ADVANCED HAIR RESTORATION: CONCEPTS FOR EXPERTS
As explained by Dr. Epstein

For most of my patients, my reassurances that the results of their transplant will be undetectable with moderate density, coupled with viewing photos of and speaking with one or more of my former patients, is sufficient for allowing them to make their decision.

Not infrequently, however, I consult with patients who are seeking more scientific and detailed explanations of what to expect. It is always my pleasure to discuss with them all the advanced issues involved in hair transplantation, particularly as to how it applies to their particular case. Because of the importance of this educational process, I choose to perform all of my own consults personally, not relying upon a "consultant" who typically is nothing more than a salesperson.

What follows is a discussion of some of the more esoteric, scientific issues involved in hair transplantation.

Understanding the relationship between naturalness and density and the factors that go into these two primary goals of every patient is essential.

First and foremost, it is my goal to achieve the most natural appearing hair transplant for every patient. Since devoting my practice full-time to microscopic follicular unit grafting in 1999, I have had the technical ability to achieve this elusive goal. However, it is the artistic aspect that assures that undetectability can be attained. I like to think of the grafts as the "paint" with which I use, but it is only through perfect brush strokes that a "masterpiece" can be achieved. These brush strokes are the individual recipient sites that I personally make, which determine the pattern of hair growth, the direction of growth of each individual hair, and the position of the hairline. Let's take a look how each of these three factors fit in.

The pattern of hair growth - there are two main concepts here. First: most natural non-transplanted hairlines consist of a feathered hairline with fine single hairs, progressing to greater and greater density as it proceeds centrally. This is achieved by using the finest one-hair micrografts along the hairline, with more closely placed two-hair micrografts behind them, until the central forelock of maximal density is achieved by the closest placement of three-hair micrografts. Second: close observation of the natural hairline reveals that there is both macro-irregularity (the undulating up and down curvature along the anterior hairline that my Australian colleague Dr. Jennifer Martinick refers to a "snail's trail"; and micro-irregularity (alternating zones along the anterior hairline of greater and lesser density). Recreating this macro and micro-irregularity (see, I warned you that this would be an advanced discussion) creates, you guessed it- naturalness.

The direction of hair growth - through proper angulation of the individual hairs, naturalness and density can be maximized. Essentially, by directing transplanted hairs to grow in a more anterior direction, and having the hairs thus grow forwards (rather than straight up as I so often see in patients seeking reparative procedures), the appearance is more natural, and the density is maximized. At times, to further enhance density, it is possible to make the individual recipient sites in a coronal (side to side) rather than sagittal (front to back) orientation. Enough said about that.

The position and shape of the hairline - the third key to assuring a natural result. I spend a great deal of time and effort analyzing each patient's facial structure and shape, as well as discussing with them their expectations, to come up with a hairline that is in harmony with their face and achieves their goals.

The uncontrollable factors: donor site density and the quality of donor hair

To return to the fine art analogy: if we think of the recipient sites as the "brush strokes", and the grafts as the "paint", it is the microscopic dissection process that creates the "paint", while the actual donor hairs are the "ingredients that go into the paint". These "ingredients" include the color and curl of the hairs, the caliber of the individual hairs (fine versus thick), and the density of the donor areas (how close the hairs are to each other). Genetics determine these factors, and they definitely have an effect on the final outcome of the procedure.

For example, in patients in whom the hairs in the donor area are light in color, fine in texture, and spread out from each other, a natural appearance will be easier to achieve, but the density will be somewhat low, despite how close together I am able to place the grafts. On the other hand, in patients who have thicker, darker hairs that grow densely together, density will be greater because the hairs are thicker and the individual follicular units will contain on average more hairs, but more attention to detail must be paid to assure that an undetectable hairline is achieved. Furthermore, because of the greater density of the donor area, I will be able to transplant a greater number of grafts, sometimes as many as 3,000 or more in a single procedure, assuming the patient is a candidate for a large megasession.

Micro/minigrafting versus follicular unit grafting versus follicular unit extraction- Which is the best?

Without being too presumptive, it can be said that follicular unit grafting (FUG) is the gold standard in hair transplantation, despite the fact that the majority of hair transplant surgeons and the large hair transplant clinics do not offer it or offer it in a "bastardized" format. It is only through the binocular microscopic slivering and dissecting of each individual graft that the patient can be assured of: no scarring in the skin of the area of the transplants; as much as 30% more hair will grow due to the more careful and accurate process of the dissection (with rates of hair growth as high as 90% and greater); healing will be quicker (typically 7 to 8 days versus 10 or more days until the crusting completely falls off); only 1 hair grafts will grow along the hairline (rather than accidentally 2 or 3 hair grafts in this area that "shout" hair transplant); and, the overall result will be more natural because hairs will continue to grow in their natural state of "follicular units".

A greater allocation of resources is required to perform FUG properly. In my office, as many as 10 assistants will perform the dissection of a single patient's grafts. By using this many assistants, perfect grafts can be achieved, and the procedure can be completed in the shortest amount of time, thus assuring the best rate of hair growth (as with any transplant procedure, such as of a kidney or heart, the shorter the period of time that the organ or hair is out of the body, the better the chance it has of surviving).

Finally, follicular unit extraction, or as I call it, follicular unit microextraction (FUM), is a relatively new procedure that has a small but definite role in the field. With FUM, rather than removing the donor hairs as a single strip from which thousands of grafts are dissected out, the grafts are instead removed one at a time using a tiny (1.3 mm or smaller) circular punch. A very demanding and exacting procedure, FUM relies upon the surgeon (me) to perfectly align this tiny punch with the direction in which the hairs in a single follicular unit of usually two or three hairs are growing. As you guessed it, the procedure is challenging, and in certain patients, especially those with curly or fine hairs, it is not very successful. For the approximately 25% of patients who are appropriate candidates, the limited numbers of grafts that can be harvested in a single procedure (ranging from 300 to as many as 500 grafts before I cannot see straight) limit its suitability, as patients often need to undergo multiple procedures. However, the benefits of avoiding a donor site incision more than compensate for the increased cost and limited single procedure results for a small percentage of patients.