16. What is scalp reduction and how is it different from hair transplantation?

Hair grows one half inch a month for about 1000 days (anagen phase), enters a brief catagen phase, rests for 100 days and then falls out (telogen phase). The cycle is constantly repeated with about 90% of hairs in anagen phase and 10% of hairs in telogen phase at any given time. The average adult has about 100,000 hairs. However, over a lifetime, 25% of men will become significantly bald, 25% will have minimal hair loss, and the remaining 50% will be somewhere in between.  The diagram to the left pertains to non-scalp hair which has an anagen phase of several months rather than several years.

2. Isn't there a normal variation?
Yes, every one's hair is not alike. Contrary to what you might think, hairs do not grow individually. They are distributed in groupings of one two, three, or four hairs called follicular units. The average number of hairs in each follicular unit is about 2.3 but can vary significantly between individuals. Furthermore, each person has his or her particular hair shaft diameter, hair color and hair texture. All of these factors are significant when a patient is being evaluated for hair restoration surgery.

3. What happens in baldness? What is miniaturization?
When hair falls out in typical male baldness, it is not a normal hair that falls. In the balding process, the hairs on the top of the head go through shorter and shorter anagen cycles. With each cycle, the diameter of the hair shaft becomes progressively less in diameter. Eventually the hair in the balding area becomes so thin that it vanishes. The process is called miniaturization. But, regardless of how much hair is lost on top, no significant miniaturization takes place the area of the back and side horseshoe. Surprisingly, 50% of scalp hair must be lost before it is ever noticed!

5. Who is a good candidate?
For some patients, a hairline may need re-creation; for others, more extensive hair replacement may be required. A few patients may want to add density to existing transplants, and others might want to correct a transplanted hairline with which they are dissatisfied. Some patients want to correct sparse eyebrows or scars on the scalp. All these individuals, both men and women, are good candidates for the procedure.

CLICK TO ENLARGE

7. How is the procedure performed?

Under local anesthesia, the donor hair grafts are harvested from a strip of skin in the horseshoe fringe (Zone 8) that is genetically programmed to grow forever. Then, recipient sites are created in the area of hair loss by making tiny incisions of 0.9 - 1.1 mm into the bald skin. (A dime is 1mm thick) Meanwhile, the donor hair grafts are carefully prepared and separated into small units containing usually one, two or three hairs. The grafts are carefully placed into the recipient sites. Four to 5 hours later, the patient leaves with no bandage. The donor site in the back of the head is invisible. We will shampoo your hair the next day, and you shampoo it 48 hours and daily thereafter. Sutures are removed from the donor site in 10 - 14 days. Three to five months later, the transplanted hair begins to grow, and continues to grow a half inch per month for the rest of your life.

8. Why do some transplants look "more natural" than others?
Although hair transplantation has been performed for years, it's never become as popular as you might expect. With good reason...it often looks conspicuous and unnatural! One reason is that old fashioned grafts were simply too big. They contained 10 to 20 hairs, and when they grew, a tufted doll's head resulted. Today, many surgeons use 5-8 haired “mini” grafts… not as bad as the old style but definitely tufted in appearance when wet with water. However, if the grafts are made very, very small, with only one follicular unit per graft, the density of the hair can be more evenly distributed and exactly approximate Nature's way. This is the basic principle that's used in what's commonly called follicular unit or micrografting.

Many clinics don’t trim away the intervening skin between each follicular unit, so that the graft is transplanted to the bald area with more skin than is necessary. To remove the intervening skin (and not damage the oil gland and tiny adjacent telogen hairs) is a very time consuming process and requires both high magnification and experience. However it’s worth it. Grafts with excess skin trimmed off can be more densely packed, and the occasional light skin color that surrounds each hair is eliminated. “Trimmed follicular unit grafts” are the gold standard for hair transplantation. Often, they are not performed because the task is simply too time consuming and expensive. When hairlines are created with trimmed follicular unit grafts, the results are astonishing! At The Hair Loss Center we prepare “trimmed follicular unit grafts” exclusively!

CLICK TO ENLARGE	CLICK TO ENLARGE

Dr. Cohen uses “trimmed follicular unit, one haired grafts” in the front hairline, exclusively. We’re talking 200, 400 or more! The grafts are not planted randomly as they were in the area from which they were taken. Only the single hair grafts are placed in the front rows, behind them the two hair grafts, and behind them the three haired grafts. Again, incredible attention to detail attempting to duplicate the subtle feathered look of a natural thinning hairline. The front rows are single hairs, still attached to their oil gland, trimmed of excess surface skin, exiting the scalp at a 30 degree angle, delicately handled, refrigerated and submerged in nutrient solution throughout the entire process. The hair transplant pictured above was performed on a bald 30 year-old man. The frontal hairline contains 675 single hair grafts!

CLICK TO ENLARGE	CLICK TO ENLARGE

Great looking transplants are a combination of both craftsmanship and artistry. They don't result from the labors of inexperienced technicians or surgeons. If profit-motivated, shortcut automated methods are used, and they frequently are; it often results in incomplete growth, scarring, changes in skin color and texture, and misdirection of hair growth. Plain and simple...transplants that look and behave like real hair are very difficult to create. They're the result of years of experience, surgical dexterity, precision, and meticulous attention to detail. And you as a potential consumer should be looking for these qualities in your surgeon. Opting for what’s least expensive will be seen as a reminder, each morning as you look in the mirror...for the rest of your life!

Essentially none. Most patients describe the session as easier than a visit to the dentist. A mild sedation pill is given followed by local injection of lidocaine. A microdroplet computerized device (called a CompuMed) is used to administer one half drop of anesthetic per second. At his slow rate, the discomfort of the injection is essentially imperceptible. Once the anesthetic has been placed into the scalp skin, it is completely numb for the duration of the procedure. Complications almost never occur, but occasionally a patient may have swelling for a few days after the procedure.

14. What about 2% and 5% minoxidil (Rogaine)?
Rogaine 2% (Upjohn) will slow down hair loss in both men and women, and is reported to stimulate some hair growth in about 25% of patients who use it. It’s a solution that is applied to the scalp twice daily. According to the manufacturer, it is more likely to grow hair on the back of the scalp, rather than the frontal hairline. If new growth does occur, the density is minimal. If minoxidil is discontinued, the regrown hair will fall. Rogaine 5% is reported to work about 45% more effectively than Rogaine 2%. We've found that a logical approach is: Replace lost hair with transplants, and use minoxidil to preserve what remains of the original hair. See Non Surgical Hair Restoration.

Propecia 1 mgm. (Merck) is a once-a-day pill for the treatment of hair loss in men. It was introduced in February 1998. In a five year study, 90% of balding men showed no decrease in their hair counts. The amount of hair growth that one can expect is variable, with moderate to significant regrowth density in less than 15%. Chemically, it is finasteride, a pill that is used in 5mgm doses for patients with prostate enlargement. Finasteride appears to be quite safe and has been on the market for years. Propecia is responsible for sexual dysfunction, i.e impotence and decreased libido in about 0.5% of patients who use it. The drug has proven not to work for women with pattern hair loss, and should not to be used by women in child-bearing years. Men using Propecia can safely impregnate females with no fear of fetal abnormalities. A new drug called dutasteride (Glaxo) is being used much in the same way Propecia is used. It has been reported as being more effective, but it has more side effects. See Non Surgical Hair Restoration.

Yes. Unfortunately, some women develop hair loss in a pattern similar to that of men. And although there is rarely a recession of the front hairline, there can be significant loss of density and mass. Women with hair loss are evaluated for hormone imbalance and other dermatologic disorders. If none are found, the hair loss often responds to minoxidil. The good news is that transplants provide a dramatic improvement in hair density and for many women is the treatment of choice. Some of our most enthusiastic and satisfied patients are women! 

With single and two hair grafts, prepared under the microscope, eyebrows can be created or made denser. The results are dramatic and undetectable. However, transplanted eyebrow hair must be periodically trimmed because it will grow the length of scalp hair. Surgical scars from facelifts and brow lifts can also be corrected in the same manner.

19. How much hair should I lose, before I consider having the procedure performed?

CLICK TO ENLARGE

We suggest getting started before your hair loss becomes too extensive. That way, hair from adjacent areas can be used to camouflage the surgical site. Remember, the surgical site is only visible for about 9 days during which time there are more than 1000 pinhead sized scabs. When these fall off, the scalp looks perfectly normal. With today's techniques, we're able to fill-in and re-create hairlines in a manner so subtle, it's almost impossible to tell that anything was done.

CLICK TO ENLARGE

Sometimes. Unfortunately a small number of transplants are performed by surgeons who are not adequately trained or experienced. Sometimes the results are disappointing, other times they are disastrous! Dr. Cohen has years of experience performing corrective procedures. Most of the time, he can move hair lines and grafts to make them look more normal. This bit of information should serve as a warning to those patients considering hair restoration surgery. Be familiar with your surgeon’s work; ask for picture or better yet videos. Speak to his patients, ask for credentials, etc. The best way to treat a problem is to avoid it in the first place. Seriously consider having your procedure performed by a certified diplomate of the American Board of Hair Restoration Surgery.

An increasing number of physicians have entered the field of hair restoration surgery in the past few years. In order to call one's self a "hair transplant" or "hair restoration" surgeon, there is no special exam or course work that is required. A society called the International Society of Hair Restoration Surgery is open to any and all physicians who choose to apply, even if they do not perform hair restoration surgery!

Mission of the ABHRS: To act for the benefit of the public to establish specialty standards and to examine surgeons' skill, knowledge and aesthetic judgment in the field of hair restoration surgery.  

The American Board of Hair Restoration Surgery/International Board of Hair Restoration Surgery (ABHRS/IBHRS) is the largest worldwide entity to have established standards for certification for education, training and experience in Hair Restoration Surgery. Physicians who are eligible to apply for ABHRS/IBHRS certification have demonstrated the accumulation of significant experience in the field of Hair Restoration Surgery and have all shown a commitment to high standards of training and education. Those who have achieved certification have demonstrated advanced knowledge in the art and science of hair restoration through peer-reviewed examination. While there is currently no American Board of Medical Specialties (ABMS) certification specific to hair restoration, the ABHRS/IBHRS is the only certification recognized by the International Society of Hair Restoration Surgery, the largest hair restoration educational organization in the world. You may visit their website at http://www.abhrs.com/members.php

Several other organizations have websites with published lists of preferred hair restoration surgeons. (The surgeons have been selected by the lay organizer of the site). The ABHRS is the only formal organization that uses a panel of physician judges and demands that candidates pass a written and oral examination.

22. How many procedures will I need?

CLICK TO ENLARGE