Dr. Michael Beehner

This 42 y/o female, who never had eyebrow hairs, presented wanting eyebrow transplantation. She had previously only painted on eyebrow makeup pencil markings. She had one session of 320 1-hair micrografts (160 to each side), which were placed within the outline shown. The "after" photos show her a year or so later after only one session. On the day of the photos she had 280 additional grafts placed, 140 to each side. I prefer to use only 1-hair grafts, because I can then use the tiniest needle possible to make th holes, usually a 22 g one. We take time to rotate each graft so that the curve of the hair "flows" with the overall direction of the eyebrow contour. We allow the hairs harvested to be quite long, so that we can actually see this slight curve, which will be present even in patients with apparently straight, non-curly hair. Mike Beehner, M.D.

Kelli, In 20 years of doing hair transplants and using a four day "burst" of 60mg/40mg/40mg/40mg over that time, I have never in 4600 procedures seen or heard of the side effect you describe occurring. We actually give the first dose of 60mg just before the procedure. There are THREE SITUATIONS in which I do NOT use Prednisone following the surgery: 1) active peptic ulcer disease 2) diabetes mellitus (it can make it swing out of control for a few days) 3) if there is any question of not wanting to decrease someone's immune system level (such as recently treated lyme disease as an example) Except for these, I think it is a very, very safe thing to do and does dramatically reduce the incidence of post-transplant swelling in the forehead and eyes area. The most serious side effect of steroid usage, but one that usually only occurs after prolonged usage (such as for ulcerative colitis or severe asthma) is aseptic necrosis of the hip joints, in which the femoral head loses it's blood supply and hip replacement is needed. I have only seen it once in my medical life and it was after several months of prednisone for ulcerative colitis. Having something like this occur with such a short burst of prednisone dosage would be a one in five million shot of occurring. Mike Beehner, M.D.

Raphael, When you talk about "donor density" being good, it can refer to one of two things, and usually a combination of both. They are: 1) Number of FU's per square centimeter. and 2) Number of hairs per average FU. As Bill stated, you need someone with a little experience and a special magnification viewing instrument to do it. It's almost impossible to do without clipping the hair in the area close to the skin. We usually use a 0.5 x 0.5cm area to count in and then just multiply by 4, since it is very difficult to count a whole square cm and keep track of which ones you have counted and which ones you haven't as the process goes along. Before surgery and taking a donor strip, since we already have the donor area shaved down anyways, we usually count 3-5 of these 0.5cm square areas to be sure we didn't just test one sample area higher than the others. At a consultation, if someone wanted a numerical density measurement, most of us would only clip the hair in a small area for one count. I don't initiate this at my consultations, as I consider it a little "invasive" and aggressive from the patient's standpoint. Most hair surgeons who have a lot of experience can simply lift the hair and look at it, or even better, use the densitometer instrument and look at the long hairs, which gives us a great idea of both FU density and number of hairs per FU. It's just that a formal count is pretty much impossible without cutting the hair. Even if you had the instrument at home obviously you couldn't measure your own donor density, and I doubt even a friend would be able to do it on a first try. Mike Beehner, M.D.

BigBill, I wouldn't be too discouraged. While it is true that horizontal surgical scars have more of a tendency to widen when they are in that lower section below the occipital bump, I have had a lot of success with scars down there by limiting my excision to only being 5mm wide. If you leave the sutures in a little longer (2-2 1/2 weeks) and keep the patient from flexing the neck during the early weeks, I find that they are improved most of the time. When you go over 5-6mm in width, the scar stretches too much and, like a rubber band, just re-stretches to what it was or worse. If you gain and keep the 5mm reduction of scar width, then you can either do it again a few months later, or you can then FUE into the scar with better results. We often combine tattoo dots along with FUE to get the best result on a scar. If a patient wants more hair transplanted, I would definitely argue against taking any more donor hair contiguous with that lower scar, and would definitely warn against taking donor hair PLUS taking the whole scar out. I can almost guarantee you the scar will be much worse than it is now. Improving donor scars is like sneaking up on a bear. You go slow and easy, and the bear doesn't turn around and bite you. Mike Beehner, M.D.

Maxxy, Thanks for your comments. This patient, unlike most of the patients I have had over the years that choose to dress and appear as a woman, has not sought legal female status as a transgender person, but is comfortable staying a male in that regard. I can't give a lot of other background for confidentiality reasons. Mike Beehner, M.D.

Your assumption is right. The finasteride helps the non-transplanted hair that is still present on top, but is susceptible to male pattern baldness. It indirectly helps the transplant, simply because everything looks a lot fuller several months down the road if the native hairs aren't dropping out around the newly transplanted ones. The surgeon ends up getting credit for both, even though the medication is responsible for one of the two positive effects. On the other hand, we often get blamed when a transplant fails to meet the patients expectation for additional density, sometimes not because the transplanted hair didn't grown in great, but rather because of the gradual thinning of the ones that were there to start with. Mike Beehner, M.D.

This 55 y/o male who desired the physical appearance of a female presented for his first HT procedure in 2005, at which time 1238 grafts (1027 FU's and 211 MFU's) were placed in the front hairline region, recessions, and temples. A second procedure was performed the following year of 1413 grafts (1203 FU's and 210 MFU's) were placed for a total of 2651 grafts (6817 hairs). The patient is coming in after Jan 1st for a final third procedure for maximal density. The patient had a face lift performed in 2008, which helps also account for the dramatic difference in his overall appearance.

I think your question was regard to whether or not using finasteride helps prevent the "effluvium" or dropping out of the newly transplanted hairs for the 3-4 month period. My answer would be that I have not seen any convincing evidence that finasteride (Propecia/Proscar) or topical minoxidil has much effect on whether or not this happens. I think it's a great thing to be on finasteride if you are having a transplant, because there will be an increase in hair mass for a few years due to the medication, and that increase, along with the gain of the transplanted hairs, will look a lot more impressive on top than if the patient only gets the transplants but allows male pattern baldness to cause his remaining "native" hairs on top to drop out. Mike Beehner, M.D.

We give our grafts fairly loving and gentle care but haven't been able to change those statistics. In talking with my colleagues over the years, that is the usual experience. I would be interested to know if any of them have one that is different. Studies have been done using finasteride and/or minoxidil to try and change them, but I am not aware of any appreciable influence on preventing transplanted hairs from going through that "hibernation" stage before growing. Mike Beehner, M.D.

Your impression is correct, in that the great majority of the hairs that are transplanted (most of which are only 1/8th inch long) are shed during the first few months, before the "real" hairs appear 3-4 months post-operatively. They usually shed in one of two ways: some fall off with the scab at the 6-10 day point, while others just "sit in place" in the skin, even though down deep in the skin they are literally disconnected from the follicle (the living part of hair), which shrivels up and hibernates for that time period. These short stubs then can sit there for weeks or the can fall off at anytime. The best way to tell a "disconnected," non-growing one from one that is going to grow is to simply look at it a couple of weeks later. If it is longer, then it is growing. Simple as that. I find that around 5% of hairs keep on growing from the day they are transplanted, and in some patients, this percentage is even much higher, but they are definitely the exceptions. The other issue you alluded to was what percentage of the hairs that are transplanted actually survive and grow. Many studies have been done to look at this, some with tiny boxes out in the middle of bald skin, and others deep in the center of a thousand other sites, and the averages are somewhere around 90% survival for all FU's, and around 99% for MFU grafts (DFU's and TFU's). The FU studies range from the high 70's to even higher than 100% (due to hidden telogen stage hairs that later grow). The percentage you receive from your doctor will depend on the skill of him/her and the staff more than anything. In two research studies I conducted, 1-hair FU's did not survive as well as 2-hair FU's. Again, the probable reason for this is the same as for why MFU grafts survive better - namely, because of the extra protection and buffering against the elements of drying and trauma that the extra tissue between the follicles provides. Mike Beehner, M.D.

My belief is that it doesn't make any difference what shampoo you use. All shampoos are simply soaps. Consumer Reports has done two extensive analyses of shampoos over the past ten years and published them, and their conclusion was exactly what I stated above. At our clinic we give out a "courtesy" gift tube of Nexus' Therape shampoo to each patient, but not because we believe it superior to all others, but simply as a gift. It has a slight nostalgic value to me also, since that is what the clinic gave out back in 1982 after each of my first three transplant sessions and I loved the way it smelled (have since lost most of my sense of smell and don't enjoy that aspect of using it). There are some shampoos that have added ingredients to help with seborrhea (dandruff) and these might be of extra benefit to patients who suffer from that. Also, the Grafcyte kit, which many of our patients opt to purchase, includes a container of their shampoo with the copper peptide in it. I have seen some great results one week later with patients who used the Graftcyte kit, but whether or not the shampoo portion of the kit had anything to do with the quick disappearance of the redness and scabbing I have no idea. I am pretty sure that the frequent spraying is what helps the most. Lastly, there are some shampoos that are labelled as "volumizers." They add a little bit of a protein coat to the hair shaft to make it seem fuller. Being a person with fine hair, I have used these from time to time and have noted a slight benefit along the lines of what they promise. But the bottom line is that most of what hits you in print and over the air waves is all advertizing hype, created by people in rooms writing advertizing "come-on's". The other piece of advice that Consumer Reports gave was to try a bunch of different shampoos and if one of them makes your hair feel better or look more natural for some reason, by all means go ahead and use it. The choice will be very different for different people though. Mike Beehner, M.D.

This 50 year old male who is almost to the point of a Norwood VI level of hair loss, presented requesting hair transplantation, and he chose the "all-FU" method, rather than the "combination" method (in which around 20-30% of the grafts in the first couple of sessions are DFU's or TFU's of 4-6 hairs). 3063 FU's were placed, of which 30% were 1-hair FU's, 50% 2-hair FU's, and 20% 3-hair FU's. Around one-third of our patients are done exclusively with only FU's densely packed. The public perception of our practice has certainly been that we use the MFU's in almost all surgeries, but we are equally comfortable using all FU's. We especially favor the all-FU approach when the area of concern is a smaller one, such as with deep recessions and erosion of the front hair line. You will note on the pattern drawing on his head that we drew in a small circular zone in the "frontal core" region, which was approached with "stick-and-place" by myself, placing around 150 two and three-hair FU's into tiny 20 and 19g needle sites. The zone around that was transplanted at moderate density, using all 2's and 3's, and the rear and side zones were filled with 1's and 2's with slightly lesser density. The front hair line had 600 FU's placed. Mike Beehner, M.D.

In answer to your question, scalp donor hair, when transplanted to the eyebrows does seem to behave like scalp hair and most of my eyebrow patients report having to trim their eyebrow hairs every 1-2 weeks to keep them at the proper length. There have been a handful of studies by Dr. Hwang of South Korea and Dr. Cole that they claim showed that hair transplanted elsewhere took on some of the properties of the site it landed in. I myself haven't studied that in a scientific way up till now, but my clinical impressions over the years of having transplanted beard hair, chest hair, and scalp hair to eyebrows is that I haven't noted this modification of the hair's behavior (growth rate, character of the hair, etc). This is an area, especially regarding eyebrow hairs, that needs a definitive study on rate of growth. Mike Beehner, M.D.

This 40 y/o male, who has never had eyebrow hairs, presented in 2005 for eyebrow hair restoration. We placed 165 1-hair grafts into each eyebrow at his first session, and another 145 into each eyebrow at a second session 2 years later in 2007. In January of 2009 he had an additional 115 placed in each side, and he now presents 9 months later. Photos are shown of his result after two procedures in January and also his most recent photos. I like to use all 1-hair micrografts in doing eyebrow transplants, which allows me to use a very small 22g needle to make the recipient sites, and we leave the donorhairs long (around 1/2 inch long), so that we can see the bend that exists in almost all hairs, so that we can rotate the graft so the curve of the hair flows with the direction of the eyebrow itself. Mike Beehner, M.D.

Hairfreak, I have been doing hair transplants for 21 years, so I overlapped a couple of years during the "plug era," when all we had was the large 4mm 18-24 hair plugs. At that time I knew of two hair salons that did an outstanding job of cutting and styling a few of my patients' hair so that the transplants looked remarkably natural, so I would steer other patients of mine to these hairdressers. Since the grafts have become much smaller and the sessions larger, this is totally unnecessary and I feel any good hairdresser can do an equally good job with transplanted hair as with normal native hair in a non-balding male. Obviously, depending on how thin or wide the donor scar is, they have to be aware of some minimal length to leave the hair so that the scar doesn't show. The width of the scar in most instances is directly related to how many transplant procedures they have had. Most men with either one or two surgeries look almost undetectable. When you get up to 3 or 4, then it can get 2-4mm wide sometimes. Usually hair at least one-half inch long will cover almost any scar. Mike Beehner, M.D.

This 50 y/o male with extremely fine hair caliber presented a few years ago and during that time had two medium-size "combination graft" sessions totalling 3210 grafts (8707 hairs). He plans to have a final procedure for additional density and some camoflaging of the crown area. His 3210 grafts included 2390 FU's and 820 DFU/TFU's. Mike Beehner, M.D.

Captain O, If you are obviously thinning when you look in the mirror and can pretty easily see your scalp through your hair, then you are right in that you are on a "progressive loss" curve, BUT, you should realize that the long full hairs you see on the brush or shower floor are NOT lost hairs, but rather are full length and full diameter hairs, which we term "terminal hairs." Such a hair will always be replaced by another hair when the follicle comes out of its telogen "slumber" of 3-4 months. That hair may come back strong just as the one you found on the shower floor, OR it may come back in the next anagen cycle slightly miniaturized (smaller, "wispier" diameter and limited length it will grow), and then the next cycle it will be even wispier and shorter, until it falls out for the last time as a short, thin hair you can barely see. Part of the problem with your calculations is that you usually are missing around 50% of your hair mass by the time you realize you might be losing your hair and it appears thin in the mirror. As was already pointed out to you, a consultation with an experienced hair surgeon is your best bet, and you might want to update that visit in light of what you reported. Mike Beehner, M.D.

This 39 y/o male presented to us several years ago with basically an advanced Norwood VI pattern (bordering on a Norwood VII). We told him a reasonable goal would be to fill in the midscalp and frontal regions and leave the vertex (crown) in the back bald, as there was such a large square area that was balding. Over the next few years he had three larger sessions and a three additional tiny "touch-up" sessions in specific areas, for a total of 6676 grafts (5371 FU's and 1005 DFU's). The caliber of his hair is "fine." Views are shown before and after of the rear vertex view. We actually did later place around 800-900 1-2 hair FU's in there to create a little "fine" cover, but you can tell from the photos that that many FU's doesn't create that dense of a cover in such a large area. I also apologize for the excessive red tint on a couple of the photos, as we were still adjusting our "white balance" on the then new digital camera. Mike Beehner, M.D.

In answer to the one commentator regarding two points he made: There's a difference in how a scar looks in relation to how much width was taken. Taking, say, a 1cm strip plus a 6mm wide scar results in a much different looking scar than just taking the 1cm strip and coming back 8 months later and taking the scar out. Regarding the cost to the patient, I, along with probably the majority of hair surgeons, don't charge anything for work I do to improve a scar that I was responsible for. If I am working on a scar that was the result of another surgeon's work, I do make a small charge when I do this work. Mike Beehner, M.D.

Vanitysucks, Actually, it would theoretically be far better to take out the next donor hair and the strip as SEPARATE procedures. When you have your next transplant done, the surgeon could harvest the amount of hair that is necessary to accomplish what you want done,removing the donor strip from precisely above or below the old scar, and then AT A SESSION SEVERAL MONTHS LATER he could excise ONLY the scar. This way there is a minimum of tension on the scar closure and you will get a minimum of "stretchback" and end up with a much thinner scar. Because you have a wide scar, you already have evidence that you have one of those scalps that tends to "scar wide" if a moderate amount of tension is placed on it. Why tempt the fates again? If on the other hand the portion of your scar that is wide is only at the rear corners, then sometimes the surgeon can take the needed donor hair from the flat area in back and along the flat sides and then IN CONTINUITY excise the wide scar areas at the corners. This would be one way to keep it to one session. Obviously, if the "wide" scar actually isn't all that wide, say 3-4mm or so, and there is plenty of laxity, then, yes, I will sometimes go for both at the same time, but I would keep the width of the hair strip removed fairly narrow to minimize the closure tension. If the patient wants a fair amount of hair, then sometimes you have to go longer with the strip to accomplish this, which is far better than going wider. Mike Beehner, M.D.

Dear Avolat, I sympathize with you. We don't have really good medical treatment for female pattern hair loss at this time. I will try to review the various options for you in this note in hopes it helps give you a little better view of your choices. As you know finasteride and dutasteride have not been proven at all to help women's hair loss, as it is not affected hormonally the same way a man's is. I hope you gave the minoxidil at least a good year's trial before giving up on it also. You can't take it for 2-3 months and make a judgement about it's effectiveness for you. Also, many experts recommend for women to work up to the 5% level strength if they tolerate it, or alternate 2% with 5%, as I often do. It works better for preventing future hair loss than it does for actually growing any new long hairs. Other medical approaches are: spironolactone, which has to be used in high doses, at least 100-200mg a day. I have heard a few cases in which it worked wonders. Many doctors are uncomfortable prescribing it, as it raises the potassium and can make the lupus antibody go positive (no proof it causes lupus though). I have avoided prescribing it for women but have encouraged some women to consult with an endocrinologist about possibly considering it under their medical supervision. I am not a big fan of the laser therapy. My gut feeling, after all the talks I've heard and the hundreds of patients I have spoken with who have used it, is that perhaps 15% of patients realize a benefit, which is short-lived over a couple of years. That's an awful lot of bitterly disappointed patients and a lot of money spent. There was one talk at our ISHRS meeting in Amsterdam though which was a little more encouraging, so it might be worth a try. Once you get past medical treatment, you are looking at four choices: doing nothing, using camouflage products (Toppik, Dermmatch, etc), non-surgical hairpieces, or hair transplants. Usually the decision comes down to the last two choices. The simplest way to help make that decision is to have a hair expert, who has the capability of examining your hair under high magnification, carefully examine the hairs on the back of your head. If there is significant "miniaturization" of the hairs there, then you will probably not be real happy with the results of a transplant, although some of these women can be made reasonably happy for 10-15 years by moving this hair. Most of these women are best served with one of the modern, human-hair, lightweight hairpieces that are getting better and better. Most hair surgeons are able to recommend who in your area does high quality work. If the hair in the occipital (rear) area is of high quality with minimal or no miniaturization, then you most likely could be significantly helped with hair transplantation. You will probably have to commit to a certain styling pattern, so that the surgeon can "cheat" and load up certain areas more than others. The reason this is necessary is that most women with female pattern hair loss do not have really high quality donor hair on the sides of the head as men do, so we are limited to harvesting the good donor hair from the flat back area of the scalp. Usually 1600-2200 FU's can be obtained in a single session in most women, using a slightly wider strip. It takes a minimum of two sessions and there is a 20-30% chance of some mile "shocking" to some of the weaker, vulnerable hairs presently on top, such that you take a small backward step the first couple of months, but then head into positive territory usually by 4-5 months. I find that 80% of the women who consult with me are good candidates. The only things that disqualifies a woman as a patient is a poor donor area or unrealistic expectations. I wish you the best with your problem. Mike Beehner, M.D.

This 46 y/o male first began his transplants in 2001 and has spread 3 small sessions over the time since then. When he started, our sessions were typically smaller than they are today. His last session was a couple of years ago. He has received a total of 3419 grafts (not including his most recent "touch-up." Those were composed of 2644 FU's and 775 DFU's for a total of 10,015 hairs.

Kt, There is absolutely no way at this time to tell if it is permanent or temporary. Statistically, 90-95% of these will grow back the hair that was shocked and the scar will be far less noticeable. Whether it is permanent or not, if you could cite one factor that would determine its probability or not, would be the amount of TENSION that was present after it was closed. The odds are in your favor. In the meantime, I would adopt a little longer hairstyle. Painting a little Dermmatch on the scar can do wonders also. Mike Beehner, M.D.

"BigBill:" I don't think I made myself as clear as I should of. These three shorter strips are taken immediately adjacent to and even includes usually 1-2 mm of the old scar. These are then closed up. One is on the rear flat area of the back of the head and the other two are on each lateral side. There is a small perhaps one inch segment at the corner which is NOT taken. Again, this is only done when you still need more hair, despite the fact a less than ideal scar width may be present. The scar is then dealt with later on after the transplanting is done. If someone really stretches due to very hyper-elastic skin, then one might make the decision to do the rest of the transplanting using FUE, which would not make any of the horizontal scars worse. I just feel the quality and survivability of strip grafts are far superior to FUE grafts, simply because a strip graft is carefully dissected out under microscopic vision, whereas an FUE graft is tugged out of a tiny hole and they aren't all perfect looking. Mike Beehner, M.D.

Bigbill1234: All of the comments have been great ones. When I get a patient with a scar that is around 9mm wide or so, my first question is: are you done having transplants, or do you plan to have more? If the patient still needs more hair, then the donor hair has to be obtained in a way that doesn't make the wide part of the donor scar worse. Since these wide areas are most commonly at the two rear corners just behind the ears, a good plan is to leave that section intact and instead cut three shorter strips from just above the old one, but not too wide of a strip and go a little longer if you need more hair. Leaving these short segments intact at the corners, helps keep the whole length from stretching. Once the patient is all done having transplants, then you can decide the best way to deal with the scar. If I choose the excision route, which is certainly always the easiest, I try and divide it into two procedures. I find that if you go for the whole 9 or 10 mm at once, you create too much tension and it "snaps back" almost as bad as it was in the first place. I prefer to take only 5mm of width out, and then go back in several months later to get another 5mm. By doing it this way, I find that I "lock in" 90% of my gains, whereas I lose almost all of it when I go for too much. Also, ironically, the patient often looks so much better with the first narrow excision, that he doesn't feel the need to have a second procedure. If a patient like this presents, in whom some surgeon has already made one attempt at cutting it out and it is still wide, then I virtually never try to cut it out, but rather go to FUE grafts into the scar and possibly the addition of tattoo dots with the FUE grafts. Mike Beehner, M.D.