1. What's new in how you perform hair transplants today?

2. What do you mean by "Natural Hair Groupings" and how is this a benefit?

3. What is the stereoscopic microscope and how is it a benefit?

4. Dr. McAndrews has been featured on ABC News, CBS News (Special Assignment), Fox News, KCOP (Channel 13) News, Good Day LA, and other News channels.  What's different about your office?

5. Do I need to wait until I am completely bald to have a hair transplant?

6. How many hair transplant sessions will I require to achieve the density I desire?

7. What about "Scalp Reductions" and "Flaps"?

8. What about "Laser" hair transplants?

9. What about mega-sessions?

10. What about repair work?

11. What are important qualities for a hair transplant surgeon to possess?

12. Do you believe you need to perform three hair transplants a day, five days a week to be the best hair transplant surgeon?  Why do you do only one hair transplant a day?

13. Do hair transplants hurt?

14. Will I have any scars?

15. What is "Follicular Unit Extraction" and how is it different from the "strip excision" technique of obtaining the donor hair?

16. Are there people who should not have hair transplants?

17. You teach the residents at USC/LA County Medical Center about hair transplants. Why do you do this?

18. One of your patients, who had his first hair transplant at one of the "Big Hair Transplant Clinics," before coming to you, was surprised to find you were involved in every step of the process.  Why should he be surprised?

19. Many of your patients are quite concerned about their anonymity. How do you assure this?

20. How much does it cost?

21. Do you show pictures?

1. What's new in how you perform hair transplants today?

There are two recent innovations that have revolutionized hair transplants.  The first is transplanting each individual natural grouping of hair as a unit and the second is the use of the stereoscopic microscope to dissect the hair to be transplanted into follicular units.

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2. What do you mean by "Natural Hair Groupings" and how is this a benefit?

Hair does not just come out of the scalp individually, one by one, but actually grows naturally in groups of one to four hairs with a fibrous sheath surrounding group.  Since that is how God designed everyone’s scalp, that is how I perform a hair transplant.  I transplant the single hair grafts on the hairline and the natural groups, with three and four hairs, farther behind for density.  The benefit of transplanting individual, "natural hair groupings" is the completely natural look I achieve and the higher survival rate of the transplanted grafts.

To try to obtain a natural look, many doctors now perform transplants with what is called "single hair micro grafts." They separate the "natural hair groupings" into single-unit hair grafts and transplant the hairs individually. By separating the natural groupings of hair, the transplant surgeon is going against nature. A study published in the Journal of Dermatologic Surgery showed that the survival and quality of these grafts markedly decreases. (Follow this link for photos and results of this study) I think God is an excellent architect; therefore, I try to mimic his pattern, instead of trying to change it.

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3. What is the stereoscopic microscope and how is it a benefit?

The stereoscopic microscope is probably the most important innovation in hair transplants. The "natural hair groups" must be preserved intact during dissection to insure increased survival and growth. Many doctors dissect with the naked eye or with minimal magnification. That leads to increase transection and destruction of the hair. When dissecting the donor hair without the stereoscopic microscope it is nearly impossible to ensure that the "natural hair groupings" will remain intact.

For a balding man seeking a transplant, his most precious commodity is his donable “hair bank.”  The use of the "stereoscopic microscope" to dissect the grafts enables me to visualize each and every individual "natural hair grouping."  By using the "stereoscopic microscope" the trauma to the surrounding hair is greatly reduced and our patients receive superior quality grafts with a much higher incidence of survival.  I can now achieve survival rates of 95 to 100 percent, as compared to other techniques where the survival rate is much less.  The "stereoscopic microscope" also enables us to trim excess tissue away from the hair follicle, therefore, smaller incisions can be made, which enables us to pack the grafts closer together to give a denser look.

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4. Dr. McAndrews has been featured on ABC News, CBS News (Special Assignment), Fox News, KCOP (Channel 13) News, Good Day LA, and other News channels.  What's different about your office?

I strive to be on the forefront of hair transplant technology.  Using technologies like the stereoscopic microscope and the "natural hair grouping grafts," I provide my patients with the best hair transplant results and the highest level of care.

There are vast differences in our office’s philosophy and our approach to a balding patient, when compared to the mass-marketing hair transplant clinics.  I believe in treating our patients, as I would like to be treated, with that in mind:

• I perform only one hair transplant a day with the assistance of a very experienced staff. Our undivided attention on the day of the hair transplant belongs to that patient, because we realize this is one of the most important commitments a patient will ever make about his or her appearance.  I want my patients to feel assured that I am not rushing through the procedure because I have other hair transplant going on at the same time or that another is scheduled after the procedure.

• I am personally involved in every step of the hair transplant.  I do not believe that the responsibility for the procedure should be handed off to a medical technician.

• I have always been a patient’s advocate.  I spend time educating each patient before a decision to proceed with any procedure is made.  I believe that it is very important to completely address every concern and answer every question a patient may have. When necessary, I explain why a hair transplant may not be the best solution for the patient.  It is my responsibility as a physician to always do what is in the best interest for my patient.

• I always respect the patient's desire for privacy and confidentiality.

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5. Do I need to wait until I am completely bald to have a hair transplant?

The insertion of hairs between your existing hairs, leaving them undisturbed, can systematically restore density to your scalp hair. Thus, the grafted hairs may compensate for the loss of your natural hair. The successive placement of many of these grafts over several sessions can even prevent the appearance of baldness in selected patients with remaining, but thinning hair.

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6. How many hair transplant sessions will I require to achieve the density I desire?

Grafts can generally be situated no closer than 1/16 inch from each other without potentially sacrificing the blood supply. However, normal human hairs are located much closer together than this. Thus, the average person usually wants two to three sessions in order to achieve their desired density. The timing of these sessions depends, of course, on the rate of progression of loss of remaining natural hair and the needs of each patient. Generally, sessions are spaced at a minimum of six to eight months apart in order to allow the new grafts, and blood supply, to become established. It is important to realize that a dense result cannot be achieved with one session of micrografts.

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7. What about "Scalp Reductions" and "Flaps"?

I have performed scalp reductions and “flaps” in the past, but with the current state of hair transplant technology, I can achieve far better and more natural looking results with the natural grouping of micrografts. I no longer perform scalp reductions or flaps because I do not see any advantage in those procedures and because the risk to the patient is much greater.

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8. What about "Laser" hair transplants?

New technology should only be used if its benefits outweigh its risks. The benefit to the doctor is that there is less bleeding using a laser. This is of no benefit to the patient and actually is a huge detriment because it can diminish blood supply to the transplanted hair.

The down side of the laser procedure is:

• It can stop all bleeding, which is needed to nourish the hair transplant (it's like trying to plant seeds in dry soil).

• There are studies showing a decreased survival rate for grafts.

• It can destroy existing hair or prior transplanted hair in the recipient area.

• The transplanted hair, if it survives, takes longer to grow in. With the present state of laser technology, I cannot ethically use it on my patients and I definitely will not use it to market my practice. After all, the goal of performing any procedure should be to benefit the patient, not the transplant surgeon.

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9. What about mega-sessions?

I am not a big fan of "mega-session" hair transplants. The reason for this is simple. Many technicians from the mega-session hair transplant clinics are relating in to the hair restoration journals that they are noticing a lower survival rate of transplanted hair in some patients receiving between 1,500 and 2,000 grafts in one session. As I said before, you only have a fixed amount of donable hair and I think it's unwise to potentially waste this supply because the doctor or the patient is in a hurry (I consider it like driving on the freeway. I know it’s generally safe to go 55 mph on the freeway. However, at what speed does it become unsafe? When I drive 200 mph, I just don’t know when I am going to crash; therefore I feel it is reckless and foolish to do so.) I just do not understand why so many doctors and hair transplant technicians are trying to push the envelope of safety.

There is only one constant in hair transplants and that is the "Donor Bank" in limited. It is of utmost importance not to compromise by rushing the desired outcome, a natural looking head of hair. I will continue to be conservative about the amount of follicular units I transplant in one session; speed is not to the essence when it comes to hair transplantation.

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10. What about repair work?

Unfortunately for our patients, much of our practice deals with repair work. Almost all the corrective surgery patients that have the "cornstalk" look or the unsightly "flaps" along the frontal hairline that need to be corrected for the patient to have a more natural hairline. Even the patients with abnormally low hairlines can have previously “installed” plugs removed, dissected under our stereoscopic microscope, and re-transplanted for a more appropriate and natural looking outcome.

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11. What are important qualities for a hair transplant surgeon to possess?

There are many important qualities, but probably the three most important are:

• Proper training.  Any physician can legally perform hair transplants, even if they have no or little training.  I believe it is very important that hair transplant surgeon have formal training in hair transplants, under the strict guidance of a residency program or a fellowship.  It behooves a prospective hair transplant patient to look into the background (i.e.- training and malpractice suits) of the doctor they choose. (Follow this link to view Dr. McAndrews's curriculum vitae.

• Insight/Artistry.  It is very easy to make a hair transplant look good for the first five years.  What takes skill is to have the foresight and wisdom to plan a hair transplant so it still looks good in 20 years.  This comes with years of proper training and experience. One cannot learn this from reading a book or by taking a weekend course.

• Integrity.  This does not need to be explained.

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12. Do you believe you need to perform three hair transplants a day, five days a week to be the best hair transplant surgeon?

No, I believe quite the contrary.  If this were true, McDonalds would be a "5 Star Restaurant."  I believe that when you run an assembly line, the patient gets lost in the process and quality decreases drastically.  As doctors we are human, so we can only be at one place at a time.  If we perform three or four hair transplants at the same time, there will be two or three patients having the operation performed by the unsupervised technicians while the doctor attend to on patient.  I fail to see the quality in such a practice.

Why do you do only one hair transplant a day?

I believe in quality, not quantity.  Our patients deserve more than to be "herded" in and out of the operating room.  Our patients are quite discerning and they, rightfully so, would not tolerate this.  By doing only one hair transplant a day, they are assured that the focus of all our energy and attention for that day is theirs and theirs alone.  They will never feel like they are being rushed through a procedure.

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13. Do hair transplants hurt?

Most of our patients say it is a lot less painful than going to the dentist.

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14. Will I have any scars?

The strip excision hair transplant technique removes hair from the sides and the back of the scalp (good genetic hair) in order to transplant it to the balding area.  The benefit of the strip excision hair transplant technique is that it minimizes the surface area of donor tissue being exposed to “blind dissection.”  This tissue is then dissected with “full visualization” under the stereoscopic microscope into the follicular unit grafts. The strip excision hair transplant technique minimizes the amount of hair being transected, which in turn maximizes the survival of the transplanted grafts.

The strip excision technique should leave a fine line of a scar in the donor area that even a short haircut should hide.

Scar one year following the hair transplant.

The nature of the scar is affected by three main factors:

• The width of the strip taken.  The wider the strip taken, the more likely there will be tension on the suture line creating a spread scar.  Many of the mega-session clinics, out of necessity, remove very wide strips of scalp, which created the “bad donor scars” talked about on the Internet.  The width of the donor strip should be limited in order to create a fine line of a scar.

• The surgical technique of the physician.  It is important to find a physician who is formally trained in hair transplantations.

• The patient’s ability to heal.  Unfortunately, some patients do not heal as well as others.  For this reason, occasionally a patient develops a slightly spread scar, even in the best surgeon’s hands and with a conservative narrow strip.

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15. What is “Follicular Unit Extraction” and how is it different from the "strip excision" technique of obtaining the donor hair?

It is very important to understand the limitations of hair transplants because the limitations should dictate whether a technique or technology should be used.  The primary limitation of hair transplants is that there is a fixed amount of good genetic hair that can taken from the back and sides of the scalp to transfer to the balding regions.  Therefore, as hair transplant surgeons, we should do everything in our power to ensure the highest percent of grafts survive and grow.

When it comes to removing hair from the donor area (the hair bank), we remove this tissue blindly (i.e. - we cannot see what we have done until after we have removed the tissue) using any device {scalpel, multi-blade knife, punch excision, or follicular unit extraction).  This is a huge problem since the only time we know if we transected or destroyed these hair follicles is after the damage is done (after we have removed the donor tissue).  Therefore, it is best to have as little surface area as possible exposed to any device removing tissue.  Once we have this tissue out, we can then dissect it into smaller grafts (follicular units) with full visualization under a stereoscopic microscope (which immensely decreases the damage to these very precious and limited good genetic hair follicles).

Follicular unit extraction (FUE) is a slightly modified version of the old technique used in the 1960-1980's.  Instead of punching out 1-5 mm plugs and letting this tissue “granulate in (i.e.- heal on its own),” the follicular unit extraction technique punches out a 1 mm plug and then the hole in the donor area heals on its own, over the next week.  The advantage of the FUE technique over the “strip excision” technique is the patient is not left with a linear scar in the donor area.  The disadvantage of the FUE technique is that it immensely increases the surface area of donor hair being exposed to a blind excision technique, which leads to increased damage to the hair follicles and ultimately wastes the very limited donor hair supply.  This technique permanently removes this good genetic hair from the "hair bank" and replaces it with a "scar" (albeit a very small scar that is usually hard to see).

There have been no studies looking at the survival rate of the transplanted hair using the FUE method.  Neither has there been any studies looking at the potential destruction of the hair in the donor area.  There has been only one study published looking at the transection rate (which leads to poor survival rate) of the hair that was removed from the donor area and in this study there was approximately 20% transection rate in the “perfect candidates.”  The transection rate increased drastically in non-perfect candidates.

In contrast, the strip excision technique affects a smaller overall surface area, which limits the damage to the surrounding follicles.  The strip excision method should leave a fine line scar in the donor area, which even a short haircut should hide.  Unfortunately, many of the “mega-session clinics” and doctors remove too wide of a donor strip in order to obtain the necessary number of grafts.  This can often result in wide “spread” scars that are difficult to hide and often require further treatment after the hair transplant to minimize their appearance.  In addition, this scarring can cause unnecessary damage to the surrounding follicles, which also reduces the amount of good donor hair in the “hair bank”. (Follow this link for information on Donor Scars).

It is imperative that as hair transplant surgeons, we respect the limitation to a hair transplant and do everything in our power to use only those techniques and technologies that ensure the highest percent of grafts survive and grow in a person with limited donor supply.

I have been performing the FUE technique since 1994 and therefore feel there is a place for the follicular unit extraction (FUE) technique.  I perform this technique on patients with an unlimited donor supply (female with alopecia secondary to a scar) or a patient who absolutely does not want a linear scar in his donor area and is “fully informed” that the survival rate of the transplanted grafts is going to be much less.  I believe it is vitally important every patient is fully informed of the pros and cons of the different techniques in order for him/her to make an educated decision.

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16. Are there people who should not have hair transplants?

Hair transplants have a very high satisfaction rate, when we choose the right patients. Here are a few examples of poor candidates:

• It is a general rule that the young patients (18-25 years old) are poor candidates. However, there are now medications to treat androgenic alopecia that we did not have several years back.

• A patient who is unrealistic about what a hair transplant can accomplish.  If a patient's expectations do not match what I feel is realistic, then it is not a good idea to proceed with the surgery and I will not perform it.

• Finally, a patient who doesn't want a hair transplant, but is getting the transplant because  someone else wants the patient to.

As physicians it is our responsibility to educate patients on all the treatment alternatives, when they are not a good hair transplant candidates, and to tell them why they should not have a hair transplant.  Our number one responsibility is to be the patient's advocate, even if it's against their wishes.

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17. You teach the residents at USC/LA County Medical Center about hair transplants. Why do you do this?

A residency program is the setting in which a physician should be learning and perfecting his skills on certain procedures.  I feel it is my obligation to pass my knowledge on to the residents in training in order for them to perfect their skills on hair transplants.

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18. One of your patients, who had his first hair transplant at one of the "Big Hair Transplant Clinics," before coming to you, was surprised to find you were involved in every step of the process.  Why should he be surprised?

Many clinics that performing hair transplants have their technicians perform most of the hair transplant procedure.  The doctors at these clinics usually only remove the strip of donor hair and maybe makes the incisions in the scalp, and then they have the technicians do the rest of the hair transplant.  I believe the doctor should be involved in ever step of the hair transplant process.  Physicians have had extensive training on this procedure, more than any technician. Don’t get me wrong, there are some very experienced hair transplant technicians that  I absolutely trust, but I feel they should be assisting me and not replacing me in the hair transplant surgery.

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19. Many of your patients are quite concerned about their anonymity. How do you assure this?

We pride ourselves on the professionalism of our staff and realize the sacredness of doctor-patient confidentiality. We perform only one hair transplant a day so we do not have patients coming in and out facilities throughout the day. Since we perform only one hair transplant a day, we don’t need to have a large staff that is constantly turning over. We have a small, very experienced staff. We have never had a patient complain of their confidentiality being compromised.

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20. How much does it cost?

Prices vary depending on the extent of the hair transplant, the number of grafts transplanted, the site of the hair transplant, and whether the surgery is corrective. Our minimum price is $4000 and the average price ranges between $10,000 and $20,000. We accept checks, credit cards, and have a payment plan.

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21. Do you show pictures?

I do show pictures to patients, but there is something you need to know about the photos:

• For most of our patients, a hair transplant is a very private and personal matter; they do not want their pictures shown to other people.  We put an extreme value on the confidentiality of our patients.

• Pictures have been used in the past to deceive the patient.  Different camera angles or lighting can make a person’s hair look like a "before and after" on the very same day.  This is very misleading and gives the patients unrealistic expectations. We pride ourselves on matching expectations with reality.

• Pictures generally give patients an appearance of having more hair.

If a potential patient wants to see our work we have several patients that do not mind talking or meeting with them. When a candidate for hair transplants sees one of our patients in person, there is no way to deceive them; they see the results first hand.

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