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Dr. Michael Beehner

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Everything posted by Dr. Michael Beehner

  1. Sorry, I forgot to complete my answer and say what could in fact be done for the patient who ends up in mid-life with an area of dense transplanted hair surrounded by a halo. By the way, these people often become social recluses and won't be seen outside the home without a hat on. I have met many of them in my career. It is a very sad situation. The good news is that it is almost always possible to make things better. It usually is necessary to "soften" the density of the areas on the lateral and rear edges of the transplanted hair. This will require some new FU grafts, which can usually be salvaged from what remains of the usual donor areas - often using FUE in the high and low areas where a scar can't be used - and also by simply removing some of the rear and side stronger grafts and using them in a more spread out, sparser pattern around the stronger central hair. The goal is to create a GRADIENT at the two lateral sides and rear, trying to visually bridge the bald ally that separates the mass of hair on top from the side fringes. Oftentimes, this all goes down a lot better if the patient adopts a hairstyle of sweeping it back to one of the rear corners. It also often takes around two sessions to pull this off, as the amount of invasive work you can do at one sitting is limited by blood-supply considerations. Mike Beehner, M.D.
  2. Notgoing2gobald, It sounds like you are asking about what a surgeon does once the damage is done and a presumably now middle-aged or older man who was transplanted when he was younger, now presents with an island of hair on top with a "halo" of bald skin around it and not much donor hair left to correct the problem. Hopefully this unfortunate predictament will become rarer as physicians get smarter about matching their translant patterns with the natural history of male pattern baldness. However, the combined pressure of patients presenting with unrealistic expectations and the physician's eagerness to please or to fill a booking in his/her schedule for financial reasons can lead to young men being filled in densely in a way that can not be sustained in later years and will most likely look detectable as abnormal, particularly when the patient's total available "safe" donor hair was used to do the early work. Looking at the problem from the early point, that is, when the patient is before the physician and a plan is being laid out - each patient is different and unique. You have to look at their family history, but not rely on it too much. A very important factor, especially in the 29-31 year old, where you start to get tempted to more aggressive, is to look under magnification for miniaturized hairs in the nearby fringe areas to see if it is indeed strong hair with very little miniaturization present. If there IS miniaturization, even just 5-10%, then a conservative, "frontal forelock" type of pattern is a wise course of action and will frame the face nicely. In this mode of planning, the surgeon creates a front-central forelock of density that extends back into the middle portion of the midscalp, and then decreases the density in a gradient toward the sides and toward to back. The idea is to create a pattern that actually exists on some men's heads as they naturally bald - at least 20-30% of men have this pattern as they lose their hair. And if you accomplish this, then twenty years down the road that transplant will not draw attention because it mimics a pattern that exists on many men's heads naturally. If a man does reach 38 or so and these dire fears don't come true, then everyone can become more aggressive and use the remaining donor hair in a more aggressive manner, simply because it's easier to see the future of a man's hair loss pattern at that later age. Mike Beehner, M.D.
  3. The reason I don't fill in the temples in men younger than 35 is similar to why I don't fill in the crown/vertex in men under the same age: It is too difficult to predict in a younger male how bald they will someday become. In most men the anterior border of the temples migrates rear-ward over the years, and in a certain percentage of men with male pattern baldness, the side fringes drop way down to a Norwood VII level of hair loss. If the surgeon committed a bunch of valuable donor hair to filling in those temple areas when they were young and they do in fact go on to progress to marked degree of baldness, then valuable donor hair was used which could have been used on top, and, more importantly, that hair can appear very strange and abnormal looking if everything it is connected to moves away and leaves it almost looking somewhat isolated. I think a surgeon has to have some sort of a "line in the sand" for some of these issues as to where to put hair, and that's where I have set my limits. I think for the younger male the overriding great thing a hair transplant does for them is frame the face and erase the high bald forehead that has nothing at the top of it defining it. The temples and crown are sort of "extra's" that are nice to have, but only at an age when they can be safely done without doing any harm to that patient's future appearance. Mike Beehner, M.D.
  4. Final photo attached. Will use Photo Album of Patients section next time, as I'm only able to enter one photo at a time. Mike Beehner, M.D.
  5. Will try and add the other temple photos here, as only one went through on the first try. M. Beehner
  6. cricket lover, You might be reassured to know that the majority of men have asymmetrical patterns and depths of recession, when comparing the two sides. In the past 18 years of evaluating these on patients, this has become clear. Obviously, in most men there is a minor variation, but in some it is quite striking and creates a challenge when drawing in the hairline that will be used. In our own practice, in men over the age of 35 we transplant the anterior temple area and points in around 40% of all such patients. It helps greatly in framing the face and "holding up" the new frontal hairline hair. Many men in their 40's and 50's also have pronounced graying in this area, and the simple transferring of some of the darker donor hairs from the back into this temple area helps darken them up a bit and make them look more youthful. I will try to add a few photos of a couple of patients in whom we did this to give you an idea of how they can help in fully creating the new hairline on a male patient with male pattern hair loss. The patient with the darker hair is 49 year old and had three transplant sessions to create what you see here. The second one, with a lot of gray hair present, had two sessions and you can see that the temple areas look darker in the "after" photo. Mike Beehner, M.D. Mike B
  7. Dear Bchap, I am assuming from your comments that the wide scar is throughout its length and not localized only at the two parietal corners, which are the most notorious sites for widening. There are three approaches that could be taken. One would be to take three small strips that are not connected together, leaving an un-touched gap at the corners, to help stabilize things. If your wide, detectable area is primarily most noticeable at the corners and behind the ears, this would make the most sense, as these two areas would not be worsened. Since you had the widening with your second procedure, the width of these new strips should be on the narrow side to avoid tension on closing the wound. These small strips should be taken contiguous with your old scar, so you end up with a single scar and not "stacked" scars (which look hideous and much more detectable than a single wide scar). The second approach is to simply remove a long, narrow strip along the top of your old scar, of sufficient length to provide the grafts you need, close it in two layers,leave the stitches in for two weeks, and then - assuming you are truly done with transplanting - come back a year later after some laxity returns, and have a narrow scar excision procedure done, removing a narrow strip of scar tissue the full length of your scar. If for some reason excision is not possible due to scalp tightness at that time, then FUE into the scar could be done instead. The third alternative would be to have an all-FUE session done, which wouldn't put additional stretch and stress on your present scar, but such a session would be a lot more expensive and time-consuming, which is a prohibitive obstacle for many patients. The last recommendation would be to make sure your expectations for additional hair are not outlandish, which would put pressure on your doctor to take more hair than possibly should be harvested from your scalp, given your desire to wear your hair on the short side and your propensity for scarring. Obviously, the best judge on these things will be your hair surgeon, who will examine your scalp and scar and decide which approach is best. These are some of the thought processes we go through when someone with a problem similar to yours presents. Best wishes, Mike Beehner, M.D.
  8. I think it is best to reserve the use of the trichophytic closure for the LAST donor closure that patient has. As we all know, it is very rare that someone is filled in and totally satisfied with a single session. Most patients come two or three times in those early years to get the hair they want. Each time you perform a trichophytic closure, you have to extend the width of the donor tissue taken by an extra 1.5-2mm. in order to obtain the area of partially transected follicles that will grow through the scar. Thus, if a man and his hair surgeon both know that three sessions over a period of 3-5 years are needed to obtain the final result they want, by doing a trichophytic closure each time, 3mm of extra donor tissue width will be excised, which isn't necessary to do and sets the table for more tension on the final closure, which is when you want the least tension possible, so the "slide-over" of the lower trichophytic edge will set in place with no stretchback. The only exception I make to this general approach is when a man plans to have a several year gap between sessions. Then I think it makes sense for optimal cosmesis to have the trichophytic closure done. Mike Beehner, M.D.
  9. The whole issue of Propecia or Rogaine only working in the crown/vertex region of the scalp is totally false. The reason the two companies have to say that in their advertizing is that the studies they conducted on their drugs were done in those areas, and, because of the strict rules of the FDA, one can only say a drug works in the area in which you studied it. I have had many, many patients given either or both drugs who have benefited in all other areas of the scalp, including the midscalp on top, the frontal region, and even rarely in the balding recessions in front. Topical minoxidil and oral finasteride do work synergistically, but I find most men aren't motivated enough or willing to invest the money into taking both. Research also shows that the prescription-strength Nizoral shampoo in the 2% form may have a slight pro-growth effect on hair also. I'm still somewhat of a skeptic on laser and would want to see far more convincing proof before making it a routine recommendation in my practice. Mike Beehner, M.D.
  10. It was interesting to see "baby oil" mentioned in the context of post-care after a hair transplant. I will share one use of baby oil during post-op care that we have found occasionally useful: One of the various treatments for speeding up the shedding of scabs from the recipient sites after a hair transplant is the daily (or twice daily) application of a thin layer of a petrolatum vehicle, such as Bacitracin Ointment or Vaseline (a clean, new jar preferably). Since it is desirable to shampoo and clean the scalp each day, when one first gets in the shower and wants to remove the previous day's application of this greasy stuff, if one first applies a little baby oil to the scalp and rubs it gently in, it helps "liquify" the thicker petrolatum material and make it easier to clean off with a soap such as Dawn dish detergent in very small amounts. Then the patient can use their usual favorite shampoo and/or conditioner. All of this is obvously done very gently with the smooth balls of your fingers. In recent years around half of our patients use the Graftcyte spray kit with the twice daily moist applications and the other half simply apply vitamin E cream each evening and shampoo it off the next am. The Vaseline method in my opinion works about as well as Graftcyte and is our "poor man's method" for removing the scabs a little faster. Mike Beehner, M.D.
  11. This debate as to whether or not a hair translant surgeon should do pre-operative blood testing has been going on for years and is probably pretty evenly divided in numbers as to supporters for the two opposite opinions. First of all, the main two conditions that are being checked for by the doctors who do test are HIV and Hepatitis C. Others will check a blood count, clotting studies, chemistry studies (liver, kidney function, etc). One advantage of having this information on the patient's chart before surgery is that, should the surgeon or one of his assistants be stuck by a bloody sharp during the surgery, immediate measures can be taken to minimize the chance of later serious infection for that person. There are anti-HIV drugs that can be started quickly for instance. If one has to wait for the patient's blood tests to come back, there is a slight delay. One weakness to this strategy is that the blood tests do not become positive sometimes for a few months from the time a patient might be come infected, so that a surgical team could conceivably relax their way of doing things with a "negative" HIV and Hep C test, and yet still be vulnerable to becoming infected. Our own clinic happens to be one of the ones that does not require blood tests, except in the case of female patients, in whom I want to make sure that some appropriate blood work has been done in the previous two years to rule out thyroid, low iron, and possible hormonal causes for hair loss. Most doctors, like myself, who don't routinely obtain blood work, perform each surgery as if the patient actually was positive for one of these infections. (Obviously, the doctors who do test pretty much do this also, I should add.) We never have two hands moving at the same time over the head when a sharp is being used. We keep all open sharps off the surgical tray except as urgently needed at that time and with the sharp ends protected up against or under a covering object so that a sweep of the hand could not encounter the sharp edge or point. All gauze is kept off the tray, as it can cover a sharp. A large sharps throwaway red bin is directly behind me in which I immediately throw any sharp I am done using. Eye, nose, mouth, and skin coverage are also an important part of these precautions, as blood or bloody fluid can spray at times during the operation. I should add that in our consent form the patient agrees to have his blood drawn should an accidental stick occur. Both positions have their merits. I happen to have a smaller practice in which I am on top of every detail and pretty much direct how each maneuver of a sharp is handled, so I feel I have control of keeping unnecessary sticks to an absolute rarity. If I was the director of a larger clinic with several doctors working for me and a large number of assistants, I think I would feel a greater "corporate" responsibility for all of these people, whom I wasn't personally supervising every minute, and also would feel a greater medical-legal threat to this larger entity, and I too would probably test each patient to protect myself and them, both from a health standpoint and from a medical-legal one. As I mentioned before, because even a "negative" patient could be infected, I feel most comfortable in my sized practice not testing and using universal precautions during each case as if the patient was infected. It goes without saying that, if during the initial consultation I have any doubts as to the patient's health status, I will always refer him back to his own physician for evaluation or send for his records to document that he is healthy. Mike Beehner, M.D.
  12. Bill's answer is correct. The transplanted hairs, which should have been taken from an area of donor hair not susceptible to male pattern baldness, will not be affected by stopping minoxidil. However, there are some doctors, including myself, who will occasionally have a hair transplant patient of ours use minoxidil, usually a 5% application every night, for a month before and a month after the surgery, when we suspect that the blood supply in the scalp may be less than ideal, such as in a patient who has had a lot of past transplant work or scalp reductions. We know that monoxidil is a vasodilator (dilates blood vessels), so perhaps it helps the blood supply in these partly compromised patients due to this effect, but more likely is the fact that we don't know exactly how minoxidil works, but probably more important is that we know minoxidil is a "growth factor" for hair, and perhaps helps these patients on this account. In either case, the evidence is mostly anecdotal and not a result of any good scientific research that I know of. Since it does no harm and may be of some help, a lot of it will use it from time to time. Probably more important is easing up on the spacing of grafts and limiting the epinephrine usage in the tumescent fluid to make sure all of the grafts grow and survive. The other unfortunate aspect of minoxidil treatment is that you have to be religiously dedicated to continuing it without any lengthy "vacations" from treatment, or you will lose your gains. In the very young male patient, who wants to use every tool at his disposal to hang on to his hair, adding minoxidil to oral finasteride (Propecia) has a "synergistic" effect and should be strongly urged. Mike Beehner, M.D.
  13. If a patient jumps between several doctors to complete his final hair transplant result, I would question the quality and depth of the initial consultation. It is this all-important visit at which the surgeon assesses the particular needs of the patient, the ratio between balding scalp and available donor hair, the patient's unique hair characteristics, his financial ability to complete the task, and, perhaps most important, the patient's psychological stability and maturity. A bond of trust is formed, a plan is laid out and both surgeon and patient "buy into" that plan. Obviously, sometimes things such as financial hardship (loss of job), marital changes, or illness can get in the way of that exact plan unfolding on schedule. How the patient wants to style his hair and how long he expects to be able to cut his donor area hair down to also factor into the equation of the plan. I have had people come to me who clearly wanted to keep the option to shave down their heads and wanted FUE, and I gave them a list of doctors who enjoy doing large sessions using this modality, as I usually limit my FUE sessions to around 400-500 grafts. People needing scalp expanders to cover large areas of burn damage I likewise refer to a hair surgeon who has this in his repertoire. But 95% of the patients who have a first session with us stick with us and complete the plan we set up at that first consultation visit. When the patient leaves from their first surgery, we give them a 4-page handout titled "Expectations," which explains what to look for and when, so their expectations are realistic. Each surgeon, no matter how exalted his reputation, has occasional cases where the donor scar is wider than he would like or the growth is less than desired, and those patients occasionally do end up in another surgeon's office, but, if the doctor-patient relationship is good, he will return to his original surgeon and that surgeon will "make good" on reaching the original goals one way or another. But it's important for that second surgeon to be a little understanding of what happened and lot lambast the previous surgeon's reputation to the patient or on the internet, as that same surgeon almost surely has some of his patients doing the same thing and showing up in other doctors' offices. We only see other doctors' unhappy patients, we don't see all the happy ones who are sticking with that doctor. Obviously, if a surgeon is consistently butchering patients, you maybe have an obligation to speak up, but that's the exception today fortunately. Mike Beehner, M.D.
  14. There are a number of clues, both during the initial physical exam and in the early stages of surgery, when a hair surgeon may suspect he is dealing with a scalp that is a little more hyper-elastic than usual and at risk for forming a wide scar: We routinely at the consultation push the scalp in from each side to see if it is easy to make multiple folds and just how far the fingers actually travel as a way to judge the scalp's laxity. Also, many patients have past scars from other surgeries on their body and examining them is a valuable way to anticipate how their donor scar may heal. At the time of surgery, when we inject tumescent fluid (saline with some epinephrine added) into the donor tissue, if it "balloons up" with very little tissue resistance, that is a tell-tale sign to me that I might get a wide donor scar, especially if I take too wide a strip and create tension at the level of the donor scar. When I see this, I narrow my previous plan for strip width and take a little longer strip, if possible, in order to get the amount of hair I need for that session. If a surgeon suspects after the consultation is over that a patient may have a problem in this regard, it is important to warn the patient of this, and, assuming he/she wants to go ahead, have them agree to wear their hair just a little bit longer on the sides if it should occur and also tell them about being able to use FUE grafts for camouflage later on when the transplant sessions are completed. Mike Beehner, M.D.
  15. The cut across the hair follicles within that extra 1-1.5mm of scalp cuts across the follicles at a fairly high point in the follicle, leaving the important germinal structures intact beneath, so that the hair can continue to grow. In a tricophytic closure, these hairs are growing upward around the same time as the scar is forming, so the goal is to get these partly lopped-off hairs to grow up through the scar tissue and provide camouflage, so a horizontal white line is not seen through the hair. There are some patients who have such short follicles - I've see several that were around 2.8-3.2mm in length - in whom making that tricophytic cut could be dicey and maybe better not made, for risk of actually damaging some of the follicles. Mike Beehner, M.D. Mike Beehner, M.D.
  16. Bill, I think I had a "typo" there: I meant to say that reading in bed with your neck extremely flexed down on your chest would INCREASE the tension on the scar, not LESSEN it. Sorry about that. 6-8 weeks is probably a reasonable description of the time it may be wise to take some of those precautions, while the true healing (union) of the scar is forming. Laxity (or elasticity) of the scalp that is moderate in amount is generally a GOOD thing and enables us to remove a strip of donor hair 2-3 times and still end up with a fairly thin, and hard to detect scar. It is when someone is beyond moderate and truly hyper-elastic AND when too much tension is put on that area due to an overly wide strip being harvested, that it can work against ending up with an acceptably thin donor scar. Mike Beehner, M.D.
  17. Bill, Your description is fairly accurate. The extreme form of this is a syndrome called Ehlers-Danlers Syndrome, in which the skin is ridiculously stretchable. These patients usually have hyper-mobile joints and other body idiocynrocies. In the "hey day" of scalp reductions, the surgeons (including myself) loved those patients with the super-lax scalps, but we learned over time that these were the very ones that had significant stretchback and five months later looked almost the same as before the scalp reduction. This same pheonomenon occurs at the donor scar in hyper-elastic patients. Mike Beehner, M.D.
  18. Dear "Female Hair Loss" The dice are pretty well cast as to how your scar is going to turn out. It's a combination of your natural elasticity (too much is almost a worse thing to have than too little, by the way)and the width of the donor strip you had taken. Both of these contribute to how much tension existed in bringing the two edges together. One thing that some hair surgeons believe can help before surgery, which is pro-active and something you can do, is to do scalp massage/stretching - pushing and pulling the scalp together and apart in the up and down plane. After surgery, the only thing I know that can theoretically help a little is leaving the sutures or staples in a little bit longer, to give time for the hair-bearing scalp above and below the scar to stretch out a little and reduce the tension that will exist at the scar when those sutures holding it together are removed. Applying Neosporin, etc probably won't affect it. An ointment vehicle can help reduce the crusting and itching of the donor scar in the early weeks however. Around 10% or so of all patients are allergic to the Neomycin in Neosporin and can get a nasty allergic reaction, so that may not be the best thing for everyone to use. I suppose avoiding positions and activities that bend the head and neck extremely forward, such as sit-up/crunches and reading in bed with your head bent on a pillow looking down at a book, may also lessen the tension on the scar in the early weeks, but mostly it is now out of your control. It is common to feel some localized tender areas and a little bumpiness along the scar, and, as long as there is no swelling or redness, it is usually nothing to worry about. Mike Beehner, M.D.
  19. If someone presents to a hair surgeon with a donor scar that is too wide, there are two ways to treat this problem: FUE grafts into the scar, or excision. A trichophytic closure should only be used at the time of the scar excision if the full width of the scar is excised. If a patient has pretty good laxity of the scalp around the scar, my preferred approach is to excise only a 5mm strip of the scar tissue out, and then re-evaluate the patient a few months later to see if any stretchback occurred. If a good reduction was achieved, often it is enough to make the patient happy and he doesn't request any more surgery. If the scar was quite wide to start with and there was an improvement from the first excision and good laxity still exists, then a second narrow excision can be done. If the full width of the scar was only 5mm wide to begin with, then a trichophytic closure could be done, but it does involve excising (at partial depth across the hairs within that section) an extra 1.5mm of scalp in addition to the other 5mm. I find that by limiting myself to taking a narrow section of scar tissue only, stretchback doesn't occur in the scar. In my experience stretchback does happen most of the time if an ambitious excision of a wide scar is attempted. If the patient has already had one attempt at reducing the scar before he gets to you, then it is almost always futile to attempt another excision, and FUE into the scar is the preferred way to camouflage the scar. Also, if there is any question as to the adequacy of the scalp's laxity near the scar, then FUE of hairs above or below the scar and planting them into the scar is the best course to take. FUE usually has to be done twice a few months apart, because scar tissue cannot deliver the necessary blood supply to densely planted FU grafts. In my own practice, I find that the FUE approach for wide scars is best in around 60% of cases. Of course the best way to not see wide scars is for all hair surgeons to be conservative in the width that they harvest at any given transplant session. Mike Beehner, M.D.
  20. Nine out of ten times, it turns out that the best place to mark the lower border of the donor strip to be taken does in fact lie just over the level of the occipital tubercle ("bump") on the back of the head. This level corresponds to a point, below which lies around 1/3 of the dense donor hair and above which lies around 2/3 of the same. Assuming at least a couple of sessions are done and that the surgeon takes the second strip just above the first scar (removing the scar at the same time), this is usually a good point to mark this lower strip level. But there are exceptions. Some men show evidence of thinning up from the nape of the neck. In these sometimes the strip is taken slightly higher up if there is a sufficient height of "safe" donor hair there. In each patient an experienced hair surgeon uses a great deal of judgement in choosing at which level the best hair to take is located. The scalp below the level of that bump doesnt' have a galea layer (the layer of "gristle" that is tough and is the continuation of where the neck and forehead muscles extend over the scalp) and thus in many male patients scars placed in this lower territory have a tendency to stretch out into a wide donor scar. The other mistake that is sometimes made is to take the donor strip too high in the donor area of a man who will go on to bald down into the area where the strip was taken - which results in these transplanted hairs later being lost . The only time I will take the donor hair below the level of the occipital tubercle is occasionally in a female patient in whom the density of the hair in this lower region is the best donor hair in terms of density and caliber of the hairs. Most women with female pattern hair loss don't have great density in the side areas of their scalp, so the great majority of the donor hair has to come from the back wall of hair. Since they wear their hair longer than men, if the scar down there is 2-3mm wide, it isn't quite as big a problem. In some young men the hair surgeon might notice hair thinning coming up from the nape of the neck and also see the vertex (crown) in back "scooping" down pretty low, leaving a fairly narrow area of dense hair. In these men, it is important to always leave some amount of thick hair there to "shingle" down in back, so I mark off the central 2 inches of the back of the head and don't harvest in that small middle section of hair, but instead harvest two separate strips to each side of that area, where the height of donor hair is higher and the scar will be well hidden by hair above and below. Mike Beehner, M.D.
  21. "Whisker hair" is a very non-specific sign, one first described by O'Tar Norwood, the creator of the Norwood Baldness classification system, which he felt was an omen for later significant balding. It's just one more little clue that would make a hair surgeon a little more cautious in a very young man. I will try to attach a couple of photos of examples of "whisker hair." Mike Beehner, M.D.
  22. That's a reasonable question to ask. I'll try my best to answer it. I'll start by saying that many of the men in their 40's that now have a Norwood VI level of baldness (that is, they are bald in a "horse-shoe" shaped area, with the side fringes still up high where the vertical/horizontal plane changes) - if you used both of your thumbs and middle fingers to make a large circle, and you put them around the entire top of the head, encircling both the frontal and the midscalp regions, and then go and do the same around the entire crown in back,- very often you will find that the two square areas are almost identical in size. So you have two "40 acre lots" to deal with. Which is the most important? The front and top, of course. So, in a young guy like yourself, we know that we can always at the very least perform a "forelock" type of transplant in dire cases that look like they might go on to a Norwood VII, and for most men can usually fill in from one side fringe to the other and create a full frontal hairline, feeling pretty confident that there will be enough donor hair over one's lifetime to keep that area filled in and natural . But it's a whole other story to begin that same large project in the back area on a man in his 20's. First, the vertex in back is admittedly not the most important area of hair loss, and it has a notorious reputation for dramatically enlarging to an extent that in some men you can never quite chase the borders with enough transplants to keep it filled in and dense appearing. The crown is also much more difficult to make look full compared to the top of the head, because "overlap" isn't used very much due to the "whorl" arrangement of hair. Some of the warning signs that might make a hair surgeon go to a "forelock" type of transplant pattern rather than a side-to-side fill in would be the following: family history of Class VII males, "whisker hair" (curly, oily looking hairs around the ears, an indistinct fringe without a strong border of dense hair, and a history of his hair loss occurring rapidly over a short number of months/years. The most important thing that hair transplantation does for most males is FRAME THE FACE, and it doesn't take that much hair to begin to do that for almost anybody. The only thing required on the patient's part is that he have realistic expectations for what can be done, given his age and apparent "safe" donor supply. Mike Beehner, M.D.
  23. Most of the factors that we think have to do with "shock loss" of native hair following a hair transplant procedure all take place at the time of surgery. The two most important things are: one, the VULNERABILITY of the hairs that exist on top, and two, the AGGRESSIVENESS with which the recipient sites are made. If a large percentage of those remaining native hairs are "miniaturized" (limited length and decreased diameter; ie: "wispy") they are much more likely to be shocked than a strong "terminal" hair is. When recipient sites are aggressively made, whether it is the closeness with which they are made or the width, depth, or length of the individual sites, native hairs can be lost either by taking a "direct hit" by the instrument used or simply as a "shock" reaction to having all these cumulative injuries occurring so close to them. The THICKNESS OF THE SCALP is another key factor. The plexus of key arterial vessels that network to supply blood supply to the scalp lay deep in the scalp over the "galea" layer (the thick gristle at the bottom) deep in the subcutaneous fatty layer. It this subcut layer is nonexistent, then it is hard for the doctor to avoid injuring those deeper vessels, even with tumescence. The amount of EPINEPHRINE (ADRENALINE) used in the tumescence solutions is a key factor also. We use this to control the bleeding during scalp surgery, but if too great a concentration is used, it clamps up the arterial supply during surgery to some degree and can help provoke a temporary shock and effluvium reaction to the hair. And, last but not least, there is INDIVIDUAL PATIENT VARIATION in this whole thing. No two people react the same to the identical same surgery. Some shock easy, particularly females, and some don't seem to shock at all. I personally fell that EVERY patient to some small degree experiences some shock loss, but it isn't enough to be seen by the naked eye. If one of the ten main arteries supplying the scalp gets transected during harvesting of the donor strip, that certainly has to play some role. Examining each patient's scalp with magnification (30x or 50x) and communicating to him or her the degree of miniaturization and risk for shock may help alleviate the later surprise at its actually happening. Whether laser therapy will play a role in this regard is still unproven and I remain skeptical at this time. How do we prevent shock loss? We use the minimal concentration of epinephrine we can. We limit the depth of our recipient sites with depth-control holders for our needles. We know that coronal (perpendicular) alignment of slits that are a little long (over 2mm probably) in the central areas is a risk for later necrosis or poor growth, since the vessels supplying the skin rise up perpendicularly and these are sheered by such sites. Many of us empirically, based on anecdotal cases, recommend Rogaine for a month before and after our cases. I only do this for all females and for those men who have had a lot of surgery in the past, especially if they have had scalp reductions or have a thin scalp. If the scalp is thin, the surgeon has to "let up" on the density of planting to allow blood supply to get to each graft. The bottom line is we have no "magical" way to prevent it, but with common sense we can keep it to an absolute minimum. Mike Beehner, M.D.
  24. Chris, This is a common problem for young men, who want to have everything restored. I think your doctor was very wise in telling you what he did. You have no idea (nor does anyone else, including the doctor) how bald you may become some day. And if you start filling in the crown/vertex as part of the initial plan on a man in his 20's, and male pattern baldness progresses and logarithmically enlarges, as it almost always does, and the project in that area can't be completed, you will have a huge bald halo around a patch of transplanted hair and will look very abnormal, and there won't be any donor hair left to fill in the halo. By the time a man gets into his later 30's the surgeon gets a much better sense of where a patient is going to end up with regards to the eventual expansion of the crown and also the amount of "safe" donor hair that is remaining and then he can make a much more accurate determination as to whether he has a good safe margin of donor hair reserves to do everything that you want. The unfortunate truth, despite some of the wonderful medicines we have available now, is that male pattern baldness is a progressive condition. Propecia et al only stall the balding process; they don't arrest it.You only have to look around you at all the 60 and 70 year old men to see where things can end up. Each one of them was 29 once. Picture what there head would look like if a surgeon at that time tried to fill in all of the bald area. It takes courage for a hair surgeon to turn down a request like the one you made. You will thank him some day. The problem is that, if you keep looking around, you will probably find a hair surgeron who WILL fill it in and do your future a disservice. I have seen ten or so men over the years who had exactly that done at some time 10-15 years earlier and their head looked like a dead animal died in the middle of their head. They always asked me to remove all of the grafts, no easy task. I hope you accept his advice. Mike Beehner, M.D.
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