Dr. Paul Shapiro

StaggerLee Your question about survival is a good one but the answer is complex. When we talk about the survival of our surgeries we are honestly going by gut feeling and what we know should look like 95% survival. To truly know the survival of a transplanted area, the area needs to be tattooed and photographed prior to surgery. The pre surgery photo gives us a count of the hair present before surgery. Then the incisions made need to be photographed and counted. Lastly, the grafts need to be planted and can be re-photographed. Most studies done this way are done using 1 sq cm tattooed boxes. In a year we can then take a photo of the tattooed area and count the number of hairs. And even using this method is not accurate because about 10 to 15 of a person’s hair is in the catagen stage and cannot be seen. The only way to really measure survival is to transplant onto a completely bald head and mark out sq cm areas with a tattoo. Some studies have been done using this technique but they are done with very few grafts. If one studies 5 areas and plants at a density of 40 FU/sq cm in each box, then that is only 200 hairs. That is a lot less the planting 2,000 hairs and it takes a lot less time. The studies that have been done show that even under the best conditions we do not get 100% survival but can achieve 95% survival. At SMG we have a good feel for what 95% survival should look like since we have done so many surgeries. But we do not accurately measure the survival and I am not aware of any clinic that does. One of the main reasons is that not many patients want 1cm square boxes tattooed on their scalp. As Janna said the survival of our FUE cases using special holding solutions, ACell and ATP spray are getting better and are approaching our strip survival. But I do think overall the survival is best in our strip cases. But since we are not doing exact measurement and comparisons, this is just our observation. I hope this better explains how we judge survival.

This patient had a high donor density and good donor laxity. Both are needed to get a yield of 4,000 FU’s. His donor density averaged 100 FU/sq cm. The majority of our patient’s donor density averages around 80 FU/sq.cm. Also he had good donor laxity. I could take out 1.8 cm wide strip in the middle safely and still get an excellent closure. I would say that only 10% to 15% of the patients who present to our office with Norwood type VI balding have donor that could yield 4,000 grafts.

Yes I do mean the motorized safe system

Hariri That is a good question. It is true that by using the Robot there will be less fatigue of the surgeon and that is a good thing. Even though we all like to think we do our best all the time. We all do a better job if we are less fatigued. But if that was the only reason for using the Robot we would not have invested in it. We are using the robot because we feel it has the potential to be superior to all other methods of Follicular Unit Extraction. The robot has two punches. First it makes a scoring punch with a sharp punch, and then it makes a deeper punch with a dull punch. We believe this method using the robot to visualize and guide the punch has the potential of yielding superior grafts with less transection and more tissue around the grafts. FUE is still a relatively new process compared to the traditional strip technique. There are many ways the follicles can be extracted and there still is a debate whether any one method is superior. There are sharp punches and dull punches. There are various mechanical assisted devices for both sharp and dull punches. The Robot is one of many mechanical assisted devices. The difference between a sharp and a dull punch is how deep one can go. With a sharp punch the surgeon needs to be very precise with the depth of the punch. If the punch goes lower than the bulge of the hair follicle it is easy to transect the hair. The hair then is harvested by carefully pulling the graft out, and this can leave the hair bulb with very little or no extra tissue around it. Also, the graft can be damaged during this pulling process. When using a dull punch, the punch can go all the way down to the hair bulb. Instead of cutting the dull punch separates the graft from surrounding tissue by bluntly dissecting around the graft while the graft straightens. In theory using a dull punch there can be more tissue around the grafts and thus better survival. Also the grafts are already separated from the tissue so there is little or no trauma in removing the graft. The disadvantage of a dull punch is the grafts can get buried Just to be clear the Robot is one of many mechanical assisted devises. All of these make it easier on the surgeon. There is the SAFE system which also uses a dull punch. The Neograft machine and the powered FUE isolation device both use a sharp punch. There are other mechanical devices I have not mentioned. All these machines can yield excellent results when used correctly by an experienced surgeon. At Shapiro Medical Group we use the SAFE system and the Robot. We believe ultimately the Robot has the potential to yield superior results. The robot is constantly improving. New hardware is constantly being developed to make the robot more accurate and they have developed a .9mm punch. At present, in most of our FUE cases with the Robot we are also extracting some grafts using the SAFE system. Since we have only been using the Robot for 6 months we are just starting to get results in. We want to compare the results to see if there is a difference in graft survival and donor scarring. Because the Robot is a new technology we are going slow and taking limited cases. We do not have any 6 month follow up cases yet. So I cannot give you any information on our results compared to using the SAFE system. I can say that the grafts extracted when using the Robot look as good as the SAFE method and I am expecting excellent results. I hope this informatioin is helpful Dr. Paul Shapiro

Samsri You are a Nrowood type 6 going onto a type 7. Without knowing your age and if you are on medical treatment it is difficult to give you an exact number. But I would estimate you would have a session of 3,000 to 4,000 hairs and that would only cover the front half to the front two thirds to the top of the crown. You do have loss in the lateral hump areas and some hair needs to be used to build that up. You hair looks coarse and dense. Usually that means your donor density has less FU/sqcm then the average patient. But one of your hairs has more volume then someone with fine thin hair. In cases like yours the amount of FU we can get from the donor area is less than sometimes expected but the volume transplanted is more then expected. Most clinics, including ours will do consults without a charge. If you are interested in more detailed consult please call our office. I hope this is helpful Dr. Paul

Harriri: Like I stated there are many reasons for a wide scar. The most common reason is too much tension on the closure. There are various methods we use to estimate the laxity of a patients donor area. Usually we estimate correctly but sometimes our estimates are off. Sometimes the difference of just .1cm in the width of the incision can make the difference between a good closure and a tight closure. But there are many other reasons for a wide scar. Some patients have thick tissue that does not approximate as easy the doctor thinks it will. I find that patients who have played American football, Hockey, or Soccer can sometimes have thick tight tissue. If a patient has had previous surgery the area will have more tension than expected. I have some patients who had a lot of falls as a child and find some deep scarring from previous injuries. Often I will ask the patient and then he will remember some old fall or injury as a child. Decrease circulation can contribute to scarring. This can be due to undiagnosed atherosclerosis or diabetes. The blood vessels that supply the donor area are deep below the dermis. Sometimes they are not so deep and some get cut. If blood vessels are cut this can sometimes compromise blood flow to the donor and contribute to a large scar. It is important that patients follow the post op instructions to get the best scar. I suggest no heavy exercise for at least 2 weeks to get the best scar. I know it is difficult for some patients to adhere to these post-operative instructions. Too much exercise or lifting prior to healing can cause the scar to stretch. There are some patients who have “loose” collagen tissue and just tend to scar easy. In these patients a doctor can do everything correctly and there still will be a wide scar. Scar revisions usually don’t work in these patietns. They just stretch again. Some of these patients will have known collagen tissue disease but most do not have any specific syndrome. There is one way I believe Acell could contribute to a large scar. The ACell strip needs to be placed deep in the closure below where the dermal tissue is approximated. If the strip ends up between the dermal tissue it can cause a wider scar, so the placement of the ACell strip is important. So as you can see there are many factors that can affect donor scarring. I am not sure why this particular case had a wider then expected scar. I hope this is helpful Dr. Paul

We do use ACell at SMG and have not found any detrimental effects. Just because a surgery had a poor outcome and ACell was used does not mean that ACell is the cause of the poor outcome. There are many other factors that could cause a wide donor scar and poor outcomes. ACell is a wound healing product made of Extracellular Matrix, which is the structural tissue between cells. In this matrix are structural proteins, growth factors, and anti-infective peptides. The structural proteins work like a scaffolding for the body’s cells. There are many studies which show Acell promotes wound healing. It has been shown to be effective in surgeries involving the heart, esophagus, hernia, surface injuries, bladder, orthopedics, and ear drum. It has helped humans heal fissures in skin, ligament, and muscle tissues. It can inhibit fibrotic scarring and promote the production of new blood vessels. It also has been shown to recruit cells which promote tissue regeneration. In hair transplant surgery ACell has been used in a few different ways. ACell comes in a powder form and a flat sheet. We use the powder to coat the graphs before we place them into the skin. We do this in all our FUE cases and sometimes in our Strip cases. We do think we have had superior growth in our FUE cases with the use of ACell. Some physicians are putting ACell in the FUE extraction sites to promote healing. We have not done that. The ACell sheet is used in wound healing. I have tried using ACel strip in scar revisions but have not seen a significant difference. I do not think ACell is effective in scar tissue. But the results were never worse than expected. Since the last International Society of Hair Restoration Surgery meeting I have been using thin strips of the ACell sheet in all cases in which I think they will be a second case. Dr. Jerry Cooley presented his experience with ACell and donor scars. In his experience the width of the donor scar is not affected by ACell. That is determined by many factors such as donor tension, circulation, skin tissue characteristics, and proper adherence to post op instructions. What he did notice is that the quality of the tissue under the scar is less fibrotic and softer. I find this to be significant, because the underlying fibrosis of the tissue after an initial surgery will limit the laxity for the next surgery. So if we can reduce this fibrosis when a patient needs a second surgery there will be less tension. This will enable us to remover more donor and get a better yield with a good closure. Below is a photo from Dr. Cooley’s lecture. As you can see, when comparing the ACell side to the control side, the donor scar looks very similar on the surface. But there is much less fibrotic tissue underneath the skin on the ACell side. You can see using ACell was not detrimental, but helped the donor healing. So using the ACell sheet will not affect the way the donor scar looks, but will affect the tissue quality.

Montreal ACell is an extracellular matrix with growth factors. It is made from porcine bladders. It is safe in Humans, because it is acellualr. It was originally formulated for wound healing and has remarkable results. It has been used in hair transplants because the follicular unit graft needs growth factors to stimulate progenitor cells to make the new blood cells and tissue for a healthy follicle. We are using it in all our FUE cases because we believe the follicles are more fragile than strip cases. We are just seeing the results using Acell. It could be used in traditional strip cases also, but our survival is so good in strip cases we are not using it in most of our strip cases.

Cant Decide: I understand what you are saying and I do think it is importatn to give these areas good density. They usually are not as dense as the central core area, but should be dense enough to block light and frame the face. What density I plant there can really vary by case. But you are correctr in saying thi is an important area to frame head. That is why I make a circle in the crown with those side angles down lower. I hope this makes sens Dr. Paul

Cant Decide: There is no set rule whether to put hair in the crown or not. What is important is that we take in future hair loss into consideration so that if the patient progresses there is enough donor to make the hair transplant look natural. In this case the patient did not want his hairline very low and was happy with a mature frontal-temporal angle. I kept the front of his hairline high at 9 cm above the glabella and his frontal temporal angles mature. In these patients I will shrink the crown, but not completely cover it. It is usually safe to put hair at the top of the crown. Also the hair in the top of the crown is at a lesser density of around 25 to 30 FU/sq.cm to give it some coverage, but not very dense. In the photograph of his crown I have drawn in green the potential future crown hair loss and in red how far down I would go in his case. So if he becomes a Norwood type 6 or 7 he will still have some crown showing. I hope this answers your question.

Dr. Paul Shapiro: 4400 FUT grafts on 28 year old Norwood type 4. 14 Days Post Op with hair cut short. This 28 year male came by for his suture removal 2 weeks post op. His native hair was buzz cut so all the hair you see on the top of the scalp and hairline is transplanted hair. A lot of patients want to know what they will look like after the surgery. Like this patient, most patients redness and scabbing is gone by 2 weeks. As you can see, with a good haircut, it is difficult to tell that he had a hair transplant. Most likely all the transplanted hair will shed in a month, but his native hair should grow about ? to ? inch a month. His graft count was as follows: · 1 hair - 1113 · 2 hair – 2484 · 3 hair – 756 · 4 hair – 47 · Total grafts – 4400 · Total hairs – 8564

Dr. Paul Shapiro—1968 FUT grafts on Female Patient to Lower Hairline. Six Months post op This 27 year old female has always had a high hairline. Her goal was to lower her hair line. She did not have any evidence of Female Androgenic Alopecia. Her donor laxity and density was good. I took out two strips. One was 1.4 cm wide by 9 cm long and the other was 1.2 cm wide by 7.5 cm long. The hair count was as follows: · 394 one hair FU · 1060 two hair FU · 514 three hair FU Total FU-1968, Total hairs- 4056 She came in for her 6 month post op and was very pleased with her results. I expect to see more thickening and hair growth at one year.

JustAGuy I think what is confusing is that we are talking about transplanted hair miniaturizing, not completely falling out. Those are two different issues. Sometimes when we use the term shed, we are talking about miniaturizing, not completely losing the whole follicle. Sorry about the confusion and the term shedding is not a very accurate term. As I said there are some rare cases in which the results initially look good, but then the transplanted hair thins prematurely. This is very rare, but can happen. I have never seen a case in which the results were good and then 15 months later the transplanted hair permanently fell out. The only cases I have seen in which transplanted hair actually fell out are from some older cases in which the old large grafts were taken from the unsafe donor area. Thus these hairs finally succumbed to the affects of DHT. And in these few cases the transplants were done 15 to 20 years ago. When the hair miniaturizes the decrease in volume of hair is much greater than the decrease in diameter of the hair. This is because the volume of the hair follicle is 3.4X the radius squared x the length of the follicle. So it may seem like the transplanted hair has fallen out when it has just miniaturized. I have done transplants on patients who have see through hair and one would guess they have a density of 10 or 15 FU’s/sq.cm. But when I took an actual photo of their hair after I cut it short, I measured a density of 50 or 60 hairs/sq.cm. but the area looked bald because the hair was so thin and miniaturized. You ask if there are reported cases like yours. I have not heard of a case like yours with such significant hair loss after 15 months of surgery. You did mention that Dr. Feller has not had the opportunity to examine you in person. Without examining you he is most likely giving you an array of possible explanations and that is why you may be getting some contradictory information. Even with photographs, it is difficult to evaluate miniaturized hair unless one is looking at the hair under magnification. Sometimes under magnification we can tell if you are experiencing loss of existing hair or miniaturization of transplanted hair, but that can be difficult. Because what you are describing is unusual, I do think it would be a good idea for you to get a medical work up for both endocrine and dermatological causes for your sudden hair loss. I am not sure how long this hair loss has been going on but you may be experiencing some form of chronic telogen effluvium. This can look like permanent hair loss. Also there is a condition of diffuse alopecia areata which can look like what you are describing. If for some reason you are having fluctuations in your Testosterone, or thyroid hormones that could cause hair loss. Also there is some evidence that high prolactin levels can cause hair loss. As I mentioned in a previous post some supplements can cause hair loss and even heavy metal in ones diet can cause hair loss. If all medical explanations are exhausted there may be something unusual with your biology as you pointed out that may never be diagnosed. In summary the cases I have heard of that are similar to yours, are cases of donor hair miniaturization, not actually complete hair loss. I have also had cases when I have gone between existing hair and when that existing hair thins, the transplant looks worse. There are some patients whose donor hair will get very thin and decrease in density with age, but this happens 10 or 20 years down the road, not 15 months down the road. Usually, this does not happen until the patient is in their 60’s. There have been a few cases I have seen reported of significant donor hair loss 10 years after surgery, but not 15 months after surgery. And usually there are other medical factors that may explain some poor circulation or other medical conditions. I hope this is helpful Dr. Paul

When I evaluate a patient for a transplant there are some indications that the patients donor hair may thin at an early age in the future and in these patients I am very cautious. I am cautious with the following patients: patients with diffuse thinning and miniaturization throughout their scalp, patients who are significantly bald before they are 30, patient in which there is already miniaturization in the donor area, and patients who have significant thinning in the lower crown near the safe donor area. Most other patient’s donor hair is secure for many years. That is why we see most of our transplant patients happy and with good results holding for 10 15 years. The senile alopecia that happens in the donor area usually does not show up until a patient is in their 50’s or 60’s. All transplanted patients have the risk of senile alopecia. This is a thinning, not a total loss of hair. Usually this thinning is minor and it can be accompanied with some minor thinning of the transplanted hair. Sometimes it is more significant and the transplanted hair can look very thin and the donor can thin out. We cannot predict when this will happen or to what extent. But most patients have enough donor hair that if they want to they can thicken up the transplanted hair with another transplant and still hide the donor scar. There are few patients who have good donor and no miniaturization in the donor are and despite good growth after their transplant, will start to thin 2 or 3 years post operatively. We do not know why this happens. There may be more than one reason for this type of patient and fortunately this is a very rare phenomenon. In answer to your question about the donor scar, even if the donor hair thins, we leave enough hair to hide the donor scar. That is why it is important to leave about 50% of the donor hair to hide the scar. Aaron1234 pointed out that some men in their 70’s their donor area is completely gone. I don’t see that often. But it can thin significantly. But if the scar is minimal and they wear their donor hair at the proper length, even in these men the scars are not easy to spot. This usually only happens in Norwood type 7 patients. And by the time a patient is 30 we can usually tell if they have a good chance of progressing to a Norwood type 7. I hope this answers your questions.

TC17 You raise a good question. Since there are many reasons why transplanted hair might thin, the answer is not straight forward. If the transplanted hair is only thinning, but still present then as Dr. Feller pointed out, another transplant may add the density that will make it look good. Remember that there is always hair in the donor area, even if it thins out. If the transplanted hair is falling out that is another story. And sometimes a second transplant will help and sometimes not. Sometimes there are vascular or immune system issues we don't understand and they are temporary. Sometimes a second transplant will take, and sometimes it won't. So in those rare cases it is difficult to decide what to do. I would always take a skin biopsy in a patient like this to rule out unusual dermatological conditions. But these types of cases are very rare. In most cases the donor hair is just thinning and miniaturizing, not actually falling out. I hope this is helpful Dr. Paul

To all who posted: I do think this is a real patient I performed surgery on three years ago. I reviewed his chart and we have not heard from him since his surgery. We always send a six month and one year follow up letter to all our patients to see how they feel about their results. In that way we can address any issues head on within the year of the surgery. We do stand by our results and when a patient has results that are less than expected we do work with them. I have sent a pm to Mitch and hope to hear from him so we can go over his concerns. I would just like to review some reasons why after three years a patient’s hair transplant may starts to thin. As mentioned already, sometimes we are transplanting between existing hairs. And as this native hair starts to thin, it looks like the transplanted hair is thinning. Also there is the phenomenon of seasonal shedding in which more hair then average goes into the resting stage which last about three months. After three months this hair should start to re-grow. There are factors besides DHT that can contribute to hair thinning. Many medications can cause hair thinning. So I always ask about new medication when I see unexplained or sudden hair loss. Also some supplements, such as creatine, have been connected with hair thinning. Too much selenium or zinc can cause hair thinning. There was a product that the FDA took off the market recently, called Total Body Formula, which had very high levels of selenium and cause hair thinning. I always tell patients if they are taking supplements not to exceed the FDA recommended dosage. Taking products that cause the Testosterone level to rise or taking testosterone can cause hair thinning. Also, having a high prolactin level has been linked to hair loss. Sometimes there are dermatological conditions that are hard to diagnose without a skin biopsy. If a patient is having unexplained hair loss, or poor transplant growth, I sometimes recommend having a skin biopsy done of the thinning area. Although transplanted hair is permanent, it can thin over time. Transplanted hair will retain the characteristics of one’s donor hair. We tell our patients that some men’s donor hair will thin over time. The donor thinning is not the same as Androgenetic Alopecia. No matter how bald one gets, there is always a strip of donor hair left, but with time most men’s donor hair will decrease in caliber and sometimes the actual Follicular Unit Density will decrease. We call this senile alopecia. Usually we don’t see this until one turns 50 or 60, but it can happen at an earlier age. So the transplanted hair will permanently cover the area it is transplanted into although it can thin with time. Finally, all hair transplant doctors report an occasional case in which the hair transplant grows well in the first few years and then a lot of the transplanted hair will shed. This is rare, but can happen. It is discussed in hair transplant meetings but so far we cannot predict in which patients this will happen and why it happens. I hope this information is helpful

This 31 year old male has medium caliber, dark brown hair. He had a good donor density of about 90FU/sq.cm and an average scalp laxity. He wanted to reconstruct his hairline. He was not interested in bringing it down. He also did not want a big case in which we cut his hair. Our plan was to cover only the front hairline and a bit of the central tuff with around 1,500 grafts. His hair count was as follows: · 682 one hair FU · 861 two hair FU · 61 three hair FU Total FU-1604, Total hairs- 2587 I have included a photo of where we drew in the proposed hairline. Unfortunately I do not have any one day or 14 day post op photos.

This 30 year old male has medium caliber, dark brown hair. He had an average donor density of about 85FU/sq.cm and an average scalp laxity. Our plan was to cover only the front 1/3 of scalp with 2,000 to 2,500 FU. Because he was only 30 with a strong family history of hair loss we were trying to get good coverage with a density of 30-35 FU/sq./cm. He is not a candidate for denser packing because he does have the potential for more hair loss and may become a Norwood type 6 by family history. I also kept the hairline above the wispy widow peak he had. He wanted a more rounded hairline and he most likely will lose that hair in the future. Also, if I lowered the hairline and he progressed to a Norwood type 6, he may not have enough donor to cover the front two thirds of his scalp in the future. He started propecia at the time of the transplant. He responded well to propecia and you can see the increase density behind where I did the transplant. His hair count was as follows: · 512 one hair FU · 1405 two hair FU · 393 three hair FU · 1 four hair FU Total FU-2311, Total hairs- 4595 I have included a 1 day post op photo to show the area transplanted and the pattern.

This 49 year old male has fine brown hair. He had a good donor density of about 95 FU/sq.cm and an average scalp laxity. My plan was to cover the frontal temporal angles, and the crown and reinforce the hair in the central core. I estimated I would need 3,000 FU for this case. Posterior trichophytic closure was done. I do not have any post op photos of the donor scar. We did not take any pre-op photos of the crown from the front, but the top photos give an idea of what the crown looked like pre-op His hair count was as follows: · 820 one hair FU · 1645 two hair FU · 565 three hair FU · 57 four hair FU Total FU-3087, Total hairs- 6033

Dr. Paul Shapiro—3211 FUT grafts on Class V Patient. Six Months post op This 34 year old male has fine light brown-blond hair. He had a average donor density of about 82 FU/sq.cm and an below average scalp laxity. I was able to remove a strip that was 1.5 cm wide by 26 cm long. That means I removed a total of 39 sq.cm. of donor hair. His hair count was as follows: · 694 one hair FU · 1715 two hair FU · 703 three hair FU · 99 four hair FU Total FU-3211, Total hairs- 6629 With this amount of hair I could cover the front ? of the scalp but not the crown. I have included a 10 day post op photo to show the area covered in the transplant. He was not interested in covering the crown but has enough donor if he wishes to have the crown transplanted at a further date.

Dr. Paul Shapiro—3138 FUT grafts on ClassI V Patient. One year post op This 50 year old male has fine light brown hair. He had a limited donor density of about 70 FU/sq.cm and an average scalp laxity. I was able to remove a strip that was 1.8 cm wide by 10 cm long in the middle and 1.6cm wide by 16.5 cm long on the sides. That means I removed a total of 44.4 sq.cm. of donor hair. This was after doing stretching exercise. Because the closure was on the tight side I did not do a trichophytic closure but as you can see the scar is minimal. His hair count was as follows: · 732 one hair FU · 1966 two hair FU · 417 three hair FU · 14 four hair FU Total FU-3138, Total hairs- 6000 He was a candidate for a larger case but with his donor density below average and his scalp laxity being average I got the 3,138 FU. He is very happy with his results but is going to schedule a second surgery to get more density.

This 55 year old male came in for a 2 year follow up visit. His goals were to bring down his frontal temporal angles and hairline work. He was happy with his frontal hairline so I did not lower it. He also had good hair in his central core area so I did not transplant into the central core. The 3 and 4 hair FU grafts were placed along the inside edge and posterior parts of the frontal temporal angles. His graft breakdown is: 1873grafts - 3736hairs 1's-483 2's-1879 3's-429 4's-22

Dr. Paul Shapiro—2409 FUT transplantation on a Norwood II—12 months post op This patient came in for his 1 year follow up very happy. I used most of the grafts to recreate his hairline and frontal-temporal angles. I did reinforce his Central Core area with the 3 hair grafts. His graft breakdown is: 2409 grafts—4788 hairs 1’s-476 2’s-1487 3’s-446 G

Hi Janna is out of town for the week. To answer your questions about density and FUE. The outcome should be the same whether we use FUE or Strip. The difference is in the way the grafts are harvested. But the way we plant the hair is the same. In general we limit our FUE cases to around 2,000 to 2,500 hairs and that will take 3 days. If a patient needs a larger case then we need to use strip. As for the question of density. I planted the hairline at a density of 60FU/sq.cm. I would call that dense packing and I only do that in patients who are good candidates for dense packing. He is a 38 year old male who has hair loss in the Norwood type II pattern. Most of the males in his family do not progress to more than a Norwood type IV but he does have an uncle who has Norwood type V hair loss. His donor density was good and he had very minimal crown loss. He also had no miniaturization in his central core area and top of his crown. If he was younger,(in his 20's)or had more extensive hair loss then I would have used lesser densities of 40-50 FU/sq.cm in the hairline. Dr. Paul

Hair is one of the fastest growing tissues in the body. You may have heard that hair has three stages of growth: Anogen, catogen, and telogen. A simple way to look at it is that hair is in the growing phase (Anogen), transition phase (Catogen) or resting/shedding phase (Telogen). At any given time, most of one’s hairs are in the growing phase (80 to 90 percent) but some of one’s hairs are always shedding. Any type of trauma can cause more of your hair to shift from the growing phase to the shedding phase. Even emotional stress can cause hair to shed. As well as poor nutrition, a high fever, etc... The shock loss you are experiencing means that more of your hair is in the shedding phase, which is part of your hairs natural life cycle. The stress of the surgery put more of your hair into the resting phase and then shedding phase. Since this is a part of the hairs normal life cycle it should come back. As RC West pointed out there may be some of your hair that was miniaturized and on its way out and that hair may not come back Most of your shock loss hair should come back. I know this is frustrating because you look like you have less hair then more. It is easy for me to say be patient, but the shock loss hair should return. It will just take longer for you to see the full result of your surgery I hope this is helpful Dr. Paul