Dr. Michael Beehner

I think each hair surgeon has an unofficial "cut-off" age line that he or she is comfortable with. For me it is 23. However, if the front-central framing of the face is disappearing in a 21 or 22 y/o fellow, I will consider placing some FU grafts in the front half of a forelock-type pattern so that his face is somewhat framed. In doing so, I am not cutting across the temples trying to connect to anything on either side. If there are danger signals that a young man could go on to a Norwood VII (fringes down the sides of the head), then I will only do an oval or "shield" shaped forelock pattern, which mimics a normal stage of hair loss that a lot of men naturally pass through. Those signals could include male relatives with Class VII baldness, "whisker hair" above the ears (curly hairs), indistinct fringe with miniaturization in the upper fringe. I stay out of the crown/vertex and the side temples area (just above the sideburns) in men under 35, because filling in these areas in a young man could backfire with a very freakish look later in life that the patient would regret. I certainly agree with the strategy of getting the very young men on both minoxidil and finasteride and have had a lot of very nice results with this regimen. However, if a 23 or 24 year old young man is clearly starting to bald and wants help, I think that, as long as his expectations and general psychological state are reasonable and normal, we should try and help them. But the plan has to be conservative and take into consideration the "worst-case-scenario" for that young man. Mike Beehner, M.D.

Reply to "Since21" The graft count mainly had to do with the fact that, when you use MFU grafts in that front-central area, you don't need as many grafts in that region due to the necessary spacing these grafts should have. It also has to do with the real world of what an individual patient can afford. I offered him the option of 2000 FU grafts dense-packed in the same area, but he chose the other "combination" approach. The number of grafts he had costs $4700 and does a nice job of covering and blocking light from hitting the scalp in the viewer's eye. The 2000 FU's would have cost $8900. It doesn't mean that one is better than the other either. I don't use the combination approach unless the patient makes it clear to me that they will come for a second session in order to fill in the gaps. I should add that the majority of the "all-FU" patients return for a second session to achieve the density they would be happy with the reset of their lives. In around 30% of patients we "hit a home run" and accomplish everything in one session, but these patients are usually those with coarse hair and lots of 2-hair and 3-hair FU's percentage-wise. This patient had relatively fine hair. Mike Beehner, M.D.

This 47 y/o male presented to us around a year ago and wanted the frontal shelf (front 40% of the scalp) filled in to help frame his face. He underwent a first session of 1053 grafts, consisting of 753 FU's and 300 DFU's (double follicular unit grafts of 4-5 hairs each). The "after" photos are from one year after the surgery. He had a second session that day of similar size to add to the density. He was initially biopsied, to make sure that the hair loss process was typical hereditary androgenetic alopecia, and not from an autoimmune cause such as alopecia areata or lichen planopilaris. The biopsy confirmed that it was ordinary hereditary male pattern baldness and so we proceeded. This is an example of how blending different size grafts can enable the hair surgeon to make a big difference without having the patient spend a lot of money. The attribute I like the most about using MFU grafts is that they block light better than scattered FU grafts used exclusively. Mike Beehner, M.D.

I probably should have made it clearer that around 2000 of those grafts were placed in the large frontal and anterior midscalp region. He did have more grafts placed at the hairline and temples than I usually do, but that was because the patient was very persistent in wanting those areas as absolutely dense as I could make it. We fill in these areas usually quite nicely with two sessions these days. Mike Beehner, M.D.

This 55 y/o male-to-female trans-gender patient presented to me for her first hair transplant surgical procedure in July of 2012. In December of 2010 she had a scalp advancement and other facial surgery performed in South America. She wears a wig presently, as she didn't think the result from that surgery left her looking natural. The left side of her hairline was much lower than the right side. She also had scant hair in the two temple areas, especially on the right side. A feminine hairline was drawn, as seen in one of the photos. She was also somewhat thin all over the top of her head, so part of the goal was to make this area dense and also the rear vertex/crown. In total, 2076 grafts were placed, equal to 5394 hairs. 350 FU's were placed in the right temple zone, 290 on the left temple. 400 FU in the crown and 600 along the front hairline. 414 "slit MFU grafts" were placed in sagittal slits throughout the midscalp region and into the frontal region. The "after" photos shown here are one year after her procedure with us. She will soon be coming in for her second procedure, in which we hope to place around 2500 FU grafts. Mike Beehner, M.D.

This 50 y/o male first presented to my clinic 12 years ago. He was in for a "touch-up" session recently. He had two surgeries of 1175 and 1048 grafts respectively prior to the 8 year photos shown. At the 8 year point he underwent a procedure of 1043 FU's. A third set of photos, which were taken at the 12 year point in time are shown for each view. In total, he received 3316 grafts, of which 2609 were FU's and 657 were MFU grafts of 4-6 hairs each. So, for each of five views, a "before-surgery" photo, an 8 year photo, and a 12 year photo are shown. He is now 62 years old. Almost all of the grafts were placed in the front two-thirds of the scalp. In the course of the surgery he had, we did manage to place a couple of hundred FU's in a sworl into the crown to give it a lightly scattered, natural look that wasn't shiny bald. This area was not a big priority for the patient. Mike Beehner, M.D.

In my opinion, beard and/or chest hair should be the last resort in looking for donor hair. The only time beard hair might be a first choice would be in the instance of transplanting a mustache in someone missing an area from burns or heredity. Scalp hair, however you can get it, is always the first choice for transplanting the scalp, simply because its texture, diameter, curl, etc are all exactly the same as what was there before. We have done over 30 cases of harvesting beard or chest hair (in 6 cases we harvested both). Beard hair has the advantage of growing fairly long with a longer anagen (growth) phase. Chest hair only grows to around 1 1/2-2 inches at most in length. Neither one can be used at the hairline or at the rear border, as they are likely to "stick out" like a "pig in the poke." They should only be placed centrally for "fill," The beard is the best non-scalp place to obtain donor hair, but in the typical man who shaves every day, there is a limited area for harvesting confined to the underside of his chin and upper neck. I find that the scars are fairly undetectable. There was one case in which there was a slight depression to the sites and I performed a small dermabrasiion procedure which made this difference disappear. One of the advantages of having FUE available as a tool is that we can harvest some grafts down low and high in the donor area which a strip couldn't reach before without a visible scar being seen. Mike Beehner, M.D.

Thanks for the kind comments. In answer to the person who asked how many grafts his most recent session was, it was a small 600 FU case using FUE, which I placed "into the cracks" in the front two inches of the frontal scalp for additional density. The hairline already had a "soft" look, and I feel it can hurt the final result to keep going into this edge area, as you then run the risk of making it a "hard" edge, which looks unnatural. The other question was regarding the patient's donor reserves. He has tons of donor hair and his scalp is very loose. In fact his scalp is slightly hyperelastic, which caused a 4mm wide scar in back, which I excised at the last session. His hyperelastic scalp was the reason I chose FUE for this most recent session, to avoid any risk of his ending up with a wide scar. Mike Beehner, M.D.

This 30 y/o first came to us in 2008 and since then has had four separate procedures totaling 5790 FU's in the temple and hairline area. Some of these were placed within the frontal region also, which showed signs of thinning with miniaturization. Likewise, a small portion of the grafts were also placed in a small thinning area of the crown in back. Tiny 0.7 and 0.8 mm custom cut slit blades were used to make the recipient sites at the edge and 1mm sites were used for the 2-hair and 3-hair FU's behind this outer zone. Mike Beehner, M.D.

This 52 y/o male presented six years ago with a Norwood VII level of hair loss. A large frontal-midscalp forelock pattern was used over three moderately large sessions of 1550 grafts each time. He also came two other times for small "touch-up" sessions to place more grafts toward the back of the midscalp for fullness - all totaling 6700 grafts, with 900 of them being MFU grafts (4-6 hairs) and the rest FU grafts. The important points concerning the forelock pattern are these: a) The rear vertex/crown is pretty much left alone. There just isn't enough donor hair to make a difference back there b) The face is framed strongly with hair, especially the front-center portion c) A "mirror image" is created at the side, in which the forelock brushes up against the "hump" of the side fringe, even if that has to be transplanted to effect this appearance. This can be seen on the side photos I have here. I believe I presented him a few years ago after he had two sessions. The "after" photos now show the mature, final result I was able to achieve. d) In doing the above, a "triangle" space is left on each rear side, which I call the posterior parietal triangles. This area is transplanted with FU grafts somewhat sparsely in comparison with the rest of the forelock body. Mike Beehner, M.D.

As I have said many times in the past, for Norwood VII patients with their side fringes down the side of the head, I use what I term a "forelock pattern" approach. This basically has two principal features: One, the main area of relative hair density is created in the front-central aspect of the man's scalp. And second, the vertex/crown area way in back is pretty much left alone. In other words, you try to make a difference in the most important area of the head which frames the face, and, due to the very limited donor resources and the vast area that needs filling in, you prioritize and hopefully the patient in the consultation sees the wisdom of that approach and you end up with a very happy patient who otherwise would face being very, very bald the rest of his life. It is also possible to look for warning signs in young men in their 20's who you can predict have a strong chance of going on to a Norwood VII pattern later in life. In such young men, I use a forelock template when getting them started with hair transplantation. I have attached two examples of mature aged men with Norwood VII balding patterns. The one gentleman, whom is viewed from the right oblique angle, he had only one session of 1500 grafts, and was actually having his final, second session the day the "after" photo was taken. The other fellow, who is viewed from the left side, had two sessions of around 1600 FU's each time. His drawn pattern is shown also, which shows the pear-shaped area in the front-central region which was transplanted with more density and using more 2-hair and 3-hair FU's in this region. The drawn pattern from the side view shows the use of "filling in the humps" on the side, so that there is a meeting of low density FU's near the crease on top, thus creating a "mirror image" effect. Mike Beehner, M.D.

If you are now witnessing progressive hair loss at the very young age of 22, this most certainly means that you are headed for an extensive balding pattern, a Norwood VI for certain, and possibly a Norwood VII. I agree that, if you have some native hair on top and hopefully aren't shiny bald already, it would be a good idea to use topical Minoxidil 5% every night and get on finasteride oral medication. You will still eventually realize your hereditary destiny, but, for many young men, these medications help you hold on to a lot of your present hair and even additionally thicken it during these socially important years (dating, school. career, self-image, etc). The other important point is that you shouldn't rush out and get a hair transplant. If you ended up in the wrong hands and someone simply "sprayed" grafts all over the huge area that will someday become bald, it will look like nothing was done and you will not look natural later on. Assuming your donor hair is decent, most reputable hair surgeons today in 1-4 years would consider doing a "forelock" type of pattern which can frame your face and give the natural illusion of a man with hair on his head. The rear crown almost certainly will have to be let go to baldness, but with various styling patterns and a judicious use of the donor hair you have a few years from now, you still have the hope of framing your face with hair. A forelock pattern uses "gradients" of density, with the front-center portion being the densest, and the density then trailing off to the back and to the sides to mimic a natural stage many men go through in losing their hair. Thus it will never draw attention by others as looking unnatural, no matter how bald you become. The other very good choice, especially if you have the right shape of head, is to just shave your hair and keep that look for the rest of your lives. My bias is always more toward strip harvesting rather than FUE, but I do have to point out that I think the strip would work best for you, since the strip would give you the very best grafts in the center height of the hair you will have for life. If you spread FUE over a large area, it is very possible that a lot of those hairs will have been harvested from the lower and higher areas that will eventually thin or turn bald, and your grafted hairs will "turn into a pumpkin" and will be lost. In summery, get on meds now, consider in a couple of years a consultation with an experienced hair surgeon concerning a forelock type procedure, and also consider the alternatives of going bald (shaved), or even obtaining a non-surgical hairpiece. Best wishes. Mike Beehner, M.D.

In answer to the one reader's question, this patient's 3rd session would consist of around 1600 FU grafts, for an additional 3500 hairs, which would bring him up to around 10,700 hairs or 3850 grafts. The DFU grafts (some are TFU's) arecut from a slightly wider "sliver" which is 2 fu's wide rather than the traditional 1-FU wide width of the usual sliver. This sliver is then turned on it's side and the groupings of 2 adjacent FU's are then dissected out under the microscope. Mike Beehner, M.D.

This 55 y/o male presented two years ago for his first of two transplant procedures. Because he was an advanced Norwood VI/VII pattern and his donor density was relatively sparse, I elected to use a "shield" frontal forelock pattern, which emphasizes front-central density and a gradient of decreasing density away from the stronger forelock area. He is returning for one final session to increase density and the coverage toward the back a little bit. The "after" photos shown here are only 9 months after his 2nd procedure, so there would still be another 20% or so of "hair mass" increase that should occur in the next 4-8 months. Overall, he had 2858 grafts, with 2244 of them FU's and 614 DFU's (4-6 hairs each), for a total of 7181 hairs received. Mike Beehner, M.D.

One of the commentators above asked about the number of procedures used to transplant eyebrows, and also concerning whether these hairs remain short after they are transplanted. The number of procedures needed varies, mostly related to how much "native" eyebrow hair is present at the start. Many of those who only have "thinning" of their eyebrows, not almost total absence of hair like this gentleman has, do fine with one procedure. 90% of the patients in my practice with minimal hair there to start with, they come for two sessions, usually at least 10 months apart. Around 10% come back for a final "touch-up" procedure for maximal density, as this fellow elected to do. I believe strongly that you are doing the patient a dis-service if you somehow are able to make 300+ sites on each eyebrow. I don't think it's possible to have each of their paths pass through their path alone and not cut across those that have already been made. I would ask anyone doubting this to draw on paper the contour of an eyebrow square area; then take the finest point pencil you can find and try to make 300 dots within that square area. Regarding the question about final length of hair, the answer is simply that the hair will grow as it did in it's original donor site. My patients tell me that they trim the eyebrow hairs on average about every two weeks. They are basically "sculpting" the contours and shape of the eyebrows, and most get very good at it after a few months. Mike Beehner, M.D.

Thanks for the comments. Regarding the one question about where I obtained the donor hair, I always take the hair from the mid-occiput (back) of the head. My reasons are these: Most importantly, for most men these are the last hairs that will turn gray/white and will retain their dark color, which I feel is important for eyebrow hairs, so that they contrast against the light-colored skin of the face. I know that a man can color his brow hairs, but that is a pain int he neck, and I feel it is to his advantage if I can deliver dark hairs there. Secondly, those hairs have the largest diameter and thus will deliver more "hair mass" to the area. This is particularly important since I am using all 1-hair grafts. I feel that hairs obtained from the legs, arms, etc are too "wispy" and don't show up well. Also, they have very short anagen (growth) phases and long telogen (rest) phases, so they are only part-time workers. A third reason is that I feel I can deliver an undetectable scar best in the rear occiput area. Mike Beehner, M.D.

Regarding the blood supply to the scalp, we know a couple of things: One, there is a limit to how much injury you can do to the scalp before bad things happen. Most hair surgeons have seen or heard of cases of localized scalp necrosis . This is basically a "black hole", or more accurately, a black scar. Scalp necrosis is like a full-thickness burn, in that the damage if "full thickness" and cannot heal "from the bottom up,"but rather has to heal from the edge inward, for which there is only a limited distance this can cover. Some of these patients require skin grafts to get skin coverage. That's one extreme. On the other hand we know that the blood supply of the scalp is awfully good. There are ten separate arteries that supply arterial, oxygenized blood to the scalp and they cross-circulate or collateralize - the two most important ones being the paired occipital arteries in the back and the superficial temporal arteries just in front of and above the ear in the temple area. These latter two are the most important ones. Obviously, the blood supply is totally "virgin" at the time of the first transplant, which means a doctor would have to really brutalize the scalp to have necrosis following that first surgery. Most hair surgeons accept the fact that some degree of "micro-scarring" occurs following any surgery. Also, in taking a donor strip, a surgeon could transect one or more of these arteries. When enough time, usually several months or more, elapses, the body has the ability for the arterial supply of an area to develop a tremendous increase in "collateral" circulation, which means that other small vessels enlarge and increase their flow to an area that was partly damaged. On a microscopic scale, this happens in the scalp. As an arbitrary figure, 12 months is the interval most of us like to have as a minimum between transplant sessions. Doing things such as not cutting arteries, using "depth control" in making the sites, and avoiding excessive use of adrenaline in the injected solutions all help protect the scalp's circulation. The main network of small arteries resides deep in the subcutaneous layer (fatty layer) of the scalp where the lower part of the follicles are. Limiting the depth of the sites to 4-5mm usually avoids hitting these small arteries and arterioles. In the old days before 1990 or so, it was common to do sessions of 60-100 large grafts 4-5 months apart, even as few as 3 months apart. This was partly due to the fact, as you suggested, that the sessions were very small with regards to the square area the grafts covered. Whatever injury occurred was confined to a relatively small area. If a second follow-up surgery is done in a totally different area, such as the rear crown when the first session was in the frontal area, one certainly could make an argument for being able to safely do that second surgery at 5-6 months, which I have done on rare occasions. I think we are all trying to follow the "better safe than sorry" rule of thumb, and we all live in dread of ever having a patient of ours develop a necrosis area in the scalp.Respecting the scalp's circulation also helps avoid poor growth of the grafts planted. Mike Beehner, M.D.

I agree with the comments made above. Like Dr. Lindsay, we also encourage patients to put 12 months between sessions. I also make one or two exceptions with shorter intervals, usually for the same reason - namely, that someone is returning to their native country and won't be able to get back to see me a year from then. Two other reasons that weren't mentioned are that waiting the year is necessary for the blood supply (vascularity) of the scalp to return to normal to support the new grafts and to be able to respond to the new added injury that all these recipient sites bring about. The second additional reason is to make sure almost everything is growing, so that we don't trample on a graft that has already been placed. There are good studies showing that the diameter of the new hairs increase over the first 15-18 months. I also, as the commentator before me above said, encourage the men and women we transplant to wait till 18 months to make a decision as to whether or not they think they need another procedure. This applies to those patients who are trying to accomplish their hair replacement in the fewest number of sessions. Twelve months is too early to judge the final results. A fifth reason for the one year wait, and a selfish one on my part, is that I am much more likely to get some "wow" pictures if I see the patient then, rather than at 9-10 months. Mike Beehner, M.D.

This 50 y/o male had gradual diminishment of his eyebrow hairs over many years down to only a few remaining ones. He had his first eyebrow hair transplantation procedure in May of 2012, with 255 1-hair grafts being placed in each eyebrow. He returned one year later and had 205 placed in each eyebrow again, for a total of 460 per side. He returned today and we touched things up with 55 on each side to finish him up. He obviously wanted a "bushy" type of eyebrow and the outline shown in one of the photos was the one we agreed upon before starting his first procedure. He is very happy with the result so far. I feel I can do the best job and be the most artistic by using all 1-hair grafts. Obviously, some of these have to be obtained by cutting some 2-hair FU's into two hairs. What takes the most time in placing these grafts is getting the rotation correct so that the curve of the hair "flows" with the contour of the eyebrow and doesn't curve away from the skin. We use mostly 22g needle holes to make the sites. Mike Beehner, M.D.

Thanks for the kind comments. Regarding the question of the patient having other cosmetic surgery - yes, he had a little tightening up of the face without excision of tissue and also a blepharoplasty to remove some redundant tissue around the eyes. Regarding how I performed what I would term "dense packing" along with DFU's, the DFU grafts (4-5 hairs each) were placed in 16g needle sagital slits in the front-center area, well behind the front hairline zone. The hairline, except for the "feathered" soft edge was transplanted at around 40-45 FU's per cm2. The grafts were slightly larger than in a typical case because of the presence of quite a few gray hairs along with the brown ones. This particular gentleman's wife died and he was starting to date again and wanted to look as young as he could. I was perfectly willing to be aggressive for his sake in restoring the temples forward and lowering the hairline. I certainly would not do this in a 29 year old. Thanks again for the supportive comments and stimulating questions. Mike Beehner, M.D. Saratoga Springs, NY

This 71 y/o male wanted his temples filled in and brought forward, and also wanted his front hairline lowered. On his first session we performed 192 DFU's centrally and 1464 FU's dense-packed. On his second session a year later, he received 1331 FU's. He had a total of 2987 grafts (6540 hairs/follicles). The photos are lined up with the "before" photo, one with the plan drawn, and then the "after" photo a year later after his second procedure. Mike Beehner, M.D.

I reply to Spanker's question as to whether some of the procedures this trans-gender patient had have an affect on the scalp's circulation for the rest of her life or not, I think the rhinoplasty probably did not. The others - the scalp advancement, the face lift, and the bone re-shaping of the forehead - these all involve cuts (some of them full depth all the way down to the peri-osteum which is the lining over the skull bone itself. Certainly the circulation tries to heal to bridge where that cut and subsequent scar tissue is, but I don't believe it is ever quite the same. As a result, one has to, as I said, "ease up" a little on planting density, because there might not be the usual cross-circulation of blood coming in from the rear as there is with other hairline area surgery. We certainly are saved many times by the scalp's generous blood supply and 10 arteries feeding it, but the great majority of the scalp's blood supply comes from the paired occipital arteries in back and the two superficial temporal arteries near the temple (the pulse you feel when you put your finger on your upper sideburn area. Mike Beehner, M.D.

In reply to Mickey85's comment on the density of planting, I just wanted to emphasize again that this patient had a lot of bone shaping of the forehead, a hairline advancement, which involves a full-depth cut through the forehead skin and fascia, and also a face lift, and a rhinoplasty - all done in a foreign country at once a few months earlier. The blood supply in that area after all of that surgery dictates that the surgeon "ease up" on the density of planting so that 90%+ growth is realized. The second session, which is coming up, will hopefully fill the gaps enough that it looks "full". Thank you for the other comments. Mike Beehner, M.D.

This 41 y/o male-to-female transgender patient presented for a first HT session in February of this year. The "after" photos were taken only 8 months after the first surgery, so we expect some more density in the coming months. She is coming back for a final, second procedure to "fill in the cracks" and reach the density she would be happy with for the rest of her life. 1661 FU's were placed, with a large number of them going into the temple areas on each side. Her FU grafts consisted of 30% 1's, 50% 2's, and 20% 3-hair grafts. Note that there is residual scarring from a face lift, bone contouring of the forehead, and a scalp advancement surgery, which we tried to hide with our grafts. These scars also dictate that maximal planting density of grafts is not done. Two of the "before" photos featured below are after her facial surgery to tighten things up. The photo at the bottom right is a "before" photo but after her facial surgery. Just wanted to show what that procedure achieved prior to our transplanting. Mike Beehner, M.D.

In reply to Magnum's question about whether or not finasteride gives lasting insurance against hair loss, I can definitely assert that it does not halt the balding process. One lecture I heard a few years ago by an expert in this area stated that a majority of men taking the drug have an increase in "hair mass" for 4 1/2- 5 years, and then thereafter there is a gradual diminishment in hair mass. Hair mass is determined by a combination of both hair diameter and hair length. Obviously, if one's barber cuts it short, then increased diameter is the only way hair mass will increase. A man is still ahead of the game by staying on the medication, even after 5 years, because the rate of hair loss is still less than if one went off the drug. Mike Beehner, M.D.