THE GOLD STANDARD Robert Michael Elliott, MD, FAACS James ... › app › uploads › ... · Proper...

HHH rev: 1-22-2018

THE GOLD STANDARD Robert Michael El l iot t , MD, FAACSJames S. Calder, MD, FAAPM & R

U n d e r s t a n d i n g H a i r L o s s , H a i r T r a n s p l a n t s a n d H o r m o n e s rev: 1-22-2018

U n d e r s t a n d i n g H a i r L o s s , H a i r T r a n s p l a n t s a n d H o r m o n e srev: 1-22-2018

IntroductionI have put together this book in order for the public to understand the process of hair loss and hair transplants. Many people think that hair loss is the common male and female pattern baldness. In reality, they are nearly correct, as almost all cases are either male or female pattern baldness, or female unpatterned hair thinning.

Nevertheless, there are some rare endocrine abnormalities, scarring alopecias from a variety of causes, and other reasons why a person may have hair loss. That is why it is important to consult an experienced physician for proper diagnosis before deciding what you should do. The causes of female hair thinning are currently being revised.

In this book, we first walk you through the diagnostic process for each type of hair loss, and then describe the treatments available for the most common type of hair loss, pat-tern baldness.

Following that, we discuss in detail the process of hair transplantation and, finally, bring you a brief synopsis of some of the latest research regarding hair loss.

I hope you enjoy it.

ROBERT MICHAEL ELLIOTT, M.D., FAACS


Contents

Diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . 1

Medical Treatment - Male & Female . . . . . . . . . . . . 7

Hair Transplantation . . . . . . . . . . . . . . . . . . . .11

Eyebrow Restoration . . . . . . . . . . . . . . . . . . . 35

Case Presentations - Male . . . . . . . . . . . . . . . . 36

Hair Restoration Update . . . . . . . . . . . . . . . . . 47

Anti-Aging/Hormone Replacement . . . . . . . . . . . . 50

Telemedicine Consultation . . . . . . . . . . . . . . . . 71

Before & After Surgery Instructions . . . . . . . . . . . 83

Directory & Maps. . . . . . . . . . . . . . . . . . . . . 91

U n d e r s t a n d i n g H a i r L o s s , H a i r T r a n s p l a n t s a n d H o r m o n e s

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DIAGNOSIS

In your consultation, your doctor must consider:

• Actual hair loss versus hair breakage• Focal hair loss versus diffuse hair loss• Hair thinning versus hair shedding• Scarring hair loss versus non-scarring hair loss• Hair shaft miniaturization versus reduced density

Proper Diagnosis of Hair LossBefore one can decide if they might need medical treatment or a hair transplant, a prop-er diagnosis of their hair loss condition should be made by a dermatologist or hair loss specialist. Hair loss may be pattern hair loss (male or female) or non-pattern hair loss.

Most hair loss is male or female pattern hair loss, which is characterized by the gradual miniaturization of hairs – usually in a specific pattern – for a few to sever-al years until finally falling out, due to a sensitivity to dihydrotestosterone in the case of males.

HAIR SHAFT DIAMETER Normal O O O Miniaturized o o o


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D I A G N O S I S C h a p t e r 1

Norwood: Male Pattern Hair Loss

2 3A 4a 5V

2A 3V 5 6

3 4 5A 7

1 Christmas Tree Pattern2 Ludwig Pattern I3 Ludwig Pattern II4 Ludwig Pattern III

1 2 3 4

NuggetThe great majority of all hair loss is male or female

pattern alopecia. The treatment for these is chemical and/or surgical therapy.

Pattern Hair LossMiniaturized or missing hairs in a distinct male or female pattern occurs as illustrated below.

Figure #1

Ludwig: Female Pattern Hair Loss


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C h a p t e r 1 D I A G N O S I S

Non-Pattern Hair LossHair loss (or alopecia) that is not in a genetic male or female pattern is divided into: 1) Hair shedding. 2) Scarring alopecia. 3) Focal non-scarring alopecia. 4) Hair breakage problems. 5) Diffuse thinning, although recent evidence suggests that this is a genetic

condition also, which is related to deficiencies in one or more hormones as persons age.

A discussion of each follows.

Hair SheddingSometimes generalized hair thinning is caused by hair shedding. More than 100 hairs per day are significant – this usually is a telogen effluvium (hairs which have entered the resting or telogen phase of the growth cycle – and are thus falling out). When hair follicles enter the telogen phase, the hairs held firmly in those follicles become loose and fall out. Certain severe toxins, radiation or chemo can cause anagen effluvium – where hairs are shed during the anagen (growth) phase of the cycle – as the follicles are destroyed. A telogen effluvium usually occurs about three months after the precipitating event, whereas anagen effluvium occurs closer to the toxic event.

Causes of Hair Shedding (telogen or anagen effluvium)Telogen Effluvium Common Drugs That Can Anagen Effluvium –Common Precipitating Events Cause Telogen Effluvium Common Precipitating Events

Childbirth ACE inhibitors ChemotherapyGeneral anesthesia Androgens Early alopecia areataHigh fever Anticholesterol agents Loose anagen syndromeHormonal changes Beta blockers RadiationProtein-deficient diet Cimetidine ToxinsStarting or stopping OCAs Coumadin, HeparinStress LithiumSudden weight loss Oral contraceptives (OCAs)Systemic disease Vitamin A


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D I A G N O S I S C h a p t e r 1D I A G N O S I S C h a p t e r 1

Focal Non-Scarring AlopeciaEntity Distinguishing featuresSecondary syphilis Serology for syphilis (contagious)Tinea capitis (ringworm) Broken hairs, scaling, erythema, positive smear and culture (contagious)Traction alopecia Typical pattern from tractionTriangular alopecia Pattern, configuration and history on templeTrichoterlomania Shaved hairsTrichotillomania Broken hairs present from manipulation, hairs of various lengthsAlopecia areata Irregular patches, frequently round, of missing hair, scattered

throughout the scalp, usually characterized by fine, silvery hairs at the base. This is thought to be an autoimmune condi-tion which lasts for several months to several years, may be characterized by hair regrowth in some of the areas, followed by development of patchy hair loss in other areas. This is diagnosed by biopsy, appearance, hair-pull test and history.

Cicatricial (Scarring) AlopeciasHair transplant surgeons often find unusual cases where the normal patterns of male-pat-tern baldness or female-pattern baldness are not present. Usually these are unusual and irregular patterns of hair loss on the scalp, frequently accompanied by loss of pores and hair in the area in question, and often a smooth, glassy appearance on the scalp.

When these are present, it is necessary to do a biopsy to determine the process that is active.

Generally loss of pores and smooth shiny scalp indicate a scarring alopecia. The follow-ing are the types of scarring alopecia which require a biopsy:

Chronic cutaneous lupus erythematosus Lichen planus pilarisFrontal fibrosing alopecia Graham-Little SyndromePseudopelade of Brocq Central centrifugal cicatricial alopeciaAlopecia mucinosa Keratosis follicularis spinulosa decalvansFolliculitis decalvans Dissecting cellulitis/folliculitis

If there is any doubt about which condition one is dealing with, even in the rare cases where they tend to mimic a male or female pattern baldness, a biopsy should be done. Generally the biopsy will determine which condition is present.

Scarring alopecias cannot be transplanted until such time as the inflammatory compo-nent of the process has been burned out for a few years.


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C h a p t e r 1 D I A G N O S I SC h a p t e r 1 D I A G N O S I S

HAIR LOSS ALGORITHMHair Loss

Hair Breakage

Genetic Defect Trauma• Traction• Trichotillomania

Cause of Hair Loss

Non-Scarring

Non-Shedding

Scarring

Shedding <100 per day

Chronic cutaneous lupus erythematosusLichen planus pilarisFrontal fibrosing alopeciaGraham-Little SyndromePseudopelade of BrocqCentral centrifugal cicatricial alopeciaAlopecia mucinosaKeratosis follicularis spinulosa decalvansFolliculitis decalvansDissecting cellulitis/folliculitis

Male pattern baldness.Female pattern baldness.Diffuse pattern alopecia.Diffuse unpattern alopecia.Alopecia areata.

Telogen effluviumAnagen effluviumLoose anagen syndrome

Diffuse

• Endocrine deficiency such as low free T3• Vitamin or mineral problems such as low iron

Patterned

• Pattern alopecia, male or female• Alopecia areata


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D I A G N O S I S C h a p t e r 1

Hair Breakage, Causes:1) Chemical or Physical Damage2) Trichotillomonia3) Anagen Effluvium4) Hair Shaft Anomalies: Monilethrix (beaded hair) Pili torti (twisted hair) Trichorrhexis invaginata (bamboo hair) Pili annulati (ringed hair) Bubble hair (damage from heat of hair dryers, curling irons, etc.) Trichorrhexis nodosa (nodes on hair) Trichonodosis (knotted hair) Trichoptilosis (split ends) Trichoschisis (broken or split hairs)

Pattern Baldness Versus Generalized Diffuse Hair LossNote that male and female pattern baldness are just that, hair loss in a pattern, generally on the top, sides, and back of the head, but sparing a thick donor area. Other types of systemic problems such as low thyroid, iron deficiency, collagen disorder, growth or sex hormone deficiency, secondary syphilis all may cause diffuse hair thinning. If you have generalized hair thinning, you need a complete medical workup for the various causes. Also note that some people have both a pattern hair loss as well as a diffuse or gener-alized decrease in density. These people may well have both conditions simultaneously, but still require a complete medical workup, normally with lab tests and biopsy.

Comprehensive Medical Workup for Diffuse Thinning and Hair LossA) LAB: CBC, Free T3 and T4 (thyroid), Ferritin, Total and Free Testosterone, SHBG,

and Estradiol, DHEAS, Prolactin, RPR, TSH, IGF-1, DHT, Progesterone, ANAB) SCALP BIOPSIES: Vertical and horizontal sectionsC) OFFICE TESTS: Hair-pull test, hair window, KOH prep, bacterial and fungal culture

and sensitivity


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MEDICAL TREATMENT Male & Female

Medical Treatment – Male Pattern Hair LossFor optimal chemical therapy for male pattern hair loss, the combination of Minoxidil 2.5 mg tablet, which replaces Rogaine (Minoxidil) Topical, and Propecia ( 1 mg per day), is the place to start for men with early thinning and miniaturization of their hair (in a pattern as described in the chart). When you see your dermatologist or hair restoration special-ist, he will prescribe these items for you. These are generally tried for several months, following which a second set of detailed photographs are compared with the ones taken at your initial evaluation. If you have either stayed the same or improved, that is a win for the medical therapy.

You may very well need hair transplants in addition (to restore your hair), but you may have stopped the progression of the balding process with the medical therapy. For example, sometimes younger men have their hairline transplanted where it has receded in the front, but the medical therapy keeps the back from falling out for many years. The nuances of this should be discussed with your physician. Remember that Rogaine must be used twice a day to be effective.

Propecia’s generic name is finasteride, and it blocks conversion of testosterone to dihy-drotestosterone in the hair follicle to the extent of about 70%. Another prescription drug which has not been fully studied in hair loss is Dutasteride, and it may well block the levels of DHT in hair follicles down about 90%. However, with Dutasteride, you are block-ing both isoenzymes of 5-alpha reductase, and the systemic side effects have not been worked out. As men get older, side effects from these medications may present that were not present in their younger years. You need to speak to your physician about the details of this.

See the Internet for post-finasteride syndrome before starting Propecia (finasteride). There are reports of permanent impotence with men that have been on finasteride.

Men may suffer generalized hair thinning (sometimes with pattern loss also) from low thyroid or iron, as do women. In older men, low testosterone can cause thinning of the donor area on the sides and back of the head. The donor, like beard and body hair, needs testosterone.


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M E D I C A L T R E A T M E N T - M A L E & F E M A L E C h a p t e r 2

Medical Treatment – Female Pattern Hair LossAfter menopause, it is common for women to show generalized hair thinning due to lower levels of female hormones, as well as the loss of the ability to convert T4 to T3 in the tissues, which results in a low thyroid-type of thinning hair, as well as thinning of the outer third of the eyebrows.

T4 is the principal type of thyroid hormone produced in the thyroid gland. T3 is the more active form, which is converted from T4 in the tissues. As we age, the ability to convert T4 to T3 in the tissues diminishes so that many people that are in excess of 50 years old have a normal T4 level in their blood, but have diminished T3 in the tissues. This is de-termined by measuring the free T3 hormone blood level. Even if you are at the lower end of the normal range, your hair may well benefit from additional thyroid supplement, which will bring you up to the high end of the normal range. This also results in greater energy, higher metabolism, and usually some degree of weight loss. Blood workup is required, as well as a thorough evaluation by your physician. Other causes of diffuse thinning are iron deficiency, collagen disease, infectious disease, and other hormone deficiencies.

In a study by Drs. Glaser and Messenger, published in the British Journal of Dermatolo-gy, it was found that women who were being treated for androgen deficiency, including symptoms of hot flashes, insomnia, depressive mood, irritability, anxiety, premenstrual syndrome, fatigue, memory loss, menstrual or migraine headaches, vaginal dryness, sexual difficulties, urinary symptoms, and pain and bone loss were found to have an improvement in their hair thickness following several months of treatment with testoster-one.

These women were treated such that their serum testosterone level was about 300. There were no cases of increased hair loss related to the higher testosterone. In the group of over 150 women, those that responded positively to the testosterone therapy with hair thickening were generally of a medium or slim build. Those ladies who were moderate to severely obese did not respond. The reasons for that are not yet determined but may be related to insulin resistance and other endocrinologic abnormalities.

The above suggests that female pattern hair loss and female hair thinning is definitely not due to excess testosterone as was postulated for many years. It is not “androgenet-ic” alopecia because it is not caused by androgen (testosterone, etc.).

It would seem that hair follicles in women are supported by testosterone. This is the same sort of support that is seen in men for their body hair, beard hair, and donor hair around the sides and the back of the head which is used for hair transplanting.


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C h a p t e r 2 M E D I C A L T R E A T M E N T - M A L E & F E M A L E

Conversely, the hair follicles on the top of the head of many men are sensitive to DHT (the high-potency form of testosterone) in a variable distribution. Some men find that the hair follicles in the front of the head are sensitive. In some, sensitivity lies in the hair follicles in the crown and back of the head, and in some both.

In addition, there are a few women who develop a male type 3 receding hairline pattern, and studies need to be done to see what the level of testosterone and DHT is in these women.

If a woman has an extremely high level of testosterone, such as that secreted by an ad-renal gland tumor, they may, in fact, develop Class 6 male pattern baldness.

These observations suggest that a new treatment protocol for the treatment of either dif-fuse or patterned hair thinning in women, following a lab panel to evaluate their hormone status, is:

• Testosterone pellets every four months under the skin of the buttocks• Armour thyroid as needed to bring their free T3 level to 4.0-4.2• Minoxidil in either a 2% or 5% solution bid, or the M82 Minoxidil solution bid, or

as a 2.5 mg pill• Theradome LH80 Laser Cap used 30 minutes every other day• Vitamin supplement with additional vitamin D, iron and biotin supplement, vitamin

K2, selenium, DIM

Summary of Testosterone Therapy in WomenIn an article by Dr. Rebecca Glaser of Ohio, the various myths about testosterone’s role in females is clarified. To summarize:

• Testosterone is not a male hormone and is required throughout life by females. In fact, it is the most abundant biologically-active hormone in women.

• Testosterone’s role in women is not simply to improve their sex drive and libido, but rather to improve mood, decrease anxiety and irritability and depression, increase a sense of well-being, improve physical endurance, decrease bone loss and muscle loss, and decrease changes in thinking processes and memory loss, (Alzheimer’s), improve insomnia and hot flashes and rheumatoid complaints. In addition, breast pain, urinary complaints, incontinence, and sexual dysfunction are all improved with testosterone therapy. In Dr. Glaser’s clinic, androgen thera-py consists of moving the female testosterone level up to around 300, by use of various testosterone sources such as pellets, creams, and the like.


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• Outside of suprapharmacologic doses of synthetic androgens such as used by body builders, testosterone does not have a masculinizing effect on females or female fetuses.

• The myth that testosterone causes hoarseness and voice changes is simply that.• Testosterone therapy increases scalp hair growth in women, and therefore the old

concept of androgenetic alopecia being the cause of female hair loss is obsolete.• There is substantial evidence that testosterone is cardiac protective and that ade-

quate levels decrease the risk of cardiovascular disease. • Non-oral testosterone does not adversely affect the liver or increase clotting

factors. Hence, testosterone should be taken in the form of either subcutaneous pellets or creams which are absorbed through the skin.

• Testosterone therapy decreases anxiety, irritability, and aggression in females.• Testosterone is breast protective and does not increase the risk of breast cancer.• The safety of non-oral testosterone therapy in women is well established, includ-

ing long-term follow-up.

M E D I C A L T R E A T M E N T - M A L E & F E M A L E C h a p t e r 2


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Hair Transplantation– Female Pattern Hair Loss If there is sufficient donor hair on the back of the head, women can be transplanted one to three times in the area of thinning to recover decent density. Sometimes the thinning goes over the sides and back of the head so that there is insufficient donor hair to do all of it. Generally, in these cases, if one starts at the hairline and transplants back to the apex (or highest point of the head), a drastic improvement in appearance will be had by adding several thousand hairs to the top of the head. It is not necessary or possible to transplant the entire thinning area in many women.

We have been seeing ever more females with hair loss in the office. Usually this is a typical female-pattern hair loss, although occasionally there is a scarring alopecia or alopecia areata. The FUE method is normally best here.

Females with female-pattern hair loss, in about 50-70% of cases, have sufficient donor hair to transplant the top of their head, rebuild the hairline, and obtain a good result. For many years, we have done this by doing two procedures about 3-6 months apart. There is usually a temporary loss of the miniaturized fine hair in the thinning and balding areas on ladies, so rather than go through that twice, it is better to put the procedures clos-er together. Ladies have the advantage of being able to style their hair “up” in order to cover the temporary thin area, or wear a wig for a while until the hairs are all grown out. Doing it this way, the hair will be well grown out at about the one-year point from the be-ginning, or in order words, six months after the second procedure. Also it is wise to use a little bit less density in terms of grafts per square centimeter in ladies who still have a

HAIR TRANSPLANTATION Female, Male, Eyebrow & Scar

What is a Hair Transplant?Hair transplants are minor dermatologic surgical procedures in which hair follicles are transferred from the permanent and thick donor area around the sides and back of the head to areas of thinning or balding generally found on the front, top, and crown of the head, as well as eyebrows, beard areas, and sometimes even chest. In rare cases, even body hair can be used as donor, if it is very thick and luxurious in areas such as the chest.


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reasonable amount of hair in their balding area. This will reduce the hair shock after the first procedure.

Also of note, there are some women who have a diffuse thinning of their donor area, as well as all the rest of their head, plus a slight female pattern. These people are said to have diffuse pattern alopecia and, while the cause is unknown, they are not good candi-dates for hair transplantation because of the thinning in the donor area. Thus an expe-rienced physician needs to examine the donor area to determine whether or not they are candidates. Recent evidence suggests low-dose testosterone and thyroid may help immensely.

H A I R T R A N S P L A N T A T I O N C h a p t e r 3

Female pattern hair loss, biological ageing and the Leiden Longevity studyPeople age at different rates and individuals with the same chronological age vary widely in terms of health and function. Biological age describes the difference between the pop-ulation cohort average life expectancy and the perceived life expectancy of an individual o the same age. Essentially it is an indication of how well your body is functioning rela-tive to your calendar age.

Biomarkers commonly used to determine biologic age such as diet, stress levels, alcohol consumption, education levels, sleep patterns, sexual habits, blood pressure, resting heart rate strength and mobility.

Should patterned hair loss also be considered to be a phenotypic marker of biological ageing?

Fig. 1. Sinclair Scale for Grading Female Pattern Hair Loss. Stage 1 is normal. Stages 2-5 represent the appearance of progressive scalp hair loss in women when the scalp is viewed from above.

Men and women both lose hair progressively with advancing age and men and women with premature hair loss appear prematurely aged. Men and women with premature hair loss also have an increased risk of death overall and in particular from diabetes mellitus and heart disease that persists after adjusting for the known association between pat-terned hair loss and metabolic syndrome.

Noordam et al used patient data form the Leiden Longevity study to demonstrate that women with known cardiovascular risk factors such as low HDL cholesterol and hyper-tension and biomarkers of ageing such as IGF-1 and Vitamin D levels have an increased risk of female pattern hair loss (FPHL). Noordam et al also found that more advanced FPHL is associated with additional biomarkers of ageing and longevity. This supports


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the contention that FPHL is a biological marker of senescence and predictor of reduced longevity.

Male and female pattern hair loss are both genetically based, suggesting they contribute to evolutionary fitness. Male pattern hair loss (MPHL) and in particular premature MPHL have a negative impact on reproduction. While MPHL does not affect virility, premature MPHL makes men less attractive and men with premature hair loss average fewer life-time sexual partners.

Female pattern hair loss (FPHL) normally occurs at or after menopause and potentially signals waning fertility to a prospective mate. Women with premature FPHL appear pre-maturely aged and are less attractive. In addition to the psychological problems asso-ciated with premature FPHL, affected women have an increased risk of metabolic syn-drome, polycystic ovarian syndrome, hypertension diabetes and hypercholesterolemia.

Additional epigenetic factors such as methylation of the androgen receptor gene are involved both in the pathogenesis and patterning of MPHL and the pathogenesis of ageing. Epigenetic methylation is considered to be a specific biomarker of organ-specific biological ageing.

Baldness severity is an important guide when assessing the chronological age of a stranger. Moreover, patterned hair loss is also likely to be a phenotypic marker of se-nescence and premature patterned hair loss is an indicator of reduced longevity and reduced evolutionary fitness. Perhaps that is why some people perceive hair loss nega-tively and those who become our patients feel sufficiently distressed by their hair loss to see dermatologists and hair transplant surgeons for treatment.

Rod SinclairUniversity of Melbourne and the Epworth Hospital, Australia

Fig. 1. Sinclair Scale for Grading Female Pattern Hair Loss. Stage 1 is normal. Stages 2-5 represent the appearance of progressive scalp hair loss in women when the scalp is viewed from above.



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Hair Transplantation for Women’s Hairlineswho have a receded hairline, but who do not have frontal fibrosing alopecia

Before transplant: Patient hair loss due to Mohs sur-gery for skin can-cer two years prior – hairline lowered to lines drawn in above

GraftLocation

After transplant: one session of 2050 grafts covers scarring from earlier Mohs surgery and lowers a re-ceded hairline in a middle-aged woman

C h a p t e r 3 H A I R T R A N S P L A N T A T I O N


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Case Study - Female Ludwig Christmas Tree Pattern- EJ

Before

After


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Case Study - Female Ludwig Pattern II - JA

Patient pictured before transplant (above) and after one session of grafts (next page).


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After with thyroid optimization and hair transplant


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After


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History of Hair TransplantationThe history of hair transplantation began in 1931 in France, where French surgeon Passot moved some hair from a thicker area to a bald area, creating what is thought to be the first hair transplant.

In 1939, Japanese hair researcher, Dr. Okuda pub-lished his results in a Japanese medical journal re-garding his technique of inserting small hair-bearing grafts into needle-stick recipients to fill in defects in eyebrows. This publication was lost during the Sec-ond World War and later discovered in the 1970s.

Dr. Norman Orentrich, a prominent New York der-matologist and researcher, reinvented the process of hair transplantation in 1956. At that time, he was doing some experimental work on skin grafts, and noticed that the hair in the grafts grew after the grafts had been transplanted. He developed a theory of donor dominance, which states that the thicker hair from the donor area will remain thick once it has been moved to the formerly bald area. In the 1970s, many physicians began doing punch graft hair transplants using 4-mm round plugs taken from the thicker donor area in the back of the head and transplanting it to the balding area on the top of the head. The author began this in 1971, while a dermatology resident. At that time, a great deal of skill was required to get these plugs to look natural. Unfortunately, many physicians tended to plant them more or less like trees so that you could easily see the plugs sticking up on the top of the head and, of course, this produced an unnatural appearance. The correct way to place plugs was to have them exit the skin at about a 30-degree angle so the hairs overlapped each other like the shingles on a roof. In this way, when the hair was combed, it looked good, but not as good as using much smaller plugs for the

Before

1/2 done

1/2 done

After

After

Micro-Plug Dr. E Hair Transplant - 1985


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hairline. In 1981, the author custom ordered a number of sizes of very small punches down to 1.0 mm. These punches could harvest down to one or two individual hairs and, at that point, it was possible to create a natural-looking head of hair using the plug technique, properly an-gled, and properly designed. At left are some photographs of a case from 1985, showing this technique on one of the author’s patients.

In the 1990s, the method of donor harvesting (various sized, round plug grafts) evolved into using a strip, which was closed in a thin line. The donor strip was then carefully dissected under microscopes and/or high-power magnification to create small follicular unit grafts containing one to four hairs in one follicular unit.

In the 2000s, FUE (1.0 mm punches) again become popular for physicians who got wide donor scars, as a means of having thousands of white dots in the donor. Ultimately, the method is less efficient for most cases as not enough grafts are obtainable to complete most cases so FUE must ultimately be combined with FUT (strip). See the Double-Mega Procedure, Page 27.

In 2016, the author and his staff developed FUE using .85 mm punches. These .85 mm donor skin piercings heal in about one or two days. This has made possible the new con-cept of the double mega procedure which works as follows:

Strip harvest of 2000 to 3000 grafts is done on day 1.

On day 14, the sutures are removed from the previous strip donor site.

On day 15-20, micro .85 mm FUE is done above and below as well as within the previous scar to yield another 2000 plus grafts.

In summary, 5000 grafts are obtained in a period of two and one-half weeks, which is gen-erally enough to transplant the majority of fully-bald heads.


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The hair follicle is a complex but small organ, which contains nerve fibers and blood vessels around the actual hair follicle. (fig. 2) About 80% of hair follicles are paired (or come in clusters of two). The rest are either singles, triples or an occasional quad. These clusters are called follicular units because they share a common blood and nerve supply. When doing hair transplantation and dissecting the donor area, it is important not to cut these follicular units apart because this generally results in miniaturized transplanted hairs rather than the full-sized hairs that are desired.

Figure #2

Anatomy of the Hair Follicle and Follicular Unit

Epidermis

Hair shaft

Sebaceous gland

Arrector pilimuscle

Hair Bulb


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Hair Transplantation - Male Pattern Hair LossHOW HAIR TRANSPLANTATION WORKS:

Only one type of hair loss will produce a distinctive pattern of loss in men. This is called male pattern baldness and is a genetic disorder. This disorder is primarily caused by the ef-fects of dihydrotestosterone or DHT on the hair follicles on the front, top, and crown. Men have a certain amount of testosterone in their bodies, which is converted by the enzyme 5-alpha-reductase into DHT. DHT is the highly active form. In men whose front, top and vertex follicles are sensitive to DHT, there is a gradual miniturization of sensitive follicles as shown in figure 3, page 22.

In men, distinct and progressive pattern baldness usually starts in the 20s, 30s, or 40s and continues briskly for eight to fifteen years. After that, it slows down but continues on a gradual and progressive course for life.

In both male and female pattern baldness, there is a gradual miniaturization of the hairs produced by affected follicles until they eventually stop growing and fall out. The “second-ary” hairs in the common 2-3 hair follicular unit go first. This is why a person’s hair will feel finer for several years before actual baldness occurs. In male pattern baldness, the hair around the sides and back of the head is not susceptible to the effects of DHT. This hair is also not susceptible to DHT if it is moved to another area on the scalp. This concept of donor dominance makes hair transplantation possible. Only follicles from the permanent band of hair around the sides and back are used for transplantation by experienced physi-cians.

In some men, the hair follicles in the front top of the head are sensitive to DHT, in others, the hair follicles in the back top area of the head are sensitive to DHT, and in some both. After transplantation has been done for many years, patients have come back to the office complaining that their transplant was thinning. A blood test for testosterone levels shows that they are very low on testosterone. Testosterone supports the growth of hair in men on the body, the beard, and the donor area around the sides and back of the head. Therefore, transplanted hairs which are from the donor area will eventually thin as the testosterone levels fall off as men age. Of course, this is easily treated by testosterone therapy, to cause the hairs to thicken back up.

Loss of thyroid (free T3), growth hormone, and sex hormones may enhance pattern hair loss with diffuse thinning over age 45, and require hormone replacement therapy. Persons with diffuse thinning should have a lab panel done and a biopsy.


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Figure #3 shows the two general types of scalp hair, the full-growing, long terminal hair, which is what is desired in hair trans-plantation, and the vellus (or miniaturized) hair, which is not long enough to really be of any benefit in solving a hair loss issue.

Figure #3

Figure #4 shows the gradual miniaturization of hair follicles in male or female pattern baldness. Note that this process takes a few to several years and is caused by sensitivity of hair follicles to DHT (dihydrotestosterone) in male cases.

Figure #4 Time-lapse : Miniturization of hair follicles in baldness

Vellus hair(1mm long)

Terminal hair(up to 3 feet long)

Scalp Hair : Types


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LIFE CYCLE OF HAIR FOLLICLES:

Hairs on the head will grow for a period of two to five years and then go into a resting period of three to four months. At the end of that resting period, the hair follicles will re-generate and grow out new hairs. Every day a certain percentage of hairs are going into the resting phase, and a similar number begin producing new hairs. When a hair follicle goes into the resting phase, the hair becomes loose and falls out. This is why a person

loses 50-100 hairs per day, even if he does not have any type of pattern baldness problem. The reason that the three to four month resting phase comes into play here is that it is the amount of time which transplanted grafts wait before they grow, or until “shocked out” hairs return.

When transplanting hair follicles, the oxygen loss drives them into their resting phase. This is why

new hair will not grow for three to four months. When transplanting into old scarred areas in revision cases, hair may take as long as twelve to fifteen months to grow due to the limited blood supply.

When transplanting into an area that has some fine remaining hair in it, the hairs that are in between the new grafts may be shed. This means that the hair follicles go into their resting period, the hair becomes loose, and falls out. Again, these residual hair follicles will spend about three to four months in their resting phase before regrowing hair. Occa-sionally, some of these residual hairs will not regrow, because they were in the last cycle of their life.

When male pattern balding begins, before hairs are lost, several years of miniaturization of hairs go by in which the hairs become smaller and smaller and their growing phases become shorter and shorter. Finally, they begin to die off, and a person has fewer hairs than he originally had. An individual can lose about half of his overall number or volume of hairs before it is apparent that his hair is thinning.

GENERAL INFORMATION

Androgenetic Alopecia (Male Pattern Baldness) is a progressive disorder which may start at an early age and progress throughout the patient’s life. The doctor makes his best estimate of the patient’s future pattern based on family history and other factors, but it is impossible to determine exactly how far it will progress. Therefore, the patient may require additional procedures if it progresses much further than anticipated.

It is important not to begin these procedures at too young an age. If the patient does


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decide to begin at a young age, he should be conservative in his hair restoration. When losing hair slowly, it is best to replace the hair slowly, matching the rate of natural hair loss over a period of years. The patient must work with the doctor in locating the hairline according to his advice so it will not be too low or in an inappropriate place. In younger persons, it is better to start with the front..

Our office employs a staff of registered nurses, certified surgical technologists, and well trained medical assistants who perform some of the technical aspects of the procedures under the doctor’s direct supervision. Of course, all surgical cutting, receptor incisions, and layout of grafts are done exclusively by the doctor. Pre-operative and postoperative photographs are taken of each procedure for use in the patient’s medical records. All information and photos of patients are absolutely privileged.

DONOR HARVESTING & GRAFT CUTTING: All donor harvesting is done with the patient in a comfortable, prone position, not sitting up in a chair. This allows for precise visualization by the doctor in order to be able to take the single strip of hair-bearing tissue in a manner in which incisions are precisely parallel to the hair direction, or in FUE cases, the extraction precisely parallels hair direction.

FOLLICULAR UNIT TRANSPLANTATION – STRIP METHOD: Once the grafts have been harvested, the doctor will close the donor area to achieve the smallest possible scar, which is typically one to three millimeters in width. When doing a second proce-dure, and occasionally on a first procedure, it is necessary to transect certain nerves which travel through the skin in the donor strip area. These nerves eventually grow back. Occasionally, there is a small area in the top of the head in which nerve enervation does not reconnect, so there is a loss of feeling. This is not troublesome. When doing a sec-ond procedure, the doctor will include the old scar area in the new donor strip, so there will eventually be just one scar, as in the first procedure, a small one to three millimeter scar. In about two out of 10,000 cases, there may be some nerve trapping in the donor scar, which requires a minor re-excision. Hylenex injection removes tension so donor scars are very small (1-2mm). Exparel (optional) can keep the donor anesthetized for 2 weeks.

The donor strip is transferred to processing by well-trained surgical technologists and nurses who, under microscopic visualization, divide the strip into individual small sec-tions. These small sections are then dissected into the individual grafts. This is done carefully to minimize follicular damage. The grafts contain 1, 2 or 3 hairs.


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Figure #5 illustrates the four growth phases of a human hair. Note that human hairs generally grow for two to six years in the anagen phase, and then shift into the catagen and subsequently telogen phase. The telogen phase usually lasts about three months. During telogen, the hair becomes loose and falls out, and the hair follicle withers up and virtually disappears. This is shown in the illustration of return to anagen. Miraculously, after about three months, the hair follicle regenerates (from the interaction of two types of stem cells, those from the bulge area around the sebaceous gland, and others from the dermal papilla area.) Following this, the regenerated hair follicle grows a new hair, which then grows for two to six years.

Figure #6 illustrates the differences in hair shaft charac-teristics between straight hair, curly hair, and very curly to wooly hair. Note it is simply a difference in the shape of the cross-sectional area of the actual hair shaft. In other words, round hairs generally grow straight, and oval hairs grow in various degrees of curliness.

Figure #5

RESTING PHASE

5-6 Weeks

RESTING PHASE

5-6 Weeks

TRANSITIONPHASE

1 - 2 Weeks

ACTIVE�GROWTH PHASE

2-6 Years

Catagen

Club Hair

Anagen Telogen

Dermalpapilla

Secondarygerm cells

RETURN TO

Anagen

Hair Matrixforming new hair

Human Hair : Growth Cycle

Figure #6

Straight Wavy Curly

Hair Fiber : Characteristics


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FOLLICULAR UNIT EXTRACTION: Some patients prefer the alternative form of do-nor retrieval in which single follicular units are extracted by either manual punch, power punch, a robot, or neograft machine individually. Instead of having a very fine-line su-tured scar in the donor area, in this method the result is a series of very small white-dot scars in the donor area. For this method to work, the donor area has to be entirely shaved and then the grafts extracted one at a time. In general, 1000-2000 grafts are the most that can usually be extracted at one time. Lifetime total ability to extract grafts with this method is probably around 4000 to at most 5000 grafts on a very large head. Doc-tors charge more per graft for this method (because it is extremely tedious and makes the day very long). With the strip method, a 2500-3000 graft strip can be taken out on one to three occasions, each time removing the previous scar so only one scar of 1-4 mm width results. This scar is always covered by a curtain of hair hanging over it so it is not apparent. After two strip sessions, it is best to switch to FUE.

In the FUE method, using the .85 mm punch, 2500 grafts can be harvested from a full donor at least once. Depending on the thickness of the hair, an additional 2500 can be harvested at a later date. If the patient has very fine or thin hair, this is not an option. If too much hair is taken out by FUE in a patient that has thin hair, the donor will develop a thinned appearance. A full Class 6 bald person requires 6000 to 8000 grafts to fully transplant his head. With the new Double Mega Procedure method, this can be accom-plished by one strip graft of 2500 to 3000 grafts, followed by a micro FUE .85 procedure done at about two weeks later with an additional 2500 grafts, giving about 5000 grafts over a period of two and one-half weeks. As the years go by and a person with this transplant requires some additional hair around the back, this can be obtained by the FUE method down the road.

Evaluation for Follicular Unit Transplantation (FUT) When you are seen by your hair restoration physician, he will evaluate the size and progress of your hair loss. You may be in an early stage in which you will require several treatments over many years, or in a late stage where you are nearly fully bald and require one or two treatments over one to two years. Generally, the number of follicular units that can be transplanted per session vary from about 10 to 30 follicular units per square cen-timeter of baldness. A practical method which allows for transplanting most of the head in most cases is one in which the physician’s objective is to install about 15-20 follicular units per square centimeter of baldness on the first session, with a second session of similar density about one year later. The one-year delay is necessary to allow the donor area to relax and loosen up so that a similar strip can be taken in the same place as the previous one, thus removing the old scar and leaving only one fine-line scar. With good surgical technique, it is frequently possible to even do a third procedure in the same area, still leaving only one fine-line scar. However, FUE can be performed one month after strip FUT to double the number of grafts.


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Using a newly developed technique, the Double-Mega Procedure, we are able to trans-plant 5000+ grafts - enough to cover almost all cases of baldness - in just two weeks.

• 3000 grafts by strip with Exparel (two-week anesthesia)

• Sutures out at two weeks. • Next day, 2000+ grafts by micro FUE

(.85mm) above and below strip scar - and scar filled. Also Exparel.

For patients who have had one to three prior strip procedures, the best choice for a touch up is micro FUE .85mm above and below the old scar line. In most cases, hairs can also be placed into the old scar line.


In evaluating a person for follicular unit extraction, it is necessary to make sure there is sufficient density in the donor that no change will be observed when removing 2000 to 2500 micro FUE .85 grafts. FUE may also be used on very thick body hair when scalp hair is very limited.

Evaluation for Follicular Unit Extraction (FUE)

New “Double-Mega” FUE Procedure

Double-Mega Procedure in process

Hair in donor area growing out at 10 days

See page 36 for more “Double-Mega photos

Healing after five days

Crusts gone at 10 days


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Treatment Protocol to Stimulate Thinning or Transplanted Hair and to Optimize Hormones1. Check Thyroid Free T3 initially, then annually to make sure it is at top of normal

range. Also take iodine solution to supplement thyroid. Try to get free-T3 slightly super normal (i.e. 5.0).

2. Do Hair Check initially, annually thereafter.

3. Minoxidil 2.5 mg daily

4. Theradome Medical Grade Laser, 30 minutes, alternate days.

5. Ketaconazole Shampoo 3 times/week, Head & Shoulders other days (#2, #3, #4 and #5 above only if hair thinning)

6. Iron supplement.

7. Three treatments at 6-week intervals, then annually.

8. Women: Testosterone pellets and Estradiol pellets to optimize hormones. Treat with PRP to areas that do not respond to above treatment.

9. Men: Testosterone implanted pellets every 3-4 months if TESTOSTERONE IS LOW, in-cluding men who are considering a transplant, or use Finasteride Plus and Sildenafil 20 mg daily. Change from standard Finasteride to:

A. Finasteride Plus which also contains biotin, saw palmetto, and organic herbs (prescription only).

B. Sildenafil 20mg daily to avoid side effects (prescription only).

10. Treat with PRP if resistant.

11. Vitamins/Minerals – (Medical grade of these now available through Debbie)

A. Vitamin D3 10,000 IU daily. F. DIM 2100 mg daily

B. GNC Mega Vitamins, one twice daily. G. Zinc

C Biotin 6000 daily. H. Selenium

D. Omega 3 capsule daily, 2000-4000 mg I. Iodine

E. Vitamin K2 500 mcg daily.


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Laser Technology at HomeThere is a new product on the market that uses advanced clinical strength laser therapy that is easy, comfortable, convenient and can be used at home. The Theradome LH80 Pro requires only two, 20-minute sessions per week. The unit is hands-free and cord-less, enabling freedom of movement during the treatment. The Theradome unit can be purchased without a prescription. It is the first FDA OTC cleared, wear-able clinical strength laser hair therapy for home use.

Biomedically designed lasers are key to treating hair loss. The proprietary laser technology delivers maximum energy (>440 joules per treatment) and penetrates the scalp at a wavelength optimized for clinical hair restoration (678 ± 8nm). Eighty high-efficiency lasers deliver therapeutic power while providing maximum scalp coverage of 582 cm2 and generating less than 1 C of heat per 20 minute session.

Progressive stages with a minimum of two, 20-minute sessions per week.


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Why Transplanted Hairs Grow at Three MonthsNow you have learned from Figure #5 (page 25) the details of the hair growth cycle. You have learned that the resting or telogen phase generally lasts about three months. When hairs are transplanted in a hair transplantation procedure, the small hairs in the hair grafts (which are about 1-2 mm long), will generally fall out within the first two weeks following the transplant. Those hair follicles then go into the resting or telogen phase for about three months. At the end of three months, the hairs will grow out.

Before

After 5 months – Two months of growth

After two procedures - Two years out


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DENSITY OF RESULTS: By using a method of small grafts at the hairline and slightly larger

grafts on the rest of the head, we are able to achieve density, which

can appear to be as much as it was when a patient was younger. Of

course, it would not actually be the same density as when the patient

was younger. The goal is to get to about fifty-percent of original den-

sity. Fifty-percent of density generally will appear to be the same as

full density. To achieve that density usually requires two sessions of

transplants to the hairline and the top and back of the head, depending

on where hair needs to be filled in. It is possible to do a third session

for maximum density. It is expected that virtually all of the transplanted

grafts will grow. Typical growth rate is in the 98% - 100% range. All the

grafts created at the time of surgery, including any extras, are used.

When we transplant into old scarred areas in a revision case of old

transplants done years ago, the growth rate will be somewhat less.

This is due to scarring in the old section, which makes it difficult for the

blood supply to get to the new grafts. If any of the grafts do not grow,

they will be replaced at no charge, except those transplanted into old

scarred areas. Of course, thick donor hair will give a thick result, thin

donor hair will give a thin result. Density can be affected by low thyroid

(free T3), low growth hormone, or low testosterone, and these may

require treatment.


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SURGICAL DESIGN BY YOUR DOCTOR: Once the grafts have been processed, the doctor will carefully design the pattern of the recipi-ent sites using a micro-spearpoint blade.

He will lay out the design precisely so that it will match the original pattern, will blend exactly on the sides of the head with the direction that the hairs currently grow, and will form a beautiful, irregular, and natural looking hairline. The hairline can be designed to suit the patient’s wishes. It can be a hairline with high, receding corners, youthful corners, or virtually any other shape. Of course, it must fit the patient’s head shape, facial features, and other factors. The doctor will review all these aspects with the patient and recommend a design for the most flattering look. For example, prominent frontal bones can be hidden under new hair, or the temples brought forward if a forehead appears too wide. In the back of the head, the design will recreate the whorl pattern exactly as it grew originally.

The doctor strives to mimic - or improve on - the hairline that nature created. Upon observing a number of hairlines, the patient will see that the majority of them are slightly asymmetrical (shaped differently on one side than the other) and have an irregularity to the hairline itself. One of the clues that a hairline has been artificially created is that it looks too symmetrical, like it was traced around a bowl. This is unacceptable.

Patient ready for donor harvesting - second procedure. Note very small scar from first procedure. Strip (FUT) type.


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EYEBROW RESTORATION

Eyebrows are one of the most important defining characteristics of the face. Often you don’t even realize the full impact that eyebrows make until you see a person without them. With a hair transplantation, it is now possible to restore natural looking eyebrows that will last a lifetime.

Eyebrow hair loss can occur for several reasons. Physical trauma (such as burns or lacerations), medical treatments (such as chemotherapy or radiation therapy), excessive plucking, and even menopause, can all contribute to eyebrow hair loss. Loss of the outer 1/3 of the eyebrow in per-sons over 50 is usually due to a low level of thyroid hormone, the free T3. This may be treated with thyroid pills.

In the past some people opted for eyebrow tattoos to recreate lost eyebrow hair. Eyebrow transplants can be implanted over eyebrow tattoos to recreate natural looking eyebrows.

The hair to be transplanted into the eyebrows is usually harvested from either the back of the head in the middle of the scalp or just behind the ear. In both cases the hair in these areas is of finer quality, thus more accurately resembling natural eyebrow hair. With an artistic eye, and keen attention paid to the individ-uals facial characteristics, the boundaries of the new eyebrows are drawn in so that the patient can see the shape of their new eyebrows. Once the design is completed, the area to be transplanted is anesthetized with local anesthetic. Small re-cipient sites are then made with custom blades measuring approximately .7mm. Only single hair grafts are placed in the eyebrows and special care is taken to angle the eyebrow hairs as flat as possible to the skin surface and in the proper direction based on the location of the eyebrow hair. Since eyebrow hairs change directions acutely depending on where in the eyebrow you are located, this process requires a precise attention to detail,

After the eyebrow hair grafts are placed, within 24 hours they form small crusts that appear like tiny grains of sand. Within one week most of these crusts fall off. Rarely there is a small amount of swelling around the eyes which usually resolves in 2-3 days. Some of the grafts may remain and start to grow, but usually most of the grafts fall out within 4 weeks and then begin to grow again in 8-12 weeks. Since the donor hair comes from the scalp, the hair will grow longer than standard eyebrow hair and will require periodic trimming.

Eyebrow transplant over tattooed brows

C h a p t e r 4 E Y E B R O W R E S T O R A T I O N


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CASE PRESENTATIONS Male

Case Study: Double-Mega FUE Patient : E.H.

Patient had 3000 grafts by strip methodand 3000 grafts harvested by .85mm micro FUE.

After strip 3000 (2015 - one year prior)

Five days after FUE harvest (2016)

10 days after FUE harvest (2016)

10 days after FUE (Only 2015 strip ses-sion growing)

30 days after FUE harvest (2016)

During FUE harvest (2016)

C A S E P R E S E N T A T I O N S C h a p t e r 5


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Case Study: FUE vs MFUE Patient : F.A.

Three photos above show healing 30 days after harvest (2016)

The above photograph illustrates the two methods of follicular unit extraction; the standard method which includes the smaller holes varying from .8 to 1.0 mm, and the multiple FUE method which uses a 2.25 mm hole. Both heal quickly.

The 2.25 mm punch will yield four to five hairs per each punch. To get 1000 grafts requires 1000 of the smaller holes (.8 mm to 1.0 mm), but only re-quires 250 of the 2.25 mm holes to get the same number of hairs.

The advantage of the multiple FUE method is that it is more cost efficient, and we are able to charge only slightly more than the standard strip method per graft, whereas the single FUE meth-od increases the cost and therefore the charge is about 30% more.

Note that in the photograph, the FUE grafts were taken above and below a previous scar, which was the result of

C h a p t e r 5 C A S E P R E S E N T A T I O N S

Case Presentations - Male

four strip procedures done many years before the date of this final touch-up proce-dure.


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Case Study: Pattern 5 Patient : J.D.

This patient has had two full hair transplant sessions plus one touch up procedure totalling 3,488 grafts

Before Before

After After




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J.D. (continued)

Before Before

After

After



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Case Study: Density Patient : J.S.

The patient had two hair transplants of 4,894 grafts. The photo (right) was taken 14 months after second surgery; hair has reached maximum density.

Before (top & bottom) After (top & bottom) one hair transplant of 2,405 grafts




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Case Study: Pattern 5-1/2 Patient : R.A.

Before After 2100 grafts



Patient before (left) and after (right) one hair transplant at six months. This patient had one session of approximately 2,100 grafts.



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Patient after 4200 grafts

After 4200 grafts

After 4200 grafts After 4200 grafts



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Patient after 4200 grafts


After 4200 graftsAfter 4200 grafts

After 4200 grafts



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Hairline DesignProbably the most important part of the hair transplantation process is the design of the hairline. The objective is to make the person look as good and as natural as possible, whether male or female. A hairline that is slightly lower in the center of the forehead and slightly rises towards the corners will give the most attractive appearance for most men with oval heads. For men with wider brows and a more flat forehead, a more straight-across hairline will generally look the best and is commonly found in some Asian and Hispanic head shapes. This is frequently seen in Japanese and Korean persons, but note that Chinese and Vietnamese head shapes are more oval and similar to the typical Caucasian head shape. African head shapes can approach either the oval or the more flat brow appearance. Generally a female blush with rounded corners of the hairline is created when replacing a female hairline. This is especially true in women who have lost hair in the typical male 3 pattern, frequently occurring after menopause.

Patient R.A.



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Case Presentation - Revising Old Plugs

Patient J.A. after five hair transplants of 200 round “plug” grafts done else-where (top) and after four transplants of 558 grafts by Dr. Elliott to refine the “plug” look (bottom).

If you have had old transplant plug grafts which are not angled well and are unsightly, and assuming you want more density because you may have lost more hair over the years, and you would like a properly designed natural hairline, this usually can be done (with sufficient donor hair). Most of the time, it is possible to harvest a strip through the little white scars of the old plug donor areas. We simply dissect the white scars out of the strip once we have it removed. It is usually most important to build a new hairline slightly in front of the old plugs so they are hidden and no longer seen. Similarly, it is frequently necessary to fill in along the part lines or in the crown of the head with the new smaller grafts to hide the appearance of old plugs from the back.



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Progression of Hair LossGenerally, a young man who is a Class 4 by age 21, will probably be a Class 6 by age

30. Sometimes there is not enough donor hair to transplant the entire head once one projects the size of the future balding area. Nevertheless, there is usually enough donor hair to do at least the hairline and the entire top of the head, leaving only a round spot in the back if there is not sufficient donor hair. If years go by and it turns out there is sufficient donor hair and the pattern is not as rapidly advanc-ing as was suspected, at least a modest coating of hair can be put in the crown or vertex of the head, which will present a very nice appearance.

Hair Thinning in Old AgeWhen beginning transplanting on young men, it is best to decide where to put the hair-line based on previous pictures, family pictures, and with the sense of what will generally make the person look the best. It is not necessary to create a receded hairline look in young men. There are plenty of men who have non-receded hairlines well into their six-ties, the author being one. Note the pictures of the author’s grandfather, Dr. J.T. Wagge-ner, from age 28 to age 100. Dr. Waggener’s hair was quite thin at age 100, but with very little hairline recession present. Note that this thinning of old age is what is termed senile alopecia and probably results from the falloff in thyroid hormone and growth hormone in later life. It is not male pattern hair loss. If a young man has lost his hairline, it is not too early to put him on medical therapy and rebuild his hairline with a hair transplant. If donor is projected to be ultimately insufficient, transplanting must favor the front and top of the head.

Age 28 Age 62 Age 85 Age 100

John Todd Waggener, MD



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HAIR RESTORATION UPDATE

Hylenex Virtually Eliminates Donor Tightness in the Strip MethodHylenex (human recombinant hyaluronidase or HRH) is injected 1 cm above the pro-posed donor strip area after it is anesthetized. This causes an almost immediate relax-ation of the skin which then allows:

1) About a 10% larger amount of donor grafts to be harvested without tension.2) Aids greatly in the removal of previous donor scars.3) Overcomes an inelastic scalp.4) Reduces tightness in the donor area after surgery.

The relaxation of the scalp is strongest at 10 minutes and lasts for 48 hours. Forty-eight hours is sufficient time for the scalp to relax itself.

Ultimately, because there is no tension on the donor closure, there is nothing to cause the donor scar to widen. Thus with this technology, virtually all donor scars should be in the 1-2 mm range and not more.

When the strip donor is sutured, Exparel, two-week lasting anesthesia is instilled below the sutures to virtually eliminate post-op tightness.

RECENT UPGRADES IN HAIR TRANSPLANTATION PROCESS

1) The anesthetic we use is now Septocaine rather than the old Xylocaine. The reason that Xylocaine used to sting when being injected was that it had to be at an acidic pH in order to work. Septocaine is neutral and, therefore, does not sting.

2) When putting in the anesthesia, the doctors use a vibrator attached to the fine nee-dle, which makes it nearly impossible to tell that it is being done.

3) Our anti-swelling solution, which is a dilute solution of triamcinolone, has proved very successful over the last few years such that postoperative swelling is 99% eliminated. Most people get no swelling at all, but a few get a small amount.

C h a p t e r 6 H A I R R E S T O R A T I O N U P D A T E


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H A I R R E S T O R A T I O N U P D A T E C h a p t e r 6

4) We have acquired a machine which allows us to manufacture our own ultra-small blades for the recipient sites. This means that our grafts can be much closer togeth-er. There is a formula that the sum of the length of the recipient slits divided into 35 will give you the number of grafts available to place in a 1-cm square. With this technology, a maximum of 30-40 can be placed per square centimeter. This is the formula used in the hairline area with 0.8 –mm blades, or in the case of very thin hair, 0.6-mm blades. 0.6-mm blades are also used for eyebrow single-hair grafts.

5) With these smaller blades, healing is completed in about 3-4 days with ability to resume normal shampooing at 7 days.

6) In addition to hair restoration, Dr. Elliott has been prescribing anti-aging medications for a number of patients for several years. If any of you require anti-aging medica-tion, you may make an appointment with him for evaluation and laboratory tests.

7) For those with little or no donor hair, we have used chest hair for hair transplantation (FUE) a few times. This works well if you have relatively dense chest hair.

8) The latest idea for a person with Class 5 or 6 hair loss is that a strip may be harvest-ed giving 3000 grafts, and two weeks later, another 3000 may be harvested by FUE. This is the fastest method to complete full Class 5-6 hair loss.

9) Recently Exparel two-week anesthesia was introduced for the strip method, which gives 2-WEEK anesthesia to donor stitches after the procedure and when combining FUT and FUE in the Double-Mega procedure, 5000+ grafts are completed in 2-1/2 weeks. This is the most advanced method.

10) The NeoGraft system uses the Follicular Unit Extraction (FUE) method because of the vast benefits this less invasive technique offers. The FUE method removes indi-vidual hair follicles from the scalp in their naturally occurring groupings of about 1-4 hairs and are then placed in the areas of the scalp where balding has occurred. The end result is a natural looking hairline with no linear scar and a quick recovery time.

11) Robotic Hair Transplants provide permanent, natural-looking results without the plugs, pain and stitches associated with traditional hair transplants like strip surgery. This minimally invasive procedure does not leave a linear scar. Digital mapping pro-vides precise and consistent graft dissection and Digital mapping provides precise

49


and consistent graft dissection. Advanced digital imaging scans, tracks and grades each hair, selecting the most suitable for harvesting. Image-guided precision robotics remove each hair individually. Only the minimum amount hair needed is harvested.

12) PRP or Platelet Rich Plasma for hair regrowth is an in-office, non-surgical treatment that can be performed in about an hour. PRP contains growth factors and cytokines that have been shown to be responsible for stimulating and enhancing hair follicle function. Small injections of the PRP deliver the powerful platelet-derived growth factors into the skin at the level of the weak follicles. There is no activity restriction after a PRP treatment. Patients may shower/shampoo/condition their hair normally just several hours after the treatment and resume normal daily and athletic activities.

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The Answer Begins Here

?What is the Best Way to ProtectBrain, Bones, Breasts & Heart

Basic Concepts of Bioidentical Hormone TherapyThe two principal factors contributing to how youthful you look and feel are genetics and hor-mones.

Hormone replacement is one of the cornerstones of anti-aging therapy. For women, pellets containing bio-identical hormones are placed under the skin every three months to maintain proper estrogen levels. This is always supplemented by progesterone pills which are taken orally daily. For men and women, testosterone pellets under the skin are an essential thera-py. Women need a testosterone level of about 100 to 150 units for best overall body function, strength, sexual drive, and hair growth. Men need a level of about 900-1100 units.

Estradiol therapy to a sufficient level is also critical for women to be protective for Alzheimer’s. Particularly, one of the three breakdown products of estradiol is protective for Alzheimer’s and other conditions. This is also true for men. Fortunately, some of the testosterone in men’s bod-ies is converted to estradiol, such that men are also protected against Alzheimer’s, etc.

C h a p t e r 7 A N T I - A G I N G

51


See the chart in this book on Page 53 which shows testosterone levels necessary to protect for various disorders.

Testosterone and/or estradiol pellet therapy results in increased libido, energy, sense of well-being, increased muscle mass and strength, increased stamina, decreased frequency and severity of migraine head-aches, decrease in mood swings, anxiety, and irritability; decreased weight, decrease in risk or severity or diabetes, decreased risk of heart disease, and decreased risk of Alzheimer’s and dementia.

Optimizing your thyroid hormone levels is also critical to anti-aging. This is best measured by the free T3, which is the active form of thyroid, which is not bound, and is therefore available to function in your body. The normal range is about 2.2 to 4.2 in most laboratories. Dr. Rouzier in Palm Springs has vast experience with thousands of cases and has found that raising the free T3 to about 4.2 or slightly more in persons over 50, will generally provide maximum energy, maximum mental outlook, increased metabolic rate to metabolize food that is ingested, and best hair and skin growth. This is true for both men and women. A level of 4.9-5.0 seems to be best. T4 is the form of thyroid that comes out of the thyroid gland and is metabolized to T3 (the active form) in the tissues. As we get older, the ability to covert T4 to T3 in the tissues falls off. Many times when we measure the free T3 in middle-aged persons, we find it to be in the range of 2.3 to 2.4. This is insufficient. This type of free T3 deficiency is generally treated with WP Thyroid or similar products. These products contain both T4 and T3. This cannot be treated with the common thyroid supplement Synthroid because Synthroid is only T4. In addition to hormones, a number of supplements are necessary both for the homes to function at their best, for best body functioning.

WP thyroid tablets in eight sizes are available from our Orange County/Newport Beach office at (949) 263-0800. The cost is for less than pharmacies. 100 tablets, depending in size, rang-es from $30.00 to $60.00. In bulk, 1000 tablets, depending on size, range from $225.00 to $450.00. See chart on thyroid comparisons.

_________________________

I recommend that all patients read Dr. Gary Donovitz’s book “Age Healthier, Live Happier, Avoid-ing Over-Medication through Natural Hormone Balance”. This book is available from our Costa Mesa/Newport Beach office for $5.00. Please call (949) 263-0800 for a copy.

Supplementsfor hormone optimizationVitamin D3 5000 IU dailyGNC Mega Vitamins, one twice dailyBiotin 6000 dailyOmega 3 capsule dailyCitracal/Glucosamine dailyVitamin K2 500 mcg dailyDIM 2100 mg daily (from Bioresponse)ZincSelenium

A N T I - A G I N G C h a p t e r 7

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Experience Hormonal Health - NaturallyNATURAL HORMONAL BALANCE depends on a careful optimization of hormone therapies and a consistant method of delivery.

BioTE® Hormone Pellet Therapy, the use of subcutaneous pellets, is based on 34 years of research - the longest-studied form of bio-identical hormone replacement therapy.

HORMONE REPLACEMENT THERAPYHormones are chemicals made by the glands that act to control certain actions of cells and organs. In essence, hormones regulate your body’s functions and keep things running smoothly. However, these hormones can become imbalanced or deficient in a condition known as hormone imbalance.

Hormone replacement therapy is one type of treat-ment designed to correct this problem, but not all forms are created equally. BioTE® hormone pellet therapy goes above and beyond in the treatment of hormone imbalance to provide the best results.

WHAT IS HORMONE PELLET THERAPY?Hormone pellet therapy is a treatment created to address hormonal imbalance. Hormonal im-balance occurs when one or more of the body’s key hormones is deficient or otherwise not at its optimal production level. This issue can occur in men and women.

Hormonal imbalance also seriously affects bone health, breast health, brain health, heart health and other critical systems in the body. Hormonal imbalance has a frightening mix of both tangi-ble and intangible symptoms; some you may notice immediately, and others mask themselves and occur behind the scenes.

HOW DOES PELLET THERAPY WORK?Hormone pellet therapy works by steadily replacing and rebalancing the missing hormones in the body. Hormone pellet therapy has been used since 1939.

Why you should optimize your hormonesOptimal levels of testosterone/ estradiol protect bone, breast and brain against:

Alzheimer’s Aggressive prostate cancer Metabolic syndrome Osteoporosis Mortality Type 2 diabetes Loss of libido Coronary heart disease Depression Erectile dysfunction


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The BioTE® MethodFounded and directed by Gary Donovitz, MD, BioTE® is committed to providing the highest standard of patient care.

The BioTE Method of Natural Hormone Balance is based upon 34 years of documented research to ensure the safety and standard of care for all patients.

BioTE® Medical requires the highest efficacy in ALL of our products, including estradiol and testosterone pellets.

BioTE® Medical holds national contracts with two com-pounding pharmacies that provide pellets that are developed specifically to match our individualized hormone doses.

Testosterone Pellet TherapyTestosterone is an important hormone that regulates many functions in the body. You may have heard that testosterone imbalance is an issue that only effects men. That’s incorrect: Testosterone imbalance can, and does, affect both men and women. When left untreated, low testosterone can seriously damage your breasts, bones, brain, heart, joints and even your relationships. Testoster-one imbalance can be treated with testosterone pellet therapy. Testosterone pellet therapy is a treatment made to combat testosterone imbalance.

As people age, their bodies slow testosterone production. Men ages 30 to 70 will lose 1% to 3% of total testosterone production per year, and women prior to perimenopause and/or menopause lose 50% of their testosterone production. This drop in production leads to many serious symptoms.

You may have heard of menopause, the end of a woman’s menstrual cycle that leads to many difficult symptoms. But have you heard of andropause? This condition, often associated with low testosterone, is very real and incredibly serious. Andropause directly leads to reduced quality of life and a host of troubling symptoms. This condition primarily affects men over age 50, but it can occur earlier in certain circumstances. Thankfully, andropause can be treated with hormone pellet therapy.

Andropause has also been associated with increased risk of prostate cancer and early heart disease. Low testosterone is common in men with diabetes, high blood pressure, sleep apnea and other chronic diseases. Hormone pellet therapy for andropause is a safe, effective treat-ment method for low testosterone.

BioTE® Medical is the only company that requires inde-pendent, third party labora-tory testing for all hormone pellets and tests for spe-cific values in the following catagories:

• General Appearance • Potency/Sterility • Rigidity • Friability • Weight Variation • Disintegration • Dissolution • Temperature tolerance


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900

800

700

600

500

400

300

200

100

Testosterone ThresholdsRELATIVE TO DISEASE AND MORTALITY

900840770

600

450432

283231 ng/dl

332-380

UPPER LIMIT

MEAN

LOWER LIMIT

Alzheimer’s DiseaseAggressive Prostrate Cancer/Mortality

Metabolic Syndrome Osteoporosis

Mortality

Type 2 DiabetesFatigue/Libido LossCononary Heart Disease

DepressionErectile Dysfunction

Serum total testosterone in young men (ng/dl)

Estrogen Pellet TherapyEstrogen is a very important hormone, one that regulates many functions in the body. Many women suffer from estrogen hormone imbalance, where the body is producing too little estro-gen, especially near and following menopause. Estrogen imbalance has many serious symp-toms, including emotional distress, weight gain, breast soreness, frequent bleeding or heavy bleeding. However, estrogen imbalance is treatable with estrogen pellet therapy.

Estrogen pellet therapy is a treatment designed to combat estrogen hormone imbalance. Estro-gen is a hormone that primarily regulates secondary sexual characteristics, among many other things. In all, estrogen has over 400 functions in the body.

Women’s bodies normally produce sufficient estrogen, while men produce very little, but a por-tion of men’s testosterone is converted to estrogen.

Both women and men need sufficient estrogen (estradiol) to function properly and be protected against Alzheimer’s.


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Erectile function

# of erections per week

Morning erections

Sexual activity/ejaculation

Sexual thoughts/fantasies

Sexual interest & desire

Satisfaction with sex life

2Weeks to maximum effect 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52

Time of first measured change

Time CourseSEXUAL PARAMETERS

Time Course

Increase muscle strength

Increase lean mass

Decrease fat mass

Decrease waist size

Increase exercise capacity

Increase bone mineral density

Decrease waist-hip ratio

2Months to maximum effect 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52

Time of first measured change

BODY COMPOSITION & STRENGTH


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• It has the same molecular structure as human hormones

• It lasts longer than other treatments, typically around three to five months

• It’s the most widely studied form of natural hormone therapy

• It provides a steady stream of hormones in your blood

• It provides individualized dosing

• It’s inserted under the skin

The type of hormone pellet therapy we provide is called BioTE® hormone pellet therapy. This type of hormone pellet therapy is meant to be hassle-free: BioTE® hormone pellet therapy pro-vides outstanding results with minimal side effects. Pellet therapy is also the only modality that mimics the body’s normal diurnal and circadian rhythms.

Other benefits of BioTE® hormone pellet therapy are:

• It’s safe: Hundreds of studies have been completed on hormone pellet therapy, and it has been in use since 1939.

• It’s clinically effective: With BioTE® hormone pellet therapy, hormones are delivered consistently 24/7 over several months. There is no “roller coaster” effect as with other treatment types.

• It’s convenient: BioTE® hormone pellet therapy is implanted just a few times each year.

• It has a low side-effect profile: BioTE® hormone pellet therapy is the best method to increase bone density and doesn’t increase risk of heart attack, blood clots or stroke as other methods do.

BioTE® Benefits

Request Hormone Pellet Therapy Information TodayPatients who receive BioTE® hormone pel-let therapy report increased energy levels, improved libido, decreased body fat, better mental focus, improved mood and much more. Interested in exploring hormone pellet therapy? Request treatment information to-day: Call us at (949) 263-0800 or visit

www.PacificLongevityInstitute.com


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Thyroid HormonesTREATING THE SILENT SCOURGE OF THYROID DISEASE

There are over 200 symptoms related to thyroid disease. They are insidious, elusive and great masqueraders. The lab tests we are taught in medical school for this workup do not tell the whole story. Once you learn that you have to treat the patient and their symptoms rather than the lab tests, it becomes apparent what needs to be done.

Thyroid imbalance plays a role in many disorders and diseases including cardiovascular dis-ease, osteoporosis, obesity, diabetes and female infertility.

Both Dr. Broda Barnes, in his book Hypothyroidism: The Unsuspected Illness (1976), and Dr. Mark Starr, in his book Hypothyroidism Type 2: The Epidemic (2005, revised 2013), have been telling us for years that forty percent of the population is affected with thyroid disorder, but only ten percent are being diagnosed.

The thyroid gland is a vitally important hormonal gland. Located in the front of the neck where your collar bones come together, the function of this butterfly-shaped gland includes the production of


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the thyroid hormones triiodothyronine (T3) and tetraiodothyronine, also known as thyroxine (T4).

The energy metabolism of all our cells starts with thyroid. It’s not just about keeping us warm, it’s about keeping all of our cells energized. In simple terms, if you want all your cells to be effi-cient and function rapidly in their attendant processes, they need thyroid hormone.

When balancing and maintaining proper synergy in our hormonal therapies, we have to consid-er the matrix of our command center. It truly begins in the hypothalamus, which is tucked deep within the center of our brain. This little powerhouse regulates breathing, blood pressure, and heart rate. It regulates body temperature and fluid balance.

Our hormonal balancing act depends on the hypothalamus for directing all other glands in our endocrine system. The thyroid is not autonomous; it works in conjunction with other glands like the hypothalamus and pituitary gland.

T4 is not an active hormone, but rather a pro-hormone. In the thyroid and numerous other cells throughout our body, it has to be converted to T3. This will be critically important when we look at treatment options. This conversion ability diminishes after age 50-60.

Hyperthyroidism can occur when too much thyroid hormone is produced. It is most often caused by Graves’ disease or non-toxic goiter. It is rare; only one in a thousand women and three in ten thousand men get this disease. It was discovered early in the 1900s, even before we could measure thyroid hormones. Patients were “hot,” with a rapid heartbeat and shaky hands, and they were riddled with anxiety.

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Hyperthyroidism is not caused by a deficiency of a hormone, so will not be covered here.

Hypothyroidism can be divided into three disorders:

Type 1 hypothyroidism, whereby the thyroid gland does not produce enough thyroid hormone. It is easily detected by a thyroid panel blood test. This type of hypothyroidism only affects five percent of the population.

Type 2 hypothyroidism occurs at the cellular level. While the thyroid gland produces sufficient amount of T4 hormone, the body’s cells are unable to convert the hormone properly. It can be caused by thyroid receptors on the cells or in the cells being damaged and thereby not available for the thyroid hormone to bind to. This receptor problem can be inherited or can be caused by toxins in our environment. Very frequently, interaction of thyroid hormone and its target cell can be interrupted because of iodine deficiency. It’s the most common cause of hypothyroidism in the United States, affecting upwards of forty percent of Americans, primarily middle-aged women, but also men and women of any age, and children.

Type 3 hypothyroidism, more commonly known as Hashimoto’s thyroiditis, is a condition in which your immune system attacks your thyroid. The resulting inflammation often leads to an underactive thyroid gland.

Symptoms include weight gain, depression, mania, sensitivity to heat and cold, paresthesia, chronic fatigue, panic, bradycardia, tachycardia, congestive heart failure, high cholesterol, reactive hypoglycemia, constipation, migraines, muscle weakness, joint stiffness, menorrha-gia, cramps, memory loss, vision problems, infertility, and hair loss. The laboratory work-up is the same as Type 1 and Type 2, but in addition, autoantibodies may be present against thyroid peroxidase and thyroglobulin. These are two important enzymes needed to convert the inactive T4 pro-hormone to the active T3 active hormone.

The other interesting nuance is that ninety percent of patients with Hashimoto’s disease have gluten intolerance. Knowledge of this aids in therapy by replacing the deficient hormones as well as placing the patient on a gluten-free diet.

FOCUS ON TYPE 2 HYPOTHYROIDISM

Understanding Type 2 hypothyroidism is relatively simple. It will help to remember from your high school biology lesson that within each cell of your body, the mitochondria make chemical energy, similar to the type of energy you get from a battery. The energy made by the mitochon-dria takes the form of a chemical called adenosine triphosphate, or ATP for short.

Under normal circumstances, T4 and T3 thyroid hormones increase the number and activity of mito-chondria. More activity equals more energy. Think about what would happen if these little microscop-ic parts of the cell were genetically altered, or if the number of mitochondria in the cell were reduced. What if you had just enough thyroid hormone to be in the “normal range” on your blood test, but it was not enough to activate the mitochondria so they could function normally? That is exactly what happens in Type 2 hypothyroidism. An insufficient amount of inactive T4 is converted to active T3.

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Hypothyroid Medications

WP Thyroid®

Nature-Throid®

Armour®

Synthroid®

Synthroid® is a registered trademark of AbbVie Inc. Armour® is a registered trademark of Actavis

BRAND-NAME COMPARISON

Natural T3 & T4hormone replacement

Gluten andcorn free

No artificial colors

No FDA recalls(for hormone inconsistancy)

Only two inactiveingredients

Hypothyroid Medication DosagesBODY COMPOSITION & STRENGTH

WP Thyroid® Nature-Throid® Armour® Synthroid® & Levoxyl® Tirosint®

(Thyroid USP) (Thyroid USP) (Thyroid USP) (Levothyroxine) (Levothyroxine)

1/4 grain (16.25 mg)

1/2 grain (32.5 mg)

3/4 grain (48.75 mg)

1 grain (65 mg)

1.25 grain (81.25 mg)

1.5 grain (97.5 mg)

1.75 grain (113.75 mg)

2 grain (130 mg)

2.25 grain (146.25 mg)

2.5 grain (162.5 mg)

3 grain (195 mg)

4 grain (260 mg)

5 grain (325 mg)

25 mcg (.025 mg)

50 mcg (.05 mg)

75 mcg (.075 mg)

100 mcg (.1 mg)

125 mcg (.125 mg)

137 mcg (.137 mg)

150 mcg (1.5 mg)

175 mcg (.175 mg)

200 mcg (.2 mg)

300 mcg (.3 mg)*

13 mcg (.013 mg)

25 mcg (.025 mg)

50 mcg (.05 mg)

75 mcg (.075 mg)

88 mcg (.088 mg)

100 mcg (.1 mg)

112 mcg (.112 mg)

137 mcg (.137 mg)

1/4 grain (15 mg)

1/2 grain (30 mg)

1 grain (60 mg)

1.5 grain (90 mg)

2 grain (120 mg)

3 grain (180 mg)

4 grain (240 mg)

5 grain (300 mg)

1/4 grain (16.25 mg)

1/2 grain (32.5 mg)

3/4 grain (48.75 mg)

1 grain (65 mg)

1.25 grain (81.25 mg)

1.5 grain (97.5 mg)

1.75 grain (113.75 mg)

2 grain (130 mg)

*Levoxyl® is not available in 300 mcg

1 grain = 38 mcg of T4 & 9 mcg of T3 | 65 mg (1 grain) Nature-Throid® = 60 mg (1 grain) Armour®

Due to the higher bioactivity of natural thyroid, physicians may choose a slightly lower dosage to achieve similar results for patientsconverting from synthetic thyroid.


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Sub-Cutaneous Hormone Pellet TherapyThe Comprehensive Treatment to Optimize and Balance Hormones Using the BioTE Method

GARY S. DONOVITZ, M.D., F.A.C.O.G.

The BioTE method of hormone replacement is a time tested method of hormone optimization that was created from the hundreds of studies performed on hundreds of thousands of patients worldwide to successfully optimize the hormone levels of women as they meander through the “seasons” of peri menopause and menopause and men as they traverse the “seasons” of andropause.

After monitoring outcomes for tens of thousands of men and women who have benefited from this therapy, we have found results have been better than expected with more than 96% of patients satisfied and with side effects much less than that quoted in literature.

Hormone replacement therapy (HRT) is used to treat menopausal symptoms in women and an-dropause symptoms in males. Most women who take HRT for menopausal reasons are given an estrogen/progesterone/testosterone combination, except those who have had a hysterec-tomy, as they may not need progesterone. HRT has shown to reduce fatigue, improve sleep, improve libido in women and sexual performance in men, decrease muscle loss and reduce body fat (Staland 78, Thom 81, Brincat 84, and Davis 95). It also has been shown to reduce irritability, anxiety and depression. The symptoms of osteoarthritis and rheumatoid arthritis are significantly reduced. Long term, men and women will have reduced incidence of Alzheimer’s disease, heart disease, and osteoporosis (Studd 90, Sands 97, Worboys 00). There are multiple studies showing the long term reduction in breast cancer in women using pellet therapy (No-telovitz 04, Glaser 2013)02) rather than increase in the incidence of breast cancer that has been associated with oral, synthetic methyl-testosterone (Tamimi 06). Even after over 20 years of therapy with hormone implants, the risk of breast cancer is not increased (Gambrell 06).

Hormone replacement therapy by pellet implantation has been used with great success in the United States, Europe and Australia since 1938, and has been found to be superior to other methods of hormone delivery (Greenblatt 49, Mishnell 41, Stanczyk 88). It is not experimental. Pellets deliver consistent physiologic levels of hormones and avoid the fluctuations of hor-mone levels seen with other methods of delivery like pills, creams, gels and synthetic injections (Greenblatt 49, Thom 81, Stanczyk 88). Pellets are superior to oral and topical hormone thera-py with respect to relief of menopausal systems (Staland 78, Cardoza 84).

Hormones delivered by the subcutaneous implants bypass the liver, do not affect clotting fac-tors and do not increase the risk of thrombosis (Notelovitz 87).

Testosterone and estradiol delivered by pellet implantation does not adversely affect blood pressure, glucose or liver functions (Burger 84, Barlow 86, Notelovitz 84, Stanczyk 88, Davis 95, Sands 97, Seed 00, Cravioto 01). In fact, testosterone and estradiol improved lipid profiles by reducing cholesterol, reducing triglycerides, and increasing HDL cholesterol (Davis 05). This has positive benefits on the cardiovascular system.


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Hormone replacement therapy with estradiol and testosterone implants is superior to oral and topical (both the patch and gel) hormone replacement therapy for bone density (Savvas 88, 92, Davis 95, Anderson 97). The pellets not only prevent bone loss but also actually increase bone density (Savvas 88, Studd 90, Garnett 91, Savvas 92, Naessen 93, Holland 94, Studd 94, Davis 95, and Anderson 97).

Testosterone replacement therapy in men with subcutaneous implants (pellets) has been shown to be extremely effective, convenient and safe (Handelsman 90, 92, 97, Kelleher 01, 04, Conway 88, Jockenhoval 96, Zacharin 03, Schubert 03, Dunning 04). The continuation rate continues to be 93% or above. This is excellent for long term compliance and exceeds the continuation seen with all other treatments for andropause.

The routine doses of testosterone delivered by pellet implantation in recent studies are be-tween 1000 and 2400 mg in men. The pharmacokinetics and pharmacodynamics are well established showing that these doses deliver reproducible physiologic levels of testosterone for 4-6 months. A 6-9 mg daily production of testosterone is a “physiologic” level produced by the testicle. Peak serum testosterone levels with the implants are usually seen at month one. Therapeutic testosterone levels at month one are expected at the upper limits of normal for healthy young males (900-1000 ng/dL). These levels are necessary to protect the brain from Alzheimer’s disease, diabetes, heart disease, prostate cancer, osteoporosis and all-cause mortality (Zitzman M. J Clin Endocrinology 2006). By month 4 to 5 testosterone levels drop to below 500-600 ng/dL at which time symptoms return and the pellets are reinserted. Each individual has their own reproducible levels where symptoms return.

Testosterone implants have been used in women in 5 continents for decades. Doses used in studies are as low as 50 mg and up to 225 mg (Glaser and Dimitrakakis Maturitas: 2004). Normal testosterone levels are not established in females (Fertility and Sterility 2002). Symp-toms return when testosterone levels reach the upper end of endogenous ranges (Burger 85). End organ response to testosterone remains optimal (i.e., relief of depression, increase in bone density, relief from insomnia, relief from aches and pains, lessened anxiety, improved memory and concentration, increased energy, etc.) when testosterone levels at 4-6 weeks after pellet insertion are 150-250 ng/dL. Steady state is subsequently achieved at approximately half of these levels equaling 80-120 ng/dL, which is in the physiologic to slightly supra-physiologic range. It is of primary importance to titrate the dose to achieve symptom relief and minimize side effects, not to achieve some phantom blood level. As women age, testosterone receptors become less responsive and more often than not, higher levels of testosterone are required to achieve the clinical outcome desired of symptom relief and long-term protection to the brain, breast, heart and bones. Some women require upwards of 300 ng/dL to achieve these results. Side effects from testosterone therapy in women are more of a nuisance and are reversible; there are no known long-term adverse effects in women, even at supra-physiologic levels.

Patient compliance becomes a non-issue using the pellet modality.

The method of sub-cutaneous hormone replacement therapy has been consistent throughout the literature. What was needed was a refinement of the pellets themselves. BioTE Medi-cal has established the “gold standard” in pellet preparation. We standardized the process


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and then used independent labs to assure proper density, purity, potency, sterility, dissolution rate, solubility and temperature tolerance; all of which significantly affect how well a patient responds to the therapy. This extensive safeguard allows us to supply pellets with only 3% tolerance for potency (i.e. our pellets when prescribed will nearly match that requested). This is in contrast to prescribed pills and creams which may have 10-30% tolerance. We use no fillers in our compounded pellets and as such purity testing is superior. No pellets are dispensed until sterility is certified and assured.

The literature is substantial supporting sub-cutaneous hormone pellet therapy as the superior method of hormone replacement in men and women. By using the BioTE dosing site (which is based on 30 years of clinical experience), by using the highest quality pellets made in the Unit-ed States, and by continuing to educate, supervise and monitor all BioTE practitioners, we at BioTE have made pellet therapy the superior method now scalable to practitioners and patients across the country. This has established the new standard of care for HRT.

BioTE has created innovative and industry leading protocols and processes in properly balanc-ing hormones using not only estradiol, testosterone, and progesterone, but also natural support supplements like Vitamins A, D & K, Iodine and DIM. The BioTE method also aggressively treats thyroid conditions, as those contribute greatly to overall hormone balance and the well-being of the patient. All serum levels are tracked pre and post insertion as well as annually.

BioTE tracks and monitors nearly 100,000 procedures performed annually by our network of Certified Practitioners throughout the United States and Puerto Rico. Any and all complications that may arise are also tracked and include conditions such as breast cancer, stroke, heart attacks, DVTs, endometrial cancer and prostate cancer.


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Weighing Treatment Options and Costs

Injectables

Female: $80 - 100 / month Male: $70 - 100 / month

Topicals


BioTE® Pellets


CONS: Painful injections Uneven absorption “Roller Coaster” effect Synthetic hormones Adverse effects (liver toxicity, heart disease) Wears off before next injection

CONS: Did you apply enough? Must use EVERY day for any effectiveness Problems with absorption (dosage) Transference (babies, pets, spouses) Have to appy alot to increase testosterone

levels after 12 months

CONS: Pelley insertion, minor procedure Metabolism, body utilizes pellet quicker

PROS: Natural, Non-synthetic Same molecular structure as human hormones Convenience - implanted a few times a year Steady, consistant dosage Individualized dosing Protective to brain, bones, breasts, heart


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Frequently Asked QuestionsWhat is BioTE®?BioTE® is a Bio-Identical form of hormone therapy that seeks to return the hormone bal-ance to youthful levels in men and women.

How do I know if I’m a candidate for pellets?Symptoms may vary widely from depression and anxiety to night sweats and sleepless-ness for example. You will be given a lab slip to have blood work done which will determine your hormone levels. Once the doctor reviews and determines you are a candidate we will schedule an appointment for insertion.

Do I have blood work done before each treatment?No, only initially and 4-8 weeks later to set your dosing. You may have it done again if there are significant changes.

What are the pellets made from?They are made from wild yams and soy. Wild yams and soy have the highest concentration of hormones of any substance. There are no known allergens associated with wild yams and soy, because once the hormone is made it is no longer yam or soy.

How long will the treatment last?Every 3-6 months depending on the person.

Everyone is different so it depends on how you feel and what the doctor determines is right for you.If you are really active, you are under a lot of stress or it is extremely hot your treatment may not last as long. Absorp-tion rate is based on cardiac output.

Is the therapy FDA approved?What the pellets are made of is FDA ap-proved and regulated, the process of making pellets is regulated by the State Pharmacy Board, and the distribution is regulated by the DEA and Respective State Pharmacy Boards. The PROCEDURE of placing pellets is NOT an FDA approved procedure. The pellets are derived from wild yams and soy, and are all natural and bio-identical. Mean-ing they are the exact replication of what the body makes.

How are they administered?Your practitioner will implant the pellets in the fat under the skin of the hip. A small incision is made in the hip. The pellets are inserted. Two to three small sutures are placed which will self dissolve.

Does it matter if I’m on birth control? No, the doctor can determine what your hormone needs are even if you are on birth control.


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Are there any side effects?The majority of side effects are temporary and typically only happen on the first dose. All are very treatable. There are no serious side effects.

What if I’m already on HRT of some sort like creams, patches, pills?This is an easy transition. The doctor will be able to determine your needs even though you may be currently taking these other forms of HRT.

What if I’ve had breast cancer?Breast cancer survivors and/or those who have a history of breast cancer in their family may still be a candidate; however, this is to be determined by the physician. You should schedule a consultation with the Doctor.

How often will I need pellets?For women: usually every 3-4 months. For men: usually every 4-5 months.

Why are pellets better than creams, patches, shots or pills?They are pure hormone that is not metabo-lized into byproducts by going through the

liver, stomach or skin. This delivery system allows your body to use the right amount of hormone from the pellet as the blood flow surrounding the pellets picks up what is needed.

Where do the pellets go?Because they are pure hormone without fillers or synthetic ingredients, they completely dissolve.

How long will it take for my body to get back to lean normal?That depends on how much you exercise and work out with weights, as well as your age. Testosterone decreases fat and increas-es muscle and lean body mass. Testosterone also increases your natural growth hormone and therefore will improve your stamina to work out and increase muscle mass.

I have no libido - what will this do for that, if anything?Good hormone balance will greatly improve your libido. The addition of testosterone in pellet form will change everything for the better!

Specifically for Women...

I get horrible headaches - will they help me?Yes! We have had great success, especially with women who have menstrual migraines, and new migraines that appear after age 35.

Do I need other medications?If you still have a uterus, you will need to be on natural progesterone as well.

Why do I need estrogen?Estrogen is the most important hormone for a woman. It protects her against heart attack, stroke, osteoporosis, and Alzheimer’s. It also keeps us looking young and healthy.


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Specifically for Men...Does testosterone cause prostate cancer?No. Metabolites of testosterone, Dihydrotestosterone and estrone cause prostate enlargement and contribute to prostate cancer. Estrone increases and testosterone decreases as men age and as men gain belly fat. Testosterone pellets are the only replacement that reverses that trend.

How do I take testosterone pellets and not convert them to Dihydrotestosterone and estrone?Your blood levels of estrone and DHT are checked after treatment to see if they are elevated. Some men still convert to these metabolites even on testosterone pellets. If they are converting, we troubleshoot with natural supplements such as DIM and Saw Palmetto, or an aromatase inhibitor prescription.

What if I have prostate enlargement already?Testosterone pellets will make it better, if you do not convert it to DHT; we will treat that if it happens.

Will my testicles shrink while I take the testosterone pellets?Yes, they will. Testicles are suppressed by taking any kind of testosterone and they will not make as much testosterone while the pellets are working. This is not permanent and the testicle re-tains its ability to produce testosterone.

Why do I need testosterone?Testosterone is the third female hormone and is as essential as estrogen and progesterone.We need this hormone to keep our thought process quick and our libido healthy. It improves bone density, muscle mass, strength and prevents some types of depression. It is also the source of energy and solid sleep!

Will I grow unwanted hair from testosterone?Facial hair will grow with testosterone pellets, but normally no more than when you were in your thirties.


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BHRT Checklist for WomenName: _________________________________________ Date: ________________

E-Mail: ________________________________________

Symptom (please check one) Never Mild Moderate Severe

Depressive mood . . . . . . . . . . . . . L L L LFatigue . . . . . . . . . . . . . . . . . . . L L L LMemory loss . . . . . . . . . . . . . . . . L L L LMental confusion. . . . . . . . . . . . . . L L L LDecreased sex drive/libido. . . . . . . . . L L L LSleep problems . . . . . . . . . . . . . . L L L LMood changes/irritability. . . . . . . . . . L L L LTension . . . . . . . . . . . . . . . . . . . L L L LMigraine/severe headaches . . . . . . . . L L L LDifficult to climax sexually . . . . . . . . . L L L LBloating . . . . . . . . . . . . . . . . . . L L L LWeight gain. . . . . . . . . . . . . . . . . L L L LBreast tenderness . . . . . . . . . . . . . L L L LVaginal dryness . . . . . . . . . . . . . . L L L LHot flashes . . . . . . . . . . . . . . . . . L L L LNight sweats . . . . . . . . . . . . . . . . L L L LDry and wrinkled skin . . . . . . . . . . . L L L LHair is falling out . . . . . . . . . . . . . . L L L LCold all the time . . . . . . . . . . . . . . L L L LSwelling all over the body . . . . . . . . . L L L LJoint pain. . . . . . . . . . . . . . . . . . L L L L

Family HistoryHeart disease . . . . . . . . . . . . . . . LYes LNoDiabetes . . . . . . . . . . . . . . . . . . LYes LNoOsteoporosis . . . . . . . . . . . . . . . . LYes LNoAlzheimer’s disease . . . . . . . . . . . . LYes LNoBreast Cancer . . . . . . . . . . . . . . . LYes LNo


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Name: _________________________________________ Date: ________________

E-Mail: ________________________________________

Symptom (please check one) Never Mild Moderate Severe Decline in general well being. . . . . . . . L L L LFatigue . . . . . . . . . . . . . . . . . . . L L L LJoint pain/muscle ache . . . . . . . . . . L L L LExcessive sweating . . . . . . . . . . . . L L L LSleep problems . . . . . . . . . . . . . . L L L LIncreased need for sleep. . . . . . . . . . L L L LIrritability . . . . . . . . . . . . . . . . . . L L L LNervousness . . . . . . . . . . . . . . . . L L L LAnxiety . . . . . . . . . . . . . . . . . . . L L L LDepressed mood. . . . . . . . . . . . . . L L L LExhaustion/lacking vitality . . . . . . . . . L L L LDeclining mental ability/ focus/concentration . L L L LFeeling you have passed your peak . . . . L L L LFeeling burned out/hit rock bottom . . . . L L L LDecreased muscle strength . . . . . . . . L L L LWeight gain/belly fat/inability to lose weight . . . . . . . . . . . . . . . . . L L L LBreast development . . . . . . . . . . . . L L L LShrinking testicles . . . . . . . . . . . . . L L L LRapid hair loss . . . . . . . . . . . . . . . L L L LDecrease in beard growth . . . . . . . . . L L L LNew migraine headaches . . . . . . . . . L L L LDecreased desire/libido . . . . . . . . . . L L L LDecreased morning erections . . . . . . . L L L LDecreased ability to perform sexually . . . L L L L Infrequent or absent ejaculations . . . . . L L L LNo Results from E.D. medications . . . . . L L L LFamily History Heart disease . . . . . . . . . . . . . . . LYes LNoDiabetes . . . . . . . . . . . . . . . . . . LYes LNoOsteoporosis . . . . . . . . . . . . . . . . LYes LNoAlzheimer’s disease . . . . . . . . . . . . LYes LNo

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About the AuthorDr. Elliott grew up in Omaha, Nebraska, the fourth generation in medicine. He attended John Hopkins University Undergraduate, University of Nebraska College of Medicine for medical school, and University of Iowa Hospitals, Department of Dermatology for Residency. He was trained in hair trans-plantation in 1971, while a Dermatology Resident. Over the years, he invented many things which advanced the process of hair transplantation. He has always been at the forefront of the latest technology. You can rest assured that the techniques used at Pacif-ic Hair have been and will continue to be the latest technology available. He is a Diplo-mate of the American Board of Hair Restoration Surgery.

Dr. Elliott began his interest in Endocrinology by reading the Merck Manual in his grand-father’s office (the Endocrinology section) when he was 9 years old. He has always been fascinated by the many effects that the endocrine system has in controlling the human body. He was trained in bioidentical hormone replacement by Dr. Neal Rouzier in the 1990s. He has practiced bioidentical hormone replacement for his patients since. He has recently been additionally certified by Dr. Gary Donovitz’s BioTE company for the inser-tion of pellets containing either testosterone or estradiol, which are an improved method of delivering constant blood levels of hormones (which exceed the ability of hormones delivered through the skin). He lives in Orange County and is the founder of Pacific Hair Institute and Pacific Longevity Institute.


James S. Calder M.D.James S. Calder is a graduate of Creighton University Medical School. He trained in Physical Medicine & Rehabilitation at the University of Minnesota and became Board certified in PM&R.

Dr. Calder has been practicing since 1986, the last 16 years within the field of cosmetic surgery where he specializes in the surgical and non-surgical treatment of hair loss of both men and women, and bio-identical hormone replacement.

Trained by some of the most experienced and accomplished practitioners of this art in the world, Dr.Calder’s experience has grown to over 8000 cases of follicular unit trans-plantation ( FUT ) and follicular unit extraction ( FUE ) and includes expertise in the acquisition and location of hair to and from non-traditional sites inclusive of eyebrows, facial hair and beard transplantation. He lives in West Los Angeles.

Dr. Elliott and wife, Cindy - Oscars 2016

Dr. Calder and family - Christmas 2016


Privacy Notice. Your photos are never posted where the public can see them. All pho-tos submitted to us are held in strict confidence as part of your medical record. Any patient whose photos appear on the website have given us their permission and signed a model´s release.

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TeleMedicine Consultation: InstructionsFor a virtual consultation, tear out the pages 75-79, fill out and mail or fax to our office

You will need to submit a series of photos of your head (samples below; phone pics okay): front, back, both sides, and top. These can be emailed as attachments or texted to the office iPhone.

Please be sure to hold a card with your name on it so that it is visible in at least one of the photos.

FAX: (657) 394-0087MAIL: 3140 Redhill Avenue, Suite 260, Costa Mesa, CA 92626EMAIL: [email protected]: (949) 220-4160 (phone pics)DEBRA: Office iPhone (949) 423-5950 cell for text

Please take your photos like the samples below


TeleMedicine Consultation: Tear-out/Mail Page 1 of 3

B I O G R A P H I C A L D A T A

Originating office: ____________________ How did you hear about us? ________________________

Name: ___________________________________ Date: ___________________________________

Birthdate: ________________________________ Age today: ________ Marital Status: ________

Address: ____________________________________________________________________________

City: _____________________________________ State:______________ Zip: _________________

Cell Phone: ______________________________ E-Mail Address: __________________________

Occupation: ______________________________

H I S T O R Y O F H A I R L O S S A N D P R I O R T R E A T M E N T S

Hair loss began at age: ___________________

Current hair loss: L is continuing Lhas slowed down Lhas stabilized

if stabilized, for how long? _______________________

Any prior procedures (transplant, scalp reduction, etc.) for hair loss?

Date: ______________ Type: _________________ MD: _______________ City: _____________

Date: ______________ Type: _________________ MD: _______________ City: _____________

Date: ______________ Type: _________________ MD: _______________ City: _____________

Date: ______________ Type: _________________ MD: _______________ City: _____________

List any other previous treatments and / or medications for hair loss: __________________________

___________________________________________________________________________________

___________________________________________________________________________________

Using a hairpiece? LNo L Previously LCurrently

List all current medications for hair loss: __________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

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F E E L I N G S A B O U T H A I R L O S S

1) Are you very concerned about the appearance of your hair loss or other parts of your body which you consider especially unattractive?. . . . . . . . L YES L NO

•IFYES:Dotheseconcernspreoccupyyou?(Thatis,youthink about them a lot and wish you could worry about them less.) . . . . . . . . . . . . . . L YES L NO

•IFYES:Whatspecificallybothersyouabouttheappearanceofyourhairloss or other parts of your body? Please explain in detail:

_________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

NOTE: If you answered “NO” to either of the above questions, go to the Family History section on next page. Otherwise continue below.

2)Whateffecthaveyourfeelingsaboutyourhairlossorotherpartofyourbodyhadonyourlife?

Have your feelings about your hair loss or other part of your body often caused you a lot of distress, torment or pain? . . . . . . . . . . . . . . . . . . . . . . . . L YES L NO

Have your feelings about your hair loss or other part of your body significantlyinterferedwithyoursociallife?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L YES L NO

Have your feelings about your hair loss or other part of your body significantlyinterferedwithyourschoolwork,yourjob,oryour ability to function in any other responsibility in your life?. . . . . . . . . . . . . . . . . . . L YES L NO

•IFYES:How? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

Are there things that you avoid because of your hair loss? . . . . . . . . . . . . . . . . . . L YES L NO

•IFYES:Whatarethey? _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

3)Howmuchtimedoyouspendthinkingaboutyourhairlossorotherpartofyourbodyperdayonaverage? LLess than 1 hour a day L1-3 hours a day LMore than 3 hours a day

Have the lives or normal routines of your family or friends been affectedbyyourhairlossorotherpartofyourbody? . . . . . . . . . . . . . . . . . . . . . . . L YES L NO

•IFYES:Explain ____________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________

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M E D I C A L H I S T O R Y

C H R O N I C C O N D I T I O N S

P H Y S I C A L M A K E U P

FAMILY HISTORY OF HAIR LOSS (Put number in each blank below of closest hair loss classification on next page)

Father: ______________ Grandfather/F: _______________ Grandfather/ M: _____________

Uncles/F _____________ Uncles/ M: __________________ Brothers: ___________________

MEDICAL HISTORY

Allergies: _______________________________ Reactions: _________________________________

Other surgeries: _________________________ General Anesthesia: _________________________

Chemotherapy treatments? _______________ High fevers? _______________________________

Crash Diets? ____________________________ Howoftendoyousmoke? ___________________

Alcoholicdrinks(weeklyavg.): ______________ Nutritional supplements/vitamins: _____________

List all current medications:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

My diet is: LGood LFairLPoor

CHRONIC CONDITIONS

Heart: ______________________ Diabetes: ______________ SkinInfect. ______________

Keloids: _____________________ Fainting: _______________ Epilepsy: ________________

ImmuneDeficiency: ___________ High BP: _______________ Bleeding Problems: _______

Hepatitis: ____________________ Psoriasis: _______________ Seborrhea: ______________

Cancer: _____________________ Bloodtypeifknown: _______ Nervousness: ____________

Depression: __________________ SkinSpots ______________ SkinCancer ______________

Ancestory(i.e.Polish,Italian,etc.): ______________________

Color of hair as a teenager: ___________________________

Colorofskin: LFairLMedium LDark

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XMASPatternFemaleLudwigPattern’sI,II,andIII

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Number of grafts LFUTLFUE

LMonoFU #_______ _ _________ ___________

LDuo #_______ _ _________ ___________

LMDT # ________ _________ ___________

Overall area: R1 = _________ R2 _______________

Diagnosis: ____________________________________

_____________________________________________

_____________________________________________

DiffuseThinning? ______________________________

Probable future progression to: Class ______________

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Notes: ____________________________

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Pattern Alopecia is a progressive disorder which effects both men and women. No one can be sure how far it will progress.

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80PHYSICIAN USE ONLYPercentageofthinning: FRONT: ____________ TOP: ____________ VERTEX: ______________

Widthofthinning(cm): FRONT: ___________ TOP: ____________ VERTEX: ______________

Hairline length (cm): ________________________ Thinning length ( cm ): ______________________

Densitometry: Occip. _______ Temp. _______ Hair pull: _____________ hairs (normal 3/15)

Scars (Describe, if any): ________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

Condition of scalp: LNormal LScaled

Density of hair: LSparse LAvg LDense

Texture of hair: LFine LMed LCoarse

Curliness of hair: ____________________________

DiffuseThinning: ___________________________ Pattern: ________________________________

Amount of posterior sideburn hair (cm): __________________________________________________

Donor availability: BACK: LPoor LFair LGood L Exc

SIDES: L Poor LFair L Good L Exc

Prior donor depletion: _________________________________________________________________

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Patient Name: _________________________________________________ Date: _______________________

L You are a good candidate for these procedures.L Previous hair restoration procedures by other physicians have resulted in problems which may impede

yourfinalresults.L Your donor hair is limited relative to the size of the balding area.L Youhavesomedegreeofdiffusethinningandneedabloodworkup,and/orbiopsyL You need medical treatment.Usually, the interval between hair transplant procedures is 12 months. This is to allow time for the skin to remodel and smooth itself, and for hair to grow out. Of course, healing rates vary, so your interval could be more or less. Usually, 1-3 transplant sessions are needed in any one area, depending on the density desired by the patient. For example, 1-3 sessions are needed for the hairline, the top, and the crown. However, hairline, top, and crown may be transplanted simultaneously. Further, as hair loss progresses, touch-up sessions may be needed in the future to fill new areas of hair loss surrounding the previously transplanted area.

PAYMENT FOR SERVICESThere is $650 non-refundable scheduling fee.The surgical fee is due one week prior to surgery. Pacific Hair Institute accepts Discover, Visa, MasterCard and American Express. Credit cards in the name of a person other than the patient are not accepted unless that per-son is also present to sign for the charge. (We prefer no Amex.)Discover, Visa, MasterCard and American Express must be charge one week before surgery. Credit card companies are taking 3-4 days to pay. Please phone in your credit card information to our scheduling department. Cash, certified or cashier’s checks are also accepted. Because of interstate banking regulations, we DO NOT AC-CEPT PERSONAL CHECKS except 7 days prior to surgery. If you wish long-term financing, your Patient Services Director will assist you.

Rx Session One ____________ Grafts at __________________________________

Session Two ____________ Grafts at __________________________________ Fees $ ________________ per session plus $650 scheduling fee

To schedule surgery: You need to pay $1000 of the procedure fee (below) as a deposit, including $650 non-re-fundable scheduling fee, which is not refunded if you cancel, but will not be charged again if you reschedule.Balance due one week before surgery.* All post-operative visits every three to six months are included. Lab and prescriptions are paid directly to the pharmacy and are not part of the surgical fee. Lab and prescription fees are usually $100-150 for each and are usually covered by your insurance.

2017 DISCOUNTED FEES

Eyebrows (2) 3000.00**

Minimum per case 3000.00

Consults 250.00

Hylenex 85.00

Exparel (1 or 2) 400.00

Laser Cap 900.00

M82 (2 months) 110.00

PRP Treatment 800.00

ACell Treatment 400.00

Hormone EvaluationDoctor Consultation 250.00

Lab Tests (special rate) 350.00 (approx)

Private Dayper graft 12.00

plus 650.00 scheduling fee includes

housecalls for consultation and

post operative follow-up

FUT 5.00 per graftNeograft FUE 7.00 per graft

Special rates available for standby dates. Contact office

BEFORE SURGERY INSTRUCTIONS

Your cooperation is necessary in carefully following all the instructions below. This will allow us to provide you with the highest quality medical care, as well as expedite your procedure for your comfort. Please call our office if you have any questions.

PREOPERATIVE LAB TESTS (if needed):Blood tests prior to your procedure are sometimes needed, the Doctor will advise you: A ______ HIV, SURFACE ANTIGEN (for Hepatitis B), HEPATITIS C ANTIBODY,

VDRL B ______ CBC C-1 ______ MALE – Total & Free Testosterone, DHEA-S, Free T3, Free T4,TSH, PSA

(Total and Free), IGF-1, (Somatomedin C), DHT, Estradiol, Iron, ANA C-2 ______ FEMALE –Total & Free Testosterone, phototyping for xxy, DHEA-S, Free T3,

Free T4, TSH, IGF-1, (Somatomedin C), DHT, Progesterone, Estradiol, Iron, ANA D ______ Written pre-op clearance by regular physician

• The test may be sent to our outside lab, or your personal physician can do it. Lab charge is approximately $150 for group A and $300 for group C. If you want to bill your insurance, you need to send the paid lab bill to your insurance company for reimbursement.

• These tests need to be drawn at least two weeks or more prior to your first appoint-ment for a procedure.

• If you can have these tests run at your private physician’s office or lab, have the phy-sician or lab mail or fax a copy to us. (A fax is preferred; simply call the office for our fax number). It is necessary that your name be on the lab report. If you have Medi-care, have your personal MD run the tests.

• Lab costs are not part of the surgery fee.

CANCELLATION or NO SHOW POLICY:Procedures are booked in advance. We must have at least 2 weeks notice if you wish to cancel or change your appointment. The $1,000.00 scheduling fee is non-refundable, but will apply if you reschedule

DAY OF SURGERY:• Plan not to work the day of surgery and at least the next two days.• Shampoo your hair the night before and morning of surgery with Head and Shoulders

Smooth & Silky. Shampoo twice. Rub your scalp vigorously while shampooing. Do not put anything on your hair after shampooing.

• Eat a good breakfast or lunch before arriving. Do not fast.• Arrive at the office a few minutes before your surgery appointment.

MEDICATIONS:If you were given prescriptions in advance, bring them with you and use as directed. If not, we will have the prescriptions delivered to our office the day of your surgery or taken to your HMO or pharmacy. Best is to have them delivered as some pharmacies may not have all the needed prescriptions.

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OTHER COMMENTS:• Sleep elevated the first few nights on two to three pillows and a

neck pillow.• Couvre & Dermatch are scalp masking covers. You may order Cou-

vre by calling 1-800-443-4521. (Useful if you will be on camera.) Style Edit best. Available from Natalie at Soho Salon in Newport Beach (949) 232-7631. Sprays on, dries waterproof.

• You will also need to have stitches removed in approximately 12-14 days at our office, or by your local physician. (FUT only)

• The Hair Transplant procedure will result in crusts on your head for 5-14 days – usually 6.

CLOTHING:Wear a button shirt to your procedure. We will provide you with a disposable hat after your procedure. Obtain five (5) other freshly washed hats to wear. You will need a clean hat each day for the next 2-3 weeks. You can purchase a hat frame to wash hats in the dishwasher.

DRIVING HOME AFTER YOUR HAIR TRANSPLANT:Pacific Hair advises each patient that it is illegal to drive a car or operate a vehi-cle under the influence of narcotic pain medication. For a few hours after your hair transplant, the injectable medication given during your procedure generally eliminates all pain. After that, you will probably experience enough discomfort to warrant taking the narcotic medication we prescribe on the first night.In the event that you need to drive longer than half an hour after you leave our office, you are advised to have someone else transport you to your destination. If this is not possible, we recommend that you obtain lodging near our office.Note: Remember, you will usually need to return to the office 1-3 days later for a check-up. If you have traveled from out of town, please make arrangements to stay overnight somewhere near the office so that it is convenient for you to return the morning after your procedure. A ride can be provided for you, if you call to arrange this in advance with our office. A full hotel list is available by fax from our staff.

Smoker’s Warning: You shouldn’t smoke at least ten days before & after your procedure (or just quit). If you smoke, you may develop large crusts in your central scalp, minor infec-tions, minor dents under crusts, slow healing, and slow growth. If you start again, you will slow hair growth. So, at least, minimize your smoking.


DO NOT TAKE ANY OF THE MEDICATIONS LISTED ON THIS PAGEDURING THE 5 DAYS BEFORE EACH PROCEDURE.

THESE ORALLY ADMINISTERED MEDICATIONS MAY INCREASE BLEEDING TIMEDO NOT take preparations that contain aspirin or salicylic acid derivatives*

AnacinAspergumAspirinAspirin with codeineAspirTabBayer aspirinBayer children’s cold tabletsBuffaprin

BufferinChildren’s aspirinExcedrinFiorinalFiorinal with codeine4-Way Cold tabletsGoody’s Extra StrengthGoody’s Headache Powder

Meprobamate and aspirinMidol for cramps, maximum strengthMidol OriginalP-A-CWesprin Buffered

Aches-N-Pain (ibuprofen)Addaprin (ibuprofen)Advil (ibuprofen)Anaprox (naproxen sodium)Anaprox DS (naproxen sodium)Ansaid (flurbiprofen)Butazolidin (phenylbutazone)Clinoril (sulindac) CoAdvil (ibuprofen)Dolobid (diflunisal)Dristan Sinus (ibuprofen)Feldene (piroxicam)Genpril (ibuprofen)

Haltran (ibuprofen)IBU (ibuprofen)IBU-TAB (ibuprofen) Buprin (ibuprofen)Ibuprohm (ibuprofen)Indocin (indomethacin)Lodine (etodolac)Medipren (ibuprofen)Menadol (ibuprofen)Midol 200 (ibuprofen)Motrin (ibuprofen) Motrin IB (ibuprofen)Nalfon (fenoprofen calcium)Naprosyn (naproxen)

Nuprin (ibuprofen)Orudis (ketoprofen)Pamprin-IB (ibuprofen)PediaProfen (ibuprofen)Rufen (ibuprofen) Saleto-200 (ibuprofen)Tolectin (tolmetin sodium)Trendar (ibuprofen)Ultraprin (ibuprofen)Unipro (ibuprofen)Valprin (ibuprofen)• Other new preparations

DO NOT take preparations that contain nonsteroidal anti-inflammatory agents**

*** NOTIFY US IF YOU TAKE ANY BLOOD THINNERS ***DO NOT STOP ANY MEDS WITHOUT YOUR PRIMARY PHYSICIAN’S OKAY

N O A S P I R I NDO NOT TAKE VITAMINS OR PROTEIN SUPPLEMENTS IN THE WEEK BEFORE EACH PROCEDURE

* ASA = acetylsalicylic acid = aspirin

** The trade names are followed by the generic names in parentheses.

Note: We advise discontinuing the use of Rogaine one day before and two weeks after your procedure, and it is not necessary to stop Propecia if you take it.

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AFTER SURGERY INSTRUCTIONS

WARNING! - DO NOT DRIVE OR DRINK ALCOHOL WHILE TAKING PAIN MEDICATION, ATARAX, VALIUM OR AMBIEN. Do not drive, ride a vehicle, or otherwise put yourself in any position where alertness and balance are essential while you are taking your pain, muscle relaxant and/or sleeping medications, such as Valium (Diazepam), Ambien, Tylenol with Codeine, and Vicodin. All medications need to be taken after eating to avoid nausea and/or upset stomach.

MEDICATIONS:1. After surgery you will receive a prescription for antibiotic cap-sules or tablets. These are usually Cephalexin, Cipro, Ery-C or Bactrin DS. Take them as instructed.2. After surgery, you will also receive a prescription for Mupirocin (Bactroban), an antibiotic ointment. Apply a thin coat to the graft and suture areas daily after shampooing on post-op days 4, 5 and 6.3. You were given a prescription to control discomfort before you left the office. This is usually Norco, Vicodin, or Percocet. Use it as instructed on the label. Take Atarax (for nausea, itching, and sleep) with it, if so instructed.4. ITCHING: Take Atarax for itching. Do not drive as it will make you drowsey.5. You can use an ice pack on your donor area for comfort and on your forehead to reduce swelling. If you get swelling, use an ice pack for 10 minutes 1 or 2 times an hour for the first 1-3 days. (Fro-zen peas in a bag work well, if you do not have an ice pack.) You will probably not get swelling,

6. Zofran is for nausea.

Note: DO NOT put ice on your grafts. Your Doctor or Nurse will review meds at discharge

MEDICATION INSTRUCTIONS:• Cephalexin 500 mg. (Substitute with Bactrim or Cipro if allergy). Take one (1) capsule every morning

and evening until gone. This prevents internal infection. Start after you get home the first night. Take with food. You were given a capsule at the office before surgery.

• Bactroban Ointment (Mupirocin). Apply thin coat to your stitches (sutures) and grafts daily after sham-poo on days 4, 5 & 6.

• Norco (Hydrocodone) Take one-two every four hours for discomfort. Start 1-2 hours after surgery. After 24 to 36 hours, three - four (3-4) Advil/Motrin should be sufficient.

• Restoril (Temazepam) This is for sleep. Request prescription if needed.

• Shampoo: Head and Shoulders Smooth & Silky, no conditioner.

• Atarax (Hydroxizine): Take for itching. Take with Norco to prevent nausea.

• Fioricet: Take two every six hours for headache. May take with Norco if needed the first night.

• Zofran ODT: Dissolve under tongue for nausea.

CLEANING GRAFTS AND SUTURES:Do not use pure alcohol or pure peroxide to clean your grafts. This could kill the grafts!

TRADE NAME GENERIC NAME

Tylenol . . . . . . . Acetaminophen or APAP

Valium. . . . . . . . Diazepam

Vicodin . . . . . . . Acetaminophen with Hydrocodone

Norco . . . . . . . . Acetaminophen with Hydrocodone

Toradol . . . . . . . Ketoralac Tromethamine

Talwin . . . . . . . . Pentazocine

Restoril . . . . . . . Temazepam

Atarax . . . . . . . . Hydroxyzine

Zofran ODT. . . . Ondansetron

Percocet . . . . . . Acetaminophen with Oxycodone


C A R E A N D C L E A N I N G O F G R A F T S A N D S T I T C H E S :

FIRST NIGHT INSTRUCTIONS & MEDICATIONS1. Pain Medication: Atarax is for nausea, itching, sedation and swelling. Take one Atarax with each Norco. Take the

first Atarax as soon as you get home, then eat something, then begin taking your pain pill after four to five bites of food.

2. Norco Doses: A) Up to 200 lbs body weight; 1-2 every 4 hours for pain as needed. B) Over 200 lbs body weight; 2-3 every 4 hours for pain as needed for FUT, probably one for FUE.

3. Ice (This is optional): Use a bag of frozen peas alternating between forehead and donor site at one-half hour intervals. Have three to four bags so you can keep a frozen one in use. Continue this for the first two days. DO NOT put ice on grafts.

4. Position: You need to keep your body and head propped up at least 30 degrees for the first few nights. You can use a reclining chair or a stack of three pillows, or an arm chair pillow (see photo next page). Also, you may have an air pillow for use around your neck. Use the air pillow for at least the first three days. This prevents your grafts from rubbing on the pillow case. Put a clean pillowcase on every night.

5. Oozing: Slight oozing of the donor is normal. This would appear as red, clear, or amber translucent bubbles. These should be blotted with the provided 4x4 gauze which you were given. By blotting these gently, you will prevent larger crusts. For continuous oozing, apply gentle pressure for 30 minutes using a damp gauze.Or lay an ice pack under the oozing area for 60 minutes. A medical staff member will clean the crusts at the office in the morning if needed.

6. Shampoo: None the first 3 nights.

1ST THROUGH 3RD DAY AFTER SURGERY (72 hours post-op) Shower from ears down leaving ointment on

grafts and stitches

4TH THROUGH 6TH DAY AFTER SURGERY Shower, letting water run full force on top of

head; shampoo sides of head and around stitches. It’s OK if shampoo gets on grafts, gently dab to dry. Then continue dabbing Mupirocin ointment to grafts and stitches. DO NOT RUB GRAFTS UNTIL DAY 7.

Recommended vitamins (Dr E. uses these products himself)

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C A R E A N D C L E A N I N G O F G R A F T S A N D S T I T C H E S :

7TH THROUGH 14TH DAY AFTER SURGERY1. Resume shampooing in a full strength shower. Let water flow on head for about 10

minutes to soften scabs. Apply shampoo & use FINGERTIPS or SPONGE in gentle circular motion on BOTH grafts & stitches. Stop ointment.

2. Resume normal exercise routine. Do not hit your head.

3. You may begin to use cosmetic coverups such as Dermatch or Couvre.

4. Freshly washed pillowcase daily.

5. DO NOT PICK OR FORCE OFF CRUSTS. Crusts will generally be gone in 10 to 14 days.

6. Sutures are removed from your donor site after 12-16 days. You have an appointment for this. We will remove any crusts that remain at this visit.

7. Hypoallergenic skin tone cosmetics can be used to hide pinkness.

8. You may resume Rogaine, starting on the 14th day, if you have used it before your procedure, or continue the Minoxidil 2.5 mg pill (Rogaine) throughout the procedure.

FOLLOW-UP: Your first follow-up visit is1-4 days after surgery. Suture removal is 12-16 days. The doctor will want to see you at five months and then annually. No sutures on FUE.

ACTIVITY: Avoid any activity that may result in hitting your head, such as contact sports, piggy back rides for kids, etc. Be careful getting into and out of cars.

WEIGHTLIFTING: After first 5 days, weight lifting can be resumed. Cut back 25% and work back to normal weights after stitches are removed.

EXERCISE: Jogging, running, golfing, tennis, etc. is OK - AFTER 5 days.

SWIMMING: In pool after 7 days or in ocean/lake after 14 days.Always shower/shampoo after swimming.

AVOID SUNBURN: Use hat or sun block outdoors for 30 days in summer.. Wear a fresh-ly washed hat when outside for 2-3 weeks.

To help keep swelling down, sleeping with your head up, on both of these pillows is recommend-ed. These may be purchased at K-mart or Wal-Mart.

Photo A3 - Showing swelling. You could have similar swelling for 2-5 days post-op.

Photo A4 - Swelling may be accompanied by black eyes.


Day 1 Day 2

Day 3 Day 4

Day 5 Day 6

Day 7 Day 8

The following series of photographs depicts the pro-gression of graft healing during an 8 day period. Photo-graphs were taken for 8 consecutive days. Patient had transplant procedure within the hairline area.

A typical well-healed, post-op-erative donor scar of 2-5 mm in width. In old techniques, this could be up to 10 mm in width. These can later be filled with FUE.

Patient J.C. Pre-Op

Crusts will form over the newly transplanted grafts as seen in this photograph.

Patient J.C. After two years.

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NORMAL EVENTS ASSOCIATED WITH PROCEDURE

You may get some swelling of the face. This usually begins on the second day after surgery. It is most common when grafts are placed in the front of the head. DO NOT lie flat until the swelling is gone. Keep your head up. The longest known time for swelling to last is five days. You have been given steroids to help prevent swelling. You do not need more steriods. Sitting up and using ice packs are your best defense against swelling. Atarax also helps. SLEEPING: Sleep sitting up at a 30 degree angle until the swelling is gone. Use pain medication to help with discomfort. Request a prescription for sleep if needed. Purchase bed chair, see photo. Use of a recliner or four or five pillows are other options. Use ice packs on forehead 10 minutes every 30 to 40 minutes while awake for the first three (3) days. A bag of frozen peas works well for an ice pack. Wrap ice pack in a towel or wash-cloth. ITCHING: Atarax (Hydroxizine) 25 mg by mouth at bedime will relieve itching which may occur after a few days. NUMBNESS or tingling is usually temporary and will usually disappear in a few to several months. It is the result of cutting nerves during the course of the surgery. In donor harvesting, occasionally, an area will persist with permanent loss of feel-ing. THE FIRST NEW HAIRS APPEAR IN 3 MONTHS. Hair in the grafts will disappear 2 to 3 weeks after the procedure. The follicle, which is responsible for growth, remains. You must be patient. It will take several months for the hair to start growing again and reach styling length. After several procedures, grafts will take longer to begin growing.

MINOR COMPLICATIONS ASSOCIATED WITH PROCEDURE

BLEEDING: Apply direct pressure with icepack to stop. If bleeding continues, apply the same pressure again and call the office which will forward to the Pacific Hair answering service. GRAFT COMES OUT: If clean, put in saline solution (available at pharmacy), call for appointment (must be within 1-3 days) for reinsertion. If soiled or lost, let site heal, use ointment. We will replace with next treatment . RAISED OR RED AREA: If area with pimple-like appearance occurs 3-5 days after surgery, call the office for a follow-up appointment. Apply Bactroban ointment to the area and keep clean.

Smoker’s Warning: You shouldn’t smoke at least ten days before & after your procedure (or just quit). If you smoke, you may develop large crusts in your central scalp, minor infec-tions, minor dents under crusts, slow healing, and slow growth. If you start again, you will slow hair growth. So, at least, minimize your smoking.


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Robert Michael Elliott, M.D., FAACS Procedural Dermatology

Fellow, American Academy of Cosmetic Surgery Fellow, Royal Society of Medicine Diplomate, American Board of Hair Restoration Surgery

James S Calder, MD, FAAPM & RDiplomate, American Board of Physical Medicine & Rehabilitation

BEVERLY HILLS • WEST LOS ANGELES 1125 S. Beverly Dr., Suite 410 Los Angeles, CA 90035 (310) 914-4000 • FAX (424) 274-3931 Text (949) 378-1400 email: [email protected] NEWPORT BEACH AREA 3140 Redhill Ave, Suite 260 Costa Mesa, CA 92626 (949) 263-0800 • FAX (657) 304-0084 Text (949) 423-5950 email: [email protected] SAN FRANCISCO • UNION SQUARE 500 Sutter Street, Suite 510 San Francisco, CA 94102 (415) 986-1866 Text (949) 423-5950 email: [email protected]

PALM DESERT (760) 887-2344

LA JOLLA (760) 887-2344 to send Phone Pics to DR. E (949) 220-4160

to request complimentary DVD, call (949) 263-0800

Directory

After Hours (Direct)949-263-0800

Long Distance, in the U.S.A

(800) 990-HAIR

www.pacifichairinstitute.com


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Office Locations

Newport Beach Area3140 Redhill Ave., Suite 260 • Costa Mesa • CA 92626 (near Hilton on Bristol)Phone: (949) 263-0800 Fax: (657) 304-0084


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Office Locations

Beverly Hills • West LA1125 S. Beverly Drive, Suite 410 • Los Angeles • CA 90035 (across from Marriott)Phone: (310) 914-4000 Fax: (424) 274-3931

San Francisco • Union Square500 Sutter Street, Suite 510 • San Francisco • CA 94102 (across from Sir Francis Drake)Phone: (415) 986-1866

Sutter Street

Pow

ell


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DIM 60 Count $45.00

DIM is a natural aromatase inhibitor. It is not as potent as the pills Femara or Arimidex. It is a good choice for men who convert a little too much of their testos-terone to estradiol. Men need to have a reasonable level of estradiol in the 30-70 range, and so using DIM rather than one of the stronger pills is usually a good choice unless the person is a very strong aromatizer.

Iodine Plus 180 Count $40.00

Supplemental iodine is taken to make your thyroid work better, since the world has re-moved iodine in salt in recent years. In the last century, insufficiency iodine was the most common cause of thyroid disease.

ADK-10 90 Count $39.00

The reason to take the ADK vitamin com-plex is because it contains 10,000 units of vitamin D3 and vitamin K2. Vitamin K2 is protective of taking too much D3 so that you don’t get too much calcium leading to kidney stones. Of course, vitamin A is for healthy skin. Vitamin K2 also helps to reduce the deposition of calcium in your arteries, and so it is protective for cardiac disease.

Probiotic 60 Count $22.00

Omega 3 60 Count $24.00

WP THYROID

32 mg (1/2 grain) 100 Count $30.00

32 mg (1/2 grain) 1000 Count $250.00

65 mg (1 grain) 100 Count $40.00

65 mg (1 grain) 1000 Count $300.00

PELLETS

Female $540.00

Male $1040.00

Male >2000 mg $880.00

WEST PACIFIC MEDICAL LABORATORY

Female New Patient Pre-Pellet $228.50

Female Post Pellet $65.00

Female Post Pellet w/Thyroid Rx $144.00

Female Post Pellet w/Thyroid Rx & w/o TPO $122.00

Male New Patient Pre-Pellet $223.50

Male Post Pellet $78.50

Male Post Pellet w/Thyroid Rx $157.50

Male Post Pellet w/Thyroid Rx and w/o TPO $135.50

NEUTRACEUTICALS.WP THYROID


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NEUTRACEUTICALS.WP THYROID ORDER FORM

DATE: ________________________ DOB: _____________________

NAME: ______________________________________________________________________

ADDRESS: __________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

ITEM SIZE ORDER QTY EACH TOTAL

DIM 60 Count ____________ x $45.00 _________________

IODINE PLUS 180 Count ____________ x $40.00 _________________

ADK-10 90 Count ____________ x $39.00 _________________

PROBIOTIC 60 Count ____________ x $22.00 _________________

OMEGA 3 60 Count ____________ x $24.00 _________________

WP THYROID

32 mg (1/2 grain) 100 Count ____________ x $30.00 _________________

32 mg (1/2 grain) 1000 Count ____________ x $250.00 _________________

65 mg (1 grain) 100 Count ____________ x $40.00 _________________

65 mg (1 grain) 1000 Count ____________ x $300.00 ________________

ORDER TOTAL ____________________

TAX ____________________

SHIPPING ____________________

TOTAL __ ________________

PAYMENT METHOD

L CASH L CHECK L CREDIT CARD

L VISA L MC L AE L DISCOVER

Number: __________________________________________________

Expiration Date: _______________ Security Code: ______________

Name on Card: _____________________________________________

Billing Address: _____________________________________________

__________________________________________________________

__________________________________________________________

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