Comparison of Procedures
The Donor Area
As a board certified general surgeon, Dr. Keene utilized a double suture closure (internal and external) for many types of surgeries. She felt that this type of closure would be best in hair transplant surgery as well. This consists of an internal layer of dissolvable suture, which is the strength layer of the closure, and an external layer on the skin of nylon suture. This can be removed in only 5-7 days, making it much more comfortable for patients. A single layer closure often requires 10-14 days, and the suture becomes irritating to the skin, causing an annoying inflammatory reaction. When this happens, the result can be the “railroad track” scarring where the nylon leaves a visible white vertical scar across the linear horizontal one. An internal layer can also help prevent broadening of the incision, especially for large megasessions when the closure can result in more tension on the skin. The absorbable suture remains for several weeks to allow the wound to gain strength, and the result can be a finer closure.
The double closure typically results in a virtually undetectable linear scar, that is completely covered by hair in the donor area, and is typically very difficult to find after it is completely healed. Results can vary in patients with unusually tight scalps, and those who have had previous surgery that has removed some of the scalp elasticity.
Dr. Keene also uses the trichophytic closure where appropriate, which is a type of closure that further camouflages the very small linear donor scar. It has been used in plastic surgery for some time, and was introduced at the 2005 European Society of Hair Restoration Surgeon’s conference for use in the donor area closure. Dr. Keene adapted it, and has been using it since with excellent results. She uses this in patients requiring 1.5 cm or less donor strip width, who have sufficient elasticity, because it works best when tension is minimal. Basically, the technique involves making an incision to remove the donor area that is parallel to the hair shaft, then trimming one side of the epithelium (outermost layer of skin) high up on the hair shaft. When the donor area is brought together and closed, the hair shafts that were trimmed just below the surface of the epithelium will grow out through the suture line, masking the minute scar with hair.
Dr. Keene offers FUE and the strip technique for donor harvesting. Both techniques result in very little scarring, as you can see in the photo above of the donor area after surgery in the strip technique. The advantages to the FUE procedure is that it heals very quickly and minimizes recovery time. A disadvantages is that FUE can increase the trauma to the follicles, yeilding fewer 3 – 4 haired grafts. But if you prefer the FUE technique, she can provide it. In situations where the patient has had prior surgeries and has limited donor available, or needs a scar filled in and has very little donor laxity, the FUE may be preferable. Your personal preferences may be to avoid the need for suture. You can discuss your preferences in regard to FUE vs the strip technique with Dr. Keene in your consultation.
How does suture compare to staples in hair transplant surgery?
Staples are much faster and easier to place than sutures, but less comfortable than suture to lie on. They also tend to be more painful to remove. Staples are more convenient for the doctor, the appearance of the incision is comparable with both, and this has been documented repeatedly in the surgical literature. But Dr. Keene feels it is worth the extra time it takes to use suture in order to increase your comfort.
What are some of the other recipient site techniques used in the hair transplant industry and how are Dr. Keene’s different?
Plugs: A plug occurs when a hole is punched into the scalp and a graft is used to “plug” the hole. When this occurs not only is a follicle grafted, but so is skin. This newly grafted skin can cause visible scarring. Dr. Keene has never done plugs, even though they were standard when she entered this field, she did not like the results and only entered the field after being introduced to micro incisions that were first done in Europe. Dr. Keene’s current technique uses micro incisions placed close together which heal quickly, and the small amount of skin on the graft forms a tiny scab that falls off.
Since plugs are large amounts of hair and skin being placed into the scalp, unnatural “corn rows” appear because grafts are placed further apart. We insert follicular unit and DFU grafts of 1-4 hairs with very little skin moved, the small amount that does remain on the grafts sloughts off, so scars and rows do not occur.
Micro/Mini grafting: Micro grafts consist of one to two hairs and mini grafts consist of three to eight hairs. These grafts are placed further apart which can create an unnatural hairline and decreased density throughout.This technique is not done by Dr. Keene as in most cases the only natural appearing grafts are up to 4 hairs, and more than that starts to look grafty. Placing the grafts close together is also important, although it is important for patients to realize that the number of hairs moved is more important than the number of grafts, and 7000 1-2 haired grafts will not yield more density than 3500 1-4 haired grafts.
Physician’s Hair Institute’s Hair Transplant Procedure
Our procedure separates hairs into small one, two, three and four hair grafts, called follicular units and double follicular units, and places them tightly together to recreate a natural hairline and overall appearance. Other factors such as matching the existing hairs’ direction, using aesthetic ability to recreate naturalness where there is no native hair present, creating a variegated frontal hairline, using lateral incisions where appropriate (angle will always change based on area), using sharp point and custom cut blades as small as .7 mm which allows increased density, personal experience and participation throughout the surgery, and other advanced surgical techniques result in the state of the art hair transplant procedure performed by Dr. Keene. Click here for more information on How is a natural hairline created, and on the following link for more information on surgical techniques used at Physician’s Hair Institute.
At Physician’s Hair Institute refined Follicular Units are used to create a natural hairline.
Below illustrates a procedure using plugs as grafts (NOT used by Physician’s Hair Institute)
Are you a candidate for a hair transplant?
There are three main factors we consider in determining a good candidate for hair transplant surgery: current hairloss pattern, health, and future hairloss.
Since hair transplant surgery is a surgical technique using local anesthetic, good candidates for this procedure are reasonably healthy, have significant thinning and hair loss, or hairline recession. We can also repair scars left by other cosmetic surgeries such as a face lift, or from other causes.
There are no age restrictions, but it is preferable that a patient be 25 years of age or older before considering the surgical option. This is because it is difficult to determine what the future hair loss pattern is going to be in a patient younger than 25. There may be exceptions, one being if the medication stabilizes the pattern. Determining the future hair loss pattern is an important factor in deciding on where to place the hairline. You may only be losing hair in the very front of your hairline now, so want that filled in. But that may not look natural as you age, and you will need to fill in the areas behind the transplanted hair to retain a natural appearance if your natural patter recedes further.
During the initial hair transplant exam, Dr. Keene will evaluate existing hair loss and will estimate future hair loss based on your risk factors. Since hair is normally transplanted from the sides and back of the head, it is important that you have sufficient hair available to achieve your desired results. Dr. Keene will provide each patient with information so that they can determine whether hair transplant surgery and/or medical treatment may best suit their needs.
Women may have other factors to consider, so refer here for recommendations for women.
Each patient can determine the number of grafts he or she will need for a particular level of density or area of coverage. A patient will base his or her decision on density preferences and current hair loss area as well as estimates of future hair loss. We can not give the same number of hairs as nature did originally, because we are working to redistribute diminished existing hair. But since hair loss is virtually undetectable until approximately 50% of the hair is lost, it is possible to achieve the same appearance of density as a natural head of hair. Other factors include:
- Hair color – Lighter hair (decrease in contrast) requires fewer grafts than darker hair (increased contrast).
- Hair caliber – Straight or curly hair – curly hair covers more effectively than straight.
The following are a range of follicular unit grafts necessary to achieve density. This is based on follicular units, not individual hairs. One haired grafts do not yield the same results. More one haired grafts per square centimeter are required than the follicular units of 2-4 hairs, so the numbers below only give you a vague estimate. Dr. Keene will give you an estimate using the minimum numbers of grafts you should have to achieve a density that will make a significant aesthetic difference, and up to the amount she considers safe for you based on your future hairloss, laxity, budget, and other factors. For ex., with limited donor availability in one surgery, depending on our hairloss pattern, you may prefer to focus density in your frontal area, and still want thinning coverage in the crown area.
- Thin: 10-15 grafts per square cm on average – provides contour and thinning coverage, see through in certain lighting.
- Moderate: 15-30 grafts per square cm on average – moderate coverage and contour.
- Cosmetically Dense: 30-50 grafts per square cm on average – in most cases imperceptible difference between this density and normal hair.
Keep in mind that the numbers of hairs per graft impacts the density of the procedure. For example, fifteen 3-4 haired grafts (yielding 45-60 hairs) will produce as much or more hair density as thirty 1-2 haired grafts (yielding 30-60 hairs) , and thirty 3-4 haired grafts (yielding 90-120 hairs) will produce as much or more density as 60 1-2 haired grafts (yielding 60-120 hairs). Dr. Keene focuses on 3-4 haired grafts as much as possible, but the ability to achieve the higher numbers of hairs per graft varies between patients. Greater numbers of grafts per sq cm are needed if more 1 to 2 haired grafts are used.
*During your hair transplant consultation, Dr. Keene will help you determine what density is necessary to achieve your goals.Who will actually be performing my hair transplant procedure?
Dr. Keene believes all hair restoration surgeons should have the technical capability of cutting and placing grafts. Dr. Keene supervises every aspect of the hair transplant surgery, utilizing assistants to assist in hair transplant surgery, not perform it. Dr. Keene has an experienced and skilled 10 person surgical team with extensive hair transplant training, some of whom have been assisting her in hair transplants for over a decade. However, she feels that if it were herself or a family member, she would want the medical doctor to actively participate in all of the vital aspects of the surgery, including placement of the grafts, regardless of the fact that the staff is skilled–so this is what she does in her clinic. Dr. Keene’s technicians are some of the most experienced and skilled technicians in the hair transplant industry, but she will be the primary person doing your hair transplant. Part of the reason you rarely see Dr. Keene blogging is because she spends so much time in surgery. She will perform all aspects of the surgery, with assistance from her experienced hair technicians.
- How soon after hair transplant surgery will I see the new growth?
When hair is surgically moved from the back of the head and redistributed into the areas of hairloss, the transplanted hair experiences trauma. This typically causes what is referred to as shock loss, causing the shaft of the hair to fall out in about 1 to 6 weeks after surgery, while the root remains behind. The newly growing hair will begin to emerge in about 3 months after surgery, depending on your rate of growth. The hair continues to mature and add density for up to a year. There can be exceptions to shock loss, but it is best to expect it to occur. Sometimes the trauma can result in shock loss of some of the native hair (i.e. hair we did not transplant) but it is expected to grow back unless it was about to fall out due to genetics. And genetics can be combated with the use of finasteride. Dr. Keene is very careful to avoid transecting any existing hairs when she transplants hairs in between them, but trauma occurs with any incision and any surgery, so while the risk is minimized for temporary shock loss, it may still occur–so don’t panic if it happens! It will typically start to grow back within a few months. This transitional phase after surgery is the hardest part, but the wait is worth the results.
Hair Transplant Trichophytic Closure | Follicular Unit Extraction