Does it make more sense to have FUE as opposed to a strip hair transplant, just in case I do thin out more in the back and the sides? I figure that if this does happen, I can always just shave my head to a #2 and go on with my life without the fear of having a visible scar. Is this a logical approach, or have I misunderstood the benefits of FUE?
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Thank you for taking the time to write. You question is astute in that you are trying to take into account future hair loss – something not every patient thinks about. Let me try to answer you as best I can without examining you.

If you have thin hair at the back of your head, FUE may be your best option. You definitely need to check with a hair surgeon though to make sure you don’t have a diffuse unpatterned alopecia (in which case surgery would be ill-advised). FUE is a viable option for you providing you have been tested and found to be a good candidate. The testing consists of actually trying to extract a few grafts and making sure they can be removed intact. In my experience, about half of the patients who are interested in this technique are candidates for it. Recall that the actual scarred AREA (cm2) in FUE is likely greater than in the traditional strip method – it is just in little dots all over the back of your head instead of a line!

That being said, it is unlikely with EITHER method that the hair in your donor area will thin visibly OR that you would have to worry about the scar being visible if you shave your head down to a #2. The average donor area does not thin that much over time which is what makes hair restoration possible in the first place. Also, most scars performed by careful surgeons using trichophytic and a double closure (sutures both above and below the skin to reduce tension) will become visible between #2 and #3 on the average barbershop clippers. FUE is more expensive (due to the time and effort involved) and yields fewer grafts than the strip method, but since it is not as commonly performed, we have less data on its benefits than we do for the more traditional methods.

In the final analysis, the decision is up to you. You present a logical approach to try to head off potential problems, but the problems you are trying to avoid are less likely than you think. My suggestion would be to consult an experienced surgeon to make certain you do not have abnormal donor area thinning, that you are a candidate for FUE, and to make your decision from there once you have all the data! Viewing the scars of some live patients can also help.

I hope that helps!

Warm Regards,
Dr. Sara Wasserbauer

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There are no comprehensive studies yet on any of the technologies that you mentioned, the NeoGraft, FUE2, and the SAFE Scribe System. All of these different technologies have their advantages and disadvantages. For instance, the Neograft uses suction to help the doctor get the graft out of the head. The SAFE Scribe has a dull tip instead of a sharp tip, and really no one really knows what the best way is to help a doctor take those individual follicular units out of your donor area out of the back of your head.

There are a couple things about FUE in general that you should know. View Dr. Wasserbauer’s Full Video Response:

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Robert,

Thank you for taking the time to write! I am not sure I can speak for the majority of hair transplant surgeons, but through my training and experience with many of the top surgeons out there, the short answer to your question is; it is a judgement call.

The chief concern, as you identified, is whether you will do more harm to the existing hair, than good! If the existing hair is close to complete loss, I believe many surgeons would choose to help that patient by restoring a conservative area of hair/hairline.

If the hair in the area seems to be salvageable, some surgeons would feel more comfortable trying medical therapy alone for 6-12 months, while others would simply exercise caution during the transplant. Too many grafts at once with the latter approach can exacerbate shock loss, especially if the patient has fine or miniaturized hair to begin with.

If you believe you are in this latter category, it is always best to go with the hair surgeon who levels with you about the risk of shock loss; you will be replacing the hair with permanent hair, so you will have a net benefit, but the risk of significant shedding with more limited re-growth does exist.

All of the above refers to hair on the top of the scalp no matter where it is thinning. I’d like to mention, however, that the crown is a unique area with its own set of problems. If the only thinning area you want to fill in is the crown, a patient should seriously consider going on Propecia or deferring surgery entirely until it is clear that the frontal area will not need the grafts more than the back!

The reason is that the grafts are in limited supply, and you want to be able to place them in the most cosmetically beneficial area possible – get the most bang for your grafts! – so to speak. The most cosmetically beneficial area is almost always the front, since it is a natural balding pattern to have some crown loss but still have your face framed conservatively. So, whether there is some hair remaining in the crown area or not, many hair physicians would think twice about treating this area aggressively.

I hope that answers your question! Remember that the best surgeons will not treat any area that still has hair in it without having a long discussion with the patient about expectations and alternative medical treatments first. Good luck and I wish you good hair!

Warm Regards,
Dr. Sara Wasserbauer

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As for your donor area, it does sound like you have local infection and inflammation at the site.  This could have started, as your doctor said, with an ingrown hair and may have spread to the surrounding area.  It could also be what doctors call an “inclusion body” like a stitch that did not dissolve and is instead working it’s way towards the surface.  Again, I cannot tell without examining you, but either way, having your doctor treat the area either with incision and drainage or with antibiotics is a wise idea.  Shock loss can happen in the donor area from the brief interruption in blood supply during the surgery, but it never fails to re-grow.  Your situation is slightly different since your hair has thinned, so it is difficult to predict if you will regain the thickness in that area.  Unfortunately, if it has been a year, your chances of re-growth are lower, but it IS likely to stop.  Rogaine can help grow the hair thicker in that area, and laser treatments (like with a hood laser in a doctor’s office) may also be beneficial.

The important thing is to not give up!  Hair takes time to grow, and I never stop a treatment for lack of effect before I have given it at least a year to work.  Also, if your doctor does a lot of hair transplantation, he or she has likely seen something like this in the past, and I can guarantee they want to help.  Good luck and I hope that helps!

Warm Regards,
Dr. Sara Wasserbauer

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He is pretty much handicapped with this condition and would appreciate any help or advice anyone can give. He is considering a scar revision to see if there is anything that was messed up when they did the surgery. Any advice or help would be greatly appreciated! Thank You!
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What a frustrating situation!  I am so sorry to hear of your son’s plight and not at all surprised that the other doctors he has gone to have not encountered his symptoms since this sort of complication is exceedingly rare these days.  Without examining him, it is tough to fully understand what is going on – but let me try to help as best I can;

There are a few scenarios for what might have happened to your son.  He might have had a tight or inelastic scalp to begin with, or the closure on the surgery day might have been tight as well meaning the incision might have been slightly wider than average. Hair physicians can easily measure the elasticity of the donor area (using the Mayer-Pauls elasticity scale) in an office visit and this is something I would suggest initially.  If the scalp is quite tight, a scar revision might not be the best option.  It the scalp is fairly elastic, he would have more surgical options and something else might account for the pulling sensation he is experiencing.  An office visit would also allow a hair surgeon to examine the scar for signs of tension, excessive scarring, or nerve entrapment.  Thick or wide scars can enmesh the nerve and constrict it, causing tenderness or tightness.  Again, these would be rare complications of a hair surgery, but plausible scenarios given what you describe.

I would also suggest scalp stretching exercises as a means of improving the area.  To do the exercises, one needs to clasp the hands at the back of the head against the scalp (like you are leaning back in an office chair after a job well done!) and move the scalp up and down.  Patients should do this several times per day for six months – in other words, they should make it a habit.  When practiced with diligence, I have seen them give good results for several patients and the research done to date, while in small numbers of patients, consistently shows improvement in laxity.

One last possibility is that this pulling and tightness has nothing to do with hair surgery.  I have seen patients (when I was an Internist) who have the persistent sensation of a tight scalp and they are most often referred to a neurologist or anesthesiologist for treatment.  I think it is also important for him to be treated for his anxiety and stress so as not to let this condition ruin his life.  The impact of effective management of these additional issues should not be underestimated.

I sincerely hope this has helped and wish the best for your son.

Warm Regards,
Sara Wasserbauer, MD

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TRADITION! The traditional FUT (Follicular Unit Transplantation) or “Strip” technique takes a thin strip of hair from the back and sides of your head. The two sides are brought back together leaving a thin line typically 1-2mm wide as the scar. Often, a “trichophytic closure” is used which allows the hair to grow through the scar, rendering the scar all but invisible. This scar is typically visible only if you buzz your hair shorter than a #2 on a pair of standard clippers (or if you shave your head with a razor.) It is typically NOT visible if you cut the hair at a #3 on clippers (or if you leave it even longer). This goes for wet and dry hair I find.

Traditional hair transplant methods result in stitches for about 7-10 days and obtain up to several thousand grafts per session. The surgery usually takes 8-10 hours (plan on being there the whole day although smaller sessions can end earlier). There is typically nothing visible in the donor areas (back and sides of the head), even immediately after the the procedure! Good surgeons typically charge $4-5 per graft giving it a variable price tag but usually in the $5-$13K range. (Cut-rate grafts are no bargain!) Most hair surgeons agree that this method is generally best for those looking for a single large session and as close to a full correction as possible in a single surgery.

FUE! Follicular Unit Extraction (FUE) also takes grafts from the back and sides of the patient’s head individually. Depending on how the patient prefers it, you can either shave the whole head or small “micro-strips” can be shaved for optimal camouflage – but some level of shaving has to be done because the hair has to be short for effective removal. The scars are small – about 1mm in diameter, and if you shaved the head they would look like little dots scattered all over the head. You actually have more scar area with this method, but since it is not in a LINE it is much harder to see!

FUE transplants take a full day as well (8-10 hours) and requires that the patient lies face down and on their side for long periods while the grafts are being removed. Recovery takes about 3-5 days and while there are no stitches, you do have a number of little tiny scabs all over your head which can be covered with hair (or just open if the patient can shave their whole head to start with.) If you shave your whole head, I like to compare the look to being hit with a shot gun, but it heals to a bunch of tiny little pink spots very quickly so amazingly, the patients who choose this option do not seem to mind! Surgeons who practice this technique typically can obtain 500-1000 grafts in a single session and charge $20 or more per graft. The range is large since the success of the procedure depends largely on patient variables that cannot be fully determined until the surgery starts. Most hair surgeons agree that this method is generally best for those looking for a single small session or several smaller sessions to achieve a full correction.

Hope that helps everyone!

Cheers!

Dr. Sara

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Dear “Worried about Scar Camouflage,”

Thank you for taking the time to write!  An average donor harvest scar should be done with a trichophytic edge these days, so hair should be growing through it rendering it nearly invisible.  However, even without completing that extra step (which I consider essential but not all surgeons do) an average scar should be no wider than 1-2 mm.  Based on an extensive survey of my patients, a scar like this would be visible if the hair were clipped at a #2 and invisible if clipped at a #3 length.  Of course, variables like skin and hair color can impact this, but as a general rule this is what I advise my patients.

Now, as to where at the back of the head the donor area is located, the answer varies by patient, but you can get a general idea pretty easily with the following brief exercise; cup your hand at the back of your head.  The area your hand is covering should be above the two bony bumps where your neck starts, but below the ledge where your crown ends and the length should be behind the ears on both sides. This is the donor area for many patients and since the lines of tension run like a string tied back behind both ears, that is how the tissue is removed for best cosmetic result.  Larger sessions result in a longer scar and an average to expect would be 20 cm or about 7-8 inches – which is roughly the length of your hand from palm bottom to fingertip!

For those patients who want to preserve their ability to shave the head with a razor – I mean really SHAVE that area like boot camp – these expectations are especially important to hit home.  If a linear scar is unacceptable, then an FUE surgery (Follicular Unit Extraction where the grafts are removed one at a time) would be the best option.  These surgeries take longer, are more labor intensive/expensive (so not all docs do them), and require multiple sessions, but the results are natural, recovery is much faster, and the scar is, as I mentioned, typically undetectable.

I hope that helps!  Good luck!

Warm Regards,
Dr. Sara Wasserbauer

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Dear John,

Thank you for taking the time to write.  I have not heard of Dr. Richard Lee, but it is easy to check a physician’s credentials if you know in what state they are licensed.  As for the minoxidil, all the science shows us is the efficacy for the 2% and the 5% formulations.  Going higher usually increases the risk of side effects, and it might not be more effective.  Remember that minoxidil was originally a medication for blood pressure that was taken orally (at much higher doses, incidentally).  Pfizer decided to investigate it as a hair loss drug when patients began reporting the strange side effect of unwanted hair growth!  So these drugs are not without effects on other body systems.

One of the reasons Dr. Lee is able to make his own formulation with a higher potency of minoxidil (and to give it a name) is that minoxidil is now generic.  Once the patent expired and it became available over the counter, physicians and compounding pharmacists could then use it as an ingredient in their own proprietary formulations.  ScalpMed and Avacor are good examples of this in practice, and they work because their ingredients (i.e. minoxidil!) are proven to work!  You can even report the FDA approval for it on your labeling.  It is often the case, however, that the active ingredient can be obtained more cheaply in the generic form at your local pharmacy.

Your question is not a new one, however, and you are not the only person who is asking it.  If SOME is good, is not MORE simply better?  I can tell you that over the years I have had patients try every new formulation out there and report back to me, and never once have I had a home run.  If something was better, we would all be using it, doctors and patients alike, all over the world.  There is not some great conspiracy among hair doctors to keep the REAL hair remedies for ourselves.  Which is why my final advice to you would be that it is probably okay to go ahead and try it.  If it works, great!  I want to be the first person you tell about it!

Good luck, John!  Let us know how it goes.

Warm Regards,
Dr. Sara Wasserbauer

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I have undergone 3 hair transplant procedures and thought that they were successful.  However, recently  I have noticed further hair loss and am concerned that the hair transplants may not really be working for me, especially since reading that very, very few women are good candidates.  It is difficult to tell if I am seeing just the normal loss of my hair or if the transplants did not take.    Before I decide to have another procedure I want to be very sure that I am really a good candidate for the procedure. Thank you so much for your help.  – Lauren
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Lauren,

Thank you for taking the time to write.  Let me try to answer your question as best I can without seeing you and examining your scalp.

Hair loss, by its very nature, is relentlessly progressive.  This is why a hair restoration surgeon takes into account future hair loss when planning a transplant – they must place hair in areas that might need hair in the future in addition to the areas that have already lost hair.  In women, this problem can be worsened by the surgery itself – that is to say – if a hair is at the end of its life cycle, it may have its final “shed” at the time of surgery.  This is mitigated by the fact that the new hair you get from the surgery is permanent so you end up ahead in the long run, surgeons are just usually more cautious with their female patients.  Additionally, you do not mention what type of hair loss you have; is it androgenetic alopecia (female pattern hair loss), alopecia areata, or hair loss due to other medical problems?

There are a few things you wrote that are not necessarily true, though.  Women are good candidates for hair transplant surgery.  In the past it was thought that there were few women candidates, but we now are finding this is not true.  Also, if the procedure was done according to the standards now used by most hair restoration surgeons, it is unlikely that the grafts would not “take.”

Since you are looking at another surgery, and since I do not know how many grafts you have had in your three surgeries thus far or even what type of hair loss you have, here is what I suggest;  find a hair restoration doctor or a dermatologist that you trust and get a definitive diagnosis for your hair loss.  To find one, consider checking some of the independent websites like the IAHRS (International Alliance of Hair Restoration Surgeons, http://www.iahrs.org/) or even the American Hair Loss Association (www.americanhairloss.org).   This process may involve a scalp biopsy or some blood tests.  You need to know what type of hair loss you have in order to explain any continued loss of hair or any possible failure of hair transplant surgery (which would be very rare).  From there the next step would be to have that trusted hair restoration doctor evaluate what another surgery would accomplish for you.

Hope that helps and best of luck with your treatment.

Warm Regards,
Dr. Sara Wasserbauer

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Dear John,

Thanks for taking the time to write!  Let me try to answer your question as best I can.  Ventriculoperitoneal shunts are rare.  Basically they channel excess fluid from around your brain to elsewhere in the body.  These shunts do not typically involve blood or the circulatory system.

For most patients, the presence of a shunt like this should not pose a problem for surgery, but I would check with the neurosurgeon who placed it or neurologist that the patient sees for specific recommendations because the location of the shunt can vary from patient to patient.  It may or may not even be in the area that the surgical plan involves. Common risks would include infection, pain, swelling, shock loss, hiccups, redness, and scarring among others, and these are routinely discussed with your hair transplant surgeon prior to any procedure.  For the most part, however, complications with any sort of hair transplant procedure are rare.

The way you phrased your question makes me think of the legal ramifications of surgical complications.  Of course, risks, expectations, and potential complications should be discussed with your hair transplant surgeon, and since this is such a unique situation, other experts might be consulted.  As I mentioned, every shunt is different, just as hair transplant surgery involves different areas.  There is no standard of care in hair transplant as to how to handle a patient who has one.  Whether the patient should be allowed to do it or not is therefore really a question for the physicians involved.

I wish I had a more definitive answer for you, but hair transplants in patients with VP shunts are simply not that common.  Good luck!

Warm Regards,
Dr. Sara Wasserbauer

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