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| Medical Treatment Options FAQ: Will Propecia or Rogaine produce the same results? In late 1997 the FDA approved the drug finasteride to fight androgenetic alopecia (male pattern baldness) in men. Finasteride is the generic name of the drug (developed by Merck) which is marketed in a 1mg dose as Propecia, and a 5mg dose as Proscar. A single milligram is all that is necessary to achieve and maintain the hair stabilization or regrowth benefits of this medication. The 5mg dose of Finasteride (Proscar) is effective in treating some cases of enlargement of the prostate gland. Although the dose is different, these medications are the same. The medication works by blocking the enzyme that converts the male hormone Testosterone into its metabolic byproduct, Dihydrotesterone (DHT). In the case of male pattern baldness, DHT is apparently the messenger hormone that directs the hair follicle to stop making hair. Therefore, blocking the formation of DHT has been found to help stabilize hair loss and to regrow some hair in affected men. Although DHT is felt to be important in a developing male fetus, researchers do not feel it maintains any important beneficial functions in adult males. The results of two year medical trials studying the effects of Propecia in male pattern baldness revealed a greater than 83% response rate in study participants who either maintained their hair pattern and stopped losing hair, or 66% regrew an average of 10% more hair in an area of thinning hair. The medication was not felt to be effective for certain patterns such as temporal recession (hairline). It would not be expected to regrow hair in an area where an absolute loss of follicles had previously occurred. In addition to Propecia, the only other FDA approved treatment for treating hair loss is Rogaine (or any generic of Minoxidil). Other over the counter remedies exist, but have not gone through the rigorous testing required to receive FDA approval. Often, they are not placebo tested, and the studies that are done may not have statistical significance. Dr. Keene prescribes and recommends only the FDA approved medical treatments. There are also some medical devices that are FDA approved as safe to use but Dr. Keene does not recommend them as they are also not clinically proven in double bind studies.  Surgical Treatment Options What is a follicular unit? Hair exits the scalp in a bundle with one to three other hairs. The term follicular unit refers to these bundles. The image below is a microscopic view of follicular units in a .25 cm square as they occur in nature. | ||
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This image is a microscopic view of follicular units in a 0.25 cm square as they occur in nature. | |
| Physician's Hair Institute's procedure (Ultra Refined Incisional Follicular Unit Grafting and DFU) Dr. Keene uses the most advanced and effective technique of hair transplantation in the world. We remove permanent hair follicles on the sides and back of the scalp that are not affected by male pattern baldness, and employ them as donor follicles. These permanent donor follicles are then transplanted in follicular units of 1-4 hairs (the way hair grows naturally) on the crown and front of the scalp. By using follicular units of 1-4 hairs, as they appear in nature, we avoid producing unsightly "corn rows" or other unnatural effects associated with hair transplant surgeries using grafts of 6 or more hairs. In some cases, for example with very fine hair, double follicular units of up to 5 hairs are used for added density. During our procedure, grafts are placed very close together, since too much space between groupings looks unnatural. Custom blades are used to allow high density. Dr. Keene also utilizes double follicular unit grafts (DFU'). DFU's are 3-4 haired grafts that have a slight gap between groupings, but that can be placed just as closely together, or closer together, when not cut down into smaller follicular unit grafts. The advantage is that more density can be created with fewer incisions, which means a less costly hair transplant to the patient. It also results in less trauma due to fewer incisions being required to place the same numbers of hairs. Dr. Keene focused solely on FU grafts for some time, but having placed DFU grafts prior, she soon realized that DFU grafts look just as natural in areas like the crown, while providing more density at less cost. Here is an illustration of DFU vs FU:   4 haired DFU 4 haired DFU dissected into 2 FU's   3 haired DFU 3 haired DFU dissected into 2 FU's If the DFU's above were dissected and placed into 2 different incisions, they could not be placed closer together than if they were left as a single DFU graft. Looking closely at the photos above, you can see that leaving a space between does not put the hairs closer together. Each tick above is 1mm. The DFU fits into a 1.5 mm flat incision. The FUs fit into two .7 mm flat incisions, with a space in between--the total of which is larger than 1.5 mm in distance. So more hairs can be placed into a smaller area utilizing double follicular units than solely single follicular units. Remember these photos are magnified to a larger size than actual, so if you want to see what 1 mm or 1.5 mm really looks like, look at an actual metric ruler--you will see that both are extremely small. Dr. Keene does not exceed 1.5 mm in size for the incisions she makes, and she customizes the blades and incisions to as small as .7mm, depending on the individual graft sizes. In the frontal hairline only one haired grafts are placed, but behind that there is a gradual transition to the use of 1 to 4 hairs per grafts mixed-if the hairs are within 1mm of each other, we consider it a follicular unit, but if they exceed that and are still within about 1.25 mm of each other we call it a double follicular unit. Using grafts of 1-4 hairs results in a completely natural appearance. In Dr. Keene's opinion, there is typically a cosmetic advantage to using mainly more 3 to 4 haired grafts in the areas behind the frontal hairline, so she asks her assistants to focus on dissecting as many 3-4 haired grafts as possible. These are not mini grafts. We have been told by patients who have met with Dr. Keene that some other doctors have claimed she does mini grafts. That is not the case. Mini grafts were often 6 hairs and sometimes more, and would never have fit into the minute incisions Dr. Keene utilized today. Dr Keene stopped using mini grafts in the late 90's. She focused on follicular units only for some years, but than realized that the addition of some double follicular units was advantageous due to her experience. The key is in knowing where the different types of grafts should be placed, and which patients will benefit from which size fu grafts. Patients with scar tissue from previous surgeries, or low density, may not group close enough together to allow DFU's that are small enough. The patient must also have distendable skin to take sufficient donor. Only single follicular unit grafts are used in the hairline. Experience and aesthetic ability in hair transplant surgery, along with technical expertise, allows Dr. Keene to determine where DFU's are appropriate. Will I have a natural hairline and will scarring result? The procedure at Physician's Hair Institute is done in megasession hair transpants of up to 3000 grafts in one day, or up to 5000 grafts in a consecutive day hair transplant surgery, depending on factors such as donor density and scalp laxity. In general, unless we aimed to do more ones and two haired grafts, we would not be able to take enough donor to do more than 5000 grafts in a consecutive day hair transplant session due to scalp elasticity. However, it is the number of hairs moved rather than the number of grafts that yields better density. Unlike the case for more grafts, more hair moved will give you more hair!!! So you can start enjoying your new, permanent hair faster than ever. Your hair transplants will be virtually undetectable by friends and family, once they have healed, leaving a natural hairline with virtually no scarring in grafted areas. A fine linear scar in the donor area is covered by overlying hair, and is typically undetectable.  Physician's Hair Institute's hair transplant procedure leaves a natural hairline.  Donor area two weeks after hair transplant procedure.  Donor area nine months after hair transplant procedure. Comparison of Procedures The Donor Area As a board certified general surgeon, Dr. Keene utilized a double suture closure (internal and external) for many types of surgeries. She felt that this type of closure would be best in hair transplant surgery as well. This consists of an internal layer of dissolvable suture, which is the strength layer of the closure, and an external layer on the skin of nylon suture. This can be removed in only 5-7 days, making it much more comfortable for patients. A single layer closure often requires 10-14 days, and the suture becomes irritating to the skin, causing an annoying inflammatory reaction. When this happens, the result can be the "railroad track" scarring where the nylon leaves a visible white vertical scar across the linear horizontal one. An internal layer can also help prevent broadening of the incision, especially for large megasessions when the closure can result in more tension on the skin. The absorbable suture remains for several weeks to allow the wound to gain strength, and the result can be a finer closure. The double closure typically results in a virtually undetectable linear scar, that is completely covered by hair in the donor area, and is typically very difficult to find after it is completely healed. Results can vary in patients with unusually tight scalps, and those who have had previous surgery that has removed some of the scalp elasticity. Dr. Keene also uses the trichophytic closure where appropriate, which is a type of closure that further camouflages the very small linear donor scar. It has been used in plastic surgery for some time, and was introduced at the 2005 European Society of Hair Restoration Surgeon's conference for use in the donor area closure. Dr. Keene adapted it, and has been using it since with excellent results. She uses this in patients requiring 1.5 cm or less donor strip width, who have sufficient elasticity, because it works best when tension is minimal. Basically, the technique involves making an incision to remove the donor area that is parallel to the hair shaft, then trimming one side of the epithelium (outermost layer of skin) high up on the hair shaft. When the donor area is brought together and closed, the hair shafts that were trimmed just below the surface of the epithelium will grow out through the suture line, masking the minute scar with hair. How does Follicular Unit Extraction(FUE) compare to the strip technique of hair transplant donor harvesting? Dr. Keene can and has performed FUE, but advocates the strip technique. Why? Because with FUE, minute donor scarring still occurs, the scars are just more diffusely spread, and this does not result in better cosmesis to the donor area. Both techniques result in very little scarring, as you can see in the photo above of the donor area after surgery in the strip technique. But there are other disadvantages to the FUE technique. Grafts are yanked from the scalp at the bottom of the punch, with no line of vision, increasing the trauma to the follicles and increasing the liklihood of damage. Fewer 3 - 4 haired grafts can be harvested. According to a study of the FUE transection rate (i.e. rate of damage to the follicles) performed at the Madrid Live Surgery Workshop of the European Society of Hair Restoration Surgeons conference publised in the Winter 2009 ESHRS journal, FUE resulted in an average of 37% transection. "FUE produces a much higher rate of transection than all other harvesting techniques." As the Journal put it, "Improvement in FUE transection rate is a must." To read more about the FUE vs the Strip donor extraction topic, click here. How does suture compare to staples in hair transplant surgery? Staples are much faster and easier to place than sutures, but less comfortable than suture to lie on. They also tend to be more painful to remove. Staples are more convenient for the doctor, the appearance of the incision is comparable with both, and this has been documented repeatedly in the surgical literature. But Dr. Keene feels it is worth the extra time it takes to use suture in order to increase your comfort. What are some of the other recipient site techniques available in hair transplant surgery and how is Dr. Keene's different? Plugs: A plug occurs when a hole is punched into the scalp and a graft is used to "plug" the hole. When this occurs not only is a follicle grafted, but so is skin. This newly grafted skin can cause visible scarring. Dr. Keene has never done plugs, even though they were standard when she entered this field, she did not like the results and only entered the field after being introduced to micro incisions that were first done in Europe. Dr. Keene's current technique uses micro incisions placed close together which heal quickly, and the small amount of skin on the graft forms a tiny scab that falls off.  Since plugs are large amounts of hair and skin being placed into the scalp, unnatural "corn rows" appear because grafts are placed further apart. We insert follicular unit and DFU grafts of 1-4 hairs with very little skin moved, the small amount that does remain on the grafts sloughts off, so scars and rows do not occur. Micro/Mini grafting: Micro grafts consist of one to two hairs and mini grafts consist of three to eight hairs. These grafts are placed further apart which can create an unnatural hairline and decreased density throughout. This technique is not done by Dr. Keene as in most cases the only natural appearing grafts are up to 4 hairs, and more than that starts to look grafty. Placing the grafts close together is also important, although it is important for patients to realize that the number of hairs moved is more important than the number of grafts, and 7000 1-2 haired grafts will not yield more density than 3500 1-4 haired grafts. Physician's Hair Institute's Hair Transplant Procedure Our procedure separates hairs into small one, two, three and four hair grafts, called follicular units and double follicular units, and places them tightly together to recreate a natural hairline and overall apearance. Other factors such as matching the existing hairs' direction, using aesthetic ability to recreate naturalness where there is no native hair present, creating a variegated frontal hairline, using lateral incisons where appropriate (angle will always change based on area), using sharp point and custom cut blades as small as .7 mm which allows increased density, personal experience and participation throughout the surgery, and other advanced surgical techniques result in the state of the art hair transplant procedure performed by Dr. Keene. Click here for more information on How is a natural hairline created, and on the following link for more information on all of the surgical techniques used at Physician's Hair Institute. For more detail specifically on lateral incisions, click here.   (Procedure at PHI creates a natural hairline) Procedure using plugs as grafts (NOT used by Physician's Hair Institute) Here grafts use plugs which are spaced further apart, therefore, producing unnatural "corn rows".   (Plugs not used by Physician's Hair Institute) Are you a candidate for a hair transplant? There are three main factors we consider in determining a good candidate for hair transplant surgery: current hairloss pattern, health, and future hairloss. Since hair transplant surgery is a surgical technique using local anesthetic, good candidates for this procedure are reasonably healthy, have significant thinning and hair loss, or hairline recession. We can also repair scars left by other cosmetic surgeries such as a face lift, or from other causes. There are no age restrictions, but it is preferable that a patient be 25 years of age or older before considering the surgical option. This is because it is difficult to determine what the future hair loss pattern is going to be in a patient younger than 25. There may be exceptions, one being if the medication stabilizes the pattern. Determining the future hair loss pattern is an important factor in deciding on where to place the hairline. You may only be losing hair in the very front of your hairline now, so want that filled in. But that may not look natural as you age, and you will need to fill in the areas behind the transplanted hair to retain a natural appearance if your natural patter receeds further. During the initial hair transplant exam, Dr. Keene will evaluate existing hair loss and will estimate future hair loss based on your risk factors. Since hair is normally transplanted from the sides and back of the head, it is important that you have sufficient hair available to achieve your desired results. Dr. Keene will provide each patient with information so that they can determine whether hair transplant surgery and/or medical treatment may best suit their needs. Estimating number of grafts needed for a hair transplant Each patient can determine the number of grafts he or she will need for a particular level of density or area of coverage. A patient will base his or her decision on density preferences and current hair loss area as well as estimates of future hair loss. We can not give the same number of hairs as nature did originally, because we are working to redistribute diminished existing hair. But since hair loss is virtually undetectable until approximately 50% of the hair is lost, it is possible to achieve the same appearance of density as a natural head of hair. Other factors include:
*During your hair transplant consultation, Dr. Keene will help you determine what density is necessary to achieve your goals. Who will actually be performing my hair transplant procedure? Dr. Keene believes all hair restoration surgeons should have the technical capability of cutting and placing grafts. Dr. Keene supervises every aspect of the hair transplant surgery, utilizing assistants to assist in hair transplant surgery, not perform it. Dr. Keene has an experienced and skilled 10 person surgical team with extensive hair transplant training, some of whom have been asisting her in hair transplants for over a decade, all of whom have been with her for at least a year, and some who had extensive experience working with other clinics prior to hers as well. However, she feels that if it were herself or a family member, she would want the medical doctor to actively participate in all of the vital aspects of the surgery, including placement of the grafts, regardless of the fact that the staff is skilled--so this is what she does in her clinic. Dr. Keene's technicians are some of the most experienced and skilled technicians in the hair transplant industry, but she will be the primary person doing your hair transplant. Part of the reason you rarely see Dr. Keene blogging is because she spends so much time in surgery. A doctor who has copious time to blog is probably not spending much time in surgery, and depends heavily on the technicians rather than the doctor to perform your surgery. While certain aspects of the surgery require less medical knowledge, attention to detail is important, and that is why Dr. Keene has not submitted to pressure from some members of the hair transplant community to change the way she performs surgery and hand over much of the control to the technicians. How soon after hair transplant surgery will I see the new growth? When hair is surgically moved from the back of the head and redistributed into the areas of hairloss, the transplanted hair experiences trauma. This typically causes what is referred to as shock loss, causing the shaft of the hair to fall out in about 1 to 6 weeks after surgery, while the root remains behind. The newly growing hair will begin to emerge in about 3 months after surgery, depending on your rate of growth. The hair continues to mature and add density for up to a year. There can be exceptions to shock loss, but it is best to expect it to occur. Sometimes the trauma can result in shock loss of some of the native hair (i.e. hair we did not transplant) but it is expected to grow back unless it was about to fall out due to genetics. And genetics can be combated with the use of finasteride. Dr. Keene is very careful to avoid transecting any existing hairs when she transplants hairs in between them, but trauma occurs with any incision and any surgery, so while the risk is minimized for temporary shock loss, it may still occur--so don't panic if it happens! It will typically start to grow back within a few months. This transitional phase aver surgery is the hardest part, but the wait is worth the results. |
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