Cheap Clip Hair Extensions

The first and foremost mistake is having unrealistic expectations. They will necessarily lead to frustrations, no matter how good or bad the treatment was. No matter what the marketers of any hair loss product say, do not believe that you can recover all of your lost hair. Most treatments only enable you to slow down the balding process or, in better instances, to maintain the existing hair. The best possible achievement you can expect from any treatment is to regrow the hair you have lost in the previous three years. But this is only possible if you start treating your condition at an early stage in the balding process. This brings us to the second mistake many hair loss sufferers make – denying their hair loss and starting to treat their condition only after they have already developed a visible bald patch. The later you start treating the baldness, the less chances you have of regrowing the hair you have lost. In order to regrow hair you must have fine miniaturised hair left in your bald areas. This hair is often called peach fuzz. Once your hair follicles have died and there is no hair left, no miracle can rejuvenate them.

Many hair loss sufferers, as they start working on their research, get scared reading about the potential side effects of proven medicinal treatments and opt for allegedly safer alternative treatments. Marketers of natural, hair loss remedies tend to overexaggerate the negative side effects of Propecia (finasteride) and Rogaine (minoxidil) in order to lure scared consumers into buying their own product. The chances that you will lose your sex drive from finasteride or grow additional facial hair because of minoxidil are less than 1%. You should first try the proven medicinal treatments and only if you have experienced negative side effects try some alternative therapy. Starting with unproven products right away deprives you of the opportunity to test some of the best remedies available out there. If you start treating your condition with an alternative treatment, the likelihood you choose the one that works well for you is close to zero. Thus, you are almost certainly wasting time while the hair loss continues to advance. And do not believe that all natural and herbal hair loss treatments are safe. That is not true either.

Another common mistake is to use multiple treatments simultaneously. If you want to try different things, do not try them all at the same time. Any hair loss treatment requires a minimum of four months to kick in and you should allow it at least six months to get measurable results. Please note that overdosing will not speed up or improve results.

And lastly, do not overreact to shedding. Shedding is common to almost any hair loss treatment. If you start a new treatment such as Rogaine, you will first have to shed the old hair. Rogaine is assumed to stimulate hair follicles, resulting in increasing the diameter of your miniaturised hair. But this cannot happen overnight. First, the old thin fibber must be shed, and then the hair follicles rearrange themselves in order to start producing thicker hair. Typically, the first sign that the treatment is working is accelerated hair loss.

Dr. Jim Arnold should be congratulated on another excellent and detailed reporting of the ISHRS meeting. We appreciate the inordinate amount of time and effort that he has spent in recording the vast amounts of information that speed by us so quickly. It is amazing how he does it! In reading the article in the Nov.-Dec. 1997 Forum, Vol. 7, No. 6, p. 5, I noticed three small errors in the text that should be corrected. I thought that I might also take the opportunity to briefly discuss them.The text reads “Some patients may average 1or 2 hairs per unit, while others 4 to 5.” While we do see patients with very low density, or Asians, who average 1 or 2 hairs per unit, I have not seen patients who average 4-5 hairs per unit. Patients with high density can have a significant number of 4, or rarely 5 hair follicular units, but this is not their average. The graph that I presented in Barcelona, illustrating this point is shown here. Another important point is that the density (spacing) of naturally occurring follicular units is relatively constant at about 1 group/mm2 in the posterior scalp of most Caucasians, but is less in the Black races (where it averages approximately 0.6/mm2). The text also reads “Dr. Limmer finds the average number 2.3 hairs per unit, while Dr. Bernstein feels the number is closer to 3.” This is also incorrect. As I stated in my presentation, the majority of patients that we see in consultation that are surgical candidates range from 1.5 hairs/unit to 3.0 hairs/unit with an average of 2.0 hairs /unit (rather than 3). The population that actually go on to have surgery have slightly higher groupings at approximately 2.1/hairs per follicular unit. (The graph also illustrates this point). The numbers that I presented were based upon densitometry readings at the time of the consultation, taken approximately 5 cm to the left or right of the occipital protuberance. Only full-thickness terminal hairs were counted. Dr. Limmer and I spoke regarding the slight differences that we each observed and we felt that different patient populations might be a factor contributing to this small difference. The location on the scalp where the measurements were taken will also influence the results, as the follicular unit density is generally highest in the midline of the donor area and decreases laterally. Having prior knowledge of the approximate proportion of each of the different size follicular units that will be obtained in the dissection is extremely important in planning the transplant, since the larger units can be concentrated in select areas to create the appearance of greater central density without having to increase the “closeness” of the sites. These numbers are also important because the pre-operative measurement of density and the estimation of follicular unit size are two means of assessing the accuracy of the follicular unit dissection. The other statement “Hair diameter plays a significant role, as diameter may range by a factor of 5X among patients.” is also incorrect. The word “diameter” should be replaced with the words “Cross Sectional Area.” The range in terminal hair shaft diameter is approximately 2.3 fold (0.06 mm for very fine hair and 0.14 mm for the coarse hair that we often see in Asians). This represents a variation in x-sectional area of approximately 5.4 fold, since area = ~r2 or ~(1/2d)2. It is interesting to note that compared to hair density, hair shaft diameter plays a much more significant role in the volume or “bulk” of the transplant. The range in hair density in patients that we generally transplant is from 150 hairs/cm2 in those of low density, to around 300 hairs/cm2 for those with the highest. In our practice, we rarely transplant patients who present with a density of less than 150/hairs cm2 (except for Blacks and Asians) and uncommonly see patients with a density greater than 300 hairs/cm2. The range is thus a 2-fold difference. If we compare this to the 5.4 fold range in hair cross-sectional area, we see that, in theory, variations in hair diameter should have 2.7 times the cosmetic impact of variations in hair density. In reality, these variables are not totally independent. For example, the widest hair shaft diameters are not generally seen in the same patients who have the highest hair densities. Nevertheless, one can make a strong argument for the quantitative assessment of hair shaft diameter, as well as density, in the pre-operative evaluation of patients considering hair transplantation.

HISTORICAL ASPECTS A donor is better if it is as small as possible. The reason is that if a donor is big, hairs grow in . . . a very unnatural appearance. Hajime Tamura – 19431PRESERVATION OF THE FOLLICULAR UNITThe underlying premise of follicular unit transplantation is that the intact, individual follicular unit is sacred. Theoretically, they should neither be broken up into smaller units, nor combined into larger ones.2,3,4This simple idea may not seem like a radical approach to hair transplantation, but when viewed in the context of how the surgery has been performed over the past forty years (when the very existence of the follicular unit went generally unrecognized), it is radical indeed. At present, the majority of hair transplant surgeons will, at times, combine several follicular units or split them up, as they are not convinced that this has a significant impact on either the anesthetic outcome or upon growth. Practitioners of follicular unit transplantation, however, are certain that only this procedure achieves the best cosmetic results and their hair “bristles” when they witness surgical techniques that divide follicular units or transect follicles, techniques they feel preclude optimal growth and waste precious donor hair. In spite of the heated debate, good scientific studies have not yet been performed to resolve these issues.The follicular unit was first defined by Headington in his landmark 1984 paper “Transverse Microscopic Anatomy of the Human Scalp.5 The follicular unit includes:- 1 to 4 terminal follicles- 1, or rarely 2, vellus follicles – associated sebaceous lobules- insertions of the arrector pili muscles- perifollicular vascular plexus- perifollicular neural net – perifolliculum – cirumferential band of fine adventitial collagen that defines the unitTRANSPLANTING INDIVIDUAL FOLLICULAR UNITSThat scalp hair grows in follicular units, rather than individually, is most easily observed by densitometry, a simple technique whereby scalp hair is clipped to approximately 1mm in length and then counted observed via magnification. What is strikingly obvious when one examines the scalp by this method is that follicular units are relatively compact, and are surrounded by substantial amounts of non-hair bearing skin. The actual proportion of non-hair bearing skin is probably on the order of 50%, so that its inclusion in the dissection will have a substantial effect upon the outcome of the surgery. The great benefit of using individual follicular units is that the wound size can be kept to a minimum, while at the same time maximizing the amount of hair that can be transplanted.SMALL RECIPENT SITESThe importance of minimizing the wound size in any surgical procedure can not be over emphasized and hair transplantation is no exception. The effects of recipient wounding are felt at many levels. Large wounds can lacerate blood vessels and although the blood supply of the scalp is extensively collateralized, any damage to these vessels will have an impact on local tissue perfusion. An equally important issue is to minimize the disruption of the microcirculation. This is especially important when transplanting grafts in large quantities. The compact follicular unit is, of course, the ideal way to permit the use of the smallest possible recipient site, and has made the transplantation of large numbers of grafts technically feasible.Densities between 10 to 40 follicular units per centimeter are routinely reported. Densities greater than 40 follicular units per centimeter in a single session have been accomplished, but may result in a decrease yield in some patients. It is important to note that a follicular unit density of 40 units/mm2 can create a hair density of over 120 hairs/mm2 (if all 3- and 4-hair units are used in select areas), and this is a density that many hair transplant surgeons feel is not necessary, or even desirable, to exceed.TRANSPLANTING FOLLICULAR UNITS IN LARGE SESSIONSPutting aside anatomic, physiologic and technical issues for the moment, it is important to emphasize the practical reasons to strive toward large sessions. The specific events that bring a balding patient to the doctor for hair loss will vary, but the common denominator of those seeking hair restoration is to improve their appearance, and to improve the quality of their life, be it personal, professional, or social. Until the transplant is cosmetically acceptable, the disruptions from the scheduling of multiple surgeries, the limitations in activity, and the concern about their discovery, can place a patient’s life “on hold.” It should therefore be incumbent upon the physician to accomplish their objectives as quickly as possible. Some patients prefer smaller sessions for economic reasons. MICROSCOPIC DISSECTION There is probably no other aspect of follicular unit transplantation that has generated more controversy than the use of the microscope. Stereo-microscopic dissection was introduced into the field of hair transplantation by Dr. Bobby Limmer6 in 1987. The following statements summarize the use of magnification: – In order to dissect intact individual follicular units, you must be able to see them clearly.- Only magnification allows their clear visualization in both normal and scarred skin, independent of the specific hair characteristics of color, hair shaft diameter, and curl. Follicular dissection can logically be divided into two parts; the subdivision of the initial donor strip into smaller pieces and the further dissection of these pieces into individual follicular units. The first part of the procedure, the handling of the intact strip, has always been the most problematic. The intact strip however, is difficult to stabilize and is too opaque for transillumination to be useful. The dissecting microscope and other magnification methods allow the strip to be divided into sections (or “slivers”) by actually going around follicular units leaving them intact. The dissecting stereo-microscope is able to accomplish this because of its high resolution (usually 5x more powerful than magnifying loops) and its intense halogen top-lighting that provides continuous illumination, as one dissects through the strip. Back light illumination has also proven beneficial. Stability can easily be achieved by applying slight traction to the free end of the strip. The thin slivers are then laid on their sides and the microscopic dissection of the individual units is completed. With stereo-microscopic dissection, except for the outer edges of the ellipse, every aspect of the procedure is performed under direct visualization, so that follicular transection can be minimized and the follicular units maintained. CONCLUSIONThe entire field of hair restoration surgery has moved toward the use of follicular unit transplantation. While the exclusive use of follicular units is not employed by the majority of transplant surgeons, the impact of this approach has been significant. Hair restoration surgeons are becoming more scientific and precise in their approach to this field. The vague terminology of the past, i.e., round grafts, many grafts, micro grafts, has been replaced with more precise terms. We now converse in a language which details the number of follicular units per square centimeter, hair shaft diameter in microns, and incisional density of the recipient site for any given session. Perhaps the modern era of transplantation did not begin with the micrografting of the ’80’s, but it is only truly being realized with follicular Unit transplantation of the ’90’s.

IntroductionThe follicular unit (FU) was first defined by Headington and the conceptual framework for using FUs in hair transplantation was laid out by Bernstein and Rassman. It became clear to most surgical hair restoration practitioners that the single-strip harvesting and stereomicroscopic dissection techniques developed by Limmer in 1988 were the best way to both harvest and isolate FUs.Although single-strip harvesting is an extremely efficient means of obtaining tissue for subsequent dissection into FUs, it results in a linear scar. Careful technique with thin donor strips will produce very fine scars, but if the strips are taken too wide, the scar can widen to an unacceptable degree. Covering the donor area with longer hair was the only solution to widened scars, as surgical repairs of these wounds generally proved to be ineffective. As a result, a number of patients became hesitant to undergo a hair transplant procedure that had a potentially difficult-to-treat widened linear scar.In the mid-1990s, Rassman set out to find a way around this problem by directly extracting FUs from the donor area using a small punch. Early attempts were frustrated by high transection rates in a significant number of patients until Richard Shiell brought the work of Masumi Inaba to his attention.Inaba”s technique varied slighty, using a similar punch but only partially cutting down on the hair follicle and then removing the remainder with forceps. Inaba”s insight led to Rassman and Bernstein describing follicular unit extraction or the FOX procedure (FOllicular unit eXtraction), outlining an entire surgical hair restoration procedure without strip harvesting After performing the FOX procedure on patients of various nationalities it became obvious that extraction proved to be quite variable. Histologic analysis was used in an attempt to elucidate the cause of patient variability and the FOX Test was introduced, an important surgical recommendation tool to determine patient candidacy.Overall results showed that the FOX Test classified approximately 60% of all patients as candidates for the FUE procedure. However, even the good hair transplant candidates had a strong possibility of follicle transection.Two-Step TechniqueThis process is comprised of two main steps. In the first step, a sharp 1 mm punch is placed over the follicular unit and aligned to approximate the angle of the hair shafts below the skin surface. A rotational motion of the punch is then used by the hair restoration doctor to cut through the skin and isolate FUs in the epidermis and upper dermis.For a successful hair transplant procedure, the incident angle of the punch cannot vary much from the hair shaft direction or some, or all, of the hairs in the FU will be transected. Since the hair bulbs in each FU splay outward in the deep dermis and fat, it is also important to limit the depth of the punch to the upper dermis, which proves difficult.In step two, the extraction, fine rat-toothed forceps are used to apply gentle traction to the top of the FU until the unit is pulled loose from its deep dermal and subcutaneous connections. There is person-to-person variation with this procedure. To help limit variation effects, the technique was refined further, adding dissection when simple extraction proved difficult. If a graft cannot be removed with gentle traction, then the deeper part of the graft is separated from the surrounding tissue through dissection using a fine needle (with a U-shaped tip) while traction is applied with delicate forceps.With this additional dissection step, percentages of positive FOX patients increased. Despite a significant yield improvement, a large number of hair restoration patients still could not be shifted into “FUE candidacy.” In many cases transection rates were still unacceptably high and dissection times for significant cases unacceptably long; the additional step slowed the entire process.Three-Step TechniqueJames Harris presented a paper and a new solution at an ISHRS scientific meeting, in which he added an additional third step requiring new instrumentation. In this new three-step hair transplant procedure, a sharp punch is used to score the epidermis (rather than cut through the full thickness to the dermis) and then a dull punch is used (through a back-and-forth twisting motion) to bluntly dissect the FU graft from the surrounding epidermis and dermis .This variation has several advantages over the original two-step process. Using a dull punch avoids follicle transection and allows intact FUs to be extracted more easily. As the blunt-tipped punch is advanced into the dermis, splayed follicles are “gathered together,” avoiding transection. In effect, the dull-punch technique allows a full realization of the “extraction concept” with an easy-to-learn methodology. One untoward result of the three-step technique is a possible higher incidence of buried grafts, as discussed later. In addition, some of the FUs remain tethered to the subcutaneous tissue and require additional dissection.One great advantage of this addition was that it opens this surgical hair restoration technique to the inherent FOX-negative population: those with very fine hair and those with African kinky hair types. Because the procedure is performed blindly, visualization is no longer an issue, potentially increasing yield for those with hard-to-see gray hair. In addition, it appears that this FUE modification has applicability for corrective procedures, removing FUs inside old plugs.Indications for FUE have evolved considerably. Initially, FUE was limited to FOX-positive patients (that showed minimal transection) and in those in which the size of the balding area matched the surgical team”s ability to perform the procedure in an acceptable time frame – essentially small procedures in select patients. With improved techniques, Rassman reported his largest case yet in 2004: 1903 FUs performed exclusively with the original two-step technique. Harris” modification should allow these large sessions in a greater number of hair transplantation patients.Nuances of three-step techniqueAlthough the three-step technique is easier to master than the two-step technique, there are certain factors that will increase its efficiency and success.Because the subcutaneous course of follicles cannot be ascertained with great accuracy, “scoring” incisions should be limited to a depth of between 1.3 mm and 1.5 mm (approximately the level of the end of the bevel on a standard 1 mm Miltex punch) to decrease the risk of inadvertent transection. However, in hair transplant patients whose follicles are slightly longer, scoring incision depths may be increased by 0.1-0.2 mm. This increase should facilitate insertion of the “dissecting” punch and may decrease the incidence of “buried” grafts.Even though the use of a blunt punch provides protection for follicles and makes the angle of insertion less critical, follicles may be damaged if the angle is radically different from the follicle”s direction. To prevent damage, scoring incisions can be created, and their angles reassessed to obtain a more accurate estimate of the follicle”s direction and more accurately “aim” the dissecting punch.Follicle separation from the epidermis and upper dermis at the sebaceous gland may occur during extraction. This phenomenon, which has been called “capping,” can be handled in three ways. If the subcutaneous attachment is significant, a second pass with a dissecting punch can be attempted. A second option is to grasp the unit at the sebaceous gland region and pull, applying a slow, steady force. The final option, if standard dissection fails, is to leave the graft in situ and allow the skin to heal by secondary intention.Since a third step is required in this new hair restoration method, the need for efficiency has increased. Rather than performing each of the three steps for each FU in sequence, a preferred method is to identify an area to be extracted, score 25-50 FUs, dissect each one, and then extract. Assistants may help with dissection and extraction but care must be taken to identify any buried grafts for subsequent retrieval efforts.The need for tumescence varies from patient to patient, but for the most part, it has been found that tumescence may cause the dermis to become somewhat “mushy” and impede the extraction process. The hair transplant surgeon must make constant assessments of extraction success each step of the way with every patient. Ease of extraction also seems to vary with scalp location. The occipital area tends to be easier while temporal areas may require manual dissection due to a higher degree of tethering.Management of buried graftsAs previously mentioned, this hair transplantation technique has an inherent possibility of producing buried grafts. Incidence can vary from patient to patient depending on unidentified skin characteristics. It has been observed that in some patients and in some areas (the temples for example), slightly increasing scoring depths decreases the incidence of buried grafts.When a buried graft is identified, immediately apply pressure around it in an attempt to “force” the graft to the surface. If this maneuver fails, the hair restoration doctor should examine the circular incision to identify the follicle base, a key step in facilitating removal. If the follicle is not visible, use small, curved forceps with the tip directed towards the “superior” aspect of the incision in an attempt to grasp the FU. Owing to punch insertion angles, the incision depth is shallower at the superior aspect of the incision. Grafts often invert at this location by tethering to a nonscored attachment.If the graft still cannot be located, make a small incision towards the superior aspect to create a larger exploratory opening. If after these steps visualization still eludes the hair transplant surgeon, the graft should be left buried. Exact incidences of graft burial and graft recovery are not available; however, in a 40-patient and approximately 10,000-graft study, only two instances of buried grafts resulted in hair-bearing inflamed cysts requiring removal.Indications for FUEFUE is indicated in the following situations:1. When even a very thin linear scar is unacceptable (i.e. in those who shave their head or wear their hair very short)2. When a patient requests an FUE procedure and enough grafts can be harvested to meet his or her needs3. In patients with limited hair loss or those who require small sessions. This group would include patients with androgenetic alopecia in a Norwood Class 3 pattern or those with small vertex balding areas4. For limited cosmetic areas, such as widow”s peaks, eyebrows, eyelashes, mustaches5. For limited areas of alopecia secondary to dermatologic conditions6. In the treatment of widened scars resulting from traditional strip excisions7. In patients without adequate laxity for a strip excision8. For scarring from dermatologic conditions, trauma, or neurosurgical procedures9. For individuals with heavily scarred donor areas making a linear incision problematic10. In patients who tend to heal with wide or thickened linear scars11. In athletes who must resume full activity soon after the procedure12. For patients with an inordinate fear of pain or scars13. When the body or beard serves as a donor area.Contraindications for FUEContraindications for FUE include:1. Inexperience in performing FUE techniques2. Unavailability of proper instrumentation3. Inadequate and uninformed patient consent4. Unrealistic patient expectations5. Inadequate donor supply6. Scarring that makes both the two- and three-step procedures problematic.ConclusionFUE is an exciting advancement that propels the field of hair transplant surgery one step closer to the elite minimally invasive status. The promise of an almost scarless surgery is enticing to both patient and surgeon. For the hair restoration doctor who has to perform this tedious technique, there remain many vague issues ranging from ethical representations of patient results to practical realities of surgical indication. Training periods are extensive, risks of less than desirable results are high, and many technical problems have yet to be worked out.FUE clearly has a valuable place in a growing number of hair transplant candidates. Although the techniques have improved, issues of patient selection, donor area healing by secondary intention after large sessions, and imbedded grafts still remain. The reasons for selecting FUE rather than a strip harvest may be the avoidance of a linear scar, the desire for a virtually pain-free recovery period, or simply the idea of having a minimally invasive procedure.Further ReadingBernstein RM, Rassman WR, Seager D, et al 1998 Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatologic Surgery 24:957-963Bernstein RM, Rassman WR, Szaniawski W, Halperin A 1995 Follicular transplantation. International Journal of Aesthetic Restorative Surgery 3:119-132Bernstein RM, Rassman WR 1997 Follicular transplantation: patient evaluation and surgical planning. Dermatologic Surgery 23:771-784Bernstein RM, Rassman WR 1997 The aesthetics of follicular transplantation.Dermatologic Surgery 23:785-799Bernstein RM 1998 A neighbor”s view of the “follicular family unit.” Hair Transplant Forum International 8:23-25Harris JA 2004 Follicular unit extraction: The SAFE System. Hair Transplant Forum International 14:157,163,164Inaba M 1996 Androgenetic alopecia: modern concepts of pathogenesis and treatment. Springer-Verlag, Tokyo pp 238-245Kim JC, Choi YC 1995 Regrowth of grafted human scalp hair after removal of the bulb. Dermatologic Surgery 21:312-313Limmer BL 1994 Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation. Dermatologic Surgery 20:789-793Okuda S 1939 Clinical and experimental studies of transplantation of living hairs. Jon Journal of Dermatologic Urology 46:135-138 [in Japanese]Orentreich N 1959 Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479Rassman WR, Bernstein RM 2002 Follicular unit extraction. Minimally invasive surgery for hair transplantation. Dermatologic Surgery 28:720-728Rassman WR, Carson S 1995 Micrografting in extensive quantities: the ideal hair restoration procedure. Dermatologic Surgery 21:306-311Rassman WR, Bernstein RM 2002 Follicular unit extraction: Minimally invasive surgery for hair transplantation. Dermatologic Surgery 28:720-728Sasagawa M 1930 Hair transplantation. Japanese Journal of Dermatology 30:493 [in Japanese]

Hair loss can be of great concern to both men and women at some time in their lives. This concern mainly centers on fears of looking prematurely old, unattractive to the opposite sex, lack of self-esteem and, without any real justification, of being thought of as lacking virility and of even being regarded as impotent.

Here, we shall briefly outline three types of hair loss conditions of the Alopecia category. Then we shall outline five methods that are commonly used to address these conditions.

Alopecia Areata has clearly apparent bald patches, often round or oval in shape. Alopecia Areata can appear on the head, beard, and other hairy parts of the body. Even if the spots disappear within a year of treatment, it’s common for Alopecia Areata to reoccur again. Alopecia Totalis means total baldness, all the hair on the scalp has disappeared. Alopecia Universalis is the condition where there is a complete loss of hair from all sections of the body. It sometimes occurs as an extension of generalized Alopecia Areata. The whole head and body of an individual becomes bald. Hair disappears from all regions, i.e., pubic, armpits, eyelashes, eyebrows, chest, legs, beard, and other areas.

Here are five methods to treat hair loss, and these exclude hair transplanting which is outside the scope of this article.

1 Laser or low level light therapy has been shown to be beneficial to hair in several studies. Both clinical treatment and hand held laser therapy are available. Also, larger laser models can be bought for use in salons and hair replacement studios.

2 Di-hydro testosterone (DHT) is the major cause of hair loss for both men and women. DHT inhibitor products can either interfere with the conversion of testosterone to DHT or help to block DHT from binding to the hair follicle.

3 In relation to this, hair vitamin products help to aid in growth of hair; either by inhibiting DHT and/or providing the vitamins and minerals that optimizes good quality hair growth.

4 There are only two FDA-approved treatments for hair loss and one of these, Minoxidil, is the only anti-baldness drug approved for women. Originally introduced as a medicine to treat high blood pressure, it was noticed that users began to grow extra hair.

5 Hair and scalp cleansing products can be optimized to give hair and the scalp the nutrients that are needed without adding harmful chemicals like sodium laureth sulfate, cocamide diethanolamine, or alcohols that are present in most shampoos. These harmful chemicals cause these shampoo to strip hair of the essential oils that hair needs. Proper hair and scalp hygiene and nutrition is the first step to healthier, thicker and fuller hair.

In conclusion, early steps can be taken to address hair loss, however it is strongly recommended that plenty of research is done first to ascertain the real cause of the condition, that may be unique to and thus different from individual to individual, before deciding what action to take.

Densitometry is a technique that analyzes the scalp under high-power magnification to give information on hair density, follicular unit composition and degree of miniaturization. It can be used to help evaluate a patient’s candidacy for hair transplantation and help predict future hair loss. More recently, video-microscopes have been developed that can project the image onto a computer screen and provide a permanent digital record. This paper describes the value of taking objective measurements, using densitometry or video-microscopy, in the hair transplant evaluation. BackgroundOne of the earliest methods of measuring hair density was devised by Bouhanna, who used camera attachments to create a “phototrichogram,” an ultra close-up photograph of hair exiting the scalp. This method provided the capability to document the quality and quantity of hair shafts.  However, the disadvantage of this innovation was that an assessment could not be done until after the film had been developed. [1] In 1993, Rassman introduced a small hand-held instrument, the Hair Densitometer, to make densitometry easy to perform during a consultation. [2, 3].  The hair densitometer is a self-contained, portable, device that houses a magnifying lens and an opening of predetermined size.  The hair is clipped short (~ 1-mm) and the unit is placed directly on the scalp.  An assessment is made from a standard 10mm2 field.  Multiple measurements taken from different parts of the scalp are often helpful, particularly if there is significant variability from one location to another. [4] An advantage of the hand-held densitometer is that it is inexpensive and readily available to be used during the consultation and can provide immediate information regarding a patient’s candidacy for surgery.   A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler. With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10]. The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss. [10-12] A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler.  With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] [Figure 2]The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10].  The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss.  [10-12]    MiniaturizationNormally, follicular units contain 1-4 terminal hairs of uniform diameter and, occasionally, fine vellous hairs, with the two hair populations being clinically distinct.   In androgenetic hair loss, the action of DHT causes individual terminal hairs in some follicular units to miniaturize, where they begin to decrease in diameter and in length until they resemble vellous hairs. Eventually, these hairs will disappear.  In androgenetic alopecia, hairs in varying stages of involution (and thus of varying diameters) cause these two distinct populations of hairs to merge into one continuum.  The changes eventually cause visible thinning in affected areas, but may initially be detectable only through densitometry.At first, miniaturization involves only one or two hairs in select follicular units, but eventually progresses to involve all the hair follicles in genetically susceptible areas.  It has been the observation of these authors that a shift from focal to generalized miniaturization precedes the actual loss of affected hairs, so that total hair counts remain relatively constant until end-stage baldness. [8]  Said another way, the progressive thinning associated with androgenetic hair loss (particularly in the early stages) is caused by a decrease in the hair shaft diameter of an increasingly larger number of hairs, rather than by the actual loss of individual hair follicles.Miniaturization, unfortunately, can also occur in the back and sides of the scalp.  When it affects a person’s donor area, it will have profound implications for surgery. Although miniaturization in the donor area is a relatively uncommon occurrence in men, it is quite common in women, explaining why so many more men with hair loss are candidates for surgery compared to women.  In all cases, donor miniaturization must be assessed prior to considering surgery.Densitometry MeasurementsDensitometry is extremely helpful in evaluating patients for hair transplantation. When determining which persons are candidates for hair transplantation, it can be used to measure the absolute donor hair density (i.e. # of hairs/mm2), the composition of follicular units (i.e. the number of 1-, 2-, 3- and 4-hair units), and the degree of miniaturization. Although the precise hair density and composition of follicular units will not be known until after the donor strip has been completely dissected, at the time of the consultation, densitometry can tell the doctor the approximate hair density. This will enable him to determine how much hair will be obtained from a certain size strip or how large a strip will be needed for a required number of follicular unit grafts.   Densitometry will also give information regarding the cosmetic impact of the hair restoration.  Other hair characteristics being equal, if a person has a high number of 3- and 4-hair grafts, he/she would be expected to have a fuller hair transplant than a person with predominately 1- and 2-hair follicular units.  For example, a typical Caucasian would have follicular units in his/her donor area that contained, on average, 2.25 hairs each.  If there were 1 follicular unit per mm2 in the donor area (0.9 to 1.0 is normal) then one would need 2,500mm2 of donor tissue for a 2,500 graft procedure. A donor strip that was 1cm wide would need to be approximately 25cm long to contain 2,500 follicular unit grafts.  See the following table. Stereo-microscopic dissection of the donor strip would yield approximately 14% 1-hair grafts, 53% 2-hair grafts and 33% 3- and 4-hair grafts.  The single-hair grafts would be used to create a soft, natural frontal hairline and the 3- and 4-hair grafts would be used in the forelock area to create the appearance of central density.  Small variations in follicular unit density can have a significant impact on the procedure. A person of similar hair shaft characteristics (i.e. hair diameter, color and wave) that had 2.0 hairs per follicular unit, also spaced 1mm apart, would require exactly the same size strip for a 2,500 graft procedure.  In this case, however, the follicular units would, on average, have less cosmetic value and the person should expect a thinner look from the surgery as only 17% of the grafts contain 3- or 4- hairs.  In addition, the ability to create central density via graft sorting would be reduced.  On the other hand, with a donor density of 2.4 hairs per unit, 40% of the grafts will contain 3- or 4-hairs and the ability of the surgeon to create density in the forelock area using only naturally occurring follicular unit will be significant If we look at the total number of hairs contained in the follicular units, we note that for a 2,500 graft procedure, a person with 2.4 hairs per follicular unit will have 1,000 more hairs than a person with a density of 2.0. Densitometry, therefore, gives the physician information regarding the number of single hair units that can be anticipated from a given size donor strip (without having to subdivide larger units) and the degree to which the larger follicular units can create central and forward weighting to enhance the aesthetic impact of the procedure.  Donor Miniaturization  Normally, the donor area shows little or no miniaturization and the density counts described above are useful in predicting both the short- and long-term outcome of the procedure.  However, if genetic hair loss affects the donor area, the situation changes dramatically. Once full-thickness terminal hair begins to miniaturize, the cosmetic value of the follicular unit begins to decrease and the value of the grafts will be diminished.  In other words, just because hair is transplanted, it doesn’t make the hair transplant   permanent – the hair in the donor area must be permanent.      Early detection of miniaturization in the donor area is a warning sign that the donor area is not stable and that the person may not be a good candidate for surgical hair restoration.   If any miniaturization is detected in a young person, i.e. under the age of 25, red flags should go up that their donor area may not be stable.  When miniaturization is noted in a teenager, the risk of developing diffuse un-patterned hair loss (see below) is significant.  In an older adult male, some miniaturization, perhaps up to 20%, is consistent with being a good surgical candidate.  Unlike men, adult women often have significant levels of miniaturization in the donor area, so the mere presence of miniaturization is not necessarily a contraindication to surgery.  However, miniaturization does indicate an unstable donor supply and one has to make a judgment regarding the risk/reward of the procedure. The physician needs to consider the absolute number of full terminal hairs that are available for the hair transplant, the risk of further miniaturization, the area that needs to be covered, and the risk of the surgery accelerating the hair loss.  This is particularly important to consider in women, since hair is often transplanted into an area that has a considerable amount of existing hair – some of which is at risk of being shed from the surgery.  In women, when the risk of continued miniaturization of the donor area is added to the risk of the surgery accelerating hair loss in the area to be transplanted, a far fewer percentage of women are good candidates for surgery compared to men. To think otherwise is disingenuous.  Diffuse Patterned and Un-patterned AlopeciaThe importance of donor miniaturization as a factor affecting a person’s candidacy for a hair transplant was emphasized almost a decade ago in the paper “Follicular Transplantation: Patient Evaluation and Surgical Planning.”[4] In this writing, we described two conditions; “Diffuse Patterned Alopecia” (DPA) and “Diffuse Un-patterned Alopecia” (DUPA). These were first mentioned by O’tar Norwood when he devised the classification of androgenetic alopeica that bears his name.  These two conditions, however, were not detailed in his paper and never received much attention. This was unfortunate because their understanding gives important insights into how to determine who will be a candidate for hair restoration surgery. [5] Diffuse Patterned Alopecia (DPA) is characterized by diffuse thinning (miniaturization) in the front, top, and vertex of the scalp in conjunction with a stable permanent zone. DPA is usually associated with the persistence of the frontal hairline and, in the early stages, the thinning is relatively even across the top of the scalp. This contrasts with regular Norwood patients that have early hair loss at the temples and in the crown with balding that spares the top of the scalp. Patients with DPA can be good candidates for hair transplantation due to their stable permanent zone; however, they have an increase risk of shedding after the hair transplant, due to the diffuse miniaturization across the top of the scalp.   In the less common Diffuse Un-patterned Alopecia (DUPA), the miniaturization process occurs over the entire scalp, so that the person lacks a stable permanent zone. People with DUPA tend to lose their hair at an early age, often beginning in their teens. In the early stages, there may be only a slight suggestion of decreased hair volume overall and actual thinning may only be noted through densitometry. Over time, the back and sides of the scalp can take on a transparent appearance, particularly when the hair is cut short. Because the donor area is not permanent, hair transplantation is contra-indicated in patients with Diffuse Un-patterned Alopecia.    Although fully manifest diffuse un-patterned hair loss is relatively uncommon in men, there are many younger patients who have slightly increased degrees of miniaturization in the back and sides of the scalp, making the long-term stability of the donor area questionable. In these patients, the decision to recommend hair restoration surgery is particularly difficult.  As a general rule, if the decision is difficult, it is best postponed, since, over time, the stability of the donor area will become more obvious.  A mistake can leave the patient with transplanted hair that will thin over time and a donor scar(s) that may become visible. Both Diffuse Patterned and Un-patterned alopecia also occur in women. However, in contrast to men, the DUPA pattern in women is much more common, possibly occurring 10 times as frequently as DPA.  As in men, female patients with DUPA are not good candidates for a transplant, except in the instance where the goal is solely to soften the frontal edge of a hairpiece. The high incidence of Diffuse Un-patterned Alopecia in women partly explains why many fewer women are good candidates for hair transplantation as compared to men.  It is important to emphasize that other, non-genetic, causes of hair loss must be considered in cases where the balding pattern is diffuse.  These include anemia, thyroid disease, connective tissue disease, gynecological conditions, severe emotional events, and medications. Although the presence of miniaturization likely points toward a hereditary cause of the hair loss, with diffuse hair loss other etiologies must always be entertained. ConclusionDensitometry is an important tool for the evaluation of hair loss and for assessing candidacy for hair transplantation.  Measuring donor density and assessing the degree of miniaturization in the donor area should be an integral part of the evaluation of every patient in which surgical hair restoration is considered. This will enable physicians to better select those who are good candidates for a hair transplant and help identify those patients in whom the procedure is contraindicated.  For patients having a hair transplant, these measurements will enable the physician to better estimate the size of the donor strip and be better able to anticipate the aesthetic outcome of the hair restoration procedure.   References 1. Bouhanna P: Phototrichogram: a technique for the objective evaluation of the diagnosis and course of diffuse alopecia. In W Montagna et al. (eds). Hair and Aesthetic Medicine. Roma, Salus Ed. 1983: 277-280.2. Rassman WR, Pomerantz, MA. The art and science of mini-grafting. Int J Aesthet Rest Surg 1993; 1:27-36. 3. Rassman WR, Carson S. Micro-grafting in extensive quantities; the ideal hair restoration procedure.  Dermatol Surg 1995; 21:306-311.4. Bernstein RM, Rassman WR, Seager D, Shapiro R, et al.  Standardizing the classification and description of follicular unit transplantation and mini-micro-grafting techniques. Dermatol Surg 1998; 24: 957-63. 5. Stough DB, Haber RS. Hair Replacement: Surgical and Medical. St. Louis: Mosby-Year Book, Inc., 1996: 139-140.6. Van Neste D, Dumortier M, De Coster W: Phototrichogram analysis: technical aspects and problems in relation to automated quantitative evaluation of hair growth by computer assisted image analysis. In Van Neste D, Lachapelle JM, Antoine JL (eds). Trends in Human Hair Growth and Alopecia Research. Dordrecht, Kluwer Acad. Pub, 1989: 155-165.7. Hayashi S, Hiyamoto I, Takeda K: Measurement of human hair growth by optical microscopy and image analysis. Br J Dermatol 1991; 125:123-129.8. Bernstein RM , Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32. 9. Bernstein RM, Rassman WR: The logic of follicular unit transplantation. Dermatologic Clinics 1999; 17 (2): 277-95. 10. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. 11. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99. 12. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365.

I was fortunate to catch an early glimpse of the provocative article “Blind Graft Production with Cutting Grates and Multi-bladed Knives” on its way to Dr. Shiell and the Forum. The gauntlet having been tossed, let me be the first to enter the fray. The question at hand is relatively straight forward. When compared to the highly controlled stereo-microscopic dissection of donor tissue harvested as a single strip, do the potential benefits of blind graft production (which use a multi-bladed knife and a cutting grate) more than outweigh their disadvantages and possible risks? In order to make sense out of the long list of categories used to evaluate the two techniques, I have taken the liberty to organized them into the following groups:1. Intrinsic Factors – Factors affecting the surgical outcome that are intrinsic to the techniques discussed and cannot be eliminated. 2. Extrinsic Factors – Factors that may affect the hair restoration surgery, but ones that can be reasonably modified so as not to significantly impact the outcome.3. Economic Factors – Strictly economic issues that have no effect on quality. 1. Intrinsic FactorsDamage to the follicle Disruption of the follicular unit Viable hair(s) obtained per graftAmount of non-hair bearing tissue transplanted Total recipient wounding Foreign body reactionPseudo-cyst formation Quality control Patient variability Preserving donor supply2. Extrinsic FactorsTime grafts are out-of-body Risk of desiccation Staff training Staff stress and fatigue 3. Economic FactorsCost of equipment Cost of labor Cost to doctor Cost to patient What The Patient Should DoIf I were advising a patient that had to choose between the two hair transplant procedures I would suggest the following:FIRST: To each of the factors assign a GOOD rating where the technique can clearly or potentially be of benefit, a BAD rating if it may do harm, and disregard those issues that make no difference. (For simplicity, I have assigned each factor a value of 1, although some factors are clearly more important than others.) Then count them all, subtracting the bad from the good. SECOND: Pick a top-notch surgical hair restoration team that could control the extrinsic factors so that they would have little or no impact upon the surgery.THIRD: Make a decision taking into account that:- This surgery is being performed on your own body.- You only have a limited donor supply of hair.- You will have to live with the results of the hair transplant procedure (good or bad), for the rest of your life. Microscopic Dissection            Blind Graft ProductionMedical Issues- Damage to the follicle                GOOD                 BAD- Disruption of the follicular unit           GOOD                 BAD – Viable hair obtained per graft              GOOD                 BAD – Non-hair bearing tissue used                GOOD                 BAD – Total recipient wounding                    GOOD                 BAD – Foreign body reaction                       GOOD                 BAD – Pseudo-cyst formation               GOOD                 BAD – Ability to control quality                  GOOD                 BAD – Impact of patient variability               GOOD                 BAD – Preserving donor supply                     GOOD                 BADEconomic Factors- Cost to Patient                             BAD                  GOODTOTAL (good – bad)                    9                                – 9The IssuesI have eliminated the first three economic factors; Cost of equipment, Cost of labor, and Cost to doctor, since the only factor that really matters to the patient is his cost. All the other economic issues are reflected in this one and are not the patient’s problem.Extrinsic factors, if not controlled, can play a major role in the outcome of the surgery. Finding a surgical hair restoration team that is properly trained and experienced can minimize these issues. For example, the time that grafts are out of the body can be reduced by utilizing a sufficiently large staff or by taking a donor strip out in sections. Adverse effects can be further minimized or eliminated by proper graft refrigeration. Any risk of desiccation can be easily eliminated by the use of holding solutions and the proper handling of grafts just prior to insertion. In addition, automation may soon make both of these issues moot. A sufficiently large staff that is adequately rotated and working in a comfortable environment will greatly reduce stress. If the patient is diligent in his research, he can pick a surgical team that satisfies these requirements.The intrinsic factors are the real issue. A 35% incidence in follicular transection that was observed without even using a microscope is, in my opinion, an extraordinary price to pay for a cheaper, faster procedure. It is argued that follicular transection is overestimated when two fragments representing the same follicle are both counted, (this error was not made in these counts) but even if the transection was half that, it would be too much. From my personal experience with a multi-bladed knife with a inter-blade spacing of 3mm, the transection rate was about 20%, and occasionally as high as 35%, so it doesn’t surprise me that transection with blades set at 1mm would easily cause damage in the range of 35% (or even more). In fact, Dr. Rassman, in his own practice, had abandoned using the multi-bladed knife after he had observed the transection rate to be unacceptably high. The fixed blade spacing of the cutting grate used in the next step, would further compound this damage.Much has been made of Dr. Kim’s studies showing that, under controlled conditions, a portion of transected follicles will grow. What is not often mentioned by those quoting his data, is that the hair that is produced is often finer and more delicate than the undamaged, full thickness terminal hair of intact follicles. Unfortunately for the patient, hair shaft diameter is as important to the final cosmetic outcome of the hair transplant as the absolute number of transplanted hairs. Another important issue is the fact that multiple blades break up the naturally occurring follicular units. One doesn’t have to do a controlled experiment to understand that a single pass of the multi-bladed knife with blades set 1mm apart will literally decimate follicular units randomly spaced at a density of 1unit/mm2. Again, the fixed spacing of the cutting crate would further divide any follicular units that hadn’t already been broken up with the multi-bladed knife. Transplanting the whole follicular unit will insure that the greatest cosmetic benefit is obtained from each session. The compact nature of intact follicular units allows them to be placed into very small sites, minimizing recipient wounding. This, in turn, maximizes the amount of hair that can be placed into the cosmetically important areas, while maintaining a totally natural look. Minimal wounding will cause less compromise to the blood supply and produce less scarring. It will enable larger procedures to be performed at one time, and will help preserve the integrity of the recipient bed for future procedures. How much the wounding may be decreased will depend upon the surgical team, but since carefully dissected follicular units contain only about half the volume of the original donor tissue, the total wounding can potentially be cut in half. The fact that transected follicles may grow under experimental conditions should be of little consolation to the patient who wants to get the maximum benefit from his or her hair transplant procedure. Some hair restoration doctors seem to be flippant about generating hair fragments and consider only whether they will or will not grow. In fact, hair fragments are composed of keratin which can be quite inflammatory and the reaction they incite in the dermis can destroy adjacent follicles. Small hair fragments that do grow may not find their way to the skin surface and can result in pseudo-cyst formation, a locally destructive process. We have all seen this in our practices, and from my experience the incidence is significantly reduced when follicular units are transplanted intact. Bilateral controlled studies would, of course, be helpful to document this for the skeptics. The ability to control quality is another important issue. It has been argued that quality control is difficult in follicular unit transplantation. That may be true, but to ignore quality all together is certainly not the solution. A team experienced in follicular dissection can consistently generate the highest quality grafts if one puts forth the effort for proper training and continued monitoring. The problem with both multi-bladed knives and cutting grates is that the slightest deviation in alignment can increase the transection significantly and, unlike microscopic dissection which deals with one follicle at a time, there is no way to make fine adjustments along the way. A final issue is the intrinsic variability of the human scalp from patient to patient, and from one region of the scalp to another. The dissecting microscope is an exquisite instrument for adjusting to this variability. The fixed relationship of the cutting surfaces of the multi-bladed knife and the microtome cannot. Will the doctor performing blind dissection be able to adequately account for this variability in the average patient and will he risk operating on an unwary patient in whom these differences might be profound?In PerspectiveFor those of us who embraced follicular unit transplantation at the outset, it could be argued that we might have acted too hasty. . .  before all the evidence was in. But our rationale was that the procedure would improve the quality of our hair transplant. Our critic’s main objection was that it might not be worth the extra effort. If we had been wrong, there was little to lose except time, effort, and unnecessary expense. In this case, when one risks damaging the patient’s donor supply, the patients have much to lose.The sudden disregard for follicular anatomy exhibited by this “blind grafting technique” runs contrary to much of the progress that has been made in hair restoration surgery over the past 10 years. Hopefully, well-controlled studies will precede the general use of these instruments, so that the extent of damage can be accurately measured. The “blind grafters” should clearly explain all the pros and cons of this type of dissection to their patients, as well as the limited knowledge we have of this technique so far, in order that their patients have true “informed” consent. Let’s not go back to the days of the old plugs when doctors rarely told their patients all of the short and long-term consequences of their procedures.Blind graft dissection may indeed have some economic value, but what is the real cost to our patients?

Although many technical advances have been made in the field of surgical hair restoration over the past decade, particularly with the widespread adoption of follicular transplantation, many problems remain. The majority revolve around doctors recommending surgery for patients who are not good candidates.  The most common reasons that patients should not proceed with surgery are that they are too young and that their hair loss pattern is too unpredictable.  Young persons also have expectations that are typically too high – often demanding the density and hairline of a teenager. Many people who are in the early stages of hair loss should simply be treated with medications, rather than being rushed to go under the knife.  And some patients are just not mature enough to make level-headed decisions when their problem is so emotional.In general, the younger the patient, the more cautious the practitioner should be to operate, particularly if the patient has a family history of Norwood Class VII hair loss, or diffuse un-patterned alopecia.  Problems also occur when the doctor fails to adequately evaluate the patient?s donor hair supply and then does not have enough hair to accomplish the patient?s goals. Careful measurement of a patient?s density and other scalp characteristics will allow the surgeon to know exactly how much hair is available for transplantation and enable him/her to design a pattern for the restoration that can be achieved within those constraints.   In all of these situations, spending a little extra time listening to the patient?s concerns, examining the patient more carefully and then recommending a treatment plan that is consistent with what actually can be accomplished, will go a long way towards having satisfied patients.  Unfortunately, scientific advances will improve only the technical aspects of the hair restoration process and will do little to insure that the procedure will be performed with the right planning or on the appropriate patient.     Five-year ViewThe improvement in surgical techniques that have enabled an ever increasing number of grafts to be placed into ever smaller recipient sites had nearly reached its limit and the limitations of the donor supply remain the major constraint for patients getting back a full head of hair.  Despite the great initial enthusiasm of follicular unit extraction, a technique where hair can be harvested directly from the donor scalp (or even the body) without a linear scar, this procedure has added relatively little towards increasing the patient?s total hair supply available for a transplant. The major breakthrough will come when the donor supply can be expanded though cloning.  Although some recent progress had been made in this area (particularly in animal models) the ability to clone human hair is at least 5 to 10 years away.       Key Issues 1. The greatest mistake a doctor can make when treating a patient with hair loss is to perform a hair transplant on a person that is too young, as expectations are generally very high and the pattern of future hair loss unpredictable. 2. Chronic sun exposure over one?s lifetime has a much more significant negative impact on the outcome of the hair transplant than peri-operative sun exposure. 3. A bleeding diathesis, significant enough to impact the surgery, can be generally picked up in the patient?s history; however OTC medications often go unreported (such as non-steroidals) and should be asked for specifically. 4. Depression is possibly the most common psychiatric disorder encountered in patient?s seeking hair transplantation, but it is also a common symptom of those persons experiencing hair loss.  The doctor must differentiate between a reasonable emotional response to balding and a depression that requires psychiatric counseling. 5. In performing a hair transplant, the physician must balance the patient?s present and future needs for hair with the present and future availability of the donor supply.  It is well known that one?s balding pattern progresses over time. What is less appreciated is that the donor zone may change as well.  6. The patient?s donor supply depends upon a number of factors including the physical dimensions of the permanent zone, scalp laxity, donor density, hair characteristics, and most importantly, the degree of miniaturization in the donor area – since this is a window into the future stability of the donor supply. 7. Patients with very loose scalps often heal with widened donor scars.   8. One should never assume that a person?s hair loss is stable. Hair loss tends to progress over time.  Even patients who show a good response to finasteride will eventually lose more hair. 9. The position of the normal adult male hairline is approximately 1.5 cm above the upper brow crease. Avoid placing the newly transplanted hairline at the adolescent position, rather than one appropriate for an adult. 10. A way to avoid having a hair transplant with a look that is too thin is to limit the extent of coverage to the front and mid-scalp until an adequate donor supply and a limited balding pattern can be reasonably assured – an assurance that can only come after the patient ages.  Until that time, it is best to avoid adding coverage to the crown. Introduction Hair Transplantation has been available as a treatment for hair loss for over 40 years. [1]Through a majority of that time, hair transplantation was characterized by the use of plugs, slit grafts, flaps and mini-micro grafts. Although these were the best tools available to physicians at the time, they were incapable of producing consistently natural results.  With the introduction of Follicular Unit Transplantation (FUT) in 1995, doctors were finally able to produce these natural results. [2] But the mere capability to produce them did not necessarily ensure that these natural results would actually be achieved. The FUT procedure presented new challenges to the hair restoration surgeon and only when the procedure was properly planned and perfectly executed, would the patient truly benefit from the power of this new technique.[3]The ability of follicular unit grafts to mimic nature soon produced results that were completely undetectable.  This is the hallmark of Follicular Unit Hair Transplantation. [4] Of equal importance, however, is hair conservation – the one to one correspondence between what is harvested from the donor area and what ultimately grows in the recipient scalp.  Since a finite donor supply is the main constraint in hair transplantation, the preservation of hair is a fundamental aspect of every technique.  However, unlike the older procedures that used large grafts, the delicate follicular units are easily traumatized and very susceptible to desiccation, making follicular unit transplantation procedures, involving thousands of grafts, particularly challenging. [5]       As of this writing, the vast majority of hair transplants performed in the United States use Follicular Unit Transplant techniques.  Due to limited space, this review will focus on only this technique and not on the older procedures.  Nor will it focus on Follicular Unit Extraction, since this technique is still evolving and the ways to avoid the major pitfalls of this procedure are still being worked out and a subject onto itself.  As the title suggests, this paper will focus on the prevention of the various problems encountered in FUT, rather than its treatment – an equally important subject, but one that has already been covered in an extensive review. [6, 7] For those not familiar with Follicular Unit Transplantation, there is a concise review of the topic in the dermatology text Surgery of the Skin [8].  For more detailed information, several hair transplant textbooks have sections devoted to this technique. [9, 10]   The most common types of problems that occur in FUT procedures can be grouped into two broad categories; those involving errors in planning the hair transplant and those caused by errors in surgical technique. Of the two, errors in planning often lead to far more serious consequences for the patient and will be the subject of this paper.    Patient Selection AgeThe single greatest mistake a doctor can make when treating a patient with hair loss is performing a hair transplant on a person that is too young.  Although, there is no specific age that can serve as a cut off (since this will vary from person to person), understanding the problems associated with performing hair restoration in young persons can help the physician in deciding when surgery may be appropriate.  Getting it wrong can literally ruin a young person?s life. When someone is beginning to lose hair in their teens or early 20s, there is a significant chance that he (or she) may become extensively bald later in life and that the donor area may eventually thin and become see-through over time.  Although miniaturization (decreased hair shaft diameter) in the donor area is an early sign that this may occur, and can be picked up using densitometry, these changes may not be apparent when a person is still young.     If a person were to become very bald (become a Norwood Class 6 or a Class 7) then he would often not have enough hair to cover his crown.  A transplanted scalp with a thin or balding crown is a pattern acceptable for an adult, but totally unsuitable for a person in his twenties. [11] In addition, if the donor area were to thin over time, the donor scar might become visible if the hair were worn short – a style that is much more common in people who are young.  ExpectationsThis subject is very closely related to age.  For surgical hair restoration to be successful, expectations must match what can actually be accomplished.  The expectations of a young person are usually to return to the look they had as a teenager; namely to have a broad, flat hairline and to have all of the density they had only a few years before. The problem is that a hair transplant neither creates more hair (and therefore can?t increase overall density) nor prevents further hair loss (so the pattern must be appropriate as the person ages).  But since receded temples and a thin crown is not an acceptable look for a young person, the surgery should best be postponed in a person in whom this is not acceptable. As a person ages, he often becomes more realistic and is happy with what a hair transplant can actually achieve.  And, over time, if a person?s donor area proves to be stable and his hair loss limited, more ambitious goals can be attained.Chronic Sun ExposureAlthough it is common wisdom to avoid sunburns after a hair transplant, in fact, significant chronic sun exposure over one?s lifetime has a much more significant negative impact on the outcome of the hair transplant then peri-operative sun exposure.Actinic damage alters the collagen and elastic fibers so that the grafts are not grasped as securely and the alteration to the vasculature decreases the ability of the recipient tissue to support the transplantation of a large number of grafts.  Even with the very small recipient sites used in follicular unit transplantation, making sites too close can result in a compromised blood supply and result in poor growth.   Another issue is that a hair transplant will cover areas of sun damage and make cancer detection more difficult.  When the actinic related growths are finally treated, the involved sections of the hair transplant will be destroyed.  The best approach in a person with significant sun damage is to first treat the entire scalp aggressively with 5-flurouracil to remove all of the pre-cancerous lesions before hair transplant is contemplated.  One should wait at least 6-12 months after the treatment for the scalp to completely heal, as the tissue will be more friable during this period. Although this treatment can set the surgery back a year or more, it will result in better graft survival and less problems with future skin cancer detection.   Medical Conditions and MedicationsAlthough not necessarily an absolute contraindication to surgery, a number of medical conditions make the follicular unit hair transplant procedure more problematic and need to be taken into account.  Whenever significant medical conditions are present, it is always prudent to obtain medical clearance from the patient?s primary care physician or appropriate specialist.  Because the scalp is quite vascular, and FUT procedures involve a large surgical team, patients that are known to have blood born pathogens, such as HIV and Hepatitis B and C, pose some increased risk to the staff, despite the fact that universal precautions are used.  It is useful if the team is aware of the medical histories of hair transplant patients so that they can proceed with a higher degree of alert when necessary.  In an HIV positive patient, it is important to make certain that the patient?s immune status is adequate, so that the patient does not have a greater risk of infection. In patient?s with Hepatitis, it is important to assess their liver function so that the dosing of medications is appropriate. Patients with diabetes mellitus may be at greater risk of having a peri-operative infection.  In this case the normal aseptic conditions that most hair transplants are performed under might be changed to a modified sterile technique (modified in that it is difficult to prep the scalp).  This should also be considered in patients with cardiac valvular disease, implanted devices and others in whom bacterial seeding might have more severe consequences.  Antibiotic coverage should also be administered in high risk individuals, although it is not needed in routine hair restoration procedures. [12] A bleeding diathesis, significant enough to impact the surgery, can be generally picked up in the patient?s history; however medications often go under the radar and should be asked for specifically.  Patient?s often don?t think to report taking aspirin and this must be asked about as well as other non-steroidal anti-inflammatory medications.  Plavix, in particular can significantly increase bleeding during the procedure.  Alcohol, of course increases bleeding as well. [13]  One should make adjustments in a patient?s anti-coagulant medication in conjunction with his/her cardiologist or regular physician.  As a general rule, one should stop anti-platelet medications one week prior to the hair transplant, but the interval will vary depending upon the specific drug, the size of the procedure, and the importance of the medication to the patient?s health. They can be resumed three days after the procedure. If the anticoagulants cannot be stopped, it may be reasonable to proceed with a smaller session.   Since epinephrine is used in most hair restoration procedures, if a person has a history of arrhythmias or other cardiac disease that could be exacerbated by epinephrine, medical clearance from the patient?s primary care doctor, or cardiologist, should be obtained.  Epinephrine can also interact with broad-beta blocking agents such as propranolol, causing a hypertensive crisis; therefore, it is best to have the patient switch to a selective beta-blocker for the surgery. [14] A number of manipulations can be used during the procedure to control bleeding and decrease the need for epinephrine.  Among the most useful, is to scatter the recipient sites broadly over the area to be transplanted (allowing the extrinsic pathway to begin coagulation) and then filling in the areas with additional sites when the bleeding has subsided. [15]  If patients have a history of seizures, it is important that they do not discontinue their medication for the procedure and that medical clearance is obtained.  One should also remember that otherwise normal patients can have a vaso-vagal episode during the procedure; particularly during the administration of the local anesthetic.  This can be avoided by immediately placing the patient in Trendelenberg as soon as the patient complains of nausea or begins to sweat, or look pale.  A patient should be monitored with a pulse oximiter if a significant amount of sedatives or other respiratory depressants are used. The patient should be monitored closely to be sure that local anesthetics are administered in safe amounts and that the warning signs of lidocaine overdose are well known to all members of the surgical team. [16]  Finally, it is helpful to have a pre-printed summary of all the medications and their doses commonly used during the procedure. This can be given to the patient?s regular physician when seeking medical clearance. Psychological FactorsHair loss can take a psychological toll on a person?s self-esteem and cause considerable emotional distress.  When a person has underlying psychiatric issues, the impact can be more severe and, therefore, management of hair loss considerably more difficult.  It is important to identify these problems as well as other psychological factors that may play a role in a patient?s ability to clearly understand both the hair restoration process and its anticipated outcome. In some cases, counseling can be done in conjunction with hair restoration, but often it should precede treatment, especially when surgery is contemplated.  It is prudent to obtain clearance for surgery from a psychiatrist or clinical psychologist when there is a history of mental illness, or when it is suspected at the time of the consultation.A number of psychiatric conditions are particularly relevant to the successful outcome of a hair transplant.  These include Trichotillomania, Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Syndrome (BDS), and Depression. Trichotillomania is a relatively common condition characterized by the persistent urge to pull out one?s hair.  It most commonly involves scalp hair, but can also involve the eyelashes, facial hair or other body hair.  It often results in bald patches and can be identified by short hairs in the affected area that are not long enough to grasp.  Active trichitollomania on any part of the body is an obvious contraindication to a hair transplant, but if a person has a history of this condition, the doctor should also be cautious and only consider surgery if the therapist is confident that the condition has little chance of recurring.  Obsessive-compulsive disorder (OCD) is a condition characterized by recurrent, intrusive thoughts (obsessions) and related behaviors (compulsions) which attempt to neutralize the anxiety or stress caused by the obsessions.  In consultation, the OCD patient often asks a litany of questions and often asks the next question before listening to the answer to previous one.  OCD patients are extremely difficult to satisfy and even in a very successful hair transplant can focus on a minor imperfection seeming oblivious to the good overall result.   Body dysmorphic disorder (BDD) is a mental disorder that involves a distorted image of one?s body. The person is extremely critical of their physical self, despite the fact there may be no actual defect.  It should be obvious that patients with BDD will not be satisfied with a hair transplant, or other forms of cosmetic procedures, and the condition is best treated by a psychiatrist rather than a surgeon.  Another note of caution is that patients with BDD have a much higher suicide rate than the general population, even greater than patients with depression. [17]    Depression is possibly the most common psychiatric disorder encountered in patient?s seeking hair transplantation, but it is also a common symptom of those experiencing hair loss.  The doctor must differentiate between a reasonable emotional response to balding and a depression that requires psychiatric counseling.  It is important to realize that a hair transplant will be ineffective in curing a medical depression and unfulfilled expectations may lead to a worsening of the condition.References 1. Orentreich N: Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479, 1959. 2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32. 3. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. 4. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99. 5. Gandelman M, et al: Light and electron microscopic analysis of controlled injury to follicular unit grafts. Dermatol Surg 2000; 26(1): 31. 6. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part I: Basic repair strategies. Dermatol Surg 2002; 28(9): 783-94. 7. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part II: The tactics of repair. Dermatol Surg 2002; 28(10): 873-93. 8. Bernstein RM, Follicular Unit Hair Transplantation. In: Robinson JK, Hanke CW, Siegel DM, Sengelmann RD, editors: Surgery of the Skin, Elsevier Mosby, London UK. 2005. 9. Unger WP, Shapiro R. Hair Transplantation. New York: Marcel Dekker, Inc. 2004. 10. Bernstein RM, Rassman, WR. Follicular Unit Transplantation. In: Haber RS, Stough DB, editors: Hair Transplantation, Chapter 12. Elsevier Saunders, 2006: 91-97. 11. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365. 12. Haas AF, Grekin RC: Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol 1995; 32: 155-76. 13. Otley CC. Perioperative evaluation and management in dermatologic surgery. J Am Acad Dermatol 2006; 54: 119-27. 14. Gandelman M, Bellio R, Barretto M: Beta-blockers and local anesthetics with vasoconstrictors: A dangerous association. Intl J Aesthetic Restorative Surgery 1995; 3 (2): 143-45. 15. Bernstein RM, Rassman WR: Limiting epinephrine in large hair transplant sessions. Hair Transplant Forum International 2000; 10(2): 39-42. 16. Skidmore RA, Patterson JD, Tomsick, RS: Local anesthetics. Dermatol Surg 1996; 22:511-522. 17. Phillips KA, Menard W: Suicidality in body dysmorphic disorder: A prospective study.  Am J Psychiatry, 2006; 163:1280-82.  18. Bernstein RM, Rassman WR. The scalp laxity paradox. Hair Transplant Forum International 2002; 12(1): 9-10.

A hair system can be any type of borrowed hair in the form of a full wig, hairpiece, weave, hair extension or a toupee, which replaces your own missing hair. Hair systems are often the only remaining option to replace the lost hair and to regain the appearance of a full head of hair. The quality and the price of hair systems depend on a variety of factors, such as the type of hair used, the production process used to weave the wig, the foundation of the hair system and how it is attached to the scalp.

The type of hair is the first thing many buyers will ask about. Both natural and artificial hair can be used. The natural hair can be of human or animal origin. Some hair systems blend human hair with animal hair to save on cost. The human hair can be of Asian origin (the least expensive option), Indian origin or European origin (the most expensive option). Asian and Indian hair must be often bleached, which makes it brittle and less durable. Considering the harvesting methods, virgin hair is the most expensive and hair gained from combs and hairbrushes the least expensive option. Human hair requires more care than artificial hair but it looks much more authentic, lasts longer and is more comfortable to wear. Its downside is its higher cost and the fact that it can lose its colour when exposed to direct sunshine for long hours or break, as normal human hair does.

As far as the manufacturing process is concerned, hair systems can be hand-tied or machine-tied. Hand-tied wigs can also be custom made, which happens to be the most expensive alternative. The foundation of a hair system can be either a polymer or a mesh. The polymer foundation is a more affordable but also a less comfortable option. A mesh structure breathes better than polymer structures and is therefore more comfortable to wear but, besides being more expensive, it is also a less durable alternative and more difficult to maintain. Mesh is suitable for creating authentic-looking hairlines, so many wigs combine both technologies, mesh for the hairline and the polymer structure for the inside of the wig.

The method of attaching a wig to your scalp and blending it with your existing hair is an immensely important factor (more info: http://www.greyhairloss.com/hair-replacement.html). There are semi-permanently attached hair systems that are either glued to your scalp or woven into your existing hair and these can only be removed in a hair salon once every five or six weeks for cleaning. These systems cling tightly to your scalp and can be unhealthy and uncomfortable to wear after a couple of weeks of use. The temporarily-attached hair systems use double-sided sticky tape or clips to fix the hairpiece to your scalp and existing hair. They can be removed and cleaned any time you wish but can also be easily and unexpectedly removed, leading to embarrassing situations.

The final, determining factor when deciding on buying a hair system is the price. Any hair system is temporary in nature, it will not last for ever like hair transplants do. Nevertheless, they can be quite expensive. Hair transplants can cost as much as ten thousand dollars or more. Although you can get a wig for a few hundred dollars, the more authentic pieces cost a few thousand dollars and require regular maintenance costing a couple of hundred dollars a month. In addition, you have to buy at least two identical pieces, one to wear while the other is being maintained by your hair salon. Though not cheap, hair systems are often the only option to replace the lost hair for many alopecia areata patients, as well as a large percentage of female hair loss sufferers.

Patient Assessment Donor SupplyIn performing a hair transplant, the physician must balance the patient?s present and future needs for hair with the present and future availability of the donor supply.  It is well known that one?s balding pattern progresses over time. What is less appreciated is that the donor zone may change as well.    The patient?s donor supply depends upon a number of factors including the physical dimensions of the permanent zone, scalp laxity, donor density, hair characteristics, and most importantly, the degree of miniaturization in the donor area – since this is a window into the future stability of the donor supply. The size of the donor area is determined by both its width (height) and its length.  When assessing the potential width of the donor area, doctors usually assess the lowermost point that the balding will reach, i.e. the top part of the permanent zone.  However, it is equally important to pay attention to the inferior margin as well.  It is common for the hair to thin significantly at the nape of the neck as a person ages, producing an “ascending hairline.”  Since this can significantly diminish the width of the donor area, any evidence that this process may occur should be taken into account in the planning.  Loss of the temporal points is another process that has a significant impact on the donor supply. Not only does it foreshorten the potential length of the donor strip but it often portends very significant baldness.    Scalp laxity is another variable that affects the amount of available donor hair.  Very tight scalps significantly limit the amount of donor hair that can be removed through strip harvesting.  The constraint imposed by a tight scalp is not always apparent in the first session, but can plague the hair restoration down the line; therefore, it should be evaluated carefully in the initial patient assessment. A very loose scalp can present its own set of problems, as patients with very loose scalps often heal with widened donor scars. [18]    The average donor density of a Caucasian is about 225 hairs/cm2. This can easily be measured using a hand-held instrument called a densitometer. (2) When the density of a Caucasian is below 180, a hair transplant should be undertaken with great caution. In this author?s opinion, when the maximum donor density is below 150/hair mm2, a person should generally not be transplanted, as there will not be enough donor hair to make the procedure cosmetically worthwhile and the risk of a visible donor scar is too great. (3) Exceptions would be an older person with very limited expectations and in races where the normal density is lower (i.e. Asians and Africans).  Hair characteristics, particularly hair shaft diameter, are as important as the absolute number of hairs in determining the outcome of a procedure.  The amount of transplantable hair is related to both the number of movable hairs (determined by the size of the donor area, scalp laxity and donor density), multiplied by the hair shaft cross sectional area.  Since each hair in a person with coarse hair can have over 5 times the volume as a person with fine hair, the estimate (or actual measurement) of hair shaft diameter is important in determining the overall donor supply.   Miniaturization, the progressive diminution of hair shaft diameter and length (the result of the action of DHT on the hair follicle) produces thinning on the front, top and crown of the scalp and is the hallmark of androgenetic alopecia.  But the back and sides of the scalp can miniaturize as well and when a significant portion of a patient?s donor area is miniaturized, the hair in this area can be rendered useless for a hair transplant. (Figures 1 and 2) This condition, called diffuse unpatterned hair loss (or DUPA), is the most common type of hair loss seen in women and it is not uncommon in men.  It goes without saying, that every patient, male or female, in whom a transplant is being considered, should be evaluated for donor miniaturization using densitometry to make sure that the donor hair to be transplanted is stable.  Recipient DemandOne should never assume that a person?s hair loss is stable. Hair loss tends to progress over time.  Even patients who show a good response to finasteride will eventually lose more hair.  It is always best to consider the reasonable worst-case scenario when assessing how bald the patient may become, so that the finite donor hair can be allocated properly. Although the Norwood classification is very helpful in staging the hair loss, it doesn?t take into account actual scalp dimensions. Just like the donor site, the recipient area should actually be measured.  Even within a single Norwood class, there is a vast difference between a patient with a narrow forehead and one with a very broad head with respect to the actual surface that needs to be covered, and thus the number of grafts required for the restoration.  Designing the Hairline  Hairline PositionIn the adolescent, the hairline sits just above the upper brow crease formed by the upper border of the frontalis muscle directly below it.  The position of the normal adult male hairline is approximately 1.5cm above this crease at the midline). A common error is to place the newly transplanted hairline at the adolescent position, rather than one appropriate for an adult. Although the younger patient, first experiencing hair loss, may put considerable pressure on the doctor to place hair in the lower position, the physician should not yield to this demand.  Under normal circumstances, as a patient ages, his density decreases and the natural hairline will move back somewhat.  However, a transplanted hairline is immutable. Therefore, when the transplanted patient continues to thin or bald (which he invariable will) the fixed low frontal hairline will begin to look out of place, since it is natural for a person with decreased overall hair volume to have a slightly receded hairline, rather than one that is still in the adolescent position.  Hairline ShapeA similar logic applies when choosing the shape of the hairline.  As a male passes from adolescence to adulthood, his broad, flat hairline evolves into a more tapered shape with some recession at the temples.  A persistent low, broad hairline is enjoyed by those who also maintain their adolescent density. This situation is not present in those who are suffering from androgenetic alopeica; therefore, a transplanted flat hairline will not “age well” over time and will look unnatural as the patient?s overall density decreases and particularly as the crown begins to thin.  If a person is older, has maintained a high donor density, and has a small risk of extensive hair loss, a broader hairline is possible.  However, this is not this case for the person who is starting to bald at a young age, since he has a significant risk of extensive baldness and, more importantly, the extent of his future hair loss can not be known at the time the surgery is planned.  Graft Distribution The nuances of graft distribution and the multitude of problems that result from distributing grafts improperly are beyond the scope of this writing; however, there are two main but related themes that the hair transplant surgeon should be cognizant of when deciding where to place grafts. The first is to set a target area of coverage that takes into account the patient?s future balding pattern, as well as, his total donor hair supply.  The second is to forward weight the grafts, rather than distributing them evenly over the top of the scalp. Extent of CoverageThe problem of deciding how much bald scalp a hair transplant should cover can be illustrated as follows.  As an example, take a patient whose total number of follicular unit grafts available to harvest is around 5,500.  The front part of the scalp has a surface area of about 50 cm2.  The top or mid-scalp has an area of about 150 cm2 and the vertex or crown about 175 cm2. However, the size of the bald crown can vary dramatically depending upon the extent of hair loss, reaching over 200cm2 in a Norwood Class VII patient.  If the front and top of the scalp were transplanted using all of the patients donor hair, the transplanted density would be only 5,500grafts/200cm2 or 27.5 grafts/cm2 (less than 1/3 the density of the patient?s original hair). If the crown were covered as well, that would be 5,500 grafts/400cm2 or 12.5 grafts/cm2 (only 15% the density of the patient?s original hair).  Using various manipulations, such as creating different densities in different parts of the scalp, a skilled surgeon can make 1/3 of the overall density look like a substantial amount of hair. However, working with only 15% of the original density, can make the job of creating a natural look significantly more difficult, if not impossible.     The way to avoid having a hair transplant with a look that is too thin, or see-through, is to limit the extent of coverage to the front and mid-scalp until an adequate donor supply and a limited balding pattern can be reasonably assured -  an assurance that can only come after the patient ages.  Until that time, it is best to avoid adding coverage to the crown.   Another problem with transplanting the crown early is that as the crown expands additional hair will be needed to follow the expanding area of baldness outward, just to keep the first hair transplant looking natural. This may require considerable amounts of hair that will not be available to cover the front and mid-scalp if that were too bald as well. On the other hand, if the hair transplant was limited to the vertex transition point or VTP (see figure above), the restoration would look natural without further surgery no matter how far the hair loss in the crown progressed. The reason is that the front and top of the scalp represent a complete cosmetic unit, with the VTP as the natural posterior boundary – so it is natural for hair to cover this region of the scalp but not beyond.   Density GradientsAnother way for surgeons to prevent a thin, see-through look is to avoid distributing the grafts evenly over the transplanted area. It goes without saying that only 1-hair grafts should be used at the hairline, with larger grafts behind them, but there are additional ways to produce the gradations of density to mimic the way hair grows in nature.  Specifically, the greatest density should be in the front part of the scalp (shown in brown) and particularly in the frontal forelock area (shown in dark brown). The greater density in the front of the scalp forelock area can be created in two ways; by placing the recipient sites closer together in this location and by using larger follicular units in the area (i.e. 3- and 4- hair units rather than 1s and 2s).  These techniques may be use in combination to achieved greater density but, as will be discussed in the following section, if done to excess, may compromise growth.   SummaryFollicular unit transplantation is a powerful hair restoration technique that allows the surgeon to create natural hair patterns and produce results that mimic nature. The success of the procedure depends greatly on proper patient selection, accurately assessing the patient?s donor supply, and distributing the grafts in a way that is appropriate for a person who will continue to age and eventually thin over time. With thoughtful planning, major mistakes can be avoided and our patients will be able to achieve the full benefit of this remarkable procedure.  References 1. Orentreich N: Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479, 1959. 2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32. 3. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. 4. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99. 5. Gandelman M, et al: Light and electron microscopic analysis of controlled injury to follicular unit grafts. Dermatol Surg 2000; 26(1): 31. 6. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part I: Basic repair strategies. Dermatol Surg 2002; 28(9): 783-94. 7. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part II: The tactics of repair. Dermatol Surg 2002; 28(10): 873-93. 8. Bernstein RM, Follicular Unit Hair Transplantation. In: Robinson JK, Hanke CW, Siegel DM, Sengelmann RD, editors: Surgery of the Skin, Elsevier Mosby, London UK. 2005. 9. Unger WP, Shapiro R. Hair Transplantation. New York: Marcel Dekker, Inc. 2004. 10. Bernstein RM, Rassman, WR. Follicular Unit Transplantation. In: Haber RS, Stough DB, editors: Hair Transplantation, Chapter 12. Elsevier Saunders, 2006: 91-97. 11. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365. 12. Haas AF, Grekin RC: Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol 1995; 32: 155-76. 13. Otley CC. Perioperative evaluation and management in dermatologic surgery. J Am Acad Dermatol 2006; 54: 119-27. 14. Gandelman M, Bellio R, Barretto M: Beta-blockers and local anesthetics with vasoconstrictors: A dangerous association. Intl J Aesthetic Restorative Surgery 1995; 3 (2): 143-45. 15. Bernstein RM, Rassman WR: Limiting epinephrine in large hair transplant sessions. Hair Transplant Forum International 2000; 10(2): 39-42. 16. Skidmore RA, Patterson JD, Tomsick, RS: Local anesthetics. Dermatol Surg 1996; 22:511-522. 17. Phillips KA, Menard W: Suicidality in body dysmorphic disorder: A prospective study.  Am J Psychiatry, 2006; 163:1280-82.  18. Bernstein RM, Rassman WR. The scalp laxity paradox. Hair Transplant Forum International 2002; 12(1): 9-10.