Dr. Michael Beehner

PD,

Dear Phl, When Dr. Limmer first told us about the technique several years ago, I tried to order the Second Skin, but had difficulty doing so at the time, but went ahead and used the "grease helmet" concept using Telfa pads instead with the intent to leave it on for 3 days as he advises. The two men I chose to do this on at that time both had some bleeding under the bandages, and I personally came in and met them and removed the dressing the next day and put another one on. We have a protocol all written out with instructions for the patient, but have dropped off in our interest just because of those two experiences. In addition to helping prevent scabs, the "sealing" with the ointment over all the scabs also seems to prevent coagulation of the plasma components. We will probably try it again and do it this time with the Second Skin, to see if it holds everything in place without bleeding better. In the same vein, we do a fair number of eyebrows, and three weeks ago we had a woman come in several hours after her eyebrow transplant. We normally had always just put Bacitracin ointment over the FU sites (around 140 per eyebrow)and not put a dressing or bandage on them. Well she rubbed her hand over her eyebrows and around 10 of the FU's came out on her hand. I put them back in at the office, as she kept them moist when she discovered what she had done. I now start the ointment in the morning, so that the coagulation around the grafts in their sites can "take hold" and not risk falling out. This is an example of something that we all learn as we go along, and eventually settle on what works best for our practice and the distance people come to see us (to minimize inconvenience or problems for them). Mike Beehner, M.D.

Like a few of my colleagues who have had to jump in and defend their professional reputations from time to time, I feel it is probably necessary for me to do so now. Regarding the Discovery Show, it was mostly filmed in 1998-99, 5 years ago, and it was planned so that the patient on the show could have three surgeries and then be flown several months later after the last procedure to L.A. for some photos. Because of production pressures, we did the second procedure only 3 1/2 months after the first one, whereas I have a minimal interval of 6 months presently. We did take three 3mm strips in that patient's donor harvest (which does require four blades), but presently only take double strips of 4-5mm width each, which allows the cutters working under the microscopes to do plenty of slivering to isolate follicular units, but isn't as deep a slivering cut as those who cut out a single elipse. If I see any variation in direction of the hairs at the top of the strip with the bottom level, I immediately use a single knife and cut each side individually, following the angle of the hair there. An intersting follow-up to the Discovery Show is that a woman from Boston watched the show a couple of years ago, called her best friend and told her to turn on the TV, that she thought that was the man for her. She couldn't get through to the Discovery people, but a year later, by chance in the midst of 40,000 runners at the NY Marathon, happened to meet him and they are a serious twosome today. A little "Sleepless in Seattle"! The above isn't what provoked me to answer here in this forum. Rather, I would hope that my reputation doesn't rest on one discontented beard harvest patient. The patient in question had virtually no available donor hair, begged me to find hair somewhere else if I could (even once asked us to harvest peri-anal hair! - which we kindly refused. In fact, my whole staff said they would quit if I even considered such a deed.), and after the two sessions with beard hair looked quite good compared to how he looked when he first presented to us. He was made aware at the outset that this was a relatively new procedure and that there would be a scar under the chin after the procedure. I first saw a good result with this method at our 1999 San Francisco meeting by a doctor from that area in a patient who had no left-over scalp donor hair. We have done a total of 8 procedures on 5 patients, three of whom are committed to wearing beards their whole lives (always have in the past and always will), so the scar is not an issue. My opinion, after performing these 8 cases, a topic on which I have lectured in Europe (Berlin) this past summer, and at the Orlando Live Surgery Workshop, is that it is advisable to use beard hair as donor ONLY when the patient is committed to having a beard the rest of his life to hide his scar, and to only place the hairs in the central area of the scalp, never near the periphery, such as at the hairline. The spirit in which I try new ideas, such as beard harvesating, is to see if they are helpful for my patients and will benefit my profession. As examples, three years ago I came up with a procedure for elevating an overly flat flap hairline or translanted hairline, which many doctors now use. I have worked on various variations of frontal forelock designs for the extremely bald man for many years. I do at least two to three research projects a year in hair transplantation. The patients are fully informed of what is going on, and I think the information has enriched my profession. Too often on these sites, a given doctor will get "tagged" with a certain label by persons who know nothing of the quality of his work. I think that if the participants on this and other forums were more respectful and tolerant to different opinions expressed by doctors here, that more doctors would participate and the exchange of ideas here would be more informative. All that having been said, I fully respect the right of "free press" and for a little rough and tumble "give and take" here. If anyone wants to communicate with me personally off of this board regarding any of these commments, feel free to do so (e-mail address available on website) Mike Beehner, M.D.

Transplanted hair will most certainly grow on such a scalp. This transition is done all the time. I don't think there are many of us, though, that would recommend that the patient go back to his "glue-on" method after the procedure. Almost always, the patient either switches to a "clips" attachment method (with two-way tape in front, making contact beneath the transplanted hairline) or the patient goes "cold turkey" and gets rid of his hairpiece. As to growth of transplanted hair in a patient who continues to wear a hairpiece, there are some differences of opinion, but most of the experienced hair surgeons I talk with say that they see a certain small percentage of patients who have less than full growth (as compared with what they see in their non-hairpiece patients). I most definitely can recall 5 or 6 such patients in whom I was disappointed with the growth, but, on the other hand, have had over a hundred who had the same good growth I usually see in my regular patients. I can't prove it, but it seems to be more prevalent in patients with hyper-elastic, oily skin. For the last few years I have followed the advice of Dr. Bobby Limmer and Walter Unger, who have for a long time advised their hairpiece patients to go at least one week without wearing the hairpiece at all, and then, after that, to only wear it when socially necessary - such as at work, dates, etc. and in the home to take it off and simply wear a baseball cap. The exact mechanism of poor growth in some of these patients is not knows, but some have speculated it might be a "shearing" force on the new grafts, or perhaps increased temperature, moisture, bacteria counts, etc. I hope these comments are somewhat helpful in understanding your situation. Talk to your salon and they will be able to assist you in the transition. Mike Beehner, M.D.

Hairseeker, At last year's Chicago ISHRS meeting, I presented a research project I did on two gentleman, one of whom had had a scalp reduction before the transplant procedure and one who did not have such a procedure. My findings, using tattoo dots to follow the widths of the hair bearing scalp, were that, if you cut out a 10mm (1cm) width of donor strip and then went back 6 months later to see where that 1cm of "space" disappeared to, around 20% came from stretching of the neck below the hair-bearing scalp, around 60% came from the gradual stretching out of the hair-bearing fringe hair itself, and around 20% came from stretching of the bald scalp up on top. As Dr. Charles said, the effect on the crown would be virtually imperceptible to the human eye. The trick to having all of these distributions take place over the course of a 2-3 session hair transplant project is to limit the width of the strip to 1cm in most patients and to allow plenty of months (8 or more is best) between sessions, to allow the donor scalp to become loose and lax once again. I find if I follow those rules, it almost seems like magic, and the donor scars stay paper-thin. Mike Beehner, M.D. Saratoga Springs, N.Y.

Dear Baldman, It has been my experience over the years that a small percentage of hairpiece wearers that undergo transplants - perhaps 10-20% - have slightly less growth of their transplanted hair than their non-hairpiece wearing cohorts. This same impression has been seen by several other very experienced transplant surgeons I have spoken with in the last 2-3 years. When we discussed this a couple of years ago, two veteran transplant MD's whom I respect a lot passed on to me their advice for handling transplant patients who wear a hairpiece, and I have been following these for the past year or so. The most important one is that the patient not wear the system at all for at least seven days after the surgery. Second, whenever the patient is not in a social situation, such as work or out with friends or relatives, he should take the system off and just wear a baseball cap (which does not affect transplants). It is assumed that, with rare exceptions, that such a patient would have first made the transition to a "clip" attachment mechanism for his hairpiece. Two-way tape is used in the front, and sometimes a piece that is only half as wide can be used and often will touch the forehead just beneath the translanted hairline. If it touches where the new hair is, then the patient can shave that tiny area, so as to avoid pulling hairs out. Another important point is that the patient should have his salon every few months change the location of the clips, so that they are not pulling on the same groups of hair all the time. Over time this can lead to "traction alopecia" and permanent loss of hair in these small circular side areas. I would end by emphasizing that the above less-than-expected transplant growth occurs in a distinct minority of patients, but I never know which patient that will be, and it is my subjective impression that I am noticing it less since I started advising these patients as I described above. Another difficulty with wearing a hairpiece is that it is a little difficult to assess the impact of the previously transplanted hair, since it has that "matted down" look when the hairpiece is removed and never quite looks its best. It is better for the hairpiece wearer, after a couple of HT sessions to shampoo and condition his hair, and then blow dry it with styling and then look in the mirror and see if you are getting close to being able to get rid of the piece. Using Toppik after 1-2 sessions can give a nice dense look until after all the planned transplanted hair is placed. Mike Beehner, M.D.

Dear "Whoops," The typical person has around 100,000 hairs on his scalp in total, and it is normal for 50-100 to "fall out" each day. All of our hairs go through repeated "life-cycles" during our lifetime. For most men, this cycle is around 4 years, give or take a year. This means that every hair on your head takes a three month "vacation" or hibernation period every 4 years. This falling out occurs randomly all over your head. What happens is that the "follicle," which is the living part of the hair (the hair itself is a totally dead organ)shrinks up and becomes barely visible even under a microscope. The hair that was produced in the previous cycle then just sits there in its place, and will then simply disconnect and fall out when taking a shower or brushing through your hair. If you see these long hairs on the shower floor or on your brush, they are nothing to worry about. Actually the hair that you will never see again usually is a very short wispy hair that just finished its last life-cycle. These are usually so small, you don't even notice them. Some events such as chemotherapy or even donor harvesting of the donor hair, can cause the hair to all go into this 3-month telogen phase. Mike Beehner, M.D.

Dear "Danger," Most hair surgeons tell their patients not to even look for evidence of new growth of hair until 6 months, and for many men this doesn't show until as late as 12 months. What many men DO notice in the first few months, particularly for those that are in the accelerated phase of hair loss with lots of hairs shed daily, the number of hairs shed will often be noted to decrease. As evidence for my first comment, a hair surgeon from out west was considering going off of Propecia after 8 months because he didn't notice much in the way of results, but was persuaded by a colleague to hang in there with it another 4 months, and by 12 months he had a large amount of regrowth present. Mike Beehner, M.D.

Dear Arpma, The strategy you should adopt depends a lot on two things: first and foremost, your age; and second, how much "fringe hair" you have. If you are relatively young (under 35), you can be sure that your male pattern baldness pattern is going to increase. If you are over 40 and your side fringes have been stable for some years, then you are likely to end up relatively close to where you are now, except probably for some further droppage in the rear vertex border. If you are in the younger group, then Propecia will essentially "halt your heredity" for about 9-12 years, according to the projections of the recent 5-year studies that were done. You will get an increase in "hair mass" (ie: the wispy thin, short hairs will become longer and thicker) for around 4 years or so, and then there will be a very gradual decline - much more gradual than if you were not taking it - for 6-7 years, with the end result that you will end up back in 10 years where you start out. There is another type of hair loss called "senescent alopecia" which most men experience to some degree, and this is the gradual thinning of all of the hair on the side fringe areas. If you come across a man who is 80-95, you will generally notice considerable thinning of all of his hair on the sides, whether he balded on top or not. It has not been proven, to my knowledge, that Propecia halts or slows down this process. However, I take Propecia in relatively small doses with the hope that this is perhaps true. So, besides taking Propecia (myself, and a lot of hair surgeons, use it in far smaller doses than the company recommends. Most of my patients take a half tablet either daily or every other day, or Proscar 5mg as a quarter tablet every other day - works out to around 20-25 cents a day) you have the problem of what kind of hairpiece to get and how to attach it. I am sure you have already figured out that you should get a human hair one, not a synthetic one. That's a "no-brainer" if you want to even have a chance of it looking natural. My advice is, if you are committed to wearing the hairpiece for the rest of your life, to use the "glue on" method, which means that every 4-6 weeks your salon stylist will shave down a "U-shaped" area of your scalp (or perhaps, if you are bald enough, this doesn't need to be done!) and then connects it with an adhesive, leaving the front to be attached with two-sided tape, which you can lift up daily to shower and shampoo in and gain access to your scalp and hair. The great advantage of this method, compared to clips, weave attachments, etc. is that you avoid the "traction alopecia" complication, which is very common after a year or two of using any method of attachment that puts a "tug" on your existing hair. This is especially true, it seems, in men who have fine hair on the sides. It is particularly hard for us when these men, who have these little bald circles on the side from traction alopecia with the hairpiece, want to switch to a hair transplant, because we not only have to transplant the top of their head with a pattern that makes sense, but we also have to transplant these little circles. I hope the above covers your question for you. Mike Beehner, M.D.

Dear Dude I, Obviously, there are much greater changes in scar healing during the first few weeks, but I believe these changes continue for probably a year and possibly even a little longer. If you have ever seen a friend or relative's hernia or appendectomy scar (from the pre-laparoscopy days), you would have noticed that it remained pinkish in color until around 1 year had passed. Obviously, in these wounds (and in all wounds), there continues to be a long healing process. For histamine to be released there has to be a true antigenic allergy to the substance that caused it. I tend to doubt that in most cases an itchy donor scar or even seborhheic dermatitis is related to that type of chemical release and reaction, but rather is due to physical factors in the skin itself (drying, scaling, slight redness in some areas,and the component of the "viscious circle" of itch-scratch-itch-scratch that I referred to. Mike Beehner, M.D.

Itching of the donor scar several months after surgery is distinctly uncommon in my experience. If your surgeon used any absorbably sutures underneath the skin to help hold the wound together, all of the commonly used types of materials would have been long since absorbed (Vicryl, the commonest one used, usually absorbs at around 7-8 weeks) and is probably not the cause of your symptom. Two things come to mind: The first and most likely is that you might have what we call, for lack of a better term, an "itch that rashes." Even thought there is probably not any visible rash per se, this refers to a situation in which the daily physical scratching of the site becomes the CAUSE of the itching. If a person has poison ivy and never ceases to dig it up daily, he will have a itching (and a rash) ad infinitem. The second possible cause would be a mild case of seborrheic dermatitis in the scalp, which is most pronounced in the area of the donor scar. Usually persons with this condition do notice more dandruff than those without it. The first cause I referred to above can be helped by using some steroid lotion or cream along the scar (especially at night), keeping any nitetime showers more to the tepid temperature (rather than really hot), keeping the bedroom a little cooler, and a little Benadryl (25-50mg) at bedtime to help with sleep and reduce the itching sensation. Obviously, what will help in this situation the most is to keep your hands and fingernails out of the area. If the above doesn't help after a few weeks, you certainly should have your doctor examine the area. If it is seborrheic dermatitis, you will need to get a specific treatment regimen from your doctor.Good luck! Mike Beehner, M.D.

Dear East Coast, There is a lot of misunderstanding as to what some of these terms mean, which describe various types of grafts. First of all, there is no such thing as a "microminigraft". For many years "micro-minigrafting" referred to a type of transplanting in which small one and two-hair thin grafts were always called "micrografts" and anything larger than that was called a "minigraft." Micrografts were traditionally used at the front hairline and minigrafts were used behind them. Because the minigrafts in the early days were quite large, with 7-10 hairs in them sometimes, and because they often weren't used very artistically - often being placed at 90 degree angle, growing straight out of the head like a tree - they understandably got a bad reputation. During this era, which went from the late 1980's till around 1996 or so, the great majority of all grafts were cut using "loupes" of around 2-2.5 power magnification. It was somewhat of a "slicin' and dicin'" type of dissection, though with relatively decent magnification and, by high-quality practices, done with as much care as they could bring to the task. Since that time, however, the majority of practices now use microscopes of various powers to cut their grafts (the Mantis is 6x magnification, and the other stereomicroscopes, including the Mejgi ones that we employ, are 10x). Using this kind of magnification, it becomes obvious when you look under the scope that you are dealing with these little separated islands of hairs called "follicular units". In the majority of patients at least half of these are composed of 2 hairs each, a quarter of 1 hair, and another quarter of 3-4 hairs. Some of these FU's are in closer proximity to a given neighboring FU than others are. In these instances, oftentimes, if greater density is needed in the "frontal core" zone at the top of the head, the physician or his assistant cut and dissect in such a way as to encircle the two of these together, thus yielding a 4 or 5-hair "double follicular unit." The term "minigraft" and the term "micro-minigrafting" both have come to carry a negative "Wild West-shoot em'up" type of connotation, whereas the artistic use of "double FU's" and "triple FU's" ,using this type of dissection, is anything but wild. In fact, it takes a good deal of time, care, and artistic ability. When you hear that two FU's were placed together into a recipient site, this can mean one of two totally different things: If you take two slim 2-3-hair FU's and put them together in the jewelers forceps and place them side-by-side into a narrow needle hole, you then have perhaps 4-5 hairs in a very tiny space, which creates a very dark,compressed "dental floss" type of look that you would never want anywhere near a hairline or outer area. On the other hand, if you precisely cut out two FU's as one piece of tissue, along with the small amount of intervening bald skin that separates them naturally, and you place that graft into a recipient site - whether it is a small slit, a small slot, or even a small round hole - which is the same size as the graft, then those two FU's exist on the transplanted head with the natural distance between them that existed in the donor area, and they are capable of imparting natural density to the scalp in the area where they are used and needed for that task. One important place that the old term "micrograft" can truly be used is in the patient who has an overwhelming number of 2,3, and 4-hair FU's and hardly any naturally occurring 1-hair FU's. In this instance, we cut 2-hair FU's into two separate 1-hair grafts, which we then call "micrografts," according to the rules of the old terminology. These 1-hair grafts are necessary to impart a "natural" look to the front hairline, and are also necessary in the rear transplanted border. Research studies have shown that these grafts grow just as well as the intact 2-hair FU. I hope this makes this terminology clearer and takes some of the emotional overlay out of discussions involving these terms. Mike Beehner, M.D.

Dear Cobra, I would also add that Dr. Mel Mayer, Dr. Jim Swinehart, and Dr. Jim Harris are all in Denver and are all very conscientious physicians that do excellent work. I would also recommend getting a consultation with each of these, and seeing whose work and temperament you feel most comfortable with. Mike Beehner, M.D.

Dear Northeast, From a transplanting viewpoint, there isn't much difference between a Norwood V and a Norwood VI. They both have the large "horse-shoe" shaped area of balding/baldness on top, with a rim of hair visible as you look down from the top onto their head. The difference, as you alluded to, is that the Norwood V still has some residual, thinning hair - most commonly in the area we call the "mid-parietal bridge" which spans from above the ear on one side across to the other. If you look at the various Seinfeld episodes over the ten or so years of the show, you will note that in the show's early years Jason Alexander had a fairly strong mid-parietal bridge, and as the show got toward its last years, this bridge had almost totally disappeared. He had gone from a Norwood V to a Norwood VI. If the fringes on the sides fall down the side of the head, such that in looking down upon the head you see almost entirely bald skin and don't see the horseshoe of hair surrounding it from this view, then it has become the most severe degree of baldness, what we call a Norwood VII stage. Going backwards one more step, the difference between a Norwood IV and a Norwood V is that in a Norwood IV, the bridge of hair across the top is of almost full thickness quality hair, whereas it is starting to thin and break up in the Norwood Class V. Hope that clears it up for you. Mike Beehner, M.D.

Dear ARPMA, If you are going to be committed to wearing a hairpiece for a great many years, then I think the "glue on" method is the best for not harming the surrounding hairs where the hairpiece attaches. You will go in to your salon/dealer every 4-7 weeks and have a "horse-shoe" area of the hair-bearing scalp shaved down to the skin and then the hairpiece is glued onto that area. The only place this does not occur is across the front, where you will have two-way tape, which can be easily lifted up for cleaning, etc. Almost all of the other methods - clips, weaves, etc. - involve a tying on to existing hairs, which has the potential to create a chronic or intermittent "traction" or pulling on the hair, which in time can lead to small circular patches of permanently lost hair. There are some old barbaric methods of attaching hairpieces, such as "tunnels" of flesh which are surgically created and then the hairpiece "snaps on" to the tunnel, and also the infamous thick fishing line that was sewn in and out in a circle around the whole scalp and then the hairpiece was "permanently" attached to this. These patients often had pus oozing out of the holes where this thick nylon thread went through. Thank God most of these are history. When someone makes a transition from a hairpiece to a transplant, most of us insist that they switch to a "clips" mechanism of attachment, so that they can take it off every day when they get home from work and wear the hairpiece the least possible while the transplants are growing in. They often have to do this for 8 months to 2 years, depending on when they have the courage and sufficient amount of new hair to "go bare." Even in these cases, it is important for the locations of the clips to be moved around, so that they are not always pulling on the same clump of hairs during that entire time. If used in this manner, the clips work just fine. I hope that sheds a little light on your question. Mike Beehner, M.D. Saratoga Springs, N.Y.

I should probably add that I certainly was not recommending that someone go from my office to the golf course, and I was also assuming he would be using a golf cart and that the temperature was moderate and comfortable. I think it's a great game also. It just doesn't do anything for your cardiopulmonary system, and if you're lousy at the game like I am, it can make you want to sometimes tear your hair out. Mike Beehner, M.D.

I must confess that I have come across a few assistants - all of them happen to have been female and of a younger age- , of nursing and other backgrounds, that had incredible eyesight. I have one that works for me presently who inserts her grafts without having to use an eye magnifier in front of her eyes (as I and the rest of my staff do). She does, however, use the scope to CUT grafts. In answer to the question, I personally must come down on the side of saying that for it to be called true follicular units that are being dissected, one should use a dissecting microscope, at least a 6x power Mantis microscope, and probably preferably a 10x one of the standard variety. I will grant that an assistant with great eyesight, such as our Carol, could probably 9 times out of 10 cut true intact follicular units using the naked eye (or loupes), but there is so much that is missed when one doesn't use a microscope. It is like the difference between looking into the water while sitting on shore, versus getting in there with a snorkel and mask. You just see so much more. You see the tiny, dull germinal "bulge" that is around a third to halfway down the follicle (and should be preserved), down to the bulb itself, with its tiny, faint colored "dermal papilla" just beneath its underside, which also should also be preserved to get optimal and timely growth of the new hair. Even the act of accurately trimming the epidermis (skin) closely at the edge of the emerging hairs is best done with the advantage of the scope's magnification. I think most MD's and DO's that use a lot of FU's in their practice would agree with the above. Mike Beehner, M.D.

My policy regarding activity after a hair transplant procedure is to have the patients not perform any vigorous athletic activity, such as running or lifting weights, for five days after surgery. For patients asking about golf, I tell them that I don't consider it an athletic activity. Enjoyable, but not athletic. I let them golf right away. Mike Beehner, M.D.

I think there is some benefit to the general community that this topic of graft definitions has come up. These various terms describing particular types of grafts all evolved over the past 20-30 years, as the size and the means used to cut the graft changed over time. For 30 years virtually the only graft used was the 4mm large "standard" graft popularized by Dr. Orentreich, which obviously looked quite "pluggy" and gave hair transplantation a bad name for many years. When these large grafts were later quadrisected into four quarters (first suggested by a Dr. Bradshaw of Australia), these became known as "minigrafts". They were a huge improvement on the so-called "standard" plug graft, but still were very detectable (and, in dark haired individuals, quite unsightly)if planted anywhere near the front hairline, crease, or crown area. Not too long after this (still in the 1980's) some doctors, Dr. Manny Marritt of Denver, CO among them, started breaking single hairs off of these mini's and large grafts and termed this even smaller graft a "micrograft". For many years hair surgeons accepted the definition of a "micrograft" to be one that consisted of 1-2 hairs, period. During these years most hair was harvested still using the electric rotary punch and punching out 4-5mm circles all over the donor area (this is how most of my own hair transplant was done in the early 1980's), usually leaving them to simply scar in. The magnification used was almost always some type of magnifying "loupe" mechanism, either attached to ones glasses, or in the form of the large circular prism that you see for sale in catalogues occasionally. Then along came the microscope and a growing awareness of an entity called the "follicular unit" which was actually described by a researcher named Dr. Headington in the early 1980's. Dr. Uebel and Limmer were the first to use these types of grafts. Many others have come along to make contributions in how we use these grafts. In this era of stereoscopic microscopes,we thus now have the follicular unit graft, which is the naturally occurring 1-3 hair (rarely 4 or 5) graft that exists on the human scalp and in transplanting is isolated by cutting all around it to keep it intact. It is then placed in a tiny needle hole/slit in the scalp. It should be pointed out that the term "minigraft" has now come to be described more in terms of the number of hairs in the graft, generally a graft of 4-6 hairs. If one uses no magnification or uses "loupes", then we usually describe these as being "cut-to-size minigrafts." If one uses the microscope to cut these grafts, as we have done for the last 7 years in our clinic, then these so-called "minigrafts" for the most part consist of small groups of intact follicular units that are adjacent to each other as either 2 FU's or perhaps even 3 FU's, depending on the size of the graft being made and the density of the patient's donor hair. In our clinic, in an extremely dense coarse donor area which has a lot of 4-5 hair FU's, we sometimes will actually carefully divide some of these into two smaller grafts, to avoid the detectability that can occur from that many hairs coming out of the same needle hole. Such a graft looks far more "pluggy" than a "paired FU graft" of two 2-hair FU's next to each other with a little intervening skin. Oftentimes, in patients who have a very small number of 1-hair FU's or in eyebrow work (in which 1-hair grafts are preferred) it is often necessary to again divide the FU carefully into separate 1-hair "micrografts" in order to have enough 1-hair grafts to place at the front of the front hairline, temple area, or eyebrow where they are needed for naturalness. I hope the above helps to clear up some of the confusion in the use of terminology in hair transplantation. Mike Beehner, M.D.

Dear RSaff, You certainly sound motivated to hang on to as much of your hair as possible (and hopefully stimulate some new growth). I would strongly urge using both products. The Rogaine mainly works to prevent hair loss, whereas the Finasteride does that, but can also result in significant increase of hair in the first few years of use. There has been proven to be a "synergistic" effect of the two. I have a feeling that you and I are probably thinking of two different areas when the word "temple area" is used. I use it to refer to the front side hair that comes down from the corner of the front hair line vertically. I think you are referring to deep recessions on either side of the frontal tuft of hair in the front center. Sometimes, if that area of recession is deep enough, the outline of a "forelock" project would help fill in some of the deepest aspect of those areas. Most of the time, the man in his 20's wants much more - namely, to look exactly like his peers who have no hair loss. Doing this in a man with early signs of possible later significant alopecia would be very risky and something you would deeply regret some years down the road. Mike Beehner, M.D.

I see quite a few young men in consultation like yourself who are devastated by these early signs of hair loss. Although I try not to have a rigid, "line-in-the-sand" minimum age for transplanting, I generally try to get any male at least to the age of 22 with Finasteride treatment, and even Rogaine % topically, if they are motivated enough and have enough extra money to cover the costs. I take good photos at each visit yearly, to follow the progress or, hopefully, retardation or reversal of the hair loss situation. Then, at 22 or 23, those who are still desperately unhappy with the thinning of their hair can have some conservative hair transplanting done. By slowing the hair loss down and letting the young man become a little older, the patient and the doctor both gain a lot. The passage of time makes the patient wiser and more realistic of what type of a transplant will eventually be done. I agree with Dr. Limmer that a "forelock" approach, which assumes the worst situation, is always the way to go in the male in his 20's who shows signs of significant "horseshoe" shaped baldness, which means they are almost certainly going to some day be a Norwood Class VI ("horseshoe baldness") or a Norwood Class VII (top of the side fringes located down the side of the head). A man who is 20 has a hard time realizing that he very likely has 50-70 years of living ahead of him, and, no matter how much we try to wish it wasn't true, male pattern baldness really is a progressive condition. A 20 year old has no idea how far the front temple hair, including the "sideburn" area, is going to recede back, or how far down the side of his head the fringe on the sides and in the back will drop. I find it useful with younger patients to hold out my two hands and say: "you have two piles here. One is the area of your head needing hair right now, and the other is the area with hair on it. As the balding one gets bigger, the other one unfortunately must always get smaller. If the one gets really big, the other will get really small. As the area needing hair gets larger, the very thing which you need - namely, "native" hairs in the donor area - are diminishing and unavailable for the task you want done. And such a situation down the road in life is the reason for the hair transplant surgeon to always be conservative and concentrate on "framing the face" with a natural looking forelock of hair, that has a "scatter zone" of fine follicular units off to the side (to help blur the space there). This will never look bad, and the wonderful thing about this strategy is that this simple framing of the face means that the patient will never really look bald, and there will not be a "ski hill" of bare skin going up from the forehead. Then, after 10-15 years passes, if the "worst case" scenario didn't prove out and the man actually keeps a lot more donor hair than was anticipated, then a little more aggressive approach can be taken and some more areas of the thinning scalp can be filled in. Mike Beehner, M.D.

Huron, I have heard of extremely rare cases of INCREASED hair loss as you reported, rather than gain, with Propecia, but have never seen myself in the years I have been prescribing it to several hundred different men. I did want to add one possible explanation for what occurred to you, to make sure you didn't overlook another cause: If by any chance you were using Rogaine for some time prior to starting Propecia, I have heard from others that the abrupt discontinuing of the Rogaine can cause a reactive "fallout" of some of the hair that had been preserved during the time Rogaine was used, even though they immediately started on Propecia. For that reason we usually urge any patient who has been taking Rogaine and wants to switch to Propecia, that they overlap the two drugs for at least two or three months to avoid this happening. Obviously, a man can continue the Rogaine AND add the Propecia to this, but I find only a few men motivated to do both of these things, which also adds up to quite a bit of expense. There is reportedly some slight synergistic effect by using both. I certainly do urge using both drugs in men who come to me in the 17-22 age group. Mike Beehner, M.D.

Dear MB, It is possible to harvest future donor hair and not cause further wide scars - because you are right in saying that the elasticity of the remaining donor area does decrease with increasing number of donor harvests, especially if they are done all over the place. There is one marvelous, magical quality of the scalp that can allow this to happen - and that is the ability of the scalp to regain the great majority of the previously existing elasticity and laxity - but you have to be very patient and not try and pressure your doctor into taking too wide of an area and doing it all at once. In most men who are in your situation, you can take a 6-8mm wide strip (give or take a mm or two) - and obviously depending on the characteristics of your individual scalp after exam by the doctor - you CAN get a very thin scar, and then the doctor can go back 8-10 months later and remove the same width again. Sometimes, as you correctly suggested, the best way to do this is to take these strips as short segments from two or three areas and avoid other areas (such as the rear corners, which notoriously are where wide scars most commonly occur). Again, rather than try to get the 1500, 2000, or whatever number of grafts you think you need to have transplanted for you to be "set for life" (there is no such reality in male pattern baldness, by the way), think of accomplishing it in small, safe steps rather than with one grand flourish, which is almost a guarantee for a wide scar and a worse situation than you have now. Also, the suggestion made by Gary is a very valuable one, namely that the good hair not be sought out to the exclusion of removing scar tissue, as this only accentuates the percentage of your donor scalp that is covered with scar tissue.Balancing the harvest to remove old scar tissue along with hairs to transplant is the best way to end up with an improved donor area. Good luck. Mike Beehner, M.D.

I conducted a small research study in Orlando at the Live Surgery Workshop last year in which I tested various "stresses" on individual two-hair follicular unit grafts. We tested 14 such FU's with each stress or a total of 28 hairs per. One of the stresses was to dunk the grafts for a total of 30 seconds in a small cup of 3% Hydrogen Peroxide (which is the "full" strength, or the stength of the product that is bought in a store), and the grafts grew poorly - only around 10-15% as I recall. Another study box was planted with 14 similar grafts that were dunked for 30 seconds in a 1% mixture (two parts saline to one part hydrogen peroxide) and these grafts grew fine, with about a 85-90% yield. This doesn't answer the question as to whether a mixture of equal parts peroxide and saline would be harmful or not harmful, but gives some perspective to the fact that peroxide can be used to keep the operating field (the recipient area) clean without harming the grafts in my opinion, as long as the concentration is kept low. Mike Beehner, M.D.

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. We cut all of our minigrafts under the stereo-microscope and try to never cut into an intact FU, but rather corral them 2 or 3 at a time into the minigraft tissue. Several prominent FU transplanters also do this, only they call these grafts "follicular families" instead of minigrafts. 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 going to receive the best result that the combination appraoch can achieve. He is better off with all FU's, especially since at a second session FU's are easier to place between the FU's growing from the first session. Again, I want to emphasize that this is the approach that myself and many others truly believes yields the overall best results in the majority of patients. Some patients are so obsessessed with an undetectable (the word "natural" is often used here) look, that they are willing to accept a "thinner", slightly more see-through look in exchange for never going through an early stage where there may be a hint of detectability with the minigrafts. I didn't even get into the "slits" vs. "holes" debate. I use slit minigrafts in most of my female patients in the middle areas, and in male patients in areas where there is reasonably good hair that I do not want to displace or damage. I would certainly grant that a small number of doctors, with highly trained and motivated staffs, and in patients with a high average number of hairs per FU, can achieve density equal to what I am describing above - namely a result that, when viewed from above, does not allow the observer to see the scalp at all. I am simply saying that, in my opinion, that is not the majority of patients, and most of the patients I have seen who had exclusive FU work look sparser than my typical results. When you put into the mix a doctor or chain of clinics that is not focused on quality and has a high staff turnover rate, then I believe the fragility of handling high numbers of FU's which are "dense packed" can be a nightmare and can yield poor growth due to the drying of grafts and trauma. It is no coincidence that the handful of doctors who do excellent all-FU work have staff assistants who have been with them for many years and are just as motivated toward great patient results as they are. Individual doctors are different in what they can artistically do best with hair, and individual patients are different in what they are seeking and in what they bring to the table in the way of donor hair, hair characteristics, and desires for a final result. The patients also differ widely on how they balance the scales of density vs. undetectability. It is the doctor's job to be sensitive to what that patient wants and deliver the type of transplant that best answers his needs. Mike Beehner, M.D. Saratoga Springs, N.Y.