Dr Blake Bloxham

A Day in the Life: Patient III Background ... Last week, I had a pretty standard day at the office: 3,200 graft FUT mega-session and an afternoon of follow-ups and consult appointments. What was interesting about this day, however, is that 3 of those appointments were back-to-back result follow-ups. I thought each of the patients was a solid example of the "everyday" patient we see at a busy hair transplant clinic. Not the crazy, 5,000 + graft NW VI to NW I transformations or the extreme dense-packed hairline restorations on minimal thinning patients, but great examples of what the average patient can expect from a hair transplant. Common cases with good, solid results. And because of this, I thought it would be helpful to share these with the community. So I'm sharing these patients as they came in to the clinic -- even in the same order. I think this may provide an interesting "day in the life" perspective and give the average potential hair transplant patient an idea of what they can expect. Patient I: 2,500 Graft Frontal HT Patient II: 2,740 Graft Crown HT The third and final patient is a gentleman in his late 50s with an advanced (NW VI) hair loss pattern and sparse, fine ("soft") donor hairs who wanted to re-frame his face and fill the frontal scalp. The patient was not concerned about his crown -- which was fine because he had very limited donor. The patient reported that he always had a "strong widow's peak" and wanted this incorporated into the overall design. These can always be a little tricky. If you do them "too strong" you can end up with a bit of the "Dracula" look. However, many patients do want them and they often provide nice irregularity, fit facial proportions well, and allow for the illusion of a lower hairline without actually dedicating a significant number of grafts to lower them. I've also found that they look quite natural when done a little less dense (compared to the rest of the hairline) and only done with single hair grafts. So the widow's peak was incorporated into the overall design and we moved forward with an FUT procedure. The patient ended up with 2,500 grafts, which nicely rebuilt the frontal and parts of the mid-scalp. The patient came back at 12 and 24 months, and was very happy with the results. He's having a lot of fun experimenting with different styles and coloring options. So, again, I believe this is a good example of what the average patient can expect from a modern hair transplant. Here are his images: FUT scar at 12 months: Hope the community enjoyed the series. Stay tuned for more. Dr. Blake Bloxham, NY

Thank you for the kind words. Glad members like the presentations. I think it's important to present these "everyday" examples to help the average patient understand what they can expect from a modern hair transplant. Just posted patient II: 2,740 Crown Hair Transplant at 9 Months

"A Day in the Life," Patient II: Last week, I had a pretty standard day at the office: 3,200 graft FUT mega-session and an afternoon of follow-ups and consult appointments. What was interesting about this day, however, is that 3 of those appointments were back-to-back result follow-ups. I thought each of the patients was a solid example of the "everyday" patient we see at a busy hair transplant clinic. Not the crazy, 5,000 + graft NW VI to NW I transformations or the extreme dense-packed hairline restorations on minimal thinning patients, but great examples of what the average patient can expect from a hair transplant. Common cases with good, solid results. And because of this, I thought it would be helpful to share these with the community. So I'm sharing these patients as they came in to the clinic -- even in the same order. I think this may provide an interesting "day in the life" perspective and give the average potential hair transplant patient an idea of what they can expect. Click here to see Patient I: 2,500 graft frontal HT at 12 months So the second patient is in his 40s with a past history of hair transplants in the frontal and mid-scalp (he would have a very high NW pattern otherwise; one transplant session done elsewhere, one done here). He underwent two passes to the crown -- remember: it's the "black hole" of grafts. The first was a 1,640 graft pass to reinforce his native whorl (in the upper and lower crown); and the second was an 1,100 graft pass to thicken the upper portion of the crown and address some thinning right in front of area previously transplanted. He returned 9 months after the second transplant, and looked quite mature for a patient only 9 months out from a crown case -- the crown matures very slowly compared to the front; I usually don't fully evaluate until 18 months. I think this is a good example of what patients can expect from a crown. They do require a lot of strategy and grafts (and they aren't advisable for all patients), but they can make a big cosmetic impact in an area that bothers a lot of patients. Below are his 9 month images. The lighting conditions are less standardized than I'd like them to be -- it was a very busy day -- and the patient does have some oily build-up that is visible in a few images (and I can share some more zoomed in close-ups if people would like to see them). But another good example of what the average patient with general crown thinning can expect from a crown case. Stay tuned for patient III.

Last week, I had a pretty standard day at the office: 3,200 graft FUT mega-session and an afternoon of follow-ups and consult appointments. What was interesting about this day, however, is that 3 of those appointments were back-to-back result follow-ups. I thought each of the patients was a solid example of the "everyday" patient we see at a busy hair transplant clinic. Not the crazy, 5,000 + graft NW VI to NW I transformations or the extreme dense-packed hairline restorations on minimal thinning patients, but great examples of what the average patient can expect from a hair transplant. Common cases with good, solid results. And because of this, I thought it would be helpful to share these with the community. So I'm sharing these patients as they came in to the clinic -- even in the same order. I think this may provide an interesting "day in the life" perspective and give the average potential hair transplant patient an idea of what they can expect. The first patient is a patient in his late 50s with fairly advanced hair loss, but high "sides" and realistic expectations. He was looking for frontal restoration, with the plan to kind of comb the mid-scalp and vertex (which were both thinned but still present) into the transplants. Despite somewhat below average donor density, I was able to extract 2,500 grafts via the FUT technique. Surgery went well, and 12 months later the patient's goals were achieved and he is very happy with the results. FUT scar at 12 months: Stay tuned for "Day in the Life" patient II and III. Coming soon.

Thank you for the kind words. It's tough to put this patient on the traditional Norwood scale because he has more a diffused thinning pattern compared to the classic true "patterened" genetic hair loss. It's worth noting, in my opinion, that many, many patients with genetic patterned hair loss don't fit well on the NW scale. And he's one of them. A diffuse thinner is a patient who is thinning all throughout the genetically prone regions of the scalp and not just in the classic "pattern" areas you see on the Norwood scale. This can involve patients who have more of an underlying pattern and would be considered "diffuse patterned thinners" (DPA) or more everywhere on top which would be diffused unpatterned thinning (DUPA). There can also be some donor involvement, which complicates things and may be indicative of different types of alopecia. Hope this helps. Dr Blake Bloxham, NY

Donor will be maximized if FUT is used first. You can take several strips from the "sweet spot" of the safe donor region and then FUE all around the entire donor (even the "expanded" donor) -- which is virgin and untouched. FUT after FUE is very possible, but the yield from the strip will be less because it's been hit with FUE. If the entire donor is thinned out, you may also need to wear it longer to properly camouflage the scar as well.

My pleasure. Yes, online consultations are tricky and can be quite inaccurate. It's very difficult to get a good grasp based upon these type of pictures alone. I'm pleased you're seeing someone in-person. Best of luck with everything.

1978Matt has an interesting list he compiled. I'd PM him and inquire further. It illustrates the point that the dissatisfied -- or underwhelmed -- patients are absolutely out there in higher numbers. And of course it isn't reflected online, but doctors -- and I can't speak for all of them, but I can speak for the ones I've discussed it with -- see it very frequently in practice. For most, the results just simply aren't the same. There are a lot of colorful ways to have this discussion, but that's how it really breaks down in the end. However, there is absolutely a right and wrong way to do FUE. And the good clinics doing it the right way are likely to have better results. But I will say that I believe the top FUE-only clinics have one big thing in common: screening. There are good and not good FUE patients right off the bat. The top clinics tend to do a solid job screening and hence they work on better suited patient population from the get-go. And this isn't a slight or anything like that; it's a very, very good thing that they screen and perform FUE on patients who are suitable for the procedure. I also believe most unhappy patients -- and most happy patients too -- simply don't post online. They sign up, have their procedure, and then move on. Maybe it's because they are happy, maybe its because they aren't, but the majority of people simply don't post. It's a small percentage that feel very passionately one way or the other and do see it through. I also think there will be a language/geographical bias here. Take Turkey, for example. If you read the following article, you'll see one Turkish clinic state that 90% of their business comes from the Middle East -- non-English speaking. If the majority of patients aren't coming from English-speaking countries, it's unlikely that they would post on an English-speaking/non-geographically focused forum. Article: https://qz.com/954680/in-turkeys-cutthroat-hair-transplant-tourism-industry-the-biggest-losers-are-the-patients-and-syrian-refugees/ But one of the biggest issues I have personally isn't so much the results. This is obviously a huge part of it, but it's much more than that. One of the biggest issues is life-time grafts and keeping the donor in the best shape for future surgery. It's a complete farce that most people can have these very, very high FUE procedures. Some obviously have the donor for it, but the vast majority don't. What's more, there are issues with too much diffuse thinning, too much scarring under the surface, etc, that make future FUE procedures less certain. And even the most ardent FUE supporters tend to agree that FUT first allows for the most life-time grafts. So it's one thing to get a 3,000 graft procedure, be underwhelmed with the results, and then go back to augment and get it where you want. But it's a big, big problem when that one procedure can knock out the entire donor in one shot and put the patients in a bad situation up the road. And this is also where most people find out you can't simply "shave it and move on."

Thank you for the kind words. And excellent question. I don't think diffuse thinners need to immediately do FUE over FUT. However, I do believe there are situations where FUE may be a better choice for significantly diffuse thinners. Let me explain a little further. Patients who have general diffuse thinning, but still have a stable, safe area in the best part of the "SDA" (safe donor area) are good candidates for FUT. In fact, taking a strip from the "sweet spot" of the donor is kind of the crux of FUT surgery. These patients have good donor, they should have no issue concealing the incision scar, and taking a strip from this spot is very likely going to yield the most grafts. However, there is another type of diffuse thinner. Sometimes diffuse thinners are broken down into two categories: diffuse patterned thinners (DPA) and diffuse unpatterened thinners (DUPA). However, like most scales used in hair loss/hair restoration, I find that its often difficult to put patients into "boxes" like this. But the second type of diffuse thinner would probably fall more into the "DUPA" category. This is the type of patient that has fairly aggressive thinning in the traditional recipient and donor region, and there really isn't an identifiable area to take a good, unified section (IE a strip). Now, there are two very important aspects to this scenario that must be established before a procedure is scheduled: 1) The doctor must determine that the patient is a candidate for any type of surgery to begin with. If the donor is so thinned out that the grafts probably aren't going to do well or will continue to miniaturize and disappear soon (or if the patient isn't truly suffering from genetic male pattern hair loss), then hair transplant surgery probably isn't advisable at all. This is pretty rare, but it does happen. But, if a thorough evaluation of the donor and the patient's medical history indicates that surgery is an option, you can proceed. However, it must be understood that: 2) Patients who fall into this category and are better suited for FUE must understand that the plan isn't for thick, full, restoration; it is to get some light, overall coverage. The point of doing FUE over FUT in these patients is because the donor is very thin and an incision line scar may be more apparent compared to punctuate circular scars. This is because the donor is usually kept pretty short in these patients. And usually the recipient will be kept the same short length post-surgery. It's difficult to obtain enough grafts -- without really making the donor appear odd -- to really create a thick, "dense pack" sort of appearance in these patients. But you usually can extract a decent amount to recreate a hairline, and give a thinner amount of coverage. This tends to give the patient a more uniform look and it also gives the patient the opportunity to do some SMP all over the entire scalp (including the donor) and sport a clean, 3-D, "cropped" look. Now, scenario 2 is pretty specific and really only occurs in the worst "diffuse thinners." Much more of a "last resort" scenario. This is really the situation where I think FUE is the better option. And, again, it's somewhat rare. If you'd like to share some images, I'd happily take a look and let you know whether or not I think you'd fall into category 1 or 2.

2863, I don't think it will do much of anything to the scar in the long-term -- improve or worsen it. I personally don't like patients touching too much in the post-op because I think it causes more irritation/inflammation in the area. Again, I don't think it affects the incision line in the long-term, but it's usually best -- in my humble opinion -- to minimize touching as much as you can and let the body heal. I generally tell patients to limit manipulation/touching to washing and during application of things like vitamin E -- if they want to use it. Definitely touch base with your clinic and see what they recommend. Their advice is the one you should follow "to a T." Best of luck.

Rajesh, Did you send these images to your clinic? If not, I would and see what they think/recommend. Also, do you have any post-operative images? These may be useful.

Interesting. Maybe I'm too "honed in" to the lighting because I take dozens -- if not hundreds -- of patients pictures on a daily basis. Thank you for the kind words.

Thank you. Yes, I do have some "tilt" shots. The patient was experimenting with some permanent concealing methods in the crown only, and it does look a little thicker with things he's tried so I purposely omitted these because I didn't want to showcase anything that wasn't a gain from a transplant. However, he ended up wanting more transplants and now we're going to do the crown at some point in the near future. I'll put the tilts up if people would like to see them.

Hi Mikey, Thank you for the kind words. You're absolutely right with regard to the donor. Because this patient is a diffuse thinner, FUE was initially discussed and seriously considered. However, I did think he had a good, dense piece right in the "sweet spot" of the safest donor area, so we moved forward with FUT -- which is what he initially requested in the first place.

Eggz, I do quite a bit of FUT on patients who have undergone FUE previously -- either via a smaller FUE with me to "test the waters" with HT and then fully take the plunge later, or from other clinics. What Mikey quoted above rings true: it is a definite possibility to undergo a strip procedure after an FUE procedure. Obviously some things in the scalp are different and you will generally get a lower graft number from a strip, but happens all the time. As to your other questions: 1) No. It's fairly common -- much more so than what we see reflected online. Make sure the doctor knows the details of the prior procedure and really takes all of this into consideration before taking the strip. 2) 1,250 is a pretty responsible number of FUE extractions. If these were spread properly, you should not have any significant diffuse thinning in the scalp and shouldn't have a more visible FUT incision line. 3) It will make it a little trickier for the staff during the dissection phase. It's important that you go to a clinic that does a lot of FUT because you want true "super technicians" carefully dissecting those grafts under very powerful microscopes. If this is the case, you should be in good shape. 4) The incision line from a procedure of this size -- 1,200 to 1,600 grafts -- should be pretty short. So this makes concealing it post-FUE even less of a concern in my opinion. And you should do well with FUT if this is all hairline work. Hope this helps. Best of luck.

Great post.

Myr, Very difficult to tell based on those images alone. While I'm inclined to say that you don't have donor thinning and would be a good candidate for HT surgery, your hair color and the direct overhead lighting do make it look slightly thinner in some regions -- especially one spot notorious for crown "dropping." As a few other stated, do your best to go see someone in-person. This is really the only way to determine whether or not you have the donor for a procedure. Good luck.

Ramez, I have seen several patients who have SMP-ed FUE scars. The process works the same way it would into any scar. I believe the effect of increasing apparent donor density/fullness would work as long as you are keeping the hair short. If the scars were darkened to match the shortly cropped hair color, everything should look thicker. However, I don't think the effect would be the same if the hair was grown longer. You'd still notice a more diffuse thinning in the donor. I'd recommend reaching out to Erik at Ahead Ink. He posts here under the handle "HairThere." He's a great reference for all things SMP.

Gas, Thank you for the kind words. I actually did film a full comb-through video, but it came out very dark and grainy for some reason -- somewhat ironic considering that the presentation is all about lighting! I'll see what I can do with it and post any parts worth salvaging.

Again, I must disagree. We're arguing semantics or different writing/speech styles. The crux is the same. Of course FUE doctors should -- and the good ones already do -- screen heavily, and patients should be fully aware of the pitfalls before committing. To do so without this understanding constitutes a lack of informed consent. But even with meticulous screening and a trained hand, it's still more variable and less likely to give you the rich, thick, dense results that made the HT industry what it is today -- IE FUT megasessions. How much more variable? 75% growth rate on average. They should also know that it does cause diffuse skin changes in the back and limits the number of lifetime grafts. It's a much, much worse use of the donor compared to FUT. So this should confirm that I stand by the claimed differences. My stance hasn't changed at all.

"My hair looks fine in the bathroom mirror in the morning, but awful when I check it in the car!" "My hair always looks okay when I see my reflection walking into the office, but thin when I see my reflection in my computer screen." "What gives?" Sound somewhat familiar? Spend a few minutes searching the forums and you'll read a similar story: someone who isn't sure why their hair looks different in certain scenarios and hates the way it looks in one particular setting -- bathroom mirror, at the office, etc. The most common explanation is the lighting; light simply affects the way hair looks. And this was exactly the conversation I had with the patient I'm sharing today. He is a diffuse, patchy thinner in his 20s who came in for a consultation after being fed up with the way his hair always seemed to look different in different settings. And although the lighting played a role, he truly was experiencing diffuse hair loss. This frustration with his hair loss and the patchy appearance forced him to cut his hair short. However, his goal was to have some length and stop worrying about whether or not he was going to be caught in bad lighting! So I performed a 2,400 graft HT to rebuild his frontal scalp and strategically fill some of the mid-scalp -- though graft numbers were limited by his below average donor. He came back 7 months later looking great. I remembered our initial conversation with the lighting and decided to do a little lighting experiment of my own. I shot photos of him in two different settings: my office with harsh, inconsistent LED lighting to mimic an indoor/office type of lighting; and in our video studio with him seated below our overhead back light in order to mimic the brighter, more direct, and more natural outdoor lighting. Here are the comparisons: Indoor: To me, the indoor lighting looks a little more flat, dull, and much less consistent. Outdoor: To me, even though the outdoor lighting can be a little more "honest" and may even cause more of a "see through" effect, I think it provides a more vibrant, natural, consistent look. And this is how I do prefer to take images when I can. Either way, the patient is no longer having issues in either type of lighting setting and I'm very happy to have helped him achieve this. But I think it's an interesting and relevant topic about how things like lighting -- along with hair length, styling, etc -- can affect the appearance of transplanted and non-transplanted hair. So, which do you think looks better? Which works better for your hair personally?

How so? I stated that it's "MUCH" less predictable and more variable in nature. Which is the truth.

I understand what you are referring to, but I'm not sure Dr. Bisanga was stating the same. However, it's not worth getting into too deeply because for me, it doesn't change the crux of the argument: Dr. Bisanga -- who has the ability to offer both high quality FUT WITH an appropriate staff and FUE -- states that not all patients are candidates for FUE and meticulous screening is necessary. Despite the belief of some, Dr. Feller and I are not "against" the FUE procedure. I do them all the time. But it must be done under the right circumstances. And this is what Dr. Bisanga touches upon. Now, I will take it one step further and state that even under the best conditions, the outcome is still MUCH more variable compared to an FUT of similar size. But what we have spoken out against heavily is the practice of "FUE for all," and even worse is "FUE megasessions" for all. This we take issue with.

I agree with Dr. Feller's assessment. Based upon both what I have seen in clinical practice and the initial findings of the FOX testing -- this study really deserves a second look from the HT field because it correctly predicted a lot of things and gave sound reasoning as to why. A great donor, a skilled surgeon, and proper protocol are paramount to maximizing your prospects at a good FUE. However, even a "good donor" doesn't take into account how well your skin will want to let go of the grafts and how accepting your follicles will be to the FUE process. Everything can look great on paper and still not proceed as hoped.

Excellent to hear that he screens meticulously. He's clearly an ethical doctor. My interaction with him has been limited, but he's always come across as a gentleman.