Hair Extensions How To

Eyebrow reconstruction as a hair transplant technique is based on the technology first reported by Krusis in Germany in 1914 and later by the Japanese in the 1930 and 40s. In 1943, Tamara reported that single-hair grafts should be used for the hair restoration as these would look the most natural. Nearly a half-century later, when the most advanced type of scalp hair transplantation consists of using naturally occurring follicular units containing 1-4 hairs, the most refined type of eyebrow transplant still consists of using individual hair follicles. The advance in eyebrow hair restoration lies, therefore, not in the use of individual hairs – this has been known for a long time – but in the adoption of techniques used in scalp hair transplantation that enable the physician to carefully isolate these individual hair follicles from the donor scalp.The specific technique is called stereo-microscopic dissection, and it enables the surgeon to generate a hair follicle that contains all the essential anatomic structures necessary for maximum survival and growth, but that is devoid of the excess tissue that makes traditional grafts too cumbersome for the nuanced restoration of the eyebrows. A carefully dissected single-hair micro-graft, trimmed of excess epidermis, dermis and fat, has the flexibility to be inserted into the tiny opening made with a fine hypodermic needle and placed at an angle almost flush with the skin – two techniques that are essential for the most natural restoration. The tiny recipient sites allow the grafts to be placed very close together. However, when closely placed grafts are angled so acutely, the base of one follicle literally lies under the shaft of the next, so that any extra volume to the graft can leave an unnatural lumpiness on the brow. The slender, microscopically dissected grafts have no volume other than the functional follicle, so they are perfectly suited for this closely spaced, acutely angled graft placement. The Hair Cycle The normal hair cycle varies from months to years; depending upon the part of the body the hair is located. Each hair regenerative cycle has a growth phase called anagen and a resting phase called telogen. The anagen phase for scalp hair ranges from 3-6 years while the anagen phase of the eyebrow hair is significantly shorter. The rate of growth for scalp hairs ranges from .30-.41 mm per day (about a half inch per month), while the growth rate of the eyebrow hair is half of that. When scalp hair is transplanted to the eyebrow, the longer hair cycle of the scalp hair makes it grow to a cosmetically unacceptable long length. This necessitates frequent trimming of the eyebrows that is not only a nuisance, but that produces a cut end that is less elegant than the finely pointed tip of an uncut hair. Over time, the transplanted hair will assume some of the characteristics of the site that it was transplanted into and the length of the transplanted hair will begin to gradually decrease. It is not known if the transplanted follicles will eventually assume the full characteristics of the surrounding eyebrow hair, but work by Wang et al. suggests that influences of the recipient are more significant than was previously thought. Indications for Eyebrow Hair Restoration and ReconstructionA variety of conditions can result in a loss or alteration of the eyebrows. Probably the most common is self induced – caused by repeated plucking of the eyebrows for aesthetic reasons, or less often from a compulsive disorder called trichotillomania. Those who pluck hair as an obsessive-compulsive disorder (OCD) should not be transplanted without addressing the OCD first, since transplanting the eyebrow will fail as the patient returns to old habits. Other forms of physical trauma that may result in loss of eyebrows include car accidents, burn injuries, defects from surgical procedures, and radio- and chemotherapy. Burns or trauma may result in the formation of scar tissue that initially precludes hair transplantation. In these cases, reconstructive surgery may be necessary before the eyebrow hair transplant can be accomplished. Thickened scars may respond to injections of corticosteroids and, once thin, may readily support the growth of transplanted hair. Women with eyebrows that they deem to be too thin occasionally have them tattooed, but this almost invariably looks unnatural. The situation worsens as the pigment is engulfed by macrophages and brought deeper into the dermis causing the black-brown color to take on a bluish hue. The pigment can be successfully removed with lasers, but then the once thin eyebrows become totally devoid of hair. A common dermatologic condition that may cause the loss of the eyebrows (and eyelashes as well) is alopecia areata. This is a genetic, auto-immune condition that manifests with the sudden onset of discrete, round patches of hair loss with normal underlying skin. It can be treated with injections of cortisone, but tends to re-occur.Systemic diseases may also cause the loss of one’s eyebrows and there are also congenital abnormalities that are associated with the absence of eyebrows and/or eyelashes.In some patients, the disappearance of one’s eyebrows is a normal occurrence with age and genetic hair loss results from the progressive thinning (miniaturization) of the hair until it is barely noticeable. For any eyebrow transplant procedure to be successful, one must be certain that the underlying condition that caused the hair loss in the first place has been corrected. Once the hair loss is stable, hair restoration may be contemplated.The Design Persons who seek eyebrow hair restoration (or any hair transplant, for that matter) generally have particular desires, goals and prejudices on what the ideal shape of their hair should be. Creating natural looking eyebrows can be a difficult task because of the differences between a patient’s prejudices and normal eyebrow design. Eyebrows are as different as faces, so “normal” is a relative term. If beauty is the focus for females, there are rules that can be applied to help define a beautiful eyebrow. Men, who are not satisfied with their eyebrow shape, often want their eyebrows to have a special character, such as the look of Albert Einstein. Some men think that bushy eyebrows are the most desirable as they represent male virility or genius. Women, on the other hand, want delicacy and more well defined shapes. These differences in the preferences of each sex must be understood and incorporated in the design of the restoration from the outset. Beauty is not just determined by a specific angle or a precise number of grafts. The art of the restoration requires that the surgeon gets “inside the head” of the patient and understands what he or she wants to achieve. In contrast to balding men, who often cannot remember where their hair was when they were young and who are thus open to any design that will give them hair, the person seeking eyebrow restoration often has very specific ideas in mind. The doctor’s job is to moderate the patient’s perspective and make sure that it is reasonable. Mistakes are in full view and can leave a patient with a problem that may require years of plucking to correct. Proper angulation is the most important aspect of any eyebrow transplant. The hair in the upper part of the central edge of the eyebrow usually points upward to the hairline, while the hair on the lateral aspects points horizontally, towards the ears. The hair in the upper part of the eyebrow should be pointed slightly downward and the lower portion slightly upward, so that they will converge in the middle, forming a slight ridge and resembling the pattern of a feather. The eyebrows must be put in flat, or they will stick out pointing forward. The surgeon controls the direction and the distribution as the hair is transplanted into the eyebrow, and fine skills are required to densely pack single hairs into the small needle tracks that make for an undetectable wound. The TechniqueThe outline of the eyebrow transplant should be carefully delineated using a fine surgical marker according to the design that the doctor and patient had agreed upon during the consultation. Markings should also be used to indicate the directional change of the hair as one moves medial to lateral. It is often helpful to make these markings above the brow (outside the area that will be transplanted) so that they are not lost as the sites are being made. Once the markings are complete, the patient should be given a mirror to make sure that this is what they had discussed and that the design is satisfactory. At this point we find it helpful for the physician to leave the room (another staff member should still be present) to give the patient a few minutes to reflect on the design. A small amount of anesthetic should first be injected in the supra-trochlear and supra-orbital notches to create a nerve block to numb the medial and lateral aspects of the brow. Local infiltration using a mixture of xylocaine or bupivicaine and epinephrine can further anesthetize the area and provide rigidity to the eyebrows. Tumescence enables the physician to keep the recipient sites more superficial and at a more acute angle and minimizes bleeding. Due to the small volume of fluid needed, a separate tumescent mixture is generally not necessary. The use of corticosteroids and other particulate solutions should be avoided when injecting around the eyes. Recipient sites should be created using 20-22g needles (or equivalent instruments), depending upon the coarseness of the hair. If the patient’s scalp hair is very light and fine, 2-hair grafts can be used in the central part of the brow to create extra density, but these grafts should not be placed near the edges. Recipient sites should be created holding the instrument as flat as possible to the skin surface, as there is always some elevation of the graft in the normal process of healing. In making the sites, the instrument should be gripped between the thumb and the first and second fingers and held nearly flush to the skin surface. The instrument should not be held like a pencil, as this will not allow the angle to be significantly acute. The number of grafts needed for the eyebrow hair transplant can vary greatly from as few as 75 per brow to as many as 350. Men generally require significant more grafts than women. It is helpful to make the recipient sites first so that one can determine exactly how many hairs need to be harvested. It is important to remember that follicular units will yield 2-3 grafts on average, depending upon the patient’s donor density.If the donor hair is obtained from a strip, then one should excise 1 cm2 of tissue for every 200 grafts required (since there are approximately 100 follicular units averaging 2.3 hairs each per cm2). If hair is obtained via follicular unit extraction, then the staff should dissect the grafts into individual hairs as they are removed from the scalp, so that the doctor can determine exactly how many are needed. In women, the finer hair in the area over the ears should generally be harvested. In men with fine hair and coarse eyebrows, the area adjacent to the occipital protuberance is usually the coarsest hair on the scalp and may be the best match. The grafts should be inserted using fine jeweler’s forceps under loop magnification. The hair must be literally stuffed, rather than inserted, into the sites, as the site is too small to accommodate both the graft and the forceps. No dressing is required post op and the patient is instructed to sleep with his/her head elevated. The following morning, the patient should gently irrigate the transplanted area to remove any dried crusts. This should be done in the shower at least three times the day following surgery and twice daily for a week. After each shower, an antibiotic ointment should be applied to the brow to help soften any crusts and enable to them to be more easily removed with the next washing. There is often bruising after the surgery that may take a week or more to subside to normal. Bruising is usually most apparent in older patients with significant sun damage.As the transplanted hairs grow they will require occasional trimming. Using a gel or wax will help them keep the hairs flat as the hair has a tendency be unruly, particularly when they first start to grow. As mentioned above, the hair growth will tend to slow down over time and the hair will begin to assume some of the characteristics of the surrounding hair due to influence of the recipient site. Patients should understand that two or more sessions may be required to achieve a desired look. Sessions are best spaced a minimum of eight months apart so that the doctor may have the benefit of seeing the first session actually grow in before planning the second. Challenges of Eyebrow TransplantsWhen eyebrows are transplanted using scalp hair, they invariably retain some of their donor area hair characteristics of shape, shaft thickness and growth rates. If a person has coarse hair and fine eyebrows, a transplant from the scalp may not be a good match, particularly for a woman who requires delicacy of the new transplanted eyebrow. It is possible to decrease the diameter of the hair shaft by trimming off part, or all of the bulb, but this risks producing an irregularly shaped hair. Curly eyebrows from an African American kinky haired person with coarse hair may not produce the directional control that the patient needs in a transplant (as African hair has a strong character, particularly in the coarse haired person). As such, some people may not be good candidates for an eyebrow transplant. With newer placing techniques, it is now possible to place the hair so that the curve is oriented in the appropriate direction. As part of the normal healing process, wounds tend to contract. As a consequence, the cylindrical defect created by the transplanted hair will tend to contract and orient itself more vertically. This will tend to lift the hair slightly away from the skin giving the brow a bushier, unruly appearance. Making the recipient sites at a very acute angle can partially compensate for this, but some elevation may still occur. ConclusionEyebrow transplantation is a safe, out-patient procedure that can significantly enhance one’s appearance. It is particularly helpful for those individuals who have defective eyebrows caused by disease, accidents or that have been self-induced. However, eyebrow restoration is a nuanced procedure that demands technical skills and artistic knowledge beyond that required for the treatment of a balding scalp. For those physicians who have the aesthetic inclination and who are interested in taking time to develop the special skills necessary for this procedure, eyebrow restoration can produce a significant improvement in the appearance of select patients.

Densitometry is a technique that analyzes the scalp under high-power magnification to give information on hair density, follicular unit composition and degree of miniaturization. It can be used to help evaluate a patient’s candidacy for hair transplantation and help predict future hair loss. More recently, video-microscopes have been developed that can project the image onto a computer screen and provide a permanent digital record. This paper describes the value of taking objective measurements, using densitometry or video-microscopy, in the hair transplant evaluation. BackgroundOne of the earliest methods of measuring hair density was devised by Bouhanna, who used camera attachments to create a “phototrichogram,” an ultra close-up photograph of hair exiting the scalp. This method provided the capability to document the quality and quantity of hair shafts.  However, the disadvantage of this innovation was that an assessment could not be done until after the film had been developed. [1] In 1993, Rassman introduced a small hand-held instrument, the Hair Densitometer, to make densitometry easy to perform during a consultation. [2, 3].  The hair densitometer is a self-contained, portable, device that houses a magnifying lens and an opening of predetermined size.  The hair is clipped short (~ 1-mm) and the unit is placed directly on the scalp.  An assessment is made from a standard 10mm2 field.  Multiple measurements taken from different parts of the scalp are often helpful, particularly if there is significant variability from one location to another. [4] An advantage of the hand-held densitometer is that it is inexpensive and readily available to be used during the consultation and can provide immediate information regarding a patient’s candidacy for surgery.   A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler. With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10]. The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss. [10-12] A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler.  With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] [Figure 2]The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10].  The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss.  [10-12]    MiniaturizationNormally, follicular units contain 1-4 terminal hairs of uniform diameter and, occasionally, fine vellous hairs, with the two hair populations being clinically distinct.   In androgenetic hair loss, the action of DHT causes individual terminal hairs in some follicular units to miniaturize, where they begin to decrease in diameter and in length until they resemble vellous hairs. Eventually, these hairs will disappear.  In androgenetic alopecia, hairs in varying stages of involution (and thus of varying diameters) cause these two distinct populations of hairs to merge into one continuum.  The changes eventually cause visible thinning in affected areas, but may initially be detectable only through densitometry.At first, miniaturization involves only one or two hairs in select follicular units, but eventually progresses to involve all the hair follicles in genetically susceptible areas.  It has been the observation of these authors that a shift from focal to generalized miniaturization precedes the actual loss of affected hairs, so that total hair counts remain relatively constant until end-stage baldness. [8]  Said another way, the progressive thinning associated with androgenetic hair loss (particularly in the early stages) is caused by a decrease in the hair shaft diameter of an increasingly larger number of hairs, rather than by the actual loss of individual hair follicles.Miniaturization, unfortunately, can also occur in the back and sides of the scalp.  When it affects a person’s donor area, it will have profound implications for surgery. Although miniaturization in the donor area is a relatively uncommon occurrence in men, it is quite common in women, explaining why so many more men with hair loss are candidates for surgery compared to women.  In all cases, donor miniaturization must be assessed prior to considering surgery.Densitometry MeasurementsDensitometry is extremely helpful in evaluating patients for hair transplantation. When determining which persons are candidates for hair transplantation, it can be used to measure the absolute donor hair density (i.e. # of hairs/mm2), the composition of follicular units (i.e. the number of 1-, 2-, 3- and 4-hair units), and the degree of miniaturization. Although the precise hair density and composition of follicular units will not be known until after the donor strip has been completely dissected, at the time of the consultation, densitometry can tell the doctor the approximate hair density. This will enable him to determine how much hair will be obtained from a certain size strip or how large a strip will be needed for a required number of follicular unit grafts.   Densitometry will also give information regarding the cosmetic impact of the hair restoration.  Other hair characteristics being equal, if a person has a high number of 3- and 4-hair grafts, he/she would be expected to have a fuller hair transplant than a person with predominately 1- and 2-hair follicular units.  For example, a typical Caucasian would have follicular units in his/her donor area that contained, on average, 2.25 hairs each.  If there were 1 follicular unit per mm2 in the donor area (0.9 to 1.0 is normal) then one would need 2,500mm2 of donor tissue for a 2,500 graft procedure. A donor strip that was 1cm wide would need to be approximately 25cm long to contain 2,500 follicular unit grafts.  See the following table. Stereo-microscopic dissection of the donor strip would yield approximately 14% 1-hair grafts, 53% 2-hair grafts and 33% 3- and 4-hair grafts.  The single-hair grafts would be used to create a soft, natural frontal hairline and the 3- and 4-hair grafts would be used in the forelock area to create the appearance of central density.  Small variations in follicular unit density can have a significant impact on the procedure. A person of similar hair shaft characteristics (i.e. hair diameter, color and wave) that had 2.0 hairs per follicular unit, also spaced 1mm apart, would require exactly the same size strip for a 2,500 graft procedure.  In this case, however, the follicular units would, on average, have less cosmetic value and the person should expect a thinner look from the surgery as only 17% of the grafts contain 3- or 4- hairs.  In addition, the ability to create central density via graft sorting would be reduced.  On the other hand, with a donor density of 2.4 hairs per unit, 40% of the grafts will contain 3- or 4-hairs and the ability of the surgeon to create density in the forelock area using only naturally occurring follicular unit will be significant If we look at the total number of hairs contained in the follicular units, we note that for a 2,500 graft procedure, a person with 2.4 hairs per follicular unit will have 1,000 more hairs than a person with a density of 2.0. Densitometry, therefore, gives the physician information regarding the number of single hair units that can be anticipated from a given size donor strip (without having to subdivide larger units) and the degree to which the larger follicular units can create central and forward weighting to enhance the aesthetic impact of the procedure.  Donor Miniaturization  Normally, the donor area shows little or no miniaturization and the density counts described above are useful in predicting both the short- and long-term outcome of the procedure.  However, if genetic hair loss affects the donor area, the situation changes dramatically. Once full-thickness terminal hair begins to miniaturize, the cosmetic value of the follicular unit begins to decrease and the value of the grafts will be diminished.  In other words, just because hair is transplanted, it doesn’t make the hair transplant   permanent – the hair in the donor area must be permanent.      Early detection of miniaturization in the donor area is a warning sign that the donor area is not stable and that the person may not be a good candidate for surgical hair restoration.   If any miniaturization is detected in a young person, i.e. under the age of 25, red flags should go up that their donor area may not be stable.  When miniaturization is noted in a teenager, the risk of developing diffuse un-patterned hair loss (see below) is significant.  In an older adult male, some miniaturization, perhaps up to 20%, is consistent with being a good surgical candidate.  Unlike men, adult women often have significant levels of miniaturization in the donor area, so the mere presence of miniaturization is not necessarily a contraindication to surgery.  However, miniaturization does indicate an unstable donor supply and one has to make a judgment regarding the risk/reward of the procedure. The physician needs to consider the absolute number of full terminal hairs that are available for the hair transplant, the risk of further miniaturization, the area that needs to be covered, and the risk of the surgery accelerating the hair loss.  This is particularly important to consider in women, since hair is often transplanted into an area that has a considerable amount of existing hair – some of which is at risk of being shed from the surgery.  In women, when the risk of continued miniaturization of the donor area is added to the risk of the surgery accelerating hair loss in the area to be transplanted, a far fewer percentage of women are good candidates for surgery compared to men. To think otherwise is disingenuous.  Diffuse Patterned and Un-patterned AlopeciaThe importance of donor miniaturization as a factor affecting a person’s candidacy for a hair transplant was emphasized almost a decade ago in the paper “Follicular Transplantation: Patient Evaluation and Surgical Planning.”[4] In this writing, we described two conditions; “Diffuse Patterned Alopecia” (DPA) and “Diffuse Un-patterned Alopecia” (DUPA). These were first mentioned by O’tar Norwood when he devised the classification of androgenetic alopeica that bears his name.  These two conditions, however, were not detailed in his paper and never received much attention. This was unfortunate because their understanding gives important insights into how to determine who will be a candidate for hair restoration surgery. [5] Diffuse Patterned Alopecia (DPA) is characterized by diffuse thinning (miniaturization) in the front, top, and vertex of the scalp in conjunction with a stable permanent zone. DPA is usually associated with the persistence of the frontal hairline and, in the early stages, the thinning is relatively even across the top of the scalp. This contrasts with regular Norwood patients that have early hair loss at the temples and in the crown with balding that spares the top of the scalp. Patients with DPA can be good candidates for hair transplantation due to their stable permanent zone; however, they have an increase risk of shedding after the hair transplant, due to the diffuse miniaturization across the top of the scalp.   In the less common Diffuse Un-patterned Alopecia (DUPA), the miniaturization process occurs over the entire scalp, so that the person lacks a stable permanent zone. People with DUPA tend to lose their hair at an early age, often beginning in their teens. In the early stages, there may be only a slight suggestion of decreased hair volume overall and actual thinning may only be noted through densitometry. Over time, the back and sides of the scalp can take on a transparent appearance, particularly when the hair is cut short. Because the donor area is not permanent, hair transplantation is contra-indicated in patients with Diffuse Un-patterned Alopecia.    Although fully manifest diffuse un-patterned hair loss is relatively uncommon in men, there are many younger patients who have slightly increased degrees of miniaturization in the back and sides of the scalp, making the long-term stability of the donor area questionable. In these patients, the decision to recommend hair restoration surgery is particularly difficult.  As a general rule, if the decision is difficult, it is best postponed, since, over time, the stability of the donor area will become more obvious.  A mistake can leave the patient with transplanted hair that will thin over time and a donor scar(s) that may become visible. Both Diffuse Patterned and Un-patterned alopecia also occur in women. However, in contrast to men, the DUPA pattern in women is much more common, possibly occurring 10 times as frequently as DPA.  As in men, female patients with DUPA are not good candidates for a transplant, except in the instance where the goal is solely to soften the frontal edge of a hairpiece. The high incidence of Diffuse Un-patterned Alopecia in women partly explains why many fewer women are good candidates for hair transplantation as compared to men.  It is important to emphasize that other, non-genetic, causes of hair loss must be considered in cases where the balding pattern is diffuse.  These include anemia, thyroid disease, connective tissue disease, gynecological conditions, severe emotional events, and medications. Although the presence of miniaturization likely points toward a hereditary cause of the hair loss, with diffuse hair loss other etiologies must always be entertained. ConclusionDensitometry is an important tool for the evaluation of hair loss and for assessing candidacy for hair transplantation.  Measuring donor density and assessing the degree of miniaturization in the donor area should be an integral part of the evaluation of every patient in which surgical hair restoration is considered. This will enable physicians to better select those who are good candidates for a hair transplant and help identify those patients in whom the procedure is contraindicated.  For patients having a hair transplant, these measurements will enable the physician to better estimate the size of the donor strip and be better able to anticipate the aesthetic outcome of the hair restoration procedure.   References 1. Bouhanna P: Phototrichogram: a technique for the objective evaluation of the diagnosis and course of diffuse alopecia. In W Montagna et al. (eds). Hair and Aesthetic Medicine. Roma, Salus Ed. 1983: 277-280.2. Rassman WR, Pomerantz, MA. The art and science of mini-grafting. Int J Aesthet Rest Surg 1993; 1:27-36. 3. Rassman WR, Carson S. Micro-grafting in extensive quantities; the ideal hair restoration procedure.  Dermatol Surg 1995; 21:306-311.4. Bernstein RM, Rassman WR, Seager D, Shapiro R, et al.  Standardizing the classification and description of follicular unit transplantation and mini-micro-grafting techniques. Dermatol Surg 1998; 24: 957-63. 5. Stough DB, Haber RS. Hair Replacement: Surgical and Medical. St. Louis: Mosby-Year Book, Inc., 1996: 139-140.6. Van Neste D, Dumortier M, De Coster W: Phototrichogram analysis: technical aspects and problems in relation to automated quantitative evaluation of hair growth by computer assisted image analysis. In Van Neste D, Lachapelle JM, Antoine JL (eds). Trends in Human Hair Growth and Alopecia Research. Dordrecht, Kluwer Acad. Pub, 1989: 155-165.7. Hayashi S, Hiyamoto I, Takeda K: Measurement of human hair growth by optical microscopy and image analysis. Br J Dermatol 1991; 125:123-129.8. Bernstein RM , Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32. 9. Bernstein RM, Rassman WR: The logic of follicular unit transplantation. Dermatologic Clinics 1999; 17 (2): 277-95. 10. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. 11. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99. 12. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365.

In our experience, patient expectations are most often influenced by the patient’s age, stage of hair loss, and its rapidity. The young patient (those in their 20’s) with the memory of their adolescent hairline and density still clear in their minds, are also the ones most susceptible to rapid, significant hair loss and are the patients that need the most time in the education and planning process. Other factors include the person’s social situation (such as how he is perceived by significant others), and how he has been dealing with his hair loss (such as using a hair piece or the continuous wearing of a hat). It is incumbent upon the physician to educate the patient and set his expectations correctly, or the patient may never be satisfied. The patient should not be led to believe that hair restoration surgery will restore what has been lost. In the ideal situation, hair restoration surgery should maintain the patient’s adult appearance and give him the same “look” as he would have had if he had simply “matured.” The surgery should never attempt to restore the patient’s adolescent appearance. At a minimum, it can keep the patient from perceiving himself as being bald. In a patient who is distraught from extensive hair loss, this alone can be a significant accomplishment.The young, rapidly balding patient poses perhaps the greatest challenge. Even an extensive procedure may not be able to compensate for the loss that can occur during the year it takes for the implants to fully grow. In this patient especially, understanding every aspect of the dynamic nature of the hair loss is critical. The progressive nature of balding, realistic hairline placement, the sparing of the crown, and the possible acceleration of loss from the surgery itself must be clearly explained. If the patient does not grasp each and every one of these ideas, it is better to postpone the surgery. Time is always on the physician’s side, since the progression of the patient’s hair loss will make each of these issues more tangible to the patient, simplifying the education process. At the other end of the spectrum, the patient who has been bald for many years is much easier to satisfy since his expectations are generally reasonable, and modest amounts of hair will produce a marked change in his appearance. However, this same patient who has worn a hair piece for many years identifies with this look and is much more difficult to please. Like the very young patient, his reference point is a full head of hair. If this patient’s only goal is to be rid of the hair system, it is critical to determine the necessary amount of coverage that would be needed to accomplish this. If this has not been established beforehand, a transplant that might be perfect in every other respect, will be a total failure if the patient still feels compelled to wear his hair piece. Different problems are presented by patients with more limited hair loss. The person who presents with recent progression from an adolescent hairline (Norwood Class I) to a mature hairline with natural recession at the temples (Class II), should not be transplanted. It should be explained that this evolution is normal and a flat hairline would look unnatural as he ages. In this patient, one should not attempt to “fill-in” the temples. It also may not be appropriate to transplant a young, early Class III patient. However, in an older Class III patient with stable hair loss, above average density, and without a familial history of significant balding, it would be appropriate to blunt the angles produced by the bitemporal recession, but not to eliminate it. A final issue regarding expectations is related to the time frame in which the patient expects to see the results of his procedure. The normal follicular growth cycle is quite variable. In most patients, the majority of the transplanted hair begins to grow at about 3 to 4 months after surgery, with additional hair appearing over the next several months. In a small percentage of patients, the onset of growth of the bulk of the hair can be seen from 4 to 8 months or more, with additional new hair occasionally appearing up to 18 months after the transplant. Since newly transplanted hair will increase in diameter and in length, in this subset of patients, there may be continued cosmetic improvement for up to two years. There has been much speculation regarding this so called “delayed growth,” and it appears that a number of factors may be contributory. Although still speculative, some of these include: 1) the normal asynchronous nature of human follicular growth cycles, 2) the possible resetting of the growth cycle after the post surgical effluvium (shedding) to a new full cycle, 3) the staggering of hair re-growth after the post surgical shedding, 4) retarded growth as a result of graft trauma such as temperature change, desiccation and crush injury, 5) amputation of the dermal papillae during graft dissection with a time lag for it to regenerate from the bulb, and 6) local factors causing delayed growth, such as the often asymmetric elastotic changes in the skin caused by the sun reaching the unevenly protected balding scalp.Carefully controlled studies, some of which are already in progress, will be needed to sort out the relative importance of each of these factors. Regardless of the cause, it seems that great individual variability is an integral part of the transplantation process. This must be clearly explained in advance in order to keep our patients from becoming “impatient” after hair transplant surgery.The Critical SessionRegardless of how many procedures are planned, we feel that one should always regard the first transplant as the critical procedure. The patient views the first session as a statement of future sessions. The first session builds confidence, so it is essential that expectations are met. The first session is the most important, for it is the one that generally establishes the hairline and frames the face. The initial transplant also places hair in a position to camouflage subsequent procedures. In our experience, for the majority of patients, establishing the frontal hairline is the single most important function of the first procedure. At the outset, the frontal hairline should be placed in its normal, mature position. The hairline in this location should frame the face and restore a balance to the patient’s facial proportions in a way that is appropriate for a mature individual. In our opinion, the common practice of creating a hairline significantly above the mature hairline position with the intention of lowering it in a subsequent procedure should be avoided. If the intent is to conserve hair in anticipation of a very limited donor supply, one could still maximize the cosmetic impact of the surgery by creating more bitemporal recession or not extending the transplant as far back toward the crown. However, the position of the mid-portion of the frontal hairline should not be compromised, as this defines the “look” of the individual. Creating a hairline too high (in the hope of conserving donor hair) only accentuates the patient’s baldness by enlarging the forehead and distorting the normal facial proportions.The other major goal of the first session should be to provide coverage to the remaining bald scalp with the exception of the crown. Since the Norwood Class A patients, by definition, do not have hair loss extending into the crown, if possible, their entire bald area should be treated in the first session. The amount of hair needed to cover the front and top of the patient’s scalp will obviously vary depending upon the extent of baldness, but there should always be an attempt to cover these areas in the first session, even if the coverage is light. In general, areas of the scalp which already have adequate coverage should not be transplanted. Although the edges of the transplanted area should be blended into the hair bearing skin, too aggressive encroachment may accelerate hair loss and not offer any additional cosmetic benefit. The goal should not be to restore adolescent density, since this is neither necessary from a cosmetic standpoint nor (as we have discussed) mathematically reasonable. Patients desiring adolescent density should be treated the same as those desiring an adolescent hairline. They should be further educated rather than ushered off to surgery. In general, crown coverage should not be a goal of the first session, but should be addressed after the cosmetically more important front and top have been adequately transplanted. Since the front and top of the scalp are together a single cosmetic unit, the transplant may stop after this area has been treated. The patient can then evaluate for himself the adequacy of coverage from the first procedure, and if he desires more fullness or greater density, a second session can be used to supplement the area transplanted in the first. If crown coverage is attempted in the first session, the patient’s options will be much more limited, and the ability to produce an aesthetically balanced transplant might be permanently eliminated. An exception would be patients of Norwood Class III Vertex and Class IV, who are generally over the age of 30, have less risk of becoming extensively bald, and have good donor density and scalp laxity. In these situations, transplanting the crown in the first session can provide modest coverage to the area and will serve to camouflage a limited amount of further crown balding. What should be avoided in these patients is the risky practice of repeatedly transplanting hair into the crown to achieve a high degree of density, as this density can often not be supported as the balding progresses. Beside the aesthetic issues which make the first session so important, there are many surgical advantages of working on a virgin scalp. In sum, implants can be placed more easily, more securely, and closer together into a normal scalp, since the blood supply and elasticity of the connective tissue are intact. In the donor area, maximum density and scalp mobility as well as the absence of scarring will facilitate a hairline closure. To take advantage of these factors, one should attempt to achieve, in the first session, as many of the patient’s goals as possible. In our opinion, what can safely be accomplished in one procedure is best done in one procedure, and should not be spread out over two or more.When Should a Single Session Transplant be Considered?A great deal can be accomplished in the first session. However, one must be realistic in anticipating what goals may be achieved with a single surgical procedure and in which patients these goals are possible. As stated, we feel the main goals for the first session should be: 1) to provide a frame for the face, 2) to provide coverage to the front, and, when appropriate, the top and vertex of the scalp, 3) to have a totally natural appearance. In general, for the physician to suggest to a patient that he might be satisfied with a single session, he should have relatively stable hair loss. This is especially important in the Norwood Class III, IIIa, IV, and V patients whose own hair contributes to the cosmetic appearance of the front of the scalp. In patients who have little frontal hair, the first procedure may successfully frame the face and provide coverage to the anterior portion of the scalp so that even with further balding, a second procedure would not be immediately necessary. For Norwood Class VI or VII patients in which the front and top of the scalp are adequately transplanted in the first procedure, satisfaction can be achieved in one session, because further expansion of the bald crown is relatively inconsequential. However, if coverage of the crown was attempted, then as the bald crown expands, the centrally transplanted grafts would become an isolated island of hair, and further surgery would be required. A patient with lighter hair color will also have a greater chance of achieving his goals in one session as these colors reflect light and give the appearance of more hair. In addition, the low contrast with the underlying skin gives the illusion of more hair since the skin serves as a “filler” for the space between the hair shafts. In contrast, dark hair over light skin accentuates any spaces between the strands of hair. Salt and pepper hair works both by reflecting light and by creating another visual detail to detract from areas of sparseness. Certainly any patient who does not possess the genetic attributes of good hair color can easily change the color to complement the surgical procedure. Wavy hair will generally provide better coverage than straight hair and is beneficial in the transplant. As with hair color, this can be manipulated after the surgery to improve the cosmetic impact of the transplant. Very curly hair, on the other hand can, on occasion, work to the patient’s disadvantage if complete coverage of the bald area is not anticipated. Very curly hair may increase the fullness of the transplanted area to such a degree that contrast with any remaining bald area may be accentuated. In addition, very curly hair transplanted to the front and top of the scalp may not be easily combed back to cover a bald crown. The follicular density in the donor area will also impact the procedure. In patients with high density, there will be more hairs per follicular unit, and thus each implant will contain more hair. In patients with very high density, a significant proportion of implants containing 3 and 4 hairs each can be harvested from the donor area, giving a wonderfully full appearance, even from a single procedure. Patients with hair of average or above-average diameter will have the best chance of success with one procedure. The cylinder of skin surrounding the follicular unit of a patient with coarse hair is roughly similar to a unit of fine hair; however, the volume of hair is vastly different. The diameter or “weight” of the patient’s hair is a huge variable. Whereas density may vary by a factor of 3 fold, hair weight may vary from patient to patient by many times that. Although it is much easier to quantify the density (number of hairs/mm2), rather than the weight of an individual hair, the latter is probably more significant to the outcome of the procedure. Those patients with early balding who have fine, dark hair of high density are very difficult to satisfy in a single session, since the transplanted hair is often viewed against the background of the patient’s thick terminal hair population that surrounds the bald area. By contrast, in a similar patient with coarser hair, satisfaction is more easily achieved in a single session.Contrary to what one might expect, the extensively bald patient, even with low donor density, can often be very satisfied after one procedure. These patients often have very reasonable expectations and after being bald for many years are ecstatic to have hair framing their face, light coverage on top, and “something to comb.” In order for expectations to be met in one session, the realities of the supply/demand situation must be taken into account. It is obvious that for individuals in the Norwood Class VI or VII pattern, only light to modest coverage can be achieved in a single session, since the area in need of hair will exceed the total donor supply by a factor of at least 6:1, even under ideal circumstances. Finally, grooming patterns will also influence the success of a single procedure. Patients who plan to comb their hair to the side rather than straight back will have the appearance of much more fullness. Unfortunately, this hair style will not provide crown coverage. Many patients achieve the “best of both worlds” by combing their hair diagonally backwards.References:1. Bernstein RM, Rassman WR, Szaniawski W, Halperin AJ. Follicular transplantation. Int J Aesthet Rest Surg 1995; 3:119-132.2. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975;68:1359-1365. 3. Rassman WR, Carson S. Micrografting in extensive quantities; the ideal hair restoration procedure. Dermatol Surg 1995; 21:306-311.4. Headington JT: Transverse microscopic anatomy of the human scalp. Arch Dermatol 1984;120:449-456. 5. Kim JC, Choi, YC. Regrowth of grafted human scalp hair after removal of the bulb. Dermatol Surg 1995; 21:312-313. 6. Limmer BL. Relating hair growth theory and experimental evidence to practical hair transplantation. Am J Cosmetic Surg 1994;11:305-310.7. Seager D. Binocular stereoscopic dissecting microscopes: should we use them? Hair Transplant Forum Int 1996;Vol 6 No 5:2-5.8. Limmer BL. Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation. Dermatol Surg 1994;20:789-793.9. Kuster W, Happle R. The inheritance of common baldness: two B or not two B? J Am Acad Dermatol 1984;11:921-926. 10. Rassman WR, Pomerantz, MA. The art and science of minigrafting. Int J Aesthet Rest Surg 1993;1:27-36. 11. Demis DJ. “Clinical Dermatology.” Philadelphia, PA: J.B. Lippincott Co. 1994, (1) 2-35 p3. 12. Bernstein RM. Are scalp reductions still indicated? Hair Transplant Forum Int 1966; Vol 6(3):12-13.13. Bernstein RM, Rassman WR. What is delayed growth? Hair Transplant Forum Int 1997; 7 no.2.14. Cooley J, Vogel J. Loss of the dermal papilla during graft dissection and placement: another cause of x-factor? Hair Transplant Forum Int 1997; 7:20-21.

Natural PatternTo a large extent, the correct template for hairline placement, hair distribution, and density has already been supplied by nature. The closer one follows the pattern set by nature, the more natural the hair restoration will appear. A hair transplant no matter how dense or how perfectly executed will look artificial unless it produces a look that others can recognize as one they had seen before. Just as the follicular implant attempts to mimic the way hair grows in nature on a microscopic level, the overall design of the follicular implantation should strive to mimic nature on a gross level. The power of “The Isolated Frontal Forelock” recently described by Marritt and Dzubow lies in the fact that they identified a pattern seen in nature that was reproducible within the limits of the patient’s donor supply. However, the use of larger grafts for the dense posterior component limits the amount of available donor hair, and creates a natural look only when disguised by the anterior component. The main limitation of flaps and scalp reductions (even in the best of circumstances where there are no complications) are that although they achieve high density, there is no natural counterpart to the distribution they produce. Flaps bring the patient’s donor density to the frontal hairline, with a sharp demarcation anteriorly and posteriorly, a pattern never seen in nature. This area of high density must then be supported by a similar density around it to look natural and, of course, if the patient had enough hair to accomplish this, he wouldn’t have needed hair restoration in the first place. The scalp reduction, although appealing on a superficial level (“remove the bald area so there will be less area to transplant”), violates the same rules of nature as does the flap. A scar is placed in an area that should have light coverage (if any), the direction of hair is changed, the pattern of future balding of that crown will be altered, and donor density is decreased. In effect, scalp reductions are a “crown transplant” and thereby reduce the hair available for the cosmetically more important front.We feel that the optimal way to plan a hair transplant procedure would be to first assess the patient’s present pattern of loss and to anticipate his possible future pattern (considering his present age and familial hair loss patterns) using the worst case scenario as a reference point. Next, determine a person’s total donor reservoir of hair (taking into account absolute donor density, degree of miniaturization, hair groupings and scalp mobility). Then, carefully analyze his specific hair characteristics which affect the appearance of fullness and naturalness (such as wave, hair shaft diameter and skin/hair color contrast). With this information in hand , one can realistically plan how far back in time one can go along his hair loss continuum, given the patient’s particular resources. For example, a 55 year old Norwood Class 4 with a donor density of 2.3 and 20% miniaturization in the donor area and wavy hair, may be safely restored to a Class 3 using 1700 follicular units. On the other hand, a 23 year old Class 5 patient with a donor density of 1.9 and 35% miniaturization in the donor site, with fine, straight hair should be restored to a Class 3 Vertex, rather than a regular Class 3. using 1500 follicular units. In this situation, we would use 1500 follicular units and leave the crown untreated. If he were to bald extensively, he might end up years later with an isolated tuft of hair in the crown, without enough donor reserves to complete the hair transplant. Frame the Face and Spare the CrownThe patient judges the success of his hair restoration by its ability to enhance his appearance, which is in large part based upon the ability of keeping his facial features in proportion. In this regard, the second important element in proper planning is to make every effort to “frame the face”. Transplants which add density to a hairline placed too high (in the hope of conserving donor hair) only accentuate the patient’s baldness by elongating a bald forehead. It frames the forehead rather than the face. We generally place the frontal hairline one fingerbreadth (2cm) above the uppermost brow wrinkle (mature hairline). It is important to differentiate this from the patient’s original hairline which sits directly above the brow wrinkles, lacks bitemporal recession, and should not be used as a landmark for planning the hair transplant. When the donor supply is limited, it is much better to compromise towards the crown than to compromise the critically important position of the frontal hairline.The decision to transplant the crown is an important one, because compared to other areas of balding, it is the least visible but occupies the greatest area. The progressively balding crown can produce huge demands upon the donor supply, and because this area is also the least stable, hair must always be reserved for this eventuality. Furthermore, the crown expands centrifugally, rather than in the predominantly anterior-posterior direction of the front and top, with the center of the crown always having the least amount of hair and being surrounded by areas of increasing densities. Because of this, any hair placed in the center of a balding crown can result in an island of hair surrounded by a moat of bald skin. To correct this, hair of increasing density must be added around it to be aesthetically balanced, consuming vast amounts of hair that could be better saved for the front. Because of these issues, we generally reserve treatment of the crown for older patients with above-average donor density and stable hair loss of Class 3 Vertex, Class 4, and Class 5, or patients of Norwood Class 6 with high donor density and good scalp mobility. If extensive balding is a possibility, it is always best to treat the crown as an extension of the top, rather than as an isolated region to ensure that you will not be short of hair if the intervening region were to bald. Eliminate ContrastThe next element in planning the follicular transplantation is the elimination of contrast. We have already gone to great lengths to illustrate how eliminating contrast on the “micro” level is important, i.e. eliminating the contrast between the individual graft and the surrounding skin. It is equally important to eliminate contrast on the “macro” level, i.e. between one part of the scalp and the other. One of the most striking features about the balding process is that practically all of the Norwood Class A patients look aesthetically worse than their regular Norwood counterparts. In fact, most Norwood Class A patients look worse than patients in the next higher Norwood Class, in spite of the fact that those patients have more hair. Thus, a Norwood Class 4A often looks worse than a Class 5, and a Norwood Class 5A often worse than a Class 6. Clinically, we find that the Class A patients are often the most distraught over their hair loss and benefit most from the hair transplant procedure. The reason for this is simple. In the Class A patient, there is the greatest contrast between the hair bearing area and the totally bald scalp. Curly or wavy hair increases the clinical appearance of density. In the regular Norwood classes, a curly or wavy haired patient will look less bald, because any slight coverage on top will be magnified by the character of the hair. In contradistinction, curly or wavy hair will make the Class A patient look more bald, because in this patient it will accentuate the contrast. The same reasoning helps to explain why an older patient looks better as a Class 6 than a younger patient. The younger patient has had patterned androgenetic effects causing hair loss in the bald area. His donor density is essentially unchanged. The older patient, however, has had hair loss due to both patterned androgenetic balding as well as loss due to the aging process itself, the latter affecting the “permanent zone”. In addition, the older patient has a higher degree of miniaturization in the donor area, which further reduces the contrast. Furthermore, the younger patient with higher donor density will look balder than his Norwood counterpart with lower density. In patients of all ages where the bald area is too extensive to be covered by adjacent hair, the patient’s cosmetic appearance is generally enhanced by keeping the hair short, which is just another means of decreasing the contrast between the two areas. Fortunately, the higher the density of the permanent zone, the worse the bald areas look in comparison, but the more hair there is available to transplant. In a sense, hair transplants do not add hair, they decrease contrast by moving hair around. AngulationThe single most useful clue to proper angulation is to observe the patient’s existing hair. Even in very bald areas, a few vestigial hairs will often indicate the original orientation of the terminal hair. When this information is not available, the safest direction to follow, aside from the crown, is generally forward. The majority of hair anterior to the crown points forward with the angle becoming more acute anteriorly. The direction of the frontal hairline is also forward, rather than radial, and only deviates significantly from this as one approaches the temples. Horizontal placement of the frontal hair is usually appropriate, regardless of the slope of the forehead. Follicular implantation provides almost unlimited freedom in choosing the angle at which the future hair will emerge from the scalp. This is because the mechanical forces facing the larger grafts placed at acute angles do not affect the follicular implant. The delicate swirl of the crown, the abrupt directional changes of the cowlick, and the sharp angulation of the temples, can all be re-created with follicular implants. The challenge is not merely creating these angles, but observing the myriad of patterns seen in nature so that this variety can be duplicated for our patients. DistributionIn almost all cases of balding, there is a rationing of donor hair due to the necessity of covering an ever expanding recipient area with a much smaller, but finite, donor supply. We try to evenly space the individual units in a random rather than grid-like pattern and always try to increase the density in the areas of cosmetic importance. In doing so, we remember the adage “To cover a baseball field with grass, use seed rather than sod….., and if you only have a limited amount, use it in the infield.”

INTRODUCTION -Although follicular unit transplant eliminates many of the shortcomings of older surgical hair restoration techniques, such as a “pluggy” look, a “moth-eaten” donor area or midline scalp reduction scars, poor aesthetic judgment and techniques that compromise graft growth can still lead to problems. Perhaps because follicular unit transplant requires large numbers of grafts (using a significant portion of the donor area at one time), because so many staff members are involved in the process, and because some of the problems of small graft procedures are very difficult to correct, improperly performed follicular unit hair transplantation can pose a greater risk to patients than traditional grafting. The risk is compounded by the fact that many physicians perceive follicular unit transplant as a safe, risk-free procedure and describe it to patients as such. The remainder of this section will focus on some of the most common mistakes made by follicular unit transplant practitioners, particularly in the areas of planning, hair transplant design and handling large numbers of small grafts. These problems and how they may be avoided are summarized below. 1. Operating on patients that are too young or prior to medical therapy2. Failing to identify low donor density prior to surgery3. Failing to identify a tight scalp4. Harvesting a donor strip that is too wide 5. Placing the donor incision too low or too high6. Using a multi-bladed knife7. Crushing grafts during insertion8. Allowing grafts to dry 9. Placing the frontal hairline too far forward10. Creating a hairline that is too broad11. Angling hair in the wrong direction12. Attempting to cover an area that is too large Operating on Patients That Are Too Young or Before Medical Therapy – Patents in their early twenties have their flat adolescent hairline and original density fresh in their memory. A hair restoration designed with enough frontal and temporal recession to look good ones entire life will rarely satisfy a younger patient. Creating a density that is ideal for a younger person will not leave enough hair in reserve if there is further loss. In addition, at this age the extent of future balding is difficult to even reasonably anticipate. For these reasons, a hair transplant should rarely be considered in patients with androgenetic alopecia younger than 25 years old. Often a hair restoration doctor begins medical therapy and schedules surgery at the same time. However, if there is a possibility that using a medication, such as finasteride (Rogaine), can make hair transplantation unnecessary, then the medication should be used for at least a year before any decision on surgery is reached. Medication should be the first line of therapy for all younger patients with androgenetic alopecia, regardless of the degree of their hair loss. Failing to Identify Low Donor Density Prior to Hair Transplant Surgery -Assessing a potential patients’ donor supply with densitometry is of vital importance and cannot be stressed enough. A low donor density, generally less than 1.5 hairs per mm2, usually indicates that donor supply is insufficient to create adequate density or coverage, rendering the surgical hair restoration procedure inadvisable. An exception might be an older person with very conservative goals. High miniaturization in the donor area, particularly in a person under the age of 30, suggests Diffuse Unpatterned Hair Loss (DUPA) and is a contraindication to surgery.Transplanting patients with low donor density will also risk a visible scar if the hair is worn short. Follicular unit extraction is not appropriate in such cases, since it further limits the total available hair. In fact, since the contrast between bald and non-balding scalp in patients with low donor density is naturally low, their best option tends to be wearing their hair short, to decrease the contrast even more (rather than having hair transplant surgery).Failing to Identify a Tight Scalp (Scalp Laxity) – Assessing scalp laxity is an underappreciated aspect of the patient evaluation, probably because it is difficult to quantify. However, a tight scalp severely limits the total amount of harvestable donor hair and can constitute a contraindication to surgery, except when hair transplantation patients have extremely conservative goals or are expected to experience only limited balding. The constraints that low scalp laxity impose generally manifest themselves after the first transplant session. Though laxity should be judged in the pre-op evaluation, the intra-operative assessment, made while suturing, is most accurate in predicting future difficulties. Therefore, every operative report should include a record of the ease of closure and intra-operative suture tension.Harvesting a Donor Strip That Is Too Wide -In large sessions, it can be tempting to take a slightly wider donor strip in order to conserve on length. A strip that is 25 cm by 1 cm, for instance, can be shortened by 6 cm if widened by just 3 mm–and yield the same amount of hair. However, a wide strip puts unnecessary tension on the donor closure and is probably the most common cause of widened scars. If larger sessions are appropriate, and the scalp lacks adequate mobility, the hair restoration doctor should consider a longer incision rather than a wider one. If a wide donor strip has been identified as the likely cause of a stretched scar, it is advisable to wait at least eight months, to give the scar a chance to mature and regain some of its original laxity. When the next excision is made, the strip should measure at least 3-6 mm narrower than the previous one. Attempts to remove the entire width of the old scar invariably lead to a reoccurrence, or worsening, of the old scar. To facilitate healing, the new excision should extend to the hair transplant patient’s hair-bearing edge.Unfortunately, attempts to re-excise scars commonly result in either no improvement or an even wider defect. For this reason, many doctors use follicular unit extraction to place hair directly into the scar as a primary method of treatment. Placing the Donor Incision Too Low -The location of the donor incision greatly affects scalp mobility. The ideal position for it is in the mid-portion of the permanent zone that lies, in most people, at the level of the external occipital protuberance and the superior nuchal line. The muscles of the neck insert into the inferior portion of this ridge, so an incision below this anatomic landmark will be impacted by the muscle movement directly beneath it. A stretched scar in this location is extremely difficult to repair since re-excision, even with undermining and layered closure tends to heal with a wider scar. To compound the problem, one is more likely to cut through fascia with a low donor incision; and once the fascia has been violated, the risk of widening the scar rises considerably.In addition to the slightly greater risk of a widened scar, the main problems of harvesting hair too high are lack of permanence of the transplanted hair (since it may be subject to androgenic alopecia) and future visibility of the scar were the donor fringe to narrow further. Incisions made too high are best left untreated, unless the scar is wide and poor surgical technique has been identified as the cause. The temptation to transplant permanent donor hair into a high scar should be resisted, as progressive balding would isolate the hair-bearing scar, presenting new cosmetic problems.Interestingly, in the case of young hair transplant patients with traumatic scars and hair-loss patterns that are still unclear, Follicular Unit Extraction can function as a hedge against this risk. If the hair is harvested from the immediate vicinity of the scar, any future balding will affect the transplanted hair in the scar at the same rate as the hair surrounding it.Using a Multi-Bladed Knife -In order to save time, a hair restoration doctor performing large transplants may use a multi-bladed knife (one with three or more blades) for harvesting donor tissue. The resulting pre-sliced multiple thin strips are much easier to work with than a single intact strip. Unfortunately, harvesting this way causes unacceptable levels of follicular transection while destroying the naturally occurring follicular unit and is therefore incompatible with follicular unit transplant. Crushing Grafts During Insertion -Proper placing technique necessitates the use of forceps to grasp the graft by the fat below the bulb or by the dermis alongside the hair shaft in order to avoid damaging the germinative components of the follicle. Though placers often exercise enormous care while initially grasping the graft, there is a tendency to become rougher when repositioning the forceps for further inserting, replacing a popped graft or transferring grafts from the holding solution to the fingers. Since follicular units and other small grafts are particularly susceptible to crush injury after a hair transplant, improper handling can more than negate the benefits of careful stereo-microscopic dissection.Allowing Grafts to Dry -An elegant study using electron microscopy has shown that desiccation is by far the most significant form of injury to grafts and makes them much more susceptible to other forms of injury, such a mechanical trauma and warming. Grafts should therefore be kept well-hydrated with chilled isotonic solution (such as Ringer’s lactate) from the moment the tissue is harvested until the time they are reinserted into the scalp.Placing the Frontal Hairline Too Far Forward (Too Low) -Despite the fact that individual follicular units at the hairline in themselves look natural, their proper placement is no less important than in traditional grafting. The frontal hairline should be placed no lower than 1.5 cm above the upper brow crease. Particularly if the underlying skin is normal, follicular units placed too low can be removed with an alexandrite (755 nm) or diode (800, 810 nm) laser. Electrolysis is more difficult and time-consuming with transplanted follicles, but should also be considered. Punch excision is too imprecise for very small grafts and risks scarring. Creating a Hairline that is Too Broad -Since significant temporal recession is characteristic of the normal adult male hairline, a broad, flat transplanted hairline will not age well and can cause cosmetic problems if baldness becomes extensive. The treatment is the same as with low hairlines, but it should be noted that if grafts larger than follicular units were used, and/or if there is scarring of the recipient skin, punch excision with reutilization of the hair may be indicated. Angling Hair in the Wrong Direction – As noted earlier, in the front and top part of the scalp, hair grows in a distinctly forward direction, changing to a radial pattern as it approaches the crown. It emerges from the scalp at an acute angle, with the hair lying practically flush to the skin at the temples. There has been a tendency among some hair restoration doctors to transplant grafts perpendicular to the skin — probably due to the fact that the mechanics of the old plug procedures made sharp angling technically difficult. The cosmetic consequence of this is most apparent at the frontal hairline. When the hair is perpendicular, the viewer’s eye is guided to the base of the hair shaft where it inserts into the skin; conversely, when hair is transplanted in its natural, forward-pointing position, it is bowed by grooming and the eye settles on the body of the hair shaft. When grafts at the frontal hairline are transplanted in a radial direction, combing the hair in any style becomes problematic and invariably results in an unhappy patient. As with low or broad hairlines, hair that is angled in the wrong direction, particularly in the frontal hairline, should be removed. Attempting to Cover an Area That Is Too Large -Attempting to cover an area greater than the donor supply can adequately fill may leave cosmetically important areas thin or un-transplanted. In general, the first region to bald is the area where you should be most hesitant to transplant. Recession at the temples and thinning in the crown are usually the earliest manifestations of baldness, but they are acceptable, especially as patients age, so these areas may be left un-transplanted. The central forelock region, however, is generally late to bald, but when balding occurs, the patient loses the frame to his face and its restoration becomes essential.Whether or not these areas need coverage at the time of the initial transplant, an adequate amount of hair must always be reserved for critical areas, such as the forelock and top of the scalp. If donor reserves are limited, the transplantation of less critical areas should be postponed or avoided all together.SUMMARY – Developed within the past decade, Follicular Unit Transplantation has emerged as both the standard and the cutting edge in hair transplant surgery. In conserving donor hair, achieving optimal coverage and creating a natural look, follicular unit transplant represents a considerable advance over earlier methods of hair restoration. Appropriately, it also demands considerably more from its practitioners. Surgical hair restoration teams must develop the skill and stamina for the delicate handling of large numbers of follicular unit grafts, while surgeons must cultivate a keen aesthetic sensibility with regard to transplant design and graft placement. In view of the psychological aspects of hair loss, Follicular Unit Transplantation requires a thorough preoperative assessment to understand the patient’s expectations, a careful examination to determine if surgery is appropriate and, most importantly, the establishment of realistic goals. If the surgical route is chosen, meticulous attention to detail is required in every aspect of the procedure so that these goals may be realized. It is a daunting task for the hair restoration doctor and surgical team to develop the necessary expertise for perfecting Follicular Unit Transplantation; but when they do, their work can benefit patients for their lifetime.REFERENCES – {for a complete list of references, please visit http://www.bernsteinmedical.com/resources/FUHT2005-5.php}

Regarding the ability to perform hair transplants using grafts in extensive quantities, many “unanswered questions” already have answers. The first issue that “the emphasis in hair restoration has somehow shifted from the eventual outcome or product to the speed and magnitude of the process” is not correct. The outcome is, and always should be, the emphasis in any hair restoration or replacement process. The speed and the magnitude of the process, however, directly affect this outcome. There are a number of reasons; a critical element affecting the final result of the hair transplant is the motivation of the patient to reach a point where the hair restoration is cosmetically useful. Multiple partial procedures produce short term cosmetic problems, unnecessarily extend the duration of the surgical process, interfere with the patient’s daily life, and often leave the patient frustrated and unsatisfied. These patients can be so frustrated that they give up on the process entirely. The ability to perform the restoration in one or two procedures encourages a much greater proportion of patients to complete the process. Large hair transplant sessions solve other problems intrinsic to multiple small procedures. The first concerns the donor reservoir. Each time grafts are harvested from the donor area there is loss of potential donor hair due to destruction of hair adjacent to the wound edges as a result of the fibrosis associated with primary intention closures. In addition, the hair follicles adjacent to the healed suture line are often distorted and more difficult to harvest on subsequent hair transplant procedures. Minimizing the number of times the donor area is accessed, will minimize the resulting loss and distortion due to the closure. In the recipient area, the problem with fibrosis also favors fewer hair transplant procedures. In a “virgin scalp”, the blood supply travels unimpeded to the entire recipient area. However, when multiple sessions of large grafts are used, each graft placed in the recipient site induces local scarring that interferes with subsequent blood flow and has the potential to transect or seal off viable blood vessels, even if this effect is subtle. In subsequent procedures, the hair placed between existing grafts is implanted into this scarred tissue and potentially receives diminished blood flow. In hair restoration using dense packing, the donor site is created with an instrument thinner, and one that produces less trauma, than a traditional punch instrument. A blood vessel that might be pierced would immediately reseal analogous to the way a vessel heals after venipuncture. When the slender graft is then placed into the site, the graft would cause no additional trauma to the vessel. If it were true that “the diminished blood supply fails to support uniform graft take and consequently hair growth” then asymmetry, gaps or areas of variable density, would result from the dense packing technique and this is not observed, in spite of the fact that the dense packing is used predominantly in the frontal hairline, where any problem would be most obvious. The second issue, that “megasessions cannot duplicate the density of the traditional approach” is really not an issue at all. The density of the traditional approach to hair restoration is NOT one that we should aspire to. The problem with larger grafts in the hair transplant (and I include mini-grafts in this category) is that they don’t parallel the way hair grows in nature. Due to graft contraction they have a higher than normal density with greater than normal spacing in between. In nature, hairs in the frontal hairline (approx. the first 1/2 cm.) grow as single units and behind this region, the natural hair groupings contain two or three hairs. Large grafts contain too many hairs and produce an uneven density that doesn’t mimic nature. This is the cause of the most common complaint that patients have about their hair restoration procedure i.e. that it looks like a hair transplant and doesn’t look natural.The third issue, that “very small grafts, although natural, cannot be placed close enough together without injury to simulate the density of the larger grafts” has already been answered. The goal in a hair transplant should not be to simulate the density of the grafts, but that of nature. The obsession with density misses the direction we should be headed. The goal of all hair restoration surgery is to produce a fullness that will look natural as the individual ages. An attempt to match or exceed ones original density, even if only at the frontal hairline, will not only be cosmetically unacceptable in the long term, but will tax the donor bank and limit the ability for future hair transplant procedures to be able to cover additional areas as the balding progresses. In judicious planning, the grafts in the frontal hairline should contain only single hairs and be placed close enough to block the eye from looking into the scalp, but not so dense as to be unbalanced as the patient continues to bald. Finally, the statement “large sessions force distribution of the transplanted hair over the entire extent of the balding scalp” is incorrect. The transplant surgeon using extensive grafting of small follicular units has the total freedom to place these grafts in any distribution that he chooses and, if the hair restoration is planned appropriately, would be most dense in the “crucial frontal zone” that you describe. I agree that the vertex should always be left open in a young extensively balding individual with an average or below average donor density. When the patient has had permanently transplanted hair covering the front and top of his scalp, and the fullness is to his satisfaction, and he still has some reserve of donor hair to address further diminution of the donor fringe, then the crown can be addressed. And this would best be accomplished by extending the hair transplant further back, rather than treating the crown as an isolated area. Continued experience with the megasession will show that it increases the power and flexibility of the hair transplant procedure rather than limiting it. Future work should be directed at exploring the various ways this safe, but technically demanding, procedure can be of benefit to the balding patient.

Although many technical advances have been made in the field of surgical hair restoration over the past decade, particularly with the widespread adoption of follicular transplantation, many problems remain. The majority revolve around doctors recommending surgery for patients who are not good candidates.  The most common reasons that patients should not proceed with surgery are that they are too young and that their hair loss pattern is too unpredictable.  Young persons also have expectations that are typically too high – often demanding the density and hairline of a teenager. Many people who are in the early stages of hair loss should simply be treated with medications, rather than being rushed to go under the knife.  And some patients are just not mature enough to make level-headed decisions when their problem is so emotional.In general, the younger the patient, the more cautious the practitioner should be to operate, particularly if the patient has a family history of Norwood Class VII hair loss, or diffuse un-patterned alopecia.  Problems also occur when the doctor fails to adequately evaluate the patient?s donor hair supply and then does not have enough hair to accomplish the patient?s goals. Careful measurement of a patient?s density and other scalp characteristics will allow the surgeon to know exactly how much hair is available for transplantation and enable him/her to design a pattern for the restoration that can be achieved within those constraints.   In all of these situations, spending a little extra time listening to the patient?s concerns, examining the patient more carefully and then recommending a treatment plan that is consistent with what actually can be accomplished, will go a long way towards having satisfied patients.  Unfortunately, scientific advances will improve only the technical aspects of the hair restoration process and will do little to insure that the procedure will be performed with the right planning or on the appropriate patient.     Five-year ViewThe improvement in surgical techniques that have enabled an ever increasing number of grafts to be placed into ever smaller recipient sites had nearly reached its limit and the limitations of the donor supply remain the major constraint for patients getting back a full head of hair.  Despite the great initial enthusiasm of follicular unit extraction, a technique where hair can be harvested directly from the donor scalp (or even the body) without a linear scar, this procedure has added relatively little towards increasing the patient?s total hair supply available for a transplant. The major breakthrough will come when the donor supply can be expanded though cloning.  Although some recent progress had been made in this area (particularly in animal models) the ability to clone human hair is at least 5 to 10 years away.       Key Issues 1. The greatest mistake a doctor can make when treating a patient with hair loss is to perform a hair transplant on a person that is too young, as expectations are generally very high and the pattern of future hair loss unpredictable. 2. Chronic sun exposure over one?s lifetime has a much more significant negative impact on the outcome of the hair transplant than peri-operative sun exposure. 3. A bleeding diathesis, significant enough to impact the surgery, can be generally picked up in the patient?s history; however OTC medications often go unreported (such as non-steroidals) and should be asked for specifically. 4. Depression is possibly the most common psychiatric disorder encountered in patient?s seeking hair transplantation, but it is also a common symptom of those persons experiencing hair loss.  The doctor must differentiate between a reasonable emotional response to balding and a depression that requires psychiatric counseling. 5. In performing a hair transplant, the physician must balance the patient?s present and future needs for hair with the present and future availability of the donor supply.  It is well known that one?s balding pattern progresses over time. What is less appreciated is that the donor zone may change as well.  6. The patient?s donor supply depends upon a number of factors including the physical dimensions of the permanent zone, scalp laxity, donor density, hair characteristics, and most importantly, the degree of miniaturization in the donor area – since this is a window into the future stability of the donor supply. 7. Patients with very loose scalps often heal with widened donor scars.   8. One should never assume that a person?s hair loss is stable. Hair loss tends to progress over time.  Even patients who show a good response to finasteride will eventually lose more hair. 9. The position of the normal adult male hairline is approximately 1.5 cm above the upper brow crease. Avoid placing the newly transplanted hairline at the adolescent position, rather than one appropriate for an adult. 10. A way to avoid having a hair transplant with a look that is too thin is to limit the extent of coverage to the front and mid-scalp until an adequate donor supply and a limited balding pattern can be reasonably assured – an assurance that can only come after the patient ages.  Until that time, it is best to avoid adding coverage to the crown. Introduction Hair Transplantation has been available as a treatment for hair loss for over 40 years. [1]Through a majority of that time, hair transplantation was characterized by the use of plugs, slit grafts, flaps and mini-micro grafts. Although these were the best tools available to physicians at the time, they were incapable of producing consistently natural results.  With the introduction of Follicular Unit Transplantation (FUT) in 1995, doctors were finally able to produce these natural results. [2] But the mere capability to produce them did not necessarily ensure that these natural results would actually be achieved. The FUT procedure presented new challenges to the hair restoration surgeon and only when the procedure was properly planned and perfectly executed, would the patient truly benefit from the power of this new technique.[3]The ability of follicular unit grafts to mimic nature soon produced results that were completely undetectable.  This is the hallmark of Follicular Unit Hair Transplantation. [4] Of equal importance, however, is hair conservation – the one to one correspondence between what is harvested from the donor area and what ultimately grows in the recipient scalp.  Since a finite donor supply is the main constraint in hair transplantation, the preservation of hair is a fundamental aspect of every technique.  However, unlike the older procedures that used large grafts, the delicate follicular units are easily traumatized and very susceptible to desiccation, making follicular unit transplantation procedures, involving thousands of grafts, particularly challenging. [5]       As of this writing, the vast majority of hair transplants performed in the United States use Follicular Unit Transplant techniques.  Due to limited space, this review will focus on only this technique and not on the older procedures.  Nor will it focus on Follicular Unit Extraction, since this technique is still evolving and the ways to avoid the major pitfalls of this procedure are still being worked out and a subject onto itself.  As the title suggests, this paper will focus on the prevention of the various problems encountered in FUT, rather than its treatment – an equally important subject, but one that has already been covered in an extensive review. [6, 7] For those not familiar with Follicular Unit Transplantation, there is a concise review of the topic in the dermatology text Surgery of the Skin [8].  For more detailed information, several hair transplant textbooks have sections devoted to this technique. [9, 10]   The most common types of problems that occur in FUT procedures can be grouped into two broad categories; those involving errors in planning the hair transplant and those caused by errors in surgical technique. Of the two, errors in planning often lead to far more serious consequences for the patient and will be the subject of this paper.    Patient Selection AgeThe single greatest mistake a doctor can make when treating a patient with hair loss is performing a hair transplant on a person that is too young.  Although, there is no specific age that can serve as a cut off (since this will vary from person to person), understanding the problems associated with performing hair restoration in young persons can help the physician in deciding when surgery may be appropriate.  Getting it wrong can literally ruin a young person?s life. When someone is beginning to lose hair in their teens or early 20s, there is a significant chance that he (or she) may become extensively bald later in life and that the donor area may eventually thin and become see-through over time.  Although miniaturization (decreased hair shaft diameter) in the donor area is an early sign that this may occur, and can be picked up using densitometry, these changes may not be apparent when a person is still young.     If a person were to become very bald (become a Norwood Class 6 or a Class 7) then he would often not have enough hair to cover his crown.  A transplanted scalp with a thin or balding crown is a pattern acceptable for an adult, but totally unsuitable for a person in his twenties. [11] In addition, if the donor area were to thin over time, the donor scar might become visible if the hair were worn short – a style that is much more common in people who are young.  ExpectationsThis subject is very closely related to age.  For surgical hair restoration to be successful, expectations must match what can actually be accomplished.  The expectations of a young person are usually to return to the look they had as a teenager; namely to have a broad, flat hairline and to have all of the density they had only a few years before. The problem is that a hair transplant neither creates more hair (and therefore can?t increase overall density) nor prevents further hair loss (so the pattern must be appropriate as the person ages).  But since receded temples and a thin crown is not an acceptable look for a young person, the surgery should best be postponed in a person in whom this is not acceptable. As a person ages, he often becomes more realistic and is happy with what a hair transplant can actually achieve.  And, over time, if a person?s donor area proves to be stable and his hair loss limited, more ambitious goals can be attained.Chronic Sun ExposureAlthough it is common wisdom to avoid sunburns after a hair transplant, in fact, significant chronic sun exposure over one?s lifetime has a much more significant negative impact on the outcome of the hair transplant then peri-operative sun exposure.Actinic damage alters the collagen and elastic fibers so that the grafts are not grasped as securely and the alteration to the vasculature decreases the ability of the recipient tissue to support the transplantation of a large number of grafts.  Even with the very small recipient sites used in follicular unit transplantation, making sites too close can result in a compromised blood supply and result in poor growth.   Another issue is that a hair transplant will cover areas of sun damage and make cancer detection more difficult.  When the actinic related growths are finally treated, the involved sections of the hair transplant will be destroyed.  The best approach in a person with significant sun damage is to first treat the entire scalp aggressively with 5-flurouracil to remove all of the pre-cancerous lesions before hair transplant is contemplated.  One should wait at least 6-12 months after the treatment for the scalp to completely heal, as the tissue will be more friable during this period. Although this treatment can set the surgery back a year or more, it will result in better graft survival and less problems with future skin cancer detection.   Medical Conditions and MedicationsAlthough not necessarily an absolute contraindication to surgery, a number of medical conditions make the follicular unit hair transplant procedure more problematic and need to be taken into account.  Whenever significant medical conditions are present, it is always prudent to obtain medical clearance from the patient?s primary care physician or appropriate specialist.  Because the scalp is quite vascular, and FUT procedures involve a large surgical team, patients that are known to have blood born pathogens, such as HIV and Hepatitis B and C, pose some increased risk to the staff, despite the fact that universal precautions are used.  It is useful if the team is aware of the medical histories of hair transplant patients so that they can proceed with a higher degree of alert when necessary.  In an HIV positive patient, it is important to make certain that the patient?s immune status is adequate, so that the patient does not have a greater risk of infection. In patient?s with Hepatitis, it is important to assess their liver function so that the dosing of medications is appropriate. Patients with diabetes mellitus may be at greater risk of having a peri-operative infection.  In this case the normal aseptic conditions that most hair transplants are performed under might be changed to a modified sterile technique (modified in that it is difficult to prep the scalp).  This should also be considered in patients with cardiac valvular disease, implanted devices and others in whom bacterial seeding might have more severe consequences.  Antibiotic coverage should also be administered in high risk individuals, although it is not needed in routine hair restoration procedures. [12] A bleeding diathesis, significant enough to impact the surgery, can be generally picked up in the patient?s history; however medications often go under the radar and should be asked for specifically.  Patient?s often don?t think to report taking aspirin and this must be asked about as well as other non-steroidal anti-inflammatory medications.  Plavix, in particular can significantly increase bleeding during the procedure.  Alcohol, of course increases bleeding as well. [13]  One should make adjustments in a patient?s anti-coagulant medication in conjunction with his/her cardiologist or regular physician.  As a general rule, one should stop anti-platelet medications one week prior to the hair transplant, but the interval will vary depending upon the specific drug, the size of the procedure, and the importance of the medication to the patient?s health. They can be resumed three days after the procedure. If the anticoagulants cannot be stopped, it may be reasonable to proceed with a smaller session.   Since epinephrine is used in most hair restoration procedures, if a person has a history of arrhythmias or other cardiac disease that could be exacerbated by epinephrine, medical clearance from the patient?s primary care doctor, or cardiologist, should be obtained.  Epinephrine can also interact with broad-beta blocking agents such as propranolol, causing a hypertensive crisis; therefore, it is best to have the patient switch to a selective beta-blocker for the surgery. [14] A number of manipulations can be used during the procedure to control bleeding and decrease the need for epinephrine.  Among the most useful, is to scatter the recipient sites broadly over the area to be transplanted (allowing the extrinsic pathway to begin coagulation) and then filling in the areas with additional sites when the bleeding has subsided. [15]  If patients have a history of seizures, it is important that they do not discontinue their medication for the procedure and that medical clearance is obtained.  One should also remember that otherwise normal patients can have a vaso-vagal episode during the procedure; particularly during the administration of the local anesthetic.  This can be avoided by immediately placing the patient in Trendelenberg as soon as the patient complains of nausea or begins to sweat, or look pale.  A patient should be monitored with a pulse oximiter if a significant amount of sedatives or other respiratory depressants are used. The patient should be monitored closely to be sure that local anesthetics are administered in safe amounts and that the warning signs of lidocaine overdose are well known to all members of the surgical team. [16]  Finally, it is helpful to have a pre-printed summary of all the medications and their doses commonly used during the procedure. This can be given to the patient?s regular physician when seeking medical clearance. Psychological FactorsHair loss can take a psychological toll on a person?s self-esteem and cause considerable emotional distress.  When a person has underlying psychiatric issues, the impact can be more severe and, therefore, management of hair loss considerably more difficult.  It is important to identify these problems as well as other psychological factors that may play a role in a patient?s ability to clearly understand both the hair restoration process and its anticipated outcome. In some cases, counseling can be done in conjunction with hair restoration, but often it should precede treatment, especially when surgery is contemplated.  It is prudent to obtain clearance for surgery from a psychiatrist or clinical psychologist when there is a history of mental illness, or when it is suspected at the time of the consultation.A number of psychiatric conditions are particularly relevant to the successful outcome of a hair transplant.  These include Trichotillomania, Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Syndrome (BDS), and Depression. Trichotillomania is a relatively common condition characterized by the persistent urge to pull out one?s hair.  It most commonly involves scalp hair, but can also involve the eyelashes, facial hair or other body hair.  It often results in bald patches and can be identified by short hairs in the affected area that are not long enough to grasp.  Active trichitollomania on any part of the body is an obvious contraindication to a hair transplant, but if a person has a history of this condition, the doctor should also be cautious and only consider surgery if the therapist is confident that the condition has little chance of recurring.  Obsessive-compulsive disorder (OCD) is a condition characterized by recurrent, intrusive thoughts (obsessions) and related behaviors (compulsions) which attempt to neutralize the anxiety or stress caused by the obsessions.  In consultation, the OCD patient often asks a litany of questions and often asks the next question before listening to the answer to previous one.  OCD patients are extremely difficult to satisfy and even in a very successful hair transplant can focus on a minor imperfection seeming oblivious to the good overall result.   Body dysmorphic disorder (BDD) is a mental disorder that involves a distorted image of one?s body. The person is extremely critical of their physical self, despite the fact there may be no actual defect.  It should be obvious that patients with BDD will not be satisfied with a hair transplant, or other forms of cosmetic procedures, and the condition is best treated by a psychiatrist rather than a surgeon.  Another note of caution is that patients with BDD have a much higher suicide rate than the general population, even greater than patients with depression. [17]    Depression is possibly the most common psychiatric disorder encountered in patient?s seeking hair transplantation, but it is also a common symptom of those experiencing hair loss.  The doctor must differentiate between a reasonable emotional response to balding and a depression that requires psychiatric counseling.  It is important to realize that a hair transplant will be ineffective in curing a medical depression and unfulfilled expectations may lead to a worsening of the condition.References 1. Orentreich N: Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479, 1959. 2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32. 3. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. 4. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99. 5. Gandelman M, et al: Light and electron microscopic analysis of controlled injury to follicular unit grafts. Dermatol Surg 2000; 26(1): 31. 6. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part I: Basic repair strategies. Dermatol Surg 2002; 28(9): 783-94. 7. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part II: The tactics of repair. Dermatol Surg 2002; 28(10): 873-93. 8. Bernstein RM, Follicular Unit Hair Transplantation. In: Robinson JK, Hanke CW, Siegel DM, Sengelmann RD, editors: Surgery of the Skin, Elsevier Mosby, London UK. 2005. 9. Unger WP, Shapiro R. Hair Transplantation. New York: Marcel Dekker, Inc. 2004. 10. Bernstein RM, Rassman, WR. Follicular Unit Transplantation. In: Haber RS, Stough DB, editors: Hair Transplantation, Chapter 12. Elsevier Saunders, 2006: 91-97. 11. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365. 12. Haas AF, Grekin RC: Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol 1995; 32: 155-76. 13. Otley CC. Perioperative evaluation and management in dermatologic surgery. J Am Acad Dermatol 2006; 54: 119-27. 14. Gandelman M, Bellio R, Barretto M: Beta-blockers and local anesthetics with vasoconstrictors: A dangerous association. Intl J Aesthetic Restorative Surgery 1995; 3 (2): 143-45. 15. Bernstein RM, Rassman WR: Limiting epinephrine in large hair transplant sessions. Hair Transplant Forum International 2000; 10(2): 39-42. 16. Skidmore RA, Patterson JD, Tomsick, RS: Local anesthetics. Dermatol Surg 1996; 22:511-522. 17. Phillips KA, Menard W: Suicidality in body dysmorphic disorder: A prospective study.  Am J Psychiatry, 2006; 163:1280-82.  18. Bernstein RM, Rassman WR. The scalp laxity paradox. Hair Transplant Forum International 2002; 12(1): 9-10.

Going for a hair transplant in Chicago shouldn’t be a difficult prospect. With many skilled professionals offering hair transplant procedures in Chicago, finding one that’s right for you is a simple process of screening professionals and determining if the hair transplant option is really the way you want to go.

Good hair transplant Chicago professionals will tell you that the procedure is not for everyone. It will depend a lot on what is causing the hair loss in the first place and the extent of the condition. Some cases just lend themselves better to success than others. Hair transplants, however, can be very beneficial for both men and women in giving the appearance of a fuller, more youthful head of hair.

If you’ve decided to delve into hair transplants in Chicago, you’re not alone. Each year many patients make their way to Chicago practitioners in hopes of getting a newly restored head of hair. This is a great option for many as hair transplants in Chicago and elsewhere offer lots of benefits over other methods of fighting baldness. They include:

If you’re looking for a hair transplant in Chicago, make sure you take the time to find a good practitioner. Hair transplant procedures involve the actual removal of skin and the grafting of it to other parts of your head. You don’t want to find a hair transplant doctor that doesn’t know what he or she is doing. With this in mind, make sure:

Finding the right hair transplant Chicago area professional to handle your hair transplant shouldn’t be a difficult undertaking, but it’s one that does require some thought. Don’t rush into the procedure without fully understanding the benefits and the risks.

I was fortunate to catch an early glimpse of the provocative article “Blind Graft Production with Cutting Grates and Multi-bladed Knives” on its way to Dr. Shiell and the Forum. The gauntlet having been tossed, let me be the first to enter the fray. The question at hand is relatively straight forward. When compared to the highly controlled stereo-microscopic dissection of donor tissue harvested as a single strip, do the potential benefits of blind graft production (which use a multi-bladed knife and a cutting grate) more than outweigh their disadvantages and possible risks? In order to make sense out of the long list of categories used to evaluate the two techniques, I have taken the liberty to organized them into the following groups:1. Intrinsic Factors – Factors affecting the surgical outcome that are intrinsic to the techniques discussed and cannot be eliminated. 2. Extrinsic Factors – Factors that may affect the hair restoration surgery, but ones that can be reasonably modified so as not to significantly impact the outcome.3. Economic Factors – Strictly economic issues that have no effect on quality. 1. Intrinsic FactorsDamage to the follicle Disruption of the follicular unit Viable hair(s) obtained per graftAmount of non-hair bearing tissue transplanted Total recipient wounding Foreign body reactionPseudo-cyst formation Quality control Patient variability Preserving donor supply2. Extrinsic FactorsTime grafts are out-of-body Risk of desiccation Staff training Staff stress and fatigue 3. Economic FactorsCost of equipment Cost of labor Cost to doctor Cost to patient What The Patient Should DoIf I were advising a patient that had to choose between the two hair transplant procedures I would suggest the following:FIRST: To each of the factors assign a GOOD rating where the technique can clearly or potentially be of benefit, a BAD rating if it may do harm, and disregard those issues that make no difference. (For simplicity, I have assigned each factor a value of 1, although some factors are clearly more important than others.) Then count them all, subtracting the bad from the good. SECOND: Pick a top-notch surgical hair restoration team that could control the extrinsic factors so that they would have little or no impact upon the surgery.THIRD: Make a decision taking into account that:- This surgery is being performed on your own body.- You only have a limited donor supply of hair.- You will have to live with the results of the hair transplant procedure (good or bad), for the rest of your life. Microscopic Dissection            Blind Graft ProductionMedical Issues- Damage to the follicle                GOOD                 BAD- Disruption of the follicular unit           GOOD                 BAD – Viable hair obtained per graft              GOOD                 BAD – Non-hair bearing tissue used                GOOD                 BAD – Total recipient wounding                    GOOD                 BAD – Foreign body reaction                       GOOD                 BAD – Pseudo-cyst formation               GOOD                 BAD – Ability to control quality                  GOOD                 BAD – Impact of patient variability               GOOD                 BAD – Preserving donor supply                     GOOD                 BADEconomic Factors- Cost to Patient                             BAD                  GOODTOTAL (good – bad)                    9                                – 9The IssuesI have eliminated the first three economic factors; Cost of equipment, Cost of labor, and Cost to doctor, since the only factor that really matters to the patient is his cost. All the other economic issues are reflected in this one and are not the patient’s problem.Extrinsic factors, if not controlled, can play a major role in the outcome of the surgery. Finding a surgical hair restoration team that is properly trained and experienced can minimize these issues. For example, the time that grafts are out of the body can be reduced by utilizing a sufficiently large staff or by taking a donor strip out in sections. Adverse effects can be further minimized or eliminated by proper graft refrigeration. Any risk of desiccation can be easily eliminated by the use of holding solutions and the proper handling of grafts just prior to insertion. In addition, automation may soon make both of these issues moot. A sufficiently large staff that is adequately rotated and working in a comfortable environment will greatly reduce stress. If the patient is diligent in his research, he can pick a surgical team that satisfies these requirements.The intrinsic factors are the real issue. A 35% incidence in follicular transection that was observed without even using a microscope is, in my opinion, an extraordinary price to pay for a cheaper, faster procedure. It is argued that follicular transection is overestimated when two fragments representing the same follicle are both counted, (this error was not made in these counts) but even if the transection was half that, it would be too much. From my personal experience with a multi-bladed knife with a inter-blade spacing of 3mm, the transection rate was about 20%, and occasionally as high as 35%, so it doesn’t surprise me that transection with blades set at 1mm would easily cause damage in the range of 35% (or even more). In fact, Dr. Rassman, in his own practice, had abandoned using the multi-bladed knife after he had observed the transection rate to be unacceptably high. The fixed blade spacing of the cutting grate used in the next step, would further compound this damage.Much has been made of Dr. Kim’s studies showing that, under controlled conditions, a portion of transected follicles will grow. What is not often mentioned by those quoting his data, is that the hair that is produced is often finer and more delicate than the undamaged, full thickness terminal hair of intact follicles. Unfortunately for the patient, hair shaft diameter is as important to the final cosmetic outcome of the hair transplant as the absolute number of transplanted hairs. Another important issue is the fact that multiple blades break up the naturally occurring follicular units. One doesn’t have to do a controlled experiment to understand that a single pass of the multi-bladed knife with blades set 1mm apart will literally decimate follicular units randomly spaced at a density of 1unit/mm2. Again, the fixed spacing of the cutting crate would further divide any follicular units that hadn’t already been broken up with the multi-bladed knife. Transplanting the whole follicular unit will insure that the greatest cosmetic benefit is obtained from each session. The compact nature of intact follicular units allows them to be placed into very small sites, minimizing recipient wounding. This, in turn, maximizes the amount of hair that can be placed into the cosmetically important areas, while maintaining a totally natural look. Minimal wounding will cause less compromise to the blood supply and produce less scarring. It will enable larger procedures to be performed at one time, and will help preserve the integrity of the recipient bed for future procedures. How much the wounding may be decreased will depend upon the surgical team, but since carefully dissected follicular units contain only about half the volume of the original donor tissue, the total wounding can potentially be cut in half. The fact that transected follicles may grow under experimental conditions should be of little consolation to the patient who wants to get the maximum benefit from his or her hair transplant procedure. Some hair restoration doctors seem to be flippant about generating hair fragments and consider only whether they will or will not grow. In fact, hair fragments are composed of keratin which can be quite inflammatory and the reaction they incite in the dermis can destroy adjacent follicles. Small hair fragments that do grow may not find their way to the skin surface and can result in pseudo-cyst formation, a locally destructive process. We have all seen this in our practices, and from my experience the incidence is significantly reduced when follicular units are transplanted intact. Bilateral controlled studies would, of course, be helpful to document this for the skeptics. The ability to control quality is another important issue. It has been argued that quality control is difficult in follicular unit transplantation. That may be true, but to ignore quality all together is certainly not the solution. A team experienced in follicular dissection can consistently generate the highest quality grafts if one puts forth the effort for proper training and continued monitoring. The problem with both multi-bladed knives and cutting grates is that the slightest deviation in alignment can increase the transection significantly and, unlike microscopic dissection which deals with one follicle at a time, there is no way to make fine adjustments along the way. A final issue is the intrinsic variability of the human scalp from patient to patient, and from one region of the scalp to another. The dissecting microscope is an exquisite instrument for adjusting to this variability. The fixed relationship of the cutting surfaces of the multi-bladed knife and the microtome cannot. Will the doctor performing blind dissection be able to adequately account for this variability in the average patient and will he risk operating on an unwary patient in whom these differences might be profound?In PerspectiveFor those of us who embraced follicular unit transplantation at the outset, it could be argued that we might have acted too hasty. . .  before all the evidence was in. But our rationale was that the procedure would improve the quality of our hair transplant. Our critic’s main objection was that it might not be worth the extra effort. If we had been wrong, there was little to lose except time, effort, and unnecessary expense. In this case, when one risks damaging the patient’s donor supply, the patients have much to lose.The sudden disregard for follicular anatomy exhibited by this “blind grafting technique” runs contrary to much of the progress that has been made in hair restoration surgery over the past 10 years. Hopefully, well-controlled studies will precede the general use of these instruments, so that the extent of damage can be accurately measured. The “blind grafters” should clearly explain all the pros and cons of this type of dissection to their patients, as well as the limited knowledge we have of this technique so far, in order that their patients have true “informed” consent. Let’s not go back to the days of the old plugs when doctors rarely told their patients all of the short and long-term consequences of their procedures.Blind graft dissection may indeed have some economic value, but what is the real cost to our patients?

Patient Assessment Donor SupplyIn performing a hair transplant, the physician must balance the patient?s present and future needs for hair with the present and future availability of the donor supply.  It is well known that one?s balding pattern progresses over time. What is less appreciated is that the donor zone may change as well.    The patient?s donor supply depends upon a number of factors including the physical dimensions of the permanent zone, scalp laxity, donor density, hair characteristics, and most importantly, the degree of miniaturization in the donor area – since this is a window into the future stability of the donor supply. The size of the donor area is determined by both its width (height) and its length.  When assessing the potential width of the donor area, doctors usually assess the lowermost point that the balding will reach, i.e. the top part of the permanent zone.  However, it is equally important to pay attention to the inferior margin as well.  It is common for the hair to thin significantly at the nape of the neck as a person ages, producing an “ascending hairline.”  Since this can significantly diminish the width of the donor area, any evidence that this process may occur should be taken into account in the planning.  Loss of the temporal points is another process that has a significant impact on the donor supply. Not only does it foreshorten the potential length of the donor strip but it often portends very significant baldness.    Scalp laxity is another variable that affects the amount of available donor hair.  Very tight scalps significantly limit the amount of donor hair that can be removed through strip harvesting.  The constraint imposed by a tight scalp is not always apparent in the first session, but can plague the hair restoration down the line; therefore, it should be evaluated carefully in the initial patient assessment. A very loose scalp can present its own set of problems, as patients with very loose scalps often heal with widened donor scars. [18]    The average donor density of a Caucasian is about 225 hairs/cm2. This can easily be measured using a hand-held instrument called a densitometer. (2) When the density of a Caucasian is below 180, a hair transplant should be undertaken with great caution. In this author?s opinion, when the maximum donor density is below 150/hair mm2, a person should generally not be transplanted, as there will not be enough donor hair to make the procedure cosmetically worthwhile and the risk of a visible donor scar is too great. (3) Exceptions would be an older person with very limited expectations and in races where the normal density is lower (i.e. Asians and Africans).  Hair characteristics, particularly hair shaft diameter, are as important as the absolute number of hairs in determining the outcome of a procedure.  The amount of transplantable hair is related to both the number of movable hairs (determined by the size of the donor area, scalp laxity and donor density), multiplied by the hair shaft cross sectional area.  Since each hair in a person with coarse hair can have over 5 times the volume as a person with fine hair, the estimate (or actual measurement) of hair shaft diameter is important in determining the overall donor supply.   Miniaturization, the progressive diminution of hair shaft diameter and length (the result of the action of DHT on the hair follicle) produces thinning on the front, top and crown of the scalp and is the hallmark of androgenetic alopecia.  But the back and sides of the scalp can miniaturize as well and when a significant portion of a patient?s donor area is miniaturized, the hair in this area can be rendered useless for a hair transplant. (Figures 1 and 2) This condition, called diffuse unpatterned hair loss (or DUPA), is the most common type of hair loss seen in women and it is not uncommon in men.  It goes without saying, that every patient, male or female, in whom a transplant is being considered, should be evaluated for donor miniaturization using densitometry to make sure that the donor hair to be transplanted is stable.  Recipient DemandOne should never assume that a person?s hair loss is stable. Hair loss tends to progress over time.  Even patients who show a good response to finasteride will eventually lose more hair.  It is always best to consider the reasonable worst-case scenario when assessing how bald the patient may become, so that the finite donor hair can be allocated properly. Although the Norwood classification is very helpful in staging the hair loss, it doesn?t take into account actual scalp dimensions. Just like the donor site, the recipient area should actually be measured.  Even within a single Norwood class, there is a vast difference between a patient with a narrow forehead and one with a very broad head with respect to the actual surface that needs to be covered, and thus the number of grafts required for the restoration.  Designing the Hairline  Hairline PositionIn the adolescent, the hairline sits just above the upper brow crease formed by the upper border of the frontalis muscle directly below it.  The position of the normal adult male hairline is approximately 1.5cm above this crease at the midline). A common error is to place the newly transplanted hairline at the adolescent position, rather than one appropriate for an adult. Although the younger patient, first experiencing hair loss, may put considerable pressure on the doctor to place hair in the lower position, the physician should not yield to this demand.  Under normal circumstances, as a patient ages, his density decreases and the natural hairline will move back somewhat.  However, a transplanted hairline is immutable. Therefore, when the transplanted patient continues to thin or bald (which he invariable will) the fixed low frontal hairline will begin to look out of place, since it is natural for a person with decreased overall hair volume to have a slightly receded hairline, rather than one that is still in the adolescent position.  Hairline ShapeA similar logic applies when choosing the shape of the hairline.  As a male passes from adolescence to adulthood, his broad, flat hairline evolves into a more tapered shape with some recession at the temples.  A persistent low, broad hairline is enjoyed by those who also maintain their adolescent density. This situation is not present in those who are suffering from androgenetic alopeica; therefore, a transplanted flat hairline will not “age well” over time and will look unnatural as the patient?s overall density decreases and particularly as the crown begins to thin.  If a person is older, has maintained a high donor density, and has a small risk of extensive hair loss, a broader hairline is possible.  However, this is not this case for the person who is starting to bald at a young age, since he has a significant risk of extensive baldness and, more importantly, the extent of his future hair loss can not be known at the time the surgery is planned.  Graft Distribution The nuances of graft distribution and the multitude of problems that result from distributing grafts improperly are beyond the scope of this writing; however, there are two main but related themes that the hair transplant surgeon should be cognizant of when deciding where to place grafts. The first is to set a target area of coverage that takes into account the patient?s future balding pattern, as well as, his total donor hair supply.  The second is to forward weight the grafts, rather than distributing them evenly over the top of the scalp. Extent of CoverageThe problem of deciding how much bald scalp a hair transplant should cover can be illustrated as follows.  As an example, take a patient whose total number of follicular unit grafts available to harvest is around 5,500.  The front part of the scalp has a surface area of about 50 cm2.  The top or mid-scalp has an area of about 150 cm2 and the vertex or crown about 175 cm2. However, the size of the bald crown can vary dramatically depending upon the extent of hair loss, reaching over 200cm2 in a Norwood Class VII patient.  If the front and top of the scalp were transplanted using all of the patients donor hair, the transplanted density would be only 5,500grafts/200cm2 or 27.5 grafts/cm2 (less than 1/3 the density of the patient?s original hair). If the crown were covered as well, that would be 5,500 grafts/400cm2 or 12.5 grafts/cm2 (only 15% the density of the patient?s original hair).  Using various manipulations, such as creating different densities in different parts of the scalp, a skilled surgeon can make 1/3 of the overall density look like a substantial amount of hair. However, working with only 15% of the original density, can make the job of creating a natural look significantly more difficult, if not impossible.     The way to avoid having a hair transplant with a look that is too thin, or see-through, is to limit the extent of coverage to the front and mid-scalp until an adequate donor supply and a limited balding pattern can be reasonably assured -  an assurance that can only come after the patient ages.  Until that time, it is best to avoid adding coverage to the crown.   Another problem with transplanting the crown early is that as the crown expands additional hair will be needed to follow the expanding area of baldness outward, just to keep the first hair transplant looking natural. This may require considerable amounts of hair that will not be available to cover the front and mid-scalp if that were too bald as well. On the other hand, if the hair transplant was limited to the vertex transition point or VTP (see figure above), the restoration would look natural without further surgery no matter how far the hair loss in the crown progressed. The reason is that the front and top of the scalp represent a complete cosmetic unit, with the VTP as the natural posterior boundary – so it is natural for hair to cover this region of the scalp but not beyond.   Density GradientsAnother way for surgeons to prevent a thin, see-through look is to avoid distributing the grafts evenly over the transplanted area. It goes without saying that only 1-hair grafts should be used at the hairline, with larger grafts behind them, but there are additional ways to produce the gradations of density to mimic the way hair grows in nature.  Specifically, the greatest density should be in the front part of the scalp (shown in brown) and particularly in the frontal forelock area (shown in dark brown). The greater density in the front of the scalp forelock area can be created in two ways; by placing the recipient sites closer together in this location and by using larger follicular units in the area (i.e. 3- and 4- hair units rather than 1s and 2s).  These techniques may be use in combination to achieved greater density but, as will be discussed in the following section, if done to excess, may compromise growth.   SummaryFollicular unit transplantation is a powerful hair restoration technique that allows the surgeon to create natural hair patterns and produce results that mimic nature. The success of the procedure depends greatly on proper patient selection, accurately assessing the patient?s donor supply, and distributing the grafts in a way that is appropriate for a person who will continue to age and eventually thin over time. With thoughtful planning, major mistakes can be avoided and our patients will be able to achieve the full benefit of this remarkable procedure.  References 1. Orentreich N: Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479, 1959. 2. Bernstein RM, Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32. 3. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. 4. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99. 5. Gandelman M, et al: Light and electron microscopic analysis of controlled injury to follicular unit grafts. Dermatol Surg 2000; 26(1): 31. 6. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part I: Basic repair strategies. Dermatol Surg 2002; 28(9): 783-94. 7. Bernstein RM, Rassman WR, Rashid N, Shiell R: The art of repair in surgical hair restoration – Part II: The tactics of repair. Dermatol Surg 2002; 28(10): 873-93. 8. Bernstein RM, Follicular Unit Hair Transplantation. In: Robinson JK, Hanke CW, Siegel DM, Sengelmann RD, editors: Surgery of the Skin, Elsevier Mosby, London UK. 2005. 9. Unger WP, Shapiro R. Hair Transplantation. New York: Marcel Dekker, Inc. 2004. 10. Bernstein RM, Rassman, WR. Follicular Unit Transplantation. In: Haber RS, Stough DB, editors: Hair Transplantation, Chapter 12. Elsevier Saunders, 2006: 91-97. 11. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365. 12. Haas AF, Grekin RC: Antibiotic prophylaxis in dermatologic surgery. J Am Acad Dermatol 1995; 32: 155-76. 13. Otley CC. Perioperative evaluation and management in dermatologic surgery. J Am Acad Dermatol 2006; 54: 119-27. 14. Gandelman M, Bellio R, Barretto M: Beta-blockers and local anesthetics with vasoconstrictors: A dangerous association. Intl J Aesthetic Restorative Surgery 1995; 3 (2): 143-45. 15. Bernstein RM, Rassman WR: Limiting epinephrine in large hair transplant sessions. Hair Transplant Forum International 2000; 10(2): 39-42. 16. Skidmore RA, Patterson JD, Tomsick, RS: Local anesthetics. Dermatol Surg 1996; 22:511-522. 17. Phillips KA, Menard W: Suicidality in body dysmorphic disorder: A prospective study.  Am J Psychiatry, 2006; 163:1280-82.  18. Bernstein RM, Rassman WR. The scalp laxity paradox. Hair Transplant Forum International 2002; 12(1): 9-10.