Raphael84

Thank you to this patient who came to us for surgery and documented his journey and growth very well and has kindly shared the following photos representing 3,6,9,12 months post surgery. His goal was to re-establish a hair line and work back as needed to blend with native hair. We did this with a conservative approach of 3,000 grafts and in preparation of further surgery to address his crown. ☑️ PATIENT QUOTE :- "It’s hard to believe that it has been twelve months already from the procedure in Brussels. While the first few months were slow it has been great to see the progress from 4 months onwards. I am pleased with the transformation and it is great to no longer have to think about the weather and how to style my hair to cover up the front. " VIDEO:- Age: Late 30s Meds: Minoxidil Follicular Unit/Hair Count 1s = 453/453 2s = 1309/2618 3s = 1202/3606 4s = 36/144 TOTAL = 3000/6821 = 2.2 Average. PRE-SURGERY☑️ PLACEMENT☑️ 3 MONTHS☑️ 6 MONTHS☑️ 9 MONTHS☑️ 12 MONTHS☑️

Thanks for the comments. It is very nice to be able to share an afro hair case. Fewer and fewer patients are open to sharing their case nowadays, so a big thank you to the patient and it really highlights the impact that sharing cases can have for the community.

This patient came to us for a Strip surgery. The goal was to re-establish a feminine hair line and work back into the loss areas. Female patients often prefer Strip surgery as it is easier to conceal post surgery. Afro hair does have particular challenges but also benefits associated to it and it does need a specialist approach and a doctor and team who understands skin types, the curl of the graft and hair and also the directions and density they need to be placed in for a natural look. The result here is tremendous at 8 months, showing already good density and naturalness and the patient was very happy to come in for a check-up, record a video and give her testimony of the change to her that this surgery has given her. VIDEO:- FU - HAIR Breakdown 1s - 589/589 2s - 1077/2154 3s - 713/2139 4s - 21/84 TOTAL: 2400/4966 - 2.06. PRE-SURGERY https://i.imgur.com/BF7WCcH.jpg[/img] POST-SURGERY 8 MONTHS

Thanks for sharing your images and details. If I can ask your age, and also what is it that you are actually looking to achieve? Depending on your age, you look to have retained a good amount of hair, but the propensity and potential for further loss at some stage does appear to be present with the lesser density in your crown which can be seen in the contrast from lower crown to rear donor. Some retrograde may be present and showing a lesser density in the side donor. With your regimen of medication in place, you may well present a stable environment now. In your images, with the slightest more length on top, your hair looks pretty good and I wouldn't be rushing into any surgery quickly. Again, age depending it may be best to see how things play out over the next years.

This will really depend on your age, extent of loss, future loss potential, donor availability etc For younger patients with more extensive loss and the propensity for future loss, more conservative will more often than not be in your best interests and allow more donor to be retained for potential future requirements. When a patient researches and narrows down their preferred doctors, generally this will be based on an appreciation of the artistic approach of the doctor and therefore you will feel more confident following the advice and proposed design or somewhat close to that of the doctor. You may appreciate the following video that discussed optimal hairline design -

Another consideration for anybody who may have the approach in mind of having surgery and then beginning medication, is that they never know if they can tolerate the medication. Therefore any surgical approach that may be influenced by the idea of long term commitment to a particular medication, it really is more sensible to begin the medication beforehand to see how you may respond and tolerate the medication. Only then will you know if you are able to and comfortable with committing to it for the long term.

Some great advice above. I completely understand that it is not the feedback that you are looking for your and motivations and desires are to move forward with surgery, but the idea of being stable at 25 even with medication is unlikely to be honest, considering the pattern of decline that your photos present. The feedback provided by other members is intended purely in your best interests and with the long term as priority. I have seen guys at 30 who use meds and feel that their loss is stable and then to be in quite a different situation at 35. You are a young guy with some degree of loss and/or decline essentially from hairline to crown. Good to hear that you are committed to Finasteride and tolerate that well. To maximise the potential benefits of medication and to see if you may be able to achieve any improvement with medication, perhaps consider looking into minoxidil and discuss that with your doctor and hold off the idea of surgery for the next years. Proceeding with surgery at this stage, to experience further decline over the next years may leave transplanted areas disconnected from native hair, a hairline proposed at current may not be what would be appropriate at 30 with additional loss.

@Drumnjake Some great advice has been shared with you above. I have read through your thread, and apologies if I have missed it but I dont see your age mentioned? Good to hear that you are on meds and you feel things have stabilised. From your images, a few considerations are that there appears to be some thinning behind the initial cms of your hairline. Photos are not always completely accurate but depending on your age and stability, these areas may experience some further decline and as you are considering a repair surgery, depending on all specifics, it may be required and in your best interests to reinforce throughout this area to avoid any disparity or need for further surgery in the shorter term. Whilst your rear donor was the only area of your donor that was harvested, with your hair at length, it is hard to get an idea of status of the area. In your pre surgery photos where you back and sides are shorter, you can see that the side donor presents a lower density than the rear (below). It is quite common to have a drop in density in comparison to your rear occipital, but it would be in your interests to get a thorough assessment before jumping in to any additional surgery. These parietal areas generally present the most appropriate finer single hair grafts for hairline work and so with any drop in density in these areas, it really highlights the importance of getting it right this time and to ensure to have appropriate long term planning. I wish you the best moving forward.

I work as a patient advisor for Dr. Bisanga. That is correct. Dr. Bisanga would generally recommend (when appropriate for the patient) to begin oral minoxidil prior to surgery to get a sense of how a patient may respond and tolerate the medication. This will then allow the patient to have more confidence in being able to commit long term which can then have an influence on assessment and recommendations knowing that a regimen is in place. For patients who already use oral minoxidil at the time of surgery, there is no need to discontinue the medication for surgery and they continue as normal. Topicals require a period of time without application, which is normally 2 weeks before and 2 weeks after surgery. Even before oral minoxidil was available at lower dosages and before it was being discussed as an option orally for hair, many hair transplant doctors would recommend patients to begin topical minoxidil 2 weeks post surgery to encourage follicles to transition to their anagen growth stage as soon as possible, so there should be no issue using this medication 16 days post surgery, but always best to discuss all with your chosen clinic. It is also always recommended to discuss with your GP/family doctor to allow them to advise based on your family history, list on your own medical records and can then advise in case of any concerns of secondary effects. All the best.

Always best to check with your operating clinic to ensure that they do not share any alternative approaches, but oral minoxidil generally doesn't need to be discontinued throughout the surgery timeframe, meaning that you will be fine to begin at this stage.

If you are able to travel and meet in person with good repair surgeons, despite the inconvenience this really would be your best option. Repair cases are so unique and depending on your status, quite often there may be further challenges than photos can really accurately represent and so in your own best interests, a thorough consultation will allow data to be attained, some concerns potentially ruled out and a more clear and honest understanding of your current status, challenges, recommendations and realistic expectations to really try and avoid any further disappointment and move towards your objectives.

PRP isn't generally standard within a hair transplant procedure and I believe that any doctor who is achieving consistently excellent results and optimal healing, will explain that this is not due to PRP, or does not require PRP. Many clinics, generally less so in Europe, really get behind and market PRP in a way that patients may feel that they are missing out if they do not take up the option of PRP, when is most cases this is not really true.

There is a lot of nuance in regard to body hair and various sources and so if considering the possibility of surgery including body hair, it is always in your best interests to get a sense of what may be most appropriate and reliable. Body hair can differ in characteristics to scalp hair in terms of colour, coarseness, curl and cycle (growth phases), and also in count (the hair to follicular unit ratio), which is often lower than scalp and finer quality hair in sources other than beard, meaning body hair will present a lower hair count for a comparable scalp graft count. The yield can be slower to grow or lower than traditional scalp hair yield. Usually the growth phase is much shorter for body hair, with the exception of beard hair that cycles much more like scalp hair, so patience is needed when awaiting growth especially with this type of procedure that can often be into scar tissue of a repair patient.

Some good advice above and honestly it is good that you reached out to a surgeon who showed some caution and ethics as opposed to the other clinics who may have proceed regardless. 25 is a young patient regardless of extent of loss. When a patient at 25 presents signs of some decline from hairline to crown and thinning and in the temple point area, then the propensity for further loss is in place and at 25, there are still unknowns regarding potential rate of loss. The last thing that you would want to do is to proceed with surgery now, and then in the next 2 or 3+ years lose native hair amongst transplanted hair so that the area would begin to look thin and then lose behind any transplant, so that any transplanted area becomes disconnected to native hair. This would leave you in a more compromised position than your current position. Try and maintain as much as possible at this stage and optimise your regimen of hair loss preventative medication in an attempt to maximise the benefit, and see how the next several years may evolve. Wishing you the best.

Thank you for your comments. Beard hair was used in constructing and reinforcing areas of the beard. The advantages here are obviously hair type with a natural match to native beard with colour, curl and coarseness whilst also therefore leaving more scalp hair within the donor for the future if needed. The patient being 41 at the time of surgery had a stable hair status overall and good hair quality. A regimen of finasteride and topical minoxidil were already in place. Dr. Bisanga recommended to change from topical to oral minoxidil and the patient has responded well. To add a thank you to the patient for allowing permission to share his case and it was a pleasure to assist and follow his journey. A real great guy and we are all very pleased for him.

This patient of 41 years of age came to us for a repair after previous FUE surgery elsewhere. He was left with a pluggy and sparse hairline. His goals were to - ✅ Repair and refine the hairline and work back through the thinning area. ✅ Strengthen and accentuate the temple points ✅ Re-inforce the crown that was thinning throughout ✅ Add density and design to beard where there were areas of less hair. Dr. Bisanga and Dr .Kostis were able to address all of the patient's goals and here we see the outcome at 12 months for all areas. All photos have been provided by the patient and sent to us. Naturally he is very happy with all of the outcomes in the hairline, temples, crown and beard. The challenges were that the donor had areas of over harvesting and significant scars from the first surgery. We needed careful harvesting to obtain the grafts needed and including finer single hairs for hair line and temple points. Placing among the previous poor work also is more of a challenge than virgin cases but you can see the outcome is with very good density and naturalness. Beard to beard was then used for the beard transplant. Patient was advised also to commit to Oral Minoxidil. Patient Quote - “The results are fantastic. Those who know keep telling me that the results are unbelievable, and those who don’t know, they tell me that I look younger, but they can’t pinpoint as to why!” FU to Hair Breakdown 1s - 1053/1053 2s - 1492/2984 3s - 1328/3984 4s - 145/580 TOTAL:- 4018/8601 - 2.14 Average, + Beard - 1008 Video:- Pre-Surgery Donor Post-Surgery 12 MONTHS

@Bailey99 Thanks for your update and great to refresh all from your thread. It’s been some journey. No problem. I will send them over to you and you can then decide which images you would like to share.

Other forum users have shared this thread with me and asked if I can clarify some points. I am not personally the patient advisor to @patronovski and so prior to today, I didn´t have any knowledge of his case. As I understand your advisor Hilde has been in contact regularly via email, WhatsApp and phone calls throughout this period and has asked for consent to be able to share further images and details additional to what has been disclosed here to allow a more clear, thorough and honest representation now that you have shared your case publicly. To address the points that have been raised in your post - Your post suggests that 150 grafts were used to complete the surgery, when in reality more than double this graft amount was performed for the pricing that is stated and so this can be misleading especially as no donor restocking has been mentioned which included beard hair which has a unique price point to scalp and this took place in areas on both sides of the occipital donor area and as said over doubles the graft count you disclosed. The price given was also below our usual price for booking an op-room. As a repair patient with donor restocking, this is below clinic pricing. I can see from notes from initial in person consultation some months prior, ridging was explained to be present in both temples and noted and drawn on the consultation notes, that realistic expectations are important based on your objectives and that SMP was recommended after any work into the donor area. Consultation at the time of surgery explains the risk of shock loss also. From what I can ascertain at current, the messaging throughout from your advisor Hilde has been the need for patience at such an early stage where shock loss has occurred and others here independent of BHR Clinic have said the same as we have. The nature of the hair cycle means that any follicle that has experienced shock loss and entered a resting phase, will require several months (generally around 3-4 months) before transitioning into an anagen growth stage. This is the reality of the hair cycle and time is needed, especially in repair cases where skin is not virgin. Whilst we encourage all patients to share their experience and case online, it is regrettable the manor in which some of the points have been portrayed missing important elements for transparency and also the time frame of one month post surgery when shock loss needs more time to recover, when the clinic have not at any point failed to reply and Hilde has also explained that we would also take care of shock in good will should there be any issues, in order to alleviate your concerns. I would recommend you follow up with your advisor further and the best advice has been detailed by many posters above, the necessity for time.

Thanks for the further comments. I would not agree regarding graft numbers and surface area based on this patients´ personal data specifics. This highlights the lack of understanding of what may be appropriate for one patient, and not another. It is such a misconception that a "one size fits all approach" in terms of design and graft numbers are appropriate. Whilst 2553 grafts were used in this patient based on the hairline design that was proposed due to the patients age, bone structure, hair quality, characteristics and extent of loss, surface area covered and required density to achieve an optimal illusion of density, another patient may require more or less with a similar situation based on realistic objectives and long term planning. As said by the previous poster and as explained in previous videos by Dr. Bisanga, the hairline alone can demand around 500 soft single grafts, and the depth of placement in the lateral areas sits behind the frontal third. The patient is in his 40s with stabilisation behind his somewhat limited frontal loss with good calibre hair and native density. Could less grafts have been used? Yes. Would it have achieved the same result? No. Especially not at different lengths where density may well be more "exposed". The approach for this patient as with all patients was very specific to him and having used around 2500 grafts, the patient now has a great head of hair in his 40s and stabilisation throughout. He is in a great position. Very few patients allow their images to be shared publicly these days. Years ago any sharing would have meant posting only on hair restoration forums. Nowadays that means social media where reach is greater and patients understandably value their privacy in such a sensitive matter. This is one of the best cases shared of late and again we express gratitude to the patient.

12 MONTH UPDATE A big thank you to the patient for his 12 month photos. He is very happy with the outcome as per his testimony and from my side personally as his advisor, it has been an absolute pleasure to support him on his journey. I couldn't be happier for him. Quote:- "I am so pleased with the results! It is without a doubt the best decision I've ever made. Feel free to use the photos as before."

At 28 with diffuse thinning throughout a larger surface area and not currently using any medication, further surgery to reinforce density in the hairline may not be the most appropriate next step. Obviously in terms of achieving a more natural hairline, it has logic but in the next years if you will continue to lose hair behind then to have a fuller hairline and little behind this could be problematic for you. As you mention sides with finasteride and the concern with minoxidil is more skin related, maybe you can look into oral minoxidil which can be very beneficial in diffuse thinners. Placing beard into the mid scalp without stabilising may also mean that in the future, only the beard hair remains and so priority really should be longer term.

Patient wanted to address his hairline and diffused thinning in the frontal third and also to add some density to the crown. We did this with 2903 grafts and also recommended the patient take medication for stability. We will update as and when the patient sends his photos to us and hopefully through to the full 12 month period. FU/HAIR MAKE UP 1s = 403/403 2s = 1787/3574 3s = 694/2082 4s = 19/76 TOTAL: 2093/6135 = 2.9 Average PRE-SURGERY PLACEMENT SIX MONTHS WITH COMPARISONS

Hi @SY7 Thanks for posting and sharing your concerns. In terms of your personal case, Im not sure who your advisor may be or if you have met with the doctor for consultation and data such as donor density and potential graft availability have been provided, but Im sure you would find value in discussing this with them based on any data that has been measured and attained. As with any patient regardless of Norwood status, donor availability will be very unique to them based on the surface area of viable, density throughout areas of the donor and the calibre of the hair. Then depending on their follicular make up and how many single, double, 3s and 4 hair follicles they may have, will also dictate what can be "safely" extracted. If a patient has more coarse hair, higher density and predominantly 3s and 4s within their donor area, then extracting a higher percentage of grafts from within each cm2 would be more viable as the total hair count (not graft count) within each cm2 would still allow the donor to appear untouched. Alternatively if a patient may have finer hair, with a lesser density and predominantly singles and double hair follicles with few larger groupings, then a lesser percentage of grafts within each cm2 can be extracted in order to maintain an appropriate hair count to maintain the integrity of the donor area. This is without even considering potential future loss, miniaturisation and any requirements for potential future surgeries. In terms of punch sizes, Dr. Bisanga will generally use a 0.75 - 0.8mm punch on patients with caucasian hair and average hair calibre. If a patient has afro wiry hair with naturally tight curls, then the punch size would be slightly larger to ensure complete encapsulation. The comments regarding Dr. Bisanga using large punch sizes is completely unfounded and as BHR patients represent amongst the most posed on this forum, both patient and clinic posted, then this can be verified by taking a look at countless examples. The reality today is that a very small percentage of patients share their case or give permission to the clinic to do so. This means that only a very small window is seen in relation to the work that a clinic does. On this very forum, most users won’t normally share their case. Most clinics will attest to this, especially those that do not offer incentives to patients to share just as BHR don’t. The idea that Dr. Bisanga only accepts patients with excellent donors is completely false and the very fact that BHR perform more repair surgery than most clinics reinforces this. I share the following image of a patient, post surgery taken at the clinic and smaller punches than this whilst avoiding transection is not possible and the reality is if a patient is not willing to have this size of punch, then FUE is probably not the right option for them. The cases that were detailed above I believe were referring to the following first 2 cases. Also in response to only accepting candidates who have excellent donors, please take a look at the condition of the second example and the aggressive nature of retrograde alopecia, whilst also considering the dropping in the lower crown and scarring within his donor. I also share other examples of larger patterns of loss with non optimal donors.

@roritoThank you for your write up and images. Very pleased to hear of your positive experience at the clinic and Lina and the team thank you for your kind words. As have been touched on by @laverita, the day 3 photos that have been kindly shared show exceptional healing at such an early stage and the size of the extraction punches are clearly small with a real respect in terms of extraction management and space in between each extraction. Without derailing a patient posted thread, any punch will be as small as possible whilst still ensuring complete encapsulation of the hair follicle. Using a smaller than required punch will transect hair and/or damage any essential connective tissue including stem cells which will then damage the graft. @roritoI look forward to your further updates and wish you the best over the coming months.

The patient's goal was to address his recession. This was a shared surgery performed by both Dr. Bisanga and Dr. Kostis and shows the pre-surgery design for the hairline and working backwards into the recession through to the six-month stage. 2180 grafts were used to accomplish the desired look. The patient has experienced fast and significant growth already at this stage and is very happy with the outcome so far. We expect more growth and maturity over the coming months but nonetheless, he already has a very good improvement and was happy to share his journey. We will endeavour to update this case through to the 12-month mark. AGE: 37 MEDS: None GRAFT/HAIR BREAKDOWN: 1s 424/484 2s 842/1684 3s 584/1752 4s 330/1320 TOTAL: 2180/5240 - 2.4 average. VIDEO: PRE-SURGERY POST-SURGERY 6 MONTHS COMPARISON