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Chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 |17 | 18
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When, Why, and How Much?- The Importance of Planning |
| It is imperative that the probability of
second or subsequent procedures be discussed prior to the first follicular unit
transplant. This is an integral part of the long term planning that is necessary
to afford the best outcome. Multiple factors are considered in making this
judgment, including age, degree of baldness, rapidity of hair loss, hair
characteristics, donor density, scalp laxity, styling preferences, and previous
procedures. Let’s take a more detailed look at each of these factors. |
Age |
| Ironically, it is often the case that
older men, with more extensive balding, are better candidates for a single
procedure than are younger men with less advanced patterns of alopecia. The
older man who has lived with baldness for a number of years is likely to have
more realistic expectations of his transplant outcome; he may be very satisfied
with thin coverage, and a frame for the face. In addition, his degree of
balding, that is, his Norwood pattern, has very likely "declared" itself,
leaving little ambiguity in the surgeon’s mind about how future hair loss will
alter the clinical picture. The young, often rapidly balding man may be more
intransigent, and therefore more difficult to counsel. As we discussed earlier,
his vision of the appropriate hairline for himself can be wildly impractical.
Furthermore, the patient in his early twenties with, for instance, Class III,
III-A, IV-A or just limited crown balding is, to some degree, an enigma. How
quickly and how extensively will he lose his hair? An attempt, through a large,
single session, to densely transplant all the thinning areas may not be the best
option. The patient may experience acceleration of hair loss via effluvium, or
his hair loss could simply develop rapidly during the growth period for the new
grafts. If donor reserves are limited, and baldness progresses rapidly, he could
eventually be dissatisfied and unable to proceed with further surgery. This
patient needs to know that he may require two or more procedures to
appropriately follow the progression of the hair loss, and to properly conserve
his donor resources. |
Degree of Baldness |
| In a patient willing and able to undergo a
large session, sometimes the more advanced levels of balding are amenable to a
single session. The stability of the hair loss is estimable, expectations are
likely to be reasonable, and the goals are easy to state. In a single, large
session of FUT, a hairline and framing for the face can be established, top and
crown coverage may be possible, and the result can stand on its own with a
natural appearance. As we discussed above, however, the more limited patterns of
hair loss in younger men present us with a dilemma; do we wait, and if we
transplant, where and how much? These are just a few of the reasons that a
consultation with a trained and knowledgeable hair restoration physician is of
the utmost importance; there are many artistic elements to be considered, as
well as an acute understanding of both the natural history of balding, and of
the patients mental and emotional condition. |
Rapidity of Hair Loss |
| A young man who sees his hair vanishing
before his eyes is likely to be in a vulnerable and suggestible state. He most
of all needs the truth, delivered with an attitude of temperance, understanding,
and hopefully, optimism. If he is quickly progressing towards a Class VI or VII
pattern, he needs to know that complete crown coverage, for example, may be
difficult. Patients with earlier stages of balding, who have had a recent and
rapid onset, or who have just noted an acceleration of their hair loss, will
need counseling about the advisability of postponing the surgery; they must also
understand the probable necessity for multiple procedures and their particular
suitability (or unsuitability) for ongoing surgical work. |
Hair Characteristics |
| In general, the more favorable the hair
characteristics, the more likely a single session may be adequate for the
patient’s needs. Low contrast between hair and skin, curliness or waviness,
coarseness of the hair (except when there is high skin/hair contrast),
light-colored or salt-and-pepper hair all lend themselves to the possibility of
greater coverage with a lower transplanted density. To some extent, these
favorable characteristics can compensate for extensive balding and less than
wonderful donor density. |
Density and Laxity |
| We will consider these two factors
together, as they are so intimately related. The donor area must be evaluated,
both for density and for laxity, in all patients consulting for possible FUT.
(Any significant miniaturization in this area may mean the patient has an
unstable donor area and may not be a surgical candidate at all). If the density
is properly calculated, the total number of movable hairs and movable follicular
units can be estimated with reasonable accuracy. This estimate is obviously of
great value in determining a plan based on the knowledge of the existing donor
reserves. However, a determination of the density is not enough; the laxity of
the scalp also plays a role in the adequacy of the donor reserves. If the scalp
is excessively tight, either naturally or as the result of scalp reductions or
previous donor harvests, this may limit the number and size of strips that can
be excised in the future. If both density and laxity are favorable, then it is
possible that presently bald areas can be more densely transplanted, knowing
that adequate donor reserves remain to account for progression of the hair loss
pattern. This knowledge gives the patient and the surgeon more flexibility in
their approach to current hair loss, and more confidence in facing the
eventuality of progressive baldness. |
Styling Preferences |
| A patient who prefers the hair combed
straight back may have even extensive balding treated with a single procedure.
This is because the crown area can be lightly transplanted, or not at all, and
still appear as a pattern found in nature. Also, the crown can be covered by the
hair from the front and top of the head when it is styled thusly. Those who
prefer combing to the side may achieve a look of greater fullness, but may
sacrifice coverage of the bald crown, if inadequate donor supply exists. Hair
which is allowed to naturally curl may enhance the illusion of thick coverage,
as will a "dry" look, as opposed to a "wet" look. |
Timing of Subsequent Procedures |
| Although a repeat FUT may safely be done
as soon as the new hairs are in evidence, and, indeed, space will exist between
previously tightly placed FU’s for new grafts, there are valid reasons for
postponing a second procedure for 8 to 12 months. One is allowing the scalp to
regain some of its lost laxity. As the months go by, the scalp will stretch to
some extent, which will potentially allow a greater harvest, and will facilitate
an aesthetic closure of the donor site. Also, it takes about 8 to 12 months for
the full cosmetic benefit of the transplant to become evident. At this time, the
patient and the surgeon can make better judgments as to the degree of further
work that needs to be performed. A more uncommon issue is that of telogen
effluvium in the donor area; if this should occur, it is best to give the
follicles ample time to recover, so that they are more likely to be seen and
preserved during follicular unit dissection. |
Purpose of the Second Session |
| There are a number of common goals in
carrying out a second (or subsequent) session. One is to refine the hairline
(see Chapter Ten). No matter how meticulous the original placement, it is
impossible to anticipate what the true effect will be once the transplanted hair
has grown in. Density can be added to the hairline, it may be lowered, made more
or less symmetrical, or the temporal angles may be altered. A widow’s peak may
be created or accentuated and, if the hairline is too straight, it may be
rendered more irregular in order to "soften" it. In a patient with advanced,
stable baldness and adequate donor reserves, the receded temples may be
restored. In addition to hairline refinement, the crown may be transplanted (see
Chapter Eleven). The necessity of this will be more evident after the
transplanted front and top are well grown in; the patient with a new hairline
and adequate top coverage may be satisfied with a natural, "bald spot" crown
appearance, or may wish to go forward with doing the crown if donor reserves and
hair characteristics are favorable. If the hair loss has continued to be rapid,
or if much time has elapsed after the initial transplant, a second session may
be undertaken simply to follow the progression of the baldness. There may have
been permanent "shock loss" of many miniaturized hairs; there may be cosmetic
consequences from this. The baldness may have proceeded more toward the back, or
the affected area may have widened. Often, the reason is to add fullness, which
is done by increasing the density in the recipient areas. Even though the FU’s
may have been placed quite closely during the first session, with the healing of
the recipient sites, there will be intervening space available for further
grafts. This can create a further fullness, as long as the hair loss is stable
enough and the donor supply is plentiful enough. To reiterate, none of these
considerations should be a surprise to either the surgeon or to the patient. The
possibilities must be taken in to consideration early on, before the first
procedure; this education is part of the physician’s responsibility. However, in
the interest of self-empowerment, and simply as an informed consumer, the
patient is compelled to read, research, ask questions, and become as informed
about the long term probabilities as he is about the short term outcome.
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Chapter: 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 |17 | 18 |
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| Next- Long-Term Planning: the Absolute Necessity |
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