Dr Blake Bloxham

Haraald, Like Dutchie noted above, there is a very small sub-sect of patients (somewhere in the 2% range) who do not shed or experience a post-op telogen (follicular sleeping) phase after surgery. I've only seen this in one patient, and I'm still not sure. He stopped by the office at 3-4 months and already looked very good. However, I had previously performed 2 procedures on him, and this one was a "hair greed" finishing touch job, so it was difficult to tell if it was the result of no growth, very early growth, growth of his other transplants in the area, etc. Some people experience permanent shock loss. It usually only occurs when weakened follicles undergo a trauma (like surgery) and they aren't strong enough to really recover. I personally think it's a little rarer than reported, but it is a real phenomenon.

CDA, I don't know who performed the procedure or who evaluated the scar at 3.5 months; but as a doctor who does a lot of strip surgery, I have a few general comments: 1) Scars mature just like the results do. What your scar looks like at the 1,3,and even 6 month mark is different than what it will look like at the 12 month -- and possibly beyond -- mark. Up to 6 months, the scars tend to be more inflamed, more pronounced to the touch, redder, and surrounded by more visible temporary shock loss. I think it's probably a little too early to say it's "stretched" at 3.5 months. It will go through a period of maturation where it contracts, flattens, and becomes less inflamed. I'd make an assessment closer to the 12 month mark. 2) Try to limit the amount of touching and manipulating of the scar While I think it's very difficult to cause the scar to "stretch" with physical activity, I have seen many scars more inflamed and obvious in the post-operative period simply because patients were manipulating them a lot! They were palpating the scar to try and feel it, pulling up on the surrounding tissue to move the hair and get a look at it in the mirror, and rubbing it thoroughly several times a day to apply ointments and creams. My personal recommendation would be to keep this to a minimum. 3) Follow your clinic's post-op scar instructions carefully Clinics have differing theories when it comes to minimizing scarring and handling the healing donor area in the post-op. Some clinics want you to wait before engaging in certain physical activities; some want you to put certain ointments and creams on it; others want you to leave it alone. Regardless of the instructions themselves, make sure you are following your clinic's specific orders as closely as possible. 4) There can be more temporary inflammation if deep suture material was used Any idea if the clinic closed with multiple layers? The body has to break down and sometimes work this material out, and this can cause some more inflammation in the post-op period. The same temporary inflammation may be apparent if a trichophytic closure was utilized. So I hope this is helpful. Just my "two cents."

Thank you for the kind words. Hair characteristics always play a role and should be taken into account during surgical planning! Also, question for the community: Do members generally prefer video or picture presentations? We naturally do more videos now-a-days, but sometimes I feel like the picture presentations get more "buzz." Thoughts?

Why, I agree with Bill's assessment. The grafts are quite well anchored by day 5. I have my patients start gently washing with fingertips at day 4. Many scabs are dislodged during this process, but the grafts stay in place -- as the skin has sealed over and the body has created a make-shift scar around each graft under the skin. Dislodging a graft is a pretty specific and unique phenomenon. I've yet to see one that was not a very distinct trickle of blood coming from one pin-point area and creating a stream that ran down the forehead or sides of the head. You can usually see a graft (looks like a little grain of rice) laying on the scalp as well. If you didn't see this, you probably did not dislodge a graft. Even if you saw a hair come out with a scab or if there was some blood when the scab was dislodged. Hope this helps! Grow well.

A "comb-through" video of a 2,300 graft "dense pack" case. Great example of using dense packing to blend with native density in a patient with a good amount of existing hair. Patient shown at 18 months post-op. Comb-through is shown with both wet and dry hair. Patient is in his early-to-mid-30s. Enjoy!

Thank you, gentlemen!

Nice effect!

MLC, It's common to see lower donor densities in individuals with "coarse" hairs. This is because coarse hairs usually means larger, heartier follicles. The larger your follicles are, the fewer of them fit in a square centimeter -- and we measure density in follicular units per square centimeter of scalp. As several others have noted, coarse, wiry, hairs are usually great for transplants. They provide excellent thick, natural coverage. One of your hairs may be worth 2 or 3 of a "fine" haired gentleman with a higher donor density and number of lifetime grafts. Sounds like you're in a good situation. Good luck!

Dr. Lindsey, I don't know how I missed this case before. It's fantastic! I cannot believe this gentleman not only had a Juri flap, but that half of it didn't take. Truly disfiguring. I think your 3 step repair worked wonders for him. Very cool approach and I'm sure he has a new lease on life.

Jane, I agree with Dave; I see no reason why the Toppik build up would inhibit hair growth. These topical fibers are usually harmless and can be very effective in adding the illusion of density to hair.

Thank you, Bill! And a big thanks to the community and all those who interacted in the thread. I still remember speaking with Pat about the co-moderator and editorial assistant position 7 years ago. He joked on the phone that I may be the first person to in history to transition from a Hair Transplant Network team member to a recommended doctor. From that day forward, it truly became my goal. I stand here today humbled and very proud to be a recommended doctor. It's been a long and challenging journey, but I think it helped shape my philosophy on hair restoration and made me the hair transplant doctor I am today! I also wanted to take this opportunity to publicly thank my friend, mentor, and partner Dr. Alan Feller. He's truly one of the greats and it's been amazing working with him. The effort he's put into the field of modern hair transplant surgery is staggering (and the content he's put online barely scratches the surface), and it's my pleasure to continue this legacy in our practice. As usual, I am always here to answer questions, review pictures, etc, and I look forward to continuing to participate heavily in the community. Thank you. Dr B

This case is another good example of the type of FUE cases I generally accept: the "patch fill." This is a patient who understands very well the issues with doing small FUE "touch ups" every several years, but desires that approach. I love these patients. I have half a dozen or so guys who come in every 6-24 months for little patch fills with FUE. I'm continuously evaluating the donor to make sure we don't put ourselves in a bad situation, and I never do anything that I think will look unnatural. But we're usually able to come up with good little plans each time, and it's always fun. Great to build relationships with these patients too. This patient actually came in for another fill recently (he finally let me talk him in to doing the frontal scalp). I've done several sessions in him now, and we communicate quite regularly. He always knows pretty well where he wants the grafts, and we go back-and-forth a bit and come up with a plan that he's happy with and I think will look well. The results form this one were from a patch fill to do some crown work, hairline work, and mid-scalp work. I never thought I'd present his case so I do apologize for some "messy" versus "styled" conditions, but it's truly a good example of one of my "patch fill" patients, so I wanted to put him up:

My approach to FUE is a very slow, meticulous, manual one, and I limit the size of my sessions to approximately 1,500 grafts in a single sitting; so most of my FUE cases are smaller fills, more conservative approaches in select patients, and "tweaks." So I wanted to share a few examples of these cases. The first is a "hairline tweak." This is a good example of the type of FUE cases I generally do. This patient actually had two small "tweaks," and I think it worked well for him. Case done with all manual; 0.9mm - 1.0mm sharp punch (Feller Manual punch) with two handed forcep delivery.

Several members asked for some data on my FUE practice, so I wanted to share a few things. First, I just wanted to show a "walk through" of a standard FUE case. The patient is a male in his late 30s who is undergoing a roughly 1,100 graft FUE to restore some temporal recession. We had a thorough discussion of the benefits of FUE versus FUT (and also discussed our modified approach) during our consultation, and moved forward with an FUE surgery after this informed consent. Here's the walkthrough: Next I will show two cases and discuss how I think these reflect my FUE philosophy.

Hi Bill, Absolutely. I'm actually working on putting together a few presentations as we speak. I tried to get them up last night, but day ended up running long. I'll have a few examples up here soon. Thanks!

Hi suture, I can definitely put up some FUE stuff if members are interested. I do perform FUE regularly. I think we are known as a "strip" clinic, but I perform a good mix of both -- and quite a bit of our modified approach (mFUE).

Hi Bill, That is absolutely correct. Thank you for clarifying and for your help with the recommendation process!

Hi Everyone, Again, thank you for the kind words. It's truly touching to read. Mav, Just to clarify: all of the cases I presented are my solo cases. There have been many others where I worked with Dr. Feller in some joint capacity (hence why the time involved in surgery before partner and solo practitioner), but I purposely avoided sharing those because I wanted to present work that was completely my own. Furthermore, I know that I'm younger than some (though it no longer feels that way!) and I've been in the "public eye" in this field for quite some time. It's interesting because I think I'm one of the only doctors I know who wanted to do HTs while still a pre-med! Because of this, I came into the field at a much earlier time in my career than most. Therefore, I probably appear younger than doctors who did something else and then got into transplants at a later date. However, I have been performing surgical transplantation solo on patients for nearly 2 years now; I was also very fortunate to undergo a fellowship with a Coalition member, start at a very busy surgical office, and work with excellent, excellent technician staff. And within these past two years I was able to collect data on a number of wonderful patients and present it for review. I know it's tempting to say "he's young" or "he was the moderator" etc, but all I ask is an objective and unbiased review of these cases I have presented. The community has very high standards for potential recommendation, and I simply ask that the cases will be reviewed and evaluated on their own merit. Hope this makes sense!

Hi Everyone, Thank you for the kind words thus far. And let me say that I am honored and humbled to be considered for recommendation. I do want to interact and share my thoughts and feelings in this thread as much as possible. I'm actually in the middle of a case right now, but I'll do my best to address any questions or requests. In the meantime, I wanted to put a few additional cases/presentations up. These have all been up on HTN before, but I thought members may like a few more to review! 3,600 graft and 3,000 graft hair transplant(s) (actually two cases here) 2,300 graft case 4,000 graft case 2,500 grafts on a NW VII patient 2,500 graft case Enjoy! Dr B

Around a year ago I started a video series called "Buzzcuts by Bloxham." The point of the videos was to show that a dense pack with true follicular units should look like a "buzzcut" in the post-op period. So I took some video footage of a few immediate post-operative patients and asked: "Does this look like a buzzcut?" The videos seemed to play well on YouTube and the forums, and I've now received a number of requests for updates on the patients. After receiving another one just recently, I went through my records and put together an update. I figured if these individuals wanted an update, more people may be curious as well so I should just post them here. Here is the first "Buzzcut by Bloxham" presentation. The patient featured in the video and the update received 3,600 grafts via FUT: Video: Update Pics: Interesting note on this patient: You can see how his hair loss is continuing to progress forward in the crown. However, it clearly met the wall of my transplants and can go no further forward! Here's the original thread for reference: "Buzzcut by Bloxham 1" And here is the second presentation. It features a 3,000 graft case also done via FUT: Video: Update Pics: And the original thread for reference: Buzzcut by Bloxham 2. So hopefully this helps all those who were looking for an update, and I hope others find it interesting as well! I apologize for the non-standardized conditions. One patient is from the UK and emailed pictures a while back and the other stopped by while he was in the area so I snapped some shots. Enjoy!

Very frequently, patients ask for low, flat, aggressive hairline and frontal restorations. While there is nothing wrong with an aggressive approach in the right patient (and I've done them), it is often not the best long-term strategy and patients should be advised on a different course. Especially if I believe the design will not age well or look unnatural. But what about the opposite? What happens when a patient is concerned that a drastic change from a transplant won't look proper and they request a "conservative" and subtle approach? Is it always okay to "go conservative?" Can a design be "too conservative?" And is it ever appropriate to advise a patient to take a more aggressive approach? While this may seem strange to a lot of forum members, it is a request I receive on a somewhat frequent basis in the office. Patients fear that an age-appropriate hairline or dense packed frontal transplant will look like too big of a change. I can usually show patients examples, explain the growth/maturation timeline, and demonstrate that this will look natural. However, sometimes they still want a more subtle change. The following is an example of this; a patient who truly wanted a conservative and subtle change. After seeing several examples of more aggressive approaches and reviewing surgical options, he opted for a more recessed and subtle frontal band procedure. Here are his "before and after" images: And here's one he sent me with the hair wet and slicked back (just out of the shower). Just to show the hair clear of obstructions/styling. So "Pros" and "Cons" of "going conservative:" Pros: -Usually looks very natural -Reserves grafts for future surgeries -Puts patient in a good position no matter how aggressive the thinning is behind the frontal piece -Allows the patient to "go lower" in the future if the hair loss stabilizes and he decides on a more aggressive look Cons: -Less dramatic transformation -Uses more grafts in one sitting -Starting low and aggressive means the patient may be "chasing" the progressive hair loss -- and this can lead to issues with "front loading" -May create a hairline/frontal area that the patient wishes was more conservative as he ages (remember, you can always go lower later but you put yourself in a tough position if you start low because it is very hard to reverse it and make it higher later on) So what does the community think? When is it appropriate to purposely seek a more "conservative" approach on a patient who could potentially go more aggressive? Is it ever the "best play?" How conservative is "too conservative?"

Hi Davis, First, thank you for the kind words. Second, I did try to create a very thorough presentation and show how this patient looks in "everyday life." After all, that's what is truly important! This is why I included video footage of the patient -- which is always the most honest. I also thought I included an "after" picture for every "before" shot with the surgical markings. The reason why I included the "close up" shots of the hairline from each side was not only to show the work up close, but also to feature where I actually worked. Because of the restrictions in the donor, I was only able to work in the frontal 1/3rd -- for the time being. Since this is where the surgery was performed, this is where I focused the presentation. I assure you this was not meant to deliberately obscure anything; only to highlight the work that was actually done. However, I understand what you're saying: Dr. Feller and I are both very active and experienced members of this forum, so we are held to the highest standards. This reputation is something we are very proud of, so we do our best to create and present a lot of transparent content to continue educating and helping patients seeking hair transplant knowledge online. So, I do want to make sure these presentations are thorough and honest. If there are any additional shots you would like to see, let me know. I'm not at the office now, but I can check after surgery Monday to see what I have in my files. I may have some good additional comparisons. However, I did focus my energy on capturing the area where I worked; so the images do focus on the 2,000 grafts I placed in the frontal third. I hope this makes sense. Thank you for participating in the thread. And I attached the "before and after" comparisons I used in the video and the original repair video here. Hopefully this will provide some clarification as well. Pictures: Original repair video:

I refer any patient considering SMP to Erik at Ahead Ink. I recommend checking his work out.