Additional Procedures: When, Why, and How Much?

The Importance of Planning




It is imperative that the probability of second or subsequent procedures be discussed prior to the first follicular unit transplant. This is an integral part of the long term planning that is necessary to afford the best outcome. Multiple factors are considered in making this judgment, including age, the degree of baldness, rapidity of hair loss, hair characteristics, donor density, scalp laxity, styling preferences, and previous procedures. Let’s take a more detailed look at each of these factors.




Ironically, it is often the case that older men, with more extensive balding, are better candidates for a single procedure than are younger men with less advanced patterns of alopecia. The older man who has lived with baldness for a number of years is likely to have more realistic expectations of his transplant outcome; he may be very satisfied with this coverage, and a frame for the face. In addition, his degree of balding, that is, his Norwood pattern has very likely “declared” itself, leaving little ambiguity in the surgeon’s mind about how future hair loss will alter the clinical picture.

The young, often rapidly balding man may be more intransigent, and therefore more difficult to counsel. As we discussed earlier, his vision of the appropriate hairline for himself can be wildly impractical. Furthermore, the patient in his early twenties with, for instance, Class III, III-A, IV-A or just limited crown balding is, to some degree, an enigma. How quickly and how extensively will he lose his hair? An attempt, through a large, single session, to densely transplant all the thinning areas may not be the best option. The patient may experience an acceleration of hair loss via effluvium, or his hair loss could simply develop rapidly during the growth period for the new grafts. If donor reserves are limited, and baldness progresses rapidly, he could eventually be dissatisfied and unable to proceed with further surgery. This patient needs to know that he may require two or more procedures to appropriately follow the progression of the hair loss and to properly conserve his donor resources.

The degree of Baldness:

In a patient willing and able to undergo a large session, sometimes the more advanced levels of balding are amenable to a single session. The stability of the hair loss is estimable, expectations are likely to be reasonable, and the goals are easy to state. In a single, large session of FUT, a hairline and framing for the face can be established, top and crown coverage may be possible, and the result can stand on its own with a natural appearance. As we discussed above, however, the more limited patterns of hair loss in younger men present us with a dilemma; do we wait, and if we transplant, where and how much? These are just a few of the reasons that a consultation with a trained and knowledgeable hair restoration physician is of the utmost importance; there are many artistic elements to be considered, as well as an acute understanding of both the natural history of balding and of the patients mental and emotional condition.

The rapidity of Hair Loss:

A young man who sees his hair vanishing before his eyes is likely to be in a vulnerable and suggestible state. He most of all needs the truth, delivered with an attitude of temperance, understanding, and hopefully, optimism. If he is quickly progressing towards a Class VI or VII pattern, he needs to know that complete crown coverage, for example, may be difficult. Patients with earlier stages of balding, who have had a recent and rapid onset, or who have just noted an acceleration of their hair loss, will need counseling about the advisability of postponing the surgery; they must also understand the probable necessity for multiple procedures and their particular suitability (or unsuitability) for ongoing surgical work.

Hair Characteristics:

In general, the more favorable the hair characteristics, the more likely a single session may be adequate for the patient’s needs. Low contrast between hair and skin, curliness or waviness, coarseness of the hair (except when there is high skin/hair contrast), light-colored or salt-and-pepper hair all lend themselves to the possibility of greater coverage with a lower transplanted density. To some extent, these favorable characteristics can compensate for extensive balding and less than wonderful donor density.

Hair Characteristics

Hair Characteristics

On the other hand, hair that is fine will cover much less surface area of balding scalp than coarse hair.  Straight hair will not cover as well as curly hair.  High contrast situations such as black hair on white skin can make long hair appear thinner.  In these less favorable scenarios, a greater number of grafts is often required to achieve a degree of fullness equal to fewer grafts when the hair is coarse, wavy, or low in contrast.

Density and Laxity:

We will consider these two factors together, as they are so intimately related. The donor area must be evaluated, both for density and for laxity, in all patients consulting for possible FUT. (Any significant miniaturization in this area may mean the patient has an unstable donor area and may not be a surgical candidate at all).

Density and Laxity of hair

Density and Laxity of hair

If the density is properly calculated, the total number of movable hairs and movable follicular units can be estimated with reasonable accuracy. This estimate is obviously of great value in determining a plan based on the knowledge of the existing donor reserves. However, a determination of the density is not enough; the laxity of the scalp also plays a role in the adequacy of the donor reserves. If the scalp is excessively tight, either naturally or as the result of scalp reductions or previous donor harvests, this may limit the number and size of strips that can be excised in the future.

If both density and laxity are favorable, then it is possible that presently bald areas can be more densely transplanted, knowing that adequate donor reserves remain to account for progression of the hair loss pattern. This knowledge gives the patient and the surgeon more flexibility in their approach to current hair loss, and more confidence in facing the eventuality of progressive baldness.

 Styling Preferences:

A patient who prefers the hair combed straight back may have even extensive balding treated with a single procedure. This is because the crown area can be lightly transplanted, or not at all, and still appear as a pattern found in nature. Also, the crown can be covered by the hair from the front and top of the head when it is styled thusly.

Those who prefer combing to the side may achieve a look of greater fullness but may sacrifice coverage of the bald crown, if inadequate donor supply exists. Hair which is allowed to naturally curl may enhance the illusion of thick coverage, as will a “dry” look, as opposed to a “wet” look.

Those with excessive hair loss may often achieve a fuller appearance by keeping the hair trimmed closer.  We call this the “less is more” approach to hair loss.  In this scenario, closely cropped hair placed at a lower density gives the appearance of a “5 o’clock shadow”.  The total number of grafts is the same for any given donor area.  Thus, it is often impossible to fully restore the entire area of loss.  In extensive hair loss, a lower density of grafts evenly spread over the scalp can produce an illusion of greater coverage.  Often times, body hair may be utilized to amplify the appearance of fullness in extensive hair loss.  It must be pointed out, however, that body hair does grow well in all individuals, body hair does not produce adequate coverage in all individuals, and some patients do not like the appearance of body hair on their scalp.  The one source of body hair that does consistently grow is beard hair.  However, some patients do not like the coarse, curly appearance of beard hair.  Leaving the beard hair trimmed short can sometimes compensate for these characteristics of beard hair.

         The timing of Subsequent Procedures

Although a repeat FUT may safely be done as soon as the new hairs are in evidence, and, indeed, space will exist between previously tightly placed FU’s for new grafts, there are valid reasons for postponing a second procedure for 8 to 12 months. One is allowing the scalp to regain some of its lost laxity. As the months go by, the scalp will stretch to some extent, which will potentially allow a greater harvest, and will facilitate an aesthetic closure of the donor site. Also, it takes about 8 to 12 months for the full cosmetic benefit of the transplant to become evident. At this time, the patient and the surgeon can make better judgments as to the degree of further work that needs to be performed. A more uncommon issue is that of telogen effluvium in the donor area; if this should occur, it is best to give the follicles ample time to recover, so that they are more likely to be seen and preserved during follicular unit dissection.

Purpose of the Second Session

There are a number of common goals in carrying out a second (or subsequent) session. One is to refine the hairline (see Chapter Ten). No matter how meticulous the original placement, it is impossible to anticipate what the true effect will be once the transplanted hair has grown in. Density can be added to the hairline, it may be lowered, made more or less symmetrical, or the temporal angles may be altered. A widow’s peak may be created or accentuated and, if the hairline is too straight, it may be rendered more irregular in order to “soften” it. In a patient with advanced, stable baldness and adequate donor reserves, the receded temples may be restored.

In addition to hairline refinement, the crown may be transplanted (see Chapter Eleven). The necessity of this will be more evident after the transplanted front and top are well grown in; the patient with a new hairline and adequate top coverage may be satisfied with a natural, “bald spot” crown appearance, or may wish to go forward with doing the crown if donor reserves and hair characteristics are favorable.

If the hair loss has continued to be rapid, or if much time has elapsed after the initial transplant, a second session may be undertaken simply to follow the progression of the baldness. There may have been permanent “shock loss” of many miniaturized hairs; there may be cosmetic consequences from this. The baldness may have proceeded more toward the back, or the affected area may have widened.

Often, the reason is to add fullness, which is done by increasing the density in the recipient areas. Even though the FU’s may have been placed quite closely during the first session, with the healing of the recipient sites, there will be intervening space available for further grafts. This can create a further fullness, as long as the hair loss is stable enough and the donor supply is plentiful enough.

To reiterate, none of these considerations should be a surprise to either the surgeon or to the patient. The possibilities must be taken into consideration early on, before the first procedure; this education is part of the physician’s responsibility. However, in the interest of self-empowerment, and simply as an informed consumer, the patient is compelled to read, research, ask questions, and become as informed about the long term probabilities as he is about the short term outcome.

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