1.1 Our Hairs :

Our hairs are symbols of self expression. Person's hairs speak about his social, cultural, professional and religious affiliations. Hairs are rarely concealed by clothing. Baldness and hair loss have been a problem of mankind since daw of time. Cosmetic surgeon can do lot to restore condition closure to cure. It is most popular and commonly done surgery. It is relatively safe and moderate procedure. Previously it was of high cost. Now, it is affordable.

Our hairs are not only great ornaments of human beings but also essential structure of the body.

Structure of hair:

Hair is made of keratin. Hair has multiple layers. In outer layers of hair, there are overlapping layers of cuticle which cover and protect inner layers. So, these layers appear like fish scales. These scales are flat and are called cuticle. These scales point outwards and so are easily susceptible to damage. Cuticle is tough and dense keratin protein that is found in the skin and nails. Cuticle protects inner and softer tissue of the cortex. Growth of hair occurs in the cortex. Damage to cuticle hampers work of cortex and affects the growth of hair.

Cuticle proteinaceous dense material of cortical cells of cortex constitute the bulk of hair and it is called as 'body'. This body decides shape, and resistance of the hair fiber. Cortical cells and fibers run from roots of hair to the tip. So, it appears like electrical cable having closely packed hundreds of small wires. When cuticle is damaged then, cuticle scales become jagged and break off.

Follicular unit:

Intact individual follicular unit is sacred. It includes 1 to 4 terminal follicles, one or rarely two vellus follicles. It should have perifolliculum (i.e. circumtential band of fine adventitial collagen), perifollicular neural net, perifollicular vascular plexus, sebaceous gland and insertion of arrector pili muscles.

Major function of human hair is enhancing the look of the person. Scalp hair protects head from injury and sun. Eye lashes protect eyes.

Growth of hair:

Everyday hair grows by 0.35 mm. We have one lac hairs on our scalp. So, everyday, total length of newly grown length of hairs is about 33 meters. Growth of hairs is good in young age and in good health. There is considerable ariation from person to person and from time to time (even in the same individual).

Everybody loses some hair:

Everyday our hair grow and also every day we lose some of our hairs. Everyone loses 50 to 150 resting hair per day during bath and hair combing. These hair grow again.

When next cycle starts, in first phase, hair sheds off and new hair shaft begins to grow.

Level of Androgens (testosterone, dihydrotestosterone) in the body affect the development of male and female pattern of hair loss. Due to the presence of androgens, hairs in beard, axillary and pubic area develop.

Three phases of hair growth cycle: Hairs grow in non continuous cyclic pattern of growth (anagen phase). Period of growth (anagen phase) is about two to eight years. Then, phase of degradation of tissue (catagen) lasts for two to four weeks. In this phase, hair follicle is almost totally degraded. After degradation phase, resting phase (telogen phase) begins and lasts of two to four months. Generally about 10 % of hairs are in resting phase.

We have three types of hairs:

1. Terminal hairs: These are longer, coarser and darker hairs. These are present on head, under arm and pubic areas.
2. Vellus hairs: These are short, soft, fine and non pigmented hairs present all over the body except palms and soles.
3. Intermediate hairs: These hairs are in wide range from vellus hair to terminal hairs. Due to stimulus, vellus and intermediate hairs become terminal hairs.

Loss of hairs:

Loss of hair is called alopecia. It is due to variety of factors like certain medicine, hormonal factor, nutritional factor, exposure to chemicals, chemotherapy, radiation, stress, skin disease (local and general), thyroid disease, anaemia etc.

During sickness, emotional stress, after child birth, certain drug consumption, number of hairs in resting phase increase and so number of hair falling also increases.

Weathering of hairs:

Exposure of hairs in sunlight and salt water leads to structural damage of hairs and bleaching of hairs. Structural proteins of hair shaft gets damaged gradually. Such hairs are called 'surfer's hairs.' So, cosmetic appearance of hairs degrades. Such hairs are frazzled. Their shaggier appearance increases. Person appears older than of actual age. These hairs are hard to manage.

Are you a friend or foe of your hairs? Just think twice or more!!

Yes, we damage our own hairs !!! How? Read below:

Everybody wants that his hair should remain in order. So, some people do vigorous or hard combing or brushing. Braiding or tangling hairs of which damage hair. So, traction hair loss or alopecia develops.

Use of degreasing shampoos, bleaching or dyeing cause chemical damage to hair.

Our actions to improve cosmetic appearance of hairs often damages our hairs. Half knowledge is dangerous.

Hair curling, hair straightening, and long term permanent waving causes physical damage. Hard scratching with finger nails also damages hair.

We are unaware of our injustice to our own hairs:

If outer layer is damaged, inner layer is easily gets damaged. Root of hair is inside the skin. Except at the root, hair is non sensitive. We do not feel damage or trauma on the hair. So, most of us are unaware when such damage occurs due to various factors mentioned above. We continue to do injustice to our hairs. So, we continue to neglect protection of hair from damaging environmental and cosmetic factors due to lack of awareness. Due to damage inner layers lose structure and forms fissures, ridges and nodule. So, hair become 'frizzy' and hard to manage. Many males are not concerned about their hair loss but other males are too much concerned with their hair loss.

Types of ethnic hairs:

There are three ethnic types of hair.

•  Asian,

•  African,

•  Caucasian

Asian hair are circular in shape and longer in diameter. African hair are oval or elliptical in shape. Degree of shape is variable. Caucasian hair tend to be of intermediate shape between these earlier two type. Asian hair are straight with no irregularities. African hair have irregular curling and twisting. Caucasian hair are

straight but there are few irregularities of the shape. Due to curliness even less number of African hairs can easily cover the scalp and so less number of hairs are required in Africans to achieve full coverage during hair transplantation.

East Asians (Japanese, Chinese, Korean) have thicker individual hair but fewer hair per square centimeter of the scalp as compared to Caucasians. So, larger donor area is required to obtain number of hair needed for hair transplant. East Asian women have more incidence of diffuse alopecia (diffusely thinning hairs)as compared to Caucasian women. East Asian women have more failure to grow pubic hair and they tend to lose pubic hair. So, more East Asian female demand transplant of pubic hair.

Diagnosis of loss of hair:

a) Hair pull diagnostic test:

To assess problem in hair growth cycle and hair loss few hair are pulled out. If more than 25 to 50 hair are removed from the scalp by a single hair pulls it is pathological.

b) Phototrichogram:

In this test, hair of the scalp shaved on that area of the scalp. In next 3 to 5 days, consecutive photographs are taken to determine the pattern of hair growth.

c) Hair window test:

Hairs are shaved or clipped in specific area of the scalp. Then hair growth assessed over the next 1 to 4 weeks. Both of these two tests help to assess abnormalities of hair growth cycle.

d) Scalp biopsy: It is less commonly done. It evaluates mechanism of hair loss inside the hair follicle

It assesses abnormalities of hair shaft & local infection.

e) Hair analysis: Hair analysis is done to determine cause and mechanism of hair shaft abnormality. It helps to assess altered hair protein profile and drug causing hair loss. This test does not diagnose systemic disease and nutritional state.

80% of male and female patients who want to do hair restoration surgery have male and female pattern of hair loss respectively. So, they do not need extensive diagnostic evaluation.

Medical treatment:

If the hair follicles are undamaged but inactive medical treatment restores their activities. Process of reduced number of hair is called as thinning of hairs. If an individual has a problem of thinning of hair, propecia and Rogain can be used. Protein block 5 alpha reductase enzyme that creates dihydrotestosterone (DHT) which leads to thinning of hairs and male pattern baldness. Propecia is once in a day oral pill therapy. Propecia is one of the safest medicine. Only 2% have side effects. Propecia can be prescribed to women who are not planning to have children. It is costly drug. Rarely it can cause telogen effluvium where there is excess temporary shedding of hair which return completely. Propecia is the best medical treatment for androgenic alopecia. Sometimes it is difficult to predict response due to individual variations. If patient stops the course of propecia before completion of full course, results may be reversed.

Rogain is topical lotion used in males and females. It is available in regular and extra strength versions. Dutasteride (Avodart) and nizoral are other effective medicines. Monoxidil 5% is also used and gives better results. In women better results are obtained by 5% strength. Both above drugs i.e. minoxidil and propecia used simultaneously for better results.

Omega fatty acid may play role in preventing hair loss.

All above treatment must be taken under medical supervision.

Use of 5% minoxidil in females is approved by FDA. Hair conditioners do not cause any hair loss. hair because they work on stem of hairs and not on roots of hairs.

Surgical treatment: Hair transplant is main surgical treatment. If natural hairs are not available, then, hair implants can be advised. Details of these procedures is given in next chapters.

After hair transplant minoxidil is advised after one month to prevent further hair loss. because baldness is continuous process. Minoxidil should be stopped one month prior to hair transplant .

Gray hair

It is consider as sign of aging. Graying is due to reduction of melanocyte. Beard and mousthache are affected prior to scalp and body hairs. p-aminobenzoic acid may be used for gray hairs.

Have you asked a question to yourself like, "How much is my hair worth?"

1.2 Hair transplant

Before              After

'Hair is richest ornament of a women'- Church reformer Martin Luter.

Natural hairs can be transferred in bald area of the head. Less number of hairs in eyebrows, eyelid and moustache can be increased. Hair transplant is well accepted procedure all over the world. It has high success rate and produces reliable aesthetic results.

Hair transplant is a procedure of implanting natural hairs of one place to another place. It is generally done in anterior (frontal) part of scalp area. New hairline can be created in more front part with the help of this procedure and thus broad or high fore head can be reduced. In some patients, in addition they require more extensive hair replacement to cover diffused hair loss. Some may need to add more density of hair in existing hairs or transplanted hair. Sometimes earlier hair transplant needs more boosting of new hair transplant to improve more cosmetic appearance.

Thinning look of hairs is not acceptable in females. So, due to over expectation, women are not always happy after the transplant. Hair transplants in female need full thickness.

Longitudinal and cross sectional shape of hair is decided by the lower half of the hair follicle. So, new transplanted hair appear like hair at donor site.

In males although the transplanted hairs remain permanent, the other natural hairs may fall due to aging.

In certain patients, who want to undergo hair transplant and are expected to develop considerable hair loss in future, then, hair transplant is done only in front 1/3 rd part and patient should keep proper follow up to assess progression of hair loss. In some patients, hair loss is too extensive. In these patients, although it is difficult to get good results, even increase a small number of hairs placed properly can dramatically change an appearance of personality.

Most of the patients have enough hair for transplant. Patient should keep proper expectation.

Discussing during consultation :

During consultation, patient should tell history of how onset of hair loss occurred and progressed. Inform about history of hair loss or baldness in other family members. So, also inform about any skin disease, blood pressure, diabetes, heart problems. Doctor will note down pattern of hair loss, type of baldness, hair density, donor area, and patient's expectation. Doctor assesses your scalp, body health, medical and family history. He tries to find out what might be probable causes of hair loss.

Doctor tells about area to be treated, position of hairline, number and type of grafts you required and limitations in the particular case. He will note down quality, texture, elasticity, strength, density and possible future hairline.

If patient is in phase of early hair loss, his expectation is taken into account. He should also accept the natural tendency of hair loss in future. Transitional zone of potential future hair loss is also taken into account.

Routinely blood test, CBC, haemoglobin, blood sugar level, bleeding time, clotting time, routine urine analysis is advised. Sometimes additional tests are required.

Procedure of hair transplant :

Nowadays, lot of advances have developed in hair transplant. One hair per graft (each follicular unit per graft) can be transplanted. So distribution of density of hairs remains uniform. It looks more natural. Hair transplant is done under local anaesthesia and so patient is fully conscious. From posterior surface of head a donor strip of hair is removed.

The hair for transplant is obtained from the area having most dense hairs i.e. from the back and side of the head under local anaesthesia. Then, this wound is stitched. This wound heals without visible scar. The hairs near the scar hide the scar. Speed and quality of healing depends upon how nicely your body heals the wound and skill of the surgeon.

The strip of the donor skin is divided into small units to prepare one, two and three hair follicular units. In each micrograft, there are 2-3 follicular unit grafts. In follicular unit graft, there are 1 or 2 or 3 hairs. During trimming of follicular units, the excess skin around the follicle is removed under high magnification. So there is no excess skin in transplanted units. Hairline created by transplant of such hairs is useful.

A hole is created by needle of same usual thickness, which is routinely used to draw blood from the arm for examination. Each follicular unit is carefully put into each recipient site in the small hole. After 3-4 months transplanted hairs grow half inch per month.

Single haired grafts create perfect frontal hairline. In front view, single hair follicular unit is kept, behind them, two follicular hair grafts and behind them, three hair grafts are kept. Thus, attempts are made to duplicate a subtle feathered look of natural hairline. With special technique and miniaturized vacuum technique minimum trauma is done in handling hair follicular grafts.

Pain of hair transplant procedure is felt only in initial period of injecting local anesthetic solution. As some sedation is given initially so pain is experienced less severe. With special technique of use of 30 gauze needles for injecting local anaesthesia, pain is minimum. Post operatively, minimum painkillers are required.

After hair transplant, some of the existing hair may fall out temporarily because these are weak hairs and have entered in anagen growth phase.

Transplanted hairs are placed properly in order to have natural appearance. Anterior hair line is created artistically. One problem of hair transplant is body's continued loss of natural hairs. If earlier process of hair loss continues thinning of the natural hairs continues in that area. Hair growth takes time. After hair transplant most of the hairs fall out and enter the resting phase before regrowing in their new place. So, 3 to 6 months are required to regrow the hairs and few months are required to to obtain the full results.

'Graft cyte' is treatment after the hair transplant. It consists of many soaked dressing which keep area transplanted hair more safe and wet for wound healing. These are replaced after few hours. This treatment prevents falling out of hairs and preventing them from going into resting phase.

50% of skin in non-hair bearing skin is bare because follicular units are arranged relatively compact way.

Those who do not get good results should understand that beauty is in the eye of beholder. Use various styling techniques or accesses which being focus to the central face.

Women should keep same specific hairstyle. Considering her constant hairstyle, it is decided which area needs more hair transplant. The hairs transplanted in anterior area can cover bald area. Hairs can be coloured to decrease contrast between the hairs and the scalp. Increase in curl of hairs adds volume.

Hair loss in females is more diffuse as compared to discrete hair loss in males. So, transformation in women is more challenging. Usually 800 to 1000 grafts are transplanted. Some times upto 1400 grafts are transplanted. Beyond this figure is quite strainful for surgeon.

Some patients need two or three sessions. Generally, grafts do not last or rarely fail to survive. If grafts are lost, these can be replaced.

Precautions patient should take before surgery and on the day of surgery:

a)Do not use following medicines two weeks before surgery: Propesia, finopapacia, minoxidil, aspirin or anti-inflammatory medicines that contain aspirin. One week before surgery, avoid vitamin E, Ginkobiloba, Ginseng and other herbal supplement. One day before surgery, avoid alcohol and tobacco products. Before surgery, arrange for your travel to and from the surgical center.

b) On day of the surgery, wash your hair in morning, using regular shampoo. Have breakfast two hours prior to time of procedure. Do not have tight hats or caps.

On the day of hair transplant:

Typically patient will have activities as follows:

Patient signs the consent form for surgery. To reduce anxiety and pain appropriate premedication is used. He receives sedatives and antibiotics. With consultation of patient, the area of transplantation is confirmed. The new hairline is drawn onto the scalp. It is shown to the patient. Photo documentation is done. Patient is either in sitting or lying position. He relaxes and listens music or radio programme. His heart, blood pressure and oxygen saturation are carefully monitored. Each one receives full attention of staff. When one undergoes transplant of 1000 to 1200 graft, 3 to 5 hours are required and for about 2000 grafts 4 to 7 hours are required. Rest of procedure is explained above.

Bandage is removed next day morning. Patient is fit to travel out of the town. He is encouraged to contact doctor at any time.

There are no complications in hair transplant. Undergoing this procedure is like visiting dentist. Rarely at donor site, slight numbness may be felt for few days.

After hair transplant, patient can resume his light work from third day onwards. Stitches are almost invisible after three weeks. One should avoid any activity which creates pressure in transplanted area. For three weeks, active exercises should be avoided. Bath may be taken from 4 th day onwards. In next four weeks, cabs, crusts and effluvium falls off. Initially hair falls off from newly transplanted follicles. Time lag between temporary thinning of pre-existing hairs and regrowth of new hairs is called Telogen Effluvia. Then, hairs start growing after 3 months and they continue to grow for rest of the life.

After a week grafts appear pink and skin around the grafts is shiny. After two week, no sign of grafting remains. Only 15% available hairs can be transplanted.

Before              After

Hair transplant in eye brow and eye lashes for cosmetic reason:

Eyebrows and eyelashes are important for beauty of face. One needs symmetry of these areas for beautiful face. Sometimes in certain persons, the hairs of this area are lost due to physical trauma like accident, injury, thermal burns, chemical burns and electrical burns. Due to congenital problems and local or systemic disease, hairs may not grow in this area. Plucking of hairs for reshaping or due to disease like trichotillomania may cause hair loss. Sometimes medical and surgical treatment like radiation therapy, chemotherapy, surgery cause hair loss in this area. Detail history of hair loss informed by patient helps to assess possible causes of hair loss in particular individual.

They need enhancement of hair density with the help of hair transplant surgery. Before hair transplant in this area, systemic and local disease must be under control. The scar tissue trauma, burns, surgery needs excision before eyebrow or eye lashes restoration surgery.

Reconstruction or restoration of eyebrows:

If eyebrow is scarred or lost due to injury or disease, it can be reformed by hair transplant in that area or haired skin grafting. Partially, missing eyebrow can also be restored as cosmetically acceptable eyebrow.

Procedure of creating eyebrows:

A strip of hair bearing skin is removed from donor area of the scalp and is grafted at the site of eyebrow. To hide incision marks hairs are grafted into incisions also.

Rarely a pedicle flap from temple area just in front of ear with its affected blood supply is prepared, raised and transplanted to prepare size of eyebrow through subcutaneous tunnel. Then, it is stitched. The hairs from such transplanted graft needs training with gel or wax to make them flat to the skin like a natural eyebrow. These hairs may need trimming occasionally.

To create eyebrow with natural contour patient and physician work together to outline the area on patients face symmetrically. Finer hairs from donor site are transplanted as micrografts of one or two hairs. Use of single hair graft gives good cosmetic results. As mentioned above, these transplanted hairs sometimes need trimming and conditioning.

Restoration of eyelashes:

Fine hairs are selected from donor site and are transplanted. Generally, six hairs per lid may be adequate to create a natural look.

HAIR IMPLANT: -

Artificial hair transplant:

When unsolvable baldness is present, artificial hairs or Biofibres ® are used. These can also be transplanted as integration of other surgical techniques and when patient wants immediate aesthetic results. For all types of baldness and for 'trauma free donor area surgery' Biofibres ® can be used.

These hairs are tested in compliance with ISO 10993 norms.

High hair line / over sized fore head:

Hair line lowering for women. Hair line should be to the point on her forehead when the skull starts to slope downwards. Some women have receding hair line and oversized fore head. So, even mild thinning of hairs is noticed earlier. Such women are in search of solution but often they do not realize what is wrong. They often feel it is balding. Actually, it is thinning of women's hair. As such, hairs are crowning glory with the face. Patients get tired of hiding her forehead under long bangs. They spend lot of time in camouflaging that unwanted features.

To reduce forehead, there are two techniques:

1. excised about an inch of hairless skin and pull the hair line down or
2. transplant the hairs in bare skin

Hair transplant is costly procedures. Two or three day long procedures are required. For full growth of hairs, 2-4 years may require. Hairs rarely have the same texture as that of original hairs. In case of hair advancement, results are immediate. But dealing with the scar is tricky. Surgeon makes zig zag incision across the forehead while suturing surgeon buries the hair edge when he sutures the two edges together so that hairs grow in and just in front of the scar. It requires critical care because surgeon works near the vital blood vessels.

Use of tissue expanders:

When hair line needs to be advanced for more than an inch, tissue expander is put under the skin. Tissue expander is a balloon that is inflated over six weeks period to stretch the scalp. Due to placement of tissue immediate improvement in appearance is seen.

Scarred area of scalp:

It is unsuitable hair transplantation. So, reconstructive procedures like scalp reduction or scalp flap may be used. Use Minoxidil 2 months prior to hair surgery & 1 month prior to hair transplant. Along with that use Iron, folic acid, omega-3 antioxidant combinely.

Frequently asked Questions: FAQs

Q. Who is an ideal candidate for hair transplant surgery:

Ans : A person who has

a. Age above eighteen years,

b. No active scalp infection,

c. Adequate hairs on back and sides of head,

d. Stabilized hair loss,

e. Medical treatment tried without success,

Patient should not have a habit of consumption of any tobacco product and alcohol. He/she should not have diabetes, high blood pressure, hypothyroidism, keloid tendency, systemic disease, bleeding disorder. If reader feels that he fits in this category, he should consult cosmetic surgeon.

Q. Can hairs be transplanted in eyebrows, eyelashes, moustaches, pubic area, side burns?

Ans: Yes, in these areas hairs can be transplanted.

Q. When baldness runs in family? What are the possibilities?

Ans: Although male baldness is known to have hereditary factor in families with many bald males inheritance pattern is unpredictable. It is also uncertain to say about onset time of male pattern baldness. Environmental factors also affects baldness process.

Q. Some young people ask this question, "My father had baldness. Will I lose hairs like his pattern of hair loss?"

Ans: It is usually difficult to say about how fast baldness will increase. Generally, 25% men develop baldness by the age of 30 years and 40% develop by age of 40 years and 50% male develop baldness by the age of 50 years. If baldness begins earlier, it will likely to continue with aging. Sometimes occasionally pauses may be seen.

Q. In what manner male lose hairs?

Ans: Male pattern hair loss generally starts at frontal lines above the forehead and moves back in 'M' like pattern. Simultaneously or later on hairs over the vertex (crown) of the scalp are reduced. Frontal and vertex pattern may enlarge and merge into each other. Areas of temple over the ears and back of the head persist even if all hairs from other parts of scalp are lost. Even if one has not developed baldness upto age of 40, it does not mean that he will not develop. In many males, minimal and gradual hair loss is not recognized by themselves.

Q. When should I decide to undergo hair transplant?

Ans: If you have noticed your hair loss very early and hair loss is mild to moderate, have trial of medical treatment with hair restoration drug like minoxidil (Roga and finasterial). These agents slow or reverse hair loss. Thus, by taking preventive treatment at proper time, you may delay the need of hair transplant for many years by the use of these medications.

Q. How the hairs regrow and how much time is required?

Ans: Good regrowth of transplanted hairs takes place after three to four months. Initially, these hairs are thinner and softer. Soon they become thicker, coarser and darker. Sometimes, initially hairs are curlier. Exposure to sun makes the colour of hair lighter.

Q. How long transplanted hairs continue to grow?

Ans: Usually, transplanted hairs have same life span as that of hairs of donor site. Normally hair sheds off from hair follicle after every three to six years and grow again from the same root of hair follicle.

Q. Are the other natural hairs are affected after transplant of the hairs?

Ans: Natural hairs are not at all affected by transplant of the hairs. Natural hairs are very tough. These can tolerate surgery and irritation of the scalp. With the experience of hair removal, we know that usually it is difficult to remove unwanted hairs. Even if hair is plucked hundred times it regrows again.

Q. Does one need additional session of surgery?

Ans: Those who have completely bald area may need two or three surgeries at the gap of six month. If the area is partially covered with hairs, one usually needs only one sitting. Twenty five per cent density of hairs is restored in comparison to original donor site. After 2 nd sitting, 50% density is restored. Response of takeover graft varies from person to person and status of health.

Q. Can the hairs from other relatives and friend transplanted?

Ans: No, such hair transplant is not done.

Q. Can fallen hairs or hairs from other parts of body be transplanted?

Ans: No, because these have not active and alive hair roots.

Q. Are hair transplanted lasts for whole life?

Ans: Hair retains its genetic characteristic even after transplant. Hairs for transplantation are taken from donor area, which is not sensitive to baldness. So, these hairs continue to grow for rest of life.

Q. Why only few doctors perform this surgery?

Ans: This procedure is more labour intensive, it takes longer time. It needs special training.

Q. How many hairs transplants one needs?

Ans: Number of hair transplant, one need varies from person to person. It depends upon how much hair loss. one has, how much is area of baldness, how much density of hairs are required, what are goals and expectation of the patient etc. Usually one needs 500 to 1000 grafts. But one may need even more than two thousands follicular grafts.

Q. How far medical treatment is effective in preventing hair loss?

Ans: Medicines like propecia and rogaine are not effective in frontal and temple area where usually one sees hair loss. These medicine slow down the hair falls.

Q. What about cloning of hairs?

Ans: Although cloning of hairs will be boon for those who have more baldness. This procedure is still in early experimental phase.

   Before             after             Before              After

Q. What are side effects of hair transplant surgery?

Ans: Bleeding: Sometimes one may see slight temporary bleeding which stops after some local pressure for few minutes.

Pain: Pain is minimum. 50% patients do not require pain reliever. Pain killer like Tylenol may be required for few days. Some patients develop numbness on the site, which lasts for three to eighteen weeks.

Itching: Some patients do feel itching due to crusts. Medicines and shampooing helps to relieve itching.

Swelling: Swelling develops due to transplant. This swelling may last for 4 days after surgery. It develops in local area. Medicine helps to reduce the swelling.

Infection: It is rare complication. It can be controlled with appropriate antibiotic.

Some patients develop hiccups temporarily. Its cause is unknown. It can be controlled with medicine.

Scarring: Keloid and scarring may rarely develop in patients who have such tendency in past.

Cyst: Some patients develop small cyst of size of pimple in the recipient area, which usually disappears after few weeks.

Neuralgia: Due to traumatic irritation or inflammation of the nerves, some patient may feel pain, numbness, tingling or pins and needles sensation or very rarely shooting pain, which is relieved in one to four weeks.

Q. Is hair transplant painful? How much pain is felt after surgery?

Ans: Such pain or discomfort is minimal like dental surgery. It can be easily controlled by painkiller. As surgery is done after injecting local anaesthetic, so there is no pain during surgery.

Q. Does transplanted hairs need special maintenance care after surgery?

Ans: Once these hairs grow, they require same maintenance care as one's original or natural hairs on head. These hairs can be washed, trimmed and even coloured.

Q. Can the hairs from other areas of body like chest, back, stomach can be used for transplant?

Ans: Yes. These hairs can be used.

Before                After treatment       Before                After treatment

Patient's OPD sheet:

1. When hair loss started?
2. How hair loss has occurred & progressed?
3. Does any family members have hair loss of premature age?
4. Do you have general diseases like any skin disease, high blood pressure, heart disease? Do you have any skin disease?
5. What are expectations of the patient?

Examinations:

1. Pattern of hair loss
2. Type of baldness
3. Hair density
4. Extent of donor area
5. Quality of hairs: Thickness / thinness texture, strength, elasticity and density of hair in various area

Plan of treatment:

1. Medical line of treatment
2. Planned new anterior hair line
3. Types and number of grafts required
4. Limitations in particular case

Investigations advised: Hb%, CBC, BT, CT, Blood sugar level, urine routine examination.

1.3 Hair implant Biofibres ®

A process of implantation of artificial hair on the scalp and boby is called hair implant. Biofibres are used as hair implant material.

Aesthetic advantages of biofibres ®

These are biocompatible. These are fine, flexible, elastic, soft and highly resistant. So, rapid cicatrisation and pleasant appearance is seen. These are non-recognizable after implant. These can be washed and dried. They have resistance to traction. There is no capillary and bacterial adhesion. These are safe for patient's health. Results are instant. There are no incisions. There is no scar. Fibers have continuity to stay. These are available in standard thirteen colours and standard length of 15-cm. Upon request other colours and extra length of these biofibres are available. Diameter is 0.08 mm. Upon request, different thickness is available. These are straight. Three types of permanent wave or curl are available.

These biofebers ® can be used as new added hairs. Results are immediate. They appear like real natural hairs. Hair density is maintained. They do not fall out all at once. Occasionally shedding occurs.

Procedure of implantation:

Initially, 100 test fibers are implanted and watched for any allergic reaction for one month.

Later on 500 to 1000 biofibres are transplanted under local anaesthesia after every 2-3 weeks. Regular check up after 1-2 months may be necessary by surgeon.

10% of hair loss of implanted hairs is possible every year. Lost hairs can be replaced without any scarring.

1% of patients have intolerance. 11% patients have mild inflammation or infection which can be controlled.

Questions asked by patients:

Q. What is hair implant?

Ans: It is implantation of artificial hairs on the scalp.

Q. What is difference between hair transplant and hair implant?

Ans: Hair implant are artificial and non-living thing. So, no scar of removal of hairs at donor site is present. Hair transplant are natural and slight scar develops at the site of removal of hair from donor site. Implants have fixed length and cannot grow. Transplanted hairs have live base and so grow upto usual length.

Q. Who can undergo hair implant surgery?

Ans: Patient should have good health; controlled weight, healthy scalp area, normal laboratory investigations, and commitment to follow post implant protocol strictly. Thinning of hairs affects both sexes and all ages. Without having any scar all of them can be benefited by artificial hair transplant.

Q. Who should avoid biofibre?

Ans: Those who have h istory of allergy to synthetic material disease of Immune system, dismetabolic disease, on going scalp disease, psychological disease, people working in unsuitable climatic conditions should avoid biofibres.
Q. What are advantages of hair transplant over hair implant?

Ans: These are natural and growing.

Q. What are advantages of hair implant of biofibres ® ?

Ans: These can be implanted upto 8000 in spite of no natural hair at donor site. No scar develops. Results are immediate. There are only 1% chances of rejection.

Q. How many hairs are required per square cm?

Ans: Above 25 hairs are required to cover 1 sq.cm area.

Q. What maintenance care is required?

Ans: Wash hairs twice in a week with gentle massage. If dandruff develops, use medical shampoo. Have hair cut from the barber that knows maintenance care. Comb the hair gently with metal comb with wide teeth.

Q. What type of shampoo should be used?

Ans: Any commercially made shampoo having pH 7 above can be used. For very scaly scalp used shampoo prescribed by the doctor.

1.4 Removal of hairs for cosmetic reasons

When hair on the body are at proper place, these are great gift of nature. But when these hair are on unwanted or undesired place, disturbing beauty of the person, we call it unwanted hair. Since ancient times mankind has fighted with these unwanted hair with the help of pumice stone, plucking, threading, waxing, shaving etc. But man could not succeed. Human being always try to show hair in desired place & try to avoid hair at undesired place. As man become more and more culturised & social, undesired hair on the body reduced in size & colour. Hair of enough length, thickness & at proper place on the body improve our personality. These express our specific personality in social, cultural, professional & religious fields. An individual desires to remove unwanted hair prior to important cultural or social programmes. Women have strong desire to do so.

  Before             After treatment

Everybody has certain undesirable hairs. Every lovely woman is tired of plucking and waxing to become free from hairs. So, recently the trend of Laser hair removal for hairs of face and neck has become more common. Everybody likes smooth face and neck. Everybody of you can have hairless skin.

For a man or woman having excess hair or unwanted hair anywhere on the skin treatment of choice is Laser hair removal.

Hairless skin is a reality due to Nd YAG LASER and INTENSE PULSE LIGHT (IPL).

Unwanted hair or excess hair is a problem in many women. Depending on fashions, age, sex, age, season etc. site of undesirable hairs vary. If hairs are more than cultural norms, it is socially distressing. These hairs cause embarrassment to ladies of all age group. These hair many a times lead to unnecessary inferiority complex, stress, anxiety, social isolation, loneliness feeling, conscious feeling, reduction in self confidence and depression. Hair are for protection when these are on the scalp. Although we have more than total number of hair on the body of Chimpanzee / Gorilla. Now, hair are more for beauty rather than protection. We have few lakhs of hair on our body but most of these are very thin small and colourless so we do not notice them. Hairs grow 1 2/3 mm everyday. So, everyday, growth of total length of all hairs on the body is 33 meter.

So, every where in the world, some degree of hair removal is done. Women remove unwanted hairs of upper lip, chin, forehead, pinna of ear, face, neck, area between and around the eye brows, fore arms, legs, underarms (axilla), bikini line, belly, back, inner thighs, breasts etc. Everyday, men shave their facial hairs. Nasal and hairs of ear pinna are occasionally shaved. If these hairs are of dark colour, these are more embarrassing to that lady.

In past, women used to tweeze, shave, electrolysis (trying with electric needle), slitter with strong depilatory creams and pluckers. Now women have best choice i.e. LASER which is least troublesome and gives better results than all these procedure. The treatment of choice is the use of LASERs. It is the most popular approach. Increased number of hairs and unwanted hairs are due to multiple reasons as follows:

Hypertrichosis:

In some people, due to some disease, excess hairs (hypertrichosis) develop on the body. When number of hairs increase due to non androgen cause & in non androgen dependet area of the body, it is called hypertrichosis. It may be due to certain disease like thyroid disorders, malnutrition, anorexia nervosa: porphyria cutanea tarda. Certain medicine also cause hypertrichosis e.g. cortisone, phenytoin, cyclosporidin, penicillin. dilantin, anabolic steroid, minoxidil, high doses of cortisone, cyclosporine, diazoxide.

Hirsutism:

When excess male sexual pattern hairs grows in women, it is called as hirsutism. It is due to disease of endocrine gland or virilizing tumours of adrenal, pituitary and ovary glands.

It is excess growth of thick hairs on the body parts where usually there are no hairs or minimum hairs in women e.g. Growth of hairs on face, upper lip, chin, chest and areola. It is due to male hormone or androgen hormone stimulation in women. Thus, in hirsutism excess coarse hair growth in women is pattern similar to that develop in adult men. Cushing syndrome, obesity, hyper insulinemia, hyper prolactinaemia and excess growth hormone may also lead to hirsutism. When such changes are associated with musculinizing signs and symptoms the women may likely to have ovarian or adrenal neoplasm. If hair grow rapidly, it indicates such tumour. If women shows, severe or rapidly progressive hirsutism or signs of virilism (e.g. infrequent or absent menses, deepening of voice, male pattern baldness acne, increased muscle mass, increased libido clitorial hypertrophy). In such cases, having ovarian or adrenal neoplasm, serum androstenedione level is more than 100 ng/dl. Polycystic ovary disease causes hirsutism So, such cases are severe. Investigate the case promptly for hormonal levels like testosterone and dihydroepiandrosterone sulfate (DHEA-S) to rule out any androgen secreting neoplasm.

In idiopathic hirsutism cases, there is excessive genetic sensitivity of hair follicles to normal androgen level or hyper secretion of ovarian or adrenal hormone. In post menopausal age of women, work of unopposed androgen stimulates hair growth on the face. One out of six women, have hirsutism. Hirsutism indicates some androgenic problem.

Due to excess of androgen, hairs grow on upper lip, chin and chest. So, also acne, androgenic alopecia and acanthosis nigricans develop. Excess hairs may grow on unusual birth marks like hairy nevi, faun tail nevi, Becker's nevi.

Limitations of LASER hair removal: White hairs and fine velour hairs are not removed successfully by LASERs but other hairs can be removed successfully. Blonde, red and gray haired people do not respond to the treatment satisfactorily. These can be removed with CO2 laser or Radiofrequency. Dark skin persons pose more problems. So, again this laser method may be used. Those who have normal endocrine status, thick dark hairs, light skin lines and realistic expectation get maximum satisfaction of hair removal procedure.

Does your facial hairs and hair on other parts of the body worries you? Do you feel uncomfortable due to these hairs when you meet people? Consult Laser surgeon.

Methods of hair removal:

Methods mentioned below are invasive or abrasive. They produce temporary benefit.

•  Shaving :

Although shaving can be done anytime quickly, it is not acceptable for hairs of face in women. It needs to be done frequently. It may produce side effects like irritation, and pseudofolliculitis. Ingrown beard hair are difficult to shave. It produces folliculitis.

•  Waxing, plucking and threading:

These methods are commonly available in most of the beauty parlour. Although these methods of hair removal are quick and easy, these methods may cause post inflammatory hyperpigmentation, folliculitis, pseudofolliculitis and even scarring. Waxing causes greater discomfort and expense. All these methods need repetitive treatment for life time. So, considering life span of the individual indirectly there is more waste of money, time and personal energy.

•  Chemical depilators:

Chemical depilator creams are quite often advertised for hair removal. Their actions are temporary. They may cause irritant dermatitis. Thioglycolates, barium sulfide etc are used as chemical depilators. Certain drugs like eflornithine hydrochloride, anti androgens, etc are not safe for health.

•  Radiation:

Use of radiation for hair removal is not selective treatment. It has potential hazards. It cannot be repeated due to its dangers.

•  Electrolysis:

In hair removal method of electrolysis, electric current is delievered by probe to the unwanted hairs. Each type of electrolysis machine has different standards. Enough practice is required to undergo this method. This method may cause pain, scarring, pus, inflammatory pigmentation changes (hyper or hypo). This method takes long time and more sittings as compared to LASERs.

LASER HAIR REMOVAL:

Now a days LASERs are used everywhere from pointer to printer. It has its own quality of precision. Use of LASER for hair removal gives permanent result. It is most advanced, easy and cost effective methods of hair removal. It is he most advanced & the most accepted method all over the world. Laser instruments are costly. Person may feel that laser treatment is a costly treatment. Actually, a person removes hair by other method every month for his whole life. total cost of these procedures in terms of money, time & energy.

YAG, IPL and diode Laser is effective only in anagen phase. Laser hair removal saves your time wasted in non laser procedures at intervals throughout the life. It is a loss of huge time over whole life period.

Pretreatment Precautions:

•  Avoid direct exposure of that part to sunlight for four weeks prior to the treatment. Use sunscreen lotion if area s sun-exposed. Patient with sun tanned skin should avoid treatment until tan has faded. A patient with darker skin type or those who have recent sun exposure may use bleaching cream (e.g. 3% hydroquinone, 0.025% hydrocortisone) two weeks prior to the treatment.

•  Avoid plucking or waxing or electrolysis removal method for four to six weeks. One can shave the area.

•  Avoid bleaching, waxing/ plucking of hairs chemicals depilation of the hairs for 3-6 weeks prior to treatment. Stop using tanning creams. Patient having darker skin or tanned skin should use hydroquinone to reduce tan. Do not undergo bleaching treatment prior to 4 weeks.

Unbalanced hormone are often the cause of undesirable hairs on the body. This cause should be controlled before undergoing LASER hair removal. If patient has suffered from viral infection, one may start antiviral treatment. If hair undergo any infection in last 3-6 weeks, inform the therapist.

On the day of LASER treatment :

After examination by treating surgeon, shave the area to be treated or use depilatory cream. In certain cases, prophylactic antiviral agents like valaciclovir, famciclovir, aciclovir may be started.

On the day of treatment, the area is cleaned and made free of cosmetics & make up. Remove lubricants anaesthetic creams before laser session. In certain cases, topical anaesthetic one hour before the treatment with a cover of plastic wrap. Trim or shave the hairs if they are longer upto 0.5 mm stump. Do not use cosmetic lubricant on the day of treatment.

If there is some discomfort or some pains. It gives feed back information to the therapist to know whether sufficient energy is given for effective hair removal. This helps to avoid side effects of laser. If patient does not want to have such discomfort or pain then from 2 nd or next sitting local anaesthesia drug is used to prevent pain or iscomfort.

Instructions after hair removal laser sessions: -

Avoid exposure to sunlight directly. Use sunscreen (SPF 30 or more) for a week. Immediately& on next day, in some person, one may notice oedema and redness. Very rarely, crusting is seen. No special treatment is required to use cold compress for sometime to keep temperature of skin low.

Use of hydroquinone is advised when patient may likely to develop hyper pigmentation. Hydroquinone 4% cream is also advised from the next day if patient was on its pretreatment.

One may use make up & moisturizer later on. In period of treatment do not use other methods of hair removal except shaving.

Terminologies in hair removal:

Temporary hair reduction:

Temporary hair reduction is defined as a delay in hair growth for 1-3 months. It is consistent with hair cycle.

Permanent hair reduction:

When hairs are removed and do not grow even after complete growth cycle of hair follicle at a given site. Complete hair loss means loss of regrowth and hairs. It can be temporary or permanent in type.

One laser treatment produces complete but temporary hair loss for about one to three months. It is followed by partial but permanent hair loss.

Limitations:

Results of laser hair removal depend upon hair colour, hair type, hair density, hair diameter, skin condition, skin colour, hormonal factors and anatomic locations. also affects. Patient should note that thick hairs can be easily eradicated. Thin hairs are resident to treatment & are not visible & do not need removal of such true permanent hair removal is unknown and removal of all hair is unlikely. In some patients maintenance treatment is needed at the gap of 3-4 months to maintain temporary hair loss. In dark skinned patients with fine hairs have poor response as compared to fair skinned persons and persons with thicker hairs. The area which is not exposed to sun has least post procedural complications e.g. arm pit plucking.

Patient should note that true permanent hair removal is unknown and removal of all hair is unlikely. In some patients maintenance treatment is needed at the gap of 3-4 months to maintain temporary hair loss. From patient to patient there is variation in response to laser therapy.

Laser Hair removal & women:

Woman's hairs are her crowning glory. Every woman wants smooth skin without any hairs on her face, chin, upper lip, neck, legs, under arms and at the bikini line. So, she does not like any hair in these areas. She also wants the hairs of eye brows in good shape. Practically, all women have some unwanted hair on some parts of the body. So, they go through all the labour of Hercules over hairs removal. When hairs grow in wrong places the attack over these hairs is relentless.

Unwanted and excess hairs are affected by age, medicines we take, hormonal level, ethnicity and genetics. All these factors also affect their coarseness, length and colour of hairs.

What is LASER HAIR REMOVAL?

It is the most modern non invasive specific procedure of hair removal by using lasers. Q. How does Laser work?

Laser or light of specific wavelength is absorbed by melanin present in hair of follicle and so its temperature increases to destroy the follicular cells permanently.

Q. Why laser hair is chosen over other alternative methods?

When one wants to remove hairs of larger area, electrolysis, waxing, tweezing, threading are more painful, time consuming and less safe procedures. Their results are lasting for short period. Often these procedures tend to stimulate more hair growth later on. But laser hair removal process offer better and longer lasting results. It is fastest and safest among all the methods of permanent hair removal.

Q. What are the advantages of laser over electrolysis?

Laser in non invasive, safer, fast methods. Electrolysis is invasive, some what unsafe (as compared to electrolysis) and more time consuming method.

Q. In laser hair removal what risks are involved?

In some patients, having sometimes skin, temporary slight reddening of skin, and some temporary swelling may develop. Those who do not follow post treatment precautions may develop temporary hyperpigmentation due to direct sunlight exposure. If sunlight is avoided, this risk can be prevented.

Q. What are advantages of methods of laser hair removal in comparison to other methods?

Laser hair removal does not have risk of making hair grow back thicker, darker or quicker. It will certainly reduce thickness of hair and hair count. This advantages are absent in other methods including electrolysis.

Q. Is it painful procedure?

One may feel tingling and snapping sensation like a rubber band. It is the most often a feeling of discomfort rather han pain. It is quite less as compared to other methods of hair removal.

Q. How much is discomfort during LASER hair removal?

Ans: Discomfort is like a rubber band snapping against the skin and tends to create some discomfort. People with light skin tend to have less discomfort. This discomfort indicates maximum energy that can be used in particular case without any side effect. But if patient does not want even this much discomfort, then, in first sitting, maximum tolerance of energy in particular person is assessed. Later on from second sitting, this dose is delivered under topical local anaesthesia locally. Topical anaesthetic cream is applied one hour before the treatment. Ice can also be used. After the treatment skin becomes slightly pink. Patient may feel slight sunburn. Patient can attend her usual work after some time.

Q. Is hair laser removal permanent?

Laser removes all active hair follicles on the body. There are very small vellus which are not easily visible to naked eye. Due to variety of factors like age, hormone, certain medicines. If these hair become active & grow then the person may wrongly feel as if hair are recurred. To destroy dormant hair follicles sittings are given at intervals. So, in few sittings 70% to 90% of hairs are destroyed. In some patients due to some medicine, ovary tumor or hormonal imbalance, the dormant hair follicle becomes active. In such case, one may need to repeat another session. Scientifically permanent hair removal means destroying the active hair follicle permanently and so results last for many years.

Q. How to get best results from laser treatment?

To get best early and permanent results follow post treatment instructions and schedule of suggested session.

Q. Which area of the body can be treated?

Laser can treat all part of body where we do not want hair e.g. in women, upper lip, chin, bikini line, arms, legs, underarms, unwanted hairs of eye, brows for reshaping, eye lashes etc. In men, beard area, shoulders, back, ear pinna etc.

Q. How safe is laser treatment?

As it is non invasive and faster treatment, there are no chances of infection, much pain, mutation etc. Laser hair removal method which we follow and machine we used is approved by Food and Drug Administration (FDA) of America.

At some centre, there are mobile laser machines and of old generation laser machines which are less safe in comparison to non mobile heavy machines of recent generations.

Q. Does laser cause cancerous changes?

No, laser is non ionizing, light which does not cause any mutation in cell. So, laser is safe and does not cause cancer.

Q. Why laser hair removal is done in multiple sittings? OR Why there is need of treatment at certain interval?

Laser is effective against all hairs which are in active phase and destroys them forever. Laser do not destroy hairs which are in inactive phase at the time of laser exposure session. At present, no method is available to destroy hairs which are in inactive phase. After certain time, these inactive hairs become active and so, to destroy hairs which have entered in these active phase, one need another sitting. So, depending on hair growth cycle and pattern of hair growth, one may generally need 4-8 methods. The laser expert can have idea of need of more sessions only after second treatment i.e. after observing the individual response. Those who have hormonal problem, who develop this problem later on, may need maintenance sitting later on. Those who have undergone frequent lucking, threading & waxing methods of hair removal may need more sessions.

Every hair of the body passes through three cycles of hair growth. The active growing phase (Anagen), the regression phase (catagen phase) and the resting phase (telogen phase). At any given time, all hairs anywhere on the body are not in one phase of cycle. LASER destroys hairs which are in the active growing phase. So, a single sitting permanently destroys the hair which are in active phase (anagen phase). Those which are not in these phase need more sittings till all of them pass through this anagen phase. So, single sitting is not enough for any available LASER SYSTEM.

LASER acts on hairs, which are in active phase (anagen phase). Hairs grow differently depending upon hormones, ethnicity, weight, age, metabolism, medicines consumed etc. So, more than 2-3 sittings are required for hair removal. Those who have excess hairs which do not respond, need to undergo investigation for hormonal imbalance and its causes.

Q. What is difference between other methods of hair removal and laser hair removal?

Laser treatment definitely destroys active hair follicles permanently. But such permanent results are not seen in other methods. So, after some sessions of laser treatment, skin is almost free from hairs.

Q. After laser hair removal, does one need to take rest?

No, one can directly go to work after the treatment. But one should avoid direct sunlight.

Q. Is laser treatment economical?

By using other methods of hair removal, one spends small amount of money every 3-4 weeks for about 20 years. So, indirectly on summation one spends more money. Thus, indirectly much money is wasted. Summation of time and energy which patients spend is multiple times much more. So, also the summation of risk to which an individual is exposed everytime is non acceptable. Due to these valid reason, one should choose method of laser hair removal. After laser treatment, one gets 80-90% response in 3 sessions. With few more sessions, almost most of the hairs are removed.

Few patients who have hormonal imbalance or some silent medical disease have a tendency of hair growth irrespective of any method one uses for hair removal. In such patients, one may need repeat treatment of laser at interval & maintenance treatment with Lasers and results are scientifically better than other methods. Thus, laser is highly effective.

Q. How many treatments are required?

Ans: All hairs are not in active phase. So, to remove rest of the hairs at least 4 sittings are required. Most of the hairs are removed in 4 sittings. With each sitting, results go on improving. Rarely hair having fine texture may regrow. People who have hormonal imbalance or who have waxed or plucked hairs need more sittings. Q. How much time is required for each exposure per sitting?

Ans: LASER removes hair with high speed and without causing pain as compared to electrolysis: For removing hairs of back, LASER method which requires one hour and for electrolysis method requires 125 hours for some extent of area.

Ans: Your skin type and hair type is decided. What you expect is taken into consideration. Some test spots may be given.

Q. What precautions should be taken before taking treatment?

Ans: Patient of darker skin should use bleaching regimen at least two weeks prior to the first sitting. Stop bleaching or plucking hairs two weeks before treatment. It is better to shave 2 days earlier so that residual hairs will be very mall. Shaving reduces treatment time.

Do not take Laser treatment when you have suntan or sun burn.

Q. What post treatment precautions one should follow?

Ans: After hair removal treatment that part of the skin may appear slightly red and may have bumps. Cold compression helps to reduce it. Use moisturizer. Make up may be used. Use sun block of SPF 25 or more for 2 weeks.

After 2-3 weeks hairs from hair follicle will fall out. It may seem as if there is new hair growth. With the help of wash cloth these can be removed. One can shave hairs in this period.

If one notices cold sore or genital herpes, start antiviral Tab. Zavirax (Acyclovir).

Q. What is the mechanism of removal of hair by Laser?

LASER energy is attracted by colouring pigment in hair follicles. When Laser rays are absorbed by the cells of hair follicles, light energy is converted into heat energy and so these cells are destroyed. Such hair follicle destruction also destroys the secretary sac. In other procedures of hair removal secretory sac continues to send out new hair even if hair is repeatedly destroyed and even if it is ripped out by the roots. But this does not happern in case of LASER hair removal.

Laser can destroy hair follicle by photothermolysis of pigmented cells containing melanin. Laser is absorbed by these cells and not by other cells in the skin and thus destroys only the cells of root of hair. Some laser is absorbed by upper layer (epidermis) of the skin.

Q. How the skin is protected during laser hair removal?

This layer is protected by keeping it cool. Upper layer is saved by laser energy by using laser having long wavelength e.g. Nd: YAG). To protect skin, the laser exposure is given only for few millisec.

Q. Which is the best painless method and permanent method to remove hairs? What about other methods?

Ans: LASER hair removal is the most modern, the most effective, painless, best and permanent method of hair removal approved by Food and Drug Administration (FDA), USA. This is non-invasive procedure. Many hairs are targeted in a single light flash. Hairs, which respond to laser treatment, do not recur or grow again forever.

Some people use uncomfortable and unsuitable techniques like abrasive live pumice stone, depilatories threading, plucking, and waxing. These are painful and messy methods. These methods give temporary results. Electrolysis is available since few years to remove hairs permanently but it is invasive painful procedure. It involves insertion of needle into each root of the hair and delivering electrical charge. So, it has higher rate of complications. It needs repetition after a few months and sometimes years. As one individual hair is electrolysed at a time, it is time consuming method.

Q. Who should undergo Laser hair removal?

Ans: 1. If you are intelligent woman who no longer wants to be wishing in the four walls of home and if you want to mix with people without embarrassment due to your unwanted hair, you need to undergo LASER hair removal. If you are working in public offices or daily if you coming in contact with many people for business or profession or service then, it is better to undergo laser hair removal. Young girls of marriageable age should undergo laser hair removal. 2. Those who want to look smart and dress well must think of unnecessary hairs on the face and rest of the body. 3. Those who have unnecessary hairs on the area above lips, eyebrows, area between eyebrows, cheeks, pinna, neck, axilla (including arm area), arms, legs, chest area (including mammary area), bikini line should be thought of. 4. Many men want to be free from shaving everyday. Some are tired of dense beard hairs, thick hair and rapid growth of hairs. So, to reduce the number of hairs, or to eradicate hairs on chin and cheek, male may undergo laser hair removal. Common areas of unwanted body hair of women vary from unwanted body hairs on men. For everybody more than acceptable number of hairs on the body is embarrassing.

Q. Why Nd-YAG is used and preferred over the other LASER SYSTEMS?

Ans: It is absolutely best LASER currently available for any skin type. It suits most to most of Indian skin type. We also use intense light pulse for better results of hair removal. These are safe, reliable, painless and permanent methods. We have chosen it because of its proven results and unmatched track records of the experts all over the world. The long wavelength system of Nd: YAG LASERs helps to work in both light and dark skinned persons with least risk. It is approved by Food and Drug Administration of America. Now all over the world majority of people have reference to undergo Nd YAG Laser hair removal.

Q. Why Nd: YAG is preferred over diode laser?

Nd YAG laser has a longer wave length than diode laser. So, when Nd: YAG is used, less energy is absorbed at epidermis level and more energy is absorbed at deeper dermis level where route of hair is present. As wall of hair follicle has cells containing melanin and other surrounding tissue does not contain melanin, by Nd YAG laser damage to the hair follicle is more & deeper and damage to surrounding tissue is lesser. So, also, effect of Nd: YAG Laser, sub ablative rather than destructive, in comparison to diode laser. As Indian skin has less contrast with hair, laser longer wave length like Nd YAG is preferable to protect dermis.

As diode laser rays are absorbed more by melanin which is at superficial level as compared to melanin of the wall of hair follicle, so, less energy reaches at greater depth of hair bulb follicle. So, effective fluence of diode laser is the ichest in lesser quantity as compared to effective fluence of Nd YAG. Nd: YAG laser rays are less absorbed by melanin of basement layer in epidermis and more energy reaches at greater depth where follicle is present. So, hair follicles are destroyed in better way by Nd: YAG laser as compared to diode laser energy.

Q. How Nd: YAG LASER and Intense Light pulse works?

Ans: Flashes of LASER Light pass through the skin. These rays are absorbed by the pigment melanin which is present at the bulb of hair root. Such absorption destroys the root of the hair. 4-8 sittings are required at interval of 4-6 weeks for permanent hair removal.

Q. Why cost differs from clinic to clinic?

Ans: Cost differs from location to location, depending on type of LASERs. Generation of LASER SYSTEM used and facility of use of other LASER SYSTEM as adjuvant treatment for better results.

Q. How does hair grow?

Ans: Hair follicle is a punch like depressed tunnel in the skin. Hair follicle occupies a space in superficial part of skin (epidermis) and deeper part of the skin (dermis). Hairs are in 3 phases: a) Active growth phase (called anagen phase): It lasts for several years. At any given time about 85% of our hairs are in this phase. In this phase, hairs have abundant melanin, b) Regressive or catagen phase: In this phase, hairs stop growing but these hairs do not shed. About 3-4% body hairs are in this phase at a given time. This phase lasts for two weeks. Resting phase (telogen phase): In this phase, hairs fall out and new hairs begin to grow. This phase lasts 5-6 weeks. Approximately 10-13 per cent of our body hairs are in this phase at any given time.

Q. Describe structure of hair?

Ans: We see hair shaft outside the skin. It is keratinized hardened tissue. Hair shaft, which grows from the base of pouch like structures below the skin, is called as hair follicle. Thicker pigmented hairs are terminal hairs. These are thicker and pigmented. We consider these as real hairs. These are present on the scalp, eyebrows, legs, and backs.

Most of our hairs are fine and pale hairs (vellus hairs), so, even though we have more hairs than chimpanzees and gorillas per square inch of the skin, we do not appear hairy.

We believe in 3D performance

A)Your performance, b) our performance and c) technical performance. So, we are leaders in technology. Now or never. Now your beauty is in your hand. Take our help. Never in city such help was available. Never before beauty was so improvable. If you are beautiful, we will help you to improve more. If your are not, we will make you beautiful. Beauty is for presentation, confidence and social acceptability.

Beauty is for better confidence, better job, better efficiency, better success and best life.

What is indeed patient's view? What is our view? What is technically feasible? We always think three dimensionally by considering all these three questions and answers.

E xcess hairs on the back and on the chest:

Hairs on back and excess hairs on the chest is disgusting in men. To apply depilatory creams and to shave is not possible for one. Waxing and electrolysis is costly in this area. It takes a lot of time. Laser hair removal is cost effective and requires less time. Hairs on chest can be a sign of masculinity but excess hairs are embarrassing. Patient may use shaving, depilatory cream, waxing or electrolysis but LASER hair removal is ideal and effective treatment. Since recent few years, LASER hair removal is becoming popular amendment. Other hair removal methods are thought as costly, time consuming, tedious and painful.

Leg hair removal:

every six weeks. Electrolysis takes longer time and costs more than treatment by Laser. Hair removal Laser hair removal from legs 1 to

1 ½ hours is required and results are permanent.

Genital or pubic hairs:

To remove hairs by non-LASER method, from bikini and pubic and genital area has its unique problem. This area is prone for itching, irritation, ingrowth of hairs. Shaving causes micro injuries in this area and this area is less prone for healing (due to sweating and closed space) as compared to face (which is more exposed to dryness). Hair removal creams or depilatory creams are if left for longer period may cause chemical burns and their results are temporary. Ooouch bikini waxing and Brazilian bikini waxing hurts after sometime. Electrolyisis requires some outgrowth and rocedure takes longer time. All these methods can exacerbate feeling of itching, irritation and ingrowth of hairs. Rarely laser may induce hypertrichosis in non treated areas.

After Laser treatment, sometimes, regrowth of other hairs is seen. But these hairs are thinner and lighter in colour. So, these are less noticeable or not noticeable.

Therapist takes history of patients expectations, medications, history of scarring, previous hair removal strategies, local infection, endocrine status, recent sun exposure, patients habits and medications. History of use of minoxidil hampers hair removal. Patients on hormonal therapy and patients with endocrine abnormalities of those who have past attempt of hair removal or patient with skin diseases may likely to have poor results. Let therapist know hobbies and habits.

Precautions which user should follow:

•  Laser light can cause permanent damage. So, never look directly into hand piece even when wearing protective eye wear. Do not use metallic or effective surface in the room. Never allow any one near laser which in us, without proper protective eye wear.

•  Do not keep inflammable material in laser room. (e.g. rubber, ether)

•  Before using laser let the applied spirit get dried.

•  Never point laser at reflective objects such as jewellery.

Laser hair removal and photorejuvenation:

•  In light skin and dark coarse hair: In light or fair skin epidermal protection is not required. The minimum pulse width can be used. Reduce fluence by 10% on bony area. In case of fine hair more fluence is required. In case of coarse hair less fluence is required.

•  In dark skin / coarse hair: Provide epidermal protection. Use longer pulse width. Take help of precooling and post cooling. First give test dose and look for redness and pain sensitivity of patients. Review patient after 12-24 hour for delayed signs. If there are signs, reduce fluence by 10%. If there are no signs, repeat the same sittings.

•  Post treatment:Use cold aloe vera gel to prevent burning sensation. In case of burn, use antibiotic cream. Prepare video clip of satisfactory patients.

1.5 Hair Loss & baldness:

Results of hair transplant or replacement surgery depends upon texture, colour and weaviness / curliness of hairs, age of the patient, number of remaining hairs, illness status of the health. The effectiveness of drugs used to repair hair loss varies from person to person and underlying causes of hair loss in perennial case.

Different causes of Hair loss:

Loss of hairs of scalp is called alopecia. Loss of hair is due to multiple causes like skin diseases, nutritional deficiencies, imbalance, harmony and stress. In males, loss of hair on scalp is due to androgenic alopecia. Individual genetic predisposition to balding and androgenic hormones affects development of baldness in males. Aging increases hair loss.

Baldness is often wrongly blamed for vitamin deficiencies, dandruff, poor circulation of blood in scalp and excessive hat wearing.

Signs of Balding:

a) Miniaturization of hairs: This is first sign of balding. Active growth phase of hairs in anagen phase are gradually become briefer and briefer. So, hair becomes finer and shorter and less deep in colour. Due to aging, these hairs no longer provide good coverage on the scalp. The ratio between the hairs in anagen phase and those in telogen hase or resting phase is increased. So, hairs in telogen phase increase in number. Number of these hairs in telogen phase increases in area where there is a tendency of baldness. E.g. front part, top part and crowning of the head. These changes do not affect so called 'permanent zone' which is horseshoe shaped wreath of hairs around the back and sides.

b) Easy dislodging of the hairs: Second sign of balding is easy dislodging of hairs during washing, drying or combing. These hairs are seen on the comb, towel, pillow-cover or bath room drain. One may feel shocking on observing this second sign.

Different types of Alopecia:

a) Androgenic alopecia: It is common pattern of hair loss is androgenic alopecia (male pattern and female pattern of baldness). •  Alopecia aerata- in such baldness, discrete patches of baldness are observed on the scalp. They tend to occur in triangular pattern in temporal area.

•  Alopecia universalis: In this condition, entire body may be affected.

•  Toxic alopecia: It develops after severe sickness, pregnancy, high fever, chemotherapy, hypothyroidism, hypo function of pituitary.

•  Cicatrical (scarring) alopecia: It develops after tissue destruction and inflammation.

•  Diffuse alopecia (Patterned and unpatterned). It may happen in all areas of scalp i.e. permanent zone and areas vulnerable to baldness. To find out the cause complete physical check-up and laboratory work up is necessary. Scalp biopsy is taken.

Hair loss in females:

There are 3 inter dependent factors that participate in common type of baldness. These are hormones, genetics and father time. Follicles are continuously exposed to DHT. So miniaturization of hair takes place. Due to thinning of hair balding develops. The individual begins to see larger number of hairs on the comb, the towel, the pillow cover and in bathroom drains. For a youth, it is traumatic experience. Beginning of baldness is seen in 3% women at an age of 20 years. In 25% women at an age of 50 years and 30% women at an age of 80 years. Baldness in women is often underestimated because women try hard to hide baldness. In women, there is no recession of hairline. I.e. they retain anterior hairline. Women have baldness in the form of diffuse thinning due to diffuse hair loss throughout the mid scalp. Females lose hair in the late thirties and it reaches its peak at the age of fifty years when testosterone level falls.

Sometimes female has baldness like standard pattern of baldness in males. It can be exacerbated by androgen (testosterone) hormone therapy. Such women have recession of hairline. They have loss of hairs at temples and crown area. If such patient has elevated level of androgenic hormone, they cannot be benefited by propecia.

5% Rogan halts further hair loss and some regrowth of hairs takes place. 2% Rogan is used in female but for effective results, 5% concentration may be used under medical care. Individual may develop side effects like itching and redness on the scalp. Heart medication like spironolactone (Aldactome) block activity of androgens. Women on this medication may develop irregular menses, mood swings and breast tenderness. Both of these medicines may be used indefinitely.

Male pattern of baldness:

Male pattern of baldness starts due to high level of testosterone (Androgens). It begins in the late twenties. It begins with recession of the anterior hairline and generally all hairs are lost in front of recessing hair line. Hair loss is felt as surprise once it is developed. Pattern of hair loss may be different in men and women. Androgenic alopecia or male pattern hair loss is most common. Baldness in males is 'male thing'. It may be inherited. So, also female androgenic alopecia for female pattern baldness is common type of hair loss in 20% women. It may be inherited. Thinning of hair is acceptable only in women of very old age. Pattern of hair loss is not easily recognizable as those in men.

Pattern of hair loss in female androgenic alopecia:

•  diffused thinning of entire scalp with

•  More hair loss in front part of the scalp not involving frontal hair line or involving frontal hair line.

•  Diffuse hair loss with thinning towards the back of the scalp.

•  Alopecia areata: Hair loss in patches. So, islands of retained hair develop. It is a recurrent disease in scalp and eye brow area. Hairs usually grow back in 6 months to one year but hair loss in some area may recur in future. It may be autoimmune disorders. Anxiety and stress aggravates. Use corticosteroids locally, topically or by injection. Minoxidil (Rogaine) may help. If disease is old, results are poor. When hair loss affects whole scalp it is called alopecia totalis.

•  Triangular alopecia: hair are lost in temporal areas. It can be treated surgically or medically.

•  Scarring alopecia: It is due to scar in that area. Disease can also cause scarring e.g. autoimmune condition like lupus erythematous. Scleroderma, bacterial infection (folliculitis), fungal infection and viral infection (Herpes zoster).

•  Trichotillomania: Due to psychological and emotional reasons patient has compulsion for pulling hairs in selected areas. Psychological cause should be treated.

•  Traction alopecia: Some women do tight braiding or corn row hair styles. So, she loses hair at hair line. Some men attach hair pins to some hairs over a long period of time and so these hairs are lost.

When baldness is in progress, hairs gradually reduce in diameter and length. Slowly most of baldness areas are affected. Gradual hair become fine (vellus) and lighter in colour. Inheritance of baldness may be from father's side or mother's side.

Daily trauma of combing and washing affects hair in resting phase (telogen) and so hair in resting phase are susceptible to hair loss.

Incidence of androgenic alopecia is more during and after menopause.

There are 3 patterns of hair loss:

• Grade I: Thinning of hair on the central scalp (top of the head)
• Grade II: Thinning of hair and patches of greater scalp of hair loss
• Grade III: Male pattern of hair loss at the front of the scalp to mid scalp.

Temporary hair loss is not treated with hair transplant.

Hair loss can be first sign of medical condition. It should be treated fully before considering hair transplant. Note hair colour, hair texture, degree of hair curl, skin to scalp hair colour contrast during hair assessment. Surgeon creatively uses colour, texture and curl of transplanted hairs to complement existing hairs and recreate an appearance of density in area of diffuse hair loss.

Telogen effluvium:

Hormonal imbalance, deficiencies of nutrients, stress and certain drug may cause it. Large percentage of hairs are shifted in shedding phase and so hair loss develops.

Loose anagen syndrome:

In fair haired person, scalp hairs become loose in hair follicles and so they lose hair by pulling or combing. It is seen in childhood. As person ages it improves.

Due to normal cyclic activities of hair growth everyone loses hair from infancy to old age. Hair follicle goes through complete hair growth cycle 10-20 times over a normal human life time. On an overage about 100 hairs may be lost daily in full head of hair. When person realizes, hair loss or growing baldness, different questions and doubts arise in his mind like "Will I lose hair permanently? Will I be really bald? How much baldness may develop? Can it be prevented? Person's stress increases due to such questions in his mind and his efforts to find real answers. When a person realizes hair loss or thinning of hairs on the scalp, he should start medical line of treatment for hair restoration at earliest. After pregnancy, hair loss may develop due to decreased levels of estrogen and more hairs shift into catagen phase. In pregnancy, catagen phase of hairs is arrested. Post fever and post traumatic hair loss can also develop.

It is difficult to predict who will have baldness at early stage. If father has baldness at early stage, son may develop it at his early stage also. There is always inherent tendency of untainted progress of baldness. All men and women produce 'male hormones' but in different concentration. In certain cells of hair follicle and sebaceous glands, there is a high level of S-alpha reductase enzyme, which converts testosterone into dihydrotestesterone. Propecia (finasteride) limits activities of 5-alpha reductase enzyme.

When woman consults for aesthetic purpose in hair loss, she should let the doctor know what she feels about her appearance and how she wants others to perceive her. What hair style she is using to reduce appearance of thinning hair, which hair style she would use after hair restoration, will she change her hair style, curl, colour after the hair restoration. Does she want a luxurious head of hairs which may require procedures like hair wearing and hair extenders.

Patients, with hirsutism, may have acne, seborrhea, obesity, acanthesis nigericans, ovarian tumours, hypothyroidism. So, ask to do USG of abdomen and T3, T4 estimation, 20% of them may have tubo ovarian mass. Idiopathic hirsutism is the most common. But hormonal assessment is done for medicolegal reason.

Cryptoteron acetate:

It can be given for 3 years with a gap of 2-3 months at 6 months interval. 80-100 mg cryptoferon acetated for 10 days prior to menstruation lie from 15 to 25 th day) low dosage of CPA (2 mg to 35 mg with ethenyl estradiol for 21 days of each menstrual cycle can also be given. Side effects: Weight gain, fatigue, loss of libido.

Spironolactones: 100-300 mg /day, side effects: abnormal menstrual cycle, tenderness and engorgement of breast.

Fenosteride 5 mg daily, oral contraceptives, metformin - a biguanide.

Gently pull some hair & if you get 4-8 hairs at a time, it is significant telogen effluvium.

Shave area & see after 48 hours how many hairs have grown.

1.6 Dandruff Baldness:

Two in every three men go bald and one in four women suffer from hair loss. For women, hair loss is cosmetic death. In females, hair loss results in severe thinning of mid scalp. Hair on the top and back of the head becomes sparse. In women lion's share of hair loss is by androgenic alopecia.

Dandruff:

Dandruff, seborrhea (excessive oiliness), seborrhoeic dermatitis (oily crusts adhering to inflamed itchy moist scalp skin) are common conditions of the scalp. Dandruff is mild form of most common scalp disease. It is due to little more than normal shedding of dead skin cells from the scalp. White flakes accumulate and adhere to the scalp. These fall on clothing, bedding, furniture. In excess oily scalp, flakes accumulate in more quantity and adhere to hair in whitish globs. When oil secretion increases e.g. in puberty or when androgenic (male) hormone are out of balance excessive oiliness crusting and itching may lead to development of seborrheic dermatitis. Dandruff is without medical consequence. Mild dandruff can be effectively managed by regular use of mild anti dandruff shampoo once or twice in a week over the counter shampoos contain ketoconazole, zinc pyrithione tar and selenium oxide. Use of minoxidil can cause or worsen dandruff in some patients. So, scalp irritation, dryness and itching increases and scalp may be broken and bleeding may develop. It develops more in winter when air is dry. Stop minoxidil or reduce its dose.

Scaly scalp :

Scale full on the collar & other parts. Dry scale can be seen in psoriasis. Systemic methotrexate is given.

Seborrhoeic dermatitis causes greasy scaly scalp.

Topical steroid with oral flucanazole, kencornazole, iatraconazole can be given.