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.

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.

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.

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.

This brief article will discuss the regions of the crown and why they are important when designing a crown for hair transplantation.  The crown can be divided into three geographic zones that run like bands across the scalp:  the vertex transition zone, or vertex transition point; the upper arc; and the lower arc.  The vertex transition point (VTP) occurs where the scalp transitions from the vertical plane of the crown to the horizontal plane anteriorly of the posterior midscalp.  The hair angles in the VTP aim primarily forward with a bit of slight splaying outward toward the side edges.  However, there is almost no whorl at this point, as almost all the hairs are angling forward.  The upper arc is the arbitrary upper half of the crown that begins above the center of the whorl; and the lower arc is the arbitrary lower half of the crown that begins below the center of the whorl.

Regions of the Crown for Hair Restoration

The VTP and the upper arc are the most important areas to create visual density, a fact that will be mapped out more in detail in the coming blog articles in this series.  The VTP is the area that can look particularly bald because light tends to strike and cast a bald appearance at the transition from the vertical to the horizontal plane of the scalp.  Therefore, stronger grafts across the VTP are very important.  The upper arc is just as important since the grafts in the upper arc sweep up to cover the VTP and sweep down to cover the lower arc.  Therefore, the upper arc is a priority in terms of graft density and stronger graft size.  The lower arc tends to be a less important area since it does not impart as much visual punch and also does not cover anything other than non-balding scalp.  Accordingly, understanding these geographic terms can be very helpful for a surgeon who is planning to allocate grafts for optimal aesthetic impact.

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

For the sake of completeness, it is worth starting our discussion of crown restoration by understanding the types of hair loss that occur in the crown as well as the types of hair growth patterns as well.  Finally, we will discuss the principle of the “billboard effect” which is to say why crown transplants may have a lesser result than transplants performed elsewhere on the scalp.

Crown Hair Loss Patterns
The types of hair loss in the crown can be divided into three patterns:  a round or oval pattern, a kidney-shaped pattern with the indentation at the top, and a coronet pattern with a smaller circle of loss adjacent and below the principal one.  Wetting the hair down and looking very carefully at the crown (especially looking for the coronet pattern that is sometimes hidden below some miniaturized hair) is important when planning and strategizing for a hair-transplant procedure.

Types of Hair Loss Patterns in the Crown

As will be discussed in the upcoming articles in this blog series, the crown typically has a whorl pattern, i.e., a spiral of hair, which must be recreated.  If someone is completely bald, then the surgeon has freedom to create the crown how ever he or she sees fit.  However, if the patient still has existing hair in the crown, then the surgeon must match the angle and flow of the existing hairs in that region.  The most common pattern is a clockwise whorl, or as pictured an “S” pattern.  The next most common is the Z pattern, with far smaller percentage of individuals having two whorls SS or a SZ.  There is however no ZZ pattern found in nature.  The diffusion pattern is much more commonly found in women.

Patterns of Hair Growth in the Crown

The Billboard Effect

The “billboard effect” describes why hairs transplanted into the crown may have per transplanted graft less visual punch than the same number of hairs transplanted into the frontal hair area.

"The Billboard Effect"

First of all, hairs transplanted into the crown region lie on the vertical plane of the scalp.  Like a billboard that is a vertical structure, you are looking straight on at the naked scalp.  Compare this with the top horizontal plane of the scalp where you are not looking straight on at the bald scalp but from an angle.  Therefore, hairs transplanted into the crown still can show visibility of the bald scalp since you are looking straight on at it.   Secondly, hairs that are transplanted into the crown in a whorl pattern are going in all different directions meaning that they splay open and thereby can show more bald scalp.  For both of these reasons, it is always important to undersell a patient what a transplant in the crown can do.  I typically admonish a patient that at times I need two full sessions to accomplish a remarkable result in the crown region, but obviously not always.

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

Over the past few years, there has been ever increasing popularity of harvesting hair without an incision on the back of the head.  This technique is known as Follicular Unit Extraction, or FUE for short.  It also has been called by other abbreviations, FOX, FIT, etc., all meaning the same thing.  Although this method has intuitive appeal, I would like to address my thoughts on why I think this technique has limited benefit in select cases.

The best indication for FUE in my opinion is in using body hair to transplant into the head for someone who literally has no more usable donor hair to transplant.  In addition, someone like who is in the military and must maintain a very short hair style is also a good candidate for FUE.  These are the best examples of when FUE can serve a fantastic purpose.

The flip side of FUE is when not to perform it or at least to understand the limitations of doing so, which I have elaborated on elsewhere on this Web site and I will reiterate in this article:

• Hairs that grow in the donor area do not grow vertically downward but splay toward the base of the follicle.  During harvesting (no matter what FUE method is used), the hairs that are extracted can be easily damaged and lead to poorer growth.
• Grafts that are harvested are “skinny” grafts that do not have the surrounding adnexa (supporting tissue) and therefore do not grow as well after transplantation, as even the pioneers of FUE have admitted.  Nothing truly compares to power magnified graft dissection during linear strip harvesting for high-quality graft integrity.
• The donor area is not free from any signs of damage (as will be discussed below) but with trapped, or buried, follicles can lead to pitting or cyst formation.  A common problem is “capping” in which only the outer skin is removed and the follicular unit is damaged and unusable.
• Curly or fine hairs are not candidates for this procedure, as transection (inadvertent cutting through and destroying) donor hair is too high, and waste is significant.
• To yield a sizable donor harvest of at least a thousand grafts (which would be a small FUT, or incisional hair transplant session), a significant area of the donor hair must be shaved short, leading to several weeks of recovery since the hundreds to thousands of holes in the donor area must heal and are exposed with the shaved donor area.  This poses a significant cosmetic problem to many individuals.  In FUT, the donor scar is not visible underneath the covered donor hair from day one.
• Since donor harvesting is taken over a very wide area on the back of the head, the area of harvest may include areas that are “unsafe”, i.e., areas that may be programmed for future hair loss.  The compact incisional-based harvest typically uses an incision that falls precisely in the area of optimal safety, i.e., hairs should not be lost over time as one ages.
• A gunshot wide harvest over the entire back of the head can lead to thousands of micro-traumas to the head that results in distorted and unharvestable hair follicles immediately adjacent to those ones that have been harvested.  Contrast this to an incision-based procedure in which all the neighboring follicles are preserved and not distorted.  This allows for improved future hair-transplant sessions.
• When a large number of grafts are harvested, a fine stippled scarring can occur in the donor area that leads to an overall diminished quality to the donor hair appearance that resembles balding in an area that is typically not subject to balding.
• Multiple sessions are needed to match one session of FUT given the limited size of each harvest and the risk of widespread scarring when harvesting is performed in the donor area using FUE.
• FUE takes much longer to perform meaning grafts have a longer ex vivo time (out of body time) that directly impacts graft viability and growth potential.
• FUE generally is more expensive than FUT when performed by experienced surgeons in the field.

Today hair-transplant surgeons are facing a very daunting issue in that a leading company perpetrating FUE claims has been pushing non-physician assistants to be the principal agents in doing a procedure and selling their machine to physicians with very little experience.  In fact, that is what in short they told me. The current president of the International Society of Hair Restoration Surgery (ISHRS), which I am a proud member, has already stated in emphatic terms the problems that this company has wrought on the quality of the hair-transplant business.  When you have inexperienced physicians performing a hair-transplant procedure no matter how fancy the machine is the results are not only poor but devastatingly so.  Understanding how hair angles grow and how to make the proper judgment when performing a hair-transplant procedure are the most important prerequisites for performing quality work.

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

What has been making rounds on the Internet this past week is a shocking report in the Journal of Sexual Medicine that states that finasteride (marketed as Propecia) for hair loss can cause permanent impotence and related sexual problems.  Merck, the manufacturer of the product, has reported between 3 to 8% incidence of sexual side effects; whereas the Journal of Sexual Medicine reported up to 38% in a study in 2008.  These numbers however have always been thought to be temporary in nature.

Michael Irwig, a medical researcher at the George Washington University in Washington D.C., the lead author of the study, argues that sexual side effects may not be temporary.  His team at George Washington University studied 71 men who reported these side effects including erectile dysfunction (ED), low libido and orgasmic issues, with average duration of ongoing symptoms being 40 months after stopping finasteride.  20% of these men reported ongoing symptoms for greater than 6 years after cessation of the medication.

I have had an email exchange with my hair-transplant colleagues from across the world regarding this matter to arrive at a collective understanding of how to educate our patients regarding these findings.  At this time, the International Society of Hair Restoration Surgery (ISHRS) is coming up with a position statement on this matter, which I will update you on as soon as it is pusblished.

My colleagues and I agree on one thing:  there are very few to none of our patients who experience permanent effects.  I personally have encountered only one patient who has reported this side effect, and I have probably prescribed over a thousand prescriptions for finasteride.  The data in this article is not controlled and only pulls from individuals who have experienced this problem.  In the general population there already is an incidence of 5 to 10% of ED in younger men with some reported incidences of 40% after the age of 40 years of age.  There are a host of physical and psychological effects that impact ED that may or may not be related to finasteride usage.

One thing is for certain, finasteride is a very effective, if not the most effective medication, for male pattern baldness and at this time is the major salvation for very young men (in their early to mid 20s) who are losing their hair and in whom surgical hair restoration may not be a safe option given the risk of ongoing hair loss and need for further hair transplants.  For those who have not experienced any sexual side effects from this medication, I would encourage you to consider continuing because I truly believe the data in this report is very soft and with the overwhelming percentage of my patients doing well on this medication I am a firm believer in its efficacy and safety.  In addition, I have found that those men who suffer sexual side effects from the medication have either had the symptoms dissipate with ongoing usage or improve just with taking the medication every other day.

I hope this blog provides a more balanced appraisal of the recent study than may be portrayed in the media and does not frighten patients who continue to do well on this medication or who are interested in starting it.

Samuel M. Lam, MD, FACS is a board certified hair restoration surgeon specializing in hair transplant procedures for men and women. 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.

The vertex transition zone (VTZ), or vertex transition point, can also be thought of as the posterior “hairline” in that it forms the transition from the flat, horizontal midscalp and the vertical plane of the crown.  As a reminder, the anterior hairline, or hairline, is formed at the intersection of the forehead and the horizontal plane of the scalp.  One can think of these two as borders on a box in which the vertex transition constitutes the back border, as illustrated in the accompanying Figure.

Figure reprinted with permission from Hair Transplant 360, Volume 1 (Jaypee Brothers Medical Publishers, 2011), Samuel M. Lam MD

The vertex transition zone is often then the posterior limit of a hair transplant that serves to rebuild the hairline and the central midscalp.  Similarly, it is oftentimes the anterior limit when a crown is rebuilt. It is rare that a surgeon will be able to rebuild a bald scalp from the front hairline all the way to include the crown in a single session because there is just not enough hair to make both areas in a single, initial pass look dense enough to be worth the effort and to be natural in appearance.  Put in another way, scattering 5,000 hairs across from the anterior hairline all the way to include the bald crown the first time can look grafty and still keep the patient looking bald.  Accordingly, the vertex transition zone serves as the juncture between session 1 and session 2 of two hair-transplant procedures with usually session 1 being allocated from the front hairline to the VTZ and session 2 from VTZ to bottom of the crown.

Besides serving as a transition zone between the front scalp to the crown, the VTZ serves another important aesthetic purpose.  If you think of the front hairline as framing the face, the VTZ serves to frame the posterior scalp.  When light strikes the front bald scalp it tends to reflect glaringly at the missing hairline where the horizontal and vertical planes of the scalp meet.  Similarly, in the back of the head the missing hair creates a stark baldness when light strikes this intersection of two planes.  Accordingly, the VTZ is a very important area to create density to reduce the illusion of baldness in this area. Further because the grafts are placed at the beginning of the horizontal plane they can serve to heighten density from even a frontal view.  Stronger grafts tend to be placed there as a priority to create the posterior head frame, or least should be considered a priority after other strategic zones are met, like the anterior hairline and central forelock, etc.

The angles of the recipient sites and the grafts placed into the recipient sites should be in a slight radial fashion to match the transition from the radial crown to the relatively straight forward directed posterior midscalp sites.  The radial splaying progressively becomes less apparent row by row going forward as the crown blends into the posterior midscalp.  The lateral or outer sides of the VTZ have a more accentuated outward-radial pattern as they blend into the posterior portion of the lateral humps, or outer temporal areas.  These subtleties are meant more for the surgeon to understand but are offered up for the reader for sake of completeness and for a thorough understanding of the VTZ and its role in a hair transplant procedure.

Samuel M. Lam, MD, FACS is a board certified hair restoration surgeon specializing in hair transplant procedures for men and women. 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.