Dr. Carlos Wesley

Thanks, CaddyTad77. Yes. I remember speaking with you and I'll answer you offline. Our engineering team is designing the next iteration of the device that we plan to test in a few weeks and display during October's ISHRS meeting. Later this week I will post images of the a few results so that members can get a sense of how we quantify growth of newly transplanated hairs. It's all pretty exciting!

Patients often come into an office wondering whether or not they are "good candidates" for surgical hair restoration. Even when told "yes" or "no" by the physician, a patient may want to better understand why they are or are not deemed a good candidate and where he or she may fit into the overall spectrum of candidacy. While young patients can certainly refer to a helpful publication authored by our practice (view here) that helps provide a ballpark for the ultimate number of donor hairs one may anticipate over their lifetime, it is helpful to know about the "miniaturization" rule. Using magnified images of a patient's donor hair, a physician can determine the number of miniaturized hairs (those of the finest caliber compared to the regular caliber terminal hairs). As a general rule of thumb, young patients who possess 25% or more of their donor hair in miniaturized form are not great candidates for the surgical procedure. Not only will a large number of the transplanted hairs likely not be permanent hairs, but also the donor scarring (either FUT or FUE) will likely become exposed over time if the surrounding donor hair continues its anticipated course of MPB. The following image depicts a relatively poor candidate for HRS on the left and a better candidate for HRS on the right. This is based on the relatively low number of miniaturized hairs present in the righthand patient's donor area. Both were of the same age. This next image also compares a poor candidate (left) with a much better candidate for the procedure (right). There are also a number of more subjective variables that help determine a patient's candidacy: the wave, curl, frizz, and color contrast between the hair and scalp. These can also influence the ultimate appearance of a patient after a full session. To put it all together, here is an image of a good candidate's donor area, recipient area prior to treatment, and his recipient area after treatment as seen under a magnified lens. The same patient's transformation after a 2701-graft FUE session with me can be viewed in the accompanying video montage.

This patient recently returned to our office to display his donor scar after two strip harvest session totaling 4020 grafts. We've been able to update his complete transformation video (seen earlier in this thread) as well as addinghttp://vimeo.com/73333653 below that is specifically focused on his donor scar.

Thanks, Spanker and agenteye, for your comments. That's the correct nomenclature, Future_HT_Doc! Since the sessions involving very large "plugs" are essentially obsolete, the term follicular unit transplantation (FUT) has taken on a new form. Now that follicular unit extraction (FUE) so clearly, specifically, and effectively refers to the idea of harvesting individual follicular units one at a time directly from the donor area, any other reference to FUT is generally assumed to be strip harvest. It's true that FUSS is a more specific term and should probably be used to more specifically describe the manner of graft harvest.

During my recent trip to Boston to see new consult patients, I also had previous surgical patients drop by. Here is an image of this patient taken approximately two (2) years after his session. While I didn’t travel with our NYC office’s best camera or have our ideal lighting, you can still get a sense of his new facial framing from the procedure. I’ve also included an updated image of his donor scar from follicular unit transplantation (FUT).

I’ve also included an image of his donor scar from follicular unit transplantation (FUT).

FFs are Follicular Families. They involved four (4) or more hair follicles and are found in patients with relatively dense and closely-packed bundles of hair. They are great for density, but not for a soft hairline. It's best to use them behind a series of fine 1-haired grafts that are blended with fine 2-hair grafts. There is always a general progression of more "full" grafts (those with a larger number of hairs/graft) when you work your way posteriorly (backwards) from the hairline as well as a progression of finer caliber hair to more coarse caliber hair. This helps generate a more natural gradient of softness to fullness. It varies, however, in patients who have minimal color contrast between their hair and scalp (surgeons can more readily add more "full" grafts closer to the hairline) versus patients who have greater color contrast between their hair and scalp (in whom the more "full" grafts are best tucked behind more fine-caliber follicles).

This patient has been known to our office for many years. He began taking finasteride about four years ago. In addition, he had been coupling this with topical minoxidil 5% for three years prior to any surgical intervention. At only 7 months, I encouraged our office to display this montage, not for the recipient growth (which will continue and you will see from all angles once it's grown in fully), but rather to illustrate the planning process in a young man. In our office's peer-reviewed publication that compiled the opinions of 34 of the world's most experienced hair restoration surgeons worldwide with nearly 1000 years of combined experience, there's a limit to the amount of safe donor scalp hair that can be harvested. The key points that I feel strongly about (and you may see differently) are: having this young patient really commit to medical treatment and seeing it's benefit before undergoing FUT or FUE; creating a cosmetic improvement that doesn't draw attention to itself (donor and recipient), but rather gives that patient a healthier look; and ensuring that the pattern will continue to be age appropriate in his 40s, 50s, etc. You can see how low this 23-year-old athlete's existing hairline currently was. Giving in to the temptation to transplant at that level would have resulted in the type of unnatural outcome (see pic below) that I've seen from patients coming in for repairs after having that overly-aggressive hairline treatment performed by other HT clinics at a patient's young age. The transplanted pattern simply doesn't match what nature had intended. It's important for a patient to look great 18 months after the procedure when the transplanted hair has fully grown in. It's equally important for them to look great 18+ years after their session when their pre-existing hair has continued to recede.

For those interested, I have attached a video that demonstrates the surgical technique involved in performing a trichophytic closure for FUT cases. It differs from a standard surgical closure in that the edge (either one or both) of the donor wound is first "prepped" (i.e. a 1mm portion is removed from the surface) before the closure is performed. Carefully bringing the newly-formed edge together with the opposing donor edge enables hair to grow through the donor scar. This helps further camouflage the donor scar. Caveat emptor: This may not be video for those with queazy stomachs. Enjoy!

Here's an update on this patient who underwent a session to the front and also the mid scalp region. While high density of transplantation is often a strong point of emphasis on this forum, it's not always the most appropriate approach. This patient desired a soft, natural-appearing coverage of his scalp with a virtually imperceptible donor scar. So, his treatment plan was designed to bring his coverage back to the vertex transition point (where the head begins to slope downwards). Often times, leaving an untreated crown while adding hair coverage around it is one of the most effective ways to generate a more natural-appearing transplant.

You're very welcome. I prefer the blunt 0.8mm punch as, in my hand, I find that it tends to minimize transection (versus sharp punch). My preference is also to limit FUE sessions to <2000 grafts/day. The out-of-body time for these types of grafts that do not possess as much protective surrounding subcutaneous tissue as those from a strip harvest can start to impact their survival after many hours.

We're certainly looking at it closely and have effectively adopted the use of both Acell and PRP into our patients' FUE donor healing. Although we haven't initiated any formal investigation, there is anecdotal evidence that it can help regenerate hair follicles from transacted hair fragments in the donor area.

Thanks for your comments. The song is "Sweet Disposition" by The Temper Trap. We learn all sorts of wonderful things on this site!

Wherever your HT was performed, that is certainly a wider than average scar, xtactic5. Good thing is that, at only four months post-op, the redness will continue to subside a bit. I agree with gillenator that you should contact your doctor's office to find out the details as it will inform you and help you plan in the future. A focused scar reduction or FUE into the residual donor scar can certainly help camouflage it down the road and allow to to comfortably wear your surrounding donor hair at a much shorter length.

At long last, this article just came out in print in the May 2013 edition of the peer-reviewed journal Dermatologic Surgery. I think another 1000 grafts via FUE is a reasonable estimate, Spanker. In addition, if you begin to include grafts harvested from the beard via FUE, you can increase that number considerably...

Thanks again for your comments. While I didn't use them in this patient, his minimal color contrast (just like that in this grey-haired Caucasian patient, for example) also makes him a great candidate for double follicular units (DFUs) that would be tucked well behind the finest hairs that are placed within a hairline. This provides great coverage as the hair gradient of softness to density progresses backwards.

Thanks for your comments. This patient also had ACell added to the donor area at the end of his FUE procedure. Regarding my FUE patients' donor areas, we've found that using a combination of PRP and ACell has helped camouflage any unwanted evidence of a donor harvest even more effectively. While this is just a series of observations at this stage, it is certainly encouraging.

Hi, james84. Since 2006, there has been evidence that PRP, when used properly, can enhance the yield of transplanted hair follicles. Here's the link to Dr. Uebel's article and I've attached a screen shot as well because the link may only be accessed via our medical practice's firewall. This was published in one of the most well-respected peer-reviewed journals in our field. MTL30, I can't begin to speculate on another doctor's numbers. Many of this patient's grafts that were placed well behind his hairline included more than 3+ hairs for added density. Fine 1s and 2s were used to establish his hairline. SamSpade, thank you…I think!

This is a very informative. I just wanted to clarify that I have used a combination of 0.75mm, 0.8mm, and 0.9mm punches for my patients (whether its scalp or beard or body FUE). The size depends on the density of donor hair in that region as well as the desired graft type (3-haired FU versus fine 1s or 2s). I use a SAFE scribe and do my own FUE on my patients (rather than outsourcing). All FUE grafts are incubated in chilled PRP prior to transplantation. This helps account for the slightly decrease presence of protective subcutaneous tissue that is inherent with FUE versus strip harvest grafts.

Relating this patient to a separate thread on FUE, we used a combination of 0.8 and 0.9mm FUE punches throughout. The beard was predominantly 0.8mm (as it is slightly more exposed) and the scalp was a combination of 0.8 and 0.9mm punches (selected based on patient's donor density in that scalp region and the type of graft desired).