Category: Physician training

If I have some miniturization at the crown and diffusely all over, this would not be considered a mature hairline would it?

Miniaturization of hair (greater than 20% small or thin shafts) is considered balding, irrespect of its location. A mature hairline begins roughly around 1 finger breath above the tip of your frontalis muscle at the frontal area and about 1 1/2 or 2 fingers breath at both corners. If you have diffuse miniaturization all over your head, consider checking your permanent zone for miniaturized hairs. A condition called Diffuse Unpatterned Alopecia (DUPA) means that you have miniaturization all over your head including the permanent zone in the occipital area. In the classic male pattern baldness, there is less than 20% miniaturization in the permanent zone in men.

What is so great about using a microscope for hair transplantation? I read some ads in the Los Angeles Times which stated: “Dr. X set new standards in hair restoration through the use of the ‘X’ Scope [Doctor’s name removed], an advanced microscope that allows more healthy hairs to be transplanted than ever before”.

At the same time, a second ad appeared which said: “Dr. Y’s new Mantis Microscope allows for greater single-hair dissection accuracy, significantly less donor hair for wastage, high hair growth success and better, denser and more natural results.”

Are you keeping up with Dr. X and Dr. Y?

Dr. X and Dr. Y somehow just came into the modern era in hair transplantation. Please look at the many articles I authored on the use of microscopes for hair transplantation which address the use of the microscope and its value. Most of what Dr. X and Y said is true. The industry standard was set by us in an article written in 1998 which conclusively showed the value at minimizing damage in harvesting grafts by the use of the microscope. What we reported was that the hair yield produced without the microscope was 25% less than the yield with a microscope. These numbers were even more dramatic in individuals with white or gray hair, where the advantages of the microscope showed hair yields from harvested strips were 40% higher than those without the microscope. The lost hairs in the count have almost certainly been tossed into the discarded tissue and were lost value to the patient. In a common idiomatic expression, ‘The baby was tossed out with the bath water’.

The focus for Dr. X and Y in claiming a breakthrough is one of ‘grandstanding’, bringing something to the forefront of importance and trying to take credit for discoveries where none is due. Microscopic dissection has been around since the 1980s’ (first introduced by Dr. Bobby Limmer). We applied the microscope to the follicular units which we defined and published in 1995 to define the standard which is now universally accepted as the golden standard for hair transplantation in everyone’s hands. The ads are largely correct, the use of the microscope is critical for significantly less donor hair wastage, high hair growth success and better, denser and more natural results. This is just what we have been doing for the past 10 years, so there is nothing new here.

So maybe the answer to your questions is: Dr. X and Dr. Y have now finally understood the standard of care and are moving into using it. It’s about time.

FYI: I changed the names of the doctors to Dr. X and Y. Buyer Beware remains the quote for the day.

Hi,

First, thank you for your wonderfully informative blog.

1) I’d like to see a dermatologist about my scalp. Would any dermatologist be okay or should I make sure it is a dermatologist specializing in hair loss? (I’m currently between III and IV on the Norwood chart. Also, I my skin seems unnaturally dry in those areas, and there are two tiny red sores that I discovered about the same time my hair loss began three years ago which have never gone away; so I think there may be a correlation.)

2) I’m in San Diego. Do you (or your associates) or anyone you can recommend in my area accept Blue Cross/Blue Shield health insurance?

Thank you very much for your time.

Insurance for medical work-ups for hair loss is covered by many insurance companies, but you will have to investigate your benefits from your present carrier. Hair transplants, on the other hand, have not been covered by insurance companies unless there is a burn or accident associated, and again, the benefits are defined as ‘covering’ those injuries for cosmetic surgeries.

If you are a male or female with hair loss, then your doctor should be able to make miniaturization mapping of your scalp. Some dermatologists do this, so you should ask their staff before you set up a visit. People who call themselves hair experts can be found in the physician search on ISHRS.org in your local area. My closest office is 120 miles from you, in Los Angeles.

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I have gone to a number of doctors and asked, as you have advised, to map my scalp for Miniaturization. They do not know what I am talking about? What should I do? Are you the only one who does this? How important is it?

There are a series of hair metrics (measurements) that any good doctor must do for a proper analysis of your scalp. First, if the doctor waves his/her hand over your head and says that you have a fine hair density, run for the hills. Good metrics require scientific measurement and the science of densitometry as I have defined it in scientific publications (such as this article from 1993 which discusses densitometry) .

If you step back for a moment, you will see that if you do not know just how much hair you have and the value of each hair, then you do not know much about the way your hair (or lack thereof) will meet your needs as you replace it. Metaphorically, think about a house, where half of the house has been eaten by termites and you need to replace the wood that is not any good. Then you want to add a room on at the same time. It would be crazy to try to do this job without assessing just how much wood is rotten (miniaturized hairs), how much wood is available from the lumber yard (assuming that you have a limited amount of wood/hair from the donor area), and how much area you intend to build up from scratch (the balding area which needs to be restored). If you can not measure any of these factors, you can not determine your needs, which must be matched against supply. It is not very complicated when you know what you are doing.

It would be absurd for a doctor to tell you that measurements are not important in determining early balding (miniaturization). It would be as if he/she is saying that the pending termite damage is irrelevant, and to just wait until the house caves in. Crazy? If you do not know if your wood supply is in 2×2’s, or 4×4’s then you do not really know the value of the essential replacement resources you have. If you have miniaturized hairs in the donor area, then you might have a disease which will contradict a hair transplant, but without measurements you can not say. If the termites have invaded the wood supply (miniaturized hairs in the donor area which is a disease in men and a common finding in women with genetic hair loss), then you can not build a house (trusses and all) with 2×2 studs alone (damaged or otherwise inadequate in quantity), you need wood beams and 18 on center 4×4 studs to support a wall properly. Likewise, you can not put in single hairs or damaged hairs into the transplant to do what god’s follicular units are doing for you now like when you were young.

So, to conclude, a doctor adds very little value to your Master Plan to help you determine what you must do over time, when the doctor does not use measurements to determine:

1. what the status of your scalp is at the time he starts Propecia with regard to miniaturization and in predicting your final hair loss pattern
2. what you are losing
3. what you have for supply to replace what you are losing or lost

This is not about the doctor making money doing hair transplants to all balding men, but rather using a full arsenal of treatments available to you, determining the value of those treatments over time and using his/her skills to your overall benefit. You have must a real clinical scientist / caring physician on your team who puts your benefit and goals above all else.

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