NHI Medical – World Renowned Hair Restoration Doctors

Our doctors have put together a list of General Questions about hair loss and hair restoration. As always, if you have specific questions, you should consult a doctor specializing in Hair Restoration.

General Questions

What can be done to minimize the effects of post-op shedding?

The first is using medication, the second is timing the transplant properly, and the third is performing a procedure using a sufficient number of grafts. Finasteride 1mg reverses or halts the miniaturization process in many individuals and is thus the logical way to decrease the risk of shedding following a transplant. Although many physicians have the clinical feeling that that this assumption is correct, there has been no controlled studies to date that prove this. Timing and the size of the transplant are the most important issues. It is important to wait until a patient is ready to have a transplant, and then to perform one of sufficient size so that if there is some shedding, the procedure will more than compensate for it – and be worthwhile. A problem that patients often run into is that they present to their doctor with early hair loss but with a significant amount of miniaturization. The doctor performs a small procedure and it doesn’t even compensate either for potential shedding or for progression of the hair loss. The result is that the patient is thinner (or more bald) than he was before the procedure. The doctor rarely blames the problem on the fact that the procedure was too small or that there the miniaturization was not taken into account, but only that the patient continued to bald. The better solution is to treat early hair loss with medication, but once you make a decision to begin surgery, and then have a procedure large enough to make a significant cosmetic improvement. As a final point, it is a fallacy that some doctor’s techniques are so impeccable that they can avoid effluvium or those “small” procedures will avoid shedding. Of course, bad techniques and rough handling will maximize effluvium, but effluvium is what hair naturally does when the scalp is stressed and it is stressed during a transplant from the anesthetic mixture and the recipient site creation. It cannot be totally prevented. In sum, the best way to deal with effluvium is to treat with Finasteride when hair loss is early, perform a transplant only when indicated and finally, to perform a procedure of Follicular Unit Transplantation with skill and with a sufficient number of grafts.

My doctor rubbed the back and sides of my scalp and told me I have plenty of hair. Can I trust this opinion?

We are all born with a finite amount of hair. Whatever the approach, no new hair is created. Scientific measurements, such as densitometry, provide the surgeon with much greater accuracy than subjective assessments when estimating your total supply of permanent hair. Accurately estimating your total donor reserves for proper long-term planning cannot be over emphasized.

My doctor told me to try a few and see if hair transplantation is for you! Is this reasonable to do?

Hair transplantation should only be started after a long-term master plan has been established. The “try a few” mentality is totally inappropriate for it does not fully inform the patient of the potential problems involved with starting a process which they may not wish to complete.

What are the reasons for male pattern balding?

The tendency towards male pattern balding is genetic and can be inherited from either the mother or father. Balding is actually triggered when dihydrotestosterone molecules chemically bond with special receptor sites on hair follicle cells. This causes the hair follicle to weaken (miniaturize) and eventually to die.

Why do hair transplants work?

Even in the most extreme balding patterns, a permanent ‘wreath’ of hair exists on the sides and back of the head. This hair is unaffected by the balding process. In Follicular Unit Hair Transplantation, a thin strip of skin containing this permanent hair is removed from the back of the head (because the skin of the scalp is flexible, the scalp can be sutured together again after the strip is removed leaving little trace that anything was done). The hair follicles are then carefully removed from that piece of skin and placed in very small surgical sites made in the thinning or balding areas of the scalp. Once transplanted, this hair behaves as it was programmed to behave in the original area it came from and will grow naturally for the rest of your life.

How do I know if I’m a good candidate for hair transplants?

Most men in good general health are candidates for hair transplantation. In order to determine your candidacy, you should arrange to have a private consultation with a NHI physician. During your consultation, the physician will measure your donor density and scalp laxity. He will also determine your balding pattern and take your individual hair characteristics such as color and wave into consideration to develop a plan for your hair restoration.

Why start now?

If you have been determined to be a candidate for restoration by a NHI physician, and if you are uncomfortable with your hair loss, why not start now? With your restoration completed, you can get on with life without this distraction.

Is it better to begin early?

A hair transplant should begun when your degree of hair loss is unacceptable to you. Not when you are only worried about future loss or “So no one will notice.” Starting early will often require multiple small sessions, and your expectations may be unrealistic.

How much hair do I have?

The Norwood classifications were adapted from the patterns described by Dr. O’Tar Norwood. There are seven classes of hair loss in the main series and five variations of these classes called the ‘A’ series. If you compare your hair loss pattern with these diagrams, you can probably see the pattern you are in now. Discussion with one of NHI’s knowledgeable physicians can help you determine how extensive your hair loss may become.

How much hair do I need?

When you have your consultation with a NHI physician, he will suggest how many grafts may be available for your first procedure (and subsequent procedures if they will be needed). This number will be based on your present balding pattern, what it may become in the future, and how much donor hair is available. When an individual has high donor density, the follicular units usually contain multiple hairs, and when an individual has low donor density the follicular units often contain only one hair. If an individual has a very loose scalp, a larger donor strip can be removed, while an individual with a tight scalp will have a smaller donor strip. When an individual has a relatively small amount of hair that can be moved, our physicians take great pains to distribute the available hair in ways that produce the best coverage.

What is the difference between density and fullness?

The word fullness rather than density, more accurately describes the visual phenomenon in what we perceive as thick hair vs. thin hair. The concept of fullness is broader and more inclusive. Density, the number of hairs/cm2, is only one of several contributing factors that are responsible for the visual impression of hair that appears “thick”. Other factors include hair shaft diameter, color, texture, and curl, which may be of equal of even greater importance than density, in contributing to the visual appearance of a “full” head of hair. In the early stages of balding the “thin look” is caused by a process called “miniaturization” where hair is reduced in size, but not actually lost. Therefore, the density (the counted number of hairs/cm2) remains the same, although the persons look of fullness can be dramatically reduced.

Will smoking affect my hair transplant procedure?

Smoking causes constriction of blood vessels and decreased blood flow to the scalp, predominantly due to its nicotine content. The carbon monoxide in smoke decreases the oxygen carrying capacity of the blood. These factors may contribute to poor wound healing after a hair transplant and can increase the chance of a wound infection and scarring. Smoking may also contribute to poor hair growth. The deleterious effects of smoking wear off slowly when one abstains, particularly in chronic smokers, so that smoking puts one at risk to poor healing even after smoking is stopped for weeks or even months. Although it is not known exactly how long one should avoid smoking before and after a hair transplant a common recommendation is to abstain from 1 week prior to surgery to 2 weeks after the procedure.

Will senile Alopecia affect my hair transplant procedure?

Diffuse un-patterned and patterned alopecia is uncommon. The medical descriptive term ‘senile’ appears in literature; unfortunately, the word implies that it impacts only the old and senile, which is not the case. It has appeared in almost every age group somewhat equally, but as each carries the malady throughout its life, the frequency increases as the population ages. However, Senile Alopecia is a more commonly accepted diagnosis for the younger population, potentially skewing population data. As a guess, its incidence amongst men is 1%. Prior to the advent of Propecia, recognizing the malady did nothing more than eliminate surgical candidacy. Now with Propecia, effective treatment is available for some. Approximately 50% of affected individuals that saw doctors at NHI have realized benefits from the drug. Most saw reduced miniaturization and a subjective appearance of additional fullness. Despite these desirable drug benefits, impacted alopecia patients seem to finish with less than desirable surgical results.

How long should I wait between hair transplant procedures?

At NHI we routinely schedule a second surgery 8-12 months after the first for the following reasons: At 8-12 months, hair length is adequate to see the effects of styling. With that in mind, the patient can work concomitantly with the surgeon to make many of the decisions regarding further distribution of grafts, and the process is more ‘owned’ by the patient. Occasionally, when hair first begins to grow, its texture may be slightly different from your original hair. After 8-12 months this generally returns to normal making decisions about the grooming easier, and grooming preferences may affect the way the next procedure is planned. Some patients have cyclical growth, which means that all of the growth may not be in and of adequate length at 4 or 5 months. Waiting the few extra months gives the person enough time to see hair growing and this can be a psycholigical advantage for the patient. Seeing the hair allows the surgeon to clearly see where to place the new grafts. For those patients with tighter scalps, the skin has a greater time to restore some of its previous laxity.

Most consumers and patients take for granted that board certification implies some level of expertise and qualification of a doctor. What is the importance of this?

In the United States there are 24 approved medical specialty boards that are overseen by The American Board of Medical Specialties (ABMS), a not-for-profit organization. Certification by an ABMS Member Board has long been considered the gold standard in physician credentialing. To be ABMS board certified means that the physician has undergone formal educational and clinical training with adequate supervised activities a medical institution AFTER earning their medical degree. After this training, they must successfully pass a level of competence through written and oral examinations. Hair transplant surgery is not a part of the ABMS so there really is not a board certified hair transplant surgeon in the traditional sense the public thinks of. Learn More

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Shock Loss

What is the medical term for shock loss?

The medical term for the very onerous sounding “shock hair loss” is “effluvium” which literally means shedding.

It would be very disconcerting to go through a transplant procedure, only to have a high number of currently perfectly good hairs fall out in the process. Is this possible from shock fall out?

It is usually the miniaturized hair i.e. the hair that is at the end of its lifespan due to genetic balding that is most likely to be shed. Less likely, some healthy hair will be shed, but this should regrow. Rarely, but sometimes, we notice some shedding of hair from a prior transplant when transplants are spaced less than one year apart. However, this hair grows back completely.

How much fallout typically occurs?

For most patients, effluvium is not a major issue and should not be a cause for concern. In the typical case, a patient looks a little thinner during the several month period following the transplant, when the transplanted hair is in its latent phase. It ends when the transplanted hair begins to grow. The thinning is often more noticeable to the patient himself, than to others. Shedding is generally noted as a thinning, rather than of “masses of hair falling out”, as the term “shock fall out” erroneously suggests.

On what variables does the degree of fallout depend?

In general, the more miniaturization one has and the more rapid the hair loss, the more likely will be shedding from surgery. Young, actively balding patients would be at the greatest risk. Older patients with stable hair loss would have the least risk.

Techniques

What is Follicular Unit Transplantation?

Follicular Unit Transplantation, a technique pioneered at NHI, is the transplantation of very small, individual, naturally occurring groups of hair called follicular units. Follicular units are comprised of one, two, three and sometimes four hairs each. These units are placed in thinning/balding areas following carefully studied natural hair growth patterns. The results are incredibly natural in appearance.  Learn More

What is Follicular Unit Extraction?

Follicular Unit Extraction is a technique used for harvesting individual follicular units during hair transplant surgery.  Each naturally occurring group of follicles, or hair grafts, can contain up to four individual hairs.   The hair transplant surgeon uses a special manual surgical punch to remove the grafts from the donor area of the scalp.  Robot-assisted surgery can also be used to perform an FUE procedure. Learn More

What is the primary difference between FUE and FUT?

During an FUT procedure, the hair transplant surgeon will cut a strip of skin from the donor area in the back of the patient’s head. The strip is dissected into individual follicular units and prepared for transplantation. The open wound left from the removal of the strip is sutured together and ultimately results in a linear scar once the donor area is healed. Visibility of the scar is dependent upon the skill of the surgeon, the patient’s ability to heal and the length of hair worn over the donor area. During an FUE procedure, the hair transplant surgeon will remove individual follicular units from the donor area using a special surgical punch. This approach leaves small punctate scars on the scalp once the donor area is healed. These scars are the size of a small ballpoint pen. The surgeon will remove the follicular units in a random pattern throughout the donor area thus leaving the patient with an even distribution of punctate scars. This uniform distribution technique eliminates the potential for the donor area to end up looking moth-eaten. The patient can confidently wear his hair long or very short over the donor area since the FUE scars are not noticeable to the naked eye.

Do I have to shave my hair from the donor area before my FUE procedure?

The donor area should be cut in buzz cut style in order to maximize the number of grafts extracted during a single FUE session. For patients with long hair, FUE can be performed by shaving multiple layers of three to four millimeters separated by flaps of longer hair that can cover the donor area. It is important to note that performing FUE in this manner may require additional FUE sessions. Long Haired FUE is an option invented and regularly performed at NHI. Ask your doctor about Long Haired FUE during your initial hair transplant consultation.

Do all hair transplant surgeons use the same tools when performing FUE?

Different doctors use different tools. The diversity of instruments among doctors is so varied that many surgeons develop their own specialized tools. For example, some doctors use a sharp surgical punch while others use a dull one or even a combination of both. Some FUE surgical instruments resemble a dental drill that rotates at a specific speed and others vibrate like a cast cutter used to remove a plaster cast from a broken arm. All of these tools produce similar results that suggest that no specific tool or technique works for every surgeon. Regardless of the types of surgical tools used to perform FUE, the most important factor is the survival of the hair graft once it is removed from the donor area. Ask your hair transplant surgeon what type of FUE instrument he uses when you meet with him at your initial hair transplant consultation.

How do doctors get qualified to perform FUE?

There is no formal training or certification available for manual FUE. Many doctors train with other experienced surgeons and then return to their own clinics and continue to learn by trial and error. In surgery, there is no substitute to human learning. The key is to learn from a hair transplant surgeon who has a long history of successful hair transplantation and who has a highly skilled surgical team with proven quality control mechanisms in place.

Is it better to pre-make recipient sites or to use the stick and place method?

We prefer to pre-make recipient sites for the following important reasons: Control of transplant design By making all the sites himself, the physician has complete control over the aesthetics of the surgery i.e. the angle of distribution of each follicular unit and the overall design of the transplant. If the physician is highly skilled, this is an extremely important advantage. Less popping When sites are pre-made there is less popping, since the act of making the sites (in stick and place) puts pressure on the surrounding skin causing adjacent grafts to pop. Popping can be a significant cause of graft warming and desiccation, which can decrease graft survival. Because there is less popping, grafts can be placed closer together, increasing the density. Easier sorting of Follicular Units When all of the sites are pre-made it is easier to sort follicular units so that you can use the larger units to create central density and the 1-hair units for the frontal edge of the hairline. In stick and place, sorting is much more difficult since the grafts are placed as they are cut. Pre-made sites can be made the day before the surgery. Less bleeding The body’s natural coagulation has a chance to work so that there is less bleeding and better visibility during the surgery. In our opinion, the purported advantages of stick and place (i.e., less chance of piggy-backing and missed sites) do not out weigh the many advantages of pre-making sites. In addition, these small advantages can be compensated for by appropriate techniques.

Do large grafts produce a better, denser result than smaller grafts?

Can a portrait painter create a better portrait with a house painter’s equipment i.e. by using a roller rather than a brush? The use of an artist’s brush is analogous to the use of very small grafts. High-quality hair transplants require fine instruments and delicate, small grafts. These grafts must be distributed in a way that balances the facial features, hair characteristics, and goals of the individual patient. Large grafts simply can’t offer sufficient flexibility to allow this “customizing” and their unnaturally high density doesn’t take into account the progressive nature of hair loss, placing the patient at great risk of having an unnatural appearance in the future. You can see for yourself what large plugs create. I don’t believe anyone today wants them. Learn More

Is removing large amounts of donor hair unsafe?

This is a statement commonly made by doctors who lack sufficient experience, or technique, in performing large sessions. The amount of hair needed for the average large session is well within the safe limits of what can be moved, provided that the procedure is done properly. It is the experience and judgment of the surgeon that will insure that the amount of hair that is harvested from the donor area is safe and appropriate. This is discussed in the following section: Learn More

Is it true that the blood supply of the scalp cannot support a large session?

No. People who make such comments don’t understand the oxygenation process in the transplanted grafts or the anatomy of the scalp’s circulatory system. The issue is one of oxygenation, not blood supply. By their very size, large grafts over 2 mm, will result in oxygen deprivation to the hair located in their center. This has been proven over and over again by observing the phenomenon called donuting (the loss of hair follicles in the center of larger grafts). In contrast, oxygen diffuses easily into grafts 1 mm or less in size. The blood supply of the scalp is among the richest in the entire body, enabling it to support the growth of large numbers of grafts, provided that they are kept very small. The Follicular Transplantation procedure performed at the New Hair Institute insures that these implants are kept to their optimum size. With this said, there can be problems if a doctor doesn’ know what they are doing as reported cases of gangrene (scalp necrosis) has been reported when a doctor used the wrong anesthetics or needles that were too large to make recipient sites.

Do scalp reductions save hair for future loss?

No! Hair is a limited resource. It is used up regardless of how it is moved and scalp reductions are just another method of moving hair around. Scalp reductions move hair to the crown at the expense of the front of the scalp, the cosmetically more important area. As a result of the reduction, the hair in the sides and back of the scalp is reduced in both density and looseness (This is why the procedure is appropriately called a “reduction”). The hair on the sides and back of the head thins considerably through the process and this, together with the tighter scalp, makes it more difficult to move the hair to the cosmetically important areas such as the frontal hairline and front part of the scalp. After a scalp reduction, the surgeon may never be able to harvest enough hair to complete the transplant. In addition, the scalp reduction can cause problems such a scarring, a thin scalp, altered hair direction, and a host of other unwanted effects. No wonder that the use of this procedure has dropped so dramatically in recent years! Learn More

Are lasers state-of-the-art technology?

No! Lasers are used by some hair transplant doctors to make the recipient sites. The laser works by using a beam of very high energy to burn a hole in the skin. But, regardless of how precise the laser, it still works by destroying tissue i.e. by making a hole. The beauty of Follicular Unit Transplantation is that the tiny follicular unit grafts can fit into very small sites that are made with a needle poke rather than by an instrument that removes healthy tissue. In Follicular Unit Transplantation, the blood vessel rich tissue that it is to receive the grafts does not need to be destroyed, so the growth is maximized.

With new surgical techniques, is it possible to restore a full head of hair?

No! All hair transplantation procedures move hair around to make you look better, but none create more hair. However, if performed properly and on the right person, it can make an incredible improvement in your appearance. The actual amount of hair you need may be as little as 25% if your original hair density. Those people with less severe balding can get a far higher density and come closer to their original look as long as the supply of donor hair is enough to meet the demands of the recipient balding area. This is something that you must speak with one of the doctors about.

If I am unhappy with a transplant performed by another doctor, can I have repair work done at NHI?

Of course, it is always better to do things right the first time. Unfortunately, many individuals have had hair restorations with less than satisfactory results. NHI has been able to develop strategies that can effectively camouflage many of the mistakes caused by less sophisticated procedures. Individuals have come to NHI from all parts of the world for repairs. To determine if you are a candidate for repairs, you should arrange a private consultation with a NHI physician.

Medications

Curious about medications in the hair restoration industry? We break that down more here.