Open Donor

A hair transplant relies greatly on the capacity of the donor area to supply enough hair to cover the surface area of hair loss; the more times the donor is entered or harvested the quality of the area will be impaired

Donor management is vital to a successful hair transplant; older techniques such as punch grafting would leave large cylindrical scarring across the donor area and greatly reduce the amount of hair and density that can be safely harvested and leave obviously visible scarring

Planning is critical, both from the donor and recipient, to prioritise on what supply is available to what the demand is in the recipient area; as the number of follicular units available is a finite resource they need to be distributed in optimum approach

When dealing with a depleted donor it is important to prioritise how the hair that can be harvested can then be used in the recipient area; very often a depleted donor also means a less than successful recipient hair result and this will require planning to get the most from the donor to give a cosmetically pleasing result in the recipient

Known as an “open donor”, the area has been depleted of hair, either due to excessive scarring by previous operations or the donor hair quality not being adequate to be used, either miniaturised or simply a low density, possibly signs of DUPA

In cases where the donor is open with punch scarring, and assuming the skin laxity still allows it can be possible to excise the scarring using the FUT technique, or strip method; this allows for the strip to be taken and then sutured leaving a single line, opposed to multiple punch scarring

A depleted donor can also occur prior to any hair transplant being performed; if the area has a high % of miniaturised hair, or a low density or hair count. If the case a hair transplant is very possibly not the answer, short or long term it is unlikely a successful result can be achieved

Research is important, having the donor area checked and examined, especially with repair hair transplant surgery so a master plan can be made and both the candidate and doctor understand the goals, priorities and limitations


How Hard To Extract Grafts With FUE

FUE, follicular unit extraction, is a blind hair transplant extraction method; meaning that as the punch enters the skin it is not possible to see the follicular unit depth or direction

Understanding the direction of the hair as it exits the skin is vital, as is depth control of the punch; as it is impossible to see with the eye so a great understanding of anatomy is required

Regardless of manual or motorised punch tools due care must be taken as any damage caused during the extraction process needs to be kept to a minimum, with around a 5% transection rate; if the transection rate gets too high then a decision has to be made whether the process should be continued

The depth the FU sits in the scalp can also alter, some more shallow or deeper than other; in general most individuals there is a small variant in depth around the head but in some cases the depth can alter dramatically, even in the same areas, making depth control of the punch harder to be consistent

If depth control is not managed correctly it can impair the quality of the graft being removed and potentially create more visible scarring with the post operation healing

The angle of the hair will alter dependent on the area of the scalp it is position in, the sides and back of the head; when punching the FU´s the positioning of the hand and body needs to change to compensate for the changes in direction; generally the sides being more acute and the back the hairs facing down

The direction of the hair as it exits the scalp can differ from how the follicle is directed under the skin; if this is not understood it can lead transecting the follicular unit, best case scenario is the FU is split and the healthy hair count reduced, worst case scenario the FU is worthless due to being divided

As FUE is becoming more and more popular it is important that the aspects mentioned are controlled. Donor management is vital the ensure the least amount of damaged is caused to the area

As each follicular unit is removed or attempted to be removed the density of hair is reduced, on smaller procedures the changes are less but if larger numbers are required there is a greater danger of over harvesting and leaving obvious scarring or areas of obviously reduced hair density

A Balancing Act

Before undergoing surgical hair restoration the donor resources need to be measured, hair density, average number of hairs per FU, skin laxity and general hair characteristics, hair to skin colour contrast, curl of the hair for example

These aspects will determine how good a hair transplant candidate an individual is, a good estimation how many grafts are available from the first procedure to future interventions, and how much coverage can be achieved

A balanced coverage does not necessarily mean total restoration with even density throughout, it simply means that from the hair line to the crown the placement does not leave a larger hair less surface area than treated

To achieve enough density on a higher Norwood scale candidate can require 7-9000 grafts from the hair line to the crown, a number that not every individual can achieve so it is important the hair transplant is planned

It is important to achieve a certain density of hair to create a shadow so the light is blocked from reflecting off the scalp; this is the basic principle that makes a hair transplant work and look natural

The hair line is generally the first area to be restored; the hair line frames the face and can have a great impact on how you look, but then behind is the frontal third, mid-section and then the crown or vertex

A hair line placed too high will reduce the potential surface area that needs to be treated but can appear unnaturally high, especially as the hair line will be perfect with no signs of thinning hair, that a receding hair line would have

A too low hair line can create two issues; as we age the hair line pattern does not match our age and changes in facial features; and if placed too low will fix the point of restoration permanently potentially making the recipient surface area too large to treat effectively

The better the characteristics the greater options are available, hair line placement and design can be more aggressive if desired and still maintain a balanced coverage even if hair loss advances to a high Norwood stage

If the hair characteristics are average or slightly below treating minor hair line hair loss may not be appropriate and it would be prudent to wait until a more obvious pattern of hair loss is evident; this will allow for a long term plan to be made to ensure a balanced coverage

As the hair resources are finite a master plan must be made from the first surgery to ensure in worst case scenario a balanced coverage can be achieved and the donor can sustain hair restoration

Along with graft placement, hair angles and orientation, and using natural follicular units an important aspect to a hair transplant looking natural is achieving a balanced coverage from the hair line to the crown.

Treating Advanced Hair Loss

Hair loss in the majority of men is progressive; an individual´s genetic disposition can be a reasonable guide to how advanced hair loss will progress. Advanced Norwood stages make defining the safe donor area easier

The size of the safe donor area is more important when using the FUE hair transplant technique as it relies on a wide surface area to extract the follicular units from; FUT extraction is more localised to a thin strip around the sides and back well within the donor area

NW5 Diffused Hair Loss Pattern Treated with 3994 FUT. Hattingen Hair Transplantation

NW5 Diffused Hair Loss Pattern Treated with 3994 FUT. Hattingen Hair Transplantation

Having the ability to measure the safe zone allows for an accurate assessment long term of how many grafts can be extracted, be it in one procedure or multiple surgical hair restoration procedures

Advanced hair loss sufferers also generally have lower expectations in terms of restoration; a natural result is priority but expectations of a low adolescent hair line is not the top significance for many

With planning it is possible to rebuild the surface area of hair loss, and on the right candidate achieve total coverage in a single procedure, even if this means a slightly lower hair density over the crown

Achieving total coverage with a natural hair density in one procedure is time efficient for the individual, only means entering the donor and recipient areas once, causing as little change to the skin and better healing

From the hair line position the area behind can be measured, frontal third, mid-section and crown; care has to be taken to measure the miniaturised hair around the demarcation zone when the sides and back meet the top of the scalp

The miniaturised areas of hair will increase the recipient surface area but must be taken into account when planning hair restoration otherwise the restored area will not meet the sides creating an unnatural island of hair

From calculating the donor hair density it is then possible to determine how many grafts/follicular units can be safely harvested and what hair transplant technique can be the most efficient to achieve as close to the required numbers

The hair characteristics will then determine what density of hair is required to be placed over the recipient area to achieve the look of thickness; the better the hair characteristics the lower density is required and greater coverage can be realised

NW6 Hair Loss Stage Treated with 7305 FUT. Hattingen Hair Transplantation

NW6 Hair Loss Stage Treated with 7305 FUT. Hattingen Hair Transplantation

If coverage cannot be achieved over the crown the hair density will be reduced as the placement reaches the vertex; this creates a natural looking pattern of hair loss and not stopping with a flat dense wall of hair

If total coverage can be achieved it is common the hair density over the crown will be reduced compared to the placement over the frontal and mid-section; few candidates can achieve total coverage and even density from hair line to crown in one procedure

Regardless of not being able to cover the crown or a lower density coverage the result can stand alone and look perfectly natural; if the individual does not wish for whatever reason to continue restoration the pattern of hair growth will be natural and balanced

If future restoration is desired then this can be performed at a later date; it is best to allow at least twelve months between hair transplant procedures; this allows for the hair growth to mature and the skin to fully heal

Correct donor management and on the right candidate can allow for upwards of 6000 grafts to be reached in a single procedure with the FUT technique; FUE procedures are generally much smaller and would require multiple sessions to get near such high numbers

Planning with any hair transplant is important as the first session the scalp is always in the best condition to maximise graft numbers; a mutually agreed plan between doctor and patient will ensure that both parties understand what can be achieved and the long term happiness of the individual

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Will There Be Changes To My Donor Area After A Hair Transplant?

Yes, after every procedure the skin physiology will change, scarring, skin laxity changes, and loss of hair density around the area. It is important to understand how the changes will affect your long term hair restoration

An educated donor management protocol is vital to maintaining the area in the best quality possible whilst maximising the graft numbers available to sustain a natural balanced coverage of hair if hair loss advances to a progressive level

A high Norwood Scale (NW6-7) hair loss candidate can require upwards of 7000 grafts dependent on the size of the surface area and the quality of the individuals hair characteristics available

Prior to any surgery the scalp is untouched, known as a “virgin scalp”; the hair density is untouched, the skin laxity the best it can be; at this stage the donor area is at its optimum quality

7305 Grafts After 2 FUT Procedures Donor Healing. Hattingen Hair Transplantation

7305 Grafts After 2 FUT Procedures Donor Healing. Hattingen Hair Transplantation

The number of grafts required will largely be determined by the surface area to cover and this can impact also on the hair transplant technique to best utilise, be it FUE or FUT, as each have individual benefits

Choosing the correct technique can impact on future surgeries and the total number of grafts available over time; the decision can result in being able to achieve total restoration on advanced hair loss sufferers or not

FUT is influenced by the skin laxity of the individual, too tight or too lax can impair the size of the strip that can be removed and the number of grafts safely available to harvest. After every procedure the skin laxity will alter slightly, some of this is due to the natural skin healing properties

If treating a high NW scale FUT can allow for the maximum number of grafts to be harvested in a one day procedure; this benefits the individual as on the right candidate total restoration can be achieved efficiently with minimum need for entering the donor area

Future FUT procedures can be performed, it is best to allow at least 12 months between as this gives the scalp time to heal internally and reduces the risk of increased visible scarring; under normal conditions if a second FUT is performed the original scar will be removed to only leave a single line

The FUE technique relies on different donor hair qualities as it removes follicular units one by one leaving hair less areas or white dot scarring from where the FU´s were removed; unlike FUT the surface area of the donor remains the same but the density of hair is reduced

FUE relies on a high starting hair density otherwise attempting to reach high numbers can leave the donor looking unnaturally thin; meaning if hair loss progresses FUE may not be a suitable hair transplant technique to use if the hair characteristics are not optimum

Most FUE procedures are smaller than FUT due to the technical difficulties of harvesting and controlling the extraction pattern so as not to remove adjacent FU´s or transect FU´s potentially leaving a higher % of miniaturised hair

Even with small FUE procedures the donor hair should be shaved and the grafts removed over the widest safe area possible; this educated pattern of extraction will minimise density loss in a specific area and reduce the trauma to surrounding FU´s

Both techniques will change the physiology of the skin and hair, safe donor management is just as important to a hair transplant result as the coverage achieved over the recipient area and should be dealt with accordingly

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Miniaturisation Of A Hair Follicle

Hair loss or hair thinning is generally a slow process and takes time to become obvious and cosmetically visible when androgenic alopecia or male pattern baldness starts; the initial signs are the miniaturisation of the hair shaft

Miniaturisation describes the progressive thinning of the hair shaft; the hair follicle producing healthy hairs starts to reproduce thinner, shorter, finer, and weaker hairs after every growth cycle finishes

Hair Follicle Miniaturisation

Hair Follicle Miniaturisation

As each hair shrinks or atrophies the coverage and thickness of each hair reduces and the scalp becomes more visible over the head, giving the appearance of hair loss

The miniaturisation process linked to Male Pattern Baldness is a genetic disposition that can be inherited from either side of the family, maternal or paternal and considered linked to DHT, dihydrotestosterone

Over time the growth cycle reduces until the hair follicle stops producing hairs; along the hair line and temporal areas resulting in a recession; a receding hair line. Miniaturisation can also occur over the crown; initially the coverage can be maintained but a thinning of the hair

Miniaturisation normally occurs in the traditional areas of male pattern baldness, over the top of the scalp, known as the recipient area; but can also occur around the sides and back of the scalp, when discussing surgical hair restoration, known as the donor area

The donor area provides the hair that can be transferred to the recipient area to increase hair coverage and is not affected by the male pattern baldness gene; and if strong will continue to grow for a person´s life time

Miniaturisation can occur in the donor area; if the percentage of miniaturisation is too high then it will affect how much hair can be transferred and used in surgical hair restoration; how much coverage with a natural looking density can be achieved

The most common signs of miniaturisation in the donor area is around the ears and nape of the neck, where either the density of hair and or the calibre of hair is weaker but this can rise up into what is known as the donor area safe zone

In extreme examples the % of miniaturisation can be higher than the % of genetically strong hair; this can also be known as DUPA. Treatment can be used on the right candidate and can improve the quality of the hair but this does not mean it should be used for hair restoration

Harvesting the hair can increase the probability that when transplanted the hair follicle with die due to the trauma of the procedure and this will impact of the result of the hair transplant

Prior to undergoing a hair transplant the donor area should be checked, the donor hair density measured and the % of miniaturisation measured, much above 10% miniaturisation caution should be taken


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Advanced Hair Loss Impacts On The Safe Donor Area

Judging the donor safe zone can be difficult in the early stages of hair loss, in fact only an educated guess can be made taking into account genetic family history, which is only a guide and cannot be taken that an individual will follow the same pattern

Hair Transplant Donor Area Safe Zone

Hair Transplant Donor Area Safe Zone

Even with advanced patterns of hair loss when the demarcation line seems apparent between the recipient surface area and the donor area, the safe zone can reduce in size due to miniaturisation around the peripheral lines, the edges of the lateral humps, the edges of the crown and rising up from above the ears and nape of the neck, retrograde alopecia

The lateral humps are the areas of the scalp that fall on the sides of the head, joining the sides to the top of the head from the hair line temple back; they become important in cases of progressive hair loss when the hair in this area begins to part from the mid scalp.

Lateral humps may still appear to be intact in some cases but the quality of the hair is weak and miniaturised; in this case it is important the area is treated otherwise an island of hair over the top of the scalp is created

The same treating the crown, as the crown can open on all sides and drop down the back of the head; this can greatly reduce the surface area of the donor safe zone; especially when using the FUE technique

FUE relies on a wide donor surface to extract the required number of grafts otherwise over harvesting can occur leaving a moth eaten appearance to the donor area. This also hinders treating higher NW cases if the donor is not strong

Retrograde alopecia generally affects the hair just above the ears and nape of the neck rising up into the traditional safe donor zone; hair may still be apparent but miniaturised and not fit to transplant as it may not grow due to the trauma of the procedure

When designing the hair line it is important to take into consideration these areas and how much needs to be rebuilt behind the hair line to achieve a natural cosmetic result; a balanced coverage of hair over the scalp

The larger the recipient surface area drives the distribution of grafts and not result in an unnatural front loaded hair transplant with a large area of hair loss behind that could be half the scalp

With advanced hair loss where the lateral humps need rebuilding, the crown has dropped and retrograde alopecia is apparent a hair transplant may not be suitable; the quality of the donor safe zone must be measures, hair density, quality of the hair characteristics and then a plan made to achieve a natural coverage and density

This can be a compromise between the individual’s goals and what can be realised; total restoration may not always be possible and the priority is to achieve a natural balance of hair with adequate fullness or hair density


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