PARTICIPANTS Michael L. Reed, MD New York University School of Medicine Robert V. Cattani, MD New York Institute for Surgical Hair Replacement

DAVID R. MARKS, MD: When we think of hair transplantation, we often think of balding men. But women lose their hair too, and more and more of them are turning to hair transplants.

Joining me to talk about the procedure are two experts. First is Dr. Michael Reed. He's Assistant Professor of Clinical Dermatology at NYU Medical Center and he directs their hair transplant program. Next to him is Dr. Robert Cattani. He's one of the founders of the American Board of Hair Restoration Surgery and he practices in New York. Welcome.

As I said, we usually think of men, but women certainly do lose their hair. How many women actually are turning to transplants?

MICHAEL L. REED, MD: This is a male dominated field historically. It was male surgeons and male patients in the 60s, 70s, and 80s, which is probably good because the techniques were so bad that no one would go near women. They were too smart to do that. But as recently as 1990 in my practice, maybe 1 out of 20 patients was a women. In the first few months of 2000, it's 50% women and 50% men. They got to be equal. This is for women, just like it is for men. The women might even take over.

DAVID R. MARKS, MD: Dr. Cattani, why would a woman choose transplantation?

ROBERT V. CATTANI, MD: First of all David, they are devastated by their hair loss, more so than men. They feel singled out. They feel this is highly unusual. They feel this may be a manifestation of something else in their medical condition. They are so bothered by it. Men who know that women will lose their hair will say, "Well, a woman can always have a hair piece." The answer to that is yes, but they detest when that hairpiece has to come off. So now they know that this is no longer unusual, that there are surgical remedies, that there is micrografting, and that there is the ability to cosmetically improve their hair loss through surgery.

DAVID R. MARKS, MD: Tell me about micrografting in women.

MICHAEL L. REED, MD: Micrografting in women is really the same as it is in men. I'll just show you a picture here. One of the reasons why we have made advances in this field is that we understand something now which is called the follicular unit concept. This is a video microscopic view, very close up of normal scalp. Here we see the hair shafts arising from the scalp. If you look at them, you can see quite obviously that it's clear they grow in little anatomical clusters which we now call follicular units. These grow anywhere from 1-6 hairs per cluster. This concept has resulted in much more natural results. We basically do micrografts of these individual follicular units, either one or two or three of them together. If we get these close enough together in an area of thin scalp in women, we can actually go in between those hairs. We can get in between those with those little instruments.

Here in the center are two little instruments. They are called tri-bevel start punches. They look like the Mercedes emblem if you look at it head-on without the circle. They have three blades. They can get in between those follicular units, allowing us to transplant now people with thin hair, not just bald scalp.

DAVID R. MARKS, MD: So what you're doing is you're filling it out.

ROBERT V. CATTANI, MD: If I may expound on what Dr. Reed has said. When we think of baldness in men, we think of almost sometimes slick baldness, which means nothing but skin. In women, that's almost never the case. They always have some hair remaining. When we were using large plugs, which everyone knows about and everyone detests, it was very difficult to make a cosmetic improvement on that. But now with micrografting -- if you captured themes of precision and tedium when Dr. Reed was speaking, that's indeed true. We use microscopes to do this. Now through micrografting, through follicular units or one or two hair grafts, we're able to go in between hairs to give patients an increased density.

Can we give them the density that they've had prior to the initiation of their hair loss? No. Can we produce an improvement that is very cosmetically acceptable? Yes.

DAVID R. MARKS, MD: You mentioned that women still have hair, as opposed to men who often go bald. We have some video of women who I guess are going bald here. That looks like a donor site ready to be harvested. But talk to me about the pattern of baldness right there.

MICHAEL L. REED, MD: One of the things that delayed doing this in women was the concept---s and actually I call it the myth-- of the inevitability of diffuse hair loss. The idea that all women are going to get thin, not just on the top, but at the back and the sides. That's just simply not true. At least not in the timeframe that we're talking about. Women in their 40s, 50s and 60s can have rather dense hair on the back of their head. So they have an adequate donor site. It's not as good as the densest men that are available, but it's certainly sufficient so that they can spare hair and move it to the top.

You can take a woman who has see-through hair who has an area that's quite thin where you really see scalp and not hair, and you can fill that in so that when you look at her, you can see hair and no longer see scalp. That can be done in some women with healthy scalps in as little as one session in one area, and they'll be satisfied.

DAVID R. MARKS, MD: You have pictures of that, right?

MICHAEL L. REED, MD: Yeah. Here is an example of a younger woman in her 30s. This is her forehead. Here is her hairline, which you can see is still there. It's weak, but it's there. It's not receded. Look at this bald spot behind it. If you look at here, there, and then you see here. This is six months after one session. Before and after. You see those new hairs growing in. They are about two or three inches in length. This is the result of one micrograft session where the grafts are placed as close together as they can and still survive. This gives her no longer see-through hair. She has hair there and not scalp.

DAVID R. MARKS, MD: That's a tremendous difference.

MICHAEL L. REED, MD: One other lady is a little more advanced. I'll show you quickly. This is an older woman. This woman, every time she saw me, she cried until finally after we did a session here, this is one session in this woman. It's a dramatic difference. These are not touched up photographs. You can still see there is still an area of thinning here. We did such a large area -- and this brings up the limits of what we can do-- that this area didn't have as good graft survival. But she came back for a second session. Now she's a civilian again. She doesn't cry anymore. She laughs. She's really happy. Women are the happiest patients. They are much happier than the men.

ROBERT V. CATTANI, MD: I think that women will come into my consultation room and they'll say, "Doctor, I have the largest collection of bandanas every known in America because I can do nothing with my hair. I can no longer style it. I can't wear it the way I want." Now we can offer them --through microfollicular unit grafting we can restore to where they can emancipate. Get rid of those bandanas. Get rid of the hats. They can now style the hair in a variation of styles. This is very important to a woman. It frees her to do her own styles again. It's much more different than in a man. They are very happy patients.

DAVID R. MARKS, MD: After you take a strip of hair from a donor site, how do you implant it into the scalp?

ROBERT V. CATTANI, MD: One of the things that we do is under microscopes, and using, if you will, the surgical equivalent of razor blades, we divide the grafts down into one and two and three hairs. We implant them in a haphazard irregular fashion.

DAVID R. MARKS, MD: First you punch holes?

ROBERT V. CATTANI, MD: Yes. You can punch holes. You can do this with a needle type of instrument. You can do it with a small surgical blade as depicted there. There is a small surgical type of blade. What we're doing there is preparing the recipient sites. Notice that we're going between the hairs. When you're using something so precise and so small, we're able to do that. Then we'll take the grafts that we harvested, and under microscopes, under magnification, implant them in the scalp. This is a tremendous surgical advance.

DAVID R. MARKS, MD: What kind of scarring is there? Are there bumps on the scalp after the procedure?

MICHAEL L. REED, MD: Almost never nowadays. Occasionally, there will be an elevation or a slight depression of a graft. Once in a blue moon a graft will get trapped and cause an ingrown hair that has to be released, but these grafts are so small that they heal, in most cases, with virtually no scarring. The scalp looks like there is nothing done there until the hair starts to grow.

In the back of the head where we remove the donor tissue, we undermine the scalp. We put in buried sutures to bring it together so there is no tension on the surface. We put in a running surface suture which comes out 14 days later. Most of these patients get a pencil line scar. The ones who are not such great healers might get a magic market width scar, but it's always covered by the hairline, and it's virtually not noticeable. Sometimes, you can't even find it.

DAVID R. MARKS, MD: It almost sounds too good to be true. There must be some...

ROBERT V. CATTANI, MD: I know that you're capturing our enthusiasm about this procedure. That wasn't always the case, I assure you. It's only in the last few years.

Yes, if you find patients that have improper or poor donor sites, you cannot give them the results they want. If you have a patient that wants it done all at one time, they are not going to be good patients. If a patient seeks out a physician who occasionally does this once a year or something or twice a year, this is not the physician for them. They are bound to disappointment. But in general, this is a very acceptable procedure that produces a very happy patient.

DAVID R. MARKS, MD: With minimal scarring. We have a picture of the scar right here.

MICHAEL L. REED, MD: That's the initial closure showing the sutures. Those will come out in 10 to 14 days. The hair will come from above and below and touch. I think it's really important for these women to be told that even though we go between the hairs and don't damage them with our micro instruments, that the native hairs are restless, and they can be shocked from the surgery. These women can have less hair before they have more hair. That's probably the biggest concern. The hairs rest for several months, and then they have to regrow. So for a period of several months the women may have to use cosmetic coverups and comb their hair differently not to reveal that there is less hair there for a while. That's really important to tell them.

DAVID R. MARKS, MD: Do you mean that the actual implanted hairs will either fall out or not grow?

MICHAEL L. REED, MD: The implanted hairs rest and don't make a hair shaft for two to three months. Then they wake up and start to grow. The hairsin the area that were there, the original hairs that we go between, the thinned out fine hairs and the remaining hairs can sometimes-- not always-- but sometimes some of them come out too. They are shocked by the surgery in the area which means the woman must know that she has less hair before she has more hair. She has to get through that period.

Also, there is soreness in the back. There is no doubt about it. It's sore back there. If you press on it, it's tender. Some women have a constitution where they will say that it's sore for a while, but once the sutures come out at 10-14 days, the soreness disappears rapidly. Then there can be numbness for a period of time in the back of the head. Numbness doesn't hurt. What does numbness feel like? Not much, but it feels different than normal sensation. That gradually will go away over a period of months.

Last of all, there are little teeny, tiny scabs that are almost never noticeable to people looking at the patient, but it makes the patient feel self conscious for 7 to 14 days until they fall off. So people have to be prepared for what happens after the surgery. Then as they start to grow, it looks fabulous and they feel healthy.

DAVID R. MARKS, MD: We have some video of the actual implantation. When you talk about shocking, it almost sounds like you're planting bulbs for them to come out in the next season.

ROBERT V. CATTANI, MD: The term for the shocking, which is an often forgettable term is called telogen effluvium. Suffice it to say, as long as you tell the patients about it, tell them that it's normal and tell them that it's temporary. They accept that very nicely. It is normal. It is temporary, and all of the hair will be restored.

Keep in mind-- and this is important, we haven't really talked about this -- the percentage of take that we implant in patients.We like to think that it's not 98% of the hairs that I transplant that will grow. It's not 99%. It's 100%. We've very confident of that.

DAVID R. MARKS, MD: So it's a great result for both women, as well as men.

ROBERT V. CATTANI, MD: Yes. If performed by a physician who is highly experienced and a patient with realistic expectations. Yes.

DAVID R. MARKS, MD: Good. Well thank you both very much for joining us.