Long Term Planning: The Absolute Necessity

Why Plan Long Term?

         “Well, after all, I want to look as good as possible right now. I’ll deal with tomorrow when it comes”. “Doc, I just want my hair back now, while I’m young enough to enjoy it. Do whatever you’ve got to do”. “Make me look like (fill in the blank with celebrity/actor/musician of choice)”.

         These statements and requests are understandable when one is dealing with hair loss, especially in the younger man. We have great empathy for the feelings behind them; some of us have been hair loss patients, too. However, such communications are also indicative of an attitude that can lead to future frustration and heartbreak, and to antipathy toward the surgeon who was foolish or greedy enough to indulge these fantasies.

Remember that with hair transplantation, it is mathematically impossible to recreate the density of youth in the bald and potentially bald areas, given the current limits of the permanent zone, or donor area. Nor is it cosmetically necessary. We work with creating the illusion of density in the balding regions, by the artful placement of grafts in a way that maximally blocks light penetration to the scalp. Indeed, hair restoration surgery does not “cure” baldness. We simply move hair around in order to ameliorate the appearance of thinness or balding.

         The technical aspects of these procedures require intense training, good hand-eye coordination, excellent surgical skills, a steady hand and a sharp eye and the ability to concentrate and endure tedium. The artistic and aesthetic aspects, on the other hand, require an integration of both cerebral hemispheres (right brain/left brain coordination). This cannot be “book-learned”; it is either part of a physician’s basic constitution, or it is not. It may be honed and improved upon, but it is not created by taking courses or by sheer force of will. Poor performance can lead to less than desired outcomes.

         Sadly enough, cosmetic disasters can also be the consequence of poor planning. Even with the use of follicular unit transplantation and associated state of the art techniques, lack of artistic foresight and proper patient selection and education can eventually lead to an unnatural appearance, premature depletion of donor reserves, visible scarring, unequal distribution of hair, unnecessary surgeries, patient dissatisfaction and frustration for all involved. It is better to risk initially disappointing the patient who has an overambitious or unrealistic plan, than to rush into surgery without

a mutually agreeable, long term plan in mind. Postponing or even refusing surgery with such an individual is the ethical and moral course of action.

         What to Look for in Your Surgeon

         First of all, you should have a consult with him, and not just a non-physician consultant. Since we’ve brought this issue up here, let’s talk briefly about the role of the non-physician consultant. These are individuals who may know a great deal about the process and results of hair restoration surgery. They may be former patients themselves, and they can play a valuable role in helping educate and reassure prospective hair transplant recipients, and assist them through the process.

         Some patients have done a fair amount of reading (often on the internet) about hair transplantation. Some of the information they have received is valid, and some of it not. The consultant can help separate the hype from the truth in these cases. On the other hand, some patients are essentially without any semblance of a knowledge base regarding their options, and require much more in the way of education. In either case, the consultant is paid to educate patients, facilitate the process, allay their fears, and often, to act as a primary contact person.

         What the consultant is not paid for is to profit personally by the patient’s decision to have surgery. Unfortunately, in some organizations, the role of the consultant is just that: to make a commission on each procedure and on every graft that the potential patient receives. The conflict of interest is obvious, and we do not believe in the use of commissioned consultants. The physician, the consultant, and the other members of the team are integral to helping the patient make an informed and rational decision as to if, when, and to what extent any surgical procedure will take place. Coercion, manipulation, and financial incentives have no place in an ethical hair restoration practice. 

         So, in addition to any other staff members the patient sees and works with, the role of the hair transplant surgeon is primary. This is indeed “where the rubber meets the road”. The surgeon must, above all others, gain the trust of the patient, help him with the often difficult decisions that must be made, and also counsel him against making possibly irrational and fear-driven choices.

         Your surgeon should check your hair carefully himself. Some form of magnification is necessary to evaluate the degree of density, and also of miniaturization. Beware if he just ruffles your hair, briefly rubs your scalp, and says that his experience allows him to “just eyeball it” and make a judgment regarding these factors. This cavalier approach does not honor you or the complexity of modern hair transplantation. Surgeons now have the information, the techniques and the tools to carry out the appropriate pre-operative planning and counseling, and they should do so!

He can tell you about your particular pattern of balding, your likely progression, the amount of donor reserves he estimates you have, what your hair characteristics are, and how all of these factors will play into the decision-making process and your likely outcome. Will multiple sessions probably be required? How many grafts might you need for an initial session? What areas of the scalp are most important for you cosmetically? All these questions and more must be answered to your satisfaction.

Remember that medical treatments like Propecia and Rogaine are adjunctive; in the context of long term planning, we must assume that they will not work, or that their action will be less than optimal, or will decrease in effectiveness over time. This does not imply that they should not be used, but it is foolhardy to make surgical planning decisions for the present or the future based on “Propecia maintaining the crown” or “Rogaine filling in the density on top”. Similarly, to count on new advancements such as more powerful medication or hair cloning in making these decisions if irrational. Properly planned and performed follicular unit transplantation should be seen as a lifelong investment that will stand on its own and stand the test of time.

If you are very young, and anxious, and you are not sure you are the best candidate for hair restoration surgery, how eager is your surgeon to operate? Is he willing to postpone and reevaluate in a year after medical treatment, or is he still pushing you to “sign up?” Sometimes the most ethical and caring physician is the one who tells you what you don’t necessarily want to hear. This is born out of an overriding concern for what is in your best interests. Honesty is of paramount importance in dealing with someone as vulnerable as a young person experiencing rapid hair loss.

Your Role as the Patient

It is said that patience is a virtue. This can be very true for the hair loss patient, and also very difficult to achieve. Remember, only a trained hair restoration surgeon can properly evaluate and counsel you as to your options, or lack thereof. Educate yourself. Communicate with your doctor, and let him know your fears; we deal with these issues day in and day out, and you are not alone in your concerns. We have heard the same questions and misgivings from other patients. Many of us have had these procedures ourselves, and have sat in the “patient’s chair”.

Don’t fall into the trap of being too compliant (“Whatever you say, doc, you’re the expert!”). This attitude may seem to make things easier and faster for you and the doctor, but it is less than ideal. The more you are in true agreement, the happier both parties will be in the end. On the other hand, a resigned or downright hostile attitude (“Go ahead, doc, you’re gonna do what you’re gonna do. I’m the next victim!”) is just counterproductive at the least, disastrous at worst. Again, there must be a real consensus of opinion and plan before you take your seat in the surgical chair.

In the rush to “get hair growing”, don’t forget to be realistic. Adolescent density is not probable, nor is it necessary. An adolescent hairline is inappropriate and odd-looking in someone middle-aged (and, someday, young people do become middle-aged. Take our word for it!) Moreover, despite your feelings at twenty-five or thirty-five, you will care about your appearance at forty-five and fifty-five, and for life. A balanced, symmetrical, natural hair transplant, done at any age, will serve you well for the duration.

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