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.

Hair Transplant for the Crown Part 3:  Understanding the Regions of the Crown

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.

Hair Transplant for the Crown Part 2: Types of Hair Loss and Hair Growth in the Crown and The Billboard Effect

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.

Follicular Unit Extraction (FUE):  Yes or No

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.

Persistent Sexual Dysfunction with Finasteride: A New Study

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.