[Hair Transplantation] #3.Consultation Process for Hair Transplantation

Transplanted hair starts growing again 3-5 months after temporary hair loss and shows maximum aesthetic effect by 1 year after the transplantation. Such delayed effect for several days or weeks is the difference of hair transplantation from general plastic surgeries that shows immediate effect. Compared to permanent growth of transplanted hair, loss of the existing hair continues over time, making the appearance even worse than before the transplantation or aesthetically unnatural. Since patients cannot accept such condition easily, clinicians may often experience various difficulties if they don’t provide full explanation on the subject in the course of consultation.



During the last 15 years of experience in hair transplantation, I would meet patients who could not satisfy with relatively good result and those who could satisfy with objectively not very good result. Patient’s satisfaction on the outcome may be expected by overall consideration of the patient’s accurate condition and expectation during a consultation, which is why consultation before a surgery is as important as the surgery itself. In addition, appropriate behavior to establish a good rapport between the clinician and patient is most important, because inappropriate behavior of the clinician or other medical staffs may lead to the patient’s disappointment, and even to a medical dispute for a not very bad surgical outcome.

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Consultation process for establishing good rapport with patients

1. Preliminary phase

Patients often wait for months or years before visiting the hospital, rather than receiving a care immediately, even if they had known the hospital and the medical staff in advance. They also tend to make an inquiry by telephone before visiting the hospital in person. The attitude of the person who answers the phone call may play as a key factor in determining whether or not to visit the hospital. Since telephone answering contributes to the first impression of the hospital, good telephone answering may have influence on the clinician-patient consultation. Staffs who answer telephones need to have enough knowledge on hair transplantation and answer the caller’s question sincerely. Warm-hearted response is effective not only for patients but also for a third person, including parents, wife or friends, who made a phone call instead of the patient, also contributing to the establishment of better rapport.



2. Consultation phase between the clinician and patient

It is very important to welcome a new patient warmly with a smile. Patients who visited for hair loss should be questioned kindly about the present medical history, family history and past medical history. Information about the patient’s job, family, hobby and sports may be also helpful for understanding the patient’s psychological, social and financial status and even for determining the possibility of hair transplantation, the number of hair strands to be transplanted, and the cost of transplantation.



Clinicians should keep in mind that the patient visited the hospital not just due to the lack of hair and that the patient might feel withdrawal and defensive at the same time due to the hair loss. Clinicians are recommended not to use direct phrases such as “you will look much younger with more hair after transplantation’ or ‘you will feel more confident’, because such expression might stir negative emotions about the patient’s appearance in his/her mind and hurt the patient’s feeling. Patients often ask ‘what are the processes of the surgery?’ not because he/she wants detailed explanation of the surgical process but because he/she is afraid of the hospital, hemorrhage, surgery or pain. Thus, the clinician needs to answer the patient’s question in a way that could reduce the patient’s fear. Patients can learn detailed surgical process from a pamphlet; excessively detailed explanation by the clinician using photos and such may rather increase the patient’s fear about the surgery.



3. Patient factors to be determined during consultation

Various patient factors, including age, the degree of hair loss and the characteristics of the donor hair, may have influence on the satisfaction and objective outcome of the surgery. Even a highly experienced clinician needs to review various patient factors sufficiently during a consultation.



(1) Age: Male pattern hair loss develops after adolescence and even early 20s often ask for hair transplantation due to progressive hair loss. Surgery would be inevitable if hair loss has progressed a lot even in young patients; however, if hair loss is not severe, hair transplantation needs to be delayed as long as possible or only minimum donor hair should be collected and the donor hair should be preserved for later in case the hair loss progresses (Figure 1). Generally, young male patients in their early- to mid-20s tend to have less satisfaction than middle-aged (40-50s) patients due to higher expectation about the outcome. Care should be taken as well because younger patients tend to have donor site scar more frequently than middle aged patients (Figure 2). Older patients in their 60-70s have lower expectation and thus higher satisfaction about the outcome, if they have no other physical condition. They also tend to experience donor site scar less frequently, making them more appropriate for hair transplantation (Figure 3).

Figure 1. Son before the surgery (26 years old, left) and father 1 year after surgery (56 years old, right). The son needs to preserve the donor site because he is highly likely to develop hair loss as his father.

Figure 2. Care should be taken in young patients in their 20-30s, who tend to experience a larger scar than middle aged or older patients due to their active wound healing process.

Figure 3. A 75-year-old male patient before (left) and 1 year after (right) 2,500 strands of hair transplantation. Hair transplantation is relatively more satisfactory among middle aged patients in general.

(2) Thickness of the donor hair: According to western standard, hair is considered as thick at ≥80㎛ thickness and as thin at ≤60㎛. Thicker donor hair contributes to increased volume of the transplanted hair and thus better outcome (Figure 4). Thin donor hair leads to less hair volume and less coverage of the scalp, resulting in decreased aesthetic effect (Figure 5). It is important, therefore, to measure the donor hair thickness to predict surgical outcome. Hair thickness can be measured by using a microscope or more recent computerized devices for easier measurement.

Figure 4. A 25-year-old male patient before (left) and 1 year after (right) 2,500 strands of hair transplantation. Thick hair contributes to a better aesthetic outcome even with a small amount.

Figure 5. A 55-year-old male patient 1 year after 2,000 strands of hair transplantation. Thin donor hair results in poorer aesthetic outcome.

(3) Density of donor hair: The average number of hair strands in the occipital region is around 130/cm² in Koreans, and 90% of them are terminal hair. The density can be considered as high if the number of hair strands is higher than this; higher density is associated with higher frequency of 2 hair Follicular Unit (FU) and 3 hair FU, as well as the tendency of better outcome (Figure 6). On the other hand, lower density or higher frequency of 1-hair FU is associated with poorer outcome (Figure 7). People generally think that male pattern hair loss develops only at the forehead or the crown of the head and not at the occipital region, which is not true. Occasionally, hair loss occurs at the lower region of the occipital region at the occipital region, in which case the donor hair becomes thin, ultimately resulting in the hair loss of the donor site. Hair transplantation should not be performed in this case (Figure 8).

Figure 6. High frequency of 2-3 hair follicular unit or high density of donor hair contributes to good aesthetic outcome.

Figure 7. High frequency of 1 hair follicular unit and low density of donor hair results in relatively poorer outcome.

Figure 8. Hair loss may develop at the occipital region, which is the donor site. Transplantation should not be performed in this case because the hair collected in this condition will fall out immediately after transplantation.

(4) Extent of hair loss progression: The extent of male patter hair loss is determined by the widely used Norwood classification. Patients in early phase of hair loss, such as in Norwood 1, 2 and 3, generally have higher expectation to have abundant hair at the transplanted area, and thus tend to feel less satisfaction. In addition, the transplanted hair will grow in place while the loss of the existing hair continues over time, making the appearance even worse than before the transplantation (Figure 9). On the other hand, patients in Norwood 5-7 stages tend to have lower expectation and thereby higher satisfaction (Figure 10). Hair transplantation should be avoided in male patients in their 20s with early phase hair loss (Figure 11). However, male patients in their 50s with early phase hair loss are less likely to develop to severe hair loss in the future. Therefore, hair transplantation can be performed in such patients, but they need to use a hair restorer, such as finasteride, for aesthetic purpose, because the transplanted hair will continue to grow and the hair loss of the existing hair will continue.

Figure 9. In young patients with early phase hair loss, transplanted hair will continue to grow while the hair loss of the existing hair will continue, resulting in serious outcome. Medication therapy should be used first while observing the prognosis before determining the time of surgery in young patients with early phase hair loss.

Figure 10. Patients with advanced hair loss tend to have high satisfaction and good surgical outcome after hair transplantation.

Figure 11. Compared to young patients (left), middle aged patients with early phase hair loss (right) are less likely to develop severe hair loss in the future and are safe to perform hair transplantation.

(5) Patient’s expectation: It is very important to confirm the patient’s level of expectation on hair transplantation during the consultation. Patients with unrealistic expectation generally do not satisfy with the outcome and often complain to the clinician. Patients with body dysmorphic disorder also tend to express dissatisfaction about the surgical outcome. It would be wise not to perform a surgery, if possible, for patients who seem overly obsessed with their appearance or are likely to have body dismorphic disorder during the course of consultation for a sufficient time.



(6) Present medical history: Hair transplantation is a relatively safe procedure, but care should be taken when there is another physical condition, as with any other surgery. Patients with a hemorrhagic disease that interferes with blood coagulation or those who are currently taking drugs that might interfere with hemostasis (such as aspirin, warfarin, etc.) need to have a consultation with their doctor before determining the surgery. Vitamin E products or other popular supplements, such as garlic juice, onion juice, ginseng juice and green vegetable juice, are advised to be discontinued from 2-3 weeks before the surgery because they dilute the blood and delays hemostasis. Patients with hypertension need to take an antihypertensive drug to lower the blood pressure because bleeding occurs a lot during the surgery. Propranolol and β-Blocker, among antihypertensive drugs, should be changed to another drug by consulting with the patient’s doctor, because these drugs may interact with epinephrine. Patients may also need to consult with their doctor for other physical conditions.



Both patients and clinicians will be satisfied with the outcome if the above factors are reviewed comprehensively before determining whether or not to perform hair transplantation.

- To be continued -

▶ Previous Artlcle : #2. Combination of Medical and Surgical Treatments for Male Pattern and Female Pattern Hair Loss

[Hair Transplantation] #2. Combination of Medical and Surgical Treatments for Male Pattern and Female Pattern Hair Loss

Male pattern Hair Loss affects about 50% of adults in western countries and about 15-20% of adults in Korea. In this condition, hair loss develops after adolescence and hair growth cycle, including the growth phase, becomes shorter than the cycle of the previous hair, gradually making hair thinner and ultimately resulting in suppressed hair growth. The most important factors of male pattern hair Loss are androgen and genetic background, the associations of which found in 1942 by Hamilton. He suggested that androgen in the presence of genetic background is the cause of hair Loss, considering the fact that the men who lack androgen due to castration before adolescence did not have hair Loss despite having genetic backgrounds, and that they developed hair Loss when androgen was administered and hair Loss stopped when the injection was discontinued. Therefore, the technical term for male pattern hair Loss is androgenetic alopecia from the combination of androgen and genetic. However, the terms male pattern hair loss and female pattern hair loss are more commonly used because the hair loss shows specific pattern for each sex (Figure 1).

Figure 1. Classification of male pattern hair loss (Norwood Classification).

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Figure 2. Classification of female pattern hair loss (Ludwig Classification)

In case of male pattern hair loss, after adolescence, testosterone becomes dihydrotestosterone (DHT) at the hair papilla where the activity of 5α-reductase is high, and DHT combines with androgen receptor, which is highly distributed on the area of hair loss, to reduce the production of growth factor, which stimulates the growth of hair matrix, or to inhibit hair growth by generating a factor that inhibits the growth of hair matrix. Female pattern hair loss is characterized by thin hair and reduced hair dense at the center of the head, while the hairline is preserved. The center region becomes larger while hair loss progresses. In this case, the hair loss develops gradually over several years, and the hair loss on top of the head becomes more widely distributed accordingly, revealing more scalp as the hair loss progresses. Unlike male pattern, female pattern hair loss does not result in complete baldhead but is characterized by slow progression of the disease, making it distinguishable from telogen effluvium, where hair falls off from the whole scalp mostly due to pregnancy or drugs.

Female pattern hair loss is known to increase in prevalence with aging, as with male pattern hair loss, and is commonly observed in post-menopausal women, although it can start from after adolescence. As the hair loss progresses very slowly, patients often does not recognize the hair loss and starts to recognize it when hair loss has progressed considerably.

For medical treatment, finasteride and minoxidil are used in male patients, but finasteride is not effective in female patients, leaving minoxidil as the only option. Finasteride, a competitive antagonist of type 2 5α-reductase, was first developed as a treatment of prostate hypertrophy but was later developed as hair loss drug after finding out that that it can stimulate hair growth. This drug inhibits testosterone from becoming DHT and reduces the level of DHT in the blood and scalp, thereby reducing hair removal.

It has been approved by FDA for 1mg per daily dose in male aged 18 years or older. It was found to improve the number of hair as well as the thickness and growth of hair length within 24 months of treatment (Figure 3). However, such effects faded away within 12 months after discontinuation of the administration. There was no remarkable side effect, except for small number of gynecomastia, even after 5 years of long-term treatment, neither an interaction with other drugs nor special effect on hepatic, renal, bone marrow, and serum lipid levels. Sperm production was not affected and, despite reports of a small number of hyposexuality and erectile insufficiency in the early phase, recent studies found that such side effects were not different from those reported by the placebo group. In principle, Finasteride is not used for women in childbearing age due to the risk of birth defects, but has been shown to be effective in a number of cases of post-menopausal women.

Figure 3. Before and 1 year after administering Finasteride 1mg

Minoxidil is a potent vasodilator, originally developed as an oral antihypertensive drug. After finding out that it caused abnormal hypertrichosis in patients who took this drug for a long period of time, external application experiment was performed to confirm hair growth effect and then it was developed as a hair loss treatment. 1ml of Minoxidil is applied on dried scalp twice a day and left for about an hour until completely absorbed. In general, female patients use 2-3% Minoxidil and male patients use 5% Minoxidil. The hair growth effect is the greatest at 16 weeks after use, along with other effects, such as increased hair volume at the area of hair loss and prolonged growth phase.

Side effects are most common when 5% Minoxidil is used compared to when 2% Minoxidil used. The most commons side effects are scalp irritation, such as dryness, scale formation and pruritus. Hypertrichosis may develop at unwanted areas, especially on the forehead among women or children.

Hair transplantation may be the most complete resolution of hair loss because the transplanted hair can grow permanently; however, the existing hair loss continues, requiring countermeasures. The 25-year-old male patient in (Figure 4) had 3,500 hair transplantation and achieved aesthetic effect after the growth of the transplanted hair.

Figure 4. Front and center of the head shows growth of 3500 transplanted hairs but the loss of existing hair has progressed on the top of the head.

However, without a post-procedural drug therapy, the existing hair loss progressed abruptly over the next one year, and the patient complained that the therapeutic effect achieved by the hair transplantation was reduced. In this case, the hair transplantation itself was not the issue but patients may express their dissatisfaction when they could not have the expected result. The 23-year-old male patient in (Figure 5) had 4,500 hair transplantation and received finasteride continuously for 2 years after the transplantation. The patient achieved an excellent outcome that would have been impossible only with hair transplantation, and the outcome may be a synergistic effect of transplantation and drug therapy.

Figure 5. Hair transplantation of 4500 hairs in combination with drug therapy showed synergistic effect.

Taken together, as the existing hair loss tend to continue, the therapeutic effect of hair transplantation declines gradually without combination with a drug therapy. It would be necessary, therefore, to combine hair transplantation with a drug therapy.

- To be continued -

▶ Previous Artlcle : #1. History and Basic Concepts of Hair Transplantation

[Hair Transplantation] #1. History and Basic Concepts of Hair Transplantation

Autologous hair transplantation is one of the most popular treatment choices for alopecia. However, it is not a simple procedure as it involves a surgical method. This article in the series will discuss general topics of hair transplantation. Dr. Hwang Sungjoo from ‘Dr. Hwang’s Hair Hair Clinic’, a famous hair transplantation center in Seoul, Korea, has contributed this article. Dr. Hwang is an internationally recognized hair transplantation expert and served as the president of Asian Association of Hair Restoration Surgeons (AAHRS) from 2011 to 2012. In his series of contributions, he will share helpful tips from basic concepts of hair transplantation to detailed surgical techniques that can provide practical benefits to our readers.

The history of medical hair transplantation is known to have begun with Dr. Okuda in Japan in 1939. Dr. Okuda, a dermatologist, performed hair transplantations on burn scars with a punch that he developed. His studies were published in Japan’s medical journals, however, the records of his discovery were not known outside Japan. In 2009, his grandson and Dr. Imagawa who was a friend of Dr. Hwang discovered Dr. Okuda’s clinic of 70 years ago along with the punches that he used and brought to light the historical discovery of Dr. Okuda (Figure 1).

[Figure 1. Dr. Okuda’s clinic and the punches that he developed]

It is also reported that in 1943 Japan, Dr. Tamura transplanted a single hair or two-hairs in patients with atrichia. This technique is similar to today’s hair transplant techniques. In 1953, Dr. Fujita was recorded to have performed hair transplantation using a punch in a leprosy patient.

The first doctor to use hair transplantation in male pattern alopecia was Dr. Orentreich of the US. He also used the punch to extract the follicles. This surgical method using the punch is known as Okuda-Orentreich technique. He proposed the idea of ‘donor dominance’ in his paper published in 1959. This theory posits that the transplanted hair retains its original properties from the ‘donor site’, which include the growth speed, hair cycles, texture and color, etc. This theory became a widely-accepted theory in the field of hair transplantation. However, in 2002, I proposed the theory of ‘recipient site influence’ for the first time in the world. This theory suggests that the transplanted hair adjusts or changes its speed of growth and follicle cycle, etc. according to the anatomical location and characteristics of the recipient site. Currently, this theory of recipient site influence is the more accepted theory in the science of hair transplantation (Figure 2).

[Figure 2. I transplanted scalp hair onto a calf in 1999. Ten years later, the transplanted hair showed very slow growth rate compared to the scalp hair and the maximum length did not exceed 15cm.]

In male pattern alopecia or female pattern alopecia, the transplanted hair is not lost after transplantation because the follicles in the donor site and recipient site do not share the same genes. In other words, the follicles in the forehead or crown with hair loss have genes prone to alopecia whereas the follicles in the back of the scalp do not carry these genes. This is why the transplanted follicles extracted from the back of the head do not develop alopecia. As the hairs from follicles extracted from the back of the head and transplanted in the forehead grow in the same manner as before transplantation, this may appear as if they retain the properties of the donor site. However, the hairs from different areas of the scalp have identical properties and it can also be said that the transplanted hair’s unchanged growth pattern is due to the influence of the recipient site. When transplanting follicles from the scalp onto the eyebrow or pubic hair, the growth slows down and the follicle cycle is shortened. On the contrary, transplanting the chest hair onto the scalp speeds up the growth and increases length of the hair. Thus, the theory of recipient site influence which proposes that the growth pattern of a transplanted hair is influenced by the recipient site, has more ground.

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In Korea, Mr. Jeongki Paek, a medical assistant working at the leper community in Sorokdo during the 1960s transplanted hair onto the bare eyebrows of a leprosy patient and this is known to be the earliest case of hair transplantation on records in Korea (Figure 3).

[Figure 3. Mr. Paek, Hair Transplant Forum; September/October 2000 Volume 10, Number 5]

In the beginning, he used a mini graft but gave up the method due to resulting unnatural appearance. He went on to use a tool for transplanting single hairs (Figure 4) to transplant single hair graft in the eyebrow site and performed this technique in over 3,000 leprosy patients.

[Figure 4. The hair implanter Mr. Paek used in 1969. Hair Transplant Forum: September/October 2000 Volume 10, Number 5]

Witnessing Paek’s success, a surgeon named Youngchul Choi learned the method of transplantation from Mr. Paek and improved on the original tool. This was the birth of Choi implanter, a tool still widely used today. In other countries, the slit method is widely used, however, Korean doctors prefer an implanter due to such history (Figure 5).

[Figure 5. Hair implanter]

The slit method, dominant in Western countries, is performed with a doctor creating a slit with a needle or blade in the anesthetized recipient site and the assistant planting the extracted follicles. This assistant-dependent method is physically less demanding for the doctor. Hair transplant using the implanter, on the other hand, is a more doctor-dependent procedure requiring the doctor to do most work.

In the early days of hair transplantation, a 3~4mm punch was used which evolved into mini graft method transplanting 4-6 hairs into 1.5~2mm punctures and this mini graft method was used upto the 1990s. Micro graft followed where 1-2 follicles were grafted onto the recipient site. This method does not use intact follicular units but divides the hairs, potentially damaging the follicle in the process. In 1988, Dr. Limmer of the US introduced the first follicular unit transplantation (FUT) method where the follicle is divided into a single, two- or three hair units using the microscope (Figure 6). Since the 2000s, FUT has established itself as the prominent hair transplant method all over the world.

[Figure 6. Punch Graft, MINI Graft, Follicular Unit Graft]

Follicular Unit Transplantation is called a few different terms in the Korean language. A single, two or three hairs grow together from a single follicle and as the transplantation preserves this follicular unit, the most valid term for this procedure may be ‘pore unit hair transplantation’ (Figure 7).

[Figure 7. Before pore unit hair transplantation (left) and one year after (right)]

Recently, follicular unit extraction (FUE) method using a 0.8~1.2mm punch and not the traditional 3~4mm punch is applied for follicle extraction from the donor site. This may benefit western patients as they tend to have short and thin follicles, however, follicles of Koreans are long and thick. Thus FUE carries the risk of transection and greatly compromises the graft survival, making it less suitable in Asians.

The International Society of Hair Restoration Surgery (ISHRS, www.ishrs.org) is a globally recognized association on hair restoration. It was established in 1993 and currently has 798 members from 63 countries. ISHRS conferences mainly feature procedures involving western patients and may not be applicable to Asians who have very different skin characteristics. This called for a new conference that focused on Asian patients. In 2010, Asian Association of Hair Restoration Surgeons (AAHRS, www.aahrs.asia) was established and the first conference was successfully held in Bangkok, Thailand in June 2011. I was inaugurated as the second president of AAHRS at the first conference in Bangkok and the second annual conference was held in Seoul in 2012.

-To be continued-