Dr Blake Bloxham

Trix, I thought I saw a non-doctor view on that video. Shame! Allow me to answer this one for you: The "tightness" or "looseness" of a scalp is usually broken down into two categories: 1) the adherence or strength of attachment to the deeper tissues (I consider this "glide") and the intrinsic characteristics of the skin. Together, these make up what I personally refer to as "laxity." Now, the glide of the scalp can be affected by a number of factors and yours can personally be improved by scalp exercises before an FUT procedure. This isn't the "tightness" referred to in the video. And in my opinion, this has less to do with scar formation that it does with factor 2: the intrinsic skin factors. Now there are actually a variety of elements in something called the extracellular or interstitial space that makes up the integrity of the tissue. But for the purposes of this explanation, I'm going to refer to them as collagen-like elements. Basically, patients with more of these collagen-like elements have a tougher, harder skin, that tends to lock down and form into a very fine scar. Patients with less of these have a looser, less rigid type of skin that leads to more "scar stretching." Now, scar "stretching" isn't actually stretching at all. Most people assume that the large scars that "stretch" occur because the two lips of the incision area are brought together, they heal, but the tension on the wound physically makes the tissue stretch out and it creates this larger scar appearance. Not true. The scar itself is actually new tissue. When the body heals a cut like that, it actually lays down new collagen-like elements to build new tissue in the gap left behind when the two lips were brought together. Patients who already have a lot of these elements tend to lay down new collagen in lesser amount and in a more organized manner; hence, a better scar. Patients with less of it -- and the more "stretchy" skin -- tend to lay down more of it in a less organized manner and hence a larger scar forms. No actual stretching of tissue involved, just the way the body lays down new tissue in different skin types. And this new tissue formation is present in FUE as well. That's why it's somewhat silly when people state that "strip scar healing is unpredictable" but FUE scar healing isn't. These same principles are the reasons why some people get very organized small dot scars that are actually smaller or the same size of the punch diameter and why others get more "amoeba-shaped" FUE scars that can be 1.5mm or greater. Now, tissue type is a "catch 22:" while people with harder skin tend to get better scars, they also don't have as much "laxity" and this generally results in smaller strips and fewer grafts. People with the stretchier skin can provide much more tissue, but they tend to heal with larger scars. Now, the real ideal situation is someone who has lots of glide AND the harder skin characteristics, because they tend to get good graft numbers and heal with a fine line that is hard to pick up. Hope this helps!

Periodic sheds are not uncommon. They can occur for a variety of reasons and usually reverse course. They can be more apparent and distressful in those with longer hair. But they are usually temporary and not an indicator of something going on. Some of what you're describing as a "thinner" appearance may be some texture changes to the hair shafts themselves from the coloring treatments. If you do have an underlying case of PCOS as well, you may want to make a visit to the endocrinologist to ensure all hormone levels are where you want them to be.

Ramez, I'm going to be the "odd man out" here and state that you can see both. I've personally seen patients experience "popping" of new grafts -- IE "new growth" -- after the 7 month mark. And of course you still see lots of maturing of the hairs that have already penetrated through the scalp. Altogether, it's still relatively early. As tough as it is sometimes, I'd recommend trying to put it out of your mind as best you can and truly evaluate at the 12 month mark. Easier said than done, I know, but it is sometimes best to let nature take its course and really assess at that point. Good luck.

Very nicely stated.

Just because the subject was brought up:

Yaz, I don't wish to argue in circles either. The point is that you can easily have that hair style with either method. And I may not be a barber, but the length you have at the safe donor area there is much longer than a 1. And it's long enough to conceal a strip scar or FUE scarring. However, you can't shave the entire donor down to a zero or it will have the visible scarring seen in the picture you posted in your original thread. It's important for researching patients to know this. And I agree with you 100%: you cannot shave down to a zero with an FUT scar ... or FUE scars, or any sort of scarring in the donor. If your goal is to shave this low, don't have a transplant. Oh, come on now! You can't make these comments and then leave. The chances of nerve pain are actually higher with FUE compared to FUT. This is because of the widespread area harvest from. We also tell our patients that they can go back to regular weight lifting once the staples are removed at 10-14 days. No greater incidence of scar stretching that we've noted.

Yaz, I'm sorry but you don't get to "hit and run" like that. When people attempt to retreat from arguments like this, it ruins the discussion for researching patients up the road. Like I said before, you're pleased with the results of your surgery and that's what matters. However, you are the one who said you can shave your donor to a zero guard, but then only showed a fade cut with very long hair above the upper part of the donor. And I did not display your donor in a terrible manner. This is the way you presented your donor in your very own thread. I didn't dig this up or present it in any other manner; I copied the link from the thread you created. Nor do I think any of this has to do with "terrible work" at all. This is regular FUE scarring. And it's not abnormal for any skin type. If you have hair transplant surgery, you have scars. Period. There are different types and ways to conceal it, but to pretend that you can "shave it to a zero" and only a "trained eye" can spot the scars is harmful to future patients. Best of luck with everything.

And Yaz ... I'm very pleased you are happy with your procedure as well. This is what is most important in the end, and we can't forget that. However, in the interest of being completely honest here, this is actually what your head looks like shaved. And I believe this is after the first procedure of around 2,000 grafts and you had another of around 2,500 or so, correct? Now, I'm not saying anything about the scarring itself, but that's just the point -- you have visible scarring that can be seen when the hair is shaved short. This is par for the course and should be clearly explained to any transplant patient considering surgery. All patients need to be aware that you will have visible scarring in some form if you have surgery. Shave low enough, and you will see it. But do not expect to just "shave it off."

Yaz, The point I was making is that you're sporting a classic "fade" cut with the hair on the upper part of the fade quite long. You could have awful scarring underneath here, and no one would ever know because you've faded below the scar. And that's what most of my FUT guys who want this look do; they leave it whatever length they want above (3 guard or higher) and go as low as they want below the scar because there is no scarring here whatsoever. I've attached a few examples that came to mind. Many, many, many more, but these were just a few I attached to show that you can easily do this style with an FUT because you have the ability to buzz as low as you want below the scar. In fact, I'd probably argue that you could pull this off easier than an FUE if you truly wanted because you have zero scarring below the strip scar -- opposed to FUE scarring throughout the donor, including the lower part of the fade. But, again, I always tell patients: don't get hair transplant surgery if you ever want to "shave" your head. I've had too many upset FUE patients from other clinics come into consults and ask what their FUE doctor did wrong because they "shaved it off" after their surgery and have visible scarring. -DOCTOR Bloxham

Actually, this fade cut is an excellent example of the type of styling many of my post-FUT patients choose. And, as expected, you can absolutely see your scarring at that level. No one should expect to shave this low after any hair transplant procedure. FUE or FUT.

Nope. We do both regularly and receive consultation requests for both on a daily basis.

As someone who actually consults and performs surgery in an area with a lot of actors, models, musicians, etc, I disagree.

Because of the significantly increased cuts to the scalp and the much larger and wide-spread area affected, the chances of "nerve damage" are actually greater with FUE compared to FUT. This is a very common online myth. You'll read about patients reporting long-term neuropathic pain in the donor post-FUE. Now, of course both procedures are still very minimally invasive with a low side effect profile regardless. You were also very fortunate to have a donor like this after so many extractions. Just like how some will have an imperceivable, "pencil thin" FUT scar, some will also heal with excellent FUE donor sites. But most don't. At the least, most end up with noticeably thin patches or a thin "block" throughout the donor region. This is because the density is simply reduced and the "shingling effect" is lost in the donor. However, most also end up with visible dot scarring in the back when/if you shave low enough. I'm going to include examples of both below. But the idea that you can simply "shave your head" post-FUE if you don't like the results is simply untrue and harmful to patients. This is patient I had come in recently for an modified (mFUE) approach repair of previous FUE work. This is his donor after several FUE patches. He is quite upset about the blown out appearance and is trying to find some type of repair. And please note that this is not a cherry-picked case, nor is is something I had to dig to find online; it's simply a patient who came to my office for surgery: The other is an example I found online -- full disclosure -- of a patient who underwent one of the large FUE megasessions being touted in certain parts of the world. As you can see by the image, he cannot "shave it off" nor does he appear to be pleased with the result of the first procedure because there are surgical markings on his scalp and he's back for more -- though I truthfully think his donor is essentially tapped: I also must disagree with the notion that FUT is "easier" to perform than FUE. Both procedures require skill, dexterity, and a solid understanding of scalp anatomy. But as someone who performs both regularly, I can attest that FUT -- on top of everything else -- requires a bit more surgical "know how," a stand-alone hair transplant surgery center (not a room in a clinic), and the ability to attract, train, and maintain a skilled staff of super technicians. FUE simply does not. And if FUT were really "easier," why did we never see "FUT tech mill" clinics popping up all over the globe like we see FUE tech mills popping up in places like Turkey today? If it was a simpler procedure that could be passed off to technicians, it should have undergone the same phenomenon we're seeing now with the FUE mill model. Regardless, I'm very happy you achieved the results you were shooting for! Thank you for participating in the thread. These discussions are helpful for patients in the end.

I disagree with the notion that public people opt for FUE. In fact, I think most "celebrities" people associate with hair transplants actually just wear partial hair pieces at public events and in movies. I have had countless patients come to me stating that they want a transplant like X celebrity and don't want one like Y celebrity, when the reality is that they both wear hair pieces and one is simply more subtle and blended with surrounding hair compared to the other. However, I always recommend FUT over FUE to the model, actor, singer, etc, patients who come in. These guys need the best chance at thick, solid, natural results in the front. This is what the camera will pick up; sparse growth and gaps in the hairline, not a linear scar in the back.

Sid, Sorry for the delay. I have not personally seen chronic pain in any of my FUT patients. I also haven't seen chronic neuropathic pain in any of my FUE guys because I'm very conservative when it comes to case size and donor management. I've heard reports of chronic numbness or pain secondary to FUT incision healing, but I have not seen it myself. And to be frank, it doesn't make a lot of physiological sense to me personally. The area from which you cut is small and confined, and should be away from large nerve roots that would lead to this sort of issue. Now, surgery is surgery so I would never state that something like this couldn't be possible; but see a lot of patients per year and haven't run into it yet. But I have run into the neuropathic issue with consulting FUE patients. I will also say that you can have temporary numbness or some neurological sensations in the donor post FUT as it heals up. But, to this day, I have not yet seen it last permanently in any of my patients.

Certainly.

Hairthere, Thank you for the kind words!

New, You didn't ruin the surgery. I've done transplants on many, many, many patients who smoke -- probably too many when you consider what we know about it in 2017! Smoking affects hair transplantation in two ways: 1) Patients who smoke have a higher incidence of poor circulation. There are a lot of factors at play here, but generally the blood supply to the scalp is lower in chronic smokers. This means that graft survival rate may be lower in a very dense pack and also your chances of overwhelming the blood supply and causing something like necrosis (small patch of focused tissue death) is higher. Your doctor likely took this into account while performing the operation. 2) Patients who smoke generally become a little more anxious and stressed while attempting to stop or cut back before, after, or during surgery. While smoking is always a negative in surgery, so is stress in the post-op. This is why I believe many hair transplant clinics don't recommend trying to quit "cold turkey" right around or after the time of surgery. I've actually had several patients book surgery and end up quitting or switching to something like gum or the vape pen by the time the procedure rolled around 3 months or so later. These guys have done fine. But usually trying to quit the day before or right after puts a lot of stress on your body during the post-op period, and this will need to be considered when coming up with your overall plan. But I don't put any weight on certain things said about smoking and hair transplants. You can have a successful HT if you smoke, and I do not believe cigarette smoke itself has any external effect on the healing grafts. Happy growing! And do quit when you get the chance! Think about the HT as a whole new healthy chapter in your life. Imagine how great it would feel to get your hair back AND kick the habit.

I studied "donor doubling" for years. I read countless papers on different bisecting methods; transplanting the upper part of the follicle with the bulge-region versus the lower portion with the DP/hair matrix/DSC region; I spoke in detail with several doctors who have attempted this (and tried to speak with a well-known one who touted donor duplication in a different manner); I even ended up authoring some pieces on it myself. The unfortunate conclusion is that it is very theoretical and not practical. The bi-section of a follicle via a blind technique like FUE is nearly impossible. You're talking about fractions of a millimeter when it comes to removing the correct region of stem cell foci. This leaves you with the alternative to try and remove the entire follicle, bi-sect it, and either implant both regions OR try to implant one back into the donor. This does not work well and would be so time consuming that it would not be practical on any sort of scale. The best study I ever came across was a group in Italy. They managed to bisect in a pretty elegant manner (though not on a scale that could be used to make any cosmetic different during a surgery) and re-implanted the part of the follicle containing the bulge. What they found, consistently, is that when this does work, the hair shaft is always noticeably thinner. What this means is that even when you do successfully perform the procedure, you're always going to end up with thin, wispy hairs. One other doctor I spoke with who had experimented with bisection in the past reported the exact same thing: he could sometimes get it to work, but the hairs always grew in very, very thin. I still continue researching and pondering over it to this day, but I would not rely on it to supplant modern hair transplantation in any of our lifetimes.

I would probably go back to the doctor who performed the prior transplants and see what he/she thinks about operating in the crown. The doctor may be able to evaluate your specific hair loss and determine whether or not jumping into the crown now is a good idea.

Chronic telogen effluvium? Seems unlikely to me. If you share some images, I may be able to offer more insight.

It's so variable that it is difficult to answer. "Shock loss" truly means that the follicle has been pushed into a "resting" (telogen) phase and needs to wake up from this before regrowing a hair. Telogen generally lasts 3 months. However, not all thinning appearance under/around the scar post-surgery is true shock loss. Sometimes it's just delayed regrowth -- with resolves within 6-8 weeks or so -- and sometimes it just looks thinner/shorter for a while because of the way the clinic trims. So I've seen it resolve as quickly as a few weeks, and I've also seen it take 3-6 months to really wake up, and it still needs to grow a satisfactory hair after this to really get rid of the thinned appearance. The good news is that the prolonged period isn't the norm and it's -- from my experience -- always temporary.

My pleasure. Very interesting question. In my opinion, the scar does not completely "heal" for 12 months. Just like the results in the front, the scar goes through a period of "maturation." I often have patients come in at 6 months, and the scar is more inflamed, less organized, and still has some residual shock loss when I compare it to the final appearance at 12 months -- which is less pink, flatter, usually a bit smaller, and shock loss is resolved. However, that's probably not exactly what you were asking. Although remodeling and maturation does take place up until the 12 month mark, it usually appears pretty much "healed" for most patients when any residual shock loss resolves (if it does occur). This can vary and also depends on what you do with your hair in the post-op. I sometimes see patients as soon as 8 weeks after surgery, and most look "healed" and normal for all intents and purposes in the back at that point. But, the question is a little more complicated and patient specific. Don't you love those doctor answers? None of these scars have been addressed. These are just normal strip scars. Addressing it usually means surgical revision, grafts into the scar, or SMP -- or some combination of these. Some doctors may also be working on other revision ideas too, so maybe more options in the future. But honestly, most people don't require these. Most of the scar "revisions" I do are when I'm doing a second strip and I'll skip around and be a little strategic to try and clean up a scar a little bit. It's usually something I do just to get the best possible appearance in the back, not because the patients are unhappy with the scar. There are some superficial vessels and nerves that are cut. The body tends to regenerate or reorganize as it heals and I have not personally noticed "long-term" damage in my patients -- FUE or FUT. I think this is one of those things that is greatly exaggerated online. You can have some numbness that persists for a while -- in the donor and recipient -- but I have not yet seen it last permanently in any of my patients. Another nice thing about FUT is that the area of damage to the vasculature and the nerves in the donor region is contained to a small area. This is unlike FUE where the entire donor is utilized (and at the same depth for all intents and purposes) so the nerve and vessel issues can be more widespread. I'd start with the recommended doctors here. Look at who is putting out consistent FUT results, who is interacting online, who has patients posting, etc, and then reach out and speak with those doctors. Ask away. Research is key.

SD, At it's current level, maybe something around 1,100 or 1,200. Crowns require a deceivingly large number of grafts. The issue, however, is your age. It is likely that your crown will continue thinning. It is even more likely that it will continue thinning in a "sun-burst" type of spreading pattern. If you hit the area now, you may be in a situation where the transplant works well, the crown continues thinning, and you're left with an "island" of transplants surrounded by bald scalp around it. Because of this, some might recommend holding off on the crown for now or using a very conservative approach to get some strategic coverage back there without using too many grafts or creating a situation where it may look unnatural up the road. Best of luck.

I agree with Bill; I'm not 100% sure this can be conclusively attributed to hair transplant surgery. Looks like this individual has hair loss that resembles more of of the diffuse, central, spreading "female pattern" hair loss. I'd probably put him around a Ludwig II using the scale below: Sometimes people with this type of pattern respond well to things like finasteride/minoxidil. So it could be something like this with concealing/enhancing methods like Bill described above. If you were going to try and restore something like that surgically, one would probably want to skip over the immediate hairline region and fill as much of the frontal, mid-scalp, and vertex as possible. The entire thing would easily be 4,000+ grafts (and likely more) based upon his hair type and the area needed. But, again, I'm still not 100% convinced this is an HT.