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Hair Transplantation

Advances in Restorative Hair Treatment

Platelet Rich Plasma (PRP) treatment for hair regrowth is an in-office, non-surgical procedure completed in about an hour.
Platelets from the patients blood are extracted and condensed, then injected into the areas of the scalp needing stimulation. PRP contains growth factors and cytokines that have been shown to be responsible for stimulating and enhancing hair follicle function.
Two excellent candidates for PRP treatment for hair loss are patients with areas of “weak quality” hair growth on the scalp, where functioning hair follicles can still be observed, and patients with small areas of alopecia areata. These patients appear to have the greatest success with PRP.
According to published reports, PRP tends to improve hair caliber and hair growth for about four to six weeks, requiring treatments as often as every other month. However, by combining ECM or Extracellular Matrix (like ACell) patients achieve a stronger and longer hair growth result of about a year before another treatment is necessary.
It takes six to twelve months to see results.
There is no activity restriction after a PRP treatment. Patients may shower/shampoo/condition their hair normally just 24 hours after the treatment and resume normal daily and athletic activities. Use of topical hair growth treatments like Minoxidil 82M or similar can resume the next day. Laser therapy treatments can also be resumed the next day.

The Treatment
After the area of concern is identified, evaluated and measured, standardized medical photos are taken. Special gentle and sterile techniques and equipment are used to separate and concentrate the platelets and plasma from a small sample of peripheral blood. A small sample of the blood and PRP is tested in a hematology analyzer to measure and document the improved platelet concentration. PRP contains growth factors and cytokines that have been shown to be responsible for stimulating and enhancing hair follicle function. The PRP may be combined with ECM or Extracellular Matrix (like ACell or BioD) for a stronger and longer hair growth result. The scalp is prepared with antiseptic solution and anesthetic (a “ring block,” not simply local anesthetic gel) is used to completely numb the scalp for a 100% painless procedure. Small injections of the PRP deliver the powerful platelet-derived growth factors into the skin at the level of the weak follicles. Electronic, mechanical microneedling is performed, after which residual PRP is rubbed on the microneedled area. A session of Low Level Laser Therapy is performed before the patient leaves the office.

Tracking Results
It’s best to measure improvements in Hair Mass Index using HairCheck months before the results are visible to the naked eye. Increases in Hair Mass Index using the HairCheck device predict how much visual improvement the patient is likely to see in the months to come. It takes six to twelve months to judge the results of PRP “visually” in the mirror or with standardized photos. Measurements are taken every three months, so the plateau phase of improvement can be tracked. When Hair Mass Index starts to decline, the patient’s next PRP is planned. With the exception of alopecia areata, the average hereditary hair loss patient can expect to need PRP with ECM on an annual basis.

Robotic Hair Transplants provide permanent, natural-looking results without the plugs, pain and stitches associated with traditional hair transplants like strip surgery. This minimally invasive procedure does not leave a linear scar. Digital mapping provides precise and consistent graft dissection and Digital mapping provides precise and consistent graft dissection. Advanced digital imaging scans, tracks and grades each hair, selecting the most suitable for harvesting. Image-guided precision robotics remove each hair individually. Only the minimum amount hair needed is harvested.

The NeoGraft System uses the Follicular Unit Extraction (FUE) method because of the vast benefits this less invasive technique offers. The FUE method removes individual hair follicles from the scalp in their naturally occurring groupings of about 1-4 hairs and are then placed in the areas of the scalp where balding has occurred. The end result is a natural looking hairline with no linear scar and a quick recovery time.

 

What is a Hair Transplant?

Hair transplants are minor dermatologic surgical procedures in which hair follicles are transferred from the permanent and thick donor area around the sides and back of the head to areas of thinning or balding generally found on the front, top, and crown of the head, as well as eyebrows, beard areas, and sometimes even chest. In rare cases, even body hair can be used as donor, if it is very thick and luxurious in areas such as the chest.

History of Hair Transplantation

Micro-plug Hair Transplant – Dr. E 1985

The history of hair transplantation began in 1931 in France, where French surgeon Passot moved some hair from a thicker area to a bald area, creating what is thought to be the first hair transplant.In 1939, Japanese hair researcher, Dr. Okuda published his results in a Japanese medical journal regarding his technique of inserting small hair-bearing grafts into needle-stick recipients to fill in defects in eyebrows. This publication was lost during the Second World War and later discovered in the 1970s.Dr. Norman Orentrich, a prominent New York der- matologist and researcher, reinvented the process of hair transplantation in 1956. At that time, he was doing some experimental work on skin grafts, and noticed that the hair in the grafts grew after the grafts had been transplanted. He developed a theory of donor dominance, which states that the thicker hair from the donor area will remain thick once it has been moved to the formerly bald area. In the 1970s, many physicians began doing punch graft hair transplants using 4-mm round plugs taken from the thicker donor area in the back of the head and transplanting it to the balding area on the top of the head. The author began this in 1971, while a dermatology resident. At that time, a great deal of skill was required to get these plugs to look natural. Unfortunately, many physicians tended to plant them more or less like trees so that you could easily see the plugs sticking up on the top of the head and, of course, this produced an unnatural appearance. The correct way to place plugs was to have them exit the skin at about a 30-degree angle so the hairs overlapped each other like the shingles on a roof. In this way, when the hair was combed, it looked good, but not as good as using much smaller plugs for the hairline. In 1981, the author custom ordered a number of sizes of very small punches down to 1.0 mm. These punches could harvest down to one or two individual hairs and, at that point, it was possible to create a natural-looking head of hair using the plug technique, properly angled, and properly designed. At left are some photographs of a case from 1985, showing this technique on one of the author’s patients.

In the 1990s, the method of donor harvesting (various sized, round plug grafts) evolved into using a strip, which was closed in a thin line. The donor strip was then carefully dissected under microscopes and/or high-power magnification to create small follicular unit grafts containing one to four hairs in one follicular unit.

In the 2000s, FUE (1.0 mm punches) again become popular for physicians who got wide donor scars, as a means of having thousands of white dots in the donor. Ultimately, the method is less efficient for most cases as not enough grafts are obtainable to complete most cases so FUE must ultimately be combined with FUT (strip). See the Double-Mega Procedure, Page 27.

In 2016, the author and his staff developed FUE using .85 mm punches. These .85 mm donor skin piercings heal in about one or two days. This has made possible the new concept of the double mega procedure which works as follows:

Strip harvest of 2000 to 3000 grafts is done on day 1.

On day 14, the sutures are removed from the previous strip donor site.

On day 15-20, micro .85 mm FUE is done above and below as well as within the previous scar to yield another 2000 plus grafts.

In summary, 5000 grafts are obtained in a period of two and one-half weeks, which is generally enough to transplant the majority of fully-bald heads.

Anatomy of the Hair Follicle and Follicular Unit

The hair follicle is a complex but small organ, which contains nerve fibers and blood vessels around the actual hair follicle. (fig. 2) About 80% of hair follicles are paired (or come in clusters of two). The rest are either singles, triples or an occasional quad. These clusters are called follicular units because they share a common blood and nerve supply. When doing hair transplantation and dissecting the donor area, it is important not to cut these follicular units apart because this generally results in miniaturized transplanted hairs rather than the full-sized hairs that are desired.

Anatomy of the Hair Follicle-fig2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hair Transplantation – Male Pattern Hair Loss

HOW HAIR TRANSPLANTATION WORKS: Only one type of hair loss will produce a distinctive pattern of loss in men. This is called male pattern baldness and is a genetic disorder. This disorder is primarily caused by the effects of dihydrotestosterone or DHT on the hair follicles on the front, top, and crown. Men have a certain amount of testosterone in their bodies, which is converted by the enzyme 5-alpha-reductase into DHT. DHT is the highly active form. In men whose front, top and vertex follicles are sensitive to DHT, there is a gradual miniturization of sensitive follicles as shown in figure 3.In men, distinct and progressive pattern baldness usually starts in the 20s, 30s, or 40s and continues briskly for eight to fifteen years. After that, it slows down but continues on a gradual and progressive course for life.In both male and female pattern baldness, there is a gradual miniaturization of the hairs produced by affected follicles until they eventually stop growing and fall out. The “secondary” hairs in the common 2-3 hair follicular unit go first. This is why a person’s hair will feel finer for several years before actual baldness occurs. In male pattern baldness, the hair around the sides and back of the head is not susceptible to the effects of DHT. This hair is also not susceptible to DHT if it is moved to another area on the scalp. This concept of donor dominance makes hair transplantation possible. Only follicles from the permanent band of hair around the sides and back are used for transplantation by experienced physicians.In some men, the hair follicles in the front top of the head are sensitive to DHT, in others, the hair follicles in the back top area of the head are sensitive to DHT, and in some both. After transplantation has been done for many years, patients have come back to the office complaining that their transplant was thinning. A blood test for testosterone levels shows that they are very low on testosterone. Testosterone supports the growth of hair in men on the body, the beard, and the donor area around the sides and back of the head. Therefore, transplanted hairs which are from the donor area will eventually thin as the testosterone levels fall off as men age. Of course, this is easily treated by testosterone therapy, to cause the hairs to thicken back up.Loss of thyroid (free T3), growth hormone, and sex hormones may enhance pattern hair loss with diffuse thinning over age 45, and require hormone replacement therapy. Persons with diffuse thinning should have a lab panel done and a biopsy.

figure 3 and 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LIFE CYCLE OF HAIR FOLLICLES:Hairs on the head will grow for a period of two to five years and then go into a resting period of three to four months. At the end of that resting period, the hair follicles will regenerate and grow out new hairs. Every day a certain percentage of hairs are going into the resting phase, and a similar number begin producing new hairs. When a hair follicle goes into the resting phase, the hair becomes loose and falls out. This is why a person loses 50-100 hairs per day, even if he does not have any type of pattern baldness problem. The reason that the three to four month resting phase comes into play here is that it is the amount of time which grafts wait before they grow, or until “shocked out” hairs return.When transplanting hair follicles, the oxygen loss drives them into their resting phase. This is why new hair will not grow for three to four months. When transplanting into old scarred areas in revision cases, hair may take as long as twelve to fifteen months to grow due to the poor blood supply.When transplanting into an area that has some fine remaining hair in it, the hairs that are in between the new grafts may be shed. This means that the hair follicles go into their resting period, the hair becomes loose, and falls out. Again, these residual hair follicles will spend about three to four months in their resting phase before regrowing hair. Occasionally, some of these residual hairs will not regrow, because they were in the last cycle of their life.When male pattern balding begins, before hairs are lost, several years of miniaturization of hairs go by in which the hairs become smaller and smaller and their growing phases become shorter and shorter. Finally, they begin to die off, and a person has fewer hairs than he originally had. An individual can lose about half of his overall number or volume of hairs before it is apparent that his hair is thinning.

GENERAL INFORMATION

Androgenetic Alopecia (Male Pattern Baldness) is a progressive disorder which may start at an early age and progress throughout the patient’s life. The doctor makes his best estimate of the patient’s future pattern based on family history and other factors, but it is impossible to determine exactly how far it will progress. Therefore, the patient may require additional procedures if it progresses much further than anticipated.It is important not to begin these procedures at too young an age. If the patient does decide to begin at a young age, he should be conservative in his hair restoration. When losing hair slowly, it is best to replace the hair slowly, matching the rate of natural hair loss over a period of years. The patient must work with the doctor in locating the hairline according to his advice so it will not be too low or in an inappropriate place. In younger persons, it is better to start with the front.

Our office employs a staff of registered nurses, certified surgical technologists, and well trained medical assistants who perform some of the technical aspects of the procedures under the doctor’s direct supervision. Of course, all surgical cutting, receptor incisions, and layout of grafts are done exclusively by the doctor. Pre-operative and postoperative photographs are taken of each procedure for use in the patient’s medical records. All information and photos of patients are absolutely privileged.DONOR HARVESTING & GRAFT CUTTING: All donor harvesting is done with the patient in a comfortable, prone position, not sitting up in a chair. This allows for precise visualization by the doctor in order to be able to take the single strip of hair-bearing tissue in a manner in which incisions are precisely parallel to the hair direction, or in FUE cases, the extraction precisely parallels hair direction.FOLLICULAR UNIT TRANSPLANTATION – STRIP METHOD: Once the grafts have been harvested, the doctor will close the donor area to achieve the smallest possible scar, which is typically one to three millimeters in width. When doing a second procedure, and occasionally on a first procedure, it is necessary to transect certain nerves which travel through the skin in the donor strip area. These nerves eventually grow back. Occasionally, there is a small area in the top of the head in which nerve enervation does not reconnect, so there is a loss of feeling. This is not troublesome. When doing a second procedure, the doctor will include the old scar area in the new donor strip, so there will eventually be just one scar, as in the first procedure, a small one to three millimeter scar. In about two out of 10,000 cases, there may be some nerve trapping in the donor scar, which requires a minor re-excision. Hylenex injection removes tension so donor scars are very small (1-2mm). Exparel (optional) can keep the donor anesthetized for 2 weeks.The donor strip is transferred to processing by well-trained surgical technologists and nurses who, under microscopic visualization, divide the strip into individual small sec- tions. These small sections are then dissected into the individual grafts. This is done carefully to minimize follicular damage. The grafts contain 1, 2 or 3 hairs.figure 5Figure #5 illustrates the four growth cycles of a human hair. Note that human hairs generally grow for two to six years in the anagen phase, and then shift into the catagen and subsequently telogen phase. The telogen phase usually lasts about three months. During telogen, the hair becomes loose and falls out, and the hair follicle withers up and virtually disappears. This is shown in the illustration of return to anagen. Miraculously, after about three months, the hair follicle regenerates (from the interaction of two types of stem cells, those from the bulge area around the sebaceous gland, and others from the dermal papilla area.) Following this, the regenerated hair follicle grows a new hair, which then grows for two to six years.Figure #6Figure #6 Figure #6 illustrates the differences in hair shaft characteristics between straight hair, curly hair, and very curly to wooly hair. Note it is simply a difference in the shape of the cross-sectional area of the actual hair shaft. In other words, round hairs generally grow straight, and oval hairs grow in various degrees of curliness.

FOLLICULAR UNIT EXTRACTION: Some patients prefer the alternative form of donor retrieval in which single follicular units are extracted by either manual punch, power punch, a robot, or neograft machine individually. Instead of having a very fine-line sutured scar in the donor area, in this method the result is a series of very small white-dot scars in the donor area. For this method to work, the donor area has to be entirely shaved and then the grafts extracted one at a time. In general, 1000-2000 grafts are the most that can usually be extracted at one time. Lifetime total ability to extract grafts with this method is probably around 4000 to at most 5000 grafts on a very large head. Doctors charge more per graft for this method (because it is extremely tedious and makes the day very long). With the strip method, a 2500-3000 graft strip can be taken out on one to three occasions, each time removing the previous scar so only one scar of 1-4 mm width results. This scar is always covered by a curtain of hair hanging over it so it is not apparent. After two strip sessions, it is best to switch to FUE.In the FUE method, using the .85 mm punch, 2500 grafts can be harvested from a full donor at least once. Depending on the thickness of the hair, an additional 2500 can be harvested at a later date. If the patient has very fine or thin hair, this is not an option. If too much hair is taken out by FUE in a patient that has thin hair, the donor will develop a thinned appearance. A full Class 6 bald person requires 6000 to 8000 grafts to fully transplant his head. With the new Double Mega Procedure method, this can be accomplished by one strip graft of 2500 to 3000 grafts, followed by a micro FUE .85 procedure done at about two weeks later with an additional 2500 grafts, giving about 5000 grafts over a period of two and one-half weeks. As the years go by and a person with this transplant requires some additional hair around the back, this can be obtained by the FUE method down the road.Evaluation for Follicular Unit Transplantation (FUT)

When you are seen by your hair restoration physician, he will evaluate the size and progress of your hair loss. You may be in an early stage in which you will require several treatments over many years, or in a late stage where you are nearly fully bald and require one or two treatments over one to two years. Generally, the number of follicular units that can be transplanted per session vary from about 10 to 30 follicular units per square centimeter of baldness. A practical method which allows for transplanting most of the head in most cases is one in which the physician’s objective is to install about 15-20 follicular units per square centimeter of baldness on the first session, with a second session of similar density about one year later. The one-year delay is necessary to allow the donor area to relax and loosen up so that a similar strip can be taken in the same place as the previous one, thus removing the old scar and leaving only one fine-line scar. With good surgical technique, it is frequently possible to even do a third procedure in the same area, still leaving only one fine-line scar. However, FUE can be performed one month after strip FUT to double the number of grafts.

Evaluation for Follicular Unit Extraction (FUE)In evaluating a person for follicular unit extraction, it is necessary to make sure there is sufficient density in the donor that no change will be observed when removing 2000 to 2500 micro FUE .85 grafts. FUE may also be used on very thick body hair when scalp hair is very limited.New “Double-Mega” FUE ProcedureUsing a newly developed technique, the Double-Mega Procedure, we are able to transplant 5000+ grafts – enough to cover almost all cases of baldness – in just two weeks.
•    3000 grafts by strip with Exparel (two-week anesthesia)
•    Sutures out at two weeks.
•    Next day, 2000+ grafts by micro FUE
(.85mm) above and below strip scar – and scar filled. Also Exparel.
For patients who have had one to three prior strip procedures, the best choice for a touch up is micro FUE .85mm above and below the old scar line. In most cases, hairs can also be placed into the old scar line.

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Treatment Protocol to Stimulate Thinning or
Transplanted Hair and to Optimize  Hormones
1    Check Thyroid Free T3 initially, then annually to make sure it is at top of normal range. Also take iodine solution to supplement thyroid. Try to get free-T3 slightly super normal (i.e. 5.0).
2    Do Hair Check initially, annually thereafter.
3    Formula 82M Scalp Solution twice daily (prescription only), or Minoxidil tablet 2.5 mg daily.
4    Theradome Medical Grade Laser, 30 minutes, alternate days.
5    Ketaconazole Shampoo 3 times/week, Head & Shoulders other days.
(#2, #3, #4 and #5 above only if hair thinning)
6    Iron supplement.
7    Women: Testosterone pellets implanted if TOTAL TESTOSTERONE IS LOW. Treat with PRP to areas that do not respond to above treatment. Estradiol pellets. Consider transplant with PRP. Progesterone sublingual.
8    Men: Testosterone implanted pellets if TOTAL TESTOSTERONE IS LOW, including men who are considering a transplant, or use Finasteride Plus and Sildenafil 20 mg daily. Change from standard Finasteride to:
A    Finasteride Plus which also contains biotin, saw palmetto, and organic herbs (prescription only).
B    Sildenafil 20mg daily to avoid side effects (prescription only).
C   Treat with PRP if resistant.
9    Vitamins/Minerals – (Medical grade of these now available through Debbie)
A    Vitamin D3 5,000-10,000 IU daily.
B    GNC Mega Vitamins, one twice daily.
C    Biotin 6000 daily.
D    Omega 3 capsule daily, 4000 mg
E    Vitamin K2 500 mcg daily.
F    DIM 2100 mg daily
G    Selenium
H    IodineLaser Technology at Home  theradome-1There is a new product on the market that uses advanced clinical strength laser therapy that is easy, comfortable, convenient and can be used at home. The Theradome LH80 Pro requires only two, 20-minute sessions per week. The unit is hands-free and cordless, enabling freedom of movement during the treatment. The Theradome unit can be purchased without a prescription. It is the first FDA OTC cleared, wearable clinical strength laser hair therapy for home use.Biomedically designed lasers are key to treating hair loss. The proprietary laser technology delivers maximum energy (>440 joules per treatment) and penetrates the scalp at a wavelength optimized for clinical hair restoration (678 ± 8nm). Eighty high-efficiency lasers deliver therapeutic power while providing maximum scalp coverage of 582 cm2 and generating less than 1 C of heat per 20 minute session.theradome-5

 

 

Progressive stages with a minimum of two, 20-minute sessions per week.theradome-2

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Why Transplanted Hairs Grow at Three Months

Now you have learned from Figure #5 the details of the hair growth cycle. You have learned that the resting or telogen phase generally lasts about three months. When hairs are transplanted in a hair transplantation procedure, the small hairs in the hair grafts (which are about 1-2 mm long), will generally fall out within the first two weeks following the transplant. Those hair follicles then go into the resting or telogen phase for about three months. At the end of three months, the hairs will grow out.How to Encourage Grafts to Grow Before Three Months
Currently our offices are in experimental trial with a thyroid (T-3) spray-on solution. This solution is applied after transplant surgery. Several cases have begun to grow at one month post-op. These are preliminary results. Some physicians recommend the cold laser for this.

DENSITY OF RESULTS:By using a method of small grafts at the hairline and slightly larger grafts on the rest of the head, we are able to achieve density, which can appear to be as much as it was when a patient was younger. Of course, it would not actu- ally be the same density as when the patient was younger. The goal is to get to about fifty-percent of original density. Fifty-percent of density generally will appear to be the same as full density. To achieve that density usually requires two sessions of transplants to the hairline and the top and back of the head, depending on where hair needs to be filled in. It is possible to do a third ses- sion for maximum density. It is expected that virtually all of the transplanted grafts will grow. Typical growth rate is in the 98% – 100% range. All the grafts created at the time of surgery, including any extras, are used. When we trans- plant into old scarred areas in a revision case of old transplants done years ago, the growth rate will be somewhat less. This is due to scarring in the old section, which makes it difficult for the blood supply to get to the new grafts.If any of the grafts do not grow, they will be replaced at no charge, except those transplanted into old scarred areas. Of course, thick donor hair will give a thick result, thin donor hair will give a thin result. Density can be affected by low thyroid (free T3), low growth hormone, or low testosterone, and these may require treatment.

SURGICAL DESIGN BY YOUR DOCTOR:Once the grafts have been processed, the doctor will carefully design the pattern of the recipient sites using a micro-spearpoint blade.He will lay out the design precisely so that it will match the original pattern, will blend exactly on the sides of the head with the direction that the hairs currently grow, and will form a beautiful, irregular, and natural looking hairline. The hairline can be designed to suit the patient’s wishes. It can be a hairline with high, receding corners, youthful corners, or virtually any other shape. Of course, it must fit the patient’s head shape, facial features, and other factors. The doctor will review all these aspects with the patient and recommend a design for the most flattering look. For example, prominent frontal bones can be hidden under new hair, or the temples brought forward if a forehead appears too wide. In the back of the head, the design will recreate the whorl pattern exactly as it grew originally.The doctor strives to mimic – or improve on – the hairline that nature created. Upon observing a number of hairlines, the patient will see that the majority of them are slightly asymmetrical (shaped differently on one side than the other) and have an irregularity to the hairline itself. One of the clues that a hairline has been artificially created is that it looks too symmetrical, like it was traced around a bowl. This is unacceptable.