Poor growth after hair transplants: Why?

Poor growth after hair transplants:  

By 8 months, a hair transplant patient should have a fairly good idea of the growth. While it's true that it can take longer (.... even up to 18 months), the vast vast majority of patients experience some nice growth by 8 months. There is no harm in waiting a bit longer - but improvement is (statistically speaking) quickly unlikely.  


Fortunately, poor hair growth following hair transplantation is not something that happens all that often. But when it occurs the surgeon will need to explore many, many possibilities, including patient factors, physician factors and scalp factors. All in all, anyone with poor growth needs to sit down with their physician to review things in detail. 

PATIENT FACTORS

There are a few patient factors to consider - and many are centred around post op care of the grafts. The other patient factor that is important is smoking. Occasionally, smokers have poor growth for reasons that are not completely understood. Other factors one might think about under patient factors are medications that impair hair growth or cause excessive bleeding. There are a few other factors as well that a surgeon will review with a patient with poor growth. 

PHYSICIAN FACTORS

Physician factors also include the physician and his or her hair transplant team. These factors  include overly tight packing of the grafts (too tight, too packed can lead to poor growth) improper depth of grafts, rough handling of grafts by technicians, harvesting of grafts, temperature of grafts and poor hydration of the grafts. All these things are important. Sometimes the density is too high to begin with in certain areas. But these are the things to think about in the "Physician Factors"
 

SCALP FACTORS

This is also an important categories. Some scalps (because of excessive sun damage or other factors) may take up grafts less efficiently and this leads to poor growth. Some scalps bleed more than others are this can rarely impact growth due to post operative "popping" of grafts. Infection post surgery can impair growth as well. And finally some patients have scalp diseases that are either present before the surgery (but could not be detected) or some patients develop new scalp diseases after the surgery that impairs the growth of the grafts. This is rare. For example some individuals rarely develop alopecia areata or rarely develop scarring hair loss problems after their hair transplant. These scalp issues can impair growth partially or completely. A scalp biopsy is sometimes needed to diagnose these problems.

 

CONCLUSION
 

As you can see there are many, many possible reasons and only with a careful evaluation and a bit of "detective work" can a few possibilities be uncovered. That said, sometimes hair transplants don't generate the results that were expected and the next time they do. Any surgeon will tell you in a busy practice, there are occasionally patient's the have less than expected growth. Hair transplant is a fascinating science - but not an exact science.  Far from it. 

Scalp Elasticity: The Mayer Paul Formula

The flexibility or "elasticity" of the scalp is an important consideration for hair transplant surgeons performing follicular unit strip surgery (FUSS also called FUT). In general terms, the more elastic an individual's scalp is, the greater the number of grafts that can be taken ...  and the better the final hair density that can be created for the patient undergoing surgery.

A number of formulas and methods have been proposed to help surgeons calculate elasticity. There are even a number of commercial available instruments and tools that can also be bought to help calculate scalp elasticity.

The Mayer Paul Formula

The Mayer - Paul Formula is a well established method for calculating the elasticity of the scalp. To calculate elasticity on the scalp, two lines are initially drawn 5 cm (50 mm) apart. Then the two lines are compressed together (ideally with the two thumbs). Then, one records how far apart the two lines are after being squished together.

Scalp Elasticity is calculated as

[(50 mm - new position in mm)/50] multiplied by 100 %

VIDEO EXAMPLE: DEMONSTRATION FO THE MAYER PAUL

In this video example, the lines have been squeezed from 5 cm apart to 2.5 cm apart (X = 2.5 for the formula in this example). The elasticity is calculated as 50 %. According to the Mayer Paul formula elasticity of 30 % or more means that a strip of at least 2.2 cm can be taken (if needed) on a first FUT surgery. In contrast, 10 % elasticity means that the strip should be kept less that 1 cm in width

Can alopecia areata occur at the location of a hair transplant?

Can alopecia areata develop at the site of a hair transplant?
 

Alopecia areata affects 2 % of the world. It is an autoimmune hair loss condition whereby the immune system targets the hair follicle causing it to fall out. Alopecia areata can develop anywhere on the scalp - and anywhere on the body where there is hair such as eyebrows, lashes, etc. 

In previous published reports, alopecia has been documented to occur at the site of a hair transplant. However, proving there is a direct link between the two is challenging. Alopecia areata usually develops in most people without trauma or injury.
 

Is a link plausible for some?

It is certainly not impossible that some sort of a more direct link could exist between alopecia and injury. I have many patients with autoimmune type reactions in the donor area following hair transplantation - including alopecia areata and lichen planopilaris. It's just really difficult to prove a direct association.

This photo show "black dots" and vellus hairs that are typical of the scalp in patients with alopecia areata. The photo also shows the scar from a previous hair transplant done using follicular unit strip surgery (FUSS).

Hair transplantation in black men: Can we do FUE?

Choosing between FUE and FUSS in hair transplant surgery

There are two ways that a hair transplant can be done nowadays: FUSS and FUE. With FUSS (follicular unit strip surgery), a strip of skin is removed from the back of the scalp and then the area is stitched up. The result is a linear scar or line. With FUE, the back of the scalp is shaved and hairs are removed from the area "one by one." The results is small tiny circular 'microscars in the area where the hairs were taken. the advantage with FUE is patients can wear their hair short in the future without worrying about seeing the scar.

FUE in black men: What the are the main considerations?

Most of my male patients with afro-textured hair want to wear their hair very short. Having a linear scar is not practical. Therefore, the decision on having FUE rather than FUSS is very important. 

Performing FUE on afro-textured hair requires much more skill than caucasian hair. The photo in the top panel on the right shows the typical curved hair follicles in afro textured hair and the photo on the bottom shows the relatively straight hair from a caucasian patient. It's easy to see why removing these hairs with a small punch would be more difficult in the top panel. 

Ensuring healthy grafts: how do I perform FUE in afro-textured hair?

In performing FUE, I focus on being flexible in the instruments I use. I don't start the day thinking that I'm going to use one sized punch over another, or do the procedure one way instead of another. One must be flexible. I generally start with a 1.17 mm punch and then move to 1 mm and then 1.3 mm and see what produced the best grafts. I move from manual punches (that I direct myself) to 'motorized' punches that drill with the help of a motor.  I go from minimal depth punches to deeper punches into the skin. All while looking at the grafts that are coming out to ensure they are healthy. 

Our hair transplant program for afro-textured is consistently able to offer FUE as a good option for hair transplantation. In fact, for most of my black male patients we are nearly routinely doing FUE rather than FUSS - a big change from just 3-4 years ago.

Follicular Unit Extraction (FUE) in Black Men and Women

Follicular Unit Extraction (FUE) in Black Men and Women

In a hair transplant, there are two main ways of removing hairs from the back of the scalp or 'donor area' :

1. Follicular unit extraction (FUE) 

2. Follicular unit strip harvesting (FUSS)

Both methods can give great results and there are advantages and disadvantages of each. Men who plan to shave their scalp in the future (or wear their hair very short) prefer the FUE method because the linear scar is not seen.  

FUE Techniques in Black Men and Women

There are several factors that influence whether someone is a candidate for FUE.  One of these is the shape and curl of the patient's hair follicles.  It is much easier to extract hairs by FUE in men and women with straight hair than men and women with curly hair.   The structure of hair in black men and women is such that it is curlier than caucasian and asian hair.  The curlier the hair, the more difficult it is to predict the path that the hair follows under the scalp and the more likley these hairs are to be damaged by FUE.  We call this damaged 'transection.' Curlier hair is much more likely to be transected during FUE. It's for this reason that a proportion of black men and women are not good candidates for FUE.  

Compare the photos below of follicular units in a caucasian hair (above):

 with photos of follicular units from a black hair (below):

You'll note the hairs are much curlier in black hair.

Conclusion 

I often recommend performing a short 'test session' prior to hair transplant surgery to ensure 100 % that hair follicles will be easy to harvest on the day of surgery and to ensure that the follicles will not be subjected to excessive damage.  Indeed a 30 minute test procedure for the patient in photo 2 peformed 4 weeks before a scheduled hair transplant confirmed that it was still possible to extract follicle by FUE with minimal damage (transection).  

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The Surgical Map: How hairs "go in" matters more than how they "come out" !

Follicular unit strip surgery (FUSS) or follicular unit extraction (FUE)

There is a lot of attention nowadays about what's a better technique for hair transplantation - follicular unit strip surgery (FUSS) or follicular unit extraction (FUE).  I perform both and both have distinct advantages and disadvantages.

But one aspect of surgery that is all too forgotten about in amongst the discussions of how to remove hairs from the back of the scalp - is how to put them back into balding or thinning areas so the result is natural.

The end result of either strip harvesting or FUE is the same - the production of "follicular units" - either one haired grafts, two haired grafts or three haired (or more) grafts. These are shown in the photo to the right.  Every patient has a different proportion of these grafts in the back of their scalps and so the planning of how they go into the balding areas must be given very careful considered. I refer to the exact plan of how hairs go into balding areas as the 'surgical map'

The surgical map in hair transplantation

If a patient is undergoing a transplant in the frontal area of the scalp, the typical surgical map would follow a pattern something like this: The one haired grafts are placed in the frontal area and placed in an irregular manner so as to create a soft and natural look. Anywhere from 100-400 one haired grafts might be placed in the front depending on the number of grafts they have and the density we are trying to achieve.  The two haired grafts are placed behind the one haired grafts the three haired grafts follow this.

A transplant session of 2000 grafts might contain:

200-400 one haired grafts

800-1500 two haired grafts

300-800 three haired grafts

One haired grafts vs two and three haired grafts

I view the one haired grafts differently from grafts that contain two and three hairs. One haired grafts are fantastic to help create a soft and natural look in areas. The three haired grafts (and too a lesser extent the two haired grafts) are importance for one main reason - building density!  The decision on where to put three haired grafts is very important. They are placed in areas where getting high density is important. 

Final comment

The way hairs are removed from the back of the scalp (i.e. FUSS or FUE) is important - but the way they go back in is more important. Ensuring the hairs are packed with the appropriate density, ensuring the sites are made at the correct angle and direction and ensuring the the one-haired, two-haired and three-haired grafts are put into the best possible locations are some of the most important factors to help ensure a natural result for patients.

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