Dr. Carlos Wesley

Great topic. One simple and effective method for relief of this short-term discomfort is applying a hot towel soaked in epsom salt water to the back of your head. This can be repeated 3-4 times for a few minutes each time. This can help soothe any discomfort, which will resolve in time. Our office conducted a study on post-op donor discomfort a few years back. While it was primarily focused on FUT, it would be interesting to also identify factors that lead to this rare occurrence after FUE as well.

Thank you for your comments. It is also worth mentioning that during his hair transplant procedure this patient had injections of platelet-rich plasma (PRP) and ACell into both his mid scalp and the frontal third of his scalp. While magnified images and hair mass measurements of the areas of his scalp not surgically treated revealed that there was very little change in hair mass from injections, the patient reported that his surgically-treated area began its post-op recovery and growth within a few weeks of the procedure (significantly earlier than the standard recovery time).

Attached, please find images of the patient's donor scar from his follicular unit transplantation (FUT) session in our office. He is approximately 13 months post-op.

Thanks, Blake. In addition to the chilled PRP as a storage solution, an ACell mixture is blended into our graft storage solution. This may also be contributing to this encouraging trend of earlier hair growth.

Thanks for you comments. Yes. He's a very happy "middle aged" man.

Thanks for you comment, abcd0000. Much appreciated.

Thank you very much. And, I enjoy seeing the very nice results posted by your clinic as well.

Thanks for your comments. Spanker, I've attached images along this patient's timeline. The first one is how he looked at the beginning when a more conservative pattern was created. The other images illustrate his follow-up session down the road. He was approached like this because - for such a young patient - I wanted to make sure that he had enough hair transplanted to always have a natural appearance in his 30s, 40, 50s, etc. Once this grew in and he was excited about advancing the pattern, then I could feel more comfortable advancing his hairline a bit during his second FUE session (seen in the last 4 images, taken about a week after his 2nd FUE session) as well as transplanting back to his vertex transition point (where the scalp starts to slope downwards). This way, even when he looses his pre-existing hair in his current very low hairline, he'll have a nice looking hairline and his entire mid scalp will be nicely covered for essentially the remainder of his life. If he were a bit older and had a more certain donor prognosis, we could have easily done the 3000+ FUE grafts at the same time. However, we both preferred the step-wise approach because it 1) gave the patient confidence that it was going to look great and 2) for financial reasons, it made the procedure more affordable (rather than a single payment). It's also true what you say, scar5, about hair shafts having more coverage when seen from the side. However, mixing punch sizes doesn't cost more in our FUE cases. It's something I always do for patients in order to vary the types of grafts harvested and for their subsequent transplant.

Here is an example of the donor area from an African-American patient of mine after a relatively-small follicular unit extraction (FUE) session. He only had about 700 grafts transplanted, but certainly could feel comfortable with a short hairstyle after a session in our NYC practice.

Thanks, OtherSyde. This WAS follicular unit transplantation (FUT) or strip harvest. I've attached a magnified image of this patient's donor scar as seen at 11 months. Now, if an African-American patient has a history of keloid scarring I would certainly first do a small test session to ensure that his/her donor closure would be successful. If not, patients should be able to wear their hair at a relatively short length like this because the additional curl of the surrounding hair provides even better coverage of any fine donor scar than straight hair.

Thanks, Rootz. It seems a little counterintuitive, but scars after having subsequent surgeries can often be even finer than they are after the first session. It's generally the mastoid region (about two inches behind and just above the ears) that are most challenging to maintain a fine donor scar. This is also generally the region with greatest tension and least scalp laxity. For this reason, patients are often encouraged to focus their preoperative scalp massages specifically in the mastoid region.

Thanks, Blake and Janna (Shapiro Medical Group). It's really refreshing when other clinics support one another. It's the best way for our field to continue its forward advancement. Much appreciated.

Thanks for your comments. I have attached a few of his pattern pictures. As you can see, patients in our practice do not need to shave their heads for an FUT procedure. In fact, the pre-existing hair is quite beneficial in that it camouflages any redness during the short-term recovery process. Therefore, patients are able to return to work or social activities earlier. In addition to the pattern pictures, I included a close-up image of the donor at the time of suture removal. This patient did a great job of keeping his donor area clean which facilitates the suture removal process and allows you to see the alignment of the donor wound edges.

@Gary1911A1: The most updated information regarding the Pilofocus technique can be viewed here. Rather than explaining it in detail during each and every in-person consultation, I thought I would simply post the 25-minute in depth presentation that describes the background and rationale behind the concept as well as the development of the surgical device and clinical results thus far. The password required to view the video is "piloscopy".

This 42-year-old male was bothered by his expanding bald crown. He elected to fill his mid scalp region. A 2475 FU session of FUT with Dr. Carlos K. Wesley covered the mid scalp. Magnified FotoFinder images show the mid scalp region before and approximately one year after his procedure. Global images (below) also display this patient's transformation.

Thanks for your comments. @irishsailor, this patient certainly has the option of coming back down the road to treat his crown and even add to the previously-untreated frontal portion if he wishes. The advantage is that he won't be obligated to do this in order to maintain a natural appearance as his inevitable course of MPB continues over time. This transplant design can serve as both a conservative eventual hairline as well as being consistent with the arc of a thinning crown. As you well know, focusing on the crown exclusively in a young patient may ultimately result in an unnatural "island" of hair over time as his MPB takes its course and the surrounding hair thins.

Here's a rather interesting finding over the past year in our office that I thought I would share with the community. Although it's purely anecdotal at this stage, I have observed that when incubated in platelet-rich plasma (PRP) and ACell during their out-of-body time, transplanted hair follicles appear less likely to shed early in the postoperative process. For illustration, here is an FUE patient of mine who, in one day, had 2060 FU transplanted throughout his frontal half. He returned over a month later (a period before which micro graft shaft shedding had occurred in years past) and very few (if any) of the transplanted hair shafts had fallen out. This provided an early framing of this patient's face as the transplanted hair length closely matched that of his surrounding pre-existing hairs. An observation that our office will certainly explore in more detail...

Thanks, Nick. It's the minimal color contrast between the color of hair and color of scalp combined with the "shingling" effect of having curly hair that can give African-American patients the illusion of more coverage with fewer grafts. I've encouraged this patient to wear his hair a few millimeters longer in order to take advantage of this "shingling" effect. But, he is just happy to be able to continue to wear his short hairstyle even after a strip harvest (FUT or FUSS).

Thanks, Jotronic, for your reply. It certainly makes for an interesting topic of discussion. While every clinic differs slightly in their approach and what works best in their hands, a point of clarification that I think is important not to gloss over is the essential shape of the grafts prior to transplantation. There should, therefore, be a limit to the degree of graft trimming. The "Hair Transplantation" textbook has, for many years, stated that: "The 'perfect' follicular unit graft (is that possessing) very little dermis, sufficient subcutaneous fat, intact sebaceous gland, and an overall pear shape." Leaving ample protective tissue around the infundibulum and dermal papilla (stem cell-containing portion of the hair follicles) shields the grafts from various environmental hazards while they are out of the body (e.g. desiccation and the trauma of being handled when transplanted). The amount of tissue has been shown to directly impact the survival of grafts in numerous studies (Dr. Michael Beeher's "surrounding tissue" study, Dr. Seager's viability study, and Dr. Greco's "crush study").[1,2,3] Looking at Beehner's study (below) we see how the amount of protective tissue does influence graft survival (especially at 19 months postoperatively). To better understand this investigation, let's focus on the grafts of the same type. So, two-haired grafts, for example, differ mainly in the amount of tissue surrounding them: from "skeletonized" (significantly trimmed) to "chubby" (not markedly trimmed). That's a 129% difference in graft survival at 19 months (see below). Now, when we focus on one-haired follicles (which are more commonly used in the hairline of patients), the difference in transplanted hair survival is even more pronounced (see below). Dr. Beehner showed a 204% difference in hair survival when the grafts were trimmed to a skeletonized shape versus their "chubby" counterparts. Why does this matter? And how does this relate to my initial posting? Well, the beauty of strip harvest (FUT or FUSS) grafts is the amount of surrounding tissue that can be included in each graft to ensure the greatest survival of transplanted follicles (see below). Trimming that to an advanced degree in order to pack them into sites that may not be able to accommodate grafts with more protective tissue may have the aforementioned detrimental effect on their ultimate survival. Now, while the general lack of protective tissue of FUE grafts is not necessarily advantageous, it may allow the grafts to more easily fit into more closely packed recipient sites. Fortunately, Jotronic, you are representing an excellent surgical clinic with skilled physicians and technicians. So, these reproduced findings may not hold true in patients with whom you have dealt. I do feel, however, that these findings are important to point out. Beehner M. A comparison of hair growth between follicular-unit grafts trimmed “skinny” vs. “chubby.” Hair Transplant Forum Int 1999;9:16. Seager DJ. Micrograft size and subsequent survival. Dermatol Surg 1997; 23:757-61. Greco JF, Kramer RD, Reynolds GD. A crush study review of micrograft survival. Dermatol Surg 1997;23:752-5.

@scar5: Propecia may delay the onset of miniaturization because it slows down the cycling of hair follicles. With each cycle, hair follicles may become progressively finer in caliber. @ali1991: There are a number of methods to evaluate hair characteristics. Any physician performing surgical hair restoration likely has something to accurately analyze hair quality in order to determine a patient's candidacy. There are instruments such as the Folliscope, the FotoFinder device, the Dermatoscope, etc. A magnified lens allows for fairly accurate analysis. If you happen to have (a whole lot of) time on your hands, you can read the chapter I authored in the Hair Transplantation textbook called "Enhanced Patient Selection: The Folliscope".* @RecedingTide: Yes. Propecia is a great adjunct to surgery. Since it is most effective in the crown and mid scalp, it allows for a surgical focus on the frontal half of the scalp and a medical approach on the remaining portions. This can certainly delay the need for subsequent sessions to those areas. Remember, though, once a patient stops taking the medication, any benefit they received is lost. So, it's essential that areas of future loss are also addressed with any surgical approach to transplanting hair follicles. *Wesley CK. "Enhanced Patient Selection: The Folliscope" Hair Transplantation, 5th Ed., Ungers and Shapiro: 82-83. 2011

Thanks, everyone, for your comments. This case was an FUT session. I have attached an image of the patient's resultant donor scar. It's helpful to see a comparison between parting the hair where there is no scar versus parting it along the donor scar. I'll be sure to have our office post more FUE cases as well. Spanker, most of our patients come from referrals from MDs and hairstylists rather than from online. This may be a reason for why you don't see as many online postings from my patients as they often aren't aware of these sites. I'll be sure to "nudge" a few as the year goes on, however, to have them share their experiences.

Thanks for your comments. He also suffered from virtually no shock loss during his postoperative process. While this is something we warn our patients of who have considerable pre-existing hair in the recipient area (my practice encourages patients to keep their hair at its normal length for FUT sessions so that they may return to work or social activities sooner), it tends to be much more common in female patients than in male patients.

Thanks for the comments, everyone. Spanker: Miniaturized hairs have a diameter less than 0.03mm while terminal hairs are larger hairs with a diameter exceeding 0.06mm and a length greater than 1cm. These numbers probably aren't going to be that helpful, however, for the average person inspecting their hair in the bathroom mirror. So, I do consider miniaturized hairs in patients relative to their normal, terminal hair shaft caliber. There are plenty of patients with finer caliber hair that are still great candidates if their donor hair consists of a very small percentage in miniaturized form. BrianR: With respect to a patient's candidacy, I am only referring to miniaturized hairs in their donor area. Good candidates will have plenty of miniaturized hairs in their recipient area because that is the area that has and will continue to thin. It is the long-term survival of donor hair that is being transplanted into that area that matters (as well as the careful planning and placement of those hairs into the recipient region).

Thanks, chrisdav and Future_HT_Doc. The chapter's in print as of last week! fueonly: It's unfortunate that you were not made aware of the likelihood of hypo-pigmentation and punctate scarring prior to you FUE session. "Invisible" is a term akin to "always" and "never" that does not have much of a place in medicine based on the methods used today. Perhaps the best thing that you can do to make other patient's aware of your experience is to describe it and post images of your recovery after the process (on that separate forum that Future suggested) so that other patients with your skin type may have a more accurate idea as to what to expect. Regarding medical boards: the American Board of Hair Restoration Surgery (ABHRS) is the certifying body specific to our field.

Two of the questions posed to me prior to presenting the details of Pilofocus' graft harvesting technique are: 1) how do we evaluate growth of transplanted grafts and 2) how is it done objectively and in a blinded fashion? This is not overly challenging when conducted within a bald area. But what if patients in the clinical trial would like to camouflage the grafts within their pre-existing hair? Two interactive links below illustrate this method of determining viability of transplanted grafts within a hair-bearing area. Hair viability analyses are performed in a double-blind manner. Therefore, the type of graft transplanted (FUE, FUT, or Piloscopic) is unknown to the observer. Software enables subtle adjustment of each image relative to the other (not possible here). Therefore, near-perfect alignment of hair shafts can be produced to most accurately quantify the presence or absence of transplanted hair when the patients return for follow-up evaluation. Interactive Example #1 (superimposed before/after sans sites) Interactive Example #2 (with based on recipient sites) Go ahead and give counting a try. I can incorporate the results of this poll in the presentation that we have been invited to deliver at the upcoming ISHRS Meeting in San Francisco, CA next month!