The Hospital Group is the uks leading hair transplant provider. Their hair loss treatment and restoration division was founded in 1992 with the knowledge that every hair transplant patient has their own special requirements. All of their staff are specially selected, trained and qualified for their individual roles and responsibilities to bring you the expert quality care and attention that you need. They only perform natural hair transplants, using Follicular Unit Hair Transplantation. This is the ‘Gold Standard’ technique and the only guaranteed way to restore your hair. Their teams’ success is as much art as science and their expert hair surgeons are leaders in the field.

Dr. Jim Arnold should be congratulated on another excellent and detailed reporting of the ISHRS meeting. We appreciate the inordinate amount of time and effort that he has spent in recording the vast amounts of information that speed by us so quickly. It is amazing how he does it! In reading the article in the Nov.-Dec. 1997 Forum, Vol. 7, No. 6, p. 5, I noticed three small errors in the text that should be corrected. I thought that I might also take the opportunity to briefly discuss them.The text reads “Some patients may average 1or 2 hairs per unit, while others 4 to 5.” While we do see patients with very low density, or Asians, who average 1 or 2 hairs per unit, I have not seen patients who average 4-5 hairs per unit. Patients with high density can have a significant number of 4, or rarely 5 hair follicular units, but this is not their average. The graph that I presented in Barcelona, illustrating this point is shown here. Another important point is that the density (spacing) of naturally occurring follicular units is relatively constant at about 1 group/mm2 in the posterior scalp of most Caucasians, but is less in the Black races (where it averages approximately 0.6/mm2). The text also reads “Dr. Limmer finds the average number 2.3 hairs per unit, while Dr. Bernstein feels the number is closer to 3.” This is also incorrect. As I stated in my presentation, the majority of patients that we see in consultation that are surgical candidates range from 1.5 hairs/unit to 3.0 hairs/unit with an average of 2.0 hairs /unit (rather than 3). The population that actually go on to have surgery have slightly higher groupings at approximately 2.1/hairs per follicular unit. (The graph also illustrates this point). The numbers that I presented were based upon densitometry readings at the time of the consultation, taken approximately 5 cm to the left or right of the occipital protuberance. Only full-thickness terminal hairs were counted. Dr. Limmer and I spoke regarding the slight differences that we each observed and we felt that different patient populations might be a factor contributing to this small difference. The location on the scalp where the measurements were taken will also influence the results, as the follicular unit density is generally highest in the midline of the donor area and decreases laterally. Having prior knowledge of the approximate proportion of each of the different size follicular units that will be obtained in the dissection is extremely important in planning the transplant, since the larger units can be concentrated in select areas to create the appearance of greater central density without having to increase the “closeness” of the sites. These numbers are also important because the pre-operative measurement of density and the estimation of follicular unit size are two means of assessing the accuracy of the follicular unit dissection. The other statement “Hair diameter plays a significant role, as diameter may range by a factor of 5X among patients.” is also incorrect. The word “diameter” should be replaced with the words “Cross Sectional Area.” The range in terminal hair shaft diameter is approximately 2.3 fold (0.06 mm for very fine hair and 0.14 mm for the coarse hair that we often see in Asians). This represents a variation in x-sectional area of approximately 5.4 fold, since area = ~r2 or ~(1/2d)2. It is interesting to note that compared to hair density, hair shaft diameter plays a much more significant role in the volume or “bulk” of the transplant. The range in hair density in patients that we generally transplant is from 150 hairs/cm2 in those of low density, to around 300 hairs/cm2 for those with the highest. In our practice, we rarely transplant patients who present with a density of less than 150/hairs cm2 (except for Blacks and Asians) and uncommonly see patients with a density greater than 300 hairs/cm2. The range is thus a 2-fold difference. If we compare this to the 5.4 fold range in hair cross-sectional area, we see that, in theory, variations in hair diameter should have 2.7 times the cosmetic impact of variations in hair density. In reality, these variables are not totally independent. For example, the widest hair shaft diameters are not generally seen in the same patients who have the highest hair densities. Nevertheless, one can make a strong argument for the quantitative assessment of hair shaft diameter, as well as density, in the pre-operative evaluation of patients considering hair transplantation.

There has been a recent surge of interest in “laser hair transplantation” that has paralleled the increased use of lasers for a wide variety of cosmetic surgical procedures. Lasers generate great enthusiasm on the part of both physician and patient, but this has sometimes exceeded the actual value of the laser as a surgical tool. An obvious example has been the use of the CO2 laser as a nonselective, destructive modality to remove tattoos which left scarring and a cosmetic deformity worse than the tattoo itself. This has been subsequently replaced by pulsed lasers with specific pigment absorption (such as the Nd:YAG, Ruby, and Alexandrite lasers) operating on the principle of selective photothermolysis that truly offers benefit in the treatment of these lesions. Super- and ultra-pulsed CO2 lasers are now being used to replace “cold steel” in generating hair transplant sites. However, before we rush to use lasers in hair restoration surgery, we should first apply logic and reason to this application, and then proceed cautiously with carefully controlled studies so our patients will only benefit from its use. The following discussion will address various aspects of current laser technology in the specific context of the most recent advances in hair transplantation techniques. The intent will be to challenge the theoretical basis for the use of existing lasers, to question some dubious claims regarding their benefits, and to suggest future areas of laser research. WHAT IS A LASER HAIR TRANSPLANT? First, it is important to clarify what is meant by “laser hair transplantation.” The present role of lasers is to solely create the holes or slits (recipient sites) for the grafts to be inserted into. To consider this a “laser transplant” is to ignore the myriad of other factors that contribute to making the procedure successful. Until lasers are involved in other major components of the transplant, such as harvesting, graft dissection, or placing, “laser hair transplantation” should be replaced with a term such as “laser site creation” to more accurately reflect its current role in the procedure. A PAINLESS PROCEDURE?The claim that laser transplantation is a painless process is misleading. The lasers currently being used are “ultra – or super – pulsed” CO2 lasers. Unlike lasers that operate by selective photothermolysis, these lasers create a hole by simply vaporizing tissue. Because the pulse (span of time the beam is on at any given moment) of these new lasers is extremely short, there is not much heat transfer or injury to “surrounding tissues.” Nevertheless, the tissue which the laser acts upon is nonselectively destroyed. Because of this, the laser is extremely painful unless local anesthesia is administered to completely numb the area prior to its use. Thus, it is not the laser that is painless. The pain-free environment is set up by the preoperative anesthesia used in all transplant procedures. BLOODLESS SURGERY The next claim, that the laser procedure is relatively bloodless, minimizes the most important physiological consideration determining the success of the transplant, namely oxygenation. The hair transplantation process should be aimed at maximizing blood flow to the implanted hair follicles, rather than reducing it, and any manipulation that compromises proper oxygenation will potentially compromise graft survival. Preliminary results suggest that when the laser sites are compared to sites made with conventional surgery, “a few patients have shown less hair yield in some of the laser grafts [1].” Dr. Unger points out that when making conventional slit sizes with the laser, “we are close to an unacceptable width of thermal damage.” The experience of Khan is similar, and he expresses special concerns of decreased growth when the distance between laser sites is 1 mm or less [2]. When using extensive micrografting techniques, the spaces between grafts are often in this range, and the cumulative thermal damage produced in large sessions may prove disastrous. It is, therefore, extremely important to objectively measure the impact of the coagulating effects of the laser on blood supply and graft survival in the setting of extensive micrografting, since this does appear to be the trend of the future [3]. As with electrosurgery, the laser specifications can be modified so that there is relatively more cutting than coagulation. It seems reasonable that work be focused in this direction, as this will decrease thermal injury while, at the same time, taking advantage of the laser?s ability to make rapid, uniform sites. PROBLEMS WITH HEMOSTASISThe coagulating effect of the CO2 laser may enhance visibility during the procedure, but the application of bi-manual traction on the skin and the judicious use of epinephrine can also provide hemostasis and allow for adequate visibility during both site creation and the placing of grafts without compromising the blood supply. Cold steel techniques that produced defects in the recipient area in the form of slits, 2-6 mm in length, or punches 1.5-5 mm in diameter, significantly compromise blood flow to the recipient site and reduce graft survival when the transplants are made too close. The laser has the added detrimental effect of sealing off the microvasculature. The poor growth with older techniques taught us the vital importance of preserving the vascularity in the recipient area, and this lesson should not be wasted when trying to increase operative visibility with the laser, especially when this can be accomplished by simpler means. INTEGRETY OF THE CONNECTIVE TISSUE Another problem created by the laser is the destruction of dermal collagen and elastic fibers. This effect on recipient tissues causes a decrease in normal skin elasticity and, as a result, grafts have an increased tendency to fall out from laser-made sites. Certainly, one would have to question if the grafts that remain are secure enough to ensure optimal growth. Work by Beeson has shown laser sites to have more necrosis and scarring 3 days after surgery and more fibrosis at 2 months than with the sites made with steel [3]. The elasticity of normal skin allows the recipient site to grasp the small follicular implants and secure them in place. This assures for the close proximity of the sides of the implant to the dermis in the recipient site, which serves to minimize microscopic dead space and hematoma formation, and facilitate healing. In a new method of hair restoration surgery recently described in the International Journal of Hair Restoration Surgery [4], where the actual follicular units are used as the implant, recipient wounds as small as 1.0 to 1.3 mm in length can accommodate as many as four hairs. This is accomplished by taking advantage of the anatomic proximity of hair within each naturally occurring group and discarding the intervening skin in the dissection. In this situation, the preservation of recipient dermal elasticity is evidenced by the fact that patients undergoing follicular transplant procedures are able to shower and gently rinse the transplanted area the day after surgery without the risk of losing their grafts. In addition, the rapid healing allows oozing and crust formation to subside over this same 24-hour period. When healing is complete, there is no clinical evidence of scarring, even when the scalp is shaved. LASERS: NEW TECHNOLOGY FOR AN OUTDATED TECHNIQUEThe major advantage that lasers are claimed to have over traditional slit and punch grafting is that they can create a slit (which purportedly looks more natural than a hole created by a punch), while, at the same time, removing tissue like a punch to make more room for the implant, in effect, having the best of both worlds. In the older techniques, where the grafts were not “anatomic” and contained hair that reached across multiple follicular units, the recipient site needed to accommodate it was unduly large, causing poor healing, as well as graft compression. In follicular transplantation, neither large slits nor punches are required to accept the donor grafts. By identifying the patient?s natural hair groupings, the implants can be pre-trimmed of the excess tissue between the groups, resulting in tiny follicular units that can be placed in very small sites, solving the problems of both recipient bulkiness and compression. Therefore, the claim that lasers have the advantage of removing recipient tissue while creating a slit has no relevance in follicular transplantation. THE DIRECTION FOR LASER RESEARCHFuture laser research should be directed toward a technology that could “read” the follicular groups “in situ.” In the donor area, the laser would dissect away the tissue between follicular units having the effect of decreasing the transplanted volume of skin, while maximizing the transplanted quantity of hair; producing an implant containing hair groups matching those found in nature. In the recipient area, current laser use is limited to areas relatively devoid of hair, as the beam would obviously damage any adjacent follicles. It is also limited in its ability to re-treat an area already transplanted, unless significant spacing were left between the previous grafts. In contrast, hand-made sites using a very small steel instrument can easily avoid existing hair or grafts, and if a follicle was “hit,” it would most likely survive the trauma or regenerate from its growth center. Much of current laser research has been directed to the production of a laser scanner that has the ability to rapidly produce uniform sites in either a grid-like pattern or random distribution without regard to the location of existing hair [5]. In order to be of general value, the laser must be able to identify the existing hair and make sites only in the intervening spaces, requiring a level of technology not presently available. Another challenge of the laser scanner would be to compensate for variability in laser effects brought on by the inherent curvature of the skull. Not only will the changing contour serve to amplify or defocus the beam by altering the effective operating distance, it will also change the incident angle of the light source and, ultimately, the direction of the hair. These adjustments are now performed manually, but are, nevertheless, critical to a successful cosmetic outcome. There is also significant variability in the thickness of the scalp from one patient to another and in different regions of the scalp. The laser must be able to at least match the sensitivity of the human transplanter who can “feel” these differences and can limit the depth, sparing injury to the larger blood vessels and nerves. In order to have a more natural appearance, modern lasers should generate sites only in a random pattern rather than according to an organized template. Finally, artistic nuances used in creating a delicate hairline, a widow?s peak, the swirl of the crown, or in rebuilding the temples (with its abrupt directional changes) would be difficult to program into the laser and might still have to be accomplished manually. A look at current research in hair transplantation worldwide suggests that in the near future, significant advances in hair restoration surgery may lie in automating the manual process, rather than in laser surgery per se. Mechanical instrumentation currently being developed will streamline the entire procedure, from the harvesting of the donor strip to the creation of sites with the simultaneous insertion of the implants. The role lasers will play in this overall process is still unclear. CONCLUSIONSAs laser technology improves, laser sites become smaller, and the problem of thermal damage is adequately addressed, the advantage of rapidly producing large numbers of uniform sites will make the laser a more valuable tool. When the laser, directed at the donor area, can cut skin by “reading” the spaces between the natural hair units with minimal thermal injury, it will significantly alter the transplant process and create a more compelling argument for its use. And until the laser scanner can be designed to avoid existing hair, this instrument will not be truly versatile. Hopefully, this level of sophistication is not “light years” away. Until then, let us be cautious and allow time for science to catch up with our enthusiasm. Only when the power of the laser has been applied successfully to all of the critical elements of the procedure may we rightfully use the term “laser hair transplantation.”REFERENCES1. Unger WP. More on laser use. Hair Transplant Forum Int 1995; 6:15-16.2. Arnold JE. Report on ASHRS Orlando meeting. Hair Transplant Forum Int 1995; 6:4-5.3. Rassman WR, Carson S. Micrografting in extensive quantities. Dermatologic Surgery 1995; 21:306-311. 4. Bernstein RM, Rassman WR, Szaniawski W, Halperin AJ. Follicular transplantation. Int J Aesthetic Restorative Surg 1995; 3:119-132. 5. Unger WP. Laser Hair Transplanting. Int J Aesthetic Restorative Surg 1995; 3:137-142.

Regarding the ability to perform hair transplants using grafts in extensive quantities, many “unanswered questions” already have answers. The first issue that “the emphasis in hair restoration has somehow shifted from the eventual outcome or product to the speed and magnitude of the process” is not correct. The outcome is, and always should be, the emphasis in any hair restoration or replacement process. The speed and the magnitude of the process, however, directly affect this outcome. There are a number of reasons; a critical element affecting the final result of the hair transplant is the motivation of the patient to reach a point where the hair restoration is cosmetically useful. Multiple partial procedures produce short term cosmetic problems, unnecessarily extend the duration of the surgical process, interfere with the patient’s daily life, and often leave the patient frustrated and unsatisfied. These patients can be so frustrated that they give up on the process entirely. The ability to perform the restoration in one or two procedures encourages a much greater proportion of patients to complete the process. Large hair transplant sessions solve other problems intrinsic to multiple small procedures. The first concerns the donor reservoir. Each time grafts are harvested from the donor area there is loss of potential donor hair due to destruction of hair adjacent to the wound edges as a result of the fibrosis associated with primary intention closures. In addition, the hair follicles adjacent to the healed suture line are often distorted and more difficult to harvest on subsequent hair transplant procedures. Minimizing the number of times the donor area is accessed, will minimize the resulting loss and distortion due to the closure. In the recipient area, the problem with fibrosis also favors fewer hair transplant procedures. In a “virgin scalp”, the blood supply travels unimpeded to the entire recipient area. However, when multiple sessions of large grafts are used, each graft placed in the recipient site induces local scarring that interferes with subsequent blood flow and has the potential to transect or seal off viable blood vessels, even if this effect is subtle. In subsequent procedures, the hair placed between existing grafts is implanted into this scarred tissue and potentially receives diminished blood flow. In hair restoration using dense packing, the donor site is created with an instrument thinner, and one that produces less trauma, than a traditional punch instrument. A blood vessel that might be pierced would immediately reseal analogous to the way a vessel heals after venipuncture. When the slender graft is then placed into the site, the graft would cause no additional trauma to the vessel. If it were true that “the diminished blood supply fails to support uniform graft take and consequently hair growth” then asymmetry, gaps or areas of variable density, would result from the dense packing technique and this is not observed, in spite of the fact that the dense packing is used predominantly in the frontal hairline, where any problem would be most obvious. The second issue, that “megasessions cannot duplicate the density of the traditional approach” is really not an issue at all. The density of the traditional approach to hair restoration is NOT one that we should aspire to. The problem with larger grafts in the hair transplant (and I include mini-grafts in this category) is that they don’t parallel the way hair grows in nature. Due to graft contraction they have a higher than normal density with greater than normal spacing in between. In nature, hairs in the frontal hairline (approx. the first 1/2 cm.) grow as single units and behind this region, the natural hair groupings contain two or three hairs. Large grafts contain too many hairs and produce an uneven density that doesn’t mimic nature. This is the cause of the most common complaint that patients have about their hair restoration procedure i.e. that it looks like a hair transplant and doesn’t look natural.The third issue, that “very small grafts, although natural, cannot be placed close enough together without injury to simulate the density of the larger grafts” has already been answered. The goal in a hair transplant should not be to simulate the density of the grafts, but that of nature. The obsession with density misses the direction we should be headed. The goal of all hair restoration surgery is to produce a fullness that will look natural as the individual ages. An attempt to match or exceed ones original density, even if only at the frontal hairline, will not only be cosmetically unacceptable in the long term, but will tax the donor bank and limit the ability for future hair transplant procedures to be able to cover additional areas as the balding progresses. In judicious planning, the grafts in the frontal hairline should contain only single hairs and be placed close enough to block the eye from looking into the scalp, but not so dense as to be unbalanced as the patient continues to bald. Finally, the statement “large sessions force distribution of the transplanted hair over the entire extent of the balding scalp” is incorrect. The transplant surgeon using extensive grafting of small follicular units has the total freedom to place these grafts in any distribution that he chooses and, if the hair restoration is planned appropriately, would be most dense in the “crucial frontal zone” that you describe. I agree that the vertex should always be left open in a young extensively balding individual with an average or below average donor density. When the patient has had permanently transplanted hair covering the front and top of his scalp, and the fullness is to his satisfaction, and he still has some reserve of donor hair to address further diminution of the donor fringe, then the crown can be addressed. And this would best be accomplished by extending the hair transplant further back, rather than treating the crown as an isolated area. Continued experience with the megasession will show that it increases the power and flexibility of the hair transplant procedure rather than limiting it. Future work should be directed at exploring the various ways this safe, but technically demanding, procedure can be of benefit to the balding patient.

State of the art, natural hair replacement surgery by Dr. Kahen hair transplant surgeon, Beverly Hills Hair Restoration Clinic, Los Angeles Hair Transplant Center, hair loss treatment.

Do you know that half the men in the United States suffer from hair loss at the age of 50? Hair loss treatments using transplants have become the number-one cosmetic procedure for men and women in the US. Even women are suffering from thinning of hair or patterns of baldness and are looking out for newer methods of cure for baldness. Each year there are more than 20,000 consultations and five million transplant procedures. People are also increasingly on the look out for hair loss solution.As we grow older there is a general decrease in our stamina. Our appearance also starts changing with wrinkles on the face and hair loss. Hair loss in men or women can make one look older than their chronologic age. To prevent our appearance from getting older we can always opt for hair restoration procedures either alone or in combination with a procedure for facial skin rejuvenation to take the years off from our age.

In the United States, approximately 35 million men and 20 million women are currently experiencing hair loss. If you are one of these people, one of the main issues you may have before deciding to restore your hair is hair transplant cost. For a hair transplant, the prices fluctuate from expensive to affordable depending on the doctor. The financial amount for a hair transplant is at a record-breaking low, especially when a person takes into account the first-rate quality of transplants in this era. When a prospective client does research on getting a hair transplant surgery, it’s crucial to note that it’s not like purchasing a refrigerator or a leather recliner, in which there are differing prices for the same exact model if a person does enough bargain hunting. Also, when it comes to a hair transplant, there can be significant discrepancies in the quality of the transplant you receive. Over the last decade, the hair transplant industry has seen a lot of changes in method and technology. There were hair transplant centers that made it a point to continue using the most effective and proven procedure methods introduced at meetings and continued to use the most updated technologies to make surgeries more accurate. Also, and I hate to see it, I know of transplants done without regard to a patient’s facial aesthetics. Skipping on a few details in the process can prove to be catastrophic. Small changes here and there in the direction and distribution of transplanted hair might mean the difference between a beaming, happy client and an unsatisfied patient. Apart from the artistic aspects of a hair transplant, the preparation and maintenance of hair grafts are absolutely essential and are to not ever be taken for granted, which may result in shoddy hair growth after surgery. Considering these points, getting a hair transplant by a qualified hair restoration surgeon is well within the range of affordability. In the present age, the price of a medical hair restoration is at its lowest since hair transplant practices began in the early 1990s. Today, due to the current state of the economy, a lot of hair transplant centers are promoting special discounts and promotions which wouldn’t exist in a more thriving economy. In the present, because of the crashing economy, the affordable prices of a hair transplant is a good incentive for people to get it done with a notable cash discount. I must warn you, though: although places offer very competitive hair transplant pricing, I must say the hair restoration industry is a buyer-beware market. It isn’t like comparing two sport coats. In other words, there may be a marked difference in quality. Keep in mind: a hair transplant will have a life-long effect on your physical appearance, especially face. This is a procedure which ought to be given serious though. Even if a hair transplant center uses the most updated surgical procedures and the most prestigious personnel, they can’t dip below a certain price range, or else they won’t profit. Watch out for unbelievably low prices and massive discounts. It’s essential to meet the doctor in real life. Several of them. Do personal research, which will enable you to ask the right questions about the techniques and types of service being provided. When deliberating over a hair restoration, or other types of cosmetic surgery, I recommend you don’t go bargain shopping. It just isn’t the right way to go about it. There are a lot of hair restoration offices offering astronomically discounted hair transplants. Let me remind you, there is one fact about hair transplants which has the potential to be wonderful or regrettable: the result. Also, if you’re a resident of San Diego and are interested in a hair transplant, google San Diego Hair Transplant.