Hair Transplant 360 (For Physicians), Volume 1 Samuel M Lam
INDEX
×
Chapter Notes

Save Clear


Hair Transplant Preoperative 3601

 
History and Where We Are Today
Everything begins with the history. We must know where we came from to know where we are and where we are going. It may not seem cogent to discuss history in a book dedicated only to practical information but it is an important starting point in my opinion for every would-be surgeon. Knowledge of history provides context to our present endeavors and permits us to grow forward from that point. To appreciate the breadth of modern hair restoration we should begin with a cursory review of the changes over the past half-century, especially as it relates to current models of thinking. Perhaps the author cannot help that inclination given the fact that he was a history major in college and relished the joy of seeing the present as a trajectory of the past. This historical recounting however is not exhaustive but selective to express the important turning points that author envisions and have been fundamental in the development of the field that have brought us to where we are today.
Hair restoration began in the 1950s with Norman Orentreich, the famed New York dermatologist, who discovered the principle of donor dominance. He established that hair grafts (at the time harvested via 4 mm round punch grafts) from the occipital scalp, if transplanted to the frontal and midscalp regions of alopecia would continue to flourish without being subjected to future hair loss despite their new location. This concept of donor dominance underlies all modern hair restoration endeavors.
During the early development of the field of hair restoration, occipital hair was harvested and transplanted using a round punch graft. These relatively small transplant sessions were performed serially, leaving the donor area riddled with “shotgun” scars and the recipient areas only partially treated. As the hair loss inevitably progressed, many patients were left with exposed unnatural-appearing grafts and depleted donor hair that in turn could not cover the problem.
2
zoom view
Figure 1.1: In the 1980s, Headington discovered that hairs on the scalp do not grow singly, but in groupings that have come to be known as “follicular units”. A follicular unit comprises groups of 1 to 4 hairs that grow in clusters spaced a short distance away from a neighboring follicular-unit cluster.
Two limitations of hair transplantation at the time were observed: the transplanted hair looked “pluggy” and the donor area was unsightly and poorly managed.
In the early 1980s, the large 4 mm round grafts (containing 16 to 20 hairs) were sectioned into smaller half grafts (8 to 10 hairs) and quarter grafts (4 to 5 hairs). These grafts were still inadequate to achieve the desired level of naturalness so further refinements were necessary. The advent of donor strip harvesting (rather than single punch grafts) and the progression toward smaller grafts so-called minigrafts (5 to 10 hairs) and micrografts (1 to 4 hairs) greatly improved overall hair-transplant results. Around the same time, recipient-site creation evolved from round punches to linear slits, which also served to enhance aesthetic outcomes tremendously. However, in the late 1980s, following Headington's thesis that hair grew in natural clusters on the scalp of one to four hairs called “follicular units”. Bobby Limmer began to transplant grafts that were dissected along these natural cleavage planes. Thus was born Total Follicular Unit Transfer (TFUT) (Fig. 1.1).
Total Follicular Unit Transfer has dominated the thinking and practice of hair restoration for the past 15 years. Unquestionably, follicular units can provide uncompromised naturalness. However, the major complaint of TFUT was the ability to achieve significant hair density, especially after one procedure. Several theories were developed to explain this limitation; the most accepted explanation was that the spacing between grafts is too wide, which led to the development of dense packing grafts. Consequently, the number of hairs per square centimeter increased significantly but contradictory results in terms of perceived hair density were observed. The tightly packed grafts did not produce higher hair density. 3The reason for this observed phenomenon is still debatable, i.e., whether the lack of density arises from compromised circulation or from the use of only extremely small-sized grafts. Although TFUT is still the most widely practiced type of hair transplantation today, the complaint about insufficient density may be explained by the fact that the donor hair yields on average 75% of one and two-hair grafts and only 25% of three and four-hair grafts. Therefore there are fewer grafts available to recreate central hair density. Considering the persisting request for higher density in transplanted results, the pendulum may be swinging away from the exclusive use of Follicular Unit Grafts (FUGs) toward a combination of FUGs and (Di-Follicular Unit Grafts) DFUGs. Hair-transplant surgeons began to contemplate whether mixing the older, larger grafts with the newer smaller grafts could yield a natural result that did not compromise hair density. This method, which this book spotlights, combines standard FUGs distributed in the periphery of the transplanted zone (like the hairline) to maintain a “soft” appearance and Multiple Follicular Unit Grafts (MUGs) predominantly containing 2 follicular units per graft, or also known as Di-Follicular Unit Grafts (DFUGs or DFUs), to impart “strong” central hair density without truly compromising naturalness. Using both FUGs and MUGs during a hair-transplant session is referred to as Combination Grafting (CG).
Combination grafting differs from the era of the older, large grafts in their design and distribution (Fig. 1.2). First, the large round grafts, the so-called “plugs”, were placed in exposed areas like the hairline and crown, where today only smaller FUGs would be placed. Second, the large round grafts contained more than three times the number of hairs than today's MUGs and by virtue of their size, made each individual graft be perceived as a distinct entity. In addition, these very large round grafts were predisposed toward being compressed down to a tuft of hair, i.e., a “plug”. Third, the older grafts were often placed poorly angled and spaced, making the surgical result “pluggy” in appearance.*
Not every patient is a candidate for CG. Individuals with very coarse, straight dark hair on pale skin may be less than ideal for MUGs. In these patients, the challenge is to maintain naturalness while effectively blending larger and smaller grafts. In this situation, TFUT could be a better choice, especially for the starting hair-transplant surgeon. Conversely, individuals with very fine, blond or white hair may almost mandate a CG approach. In these patients, MUGs are not only well tolerated, but the size and the number of hairs that are transferred per graft compensates for the fine hair diameter thereby yielding the best prospect for visual hair density. This book will discuss the indications for both CG and for TFUT to offer these two alternative techniques as viable options for a surgeon who can apply judgment and artistry to the right technique for the right patient.
4
zoom view
Figure 1.2: The old “plugs” that were popular from the 1950s to 1970s used large, 4 mm round punch grafts that contained 16 to 20 hairs that were used exclusively throughout the scalp. The very large plugs appeared unnatural for multiple reasons. They were placed along the periphery of the transplanted area and therefore visually exposed. Due to their size, they looked unnatural and were predisposed toward compression, i.e. the transplanted graft would shrink into a central mega-tuft of hair. They also permitted see-through effect, i.e. the viewer could see the edges of the grafts, making them highly visible and thereby unnatural in appearance. Today, multiple follicular-unit grafts, or MUGs for short, are created with linear slits and placed in a tightly interlocked arrangement containing only half the number of hairs that were originally contained in a plug. In addition, MUGs are placed strategically behind multiple rows of tightly interlocked follicular-unit grafts (FUGs) that are much smaller and prohibit direct visualization of the larger MUGs. With the very tight arrangement and distribution of MUGs, the viewer has a hard time seeing these grafts as distinct entities. Of course, the skill of the surgeon to select the right candidate and to execute the procedure correctly (angle and distribution of the MUGs) will ultimately determine the naturalness of any surgical result.
 
Preoperative Considerations
Excellent hair transplantation requires both an in-depth knowledge of hair loss as a medical disease process as well as the intricacies of a superlative surgical technique. Many excellent textbooks have been written on the subject of hair loss,1,2 and this chapter is not intended to provide an exhaustive review. Nevertheless, the fundamental knowledge that an excellent surgeon must have to avoid unethical and unsafe surgery in his or her patients will be presented herein and hopefully will stimulate more assiduous study outside the confines of this textbook.
As hair restoration as a surgical discipline is only recently emerging with organized, well-structured and accredited training programs, many surgeons who have chosen to practice hair transplantation have struggled to perform 5quality hair-transplant work. Owing to the ignorance of the complexity of hair restoration or their cavalier attitude to the requisite technical skills to perform the procedure, some surgeons are still delivering suboptimal results, while those who are considering hair transplantation are lost in a sea of scattered information. This chapter will attempt to summarize both aspects of excellent hair restoration, the medical knowledge and the surgical artistry, all the time remaining focused entirely on the pragmatic aspects of hair transplantation.
 
Male-Pattern Baldness
The most commonly encountered type of hair loss that a practicing hair-transplant surgeon will encounter is Male-Pattern Baldness (MPB), also known as androgenetic alopecia, so this topic assumes primary importance in our discussion. However, a man losing his hair should not be automatically considered to suffer from MPB if there are other signs that may indicate a separate disease process, which will be covered in the following section entitled, “Hair Loss Diseases and Hair Restoration”. As mentioned, excellent hair-transplant results are predicated not only on outstanding technique but also on knowledge and judgment of conditions of hair loss.
Male-pattern baldness arises from a genetic predisposition toward alopecia that is derived from multiple gene loci. Accordingly, the familiar thought that MPB is derived from one's maternal father is entirely inaccurate and overly simplistic. Although an individual's family history of affected members should be undertaken thoroughly and documented properly, the greater number of affected family members would only suggest, albeit inconclusively, that the individual may have a higher likelihood to progress toward a severer degree of alopecia. Better indicators are the individual's age, extent of hair loss and rate of hair loss.
Given the progressive nature of hair loss, the surgeon must consider if the supply of donor hair will accommodate the future demands of hair loss in that individual. Before even attempting the first hair-transplant session, the surgeon must envision the feasibility to “finish the painting”, i.e., to paint an ever-enlarging canvas (continually balding scalp) with ever diminishing paint supply (dwindling and depleting usable donor hair). A surgical result that looks “appropriate” today could be potentially exposed as the transplanted hair remains and the surrounding naturally existing hair falls out, e.g., when the hairline or vertex is transplanted in the early phase of rapid hair loss. The surgeon must be mindful of whether the patient will retain sufficient donor hair to cover the exposed scalp with ongoing loss as the patient ages so as to avoid the appearance of an unnatural hair pattern that does not exist in nature. Understanding natural patterns of hair loss will help the surgeon to minimize creating an unnatural 6result but also to understand how to correct one if the patient loses existing hair around a transplant. The Norwood scale describes the normal variations of male-pattern hair loss (Fig. 1.3).
As hair loss is progressive in nature, the surgeon has a true dilemma when dealing with the younger male patient who may be rapidly undergoing hair loss in his teenage years or early to mid twenties. Although hair loss can be devastating to almost any person who experiences it, the younger male patient can be more acutely impacted during this critically social phase of life when most of all his peers sport a full head of hair. Overwhelmed with anxiety of looking older than his age and feeling like the only person affected in his peer group, many young male patients desire a very low hairline reconstruction to match that of their peers and to create an age-appropriate appearance. However, it is precarious in most cases even to perform hair transplantation in this age group let alone do so aggressively with a low hairline. Given the fact that most men who begin to lose hair this early in life will proceed to a Norwood VI/VII pattern, they will lack sufficient donor hair to make an early transplanted result appear natural later on. Hair transplant in the young male patient poses one of the most challenging ethical and psychological dilemmas for any hair-transplant surgeon.
Although surgeons should refrain from rushing to perform surgery on a young male patient, to state that a surgeon should never operate on a young male patient may be a bit excessive. Walter Unger relates a story where a teenage boy stood on the precipice of suicide due to his hair loss despite intensive psychological counseling. Unger opted to perform a conservative hair transplant on this individual with the patient fully educated and aware that in later life he might require a hair system/hairpiece to maintain a natural appearance.3 Clearly, the inexperienced surgeon should not rush into “helping” the patient by performing the surgery; rather the surgeon should help the patient understand the benefits and limitations of the hair-restoration procedure. Fortunately, medical management with finasteride and minoxidil can provide an important treatment option to retard the progression of hair loss thereby hopefully delay any surgical procedure. These medications should be purposefully and strongly advised to the young male patient losing his hair. For more details on the role of medical management for hair loss, please review the following section, “Medical Management for Hair Loss”.
At least, young (and older) men who are not the ideal candidates for hair transplantation have the option to follow today's fashion and shave their pate completely. Once hair transplant is performed, shaving one's head may no longer be an available option. With conventional linear donor strip harvesting and almost undetectable trichophytic closure (discussed in the next chapter), shaving one's hair may still reveal some scar in the donor area.
7
zoom view
Figure 1.3: The Norwood or Norwood-Hamilton scale grades degrees of male-pattern baldness. Type I shows minimal to no hair loss along the fronto-temporal expanse. Type II exhibits both fronto-temporal recession that does not extend further than a line drawn through a coronal plane, 2 cm anterior to the external auditory canal. Type III hair loss refers to fronto-temporal recession that extends posterior to the coronal plane that lies 2 cm anterior to the external auditory canal. Type III vertex indicates hair loss that primarily affects the vertex (or crown) region with or without accompanying fronto-temporal recession that does not exceed that described in type III. Type IV reveals greater fronto-temporal loss than exhibited in type III along with marked hair loss in the crown area but with a moderately dense swath of hair that bridges the intervening expanse between the two areas. Type V hair loss shows more extensive alopecia in both the fronto-temporal and vertex areas with only a small bridge of dense hair between the two areas that remains. Type VI hair loss reveals a complete absence of any remaining hair that separates the two now confluent areas of alopecia. In addition, the hair loss is more extensive laterally and posteriorly. Type VII represents the most severe expression of male-pattern baldness with only a narrow-horseshoe configuration that remains along the posterior and lateral border of the hairline. Norwood also classified a variant of hair loss that afflicts approximately 3% of male patients with alopecia in which the fronto-temporal recession marches progressively posteriorly in a uniform fashion without a central, anterior peninsula of hair. Type IIA refers to a condition in which the entire anterior hairline is receded uniformly across the forehead but does not extend any further posteriorly than 2 cm anterior to the mid-coronal line. Type IIIA reveals alopecia that extends to the mid-coronal line. Type IVA signifies alopecia that has extended past the mid-coronal line. Finally, Type VA indicates significant recession of the hairline into the vertex, and severer forms of this variant become indistinguishable with types V and VI.
8
Even with excellent hair-transplant methods, a shaved head can still reveal minor surface irregularities in the transplanted recipient region. Further, if a young patient undergoes hair transplant and then changes his mind and wishes to remove transplanted hair and shave his head, transplanted hairs can be more recalcitrant to laser hair removal so that may not be a viable option either. Therefore, all candidates for hair transplant should be fully consented that shaving their hair after a hair transplant may not be a feasible option.
Besides the age of the patient, the rate and extent of hair loss will also play a large role in determining what a surgeon can or cannot do for surgical hair restoration. In addition, high donor hair density will provide a better likelihood for a favorable result with a concomitant insurance policy for future loss, as more “funds” remain in the “bank”, i.e., “donor hair” in the “occipital scalp”, for withdrawal. The worst-case scenario obviously would be a young patient with already extensive hair loss who is rapidly losing hair and exhibits a poor donor hair supply. The best-case scenario is a mature male patient who has tremendous donor hair density and only limited hair loss that is slowly progressing. The reality in most cases exists somewhere between these two extremes, and that is where surgical judgment comes into play and the ethical obligation that a surgeon must have not only to create a natural surgical result but also to ensure that such a result can be maintained over the lifetime of that individual (with sufficient donor hair for future sessions to maintain the result as required). Further details regarding the thinking process necessary in approaching a patient for hair transplant are discussed in the section “Consultation and Preoperative Planning”.
In MPB, men do not simply lose their hairs. Instead thick, long “terminal” hair gradually transform into wispy, short, almost see-through “vellus” hair, which in turn fall out and are lost. This process known as miniaturization describes the principal method by which MPB occurs. Further, anagen cycles can shorten from 4 to 6 years to 1 year or less with an increase in the percentage of telogen hairs, with this process contributing to the loss of hair in MPB. The miniaturized, or vellus, hairs are the targets for medical treatment (finasteride and minoxidil), with the objective to revert these hair back to thicker, terminal hairs, albeit the results are only maintained as long as the patient is taking these medications. It is also important to determine the percentage of vellus hairs that exist in the region of the scalp intended for transplantation for two reasons: One, if the vellus hair reverts into terminal hair, the gain in hair volume may be sufficient to delay the need for a surgical intervention, and second, these hairs are more susceptible to temporary shock loss following transplant, which may occur approximately 6 weeks to 3 months after the procedure. Accordingly, patients who have a very high percentage of miniaturized hairs should be advised to take finasteride and/or minoxidil for several months prior to hair transplant to minimize social embarrassment that can arise during the time of temporary shedding. Prolonged medical management (> 6 months) with finasteride and/or minoxidil (preferably both) can limit but not entirely prevent this temporary effluvium postoperatively.
9
 
Women and Hair Loss
Although hair loss in men can engender considerable psychological upheaval, the effect on women can be even more emotionally crippling. Women do not have the option to shave their head, and hair can be a leading sign of feminine allure that when lost can be ruinous to a woman's self esteem. Further, hair loss in women may be viewed as unnatural, unlike MPB, and may elicit thoughts that the condition reflects an underlying disease process (which it indeed might, as will be discussed). Many surgeons believe that women suffer hair loss only in the postmenopausal setting owing to the higher proportion of circulating androgens that begin to rise. Accordingly, the term androgen pattern baldness, androgenetic alopecia or MPB is used to describe this condition even in women. However, women can lose hair prior to menopause and do so without an underlying medical cause, as men do, simply affected by their genetic predisposition toward it.
Although a good percentage of women do lose their hair without a discernible, identifiable cause, the surgeon should almost always investigate the possibility of a metabolic process or other factor as leading to the exhibited alopecic state. The most common metabolic causes for hair loss in women are hypothyroidism, iron-deficiency anemia related to menses, or some kind of hormonal imbalance. The authors routinely enlist the help of an experienced dermatologist (as needed) and internal medicine specialist who can help establish the presence of a hair/scalp disorder or metabolic imbalance, and respectively, treat the cause for a specific case of alopecia. Initial inquiry during the consultation into the type of hair loss (active shedding versus gradual), pattern (patchy versus global), and onset (pregnancy, fever, hairstyling services, etc.) can help elucidate the reason for the hair loss and may obviate the need for a referring consultation (Table 1.1). The specifics of a hair-loss analysis will be discussed in the following section, “Hair-Loss Diseases and Hair Restoration”.
Two specific conditions of hair shedding that relate to women will be discussed herein, hormone-related telogen effluvium and chronic telogen effluvium,4 even though Telogen Effluvium (TE) will be more systematically reviewed in the hair-loss disease section. Women are more subjected to a type of limited hair shedding known as telogen effluvium than men.
10
Table 1.1   Female hair loss evaluation
  1. Full chemistry profile
  2. Thyroid function studies
  3. Sedimentation Rate (checking for inflammatory diseases)
  4. Serum iron levels (including ferritin)
  5. Male/female hormone levels (including testosterone and dehydroepiandrosterone sulfate [DHEAS])
Telogen hairs, which are hairs that are in the non-growth phase, account for approximately 10% of hairs on the scalp at any given time that translates into approximately 60 to 100 hairs falling out physiologically on a daily basis. Conditions that lead to sustained higher levels of estrogen, e.g., pregnancy and ingestion of oral contraceptive pills, can maintain a disproportionately high percentage of hairs in the anagen, or growth, phase. Upon release of this estrogenic influence, hairs that abnormally persist in anagen will synchronously cycle into telogen causing perceived extensive hair shedding. Although hormone-related hair loss is self-limited in nature, use of minoxidil can reduce the extent of hair shedding and transition the patient during the phase of active TE. The use of minoxidil in women will be covered more in depth in the section on “Medical Management for Hair Loss”. Chronic TE describes a condition that is relatively uncommon but still prevalent in women, especially in the age group of 30s to 60s, who experience periodic hair shedding that can be substantial in extent but never enough to cause significant alopecia or progress to complete baldness. Reassurance that chronic TE will not lead to total alopecia should be offered. However, chronic TE is a diagnosis of exclusion. Although no treatment has been well established, topical minoxidil and topping serum ferritin levels off to fall within the male reference range have been found to be beneficial.5
When women lose hair, they tend to exhibit different patterns of alopecia than prescribed by Norwood for MPB. The classic grading scale is the Ludwig system (Fig. 1.4) that describes the overall pattern of female hair loss as being more of a global diffuse loss across the central scalp oftentimes sparing the frontal hairline (Fig. 1.5).
As mentioned, women can also exhibit the classic fronto-temporal recession, like men, especially in the post-menopausal setting when androgens exert a greater influence (Fig. 1.6).
A third type of hair loss described by Elise Olsen6 is the Christmas tree pattern in which a Christmas tree shape of alopecia can be seen, i.e., a triangular shaped loss, clearly visible when the patient bends downward with the hair parted in the midline (Fig. 1.7).
11
zoom view
Figure 1.4: This illustration shows the classification scheme for female-pattern baldness as defined by Ludwig. Thinning tends to be more generalized than in male-pattern baldness.
zoom view
Figure 1.5: This individual shows a Ludwig type of diffuse female-patterned hair loss. The hairline can be spared or affected with this type of loss. In this case, the individual demonstrates preservation of the hairline.
zoom view
Figure 1.6: This postmenopausal woman shows fronto-temporal recession similar to the type of hair loss experienced in male-pattern baldness.
Olsen contends that this pattern of hair loss is the most frequently encountered but under diagnosed since it is not evaluated in the aforementioned manner. The base of the tree pattern is along the frontal hairline (which can be spared or affected) with the apex toward the occiput. The speculation behind why women maintain their hairline may be due to the higher circulating presence of the hormone aromatase.
12
zoom view
Figure 1.7: This woman demonstrates a Christmas tree pattern of hair loss described by Elise Olsen in which the base of the tree is noted anteriorly and the top of the tree is situated toward the crown. The Christmas tree pattern is most easily revealed with the patient looking downward with the hair parted in the midline.
In addition, beside the obvious hair loss on the top of their head, women may demonstrate thinning of the donor area as well. Often, the temporal area, and at times, the occipital area can also show signs of thinning, which in return may significantly limit the capacity for adequate hair restoration.
It is important that when approaching hair restoration for women to consider that expectations may differ from those of men. When men lose their hair, their objective is to frame the face and oftentimes any reasonable amount of hair transplanted to cover their MPB would lead to satisfaction. In contrast, women often seek to restore their lost hair volume, which may be a more difficult objective to achieve. With women who may exhibit a more diffuse pattern of hair loss rather than discrete zones of alopecia, with a simultaneous thinning of their donor area, it is important to plan a hair-restoration procedure strategically. It may be wise to target areas of maximal hair loss that can optimally affect hairstyling, e.g., focusing on where the hair parts or in the central forelock (this area will be further discussed in the next chapter), an area that may be more important to fill in order to create greater perceived hair density. At times combination grafting can provide more of a visual punch in women who suffer from loss of central hair density and who therefore require only these stronger grafts. In any case, it is always wise to establish realistic expectations preoperatively, e.g., that the hair will not be as full as in youth but the objective is to improve upon their current situation.
13
 
Medical Management for Hair Loss
This is a very important topic to understand both for individuals who are contemplating hair transplantation and for those who are not. There are only two FDA-approved medications currently, oral finasteride (marketed as Propecia by Merck) and topical minoxidil (marketed as Rogaine by Pfizer, now owned by Johnson and Johnson). Finasteride and minoxidil are approved for male hair loss; whereas only minoxidil is approved for female hair loss. Finasteride has been shown to bear a teratogenic potential for the male fetus in women of childbearing age who take it but not in men who father children and who are on the medication. Therefore, finasteride is absolutely contraindicated in pre-menopausal women and has revealed as only equivocal benefit in those who are postmenopausal. In several controlled studies in postmenopausal women, finasteride was shown to have no benefit,7,8 whereas one more recent uncontrolled study indicated that there might be some gain in postmenopausal women who take finasteride.9 The authors prescribe finasteride in select post-menopausal women who desire more benefit than what minoxidil alone can provide and who have reported some moderate success on this added therapy. However, this commentary is entirely limited and anecdotal in nature.
Initial FDA trials in the late 1990s focused almost entirely on the benefits that finasteride and minoxidil have on the vertex, also referred to as the crown region.10 However, subsequent studies have shown proven benefit of both medications in the frontal, temporal and midscalp hair. Therefore, anyone who claims that finasteride and minoxidil are only intended for restoration of the crown region subscribes to outdated information that remains on the package inserts, which can only print the benefit for the vertex based on original FDA trials.11 Unfortunately, whatever hair was activated by using finasteride and/or minoxidil, cessation of the medication will lead to allowing hair to become inactive again, and one's hair will reverse to the appearance the individual had before starting the medication as well as lose all the hair retained over the period of time the individual was on the medication. As it takes approximately 6 months to build up visible effect of the medication, it usually takes the same time for hair to reverse to its starting point once the individual stops the medical treatment. Taking both medications have shown to have a synergistic benefit for the individual and when an individual decides to stop one medication, the benefits gained from the single product will disappear but the improvement attained from the other product will be maintained for as long as the individual continues on with that product.
The hair-growing effects of finasteride were discovered accidentally when the finasteride 5-mg pill (marketed as Proscar by Merck) was given to patients to manage Benign Prostatic Hypertrophy (BPH). Subsequent studies found that 14a 1-mg dosage was adequate to combat alopecia, which is marketed as Propecia.12 Propecia is a prescription-only medication and at the time of publication of this textbook still on patent by Merck, so no generic versions exist.§ Finasteride works as a type II 5-alpha reductase inhibitor, where 5-alpha reductase is the enzyme responsible for converting Testosterone (T) to Dihydrotestosterone (DHT). The presence of circulating DHT impacts hair follicles susceptible to hair loss and therefore a lower level of serum DHT can slow progression of hair loss and reconvert vellus hairs back into terminal hairs. The type II 5-alpha reductase is found predominantly in the hair follicles (and the prostate).
Finasteride is cleared hepatically and caution should be exercised in individuals with liver dysfunction. Dosage need not be adjusted with renal insufficiency. Finasteride does not affect the P450 system, and no drug interactions have been reported. Side effects occur in less than 2% of the patients and include 1.8% with decreased libido (1.3% placebo), 1.3% with erectile dysfunction (0.7% placebo), and 0.8% with decreased ejaculate volume (0.4% placebo). There is no statistically significant difference between treated and placebo side effects when taken separately, but there is statistically significant difference when all side effects are considered together (3.8% versus 2.1%). Moreover, side effects resolve in 58% of individuals who continue treatment.13 Finasteride is known to reduce serum prostate-specific antigen (PSA) by 30% to 50%. Accordingly, individuals over 40 years of age who are taking finasteride should be informed about their altered PSA value (the value should be doubled for clinical interpretation) and advised to make certain that their primary-care physician is consulted. As mentioned previously, women of childbearing age should not ingest finasteride or handle crushed pills for the risk of a teratogenic effect on a male fetus. Although teratogenecity is not a problem when men ingest finasteride, decreased sperm count and semen volume, which may rarely occur, may compromise their fertility. Therefore, men who have failed to conceive in their previous attempts may consider stopping finasteride during their future attempts at conception. Finasteride was once banned in sports because of its potential as a steroid-masking agent but recently has been approved for use in the Olympics, FIFA and many other sports. Still, it is advisable to check with the specific sports federation before prescribing finasteride to an athlete.
In 2005, the Prostate Cancer Prevention Trial (PCPT) showed that finasteride at a dosage of 5 mg per day intended for Benign Prostatic Hypertrophy (BPH), decreased the likelihood for prostate cancer by 25% as compared with placebo.14 However, it appeared that finasteride increased the specificity and selectivity of prostate cancer detection, thus a perceived increased rate of high Gleason grade tumors. The 2008 PCPT update showed that the reason for the results found in the previously mentioned study arose from the reduced prostate size and thereby a higher detection rate rather than a higher cancer rate. Interestingly, this study showed a 30% reduction in the risk of prostate cancer with the use of 5 mg finasteride.15
15
Another medication relevant to the field of hair restoration is dutasteride (Avodart by Glaxo Smith Kline), which is a potent inhibitor of both Type I and Type II isoenzymes of 5-alpha-reductase. In 2002, the FDA approved the use of dutasteride for the treatment of BPH but currently there is no clinical indication for MPB. At a 0.5 mg daily dosage, dutasteride reduces DHT by over 90% as compared with finasteride, which reduces DHT by 65% at a 1 mg daily dose. As Type I 5-alpha-reductase accounts for 30% of circulating DHT, dutasteride blocks the Type I enzyme 60% better than finasteride. The type I enzyme is found in the brain of children and adults of both sexes and may play a role in non sex-related steroid functions. Some researchers claim that the presence of the Type I enzyme can serve to protect against breast cancer. Phase II clinical trials for the treatment of MPB have shown that at 6 months there was an increase of 96 hairs in a 1-inch circle compared with 72 hairs with the 5 mg dosage of finasteride, possibly a 33% greater efficacy. These early results must be weighed against the problems of taking a combined Type I and II 5-alpha-reductase inhibitor as well as the limited and less controlled nature of a phase II trial. A phase III trial undertaken in Korea was conducted, and results are consistent with the above findings. At this time, the authors rarely if ever prescribe dutasteride because of its unknown long-term effects. Additionally, the serum half-life of dutasteride is approximately 10 times longer than finasteride; side effects are greater; and side effects tend to take about 10 times longer to resolve. Treatment with dutasteride for MPB is currently experimental and off-label.
The effects of minoxidil on hair growth were also discovered on the sidelines of another treatment. Originally used as an intravenous medication to mitigate severe hypertension, individuals who received minoxidil observed hair growth not only on their scalp but also on their body. Further investigation led to the topical use of minoxidil. Although, the initial early reports of oral minoxidil for hypertension linked minoxidil to increasing the risk in heart-disease patients,16 localized topical minoxidil for hair loss is safe and is entirely an over-the-counter treatment. Nevertheless, the authors are more reluctant to recommend the product in those individuals with a significant cardiac risk profile.
Minoxidil is currently manufactured as a 5% and 2% concentration topical solution intended for direct application to the scalp (not hair). The 5% concentration is designed for male patients, whereas the 2% concentration is 16designated for women. However, women who desire a more vigorous treatment algorithm can take the 5% concentration as an off-label indication so long as they understand the slightly higher risk for the growth of unintended facial hair, which will regress with cessation. Interestingly, although the 5% concentration in women can show an increased rate of hair growth early on, there is no statistically significant difference in results between the 5% and 2% concentration after 1 year of usage.
The mechanism of action for topical minoxidil is unclear. As a potassium channel agonist, the cellular effects on hair growth are only speculative. However, it is known that minoxidil can cycle hairs out of telogen (the resting phase of the hair cycle) and push them into the anagen growth phase and also lead to a more sustained anagen period. Accordingly, many individuals will experience increased hair shedding early on in treatment and should be advised that this phenomenon actually will have a positive impact on their hair loss, as hairs move from telogen to anagen. Hair shedding may be experienced for several weeks early on with new hair growth expected within 6 months from the start of treatment. Also, because of this effect that minoxidil has on migrating hairs from telogen to anagen, minoxidil is a recommended treatment for individuals who suffer from acute or chronic telogen effluvium.
The main side effect of minoxidil is an irritant or allergic contact dermatitis (primarily due to the propylene glycol found in the solution form), which causes a flaky and pruritic scalp and accounts for one of the two major objections for the use of minoxidil (the other one is that minoxidil makes one's hair look oily). However, Rogaine brand released 5% foam that removed the propylene glycol ingredient thereby reducing the incidence of dermatitis and as a side benefit, the undesired oiliness. Currently, the foam is only manufactured as a Rogaine brand and is unavailable in a generic formulation.
Although finasteride and minoxidil can provide wonderful results, they are not a replacement for hair transplantation. As standalone treatments, finasteride and minoxidil can convert many wispy vellus hairs back into thicker terminal hairs (but not universally or uniformly so). Therefore, as mentioned in an earlier section, for those individuals who have lost all hair including vellus hairs, (what the authors like to refer to as “slick baldness”), neither finasteride nor minoxidil will provide any benefit. There is confusion over what exactly finasteride and minoxidil do for hair loss. Do they regrow hair? Do they slow down hair loss? The answer in essence is yes to both questions. There are three observable effects of medical treatment: Preserving the status quo (hair is maintained and the progression of hair loss diminished), increase in hair volume (fine vellus hairs are reverted into thicker terminal hairs) and increase in hair count (with fewer hairs going into telogen stage, fewer hairs are falling out). 17Ultimately, hair loss is progressive so medical management will retard but not necessarily arrest this process. That limitation should be emphasized to every patient willing to consider medical treatment of alopecia.
As established, finasteride and minoxidil do not entirely restore a full head of hair. However, they can contribute to a better aesthetic result when combined with hair transplantation, which in turn is intended to create a substantial and sustainable aesthetic impact. If 10 hairs could be transplanted into a specific area and if another 5 hairs are converted from vellus to terminal hairs in that same area, then the overall hair density will be much better. Besides creating a better visual result, medical management will also help retard further hair loss and lengthen the time interval necessary for the next hair-transplant session. This is particularly important when considering crown restoration.
The crown region requires a large number of grafts expended to create the same aesthetic impact as the frontal hairline and midscalp region. This fact is particularly important considering that the crown can continue to recede as one ages and a large number of grafts may be required to cover this further loss to avoid an unnatural appearance. With that in mind, crown restoration should probably be undertaken only in individuals who have enough donor hair to complete the task and are willing to undergo a future transplant to pursue further hair loss and consequent scalp exposure. Along those lines, medical management can be particularly important to buy as much time as possible by slowing down crown hair recession.
With hair loss being a multibillion dollar industry, there is a plethora of products in the marketplace and on the Internet that claim to regrow hair. Many of these products work because they contain minoxidil but are not worth the claim of superior results. To review all or many of these remedies lies beyond the scope and relevance of this chapter. Because of its popularity, we will address the herbal medication saw palmetto (an extract from the fruit Serenoa repens), which has been shown to reduce BPH. Accordingly, it has been thought to be influential in MPB as well. Only one limited study showed improvement in MPB that was reportedly conducted in a randomized, double blind and placebo-controlled fashion.17 However, larger trials are necessary to establish a clear clinical role for such herbal, alternative medications. Suffice it to say that the hair-transplant surgeon should familiarize himself or herself with the current products that are being hawked so as not to be blindsided by a patient's query. A healthy dose of skepticism should always be maintained by the wary scientist.
18
 
Hair Loss Diseases and Hair Restoration
All hair loss should not be reflexively thought of as MPB. Obviously, if a 45-year-old gentleman presents with progressive thinning and miniaturization in a Norwood-MPB pattern without any other remarkable history or physical examination, then perhaps it would be safe to say that the problem is MPB. This book is not simply intended to show a prospective surgeon how to perform aesthetically sound hair transplantation but also when not to operate on a patient. The reader is encouraged to undertake a more in-depth study of how to recognize types of hair loss before beginning a career in hair restoration so as to perform safe hair-transplant surgery. Nevertheless, this chapter will outline an essential framework of knowledge that any surgeon should know about hair loss as a prerequisite that can serve as a guideline for further study. Recognizing when hair loss is a medical rather than surgical condition is very important, and dermatologic and medical colleagues should always be kept in mind as referrals for these difficult cases.
When evaluating hair loss, the surgeon should define the parameters for the problem at hand: first, how long has the condition been going on (and the nature of it: Periodic, progressive or resolving); second, if the condition is diffuse or patchy; if there is hair shedding or hair breakage; and third, whether there is any other recent events surrounding the hair loss condition (fever, pregnancy, etc.). Although these questions are not exhaustive, they can serve as the basis for an incipient investigation into the patient's specific condition of hair loss. If the hair loss began in childhood, clearly genetic influences and hereditary conditions should be explored. These genetic disorders (like Menkes Kinky Hair disorder, etc.) lie beyond the scope of this chapter. If the onset of hair loss is recent and the loss is rapid, discovering the underlying cause and stabilizing the loss is a paramount concern. If the hair loss is focal, i.e., localized in nature, the physician should be thinking of alopecia areata, tinea capitis, or trichotillomania (obsessive hair pulling) and refer the patient to a dermatologist as an initial screening effort. If the hair loss is diffuse in nature, telogen effluvium, anagen effluvium, or MPB should be considered as likely candidates depending on the history and physical examination. For a male with progressive shedding, the hair loss is most often MPB and should be treated with finasteride and minoxidil. It is interesting to note that one has to lose 50% of one's original hair in a specific area in order to notice any discernible thinning. For a female with progressive shedding, before establishing whether the loss is FPB, questions 19and workup should eliminate an alternative diagnosis, such as thyroid abnormalities, irregular menses, estrogen imbalance, anemia, etc. The conditions that can elicit a positive history for telogen effluvium would be a recent history (usually several months prior) of fever, anesthesia, crash diet, low protein diet, pregnancy in women, etc. If the hair is shedding, a further refining question would be whether the hair is coming out by the roots or showing signs of abnormal breakage. Hairs that fall out by the root suggest telogen effluvium or MPB. Conversely, hair breakage could indicate an anagen effluvium or structural hair shaft defect. Hair shaft defects can arise in infectious diseases, like tinea capitis, that can cause hair breakage or due to the damage caused by the use of harsh hairstyling chemicals or straighteners. Anagen effluvium that occurs with chemotherapy agents causes nearly total hair loss because most hairs are in the anagen phase and their growth becomes interrupted with these cytotoxic medications.
After a careful history is taken, physical examination should be conducted next. In non-scarring alopecias (like MPB, alopecia areata, telogen effluvium, etc.), the area of hair loss will still maintain visible follicular pores, whereas scarring alopecias (like lupus, lichen planopilaris, etc.) will show areas devoid of follicular pores and may also demonstrate an associated appearance of scarring, scaling and erythema. Evaluating the pattern of hair loss will also be helpful, as alopecia areata exhibits a random distribution and MPB follows typical patterns of hair loss.
Evaluation of the hair shaft as to caliber, fragility, length and shape can help to determine the presence of any hair shaft defect. A pull test can be administered in which approximately 60 hairs are grasped between the thumb, forefinger, and middle finger and gently tugged. Greater than 10% of hairs that are released indicate an abnormal pull test. Of note, individuals should not shower for at least one day prior to the pull test. Generally speaking, a pull test will help remove telogen hairs but not normal anagen hairs that are firmly anchored. An excessive number of telogen hairs may reflect a telogen effluvium. Abnormal anagen hairs that are pulled out can indicate either an anagen defect or a relatively uncommon childhood condition known as loose anagen syndrome. To differentiate between anagen and telogen hairs, the hair shafts should be evaluated under a microscope. Telogen hairs exhibit a classic, club-shaped appearance with a semi-transparent root.
A trichogram or pluck test requires the use of a hemostat with a rubberized end in which 60 to 80 hairs are grasped and forcibly plucked out, twisted and lifted from the scalp. Hair shafts are cut about 1 cm above the root, and the roots are evaluated on a microscope. Anagen hairs are distinguished from telogen hairs and the anagen/telogen ratio is established. Unfortunately, anagen hairs 20that are removed can appear distorted and dystrophic from the force of the pull. Therefore, the trichogram is rarely performed today. A scalp biopsy can be much more informative and should be considered when evaluating unusual hair or scalp conditions. Recruiting a dermatologist (if you are not one) should be considered in these cases when a more elaborate scalp/hair evaluation is mandated.
Normal, physiologic hair shedding is defined as falling below 100 to 150 hairs per day. The shed hairs are collected from the shower, brushes, and skin and placed daily into separate plastic bags. Days in which showering occurred should be noted, with increased shedding expected on those days. A 7-day diary defines the usual period of study and repeated during perceived active shedding.
Laboratory workup should also be considered when indicated. Serum ferritin levels can be a sensitive indicator for iron deficiency anemia that can lead to a diffuse hair loss in women. Thyroid function tests, specifically the Thyroid-Stimulating Hormone (TSH), may also be an important part of the evaluation. Any virilizing signs in women including irregular menses, hirsutism, or acne should be evaluated with both free testosterone and Dehydroepiandrosterone Sulfate (DHEAS). When lupus is suspected, a serum Antinuclear Antibody (ANA) will be elucidative.
Understanding when hair-transplant surgery is safe to perform should always be a prerequisite. For example, transplanting hair into zones of active shedding may prove disastrous depending on the root cause of the shedding. In telogen effluvium, the condition is temporary in most cases and does not require surgical intervention. Anagen effluvium that arises from chemotherapy is temporary in nature and rebounds after the offending agent is removed and should not be transplanted (also there would not be any donor hair to do so). Transplanting hair into active (compared with burned out) lesions of scarring alopecias like lupus or lichen planopilaris will most likely lead to poor to no graft uptake and therefore is contraindicated. When a lesion becomes burned out entirely is controversial, and assistance from a dermatologic colleague should be enlisted before contemplating surgery. Even in burned-out conditions, graft uptake may be poor and test grafts should be contemplated. Unfortunately, even when test graft results take, ultimately they can still fail over time either as the condition flares back or even in a dormant setting. An absolute contraindication for hair-transplant surgery is a condition known as Diffuse Unpatterned Alopecia (DUPA) in which the potential donor hair is also miniaturized. Without any safe, usable donor hair, hair-transplant surgery should be avoided, and alternative measures like hair systems and camouflaging products should be entertained (see below).
21
22
zoom view
Figure 1.8: Hair growth can be divided into three phases: Anagen (active growth), catagen (active loss) and telogen (resting phase). In the scalp, 90% of hairs remain in the anagen phase. Catagen only lasts about 2 to 3 weeks and is characterized by the hair-shaft separation of the dermal root, and it is recognized by a thin connective tissue strand connecting the two. About 10% of hairs are in telogen phase at any given moment and this lasts about 2 to 3 months. Catagen phase is the shortest of three phases and occurs prior to telogen. As the basal attachment becomes even more attenuated, the hair shaft detaches from the dermal root resulting ultimately in the hair falling out (known as exogen). Scalp hairs are asynchronously in these three cycles at any given time.
23
24
 
Hair Replacements, Hairpieces and Wigs
Although it may seem that learning about non-surgical hair restoration is futile for a surgeon, it is important that a surgeon at least be familiar with hairpieces for the following enumerated reasons. Some patients may want to transition from wearing a hairpiece over to a hair transplant and a surgeon should know how to guide a patient in doing so. Other patients may not be a candidate for hair-transplant surgery because of cardiovascular risk, lack of interest, lack of sufficient donor hair to cover extensive baldness or financial limitations (although a hairpiece can be a more expensive option over time).
First, we should clarify terminology. A hair replacement (hair system or hairpiece) is a partial synthetic or natural hair prosthesis as compared with a 25wig which covers the entire scalp. A wig is a term used to describe what a woman would wear and a cap (a less frequently used item in men because of the persistence of the occipital fringe in men with MPB) describes a similar all-encompassing prosthesis for men. Great strides have been made when it comes to the naturalness of hairpieces today. Unlike the old thick, synthetic, and poorly shaped “rug” that looked unnatural, today's thin, laced-front hair replacements are made of natural hair and almost undetectable. The reason modern hair replacements look less obvious is that the hairs are woven through a transparent mesh base that attaches to the scalp that can simulate natural hairs emanating from the scalp. Another reason is that they contain significantly fewer hairs (closer to the natural hair density).
Hair replacements can be attached to the scalp through a variety of mechanisms. Tape adhesives are used for daily adherence so that the hairpiece can be easily removed at night time. Glue adhesives provide more durable bonding and oftentimes can keep a replacement in place for upwards of a month. Similarly, hair weaving uses existing hair to provide anchorage to the hair system through inter-weaving the two together. Weaving can also provide a month of time for a hair replacement to remain in place before maintenance is required. Lastly are hair clips, where a hair replacement is secured with several sets of little combs that clip to a person's hair.
Maintenance of a hair replacement involves cleaning it, at times coloring it, repairing it, replacing it, as well as bonding it back on. Hairstyling requires special sensitivity and technique to provide proper blending and is usually carried out in specialized salons where men who wear hair replacements can feel more comfortable in that environment dedicated to their needs.
The benefit of hair replacements is that they can provide immediate gratification as opposed to a hair transplant that requires 6 months or beyond to see the result and that may require additional session(s) to attain the desired level of density. Further in individuals with extensive baldness (Norwood VII) or poor donor hair density, hair replacements may be the only method to attain acceptable levels of hair density. Although the initial cost of a hair replacement may be less expensive than a hair transplant, the ongoing maintenance fees far exceed a hair transplant after a year or few years. In addition, the time investment for maintaining a hair replacement can be considerably more laborious than the hair obtained with a hair transplant, which by contrast requires no additional care.
The major disadvantage of wearing a hair replacement is that no matter how natural it may appear, there is a possibility for the hair replacement to be displaced and reveal its underpinnings: The wearer is always worried that he may be “found out”, and for that reason avoids certain activities like swimming 26or group trips. The upkeep and the worry of being discovered are the most common reason one may choose to undergo hair transplant. For those who transition from hair replacement to hair transplant, having a “cover up” during the transition period may be an advantage. For a surgeon, the difficulty of dealing with an individual who wears a hair replacement is conveying two major limitations of the surgical result: One, that hair transplant cannot match the excessive density and the very low hairline of a hair replacement; and two, that the individual needs to make some adjustment in the way a hair replacement is worn after the hair transplant (See below for details.).
There are two groups of individuals wearing a hair replacement that can benefit from hair transplantation: individuals who wear hair systems and who are looking to transition out of them with a hair-transplant procedure and individuals who are not candidates for hair transplant because of insufficient donor hair but desire to enhance the appearance of their hair replacement through temporal-point reconstruction.
An individual who is used to the unmatched density of a hair replacement must be fully aware that the density achieved following a hair transplant may not be comparable to a hair replacement or that it may not be achieved in a single session. For an individual with advanced hair loss, yet robust hair density, replacing the hair replacement with transplanted hair may take 3 to 4 sessions. Nevertheless, most people seeking hair transplant are willing to compromise hair density or selecting the restoration only of the front and top of the scalp and accept an exposed vertex for the freedom of having their natural hair (as long as they understand the limitations and advantages of hair transplantation). A low hairline is often a give away of someone wearing a hair replacement, and a detailed consultation should address what constitutes a natural hairline, such as facial proportions and hairline recession with aging, and thereby focus on educating a prospective patient to create realistic expectations and perhaps a more natural-looking option.
For someone looking to transition out of a hair system, care should be given to how the hair replacement is attached following the hair-transplant procedure. Immediately after the procedure, instead of the aforementioned methods of attachment (tapes, glues, weaving), the hair replacement must be held in place with specialized clips for two reasons. First, tapes and glues cannot be used over the transplanted-hair area because they can damage or pull out grafts. Second, weaving is not allowed since the hair replacement should be removed at night to allow the individual to maintain proper hygiene of the transplanted area. In addition, the individual needs to be instructed to keep the transplanted area exposed as much as possible, even if taking the hair replacement off only at night, for optimal follicular growth. The transition period depends on the personal 27comfort of each individual and it may take between 9 to12 months for a modest result and several years for a major restoration.
As hair replacement continues to be more natural through technological advances, the major problem that remains is matching the temporal hair loss with the hairline hair loss. The usual giveaway for even a well-constructed hair replacement is the fact that it does not match the temporal hair loss. This unnatural pattern looks like the individual is wearing a baseball cap or so-called “lid effect”. For the individuals with a Norwood VII pattern and poor donor hair, hair transplant may not be an option if the individual desires to fill the entire bald scalp. In those advanced cases of hair loss, wearing a hair replacement may be the best choice for that particular individual. However, unless the person wears a full cap (like a wig), hair replacement does not address the sideburns and temporal region; and hair transplantation can provide an excellent compliment in order to achieve a more natural appearance by transplanting hair in the temporal region to match the hairline of the hair system. In those advanced cases of alopecia, hair loss usually extends to the temporal region; and rebuilding the temporal hair (temporal-point reconstruction) to match the hair system can provide a more natural and youthful look.
 
Camouflaging Products
Camouflaging agents are topical products applied to the hair or scalp to increase visual density of thin, see-through, hair. In general, these agents are matched to the color of the individual's hair and are intended to camouflage the visibility of the bald scalp. It is important that a hair-transplant surgeon be able to counsel a patient appropriately regarding these products because they are a valuable adjunct to hair restoration. Camouflaging products can be used to cover existing baldness, to delay the need to undergo hair restoration, or to add more hair density either while the transplanted hair is starting to grow or in anticipation of a second transplant session, and finally, in the postoperative setting to ease the shock and inconvenience caused by postoperative thinning (telogen effluvium).
The two most popular camouflaging agents are Toppik (Spencer Forrest, Inc.) and DermMatch (DermMatch, Inc.). Toppik is applied to the hair to increase visual density, whereas DermMatch is applied to the scalp to decrease the visibility of the naked scalp.
Toppik is composed of wool fibers that attach magnetically to the hair, which can be affixed to the hair more tenaciously with additional hair sprays. A disadvantage of fibers is that they can come off easily onto clothes or pillows and are slightly messy during application. Although light rain should not cause a problem, a heavy downpour will displace the product and may cause social 28embarrassment. Toppik comes in a range of color shades. An accessory bulb spray attachment aids in the smooth application of the product onto the hair and scalp, as it is important to apply it to both areas. DermMatch is a powder cake that is applied with a wet sponge applicator to the scalp and is advertised as water resistant. It can usually survive light rain but will fail in heavier water situations. It is excellent for applying to focal areas of loss and can be used in light-colored hairs, such as white hair. It is an excellent product that can dull down the shiny scalp and minimize the see-through effect of thin hair. However, it takes longer to apply, especially with longer hairstyles. DermMatch comes in eight different colors.
Couvre (Spencer Forrest, Inc.) is a lotion consisting of a sesame-seed emulsion that requires direct application to the scalp. It has the consistency of cream shoe polish and is relatively water resistant. Sprays like ProThik (Aquilia International Ltd.) and Fullmore (Spencer Forrest, Inc.) are easily and quickly applied and are water resistant. However, like fibers they can be messy and cause soiling of clothing and furniture. Inhalation of the agent should be monitored during application. In general, all of these products should not be applied until the scabs fall off or are removed on the 7th postoperative day following hair transplant. Proper hair hygiene between applications is of critical importance to assure a healthy scalp and good hair growth.
 
Consultation and Preoperative Planning
The three primary objectives of a consultation and preoperative planning are, first, to establish a rapport with a prospective patient, second, to educate him or her about the nature of hair loss as well as the benefits and limitations of hair transplantation, and finally, to evaluate one's individual situation and determine a short- and long-term hair-restoration plan.
The consultation begins with establishing rapport with a prospective patient and asking about his or her concerns regarding hair loss and desires for hair restoration. In general, today it is a rather common practice to have a surrogate, or non-medical associate, perform a large part of the initial consultation. Whether a surgeon decides to incorporate such upfront ancillary assistance depends on numerous factors including cost of doing so, risk of diluting the physician-patient relationship, and the liability of a non-medical personnel inadvertently dispensing medical advice. An associate should not replace the role of the physician but serve as a bridge to help answer basic questions regarding the hair-restoration process and general principles of hair loss and hair transplantation. With a busy practice, an associate can play a valuable role in streamlining the preoperative schedule. Nevertheless, the surgeon should always meet with the prospective patient to render proper diagnosis and to establish treatment protocols.
29
Before discussing the aesthetic objectives for hair restoration, the prospective patient should be educated on the nature and progression of hair loss with all of the many details elaborated in previous sections kept in mind. If the patient is deemed to have male-pattern baldness by history and examination, the surgeon can move forward with a treatment plan to restore the lost hair. With any female, the consultation becomes more elaborate in determining whether appropriate metabolic or dermatologic workup would be required before contemplating hair-restoration surgery. With any signs of abnormal shedding, breakage, etc. the consultation should initially focus on determining whether there would be any contraindications to undertaking transplant surgery, which would be confirmed by assiduous clinical evaluation of the scalp and hair. Further physician referral, laboratory and scalp workup, and medical intervention should be enlisted as deemed relevant.
During the initial intake history, the salient points that should be covered include exploring the nature of the hair loss and the measures that the individual has attempted to rectify or ameliorate the condition. Medical management, both FDA-approved (minoxidil and finasteride) as well as non-approved (Provillus, Avacor, Saw Palmetto and other herbal remedies), should be recorded as far as extent and period of usage and effects of the intervention (hair growth, retardation of hair loss, effectiveness or ineffectiveness, dermatitis or other side effects). Besides medical treatments, review of previous use of hair replacement and camouflaging products can also be instructive and informative. In short, every treatment that the individual has tried should be documented and discussed.
After discussing what the patient has attempted in the past to remedy his or hair loss, the physician should investigate what medical options are available for the patient. Even if a patient is a surgical candidate, the physician should rightfully elaborate on the available medical options to retard further hair loss. The authors almost always incorporate a treatment plan of medical management for hair loss using only FDA-approved medications in every patient who would benefit from this intervention and not hold any contraindications.** Medical management, preferably with both finasteride and minoxidil for the male patient and minoxidil for the female patient, should also be seriously considered in an individual exhibiting extensive miniaturization in which hair transplant could lead to unbearable, albeit temporary, telogen effluvium postoperatively. A minimum of 3 months (preferably 6 months to a year) on medical management 30will help reduce the likelihood of postoperative shedding, especially in these individuals who are susceptible to experience this condition. Almost every female should be vigilantly counseled on the use of preoperative minoxidil to minimize shedding, a phenomenon that is much more common in the female population. In some situations, a prospective patient would need medical treatment for several years before requiring surgical intervention, and surgeon or ancillary person should not neglect this time to build valuable rapport. If the medically treated patient has a good experience with the physician's office, that individual will be more inclined to undergo a surgical procedure at that surgeon's clinic when it is deemed necessary.
After a careful history is taken, the patient's hair and scalp should be meticulously evaluated. The recipient and donor sites should be studied under close scrutiny and recorded in the preoperative notes. The recipient area should be observed for the extent of hair loss, the pattern of hair loss, and the presence and degree of miniaturization. Beyond the basic evaluation for hair loss, the surgeon also should hunt down any signs of abnormal hair or scalp pathology (guided by clinical history) that would contraindicate surgical intervention, e.g., abnormal breakage/fragility, abnormal patterns like the circular zones of hair loss in alopecia areata, and scalp erythema/plaques that would indicate psoriasis/seborrheic dermatitis or worse yet a scarring alopecia. It is worth noting that it would be wise to enlist the assistance of a dermatologist with any of these conditions to make sure that the patient is a proper surgical candidate. Even transplanting from or to areas with active or inactive psoriasis or seborrheic dermatitis might cause the disease to be transported to new areas that were once quiescent and affect the success of a hair transplant. Previous transplanted hair should also be part of any recipient-site evaluation looking both for favorable results (good angulation, size of grafts and density) along with poor results (bad angulation, improper graft sizes in certain regions, “plugginess”, pitting, compression, cobblestoning, an unnatural shaped and positioned hairline, etc.).‡‡
The donor area should be similarly evaluated for any signs that would contraindicate surgery with an absolute contraindication being miniaturization of the donor hair in conditions like Diffuse Unpatterned Alopecia (DUPA). Donor hair density (high, medium and low) should be determined along with scalp elasticity and integrity. Previous donor scarring may prevent the scalp from adequately stretching to accommodate wound closure, and lack of scalp elasticity can limit the number of available donor hairs needed for further transplant sessions and should be noted. Although no firm scientific foundation has been established for preoperative scalp exercises, the authors prefer to have a patient undertake manual scalp exercises to loosen a tight scalp. We have found these exercises anecdotally to be highly beneficial in reducing wound-closure tension and even in patient comfort levels in the donor area postoperatively. These exercises consist of cupping interlocked fingers and squeezing the scalp repeatedly to stretch and relax the scalp several minutes a few times a day for several weeks or months leading up to the transplant session. The donor hair should also be evaluated for regional density, caliber and curl. In order to achieve naturalness and high visual density, fine hair is suitable for hairline reconstruction because it gives a softer appearance, whereas strong hair should be used for central density because it adds volume. Further, white hair is ideal for the temporal or lateral hump reconstruction because it blends better with the surrounding hair. Hair caliber or color may change from one donor region to another in the same person as an example between the mid-occipital and the postauricular area. This phenomenon of regional hair differences should be taken into consideration when planning where transplanted hair will be distributed in the recipient area. Hair in the temple region may exhibit greater numbers of single- to two-hair follicular units, while the occipital region would more likely have predominantly two-, three- and four-hair follicular units. In addition, the spacing between follicular units may vary significantly from very dense in the occipital region to sparse in the temporal area or from coarser, sparser hair in the upper occipital region to finer, denser hair in the lower occipital region. Recognizing these variations indirectly translates into a surgeon's ability to harvest sufficient donor hair to accomplish the requisite transplant goals. Special attention should be paid to the inferior aspect of the occipital donor region to differentiate fine hair from miniaturized hair observable in retrograde hair loss, occurring along the nape of the neck upwards, the latter of which is unsuitable for transplantation. These regional subtleties will be covered with greater depth in the second volume of this book dedicated to assistant knowledge and proficiency.
31
The next order of business is to plan the hair-transplant procedure. During this phase of the consultation, good evaluation and communication are the keys. If the physician who is establishing the hair-restoration plan underestimates the extent of the reconstruction, this mistake may lead to a costly situation of over-promise and under-delivery. Conversely, if the patient has vague expectations and the consultant does not clarify those expectations or does not communicate clearly the plan of restoration, any miscommunication may breach trust and destroy any rapport built with that patient. When conducting a consultation, one should keep the following in mind:
  • Ensure that the prospective patient expresses realistic expectations. This means understanding the progressive nature of hair loss and that hair 32transplantation is not a one-time solution. Communicating with clarity the area to be treated, the position and shape of the hairline, as well as targeted hair density can minimize miscommunication and future disappointment. The authors outline the area of hair reconstruction with an erasable eyebrow pencil and document the proposed design by taking a photograph preoperatively.
  • If a large area needs hair restoration and the donor area is abundant, then the recipient area should be addressed in two separate procedures and treated in the order of priority, hairline first, vertex second. The reason for this strategy is that once the hairline is restored and an individual has a frame to his face, he will be more eager to undergo vertex reconstruction. In addition, the hair from the front and top can be combed back and used to camouflage the vertex in anticipation for a second procedure. If the donor hair is scarce, then the recipient area could be treated creatively and strategically in order to create the most visual density and best use of the transplanted hair. For example, in a female prospect, if the entire top and both temples are affected and the donor hair is medium to low density, then hair may be transplanted in a T- or L-shaped design to improve the density behind the hairline and along the hair part. If the person parts the hair in the middle, then a T-shape would be beneficial (imagine the letter T upside-down and the horizontal bar positioned behind the hairline). If the person parts her hair on the right side, the L shape would be advised (again, horizontal bar would be behind the hairline) and if the person parts her hair on the left side, the mirror image of the L shape would be designed (Figs 1.9A to C). The design may be drawn with an erasable eyebrow pencil, the patient consented on the design, and the agreement documented photographically.
  • If the patient has a significant number of vellus hairs in the recipient area and he or she is not on medical treatment, postoperative shedding should be thoroughly discussed and not merely casually mentioned.
    zoom view
    Figures 1.9A to C: This illustration shows three prospective methods to transplant a woman with diffuse baldness and with limited donor hair. (A) A woman who parts her hair on the right side can have the hair transplanted principally along the part and in the central forelock, an area behind the hairline. (B) A woman who parts her hair on the left side will have the mirror image of the L shape so that one limb falls along the part. (C) For a woman who parts her hair in the middle, an inverted T shape can be created so that one limb of the T falls along the central part.
    33
    The majority of patients experience some postoperative shedding, which will raise some degree of concern anyway. Therefore, the authors prefer to start almost every patient on medical therapy first and schedule the surgery sometime between 1 to 6 months out. It is worth mentioning that even transplanted hair may be affected with postoperative shedding. The patient should always be reassured that the hair will regrow within 3 to 6 months.
  • With male-pattern baldness presenting earlier in life, it is important to reiterate the ethical guidelines of treating a young patient in his teens or early to mid 20s. The surgeon should always be mindful that the permanent nature of a hair-transplant result would be carried forward for the patient's entire life with the burden of ever-dwindling donor supply in the face of an ever expanding zone of alopecia. Particularly, the surgeon should be very cautious in deciding to transplant the crown/vertex region in someone younger than his late 30s given the extensive number of hairs required to fill this area and the ever-expanding nature of the crown region. First, the crown should be considered a less important area to fill aesthetically as compared with the hairline and midscalp since most people see the front of one's head much more often than the back. The hairline and midscalp regions provide a frame to the face, which is aesthetically pleasing and rejuvenating. Without a frame to the face, an onlooker's eyes constantly dart upward to a receding landscape without a frame to guide one's view back down to the most important facial attribute, the eyes. In addition, if the patient had a vertex reconstructed once and continues to lose hair in both the vertex and the frontal/top area, his hair pattern may become obviously unnatural. This should be explained to the patient almost until it becomes his choice not to do a rushed transplant of the vertex. If the patient's attention is solely in the crown and he has extensive frontal baldness, the other reason to avoid simply transplanting the crown is that the crown will not look natural being transplanted alone with extensive frontal baldness. In situations when the age and compliance to medical treatment make one a good candidate for vertex restoration, a surgeon should still be cautious not to underestimate the zone of alopecia requiring a transplant. To evaluate the actual size of the affected area, the surgeon may wet the patient's hair in order to examine the true extent of vertex hair loss.
    The crown is also technically a very difficult area to master the given complex pattern, angulation and density that must be recreated with precision. This design work also lends itself to added problems, including issues with perceived density and ongoing recession. As the transplanted hairs are positioned splayed out in a circular whorl fashion, the same number of 34transplanted grafts will have a lesser effect on visual density in the crown than in the hairline and midscalp. In addition, the crown stands out like a billboard since it rests on the vertical scalp plane and can be viewed head on making the bare scalp visible and the need for smaller grafts to maintain naturalness an important criterion, both of which compromise overall visual density. Finally, some experts believe that graft survival can be slightly less in the crown than in the midscalp region owing to the differences in inbound vascularity. These facts should be stressed to the patient preoperatively and in many cases the crown must be approached with two full sessions to accomplish the desired level of perceived density. Obviously, the crown can be transplanted before the hairline and midscalp if that is the only area of hair loss and the patient (and surgeon) understands the above limitations.
    Medical management should be considered a very important adjunct when considering transplanting the crown for two reasons. First, the crown tends to be very prone to postoperative shock loss, which can be disconcerting and unnecessary if medical management with finasteride and preferably minoxidil are used for many months prior to undergoing surgery. Second, the crown as mentioned is much more susceptible to ongoing recession, which can easily expose a surgical result when an unnatural halo develops between the transplanted central zone and the ongoing leading edge of recession.
  • It is almost never wise to plan to transplant from hairline all the way back to fill the entire crown in a single session. There will not be sufficient grafts to complete this task and achieve an aesthetically pleasing result because the spotty coverage can look grafty given the wide spacing between grafts and that the overall density would be insufficient to prevent a “see-through” effect.
  • For women, planning for a hair transplant can proceed entirely differently than for men. Although many men desire a very low straight hairline, this pattern can be unnatural in a mature individual with already signs of advancing hair loss or would become unnatural overtime in a younger individual transplanted aggressively in this fashion as he matures in age with ongoing hair loss. However, for women a closed fronto-temporal angle and more robust central hair density are important hallmarks of feminine appeal and should be aesthetically targeted in appropriate cases. At times women exhibit a sparser donor area so planning the hair transplant to optimize the visual effect of transplanted grafts can take a priority in the preoperative phase. For example, if the midscalp is relatively exposed, oftentimes the area that can impart the illusion of greatest visual density is the central forelock,§§ which should be transplanted more densely in many incidences.
    On other occasions, the female hairline may take precedence and exhaust a greater percentage of usable grafts. If the woman parts her hair in a certain manner, the exposed hair part can be targeted to increase visual density for two reasons: the parted hair area can look sparser than other areas because it is splayed open and the scalp is exposed; the hair transplanted into the part can travel a greater distance as it camouflages the scalp. The subtleties of effective hair transplant in the female patient are acquired with accumulated experience and associated clinical judgment (Fig. 1.9).
  • When a patient has had a hair transplant previously, both his donor and recipient areas need to be examined and evaluated. The examination of the donor area consists of evaluation of the scalp elasticity, whether the previous scar needs revision, donor hair available, hair quality and density, etc. The recipient-area examination would encompass the position and shape of the hairline; the angle, orientation, size and quality of the transplanted hair; growth rate; overall hair density; and naturalness. In addition, the patient should be questioned about the experience he or she had with the previous procedure and address all possible concerns. In general, the authors advise not to undergo a follow-up procedure sooner than 9 months after the last session. However, the experienced hair-transplant surgeon may elect to do a staged, two-session procedure separated by only 6 months in the right candidate with appropriate scalp laxity, less donor-tissue width removed during the first session, good donor scalp healing, and plan to undertake the second transplant session in a different scalp region than the first. Nevertheless, a minimum of 1 year is more advisable as a safer interval for permitting sufficient time for the majority of graft growth as well as donor wound healing and return of laxity.
35
For all of these reasons, hair restoration planning should meet some or all of the following criteria based on judgment:
  1. Appropriate age to consider hair restoration. Given ongoing hair loss, a patient should be mature enough to understand the limitations of depleting donor hair for hair restoration, make a thoughtful commitment to medical treatment for hair loss, and accord the financial investment that will be required for several sessions as needed.
  2. Sufficient donor hair density to accomplish the task and to maintain sufficient reserves to address future hair loss.
  3. The psychological understanding that a hair transplant would most likely be necessary again if the individual is relatively on the younger-age spectrum.
  4. The need for medical management to limit temporary, postoperative shock loss and to retard ongoing recession.
    36
  5. Examination of the donor and recipient hair for quality and color; planning for regional allocation of hair from donor to recipient, i.e., using fine hair for the hairline, white hair for the temples, thicker hairs and larger follicular units for central hair density, etc.
  6. The final part of the consultation should review the nature of the surgical procedure and the expectations for the immediate postoperative period and the later stages of hair growth over the first year following hair-restoration surgery. The patient should have a good understanding of what he or she is required to do during the week following surgery as well as other aspects of the recovery process, the details of which are covered in the postoperative section of the next chapter. Obviously, if the surgeon does not agree that the plan is proper then the surgeon should not operate regardless of the patient's wishes.
 
Preoperative Session
The purpose of the preoperative session is to prepare the patient for surgery and to address any concerns. During this visit, the surgical plan is reconfirmed with the patient, the steps of the surgery explained, preoperative and postoperative instructions reviewed, and the preoperative packet given to the patient (which contains prescriptions, shampoo, physician contact information, and written pre- and postoperative instructions).
A thorough medical history is taken and a basic physical examination performed in order to determine if any contraindications for surgery, such as bleeding problems, presence of a defibrillator, etc. would exist to preclude the procedure. Every patient who has a heart condition and/or is over 50 years of age is ordered to obtain medical clearance from his or her primary care physician. Despite a formal medical clearance, some patients still may not be suitable candidates for even office-based surgery given their ASA risk profile.
The patient is ordered to stop using aspirin and aspirin-related products 7 days before and after the procedure and to stop alcohol and minoxidil application 2 days prior to surgery (resuming minoxidil 7 days afterward). The patient is given Hibiclens shampoo to wash his/her hair the night before and the morning of surgery, which eliminates the need for postoperative prophylactic antibiotics. A prescription for narcotics and sleeping pills are given to the patient to ease any discomfort and anxiety during the first several days following surgery. The patient is advised not to drive after surgery and instead to arrange transportation. The patient is also requested to bring with him or her, a baseball cap to cover the transplanted area after surgery.¶¶
37
 
Other Topics
 
Standardized Photography
As part of the operative record, excellent photographs are mandatory for medico-legal purposes, patient communication, self-appraisal, and for potential marketing options. Physicians who already work in the cosmetic field are attuned to the nuances of good medical photography. Others who are entering the field of cosmetic surgery may be lost as to how to create standardized and superlative clinical photography. In any case, this section will help guide a physician of any stripe on how to take excellent photographs that pertain to hair-transplant surgery as well as review fundamental principles that underscore great clinical photography in general.
The adage that an individual has only one chance at a good before photograph but a thousand chances of obtaining a good after photograph should be respected, making the preoperative photographs the most important images to get right. However, the other aphorism to adhere to is that the only photograph you regret is the one you did not take, so always take photographs to track a patient's progress over time. The patient may become lost to follow up and you may have no record of your results if photographs are not taken serially. Photographs need to be standardized for lighting, distance, illumination, background, hairstyle with the area of alopecia fully exposed, camera settings and patient positioning. All of these criteria are important and should be treated as such. In addition, if a single photographer can be assigned to the task, so much the better, as even the way the photographer holds the camera and positions the patient can influence the standardization of the image.
Ideally, a dedicated photo alley should be allocated for clinical photography. If different rooms are borrowed to take photographs, the variances in lighting will almost always affect the quality of the result adversely, leading to unprofessional and unstandardized photographs. Instead, a very small room (preferably shaped in a rectangle) with a strong overhead, cool fluorescent illumination is sufficient in our office to create the ideal photographs without need for elaborate flash or fill lighting. As noted, the larger the room is the more lighting is required to illuminate the room uniformly: If the room is large and the overhead lighting is weak, the photograph will look shadowy. As a guide, the dimensions of our photo alley are 8 feet by 6 feet and 6 inches. In addition, the digital camera should be set to white balance for fluorescent lighting and adjusted further (exposure settings, aperture, etc.) as needed to standardize and properly expose the image. The same digital camera should be used for all photography: A change in camera and/or settings will easily throw off standardization of the image.
38
zoom view
Figure 1.10: This photograph shows our dedicated photo alley designed for optimal standardization of clinical photography. The room that is 8 feet by 6 feet and 6 inches in size is small enough to minimize wasting valuable real-estate space but also intended to facilitate greater illumination of the photograph as described in the principal text. The two stools are allocated for patient and photographer allowing for rotation and movement as needed. The four green dots on the walls are numbered 1 through 4 to indicate to the patient how to turn to each photographic position. The background wall is painted in light blue color, and the room has an automatic door closing system to eliminate the possibility of any ambient light entering the room by an unintended open door.
The room should obviously have no ambient lighting, e.g., a window that can change the lighting conditions based on season, time and weather, leading to uncontrolled and variable shadows. The room in our practice also has a self-closing door to remind the photographer that no photographs should be taken with the door open, which would emit variable degrees of ambient lighting. In order to create a standardized background, the wall should be painted light blue (which does not swallow facial and hair features like a dark blue wall can potentially do.) By painting the wall rather than hanging a backdrop element, there is no risk that the backdrop will wrinkle over time and make the background element unprofessional and distracting (Fig. 1.10).
Patient positioning is another important topic. A low-back (or no back) stool with wheels should be used so that the patient can be easily moved and rotated without the risk of the back of the stool ever being seen in the background. The patient should have no hairstyling products on if possible or if there is minimal product in the hair it should be the same in the preoperative as the postoperative photographs. The hair should be parted to expose the area of alopecia, e.g., if the patient has a “combover”, that should be combed away to expose the area of alopecia in the same way for preoperative and postoperative images. Obviously, a hairpiece, hair camouflaging product, or other obstructive elements should all 39be removed for any photograph to be meaningful. If the patient wears eyeglasses, they can be removed, but whatever policy is subscribed, it should be followed by the same protocol for all preoperative and postoperative photographs.*** The same distance from photographer to patient is controlled by having the photographer and patient sit at the extreme ends of the room every time. Four dots are marked on the wall: one at three-fourth oblique left (marked as 1), lateral profile left (marked as 2), three-fourth oblique right (marked as 3), and lateral profile right (marked as 4). By marking these dots numerically, the photographer can direct the patient to look at 1, then 2, then 3, then 4, as an easy way of communicating the desired directions to be followed. The positions needed for each photographic session are as follows: frontal view, three-fourth oblique left, lateral profile left, three-fourth oblique right, lateral profile right, facing the rear wall (to see the vertex at eye level), facing the rear wall but looking up toward the ceiling (to visualize the vertex completely exposed), forward directed but face toward the floor (to expose the top of the head from hairline to the start of the vertex), and any additional images of scars or other areas that would be relevant for the transplant in question [Figs 1.11(A to H) and 1.12 (A to H)].
Some finer points regarding patient positioning should be explained. The patient should not be smiling during any photograph to ensure standardization. It is disconcerting to see a serious patient beforehand and a smiling one afterward because it is not as scientific as would be desirable. The patient's head position should follow a Frankfort horizontal plane in all non-vertically tilted positions, e.g., frontal facing, three-fourth oblique views, lateral views and rear view. The Frankfort horizontal plane is defined as a line drawn through the porion of the ear (top of the external auditory canal or tragus) through the inferior aspect of the inferior orbital rim that should be parallel to the floor. The natural tendency of any patient is to tilt the head upwards on all eye-level views to make his or her neck appear more svelte. Constant verbal reminders from the photographer should counter this predilection of the patient. In fact, in our photo alley, we have a small sign posted for the photographer as a reminder to instruct the patient that reads: “no smiling, chin down”. When the patient turns to the oblique and lateral views, the tendency is to turn the head only: doing so can render the image unprofessional. The patient should turn the legs and body to be in alignment with each position and should be reminded to do so as needed. When the patient is turned at the profile view, the contralateral eyelashes and eyelid should not be seen in the image, i.e., the patient should be exactly 90 degrees from the photographer's view. These subtleties in patient positioning can make the difference between a mediocre and an outstanding scientific photograph.
40
zoom view
Figures 1.11A to H: This series of before the surgery photographs, which depict standardized photographs of a patient in all recommended positions (face forward, left oblique, left lateral, right oblique, right lateral, posterior, posterior with head toward ceiling, anterior with head toward floor) with areas of alopecia exposed as needed.
 
Office Management and Leadership
Although this book is directed toward understanding how to perform hair transplant surgery, the author does not believe that it would be complete without some remarks on the business side of running a hair-transplant clinic as well. The focus of this section will be on universal principles that have helped the author build a successful business enterprise that is contingent on multiple factors that lie beyond just an excellent surgical outcome. Considering today's competitive market and the fact that hair restoration is a team endeavor, a physician is required to invest both in his medical education and to develop his or her business acumen as well.
41
zoom view
Figures 1.12A to H: This series of after the surgery photographs, which depict standardized photographs of a patient in all recommended positions (face forward, left oblique, left lateral, right oblique, right lateral, posterior, posterior with head toward ceiling, anterior with head toward floor) with areas of alopecia exposed as needed (Of note, his postoperative oblique photographs show his head slightly tilted upward too far).
The author's real passion is for leadership, which he must engage in as a serious endeavor on a daily basis, especially considering that he run four concurrent businesses: His plastic surgery and hair restoration practice, a hair salon, a spa, and a building along with managing the tenants within.
Leadership begins with “getting the right people on the bus” as celebrated business author Jim Collins has espoused in his book, Good to Great.18 Hiring the right people who share your values and align with your vision and inspiring them toward greatness are the key elements in a successful business. The best way to find those people is to ask your staff, “Who is the best person you know for this job?” You can ask your staff who the best person they have ever worked with that would fill the needed employment slot, which may prove to be the most reliable indicator for the future success of that potential new hire. Geoff Smart's book, Who,19 is a great resource that elaborates on how to hire 42individuals through what he terms ‘topgrading’. The author uses it for all his hires and it helps winnow down the selection process rather rapidly. It is a must read.
Another book that has greatly influenced his perspective on how to run a business is Daniel Pink's book, Drive: The Surprising Truth About What Motivates Us.20 Pink argues that there are two types of work: algorithmic and heuristic. Algorithmic work refers to menial tasks that require point A to point B thinking like a checkout clerk at the grocery store. Heuristic work is creative that requires right-brained thinking to solve a problem based on one's own imagination. It is important to get all of the individuals in an organization to see their work as heuristic. By doing so, they take ownership in their career and will help to solve complex problems through their own initiative rather than because it was in their job description.
Finding meaning in work is the underlying objective that a great leader must impart to his or her staff. The story of the stonecutters is illustrative of this concept. Once there were two stonecutters working in a field. A man approached the first stonecutter and asked him, “What are you doing?” The first stonecutter replied, “I have been toiling in this terrible heat now for 10 years. I have a lack of water, a lack of money, and I hate this job. All I do is cut stones every day”. The man walked farther by twenty yards and encountered a second stonecutter. He asked him, “What are you doing?” The second stonecutter responded enthusiastically, “Well, I am building a cathedral. I have been doing it for 10 years. I don't know even if I will see the day when it is done. Sure, the days are long and the work is hard, but I love what I do because I know I am part of something big. I'm helping to build a great cathedral”. How do your workers see their work? Are they cutting stone or building a cathedral? I personally make it a point to show my staff the before-and-after results almost every day and to recount our success stories of how we have touched a patient's life.
Another book that has profoundly influenced me is Simon Sinek's Start with Why: How Great Leaders Inspire Everyone to Take Action.21 Sinek, whom I have had the pleasure to listen to speak several times, argues that most companies are very focused only on the what, i.e., their product or service. They forget a more fundamental raison d'être of why they are even there. Sinek argues the reason that Apple fanatics are Apple fanatics is not that they love the design (that is what they and the author included would admit to) but that they want to look at themselves as individuals who are iconoclasts. Apple fanatics are zealots because they connect with Apple's ‘why’ even though they might claim it is just the ‘what’ that matters. Apple Inc. starts with the why of what they do: “Think Different”. The author has focused his business on the why: They are here to take care of people and to transform lives. When they get to their why 43and their company's culture is consistent with that why then they can accomplish miracles.
There is a saying that culture is not part of the game; it is the game. It is everything that must suffuse a company from top to bottom. The companies that have lasting appeal have a deeply inspired culture that propels the staff and the people within the organization forward. The way a staff member answers a phone can be carefully scripted (and scripts do help and work), but when a deeply abiding culture is present the way they answer that phone can be felt on the other end of the line. When patients come through the door and walk into an office where the culture is king, they notice a palpable difference.
Where does culture start? It always starts from the top. If the leader is greedy, narrow-minded, angry, petty, or jealous, his or her attitude and outlook will define the culture for the organization whether wittingly or unwittingly. The change for a culture begins with the leader who must constantly work on himself or herself for positive change toward greater peace, love, and clarity so that those qualities will radiate throughout the organization. The staff must feel that culture vibrantly as a real quality that is not only passed through lip service but through daily consistent action. When encountering a patient-staff conflict, the physician should be equitable in the way that the situation is handled but the loyalty should fall back toward the staff not toward the patient since you can much more easily replace a patient but not quality staff. The staff is the crew on a ship. If they are cargo, let them go. If they are crew, they become indispensable and must be treated that way so that the ship does not sink. The author always tries to view his business like a ship with valuable crew members that are sailing with him to help get to their mutual destination.
Another valuable writer on leadership is John Maxwell. His 21 Irrefutable Laws of Leadership22 and his Leadership Gold23 books have greatly shaped the author's thinking. Along the same concept shared above, he contends that if you want to hire a person that scores an 8 on a 10-point scale, you must be at least a 9 or higher because an 8 will not follow a 6. Working on your own leadership skills will help you bring better people on board and keep them there. He also argues that we should all work within our strength zone, and hiring people against our weaknesses is vital. I am a creative, forward-thinking, intuitive, right-brained leader; but I am not a detail-oriented, left-brained, number-calculating individual. I have hired more left-brained individuals to compensate for my weaknesses. You do not want to partner with someone who is a carbon copy of yourself. Finding people who complement you is the start of creating a successful team.
Hopefully, this introduction to the author's thinking about how to run a successful business was not desultory but enlightening. Even if you knew most 44of this material, the author hopes that you were able to find one or two small gemstones to make it worth the read. We all can grow as leaders, and the author himself has worked tirelessly to improve himself as one.
 
Marketing
Although this is a separate section, it really begins with the previous section on leadership. The best marketing is not only creating the best results for a patient but also the best experience. Having staff that buy into your vision and work as team members to fulfill that vision will engender a powerful word-of-mouth campaign that is invaluable. Invest in your staff and they will invest in your business. Beyond leadership, there are some marketing concepts that may be helpful for a beginning physician who is striving to build a successful hair-restoration practice.
When the author first started his practice in facial plastic surgery, he used to include the service “hair transplant” at the end of his menu list. Doing so yielded him no prospects through his door for consultation. Hair restoration must be developed as an entire different arm of one's practice, if it is not the only procedure one is desirous of doing. Advertisements, Web sites, brochures, etc. must all be 100% focused on hair restoration. The current consumer is much savvier than years past, especially with the Internet becoming an indispensable part of any marketing strategy. Building a detailed, informational, quality Web site is a necessary, first start for a physician who is serious about marketing his hair-transplant business and is expecting it to grow that business year after year.
For any business wanting to establish itself as a contender in the field, the business must be well versed in its Unique Selling Proposition (USP). One's USP is what is communicated to a patient on the Web site, over the phone, and in person. That message must be clearly articulated and consistent. Our USP is a boutique, non-chain, hair-transplant center that performs only one surgery a day without discomfort using highly specialized staff who are leaders in the field and who are never outsourced or rotated in order to achieve seamlessly natural results that are gender and ethnically sensitive. When you have a clear vision of who you are, the USP should be your differentiator for a prospective consumer to choose you in a competitive marketplace.
 
Concluding Thoughts
In this opening chapter, the author has worked to distill the most important concepts that a physician should understand before operating on his or her first patient for hair transplantation. The reader is encouraged to augment his 45or her knowledge base by researching books in the reference section of this chapter that have been instrumental in the growth of his own understanding of medical hair-loss diseases and how they impact when or on whom he should or should not operate. A safe surgeon is a knowledgeable one. Unfortunately, most surgeons who enter the field of hair restoration do not know what they do not know. This chapter will hopefully provide the impetus for a lifetime of ongoing self-education with the aim to yield safer patient outcomes.
References
  1. Shapiro J. Hair Loss: Principles of Diagnosis and Management of Alopecia. In: Martin Dunitz (Ed.); 2002.
  1. Olsen EA. Disorders of Hair Growth. In: McGraw-Hill Professional;  2003.
  1. Hair Transplantation. In: Unger W, Shapiro R (Eds.). 4th Edition. Informa HealthCare;  2004.
  1. Whiting DA. Chronic telogen effluvium. Dermatol Clin. 1996; 14(4):723–31.
  1. Van Neste DJ, Rushton DH. Hair problems in women. Clin Dermatol. 1997; 15(1):113–25.
  1. Olsen EA. Female pattern hair loss: clinical features and potential hormonal factors. J Am Acad Dermatol. 2001; 45(suppl pt 2):S69–124.
  1. Roberts J, Price VH, Olsen E, et al. The effects of finasteride on post-menopausal women with androgenetic alopecia. In Hair Workshop: Brussels, Belgium; 1998.
  1. Price VH, Roberts JL, Hordinsky M, et al. Lack of efficacy of finasteride in postmenopausal women with androgenetic alopecia. J Am Acad Dermatol. 2000; 43(5 Pt 1):768–76.
  1. Iorizzo M, Vincenzi C, Voudouris S, et al. Finasteride treatment of female pattern hair loss. Arch Dermatol. 2006; 142(3):298–302.
  1. Kaufman KD, Olsen EA, Whiting D, et al. Finasteride in the treatment of men with androgenetic alopecia. Finasteride Male Pattern Hair Loss Study Group. J Am Acad Dermatol. 1998; 39(4 Pt 1):578–89.
  1. Leyden J, Dunlap F, Miller B, et al. Finasteride in the treatment of men with frontal male pattern hair loss. J Am Acad Dermatol. 1999; 40(6 Pt 1):930–7.
  1. Roberts JL, Fiedler V, Imperato-McGinley J, et al. Clinical dose ranging studies with finasteride, a type 2 5-alpha-reductase inhibitor, in men with male pattern hair loss. J Am Acad Dermatol. 1999; 41(4):555–63.
  1. Merck-sponsored study. For information, contact Merck directly: Merck and Co., Inc.: Professional Services-DAP, WP1-27, PO Box 4, West Point, PA 19486-0004.
  1. Can Prostate Cancer be Prevented? [online] cme.amcancersoc.org. [May 25, 2005].
  1. Potosky A, Miller B, Albertson P, et al. Finasteride does not increase the risk of high-grade prostate cancer: A bias-adjusted modeling approach. Cancer Prevention Research.  Published online first on May 18, 2008 as 10.1158/1940-6207. CAPR-08-0092.
  1. Martin WB, Spodick DH, Zins GR. Pericardial disorders occurring during open-label study of 1,869 severely hypertensive patients treated with minoxidil. J Cardiovasc Pharmacol. 1980; 2 Suppl 2:S217–27.
  1. Prager N, Bickett K, French N, et al. A randomized, double-blind, placebo- controlled trial to determine the effectiveness of botanically derived inhibitors of 5-alpha-reductase 46in the treatment of androgenetic alopecia. J Altern Complement Med. 2002; 8(2):143–52.
  1. Collins J. Good to great: why some companies make the leap…and other's don't. Collins Business; 2001.
  1. Smart G, Street R. Who: the A method for hiring. Ballantine Books:  New York;  2008.
  1. Pink D. Drive: the surprising truth about what motivates us. Riverhead; 2009.
  1. Sinek S. Start with why: how great leaders inspire everyone to take action. Portfolio Books Ltd:  Richmond;  2010.
  1. Maxwell JC. The 21 irrefutable laws of leadership: follow them and people will follow you. Thomas Nelson:  Nashville;  2007.
  1. Maxwell JC. Leadership gold: lessons I've learned from a lifetime of leading. Thomas Nelson:  Nashville;  2008.