The Importance of Planning
It is imperative that the probability of second or subsequent
procedures be discussed prior to the first follicular
unit transplant. This is an integral part of the long
term planning that is necessary to afford the best outcome.
Multiple factors are considered in making this judgment,
including age, degree of baldness, rapidity of hair loss,
hair characteristics, donor density, scalp laxity, styling
preferences, and previous procedures. Let’s take
a more detailed look at each of these factors.
Age:
Ironically, it is often the case that older men, with
more extensive balding, are better candidates for a single
procedure than are younger men with less advanced patterns
of alopecia. The older man who has lived with baldness
for a number of years is likely to have more realistic
expectations of his transplant outcome; he may be very
satisfied with thin coverage, and a frame for the face.
In addition, his degree of balding, that is, his Norwood
pattern, has very likely "declared" itself,
leaving little ambiguity in the surgeon’s mind about
how future hair loss will alter the clinical picture.
The young, often rapidly balding man may be more intransigent,
and therefore more difficult to counsel. As we discussed
earlier, his vision of the appropriate hairline for himself
can be wildly impractical. Furthermore, the patient in
his early twenties with, for instance, Class III, III-A,
IV-A or just limited crown balding is, to some degree,
an enigma. How quickly and how extensively will he lose
his hair? An attempt, through a large, single session,
to densely transplant all the thinning areas may not be
the best option. The patient may experience acceleration
of hair loss via effluvium, or his hair loss could simply
develop rapidly during the growth period for the new grafts.
If donor reserves are limited, and baldness progresses
rapidly, he could eventually be dissatisfied and unable
to proceed with further surgery. This patient needs to
know that he may require two or more procedures to appropriately
follow the progression of the hair loss, and to properly
conserve his donor resources.
Degree of Baldness:
In a patient willing and able to undergo a large session,
sometimes the more advanced levels of balding are amenable
to a single session. The stability of the hair loss is
estimable, expectations are likely to be reasonable, and
the goals are easy to state. In a single, large session
of FUT, a hairline and framing for the face can be established,
top and crown coverage may be possible, and the result
can stand on its own with a natural appearance. As we
discussed above, however, the more limited patterns of
hair loss in younger men present us with a dilemma; do
we wait, and if we transplant, where and how much? These
are just a few of the reasons that a consultation with
a trained and knowledgeable hair restoration physician
is of the utmost importance; there are many artistic elements
to be considered, as well as an acute understanding of
both the natural history of balding, and of the patients
mental and emotional condition.
Rapidity of Hair Loss:
A young man who sees his hair vanishing before his eyes
is likely to be in a vulnerable and suggestible state.
He most of all needs the truth, delivered with an attitude
of temperance, understanding, and hopefully, optimism.
If he is quickly progressing towards a Class VI or VII
pattern, he needs to know that complete crown coverage,
for example, may be difficult. Patients with earlier stages
of balding, who have had a recent and rapid onset, or
who have just noted an acceleration of their hair loss,
will need counseling about the advisability of postponing
the surgery; they must also understand the probable necessity
for multiple procedures and their particular suitability
(or unsuitability) for ongoing surgical work.
Hair Characteristics:
In general, the more favorable the hair characteristics,
the more likely a single session may be adequate for the
patient’s needs. Low contrast between hair and skin,
curliness or waviness, coarseness of the hair (except
when there is high skin/hair contrast), light-colored
or salt-and-pepper hair all lend themselves to the possibility
of greater coverage with a lower transplanted density.
To some extent, these favorable characteristics can compensate
for extensive balding and less than wonderful donor density.
Density and Laxity:
We will consider these two factors together, as they are
so intimately related. The donor area must be evaluated,
both for density and for laxity, in all patients consulting
for possible FUT. (Any significant miniaturization in
this area may mean the patient has an unstable donor area
and may not be a surgical candidate at all).
If the density is properly calculated, the total number
of movable hairs and movable follicular units can be estimated
with reasonable accuracy. This estimate is obviously of
great value in determining a plan based on the knowledge
of the existing donor reserves. However, a determination
of the density is not enough; the laxity of the scalp
also plays a role in the adequacy of the donor reserves.
If the scalp is excessively tight, either naturally or
as the result of scalp reductions or previous donor harvests,
this may limit the number and size of strips that can
be excised in the future.
If both density and laxity are favorable, then it is possible
that presently bald areas can be more densely transplanted,
knowing that adequate donor reserves remain to account
for progression of the hair loss pattern. This knowledge
gives the patient and the surgeon more flexibility in
their approach to current hair loss, and more confidence
in facing the eventuality of progressive baldness.
Styling Preferences:
A patient who prefers the hair combed straight back may
have even extensive balding treated with a single procedure.
This is because the crown area can be lightly transplanted,
or not at all, and still appear as a pattern found in
nature. Also, the crown can be covered by the hair from
the front and top of the head when it is styled thusly.
Those who prefer combing to the side may achieve a look
of greater fullness, but may sacrifice coverage of the
bald crown, if inadequate donor supply exists. Hair which
is allowed to naturally curl may enhance the illusion
of thick coverage, as will a "dry" look, as
opposed to a "wet" look.
Timing of Subsequent Procedures
Although a repeat FUT may safely be done as soon as the
new hairs are in evidence, and, indeed, space will exist
between previously tightly placed FU’s for new grafts,
there are valid reasons for postponing a second procedure
for 8 to 12 months. One is allowing the scalp to regain
some of its lost laxity. As the months go by, the scalp
will stretch to some extent, which will potentially allow
a greater harvest, and will facilitate an aesthetic closure
of the donor site. Also, it takes about 8 to 12 months
for the full cosmetic benefit of the transplant to become
evident. At this time, the patient and the surgeon can
make better judgments as to the degree of further work
that needs to be performed. A more uncommon issue is that
of telogen effluvium in the donor area; if this should
occur, it is best to give the follicles ample time to
recover, so that they are more likely to be seen and preserved
during follicular unit dissection.
Purpose of the Second Session
There are a number of common goals in carrying out a second
(or subsequent) session. One is to refine the hairline
(see Chapter Ten). No matter how meticulous the original
placement, it is impossible to anticipate what the true
effect will be once the transplanted hair has grown in.
Density can be added to the hairline, it may be lowered,
made more or less symmetrical, or the temporal angles
may be altered. A widow’s peak may be created or
accentuated and, if the hairline is too straight, it may
be rendered more irregular in order to "soften"
it. In a patient with advanced, stable baldness and adequate
donor reserves, the receded temples may be restored.
In addition to hairline refinement, the crown may be transplanted
(see Chapter Eleven). The necessity of this will be more
evident after the transplanted front and top are well
grown in; the patient with a new hairline and adequate
top coverage may be satisfied with a natural, "bald
spot" crown appearance, or may wish to go forward
with doing the crown if donor reserves and hair characteristics
are favorable.
If the hair loss has continued to be rapid, or if much
time has elapsed after the initial transplant, a second
session may be undertaken simply to follow the progression
of the baldness. There may have been permanent "shock
loss" of many miniaturized hairs; there may be cosmetic
consequences from this. The baldness may have proceeded
more toward the back, or the affected area may have widened.
Often, the reason is to add fullness, which is done by
increasing the density in the recipient areas. Even though
the FU’s may have been placed quite closely during
the first session, with the healing of the recipient sites,
there will be intervening space available for further
grafts. This can create a further fullness, as long as
the hair loss is stable enough and the donor supply is
plentiful enough.
To reiterate, none of these considerations should be a
surprise to either the surgeon or to the patient. The
possibilities must be taken in to consideration early
on, before the first procedure; this education is part
of the physician’s responsibility. However, in the
interest of self-empowerment, and simply as an informed
consumer, the patient is compelled to read, research,
ask questions, and become as informed about the long term
probabilities as he is about the short term outcome.
