Follicular Unit Extraction – FUE

Follicular Unit Extraction (FUE) – Advantages or disadvantages

My patients always ask about advantages and disadvantages of Follicular Unit Extraction so I thought this topic makes a good post for the blog. Before going over these points I have to say, although we at Parsa Mohebi Hair Restoration offer the most advanced techniques of FUE nationwide, most of our patients are still being transplanted by strip technique and I don’t recommend FUE to everyone and select my FUE patients very meticulously. Here are the main reasons why we do recommend FUE to some people and not to everyone.

Advantages

  • FUE does not leave a linear scar, which is great for those who want to wear their hair very short on the back or the ones who may need to shave their head in the future (like actors).
  • FUE has a more comfortable healing process with decreased healing time.
  • No restrictions in physical activities for those who want to do strenuous exercise right after FUE procedure.
  • FUE is a viable alternative for those who have tight scalp that makes strip surgery risky or impossible.
  • Follicular unit extraction makes it possible to harvest hair from body, beard or almost everywhere else.
  • FUE is very useful when we need limited number of grafts like for restoration of eyebrow hair.

Disadvantages

  • The biggest disadvantage of follicular unit extraction is that the maximum follicular unit graft yield is lower than when it is done with strip technique due to higher rate of follicular transection compared to the strip technique.
  • Although linear scar is not present after FUE, small punctuate scars will be there that may make future FUE hair transplant surgeries more difficult or impossible.
  • Not everyone is a candidate for FUE and patients need to be tested with FOX before proceeding with the surgery.
  • FUE procedure takes much longer to perform compared with strip FUT procedure.
  • FUE is more laborious thus it cost more compared with strip technique hair transplants.
  • In FUE, we have more chance of burying grafts that increases the risk of having folliculitis (tiny inflamed cysts under the skin) on the donor area.

Mega Session Hair Transplant Surgery

Mega session hair transplant surgery has been around for almost a decade since Dr. Rassman and others started doing bigger and bigger sessions. Before 1993 all could be done was less than 1000 and occasionally 1500 grafts per each session. Using newer techniques and larger team of experienced technicians, we at Parsa Mohebi Hair Restoration are currently performing large sessions on a regular basis.

Not all physician teams are equal. If a doctor routinely performs sessions in over 2500 graft size, then it would be safe to assume that this doctor has mastered the skills required for large session. Unfortunately, not all doctors have either the teams or the skills to accomplish the feat on a routine basis. Limiting the size of the session to under 2000 grafts, it may take more surgical sessions to accomplish the same goal as when twice the number is transplanted.

Many factors should come together for a megasession hair transplant surgery. First, the surgical team must be trained in doing large sessions with fast, efficient cutting and placing. The following points must be available for the surgery to be successful. The sessions should not take more than eight to ten hours, for more than that, the grafts that are out of the body awaiting placement produces reduced graft growth. Hair transplant surgeon should keep a larger team of technicians to help reducing the time of surgery.

The surgeon must know the nuances of prolonged anesthesia without increasing the risks to the patient.The patient’s scalp laxity must be very loose so that a wide strip can be taken safely (often these strips measure greater than 2cm in width and 22cm in length).The patient’s density must be high (50% higher than normal densities). Large sessions might carry increased risk of swelling and redness after surgery, but overall are not more risky than smaller sessions, but the above criteria must be bet or the yield would not be there. At Parsa Mohebi Hair Restoration, we offer megasessions to patients with extensive baldness with good donor quality with excellent results.

Psychology of Hair Transplant

I just received the last issue of the Hair Transplant Forum International, the Journal of International Society of Hair Restoration Surgery (ISHRS). Our article, Psychology of Hair Transplant‚ is published as the cover article on this issue of the journal. I also have a copy of the article in our hair loss library in our website. Here is the abstract:

Psychology of Hair Transplant

 

Parsa Mohebi, M.D., William Rassman, M.D.

Balding and its psychological impacts has been the subject of many studies in the past. The relationship between hair loss and stress is clear to all clinicians who practice in this field. Negative psychosocial impacts of hair loss in male patterned baldness and in women with generalized thinning have also been seen. Many of us (hair transplant surgeons) have seen the negative effects of hair loss on self esteem and self-image.

We know that hair loss impacts some men sex life and their stability with regard to career choices in men of different ages. Despite the solid evidences and published literature on psychological impact of hair loss, the corrective effect of medical and surgical hair restoration has never been studied. After observing the drastic changes in patient behavior and the high level of patient satisfaction in those who had hair transplant procedure, we were motivated to look into the psychological impact of hair restoration on different aspects of a patient’s life.

Psychology of Hair RestorationWe came up with a series of criteria that could have been modified by having a hair restoration procedure; we used some indexes that were previously studied comparing bald and non bald men on different psychological variables. We initially performed a pilot study and asked patients about different aspects of their lives during their post op visits. We gave our patients open ended questionnaires and probed their psychological state after their hair restoration procedure was complete. Eventually we focused in on eight major criteria that have been reported and documented as variables associated with hair loss in the literature. We collected a subset of them in our pilot study. Included were questions on the general level of happiness, energy level, feeling of youthfulness, anxiety levels, self confidence, outlook on their future and impact on their sex life.

We have chosen the patients who had their first hair transplant surgery between one to three years from the time of our study, so they had seen the final result of their hair restoration procedure. We limited the study to male patients with male pattern baldness and the ones who had surgeries less than three years ago so they still had a fresh memory of the changes they experienced. Each patient had exclusively follicular unit transplants that reflected our standard of care for that period. We sent a questionnaire with a brief description on the nature of this scientific study. We did not collect any patient identifiers and the response was totally voluntary. We sent the two hundred questionnaires with stamped return envelope.

The response rate to our questionnaire was 37 (18%). Each patient was used as his own control since we asked about the changes that they experienced after surgery in comparison to those variables before the surgery. We used T-test to compare patient’s responses. Table 1 shows the mean and standard error in eight different criteria that were asked. Patients had significant improvements in all eight criteria regardless of their stage of baldness and their ages.

In another attempt to compare psychological changes that patients experienced in different stages of baldness, we divided patients into two groups: (1) those who had Norwood IV patterns or less and (2) the ones with Norwood V patterns and above. We observed the most significant difference in two categories, (a) sex life and (b) career experience. Patients with less balding had a greater impact on their sex life and career when compared to patients who had more advanced stages of hair loss. These changes were not age related.

Hair restoration surgery can affect many aspects of a patient’s life. Hair transplant can potentially reverse psycho-social problems associated with hair loss. The positive impact of hair restoration surgery is more visible among patients who suffer from those undesirable effects the most. In early stages of hair loss, patients may have more awareness of their condition and they might be more affected than men in the later stages of hair loss.

Patients who experienced hair loss at an early age while involved in an active social life were more prone to the negative side effects of balding. That could explain why younger people with hair loss appeared more benefited by hair restoration procedures. Also it could be assumed that hair loss can have a negative impact on a patient’s outlook which seems to reverse after receiving a hair restoration procedure which improved their outlook.

Low response rate from a blind mailing has always been a drawback in questionnaire studies. We received 37 out of 200 of the questionnaires that we sent out (response rate was 18.5%). Giving incentives to responders may be a good way of increasing the participation rate of any questionnaire studies. We presented the result of this study at the annual scientific meeting of ISHRS and have been contacted by many of our colleagues who expressed interest in collaborating in a larger scale study. We are currently trying to rise funding for repeating this study to optimize our response rate and the statistical value of the study.

If you have any questions on the content of this article you can contact Parsa Mohebi Hair Restoration office at Los Angeles through email at info@parsamohebi.com or phone.

22 Year Old with Stage Three Hair Loss

Question:
I am a 22 year old white male with some recession in the corners that has been bothering me in the last two years. Am I eligible for a hair transplant procedure?

Answer:
I generally don’t recommend hair transplant before the age 24 (with some exceptions). We need to have a better understanding of the pattern of your hair loss before coming up with a surgical plan. If you are destined to become a stage VII (advanced stages of hair loss) the plan should be totally different than if you are going to stop at stage III.

We can usually see the final pattern of baldness by the age of 23 or 24 with a microscopic examination of scalp. We should be able to determine whether or not you are going to stop at stage III or if you are heading to more advanced stages such as VI or VII. We can densely pack the corner areas knowing that the patient had plenty of reserve and is not going to lose much more. But if you are supposed to become severely bald, we should be more conservative in repairing your frontal corners knowing that you are going to need a good portion of your hair for the top and crown areas of your scalp in the future.

If I see the evidences of end stage hair loss at an earlier age, I can more safely plan for hair transplant at that age rather than waiting for a more advanced age since the patient is already showing the signs of sever baldness.