Hi Pat,

I have a question for you regarding the Coalition. Do all of the physicians who comprise the Coalition use "lateral slits?"

Thanks,
GuitarPlayer

Guitarplayer,

As you and other knowledgable patients know, the standards for the ultimate patient friendly hair transplant surgery have shifted higher in recent years. Today clinics on the cutting edge (forgive the pun) should idealy be making very tiny incisions that enable them to dense pack grafts when appropriate for a patient. They should also have the staff and skill to preform large sessions when appropriate for the patient.

In this community this relatively new and patient friendly procedure is described as "Ultra Refined Follicular Unit Hair Transplantation".

Only those physicians who have mastered follicular unit grafting and stepped up to the challenge of performing Ultra Refined Follicular Unit Hair Transplantation with excellent results are eligable for membership in the Coalition of Independent Hair Restoration Physicians. To read more about these standards, click here.

As masters of follicular unit grafting members of the Coalition also pay careful attention to the angle, direction and orientation of each graft as it will determine the ultimate direction and angle of the hair's growth. Some use lateral incisions, while other members use sagittal incisions.

There has been a fair amount of debate among top hair transplant surgeons about the relative advantages and disadvantages of incisions made perpendicular to the direction of the hair's growth (also referred to as "lateral" or "coronal" grafting) versus incisions made parallel to the direction of the hair's growth (also referred to as "sagittal").

I have seen many surgeries in various top notch clinics using both parallel and or perpendicular incisions, with both incisions producing highly refined and minimally invasive outcomes. Physicians can carefully control both the angle and direction of the transplanted follicles using either parallel or perpendicular incisions. I have seen Coalition surgeons such as Dr. Charles, Dr. Hasson, Dr. Bernstein, Dr. Konior and others perform surgeries in which all the incisions were made perpendicular with excellent results. Yet I have also seen top surgeons like Dr. Jeff Epstein, Dr. True, Dr. Shapiro and others perform excellent and highly refined dense packed surgeries using parallel incisions.

Much of the advantages typically associated with the "lateral" technique such as dense packing and minimally invasive incisions are not due to the orientation of the incisions (either parallel or perpendicular) but to the tiny size of the incisions that many top surgeons like Dr. Hasson and Dr. Wong are now using. Some of the surgeons who are doing ultra refined follicular unit grafting with very tiny blades or needles do make their incisions perpendicular, in at least some areas, while others still prefer to use parallel incisions.

When visiting Dr. Ron Shapiro in Minneapolis a couple of months ago he took almost an hour to explain what he felt were the relative advantage and disadvantages of "perpendicular" incisions versus " parallel " incisions and why he prefers to use parallel incisions for most of his incisions.

Traditionally incisions made in the hair transplant recipient area were made parallel to the direction of the natural hair. My understanding is that most surgeons felt that such parallel incisions between existing hairs minimized the chance of severing existing hair follicles. Many also felt that since blood vessels in the scalp ran vertically that incisions made parallel to these vessels would severe fewer blood vessels and thus create less disruption to the scalp.

To help me visualize this Dr. Shapiro asked me to imagine the blood vessels in the scalp as spaghetti hanging down from the ceiling. Then to imagine a big sheet of metal cutting across the room perpendicular to these blood vessels. In his opinion this sheet of metal representing a flat blade would cut more blood vessels. He then suggested I imagine a sheet of metal cutting into the room parallel to these hanging vessels. In his opinion such a sheet or blade would tend to cut in between the vessels and thus cut less of these vessels.

However, since the blades that Hasson and Wong and other leading surgeons now use are smaller and less wide this traditional concern is now not as important.

In my opinion, the idea that grafts with two or more hairs will tend to fan out across the scalp and thus create a greater illusion of density has some merit. Dr. Shapiro also seems to feel this way and thus typically does create perpendicular incisions for the 3 and 4 hair grafts that are placed in the mid scalp regions.

I think the most important advances in the hair transplant surgery in the past few years has been the evolution from standard follicular unit grafting to ultra refined follicular unit grafting. Ultra refined work using very tiny blades and or needles enables surgeons to dense pack very small grafts, while minimizing trauma to the scalp. In addition the careful orientation of the grafts in terms of direction and angle has also improved as surgeons have mastered follicular unit grafting. This enables patients to potentially get one pass sessions with faster healing and completely natural results.

Thus given the honest difference of opinions regarding the relative importance of lateral versus sagittal incisions membership is not determined by this particular technical issues.

Thanks for the response Pat! Very interesting read. I feel like an expert now in regards to lateral and sagittal incisions.