More on DPA and DUPA

DPA ( Diffuse Patterened Alopecia and DUPA (diffuse unpatterned alopecia) also check:

http://goodbyehairloss.blogspot.com/2007/08/ht26_27.html

In addition to the regular Norwood Classes (I to VII) and the Norwood Class A’s (Ia to Va), there are two other types of male baldness that O’tar Norwood has termed “Diffuse Patterned Alopecia” and “Diffuse Unpatterned Alopecia.” Although these patterns receive little attention, they appear to be quite common and present special problems for the transplant surgeon. We have attempted to further define and stage these two types of balding in order to gain insight into their appropriate management.
DUPA (Diffuse Unpatterned Alopecia) will not appear in a month. If and when it hits, it will develop over a long period of time (months to years). Chemical damage, on the other hand, will have a short cycle.
We do not understand a great deal about DUPA, but we are aware that the zone of hair around the sides and back of the head may not be permanent in everyone throughout their lifetime. If you go to an old age home and look at many of the men there, about 1/3rd to a half of the men over 80 have a see-through look on the sides and back of the head. When this is evaluated by mapping out the scalp for miniaturization you will see many thin hairs in this ‘donor rim’ that should not be there. This diffuse alopecia may extend throughout the head, even in men who have no balding. These are the people withs of DUPA. I believe that a condition, which the dermatologists have labelled ‘senile alopecia’, is something that hits men in all decades of life and a few men develop this condition when they are in their 20s or 30s. The use of Finasteride (Propecia) has benefits to about half of these men. Many of the poor transplant results that are seen occurs when the patient has DUPA and the surgeon does not check for it. The transplants become thin and the donor area, which was see through prior to the procedure, gets more see through after. I strongly warn every one of those patients I see with DUPA against having hair transplants and consider this condition a contra-indication for hair transplant surgery.
Diffuse Patterned Alopecia (DPA) is an androgenetic alopecia characterized by diffuse thinning in the front, top, and vertex of the scalp in conjunction with a stable permanent zone. Diffuse Patterned Alopecia is usually associated with the persistence of the frontal hairline represented by the hairline position of the Norwood Class II or Class III patient. Especially in the earlier stages, the thinning generally extends to the vertex without significant hair loss in the crown. It differs from the regular Norwood classification in that, when the hair loss is first noted, it is already in a stage resembling a thinning Norwood Class VI, rather than having progressed through the Norwood stages III, III Vertex, IV, and V, which are characterized by continued recession at the temples, an expanding vertex/crown, and the presence of a defined bridge separating the anterior and posterior portions of the scalp. In addition, there is an absence of the residual triangular elevation in the parietal region that helps to define the typical Norwood Class VI patient.
Diffuse Patterned Alopecia differs from the less common Diffuse Unpatterned Alopecia (DUPA) which is also androgenetic, but lacks a stable permanent zone. Diffuse Unpatterned Alopecia( DUPA) patients have a similar progression of balding as the DPA patient except that the progression is often more rapid and will more likely eventuate in a “horseshoe pattern” resembling the Norwood class VII, except that in contrast to the Norwood VII, the DUPA “horseshoe” can look almost “transparent” due to the low density. The differentiation between DPA and DUPA is critically important because DPA patients are often good candidates for an appropriately timed transplant, whereas DUPA patients should almost never be transplanted because they will inevitably have extensive hair loss without a stable zone in which to harvest the hair.
Both Diffuse Patterned and Unpatterned alopecia also occur in women. However, in contrast to men, the DUPA in women is much more common, probably occurring 10 times as frequently as DPA. As in men, the female DUPA patients are not good candidates for a transplant (except in the instance where the donor hair is used solely to soften the frontal edge of a wig). The high incidence of Diffuse Unpatterned Alopecia in women partly explains why so few women have their hair transplanted. It is also important to emphasize that a non-androgenetic differential must be considered in all unpatterned alopecias. This is especially true in women, where a host of medical conditions can produce diffuse unpatterned hair loss including anemia, thyroid disease, connective tissue disease, gynecological conditions, and severe emotional problems.
We find densitometry to be helpful in distinguishing Diffuse Patterned Alopecia from Diffuse Unpatterned Alopecia. A donor density in the range of 1.0 to 1.5 hairs/mm 2 with donor miniaturization in excess of 35% indicates an unstable permanent zone and precludes a diagnosis of DPA. As discussed in the section “Predicting Short- and Long-Term Hair-Loss,” these densitometry readings in a younger patient, even with little clinically apparent hair loss, point toward a high risk of extensive balding. The importance of densitometry is that not only will it help to distinguish between DPA and DUPA, but it can help to predict which patient will not be a good candidate for a transplant even before visible balding has begun. “

Density Myth

Follicular unit density is generally highest in the midline of the donor area and decreases laterally. The majority of patients have density range from 1.5 hairs/unit to 3.0 hairs/unit with an average of 2.0 hairs /Follicular unit

The density of naturally occurring follicular units is 60 to 100 follicular units ( or 120 hairs to 300 hairs) per sq.cm Lower in this range in blacks and higher in this range in Caucasians.

"Cross Sectional Area." or diameter the range in terminal hair shaft diameter is approximately 60 micron to 140 micron.

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.

Natural hair groupings in this case might be 20% 1's, 45% 2's, 30% 3's, and 5% 4's.

In our experience, the average donor density for all patients (both bald and non-bald) seeking a consultation for hair restoration surgery has an average donor density of 200 hairs/cm2. In general, for individuals with straight hair of average diameter, the donor density must be at least 100 hair/cm2 in order to adequately cover the donor area and not have it appear too thin. A density of 100 hair/cm2 is also the minimal density needed to hide an average donor scar. If a patient has wavy or thick hair the minimum density may be slightly less and in patients with very fine, straight hair the minimum density will be more.

A unit change in donor density away from the norm will produce a two-fold change in the availability of transplantable hair. For example, compared to the average person (with a donor density of 200 hairs/cm2), a balding individual with a donor density of 270hairs /cm2 (which is a 35% increase) will have 70% more hair available to transplant. Conversely, a person with a donor density of 130 hairs /cm2 will have 70% less transplantable hair, and may not be a candidate for surgery regardless of his Norwood classification. If he were to bald extensively, almost any type of hair restoration would leave him desperately short of hair and short on coverage in the donor area..

An average scalp is approximately 500 cm2. Since the normal, non-balding scalp has 100 follicular unit/cm2, and each unit contains on the average 2 hairs (yielding a density of 200 hairs/cm2), the average scalp would have 100,000 hairs in total. The permanent zone normally represents approximately 25% of this area, and half is available to be moved without the donor area appearing too thin. Thus, in theory, 12.5% of the scalp would be available for transplantation. This donor area would contain 12,500 hairs or 6,250 implants, averaging two hairs each. When a patient’s density is higher, a greater proportion of the donor hair can be used for the transplant.

Hence numbers are not as dismal as they appear. In a completel

y bald area, 17% of the patient’s original density offers a vast cosmetic improvement over having no hair, especially if the transplant is totally natural, and the patient has realistic expectations. But most importantly, the aesthetic impact of these absolute numbers can be improved upon with “artistic” adjustments in the “weighting” of the implants. In addition, if it can safely be assumed that the patient will not be extensively bald, then more hair can be committed to a more limited area. Great care must be taken so that excessive amounts of hair are not removed from the donor area to treat a limited area of recession, given the possibility that such a patient may need to reserve his donor hair to cover an almost certain evolving hair loss process over time.

The decision regarding moving hair reserves to meet patient’s goals must be a joint one between patient and doctor. The doctor has the obligation to fully inform the patient of the consequences of donor hair depletion when planning any reconstruction. We feel that the solution to increasing recipient density should be to perform a properly planned second procedure using follicular units and not to increase the size of the implants, since this will result in a density that is either equal to or greater than (due to compression) the

density of the donor area. This density will either be unnatural for a mature patient whose density in the front and top of his scalp should be less than in the donor area, or unrealistic if future hair loss should occur (and this level of density cannot be maintained). Conversely, splitting up the follicular units would not increase the density either. This would only produce groupings smaller than occur naturally and would run the risk of having poor growth and an appearance that was too thin.

n general (assuming straight, brown hair of average hair weight, and light skin), 50% of the hair in a given area may be lost before any appreciable change is noted. For the average person, with a density of 2.0, this would result in a density of 1 hair/mm2

hese numbers are not as dismal as they appear. In a completely bald area, 17% of the patient’s original density offers a vast cosmetic improvement over having no hair, especially if the transplant is totally natural, and the patient has realistic expectations. But most importantly, the aesthetic impact of these absolute numbers can be improved upon with “artistic” adjustments in the “weighting” of the implants. In addition, if it can safely be assumed that the patient will not be extensively bald, then more hair can be committed to a more limited area. Great care must be taken so that excessive amounts of hair are not removed from the donor area to treat a limited area of recession, given the possibility that such a patient may need to reserve his donor hair to cover an almost certain evolving hair loss process over time.

The decision regarding moving hair reserves to meet patients goals must be a joint one between patient and doctor. The doctor has the obligation to fully inform the patient of the consequences of donor hair depletion when planning any reconstruction.

We feel that the solution to increasing recipient density should be to perform a properly planned second procedure using follicular units and not to increase the size of the implants, since this will result in a density that is either equal to or greater than (due to compression) the density of the donor area. This density will either be unnatural for a mature patient whose density in the front and top of his scalp should be less than in the donor area, or unrealistic if future hair loss should occur (and this level of density cannot be maintained). Conversely, splitting up the follicular units would not increase the density either. This would only produce groupings smaller than occur naturally and would run the risk of having poor growth and an appearance that was too thin.

In a patient with a density of 2.4 hairs/mm2, the yield would be: 20% 1 hair implants 35% 2 hair implants 30% 3 hair implants 15% 4 hair implants

If we see with different perspective if the donor area has say 12500 hairs or 6000 Follicular units for the coverage of 375 cm2 area of the stage 7 Norwood baldness. If this hairs are equally distributed the density per cm2 would not be more than 16 /cm2. For say class 6 baldness the area may be 270 cm2 the equal distribution of 6000 follicular units will yield density of 22 FU / cm2. In other words if you are looking for density of 60 /cm2 in the entire area you would need 270 x 60 = 16200 FU ! But for good natural look it is important that one should have higher density in the front esp. in the hair line area (front 1 to3 cm) of at least 35 to 50 FU /cm2. This will obviously reduce the density in the area behind it because the available donor hair from the back are limited ( i.e. up to 6000 FU). More over covering the crown area with high density can consume a large number of FU and still will not give a dense cover because the whorl in the crown has centrifugal direction form the centre of the whorl and there is no shingling effect as in case of the front. More over crown is not making the framework of the face like the hair line so is cosmetically not as significant as the hair line and therefore priority should be given to the frontal cover rather than the crown cover. Our looks is judged majority of time from the front (Hair line) and very occasionally from the back side (crown).

PRP (Platelet Rich Plasma)

What is PRP? Platelet rich plasma is concentrated blood plasma which contains approximately five times the number of platelets found in normal circulating blood. Human blood is comprised primarily of red blood cells (RBC), as well as white blood cells (WBC), platelets, and plasma. By initiating the first step of coagulation, platelets are the key to the body’s ability to heal wounds.

It is thought that by increasing the platelet count in a wounded area, the body’s healing to that area would be accelerated – explaining the use of PRP (platelet rich plasma) in wound healing.

Platelet rich plasma is concentrated blood plasma which contains approximately five times the number of platelets found in normal circulating blood. In addition, blood plasma contains the growth factors PDGF and VEGF and other bioactive proteins that aid in wound healing. To obtain PRP, a patient’s blood is spun in a centrifuge that separates the solid from liquid components. This separated “solid” portion of the blood is PRP (platelet rich plasma)

PRP is used in many areas of medicine, including the acceleration of healing of tendon injuries, the treatment of osteoarthritis, in some aspects of dental work (i.e. jaw reconstruction), and in cardiovascular medicine. The concentrated form of plasma has been shown to accelerate wound healing and tissue repair and, thus, could potentially benefit hair restoration procedures.

In hair transplantation, PRP can be injected into the recipient site area to theoretically stimulate the healing of the transplanted grafts and into the donor area to facilitate healing of the donor incision.

Mechanism of Action in Hair Transplants

Basically, a small amount (50cc) of your blood is taken before surgery. The platelets, which are part of your blood and help with healing of wounds, are separated to form a solution called platelet rich plasma. The follicular unit grafts are bathed in this PRP before being implanted. The PRP is also injected in the scar and recipient sites.

Hair follicles survive through the absorption of oxygen from surrounding tissue. It is conjectured that the introduction of platelets and white blood cells through platelet rich plasma (PRP) would amplify the body’s naturally occurring wound healing mechanism. Others propose that PRP can actually stimulate the stem cells (dermal papilla) of the newly transplanted hair follicles. Some practitioners also claim that PRP can be used to stimulate the growth of follicles, thereby reversing hair miniaturization seen in androgenetic alopecia and even preventing hair loss.

While there is much conjecture as to the benefits of using PRP during hair transplantation and its use in the medical treatment of hair loss, there is little scientific evidence to support these theories at the present time. This is an exciting new area in the field of hair restoration that awaits further scientific data.

[Graft survival and the use of platelet rich plasma in hair transplantation

Our interest was stimulated by two previous hair restoration physicians, Carlos Uebel from Brazil and Joseph Greco from Florida, who reported improved healing and graft survival with use of PRP.

Vascular factors include the immediate post-operative oxygenation and successful revascularization of each graft. Unlike organ transplants where the transplanted organ is hooked up to a new blood supply, hair transplants are “free” grafts which are surgically implanted without re-attaching a new blood supply (because that would be impossible to do with hair follicles). Until this process is complete, the graft must survive by passively absorbing oxygen from the surrounding tissue. We have been using and testing a variety of techniques to ‘prime the pump’ so to speak: topical hyperbaric oxygen, vasodilators, and angiogenesis stimulators. This is where platelet - rich plasma (PRP) comes in.

How does applying PRP help transplanted hair? Remember that platelets are key players in the body’s wound healing mechanism. Whenever there is a wound (e.g. an incision to place a hair graft during hair replacement), the platelets are trapped in the clot and are activated to release various hair growth factors that stimulate the healing process. These naturally occurring growth factors include:

• PDGF (Platelet derived growth factor)
• TGF-a & b (Transforming growth factor alpha & beta)
• EGF (Epidermal growth factor)
• FGF (Fibroblast growth factor)
• Insulin-like growth factor (IGF)
• PDEGF (platelet derived epidermal growth factor)
• PDAF (platelet derived angiogenesis factor)

These factors stimulate new blood vessels to form (angiogenesis) and collagen to be produced. Cells are stimulated to divide and go into action surrounding the wound. In addition, white blood cells present in the area help eliminate bacteria in the area. PRP merely amplifies this naturally occurring wound healing process by providing increased numbers of platelets and white blood cells to the wound. It is important that the PRP be concentrated enough to have a therapeutic value and some techniques and devices in use by some physicians today may not accomplish this. produce at least 1.5 million platelets/1ml, well above the therapeutic threshold. This represents about a five-fold increase compared to the platelet count in circulating blood (for 10 cc of PRP).

Follicular unit transplantation outcomes may be increased by the correct application of PRP.

• Donor site pre-treatment with PRP ( purpose is to provide platelet cell therapy and platelet-derived growth factors, both of which are key elements in wound healing).
• Recipient site pre-treatment with PRP ( this seems to be an important factor affecting graft growth and survival rates).
• Optimal use of intra-operative PRP and platelet-derived growth factors, in and around the graft
• Graft emersion in PRP ( “ soaking the graft in the PRP gel”)

Following advantages are claimed by use of PRP

1. to enhance donor site wound healing
2. to decrease the incidence of infection
3. to reduce donor scarring
4. to increase donor scar tensile strength
5. to enhance recipient site healing (which should increase growth)
6. to be utilized as an effective treatment protocol in severe cases of wound dehiscence or infection.

Today, physicians and scientists demonstrate that platelet rich plasma may actually wake up dormant follicular stem cells and could quite potentially become the next major breakthrough in treating hair loss and growing hair. While some people feel this is yet another marketing attempt to rob balding men and women of their hard earned money, others are very excited by its potential.

Smoking and Hair Transplant

Dear friend yes smoking is generally injurious to your health but it also tends to shrink your small blood vessels in your skin and therefore can affect your healing of the wounds in the early post operative period but but it is also known to delay and reduce the growth rate of the new hair. So chose between smoking and hair

SEX DRIVE DHT AND HAIR LOSS

No the need for the sex drive does not increase the hair loss because for the sex drive the responsible hormone is not DHT but Testosterone and . DHT level in the blood does not go up but actually it is raised in the genetically vulnerable hair roots on the central and top scalp.

terminology

Ways of marketing and oneupmanship sometimes create very confusing terminology for the layperson and following para will help to clarify I hope 1. HT or Hair Transplant was done as Punch Graft before the 20 years but due to bad cosmetic results it is no more done. Today the Follicular Method is the Gold Standard of Hair Transplant. In the older Punch method a circular hollow punch was used to remove a cylinder of hair bearing tissue from the donor site ( which contained hair roots or Hair Follicles). This was transplanted in the bald are. But this Punch Grafts grew 10 to 25 hairs in the bunch and that gave Baby Doll appearance. Later it was discovered that the naturally hair grows from the hair "Follicle" which can be in the group of one. two ,three or four and not in 10 to 25. This natural group of Follicles is called "Follicular Unit" or the "root" . The surgeons started separating the Follicular Units and that is also called "Graft". The method that uses such Follicular Unit Grafts is called Follicular Method. There are basically 2 methods of Follicular Transplant: (1. Strip Method and 2. FUE- stitch less method) In a usual "strip method" follicles are separated after strip is harvested from your donor site (from the back of your head). The donor area is closed by an absorbable stitch and the follicular unit grafts are individually dissected from the this strip for transplant. 2nd method which is more modern is "the stitch less procedure" (FUE- Follicular Unit Extraction). This does not involve removal of strip or stitches. The Grafts are individually extracted from the scalp with micro punch blade. As it is said there are more than one ways to skin a cat so are many minor variation in technique of FUE and are given different names as follows: Follicular Unit Extraction FUE - Most common and accepted name. FOX or FX ( Bill Rassman-LA) Woods technique, TOP-UP technique (Ray wood - Sydney) DHI (Direct Hair Implantation) FIT (Follicle Isolation Technique) (Dr. John P Cole-Atlanta & N.Y.)- SAFE (Surgically Advanced Follicular Extraction)- Dr. James A Harris- ENT Denver Colorado FUSE (Follicular Unit Separation Extraction) – Dr Arvind Poswal Follicular unit micro extraction (or FUM) - Dr. Epstein (NY) During the transition from old punch method to modern Follicular method there was a phase when surgeons cut the grafts of size smalled than that of a punch graft but bigger than that of Follicular unit they were named as "Minigrafts" or "Micrografts" and "Slot Grafts" or "MUG" ( Multi Unit Grafts) or "Paired Grafts" etc.

TESTIMONIALS

Dear friend you have posed a very practical issue and here are some more recent screen shots of the mails from my patients. I hope that helps. Click on each screen shot to enlarge.

DENSITY AND RESULT OF TRANSPLANT

	Asian	Caucasian	African
Density of Follicular Unit per sq. cm/ sq. inch/ sq. m. m.	60- 80 per sq. cm or 375 -500 per sq. inch or 0.8 per Sq. m. m.	100 per sq. cm or 625 per sq. inch or 1.1 per Sq. m. m.	60 per sq. cm or 375 per sq. inch or 0.65 per Sq. m. m.
Hair per per sq. cm/ sq. inch/sq. m. m.	120 – 160 per sq. cm or 750 -1000 per sq. inch or 1.6 per Sq. m. m.	200 per sq. cm or 1250 per sq. inch or 2.2 per Sq. m. m.	120 per sq. cm or 750 per sq. inch or 1.3 per Sq. m. m.
Total hair in scalp	80000	100000	60000
Total Donor graft available	Medium due to medium density and smaller size of donor	Maximum due to higher density and larger size of donor (> 35 cm x 7.5 cm = 262 cm2)	low due to low density and smaller size of donor
Donor hair character	More thickness	Average thickness but usually skin hair contrast is less esp. with blonds and light hairs	More 3 or 4 hair follicular units and curly hairs

In the head of an average male with a hair bearing area of approximately 80 square inch area,

The more the density, the more is the movable hair the number of square inches of scalp that can be moved depends upon the looseness of the scalp (something we call Scalp Laxity). The more square inches we can safely move, the more hair we can transplant

With good decision making by the doctor, large sessions should not scar more than multiple smaller sessions but there may be a cost for aggressive decisions in large session transplantation if the doctor is not experienced in such procedures. So there is a balance between what can be done and what should be done. The real issue here is not if it can be done, but whether or not they will actually grow. Various factors affect the overall outcome of the transplant are

1. Density of the hair: A doctor can transplant as high as 50% of the original density but hair transplant is not an Olympic contest of how may grafts one can place in a sq. cm. But it is certainly an issue where you have to see that how many grafts really grow. It is important to focus more in the issues of coverage and fullness. Some studies have shown that by crowding the grafts more than 40 per square cm, blood supply may be compromised & the successful growth of these grafts starts to fall off significantly. If there is hair already present in the transplanted recipient area, there is great likelihood that it would damage the existing hair as well as obtaining poor growth. Well the area of grafting is important; the hairline needs higher visual density than the area behind it for cosmetic reasons.

2. Donor Laxity: Tight scalp restricts the harvestable number of grafts in a megasession because the width of the strip that can be removed becomes restricted.

3. Donor Area size: Assuming normal density of hair, a person with the Norwood Class 7 hair loss pattern (the worst case) will lose 70% of the total hair he was born with. This will leave him with a 3 inch by 14 inch wreath of hair around the back and sides of his head. This area is less in the Asian head due to smaller size of the head both in the hight and the length.

4. Donor Scarring: More the number of surgeries done more is the donor scarring and more is the possible loss in the scarring and therefore less is the available grafts. Therefore megasessions can harvest more number of total grafts than multiple smaller sessions which lead to multiple scars.

5. Hair shaft thickness. The coarser the hair, the better it supplies bulk. Hair bulk is a critical element in producing fullness and coverage. Coarse hair is better than fine and wavy is better than straight in giving the volume or coverage. For the same coverage given by 1000 hairs of 80 micron diameter one needs 1300 hairs of 0.7 micron and 1800 hairs of 0.6 micron and 2560 hairs of 0.5 micron diameter. A blonde with white skin, may only have to return 15% of the hair density, with coarse dark hair , you might get away with 25% of your original density, and if your hair is wavy with good thichness it may be even less. On the other hand Fair skin with thin black hair may require more number of grafts to be transferred to achieve the reasonable coverage. Oriental hair with good shaft thickness has better coverage capacity compared to thin Caucasian hairs.

6. Pre existing DUPA: For an African or Asian man under 25, a donor density of 120 per sq.cm. without “DUPA-Diffuse Un Patterned Alopecia” may make a good candidate with high quality hair, while a Caucasian with he same density having DUPA might make a very bad candidate for a hair transplant for many reasons..

7. The size of the balding area. The more bald you are, the more hair you might need. Sometimes, the goals has to be more realistic due to limited supply or a demand that is too high. One with the impaired vision aims for the best possible improvement in vision by the treatment but one with the loss of both eyes should aim of a helpful stick or a faithful leading dog. Stage 7 may have bald area of 250 sq.cm or more to give coverage to that area with average density of 30 would need 250 x 30 = 7500 grafts which need at least 2 sessions to give coverage.

8. The characteristics of your hair. African hair due to its curliness has a better coverage and volume giving capacity. The Italians and French had the best wavy hair. Straight is the most challenging, as found in many Asians.

9. Color/contrast between hair and skin color. This is critically important. A Class 6 pattern blonde person could reduce his hair population to 85% of its original density and still look full as the blonde hair and blonde skin have low contrast. The same applies to black hair and black skin, brown hair and brown hair, sandy hair and sandy skin and any skin color with white hair. Salt and pepper hair works very well. It difficult to achieve good result in people with white skin with black hair.

10. Length of the hair: Longer the hair the better the coverage and fullness. I normally advise the transplant candidate to keep transplanted hair long and not very short.

11. Elasticity of Recipient: Scarred or callous scalp tissue: The health of the scalp determines just how close you can place the grafts (for scalp that is atrophic and lost its infrastructure of blood vessels, glandular structures and fat; less density is often better). The reasonable upper limit of density numbers from a transplant perspective is up to100 - 120 hairs per square cm. This type of density, however, requires supple skin that still has elastic properties. Scars do not have this characteristic. Also scars have an abnormal blood supply when compared with normal skin. Much of the infrastructure and microcirculation in the vasculature is not present in scar, so transplanting very high densities may not produce good growth.

12. Skill and Ability of the surgeon and team: to transfer this number safely the size of the instruments for making sites, the skill of the surgical team at placing grafts tightly together

13. Other Characters; emerging angle, oiliness, sheen, static electricity etc.

POST OPERATIVE RECOVERY

Dear friend this is a very useful question for all those who want to undergo HT to be answered. I give you a calendar of recovery and for resuming various activities: The following table is the general guideline for the anticipated course for the average patient undergoing Hair Transplantation.

Time after HT	Progress & Recovery	Activity possible or required
Day 1 Immediately after surgery	Heavy headedness, mild headache or rarely momentary giddiness. Need some pain killer. Grafted site may ooze some blood.	Grafted and the donor site needs to be washed gently after 4 to 5 hours with baby shampoo and spray of clean water. Can comb the hair carefully with the wide toothed comb. A short walk, watching TV etc. Go to the sun with a cap on for 2-3 months Eat every thing that you like. Sleep on the back; avoid sleeping on sides or on tummy. Sit at 45 degree angle with the back and the head bent backwards. Avoid “yes” & “No” neck movements of neck. No Tobacco; smoking (healing and hair growth problems) or alcohol. Avoid hand kerchief or Bandana on the recipient. Passive sex (masturbation) is ok
Day 2	Some soreness, tightness and numbness. Need some pain killers	Hair Oil can be used ( may even help to soften the scabs) Can use ice packs for 2-3 days on forehead to avoid swelling
Day 3-4	Soreness begins to disappear. Occasional pain killers needed. Some numbness may continue Scabbing is largely gone if properly washed. Moderate redness may be present. Some swelling may appear on forehead. Hair transplant grafts should have firmly set in and humidity/sweating should not affect them	Active Sex is Ok now
1 week	Soreness is generally gone. Occasionally some numbness persists. Redness is minimal to absent. Swelling is usually gone. Scabs start separating& the hair may also fall along with the scab but the graft is taken by the body.	Can start full aerobic exercise ( walk, run, yoga etc but no sit ups, pull ups or weight lifting)
10-12 days	Grafts are now well incorporated in the body and it is ok to remove the scabs by rubbing during the bath
2 weeks	Looks and feels like a 4-day-old beard. Sutures begin to absorb. Discomfort is gone.	Hair cut, colour, style, use of relaxer or bleaching etc is possible provided the wounds are healed and the scabs are gone. Sports can be started. Concealers like Toppik can be used and Non comedogenic Sun screen lotion can be used to protect scalp Scalp massage is possible now
1 month	Transplanted hair is shed as the follicles enter a dormant phase. Knots at the ends of the absorbable sutures fall off.	Can start weight lifting, pull ups, or sit ups. Sun bathing,
3-6 Months	Transplanted hair begins to grow first as very fine hair. Any residual numbness in the donor area is generally gone.	Scalp exercise to facilitate the 2nd Hair Transplant session can be started now.
8 months	Transplanted hair becomes combable or groomable but transplant appears thin as hair continues to grow and thicken. Slight textural change in hair is occasionally present.	It may be possible now to go for 2nd session of transplant now
1 year	expect over 95% of the grafts to have grown
1-2 year	There may be additional fullness during the second year. Any textural change in hair usually returns to normal

Usual Time of Recovery and Resuming of activities:

Pain, discomfort or tightness in the donor area: 2-5 days

Swelling: Immediate swelling of anaesthesia disappears after few hours but the post operative swelling although less common these days may appear after 24 hours and usually disappears in 3-5 days

Numbness: the head lasts because of anaesthesia for few more hours after surgery but numbness above the stitches may last from 1-12 months.

Scabs: by regular cleaning usually gets cleared by 3-7 days if it is there it can be removed by rubbing during bath after 12 days

Sun Exposure of scalp is avoided for 2-3 months by use of cap/ cover or Sun block

Passive sex is possible even from day 1 and active sex after 2-3 day is Ok

Avoid smoking for 3-6 months

Walking is ok from day one

Aerobic exercise (walk, run, yoga etc but no sit ups, pull ups or weight lifting) after 1 week

Weight lifting after 1 month

Hair cut, colour, style, use of relaxer or bleaching etc is possible after 2 weeks provided the wounds are healed and the scabs are gone

Grafted hairs will fall some along with the scabs and the rest by 1 to 2 months

New hairs start growing by 3-6 months and Transplanted hair becomes combable or groomable but transplant appears thin as hair continues to grow and thicken. Slight textural change in hair is occasionally present. There may be additional fullness during the second year. Any textural change in hair usually returns to normal

MEGASESSION & HOW MANY GRAFTS CAN BE DONE IN ADAY?

Well with the evolution of Hair Transplant procedure there came more enterprising surgeons and patients who demanded more grafts in one session. In 80s and 90s where most surgeons used to offer 500 to 1000 graft every session and would ask the patient to take multiple sessions. Meaning of Mega session varies from centre to centre; but over 1000 grafts is usually considered as mega session. The limit of mega session depends on many factors:

1. Willingness of surgeon and patient
2. Well trained and well equipped team for taking the endeavour efficiently and quickly. It is well organised effort by a well experienced team only this can be delivered successfully.
3. Donor capacity or density. Every individual’s donor site I different. There are some Asians with the donor density of only 50- 60 Follicular Units per sq. cm where as there are some Caucasians with about 150 FU per sq. cm. density. So there can be vast difference in the number of harvest from the same size of area in both these individuals. Most Asian heads are shorter that the longer heads of the Caucasian and the same may be true for the height of the donor area too. So Caucasians can donate larger area of skin and therefore larger number of grafts too.
4. Donor Laxity: Well tight scalp can not mobilise large strip of skin and therefore laxity of scalp is one very important feature to determine for the mega session.

With all these factors considered there are number of times where over 4000 grafts have been grafted in a day by us.

The main benefits of the Mega session are:

1. Goals accomplished quickly

2. Fewer traumas and damage to donor hair and less donor scars considering multiple scars of smaller sessions

3. More graft harvest than multiple small sessions. Smalller sessions have higher likely damage to the donor follicles while strip removal and also dut to scarring

4. Comparatively less expensive for patient in terms of travel, surgical and off the work time.

Usually it is safe in the hands of experienced surgeon there can be some potential Downsides of Mega session:

1. Necrosis of the skin if it is done without taking in to consideration of the skin laxity.
2. Poor growth: The grafts after harvesting have to be well preserved and should be placed back in the body within 8 to 12 hours otherwise their survival rate goes down. Some times Mega session is done for dense packing of the limited recipient area. The dense packing over the 35- 40 graft per sq.cm. would lead to lower survival rate.
3. Stretched Donor scar if the donor area is closed under too much tension
4. Slightly higher Anaesthesia risk: due to larger dose of Local Anaesthetic agent is consumed in larger area and for longer period of surgery

HIGH SALT IN THE WATER

It is a common myth that salty water causes hair loss. High salt in the water of sea or bore well etc ( or for that matter even chlorine in the swimming pool water) can damage the cuticle ( a tough outer cover of the hair shaft) thereby affect the texture of the hair and may make it dry and brittle. But this water does not reach to the hair root and therefore only the hair outside the skin get affected. The growing capacity and the part of the hair that emerges from the skin does not grow abnormal But most importantly it does not lose its capacity to grow because of high salt. Well had it been so all your hair might have been affected and all that go for swim or all in your area should be bald. The hair loss you are describing is more likely to be due to Genetic and hormonal reasons ( you can make it certain by having your hair mapped for Miniaturization) Due to the stress of your work pressure in your new location this genetic hormonal effects might have aggravated.

WHAT CAN GO WRONG IN HT?

Hair transplantation does not penetrate any body cavities like skull, chest or abdomen. Hair Transplant is a skin surgery & is like taking off moles or warts. In over 550 procedures I have not seen any serious complications happening. The procedure is done under Local Anaesthesia and not general anaesthesia and therefore you are awake all the time and the any serious side effects are practically by passed.

Although the risks are very minimal and serious or long term side effects are exceedingly rare , for the consumers knowledge I have tried to collect extensive list as under:

A: Easily avoidable by a good doctor and patient:

1. Infection of the donor and transplant sites: I have never seen any serious infections as the scalp has a wonderful blood supply which prevents and protects against these infections. This occurs if the sterile techniques are not used ( e.g. disposable needles, sterilized instrumentations etc.) if poor post operative hygiene is kept.
2. Swelling in the operated site: The head may look swollen at the end of the procedure due to the anesthetic fluid in the tissue for a few hours. This gets alright by the next morning. The swelling due to the surgery is a natural reaction after 24 hours but this is usually minimal and lasts for 2-5 days. Mild Swelling after surgery is common. The swelling may work its way down to the eyes three or four days after the surgery this may frightening although it eventually goes away. Sleeping with the face down for first 3-4 days could swell your face by dependent edema- so avoid that position for 3-4 days. Sit with the head bent backwards to bypass the swelling to the back side of head instead of coming to the front. Sleeping on side would make your side swell up due due dependent edema your ear may change the position for a day or two until the swelling subsides. but the use of post-operative steroids may be helpful at reducing or eliminating swelling. Rarely delayed swelling could be due to allergic reaction to the Minoxidil application started post operatively.
3. Itching if the operated site: Seen usually during healing phase so in a way good indicator of healing. This could be due to dryness or allergy to Minoxidil application. This is also temporary symptom for a few days but can easily be taken care of by proper scalp cleaning and supplementing with hair oil or other skin emollient e.g. conditioner for the dry hair, for few days.
4. Flaking: If you do not wash your hair vigorously after 10 days of hair transplant, you will have crusting that may last for a month or more. Dry skin that may follow a hair transplant requires good skin care in terms of shampooing not just hair but also the skin underneath. For people with dry skin and hair may supplement some hair conditioner or hair oil.
5. Reaction.s to the local anesthetic: This occurs if you are sensitive/ allergic to it or if you are given over dose. Even this is exceedingly rare because the medications used like Lignocaine and Sensorcaine are intensively studied local anesthetic agents and have very high safety margin and their safe dosage are well defined. Local anesthetic toxicity can result in seizures, respiratory depression or arrest, hypotension, cardiovascular collapse or cardiac arrest. Paracetamol, aspirin, vitamins, alcohol and other such substances should be absolutely safe, but on very rare occasions, each of these can kill. When used in ‘overdose’ and untreated, these medications (including Lidocaine) can be lethal. This can although very rarely occur esp. in patients who had pre existing conditions, such as gross obesity, known cardiac disease, epilepsy, chronic obstructive pulmonary disease, and liver disease that can significantly affect anesthesia dosage and care. In all such cases most of the adverse events can be avoidable with skilled medical care
6. Mild pitting or tenting around the transplanted hair: this can be avoided by making appropriate size holes and making the appropriate size grafts. Easily avoidable by a good hair transplant surgeon.

B. Occur in spite of the best care by Doctor:

1. Wide scar: Scarring always happens when the skin is cut, but newer techniques of wound closure usually prevent that from occurring at socially detectable levels. With each successive procedure there is possibility of slightly wider scar 5% after 1st 10% after 2nd surgery and more after 3rd. More chances in dark or black people. Rarely do these scars become cosmetically significant unless one shaved his head and in that case, all such scars will be seen no matter how perfect the healing is. Wide scars can best be corrected by planting some FUE hair in the cosmetically visible area and some times hair colored tattoo in the scar helps. People with keloidal tendencies should avoid this surgery.
2. Bleeding: spotting of blood on the pillow the next morning due to some oozing from the stitch area is not uncommon for 2-4 days and is event less and one should keep the stitched area clean by twice daily shampooing for period of 10 days . Some oozing from the recipient site is usual and that requires twice daily gentle shampooing with spray bottle if possible to prevent crusting. Sudden late bleeding from the donor up to 2 weeks could be due to some strenuous activity or that from recipient area could be due to dislodged graft. This may require immediate pressure at the site of bleeding with the clean finger tip for 7 minutes by watch and once it stops you may consult your doctor.
3. Numbness or hypersensitivity above the donor area (This can happen only in strip method due to cut superficial nerves FUE does not have such a problem) or recipient site (usually temporary for 3-6 months – till the new nerve growth takes over). Massage or tapping of the hypersensitive scar help to retain the sensitivity.
4. Redness in recipient area: Generally, the redness goes away after about a week or two. This is due to what is known as "Histamine positive skin". It is the way how your body reacts to irritation with resultant vasodilitation (more blood flows through your skin). This is more common in white or fair skin and very rare in dark or black skin. The good thing is; redness will slowly fade away in few weeks. Use of steroids ointment for a few weeks will expedite this fading. Copper Peptide shampoo may help. A disguising light makeup (Couvre, Toppik or Nenogen) is also useful at times. avoid sun irritation.
5. Failure of the hair to survive the procedure or Poor hair Growth - this happens if there is improper technique or wrong case selection of Hair Transplant (alopecia areata or scarred area. Poor hair growth may be attributed to the smoking during the post operative period because out of those who had poor growth were smokers.
6. Shock loss occurs in the recipient area especially in young( below 30years and females) in first 3 months following surgery. The best way to reduce the risks for shock loss in males is the use of Finasteride 1mg to be taken orally 2-4 weeks prior to the surgery and for the subsequent few months and in females Minoxidil and Low Level Laser Therapy may help beside reassurance. Usually the miniaturized hairs of the recipient area shed and some may be lost permanently.
7. Pimples or Folliculitis or cysts: It is not uncommon to have a few pimples in the first few months as the new hairs grow in. Folliculitis or cysts in the scalp are most often caused by (1) remnants of the previous hairs that were not shed but put below the skin or (2) pieces of the sebaceous glands that are putting out sebum below the skin and collecting below the skin, or (3) grafts that were placed too deeply or piggybacked one on top of the other (4)Ingrown hairs. This is cared for by just keeping the scalp clean. Sometimes popping these pimples yourself works, or doctor can drain the cyst. Wet warm compresses will help. Steroid application may work in initial period of pimple. Sometimes these ingrown hairs have infectious which might require an antibiotic.
8. Wavy or rough transplanted hair: This although rare to see could be due to 1. poor support of sparse transplant 2. bent ir partly folded roots while transplant or 3. microscopic scars in graft is influencing the direction of hair growth and the character of the hair.This usually corrects after one hair cycle (about 3 years). As a temporary solution use of gels, mousses, and good conditioners will help to solve this problem.
9. Difference in color of transplanted hair and the native hair: Donor hair has thicker shaft and have heavier pigments due to lower exposure to sun compared to the hair on the top . As a result sometimes the native hairs may look lighter in color compared to the transplanted hair. This difference usually fade over a period due to bleaching effect of sun on the transplanted hair.
10. Delayed hair growth: On occasional cases the hairs started growing after 8 to even 12 months post operatively. The reasons for that are not accurately known. Minoxidil to increase the scalp blood supply and Laser comb may be of some help at least theoretically

So your biggest risk is in the choice of your surgeon.. Choose a surgeon with a good reputation with proper facilities, experienced staff. Lastly, choose someone with whom you feel comfortable. Do your homework, shop around, make visits to their offices for consultations and ask to see plenty of before and after photos of their previous work.