Clip Hair Extensions

INTRODUCTIONWithin the past decade, Follicular Unit Transplantation has transformed hair transplantation from a cosmetically unpredictable procedure to one that can produce consistently natural results. The key to its effectiveness lies in the fact that scalp hair tends to grow in tiny bundles, called “follicular units,” rather than individually. By working with these naturally occurring units, instead of larger or smaller grafts, Follicular Unit Transplantation creates as natural a look as possible while minimizing the transplant wound size and accelerating post-operative healing. A recently developed refinement, Follicular Unit Extraction, promises to eliminate, for select candidates, the procedure’s most invasive aspect: the surgical removal of a strip of tissue from which the units are harvested.Follicular units are made up of one to four terminal hairs, one to two vellus hairs, their associated sebaceous glands, neurovascular plexus, an erector pilorum muscle, and a circumferential band of adventitial collagen, the perifolliculum. The tendency of scalp hair to grow in this way, rather than in single hairs, can be most easily demonstrated by clipping the hair to approximately 1 mm in length and then viewing it with a densitometer at x 30 magnification in a 10-mm field. What this also reveals is that these compact units are surrounded by significant amounts of non-hair-bearing scalp. Including this extra skin in the dissection — as do hair transplants with larger grafts, such as plugs and minigrafts — requires a larger recipient wound, as well as risking visible scarring in the skin around the grafts and distortions of the growing hair. Although simple in concept, Follicular Unit Transplantation has many nuances and complexities. Those wishing to perform Follicular Unit Transplantation in their clinical practice are encouraged to join the International Society of Hair Restoration Surgery (ISHRS) and attend its annual meeting, subscribe to Hair Transplant Forum International (the trade publication for hair transplant surgeons), and follow relevant medical literature (particularly Dermatologic Surgery). Although it is not an accredited board, certification by the American Board of Hair Restoration Surgery (ABHRS) indicates a basic competency in the field and requires three years of clinical experience and passing both oral and written examinations. The process of preparing for ABHRS certification is a worthwhile endeavor and recommended for those serious about surgical hair restoration. HISTORICAL VIGNETTEReports of successful hair transplants appeared as early as 1930 in Japanese literature, beginning with Sasagawa’s hair-shaft insertion procedure and then Okuda’s success in pioneering 2- to 4-mm punches for the treatment of various alopecias of the scalp, eyebrows and moustache. Okuda made the important observation that using smaller punches in the recipient area improved cosmetic results.By 1943, Tamura had treated 137 cases of non-androgenetic alopecia of various etiologies using techniques very similar to modern-day hair transplantation. For instance, he harvested donor grafts by making an elliptical incision that was sutured closed, prepared recipient sites with a thick needle, stored grafts in physiologic saline, and observed post-operative telogen effluvium. Most significantly, Tamura demonstrated that single-hair grafting resulted in growth practically indistinguishable from naturally grown hair — and much more natural-looking than hair transplants using larger grafts. But it took several decades before Western surgeons would apply Tamura’s insights to their hair restoration procedures.The first hair transplant surgery in the United States was performed by Dr. Norman Orentreich in 1952 with grafts measuring 6 to 8 mm in diameter, significantly larger than those of either Tamura or Okuda. At first, incredulous editors rejected Orentreich’s work, not believing that hair transplantation was even possible. He finally found a publisher in 1959, in the Annals of the New York Academy of Science. The paper laid out the concept of “donor dominance” — the idea that grafts continue to show the characteristics of the donor site after they have been transplanted to a new site. This remains the basic tenet of all hair transplantation surgery. Yet while donor dominance insured that transplanted hair could grow, it did not guarantee that the results would look natural.Not until 40 years later would hair transplants in the United States start to produce consistently natural-looking results and promise predictable cosmetic improvements in most patients. It was a slow evolution, but the large grafts used throughout the sixties and seventies eventually gave way to minigrafts in the eighties and mini-micrografting in the early nineties. The stage was then set for Follicular Unit Transplantation. First appearing in the medical literature in 1991 it quickly emerged as the standard in hair restoration — supplanting mini-micrografting in the treatment of androgenetic alopecia and rendering other well-established procedures such as scalp reductions, scalp lifts and flaps virtually obsolete.So swift was Follicular Unit Transplantation’s ascent that the two standard textbooks on surgical hair restoration, published in 1995 and 1996, as well as the most comprehensive text on trichology, published in 1997, make not one mention of the terms “follicular unit” or “Follicular Unit Transplantation.” At the 1996 meeting of the International Society of Hair Restoration Surgeons, three seven-minute presentations on the procedure were given; but at the 2002 meeting, Follicular Unit Transplantation was the subject of entire seminars and workshops and suffused every aspect of the weeklong gathering.The follicular unit was first defined by Headington in his landmark 1984 paper “Transverse Microscopic Anatomy of the Human Scalp.” Follicular Unit Transplantation had its origins in the microscopic dissection techniques of Dr. Limmer in 1988 that was described in his paper “Elliptical Donor Stereoscopically Assisted Micrografting as an Approach to Further Refinement in Hair Transplantation” in 1994. The term “follicular unit” was introduced into the hair transplant literature by Bernstein and Rassman in 1995. The conceptual framework for Follicular Unit Transplantation was mapped out by these authors in the publication “Follicular Transplantation” and in the paired articles, “Follicular Transplantation: Patient Evaluation and Surgical Planning” and “The Aesthetics of Follicular Transplantation” (1997).The name “Follicular Unit Transplantation” was formalized by a group of hair restoration surgeons in a 1998 publication in Dermatologic Surgery. In this paper, the procedure was precisely defined and included the two basic techniques, single-strip harvesting and stereo-microscopic dissection, as integral parts of the procedure. However, since follicular units can now be harvested directly from the donor area without the necessity of a strip incision (using Follicular Unit Extraction) the original definition has become too restrictive. The term Follicular Unit Transplantation should now be used to encompass all hair restoration procedures that utilize naturally occurring, individual follicular units exclusively in the surgery, regardless of how these units are harvested. The caveat, of course, is that the harvesting technique must always maintain the follicular unit’s integrity.

For those bald people who can afford hair transplants, it is a day of celebration and rejoicing. The hair restoration industry has discovered something notable: Thyrotropin-Releasing Hormone, better known as TRH. These dedicated scientists believe that TRH, after careful consideration, will turn out to be a really major player in the quickly progressing hair transplant industry.About seven months ago, a new research study about the hair growing cycle was made known to the public in the Journal of the Federation of American Societies for Experimental Biology (FASEB Journal). In Germany, the hair study was performed by Dr. Gaspar at the famous University of Lübeck, Department of Dermatology and Department of Internal Medicine.Hair growth researchers, with prior insight, decided to study whether human hair follicle functions were modulated by thyrotropin-releasing hormone, as it has been discovered in human tissue. Making conclusions from their study, the scientists said that the epithelium of human scalp hair follicles reveals not only TRH receptors (TRH-R), but also TRH itself at the gene level and protein level.These dedicated scientists found stimulation of dissected organ-cultured hair growth with thyrotropin-releasing hormone stimulates hair follicle elongation, extends the hair growth cycle phase (anagen), and keeps it from being terminated by TGF-beta2. In addition, it increases proliferation and prevents the apoptosis of hair matrix keratinocytes.

To conclude our study, we can truthfully say that thyrotropin-releasing hormone operates as an consistent hair-growth stimulator. Let’s not forget to mention, it’s proven to be a good searching tool for identifying functions of thyrotropin-releasing hormone and hair follicles.In the near future, it may be a major player in the hair transplant industry.

For other cosmetic-type questions and answers, do a Web search on Dermal Fillers in Orange County. Also, if you’re curious about facial filler, dysport, or botox, check out a Beverly Hills Med Spa.

Alopecia areata is an unpredictable disease affecting about 2% of the world’s population and is the second most common type of hair loss after male and female pattern baldness. It is often called spot baldness or patch baldness due to its patchy balding pattern. In severe cases, it can affect the whole scalp (alopecia totalis) or the entire body (alopecia universalis). It is not yet known what causes alopecia areata. It is believed to be an autoimmune disease triggered by a person’s autoimmune system, which decides to attack its own hair follicles. Sometimes the hair grows back a few years later and stays and sometimes it falls out again. Although there is no treatment for alopecia areata that works 100%, some treatments have been proven to improve this condition. The most popular treatment option, which does not require a doctor’s prescription, is topical minoxidil, such as Rogaine. It can be used alone or in combination with other medicinal treatments that will be discussed later.

The most common prescription treatments for alopecia areata are corticosteroid shots, injected straight into the bald spot, and steroid gels and creams. Corticosteroid injections are a more effective but also the more painful option of the two. The aim of this approach is to suppress the autoimmune reaction but it has been proven to work only on small bald spots. Another common treatment for small bald spots, which is thought to affect the autoimmune reaction, is the application of topical anthralin. Anthralin is a tar-like substance used to treat psoriasis.

Topical immunotherapy is the most common form of treatment for extensive alopecia areata (for more info read: http://www.greyhairloss.com/blog/alopecia-areata-treatments.html). It employs an immunosuppressant such as cyclosporine that is applied to the skin to cause a skin reaction similar to mild eczema, which in some cases leads to hair re-growth. This method is also the most radical form of treatment, causing an array of negative side effects.

Another therapy for extensive alopecia areata is PUVA, which stands for “psoralen plus ultraviolet A radiation”, consisting of a topical or oral application of psoralen, followed by ultraviolet radiation. This method is better tolerated than topical immunotherapy but it is also less effective.

A recently conducted clinical study with sulfasalazine also spells some promise for patients with severe cases of alopecia areata. Sulfasalazine is an anti-inflammatory medication first applied to treat rheumatoid arthritis and is hoped to soon be used to treat alopecia areata.

This is the overview of the most common medicinal treatments for alopecia areata. There obviously is a number of other alternative therapies that are claimed to help treat this condition and do not require a doctor’s visit. Consumers should be aware that none of these products has ever been clinically shown to be effective in treating alopecia areata and such claims are legitimate only because these products are not regulated pharmaceuticals but non-regulated cosmetics.

During a hair transplant, the individual implants, or follicular units, are obtained from the patient’s scalp during dissection. The basic concept in dissection is to identify the patient’s natural hair groupings and to isolate individual follicular units. A delicate balance must be reached between the goal of having the implant purely follicular and leaving enough peri-adventitial stroma to ensure that the implant is not damaged and hair is not wasted. This balance is achieved through the extensive experience of a highly motivated hair restoration staff, including surgeons and assistants trained specifically for this task. Because the implants are so small, they are more sensitive to desiccation and temperature change. Therefore, handling and quality control at every level of the procedure are crucial to obtaining good results.The initial harvest scores the strip just below the level of the hair follicles into 0.3 cm wide longitudinal sections with each attached to the other by the loose connective tissue of the subcutaneous layer. The sections are cut into pieces 1 cm in length. Each piece is then further subdivided, and the follicular units are identified, under magnification, and dissected free of surrounding skin. Many hair transplant surgeons prefer a #10 Personna blade and cut on tongue depressors that have been soaked in sterile water (not saline) until they are ready to be used. Immediately before use the excess water is removed with a piece of gauze. The purpose of soaking is to help maintain the moisture of the implants and to prevent the tongue depressors from absorbing water from the saline soaked implants, thereby increasing the relative concentration of the saline.Dissection of the follicular units is the most labor intensive and critical part of the follicular implantation process. It is common for hair restoration surgery centers to use up to 12 highly trained cutters to produce the implants for a single large case. Proper planning of the recipient area is absolutely dependent upon accurate information regarding the yield of the donor harvest. The dilemma in planning is that waiting until all the units are dissected before implanting extends the length of the surgery beyond medical feasibility and starting before the surgeon has information about the total number of 1, 2 and 3 hair units, limits the ability to make precise decisions regarding size, density and distribution of the recipient sites. Although it would seem that information gleaned from pre-operative densitometry measurements together with the patient’s hair characteristics and the calculations described above would be adequate for the creation of the recipient sites, in actuality, once the dissection begins, new crucial information is obtained. For example, patients with gray-white hair can have either dark or light roots. In the latter case, due to decreased visibility, the cutters must leave more stroma around the units, increasing the implant size. As a result, a two-hair implant might require the same size site as a three-hair unit. On the other hand, in patients with fine hair, two hair units may be placed in a site made to accommodate single hairs. In patients with kinky hair, the hair shaft is often so curved below the level of the skin that close dissection of the units is impossible. Sometimes this is not the case; the kinky hair behaves during dissection as if it were straight. In all cases, the smallest possible site is used for the respective implant in order to minimize injury to the recipient site and to allow for the very close placement of the follicular units.In order to take into account these variables, the hair replacement staff is often instructed to take random pieces from the cut strip, and representative units are matched with sample sites. Placing of sites is then limited to the frontal hairline until the first projection of the implants is made. Accurate projections of the total number of units that will be obtained from the donor harvest are critical for the correct placement of the sites with respect to size, density and distribution, allowing the creation of sites to proceed while the cutting is still in progress.At the beginning of the follicular hair transplant, both the cut pieces and individual implants are typically held in 0.9% Saline chilled to 59 degrees Fahrenheit. They should never remain out of chilled solution longer than 3-5 minutes. The placers then rest a small amount of follicular units on back of the opposite hand used to hold the forceps. The placers wear powder-free gloves and place gauze under the glove beneath the area where the moistened implants will lie to prevent heat transfer from the hand into the implants. Implants are inserted with curved jeweler’s forceps. At the beginning of the placing, each assistant will determine his or her placing speed, which depends upon the placer’s skill and the patient’s specific hair and scalp characteristics. Once the speed has been determined for each specific case, it is easy for them to determine the amount of grafts that can be safely handled at any one time.Hydrogen peroxide is very effective in removing residual blood from the scalp and acting as a mild hemostatic agent through a variety of possible mechanisms. Although it seems to produce only minimal amounts of significant toxicity in normal usage, great caution should be exercised when using hydrogen peroxide during follicular transplantation and direct contact with viable tissue should be avoided. Fortunately, hydrogen peroxide is rapidly broken down to oxygen and water. In order to minimize its contact with the implants or with open wounds, hair restoration surgeons and assistants should never spray or apply peroxide directly to the scalp. Many practices use a 3% hydrogen peroxide solution diluted to 1 part hydrogen peroxide to 4 parts water, making an effective concentration of hydrogen peroxide of 0.6%. Any bleeding in the recipient area is stopped by applying direct pressure with dry gauze, not with peroxide. After the bleeding has subsided, 3×3 gauze is sprayed with the diluted peroxide and then applied to the skin to remove residual blood.

So you have decided that hair restoration and hair transplants are for you! What great news! Now the question becomes exactly are you going to pay for it?
Since the cost of hair restoration and hair transplants can vary wildly between the surgeons who perform this procedure, it is important to do your research to find out not only where you can get the best hair transplant but also where you can get the most bang for your buck.
There are some physicians who charge per graft while there are others who charge per transplant session. There is also such variety in the amount of transplanted hairs that your surgeon will be able to graft at one time.
For example, on average, a single graft can range from 1-5 hairs. Hair transplant clinics also vary in what they can do since some clinics are capable of using 1000 grafts to replace any where between 1000 and 1500 grafts and yet another will be able to replace between 2000 to 4000 hairs.
Strange!
In the recent years and hair restoration costs have become more affordable. Not all that long ago it wasn’t uncommon for a single hair craft to cost $15. Even now, hair restoration can be a pricey proposition and can range from $2.50 to $10 per graft! Okay, while that is certainly a savings from previous high charges, that doesn’t sound too bad until you realize that depending on the size of the area to be transplant, the total cost can be as high as $15,000. Costs are also predicated on the expectations of the patient since patients may decide to have more extensive transplantation than is actually necessary particularly if there is a certain “perfect” look in mind.
At the present time, the most efficient and effective hair transplant clinics do more extensive sessions covering more of the balding area in a shorter amount of time. The good news is that there has been great progress over the years in the arena of hair restoration and hair transplants are much more effective and less traumatizing than in previous years. While the internet has helped to lower the costs of hair restoration, this has also made hair transplant surgery much more available to the general population.
Of course one of the most exciting things about being able to afford hair transplant surgery is that many of the clinics offering this service, also offer a payment plan that most people can afford. So if you are interested in hair transplant surgery and don’t have the full bundle of cash, the financing it can allow you to get your hair restoration started now instead of when you save up all the money needed.
So if you have decided that hair restoration is right for you, then you must consider hair restoration cost before you make any final decision. You may be able to finance the cost or you can certainly pay for the entire procedure up front. Just be careful…you get what you pay for…and hair restoration cost are no different!

HISTORICAL ASPECTS A donor is better if it is as small as possible. The reason is that if a donor is big, hairs grow in . . . a very unnatural appearance. Hajime Tamura – 19431PRESERVATION OF THE FOLLICULAR UNITThe underlying premise of follicular unit transplantation is that the intact, individual follicular unit is sacred. Theoretically, they should neither be broken up into smaller units, nor combined into larger ones.2,3,4This simple idea may not seem like a radical approach to hair transplantation, but when viewed in the context of how the surgery has been performed over the past forty years (when the very existence of the follicular unit went generally unrecognized), it is radical indeed. At present, the majority of hair transplant surgeons will, at times, combine several follicular units or split them up, as they are not convinced that this has a significant impact on either the anesthetic outcome or upon growth. Practitioners of follicular unit transplantation, however, are certain that only this procedure achieves the best cosmetic results and their hair “bristles” when they witness surgical techniques that divide follicular units or transect follicles, techniques they feel preclude optimal growth and waste precious donor hair. In spite of the heated debate, good scientific studies have not yet been performed to resolve these issues.The follicular unit was first defined by Headington in his landmark 1984 paper “Transverse Microscopic Anatomy of the Human Scalp.5 The follicular unit includes:- 1 to 4 terminal follicles- 1, or rarely 2, vellus follicles – associated sebaceous lobules- insertions of the arrector pili muscles- perifollicular vascular plexus- perifollicular neural net – perifolliculum – cirumferential band of fine adventitial collagen that defines the unitTRANSPLANTING INDIVIDUAL FOLLICULAR UNITSThat scalp hair grows in follicular units, rather than individually, is most easily observed by densitometry, a simple technique whereby scalp hair is clipped to approximately 1mm in length and then counted observed via magnification. What is strikingly obvious when one examines the scalp by this method is that follicular units are relatively compact, and are surrounded by substantial amounts of non-hair bearing skin. The actual proportion of non-hair bearing skin is probably on the order of 50%, so that its inclusion in the dissection will have a substantial effect upon the outcome of the surgery. The great benefit of using individual follicular units is that the wound size can be kept to a minimum, while at the same time maximizing the amount of hair that can be transplanted.SMALL RECIPENT SITESThe importance of minimizing the wound size in any surgical procedure can not be over emphasized and hair transplantation is no exception. The effects of recipient wounding are felt at many levels. Large wounds can lacerate blood vessels and although the blood supply of the scalp is extensively collateralized, any damage to these vessels will have an impact on local tissue perfusion. An equally important issue is to minimize the disruption of the microcirculation. This is especially important when transplanting grafts in large quantities. The compact follicular unit is, of course, the ideal way to permit the use of the smallest possible recipient site, and has made the transplantation of large numbers of grafts technically feasible.Densities between 10 to 40 follicular units per centimeter are routinely reported. Densities greater than 40 follicular units per centimeter in a single session have been accomplished, but may result in a decrease yield in some patients. It is important to note that a follicular unit density of 40 units/mm2 can create a hair density of over 120 hairs/mm2 (if all 3- and 4-hair units are used in select areas), and this is a density that many hair transplant surgeons feel is not necessary, or even desirable, to exceed.TRANSPLANTING FOLLICULAR UNITS IN LARGE SESSIONSPutting aside anatomic, physiologic and technical issues for the moment, it is important to emphasize the practical reasons to strive toward large sessions. The specific events that bring a balding patient to the doctor for hair loss will vary, but the common denominator of those seeking hair restoration is to improve their appearance, and to improve the quality of their life, be it personal, professional, or social. Until the transplant is cosmetically acceptable, the disruptions from the scheduling of multiple surgeries, the limitations in activity, and the concern about their discovery, can place a patient’s life “on hold.” It should therefore be incumbent upon the physician to accomplish their objectives as quickly as possible. Some patients prefer smaller sessions for economic reasons. MICROSCOPIC DISSECTION There is probably no other aspect of follicular unit transplantation that has generated more controversy than the use of the microscope. Stereo-microscopic dissection was introduced into the field of hair transplantation by Dr. Bobby Limmer6 in 1987. The following statements summarize the use of magnification: – In order to dissect intact individual follicular units, you must be able to see them clearly.- Only magnification allows their clear visualization in both normal and scarred skin, independent of the specific hair characteristics of color, hair shaft diameter, and curl. Follicular dissection can logically be divided into two parts; the subdivision of the initial donor strip into smaller pieces and the further dissection of these pieces into individual follicular units. The first part of the procedure, the handling of the intact strip, has always been the most problematic. The intact strip however, is difficult to stabilize and is too opaque for transillumination to be useful. The dissecting microscope and other magnification methods allow the strip to be divided into sections (or “slivers”) by actually going around follicular units leaving them intact. The dissecting stereo-microscope is able to accomplish this because of its high resolution (usually 5x more powerful than magnifying loops) and its intense halogen top-lighting that provides continuous illumination, as one dissects through the strip. Back light illumination has also proven beneficial. Stability can easily be achieved by applying slight traction to the free end of the strip. The thin slivers are then laid on their sides and the microscopic dissection of the individual units is completed. With stereo-microscopic dissection, except for the outer edges of the ellipse, every aspect of the procedure is performed under direct visualization, so that follicular transection can be minimized and the follicular units maintained. CONCLUSIONThe entire field of hair restoration surgery has moved toward the use of follicular unit transplantation. While the exclusive use of follicular units is not employed by the majority of transplant surgeons, the impact of this approach has been significant. Hair restoration surgeons are becoming more scientific and precise in their approach to this field. The vague terminology of the past, i.e., round grafts, many grafts, micro grafts, has been replaced with more precise terms. We now converse in a language which details the number of follicular units per square centimeter, hair shaft diameter in microns, and incisional density of the recipient site for any given session. Perhaps the modern era of transplantation did not begin with the micrografting of the ’80’s, but it is only truly being realized with follicular Unit transplantation of the ’90’s.

Surgical procedure is popularly used for those who have saggy, excess skin as a result of weight loss. You can go for thigh lift, arm lift, breast lift. Your sagging abdomen skin can be made firmer post pregnancy. Aging and weight loss are other causes for sagging abdomen which needs to be tucked. You can try out cosmetic surgical procedure known as “body lift”. Other surgical procedures for thigh lift, breast lift or fat reduction includes Vaser LipoSelection System Ultrasonic-assisted Liposuction (UAL) and Power-assisted Liposuction (PAL).

Enhance your body contours and look great!

With the help of surgical treatments you can improve your figure and achieve firmer and more attractive-looking legs, breast, abdomen, back, buttocks etc. Get rid of those ugly looking flab which is a result of pregnancy, age or sudden weight loss. Your skin may have lost its elasticity due to “over extension” caused by being overweight too. With the help of body lift, certain areas such as abdomen, legs, breast, groin, arms, chest, buttocks and thigh area can be worked out to remove excess skin tissue of the body.

Your buttocks can be made firm with an incision made to create more prominent contour of the back or buttocks. It is achieved by excess skin or unwanted skin removal. Body lift procedures are carried out in various part of the body to gain a more appealing result. Other than this, massage with oil also helps post pregnancy and during old age. This helps to make the sagging skin firmer and gives elasticity to your skin. It also makes your skin glow. Massaging your breast will help keep them firm and increase the breast size if they are too small. Proper blood circulation is boosted with the help of massaging and as a result the breast tissues grow back.

Contour Ab Belt of a good brand will help to some extent, provided you have a well balanced diet. Ab belt or flexi belt functions as abdominal toning tool. Remember, to find out about the product from your relatives or friends who have used it before and then consider buying them. Happy exercising!

Unlike some of the other available ab energizers, this particular ab shocker is made to be used only on the abdomen. Like others, though, it is portable and can be worn under clothing while doing a variety of activities. Consider this product, after through examination as it has its own advantages and disadvantages.

IntroductionThe follicular unit (FU) was first defined by Headington and the conceptual framework for using FUs in hair transplantation was laid out by Bernstein and Rassman. It became clear to most surgical hair restoration practitioners that the single-strip harvesting and stereomicroscopic dissection techniques developed by Limmer in 1988 were the best way to both harvest and isolate FUs.Although single-strip harvesting is an extremely efficient means of obtaining tissue for subsequent dissection into FUs, it results in a linear scar. Careful technique with thin donor strips will produce very fine scars, but if the strips are taken too wide, the scar can widen to an unacceptable degree. Covering the donor area with longer hair was the only solution to widened scars, as surgical repairs of these wounds generally proved to be ineffective. As a result, a number of patients became hesitant to undergo a hair transplant procedure that had a potentially difficult-to-treat widened linear scar.In the mid-1990s, Rassman set out to find a way around this problem by directly extracting FUs from the donor area using a small punch. Early attempts were frustrated by high transection rates in a significant number of patients until Richard Shiell brought the work of Masumi Inaba to his attention.Inaba”s technique varied slighty, using a similar punch but only partially cutting down on the hair follicle and then removing the remainder with forceps. Inaba”s insight led to Rassman and Bernstein describing follicular unit extraction or the FOX procedure (FOllicular unit eXtraction), outlining an entire surgical hair restoration procedure without strip harvesting After performing the FOX procedure on patients of various nationalities it became obvious that extraction proved to be quite variable. Histologic analysis was used in an attempt to elucidate the cause of patient variability and the FOX Test was introduced, an important surgical recommendation tool to determine patient candidacy.Overall results showed that the FOX Test classified approximately 60% of all patients as candidates for the FUE procedure. However, even the good hair transplant candidates had a strong possibility of follicle transection.Two-Step TechniqueThis process is comprised of two main steps. In the first step, a sharp 1 mm punch is placed over the follicular unit and aligned to approximate the angle of the hair shafts below the skin surface. A rotational motion of the punch is then used by the hair restoration doctor to cut through the skin and isolate FUs in the epidermis and upper dermis.For a successful hair transplant procedure, the incident angle of the punch cannot vary much from the hair shaft direction or some, or all, of the hairs in the FU will be transected. Since the hair bulbs in each FU splay outward in the deep dermis and fat, it is also important to limit the depth of the punch to the upper dermis, which proves difficult.In step two, the extraction, fine rat-toothed forceps are used to apply gentle traction to the top of the FU until the unit is pulled loose from its deep dermal and subcutaneous connections. There is person-to-person variation with this procedure. To help limit variation effects, the technique was refined further, adding dissection when simple extraction proved difficult. If a graft cannot be removed with gentle traction, then the deeper part of the graft is separated from the surrounding tissue through dissection using a fine needle (with a U-shaped tip) while traction is applied with delicate forceps.With this additional dissection step, percentages of positive FOX patients increased. Despite a significant yield improvement, a large number of hair restoration patients still could not be shifted into “FUE candidacy.” In many cases transection rates were still unacceptably high and dissection times for significant cases unacceptably long; the additional step slowed the entire process.Three-Step TechniqueJames Harris presented a paper and a new solution at an ISHRS scientific meeting, in which he added an additional third step requiring new instrumentation. In this new three-step hair transplant procedure, a sharp punch is used to score the epidermis (rather than cut through the full thickness to the dermis) and then a dull punch is used (through a back-and-forth twisting motion) to bluntly dissect the FU graft from the surrounding epidermis and dermis .This variation has several advantages over the original two-step process. Using a dull punch avoids follicle transection and allows intact FUs to be extracted more easily. As the blunt-tipped punch is advanced into the dermis, splayed follicles are “gathered together,” avoiding transection. In effect, the dull-punch technique allows a full realization of the “extraction concept” with an easy-to-learn methodology. One untoward result of the three-step technique is a possible higher incidence of buried grafts, as discussed later. In addition, some of the FUs remain tethered to the subcutaneous tissue and require additional dissection.One great advantage of this addition was that it opens this surgical hair restoration technique to the inherent FOX-negative population: those with very fine hair and those with African kinky hair types. Because the procedure is performed blindly, visualization is no longer an issue, potentially increasing yield for those with hard-to-see gray hair. In addition, it appears that this FUE modification has applicability for corrective procedures, removing FUs inside old plugs.Indications for FUE have evolved considerably. Initially, FUE was limited to FOX-positive patients (that showed minimal transection) and in those in which the size of the balding area matched the surgical team”s ability to perform the procedure in an acceptable time frame – essentially small procedures in select patients. With improved techniques, Rassman reported his largest case yet in 2004: 1903 FUs performed exclusively with the original two-step technique. Harris” modification should allow these large sessions in a greater number of hair transplantation patients.Nuances of three-step techniqueAlthough the three-step technique is easier to master than the two-step technique, there are certain factors that will increase its efficiency and success.Because the subcutaneous course of follicles cannot be ascertained with great accuracy, “scoring” incisions should be limited to a depth of between 1.3 mm and 1.5 mm (approximately the level of the end of the bevel on a standard 1 mm Miltex punch) to decrease the risk of inadvertent transection. However, in hair transplant patients whose follicles are slightly longer, scoring incision depths may be increased by 0.1-0.2 mm. This increase should facilitate insertion of the “dissecting” punch and may decrease the incidence of “buried” grafts.Even though the use of a blunt punch provides protection for follicles and makes the angle of insertion less critical, follicles may be damaged if the angle is radically different from the follicle”s direction. To prevent damage, scoring incisions can be created, and their angles reassessed to obtain a more accurate estimate of the follicle”s direction and more accurately “aim” the dissecting punch.Follicle separation from the epidermis and upper dermis at the sebaceous gland may occur during extraction. This phenomenon, which has been called “capping,” can be handled in three ways. If the subcutaneous attachment is significant, a second pass with a dissecting punch can be attempted. A second option is to grasp the unit at the sebaceous gland region and pull, applying a slow, steady force. The final option, if standard dissection fails, is to leave the graft in situ and allow the skin to heal by secondary intention.Since a third step is required in this new hair restoration method, the need for efficiency has increased. Rather than performing each of the three steps for each FU in sequence, a preferred method is to identify an area to be extracted, score 25-50 FUs, dissect each one, and then extract. Assistants may help with dissection and extraction but care must be taken to identify any buried grafts for subsequent retrieval efforts.The need for tumescence varies from patient to patient, but for the most part, it has been found that tumescence may cause the dermis to become somewhat “mushy” and impede the extraction process. The hair transplant surgeon must make constant assessments of extraction success each step of the way with every patient. Ease of extraction also seems to vary with scalp location. The occipital area tends to be easier while temporal areas may require manual dissection due to a higher degree of tethering.Management of buried graftsAs previously mentioned, this hair transplantation technique has an inherent possibility of producing buried grafts. Incidence can vary from patient to patient depending on unidentified skin characteristics. It has been observed that in some patients and in some areas (the temples for example), slightly increasing scoring depths decreases the incidence of buried grafts.When a buried graft is identified, immediately apply pressure around it in an attempt to “force” the graft to the surface. If this maneuver fails, the hair restoration doctor should examine the circular incision to identify the follicle base, a key step in facilitating removal. If the follicle is not visible, use small, curved forceps with the tip directed towards the “superior” aspect of the incision in an attempt to grasp the FU. Owing to punch insertion angles, the incision depth is shallower at the superior aspect of the incision. Grafts often invert at this location by tethering to a nonscored attachment.If the graft still cannot be located, make a small incision towards the superior aspect to create a larger exploratory opening. If after these steps visualization still eludes the hair transplant surgeon, the graft should be left buried. Exact incidences of graft burial and graft recovery are not available; however, in a 40-patient and approximately 10,000-graft study, only two instances of buried grafts resulted in hair-bearing inflamed cysts requiring removal.Indications for FUEFUE is indicated in the following situations:1. When even a very thin linear scar is unacceptable (i.e. in those who shave their head or wear their hair very short)2. When a patient requests an FUE procedure and enough grafts can be harvested to meet his or her needs3. In patients with limited hair loss or those who require small sessions. This group would include patients with androgenetic alopecia in a Norwood Class 3 pattern or those with small vertex balding areas4. For limited cosmetic areas, such as widow”s peaks, eyebrows, eyelashes, mustaches5. For limited areas of alopecia secondary to dermatologic conditions6. In the treatment of widened scars resulting from traditional strip excisions7. In patients without adequate laxity for a strip excision8. For scarring from dermatologic conditions, trauma, or neurosurgical procedures9. For individuals with heavily scarred donor areas making a linear incision problematic10. In patients who tend to heal with wide or thickened linear scars11. In athletes who must resume full activity soon after the procedure12. For patients with an inordinate fear of pain or scars13. When the body or beard serves as a donor area.Contraindications for FUEContraindications for FUE include:1. Inexperience in performing FUE techniques2. Unavailability of proper instrumentation3. Inadequate and uninformed patient consent4. Unrealistic patient expectations5. Inadequate donor supply6. Scarring that makes both the two- and three-step procedures problematic.ConclusionFUE is an exciting advancement that propels the field of hair transplant surgery one step closer to the elite minimally invasive status. The promise of an almost scarless surgery is enticing to both patient and surgeon. For the hair restoration doctor who has to perform this tedious technique, there remain many vague issues ranging from ethical representations of patient results to practical realities of surgical indication. Training periods are extensive, risks of less than desirable results are high, and many technical problems have yet to be worked out.FUE clearly has a valuable place in a growing number of hair transplant candidates. Although the techniques have improved, issues of patient selection, donor area healing by secondary intention after large sessions, and imbedded grafts still remain. The reasons for selecting FUE rather than a strip harvest may be the avoidance of a linear scar, the desire for a virtually pain-free recovery period, or simply the idea of having a minimally invasive procedure.Further ReadingBernstein RM, Rassman WR, Seager D, et al 1998 Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatologic Surgery 24:957-963Bernstein RM, Rassman WR, Szaniawski W, Halperin A 1995 Follicular transplantation. International Journal of Aesthetic Restorative Surgery 3:119-132Bernstein RM, Rassman WR 1997 Follicular transplantation: patient evaluation and surgical planning. Dermatologic Surgery 23:771-784Bernstein RM, Rassman WR 1997 The aesthetics of follicular transplantation.Dermatologic Surgery 23:785-799Bernstein RM 1998 A neighbor”s view of the “follicular family unit.” Hair Transplant Forum International 8:23-25Harris JA 2004 Follicular unit extraction: The SAFE System. Hair Transplant Forum International 14:157,163,164Inaba M 1996 Androgenetic alopecia: modern concepts of pathogenesis and treatment. Springer-Verlag, Tokyo pp 238-245Kim JC, Choi YC 1995 Regrowth of grafted human scalp hair after removal of the bulb. Dermatologic Surgery 21:312-313Limmer BL 1994 Elliptical donor stereoscopically assisted micrografting as an approach to further refinement in hair transplantation. Dermatologic Surgery 20:789-793Okuda S 1939 Clinical and experimental studies of transplantation of living hairs. Jon Journal of Dermatologic Urology 46:135-138 [in Japanese]Orentreich N 1959 Autografts in alopecias and other selected dermatological conditions. Annals of the New York Academy of Sciences 83:463-479Rassman WR, Bernstein RM 2002 Follicular unit extraction. Minimally invasive surgery for hair transplantation. Dermatologic Surgery 28:720-728Rassman WR, Carson S 1995 Micrografting in extensive quantities: the ideal hair restoration procedure. Dermatologic Surgery 21:306-311Rassman WR, Bernstein RM 2002 Follicular unit extraction: Minimally invasive surgery for hair transplantation. Dermatologic Surgery 28:720-728Sasagawa M 1930 Hair transplantation. Japanese Journal of Dermatology 30:493 [in Japanese]

Hair restoration is the surgical procedure aimed at permanently correcting male pattern baldness. It is a generic term to define a number of methods used to restore hair to balding areas. Hair restoration methods involve topical, oral and surgical treatments. Various methods of hair restoration surgery

There are various methods of hair restoration surgery for you to choose from. The two chief methods that you can opt for are – a.) Scalp Flap Surgery and b.) Scalp Reduction Surgery.

A. Scalp flap surgery – It entails moving a flap of skin and underlying tissues from one scalp area to the other. The surgeon first cuts out a section of the scalp where there is no hair growth He then replaces it by a flap of hair-bearing scalp. The size and placement of the flap will depend on your requirements. You do not need to worry about the scar. It will be covered by the relocated hair.

The objective of this hair restoration method is used to rectify a non-traumatic cosmetic defect. It is also used to repair a traumatic injury site and restore its functionality and cosmetic appearance. Another use of scalp flap surgery is repairing a skin defect caused by congenital malformation. The advantages of this hair restoration surgery procedure include natural frontal hairline, proper hair placement in temporal areas, hair pattern distortion avoidance, etc. However, it runs the risk of certain side effects. They include permanent hair loss at donor sites, scarring at donor or recipient sites, blood supply failure to the flap, etc. Scalp Reduction Surgery – Scalp reduction surgery is the hair restoration procedure usually meant for people with posterior baldn

B. ess. It is into removing bald scalp and bringing the half-bearing scalp closer to it to fill in the bald area in the scalp. In this hair restoration surgery the surgeon reduces the baldness by cutting out a segment of the bald scalp skin. The hair restoration process in scalp reduction surgery has two parts. The first part includes the surgical removal of the bald portion of the scalp. The other part entails hair-bearing scalp being upwardly stretched to replace the bald scalp that has been removed. You many need the scalp reduction surgery to be conducted in combination with the surgical procedure called brow lifting. This procedure removes the frown lines from the forehead and crow’s feet from around the eyes. In your case this surgical procedure can be carried out through scalp extension or scalp expansion device. In this technique the hair-bearing scalp skin is stretched causing better coverage to bald areas of the scalp. This hair restoration surgery is often combined with hair transplantation. What’s the objective? Well, one possible objective is to “fine tune” hair restoration in your anesthetically sensitive areas. One example of such an area is your frontal hairline.

The scalp reduction surgery can be conducted before, during or after hair transplantation. The appropriate time will be identified mainly on the basis of your need. How to decide which scalp reduction technique is correct for you? That depends on various factors like your hair loss degree, laxity of the scalp, donor hair amount, etc. The possible complications and side effects that you may face include scarring at the suture lines, scalp skin “stretch back” at the excised bald area and central midline scar called slot deformity. Recent advances in hair transplantation – The emergence of some relatively recent advances in hair transplantation techniques offer better surgery outcomes for pattern baldness. These new hair restoration techniques are less complicated and painful. Follicular Unit Transplantation – At present it is considered to be the most reliable hair transplant technique. Its success rate is almost 10 per cent. A follicular unit is a physiological unit that needs to be extracted and transplanted as an intact unit. Its advantages include natural looking hair, more effective surgery due to the use of stereoscopic microscopes for dissection, avoidance of damage to the follicular unit, etc. However, it is a time consuming procedure. Direct Hair Implant (DHI) – The minimally invasive hair transplant procedure for follicular hair transplant, DHI is free from the use of scalpel, stitches and a donor strip. The technique is based on the transportation technique named Follicular Unit Extraction (FUE). FUE exemplifies the latest extraction procedure for follicular unit transplants procedure. FUE includes the use of custom-made, precise micro-surgical tools. There is direct extraction of follicular units one by one, instead of dissection. One main advantage of FUE is possibility of quality control during the transplantation procedure. Besides, it is a simple and painless procedure. Choosing the right clinic

Be very careful while choosing your hair restoration clinic. A standard clinic will successfully help you realize your hair restoration dream. On the other hand the selection of a wrong clinic will lead to a faulty service. The various factors that determine the credibility of a clinic include the feedback of former patients, legal status (i.e. whether any lawsuits are pending against the clinic), the professional kills of the surgeon, etc.

Densitometry is a technique that analyzes the scalp under high-power magnification to give information on hair density, follicular unit composition and degree of miniaturization. It can be used to help evaluate a patient’s candidacy for hair transplantation and help predict future hair loss. More recently, video-microscopes have been developed that can project the image onto a computer screen and provide a permanent digital record. This paper describes the value of taking objective measurements, using densitometry or video-microscopy, in the hair transplant evaluation. BackgroundOne of the earliest methods of measuring hair density was devised by Bouhanna, who used camera attachments to create a “phototrichogram,” an ultra close-up photograph of hair exiting the scalp. This method provided the capability to document the quality and quantity of hair shafts.  However, the disadvantage of this innovation was that an assessment could not be done until after the film had been developed. [1] In 1993, Rassman introduced a small hand-held instrument, the Hair Densitometer, to make densitometry easy to perform during a consultation. [2, 3].  The hair densitometer is a self-contained, portable, device that houses a magnifying lens and an opening of predetermined size.  The hair is clipped short (~ 1-mm) and the unit is placed directly on the scalp.  An assessment is made from a standard 10mm2 field.  Multiple measurements taken from different parts of the scalp are often helpful, particularly if there is significant variability from one location to another. [4] An advantage of the hand-held densitometer is that it is inexpensive and readily available to be used during the consultation and can provide immediate information regarding a patient’s candidacy for surgery.   A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler. With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10]. The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss. [10-12] A number of other hand-held instruments to measure density have been developed with the similar basic elements of magnification, illumination and a calibrated field or ruler.  With more recent technology, digital trichograms allow the physician to take quantitative measurements of hair shaft diameters and provide an immediate, permanent record of this information. [5-7] [Figure 2]The densitometer was initially used to quantify a patient’s donor density, to estimate the total number of grafts that could be safely obtained from the donor area, and help predict the change in reserves over subsequent transplant sessions. [3] With the introduction of Follicular Unit Transplantation in 1995, these authors began to use densitometry to assess follicular unit composition (the number of terminal and miniaturized hairs that each individual unit contained) and follicular unit density (the spacing between units), as these additional factors were found to be important in the assessment of the donor supply and in the overall surgical planning of follicular unit transplantation procedures. [8-10].  The use of densitometry was soon expanded to guide the surgical treatment of those with racially distinct hair characteristics, to improve the diagnosis and treatment of balding women, and to further define the conditions of diffuse patterned and un-patterned hair loss.  [10-12]    MiniaturizationNormally, follicular units contain 1-4 terminal hairs of uniform diameter and, occasionally, fine vellous hairs, with the two hair populations being clinically distinct.   In androgenetic hair loss, the action of DHT causes individual terminal hairs in some follicular units to miniaturize, where they begin to decrease in diameter and in length until they resemble vellous hairs. Eventually, these hairs will disappear.  In androgenetic alopecia, hairs in varying stages of involution (and thus of varying diameters) cause these two distinct populations of hairs to merge into one continuum.  The changes eventually cause visible thinning in affected areas, but may initially be detectable only through densitometry.At first, miniaturization involves only one or two hairs in select follicular units, but eventually progresses to involve all the hair follicles in genetically susceptible areas.  It has been the observation of these authors that a shift from focal to generalized miniaturization precedes the actual loss of affected hairs, so that total hair counts remain relatively constant until end-stage baldness. [8]  Said another way, the progressive thinning associated with androgenetic hair loss (particularly in the early stages) is caused by a decrease in the hair shaft diameter of an increasingly larger number of hairs, rather than by the actual loss of individual hair follicles.Miniaturization, unfortunately, can also occur in the back and sides of the scalp.  When it affects a person’s donor area, it will have profound implications for surgery. Although miniaturization in the donor area is a relatively uncommon occurrence in men, it is quite common in women, explaining why so many more men with hair loss are candidates for surgery compared to women.  In all cases, donor miniaturization must be assessed prior to considering surgery.Densitometry MeasurementsDensitometry is extremely helpful in evaluating patients for hair transplantation. When determining which persons are candidates for hair transplantation, it can be used to measure the absolute donor hair density (i.e. # of hairs/mm2), the composition of follicular units (i.e. the number of 1-, 2-, 3- and 4-hair units), and the degree of miniaturization. Although the precise hair density and composition of follicular units will not be known until after the donor strip has been completely dissected, at the time of the consultation, densitometry can tell the doctor the approximate hair density. This will enable him to determine how much hair will be obtained from a certain size strip or how large a strip will be needed for a required number of follicular unit grafts.   Densitometry will also give information regarding the cosmetic impact of the hair restoration.  Other hair characteristics being equal, if a person has a high number of 3- and 4-hair grafts, he/she would be expected to have a fuller hair transplant than a person with predominately 1- and 2-hair follicular units.  For example, a typical Caucasian would have follicular units in his/her donor area that contained, on average, 2.25 hairs each.  If there were 1 follicular unit per mm2 in the donor area (0.9 to 1.0 is normal) then one would need 2,500mm2 of donor tissue for a 2,500 graft procedure. A donor strip that was 1cm wide would need to be approximately 25cm long to contain 2,500 follicular unit grafts.  See the following table. Stereo-microscopic dissection of the donor strip would yield approximately 14% 1-hair grafts, 53% 2-hair grafts and 33% 3- and 4-hair grafts.  The single-hair grafts would be used to create a soft, natural frontal hairline and the 3- and 4-hair grafts would be used in the forelock area to create the appearance of central density.  Small variations in follicular unit density can have a significant impact on the procedure. A person of similar hair shaft characteristics (i.e. hair diameter, color and wave) that had 2.0 hairs per follicular unit, also spaced 1mm apart, would require exactly the same size strip for a 2,500 graft procedure.  In this case, however, the follicular units would, on average, have less cosmetic value and the person should expect a thinner look from the surgery as only 17% of the grafts contain 3- or 4- hairs.  In addition, the ability to create central density via graft sorting would be reduced.  On the other hand, with a donor density of 2.4 hairs per unit, 40% of the grafts will contain 3- or 4-hairs and the ability of the surgeon to create density in the forelock area using only naturally occurring follicular unit will be significant If we look at the total number of hairs contained in the follicular units, we note that for a 2,500 graft procedure, a person with 2.4 hairs per follicular unit will have 1,000 more hairs than a person with a density of 2.0. Densitometry, therefore, gives the physician information regarding the number of single hair units that can be anticipated from a given size donor strip (without having to subdivide larger units) and the degree to which the larger follicular units can create central and forward weighting to enhance the aesthetic impact of the procedure.  Donor Miniaturization  Normally, the donor area shows little or no miniaturization and the density counts described above are useful in predicting both the short- and long-term outcome of the procedure.  However, if genetic hair loss affects the donor area, the situation changes dramatically. Once full-thickness terminal hair begins to miniaturize, the cosmetic value of the follicular unit begins to decrease and the value of the grafts will be diminished.  In other words, just because hair is transplanted, it doesn’t make the hair transplant   permanent – the hair in the donor area must be permanent.      Early detection of miniaturization in the donor area is a warning sign that the donor area is not stable and that the person may not be a good candidate for surgical hair restoration.   If any miniaturization is detected in a young person, i.e. under the age of 25, red flags should go up that their donor area may not be stable.  When miniaturization is noted in a teenager, the risk of developing diffuse un-patterned hair loss (see below) is significant.  In an older adult male, some miniaturization, perhaps up to 20%, is consistent with being a good surgical candidate.  Unlike men, adult women often have significant levels of miniaturization in the donor area, so the mere presence of miniaturization is not necessarily a contraindication to surgery.  However, miniaturization does indicate an unstable donor supply and one has to make a judgment regarding the risk/reward of the procedure. The physician needs to consider the absolute number of full terminal hairs that are available for the hair transplant, the risk of further miniaturization, the area that needs to be covered, and the risk of the surgery accelerating the hair loss.  This is particularly important to consider in women, since hair is often transplanted into an area that has a considerable amount of existing hair – some of which is at risk of being shed from the surgery.  In women, when the risk of continued miniaturization of the donor area is added to the risk of the surgery accelerating hair loss in the area to be transplanted, a far fewer percentage of women are good candidates for surgery compared to men. To think otherwise is disingenuous.  Diffuse Patterned and Un-patterned AlopeciaThe importance of donor miniaturization as a factor affecting a person’s candidacy for a hair transplant was emphasized almost a decade ago in the paper “Follicular Transplantation: Patient Evaluation and Surgical Planning.”[4] In this writing, we described two conditions; “Diffuse Patterned Alopecia” (DPA) and “Diffuse Un-patterned Alopecia” (DUPA). These were first mentioned by O’tar Norwood when he devised the classification of androgenetic alopeica that bears his name.  These two conditions, however, were not detailed in his paper and never received much attention. This was unfortunate because their understanding gives important insights into how to determine who will be a candidate for hair restoration surgery. [5] Diffuse Patterned Alopecia (DPA) is characterized by diffuse thinning (miniaturization) in the front, top, and vertex of the scalp in conjunction with a stable permanent zone. DPA is usually associated with the persistence of the frontal hairline and, in the early stages, the thinning is relatively even across the top of the scalp. This contrasts with regular Norwood patients that have early hair loss at the temples and in the crown with balding that spares the top of the scalp. Patients with DPA can be good candidates for hair transplantation due to their stable permanent zone; however, they have an increase risk of shedding after the hair transplant, due to the diffuse miniaturization across the top of the scalp.   In the less common Diffuse Un-patterned Alopecia (DUPA), the miniaturization process occurs over the entire scalp, so that the person lacks a stable permanent zone. People with DUPA tend to lose their hair at an early age, often beginning in their teens. In the early stages, there may be only a slight suggestion of decreased hair volume overall and actual thinning may only be noted through densitometry. Over time, the back and sides of the scalp can take on a transparent appearance, particularly when the hair is cut short. Because the donor area is not permanent, hair transplantation is contra-indicated in patients with Diffuse Un-patterned Alopecia.    Although fully manifest diffuse un-patterned hair loss is relatively uncommon in men, there are many younger patients who have slightly increased degrees of miniaturization in the back and sides of the scalp, making the long-term stability of the donor area questionable. In these patients, the decision to recommend hair restoration surgery is particularly difficult.  As a general rule, if the decision is difficult, it is best postponed, since, over time, the stability of the donor area will become more obvious.  A mistake can leave the patient with transplanted hair that will thin over time and a donor scar(s) that may become visible. Both Diffuse Patterned and Un-patterned alopecia also occur in women. However, in contrast to men, the DUPA pattern in women is much more common, possibly occurring 10 times as frequently as DPA.  As in men, female patients with DUPA are not good candidates for a transplant, except in the instance where the goal is solely to soften the frontal edge of a hairpiece. The high incidence of Diffuse Un-patterned Alopecia in women partly explains why many fewer women are good candidates for hair transplantation as compared to men.  It is important to emphasize that other, non-genetic, causes of hair loss must be considered in cases where the balding pattern is diffuse.  These include anemia, thyroid disease, connective tissue disease, gynecological conditions, severe emotional events, and medications. Although the presence of miniaturization likely points toward a hereditary cause of the hair loss, with diffuse hair loss other etiologies must always be entertained. ConclusionDensitometry is an important tool for the evaluation of hair loss and for assessing candidacy for hair transplantation.  Measuring donor density and assessing the degree of miniaturization in the donor area should be an integral part of the evaluation of every patient in which surgical hair restoration is considered. This will enable physicians to better select those who are good candidates for a hair transplant and help identify those patients in whom the procedure is contraindicated.  For patients having a hair transplant, these measurements will enable the physician to better estimate the size of the donor strip and be better able to anticipate the aesthetic outcome of the hair restoration procedure.   References 1. Bouhanna P: Phototrichogram: a technique for the objective evaluation of the diagnosis and course of diffuse alopecia. In W Montagna et al. (eds). Hair and Aesthetic Medicine. Roma, Salus Ed. 1983: 277-280.2. Rassman WR, Pomerantz, MA. The art and science of mini-grafting. Int J Aesthet Rest Surg 1993; 1:27-36. 3. Rassman WR, Carson S. Micro-grafting in extensive quantities; the ideal hair restoration procedure.  Dermatol Surg 1995; 21:306-311.4. Bernstein RM, Rassman WR, Seager D, Shapiro R, et al.  Standardizing the classification and description of follicular unit transplantation and mini-micro-grafting techniques. Dermatol Surg 1998; 24: 957-63. 5. Stough DB, Haber RS. Hair Replacement: Surgical and Medical. St. Louis: Mosby-Year Book, Inc., 1996: 139-140.6. Van Neste D, Dumortier M, De Coster W: Phototrichogram analysis: technical aspects and problems in relation to automated quantitative evaluation of hair growth by computer assisted image analysis. In Van Neste D, Lachapelle JM, Antoine JL (eds). Trends in Human Hair Growth and Alopecia Research. Dordrecht, Kluwer Acad. Pub, 1989: 155-165.7. Hayashi S, Hiyamoto I, Takeda K: Measurement of human hair growth by optical microscopy and image analysis. Br J Dermatol 1991; 125:123-129.8. Bernstein RM , Rassman WR, Szaniawski W, Halperin A: Follicular Transplantation. Intl J Aesthetic Restorative Surgery 1995; 3: 119-32. 9. Bernstein RM, Rassman WR: The logic of follicular unit transplantation. Dermatologic Clinics 1999; 17 (2): 277-95. 10. Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. 11. Bernstein RM, Rassman WR: The Aesthetics of Follicular Transplantation. Dermatol Surg 1997; 23: 785-99. 12. Norwood OT. Male pattern baldness: classification and incidence. So. Med. J 1975; 68:1359-1365.