Dr. Michael Beehner

This 43 year old female with thinning at the front hairline and receding temple areas came to us to have her hairline lowered and the temple areas built up. She had one session of 1726 FU grafts (comprising 3798 hairs). The "after" photos were taken one year later. Her FU's consisted of 20% 1- hair grafts, 50% 2-hair grafts, and 30% 3-hair grafts. She is quite happy with her current density and will return for further grafting if she thins further behind that area. Mike Beehner, M.D.

This 37 y/o gentleman came to our clinic in 1999, having had two scalp reduction procedures and a large single session with "slit" minigrafts, which were "pitted" in appeareance and directed in the wrong direction and angle. He underwent three procedures over a three year period of time with us, in which we placed 3362 grafts, composed of 2450 FU's and 922 DFU's, for a total of 9417 hairs. The obvious minigrafts were carefully trimmed down using the "Lucas Technique," whereby a portion of the hairs are cored off and then re-cut and put elsewhere. He came back to see us, now 14 years since his last procedure. We don't see as many of these old "pluggy" results now as we did in the earlier years, but our approach surgically is still the same. Mike Beehner, M.D.

This 53 year old male with light brown -mixed-with-gray colored hair presented for his first procedure 3 years ago. He has had 2 surgeries overall, and the photos were taken one year after his second one. In total he received 3538 grafts, of which 2806 were FU's and 732 were MFU grafts. A total of 9106 hairs were delivered in these two sessions and he plans to come for a third one which should give him maximal density. At each of his sessions the entire top of the head, including the vertex/crown in back, were filled in with grafts. His hair was very fine in diameter. Mike Beehner, M.D.

This transgender's scars were not that stark in appearance and the FU grafting in the area readily camouflaged them. In general, when a hair surgeon is transplanting in the hairline area with past scars, it is important to ease up a little on the density so each of the grafts gets adequate blood supply. These scars are full depth and create a barrier to the cross circulation which the scalp enjoys. Mike Beehner, M.D.

This 55 y/o trans-gender patient presented for hair transplantation in February of 2014 and had one session of 1617 FU grafts in the frontal region and temple areas on both sides. Her naturally occurring follicular "bundles" consisted of 15% 1-hair grafts, 70% 2-hair grafts, and 15% for 3-hair grafts. She had one additional "thickening" session a week after these photos were taken. Mike Beehner, M.D.

This patient, who is 69 presently, had his first HT of only 935 grafts (545 FU's and 390 MFU's totaling 3203 hairs) in 2001 at the age of 55. At that time, that was the average size of our sessions. 13 years later, in 2014, he had a second session of 1578 grafts (1258 FU's and 320 MFU's comprising 4687 hairs). The "after" photos here are taken a year later after that second session. He comes in now seeking a possible third session for his final density that he will hopefully be happy with the rest of his life. Mike Beehner, M.D.

This 43 y/o male had two sessions performed by myself. The first one, in August of 2013, was larger, with 1820 grafts and 5023 hairs being placed in the entire male pattern baldness area including the rear crown. 1330 were FU's and 490 were DFU grafts of 4-5 hairs each. In October of 2014 he had a smaller session of 1604 FU's, with the limited request by the patient that we only try and make the front half of this area denser. The "after" photographs were taken around 9 months after this second session. Mike Beehner, M.D.

Matt, I did say that the FUE growth percentage was 70.1% for the three patients, minus the "out-lier" who had very poor FUE growth. I agree with you that it would be nice if docs doing all-FU did a good study of how many can be found a year later, but they have not happened. I do think there are a few in the offing now and it will be very interesting to see what their percentages are. Mike Beehner, M.D.

Newbie, Thanks for posting your reactions to the study I did. I agree that it would be interesting to have a hair surgeon who primarily only does FUE now to conduct a study similar to mine. It would only have meaning if that physician was good at doing FUT hair transplantation prior to having switched to FUE. Otherwise the FUT results will be unnecessarily handicapped and low. I think the average of 86% for the four patients I chose was "in the ballpark" for what most studies have shown. One of the patients had a 95% FUT survival, but the oldest of the gentlemen had an atrophic, think scalp and only had a 76% survival, despite our carefully placing each graft. As I said, the sum average of all of the studies I could find 4 years ago was 89% and you have to remember that a lot of these studies were done in bare scalp areas with nothing else around them, only the study grafts in the middle of virgin scalp with virgin blood supply. The study boxes for these four men were surrounded by a large, dense number of FU and MFU grafts. Regarding whether we placed all the grafts in, the answer is that for the "capped" grafts, that is, those in which the top portion broke off and the bottom two-thirds was left in the scalp, no, we didn't plant that little piece of the top of the follicle. For grafts that were plucked out but were seen to have a transection of at least one of the follicles, we did plant all of them, but not in the study boxes. The patient received them elsewhere. I would estimate that either capping or mid-follicle transection with full removal of the graft occurred in somewhere around 5% of the attempts. Each patient is different and I'm sure the percentage of these occurrences was different for the four men. A lot of hair surgeons and clinics glibly tell their patients that 95% or 100% of the follicles survive, but I can assure you they are saying this based on optimistically "eye-balling" their results and not from having done any careful studies on their own patients. Mike Beehner, M.D.

Just to set the record straight, I thought I would summarize the findings of my 3-year, 4-patient study of 1780 follicles, comparing the approximately 1 year survival of FUE and FUT/microscope dissected grafts. I used the Safe-II system with the dull-edge punch for harvesting the FUE's. I looked at 1-hair, 2-hair, and 3-hair FU's, and these three different sizes all did about the same, with the 3-hair ones slightly ahead of the other two, but not statistically significant. We placed the grafts carefully into sagittal slits of 0.8, 1.0, and 1.1mm in length respectively for the three different sized grafts. One of the four patients was what I would call an "out-lier," in that his FUE survival was far worse than the other three. Only 33.6% of his follicles grew hairs. He did, however, have respectable FUT growth at 83%, so it's not clear if the occasional (perhaps 1 in 10 or 20) patient has a result like this with FUE, or whether this is truly rare and shouldn't be counted in my study. I will below list how the two different kinds of grafts did in each of the four patients. I will then summarize the final survival rate of "findable" hairs at 11-14 months for all four patients taken together and then for only the three patients, minus the out-lier. FUE FUT Difference Patient #1 74/220 (33.6%) 183/220 (83%) 49.4 % Patient #2 163/220 (74.1%) 192/220 (87.3%) 13.2 % Patient #3 187/250 (74.8%) 238/250 (95.2%) 20.4 % Patient #4 123/200 (61.5%) 152/200 (76%) 14.5% All patients combined: FUE......547/890 (61.4%) FUT......765/890 (86%) Three patients (minus the "out-lier") FUE.......473/670 (70.1%) FUT.......582/670 (86.9%) Are these percentages applicable to everyone who does FUE? I don't know. I would assume that those who do FUE all the time may have better numbers. I am also quite sure that the newcomer to FUE, especially the physician who delegates most of the tasks to staff, do much, much worse. This is only the beginning of our effort to find out the real difference. I had performed around 105 FUE cases prior to my doing this study, so I'm certainly in the middle group of reasonably skilled FUE surgeons. Additional studies are under way and it will be interesting to see how they all turn out. As a guidepost to use in judging the above, a few years ago I did a "meta-analysis" of every study done up to that date of FU survival (these were all done from a strip and microscopic dissection) and the 29 studies I looked over averaged 89.4% survival of FU's; that is, one year later, this was the percentage of terminal hairs that could be seen relative to the number of follicles planted. The big difference between FUE and FUT grafts is that FUE grafts have to be "plucked" free from their bottom-most attachment, and this action very often results in most of the protective fatty tissue being stripped off of the graft, thus leaving it more susceptible to drying and to trauma in handling during the placement phase. Another important point is that my study and others only start out with the grafts that make it to the starting line. In FUE, especially with sharp-edged punches, there are a fair number of follicles that are transected as they veer away from each other beneath the skin. Often the follicles are like seaweed, and a straight, cutting surface will cut across many of the follicles. Some defend this by saying that the transected hairs will grow anyway, but one recent reference I read stated that only 60% of transected FUE follicles resulted in a visible hair later on. My personal opinion is that harvesting with a strip method and then cutting the grafts perfectly under the view of a microscope remains the "gold standard" for hair transplantation. That being said, I think there are many instances, certainly in my practice, where it is imperative that every hair surgeon should know how to harvest grafts well using FUE. There is a long learning curve to becoming proficient at FUE. Also, with each patient the first 20 to 30 grafts are a process of "getting to know" that person's unique hair and follicle structure, as they are all different regarding angle, how deep to drill with the punch, how large a punch to use, etc. etc. Michael Beehner, M.D. Saratoga Springs, New York

He had his large graft work done 15 years prior to now. He also developed a 1 1/2 inch wide "halo" around the grafts that were placed in the rear crown. Mike Beehner, M.D.

This 51 year old male, who had received a front-central area of large plugs and wished to have this area made to look more natural had three sessions with FU grafts and some Lucas "cut-outs" to accomplish the transformation you see in the attached photos. Mike Beehner, M.D.

This 38 y/o male presented to us having had extensive large graft transplanting many years ago and wanted the hairline and the crown to be made "softer" and more natural in appearance. The photos here show how the Lucas Technique, first popularized by Dr. Manfred Lucas of Germany as a way to "pare down" the tree-trunk appearance of large grafts and leave some behind at the same time. The follicles removed are then cut up into smaller grafts and re-planted. This gentleman had two sessions with us over 3 years and received a total of 2210 grafts, m,ade up of 1864 FU's and 346 MFU grafts, for a total of 4993 hairs. We utilized 130 "cut-outs" of various sizes in order to accomplish this change in his appearance. The rear crown was "softened" with the harshness of the large grafts removed and the front hairline was softened and the solidity of the plug-wall was broken down to appear more natural. Mike Beehner, M.D.

This 40 year old male had a single session performed one year ago. He had a very dense donor area with 124 FU's per square centimeter. The plan is for him to have one more session to be finished. The side temples were done also with 150 FU's being placed in each one. His entire frontal and midscalp areas were filled in, excluding the lower vertex way in the back, which he can have filled in later if he wishes. 270 MFU grafts (ave. 5 hairs per) placed in 1.3mm round holes were used in the frontal core area, and an additional 230 MFU grafts in the form of "slit grafts" (ave. 4.5 hairs per) were placed throughout his central area where he has some existing native hairs. Mike Beehner, M.D.

Scandinavian, I would say that having a one or two week period after surgery during which you don't wear the hairpiece at all is necessary. After that, as I said, it's more a matter of just trying to have it off your head any time periods that you can do so, such as after you get home from work, while sleeping, or times you can be out and around with a baseball cap on. It's actually the rare patient of mine who elects to just throw away the hairpiece after the first surgery. We realize you have to live in the real world and not shock those around you. I will add one thing though: Many of my hairpiece patients over the years told me that no one knows they have a hair piece, and then, after the transplanted hair grew in and they did finally get rid of the piece, many of them would say that friends and relatives confided to the patient that they knew all along. Mike Beehner, M.D.

Regarding the issue of wearing hats, I have never found any problem with that, whether it is a baseball cap or a ski cap ("beanie") in the winter, they are fine. The only problem issues in my experience are hairpieces and tight fitting helmets. After one week we let patients resume using a helmet, such as a construction worker who works in a "hard hat" zone. Also, regarding the two-way tape, I advise the patient to cut it down the middle and make the width of the tape very narrow, and just put enough at the far front aspect of the hairpiece to hold it in place. Usually the hairpiece goes down further than the line I will transplant at, so there is some room beyond where the transplanted grafts are, so that the tape doesn't pull them out. Mike Beehner, M.D.

Around 15 years ago I was talking with a couple of veteran hair surgeons about this issue of what to do with the hairpiece patient who has a hair transplant procedure. I had a few of these patients who went to wearing the piece a couple of days after the transplants who had poor growth later on, and they stated they had also seen this happen and had changed their policy to having the patient not wear the hairpiece the first week after surgery, and then switching the hairpiece to a clip attachment method with the two way tape in front. I have followed this policy during the past 15 years or so and have had pretty good results with hair growth in these patients. However, I have noticed that 5-10% of these men did have what seemed to me somewhat less-than-ideal growth. I always am grateful when hairpiece patients say they will throw the piece away after their first procedure, but these are in the minority. Most have to get back to work and don't want that drastic of a change in their appearance. Some patients don't shed the hairpiece until after two or even three transplants. One more thing: the positioning of the clips on the hairpiece have to be changed every 2-3 months so that the clips aren't pulling on the same small group of hairs, which can cause a small bald circle. I also advise these men to take their hairpiece off as soon as they get home from work or other social engagements and only wear it when you absolutely have to. There has been much talked about over the years as to the cause of the poor growth that sometimes happens for hairpiece wearers. My own best guess is that the "shuffling" of the piece on the grafts somehow interferes with the grafts becoming rooted and supplied by nutrients in the vascular system of the scalp. Others have wondered if bacteria under the piece or the increased warmth of this area could be causative agents. Mike Beehner, M.D.

Sorry about the confusion. He was 45 when he had his first transplant and is 56 now. He does color his hair, which makes him look a little younger. Mike Beehner, M.D,

This then 45 year old male came to us in 2004 for his first procedure of 1363 grafts using a "combination" approach of mostly FU's supplemented by DFU grafts in the front-central area. He had subsequent procedures of similar size in 2006 and 2011. He came by the other day and the "after" photos shown here were taken then. In total he has received 4208 grafts, comprised of 10,495 hairs. He had 3645 FU grafts and 628 DFU grafts. He received a light covering of natural looking FU grafts in his small crown area in back. Mike Beehner, M.D.

This patient was "all-FU" planted at medium to high density. As I said, he had no miniaturization at all in the rear 2/3rd of his scalp and none of his male relatives were completely bald. When I see clear signs (ie: miniaturization on high-power examination), then I back off and do usually go to a "combination" approach with mostly FU's, but some DFU grafts in the front central for density. We shave nothing except the exact narrow, horizontal area where the strip will come from. If the physician and the patient are not too greedy for too many grafts, you get wonderful scars that are hard to detect, and the grafts are coming from the central, absolutely best area of the donor hair, whereas with FUE often you see high and low areas being harvested. The future of those hairs can sometimes be limited as they age and bald further. Mike Beehner, M.D.

His grafts were all from a strip. His result, even from close-up, appeared dense similar to the hair of a man who hasn't lost any hair. As you probably know, we only have to re-create half of the original density in order for it to appear the same as full density. For example, if a balding man originally had 90 follicular bundles per square centimeter, and now is totally bald some years later, if we can transplant 45 FU's per cm2, we can duplicate the same look. Mike Beehner, M.D.

In answer to the two questions posed above as to whether or not we could have done the 3000 grafts in one session, there definitely was a strategy involved. First of all, for men with only receding in the lateral fronto-temporal areas, we do like to use the relative "dense packing" of FU grafts as our grafting method. Because of his age, we were fairly sure this receding would progress during the next 10-20 years further back. On 30x magnification, he did not show miniaturization in the back half of his head, so I feel fairly confident he will not bald in this area for some time, if ever. We did not want to "shock" the hair he had in his frontal tuft of existing hair. We placed the grafts during his first visit at around 35-40 FU/cm2, which is a comfortable density for our team, with large enough slit recipient sites that we can safely get them in without worrying about trauma to the grafts due to sites that are "too tight." And the last reason, and perhaps the most important, is that I have great respect for the blood supply of the scalp, and I like to not overwhelm it with super density. I feel this way I get a higher yield of survival to my grafts. Regardless of how dense a first session is, if you polled such patients, you would find that the vast majority of them choose to come back for a second "fill in" session anyway. Taking two sessions also allows the hair surgeon more chance to be artistic and "paint" a final picture that is more in harmony with a natural look. I will attach two photos of how he looked after only the one session of 1500+ grafts, which I thought was fairly decent. But he wanted it thicker. Many of my patients would have stopped with the result we obtained after that first one. Mike Beehner, M.D.

This 23 y/o came to us first in 2013 and had an initial session of 1559 FU's placed in the far frontal area only, for a total of 3118 hairs at the time. His results after that first session were posted here in June of 2014. In July of 2014 he had a second session to increase the density even more. 1537 additional FU's were placed amongst the first grafts, and those photos are shown here 12 months later. Mike Beehner, M.D.

This 59 year old male with a Norwood V current pattern of hair loss had his first H.T. with us in April of 2013 (1809 grafts consisting of 1329 FU's and 480 DFU's) and a second H.T. in March of last year of 1552 FU grafts. One year later he presented for an evaluation and I took the attached "after" photos. He received a total of 9086 hairs in the two sessions. Mike Beehner, M.D.

This 62 y/o male presented seeking coverage of the entire top of his large balding area. He received a total of 2344 grafts, which were comprised of 1643 FU',, 453 DFU grafts (1.3mm diameter holes), and 110 DFU's (1.9mm slits) for a total of 7344 hairs. The "after" photos were taken one year later when he had a second session nearly as large as his first. Mike Beehner, M.D.