Regrowth's Interview with Dr. Paul McAndrews, continued.

Regrowth: How long have you been performing transplants and how many do you estimate you have performed (patients and procedures)?

McAndrews: Dr. Corbett has been performing hair transplants since 1962 and is one of the pioneers in the field of transplants. He has performed thousands of hair transplants on thousands of patients and has taught hundreds of Dermatology residents the art of hair restoration.

I was trained in a residency program at USC/LAC on the art of hair restoration under the guidance of Dr. Corbett and have been performing hair transplants for approximately 6 years. I have performed hundreds of hair transplants on hundreds of patients and taught many Dermatology residents the art of hair restoration.

However, our philosophy is quality, not quantity. We perform only 1 hair transplant a day and are involved in every step of the hair transplant process, which assures our patients our focus is exclusively on them. As doctors we are human, so we can only be at one place at a time. Therefore, if we are performing 3-4 hair transplants at the same time there will be 2-3 patients having the operation performed by technicians unsupervised. We fail to see quality in that system, and fail to see how this makes a better hair transplant.

Regrowth: Do you see many women for transplant operations, and is this number increasing?

McAndrews: Approximately 5-10% of our hair transplant surgeries are on women. Over the last couple of years the number has been increasing slightly.

Regrowth: Are women more or less suited to transplants than men?

McAndrews: There is much in the literature that women are not good hair transplant candidates because of diffuse hair loss. However, the most important decision on whether to go ahead with a hair transplant, be it in a female or a male, is if she/he is realistic about the treatment outcome.

Regrowth: We hear so many different terms for grafts from different practices. Which grafts do you perform and why? Do you transplant only follicular units?

McAndrews: We perform only "natural hair groupings/follicular units." Everyone's scalp naturally has the hair exiting the scalp in groups of 1-4 hairs with a fibrous sheath surrounding them. Since this is how God designed the scalp, we believe there is no more natural way to transplant the hair. There are many doctors that separate and transplant these "natural hair groupings" into single hair grafts. By separating these natural groupings of hair, it is going against nature and a study published in the Journal of Dermatologic Surgery showed that the survival and quality of these grafts markedly decreases. We think God is an excellent architect therefore we try to mimic his pattern, instead of trying to change it.

When a patient gets "plugs", "slits", "slots" or "mini" graft transplants it mandates that the patient continues to have transplants until the whole balding scalp is filled in or the contrast between these dense grafts and the bald scalp will give a "pluggy" look. If a patient gets "follicular unit" transplants and stops after only one hair transplant session it might look naturally thin, but never pluggy.

The bigger grafts are also wasteful (studies show the human eye cannot detect the difference between 50% density versus 100% density, therefore our goal should be to achieve 50% density in the balding area). The biggest grafts will actually get compressed into more than 100% density in the balding scalp. These bigger grafts could be placed over twice the surface area of the balding scalp without affecting density of the hair detectable by human eye.

Many doctors that have not learned how to perform follicular unit transplants state that follicular unit transplants cannot achieve the density that can be achieved by the bigger grafts. As we stated before, we do not want to achieve a density of 100% because it is wasteful. We want to achieve a density of 50%, which definitely can be achieved with follicular transplants.

Regrowth: How many grafts or hairs do you transplant in one session?

McAndrews: Our average transplant is anywhere from 500-1200 grafts. The most we will perform in one session is 1400 grafts.

Regrowth: Do you believe in the megasessions method of transplantating large numbers of hairs all in one session?

McAndrews: We are not big fans of "megasession" (i.e. - 1500 or greater) hair transplants. A patient only has a fixed amount of donatable hair in his "hair bank" and we think it's unwise to potentially waste this precious supply because the doctor or patient is in a hurry. There have been reports in the literature of lower survival rate of transplanted hair in a number of patients getting over 1500 grafts in one session.

An analogy is driving your car on the freeway at speeds of up to 200mph. You could get to your destination safely and save some time, but the faster you go the more unpredictable and unlikely that you are going to get there safely. We just don't believe that when we are doing cosmetic surgery on our patients, it is time to push the envelope of safety and potentially waste the limited supply of donor hair.

Regrowth: How many transplant sessions does your average patient go through?

McAndrews: Our average patient goes through 2-3 hair transplants.

Regrowth: Some practices offer guarantees that their grafts won't fall out and if they do that they will replace them. Do you offer any such guarantees, and how could you tell if any of your grafts fell out anyway?

McAndrews: If one of our patients did not grow the hair we transplanted, we would never charge them (fortunately, this has never happened to us). The only way you can tell if any of the grafts did not take is to know the number of grafts placed per cm2 in a certain area and then count the density of hairs/cm2.

Regrowth: Do you have any idea what percentage of your patients would say they are satisfied with their results once they are finished?

McAndrews: We spend a considerable amount of time talking with our patients and making sure our patients' expectations are realistic. If their expectations are not realistic or they are not a good hair transplant candidate, we will not perform the transplant. We do not know of any of our patients that are not satisfied with their results once they were finished.

Regrowth: Do you ever turn patients down who seem to have psychological problems regarding their hair loss? What percentage of patients are these?

McAndrews: It is our responsibility as physicians to always do what is in the best interest for the patient and be the patients' advocate, even if it's against their wishes. If a patient is not psychologically stable at the time of the transplant, then it is not in the patient's best interest to perform the transplant. We would say that approximately 2% of patients we interview during a hair transplant consult would meet this criterion.

Regrowth: Do you ever turn patients down just because their amount of loss is too extensive for them to get good results? What percentage of patients?

McAndrews: "Good results" is a very subjective term. For one patient, "good results" means to have a head of hair like they did when they were 17 years old -- we turn down this patient every time. While for another patient with very extensive hair loss, "good results" may mean a thin look in the frontal hairline with no transplants in the back -- we can satisfy this patient every time. Every patient has different expectations. It is imperative to make sure each patient's "hair bank" has enough hair in it to match his individual expectations and if his expectations do not match reality, we do not proceed with a hair transplant. We turn down approximately 20-30% of patients coming to us for a hair transplant because of this issue.

Regrowth: Do you ever turn patients down who haven't lost enough hair yet to know what their final amount of hair loss will be? What percentage of patients?

McAndrews: The most important determinant of the extent of hair loss a patient is going to experience is the extent of hair loss in his/her family tree and how young the patient was when the hair loss started. As a general rule, the younger the patient is when he experiences hair loss, the more conservative a hair transplant has to be because they eventually will have the least in their hair bank and the most surface area of balding scalp. Unfortunately, the younger the patient is, the more aggressive the patient wants to be (i.e. - wanting an aggressively low frontal hairline and transplanting hair in the vertex) and this makes them poor candidates. It is very easy to make this patient happy for the first 5 years with a hair transplant, however 20 years down the line the patient will be quite unhappy that his fixed "hair bank" has been used up in inappropriate areas that no longer look good. I think it is imperative that a hair transplant surgeon has the foresight to make sure the hair transplant will not only look good at 5 years, but also at 20-30 years. Therefore, we do not perform many hair transplants on young men and usually try to get them to start Propecia or Rogaine. Occasionally, we do perform transplants in young men who are realistic about where the hair should be transplanted. We turn down approximately 90% of men under the age of 25.

Regrowth: How can a patient know when he has lost enough hair to make transplants worthwhile without worrying about further loss causing poor end results?

McAndrews: One can not tell if a person has hair loss until he or she loses more than 50% of the hair. If a patient has a density of 50% or more, increasing the density from 50% to 70% will not show a clinically significant difference. A transplant should not be performed if the patient expects to have a clinically noticable difference. However, we have performed transplants in patients in the entertainment industry with a density of greater than 50% because they never want their hair density to drop to a point where they have clinically noticable hair loss. They understand that this is not going to make the hair look denser, but is laying the foundation for the future, and as "genetically programmed" hair in front or on top of the scalp falls out they get transplants to stay up with nature.

Nowadays with the proper foresight of the hair transplant surgeon, a hair transplant patient should always look natural, even if a patient only has one hair transplant. If a patient loses the rest of his hair that was genetically programmed to fall out and only the transplanted is left it may be a very thin look, but still should look natural.

Regrowth: What general guidelines do you look for to tell if someone has enough hair left to have a transplant?

McAndrews: The average person has a density of 200-220 hairs/cm2 in their donor bank. As a general rule, if the "hair bank" has a density of 100/cm2 or less, the "hair bank" does not have anything left to donate (i.e. - the hair is thin enough on the side of the scalp that you may be able to see the scar left from the removal of the donor strip. However, the most important guideline that dictates whether we will perform a hair transplant on a patient is if the patient's expectations and ultimate goals are realistic with the amount of hair they have left in the bank.

Regrowth: How painful are the shots to the scalp for local anesthetic?

McAndrews: The injections of the local numbing medication to the scalp should not be uncomfortable. Most of my patients state that the discomfort with a hair transplant is less than going to a dentist. As Dermatologists, we have found there are numerous techniques that minimize the discomfort of local anesthetic: 1) use the smallest guage needle possible, 2) inject the solution slowly, and 3) neutralize the pH of the acidic local anesthetic.

Regrowth: How noticeable is the surgery immediately afterwards? How soon can someone go out in public without it being obvious that they've had surgery?

McAndrews: The answer to this question depends on the amount of existing hair the patient has in order to hide the grafts. If a patient does not have any hair to hide the transplanted grafts, the scabs will be noticable for 1-2 weeks, which he could hide with a hat or a hairpiece. If a patient has hair in the transplanted area the grafts can be hidden and will be unnoticable immediately after the procedure. I have had a patient go back on live television within 4 days following surgery. Some patients can get "swelling" of the forehead that occurs around day 2 post-op and resolves by day 5 post-op.

Regrowth: How long does it generally take incision scabs to go away?

McAndrews: The scabs usually take 1-2 weeks to resolve. However, since we started using Polysporin at the graft site most patients' scabs are resolving in 5 days.

Regrowth: Several people have posted that transplant doctors have told them that transplants would not cause any existing hair to fall out and then it did. Do you warn patients of this and how frequent is it? Are these hairs that have gone into a resting phase due to trauma of surgery and will grow back or are they MPB affected hairs that have fallenout early due to surgery and will not grow back?

McAndrews: I do not understand how an educated doctor who has been trained in diseases of the hair and hair loss would not know that a patient could experience hair loss following a hair transplant. After any major psychological or physical (i.e. - childbirth, appendectomy surgery, hair transplants, and medications) trauma, it can cause a "telogen effluvium" in the patient. The average person has only 10-15% of their scalp hairs in the resting/falling out phase (telogen), while the rest of the hairs are in the growth phase (anagen). In telogen effluvium, an increased number (30%) of hairs go into the resting phase, so the patient experiences a shedding of hair (similar to a dog shedding). The good news is, just like in a dog, those same hair follicles go back into a growth phase and the hairs grow back.

When the laser is used to make the incisions used in the balding area, the laser can destroy the existing hair follicles in the area. We have not seen this when a needle is used to make the incisions.

The question of whether the trauma of the hair transplants causes MPB affected hairs to fall out early does not make sense in what we know causes androgenetic alopecia but there has never been a study looking at this.

Continued >

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