View Full Version : Conundrums, ideas, and solutions

John P. Cole, MD
04-06-2012, 08:01 PM
This section is supposed to be for hair transplant results. After reaching over 13,000 hair transplant results, I did not know what more value there was to showing before and after results. After pushing the envelope on procedures since 1990 until now, I was not sure what would be of interest to patients. Then suddenly after seeing a post showing over 9000 grafts in a single procedure, it dawned on me. What patients need is not so much a documentation of before and after results. What is of value is a feature on hot topics designed for education to both physicians and patients. The overall objective is to bring up a topic and have physicians and patients post their personal opinions based on experience and insight.

As I have already stated, I performed over 7000 grafts first in 2003 and then I exceeded 13,000 grafts in 2005. What I found in these super-mega-sessions was what the results were highly variable. Sometimes they were quite good and sometimes they were not good at all. My conclusion was that we should not exceed 7000 grafts and 7500 was probably the top. Fast-forward to 2012 and we now have another physician exceeding 9000 grafts. This result may turn out great especially considering that the patient really started with a good bit of coverage. Then again such density may overwhelm the bodyís capacity to handles such a load of anoxic tissue that free radicals along with reperfusion injury. All of which may overwhelm the bodyís capacity to deal with the transplant load. No one knows for sure, but my personal experience is that some patients do well with large numbers of grafts in an isolated area and some patients do poorly. Furthermore, you canít get much to grow subsequently. Therefore, I donít recommend such large sessions, and Iíve been saying this for many years.

Perhaps some other physicians have experience in these super-mega-sessions. I already know of one other physician who has exceeded the 9000 graft mark well before this most recent example. Iíd like to hear their experiences and results. Such remarks would be of value to physicians and patients alike.

I belong to a group of experienced hair transplant physicians who trade emails daily. The group consists of over 40 physicians. We all learn from one another. I thought it of value to open the forum up to more physicians and include patients. Obviously we cannot discuss private matter in this open forum, but we all have the opportunity to educate and learn from one another. So, Iíll start it off with one topic.

Now another topic of value.

Following a hair transplant, the relocated grafts are supposed to loose their hair. This is due to a transition from the growing phase to the resting phase. Nobody knows why hair shifts from the growing phase to a resting phase following a hair transplant. It happens in almost 100% of hair transplant patients, however. Rarely, very little hair falls out. Why does hair stay at times?

Here is what we know. We know that hair shifts from the anagen phase to a resting phase abruptly. This rapid shift is termed anagen effluvium rather than telogen effluvium. Telogen effluvium is a loss of hair when resting hair is avulsed when new anagen hair resumes growth. Telogen effluvium is a normal cycle with all hair, which grows (anagen), shifts to resting (catagen), and rests (telogen). Telogen effluvium is the loss of hairs when new growing hairs push the old resting hair out of the way. This is similar to when adult teeth push the resting baby teeth out of the way. The difference with hair is that the growing, resting, and avulsing phases occur over and over, where as with teeth the transition occurs only once. Telogen hairs have a normal club structure. The avulsed hairs from anagen effluvium following hair transplantation have a characteristic ďJĒ shape.

Following hair transplantation, hair is supposed to fall out. Often times the hair does not fall out entirely. This may lead to a retained hair protein fragment that lacks supporting cellular structures such as the dermal sheath, outer root sheath, and inner root sheath. This retained hair fragment is in reality a foreign body to the skin. Eventually, the skin will either isolate it by forming a dry cyst similar to a black head around the hair follicle or a wet cyst more similar to a red, raised pimple around the hair follicle. The body will either wall off the foreign body (dry cyst) or attempt to extrude the foreign body (wet cyst).

Hair transplant recipients often do not understand what is happening. What they do know is that they are concerned about their hair loss enough to have submitted themselves to an elective hair restoration surgery procedure. When the grafts are placed, patients tend to follow a hands off protocol. Transplanted hair will often come off with the scab. Cleansing products that accelerate scab removal such as Haircycle Biotin Spray often eliminate scabs quicker, but leave the resting, non-growing hair on the scalp. Patients are afraid to aggressively scrub their scalps following a hair transplant out of fear that they might inadvertently damage their grafts. This often results in many retained hair follicles that can lead to foreign body affects (dry and wet cysts). Dry cysts tend to be painless like a black head. Wet cysts tend to hurt like an inflamed pimple or boil.

Dry cysts tend to develop over time. Wet cysts tend to develop about the time hair resumes growth. For this reason, many physicians attribute wet cysts to ďingrown hairĒ. I have challenged physicians for years to demonstrate that these wet cysts are due to ingrown hairs, but it is extremely rare to find an ingrown hair in one of these cysts. An ingrown hair will have greater length and it will be coiled like a spring. They do occur randomly, but rarely. Most wet cysts in fact are due to retained non-growing hair follicles.

The problem with non-growing hair follicles beyond cyst formation with or without pain is the post-inflammatory consequences. These consequences are the unknowns. The unknowns might be post-inflammatory autoimmune reactions that impair follicle growth. No one knows for sure, but inflammation might lead to poor growth. Perhaps there is a critical mass where the degree of inflammatory response triggers an overwhelming response that wipes out follicle growth. This is my concern and this is why I recommend that patients attempt to remove non-growing hair follicles.

The first thing to recognize is that transplanted hair follicles will elongate following hair transplantation. Then these follicles will cease elongating and remain a specific length. When patients see hair in areas that were void of hair to begin with, they get excited. Many times they forget that these non-growing hair follicles are destined to fall out with or without their help. They do not want to risk damaging their hair transplant so they leave the resting follicles alone. The mistake is that the non-growing hair follicles should be removed. The long term result may be the same, but then again it might not so the prudent action is to remove non-growing hair follicles.

This case demonstrates retained, non-growing hair follicles that were transplanted about one month ago. The patient was quite wise to limit the height and breadth of his hairline because over time he is headed to a NW class 5. By liming the location of the hairline today, we are able to add more hair volume to the entire area over time or to make a higher hairline more congruous with crown loss at a later point in life. In other words, Iím no fan of low, broad hairlines because it is impossible to restore 50 or 60% of ones total hair loss from the remaining 40 to 50% of hair. Crowns in general require nearly 100% of the original hair mass to look full while 30 to 40% will usually suffice in the front. Still the math does not work out so low hairline in those destined to a NW 6 are not an optimal solution without alternative solutions such as cloning or body hair. Neither is a guarantee so my recommendation is not to attempt something until you know you can succeed. While I can do over 9000 grafts in a single session, I donít know my patientís future so I don't recommend we start with the bar high and risk enormous failure over time. It is better to set the bar low and work your way up based on success rather than attempt procedures with a lower probability of success as a result of aggressive failures.

The retained, non-growing hair needs to be removed. The hair will come out like pulling a pin out of warm butter. If you have to jerk the hair as if you were plucking it, leave it alone. If it still does not grow, try removing it at a later date.

The non-growing hairs are still short. His residual non-transplanted hairs are longer and have grown significantly since the date of his transplant about one month ago. The thinning areas, as well as the bald areas have been transplanted.

In this instance, the grafts in the right frontal peak area were more resilient to fall out than those on the right frontal peak area. More grafts are retained on the right side. Still most of these hairs are not growing. They need to be removed.

The next photo shows what a non-growing hair follicle looks like. It looks like a ďJí. There is no club structure. You have not damaged the cells that will replace the lost follicles. You have only removed a non-growing protein structure that will eventually lead to either a most or dry cyst.

The bottom line is that after one or two month you should attempt to remove any non-elongating follicles because they are simply dead protein that can lead to a foreign body reaction. Such removal leads to a healthier scalp and a long-term better result.

Does anyone else have an opinion on what causes wet and dry cysts? Is it ingrown hairs? Is it a result of incision sites that push epidermis below the skin surface? If so, why does it take about three months for pushed epidermis below the skin surface to cause a painful, red cyst. Do you have photos to back your conclusions? Does anyone have a good idea on how to remove retained non-growing hairs safely and quickly? Does anyone else think that such retained hair follicles pose a risk to patients? What do patients think about them?

On another note, in this patient we used concentrated PRP on one side and non-concentrated PRP on another side for comparison. Both sides have minimal redness after one month. Neither side is exhibiting better growth at one month. Thoughts?

John P. Cole, MD
04-06-2012, 08:57 PM
The value of FUE in general is to redistribute follicular units one at a time from area of high density to areas of low density without producing a strip scar.

Strip procedures in general produce two grafts for every follicular unit removed. In other words a 4000 graft strip procedure results from 2000 natural follicular units.

FUE properly performed removes natural follicular units. In other words a 4000 graft procedure optimally results from 4000 natural follicular units. Of course there are FUE physicians who will fractionate follicular units just like strip surgeons and charge you two or three times for every follicular unit removed. A good way to evaluate this is to look at the number of single hair grafts produced. Single hair follicular units in a person with normal follicular (hair per graft) density are rare. Single hair production rates are indicative of follicular unit fractionation and suggest that multiple hair follicular units are broken into more than one graft. If the total number of single hair grafts in an average patient exceeds 8% of the total graft count suspect double billing for each follicular unit. In reality the total number of single hair grafts should be far less. The usual practice with strip surgery is to make two grafts out of every follicular unit. In other words you pay twice for every follicular unit harvested. It is really not the physicianís fault with strip surgery because he has no idea what is going on because he rarely if ever cuts grafts (he does not know how to do it). In other words, the physician is not involved in graft cutting so he is oblivious to what the surgery techs do.

Here is an example of a patient who received over 9000 grafts from FUE over a 10 year span of time. He has no strip scar.

As he lost hair we added it.

We measured his cross sectional trichometry or trichometric index in four areas. What we found after 9000 grafts was that the cross sectional trichometry in all four areas was the same. What this means is that the overall hair mass (diameter, hair density, hair length) in all four locations was the same. This is the value of FUE.

With a strip procedure you increase the trichometric index in the recipient area, reduce the trichometric in the donor area, while creating a potentially obvious strip scar that has a trichometric index of zero. FUE on the other hand sequentially blends the trichometric indexes without creating a strip scar. Both FUE and strip surgery decrease the trichometric index. Only FUE avoids the strip scar. Only FUE allows the patient to potentially have an overall symmetrical trichometric index without an area void of hair with distorted hair growth angles on either side know better as the preverbal strip scar.

The trichometric index is the easiest way to evaluate hair loss, hair restoration response, response to medication, potential hair loss, and lack of hair loss. No other clinic I know of measures the trichometiric index in all patients in four zones (donor area, frontal area, mid-scalp, and crown). When we measure this very sensitive index we know if you are loosing hair. We know if you responded to treatment. We know that it takes far more coverage to make the crown look full than it does in the front. It is valuable too for physicians and patients. If your physician is not using it, we suggest that you request that he begin. He can tell you if you are loosing your hair in the top, crown or front with this device. He can also measure how you respond to treatment. The instrument is not cheap. Most physicians will not spend more money to evaluate you so it is up to the patient to insist that the physician evaluate them with this device.

Thoughts from physicians or patients?