Common Fallacies in Hair Transplantation

The following sections address some fallacies, which are commonly disseminated by hair transplant surgeons still using the older techniques:

Fallacy # 1

A large number of small grafts cannot get the needed blood supply to grow properly.

Explanation:

Since the scalp has one of the richest blood supplies of any region of the body, and its blood supply is anastomotic (comes from many directions and is all interconnected), it can easily support large numbers of grafts, provided that the wounds made in the recipient site are very small. The great advantage of Follicular Unit Transplantation is that the grafts are small enough to fit into very tiny recipient sites.

Those who make these comments usually have little experience with using small grafts and don't understand the anatomy of the scalp's blood flow and graft oxygenation. The main issue is one of oxygen diffusion. Since oxygen must diffuse into the center of the newly transplanted graft, by their very size, very large grafts will be oxygen deprived in their center. This has been shown over and over again by observing the phenomenon called donuting, the loss of hair follicles in the center of larger grafts. This phenomenon is easily noted in larger grafts, but does not occur in follicular unit grafts since the distance that oxygen must travel to reach the center of the graft is so short.

The ability to transplant large numbers of grafts in a finite area is not unlimited. This is based upon many factors and requires the judgment and skill of a very experienced surgeon to determine what number is appropriate.

Fallacy #2

Large grafts produce a better, denser transplant result than smaller grafts.

Explanation:

The density of a given area is determined by the total amount of hair transplanted, not by the size of the individual grafts. Larger grafts don't ultimately give you more hair; they just produce an unnatural look. Can an artist create a better portrait using a fine brush or using a house painter's roller? The finest hair transplants require fine instruments and delicate, small grafts used in large numbers. These grafts must be distributed in a way that balances the patient's individual facial features and hair characteristics. Large grafts simply don't offer sufficient flexibility to allow this `customizing,' and they `weight' the transplanted area out of proportion to the rest of the scalp.

Fallacy #3

Larger grafts can produce a denser hairline than smaller grafts

Explanation

This misstates the true aim of a hair transplant. The goal should not be to establish an abrupt hairline, but to create a natural look. A very dense hairline is usually not appropriate for most people as they age, just as a very flat hairline is not appropriate. This is especially true for someone that has less hair due to balding. It is up to the surgeon, as an artist, to ensure that the balance of density and naturalness is just right to give his patient the best look possible. A dense frontal hairline made with larger grafts will never look as natural as a properly designed hairline using fine delicate grafts This is not to say that you can't achieve satisfactory density with small grafts. You certainly can! The issue is that the density of the transplanted area should always be appropriate for the long-term goals of the individual.

Fallacy #4

"Try a few and see if hair transplantation is for you."

Explanation:

This is one of the most disturbing comments made by a doctor. Hair transplantation should only be done with a master plan in mind. The 'try a few' mentality is, in our opinion, medical malpractice for it does not fully inform the patient of the potential problems of starting a process, which he (or she) may not wish to complete.

Fallacy #5

For a young balding man, the doctor rubs your hair in the back and sides of your head and announces: "You have plenty of hair."

Explanation:

Each and every one of us is born with a different, but finite, quantity of hair. Whatever the approach, no new hair is created. Scientific measurements, such as densitometry, provide the surgeon with much greater accuracy than subjective assessments when estimating your total supply of permanent hair. The importance of accurately (and honestly) estimating your total donor reserves for proper long-term planning cannot be over emphasized. Beware of a doctor who says that you are a 'great candidate for a transplant' before he spends the time to carefully examine you.

Fallacy #6

By cutting out some of the bald area in the back, scalp reductions save hair for future loss in the front

Explanation:

In our opinion, doctors who make such comments reflect an unacceptable level of knowledge for they do not understand that hair is a limited resource. It is used up regardless of how it is moved, and scalp reductions are just another method of moving hair around. A scalp reduction is not a magical process (as it is often portrayed). It moves hair to back of the scalp at the expense of the front. As a result of a scalp reduction, the hair in the donor area thins considerably and scalp's laxity (looseness) is decreased. This means when the frontal hair is lost, the surgeon may never get the quantity of hair needed to meet the patient's needs, as the hair supply might run out prior to the completion of surgery.

As most people want to frame their face, the frontal restoration usually takes precedence over the crown for hair redistribution purposes. If the crown is treated first, the surgeon must be certain from the very start that the way the hair is distributed leaves enough in reserves to cover the remainder of the balding scalp. Scalp reductions, by addressing the crown first, significantly compromise the ability to do this. In addition, scalp reductions can cause problems such as scarring, a thinned scalp, altered hair direction, and a host of other unwanted effects, that become more and more difficult to deal with as the patient's baldness progresses. No wonder that the use of this procedure has dropped so dramatically in recent years!

Fallacy #7

Removing large amounts of donor hair is unsafe

Explanation:

This is a statement commonly made by doctors who lack sufficient experience in performing large sessions. If follicular dissection is performed carefully, under microscopic control, the amount of hair needed for the average large session is well with-in the safe limits of what can be transplanted. The careful judgment of an experienced surgeon will insure that the amount of hair that is harvested from the donor area is safe and appropriate-ate.

The amount of moveable donor hair reflects the size of the donor area, the person's scalp looseness, the number of hairs per square inch, and the amount of scarring (if any) from previous surgeries. This must all be carefully assessed in advance of the surgical procedure. It will be part of every patient's initial evaluation at NHI.

Fallacy #8

With new laser technology, recipient sites can be made without injury to the transplanted area.

Explanation:

Lasers were introduced into hair transplantation in order to rapidly produce slits (that supposedly looked better than punch holes) and to remove tissue to accommodate large grafts and eliminate compression. The exclusive use of follicular units obviates the need for lasers since they fit into very tiny micro-slits that can be created without removing tissue. Regardless of how precise the laser beam, or how small the zone of thermal burn around the wound that it produces, the laser still makes a hole or slit by removing tissue. This is essentially the same type of wound that was produced by the cold steel punches of the early days of hair transplantation. Lasers will always produce more injury to the recipient area than a micro-slit in which recipient tissue is not removed.