This man in his early 50s had 2 brain surgeries, 8 and 9 years before his hair transplant. This left him with 7 burr holes in his skull and 2 long curved scars near his hairline and on top of his head. His scalp was stretched tight and thin. At first, his hair hid the scars but he also gradually developed genetic hair loss in a Norwood 5-6 thinning pattern. His main goal was to transplant enough hair in front to hide his surgical scars better and to frame his face. He hopes to later transplant his midscalp. He does not plan to transplant his crown because he does not have much scarring there and he would like to accomplish his goals with as few surgeries as possible.

He has more 3s than 2s than 1s so he has more hairs per graft than average to compensate for his finer hair.

His CT scan confirmed the absence of bone below the skin depressions. Since the skin was quite thin over the burr holes, we elected not to transplant grafts over the holes rather than to try transplanting with strict depth control.

He had 2944 grafts transplanted to the frontal area. His grafts were placed at 56 per sq cm in the frontal forelock, 49 behind his hairline then 42 then 36 then we faded out at the back of the frontal area. With the tightness of his skin from his previous surgeries, he had a lot of graft popping, especially near the scars. Popping means placing one graft results in a trampoline effect and 1 or 2 previously transplanted grafts can partially come out. Those grafts have to be gently tucked back in right away before placing another graft. If the ???popped grafts??? are not noticed right away they can dry out or if they are manipulated too much, they can get damaged and either of those factors could lead to poorer growth. Popping slows a case down considerably. Despite taking about 4 hours longer than usual to complete, he had very good growth of the transplanted grafts.

We took the maximum safe donor strip that his VSL (vertical scalp laxity) would allow at 10 mm wide on his sides and 14 mm wide in back. Since the edges could oppose but not overlap before routine undermining, we elected not to do a trichophytic closure. He has a 1 mm wide non-trichophytic scar but his donor scalp is still not that flexible after 12 months. His VSL measurements are now between 8 and 10 mm. We could currently safely transplant another 2000 grafts to his midscalp but he is trying scalp stretching exercises to see if he can gain some more flexibility to increase the number of available grafts for his next session.

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Cam Simmons MD ABHRS
Canadian Hair Transplant Centre,
Toronto, Ontario, Canada

Dr. Cam Simmons is a member of the Coalition of Independent Hair Restoration Physicians