Questions & Answers: Follicular Unit Grafting

Why is the care that I receive from Dr. Rose the best?

Dr. Rose personally meets with patients. Lay consultants are not utilized. Dr. Rose interviews and examines the patient. He reviews the causes of hair loss relevant to the patient and maps out a plan for treatment.

Dr. Rose primarily focuses on treating one patient per day. Some physicians may try to perform surgery on 2 or more patients and treat as many as 5 or more patients in a single day. In such instances it may be very difficult to maintain quality control.

Dr. Rose designs the hairline and donor area. He obtains all of the grafts and performs the suturing of the donor wound if strip harvesting is used. Dr. Rose makes all of the recipient sites and does some of the placing of the grafts. In some instances, he will prepare a portion of the grafts.

In some practices, the technicians may draw in the hairline and suture the donor area. At times technicians have been utilized to obtain the donor strip and make recipient sites.

Dr. Rose emphasizes the use of Follicular Unit Grafting. These grafts are prepared with microscopes. Many physicians state in their advertising that they use follicular unit grafts and microscopes when in fact they do not.

What is the cost of hair replacement?

For Follicular Unit strip harvesting cases the cost is about 4-5 dollars per graft. The larger the hair restoration case, the lower the cost. As an example a 2,000 graft case will cost about 8,500 dollars which includes lab work.

For FIT the cost per graft is about 10 dollars per graft.

Can the procedure be financed?

Yes. A patient may apply for Care Credit, a medical credit card which provides no interest for 12 months.

How long does the procedure take to perform?

Our usual case will take several hours. This can vary widely depending on the size of the case and the ease of placement of the grafts.

FIT cases take longer and typically we can obtain more grafts in a single session with strip harvesting. FIT patients may elect to have two sessions of surgery on consecutive days to reach similar numbers of grafts that can be obtained in a single session of strip harvesting.

During the procedure patients can watch movies, listen to music or simply relax. Preoperative medications are given to help patients relax and be comfortable.

We also provide lunch for patients. We make every effort to provide a comfortable experience for our patients.

Can I have a phone consultation instead of having to travel to the office?

Many of our patients come from out of our vicinity and in fact many come to us who live outside the United States.

In such instances patients can contact us by e mail or phone and their situation can be assessed. We encourage potential patients to send photographs by email or simply send the hard copies so that a more accurate assessment can be given

If a patient elects to have the surgery, we encourage the person to arrive a day or more before the planned procedure to have a consultation in person and review the proposed surgery.

What is Follicular Unit Grafting?

Follicular Unit Grafting is based on recognizing that hairs in the scalp grow in naturally occurring groupings - Follicular Units.

Dr Rose amongst several other physicians developed the techniques utilized in this process. Crucial to the technique is the use of microscopes to prepare follicular units.

To conserve donor hair Dr. Rose uses a single blade technique that he has perfected. The donor tissue is harvested and in the strip harvesting process the tissue is dissected to provide slivers of tissue. These slivers prepared under the microscope are 1-2 follicular units in width. The slivers which are akin to slices of bread are further dissected to obtain the intact follicular units.

The recipient sites are then made with a variety of blades and the grafts are carefully placed into the recipient sites.

Using this technique we routinely place over 2000 grafts in a single session.

What about multiblade harvesting?

With mutiblade scalpels there is a greater rate of transection, essentially damage to the donor hair follicles. Because of the offset of the blades and the change in angles of hairs from one portion of the scalp to another it can be difficult to obtain the tissue without damaging significantly more hairs and disrupting follicular units.

Physicians may use multibladed knives because the tissue can be harvested more rapidly.

Do you make all of the recipient sites before placing the grafts?

The majority of the recipient sites are made at one time. Dr. Rose generally leaves some recipient sites to be made for the end of the case. These sites are used to further refine the work. At times, we may move in stages depending on the degree of bleeding that is experienced in making the sites.

By making most of the sites initially, Dr. Rose can better develop the hairline and general design of the grafting pattern. He can provide a clear course of placement showing where the appropriate follicular units belong. Additionally, bleeding can be better controlled.

Other methods of preparing sites such as “stick and place” seem to make it more difficult to obtain optimal aesthetic appearance. The physician loses site of the overall sense of the recipient area.

Why do some patients complain about donor scars?

There are patients who have had unsightly donor scars. These scars are often wide, stretched out and barren of hair. Some of these occurred years ago when larger sections of donor tissue were taken as compared to the techniques generally employed today. Unfortunately, some physicians continue to take strips that are wider than necessary and the problem is compounded by the clousure of these wound under substantial tension. This can often cause vertical lines across the donor scar where additional hair loss has occurred because of the poor closure.

Dr. Rose finds that the donor scars produced are particularly excellent. The scars are often one mm or two in width and in many instances the scar is not even appreciably visible with the hair lifted and the scalp skin exposed.

Dr. Rose attributes his success to careful examination of the donor area and assessment of the laxity of the skin. He tries to keep the width of the strip relatively narrow. Most of the strip obtained is 1-1.3 cm in width. If there is any concern about the difficuly in closure, one incision is made in the donor area and the tissue released from it’s attachments to the underlying tissue and measured before the second incision is made.This ensures closure made with little or no tension on the wound.

Do mini grafts or large grafts need to be used to achieve density?

Density is the number of grafts used and the characterisitics of the hair. The Follicular units can be placed extraordinarily close (dense packing) Coarse hair provides better coverage than fine hair and light colored hair or grey hair provides better camouflage when used on a person who is fair completed.

A person with fine black hair and fair complexion would require substantially more grafts to give the impression of density as compared to a patient with coarse blond hair and a fair complexion. The contrast between dark hair and a fair complexion provide a greater opportunity for the human eye to pick up on the relative number of grafts.

In patients with light colored, salt and pepper or grey hair and a fair complexion we may utilize paired follicular units or multiple follicular units to try to simulate a greater feel of density.

Assuming there is enough donor hair, high levels of density can be achieved by utilizing follicular unit grafts solely.

By using follicular unit grafts an unnatural appearance can be avoided and patients can stop at anytime in terms of going for more grafts while being assured that the grafting with follicular units will always appear natural.

Can the scalp blood supply support dense packing?

The scalp has a remarkable blood supply. Many people have experienced this firsthand. A minor cut to the scalp and produce substantial bleeding.

The scalp is supplied by six primary arteries and even if 4 or perhaps 5 were tobe cutthe scalp tissue could still be preserved. With this network of vessels 2-3 thousand follicular unit grafts can be supported in a relatively small area such as the frontal one third to one half of the scalp.

Can anything be done to repair work that was done previously?

Yes. We perform many hair transplant revisions. In some instances grafts may need to be removed or partially removed. In rare instances we have to remove a portion of tissue and perform a brow lift.

Often times we can strategically place follicular unit grafts to camouflage the previous work.

In some cases laser hair removal can be employed.

What is meant by shock loss?

On occasion some exiting hairs in a region to be transplanted are shed after the procedure. Most of these hairs will regrow but some hairs that are perhaps near the last stage of cycling before being lost do not recover.

In our hands shock loss seems to occur at a low level. Very few patients seem to notice a significant amount. Dr. Rose attributes this to the technique that we use for making recipient sites and placing grafts

Dr. Rose utilized relatively high magnification with surgical loupes used for cosmetic and microsurgery to prepare the recipient sites. This allows him to see between existing hairs follicular units and find open areas to place the sites.

There is less damage to existing hairs and less of an inflammatory response.

We also use loupe magnification and other forms of magnification to place the grafts. Dr. Rose believes that this further helps to diminish the chance of shock loss.

Can I do anything prevent shock loss?

The chance of shock loss may be further be diminished by using Minoxidil preoperatively and postoperatively. Finasteride may also help.

Can I achieve a natural hairline?

Yes. Dr. Rose has focused a great deal of my research into understanding the elements of composition of the hairline. In fact he was the first to present a lecture and paper delineating the components of a natural hairline. The paper was originally published is and since that time he has added additional elements.

Dr. Rose has lectured extensively on the subject and has taught at numerous workshops on hair line design and other aspect of hair restoration.

Is Dr Rose Invloved in Basic Science Research?

Yes. Apart from his clinical interests, he is also involved in basic science research concerning hair. A field of interest has been “apoptosis” controlled cell death and it’s role in male pattern hair loss. Along with Dr. Michael Morgan at the University of South Florida, Dr. Rose published a paper examining the rate of apoptosis in the occipital scalp versus the vertex in men who are balding.

He is currently involved in a research project studying the effects of low level light lasers on apoptosis. This may help us understand a mechanism of action for these lasers.

What about cloning and other biotechnology?

Dr. Rose thinks that it will be a long time before hairs are cloned. It is far more likely that we will be able to take various mature hair cells and develop larger numbers of these cells and implant them directly or allow them to grow into hairs in a test tube environment and then implant them.

Dr. Rose is working with a company named Intercytex located in England. He has been able to take cells from the dermal papilla which is from the lower portion of the hair bulb and place them in a solution that allows them to multiply. The cells have been placed in mice that do not have an immune system and we have been able to grow human hair

Currently Dr. Rose is undertaking human clinical trials in England and is very optimistic.

He also believes that new medications will be forthcoming that will outperform Minoxidil and Finasteride. Gene therapy may also play a role in treating hair loss.

What about Board Certification?

Many physicians advertise that they are Board Certified. This phrase can be misleading for several reasons. Traditionally the only recognized “Boards” in medicine have been those approved by the ABMS – The American Board of Medical Specialties. This organization is responsible for accrediting medical schools and residency program specialties such as Dermatology and Plastic Surgery amongst others. Physicians who seek to be Board Certified must graduate from approved residency programs which can be from 3-5 years and the candidates must take extensive examinations besides meet various requirements of clinical experience.

Dr. Rose completed a residency in Dermatology at Temple University Skin and Cancer Hospital in Philadelphia. He received his Board Certification in Dermatology which included experience in the diagnosis and treatment of numerous forms of hair loss.

In recent years physicians who for various reasons may not have completed approved residencies or sought certification in areas not considered appropriate for board certification by the ABMS, simply started their own “boards” In fact many physician depending on the sate in which he or she practices can simply start his or her own board in anything. There is no organization to scrutinize the board and no residency or training period is required.

Some physicians advertise that they are board certified in Hair replacement by the ABHRS. This is an organization not recognized by the ABMS. It was started by several physicians some of whom possess boards in recognized specialties and some who had no board certification in any medical specialty. The ABHRS has criteria for membership such as the number of hair transplant cases performed and ACLS. There is an oral and written examination. No residency is in place for training but there are several physicians who provide” fellowships” for physicians who want to learn how to perform the procedure.

Members of the ABHRS appear to have a sincere desire to advance our knowledge and skill in Hair replacement and educate the public.

The ABHRS is an effort to provide credibility for physicians performing hair transplants, especially those who are not boarded in dermatology or plastic surgery.

Other boards exist created by various physicians and again not recognized by the ABMS.

Does Board Certification guarantee competence?

Unfortunately, Board Certification does not guarantee competency. The ABMS boards are supported by the fact that physicians must complete a residency and certain clinical skills must be demonstrated.

The ABHRS requires that candidates provide evidence of performing a certain number of hair transplant cases and some results are reviewed. Physicians who sit for these boards may not have any experience with scalp reductions, flaps, punch grafting or other surgical techniques. Their experience with the diagnosis of other forms of hair loss may be limited.

Is the hair transplantation procedure painful?

Patients are given preoperative medications including diazepam a sedative and vicodin a pain killer. There may be some pain in anesthetizing the donor area and recipient areas initially with local anesthesia. After the first injection subsequent injections are relatively pain free.

Once the initial local anesthesia is given patients generally remain pain free during the rest of the procedure. If the patient feels any pain during the rest of the procedure, additional pain medications can be given promptly

Postoperatively patients may notice some discomfort in the donor area for a day or two. Some patients may not experience any discomfort.

What are the risks?

Hair replacement is a very low risk procedure. The chance of infection is extremely low. On occasion patients may experience some swelling in the frontal area. There can be some altered sensation in the donor area for several months.

There can be some minor bleeding from the donor area and on very rare occasions a hematoma can develop. This is a collection of blood under the skin that may need to be relieved.

Can a hair transplant give me a full head of hair?

Yes and no. This all depends on how large an area needs to be covered and how much donor hair is available.
Patients with extensive hair loss such as those with type V-VI Norwood patterns may be able to have overall coverage but some due to lack of donor hair, may not have dense coverage. Patients with very extensive hair loss who are type VII cannot expect to obtain full coverage. These patients may only be able to have what is referred to as a frontal forelock. This would be similar to Jack Nicholson.

The problem of donor hair availability is one of mathematics and available resources. At birth humans have approximately 80 – 100 follicular units per square centimeter. To notice significant baldness the density may be down to less than 40 follicular units per square centimeter. Depending on the surface area of loss and recognizing that there is a limited area from which donor hair can be taken and a limited number of follicular units, it may be mathematically impossible to restore the original density.

What is the approximate surface area of the frontal area and crown?

For most people the surface area for the frontal area is about 80 – 100 square centimeters.

For the crown the surface area often exceeds 100 square centimeters as well.

The general approach in patients with type 4-6 hairloss is to restore the frontal one half of the scalp and perform an initial session in excess of 30 follicular units per sq cm. This calculates to about 2000 –3000 grafts.

How long should a patient wait in between sessions?

We generally advise that patients wait at least 9-12 months before considering another session.

What is graded density?

This refers to constructing areas of high density and areas of lower density that fit with aesthetic considerations. For instance the frontal hair line area (approximately 1cm) is often implanted at 40+ FUs per sq cm.

Why Does Hair transplantation work in males?

Curiously some hairs in males are genetically programmed to remain. These hairs are less sensitive to DHT. These hairs also retain the ability to continue to grow normally when the hairs are transplanted to another area.

At what age should a person consider hair transplantation?

In general we try offer hair transplants to patients 22 years of age or older. In rare instances, Dr. Rose will consider hair replacements in males younger than 22.

Is every one a candidate for the procedure?

No. Some patients have dermatologic or other medical problems that prohibit us from trying to do a hair transplant procedure. Some patients may simply not have enough donor hair and some patients with diffuse hair loss are not good candidates for the procedure.

What is a scalp reduction?

Scalp reduction is a surgical technique based on cutting out areas of bald scalp to reduce the area of hair loss. There are various designs but most commonly a midline reduction going from the front to the back of the head is utilized.

Scalp reductions were very popular at one time but they have fallen out of favor because some patients had poor scar results.

What is a Frechet extender?

This is an elastic band with hooks in it that can be inserted under the scalp to try to decrease the area of bald scalp. The device pulls the hair bearing skin from both sides of the scalp toward the middle. After the device has been left in place for about 4 weeks it is removed and the excess skin is removed in a scalp reduction procedure.
Sometimes the process is repeated. Once completed the patient may need another procedure to try to restore normal hair direction at the back of the head.
The misdirection can occur because the reduction brings the hair together in a straight line creating a sort of “slot”.

What is the ISHRS?

The International Society of Hair Restoration Society is an organization dedicated to the education of physicians interested in hair restoration. It is composed of over 600 members from all over the world.
The ISHRS has yearly meetings and sponsors multiple workshops each year.

What happens to the hairs after they are transplanted?

During the first few weeks the hairs that were implanted usually fall out. This is NORMAL. The hair shaft is released but the growing portion of the hair remains.
It then takes 3-5 months for the hairs to BEGIN to grow. Significant results may not be visible for 6-9 months. At about 12 -13 months the final results are visible.

When should I begin shampooing?

We recommend shampooing the day after the procedure. We provide detailed instructions on how to shampoo.
We recommend that patients prepare the shampoo in a bowl with water and then apply it to the scalp. The patient should use the pad of the fingers to gently massage the scalp. The shampoo should stay on for a minute or so and should then be removed with warm water (NOT HOT). The water should be poured over the scalp with a bowl. This method should be use for the first week.

What if I lose a graft?

Don’t panic! This can happen the important thing to do is to apply pressure to the site for 5 minutes to stop any bleeding.

What about those white raised areas I see when I shampoo?
The white raised areas are the grafts that have absorbed water. This is okay, but it is important not to stay in the shower for more than a few minutes.

What about hyperbaric oxygen?

There is evidence that hyperbaric oxygen can help wound healing. One could imagine that such treatments may help in promoting the healing after Hair Transplant procedures and may help grafts grow.
There is no data to support any claims at this time but studies are being done.
We offer the treatments to patients who are interested in them. Patients may have treatments before and after the procedure. The cost is about 250 dollars per treatment and most patients will have 5-7 treatments.

What about low level light lasers?

There is a lot of debate about whether low level light lasers might work. A study by Hair Max shows that their laser can promote hair growth. They were given permission by the FDA to make this claim. That said the amount of growth seems to be very variable.
I have seen patients who feel they had some response and others who feel that the device did not work. It should be noted that we do not know if the patients used the device properly and for the recommended amount of time.

Other devices that make similar claims such as Sunetics are available.

It is clear that we do not know the optimal energy, wavelength of light and the amount of time to expose the scalp to the laser to achieve the best results.

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