Hair Restoration Blog

In a standard hair transplant procedure (follicular unit transplant through strip technique), having adequate scalp laxity is crucial to avoid complications in the donor area. Doing so has required the individual judgment of an experienced hair transplant surgeon but still leaves room for human error. If the surgeon removes too wide of a strip, there may be issues with wound closure, a visible wide scar, telogen effluvium (hair loss around donor wound), and/or skin necrosis. Areas around the scalp most at risk are the mastoids or the area behind ears.

Laxometer has been designed to minimize hair transplant complications (in 15th annual meeting of International Society of Hair Restoration Surgery) by helping assess scalp laxity more accurately prior to a hair transplant procedure. After the first assessment, the patient then practices the scalp exercise to increase mobility and is then reassessed the day of surgery. The more laxity the patient has the higher the chances of increasing the number of grafts that can be transplanted in a single hair transplant.

We performed a study on 37 different patients to assess the success and functionality of laxometer. In all of these patients, half of the donor wound was closed during the procedure to evaluate the impact of donor excision on the laxity of the donor area. Three (3) locations of donor area were assessed before and after incisions were made:

I.    Right side
II.    Mid line
III.    Left Side

The laxity of the sides were measured approximately 10-15cm above the mastoid bone from the midline. The incision was made using a double bladed knife to insure uniformity.

After excising the first half of the strip, laxity was measured on the secondary section prior to full incision and excision. If laxity has been compromised due to the first excision and closure, then the second incision will be smaller. Out of the 37 patients that underwent follicular unit transplantation through strip technique, only six (6) patients required a smaller incision due to a lesser laxometer reading caused by reduction of laxity. Our study shows that wound tension:

I.    May increase on the secondary side in some patients (~16% chance)
II.    May not be an issue in most patients (~84% chance)

Laxometer helps determine scalp laxity before, during, and after a hair transplant procedure for optimal excision and closure. It helps determine the maximum amount of tissue that can be excised safely helping increase the chance of more grafts that can used a single session. This practice is best applied on patients undergoing a mega-session hair restoration in which over 2500 grafts are being transplanted in one hair transplant session.

This type of “hair test” is done by a hair transplant surgeon or dermatologist to find out the rate of telogen hiar. It’s a simple procedure. The doctor pulls hair to find out the number of hair follicles in the resting phase. The way the test works is that the doctor grasps a couple of hair shafts between the pointing finger and thumb, then pulls them ever so softly. There are two classifications of hairs: Anagen, which are growing hairs that ought to remain in place; and telogen: hairs that should pull out rather easily.

By keeping track of the number of pulled hairs, a person can approximately calculate, in the telogen state, the hair follicle percentage. For example, if a person pulls on 10 hairs and then 2 come out, then the telogen hair follicles frequency is 20%.  If extracted hair follicles percentage is up to 25%, that is still considered OK, but if it’s over 35%, it is not normal and shows that there’s a disproportionate amount of hair in the resting phase.  This condition is often seen in Telogen Effluvium (TE).

Even though this hair-pulling test seems simple, a person may come to the wrong conclusions if they do not carry out the test properly and he or she does not have a full comprehension of the test’s limitations. The biggest concern is that the test results may be affected by what the patient did with her hair in the preceding hours. When the patient washes her hair, it will cause many of the telogen hairs to fall out.

There are several factors which can increase the accuracy of the hair pull test. The hair pull test can be ratcheted up to another level by conducting the “unit area trichogram”. This type of test requires that a couple hair follicle samples are grabbed from the scalp utilizing rubber-covered forceps; both telogen and anagen hairs are yanked. These hairs are to be placed on a glass slide and inspected using a microscope. After that, the dermatologist is to count up the telogen hairs and the anagen hairs as well.  The test can help the doctor in differentiating a variety of hair loss conditions.

Q:

hi

I come from china ，I would like to consult your organization a few questions:

In your experience,usually Asians（chinese people) the normal growth of the number of roots Per cm² of hair? Head at the top and post-occipital whether there are different?
using FUE technology，on one operation ，After the occipital Site  get the maxinum number of FU (Asians including 2-3 days operation) at present,how much FU can be planted per square centimeter on Planting area? Between the scope of? and the percentage with normal?

Looking forward to your reply Details!

Thanks for your questions.

A:

Here are the answers in the order they were received:

The number of hair follicles

The number of hair follicles in non-balding areas of scalp like occipital areas have been studied.  A range of 80 - 120 follicular units (FUs) per centimeter were reported. The density of follicular units vary in different locations of the scalp. Also, the number of hairs per follicular unit vary in different areas and with different races. For example, Asians usually have less number of hair follicles per cm², so even with similar number of FUs per cm², the density of their donor area is still less than Caucasians. To calculate the number of hair per cm², you have to average the number of hairs per FU and multiply it by the number of FUs per cm².

Difference of hair on top and back

The shaft of hair may or may not be different in different areas of the scalp. Obviously, if you are balding, you see more miniaturization and less terminal hair, which makes the appearance of the hair less dense on the area. However, without baldness, hair quality would be the same in back and top of the head.

FUE and number of grafts

FUE (Follicular Unit Extraction) is more labor intense and requires more time for harvesting the grafts. For that reason, FUE procedures are generally smaller in terms of the number of grafts per session. What we do at US Hair Restoration is up to 1,500 grafts per day on average, for 8 to 10 hours work in a FUE procedure. The number may occasionally go up to 2,000 grafts, too, but not everyone can expect to get that number with FUE.

Density of transplanted hair

There are many research projects on this topic. The number can be as high as normal density in some circumstances. However, practically we can make up to 35%-40% of the normal density in one session. This is a good number if you consider that the density of hair on frontal areas could be about half of the hair on the donor area in some patients, so 35%-40% is not that far from the normal density in those patients.

Q:

I had a hair transplant surgery a month ago.  As it turns out, I have a huge amount of shock loss right now.  As i’ve never taken propecia before, do you think it’s too late to combat this shock loss with propecia?  Any suggestions on how i could eliminate this shock loss from further damage?  I hope my hair will return.

A:

To prevent shock loss, it is never too late for Propecia (finasteride) if you really need it. You may not get the maximum benefit as if you started on the medications before your hair transplant, but your shock loss may not have been completed yet.

We generally start our patients on Propecia a few days prior to their hair transplant so the medication is in the system at its therapeutic level on the day of surgery.

Many people choose to continue the medication after hair restoration surgery and we encourage that. We continue the medication for 6 to 8 months after the hair transplant, depending on the degree of miniaturization for patients who do not want to be on finasteride for the rest of their lives or the ones who have minimal miniaturization. After the first few months, the chance of shock loss due to the hair restoration surgery is very minimal but it still may occur.

Q:

Thanks Dr. Mohebi,

Your input is much appreciated.  The shock loss you had mentioned has been my concern, as a few of my frontal hair seem lighter than before.  You had mentioned that the shock loss might be visible for a few weeks to months - will it be the case that after that shock loss stage, the hair will likely return back to original form?

There’s a very important question that i would like to ask you, and was thinking the it would be great for the blog to have.  Basically, when you saw my before and after picture, i feel like i changed a bit.  The “after” picture seems like i have more redness, and i’m hoping it’s not the case where the hair transplant affects the circulation (e.g., tight donor area/scalp affecting the blood flow to my head).  My surgeon told me before the procedure that i will eventually be back to the way i was before (i.e., the “before” picture), but just have a new scar and more gafted hairs.  That’s the ultimate question: would you agree that a patient who does a hair transplant will relatively return to the condition that he was before the particular sugery (w/ of course, a new scar and more hair)?  This is what keeps me up at night, thinking perhaps my scalp has worsened, or i am now more prone to lose hair.  I hope that’s not the case, and every patient should be aware about before she or he gets a hair transplant done.

Thanks again for your help.  If I see you in person at your office, I might be interested in discussing about future scar work.

A:

What is hair transplant shock loss

Some of the hair shafts that fall off due to shock loss might come back. Especially if the shock loss happens in an area with permanent hair like back of the head. However, losing hair in the frontal area because of shock loss might not be completely reversible. But, you have to understand that falling hairs are the ones that were supposed to fall off anyway and a hair transplant just accelerates the loss.

How to prevention shock loss

Again, using finasteride can significantly reduce the extent of shock loss. After surgery, in the transplanted area, the tightness should not affect the circulation of the scalp. After a few days to weeks, on the donor area, the tightness goes back to normal.

Donor scar in strip hair transplant

And to answer to your last question, I do not agree you go back to the condition before surgery with only a new scar and some more hair. What I personally do in a repeat surgery is remove the old scar; the patient at the end has only one scar that at times may be even better than the initial scar.

How to improve the appearance of the scar

I perform tricophytic closure when I think it is the final surgery that the patient may need.  Tricophytic closure is when we close scalp skin on the back in a way that hair can grow through the scar.  Tricophytic closure reduces the contrast between donor scar and surrounding areas that eventually improve the appearance of the scar, so you are not more prone to hair loss because of your hair transplant.

In some cases and when we are looking for even less visible scar, the scar may get filled with FUE into the scar in a few months from the initial surgery.

Be patient and you should be able to see results in the coming months.

Q:

Dr. Mohebi,

I have read your blog for months now and I like the way you respond to questions. You don’t sound like most other hair transplant doctors that say anything to get you in their surgical chair.

This is my story; I lost my hair in a patchy form in 1979, one patch the size of a quarter dollar on top of my left ear and the size of a nickel on top of my right ear and one size of a bigger silver dollar on the top of my hair just on the front hairline. Since 1979 it never increase nor decrease in size. in 1992 I had HT of 400 grafts which completely erase the big silver dollar on top.

The one on the sides have transplanted hair but not enough density to complete erase them. 1993 the same HT doctors added 200 graft which is the only money l have then. By 2004 when l add 699 grafts my hair start to look like my father. My father have the ” horse shoe” shape can of lose. Every part of my hair growing area is hair, enough for me to hold with the tip of my finger, but they don’t grow out long and strong enough. I went to a place called Washington xx center they place a hand tool on my heard where it appears there is no hair and on the computer monitor I saw a lot of hair. Although, they told me I don’t need HT but to buy their laser machine for $3500 which l didn’t buy. but how could l have all that hair and they refuse to grow. I presently use Rogaine form.

Since 2004 l have had difficult financial situation and HT was not possible But I am back now by the Grace of God. But l want to use this money I save wisely. My goal is to have a mega session so I don’t have to keep doing this HT problem. The emotional  toll of this hair loss is devastating to me. With my pix attached, what and how do you think I can realize my dream and goal. one last question, How do you cater for patient on the east coast? I live in the Washington D.C metro area, will I get a discount from you as regard the expensive Beverly Hills hotels and flight?.

I will appreciate a detail response.

Thank you Dr. Mohebi

A:

Hair Transplant surgery has evolved in the last 10 years thanks to microscopic techniques and research which elucidated the mechanism of hair loss and hair restoration surgery.  We now can transplant with maximum natural results. We also increased the number of grafts which could be safely removed and harvested during a single hair transplant procedure. Mega session hair transplants have been a very hot topic and an interesting idea for many people who have a large balding area that cannot simply be covered with anything less than 3000-4000 grafts.

At the offices of US Hair Restoration, we evaluate every patient for the quality of donor hair and scalp which will determine the number of grafts that could be safely harvested and transplanted in one surgery. Many people who are getting their first surgery can have over 3000 grafts.  We have numbers of up to 5000 grafts, too.

Laser hair restoration is a pretty new concept and unfortunately we still do not have enough solid research published in peer reviewed journals documenting its effectiveness. There have been some results in smaller studies with some effect. However, I would rather wait on that until we have more research-proven documents in that regard.

You need to be evaluated for your donor potential and can consider surgery after that.  US Hair Restoration has hair transplant travel reimbursements for patients like you who have to fly from other cities.  We also provide hotel and transportation to and from the hotel for anyone who has to commute more than 50 miles to get to our hair restoration center.

I just gave a lecture on a new application for Laxometer in mega and giga session hair transplants in the annual ISHRS (International Society of Hair Restoration Surgery) meeting in Amsterdam, Netherlands.  As we presented the Laxometer in the prior hair restoration scientific meetings, Laxometer can make us capable of increasing the precision of strip removal method of follicular unit hair transplants while minimizing the risk of donor scar complications.

This year, I presented a new application for Laxometer for its use in patients who have limited laxity of the scalp due to prior hair restoration surgeries or for those who require a maximum number of grafts in one session (3000+, 4000+, 5000+ and so forth).  I performed a research in US Hair Restoration last year in which we removed the strip in sequences for hair transplant surgeries using Laxometer before and after removal of each section of the strip.  This method has increased the safety of the strip removal while decreasing the risk of donor wound complications.

The result that was presented in the ISHRS meeting indicated the effectiveness of Laxometer at increasing the number of grafts in a strip hair transplant while minimizing the donor complications of a hair restoration surgery.  Based on our findings, we now use Laxometer in our California hair transplant offices on a regular basis and obtain positive results consistently.

Yes, I am  back from Amsterdam.  I spent one week there and I was mostly involved with the meetings of the International Society of Hair Restoration Surgery.  The city of Amsterdam was beautiful and I still cannot believe in this day and age people still bike to work on a regular basis in a capital city in Europe.

As always of every year, we had a large number of hair transplant surgeons come from all over the world. My lecture this year was on a new application for the Laxometer and the title was Laxometer and Sequential Strip Removal for Increasing the Safety of Strip Removal in Mega-session Hair Transplants.  We will be placing a summary of the lecture in the hair loss library on our website US Hair Restoration soon.

The research results that was presented by the consultant of Intercytex for hair multiplication was disappointing and basically despite the fact that they announced they started Phase III of the study, this year they said they have not even finished the II yet.  They claimed financial problems to be the cause of that.  We will look closely as we were before to see what is going to be out in the horizon for hair multiplication or as it is often called “hair cloning”.

Several new automated techniques were also introduced for FUE harvesting but I was not impressed by any of those.  It seems like no one could come up with an ideal technique for the automated FUE that does not have significant problems.  We will continue with the manual methods for FUE hair transplant graft removal and placement at this time.

There were many nice discussions on new techniques in making sites, closing the donor wound and preparation of the hair transplant grafts.  The aesthetic aspects of hair restoration surgery was also discussed in many sessions and nice new concepts were introduced by several doctors.  Hairline design and temple points were again discussed and it seems that more doctors are realizing the importance of restoration on hair in the temple areas.  We at US Hair Restoration are very big in restoration of the temple points in the patients that need it and temple hairline is a necessary part of our hair restoration and hairline designs.

The comparison of the maintaining solutions is always part of the discussions.  This year there were a few nice comparative researches on densely packed hair and also the comparison of the grouping of the hair grafts in follicular unit form or isolate single hair groups.

Hair Restoration is one of the young fields of cosmetic surgery.  It has been revolutionized in the last 10 years with development of the idea of follicular unit transplantation and stereotactic microscopy that gave us the capability of producing such great results that are undetectable from the natural hair.  Presence of hair transplant doctors in scientific meetings of this kind help the hair transplant surgeon to be able to deliver the highest standard of hair transplant to his patient that can eventually guarantee both the doctor and the patient satisfaction.  I recommend the meeting of ISHRS to every doctor who performs hair transplant surgery as a big part of his practice.  In fact I do not understand how some doctors can afford not to be there while new findings are changing the face of hair restoration medicine on a regular basis.

Q:

I had a hair transplant (FUE) over 2300 grafts 6 weeks ago all in my front and hairline and I still have over 90% of all my transplanted hair and was also wondering if this is normal since everywhere I read that all transplanted hair will completely fall out between 1 to 2 months. I hope that I am part of that 10% you spoke of in this blog.

A:

Yes, you might be.  Every now and then we have seen patients who do not follow the regular pattern of hair loss and hair growth after hair transplant.  As we mentioned before, most patients lose all transplanted hair in 2-3 weeks after their hair transplant.  This is because the change in the physiologic environment of the hair forces the hair follicles into the telogen phase.  Patients generally do not have any hair on the transplanted area from 3 to 6 weeks after surgery.  When new hairs start to sprout, they become long and thick in the next few months after that.

There is some exceptions and every now and then we see patients who not only do not lose their transplanted hair, but their transplanted hair keeps growing from day one after hair restoration surgery.  You might be one of those exceptions.

There are also reports on some patients who have delayed growth on their hair growth and they do not see any growth in the first 6, 8 or even 12 months.  We do not know what is causing that but it has been anecdotally reported.  Close supervision of the patient and serial follow ups is needed to reassure the patient that he or she does not have any serious problem and the transplanted hairs are not wasted.

Q:

I just had a few questions following the consultation,

As you said I have slightly more miniaturization in the crown than the donor area, but still in normal range, what would cause me to have more in one area than another other than MBP, is that normal for non MPB scalps?

• Could finasteride worsen the hairline due to the rise of testosterone, or is that irrelevant?
• Are there any safe and minor treatments to slow the progress of maturation or reverse it that you would recommend at this stage?

A:
I will be sending you a letter with all information that we discussed during our consultation at US Hair Restoration Beverly Hills Office.  You may have very initial signs of MPB, but the numbers for miniaturized hairs are not far from high normal.  Let us wait and see your progress before putting you on hair loss medication finasteride.  Early stages of male patterned hair loss may not always be obvious enough in our scalp microscopic evaluation to be differentiated from having upper normal levels of miniaturization.  Propecia (finasteride) is a great hair loss medication to prevent balding, but I know many people who went on it without the proper documentation of their miniaturization.  These hair loss patients may have to take it for the rest of their lives without knowing that they have really needed it to start with.

The main cause of hair loss is DHT (Dihydrotestosterone) and not testosterone, so finasteride can not deteriorate your hair loss or hairline maturation changes. Maturation of hairline is a natural phenomenon and should not be mistaken with balding.  We do not want to stop it.  I do not recommend any medications to stop the maturation of hairline either.