Hair loss isn't just about genetics or male pattern baldness. Aging, stress, and environmental factors can also take a toll. Dr. Jason Bloom joins Dr. Bass to discuss solutions for thinning hair, hair loss, and baldness, from everyday treatments like minoxidil to advanced options like hair transplant surgery.
Find out how FUE (Follicular Unit Extraction) and FUT (Follicular Unit Transplantation) hair transplant procedures work, along with the pros and cons of each. Plus, Dr. Bloom shares his personal journey with hair transplant surgery to give you a firsthand look at what to expect.
Drs. Bass and Bloom cover:
- The importance of planning ahead before a hair transplant
- Why harvesting a strip of hair from the back during FUE doesn’t mean losing that hair
- How NeoGraft helps achieve natural-looking results
- The maximum number of grafts you can safely transplant at once
- Other transplant areas, including beards, eyebrows, and even scars
- Exciting advancements on the horizon for hair restoration treatments
About Jason Bloom, MD
Located in Bryn Mawr, Pennsylvania, Dr. Jason Bloom is a double board certified facial plastic and reconstructive surgeon. He is an Adjunct Assistant Professor of Otorhinolaryngology – Head & Neck Surgery at the University of Pennsylvania and Clinical Assistant Professor (Adjunct) of Dermatology at the Temple University School of Medicine.
Read more about Philadelphia facial plastic surgeon Jason Bloom, MD
Transcript
Summer Hardy (00:01):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host Summer Hardy, a clinical assistant at Bass Plastic Surgery in New York City. I'm excited to be here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. The title of today's episode is Give Me Down to There Hair. What are we talking about today, Dr. Bass? Adding or subtracting hair? Because it can go either way.
Dr. Lawrence Bass (00:30):
That's right. Summer. Today we're talking about hair transplantation and the general idea of adding hair or boosting hair growth. We'll have another upcoming episode about hair removal. So the basic idea is that people have balding, sometimes that's just the result of aging. Sometimes that's male pattern baldness that's genetically transmitted. But even with aging and sometimes with medical conditions, there's considerable hair thinning. And that hair thinning is not exclusively something that happens in men. It happens very commonly in women as they age also. So that's partly genetics. It's partly aging changes, environmental conditions and stress. But all of these things are things we'd like to chase and get a handle on.
Summer Hardy (01:27):
Alright, I'm starting to get the idea, but what are the basic treatments for hair thinning, hair loss and baldness?
Dr. Lawrence Bass (01:34):
So there are pharmacologic treatments and hair transplant. So pharmacologic treatments are usually topical lotions or oral medications. And the number one that's been out for decades topically is something called minoxidil. This is a vasodilator. It's applied as a gel or a moose or a lotion. It dilates the blood supply to the hair follicles ramping up their activity. And it can be quite effective if it's used as intended to stimulate hair regrowth in someone who has thinning hair that works cooperatively, in other words, by a different mechanism with another medication Propecia. Propecia blocks testosterone, really DHT dihydrotestosterone, which is what affects the hair follicle in men. So that's a medication for men. But if people use both of those, it can have a big effect on hair regrowth, especially for thinning hair. There's a lot of use of minoxidil nowadays, orally as well as topically, and that can amplify the effect.
(02:59):
But separate from that is the field of hair transplant. And to discuss this, I brought Dr. Jason Bloom back to the podcast to discuss his expertise in hair transplantation and Dr. Bloom is a facial plastic surgeon in Bryn Mawr, Pennsylvania. He did his ear, nose and throat training in University of Pennsylvania and then his facial plastic surgery fellowship at New York University as well as Manhattan Eye, Ear & Throat Hospital. And that is where I did my plastic surgery training. So we share some institutional experience in common, but currently Dr. Bloom serves as co-director of the Facial Plastic and Reconstructive Surgery Fellowship at University of Pennsylvania. So Dr. Bloom, thank you for joining us again.
Dr. Jason Bloom (03:58):
Well, it certainly is so nice to be here. I always love talking to you guys and the invite is always very exciting when I get to talk about some topics that I'm very passionate about
Dr. Lawrence Bass (04:12):
And I try to bring you to talk about things that I'm excited about, that you are excited about, and we can pick apart these issues a little bit to help the listeners understand better. You do a tremendous job of explaining that in an understandable way for folks. This is definitely a hot topic. Can you tell us a little bit about the basic techniques today for hair transplantation?
Dr. Jason Bloom (04:37):
Yeah, so there are two main, I would say techniques for modern hair transplantation, and these are typically called FUT and FUE. And what those stand for is follicular unit transplantation and follicular unit extraction. So in a case of follicular unit transplantation or FUT, what happens is a small kind of area of the skin on the back of the head is excised. And so it's almost like a large strip of skin is removed almost from ear to ear behind in the back of the head and that is removed. So you can imagine taking about a one inch strip of hair out from behind the head. That area where the strip was excised is then closed with a layer of sutures. And then what happens is we take the strip, so imagine it's about let's say eight inches long and one inch wide and are able to remove the small groups of hair from this strip and then transplant it to the area in the front of the hair that is missing hair to create either fill in or a bald spot. The other type of surgery and hair restoration technique surgically is called follicular unit extraction. In this kind of a technique, the back of the hair is shaved, basically the entire back of the hair is shaved and the follicular units are extracted one at a time in between one to three hairs groups with one millimeter almost like punches. Then each of these follicular units consisting of one, two or three hairs is then transplanted to the front of the hair.
Dr. Lawrence Bass (07:02):
So I just explain for the listeners, how do we get away with taking a strip of hair out from the back If someone's going bald, aren't we risking losing that hair? We're taking out that strip of hair and we're going to put it in. Why isn't that at risk?
Dr. Jason Bloom (07:25):
So I mean, that's a great question. So basically what happens is the back of the head in males for example, is not subjected to the same types of hormonal hair loss that we see in the hairline and on top of the head. So if you think of someone could be almost completely bald, you're still going to maintain the hair in the back of the head and even sometimes around the sides. But male pattern baldness as well as even in more advanced cases kind of starts in the front and starts to move back. And then you can get the vertex or the part right on top of the head, but the areas along the back we typically maintain and we don't lose hair in that area. What I say is that the message for, and this is basically the whole idea behind modern hair restoration surgical techniques, is that I tell patients the message for hair growth lives in the follicle. And what we're doing is we're moving the follicle no matter how you get that follicle, either with an FUT or an FUE technique, and we're transplanting the follicle to the front of the scalp. And so the nice thing is that now the transplanted hair will grow like the hair on the back of your head, not like the hair on the front.
Dr. Lawrence Bass (09:09):
That's great. And again, explain for the listeners, when you do follicular unit extraction, so you're taking out one hair follicle at a time, typically times thousands. How is this mechanically accomplished? What happens to get those hairs out?
Dr. Jason Bloom (09:29):
So in these cases when you're doing follicular unit extraction, like I said, the back of the scalp is shaved down and it almost looks like one of the techniques that we use is called NeoGraft. And basically there's a small drill or punch, which is one millimeter wide, and each of these grafts are punched out and then suctioned into a collection container that allows us to then take these grafts and sort them out and we sort them on a petri dish. So you can see the follicular units with one hair, follicular units with two hairs and follicular units with three hairs. And I can explain why that's important to getting a natural look. And the reason why that happens is because what we used to do is literally take a punch biopsy, which was about a four millimeter chunk of the hair from the back and transplant that to the front.
(10:40):
And what you just saw was typically known as corn rows where there was just huge areas of these multiple grafts coming out and it looked very unnatural. But if you look at someone's actual natural hairline, you will see that along their most anterior hairline, there's areas where one hairs are one hair is coming out and then a little bit behind it, there's areas where there's two hairs coming out and then behind it three. So the most anterior parts of the hairline really have one hair coming out of each of these areas and that looks the most natural.
Dr. Lawrence Bass (11:23):
And I just again want to further clarify. So the idea of something like NeoGraft is not a doctor or technician standing there with a punch, but this is automated or robotic, if you will, to allow very precise hoist again of these thousands of hair follicles.
Dr. Jason Bloom (11:46):
Yeah, so that company makes, there are robots that do that, typically known as artists is one of them, and they have a computer generated kind of map to remove the follicles. The interesting thing about that technique is that you still have to have someone, it punches out the follicles, but you need to still have someone remove them from the scalpel and then do the transplantation, whereas a procedure with a, it's almost like a little dental drill kind of thing where it suctions it into the collection tubing. The nice thing about that is that there's no trauma to the follicular units because it is just suctioned into the tubing. You don't have to pick it out or pluck it out of the scalp. It is suctioned into it. So it's a lot less trauma to the follicles.
Summer Hardy (12:47):
These techniques sound really interesting. What are the advantages and disadvantages of each technique? Is there a preferred patient for each and which do you prefer and why? Dr. Bloom?
Dr. Jason Bloom (12:57):
So that's a great question. There are certainly benefits and risks to each of these. I think the benefits to the follicular unit transplantation or the FUT is that you can take out a wide swath of scalp and get thousands of hair grafts in a single session, which sometimes can be more than an FUE treatment because in cases like that, you don't want to over harvest the back of the head, so you don't want to make a bunch of little punches in the same area. You kind of have to spread it out over a larger area. But if you took a strip out, you can use every single one of those grafts out of a single strip. Additionally, I think a benefit of FUT would be cost. It's typically less expensive in general than an FUE technique. There's also very quick healing because you're just healing an incision versus FUE where you have to have the back of the hair grow back.
(14:17):
And one other benefit is that it doesn't require shaving the hair. So the donor area you can be back to, there's less downtime in the donor area because that area is not shaved. So I think those are the benefits of FUT. Now in my mind there are many other benefits to FUE, the follicular unit extraction. That is why it in my mind, is my preferred method. So FUE, the benefits are there is zero cutting. If you want to wear your hair short in the back, you are not going to see the large linear scar that you get from performing follicular unit transplantation. There is essentially no scar because you have one millimeter hole punches in the back of the scalp. Those heal over very well. Now instead of having one long scar that you have to heal, there is quick healing. And I would say the donor site grows back over the hair in about one week.
(15:33):
So it looks like you have a funky haircut for about a week or two, but it does heal over very nicely. Additionally, I think that you can really, it looks very natural, similar to the FUT because you are transplanting the hairs in smaller units, whether it's smaller groups, whether it's one, two, or three hairs, which I think is important nowadays because the punch method is no longer really utilized. And both of them can be done nicely in the office with under local anesthesia. So I typically tend to do a lot of FUE in my office because I think patients don't want the scarring in the back and it's a little bit easier to recover from because it's a little bit less painful and it takes a while for the sutures and things to heal in the back versus small little punches. I like FUE so much so that about eight weeks ago I had my own transplant. So my partner, Dr. Julie Shtraks, who is a facial plastic surgeon, did my transplant in the office. So I like to say I'm not only the hair club president, but I'm also a client.
Summer Hardy (17:07):
Thanks for explaining. And since you had the procedure done yourself, can you explain a little bit about it, how long it takes, how many hairs are transplanted at a sickle session, how long it takes to see results, things like that?
Dr. Jason Bloom (17:22):
Absolutely. So typically this is performed in the office, the back of the head. I actually went the night before and got a, it's called a skin fade where the back of my hair was really kind of tapered down and faded all the way to the skin in the back. And we come in and typically I had a Valium to just kind of relax myself a little bit and the area is then shaved down and numbed. So Dr. Shtraks did numbing injections in the back of my scalp. And the first part of the procedure you're laying kind of in almost like a massage table idea where your face is in a face cradle and you're laying face down. It's then numbed up in the back and after the initial numbing they do a ring block and then add basically tumescent anesthesia, which is basically salt water and some of the numbing to numb up the back of the head.
(18:31):
And during this time, I honestly had some air pods in. I was listening to music, I fell asleep, and that procedure took a couple hours, I think it was two hours, two and a half hours to perform, and then they're actually plucking out or extracting each of the follicular units. At that point. When that was done, after a couple hours, I then got up, I went to the bathroom, had lunch, and now for the remainder of the procedure, you're sitting in kind of like a beach chair position in the surgical chair. And at this point they again numb the front area. So the donor area is then rewrapped, and then the front is then numbed and the new recipient sites are made and this is made with a needle. And then each of the follicular units is then transplanted hair by follicle, by follicle to the front areas that need more volumes. And so this did take about a total of between eight to 10 hours. So you're sitting there, I did have another volume kind of halfway through, and we typically do anywhere from 1500 to 3000 follicular units. At one time I had twenty six hundred and thirty five units, grafts performed. But typically we don't like to go over 3000 units at any one time for time concerns as well as over harvesting concerns in the back.
Summer Hardy (20:22):
Got it. And what are the aesthetic goals? Back to a 20-year-old hairline?
Dr. Jason Bloom (20:27):
Man, I wish I could have my 20-year-old hairline back, but I would say the aesthetic goals really vary amongst patients. I always say that in a patient with more extreme hair loss, I typically say start in the front what most people see. And some of these cases I'll perform like the frontal tus or to kind of create a more frontal hairline on the first procedure, and then patients will come back and maybe do the vertex or more posterior aspects of the scalp that are bothering them less. And I always say start with the areas that are bothering you more. For me, I was at a spot where I didn't have a massive amount of hair loss, but I wanted to strengthen the troops, as I say, to densify some of the areas that were beginning to thin. And that was my main goal to do that. Some people, I did fill in along my hairline a little bit, but my main concern was I was starting to thin and I wanted to prevent further recession of the hair that I had.
Summer Hardy (21:52):
That makes a lot of sense. What other areas can be transplanted?
Dr. Jason Bloom (21:58):
Hair transplantation or restoration has really advanced over the last even 10 years. So people are coming in with issues in terms of transplanting eyebrows, sideburns, mustache or beard transplants. If you have a traumatic injury and scarring, you can actually put hair into the scars and fill in those areas. So it has really advanced. There are multiple areas of the face and neck with example, with beards and things like that that can be transplanted.
Dr. Lawrence Bass (22:39):
That's really super. And we've mostly focused on pure aesthetic applications, but there are a lot of medical conditions that cause hair loss sometimes in patchy or irregular fashions, or even in very young people in their twenties, not like male pattern baldness. So are transplant techniques useful in scarring skin conditions like alopecia areata?
Dr. Jason Bloom (23:12):
I mean, that's where it becomes to, it becomes an issue that I tell patients we need to rule out other issues for hair loss. So alopecia areata is sometimes called spot baldness and it can be an autoimmune disease that causes hair loss in some of these areas. So basically it's a situation where the immune system itself attacks the hair follicles, which can actually cause them, you can the hair. So in those kind of cases, it's important to address the medical concerns first before you're performing a hair transplantation procedure.
Dr. Lawrence Bass (23:58):
And that's still a very tough problem in dermatology, but there is some interesting research going on looking at ways to try to control the inflammatory process that causes different scarring, alopecia conditions like that.
Dr. Jason Bloom (24:17):
Yeah, frontal fibrosing alopecia and things like that. There are a number of different, actually dermatologic conditions that many dermatologists. I know George Cotsarelis, who's the chairman of dermatology at Penn, has really dedicated his life's work to the treatment of hair and hair related diseases. So dermatologists have studied this for many years and researched this extensively.
Summer Hardy (24:46):
So you touched on some challenges to hair transplantation. Are there any other unsolved problems in hair transplantation and what would you say the future is?
Dr. Jason Bloom (24:56):
Yeah, I mean I think some of the issues, as Dr. Bass was saying with some of these more autoimmune conditions are still yet to be figured out and how to improve them. Things like covid was having just wreaking havoc on people's hair because we know that the hair growth cycle is about a six month cycle, and you can go from what's called an antigen or a growth phase of the hair to telogen, which is more of a resting phase, and sometimes it takes months to go from one phase to the other. And so things like viruses, stress, pregnancy, just hormonal, different hormonal mixups and things like that can cause the hair to go into a resting phase, chemotherapy, things like that. We don't know why necessarily they go into these phases, but we do know that they can happen. Now interesting, I think the future is really trying to figure out how to get the hair follicles themselves from a resting phase from that telogen phase and convert it back to an antigen or a growth phase.
(26:35):
So I think a lot of the future really is, and this is, some companies that I don't even know if I can necessarily even talk about that, but I've made investments in have this is some really cool future ideas of actually topical medications to turn the hair follicle from a telogen to an antigen phase. And that's really the future to be able to change the actual growth pattern of the hair follicle to grow more hair is truly the future. And there are some kind of surgical advances that are the future and that would be able to take that robot that I was discussing earlier. And is that robot going to be able to now make the holes and transplant the hairs itself? So go from a extraction to a transplant? Yeah, I mean this is the future. I think we're getting better and better with some of this technology, but we'll see what the future holds.
Dr. Lawrence Bass (27:45):
And that's a great point. For a long time people were trying to figure out ways to get stem cells into follicles because even when you go bald, the follicle is still there. It just doesn't have live active hair producing cells. It's become sort of a ghost town of a hair follicle, but it's not gone. And so people were hoping to put stem cells into hair follicles and get them to grow hair again. Well, anything's possible, but that's probably not what we're going to see anytime soon. But we do things to biologically modulate follicles now, and one of those is injecting platelet rich plasma. There's increasing investigation of injecting exosomes to try to reboot the message to the follicles. So what's your experience and what role do you use PRP for in your hair transplant practice?
Dr. Jason Bloom (28:53):
Yeah, so I think there is some pretty, at this point, pretty sufficient data out there that shows that PRP or we actually use PRF, which is platelet rich fibrin, injected into the scalp is probably the best treatment for nonsurgical hair restoration. And we do do that in our office and we think it helps and not necessarily sometimes to regrow hair, but also to prevent further loss. Exosomes, as you mentioned, are kind of like the next hot thing. We haven't been injecting exosomes in my office so much as we've been microneedling them in. I still think that there hasn't been a lot of really controlled trials as much as, and there is some anecdotal data out there for exosomes. This is, I think, again, this is the future to look at how these can potentially help in the nonsurgical manner. We have been using it and I'm excited to see if this can help further and there are topical exosomes products that we offer as well. Yeah, I think that is going to be the future to see if some of these topical products are and are going to ultimately be able to save people the need for transplantation.
Summer Hardy (30:38):
It sounds like there are a lot of options for the future of hair transplantation, and what are your takeaways, Dr. Bass?
Dr. Lawrence Bass (30:44):
So we are always trying to control the biology so that we can avoid the need for surgical intervention, but the surgical interventions also are increasingly refined. It's important when thinking about hair transplant to think about your aesthetic goals and end points. We'd like to have that 20-year-old hair line just like when we have a facelift, we'd like to look 20 again, but that's not where we're going to get. That doesn't mean it isn't meaningful and extremely valuable, but it's important to define what you're aiming for so that you can get there and understand what's going to be involved in getting there. Sometimes it's more than one session of plantation, depending on what's happening with your hair. Understand the process that's going to be involved in the timeline. As you heard Dr. Bloom mentioned, it takes a number of months until the transplanted hair again wakes up out of telogen resting phase to antigen starts growing again.
(31:55):
So that's going to take a number of months, so you have to plan ahead a little bit. When you visit a provider, a surgeon to have hair transplant, try to see examples of their work, understand their artistry because it's not just about how many follicles, it's about the aesthetics. Hair transplantation nowadays is very natural looking because of the way the transplanted hairs are patterned to create a hairline and to create hair density in the areas that have lost hair. So it's not like 50 years ago when it was a doll's hair kind of look. It's very natural in your own living hair.
Dr. Jason Bloom (32:44):
I think that is just, if I could say one other thing, I think that's really important because there is a lot of aesthetic and artistry that goes to it. The hairline should be varied and irregular because if you're just putting all the hairs in a line across the forehead, it's going to look very artificial. But we kind of draw in a jagged line so that it looks more natural and we know to put the single hairs, as I was saying, the closest farther upfront. So you can see individual hairs coming out of the hairline, then you can use the follicles with two and three hairs behind it, but it's that irregularly, irregular hairline that looks the most natural and not something going straight across.
Dr. Lawrence Bass (33:41):
Exactly, imperfection in this case in the sense of being irregular is what looks real and perfection and regularity is obviously artificial. Well, thank you Dr. Bloom for joining us today and allowing us to pick your brains about yet another area of your extensive expertise.
Dr. Jason Bloom (34:04):
Well, it certainly is nice joining you on the podcast, and I really appreciate you for having me. I look forward to seeing you at a meeting upcoming in the next six to eight months where you can really see my hair, hopefully will be flowing.
Dr. Lawrence Bass (34:20):
Right. You'll have hair down to there.
Dr. Jason Bloom (34:24):
That's what we're going for.
Summer Hardy (34:25):
Thank you Dr. Bloom, for joining us again on the podcast. It's always a pleasure to have you. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. Follow us on Apple Podcasts, write a review and share the show with your friends. Be sure to join us next time to avoid missing all the great content that is coming your way. If you want to contact us with comments or questions, we'd love to hear from you. Send us an email at [email protected] or DM us on Instagram @drbassnyc.
