Doing the Math

[John P. Cole, MD]

Surgical evaluation involves collecting as much data as possible in addition to family history and patient expectations.

For example, we evaluated and treated this patient today. His cross sectional trichometry in his donor area was 89. Average is 69. He has loss confined to the frontal area. His hair diameter is 69. He is a NW 3A. He has 70 FU/ sqcm and 170 hairs per sqcm. He has 16415 total follicular units in his donor area.

We used a 0.85 mm punch to harvest his donor area. His transection rate was under 1%. He averaged 2.48 hairs per graft laterally and 2.8 hairs per hairs per graft centrally.

Based on his donor area characteristics, his expectations, and his surface area of loss, he is an optimal candidate fro hair restoration surgery. We evaluate all of these characteristics prior to every procedure. This is how one thoroughly evaluates a patient for hair restoration surgery. Of course, it helps to have a family history, but at age 47, we do not expect more significant hair loss in this patient.

[John P. Cole, MD]

Here's another example. A 24 year old patient heading to a NW 3V based on exam wanted to treat the front of his scalp. His donor area CST is 114. This is very high and quite good.

His family history includes a NW 5 in his father and his mother has a brother that is a NW 3V.

His CST in the front of the scalp is 49, in the mid-scalp it is 62, and in the crown it is a 26. His hair density is 200 per sqcm, which is quite high and he has a hair density of 176 per sqcm. He has a mean hair shaft diameter of 78 micrometers.

On exam he has thinning on the frontal hairline beginning at 5 cm above the glabella. He has more noticeable loss on the right side with much less loss on the left side. He would like to rebuild his hairline at it's present location. Most 24 year olds with hair loss do want to restore their youthful hair line. Even though his CST is only 26 in the crown area, one has to look carefully to see the thinning. Coverage is maintained primarily because he had such wonderful hair characteristics to begin with. He has lost 77% of the hair mass when compared with his donor area. However, consider that the average donor area has a CST of 69. Thinning becomes evident when about 50% of the hair mass is lost in the crown area of the average scalp. while he has lost 77% compared to his personal donor area, he has lost only 62% when compared to the average scalp. Thus, he appears to have early thinning as opposed to someone with less hair mass to begin with (lower density or finer hair).

His CST measurements do tell us that he has loss all over the top of his head. Thus, he is heading toward the more advanced hair loss seen in his mother's brother rather than in his father.

He has wonderful donor area characteristics. Still, we expect him to eventually become a NW 5 even though he really looks more like a NW 2V now and an early one at that. His wonderful donor characteristics make him a very suitable candidate for hair restoration, but he has other options. One would be Propecia combined with maximal medical management and the other would be PRP. He could certainly attempt a non-surgical solution first. On the other hand, the only sure way to restore his loss in the front now is hair restoration surgery.

What he should not do is build his hairline where it currently is located. One cannot build a 5 cm hairline in a 24 year old who is headed to a NW 5 even with his wonderful donor area characteristics. Any surgical approach in this 24 year old should be conservative because we expect him to have significant hair loss in the future.

This is a difficult decision for a 24 year old that still has some hair at 5 cm. Still, it is the right decision even though his hair loss appears to be quite minimal at this point in his life. This underscores the need for a through exam, diagnostic data, and a family history. If one simply approached this case based on where he appears to be thinning without doing an assessment of what to expect over time, there is a much greater likelihood that this patient would be in a difficult situation in 10 or 20 years. One should always approach a case with as much diagnostic data as possible. Short hair styles prohibit CST measurement, but they are invaluable in predicting future hair loss. Unfortunately, the test has not been out long enough for most patients to have benefited from the diagnostic information.

[35YrsAfter]

Hair restoration on the surface appears to be more of a free-form art. We see a lot of results from doctors worldwide reflecting a free-form approach to hair restoration. Hair restoration is an objective, measurable, calculable, computable, quantifiable art. Guesstimated hair transplants commonly don't look natural. If they do look natural, chances are that both the patient's donor resources as well as his/her finances were not maximally respected and utilized.

35YrsAfter also posts as CITNews and works at Dr. Cole's office
forhair.com
Cole Hair Transplant
1045 Powers Place
Alpharetta, Georgia 30009
Phone 678-566-1011
email 35YrsAfter at chuck@forhair.com
Please feel free to call or email me with any questions. Ask for Chuck

[Artista]

Hello Dr Cole.. great thread!
Congrats , I heard that the Conference went well for all involved. Take care!!

[John P. Cole, MD]

Yes, it was a good meeting for all. There were some great presentations. We did two workshops on FUE trying to show physicians how to remove grafts at burst rates over 2000 per hour. We presented our Acell regeneration studies to date. Carlos Wesley's presentation was quite interesting. He has been quite fortunate in getting financial backing to develop an interesting approach to hair removal. I think there are plenty of questions related to his approach, but it's cool technology.

[Artista]

I agree Doctor,
I have been so impressed with Acell since its inception so many years ago now. Founder, Dr. Alan Spievack (RIP) first applications of his 'pixie dust' were quite amazing.
Im surprised that so many people do not know of Acell's origins prior to its introduction to hair treatments Dr Cole.
I know you have known all about its history , and of course of Dr Spievack (and his brother) .
I feel that you are leading the charge in Acell's exciting developments regarding hair treatment. Im glad that you and Dr Wesley were able to finally meet and exchange thoughts.
Yes, there are of course still plenty of questions to his approach as with any new treatment/method. In time all questions will be answered.
I certainly would like to speak with you at some point Dr Cole!
Im so glad that you are active on this particular forum.

[John P. Cole, MD]

I found him to be bright and personable. I enjoyed his presentation. I do not think he will see any regeneration from Acell unless he comes up with a different method of extraction, however. He cores out a punch biopsy with anything from a 2.0 mm punch, which is huge, to a 1.2 mm punch. In doing so, he removes all of the stem cells, which is part of his rationale for limited the incision depth to 1 mm below the skin surface. You can pack this hole with all the Acell you want, but the only stem cells remaining are those from adipose tissue and some dermis. You have removed the entire bulge, all of the CK15 positive cells and all of the CD 34 stem cells. You have no hair follicle stem cells remaining.

I disagree with his interpretation of the Beehner study where Dr. Beehner found a better survival in chubby grafts perhaps for the same reason. It is harder to count all of the hairs in a chubby graft than in a skinny graft so you fail to count all of the hairs. As a result, you tend to come up with a survival rate that shows a higher percentage than you suspect. Sometimes you even wind up with more hairs than you supposedly transplanted. How can you transplant 100 hairs and get 110 to grow. You don't. You transplant 120 hairs and get 110 to grow, but you miss counting 20 of the hairs.

I worry about how the healing will be in the subcutaneous adipose and lower dermis. Acell may help this form more normal tissue, but there will be no hair follicles.

the beauty of our work is that we are getting flawless healing and some follicle regeneration. All we need to do now is first finalize our follow up studies and second find a way to seal the donor area with a more affordable price and a product that is commercially available.

Still I love what he is doing and look forward to getting my hands on a unit some day. There are going to be some FDA hurdles to get this device approved because it has a ton of technology in it including lasers, etc.

All the best. I'm sure we will chat soon.

[Artista]

Thanks Dr Cole, by the way,,I did once again leave my contact information with your office today.
I am off of work today, all day, so if you have the time..feel free to call.
I wont take up a lot of your time my friend..sincerely Artista

[John P. Cole, MD]

This patient is a NW class 2. He is 38 years old. There is plenty of existing hair between his original hair line and the extent of his loss. He wants to re-build his pre-existing hairline. He is a model and wants to maintain his competitive advantage.

His donor density is 82 FU/sq cm, his hair density is 217 per sq cm, he averages 2.66 hairs per FU, he has 16,590 FU in his donor area, and his mean hair shaft diameter is medium fine at 72.1 micrometers.

His surface area of thinning is 36.18 sq cm.

The first question is what sort of candidate is this patient for a lower 7 cm hairline? Based on his donor area measurements, he is a great candidate, but there are two factors we need to look at. One is the potential for future hair loss based on his family history and his cross sectional trichometery. His family history does not provide much information because his father has no hair loss and there is some hair loss in distant relatives on his mother side that varies from minimal to maximal. His cross sectional trichometry provides a great deal of information. There is no evidence of loss at 15 cm or 20 cm above the glabella. The loss is limited to the frontal area and currently only a 26% loss. There is actually more hair on the top and crown of this patient than there is in the donor area. His donor area CST is 92, which is quite high. He is 115 at the top of the crown. In that crowns require more hair to look full, it is not surprising that the crown would be higher in many individuals. This allows for an extra cushion over time for hair loss.

Thus, based on his age, his degree of hair loss, his donor area characteristics, and his cross sectional trichometry, this patient can do anything he wants because there does not seem to be any evidence that he will suffer a great degree of hair loss.

If you know all of your objective data, you can make rational decisions regarding treatment of your hair loss and your patient’s hair loss.

[gillenator]

I so appreciate the scientific, mathematical approach at initial examination, something that I have been advocating for years. And the identification and classification of the hair characteristics are so critical because the more promising the hair qualities are, the better upper-end result that can be achieved considering the skills of the surgeon are optimal.

Dr. Cole, I have a question. Consideration of family history of hair loss on both sides is undoubtedly the best barometer of future loss for the individual IMHO.

Do you look for areas of miniaturization when examining the scalp, especially the areas that border the recipient area and crown? And what dictates how many grafts you utilize to transition into those areas that are clearly diffusing especially in the frontal core?

[John P. Cole, MD]

Gillenator, you have always been ahead of your time in both patient education and hair loss solutions. I've known you over 10 years and you have always been ahead of the curve.

You question is excellent. In the past the only indicator of future hair loss was miniaturization. I say indicator because anyone can spot hair loss, which is a loss of density. The initial signs are a loss in diameter and a loss in color (pigment). Diameter changes are quite subtle initially, however. This is where cross sectional trichometry comes into play. We can spot small changes early on when miniaturization really is not evident.

What we are looking for with CST is evidence of loss in other places and most importantly all over the head. If the CST is at or above the donor area in the crown and top of the scalp, you are not showing signs of loss there at this point. there is no reason to consider treatment in these areas. If there is a sign of loss in these areas, one must decide if it is prudent to transplant areas of future loss based on age and the donor area supply.

When i see hair loss in the frontal area, i do my best to treat up into the area where i see miniaturization. I may treat the bald areas with 40 to 60 grafts per sq cm, but in the miniaturizing areas, i try to treat with lower densities of say 20 per sq cm. Lower densities minimize the risk of shock loss. Areas of early miniaturization really look full so we are not trying to completely replace these areas. All we are trying to do is put a handful of grafts there in case that area of early miniaturization really begins to accelerate over a short span of time. The last thing we really want is to have a bald spot develop perhaps behind the hairline area that we built today. This simply requires the patient to come back sooner to fill in the gap. Thus, when i see miniaturization in the frontal area, i go ahead and build at a low density into the areas where i see miniaturization. This approach recedes the frequency of visits by my patients without significantly increasing their cost. Again, a stitch in time saves nine. There is no reason to restore the original density in these behind the hairline areas. you just need to eliminate the potential for a bald zone. In doing so, you eliminate unnecessary follow up visits.

The crown is far more complex. If you build in the center of the crown, later on a patient can loose the perimeter. Now you have hair in the middle and nothing in the perimeter. That's not a good scenario. In some instances it is a precursor to the next procedure. in to others, it is the disaster waiting to happen. You have to individualize this.

I approach all crowns the same way from the frontal area back to the top of the crown. There are two hairlines. One in the front and one in the back. If you build a natural hairline in the front and a poor hairline in the back, anyone sitting behind you on an airplane will see "HAIR TRANSPLANT". ONe must always build two hairlines - front and back.

In the crown, it is better to build from the periphery in. Hair loss begins centrally to out so you want to build from outward to in. Restore natural loss rather than unnatural restoration.

The next point is huge. One with a large caliber hair can loose up to 82% of their original hair mass and look full with longer hair in the front. However, a person with coarse will look think in the crown area after loosing only 50% of their original hair mass. Unfortunately, a person with fine hair will look think after loosing a smaller percentage of their original hair masse, but they must also restore more than 50% of their original hair mass to look full. In other words, crown restoration is remotely possible to completely impossible. Be careful how you proceed here. Work delicately and naturally. Individuals loose diameter first, then hairs per follicular unit, then follicular units. The most natural way to restore this is single hair grafts and 2 hair grafts. Anything larger looks like a transplant. Single hair grafts in the crown look best, but they provide the least coverage. the question you must ask yourself is whether you want natural or more coverage at the expense of appearing to all your friend that you've had a hair transplant. I wish i could sugar coat it, but i can't and your friend certainly will not sugar coat something that is obvious regardless of how hurtful their comments are. Remember, they don't recognize how much hair loss affects you because they don't have it. They kid you only because they don't comprehend the pain you are going through. They embarrass you only because they think it is funny and you obviously don't care because you let something ridiculous happen to you.

Anyway, I try to do the fewest number of grafts where there is miniaturization to first avoid shock loss and second to avoid a repeat visit soon to address these areas. A handful of grafts often puts off a visit for many years. Failure to treat these area with a handful of grafts often results in a repeat visit in a year. I am also very careful in the crown area and i take this on an individual basis. In individuals who are showing evidence of moving to a NW 3V or better, i try to build a second hairline behind the frontal area because i anticipate that this hairline will someday (perhaps quite soon) become evident so we don't want anyone recognizing what we have done as a hair transplant. When i approach a crown, i try to make the result look natural for decades to come.

[35YrsAfter]

When i see hair loss in the frontal area, i do my best to treat up into the area where i see miniaturization. I may treat the bald areas with 40 to 60 grafts per sq cm, but in the miniaturizing areas, i try to treat with lower densities of say 20 per sq cm. Lower densities minimize the risk of shock loss. Areas of early miniaturization really look full so we are not trying to completely replace these areas. All we are trying to do is put a handful of grafts there in case that area of early miniaturization really begins to accelerate over a short span of time. The last thing we really want is to have a bald spot develop perhaps behind the hairline area that we built today. This simply requires the patient to come back sooner to fill in the gap. Thus, when i see miniaturization in the frontal area, i go ahead and build at a low density into the areas where i see miniaturization. This approach recedes the frequency of visits by my patients without significantly increasing their cost. Again, a stitch in time saves nine. There is no reason to restore the original density in these behind the hairline areas. you just need to eliminate the potential for a bald zone. In doing so, you eliminate unnecessary follow up visits.

Our patient last Friday had his hair restoration surgery several years ago with a large, well-known clinic. He came to us for hairline repair and increased density behind his hairline. His previous surgery was strip and he has a scar about 6mm wide in places. He is able to cover the scar with longer hair and is not concerned with repairing his scar at this time. Young men will often have hair transplant surgery to thicken up their existing hair and strengthen their hairline. Our patient had multiple hair grafts placed in the hairline area at low density. This method of placement does not look natural and our patient mentioned to me that sometimes people would stare at his hairline. Multiple hair grafts on the hairline is a common mistake some hair restoration physicians make.

35YrsAfter also posts as CITNews and works at Dr. Cole's office
forhair.com
Cole Hair Transplant
1045 Powers Place
Alpharetta, Georgia 30009
Phone 678-566-1011
email 35YrsAfter at chuck@forhair.com
Please feel free to call or email me with any questions. Ask for Chuck

[35YrsAfter]

IMO, the hairline was too straight as well. Here is the photo:

35YrsAfter also posts as CITNews and works at Dr. Cole's office
forhair.com
Cole Hair Transplant
1045 Powers Place
Alpharetta, Georgia 30009
Phone 678-566-1011
email 35YrsAfter at chuck@forhair.com
Please feel free to call or email me with any questions. Ask for Chuck

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