Category: Physician training

Hey Doc, generally speaking where does the donar site begin and how much donor hair do I have. It obviously ends in the back of the neck. But where at the back of the head does it start, speacially if your a early norwood recipient.

This answer is going to be a little long and technical, but hopefully some find interest in this…

Donor Area:
The donor area is always the rim of hair that is seen in the Norwood Class 7 patient (see art at right). It starts at the occipital prominence of the skull (back of the skull) and goes up in the midline to a height of about 2 1/2 inches. It runs from the temple prominences by the forehead from one side to the other. The total measurement depends upon the size of the head. Large heads might have a 15 inch measurement from temple prominence to temple prominence and let’s say 13 inches to be safe, of which 1/2 inch on each side is not usable because any hair extraction from that close to the forehead will show as a thin donor area or a scar from the frontal view. So if you were to harvest the donor area (either by strip or FUE) the donor area would measure 12 inches long multiplied by 2.5 inches high or 30 square inches of scalp in a person with a typical size head. Half of that 30 square inch number would produce 15 square inches of usable donor hair. Each square inch in a Caucasian’s scalp with average hair density contains 1250 hairs which if multiplied times 15 square inches (half the donor area) would give 18,750 permanent movable hairs or in theory 9,375 two hair follicular units (grafts). I know this estimate is high, because the side rim of the donor area usually has a lower donor density than hair in the main part of the scalp.

Density:
We must really talk about the amount of hair that must be left behind after harvesting not the hair we are going to take out. In the average Caucasian with average hair density, both residual and donor hair amounts are equal so that we will not be able to ‘see through’ the remaining donor area after the maximum number of transplants are taken; however, the lower the donor density, keeping the 18,750 hairs in place (to prevent a see-through look) causes the surgeon a problem and in removing the donor strip, the remaining donor skin will almost certainly stretch, reducing the remaining density.

Hair Character:
When a typical Asian patient comes for a hair transplant, the removable hair is substantially reduced (it will leave behind 80% of 18,750 hairs or 15,000 hairs). Let’s go through the calculations again for a typical Asian patient with 20% less donor density than a Caucasian. The Asian patient would have 15 square inches of usable donor hair and 15,000 remain after the donor strip is harvested. The total supply of the donor area for the hypothetical Asian would be 15,000 hairs or 7,500 grafts. If we then go to a person of African heritage, that number reduces even further (densities in the African can average as low as 60% of a Caucasian’s density). The removable donor area will yield 11,250 hairs or 5,625 grafts. As the donor area is harvested, it will stretch, reducing the remaining density substantially for future procedures.

It should be evident to the reader, that the size of the bald area is a critical determinant (need vs availability), a conundrum of clear proportion as the real donor hair availability becomes apparent. The quality of the hair (thin vs thick) the character of the hair (straight vs wavy or kinky) and the color of the hair and skin (donor contrast between hair and skin color) must play a significant role in the art of the hair transplant and where to put what hair is available. Make no mistake, this is an art form.

Keeping Some Doctors Honest:
By the above calculations, the Asian patient or the African patient has substantially less hair that can be used for hair transplantation. These calculations assume that the looseness of the scalp is not a variable (of course this is not really true) and that scarring is not a problem (everyone scars to some degree and those that scar worse are in a difficult situation for taking larger number of grafts).

Maybe you will understand better why I get so angry when doctors say that they can transplant numbers of grafts that are in the stratosphere. Some of the recommendations I hear smell of dishonesty or a naivety of the doctor to the basic mathematics of the hair transplantation process.

I have received a job offer that seams to good to be true. I responded to and add for an administrative assistant listing and at the interview they offered me a position as a hair restoration technician. I believe that I am under- qualified with a Bachelor’s Degree in Music Business. Is it customary to only hire women technicians? How do I know if this job is legit?

Training for a hair transplant technician takes considerable time and to become proficient once the skills are learned, may take a few years. If the doctor has experience training technicians and you like the detailed work that is involved, then you can embark on this as a career move. I would hope that the doctor who offered you the position does not let you loose and expect that you will become an instant member of the surgical team, making many mistakes along the learning path. It often helps if you have some medical assistant training so you understand the sterile technique process.

Dr Rassman,
You may or may not have seen this post on the online forums that you visit. Dr Shapiro was the only Dr to answer these questions and as a reader of the forums i wanted to see if you would answer them about NHI?

Do all NHI’s surgical technicians have valid, unrevoked, or unsuspended certificates/licences? Do they place the grafts in the receptor sites during HT surgery? And if they do, Is The surgeon in the room all the time with his HT patient,supervising that process of grafts transplant?

At the New Hair Institute, our technicians were all internally trained by me. They are not certified by any state agency. If you check with Dr. Shapiro, you will find that I was the doctor who trained him in FUT. Our technicians do both cutting and placing of the grafts and the surgeon is either in the room or close by checking on the progress of the technicians frequently. As these technicians have been trained by me, I know what is happening at all times. I am supervising everything that goes on before and during the surgery. Either Dr. Pak or I usually see the patient the next day when we wash the hair and make sure that the scalp is clean of all crusts (mostly done on the day of surgery).

The quality of the technicians determine the results you will get after 8+ months have passed. I recently met with a patient who had over 4000 grafts from an experienced doctor (at another clinic) with what I suspect was a very weak and inexperienced team. When I viewed his results 1 year after his procedure, it was evident that there was easily a 90% failure of the grafts to grow. If the surgeon does not have absolute control over the technical process minute by minute and the technicians and nurses are not very experienced, these large sessions often fail. Here I am just questioning the quality of the technician work in this particular patient. Many doctors have difficulty in hiring experienced people, particularly if they attempt these large sessions and hire inexperienced people. The sloppy work by many itinerant technicians reflects poor training and the patient becomes a victim, never aware of what is happening to him. Even the technicians are victimized by the heavy workload of a very large surgical case and few can manage the tedious work for hour upon hour (e.g. often 7-9 hours for a 4000 graft case with a highly experienced and competent team).

The tragedy here is not just the wasted money (for many people their life savings) but the depletion of the donor hair supply (an invaluable and non-replaceable resource). I warn patients all of the time that as they do their diligence, they should command the ‘team’ nature of this surgery and not go for the least expensive bargain available. This patient paid $2/graft and lost a considerable amount of his donor supply. To say he got what he paid for would be insensitive on my part.

I work for a surgeon. He wanting to provide hair transplant services- some in office. He had said something about having a technician to assist with the hair follicle grafts- Does this technician require certification and if so where do you obtain this?

The International Society of Hair Restoration Surgery (ISHRS) has information about fellowship programs for physicians here. It is very difficult to train a good hair transplant technician. It often requires months of daily constant practice, the initial work under close supervision. I have trained a few dozen techs and many of them want to quit within days of starting training. Errors on the part of the technician can kill the transplants from a variety of causes, including drying of a graft (usually killed in 10-20 seconds of air exposure), rough handling, killing the growth center, poor placing, and depth control. The hand-eye coordination is really difficult for placing a graft. Ask your doctor to visit an experienced hair transplant surgeon and try out some of the process. If you wanted to become a hair transplant technician, that may just change your mind. For the patient, the worst thing he can have is a technician given too much responsibility during the training process, as many grafts will die as the technician learns the process. Remember, I said it may take six months to a year to get competent and years more to get really good. As a patient, I would want an experienced technical crew. There are very few doctors that developed the skills to train a hair transplant technician so one might wonder where they got their training from.

Long story short, there is no certification for this job… just lots of training time and constant, daily practice. If your doctor expects to get growth from a hair transplant, the worst thing he/she could do is to pass on the responsibility to you (no disrespect intended).