Realistic expectations are essential to the success of hair transplantation; setting them is the responsibility of both doctor and patient. The doctor must provide each patient with enough information to make an informed decision. This is the doctor’s legal obligation. Every hair follicle lost because of genetic balding (androgenic alopecia) is lost forever. If you compare a head of hair to an apple, as the balding process progresses, parts of the apple are being lost. In cases of advanced baldness (a person with a Norwood Class 7 baldness pattern), such a person has lost up to 75% of the apple and as such, he should not reasonably expect to get a full head of hair back.
It would be impossible for anyone to make 25% of an apple look like 100% of an apple. However, if 20% of the apple was lost, a skilled person could reconstruct the apple so that the missing 20% could be disguised. The goal of a hair restoration procedure is to make a patient appear to have more hair than he actually has. This is where the art form must be balanced against the technical skills of the surgeon.
The combination of art and technique cannot overcome limitations in the quality or quantity of the supply of hair. Generally, the more hair lost, the less full the appearance of the restored hair. All hair restoration procedures, including hair transplantation, actually move hair from one place on the head to another. New hair is not created, but redistributed from the back and sides of the head (where there is an abundant supply) to areas where there is little or none. No surgical procedures create new hair. Scalp reductions do not preserve hair for use in transplants, as some physicians claim, for the same wreath of permanent hair is stretched to cover a wider area in the crown, thereby thinning it. Flaps move large areas of hair from the wreath of permanent hair, leaving significant scarring and distortion of scalp anatomy in the process. Traditional large 4 mm hair transplant grafts, transfer plugs of hair into bald areas, creating patches of hairy skin and thus create the doll’s head look, so commonly associated with hair transplants.
In modern hair transplantation, very small naturally growing groups of hair follicles are moved. These follicular grafts are less noticeable than larger grafts and are often indistinguishable from the natural groups of hair growing in adjacent areas of the scalp. The grafts are placed into a pinhole that may leave no discernible scar. The density of the transplanted hair in its new location cannot equal the density of the hair that was originally in that location. In thinning areas, transplanted hair can significantly increase the apparent density by adding hair follicles or groups of hairs and mixing these with existing hair. The key is to add density inconspicuously. The hair in the new location must appear as full and natural as possible.
Unless a very bald man has a high hair density and a loose scalp, there is not enough hair to cover the entire head. A very thin head of hair, a very conservative, high hairline, and/or deliberately leaving the crown area un-grafted or very thin, may be the only available options; this must be understood when a patient makes the decision to have surgery. This is particularly true if the patient’s hair density is below average. In patients with extensive hair loss and low-density of donor hair, there is no way that transplantation can achieve a full head of hair. Special artistic techniques, however, can exploit what hair remains. Many of these individuals will be satisfied with a high hairline that does not have a distinct edge. This produces a natural but well-framed thin look. High contrast hair-to-skin color combinations make more advanced hair loss harder to restore.
Both the patient and the doctor bring their own expectations to the process. For the patient, there is no substitute for doing proper research into the subject. Patients must accept the responsibility for their actions and choices if they fail to do the necessary research prior to having surgery. Anyone contemplating such services can only protect himself by educating himself.
A patient’s education should include reading general material on the subject that has been produced by the doctor being considered for the transplant service. A review of this material can reveal a great deal about the particular medical group; it will also tell you whether the doctor wants educated patients.
An educated consumer should learn to recognize marketing gimmicks and how such gimmicks can be used to set false expectations in selling hair transplants. Beware of a one-sided, very positive interview. Educating prospective patients and giving them the information necessary, including negative information, to make these very important decisions with confidence is the purpose of the interview with the doctor.
Coverage Goals
The doctor must discuss your hopes and expectations in light of the physical realities and financial constraints of your particular case. NHI affiliated physicians will work with you to develop realistic goals that are possible to achieve. It is impossible to determine exactly how many procedures it will take to accomplish the coverage you may want. Many people change their goals as their perspective changes with more hair. What we call “hair greed” often reflects a high satisfaction with the initial hair transplant and must be calculated into your decision-making formula.
Hairline Design
The doctor should sketch a hairline on your head and photograph you so that you can give your insights on a hairline location that meets your needs, your family and ethnic background, and your budget. The choice of hairline (how high, how flat, etc.) is very personal and depends on your head, facial shape, ethnicity, family characteristics, hair reserves, and personal goals.
In general, it will transplant your hair in a natural distribution, (the way it naturally grows), so you may groom it as you choose. This is realistic in individuals who have above average hair densities and/or more than enough hair to gain the desired coverage for the area being covered. In individuals with low-density hair or an extensive balding area, weighting the hair to one side or the other may produce better coverage from the hair that can be safely harvested. In some instances where a patient has had previous transplants that were improperly distributed, and the patient has a limited donor supply, we may choose to distribute the repair transplants in a way that will most effectively camouflage the existing transplants.
Styling Tricks and Adjuncts
A patient can make his hair appear thicker by using various mousses, gels and wetting agents. In addition, having a permanent can make straight hair wavy. A good hair stylist can make what we might consider poor hair characteristics look like better hair characteristics. In addition, scalp-coloring agents, which come in many product forms, can color the scalp to reduce high contrast between skin and hair color. By combining styling products with the talents of a good stylist and a skilled hair transplant surgeon, many individuals can achieve fuller results than with hair transplantation alone. This is particularly important for individuals who have depleted their donor supplies by having surgery that used older techniques.
Financial Planning with Your Budget
Your financial situation will determine how many grafts or how much work you can afford. You should not rush into the transplant process unless you can afford to follow-up with enough work to leave you with a normal appearance. To facilitate this, it offers various treatment plans and financing programs to patients who qualify. In these situations, the goals of the patient must be based on economics. Often, a patient is inclined to do only the work he feels he can afford rather than to follow the recommended treatment plan. Patients should clearly understand the aesthetic consequences of purchasing less than the recommended number of grafts. The doctor should be inflexible when it comes to creating a “work in progress” that will lead to an unhappy outcome. Hair restoration surgery is elective surgery and because it is elective, there is plenty of time to think about it thoroughly before commencing the process. Normally, a major cause for patient dissatisfaction is associated with moving less hair than was recommended. Often, doctor advises patients to wait until financial resources can be balanced with an appropriate procedure that is designed to meet reasonable goals. The rate of hair loss must also be taken into account, particularly in young men with early, rapid onset balding or thinning.
Financial Planning for the Progressive Nature of Hair Loss
Given the large number of grafts it routinely place in a single session, a patient may find that all the work he or she will ever require is accomplished in a single session. However, the patient’s balding pattern often dictates the necessity of additional procedures. This is the case when the restoration involves following a receding hairline, particularly in a young patient just starting on his balding pattern. After the initial procedure, the patient is committed to additional procedures as his hairline recedes; the patient must clearly understand the financial commitment he is entering into before having his first surgery. Each hair loss patient has a natural stopping point. Completing the restoration process to this point will allow the patient to have an aesthetically acceptable result. Some individuals can stop after one procedure and some cannot. It is imperative that an individual recognize the category he is in before commencing his hair restoration program
Patients with Previous Hair Restoration Surgeries
Unfortunately, more than 1 million men started the hair transplant process with pencil-size grafts. This produced the well-known cornrow or doll’s head look that characterizes the early hair restoration era. In addition, these older procedures were frequently wasteful of hair and produced significant scarring around the sides and back of the head. These early techniques produced cosmetic deformities that may be repaired or corrected with Follicular Unit Transplantation.
1. Hair Restoration History: Your history allows your physician to estimate the required work and the availability of donor hair. The following information is collected:
•Number and type of procedures, names of physicians, and dates,
•Condition of donor area and donor area scars from previous surgeries, and
•Description of current hair systems.
2. Satisfaction and Need for Camouflage: The patient (work-ing closely with the physician) will determine his priorities for additional work. Often focusing on making the hairline look more natural by hiding or removing plugs or scars.
3. Characterization of Donor Area: This critical assessment is needed to determine how much movable hair is left in the donor area. This will determine how much total additional work can be done and the number of grafts that may be attempted in each additional procedure.
4. Status of the Recipient Areas: Each patient should create a list of the goals to be addressed. As the donor supply is often limited, this list will be the basis of a new Master Plan for the repair. Many times, the list may be more extensive than the donor supply can support. Compromises may be necessary, because once the donor supply is fully exploited, further hair restoration procedures will not be possible. This list must not only to itemize the hair coverage issues, but also problems such as cobblestoning, scarring and plugginess. All of the above information will be used to create a unique plan for each patient.
Realities of Rebuilding Your Hairline
Regaining the hair density of your youth is not a realistic goal. Although some doctors may claim that high hair density can be achieved without a “pluggy” appearance, such claims are misleading. There number of hairs that can be redistributed to cover your balding areas is finite.
In addition to the problems inherent in redistributing a limited amount of hair, there are also limitations on how close together transplanted hair can be placed. A relatively thick hairline can give the illusion of more hair and fullness, but achieving this natural appearance is not easy. Auto-transplantation is the science of moving an organ or tissue from one part of the body to another part. Hair follicles constitute an organ that includes the vital support structures needed for the hair to live and grow.
Because of the need to preserve the sustaining organ during the hair transplant procedure; the physician must extract a safe amount of tissue surrounding the follicle. This extra tissue limits how closely hair can be packed together. Though it may be difficult to mimic nature’s density, certain techniques allow the packing of hair to create a natural appearance. In addition to the problems associated with transplanting follicles containing extra tissue, the volume of the scalp also affects the ability to densely pack hair grafts. By placing follicles into the holes placed in the scalp, there is an increase in mass in the area of transplant. If the holes are too close, the insertion of grafts in one section will force grafts out of adjacent sections.
This is a mechanical problem, not a blood supply problem. The skills required to manage this problem well take years to learn; it is for this reason that dense packing is not widely accepted.
Through a series of such procedures, successive groups of small grafts (1-4 hairs) are placed in a way that creates a dense appearing hairline with a normal, soft transition that frames the face. To appear natural, grafts must be graded with 1-hair units in the leading edge and larger units behind the leading edge.