Dr. David Josephitis

Wavemaster, I know you are concerned that the scalp hair is not an exact match to the beard that you are planning on replacing. There are a few reasons why this is still the best option for you though. First of all, the hair that will be used most likely, will be that from the back like you mentioned, that is the coarsest. When the hair is transplanted in the beard area, many zones will be filled in with 2 - haired grafts. (The outer transition zones will of course be single haired grafts) This way, the hair will appear the thickest. Most beard hair naturally is only coarse single hairs. By doing this we can help mimic the density of your natural beard. The use of other body hair for the beard is not appropriate for a couple of reasons. First of all, you need quite a bit of donor (500+) That would be quite challenging for the pubic region. Also, when you are working in other areas of the body the yield (how many grafts take) is also lower. You might get a very patchy result. Finally, the pubic hair as well as other areas of the body have hair that grows for a much shorter time than the beard. This could also leave patches of bald spots when the transplanted hair decides to fall out before regrowing again.

new, I think that is actually perfectly fine to do. I actually recommend this to my patients occasionally. Most of the time, because of hair styles, the regular minoxidil is very greasy and does not work out as well for the 9-5. The foam is a much nicer product during the daylight hours. The regular is a little cheaper and is just fine to apply in the evening. I think it is important to try to continue treatment twice a day. If this is how you want to do it, you should continue it. As a side note, some physicians feel that the foam version may not penetrate to the scalp as effectively as the foam. So in that respect, by using the regular you are also making sure you have at least one very good treatment per day.

kojac, The photo you sent looks perfectly normal at one month. I believe you are more concerned about the recipient area (top). I have seen that some patients retain that reddish appearance for a much longer time than others. While typically it resolves at one month, it can linger for up to 6 months or more (it becomes much more subtle over time.) Most of the time it has to do with the patient's complexion. Also, it is very critical to avoid the sun for a few months after surgery as this can also cause redness. Finally, I have seen the early use of minoxidil after surgery cause this as well. In the end though, the redness will fade over time. It just may take a little longer for you.

GreyG, People can have HT for a variety of reasons. Some as you mention, get the HT after they have had much loss. In these patients, the results can be quite dramatic. Others, get HT when they have some thinning that is mainlynot yet noticeable to the casual observer. They patients don't want to go through that "thin" phase. Others like yourseld with just small areas of loss wish to improve on those area. While the overall change may not be as impressive as my first example, the difference is definitely welcomed by the patient. One concern by doing a small session as you are discussing is that if you have any more hairloss, you will need to continue with additional HT in order to avoid an unnatural looking phase. Yes, there is some concern of shock loss after surgery. This is usually in the recipient area and, in my experience, usually occurs in patients with the diffuse thinning.

I am happy to hear that you have found a physician and are comfortable with the surgical plan to correct your thinning vertex. You must keep in mind that the vertex is a challenging area to transplant and that the future hair loss in that area is quite uncertain. Depending on your age and rate of hair loss, much more hair can be lost in this area creating a real need to have to do more surgery in the area. Because of the limited amount of donor in the area and the potential additional need in the front of the scalp, I would be careful how much of the donor you dedicate to the vertex. I am sure you have already considered or started prevenative meds. These are very helpful in maintaining the vertex for the future. Vitamin supplements are largely unneccessary for most of the population. The Western diet although unhealthy in many other respects, contains all or most of what it takes to develop healthy hair and nails. If for some reason, you note brittle hair and nails and your hair tends to fray or break off, you may have a deficit. In this society though, more common issues are thyroid deficiencies, hormonal imbalances or anemia that can cause structural hair problems. For these, you should see your primary care physician. Otherwise, if you desire, a simple multivitamin should be fine.

Beebz, Hope all is well! Unfortunately, when a person goes completely bald in an area, the follicle actually shrinks to the point where it is gone. There really is no "base" or root of this native hair anymore. There may be some remnant left, but with our current treatment and knowledge, we aren't able to revive these hairs. Sometimes if the hair is miniaturized or thinned, meds, laser or PRP can help to reverse this process. When a bald area is transplanted into, there is no risk of damaging these "dead" follicles. The new transplants can be placed in an orderly placed pattern. If there are fine or thinning hairs in the area, the physician is sure to avoid those areas. The high maginification loupes we use help us to avoid even the smallest of hairs.

Qneedhair, Cowlicks or swirls in the vertex of the scalp are actually quite necessary. I understand you didn't "want" them growing up, but they are really just a natural pattern that has to be reproduced in a hair transplant. The best way to understand why I am saying this is to look at a young boy's head and really study the cowlick. If you look carefully, it is really just a slowly changing direction of the hair. Hair in the front of the head is forward facing and hair on the back and sides is downwards facing. Those directions cannot be changed. The only way for the hairs in the front to transition into hairs facing downwards on the sides and back is to have this swirl. The swirl allows the hair to change direction. Don't get me wrong. If it were possible to reconstruct a vertex without a swirl, all hair surgeons would do it. Swirls, even when transplanted, still give a thinner look. If there was a way to lay the hair down flat in the vertex like in the frontal area (and still look natural), the density would appear higher. If you look at that same young boy, you may even see scalp at the center of the swirl. He is not balding there; it is natural. The hairs point straight up and out in the swirl and do not give a maximum density. With regards to your double swirl issue, there may be some options. Sometimes, if one swirl is stronger than the other in my patients, I will try to just recreate the stronger one and forget about the other. With the growth of the new transplant and the slow loss of native hair, the secondary swirl will no longer be important. I am not sure if this is possible with you but it might be worth asking your hair transplant physician.

hyperhair, Transplanting into the crown at a younger age (typically 35 or younger for most physicians) is a highly debated topic. Some docs never transplant into the crown feeling that there is never enough donor to adequately cover both the crown and future frontal loss. Some docs place number of grafts into patients with hairloss that is more stable or with patients that have been on meds for many years. It is very dependent on the patient, their age, hairloss history and the use of preventatives. In your case, it appears that you have had a good number placed into the crown. I can't tell exactly the size of your loss because the photo is zoomed in. The area you are asking about actually has a special name "coronet" (the shape of the instrument). This is just additional hairloss below and outside of the general crown thinning. It can mean that your hairloss may be more severe as you age. It is good that you have been on the meds for many years now. Hopefully they have helped to stabilize the loss that you have right now. Typically it is not a good idea to transplant into this lower area (coronet) of the crown at such a young age. Many times the hair transplanted into the crown does grow in a manner that can somewhat cover that area below. Either way, I would maintain the current meds you are on, and wait the year for the final transplant results.

Rashid35, The answer to this question will vary from one person to another. Some people get on meds and it adds very little density or helps only a small amount in regrowing some of those smaller miniaturized hairs. These people still may benefit from the meds as they most likely are helping to prevent more loss. Other people, like yourself, see some excellent improvement on meds and a slight reversal of the finer hairs. For many of my patients, I ask how conservative they want to be. If they want to wait and see what the meds do first and then after a year go ahead with the surgery, that is perfectly acceptable. For others, they don't want to wait that long as the transplant can take up to a year to come in. It really depends on how quickly they want to see changes. For you though, you have a tougher decision. It appears that you are actively seeing improvement. You might want to wait the full 9 -12 months prior to undergoing a procedure. That way the surgeon can you can see where you would most benefit from adding more hair. (It might be different from where you were before meds) Also, it helps the surgeon avoid damaging hair follicles during the tranplanting process that may not yet be visible. (They are still growing from the meds)

HTN community, I am truly honored to be considered for coalition membership. This forum is a huge asset to potential hair patients everywhere. I have enjoyed following the posts over the years and taking part where I can in helping out fellow members. I look forward to many more years working alongside those interested in the field of hair restoration surgery. Working at Shapiro Medical continues to be a wonderful experience for me. There is really nothing like doing what you love at a world-class facility. Markee. As far as pricing goes, it can be quite variable as Bill has mentioned. The cost is really determined by the number of grafts that you need to accomplish your goals. Everyone's goals are different. Our clinic, like many others, charges by the total number of grafts. Also, if you want to go the FUE route, the prices are a bit higher as the surgery is more demanding on the surgeon and the staff. I encourage you to contact our clinic and schedule an in-house or telephone visit with our consultant Matt Zupan. Thanks

The biggest factor in determining whether to use permanent vs semi - permanent SMP is future hair loss. Many younger patients with early hair loss come to our clinic not wanting to do surgery but want a solution nonetheless. They may or not be on meds for prevention. These patients in my opinion are better served by going the semi permanent route. The reason that this is a better option is as follows. As these patients lose more hair they will need additional SMP. It is not as simple as just adding more pigment into the areas that have faded. The problem with patients who lose more hair is that they need a different pattern and level of density of SMP. If one only adds to the pattern that was originally made, the SMP will only become more obvious (relatively darker looking) instead of less obvious. The magic of SMP is that it is subtle and natural looking. The beauty of semi permanent is that as one loses more hair, the pattern, density and area of SMP coverage can be modified. This cannot be done if one has a permanent pigment already in place. Medications are helpful in preventing hair loss. They are not required though in order to use permanent SMP. I think the key to using permanent is that one feels that the hair loss is more "stable." One can never be 100% certain that no more hair loss will occur. Still, as physicians we try to determine what is in the patient's best interest. A young patient with early hair loss will most likely develop worsening loss over time. This is especially true of one who is not on meds. An older patient without loss over the last few years or a patient who has been on meds for years without much more loss have a more "stable" picture of their hair loss. These "stable" patients, in my opinion are better candidates for permanant SMP. At Shapiro Medical we feel that SMP should be tailored to what is in the patient's best interest. Having said that, in the near future, we will also be doing permanent SMP in addition to semi permanent depending on the patient's needs.

EvansTelly, 7 days post op is a fairly safe time for the grafts. At Shapiro Medical this is when we actually encourage patients to begin to use their finger tips to gently massage away any of the remaining scabs. At this point, any scabs that fall are perfectly normal. Also, some hair may fall along with the scabs. This too is to be expected. The follicle remains in the scalp but the external hair typically does break off. At about a months time, most patients should see the cast majority of the transplanted hair has fallen off. Usually the only window of time that a graft can fall out and cause bleeding is in the first 1-3 days. During this time, the graft can be bumped out or fall out if there is any rough handling of the scalp. There is not typically any pain associated with this.

second, This is an important concept that is not always talked about in hair restoration. Most of the time, everyone talks only about coverage and density. The final results of surgery not only depend on these aspects, but also quite a bit on the individual patient's original hair characteristics. As you can imagine, the more scalp one sees the more one appears to be thinning. Some people have curly or kinky hair which does a great job of covering more area of scalp than those with straight thin hair. Also, the light and dark contrast plays a big part in the illusion of fullness. If someone has, for example, very light skin and very dark hair they will appear thinner than the same person but with darker skin. You pointed out that when you cut your hair it looks thinner. You have to imagine that below a certain length you take away a lot of the voume and coverage of the hair. If you had more hair (or native hair density for that matter) it wouldn't matter much if you cut your hair very short. But for those with transplants, you have to remember that you have a limited amount of hair and you have to use that hair to the max. Interestingly emough, if you let your hair grow very long hoping that "more is better" it may also again appear thinner. This is because as the hair grow longer it also gains weight and may pull down and apart revealing more scalp. There is definitely a "sweet spot" length of hair for each person. Finally, you mentioned the point that under certain lights you look thinner. This again goes to the point of having limited hair to work with a transplant patient. After having surgery, you will notice that you look much better under normal circumstances. Still, there are times, such as in bright light or after a shower, when you will again look thinner. You have to remember that before you had any hair loss, you had 100% of your native hair density. After surgery (assuming you were completely bald before) You may get anywhere from 20-40% of your native density. There is no surgical way currently to get the original density back for those with considerable loss. You will still occasionally have "bad hair" days and certain environments will be harder than others. This is one of the reasons why patients have additional procedures to increase the density.

This is a good topic of discussion. At Shapiro Medical we also routinely make the incisions the night before a large FUE case. It does sound strange, I know, but you must look at the logic behind it. All grafts, especially FUE grafts have a limited time they should stay out of the body. The sooner they can be placed back into the recipient sites the better. Having said that, we routinely like to make site prior to extracting any grafts. If the surgery is somewhat smaller, (1800 grafts or less) we can make the sites in the morning and then extract the grafts followed by planting in the afternoon. If the grafts are extracted first in the morning and then the site are made, the grafts must wait an extra 1 -1.5 hours (average time it takes at SMG to make sites) before being planted. This is not ideal. The reason we would make sites the night before is that if we plan on doing a larger surgery (1800-2500) we won't be able to make sites in the am and do 4+ hours of extraction followed by placing. The patient would be in the office until 8 or 10 at night! That is not good for the grafts or the patient experience. Finally, on the question of practicality of making sites the night before. We typically have the patient come in around 2pm and we go through the plan thouroughly. We cut the hair and make the sites. The patient is out of the office in 2-3 hours. We dye the sites so that they are easily visible the next day. Believe it or not, the sites are very easy to work with the next day. Our staff at SMG routinely pre -dilate the sites (open them with forceps) prior to planting the grafts anyway so we put as little trauma on those fragile FUE grafts. Our staff actually feels that the pre made sites are sometimes easier to work with and the grafts may be less likely to pop in a dense packing situation. Also, there may be some theoretical benefits to making the sites earlier. There may be some growth factors and early revascularization occurring overnight to the area that may make the grafts take better. We don't have any good data on that, but it is a possiblity. In my mind, the only negative issue is that the patient would have to be numbed another day. In our office, we don't rush our procedures, so prior to making sites the night before, we had all 2 day FUE cases where we would do 50% of the case on each day.

I am glad to hear there is some excitement regarding this study. We too are looking forward to getting results after we have enough patients. We are actually still actively seeking patients for the study. This is a blurb from one of our advertisements for the study. "The world-renowned hair transplant clinic of Shapiro Medical Group is seeking qualified candidates for an exciting new study. We have received a study grant from the International Society of Hair Restoration Surgery (ISHRS) to study the differences between the two types of hair transplantation known as FUT (follicular unit transplantation or “strip” surgery) vs. FUE (follicular unit transplantation). Both types of transplantation, in our hands, produce excellent results, but we would like to see if there are subtle difference with using one over the other. We are actively looking for males with a Norwood 4a or higher (bald on the front third or half of head). Also, we are requesting patients that have never before had a hair transplant surgery. Finally, you should be willing to follow up at the office for evaluation once the new hair grows in. Qualified candidates will receive a significant discount for participating in the study." Dr. Ron Shapiro and I will both be working on all of the patients. If there are any other questions please direct them to our main office and we can determine if you are a candidate.

giantanddwarf, I think that is an excellent observation on your part. This "turning point" as you call it is actually what happens. As many will tell you, one doesn't start to notice their hair thinning until around 50% of the hair in that area is lost. Still, when you are getting close to the 50% mark, you may notice that some days you look thinner than others. You may style your hair differently one day or be in a bright light another and may look thinner. You have less flexibility with your styling. Hair loss continues though, and you may find it harder to have days where your hair doesn't look thin. This "tipping point" is when no matter what you do, you look thin. Many can think that at this point something dramatic must have happened and that they have lost a lot of hair all at once. As you correctly surmised though, they are just continuing to lose hair at a relatively constant rate. So many times do I see patients with much hair loss (norwood 4 or 5) that believe they just started to thin a year or two ago. The truth of the matter is that they didn't realize that they had been losing hair for many years already. Sometimes, patients that have started minoxidil or finasteride that experience shedding don't realize that sometimes a small amount of hair loss can make a big visual difference.

HTsoon, I am not sure I would recommend knowingly depleting your scalp donor area only to follow up with beard hair into the area. I feel a safer approach is to take only the amount of scalp donor available with FUE and then to have beard and SMP as a back up. It is always nice to have additional hair resources available to improve the scalp donor if the patient decides over time to cut their hair shorter, certain areas of the scalp are inadvertently thinner now because of FUE harvesting, etc. Unfortunately, we don't have any post pics of beard into FUE sites as it is not as common of a procedure. I am glad you brought up SMP. In our clinic it is becoming more important as an adjunct to FUE into the strip scar or into FUE sites. I think it does well to help camouflage areas.

I think using beard hair for depletion is a very interesting and valid approach. At SMG we have only been taking this approach for the older style surgeries where patients had the larger scars from "plugs." This works very well with beard hair. We haven't yet had to use beard into the scalp of a contemporary FUE patient. I think it is an excellent idea and feel that with the right patient we might do this more often. I think as more patients get second and third FUE procedures, we may see more of a need to replete the scalp donor area.

gbhscot, Yes, we typically always will spread out the beard grafts amongst the other scalp donor grafts. I like to think of beard hair as "filler hair." It is there just to give more numbers and volume of hair to the overall result. It would most likely not have a good aesthetic value by grouping beard hair. Also, I think that not all are good candidates for the addition of beard as donor hair. You mentioned the example of a light-haired patient with dark beard. This patient probably would not be a good candidate as the beard hairs no matter how dispersed they were might be noticeable.

FUE has become more prevalent over the past few years. There are many good reasons for this including an increase in the number of high quality results. Although, many clinics claim to do very large “mega” session FUE cases, at Shapiro Medical we have stayed cautious and conservative with our large FUE cases. As we all know, the “SAFE” donor zone is a defined area and venturing out of that area will indeed give more grafts, albeit grafts that may not last a lifetime. At our clinic, an average “large” FUE case is 2400-2700 grafts. This type of FUE will also typically take 2 days as we do not like to put additional stress on the patient as well as the grafts by doing it all in one day. I wanted to briefly present a recent case of our done at SMG where we increased our overall number of grafts by adding beard donor hair. Typically beard hair has been used as a donor when all of the other areas of donor are depleted. This has been for good reason as beard hair is typically only one or two haired grafts. Also, the characteristics of beard are not the same as scalp. Finally, although, beard grafts grow well when transplanted, they don’t typically have a lower yield (growth rate) than scalp. This patient was a 28 y.o. male with a 5+ year history of hair loss. He has not yet started preventative meds. He was a Norwood 4 with a donor density of 68 FU/cm2. This patient wanted as much covered in one session as possible. With his lower density and the patient choosing FUE over FUT (FUT can often get more grafts on the first pass) we looked for additional areas of donor in this patient. Beard was the likely choice. Risk of scarring or hypopigmentation, although still a risk, is not common in the beard. Also, the beard that was used was under the chin, so it is less visible. Because of the increased number of grafts, the patient came into the office for a total of 3 days. The first day was relatively short as only the incisions were made in the scalp. Day 2 and 3 consisted of FUE extraction of the scalp and beard. All the grafts that were extracted each day were transplanted on the same day. We ended up extracting 2600 from the scalp and 499 from the beard for a total of 3099 grafts. These are the pre and post op photos. This is a close up of the beard after extractions. The scalp donor delivered a somewhat average distribution of grafts. The beard gave 400 single hairs and 99 double hair grafts. Thankfully, beard hairs are typically thicker than scalp hair so they do help with density. Also, the beard grafts were only placed in the midscalp and used for added density. Beard should not be used in the hairline or other areas that are readily visible.

Two weeks after a HT surgery is usually a good time for most activities to resume including sports. The skin surrounding the grafts is healed and there is little /no risk for losing grafts. After two weeks we usually even encourage patients in the shower to gently massage any of the remaining scabs that may still be lingering on the scalp. Having said that, wearing a hard hat or helmet that will cause much friction and/or pressure on the newly grafted area is not always a good idea. A short amount of time is fine, but hours of rubbing on the healed scalp could result in irritation/ infection of the area. A solution to this problem for a bike helmet is to possibly wear a skull cap or bandana over the grafted area followed by the helmet. This will reduce any amount of friction over the area. With regards to the hard hat it is a good idea to make sure none of the straps are directly putting pressure on the newly grafted areas.

Carlc, To shave or not to shave? Sometimes it is tough to say. It would probably be good to send some photos of the area of the head that you are planning to do transplantation. Typically here at Shapiro Medical like with Rahal, we shave when we can and when it will benefit the patient. If there are reasons why the patient can't shave or it would make going to work / home life impossible, there are usually exceptions. The major reason we like to shave the recipient area is to maximize the total number of grafts we can put in an area and to reduce the time the grafts are out of the body. We like to do this on surgeries where we are dense packing or in patients that we area doing a large total number of grafts (3000+) Having said that, if a patient can't shave his hair short for one reason or another, we can still do the surgery, just at a slightly lower overall density. Some surgeons disagree with this line of reasoning and never shave the head. This is also fine for those clinics. At SMG we find being flexible is the best way to go for the patient. It sounds like you are planning on doing some work in the front and vertex. If that is the case, there would only be 1500 -1800 grafts going into the frontal half. This may be possible without having to shave. Pics and/or an exam would be necessary to determine this.

CJ, I think minoxidil would be a good idea to start at this time. Yes, some docs are fine with starting the med right after surgery while others wait until the redness fades. My belief is that it can be patient dependent. Minoxidil actually can increase blood flow to the scalp and in those people that are susceptible, a redness in the scalp may develop for a longer time period post op than if they had not used the med. I know after my own transplant, I started minoxidil 2 weeks after and developed a red scalp. Restarting minoxidil now will be beneficial to you for a couple of reasons. It will help prevent future loss of your already thinning hair. (you may have been on it already prior to surgery). Also, even though you have shed post op as you mentioned, in my experience patients can regrow the transplanted hair at a somewhat quicker rate.

esrec, Glad you are happy with how it looks at this point. Yes, as you suspected, the final result in a year will be slightly different from what you see now. Typically, as you mentioned, the difference is really in density. At SMG we always transplant with the hair a couple centimeters long. Now, this is primarily for us to prevent putting two grafts in one site and also to make sure we add as much density as is safely possible. The other nice thing about the "preview" length of hair is that it gives you a great idea of where the final hair will be. The hairline that you discussed with Dr. Shapiro and that you see now will be the same. It may only vary somewhat in a 3 dimensional aspect as the hair grows out. The one issue that some patients note is the density aspect from post op to final result. After surgery, the scabbing along with the transplanted hair gives an illusion of more fullness and density than was actually transplanted. You can think of this like adding a topical cosmetic on the scalp to darken it. You appear to be doing a great job of cleaning the scalp, so most of the scabs are probably gone. When all is said and done a year from now, the length of the hair that you decide on will help considerably in determining the "appearance" of density. If it is too short or too long it may appear thin. You will get a feel for the best length and look when it grows out.

33, Interestingly enough, I think the transection rate may actually improve slightly throughout the day. I believe it has to do with muscle memory and the physician having a better understanding of the patient's grafts. We performed the study at the beginning of the study. It would have been interesting to also study the results at the end of the study to compare. You are right too. Physician fatigue can also play a part in transection rate. The overall ease or difficulty of the patient in general determines how much of a factor fatigue will play. The photos I showed where from a patient who had at least 2000 grafts taken. All of our study patients had an average of 2000 or more grafts. They were all virgin FUE patients though. From experience, working with patients with 2nd or 3rd FUE, it does get more challenging to conceal the scar. This as with all things in medicine, is highly dependent on the patient. Some patients start with high density, coarse and curly hair. Those patients can get away with more FUE grafts over their lifetime. Others with fine, low density hair may not be able to cover the donor area as well after multiple FUE sessions. In general, it is not much more difficult to remove hair in subsequent FUE sessions. We are just not typically able to remove as many grafts.