Clip Hair Extensions

In today’s world, where people don’t have time to work out or spend few extra minutes taking care of their hair, there are hair products available which make life easy. Do they really make life easy is something we need to ponder about before using them. There are some who love to brush their hair all day, and claim to have read that it helps hair grow faster, but in fact this is a myth and not true. If we brush our hair too much, it could lead to hair breakage and damage. Most experts advise people to use a comb and not a brush on their hair, no matter what the length is. This is said to untangle all the knots and not be harsh on the hair. Similar, use of hair dryer on a daily basis to dry hair after wash is also not good. It will help keep your hair dry and save you time in towel drying it, but the heat will harm the strands making them break easily. Since work piles up and one needs to rush to their work place, the only task on which they can save time is in such trivial yet important ones.

Women all over the world spend hundreds of dollars on hair dryers, straighteners, irons and on curlers. What they fail to realize is that these hair products will help in creating a new chic look, but will not help hair grow or curb hair loss. Every time a person uses the hair iron, they are subjecting their delicate strands to high temperatures which could cause breakage and hair losing its natural nutrients. If they have frizzy hair, and want to straighten it to make it look smooth and silky, they might use straighteners. All this will lead to drawing away the moisture content from our hair leaving it dry and dehydrated. Again if one were to use hair dryer every time they wash their hair or while setting their hair, the heat generated will harm the hair cuticles causing them to break away.

Trying to stay in sync with fashion and emerging trends will lead to us spoiling our natural beauty while trying to look like someone we are not. For models and actors, they need to let the director decide the look for the day and patiently endure all the treatments they are subjected to. Putting on make up, changing hair styles every couple of minutes, wearing different outfits, is all part of their profession, but it does take a toll on their overall health including their hair. In such cases, they are advised to use hair products that have moisturizer and adequate stimulants to revive the blood cells. They are also encouraged to take vitamin supplements to keep their body energetic and fit.

It is not easy adapting to different emerging trends, and following them. There are some who are still sporting the look that was around in the 70s and for them, this is the most comfortable. There are others who change their hair styles, cut their hair regularly and get other treatments done so they fit in with their peers or grab attention to themselves. These people need to make use of the available hair care products if they wish to maintain their tresses ten years from now.

It is important to keep up with the fashion world, but not at the expense of putting your health at risk. This will not be of any use to you as you will end up losing all your hair.

Questions and answers from US Hair Restoration could be found on their website. At Los Angeles Hair Transplant Clinic of US Hair Restoration patients are examined and assessed for hair transplant surgery. There is a wide web presence and patient’s education on different blogs and forums on hair restoration surgery. Following you can find some of the recent questions that are answered by Dr. Mohebi in the popular web log of US Hair Restoration (Hair Restoration Blog). Patients ask about hair restoration with donor hair from other people of the same family. Other questions include, body hair transplant, hair transplant from other parts of the body such as armpit and pubic hair. Balding patients who had hair transplant want to know whether or not they may lose the transplanted hair. Below is the answer to those questions and a few more on hair loss treatment in our California hair transplant center.

OK the first question was on the use or the hair of other members of the family as donor? The answer is, no, the transplanted hair acts as a transplanted organ and will be rejected unless patient is on anti-rejection medications like what we can see in kidney transplant.

Can the transplanted hair at the fore part of the head get receded again? If yes, how long does it take to begin? The answer is no again, transplanted hair will not recede. With the new techniques of evaluation of hair loss before hair transplant that we offer in our Los Angeles California hair transplant centers, they determine the quality of the donor area, before hair transplant surgery. Most men with typical male pattern hair loss are expected to have stable donor hair and they never lose them. Transplanted hair is considered permanent and there is no chance that patients lose it in regular male pattern baldness. However patient may continue to lose his own native hair if there is any left around transplanted hair. US Hair Restoration recommends finasteride to most patients peri-operatively to prevent shock loss that could be seen after hair transplant surgery.

One patient was concerned with the scar of the back and asked if the hair recedes to the back of the head, the scar of the surgery appears and it is so ugly. What should we do in this case? And in the case of FIT (FUE) after receding in the back, that area looks very sparse and with little hair? These make a bad appearance. What should be done in this case? Scar or a hair transplant surgery with strip technique should never be seen if placed properly. The only way you can see the scar is if you decide to shave your head. If you plan to shave your head for any reason scar of the strip technique surgery may be seen and you may want to choose FUE or as some people call it FIT (Follicular Isolation Technique).

Follicular Unit Extraction – FUE or FIT are the same and if done properly should get hair follicular units evenly throughout your donor area on the back and it should not look like it is thinned out in any particular area. At the Los Angeles hair restoration surgery clinic of US Hair Restoration, the donor area is evaluated with microscopic miniaturization study to confirm its stability on all areas before proceeding with FUE surgery. For sure the donor area on the back of the head will be thinner than before the hair restoration surgery, but density of the hair on the back of our head is not what makes you look bald. Not having a solid frame for your face is responsible for the appearance of baldness and can make you look older and restoring this frame restores youthfulness of the face.

There has been a recent surge of interest in “laser hair transplantation” that has paralleled the increased use of lasers for a wide variety of cosmetic surgical procedures. Lasers generate great enthusiasm on the part of both physician and patient, but this has sometimes exceeded the actual value of the laser as a surgical tool. An obvious example has been the use of the CO2 laser as a nonselective, destructive modality to remove tattoos which left scarring and a cosmetic deformity worse than the tattoo itself. This has been subsequently replaced by pulsed lasers with specific pigment absorption (such as the Nd:YAG, Ruby, and Alexandrite lasers) operating on the principle of selective photothermolysis that truly offers benefit in the treatment of these lesions. Super- and ultra-pulsed CO2 lasers are now being used to replace “cold steel” in generating hair transplant sites. However, before we rush to use lasers in hair restoration surgery, we should first apply logic and reason to this application, and then proceed cautiously with carefully controlled studies so our patients will only benefit from its use. The following discussion will address various aspects of current laser technology in the specific context of the most recent advances in hair transplantation techniques. The intent will be to challenge the theoretical basis for the use of existing lasers, to question some dubious claims regarding their benefits, and to suggest future areas of laser research. WHAT IS A LASER HAIR TRANSPLANT? First, it is important to clarify what is meant by “laser hair transplantation.” The present role of lasers is to solely create the holes or slits (recipient sites) for the grafts to be inserted into. To consider this a “laser transplant” is to ignore the myriad of other factors that contribute to making the procedure successful. Until lasers are involved in other major components of the transplant, such as harvesting, graft dissection, or placing, “laser hair transplantation” should be replaced with a term such as “laser site creation” to more accurately reflect its current role in the procedure. A PAINLESS PROCEDURE?The claim that laser transplantation is a painless process is misleading. The lasers currently being used are “ultra – or super – pulsed” CO2 lasers. Unlike lasers that operate by selective photothermolysis, these lasers create a hole by simply vaporizing tissue. Because the pulse (span of time the beam is on at any given moment) of these new lasers is extremely short, there is not much heat transfer or injury to “surrounding tissues.” Nevertheless, the tissue which the laser acts upon is nonselectively destroyed. Because of this, the laser is extremely painful unless local anesthesia is administered to completely numb the area prior to its use. Thus, it is not the laser that is painless. The pain-free environment is set up by the preoperative anesthesia used in all transplant procedures. BLOODLESS SURGERY The next claim, that the laser procedure is relatively bloodless, minimizes the most important physiological consideration determining the success of the transplant, namely oxygenation. The hair transplantation process should be aimed at maximizing blood flow to the implanted hair follicles, rather than reducing it, and any manipulation that compromises proper oxygenation will potentially compromise graft survival. Preliminary results suggest that when the laser sites are compared to sites made with conventional surgery, “a few patients have shown less hair yield in some of the laser grafts [1].” Dr. Unger points out that when making conventional slit sizes with the laser, “we are close to an unacceptable width of thermal damage.” The experience of Khan is similar, and he expresses special concerns of decreased growth when the distance between laser sites is 1 mm or less [2]. When using extensive micrografting techniques, the spaces between grafts are often in this range, and the cumulative thermal damage produced in large sessions may prove disastrous. It is, therefore, extremely important to objectively measure the impact of the coagulating effects of the laser on blood supply and graft survival in the setting of extensive micrografting, since this does appear to be the trend of the future [3]. As with electrosurgery, the laser specifications can be modified so that there is relatively more cutting than coagulation. It seems reasonable that work be focused in this direction, as this will decrease thermal injury while, at the same time, taking advantage of the laser?s ability to make rapid, uniform sites. PROBLEMS WITH HEMOSTASISThe coagulating effect of the CO2 laser may enhance visibility during the procedure, but the application of bi-manual traction on the skin and the judicious use of epinephrine can also provide hemostasis and allow for adequate visibility during both site creation and the placing of grafts without compromising the blood supply. Cold steel techniques that produced defects in the recipient area in the form of slits, 2-6 mm in length, or punches 1.5-5 mm in diameter, significantly compromise blood flow to the recipient site and reduce graft survival when the transplants are made too close. The laser has the added detrimental effect of sealing off the microvasculature. The poor growth with older techniques taught us the vital importance of preserving the vascularity in the recipient area, and this lesson should not be wasted when trying to increase operative visibility with the laser, especially when this can be accomplished by simpler means. INTEGRETY OF THE CONNECTIVE TISSUE Another problem created by the laser is the destruction of dermal collagen and elastic fibers. This effect on recipient tissues causes a decrease in normal skin elasticity and, as a result, grafts have an increased tendency to fall out from laser-made sites. Certainly, one would have to question if the grafts that remain are secure enough to ensure optimal growth. Work by Beeson has shown laser sites to have more necrosis and scarring 3 days after surgery and more fibrosis at 2 months than with the sites made with steel [3]. The elasticity of normal skin allows the recipient site to grasp the small follicular implants and secure them in place. This assures for the close proximity of the sides of the implant to the dermis in the recipient site, which serves to minimize microscopic dead space and hematoma formation, and facilitate healing. In a new method of hair restoration surgery recently described in the International Journal of Hair Restoration Surgery [4], where the actual follicular units are used as the implant, recipient wounds as small as 1.0 to 1.3 mm in length can accommodate as many as four hairs. This is accomplished by taking advantage of the anatomic proximity of hair within each naturally occurring group and discarding the intervening skin in the dissection. In this situation, the preservation of recipient dermal elasticity is evidenced by the fact that patients undergoing follicular transplant procedures are able to shower and gently rinse the transplanted area the day after surgery without the risk of losing their grafts. In addition, the rapid healing allows oozing and crust formation to subside over this same 24-hour period. When healing is complete, there is no clinical evidence of scarring, even when the scalp is shaved. LASERS: NEW TECHNOLOGY FOR AN OUTDATED TECHNIQUEThe major advantage that lasers are claimed to have over traditional slit and punch grafting is that they can create a slit (which purportedly looks more natural than a hole created by a punch), while, at the same time, removing tissue like a punch to make more room for the implant, in effect, having the best of both worlds. In the older techniques, where the grafts were not “anatomic” and contained hair that reached across multiple follicular units, the recipient site needed to accommodate it was unduly large, causing poor healing, as well as graft compression. In follicular transplantation, neither large slits nor punches are required to accept the donor grafts. By identifying the patient?s natural hair groupings, the implants can be pre-trimmed of the excess tissue between the groups, resulting in tiny follicular units that can be placed in very small sites, solving the problems of both recipient bulkiness and compression. Therefore, the claim that lasers have the advantage of removing recipient tissue while creating a slit has no relevance in follicular transplantation. THE DIRECTION FOR LASER RESEARCHFuture laser research should be directed toward a technology that could “read” the follicular groups “in situ.” In the donor area, the laser would dissect away the tissue between follicular units having the effect of decreasing the transplanted volume of skin, while maximizing the transplanted quantity of hair; producing an implant containing hair groups matching those found in nature. In the recipient area, current laser use is limited to areas relatively devoid of hair, as the beam would obviously damage any adjacent follicles. It is also limited in its ability to re-treat an area already transplanted, unless significant spacing were left between the previous grafts. In contrast, hand-made sites using a very small steel instrument can easily avoid existing hair or grafts, and if a follicle was “hit,” it would most likely survive the trauma or regenerate from its growth center. Much of current laser research has been directed to the production of a laser scanner that has the ability to rapidly produce uniform sites in either a grid-like pattern or random distribution without regard to the location of existing hair [5]. In order to be of general value, the laser must be able to identify the existing hair and make sites only in the intervening spaces, requiring a level of technology not presently available. Another challenge of the laser scanner would be to compensate for variability in laser effects brought on by the inherent curvature of the skull. Not only will the changing contour serve to amplify or defocus the beam by altering the effective operating distance, it will also change the incident angle of the light source and, ultimately, the direction of the hair. These adjustments are now performed manually, but are, nevertheless, critical to a successful cosmetic outcome. There is also significant variability in the thickness of the scalp from one patient to another and in different regions of the scalp. The laser must be able to at least match the sensitivity of the human transplanter who can “feel” these differences and can limit the depth, sparing injury to the larger blood vessels and nerves. In order to have a more natural appearance, modern lasers should generate sites only in a random pattern rather than according to an organized template. Finally, artistic nuances used in creating a delicate hairline, a widow?s peak, the swirl of the crown, or in rebuilding the temples (with its abrupt directional changes) would be difficult to program into the laser and might still have to be accomplished manually. A look at current research in hair transplantation worldwide suggests that in the near future, significant advances in hair restoration surgery may lie in automating the manual process, rather than in laser surgery per se. Mechanical instrumentation currently being developed will streamline the entire procedure, from the harvesting of the donor strip to the creation of sites with the simultaneous insertion of the implants. The role lasers will play in this overall process is still unclear. CONCLUSIONSAs laser technology improves, laser sites become smaller, and the problem of thermal damage is adequately addressed, the advantage of rapidly producing large numbers of uniform sites will make the laser a more valuable tool. When the laser, directed at the donor area, can cut skin by “reading” the spaces between the natural hair units with minimal thermal injury, it will significantly alter the transplant process and create a more compelling argument for its use. And until the laser scanner can be designed to avoid existing hair, this instrument will not be truly versatile. Hopefully, this level of sophistication is not “light years” away. Until then, let us be cautious and allow time for science to catch up with our enthusiasm. Only when the power of the laser has been applied successfully to all of the critical elements of the procedure may we rightfully use the term “laser hair transplantation.”REFERENCES1. Unger WP. More on laser use. Hair Transplant Forum Int 1995; 6:15-16.2. Arnold JE. Report on ASHRS Orlando meeting. Hair Transplant Forum Int 1995; 6:4-5.3. Rassman WR, Carson S. Micrografting in extensive quantities. Dermatologic Surgery 1995; 21:306-311. 4. Bernstein RM, Rassman WR, Szaniawski W, Halperin AJ. Follicular transplantation. Int J Aesthetic Restorative Surg 1995; 3:119-132. 5. Unger WP. Laser Hair Transplanting. Int J Aesthetic Restorative Surg 1995; 3:137-142.

The follicular unit was first defined by Headington in 1984.  He described an FU as consisting of “two to four terminal follicles, and one, or rarely two, vellus follicles, the associated sebaceous lobules, and the insertions of the arrector pili muscles… a single follicular unit is circumscribed by the investing stroma, the perifolliculum.” He went on to say that “the normal density of follicular units is about one per square millimeter.” (1) In the first paper on follicular unit hair transplantation, published in 1995 (2), Bernstein and Rassman used this definition of Headington.  Limmer, who had been referring to these naturally occurring groups as “stereoscopically assisted micrografts”(3) and Seager, who called them “follicular bundles” (4) soon began to use the term follicular unit as well. Limmer’s technique of using stereo-microscopic dissection, the backbone of follicular unit transplantation, required expensive equipment, special technical skills and was very labor-intensive.  Because of this and because many doctors at that time did not grasp the importance of microscopic dissection, or of even using follicular units in the hair transplant, other, more easily to perform procedures were being performed. Surprisingly, due to the increasing power of the internet, follicular unit transplantation became a buzz word in the hair loss chat groups more quickly than it was accepted by their doctors. (5)  This put significant pressure on hair restoration surgeons to learn about the new procedure and adopt its technology.  Although many quickly adapted their practices to perform FUT, others merely changed their marketing – some advertising that they performed follicular unit transplantation, even before buying microscopes. Partly as a response to the misrepresentation, but mainly to further the science, in 1998, a group of 21 hair transplant surgeons, that included Bob Bernstein, Bill Rassman, David Seager, Ron Shapiro, Jerry Cooley, O’Tar Norwood, Dow Stough, Mike Beehner, Jim Arnold, Bobby Limmer, Marc Avram, Bob McClellan, Paul Rose, Guillermo Blugerman, Marcelo Gandelman, Paul Cotterill, Bob Haber, Roy Jones, Jim Vogel, Ronald Moy and Walter Unger joined forces to write “Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques.” (6)In their words, the purpose of the publication was to “provide hair restoration surgeons with guidelines to . . .  facilitate communication among physicians, stimulate research, increase the accuracy by which hair transplant procedures can be represented to our patients and, ultimately, improve the quality of the care that we offer them.In the paper, the following definitions were agreed upon: Follicular Unit – The follicular unit of the adult human scalp is a naturally occurring entity that consists of 1-4, and occasionally 5, terminal hair follicles, 1, or rarely 2, vellus follicles, the associated sebaceous lobules, the insertions of the arrector pili muscles, its neural and vascular plexuses, and the fine adventitial collagen which surrounds, and defines, the unit (the perifolliculum).Follicular Unit Graft – A graft that is obtained by dissecting out the individual, naturally occurring follicular unit. This is also referred to as a follicular unit implant, a term which implies that (unlike most grafts) the ratio of hair/skin is greater in the follicular unit implant than in the original donor area, since some of the non-hair bearing tissue has been trimmed away in the dissection. Micrograft – A 1-2 hair graft. It may consist of naturally occurring one and two-hair follicular units or be derived from larger units which are subdivided. Minigraft – A 3-6 hair graft derived from either a single follicular unit, multiple follicular units, or multiple, partial follicular units. As suggested by Walter Unger, this may be further classified into small minigrafts of 3-4 hairs, and large minigrafts of 5-6 hairs. Slit-graft – A 3-6 hair graft derived from either multiple follicular units, or multiple, partial follicular units where the dissection technique specifically attempts to produce a linear arrangement of follicles, or follicular units. This may be further classified into small slit-grafts of 3-4 hairs, and large slit-grafts of 5-6 hairs.Follicular Unit Dissection – A technique in which naturally occurring, individual follicular units are dissected from donor tissue that has been removed as a single strip (rather than with a multi-bladed knife of more than two blades) in order to keep the follicular units intact. Some non-hair bearing tissue is removed to decrease the overall bulk of the implant. Stereo-microscopic dissection is required. Mini-Micrografts or Slit-grafts Cut to Size – A dissection technique whereby the donor strip is subdivided to produce grafts of specific sizes as defined by the number of hairs they contain and/or the size of tissue that will fit into a specific recipient site. The removal of excess skin is not required. The dissection can be performed with or without magnification and the donor tissue may be removed as a single strip or with a multi-bladed knife. Follicular Unit Transplantation – A method of hair restoration surgery where hair is transplanted exclusively in its naturally occurring, individual follicular units. Single strip harvesting and stereo-microscopic dissection are required. The grafts must be placed into small recipient incisions.  Mini-Micrografting – A method of hair transplantation which uses grafts containing 1-6 hairs, in groups that do not necessarily correspond to the naturally occurring follicular units. The recipient sites may be either incisions, excisions (tissue removed), or both.Two Terminology Extremes: Science vs. Marketing Soon after the publication, Seager suggested to add another term, the “Follicular Family Unit.” (7) To paraphrase Dr. Seager:           When dissecting follicular units, it is sometimes unclear as to which unit a seemingly “stray” hair belongs.  In other words, occasionally it is not completely obvious where one follicular unit ends, and an adjacent one begins. When one is specifically trying to create increased density, a stray hair would be included with an (unusually) close neighboring, larger follicular unit, containing possibly three hairs.  This technique would create a four-haired unit, when there may have been no four-haired units there at all.  One must find two separate units that look close enough to almost “belong together.”  If the two contiguous units are chosen correctly, the resulting unit can be very difficult, sometimes impossible, to distinguish from a naturally occurring follicular unit.  The key to success in this endeavor is the concept of the “Follicular Family Unit.”  If any (“non-family”) two-follicular units are randomly doubled up, the resulting graft will be more the size of a minigraft, rather than a micrograft.  It would need a larger recipient site, which would preclude dense packing because of both technical planting limitations and impairment of scalp vasculature.  If, on the other hand, despite their larger size, they are forced into minute micrograft-sized recipient sites; they would be traumatized during attempts at insertion. Although the term “follicular family unit” was introduced to account for the variability in the anatomy of the follicular unit and to take advantage of these variations in the surgery, other terms were not necessarily based on purely scientific considerations.   A blatant misrepresentation of the term follicular unit was “Follicular Unit Coupling – The Role of Slot Grafting in Hair Transplantation.” (8)  In this case, the author attached the new term to the original slot grafting method.  This was a technique that used slit grafts harvested with a multi-bladed knife and then cut into thin pieces and placed into large slots of skin removed with a rectangular punch.  The term was new and a marketing campaign followed, but the technique was the same as the original one, with no-attempt whatsoever to use, or preserve, follicular units. Between these extremes, is the ongoing struggle to describe what we do in a clear, precise way – in the face of ever evolving concepts and techniques, and an ever increasing number of terms.  The issue at hand is to be able to distinguish which terms are adding to the science and which are just blurring it.  Making Sense of the FU SaladFrom the opening list of acronyms, all used at the recent ISHRS meeting, it seems that we again need to step back and examine the new terms, to see which represent distinct ideas or techniques and which are, perhaps, redundant.  What follows is a first-pass attempt at sorting out the six terms that, in our opinion, are the most confusing, and have the most overlap. They come in two groups: The first is FU Coupling, FU pairing, Double FUs (DFUs) and Multiple FUs (MFUs). The second group includes FUE and FIT.With respect to the first group, we think that there are two distinct situations that doctor’s are trying to communicate with these terms. The first is the technique of placing two separately dissected follicular unit grafts into one recipient site.  This is distinct from the commonly used term “Doubling-up” which many doctors have used to refer to placing two micrografts in one site.  Our suggestion is to use the term FU pairing to refer to the technique of placing two separately isolated follicular units into one recipient site.  We suggest discarding the term FU Coupling as it has been incorrectly associated with slit grafting procedures in past literature and its use will be confusing. The second situation is when a doctor places two (or more) follicular units, that have not been separated in the dissection, into one hole.  In our view, this is clearly not follicular unit transplantation. The reason is that a main advantage of FUT was that in isolating FUs one would remove some of the non-hair bearing skin between FUs, to decrease the bulk of the graft. This, in turn, would allow the doctor to use a smaller recipient site, create less wounding, allow for safely transplanting a larger number of grafts in a single session etc, etc.  Using multiple non-dissected follicular units, in our view, creates a larger wound and accomplishes none of these goals.We are not suggesting that doctors should abandon this technique. Some excellent surgeons incorporate these grafts into their procedures.  We are merely suggesting that it not be called FUT.  Well then what should one call them?  Our answer is to call them what they have always been called, namely micro-grafts, mini-grafts and slit grafts. If one argues that they are now different due to the use of the stereo-microscope, then we agree.  In this case, the grafts should be called microscopically dissected micro-grafts, mini-grafts and slit grafts, to communicate the fact that follicular transection may be avoided.  But these are still not follicular unit grafts any more than a pedicle flap is follicular unit transplantation.  To avoid confusion, we suggest eliminating the terms DFUs and MFUs. So what should we call eyebrow transplants? According to the technique used by most hair restoration surgeons, where they divide up the donor strip into single hairs, it should be called one-hair micrografting.  If one uses the contra-lateral eyebrow for donor hair, then this can truly be referred to as FUT.    FUE and FIT The increased transection rate of FUE harvesting techniques that use a sharp punch (relative to single-strip harvesting and stereomicroscopic dissection) had some doctors immediately question whether this procedure should be classified as a type of follicular unit transplantation. (9)  With the introduction of the blunt dissection technique by Harris, that significantly decreased damage to follicles and increased the preservation of follicular units, the argument for classifying FUE as a type of FUT is considerably stronger – but certainly not bullet-proof – since in some cases significant transection remains and in others the entire follicular unit cannot be captured. (10)The Follicular Isolation Technique (FIT), is a term used by Cole and Rose that refers to an FUE technique that uses a punch with a “stop” to limit the depth of penetration. Although these authors and other physicians question the need for a depth-stop in the extraction technique, FIT is possibly a better term than FUE if the entire unit is not being captured.  In our view, when the goal is just to extract hair, rather than intact follicular units, the term FIT is preferable.Conclusion In sum, these authors suggest that the following four terms and definitions be added to the original classification. Follicular Family Unit  Two closely contiguous follicular units that are dissected as one graft, so that they can fit into the same size recipient site as the largest naturally occurring follicular unit normally used in the procedure.FU pairing  The technique of placing two separately isolated follicular units into one recipient site.  FUE  Direct donor extraction procedures where the intent is to extract the entire follicular unit. If a depth stop is used, this should be indicated.FIT  Direct extraction procedures where the intent is to extract individual or multiple hairs smaller than the entire follicular unit. (In other words, the direct extraction of micro-grafts.) If a depth stop is used, this should be indicated. Micro-grafts, mini-grafts and slit grafts that have been dissected microscopically to prevent follicular transection should be referred to just that, namely: microscopically dissected micro-grafts, mini-grafts and slit grafts.  These authors do not feel that these procedures should be classified as a type of follicular unit transplantation.  We also suggest that the terms FU Coupling, DFUs and MFUs are confusing and should be abandoned.  References1.    Headington JT: Transverse microscopic anatomy of the human scalp. Arch Dermatol 1984;120:449-456. 2.    Bernstein RM, Rassman WR, Szaniawski W, Halperin A. Follicular Transplantation.  Intl J Aesthetic Restorative Surgery 1995; 3: 119-32. 3.    Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation. Dermatol Surg 1994;20:789-793.4.    Seager D. Binocular stereoscopic dissecting microscopes: should we use them? Hair Transplant Forum Int 1996; 6(4): 2-5.5.    Bernstein RM: Microscopophobia. Hair Transplant Forum International. 1998; 8(5): 23. 6.    Bernstein RM, et al.  Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatol Surg 1998; 24: 957-63. 7.    Seager D. Dense hair transplantation from sparse donor area – introducing the “follicular family unit.” Hair Transplant Forum Intl 1998; 8(1):21-23.8.    Bernstein RM, Rassman WR, Marritt E, Seager D, et al: A slot by any other name.  Hair Transplant Forum International 1999; 9(6): 175.9.    Rassman WR, Bernstein RM, McClellan R, Jones R, et al. Follicular Unit Extraction: Minimally invasive surgery for hair transplantation. Dermatol Surg 2002; 28(8): 720-7.10.    Harris JA. The SAFE System: New Instrumentation and Methodology to Improve Follicular Unit Extraction (FUE). Hair Transplant Forum Intl. 2004; 14(5): 157, 163-4.

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 ViewThe 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 AgeThe 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.  ExpectationsThis 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 ExposureAlthough 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 MedicationsAlthough 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 FactorsHair 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.

At our Orange County Hair Transplant Clinic, we received an email from a patient who already had a hair transplant from another clinic. He writes: “I received hair restoration surgery… and my hair never grew in the area and I followed all the directions carefully.” He then asks, “Is there any other solutions to bring back my hair?”Hair transplant surgery can seem as a simple procedure but there are certain factors that can cause suboptimal growth of newly transplanted hair. It is OK for any patient who is considering or has had a hair transplant procedure to be concerned about the survival of their newly transplanted hair. These issues can be categorized into two factors:

Both can potentially determine what the outcome of your hair transplant procedure will be.Technical Issues

Patient Factor

Results are usually more evident after about one year so we recommend having your hair reevaluated by a good hair transplant surgeon if there is any doubt. Once a reevaluation is completed your hair transplant surgeon can help you treat the disorder that caused your less than desirable growth results and even tell you what may have caused your condition.

US Hair Restoration Weblog posted the original blog titled Unsuccessful Hair Transplant

Surgical versus non surgical management of Baldness

(www.divinecosmeticsurgery.com)Baldness is probably the most rampant of plastic surgical problems, and indeed is the most common consultation in males in a Plastic Surgeon’s office. We know the reasons for baldness, and it should not come as a surprise to learn that baldness is also present in females, evidenced by hair thinning and then patches of baldness, particularly in the perimenopausal and post- menopausal women. Various surgical and non surgical procedures like hair transplant, hair weaving and bonding, wigs, medical therapy like minoxidil and finasteride are in use and present a confusing array of treatment for the bald patientSo what are the choices Hair loss and thinning is a direct effect of the role of testosterone on the its receptors in the scalp, and the hair region in the back of the head is usually fairly resistant to the effects of testosterone, and thus maintains hair for longer periods. It is these facts that are the basis of various treatment modalities.Role of Medical therapy Finasteride is a testosterone receptor blocker, and blocks the effect of testosterone. Thus it allows a decrease in hair fall and probably gets back a few of the faller hair, in that the nano hair, that are there, probably get thicker. It is a drug, used primarily in older patients with prostate problems. In baldness the dosage that is prescribed is very small from 1 mg daily to alternate days; at this dose there are virtually no side effectsMinoxidil is an agent that increases the blood supply of the scalp, and indirectly increases the density of the hair, and a small reduction of hair fall. However, less than half of the people who actually use it, have a tangible benefit. Both these drugs need to be taken for prolonged periods, often the life time.Hair transplant – this is the only true solution to baldness. The surgical procedure which is a single day job, done under local anesthesia, and hardly any discomfort, is the only natural procedure available. The hair that is implanted, almost never falls, can grow to any length, and do not require maintenance. There are almost no precautions to be taken after a hair transplant. It is possible to repeat the procedure after 6 months gap for almost 3 times. However we have to know that hair transplant requires 6 months for effect to show, as the hair has to pass through a natural phase. Also, we cannot assure a density, that was present in younger ages, and for one to achieve that kind of density, repeat procedures are required.Hair weaving, bonding – these are artificial procedures, in which someone elses hair is used to cover the head. The hair is fixed to the head with silicone adhesives, or with clips or sutures to the remaining hair. The advantage is that it is a fast procedure, painless, instant, and gives a great density. However low costs should not influence the decision, since one has to go the beauty parlour every 2 weeks to get it refixed, adding to the costs. Also one cannot go out in a strong wind or heavy rainfall, cannot swim, or airdive, or perform any exertional outdoor activity or physical contact sports. Sever allergies are known to occur with the adhesives, and hair gets loose from the constant traction of the clips that is used to fix the patch.HAIR TRANSPLANT IS THE BEST !!!!!!!!!!!About Me Dr Amit Gupta is a Plastic Surgeon from Maulana Azad Medical College, Delhi, who has specialized in the fields of Minimally Invasive Cosmetic Surgery, Microfollicular Hair Transplant, and Lasers. He was awarded with Gold Medal during his training for his academic days, Dr Amit Gupta joined the superspeciality Course of Plastic Surgery at Maulana Azad Medical College which he cleared in 2007 in his attempt. During his training he underwent training in Burns Trauma Management Cancer and Microvascular Surgery Reconstructive and Congenital Defect Correction Surgery. He then pursued specialized fellowships in Cosmetic Surgery in Belgium (Europe) and Brazil. He has trained with Dr Patrick Tonnard in Belgium where he was trained in MACS Lift Surgery which is the most current development in the field of Facial Rejuvenative Surgery in Europe. He then pursued fellowships in Cosmetic Surgery in Brazil where he trained with the likes of Dr Ruth Graf and Dr Ana Zulmira who are regarded as icons in Cosmetic Surgery

In doctors word hair loss is known as Alopecia. Though the term alopecia is common for loss of hair from both body and head, yet it is the head hair that is most common worry between men and women. Thinning hair by hair loss can lead to baldness which often brings along social and aesthetic issues in a person’s life. Baldness is often seen as a mark of old age and depletes your looks thereby affecting your self confidence. From old age, the loss of hair was a social taboo that used to be treated through wigs. Wigs were false hair caps that could have been worn over head and kept in place with help of adhesive or clips. However hair wigs were an uncomfortable solution to bald heads. Today’s youth has a lot of option for hair restoration. Hair Laser treatment, hair transplant, hair weaving are all very popular treatments these days among both men and women. Hair Loss can be a result of other diseases and medications. Apart from that there are different other reasons for hair loss which includes heat damage, hereditary disorder, iron deficiency, compulsive hair pulling etc. Hair Loss due to hereditary reasons is most common among men. This includes male pattern of baldness or androgenic alopecia where hair thinning occurs on a section of the head. If you are looking forward to learn more reasons of hair loss and different hair loss treatments then one site that can be very helpful to you is www.transitionshair.com.au

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HISTORICAL ASPECTS A donor is better if it is as small as possible. The reason is that if a donor is big, hairs grow in . . . a very unnatural appearance. Hajime Tamura – 19431PRESERVATION OF THE FOLLICULAR UNITThe underlying premise of follicular unit transplantation is that the intact, individual follicular unit is sacred. Theoretically, they should neither be broken up into smaller units, nor combined into larger ones.2,3,4This simple idea may not seem like a radical approach to hair transplantation, but when viewed in the context of how the surgery has been performed over the past forty years (when the very existence of the follicular unit went generally unrecognized), it is radical indeed. At present, the majority of hair transplant surgeons will, at times, combine several follicular units or split them up, as they are not convinced that this has a significant impact on either the anesthetic outcome or upon growth. Practitioners of follicular unit transplantation, however, are certain that only this procedure achieves the best cosmetic results and their hair “bristles” when they witness surgical techniques that divide follicular units or transect follicles, techniques they feel preclude optimal growth and waste precious donor hair. In spite of the heated debate, good scientific studies have not yet been performed to resolve these issues.The follicular unit was first defined by Headington in his landmark 1984 paper “Transverse Microscopic Anatomy of the Human Scalp.5 The follicular unit includes:- 1 to 4 terminal follicles- 1, or rarely 2, vellus follicles – associated sebaceous lobules- insertions of the arrector pili muscles- perifollicular vascular plexus- perifollicular neural net – perifolliculum – cirumferential band of fine adventitial collagen that defines the unitTRANSPLANTING INDIVIDUAL FOLLICULAR UNITSThat scalp hair grows in follicular units, rather than individually, is most easily observed by densitometry, a simple technique whereby scalp hair is clipped to approximately 1mm in length and then counted observed via magnification. What is strikingly obvious when one examines the scalp by this method is that follicular units are relatively compact, and are surrounded by substantial amounts of non-hair bearing skin. The actual proportion of non-hair bearing skin is probably on the order of 50%, so that its inclusion in the dissection will have a substantial effect upon the outcome of the surgery. The great benefit of using individual follicular units is that the wound size can be kept to a minimum, while at the same time maximizing the amount of hair that can be transplanted.SMALL RECIPENT SITESThe importance of minimizing the wound size in any surgical procedure can not be over emphasized and hair transplantation is no exception. The effects of recipient wounding are felt at many levels. Large wounds can lacerate blood vessels and although the blood supply of the scalp is extensively collateralized, any damage to these vessels will have an impact on local tissue perfusion. An equally important issue is to minimize the disruption of the microcirculation. This is especially important when transplanting grafts in large quantities. The compact follicular unit is, of course, the ideal way to permit the use of the smallest possible recipient site, and has made the transplantation of large numbers of grafts technically feasible.Densities between 10 to 40 follicular units per centimeter are routinely reported. Densities greater than 40 follicular units per centimeter in a single session have been accomplished, but may result in a decrease yield in some patients. It is important to note that a follicular unit density of 40 units/mm2 can create a hair density of over 120 hairs/mm2 (if all 3- and 4-hair units are used in select areas), and this is a density that many hair transplant surgeons feel is not necessary, or even desirable, to exceed.TRANSPLANTING FOLLICULAR UNITS IN LARGE SESSIONSPutting aside anatomic, physiologic and technical issues for the moment, it is important to emphasize the practical reasons to strive toward large sessions. The specific events that bring a balding patient to the doctor for hair loss will vary, but the common denominator of those seeking hair restoration is to improve their appearance, and to improve the quality of their life, be it personal, professional, or social. Until the transplant is cosmetically acceptable, the disruptions from the scheduling of multiple surgeries, the limitations in activity, and the concern about their discovery, can place a patient’s life “on hold.” It should therefore be incumbent upon the physician to accomplish their objectives as quickly as possible. Some patients prefer smaller sessions for economic reasons. MICROSCOPIC DISSECTION There is probably no other aspect of follicular unit transplantation that has generated more controversy than the use of the microscope. Stereo-microscopic dissection was introduced into the field of hair transplantation by Dr. Bobby Limmer6 in 1987. The following statements summarize the use of magnification: – In order to dissect intact individual follicular units, you must be able to see them clearly.- Only magnification allows their clear visualization in both normal and scarred skin, independent of the specific hair characteristics of color, hair shaft diameter, and curl. Follicular dissection can logically be divided into two parts; the subdivision of the initial donor strip into smaller pieces and the further dissection of these pieces into individual follicular units. The first part of the procedure, the handling of the intact strip, has always been the most problematic. The intact strip however, is difficult to stabilize and is too opaque for transillumination to be useful. The dissecting microscope and other magnification methods allow the strip to be divided into sections (or “slivers”) by actually going around follicular units leaving them intact. The dissecting stereo-microscope is able to accomplish this because of its high resolution (usually 5x more powerful than magnifying loops) and its intense halogen top-lighting that provides continuous illumination, as one dissects through the strip. Back light illumination has also proven beneficial. Stability can easily be achieved by applying slight traction to the free end of the strip. The thin slivers are then laid on their sides and the microscopic dissection of the individual units is completed. With stereo-microscopic dissection, except for the outer edges of the ellipse, every aspect of the procedure is performed under direct visualization, so that follicular transection can be minimized and the follicular units maintained. CONCLUSIONThe entire field of hair restoration surgery has moved toward the use of follicular unit transplantation. While the exclusive use of follicular units is not employed by the majority of transplant surgeons, the impact of this approach has been significant. Hair restoration surgeons are becoming more scientific and precise in their approach to this field. The vague terminology of the past, i.e., round grafts, many grafts, micro grafts, has been replaced with more precise terms. We now converse in a language which details the number of follicular units per square centimeter, hair shaft diameter in microns, and incisional density of the recipient site for any given session. Perhaps the modern era of transplantation did not begin with the micrografting of the ’80’s, but it is only truly being realized with follicular Unit transplantation of the ’90’s.

Densitometry is a technique that analyzes the scalp under high-power magnification to give information on hair density, follicular unit composition and degree of miniaturization. It can be used to help evaluate a patient’s candidacy for hair transplantation and help predict future hair loss. More recently, video-microscopes have been developed that can project the image onto a computer screen and provide a permanent digital record. This paper describes the value of taking objective measurements, using densitometry or video-microscopy, in the hair transplant evaluation. BackgroundOne of the earliest methods of measuring hair density was devised by Bouhanna, who used camera attachments to create a “phototrichogram,” an ultra close-up photograph of hair exiting the scalp. This method provided the capability to document the quality and quantity of hair shafts.  However, the disadvantage of this innovation was that an assessment could not be done until after the film had been developed. [1] In 1993, Rassman introduced a small hand-held instrument, the Hair Densitometer, to make densitometry easy to perform during a consultation. [2, 3].  The hair densitometer is a self-contained, portable, device that houses a magnifying lens and an opening of predetermined size.  The hair is clipped short (~ 1-mm) and the unit is placed directly on the scalp.  An assessment is made from a standard 10mm2 field.  Multiple measurements taken from different parts of the scalp are often helpful, particularly if there is significant variability from one location to another. [4] An advantage of the hand-held densitometer is that it is inexpensive and readily available to be used during the consultation and can provide immediate information regarding a patient’s candidacy for surgery.   A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler. With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10]. The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss. [10-12] A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler.  With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] [Figure 2]The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10].  The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss.  [10-12]    MiniaturizationNormally, follicular units contain 1-4 terminal hairs of uniform diameter and, occasionally, fine vellous hairs, with the two hair populations being clinically distinct.   In androgenetic hair loss, the action of DHT causes individual terminal hairs in some follicular units to miniaturize, where they begin to decrease in diameter and in length until they resemble vellous hairs. Eventually, these hairs will disappear.  In androgenetic alopecia, hairs in varying stages of involution (and thus of varying diameters) cause these two distinct populations of hairs to merge into one continuum.  The changes eventually cause visible thinning in affected areas, but may initially be detectable only through densitometry.At first, miniaturization involves only one or two hairs in select follicular units, but eventually progresses to involve all the hair follicles in genetically susceptible areas.  It has been the observation of these authors that a shift from focal to generalized miniaturization precedes the actual loss of affected hairs, so that total hair counts remain relatively constant until end-stage baldness. [8]  Said another way, the progressive thinning associated with androgenetic hair loss (particularly in the early stages) is caused by a decrease in the hair shaft diameter of an increasingly larger number of hairs, rather than by the actual loss of individual hair follicles.Miniaturization, unfortunately, can also occur in the back and sides of the scalp.  When it affects a person’s donor area, it will have profound implications for surgery. Although miniaturization in the donor area is a relatively uncommon occurrence in men, it is quite common in women, explaining why so many more men with hair loss are candidates for surgery compared to women.  In all cases, donor miniaturization must be assessed prior to considering surgery.Densitometry MeasurementsDensitometry is extremely helpful in evaluating patients for hair transplantation. When determining which persons are candidates for hair transplantation, it can be used to measure the absolute donor hair density (i.e. # of hairs/mm2), the composition of follicular units (i.e. the number of 1-, 2-, 3- and 4-hair units), and the degree of miniaturization. Although the precise hair density and composition of follicular units will not be known until after the donor strip has been completely dissected, at the time of the consultation, densitometry can tell the doctor the approximate hair density. This will enable him to determine how much hair will be obtained from a certain size strip or how large a strip will be needed for a required number of follicular unit grafts.   Densitometry will also give information regarding the cosmetic impact of the hair restoration.  Other hair characteristics being equal, if a person has a high number of 3- and 4-hair grafts, he/she would be expected to have a fuller hair transplant than a person with predominately 1- and 2-hair follicular units.  For example, a typical Caucasian would have follicular units in his/her donor area that contained, on average, 2.25 hairs each.  If there were 1 follicular unit per mm2 in the donor area (0.9 to 1.0 is normal) then one would need 2,500mm2 of donor tissue for a 2,500 graft procedure. A donor strip that was 1cm wide would need to be approximately 25cm long to contain 2,500 follicular unit grafts.  See the following table. Stereo-microscopic dissection of the donor strip would yield approximately 14% 1-hair grafts, 53% 2-hair grafts and 33% 3- and 4-hair grafts.  The single-hair grafts would be used to create a soft, natural frontal hairline and the 3- and 4-hair grafts would be used in the forelock area to create the appearance of central density.  Small variations in follicular unit density can have a significant impact on the procedure. A person of similar hair shaft characteristics (i.e. hair diameter, color and wave) that had 2.0 hairs per follicular unit, also spaced 1mm apart, would require exactly the same size strip for a 2,500 graft procedure.  In this case, however, the follicular units would, on average, have less cosmetic value and the person should expect a thinner look from the surgery as only 17% of the grafts contain 3- or 4- hairs.  In addition, the ability to create central density via graft sorting would be reduced.  On the other hand, with a donor density of 2.4 hairs per unit, 40% of the grafts will contain 3- or 4-hairs and the ability of the surgeon to create density in the forelock area using only naturally occurring follicular unit will be significant If we look at the total number of hairs contained in the follicular units, we note that for a 2,500 graft procedure, a person with 2.4 hairs per follicular unit will have 1,000 more hairs than a person with a density of 2.0. Densitometry, therefore, gives the physician information regarding the number of single hair units that can be anticipated from a given size donor strip (without having to subdivide larger units) and the degree to which the larger follicular units can create central and forward weighting to enhance the aesthetic impact of the procedure.  Donor Miniaturization  Normally, the donor area shows little or no miniaturization and the density counts described above are useful in predicting both the short- and long-term outcome of the procedure.  However, if genetic hair loss affects the donor area, the situation changes dramatically. Once full-thickness terminal hair begins to miniaturize, the cosmetic value of the follicular unit begins to decrease and the value of the grafts will be diminished.  In other words, just because hair is transplanted, it doesn’t make the hair transplant   permanent – the hair in the donor area must be permanent.      Early detection of miniaturization in the donor area is a warning sign that the donor area is not stable and that the person may not be a good candidate for surgical hair restoration.   If any miniaturization is detected in a young person, i.e. under the age of 25, red flags should go up that their donor area may not be stable.  When miniaturization is noted in a teenager, the risk of developing diffuse un-patterned hair loss (see below) is significant.  In an older adult male, some miniaturization, perhaps up to 20%, is consistent with being a good surgical candidate.  Unlike men, adult women often have significant levels of miniaturization in the donor area, so the mere presence of miniaturization is not necessarily a contraindication to surgery.  However, miniaturization does indicate an unstable donor supply and one has to make a judgment regarding the risk/reward of the procedure. The physician needs to consider the absolute number of full terminal hairs that are available for the hair transplant, the risk of further miniaturization, the area that needs to be covered, and the risk of the surgery accelerating the hair loss.  This is particularly important to consider in women, since hair is often transplanted into an area that has a considerable amount of existing hair – some of which is at risk of being shed from the surgery.  In women, when the risk of continued miniaturization of the donor area is added to the risk of the surgery accelerating hair loss in the area to be transplanted, a far fewer percentage of women are good candidates for surgery compared to men. To think otherwise is disingenuous.  Diffuse Patterned and Un-patterned AlopeciaThe importance of donor miniaturization as a factor affecting a person’s candidacy for a hair transplant was emphasized almost a decade ago in the paper “Follicular Transplantation: Patient Evaluation and Surgical Planning.”[4] In this writing, we described two conditions; “Diffuse Patterned Alopecia” (DPA) and “Diffuse Un-patterned Alopecia” (DUPA). These were first mentioned by O’tar Norwood when he devised the classification of androgenetic alopeica that bears his name.  These two conditions, however, were not detailed in his paper and never received much attention. This was unfortunate because their understanding gives important insights into how to determine who will be a candidate for hair restoration surgery. [5] Diffuse Patterned Alopecia (DPA) is characterized by diffuse thinning (miniaturization) in the front, top, and vertex of the scalp in conjunction with a stable permanent zone. DPA is usually associated with the persistence of the frontal hairline and, in the early stages, the thinning is relatively even across the top of the scalp. This contrasts with regular Norwood patients that have early hair loss at the temples and in the crown with balding that spares the top of the scalp. Patients with DPA can be good candidates for hair transplantation due to their stable permanent zone; however, they have an increase risk of shedding after the hair transplant, due to the diffuse miniaturization across the top of the scalp.   In the less common Diffuse Un-patterned Alopecia (DUPA), the miniaturization process occurs over the entire scalp, so that the person lacks a stable permanent zone. People with DUPA tend to lose their hair at an early age, often beginning in their teens. In the early stages, there may be only a slight suggestion of decreased hair volume overall and actual thinning may only be noted through densitometry. Over time, the back and sides of the scalp can take on a transparent appearance, particularly when the hair is cut short. Because the donor area is not permanent, hair transplantation is contra-indicated in patients with Diffuse Un-patterned Alopecia.    Although fully manifest diffuse un-patterned hair loss is relatively uncommon in men, there are many younger patients who have slightly increased degrees of miniaturization in the back and sides of the scalp, making the long-term stability of the donor area questionable. In these patients, the decision to recommend hair restoration surgery is particularly difficult.  As a general rule, if the decision is difficult, it is best postponed, since, over time, the stability of the donor area will become more obvious.  A mistake can leave the patient with transplanted hair that will thin over time and a donor scar(s) that may become visible. Both Diffuse Patterned and Un-patterned alopecia also occur in women. However, in contrast to men, the DUPA pattern in women is much more common, possibly occurring 10 times as frequently as DPA.  As in men, female patients with DUPA are not good candidates for a transplant, except in the instance where the goal is solely to soften the frontal edge of a hairpiece. The high incidence of Diffuse Un-patterned Alopecia in women partly explains why many fewer women are good candidates for hair transplantation as compared to men.  It is important to emphasize that other, non-genetic, causes of hair loss must be considered in cases where the balding pattern is diffuse.  These include anemia, thyroid disease, connective tissue disease, gynecological conditions, severe emotional events, and medications. Although the presence of miniaturization likely points toward a hereditary cause of the hair loss, with diffuse hair loss other etiologies must always be entertained. ConclusionDensitometry is an important tool for the evaluation of hair loss and for assessing candidacy for hair transplantation.  Measuring donor density and assessing the degree of miniaturization in the donor area should be an integral part of the evaluation of every patient in which surgical hair restoration is considered. This will enable physicians to better select those who are good candidates for a hair transplant and help identify those patients in whom the procedure is contraindicated.  For patients having a hair transplant, these measurements will enable the physician to better estimate the size of the donor strip and be better able to anticipate the aesthetic outcome of the hair restoration procedure.   References 1. Bouhanna P: Phototrichogram: a technique for the objective evaluation of the diagnosis and course of diffuse alopecia. In W Montagna et al. (eds). Hair and Aesthetic Medicine. Roma, Salus Ed. 1983: 277-280.2. Rassman WR, Pomerantz, MA. The art and science of mini-grafting. Int J Aesthet Rest Surg 1993; 1:27-36. 3. Rassman WR, Carson S. Micro-grafting in extensive quantities; the ideal hair restoration procedure.  Dermatol Surg 1995; 21:306-311.4. Bernstein RM, Rassman WR, Seager D, Shapiro R, et al.  Standardizing the classification and description of follicular unit transplantation and mini-micro-grafting techniques. Dermatol Surg 1998; 24: 957-63. 5. Stough DB, Haber RS. Hair Replacement: Surgical and Medical. St. Louis: Mosby-Year Book, Inc., 1996: 139-140.6. Van Neste D, Dumortier M, De Coster W: Phototrichogram analysis: technical aspects and problems in relation to automated quantitative evaluation of hair growth by computer assisted image analysis. In Van Neste D, Lachapelle JM, Antoine JL (eds). Trends in Human Hair Growth and Alopecia Research. Dordrecht, Kluwer Acad. Pub, 1989: 155-165.7. Hayashi S, Hiyamoto I, Takeda K: Measurement of human hair growth by optical microscopy and image analysis. Br J Dermatol 1991; 125:123-129.8. Bernstein RM , Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32. 9. Bernstein RM, Rassman WR: The logic of follicular unit transplantation. Dermatologic Clinics 1999; 17 (2): 277-95. 10. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. 11. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99. 12. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365.