Who are the most suitable candidates?
Hair transplant representatives and sales personnel will make you believe that you are a great candidate for a transplant, that you have an excellent donor zone, that you will achieve a natural result and that your head will be as densely populated with hair as it was in your youth. Don’t trust them; everybody needs to be evaluated individually by the surgeon or surgeons who are going to perform the transplant. First of all, a transplant should always be considered as the ultimate phase in medical treatment. A hair transplant does not cure alopecia; it only attempts to repair those areas which have been irreversibly affected by the androgens. Therefore, surgery is not preventative but reparative. A transplant is only a transitory patch if the natural history of the patient’s hair loss is not taken into account. There are some basic criteria which act as a guide for us in deciding if a hair transplant would be helpful or not. Age: Younger patients (less than 30 years) are generally not suitable candidates as their hair loss has not yet gone to completion, meaning that it has NOT YET STABALISED. To perform a hair transplant too early and without determining the level of stability can lead to a poor distribution of the transplanted hair given that the surgeon cannot know exactly how much native hair is going to be lost. What could be a great result now may not be in the future, since transplanted hair never falls out. Those who have unstable alopecia, (whatever the age is, but mainly in younger patients) are primarily candidates for medical treatment (Finasteride +/- Minoxidil). In 80% of cases, age related stability is achieved around 40 – 45 years. Sex: The pattern of baldness is different in men and women. Receptor area: In men the areas with alopecia are more local and the extension, miniaturization and total disappearance of hair is more frequent. In women the distribution of hair loss is more spread out and extends over the entire head and the alopecia is seen as thinning and not as complete loss of the hair in any specific areas. Donor area: In men the donor area tends to be more extensive, mainly in the temporal-occipital areas. In women the temporal area is also affected by the androgens, meaning that the lower occipital is the only area which can be used for both sexes. In both cases the ideal indicator that a transplant is feasible is the hairs stability, so that a long lasting result can be guaranteed. Extension of hair loss: Obviously the greater the area affected then the less donor area is available and thus results will be limited. A patient who is worried about their hair loss and with incipient alopecia, if quickly controlled with medication then with a normal donor zone a complete repair with good density in the receptor zone can be achieved. A patient with advanced alopecia can hope to achieve partial cover and/or moderate densities in the area with a good donor zone area. The stability also lets us be more ambitious in density in the affected area as we are not expecting any significant progression of the alopecia. Density of the donor area: Hair density is defined as the number of follicular units which exist per square centimetre. The greater the density of the donor area then the more follicular units can be transplanted. Patients with density of less than 60 follicular units per cm2 are poor candidates. Unidades foliculares múltiples (MFU): Or family of follicular units; this is a characteristic which some patients have and which greatly increases the extraction capacity of units in the donor zone. This is a point where there are various units close together in a reduced space (for example, units of 2+1, 2+2, 3+1, 2+1+1 etc..). This allows us to extract one of the units, leaving the others behind to occupy the space and thus avoid “white dots” (white gaps or points) in the donor zone. Number of hairs per follicular unit: In the donor zone we find units of 1 – 4 hairs. In the end the coverage achieved is directly related to the number of hairs inserted. And it’s clear that inserting 1000 units of 2 hairs is not the same as inserting 1000 units of 3 hairs. The higher the number of units that have more hairs then the better will be the result. In a transplant of the front hair line, we need units of only 1 hair (singles) to produce a natural looking hair line. Behind the front line we use units of 2 hairs and then units of 3 hairs. In the crown it isn’t necessary to use units of 1 hair, but we do need many units of 3 hairs to guarantee coverage in an area where the hair is distributed in a centrifugal pattern emanating from a central cowlick. Therefore, and depending on the area to be covered, our needs can also vary. The objective is to always be between 2.0 and 2.5 hairs per follicular unit. If the patient doesn’t possess the desired units and the range is less than 2.0 hairs per unit, then obtaining good coverage is difficult. Type of hair: This factor is of equal or greater importance than the density of the donor zone. The texture (thickness), colour and structure (straight/curly) are important factors to evaluate before a transplant and because of these the number of units required in the same zone is different for each patient. Texture: The normal thickness of hair is between 50 and 60 microns. A hair of 70 microns is very thick while a hair of 40 microns barely provides coverage. We have to consider a follicular unit as consisting of various hairs, therefore we duplicate or triplicate the thickness at the point of insertion of the unit (that is to say, 3 hairs of 70 microns thick is equivalent to 210 microns; 3 hairs of 40 microns is equivalent to 120 microns). And even though measured in microns, this is still a large difference. Therefore a thick hair is more desirable than a fine hair for creating greater coverage. Hair colour: This is another point which can be good or bad. It is known that the effect of greater coverage is achieved when the colour of the hair more closely matches the colour of the scalp. For someone with very dark hair and a white scalp, any kind of hair loss is very quickly noticeable. Having light brown, blonde or grey hair is an advantage in this respect. Finally, hair which has two colours (those that have white and black hair or artificially using highlights) offers a greater effect of coverage. Structures: Obviously a curly hair will give greater sensation of coverage than a straight hair as it has more spatial volume. The only thing against curly hair (which is also curly beneath the skin) is that it is technically more difficult to extract than straight hair. Race: Asians have very straight hair and usually have less density than Caucasians, so there is need to have experience with this kind of hair. Dark skinned persons tend to have very dark curly hair, and since the skin is the same colour then very little contrast is offered and so the appearance is much better. On the negative side, their scars tend to form keloids and so there is more possibility of the scar being noticeable with the strip technique. The hair density in these patients is also less than in Caucasians who have a wide range of hair and skin. Skin laxness: This is important only when evaluating for the strip technique (unnecessary for FUE). The donor zone´s laxity needs to be tested before operating to calculate the area to be extracted and avoid problems when closing the wound (traction = complications vs. a wide scar). Those that have poor elasticity in the occipital zone could be candidates for individual extraction of follicles (FUE). The elasticity can be increased through exercises performed on the skin of the donor zone.  
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Advanced Hair Transplant Clinic PIONEERS IN SPAIN Year 2003 FUE TECHNIQUE