A Discussion on Hair Transplant Donor Management Guidelines

For people looking to restore their hair through multiple hair transplants, particularly young people, good donor management is critical to the individual’s successful outcome. Donor hair management is evaluated by three major factors: the person’s age, the person’s degree of hair loss, and the person’s donor availability. These factors will determine what a hair transplant surgeon recommends for surgery in regards to amount of grafts, hairline design, and areas covered. For example, a surgeon would most likely recommend a more conservative hairline and graft amount for the first procedure of a 24 year old man who had thinning at his hairline and crown, compared to what would be recommended to a 40 year old man with only recession at his hairline. Overall, the general rule of thumb for hair transplants has been to be conservative because hair loss continues and donor hair has a limit to it. A practical and intelligent approach, indeed.

Diagram of Donor Regions

But what if we weren’t limited to a finite amount of donor hair anymore?

It’s been dreamed about forever, talked about for decades, yet is extremely likely that we will actually have the capacity to create more hairs than what we started with within the next couple years. I mean like, within the next term of our next president. The two front runners to bring this technology to market are Replicel and Histogen. Let it be stated clearly that, of course, nothing in the future is guaranteed. But, if you’ve been paying attention to the world of hair regeneration technology, and regenerative medicine in general, over the past 8 years, you’d have a reason to believe that the current estimated timetable for the release of one of these products is likely.

I’m not basing this discussion on just these two companies. They both do have a high potential to put an effective hair growth therapy on the market within the next 2 years, but of course there are others. The human scientific capacity as a whole multiplies every year, and every year there are more researchers actively working to crack the code of unlimited hair regeneration. The point is, things are changing and there is enough evidence to believe we will have a multitude of advanced hair technology within the next decade.

So, what about donor management then? Does it still have the same significance that it did 10 years ago? As far as I can see it, the answer has to be “no.” I want to make a few points clear as I get into the heart of this discussion. First off, I definitely do not think that it is entirely responsible or prudent to completely throw the idea of donor management out the window because we seem to be a few years away from a regenerative hair technology. I will also acknowledge that it is a lot easier for me to have my stance on this subject than it is for a hair transplant surgeon who actually has to perform surgeries and is responsible for their patient’s outcomes. I simply wrote this article because I believe it is time to start having this discussion. Still, to imagine a surgeon reasoning with  25 year old patient about conservation and “what he may look like in 20 years” does not seem completely in touch with reality to me. Even a conservative outlook would acknowledge that in the course of the next 20 years the world of hair restoration will be in a remarkably different place than it is now.

I wanted to hear the opinion of a professional who deals with this subject everyday. Dr. John Cole, a surgeon in the field of hair restoration, had this to say on the subject:

“Enthusiasm is contagious and stimulating. It is fascinating to think we are on the brink of major breakthroughs that will give us an unlimited number of hair follicles. Indeed we have numerous products directed at numerous different pathways of hair loss both from the perspective of hair regeneration to the reversal of hair loss. There are numerous products directed at the WNT pathway. We are bringing a WNT up-regulator product to the USA from Italy, which is known as Deltacrin.

However, the question is whether we can be more aggressive with hair line location and with the hair we harvest from the donor area. By age 49 sixty-seven percent of men are a NW 2 or worse. Thus, when we design a hairline, the first thing to consider is whether we want to be married to a youthful hairline the rest of our life.

From the perspective of donor area management, we are already more aggressive today than in 2005. We are going outside the traditional donor area for a variety of reasons. One goal is to focus on an even distribution of follicles throughout the scalp. This is best accomplished by harvesting outside the traditional safe donor area. We must remember that only three percent of men will lose hair higher on the sides of the scalp by age 60, so why not give them hair when they are younger and they can appreciate it. Another reason we are more aggressive is the use of Acell in the donor area extraction sites. We found that with a minimum depth FUE approach and the use of Acell to stimulate follicle stem cells, we could not locate 48% of the donor extraction sites. Without Acell, we could find all of the extraction sites. In one study we saw follicle regeneration of at least one hair in 42% of our extraction sites.

There is plenty of reason to be optimistic about the potential for follicle regeneration and follicle resurrection. As suggested, the hair restoration surgeon cannot take chances with the future of young patients because there is no guarantee that current advances will create an inexhaustible supply of hair nor that the advances will work well in all individuals. Yes, it appears that advances are around the corner, but there is still no way to predict how many blocks away that corner is.”

Dr. Cole made a great point about being married to a youthful hairline for the rest of one’s life. It is definitely something that should be considered before a surgery. I don’t personally see it as a deal breaker. If having a youthful hairline for the rest of one’s 20s, then 30s and 40s meant that they had to have the same hairline at age 70, it seems like a fair deal to me. Even if surgeons rightfully so do not change their donor management strategies just yet, I do believe it is time for some to begin pondering that the next 20 years of their practice will be different than their previous 20 years.

This is a great start to the discussion. Please feel free to share this article or add a comment.