Dr Blake Bloxham

Trix and Jack, Thank you. Glad you enjoyed the video.

Trix, There are things you can do to address the scar IF you need to. I find most patients don't. Not because there isn't a scar, but because it just doesn't become an issue. I tell my patients that almost everybody falls into what I call the "normal healer" category. This means you have reasonable skin characteristics and scalp glide (which together create the scalp "laxity" effect). I don't really like the "pencil thin line" description of a potential strip scar, but I do tell these patients that normal healers will end up with something between the "pen line" if you're an excellent healer with all the right characteristics to something a few millimeters (2-3) larger like a "marker line" if you have the potential to "stretch" a little bit. Everyone in that realm can generally go down to around a #3 on the buzzer before the scar line is apparent. What a lot of guys are doing now, I've noticed, is the "fade" that hairsgone shared above. This still gives you the opportunity to go very short below the scar (and shorter than you could go with FUE dots down there) and fade up if you want the tight look. Scarring is a reality of surgery. FUT, FUE, etc; you will have scarring and it is the trade-off for restoring your hair. So I don't think either type of scarring should be downplayed or over-hyped. You will always have some type of scarring back there, and it is something you must accept before surgery. I believe the trade-off is very much worth it for the vast majority of patients, and I find that the scars -- FUE or FUT -- tend to never really get discussed when I'm doing follow-ups with patients at 6 or 12 months AS LONG AS the results in the front are good! I've attached a few videos of scar comb-throughs. Some are great, some are more of the "marker line" I described; but it should give you a good idea of what you might be looking at: (PS: one of those scars is actually after two procedures totaling over 5,000 grafts). Dr Bloxham. New York

John, A lot of interesting content here! I wanted to address a few things: First, you are correct that "stripping out" with FUT and then moving to FUE if/when you need it maximizes your lifetime grafts. What is excellent about the FUT technique is that aside from the fibrosis/tissue damage from the linear scar, all the surrounding tissue is virgin. You can continue to take from the same scar line and remove a large piece of this virgin tissue with each subsequent harvest with only one donor scar (which can increase with subsequent strips) and no diffuse loss of density. When the doctor thinks you've done as much as you should via FUT, you still have a good sized donor area with native density left. Perfect for FUE harvesting. I've done 8,000+ grafts on patients via FUT and told them they could still do a good pass via FUE without risking over-thinning and making the scar more apparent. Truly great to be able to maximize the donor in patients like this who really need it. If done with a proper size punch, I don't think FUE necessarily damages surrounding donor follicles via something like cutting (transection). While this can occur, good technique should avoid it. However, surrounding follicles can be compromised in two other ways: 1) the scarring that occurs in a wide-spread manner underneath the skin can invade the unharvested follicles and make them very difficult -- and in some patients nearly impossible -- to extract in the future; 2) the wide-spread vascular damage tends to cause a miniaturization throughout the donor. You get this phenomenon underneath a strip scar (usually after several passes; and I think this is what you're referring to as the "stretch" above) to some extent, but, as you stated above, the vascular damage is minimized in this approach and so the miniaturization is contained. But you are correct that with large FUE procedures you can get a "moth eaten" ("chewed out," as you described above) appearance that does not occur with FUT. However, of course you still do get a scar with FUT as well. No such thing as a "free lunch," right? You can do FUT after FUE, but the number of grafts you get from the strip is disappointing because half of the follicles have been harvested. I've been in this situation before. It's not fun telling an FUE repair patient you took a full strip and only got out 1,000 grafts because every third one was missing. There are interesting studies about a lot of what you described published in the ISHRS journal. However, most of these are in print and not online -- though the society is starting to move them over. I can try to transfer some over at a later point, but a lot of what you'll get will be explanations from doctors based on their experiences and observations. However, I definitely agree with a lot of what you're saying here. If you think you're going to continue thinning or need a lot of grafts, start with FUT and move to FUE if/when you need it. Best of both worlds, and I don't think you'll be sorry! Dr. Bloxham New York

SD, How old are you?

Ted, Various studies have examined the function of the follicle's sebaceous gland and how it changes with androgenic alopecia (male pattern hair loss). However, I don't think there is a direct correlation between the function of this particular oil gland and sebborheic dermatitis (SD) nor have I seen any correlation between finasteride usage and SD. You'll probably notice the same amount of build-up whether you're on or off the finasteride. And I don't think the prescribing doctor would see the SD as a reason not to recommend finasteride. However, you should really discuss it with him/her when you make the appointment to inquire about a finasteride prescription. Good luck!

AZ, Thank you for the kind words. I generally don't focus on grafts per cm^2. It really comes down to where you're working in the scalp, the patient's physiology, and the patient's follicle/hair characteristics. A patient with thick, coarse, wavy hair is going to achieve a density at 45 grafts per cm^2 equivalent -- or better -- to a patient with fine, light, straight hair at a much higher density -- something like 60 grafts/cm^2. In general, however, I'd say the hairline gets up into the 60+ category and the areas behind it are a gradient between 40 to 55. All done very strategically to minimize skin damage and avoid issues with blood supply compromise. Hope this helps. Dr Bloxham

Patients frequently ask if they will be able to "slick" their hair back with styling products after a hair transplant. This wet, slicked-back look is a tough one to pull off. So it's not always a possibility for all transplant patients. I recently had a patient stop back by for his 12 month follow-up. He admitted to me that his secret goal for the transplant had been to wear his hair gelled and slicked-back like he did in high school. Happy to report he was able to pull it off, and I wanted to do a "comb-through" video presenting it as he styles it: Enjoy! Dr. B

The gym shots look great. No one would know that isn't razor stubble. Nice work. When is the commercial airing? And where?

Jon, How often are you showering, and, more importantly, how often are you washing your hair when you shower? All individuals, even those not suffering from androgenic alopecia (aka male pattern hair loss) lose anywhere from 50 to 100 (some even say 150) hairs per day. This is just due to the way hair follicles cycle. It's completely normal and not indicative of any problem. What's more, individuals who don't wash their hair daily tend to get an accumulation of these shed hairs that seem to fall out in greater numbers when washing. The reality is that the same number of hairs are shedding, but you're seeing them in greater numbers because you're physically removing them every other day instead of every day. The medication isn't likely to lose efficacy this quickly. Nor would switching to another "brand" likely do much. If you're doing well on this medication, the prescribing doctor would probably tell you to stay on it. And you may want to make an appointment with him/her to follow-up with these concerns and see how you're doing with the new med. But it sounds pretty normal altogether. Likely just natural follicle cycling. May appear more dramatic because of the amount of hair washing or something like a seasonal shed. Hope this helps! Dr B

Daryl, It happens. Try not to beat yourself up over it. You know the cosmetic difference between a transplant of 1,939 grafts and one of 1,940 grafts? Pretty slim. If you only lost one -- or even a few -- grafts, it will have no cosmetic impact in the end. Nor does dislodging one graft usually affect the others after the fact. You probably just lost one graft, you'll be extra careful now (not that you weren't being already), and it won't be a problem. Best of luck. Dr B

KB, I've done surgery on many patients suffering from sleep apnea. I don't think there is any connection between sleep apnea and hair loss or the success rate of hair transplantation. Two things I would keep in mind: 1) If you wear a CPAP, discuss the type of mask with your doctor. Some of them have straps that may go right over where the grafts are placed. Others have a tendency to ride up in the night, and could easily end up rubbing the hairline. 2) Let the team/doctor know that you may have apneic episodes during the procedure if you do fall asleep. A lot of patients fall asleep during graft placement. You may want the team to wake you up if you're experiencing frequent apnea, and you'll definitely want them to be aware of the pauses so they don't panic! Best of luck. Dr B

Sean and Dave, Thank you for the kind words.

Spanker, Yes, we discussed it. However, the patient and I decided to move forward with the plan because of some concerns I had about scarring that low on the forehead and the patient's desired hairline shape. I usually try to transplant around opposed to removing grafts when I can. It requires a slightly larger than normal FUE punch to really get the full graft -- when you're dealing with these minis or some variation of plug -- and the scarring can be an issue in such a visible area. Not to mention that complete extraction in a transplanted graft is not a guarantee. So you could end up with a scar and a persistent part of a mini graft in that area!

Spanker, It was happening in 2009, and it's unfortunately still happening today. After years of being on the forums, I was a little isolated in my thinking that everyone was using true microscopically dissected follicular units. They are not. Harin/Mick, Thank you for the kind words. His growth is great for 6 months; especially considering the fact that his scalp was compromised from the prior procedures.

Great example of transplants "standing the test of time." Congratulations!

Chev, Interesting one. Not sure if I've been asked this personally before. I don't like direct heat from the sun hitting the scalp in the post-operative period, but this is because of the potential to burn the scalp. So a little different in this scenario. I think 10 days would probably be okay. A lot of saunas, hot tubs, etc, can be "hot beds" for bacteria -- they love warm, damp environments -- so make sure you aren't exposing the post-operative scalp to this. Also, be aware that the heat will cause a lot of vessels in the scalp to dilate and the post-op redness will likely appear more red after a session. But I'd probably tell one of my patients 10 days. As always, make sure to discuss it with your clinic and follow their post-op instructions to the letter. If they say to avoid it for more than 10 days, do it!

Speegs, Good point about the contrast between the skin and hair tone. Always something to take into consideration. And these mini-grafts were definitely less sinful than others I've seen and fixed in the past. The unfortunate part, however, is that the initial surgeries weren't performed that long ago! Normally I see work like this in patients who had surgeries done decades ago, not a few years ago. And thank you for the kind words!

Want to share a case I think the community will find interesting! Case: Patient underwent two "mini-graft" procedures at a local clinic. The first was a 600 graft procedure that created a very low and flat hairline. The patient wasn't happy with the results and returned to the same doctor. The doctor believed the solution was to use an additional 700 mini-grafts to naturalize the results by making the existing hairline "broken-up" and "irregular." Now, this is something we do in modern procedures in order to create a natural, feathered result. So what's the problem? Well, in modern hair transplantation, this is achieved using ONLY 1-haired follicular units. Unfortunately for this patient, it was done using large mini-grafts. So this made the already low, flat, and unnatural hairline even more apparent. When the patient presented for the consult, he described the hairline as a "zipper" in the front of his head, and something he constantly hid with his otherwise great surrounding hair. He also formed a noticeable gap between his native hairline and the transplanted hairline -- exaggerated by how low the hairline was created. Here's how he presented during the consultation: Thankfully he still had good donor and I believed I could work with his existing strip scar. So we decided to move forward with a dense pack repair with true follicular units, aimed at both camouflaging the larger grafts and recreating a normal appearance in the frontal scalp. Surgery: Surgery presented the following challenges: 1) Because of the unnatural appearance of the mini-grafts, I could not create a hairline behind the pre-existing work. This meant the new hairline needed to be created lower and flatter than I would normally work. This also meant it had to be very dense in order to look natural that low -- and very dense packing must be done carefully in repair cases. 2) Dealing with the asymmetry of the previous hairline. While a degree of "asymmetric symmetry" is always needed in hair transplant, the previous work was very uneven and I had to be quite "creative" in my surgical plan. But we created this plan and prepped the patient for surgery. Here's a view of the mini-grafts right before I took the strip: And here are the new slits ready for graft implantation. As you can see, a very dense pack for the reasons discussed above: And here he was at staple removal day. So far, so good! This picture -- when compared with the pre-op shave -- really illustrates the difference between spreading larger grafts, and dense packing follicular units: 6 Months Later: And here is a video (with wet and dry comb-through) and "before and after" comparison pictures taken at 6 months. I'm very pleased to see the transformation the patient underwent in only 6 months (generally only the "halfway point"), and even happier to report that he's able to style his hair normally for the first time since he "took the plunge" with surgical hair restoration. Video: Comparison Pictures: So, I hope the community finds the case as interesting as I did! Enjoy, Dr Bloxham Feller & Bloxham Medical, PC

Andy, I wouldn't speculate. You'd have to ask them. Better yet, ask them to join the discussion here. It would be great to get multiple doctors discussing. I'd happily participate.

Mick, I definitely understand what you're saying. To be fair, however, the title of the thread is "Feller and Bloxham;" we were definitely going to chime in! Hopefully people get some useful information out of it. And thank you for the kind words about the videos. Glad you enjoyed them.

As always, some interesting debate indeed! Trix, Thank you for the "shout out," and for watching the videos. Glad you found them helpful. We truly enjoy making them, and will continue to do so. Most importantly, however, did you ever share any details about your specific case? Pictures, estimated graft number, age, familial hair loss, etc? This may help determine the best approach for you moving forward. Perhaps I missed it, but I didn't see any. A few other points I wanted to touch upon: FUT megasession versus FUE megasession: I disagree with the premise that a megasession is a megasession and both are an equal "gamble." Putting aside the yield issues -- and the best objective studies we currently have available do show a statistically significant difference in growth yield -- the FUE megasesion is a very different beast compared to the FUT megasession because of the donor implications. The beauty of FUT, and why I strongly push it for young patients with the potential for progressive and aggressive future loss, is the way it effectively utilizes the donor and leaves virgin tissue for future surgeries. With an FUT megasession, a strip of the best area of the donor is removed in it's entirety -- meaning the bald patches between the follicles are removed as well, only one area of damage is left behind (the strip scar), and the patient has the option for more FUTs (from untouched tissue), FUEs from above and below the linear scar, or a combination of both. Even if 0 of those 3,000 grafts grew for some unheard of reason, the patient still has excellent donor to pursue other options.The same simply cannot be said for an FUE megasesion. First, obtaining megasesion numbers -- which I consider 2,500 or above -- via FUE in almost all instances requires more than 2,500 attempts. So what should be donor damage from 2,500 grafts removed actually usually ends up being much greater. Second, in order to obtain these numbers without significant depletion one must hit the entire donor area in one shot -- and usually unsafe areas, but that's another discussion. This means the entire donor has been hit and there are no longer virgin areas to utilize in future surgeries. Not only can this be a problem if patients have more sub-dermal scarring, diffuse miniaturization from vascular damage, and grafts don't come out as well during the second round of FUE, but taking out more than *33%-50% of the total donor capacity risks unnatural looking thinning in the back (*the 33% number comes from a very interesting presentation recently presented by Coalition member Dr. Paul Rose). So you can really knock out an entire donor area in one pass with a megasession. And no, I'm sorry, but just "shaving it off" isn't an option for most patients who have had FUE in the donor -- despite what many are told. Here's an article I wrote about the difference between the two. I'm also going to share an image I included in that article. Not to be inflammatory, but to show some of the realities of FUE megasessions that we see in the office but are not discussed online. Article: What is a Hair Transplant Megasession? And here's the donor of a patient who visited us. He has FUE work done by many renowned "learning curve" advanced doctors in Europe: Obviously there was not much I could do for this patient -- who still actively wanted more work. He could have had the worst strip scar in the universe and I would have still been able to do another strip, do mFUE using the strip scar, or FUE around it. But nothing you can do when the donor has been hit by an FUE megasesion like that. And I do not think he will be shaving his head anytime soon. Lifetime graft number with FUT first versus FUE first: Kramer, as you can glean from my discussion above, doing FUT prior to FUE is the best way to maximize your lifetime grafts. If you're a young patient who is likely to have aggressive loss in the future, this is the method I almost always recommend.

Each follicular unit is its own entity, so technically some could shed and others could not. However, I've noticed its usually one way or the other -- and it's almost universally the "other" (meaning they do shed). No, it will have no effect on the final results. That's great. Nicely stated!

I agree with the consensus above; the amount of recession appears like a bit more than natural hairline maturation. Seeing a hair loss doctor in-person is your best first step. Good luck!

Some anti-depressant medications do list hair loss as a rare side effect. However, almost all medications do list "hair loss" somewhere on sprawling list of "potential side effects." Personally, I have never seen this. I've had many patients on different classes of anti-depressant medications undergo hair transplantation successfully, and I've never noticed any correlations nor have I had them alter their medication regimen. Make sure you discuss any medication changes with the doctor who prescribed the anti-depressant. He/she is the only one who should make changes. My guess, however, is he/she would tell you it's not a common occurrence and to continue the medication.

Eddie, The most important thing you can do is follow your own doctor's instructions carefully. Now, that doesn't mean you can't err on the side of "extra" caution -- as patients often do. But if you follow the clinic's post-op instructions to the letter, you should be good. If you were my patient, I'd have no problem with you swimming after two weeks. By this point in time, the skin has healed over the grafts and formed a pretty strong barrier. It would be difficult for any caustic substance to really get in there and irritate the grafts. Not to mention the fact that the body has already formed a protective scar around the grafts and is likely already nourishing them with a developing blood supply. So they are pretty much like any other follicle at that point. A little more sensitive to some things, but I don't think swimming would hurt much at this point. But what your doctor says is law! Hope this helps. Grow well. PS: If you are swimming outside, the sun is the real enemy -- in my opinion. Make sure you don't get a burn on the scalp two weeks after surgery.