Dr. Michael Beehner

Her FU breakdown was 35% 1-hair, 45% 2-hair, and 20% 3-hair. You're correct, in that she had good "body" to her donor hair, which makes a huge difference compared to dealing with someone with fine, silky hair. Mike Beehner, M.D.

This 49 y/o female presented complaining of see through areas in both the temples and along the front hairline and requested that they be made denser. 2190 FU's were dense packed into this area using 20, 19, and 18g solid core needles to make the recipient sites. Mike Beehner, M.D.

This 25 y/o male presented to Saratoga Hair Transplant Center with deep recessions and a weakening frontal tuft of hair, wanting a stronger framing to his face in front. In October of 2008, he had 1300 FU's (30% 1's, 60% 2's, and 10% 3's) placed in only the frontal rim area using custom lateral slits of the 0.8mm and 1mm size. The patient plans to have one more smaller "fill-in" session to increase the density slightly more. Christopher Pawlinga, M.D.

I performed my last scalp reduction 10 years ago, but did many of them my first 10 years before that. The one writer is correct, you felt like a miracle man when you held that "before" Polaroid next to the "after" one and proudly gave the patient copies. But a few months later they always stretched back to some extent. Nine years ago I did a study on 11 consecutive scalp reduction patients and found that the stretchback percentage was around 40%. For example, if you removed a 5cm wide area of bald scalp, a few months later the side-to-side measurement would be as if you only removed 3cm instead of 5cm. There are several other negatives also. While 80% of them had wonderful scars that were virtually impossible to see later on, the other 20% could shine in the night almost and were devilish to camouflage with grafts. One of the biggest negatives is that it thins the scalp and in my opinion compromises the blood supply for the scalp for when you transplant it. Many patients who had a couple of reductions would have a paper-thin scalp when you felt it. And finally, it takes away from the laxity that you want in the donor hair for removing a couple of strips at the time of transplanting later on. All that having been said, there are still unique situations in which I would offer one, and in fact have offered one on two occasions, but neither patient took me up on it. Mike Beehner, M.D.

BeHappy, That's certainly the record for number of procedures on one patient I have ever heard of! I'm impressed that, after all of that work, Dr. Feller is able to get 500 grafts for you with FUE in 2-3 procedures. My guess is that the middle level of your donor hair is "mined out," and the bottom and top are the only places where hair can be located, which makes the FUE method the preferred way to go, as you don't want scars in those places. The other big reason for small sessions is blood supply. I am sure it is somewhat compromised after the work you have had done, and I am guessing it is the reason you aren't happy with the amount of hair on your head after all those procedures. Even if 2000 FU's were available, I would hazard a guess that you might get 30-40% survival with a scarred, compromised recipient scalp area. It is far better to get 80-90% survival of a smaller number and then, after a period of recovery, to go back for a few more. Also, at this point, as I think you also alluded to, you probably need to settle on a hair style and target whatever few grafts you do have placed into an area that will make a difference. Usually the frontal core is always the first priority for density, and then other areas can be attacked. I don't blame you for being frustrated, but I think you misplaced your anger on a physician who was giving you good advice. Mike Beehner, M.D.

The patient was only on estrogen medication. The key thing in my mind is having a high percentage of 2-hair and 3-hair FU's to put in the slits just behind the front edge, so that you're not wasting a recipient site by only placing one hair in it. This leads to a thin result. The other thing that helps, besides a high percentage of 2/s and 3/s is to have hair that has some "body" to it (diameter, coarseness), as it "fills" much better. Obviously the overlapping of hairs over each other contributes to the illusion of density also, which is why making the sites at an acute angle is so important. She still needs one more session to be as full as I'd like her final result to be. I didn't show this with the intent of stating I have finished on her, but rather to simply show that one session can begin to make a difference in the appearance and "face framing" of a person like this that wants the hairline and temples moved forward. Mike Beehner, M.D.

This 45 y/o female transgender patient presented for advancement of normal male recessions forward into a more feminine hairline and temple region. One session of dense-packed FU's was performed using 0.7, 0.8, 0.9, and 1.0 custom lateral slits in the frontal rim and temple regions. The hairline was brought forward almost one inch and the temples were filled in and a shallower curve was created in the fronto-temporal recession. The patient will be having one more sesion to make these areas even fuller. Mike Beehner, M.D.

You may want to wait a short while, since a new edition of the Unger/Shapiro book (entitled "Hair Transplantation") will be coming out later this year or early next year. Also, just a few years ago, there was an excellent smaller text published, also titled "Hair Transplantation", edited by Drs. Haber and Stough. Mike Beehner, M.D.

hdude46, I have added to the photo gallery a couple of examples of what I would call "indistinct fringes" in young men in their 20's, both of whom I feel are at risk for later becoming a Norwood VII. For this reason they both had a "forelock" type of pattern used in their tranpslant procedures. When using magnification in the upper fringe, you typically will see 5-15% of the hairs are miniaturized, which usually helps "tell the future" - and it isn't good. Mike Beehner, M.D.

This male in his mid-50's was presented in this section several weeks ago, and one of the commentators asked if it was possible to find out what he looked like when he was a young man, andif there would have been clues at that time that he was destined to have this much hair loss in the future. I contacted the patient, who gave permission to use the photos, and this black and white photo is this man when he was 28y/o. As you can see, he had what for all intents and purposes looks like a pretty decent head of hair. So you would be left with taking a good familyl history, looking for miniaturization, and, most importantly, also just being conservative in the planning if he started his transplants in his 20's. This is why it is so perilous and risky to bring the fronto-temporal angles way up and flatten them out or totally fill in the crown/vertex in young men. You run the real risk of turning them into freaks some day, who will be recluses and never present themselves in any social situations. We hold these people's future in our hands and can ruin it if we are short-sighted. This patient recently had two procedures done to produce the look that you see, and did undergo a third procedure which hasn't grown out yet. Mike Beehner, M.D.

This 50 y/o female presented in June of 2007 for her first HT procedure of 1008 FU's and 260 MFU "slit" grafts (total 1268) and returned one year later for a second session of 1760 FU grafts. The "after" photos show her one year after her second session. She plans a third session next summer. As you can tell from the photos, she also went on a diet and lost a significant amount of weight after her first procedure. I might add that we transplant the side temple areas in almost all of our female patients. In a couple of the after views, these hairs along that front border of the temple can be seen. Mike Beehner, M.D.

There is no question that receiving needle injections into the scalp is a painful thing. I know from first-hand experience, as my first 7 of 9 procedures all featured needle injections with no sedation or narcotics given at all (I had nitrous for my last two). In my 20 years of practice I have learned a few things about making the pain minimal, largely because I realized what the patient would be going through. Before reviewing some of the "pearls" I have learned on reducing the pain of a transplant, I do want to emphasize that the pain of needle injections is definitely much greater when done in areas scarred from previous transplant procedures, whether it is in the donor or the recipient areas. There are seven things I would list: 1) Use some SEDATION if possible. Some states have restrictions on what routes can be used. IV is best, but subcutaneous Versed works wonderfully and gives amnesia and sedation for the procedure. Even Ativan (lorazepam) under the tongue works well. You do have to be certain the patient doesn't drive home though with the drug in his/her system. 2) Use a NARCOTIC. Even a Percocet or Vicodin tablet a half hour before you start raises the pain threshhold and makes everything a little more tolerable. Best of all, narcotics are synergistic with the sedatives in the Valium family and each makes the other work better. Demerol IM is our narcotic of choice in most of our cases. 3) Inject the volume of the local anesthetic SLOWLY. The rapid filling into the tissues of the lidocaine is what hurts more than the prick through the skin. The ultimate in "slow" is a machine commercially sold as "The Wand," which takes awhile but delivers the local very slowly and painlessly. 4) CUSTOM-MIX THE LIDOCAINE AND EPINEPHRINE; In the commercial lidocaine bottles that already have epinephrine in them, there is a preservative also which keeps the epinephrine from breaking down, and that preservative makes the solution very acidic, which makes it sting like crazy. If a nurse gets to the office around a half hour early and pre-mixes the epi into the plain lidocaine syringes before surgery, that sting doesn't happen. 5) Use a SUPRA-ORBITAL BLOCK. You can hold a small ice cube (as we most often do) or use a vibrator at the point near the inner eyebrow to perform this block and it is hardly felt at all. We use Marcaine with epi, as it numbs the frontal and midscalp regions of the scalp for 8 hours in our experience. 6) DISTRACTANTS: As an injection is going on, there are a number of distractants the surgeon can use to help minimize what the patient feels. A small ice cube for cold, pressing for pressure, and the vibration of the nose of a vibrator are three very good ones. 7) Use of the DERMOJET in the donor area. This is an automatic injector device made in France that has been around for over 30 years that allows the surgeon to inject a small amount of 2% lidocaine into the skin in the donor area lightening quick. I have had both needles and this used, and I believe this is far less painful than needles. The skin is a little too dainty and sensitive in the forehead or temples to use this, so I reserve it for the back. Between this in the back and the supraorbital block in front, the whole head is numb and the patient virtually hasn't felt anything. I will repeat again that if you have row upon rows of scars all over your head from old surgeries, then you do have the most difficult scalp there is for numbing without any discomfort. You just have to want it real bad and hope your surgeon uses every trick he knows to minimize the pain. As Bill Clinton once famously said, "I feel your pain." Mike Beehner, M.D.

Perhaps I didn't make it very clear, but with old plugs in the crown/vertex, after punching them out with a large punch (3.0mm is my favorite), it is necessary to place a tiny suture in each one and close them and not let them heal openly. Not suturing them would leave very noticeable white scars everywhere. I tailor the size of punch to use to the area being taken up by the hairs in any given graft, often using 3 different sizes and matching them up size-wise. It's a tedious business, but in the end almost anyone can be made to look fairly natural looking when it's all completed. Mike Beehner, M.D.

What you are describing is done fairly commonly, though less in recent years than it was 10 years ago. It usually requires two sessions to remove all of the offending hairs. Usually the ones in the crown/vertex are the ones that most urgently need to be removed. The other point I wanted to make is that, if your scalp is smooth and not very ruddy and shows small imperfections, then, when all the grafts have been removed, often laser resurfacing or dermabrasion will give a smooth, undetectable appearance to the scalp surface where the grafts were removed. So often it is a three-stage operation to accomplish what you are describing. Mike Beehner, M.D.

I thought Dr. Shapiro's article was very thorough and helped explain some of the terminology differences for the different grafts. I wanted to add that an important reason for having different size grafts is for CREATING GRADIENTS of hair density on the balding head. In perhaps half of the men who come to us, we look at their donor area and the area on top that will probably bald in the future, and we realize we can't fill in everything. Simply creating "wall-to-wall-carpet" of FU's in the same density and hairs/graft from one side to the other is not very artistic and has a tendency to often create a "see through" result. But when the surgeon thinks things through and plans where he/she is going to use the 3-hair FU's, the 2-hair FU's, and what planting densities will be used, then one can imitate some stage of early natural hair loss in a man and have it look good for the rest of that person's life span. We have two tools for creating a gradient: the density we choose to plant the grafts, and the number of hairs per graft. I, along with a lot of other current practitioners, feel that the DFU graft of 4-5 hairs is very valuable in the front-central "core" area for blocking light from revealing the scalp and in creating visible density. It does take some judgement in selecting which patients are appropriate for these slightly larger grafts. Someone with coarse, dark hair and pale skin would not be a candidate. Virtually all patients with "salt and pepper" colored hair I believe are excellent candidates for this approach. The important thing to remember is that these grafts have to be used in such a way that you don't actually see the individual grafts when viewing the patient. We typically place 500 FU's along the front hairline to outline the front view of the patient's hair and also use them in large amounts along both sides and in the rear areas. Mike Beehner, M.D.

Bllorayne, When "shocking" occurs to the hair follicles, this causes them to go into the "telogen" (rest) phase for 3-4 months and then they return for the next "anagen" (growth) cycle that was supposed to occur, so you in effect move the time line up and those hairs are experiencing what should have happened 4-5 years later. The only hairs that you will completely lose then are those wispy, short ones that were on their last life cycle and also any follicles that were totally transected by the recipient site instrument, which is a lot more likely the denser the packing of sites is. You might counter with an argument that an individual hair surgeon is so good that he/she places the new sites precisely between the native hairs; the problem is that follicles don't necessarily descent straight down or even straight at the angle the hair appears to be at. They are often like sea-weed and curve all over the place under the skin, thus allowing a lot of transection. The good news is that a transected hair is not totally lost, since four different research studies by Kim, Swinehart, Limmer, and Reed all show a decent percentage of them will survive and regrow, because either of the growth centers, the bulb or the bulge, were left unharmed. This is one reason that I think reasonable planting densities of around 30 FU's per cm2 is a pretty good approach when there is a lot of native hair present. Mike Beehner, M.D.

I think you are referring to propylene glycol, the preservative that is the vehicle the minoxidil solution comes in. The foam product does not have this in it. I am not aware of any problem even with the propylene glycol. I have never noticed decreased growth in my patients and am not aware of any cytotoxic effects of the chemical. Even if there was some mild effects, I feel the seal is pretty good by 4 days in terms of protecting the follicle structure that is under the skin. I'm always open to new information, and if someone has something of a scientific or proven level, I would be happy to learn of it. Mike Beehner, M.D.

For many years now I have had my patients resume Rogaine (minoxidil) 4 days after the transplant, obviously cautioning them to be gentle and careful in the application process. The main concern with restarting Rogaine immediately after a transplant is that minoxidil is a very potent blood pressure drug which drops blood pressure. In the first couple of post-op days I feel that there is a certain "raw" portal of entry for the drug into the system quicker than what normally occurs with the skin epidermis there as a slow-entry gateway. I think enough coagulation and sealing off of the sites has occurred by 4 days to allow the drug again and have never had an instance of a patient getting light-headed or fainting from doing this. Besides people that have been on Rogaine all along, there are a fair number of patients in whom I place them on minoxidil 5% every night for a month before the procedure and a month after it, to perhaps help the yield be high and to lessen the chance of an effluvium "shock" reaction. Most of these patients are either women, in whom shocking is much more common, or in males who have had extensive past work with presumed decreased vascular supply to the scalp, and there is anecdotal reports from several doctors that minoxidil helps in this regard. Minoxidil, besides being a vasodilator, is also a "growth factor" for hair and thus may help. I can't prove that it does, but have had no negative experiences in using it in this way for well over 10 years. Mike Beehner, M.D.

I just noticed Bill's reply concerning my comment regarding what might happen if all men with male pattern baldness lived to be 100, and I agree with him. I didn't mean to imply in my earlier statement that all would progress to Class VII as an end stage, but was referring to the collective group of Class VI's and Class VII's. My strong hunch is that, even at 100, a fairly large group of men might still hang on to residual native hair in some regions on top. Mike Beehner, M.D.

I agree. I think the 35-40/cm2 is a very adequate density with which to plant FU grafts, especially if a good portion of them are at least 2-hair FU's. This density helps the surgeon to try and avoid having a "direct hit" on pre-existing hairs/follicles and minimized the chance for "shocking' to that existing hair, assuming it isn't taken out directly by the cut of the needle/slit immediately adjacent to it. Another fact to keep in mind is that almost no one is completed in one session. Some clinics will promise this, but, if you go down the line with anyone who has been to any clinic seeking what for them subjectively is that elusive "full head of hair," they all went 2-3 times to get the density they ended up being happy with. In that context, starting out with a 30-40 FU per cm2 density is a very reasonable starting point if a relatively large area is going to be covered (such as the frontal and midscalp areas). If the goal was to fill in a relatively small area that was largely void of pre-existing hairs, then I think it makes more sense to push up toward 50-60 grafts/cm2, since you ARE pushing for a possible one-pass result and there is no chance of shocking any hair in the area. The last point I would make is that Indian males typically have a rather coarse caliber hair, and if a fairly large percentage of the FU's are 2 and 3-hair ones, then 40 grafts per cm2 is probably the maximum you would want to go to. Mike Beehner, M.D.

HDude46, That's a very good question! Maybe if they all lived to be 100 they actually would. As a general rule, if you see a man in his 30's, 40's, or 50's with some residual "strong" hair on top amidst obvious hair loss behind, around, or in front of it, it is a very safe bet to assume that over the next decade or two that "strong" hair will gradually thin and possibly even disappear. However, like you I also over my 20 year hair surgery career have seen men who defied this theory of "progressive hair loss" and seemed to stay still at a particular stage, whether it was an intact hairline with baldness behind, a large oval forelock with baldness all around it, or a Norwood "Variant" class person who has hair loss off the front only going backwards with strong hair throughout the crown/vertex region. One fellow at my church has a shiny 2 1/2 - 3 inch crown with thick hair all around and it hasn't changed in 15 years. We should all be so lucky! Mike Beehner, M.D.

In addition to the typical "Norwood" classification progression of hair loss which Bill described, namely gradually deepening recession in front combined with an enlarging crown/vertex until the two meet in the middle to produce total u-shaped baldness, though the commonest progression pattern is not the only one. Three other patterns which are seen fairly often in our practices are the following: a) The "diffuse thinner" who has no one area that is stronger or denser than another. All the hair in the horseshoe shaped area on top just thins at exactly the same rate and disappears together also. b) The "forelock" pattern, in which a roughly oval shaped area of hair in the front-central is denser than the alleys to each side and the large area behind it. Gradually, a forelock much later in time does become thinner and often disappears and becomes total baldness on top. c) The "intact hairline" pattern, in which the early baldness is in the rear crown/vertex and gradually expands until it comes right up to behind the hairline. Al Gore is an example of this pattern of hair loss. Mike Beehner, M.D.

I use both lateral slits and small solid core needles and choose one or the other in a given area based on what my goal is and whether or not there is hair in the area. When I want to create maximal density at that session and the scalp is bald or extremely thin, I now always use lateral slits. You simply can't match their density with needles of similar size. However, there are a couple of reasons to use needles. When there is hair in the area being transplanted, especially when it is of medium density or more, the bevel of the needle and it's overall tapered shape I believe pushes the hairs aside, whereas I think the very sharp, thin lateral slit with the spade-like sharp razor end cuts anything in its path as it descends. This is a small difference, but I think it can be significant in some cases. The other reason to use needles is when you want the dilating benefit that a needle give to a recipient site. In a hairy area in a dark or medium-dark patient, the needle sites are easier for the placers to see and thus sites are not missed. Like most issues in hair transplant surgery, there usually is no black and white answer where one thing is always the way you do something, but rather it is usually a nuanced thing that requires some thinking and an evaluation of which tool will best do the job. Mike Beehner, M.D.

Ikki, You didn't say how old you are, as that influences my approach with a patient. I am more aggressive with pushing both medications if a man is relatively young (17-25). If you intend to take only one medication, then the clear-cut first choice in my opinion should be finasteride. I commonly prescribe either a full 1mg tablet every other day, or more commonly, a quarter of a generic 5mg tablet every other day. For men over 35 I relax it to Mon-Wed-Fri. Merck's own research shows that as little as 0.2mg per day suppresses DHT pretty decently. Minoxidil's main benefit is in slowing hair loss, but it can also add a little to increased hair growth, but the "messiness" factor is a greater and, if you stop using it for several weeks, you can lose all of your gains. I think a lot of non-hair-specialists push minoxidil because that is what they first heard of in the way of hair loss treatment and because they're a little unfamiliar with finasteride or fear that the sexual side effects are more common that they really are. In my experience, in men in their 20's and 30's they are really uncommon. I would contact another doctor who may be more up on things. Mike Beehner, M.D.

I agree with the other two physicians that closure tension and the hyperelasticity of the individual patient are the two biggest factors in ending up with a wider than desired scar. I do think that the parietal corner, where the flat occipital aspect of the donor area curves around toward the area behind the ear and the side of the head, is the area most likely to make a patient unhappy with a wide scar. For that reason, I take a narrower strip in that area as compared with the rear center area. Three other things that I think help minimize stretching of the scar are the following: First, leaving the sutures in as long as possible. And here staples may be a little better, as they are more non-reactive and less likely to be covered with the skin as it heals. Second, for a couple of months after surgery I ask that the patient try to avoid activities in which the neck is acutely flexed down on the chest, such as doing abdominal crunches or lying in bed on three pillows with the neck bent reading a book on one's chest. The third thing that can be done is to leave a permanent suture, such as nylon under the skin holding one of the layers together permanently. I prefer the lower dermis for this suture with an inverted knot, usually around three of them in total. It's important to pay more attention to strict sterile technique when leaving a foreign body under the skin. But, as mentioned, I agree the single biggest factor is the width of strip taken. I tend to be conservative and recently have been a little better about urging patient to do scalp stretching exercises as Dr. Wong does in his practice. Mike Beehner, M.D.