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Dr. Michael Beehner

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  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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
  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
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