the surgery. An honest hair specialist will take the time to explain this to you, and not just push you into getting the transplant. Otherwise, you might end up paying for a procedure, whose results you are unhappy with.
Is your hair specialist an expert in the field?
“Any physician even with basic training can successfully transplant hair and make it grow,” says Legacy Hair Center CEO Ronnie Talent. “But to make it aesthetically pleasing, and undetectable requires artistry only those with advanced training can attain.”
In contrast to emergencies such as a ruptured appendix or a broken bone, you have the luxury of time to choose the doctor who will perform your hair transplant. Do not hesitate to ask for your hair specialist’s qualifications. You should be aware that non-surgeons and even non-doctors may legally perform the procedure. However, only the finest of hands and in-depth knowledge of facial aesthetics will give you the outstanding results you need.
Are you getting your money’s worth?
Hair restoration and hair replacement centers employ various strategies to market their services nationwide. Some use full-scale TV and magazine advertisements, while others rely on word of mouth. As such, the cost of hair transplantation varies considerably with each center. Your decision to pick one hair loss center over the other should not be influenced by price alone. There are cheap hair loss options out there, but will you be satisfied with the results? You may be able to save money now, but then regret the decision later when you decide to have an unsatisfactory hair transplant corrected.
“Much of the work we do is corrective” Talent claims.” Many doctors make the hairline too dramatic, and don’t use common sense. A 45 year old man will not look normal with a 17 year old’s hairline.”
By working well with your trusted hair specialist, you can expect hair transplantation to bring back the vitality that you have once lost. It’s time to throw away your scarves and ball caps. Today is the beginning of the rest of your life.
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For years, you have endured raised eyebrows and scrutinizing stares when people see your balding head. You may have resorted to wearing all sorts of ball caps or scarves, just to keep people from noticing your progressive loss of hair. The stuff you bought from the infomercial didn’t grow any hair either, and your confidence is shattered.
Today, things will change. You have finally decided to consider a hair restoration procedure as a solution to your hair loss problem. The decision to undergo hair restoration is a life-changing one. You must think over your options carefully. Also, you need be guided by a hair loss specialist who has the expertise and experience to help you make the right decision. Ultimately, this will determine your level of satisfaction after the procedure.
Here are the questions you should ask before undergoing hair restoration surgery:
Are your expectations realistic?
While the techniques of hair transplantation are nearing perfection, you should realize that hair transplantation is not for everybody. You don’t actually grow new hair when you undergo the procedure. Instead, hair from healthy regions of your scalp (the donor site) is transplanted to your scalp’s balding areas (the recipient site). You have to wait 2 months for the transplanted hair to grow normally, and 6 months for it to look natural.
Hence, the amount and quality of your remaining hair and your age will determine the results that you may expect from the surgery. An honest hair specialist will take the time to explain this to you, and not just push you into getting the transplant. Otherwise, you might end up paying for a procedure, whose results you are unhappy with.
Is your hair specialist an expert in the field?
“Any physician even with basic training can successfully transplant hair and make it grow,” says Legacy Hair Center CEO Ronnie Talent. “But to make it aesthetically pleasing, and undetectable requires artistry only those with advanced training can attain.”
In contrast to emergencies such as a ruptured appendix or a broken bone, you have the luxury of time to choose the doctor who will perform your hair transplant. Do not hesitate to ask for your hair specialist’s qualifications. You should be aware that non-surgeons and even non-doctors may legally perform the procedure. However, only the finest of hands and in-depth knowledge of facial aesthetics will give you the outstanding results you need.
Are you getting your money’s worth?
Hair restoration and hair replacement centers employ various strategies to market their services nationwide. Some use full-scale TV and magazine advertisements, while others rely on word of mouth. As such, the cost of hair transplantation varies considerably with each center. Your decision to pick one hair loss center over the other should not be influenced by price alone. There are cheap hair loss options out there, but will you be satisfied with the results? You may be able to save money now, but then regret the decision later when you decide to have an unsatisfactory hair transplant corrected.
“Much of the work we do is corrective” Talent claims.” Many doctors make the hairline too dramatic, and don’t use common sense. A 45 year old man will not look normal with a 17 year old’s hairline.”
By working well with your trusted hair specialist, you can expect hair transplantation to bring back the vitality that you have once lost. It’s time to throw away your scarves and ball caps. Today is the beginning of the rest of your life.
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Are You Afraid of Hair Restoration?
Legacy Hair Center asked:
You’re losing your hair. Your doctor has just explained to you that hair restoration is the definite solution to your hair loss. He says that without intervention, you’re probably going to end up looking like your bald uncle. Hair restoration surgery offers hope. Still, you remain hesitant.
But will you let this opportunity to reclaim your hair pass, just because you’re afraid of something you have never tried?
Will it be painful?
Fear of pain is the main reason why most people are hesitant to undergo hair transplantation. You may have heard of relatives or friends who previously underwent the procedure, and complained that it “hurt like hell.” You should realize, however, that the procedure has drastically changed over the past 4-5 years.
Ronnie Talent, CEO of Legacy Hair Center in Charlotte shares, “I used to work for the worlds largest hair restoration and hair replacement chains, and I’ve seen thousands of men and women go through this”. He adds” Many of the larger practices still use the “old way” of administering the anesthesia, which was sometimes a little uncomfortable.
We use the Pyllo Anesthesia Method, our patients described the pain during the entire procedure as almost non-existent. I’ve heard at most 1, in a scale of 1 to 10.”
Using advanced techniques for giving anesthesia, a well-trained hair specialist can ensure your comfort throughout and after the procedure. Before surgery, you may also be given medication to alleviate your anxiety.
Will your friends notice?
The stigma of an ugly hair transplant may be worse than that of a balding head. Perhaps you’re worried about colleagues teasing you on your failed attempt at hair restoration. You wouldn’t want complete strangers to give you the puzzled look, wondering why you have doll-like hair. Besides, you don’t just want more hair. You want a natural hairline, too.
“The most important part of the restoration procedure is the hairline… “ Talent adds.” If you simply need a little more density in the back, many doctors can do that. But if they want an undetectable hairline, they have to see someone who offers advanced frontal and temporal hairline techniques, or they’ll spend their lives having people stare at their hairlines.”
The solution to these concerns is simple: seek an experienced hair loss expert. Do not be misled by large-scale advertisements; they may tell you only half-truths. Try to look for previous clients. Find out if they were satisfied with the outcome and listen to their recommendations. Hair transplantation doesn’t just require surgical skill. Your doctor should have the artistic creativity to give you aesthetically pleasing results.
Will you be able to afford the cost?
The cost of hair transplantation varies from one hair loss center to another. The cost will also depend on the number of sessions you require to cover your scalp’s balding areas. Your hair specialist will take into consideration your age and the quality of your hair among other factors, and should be able to give you a reasonable estimate.
Do not be ashamed to ask about hair loss options within your budget. An honest hair specialist will explain to you the pros and cons of both surgical and non-surgical hair loss options. Your hair specialist should take the time to answer your questions, and not just push you into getting the procedure.
In the end, it is most important that you trust your hair specialist. Only then will he be able to allay your fears, guide you to reasonable expectations, and give your satisfactory results.
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You’re losing your hair. Your doctor has just explained to you that hair restoration is the definite solution to your hair loss. He says that without intervention, you’re probably going to end up looking like your bald uncle. Hair restoration surgery offers hope. Still, you remain hesitant.
But will you let this opportunity to reclaim your hair pass, just because you’re afraid of something you have never tried?
Will it be painful?
Fear of pain is the main reason why most people are hesitant to undergo hair transplantation. You may have heard of relatives or friends who previously underwent the procedure, and complained that it “hurt like hell.” You should realize, however, that the procedure has drastically changed over the past 4-5 years.
Ronnie Talent, CEO of Legacy Hair Center in Charlotte shares, “I used to work for the worlds largest hair restoration and hair replacement chains, and I’ve seen thousands of men and women go through this”. He adds” Many of the larger practices still use the “old way” of administering the anesthesia, which was sometimes a little uncomfortable.
We use the Pyllo Anesthesia Method, our patients described the pain during the entire procedure as almost non-existent. I’ve heard at most 1, in a scale of 1 to 10.”
Using advanced techniques for giving anesthesia, a well-trained hair specialist can ensure your comfort throughout and after the procedure. Before surgery, you may also be given medication to alleviate your anxiety.
Will your friends notice?
The stigma of an ugly hair transplant may be worse than that of a balding head. Perhaps you’re worried about colleagues teasing you on your failed attempt at hair restoration. You wouldn’t want complete strangers to give you the puzzled look, wondering why you have doll-like hair. Besides, you don’t just want more hair. You want a natural hairline, too.
“The most important part of the restoration procedure is the hairline… “ Talent adds.” If you simply need a little more density in the back, many doctors can do that. But if they want an undetectable hairline, they have to see someone who offers advanced frontal and temporal hairline techniques, or they’ll spend their lives having people stare at their hairlines.”
The solution to these concerns is simple: seek an experienced hair loss expert. Do not be misled by large-scale advertisements; they may tell you only half-truths. Try to look for previous clients. Find out if they were satisfied with the outcome and listen to their recommendations. Hair transplantation doesn’t just require surgical skill. Your doctor should have the artistic creativity to give you aesthetically pleasing results.
Will you be able to afford the cost?
The cost of hair transplantation varies from one hair loss center to another. The cost will also depend on the number of sessions you require to cover your scalp’s balding areas. Your hair specialist will take into consideration your age and the quality of your hair among other factors, and should be able to give you a reasonable estimate.
Do not be ashamed to ask about hair loss options within your budget. An honest hair specialist will explain to you the pros and cons of both surgical and non-surgical hair loss options. Your hair specialist should take the time to answer your questions, and not just push you into getting the procedure.
In the end, it is most important that you trust your hair specialist. Only then will he be able to allay your fears, guide you to reasonable expectations, and give your satisfactory results.
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Why People Lose Hair
Legacy Hair Center asked:
Do you find strands of hair clinging to your comb, or collecting in your bathroom drain? Don’t be alarmed . Most of the time, it’s just your hair going through its normal stage of shedding. On the average, you lose 50 to 100 strands of hair each day. Shed hair is replaced by new hair, and the hair growth cycle starts over. However, if you notice your hair thinning or falling out excessively , you may need to seek professional help to avert baldness, or alopecia.
Alopecia can affect anyone. And- it’s not always determined by “the mothers genetics”. Truth is, there are several causes of alopecia. Let us take a look at a few reasons why people lose hair.
The most common cause of baldness in both men and women is androgenetic alopecia or pattern baldness. This is caused by increased levels of androgens or male hormones. It may be hereditary. You may notice an M-shaped thinning of hair in your temples and crown if you are a male, or thinning in the central and frontal scalp if you are a female.
On the other hand, a bald spot on your scalp may be due to alopecia areata. In this condition, your immune system produces antibodies that normally fight off harmful microorganisms, but instead damage your hair follicles, leading to hair loss that appears as smooth round patches.
If you underwent surgery or had a severe illness during the last 3 months, you may also notice hair loss that is more than what you’re used to. As a natural reaction of your body to a stressful life situation, about 50% of your hair enters the resting phase of hair growth. Because shed hair is not immediately replaced, thinning of your hair becomes apparent. This temporary hair loss is called telogen effluvium. Your hair will grow back once the underlying illness resolves.
Hormones also play a role in hair loss that is associated with thyroid diseases and pregnancy. An excess or a decrease in your thyroid hormones may lead to alopecia. After giving birth, the abrupt decrease in the level of the female hormone estrogen causes temporary yet massive hair shedding. Other medical conditions that may lead to hair loss include fungal infections, diabetes, lupus and intake of certain medications.
“You would think that most of of our hair loss clients would be men,” says Ronnie Talent, SEO of Legacy Hair Center in Charlotte. ” Roughly 70” of our new hair loss inquiries are women. Many people don’t realize that 25% of women will also suffer from thinning hair.”
Are you aware that even your hairstyling habits can cause hair loss? The constant pulling of your hair when you wear pigtails, cornrows or a tight ponytail damages your hair follicles, leading to traction alopecia. Improper and frequent use of hair treatments may also weaken your hair and cause breakage. Some people are unable to control the impulse to pull out their hair. In these cases of trichotillomania, psychological intervention is also necessary.
Finding the reason why you lose hair is important. It will guide your dermatologist or hair specialist in deciding which hair loss option is appropriate for you. You may have to receive oral and topical medications, or undergo procedures such as laser hair therapy, hair transplantation, or hair replacement. “The Hair Replacement technology that is used today is the same technology used in Hollywood, “says Talent . “Now- if you suffer from hair loss, you have the option to use that technology, and look the way you want to look.”
The important thing is that you seek consult from an expert, who can guide you to the right diagnosis and give you the best possible treatment.
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Do you find strands of hair clinging to your comb, or collecting in your bathroom drain? Don’t be alarmed . Most of the time, it’s just your hair going through its normal stage of shedding. On the average, you lose 50 to 100 strands of hair each day. Shed hair is replaced by new hair, and the hair growth cycle starts over. However, if you notice your hair thinning or falling out excessively , you may need to seek professional help to avert baldness, or alopecia.
Alopecia can affect anyone. And- it’s not always determined by “the mothers genetics”. Truth is, there are several causes of alopecia. Let us take a look at a few reasons why people lose hair.
The most common cause of baldness in both men and women is androgenetic alopecia or pattern baldness. This is caused by increased levels of androgens or male hormones. It may be hereditary. You may notice an M-shaped thinning of hair in your temples and crown if you are a male, or thinning in the central and frontal scalp if you are a female.
On the other hand, a bald spot on your scalp may be due to alopecia areata. In this condition, your immune system produces antibodies that normally fight off harmful microorganisms, but instead damage your hair follicles, leading to hair loss that appears as smooth round patches.
If you underwent surgery or had a severe illness during the last 3 months, you may also notice hair loss that is more than what you’re used to. As a natural reaction of your body to a stressful life situation, about 50% of your hair enters the resting phase of hair growth. Because shed hair is not immediately replaced, thinning of your hair becomes apparent. This temporary hair loss is called telogen effluvium. Your hair will grow back once the underlying illness resolves.
Hormones also play a role in hair loss that is associated with thyroid diseases and pregnancy. An excess or a decrease in your thyroid hormones may lead to alopecia. After giving birth, the abrupt decrease in the level of the female hormone estrogen causes temporary yet massive hair shedding. Other medical conditions that may lead to hair loss include fungal infections, diabetes, lupus and intake of certain medications.
“You would think that most of of our hair loss clients would be men,” says Ronnie Talent, SEO of Legacy Hair Center in Charlotte. ” Roughly 70” of our new hair loss inquiries are women. Many people don’t realize that 25% of women will also suffer from thinning hair.”
Are you aware that even your hairstyling habits can cause hair loss? The constant pulling of your hair when you wear pigtails, cornrows or a tight ponytail damages your hair follicles, leading to traction alopecia. Improper and frequent use of hair treatments may also weaken your hair and cause breakage. Some people are unable to control the impulse to pull out their hair. In these cases of trichotillomania, psychological intervention is also necessary.
Finding the reason why you lose hair is important. It will guide your dermatologist or hair specialist in deciding which hair loss option is appropriate for you. You may have to receive oral and topical medications, or undergo procedures such as laser hair therapy, hair transplantation, or hair replacement. “The Hair Replacement technology that is used today is the same technology used in Hollywood, “says Talent . “Now- if you suffer from hair loss, you have the option to use that technology, and look the way you want to look.”
The important thing is that you seek consult from an expert, who can guide you to the right diagnosis and give you the best possible treatment.
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Are there any ways to help regrow thinning hair?
magster asked:
I am currently 19 and have very thin hair. I use to dye my hair about once every two - four months starting when I was about 13. I stopped coloring my hair so often and cut down to twice a year when I was 16. I started to notice the hair thinning when I was about 16-17. Hair thinning does occur in the family, like my mother has thin hair, and her mother has thin hair, but my mother’s isn’t as thin as mine. I don’t lose hair, it just the hair that’s lost doesn’t grow back. I have not colored my hair in the last year. What are some products that are good for thinning hair? I’ve heard about rogaine, but I’m iffy about trying it.
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I am currently 19 and have very thin hair. I use to dye my hair about once every two - four months starting when I was about 13. I stopped coloring my hair so often and cut down to twice a year when I was 16. I started to notice the hair thinning when I was about 16-17. Hair thinning does occur in the family, like my mother has thin hair, and her mother has thin hair, but my mother’s isn’t as thin as mine. I don’t lose hair, it just the hair that’s lost doesn’t grow back. I have not colored my hair in the last year. What are some products that are good for thinning hair? I’ve heard about rogaine, but I’m iffy about trying it.
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What does it mean when you have a Bald Eagle following you?
Rathaford asked:
I have a Bald eagle that gets within 25 feet above me when I go outside to get the mail this past week. Its like he is watching me and trying to tell me something. I’ve also been seeing them along side the road while driving. Last week while driving my car I had a Bald Eagle dive down touch the ground within 15 feet of me and then jump back up in perfect timing of the same time I was going the opposite direction past him. While at the beach the other day I had one circling over head. Before this year Bald Eagles where rare around this area in Iowa.
The Bald Eagle is a magnificent site close up and appears to be friendly in nature.
Growing spiritual nature? I have been getting back the spiritual nature to go skinny dipping. This is after a long hard summer and fall doing chemo and radiation fighting my lung cancer. I was suppose to be dead about now. But they say its still in remission and I’m feeling much better thankyou.
Sign of Freedom perhaps?!
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I have a Bald eagle that gets within 25 feet above me when I go outside to get the mail this past week. Its like he is watching me and trying to tell me something. I’ve also been seeing them along side the road while driving. Last week while driving my car I had a Bald Eagle dive down touch the ground within 15 feet of me and then jump back up in perfect timing of the same time I was going the opposite direction past him. While at the beach the other day I had one circling over head. Before this year Bald Eagles where rare around this area in Iowa.
The Bald Eagle is a magnificent site close up and appears to be friendly in nature.
Growing spiritual nature? I have been getting back the spiritual nature to go skinny dipping. This is after a long hard summer and fall doing chemo and radiation fighting my lung cancer. I was suppose to be dead about now. But they say its still in remission and I’m feeling much better thankyou.
Sign of Freedom perhaps?!
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How do I take care of thinning hair?
That New Guy asked:
My hair is thinning and receding a bit in the front. What are some products or some other kinds of things I can do to help get my hair to grow a little fuller in the front?
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My hair is thinning and receding a bit in the front. What are some products or some other kinds of things I can do to help get my hair to grow a little fuller in the front?
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What is Saw Palmetto and How it Helps in Preventing Hair Loss?
Hair Fall Guide asked:
What is Saw Palmetto ? Saw Palmetto also known as Serenoa repens is a topical palm like small plant mostly found in North America. Extract derived from fruits or berries of saw palmetto as well as the whole berry itself is highly enriched with fatty acids (lauric acid, lauric acid, oleic acid, myristic acid, and palmitic acid), polysaccharides) and phytosterols(plant sterols. It’s extract is widely sold as an aphrodisiac for men and women. An aphrodisiac is an agent which is used in the belief that it increases sexual desire.
Uses of Saw Palmetto
Saw palmetto has also been used in treatment of a wide range of conditions including treatment of benign prostatic hyperplasia (BPH) a condition marked by enlarged prostrate, other urinary tract problems, skin conditions, thyroid defeciences, genital, impotence, hormonal imbalance, bladder inflammation etc. Among other advantages it can also be taken to revitalize skin, improve urinary flow in men, breast enlargement in women and clear chest congestion caused due to cough, asthma and bronchitis.
Role of Saw Palmetto in hair loss prevention
Lately it has been widely accepted as a very effective herbal treatment to reverse hair loss and treat conditions like alopecia. It is considered to be one of the best organin hair loss treatment available today. Scientific evidence suggests that Saw Palmetto bio active ingredients prevent conversion of testosterone into DHT and additionally prevents DHT from binding to androgen receptors hence helping control male hair loss . DHT In order to under the role of saw palmetto in preventing hair fall due to its essential to understand the root cause.
It thus helps revive hair follicles, improve hair strength, body and shine, make scalp less sensitive to stress and irritation. So if you are looking for safe products for hair loss Saw Palmetto is one option you should consider first. Although it is not known to help sudden hair shedding but if taken over a period of time it certainly would help prevent alopecia and atleast prolong a condition where a lot of people may go for surgical option such as transplant for restoration of their crown. Taking it alongside some essential vitamins and minerals would help further.
Is there any side effect associated to the use of Saw Palmetto?
There is no known or documented side effect associated with the use of Saw Palmetto both externally and internally.
However, if you have any concerns its always best to consult your physician.
How is Saw Palmetto used?
Internally:
Recommended dosage for Saw Palmetto is between160 mg/day to 320 mg/day if taken orally.
Externally:
Saw Palmetto can be purchased as an oil extract or as an ointment which can be gently massaged into the hair roots. Since it’s components are lipophilic in nature they are well extracted into the oil base, and are easily absorbed by the skin, therefore providing a more productive treatment. If applied before hair wash, let at least half an hour (better 1-2 hours) to absorb. For better absorption warm up in warm water or microwave (5 - 10 sec) before the application. Preferably, it should be applied at night before you go to sleep and left overnight which leads to best results due to better absorption.
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What is Saw Palmetto ? Saw Palmetto also known as Serenoa repens is a topical palm like small plant mostly found in North America. Extract derived from fruits or berries of saw palmetto as well as the whole berry itself is highly enriched with fatty acids (lauric acid, lauric acid, oleic acid, myristic acid, and palmitic acid), polysaccharides) and phytosterols(plant sterols. It’s extract is widely sold as an aphrodisiac for men and women. An aphrodisiac is an agent which is used in the belief that it increases sexual desire.
Uses of Saw Palmetto
Saw palmetto has also been used in treatment of a wide range of conditions including treatment of benign prostatic hyperplasia (BPH) a condition marked by enlarged prostrate, other urinary tract problems, skin conditions, thyroid defeciences, genital, impotence, hormonal imbalance, bladder inflammation etc. Among other advantages it can also be taken to revitalize skin, improve urinary flow in men, breast enlargement in women and clear chest congestion caused due to cough, asthma and bronchitis.
Role of Saw Palmetto in hair loss prevention
Lately it has been widely accepted as a very effective herbal treatment to reverse hair loss and treat conditions like alopecia. It is considered to be one of the best organin hair loss treatment available today. Scientific evidence suggests that Saw Palmetto bio active ingredients prevent conversion of testosterone into DHT and additionally prevents DHT from binding to androgen receptors hence helping control male hair loss . DHT In order to under the role of saw palmetto in preventing hair fall due to its essential to understand the root cause.
It thus helps revive hair follicles, improve hair strength, body and shine, make scalp less sensitive to stress and irritation. So if you are looking for safe products for hair loss Saw Palmetto is one option you should consider first. Although it is not known to help sudden hair shedding but if taken over a period of time it certainly would help prevent alopecia and atleast prolong a condition where a lot of people may go for surgical option such as transplant for restoration of their crown. Taking it alongside some essential vitamins and minerals would help further.
Is there any side effect associated to the use of Saw Palmetto?
There is no known or documented side effect associated with the use of Saw Palmetto both externally and internally.
However, if you have any concerns its always best to consult your physician.
How is Saw Palmetto used?
Internally:
Recommended dosage for Saw Palmetto is between160 mg/day to 320 mg/day if taken orally.
Externally:
Saw Palmetto can be purchased as an oil extract or as an ointment which can be gently massaged into the hair roots. Since it’s components are lipophilic in nature they are well extracted into the oil base, and are easily absorbed by the skin, therefore providing a more productive treatment. If applied before hair wash, let at least half an hour (better 1-2 hours) to absorb. For better absorption warm up in warm water or microwave (5 - 10 sec) before the application. Preferably, it should be applied at night before you go to sleep and left overnight which leads to best results due to better absorption.
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Avoiding Pitfalls in Planning a Hair Transplant (part 1)
Robert M. Bernstein, MD, F.A.A.D. asked:
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.
Health Insurance Quotes
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.
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Avoiding Pitfalls in Planning a Hair Transplant (part 2)
Robert M. Bernstein, MD, F.A.A.D. asked:
Patient Assessment
Donor Supply
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.
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.
The size of the donor area is determined by both its width (height) and its length. When assessing the potential width of the donor area, doctors usually assess the lowermost point that the balding will reach, i.e. the top part of the permanent zone. However, it is equally important to pay attention to the inferior margin as well. It is common for the hair to thin significantly at the nape of the neck as a person ages, producing an “ascending hairline.” Since this can significantly diminish the width of the donor area, any evidence that this process may occur should be taken into account in the planning. Loss of the temporal points is another process that has a significant impact on the donor supply. Not only does it foreshorten the potential length of the donor strip but it often portends very significant baldness.
Scalp laxity is another variable that affects the amount of available donor hair. Very tight scalps significantly limit the amount of donor hair that can be removed through strip harvesting. The constraint imposed by a tight scalp is not always apparent in the first session, but can plague the hair restoration down the line; therefore, it should be evaluated carefully in the initial patient assessment. A very loose scalp can present its own set of problems, as patients with very loose scalps often heal with widened donor scars. [18]
The average donor density of a Caucasian is about 225 hairs/cm2. This can easily be measured using a hand-held instrument called a densitometer. (2) When the density of a Caucasian is below 180, a hair transplant should be undertaken with great caution. In this author?s opinion, when the maximum donor density is below 150/hair mm2, a person should generally not be transplanted, as there will not be enough donor hair to make the procedure cosmetically worthwhile and the risk of a visible donor scar is too great. (3) Exceptions would be an older person with very limited expectations and in races where the normal density is lower (i.e. Asians and Africans).
Hair characteristics, particularly hair shaft diameter, are as important as the absolute number of hairs in determining the outcome of a procedure. The amount of transplantable hair is related to both the number of movable hairs (determined by the size of the donor area, scalp laxity and donor density), multiplied by the hair shaft cross sectional area. Since each hair in a person with coarse hair can have over 5 times the volume as a person with fine hair, the estimate (or actual measurement) of hair shaft diameter is important in determining the overall donor supply.
Miniaturization, the progressive diminution of hair shaft diameter and length (the result of the action of DHT on the hair follicle) produces thinning on the front, top and crown of the scalp and is the hallmark of androgenetic alopecia. But the back and sides of the scalp can miniaturize as well and when a significant portion of a patient?s donor area is miniaturized, the hair in this area can be rendered useless for a hair transplant. (Figures 1 and 2)
This condition, called diffuse unpatterned hair loss (or DUPA), is the most common type of hair loss seen in women and it is not uncommon in men. It goes without saying, that every patient, male or female, in whom a transplant is being considered, should be evaluated for donor miniaturization using densitometry to make sure that the donor hair to be transplanted is stable.
Recipient Demand
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. It is always best to consider the reasonable worst-case scenario when assessing how bald the patient may become, so that the finite donor hair can be allocated properly. Although the Norwood classification is very helpful in staging the hair loss, it doesn?t take into account actual scalp dimensions. Just like the donor site, the recipient area should actually be measured. Even within a single Norwood class, there is a vast difference between a patient with a narrow forehead and one with a very broad head with respect to the actual surface that needs to be covered, and thus the number of grafts required for the restoration.
Designing the Hairline
Hairline Position
In the adolescent, the hairline sits just above the upper brow crease formed by the upper border of the frontalis muscle directly below it. The position of the normal adult male hairline is approximately 1.5cm above this crease at the midline). A common error is to place the newly transplanted hairline at the adolescent position, rather than one appropriate for an adult. Although the younger patient, first experiencing hair loss, may put considerable pressure on the doctor to place hair in the lower position, the physician should not yield to this demand.
Under normal circumstances, as a patient ages, his density decreases and the natural hairline will move back somewhat. However, a transplanted hairline is immutable. Therefore, when the transplanted patient continues to thin or bald (which he invariable will) the fixed low frontal hairline will begin to look out of place, since it is natural for a person with decreased overall hair volume to have a slightly receded hairline, rather than one that is still in the adolescent position.
Hairline Shape
A similar logic applies when choosing the shape of the hairline. As a male passes from adolescence to adulthood, his broad, flat hairline evolves into a more tapered shape with some recession at the temples. A persistent low, broad hairline is enjoyed by those who also maintain their adolescent density. This situation is not present in those who are suffering from androgenetic alopeica; therefore, a transplanted flat hairline will not “age well” over time and will look unnatural as the patient?s overall density decreases and particularly as the crown begins to thin.
If a person is older, has maintained a high donor density, and has a small risk of extensive hair loss, a broader hairline is possible. However, this is not this case for the person who is starting to bald at a young age, since he has a significant risk of extensive baldness and, more importantly, the extent of his future hair loss can not be known at the time the surgery is planned.
Graft Distribution
The nuances of graft distribution and the multitude of problems that result from distributing grafts improperly are beyond the scope of this writing; however, there are two main but related themes that the hair transplant surgeon should be cognizant of when deciding where to place grafts. The first is to set a target area of coverage that takes into account the patient?s future balding pattern, as well as, his total donor hair supply. The second is to forward weight the grafts, rather than distributing them evenly over the top of the scalp.
Extent of Coverage
The problem of deciding how much bald scalp a hair transplant should cover can be illustrated as follows. As an example, take a patient whose total number of follicular unit grafts available to harvest is around 5,500. The front part of the scalp has a surface area of about 50 cm2. The top or mid-scalp has an area of about 150 cm2 and the vertex or crown about 175 cm2. However, the size of the bald crown can vary dramatically depending upon the extent of hair loss, reaching over 200cm2 in a Norwood Class VII patient.
If the front and top of the scalp were transplanted using all of the patients donor hair, the transplanted density would be only 5,500grafts/200cm2 or 27.5 grafts/cm2 (less than 1/3 the density of the patient?s original hair). If the crown were covered as well, that would be 5,500 grafts/400cm2 or 12.5 grafts/cm2 (only 15% the density of the patient?s original hair). Using various manipulations, such as creating different densities in different parts of the scalp, a skilled surgeon can make 1/3 of the overall density look like a substantial amount of hair. However, working with only 15% of the original density, can make the job of creating a natural look significantly more difficult, if not impossible.
The way to avoid having a hair transplant with a look that is too thin, or see-through, 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.
Another problem with transplanting the crown early is that as the crown expands additional hair will be needed to follow the expanding area of baldness outward, just to keep the first hair transplant looking natural. This may require considerable amounts of hair that will not be available to cover the front and mid-scalp if that were too bald as well. On the other hand, if the hair transplant was limited to the vertex transition point or VTP (see figure above), the restoration would look natural without further surgery no matter how far the hair loss in the crown progressed. The reason is that the front and top of the scalp represent a complete cosmetic unit, with the VTP as the natural posterior boundary - so it is natural for hair to cover this region of the scalp but not beyond.
Density Gradients
Another way for surgeons to prevent a thin, see-through look is to avoid distributing the grafts evenly over the transplanted area. It goes without saying that only 1-hair grafts should be used at the hairline, with larger grafts behind them, but there are additional ways to produce the gradations of density to mimic the way hair grows in nature. Specifically, the greatest density should be in the front part of the scalp (shown in brown) and particularly in the frontal forelock area (shown in dark brown).
The greater density in the front of the scalp forelock area can be created in two ways; by placing the recipient sites closer together in this location and by using larger follicular units in the area (i.e. 3- and 4- hair units rather than 1s and 2s). These techniques may be use in combination to achieved greater density but, as will be discussed in the following section, if done to excess, may compromise growth.
Summary
Follicular unit transplantation is a powerful hair restoration technique that allows the surgeon to create natural hair patterns and produce results that mimic nature. The success of the procedure depends greatly on proper patient selection, accurately assessing the patient?s donor supply, and distributing the grafts in a way that is appropriate for a person who will continue to age and eventually thin over time. With thoughtful planning, major mistakes can be avoided and our patients will be able to achieve the full benefit of this remarkable procedure.
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.
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Patient Assessment
Donor Supply
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.
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.
The size of the donor area is determined by both its width (height) and its length. When assessing the potential width of the donor area, doctors usually assess the lowermost point that the balding will reach, i.e. the top part of the permanent zone. However, it is equally important to pay attention to the inferior margin as well. It is common for the hair to thin significantly at the nape of the neck as a person ages, producing an “ascending hairline.” Since this can significantly diminish the width of the donor area, any evidence that this process may occur should be taken into account in the planning. Loss of the temporal points is another process that has a significant impact on the donor supply. Not only does it foreshorten the potential length of the donor strip but it often portends very significant baldness.
Scalp laxity is another variable that affects the amount of available donor hair. Very tight scalps significantly limit the amount of donor hair that can be removed through strip harvesting. The constraint imposed by a tight scalp is not always apparent in the first session, but can plague the hair restoration down the line; therefore, it should be evaluated carefully in the initial patient assessment. A very loose scalp can present its own set of problems, as patients with very loose scalps often heal with widened donor scars. [18]
The average donor density of a Caucasian is about 225 hairs/cm2. This can easily be measured using a hand-held instrument called a densitometer. (2) When the density of a Caucasian is below 180, a hair transplant should be undertaken with great caution. In this author?s opinion, when the maximum donor density is below 150/hair mm2, a person should generally not be transplanted, as there will not be enough donor hair to make the procedure cosmetically worthwhile and the risk of a visible donor scar is too great. (3) Exceptions would be an older person with very limited expectations and in races where the normal density is lower (i.e. Asians and Africans).
Hair characteristics, particularly hair shaft diameter, are as important as the absolute number of hairs in determining the outcome of a procedure. The amount of transplantable hair is related to both the number of movable hairs (determined by the size of the donor area, scalp laxity and donor density), multiplied by the hair shaft cross sectional area. Since each hair in a person with coarse hair can have over 5 times the volume as a person with fine hair, the estimate (or actual measurement) of hair shaft diameter is important in determining the overall donor supply.
Miniaturization, the progressive diminution of hair shaft diameter and length (the result of the action of DHT on the hair follicle) produces thinning on the front, top and crown of the scalp and is the hallmark of androgenetic alopecia. But the back and sides of the scalp can miniaturize as well and when a significant portion of a patient?s donor area is miniaturized, the hair in this area can be rendered useless for a hair transplant. (Figures 1 and 2)
This condition, called diffuse unpatterned hair loss (or DUPA), is the most common type of hair loss seen in women and it is not uncommon in men. It goes without saying, that every patient, male or female, in whom a transplant is being considered, should be evaluated for donor miniaturization using densitometry to make sure that the donor hair to be transplanted is stable.
Recipient Demand
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. It is always best to consider the reasonable worst-case scenario when assessing how bald the patient may become, so that the finite donor hair can be allocated properly. Although the Norwood classification is very helpful in staging the hair loss, it doesn?t take into account actual scalp dimensions. Just like the donor site, the recipient area should actually be measured. Even within a single Norwood class, there is a vast difference between a patient with a narrow forehead and one with a very broad head with respect to the actual surface that needs to be covered, and thus the number of grafts required for the restoration.
Designing the Hairline
Hairline Position
In the adolescent, the hairline sits just above the upper brow crease formed by the upper border of the frontalis muscle directly below it. The position of the normal adult male hairline is approximately 1.5cm above this crease at the midline). A common error is to place the newly transplanted hairline at the adolescent position, rather than one appropriate for an adult. Although the younger patient, first experiencing hair loss, may put considerable pressure on the doctor to place hair in the lower position, the physician should not yield to this demand.
Under normal circumstances, as a patient ages, his density decreases and the natural hairline will move back somewhat. However, a transplanted hairline is immutable. Therefore, when the transplanted patient continues to thin or bald (which he invariable will) the fixed low frontal hairline will begin to look out of place, since it is natural for a person with decreased overall hair volume to have a slightly receded hairline, rather than one that is still in the adolescent position.
Hairline Shape
A similar logic applies when choosing the shape of the hairline. As a male passes from adolescence to adulthood, his broad, flat hairline evolves into a more tapered shape with some recession at the temples. A persistent low, broad hairline is enjoyed by those who also maintain their adolescent density. This situation is not present in those who are suffering from androgenetic alopeica; therefore, a transplanted flat hairline will not “age well” over time and will look unnatural as the patient?s overall density decreases and particularly as the crown begins to thin.
If a person is older, has maintained a high donor density, and has a small risk of extensive hair loss, a broader hairline is possible. However, this is not this case for the person who is starting to bald at a young age, since he has a significant risk of extensive baldness and, more importantly, the extent of his future hair loss can not be known at the time the surgery is planned.
Graft Distribution
The nuances of graft distribution and the multitude of problems that result from distributing grafts improperly are beyond the scope of this writing; however, there are two main but related themes that the hair transplant surgeon should be cognizant of when deciding where to place grafts. The first is to set a target area of coverage that takes into account the patient?s future balding pattern, as well as, his total donor hair supply. The second is to forward weight the grafts, rather than distributing them evenly over the top of the scalp.
Extent of Coverage
The problem of deciding how much bald scalp a hair transplant should cover can be illustrated as follows. As an example, take a patient whose total number of follicular unit grafts available to harvest is around 5,500. The front part of the scalp has a surface area of about 50 cm2. The top or mid-scalp has an area of about 150 cm2 and the vertex or crown about 175 cm2. However, the size of the bald crown can vary dramatically depending upon the extent of hair loss, reaching over 200cm2 in a Norwood Class VII patient.
If the front and top of the scalp were transplanted using all of the patients donor hair, the transplanted density would be only 5,500grafts/200cm2 or 27.5 grafts/cm2 (less than 1/3 the density of the patient?s original hair). If the crown were covered as well, that would be 5,500 grafts/400cm2 or 12.5 grafts/cm2 (only 15% the density of the patient?s original hair). Using various manipulations, such as creating different densities in different parts of the scalp, a skilled surgeon can make 1/3 of the overall density look like a substantial amount of hair. However, working with only 15% of the original density, can make the job of creating a natural look significantly more difficult, if not impossible.
The way to avoid having a hair transplant with a look that is too thin, or see-through, 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.
Another problem with transplanting the crown early is that as the crown expands additional hair will be needed to follow the expanding area of baldness outward, just to keep the first hair transplant looking natural. This may require considerable amounts of hair that will not be available to cover the front and mid-scalp if that were too bald as well. On the other hand, if the hair transplant was limited to the vertex transition point or VTP (see figure above), the restoration would look natural without further surgery no matter how far the hair loss in the crown progressed. The reason is that the front and top of the scalp represent a complete cosmetic unit, with the VTP as the natural posterior boundary - so it is natural for hair to cover this region of the scalp but not beyond.
Density Gradients
Another way for surgeons to prevent a thin, see-through look is to avoid distributing the grafts evenly over the transplanted area. It goes without saying that only 1-hair grafts should be used at the hairline, with larger grafts behind them, but there are additional ways to produce the gradations of density to mimic the way hair grows in nature. Specifically, the greatest density should be in the front part of the scalp (shown in brown) and particularly in the frontal forelock area (shown in dark brown).
The greater density in the front of the scalp forelock area can be created in two ways; by placing the recipient sites closer together in this location and by using larger follicular units in the area (i.e. 3- and 4- hair units rather than 1s and 2s). These techniques may be use in combination to achieved greater density but, as will be discussed in the following section, if done to excess, may compromise growth.
Summary
Follicular unit transplantation is a powerful hair restoration technique that allows the surgeon to create natural hair patterns and produce results that mimic nature. The success of the procedure depends greatly on proper patient selection, accurately assessing the patient?s donor supply, and distributing the grafts in a way that is appropriate for a person who will continue to age and eventually thin over time. With thoughtful planning, major mistakes can be avoided and our patients will be able to achieve the full benefit of this remarkable procedure.
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.
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