Raphael84

16 hours ago, GoliGoliGoli said:

Thank you for the very detailed answer. I am currently scheduled to get 4000 grafts with a reputable Dr in November. This will be to cover my hairline and scalp. Do you think 4000 over two day session is risky for these reasons you explained? I know 4000 is the maximum most reputable Dr's will do, but is 4000 even pushing it? Asking @Eugenix Hair Science@Eugenix Hair Sciencesas well, thanks!

It really depends on many factors specific to the patient and therefore why a unique surgery approach for each patient is essential.
Donor density is obviously an influential factor. Patients with significantly above average density may be able to achieve higher graft counts providing their donor is healthy.
Density however is not the only consideration.
FUE takes from surface area and therefore patients who may have a dipping or drop in the lower crown or potential retrograde alopecia with thinning from the nape of the neck moving upwards and possibly weakness above and around the ears, may mean that despite a natively higher density, weaker areas limit the surface area viable for FUE extraction.

4000 is pushing the average donor. We would personally prefer to see the patient in person for consultation before recommending or considering a 4000 graft surgery and much more commonly a patient may safely reach 3500 grafts for example. 

If the donor is pushed too much, then due to the overall negative effect that this can have on untouched grafts as detailed in my above post, this would mean that less grafts would be available in subsequent procedures due to a decline in general health of the donor and that is never the preference.

If you have no concerns with dipping in the crown or retrograde alopecia and density is high, then 4000 grafts can be achieved, but again this is not every patient.

The following case is a good example of higher graft counts being suitable.

You can see the patients rear donor has great height. No signs of decline in the lower crown or anywhere within the rear occipital, and you can see the strength and density moving toward the nape which is not so common.

This patient had an average density of 82.5 follicles per cm2 (70 - 75 is an average patient) so he was above average and his donor allowed a "safe" zone of 8cm in height and 32 in length, providing a surface area of 256cm2.
Another patient may only be able to consider a surface area of donor of 180cm2 for example, and therefore density is not the only consideration.
 

In regard to over harvesting, obviously it is the amount of grafts that are extracted that creates the main issue. But the problems created, do not stop there.

In most cases, it is due the very large graft numbers being taken in single procedure, which is more than the donor can safely provide. In other cases, graft numbers can be more conservative, but when focus is only in the richer occipital rear donor for example and therefore surface area of donor utilised is much smaller, then if not optimally managed, the obvious moth eaten appearance can still occur.

In the punching and extraction process and as follicles are essentially cut from the surrounding tissue, the scalp experiences a level of trauma. The more extraction sites in any cm2 of donor, the more blood vessels below the scalp are disrupted and the more extreme the "trauma".

Due to the "over-disruption" of these blood vessels which are responsible for healing and providing "nutrients" to the follicles that are untouched, healing in these areas can be sub optimal meaning not only have too many grafts been taken from a particular area, but the follicles left in tact also experience decline in terms of potential miniaturisation and thinning of the structure of the hair due to such disruption.

Below I share two videos with Dr. Bisanga explaining these concerns further. The second video due to some blood being visible means it is only available on the YouTube platform, but it is well worth the watch.

With the phenomenal rise of social media, there is a flooding of experts in any field and this is not necessarily a bad thing. We all like to have entertainment and most of us appreciate education. The danger however is that we can equate online presence, subs, views, likes and comments with competency. Don't get me wrong, some individuals may be very talented and also in our field, that may carry into the operating room as well as on camera, but it would be unwise to listen to "experts" who are great at talking or presenting but really have no pedigree or portfolio of cases to share their own work.

We can all be guilty of it. We can be armchair footballer managers and could do better than any referee and find ourselves yelling at the TV, but that is a world apart from actually playing. 

I have seen a rise of apparent "EXPERTS" conducting consultation and am often left very bemused that the outcome is zero empirical data and certainly nothing to base a hair transplant on. I am not referring to zoom calls or photo assessment but actual hands on in clinic consultation with the doctor, but with no data given aside from a casual "you are a good candidate" take home summary.

Always look beyond the videos to see the actual work, the history, the patients, the portfolio, accreditations, peer reviews etc..If they are not able to measure your density then will they be able to perform surgery?

@New_Barnet_Please
Thank you for you update. I have been awaiting this one.

To be honest you have never looked back from those early months post surgery and I have always appreciated your documentation, photo quality and words as Im sure much of the community has.

Good to hear that you have been able to be consistent with your regimen and that you feel that this has stabilised potential shedding that you experienced and overall completely natural. Nobody would ever suspect that you had surgery.

It should be an enjoyable summer!

This patient has kindly sent further updated photos and is very happy with the result and is now thoroughly able to enjoy her hair!
From worrying about it to forgetting about it with this dramatic change and newly found confidence.

VIDEO:-

COMPARISONS

Hi @Afro

You may find this thread offers some insight -

Hair loss does not discriminate! It has no respect for your status! Rich or poor! Young or old!

The truth is you are more likely than not to suffer from hair loss to some degree, and we see that in royalty, celebrity, sportsperson, and even the to the super rich billionaires, including the world's richest man - Elon Musk.

What we can however do, is deal with cards that life plays us to the best of our abilities. We can change the future, if not the past.

In this video presentation, we go beyond the usual reviews and look at the the cause as well as the "cure" and see where Elon's loss most likely came from and what he himself did to address it, contributing to the successful and hair confident person he is today.

How many surgeries did he have?
Why is the scar line so long?
What is the advantage of this?
Why didn't he do FUE?

This and other aspects will be touched on in this brief review on Insider Voice.

Excellent Joe.

Thank you for the update and coming along nicely at such an early stage.

Thank you for the update and I look forward to the next one.

This patient wanted to address his loss from the hairline to the mid-scalp area. This was addressed using 4,000 grafts via FUE over a two day surgery. With careful and well spread harvesting, this patient will have more donor supply left for future loss if needed. 

Here the result is presented at 8 months with photos provided by the patient and we will continue to update to the 12 month period with photos and hopefully video content.

PATIENT QUOTE:-
"I am very happy my with my results. I’ve seen the results of friends of mine who had hair transplants elsewhere and they aren’t nearly as good.
Thank you and Dr Bisanga. The pandemic made the process quite difficult but you were very patient and helpful."

GRAFT/HAIR BREAKDOWN:-
1s - 513/513 Hairs
2s - 2059/4118 Hairs
3s - 1144/3432 Hairs
4s - 284/1136 Hairs
TOTAL: 4000/9199 = 2.29 Average.

VIDEO:-

8 MONTHS

It is well documented that in the wrong hands, FUE can cause severe damage to the donor area throughout what can be  a very large area. Commonly we see the rear occipital area obliterated by doctors or technicians who have no real care about donor management or how they get the grafts, as long as they get them.

Strip(FUT) is traditionally more local and taken from a "safe" zone, usually leaving the remainder of the donor in good condition as the strip takes the entire surface area within a defined zone.
There are risks however of miniaturisation under a scar and also if the strip is cut too high, it can be problematic in becoming exposed as loss progresses and the patient´s crown and lateral humps can drop.

Having the opportunity to have a thorough consultation prior to making any decision for surgery is always the best case scenario and really allows the patient time to consider all details and the suggested hairline design so if they do decide to proceed, then they are better prepared and can suggest any changes that they may have in mind and I think that this was a factor that helped you with your decision if Im not wrong.

Having followed up with the clinic, Dr. Bisanga and Dr. Kostis, they have confirmed that there was a particular external incident the day prior to surgery and that Dr. Bisanga had to leave the clinic due to an emergency. This was not at all related to any lateness as Dr. Bisanga has waited hours for patients on many occasions as this can happen with delays and international travel, but due to the circumstances and with the knowledge that surgery and patients of that day had already been completed and knowing that Dr. Bisanga could discuss all details and design hairline etc in the morning pre surgery, then his emergency was attended to.

Looking forward to updates over the next months 

This young man, full of life and energy, a model and instagram favourite full of confidence and the world at his feet, like many, took the decision to have a hair transplant at a very young age.

The problem is not only that he was not able to tolerate medication, but actually also other factors here that are not expounded upon on most videos, that really need to be noted and discussed.

On a weekly basis we receive interest and enquiry at the clinic from individuals in their early 20s that detail their perceived stabilisation sometimes with medication and sometimes without.
The truth is that I have seen many patients who felt their hair was stable at 25, to then be in a very different situation at 30 and there are factors that present the risk of surgery at such a young age such as detailed in this video.

For those of us who are genetically predisposed to male pattern baldness, we will continue to lose hair due to the progressive condition into our late years. Whilst medication can be essential and extremely effective, it does not mean that our loss will not progress at any stage.

With that being said, a patient who presents perceived stabilisation at 25, does not mean decline will not occur between 25-30, 30-35 etc and this is the key to having an appropriate approach with the long term in mind, as opposed to a short term fix that may leave you compromised in the future just like the guy in the video.

Loss from 18 - 25 for example represents a period of only 7 years. This timeframe represents less than 1/5 of the timeframe between 25 and 60 years and so this must be considered and in this case surgery was performed at an even younger age and the result and consequences are for all to see.

@Hairlinedreamer

Congratulations on completing your surgery and thank you for sharing your case with such a thorough and well documented write up. No doubt, just as you took inspiration from patients on this forum, your thread will be of great value to other potential patients.

Thank you from myself and Hilde for your kind words. We play a small part in the process and whilst we have no direct influence on the result, I as a patient myself know that the interaction and communication with the team and your advisor is an important relationship and so that element of satisfaction is essential for me personally.

Your photos look great and your appropriate hairline design and quality of work is evident.

Relationship with the clinic has only just begun and I very much look forward to the next months and following and supporting your journey.

@Jonulous

Congratulations on completing your surgery.
Thank you for your great documentation and images.
It has been a real pleasure to be in contact and assist over the last 2/3 years and delighted for you that dates etc were able to align with your availability for you to proceed with surgery.

You have been extremely thorough throughout and very efficient with all of the information and requests of the clinic which really helps for a smoother process and communication in general.

You had a pretty good head of hair at 47 years of age pre surgery and no doubt these near 2300 grafts will make a significant difference to your hairline and framing your face.

Your photos look great and healing is on point.

I look forward to the next 12 months for you and as you know, anything you need, you have our full support.

Best

Ian

I am very pleased to be able to present the opportunity to consult in person with Dr. Bisanag next week, Wednesday 25th May in Bethesda, Maryland.

It is a late change to Dr. Bisanga´s schedule, but due to much interest and demand, Dr. Bisanga wanted to make himself available and accessible in his upcoming travel to the US.

If you may have interest to meet Dr Bisanga in person and have him thoroughly assess your hair loss, donor density, follicular grouping, condition of hair, laxity, design etc and provide his recommendations moving forward, this may be a nice opportunity to do so.

Consultations are very limited with only a final few time slots available, so please do reach out at your earliest convenience to avoid disappointment.

Thank you, and Dr. Bisanga looks forward to meeting you.

ian@drchristianbisanga.com

A big thank you @HumbleManfor your documentation, consistency and quality of images.

As can be seen in your thread, your decision to share your case and journey has been very well received and will go a long way to help other individuals who may be in a somewhat similar position to yourself, to understand what options may be available and what can be achieved.

All of us at BHR are very happy for you and your growth at this stage and you have more improvement and maturation to look forward to.

I hope you enjoy the video -

@Whipaway

Thanks for the update.
Great to hear that you have not been as concerned as "hiding" your head as you felt you would be pre surgery. This is often the case. Many of the anxieties pre op never come to fruition and we worry about many non issues, but such is part of the process.

Redness will fade as you know, so persevere with aloe vera and allow time to run its course.

Great that the first month has felt like it has flown by. Always helps just to relax and not be too obsessive and before your know it, initial signs of growth are present and exciting times ahead.

I look forward to your next months.

This result has received much attention on our YouTube channel and we have received further questions related to some of the intricacies and details of this surgery and approach and therefore wanted to present a video review to break down some of the important factors.

Whilst photos show the result, the additional commentary presents further depth of information that you may not be aware of at first glance.

Enjoy!

Christopher

Thank you for your permission to share the following video showing your case review. The additional surgery room footage that can be seen at the end of the review really helps to understand the challenges and intricacies of your surgery.

Great to see you on the right track and looking so well.
 

Thanks for the update Joe.

Looking great at only 2 months and things are moving along nicely.
You can see here pre op comparison and your temples are showing early signs of filling in.
Some exciting months ahead.

Time for an update.

I wanted to provide photos and a video comb through showing my current status at 15 months post surgery.

Due to being very fortunate and achieving impressive early growth, much of the obvious transformation really occurred in those first 5-6 months which considering my scalp was not "virgin", was a real positive and somewhat unexpected. I was prepared to be patient and thought I may require more time.

Having said that, between 6-12 months I was definitely personally aware of the hair settling and maturing and even after the 12 month stage, the restoration and reinforcement of my delicate temple points have noticeably settled further.

I was discussing with a patient recently how that despite never forgetting how you may have felt pre surgery, being overly conscious and being aware of lighting etc, your results quickly become the norm and on a day to day basis, you really do forget, which is a great thing and ultimately the aim, allowing you to move forward/on and enjoy your new hair.

Big thank you again to Dr. Bisanga and the team for such a result and the positive impact that is associated with my transformation and thank you to Stephen for providing commentary to my video thread.

Each persons donor area is unique to them. Their donor density, follicular grouping (how many hairs in a follicle 1/2/3/4), any miniaturisation and the calibre of their hair. It is a persons donor that will influence how many grafts can be extracted from that area safely, without showing visible signs of extraction.

Patients with average donor density are generally not able to provide more than 3000 grafts from their donor area in one procedure. More favourable donor density and data can allow higher grafts counts, but a lesser percentage of patients can provide near 4000 grafts and this would require higher natural density.

If the patient may have other limitations such as a dipping in the lower crown and/or retrograde alopecia meaning decline from the nape or above the ears, this then presents a limitation in terms of "safe" surface area in the donor and graft availability will reflect this.

Below your scalp in your donor area you have small blood vessels that will play a crucial part in donor area healing post surgery. It is important not to make too many extraction sites in one surgery that would put too much in terms of demand on these blood vessels which could compromise healing.

For those patients who may have high graft demands, It is in the best interests to plan restoration over subsequent surgeries to allow healing of the donor before revisiting and a managed donor extraction pattern will then allow maximal grafts in the long term.

You can often see low quality clinics pushing 4000 - 5000 grafts in patients whose donors honestly can not support this and the effect is either signs of over harvesting, or it compromises the donor with non optimal healing due to the "trauma" of such high graft numbers, and the donor may not recover as it would, meaning less graft availability in the future.

Thank you to @MachoVatofor such a well documented journey and for staying consistent with high quality and transparent images.

As a nice addition and thank you for the patients permission, the following video with walk through commentary is nice touch to summarise this thread in video format.

Many thanks and @MachoVato, you look great.

Great that you have a regimen of preventative medication in place and feel that your loss has stabilised over the last years. That is important.
 

At 26 you would still be a younger patient and therefore any surgery must be mindful of this in its approach.

Your posted images don’t present your loss to be able to comment on that specifically, but back to your original question, your donor would appear fine from these photos without any obvious concern.

I wish you the very best in your next steps and however you may proceed.

Thanks for additional photos.

Your sides appear healthy and you have retained your natural temporal points and shape it would seem which is positive.

In terms of graft recommendations, the photos that you have shared do not show/expose your loss to be able to understand surface area of decline and how many grafts may be appropriate.

Are you using any hair loss preventative medication?
At 26 and considering a hair restoration procedure, without having yet seen your pattern of loss and the area that you are intending to restore, but with your crown also opening, hair loss preventative medication would likely be key and influential in terms of your best interests over the long term.

Without medication, it is safe to say that your loss will likely evolve, as is the nature of a progressive condition such has androgenetic alopecia. With your crown opening, should this progress and your lower crown experience decline and drop, then what may be deemed your "safe" donor area today, may not be the case in 10-15 years due the advancing of crown loss, meaning that any grafts extracted from higher in you donor, may suffer decline and have concern regarding longevity.

Depending on the extent of your current loss and potential progressive pattern, maintaining native hair is generally the first step and oftentimes essential, and in doing so and with a positive response, long term graft demands should hopefully be less with a healthier and "larger" donor area over the long term to be able to meet those demands.

The following video details the need for medication and the "safe" donor area -