Combining Medical Hair Loss Treatment with Hair Transplantation

Prior to moving forward with hair transplantation, many male and female patients have already tried a variety of medical hair loss treatments.  A question they frequently ask is whether they should stop the medical hair loss treatments if they proceed with hair transplantation.  This blog answers that question and also discusses how those medical hair loss treatments may complement the surgical option.

Common male medical hair loss treatments include topical minoxidil (Rogaine) and finasteride (Propecia).  Common female hair loss options include oral spironolactone, topical (Rogaine), and oral minoxidil.  An important fact that I share with my patients is that while hair transplantation can recreate a hair line or fill in an area of baldness, it does not stop the progression of hair loss.  That is an important concept given that performing a hair transplantation is just one step that occurs along a patient’s hair loss (and hair restoration) journey throughout their life.  As such, one needs to plan for all contingencies including the degree of further hair loss they can expect to experience based on their family history, age, and personal history of hair loss.

Medical hair loss treatments like oral finasteride for men can slow down further hair loss and can be complementary to performing a hair transplantation.  Conversely, some men want to avoid oral finasteride, and this is actually the reason they prefer the surgical option for hair restoration.  Hair transplantation can definitely be performed in patients who prefer not to use medical hair loss options.  However, it’s important for patients to understand that one can have further hair loss after hair transplantation.

Interestingly, the transplanted hairs originate from a part of the scalp (the back of the scalp) that is more resistant to further hair loss.  However, the non-transplanted hairs around those transplanted hairs may be more susceptible to further hair loss if one is not also on a medical hair loss therapy.  Given that Dr. Ratushny is a Harvard-trained, board-certified dermatologist and has expertise in medical hair loss and surgical hair transplantation, he can offer comprehensive medical advice to his patients about all of their medical and surgical options and how they can complement each other.

source https://mahairtransplant.com/combining-medical-hair-loss-treatment-with-hair-transplantation/

Hairline Design Concepts for Hair Transplant

One of the most important aspects of hair transplantation is pre-procedure planning.  Hairline design is a critical piece of that planning process and involves determining where the transplanted hairs will be placed.  Since hair transplantation is permanent, identifying the correct “new home” for the transplanted hair follicles is as vital as having the correct techniques in harvesting and placing those follicles.

Dr. Ratushny understands this critical part of the process and has a thorough discussion with his patients about how to optimize the hairline.  Although many patients would love to bring their hairline down to where it was when they were 17 years old, that is not always in their best interest for long-term results.  Dr. Ratushny makes sure to communicate with his patients that the goal of hair transplantation is not to only look excellent one year from the day of the transplant but to continue to look natural many years down the road.  Trying to lower a hairline too low may result in having to chase the hairline back if there is further hair loss of the non-transplanted hairs.  This is because most pattern alopecias (male pattern and female pattern) are progressive and thus finding someone like Dr. Ratushny who specializes in both medical hair loss management as a dermatologist and surgical hair loss management as a hair transplant surgeon is key to achieving good outcomes through proper planning and execution.

A good hairline design for hair transplantation also has natural irregularities, similar to the natural irregularities found in a natural hairline of someone who has not had a hair transplant.  It’s always helpful to identify the patient’s natural hairline and base the design of the transplanted hairline on their natural hairline.  However, a hair transplant surgeon needs to make a mutual decision with their patient about where it makes the most sense to place the transplanted hairline in a way that will yield long-term natural-appearing results.

Hairline design will vary between males and females.  A hair transplant surgeon has to be careful in the design of a male hairline to include some natural fronto-temporal recessions (areas of the “widows-peak”) since eliminating these completely can lead to femininization of the male hair line.

There are many considerations that Dr. Ratushny takes into account in hairline design.  Most importantly, Dr. Ratushny provides his expertise to his patients and works together with them to determine what would be the most realistic hairline that will stand the test of time.

source https://mahairtransplant.com/hairline-design-concepts-for-hair-transplant/

The Benefits of KEEP Implanters: Sometimes “Dull” is Good

Placing follicular units into recipient sites is the critical final stage of hair transplantation.  Dr. Ratushny and his hair transplant surgical technicians take great care to ensure that this part of the procedure is well-planned and well-executed.  To help him with this, Dr. Ratushny and his team use the latest technology called implanters.  In a past blog post, Dr. Ratushny detailed his use and expertise with sharp implanters, and in this blog post he describes the expertise MassDerm Hair Transplant Institute developed with using KEEP implanters, also known as “dull implanters.”

Prior to the invent of implanters, forceps were used by hair transplant technicians to place follicular units into the recipient sites of the scalp created by the hair transplant surgeon.  This technique is still used by many clinics and certainly requires a significant amount of expertise (and can produce great results).  One of the downsides of using only sharp forceps by hair techs for follicular unit placement is that sometimes grasping the follicular units with forceps may result in crush trauma to either the bulb or the bulge area of the hair follicles (where the stem cells reside).  This can result in decrease of growth capacity and rarely failure of growth of individual traumatized hair follicles.  Additionally, placing with sharp forceps may result in additional trauma to the scalp and result in extra bleeding.

Dr. Ratushny and his team started using KEEP implanters (a type of dull-tipped implanter) because their use overcomes the shortcomings of using just sharp forceps for hair placement.  Similar to sharp implanters, KEEP implanters minimize trauma to the follicular units and the scalp.  The main difference is that dull-tipped implanters are employed by Dr. Ratushny’s hair transplant surgical assistants and the hair follicles are placed into recipient sites that Dr. Ratushny creates himself.  The tips of the KEEP implanters are dull so that there is minimal trauma to the recipient sites on the scalp as Dr. Ratushny’s surgical assistants gently place the follicles.  Additionally, KEEP implanters can be rolled to load them with hair follicles, thus decreasing trauma to the follicles during handling prior to placement into the scalp.

In cases where KEEP (“dull”) implanters are used, Dr. Ratushny personally creates every single recipient site in the recipient area of the scalp, paying close attention to the direction, depth, size of recipient site, and angle of hair placement.  Then, Dr. Ratushny’s hair transplant surgical assistants use KEEP implanters to gently place the follicular units within the recipient sites that Dr. Ratushny creates.  This technique allows Dr. Ratushny to retain the artistry in design of direction, curl, position, and angle of the hair follicles and allows his surgical assistants to place the follicles in a way that preserves their viability by minimizing unnecessary manipulation.

source https://mahairtransplant.com/the-benefits-of-keep-implanters/

The Benefits of Sharp Implanters in Hair Transplantation: A Specialty of Dr. Vlad Ratushny

Hair transplantation is split up into two parts, the harvesting of hair follicles from the donor zone (back of head) and the placement of hair follicles into recipient sites on the front and top of the head. Dr. Ratushny employs the latest technology in both follicular unit harvesting and follicular unit placement. For placement, Dr. Ratushny uses both dull and sharp implanters to assist him in placing the follicular units, depending on the patient case.

Implanters are medical tools that hold hair follicles and allow their placement in the most gentle way possible. The use of implanters minimizes the trauma to the follicles themselves and to the scalp where the hair follicles are placed. Dr. Ratushny is one of the few hair transplant surgeons who uses sharp implanters to place grafts himself. These implanters maximize the efficiency of Dr. Ratushny’s surgical technique and allow him to create the recipient sites and placing the follicular units within the recipient site in one smooth motion. This advanced technique allows for minimal manipulation of the hair follicles and minimal trauma to the recipient site on the scalp.

Dr. Ratushny’s hair transplant surgical assistants are very skilled at the difficult task of loading the sharp implanters and handing them to Dr. Ratushny in a way that allows him to maintain focus on the recipient area of the scalp without breaking his attention or momentum. Dr. Ratushny uses surgical loupes for magnification of the recipient site so he can place the hair follicles in between the patient’s existing hair follicles without affecting the existing hair follicles. Dr. Ratushny’s experience with sharp implanters allows him to more densely pack hair follicles, while still overseeing the aesthetic artistry of follicular unit placement. Dr. Ratushny thoughtfully pays attention to the positioning, angle, and curl of follicles that he places. Patients typically note less pain after the procedure given that there is a minimization of trauma to the recipient site of the scalp.

Other cases call for dull implanters, which similarly minimize trauma to the follicular units and the scalp. The main difference is that dull implanters are employed by Dr. Ratushny’s surgical assistants and the hair follicles are placed into recipient sites that Dr. Ratushny creates himself. Dr. Ratushny will discuss dull implanters in a later blog post.

source https://mahairtransplant.com/the-benefits-of-sharp-implanters-in-hair-transplantation-a-specialty-of-dr-vlad-ratushny/

Gauging Your Stage of Male Pattern Hair Loss

More than 80 percent of men and nearly 50 percent of women experience significant hair loss in their lifetime. Dr. Ratushny understands that the treatment of hair loss is not a one-size-fits-all process. Dr. Ratushny likes to perform a personalized evaluation of each of his patient’s hair loss and compose a tailored treatment plan based on the severity of hair loss and patient goals. One key aspect is to understand the severity of hair loss.

The Hamilton-Norwood Scale ranks male pattern hair loss according to 7 stages. This hair loss measurement scale was first introduced by James Hamilton in the 1950s and later revised and updated by hair transplant surgeon Dr. O’Tar Norwood in the 1970s.

Stage 1: No significant hair loss noted. Even though this is a Stage on the male pattern hair loss scale, Norwood 1 is considered a control stage where no hair loss is present.
Stage 2: Slight recession at the temples, often symmetrical. This is also considered to be an adult or mature hairline. Norwood 2 indicates that a man is transitioning from a teenage hairline to an adult one and doesn’t indicate clinically significant hair loss. In general, treatment is not recommended at this Stage since it may never progress to clinically significant androgenetic alopecia (Norwood Stage 3)
Stage 3: This stage is where clinically significant baldness is evident and at this stage is where we recommend hair transplantation and/or medical treatment options for hair loss. There is symmetrical deep recession at the temples that are sparsely covered by hair or bald. Stage 3 Vertex indicates that the hair loss is targeted in the crown (vertex) but the hairline has minimal recession as is seen in Stage 2.
Stage 4: More severe recession at the temples than in Stage 3 and sparse or no hair on the crown. The two areas of hair loss are separated by a band of moderately dense hair that extends across the top of the head.
Stage 5: The temporal and crown hair loss is more advanced than in Stage 4. The crown hair loss is still separated from the frontal hair loss but the band of separating hair is sparse and narrower.
Stage 6: The balding areas on the temples now becomes continuous with the hair loss at the crown. There may be some sparse hairs in the area where there previously was a hair band separating the two zones.
Stage 7: This is the most advanced stage of male pattern hair loss with only a narrow band of hair in a horseshoe shape on the sides and back of the scalp. The remaining hair is usually fine and not dense.

Norwood Class A: Norwood Class A is a variation of the Norwood scale for the less common form of hair loss where the hairline recedes back uniformly rather than in the dual locations of frontal hairline and crown. In this type of hair loss, the hairline recedes from the front to the back, without leaving an island of hair in the middle.

Since hair loss is progressive, a patient’s hair loss journey may take them through various phases of the Hamilton-Norwood Scale throughout their lifetime. Some individuals are genetically destined to progress to Stage 7 hair loss, while in others, the hair loss stops at an earlier stage. During your consultation with Dr. Ratushny, he may try to gauge the speed of progression of your hair loss, as this will inform the surgical treatment options that are available to you.

source https://mahairtransplant.com/gauging-your-stage-of-male-pattern-hair-loss/

Donor Site Management II: Maximizing Your Long-Term Potential for Hair Transplantation

One important decision you will make when planning a hair transplant procedure is whether to get a strip excision (AKA follicular unit transplantation/FUT) or follicular unit excision (FUE). While some hair transplant surgeons only have the technical capacity to offer an FUE, Dr. Ratushny feels that it is important to offer both procedures to his patients. There are many variables you should consider when making this decision. One variable is whether you plan to crop your hair very short or shave your hair in the future. If so, Dr. Ratushny typically recommends an FUE. If you do plan to keep your hair length longer, Dr. Ratushny usually recommends FUT/strip excision. Also, FUT/strip excisions are preferable to use for female patients. One important variable you should consider is your total donor capacity, or the average number of hairs that you can transplant over your lifetime from the back of your head (donor zone) to the front/top of your head (recipient zone).

The total donor capacity depends on the type of hair transplant procedure you choose, with strip excisions allowing a greater amount of harvestable follicles than FUE. Typically, the total lifetime donor capacity ranges from 3000 to 6000 follicular units if one proceeds with only FUE procedures. In contrast, strip excisions allow for a total donor capacity of 5000 to 8000 follicular units. The reason for the greater capacity for strip excisions is that Dr. Ratushny can remove all the follicles within the strip during one procedure in the most optimal donor area in the mid back of your head. Subsequently, a repeat procedure can be done in a way that we remove the original strip scar so that we don’t create multiple strip scars in the back of the head. In an FUE procedure, Dr. Ratushny uses the WAW-FUE device to remove every 3rd or 4th follicle throughout the donor zone in the back of your head. During repeat FUE procedures, Dr. Ratushny is very careful to retain enough hair follicles in the back of the head to camouflage the donor area. Overharvesting of the donor zone in an FUE procedure may result in a spotty appearance in the back of the head, which Dr. Ratushny tries to avoid in his patients. If one gets both strip excisions and FUE in successive hair transplantation procedures, one can further increase potential total donor capacity.

Dr. Ratushny recommends a conservative approach with hair transplantation to avoid overharvesting your donor zone with 1 or 2 massive procedures. The reason for this is that if you remove all the useable donor hairs in the back of your scalp, your options are limited if you have further hair loss after your initial procedure/s. Also, the density of hair placement in an individual procedure is limited by the fact that placing at too high of a density can create hair “popping” and may result in decreased growth of transplanted follicles that are placed too close together. However, if you place hairs at a given density for an initial procedure, you always have the option of increasing that density in a subsequent procedure by placing grafts among the already transplanted hairs.

It is for all these reasons that Dr. Ratushny prefers to do hair transplantation using a conservative number of grafts per procedure, in a way to preserve donor density and appropriately manage the donor area of his patients. This gives his patients more options in the future for dealing with further hair loss or increasing hair density at various areas on their recipient site.

source https://mahairtransplant.com/donor-site-management-ii-maximizing-you-long-term-potential-for-hair-transplant/

Donor Site Management: Ensuring Success and Flexibility

Getting a hair transplant involves, on the basic level, moving hair follicles from the donor zone at the back of your head to the recipient area on your hairline or top of your head. While we typically focus on the recipient area where the hair follicles are being placed, it is important to consider the donor area from where the hairs are obtained.

One question that I sometimes get from patients is whether the hairs that are removed from the donor area on the back of the head grow back after the transplant. The answer to that question is no, they do not grow back. However, when I harvest the hairs at the back of the head for an FUE procedure, I take special care to remove the hair follicles in a pattern so that the removed hairs are easily camouflaged by the remaining hairs. Similarly, I perform a strip excision with the end goal of having a fairly imperceptible linear scar in the donor zone on the back of the head. However, the scars for both FUE and strip excisions can vary depending on a lot of individual factors regarding scar healing, which are unique for each person.

Given that there is a limited lifetime supply of donor follicles that your hair transplant surgeon can harvest from the back of your head, your surgeon has to be thoughtful about donor site management and number of follicles moved per procedure. Since hair loss is a progressive condition, patients have to consider that hair transplantation is about managing a “moving target.” It is important for patients to go to a hair transplant surgeon who properly understands donor site management.

Your hair transplant surgeon should be thoughtful about where they place the hairs during each procedure in order to create a natural appearance. That natural appearance has to be maintained not only a year after your transplant, but also 10 years after, if/when you have further hair loss of non-transplanted hairs. Also, you want to be able to retain enough useable follicles in your donor area for future procedures. This allows your surgeon to increase the density of your initial transplant, fill in areas of your scalp not filled in in your initial procedure, or to account for further hair loss you may experience in the future.

Dr. Ratushny considers a relationship with his patients as more than just being an operator for a one-time procedure, but rather as an expert working with his patients to manage their hair loss from both the medical and surgical aspects over their lifetime.

In a future blog post, Dr. Ratushny will discuss the maximum number of hair follicles that can be moved from your donor zone. Interestingly, maximum number of follicular units available for harvesting over a lifetime is different if one has successive FUE hair transplants versus strip excisions. Look out for the future blog post to learn more!

source https://mahairtransplant.com/donor-site-management-ensuring-success-and-flexibility/