Dr. Michael Beehner

In my note I mentioned my policy of recommending that helmets not be worn for a week after the transplant. I don't have personal experience as a patient going back to wearing a helmet a week later, but regarding my patients who followed this advice, I don't know of any adverse effects on hair growth later on. The other issue is that there is a donor scar present and the pressure of the helmet could be uncomfortable there, depending on where the cushion points inside the helmet are. Mike Beehner, M..D.

57mph, The question you pose is the million dollar question. I'm not sure anyone knows the exact answer, but I'll give you my attempt at honestly answering it. For starters, I think the permanency of the transplanted hair varies some from one patient to another. There are patients I have seen over a 20 year period (including looking in the mirror every day at my own hair, which was transplanted 29 years ago) and it seems the transplanted hair has thinned more than the remaining donor hair has. There are also a great many patients I have observed over those 20 years from my early days of doing HT who are still very full. There are a few facts that have been proven and are general knowledge: First of all to some degree, almost all men and women develop what is inappropriately named "senile alopecia." This refers to the gradual thinning of hair everywhere on the head in people as they age. This varies tremendously among individuals, but I do believe everyone does thin from their 40's up and through their 70's and 80's - some to such a small degree that it may not seem noticeable. Another fact that has been proven with research is that the diameter of the resultant transplanted hair in most studies has been measured to be slightly less than when it was originally in the donor area. Thus there is probably less "hair mass" right from the get-go. The third factor, which I think is important, is that most of us gray, and as the percentage of gray hair increases, especially in Caucasians, the hair "disappears" visually against the background of the scalp behind it. Even when people dye their hair, after a week or so, the roots grow out white so that it starts to look thinner, especially in the part, creases and rear vertex area. But the good news is that in virtually everyone who has been transplanted, regardless of the technique or graft sizes used, the great majority of the hair does continue to grow and survive and help that individual frame his face and look better than he would if he had never done it. One additional point I would like to make is that a lot of patients change their hair styles during their life, and, if they go to having shorter hair, they are going to lost the valuable overlap and shingling that longer hair provides. This is one of key ways that transplanted hair looks full, since we are never transplanting in the density that originally was on our heads at age 15. The whole issue of how to wisely use the donor hair in a given patient, given that patient's risk for going on to a Norwood VII is another whole subject for another day. Suffice it to say that you want to select a physician who is a little conservative and has plenty of experience. Mike Beehner,M.D..

This gentleman first presnted in 2004 at age 43 and at that time had a session of 1322 grafts, comprising 950 FU's and 372 MFU's for a total of 3499 hairs. Five years later he returned for a larger session of 2023 grafts (1821 FU's and 202 MFU's) making 4955 hairs for that session. In total he received 3345 grafts (2771 FU's and 574 MFU's) for a total of 8454 hairs. He is quite pleased with the density received from these sessions and at the present time doesn't see the need to have more work done. Mike Beehner, M.D.

Corvetteser, I generally tell my patients that 10-12 months is the earliest I would recommend a second procedure. The reasons are four: 1) It allows time for the blood supply to return near normal to support the next surgery. 2) It allows the donor area to become lax once again, so that a second strip can be taken out without undue tension on the closure and the possibility of a wide scar. 3) You want all of the hair to be growing at the time of the subsequent surgery, so you don't puncture a new recipient site right on a previously placed graft. 4) You want the patient to see some concrete evidence that is relatively impressive that the hair indeed grows, so he/she will be motivated to go through and pay for another procedure. For women and men with a fair amount of native hair still on top who have one procedure, I will usually recommend waiting 18 months if they want to see the "full flowering" of the most recent procedure, so as I best make a determination as to whether they need another session. Mike Beehner, M.D.

Aseda, Since he is 51, I must confess that I don't push finasteride real hard on this age group of men, due to the fact that over the years I find the sexual side effect incidence higher for them, perhaps as high as 15% of men. I do let them know that it is available. Another factor for men in their 50's is that they often don't care as much about the crown/vertex as the men in their 20's and 30's. However, I am pretty sure around 70-80 of my patients taking finasteride are over 50. This man chose not to be on it. Mike Beehner, M.D.

This 51 year old man had his first transplant procedure 11 months ago and recently came in for a "mini-consultation" to plan for and set up his second (and hopefully, final) surgery. He received a total of 1730 grafts, of which 1275 were FU grafts and 455 were DFU's (double follicular units of 4-5 hairs each). These latter were placed into the central regions for density. 510 FU's were placed along the hairline zone and 510 were also scattered into the rear vertex/crown area for light coverage. Michael Beehner, M.D.

This woman in her mid-20's presented with significant loss of eyebrow hairs due to past over-plucking. She expressed a wish for a thicker eyebrow width than the usual slender pattern preferred by most of our female patients. Also, keep in mind that in the photo with the small purple dots outlining where we were going to place the grafts, that we place them INSIDE the lines and not over the lines at all. This method has worked well for us. Also, I prefer to use all 1-hair grafts, some of them naturally occurring 1-hair FU's and the others from splitting a 2-hair FU into 2 single micrografts, one of the rare instances when that is the more exact term to use. She had 170 1-hair grafts placed in each eyebrow and recently on the day of the "after" photos returned for a second session, in which we did 160 grafts on each side. She should be done after they grow out. Mike Beehner, M.D.

I forgot to include a top photo of patient "before" surgery. Should be attached here. MLB

The patient in the attached photos is a 45 y/o male who first presented in 2004, at which time he had a 1363 "combination graft" procedure of 1010 FU's and 353 MFU grafts, which filled in the top of the head and also the temples on both sides. He returned 2 years later in 2006 for 1325 grafts (1050 FU's and 275 MFU grafts). He received a total of 7390 hairs. Important to note is that his hair was extremely coarse and full. He returned 5 months ago for 1585 FU's as a final fill-in for additional density. That session is not reflected in these photos. Mike Beehner, M.D.

Since this thread has been raised up from the bottom of the sea, I thought I would just add a final cheery and upbeat epitaph to the thread. As Bill related, the patient for his own personal reasons, wanted the thread removed and asked me if I would help in doing so, and so I agreed to contact Bill. I agree with the decision to let it stand as is, to keep the principle of "transparency" alive and well here. Anyway, in my recent communications with the patient, he had this to say about his eyebrow work: "My eyebrow came in great and I am forever grateful to you thanks for asking! I really feel like you changed my life for the better thanks to your generosity and kindness (as well as skill!)" So things ended on a good note. As far as I know the patient's identifiable photos (face) nor his name have never been included on this thread and I hope he feels that his privacy has not been invaded in any way. Looking back over my decision to help him out, I don't regret doing so, and will try and keep an open mind on similar requests in the future. Mike Beehner, M.D.

This 37 y/o female presented a couple of years ago seeking surgical thickening of the frontal region of her scalp. She had a 10 year history of progressive thinning in this area. She had 1632 FU's placed (average 2.1 hairs per graft) two years previously, and now presents for a second session for additional density, at which time 1550 FU's were placed "in the cracks." As is obvious, she changed her hair color since her first visit. Mike Beehner, M.D.

The answer to your question about what to do about the crown does not have one answer for all men in their mid-30's. There are some men with only moderate donor stores and an already fairly wide crown/vertex, which you know is going to enlarge more during the next 20 years, in whom it is probably a better idea to stay out of that area and concentrate on filling in the top, which there is enough donor hair to do a good job with. Such an approach frames the face and from most angles looks to people like a "full head of hair." Then there are some other men who have very ample donor hair height and the back of the vertex is way up high, almost at the transition between the horizontal and the vertical, in which you look at a man of 35 and the whole thing is a "slam dunk." 35 is a whole lot better for making this decision than 25. I would never do that in a 25 year old, namely, commit to going down the back hill with grafts. So, the answer is to see a hair surgeon you trust and get his honest opinion of what's best. Sometimes this can be accomplished with four views sent over the internet (front, top, rear, and one side), but nothing beats having the doctor put his hands on the scalp and feel the laxity and thickness of the scalp, and put the 30 power magnifier on the scalp to see how the FU's shape up. Each patient is different. Mike Beehner, M.D.

I don't know if anyone knows for sure, but I have always told my patients to wait around 3 weeks. As I said above, the follicle is the only thing that is "alive" as such in the follicle/hair structure, so one would want the skin surface healed sufficiently that chemicals on the surface wouldn't harm the follicles that were recently planted. Hydrogen Peroxide is another liquid that is toxic to grafts and should not be used during the first week at the very least. Mike Beehner, M.D.

Byron, Ammonia and peroxide are the two ingredients in hair dyes that can cause some brittleness and possible breakage of hairs. They have no effect on the follicles which are the "living" part of the hair and located under the skin. Peroxides are in almost all hair coloring agents that lighten the color of the hair. Ammonia is in most products that color the hair permanently ( that is, until the roots grow out and the newest portion of the hair stalk shows some gray). The reason going to a salon is always preferable to doing it yourself is that the salon professional can apply the new coloring to the root portion that is not permanently colored and avoid or minimize "re-coloring" the portion done before. The repeated bombardment of the hair with ammonia can in some persons lead to breakage, which means there would be less hair mass on the head and it would appear as if you had less hair. Consumer Reports around 10 months ago did an article on hair coloring products and the highest rated one for men was Clairol Natural Instincts for Men. The amount of ammonia in this product is reportedly less than in most products. There are also "rinse" colorings which have to be applied daily after (or, with some products during) showering. They can't harm the hair shaft but require frequent application obviously. Mike Beehner, M.D.

This 38 y/o male had a single sessions of 1730 FU grafts placed in the front 1 1/2 inches of his hairline to bring it forward and also in both side temple areas. These photos are taken 15 months after the surgery. One more session is planned to accomplish increased density in this region. Recipient sites were made with lateral slit blades with the following widths: 0.8, 0.9, and 1.0 mm in width. All of the "before" photos will be listed together first and then the "after" photos will follow. Included will be photos right after the sites were filled. The dark blue coloration is from methylene blue dye, which clears in 2-3 days and is used for being able to achieve closer sites and to not miss them while placing the grafts. Mike Beehner, M.D.

I will attach below two photos from his initial surgical session, both without any pen marks on the head, one with the hair on top clipped together and one without any clip there. Mike Beehner, M.D.

This 52 y/o man came to us in 2007 and has had a total of two sessions and recently returned for photos. His first session was 1655 grafts (1423 FU's and 232 DFU's) for a total of 4038 hairs. His second sessions was 1693 grafts (1493 FU's and 200 DFU's), comprising 3888 hairs. In all he received 3348 grafts making up 7926 hairs. He has fine hair caliber. Each side temple point area received around 340 FU's each over the two sessions. Mike Beehner, M.D.

Two years ago I did an extensive research study comparing grafts stored in normal saline for half of the 16 study boxes and grafts stored in hypothermosol solution with ATP added to it in the other half of the boxes. ATP is a chemical in our bodies that fights apoptosis (cell death) which occurs in the absence of oxygen. We planted grafts in the paired study boxes (one saline, and the other hypothermosol/ATP) at the following time points: 2 hours, 4 hours, 6 hours, 8 hours, 24 hours, 48 hours, 72 hours, and 96 hours. The findings from this research is basically that for under 8 hours they are similar from a statistical standpoint. This confirmed the results Dr. Bobby Limmer in Texas achieved 19 years ago in his landmark study going out to 48 hours.In our study, for 24 hours and thereafter, there was a huge difference in survival in favor of the Hypothermosol/ATP grafts doing much, much better in survival percentage. Besides the superiority in percentage of grafts that survived, there was also a qualitative difference between the grafts in saline and those in hypothermosol at 24 hours and beyond, again with the hairs growing from the Hypothermosol/ATP boxes being much fuller in diameter, while the ones in saline were thinner. If anyone wants to know the exact percentages, I could dig them up and put them here. In our own practice we use Plasmalyte solution to hold all of our grafts, which is very close in ph (acidity) to human plasma. Dr. Bill Parsley recommended it to me around 4-5years ago. It is certainly more expensive than saline, but not exorbitant. Hypothermosol (and especially if ATP was added) on the other hand is much, much more expensive and, if used routinely in HT, would have a serious impact on the price patients would have to pay to have the procedure done. The evidence so far certainly does not support the routine use of such an expensive solution. Perhaps there might be the occasional patient in whom a large number of pluggy grafts are being FUE's out of the scalp and recycled into the scalp. Such grafts may be more susceptible to cell death and benefit from this type of fancy solution. Dr. Jerry Cooley has also done recent research using Hyporthermosol with ATP added (in fact, he gave me the idea!), but I don't think we can even sort out from our research what percentage of the benefit was due to the Hypothermosol versus the contribution from the added ATP. The instances in which grafts have to be placed days later are very rare. I have only had one such episode in 22 years, when around 10 years ago a 35 year old developed chest pain and sweating during the procedure right after we had harvested all of the donor hair and had made around 200 small recipient sites, and we had him moved immediately by ambulance to the hospital, where he was cleared that night at 10PM and sent out with a diagnosis of a virus and some hyperventilation. He called me that night and we agreed to meet the next day, at which time we inserted the grafts and finished the procedure. These grafts were out 24 hours and grew fairly well from visual observation. In all truth, it's pretty much impossible to distinguish 70% growth from 95% growth, which has been proven by Dr. Manny Marritt years ago and published in Derm Surg Journal. So the bottom line is that the jury is still out somewhat on what the perfect solution is. We've been using Plasmalyte for around 4 years now for the theoretical reasons I noted above, and I can't say that I have noted any difference grossly from the growth we received all those years using saline. Mike Beehner, M.D.

Just to provide proof that we indeed did suture together ALL of the punch-out sites, the following photo is provided. One thing to bear in mind is that, regardless of what size punch you use in cutting these old grafts out, with a single pass procedure there will always be some hairs that don't get removed and still grow - so it always requires a second smaller pass with usually a smaller punch to get complete eradication of the hairs. This patient has very fair Irish/English scalp skin and the redness you see will most certainly be better at the one year point, but I think it cosmetically will look best with some dermabrasion or laser resurfacing to give it an "even" homogenous look, which is what he is after. Mike Beehner, M.D.

This 25 y/o came to me a few years ago and had a frontal-midscalp forelock type of pattern used to create his hair transplant. He had extensive baldness for his age, and my fear was that he may some day be a Norwood VII stage, so I was conservative. He returned a few months ago for his second session and these photos were taken at that time. 1481 grafts in total were placed, made up of 1131 FU's and 350 DFU's/TFU's for a total of 4409 hairs. He was quite happy with the improvement up to that point and the fact that his face was now framed with hair. He had very fine hair, which did not have a lot of "body" to it. Mike Beehner, M.D.

I will try to give a hair transplant surgeon's point of view of this problem of "what age is too young to transplant at?" For me personally, 23 is my somewhat "unofficial" cut-off age for transplanting a young man. I have made a couple of exceptions in recent years and done a 21 and a 22 year old, but only with very conservative framing of the face with a front-central forelock of hair to help out their appearance. Two other unofficial "rules" I follow in my practice is not to transplant the rear vertex or the side temple (sideburn) areas in men under the age of 35. This is because, if the man goes on to extensive baldness, then these grafts will be sitting out "high and dry" by themselves without hair to support it in the temples, and, even worse, will look like a "bulls-eye" in the vertex. Then you have a patient who is a social recluse and very bitter about ever having done it. The replies given so far have been excellent and right on the money. I would start by saying that a 19 or 20 year old is almost never mature enough to appreciate the whole situation. He knows one thing: his peers have full heads of hair and he is afraid he is losing his. At this age, when your social life and dating the opposite sex are so important, that young man will have blinders on to everything else. In such a situation, if he is a man who because of family history or already extreme miniaturization way out wide, you fear he will someday be a Norwood VII, he is not going to appreciate the fact that any transplanting has to stay out of the rear crown area and out of the recession/temple areas, or that a "forelock" type of pattern is perhaps the best one for him in terms of avoiding an abnormal look later in life. The second obvious reason is that male baldness pattern is progressive throughout life and you have no idea, when looking at a 19 year old or even a 21 year old, how bald he will be when he is 40 or 50. We do start to get some hints of where he will end up as the patient gets into his middle and late 20's. For that reason, when I do transplant a 23 year old, I am always conservative and assume the worst case scenario will develop. I use a forelock design, which does connect to the sides, but with a definite gradient of density stronger in the front-central and tailing off as it approaches the sides. What I am trying to do is mimic a natural stage of hair loss that a significant number of males normally pass through on the way to balding. That way, anyone looking at them, even 20 years later, will not pause and wonder if what they see on his head is normal or not. The corollary of not knowing how bald someone will be is not knowing how much "safe" donor hair will be available over the long haul. A lot of men also have what we call "nape thinning", which is a loss of hair from the neck up into the lower occipital hair in back. One final point: Like everyone else, I try to put all young men on finasteride for all the obvious reasons. It does not hold off the eventual hereditary pattern that man will get however. Some of us think it puts it off by 8-12 years or something of that order. So when a young man presents to see me at 23, 24, or even 26, who has been on finasteride for a few years, it is even harder to tell where he is heading, because the finasteride MASKS what would normally be happening if the patient weren't on it. Some people on these forums comment as though going on finasteride somehow confers some permanent benefit for the young man. That is not true. It's great for holding on to or even increasing the "native" hair for several years more than it would normally be around, but it doesn't change the eventual long term picture. Mike Beehner, M.D.

This 41 y/o male, who is close to becoming a Norwood VI level of baldness, first presented 9 years ago for his first session of 1031 grafts, a couple years later for 1018 grafts, and finally for 1184 the last time. All total, he had 3233 grafts, made up of 2254 FU's and 979 MFU grafts, all cut under the microscope. He was blessed with coarse, dense donor hair, which made the pictured results much more dramatic than normally would be attained with that number of grafts. The total number of hairs moved in the three procedures was 9832. Mike Beehner, M.D.

I'm not sure anyone knows that exact answer - that is, namely to the situation where a man has been using both for a good long time, such as a year, and then stops the Rogaine. I have not seen any studies on that issue. My hunch is that there may be an occasional person who does shed and takes a small step backwards. I do know that we generally do recommend that a man who has been on Rogaine and wants to go on finasteride instead, we have him continue the Rogaine for another 6 months and then slowly decrease it. We have noted some shedding in some men when abruptly switching one for the other. Mike Beehner, M.D.

Johnny, In my experience using finasteride the past 13 years or so and topical minoxidil for the past 17 years, I feel finasteride is at least 10 times more valuable. Finasteride can take a wispy, limited-length hair and change it to a coarser and longer hair the next hair cycle. I find that around 80% of my patients have a positive response to it and it is easy to maintain the treatment, since it only involves taking a pill 3-4 times a week. Minoxidil has more muss and fuss to it, and you have to be fanatically, religiously faithful in its use or you turn into a pumpkin and lose your gains if you take a month or two off. It also is more useful for preventing hair loss than it is for growing hair. That all having been said, when I get a 19 year old young man who is losing his hair and wants to do everything possible, I strongly recommend using BOTH drugs, as they are synergistic (the sum result is greater than the parts) and I have been very impressed with this approach in these younger patients, especially since I can't offer such a young man hair restoration surgery. The middle aged and older men in my practice I find just don't stay with the Rogaine routine. They don't like the greasiness, the mess, etc and only a small percentage of them follow the treatment instructions on a month in and month out basis. Sexual side effects with finasteride treatment are very rare in my practice in the men in their 20's and 30's. I have read on the internet of a patient or two who have claimed permanent sexual side effects from finasteride, and, all I can say, is that I am in e-mail communication with a lot of my colleagues on a regular basis and none of them including myself has ever witnessed this, despite having given it to tens of thousands of patients. Mike Beehner, M.D.

This 47 year old male underwent two transplant procedures at our office, in May of 2008 (1325 grafts) and another one in August of 2009. The other day he had his final touch-up session of 1700 FU grafts in all the remaining "cracks." In total his 2762 grafts were comprised of 2099 FU grafts and 663 double-FU slit grafts, for a total of 7139 hairs. Photos are shown of the results a year after his second session. The hair color differences in two sets of photos has to do with us still trying to get our "white balance" setting just right in our camera, and has nothing to do with hair dye or trips to the beach. Mike Beehner, M.D.