Dr. Michael Beehner

Arfy, A typical distribution of grafts over three sessions on, let's say, a Norwood VI baldness with a span of 12 cm across from one fringe edge to the other would be as follows: 270 FU's at the front hairline (around 120 1-hair FU's, 120 2-hair FU's, and 50 3-hair FU's), 50 FU's down each side "crease" area, and 140 FU's at the rear "curved rim", if the crown were not being done. If the crown were being done, I would use around 300-350 in a swirled pattern there, with none of them being less than a 2-hair FU, in order to maximally impact the visible density in this region. That's a total of 510 FU's for filling in the front 2/3rd of the scalp, and 670 FU's if the crown is being included. The number of 1.3mm small round minigrafts would be around 330, with 60 1.5 round minigrafts in the central region (if hair characteristics were such that they would not be detectable. If such is not the case, I fill this area also with the 1.3's, and wait until the second session to place 1.5's here "under the cover" of the smaller pre-existing 1.3's) So in summary, a fellow getting the front two-thirds of the scalp filled in (my commonest sized session) would receive a total of around 910 grafts, of which 510 would be FU's and 400 minigrafts. At the time of a SECOND SESSION, the ratio starts to tilt much heavier toward FU's, with around 650 FU's and 260 minigrafts. At the THIRD SESSION, this would be around 700 FU's and 200 small minigrafts. Getting to your more important question, I don't believe in my hands that the patient is getting a "second rate" product because the minigrafts are used. As I stated, if the patient wants a maximally "full" look and is willing to come 3-4 times, I truly believe he will receive the best result with this approach. I did say, however, that if the patient is only going to come once or twice - a very important qualification - then he is NOT

A patient, writing under the pseudo-name, "Ron Danny," under the category "Post Your Own Pictures" asked if I would comment on the use of minigrafts in hair transplantation. In my opinion they can, if used appropriately, be an invaluable set of "paint brushes" to have in your set of tools with which to practice the art of hair restoration surgery. I don't think they should be used in every patient though. Why are they valuable? The most important reason, in my opinion, is that they help in creating gradients of hair density on the scalp. I like to feather the very front hairline with 1-hair FU's (and if there aren't enough 1-hair FU's, it is wise to split 2-hair FU's into separate 1-hair units to have enough of them) and then quickly switch to 2-hair FU's within 1/8-1/4 inch from the front, in order to begin that gradient, and then 3-hair FU's just behind those. If a transplant is done with all FU's, the surgeon is usually left using mostly 1-hair FU's for the entire front hairline, in order to preserve the more "central" areas for the 2's and 3's. In transplanting this central area of the scalp (which is on the horizontal plane), my usual preference ??“ if hair characteristics are favorable (ie: not too dark of hair with marked contrast to pale skin) ??“ is to place very small minigrafts in a random pattern (not rows), at a very steep angle (so that they overlap each other and style nicely), and very close together (using a minimal-depth incision, which allows for this close density without hitting the deeper blood vessels of the skin). They should never be placed on the front hairline, in either of the creases, or used in the crown (vertex) region, unless a patient has almost white hair. The decision as to which route to take ??“ all FU's, or a combination of FU's and minigrafts ??“ takes place at the time of the consultation. If the patient states he only wants to come for one or two sessions, then FU's only should be used. If the patient expresses zero tolerance for any detectability in the early phases of the transplant growing in, then all FU's should be used. The choice for including minigrafts in the transplant project also should include the understanding by the patient that there will be at least three sessions. You cannot adequately make a final judgement on a combined hair transplant after two sessions. About half of the patients, especially those with finer caliber hair and those with darker hair, in my practice come for a fourth and final session, in which I recommend around 900-1100 FU's "in between all of the cracks," to finish off the project. Returning to the advantages of including minigrafts: It is safer to go back in the second and third time with minigrafts and still get a high percentage yield with them, precisely because you can see where the small groups of 4-6 hairs are, and can easily place the subsequent grafts in the spaces that exist. With FU's, if you go back for further visits, it is somewhat easier to "cut the legs out from under" the previously placed grafts. I did a somewhat complicated research study on a completely bald Norwood Class VI man over the span of three transplant sessions, of 1350, 1250, and 1150 "combined" grafts per session, and studied a small tattooed "study area" in the center of the FU and the minigraft zones. After the first session, there was near 100% growth in both zones; But after three sessions, the growth rate was in the 80-90% range for the minigrafts, and was in the mid-50% range for the FU's. The FU's were placed at a density of 25 per cm2 at each session. The logical conclusion I would draw from that is that, if you are going to have an "all-FU" approach taken, then a one-time pass using "dense packing" (such as Dr. Seager and Dr. Limmer have advocated over the years) makes the most sense. Likewise, if someone intends to transplant two or three times, then the use of minigrafts in the central regions would be the most appropriate way to transfer donor hair safely and achieve density. The last advantage of minigrafts is that it is a much more efficient and less expensive way of moving hair into the central region of the scalp. This results in being able to charge a price per session that doesn't reach beyond what the middle-class can afford to pay, and doesn't require as much staff-hours of help to perform the procedure. The donor hairs are also not "out of the body" as long, if the procedure is performed more expeditiously. It is my opinion that, in transplanting a Norwood Class VI bald man (typical horseshoe shaped baldness) it takes minimum of 8000-9000 transplanted hairs, and probably 10,000-12,000 in fine-textured-hair patients, to create the appearance of a relatively "full" head of hair. Also, the surest way to fine donor scars is not to take more than 2500-3000 hairs per session. When the surgeon goes back 6-8 months later, the skin has the marvelous capability to "soften up" again and give up another strip of reasonable width and still keep the one scar to a thin line that is not detectable. I realize anything but an FU has received a bad reputation and is routinely trashed by a lot of the "regulars" at this and other forums. I empathize with their bitterness and disappointment. Most of them were the product of the work of a previous era, during which these larger grafts, for whatever reason, were the best the hair surgery community had to offer for almost 30 years. But I do believe that much of this overly negative commentary stems from these individuals over-reacting to the harm and disfigurement that was done in previous years with large grafts??“ especially the old "standard" grafts ??“ and running in the other direction to the smallest graft they can find and are championing it. I also see a lot of men in my practice who look terrible and have minigrafts as a large part of why they look terrible. In most such cases, the grafts often come off of the scalp in almost a perpendicular angle straight out. If I was going to pluck a doctor off of the street, who had no experience in this field, and have him placing hair grafts three weeks later, I would probably want him using only FU's, since the chances of him causing harm would be much less, unless he were to mess up the placement of the hairline. But, if a doctor told me he wanted to take a few years to truly master the art of hair restoration and wanted to be able to best take care of the widest range of patients that would present to him during his career, with patients presenting different demands for visual density, having different calibers of hair, different colors of hair, - then I would definitely want to teach him how to artistically use minigrafts. The most important aspect to their use is the angle they are placed at and that they be small minigrafts of six hairs or less. I will close this overly long explantation now, but felt it was important to speak up for the benefits of including minigrafts in some transplant projects. I would ask that people keep an open mind and realize that for some patients they can play a valuable role in creating density and gradients ??“ without harming the naturalness of the final result. I think the patient should choose which method he wants used after having been told the advantages and limitations of both approaches. Mike Beehner, M.D. Saratoga Springs, N.Y.

A patient, writing under the pseudo-name, "Ron Danny," under the category "Post Your Own Pictures" asked if I would comment on the use of minigrafts in hair transplantation. In my opinion they can, if used appropriately, be an invaluable set of "paint brushes" to have in your set of tools with which to practice the art of hair restoration surgery. I don't think they should be used in every patient though. Why are they valuable? The most important reason, in my opinion, is that they help in creating gradients of hair density on the scalp. I like to feather the very front hairline with 1-hair FU's (and if there aren't enough 1-hair FU's, it is wise to split 2-hair FU's into separate 1-hair units to have enough of them) and then quickly switch to 2-hair FU's within 1/8-1/4 inch from the front, in order to begin that gradient, and then 3-hair FU's just behind those. If a transplant is done with all FU's, the surgeon is usually left using mostly 1-hair FU's for the entire front hairline, in order to preserve the more "central" areas for the 2's and 3's. In transplanting this central area of the scalp (which is on the horizontal plane), my usual preference ??“ if hair characteristics are favorable (ie: not too dark of hair with marked contrast to pale skin) ??“ is to place very small minigrafts in a random pattern (not rows), at a very steep angle (so that they overlap each other and style nicely), and very close together (using a minimal-depth incision, which allows for this close density without hitting the deeper blood vessels of the skin). They should never be placed on the front hairline, in either of the creases, or used in the crown (vertex) region, unless a patient has almost white hair. The decision as to which route to take ??“ all FU's, or a combination of FU's and minigrafts ??“ takes place at the time of the consultation. If the patient states he only wants to come for one or two sessions, then FU's only should be used. If the patient expresses zero tolerance for any detectability in the early phases of the transplant growing in, then all FU's should be used. The choice for including minigrafts in the transplant project also should include the understanding by the patient that there will be at least three sessions. You cannot adequately make a final judgement on a combined hair transplant after two sessions. About half of the patients, especially those with finer caliber hair and those with darker hair, in my practice come for a fourth and final session, in which I recommend around 900-1100 FU's "in between all of the cracks," to finish off the project. Returning to the advantages of including minigrafts: It is safer to go back in the second and third time with minigrafts and still get a high percentage yield with them, precisely because you can see where the small groups of 4-6 hairs are, and can easily place the subsequent grafts in the spaces that exist. With FU's, if you go back for further visits, it is somewhat easier to "cut the legs out from under" the previously placed grafts. I did a somewhat complicated research study on a completely bald Norwood Class VI man over the span of three transplant sessions, of 1350, 1250, and 1150 "combined" grafts per session, and studied a small tattooed "study area" in the center of the FU and the minigraft zones. After the first session, there was near 100% growth in both zones; But after three sessions, the growth rate was in the 80-90% range for the minigrafts, and was in the mid-50% range for the FU's. The FU's were placed at a density of 25 per cm2 at each session. The logical conclusion I would draw from that is that, if you are going to have an "all-FU" approach taken, then a one-time pass using "dense packing" (such as Dr. Seager and Dr. Limmer have advocated over the years) makes the most sense. Likewise, if someone intends to transplant two or three times, then the use of minigrafts in the central regions would be the most appropriate way to transfer donor hair safely and achieve density. The last advantage of minigrafts is that it is a much more efficient and less expensive way of moving hair into the central region of the scalp. This results in being able to charge a price per session that doesn't reach beyond what the middle-class can afford to pay, and doesn't require as much staff-hours of help to perform the procedure. The donor hairs are also not "out of the body" as long, if the procedure is performed more expeditiously. It is my opinion that, in transplanting a Norwood Class VI bald man (typical horseshoe shaped baldness) it takes minimum of 8000-9000 transplanted hairs, and probably 10,000-12,000 in fine-textured-hair patients, to create the appearance of a relatively "full" head of hair. Also, the surest way to fine donor scars is not to take more than 2500-3000 hairs per session. When the surgeon goes back 6-8 months later, the skin has the marvelous capability to "soften up" again and give up another strip of reasonable width and still keep the one scar to a thin line that is not detectable. I realize anything but an FU has received a bad reputation and is routinely trashed by a lot of the "regulars" at this and other forums. I empathize with their bitterness and disappointment. Most of them were the product of the work of a previous era, during which these larger grafts, for whatever reason, were the best the hair surgery community had to offer for almost 30 years. But I do believe that much of this overly negative commentary stems from these individuals over-reacting to the harm and disfigurement that was done in previous years with large grafts??“ especially the old "standard" grafts ??“ and running in the other direction to the smallest graft they can find and are championing it. I also see a lot of men in my practice who look terrible and have minigrafts as a large part of why they look terrible. In most such cases, the grafts often come off of the scalp in almost a perpendicular angle straight out. If I was going to pluck a doctor off of the street, who had no experience in this field, and have him placing hair grafts three weeks later, I would probably want him using only FU's, since the chances of him causing harm would be much less, unless he were to mess up the placement of the hairline. But, if a doctor told me he wanted to take a few years to truly master the art of hair restoration and wanted to be able to best take care of the widest range of patients that would present to him during his career, with patients presenting different demands for visual density, having different calibers of hair, different colors of hair, - then I would definitely want to teach him how to artistically use minigrafts. The most important aspect to their use is the angle they are placed at and that they be small minigrafts of six hairs or less. I will close this overly long explantation now, but felt it was important to speak up for the benefits of including minigrafts in some transplant projects. I would ask that people keep an open mind and realize that for some patients they can play a valuable role in creating density and gradients ??“ without harming the naturalness of the final result. I think the patient should choose which method he wants used after having been told the advantages and limitations of both approaches. Mike Beehner, M.D. Saratoga Springs, N.Y.

Dear "follicle," You asked about whether the donor hair should be harvested on the occipital protrusion at the back of the head, or below or above it. When I evaluate the donor hair in the rear (and on the sides), I take into consideration a number of factors: First of all, how old is the patient? Obviously a lot can change over the years in a younger patient - both at the bottom and the top of that fringe of hair I see before me in back. If the patient is in his 40's or 50's, then the pattern before us is much more stable and predictable for the rest of that man's lifetime. Second, a hair transplant surgeon notes the presence of any "retrograde alopecia," which is thinning of hair from the nape of the neck up. This is fairly common in many men,perhaps in as many as half of all the men we transplant. So obviously you don't want to take hair from an area low enough that it may someday thin - in which case the hair harvested from that area will likewise thin in its new home on top of the head. And the worst thing of all is to harvest the donor strip from high in the rear occipital hair, just beneath the edge of the strong fringe of hair - as progressive enlargement of the "crown" area is almost a universal given in any balding man's future. My own approach is to place one of my fingers at the bottom of the "strong" hair present just above the neck and another one at the top of the occipital fringe hair where it is also strong. I then place a third finger one-third of the way up from my bottom point to the top point, and THAT is where I cut my strip - not too low, and definitely not too high. With this method I feel confident that the hair I am using will be hair that the patient will keep on the top of his head for the rest of his life. By the way, using this method, around 8 out of 10 times that point ends up being the exact location of the occipital protuberance. The other 20% of the time, it is either slightly above or slightly below it. It will be above it when there is significant thinning of the man's hair at the nape of the neck. Mike Beehner, M.D.

Reply to EMantagno (Eric) Eric, I went back to the November photos you sent and reviewed them. It appears you have had a Y-shaped ("Mercedes") scalp reduction (I am assuming and hoping it was only one, and not more, which would cause the scalp to thin more). You have a fairly strong front hairline which is reasonably high in its placement, which is good, as it leaves room to put some more natural contour and "feathering" in front of it. At the same time, this "wall" has to be broken down a little and softened in appearance, as no amount of micro's/FU's will completely hide it. There is a technique, first promoted by Dr. Manfred Lukas of Germany (who died a few years ago) in which a very small cylinder punch (with electric drill mechanism, which lends toward crisper, sharper removal of the hairs, so they can be used again) of a few of the hairs at different places along the hairline are removed and the resulting hole fills in nicely within a week or two. The square area of balding scalp that you have is reasonably large, but, on the other hand, it looks like you may have substantial amount of donor hair, as your fringe appears to come all the way up the side of your head. A rear and side view would give a better idea of the amount of donor hair available. Obviously, some part of it will have circle scars from harvesting your previous grafts. The bottom line is that it could all certainly be made to look better. You don't have enough donor hair most likely to fill in the entirety of your bald area, but if you opt for having the front 60-70% filled in and are willing to adopt a hairstyle in which the hair is swept back (either to either rear side in back or straight back), I think the final look would be a natural one and it would be your own natural hair. It would probably require around three transplant sessions. Another factor is whether or not you are coloring your hair or not. If you are and your natural color is a mixture of brown with gray, your transplanted result would look more natural if you let a little of that gray return. I also find that it is sometimes difficult to get a man who has worn a large thick hairpiece all of his life to trade that full look for somewhat lower density. A man has to dislike the hairpiece so much that he is willing to trade that density for the natural, but slightly less full look of a good transplant. There are any number of fine surgeons in your area who could probably perform the steps I outlined above. I wish you the best. Mike Beehner, M.D.

Oliver, There is certainly some variability in when transplanted hairs "come out" and start growing. For most patients, there is always that 1-5% of the hairs that "take off" from the start and never go into their "hibernation" phase. The great majority of transplanted hairs make their initial appearance between three and four months from the time of the surgery. Around 20% of my new patients (especially the ones who start out bald) notice the first hair at 2 1/2 months. Two things that I think are important to mention are these: First, in subsequent sessions after the initial one (when the blood supply system for the scalp is "virgin"), the appearance of the new hairs can be delayed slightly. It is a little hard to tell if this is indeed true across the board or not, because the first session will always be the most dramatic one (especially if nothing was there in the first place), and the hairs from the second session will be quite short in their first month or two of appearing and may be difficult to notice in the mirror as they stand between the taller-shouldered first session hairs. Second, Dr. Martinick of Australia did an elegant study of follicular units, in which she proved that there can still be the appearance of new hairs as far out as 18 months after surgery. One final point is that transplanted hairs that just come out are of smaller diameter than they will be a few months later, which tends to help make them "invisible" also when trying to see if your new hair is growing. Hope that helps. Mike Beehner, M.D.

Dom, Donor area pain 8 months later is distinctly uncommon in my experience. It sounds like perhaps what you had instead was simply tenderness to firm palpation (finger pressure) in some spots along the donor scar. That certainly is a reasonable thing to have. I personally last had a tiny "touch up" session around a year ago and, upon reading your note, pressed along my scar and noted like you there were two spots that were slightly sore when pressed firmly. The important thing is that patients don't walk around feeling pain there. Obviously, as anyone who has had a transplant knows, during the week after the transplant, the area that causes the most discomfort, especially when trying to find a comfortable position to sleep in, is the donor area. Thankfully, that improves dramatically simply by having the sutures (or staples) removed and gets better by leaps and bounds in just a few short days. The only case of persistent donor pain that I have seen in my practice occurred around 5 years ago in a 65 year old man who had his first transplant with me. He had had a one-sided flap rotated into the right frontal area of his head many years earlier. For some number of weeks after his transplant with me, he complained of pain with even light touch in one spot on the donor scar. When I examined him, there was no redness or swelling, but it was somewhat sore to the touch. Thinking it was probably a neuroma, I first tried an injection of a cortisone medicine, and this did not help in the next few weeks. We then did a "en bloc" dissection in the shape of a small elipse (football shape) of the area, all the way down to the galea (the "gristle" layer that underlies the scalp), and this resulted in complete disappearance of his pain and the soreness. I have not seen it since. The other factor in pain during the first few weeks after a hair transplant procedure is the tightness resulting from the tension in closing the wound after taking out a given amount of hair. I don't have to tell you that you had about as large a session as is possible to have, so I wouldn't be surprised that you experienced some discomfort the first few weeks - but that should not be a factor 8 months later. Good luck with your healing. I am sure you will do well. Mike Beehner, M.D.

Gary, Unfortunately, there have been no really good studies of "shocking" to hair during hair transplantation. The best we can do is to pool our collective experiences of when this happened and look at the particulars of those patients and sessions. Obviously, "shocking" only occurs in patients who have some remaining hair on top, which in most of our practices is the majority of our patients. If that remaining hair is very "weak" and vellous (thin, wispy, and limited in how long it will grow to), then it is far more vulnerable to this occurring than if it is relatively strong hair with good caliber and length. I would say that "shock" to the degree that either the patient or I notice it, occurs in less than 10% of cases in which there is pre-existing hair on the patient's head. Remember that about 50% of hair has to be missing before it is fairly easy to notice that things have become thinner. Because of this, it is my gut feeling that some small degree of shocking probably occurs in every transplant (unless the patient is shiny bald), but it is neither noticed by the doctor nor by the patient. The hair then starts growing back three months later. Factors during surgery, I believe, play a very important role. If the surgeon packs the grafts extremely close together, there is obviously more chance of direct trauma to the follicles of those remaining hairs, and such dense packing also increases the chance of blood supply embarassment to those remaining hairs, which most of us feels is the main cause. Using too high a concentration of epinephrine (Adrenaline) in our local anesthetic solutions and saline tumescent fluids can also play a role in transiently depriving some of those hair follicles of their full blood supply during surgery. Cigarette smoking has also been mentioned as a risk factor for shock, although I haven't noticed a relationship in my practice. Most hair surgeons I have spoken to relate that "shock" is much more common in their female patients than in their male ones. The reasons for this aren't entirely clear, although usually the women that seek our services already have vellous hairs on top of their heads. Severe "shock" with major dropout of a large amount of hair that was dramatically obvious has only occurred in my practice four times, in three men and one women.The only single factor that was present in all four was that they had all had at least two previous hair transplant procedures, and in all four instances, all of the hair that fell out, plus the new transplanted hair, all grew out later and was much fuller than before surgery. Since the last time this occurred two years ago, in my practice I have further reduced my concentration of epinephrine in our saline solutions and haven't noticed it since then. I hope that helps answer your question.

We haven't had any experience using ProThick (although I have heard from others it is a very good product), but have extensively used both Derm Match and Toppik in our patients after the transplants and have our patients start using them a couple of days after the transplant. Obviously, with the Derm Match, which is applied to the skin and not to the hair like Toppik, we have them be very careful so as not to disrupt any of the grafts. If a man has some residual hair of his own on top, or has already had one transplant session and is now having his second, these strategies work very well. Another benefit of them is that they often allow a man to get rid of his non-surgical hairpiece earlier than he otherwise would be able to. Mike Beehner, M.D.