Why I Developed UGraft Zeus

The difficult frontiers of FUE were not theoretical to me. They emerged from problems patients brought into my practice. Some patients with severe baldness needed donor supply beyond the traditional scalp, making efficient use of beard and body hair important. Some repair patients had already depleted conventional donor resources and also needed alternative donor areas. Tightly curled hair and tougher skin created another demanding FUE scenario. High-profile patients and others seeking minimal downtime also wanted options that did not require shaving the head.

Those different needs pushed me toward a platform that could work across regular shaved FUE, Afro-textured or tightly curled hair FUE, long-hair FUE, and body-hair FUE. The goal was not a separate answer for every donor scenario, but a more adaptable system.

A Skin-Responsive Approach to FUE

UGraft Zeus uses an Intelligent Punch and a skin-responsive driver designed to navigate differences in hair angle, follicle direction, skin thickness, and skin firmness during extraction. The short video demonstrates a simple donor-region selection, after which the system calibrates for the selected donor area.

That adaptability is intended to extend across traditional scalp FUE, tightly curled hair, long-hair procedures, and body-hair FUE. My work also led to a donor assessment and classification approach intended to help physicians anticipate FUE difficulty rather than discover it only after surgery has begun.

One Platform for Different Donor Scenarios

The video presents UGraft Zeus as a patented FUE technology designed for multiple donor scenarios and describes it as the most multicenter-studied FUE device. The broader purpose of the development was to simplify a technology created for difficult cases so that other physicians could use the same platform across a wider range of patients.

FUE planning remains individual. A hair transplant before and after comparison cannot determine whether the same approach is appropriate for another person. Donor supply, hair characteristics, skin characteristics, and the planned procedure all require medical evaluation. Technology can be designed to adapt, but treatment planning still begins with the individual patient.

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Medical Disclaimer

This content is for educational purposes only and is not a substitute for individualized medical advice, diagnosis, or treatment. Suitability for FUE and treatment planning require an individual medical evaluation. Individual results vary.

Further Reading

1. https://dru.com/a-new-follicular-unit-extraction-fue-classification-system-for-hair-transplant-patientsa-new-system-to-evaluate-fue-hair-transplant-patients/
2. Umar Sanusi. Body Hair Transplant by Follicular Unit Extraction: My Experience With 122 Patients.Aesthetic Surgery Journal 2016; DOI: 10.1093/asj/sjw089. Published September 22, 2015.
   https://pubmed.ncbi.nlm.nih.gov/27241361/
3. Umar, S.et al. (2021) A novel follicular unit excision device for all-purpose hair graft harvesting, Clinical, cosmetic and investigational dermatology. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8605797/ (Accessed: 03 August 2023).
4. Umar S, Shitabata P, Rose P, Carter MJ, Thuangtong R, Lohlun B, Benhiba H, Oguzoglu T, Zollinger MM, Maldonado J, Gonzalez A, Novosilska M, Gómez Zubiaur A, Marti M. A New Universal Follicular Unit Excision Classification System for Hair Transplantation Difficulty and Patient Outcome. Clin Cosmet Investig Dermatol. 2022 Jun 27;15:1133-1147. doi: 10.2147/CCID.S369346. PMID: 35784270; PMCID: PMC9249093.CopyDownload .nbibFormat:
   https://www.dovepress.com/a-new-universal-follicular-unit-excision-classification-system-for-hai-peer-reviewed-fulltext-article-CCID
5. Umar S, Khanna R, Maldonado JC, Chouhan K, Gonzales A. Beard and Body Hair Transplantation by Follicular Unit Excision Using a Skin-Responsive Device: A Multicenter Study. Dermatol Surg. 2024 Mar 1;50(3):306-308. doi: 10.1097/DSS.0000000000004061. Epub 2023 Dec 20. PMID: 38127669; PMCID: PMC10904000.
   https://pmc.ncbi.nlm.nih.gov/articles/PMC10904000/
   

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A Change Her Family Could See

Dr. Sanusi Umar begins by noting the visible difference in Mia’s hair since he had seen her roughly two months earlier. He describes the change as “night and day” and says her hair was “really growing back with a vengeance.” The conversation then turns from hair growth to what Mia’s family had noticed in the way she was showing up in everyday life.

More Outgoing, More Comfortable

Dr. Umar asks what has changed for Mia in terms of happiness, eye contact, and how she presents herself to the world. Her family’s answer is direct: “She’s outgoing a lot more.” They also say she is making more friends and feels more confident when she goes to playgrounds and parks.

That confidence shows up in a specific way. Her family says Mia is now more comfortable walking up to other children and asking them to play with her. They also describe a change in the way she approaches other children, saying she no longer seems as worried when she does it.

When Progress Means More Than Hair

The chapter connects Mia’s visible hair progress with the changes her family is seeing in her social confidence. Their comments focus on everyday moments: making friends, going to the park, approaching other children, and asking them to play. For her family, those changes have become an important part of the story alongside hair restoration and hair growth treatment.

Dr. Umar responds, “That’s really great to hear.” The chapter closes on that encouraging note while leaving Mia’s continued progress for the next part of her story.

Watch the Chapter

Watch Mia’s Baldcast chapter on YouTube

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https://dru.com/hair-surgery-hair-loss-medication-services/

Medical Disclaimer

This is one patient’s experience. Individual results vary. This content is for educational purposes only and is not medical advice.

Further Reading

1. https://dru.com/mia-alopecia-hair-growth-progress/
2. Umar S, Kan P, Carter MJ, Shitabata P. Treatment-Refractory Central Centrifugal Cicatricial Alopecia Responsive to a Novel Botanical Treatment. Clin Cosmet Investig Dermatol. 2022;15:609-619 https://doi.org/10.2147/CCID.S358618

The post Video: Mia’s Growing Confidence With Alopecia appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

When the Princess Experience Had to Wait

Mia had been looking forward to the Bibbidi Bobbidi Boutique experience, but her family had to tell her they could not do it at that time. Dr. Umar asks how her parents explained the situation and how they resolved such a difficult moment for her.

Her Parents Chose Reassurance

Mia’s mother describes the moment plainly: “Oh, yes it was traumatic.” She says that she and Mia’s other parent walked out with her, comforted her, and tried to explain what was happening in a way she could understand.

Their message centered on time. They told Mia that her hair was going to grow back and that she needed to give it time. The conversation did not erase the disappointment, but it gave the family a way to answer the immediate question of what would happen next.

A Promise to Return

The parents then gave Mia something specific to anticipate. They told her that when her hair was back, they would return to Bibbidi Bobbidi Boutique so she could have the experience she had wanted.

Mia’s mother recalls the result of that reassurance simply: “So that made her happy.” In a chapter centered on hair loss and childhood disappointment, the family’s response is about comfort, patience, and a future moment they can look toward together.

What Comes Next

This short chapter stays with the family’s response to that experience rather than moving ahead to later events. Dr. Umar’s question brings the focus back to how Mia’s parents supported her in the moment and how a promise to return helped restore some happiness. The next chapter continues Mia’s story.

Watch the Chapter

Watch Episode 5, Chapter 21 on YouTube: YouTube Short

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https://dru.com/hair-surgery-hair-loss-medication-services/

Medical Disclaimer

Individual experiences and results may vary. This content is shared for educational and awareness purposes only and is not medical advice.

Further Reading

1. https://dru.com/mia-disneyland-alopecia-totalis-baldcast-episode-5-chapter-20/
2. Umar S, Kan P, Carter MJ, Shitabata P. Treatment-Refractory Central Centrifugal Cicatricial Alopecia Responsive to a Novel Botanical Treatment. Clin Cosmet Investig Dermatol. 2022;15:609-619 https://doi.org/10.2147/CCID.S358618

The post Video: Mia, Alopecia, and a Promise to Come Back appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

Imagine fixing a bad hairline with leg hair. That is the premise of this short hair transplant before and after case. The patient came in with a harsh, pluggy-looking hairline from previous hair transplants, and the corrective plan used leg hair to help create a softer transition at the front of the scalp.

Why Leg Hair Was Used in the Hairline

For this corrective FUE hair transplant (follicular unit extraction), Sanusi Umar, MD used leg hair as part of the hairline restoration with U-Graft FUE technology. The supplied caption describes the goal as creating a softer, more natural-looking transition rather than leaving the harsh, pluggy appearance produced by the patient’s previous hair transplants.

The case was published in JAMA Dermatology for its use of leg hair in hairline restoration. The supplied material also notes that U-Graft technology, including U-Graft Zeus, has been demonstrated for body hair extraction in a multicenter study published in Dermatologic Surgery.

The Body Hair Transplant Result Shown in the Video

The short video moves directly from the earlier hairline to the later appearance. Its closing line describes the result simply: “His hairline looks natural, smooth, and soft.” The final comparison is labeled “2 years after BHT,” giving viewers the follow-up point shown in the video.

A Different Source of Hair for Corrective Restoration

This case highlights a less familiar option in hair restoration: using body hair when the treatment plan calls for it. Here, leg hair was incorporated into a corrective transplant to address the appearance of a previously transplanted hairline. The result shown in the supplied material is a softer, smoother, more natural-looking hairline.

Individual treatment planning depends on the patient and the clinical situation. The images and result in this case describe one patient’s experience and should not be taken as a guarantee of the same outcome for others.

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Medical Disclaimer

This content is for educational purposes only and is not medical advice. Individual treatment plans and results vary. A qualified physician should evaluate whether a particular treatment approach is appropriate for an individual patient.

Further Reading

1. https://dru.com/best-hair-transplant-repair-doctor-in-the-world/
2. Umar, S. and Popescu, F. (2023) Allogeneic hair transplant in a kidney transplant recipient : Dermatologic surgery, Dermatologic Surgery. Available at: https://journals.lww.com/dermatologicsurgery/Fulltext/9900/Allogeneic_Hair_Transplant_in_a_Kidney_Transplant.458.aspx (Accessed: 03 August 2023).
   https://www.ovid.com/jnls/dermatologicsurgery/fulltext/10.1097/dss.0000000000003880~allogeneic-hair-transplant-in-a-kidney-transplant-recipient

The post Video: Hair Transplant Before and After: Using Leg Hair to Soften a Hairline appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

A Disney Experience Mia Was Excited to Have

During the Baldcast conversation, Dr. Sanusi Umar asked Mia’s mother to revisit an incident she had mentioned earlier in the interview. Mia’s mother explained that Disneyland was “her thing.” The family booked tickets and, once there, approached Bibbidi Bobbidi Boutique to ask whether Mia could participate in the princess makeover experience.

Her mother described the experience Mia wanted: having her hair done, dressing up, and sharing in the same Disney-themed moment as other children. She asked whether the boutique could take her daughter because, as she put it, “She will love that experience.”

Turned Away Because She Did Not Have Enough Hair

According to Mia’s mother, the answer was no. She recalled being told that the boutique could not provide the experience because Mia did not have enough hair. For a child living with alopecia totalis, the rejection meant missing an experience she wanted to share with other children around her.

“That was kind of sad and upset for her,” her mother said. Mia wanted the same experience as the other children walking around in Disney dresses with their hair done, but she did not get to have it.

The Human Side of Childhood Hair Loss

The story gives Dr. U and the Baldcast audience a glimpse of how hair loss can intersect with ordinary childhood experiences. In this chapter, the focus is not on a hair loss diagnosis and treatment plan or a visit with a scalp specialist. It is on one specific memory shared by Mia’s mother: her daughter wanted to participate, dress up, and feel included, but her lack of hair became a barrier.

Mia’s story continues beyond this moment. This chapter preserves her mother’s account of what happened at Disneyland and why the experience stayed with the family.

Watch the Chapter

Watch Mia’s Baldcast Episode 5, Chapter 20 on YouTube

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https://dru.com/hair-surgery-hair-loss-medication-services/

Medical Disclaimer

This article is shared for educational and awareness purposes only and is not medical advice. Individual experiences may vary. Questions about hair or scalp conditions should be discussed with a qualified medical professional.

Further Reading

1. https://dru.com/alopecia-totalis-mia-disneyland-experience/
2. Umar S, Kan P, Carter MJ, Shitabata P. Treatment-Refractory Central Centrifugal Cicatricial Alopecia Responsive to a Novel Botanical Treatment. Clin Cosmet Investig Dermatol. 2022;15:609-619 https://doi.org/10.2147/CCID.S358618

The post Video: Mia and the Disneyland Moment Alopecia Totalis Took Away appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

The conversation stays focused on one family’s experience with alopecia and hair growth treatment. Rather than presenting the process as immediate, the chapter shows how meaningful a change in pace can feel after a long period of watching and waiting.

From Slow Progress to Thicker Hair

Dr. Umar asks Mia’s father how he felt when he started seeing more than the earliest signs. He specifically points to seeing actual, thicker hair growing, which the conversation places around four or five months earlier. Mia’s father answers simply: “I felt very happy for her.”

That happiness came after a period when Mia herself felt the progress was taking time. Her father remembers her saying, “My hair is on the way,” while also recognizing that it was coming in very slowly.

When the Growth Seemed to Speed Up

The chapter marks a change after Mia started using the product discussed in the video. Her father says the hair growth appeared faster afterward. The supplied material does not name the product in this chapter, so the focus remains on what the family observed rather than on making a broader treatment claim.

For Mia’s father, seeing that difference carried emotional weight. He says the change gave him “a lot of joy for her.” Dr. Umar responds to the family’s observation without turning one patient’s experience into a guarantee for others.

Patience Still Shapes Mia’s Alopecia Story

Mia’s experience in this chapter is less about a single dramatic moment than about recognizing progress after a slow start. The caption reinforces that perspective: hair restoration can require patience, and noticing positive change can bring real joy to a family that has been carefully watching the process.

The chapter does not establish that the same timing or response should be expected for anyone else. It records one point in Mia’s continuing story and the relief her father felt when the growth appeared to be moving faster.

Watch the Chapter

Watch Baldcast Episode 5, Chapter 19 on YouTube.

Take the Next Step

Continue with Mia’s chapter on Instagram and TikTok. Stay with The Baldcast for more of Mia’s continued progress.

Medical disclaimer: This article is for educational purposes only and is not medical advice. Individual experiences and results vary. A qualified healthcare professional should evaluate questions about diagnosis or treatment.

Further Reading

1. https://dru.com/mia-alopecia-hair-growth-progress/
2. Umar S.  and Carter M.A Multimodal Hair-Loss Treatment Strategy Using a New Topical Phytoactive Formulation, Case Reports in Dermatological Medicine / 2021
   https://www.hindawi.com/journals/cridm/2021/6659943/

The post Video: Mia’s Alopecia Progress: When Hair Growth Began to Feel Faster appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

Mia began treatment in January. By the time Dr. Sanusi Umar reviewed the timeline later in the year, the discussion was not about one sudden turning point. It was about months of consistent care, careful observation, and small changes becoming visible over time. For a family watching alopecia closely, those early signs mattered.

The First Signs Appeared Around Month Four

Dr. Umar traces the timeline back to the start of Mia’s treatment and notes that her family began seeing early signs of hair growth at about the four-month mark. In the video, he summarizes the milestone directly: “So around four months, you started seeing these early signs of growth.”

Alopecia Treatment Was Followed Over Months

The chapter places that early change within a longer routine. The supplied timeline says Mia continued with Gashee topical and oral products along with derma rolling while her progress was observed. Dr. Umar also explains that by December, months had passed since the treatment began, underscoring how long the process had been followed.

That context is important because the chapter does not frame hair restoration as immediate. Instead, Mia’s experience is presented as gradual. Her family noticed something beginning around month four, while the routine continued in the months that followed.

Why the Timeline Matters

For Mia’s family, the timeline gives meaning to each stage of progress. It shows that the first visible signs were not the end of the process, but an early point within ongoing care. The chapter’s message is measured: meaningful changes may take time to become visible, and one patient’s experience should not be treated as a promise for someone else.

Mia’s story continues beyond this chapter. For now, the focus is the patience built into her treatment timeline and the significance of those first signs that her family noticed several months after starting.

Watch the Chapter

Watch Baldcast Episode 5, Chapter 18 on YouTube.

Take the Next Step

Continue with Mia’s chapter on Instagram and TikTok. Stay with The Baldcast for more of Mia’s continued progress.

Medical disclaimer: This article is for educational purposes only and is not medical advice. Individual experiences and results vary. A qualified healthcare professional should evaluate questions about diagnosis or treatment.

Further Reading

1. https://dru.com/mia-alopecia-first-signs-hair-growth/
2. Umar S.  and Carter M.A Multimodal Hair-Loss Treatment Strategy Using a New Topical Phytoactive Formulation, Case Reports in Dermatological Medicine / 2021
   https://www.hindawi.com/journals/cridm/2021/6659943/

The post Video: Alopecia Progress Takes Time: Mia’s Early Signs of Hair Growth appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

If this sounds like you, this article is for you:

• You are consistent with treatment, but your hair loss or baldness still progresses.
• Minoxidil and/or finasteride helped at first, then results slowed or stopped.
• You have “dandruff” or scalp irritation that keeps coming back.
• A hair transplant result was disappointing, unpredictable, or did not last.

If you are doing “all the right things” for your androgenetic alopecia or pattern baldness, but results are stalling, read this.

Androgenetic alopecia (AGA), also known as male pattern baldness (MPB) or female pattern hair loss (FPHL), is common, visible, and emotionally heavy. Many patients do everything they are told: minoxidil, finasteride (or dutasteride), devices, shampoos, supplements, and still find that progress slows, stops, or becomes unpredictable.

When that happens, it is not always “bad luck,” and it is not always “you waited too long.”

The study titled “Perifollicular Inflammation and Fibrosis in Androgenetic Alopecia: Implications for Diagnosis and Treatment – A Comparative Histopathologic and Clinical Study with Normal-Appearing Scalp” was published in the peer-reviewed Clinical Cosmetic and Investigational Dermatology journal. There, we describe a specific histologic pattern that can live quietly under the surface and help explain why some AGA and pattern baldness patients stop responding as expected, progress faster, or respond unpredictably to both medical therapy and hair restoration surgery.

It is called PIILIF, short for Perifollicular Infundibulo-Isthmic Lymphocytic Infiltrates and Fibrosis.

Quick takeaways

• PIILIF is a low-grade, immune-type inflammatory and early fibrotic pattern found around the upper portion of hair follicles (infundibulo-isthmic region) that can coexist with AGA and pattern baldness.
• It can be easy to miss clinically and can be mislabeled as “seb derm” or “just dandruff.”
• It may help explain why finasteride or minoxidil alone may not be enough for some people over time.
• It supports a dual-pathway strategy: address the hormonal pathway and the immune-fibrotic pathway, not one or the other.
• This is exactly why I created the Inflammatory AGA Screen Program (PIILIF Track).
• Important classification insight: the paper proposes that what has been described as fibrosing alopecia of patterned distribution (FAPD) aligns with a later stage of AGA-PIILIF, and recommends staging AGA-PIILIF by the degree of perifollicular fibrosis to support earlier recognition and intervention.

The missing link for AGA medication non-responders

This section is for the patient who is not planning surgery (or not yet), but is frustrated because the standard plan is not delivering what it should.

If the scalp environment is immunologically active and early fibrosis is already present, “more of the same AGA routine” is not always the answer.

The answer is:

• better biology control
• better targeting
• better timing

Here is the practical point

If PIILIF is present, “DHT control only” can leave a second driver running.

Standard AGA treatment often focuses on androgen signaling and follicle cycling support (for example, finasteride and minoxidil). That can be appropriate, but in a subset of patients, there is an additional layer: a perifollicular inflammatory and early fibrotic process that may continue even when DHT is addressed.

That is why some patients report:

• good early improvement, then slow decline again
• a stable period, then sudden acceleration
• “I’m consistent, but the response does not match the effort”

What this changes in real life

For the non-responder, the best move is not to guess harder.

It is to confirm what is actually happening in the scalp environment, and then treat the relevant pathways when indicated.

That does not mean every patient needs a biopsy.

It means:

• for non-responders, ambiguous cases, or high-stakes decisions, it is worth considering early diagnostic confirmation, not late.

What is PIILIF, in plain language?

PIILIF describes a subclinical perifollicular inflammatory pattern that concentrates around the upper follicle and is associated with early perifollicular fibrosis.

Key idea: it can be present even when the scalp looks “quiet,” and it can be present even in areas that are not yet visibly thinning or bald.

This matters because once fibrosis progresses, it can reduce the predictability of regrowth and restoration. That is why early recognition is the whole game.

Seeing PIILIF makes the concept clearer.
The short video below illustrates how PIILIF can exist beneath visible pattern baldness and why scalp biology matters when treatments or hair transplants stop responding.

Where FAPD fits: why this paper matters beyond “routine AGA”

If you have heard the term FAPD (fibrosing alopecia of patterned distribution), you already know it sits at the crossroads of two worlds:

• pattern hair loss that looks like AGA or male pattern baldness, and
• fibrosing/scarring biology that behaves more like early scarring alopecia

The key contribution of the paper is that it proposes a unifying framework:

• FAPD may represent a later, more fibrosing stage within the AGA-PIILIF spectrum, rather than a completely separate diagnosis.
• The paper recommends staging AGA-PIILIF by the degree of perifollicular fibrosis, which supports earlier recognition and more informed management decisions.

For patients, the takeaway is not to panic about “scarring.”
The takeaway is precision: if inflammatory and fibrotic drivers are present, it changes what “optimal care” looks like and why durability sometimes requires more than growth stimulation alone.

Why PIILIF gets mislabeled as seb derm or “just dandruff”

Many people with PIILIF report flaking, scale, or irritation. So it is easy to default to seborrheic dermatitis (“seb derm”) or “dandruff.” Whatsmore, the trichoscopic features of PIILIF may show similar findings associated with seborrheic dermatitis

But in our cohort, true seborrheic dermatitis on biopsy was rare compared with PIILIF.

Even when anti-dandruff shampoos temporarily improve scale or redness, that does not necessarily address the deeper perifollicular inflammatory process.

If you are treating “seb derm” aggressively and hair outcomes are still slipping, it is time to consider whether the label is wrong.

Why this matters for hair transplant planning

If the scalp environment is immunologically active and early fibrosis is already present, “more grafts” is not the answer.

The answer is:

• better biology control
• better planning
• better timing

In higher-risk candidates, pre-transplant control of PIILIF and biopsy-informed planning are advisable.

That does not mean every patient needs a biopsy. It means that for non-responders and high-stakes surgical candidates, diagnostic confirmation should be considered early rather than late.

Who should consider PIILIF screening?

You should at least consider PIILIF screening if you relate to one or more of these:

• You are not responding as expected to a well-run AGA regimen (meds, topical plan, lifestyle, compliance is solid).
• You have been told you have “seb derm” for years, but hair continues to miniaturize.
• You have advanced AGA or you are a complex case (including prior surgery, donor depletion, body hair follicular unit excision (FUE) or beard hair FUE reliance).
• You are planning a transplant and you want to reduce the risk of disappointing yield, ongoing thinning, or unpredictable healing.
• You are 44 years or older.
• You have perifollicular scale, redness, itch, tenderness, or shedding that does not match the clinical look of “routine AGA.”
• You developed overt features of scarring alopecia or severe inflammation after a hair transplant.

The Inflammatory AGA Screen Program (PIILIF Track)

I created this because too many complex patients with hair loss and baldness were being managed with a one-pathway playbook.

Program name: Inflammatory AGA Screen Program (PIILIF Track)
Format: Virtual first (with in-person follow up when needed)
Deposit: Required to protect quality, reduce no-shows, and allow proper time allocation

What the PIILIF Track helps us do

• Identify whether a patient’s AGA is likely “standard AGA” alone, or AGA plus PIILIF biology.
• Decide when a biopsy is appropriate and where it should be taken to improve diagnostic yield.
• Build a personalized plan aimed at:
  • controlling the inflammatory axis when indicated
  • reducing progression and improving durability
  • planning surgery only when the scalp biology is optimized

Long-Term Care Matters Long-term

Sustainable treatment matters because AGA‑PIILIF is a long game
When PIILIF is present, the goal is not a short burst of change. The goal is long-term stability of the scalp environment. PIILIF is best understood as a chronic, genetically influenced tendency toward follicle‑centered inflammation and early fibrosis that is not “cured” once and for all. It is managed. That reality changes how we choose treatments.

Control, not cure, means the plan must be livable for years
If control may need to be maintained for the long term, the foundation of care should be something a patient can realistically sustain. This argues against building the core plan around high‑burden or high‑risk approaches, especially because AGA‑PIILIF can be subtle compared with overt primary scarring alopecias. The biology may be meaningful even when the scalp looks “quiet,” but the management must remain practical and tolerable over time.

What we evaluated in our cohort
Because the working model involves long-term control, the study emphasized steroid-sparing options that may be suitable for longer-term use, with short-course therapies used selectively. Selections were informed by peer-reviewed literature on steroid-sparing management in primary cicatricial alopecias. Treatments used in the cohort, often in combination and individualized to the patient, included:

• Dutasteride and finasteride
• Oral minoxidil
• Topical calcineurin inhibitors
• Minocycline or doxycycline (typically as a time‑limited course)
• A selected phytoactive approach: Gashee topical and Gashee oral

What showed the clearest statistical signal in our analysis (and what did not)
In this retrospective cohort analysis, only some interventions showed a clear statistical association with improvement. In order of p‑value significance, the strongest signals in our dataset were observed with:

1. Topical and oral phytoactives (Gashee)
2. Topical calcineurin inhibitors
3. Minocycline
4. Dutasteride

Other treatments used in the cohort (including finasteride, oral minoxidil, and doxycycline) did not show the same level of statistical signal in this dataset. This may reflect sample size, duration, selection bias, combination regimens, dosing, or when and how an agent was deployed, rather than proving a treatment has no role.

The practical takeaway
The point is not that every patient needs every component. The point is that when AGA‑PIILIF biology may require long-term management, the strategy should prioritize approaches that are realistic to sustain, steroid‑sparing when appropriate, and matched to the level of inflammatory and fibrotic activity.

How this relates to Phytoactives
Within a long-term, steroid‑sparing framework, a phytoactive topical or oral option may be considered as supportive care as part of a broader plan, particularly when long‑term tolerability is a priority. In our cohort analysis, the use of Gashee in both topical and oral forms showed the strongest statistical signal among the steroid‑sparing measures evaluated, but this study is observational, and larger studies are needed to confirm and refine these findings. Gashee is not a substitute for diagnosis and is not positioned as a cure. It may be one tool within a clinician‑guided program when it fits the patient’s overall plan and risk profile.

Where a phytoactive product like Gashee fits (and where it does not)

Important points of clarification.

What Gashee is not

• It is not positioned as a “cure” for AGA, hair loss, or baldness.
• It is not a replacement for diagnosis.
• It is not a substitute for physician-directed therapy when stronger interventions are warranted.

Where Gashee can fit logically in the PIILIF conversation

PIILIF changes the strategy from “only push growth” to “optimize the scalp environment and protect follicle viability.”

Because AGA is a long-course condition, and because PIILIF (when present) can behave like a persistent, low-grade inflammatory process, long-term tolerability matters. That pushes smart clinicians toward steroid-sparing approaches whenever feasible.

In our PIILIF work, the practical takeaway is that some patients benefit when care includes scarring alopecia or PCA (primary cicatricial alopecia)-style anti-inflammatory and anti-fibrotic measures alongside appropriate androgen management.

In that context, phytoactive support can be part of a long-term maintenance philosophy, particularly for patients who need a plan they can sustain.

Gashee exists in both topical and oral forms. In my practice, when it is used, it is used as part of a broader plan, not as a standalone promise.

Important note: Gashee is designed to support the scalp environment as part of a broader hair loss program. It is not intended to diagnose, treat, cure, or prevent disease. Individual results vary.

The bigger point: stop guessing. Start staging.

If the biology is wrong, the plan will be wrong.

PIILIF gives us a clearer framework for:

• earlier detection
• better durability
• better surgical planning
• fewer “mystery non-responders”

If you are a patient who feels stuck, or a clinician managing difficult AGA cases, the PIILIF Track is built for you.

Next steps

Patients: Request a PIILIF Track evaluation
Start the PIILIF Track Intake

Clinicians: Refer a complex AGA case for PIILIF screening
Clinician Referral: PIILIF Track

Medical and product disclaimer

1. Gashee is designed to support the scalp environment as part of a broader hair loss program. It is not intended to diagnose, treat, cure, or prevent disease.
2. This article is for educational purposes and does not provide medical advice. Diagnosis and treatment should be individualized and guided by a qualified clinician. Product statements have not been evaluated by the FDA. Products are not intended to diagnose, treat, cure, or prevent any disease.

FREQUENTLY ASKED QUESTIONS

PIILIF, FAPD, treatment resistance, and what to do next

1) What is PIILIF?

PIILIF stands for Perifollicular Infundibulo-Isthmic Lymphocytic Infiltrates and Fibrosis. In plain terms, it describes a low-grade immune-type inflammation and early fibrotic change occurring around the upper portion of the hair follicle. It can coexist with androgenetic alopecia (AGA), also known as male pattern baldness or female pattern hair loss, and may be present even when the scalp looks “normal” on casual inspection.

2) Is PIILIF the same as FAPD?

Not exactly. FAPD (fibrosing alopecia of patterned distribution) is a term typically used when patterned hair loss shows a more advanced fibrosing or scarring-leaning biology. The key insight from this publication is that FAPD may align with a later stage within an AGA-PIILIF spectrum, rather than representing a completely separate condition.

From a practical standpoint, this means that earlier recognition of inflammatory and fibrotic drivers matters. Identifying AGA-PIILIF before extensive fibrosis develops allows clinicians to plan care with durability in mind, when the biology may still be more modifiable.

Waiting until the histologic features associated with FAPD are fully established may correspond to a more treatment-resistant stage. For this reason, the authors emphasize the value of recognizing and addressing AGA-PIILIF earlier, rather than deferring evaluation until later stages when fibrotic changes are more entrenched.

3) Do I need a biopsy to know if I have PIILIF?

Not everyone needs a biopsy. A biopsy becomes more relevant when your provider finds signs of inflammation on magnified (trichoscopic) examination of your scalp. The threshold is reduced if you are already a non-responder, your presentation is ambiguous, you have symptoms that do not fit “routine AGA” (itch, tenderness, burning, persistent scale), or you are making high-stakes decisions like hair transplant planning. The goal is not to biopsy everyone, it is to confirm scalp biology early when the stakes or uncertainty are high.

4) Why did my finasteride or minoxidil stop working?

There are several reasons treatments may stop working, and not all are about the medication itself. The main concept here is that AGA or pattern baldness is often treated as purely androgen-driven, but in a meaningful subset of patients an inflammatory and early fibrotic process may be operating in parallel. If that second driver is active, “more DHT control” alone may not fully stabilize the situation, which is why biology-aware evaluation and a dual-pathway strategy may be needed in selected cases.

5) Can PIILIF affect hair transplant outcomes?

It can. Hair transplantation is not just about graft numbers or technique, it is also about the health of the recipient scalp environment and long-term stability of surrounding native hair. If inflammatory-pattern biology and early fibrosis are active, predictability and durability can be affected, which is why scalp optimization and biopsy-informed planning can be important in higher-risk candidates.

6) What are phytoactives, and where do they fit in a long-term plan?

Phytoactives are plant-derived compounds that may support the scalp environment as part of a broader hair loss program. In a long-term maintenance context, many patients and clinicians prefer steroid-sparing approaches when appropriate, especially when scalp inflammation behaves as a chronic, low-grade process. In that framework, a phytoactive topical or oral product can be considered as supportive care, but it is not a replacement for diagnosis, and it should be used as part of a clinician-guided plan when stronger interventions are indicated.

7) Does PIILIF require lifelong treatment?
PIILIF, when present, may behave like a chronic, genetically influenced inflammatory tendency around hair follicles. The practical goal is long-term control and stability, not a one-time cure. Some patients may need ongoing maintenance for years, with the plan adjusted over time based on symptoms, exam findings, and overall risk profile under clinician guidance.

8) Do I need strong steroids or immunosuppressants to control PIILIF?
Not necessarily. AGA-PIILIF can be subtle compared with overt primary scarring alopecias, so aggressive therapy is not automatically the default. In our cohort, the emphasis was on steroid-sparing strategies that can be considered for longer-term use when clinically appropriate. Treatment choice and intensity should be individualized and supervised by a qualified clinician.

9) What kinds of long-term, steroid-sparing treatments were used in the study?
In this cohort, patients were managed with a steroid-sparing approach tailored to clinical context and often used in combination. Treatments used included dutasteride or finasteride, oral minoxidil, topical calcineurin inhibitors, and time-limited tetracyclines (such as minocycline or doxycycline). A selected phytoactive topical and oral option (Gashee) was also used as part of the broader scalp-care plan when appropriate.

In this retrospective dataset, the clearest statistical associations with improvement were observed in regimens that included: Gashee topical, Gashee oral, topical calcineurin inhibitors, minocycline, and dutasteride. Because many patients received combination regimens, these findings do not establish that any single component alone caused the observed outcomes. Observational findings do not prove cause and effect, larger studies are needed, and individual results vary. Gashee is not intended to diagnose, treat, cure, or prevent disease.

Important note: Products and supplements are not intended to diagnose, treat, cure, or prevent disease. Individual results vary, and medical decisions should be individualized with a qualified clinician.

The post Video: Read This If Your Hair Loss Treatment or Hair Transplant Has Stopped Working. What Science Shows appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

Scalp Micro-Pigmentation VS. Head Tattooing

While SMP and head tattooing may seem similar, they have different purposes and will give patients distinct results. Head tattooing employs traditional tattooing methods, and the results are more decorative and artistic than realistic. It employs standard tattoo ink applied deep into the dermis, and it could discolor to blue or green, migrate on the skin, and can be difficult to reverse without the use of laser tattoo removal.

Meanwhile, SMP is a clinical technique performed by trained practitioners to simulate the appearance of natural follicles. “We use specialized ink and a specialized technique,” said Dr. Umar. “Usually very superficial, to impact this look of scalp, creating the effect of stubble on the head in a pattern that mimics the natural distribution of hair.” Ultra-fine needles are used to deposit pigment into the upper dermis, resulting in a natural-looking hairline and density.

Why Patients Choose Head Tattoos

Many individuals seek head tattoos to reclaim confidence or camouflage balding. While the sentiment is valid, it’s important to distinguish between artistic intentions and clinical outcomes. SMP is tailored to restore the appearance of hair, not simply distract from its absence. Our patient Michael came into the Dr. U Hair and Skin Clinic seeking a procedure like this to achieve a fuller look while sporting a crew cut style. That’s when Dr. Umar suggested he get scalp micropigmentation (SMP) to complement his hair transplant results.

This technique is especially effective for:

• Camouflaging hair transplant scars
• Enhancing the appearance of hair density
• Refining hairlines after transplantation
• Creating a natural buzz-cut look

Patients like Michael demonstrate that hair restoration is not always about regrowth. Sometimes, it’s about recreating the illusion of density in a way that aligns with a patient’s lifestyle and appearance goals. SMP provides a subtle, impactful solution that empowers patients to wear shorter styles with confidence.

A Nonsurgical Approach To A Fuller Head Of Hair

SMP involves strategically tattooing pigment to the skin to create the appearance of stubble, making the scalp look fuller while softening harsh hairlines that were a result of hair transplants. In Michael’s case, it was used to disguise his strip hair transplant scar and give his buzzed hairdo a dense yet natural appearance. Because of his successful hair transplant with the Dr.UGraft® system, he was the ideal candidate for this procedure. “It’s the perfect use of SMP,” said Dr. Umar. “You have the hair, and then you just augment the density.” 

Subtle Yet Impactful Results Through SMP

Now, Michael can happily shave his head without worrying about bald patches and his previous scarring. The combination of FUE and SMP gave him realistic results, a softer hairline, and scalp density that he can be proud of. “I think this is the only combination of procedures that could’ve achieved this result from any doctor,” said Michael. “It looks so natural that nobody has commented on it.” These results fade gracefully within 18 to 24 months, and the procedure can be redone to achieve a fuller appearance of hair without the need for invasive surgeries.

Is Scalp Micropigmentation Right For You?

Follicular unit excisions have steadily grown in popularity, but many patients don’t realize that they have the option to complement their hair transplant results with SMP. As you have seen with our patient Michael, this procedure can render a realistic hairline and fullness that elevates your look, whether you’ve had hair transplantation surgery or not. To learn if scalp micropigmentation is right for you, book a free online consultation with Dr. Umar by filling up this form.

Individual results may vary. This story reflects one patient’s personal experience with scalp micropigmentation with Dr. Umar. Consult with a qualified physician for personalized advice.

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Dr. U has helped even the most severely scarred patients find the relief they crave. To ask any questions you may have about hair restoration, you can submit them using the button below:

Free Hair Consultation

Further Reading:

1. https://dru.com/laser-tattoo-removal/
2. Umar Sanusi. Hair transplantation in patients with inadequate head donor supply using nonhead hair: report of 3 cases. Ann Plast Surg 2011; 67(4):322–5.
   https://pubmed.ncbi.nlm.nih.gov/21540728/

The post Video: Scalp Micropigmentation vs. Head Tattoo: Which Is Right for Your Hair Loss Journey? appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.

Why Standard Tools Fail

Afro hair is tightly curled underneath the skin, and the follicles curve in a way that’s hard to see or follow with regular FUE tools. Most standard punches are straight and can’t adapt to this curvature, so they cut through the follicles instead of removing them intact. This is what’s called a transection, and it renders the graft unusable. When surgeons attempt FUE with these conventional devices, the results are often discouraging: high transection rates, poor graft survival, and patients left feeling hopeless about restoring their hair density.

Dr. Sanusi Umar’s Solution To Afro Texture FUE

Designed with inclusivity in mind, the Dr.UGraft Zeus system adapts intelligently to different hair and skin types, including tightly coiled, Afro-textured follicles, reducing the risks that have historically excluded these patients from FUE procedures

The device includes intelligent presets for:

• Afro-textured hair
• Straight or wavy hair
• Beard and body donor hair
• Long hair FUE

The system efficiently covers all FUE scenarios by providing adjustable torque, rotational speed, and movement dynamics. These work in tandem with an advanced hybrid smart punch to optimize follicle harvesting for different skin and hair types. Other standard devices don’t have these custom modes, and, combined with a sharp punch, they more often transect coiled Afro hair. The Dr.UGraft Zeus device is the only all-purpose device capable of performing FUE on textured hair, making it a particularly useful tool for African descent patients who want to undergo hair transplant surgery.

Watch the Dr. UGraft Zeus device in action in this Youtube Short:

POV: Afro beard hair, pulled to perfection by Dr. Umar #reels #shorts #asmr #satisfying # #DrU #hair

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Proven Results Backed By Numbers

An independent study by Dr. Umar found that the Dr.UGraft Zeus device yielded consistent results across African descent patients who underwent FUE with it. Less than 10% of the follicular units extracted were broken and transected, whereas standard FUE tools with sharp punches can have a transection rate of up to 80% on coiled, Afro-texture hair.

An Inclusive Tool For All Hair Types

As the inventor of the Dr.UGraft® Zeus system, Dr. Umar has not only demonstrated his expertise in hair transplant surgeries, but he has also made the procedure more inclusive to traditionally underserved communities, particularly African descent patients, whose physical characteristics, heritage, and gene mixing have made them a particularly challenging group for FUE. By embracing the diversity of hair types, including those traditionally labeled “too difficult,” Dr. Umar has created a pathway for healing, confidence, and inclusion.

If you have Afro-textured hair and practitioners told you that hair transplants are not an option, it is time to explore the possibilities with Dr. UGraft Zeus. Fill out our online consultation form and discover a treatment designed for you.

Individual results may vary. This story reflects one patient’s personal experience with follicular unit extraction with Dr. Umar. Consult with a qualified physician for personalized advice.

The post Why Standard Hair Transplants Fail Afro Hair and How Dr. Umar’s Innovation Restores Hope appeared first on Dr. U Hair & Skin Clinic | FUE Hair Restoration, Dermatology and Laser Surgery | Los Angeles, Manhattan Beach | Dr Sanusi Umar MD.