Dr. William Reed

These results are the first followup photos taken six years after one procedure of 2280 follicular unit grafts. The patient finally came in to get a prescription for finasteride.

These photos show the 7 month results of one procedure of 2909 grafts in a 27 yo. Apologies for the poor standardization of the before and after photos, but, nevertheless, I think you'll agree nothing is lost in the comparison. As I've often stated, one procedure is more styling dependent. This patient uses his new hair mass effectively with his chosen style by having the hair flow forward over the hairline. I think it is important that the patient be aware that there is likely to be too little hair when his balding has finished in several decades to appropriately manage the balding pattern in his crown. Using very much of his donor in the crown should be carefully considered before proceeding with transplantation.

I appreciate the supportive remarks and appreciate how they reflect an understanding of what I had hoped to express about variables that impact the outcome of a procedure. Thomas2012 asked a couple of good questions: FUE or strip for procedure #2 and coverage goal. Regarding the first question, I think that at least a strip for #2 is appropriate since he already has had a strip for the first procedure and therefore has the linear scar. I could see an argument for FUE, however, in view of the increased number of "weak grafts": FUE would allow the surgeon to "cherry pick" only the stronger grafts. As long as FUE grafts are twice (or more) as expensive than strip grafts, I don't think it is a particularly strong argument but that would be for the patient to decide. Another option would be to do a combination of FUE and strip for #2 and again this would be for the patient to decide whether the extra grafts from FUE are worth the cost. I think that this patient feels we are close enough to satisfactory coverage that the combination is not worth the expense. With regards to Thomas' second question, it's hard to quantitate "density" and even more difficult to quantitate "hair mass" which is probably the more important parameter. Hair mass is the density of grafts (grafts per cm2 for example), the diameter of the hairs and the length, i.e. the style (and other factors such as the wave of the hair and color contrast of the hair to the skin color also add to the look of fullness). The patient can have a sense of what the outcome will look like after #2 because of the outcome of #1 but it is hard to "quantitate" it. At this time I think he is inclined to place the grafts fairly evenly throughout since the first procedure has established a fairly satisfactory "density gradient" with more density up front in a stage 3 vertex pattern. I hope this answers your questions satisfactorily.

This is the 10 month result of 3535 follicular unit grafts, the first of two procedures. Of significance is that this gentleman, as is not uncommon with older ages, had a relatively high percentage of "weak" grafts, i.e., a two hair graft that had a full diameter hair and one that had a smaller diameter. Such a 2 hair graft would approximately result in a hair mass equivalent to a one hair graft of a larger diameter. (Normal hair fiber diameter ranges from fine hair at perhaps 40 microns to strong hair fiber up to approx. 80 microns.Hair mass is equal to pi times the square of the radius.) The second procedure will probably allow a maximum harvest of perhaps 2800 grafts and the patient will probably opt to spread them rather evenly throughout the balding area including the crown/vertex. There is no cheating the reality of a balding area of 200 cm2 needing as many grafts as we can obtain from two procedures. 6000 grafts from two procedures will be spread out over 200 cm2 of balding at a density of 30 grafts or 60 hairs / cm2. This is not high density. The patient needs to understand this ahead of time. The older patient, however, and perhaps unlike the younger patient, is often very happy to be given a hairline even though the crown remains fairly bald. PS Sorry for the poor photo quality in a couple of the "afters".

These photos are the results of one procedure of 2149 FUGs with the followup being 18 months after the procedure.

These photos represent the 7 month results from one procedure, a maximum harvest, whose top priority was to create the hairline drawn and whose secondary priority was to thicken the hair mass behind the hairline. She plans another procedure to further thicken the hair mass in the frontal forelock and the vertex. She is happy with the results that one session achieved in the hairline and I don't necessarily disagree with that feeling. However, I think there is always some refinement possible with a second procedure to at least some areas of the first procedure results.

Thanks, Mick. I appreciate the supportive words.

These photos include one year followups of one procedure of 2359 grafts.

Thanks, Mick. And thanks, too, to RCWest and Spanker for the discussion.

Agreed: "depending on what it [goal] is." The problem is that the patient doesn't know what the goal is until he sees the hair growing. (Due to variables in density, hair diameter, styling as discussed in the initial remarks other patient examples are unrelaible.) Therefore, the doctor can't really say what will be necessary either. That is why I think it most respectful to the patient to always include the possibility of needing more grafts from additional procedure(s). However, the physician can have a pretty good idea that one procedure will not suffice if the patient insists on a short hair style since 40 grafts/cm2 is too sparse to be likely to succeed in achieving adequate density. However, even this cannot be counted on since fine blond hair can look really good at that lower density.

Hair transplantation is a very satisfying procedure both to the patient as well as his doctor. The most common dissatisfaction, however, comes from disappointment in the density achieved with one procedure. The solution, if such dissatisfaction occurs, is another procedure to increase the density, but this roughly doubles the expense for the patient. One procedure has several important characteristics that need to be understood by the patient in order to avoid this disappointment: 1. Common consensus is that the maximum density that can result in reliably good growth is around 40 graft sites / cm2 for 2 and 3 hair FUGs and perhaps 50 / cm2 for the one hair grafts at the leading edge of the hairline. 2. The density achieved from this density is perhaps a 60% dense result. ("Fullness" is more optical than mathematical and is impacted by factors other than just density including hair fiber diameter, color of hair vs the skin color and waviness of hair. "Fullness" is also often more a reflection of "hair mass", i.e., hair diameter, length as well as density.) 3. At maximum density 2800 grafts will cover only approx. 70 cm2 (2800 / 40 = 70). Most people have more than 70 cm that require some coverage as in this case shown here. Therefore, certain areas will have less density than 40 sites / cm2 and the resultant, theoretical 60%. 4. These points mean that one procedure will be more "styling dependent" than, for instance, doubling up the density with a second procedure. These photos show at 8 months the results of a pattern covering in excess of 70cm2. We were able to obtain a total of 2324 grafts from a maximum harvest that wasn't as long a strip as usual due to decreased density above the ears and a donor density that is somewhat below average (see photo). The strip width was as wide as 1.5 cm. The fullest result possible was imperative due to an important upcoming life event. I would submit that a styling dependent full look will be achieved for this upcoming event in another two months when the hair of the mid frontal forelock grows longer to allow more hair mass to cover the thin area shown in the photos. Looking at the uniformity of the graft growth at the hairline, I think most of the grafts are growing at 8 months. However, there may be some more hair mass from the grafted hairs attaining their longer, optimal lengths. A second procedure may be necessary just for ease of achieving a style that will be durable enough for wind and water.

As the title states, this is one procedure of 1609 follicular unit grafts with an 18 month followup. I find this useful to represent the density and hair mass achieved with one procedure in a patient how has strong black hair. This patient is happy with the result; other people may feel that the density needs to be "doubled up" with a second procedure. Some styles will work better with this density than would other styles.

This example represents 3166 grafts with 359 double follicular units (DFUs) into the mid scalp since the density was so good: they fit into a 1.5 mm slit. Some grafts at a submaximal density due to pre-existing miniaturized hair were placed into the crown and posterior frontal forelock in front of the crown. The followup is 3.5 years after the procedure.

Sorry to use an abbreviation that I hadn't defined. FUG stands for "follicular unit graft".

Thanks, Mick.