Prof101

yes I thought about it and did so a couple of times, everyone told me I look much worse with a shaved head. And i hated that look as well. I agree that this is the first thing one would try and I did

3 months post op (1700 to crown with Dr Couto) I am trying not to look at my hair every day, in fact, it has been a month since I did. And when I did today I am extremely concerned about the donor area. While my donor area was not THICK, it was definitely well covered. As per the picture attached (last pic blue shirt is BEFORE FUE). But now it is completely see through, as per the other two pictures of sides. One not combed and one combed for maximum coverage. Recipient area I don't see much action but I know it is too early (so no need for before and after) I contacted Dr. Couto and we will see what he says, but any thoughts please let me know. Is this normal at all?

At this point I really think we can all contribute to this promising avenue by simply reaching out to our respective surgeons and spreading the word about Dr. Barghouti's fantastic effort and findings I personally told Dr Couto and he seemed curious. We need to see many doctors trying this. Science takes time, so hopefully we will see a coordinated push.

haha well what. I call sprinting is probably jogging for you then. Thanks everyone... yes it was an FUE

I used to sprint 1 mile 2-3 times a week, plus lift some weights (high intensity low rep) When would it be safe for me to go back to that? Since by now the grafts are definitely fully anchored, do I have to worry about anything? So far I have been just walking daily as exercise Thanks

As far as I know, the only doc in the US (or one of the very few) who will take time to objectively measure your donor density and miniaturization is Dr. Mohebi in California. Not sure where you are located but I assume US If you are in Europe Dr. Mwamba is even more thorough. Both will give you an honest opinion about donor density ... which none of us can really best of luck

Any thoughts on this folks? I found that I can hold the cap without pressing over my scalp, but worried that the heat from the laser would damage grafts. I feel I don't want to mess with this unless Drs think it is OK. I have read that it helps with circulation and with regeneration.

Dr Couto recommended to me Aloe vera gel (without alcohol, organic) and Rosa mosqueta at night, after 10 days. Not sure whether it is my skin type (even though I am white) or the treatments, but now at week 3 and the redness is minimal compared to what I have seen here.

Thanks, sounds good. I would rather spare myself the trouble and risks.

I am 3 weeks post-op. I am not sure when it is safe to do PRP, I heard 1 month, and perhaps to be on the safe side I can wait a bit longer. I just don't know where to do it. I did my HT with Dr Couto and he said you have to carefully select the clinic (not all do a good job). Any suggestions of a reputable place to do it in the US? Thanks

I just did a HT with Dr Couto, 3 weeks pot op, and want to use laser. Actually Dr. Mwamba had recommended doing LLLT and want to do so. I have a "IGROW" but it puts pressure on the scalp wearing it, and I am not sure this is the best idea now. Any recommendation for a system that does not touch the scalp?

Was frankly hoping to get answers as well (and that this thread is not just a one way highway): 1. I understand that the transplanted follicles to shed the hair within 3weeks-2 months. But I thought between surgery and the time they fall, they usually grow a bit, right? In my case they have been the same length. 2. Does the donor area usually experience some form of shock loss? How long is it normal to have an over-harvested look in the donor area? Thanks for the comments

Just to correct a confusion on this thread. No Couto does not do the extractions and he is open about it. And his reason is not a bad one. He told me he thinks placement is super important and he does not want to be exhausted by the time the placement comes. So the person who does the extraction is a clinician and he explained to me he trained him for 6 years. I am however disappointed that the Dr is not at least present during the first hour to see how things are going. The extraction started without the doctor being in the room as far as I recall. The irony is that Dr Couto is down to earth kind and communicative while the tech is neither. Had I been notified of what was happening, I would not have been in this mess.

Thank you this helps. This however means that there is something not right in my case, as my transplanted hairs have no changed in length at all since 2 weeks ago, while the donor and other area have grown. I am nervous.

I am writing this post because I promised several of you I will do so. I can tell the interest in Couto cases. I delayed writing this as I am depressed/disappointed/and did not feel like writing a bad review. I like the doc. I was unlucky. TLDR: Dr. Couto is a super nice and friendly doctor. From everything I have seen he cares most about his craft and has outstanding results. He does benefit from the fact that people in the area tend to have a very thick donor area (I have seen that walking around, lucky guys) including high ratio of hairs to FU (can be seen from his youtube examples). He does the implanting himself, which explains his outstanding results. A clinician (perhaps an MD) does the extraction for him and has been trained for 6 years before. Couto stands by his work. He does celebrities, soccer players, and is expanding. The downside with him as with 99% of surgeons is that they do not bother to take measurements (which is hard to fathom), and in my case that cost me big time. I went there for hairline/top HT and I ended up with an extensive crown HT without wanting it. Yep. Background: I am 40 yrs old NW 4 genetically heading to 6, but thanks to meds been almost perfectly stable for more than 5+ years now. 12 years ago, the only bald area was the crown, it bothered me a lot, so I did a 700 grafts with Dr Jeff Epstein in FL. I was an "executive" HT in that the recipient area was not shaved. During the procedure Dr Epstein told me that my hair is super easy to extract, my follicles looked healthy when extracted I guess. He kept repeating that for some reason. After that transplant a family tragedy happened and I really did not bother documenting the progress of my HT. I remember not being impressed. Someone in the family asked me what I did for my hair to grow, so I guess it was visible to some extent at some point. All I know is that once I started going to surgeons for consultation in the last 2 years, most were unimpressed with the result. While clearly my hair loss was very aggressive between 2010 and 2015, the transplanted hairs that survived look much less than 700 grafts. At every since consultation I have made in the last 2 years (Hasson, Mohebi, Mwamba, Couto) I have mentioned the poor outcome of my operation with Dr. Epstein and my concern whether this is due to me and not to Dr. Epstein. This concern was dismissed. Everyone told me it was not a great job he did, big FUE scars, and that HT has evolved so much since then that I do not need to worry. I asked for a test transplant (e.g. 100 grafts) from the first 2 I have seen and both thought that was unnecessary. The takeway from these consultations was that my density is below average, that I have roughly 3K to be on the safe side. Dr. Mwamba is the only one who took careful measurement (although not super detailed) and Dr. Mohebi took quick measurements of density, thickness, and miniaturization (which I appreciated and was the reason I went to him). The doctors disagreed on my hair caliber. Dr Mohebi wrote it was thick, Dr. Couto and Dr Hasson said it was thin, and if I recall Dr. Mwamba said it is around average. They all said that my hair is straight (although it is wavy-ish). I saw these doctors in person, naturally, because my donor area is deceptive. It looks thick in picture and in person when grown long, but it is below average density. But think about it: For my donor area to look dense and healthy (get complements on it for some reason) it is hard to believe that all characteristics of it are bad: poor density and caliber. Perhaps the waviness at the very least is helping, don't know. I agreed with all doctors that we will be doing the top and hairline and we will leave the crown for a later surgery, perhaps with help from body bear hair which is abundant. With Dr. Mwamba I discussed Fit farming, and he said indeed it is a possibility to implant up to 5K beard/body hair in donor if I am willing to keep it short, and like this use up to 2.5 K in crown. Something that I kept in mind. Consultation with Dr Couto: I was "lucky" that the time between contact-consultation-surgery was relatively short with Dr Couto. Rare. I saw him in April 2022. But spent a good 1 hour with me. He did look at my scalp and hair using the scope but did not take measurements. Felt my hair is thin, and density is below average. Scalp condition is good. He also said that my average FU has only 2.2 hairs, which he did not like. I did ask him whether that is a major issue. I did tell him - like I told all doctors - about my experience with Dr. Epstein. Besides I don't even need to tell him, he had this on his medical notes and he has a good clear view of my crown. He was more optimistic than Mwamba. He thought I have more than 3K and there is most likely a room for a second surgery to be done on the crown in a year. But he did not want to confirm that until we are done with the 1st surgery and wait 12 month to see full result. He suggested we start with top/hairline because it frames my face. I said of course, I did not imagine doing the crown before feeling comfortable that I have enough donor for everything else. A top/mature hairline with an empty crown is more natural than the other way around, naturally. We have all seen Dr Couto's signature results, and amazingly natural hairline, I I thought whether he is correct that there is more than 3K is moot at this point since he decided to follow the same plan offered by all doctors (~3K top and hairline). Surgery day and the big surprise: Almost everyone at the clinic is very nice and welcoming. We start with a consultation with the doctor, and filling of the medical forms. There is one line on this form that required me acknowledging that some patients scalp is such that they do not respond well to HT. So I took this opportunity to remind him of my surgery with Dr. Epstein and told him if there is ANYTHING that he sees as unusual about my scalp please let me know immediately. My plan was that: if indeed something is not right (despite the assurances of docs) I would ask Dr Couto to just do a small test and I would nevertheless pay the portion of the HT that he would feel would be fair. The Surprise The technicians took it from there. About 2 hours later the tech goes out for a bit (assume he goes and speaks with Dr Couto) and Dr Couto comes in and start having a conversation with the tech (again the latter could be an MD I am not sure, he sure acted cocky like one). I understand un pocito of spanish (actually a bit more than pocito) and I felts something is not right. I asked Dr. Couto and told him: I feel something is not right. What is going on? Dr Couto starts telling me this: - My donor looks thinner than when he first saw me (7 months ago). He wondered whether I had like a seasonal shed. (not that I am aware of, no fall or thinning that I saw) - Dr Epstein had left FUE scars and he wants to avoid extracting from nearby. - My follicles are thin and short while my scalp is thick, harder to extract. Raising concerns about survival. I was enraged that this was not told to me (like I had asked) as soon as the extraction began. I asked: How many have you extracted? They said roughly 750-800. I asked to speak with the doctor alone. We went to his office. I told him doc, I am not comfortable losing any more grafts that might not survive. I wish you told me earlier. The surgery was planned for 3 days, with 1K each day. I told him doc, I want to stop now, I will pay you for 2 days (i.e. 2000 grafts for 800) as a compensation for the staff showing up and all (did not want money to be an issue in his decision making). Let us use this 800 as a test somewhere. Again I wished it was only 200. I mentioned the crown as a potential place to do the test. Because if the survival turns out to be 50% this would make for a horrible hairline but for the crown, it would not make much difference at all. He said it is a good idea. After lunch he started working on implanting follicles in my crown. I was depressed naturally. After 2 years of research and preparation. I made major life decisions based on this. Also I felt that this could have been easily avoided by taking better measurement (it is an industry wide problem, not Dr Couto's problem), and by prompting me early during the surgery of the situation. I think the technician should have gone and spoke with Dr Couto immediately instead of waiting for 700 grafts. While Dr. Couto was implanting my crown, he was chatting with the staff in spanish. He was telling them that in some cases some patients due to unknown biological reasons do not respond well to hair transplant. I don't think he is aware that I understand spanish. This was a more of a reason for him to stick to the "test" strategy. After about 2 hours or so, Dr Couto grabs my phone and shows me a picture of my crown. To my HORROR he put all ~800 grafts in half of the crown. I told him Dr Couto, you did what? You mean you plan to do 800 on the other side? He said yes. I told him I did not know that. I thought the 800 was just a test. But I wanted to be respectful of him in front of his staff and also it was too late to make a fuss. There is nothing I can do about this anymore. I was already depressed. The next day I went back for another 800 from the other side. Note that only the sides and the sides of the back were used and not the lower back despite it being the denser area. They said because Epstein overharvested that area. Although to me it still looks like the most dense. So the plan went from me having a HT in front/top and explore possibilities for crown afterwards to me putting the bulk of what I had available to the crown. Dr Couto himself had told me that after a while the meds will weaken, hair will get thinner, so hair loss will progress even when on med (in the long term). And now it seems like I am heading for a situation of having a crown-hat. He told me don't worry, we are on the same boat now, and he will not leave me alone (which felt reassuring) but at the same time he felt skeptic that much can be done about the front. He refused to discuss numbers. So he urged me to take oral minox and add dutasteride (currently on Fin), otherwise I will end up with an island in the long term. He told me to come back in a year. He said he is curious about how my donor area will look like. Conclusion: I think I have done what is advised of prospective hair transplant patients. Extensive research, and consultations with the best in the world. I settled on a plan that all had agreed on, and decided to go with the one who is most known for efficiency (more with less) and impeccably natural hairline. I have told my doctor that money is not the issue. That he can stop the surgery in the beginning if something went wrong. (As I mentioned in one post, Dr Feller used to do that with patients he felt they are not great candidate and would not ask for a dime. Highly ethical). I ended up with a HT to not the area of choice, and a plan of action that involves dutasteride and oral minox. I hope Couto will not abandon me on this journey in case I need him again. I think if you have a good donor he is a no brainer. I am depressed. Needless to say. Question I am 2 weeks post op. I know that recipient area will fall out over the next few weeks. But isn't common for it to grow in length a bit until it falls out? So far it has not moved an inch.

To clarify my question: I understand that they will fall and I understand the ugly phase, I am talking about the time period before they fall. Week 1-week 3 or so, do they continue to grow or are they static? I have seen in most cases they continue to grow some before they fall.

I am at 2 weeks, and my recipient is the same length from 2 weeks ago, but donor and other areas have grown longer. Have seen from others that hair continues to grow before it falls. Some recipient area hairs have fallen out.

I think the best way we can help with this research is to reach out to the surgeons we have seen and point them to Dr. Barghouti's research - as he also encouraged more collaboration on this. By next year we could have a dozen of clinics trying this. I was at Couto and he was not aware of this, so I told him I will send him the study and a link to this thread. I have a question to @DrTBarghouthi : how many follicles were extracted from the area that is growing this follicle in the picture? Just in case the drug is indeed causing regeneration, it would be nice to know what is the % of follicles that regenerated. If Veterporfin (V) is statistically associated with higher growth from the donor region compared to control, there are still two confounding factors that need to be ruled out: 1- Is the better skin healing in V allowing existing dormant follicles to grow compared to the untreated donor? To address this statistically, the Treatment area perhaps needs to be compared to a control non harvested area 2- Is V causing a growth in existing dormant follicles through a different mechanism? That is even if the growth of what seems to be either dormant or regenerated hairs is higher than non harvested controls, one still cannot rule out this hypothesis that V is better than non-treatment in non-harvested. This might call perhaps for a biopsy of a donor non harvested control vs V-treated. Thank you for the update doc!

Not sure why some people jumped to the conclusion that you should shave your head. Maybe I am missing something. Is it possible that you have an amazing donor and you don't know about it? I think the best plan to to have a complete mapping/analysis of your hairloss, see what you have in case it progresses, and see what are your plan B/C if progression continues.

THIS. The only way to find out is to go to someone who not only takes measurements, but does so carefully and takes them seriously. I just made a post about how this should be a standard in the industry. Unfortunately, photos can be misleading, although of course they help narrow down the range of estimates. best of luck

Thanks for your comments. 1. Standards do not provide guarantees, but reduce risks. The fact that a subpar clinic uses it is not an argument against at all. In fact the ones you mention did very well by international standards at some point until they turned into large production. If there is any science to HT, then measurement should be part of it. In this day and age, not taking measurements of the donor available, the caliber, the miniaturization rate, etc, is frankly quite irresponsible. It also helps clinics remain honest. Which is critical. (Again, does not guarantee!) 2. Again, you are reading "ensure" when I am not implying this. Also I am not referring to the quality of the HT here, but the quality of the patient's grafts. It will make sense once you take that into account. 3. Perhaps the reason it does not happen often is that the clinic feels bound to a contract creating conflicts of interest.

Thanks for the reply @Gatsby Absolutely, education is very important. Usually, you are right that through competition, the industry would adapt to a more educated population. But despite the tremendous growth in online information available to consumers, and a clear trend of a more educated patient population, in my opinion the industry has yet to meet this demand for more informed data-dependent surgery plans. There is a market failure somewhere. Also botched HT result in a huge psychological trauma that should be factored in under "patient safety"

This website is providing enormous service for the HT community. And I hope that it will continue to foster honest communication between patients and doctors. I have a disorganized list of misgivings about the current standards of care. I frame them as suggestions for standards of care. I believe they are *necessary* to an HT surgery, and should not be a luxury. I do not need to remind people on this site how big of an investment is an HT procedure, or as in many cases, procedures. Add up the financial cost, the emotional rollercoaster, the time commitment including for tough recovery phases, the diligence and research, HT are perhaps the most difficult decision a hair loss suffer would make in their lifetime and the largest investment. Yet we continue to see terrible outcomes many of which would have been easily spared with better care and planning. 1. Thorough objective measurements should become a standard. It is not a secret that only a handful of surgeons spend time measuring density, caliber, and miniaturization during consultation or even on the day of surgery. This is despite the fact that HT is facing laws of physics (in addition to genetics) and the fact that instruments are available to make such measurement. This really very absurd. Put into any other medical context, and that would make the industry look centuries behind. It is not a coincidence that Dr. Zarev who has held the attention and the admiration of so many on here is one of the few, if not only, to take a detailed measurements of density and distribution not just across the main zones, but also sub-zones. He has a software that helps him with such calculation, punching numbers on a map of a scalp. There is NO reason why this cannot be done, if patients push for such standards. It will come with a more expensive consultation or a markup on the cost of HT, that I think most would be happy to pay. It could be optional, as long as it is available. While some measurements cannot be taken accurately without a shaven head, at least this option should be available to those that shave their head for the consultation. 2. Doctors should be incentivized to accept small test procedures. How and why, it can be debated. Some doctors currently nicely offer this test option (such as Dr Mwamba who is known to perform repairs on difficult cases). This is particularly useful for difficult cases where there is uncertainty about the patient's response, the quality of donor area etc. I have approached several doctors in the past for such a test procedure and most of them declined or tried to convince me it is unnecessary, despite me having experienced a failed surgery in the past. 3. The contract should have a clause that describes Plan B or a resolution strategy in case information come to light during the procedure that would change the optimal plan of action. This risk is minimized if (1) and (2) are available options. I remember that at one of my earliest consultation was with Dr Feller in NY (one of the leading FUE surgeons circa 2010) he told me something along these lines (paraphrasing): sometimes when I start to extract I find some problems with the grafts (weak, unhealthy, fragile) and decide to cancel the surgery. While Dr. Feller generously fully assumed that financial risk (did not charge his patients for a fraction of the surgery) it does not have to be the case. There should be no excuses to an ex-post assessment on this front (i.e. "I just removed 1K grafts and noticed they are not [this and that]"). 4. If the clinic requires us to sign an NDA agreement it should be upfront about it when scheduling the surgery. We get a list of dos and don'ts ahead of the procedure. It is not much to ask to include the form that you would be asked to sign. A clinic in LA refused to scan/email me the documents that I need to sign and would not respond whether there is an NDA included (I learned there was thanks to this website so I cancelled). 5. The clinic must inform the prospective patients about who usually does the extraction and the placement at the clinic, and whether they can make a commitment on this level. It is understandable that some clinics cannot commit on this level, but clarity on this issue would resolve many complaints. 6. The doctor should not have the right to improvise in the operating room without the knowledge of the patient. This should be obvious but you would be surprised that it does not seem to be a hard rule. The patient needs to be made aware of changes to the recipient area before the fact. If the doctor decides to re-draw the recipient, the patient needs to be told about it, it must be shown to him, etc. Would very much welcome other patients adding their own suggestions.

It seems to me that two large sessions spread by X months should be a good strategy in that case. They do a pre-shave test to only pick the anagen at each time. @Gatsby you used quite a bit of body hair if I recall no? How is that working for you?

I have never ever seen chest hair looking remotely good on the scalp - when grown to medium length - except, in this case by Dr Zarev: https://www.hairtransplantation.bg/index.php/bg/event/6050FUEChestGrafts Don't know how to explain that