MadMan

KO said: "Personally, I feel that hairlines are only one part of the overall transplant, and while they attract a lot of attention from people, I don't believe they are necessarily the most important aspect, especially for higher Norwoods. The importance is also lessened by what hairstyle you wear." To me, the importance of the hairline work can’t be overstated when it comes to a transplant. Anything the least bit off invites the dreaded upward drift of the gaze from people you meet. Those “looks” can come from a subpar hairline design (shape, location, framing of the face) or from subpar technical execution (density, angulation, natural irregularity), or both. Both the design of the hairline and its technical execution are equally important. If not just right, either one can mar an otherwise “successful” hair transplant. If you have to hide the transplanted hairline zone by letting the hair fall forward, I would not consider the transplant successful, let alone optimal or elite. With today's transplants by the elite surgeons, it isn't an either-or situation. You can have both a good look of density and a natural-looking hairline that well frames the face, even if you fall in the Norwood 4a or 4 range. FUE2014 said: "Hey madman, appreciate your opinion. Can you provide any examples from the link below . . . of NW4 work from Lorenzo which you don't feel is compatible with the work from top strip docs? Cheers." Thank you for the link to Dr. Lorenzo’s portfolio of NW 4 cases. Some of those look very, very good. As I’ve said before, Dr. Lorenzo has made remarkable strides with FUE, and he posts more FUE restorations of higher Norwood guys than anyone I am aware of. I just wish he would ditch the implanter pens, at least for the frontal zones. Whatever the benefits of implanter pens for FUE graft survival in Dr. Lorenzo’s skilled hands, those benefits come at the expense of the cosmetic benefits of the lateral slit technique – the current gold standard for restoration of the frontal zones with follicular units. You can’t make slits (lateral or, per older technique, sagittal), with round hollow needles, which brings up the other compromise of implanter pens: the relatively large hole they must make in order to accommodate the graft. The hollow implanter needle must be larger in diameter than the follicular unit and surrounding tissue being pushed through it. Lateral (coronal) slits made with custom sized flat blades, on the other hand, are what the name suggests: tiny, razor thin, flat lateral “slits,” which allows for denser packing with more refinement, naturalness, and greater actual and apparent densification. I also would like to see Dr. Lorenzo build in more micro irregularity into his hairlines for a more natural look. And I’d like to see him bring the hairline a bit more forward (lower), advance the sides, and close the temple corners somewhat in appropriate cases, even if conservatively so for age appropriateness. Often he either continues the hairline across to meet the recessed sides (creating the “hairpiece look”) or he employs the concave “swoops” or “curves” around the corners (a design which rarely appears in nature and which can be a transplant tip-off). I suspect that he does these things in order to preserve the roughly 6,000 scalp grafts available to be harvested via FUE for any given patient. I suppose this is why some say that FUE is better suited for lower Norwood patients. I’m not saying that Dr. Lorenzo’s restoration work in the frontal zones for his Norwood 4a/4 patients looks bad. Not at all. I’m just saying it isn’t cosmetically equivalent to the very best work available today, which, in my opinion, is the purview of a few elite strip docs at this point in time. How much, if any, this has to do with current limitations of FUE as a means of harvesting viable grafts from scalp donor for transplantation is an open question. Future HT Doc said: "I'm actually a bigger fan of custom blades with forcep placement as well. I think Dr. Erdogan is a good example of utilizing this proven technique in FUE procedures. You may not be a fan of his hairline design, but I think he utilizes the placement technique as well as those using it with strip." I'm not as keen on Dr. Erdogan's hairline and frontal zones work as you are -- nor is my girlfriend, who has a good eye for such things but doesn't spend every free moment on hair transplant forums. I applaud Dr. Erdogan for the good yield he seems to get from FUE and for his use of custom blades and forceps placement. I think his hairlines would look more natural if he would build more micro irregularity into them. But besides that, there is something else a bit “off” to me about his hairline work, though I can’t put my finger on it. Ironically, it might be overly dense packing. Or maybe it is angulation issues, or designs that are too straight across. I’m not exactly sure what it is, but to me, his transplanted hairlines often look, well, transplanted. It doesn't seem to have anything to do with FUE per se, just an aesthetic, approach, and technique that often looks a little odd to me. For these reasons -- and I acknowledge they are subjective -- I can't say that Dr. Erdogan is turning out Norwood 4a/4 restorations via FUE that are the cosmetic equivalent of the very best Norwood 4a/4 restorations being turned out today. Sethticles said: "Madman, i was a NW IV almost NW V i have had FUE HT and the transformation is fantastic, go to my home page and look for yourself, feel free to pick the shit out of my photos, complain all you want about hairlines or density, but im satisfied somehow think the name MADMAN you will never be satisfied, Next year Im going for another FUE & trying BHT with Dr Bhatti, just to top up a few places which was always our agreement. Strip is yesterdays news..." I am SO thrilled for you that you received a restoration you are happy with!! Truly. Getting a hair transplant is a huge decision, and you seem to have done your research, found a surgeon you were comfortable with, and are more than pleased with the results. I can't see a lot of detail in your before-and-after photos, but you seem to have gotten good growth and are happy. Although I don't find Dr. Bhatti's posted work to consistently measure up to the work I personally would term elite, that doesn't mean his work isn't solid. I'm sure you wouldn't be as satisfied as you are and wouldn't be having a second procedure with him if it weren't. I don’t want you or others here to think I am knocking FUE. I’m not. I’m just waiting for the emergence of docs and clinics to turn out FUE restorations of Norwood 4a’s and 4’s that are every bit as gorgeous, natural, dense and refined as the best of the best strip work currently being done. Whether that is possible via FUE remains to be seen, but I remain hopeful. Thanks everyone for input to this thread thus far.

Well, I still say that for middle-of-the-road Norwood guys (4 or 4A), there isn’t currently an FUE option that is the cosmetic equal of elite strip work. The thing is, I think that FUE technology has progressed to the point where it could offer the cosmetic equivalent of elite strip work for NW 4’s/4A’s. I just don’t think there are FUE practitioners presently doing so. Dr. Lorenzo has been mentioned, but he is one of the FUE docs I was referring to in my original post when I mentioned prominent FUE docs whose hairline and frontal work are, in my view, cosmetically compromised (compared to elite strip work) by their use implanter pens rather than custom sized blades and lateral slits. Dr. Doganay is the other. I think it is telling that the photo presentations of Dr. Lorenzo’s work rarely feature close-ups of the hairline work with the hair pulled back. When they do, or when seen on video, the frontal and hairline work looks (to me) okay but not nearly so refined, densely packed, shingled, and natural as the hairline and frontal work turned out by the preeminent strip docs. I also don’t care for the hairline designs in many of Dr. Lorenzo’s cases, in macro and micro terms. With due respect to Dr. Lorenzo’s dedication to FUE and his considerable surgical skills, his results generally strike me as looking alright . . . for FUE. An area where he seems to shine, though, is crown work. I will give him that. I just wouldn’t choose him for a Norwood 4A restoration if I wanted an utterly natural result that is undetectable as a transplant. What about the FUE docs who use custom sized blades and lateral slits for their recipient sites, you ask? Dr. Ergodan is one such doc. But to my eye, his hairlines look blunt, harsh, and a bit “off.” I think this is partly due to an insufficient degree of micro irregularity built into the frontal hairline. It might also have something to do with overly dense packing and/or odd angulation. Whatever the reasons, his hairline work doesn’t appeal to me, despite the excellent yield he seems to get from FUE. The hairline designs, approaches, and execution of other prominent FUE docs (e.g., Bisanga, Ferudini, Mwamba) also fall a bit short in my view compared to the very best strip docs. And many if not most of their posted FUE cases are of lower Norwood guys and/or somewhat lower graft counts than the full-fledged NW 4A/4 restorations that are the subject of this thread. Dr. Diep has posted some 3,000-4,000 graft FUE cases that look very good, but I personally think he overdoes it on the hairline zig-zagging, and his use of needles to make recipient sites, while better than implanter pens, still falls a bit cosmetically short of custom cut blades and lateral slits. I also don’t care for the concave hairline design he seems to use for every case. It also concerns me that he never shows the donor area intra-operatively or post-operatively. Whose FUE work do you like, you ask? Well, some of Dr. Maras’ (HDC Clinic) work looks promising, and Dr. Paul Shapiro and Dr. Rahal have begun posting some lovely FUE work. But the posted cases have mostly been of lower Norwood guys, so I think the jury is still out on these docs as an elite strip-equivalent FUE option for NW 4A or 4 guys. Just my opinion.

I thought things around here were getting a bit calm and tepid so I thought I would stir things up. Truly, though, I hope the ensuing debate/discussion changes my mind or at least benefits the community in assessing the current state of FUE options for middle Norwood cases relative to elite strip work for such cases. I am not anti-FUE. I would go for an FUE restoration in a heartbeat if there were a doctor and clinic turning out NW IVA and IV cases that were as cosmetically appealing to me (yes, subjectivity is involved) as those of the elite FUT docs whose work I especially like.

If only there were FUE docs consistently turning out results for, say, Norwood IVA’s that are cosmetically indistinguishable from the results produced by the elite strip docs. Alas, I can’t say there are. PLEASE prove me wrong. I choose Nordwood IVA for this exercise because I am one but also because this is middle of the road for hair loss and represents a substantial number of men in their 30s, 40s, and 50s. My conclusion holds even more so for full-fledged IV’s. Anyway, after much research and viewing photos and videos until I am nearly blind, my (subjective) conclusion regarding the present state of FUE for the Norwood IVA’s (and IV’s) of the world is this: --PERSONAL CONCLUSION -- For guys needing, say, 3,500-4,500 grafts for a cracking result (complete rebuild of zones 1-3 with some corner closure and shoring up of temple peaks), there isn’t presently an FUE doc consistently producing results as dense, natural, and refined as the results consistently produced by the elite FUT docs for such cases – especially for the critically important hairline and frontal work. In reaching this conclusion, I have taken into account single day and multi-day FUE mega sessions as well as staggered FUE sessions separated by a number of months. I have taken into account prominent FUE-only docs as well as prominent docs that offer both FUE and FUT. There are some FUE docs who appear to be getting acceptable FUE yield from large graft-count transplants via multi-day or staggered procedures, albeit still with lower growth rates than the best strip docs achieve for comparably sized cases. However, in my view, the hairline designs, hairline execution, and frontal work of these FUE docs simply aren’t on par with the elite strip docs. Part of that is a matter of the doc’s personal aesthetic and technique, while part seems to pertain to the use of implanter pens by some of these docs. (I’ve concluded that implanter pens, which create relatively large round holes as recipient sites, deprive the doc and patient of the ultra refinement, shingling, and naturalness of the lateral slit technique offered by the use of custom cut blades.) The remainder of the difference must be attributed to the limitations of the extraction technique itself. I would love to be proven wrong. What Norwood IVA or IV guy wouldn’t want a gorgeous, dense, undetectable, utterly natural 4,000+ restoration that is the cosmetic equal of those routinely produced by a handful of elite strip docs, but without a strip scar? As of today, though, I don’t think that is available, not consistently or predictably anyway, and maybe not at all. Any takers?

I was referring to custom cut blades vs. needles vs. some other tool for making recipient sites. Does Dr. Rahal not use custom cut blades to make his recipient sites? Thanks for the other info, Joe. I think that Dr. Rahal's policies regarding consecutive day FUE sessions, max grafts per FUE session, and waiting period between FUE sessions are responsible and reflect a concern for the best interests of the patient.

Beautiful work! Very interesting and informative to see the growth progression. Also, JoeT -- Does Dr. Rahal make lateral slit recipient sites with blades for FUE grafts, as I think he does for FUT grafts? Does Dr. Rahal do consecutive day FUE sessions if more grafts are needed for the restoration, or does he have a max number of grafts per single day FUE session (if so, how many?) and then require a healing/growth period before the next FUE session (if so, how many months?)? Thank you for the info.

Rocketmas, Judging from your photos, both docs are spot on with their recommendations. The fact that both these masters of hair transplantation recommend essentially the identical design and graft count should tell you something. Both indicate a slight lowering of the hairline, with a bit more in the center, and both would fill in the corners somewhat, for a hairline and sides that should frame your face beautifully and be appropriate at your current age and in the future. Anything more aggressive would, in my opinion, appear “off” and not serve you well as you enter your 50’s and 60’s. Plus, if you should thin in the vertex and crown later, you will have plenty of reserve to handle it. It is difficult to tell the condition of your temple points from your photos, but it wouldn’t take many grafts to strenghten them a bit if they are a concern. You really could flip a coin on this one and be assured of a terrific result. If I were in your shoes, the weight might fall ever so slightly in favor of Dr. Rahal for two reasons: 1. You don't require a mega-mega session (5,000 - 9,000+ FU's), of which Dr. Hasson is the undisputed king, and 2. Densely packed, beautifully designed and executed frontal zone and hairline work for Norwood II's and III's such as yourself seem to be a particular Rahal specialty. But as I say, based on the results I've seen from both these maestros and their virtually identical assessments of your case, a coin flip might serve you as well as a deliberate choice. Great luck with your decision and procedure!! MadMan