Dr. Paul C. Cotterill

I have limited my practice solely to hair transplantation since 1986. I lecture internationally on the topic of hair transplantation and have been involved in giving numerous courses to new physicians around the world. I am one of approximately 100 physicians who have been certified by the American Board of Hair Restoration Surgery. Just as it is very important for the surgeon to perform all the surgery, it is equally important to have expert assistants assisting the surgeon. As mentioned previously, my office uses only the latest, cutting edge equipment and techniques, including the stereoscopic binocular microscope that is used to dissect every graft. As a result, I am able to offer state of the art follicular unit grafting to all my patients.


→ close ← Some physicians use consultants and others don't. I am one of the physicians who is strongly opposed to the use of non-medical consultants being used either before or after the patient sees the physician. While consultants may speed up the time of which the physician has to spend with the patient I feel that the time spent with the patient is one of the most valuable aspects of visiting the physicians office for the first time. This is the time when not only the patient gets to know the physician and gets an idea of what can and cannot be achieved with transplants, this is also the time when the physician gets to know the patient and can assess for realistic or unrealistic expectations. A non-medical consultant may not always have the patients' best interest at heart, but is really just trying to make a sale. I spend anywhere from 45 minutes to an hour with each patient in consultation. I also urge patients to return as often as they like with friends, family members, etc. I also encourage patients to see any of my other hair transplant patients to appreciate first hand the excellent results that can be achieved with hair restoration.

→ close ← More and more doctors that perform hair transplants are leaving a lot of the surgery up to nurses and assistants. Some doctors do not remove the donor strip or suture the donor area, do not make the recipient sites or plant the grafts themselves. I take a different approach and have become even more involved in the procedure. I feel it is crucial to the success of the transplant that the doctor remove the donor strip, suture the area, make all the recipient sites and assist in planting the grafts. The nurses and assistants, in my office, will prepare the donor strip and assist me in planting the grafts. In this way, I am intimately involved in overseeing all aspects of the surgery. I would also like to emphasize that I will only perform 1 operation at a time, and do NOT have other surgeries running at the same time. I see all my patients the following day when they return to have their hair washed, as well as seeing patients at 1 week when sutures are removed.

→ close ← Women also suffer from androgenetic alopecia (female pattern hair loss). I have given many lectures internationally on the subject of hair transplantation in women. A study that I performed* on 827 women over a 10 year period showed that 70% of women in consultation were candidates for hair restoration surgery. Some physicians do not like to treat women with female pattern thinning as they feel they do not make good candidates and have unrealistic expectations. This gets back to a previous comment I made in that it is paramount that the physician take the time at the initial consultation to assess for realistic and unrealistic expectations. In my experience (which is one of the largest groups of female patients having had hair restoration in the world) properly selected females make excellent patients and have excellent results. The next most common reason for female patients seeing me in consultation is a result of hair loss and scarring after face lifts. This problem is very nicely treated with hair transplants as are eyebrows that are thin or have been over-plucked in the past. *Application and Approach to Hair Transplantation in Females, The American Journal of Cosmetic Surgery, Vol 14, No. 2, 1997.

→ close ← My first pearl is take your time. Do not be in any hurry. When you see a physician for the first time bring prepared questions with you, ask lots of questions and see lots of photos. Be sure that the photographs that you are looking at are the ones of the physician you are speaking to, and that they are not retouched. How long has the physician been performing hair transplants?, does he do any other type of surgery?, what percentage of his practice is hair transplants? Does he advertise? Spending a lot of money on expensive advertising does not always mean that that physician is any better, or worse, than a physician who relies on referrals from other physicians or word of mouth from happy patients. Make sure the physician answers all your questions appropriately. Ask to see the offices and O.R.'s. Ask to see patients' of the physician. Make sure that the person you are speaking to is the person who will be performing the surgery, and is not a consultant. Does the physician offer different types of grafts and techniques? Some physicians like to perform only one type of graft or use only one type of technique. Because patients expectations, goals, hair characteristics, amounts of hair loss and future hair loss can differ, what may be best for one patient not be best for another. I offer different grafting techniques, different grafting sizes and approaches depending on what is discussed at consultation.

→ close ← Some physicians do not suggest or perform scalp reduction. While scalp reductions are not as important in as many people as they were prior to use of micro/minigrafting they are still very important in some patients. Scalp reductions are very important in patients who have a large wide bald area and limited amount of donor tissue, but also desire to have more of the scalp transplanted than otherwise could be attempted if reductions weren't done. Scalp reductions cut out bald or thinning scalp tissue and help to shrink the bald area so that the limited amount of donor tissue can be used to that much better advantage. Scalp reductions are not appropriate for everybody however, and successful hair transplantation can be performed in many patients without scalp reduction. This is something else that must be assessed at the time of the initial consultation.

→ close ← FUE is a relatively new technique whereby individual 1-3 haired follicular unit grafts are removed from the donor area at the back of the scalp, 1 at a time, using very small 1.0 mm circular punches. The benefit of this technique is that the traditional scalpel used in taking out a donor strip is not used. The resulting hole when a 1mm punch is used is so small that the hole does not need to be sutured and will heal with a very small scar. Some physicians market this procedure as , 'Scalpel - less and scar less'. This is misleading since a scalpel is used, not a straight linear scalpel as is used in the more traditional strip excision method, but a circular scalpel (biopsy punch), in stead. The skin is still cut and a scar is still made. It is just a very small scar. To be fair, the scar from the traditional scalpel is also very small, if done properly. A benefit of FUE is that there is the possibility of shaving the hair on the scalp right off, if the patient wants a shaved head at some future time. However a very big downside is that in young men with ongoing male pattern hair loss or in men with pre-existing male pattern hair loss, in order to get enough hair using the FUE technique thousands of holes need to be removed from the back of the scalp, the procedure can take 1-3 days, and the entire back of the scalp needs to be shaved. If a patient requires 1, 2 or 3 large sessions requiring 1000 - 2000 follicular unit grafts per session , then as one can imagine, the back of the scalp will begin to look very moth eaten, and scars will most likely be seen when the hair is shaved.

Dr Cotterill's opinion of FUE is that it is a very nice technique to be offered in certain select circumstances. But FUE is not appropriate for full, large sessions.

Dr. Cotterill will offer this technique, in addition to the traditional strip excision technique, in the following circumstances:

• If a patient requires a very small session such as to fill in a scalp scar or to fill in an eyebrow, and the patient does not like the idea of a linear ( straight ) scar in the donor area.
• If a patient requires only one, very small session and wants to be able to shave their hair right down to the scalp.
• If a patient has had extensive procedures in the past, and has only very limited donor area left and requires a very small session to the scalp.
• If a patient requires a very small session, has limited donor hair, and wants to use hair from another part of the body, such as the chest.

→ close ← As each patient is different in terms of: the amount of thinning, the amount of donor hair available, the amount of scalp to be treated in each session, and the type of graft to be used; it is impossible to give an exact amount per session, without seeing the patient first in consultation. Alternatively, some physicians charge per graft. The patient is charged for each graft whether it is a 1 hair graft, 2 hair graft, or 20 hair graft. I charge per session, however the fee may be more or less depending on the general size of session. It is important to know when deciding on the cost that a physician has given you, not only how many grafts, but also how many hairs are being transplanted in each session. As I have mentioned previously if a physician is to charge 'x' amount of dollars per graft for transplanting 2,000 one to two hair grafts you may be actually getting less hair than say a physician who transplants a combination of 700-800 grafts ranging in size from 1-2, 2-3, 3-4, 4-5, 5-6 hairs per graft, which can total 2,500 - 4,000 or more hairs.

I charge per area for each session. A full session to the front half of the scalp will cost approximately $5,000.00 to $7,500.00 plus taxes, ( 3000-4000 plus hairs in varying sizes of follicular unit grafts). If the crown (back half of the balding area ), is transplanted, in addition to the front I charge $7,500.00 to $9,500.00 plus taxes, ( 6000-7500 plus hairs in varying sizes of follicular unit grafts ). ALL COSTS ARE IN CANADIAN DOLLARS.

→ close ← This is when the physician transplants 3,000 to even 6,000 or more very small grafts in a session. The implied objective is to transplant a larger portion of the bald area, and to do it more quickly than in the past. Be careful! One must always compare apples to apples. There are a few points to consider; 1) If a session of 3,000 grafts are all 1 hair grafts (which equals 3000 hairs) then that may actually represent fewer hairs being transplanted than say 1500 grafts with from 1- 5 hairs per graft, (on average 3 hairs per graft) which would yield 4500 hairs; 2) If the megasession is spread over both the front and back half of the scalp you may be starting to treat an area (the back half) which, if you are a young patient, would have been better left untreated. You may for example end up having an island of hair with a sea of baldness around it - because the baldness has extended beyond what was originally estimated - and not enough grafts left in the donor region to fix the problem. 3) The more grafts transplanted, the more incisions in the recipient area and the greater the interruption of blood supply to the grafts. If more than 3,000 plus grafts (depending on the size of the area) are transplanted in a single session, some of the grafts may not grow at all, while some may grow fewer hairs than they would have if the sessions were smaller. I will do megasessions only in appropriate patients. In those patients I am happy to perform a session of 2000 - 3000 or more 1-2 hair "micrografts". However, I make it clear to the patient that although this will blend in very quickly it will produce a somewhat thinner look and may further sessions to create the sort of density most patients want. Additionally, these operations generally take 5 - 6 hours or more.

→ close ← Dense packing is where large numbers of grafts are placed closer together in a single session than has generally been done in the past. The objective is to produce a dense result with only one session. The problem with dense packing is that as noted earlier the blood supply can be impaired and occasionally very little hair grows.

→ close ← Hair grows from the scalp in naturally occurring bundles of 1, 2, or 3 hairs that are clumped together in a single "follicle" or sheath. This can be seen with good magnification either by magnifying glasses, loops, illumination from below the grafts, or with stereoscopic microscopes. In our office stereoscopic binocular microscopes are used to dissect every graft. Exclusive follicular unit transplantation comes back to a point I made previously about only treating the top of the scalp with 1-3 hair grafts. While they blend in very naturally, the end result of only 1 or 2 sessions is generally a thinner look than most patients would like to have. Most patients can obtain excellent and natural looking results with better density by using a combination of grafts such as 1-3 hair follicular units for the hairline zone and a follicular unit family employing 2 combined follicular units that can contain 3-6 hairs, all held together in there naturally occurring bundles. In this manner one can achieve added fullness behind the hair line zone , while at the same time preserving the integrity of the follicular unit through the use of excellent visualization with microscopes, and yet not so big a graft as to look pluggy added density.

→ close ← When the donor area strip is removed from the back of the scalp, from the permanent hair bearing area, the wound is sewn together. Some physicians use staples, others use either dissolvable or non-dissolvable sutures. Dr. Cotterill prefers to use sutures as he feels they cause less discomfort for patients compared to staples. The wound edges are closed and the resulting scar, in most patients, will heal as a pencil line thin scar that is easily camouflaged by the hair at the back of the scalp. Trichophytic Closure is a new technique that Dr, Cotterill uses whereby a small piece to superficial donor scalp is clipped off from one of the wounds 2 edges before they are sewn back together. This technique allows the hair from the clipped edge to grow through the scar, which yields an even smaller, pencil line thin scar that in many cases is not even detected on close inspection.

→ close ← Laser hair transplantation was pioneered by Dr. W. Unger and Dr. L David. Up to this point many lasers have been tested but none of the present generation of lasers has been found to give a consistently superior result over traditional methods. I addition there is usually more postoperative crusting and a longer delay before transplanted hairs begin to grow. At this point lasers for use in hair restoration, are in my opinion used, by some, as more of a marketing tool, than a clear cut scientific advance.

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→ close ← In the early 1980's, scientists found that they could remove cells from the base of a growing hair and culture that cell to produce millions of cells from it. This work has been done on mice and rats whose hair follicles are not that much different than humans. This process has been improperly called "cloning of hair" and should be called "cell therapy". At several study sites around the world, including Toronto, Canada at the University of Toronto, researchers have been able to identify and grow dermal papilla cells (DPC).

For the animal studies athymic mice whose compromised immune systems are less likely to reject foreign material are being employed. Once these researchers can demonstrate that these cells can produce hairs successfully in such mice, and then in humans, the ultimate challenge is to devise an optimal method for introducing the DPC into the human donor. The end goal of course is that instead of depending on a time consuming method of donor hair harvesting and limited supplies of donor hair that we have now, we will be able to have an easily accessed unlimited supply of donor hair. Dr. Unger explains that finding the right cell and the right "food" for that cell took over a year. Similar studies are being conducted in Japan and The Netherlands. Once the cells are reintroduced into the human scalp there is the concern of growing the hair in the right direction and at the right angle.

Currently, cells can be removed from a human patients hair, multiplied to millions of similar cells and injected into immune compromised mice , that will successfully grow hair. The next step is to gain ethics approval for testing in humans, once the technique has been perfected.

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