Dr. Michael Beehner

I was sorry to hear the poster sound so pessimistic about a Norwood VII stage of baldness. These men can be helped. By definition, a Norwood VII stage means that the side fringe is somewhere down the side of the head. Obviously, there is an awful lot of bare real estate up on top crying out for hair - which is pretty short in supply precisely because of the low fringes. As Pat suggested, the only thing that works for these men is some type of "forelock" pattern. A "wall to wall" filling in of hair is impossible. What is a forelock pattern and what are the essentials for creating one in hair transplantation? The first and most important point is that a forelock attempts to FRAME THE FACE of the patient, with its maximum density being in the front-center of the scalp (or the "frontal core," as Ron Shapiro has named it). Secondly, to create a forelock,the surgeon must create a GRADIENT of hair density, with the greatest density being down the front-center aspect of the head. The gradient can be created from "strong" to "sparse" in a number of ways, but the two best ways to accomplish this are to use grafts with larger numbers of hairs within them centrally and grafts of less hairs in the side "mirror image" areas. The second way to create a gradient, and probably the most important one, is to VARY THE PLANTING DENSITY of the grafts. This certainly applies if all FU's are used. I tend to use DFU's centrally, then 2-hair FU's just outside them, and finally 1-hair FU's in the sparsest areas. Between the body of the forelock and the side fringe a "blur" of sparse hair is created, which visually connects the forelock and fringe, but doesn't use up a lot of hair. The same is true in the two rear triangle areas where sparse FU's are placed. If you look carefully around you at men who are gradually losing their hair, there is a subset of men who have this exact stage of hair loss on their heads at some given time. The third part of a forelock plan is to NOT fill in certain areas of the scalp. These would include the vertex in the rear (the downhill circular area way in back) and the fronto-temporal gulfs in front to either side of the forelock. I have had men style their hair in a variety of ways after receiving a forelock transplant, but I the one that works best in my opinion is to sweep it back to the rear right corner of the scalp. So, the bottom line is: if a man is willing to lower his expectations and wants a natural pattern of hair that frames his face and which, for all intents and purposes, from the front view looks almost like a full head of hair, then this is a worthwhile way to transplant such a patient. To give an idea of what these projects look like, I will post some photos of some forelock results in the "photos" section of the Forum where they might be easier to view. Mike Beehner, M.D.

Dear "Hairlossnewbie," It IS possible to implant artificial hairs surgically into the scalp and have them remain there, but it is not legal to do so in the United States. This is done in Italy, Japan, and Australia that I know of and I'm sure in a few other countries. Incidentally, these are not hairs cut off of someone's head, but rather are chemically manufactured out of a material that is designed to provoke the least possible tissue reaction and still look like and feel like human hair. The problem is that each year you have to have another thousand or two replaced that work their way out, and, most important of all, there is what we call in surgery a "fibrosis" reaction to the artificial hairs being implanted, that is, an inflammatory hardening and often redness coloration in the area the artificial hairs are implanted into the scalp. A doctor in Australia that I greatly respect who has done quite a few of these, states that this method should only be used for those men who desperately want something looking like hair on their head and don't want a hairpiece and who are absolutely out of donor hair or don't have it in the first place. In general, if you are a young male, which you sound like you are, and your desire is to have a head of hair that is exactly of the density and square area as when you were 15, this is almost certainly not going to be possible if you already have the typical early signs of male pattern baldness. Until you are willing to be satisfied with something less than that full head of hair, you should hold off making any permanent decisions, take medication to hold off hair loss, and continue to learn all you can. I should add that your impression of hair transplantation is a little pessimistic compared with the results, both in the donor and the recipient area, that most good hair surgeons are able to accomplish. Your comment that you don't want "thin hair on the back of my head" indicates to me that you should hold off on a transplant at this time if your age is young. Best wishes. Mike Beehner, M.D.

I respect the opinions of the posters above, but wanted to simply make a few clarifying statements, since I have been closely associated with the American Board of Hair Restoration Surgery since its beginnings and feel I have a pretty good perspective on the role the Board has tried play for our profession. I was in the first class of 40 in 1997 who took the written and oral exams then. The criteria for sitting for the exam were much more stringent then. I was the chairman of the written examination committee for 5 years, and later served as President of the Board in 2005. As Dr. Nusbaum so well outlined, the Board was started as a good-faith effort on the part of hair surgeons to show to the public and to various governing bodies (this is particularly true in other countries, where we have many diplomates)that we were willing to have some way of certifying that a physician at least possessed a good level of expertise and clinical judgement and was willing to be retested on a regular basis during his practice years. The first requirement of an ABMS board is that there be a residency program requirement, except for the very first few years of any board, when they would allow men with many years of experience to "grandfather" in by simply taking the exams. The problem with hair transplantation is that almost everyone in the field except for a handful, first were trained in another speciality where they may or may not have achieved Board Certification by an ABMS Board. They then had a mid-career switch to hair surgery after becoming interested in it later in their professional life. It is not practical for a man or woman who is settled with children and a family and financial obligations to suddenly take 2-3 years of his life at very low pay to study hair surgery. The ABHRS thus becomes at least a measuring stick for competence that can be put before the public as some reassurance concerning knowledge and clinical judgement. My biggest regret with regard to the Board, and one which Dr. Feller amply spoke about, is the mis-use in advertizing that some members of our Board have been guilty of over the years, which has created hard feelings and resentment. This has been clamped down upon severely in the last few years. For example, a doctor is forbidden to say something like "the only Board Certified hair surgeon in the area" or even "Board Certified" with regards to the ABHRS. We recommend following the California rules, by which the term "Board Certified" DOES refer to an ABMS board. Rather, we urge diplomates to simply state: "Diplomate: American Board of Hair Restoration Surgery". Just like Dr. Nusbaum, the period of time leading up to my taking the Board exam was a wonderful push for me to increase my knowledge and expertise in our field, especially in the area of hair loss diagnosis - with regard to some of the other non-hereditary causes. I am boning up on these once again as I prepare to take my re-certifying exam 10 years later. With regard to the original group of 15-20 doctors who started the Board and awarded themselves "Board Certification", they are now due to take the re-certification exam in Las Vegas at the ISHRS annual meeting in order to remain Board Certified as do those of us who were certified in 1997. There is no truth in the statement that ABHRS members can't post on the internet in chat rooms or any thing of the sort. I certainly would have known about such a policy if it existed, since I've been on the Board of Directors or been an officer for most of the past 8-9 years. That has never come up or been mentioned to the best of my knowledge. Yes, there is a problem in offering training to new doctors or mid-career doctors wanting to make a career change, who want to learn hair surgery. Many of these doctors, like Dr. Feller and myself, came to be interested simply because we went through the experience of being a patient and saw the tremendous self-esteem lifting it offered in our lives to go from a bald guy to one with hair. There does exist a fellowship experience with rigid guidelines which the ISHRS set up several years ago, and 10-15 people have gone through that, including a fellow I trained two years ago. Most of the groups or doctors offering this do so in order to gain a partner or member to their group. It is a very financially draining and exhausting physical task to undertake this for a year. The ISHRS is now working hard on creating a "modular" experience plus an on-line learning center with interactive CD's and live "webathons" for doctors to learn, while still maintaining their practice. In the past, the doctor with a strong desire to learn hair surgery simply read everything he could, went to as many meetings as he could, especially the ISHRS live surgery workshop in Orlando (the best of its kind), and then would visit as many kind-hearted doctors as he could to see how others did it, and then, if he or she was lucky, would persevere to the point that they eventually got the courage up to start treating patients. I agree that Pat's site and the other independent web sites on the internet serve a valuable function in allowing patients to post their experiences and put it out there for people to see when making a decision. Pat takes this one step further by actually getting out in his little home/bus and watches first hand doctors doing their surgery. But, doctors themselves also have to take initiative in having their own educational bodies and certifying bodies. The International Society of Hair Restoration Surgery is the main educational hair body in the world, and does a lot of very worthwhile things for our profession: the annual meeting is open to all hair surgeons, with every manner of transplanting, where they can present their research and ideas in an open forum. We have The INTERNATIONAL HAIR TRANSPLANT FORUM, a every other month professional publication with articles and opinions in it. The American Board of Hair Restoration Surgery, on the other hand, is the certifying body in our field. The ISHRS this past year formally recognized the ABHRS as the only board certifying body for hair restoration surgery. The last comment that I wished to address was the notion that the ABHRS favored some particular method of hair transplantation or had a bias against "megasessions." This could not be further from the truth and has never been a position I have been aware of. It is true, that as the years have passed and our field has changed, we have had to change a lot of the exam questions to have them reflect the current ways of doing things and to make sure they allowed for the different camps of hair transplant philosophies to be represented, such that an answer was never right or wrong based on whether you subscribed to doing megasessions or not. The exam has never been biased such that someone with a particular philosophy of hair transplantation was negatively affected taking the exam. In the oral portion of the exam in which clinical judgement if tested, as long as the examinee could back up his opinions and plans for a patient, they were valid. So, in summary, I would simply ask that any of the lay public or physicians who haven't yet taken the opportunity to become part of the ABHRS, have an open, tolerant mind and try to make things better by working on the "inside" along with us. All are welcome. The ABHRS is not perfect, but it is a sincere attempt by hair surgeons to raise the standards of our field. If you go to <http://www.abhrs.org> you will see that the members comprise a great many respected hair surgeons. Mike Beehner, M.D.

Pat, I truly believe that following almost every hair transplant in which grafts are packed in reasonably close together that there is at least some mild degree of "shocking" to previously existing hairs, both "native" and even some of the previously transplanted ones. So,as a result, in the several months after the procedure you are not only waiting and watching for the newly transplanted hairs to start growing and get long enough to make some kind of visual impression on you, but you are also probably observing the gradual recovery of some hairs that were there before the procedure and which now have to sit out their 3-4 month telogen "rest" period and then begin growing all over again at a half-inch a month. The only hairs that would be permanently lost would be either those wispy "native" hairs that were on their last life cycle or hairs that were physically damaged during the transplant process while making the recipient sites. All of this together can easily make someone at 6-9 months be wondering if they are going to gain anything, but it's amazing at 12-15 months how many of these patients report that everything is much fuller than at that earlier time point. Mike Beehner, M.D.

I was truly sorry to see the post earlier this year in which "Stumper" stated that he was unhappy with his first transplant session at our clinic. While I take full responsibility for even one patient not being satisfied with some aspect of their surgery, I did want to set the record straight on the circumstances of his surgery, which should be considered by anyone reading his posts. I did not do the surgery myself personally; let me explain. Approximately two years ago I was approved by the ISHRS (International Society of Hair Restoration Surgery) as an instructor in their formal Fellowship Program and I took on a full-time fellow. It is an intensive one-year program in which there are strict guidelines for 3 hours of didatic interchange between the Fellow and instructor each week, instruction in cutting and placing grafts in the early weeks,teaching of how to conduct consultations, attendance of two major hair conferences during the year, and finally, actual experience in performing hair transplant surgery. I had taken this physician as a fellow around 4 months or so before Stumper's surgery, and the first three months of his time was spent learning the skills the technicians perform, cutting and placing. After that and having assisted and observed me performing over 90 transplant procedures in that 3 month period, we gradually secured over the course of the rest of that year 50 patients like "Stumper" who agreed to let our fellow perform the surgery by himself under my supervision, and in exchange we gave each patient a steep discount in their price (average around $1700 off). Stumper was the 6th patient operated on by our fellow. I have seen at least 25 of these 50 patients back and the results were excellent. I will try to post some of these photos of the work done by Dr. Chris Pawlinga in the photo section, as I had difficulty figuring out how to attach them to this note. Since the fellowship year was completed September 30th of last year, Dr. Pawlinga has gone on to perform over 90 surgeries on his own as an associate in our practice and has had excellent results and enjoyed wonderful rapport with his patients. Again, I am truly sorry this patient was not satisfied at that 8 month point after one session. I saw him myself three times during the month or so after the surgery for little things he wanted checked, and we even took his sutures out after Dr. Shapiro's surgery as a courtesy. I wish I was present that day to see the results of our transplant work, but I was out of town on the day my nurse did this for him. We operate on around 300 people each year and I honestly can't recall another patient who was this profoundly unhappy in quite a few years. This is the first negative poster we have had about our practice in many years. After most of our first sessions grow out by 8-10 months, the density on top, even in bald men, is very acceptable and is not "tufty" to an observer. Most of our patients come to us wanting the entire top horizontal area of the scalp filled in with hair, and I find this is best accomplished if performed over 2-3 sessions using a combination of 70-80% FU's and 20-30% MFU's (multi-follicular unit grafts), all cut under the microscope with care not to damage any follicles. There is a brief period of a few months when the hair is short, before significant overlap occurs, when there can be some detectability on the middle, particularly if the patient has dark hair or a pale scalp. We also do all-FU procedures, and we try to sort this out in the consultation as to which one the patient wants. There are some patients with such an obvious contrast of dark hair and pale skin that we tell them we will only use an all-FU approach. Obviously, the extremely dense all-FU approach has the two negatives of either having to be limited to a somewhat smaller area and of being more expensive for that single first procedure if an equivalent number of hairs/follicles are going to be moved. The "combination" approach has the benefit of being more affordable and gives very predictable density after 2-3 procedures. Another situation in which we perform dense all-FU surgeries is for those with mild recession and flat temples which need filling in, in whom we can try to pull it off in "one pass" with around 2000-2500 FU's. Half of these patients still later need some filling in for fully satisfactory density. Again, I take full responsibility for what happened in my fellowship program, but did want to set the record straight for anyone judging our practice. Incidentally, I am not currently instructing a fellow and am taking a rest from this particular academic activity, but do allow many doctors to come for a few days at a time to observe us. There are varous approaches in hair translant surgery by different doctors, most of whom obtain excellent results with their methods. When Pat Hennessy visited us, he did urge me to try to be more active in helping educate the public about some of these different approaches. Many others besides myself are coming back to using slightly larger grafts of 2 FU's each in the central areas in order to obtain more visible density in their results. In the coming months I will try to take more time in this regard. Thank you. Mike Beehner, M.D.

From many years in transplanting, I can tell you that in my experience, when I can get 10,000-12,000 hairs moved to the top of someone's head (I am referring to the horizontal plane - the entire frontal and midscalp areas, back to the point at which the vertex starts to head downhill in back), the patient's hair starts to look relatively full on top and he is happy. If the hair caliber is fine in caliber or the color-to-skin contrast is a stark one (dark hair and pale skin), then another 2000 hairs is usually necessary. If the vertex in back or the side temple areas consume some of the transplanted hair, then, obviously, one needs to transplant additional hairs to account for this work also. The ideal patient has coarse caliber hair and has some curl to his hair, which lends much to the visual appearance of "fullness". Having 10,000-12,000 hairs give a "full" appearance also depends on the patient using a reasonable styling method that uses some "overlap". If someone wants to style his hair as a "flattop" and buzz all the hairs short or part it down the center, then a lot more hair is necessary for such a pattern to work. Part of the fun and challenge of hair transplantation is figuring out, for each given patient, with his age, amount of donor hair, and projected eventual degree of baldness, what will work best. There almost always is a pattern that will give a patient a natural looking frame to his face, as long as the patient has realistic expectations and accepts the limitations his particular situation presents. Mike Beehner, M.D.

Dear Invisible, The concept of using a "frontal forelock" concept in hair transplantation has been around for almost 15 years and was first popularized by Manny Marritt, M.D. of Denver, who is now retired. I have written several journal articles and textbook chapters on the subject in the years since. It is basically an approach or pattern in which the surgeon tries primarily to create a natural area of transplanted hair in the front-central portion of the balding scalp, such that the face is properly framed at a natural height in the forehead, and usually it leaves a natural, and sometimes even slightly deep, frontal-temporal recession area to each side. Most of the time the hair is transplanted back into the midscalp area also, often in the form of an oval or shield-like shape, and with "scatter zones" of many fine 1 and 2-hair FU's to both sides to lightly "blur" the space between the forelock and the side fringes. This type of approach is used primarily in three types of patients: One: the very young patient who shows warning signs of someday becoming very bald; signs such as a family history of males with Class VII baldness downt he sides of the head, "whisker hair" around the ears, an indistinct fringe area where a strong border is not noted, and, of course lastly, a very young age, especially early 20's. Two: the man who is already very bald and the ratio between donor hair to bald recipient area is way out of proportion with little to use to cover a huge area. A forelock artistically done can frame the face, and with certain styling patterns (the best one is taking the hair back and slightly to one corner). Three: The man coming for corrective surgery who had large plugs placed all over his head. The surgeon can adopt a plan to harvest these grafts that are in the rear vertex and rear midscalp and bring them in FU form and using a proper gradient of density into the frontal forelock area and try to recreate a natural look with what hair is available. In summary, it is a very valuable addition to the armamentarium of the hair transplant surgeon. The patient needs to be accurately informed about what is being done and not have unrealistic expectations. Mike Beehner, M.D.

A quick edit to my previous post: I re-read it and saw where I stated that after my ten mile run the day after surgery, I had a problem. I meant to say I had NO problem! Not recommending it though! Mike Beehner, M.D.

I would agree with the one responder who said to go by what your own hair surgeon recommends. Each of us becomes comfortable with a certain set of guidelines that work for us over the years. Those of us who have been hair transplant patients ourselves probably have an even better idea of what is a reasonable, practical limit of time before taking on full sports activities. In my practice, I tell my patients to lay off of "heavy" exercise for 5-6 days and swimming for around 8 days. When the patient asks what I mean by "heavy", I mention lifting weights and sports or exercises which include vigorous running. Obviously, any sport that has a risk for getting hit in the head would be out until all the scabs had fallen off (football, team racketball, etc). Simple things such as a brisk walk, hitting a tennis ball back and forth, or golfing with a cart (sorry golfers, but it isn't really exercise!) I let them do the next day if they want to. If I had to think about the actual "medical" reasons for having these limitations, I guess my main two that I tell the patients are one, that vigorous exercise raises the blood pressure while you are engaged in it, and if there was a small spot somewhere in one of the recipient sites or along the edge of the donor area that was barely being contained with the blood's coagulation, you wouldn't want that increase of blood pressure to be the difference between having a small artery branch bleed or not (probably most important actually for that first night after the surgery; I doubt it means much after that.) The second is that one sweats quite a bit with exercise, and sometimes the body becomes dirty with contact with dirt flying, etc in some sports, and could that possibly increase infection risk? I must say that I can't recall anyone in my 15 years of transplanting who broke one of the above rules (and I'm sure many of them did! I ran 10 miles the day after my second transplant in 1982)and had a subsequent problem. The commonest thing that actually does happen,which has nothing to do with the topic of limiting exercise is that many, many patients - who have never hit their head in their entire life - will hit their head on a car door or any of fifty other things during those first few days. Rarely, there will be a little bleeding and sometimes they knock a graft or two loose, but usually there is no harm. Short of putting some sort of suspended helmet on all patients post-op, I don't know of any prevention for this. Also, men with hard-hat jobs, we have them not work for at least a week after the transplant. The last reason for having the physician stating some limits, I suppose, would be for the doctor to take himself off the hook in case anything did go wrong that first week and the patient blamed something on an activity which he thinks the doctor should have told him not to do. So I suppose the main difference between doctors' different regimens is how much risk they want to take for being blamed in this regard. I have a hunch that we could probably have patients do whatever they want as soon as they want, short of team contact sports (including basketball), and there would be no problems. But, I am not willing to take that small risk. Mike Beehner, M.D.

Gillenator, We use a tattoo gun which has disposable sterile needles and sheaths at the end of them, and use a combination of white and light brown tattoo ink, which, when placed on the scalp, is not that detectable, but is easy to find by the physician with magnifying lens on. It is rare that a patient asks for us to later remove it. As to the effect of ischemia reperfusion injury, there has been some research by Dr. Cooley and by the members of the Moser Clinic in Austria/Germany on the subject, and apparently there are some chemical products released which do have some effect on the cells of the follicle and probably have a little to do with the follicle immediately going into the telogen (rest/hibernation) phase after transplanting. Dr. Limmer did a classic study a number of years ago which showed that the yield of grafts kept outside the body didn't start to decrease till after 8 hours, if kept cold and moist during that interim. As to the difference between clinics doing 3-4 sessions, versus those that do a single procedure, usually the size of the staff is proportionate to the amount of work being done, and I don't know and have never heard of any clinic that "stacked" their patient's workload in such a way that the grafts were held outside the body while other patients were being worked on, so I don't think that applies to any hair restoration physicians. As to FUE/FIT, etc. I am not aware of any studies yet that have been completed concerning follicle survival with that method. Hopefully, we will be seeing some results in the next year or two. Mike Beehner, M.D.

Dear Curious, Individual follicles (the portion of hair which is alive and resides under the skin) pass through three different life phases. For 4-5 years at a stretch they are in "anagen" phase or the growing phase. Then there is a brief "catagen" phase during which the sheath holding the hair base separates away from the dark bulb and dermal papilla at the bottom of the follicle, and then the follicle enters a 3-4 month phase called "telogen." Getting back to your question, when a hair surgeon and his staff cut up the individual grafts, if those follicular units (groups of 1-3 hairs) are trimmed "down to the bone" so that there is no fatty or connective tissue seen around them, then the odds of any "hidden" telogen phase hairs being present are pretty low. Whereas, if the grafts are trimmed slightly "chubby" with some of this connective tissue present, then there is a greater chance of some of these telogen phase hairs being present, even though at the time of donor harvest they really can't be seen or counted as being one of the hairs planted on top. So if there are some of these hidden telogen hairs adjacent to the more visible hairs, then later on, when these telogen hairs grow into the anagen phase, you get a higher number of hairs then you started out planting, and thus a percentage of hairs surviving that is actually higher than 100%. There are 5-6 studies in which the person conducting the research came out with a survival rate over 100%. Some observers think that after a transplant surgery that all of the hairs are synchronized together into the anagen phase, and that probably with the passage of time (years) they gradually randomize into both anagen and telogen phases and the percentage of hairs that are present at some future point would drop by a small percentage. In a small 4-6 hair minigraft, there is even a greater chance of these telogen hairs occupying some of the space between the FU's contained therein. Obviously, in creating a natural looking transplant, if these kinds of grafts are used, they must only be placed in the front-central region, where they are hidden behind all of the surrounding FU's and contribute a dense look to the final product. I hope this helps clear up how you could obtain a survival of greater than 100% Mike Beehner, M.D.

I'll jump in and share some of the research results that have actually been done on this subject, since I recently had to review this to write the chapter on the subject in the new textbook ("Hair Transplantation", edited by Walter Unger and Ron Shapiro, 2004, Marcel Dekker Publishing). In the 15-20 studies that have been done to date on either "combination-FU" grafts (minigrafts/ 4-8 hairs each) and FU grafts (1-3 hairs each), the percentage of survival has been close to 100% in the combination-FU grafts and has varied all over the board in the FU studies,mostly averaging around 90% survival.This is most certainly because of the fact that the slightly larger grafts have more "protection" and buffering with the extra tissue that is present. It is simply harder to dry out or traumatize an individual follicle in such a graft. Dr. Seager and I conducted separate studies a few years ago comparing survival of very "skinny" FU's versus "chubby" FU's (ones with a fair amount of the connective tissue left around the FU) and we obtained similar results, with 113 and 133% survival of the "chubby" ones and survival in the low 90% for the skinny ones. At the 2003 ISHRS meeting in New York, Dr. Kim of South Korea and myself presented separate studies of FU survival and we both got identical 90% survival rates. A big factor in FU survival is whether or not one is studying the first transplant session on a virgin scalp. In a study I conducted three years ago, when I went in a second and a third time and measured survival in small tattooed "study boxes", the cumulative survival of the hairs in the FU's dropped from around 95% to 75% after the second session and down to 59% after the third session. This study was done with 18 gauge needles and most of us use slightly smaller recipient sites now or the small lateral slits. In as study we did on 2-hair FU's in 1cm2 boxes planted at 20, 30, 40, and 50 FU's per cm2, using 20gauge needles and a "stick and place" method (with myself making the holes and placing the grafts), we obtained 95% survival at 30/cm2 and 89% survival in the 40 and 50/cm2 boxes. Prevous studies by Dr. Mayer and others had shown that with 18g needles, lower survival occurred when one tried to place 30 or 40 per cm2. The bottom line on survival with FU's has to do with the fact that the FU is a somewhat vulnerable graft in terms of drying and being handled (trauma), so the care, dedication, and skill of the assisting staff of the transplant surgeon is what determines whether 50% or 100% of them survive. Mike Beehner, M.D.

Dear "Danger," We have our patients use Toppik even during that first week. I am not aware of any toxic qualities of the chemicals to the grafts. The main point is that the patient has to be gentle in his/her shampooing technique those first several days, gently using the balls of the fingers to rub in the shampoo, etc. and not letting a shower spray that is too hard to directly hit the graft sites. We also recommend DermMatch often, which also can be carefully used even during that first week, if it's important and necessary for that person to get back to work and be unrecognized as a hair transplant patient. The wonderful thing about Toppik is that a person with just a single sessions's growth or someone who has some scattered fine hairs all over even just after a first HT can use the Toppik and make it look like there is three times as much hair mass on his head. Another good camouflage pointer for persons who have to get back to work early, is to use "base makeup" touches on any reddish dots that may remain where the FU's were placed, so that it looks like the normal skin in that area (especially helpful near the temples and front hairline). Mike Beehner, M.D.

Herbert, Strong terminal hairs on top in the recipient area are much more resistant to being "shocked" in my opinion, and, if it did occur, they would recover after their 3-4 month telogen hibernation phase and grow out full again. The most obvious way they could be taken out early would be if dense packing cut across the follicle shaft itself. This could either kill the hair or cause it to come back in a much "wispier" form. Research experiments by a number of physicians (Kim, Mayer, Limmer, Swinehart, and others) has shown that a certain percentage of "half-follicles" will indeed grow, but usually don't grow in their previous robust state. The other two factors that I believe would impact good strong terminal hairs in the recipient area would be extreme dense packing (which almost by definition dramatically increases the odds of transecting the hairs between these dense recipient slits/holes) or the use of excessively strong epinephrine (Adrenaline) concentrations in the fluids used in those tissues. The bottom line is that, if the physician respects the blood supply to these good hairs in the area being transplanted, "effluvium" to these hairs is very uncommon. And if it does occur with a strong hair, the overwhelming majority of those hairs will grow back as before. There has been some interesting research and speculation by a Dr. David Whiting in Texas that some full-thickness terminal hairs are capable of directly going to extinction in one step without going through the short, wispy stage. There is still a little bit of "mystery" left regarding this subject that we don't totally understand. Mike Beehner, M.D.

Herbert, Yes, you are right. Having a hair transplant very often does lead to losing the miniaturized hair on top earlier than you would have otherwise without having a transplant. When you make the decision to have a transplant, you have to be so motivated on obtaining some dense, natural coverage from the hair transferred from the back of your head, that you're willing to put up with this other possible loss, should it occur. As I mentioned, it usually is only an issue for 2-3 months, after which the newly transplanted hair makes it a moot issue. For people who are ultra-paranoid of anyone at work or in their family from noticing that they have undergone hair transplantation, this can be tough to accept. This whole issue is a lot easier for the man who has some means of "cover-up," such as a hairpiece, a big comb-over, a job that allows wearing a hat all the time, or some strong hair in the rear that can be combed forward. Mike Beehner, M.D.

Herb, In a relatively small percentage of hair transplant procedures, there will be a mild "shocking" to some of the "native" hairs within the "horse-shoe" shaped area on top. This is more likely to occur with very large sessions or with very dense packing, and is more common in females than in males. What occurs is that those hairs get "bumped" into their next life-cycle. Each hair on our heads grows for 4-6 years and then the hair follicle (the living portion that is under the skin) shrinks for three months, disconnecting from the hair shaft coming out from that follicle. The hair follicle then falls off into the shower drain or on to the brush that passes through the hair. We all lose around 70-100 hairs a day in this manner because of this normal "cycling." When a man is gradually "thinning," by definition he has a relatively high percentage of "miniaturized" hairs on top. These hairs are limited in how long they will grow and their shaft diameters are thinner and wispier. In the next life-cycle, they will grow even shorter and thinner in diameter. They eventually reach a turnover in life-cycles where it disappears from the scene and doesn't return even in wispy form. These hairs are certainly more susceptible to the "shocking" that occurs with transplant surgery. Their loss is also much less noticed when the transplanted hair starts growing out, since the new hairs are full diameter hairs that will grow long and they dwarf the contribution these wispy hairs would have made. It is disconcerting, however, for a patient when they look in the mirror two months after a transplant and realize they look thinner than when they presented to Dr. X. Some doctors believe that pre-treating with Rogaine twice a day for a month or so before and after surgery helps to prevent some of this. There is no hard proof, but a lot of anecdotal stories by doctors suggests it might help. I use it before and after all surgeries on females and on men who have had a lot of work in the past. One additional factor in causing "shock" during transplant surgery is the concentration of Adrenaline in the tumescent saline solution used. Around 5 years ago I greatly reduced the concentration we used and I have only seen one really noticeable shocking of existing hairs in that time span (occurred in a female 1 1/2 years ago). I hope that helps answer your question. Mike Beehner, M.D.

I would agree with everything Dr. Brad Limmer said. The problem with a young man in his early 20's is that it almost doesn't make that much difference whether or not he is a Norwood III (receding and/or early crown thinning) or VI ("U"-shaped baldness on top), because you still don't know how bald the patient before you will be in 20 years. Any miscalculation or bad assumption on the hair surgeon's part could result in a very unhappy patient when he reaches his late 30's or 40's. As Dr. Limmer said, a "forelock" type of transplant, with a gradient inward toward its center is the only proper way to transplant a man in his younger 20's. I try very hard not to transplant young men under the age of 23, as the pace of hair loss can be awfully rapid and accelerated during this period from 19-23. It can also accelerate after 23 too, of course, but if a man over 23 is losing the framing of his face and wants it restored, I don't think it's fair to deny him a forelock type of framing, which can be modified later to "stand alone" and look natural, regardless of what occurs later on. I also try very hard to put all young men on Propecia or Proscar, but I'm not sure the surgeon really is that much smarter 3-4 years down the line than he was when he first interviewed the patient at age 21 or 22, because the Propecia "masks" the normal hair loss that these patients will have and actually increases the hair mass in around half of the men taking it. The main advantage for holding off on transplanting and using medical therapy is probably to allow the young man to get a little older, a little wiser and more mature, so that he might be more likely to accept a more conservative "forelock" type of approach. There are a few men in their 20's in whom their hair loss is akin to a stampede of buffalos and Propecia only slightly slows down the pace of hair loss, and it's nice to have the luxury of those 2-4 years to see if a given young man is one of these. Mike Beehner, M.D.

In recent years, the length of time interval recommended between hair transplant sessions has been increased, and for a number of good reasons. In my own practice, if the head is relatively bald or quite thin, 6 months is the earliest I will perform the second procedure. If there is a fair amount of pre-existing hair remaining on top, then 8 months is my minimal interval till the second procedure. 8 months is my minimal interval between a second and third procedure. The reasons for waiting a period of several months or more are threefold: 1) The blood supply to the scalp has a better chance to "regroup" and heal, returning somewhat closer to the normal state it was before transplanting was carried out 2) The hair transplanted at the preceding session is growing out, so that the surgeon won't accidentally "hit" any of those hairs, and also so that the patient sees the fruit of his financial investment, so that he isn't entering the next procedure only on faith. Remember, that the hair doesn't even start to grow out until 3-4 months after the procedure, and then only at 1/3 to 1/2 inch per month. 3) The scalp in the donor area has a chance to return to (or close to) its original laxity, so that, when the second strip is removed, it is easy to still end up with a single thin scar which is hard to notice. Many surgeons who "dense pack" a region of the scalp (such as the frontal area), recommend waiting a year between sessions. In female patients, I usually recommend at least 8 months before a second procedure, and most women wait around a year before their second one. Mike Beehner, M.D.

Dear Steven62, You pretty much answered your own question quite nicely. The answer is "yes," a man in his mid-20's can be transplanted, but usually only in a very conservative way, and, hopefully, with the person also on finasteride medication (Propecia or Proscar). When a young man presents to me (or one of any age, for that matter), if I see the outline of a border shaped like a "horseshoe" on top, within which there is a demarcation of thinning or what we call "miniaturized hairs" within that area, then I assume that they are eventually going to go on to become at least a Norwood VI pattern of baldness some day (this is complete balding on top, with high fringes). In these young men, I prefer to do what we call a "forelock" design, which features an oval area of increased density in the front-center of the scalp, with finer grafts to the sides, blurring the space between the central area and the side fringes, so that it looks natural. We generally stay out of the rear vertical vertex (crown) in men of younger age. I try very hard not to transplant men under the age of 23. I hope that helps in answering your question. Mike Beehner, M.D.

In looking over my notes I posted on Propecia, I wanted to say that the 80-90% hair mass increase is what I have seen in my practice in using it in hundreds of patients, and from my private conversations with other hair specialists who have used it in many patients. For the most part, in using these figures I am referring to seeing the patient back one and two years after starting the medication. I believe the actual study,which looked at the men 5 YEARS AFTER starting the drug, (which I don't have in front of me)showed that around 30-40% of the men had a visual appearance of having more hair, 40-50% showed no worsening of hair loss, and 10% or so were thinner. If one of my colleagues have the exact numbers, they are welcome to post them. Mike Beehner, M.D.

Dear Danger, Certainly the benefits of Propecia for each patient are slightly different. The five-year studies that were completed a year or so ago suggest that, for 80-90% of users, there is an INCREASE IN "HAIR MASS" for around 4-5 years, and then a slow downward "trickle" of loss of hair mass. Hair mass refers to two things: the shaft diameter of the hair and the length to which it will grow (unimpeded by the barber's scissors). Finasteride can result in very fine hairs, and even sometimes hairs that are not even apparent, becoming almost full-diameter hairs that grow long. The initial 4-5 year period of increase in hair mass coincides with the duration of the "anagen" cycle of hair growth, which is the length of one life-cycle for a typical man's hair - so it seems that the drug in some way allows all of the hairs that are coming into the anagen phase to "catch a wave" and ride with it for the duration of the anagen cycle. In projecting the curve out into future years (beyond the number of years that the study was actually done), it would seem logical to assume, based on our present knowledge, that you are going to be ahead of the game and hang onto more hair if you continue to keep taking Propecia. The rate of hair loss is much greater in those men who were on placebo and not taking the drug, even in the later years of the study. As a final point, there is a definite synergistic effect in using Rogaine 5% twice a day in addition to taking finasteride. Synergisic means that the two of them together give a positive result greater than just using finasteride alone. I hope that is somewhat helpful in answering your question. Mike Beehner, M.D.

Dear Dude1, From the description you give of your degree of hair loss, it sounds like there is probably a lot more bald (or thinning) scalp than there is donor hair area. In such cases it is important for the transplant surgeon to use a strategy that creates a natural-looking result that frames the face, but which is not wall-to-wall carpet of hair from one fringe to the other. In most such cases the rear "crown" (vertex) area is pretty much ignored, although at the last procedure I often will put a couple hundred 1-hair FU's in a sworl there for some natural cover and to serve as "tacking hairs" to help hold in place the hair up front which is styled toward the rear. The important thing is to create a gradient of density, such that the front-center of the scalp is the strongest (densest) area and creates that all-important "framing" of the face when you are looked at from the front by people you meet. Styling with this kind of pattern can be either side to side or, better, straight back or toward one of the two side corners (I like that of taking it back to the right rear corner best). As to the number of grafts necessary, that depends most importantly on what your age is, since if you are in your 20's or early 30's, you have to assume you will get quite a bit more bald before you're through. It is probably better to talk about the number of HAIRS necessary, rather than grafts. The reason it is best to communicate about number of hairs, rather than grafts, is that many doctors, in addition to the majority of grafts being FU's, also use "combination" grafts to get density centrally, made up of 2-3 adjacent FU's. I find that most men need around 8,000-12,000 hairs to get a final result that looks relatively "full." Persons with coarse hair may look better with 8000 hairs than a man with fine hair looks with 12,000. With a forelock design, sometimes wonderful results can be achieved with 6000 or 8000 hairs. A lot depends on your hair characteristics, chiefly the caliber and color of your hair, and the density of your donor hair. I have seen near-Norwood VII patients who had incredibly dense donor hair without any characteristic thinning in the lower nape of the neck, where the hair often thins in middle age. In terms of FU's only, I would probably use 2000-2200 the first time, follow in 8 months or more with 1200-1500, and then step back for a year and see how things look, before deciding on further "touch-up" work. Another thing about your individual situation that can make a big difference is the shape and size of your head. Some men with a Norwood VI have a very wide head, and the distance from one fringe to the other fringe side can be a lot further than in a narrow head with a more elongated facial structure. This can make a big difference in the square area of scalp that requires coverage. As you probably know by now, in reading these boards, each doctor has his own philosophy of transplanting. It is important to communicate with several, so that you match up with the one you feel comfortable with. Mike Beehner, M.D.

Dear Hairseeker, A drug can still have an effect in the body even after 2 x the half life expires, especially in the tissues themselves where they work, rather than in the serum. I have spoken with several well-known hair surgeons from around the world, including Australia and Europe, who find also that even every third day spacing allows for the drug to work just fine. I generally do aim for every other day in my practice, just to be on the safe side, but with many of my patients who prefer to save money by quadrisecting Proscar 5mg tablets, I have them take the tablets Mon-Wed-Fri, and have had very good results in these patients. Mike Beehner, M.D.

Reportedly there is a scientist in Germany who used to work for Merck, who during his work with the company on Propecia, showed that it worked and maintained its effect even if taken every third day. Sexual side effects certainly do occur, but I find it is much more likely in men in their late 40's and 50's. My usual treatment dose is a half tablet every other day. Merck's own research shows that 0.2mg (a fifth of a tablet) taken daily suppresses DHT 62% and that 1mg (a full pill) suppresses DHT between 65-67%. If find sexual side effects to be quite rare with the dosage I use in my practice. Mike Beehner, M.D.

Dear PD, I will try to answer your three questions as best I can. I was simply saying that I prefer the burden of avoiding transection to be balanced between myself and my staff. By giving them two 5mm wide (still very wide by any past standards of "strips" cut by multi-blade knives) instead of one thick 10mm strip, I assume the responsibility of making sure the sides of each of those two strips is cut with minimal transection. I explained a few ways I used to help me do this (tumescence, flattening the scalp, etc.)They then can "sliver" through these 5mm strips and make the grafts we need for that particular case, FU's or combination FU's. With regard to my comments regarding an FU cut in half (a bottom and a top portion) yielding hair when planted, this rationale has been used by some in the past for using extremely thin strips and getting all the hair to grow. I was simply stating, as you also seemed to sense, that this is not a good way to produce hair, and, in my opinion is usually a losing proposition for the patient. That having been said, there are some doctors who get some pretty good results with these techniques. The last point is regarding the number of sessions. I sympathize with the fact that every patient would like to get a full transplant in one session and have it over and done with. So would have I when I sent for hair replacement surgery 23 years ago. But the fact of the matter is that it does take around 9,000-12,000 hairs on the top of the head to give the appearance of a truly "full head of hair." Most of my patients want that kind of density over a large area, usually from the front hairline to the beginning of the rear crown, and I find that three visits is a good way to give them that number of hairs over a large area. If one dense-packs in the numbers you are talking about over the entire area being transplanted, you can only have a relatively small percentage of the scalp done at one time due to the limits of what one donor strip can deliver. I am just uncomfortable taking the width of donor strips that is necesary for 3000-4000 FU's and also have some doubts as to whether the blood supply is adequate for all of those hairs to grow. I'm not saying that some of the patients done in this manner don't look pretty good; I'm simply saying that to date the research has not been done to say what the percentage of hairs that survive is with this type of transplanting. Perhaps in the next few years these answers will be available and we'll all know the best way to do it. Thanks for your questions. Mike Beehner, M.D.