By Dr. Cole, FUE Hair Transplant Pioneer

Proper Planning of the Hair Transplant Consultation Process

Doctors planning

When planning the hair transplant process, always try and anticipate the patient’s worst-case scenario. Although any hair loss is never really “predictable,” one must still make an educated judgment as to what the future hair loss will most likely be so that rational short and long-term plans can be formulated.

Assessing Patient Expectations and Completing Patient Evaluation in Anticipating Hair Loss – Short and Long Term, and Baldness

It is the most basic, and important part of planning and implementing an effective hair transplant treatment, to attempt to figure out the worst-case scenarios for the patient and to plan the treatment accordingly. Hair loss can never quite be predicted, that’s true, but to design an effective treatment scenario, one has to use one’s judgment to at least conceptualize what is the most likely pattern for future hair loss in order to develop the most rational and effective short term and long term treatment plans.

Three major factors play an important role in predicting the likely pattern of long-term loss of hair for the patient. Firstly, predicting male pattern baldness is not simple. It seems to be completely polygenic and that makes it extremely difficult to predict merely from family history. However, experience shows that specific patterns of matching hair loss, when seen in another member of the family, can be a useful tool in trying to predict the speed, progress, and the final pattern of the hair loss for the patient. This is especially true when the pattern and chronology of the hair loss in the family member match that of the patient.

The second important factor is personal history. This becomes useful in patients in their late 20’s or older. As a result, knowing the patient’s history becomes an important process, and the patient’s history is a valuable tool. The focus should be not just on determining when they first began to experience hair loss, but also to determine the rate of hair loss. Although the patient may be as young as his mid-to-late 20’s, and in the early stages of hair loss, that in itself can make it difficult to accurately predict the course this hair loss might take in the future. In fact, hair loss patterns like the Norwood Class III are almost impossible to predict at this stage as the pattern and direction of future hair loss have not begun to manifest itself yet.

The third major factor in evaluating current and future hair loss is the degree and level of miniaturization exhibited in the donor area as well as the recipient areas. The ongoing diminution of the hair shaft sizes, both in terms of diameter and length is called miniaturization. This can occur due to various factors, ranging from genetic predetermination to the effects of aging, to androgenic hormones affecting the hair follicle. As a general rule, miniaturized hairs represent 20% or less of the total terminal hair. However, miniaturization is relative and is measured by comparing the patient’s finer hair against the very thickest hair on their head. As a result, it can take years of clinical experience before this kind of measurement becomes a useful predictive tool.

Experience, with more than 5,000 patients, with comparative measurements done with a Hair Densitometer, shows that the assessment of the degree of miniaturization can have great predictive value in the evaluation of the risks and possible patterns of hair loss. General conclusions indicate that a higher degree of such miniaturization, especially in the upper sections of the donor areas usually means that this donor fringe is likely to contract over the years. The same kind of miniaturization in the entire donor area usually indicates that the most of the hair has become unstable, and the patient is at high risk of developing diffuse un-patterned alopecia, eventually leading to extensive baldness.

High levels of miniaturization in recipient areas, on the other hand, often show the scalp areas that are the frontrunners to baldness and can help in identifying the areas that are stable. This can help the clinician to anticipate the possible Norwood classification that might be applied to the patient in the future. In the earliest stages of the beginning of hair loss, high levels of miniaturization would indicate the possibility of future balding much before real hair loss becomes apparent to the clinician. The process is gradual, and numerous hairs show miniaturization long before hair loss actually begins. And this is where the real effectiveness and value of this testing rests. Because, at the beginning of the balding process, the total number of hairs in the potential balding area is usually the same as the hair in other areas, it is the process of miniaturization that would indicate the potential problem areas. However, in this scenario, the total percentage of terminal hairs becomes markedly diminished. To arrive at a reliable prediction of what the pattern of hair is likely to be, it helps if the patient is above 30 and already showing a significant amount of hair loss. However, this miniaturization measurement can be a useful predictive tool at any stage.

Overall, efficiently predicting the pattern of future hair loss for Class III patients is difficult. Unlike Class III Vertex patients, who can be reasonably expected to evolve into the Class V or class VI type, with higher chances of the transition if they have family members with Class V or class VI patterns, with Class III patients it is impossible to accurately predict whether the pattern will stabilize at the current class or intensify into extensive baldness. However, if they show a significant, above 20%, amount of miniaturization, especially across the crown, the top of the head, but not on the bridge, even when they are quite young, can warn of the possibility of progression to Class IV or Class V patterns. It also indicates possibilities of progress to Norwood Class VI or Class VII patterns. With more spread out areas showing miniaturization, especially across the front and the top of their scalp, chances are that they may develop diffuse, patterned, or un-patterned alopecia. Experts seem to agree that the total extent of this type of miniaturization, especially in the regions of the recipient area, combined with the overall rapidity of the hair loss, can be the most important factor in predicting short term hair loss. People suffering from rapid hair loss show an over 50% degree of this sort of miniaturization within the area showing balding.

In most cases, the reason that a person would seek hair transplant consultation for a hair loss problem would be if there was some kind of noticeable change in their hair loss rate. Someone who has been gradually losing hair at a more or less even rate is not too likely to suddenly seek medical help. However, someone who suddenly seen a sizeable acceleration in how fast they are losing hair, are much more likely to seek help. Yet, most of the time, these are the very patients who are likely to be unhappy with the results of their surgery. This is where careful counseling, giving them a clear and complete understanding of the way balding progress can help immensely to create realistic expectations in the patient, and minimize unnecessary disappointment. It is imperative to define goals realistically and clearly before attempting surgery in the case of patients with sudden and rapid hair loss who may have adequate donor region reserves.

Often, long term diffuse hair loss, particularly when it is rapid, and in the young, can indicate a tendency to develop a Norwood VII hair loss pattern. Associated symptoms include a higher degree of miniaturization in donor areas, a significant amount of recession over both temples, and no evidence the definitive elevated triangular segment in the parietal region which indicates Norwood Class VI hair loss pattern. (In a Class VII pattern, when seen from the side, the superior part of the rim is flat, and often slopes backward gently. On the contrary, a Class VI patient shows an elevation with a peak just in front of the ear, which is a residue of a Class V bridge that had separated the front and rear portions of his scalp.) Sometimes, a younger patient may exhibit a loss of volume in his, although it may appear to be clinically normal. In such cases, if densitometry shows their donor density to be in the 1.0 to 1.5 hairs/mm2 range, and the donor miniaturization is 35% or more, the patient is in the high-risk group for extensive baldness and might end up with insufficient donor hair. This makes them unsuitable as candidates for transplant.

Planning — Effluvium and Progressive Loss of Hair

Hair transplantation can often result in varying levels of effluvium or shedding in the areas that receive the transplant. The implanted hair often exhibits an “anagen” effluvium resulting in shedding within two weeks of the procedure and affecting as much as 90% of the population of transplanted hair. In contrast, the original hair within the patient’s recipient area, close to where the implants are, can often begin to shed. This is called a “telogen” effluvium and occurs generally after a delay of a couple of months from the transplant, and the total loss of hair rarely, if ever, crosses the 50% mark.

The correct diagnosis would be evident from the examination of the hairs. The hairs that are in the state of anagen effluvium would be terminal hairs that exhibit a certain specific dysplastic type of changes, whereas the hairs that are lost due to telogen effluvium are going to be morphologically identical to normal resting hairs. However, hair that is more likely to be subject to a telogen effluvium will generally be the miniaturized hair, and neither the healthy existing terminal hair or any hair from a previous transplantation procedure is very likely to be affected by this effluvium. Remember that each miniaturized hair has a smaller diameter and is shorter in length as compared to the corresponding healthy terminal hair. While this does not much importance on an individual basis, the fact that these hairs can often be present as bunches, in large numbers, can have quite a clinical impact. For example, in the late stages of major hair loss, and balding the entire balding area might be almost entirely populated by such miniaturized hair.

Generally, telogen effluvium is more visible and significant during the more active stages of a person’s hair loss history. The amount of active hair loss can often be substantial, especially in young patients who are balding rapidly and where the recipient areas are characterized entirely by a very high degree of hair miniaturization. When telogen effluvium affects hair that might already be close to the end of the natural life span the resulting hair loss is often permanent. Unless significant amounts of hair are transplanted to these areas, the total gain from a transplant surgery might not be quite adequate to begin to compensate for the telogen effluvium hair loss.

Before attempting a procedure, it is of utmost importance that the patient understands what it involves. They must be told that performing a hair transplant, especially in the quite early stages of significant hair loss and balding, involves replacing large numbers of these miniaturized hairs with a smaller number of more healthy terminal type hairs. This means that while the actual density of hair can never go back to what it was in the beginning, the overall visible and clinical appearance can be much improved, since the terminal hairs have a general size as well as luster of the original hair, producing a much fuller appearance. However, the really important gains from the procedures are to frame the face and to avoid having to wait for a procedure until one is significantly balder. In terms of surgical planning, to decide on the number of implants for an area with significant miniaturization, the number of implants should be more or less what would be planned for an area totally devoid of any hair.

It is noteworthy that the actual trauma of the procedure and of creating the recipient sites might not be the only factor in inducing effluvium. Other factors, such as epinephrine’s vaso-constrictive properties and more may contribute to the effect. Hence, smaller graft sizes may not have a significant protective advantage as compared to larger ones. It might even be more important to offset the telogen effluvium levels by transplanting enough hair to ensure that the net effect even after effluvium is positive and pleasing.

The process of assessing the donor reserves for transplant

The two major factors in assessing and determining total donor reserves for a patient might be to determine donor density, as well as scalp laxity. In a normal Caucasian male who has not been surgically treated, the density of follicular units towards the middle of a donor area would be 1 unit/mm2. In short, ideally, the first procedure should yield something like one follicular implant for every mm2 of harvested scalp from the donor area, provided no wastage has occurred during the procedure. However, a certain amount of loss is certain, from the harvesting of the strip, while some loss occurs while dissecting individual units. How much, depends on how skilled the surgical team is.

In the longer harvested strips, the hair density decreases toward the temples and that must be considered when assessing the area. Even within the same localized area, some people can have a wide variation in density. In addition, errors are also likely because visual identification of hair type has limitations, especially in graying patients, because these telogen follicles, comprising roughly 10% of total hair population, are not identifiable with either densitometry or gross visualization, but only with a dissecting microscope.

The density of follicular units is constant, hence the donor hair density is a clear indication to what is the number of hairs per implant, and the quality to expect from each implant. If hair density is 2 hairs/mm2, then the donor area yield will be one unit per square mm. The implants might consist of equal quantities of 1’s, 2’s, and 3’s, with 2 hairs per implant being the average. With donor density of 2.3 hairs per square mm, it will lead one follicular unit per square mm, and the implants will provide 2.3 hairs per square mm with a mix of some 1’s, with more of 2’s and 3’s, with possibly a few 4 hair units. In case the scalp is already stretched because of previous transplants, scalp lifts, or scalp reductions, the units will be much further apart, making it necessary to measure the density to estimate the possible number of implants one can obtain from the strip.

Any kind of scarring from earlier surgeries will impact the ultimate yield as well since any scar left by a donor harvest will always cause some hair loss. Additionally, scarring alters the angle of any hair around it causing more transection during subsequent harvesting. The use of parallel blades with adjustable spacing and angled at 30 degrees instead of the multi-bladed surgical knife has reduced this kind of scarring. Making use of the tumescence in the subcutaneous fat layer, while harvesting implants, increases the overall margin of safety. Notwithstanding improved techniques, there can be damage to hair follicles, more so in previously scarred scalps, because of the angle of remaining hair being altered. Racial differences also impact the number of harvestable implants per mm.

It is often possible for someone to lose quite a substantial quantity of hair volume without really noticing a change. In people with blonde, or fair hair, or white hair, it is quite likely that they will lose much more hair before they notice any thinning. Dark hair, while thinning, lets the skin show, making it evident sooner. However, the loss in volume need not always be caused by hair fall or actual hair loss. It might also be due to a decrease in the volume of each of the hair shafts from substantial miniaturization. When deciding how much to harvest, if the person has an average density of hair with average attributes, as much as half the donor area can be safely moved without changing appearance significantly. On the other hand, when a person has a donor density 25% below the average, in other words, someone with 1.5 hairs per square mm instead of 2.0, movable hair will decrease by 50% to maintain the same amount of hair in the donor area, retaining the natural look. The examination of miniaturization, therefore, has to be part of any transplant evaluation. High miniaturization levels in donor areas might indicate significant instability in much of the donor hair which must be considered during surgical planning.

Once, donor density was considered critical in determining the final donor supply. However, scalp laxity also plays a more important role in the ultimate yield of donor hair. If the scalp is loose, the harvested donor strip removes only a part of the redundancy of the scalp without much effect on density. A tight scalp, however, would stretch the scalp skin, lowering the hair density. Although the full impact of this stretching in a tight scalp may not be apparent after the first procedure, however, each subsequent surgery will see a reduced capacity for non-tension closure as well as to harvest significant donor amounts. If the scalp is tighter than usual, long-term surgical goals have to be re-planned to deal with a limited donor hair supply. In fact, scalp reductions are generally not recommended because of these adverse effects on donor density and scalp laxity.

It is also considered the dimensions of the patient’s donor area. This is measured from three centimeters behind the hairline at one temple to the same portion of the scalp on the other temple. Ideally, the length should be 30 cm or more. A shorter length would require more conservative harvesting goals. The recession of hair at the temples might indicate extensive future balding. Densitometry can help assess how stable the hairline at the temple is. Another important factor is the height of the patient’s permanent zone which can vary widely, even within Norwood Class VII patients. Densitometry can measure miniaturization, assessing its possible future dimensions.

Expectations of the Patient

What a patient expects from a consultation is influenced by their age, the stage of their hair loss, and how rapidly they are losing hair. Younger patients who still have a clear memory of adolescent hair density and hairline are also more likely to experience rapid hair loss. They are the ones needing more education time and planning. Other factors of influence might be the social situation like the reactions of peers and significant others, or how they have dealt with hair loss so far, such as hairpieces, constant wearing of headgear, etc. the physician must adequately educate and set patient expectations right to ensure satisfaction.

The patient cannot be allowed to imagine that hair restoration actually restores the hair growth he has lost. Under ideal conditions, hair restoration only maintains the adult appearance, giving the patient the same “look” he might have acquired with age. It cannot and must not attempt to return the scalp to its adolescent appearance. It can, however, prevent the appearance of being bald, which is a significant difference to someone suffering extensive and rapid hair loss.

The greatest challenge for hair restoration in a young patient who is facing rapid hair loss is that extensive procedures may fail to compensate for the hair they will lose over the year while the implants grow. It is important for such patients to comprehend the dynamic process and nature of hair loss. They must be clear about the progressive nature of hair fall and balding, understand the realistic placement of hairline, the need to spare the crown, and understand the possibility of accelerated hair loss from surgery. It is better not to attempt surgery until these aspects are clear. Over time, the very progression of hair loss tends to make these issues tangible and real, making the education process simpler.

On the other hand, a patient bald for a certain number of years has more reasonable expectations and considerably fewer amounts of transplanted hair produce a noticeable change, unless they are used to a hairpiece. If they identify with the look a toupee provides, they will be as hard to please as patients in their 20s, because their reference point will be the thick hair of the toupee. If they wish to discard their hairpiece, one must determine the amount of transplant coverage necessary to achieve this. Unless this is made clear beforehand, the transplant can be disappointing, prompting the patient to go back to the hairpiece.

Patients with a limited amount of hair loss present a different kind of problem. For people seeing recent progression to a mature hairline showing hair recession at the temples, (Norwood Class II) from the recent adolescent (Norwood Class I) hairline has no need for a transplant. This evolution is normal, and the patient must be counseled that a flat hairline like adolescence would not look natural as he matures. Transplants may not be appropriate in the early Class III pattern patient, but older more mature Class III pattern patients who show a stable hair loss and more than average density can benefit from a transplant if they have no family history of extensive baldness. In such cases, surgically blunting the sharp angles of bitemporal recession to be appropriate.

Another issue that often arises is the time frame within which the patient has expectations of results. The follicular growth cycle can vary but the majority of the surgically transplanted hair will show growth at 3 to 4 months post-surgery in most cases, with more hair appearing slowly during the several successive months. A small minority of patients experience delayed growth with the bulk appearing between 4 to 8 months, and additional hair appearing for up to 18 or more months after surgery. Newly transplanted hair increases in diameter as well as in length, so this lucky subset experiences cosmetic improvement for longer.

The First Session is Critical

No matter how many transplant procedures may be planned, the first transplant is always the critical one. The patient sees this first session in a prophetic light, as a precursor or indicator of the future. The first transplant session can help build patient confidence, hence meeting expectations is important. This session will establish the hairline, and create the future frame for the face, placing hair in positions designed to camouflage later procedures.

In the majority of transplant patients, this establishment of the front hairline becomes the most important process of this first transplant procedure. The frontal hairline needs to be placed in the normal, mature hair position, framing the face, restoring balance to the facial proportions in an age-appropriate manner. It is preferable, in our opinion, to avoid the common practice of beginning a hairline far above the position of the mature hairline and then lowering it with subsequent procedures. Even when trying to conserve hair, as a result of a limited donor hair supply, one must attempt to maximize the procedure’s cosmetic impact by creating a little more bitemporal recession or extending the transplant less far toward the crown. The position of mid-portion frontal hairline defines the person’s look, and must not be compromised. A too high hairline, in the attempt to conserve donor hair, will accentuate baldness by making the forehead larger and distorting facial proportions.

The first session must also aim to provide adequate coverage to all remaining portions of the bald scalp except to the crown. Norwood Class A pattern patients, do not experience hair loss over the crown area. If possible, the first session should treat the entire bald area. Even if the coverage is fairly light, an attempt must be made in the first session to cover both the front as well as the top of the scalp. The areas of the scalp that already have sufficient coverage need not receive transplants, although the transplant edges must be blended with the natural hair-bearing scalp. If the encroachment is too aggressive it can accelerate hair loss reducing the cosmetic benefit of the procedure. Attempts to restore adolescent density or hairline are cosmetically unnecessary and mathematically unreasonable, and patients desiring such a result must be further counseled before surgery.

As a general rule, crown coverage is not an appropriate first session goal and must be addressed later, after achieving the cosmetically important goal of front and top coverage. Being a single unit cosmetically, when the transplant has covered the front and top areas, it may even be discontinued. It would then be up to the patient to evaluate the resulting coverage from this first session. If he should desire further fullness and density, he can schedule a second session to supplement the first transplant. Attempting crown coverage at the first session can limit, or permanently eliminate the options for producing a balanced and aesthetic transplant. The exception to this rule is the Norwood Class III Vertex as well as the Class IV patients, over 30, who have a far lower risk of extensive baldness, have strong donor hair density as well as superior scalp laxity. In such cases, transplanting to the crown can give some coverage and camouflage a bit of further balding in the crown area. However, the high-risk practice of repeated transplantation into the crown for high density must be avoided.

Apart from the aesthetic issues giving importance to the first session, there are advantages for a surgeon working on a previously untouched scalp. The implants are easier to place, they remain more secure, and they can be placed much closer together because the elasticity of a normal scalp and the blood supply and connective tissue is completely intact. As for the donor area, that too has a maximum density on a fresh scalp, and the mobility is better because a lack of the previous scarring facilitates a better hairline closure. Given these advantages, the first session should try to achieve as much of the final transplant goal as surgically possible. It is best to achieve as much as safely possible in one surgical procedure rather than stretch it out over multiple procedures.

When to Consider a Single Session Transplant

Although it is evident that a lot can be achieved in the very first session, it is still wise to be realistic in goal setting and deciding what can be safely achieved in a single procedure, or which patients are best suited to single transplants.

As stated previously, the principal goals for a first transplant session are:

  • To frame the face
  • To gain coverage at the front, and/or top and vertex areas of the scalp
  • To gain a natural appearance

As a general rule, in order to suggest a single session transplant, the physician should be sure that the patient has a more or less stable rate of hair loss, especially if he is in Norwood Class III, IIIa, IV, or V categories. In such cases, the patient’s own hair adds to the front of the scalp’s cosmetic appearance. For patients with little or no frontal hair, a first procedure would frame the face while providing coverage to the back, so that a second procedure may not become necessary even if further balding occurs. In the case of Norwood Class VI or VII patterns, where the top and front of the scalp are transplanted adequately in a first procedure, there would not be a need for a second as any further balding at the crown would be relatively inconsequential. In case coverage is attempted at the crown, expanding the bald crown could isolate the centrally transplanted hair grafts necessitating further surgery.

A person, who has lighter colored hair, has a better chance of meeting his aesthetic goals in a single session because the colors will reflect the light and create the illusion of more hair, while the low contrast of the hair with underlying skin adds to the illusion. In people with dark hair and light skin, any interfollicular space is accentuated, whereas salt and pepper hair reflects the light and creates a distracting visual detail taking attention away from any sparseness. It might be advisable for a patient to change to good hair color to act as a complement to the single surgical procedure.

Additionally, wavy hair generally provides better sparseness coverage so, one can consider manipulating straight hair into a wavy appearance after surgery to add to the cosmetic effects of a transplant. However, very curly hair can be a disadvantage especially when a complete coverage cannot be anticipated. This type of hair may accentuate the over the fullness of transplanted hair as contrasted with remaining bald areas. It is also not easy to comb back this type of hair from the transplanted areas at the front or top to cover the un-transplanted bald crown.

The result of the procedure may also depend partly on the follicular density of the donor area. With a high density, each implant harvested will contain multiple hairs, and a sizeable number of implants might contain 3 or 4 hairs each, giving the transplanted area very full appearance.

The best chances of single transplant success are in cases with hair of average, or of above-average diameter, since the volume of the hair is different. It is a huge variation, the diameter and the weight of hair, and is much more difficult to determine than density which varies by only a factor of 3. The weight of hair varies from one patient to another by many factors. Density is easier to quantify than weight, but weight probably has more significance in the final outcome. Early balding in patients with fine, high-density dark hair are difficult to rectify with a single session procedure. The finer transplanted hair is set off by the background of the existing thick hair around the bald area, making it noticeable. A similar case with a patient who has coarser hair would give better aesthetic results and satisfaction even with a single transplant session.

Unexpectedly, an extensively bald person can often feel satisfied even after a single procedure, even with low donor density. They are more likely to have reasonable expectations, plus they feel better about having a frame for their face after years of baldness, even if it is only light coverage. In general, to ensure that expectations are met even with one session, one must take supply and demand into account. With patients in Norwood Class VI and VII patterns, it is only possible to achieve light or modest coverage with a single session of transplant, because the recipient area exceeds donor supply by 6 to 1 or more.

Finally, post-surgical grooming will influence the final success of single transplant procedures. Patients who will comb to the side instead of straight back achieve a better appearance of fullness, although it will not give much crown coverage. The best way to achieve aesthetic results might be to comb the hair diagonally to the back.


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