Hair Restoration

Hair Transplant Procedure Information

  1. At the beginning of each session, the patient is given a mild tranquilizer (usually Valium) either orally or intravenously. This minimizes anxiety, reduces discomfort and helps to prevent or decrease any side effects that might be caused by the anesthetic.
  2. Hair in the donor area is clipped to a 2 mm length in one or two zones that are less than 12 mm (1/2") wide, and 10-20 mm (4-8") long. If the hair in the donor area is left 1" - 2" long, the hair above the donor site should completely camouflage these areas immediately after the procedure.
  3. The donor area and the recipient area are anesthetized by injecting a local anesthetic with a very small gauge needle (that is about the size of an acupuncture needle). Anesthetizing the area is the only uncomfortable part of the session and although it may be hard to believe, we have been told by many patients that the above technique usually causes less discomfort than a visit to their dentist.
  4. After the anesthetic has taken effect , a specially designed scalpel is used to cut an ellipse of hair-bearing scalp from the donor areas. (A similar method can also be used to remove scars). The ellipse, with the use of a stereoscopic microscope is then carefully slivered into smaller loaves of hair, which are then further dissected into single or double follicular units ( follicular unit family ). Microscopes are used to section every graft.
  5. In general the smaller the size of the graft used the less noticeable treatment will be post-operatively and as one goes from session to session. On the other hand the smaller the graft the less density will be achieved with each treatment. The following is a description of the types of grafts that can be employed:

    1. "Micrografts" are obtained by slicing the donor tissue into very small sections, regardless of whether the naturally occurring bundles are kept together or not. These types of grafts are called, "grafts cut to size". Microscopes are not usually employed when creating these grafts but instead the grafts are cut without keeping the natural integrity of a follicular unit in tact. Some surgeons feel that by cutting through a FU can damage the valuable hair follicles. Dr. Cotterill agrees with this and USES MICROSCOPIC DISSECTION TO OBTAIN FU,s ON ALL GRAFTS. Naturally occurring 1-3 hair bundles, as seen best with a dissecting microscope are called Follicular Units. The new techniques available today enable patients to wear their hair in virtually any style, even combed straight back. It should be pointed out that if an area is totally transplanted, without any pre-existing hair remaining, then the one way the hair may not be able to be worn is parted straight through the middle.

    2. "1 - 4 haired Fus can be used in a "½ to 1" wide zone in front of slightly larger 3-7 haired FU Families , to produce a natural looking hairline with gradually increasing density, or alternately may be used (in approximately 85% of our patients) for the entire recipient area. They are also used in areas such as the crown which does not need the density of larger grafts. FU,s and multiple FU,s are important new resources for those patients who only want (or need) lighter coverage, have or will have very large bald areas, or have very little hair in the donor areas; a limited supply of donor grafts can cover a greater surface area because these smaller grafts produce a sprinkled type of hair growth that is far more natural looking than the "pluggy" or "barbie-doll" look that may be produced by larger grafts, until such time as the area is densely transplanted.

      This type of graft is especially useful for patients who have fine textured and/or light coloured hair, and those who have (or will have) sparse temple hair in whom densely transplanted frontal hair would look unnatural.

    3. "Standard" grafts, are grafts which contain 8-30 hairs. These are the traditional grafts that up until about 15 years ago were the standard grafts employed by all hair restoration surgeons. These grafts are placed into round holes made in the recipient area, with a small punch. The holes are placed approximately 1 graft apart, in a "checkerboard" fashion, to leave a surrounding blood supply. The result however was a very "pluggy" look. As a result "Standard" grafts have come into disfavor and are very seldom, if ever, used any more. There is no reason that with today's techniques that with even 1 session on a bald area for the appearance to look "pluggy" or "like a transplant". Therefore I only use single or double follicular units in all new patients.

    In general FU,s and multiple FU,s produce more natural looking results than an equivalent amount of donor tissue transplanted as standard grafts. However, because no bald skin is actually removed (hair is only added), FU,s or multipleFU,s do not ultimately produce the same hair density as standard grafts or round minigrafts - unless more donor tissue is used than would be for round grafts.

    This is an important but seldom mentioned drawback of treating patients with only micrografts or single one or two haired"follicular units" On the other hand "all micrograft" or 1-3 hair single follicular unit sessions are ideal for treating individuals who are willing to do extra sessions for high density in return for possibly less noticeability during treatment, or for those who are genuinely not interested in high density. Lastly, FU,s and multiple FU,s are very advantageous in treating areas that still have persisting hair - for example in patients who have relatively early MPB or female thinning. Slits and needle holes can be placed between existing hair and none is sacrificed as occurs during the making of a round hole for minigrafts and standard grafts. EACH CASE MUST BE CONSIDERED ON AN INDIVIDUAL BASIS. There are a number of factors which influence the decision as to which type of grafts will be used and where they will be placed; these include the texture and colour of hair, hair density, the size of the donor area, the size of the site to be transplanted, and patient goals. In many individuals, a combination of two or more of the graft types will be used, and in others only single FU,s will be utilized. You will be shown photos of what you can expect from each. No one type of graft will provide "the best of all worlds" for all patients
  6. Grafts are held in place by coagulated blood. To keep them secure and properly oriented, a turban-like bandage may be applied after the operation and left in place overnight. The following day the bandage is removed, the area is cleansed and the hair washed. If you are having the front half of your scalp transplanted, and if there is no more than the average amount of bleeding during surgery and you are willing to remain in the office for 2 hours after the procedure is completed, you can go home without a bandage. (Most patients seem to prefer the security of an overnight bandage). Patients who prefer no bandage must book their appointments for mornings only. You should still return the next day for follow-up cleansing, hair washing, and check up.

Number of Hair Transplant Procedures Required

Generally, the front third to half of a completely bald area can be completely finished in 2½ - 3 sessions if only FU,s and Multiple FU,s are being used. Some patients may be happy with the coverage and fullness of 1 session on a bald area. However most want more density than what 1 session on a bald area will achieve. Patients who believe they can be completed in only one session and have relatively dense hair are being unrealistic. One session of all single FU,s, (containg 1-3 hairs), can look very natural and can stand on its own very well, however the density or fullness is for most people less than what one would expect for reasonable density. Some hair types, ( course, wavy, with salt and pepper or light brown/blond hair ) lends itself to a very nice result with 1 session. A patient with straight, sparse and black hair would have an understandably thinner look and unless the patient had low expectations , he would probably want the benefit of the density of 2-3 sessions. Patients should be wary of doctors that claim most of the bald area of the scalp can be completed in 1 session, unless a thin look is desired.

Transplant sessions may be done as far apart as the patient wishes; however, they are not done in any given area without a minimum 8-12 month interval between sessions. The number of grafts that should be transplanted at one session and the frequency of transplant sessions depend on the characteristics of each individual case; this can be planned out in advance for each patient. Additionally, larger sessions that cover both the front half of the scalp as well as the crown, in appropriate patients, can also be performed at the same time.

It is becoming more common for patients to have one or "early" transplanting session, before hair loss has reached an advanced stage. The benefit of these early sessions is threefold: the remaining hair provides natural camouflage for the initial session; the transplanted hair (once it has grown) provides additional coverage for any later sessions; and sessions can be spaced farther apart, thus spreading the inconvenience and cost over a longer period of time.

In less than 10% of patients there may be some mild thinning involving the pre-existing hair of the recipient area within the first two to three weeks after a transplant. This thinning (if it occurs) is temporary and the hair will regrow at the same time as the transplanted hair begins to sprout.

TRANSPLANTING WITH ONLY ‘1-2 Haired Follicular Units’, "MEGASESSIONS", AND "DENSE PACKING" OF GRAFTS

If you have relatively fine and/or light coloured hair and if you feel you would be satisfied with light to moderate hair density, you may want to consider using only 1-2 hair follicular unit grafts for your transplanting. There are four advantages to such an approach:
  1. FU’s cause the least damage to any existing hair in the recipient area
  2. FU’s produce the least amount of post-operative crusting
  3. FU’s generally grow somewhat faster than other types of minigrafts, and
  4. FU’s - even in a totally bald area produce absolutely no clumping or plugginess
In fairness it should be pointed out here that if slightly larger graft with 3-5 hairs is used behind the hair line zone of 1-3 haired grafts instead of all 1-2 haired grafts there is virtually no damage to existing hair and with most hair types there is essentially no plugginess either.

Transplanting an entire bald head in one or two "megasessions" of 3000 or more 1-2 haired grafts per session is possible, but will require sessions of 8-10 hours each. As indicated above such sessions will usually produce only relatively low hair density unless they are repeated . These operations are also more physically and emotionally stressful than standard transplanting sessions, and should not be undertaken by any one who isn't in excellent physical condition. Practically speaking therefore, megasessions of 1-2 haired follicular units are only used in relatively young or fit patients for whom time and minimum noticability is more important than greater hair.

Patients are often anxious to have as much done as quickly as possible and are therefore anxious to believe a physician who tells them that there is no intrinsic problem with very large, lenghthy megasessions. However, the possibility of lesser hair yield permanently should be weighed against the temporary convenience of a faster result.

Laser Hair Transplants

The first surgeons to use a C02 laser in hair transplanting were Dr. Walter Unger and Dr. Larry David, working together in Los Angeles in September 1992. Despite advertisements and media reports that suggest laser transplanting produces superior results with less bleeding and pain you should know that such claims are as yet not confirmed. The C02 laser is a very promising tool that has not yet been completely perfected for hair transplanting. At this point in time lasers do not produce a superior result to using scalpels and steel blades, and unfortunately have been used more as a marketing tool.

What To Expect After Each Hair Transplant Session

A crust or scab will form over each graft shortly after the procedure, and will remain attached for seven to fourteen days. When the area is healed, the crusts will then separate from the scalp and fall off, leaving a clean, pinkish area to indicate the site of each graft. Although these crusts are visible during the one to two week healing period, many patients can camouflage them by combing the adjacent hair over the transplanted site. If a hairpiece is normally worn, it may be used to conceal the crusts after the first week (and should be worn as little as possible for an additional week). Follicular unit grafts with 4-6 hairs leave much less visible marks, and are virtually undetectable within seven to ten days. The holes made for 1-3 hair single follicular units, essentially disappear within a few days to a week.

The hairs in the transplanted grafts are shed between the second and eighth week after the procedure. Sometimes many of these hairs fall out attached to the separating crusts; occasionally they persist longer. Rarely, one or two of the transplanted follicles do not shed their hair at all, but continue to grow immediately after the procedure. With these exceptions, the grafts are usually bare for a period of ten to fourteen weeks after the operation, during which time the hairs are shed and the follicles recuperate to produce new hair. A new generation of hair is usually visible at the surface of the scalp by the twelfth week after transplanting, but this may occur slightly earlier, or up to eight weeks later in a few patients. These hairs grow at the same rate as they did in their original location (which is usually 1/2 inch per month).

When a large area is transplanted, swelling of the forehead frequently occurs. While this swelling is usually mild, and lasts only two to four days, it occasionally can be severe enough to cause a large amount of puffiness around the eyes (approximately one out of fifty patients have swelling bad enough to cause "black eyes").

Generally the swelling begins two to three days after the procedure and is most noticeable after the first session; with subsequent treatments, it usually occurs in a milder form or not at all. In view of this, if possible, it's advisable to schedule a holiday to coincide with the first session. Please be assured that the swelling is ALWAYS temporary and has no harmful effect on the healing transplants.

Contrary to what many patients have been told, the scalp (hairy or bald) has an excellent blood supply. A certain amount of bleeding during the transplant procedure is expected and is simply controlled by applying pressure. The donor area is stitched closed to produce better scars and to minimize bleeding. The stitches are removed seven to ten days later.

The physician or nurse will wash your hair the day after surgery when the bandages are removed. You may gently shampoo on the second day after transplanting. Even if you do not have a bandage it is highly recommended for you to return the next morning to have your hair washed and all the grafts inspected

Patients from out of town are required to stay in town overnight, after the transplant procedure, so that the bandage can be removed and/or the area properly cleansed the day following surgery. They should not drive themselves home on the day of surgery because of the lingering effects of medications.

Ingrown hairs are occasionally a temporary problem, especially when follicular unit grafting is used and especially if the hair tends to be naturally curly. It is easily. controlled, does not cause any permanent damage and does not occur in a majority of patients.

A temporary decrease in scalp sensitivity is always noted after transplanting, because nerves are cut as donor grafts are taken and recipient sites are prepared. Usually this will correct itself completely in three to eighteen months as the nerves regenerate. Rarely there may be a permanent slight degree of decreased sensitivity in one area or another.

Final Results

It is impossible to predict precisely how many hairs will appear in any given graft but at least 90% and often 100% of them will normally survive transplanting. We have never encountered a patient who showed no growth whatsoever.

After a period of four to six months, the skin surface of the grafts has usually blended in perfectly with the surrounding scalp. In some patients, however, the grafts may be a shade lighter in colour until they are "aged" by sun exposure. The grafts are usually level with the surrounding scalp, but are occasionally slightly elevated. Such grafts are easily flattened down with an electric needle without interfering with hair growth. This is only necessary in approximately one out of every hundred patients.

The final appearance is that of "early thinning", which is not meant to imply "thin" hair, but rather, to convey the idea that you cannot expect to look like you did when you were a teenager.

In summary, with the new techniques of follicular unit grafting using all 1-3 hair single follicular units, the hairline no longer appears as abrupt or dense as was the case with older traditional grafts. Single follicular units create a very natural-looking, soft, hairline. They also do not result in the removal of any existing hair in the recipient area and are, therefore, advantageous for transplanting in patients with "early" MPB or female thinning.

Update on Propecia (Finasteride 1 mg)

Dr. Cotterill has been an investigator for Merck Corporation for the last ten years. Dr. Cotterill was involved in a press conference held in Toronto in June of 1998 to announce the passing of Propecia as a prescribed medication for Male Pattern Baldness in Canada.

The following is a synopsis of the findings of a two year drug study:

Propecia (Finasteride 1 mg) has just been given approval by the Health Protection Branch of Canada for release as a prescribed drug. This medication is marketed by Merck Frosst and is now available in pharmacies at approximately $1.50 per tablet. The two year data from clinical trials involving 1,879 men with pattern hair loss involved 4 Canadian centers of which Dr. Paul Cotterill and Dr. Walter Unger were the Ontario Investigators. The clinical trials were done in men aged 18-41 with mild to moderate hair loss on the top of the scalp. Results showed that there was no more hair loss in 83% of men after 2 years. Additionally, there was hair regrowth in 66% of men. This figure was broken down into 30% of men having mild regrowth, 31% having moderate, and 5% dense regrowth. This medication is very well tolerated, less than 2% of men experienced side effects. 1.8% experienced a mild decrease sex drive. If you do experience side effects that troubles you, once you stop the medication any benefit that you may have on the scalp is lost within twelve months and you go back to the way you would have been had you never used the medication.

There is no cross-reaction with this medication with any other medication. Additionally, you may take the medication before, after, and during hair transplants.

The 5 and 6 year clinical trial data has recently been presented and is continuing to show favorable results.



If you would like any further information, please contact Dr. Cotterill.