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10. What is a follicular unit? What is a follicular unit graft? Hair naturally emerges from the scalp in clusters or groups. In fact, on average only 10% of hair emerges from the scalp as a single hair. This grouping is called the "follicular unit." There are usually two to four hairs in the cluster but some hair types have five or even six. The average hairs per cluster or "follicular unit" is two. A follicular unit graft is a graft cut to this smallest grouping and, therefore, averages two hairs per graft. See Dr. Reed’s thoughts on the pros and cons of follicular unit grafting as were presented by him at the American Society of Dermatologic Surgery’s annual meeting and at the International Society of Hair Restoration Surgery’s annual meeting as well as will appear in the lead article of the next issue of Hair Transplant Forum International 11. What is hair volume and why is it important? Hair volume is the combination of hair density (the number of hairs per square inch or centimeter), hair length, and the diameter of the hair shaft. The hair volume is what is meant when you consider how thick the person’s hair appears. Hair volume is a much more important consideration than hair density when considering outcome and what surgical technique to use. See Dr. Reed’s thoughts on this matter as were presented by him at the American Society of Dermatologic Surgery’s annual meeting and at the International Society of Hair Restoration Surgery’s annual meeting as well as will appear in the lead article of the next issue of Hair Transplant Forum International. 12. What is the difference between a follicular unit graft and a micrograft? A follicular unit graft is defined elsewhere. A micrograft is one or two hairs per graft. These are used in the combined follicular unit grafting surgical technique to define a subtle, "feathered" appearance to the scalpline and to any border of transplant with skin or in any low hair density situation. The one and two hair follicular unit grafts (i.e. the large percentage of them) are therefore micrografts. Micrografts that have been harvested from the donor from a cluster rather than from splitting a cluster apart are also follicular unit grafts. However, for example, if we split apart a three hair follicular unit to get a one or two hair micrograft, that micrograft would not be a follicular graft! Are you glad you wondered? At La Jolla Hair Restoration, all of our micrografts are from follicular units and are therefore also follicular unit grafts. The rare situation where we would intentionally make micrografts from splitting apart follicular units is the person with very strong, thick diameter hair whose thick diameter will not look as natural as quickly as when the diameter is compromised by cutting the follicle away from a tight cluster. Survival is compromised in this situation as well, however. 13. How big should my combined follicular unit graftings be? The size of you combined follicular unit graftings depends upon several factors: 1, Your hair color relative to the color of the skin of your scalp. The closer the colors, the larger the combined follicular unit grafting can be. 2, Your hair shaft diameter. The larger the diameter, the smaller the combined follicular unit grafting should be because the smaller will be the number of hairs that will appear unnaturally pluggy. 3, The final density to by obtained. The lower the final density that is the goal, the smaller the combined follicular unit grafting should be. In Nature, usually but not always, as the hair becomes more sparse, the number of hairs per cluster becomes smaller. The hair shafts are also becoming more miniaturized as the hair becomes more sparse. Inasmuch as we cannot easily miniaturize the hair shafts we would want to tend toward lower numbers of hairs per graft to lower the hair volume defined by each graft. 4, The proximity to an edge of the transplant. A larger combined follicular unit grafting (eg. 4 to 6 hairs) should not be placed immediately behind the micrografts. Smaller combined follicular unit graftings should be used to provide a more smooth gradient of hair density. 14. What about Propecia/Finsteride? PROPECIA (ORAL FINASTERIDE) IN THE TREATMENT OF ALOPECIA
ANDROGENETICA & INSTRUCTIONS FOR USE
There is no doubt that androgens are intimately involved in causing male pattern baldness. Famous castrati in the time of Handel and Teleman not only retained strong soprano voices, but were assured of a lifetime of beautiful locks. Hamilton, known popularly for the Hamilton Scale of grading male pattern baldness, noted that castration after the onset of puberty arrests the progression of human alopecia. On the other hand, the administration of therapeutic doses of testosterone to hypogonadal adult males results in the loss of scalp hair in many of them. The active androgen in the balding scalp appears to be dihydrotestosterone, which is produced from testosterone through the activity of the 5-alpha-reductase enzyme. Biopsies and biochemical analyses corroborate the elevated 5-alpha-reductase levels in the frontal scalp of balding men and the lack of hair loss in human males with 5-alpha-reductase deficiencies. In fact, the levels of 5-alpha-reductase is usually 4 times higher in balding areas than the occiput, which is not affected in male pattern baldness. Propecia, also known as 1 mg. finasteride, is a potent inhibitor of human type 2 5-alpha-reductase. Finasteride, manufactured and marketed by Merck Pharmaceutical as Proscar, has been shown to be effective in the treatment of benign prostatic hyperplasia. At the therapeutic dose of 5 mg/day, finasteride lowers serum dihydrotestosterone levels in men by 65-80% compared to baseline levels and decreases intraprostatic levels of dihydrotestosterone by 85% compared to placebo. 14. Is finasteride/Propecia something I should consider taking? I consider the introduction of finasteride/Propecia/Proscar to be a revolutionary addition to our hair restoration solutions. This medication stops the progression of hair loss in 85% of men. It results in significant regrowth in the crown area in 66% and over 40% get noticeable improvement in the frontal forelock (the area from the scalpline to the crown.) Improvement of temporal recession is uncommon but does occur. As you will notice, I was opposed to its use when it was first introduced in the spring of 1998. See Reed/Propecia/Hair Transplant Forum 1998. I have since changed my mind and have been using the medication since the spring of 1999. My best medical judgment at this time is that finasteride/Propecia/Proscar will prove to be a healthy medication for men over their early 40s to take as it will probably lower the incidence of prostate cancer significantly. A study supporting this hypothesis was published in the New England Journal of Medicine in 2004. Additionally, finasteride will prevent excessive enlargement of the prostate gland that is often a problem as one ages. Finasteride is available by prescription only. Your family physician will probably be supportive of its use. I would recommend, for cost reasons, the use of taking a quarter of the 5mg tablet named Proscar rather than using the 1mg tablet of finasteride called Propecia. Extensive information on the drug is available at the Merck web site www.Propecia.com. You should be very aware of how to use the drug around a pregnant woman. 15. What about using minoxidil/Rogaine and its use in combination with finasteride/Propecia? Should I use the 2% or 5%? I represented the International Society of Hair Restoration Surgery at the Hair Research Society meeting in 1998 inWashington, DC. This meeting occurs every three years and is attended by all of the leading basic science people in the field of hair research. These scientist seemed to all share the view that finasteride should be combined with minoxidil/Rogaine as the two together were strongly felt to be better than either one alone. I have never been impressed with minoxidil when used alone but I do recommend it in combination with finasteride. In the past, I generally recommended the 2% generic minoxidil vs the 5% mainly for cost considerations and for the reason that so little science supports the use. I have more recently changed my opinion and recommend the 5% as the data suggest it to be more effective. Using minoxidil twice a day is essential if it is used alone but I advise people to use it even once a day in combination with finasteride if that is all that their life style will tolerate. Also, some people note that the 5% makes their hair look too "greasy". If this be the case, I suggest using the 5% at bedtime and the 2% in the morning after showering since the 2% doesn't seem to cause the "greasy" appearance. If a person is opposed to finasteride/Propecia and will use minoxidil/Rogaine I recommend he does that but state that it has to be used twice daily or not used at all. 16. I understand that my own hair is transplanted to areas where it has already fell out; however, has all the hair that is going to fall out, fallen out? What happens if hair is transplanted near other hair that will eventually fall out? I'll just have bald spots in different places. There are two approaches. One approach is to use medical means to stop the progression of balding. With Propecia this is accomplished in 85% of men. Additional use of minoxidil/Rogaine provides additional, unquantified benefit. The other approach is not to use medical means to turn male pattern balding into a non-progressive condition and, if balding continues, to transplant the newly bald areas. The rate of hair loss in combination with where the newly bald area isdetermines how soon you will feel the need to correct the progressive hair loss. In general, the time required to achieve a look that might be "awkward" from this progressive balding is longer than you might think. 17. My hair is very thin and wispy. Will hair transplanted from other parts of my head clash with the existing hair? There is generally no problem blending in the thicker donor hair with the fine hair which has been withered by years of male pattern balding. The stronger hair can be merged into the transition zone of the finer hair. This "feathering" is similar to what must be done with transitioning the scalp hair into the forehead with the use of a tapering density of micrografts. 18. What is a megasession? "Megasession" is a term whose definition varies from surgeon to surgeon. One thousand grafts used to be an accepted number for defining a megasession. In 2005, the number is probably higher and in the range of 4500 hairs or more. The number of hairs in the grafts seems to vary in such a definition. Grafts of total follicular unit composition will average around two hairs per graft. Some people's hair characteristics will have follicular units averaging closer to three hairs. As noted elsewhere, double follcicular unit grafts are usually 4 hairs per graft. At La Jolla Hair Restoration the combined follicular unit graftings rarely exceed five hairs and are usually three and four hairs. By mimicking what occurs in nature, Dr. Reed feels the most natural result is achieved with the highest degree of certainty. The usual "maximum harvest" consists of a 1 centimeter wide strip of donor hair 25 to 30 square centimeters long. This consists of 4500 to 6000 hairs depending upon the length of donor available to harvest and the density of your donor hair. On average this makes from 1400 to 1800 micro and combined follicular unit graftings. Of course the higher the proportion of the one hair micrografts relative to the multi-hair combined follicular unit graftings, the higher the number of total grafts. Hair transplant procedures that consist of 2000-3000 grafts rarely transplant more hair than the above 25 to 30 square centimeters. The larger number of grafts is explained by the fewer hairs per graft. Not uncommonly, however, it is not inappropriate to take a wider than one centimeter strip on your first procedure only. There is often sufficient laxity of the donor area to allow such an approach. The risk of doing so, however, is the increased chance of a wider scar in the donor area than if one stayed with the one centimeter width but this approach would allow for more than 25 to 30 square centimeters to be removed. Of course judgement and an individualized approach that takes into account the whole hair restoration plan are the critical factors. We feel it is important that a person who is interested in this procedure be aware that more than one procedure may be necessary in some cases. Your personal lifestyle and genetics will determine if you will experience more hair loss in the future. It is important to discuss before your first procedure your expectations for the present and long term objectives. You will be given ample time to discuss your concerns with Dr. Reed during your initial complementary consultation. If you are not in the San Diego area, most people are happy with what can be accomplished by sending Dr. Reed photos and then discussing matters with him during a phone consultation. Send us an email if you would like to discuss these matters further.
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