Dr. Michael Beehner

Your question is one that hair surgeons wrestle with constantly and are always trying to figure out in their daily practices. We have several things that help us an awful lot though. Most important is the patient's age. If the patient is in his late teens, twenties, or even early thirties, then all bets are off and a surgeon could be very wrong in telling the patient he will never bald. And the absence of miniaturization in the younger ages, though a little reassuring, is no guarantee that they won't bald some day. I agree that the family history is helpful to know, but no guarantee either way. Exceptions are very common. I agree with one of the notes above that looking over the various areas of the scalp with high magnification (30-60x power) for miniaturization is very valuable. I feel it gives me a peek at perhaps the next 15-20 years of the patient's life. So if I have a 45 or 50 year old man in front of me, I usually will tell him that it's highly unlikely that he will lose his hair on top if I see no miniaturization. If a hair surgeon sees more than 5% miniaturization in an area, then that usually means that eventually they will go on to thin in that area over the years, and, if they live long enough, reach shiny baldness in that area. One very helpful sign for me is whether or not, when I view the patient's scalp from above, if I see even the slightest hint of a U-shaped difference in density near the fringes, no matter how subtle, I almost always find miniaturization on magnified exam and feel very confident they will eventually probably end up a Norwood VI. The age at which that will happen can vary drastically from one man to another. And of course, if they take finasteride, their hair loss will often be stalled at least another ten years. To me, whether a man is a Norwood 3-v, IV, or a class V means very little to me in terms of what my plan will be; I treat them all as I would a Norwood VI patient (U-shaped baldness). The progression of a Norwood IV to an advanced Norwood VI can be easily seen by simply watching Seinfeld re-runs. In the early years of the show Jason Alexander was a Norwood IV. Halfway through he was a Norwood V, and near the end of the show's run he had reached a Norwood VI. So I can turn on the show and tell about what year it was just by looking at "George Costanza's" head. I certainly would not tell the 29 y/o patient above that he probably will never bald, nor even a 35 year old. A now-retired doctor from out west used to include in his lectures photos of several famous Hollywood types who seemingly had full heads of hair up to the age of 40 and then went on to be nearly bald by the age of 60. Some of them, as best as I can recall, were Johnny Carson, Clint Eastwood, Don Ameche, Paul Newman and several others. Ironically, even though it's nice to be on finasteride to preserve your hair longer, it does somewhat "mask" what is really going on when evaluating your heredity's affect on your hair-loss status. 35 is my cutoff age for starting to feel confident about where a man is heading the rest of his life. I'm sure I will make an occasional mistake, but I think 95%+ of the time, I will be pretty accurate. After 35 I usually will agree to do the temples, bring the recessions further forward and fill in the vertex - providing there is a generous cushion of donor supply present. In summary, I think most patients in their late 20's and early 30's should be looking mainly for a framing of the face in front and not looking to have the crown/vertex in the back filled in. Mike Beehner, M.D.

You have to be careful. The crown (vertex) can be a dangerous place. If you are in your 20's, I firmly believe that the crown should never be transplanted during that age range. If one is in his 30's, then I think any coverage done there should be on the "light" side WITHOUT maximal density. The reason is that often in a man with male pattern baldness, the borders of the crown can expand, such that the square area of the crown zone increases logarithmicly. If a younger man has this zone filled in densely, there is the danger that 10-20 years down the road there could be a 1-2 inch wide "halo" of bald skin around it, which is a very unnatural thing. I have seen many of these from old transplants. Light coverage, on the other hand, fans out in the whorl direction typical of the crown's hairs. If the crown enlarges, they simply fan out a little further to help cover that bald area and it isn't that hard to find some donor hair to fill that space in to match the density of what is already there. But with a dense central part of the crown filled in, you then have to match that extreme density, which is usually impossible to do in the face of a shrinking donor area. For men over 40 with a small to medium size crown and ample donor stores, I do think it is possible to "dense pack" and "go for it." It is ideal, when doing so, to only do that area, as then the blood supply to the area is very good, without other recipient holes in the front compromising that area's circulation. Returning again to the younger male, many of them only have hair loss in the crown at the time they see the hair surgeon, but many of them go on to lose the hair on top and in front later on, which is always a more important area to fill in. That is another reason for not using up a large amount of the donor hair in the rear crown. To give an extreme example, the photos here are of a 45 year old man who came to me many years ago, who at the age of 25 had the small hole in the back that was bald filled in with the grafts that were used at that time, which happened to be the large plugs. As you can see, during those 20 years his crown expanded and a huge halo resulted. The second photo shows the result after I removed all of these grafts and placed FU's at the upper border. So the message is: Be careful what you wish for. Be conservative in the crown, especially if you are younger. Mike Beehner, M.D.

I'm sorry but I can't at this time. It's only a study of two patients. I think in the next year or two there will be several other studies along the same lines, and I think the real conclusions will come when we can put a bunch of these together. Mike Beehner, MD.

This 39 year old male 9 months ago had his first hair transplant procedure. He was thin in the back half of his head and virtually bald in the front half. He volunteered for a research study, which required 6 small boxes (see photo in gallery) to be used. We used a "combination" method, which uses both FU grafts and DFU grafts (4-5 hairs each). He received a total of 1729 FU's and 400 DFU grafts for a total of 5931 hairs. The photos are taken only 9 months later. The study that was performed was one comparing FUE graft growth and FUT growth. Mike Beehner, M.D.

Yes, I would agree with you that the glabella would probably lie halfway between the two lines you drew. Mike Beehner, M.D.

The measurement ranges you listed sound more like measurements from the glabella for younger and possibly middle-aged men, but I think that distance from the supra-eyebrow line might be the average hairline height for men in their 50's, 60's, and 70's. Mike Beehner, M.D.

Two different reference points are used by physicians with regard to measuring the "height of the hairline." One is the glabella, which corresponds roughly to the spot at the top of your nose where, if you push your finger in, you can't go any further. The other is a horizontal line drawn across the top of the eyebrows. I personally prefer to use the supra-eyebrow line, but it is important for any physician giving a number of cm's that the hairline is situated at, to also say which reference point he/she is using. One virtue of the glabella is that it can't move. Using the line above the eyebrows, it is important that the patient relax his face and forehead muscled in a neutral manner. Despite this possible interference, I greatly prefer to use the line above the eyebrows. There is about a 8-10mm difference between using these two reference points, which is why just throwing a number out there can be confusing and misleading. Mike Beehner, MD.

Dear "Can't Decide," I hadn't noticed that many posts about that, but you could be right. I think this is the kind of website that will get a lot of the negative comments congregating in one spot, and that the overall incidence among all hair transplant doctors is low, a very small percentage voicing their complaints in one place may make it seem more common. In 24 years of transplanting, I have only had 2-3 cases of donor area shocking, and, fortunately, the hair all returned in each of these patients. I should add that the best way to close a donor wound that a doctor finds is too wide to close without a lot of tension, is to put sutures in and pull them, but not tightly, and leave the wound actually open. It will granulate in (fill in gradually with scar tissue), and then at a later time, when the scalp is looser, some or all of that resultant scar can be cut out and removed. The late Dr. David Seeger was the first one to write about this preferred method of treatment, and I have resorted to it 3-4 times over the years, and never with shocking occurring afterwards. Mike Beehner,l M.D.

Shock loss in the donor area is a very, very rare event. When it does occur, it is almost always caused by excessive tension in closing the wound. This excessive tension can be because the patient's scalp was very rigid and didn't have much laxity, or because a wider strip was taken than should have been. This latter sometimes occurs because the patient is pushing the doctor for a larger number of grafts than his scalp laxity and density will allow for. The only reason shock loss could be slightly more likely at a second session is because the laxity often decreases just slightly with each strip excision. In my practice, I usually go one millimeter less in width with the next session. Mike Beehner, MD

This 30 year old male 11 months ago had his first HT procedure with 1696 grafts being placed, which came out to 4072 hairs. 380 MFU grafts were placed in the central area in his forelock plan in the photo. 1316 FU's were placed in front of and to the sides and back of this central area of MFU's. He will be returning shortly to have a second session for additional density. Mike Beehner, M.D.

This 67 y/o woman who has had very thin hair for a long time came in for a single HT session in March of 2012. The "after" photos are taken 15 months after that first transplant session, when she came for her second procedure to add more density. She received 1278 FU grafts and 330 small "slit" grafts of 4-5 hairs each (DFU's), for a total of 3557 hairs. She was quite pleased with the improvement. The donor hair that was of good quality was limited to the rear, occipital region of the scalp, which limited how many grafts could be harvested at one time. Mike Beehner, M.D.

This 45 y/o female presented first in 2007 for her first session and had another one 3 years later. These sessions totaled 4319 grafts (3989 FU's and 330 MFU grafts) comprised of 8582 hairs. On the day of the photos she had her third session for additional density. Mike Beehner, M.D.

I had a wonderful one hour visit with this patient at the end of my work day today and feel very good that I believe his expectations are now a little more realistic and that there is a relationship of trust between us, such that he is going ahead with a second procedure along the lines we planned originally. I am not sure how much donor hair we will be able to harvest, and we left it that he would trust me to take what I thought I could get without compromising him in the way of any undue tension on the closure or marked worsening of the donor density. I had intended to explain my view of this patient's situation in a note late yesterday, and just ten minutes before I was going to post the note and photos, the patient called in to the office to arrange a visit with me today, so I held off for that reason. The patient and I looked over photos I had taken before his surgery with me, and he realized that he had thin density even then on the sides when the hair was short or lifted up. (The following is the letter I was prepared to send the evening before, which the moderators had asked me to provide in response and which I told the patient I would do.): I would like to add my viewpoint to this patient's situation and what occurred at our surgery and afterwards. I will try to include with this post three "before" surgery photos, along with three photos from our mini-consultation visit 9 months after the procedure. Because of his relatively young age (early 30's) and the fact that I felt quite certain that someday he would have a much larger than usual horseshoe-shaped bald area on top, I used somewhat of a modified "frontal forelock" pattern. By this I mean, I tried to create in the marked off zone (seen in the top-down view in the "before" photo) just behind the hairline an increased density of grafts by using DFU's and TFU's. The large area behind and to the sides of this denser front-central zone I refer to as the "wraparound zone," and in this area we scattered 800 FU's sparsely throughout it to begin some light coverage and create a gradient away from the denser forelock region. 620 FU's were used to create the frontal hairline. The rear crown/vertex was not transplanted. We used dissolvable (Chromic catgut) suture to close his donor area, which I do rarely for those who say that getting the sutures removed would be difficult for them to do. I don't think doing so had anything to do with any problems post-op. When measuring the donor area density of hairs before his first surgery, I sampled three 5mm x 5mm squares under magnification and counted 19, 19, and 18 respectively in these views, which averages out to around 75 FU/cm2, which is below average for most males. I did not measure the density of the side areas and in hind site wish that I had. As we do for the majority of our patients, he was given a choice of having the "combination" approach with both FU's and DFU/TFU's (total of 1700 grafts) or an all-FU approach with 2500 FU's. It turns out he received the equivalence of around 2200 FU's with our combination approach that day. His FU's were 30% 1-hairs, 60% 2-hairs, and 10% 3 hairs. I would also like to point out that my operative report showed there was "no tension" in closing the donor wound edges. Usually, when donor area shocking occurs, it is almost always related to excessive tension on the wound closure, which was not the case here. The photos I am attaching show three before surgery and three taken 9 months later at our Newburgh, NY office in follow-up. The close-up view of the left side with the comb holding the hair up was taken at that 9 month time point also. When I saw him at that follow-up visit, I noted that the rear scar was very thin, as was the right side. On the left side there was perhaps some mild donor thinning limited to an area around 10mm in width. I took a photo of the area with a comb lifting the hairs above it. I thought his hair growth on top was what I expected to see at 9 months. That consultation took place in early January of this year (the surgery was in April of 2012). About 2 months later, we exchanged lengthy e-mails, in which the patient stated his hope that there would eventually be no "see-through" areas on his scalp, and he once again stated that the "shock loss" areas on both the right and left donor areas above the ears were slow to get better. The patient mentioned a patient that we posted on the HTN who had a very full result, and I pointed out in my reply that this patient had much coarser hair and his donor density was much greater. I responded by again going over the plan to increase the density at the next visit in the areas we transplanted the first time and also encouraged him to do scalp stretching exercises before the next procedure. So that's a recounting of what went on between the patient and I prior to this evening's meeting. I think the biggest factor present here in all this is that somehow we failed to communicate on what the reasonable expectations for him were. He may have had a vision in his head of virtually no baldness or thinning being present when all of his transplanting was finished, which is unrealistic, given his young age and already fairly large area of hair thinning and loss. I had a vision of framing his face so that, after 2-3 procedures, you couldn't see through the hair in front, but that there would be still moderate thinning of density behind that area due to the limitations of donor density and supply. I am grateful that the communication lines and bond of trust were opened up and carried us all through this. Our philosophy is to stick with each one of our patients until they are happy, no matter what that takes. People sometimes ask me if we give any sort of "guarantee," and I simply reply with the above statement and our 24 year record of holding good on that promise. (The 2nd, 4th, 5th, and 6th photos are "after" photos". The other three are "before" ones) Mike Beehner, M.D. Saratoga Springs, NY

I would agree that two weeks out about the only thing you could do is have a deep sunburn that reached down deep into the dermis of the skin. The main things that will influence the survival of the grafts you already have in your scalp are the conscientiousness of the doctor and staff that conducted your procedure. This means that they paid close attention to avoiding any trauma to the grafts in cutting and handling them, and also kept them moist the entire time and in the ideal solutions at a cold temperature; A final factor is the "time-out-of-body" for the grafts. If grafts are all harvested early in he morning and the last graft doesn't get placed until 5 or 6 PM, then those grafts are not going to do as well. For large sessions, the donor harvest should be done in step-wise harvests to avoid this. So, in summary the success of your transplant has everything to do with what physician you chose to do your procedure and the integrity of that physician and his/her staff. Mike Beehner, M.D.

This 31 year old male presented a couple of years ago with irregular indentations in his natural hairline which he didn't like and requested that we transplant into these areas to make his hairline appear more even and symmetrical. We dense-packed at a density of approximately 60FU per cm2, placing 300 FU's in the front-central hairline area as shown in the photos. The First few photos show his "before" situation, and the last three photos are two years after this one procedure. On the day of the "after" photos he had 130 more FU's placed "in the cracks" using a stick-and-place method by myself. Mike Beehner, M.D.

Dabra, You asked what I would advise you to do. Obviously, as one of the other commentators mentioned, your doctor has examined you and knows your age, the amount of laxity in your scalp, the density of the hair, whether there is hair that can be harvested in the lateral areas above the ears, and a whole host of other things that I don't know. If you don't have that much more that has to be done, perhaps no more than 2000-3000 FU's, then perhaps FUE is the best way to go, as long as your fringe margins don't drop down past where the FUE grafts are harvested, I personally think the grafts cut under a microscope from a strip are far superior to FUE grafts, which are "plucked" out of the hole made and thus are often denuded of protective tissue in their lower part. You're going to lose a little bit either way you choose: If you go with FUE and have a lot of that work done, then the hair shingling down over your double scars is going to be less dense and fewer in numbers. If you do a strip just above (and contiguous with) the upper scar you have, then there is a good likelihood that scar will widen slightly. What to do is a decision only you and your doctor can make together, based on all the factors I mentioned. My strong recommendation to anyone just starting out getting a hair transplant is to go with the strip method if you have a large area that is going to need to be filled in over the years and make sure you end up with only one scar. When everything is done as far as your hair transplant needs, the scar can then be dealt with using FUE grafts, tattoo dots,and/or partial excision of the scar. Sometimes a trichophytic closure can be used if the area excised isn't too wide. I stand by my statement that it is near impossible to turn two stacked scars, especially if they're wide in any way, into one thin scar through some surgical procedure. You would need a "perfect storm" of factors present: 2 thin scars about 1cm apart and a lax scalp. This is rarer than hens' teeth. Alix: Alix, you said you would go on to have a THIRD scar stacked with the other two and said your doctor plans to make everything nice with some corrective procedure when it's all done. Other than some camouflaging with FUE and tattoos, I have no idea what he could have in mind. I would avoid that third scar and just have him harvest a narrow strip just above the upper scar and, if possible, try to excise some portion of that upper scar at the same time if the laxity allows for it. Good luck. Mike Beehner, M.D.

I assume you mean that the two strip scars are "stacked" on top of each other. It is totally unrealistic to assume that they can both be cut out and the bottom edge of the lower scar and the upper edge of the upper scar can be brought together. That virtually never happens, unless you went to the extent of using a balloon expander. What you don't want to do is take any of the hair that lies between the two scars, as this hair directed downward is your savior for camouflaging the bottom scar. If you take any of this hair, you will create the visual image of the two scars being one massive, ugly scar. Another thing I try to do in those situations is, when doing FUE, is not to do the FUE in the 1/4 inch or so above either scar, so that area of hair has maximal density for camouflaging the scar below it. If there is sufficient laxity and there is a pretty good height of "good" donor hair either above the top scar or below the bottom one, taking another narrow strip at one of these places is the best course of action, during which you can have that scar excised also if it is slightly wide. Mike Beehner, M.D.

I do think there is a point at which the hairline is too high and it isn't worth even transplanting, because you are not truly framing the face at that height. I almost never place a hairline higher than 8cm above a line across the top of the eyebrows. My average for all comers is between 6.5 and 7.5, with 7cm being the commonest height. Two factors that weigh heavily on where that line should be are the age of the patient and how far forward the side temple hair projects forward. If the patient is young and there are signs that they are going to someday be very bald and the temple hair is thinning also, then I will often put it up near 7.5-8cm. On the other hand, if the man is 50 and his temple hair is way forward and the area that is thinning is already down at 5cm above the eyebrows, then I'll just continue his hairline there. It has to be individualized and evaluated for each patient by a hair surgeon who has extensive experience. Mike Beehner, M.D.

This patient has faithfully been using Rogaine twice a day for many years. It's unusual that one of my patients is faithful with this regimen. My own experience has been that minoxidil (Rogaine) is much better at slowing hair loss than in growing long full hairs from short, wispy ones. This case may be a testament to its being able to slow hair loss. Mike Beehner, M.D.

This 41 year old male presented for his first transplant in December of 2011 and came back to see me the other day to prepare for his second session to add density. We placed grafts throughout the entire front 3/4 of the balding area on top, using a total of 1843 grafts, comprised of 430 DFU grafts (average of 4.5 hairs per graft) and 1413 FU grafts. His natural FU's were 25% 1-hair grafts, 50% 2-hair grafts, and 25% 3-hair grafts. A total of 5118 hairs were moved in this first procedure. He mainly didn't like his high forehead and also the loss of density on top which had been quite progressive the past five years. Mike Beehner, M.D.

This 43 y/o male presented in 2009 for his first procedure of 2524 grafts equaling 6188 hairs (2053 FU grafts and 470 MFU grafts). He had a second large session a year later, bringing his totals up to 5229 grafts (11,311 hairs). He is coming in next month for a small touch-up session for his crease and crown. His FU bundles were mostly 1-hair ones and 2-hair ones, with only a few 3's, which limited the density we could create in one session in the FU zones. Michael Beehner, M.D.

This then 47 year old man came to us for his first procedure in December of 2007, when he had 2487 FU's placed diffusely, with heavy concentration in the temples and front hairline, which he wanted lowered by almost an inch. He had a second similar size procedure one year later in the same area, and a third again one year after that. In total he has had 6979 FU's. His "after" photos are shown. His father was totally bald, and the patient does have miniaturization all over his head, even though it looks reasonably full in the midscalp on casual examinationl. He wants to aggressively stay ahead of mother nature's fate for him. Mike Beehner, M.D.

I know Dr. Boden quite well from seeing him at numerous hair transplant meetings and live surgery workshops and can vouch for the fact that he is one of the real class guys in our field. I have seen him operate at the Orlando live surgery workshop and his skills are top-notch. I am always sad when some of the veteran posters on this site pile on and put down someone without knowing anything about their actual surgical results or the integrity of the individual himself. It is obvious that there are some physicians who vigorously promote themselves and their patient results on various forums, and there are other physicians who keep quite busy with patients in their locale and don't feel the need to engage in this level of self-promotion. Ironically, some of the nicest guys in our field fit this description, which makes it all the more painful to see them hung out to dry in forums such as this. Were I a young fellow with balding (which I was), I wouldn't hesitate for a second to entrust my transplant to Dr Boden. And like one of the patients above, I certainly was not called by Dr. Boden to put this post up. Mike Beehner, M.D

My opinion in almost cases is that the second strip should be 1mm narrower than the first strip. I take a second strip exactly above the first one. In most cases the first strip's scar is almost undetectable, usually 1mm or less in width. The flat part of the occipital part of the scalp in back can be cut wider than the rest. Once you come to the curve around the back of the head and into the area behind the ears, it is important to narrow the width of the striip taken, as this is the trouble spot for widening of the scar. I typically take a 1.3 or 1.4 cm wide strip in that flat occipital portion of the scalp for a distance of around 10.5cm. I then narrow the strip's width down to 1.1 cm wide as I begin the turn and keep it at that width the rest of the way laterally. If it is necessary to do a third procedure, I leave a small "pillar" of intact scalp at both corners, so that I am essentially taking three separate strips - one in the back and one on each side. Leaving this small intact "pillar" anchors the scalp together and prevents the classical widening that often happens with third-time strips in that area. For females, where oftentimes the occipital region is the only area with hair worth harvesting, I will push the limits in order to get enough hair to make the procedure worthwhile for the patient and I will push as high as 2 cm wide if I think there is enough laxity. With undermining, it is possible to easily close such a wound, as long as it isn't taken too far laterally and around the corner at that width. Mike Beehner, M.D.

This 46 y/o male in 2003 had a single HT session of 1250 grafts (3204 hairs), consisting of 974 FU's and 221 DFU's. His main complaint was his high forehead and the recessions that were fairly deep. Our main goal was to create a natural hairline that was set a little lower. He was pleased with the changes this made in his hairline and came back for having us add further density with a second session. Mike Beehner, M.D.