Dr. Carlos Wesley

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).

We use a 0.8mm SAFE Scribe for most beard FUE. When the RPMs are turned down most of the way the transection rate is extremely low as the tip doesn't cut the follicle bulb, but rather encloses it within the cylinder prior to extraction.

The figures (e.g. graft yield) in our video are to reflect the published works of various surgeons in our field. Certainly there will be variation based on not only punch size, but storage solution, graft out of the body time, and graft handling technique used.

Thanks, Gary. Your comments are much appreciated.

Most patients that opt for FUE over the traditional strip harvest do so because they wish to wear their hair at the shortest possible length. This patient, however, was simply motivated by the more comfortable post-op healing process in the short term that generally occurs after an FUE session.

Thanks, hairthere. A little goes a long way in patients with great hair characteristics. Although many African-American patients may have slightly less donor density than Caucasian patients, the minimal color contrast and "shingling effect" of the newly transplanted hair provides great coverage.

Points well taken. If we had to generalize in our office when we most often encourage the trichophytic closure, it would have to be in patients with the greatest degree of color contrast between their hair and their scalp (e.g. jet black hair and pale white skin). Camouflaging any regularity in the form of a fine linear donor scar tends to benefit these patients most.

Thanks, 1978Matt and Future. We've seen increasing evidence that the incubation of grafts in chilled PRP has led to slightly earlier growth in our patient population. We'll keep and eye on this trend to get a better understanding of its true benefit.

According to this published study of 118 men (range 20 - 61 years old) with androgenetic alopecia (AGA) from 2011, patients over 30 years old with higher AGA grades demonstrated more improvement that their younger counterparts with a smaller degree of hair loss.

This is currently the longest investigation of finasteride 1mg (Propecia) efficacy. I should also mentioned that side effects were reported in 6% of patients (decreased libido and erectile dysfunction). Persistence of hair growth was not significantly less after ten (10) years versus after five (5) years of therapy.

Thanks for your comments. Many of these hairlines have previously been presented in the standard format (with before/intraop/after images) and the others will also be similarly presented. We just felt this would simply be a more enjoyable (read, shorter) way of presenting the various hairlines from our office. We'll have plenty more to come in the standard format!

Thanks for your comments. Every patient is a bit different, Brian, in terms of their rate of hair growth. In our office, we always let patients know that - while they can start to appreciate full growth at about one year - newly transplanted grafts may still be coming in even 18 months after their procedure. You have much to look forward to over the next many months!

Patients so often, when electing for FUT or the classic strip harvest, inquire about whether or not they should have a trichophytic closure. There are so many variables involved in this decision that even the major conference in our specialty has dedicated entire sessions to this topic.

These images illustrate that even within the same patient, the decision as to whether to "tricho or not tricho" can vary. All images are from my patient on his 3rd postoperative day using sterile nylon sutures for the donor closure. The first image is simply a schematic to illustrate where the magnified images where taken. The following image is a "standard" (non-trichophytic) closure used in the temporal areas where the patient had relatively low density. A trichophytic closure would not have made much sense here since little hair could've grown through the scar. The last two images were of the patient's occiput (back of his head). I did use a trichophytic closure in this region (both images) because of the hair density. In the first "tricho" image, you can see that the hair is going to grow through the scar. In the second, there is little noticeable hair along the donor suture line. However, this doesn't mean that there still won't be hairs buried within the closure that will ultimately grow through to further camouflage the donor area!

The patient in this video benefitted from a trichophytic closure in his donor area.

Thanks for your 'bump', Future, and for all comments thus far. I'm currently wrapping up a trip in Brazil during which I gathered follow-up images from patient #6 who underwent the initial clinical trial. @HARIRI, there was an update posted in late December of 2011 (included below) that was placed on a different thread.

While the February 2013 date was admittedly a bit overly ambitious, we're performing another cadaveric study in mid March to ensure the consistent creation of the same type of grafts that were used in the initial clinical trail. Once that has been demonstrated consistently and safely, we'll be able to initiate another trial. I've also applied to present all the details surrounding this surgical technique at the October 2013 International Society of Hair Restoration Surgery Meeting (in time to help HARIRI's crown!). I look forward to sharing everything with you at that time.

This is a nice summary of the post-op recovery process, Bill. I've attached a clip of a few of my patients (both FUT and FUE) a few weeks post-op in order to provide a sense for what it actually looks like during the recovery process. Patients in our practice undergoing FUT do not need to shave their head.

@sigtran: you can simply use a cotton ball soaked in rubbing alcohol and rub the ingrown hairs at this stage. This provides a clean surface for creating a micro abrasion to liberate any underlying follicle. A topical mupirocin 2% ointment can also benefit an area that is markedly itchy and red. Finally, I'm assuming that you meant "popping" in your final question. That will not impact the final result. Not doing what you actually inquired about in 3) can certainly have more calamitous consequences…

Thanks for all of your comments.

@Shyguy, because this patient has such great donor reserve for his age (almost 50), his donor-to-recipient ratio (the number of scalp donor follicles he'll have to treat the anticipated areas of hair loss in the future) probably won't require more than what he has "in the bank", so to speak (what's available in his scalp safe donor).

However, I do think that the use of body hair is a reasonable option in patients with a more limited scalp donor hair follicle reserve. Ideally, the initial recipient pattern creation would account for how many 'permanent' donor hair follicles the patient is destined to have over his or her lifetime. Perhaps this has earned me the label of "conservative", but it is certainly important to not use all of your lifetime available follicles in one area of your scalp without accounting for what you'll likely want in the future.

Thanks, zenmunk. This patient has plenty of permanent follicles remaining to treat his mid scalp in the future.

Good points, Spanker. This number represents only the number of 'safe' grafts harvested via strip harvest. Inclusion of FUE grafts from the periphery within the safe donor area would increase these estimates slightly.

The survey gathered the opinions of 39 of the most seasoned HT surgeons worldwide. They each provided a range for each of the six scenarios (below average, average, above average density for a future Type V and Type VI MPB 30-year-old patient). From these estimates, we calculated both the average and the standard deviation of the responses. Again, while these figures should not be treated absolute scientific dogma, they certainly establish the best available guidelines for treating this type of patient seeking HT.

In the attached figure, you can view the chart within the publication. The absolute best case scenario reported is about 12,000 'permanent' FU for a Type V MPB-destined patient at age 30. Not knowing any details behind the case you described, I can think of a couple of possibilities:

• The botched 3000k-graft session didn't really consist of 3000 naturally-occurring FU, but rather a number of "cut down" FU to artificially increase the number of grafts reported.
  
• The patient was destined to have less severe hair loss than a Type V MBP
  
• If everything was performed with FUE harvesting, the patient may very well have had a number of FU harvested and subsequently transplanted that were not permanent follicles. These will last only temporarily and the resultant punctate scarring from where these follicles were harvested will become exposed over time.
  

The final bullet point is the impetus for establishing these very important surgical planning guidelines.

Thanks for the comments. The density of transplantation in this case was still about 35-40 grafts/cm2.

I do vary FUE punch sizes on my patients (0.75 - 1 mm). Generally, I prefer utilizing 0.8 and 0.9 mm FUE punches to "cherry pick" specific types of grafts for different regions of the recipient pattern. Much of the variety also simply comes from the area of the donor scalp from which the grafts are harvested. Most coarse 3's and FF's (follicular families) come from the occiput (back of the head) while the fine 1's and 2's can be found more frequently in the temporal area.

Follicle transection rates depend on the patient characteristics as well as the inner diameter of the punch. Among the field's most experienced practitioners of FUE, transection rates range from 2% to 8.5% for the 1-mm punch and from 3% to 10% using the 0.75-mm punch. A 1-mm punch can exact an average graft of 2.5 hairs/graft, while a 0.75-mm punch yields approximately 2.1 hairs per graft. I think most of us on this forum agree, however, that punches of 1mm or larger can result in visually unacceptable donor area scarring.

Many practices like patients to use minoxidil around their surgery because it shifts a higher percentage of hairs (pre-existing and transplanted) into the anagen (growth) phase. Anagen hairs are more "sturdy", if you will, as their root is more deeply embedded than follicles in the telogen phase. The real benefit of minoxidil, therefore, is minimizing "shock loss" during the first few months after a surgery.

Hi, all.

Thanks for your comments and I do agree with what each of you have said. Perhaps the title of this post should be rephrased to say something more along the lines of: "A mid scalp surgical approach to a young patient who did not want to take or continue taking finasteride"

This is simply a surgical pattern that - rather than focusing a session in the crown/vertex of a young man - assumes the eventual progression of MPB (both on the sides and behind the area treated). The lateral regions (sides where he currently has hair) have been addressed with this session with transplanted grafts (as seen in the outline of the pattern) and the posterior (back) border of the pattern was feathered (akin to a hairline) with a concave arc. In time, he'll continue to thin in the crown/vertex and this concave border will be consistent with natural circular patterns of crown thinning.

Even if he never choses to return for another session to the frontal third, he'll be left with a natural-appearing conservative hairline in the front border of this pattern.

Believe me. Continuation of finasteride was encouraged during his first visit to my office. Even as we touch base down the road, I'll remind him of finasteride's demonstrated benefit to patients in their 30's over other patients of other age groups…