COMMON QUESTIONS AND ANSWERS

The answers to the questions in this section of the website represent Dr. Unger's personal professional opinions—based on his practice experience. Other physicians may answer them differently because of different experiences over their careers. We therefore recommend you also consider reviewing the following ISHRS subjects/site for perhaps a different point of view.

http://www.ishrs.org/hair-articles.htm

What is a reasonable long-term hair transplant goal for a man with an average-sized area of Male Pattern Baldness (or who is destined to develop an average-sized area)?

In the long term, the answer is of course the same, whether someone is already bald or is only destined to develop an average-sized area of Male Pattern Baldness (MPB). However, let's begin with a definition of "average". Figure 12 shows the "types" or degrees of MPB as defined by Drs. Hamilton and Norwood. While their schematic drawings don't cover all the variations of MPB, they are by far the commonest way that doctors define the severity of MPB. For a large majority of men Type V or Type VI MPB is what will likely develop over time, and so we will use Type V to Type VI as the "average".

The answer to the question is that a man with Types V or VI MPB can expect to transplant from the hairline back to a zone where the head changes from a more or less horizontal orientation to a more or less vertical one at the start of the "crown area", in two sessions of approximately 1500-2500 Follicular Units (FU) each, provided only that the scalp in the donor area has average laxity, average hair density and the surgical team is skilled. Two such sessions at an average density of 25-30 FU/cm² would usually produce very nice hair density (Figs. 4, 5, 17). If the objective was higher than average hair density (generally, an unwise long-term goal) either more FU/session or a third session would be necessary. (See also "What are the advantages and disadvantages of "dense packing"?) If the balding area is limited to the frontal area, a single hair transplant of 1500-2500 FU is nearly always sufficient (Figs. 2, 3, 6, 7, 14). If the individual wants to also transplant his crown area, another one or sometimes two sessions would be required (if the donor area was in fact sufficient to yield three or four sessions).

What are the advantages and disadvantages of megasessions?

The larger the number of grafts per session, the larger the area that can be treated. Quite naturally, therefore, many patients prefer "megasessions". The definition of the term "megasessions" varies from physician to physician. We refer to all sessions of greater than 2500 to 2750 units per session as "megasessions". We prefer to limit ourselves to sessions that are approximately 2500 FU or less per session for several reasons:

1.      The more incisions made in the recipient area, the more blood vessels will be cut and the less optimal the blood supply in the recipient area will be. Remember that if 2500 FU are being transplanted even a 1 mm long recipient-site incision (typically made with a 19-g needle or a comparable small blade) means that 250 cm (10 feet) of incisions will be made in the area being treated. We believe that this is trauma enough to an area that is quite often the size of the palm of a typical man's hand. If the incisions are smaller than 1 mm then the number of grafts can be increased above that number. If they are larger than 1 mm then the number should ideally be decreased.

2.      The larger the session the more physical and emotional strain the patient, the physician and all his/her assistants are under. Hair restorations surgery is part science and part art. It is therefore and best carried out when everybody is relaxed and under as little emotional and physical strain as possible. A session of 1500 to 2500 FU usually will produce very nice hair density in one of either the frontal, mid-scalp or crown areas.

3.      The more grafts transplanted the longer the sessions will take and the longer the donor tissue will be out of the body. Most practitioners are uncomfortable with that period being longer than approximately 8 hours. Usually sessions of more than 2500 FU will take more than 8 hours.

4.      Often, the only way one can get more grafts per session is to take a wider strip than usual. However, the wider the strip is, the greater the wound tension on closure becomes. The more the wound tension, the greater the chance you have of developing a wider than average donor area scar. This does not mean that most patients who undergo a megasession will develop a wide scar, but, in general, it does mean that the chance of that occurring increases.

What are the advantages and disadvantages of "dense packing"?

We define "dense packing" as anything more than 35 FU/cm². If the recipient site incision is only 1 mm long that means that at density of 35 FU/cm², one produces a total of 3.5 cm of incisions in every cm² of scalp. Nearly all studies have suggested that increasing total incisions length above that number will result in less optimal hair survival in the grafts—and these studies have been done under ideal circumstances, not in the course of every day routine practice. (For example, see Table 1 below.) It is possible to get better hair survival with densities above 35 FU/cm² by making smaller recipient site incisions which in turn requires smaller grafts or maximum trimming of tissue around the hair follicles. However, the latter makes the grafts more susceptible to dehydration and physical trauma as they are being prepared, stored, transferred to, and inserted into the recipient area sites. The need of perfection in the performance of all members of the surgical team must increase as the number of grafts per cm² goes up and the size of the graft and incisions go down. We believe it becomes increasingly difficult to promise such perfection as FU density increases above 35 FU/cm², during a procedure that often includes seven or eight people working on a patient from 7:30 a.m. to between 3:30 and 5:30 p.m. We therefore recommend that ideally 30 FU/cm² be employed in virtually all areas of the recipient area.

Just as importantly, 25-30 FU/cm² produces a very good appearance in nearly all patients (Figs. 2 to 7, 14 and 17). Given the limited supply of donor tissue and the unknown extent of the eventual area of baldness in any individual, we prefer to leave as much donor hair "in the bank" as possible for future use—especially in younger men. This is preferable, in our opinion, to producing very dense hair growth in one area at the cost of increasing the possibility of running out of grafts for other areas that the patient will eventually develop, and that he might want to treat. Cosmetically good results only became possible at 25-30 FU/cm² because there were enormous advances in FUT technique from approximately 2000 to 2005. For example, Table 1 summarizes the results of three FUT studies carried out by Dr. Melvin Mayer and colleagues, all of whom are respected and highly competent FUT proponents (see Table 1 below). Hair survival at the now commonly used density of 30 FU/cm² went up from 72.5% to 98% during that time period. This, "in a nutshell" is the reason I switched from using FUT in a minority of my patients to using it for 99% of them, approximately three to four years ago.

Notwithstanding the above, the use of up to 40 FU/cm² in small areas such as a small egg-shaped area in the midline of the frontal area is often used for FU containing three or more hairs each. Such small areas are not that demanding on the staff and especially in an "egg-shaped" midline frontal area (Fig. 12) can produce an appearance of great density in the entire frontal area at the "cost" of very few extra FU/cm².

Do I have to wait until I'm bald or nearly bald before I have a hair transplant?

Definitely not. There are many advantages to beginning transplanting before the thinning becomes easily more noticeable to others. The main ones are that, a) you don't have to go through the embarrassment of obvious balding or being bald, and b) it usually allows you to spread the inconvenience and/or the cost of transplanting different areas over a longer period of time.

But, the more hair that's present in the thinning area, the more skilled the physician has to be when he/she is making the recipient area incisions and the more allowance that must be made for the thinning to extend into new areas with the passage of time. For example, unless the recipient site incisions are made at exactly the same angle and direction of the existing hair, many of them could be lethally injured and little or no gain in hair density could be achieved. Both skill and patience are required to avoid such an outcome. Depending on the amount of hair present and the complexity of the hair angles and directions, it's not uncommon for a good surgeon to spend 1½ to 2½ hours on just this segment of the procedure. The mental and physical demands of a large FUT session is the main reason why I think it is best for most hair restoration surgeons to limit themselves to one such surgery per day.

In addition, as alluded to above, unless a substantial effort is made to anticipate future areas of hair loss, and those areas are treated at the same time as the more obvious areas of thinning, one can end up in what may seem to be an ongoing chasing of relatively quickly developing new areas of hair loss. For many years we have recommended wetting the hair prior to mapping out the limits of the area to be transplanted so that such less easily noticeable areas can be treated at the same time. If this is done, the possibility of a "chase" is substantially reduced, at least for many years (Figs. 4, 6, 13, 14). Of course nobody has a magic crystal ball that can tell you how large any balding area will become 15, 20, 30 or even 40 or more years down the road, so the older you are when you begin transplanting, the more likely later sessions in the same or adjacent areas may not be required. The absence of a perfect crystal ball is why I also recommend leaving one or two sessions of grafts "in the bank" in the donor area in younger individuals. That way, if your balding area eventually does extend further laterally than your doctor expected, you still have hair available for further transplanting.

There is, of course, a "cost" to treating less obvious areas of hair loss at the same time as more obvious area are transplanted: If one is using the same number of grafts in both instances, sometimes you will end up treating less obvious areas of hair loss lateral to the more noticeable areas of thinning, instead of being able to transplant farther towards the back of your head in areas that are currently noticeably thinning. Some doctors prefer to do the latter while I prefer to do the former, but ultimately the final choice belongs to the patient.

It is important to remember that if you transplant into a hair-bearing area, the hair density that is initially achieved will be greater than it will be when the untransplanted hair in that area eventually falls out years later. That's because you initially will have both the transplanted and untransplanted original hair in that area (Figs. 6, 7, 8, 14, 17, 18-20) but eventually you will have only or primarily the transplanted hair. In fact, with the passage of time, you probably won't have all of the latter! The transplanted hair grows in its new place for only as long as it would have in its original location. As you get older, the rim hair, from which you got your donor hair, nearly always gradually gets sparser. That means even some of the transplanted hair may not be permanent. Luckily, much of it is—especially if your doctor chooses to always take your donor hair from the middle of the densest area of the rim. The latter is because the thinning in the rim progresses from both its upper and lower borders so the densest zone in the middle of the rim hair is least likely to thin out with time. In addition, as your hair gets whiter with age, it also looks thicker than darker hair does, so an additional "touch-up" transplant is often not necessary.

By the way, most of the reasons some doctors give for preferring to not operate on men who are not yet bald are the same ones most of them used to give for not treating women with Female Pattern Hair Loss (FPHL). Yet now, most hair transplant surgeons are quite willing to operate on a substantial percentage of women.

Should I wait until I'm 25, 30, 35 years old or older before I start hair transplanting?

Because of the potential prognostic problems discussed in my answer to "Do I have to wait until I'm bald?" some doctors recommend just that. Certainly the older you are when you begin transplanting, the easier it becomes to determine the eventual size of your bald area and this minimizes the possibility of unanticipated areas of baldness appearing over time. I think most hair restoration surgeons therefore prefer to operate on older patients. But I believe that the best answer to this question really belongs to the completely informed patient who has to live with the consequences of the answer. Some men, for example, are severely emotionally distressed by their hair loss, some men feel their career depends more than usual on their appearance or that their social life or self-confidence is being too adversely affected by their balding. The longer you can wait to start transplanting the better, because the more accurately your doctor will be able to estimate how big or small both your bald recipient area and permanently hair-bearing donor area will eventually become. So by all means wait if you can, but don't feel you must do so until you talk to an ethical physician. And if you're young, a) try to do no more than two sessions until you are at least 30 to 35 years old, b) try to keep one or two potential sessions in your donor area "bank" for the future (in case your doctor's estimate was too optimistic and, c) ideally, I believe your doctor should leave only one linear scar in your donor area, no matter how many transplants he does on you. (See below). Also, I believe you should be more reluctant to have "dense packing" or "megasessions" carried out because of the increased difficulty of accurately assessing your long-term donor/recipient area ratio. (See also below.)

What are the advantages and disadvantages of leaving only one linear donor area scar (regardless of the number of sessions)?

There are several advantages:

A)   As men with MPB get older, the balding process gradually invades the "permanent" donor rim hair from both its highest and lowest margins, respectively from the obviously balding area and the nape of the neck. Whether or not the "invaded" area eventually goes bald or not (you may die before it does) it will nearly always lose some of its original hair. As I mention elsewhere, not all the rim hair is permanent. The place that will most likely thin out the least over time is the middle of the thickest zone of hair in your rim—that is also the most distant from the rim hair margins. The first donor strip should therefore always be taken from this most permanent zone. Subsequent donor strips should also be harvested from this area for the same reason. That means the scar from any prior session(s) should ideally be somewhere within any subsequent strips—again for hair longevity reasons. It is more difficult and time-consuming to prepare FU grafts from the areas immediately adjacent to a linear scar—which is one of the main reasons why many hair transplant surgeons prefer to not do this. But because of maximum longevity, I think the time and effort are worth it.

      The hair density on either side of the scar also decreases as the edges of the donor wound are stretched together prior to suturing or stapling. The scar itself is of course hairless. This means that if you want to get the same number of FU as you harvested in the prior strip(s), you have to take a wider strip on each subsequent session. As long as scalp laxity permits a wider strip to close with essentially no tension, there is no problem with that approach. But if a wider strip results in too much tension when the wound is closed, you may get a wider scar than on the prior occasion(s). I believe that the finest scar you can get after each session is more important than getting the same number of FU with each session (or even more FU). In brief, in the long run, closing wound tension is more important than the number of FU.

B)    If the scar from a prior session is below or above a new donor strip site, that scar will somewhat decrease the blood supply to respectively either the lower or upper new wound edge. Therefore the new scar may not be as narrow as the prior one.

C)    If the scar from a prior session is below a new donor strip site, it will not only result in a decrease of the blood supply to the lower wound edge but will also increase the amount of tissue swelling that always occurs post-operatively at the donor site. This is because such a scar will to some extent delay the drainage of the post-operative swelling down towards your neck. This too would tend to cause a less ideal scar to form.

In summary:

In all the years that I have been transplanting hair, virtually all the cosmetic problems that have eventually occurred have done so in the donor area—not the recipient area. And nearly always the problem has been that the multiple scars that were typically (until recently) produced in the donor area—and that were once easily covered by the dense surrounding donor rim hair—gradually became noticeable as that rim hair thinned out with time. I believe that the concept of a single donor strip scar (regardless of the number of sessions) will eventually be seen as important to the donor area as FUT has become to the recipient area. Having said that, there are rare exceptions to this advice, mostly in older individuals in whom I sometimes will use a new and usually lower donor site for the last session.

What are the advantages and disadvantages of "trichophytic" closure of the donor area?

Tricophytic closure of the donor area consists of the trimming of a portion of the most superficial layer of the skin—the epidermis—off one edge of the donor wound prior to closing it, such that the hair on the other edge of the wound might grow through the scar and render it virtually invisible. As mentioned elsewhere in this website, we strongly recommend that the scar be excised as a component of any strip that is carried out subsequent to the first one. (See "What are the advantages and disadvantages of leaving only one linear donor area scar regardless of the number of sessions?") In addition, good conventional harvesting technique results in a scar that is no more than 0.1 mm to 0.5 mm wide in a large majority of patients. Moreover, it should run through the densest hair in the donor rim. Because of the preceding three factors, the donor area scar—even after multiple surgeries—is not noticeable in nearly all patients, including when the hair is wet, unless one looks carefully for it (Figs. 24 to 27).

Furthermore, if hairs grow through a scar, it becomes more difficult to dissect those hairs out of the scar tissue without lethally injuring them, if the scar is included in a subsequent donor area harvest—as we recommend. If donor scars are narrow enough to be found only on close inspection, there is no cosmetic reason for undertaking this extra difficulty and follicular danger except when the last strip is taken, when obviously one would like to produce as "invisible" a scar as possible. On the other hand, for those few individuals who have noticeable scars or heal with wider than average scars because of their inherent healing characteristics, trichophytic closure is worthwhile using, as is Follicular Unit Extraction (FUE) after the last session. (See "What are the advantages and disadvantages of Follicular Unit Extraction?") Finally, if despite the foregoing discussion you would still prefer to have trichophytic closures with each session, tell your surgeon. It is extremely easy to do and only takes an extra few minutes of operative time.

What are the advantages and disadvantages of Follicular Unit Extraction (FUE)?

FUE is a method of obtaining individual FU directly from the scalp, instead of microscopically dissecting them from a strip of donor tissue that has been excised from the scalp. A small sharp punch, similar to a cookie cutter and usually 0.8 – 1.0 mm in diameter is used to superficially incise the skin around the FU which is then extracted with a combination of pressure and tension.

I believe FUE is ideal for some people with very tight scalps and for most of those who have noticeable linear scars from prior old-style hair transplanting in their donor areas (Fig. 22). FUE can always be used to camouflage or eliminate even a good linear scar after the last strip is excised. I also believe that a combination of single scar strip donor harvesting and FUE—after all the strips that could and should be excised have been removed—will increase the number of FU that can be obtained from any donor area. Some have called this "hybrid donor harvesting". But remember, the farther this FUE strays from the middle of the densest rim hair, either upwards or downwards, the greater the chance that some or all of the hair in FUE grafts will eventually be lost. (See "What are the advantages and disadvantages of leaving only one linear scar in the donor area regardless of the number of sessions?) That is the main reason why I believe FUE should nearly always be employed as a "second line" approach rather than as a "first line" that some recommend. Extremely long sessions, generally fewer grafts per session, and higher costs (per FU) of FUE vs. strip harvesting are less problematic to me than the preceding. On the other hand, less post-operative pain, no sutures and sometimes the ability to shave the head without any scarring being noticeable are understandable attractions of FUE.

Body-to-scalp FUE can also sometimes be worthwhile under the same circumstances noted above, but we are at a very early stage of this technique. At present, (summer 2007), even the "masters" of Body-to-Scalp FUE have found hair survival exceptionally variable, so those who want to try it should keep that in mind. There are other reasons that I currently prefer strip harvesting to FUE for most patients that I won't go into here. Some will almost certainly be overcome with the evolution of FUE or the instruments used in FUE. However, for the time being, I recommend FUE for only a few of my patients. And remember that FUE can be done well or badly (Fig. 23), so choose your surgeon carefully.

When looking at the "before" and "after" photos, what should I be looking for?

The apparent hair density of a transplant of course depends not only on the number of grafts used, and the size of the area treated but also the hair characteristics. Fine-textured hair, for example, maximizes naturalness while the coarser, frizzier, wavier or curlier the hair, the thicker the hair will look. In general, the less color difference between the skin and hair, the thicker the hair will appear, but if FUT is used this is a less important parameter. It's important to remember the above when one looks at before and after photographs. Similar before and after head positions and lighting are also important factors to consider—especially on the Web. Holding the head at a slightly different angle can have a profound impact on the apparent density of hair so always look for comparable head positions in "before" and "after" photos (Fig. 4). And of course less light makes the hair look thicker than more light.

What are the most important questions to ask during a consultation for hair transplanting?

The first and most important question to ask is if the person you are meeting with is a physician or better yet, if he/she is the physician who will be carrying out your surgery. There is usually a difference between a non-physician, even a well-prepared one, and a physician giving you the information. If the person you are meeting with is the individual who will be carrying out your surgery, he/she will be more knowledgeable than anybody else as to what exactly will be done during the surgery. In addition, there is a better chance that the purpose of the consultation is not to talk you into undergoing the procedure—subtly or otherwise—but rather to give you information about it. Having said that, the following are eight good questions to pose to whoever is interviewing you:

a) What aspect of the surgery is carried out by the physician and what aspect or aspects will be carried out by his assistants/technicians/nurses? In particular, it is best that the design of the hairline and area to be treated, the incising and suturing of the donor area and the making of all recipient site incisions be done by the physician. In most offices, technicians/nurses will be dissecting the grafts from the donor strip that is removed and inserting the grafts once the physician has made all the recipient sites. These are extremely time-consuming portions of the surgery and if a single individual were trying to carry out a typical transplant session himself/herself, the procedure would last three or four times as long as it usually does. For example, it is quite typical for a follicular unit transplant (FUT) session of 1500 to 2500 follicular units (FU) to take from 7:30 a.m. until between 3:30 p.m. and 4:30 p.m. The longer a procedure lasts, the greater the chance becomes for a) unwanted side effects to occur in the patient and, b) for some of the hair follicles to die while waiting to be inserted. Once the recipient sites have been made by the doctor, the density of hair in different areas, as well as hair angle and direction in every area, has already been decided upon by the physician. (The graft can only be inserted at the same angle and direction as the incisions were made.) Also, inserting the grafts in the least traumatic way and as quickly as possible is a more important factor than whether the physician is inserting the grafts or whether somebody else is doing that.

b) How many years experience do members of the surgical team have with hair restoration surgery?

c) How many hair restoration surgeries has the physician carried out prior to you seeing him/her?

d) Where did the physician go to medical school and what specialty training has he/she had?

e) How many hair restoration surgeries are carried out each year in the physician's office?

f) How many hair restoration surgeries does the physician carry out per day?

In most situations, ideally if you are planning a session of 1500 or more grafts you should be the only patient that your doctor is operating on that day. While good work is possible if more than one session is carried out by the same doctor, it is more likely that he/she will be under less pressure and of course the physician's attention will be devoted completely to you if yours is the only surgical procedure he/she is doing. (If small sessions are being carried out, more than one surgery becomes more acceptable.) Somewhat similarly, although many hair restoration surgeons' offices often provide other cosmetic services, if your doctor is busy enough to be able to limit his/her practice exclusively to hair transplanting, it is a good sign of both his/her reputation for good results and the office staff's skills, duties and therefore expertise.

g) How many grafts will be transplanted during your treatment that day? What kind of grafts are they? How many hairs do each of them contain?

Some clinics refer to the numbers of hairs they transplant per session and others to the number of grafts they're going to transplant. Be sure you understand the difference because there is usually more than one hair per graft and ultimately the number of hairs moved is more important than the number of grafts.

h) How densely will the grafts be transplanted?

If FUT is being carried out, generally, the safest maximum hair density for the grafts is approximately 30 FU/ cm² give or take 5 FU/cm² (see also "What are the advantages and disadvantages of dense packing?"). Perhaps more importantly, remember always that there is a limit to the amount of hair that can be removed from the donor area over your lifetime. A goal of "thick" hair is usually unwise, especially in young patients—because the more hair you use in one area, the less hair you have left in the donor area to use in other balding or bald areas that you have now or might develop over the years. Moreover, densities of 25-30 FU/cm² produce hair densities that satisfy the vast majority of patients (Figs. 2 to 7 and 17).

Is hair transplanting a reasonable option for women?

All women contemplating hair restoration surgery should first see a dermatologist—preferably with a special interest in hair loss—or an endocrinologist to be evaluated as to whether there is any medical cause for their hair loss and whether those problems can be satisfactorily treated medically instead of surgically.

Hair transplanting was not an option for most women years ago because of the older techniques that were utilized then. It is surprising however, how many doctors, and even dermatologists, are still unaware of the fact that modern hair transplanting techniques have improved so much that many women with pattern hair loss are now candidates for the procedure. In fact, most of the women we see for hair loss are reasonable candidates (Figs. 18 to 21).

The most important factors that need to be evaluated when a woman is seen for hair restoration surgery is the long-term donor/recipient area ratio and, given the limitations of the donor/recipient area ratio, her expectations for the procedure—in specific, the location and extent of the areas that can and should be treated, as well as the density of hair that can and should be produced in those areas. In most women, because of less satisfactory donor/recipient area ratios than in most men, the best goal is usually to transplant only the most cosmetically strategic areas of hair loss. The hair in the thickened areas is then used to comb over those thinning areas that weren't treated. Scars and hairless areas, subsequent to cosmetic surgery, can also be successfully transplanted (Figs. 21 and 33). (An article published in the Journal of the American Academy of Dermatology about the current state of hair restoration surgery for women can be accessed on this website by returning to the main menu.)

Can people with cosmetically unsatisfactory results of hair transplanting improve their results with modern techniques?

People with cosmetically unsatisfactory results of hair transplanting can be divided into four major groups, a) noticeable scarring in the donor area, b) recipient area "repairs" in which many errors in technique were made (for the time in which the procedure was done), c) "retrofits" in which good technique was used (for the time in which the procedure was carried out), but results are outdated as compared to today's standards and, d) the hair loss has advanced into untreated areas. Because of substantial improvements in both donor area harvesting techniques and FUT, many patients in all of these groups can be helped (Figs. 28 to 32). In particular, virtually all hair transplanting carried out prior to l995 can benefit from a "retrofit". This subject is too long to be properly discussed here, but suffice it to say that it would be wise for anybody who is unsatisfied with previous hair transplanting to have a consultation with a good hair restoration surgeon to see if enough donor hair reserves are available, and what is possible to achieve with those reserves.

When is medical treatment preferable to surgery, and what drugs are available?

There are only two drugs that have been scientifically proven to be effective for regrowing lost hair or slowing down hair loss in some men with MPB: minoxidil (Rogaine) and finasteride (Propecia). (I was one of the investigators in multi-center studies on both of them.) Both of these drugs work best in the earliest stages of hair loss, in crown area baldness or balding and less well in the mid-scalp area. Neither drug has ever been scientifically studied for its effectiveness in what hair restoration surgeons call the frontal area (see Fig. 4a). Nevertheless, based on anecdotal information, some patients have shown some benefits in that area. Therefore, a trial of Propecia with or without Rogaine may be worthwhile trying before one commits to surgery just in case you will be one of the responders—especially for the crown hair loss. Using these drugs after a hair transplant may also be useful in slowing down further hair loss and therefore delaying the need to undergo additional surgery. Both medications can only delay further loss or increase hair density temporarily so some patients prefer starting with hair transplanting rather than drugs.

Minoxidil is applied twice daily to the scalp in a liquid or foam form, has very few side effects, and in very few individuals, however it can produce irritation of the skin, heart palpitations or decrease blood pressure resulting in a feeling of lightheadedness in a small percentage of people. Propecia, which is supplied as a one a day pill, has been associated with decreased sex drive in 1.8% of patients, erectile dysfunction in 1.3% and decreased semen volume in 0.8%. There are other less common side effects that may occur with both medications but all disappear within a few weeks if the drug is discontinued. Men who are taking Propecia should advise their family physician that they are using it because PSA tests, which are often routinely done on men over the age of 45 years as a "marker" for prostatic cancer, are affected by the drug. Usually, whatever PSA reading is reported must be doubled to get a more valid reading.

Minoxidil is a useful drug for women to try before deciding to go ahead with hair restoration surgery. Propecia is contra-indicated for all women prior to menopause as it may produce unwanted side effects in a male fetus. There are other drugs that may be useful in slow downing hair loss or sometimes regrowing hair in women with female patterned hair loss (FPHL). Women with FPHL should consult with a dermatologist and/or an endocrinologist for investigation and further information about these drugs.

How do I find a good hair restoration surgeon?

The best way to find a competent hair restoration surgeon is to ask your dermatologist or family doctor who you should consult with for this procedure. They are in a far better position to find out this information than you are. Advertisements on the Web, in newspapers, magazines and on television are a poor substitute for professional advice. Your hairstylist may also be a good source of information. The websites of the International Society of Hair Restoration Surgeons (www.ishrs.org), the European Society of Hair Restoration Surgery (www.eshrs.org), as well as the American Board of Hair Restoration Surgery (www.abhrs.com) are also sources of information that you should utilize. However, it is the consultation with the one or more doctors that you meet with before you decide to proceed that is most important. You should be comfortable with and feel you can trust the doctor, and he/she should also feel comfortable with you during that consultation. You should also see as many "before and after" photographs as possible to satisfy yourself that he/she is capable of producing acceptable results. Unfortunately, belonging to any of the societies mentioned above does not automatically mean that the physician can produce cosmetically acceptable results for you; it simply means that they are interested enough to belong to those teaching organizations. In the case of the American Board of Hair Restoration Surgery, they have also passed examinations that certify extra knowledge, especially with regard to surgical safety. Once again, the interview with the doctor is the most important guide you can have to your likely happiness with the results.

What does Dr. Unger think about "laser hair transplanting"?

He and Dr. Larry David were the first physicians to study the possible use of lasers in hair transplanting. The evolution of hair transplanting techniques has resulted in there currently being no surgical advantage of using lasers in hair transplanting.

Can hair transplanting be used to repair scars from trauma (accidents) or cosmetic surgery?

Despite many physicians, including plastic surgeons, believing otherwise, the answer to this question is yes. (Figs. 21 to 33).

What does Dr. Unger think about hair cloning?

From 1998 to 2003, Dr. Unger co-directed studies at the University of Toronto on what is popularly called "cloning" of hair. Stem cells are removed from the patient's hair and millions of similar cells can be grown in a culture medium within several weeks. These cells, when injected into immune-compromised mice, almost always produced hair. The ultimate objective was and is to inject them back into the human donor and be able to grow unlimited amounts of hair. Clearance for human testing by the University of Toronto Ethics Committee was obtained in October 2000, and studies began in late spring 2001. Two human studies were carried out. One produced hair in 1 of 10 subjects and the second in 3 of 13 study subjects (though less vigorous growth than in the first study). We have temporarily discontinued these studies because of proprietary problems related to the original funding and Dr. Unger’s time constraints. Hopefully, these problems will be resolved soon.

Unfortunately, thus far (January 2008), "cloning" hair has run into the same obstacles as those encountered when investigators have tried to "clone" cells for spinal cord injuries, heart, pancreas and liver tissues, etc. The stem cells have been identified and grown in culture media and produce the desired effect in experimental animals, mice or rats but for some reason do not consistently produce satisfactory results in human studies. Periodically, the public will read about "new breakthroughs" in cloning. Beware. So far, especially with regard to hair—the media or representatives of business interests have had a tendency to either repackage old information as "new" or have taken information out of context so as to make it more newsworthy than it really is. We believe that the obstacles to cloning in humans will be overcome in the not too distant future; there are so many outstanding investigators studying the problem and funding is rarely a problem. Try to be patient.