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.

Dr Reed,

 

I think this is an excellent post and result thus far.

 

Mick

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

The important thing is that a patient in this situation is told that he will need more that one procedure to reach his goal (depending on what it is), and that he had donor issues before the case started. As far as needed grafts, I would have guessed him at at least 3500, which at over 70cm2, seems like it would be appropriate, depending on the doctor. I hope he gets another pass if he wants one.

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.

Thanks. Yes, he's going to do one or two more procedures to get reasonably dense coverage in the crown. I think he's old enough and has maintained enough density of fairly big diameter hair to let him have this option of going into the crown. I doubt that meds alone would do enough for him. I may have omitted saying that he started finasteride at the time of the procedure.

These photos represent the first of two or three planned procedures to manage this 47 year old man's hair loss. The total grafts were 3071 from a maximum harvest and the followup photos are 7 months after the procedure. The second procedure which is anticipated to occur at about 12 months after the first is expected to yield in the range of 2500 grafts.

This gentleman had a maximum harvest of 1528 grafts including 245 double follicular unit grafts. His fine caliber hair made him a good candidate for these 4 hair, double follicular unit grafts. He had had a previous procedure from another physician and he felt that few of the grafts grew. His skin is thin and tight. Hence the removal of the scar from the first procedure and these skin characteristics limited the amount of hair I could obtain. In view of this limitation, he chose not to graft the right side of the hairline, other than grafting the right temporal point, so that he could have more grafts available to graft the crown. He also began finasteride with this procedure. The followup photos are a couple of years after the procedure.

This gentleman received a maximum harvest totaling 2139 total grafts including 374 double follicular units. He has very fine diameter hair and demonstrates several points. A positive point regarding fine hair is that it is easier to have it look natural after the density obtained by one procedure. (His salt and pepper color also helps.) The weak aspect of fine diameter hair is that less hair mass is transferred for each grafted hair compared to bigger diameter hair. Regardless of what the hair diameter is, one procedure is more styling dependent than when a second procedure is done to essentially double the density of grafted hair, i.e., there are more styling options with the doubled density from two procedures. It happens that this man likes the style shown and that style is also the best style for one procedure. Therefore, he will probably not have another procedure. It should be noted that the hairline needs to have at least some recession in the design to go along with the lower density and lower hair mass that results from both one procedure as well as the smaller diameter hair.

This gentleman has had multiple procedures including scalp reductions over several decades with several surgeons. He has very fine hair which makes it more difficult to cover the donor scars than he would like. We agreed we should do a test case of a small number of beard hairs extracted by FUE to see if the beard hair is too different a texture to blend well with the fine hair in the donor as well as to confirm what his scarring will be on his neck and chin. I will show the results when they have grown in.

Happy Holidays to all!

These are the before and after photos of two procedures totaling 4421 grafts. The first procedure was 2370 grafts with 350 double follicular unit (4 hair) grafts (DFUs). The donor strip was 1.3 cm wide x 29 cm in length. The second procedure was 2151 total grafts including 300 DFUs and was also a maximum harvest. The results following the first procedure were published last month.

Thanks for your thoughtful, fair and balanced reply, Corvettetester. BTW, the number of grafts used was limited by the amount of donor obtainable. Also, more dense packing does not produce more density in my hands. Density and fullness are two different parameters, of course, but both seem to be determined more by hair fiber diameter and reliable, non-miniaturized growth (with miniaturization often and unpredictably resulting from too densely packed a pattern) than from creating a pattern of ever higher densities. However, progress is made by listening to what others are doing and trying to figure out not only how they do it but, also, what percentage of the time they can do it. I remember one of my favorite quotes from back in the 90s when Dr. Rassman retorted to critics of his 1000 graft "megasessions" by saying (perhaps paraphrasing a bit), " To those who say it can't be done, I say, 'Stand out of the way for those of us who do it everyday!' ". So I'm not saying that density over 40ish grafts/cm3 can't predictably be done by anybody, I'm just saying that as a skeptic and late adaptor, I don't think one session can reliably produce much more density than the case I presented and that more "dense" appearing cases are often the result of styling or hair fiber diameter. The case I showed is the standard to which I would like to be held accountable by people considering working with me. Again, Corvettetester, your remarks are fair and thoughtful. You obviously know our subject well.

Thanks for your kind words, too, RCWest. Trying to do what's best for the patient is best for everybody.

These are the before and after photos of one session of 2353 grafts of which 300 were DFUs (double follicular unit grafts of 4 hairs each). The followup photos were taken at the time of a second procedure that was meant to increase density, especially along the part side of the hairline. These photos represent the "70% dense" result that I think one procedure can reliably produce. You can see how the styling is more important with this density which, in my opinion, looks better with the "combed across" look as opposed to styles which take the hair to the rear. Of course hair color and its fiber diameter contributes to the appearance of fullness and the acceptability of different styles and hair directions.

The first reaction by most visitors to this site, I would think, is one of little interest in this example. Think again, though. This gentleman is an age that most of us are likely to achieve. Many of us, since we visit this site motivated by our balding, will become this bald. Many of you in your 20s and early 30s are educated enough in hair loss to ask the good question of “won’t I keep balding?” Of course, the answer is, “Of course!” This gentleman’s transplant pattern illustrates the “3 vertex” pattern, and, in my opinion, is a safe pattern to transplant at any age. Many of you will say, “ I would rather shave my head or do nothing than to have that look”. I can understand that opinion considering your likely youthful stage in life and the degree of balding that you are currently facing, but placing hair in this pattern can rebuild your hairline and give you a much more full head of hair.

This reaction, however, misses the point. The point is that in treating the young man with balding, we are trying to find the balance between short term satisfaction and long term respect for balding possibly going as bald as it has with this gentleman. In those of you who can find satisfaction for to your pattern of balding short term by adding hair into this “3 vertex” pattern, it is my opinion that you can find this short term satisfaction with a high degree of confidence that your transplants can look satisfactory (though thin and with little coverage of the crown) if you continue to bald to an advanced stage hair loss as in this case. Short term you can probably transplant with a higher density than was done here.

Three caveats: 1) The hairline needs to show some recession. A fifteen year old’s hairline combined with a large bald crown does not occur in nature. That degree of recession depends upon the shape of the skull and face and is beyond the scope of this short case presentation. 2) Maintaining crown (vertex) density has to be left to medical management for the most part. Very low density grafting of single hair grafts can often be considered, and 3) a small number of people will bald in their donor areas which will result in the hair of the grafts falling out in later years as well as showing the skin, and, therefore, the scars of the strip or FUE procedures in the donor areas. This occurs in a very low percentage of people but is a concern nonetheless.

The first procedure in this case was with 2000 grafts and the second with 2200 fugs. I do not have a followup for the second procedure but perhaps it is useful to show the grafting pattern: that a more dense connection between the hair on the side of the head and that on top as well as more density in the frontal peak is aesthetically a good idea and the patient wanted to have some low density grafting in his crown instead of more density up front. I agree with his preference.

Bottom line: I think it is more important WHERE grafts are placed as opposed to when, i.e. at what age.

These photos are of a second procedure done with the first procedure results from this patient presented last month. I think these results from the first and second procedure are representative of the density that is achievable with each respectively. Specifically, one procedure can produce a density that is limited by how close together the pattern of slits can be made. To get more density, a second pattern of slits can be made in between the pattern of the first procedure after the first procedure has healed and the hairs have grown out. The appearance of density is the result of more than just the number of hairs growing: it is also the result of the diameter of the hair as well as the color contrast of the hair relative to the skin, the waviness and the angle of exit that the hairs have at the hairline. Nevertheless, this patient has average hair fiber diameter and the color contrast between the hair and skin is roughly midrange. As noted with the first procedure results, the patient had had another procedure done elsewhere and the hairline design was made to lower the left side to make it more balanced.