how to beat hair loss - origenere

how to beat

hair lossthird edition

Antonio A. Armani, M.D.University of Toronto

redom books inc.233 Carlton streettoronto, ontario

Canada M5a 2l2telephone: (416) 363-6655

1-800-365-6220Fax: (416) 363-1589

© Copyright 1999 by antonio alvi armani, M.d.

All rights reserved. Printed in Canada. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in articles and reviews.

How to Beat Hair Loss does not offer medical ad-vice to replace the services of a physician or surgeon. The information provided here is collected from various sources and represents an effort to inform you about the options available to treat hair loss. It is intended to assist you to work with a trained medical and other hair care professionals. The author assumes no responsibility for us of information provided here or any other manner. For information address:

redom books inc.233 Carlton streettoronto, ontario

Canada M5a 2l2telephone : (416)363-6655

1-800-365-6220Fax : (416)363-1589

[email protected]

ISBN 0-9683898-1-3

about the author

Dr. Antonio Alvi Armani has written this book as a source of information for men and women suffering from hair loss. He is a hair transplant surgeon who graduated from the Uni-versity Of Toronto. Dr. Antonio Alvi Armani is dedicated to research and development of new medical, surgical and alternative therapies for hair loss. His hair transplant practice and research centre is located in the city of Toronto, Canada, where he is the director of Cosmetic Surgery Spa.He graduated from the University of Toronto Medical Pro-gram with M.D. Honours, after which he went on to per-form his residency at the Toronto Hospital. He is a member of the American Academy of Cosmetic Surgery, the Inter-national Society of Hair Restoration Surgery, member of the American Society of Hair Restoration Surgery, Italian Soci-ety of Hair Restoration Surgery, the Ontario Medical Asso-ciation, the College of Physicians and Surgeons on Ontario, and the Canadian Medical Association. Dr. Antonio Alvi Armani has won numerous awards in-cluding the: J.W. Billes Admission Scholarship, University of Toronto, W.K. Mc Gillis Trophy, Gold Medallist, Yetive Heard Memorial Trophy and Steven Clarfield Trophy, Italian Soci-ety of Hair Restoration Surgery Award, Toronto Sun Read-ers Choice Award 2002, for Best Cosmetic Surgeon, XTRA Magazine Readers Choice Award 2002 for Best Cosmetic Surgeon. He has written articles and books on various aspects of hair loss, dieting, weight loss and fitness, and is conducting clini-cal research in the fields of hair transplantation and clon-ing of hair.

to my patients who have allowed me to assist them

Acknowledgments

I owe gratitude to many people who along the way of my career have helped in supporting and guiding my work. I cannot possibly list all those who deserve credit but I must mention the names of a few that have been most instrumental in producing this book.

I owe special gratitude to my main mentor in the field of hair loss Dr. Dow B. Stough Jr. Dr. Stough trained me in hair transplantation surgery and was the major influence in my development as a hair loss surgeon. Dr. Stough has produced a masterful reference book that have been a constant source of reliance to me. I thank him for this.

I must also thank the following individuals who have provided technical assistance in the production of this book: Dr. Shaheen Azmi who edited it and helped to de-velop its design; Fernando Andrejin who photographed the pictures and was a constant source of technical assistance; and Alex Vasolla who drew its illustrations.

Last but not least I must thank my parents and family members who have nurtured me and who have always been there to support me in my every venture.

i

Table of ContentsIntroductIon ........................................ 1SectIon 1: KnowIng your type of haIr loSS ......... 5chapter 1: genetIc haIr loSS ................................................ 6chapter 2: other typeS of abnormal haIr loSS ....................... 25 a. dIet related haIr loSS ...........................................................25 b. drug related haIr loSS ..........................................................26 c. dISeaSe related haIr loSS .......................................................27 ¨ skin diseases of the scalp ........................................................ 28 ¨ telogenic and anagenic alopecias ........................................... 28 ¨ sudden unexplained hair loss (alopecia areata) ........................... 29 ¨ thyroid diseases ..................................................................... 30 ¨ psychological diseases .......................................................... 31 ¨ cancer related hair loss ........................................................ 31 ¨ saha syndrome ..................................................................... 32 d. haIr loSS due to external InjurIeS to the Scalp ........................ 33 e. haIr loSS cauSed by poor haIr care ........................................34

SectIon 2: treatment for genetIc haIr loSS ....... 39chapter 1: medIcal treatment ......................................41 a. rogaIne .............................................................................41 b. propecIa .............................................................................44 c. comparIng rogaIne and propecIa .........................................47 d. other emergIng drugS ..........................................................52chapter 2: SurgIcal treatment ......................................55 a. baSIc queStIonS about SurgIcal treatmentS .............................55 b. follIcular unIt StrIp Surgery (fuSS) .........................................65 c. follIcular unIt extractIon (fue) ............................................75 d. comparIng fuSS and fue methodS ...........................................83 e. goalS of haIr tranSplant Surgery ..........................................89

ii table of contents

f. rISKS aSSocIated wIth haIr tranSplantS ..................................109 g. repaIr caSeS .......................................................................111 h. caSe StudIeS .......................................................................125 I. the future of SurgIcal treatment ...........................................182

chapter 3: alternatIve treatmentS ...............................192

chapter 4: haIr replacement treatment ..........................200

SectIon 3: about your haIr .........................xx

chapter 1: anatomy of the haIr and haIr follIcle ..................xxchapter 2: ruleS for good haIr care ....................................xx

a fInal recommendatIon ....................xx

appendIx a: Sample conSent form ..........................xxappendIx b: Sample pre-operatIve InStructIonS ........xxappendIx c: Sample poSt-operatIve InStructIonS ......xx

gloSSary .........................................xx

Index ...............................................xx

KNOWING YOUR TYPE OF HAIR LOSS 5

1knowing your type

of hair loss

1. genetic hair loss ................................ 62. other types of abnormal hair loss ...... 25 a. diet related hair loss ................................................... 25 b. drug related hair loss ................................................ 26 c. disease related hair loss .............................................. 27 ¨ skin diseases of the scalp ........................................................ 28 ¨ telogenic and anagenic alopecias ........................................... 28 ¨ sudden unexplained hair loss (alopecia areata) ........................... 29 ¨ thyroid diseases ..................................................................... 30 ¨ psychological diseases .......................................................... 31 ¨ cancer related hair loss ........................................................ 31 ¨ saha syndrome ..................................................................... 32 d. hair loss due to external injuries to the scalp ................ 33 e. hair loss caused by poor hair care .............................. 34

6 KNOWING YOUR TYPE OF HAIR LOSS

The first thing everybody with hair loss must know is what type of hair loss they have. Some people suffer from certain types of hair loss that are temporary, which may result from a variety of causes. While these may be very stressful, many of these ailments can be corrected without resorting to major treatments. On the other hand, most men and women who suffer from hair loss are predisposed to genetic pattern hair loss. This type of hair loss is hereditary and progressive. Many people who suffer from this turn to medical, surgical and alternative treatments to combat their hair loss. In this chapter, you will learn about the different types of hair loss so that you may classify your own type and begin the task of finding proper treatment. You should, of course, have your problem confirmed by a trained professional. But you know yourself best, and only you can help your professional by providing accurate and relevant information about your hair loss based on the information that you find here.

NOrMal haIr lOSS

Normally, each person will have around 100, 000 hairs on his or her scalp at any given time. Some of these hairs routinely take a rest from growing every few years and eventually fall out. These same hairs re-grow from their roots. as a result, the average person can expect to shed 50 to 100 hairs everyday. however, this type of normal hair loss should be spread out over the whole head and should not result in any balding or excessive thinning of hair on any particular part of the scalp.

aBNOrMal haIr lOSS

abnormal hair loss is the falling out of excessive hair that leads to unusual thinning or balding at specific spots on the head, which is probably the type of hair loss you are experiencing. Medical professionals call abnormal hair loss alopecia. alopecia can be caused by many factors but the


most common factor is your own genes, meaning that you inherit the tendency to lose your hair. This type of alopecia affects over 95 per cent of all cases of balding or thinning hair for both men and women. This type of genetic hair loss is given many names, including “male pattern baldness” or “female pattern baldness” because of the consistent pattern that the hair loss tends to follow in both men and women. Its medical term is “androgenic alopecia” because it is believed that hereditary hair loss is associated with changes in the amount and activity of male hormones called “androgens”. I will be referring to this type of hair loss as “genetic hair loss” because it is the easiest to remember and because it does not suggest that it only applies to one sex or the other. It is important to remember that your hair loss may be the result of a combination of factors. Other factors may speed up or increase your hereditary balding. Keep this in mind because it is a major error that many people make when determining their own type of hair loss and responding to it. That being said, since hereditary balding is the most common type of hair loss, I will be discussing it first, followed by a brief discussion of the other types of abnormal hair loss.

ChaPTEr 1: GENETIC haIr lOSS

hOW COMMON IS IT?

Genetic hair loss affects almost 50 per cent of all males and almost 40 per cent of all females as they age. This means that if people lived long enough, almost half of the population would show significant hair thinning or balding. Some ethnicities are more affected than others are. People with European origins show more hereditary tendency to hair loss than other ethnicities, though other groups are affected to a degree as well.


HOW dOES IT OCCur aNd CaN IT BE CurEd?

like so many ailments that afflict us, medical professionals are not certain as to what directly causes genetic hair loss. It is something that is programmed into your genes, but what causes the genes to act and what they cause your body to do, it not entirely known. as a result, there is no sure, full-proof cure for this kind of hair loss that we know of. researchers have different theories about the way genetic hair loss works and they are working on various possible solutions based on these clues. The most common explanation for how genetic hair loss works suggests that it works through a complicated chemical process operating in your body. Most researchers associate it with the chemical changes that occur with the male hormone testosterone as you age. Both men and women have this male hormone but the level of testosterone is different for the sexes and changes with aging. There are also other chemicals, which react with testosterone, that change as you age and may influence hair loss. Because most researchers believe that genetic hair loss is caused by chemical reactions in your body, most of the research being done in the field has focused on finding chemicals that can reverse the chemical causes of genetic hair loss, and then forming them into medical drugs suitable for usage. recent discoveries have found that an enzyme called “5-alpha reductase” is excessively produced by the hair follicles of people with genetic hair loss. The enzyme combines with testosterone, one of the male hormones present in both men and women, to form a new chemical called “dihydrotestosterone” (dhT), which is known to cause hair to fall out. This chain of chemical reactions is one among many possible chemical chains that researchers are currently investigating in relation to genetic hair loss. In the last few years, researchers have been working on many different drugs for combating genetic hair loss, but so far only two have shown success in doing so. This first drug is called minoxidil, and it is currently being marketed by the


upjohn Company under the name rogaine as a topical solution for both men and women. The second drug is called finasteride, and it is currently being marketed by Merck & Co. under the name Propecia in a tablet form for men only. The advantages and drawbacks of both these drugs, along with other drugs that are being tested and that show promise, will be outlined later in the chapter on medical treatments for hair loss.

WhaT dOES IT lOOK lIKE?

Males with genetic hair loss often become at least partially bald and the hair loss follows particular patterns. The most common pattern of genetic hair loss for men is characterized by a thinning of hair at the hairline and/or the crown area. Over time, the thinning expands, receding from the hairline and in a circular fashion from the crown, until the two areas of baldness meet in the middle. The final result is a completely bald scalp except for a strip of hair along the back of the head above the nape of the neck. Though this is the most common pattern that male pattern baldness follows, there are many other variations as well. Norwood’s classification describes this most common pattern but it is somewhat limited in addressing the other possibilities, including the one that applies to women. In the following section, I will outline the new patterns of genetic hair loss that have been identified, giving you a better understanding of the variety of ways in which genetic hair loss occurs. Norwood’s classification has been used to classify male pattern hair loss for many decades and has been useful in many cases. however, it is not complete. Norwood’s classification only describes one pattern of male genetic hair loss on a scale of seven degrees of severity. Therefore, a reclassification of genetic pattern hair loss is necessary to account for the other possible patterns of male and female genetic hair loss.


Genetic Pattern Hair Loss.Progression of hair loss for men according to Norwood’s classification

Alternative male patterns

2A

3A

5A

6A6

2

5

4

3v

3

1

7


Another depiction of the progression of genetic pattern hair loss according to Norwood’s

classification

2

3 3 Vertex

4 5

6 7

1


Another depiction of genetic patterns ofhair loss according to Norwood’s

classification

4A

5A

6A

7A

3A


Progression of hair loss for women according to Ludwig’s classification


drug-related hair lossMany prescription drugs can cause varying degrees of hair loss for some people. It is likely that you have seen cancer patients who have lost hair after undergoing chemotherapy. In fact, most cancer-fighting drugs

Class 1

no hair loss

Class 1

mild hair loss

Class 3mild to

moderate hair loss

Pattern1

Pattern2

Pattern3

Pattern4

Pattern5


Class 4mild to

moderate hair loss

Class5mild to large

hair loss

Class 6large

hair loss

Class7complete hair loss

cause hair loss. In addition, close to 300 more commonly employed drugs are known to be associated with hair loss.

drugs commonly associated with hair loss


New classification of genetic hair loss:Pattern 1

Norwood’s traditional pattern where hair loss progresses from the back and the front, and meets in the middle.

Examples of pattern 1 genetic hair loss



hair loss progresses only from the front hairline and recedes backwards while maintaining the crown area.hair loss occurs mainly in the crown area and moves forward.




The frontal hairline remains intact.“ludwig’s Pattern of hair loss” – Commonly seen in female




pattern hair loss, though it occurs in men as well. hair loss starts in the center and moves sideways towards the ears. This type of hair loss rarely results in total baldness.“Crescent-shaped hair loss” – This pattern is common in men


Examples of pattern 4 genetic hair loss in a male

Examples of pattern 4 genetic hair loss in a female



from the Mediterranean and the Middle East, although it does occur in other ethnic groups as well. hair loss begins at the two temples and moves in a circular pattern backwards, leaving a small forelock of hair at the frontal hairline.



Tom K.:Male Pattern Baldness

Age: 38Occupation: Construction WorkerMedications: NoneMedical History: No significant illness Family History: Father and two brothers all have significant hair loss

It was one year ago that Tom went to see a surgeon concerning his hair loss. He had tried a number of herbal products with no change in hair growth. Based on his family history and on detailed examination of his scalp, it was clear that Tom had male pattern baldness. His surgeon discussed his options with him, including medications like Rogaine and Propecia and hair grafting surgery. Tom and his surgeon decided that hair grafting surgery was his best option to replace his lost hair. In addition, after surgery his surgeon suggested that he employ medications to slow further hair loss and help retain his new full head of hair. The hair grafting surgery went well, and Tom feels rejuvenated with his restored hair.


Female pattern baldness top view

Female pattern baldness frontal view

FemALe ANdRoGeNIC ALoPeCIA (FAGA)

As has already been discussed, women can suffer from genetic pattern hair loss just like men do and both forms of genetic hair loss are caused by similar chemical factors. The difference is that it is much less common for women than it is for men, and the hair loss follows a different pattern. Women with female genetic hair loss tend to experience a progressive thinning of the scalp hair only around the crown area. It is also usually more diffuse and central than male genetic hair loss; and it is often referred to as a ‘widened part’. Less commonly, women may have a receding hairline similar to that seen in balding men. It is unlikely that female genetic hair loss will result in total baldness, though it does occur. Aside from female genetic hair loss, there are other ways that women may suffer from hair loss that will be discussed in the next chapter.


Mary L:Female Pattern Baldness

Age: 42Occupation: Marketing ConsultantMedications: NoneMedical History: No significant illness

It was two years ago that mary L. went to see a surgeon regarding hair loss. She was anxious that she was losing too much hair too quickly. She was afraid that all her hair would fall out and felt desperate that something had to be done. on examination, it was clear that mary was losing hair diffusely in the centre “widened part” of her scalp. This type of hair loss is a typical form of female pattern baldness. Her surgeon reviewed her medical and family history and performed a physical examination and laboratory testing. After this detailed review, it became clear that mary was losing hair as a result of her genetic makeup. Weighing all factors it was decided to start her on Rogaine treatment. Shortly thereafter mary’s hair loss slowed down.


Chapter 2: OThEr TYPES Of aBNOrMal haIr lOSS

hair loss can be triggered by many factors other than genetic predisposition. While these other types of hair loss only make up five per cent of abnormal hair loss cases, they can be more severe in their effects. however, the good news is that these other types outlined below are almost always temporary or are often treatable. I will briefly discuss each of these common types of hair loss as well as the main treatments usually given for them.

dIET-rElaTEd haIr lOSS

Protein: There are a number of nutritional deficiencies that can cause hair loss by altering your hair’s structure or hair cycles. among these, protein deficiency is one of the most common. Your hair is composed mostly of proteins, the same materials that your nails are composed of. If your food does not provide you with enough protein then both your nails and your hair may be negatively affected. Protein is found in common foods like meats, poultry, fish, beans and dairy products. If a protein-deficient diet persists then your hair will go into a premature resting stage and will start to fall out within a few months. unfortunately, many people simply do not eat well, or they become caught up in some fad diet. The kinds of things to watch out for are poor eating habits that lack in protein, vegetarian diets, or fad diets that restrict the amount of protein you consume.

Iron: another possible cause of diet-related hair loss is a low level of iron in your blood, which might result from an inadequate amount of iron in your diet. foods that are common sources of iron include potatoes, dried beans, liver, beef, fortified cereals, raisins, spinach and broccoli. an inadequate amount of iron in your blood may also result from some difficulty your body has in absorbing iron, which is commonly linked with the condition anemia.


Vitamin A: another nutrient that can affect your hair is vitamin a, which can be found in whole eggs, milk and liver. Both an inadequate and an excessive amount of vitamin a can cause hair loss. Too little of this vitamin can result in a condition called hyperkeratosis. It occurs in your hair follicles and in the sebaceous glands (the small glands in your skin that secrete oil into your hair) and it can complicate hair growth. Conversely, too much vitamin a can prevent proper keratinisation (the process by which a protein called keratin builds your hair and nails), resulting in a kind of hair loss referred to as ‘toxic alopecia’.

Other nutritional deficiencies that can affect your hair growth include deficiencies of: essential fatty acids, zinc, copper and vitamin C. fortunately, the damage done to hair by this type of diet-related hair loss is only temporary and can be corrected by simply improving your diet. Your dietary history is one of the first things a medical doctor who specializes in skin and hair would ask when assessing your hair loss problem. Before considering anything else, you should assess your own diet in relation to any hair loss problems you may be experiencing.

druG-rElaTEd haIr lOSS

Many prescription drugs can cause varying degrees of hair loss for some people. It is likely that you have seen cancer patients who have lost hair after undergoing chemotherapy. In fact, most cancer-fighting drugs cause hair loss. In addition, close to 300 more commonly employed drugs are known to be associated with hair loss.

drugs commonly associated with hair loss :

Birth control pills heart disease and high blood pressure pills, especially beta blockers and ace inhibitors, like captopril Blood thinners, like heparin drugs for gout and arthritis, like allopurinol


antidepressants, like lithium carbonate diet drugs, like phentermine Cancer-fighting drugs hormone replacement therapy

drugs used to treat Parkinson’s disease, like levadopa Performance-enhancing steroids acne medications derived from vitamin a, l ike isotretinoin anti-inflammatories, like naproxen Cholesterol-lowering drugs anti-convulsants anti-fungals drugs used to treat thyroid disorders ulcer medications, like Pepcid

dermatologists always ask about drug histories, in addition to your dietary history, before diagnosing hair loss problems. Even drugs that are not currently associated with hair loss may cause you to lose hair, so you should take your drug consumption history into consideration no matter what. fortunately, drug-related hair loss is easily treated by simply discontinuing use of the drug causing the hair loss. There are usually several drug options to treat every condition, so you should be able to find an alternative that does not cause you to lose your hair.

dISEaSE-rElaTEd haIr lOSS

There are dozens of diseases and conditions that can result in some type of hair loss. In this section, I will outline the major classes of diseases that cause hair loss, the kind of hair loss that they cause and possible treatments that are available. Since so many common ailments and conditions can cause you to lose hair, your recent and long-term health


history is one of the first things a medical doctor would question when assessing a case of hair loss. You should also question your own medical history to determine if disease is a factor in your own hair loss.

Skin diseases of the scalp

There are a number of different conditions that can affect the scalp and cause varying degrees and types of hair loss. These include: infections like syphilis and ringworm; infestations like pediculosis, which is caused by lice; inflammatory diseases like folliculitis; genetic diseases like darier’s disease and other syndromes of the skin like psoriasis. The hair loss in each case is usually only partial and can be treated.

Ringworm: ringworm is a contagious disease that is caused by the infection of fungus. It results in small, scaly patches on the skin and, when it occurs on the scalp, is also followed by a loss of hair. It can be treated effectively with a topical solution.

Darier’s disease: darier’s disease is a genetic disorder characterized by dark, crusty patches on the skin, sometimes containing pus, which results in the hair becoming rough and dry with patches of baldness.

Psoriasis: Psoriasis is a chronic skin disease characterized by scaling and inflammation. It is a disorder of the immune system that occurs when cells in the outer layer of the skin reproduce faster than normal and pile up on the skin’s surface. The hair loss is reversible with treatment.

Telogenic and anagenic alopecias

To understand this type of hair loss, you first need to be familiarized with the hair growth cycle. all human hairs go through a natural cycle beginning with growth, called the anagen phase, followed by a period of rest, called the


telogen phase, and ending with the hair falling out. When only the hairs that belong in a particular phase fall out, we call this either anagenic alopecia or telogenic alopecia. dozens of factors can cause either of these alopecias, including stress, chronic diseases and nutritional deficiencies. Many of these different factors send anagen hairs prematurely into the resting stage and result in excessive shedding months after. This is called telogenic alopecia. In this section we will discuss some of the more common telogenic and anagenic syndromes.

Loose anagen syndrome: This condition generally affects young, Caucasian blonde girls, although anyone is susceptible. The characterizing symptom is the ability of anagen hairs (hairs that are in the anagen, or growth, stage of the hair cycle) to be pulled out easily and painlessly. In children ages 2 to 5 years with loose anagen syndrome, the hair is usually unable to grow past the ears, though the density is otherwise unremarkable and the hair is not particularly fragile otherwise. Treatment is usually unnecessary because although loose anagen hair grows slowly, it does grow and if it is accidentally pulled out, it grows back quickly.

Pregnancy and childbirth: The stress of childbirth, similar to that of a severe fever or chronic illness, can prematurely push anagen hairs into the resting stage, resulting in excessive shedding some months later. hormonal changes that occur during pregnancy also play a part in this telogenic alopecia. The slight hair loss should fix itself within 6 to 12 months.

alopecia areata

hair loss may sometimes affect otherwise healthy people with good eating habits, no notable diseases or injuries to the scalp that can explain such a loss of hair. When this occurs, it is referred to as ‘alopecia areata’. This unpredictable but common disease affects 1.7 per cent of the world’s population. although it can affect men and women of all ages, onset most often begins in childhood. In most cases, the hair falls out in round patches all over the


scalp and body. In some extreme and rare cases, the hair loss may lead to a complete loss of hair all over the head and body. alopecia areata that causes complete hair loss of the scalp is called ‘alopecia totalis’ and when it causes hair loss over the whole body it is called ‘alopecia universalis’. It is believed that alopecia areata is caused by the immune system unexpectedly, and usually temporarily, attacking the hair follicles, causing them to fall out and preventing re-growth in some cases. however, it is not known why this occurs. Cases of alopecia areata usually disappear on their own and never occur again. If this type of hair loss persists, however, medical treatment is a possibility. Various steroids, Propecia, rogaine, and various immunogens (drugs that interfere with the immune system) have been found to be effective in combating alopecia areata. although alopecia areata is not life threatening, it is so dramatic in its effects that it often damages the mental and emotional states of its victims. for this reason, many support groups have been established to help people cope with alopecia areata. You can find a local support group in most countries around the world by contacting the National alopecia areata foundation via their website at www.alopeciaareata.com.

Thyroid diseases

Your thyroid gland resides in your neck and is responsible for producing hormones that are involved in many of your body’s functions, your metabolism in particular, making its proper functioning vital to your overall health. hypothyroidism occurs when your thyroid is under-active, meaning it is producing inadequate amounts of hormones. When this occurs, there is a slight shedding of the hair on the scalp, and possibly of the armpits and pubic area. an under-active thyroid gland may become enlarged due to a bombardment of thyroid-stimulating-hormones (TSh) produced by the pituitary gland, which occurs in order to


entice the thyroid to produce more hormones. The result is the creation of ‘goiter’. The most common cause of hypothyroidism is a previous (or ongoing) inflammation of the thyroid gland that leaves a large percentage of the gland’s cells damaged or dead. This kind of inflammation is most likely the result of autoimmune thyroiditis, which is caused by the patient’s own immune system. hypothyroidism may also be caused by certain medical treatments that, indirectly or directly, affect the thyroid gland. The hair loss that results from thyroid disease can be reversed by treating the condition that is affecting the thyroid gland. There are many other symptoms of thyroid disease, including fatigue, weakness, weight gain, dry skin, intolerance to the cold, constipation, memory loss, muscle aches and/or depression. The proper functioning of your thyroid gland is very important and is worth seeing a medical doctor if you think you may be experiencing some or all of these symptoms.

Psychiatric and psychological diseases

The most common type of psychological condition that can cause hair loss is stress. Excessive stress can cause telogenic alopecia, which is described above.

Anorexia nervosa: anorexia nervosa occurs when someone restricts their diet to such a degree that there are nutritional, endocrinal and psychological impairments. The hypocaloric diet (meaning there is an insufficient amount of calories being ingested) may result in a loss of hair. This may also be accompanied by an increase in lanugo (the fine, light hairs that cover the body) on the face, trunk and arms.

Cancer-related hair loss

Neoplasic alopecias: This term refers to hair loss that results from cancer spreading from one area of the body to the scalp. The word ‘neoplasic’ comes from the word ‘neoplasm’, which means ‘tumor’.


The susceptibility of the scalp to neoplasic alopecia is higher for women with breast cancer and for men with lung cancer in particular, as opposed to other types of cancer. It is believed that mucines, a certain kind of protein created by breast and lung carcinoma, degenerate the cells of the outer root sheath of the hair follicle. however, not all cases of breast or lung cancer will cause hair loss. Ovarian and adrenal tumors are also likely to cause hair loss. Both types of tumors can cause hyperandrogenism, which is the excessive production of androgens (male hormones). androgens are known to play a key role in male and female pattern baldness. Once the tumor has been removed, however, the hair loss should go away.Cancer-fighting drugs: Most cancer-fighting drugs, like chemotherapy, attack the body, including the hair follicles, and cause considerable hair loss. The hair should grow back after the treatment has stopped.

Saha syndrome

Saha syndrome is a skin condition that only affects women and is caused by hyperandrogenism, which is the excessive production of male hormones (androgens) and which occurs in the whole body (cases of hyperandrogenism affecting only particular parts of the body are considered different conditions). The four main symptoms of this syndrome make up the acronym ‘Saha’: seborrhea, acne, hirsutism and alopecia. These four manifestations appear in this order, although not all women suffer from all of them. all sufferers of Saha syndrome do experience seborrhea, however. Seborrhea is a skin condition characterized by inflammation, dry or oily scaling, crustiness and/or itching. It is so called because of the excessive production of ‘sebum’ (the oily secretion of the skin) that causes the condition. The acne associated with the syndrome is considered part of the condition because the increased sebum production that causes acne in this case is caused by androgenic action. hirsutism, the third symptom, is the excessive growth


of male-pattern hair in women, also caused by an increase in androgens. The hair loss that accompanies Saha syndrome is also caused by excessive amounts of androgens and results in typical female pattern baldness. a uniform clearing of the scalp of the crown occurs, though total alopecia is unlikely and the frontal hairline remains intact. Treatment of Saha syndrome includes several drug options, including the use of antiandrogens and estrogens (female hormones).

haIr lOSS duE TO ExTErNal INjurIES TO ThE SCalP

hair loss commonly occurs as a result of something as simple as physical stress being put on the hair, the destruction of the hair follicles themselves or excessive amounts of hair being pulled out of the scalp. In these cases, we say that the hair loss is due to ‘external injuries to the scalp’ as opposed to a skin disease or disorder.

Cicatricial alopecias

hair loss may occur due to the destruction of the hair follicle. In this case, the skin of the scalp is somewhat like scar tissue and is therefore unable to produce hair, meaning that the hair loss is permanent and the only option is surgical treatment. This destruction of the hair follicles can result from mechanical, physical or chemical trauma (which may include the use of acids, chronic traction, electrical or thermal burns, or freezing), as well as tumors, special skin diseases or severe infections such as syphilis. The destroyed hair follicles may not necessarily cover the entire scalp, depending on the method and type of damage. again, the only option for this kind of hair loss is surgical treatment.

Trichotillomania

hair loss among children can occur as a result of


a usually unrecognized behavioral disorder known as trichotillomania. It is characterized by uncontrollable hair pulling, similar to impulsive disorders such as pyromania or kleptomania. The disorder usually appears in males at the age of 8 and in females at the age of 12 and has a prevalence of about one per cent. Sufferers of trichotillomania generally spend about one hour per day pulling their hair out. This can last for a few seconds or minutes, or it may last for prolonged periods of time. Some may try to resist the urge, while some are unaware of its occurrence, pulling hair absent-mindedly while driving, reading or watching television. While the disorder itself is a stressful condition, the hair loss that results is an unfortunate additional complication that affects many children and teenagers psychologically and emotionally. The hair loss that occurs is usually focused on the scalp, but it may also occur among the eyebrows, eyelashes and pubic region. hair loss is usually patchy, irregularly-shaped and occurs most often on the side of the body that coincides with the person’s predominant hand. Most sufferers of trichotillomania are likely to feel embarrassed about the disorder and may try to hide their hair loss, prolonging diagnosis and complicating treatment. Treatment for trichotillomania involves behavioral therapy and/or medication. Possible drugs include mood stabilizers, anxiolytics (drugs that work on the central nervous system to relieve anxiety), neuroleptics (also known as antipsychotics) and topical agents including steroids. however, behavioral therapy has been found to be more effective than drug therapy, especially if the hair pulling has only been occurring for less than 6 months and because there are no clear guidelines for how drugs should be used to treat trichotillomania. With therapy, sufferers of trichotillomania can overcome this disorder and resume their normal lives without worry of uncontrollable urges or hair loss.

haIr lOSS duE TO POOr haIr CarE

The effects of poor hair care on hair loss are significant.


unfortunately, there are many styling habits and treatments that are bad for the overall health of your hair and that promote hair loss. hairstyles that require unusual pulling, dying or conditioning may severely stress the natural workings of your hair and may lead to unusual balding. When a high degree of physical stress is constantly being put on the hair for styling purposes, hair loss may occur. This condition is referred to as ‘cosmetic alopecia’. It is usually caused by the constant use of curlers, brushes and other tools used to style hair as well as hairstyles that pull the hair. The alopecia appears as a slight shedding of the hair and occurs because the strain that the hair is put under leads to reduced blood flow in the capillaries at the bottom of the hair follicles. The hair’s growth is stunted and eventually leads to a slight loss of hair a few months later. This usually affects the triangular areas above and in front of the ears, though it is dependant on the direction in which the hairstyle is aimed. It is also possible to damage the hair follicles and/or the scalp itself with the constant use of chemicals used to curl or dye the hair. In most cases of cosmetic alopecia, the reduced blood flow that causes the hair loss disappears after the pressure is removed, although the shedding may take a few months to return back to normal.


Anna S. : Losing Hair Due to Iron Deficiency

Age: 32Occupation: Receptionist

Anna S. initially saw a surgeon three years ago, complaining of ongoing hair loss over six months. A history and medication review indicated no significant findings. No one in her family had lost significant hair before. On physical examination, it was discovered that her hair was thinning mainly on the crown area of her head. Her blood tests showed an iron deficiency, and she informed her surgeon that she had been experiencing unusually heavy periods over the last year. It was diagnosed that her hair loss could be related to this. Anna started on iron therapy and it was recommended that certain dietary changes be made to support this. Within three months Anna’s hair loss had stopped. Within six months Anna’s hair was back to normal, and she was much relieved. She has had no recurrence of hair loss ever since.


Julia B. : Losing hair because of Hypothyroidism

Age: 27Occupation: Homemaker

Julia B. went to a clinic complaining of fatigue, increase in weight, and sparse hair on the scalp and on the eyebrows. She was not taking any medications. Julia had no family history of hair loss. Physical examination showed dry skin, diffuse hair loss, and noticeable loss of hair on both eyebrows.

Lab testing revealed that Julia’s TSH levels were elevated. Julia was suffering from hypothyroidism (the slowing of the thyroid gland). often such a condition causes the unusual loss of hair not only on the scalp but on other parts of the body. Julia was started on a thyroid replacement medication. In six months not only was her hair restored to normal, but Julia found herself less fatigued and in better overall health.


Peter K. : Losing Hair Because of a Medication

Age: 40Occupation: Accountant

Peter came to see me after having suffered ongoing hair loss for over three years. He had no family history of hair loss, but Peter did have high blood pressure for the last five years. He had been on a drug called Propranolal, a type of beta-blocker medication, that is often used to control high blood pressure. A physical examination showed his hair to be thinning diffusely at the center. It was suspected that Peter’s hair loss was caused by his blood pressure medication. The Propranolal that he was taking was replaced with another medication, and He was monitored for the effect this would have. Slowly but surely Peter’s hair loss was reversed. After one year all his hair was regained.


Many people with other types of hair loss aggravate their situation by poor hair care habits. for example, there are many genetically balding people who are losing more hair than they should be and at a faster rate because of poor hair care habits. In these cases, people can forestall the appearance of baldness for years by maintaining good hair care. You can learn how to properly take care of your hair and prevent, or forestall, the appearance of balding later in this book in the section regarding ‘rules for good hair care’.

39

2treatment options

for hair loss

1. medical treatment ...........................41 a. rogaine (minoxidil) ................................................... 41 b. propecia (finasteride) ................................................ 44 c. comparing rogaine and propecia ............................. 47

d. other emerging drugs ............................................... 52

2. surgical treatment ..........................55 a. basic questions about surgical treatment ..................... 55 b. follicular unit strip surgery (fuss) .............................. 65 c. follicular unit extraction (fue) ................................ 75 d. comparing fuss and fue methods ................................ 83 e. goals of hair transplant surgery ............................... 89 f. risks associated with hair transplants ....................... 109 g. repair cases ........................................................... 111 h. case studies ........................................................... 125

i. the future of surgical treatment ................................ 182

3. alternative treatment ....................1924. hair replacement treatment ............200

40 DRUG TREATMENTS FOR HAIR LOSS

Over 90 per cent of all hair loss cases fall under the category of genetic hair loss. For this reason, all the treatment options discussed in this section, with the exception of hair replacement therapy, are meant only for the treatment of genetic hair loss. For all other types of hair loss, you should contact a qualified medical doctor to discuss treatment options. And while this section is meant to guide you in treating your hair loss, you should always contact a medical doctor before beginning any treatment program.

DRUG TREATMENTS FOR HAIR LOSS 41

The treatment of genetic hair loss with medication, taken either orally or applied topically on the scalp, has long been the dream of people suffering from this type of hair loss. But until recently this hope has been nothing but a dream. During the last couple of decades researchers have been developing two drugs that have proven effective in combating genetic hair loss. First the drug minoxidil, which is now marketed as Rogaine, was approved by the Food and Drug Administration and later on the drug finasteride, which is now marketed as Propecia, was also approved for use in fighting genetic hair loss. There are also many other drugs and combinations of drugs that are now being tested and which may be available in the coming few years. It should be noted, however, that there is always the risk of side effects with any medications. Also, it takes decades to completely understand the full effects of any drug and many of these drugs have not been around long enough to determine these full effects.

RogAIne (mInoxIDIl)

Rogaine was introduced as a new drug for promoting hair growth by the Upjohn Company in 1988. It is sold as a topical solution, which means that it is a rubbing solution meant for the balding areas of your scalp. It comes in either a 2 per cent or a 5 per cent solution depending on how much

chapter one:medical treatment


minoxidil the solution contains. Rogaine is available over the counter and should be applied on the balding area(s) twice a day, every day.

How does Rogaine work?

Although there is only a small percentage of minoxidil in Rogaine, it is this drug that makes it work. minoxidil is known as a hair growth stimulator. It was originally marketed in a tablet form for the treatment of high blood pressure and unwanted hair growth was one of the common side effects. It is unclear why it is able to do this.

How effective is Rogaine?

While the Food and Drug Administration recognizes that Rogaine works, it is well known that it doesn’t work for everyone. Recent studies show that when the 2 per cent solution is used properly, it can stimulate hair growth 30 per cent of the time, with a slightly higher rate in females. And the new 5 per cent solution has shown only slightly more success than the weaker solution. Rogaine is most effective when used at the first signs of balding and in relatively small areas of hair loss. It is also more effective in the center of the scalp than on the frontal hairline. Rogaine can inhibit further hair loss and can be used to supplement hair transplantation. It should be noted, however, that if you stop using Rogaine you will lose any hair re-grown while you were using it. This means that once you start using Rogaine, you must continue to use it for the rest of your life to enjoy its benefits.

Are there any side effects to using Rogaine?

every drug has some side effects. In the case of Rogaine the drug that makes it work, minoxidil, has a dangerous effect on the body (and the heart in particular) if


taken orally. When it is diluted in a solution for topical use, as it is in Rogaine, the side effects are less severe because the amount of minoxidil entering the body is much less. However, even in small doses the use of minoxidil does have some minor and major side effects that should be noted.

Minor side effects: These include skin irritations on the scalp such as dry red skin, flaking and itching; nausea and vomiting; and diarrhea. These are short-term, temporary side effects that should go away when your body adjusts to the use of Rogaine.

Major side effects: These include back and chest pain; cold-like symptoms; rapid heartbeat; fluid retention; difficulty breathing; weight gain; worsening of hair loss. These are very rare, extreme side effects that are similar to the effects of minoxidil taken orally.

Also, Rogaine is not safe for people who: Show allergic reactions to minoxidil; have heart disease; have high or low blood pressure; have skin diseases like dermatitis; are pregnant; or who are nursing mothers.

What improvements can we expect in the near future?

The most likely advancements in the use of Rogaine will come from two different approaches:

Increasing the amount of minoxidil: like the addition of the 5 per cent solution to the 2 per cent solution, researchers have been trying to improve the effectiveness of Rogaine by increasing the amount of minoxidil in the solution.

Increasing the ability of minoxidil to enter the skin: Researchers have also been trying to make Rogaine more effective by increasing the ability of the minoxidil in the solution to enter the skin and cause hair growth. Tests have shown that if


minoxidil is mixed with certain other substances it may be able to enter into the skin better and cause more effective hair growth.

Final recommendations for Rogaine

only use Rogaine if your health is good, if you are willing to test how it works for more than one year while accepting the possibility of failure, if you are disciplined in taking medications and following detailed instructions, and if you are prepared and able to pay to use Rogaine for the rest of your life.

PRoPeCIA (FInASTeRIDe)

In late 1997, the Food and Drug Administration approved Propecia for distribution in the United States as a hair-restoring drug. It is sold by the company merck in 1 mg pill form by prescription only. It is the first pill that effectively treats genetic hair loss. The active agent in Propecia is a drug called finasteride. It was originally used in a prostate medication called Proscar that was found to grow hair. Propecia is a lower-dose form of Proscar developed specifically to fight hair loss. one of the main differences between Rogaine and Propecia is that Propecia should only be used by men. It is dangerous for women of childbearing age and can cause severe birth defects in women that have handled Propecia in any way. Possible dangers aside, Propecia does not work for any women of any age.

How does Propecia work?

Finasteride is the active agent in Propecia. It works by manipulating the underlying chemical causes of genetic hair loss. We know that men with genetic hair loss have increased levels of a hormone called dihydrotestosterone


(DHT) in their scalps and it is believed that the presence of DHT in the scalp is related to the thinning of hair follicles and the resulting genetic hair loss. DHT is a by-product of the male hormone testosterone, which is converted to DHT when it reacts with a natural enzyme that is found in human skin cells called 5 alpha-reductase (5AR). Propecia does not directly counteract DHT itself, but rather blocks the action of 5AR to indirectly reduce the presence of DHT.

How effective is Propecia?

Propecia seems to be at least as effective as Rogaine. It is particularly potent in preventing further hair loss but is not as successful in stimulating new growth. Studies suggest that about 80 per cent of balding men can stop any further hair loss by taking Propecia. In addition, two out of three men may see some re-growth of hair. However, Propecia only works for men who have mild to moderate hair loss. Balding men with major or complete hair loss will not benefit from Propecia. Like Rogaine, Propecia is more effective in the center of the scalp and less so along the frontal hairline. Propecia must be taken for at least three months before seeing any results. Because hair generally grows at a rate of about ½ an inch per month, it usually takes between three to six months to see the full effects of Propecia. If there is no significant growth after 12 months it is unlikely that Propecia will ever work. Also like Rogaine, Propecia is effective only for as long as it is taken. This means that all benefits of using Propecia will be lost if you ever stop using it.

Are there any side effects to using Propecia?

Contrary to the dangerous effects that Propecia has on women, it is generally well-tolerated by men. The Food and Drug Administration described Propecia as having only infrequent side effects that affected only a small number of men.


General side effects: These include allergic reactions such as rash, hives, itching and swelling of the lips and face; breast tenderness and enlargement; and testicular pain.

Sexual side effects: Less desire for sex, difficulty in achieving an erection; decrease in the amount of semen; and problems with ejaculation. These side effects occurred in less than 2 per cent of men and were only temporary.

Some men in particular should not take Propecia. These include men who have allergies to finasteride or a related drug or who have liver function abnormalities. men for whom the noted side effects are unusually severe or long-lasting should only continue using it with caution and under the direct guidance of a medical doctor. As has already been mentioned, Propecia is also not safe for women and may cause severe birth defects. Women should not even handle broken or crushed tablets, although all Propecia tablets have a protective coating when intact. Also, men taking Propecia pose no danger to women or their fetuses. Although there are no known dangers in mixing Propecia with other drugs, the use of this drug has been linked to decreases in levels of prostate-specific antigen (PSA). Though this decrease is insignificant in itself, PSA levels are often measured for diagnostic reasons in the case of men suspected of prostate cancer or other prostate problems. Because of this, all patients taking Propecia, especially those with prostate illnesses of any kind, should inform their doctors of the usage.

What improvements can we expect in the near future?

Although Propecia is relatively new on the market, there have been several novel approaches to obtaining greater results from its use.

Using Propecia as a topical solution: one approach has been


to formulate finasteride as a topical solution, like Rogaine. This approach is more common outside of the United States, but some American companies are already selling finasteride in this form. At this point, however, a topical form of finasteride remains experimental as there have been no clinical studies that have shown the effectiveness of a finasteride topical solution.

Combining Propecia with Rogaine: It is believed by some that Rogaine and Propecia can complement each other by combining Rogaine’s ability to stimulate new growth with Propecia’s ability to prevent further hair loss. This, however, is a relatively new approach and little has been done in the way of scientific studies to verify its effectiveness.

Final recommendations for Propecia

Rogaine Propecia Comment

Cost

Safety

About $30 USD per month

Safe for both sexes, except for those with heart, blood or skin problems

About $50 to $60 USD per

Rogaine is a little cheaper

Safe for men only

men may choose either, but women can only use Ro-gaine

U s -Topical solu-tion, twice a day every day continuously

Single tablet taken once ev-ery day continu-ously

Propecia is easier to use but both must be used for life


COmpAring rOgAine And prOpeCiA, COntinued

Rogaine Propecia Comment

effect-i v e -ness

extra strength (5 per cent solution) can help 2 out of 3 people regain minimal to moderate amounts of hair in the cen-tral baldings areas of the scalp. There is a 10 to 40 per cent chance that your hair regrowth will be significant. It may take up to one year to see full effects.

Can help 2 out of 3 men regain minimal to moder-ate amounts of hair in the central bald-ings areas of the scalp. Almost 90 per cent effective in preventing further hair loss. There is a 30 to 60 per cent chance that your hair regrowth will be significant. It may take 3 to 6 months to see full effects.

Propecia is more effective in preventing further hair loss. Rogaine is more effective in stimulating new growth. Propecia shows results in less time than Rogaine.

Side effects

Temporary side effects: skin irritations on the scalp; nausea and vomiting; and diarrhea. Rare side effects: back and chest pain; cold-like symptoms; rapid heartbeat; fluid retention; dif-ficulty breathing; weight gain

Temporary side effects: rash, hives, itching and swelling of lips and face; breast ten-derness and enlargement; testicular pain; sexual impair-ment including problems with ejaculation

Side effects are rare with either drug. long-term effects are un-known for both drugs.


examples of crownal hair loss helped by propecia


Anterior mid-scalp hair loss helped by propecia


oTHeR emeRgIng HAIR gRoWTH DRUgS

Although Rogaine and Propecia are the only two drugs currently approved by the Food and Drug Administration to combat genetic hair loss, there are several other drugs that have shown great promise in restoring hair loss. These are not likely to be miracle cures but they may be more effective than current versions of Rogaine and Propecia, and they may display features more suited to your needs. You should know what other drugs may soon be available besides Rogaine and Propecia. All of these drugs are still being tested and some are being seriously investigated by large pharmaceutical companies that are investing millions of dollars to make them work.

Dutasteride

Dutasteride is another 5 alpha reductase inhibitor like the finasteride used in Propecia but it is currently being marketed as Avodart for the treatment of benign prostatic hyperplasia. Researchers are trying to formulate a form of dutasteride that can be used for the treatment of genetic hair loss. Like finasteride, it will likely have side effects on male sexual functioning.

Antiandrogens

Antiandrogens are drugs that prevent androgens (male hormones) from working. These drugs have shown the most promise in being able to provide a cure for genetic hair loss, as androgens are known to play a key role in causing this kind of hair loss. Antiandrogens are used to treat many different ailments and one of the side effects commonly seen during their usage has been the stimulation of hair growth all over the body. Because male hormones are important to the proper functioning of many male bodily functions, possible side effects of using antiandrogens include impairment to male


physical characteristics and sexual desire and potency.

Work has been done to develop antiandrogens that are safe for men to use to combat hair loss while avoiding the unwanted side effects. Finasteride, the drug in Propecia, is an example of one such drug because it does not directly inhibit male hormones but rather inhibits an enzyme that interacts with male hormones. Because antiandrogens target male hormones, antiandrogens are generally safer for women. Since women are less damaged by the side effects of antiandrogens they are more effectively treated by them. In europe, antiandrogens have been officially used to treat genetic hair loss in women for years.

one of the two drugs approved by the Food and Drug Administration for the treatment of genetic hair loss is Rogaine, whose active agent minoxidil is not an antiandrogen. So it would not be surprising to discover that the most effective drug treatment for genetic hair loss might emerge from a type of drug that is also not an antiandrogen. outside of the antiandrogens, there have been several drugs that have shown some promise as a treatment for genetic hair loss. The most prominent of these that are currently being developed and tested include the drugs listed below. look for these drugs to emerge in the near future to complement Rogaine as a drug treatment for genetic hair loss.

Tricomin

The American pharmaceutical company ProCyte is testing this drug in France. It has shown some effectiveness in increasing new hair growth by 40 per cent for three out of four of the balding men who used it in testing. Tricomin is a compound chemical that helps restore the health of skin tissue. The compound drug is applied on the skin like Rogaine and is believed to restore a healthy skin base for new hair to grow.


Cyclosporine

In several scientific studies conducted over the last few years, this drug successfully re-grew hair for at least some of the balding men who used it in testing. It is a type of drug called an immunosuppressive, meaning that it fights the body’s immune system. Immunosuppressives are usually given to patients to prevent organ rejection after a kidney, liver or heart transplant. Some experts believe that the ultimate cause of genetic hair loss is the immune system receiving the wrong messages that hair on certain parts of the scalp are foreign to the body, causing the immune system to attack them. In tests, cyclosporine was applied on the skin in the same way as Rogaine. This is done to localize the suppression of the immune system to the scalp and protect the rest of the body from the effects of the drug. The partial success of cyclosporine is fueling great interest in researching and developing immunosuppressive treatments for genetic hair loss.

Cyoctol

This drug has shown enough promise for Squibb, a major pharmaceutical company, to work on developing and testing it as a treatment for genetic hair loss. It is believed to combat hair loss by binding itself to the roots of hairs and protecting them from the negative effects of dihydrotestosterone (DHT), which is linked to genetic hair loss.

Diazoxide

The Food and Drug Administration is currently testing this drug for approval. It is usually used to treat symptoms of diabetes, such as abnormally high blood sugar. When it is used orally for this purpose, it has the side effect of causing hair growth all over the body. Recent research on diazoxide has been focused on developing it for treatment of genetic


hair loss by trying to control and direct the hair growth to the scalp.

55

chapter two:surgical treatment

Like medical drug treatments, surgical treatments for hair loss have developed significantly in the last couple of decades. However, unlike medical drug treatments that are still years away from being able to provide a full head of hair, recent advancements in surgical treatments have made it possible to achieve the appearance of a full head of natural hair. At this point in time, surgical methods are the surest and most effective way for most balding people to restore natural hair to a balding head.

BAsic questions ABout surgicAL treAtments

What are surgical treatments?

There are several types of surgical treatment for hair loss. They all involve the movement of hair from areas of your scalp that normally never go bald, such as the back and sides of your head, to the balding areas of your scalp, usually the central area on top and the frontal hairline. What is important to recognize about all surgical treatments for hair loss is that no surgical method can give you new hair or restore any of your lost hair. They can only redistribute what you still have. It is also important to

56

remember that surgical treatments for hair cannot prevent further balding. When deciding to employ any surgical treatment you must consider the possible progression of your hair loss as well as what you have already lost.

Who is a good candidate for surgical treatment?

Because surgical treatments of hair loss can only move existing hair from one area to another, it can only work properly with people who have enough remaining hair to cover the balding areas, and who are likely to retain it for some time. With recent advances in hair transplantation even people who have lost up to 50 per cent of their hair can get the appearance of a full head of hair with surgical treatment. But even with less than half your hair left, you can still benefit from hair transplantation and have your remaining hair redistributed in a way that looks natural and attractive.

When is surgical treatment appropriate?

there are several different situations in which hair transplantation is the best method to treat your hair loss.

To produce a natural hairline: A hair transplant is always required to produce a natural looking frontal hairline. the frontal hairline is the most important part of hair restoration because it is the most prominent part of your hair. The creation of a natural looking frontal hairline requires the restoration of a delicate pattern of hair lengths at various angles, which leaves little room for error.

To fill in thinning hair: When hair only appears to be thinning, short of complete balding, then hair transplantation can provide the restoration of a full set of hair. small grafts of one, two or three hairs can be precisely placed amidst thinning hair to restore a natural looking density.

To implant on scars left by surgical cuts to the scalp: scars left from surgical cuts into the scalp or physical traumas can be effectively concealed by transplanting hair into the scarred

57

skin tissue.

What are the different types of surgical treatments?

Currently, there are two methods of hair transplantation that offer the best and most natural results possible. These are follicular unit strip surgery (FUSS) and follicular unit extrac-tion (FUE).

Both the FUSS and FUE procedures involve the extraction of follicular units from a donor area on the head. Follicular units are small groupings of one, two or three hairs that grow naturally on the scalp. These follicular units are taken from areas on the head where hair is genetically programmed not to fall out. They are then implanted in the balding areas of the scalp, where the transplanted hair will continue to grow naturally. The FUSS and FUE procedures approach this method differently, but both provide exceptionally natural results and are by far the most popular methods with surgeons and patients.

How much does surgical treatment cost?

The cost of hair transplantation can vary enormously depending on who is performing it. Typically a doctor will transplant 1000 to 4000 grafts in one session that can last anywhere from two to twelve hours. The cost of the procedure is based on a price per graft. The grafts used in the FUSS procedure range in cost from $5 to $8 USD each. The grafts used in the FUE procedure range in cost from $12 to $25 USD each. Depending on the number of grafts being transplanted, the cost of the procedure can run into the thousands, but patients should remember that a hair transplant is a permanent and life-long investment.

58 SURGICAL TREATMENTS FOR HAIR LOSS

Alex: Male Pattern Hair Loss

Candidate for Surgical Treatment

Age: 52Occupation: engineerMedications: noneFamily history: brother has similar hair loss

Alex had been losing hair for 10 years. He was losing his hair slowly but progressively over that time. Each year seemed to get worse and worse. It began to effect his self-image. Since his brother had also displayed signs of male pattern hair loss it was clear that Alex had genetically-related male pattern baldness. His surgeon outlined for Alex all his treatment options. He could start on hair growth medications like Rogaine or Propecia to decrease further hair loss or he could undergo surgery with follicular unit micrografting to replace his lost hair. He thought about if for several days and discussed this with his wife and friends. In the end he felt that he needed to restore his hair to its former glory. He opted for surgery. Alex and his surgeon decided together that he needed about 1500 grafts

SURGICAL TREATMENTS FOR HAIR LOSS 59

Ideal candidates for surgical hair transplant

Crownalhair loss:top view



Frontal and central hair loss:

Front view


front view



Frontal hair loss: Front view


Front view



Temporal hair loss: Side view

Temporal hair loss: front view



Temporal hair loss:

front view

Temporal hair loss: side view



Central hair loss:

Front view

Central hair loss: Side view




Top view


Side view


FOLLICULAR UNIT STRIp SURGERy (FUSS)

The FUSS procedure involves the extraction of follicular units from narrow strips of scalp taken from donor areas on the back and sides of your head. The removal of these strips result in virtually undetectable scars. The follicular units are cut out from these strips and implanted into the balding areas of your scalp in pin-sized, surgically created holes. These sites will also heal in just a few days, leaving no

step three: making the grafts

the strips of skin taken from the scalp are cut into small grafts. Each of the small units is called a graft because it is intended to be placed in the bald portion of your head where it is supposed to literally ‘graft’ or meld into the existing skin.

step four: making the recipient sites

Following the plan previously sketched on the scalp, small holes are cut. A thin gauge needle is used to prevent damage to the skin while making the holes needed for transplanting into the bald areas of the scalp. First, anesthetic and extra fluids are injected into the skin, causing the surface area to increase. the needles are inserted into the skin to make the holes. With small enough holes, there is no tissue damage.

Step five: placing the grafts

Each graft is carefully placed according to the plan into specified holes. Usually 1000 grafts are more implanted in a single transplanting session. Mega sessions may involve the transplanting of 1500 to 4000 grafts in one session.

FOLLICULAR UNIT ExTRACTION (FUE)

The follicular unit extraction (FUE) method, like the


session that can be performed in a single day. Each of these sessions of hair transplantation involves the following steps:

step one: making a plan

A careful plan is made to design and mark a hair transplant map on the patient’s scalp. In making this plan, the hair transplant surgeon is using the principles that govern a natural head of hair to design a transplant that will look appealing and go undetected.

step two: Harvesting the hair

using local anesthesia, a small strip of skin is cut out from a selected hairy portion of your head. The selection of this area as a source of hair is based on a few considerations. First, the portion of the scalp to be stripped should not be susceptible to balding. Otherwise, the transplanted hair would eventually fall out of its new location, defeating the point of the transplant. Also, the selected portion of the scalp should be selected on the basis that after stripping and

harvesting the donor grafts follicular unit strip surgery (fuss)


The two different cuts: The top shows the ellipse cut where the skin with hair is removed by cutting around the edges. The multi-bladed cut shown below often transects many hair follicles.

FUSS method, involves the transplantation of follicular units from donor areas on the back and sides of the scalp to the balding areas. The difference between the two is that the FUE procedure extracts follicular units directly out of the scalp, one by one, using precise instruments and a high-powered microscope. this second and newer method of follicular unit


The strip is removed from the donor area.

The strip will be dis-sected into the follicular units under a micro-scope

The individual follicular groups of 1, 2, and 3 hairs will be transplant-ed to the balding area

SURGICAL TREATMENTS FOR HAIR LOSS 73 transplantation has the advantage of requiring no major surgical excisions. But while the FUSS procedure allows a large number of follicular units to be removed from a single strip of scalp, a fewer number can be removed during a single session of the FUE procedure because each unit must be removed one at a time. However, a session can be repeated one or two days apart. The FUE method of transplantation is particularly good for those who do not have a lot of hair in their donor areas, those who are afraid of the surgical aspect of hair transplantation and for those who do not want any surgical scars in the donor areas. Due to the lack of cutting involved with the FUE procedure, patients retain the option of wearing

step four: making small holes


Small gauge needles used to expand the recipient area for the grafts.

their hair very short without worrying about the appearance of minor scarring. The grafts used in the FUE procedure are thinner than the ones used in the strip technique. this is an additional advantage because grafts can be placed closer together, which means that more grafts can be implanted to maximize the density of the transplant. Thinner grafts are also more


step six: Allowing the grafts to settle

the grafts are left to settle in their new places and the scalp is allowed to heal for several months. During this healing process, the skin closes around the grafts. the hair from the transplanted grafts usually falls out as a result of the shock of transplantation. However, after a few months the roots of the hair usually recover and the hair re-grows.


easily inserted amidst thinning hair to improve density and they reduce the effect of shock, which causes hair in the transplanted area to temporarily fall out after the procedure.

then the skin with the hair follicles was removed and cut into smaller hair grafts.

In the first operation 586 grafts from AA were transplanted in FA and in the second operation 594 grafts from FA were transplanted in AA. the transplants were performed on the temples of both subjects, giving us a clear observation of hair growth. Also, the identification of hair growth was facilitated because AA’s hair was black and FA’s hair was brown. postoperative hair growth was measured at 9 months and at 14 months, and pictures were taken at different intervals to monitor growth at various stages.

* pictures of AA and FA

Results: postoperative hair growth was measured at 9 months and at 14 months. At 9 months, 45 of the 586 grafts on FA were considered surviving grafts. The number of surviving grafts was not determined on AA. At 14 months there were no surviving grafts on FA.

* chart of results

Conclusion: This study shows that allo-hair transplants do not work in the traditional format. However, there is reason to believe that the hair itself is not antigenic but the tissue surrounding the hair follicle is the reason why the hair was unable to survive. It will be necessary to introduce modifications to the method of transplantation to change the structure of the surrounding skin so it does not reject allo-transplanted hair follicles. if the antigenic nature of the skin can be limited, this may present a new approach to the surgical treatment of hair loss.


harvesting the donor grafts follicular unit extraction (fue)


Follicular units are extracted with the use of


Donor area for Follicular Unit Extraction (FUE) one day after surgery. Donor hair has been extracted one at atime.


3 weeks post-Follicular Unit Extraction (FUE) surgery

No scalpel, sutures or staples results in a donor area with no scars.


The FUE technique does not require any stitches or staples because there is no traumatic surgery involved with the harvesting of the donor hair. This non-scalpel

technique also allows for a faster recovery because there is

no major surgery involved as there is with the usual


These pictures were taken on the day after 395 grafts were transplanted using the Follicular Unit Extraction

(FUE) technique. The small dots in the donor area represent the follicular units that have been extracted

one-by-one and transplanted to the front of the patient’s head.


comparison of fuss and fue methods

Hair is harvested by extracting a strip from the donor area. Requires scalpel surgery Requires sutures or staples Minimal scarring in the donor area

follicular unit strip surgery:


Individual follicular units are extracted one-by-one. No major scalpel surgery involved No suture or stapling involved No scarring involved

follicular unit extraction:comparison of fuss and fue methods


comparing needles gauge for fuss and fue


comparing fuss and fue grafts


comparing density for fuss and fue

50 to 60 grafts per square centimeter using 18 - 20 gauge needles in FUSS transplants.

70 to 80 grafts per square centimeter using 21 - 23 gauge needles in FUE transplants, achieving greater density in the

hairline. than with the FUSS procedure.


comparing advantages and disadvantages for fuss and fue

Follicular Unit Strip Surgery

(classic method)

Number of grafts

this method allows up to 3500 to 4000 grafts to be trans-planted in one session

Follicular Unit extraction

Surgical compo-

Who is best suited

Aver-age

Generally limited to 750 to 1500 grafts per day, though sessions can be repeated over 2 to 3 days in a row for more grafts, up to 2500 to 3000 grafts

major surgical component, large excision and bleeding. Staples or sutures are required for 1 to 2 weeks to close the opening, meaning surgical risks

minor surgical com-ponent with no major excision. skin closes very quickly requiring no staples or sutures, meaning minimal surgical risks

medium to large baldness

those who do not wish to have any scarring at all

$5 to $8 USD/graft $10 to $25 USD/graft


GOALS OF HAIR TRANSpLANT SURGERy

natural appearance

The artistry of hair transplantation begins with the proper design of the frontal hairline. It is vital that the hairline be de-signed to suit the patient’s face so that the transplant appears natural and goes undetected to the casual observer.

The hairline must be carefully placed in relation to the rest of the face to ensure this natural appearance. Leonardo Da Vinci’s formula for the face produces the best results for this purpose. the formula is as follows: the distance from the eyebrows to the hairline is half the distance from the eyebrows to the bottom of the chin. By following this formula, each hair transplant should be unique and suited to the patient. This may be age-adjusted so that younger patients have lower hairlines and older patients have slightly higher ones.

A combination of follicular unit micro-grafting is the only way to perform the precise manipulations needed to pro-duce this natural-looking hairline. An irregular pattern of hair distribution is created with a combination of one-, two- and three-haired follicular units for a natural look. A soft frontal zone is made with single-haired follicular units and then the transition to high density is made with the placement of two- and three-haired follicular units farther back.

The crown and temples are other areas that must be properly designed. If transplantation is needed in the crown area, the hairs should follow the natural swirling pattern char-acteristic of this particular region. Also, the way the hairline meets the temples requires correct angling and blending into the rest of the hair behind the ears.


hairlines


In the following cases you will see pictures of younger patients. The restored hairlines are lower and the temple angles are closed in order to give the patients their youthful look back.

BeFOre AFTer


In the following cases you will see pictures of the restored hairlines of middle-aged men. The hairlines are generally higher and the temple angles remain open to better reflect the age of the patients.

BeFOre AFTer


BeFOre AFTer


One way of restoring a natural hairline is by closing the temple angles as demonstrated in the diagram above. Exposed temple angles indicate a receding hairline.


Maximum density

It is important that your hair transplant provide enough density to cover the balding areas of your scalp. This should be discussed in the initial consultation with your doctor as your financial investment in your surgery is dependant on this. the hair transplant surgeon can, and should, outline the density you should be able to achieve with a certain number of grafts.

The average person, before the onset of balding occurs, has 100 to 200 follicular units per square centimeter of the scalp. For a hair transplant, a density of 50 to 80 follicular units per square centimeter is optimal and is possible for an experienced surgeon in a single session. Future sessions can build on this density. Follicular unit extraction (FUE) has contributed significantly to the achievement of greater density. By extracting the follicular units one by one using the FUE technique the grafts are thin enough to pack them in closer together and thus achieve maximum density.

density per square centimeter

Normally, a person would have 100 to 150 grafts per square centimeter. Today, a maximum density of

70 to 80 grafts per square centimeter can be achieved with follicular unit transplantation.


natural density


regions of the scalp: 1, 2 60 - 70 grafts per cm square centimeter (high density)3 70 - 80 grafts per cm square centimeter (maximum density)4 50 grafts per cm square centimeter (medium density)5 30 - 40 grafts per cm square centimeter (light density)

distribution of density


BeFOre

IMMedIATeLy AFTer grAFTIng

the following pictures demonstrate density in transplanted patients


After transplant: 70 to 80 grafts per square cm



BeFOre




AFTer



AFTer


BeFOre



BeFOre


AFTer



BeFOre AFTer




AFTer

AFTer



world record: largest session done over two days

mega-sessions

With new advances in hair transplantation, mega-sessions are more common. these sessions allow for large amounts of grafts to be transplanted in a single procedure.

Currently, the world record for the most amount of grafts completed in one session over two consecutive days is:

6, 298 grafts BeFOre AFTer


Before and after pictures of the patient can be seen in the previous two pictures. this patient wanted the whole head covered at once from the front hairline to the crown. The whole procedure turned out to be the largest session ever done over two consecutive days. The results (also shown below) were exceptional considering the high degree of difficulty associated with a hair transplant session of this size. The patient was extremely pleased with regaining his youthful look and achieving excellent density. The growth in this patient was excellent, with over 95 per cent of the follicular units transplanted surviving.

Age: 33Profession: Import/ExportOne Session: 6298 grafts

BeFOre AFTer

world record: largest session done over two days


world record: largest session done in one day

Age: 41Profession: UpholsteryOne Session: 4624 grafts

BeFOre AFTer


permanence

transplanted hair is permanent. it is taken from the back and sides of the scalp where the hair is genetically programmed not to fall out. When it is transplanted to the front and top of the scalp it maintains its original genetic make-up to not fall out. That being said, hair loss is usually progressive. Future hair loss must be anticipated by you and your surgeon. you can minimize this progression by planning your surgeries carefully at the opportune times. Although the transplanted hair is permanent, you may lose your non-transplanted hair with time and age. The best solution is to replace any hair that you may lose with permanent hair from the back and sides of the scalp.

RISkS ASSOCIATED WITH HAIR TRANSpLANTS

Hair transplantation is a relatively minor surgical operation and is generally safe. Nevertheless, there are some notable risks that are associated with hair transplanting that may complicate the success of the operation. These risks include:

infection

With every surgical incision to the skin there is always the risk of infection. An antibiotic is usually sufficient to fight off the threat of an infection and its spread.

swelling on the forehead

Swelling usually occurs in the forehead after hair transplantation. sometimes the swelling can spread to other parts of the head but it usually resolves itself in less than a week after the procedure and does not affect the patient’s health in any way.


Bleeding and scab formation

In both the donor and the transplanted areas of the scalp bleeding and scab formation may occur after the procedure. this should clear up in two to three weeks.

scarring in the donor areas

With the FUSS method of transplantation, minor scarring will occur in the area(s) where the donor tissue was removed. This is not a concern with the FUE method.

Numbness in the scalp

sometimes there is a loss of sensation in the scalp as a result of nerve damage. If this occurs it is usually temporary but may last longer in rare cases.

Headaches, pain or tingling sensations

the shock of hair transplantation sometimes leads to sensations and pain that are often temporary. In some cases, however, this may last longer.

Dizziness or fainting

these side effects sometimes occur in patients with high levels of anxiety. This is temporary and subsides with increased fluid intake and rest.

uneven graft setting

Sometimes grafts heal in such a way as to be uneven with the surrounding skin.


poor growth of hair follicles

Grafts may also grow poorly. This may happen all over the transplanted area or in a small area. there are many possible reasons for poor growth and it often occurs unpredictably.

A full list of possible risks and complications can be found in the appendix under the consent form.

REpAIR CASES

repair work requires far more experience on the part of the surgeon and is an endeavor that combines surgical and aesthetic skills to meet the patient’s expectations. A case that would qualify for repair work includes a transplant that included or resulted in any of the following: Grafts that were too large, an improperly designed hairline, hair transplanted in the wrong direction, significant scarring in the transplanted area, difficulty dissecting under magnification, a large amount of tension, poor growth, donor wastage or donor area scarring. With the use of follicular units, most errors from initial transplants can be fixed. In cases where the hair was placed awkwardly or angled incorrectly, the surgeon can coordinate a surgical plan to ‘remodel’ the design of the hair. Hairs may be moved, or removed, to optimize the outcome of the repair work in terms of the overall appearance. setting goals with the patient before the repair work is performed will also help to ensure satisfaction and the most natural results possible. the following two cases are of patients who have had surgical treatment in order to repair previous procedures.


BeFOre AFTer

surgical repair case 1


CASE SUMMARy· Pictures were taken 5 months post surgery· young Afghan Canadian· Scalp burnt with oil in childhood· Plugs transplanted by another surgeon· Diffuse scarring secondary to burn and secondary fibrosis· Fibrosis and scarring also due to plugs· Tremendous scarring covered with follicular units· Advised smaller surgeries for repairing area to maximize blood supply· Very good results· Next surgery planned for two months later

Age: 19Profession: Machine operatorOne Session: 1, 281 grafts



BeFOre AFTer

CASE SUMMARy· Plugs repaired on sides and temples where there was considerable scarring and fibrosis. · Covered nicely with follicular unit micrografts.

Age: 30Profession: PharmacistOne Session: 2, 490 grafts



pRACTICAL DETAILS OF HAIR TRANSpLANT SURGERy

the following section will go into some depth detailing the practical stages involved in the hair transplantation process.

Finding a good hair transplant surgeon

the first stage of the hair transplantation process involves finding a good hair transplant surgeon. Surgical treatment of your hair loss requires you to put a lot of trust in the hands of the doctor you choose to perform your transplant. the advice of an experienced, skilled and honest doctor is invaluable in dealing with your hair loss and the various options. The best method of finding a good surgeon is often the internet. this provides patients from all over the world a variety of choices from their home computers. Most hair transplant centers have their own websites and you can research their services from the comfort of your home. The website is also often a reflection of the surgeon’s office and can offer insight into the philosophy of the clinic. Other methods of finding a good surgeon are through newspapers, television, magazines, radio, your local phone directory, hair salons and spas, doctor’s offices and billboards. When looking at these ads, beware of negative ads that attack other hair transplant centers. true professionals will not resort to attacking other hair transplant surgeons. Finding a good doctor takes some effort. Here are some rules to follow that should help you find a good doctor to work with.

Check his/her credentials: check to see that the medical professional is fully qualified from a reputable university. Check with your local licensing board to make certain that he or she is fully licensed.

Get a list of doctors from a neutral source: Do not rely on


the advice of someone who is promoting a service for-gain regarding the reputation of a particular surgeon. there are many websites that look impartial, but are actually paid to advertise and promote particular surgeons and hair transplant centers. patients should ask the site owners if they are financially compensated by the surgeons on their recommended lists.

Get a second opinion on any treatment plan suggested: Even if you have already selected a surgeon to go to, get at least one more opinion from another medical professional. There is no harm is looking for confirmation of what you have been told.

Questions to ask yourself when looking for a doctor:

1. is the surgeon up-to-date in the latest surgical techniques, including follicular unit strip surgery and follicular unit extraction?2. Has the surgeon performed a variety of hair transplant cases?3. is the surgeon interested in individualizing each transplant according to age, ethnicity and individual facial features, as opposed to doing the same transplant pattern on all their patients?4. Is the surgeon artistically competent?5. Has the surgeon performed transplants of higher degrees of difficulty, as well as repair cases?

These rules may make selecting a doctor a more difficult process, but if you follow them you should be protected from the many abuses that take place all the time in the hair restoration business.

the consultation

in looking for a hair transplantation specialist, the potential patient will have to go to an initial consultation. At this stage there are several things to look for:


The clinic: Look at the clinic when you are visiting your surgeon for the consultation. is it clean? is it organized?

Discussing your history: Is your history taken in detail, either through written forms or discussed verbally? Is the staff concerned with your overall health and the impact of surgery on other medical conditions? Is the surgeon giving you enough time to give your point of view on your hair loss history?

Expectations: This is one of the most important things to clarify before you book any surgery. Are you and your surgeon clear on what you are expecting from surgery? Can he or she meet your expectations? you should both understand what can realistically be expected from your surgery.

The number of grafts: The number of grafts you will need is the most difficult decision to make in the hair transplantation process. This should be a joint decision between the patient and the surgeon and should be discussed in some depth during the consultation. you will need to take into consideration: How much coverage you want; the cost of the procedure; and how many sessions you are willing to have performed. your surgeon should be able to provide you with the following information: The anticipated coverage and density associated with the number of grafts; the length of time that will be involved; the services provided by his or her clinic during longer procedures; the level of required sedation; and his or her recommendations. you may decide to get anywhere from 500 to 4000 grafts in one session or in multiple sessions. To provide a better picture of what is entailed in selecting the number of grafts, see the following chart that summarizes all the information you need to make this decision: The coverage that can be anticipated based on various amounts of grafts; the length of the donor strip needed in the case of the FUSS procedure; and the expected costs from various centers. this chart summarizes grafts that deal with one-, two- and three-haired follicular units. some surgeons use larger grafts and their fee


FUEfee

range (USD)

1, 000

summary of number of grafts

Number of grafts Coverage

FUSS strip size

(cm)

FUSS fee

range (USD)

1, 500

2, 000

2, 500

3, 000

4, 000

Small coverage- Front hair line OR- crown or- temples

Medium coverage- 1/4 top bald OR- Front hair line OR- crown or- temples or

Med-Large coverage- 1/2 top bald OR- Front 1/2 OR- Back 1/2

Large coverage- 1/2-3/4 top bald OR- Front 1/2-3/4 OR- Back 1/2-3/4

Large coverage- 3/4 top bald OR- Front 3/4 OR- Back 3/4

Large coverage- 3/4 top bald OR- Front 3/4 OR- Back 3/4

10 x 1

15 x 1

20 x 1

25 x 1

30 x 1

2 strips10 x 130 x 1

4, 000 -8, 000

6, 000 -12, 000

8, 000 -16, 000

10, 000-20, 000

12, 000 -24, 000

16, 000 -68, 000

6, 000 -17, 000

9, 000 -25, 500

12, 000 -34, 000

15, 500 -42, 500

18, 000 -51, 000

24, 000 -68, 000


schedules vary.The procedure: As a patient, you have a right to have the surgeon go over the entire procedure in detail, step by step.

Risks and complications: Ask the surgeon about any possible risks and complications associated with surgery. This should first be given verbally during the consultation. It should also be given in writing later on before any surgery. you should review these with the surgeon beforehand.

Pressure-sales tactics: Be wary of pressure-sales tactics being used on you. Do not allow yourself to be pressured into signing any surgery agreement too soon.

Before the surgery

Most good hair transplant centers will bring you in for a preoperative assessment. This may include the signing of consent forms, preoperative instructions and payment.

The consent form: The consent form should outline in easily understandable terms any complications that may occur. you should discuss these with your surgeon. See Appendix A for a sample of a typical consent form.

Preoperative instructions: These instructions should be as detailed as possible. A detailed information package that lists all instructions should be provided. Review the package and ask any questions you may have. See Appendix B for a sample of a typical preoperative instruction package.

the most important of these instructions to take note of are: Things to be avoided: Various medications and drugs will need to be avoided for two to three weeks prior to surgery. these would include alcohol, vitamins, AsA containing medications, marijuana and any other illicit drugs.


Clearance of medical drugs: patients taking any medical drugs will need to have these cleared by the surgeon to make sure it is okay to use them during the hair transplantation process.

Day of the surgery

On the day of the surgery several precautions would need to be followed. It is advised that patients do the following:

1. Go to bed early the night before the procedure. Surgery will test your patience and you will need to be well-rested.2. Have a good meal. For a morning surgery you should have a good breakfast. For an afternoon surgery you should have a good lunch.3. Bring extra clothing. your clothing may get wet or soiled during surgery. Also, wear comfortable shoes and loose pants.4. Bring CDs or videos. Many hair transplant centers provide their patients with a choice of listening or viewing material. If you prefer your own material, bring it with you.5. Be on time for the surgery. It is a good idea to be there 15 minutes early so that you can relax beforehand. Allow for traffic delays.6. Arrange for your drive home. you will be medicated after surgery and unable to drive yourself home. Arrange to have someone drive you home or spend the night at a hotel near the surgeon’s office.7. keep the surgeon’s phone number handy. After you leave the surgeon’s office make you are able to reach him or her in case of an emergency.

each hair transplanting technique involves different steps. The following is a step-by-step outline of the follicular unit strip surgery and follicular unit extraction methods.


Follicular unit strip surgery (FUSS):

- preoperative medications are given. They may include antibiotics and/or sedatives (usually Valium or Midazolam).- The patient is seated on the operating room table.- The donor strip to be removed will be shaved.- The patient will be asked to lay face down on the table on a special pillow with the center removed. This will stabilize the head for strip harvesting. Other surgeons may have the patient sitting up in something like a dentist’s chair.- Anesthetic solutions are injected into the donor strip area. These include: xylocaine 2% or Morcaine (for freezing), adrenaline (to decrease bleeding), sodium bicarb (to decrease stinging) and normal saline (to puff up the area and move the hair follicles away from the scalp to facilitate cutting).- The donor area is surgically cut with a single blade in an elliptical pattern or with a multi-bladed knife. Because of the freezing in the area you should not feel any of this cutting at all.- The donor strip is removed from the scalp area. Any bleeding is controlled by electric cauterization.- the area is sutured up or staples are inserted.- The area where the strip was removed is bandaged.- The strips are taken away to be cut in to grafts.- the recipient area is prepared for transplantation either by having anesthetic solutions injected into it or by having a nerve block performed, based on the preference of the surgeon.- the recipient area is cleaned and the incisions are made with very fine needles where the grafts should go.- the grafts are then inserted into these incisions.

How you will feel: you will feel little to no pain during the procedure. Only the initial freezing will be felt. Most patients find it better than going to the dentist.Follicular unit extraction (FUE):


- preoperative medications are given. They may include antibiotics and/or sedatives (usually Valium or Midazolam).- The patient is seated on the operating room table.- The donor area will be shaved.- The patient will be asked to lie down on one side or to sit up in something similar to a dentist’s chair.- Anesthetic solutions are injected into the donor strip area. These include: xylocaine 2% or Morcaine (for freezing), adrenaline (to decrease bleeding), sodium bicarb (to decrease stinging) and normal saline (to puff up the area and move the hair follicles away from the scalp to facilitate cutting).- The donor follicular units are harvested one at a time. you should not feel anything due to the freezing.- the extracted follicles are put in saline.- the recipient area is prepared for transplantation either by having anesthetic solutions injected into it or by having a nerve block performed, based on the preference of the surgeon.- the recipient area is cleaned and the incisions are made with very fine needles where the grafts should go.- the grafts are then inserted into these incisions.

How you will feel: you will feel little to no pain during the procedure. Only the initial freezing will be felt. Most patients find it better than going to the dentist.

Immediately after the surgery

There are several things to know about the post-surgery phase of hair transplantation for both the FUSS and FUE procedures.

Bandaging: The degree of bandaging will depend on the preference of the surgeon. Some surgeons prefer bandaging the whole head, some prefer bandaging just the donor area and some prefer no bandaging at all. All of these are


acceptable.

Rest: After returning home the patient should have a good meal, get plenty of rest and sleep with the head at a 45 degree angle.

Things to be on alert for:

- Bleeding: Any sign of bleeding, either from the suture line or from the transplanted area, should be reported immediately to your surgeon or to an emergency room. Sometimes sutures can become loose and excessive bleeding may result. This should be attended to immediately. This is less likely to occur with the FUE procedure because there is no suturing involved and because the extraction points in the recipient area are very small and tend to close up quickly.- Swelling: Some temporary swelling is natural for both procedures and is to be expected.- Fever: The presence of a fever after surgery usually indicates an infection. Surgeons often prescribe antibiotics to be taken after surgery as a precaution against infection. The persistence of an infection should be reported immediately to your surgeon or to an emergency room. Again, this is less likely with the FUE procedure because there is no major surgical incision.- Headache or pain: the presence of headaches or pain is fairly common after surgery. The surgeon and the patient should anticipate this. Such pain is usually found in the area of the suture. The absence of sutures in the FUE procedure will eliminate some of the possibilities of headaches. Most patients who have undergone a FUE procedure report no headaches or pain.- Nausea and vomiting: Sometimes a patient may experience nausea or vomiting. This is usually related to the injection of anesthetics or to the ingestion of sedatives or pain-relieving medications. An anti-nausea medication can be used to combat this and should be prescribed by your surgeon as a precaution.


Later post-surgery

After the surgery, the waiting period for the results begins. The following indicates what can be expected during this stage:

The day after: most hair transplant centers look at the suture line the day after the surgery. FUE patients are also examined the next day. The patient should lightly wash his or her head for the first one or two weeks after surgery without touching the transplanted area. It is also very important that the patient avoid itching or scratching this area.

During the first two weeks: sutures or staples come out 10 to 15 days after the FUSS procedure. Swelling may occur on the forehead and around the eyes because of the freezing solution moving down from the scalp. Scabs will form over the transplanted area. This area should be dabbed gently using vitamin E oil to dampen the scabs. Any heavy exercise or strenuous activity should be avoided for three to four weeks post-surgery.

During the first month: most of the transplanted hair will fall out in the first month after the roots take hold due to the shock of transplantation. The result will be that the patient will look like he or she did before the surgery. While this may be a time of much worrying, the roots will grow new hair. The loss of hair may be less with the FUE procedure.

During the first six months: The first growth of hair usually starts to appear sometime in the second or third month after surgery. By the six month mark there is growth of about 50 to 60 per cent of the transplanted follicles. patients at this stage are fairly happy and can see an appreciable difference. A second session can be held at this time to increase density in the transplanted area. Hair growth will continue for the next six months.

During the first year: It takes up to a full year to see the


patient and surgeon checklist

Patient Surgeon

1. Have realistic expectations2. Understand the cost, time and tolerability of a transplant session or sessions3. Follow preoperative instructions4. Understand the full surgical process5. Follow postoperative instructions

1. Anticipate and understand the patient’s expectations2. Discuss the procedure in detail, including all possible risks and complications3. Provide informed consent and preoperative instructions4. Provide all necessary comforts for longer sessions5. Be available during the postoperative period

CASE STUDIES

The case studies shown on the following pages involve transplantation using follicular unit transplantation methods.


BeFOre AFTer

case study 1


CASE SUMMARy• Pictures are one year post surgery• younger patient with thick black hair and olive skin • Spanish background, American• Needed higher density • Hairline already lower.• Focused on completing the hairline and mid section• Grafts placed artistically to give an overall impression of far greater number of grafts and maximum density. Age: 32 Profession: Business Manager One Session: 2, 527 grafts

case study 1


CASE SUMMARy· Pictures 6 months post surgery. · young Canadian of British descent. · Curly hair, light skin. · Lower hairline, temples closed. · Very high density in the front hairline. · On preventative medication for future hair loss.

BeFOre AFTer

case study 2


Age: 24Profession: MarketingOne Session: 1, 990 grafts

case study 2

BeFOre AFTer


case study 2: close up the hairline


CASE SUMMARy· Pictures are 9 months post surgery · younger patient · French background, blond thin hair, Canadian with light skin · New lower hairline. · Temple angles closed · Hair distribution crucial to cover front 1/2 scalp in a natural dense look.

BeFOre AFTer

case study 3


Age: 36Profession: ConstructionOne Session: 2, 383 grafts

BeFOre AFTer

case study 3


CASE SUMMARy· Pictures are from one year post surgery. · Middle-aged American. · Medium brown hair, light skin. · Wide area coverage. · Higher hairline suitable for his age. · Temple angles slightly closed. · Very good density over a large area.

BeFOre AFTer

case study 4


Age: 53Profession: AnalystOne Session: 3, 052

BeFOre AFTer

case study 4


BeFOre AFTer

case study 5


CASE SUMMARy· Pictures from one year post surgery. · Canadian with an Iranian background · Dark thick hair, olive skin. · Wanted very high density. · Achieved a very normal looking, super dense hairline and midscalp

Age: 37 Profession: Restaurant Business Two Sessions: 27, 732, 258 grafts Total: 5, 031

case study 5: close up of hairline


CASE SUMMARy· Pictures 6 months post surgery. · young Canadian of Polish descent. · Needed a lower hairline and temple angles closed. · Needed to look his age or younger. · On preventative therapy for future hair loss.

BeFOre AFTer

case study 6


Age: 26Profession: Business administratorOne session: 2, 041

BeFOre AFTer

case study 6


CASE SUMMARy· Canadian - British descent. · Brown hair, light skin. · Dense front hairline. · Temples closed. · Overall, artistically done hairline and high density gives the patient a more youthful look. Age: 50 Profession: Oral Surgeon Two Sessions: 25, 102, 209 Total grafts 4, 719

BeFOre AFTer

case study 7


CASE SUMMARy• Pictures from 6 months post surgery. • young patient, Italian/ Canadian. • Thick black hair, olive Skin • Hairline restored to original position • Temple angles closed • Creates a more youthful appearance suitable for his

age and for the future • Taking prophylactic medications to prevent future

hair loss.

BeFOre AFTer

case study 8


BeFOre AFTer

Age: 24Profession: MechanicOne session: 1, 852 grafts

case study 8


Age: 29Profession: StudentOne Session: 1, 171

BeFOre AFTer

case study 9


case summary· Pictures from one year post surgery. · young African patient. · Curly, thick, black hair. · Dark brown skin. · Front hairline restored with good density. · Temple angles closed



BeFOre AFTer

case study 10


CASE SUMMARy· Pictures from one year post surgery. · young American of British descent. · Dark medium thick hair. · Light skin. · Wanted lower hairline and temple angles closed. · Achieved very high density and a very natural looking hairline.

Age: 35 Profession: Driver Two Sessions: 18, 491, 440 Total grafts 3, 289

case study 10


BeFOre AFTer

case study 11


CASE SUMMARy• Pictures one year post surgery. • Middle Eastern background, Canadian. • Dark curly hair. • Medium brown skin. • Lower hairline and temple angles closed. • High density look overall.

Age: 33 Profession: Security Two Sessions: 20, 071, 474 Total grafts: 3, 481

case study 11


BeFOre AFTer

case study 12


CASE SUMMARy· Pictures one year post surgery. · young Canadian of Irish descent. · New hairline lower with temples closed to create a more youthful look for his age · On preventative medication for future hair loss

Age: 26 Profession Student One Session: 1, 587

case study 12


BeFOre AFTer

case study 13


CASE SUMMARy· Pictures 6 months post surgery. · Middle aged, Italian Canadian. · Curly silver pepper hair. · Olive skin. · Wide area coverage. · Medium density front hairline. · Low density back. · Overall, one session covered very large area very well.

Age: 46 Profession: Construction One Session: 3, 170

case study 13


CASE SUMMARy· Picture one year post surgery. · Canadian of British descent. · Thin brown hair. · Light skin. · Mid-scalp hair loss. · Goal to increase density. · Typical female transplant.

BeFOre AFTer

case study 14


Age: 43Profession: Business ownerOne session: 2, 000

BeFOre AFTer

case study 14


BeFOre AFTer

case study 15


CASE SUMMARy· Pictures 9 months post surgery. · Canadian of British descent. · Thin blond hair. · Light skin. · Goal was to repair the hairline and close the temple angles.

Age: 40 Profession: Multimedia developer One Session: 2, 217

case study 15


BeFOre AFTer

case study 16


CASE SUMMARy Age: 52 Profession: Businessman One Session: 3, 533

BeFOre AFTer

case study 16


BeFOre AFTer

case study 17


· Pictures one year later. · Dark thick hair, brown skin. · New lower hairline and temples closed. · Wide area coverage. Age: 26 Profession: Plastic Factory Two Sessions: 22, 081, 863 Total grafts: 4, 071



BeFOre AFTer

case study 18


CASE SUMMARy· Dark hair, brown skin. · Largest session ever done in one day. · Front to back, full scalp surgery. · Front hairline: moderate to high density. · Remaining area: fair to moderate density. · Overall: good result in wide area coverage in one session

Age: 41 One Session: 4, 624

case study 18


CASE SUMMARy· Indian American. · Dark hair, olive skin. · Middle area of head was bald.· High density was achieved with repair of the hairline

BeFOre AFTer

case study 19


Age: 47Profession: EngineerOne Session: 1, 603

BeFOre AFTer

case study 19


CASE SUMMARy· European background - Canadian. · Brown thin hair, light skin. · Had a transplant prior to this surgery, as seen in the before pictures - with almost no results. · High density session seen in the after pictures with a lower hairline and temple angles closed. · Overall, a much more youthful look.

BeFOre AFTer

case study 20


Age: 35Profession: NeurosurgeonOne Session: 2, 793

BeFOre AFTer

case study 20


CASE SUMMARy· Pictures 5 months post surgery. · young Iranian Canadian. · Dark thin hair, olive skin. · Lower hairline, temples closed · Density will increase over the next 7 months.

BeFOre AFTer

case study 21


Age: 22Profession: Sales ManagerOne Session: 2, 094

BeFOre AFTer

case study 21


BeFOre AFTer

case study 22


CASE SUMMARyAge: 47 Profession: Showroom ManagerTwo Sessions: 23, 031, 922Total Grafts: 4, 225



CASE SUMMARy· European - Canadian background. · Brown thin hair, light skin. · Class 7 baldness on the hair loss scale· Natural, high hairline with temple angles left open. · Medium density.

BeFOre AFTer

case study 23


Age: 54One Session: 2, 552 grafts

BeFOre AFTer

case study 23


CASE SUMMARy· European Canadian. · Blond hair, light skin. · Front half of head covered. · Low hairline, temple angles closed. · Excellent results with a more youthful look for the patient.

BeFOre AFTer

case study 24


Age: 26Profession: Network AdministratorOne Session: 1, 718 grafts

BeFOre AFTer

case study 24


CASE SUMMARyAge: 44Profession: ConstructionOne Session: 1, 098 grafts

BeFOre AFTer

case study 25


BeFOre AFTer

case study 25


CASE SUMMARy· Pictures one year after surgery. · young American of British descent. · Brown thin hair. · Light skin. · New lower hairline. · Temples closed. · More youthful look.

BeFOre AFTer

case study 26


BeFOre AFTer

Age: 28Profession: Airline PilotOne Session: 1, 508 grafts

case study 26


CASE SUMMARy Age: 29 Profession: Warehousing Two Sessions: 1, 707 and 1, 310

BeFOre AFTer

case study 27


BeFOre AFTer

case study 27


CASE SUMMARy· Italian Canadian. · Dark curly hair. · Crown area with large density. · On preventative medications for future hair loss.

Age: 46Profession: Restaurant OwnerOne Session: 3, 032 grafts

BeFOre AFTer

case study 28


THE FUTURE OF SURGICAL TREATMENT

the future of hair transplantation is developing fast. Three revolutionary new techniques are emerging that show great promise: Cloning, gene therapy and donor hair.

cloning

There are currently two methods of cloning being developed by researchers. The first is called ‘in-vivo cloning’. It involves cutting the hair follicle at different levels to produce more than one follicle. Dr. kim from korea has made significant contributions in this method. He has found that by cutting the follicle midway at the stem cell level, two follicles can be reproduced from one, though they are thinner in diameter than the normal hair follicle. the cutting must be made precisely at a very specific level to produce very specific stem cells. The other cloning method being researched is called ‘in-vitro cloning’. In this method, the stem cells from the hair follicle are taken and grown in a petri dish. In this way new duplicate cells are cloned. Later, these new cells can be inserted back into the scalp instead of follicles with hair. It is believed that hair may be able to grow from the cells themselves. There are five or six centers in the world trying to perfect this technique, which would mean that even the man or woman with very few hairs could have thousands of cells replicated in a petri dish.

Gene therapy

Another method to restore lost hair that is likely to emerge in the near future is gene therapy. Gene therapy promises the potential to grow new hair follicles, as opposed to just stimulating dormant follicles to grow hair again. several researchers around the world have begun work on gene therapy to restore hair in lab mice and have displayed some degree of success.


Introduction: Auto-transplantation of hair normally provides satisfactory correction of baldness. Auto-transplantation refers to a normal hair transplant where the redistribution of hair follicles occurs within in the same individual, from one area of the body to another. Allo-transplantation of hair is the transplantation of hair from one individual to another individual. this has never been attempted because hair is considered

The idea behind gene therapy is to correct an inherited condition that prevents hair growth by introducing a DNA sequence (a genetic chemical) into the balding scalp. The introduced DNA sequence itself does not correct the problem causing baldness, but it creates a sequence of chemical transactions that enter into the patient’s cells. This makes the cells start producing the proteins necessary to give the skin the ability to produce new hair follicle cells. Several researchers have been looking at gene therapy for some time now. One of the leaders in this field is Dr. Elaine Fuchs at the University of Chicago. She has been able to successfully convert normal skin cells into hair follicle cells using gene therapy on mice. These mice have displayed impressive new hair growth in balding areas. But the existence of side effects that include the growth of tumor cells may endanger the future of gene therapy as a treatment method of hair loss. Dr. Fuchs, however, is confident that these side effects can be eliminated with further development of gene therapy methods.

Donor hair research

This research is the first of its kind. I initially presented it at the International Society of Hair Restoration Surgery (ISHRS) meeting in puerto Vallarta, Mexico in 2001. This article was then published in 2002 in Hair Forum by the ISHRS. study: hair transplant in incompatible hosts


strongly antigenic, meaning that if it were transferred from one person to another, the recipient’s body would be likely to reject the new hair. However, in 1999 it was reported for the first time by Jahoda et al. that human hair follicles could be induced to grow in an incompatible host of the opposite sex. With these recent advances in follicle cell transplants in incompatible hosts it was considered necessary to evaluate an allogenic hair transplant. A study was conducted where the goal was to determine whether an allotransplant can be successful or not. If unsuccessful, then the goal would be to determine why it had failed and how to overcome the obstacles.

Objective: An allo-transplant in two unrelated individuals was performed. the growth of the hair in the incompatible hosts was observed over a period of 14 months.

Materials and/or methods: To test this hypothesis, two different male donors were selected: AA and FA. Hair follicles from AA were taken and successfully transplanted in FA. In another similar operation, hair follicles from FA were taken and transplanted in AA. Each of the subjects was provided with preoperative medications and an area of scalp measuring 6cm by 1cm was shaved and anesthetized. then the skin with the hair follicles was removed and cut into smaller hair grafts. In the first operation 586 grafts from AA were transplanted in FA and in the second operation 594 grafts from FA were transplanted in AA. The transplants were performed on the temples of both subjects, giving us a clear observation of hair growth. Also, the identification of hair growth was facilitated because AA’s hair was black and FA’s hair was brown. postoperative hair growth was measured at 9


Two maledonors AA& FA

Donor Recipient

586micrograftsobtainedfrom AA andtransplantedon FA

594micrograftsobtainedfrom FA andtransplantedon AA

Allo-transplant: Method for transplant between incompatible

Transplanting was done on the temple areas for better visibility. Also, AA has black hair and FA has light brown hair, and that color difference would facilitate identifications of hair growth.


Pre surgery


Immediately after surgery


4 months post surgery


months and at 14 months, and pictures were taken at different intervals to monitor growth at various stages.

Results: Postoperative hair growth was measured at 9 months and at 14 months. At 9 months, 45 of the 586

grafts on FA were considered surviving grafts. The number of surviving grafts was not determined on AA. At 14 months there were no surviving grafts on FA.

Conclusion: This study shows that allo-hair transplants do not work in the traditional format. However, there is reason to believe that the hair itself is not antigenic but the tissue surrounding the hair follicle is the reason why the hair was unable to survive. It will be necessary to introduce modifications to the method of transplantation to change the structure of the surrounding skin so it does

Subject

Number ofgrafts

countedat 9

months

Numberof graftscounted

at 14months

45 0

N/A N/A

192

chapter three:alternative treatments

In the last few years great interest has been expressed in various alternative medicines and how they can help treat genetic hair loss. Some very specific remedies for hair loss have been developed and this chapter will review the ones currently available and the advantages and disadvantages of these treatments.

The emergence of alTernaTIve medIcInes

many doctors frown upon alternative medicines and suggest that re-growing hair with alternative treatments is not possible. But the fact is that millions of people in the western world have been turning to alternative medicines in the last few decades to deal with problems that doctors and conventional medicine cannot help them with. a study published in the new england Journal of medicine reports that about one third of americans surveyed preferred alternative medicines over conventional ones to deal with their health needs. looking for a solution to hair loss in alternative medicine is not necessarily the recommended choice but it is an option that should not be denied to those who prefer it. There are many who swear by the effectiveness of alternative treatments to treat every health problem, including hair loss, and you may have come across some individuals who claim that it has worked for them.

ALTERNATIVE TREATMENTS FOR HAIR LOSS

This section on alternative treatments for hair loss is being included here to allow you to have a full understanding of all the options you have for fighting hair loss, but no strong claims will be made for any of these alternative treatments. You must use your own good sense when sifting through these options.

how do alternative medicines work?

The term alternative medicine refers to various medical systems practiced by trained professionals all over the world that have roots in the traditional medicines of the ancient world. some of these medicines are continuations of ancient medical traditions like acupuncture and traditional chinese and Indian herbal medicines. others are newer medical systems developed from the principles of ancient systems of medicine like homeopathy, cell therapy and magnetic field therapy. all alternative medicines are based on a more holistic understanding of the human being than understood by conventional modern medicine. conventional medicine thinks of the human being as primarily a physical body, while holistic medicine sees the human being as a trio of mind, body and spirit. conventional medicine looks for causes to ailments on the physical level only. holistic medicine, however, looks deeper into all levels of the human being for causes and this, according to its proponents, is its greatest strength. all alternative medicines try to consider the whole human being using a number of methods to cure inner distortions that cause physical ailments.

how do alternative medicines treat hair loss?

alternative medicines look for the inner psychological and spiritual causes of hair loss. While hair loss and its causes are different for each individual, similar patterns may exist. The treatments that the various alternative medicines offer

194 ALTERNATIVE TREATMENTS FOR HAIR

for hair loss try to correct the inner imbalances that are understood to be the underlying causes of hair loss. modern medical research has acknowledged an astonishing phenomenon that suggests how alternative medicine’s approach may work. This phenomenon is referred to as the ‘placebo effect’. a placebo is a dummy drug that has no actual medical effect but works because the patient believes that it is helping them. The improvement in health that results is called the placebo effect. studies consistently show that between 30 per cent and 40 per cent of people will show improvement with all sorts of health problems as long as they believe they are taking a medication that will help. There has even been evidence of hair growth due to the placebo effect in patients with hair loss. The placebo effect suggests that it is possible to correct health problems by mobilizing the emotional, psychological and spiritual forces within each of us, and this is precisely what alternative medicines try to do by using various outside keys to trigger inward changes.

common alTernaTIve TreaTmenTs for haIr loss

saw palmetto

saw palmetto is an herbal product that has shown some evidence in being able to slow hair loss. It is made from the extract of berries from a palm tree native to the south atlantic coast and is also often used to treat an enlarged prostate. It works by inhibiting the activity of an enzyme linked to the chemical processes responsible for genetic hair loss, similar to the way finasteride, or Propecia, works.

vitamin e

vitamin e is an important vitamin known for its anti-aging effect, which is due to its ability to act as an antioxidant. It prevents oxidation of free radicals in the body, thus protecting tissues against oxidation and generally helping


the upkeep of the skin and hair. The recommended daily dosage of vitamin e is 10 mg per day for an adult. But for the purposes of treating hair loss, 400 mg to 800 mg should ideally be consumed on a daily basis though you should consult a doctor to determine what the best amount is for you. common sources of vitamin e include: Wheat germ, almonds, hazel nuts, sunflower seeds and oils. Possible reactions to excessive amounts of vitamin e include: nausea, vomiting, dizziness, diarrhea, itchiness and fatigue.

vitamin c

vitamin c is also an excellent vitamin for good skin and hair. like vitamin e, it is an antioxidant and treats hair loss in a similar fashion. It is not likely to stimulate new growth, but it may help maintain existing hair. a dosage of 500 mg to 1000 mg taken orally on a daily basis is ideal to maintain hair. It should be stressed that adequate hydration is necessary to accompany the intake of vitamin c to avoid the development of kidney stones. common sources of vitamin c include: Broccoli, cantaloupes, cauliflower, citrus fruits, kale, mangoes, peppers, potatoes, spinach, strawberries and tomatoes. Possible reactions to excessive amounts of vitamin C include: diarrhea, abdominal cramps, sleep disturbance, nausea and vomiting.

multivitamins

It is argued that everyone should take a multivitamin every day because we may become deficient in many nutrients, regardless of our diet. as noted earlier in this book, hair loss may result from poor overall nutrition or particular dietary deficiencies. This is where a multivitamin can be a valuable asset in fighting hair loss. But before you choose a multivitamin, you should consider a few things first: 1) your activity level, 2) your stress level and 3) any medical conditions. not every multivitamin is perfect for everyone. for


example, if you are active or have a stressful life, you will likely need a higher dose multivitamin. If you have some contra-indication to high dose multivitamins, you should take a lighter one. This can be discussed with your healthcare and dietary guide. a general rule is to try a time-release multivitamin that slowly releases the vitamin ingredients over time. This will improve the absorption of all the vitamins.

oTher alTernaTIve TreaTmenTs

various other alternative medicines offer general suggestions to promote hair growth. You can act on many of these by yourself, but it is recommended that they only be tried in consultation with a trained professional. experience suggests that those who have a strong belief in alternative medicines tend to benefit from them, whereas those who are skeptical do not. The faith you put into these alternative self-help practices seems to play a key role in their effectiveness. otherwise, this book makes no claim for them other than that they have worked from some people in some circumstances.

acupuncture

acupuncture is an ancient chinese system of medicine that treats many ailments by attempting to restore the inner imbalances that cause them. Acupuncture identifies an elaborate system of points on the body called accupoints that are connected to inner forces, which are manipulated with needles and other devices to restore balance and cure various ailments. a trained acupuncturist will know which accupoints to manipulate to stimulate hair growth. There have been individuals who have claimed success in growing hair after acupuncture treatment, but there are also others who have felt that it was no benefit to them and a waste of money. for information about acupuncture and how to find an accredited acupuncturist in your area contact the American Association of Oriental Medicine (www.aaom.org) or the american academy of medical acupuncture (www.


medicalaccupuncture.org).

aromatherapy

aromatherapy is a branch of herbal medicine that uses the essential oils of various plants to produce medically beneficial effects on the body. Herbal remedies may increase circulation, disinfect the scalp and result in stimulated hair growth. aromatherapists recommend four essential oils to deal with hair loss: lavender, rosemary, thyme, bay, cedarwood, grapefruit, jojoba oil, lemon, roman chamomile and sage. The rubbing of these essential oils on the balding parts of the head is prescribed as a possible way to fight hair loss. as a precaution, rosemary oil should not be used by those with high blood pressure and lemon and grapefruit oils are likely to irritate sensitive skin. For more information on aromatherapy and how to find essential oils and an aromatherapist in your area, you can contact the national association for holistic aromatherapy (www.eskimo.com/~hhnews/naha).

ayurvedic medicine

ayurvedic medicine is an ancient Indian herbal medicine that has been around for almost 5000 years. Two ayurvedic herbs are generally prescribed to stimulate hair growth: ashwagandha and amla. These herbs are usually taken in pill form or as rubbing oils for the scalp. for more information about ayurvedic medicine and products dealing with hair loss and other health problems, you can contact the national Institute of ayurvedic medicine (NIAM) (www.niam.com).


homeopathy

homeopathic medicine is an alternative medical system developed in germany that is now practiced all over the world. It cures ailments by prescribing dilutions of natural substances that trigger the body’s own natural healing processes. The homeopathic medicines sepia, arnica and acidum nit are often prescribed to stimulate hair growth. They come in liquid form and are generally taken with water. for more information about homeopathic medicine and for referrals to professionals in your area, contact the National Center for Homeopathy (www.healthy.net).

naturopathic medicine

naturopathic medicine is a comprehensive medical system that combines many of the traditional nature-based medical systems of the world. It focuses on the entire human being to identify the source of physical ailments and then tries to utilize the body’s own ability to heal by focusing on various natural treatments. since naturopathic medicine combines so many different approaches it has several different remedies for hair loss. some of the easier ones to try include:

Diet: various fresh raw juices are sometimes given to stimulate hair growth, including one combination of carrots, beets, spinach, nettle and alfalfa juices mixed with onion juice.

Herbal rubs: one herbal rub that is sometimes prescribed for hair loss involves massaging the scalp with a combination of one part rosemary oil and two parts almond oil on a nightly basis.

for more information on these and other naturopathic remedies for hair loss, contact the american association of


Naturopathic Physicians (www.naturopathic.org).

advantages disadvantages

• seems to work for some people who have faith in alternative medicines• offers many different choices• You can try some remedies at home• costs less than conventional treatments• generally involve few risks and complications

• most alternative treatments have not undergone scientific studies to determine effectiveness over a simple placebo effect• does not seem to work for those who do not have faith in alternative medicines• Its low cost becomes irrelevant if it does not work• It can be dangerous if it is unwisely relied upon


advanTages and dIsadvanTages of alTernaTIve

TreaTmenT

This section on alternative medicines has been included in the interest of providing you with all the possible options for fighting hair loss. The following summarizes the advantages and disadvantages that you should take into account when considering alternative treatments for your hair loss.

Final recommendations

You should try alternative medical treatments:

• If you don’t like conventional methods of treatment• If you cannot afford other forms of treatment• If you have faith in them• Only in consultation with a professional trained in the particular form of alternative treatment

200

chapter four:hair replacement treat-

ment

Hair replacement is the last major approach to dealing with hair loss. The basic idea of hair replacement is to replace your natural hair with various types of additives that make your hair look natural and complete. For most balding people it is a last resort, but because of improving techniques it has become increasingly attractive even for those who have other options. Over 500, 000 hair addition pieces are sold every year in the United States alone. There are two basic ways to replace your hair. The first is to camouflage your hair loss by filling out or intensifying your existing hair with various products and the second is to cover your hair or add to it with some form of hair piece.

CamOUFlaging yOUr Hair lOSS

There are a number of products available to you for camouflaging your hair loss. All of them assume that you have some hair remaining and that you only want to make this existing hair look more full and complete. if you only have some thinning areas of baldness then camouflaging is a realistic and affordable option. many people have relied on these simple methods and have been quite satisfied.

HAIR REPLACEMENT TREATMENT 201

There are two ways of camouflaging your hair loss. you can thicken your existing hair or you can apply substitute hair in thinning areas.

Thickening your thinning hair

This is a common approach to thickening thin hair where the goal is to create the illusion of thick hair by raising the hair away from the scalp. The way hair thickening is usually done is through rubbing various types of hair thickening leave-in conditioners into the hair after shampooing and towel-drying. These conditioners apply a thin layer of some polymer over the hair shaft. a polymer is a chemical combination that sticks to the hair shaft leaving a plastic-like layer around it. The polymer creates a smooth surface over the hair shaft, making it thicker and simultaneously easier to manage. Common thickening conditioners include those from oil-based Pomade creams as liquid rub-ins containing glycerin-based products or as oil sheen sprays. Other hair thickening products include hair sprays, thickening gels and thickening mousses.

Camouflaging using canned hair

The second way to camouflage hair loss is to apply colored substances that look like your natural hair to the thinning portion of your scalp. There are many products that accomplish this and they are often referred to as ‘canned hair’ because they come in cans and are sprayed on the scalp to fill in the gaps. A dermatologist can recommend a product of this type that is most suitable for you.

Hair PieCeS

Hair pieces are any external hair-bearing devices that are added to the scalp or to existing hair to give the

202 HAIR REPLACEMENT TREAT-

appearance of fuller looking hair. These include numerous apparatuses and products available all over the world, including the following:• Wigs: Hair-bearing devices formed on a base material and designed to cover your entire scalp. if you have no hair of your own, this is your only option.• Demi-wigs: Similar to wigs except that they do not cover the frontal hairline.• Toupees: Hair-bearing devices formed on a base material and designed to meld with your existing hair.• Extensions: Hair-bearing devices that attach on to your existing hair to make it appear longer and fuller.• Hair units: Hair-like clumps that fit into your existing hair to make it appear fuller.• Hair weaves: Synthetic or natural hair that is weaved, braided or knotted into your existing hair to make it look fuller.

almost all of these devices are available ready-made and are relatively inexpensive. However, for anyone serious about replacing lost hair with a hair addition only a custom-made device can appear natural and be maintained in a safe and comfortable manner. Despite various shapes and sizes, all of these hair addition devices share several basic characteristics. To make a custom-made version of any of these devices, you have to answer three basic questions to know what type is best for you.

1. Do you prefer a natural or synthetic hair device?2. if the device has a base material, what type of base do you prefer?3. How do you want the device attached to your head?

To answer these questions, you have to do a lot of research and decide on your own preferences. a good specialist will detail each option for you and help you make a decision that is right for you. you can begin your research here with a few brief outlines to help you answer the previous questions.


natural or synthetic hair?

every hair addition piece employs either your own natural hair (if you have enough), purchased human hair, synthetic hair or some combination of these. although it would seem obvious that natural hair is always better, all things considered it is not so clear that this is the best choice. Because natural hair has to be purchased from willing human sources it is relatively expensive and what is available may not meet your needs. Due to availability, workability and cost, most hair additions use indian hair but if you have a european background then such hair must be treated and colored to fit your needs. This coloring fades somewhat every few months and needs to be constantly re-colored. However, human hair does tend to mix in better for those who still have existing hair. it is also preferable to those with an active lifestyle. aside from a slight disadvantage in appearance, synthetic hair has many advantages over natural hair. most synthetic hair fibers are made of plastics from molds and are consequently readily available. They are also relatively inexpensive compared to human hair and easier to maintain because they dry faster and their colors do not fade as easily. For most people in the western world, synthetic hair is the more logical choice unless you have a stigma about wearing fake hair or you are allergic to synthetic materials.

What type of base?

if your hair addition requires a base, as in the case of a wig or a hair piece, then the first question to answer is what type of base should be used. There are two types of bases that are common today: mesh-like bases and solid bases. generally speaking, mesh-like bases are better ventilated and are more comfortable, while solid bases allow for vacuum fitting and fit directly on the scalp. They each also have drawbacks that result from the method of attachment


to the scalp. The decision between the two types of bases should consider the strengths and disadvantages of each type in consultation with your specialist.

What method of attachment to the head?

There are few things more embarrassing than a hair piece coming off and revealing a balding head. Various methods have been devised to firmly attach hair replacements to the head to guard against this possibility but there is currently no ideal mechanism of attachment. all the existing methods of attachment have notable drawbacks that need to be considered. at present there are only two possible ways to attach hair pieces to the head: Directly on the skin of the scalp or to some existing hair on the scalp. attaching a hair piece to the scalp is considerably more difficult and fraught with complications than attaching it to existing hair. For this reason, if a person has enough existing hair left, attachment to this hair is usually preferred over trying to attach it to the scalp. That being said, a single person may benefit from a combination of these attachment mechanisms. Depending on your specific needs you might find it beneficial to alternate attachment mechanisms over time.

Attaching to existing hair: When a person has some existing hair then it is almost always preferable to attach a hair piece to this hair in some manner. a hair piece can be attached to the existing hair either in a temporary manner using clips or in a semi-permanent manner using one of three common methods: Bonding, sewing or weaving/braiding. These methods offer the advantage of allowing hair pieces to function like normal hair for a relatively long period of time. They are also the most comfortable and the most natural looking attachment methods. But since they are attached to permanent hair they are subject to the changes that normal hair growth causes. as a result, these attachments typically last for two to six weeks before they need professional readjustment.


• Bonding: The most popular semi-permanent method of attaching a hair piece to existing hair is bonding. in this method the hair piece is attached by using a special glue gun to attach a ¼ inch vinyl strip at each edge of the hair piece to matching bonds of cut hair, not the scalp. as the existing hair grows the hair piece loosens and needs re-bonding. The chief advantage of bonding is its relative simplicity and the cost benefit compared to other methods of semi-permanent attachment.

• Sewing: Sewing is less common than bonding, though it shares many of its characteristics. Tiny loops are sewn into the fringe of the hair piece. Several existing natural hairs are pulled through the loops of the hair piece and are fused together by knotting or using glue. as the existing hair continues to grow, the hair piece loosens and needs to be re-fused. The chief advantage of sewing is that it does not necessarily require the use of an adhesive.

• Weaving or braiding: These have long been used as methods of thickening thinning hair. For this purpose, small sections of the hair piece are formed into clumps and attached to the existing hair by carefully weaving natural hairs into the hair piece using fine, durable strings. In recent years, the idea of weaving has been introduced as a way of attaching larger hair pieces to a mostly balding head. The chief advantage of weaving is that it allows for easier cleaning of the scalp as opposed to other methods of semi- permanent attachment.

The disadvantage of attaching a hair piece to existing hair that is shared by all such mechanisms is that this kind of attachment puts unnatural amounts of tension on the existing hair. if this is not carefully considered while creating the attachment mechanism the result can be that the hair piece will lead to further hair loss. it is very important for a hair piece that attaches to existing hair to be properly designed to avoid this problem.


Attaching to the scalp: If you lack a sufficient amount of hair, or your hair is not strong enough, then you have no choice but to attach a hair piece to your scalp in some manner. Currently, there are three recognized methods of attaching a hair piece to your scalp: By using an adhesive, with vacuum suctioning, or by using a surgically-made loop in the skin. each of these methods is reasonably safe and maintains certain advantages and disadvantages that you should thoroughly discuss with your specialist.

• Adhesive: adhesives that can be used to attach a hair piece to your scalp fall into two categories: glues that make a direct attachment to the scalp or double-sided tapes that attach the hair piece to the scalp. every time the hair piece is attached to the scalp a thorough cleaning of the adhesive substance must be done to maintain proper hygiene. The chief advantage of adhesive attachment is that is allows for quick and frequent removal of the hair piece at minimal cost.

• Vacuum fitting: If a hair piece is precisely fit it can be attached to the head by suction. The hair piece will naturally pull into the scalp as a vacuum is created under your scalp. The chief advantage of a vacuum attachment is that it is the most comfortable and easiest to remove and re-attach.

• Using a surgically-made loop in the skin: in this method, a number of loops of flesh are created in the scalp skin and clips are anchored into these loops that firmly hold down a hair piece. The surgical operation needed to create the loops requires a bridge of skin to be cut and raised from the scalp. The result looks like a fleshy tunnel-like outgrowth of skin. The surgically created loops have to be frequently cleansed to prevent infection. The chief advantage of this method of attachment is that it provides the surest grip of all methods of semi-permanent attachment to the scalp.

What are the costs of a hair piece?

The cost of an effective hair piece is not cheap. if


you expected that hair replacement would be a cheaper investment than surgical or drug treatment than you were mistaken. it is not uncommon for hair replacement to cost thousands of dollars annually. There are also hidden costs that most people don’t immediately detect and are usually not told about. Depending on the chosen hair replacement piece a proper evaluation of the total cost may need to take into account four different components:

1. The cost of the hair piece itself2. The cost of the servicing and maintenance3, The cost of the attachment method4. The cost of the maintaining the attachment method

The cost of the hair piece: Because of the enormous variety of hair replacement pieces and the various options available with each, it is difficult to indicate precise prices for every hair piece. generally speaking, a hair piece can cost anywhere from $100 USD to $5000 USD. The cost of the hair piece will conform to the following rules:• Custom-made usually costs more than ready-made• Human hair costs more than synthetic hair• Because of the need for more detail, the less hair on the hair piece the more costly it will be• A hair piece’s price will rise with the more human labor needed to produce and service it• Big advertiser’s charge more money

The cost of servicing and maintaining the hair piece: On average, any hair piece will last no more than 18 months before it will need to be replaced. you can expect to pay the full cost of making a hair piece almost every year. also, good maintenance generally requires frequent servicing of the hair piece before it is replaced. The cost of normal servicing may vary enormously depending on the type of the hair piece. as a general rule the servicing costs are higher the more the initial cost of the hair piece. One hidden cost that many tend to overlook is the cost of replacing a hair piece while it is being serviced. if you are very conscious of


maintaining your appearance then just any replacement for your hair piece will not be enough. if this is the case, then you will need to buy a second hair piece to back up your original.

The cost of the attachment method: This cost is only high for a few methods of attachment. Whenever a hair piece requires surgical manipulation, you can expect its cost to run into the thousands of dollars. and whenever a hair piece requires the attention of a professional, you can expect its cost to run normally into the hundreds of dollars.

The cost of maintaining and servicing the attachment method: There is always some cost in maintaining and servicing the attachment method. in some cases, like semi-permanent methods of attachment, these costs are upfront. These methods require the attention of a professional every few months and can cost up to $1000 USD annually. in most cases, the cost of maintaining and servicing the attachment method is a hidden cost that many people don’t immediately consider. in some cases this may be minor, as in the case of routine purchasing of adhesives and cleaning fluids. However, in cases where complications affect not only your hair piece but also your health the costs of servicing an attachment method can be very high.

CHOOSing a gOOD Hair rePlaCemenT SPeCialiST

Hair replacement is big business in the western world. Billions of dollars are spent on it annually and there are many practitioners and specialists out there looking for your business. like surgical treatment, there are many practitioners to choose from and many difficult choices to make. The advice of a good hair restoration specialist is almost indispensable. But you have to be careful about which hair replacement specialist you choose. There are many whose knowledge of hair replacement extends only to the product they are trying to sell you. Finding a good hair replacement specialist takes work


ToP ANd boTToM sIdEs of A fuLL wIg.THE boTToM PICTuRE dIsPLAys A sTRIP RuNNINg ARouNd

THE


and patience. The following rules will help you find someone that will help you sort through your options and guide you in choosing the right hair replacement solution. These rules require more work in finding a hair replacement specialist and a hair replacement plan but they are essential if you want to protect yourself.

Don’t rely on advertisements in papers or magazines

Big advertisers are usually just selling one product. The biggest advertisers are also usually the most expensive practitioners and not necessarily the best. The best advertisement is always word of mouth from a pleased client.

get a list of specialists from a neutral source

Don’t just look for a list of hair replacement specialists from your local phone directory. You can find out about the different specialists in your area through other means: By asking someone who has already used one; by checking with your dermatologist; or by contacting the american Hair loss Council (www.ahlc.org).

Talk to more than one hair replacement specialist

you should consult many practitioners before you consider committing yourself to anyone. look at all the different services they offer and compare the prices. Distinguish between the ones who want to work with you to find a solution from those who want to sell you what they have. make certain you select someone who will spend time with you to explain things without making you feel that you owe him or her something for taking this time. Before settling on any one practitioner to work with ask to see real people he or she has treated. Pictures can be deceptive. ask for phone numbers and addresses of several


clients of the specialist and, if possible, to meet and talk with them.

Don’t be tempted by low prices

low prices often mean hidden costs or poor craftsmanship. Use the section on cost above to figure out the real cost of a hair replacement piece.

get second judgments on any hair replacement plan

it never hurts to get a second opinion on any hair replacement plan you are considering.

aDvanTageS anD DiSaDvanTageS OF Hair rePlaCe-menT

Final reCOmmenDaTiOnS

you should try hair replacement if:

• If you have no other options because your baldness is too far gone or progressing too quickly• If you can live with fake hair• If you can afford to maintain the cost of quality hair replacement, which is more expensive long-term than surgical treatment• If you would like to use it as a means of supporting other treatment methods


advantages Disadvantages

• results can be seen relatively quickly• Quality hair replacement can restore a natural look to almost anyone• Costs are well known• relatively pain-free• risks and complications are minimal and rare• non-commital• Can be a useful bridge until you decide on a more permanent solution or until more effective surgical and drug methods are developed

• it isn’t your own, natural hair• Quality hair replacement requires considerable maintenance• Quality hair replacement is expensive• it takes a patient and thoughtful process to find a good hair replace ment specialist


Comparing wigs with surgiCal treatment for hair loss

Wigs Surgical treatment

• it is not permanent• it is more expensive on a long-term basis• Provides less confident results• maintenance is time- consuming and costly• restricting in sporting and social contexts• There is always the fear of exposure

• your own permanent hair is transplanted• expense is much less on a long-term basis• Provides confident results• no long-term maintenance • no restriction in sports or social events, including swimming• There is no chance of exposure

277

a final recommendationTo fight hair loss is understandable, but we must learn how

to maintain a sense of balance in this pursuit. I have seen too many men and women who have allowed their hair loss to undermine their sense of self worth. Some of these men and women have developed a mania bordering on paranoia in response to their hair loss. These men and women act rashly out of desperation to fight their hair loss. Unfortunately, they may suffer great pain and loss when their rash actions result in their hopes being dashed in some way or another.

What everyone who is fighting hair loss needs is knowl-edge of what is happening to them and knowledge of the most-up-to-date and safe procedures that can help them in this fight. It is for this reason that I have written this book. Having studied the book now, you should be aware by now that there is no full proof and simple way to defeat hair loss. There are many choices to make; every choice has its costs and benefits. At least now you are well prepared to thoughtfully proceed in fighting your hair loss. The informa-tion I have given you, when used in consultation with trained professionals, is sufficient for you to fight this battle and win to some degree.

I say “to some degree” because as a medical doctor I have learned to accept certain realities. If you are a victim of hereditary hair loss you are fighting a battle against time. For most people hair loss is an irreversible part of the aging process. Despite fantastic claims to the contrary, the truth is that aging is irreversible and we are all going to experience its hardships in one way or another, including for many with hair loss. The real issue is not whether our bodies will experi-ence the ravages of aging, but how we deal with it.

In the end remember this, you are more than your hair. As long as you can realize that your hair is not everything then you can learn to deal with its loss, and thoughtfully find a way to restore its appearance with as little cost and pain as possible.

I wish all men and women the best in the future.

279

appendixIn this appendix I provide sample drafts of three

important documents that are commonly provided by hair transplantation centres. The samples are actual documents I use in my own practice. The drafts provided include:

Appendix A: Sample Consent FormAppendix B: Sample Pre-operation InstructionsAppendix C: Sample Post-operation instructions

280 appendixAppendix A : sAmple consent form for surgicAl hAir trAnsplAntAtion

DR. ANTONIO A. ARMANI 233 Carlton St. Toronto, Ontario, Can. M5A 2L2. Tel: (416) 363-6655 / 1-800-365-6220 Fax: (416) 363-1589

CONSENT FORM FOR SURGICAL HAIR TRANSPLANTATION

As a patient you have the right to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and the hazards involved.

1) I _______________ do hereby consent and agree to have hair replacement surgery performed upon me, and any other medical services, which during the procedure become medically reasonable and necessary.

2) I am aware that good results will depend, in part upon my completing the necessary number of operations, which has been estimated to me to be ___ session(s). However, because many variables exist, I have not been promised or guaranteed good results. I also understand the quality and amount of my preexisting hair is a major factor in the ultimate results. I understand I will not have hair the same thickness as I had prior to the onset of my hair loss.

3) Prior to consenting to hair replacement surgery, I state that I have read and discussed with my physician the following literature, which has been supplied to me:

1. Brochure 2. List of Complications 3. Preoperative Instructions 4. Fee Schedule of Current Charges Per Session

PAGE 1 OF 6 INITIAL:

appendix 281 Appendix A : sAmple consent form for surgicAl hAir trAnsplAntAtion

4) I fully understand the results that I may reasonably expect. An explanation of this procedure has been given to me. I do understand that I will not have a full head of hair after the procedure is complete. I understand that visibility of the sites following a hair transplant procedure can last several days.

5) A transplant may not look natural on those with dark hair and light skin.

6) Dr. Antonio A. Armani has suggested ________ session(s) of grafts as a minimum. I understand that more operations may be recommended at a later date. I understand that all rec-ommendations made during my consultation and treatment are estimates and may change at a later date. __________ (Initial)

7) I understand there will be scarring associated with this proce-dure. I understand that hair transplants are not perfect.

8) I am aware that complications may occur. The more com-mon complications and a partial list of rare complications of this surgery have been explained to me and I have reviewed a list of them, which I signed and dated. A copy of that list is attached to this request. Unforeseen, rare complications, such as unanticipated reaction to medication and anesthet-ics, uncommon infections, and unusual healing responses (wide scars) are a possibility. Every unforeseen complication may not have been discussed with me in detail, but I under-stand that such risks do exist.


282 appendix

Appendix A : sAmple consent form for surgicAl hAir trAnsplAntAtion

9) I consent to and authorize the administration of such local an-esthetics and nitrous oxide as may be considered necessary by those performing the surgery on me.

10) I consent to and authorize the performance of cosmetic sur-gery by Dr. Antonio A. Armani, M. D., associate doctors, and hair assistant technicians.

11) I believe I have been well informed. I understand that al-though good results are hoped for and expected, cosmetic surgery results can not be guaranteed because of the nature of the human body and the healing process. There are also risks of reasonable error in judgment and implementation, which is possible in any surgical procedure.

12) The pros / cons and alternatives to transplants have been explained. I have the option of doing nothing at all, wearing a hairpiece or wig, using prescription medication, or receiving a transplant. A combination of the above is also possible I am informed of all options.

13) It has been explained to me that the amount and location of future hair loss on the scalp, including the side or back area can not at this point in time be predicted. I do understand it is possible to lose my existing hair at any point in time in the future. I do understand this may effect the appearance of the grafted area. Hair transplants may not be permanent. They are usually very long lasting but, rarely, have been noted to fall out after one to ten years. In the majority of men some thinning of all areas occur. Most men do not lose all of their donor (back of the head) area with age. A very small per-centage of men (less than 10%) do lose a majority of their donor hair and this could affect the final result.

14) This consent was read and signed while I was not under the influence of medications that cause drowsiness.



appendix 283

15) I certify that this form has been fully explained to me that I have read it, or have had it read to me, that the blank spaces have been filled in, and that I understand all of it’s contents.

16) Some postoperative discomfort may be experienced. (Initial)

17) Dr. Antonio A. Armani and Cosmetic Surgery Spa does offer procedures that will obtain the best results for the patient, ir-respective of any profit motive.

18) I have had opportunities to ask questions on this subject.

19) I acknowledge that no guarantee has been made as to the results that may be obtained.

20) I acknowledge that I am responsible for payment of these services with no possibility of fee reimbursement regardless of graft growth.



284 appendix

IN THE PATIENT’S OWN HAND WRITING

(Initial)

I have read and understood this consent form and fully agree to all its points.

_____________________ ____________________PATIENT’S NAME (PRINT) PATIENT’S SIGNATURE

_____________________DATE: PATIENT’S INITIALS:

___________________________________________________ADDRESS / CITY / PROV. / STATE / POSTAL / ZIP CODE

_____________ _____________ ___________HOME PHONE WORK PHONE CELLPHONE

______________ ____________________WITNESS NAME WITNESS SIGNATURE



appendix 285 MORE COMMON COMPLICATIONS

1) Nausea and vomiting from pain medication2) Bleeding (less than 1%)3) Infection (less than 1 %)4) Excessive Swelling (20-30%)5) Temporary headache6) Temporary numbness of the scalp7) Scarring around the grafts8) Poor growth of grafts9) Reactions to medications (less than 1 %)10) Fainting (less than 1 %)11) Occasional small ingrown hair-causing a cyst (less than 1%)12) Scarring of the donor area, wide scars are possible (less than

1%) INITIAL:

RARE COMPLICATIONS (Partial list only)

1) Keloid formation2) Complete failure of growth of transplanted hair3) Persistent scalp pain4) Total loss of donor hair5) Permanent numbness of scalp6) Noticeable scarring of donor area7) Loss of transplanted hair8) Allergic reaction or medication-related problems

INITIAL:

I have read and understand all of the possible complications listed above.

DATE:__________ TIME:______ A.M / P.M.

________________ _______________ ________ PATIENT’S NAME SIGNATURE INITIAL

WITNESS NAME WITNESS SIGNATURE

PAGE 6 of 6 INITIAL:*Consent-taken and modified from consent used by

Dr. Dowling B. Stough Jr.

286 appendixAppendix B: sAmple preoperAtive instructions for surgicAl hAir trAnsplAntAtion surgery

DR. ANTONIO A. ARMANI233 Carlton St. Toronto, Ontario, Can. M5A 2L2. Tel: (416) 363-6655 / 1-800-365-6220 Fax: (416) 363-1589

PREOPERATIvE INSTRUCTIONS FOR HAIR TRANSPLANTATION SURGERY

FOR: PATIENT’S NAME Date / Time of Surgery:

IMPORTANT: YOU MUST STRICTLY FOLLOW THESE INSTRUCTIONS TO AvOID COMPLICATIONS (i.e. excess, bleeding and/or longer healing process) AND ENSURE THE BEST POSSIBLE RESULTS.

Two (2) WEEKS PRIOR TO SURGERY:

1. ELIMINATE Intake of Vitamin E capsules or vitamin pills con-taining Vitamin E.

2. Notify our office regarding any medications you are currently taking or might be allergic to at the time of surgery. They may have to be discontinued or substituted with an alternative drug.

3. Stop use of Minoxidil (Rogaine) or M.A.O. inhibitor drugs (some antidepressants)

4. DO NOT take any ASPIRIN (ASA) or any drugs containing As-pirin - see enclosed sheet - (e.g. some cold remedies). Note: You may use Tylenol

5. DO NOT drink any alcohol (wine, beer, liquors)

6. DO NOT use any non-approved drugs. Eg: marijuana, hashish or others.

7. Do not get a hair cut 2 weeks prior to surgery.

appendix 287 Appendix B: sAmple preoperAtive instructions for surgicAl hAir trAnsplAntAtion surgery

ON DAY OF SURGERY: 1. A gown will be provided during the surgery. For your own comfort you may wish to wear sweatpants for longer surgeries.

2. Wash your hair well in the morning prior to surgery.

3. Make arrangements to take a taxi home or have someone pick you up on the day of the surgery. You will not be able to drive home. Also, you can arrange to stay in a hotel near the clinic. Ask our staff.

288 appendixAppendix B: sAmple preoperAtive instructions for surgicAl hAir trAnsplAntAtion surgery


MEDICATION PRECAUTIONS FOR SKIN SURGERY PATIENTS

The following is a list of the more common medications and substances that can increase your tendency to bleed:

Phone numbers: Office:(416) 363-6655 / 1-800-365-6220Dr. Antonio A. Armani’s cell phone: (416) 543-2716

Home: (416) 944-3805

DolobidDristanEaspirinEcotrinEmpirinEmprazilExcedrinFeldeneFiorinal4-way Cold tabsIbuprofenIndocineIndomethacinMeclomenMediprenMidolMotrinNalfonNaprosynNorgesicNuprinPercodanPhenaphen

AdvilAlcoholalka SeltzerAnacinAnaproxAnaproxinAPC5 ASAAscodeenAscriptinAspirinBufferinBrufenCephalgesiCheracol CapsuleChildren’s AspirinClinorilCongesprinCopeCoridicinCoumadinDarvonDarvon with ASA

QuagesicRobasisalRufinSine OffSine AidTrandateTrentalTrigesicTrilisateVanquishVitamin EVoltarenZectrinZorprin

appendix 289 Appendix c: sAmple postoperAtive instructions for surgicAl hAir trAnsplAntAtion surgery


POSTOPERATIvE INSTRUCTIONS HAIR TRANSPLANTATION SURGERY

FOR: ______________________________________ Scheduled Date / Time of BANDAGE REMOvAL: Next day after surgeryScheduled Date / Time of SUTURE REMOvAL: One week after surgery

DAY OF SURGERY: BLEEDING

If Bleeding Should Occur:

Call Dr. Antonio A. Armani at his cell number (416) 543-2716 or at home (416) 203-8553 and apply pressure 10-15 minutes over the bleeding area

NEXT DAY AFTER SURGERY:

1. Medication Instructions: See Attached Sheet

2. Sleep at 45 degree angle for 3 days.

3. Do not wash the transplanted area for one week until the stitches have been removed.

4. You can only wash the back (donor) area, do this gently the next day after surgery.

5. The bandage will be removed the next day after surgery and the donor and recipient areas inspected.

6. You may have swelling: use ice packs or ice on the area of swelling.

290 appendix

General:

1. 7th Day Following Surgery - You will have an appointment approximately 7 days following surgery to have the sutures removed.

2. CRUSTS – Do not pick at the crusts. They will fall off in 2-3 weeks. You may use Vitamin E oil on them if they are not fall-ing off.

3. EXERCISE: For the first 2 weeks following surgery, you should refrain from exercise and strenuous work.

4. VITAMINS: You may take Vitamin E, 400 I.U. to 800 I.U. daily. Also you may take vitamin C 1g to 2g daily. Drink plenty of fluids. You may also take a multivitamin with these.

5. MINOXIDIL (Rogaine) and/or PROPECIA: You should discuss with Dr. Antonio A. Armani the options of taking either or both for the growth of the transplanted hair and to prevent further hair loss.

6. HAIR PRODUCTS: You should discuss with Dr. Antonio A. Ar-mani choices in the following for your specific hair type.

-Shampoos-Hair conditioners-Hair gels and mousses -Hair coloring and perms

Appendix c: sAmple postoperAtive instructions for surgicAl hAir trAnsplAntAtion surgery

appendix 291

If you have any complications or concerns, which were not addressed in this handout, please contact our office at (416) 363-6655 / 1-800-365-6220 / Dr. Antonio A. Armani’s cell number (416) 543-2716 or his home (416) 944-3805. Our staff will be more than happy to answer your questions.

Appendix c: sAmple postoperAtive instructions for surgicAl hAir trAnsplAntAtion surgery

293

glossary

294

glossaryAccupuncture: An ancient Chinese system of medicine

that treats ailments by manipulating key points located on the body. It offers some treatments for dealing with hair loss.

Alopecia: The medical term for all types of hair loss.Alopecia Areata: A type of hair loss caused by unknown

factors. It results in sudden loss of hair, not only on the head but also on other parts of the body.

Alternative Medicines: Types of medicine which are based on holistic medical principles, and which are gaining increasing popularity and acceptance. They include medical practices like acupuncture, traditional Chinese and Indian medicines, homeopathy, cell therapy, and magnetic field therapy.

Androgens: Male hormones that are known to relate in some way to hair loss.

Antiandrogens: A family of drugs which combat the effects of androgens or male hormones, and which have shown the ability to combat hair loss. Some antiandrogens that are being tested to treat hair loss include: Cimetidine, spironoclactone, and progesterone.

Aromatherapy: A branch of herbal medicine which uses essential oils of various plants to create medically benefi-cial effects on the body. It offers several prescriptions for dealing with hair loss.

Ayurvedic Medicine: The ancient herbal medicine of India, which offers several different treatments for dealing with hair loss.

Bonding: A popular method of attaching a replacement piece to existing hair, which uses an adhesive.

Canned Hair: A method for camouflaging hair loss that sprays or applies colored substances to the thinning por-tion of the scalp to simulate hair.

Cloning: The process of making copies of living cells. At-tempts are now being made to clone hair, thus making it possible to create an indefinite supply of natural hair strands for hair grafting.

Conventional Scalp Reduction: A form of scalp reduction that aims to remove only restricted sections of balding

glossary

on the top of the head. Cyclosporine: A drug that is being tested as a possible

treatment for hair loss. It is a type of drug that suppresses the body’s immune system.

Cyoctol: A drug that is being tested as a possible treat-ment for hair loss. It is believed to work by protecting hair roots being attacked by dehydrotestosterone.

Cyproterone acetate: A strong antiandrogen that has been used in Europe to treat hair loss in women.

Dehydrotestosterone (DHT): A type of male hormone that is a major factor leading to hereditary hair loss.

Diazoxide: A drug that has shown promise towards com-bating hair loss. It is drug normally used to treat diabetes.

Dermatologist: A medical doctor who specializes in care of the skin and the hair.

Dutasteride: Dutasteride is another 5 alpha reductase inhibitor. It blocks, receptors 1 and 2. The effect of Dutasteride is to decrease OHT. It is still undergoing phase II and phase III trials for hair loss. Finasteride: A drug that has proven to have significant

ability to combat hair loss. It indirectly acts to inhibit the growth of dehydrotestosterone, and is the active ingre-dient in Propecia.

FUE:Follicular Unit Extraction is the hair transplant tech-nique, which extracts the follicular units one-by-one from the donor area. This technique does not require a scal-pel and therefore no sutures or staples are involved. As a result there is no scaring in the donor area of the scalp.

FUSS: Follicular Unit Strip Surgery is a hair transplanting tech-nique that extracts donor hair from the scalp by using a scalpel to remove a strip of the scalp with the donor hair on it. The strip is further dissected with the use of micro-scopes into the individual follicular units.

Hair Extensions: Hair-bearing devices that attach on to your existing hair to make it appear longer and fuller.

Hair Follicle: The central root of a strand of hair.Hair grafting: A type of hair transplantation surgery in which

slices of hair-bearing flesh are removed from a hair-bearing part of the head and “grafted” into parts of the head which are balding.

296 glos-

Hair Replacement: The methods of dealing with hair loss that replace your natural hair with various types of addi-tives that make your hair look natural and complete.

Hair Thickening: A method used to camouflage hair loss by thickening remaining hair. Various types of hair condi-tioners can be employed to thicken hair.

Hair Units: Hair-like clumps that fit into your existing hair to make it appear fuller.

Hair Weaves: Synthetic or natural hair which is weaved, braided, or knotted into your existing hair to make it look fuller.

Genetic Hair Loss: A type of hair loss related to genetic disposition. It follows a standard pattern in most of its victims. It usually starts with thinning of the hairline at the temple and/or at the crown of the head, and progresses over time. It is the most common type of hair loss, affect-ing as many as 50% of all individuals as they age.

Homeopathy: An alternative medical system developed in Germany, which cures ailments by prescribing dilu-tions of natural substances which trigger the body’s own natural healing processes. It offers some prescriptions for dealing with hair loss.

Male Pattern Baldness: The most common term for heredi-tary hair loss. It is called Female Pattern Baldness when its affects women.

Micro-graft: A slice of flesh with only 1 or 2 strands of hair, which is employed in hair grafting surgery.

Mini-graft: A slice of flesh with 3 to 5 strands of hair, which is employed in hair grafting surgery.

Minoxidil: A type of drug called a vasodilator. It has the effect of decreasing blood pressure and is primarily used to treat high blood pressure. It is also known to cause hair growth in some cases, and is the active ingredient in Rogaine.

Naturopathic Medicine: A comprehensive medical system that combines many of the traditional nature-based medical systems of the world. It offers many prescriptions for dealing with hair loss.

Placebo Effect: The improvement in health, including in hair growth, that researchers find result when patients are

glossary

given placebos or dummy drugs as part of research test-ing of drugs.

Propecia: The brand name for a tablet used to treat hair loss. Its active ingredient is finasteride. It is currently one of the only two drugs approved for hair loss treatment by the United States Food and Drug Administration.

Rogaine: The brand name for a rubbing tonic used to treat hair loss. Its active ingredient is minoxidil. It is currently one of the only two drugs approved for hair loss treat-ment by the United States Food and Drug Administration.

Scalp Expansion: A procedure now routinely employed to expand sections of the scalp to improve results of scalp reduction surgery. There are several different methods employed to expand scalp skin.

Scalp Flaps: A new and effective type of scalp cut used in scalp reduction surgery, which involves cutting into the side of the hair-bearing scalp and rotating the resulting flap-like pieces of scalp up to cover the cut-out portion of the balding scalp.

Scalp Lifting: A highly effective radical form of scalp reduc-tion in which large portions of the scalp are detached from the scull and lifted and flapped to cover balding areas of the scalp which are surgically removed.

Scalp Looping: A method of attaching a hair replacement piece, which surgically creates small loops in the scalp flesh which hair pieces clip in to.

Scalp Reduction: An operation in which areas of balding are surgically removed with the remaining scalp being stretched and stitched together to reduce or eliminate balding.

Sewing: A method of attaching a hair replacement piece to your existing hair, which “fuses” the hair piece to strands of hair either by knotting or by employing an adhesive.

Toupees: Hair-bearing devices formed on a base material and designed to meld into your existing hair.

298 glos-

Tricomin: A compound chemical that has shown some promise in fighting hair loss in tests conducted in France.

Weaving: A method of attaching a hair replacement piece to your existing hair, which sews or weaves existing hair into the hairpiece.

Wigs: Hair-bearing devices formed on a base material and designed to meld with your existing hair.

299

IndexA

Alopecia, See Hair loss Alopecia Areata Sudden unexplained. See Hair loss Alternative medicine acupuncture 252 advantages and disadvantages of 256 Aromatherapy 253 Ayurvedic medicine 253 homeopathy 254 how they work 251 Naturopathic medicine 254 recommendation about 256 relevance of alternative medicine 3 treating hair loss 251

American Academy of Medical Acupuncture 251American Association of Naturopathic Physicians 253American Association of Oriental Medicine 251Androgenetic alopecia . See Hair LossAntiandrogen drugs 239 how they work 239 safety for men 239 safety for women 239 side effects of 238Auto immune disorder 24

B Balding 159

CCalifornia College of Ayurveda 254

300 indexCamouflaging hair loss defined 258

thickening hair 259Cancer 24Colitis 25Conventional scalp reduction. See Scalp reduction.See scalp reduction Crohn’s disease 25Cyclosporine 240Cyoctol 241

DDehydrotestosterone (DHT) 228, 238, 241Diazoxide 241Dr. Kieth Kaufman 228Drug treatment advances in 2

Dutasteride 238

E Experimental drugs 237

F Female conditions. See Hair Loss, disease-related Female pattern baldness. See Hair loss, hereditary Finasteride. See Propecia Food and Drug Administration, 2, 21, 222, 223, 227, 237,

239, 241Fusion 268

index 301

G

Gene therapy 209

H

Hair care chemical treatments 274 drying 275 exposing hair 275 pulling hair 275 rules for 274 - 276 shampoos 274 using a conditioner 274Hair extensions 260Hair follicle cloning. See Hair grafting Hair grafting advertising 116 consultation stage 116 costs of 115 defined 65, 115 expectations for 117 finding a specialist 116 hair follicle cloning 208 risks of 114 steps in 65 when appropriate 88Hair loss 1 abnormal 6 diet-related 22 drug-related 23 hereditary causes of 7 incidence of 1 prevalence 12 symptoms 12

302 index

normal 5 poor hair care 33 stress-related 24 sudden unexplained ( Alopecia Areata ) 32Hair piece attaching to hair 262 attaching to scalp 264 base type 260, 262 cost of 267 custom building 260 defined 260

finding a good specialist for 269natural hair fibre 261synthetic hair fibre 261types 260

Hair replacement advantages and disadvantages of 271 popularity of 258Hair units 260Hair weaves 260How to find a good hair surgeon 136

I International Society of Hair Restoration Surgery 137

L Lupus 24

M Male pattern baldness. See Hair loss, hereditaryManual scalp expansion 200Merck & Co. 21Micro-graft and Mini-graft uses for 88Micro-grafts and mini-grafts

index 303

defined 88Minoxidil . See Rogaine

N National Alopecia Areata Foundation 33National association of Holistic Aromatherapy 255National center for Homeopathy 256National Institute of Ayurvedic Medcine 255Neutrogena T/Gel 229New England Journal of Medicine 248

P Parathyroid disease 24Placebo effect 249Promising drugs Cyclosporine 240 Cyoctol 241 Diazoxide 241 Tricomin 240Propecia advantages and disadvantages of 243 compared to Rogaine 244 costs of 237 effectiveness of 228 general background 227 how it works 228 people not safe for 229 side effects of 230Proscar 227, 250Prostate-specific antigen (PSA) 236

304 index

R Ringworm 23Rogaine advantages and disadvantages of 242 compared to Propecia 244 costs of Rogaine 223 discovery of 223 drug profile 223 effectiveness of 21, 223 future of 226 people not safe for 226 recommendations about 242 side effects of 225

S Scalp expansion. See Scalp reduction Scalp lifting. See scalp reduction Scalp reduction Conventional defined 196 limitations of 198 risks of 198 Scalp lifting defined 202 risks of 205 steps in 202 who suitable for 204 With scalp expansion defined 199 methods of 199 risks of 201 with scalp flaps 199Surgical treatment

index 305

Surgical treatment advances in 2 advantages and disadvantages of 135 future of 207 nature of 54 types 55 who appropriate for 55

T Thyroid disease 24Tissue expansion 200Tissue extension 200Toupees 260Tricomin 242

W Weaving 264Wigs 260

how to beat hair loss - origenere

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