Cam Simmons MD ABHRS

This man in his mid-50s had worn a turban for most of his life. His hair was twisted in a top-knot and there was a tight band around his hairline. He suffered from Traction Alopecia that most affected his temporal points but also created some irregular loss in his frontal hairline. The traction also likely markedly altered the direction of the spared hair near his hairline.

He was content with his frontal hairline and was only interested in transplanting his temporal areas. We transplanted 1994 follicular unit grafts at about 42 grafts per square cm, paying particularly close attention to the direction and flat angulation of the grafts.

I apologize that the best follow-up photo I have of the left side view was taken with a camera phone and the quality is poor. His hair is fully grown so I will not have the opportunity to take more photos.

Originally posted by aaron1234:

Could someone explain the difference between laterals and sagitals. I'm clueless. Thanks.

Hi aaron1234

When placing grafts in a 3-dimensional position, we talk about direction, angle, and orientation of follicular units (and depth).

Hair on the scalp has a flow to it much like the flow of water in a river. The hair grows in a direction that usually flows outward from 1 or 2 whorls. If we say that a particular graft grows forward and slightly toward the right, we are discussing the direction of that graft.

If we say that the graft is growing upward at a 30 degree angle to the surface of the scalp, we are discussing its angulation.

The orientation of the graft can be the most difficult concept to understand. A recipient site slit is longer in one direction and much narrower in another. The orientation of the slit is said to be "sagittal" or "parallel" if the slit is longest in the direction of hair growth. It is called "coronal", "lateral", or "perpendicular" if the slit is longest perpendicular to the hair direction. Technically, "sagittal" means in a line between front and back, and "coronal" means in a line from side-to-side. Because of tradition, the terms are still used even though sagittal slots aren't really sagittal and coronal slits aren't really coronal - especially in the whorl.

If the slit is longer than the graft is wide, there can be play that might affect the angulation more in a parallel slit than with a perpendicular slit but that play would affect the direction more with a lateral slit. If the graft and slit are well-matched there is less wiggle-room for either the direction or angulation to change.

Drs. Hasson and Wong first promoted the notion of creating lateral slits because they said the hairs in a follicular unit placed in a lateral slit would line up side-by-side and create more of a shingling effect than if they lined up front-to-back in a sagittal slit. While some follicular units do have parallel hairs, many have criss-crossing hairs or bundles. The orientation is clearly less important for those follicular units

I believe that in the whorl, just as in other parts of the scalp, the correct direction and angulation of the grafts are more important than the orientation.

Thanks for posting these photos Dr. Beehner. They better demonstrate the need for long-term planning than a thousand words.

Your patient must also be pleased that his follow-up photo looks more like his 28-year-old photo than his pre-op photo.

This lady had gradual hair loss throughout the front and top of her scalp but had a bit denser hair in her hairline, as is common in female pattern hair loss. Her miniaturizing hair on top would not grow as long as she would like. She wore her hair short and parted above her right eye and her hair predictably looked thinnest in the front and where it was parted. She had brown, salt-and-pepper, slightly wavy, average diameter hair.

Her hair transplant was designed to look best with her right part. The grafts were dense-packed in her midfrontal forelock and along the front of her part and blended outward into her existing hair. She had a single-layer, trichophytic top-edge closure. (I now typically do a single-layer, trichophytic lower ledge closure with routine undermining.)

She switched to a left part before having her hair transplant and wore it afterward to help hide her hair transplant and any shock loss. She also started Minoxidil. After about 6 months, she switched back to a right part. She continues to wear her hair parted above her right eye but is growing her hair out longer.

Originally posted by generic1:

Hey guys,

 

My research phase is drawing to a close and I'm about to choose a surgeon pretty shortly.

 

I want to make sure my pre-op photos are good enough for everyone to evaluate for the before and after stages. I've tried to mix in a variety of lighting brightnesses and flash settings.

 

Thoughts? Suggestions?

Hi generic1

I understand that you want to protect your privacy and are demonstrating cropped photos here.

Did the doctors see photos that show your whole face? I use facial proportions and facial features to help me design hairlines. If some or all of the doctors had only cropped photos to work with, that might account for some of the differences in the hairlines they drew.

Originally posted by BobbyZ36:

... I would think nape of neck hair is the solution for most. Yes I understand it's been said that this hair is not totally immune to DHT and may fall out later, but I've yet to see concrete proof of this. I've never seen a study about this subject... and I also have made a point to look at the neck of balding men over the past few months and I've yet to see one who has lost this neck hair...

/QUOTE]

 

Hi BobbyZ36

 

I think it is fair to say that most men don't lose a lot of hair from the nape of their neck but some do. Especially for young men, it is hard to predict who will keep their neck hair and who will lose it.

 

This is a photo of a man in his 50s with a Norwood 7 pattern of hair loss. He has had Retrograde Alopecia, which is fairly common for men with a Norwood 7 pattern. Retrograde Alopecia is recession of the hair from the neck up. It is easy to see that if he had had nape hair transplanted into his hairline 10 or 20 years ago, there wouldn't be much left now.

 

It is also interesting to note how low his hairline has receded in his crown. I have seen photos in this forum of patients, who seem to be in their 20s or 30s, who have had FUE grafts or even strips taken from higher than this.

 

The safe zone is well-described in our medical literature but it is probably easiest to describe as the fringe of hair you would be left with if you developed a Norwood 7 pattern of hair loss, like this man. If you take grafts from above or below the safe zone, the hair in those grafts could disappear later and scars could become visible (whether produced by strip removal or FUE.)

 

As the hairline is critical, most doctors want to create a natural-looking hairline that will last by using scalp hairs from the safe zone.

 

I hope this helps.

Originally posted by Dr. Glenn M. Charles:

I would be the first to admit that Hair Transplantation is one of the most staff dependent procedures in medicine. You have to remember that these are the people that create the grafts and do most od the placing. That means that they are handling the grafts much more than the doctor. It is critical that they are watched very closely by the doctor and that they also take as much pride in the job as the physician. I value my staff and realize that I would not be where I am today without them.

I would like to echo Dr. Charles' opinion.

Hair transplantation is a team sport. The doctor is the quarterback, coach, and general manager but you can't win championships without great players.

When hiring and training a technician, you need someone who has manual dexterity, people skills to make patients and staff comfortable, but mostly you need someone who is dedicated to being the best at what they do.

There are many steps in every hair transplant and the results are only as good as the results of the poorest step. High quality work from Doctors, Sliverers, Graft-cutters, and Planters is essential for consistent high quality results.

Ultimately the doctor is responsible for everything. It is up to him or her to make sure that he has got the right people on the bus, the right people in the right seats, and the wrong people off the bus (as per Jim Collins in "Good to Great".)It is also up to the doctor to supervise every step of the procedure. I have staff that are self-motivated and reliable so I can trust them to do what they do best. Supervising them involves spot-checking each step throughout the day and fine-tuning the plan as we go. If I had to look over every staff member's shoulder every minute of every day that would mean I put the wrong people on the bus in the first place.

Great doctors only keep great technicians on their team and great technicians only want to work for great doctors. I am blessed with a fantastic staff, who are highly skilled and always do their best work ... and I should tell them this more often!

Originally posted by Abedogg:

GQ - I'm no doc, but if this is a tool that extracts and directly places, how can the doc be sure that the graft is not transected?

(assuming the graft stays in the instrument from donor to recip).

 

Abe

Abe

As far as I know this in only a tool for implantation and it can't be used for extraction. However one obtains grafts, those grafts are transferred to the implanter for placement.

I have never used them myself so I am not an implanter expert.

Originally posted by Mr. GQ:

will some kind doctor please take a look at this video and let me/us know what kind of graft placement is going on there. is this typical placement? is it stick-n-place technique? or what in the world is going on there??? i always thought that the grafts are placed with some kind of tiny forceps. do you see any advantages (pros or cons) to this placement technique?

 

here is the link (only first 30-40 sec. needs to be seen):

http://www.youtube.com/watch?v=oJ-LiM_rbRM

 

THANK YOU IN ADVANCE!!!

Mr. GQ

I have looked at the video and the doctor appears to be using a "Choi implanter" or something like it. I think he is repeatedly passing the used instruments to an assistant off-screen and is being passed another instrument that has had a graft "loaded." The implanter has a hollow needle and an assistant loads a graft into the implanter's chamber (usually with forceps. Often there are a few assistants loading the implanters because they take longer to load than to use. The doctor makes an incision with the needle then pushes the plunger on top to insert the tip of the graft into the incision then uses the tip of the needle to guide the graft into the incision. It is up for debate whether there is more handling or less handling of grafts with this method compared to using forceps to insert a graft directly into an incision. Careful and skillful handling of grafts is required with either method.

I don't have any direct experience with this instrument. I have heard that the instrument can get dull quickly so some doctors still pre-make the incisions then just use the implanter to plant the grafts. Implanters tend to work best with straight, coarse single haired grafts or narrow doubles and are said to be less well-suited for larger follicular unit grafts. I believe that implanters are used more commonly in Korea than in Canada or the USA. However, when I did a Google image search I found the best photos and diagrams on a British site.

If another doctor has experience with implanters and would like to correct or modify my note, I promise that I won't be offended.

Kind regards,

While I don't use multi-follicular unit grafts myself, I agree with Dr. Beehner that hair transplantation is an art and there is more than one way to get great results.

Dr. Beehner is one of the most analytical doctors in the ISHRS and he has made great contributions to the field of hair transplantation. It is clear that he thinks carefully about everything he does, including where he does and doesn't use MFUs.

I had 4 mm punch grafts in 1989 and it took 5 years for me to take money out of our family budget to start filling in around them. I therefore appreciate both sides of the cost vs. naturalness argument.

The cost of a hair transplant relates to the work done and the time spent. We try to get the most cosmetic impact from each graft so we can work within a patient's budget as much as possible. Using MFUs is one way to economize but there are others.

I prefer to use all follicular units because you can get good density without using MFUs and FUG bear closer scrutiny. My dark-haired, big plugs on white skin are hidden quite well with the minigrafts I had in 1994 and 1998. The minigrafts are hidden by the follicular units I had in 2001 and 2004. Others don't notice them but I can still find them. (These days, the plugs would have been reduced and the follicles reused!)

Every doctor who wants what is best for his or her patients will use the techniques or strategies that work best for them. Some doctors get great results with lateral slits and skinny grafts. In fact, we did switch to lateral slits in the leading edge of the hairline. However, we stick-and-place chubby grafts most of the time because I believe that that is what works the best in our hands. Doctors have to learn and adopt 'new and improved' techniques but we don't have to abandon older techniques if they work well and are used in our patients' best interests.

These numbers don't fit with my experience or with "Norwood's study of 1000 men by type and age", as published in Unger's textbook.

In Norwood's study, 6% of men had 'Type III' (Stage 3) loss before 30 and 3% of men had Stage 4 loss before 30. (Total for both stages = 9%). 11% of men between 70 and 79 had Stage 7 loss in contrast to only 3 % of men between 40 and 49. If you assume that more men aged 45-49 will have N7 loss than those aged 40-44, you could argue that over a third of men with N3-4 loss before 30 will have N7 loss before 50. It isn't quite as scary as the quote attributed to Dr. Humayan but it is scary enough.

Most people with AGA probably start losing hair at puberty but don't notice it until their mid-to-late 20s or older. It is safest to assume that the earlier you see hair loss, the higher the chance you have of losing a lot of hair.

I always plan for the worst and hope for the best. That is I assume that everyone will stop taking or using their meds and that everyone with AGA in their 20s and 30s will eventually develop at least a Norwood 6 pattern and that some will get a Norwood 7 pattern. Some would argue that this is too cautious but it fits well with the medical philosophy 'First, do no harm.'

Thanks Mr. GQ

I do some FUE but I do much more FUT-T (Follicular unit transplantation with trichophytic closure.)

For FUE, I mostly use Dr. Harris' SAFE technique and do all the extraction myself. As with any skill, you need to do it well before you do it quickly. Speed comes after lots of practice. With closely clipped, straight hair, I can extract and transplant 1000 grafts per (long) day. With long, straight hair or short, very curly hair, I can extract and transplant 600 grafts per day. I am not the doctor to pick for FUE megasessions. My fees reflect the work required so a 1000 graft FUE session currently costs the same as a 3000 graft FUT-T session.

FUE can be a valuable tool to reduce bigger grafts and then reimplant the follicular units. I also find FUE useful if a small number of grafts are required, as in eyebrow or scar transplants. If someone wants to keep their hair very short, FUE scars may still be less noticeable than trichophytic scars (but I am working on that.)

I still encourage most patients with a significant area of hair loss to have FUT-T because it is much more economical, takes less time, and I have much more experience with FUT and more confidence in it. Most patients do not intend to shave their head after a hair transplant and modern trichophytic scars are easy to hide with hair as short as ?? to ?? inches long.

After all is said and done, if a patient chooses FUE over FUT-T, I will do it. So far, I have had good results. I still suspect that you won't see many FUE results in my photo gallery in the near future.

As paraphrased from Jim Collins' book 'Good to Great', one needs to focus on what they can do best but can't ignore other important technologies. I, personally, would rather be a world-class FUT-T doctor who can also do FUE than a world-class FUE doctor who can also do FUT-T.

Thank-you all for your comments and suggestions.

As a result, I will add close-up hairline and donor scars as part of my routine at future follow-up visits.

Bill reported accurately but I have gradually changed my trichophytic technique since our interview.

I routinely measure the vertical scalp laxity and plan to keep the donor strip narrow enough to avoid undue tension. Particularly with simple closure for younger men, scars that are narrow at 1 month may stretch a bit in the next few months. Either using deep sutures in a 2-layer closure or undermining the edges a short distance just below the follicles (and well above the nerves and vessels) can reduce the forces that would tend to stretch the scar. Each method has its own benefits and risks. I have actually not used a 2-layer closure since October 3, 2008 but now routinely undermine at least one edge no further than the width of the donor strip (as per Dr. Frechet's technique.) I have adopted Dr. Rose's technique in taking a ledge off the bottom edge. Each doctor will find what works best and most consistently for them. Whatever works best for them is best. This technique is currently what works best for me.

I know that I will not be able to be as active as Dr. Feller in the forum but I will try to answer your questions.

Regards,