Dear Dr Reddy,

I have had a 2300 graft strip surgery 3 months ago to the front and temple region. I am not happy with the density and also the direction of the hair. I have heard that with the specialised implanter used in H+ technique, you can achieve better density and also better direction than traditional strip procedures.

My question is can the density and direction be improved and if yes, how soon can this be done after my first surgery?

Thanks for your question. Before I start answering your question, I would like to reassure you that 3m is still very early days to determine the success or failure of your strip surgery. I do not belong to the school of thought that FUE is better than strip surgery. My belief is that both surgeries should complement each other.

Moving on, yes we use a specialised implanter pen that helps in achieving better control over the angle and direction, whilst protecting the vital structures of the graft.
With regards to density, a couple of factors influence the density. Logic says that to achieve the desired coverage a surgeon should aim to achieve 50% of the density of the donor area. Any density beyond that would not provide any additional benefits.
So the answer to your question is that we can achieve the desired density in one procedure with the H+ technique.

With regards to answering your second question, I always advice my patients to wait at least 6 months before contemplating the second procedure.
The reasoning behind this is that you have to wait 6m before you could assess the success of the first surgery and hence you can plan your second surgery better, without disturbing the healing process.

Hair restoration with FUT( Strip Surgery) has been around for nearly 20 years. Though the method of extraction has got significantly better with the use of tricophytic closure, there is very little chance of avoiding linear scarring which is visible when the hair is shorter than 2-3 mm. There are many ways by which the appearance of the scar can be reduced. One of the most recent advances is by using FUE.

In this method, Follicular units are extracted using a 0.9 mm punch. When meticulously extracted, leaving plenty of room in between grafts, FUE should leave no visible scarring even with very short hair.

One Key thing to consider is that the scar tissue is unlike normal skin in that the normal architecture is destroyed and hence the expectation level should clearly be revised in that the client should be explained that there is a possibility that some of the grafts might not be taken up.

Keeping this in mind, the surgery should be planned in such a way as to achieve the best camouflage. The results can be improved by a proper preparation of the donor scar and using sufficient tumescence. Another surgical consideration that should be pencilled in is that in order to achieve the desired result, grafts need to be placed in the healthy tissue on either side of the scar tissue.

At Cosmetic Medical Group we have achieved exceptional results with regards to scar correction following a previous strip surgery or scars induced by trauma to the scalp, eyebrows or side burns. Please pop in for a no obligation free consultation to discuss your needs with our specialist.

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Dear Dr Raghu Reddy. I am a 23 year old male, losing hair in the frontal and temples. I have been using minoxidil with some benefit. I have done a bit of research and have strongly considered the H+ hair restoration procedure. My fear is of shock loss. Do you think I am a good candidate for the H+ procedure and how do address shock loss.

Dear Steve thanks for your question. With regards to your first question about being a suitable candidate for the H+ hair restoration technique, we have stringent protocols with regards to patient selection. Age is certainly a factor .There is two ways are looking at it. You do need to understand that hair loss is progressive and this might not be the last procedure you will have and we need to plan ahead to address any future loss. Looking from a different perspective, you are 23 and if your hair loss is affecting you a lot and we have a technique which can give you natural results with minimal trauma and downtime then why not. What I would recommend though is to make an appointment for hair analysis before making the final decision.
Coming to your second question regarding shock loss, yes it is definitely an issue with any kind of hair restoration technique. There are numerous reasons behind shock loss and this is something I always consider and explain to the patient during my consultation for hair loss. With regards to management of shock loss, there is not a substantial body of evidence that supports any particular management protocol. I have my own protocol for preventing shock loss and it has worked well for me. I am sure other surgeons would probably have their own protocols.
 But as mentioned earlier, whatever hair restoration procedure you decide to undergo, make sure your surgeon has addressed all your concerns and answered all your questions to your satisfaction.

Dear Dr Reddy, though you claim no linear scarring with H+ technique, i have read a few patients complaining of a golf ball like appearance on the donor area. Could you kindly throw some light on this?

Dear Mr TA, thanks for your question. I have to agree with you on the fact that, I have myself seen a few patients with FUE ending up with patchy areas of visible scalp on the donor area. I would assume this is secondary to over enthusiastic extraction on part of the surgeon, whereby a lot of the grafts are extraction from one zone.
A lot of effort goes into the preparation of an extraction zone and I suspect this could be the reason why some surgeons prefer to stick to a small zone. Also the fact that it is easier to extract from certain areas of the donor areas than others, it is quite possible that this might influence a surgeon in the thought process of extraction.
With the H+ technique, we have totally moved away from focussing on one single zone and working the entire permanent zone. To second this, we have stringent protocols for extraction (Kindly attach a lead to protocols for extraction).
I have always believed in the fact that that the surgeon should aim to get maximum yield with minimal or no transection.

Though a very intrresting question, not a lot of work has been done with regardsto answering the question. Follicular units naturally occur as 1,2,3,4 and sometimes upto 7 hair grafts. In the traditional strip surgery the surgeon has access to different sized grafts availabe from the extracted strip & place accordingly.

With the H+ technique, the surgeon can pick and choose the size of FU'S required to get the desired results. The success of the H+ or any FUE technique is directly dependent on the quality of grafts extracted. This has been backed by studies by Beehner and Bernstein who clearly suggests that in the follicular unit, the whole is greater than the sum or its parts.

From my experience, I have clearly observed that follicular units that are intact have significantly better outcomes than split ones. Hence we have been able to achieve very natural looking results with the H+ technique. 

Since the introduction of FUE in the early part of the century, there have many refinements to the technique. Though patients of African descent are believed to be among the best candidates for hair restoration surgery, because of the low colour contrast between their skin and hair, and the excellent coverage provided by its curl or kink, the results with FUE have been very poor .The main reason being that the quality of grafts extracted have been of a poor quality due to the unpredictable nature of the curl of the hair. Understanding the unique hair qualities of African hair enables the surgeon to help the African/African American patient achieve the best possible results.

The hair shaft of African hair is oval on cross section (in contrast the round shafts of Caucasians and Asians). This configuration allows the hair shaft to twist on itself and form the characteristic kinky or curly hair. This hair type provides excellent local coverage since each hair covers a large area around it. However, a limitation of this hair type is that the tight curl doesn't allow the hair to be easily combed back to cover thin or bald areas that are some distance behind it. To compensate for this, the surgeon should place at least a small amount of hair in all of the areas that need coverage.

African hair can be divided into two distinct, but overlapping types; one that is wiry and tightly kinked and other that has a looser, more wavy kink with a softer feel. The surgery in each case must observe slight differences.

African patient with density of 1.6 hairs/mm2 and tightly kinky hair	African patient with density of 1.6 hairs/mm2 and curly-kinky hair

African hair is also unique in that the density of naturally occurring follicular units is relatively low (they are spaced farther apart). Africans have an average density of about 0.65 follicular units/mm2, in contrast to Caucasians with an average density of 1.0 follicular unit/mm2. During the transplant, the surgeon must account for this by spacing the grafts in African/African American patients slightly further apart to insure that there will be adequate coverage of the areas to be treated. Technically this works well, since the slightly larger grafts cannot be placed quite so close together.

The following table compares some easily measurable aspects of the follicular units in Africans/African Americans and Caucasians.

Another important consideration when transplanting those of African descent is the characteristics of the donor scalp. Their scalps tend to be thicker, more fibrotic and less distensible.

A final issue in transplanting Africans/African Americans is their increased risk of hypertrophic scarring and keloids. Although the incidence of keloid formation is rare in the back of the scalp, the formation of hypertrophic scarring is quite common. It is of paramount importance to identify that a condition called Acne Keloidalis that commonly occurs among African community. This presents as small bumps on the back of the scalp and this needs to be identified and addressed by the surgeon.

We at Cosmetic Medical Group understand the unique nature of African hair and have had consistently good results with the H+ technique. We can safely say that, due to the unique nature of this procedure, we are confident of achieving highly natural and satisfying results and hence back it up with a written guarantee.

We at Cosmetic Medical Group understand the unique nature of african hair and have had consistently good results with the H+ trechnique . We can safely say that ,due to the unique nature of this procedure , we are confident of acheiving highly natural and satisfying results and hence back it up with a written guarantee.