Are You a Surgical Candidate? Why or Why Not?

[Dr. Carlos Wesley]

Patients often come into an office wondering whether or not they are "good candidates" for surgical hair restoration. Even when told "yes" or "no" by the physician, a patient may want to better understand why they are or are not deemed a good candidate and where he or she may fit into the overall spectrum of candidacy.

 

While young patients can certainly refer to a helpful publication authored by our practice (view here) that helps provide a ballpark for the ultimate number of donor hairs one may anticipate over their lifetime, it is helpful to know about the "miniaturization" rule. Using magnified images of a patient's donor hair, a physician can determine the number of miniaturized hairs (those of the finest caliber compared to the regular caliber terminal hairs). As a general rule of thumb, young patients who possess 25% or more of their donor hair in miniaturized form are not great candidates for the surgical procedure. Not only will a large number of the transplanted hairs likely not be permanent hairs, but also the donor scarring (either FUT or FUE) will likely become exposed over time if the surrounding donor hair continues its anticipated course of MPB.

 

The following image depicts a relatively poor candidate for HRS on the left and a better candidate for HRS on the right. This is based on the relatively low number of miniaturized hairs present in the righthand patient's donor area. Both were of the same age.

 

 

This next image also compares a poor candidate (left) with a much better candidate for the procedure (right).

 

 

 

 

 

There are also a number of more subjective variables that help determine a patient's candidacy: the wave, curl, frizz, and color contrast between the hair and scalp. These can also influence the ultimate appearance of a patient after a full session.

 

To put it all together, here is an image of a good candidate's donor area, recipient area prior to treatment, and his recipient area after treatment as seen under a magnified lens. The same patient's transformation after a 2701-graft FUE session with me can be viewed in the accompanying video montage.

 

 

 

 

 

[chrisdav]

Great post Dr Wesley - big fan of your clinic.

 

Is there any more news on the Pilofocus?

[Wes310]

Well said. Unfortunately most doctors do not give a fair evaluation of the donor area and will hide behind statements since as "I can't predict the future" and crap like that instead of using science to give a fair, educated guess on the donor area. At the very least doctors should look at the donor area and refuse to operate on people who are not candidates instead of just taking their money.

 

I am glad to see a doctor on this site talking more about miniaturization of the donor area. This is something that most patients don't understand and most doctors don't want to talk about because it will hurt their income.

[Spanker]

Do you consider and hair not equal to that of the thickest caliber miniaturized?

[BrianR]

I'm 56 and my doc said I have excellent donor hair, are the miniature hairs in the donor area or are they in the area of the transplant..... What I'm saying is, I'm guessing the miniature hairs aren't in your safe zone because the reason they're miniature is because they won't be reproducing new hairs for long?

[MAGNUMpi]

Important thread. Thanks Dr. Wesley.

[Denny]

Thank you very much for this thread, Dr. Wesley!

[Dr. Carlos Wesley]

Thanks for the comments, everyone.

 

Spanker: Miniaturized hairs have a diameter less than 0.03mm while terminal hairs are larger hairs with a diameter exceeding 0.06mm and a length greater than 1cm. These numbers probably aren't going to be that helpful, however, for the average person inspecting their hair in the bathroom mirror. So, I do consider miniaturized hairs in patients relative to their normal, terminal hair shaft caliber. There are plenty of patients with finer caliber hair that are still great candidates if their donor hair consists of a very small percentage in miniaturized form.

 

BrianR: With respect to a patient's candidacy, I am only referring to miniaturized hairs in their donor area. Good candidates will have plenty of miniaturized hairs in their recipient area because that is the area that has and will continue to thin. It is the long-term survival of donor hair that is being transplanted into that area that matters (as well as the careful planning and placement of those hairs into the recipient region).

[scar5]

Great post.

 

What about the effects of Propecia on minaturization?

 

Two little extra gems

 

a) For the SMP curious, look how those very black hairs go blue the moment they go under the skin!!!

 

b) When does the guy look best (and) youngest?

 

For me, not the 11th month, but 6 days post op. At 11 months he looks 10 years older. A case for some brown hair dye?

[ali1991]

Is there a way to know whether your donor is minaturized or not?

 

I'm 22 and planning a FUE with Dr.Hakan, but I would rather get the minaturatization exam done first before proceeding?

 

Who should I consult to get that checked?

[RecedingTide]

Nice of Dr. Wesley to keep it real. The elephant in the room is of course propecia. I know for a fact that some doctors won't transplant a patient unless they're on it and I suspect that in many of these cases it has as much to do with maintaining the calibre of the transplanted hair and integrity of the donor as it does with stopping further native loss on top.

[Dr. Carlos Wesley]

@scar5:

Propecia may delay the onset of miniaturization because it slows down the cycling of hair follicles. With each cycle, hair follicles may become progressively finer in caliber.

 

@ali1991:

There are a number of methods to evaluate hair characteristics. Any physician performing surgical hair restoration likely has something to accurately analyze hair quality in order to determine a patient's candidacy. There are instruments such as the Folliscope, the FotoFinder device, the Dermatoscope, etc. A magnified lens allows for fairly accurate analysis. If you happen to have (a whole lot of) time on your hands, you can read the chapter I authored in the Hair Transplantation textbook called "Enhanced Patient Selection: The Folliscope".*

 

@RecedingTide:

Yes. Propecia is a great adjunct to surgery. Since it is most effective in the crown and mid scalp, it allows for a surgical focus on the frontal half of the scalp and a medical approach on the remaining portions. This can certainly delay the need for subsequent sessions to those areas. Remember, though, once a patient stops taking the medication, any benefit they received is lost. So, it's essential that areas of future loss are also addressed with any surgical approach to transplanting hair follicles.

 

 

*Wesley CK. "Enhanced Patient Selection: The Folliscope" Hair Transplantation, 5th Ed., Ungers and Shapiro: 82-83. 2011

[thisguy1]

Bumping thread because of education value. Nice to see the magnified images and what it means and what doctors are looking for with the damn miniaturized hairs.

 

Also fascinating to see the post op magnified view of a treated area to see how its density compares to a "normal" area.

[HairsGone]

Yes certainly a very good thread and informative.

[Dutchie]

Dr. Wesley, approximately what percentage of patients who come into your office do you have to turn down for a transplant?

[Rashid36]

Many places just give a graft number and price but don't tell if a person is suitable or not or explain why.

People don't like to be told they are not suitable and clinics want to make money.

 

Please see the 3 pictures enclosed and let me know what you think, thanks

[Dr. Carlos Wesley]

Glad to see there is interest in this thread. It's an important topic.

 

@Dutchie, I'd say that for about 30-35% of my consults I discourage undergoing hair restoration surgery. That doesn't mean, however, that there is no alternative. Between the various topical meds that exist and platelet-rich plasma (PRP) therapy (something I know that remains understandably controversial on this forum), there are numerous methods to improve a man's or woman's hair status.

[ontop]

Is there a way to know whether your donor is minaturized or not?

 

I'm 22 and planning a FUE with Dr.Hakan, but I would rather get the minaturatization exam done first before proceeding?

 

Who should I consult to get that checked?

 

I guess the average person wont be able to see so best place to go is a ht clinic near you so they can put you scalp under high microscopic lens.

 

Love to read & see Drs going over & above to educate hair loss guys.

great post Dr Thank you.

[ontop]

Many places just give a graft number and price but don't tell if a person is suitable or not or explain why.

People don't like to be told they are not suitable and clinics want to make money.

 

Please see the 3 pictures enclosed and let me know what you think, thanks

 

Rashid35

Have you physically been to a HT clinic to have a exam on your scalp?

I recall you saying that you sent pictures to number of top worldwide doctors & several of them said just by looking at your picture's that your not a good candidate.

Saying that unless you physically see several doctors then you will have a clear idea.

my point is that its impossible for a doctor to valuate you on this post or even forums.

[Rashid36]

The thing is when i did go to clinics i was not seen by a doctor.

I was seen by clinic manager, someone who had a ht with the clinic and now works for them, sales etc

Some just looked at my hair, one used a magnify glass and one used a computer camera [3 pictures above]

 

I agree pictures online cannot tell but the top doctors were asked there opinion and based on the pictures they were very sure i was not suitable as i posted the reply they gave in my thread.

 

I have been booked for an in person consultation so just waiting now.

[Rashid36]

Another thing i learnt is the importance of knowing who will do the actual surgery

[ontop]

Another thing i learnt is the importance of knowing who will do the actual surgery

 

Take a read of this members post so it may give you some hope good luck link below

 

http://www.hairrestorationnetwork.com/eve/180319-3-900-grafts-norwood-6-7-dr-diep-dr-behnam.html

[Rashid36]

Yes Htsoon and harins case give me hope but i understand everyones hair etc is different.

 

I can see alot of white hair now in my beard and head hair.

I wonder if hair turning white on the sides would affect ht or not ?

 

Also if a doctor can do a ht in 1 go front, mid and crown is that not better than having just front and mid then waiting over a year to have the crown worked on ?

[Melvin- Admin]

Bumping this amazing thread, still very relavant today.