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Timothy Carman, MD

Frequently Asked Questions

The collective opinions herein are those of both Dr. Reed and Dr. Carman. These opinions can vary depending upon the specifics of the circumstances being considered.

1. Who is a candidate for a hair transplant?

2. Is this really permanent?

3. Is there much pain involved?

4. Will people notice that I have had a hair transplant immediately after the procedure?

5. Will I need to do this more than once?

6. Why should I consider this procedure?

7. How many people assist the physician?

8. How much does this cost?

9. What type of hair loss do I have?

10. What is a follicular unit? What is a follicular unit graft?

11. What is hair volume and why is it important?

12. What is the difference between a follicular unit graft and a micrograft?

13. How big should my combined follicular unit graftings be?

14. What about Propecia/Finsteride? Is finasteride/Propecia something I should consider taking?

15. What about using minoxidil/Rogaine and its use in combination with finasteride/Propecia? Should I use the 2% or 5%?

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?

17. My hair is very thin and wispy. Will hair transplanted from other parts of my head clash with the existing hair?

18. What is a megasession?

1. Who is a candidate for a hair transplant?

In general, any male or female who has thinning and/or balding areas of the head due to a non-scarring form of hair loss, and who has an adequate donor supply, is a candidate for this procedure.. This procedure is most often elected to treat male pattern hair loss. It is also indicated for limited treatment of female pattern hair loss. Hair transplantation is also very useful in addressing scarring to the hair bearing scalp, whether due to previous plastic surgery or trauma. It is very important that patients understand that only a trained, experienced Hair Transplant Surgeon should be trusted to reliably and accurately assess if you are a suitable surgical candidate. The physician will consider such factors as your age, family history, your individual hair loss pattern, future loss expectations, the color and curl of your hair and whether or not you have sufficient donor supply, to come up with a  transplantation plan that is appropriate for you.

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2. Is this really permanent?

Yes. This surgical restoration takes hair from the back of your head from an area called the donor area. Donor hair is very resilient to the balding process and as such makes excellent hair to be used for transplantation.

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3. Is there much pain involved?

Pain is well controlled with modern anesthetic techniques. This procedure is done under a local anesthetic so that during your transplantation you may watch a video, listen to music or take a nap.

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4. Will people notice that I have had a hair transplant immediately after the procedure?

Immediately following your transplant the procedure may be noticeable upon close inspection. This depends on how much work is being performed and how much hair you currently have. In some cases immediately after the procedure the work is virtually undetectable to the untrained eye. If you and the doctor decide to add density to thinning areas then it will be less likely to show during those first weeks as compared to recreating a new hairline on bald scalp. In either case, the appearance of the fresh hair transplant will not last as the new hairs grow.

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5. Will I need to do this more than once?

Some men may require more than one treatment to get the desired amount of hair restored while others will need only one treatment to obtain their desired appearance. Male pattern balding is a progressive and the newly transplanted hair will not cover future hair loss. The progressive nature of male pattern balding may be substantially slowed or reversed with the use of finasteride and minoxidil. Continued use of these medicines may have the effect of eliminating the need for future surgical procedures.

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6. Why should I consider this procedure?

If you are concerned about hair loss, this is the only permanent solution. There are many other methods and quick fixes and cover-up’s, but no other permanent solutions.

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7. How many people assist the physician?

The number of grafts that you and the doctor decide upon will dictate how many surgical assistants he will require. The number will vary between two and five assistants, depending upon the size and complexity of the case.

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8. How much does this cost?

For most people this is one of the most important questions. The cost is determined by how much work you want to have done, and ultimately, the number of grafts you have available for the session. We try to make this procedure as affordable as possible. For more information, see the price table in the financing section.

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9. What type of hair loss do I have?

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.

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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

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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.

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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.

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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.

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14. What about Propecia/Finsteride?

PROPECIA (ORAL FINASTERIDE) IN THE TREATMENT OF ALOPECIA ANDROGENETICA & INSTRUCTIONS FOR USE
Reduces 66% + – of DHT in blood serum
FINASTERIDE

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.

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.

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15. What about using minoxidil/Rogaine and its use in combination with finasteride/Propecia? Should I use the 2% or 5%?

In clinical practice it has been observed that when finasteride/Propecia is used in combination with minoxidil/Rogaine that the result is “synergistic”.  What this means is that the beneficial effect on hair quality is greater than what would be predicted by adding the effect of each one to the other (1 + 1 = 2). So, instead of 1 + 1 = 2, 1 + 1 = 3!!

I recommend the 5% as the data suggest it to be more effective than the 2%. Using minoxidil twice a day is recommended in order to receive maximum benefit. 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 impart that “greasy” appearance. I advise patients to use it even once a day (at night) in combination with finasteride if that is all that their life style will tolerate due to the unacceptable way it leaves their hair due to that “greasy” appearance..

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16. I understand that my own hair is transplanted to areas where it has already fallen 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? Won’t I 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 is determines 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.

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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. One of the more pleasing aspects of re-creating natural patterns of growth is in utilizing these qualitative differences in size and thickness, along with a placement design that features variability in density and angulation to produce a work of art that represents the concept of “the whole being greater than the sum of it’s parts”.

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18. What is a megasession?

The term “Megasession” is one whose definition varies from surgeon to surgeon. A two thousand graft case used to be an accepted number for defining a megasession. In 2014, the number is probably higher and in the range of 3500 follicular units or more. There is a general misconception that the larger a case size, the “better”. Again, this perspective is more of a marketing one than anything having to do with the surgical procedure itself. In reality, the upper limits of what can be conservatively harvested from the donor area in a single session has more to do with the surgeon and his ability to recognize and respect the individual’s tissue characteristics than anything else. The ability of the surgeon to manage the artistry in creating a long term natural appearance is closely tied to his talent in consistently judging the proper and appropriate amount of tissue to be utilized in a single procedure. Over-utilization is the number one cause of donor area complications, and in general, a hallmark of an inexperienced surgeon. While trendy terms and concepts may come and go, sound surgical principles are the foundation of artistically strong results.

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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. Carman 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. Carman photos and then discussing matters with him during a phone consultation. Send us an email if you would like to discuss these matters further.

If you still have additional questions, you can simply click to contact La Jolla Hair Restoration!