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Hair transplant training for doctors

Who are the doctors that get formal and comprehensive training in hair transplant? None. When we need surgery for eye, we search for eye surgeons. Doctors that are formally trained in the field of eye surgery. It is taken for granted that only trained eye surgeons would perform eye surgery. Similarly, it is assumed, mistakenly, that only doctors formally trained in hair transplant would offer hair transplant. Any doctor, from any field of medicine, can offer hair transplants. --------------------------------------------------------------------------- Where can doctors get formal and comprehensive training in Hair transplant? In no medical college. In no medical speciality. If modern hair transplant methods were routinely practiced and training offered in medical colleges and the hospitals affiliated to them, we would see patients going to those institutions for their hair transplants. -------------------------------------------------------------------------- Combination of the above two factors is partly responsible for the majority of bad hair transplants we continue to see today. It is a sad but true state of affair that we hope to rectify. But for now, it is important for the prospective patient to be aware of these facts and understand the true reason why it is so important to do their research prior to getting a hair transplant done. Regards, Dr. A  www.fusehair.com

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Trimming of grafts v/s placing them direct

Dear readers, This is another interesting topic. Once the grafts are extracted, should they be implanted as such or should the excess tissue be trimmed. This is even more important for the grafts extracted by the fue method. In my opinion, and experience, it would be very bad if the grafts were not trimmed of excess tissue. The reason is very simple. In older times, recipient holes were made. Nowadays we make recipient slits . There is a crucial difference between the two. When making a hole, tissue is taken out (much like digging a pit in ground). When making a slit, no tissue is taken out (somewhat like an injection needle going in and coming out). So, when a recipient slit is made and filled with an untrimmed graft, one is putting in excess tissue which may likely lead to cobblestone appearance (you are stuffing up a hole that does not exist). One needs to put in the bare necessary minimum to acheive the most aesthetic result. So, in my personal opinion, if someone says that their USP is that they are just extracting the grafts and placing them into recipient slits without touching or trimming them under magnification, they are not only doing less work, they are making a virtue of their lethargy. Remember, we are not transplanting skin. When transplanting follicular unit grafts into slits, its our duty to transplant the follicular unit alone, with bare minimum excess baggage. Regards, Dr. A  www.fusehair.com

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Recipient slits - pre prepared v/s stick and place

Dear readers, This is a topic that is not discussed often. But I feel that it merits attention.

There are 2 basic ways of making the recipient slits. 1. Make all of them at one go, before transplanting the grafts (pre prepared) 2. Make one slit at a time and simultaneously place the graft into the slit. Then proceed to make the next slit and so on... (stick and place method) -------------------------------------------- I personally prefer the first. Reasons 1. All the slits are made at one go keeping in mind the angulations and densities, by the doctor (in pre prepared method). In stick and place method, there is a wide time interval between making the complete slits during which the directions, angles etc. could vary 2. In stick and place method, (unless the procedure is a very small one), the recipient slits would be made by more then one person. That could lead to a difference in aesthetics in the final result. 3. In stick and place method, there is a very real possibility of graft popping out from the previous slit when a new slit is made adjacent to it. Leading to avoidable graft trauma. 4. To avoid this popping out the graft placer may make the recipient slits further apart, leading to a low density transplant ------------------------------------------ In view of the above, I prefer that all the recipient slits be made at one go and do not advise the stick and place method. Regards, Dr. A  www.fusehair.com

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Testing for local anesthetic sensitivity

Dear readers,

It is a vital small detail. In case you have not had local anesthetic ever in your life (or in recent years), a test dose of local anesthetic should be performed before the start of your procedure. While relatively rare, Xylocaine (local anesthetic) sensitivity is something your treating doctor should watch out for. Regards, Dr. A www.fusehair.com

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2 effluviums - a must read

Dear readers,

There is Anagen effluvium and telogen effluvium. Both of these are not classic male pattern baldness. However, its very important to understand about them. A lot of hair loss happenings/coincidences can be explained if these 2 are understood. First, we shall talk about telogen effluvium

Telogen effluvium (TE)  In animals, hair/fur goes into synchronized telogen and are shed. This is called telogen effluvium. It occurs in humans during phases of extreme stress, malnutrition, post pregnancy or when under certain drug therapy. For telogen effluvium to occur a significant proportion of hair have to switch from anagen to telogen at the same time. The hair are shed 2 to 3 months later. Telogen effluvium may be acute or chronic. When hair sheds persistently for more then 6 months, its termed chronic. Chronic telogen effluvium is more common in females. Acute Telogen effluvium is seen in many infants as a band of hairloss around the occiput that occurs 2 to 3 months after birth. In order for a large number of hair to simultaneously switch from the anagen phase into the telogen phase, the body has to undergo some systemic injury. There is usually a lapse of 2 to 3 months between the inciting cause and the hair shed. Therefore, it is often difficult to identify the exact cause in many cases. A telogen effluvium is not caused by topical medications. But because there is a required time lapse of several months between the inciting cause and the excessive shedding of hair, the exact cause of the telogen effluvium is often not positively identified. Hair shed is known to occur 2 to 4 months after pregnancy. This can be considered a classic example of telogen effluvium. Other suspected causes of telogen effluvium include menopause, severe illness, job change, crash diets, major surgery, severe bloodloss, heavy metal poisoning etc. Hyper and hypothyroidism, SLE, end stage renal disease are other reasons. Medications, including anticoagulants, anti inflammatory agents, retinoids, calcium channel blockers etc. are some known causative factors of TE. In all cases, the common factor is some form of physiologic stress several months before the hair shed. Diagnosis  1. Hair pull test : Hold a bunch of hair between the thumb and fingers and pull firmly. Unlike in normal conditions, where 2 to 4 hair may shed, one notices a high number of hair coming out. Usually between 20 to 30. This test will be positive even in the scalp areas resistant to pattern hairloss, like the occiput area. At the same time, note that there are no slick bald patches like in alopecia areata. The hair that get pulled out in the test will be club hair. An obvious history of an inciting cause and the time frame between the physiological insult and the actual hair shed is usually sufficient to clinch the diagnosis. A biopsy is usually not required. Treatment  Telogen is actually a variation of a normal hair shedding process, which occurs prematurely and in a synchronized manner in TE. Therefore, there is little in way of treatment except reassurance. One must eliminate or treat the inciting physiologic event. Assuming there is no repeat of the physiologic insult, the hair should get replaced in 6 to 12 months. In certain cases, telogen effluvium can coincide with early stages of Male pattern hairloss. In such cases, the hair that replace the shed hair may be miniaturized, giving the impression that the inciting physiologic event gave rise to male pattern hair loss. Hair transplant is not recommended treatment for Telogen Effluvium.

Regards, Dr. A www.fusehair.com

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Graft estimates

Dear forum readers, Graft estimates is another important topic for patients researching HT options for themselves. How does the doctor give graft estimates for a patient? The wrong way to do this is to limit the graft estimates to the number of grafts the doctor/clinic can perform e.g., I have come across Norwood 6 level of baldness patient given graft estimates of 2500 grafts at some clinic. What is happening in this scenario? At best, there is a miscommunication. The doctor maybe telling the patient that 2500 grafts is the total number of donor grafts he can perform for the patient. The patient on the other hand may tend to believe that 2500 grafts will give him good coverage (maybe even a full head of hair). So for the prospective patient it is important to keep the following information in mind - The full non balding adult scalp has average 100,000 hair follicles (or 40,000 follicular unit grafts). The numbers may differ among different races. The blond Caucasian have higher number of total follicular unit grafts while on the other extreme are the negroid and the Oriental/fast east people. Nevertheless, one gets a base idea. Now, if you look in the mirror and see that half the original hair have succumbed to the effects of male pattern hairloss (hair have vanished/miniaturised); you would realize that the number of follicular units lost is approximately 20,000 (half of the original 40,000). 2500 or even 5000 follicular unit grafts are not going to return the original head of hair back to you. What you will need to do is sit down with your doctor and devise the sort of hair restoration you plan. Depending on the HT doctor's philosophy and capability, he should let you know the total number of fu grafts available for transplant at his hands. Then he will let you know what he can accomplish with the said number of grafts. If what he can accomplish is alright with your expectations, go ahead. Else, you will atleast be clearly in the picture and may decide that HT is not worth the trouble for you. There is more on this topic but that for later. Regards, Dr. A www.fusehair.com

P.S. - meantime, you may like to research about how much total donor fu grafts YOU have available for use. 

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Scalp donor area stretching exercises

� Sir � � If a patient goes strip surgery and he/she is not doing scalp � exercise,then what would be the effect on scar.Or this exercise necessary � for second surgery for more yield HT. � � Up to how much time or months scalp exercise is necessary. � � Regards � Nitesh

Dear Nitesh, Scalp donor area stretching exercises is a very important topic. The part of the scalp considered safe for donor harvesting by strip has numerous connective tissue attachments to the aponeurosis below it. These attachments do not permit the scalp skin to slide over the underlying tissue and skull. To compare, try pinching the skin over the back of your wrist. You will notice it is very easy to do so. Try doing the same on the scalp skin at the back of the head. You will find it much more difficult. ---------------------------------------------------- Scalp donor area stretching exercises aim to loosen the connective tissue attachments of the scalp skin to the underlying tissue. This helps : 1. Hasten healing as there is less stetch on the suture line, 2. Minimizes the chances of post HT scar widening, 3. Maximizes the grafts that can be extracted in a single strip FUHT procedure. ------------------------------------------------------ Scalp donor area stretching exercises would be beneficial to all. Whether going for the first procedure, or a subsequent one. Let me know if you have further queries. Regards, Dr. A  www.fusehair.com

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Customisation of hair transplants as per the patient requirement

Dear forum readers, This is another often overlooked aspect of hair transplants.

One must spend time with the person and ask him/her what they want. This is one question I ask my patients and they are usually surprised.

Dr. A - What do you want? Pt - Of course, I want hair.   Dr. A - I need to know 1. what bothers you most about your hair, 2. your priorities in terms of the different areas of hairloss, 3. the sort of hairline you want 4. Depending on how much donor you have, how much do you want to use right now given your age and your family predisposition to further hairloss. Pt - You are the doctor, I guess you are the best judge. This is where I stop. Remember, as a hairloss sufferer and as a recipient of a hair restoration, you are the one who is going to look at the results everyday in the mirror. To one person, the bald crown may be more bothersome while another may want a really youthful hairline even if the crown is bald or thinning. This personal psychological aspect is something that you as a patient must communicate to your HTdoctor. Even better, see multiple results, search for a person with hairloss and hair characteristics similar to yours and the resultant transformation and point it out to your doctor that this is what you want. If it is something he feels unrealistic or not possible for you, he will say so. If not, then atleast you will look in the mirror and be able to think that ... yes, this is what I wanted (not that this is what my HT doctor thought best for me). Regards, Dr. A  www.fusehiar.com

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Baldness / Hairloss in women - some basic information

In recent months there has been a lot of enquiries on this topic. So I compiled a basic shortlist. Please do not hesitate to add to the list of causes and possible treatments. I have kept this simple though there do exist other complex and rare conditions that may be causative factor.

Baldness / Hairloss in women Hairloss is becoming increasingly common in women compared to previous decades. Some of the common causes of such hairloss / baldness are : 1. Hormonal �Any changes in female hormone levels can lead to increased hairloss. This can happen in conditions like menopause, surgical removal of ovaries, thyroid problems or sometimes due to prolonged oral contraceptive therapy. Correction of the hormone levels is usually sufficient to treat this type of hairloss. 2. Telogen Effluvium (T. E.) � T.E. is a medical term which means that a lot of hair go into resting/ dormant phase at the same time. Therefore, a lot of hairloss is noticed. The most common incidence in T. E. is seen approximately three months after child birth. This is further aggravated by the stress and insufficient diet that ladies usually resort to nowadays to reduce their weight after child birth.

Other common cause of T. E. is extreme dieting. The good news is that if corrective measures are taken hair lost will grow back. 3. Female Pattern Hairloss (also called Androgenic Alopecia) - This is genetic in nature and is usually noticed in successive generations. In this type, hair is usually lost from the central part area. Medical measures are rarely effective for this type of hairloss. Hair Transplant however can be performed in such case to get growing hair into the balding area does increasing its density.

4. Use of harsh chemicals e.g. for hair straightening, coloring can cause hairloss. 5. Traction alopecia � This refers to hairloss due to continuous traction/pull on the hair. This occurs if hair are tied very tightly e.g., in beads or due to use of hair extensions. Hair transplant can be used to regrow hair in such type of hairloss but the underlying cause should be removed. Regards, Dr. A  www.fusehair.com

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Psoriasis and hair transplants

Scalp Psoriasis Please remember scalp Psoriasis does not cause permanent balding. It may lead to a temporary hair shedding in the psoriatic patches. However, upon remission, the hair grow back in those plaques. When planning a scalp to scalp HT, it's prudent to first treat any Psoriatic patches. Psoriatic patches, most commonly, develop in the back of the scalp (donor area), though may occur as discrete patches in almost any part of the scalp. Treatment of psoriasis in the scalp presents its own unique problems. 1. The hair covering the psoriatic plaques, prevent adequate sun exposure. Sunlight exposure, in form of UV light, is a known treatment for Psoriasis. 2. The presence of hair make application of many topicals difficult and messy. 3. Scalp psoriasis may be overlapped by seborrhoeic dermatitis. Scalp care - Keeping the above things in mind, the following is a suggested scalp care regimen. 1. Go for a buzz cut, if possible. That will help by more UV exposure to the affected area and will make application of topicals easier. 2. Coal tar and Ketoconazole shampoos. Remember that medicated shampoos need to be massaged into the scalp and left in for a longer time. We recommend that you wet your hair first, apply the shampoo and leave it on for 10 minutes before rinsing it off. Coal tar shampoos are sufficient for starting treatment for most scalp psoriasis patients. Ketoconazole can be added if the psoriasis is accompanied with seborrhoeic dermatitis (also called Sebo-psoriasis) and/or fungal infections. Use these shampoos twice a week. For people who do not like the smell of these medicated shampoos, post bath, they can shampoo again with a non medicated shampoo of their choice, followed by a conditioner. That should take care of the smell issue. For those suffering from more severe psoriasis, use of topicals may be required. Topicals may be in form of steroids (Diprovate lotion is easier to apply as it is alcohol based instead of cream/oil base) can be used to alleviate the itching. Prolonged use of steroids should, however, be avoided. Its best to use them intermittently. Coal tar creams, salicylic acid creams and Coconut oil compound ointment are more effective (though messy). Apply these creams by rubbing them into the plaques. Wait for 1 hour and then shampoo them out. Or, apply them before bedtime and leave them overnight. Wash the next day. Resistant or difficult to treat psoriatic patches may require Dithranol, Calcipotriol, phototherapy and oral medications. Please remember that all treatments mentioned above must be taken under proper medical supervision. It's best to go for a hair transplant procedure once the psoriasis is under control. Regards, Dr. A 

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Alopecia areata (& alopecia totalis and universalis)

Alopecia areata occurs in 0.1% of the human population. However, in absolute terms, even that 0.1% is a huge number. Alopecia areata is diagnosed clinically as a smooth patch on the scalp. Hair is usually lost in a matter of days. It is thought to be an autoimmune disorder - that is, the body's immune system starts attacking its own hair follicles in a particular area. Why that happens, and only in a particular area, is not known. In most cases, especially, if the patches are small, they heal on their own. In other cases, steroids have been tried (orally, topically or as intradermal injections) with mixed results. However, the adverse effects of using corticosteroids on a long-term have to be weighed in when deciding to use them. It has been observed that psychological stress aggravates this condition. However, that is an anecdotal finding. In the healing or regrowth phase, it's noted that the hair that grows back is initially non pigmented and thinner. Later, it regains its pigmentation and diameter. In rare cases, the hair loss may spread to the complete scalp. Then it is called alopecia totalis. If hair is lost from the complete body, including eyebrows, nasal and pubic hair, then it is called alopecia universalis. Hair transplant is NOT a treatment for alopecia areata. The only rare situation in which transplant may be performed is if there is a stable, small patch that is not spreading (for atleast 1 year) and has been resistant to medical treatments. More information about this set of hair loss condition can be found at http://en.wikipedia.org/wiki/Alopecia_areata 

Dr. A www.fusehair.com

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Hair loss need not always be baldness/androgenic alopecia

Dear forum readers, I sometimes come across patients suffering from hair loss due to causes not as common as androgenic alopecia. Recently I came across another example of hair loss - this one due to Lichen planopilaris. In most of the instances, I have found that the majority of the medical community is as clueless about the causes and treatments of the less common forms of hair loss as the general population. It is vital that these forms of hair loss be discussed too. It's also important to know when (and if ever) hair transplant can be an option for them. I shall devote the next few posts to these topics. Please feel free to join in the discussion with questions, comments, experiences and suggestions.

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Reducing post operative pain in strip FUHT procedure

Dear forum readers, Pain and tenderness in the strip donor area, especially on the night immediately after the procedure has been performed, is a concern for some patients.

It is a good idea to inject the suture line with Injection Bupivacaine toward the end of the procedure. Bupivacaine is a long-acting local anaesthetic and very helpful in numbing the area overnight. Usually, 1ml is sufficient to lightly infiltrate the entire suture line in a full-length strip wound. Please do discuss this with your hair transplant doctor before going for the HT. Regards, Dr. A 

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I made a song… probably would never have predicted I’d make a song like this :P https://youtu.be/2YWQPnJT4js

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Evolution of hair transplants and some myths

For sake of convenience, I shall summarize the evolution of hair transplants from the 1950s. 1. Plug grafting - 4 to 5mm hair root bearing plugs were excised from the permanent donor area at the back and sides of the scalp and transplanted to the bald scalp, where they sprouted hair. 2. Minigrafts - 4mm plugs were bisected into 2 to 4 pieces. These were called minigrafts. They were transplanted in front of the 4 mm plugs to reduce the visible pluggy effect. 3. Micrografts - The plugs (or strip in some cases), were dissected into 1 to 2mm pieces containing 1 to 4 hair. These were called micrografts 4. Open shotgum harvesting v/s strip excision - Somewhere between the 1970s to 1990s, the open shotgun harvesting was gradually abandoned and replaced with suturing close the extraction site. Gradually the extraction was done in form of a strip. 5. Follicular unit dissection - The grafts were dissected under microscopes in their naturally occurring groupings called follicular units. 6. Follicular unit extraction - Individual follicular units were extracted from the scalp donor area. This did away with the necessity of a suture closure. The extraction tools and sites gradually became smaller. 7. Body hair to scalp transplants gave valuable additional donor hair eventually reaching a stage where the most robust beard donor hair could be harvested and transplanted. 8. All along this time in past about 15 years the number of follicular units that could be transplanted increased. This led to larger transplant sessions giving better hairline designs. The myths or missteps along the way I shall write down separately.

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Experiencing unwanted hair loss after childbirth? It may not happen after every child, but it IS normal. Our new blog post discusses the dilemma of postpartum hair loss and tips for dealing with it: http://bit.ly/2wi6pN0

How to Deal with Postpartum Hair Loss

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Pain in hair transplants

� I want to know on a scale 1 to 10, how painful is hair transplant with 10

� being the most painful? The pictures I see on this board look horrifying � as if someone is being stabbed thousands times in the head.

I think this question would be best answered by patients who have already got the procedure done. However, in brief - 1. Injections of local anaesthesia are given in the donor and recipient areas to render them numb/ pain-free. So, the actual surgical procedure itself is pain-free (even though it may look messy or horrifying in the pictures). 2. In strip FUHT, the sutured donor area will be tender after the effect of anaesthesia wears off at the end of the procedure. Painkillers are prescribed for the same for 5 days. 3. The recipient area is usually pain-free at the end of the procedure. 4. The donor area of FUSE/fue is usually pain-free even after the effect of anaesthesia wears off. There may be minor discomfort or soreness for a couple of days. Most patients do not feel the need of painkillers after a FUSE/fue procedure.