Category: Hair Transplantation

Why do so many “consumer advocates” on the forums and other so-called “experts” advise when choosing a hair transplant surgeon to avoid one who uses a multi-blade scalpel?

Everyone says a surgeon will obtain better results when using a single-blade scalpel and that all the better surgeons use them. I found this not to be true, because I know at least a few “world class” hair transplant surgeons who prefer the multi-blade knives.

Does it really matter? What do you use and what are the pro and cons, if any, to the use of each tool?

When a strip is cut out, there is a cut on the upper edge of the strip and on the lower edge of the strip, so one or two blades will accomplish the same thing provided that the double blade knife is designed to cut along the angle of the hairs. When additional blades are used (8 blades for example) there is more damage created, because the inner blades are blind cut and the surgeons has no control of them. I generally estimate that the upper and lower cut lose about 2% of the total hairs in the strip, so if you use 8 blades, then 16% loss could occur from the blind cutting.

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Hello doctor Rassman. I know you have answered similar questions like this one before however I would still appreciate some information. I was thinking about getting a hair transplant about two years ago so I went to Bosely but decided not to go through with it on account of the sales people and how I did not believe they cared about my best interest. I have done a lot of research on the many different surgeons and techniques available in the field of hair transplantation. I have come to the conclusion that if in fact I was to opt for a hair transplant, follicular unit extraction will be my best option and only if performed by a highly qualified surgeon such as yourself and a few other qualified surgeons (all members of ishrs). I am currently a norwood 6 receding hairline, loss in crown, and diffuse thinning (typical mpb)and more than likely will advance to a norwood 7 as I age. I have been shaving/buzzing my hair for the last two years and am ok with it. I have begun shaving it recently due to more loss in the frontal region.

I have real specific goals for my hair loss and am a little unsure whether or not my goals are realistic. I wish to add hair along my receded hairline (not lower it) so that it may be more defined but still mature, and go back to buzzing my hair to a #2 or #1. Eventually I know my hair loss will progress so I still wish to have the option of shaving my head but still have a vague hairline. Basically what I want is to have a noticeable hairline buzzed and/or shaved. My main concerns of course are future hair loss and scarring. As long as it looks natural as I age and cannot be detected, I am fine even with limited coverage. I understand that fue is not completely scarless however since I am looking for coverage rather than density, my hope is that less grafts can be used sparsely to create a sort of illusion of stubble on the front and frontal mid portions of the scalp without risking over scarring. I hate to throw this in there but I heard that one may to minimize scarring is to add body hair to the donor area at the same time the grafts are dissected. Although it yields a lesser success rate than that of head hair, it may be a good idea in this particular situation as a filler as I am all for more coverage if possible.

I realize that the only true way to answer this question will be to examine me and do the fox test to see if this can even be accomplished, but lets say hypothetically that I am a good candidate for fue. Can this be accomplished? I would definitely prefer some hair on the top of my head than none even if shaved. Thank you for your time Dr. Rassman. I will be sending this message to two other ishrs surgeon members for their opinions.

P.S.-If you need some pictures to get an idea of where I am ,that is my hair loss, feel free to ask. I will be taken some soon.

It’s really hard to tell if what you’re asking for is even possible for you. So yes, please send extensive pictures (and reference this post). If you have adequate density and are becoming a Norwood Class 7, you will need a careful analysis of the various Master Plans with a transplant. This is far too complex to cover here and elements of this have already been discussed by me on other posts. After sending me your photos, arrange a free telephone consultation with me (310-553-9113) and I will then cover as much as I can without seeing you, since I assume you are not near either of my California offices. If you can make it to California, that would even be better for an in-person examination.

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I recently met a prospective patient (Asian male) with a very low hair density who kept his hair very short. He wanted a follicular unit extraction (FUE) procedure and I strongly advised against it as in his particular case, the tiny white punctuate scars he would get from FUE might become detectable. His skin was a dark olive color. He did consult with another doctor by phone who told him after seeing his photos that he could easily get 4000 FUE grafts in the first session followed by 3000 in a second session and that he would have a reasonably full head of hair.

We then discussed a strip procedure and I told him that in a single session he might get approximately 1500 grafts, yet still another doctor told him that he easily could get 3500 grafts from a strip session. The prospective patient asked me why these other doctors were so enthusiastic about the surgery they recommended and why I was so low with my estimates on the strip procedure. I told him that I was an ordinary, mortal doctor with human limitations and he needs to understand that this is more than a number difference because the doctors may be talking about different things. I always talk about follicular units which is the graft count that I obtain at surgery. In other words, I’m not going to recommend something to this patient that will ultimately not be in his best interest and I am not one who victimizes patients for what they have in their wallet by charging for something that is not a follicular unit.

There is math and economics in these various estimates. For example, this patient’s graft count could be pushed higher if the grafts were divided so that each graft would have less hair. What one doctor calls a graft (1-3 hairs each) another doctor can cut down into grafts that contain less hair each (shifting to mainly 1 hair grafts) and get the illusion that there is more ‘value’ because the number of grafts is higher. If the amount of hair is say 5000 hairs, one can produce grafts ranging from 1500 to 5000 grafts from this hair count. So first, one has to define what the doctor means by a graft, does he cut them down into small units to get higher number of grafts? Economically for the doctor, it is better to cut these follicular units down (in the number of hairs each) because the fee is based upon the number of grafts. So more grafts means more money for the doctor (and higher fees for the patient). What matters is not just the graft count, but the total amount of hair that is removed in the procedure. Then add to that the way it is divided into small hair units (ideally it should be true anatomical follicular units). In the case of a strip procedure, the value would reflect the ‘area’ of excised scalp. Grafts should reflect the normal anatomy of the follicular unit that G-d created, not one that the surgeon invented (a subset of the follicular unit devised to push up his income).

We are not all equal with regard to the amount of hair that can be moved in a single session because the hair density between people can vary significantly (some people have more than twice the hair density of others). Also the looseness of the scalp may mean than in one patient twice as much scalp can be moved than in another patient. Merging these two measurements, when comparing two people, the maximum safe capacity for moving hair can reflect differences of 4-5 fold. I believe what is ethical from a fee point of view, should reflect the amount of work that the surgeon and his team invest in performing in the surgery. That is why, if true follicular units are what is counted, then the ‘apple for apple’ comparison is appropriate in the calculations for value. A patient should demand knowing that he is receiving follicular units, and not a number reflecting a subset of the follicular units for the purpose of pushing up fees.

We spent some time talking about what he could and could not expect. Expectations really reflect the amount and distribution of hair used in the transplant. The issue of value discussed above, should reflect the number of actual ‘true’ follicular units removed. It is wrong for not educating the patient. A doctor who did not take the time to review what he was going to do, how he was basing his graft count, what constitutes a graft and how he determined the charges for each graft is not doing his job. If you know this information, then you have done the proper research and you have a better chance of getting what you are paying for.

For further reading, plenty of similar links to past blog posts can be found here.