Ask The Fellows

Ask Your Hair restoration Doctor:
The ISHRS Fellows answer your hair restoration and hair loss questions

Why are more doctors now preferring FUE?
David Josephitis, DO, FISHRS

     There are many different ways in which to address this observation. Over the past decade, there has been a great rise in the number of FUE procedures performed worldwide. In fact, there was a six-fold increase in the total number of patients undergoing FUE from 2007 to 2013, whereas during the same time period, there was very little growth in the yearly average of FUT.* There appears to be more of an evolution in the use of FUE going on than there is simply more physicians choosing FUE over FUT. One factor among many may be that the indications for the use of FUE have been growing as physicians have improved their techniques leading to a concomitant increase in yield, a lower transection rate, and a more reliable result. FUE has opened up hair transplantation to more candidates than ever before. There are those patients who psychologically did not want the strip procedure and those patients who desired a shorter haircut who are now becoming new patients. FUE has been found useful as a way of getting more donor out of patients previously unable to do any more strip procedures. The procedure has also found value in giving surgeons an ability to harvest additional hair from other areas of the body, which was not practical before. And these are just a few examples. FUT may continue to be the procedure of choice for the majority of surgeons and their patients, but the broadening use and benefits of FUE will surely drive the field of hair transplantation to an ever-widening audience.
     *International Society of Hair Restoration Surgery: 2007 & 2013 Practice Census Results. Retrieved from www.ishrs.org Media Center.

What creates the perfect hairline?
Bertram Ng, MBBS, FISHRS

     The basic in hairline design is well described in Unger’s and Lam’s textbooks.1,2 Here are just some of my personal tips:

     Naturalness: The hairline has always been described as the upper frame of the face. It should be created in such a subtle way that the eyes remain the focus of attention.

     Density: If you cover a small area with a good density, the patient is happy to pay for a second procedure to cover more. If you cover a large area with low density, the patient will either demand a refund or a free session, or badmouth you on the internet. So don’t be too generous in offering a low hairline. The lowering of just 1cm will demand an extra 300-400 grafts.

     Aspect: Here, aspect refers to the ratio between the height and width of the forehead. When lowering the frontal hairline, you may have to bring forward the temporal hairlines as well. The fronto-temporal points should be located in a line above the lateral canthus.

     Symmetry: Take some pictures of the hairline you’ve drawn. Ask the patient to check the camera pictures as well as the mirror reflected images. Explain that there may be a discrepancy in symmetry between the two. Retrace the hairline until the patient is happy with both.

     Widow’s peak: Setting a midpoint with the widow peak may reveal any facial asymmetry. Try not to create one unless the temporal hairlines are equal distant from the midline.

     Orientation: Ask the patient how he or she would like to comb his or her hair. The angle and direction of the transplanted hair should flow with the existing ones to help in styling.

References
1. Unger, W., et al. Surgical Planning and Organization. In: Hair Transplant, 5th Edition. Informa, 2011; pp. 106-190
2. Lam, S. Creative Thinking Through Case Studies 360. In: Hair Transplant 360 for Physicians. Jaypee, 2011; pp. 143-169.

What are the best ways to treat female alopecia?
Kongkiat Laorwong, MD, FISHRS

     Women who present with hair loss should have a detailed medical history, scalp examination, and workup to rule out the other causes that can be treated, such as polycystic ovarian cyst, hypo- and hyper-thyroidism, or chronic iron deficiency, and scalp biopsy should be done if necessary before the diagnosis of female pattern hair loss (FPHL).

     The treatment should start with non-surgical options and then consider the addition of hair transplantation. The non-surgical treatments include topical 2% and 5% minoxidil lotion or foam type (only FDA approved), oral spironolactone, finasteride, contraceptive pills, ketoconazole shampoo,1 low level light therapy (LLLT), and platelet rich plasma (PRP) injection. These treatments can be combined to make the results better and increase patient satisfaction; patients should be encouraged to try treatment for at least 6-12 months.

     During treatment, follow-up and monitor the result or progression with dermoscopy, HairCheck, and global photography, and also monitor for side effects.

     Hair transplantation should be considered in Ludwig type 2-3 hair loss after non-surgical treatment has been tried for 6-12 months. Assessment of donor hair is the most important factor determining the result because not everyone is a good candidate. The consequences and complications of the procedure, such as the shock loss, must be discussed with the patient to avoid unrealistic expectations.
After surgery, non-surgical treatment should be continued to prevent further hair loss and stabilize the existing hair, because the hair loss will otherwise worsen.

Reference
1. Rogers, N. Medical therapy for female hair loss (FPHL). Hair Transplant Forum Int’l. 2014; 24(3):86-88

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