Common Questions and Answers

The answers to the questions in this section of the website represent Dr. Unger’s personal professional opinions—based on his practice experience. Other physicians may answer them differently because of different experiences over their careers. We therefore recommend you also consider reviewing the answers to the following questions in other ISHRS members’ websites.

What is a reasonable long-term hair transplant goal for a man with an average-sized area of Male Pattern Baldness (or who is destined to develop an average-sized area)?

In the long term, the answer is of course the same, whether someone is already bald or is only destined to develop an average-sized area of Male Pattern Baldness (MPB). However, let’s begin with a definition of "average". Figure 1 shows the "types" or degrees of MPB as defined by Drs. Hamilton and Norwood. While their schematic drawings don’t cover all the variations of MPB, they are by far the commonest way that doctors define the severity of MPB. For many men Type V or Type VI MPB is what will likely develop over time, and so we will use Type V to Type VI and average fringe hair density as the "average".

The answer to the question is that a man with Types V or VI MPB can expect to be able to transplant, from the hairline back to a zone where the head changes from a more or less horizontal orientation to a more or less vertical one at the start of the "crown area" in two sessions of approximately 1500 – 2500 Follicular Units (FU) each. The "frontal" and "midscalp" areas including "evolving areas" that still have some original hair but where it is likely to be lost in the future (Figure 13 and 22 The preceding is provided only that the scalp in the donor area has average laxity, average hair density and the surgical team is skilled. Two such sessions at an average density of 25-30 FU/cm² would usually produce what is a cosmetically very satisfactory hair density for virtually all patients (Figs. 16-19).

If the objective was higher than average hair density (generally, an unwise long-term goal for most patients) either more FU/session or a third session would be necessary. (See also "What are the advantages and disadvantages of "dense packing?") If the balding area is limited to the frontal area, a single hair transplant of 1500-2500 FU is nearly always sufficient especially if there is some persisting original hair in the area (Figs. 16-19 and 23-27). If the individual wants to also transplant his crown area, another one or sometimes two sessions would be required (if the donor area was in fact sufficient to yield three or four sessions).

What are the advantages and disadvantages of megasessions?

The larger the number of grafts per session, the larger the area that can be treated. Quite naturally, therefore, many patients prefer "megasessions". The definition of the term "megasessions" varies from physician to physician. We refer to all sessions of greater than 2750 units per session as "megasessions". We prefer to limit ourselves to sessions that are approximately 2750 FU or less per session for several reasons:

1. The more incisions made in the recipient area, the more blood vessels will be cut and the less optimal the blood supply in the recipient area will be. Remember that if 2500 FU are being transplanted even a 1 mm long recipient-site incision (typically made with a 19-g needle or a comparable small blade) means that a total of 250 cm (10 feet) of incisions will be made in the area being treated. We believe that this is trauma enough to an area that is quite often little more than the size of the palm of a typical man’s hand. If the incisions are smaller than 1 mm then the number of grafts can be increased above that number. If they are larger than 1 mm then the number should ideally be decreased.

2. The larger the session the more physical and emotional strain the patient, the physician and all his/her assistants are under. Hair restorations surgery is part science and part art. It is therefore and best carried out when everybody is relaxed and under as little emotional and physical strain as possible. A session of 1500 to 2500 FU usually will produce very nice hair density in one of either the frontal, mid-scalp or crown areas.

3. The more grafts transplanted the longer the sessions will take and the longer the donor tissue will be out of the body. Most practitioners are uncomfortable with that period being longer than approximately 8 hours. Usually sessions of more than 2500 FU will take more than 8 hours.

4. If grafts are being obtained using the "strip" method (Fig 7-9), the only way one can get more grafts per session is to take a wider strip than usual. However, the wider the strip is, the greater the wound tension on closure becomes. The more the wound tension, the greater the chance you have of developing a wider than average donor area scar. This does not mean that most patients who undergo a megasession will develop a wide scar, but, in general, it does mean that the chance of that occurring increases.

If the grafts are being obtained using the Follicular Unit Extraction (FUE) method, whether manual or motor driven or robotic driven punches, the surgeon will often have to decide if he will get more than usual numbers of grafts by getting them in donor areas that contain higher percentages of very likely temporary hairs (Fig 10d and 10e) or by taking the grafts closer together than is generally wise (Fig 10 a-c). The disadvantages of either of these options are discussed fully in the "Principles" section of this website

What are the advantages and disadvantages of "dense packing"?

We define "dense packing" as anything more than 35 FU/cm². If the recipient site incision is only 1 mm long that means that at density of 35 FU/cm², one produces a total of 3.5 cm of incisions in every cm² of transplanted scalp. Nearly all studies have suggested that increasing total incisions length above that number will result in less optimal hair survival in the grafts—and these studies have been done under ideal circumstances, not in the course of every day routine practice (for example see Table 2 below). It is possible to get better hair survival with densities above 35 FU/cm² by making smaller recipient site incisions which in turn requires smaller grafts or maximum trimming of tissue around the hair follicles. However, the latter makes the grafts more susceptible to dehydration and physical trauma as they are being prepared, stored, transferred to, and inserted into the recipient area sites. The need of perfection in the performance of all members of the surgical team must increase as the number of grafts per cm² goes up and the size of the graft and incisions go down. We believe it becomes increasingly difficult to promise such perfection as FU density increases above 35 FU/cm², during a procedure that often includes seven or eight people working on a patient from 7:30 a.m. to between 3:30 and 5:30 p.m. We therefore recommend that ideally 30 FU/cm² be employed in virtually all areas of the recipient area.

Just as importantly, 25-30 FU/cm² produces a very good appearance in nearly all patients (Figs. 16-19). Given the limited supply of donor tissue and the unknown extent of the eventual area of baldness in any individual, we prefer to leave as much donor hair "in the bank" as possible for future use—especially in younger men and women. This is preferable, in our opinion, to producing very dense hair growth in one area at the cost of increasing the possibility of running out of grafts for other areas that the patient will eventually develop, and that he might want to treat. Cosmetically good results only became possible at 25-30 FU/cm² because there were enormous advances in FUT technique from approximately 2000 to 2005. For example, Table 3 summarizes the results of three FUT studies carried out by Dr. Melvin Mayer and colleagues, all of whom are respected and highly competent FUT proponents. Hair survival at the now commonly used density of 30 FU/cm² went up from 72.5% to 98% during that time period. This, "in a nutshell" is the reason I switched from exclusively using FUT in a minority of my patients to using it for virtually 100% of them in 2004-2005.

Notwithstanding the above, the use of up to 40 FU/cm² in small areas such as a small egg-shaped area in the midline of the frontal area is often used for FU containing 3 or more hairs. Such small areas in the egg-shaped "high density area" in the midline frontal area (Fig. 22) can produce an appearance of great density in the entire frontal area at the "cost" of very few "extra" FU/cm².

Do I have to wait until I’m bald or nearly bald before I have a hair transplant?

Definitely not. There are many advantages to beginning transplanting before the thinning becomes easily more noticeable to others. The main ones are that, a) you don’t have to go through the embarrassment of obvious balding or being bald, and b) it usually allows you to spread the inconvenience and/or the cost of transplanting different areas over a longer period of time.

But, the more hair that’s present in the thinning area, the more skilled the physician has to be when he/she is making the recipient area incisions and the more allowance that must be made for the hair loss eventually extending into new areas with the passage of time. For example, unless the recipient site incisions are made at exactly the same angle and direction of the existing hair, many of them could be lethally injured and little or no gain in hair density could be achieved. Both skill and patience are required to avoid such an outcome. Depending on the amount of hair present and the complexity of the hair angles and directions, it’s not uncommon for a good surgeon to spend 1½ to 3½ hours on just this segment of the procedure. The mental and physical demands of a large FUT session is the main reason why I think it is best for most hair restoration surgeons to limit themselves to one such surgery per day. Despite the preceding, and as hard as it is to believe, there are some otherwise very prominent hair restoration surgeons who do not think that the above is necessary – especially in the hairline zone!? Not surprisingly they can usually be recognized by their reluctance to operate on areas that still have persisting hair in the proposed recipient area and especially if they are women.

In addition, as alluded to above, unless a substantial effort is made to anticipate future areas of hair loss, and those areas are treated at the same time as the more obvious areas of thinning, one can end up in what may seem to be an ongoing chasing of sometimes relatively quickly developing new areas of hair loss. For many years we have recommended wetting the hair prior to mapping out the limits of the area to be transplanted so that such less easily noticeable areas can be treated at the same time. If this is done, the possibility of a "chase" is substantially reduced, at least for many years (Figs. 12, 18 and 24). Of course nobody has a magic crystal ball that can tell you how large any balding area will become 15, 20, 30 or even 40 or more years down the road, so the older you are when you begin transplanting, the more likely later sessions in the same or adjacent areas may not be required. The absence of a perfect crystal ball is why I also recommend leaving one or two sessions of grafts "in the bank" in the donor area in younger individuals. That way, if your balding area eventually does extend further laterally than your doctor expected, you still have hair available for further transplanting.

There is, of course, a "cost" to treating less obvious areas of hair loss at the same time as more obvious area are transplanted: If one is using the same number of grafts in both instances, sometimes you will end up treating less obvious areas of hair loss lateral to the more noticeable areas of thinning, instead of being able to transplant farther towards the back of your head in areas that are currently noticeably thinning. Some doctors prefer to do the latter while I prefer to do the former, but ultimately the final choice belongs to a fully informed patient.

It is important to remember that if you transplant into a hair-bearing area, the hair density that is initially achieved will be greater than it will be when the untransplanted hair in that area eventually falls out years later. That’s because you initially will have both the transplanted and untransplanted original hair in that area (Figs.16-19) but eventually you will have only or mostly the transplanted hair. In fact, with the passage of time, you probably won’t have all of the latter!

One further caveat; the transplanted hair grows in its new place for only as long as it would have in its original location. As you get older, the fringe hair, from which you got your donor hair, nearly always gradually gets sparser. That means even some of the transplanted hair may not be permanent. Luckily, much of it is—especially if your doctor chooses to always take your donor hair from the middle of the densest area of the fringe. The latter is because the hair loss in the fringe primarily progresses from its upper, lower and frontal borders so the densest zone towards the middle of the fringe hair has the highest percentage of permanent hairs. (See also "Follicular Unit Extraction" and "Strip Harvesting". In addition, as your hair gets whiter with age, it also looks thicker than darker hair does, so an additional "touch-up" transplant in previously transplanted areas is often not necessary. (Fig 28)

In summary, most of the reasons some doctors give for preferring to not operate on men who are not yet bald are the same ones most of them used to give for not treating women with Female Pattern Hair Loss (FPHL). Yet now, most hair transplant surgeons are quite willing to operate on a substantial percentage of women.4

Should I wait until I’m 25, 30, 35 years old or older before I start hair transplanting?

Because of the potential prognostic problems discussed in my answer to "Do I have to wait until I’m bald?" some doctors recommend just that. Certainly the older you are when you begin transplanting, the easier it becomes to determine the eventual size of your bald area and this minimizes the possibility of unanticipated areas of baldness appearing over time. I think most hair restoration surgeons therefore prefer to operate on older patients. But I believe that the best answer to this question really belongs to the completely informed patient who has to live with the consequences of the answer. Some men, for example, are severely emotionally distressed by their hair loss, some men feel their career depends more than usual on their appearance or that their social life or self-confidence is being too adversely affected by their balding. The longer you can wait to start transplanting the better, because the more accurately your doctor will be able to estimate how big or small both your bald recipient area and permanently hair-bearing donor area will eventually become. So by all means wait if you can, but don’t feel you must do so until you talk to an ethical physician. And if you’re young, a) try to do no more than two sessions until you are at least 30 to 35 years old, b) try to keep one or two potential sessions in your donor area "bank" for the future (in case your doctor’s estimate was too optimistic and, c) ideally, I believe your doctor should leave only one linear scar in your donor area, no matter how many transplants he does on you. (See below). Also, I believe most of you should be more reluctant to have "dense packing" or "megasessions" or "Follicular Unit Extraction" carried out because of the increased difficulty of accurately assessing your long-term donor/recipient area ratio, as well as the density and caliber of the hair in the remaining donor fringe (which also decrease to variable degrees – see below and the "Principles" section of this web site.

Strip Harvesting, what are the advantages and disadvantages of leaving only one linear donor area scar?

There are several advantages:

A) As men with MPB get older, the balding process gradually invades the "permanent" donor fringe hair from both its highest and lowest margins, respectively from the obviously balding area and the nape of the neck. Whether or not the "invaded" area eventually goes bald or not (you may die before it does) it will nearly always lose some of its original hair. As I mention elsewhere, not all the rim hair is permanent. The place that will most likely thin out the least over time is the middle of the thickest zone of hair in your fringe, that is also usually the most distant from the fringe hair margins. The first donor strip should therefore always be taken from this most permanent zone. Subsequent donor strips should also be harvested from this area for the same reason. That means the scar from any prior session(s) should ideally be somewhere within any subsequent strips—again for hair longevity reasons. It is more difficult and time-consuming to prepare FU grafts from the areas immediately adjacent to a linear scar—which is one of the main reasons why many hair transplant surgeons prefer to not do this. But because of maximum longevity, I think the time and effort are worth it.

The hair density on either side of the scar also decreases as the edges of the donor wound are stretched together prior to suturing or stapling. The scar itself is of course hairless. This means that if you want to get the same number of FU as you harvested in the prior strip(s), you have to take a wider strip on each subsequent session. As long as scalp laxity permits a wider strip to close with essentially no tension, there is no problem with that approach. But if a wider strip results in too much tension when the wound is closed, you may get a wider scar than on the prior occasion(s). I believe that the finest scar you can get after each session is more important than getting the same number of FU with each session (or even more FU). In brief, in the long run, closing wound tension is more important than the number of FU.

B) If the scar from a prior session is below or above a new donor strip site, that scar will somewhat decrease the blood supply to respectively either the lower or upper new wound edge. Therefore the new scar may not be as narrow as the prior one.

C) If the scar from a prior session is below a new donor strip site, it will not only result in a decrease of the blood supply to the lower wound edge but will also increase the amount of tissue swelling that always occurs post-operatively at the donor site. This is because such a scar will to some extent delay the drainage of the post-operative swelling down towards your neck. This too would tend to cause a less ideal scar to form.

In summary:

In all the years that I have been transplanting hair, virtually all the cosmetic problems that have eventually occurred have done so in the donor area—not the recipient area. And nearly always the problem has been that the multiple scars that were typically (until approximately 2003) produced in the donor area—and that were once easily covered by the dense surrounding donor fringe hair—gradually became noticeable as that fringe hair became sparser and finer textured with time. I believe that the concept of a single donor strip scar (regardless of the number of sessions) will eventually be seen as just as important to the donor area as Follicular Unit Transplanting (FUT) has become to the recipient area. Having said that, there are rare exceptions to this advice, mostly in older individuals in whom I sometimes will use a new and usually lower donor site for a last session.

Why wouldn’t every doctor who does hair transplanting use "trichophytic closures" for the donor area wound?

To begin with, you should know that trychophytic closure is not difficult and takes no more than a few minutes to do within an operation that takes many hours. There therefore should be no reluctance on the part of the physician to do this, and it follows that everybody isn’t doing this there must be some reason or reasons why that is the case. The answer to the question however, begins with the reality that hair transplanting is a complex procedure that involves many components that can alter the results both in the donor area and in the recipient area. Altering one component can often alter the usefulness or need for another component. With regard to the donor area, obviously if the surgeon is producing scars that are wide enough to cause cosmetic problems for his patients, he would be inclined to add a procedure such as trichophytic closure of the wound, if for no other reason because as noted above, it is so easy to do. If on the other hand his patients are typically very satisfied with their scar results, he may decide to not add it to his technique because of drawbacks which will be discussed briefly below. Similarly, if the surgeon is accustomed to taking strips that are wide enough that closing wound tension is substantial, his/her patient will be more prone to produce a wider scan than somebody who believes in closing the wound with very little tension. (There are some surgeons who believe that if you don’t close a wound with considerable tension, you are "cheating" the patient out of the maximum number of grafts that can be harvested.) Another example would be using what is referred to as "double-layer closure" in which not only the skin is sutured closed but the deeper tissues are closed with another layer of sutures that only dissolve after four to twelve weeks. Most surgeons who like to close their wounds under a lot of tension, to maximize graft numbers, typically use this double-layer closure. But the deep sutures also come with some drawbacks (see below). The above factors and others are taken into account by a surgeon when he decides which combination of alternatives he is going to use in closing his wounds.

But getting back to where we started from, it all begins with a disproportionate number of patients who are getting scars that are cosmetically unacceptable to them. If this is rare, as it is in my practice, and if you expect to operate on the patient again, within one to three years, you might prefer to avoid deep sutures and/or trichophytic closure during a first surgery on that individual.

So what are the drawbacks of trichophytic closure and deep sutures?

Trichophytic closure:

  • A slightly narrower strip has to be taken in order to accommodate for the small extra width of the excision once one side of the wound is shaved off in preparation for closure. Therefore one ends up with either somewhat fewer FU harvested, or a tighter closure, which in and of itself can cause a wider scar.
  • The whole purpose of a trichophytic closure is to get the hair to grow through the scar to camouflage it but this means that the goal is a period of "ingrown" hairs. In many people this does not involve much irritation or discomfort but in others it does. As the latter will last anywhere from four to twelve weeks, in those individuals, it is an added and, in my patients nearly always unnecessary postoperative discomfort. In addition, ingrown hairs can become secondarily infected by bacteria which can also make the scar wider rather than narrower in the areas in which the infection occurs, and of course may require antibiotic therapy – sometimes both prolonged oral and topical – to control the infection.
  • When trichophytic closure was first suggested for donor wound closure by Dr. Patrick Frechet, some years ago, virtually everybody tried it, including me. I found that the scar was virtually never better than when I hadn’t used it, I was getting fewer grafts and too many of my patients were complaining about the irritation caused by ingrown hairs. As a result of that, I discontinued the use of routine trichophytic closure and saved it for the second session in only those patients who developed a slightly wider than usual scar on the first occasion.

Deep (two-layer) donor wound suturing:

Deep sutures have the great advantage of persisting and keeping the edges of the wound together for a much longer period than do the superficial sutures that are typically removed eight to ten days after surgery. The deep sutures, as mentioned above on this site, will last for four to twelve weeks (depending on which suture I am using) before they dissolve away completely. That allows the healing wound to mature and become more stable before all sutures are gone. This is particularly important for people who have more mobile ("lax") scalps than average. The scar in individuals with those characteristics often is normal when the superficial sutures are removed but over an ensuing several weeks, it widens. It is thought that scar tissue in those patients takes longer to mature and become stabilized. Therefore prolonging the persistence of sutures that are holding the wound together avoids or minimizes the spread of the scar.

However, the reason why these sutures dissolve away is that they cause their dissolution by the body because they are a "foreign body" that the body attacks and eliminates. A component of this "attack" is inflammation which results in the donor wound looking slightly more red, for a longer period of time than occurs with only superficial sutures, and often at least some discomfort that persists for two to four weeks. The inflammation can also cause more temporary hair loss of the skin adjacent to the scar, and therefore possibly some temporary noticeability if the patient wants to wear his hair quite short. It must be emphasized that using deep sutures usually does not cause anything that will bother the patients in a significant way, but occasionally it does. Although it takes substantially more time than trichophytic closure would, and occasionally causes some temporary irritation, I use "interrupted" deep sutures in virtually all of my patients instead of the latter because in the context of everything I do, I believe it is a better option for my patients. Finally, I want to emphasize that 90 to 95% of my patients’ scars look like those shown in Figures 7-9.

Is it advantageous to go to a hair restoration surgeon who is using Platelet Rich Plasma (PRP)?

Probably PRP, especially with various substances added, will turn out to be helpful for accelerating hair growth and increasing hair survival rates in hair transplantating but most studies thus far combined PRP with other and differing substances and are not scientifically valid for a variety of reasons. When this is combined with variable concentrations of platelets (often not even mentioned in the studies) and dosing parameters used by various investigators, this means that choosing a hair restoration surgeon on the basis of whether he/she is using PRP would at this stage not be scientifically warranted. In addition, other adjunctive treatments might work better than PRP – for example Minoxidil application. We simply don’t know at this point.

Notwithstanding what I have written above, we are routinely using a Hypothermosol holding solution, and both liposomal ATP and PRP in our office because there is no known negative downsides and there are good theoretical reasons to think they will be helpful. As well, the added time and cost are minimal. As this represents a voluntary inclusion in what I consider clinical investigation, it is also done without an extra charge to the patient.

LIPOSOMAL ATP

On a theoretical basis, Liposomal ATP might accelerate the uptake of oxygen by transplanted cells and therefore produce faster and better healing and better hair survival. Its effect is currently being studied by a number of well respected hair restoration surgeons. On the other hand, the optimal concentration of ATP in solutions that are used in hair transplanting, has not yet been determined. The most optimal concentration is an important matter as it is well known that too much ATP can be toxic to cells i.e. bad for cell survival. As with Platelet Rich Plasma (PRP), there are theoretical reasons why one might be inclined to try this preparation but just as with PRP it would probably be most useful for patients who are undergoing "megasessions" and/or "dense packing" of grafts. Also, it is worthwhile remembering that there are good studies that have shown that hair survival is 98% or better if transplanting is done at 30 FU/cm2 or less, so one has to question its need if that graft density is being used. Notwithstanding what I have written above, as previously noted, we are using both ATP (in a modern fashion) and PRP in our office without charge to the patient.

What are the advantages and disadvantages of Follicular Unit Extraction (FUE)?

FUE is a method of obtaining individual FU directly from the scalp, instead of microscopically dissecting them from a strip of donor tissue that has been excised from the scalp. A small sharp punch, similar to a cookie cutter and usually 0.8 – 1.1 mm in diameter is used to superficially incise the skin around the FU which is then extracted with a combination of pressure on the surrounding skin and tension. I believe FUE is ideal for some people with very tight scalps and for most of those who have noticeable scars from prior hair transplanting in their donor areas (Fig 5 and 10). FUE can always be used to camouflage or eliminate even a good linear scar after the last strip is excised. I also believe that a combination scar strip donor harvesting and FUE – the latter after all the strips that could and should be excised have been removed – will increase the number of FU that can be obtained from any donor area. Some have called this "hydrid donor harvesting". But remember, the farther this FUE strays from the middle of the densest fringe hair, either upwards or downwards or towards the temple hairline the greater the chance that some or all of the hair in the FUE grafts will eventually be lost. (See "The Principles" in this website if you are seriously considering FUE, as well as "What are the advantages and disadvantages of leaving only one linear scar in the donor area regardless of the number of sessions?" The preceding is the main reason why I believe FUE should nearly always be employed in most (though not all) patients as a "second line" approach rather than as a "first line" that some doctors recommend. Extremely long sessions and higher costs (per FU) of FUE vs. Strip harvesting are less problematic to me than the above. On the other hand, less post-operative pain, no sutures and sometimes the ability to use a very short hair style without any scarring being noticeable are understandable attractions of FUE. Body to scalp FUE can also sometimes be worthwhile under the same circumstances noted above, but we are at a very early stage of this technique. At present (Spring 2016), several "masters" of Body-to-Scalp FUE have found hair survival exceptionally variable and always lower than scalp to scalp grafts, so those who want to try it should keep that in mind. There are other reasons that I currently prefer strip harvesting to FUE for most patients that I won’t go into here, but as noted above, they can be found elsewhere on this site. Some FUE problems will certainly be overcome with the evolution of FUE or the instruments used in FUE. However, for the time being, I recommend FUE for only a few of my patients. And remember that FUE, just like strip harvesting, can be done properly or improperly, so choose your surgeon carefully.

Robotic (Artas) FUE; Neograft; Power driven "punches":

All the advantages and disadvantages of FUE are the same as noted in the previous Q & A but I believe hand driven punches of various sizes if used by an expert are at this point in time better for producing minimal FU transections and the best hair survival rates.

When looking at the "before and "after" photos, in this, as well as other websites, what should I be looking for?

The apparent hair density of a transplant of course depends not only on the number of grafts used, and the size of the area treated by also the hair characteristics. Fine-textured hair, for example, maximizes naturalness while the coarser, frizzier, more wavy or curlier the hair, the thicker the hair will look. In general, the less color difference between the skin and hair, the thicker the hair will appear, but if FUT is used this is a less important parameter than with the old larger grafts. Similar before and after head positions, hair styling and lighting are also important factors to consider – especially on the Internet. Holding the head at a slightly different angle can have a profound impact on the apparent density of hair so always look for comparable head positions in "before" and "after" photos. And of course less light makes the hair look thicker than more light.

What are the most important questions to ask during a consultation for hair transplanting?

The first and most important question to ask is if the person you are meeting with is a physician or better yet, if he/she is the physician who will be carrying out your surgery. There is usually a difference between a non-physician, even a well-prepared one, and a physician giving you the information. If the person you are meeting with in the individual who will be carrying out your surgery, he/she will be more knowledgeable than anybody else as to what exactly will be done during the surgery. In addition, there is a better chance that the purpose of the consultation is not to talk you into undergoing the procedure – subtly or otherwise – but rather to give you information about it.

Having said that, the following are eight good questions to pose to whoever is interviewing you:

a) What aspect of the surgery is carried out by the physician and what aspect or aspects will be carried out by his assistants/technicians/nurses?
In particular, it is best that the design of the hairline and the area to be treated, the incising and suturing of the donor area and the making of all recipient site incisions be done by the physician and not a "nurse" or technician. On the other hand in virtually all offices, technicians/nurses will be dissecting the grafts from the donor strip that is removed and inserting the grafts once the physician has made all the recipient sites. If a robot, neograft apparatus or power driven device is being used for FUE cutting and extracting grafts is also nearly always being done by a trained and intermittently supervised nurse/technician and not by the doctor himself/herself. Each of these surgical components are extremely time-consuming portions of the surgery and if a single individual were trying to carry out a typical transplant session himself/herself, the procedure would last three or four times as long as it usually does. For example, it is quite typical for a follicular unit transplant (FUT) session of 1500 to 2500 follicular units (FU) to take from 7:30 am until between 3:30 pm and 5:30 pm. The longer a procedure lasts, the greater the chance becomes for a) unwanted side effects to occur in the patient and, b) for some of the hair follicles to die while waiting to be inserted. Once the recipient sites have been made by the doctor, the density of hair in different areas, as well as hair angle and direction in every area, has already been decided upon by the physician. (The graft can only be inserted at the same angle and direction as the incisions were made.) Also, inserting the grafts in the least traumatic way and as quickly as possible is a more important factor than whether the physician is inserting the grafts or whether somebody else is doing that.

b) How many years experience do members of the surgical team have with hair restoration surgery?

c) How many hair restoration surgeries has the physician carried out prior to you seeing him/her?

d) Where did the physician go to medical school and what specialty training has he/she had?

e) How many hair restoration surgeries are carried out each year in the physician’s office?

f) How many hair restoration surgeries does the physician carry out per day?

In most situations, ideally if you are planning a session of 1500 or more grafts you should be the only patient that your doctor is operating on that day. While good work is possible if more than one session is carried out by the same doctor, it is more likely that he/she will be under less pressure and of course the physician’s attention will be devoted completely to you if yours is the only surgical procedure he/she is doing. (If small sessions are being carried out, more than one surgery becomes more acceptable.) Somewhat similarly, although many hair restoration surgeons’ offices often provide other cosmetic services, if your doctor is busy enough to be able to limit his/her practice exclusively to hair transplanting, it is a good sign of both his/her reputation for good results and the office staff’s skills, duties and therefore expertise.

g) How many grafts will be transplanted during your treatment that day? What kind of grafts are they? How many hairs does each of them contain?

Some clinics refer to the numbers of hairs they transplant per session and other to the number of grafts they’re going to transplant. Be sure you understand the difference because there is usually more than one hair per graft and ultimately the number of hairs moved is more important than the number of grafts. I have, for example, reviewed the chart of a patient who had 7000 "grafts" transplanted, at another office, and paid for them on the basis of the number of grafts, rather than the number of hairs. More than 98% of them were 1-hair grafts instead of the more usual15 – 20% of scalp FU. Many, if not most, of the naturally occurring scalp FU had been divided to create single hair grafts, most likely for financial reasons.

h) How densely will the grafts be transplanted?

If FUT is being carried out generally, the safest maximum hair density for the grafts is approximately 30 FU/cm2 give or take 5 FU/cm2 (see also "What are the advantages and disadvantages of dense packing?"). Perhaps more importantly, remember always that there is a limit to the amount of hair that can be removed from the donor area over your lifetime. A goal of "thick" hair is usually unwise, especially in young patients – because the more hair you use in one area, the less hair you have left in the donor area to use in other balding or bald areas that you have now or might develop over the years. Moreover, densities of 25 – 30 FU/cm2 produce hair densities that cosmetically satisfy the vast majority of patients (Figs. 16-19). See also Table 1 referring to the "Average usable FU Estimates in 30-year-old Caucasian Men". Also, the lower the graft density, the larger the area that can be treated with the same number of grafts – for example, 30 FU/cm2 will cover a 40% larger area than will 50 FU/cm2 and a 25% larger area than will 40 FU/cm2. Furthermore, if grafts are being transplanted into areas that still have persisting original hair, 20 to 30 FU/cm2 will actually produce a very dense looking hair (while covering the larger areas just discussed.) (Figs 23-27). By the time you lose the rest of your original hair, you may not care if your hair is less dense than that achieved with 40 or 50 FU/cm2, and if you do – just add more hair into the previously transplanted areas at the same time you are treating a new area of hair loss. Finally, adding lower density FUT to still-hair bearing areas produces a more subtle change that is less likely to be noticed by others. (Figs 21 and 29) Often my patients choose this approach because of the subtlety whether they have persisting recipient area hair or are bald, intending to add or not add more after seeing full results.

Is hair transplanting a reasonable options for females?

The confusion about the "correct answer" is summarized in Table 4. All women contemplating hair restoration surgery should first see a dermatologist – preferably with a special interest in hair loss – or an endocrinologist to be evaluated as to whether there is any medical cause for their hair loss and whether those problems can be satisfactorily treated medically instead of surgically.

Hair transplanting was not an option for most women years ago because of the older techniques that were utilized then. It is surprising however, how many doctors and even dermatologists are still unaware of the fact that modern hair transplanting techniques have improved so much that many women with patter hair loss are now candidates for the procedure. In fact most of the women we see for hair loss are reasonable candidates. (Fig 14, 15, 19, 30). An article I wrote for Hair Transplant Forum International4 is attached to this website (Unger W., "Candidacy of Females for Hair Transplantation", Hair Transplant Forum International, Vol. 21, #24 front page and 110 – 112, July/august 2011), the official publication of the International Society of Hair Restoration Surgery. If you considering hair transplanting, you should at least read it and the attached comments of two other hair restoration surgeons.

The most important factors that need to be evaluated when a woman is seen for hair restoration surgery is the long term donor/recipient area ratio and, given the limitations of the donor/recipient area ratio, her expectations for the procedure – in specific, the location and extent of the areas that can and should be treated, as well as the density of hair that can and should be produced in those areas. In most women, because of less satisfactory donor/recipient area ratios than in most men, the best goal is usually to transplant only the most cosmetically strategic areas of hair loss. The hair in the thickened areas is then used to comb over those thinning areas that weren’t treated. Scars and hairless areas, subsequent to cosmetic surgery or trauma, can also be successfully transplanted (Fig 31-32). (An article we published in the Journal of the American of Dermatology in 2011 about the then state of hair restoration surgery for women and another, published in Hair Transplant Forum International 2014, can be accessed on this website by returning to the main menu. The latter article is strongly recommended to women who have tried medical therapy that didn’t produce satisfactory results.)

Can people with cosmetically unsatisfactory results of hair transplanting improve their results with modern techniques?

Treatment of people with cosmetically unsatisfactory results of hair transplanting can be divided into four major groups, a) revision of noticeable scarring in the donor area, b) recipient area "repairs" in which many errors in technique were made (for the time in which the procedure was done), c) "retrofits" in which good technique was used (for the time in which the procedure was carried out), but results are outdated as compared to today’s standards and, d) dealing with hair loss that has advanced into previously untreated areas. Because of substantial improvements in both donor area harvesting techniques and FUT, many patients in all of these situations can be helped (Fig 35-37). In particular, virtually all hair transplanting carried out prior to 1995 can benefit from a "retrofit". This subject is too long to be properly discussed here, but suffice it to say that it would be wise for anybody who is unsatisfied with previous hair transplanting to have a consultation with a good hair restoration surgeon to see if enough donor hair reserves are available, and what is possible to achieve with those reserves.

When is medical treatment preferable to surgery, and what drugs are available?

There are only three drugs that have been scientifically proven to be effective for regrowing lost hair or slowing down hair loss is some men with MPB: minoxidil (Rogaine), finasteride (Propecia) and Dutasteride. (I do not recommend Dutasteride for MPB because of what I consider too frequent and/or unacceptable degrees of side effects.) I was one of the investigators in multi-center studies of Rogaine and Propecia. Both of these drugs work best in the earliest stages of hair loss, in "crown" area baldness or balding and less well in the mid-scalp area. Neither drug has even been scientifically studied for its effectiveness in what hair restoration surgeons call the "frontal area" (see Fig 22). Nevertheless, based on anecdotal information, some patients have shown some benefits and sometimes good results, in that area. Therefore, a one year trial of Propecia with or without Rogaine may be worthwhile trying before one commits to surgery just in case you will be one of the responders – especially for crown hair loss. Using these drugs after a hair transplant may also be useful in slowing down further hair loss and therefore delaying the need to undergo additional surgery. Both medications can only delay further loss or increase hair density temporarily, and cessation of the drugs results in rapid loss of any prior improvement, so some patients prefer starting with hair transplanting rather than a lifetime need of drugs.

Minoxidil is applied twice daily to the scalp in a liquid or foam form, has very few side effects, and in very few individuals, however it can produce irritation of the skin, heart palpitations or decrease blood pressure resulting in a feeling of lightheadedness in a small percentage of people. Propecia, which is supplied as a one a day pill, has been associated with decreased sex drive in 1.8% of patients, erectile dysfunction in 1.3% and decreased semen volume in 0,8%. Very rarely breast enlargement can occur but resolves on its own within a few months if Propecia is discontinued. There are other less common side effects that may occur with both medications but all disappear in nearly everybody (see below) within a few weeks if the drug is discontinued. Men who are taking Propecia should advise their family physician that they are using it because PSA tests, which are often routinely done on men over the age of 45 years as a "marker" for prostatic cancer, are affected by the drug. Usually, whatever PSA reading is reported must be approximately doubled to get a more valid reading. Since 2010, internet postings by a very small percentage of patients have claimed persisting decreasing sex-drive and/or erectile dysfunction long after cessation of finasteride. These claims are being investigated by Merck (the manufacturer). One recent medical article has also reported decreased sperm counts in several patients who began with lower than normal sperm counts. Further, larger studies are underway.

Minoxidil is a useful drug for women to try before deciding to go ahead with hair restoration surgery. Propecia is officially contra-indicated for all women prior to menopause as it may produce unwanted side effects in a male fetus but many physicians sometimes prescribe it for fully informed women. There are other drugs that may be useful in slowing down hair loss or sometimes regrowing hair in women with female patterned hair loss (FPHL). Women with FPHL should consult with a dermatologist and or/endocrinologist for investigation and further information about these drugs. Of course if you decide to use any medication, including the above, you should consult a physician for a fuller description of side effects before doing so.

How do I find a good hair restoration surgeon?

The best way to find a competent hair restoration surgeon is to ask your dermatologist or family doctor who you should consult with for this procedure. They are in a far better position to find out this information than you are. Advertisements and promotion on the Internet, in newspapers, magazines and on television are a poor substitute for professional advice. Your hairstylist may also be a very good source of information. The websites of the International Society of Hair Restoration Surgeons (www.ishrs.org), the European Society of Hair Restoration Surgery (www.eshrs.org), as well as the American Board of Hair Restoration Surgery (www.abhrs.com) are also good sources of information that you should utilize. However, it is the consultation with the one or more doctors that you meet with before you decide to proceed that is most important. You should be comfortable with and feel you can trust the doctor, and he/she should also feel comfortable with you during that consultation. You should also see as many "before and after" photographs as possible to satisfy yourself that he/she is capable of producing acceptable results. Unfortunately, belonging to any of the societies mentioned above does not automatically mean that the physician can produce cosmetically acceptable results for you; rather it means that they are interested enough to belong to those teaching organizations. In the case of the American Board of Hair Restoration Surgery, they have also passed examinations that certify extra knowledge, especially with regard to surgical safety. Once again, the interview with the doctor is the most important guide you can have to your likely happiness with the results.

What does Dr. Unger think about "laser hair transplanting" and "low level laser treatment" for hair loss?

He and Dr. Larry David were the first physicians to study the possible use of lasers in hair transplanting. The evolution of hair transplanting techniques has resulted in there currently being no surgical advantage of using lasers in hair transplanting.

The subject of low level laser treatment for hair loss is more complex to explain. Many physicians now use it to slow down or reverse hair loss and believe it is effective in some patients. Dr. Unger has never seen valid scientific studies that confirm its effectiveness (which doesn’t mean it doesn’t work but also doesn’t mean it does) so he does not object to a patient trying it. (FDA "clearance" was obtained via "grandfathering" "effectiveness" and "clearance" of a similar device decades ago rather than new studies scientifically proving effectiveness.) Notwithstanding the preceding, he does not prescribe it to his patients.

Can hair transplanting be used to repair scars from trauma (accidents) or cosmetic surgery?

Despite many physicians, including plastic surgeons, believing otherwise, the answer to this question is yes (Figs 32).

What does Dr. Unger think about hair "cloning"?

From 1998 to 2003, Dr. Unger co-directed studies at the University of Toronto on what is popularly called "cloning" of hair. Stem cells are removed from the patient’s hairs and millions of similar cells can be grown in a culture medium within several weeks. These cells, when injected into immune-compromised mice, almost always produced hair. The ultimate objective was and is to inject them back into the human donor and be able to grow unlimited amounts of hair. Clearance for human testing by the University of Toronto Ethics Committee was obtained in October 2000, and studies began in late spring 2001. Two human studies were carried out. One produced hair in 1 of 10 subjects and the second in 3 of 13 study subjects (though less vigorous growth than in the first study). We have temporarily discontinued these studies because of proprietary problems related to the original funding and Dr. Unger’s time constraints. Hopefully, these problems will eventually be solved.

Unfortunately, the far (May 2016), "cloning" hair has run into the same obstacles as those encountered when investigators have tried to "clone" cells for spinal cord injuries, heart, pancreas and liver tissues, etc. The stem cells have been identified and grown in culture media and produce the desired effect in experimental animals, mice or rats but for some reason do not consistently produce satisfactory results in human studies. Periodically, the public will read about "new breakthroughs" in cloning. Beware. So far, especially with regard to hair – the media or representatives of business interests have had a tendency to either repackage old information a "new" or have taken information out of context so as to make it more newsworthy than it really is. We believe that the obstacles to cloning in humans will be overcome in the not too distant future; there are so many outstanding investigators studying the problem and funding is rarely a problem. Try to be patient.

Is it ever better to start transplanting with sessions from the back forward instead of from the front to the back?

Very occasionally, for example an individual 45-years-old (or older) with little or no evidence of hair thinning in the frontal area and midscalp; there is rarely a problem with starting by transplanting the crown area and then the midscalp area when if it loses its hair and then the frontal area when and if it loses its hair. This is because it is easier in men in this age group to more accurately assess if the likely long-term donor area will allow 3 transplant sessions to be done in pace with hair loss in the midscalp and frontal areas.

If, on the other hand, the crown and midscalp were the areas of main concern, you can start with transplanting the midscalp, ideally with a "bump" of additional grafting in the midline that goes into the thinning crown area (Fig 34). If the doctor mimics the direction of original or still existing midscalp hair, some of the transplanted hair will often be directed backwards and when it grows, will effortlessly fall over the crown area making it look better even without any grafting having been done in that area. You can therefore sometimes delay the need to transplant the crown and see if the frontal area becomes more problematic before the crown does. In the latter instance, the frontal area could be the second area transplanted instead of the crown. I have sometimes referred to the midscalp as the "marvelous midscalp" because transplanting it will often improve the appearance not only of the midscalp but the crown as described above and any thinning of the frontal area as well, at least from frontal-side viewing. The latter is because when you look through thinning frontal hair (from frontal and frontal-side views) thicker hair in the midscalp makes the frontal area hair look thicker also (Fig 35).

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