The Patient Journey

BEFORE HAIR TRANSPLANT SURGERY: YOUR EVALUATION & CONSULTATION

It is important that a patient receive an evaluation and education process to ensure he is a good candidate for hair transplant surgery. Even if a transplant is done perfectly, a patient will not be happy if the results he receives are not what he expected.  Patients have certain goals and expectations in mind when they search for physician help. They need to be educated about the procedure, what can realistically be accomplished, and if this will meet their goals.

More specifically, they need to be educated about the issue of limited donor supply and how this affects the degree of coverage we can offer to different patients. They need to learn about the issue of potential future hair loss and how this can affect the future look of a transplant. It is also important to know about the difference between the surgical density and the appearance of fullness and normal pre-hair loss density. This includes understanding why some patients can cover their entire balding area while others can only cover the area partially or not at all.

At SMG, we educate the patient about all these variables while we go through the following consultation and educational steps.

Step 1

Determine Patients Goals & Expectations: Evaluate the patient’s expectations and desire for coverage. Every patient is different. Some desire very aggressive work with total coverage. Others want more subtle coverage that will cause less drastic changes. Some want their crown and others don’t care about it. Some want a lower hairline while others want a more mature receded hairline.

Step 2

Evaluate available donor supply both in terms of the total amount and the characteristics of the hair that may influence its effectiveness at creating the appearance of density (color, curl, caliber, etc.). Every patient is different with donor supply ranging from 4000 to 9000+ follicular units.

Step 3

Evaluate the size of the recipient area that needs to be treated, and estimate how much progression on transplanted areas may occur in the future. Every patient is different based on their age, current severity of loss, family history, etc.

Step 4

Determine what can be done based on the donor and recipient evaluation. Then compare this with the patient’s goals and expectations and see if they match.

In other words:
Determine if the patient’s goals and expectations are achievable and realistic based on the above evaluation. This is a critical step.

Step 5

WHAT TO EXPECT THE DAY OF SURGERY: STRIP FUT

Arrival (30 minutes):

You will be greeted by the receptionist who will ask you to pick out your lunch for the day.  Afterward, we will take pre-operative photos and take care of any final paperwork.

Meet with Physician (as long as necessary):

After your photos, you will meet with your physician to review the surgery.

General Preparation for Surgery (30 minutes):

You will be escorted back to the surgery room to be prepared for surgery. You may wish to use the restroom at this time, however, you may take a break anytime during the surgery. Some of the things that will occur during this preparation stage are as follows:

• You will be placed in a surgical gown and asked to sit in the surgical chair.
• Your vital signs (blood pressure, pulse rate, and oxygen saturation) will be measured.
• You will be given pre-surgical medications consisting of an antibiotic, Valium, and Prednisone prior to surgery. If you have questions or are allergic to any of these medications, please call us prior to your surgery.
• You will be asked to pick out movies you may choose to watch during the day. We have a selection of DVDs and videos to choose from or you may bring in your own videos to watch. We also have channels such as CNN, Fox, etc. The surgery takes about 6-8 hours.  Some patients sleep on and off during the surgery due to the effect of the Valium, while others stay awake and watch movies or listen to music of their choice. We do not recommend reading during transplant surgery.

Preparation Of Donor Area- FUT (15 Minutes):

The physician will examine the donor area and mark the exact location and size of the donor strip of hair that is to be removed. The area of your scalp from which the strip will be removed is then trimmed and cleaned. Tape and surgical gauze are used to keep the rest of the hair up and out of the way of the selected donor area.

Local Anesthesia for the Donor and Recipient Site Areas (15 minutes):

The surgical assistants will inject the donor and recipient site areas with a local anesthetic.  Lidocaine is injected using a very small needle. You may feel a mild stinging sensation from the injection, which subsides within a minute. After the initial stinging sensation, the area is going to be numb.

Strip Removal of the Donor Area (30 minutes-1 hour):

The donor strip of hair is now removed surgically by the physician, and the area is closed with sutures or staples. You should not feel anything during this process due to the effects of the local anaesthetic. This is usually done with the patient lying on his/her stomach like in a massage chair.

Creation of Follicular Unit Grafts:

Immediately after the strip is removed, it is given to the surgical assistants to be microscopically dissected into follicular unit grafts. You may see 3-5 assistants cutting grafts with the use of microscopes. If you wish (and some patients do), you will be allowed to watch the graft cutting process through the microscope to see how perfectly and meticulously the grafts are prepared. This usually takes 1-4 hours depending on the number of graphs being prepared.

Creation of Recipient Site Incisions: (1-2 hours)

Once the physician finishes closing the donor area, he begins making the recipient site incisions. The physician will make all the tiny incisions in which the grafts will be placed.  Almost all incisions are made prior to placing the grafts in the incisions. As stated above, this usually takes about 1-2 hours depending on the number of grafts.

Lunch: (30 minutes)

Usually, procedures take long and while you will still be in the middle of an operation, lunch will be provided in the clinic. Please let us know, in advance, if you have any dietary restrictions.

Placing of Follicular Unit Grafts: (2-4)

After lunch, the surgical assistants will start placing the follicular unit grafts. Most of the placements are done by the technical staff.

Stick and Place and Fine Tuning:

During and at the end of the transplanting process, the physician will continually check the placement of the grafts. When there are about 300-400 grafts left, the procedure will be stopped and the pattern and distribution will be rechecked. At this time, fine-tuning with more incisions for the final grafts will be made and placed.

Completion:

Most surgeries are completed by 5-6:00 P.M. You will be given detailed post-surgical instructions. If the next day is a weekday, you may return to the office so we can wash your hair and check up on the post-surgery effects. You will be given an after-care kit containing post-op medications (Prednisone to prevent swelling, and pain medications like Vicodin), gauze, and a spray.

Suture/Staple Removal:

This post-op procedure is done in 10-14 days. This can be done in our office at no charge. If you live out of town, we can arrange for you to have your sutures/staples removed at a hair transplant clinic in your area, if there is one available. Or, the sutures/staples can be removed by your private physician or urgent care clinic.

WHAT TO EXPECT THE DAY OF SURGERY: FUE

The day is very similar to “Strip” FUT with some minor differences listed here.

Arrival (30 minutes):

You will be greeted by the receptionist who will ask you to pick out your lunch for the day.  After that, we will take pre-operative photos and take care of any final paperwork.

Meet with Physician (as long as necessary):

After your photos, you will meet with your physician to review the surgery.

General Preparation for Surgery (30 minutes):

You will be escorted back to the surgery room to be prepared for surgery. You may take a break anytime during the surgery. Some of the things that will occur during this preparation stage are as follows:

• You will be asked to wear a surgical gown and asked to sit in the surgical chair.
• Your vital signs (blood pressure, pulse, and oxygen saturation) will be measured.
• Pre-surgical medications consisting of an antibiotic, valium, and prednisone are given prior to surgery.  If you have questions or are allergic to any of these medications, please call us ahead of your surgery.
• You will be asked to pick out movies you want to watch during the day. We have a selection of DVDs and Videos to choose from or you may bring in your own videos to watch. We also have channels such as CNN, Fox, etc. to keep you entertained. The surgery takes about 6-8 hours. Some patients sleep off and on during the surgery due to the effect of the valium, while others stay awake and watch movies or listen to music of their choice. We do not recommend reading during surgery.

Preparation of Donor Area FUE (15 minutes):

This is one major difference. In order to do FUE, the entire donor area that will be harvested has to be shaved. So we will either shave the entire donor area and give you a “marine type” haircut” or we can get a little creative. If the procedure is small, we can just shave a strip and let the long hair cover it.

Local Anesthesia for the Donor and Recipient Site Areas (15 minutes): The surgical assistants will inject the donor and recipient site areas with a local anaesthetic. Lidocaine is injected using a very small needle. You may feel a mild stinging sensation with the injection, which subsides within a minute. After the initial stinging sensation, the area will be numb.

Graft Removal by FUE (2-4 hours):

The process of obtaining the grafts is longer since each graft has to be harvested one at a time. Depending on the number of grafts, it could take 2-4+ hours. This is done with the patient lying on his stomach.

Inspection and Organizing of Grafts:

Immediately after the FUE grafts are removed, they are given to the technicians who trim and organize them as well as place them into cold hypothermosol. This is being done while the physician continues to harvest the grafts one at a time.

Lunch: (1/2 hour)

Due to the long process, you will be provided with lunch. Please let us know, in advance, if you have any dietary restrictions.

Creation of Recipient Site Incisions: (1-2 hour)

Once all the grafts are harvested, the physician will begin making the recipient site incisions in which the grafts will be placed. Almost all incisions are made prior to placing the grafts in place. This usually takes about 1-2 hours. If it is a two-day procedure, some areas will be left for fine tuning the following day.

Placing of Follicular Unit Grafts: (2-4 hours)

After the incision process, the surgical assistants will start placing the follicular unit grafts.  Most of the placements are done by the technical staff with oversight from the physicians at regular intervals. Each graft is coated with Acell to ensure good growth of healthy hair.

Stick, Place and Fine Tuning:

During and at the end of the placing process, the physician will continually check the placement of the transplanted follicles. When there are about 300-400 grafts left, the procedure will be stopped and the pattern and distribution will be rechecked. At this time, fine tuning with more incisions for the final grafts will be made and placed.

Completion:

Most surgeries are completed by 5-6:00 P.M. You will be given detailed post-surgical instructions. If the next day is a weekday, you may return to the office for a hair wash and check-up. An after-care kit containing post-op medications will be provided thereafter.

Variations:

With FUE, there can be some variation in the order and logistics of the case depending on whether it is a one- or two-day procedure. In addition, it is better to make the incision before the FUE extractions are done, which is beneficial in some cases.

Suture/Staple Removal: There is no suture or staple removal with FUE.

WHAT TO EXPECT AFTER SURGERY

Patients often want to know what to expect from their grafts after surgery. When they will fall out and when they will start to regrow, etc. Below is a general timeline of what you can expect with respect to graft growth.

Immediately After Surgery To 3 months:

• Immediately following surgery, you will have fresh incisions that are clean but look a bit like a rash. Certain hair and skin types with little existing hair may be quite surprising on how well it is hidden (masked).
• On the second day, small scabs the size of a pin head will develop and be visible and remain on the scalp for two-six days after surgery.
• By the 8th-10th day post-op, the area should be virtually scab-free if you follow the post-op cleaning instructions. The area should be undetectable other than, possibly, your scalp being a little dry, which shouldn’t be a worry as it does not draw attention to your scalp.
• Starting around the 14th day, the hairs in the grafts will go into a resting phase during which the shaft will separate from the root and shed leaving the root behind. This is completely normal. Things will then remain dormant for about 2 months.
• Beginning at 3 months, you will experience hair starting to grow slowly. This is called the active growth stage.

3 months to 4 months:

• Generally, new hair should begin to grow after the 3rd-month mark, but everyone is different. Some experience new hair growth earlier and others a little later. Some may worry that what they see at 3-4 months is the final result, but that is not the case at all. At best, the hair growth at this time represents approximately 20% of the growth you should anticipate. When the transplanted hair first appears, it is immature, fine, thin, and light in color. As time passes, more transplanted hair will appear and will become thicker, longer, and darker.
• Itching in the recipient area or discomfort in the donor area may be expected at the three-four month mark. However, it should pass in a few months. The incision in the donor area at this time is healed but still remodeling. It will continue to improve over time. Also at this stage, a few patients may develop small pimples (folliculitis) around the transplanted area as hair emerges. If this occurs and persists, we need to be notified. There are ways of treating folliculitis.

5 months to 6 months:

• A significant change usually occurs between the 5th and 6th month. By the 6th month, about 80% of the hairs should have penetrated the skin. However, only about 50-60% of the final visual aesthetic effect will be achieved. Between the 6th and 7th month, it is the best time to schedule your follow-up appointment to evaluate the progression.

12 months to 14 months

• The visual result continues to improve for up to a year, and it is only after one full year that the final aesthetic is typically achieved. The reason for the continued improvement over the last 6 months is due to the following:
  • There still may be about 10 to 15% of the hair that has not reached full maturity. Mature terminal hair develops between 8 and 12 months postoperatively as the hair obtains its normal thickness. 
  • Hair will become longer, darker in color, and thicker in diameter. A very minimal change in diameter has a significant effect on the appearance of fullness. Remember the aesthetic effect of a hair transplant is more dramatic when a patient has no original hair (bald) in the transplanted area. When a patient has some of his/her own original hair in a transplanted area, the procedure is just as successful, but the results are less dramatic because a new hairline is not being created. In these situations, we are increasing the fullness of hair in a thinning area. 
  • Patients will notice more refinement (blending) in the transplanted area as well as an improved appearance of fullness under a greater number of circumstances.

If you have any concerns with regards to thinning hair, loss of hair, a bald area, and want to achieve fullness and a healthy head of hair, don’t hesitate to contact Shapiro Medical Group to discuss your condition and goals.