What I Learned from Writing Questions for the Board Exam in Hair Restoration

As many of you know, I am an active participant in the education of other surgeons.  I run a national course on hair restoration and also participate as faculty in many workshops.  I also have written a textbook on hair restoration, Hair Transplant 360, along with many scientific articles on the subject.  Most recently, I flew out to Phoenix for a weekend to help write questions for the written re-certification examination for the American Board of Hair Restoration Surgery, of which I am a proud diplomate.

What I learned from an entire day locked up in a room with 3 of my colleagues and an expert moderator was the importance of clarity when writing exam questions for prospective examinees.  We had a very heated debate throughout the day about a question’s validity and also the clarity with which a question was posed.  To me, I did not mind ruffling feathers or making others in the room feel uncomfortable if the intended outcome was to have a clearer, fairer, and appropriate examination.  At the end of the day, we harangued and menaced each other until we got a workable 80 questions out for the next examination.  To me, I am very proud of what we accomplished but I am more proud of the intended outcome for the prospective examinees.

I think what I have learned from this process is always to think about the goal for a procedure, which in the world of hair restoration is to have a better result for a patient even if that means ruffling feathers during the procedure regarding quality control.  If we keep our mind on the goal, which is to have a better outcome, we can all as team members performing the procedure understand that challenging each other to be better is part of the process to achieve excellence.

Dr Samuel Lam is a board certified hair restoration specialist in Dallas, TX. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair restoration forum.

The Principle of Convergence:  How to Leverage Grafts in Hair Transplantation

In the past two years I have made a small but significant modification to my hair transplant work that I would like to share with my prospective and established patients.  The concept is convergence and how to place grafts especially toward the midline of the head in such a way as to achieve even greater degree of density per transplanted graft.

Principle of Convergence Illustrated

Let’s take a step back and explain two concepts that are needed to understand how convergence works.  First, the central forelock describes the anatomic region found immediately behind the hairline zone in the midline.  It is the most important area to transplant in terms of creating visual hair density to make an individual look less bald.  In fact, I tend to use stronger 3 to 4 hair grafts in this region as opposed to 2-hair grafts elsewhere and even select the thickest 3 to 4 hair grafts for placement here for added visual punch.  In addition, I place grafts into the central forelock with added density aiming upwards of 50 to 55 grafts per square centimeter as compared with as low as 20 to 25 grafts per square centimeter in areas of less visual importance like the posterior midscalp.

The second concept to introduce before directly speaking of convergence is the effect that the shape of the head has on the transplanted grafts.  Since the shape of the head is round, grafts that are placed perpendicularly upward will have a tendency to splay open and fall outward toward the sides of the scalp like an open book.  Because the central forelock, described above, is situated in the center and is aesthetically the most important area for transplantation, if grafts fall away from the center that is a problem regarding visual density.  Accordingly, the technique of convergence rectifies this splaying and helps to concentrate graft density toward the midline.

The way that convergence works is by having the grafts slightly tilt inward toward the center and slightly also point in a directed fashion about 20 to 30 degrees toward the midline.  This direction helps the hairs naturally augment the center for visual density but also helps to counteract the natural splaying effect that occurs by virtue of the head shape.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. If you would like to schedule a consultation please call 1-888-866-3388, or visit www.HairTX.com for more info.

Here is my course promotion for my Hair Transplant Cadaver Workshop for surgeons and assistants to be held on October 14-16, 2011 in St. Louis, MO, at St. Louis University:

It Is Never Too Late To Have A Hair Transplant

When I was recently in Phoenix writing questions for the hair transplant board examination, I had a touching story recounted to me that I wanted to share with you.  A fellow hair transplant surgeon had a patient come to him at 59 years of age to ask whether it would be considered too late to have a hair transplant at that age.  The surgeon responded that he truly did not think so, and the patient underwent the procedure, with a very happy outcome.  At 75 years of age, he said his 50th wedding anniversary was coming up and he noticed that he was thinning further and wanted more hair to make him look good in time for that special event.  Clearly, at that point, he did not think he was too old to look good.

Jack LaLanne

On the flip side, I had a 27-year-old gentleman who came to me saying he would only accept a very low straight hairline and if I did not give it to him he would go down the street to the next guy.  I explained to him that he would potentially look unnatural at 40 years of age given the nature of his request.  He replied that he did not care what he would look like at 40 years old.  I declared that at 42 years of age I clearly care what I look like and that he was arguing his perspective from naiveté.  Of course, I never operated on him, and I am glad that I did not.  I like the expression, “You never regret the patient you did not operate on.”

I like the quote by Jack LaLanne, who recently passed on, who said about exercise, “Inactivity is the killer and, remember, it’s never too late.”  He died at 96 years of age and the week before he died he was doing push-ups and sit-ups.  It truly is never too late to look your best.  However, as my counterpoint to the story, you can be too young for a hair transplant or not be a good candidate for psychological or physical reasons.

Samuel M. Lam, MD, FACS is a board certified hair transplant surgeon in Dallas, Texas. To learn more about Dr Lam’s hair transplant procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.

Parallel vs. Perpendicular Sites in Hair Restoration

There has been a controversy over the past few years regarding the best method to make a recipient site.  There are basically two ways to make recipient sites parallel (also known as sagittal) and perpendicular (also known as lateral slits, or coronal).  A recipient site, as a reminder, is the “hole”, or slit, that is made by the surgeon into which the graft preparation team will insert the hair graft.  Although I use both parallel and perpendicular sites during a given procedure, my overwhelming preference is to create parallel sites.  In this article I will explain the pros and cons of parallel and perpendicular sites and then explain why I prefer parallel sites.

This photograph shows parallel sites with the front of the head corresponding with the top of the photograph.

Before we start, we need to clarify what a parallel and a perpendicular site really are.  A parallel site, as the name implies, runs parallel to how the hair shaft grows.  If you are facing a person’s head, the site is made running front to back, i.e., it is longer from front to back than from side to side.  A perpendicular site is a recipient site that runs principally side-to-side of the patient’s head.  The proponents of perpendicular sites argue that these types of site are preferred because the hair grafts will not tilt upward after placement so the front to back angle of the hair shaft will not be changed.  That is the overriding concern for doing a perpendicular approach.  That is why I oftentimes use it for the temple area or the eyebrow area where the angle has to be almost entirely flat to the scalp.  However, I have found for the central head, a host of problems with the lateral slit or perpendicular method.

Perpendicular sites in my opinion do not control the angle of the site that much better when you are using very fine instruments that are matched very well for graft-to-site fit.  When I use an 18 or 19 gauge needle to make my sites, the sites are so small that the grafts do not have much wiggle room to change angles.  In addition, I ensure that the grafts truly fit the site before starting to make my sites so that they don’t move.  Also, I make my sites at a lower angle to accommodate for even a 5 or 10 degree angle change upward, which again is unlikely and even if there is such a slight change it would not impact the final result.

Here now are the reasons why I do not perform perpendicular sites in the majority of my hair transplant procedures.  Perpendicular sites run counter to the way that the hair grows.  When trimming grafts, it is very unnatural to cut them this way because that is not how hair naturally grows.  In addition, when making the sites for anyone who has natural hair already present or previously grafted hairs, it is very easy to transect the other surrounding hairs and destroy them when making perpendicular recipient sites.  This is the number one reason why I do not make perpendicular sites.  In addition, perpendicular sites run perpendicular to blood flow, meaning that the blood supply can also be compromised.  To me preserving blood supply for optimal hair growth is important.  For these reasons, I truly believe parallel, or sagittal, sites are much preferred for 90 to 95% of my hair-transplant work with the exceptions mentioned above.

Samuel M. Lam, MD, FACS is a board certified hair restoration surgeon in Dallas, Texas. To learn more about Dr Lam’s hair restoration procedures please visit our website www.HairTX.com or call 1-888-866-3388 to schedule a consultation.