Hairtechnician

Hi Xstatic, I wanted to let you know that what Dr. Keene and some of her colleagues found when they did a study measuring the distance between the eyebrow and hairline on a sample of around 100 men age 65 and over, who reported that they had not receded, and who had never had surgery, was that there is not a pattern, it just varies from individual to individual. Moreover, although Dr. Keene isn't willing to go lower than where nature put your hairline originally, she often recreates a youthful hairline, and is very good at being able to determine where it used to be. It is important for you to know the risk of future hairloss, and highly recommended that you take Finasteride to help combat your hairloss, but Dr. Keene's opinion is that it looks better to have a youthful hairline with some hair loss behind it than a very receding look (though she works with her patients preferences). She also used to take a more conservative approach, but she has reconsidered due to her experience and observations. Even with future hairloss, the hairline still provides a frame to your face, which is important in regard to what draws the eye. We have also seen patients with that pattern of hairloss, i.e. a hairline with receding behind it, even though it is not one that is seen on the Norwood Hamilton scale, who have never had surgery. The scale is a well respected guideline, but nature tends to offer so much variability that it isn't possible to include all naturally occuring patterns. Best of luck in your decision making process.

Agenteye, Some contraindications for hair restoration surgery would include the following: if surgery could not be performed safely--for example, patients with heart or any systemic illness that is not well controlled, or if a patient is on anticoagulant therapy, and stopping that medication would place them at risk. In fact the list of health concerns that would make surgery unsafe is long, too long for this blog--but it is the responsibility of each doctor to know what they are. However, we have safely and successfully operated on many patients with diabetes--keeping in mind the caveats, and understanding of that diagnosis, that doctors are trained to pay attention to. There are many patients with a multitude of medical conditions who can safely and successfully undergo hair restoration, but that is why it is considered a surgical procedure that should be performed by a licensed medical doctor. Another relative contraindication is if the patient would have insufficient donor hair to achieve his/her goals--and some would feel that if a patient could only achieve their goals using donor hair that is likely to be non-permanent they may not be a good candidate for surgery, either (that is Dr. Keene's view). Skin or hair disorders that would prevent a successful result are also contraindications. Again, these contraindications did not appear to be the circumstance in this case. While Dr. Keene notes there are relative factors that seem to affect wound healing and the rate of hair growth, this is not a contraindication to surgery. It did impact her recommendations, and did mean she was prepared to leave the sutures in longer if there was any indication that healing was slower--but that was not necessary. It also meant that when she saw the patient for his postop follow up at 6 months she suspected that it would take more time to see all of the grafts erupt. All patients who come to our office, with or without known medical conditions, are counseled that final results can not be seen before a year at the earliest, (our post operative instructions are clear on this also), and in some cases it can take even longer. Many patients who have blogged on this site have attested to that fact. A delay in results is not the measure by which a patient is assessed, rather the end result--which even now is not apparent for Srod, but we are pleased with where his results are at the 10 month mark. There is no perfect formula to predict rates of graft growth--though in over 15 years of experience Dr. Keene has noticed that younger people tend to grow a bit faster, and gray hair tends to grow a bit slower--but even this is not a hard and fast rule. Dr. Keene is aware that as much as we know, there is still more to learn. Experience helps in predicting results, but every patient is unique.

This 61 year old gentleman came to Dr. Keene to restore his hairline and augment his crown density. She transplanted 2200 grafts to the front, and 300 to the crown. Dr. Keene had suggested he could do as many as 3600 or more grafts for the same areas, but he chose a lower density, which works for his longer hair style preference. Here is the graft break down: 1 haired grafts=343 2 haired grafts=877 3 haired grafts=889 4 haired grafts=417 Total grafts=2526 Total hairs=6432

Dear SROD, Thank you for coming in to the office for a 10 month follow up appointment. We were happy to see a change in the frame to your face (as planned) and a very nice cosmetic result in time for the holidays! Keep in mind that it is possible with hair styling to make hair look better or worse--even for people who haven't had any surgery! Your most recent posted photos don't really do justice for the change and success that was achieved. It would be rare for Dr. Keene to suggest or recommend for patients with hair loss to try to achieve the same density that nature provided--as donor areas in most people would be rapidly depleted, and donor availability could not achieve it in most cases. So, the true art of hair restoration is our ability to make less hair look like more--but this means that hair styles (especially short, or those matted with hair spray, or gel, etc.) or parted in transition areas, can make results appear less dense, too. With that in mind, when you were in you mentioned that you were actually happy with your results except for a small area in the left hair line, and commented that you were surprised at the negativity of others contributing to the blog, and that you had finally stopped reading it. However, the parting of your hair along the hair line in the photos does make it appear differently than growth seen at 7 and 10 months in our office, and may have contributed to some of the comments engendered. However, Dr. Keene has agreed that with the way you wish to wear your hair, a small area of about 7 cm2 along the left hair line could be strengthened so that it will appear more full, and allow you to wear your hair combed forward or backward. She also discussed with you the issues pertaining to the density she placed, as well as the donor harvesting method she recommended, keeping in mind your particular medical circumstances and hair characteristics. You did not mention many of the contributing and important details of your initial discussion with Dr. Keene--possibly because you aren't aware that your particular medical details were contributing factors, so we appreciate your agreeing to allow us to discuss your case in detail on the HTN forum. We always do our best to protect patient confidentiality, so needed your consent to be more specific, though we will continue to protect your identity even as we address issues for participants in the blog who do not have all of your medical details. Dr. Keene expressed to you that she based her recommendations for density in the hairline in order to blend with the natural density behind it--which was less than normal at the outset. This area is probably being affected by your personal genetics, but also by some of the medical conditions you live with (diabetes and thyroid disease). To have transplanted at a higher density would have created an abnormal imbalance in visual density, and she felt it would not have created the natural density transition that occurs in the hair line relative to hair density in the frontal area behind the hairline. She did not recommend transplanting substantially into that hair (other than a few mm of overlap), either, as it may have promoted shock loss (telogen) in hairs that appeared to be vulnerable. Instead, she encouraged you to use medication to stabilize this area--keeping in mind that if further hair loss did occur you could place grafts in that area, but if you were stabilized on medication--as most patients are, she was saving your donor hair and saving you $$. Dr. Keene does not profit from this approach; in fact, session size in our office often exceeds 3000 grafts and costs substantially more, so there was no ulterior motive to placing fewer grafts, except that she felt this was appropriate for your goals, hair characteristics and medical circumstances. It did seem that there was some irregularity in graft growth rates relative to what is expected. Dr. Keene's notes indicate at your first follow up (5 months post op), where you had trimmed the grafted area much shorter than the rest of your hair (you said you were trying to stimulate the grafts to grow faster), that you were unconsciously rubbing the area frequently during your office visit—she was not sure if that may have affected the growth, but we know that was not intentional, and she expressed that you should make a conscious effort to refrain from that action. It is not clear why graft growth rates can vary in some patients, since most patients do grow in more diffusely. It is possible that your history of diabetes or treatment with radioactive-iodine therapy for your thyroid a few years ago were contributing factors which may have resulted in slower growth at the outset. Fortunately, with the tincture of time, the transplanted hair appears to have emerged completely at 10 months, but it is anticipated you may still see some increase in hair caliber (thickness). At this time, the grafted hairs seem to have caught up to each other, and diffuse hair growth in the frontal hair line has occurred, and changed the frame to your face, making you look younger and blending nicely--as we had hoped it would. In regard to the recommendation for strip surgery, Dr. Keene felt that although strip surgery creates a temporary open wound, it is closed/sutured shortly after it occurs--and is water tight within about 12 hours. In comparison, FUE would have required that you left surgery with nearly 2000 small, but none the less, open wounds on your scalp--and given the known issues that diabetes can have on delayed wound healing and infection she did not feel this would have been advantageous to you. Each patient seen by Dr. Keene is individually evaluated and assessed, not only for their goals for surgery, but from a medical perspective--that is why it is important that patients seek the expertise of doctors who specialize in hair restoration when electing to proceed with surgery. It would be easy and advantageous for any doctor to recommend the most grafts and the most expensive donor harvesting method they could possibly charge for--but that is not always in the best interests of patients, which is our foremost consideration. We were very pleased to see that the results of your surgery--in both the frontal hair line and crown, have largely achieved the results we expected with only a modest use of your available donor hair.

Dr. Keene has performed megasessions with FUE, this number of grafts was just offered to address a targeted area of concern, because our patient didn't want another strip operation, and had not yet reached full maturity of his grafts. pupdaddy, We do not do bait and switch marketing, that is offensive as Dr. Keene is forth right and has a reputation for honesty, you clearly don't know her to make that comment--we do offer both FUE and FUT and do provide patients with information so they can make an informed decision. Dr. Keene has been very vocal about promoting competency amongst all hair restoration surgeons in both techniques of donor harvesting, among her peers, because only when surgeons are capable of offering both strip and FUE donor harvesting can they reliably offer the most appropriate procedure for a given patient. There were circumstances particular to this patient's medical history that were reviewed, and Dr. Keene's recommendations were based on that, as she does for all patients when providing her recommendations. The limited number of FUE grafts were also based on those factors. We are continuing to follow up with Sr0d.

RCWest, We do include some DFU's (double follicular units of up to 4 hairs) to increase density. So if hairs are within a mm of each other, we will typically try to keep the hairs togehter in one graft, even if there is a slight gap in between the hairs. This is because dissecting them down into 1 and 2 haired grafts, and placing them into seperate incisions that are spaced a mm apart, results in spreading the hairs farther apart. By keeping the hairs closer together, we provide higher density. However, we avoid exceeding 4 hairs per graft, because more than 4 hairs per graft can result in a grafty appearance. The DFU's are placed in strategic areas, not in the front hairline for example, but more toward central areas including the crown, with follicular unit grafts surrounding them.

Dear Coligion, Dr. Keene first evaluated you for hair loss on May 22nd, 2008, and at that time, recommended Finasteride therapy, not surgery. You then returned to the clinic in 8 months time, reporting that the medication had provided some stabilization, but that you were still unhappy with your density. In particular, her notes indicate that you were focused on various areas of the frontal scalp that you wished to address with hair transplant surgery. Dr. Keene noted that she cautioned you against this approach and explained to you that progressive hair loss would leave you with unsightly islands of grafted hairs if you opted to pursue that approach. On further discussion, Dr. Keene recounted in several areas of her notes, she explained that shock loss and progressive hair loss were significant risks to your request for surgery. Furthermore, she was aware that some young people become very focused on minor cosmetic imperfections which they perceive to be significant, and that correction can be very satisfying to them. You had also indicated to her your goal of establishing some permanent hair coverage to the frontal area, in light of your concerns about progressive hair loss based on your family history. Because of this, she agreed to proceed with a surgery that would guarantee the placement of permanent hairs in your frontal area, but in a very conservative number, and conservative area of coverage, in order to minimize shock loss. In this way she would assist you in preserving frontal hair coverage without depletion of your donor hair. Her operative note very specifically indicates that she did not place hairs in your hairline, and in fact that any grafts that were placed were several centimeters behind your existing hairline. Our post operative instructions at that time recommended you be seen in follow up every 3 months for the first year. Our notes indicate that you came to the clinic for follow up at 2 months (too early to assess your growth), 4 1/2 months, and 5 months, at which point you did not return for further follow up. However, during this time, there was no evidence of significant telogen effluvium (shock loss) caused by your surgery. Shock loss happens within the first few weeks to months after surgery. Any hair loss you experienced in the intervening 3.5 years is likely due to progression of androgenetic alopecia, especially if you have not continued to use Finasteride. Dr. Keene would welcome the opportunity to review your current situation with you, and would suggest that if you are not still using medication, you consider resuming it, possibly at a lower dose, to re-stabilize your pattern, and possibly recruit any recent hairs that have been lost. Per Dr.Keene, you can also consider using minoxidil, because although the studies that were done for FDA approval were in the crown and vertex only, therefore the FDA will only allow the pharmaceutical companies to claim effectiveness in this area, she has many patients who have benefited from application of minoxidil to the frontal area, and the orignal impetus for the pharmeceutical companies to do the studes was the fact that oral minoxidil caused generalised hair growth in many people who were using it for blood pressure control. Please call our office at your earliest convenience to schedule an appointment.

This patient came in recently for a follow up. Dr. Keene did a few small surgeries for him--the last session was 12 years ago, and though she has refined her technique, we noted that his results are still excellent today. So I am posting them to show that even 12 years ago, Dr. Keene was providing patients with a completely natural result, with the main difference being that today we can do more grafts in one session, and place them closer together. He is still very pleased with his results! The photos are from before and 5 years after his last surgery session, with one photo from 12 years post surgery. Here is the graft breakdown: 1 haired grafts 762 2 haired grafts 2359 3 haired grafts 1501 4 haired grafts 699 Total grafts 5321

This 32 year old gentleman had seen his hairline and crown gradually decline since his early 20s and decided he would like to see that reversed. He came to Dr. Keene with the goal of restoring his hairline and filling in his crown. The photos are from before, and 9 months post op, 2808 grafts. Here is the graft breakdown: 1 haired grafts 446 2 haired grafts 933 3 haired grafts 918 4 haired grafts 506 Total grafts 2808 Total hairs 7090

Just wanted to clarify, Dr. Keene provides Hyrdocodone with tylenol - the generic of Lortab. I am sorry to hear, hairtoday that you didn't realize we provide pain medication and that we do ask our patients to call us if they have pain because Dr. Keene can address that. Some people are more resistant to pain meds than others, sometimes because they had to take them for something else and developed a resistance, or sometimes because of genetics. Most find that that the Hydrocodone and tylenol works, but if not she can address it further when needed.

This 28 year old gentleman had experienced hair loss since his early 20s and gradually receded. He decided it was time to do something about it and came to Dr. Keene to fill in his temporal area, and add density to his front hairline. Dr. Keene prescribed Finasteride to help stabilize his hairloss, and filled int the front hair line with just over 1300 grafts. The photos are from before, and 10 months post surgery. Here is the graft breakdown: 1 haired grafts 442 2 haired grafts 685 3 gaured grafts 676 4 haired grafts 385 Total 2100 plus Total hairs 5380

This young woman came to Dr. Keene to even out and bring down her hairline, which was slightly receded, more so on one side than on the other. Dr. Keene evened it out, and filled it in with a little over 1300 follicular unit grafts. By the year end, when she was able to see the full results, the patient was thrilled. The photos are from before and after 12 months. Here is the graft breakdown: 1 haired grafts 357 2 haired grafts 528 3 haired grafts 301 4 haired grats 151 Total 1300 + Total hairs 2920 hairs

This patient in his 40's came to Dr. Keene to fill in his front and midfrontal area. Dr. Keene filled it in with just over 2500 grafts. I will post the details on his graft breakdown later.

Hi Hairtoday, Actually, Dr. Keene does a dual layer closure, and has done so since she began hair restoration surgery due to her experience using it as a general surgeon. That entails an internal layer of sutures that dissolves, and an external layer of sutures that is removed 1 week after surgery. Most hair transplant doctors used to do a single layer closure, but many are adapting the double layer closure technique. She also does a trichophytic closure, which means that one side of the epithelium is trimmed to allow the hair to grow out through the incision line, in order to mask the donor line. So that may be why you thought she did a tri closure. We would be happy to see you at Dr. Keene's office again. We offer a travel discount to help defray the costs of travel. Please give us a call and we can schedule you for a telephone conference with Dr. Keene.

Dear sr0d, I checked with Dr. Keene regarding your concerns. As David pointed out, it is too soon to assess your final results or success of your surgery at 6 months post operatively. Though Dr. Keene generally advises patients that it will take 6 months for the grafts to erupt, this is not a hard and fast rule, as each patient is different in their growth rates. In addition to varying genetic rates of the hair growth cycle, there are other things, such as medical and environmental factors, that may impact hair growth in general, including things like smoking, exposure to sunlight, stress, any direct trauma—and many other factors that can influence and sometimes slow the rates of growth. It is this reason why patients are advised not to anticipate the final results to be evident before a year after surgery, and this advice is part of the postoperative instructions you received. Your full period of maturation could be even longer than a year depending on these factors. Therefore, the amount of growth at 6 months is unique from patient to patient, with some patients having a lot of growth at that time, and some who have much more to come. You were interested in FUE as a less invasive procedure because of wound healing concerns. However, Dr. Keene felt that almost two thousand open round holes in the scalp, left exposed to the environment at the end of surgery, was not less invasive in terms of wound healing compared to an incision sutured closed immediately at the time of surgery. The amount of open wounding at the conclusion of surgery is greater with FUE compared to strip surgery, which was why she advised you to have a strip procedure. Dr. Keene will be happy to see you for a follow up appointment, to help address any concerns specific to your clinical circumstances, and she may also have some additional suggestions to see if your graft growth can be accelerated, as well as to take care of any cosmetic concerns in the interim. Please call the office to schedule a follow up appointment.

This young man came to Dr. Keene to fill in his hairline and his crown. Here is the graft break down: 1s) 406 2s) 849 3s) 725 4s) 230 Total grafts 2210 Total Hairs 5199

This 50 something gentleman came to Dr. Keene with the goal of adding more hair to his front hairline. The photos are from before and 1 year after 1918 grafts. Here is the graft breakdown: 1s) 211 2s) 523 3s) 753 4s) 431 Total 1918 Total hairs 5240

This patient is a hair stylist who came to Dr. Keene to fill in his hairline, including his temporal recession. These photos are from before, and 1 plus years after 2131 grafts in a session. He is very happy with his results! Here is the graft breakdown: 1 haired grafts 252 2 haired grafts 673 3 haired grafts 803 4 haired grafts 404 Total grafts 2131 Total hairs 5623

This 40 something gentleman had had 2 hair transplant procedures done elsewhere 10 years before. The prior procedures focused on the front hairline, but created an unnatural appearance due to the straightness of his hairline. Dr. Keene softened his unnatural hairline and augmented his density on the top midfront area, with about 700 FUT to the front hairline, and 1000 to the midfront. Here is the graft distribution: 1s) 299 2s) 742 3s) 488 4s) 176 Total 1705 Total hairs 3951

This young man came to Dr. Keene at the age of 27 to help restore his frontal hairline. He received 2667 grafts, and a total of 7345 hairs. The donor was removed using the strip technique. Dr. Keene also prescribed Finasteride to help prevent further hair loss. These photos are before, and 1 year after 2667 grafts. Here is the graft breakdown: 1 haired grafts: 308 (308 hairs) 2 haired grafts: 681 (1362 hairs) 3 haired grafts: 1037 (3111 hairs) 4 haired grafts: 641 (2564 hairs) Total grafts: 2667 Total hairs 7354

This 56 year old gentleman came to Dr. Keene to fill in his hair line and frontal area. The photos are from before and a little over 1 year after. He is very pleased with his results! Here is the graft breakdown: Grafts Hairs 1 haired grafts: 301 Hairs 301 2 haired grafts: 555 Hairs 1110 3 haired grafts: 755 Hairs 2265 4 haired grafts: 475 Hairs 1900 Total grafts 2086 Total hairs 5576

This 41 year old gentleman came to Dr. Keene with a goal of wearing his hat less:). When he came in for his 1 year follow up, he wasn't wearing it! Here is the graft count by number of hairs per graft: 1 haired grafts 416 2 haired grafts 1050 3 haired grafts 1099 4 haired grafts 532 Total grafts 3097 Total hairs 7941

Dr. Keene has done some actual follicular unit counts in various areas of the head on men who don't have hair loss, and found that it is more dense in the back of the head even when no hair loss is present. This is especially true for the first cm of the hair line, which can be as much as half the density of the back naturally. That is part of the reason that hair restoration surgery is successful (in the right hands) at creating a natural appearance, because at present doctors are redistributing hair from the back of the head, not creating new hair. Also, you can also lose up to 50% of your hair before you notice, in many cases. So you don't have to achieve the same density as what nature gave you originally to look natural.

Hi Spanker, Yes he is taking medication. The angle just isn't exactly the same, he didn't actually lose more of his forelock. His head is bent forward at a sharper angle in one photo than the other, but both show his full hair line, so you can tell that the temporal recession is filled in. We didn't actually have his hair combed back in the before photo either. When we do fill in areas where there is the possibility of further hair loss, Dr. Keene always recommends that the patient take Finasteride. Although Finasteride studies have not been done in the frontal area, we have seen anecdotally that it does appear to help keep the patient's hair in that area. Dr. Keene always makes sure to let patients know that there is a risk of further recession of the native hair behind the transplanted hair, allowing patients to make an informed decision. I will make a note in his chart to try to take photos from a more acute angle next time he is in and perhaps post an update then.

This young man of 26 came to Dr. Keene to restore his youthful hairline. She placed a little over 2600 grafts in the frontal hair line, filling in his temporal recession. He is very happy with his results and looks as young as he is again! Here is the graft breakdown: 1s 308 2s 681 3s 1037 4s 641 Total 2667 Total hairs 7345