Dr. Michael Beehner

Thanks for the comments. I don't know that the percentage of women with significant hair loss is rising, but most experts certainly agree that around 20% of women have significant hair loss, to the degree that they seek professional help of some sort. It is one of the most gratifying aspects of my practice, since women are devastated by hair loss and it removes one of the main identifying characteristics of beauty we associate with the female sex. It's unfortunate that around 15-20 years ago someone started the buzz that women shouldn't be transplanted, which was a leftover from the "plug" days, when they certainly weren't candidates.They have a somewhat higher incidence of mild "shocking" and also forehead swelling after surgery, but there are various techniques that can be used that greatly minimize these two things. Mike Beehner, M.D.

This 61 year old lady, who has had "thin" hair ever since her 20's, with gradual increased loss the past decade, presented in February of 2011 for her first session of 1227 grafts (806 FU's and 421 "slit MFU" grafts), and then 11 months later had her second procedure of 1120 grafts (980 FU's and 140 MFU's). A total of 5222 hairs were moved to the top of her head and she's very happy with the result. She will be coming in next month for a final session, at which time we will place more of the grafts in the back half of her scalp. Mike Beehner, M.D.

This 46 y/o male had a single session performed in October of 2009 totaling 2115 grafts comprising 5408 hairs. 1831 FU grafts and 284 MFU grafts were used to accomplish this. Each side temple area (seen in drawing of side of head in third photo) was filled with 220 FU grafts. Note that in the third photo above showing his straight up-and-down temple contour that there was no temporal peak. The "after" photo following shows this temple point starting to be filled in. Custom-made lateral slit blades were used to make all sites. The plan from the beginning was to do two sessions, but I wanted to show the impact that even a single session can make in making a difference in a man's appearance and particularly in the framing of the face. He has very fine hair, which makes this even a little more difficult. Fortunately, his donor density was way above average, with around 115 follicular bundles per cm2. Mike Beehner, M.D.

This 42 y/o patient of Dr. Chris Pawlinga's had two sessions performed exactly one year apart, with the last one being 9 months before the "after" photos were taken shown here. The patient will be coming back in three months to have the rear half of the scalp filled in further. He had a total of 2521 FU grafts and 545 DFU (double follicular unit) grafts placed. Dr. M. Beehner

If one elects to perform hair transplantation using a stick-and-place method exclusively, then there are two choices both of which have drawbacks: One is to delegate to the assistants the task of both making the recipient sites and placing the grafts, which actually is very difficult to do with two pair of hands on the head. With this method the doctor basically removes a donor strip and draws a hairline and then looks in on what the assistants are doing. The second choice is for the doctor to do the entire hair transplant procedure himself using a stick-and-place method. For the typical size sessions we do today of 2000 grafts or so, this would be a terrible way to do the procedure because the grafts would be out of the body for up to 15 hours and the doctor would be so exhausted mentally and physically that the work would not be ideal. What was certainly referred to with reference to the doctors mentioned, which is true of our clinic also, is that the sites are first made and then the doctor and the assistants alternate in placing the grafts, which is the step in the procedure that takes the most time. Then, at the end of the case, most of us save out 50-100 FU's and the physician himself looks for little "cracks" in which to place those final grafts to achieve the best density and naturalness of the hairline. Mike Beehner, M.D.

I would add two more points regarding the need to not be in a hurry removing the donor strip: First, it is important, when cutting out the underside of the strip (after the upper and lower skin incision have been made) to leave at least a thin layer of fat there, so that none of the follicle bulbs are "naked" and hanging in the breeze. This is important because the ideal graft created by the assistants doing the cutting under the microscope is one in which there is a small amount of fat left just under the bulb. This then is the ideal place to place the forceps when placing the graft, so that the bulb itself is not traumatized. Also, this fat at the base of the bulb protects the dermal papilla, an important germinal center which is present just beneath the bulb. The second point was that I think in large cases (over 2000 FU's) that the donor strip removal should be staged. In our clinic we remove around two-thirds of what we estimate we will need for the case, and then a few hours later remove the other third. The tissue removed first is the first grafts that are placed, and the last hair removed is obviously the last grafts placed. This way the surgeon limits the "time out of body" for the grafts, which has an effect on graft survival. Mike Beehner, M.D.

I agree completely with Jotronic that the blades are less traumatic than needles. But the one fact that always has to be taken into consideration with every surgery is: How can I help my assistants place the grafts with the least trauma to the grafts? Trauma to the grafts from over-handling, repeated attempts at placement, and trying to squeeze an FU of a certain size into a hole that is just slightly smaller than the graft - these are the real killers of follicles. I use the custom-cut blades in probably 80-90% of patients, but especially in those with a rigid, tight scalp I like to use solid-core needles, mostly the 20g, 19g, and 18g sizes. Besides making a lateral cut like the blades do, they also have a dilating effect on the opening, thus making placement a little easier. Mike Beehner, MD

This 50 y/o female first presented to our clinic for her first procedure in 2007 and had three procedures in total, comprised of 4219 grafts (10,422 hairs), with 3770 of them FU's and 449 "slit" MFU grafts. She is now 55 and came by the office today to show me her new faculty photo from the school she works at. She also has lost nearly 100 pounds since when we first saw her, which adds obviously to the dramatic transformation. Mike Beehner, M.D.

Guslarkin, The point you make about MFU grafts having an important role in hair transplant surgery I totally agree with. I have been using these grafts, usually DFU grafts of 4-5 hairs each, within the front-central region of the scalp in around 70% of my patients for many years and am very happy with the consistent results of density this gives my patients. In my view, the important task for the hair surgeon in the types of cases you describe - namely, a large balding area and a limited donor supply - is to create GRADIENTS of hair density, with the most important area of prime density always being the "frontal core" in the front-central region just behind the front hair line. Even with an all-FU approach this can still be accomplished by placing all of the 3-hair FU's in that area and then use 2-hair FU's around them and the 1-hair FU's along the front hairline. Besides the number of follicles per graft, the other important variant is the density of planting. I like the MFU grafts because in research studies these hairs survive consistently at near 100%, whereas FU studies average out around 89-90%. There is an art to using MFU grafts, and if it is not done correctly or on the right patients, then poor results are possible. The key is planting them at an angle, close together, not in rows, and not letting them get larger than 6 hairs at the most. In some men with dark, coarse hair and pale white skin, it is better to use all FU grafts. I feel it is unfortunate that MFU grafts aren't used more often, but I feel that when doctors and patients reacted negatively to the old large, pluggy grafts (as they should have), they over-reacted and ran right past the so-called "minigraft era" and went to exclusive use of 1-3 hair grafts. The other factor is that a surgeon obviously earns more money dividiing a given amount of donor hair in a strip into Fu's versus using some of that donor hair to make DFU grafts. There is no denying that there are wonderful all-FU results out there, and we have seen them also in our patients. The big difference is that the results are much more predictable in terms of density and fullness when MFU grafts are used in the mix from my experience. Mike Beehner, M.D.

This 35 y/o male presented 12 years ago for his first hair transplant as a Norwood V level of hair loss or advanced IV. Spread out over those years were three transplant procedures totalling 3726 grafts (2633 FU's and 1073 DFU's) equal to 10, 461 hairs. He came by the office the other day and the attached "after" photos are shown. Mike Beehner, M.D.

This 26 y/o Asian (Indian/Pakistani) patient presented in February of 2011 and at that time had a "combination" session performed of 1154 FU grafts and 423 DFU grafts in the front 2/3rd of the typical U-shaped male pattern baldness pattern area. He mainly wanted his high hairline lowered down further into his forehead. The plan was for him to have two sessions for final density, but the results shown here show what was accomplished only with the first session. It is important to note that Asian patients have much coarser hairs than the average Caucasian patient, so the visual results are always much more dramatic than the graft numbers would indicate. Mike Beehner, M.D.

Spanker, Using your drawing of MFU grafts, I assumed an arbitrary angle of light being directed to the scalp from the left of the picture down to the right at 45 degrees. This simply demonstrates my point that I think a graft of three or more hairs (even a 3-hair FU!) blocks light from reaching the scalp better. Providing that the surgeon angles the grafts at a relatively acute angle, so that "shingling" occurs, if you just took the mid-scalp region in the top-center of the scalp as an example, and you placed 250 DFU grafts averaging 4.5 hairs apiece on one patient and then placed 500 2-hair FU's evenly distributed on another identical patient in the same square area.....that the scalp beneath will be less visible to the viewer with the DFU grafts because of the light blocking properties of the larger grouping of hairs. In truth, a DFU graft of 4 or 5 hairs would have a slight gap between the two groups of hair, as it does preserve that gap and doesn't compress it to the point it disappears. The other point that bears mentioning is that research studies to date show 100% yield of MFU follicles, vs an average of 90% for FU grafts (over 40 studies done, and they range all over the place, but average at 89.1%) Mike Beehner, M.D.

Dear "Can't Decide:" When you refer to doing 3000 grafts on this man for his first session instead of the 1400 plus that we did, I am quite sure you are referring to using FU grafts. In fact, we do offer that choice to each patient. The square area we filled in with this patient's first procedure was the entire top of the head except for the downhill crown/vertex in back, which is a fairly large area. 1500 FU's spread over that area would look like nothing was done. By using the 400 MFU grafts, each of which is dissected under the microscope to contain either 2 or 3 relatively close FU grafts into one graft of 4-5 hairs, we are able to achieve a visual density in the center which with FU grafts would require the 3000 you mentioned. The difference in cost between the two procedures is six thousand for one and almost thirteen thousand for the larger. Here in upstate New York State, many more patients can afford the smaller cost procedure than the expensive one, and in fact it turns out that 80% of our patients with this extensive amount of baldness do choose the "combination" graft approach and do plan to come in for two procedures. Someone bald who chose the 3000 FU route instead, would also almost always need to come in for a second procedure also. So my intent in even sharing this patient was to simply show that using some DFU's and TFU's can enable the hair surgeon to fill in both the frontal and midscalp regions in a way that makes a significant improvement even with the first procedure. I certainly am not saying that he is done with surgery. Hope I was able to clear up that point for you. Mike Beehner, M.D. Mike Beehner, M.D.

This 29 year old male had a transplant session performed in Novemter of 2010, which comprised 1436 grafts, equal to 4072 hairs. The plan was to do 2-3 sessions in total, so this set of photos only shows the results from the first session, which the patient was quite pleased with and helped frame his face in a way that didn't exist before the surgery. He had 1036 FU's placed, including 580 of them at the front hair line zone, and also 400 DFU grafts of 4-5 hairs each placed within the frontal and mid-scalp regions. The "after" photos are taken 18 months after the first transplant, when he returned for his second surgery, which we feel will be all he needs for the next several years. Michael Beehner, M.D.

I agree with all of the comments made by Drs. Charles and Lindsey. I would add that I do try to excise the entire scalp if it is pretty clear to both me and the patient that this is his LAST transplant procedure. It saves him another trip and surgery, but this is only a good idea, as Dr. Lindsey said, if there is enough laxity and if the plan to remove the scar does not limit the surgeon from being able to harvest the amount of hair the patient is requesting. If you attempt too much and the closure is under tension, then the effort to reduce the scar backfires, and you get a "rubber band effect" of an even wider scar than when you started, despite the fact you excised the entire scar. If it is a somewhat wide scar and the patient wants as large of a session as you can achieve, then it is clearly better to put off the scar excision for a year, until when the scalp becomes lax once again and it can be done without undue tension. Even in this situation, it is still important in my opinion to end up with only ONE scar and to take the new strip from exactly above the old scar, so that there are not two scars. If the patient needs a third session in addition at some future date, then I think it is better to NOT excise the old scar, but to leave it, which will minimize the tension on the closure after the present donor harvest and the later closure also. Dr. Charles made this point also. Dr. Lindsey hit the nail on the head in noting that a personal exam and consultation with the surgeon before surgery is the best way to plan and make the right decision. No two patient situations are exactly the same. Mike Beehner, M.D.

The only times I choose to create a second scar is when a patient comes to me for a second procedure who went to another physician who placed the donor scar too high, where I think there is danger of the fringe dropping and the transplanted hair later disappearing because it came from an area that would eventually bald. Mike Beehner, M.D.

Dividing a large, dense transplant session into two sessions a day apart I think would inflict the same amount of surgical trauma and shock to the scalp as doing it on the same day. The only advantage to be gained in dividing up a large session into two days is to avoid staff fatigue, which is a significant factor in long, large cases. This is especially true for FUE cases, where the fatigue on the surgeon can add up after 8 hours of work. Mike Beehner, M.D.

If you have early signs of classical patterned male pattern baldness, then many if not most of the hairs within the U-shaped area on top will be at some point of the spectrum of miniaturization. Our hairs typically live in 4-5 year long life cycles, are then shed, and then the follicle pushes out the next generation of hair. If it is in the area of MPB, then this next hair will be a little wispier, will grow to a shorter maximal length, and will have a shorter anagen (growth) cycle. So when you have a hair transplant procedure, the trauma of the surgery can "spook" some of the follicles in the area and send them into a 3-6 month hibernation with the hair falling out. The great majority of those hairs will re-emerge, but will have a little less "mass" to them and will be a little more "see-through." I would make four points that I think would help hang on to your native hair a little longer: 1) Have your surgeon plant the FU grafts at a lower than maximal density (probably 30/cm2 or less) 2) Using the smallest possible sites helps (this task and the planting step are both best carried out with very high magnification, 4.5x or higher). 3) The surgeon should use the minimal amount of epinephrine (Adrenaline) that is necessary to control bleeding. Most hair surgeons believe that too strong of a concentration of epi can promote shocking. 4) A corollary of point #1 is that the task should be divided into two sessions instead of one. The cumulative "insult" to the follicles on top will be minimized. One final point: It is my belief that a small amount of shocking to native hairs occurs with every hair transplant procedure and is only noticeable or complained about when the number of hairs affected is quite significant. Mike Beehner, M.D.

This 47 y/o presented several years ago, having had three previous transplant sessions with the large grafts. He was quite self-conscious about it and wanted the hairline softened up and the bald area in back filled in some. His brother had been a patient of mine before that and referred him to me. We performed two sessions over that period, totalling 3738 grafts (3070 FU's and 668 DFU's) comprising 9271 hairs. He was recently in for a touchup session to make the hairline a little denser with FU"s and the enclosed "after" photos were taken. At each session we "cored out" a few of the hairs from many of the very dense plugs near the front edge. In all, we performed 74 of these small "cut-outs." This is called the Lucas Method, in honor of Manfred Lucas, a German hair surgeon now deceased who published about this method. These hairs that are removed from these large plugs are then cut up into small grafts and used elsewhere. Mike Beehner, M.D.

I would add one more important reason that I think a lot of men don't have hair transplantation done, and that is that many don't have the courage to make a change in their appearance. They are afraid what their family, co-workers, and friends will think of them to have the nerve to change something in how they look. This is especially true for macho, male professions and work places, such as prison correction officers, police men, etc, where I get reports that the ribbing these men receive is merciless if they should have a HT. I think many men, especially those who are very bald, would love to have their face framed with hair on top, but just feel it is too bold of a move for them to make and face the world with. A lot of times it takes something, such as a divorce, to push them to make that change. Mike Beehner, M.D.

This 34 y/o presented in 2002 for his first procedure, and went on to have a total of three, averaging 2226 grafts per session. Total number of grafts was 6678 (5754 FU's and 874 DFU's) for a total of 16,774 hairs. He recently came in for a trichophytic closure and narrowing of his donor scar so he could wear his hair shorter. He is now 44 years old. In looking at the before photos 10 years ago, it is obvious that he would be totally bald today had he not been transplanted. Mike Beehner, M.D.

The condition you are referring to is known as the acronym, "D.U.P.A." It stands for "diffuse unpatterned alopecia." It usually is easy to tell on close inspection of a consultation patient's scalp, but we always double-check with magnification, usually around 30x power. The density is very low and often there are a significant percentage of "miniaturized" hairs also, which do not have many more life cycles to live before they disappear. There are a number of reasons they make poor transplant candidates: The first is that, as they thin, the donor scar (or even the FUE white dots) will become more and more obvious and detectable. Another reason is that it is hard to move that much hair. I have had a couple of men over the years, usually in their early 30's, in which case things were evolving much more slowly, and we did discuss a very limited plan of "cherry picking" a number of hairs from the rear donor wall and using them to frame the face in a limited area at the front-center. I obviously pointed out the positives and the negatives, and both men elected not to go forward with it. One strategy that can work to help these men for a few years is to use a camouflage agent such as Dermmatch or Toppik. I am not aware that finasteride helps to reverse this condition. Two other situations in which a person would not be a candidate for hair transplantation are the following: a) Person with an auto-immune condition which would result in lymphocyte cells from the disease process attacking the newly transplanted follicles and not letting them survive. The two commonest conditions we encounter in this regard are Lichen Planopilaris and Alopecia Areata. Lupus is another such condition. Sometimes, after a couple of years have gone by and the process has stabilized, they can be transplanted, but the patient has to be warned that it is possible that the original condition could reactivate and attack the transplanted follicles and result in their permanent loss. If a hair surgeon does elect to later transplant one of these patients, either a biopsy (to make sure the disease is inactive) or a small area of "test grafts" is a good idea before embarking on a big session. b) The person who has only so much donor hair available, and after explaining to the patient what the most that can be done is, the patient states that would not satisfy him. You never want an unhappy patient or one whose expectations are unrealistic, given the reality of the patient's situation. Mike Beehner, M.D.

This 70 y/o male had his first transplant session exactly one year ago and is scheduled next week for his second procedure, at which time we will duplicate the first procedure for added density throughout. He was very pleased with the overall fullness he was able to achieve with only the first session. He received a total of 5561 hairs. 542 DFU grafts were placed within the central area. 610 FU's were placed along the hairline, 120 FU's along each "crease" area; and 400 FU's were scattered lightly throughout the rear vertex to give a little texture and help remove the shiny bald look. In the "after" view of the crown, you can see that this slight improvement was achieved with only this small number of FU's. Mike Beehner, M.D.

This 31 y/o male presented for his first transplant session 15 years ago in 1997. Over that time the entire frontal area has now been covered with the transplanted hairs. He has had a total of 3 sessions as reflected in the "after" photos shown here. His graft number totals 2679, with 2097 FU's and 582 MFU grafts included. Mike Beehner, M.D.

This 36 year old male presented for his first hair transplant session in March of 2010, at which time he had 1430 grafts placed (1050 FU's and 380 DFU's) for a total of 3690 hairs. Eleven months later he had a second transplant surgery, with 1369 grafts being placed (1107 FU's and 262 DFU's) comprising 3358 hairs. In total he received 2799 grafts or 7048 hairs. He recently returned for his final and third session. His fine caliber made a third session desirable, whereas in patients with medium or coarse textured hair, usually two sessions is adequate for the majority of our patients. Mike Beehner, M.D.