Dr Blake Bloxham

I've discussed the importance of the "frontal band" procedure in a few videos before, but I wanted to share a case where I feel it really was the "right move" for a patient. This patient originally contacted me about putting "a few hundred" grafts via FUE into his hairline. I examined photos he attached and disagreed with the approach. While this may have been a viable option for an older guy with stable and minimal recession, doing these little "fill" procedures in younger guys with unstable frontal zones and future loss isn't usually the best move. So I advised him to instead consider building a solid foundation with a larger, dense pack, "frontal band" FUT procedure. He thought it over and decided to go with the plan. I designed a new hairline -- that will look as natural in his 60s and 70s as it will in his 30s -- and outlined the frontal band region behind it. I then densely filled the area with 2,000 grafts via the FUT technique. 8 months later, the patient contacted me thrilled with the results! He was very pleased we went with the more strategic and "long term" plan, and sent in the following photographs. Please see the video (which contains more pictures, explanations, and an immediate post-op video) and comparison pictures below. I've also attached the 8 month shots sent in by the patient (in case anyone wants to look at it blown up). All "after" images are sent in by the patient and have been left completely unaltered. VIDEO: PICS: Enjoy!

HS, Yes, I have. I've seen patients with finer caliber hairs have more "splayed" follicles (multis) at the bulbs which necessitated larger slits; I've also seen patients with fatter hairs have slimmer bulbs and require smaller blades/slits (I've actually seen this several times in Indian patients); and it feels like I've seen all manner in between! Averages being averages, however, it usually holds that individuals with finer hairs have smaller FUGs and vice versa.

I'll see if I have some good hairline pictures. I'm out of the office for the holidays this week, but I'll pull up his file and see what I have when I'm back after the new year. By "feathered" I simply mean the hairline was more broken-up and staggered to provide a softer transition. If you look at the immediate post-op in this patient and compare it to the immediate post-op in this hairline case (2,000 Graft Hairline by Dr. Bloxham) you'll notice that the patient's hairline in this case has more irregular "peaks and valleys" and the shape is less uniform in general. Whereas the post-ops in the other case show a much straighter, defined, and more abrupt hairline. And I went into some detail about different approaches and when I think it's appropriate to do one versus the other. Interesting stuff -- to a "hair geek" like me, at least! I always have a very thorough conversation with patients about medications during consultations. Preventive medications are made for a guy like this: early hair loss with lots of follicles left to preserve for as long as possible. I always explain the pros and potential "cons" with patients, and make sure they have all the correct information to make an informed decision. Some people are adamant about taking or not taking medications. And, at the end of the day, it is their decision. Like you said above, it's the doctor's role to counsel and make sure the patient has all the information, but I can't force them one way or the other. For a patient like this who is choosing not to take preventive medications, I make sure they understand what this entails and hammer into them that this decision makes hair transplantation a very strategic, conservative, and long-term game. The donor must be left in the best shape possible, lifetime grafts must be maximized, and the approach must be smart (IE creating a more "feathered" hairline). And although I can't control the patient's decision to take medications, I can make sure the surgical plan is ethical. If this patient came in at his age with his potential and asked for a super low, flat hairline with temple point augmentation, and closed in corners, and would not budge, I wouldn't do the surgery and I'd implore him to seriously re-consider and be more conservative. But even then, there will always be physiological limits and we'll always want more hair. So it is worthwhile to really consider adjunct preventive treatments with hair transplantation. Hope this helps! Thank you for the kind words. It's been a true pleasure contributing to the community for years now, and very exciting sharing my work!

HS, Thank you for the kind words. I'm an absolute believer in dense packing. There is a definite "right" way to do it and you need to be safe and not overwhelm the tissue, but there is no doubt that the dense "frontal band" (like I did on this patient) can make a result a true "home run." I try not to focus on numbers when it comes to slits (or grafts) per cm^2. I know it probably sounds a little counter intuitive, but a lot of it comes down to 1) the overall goal, 2) the way the tissue is responding to the dense packing during slit creation, and 3) the patient's follicle size/hair type. Three is especially important; for patients with very fat follicles that grow thick, coarse hair, 45 grafts/cm^2 will provide as much, if not more, density than someone with thin follicles (and therefore finer hair) at a density of 55 grafts/cm^2 -- for example. If you tried to pack them both at 55 or 60 grafts/cm^2, you could run into some issues with overwhelming the tissue with the guy who has the fat follicles. But if you tried to pack them both at 45 grafts/cm^2, the guy with the finer follicles may not get that thick, dense look. So I kind of take all of this into account, create an appropriate blade size (I use all cutom cut blades with lateral incisions), and go as dense as I can while still maintaining a safe and "correct" look. And this refers more to the multis compared to the singles. Singles you can be a little tighter in general, but that's a whole other discussion! I'll throw up some pictures I have of slits before grafts were placed. It will probably clarify the correct "look" I'm describing a little more clearly. I think you're referring to the maximum graft number I would transplant in an "AMAP" or "as much as possible" procedure? Again, it really depends on the patient. This is an FUT approach, so it really comes down to how much I can safely extract from the back as a strip. I probably take a little more time than most in the morning figuring out my margins for the strip. The goal, in my mind, is to maximize the yield without compromising the closure. So once I know the maximum dimensions of the strip, the patient's density determines how much "AMAP" they will really get. For some, it may be 3,000 or 3,500. For others, it may be up to 5,000 or more. And I know there is some controversy when it comes to cases of this size, but I do believe it is ethical as long as it as done as an FUT -- because of my views on FUT and how it preserves the donor. Hope this helps! Again, thank you for the kind words.

Sean and Dutchie, Thank you!

Thank you for the kind words. Yes, this was done as an FUT (as was the other hairline case). I forgot to include this information!

Last week, I discussed the importance of individual planning when it comes to hairline transplantation. I touched upon how things like a patients age, likely progression of hair loss, adherence to preventive medications, and current level of hair loss all come into play. I then shared a case where I performed a 2,200 graft hairline (and frontal scalp) transplant on a young patient with a fairly significant amount of loss in the front, a hesitation towards certain medications, and a fairly high likelihood of future loss. In that patient, I took all of this into consideration and designed a more conservative, feathered hairline plan that would serve him well in the long-term and put us in a good position for future surgery. I'll put a link up at the end. So today I wanted to share another hairline case that again utilized an individual and unique approach, but is very much the opposite of the first patient. Based on this patient's age, family history/physical exam, adherence to medications (which he was on long before surgery), and facial shape/hair type, I designed a more aggressive approach. I utilized around the same number of grafts -- 2,000 -- and did a dense pack hairline rebuild. Below are images sent in by the patient (and left completely untouched) at the 12 month mark. They are included with some "befores" and intra-operative shots for comparison. This can be compared with the other case to show how hairline transplantation must be individualized. No two patients are the same and there is no "one size fits all" approach. Many factors must be taken into account, but it usually results in happy patients if everything is closely analyzed and a well-strategized plan is executed. Here is the other "opposite" hairline case for comparison: 2,200 Graft Hairline / Dr Bloxham Enjoy and Happy Holidays! Video: Pictures (attached):

Interesting thread. I think the "X factor" can be viewed in two different ways: 1) an unknown factor with a patient's physiology that simply makes them a poor responder to hair transplantation 2) an unknown factor that is outside the patient's physiology and more related to the aspects surrounding surgery. I've read articles where some doctors think patients in category 1 may have some sort of overactive immune response to the transplanted follicles. The body basically views them as "wrong" and subsequently rejects/attacks them. Frankly, I'm not convinced. While there is a basis for certain types of immune-mediated alopecia, I've never really seen any convincing evidence of this happening or being discovered after a transplant. But there are also other aspects of a patient's physiology to consider. Things like hair caliber, color, compromised vascularity to the scalp in patients with certain conditions, overloading grafts and overwhelming the blood supply in certain areas (search "Diamond of Death" in YouTube if you'd like a more detailed explanation about this -- or if you just miss hearing me and Dr. Feller!), and scarring from past surgical procedures can always play a role as well. Hopefully these are all discussed thoroughly with patients beforehand and everyone goes into the situation with a good plan and good expectations. The second category is interesting as well: Obviously there are things that can be done during surgery to contribute to an "X" factor. Graft handling, the size of the slits, out of body time, and the surgical plan all contribute. And I will say that there is an absolute unknown for FUE. I won't turn this into another one of "those" threads, but I will simply state that some patient's follicles simply don't like FUE as much as others. Drs. Rassman and Bernstein wrote a fascinating paper about some of what can contribute to this (google "FOX test" if you'd care to read it). But there are absolutely some follicles that either cannot handle the additional stress and strain of FUE extraction (even if they look good while they're being extracted) or the properties of the surrounding skin aren't conducive to FUE or don't like to let go of the follicular units. But FUT isn't immune to the "X factor" either. So I don't want to make it seem as such. It removes some variables associated with FUE, but you can still have surgical mishaps if a staff isn't highly trained to dissect and place FUT grafts. I've discussed the growth timelines before. And I do think they are wildly variable. And I do think the internet can create some additional stress for those who are on track or slightly behind, because we often see people put up awesome 6 month results online. And why wouldn't they? They're excited and want to share. But it's going to stress you out if you're only around the 40-50% mark like you should be at 6 months. And I've been guilty of putting up these "fast grower" results too! Altogether, I think the X factor will remain elusive (great way to describe it, Vox)! I'm not 100% sold on there being one identifiable physiological factor that would make a transplant fail. I do agree that there are immune-mediated alopecias, and this could happen if a transplant was performed on one of these patients. But usually these present differently that MPB and patients would know what they had before ever booking a procedure. However, there are some aspects that make some patients better candidates than others. And there can be surgical issues that relate to less than ideal growth. And I think Dolph's statement really sums up the best thing patients can do here. Good discussion!

Thank you for the kind words!

Patients are unique. Each has a different level of hair loss, a slightly different hair loss pattern, a different likelihood of future loss, different hair type, and a unique head shape. Therefore, each patient requires a unique transplant plan. Especially in the hairline region. There is no "one size fits all" approach, and what works great for one patient may not be the right approach for another. So I wanted to share an example of this type of in-depth planning: The patient is a gentleman in his 20s who was embarking on a new phase in his career. And, understandably so, he wanted to get his hair fixed before starting his new gig. He suffered from frontal (including hairline) and slight mid-scalp hair loss. He previously covered it up with a forward "comb over" and even dyed it blonde (on the advice of a hair stylist) to try and camouflage the loss (and you'll notice this in the "before" pictures). I saw him for a consultation and we agreed that hair transplantation was likely his best option in this instance. But based on his age, head shape, views on preventive medications, hair type, and family history, I explained that he should seek a more conservative and feathered approach in the hairline. This would allow for a full but also soft and natural frontal transition, and also look natural if he thinned behind where we worked. We also made donor management a priority, and ensured he had plenty "left in the bank" for future procedures. I ended up doing a 2,200 grafts transplant. He returned a little over 11 months later, and the plan worked! Please view the video and pictures below. Enjoy! Video: Pictures:

Just wanted to clarify a rumor -- without becoming involved in the discussion -- because I've now seen it posted twice on the forums: Dr. Feller is definitely not retired. Carry on!

Just wanted to clarify a rumor here -- without becoming involved in the discussion -- because I've now seen it posted twice on the forums: Dr. Feller is definitely not retired.

Dave, Sean, and HS, Thank you for the kind words! HS, I always tell patients that they will do some experimenting and figure out the new style that works best for them post-transplant. This short and "swooped up" in the front is a tough one to pull off because you need that density in the front to make it work. Luckily, I think it ended up working out very well for this patient. And no toppik used (or needed!).

Thanks, Mosd!

We have the privilege of working on a lot of patients from the U.K. And while it is tough for them to get back into the clinic for follow-up, they are usually great with sending in picture "updates" as their results mature. This U.K. patient with advanced hair loss (essentially a diffuse NW VI) came to our clinic for one of our "As Much As Possible" or "AMAP" FUT megasession procedures. We discussed his goals and decided to rebuild a frontal hairline (leaving his current parietal fringe/temporal recession for now) and fill as much thinning scalp behind the hairline as possible. I was able to extract nearly 4,000 grafts via the FUT technique, and used them to knock out a lot of his hair loss. 8 month later he excitedly sent me the following "selfies" to show his progress and express how pleased he was with the transformation! And I was as well! Truly a great guy, and I'm very pleased to have helped him out. Each image he sent (3) is shared here untouched. He's going to have someone else take photos at 12 months, so I'll update with more of the "cardinal angles" (IE a top down) at that time. The full after images are also attached below so they can be expanded and reviewed. Enjoy! Video: Comparison Pictures: And for reference, here's what I did on him:

Hi Balody, Thanks. I believe this patient is in his mid-to-late 30s. 36-38 I believe.

Glad members found this interesting and enjoyed the case. I'll put a few more of them up. Repairs are always extremely satisfying. Unfortunately, there are a lot of them out there; good news is that they usually do have some options (especially with multiple harvesting techniques available today) and we can provide them with a natural result via modern transplants! Triple, home, Spanker, HS, and Modern, Thank you for the kind words. Spanker, Agreed. But luckily, he's a "gentle giant." Truly a great guy, and I'm very pleased he's happy.

Hi Transhair, Altogether, no; dry, wintery weather wouldn't damage your transplant. It can definitely wreck havoc on your skin and cause drier, brittle hair (that looks a little thinner) in general, but it should not affect a maturing transplant. The pinkness in the scalp with the weather changes may be related to the transplant in some sense. There are a lot of changes that happen to the scalp when you pump it up with fluid, make thousands of cuts in it, and then place thousands of new little organoids into it and expect it to regrow new nerve and vascular supplies! But even if you did have some pinkness that was secondary to some change in the skin, it wouldn't hurt the follicles growing in. And it very well could be something that the blood supply in your skin did naturally before the transplant (this is actually one of the ways our body regulates temperature) and you're just noticing it it more now because you're paying attention to it. But it doesn't seem abnormal either way, and it sounds like you did the right thing by seeing a specialist -- who said something similar. The only real weather phenomenon that can affect the transplants is a legitimate scalp sunburn between month 0 to 6. Long story short, the follicles don't have good defense mechanisms against this type of direct light/heat, and it actually can affect yield. But you would have definitely known if the pinkness you're describing was secondary to a real burn like this. Hope this helps!

1) It can play a role with respect to brute coverage. But a lot of the overall density still comes down to planning and how the slits are created during surgery. And, like HS, noted hair caliber definitely plays a role as well. But you shouldn't assume that you can't get very dense results simply because you have a higher percentage of 2-follicle FUs compared to another individuals with more 3s or 4s. 2) Likely just donor characteristics. Just for reference, the average follicular unit (when comparing all the units on a patient's scalp) has 2.2 follicles per follicular unit. So, on average, the most common follicular unit is basically a "double." And if you look at graft breakdowns, you'll note this as well. The only way the numbers could really change would be if the clinic decided to dissect larger units (IE triples or quads) down into doubles, or if more singles were needed so doubles were cut down into singles (or triples into doubles and singles). This usually doesn't happen, so it will come down to donor characteristics.

Hard not to chuckle at this one. Well played.

Hi, Wanted to share a different type of case today. And one that I think the community with find interesting. The patient in the video -- Bob -- had a series of "old school" "hair plugs" done at a clinic in the late 80s/early 90s. Like many of these plug patients, he continued to aggressively lose hair and ended up with an unnatural island of plugs on the top of his scalp. He visited several clinics over the years and was basically told his donor was too damaged (he stuck with it and had more plug sessions than the average patient) and he was out of options. He came to see us not expecting much, but was pleasantly surprised when we thought he could be repaired. So I removed as much tissue as safely possible via the FUT technique from the donor and ended up with 1,500 grafts. Although there was a lot of areas requiring attention, I decided on naturalizing the hairline and filling the alleys that had opened up on the sides. It was a very challenging case all around, and I was eager and anxious to see how he progressed! He came back 8 months later and was a new man! He was very happy and actually asked to do a YouTube video with us to try and reach others who may be in the same situation. Give the video a watch. It goes through the case and also gives a little background about "plugs" and how we deal with these cases. Hope you enjoy! And let's all be grateful that we've moved beyond the "hair plug" days! Video: Pictures:

I've always liked your "farm talk" better anyways! Much more interesting to listen to. And the actual farming videos are an added bonus!

That actually made me "laugh out loud." Well played. And I'm sure you'll do just fine. Best of luck on the procedure when you do "take the plunge."

No problem. I've seen a variety of different scales used to classify based on micron diameter. But I would say 40-50 puts you in the middle of "fine" and "medium." You would probably be a fine-medium -- kind of like a medium cooked steak can be "medium rare" if it's closer to the rare side -- based on most models I've seen.

Wibbles, I wish the videos had micron break downs, because I still wouldn't personally classify these guys as having "fine" hair. Maybe finer than the average Hispanic patient, but I still would not have personally said this gentleman has fine hair if he walked through my door for a consult. Maybe others would disagree, and I don't want to purposely disagree just for the sake of arguing or anything like that; just my "two cents." I've never personally bought the argument -- or seen any convincing evidence -- that implanter pens increase yield in FUE procedures. I understand the theory behind why some feel this way, but I think you can easily argue that the amount of handling is very comparable overall, and there are also new potential compression forces introduced with the implantation. I'd also like to see guarantees that the inside of the needle itself was free of of any jagged areas that could damage the grafts as they are pulled into the bore, especially after repeated use. I attached some microscopic images to explain what I mean. You could make an argument for less out of body time for the skeletonized grafts. But to be honest, I think most of the difference in yield for FUE procedures comes from the stress and strain of the extraction process itself. You can use special devices to place the grafts back in, or transplant them as quickly as you want ... but it won't make much difference if the graft was already permanently damaged during the extraction process. Again, not trying to incite a war here nor do I want to detract from Dr Lindsey's thread!