Many of the other blog articles have touched upon various elements of quality control that lead to excellent surgical outcomes.  What I would like to do is to talk more globally about problems that I see that make a hair transplant result look fake when looking closely at the work.  Unfortunately, the public thinks that there are only two conditions that lead to fake results:  too big a graft (called a plug) and too straight or malpositioned a hairline.  Although these are two very big no-nos that can lead to bad results, there are a host of subtle problems that lead to an overall bad result especially when multiple sins are committed.

Correction of previously bad hair transplant work: hair angles are too perpendicular, grafts are too large, temples do not match, and the hairline design is too straight.

One of the most common mistakes that I see performed is that hairs that are transplanted too perpendicularly to the scalp in the frontal hairline.  First of all, hairs simply do not grow that way.  Second, they do not create favorable density in that arrangement.  Third, the insertion point of the graft to the skin is grossly visible making the graft look grafty even when the graft is a single hair.  For all of these reasons graft placement is crucial, I place my graft angles at 10 to 30 degrees relative to the scalp whereas 70 to 90 degrees simply just looks bad.

Also, grafts can sometimes look like grafts when they are placed too far apart from one another no matter how small they are.  That is why I densely pack them together so that you cannot see them, blurring the whole lot out.  The number one thing that I see at hair-transplant meetings that is a dead giveaway that something surgically was done is that few hairs were used to cover too wide an area of the baldness leading to single little tufts of hairs populating a widely bald scalp.  This does not look natural and that is a big reason why I do not transplant the crown and the front of the scalp at the same time in 90% or more of the cases.

The next problem is how the hairs are shingled, i.e., how they are layered next to each other.  I notice when I teach junior surgeons at the course that I run in St. Louis that they tend to make recipient sites in a radial fashion, i.e., their hand arches in a circle around the head mimicking the shape of the round head.  Grafts should not be placed in this fashion because not only is visual density compromised when all of the grafts are splayed open apart like an open book but because the result does not resemble how hair naturally grows on the head.  Somehow this radial orientation of grafts just looks off to the casual viewer.

The next set of problems occurs due to bad hair-transplant technician work.  When hair grafts do not fit into the recipient site, the grafts can either be chocked off and not grow or be compressed into a tuft of hair resembling a plug.   Conversely, if the recipient site is too big and hair follicles fall into the hole the graft can show dimpling at the skin, another sign of artificiality.   My team is trained to check for graft-to-site fit carefully with me before I begin to make my recipient sites and also they check that the right graft fits into the right sites as they progress.  Assistants can also damage hairs during insertion.  If the grafts are placed with too much trauma, they will either not grow or will grow out kinky like pubic hair.  Finally, if grafts are placed too high relative to the surrounding skin, the result can be a bumpy, cobblestone appearance or it may not grow out at all.  If the grafts are placed too deep relative to the surrounding tissue, they can either grow out as a cyst or show a dimpling pattern on the skin.  If grafts are inadvertently stacked one on top of another, this can also lead to cyst formation due to buried, or piggy backed, grafts.  This is why having quality assistants is so important to creating the best results possible for any given hair transplant procedure.

Other issues of poor quality control relate to the surgeon’s bad design work.  For example, grafts that are too big placed into the wrong area can look fake.  Or, as mentioned, if grafts are angle and directed poorly they can either have unnatural looking results or compromise density.  All of these myriad elements that go into a quality hair-transplant result my team and I manage consistently in every single hair transplant procedure to attain consistently high-quality results.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair transplant forum.

As many of you know, I am an active participant in the education of other surgeons.  I run a national course on hair restoration and also participate as faculty in many workshops.  I also have written a textbook on hair restoration, Hair Transplant 360, along with many scientific articles on the subject.  Most recently, I flew out to Phoenix for a weekend to help write questions for the written re-certification examination for the American Board of Hair Restoration Surgery, of which I am a proud diplomate.

What I learned from an entire day locked up in a room with 3 of my colleagues and an expert moderator was the importance of clarity when writing exam questions for prospective examinees.  We had a very heated debate throughout the day about a question’s validity and also the clarity with which a question was posed.  To me, I did not mind ruffling feathers or making others in the room feel uncomfortable if the intended outcome was to have a clearer, fairer, and appropriate examination.  At the end of the day, we harangued and menaced each other until we got a workable 80 questions out for the next examination.  To me, I am very proud of what we accomplished but I am more proud of the intended outcome for the prospective examinees.

I think what I have learned from this process is always to think about the goal for a procedure, which in the world of hair restoration is to have a better result for a patient even if that means ruffling feathers during the procedure regarding quality control.  If we keep our mind on the goal, which is to have a better outcome, we can all as team members performing the procedure understand that challenging each other to be better is part of the process to achieve excellence.

Dr Samuel Lam is a board certified hair restoration specialist in Dallas, TX. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair restoration forum.

A graft must fit a recipient site like a hand fits a glove perfectly.  Too tight and the graft becomes pinched inward leading to either hair death or a tufted fake appearance.  Too loose or too deep and the hair can fall inward into the site and cause unnatural pitting. Too short a site will lead to the hair either causing a cobble-stoned appearance or drying out and dying.  Therefore, before I make several thousand recipient sites, I always check for each sized graft will fit perfectly in terms of depth and size and progress from there.  Unfortunately, in many clinics graft-to-site fit is an afterthought rather than a preplanned strategy.  This to me is terrible negligence that leads to significant risk in a hair-transplant procedure results.

Always check graft-to-site during hair transplantation (from Hair Transplant 360, Lam SM)

Samuel M. Lam, MD, FACS, a board certified hair transplant specialist in Dallas, TX. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair transplant forum.

Although there are many types of hairlines that can be designed, for the sake of simplicity I try to discuss two basic shapes when I lecture to students at my hair-transplant course in St. Louis every year.  They are the bell-shape and the round-shape.  The bell shape is a narrower design that changes from a convex center to a concave outer portion with the transition occurring somewhere midway at the mid-pupil line, known as the lateral, anterior point.  The bell-shape works for a narrower head so that the bell matches the shape of the head, and it also works to conserve grafts and requires less aggressive a temporal hair reconstruction to match it.  For these reasons a bell shape is preferred.  A round shape is good for a wider face like on an Asian or some Hispanic faces, for example.  Because it requires more grafts to undertake and more grafts allocated to the temple area it may be less ideal for the very young patient who would require more hair-transplant sessions to maintain the result with a greater number of grafts.  Obviously, some hairlines are a hybrid design, i.e., principally round with a little transition from convex to concave.  Alternatively, the hybrid design could be a more suppressed round shape that lacks the transition from central convexity to lateral concavity.

Basic Hairline Shapes for Hair Restoration (from Dr. Lam's Textbook, Hair Transplant 360)

Samuel M. Lam, MD, FACS, a board certified hair restoration surgeon in Dallas, Texas. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair transplant forum.

Is hair restoration an artistic endeavor?  Or in fact is it simply a rudimentary technical procedure in which hair is placed into the head and only the sheer number of grafts count?  I will explain in a point-by-point manner why hair restoration is truly artistic in my opinion, focusing on three major elements:  macro hairline design, micro hairline design, and recipient site creation/graft distribution.

Artistry in hair restoration requires good judgment when designing hairlines and making recipient sites.

1. Macro hairline design – Macro hairline design refers to creating the overall shape and position of the hairline, i.e., what is initially drawn on the head as a template upon which the micro elements of the hairline (see below) will be fashioned.  Every surgeon making a hairline will create a slightly if not significantly different hairline based on experience as well as artistic interpretation.  When I design a hairline, I am always looking at how that hairline shape would best match a facial shape, ethnicity, and gender.  I also make sure that it will age well for someone.  Every hairline I design I consider a work of art to make it not only look seamlessly natural but also wonderfully shaped to match a patient’s head to the best of my ability.
2. Micro hairline design – The micro hairline refers to the recipient sites that go into the general hairline.  When designing the individual sites, it is important that the hairline look natural from a distance but also even close up.  I really spend an inordinate amount of time during the procedure looking at my work from multiple angles to ensure that my hairlines look as natural as possible.  I really consider the micro hairline the final expression of my artistic design for the macro hairline.
3. Recipient site creation and graft distribution – To me the recipient site creation is one of the ultimate expressions of one’s artistry controlled down to the very site angle and distribution.  After I am done making my sites, I sit back for a minute, take a deep breath, and enjoy the glory of my creation.  I simply love seeing my sites before the grafts go into them because they are a work of art.  That is why I have so many photos and videos showing my recipient sites.  I consider showing you my sites is like showing the seams of a handmade suit so that you can see the quality that goes into the production.  I love blending in the technical and the artistic elements.  When I attain a number of grafts for a given size given to me by my assistants from their graft preparation (e.g., 600 2 hair grafts, 500 3 hair grafts, etc.), I like to sit down and figure out how best I am going to allocate those grafts in a creative way for optimal effect for a patient.  In fact, after I have created my work I always make a color-coded guide for my staff to know how to place the grafts but also so I have a written record of my distribution so when I see a patient come in with the grafts growing in nicely I can remember w hat I did.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair transplant forum.

A sentinel hair is defined as a single-hair graft that stands 1 to 3 mm in front of the hairline.  These 1-hair grafts are intended to blur the hairline visually, i.e., to make the line look less like a line.  They are the tiny archipelagos/islands that border and float near the hairline that make the hairline look natural.

1-Hair Sentinel Hairs in Front of Hairline

What is important to understand is that when creating a hairline and making it look irregular, it is not the job of the 1-hair grafts in the front row or as sentinel hairs in front of the front row that should be relied upon to make it look irregular.  Instead the initial 1 to 2 rows of 2-hair grafts that sit behind this initial row of 1-hair grafts that should already do the bulk of the work in making the hairline look irregular.  The 1-hair grafts including the front row of sentinel hairs are used to further soften the hairline.  I love using sentinel hairs to make the finishing touch in a beautiful hairline creation.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair transplant forum.

Many patients ask me which is better finasteride (Propecia) or minoxidil (Rogaine)?  Or, do I have to take both if I am already on one of them?

The answer to the first question is that I personally believe that 70% of the results from medical management comes from finasteride so as a single treatment option I believe that it is far superior to minoxidil.  However, the answer to the second question is that the two medications together work synergistically for a much better result than can be offered with either one alone.  I like to use the analogy of playing a piano with two hands versus playing it with one hand only.

Studies have shown that men who use both medications for many years then decide to stop using one of them lose part of their result.  Conversely, men who are on one product for quite some time then add the second one notice an improvement.  For both of these cases, the reason for the change is that finasteride and minoxidil work on hair loss through two different mechanisms of action and thereby each separately work to improve the situation and together work even more effectively.  Therefore, if it is within your budget and desires to do so, consider taking both finasteride and minoxidil for optimal gains against your hair loss.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair loss product forum.

When I strategize to rebuild the head with transplanted grafts, I think globally and I think specifically.  Thinking globally refers to how I distribute my grafts over a wide area of balding scalp based on priority.  Thinking specifically means how do I think about smaller regions of the scalp for hair restoration.  This blog article will focus on more global elements involved in hair restoration, discussing the three principle areas of the scalp minus the lateral humps and the temple region (that is the lateral portions of the scalp) that I contemplate when I perform a hair transplant procedure.  These three regions are as illustrated:  the forelock (or central forelock), the midscalp (or posterior midscalp), and the crown (or vertex).

The Three Principal Hair Transplant Zones: Forelock, Midscalp, and Crown

The forelock is defined as the region that extends in front of the planned fronto-temporal recession (not the natural balding FTR but what is planned for reconstruction) and the anterior hairline.  The forelock is the centerpiece of most hair-transplant procedures because it is the area that can make a man who is balding look bald.  It also provides a good frame to the face.  Hence, it typically is of highest priority to transplant when performing a hair transplant procedure.

The midscalp refers to the region of the scalp behind the forelock that takes a secondary concern to the forelock in terms of importance.  However, it can still be very important if the baldness is extensive enough that there is involvement here.  If all the hair is transplanted into the forelock and none are allocated to the midscalp the result can look artificial or not dense enough.  This is especially true when the hair is wet and thins out accordingly.  That is why during a transplant procedure, I wet the hair to determine the effect that doing so has on the midscalp region.  If it looks sufficiently thin to create a mismatch with the forelock, I have to budget more grafts to be placed into this area.  The midscalp is also the area that characteristically may require a second hair transplant procedure if most of the hair grafts were placed into the forelock or if the individual continues to recede back into the midscalp that was not previously transplanted.

The crown perhaps is self-explanatory.  Nevertheless, it is an area that is worth discussing.  The midscalp stops at the vertex transition point (or vertex transition zone) and that is where the crown starts.  The vertex transition point refers to the area where the scalp goes from a horizontal to a vertical plane posteriorly.  It is sometimes referred to as the posterior hairline for this reason.  The crown is an area that requires a lot of grafts to do well; and that is why it is oftentimes separated out as an area dedicated for an entire hair transplant session.  For more information on the crown, please review the other crown hair restoration blog posts on the crown to understand why it takes more grafts to accomplish an excellent result in this area.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair transplant forum.

Christian Slater's Hair Transplant

Hair Transplant is as much an art as it is a science.  Many times we simply see very bad hair transplant work that scares us into not wanting to have the procedure done.  When the procedure is done well, it is seamless.  Take Christian Slater’s hair transplant, which I think is both natural and artistically rendered.  The hairline looks natural from a casual distance but also the shape of the hairline matches his face well.  The temple almost matches the hairline (but not exactly) but close enough that only a hair-transplant surgeon would be able to tell this.  Personally, I would slightly augment the temporal point to match the shape of the hairline better but this is truly quibbling.  Just wanted to show a good celebrity transplant to emulate.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To learn more about hair loss, or to schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair transplant forum.

After repeated hair transplants, the donor area can become tighter over time.  Even some individuals who have never had a hair transplant may be born with relatively tight scalps.  In these individuals when I feel the back of the scalp and it feels tighter than I would like, I prepare them for surgery with 2 to 3 months of scalp exercises to break up any scar tissue and to relax the donor area so that the incision will heal better postoperatively and also so that there is less a feeling of tightness in the first 1 to 2 weeks following surgery.

Hands clasped and positioned to engage in scalp relaxation massages in preparation for future hair-transplant sessions.

The technique involves simply clasping one’s hands behind the head as if you are leaning back on a chair.  Then you slide the palms of the hands up and down the back of the head, typically resting at the mastoid or bony bumps that are the areas of greatest tightness in the scalp.  Then, you slide the palms (still interlocked) side to side to break any adhesions or tightness in a different angle.  Then, you rotate the hands in a figure of 8 direction to further break up any adhesions.  You can do this for a few minutes a few times a day for a few weeks to a few months leading up to your hair-transplant procedure, as directed by your surgeon.  Obviously, after the procedure as the wound is healing, you definitely do not want to do this.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To learn more about hair loss, or to schedule a hair transplant consultation please call 1-888-866-3388, or visit www.HairTX.com for more info. To ask Dr Lam a question please visit our hair loss forum.