Dr Blake Bloxham

It depends on the region of the scalp. In the frontal hairline region, you can expect new hairs to start popping through around 3-4 months, start to get visible and longer around 5, and then pretty decent transformation with the caveat that they are still thinner shafts with extra "frizz" by month 6; month 6 through 9 they continue to thick and normalize, and then typically between month 9-12 the texture really starts to calm down and they mostly resemble the native hairs. Anywhere behind the "frontal band" region really can take longer to mature. And if this is the crown? Definitely give it 18 months to cook. Of course you always have to keep in mind that all patients are different. People mature at different rates and everything is "all good" as long as the end result is good. It may take some people a little bit longer to cross that finish line, but it's finishing strong that counts.

Thank you.

Hi Pedro, 1) Yes, it can be done before an HT. Obviously don't do them too close together because it would be a bit traumatic for the scalp. The only thing I warn patients about when it comes to doing SMP before the HT is that we are probably going to mess up the nice SMP work with our incisions. SMP is placed at a different level in the scalp compared to the grafts, but we have to get through that layer first. So chances are we may ruin some of the SMP you just for. Because of this, it may be better to wait until after (if you are sure you want to do both). 2) A lot of people do temporary SMP which does fade. 3) I believe the average is 24-36 months (though an SMP guru may correct me there). 4) Much less compared to a surgery. I think it is in the hundreds or low thousands of dollars. Maybe Erik from Ahead Ink will come put in his two cents. He's the one I always bounce SMP questions off of! Hope this helps.

I'm with Dr. Vories on this one: 3,500 - 4,000 sounds very high. Did the other clinics explain where they wanted to use the grafts? I think 1,800 - 2,000 depending on what you want to do with the hairline makes sense. Maybe 250 or so in the crown if this is not just a normal appearance from the natural whorl pattern -- and it very well may be.

Your first step should be seeing a doctor in person. It is not even clear whether there is anything to "grow back" at this point. Get a good sense of whether or not there is an issue before trying to treat it. If the doctor does believe it is the beginning of some male pattern hair loss, then there is a lot to be gained by starting early. But that's a big IF, and I would not put the cart in front of the horse here. See a doctor in person and let us know how it goes.

DHT, Gasthoerer makes some good points above. In general, hair tends to become a little bit more "coarse" and "wavy" when it starts to turn gray. I typically find that gray hair transplants or transplants that begin to turn gray look great due to the increased "fullness" from the hair shaft changes.

The sukh03, Certainly appears like a normal parting of very healthy hair. It may look a little thinner because of the dark color of your hair shafts and lighter color of the scalp. Any other areas where it looks thin, like the frontal "corners" or the "crown" in the very back? If you were going to develop androgenic alopecia (genetic male pattern hair loss), you would likely see it in these other areas first. Also, how old are you adn what is your family history of hair loss like? Look forward to your reply, Dr Bloxham

Hi Raja, Per our records, the patient has been on brand name Propecia for quite some time. Likely around the time of his very first surgery performed at the outside clinic. He did not start any new medications post-surgery, but did continue with the Propecia. Thanks for the question.

Today's case is an example of a nice little hairline repair procedure. The patient in the video had "1,500 grafts" (a big emphasis on the quotation marks there) at an outside clinic years earlier. He had great hair elsewhere and just wanted to fix some slight hairline recession. The clinic used follicular unit grafting, but simply did not go dense enough in the frontal band/hairline. The result was less than impressive, but the patient assumed this is all he could achieve and lived with it. Years later he did some research and realized that, maybe, what he had was not standard of care and decided to seek out another procedure. He presented to our clinic excited at the prospect of improvement, but somewhat skeptical that what we did here was different. Because of this, a conservative approach using 1,200 grafts was undertaken. The hairline was not lowered or adjusted, just addressed using dense packing. He did well and was thrilled with the results. Several years later after realizing what can be achieved with a hair transplant, he came down with a little bit of the "hair greed" and decided he wanted to flatten the hairline a little bit and really get that perfect density in the front. We used another 1,200 grafts to perfect it. He came back 3 years later to show us the results. Here are a few "teaser" comparison pictures. I only share a few because I really encourage everyone to watch the detailed comb-through video. Remember that there is only so much you can get from still photographs. Ask clinics you are considering to show you comb-through video! I wanted to state that we probably would not have recommended using so much donor in just the hairline IF the patient had any other signs of hair loss elsewhere. But because of his age, family history, and the fact that we (both Dr. Feller and myself) had seen him over a period of around 7 years with no noticeable change, we felt comfortable accommodating his request. I also wanted to thank this patient for allowing us to use his full face. And here is the video: Thank you for viewing. Look forward to the discussion. Dr. Blake Bloxham Feller & Bloxham Medical, PC www.fellermedical.com

When I evaluate a patient for hair transplant surgery, I always do something in my mind: Regardless of how much or little hair loss the patient has or how adherent they are or are not with medications, I imagine they are going to progress to a NW VI and I will need to rebuild the entire front to back using only what they have in the donor area. In my opinion, it takes around 5,000 - 6,000 grafts to do this convincingly, and the average patient can do this via a combination of FUT and FUE. By imagining the patient will essentially lose all of their hair and I only have what is available in the true safe donor area, I can plan accordingly and not take any action that will put the patient in a bad position down the road. If we rely on things that may not be used or may not even exist commercially yet, we may get ourselves into a bad situation. If we "plan for the worst and hope for the best" and act in a conservative manner, I believe the average patient who theoretically will progress to a NW VI can be satisfied with surgery alone. I have done this on patients many times, and it works. So, I do think it is very possible and quite common to achieve satisfactory coverage for a high NW patient using only surgery. But it is imperative that we act in a smart, conservative manner and use the donor as efficiently as possible.

Apologies. Glad to see that he has obtained some benefit. I must admit that I have not followed the entire thread since the beginning. I was asked to review and comment yesterday, so I was playing "catch up" a bit and may have missed some of the gains. I still stand by the rest of my post, but I am glad to see there is some improvement from the medication.

Hi PA, So just to be clear: you started 1mg finasteride in July of 2018, and seemingly did not see any sort of initial shedding phase? By around 4.5 months post-op (November), your hair looked great and you appeared to be an excellent responder to finasteride. Then from November until now, you experienced gradual and worsening thinning to the point where you believe you have pretty much lost all gains? Typically people experience a shedding phase for the first 3-4 months; the follicles are somewhat "shocked" into a telogen phase (which lasts around 3-4) and then wake up and begin functioning better -- and growing stronger, healthier terminal hair as a result. If we presume that you did not experience an initial shedding phase but did experience one starting in November, it would likely end around March or so and should start exhibiting noticeable improvement by June or July. If you were my patient, I would probably tell you to wait 6 months from when the transition from Telogen (rest) to Anagen (growth) occurred. If we say the resting cycle ended in March, you would maybe want to wait until September before declaring that you have experienced no benefit from the finasteride. Now, how likely do I think this is? Probably not too likely. However, I have seen stranger things when it comes androgenic alopecia. I also think there is another possibility; and fair warning here: I do not think my experience and opinions when it comes to finasteride are necessarily as "main stream," but I feel pretty confident in what I have seen thus far interacting with thousands of hair loss patients over the past 5 years. I personally believe finasteride is a "kick the can down the road" type medication. In the end, androgenic alopecia is genetic. It is like your height, eye color, or any other inevitable physical trait based upon your genetic code. In the end, your genes are going to win out. You take a drug like finasteride and put someone on it while they still have a lot of their own native hair, and it may help them hold on to this hair or hold on to a greater portion of the hair for a longer period. In the end, however, they are still going to get to the same point. It just may take a little longer on finasteride. When you get to a certain point where you have already lost a good portion of hair or maybe the "horse is out of the barn" a bit, the drug tends to do less. You specifically may have been further along in the process, and there was just simply less that the drug could do. Maybe an initial "bump" was all that was possible before your body started making more DHT or expressing more DHT receptors in the follicles because that is its coded mission and there was not much you could do to slow it at this point in the mission. I know this is not the rosiest of theories, but I often find it holds water. While preventive medications are great and I always have a detailed discuss about using them with patients, they do have limitations and they cannot overcome what is hard-coded in your programming. Does this mean you should give up on it if you are not experiencing side effects? No, not necessarily. But it may be time to research other adjuncts (surgery possibly being one of them) to help. Just remember to play it safe and try to stick to tested and approved treatments. Again, the above is my educated opinion based upon my experience with the medication and hair loss patients. Other doctors may feel differently and they are absolutely entitled to their own conclusions based upon their experiences. I also say the above not to discourage anyone from using preventive medications; I do think they are useful adjuncts and recommend that all hair loss patients research and consider them.

I agree that doing a little more to enhance the since thinned regions is likely best. However, I understand that this does not fit with your long-term plans. Speaking of which, how do you want to wear your hair after removing the transplanted hairs? If you are looking to keep it short, you may want to look into doing SMP all over the entire scalp and sporting a very convincing "buzz cut" with the SMP and the combination of the prior transplants plus your native hair. If you are interested in this approach or researching it more, I would recommend checking out Erik at Ahead Ink.

Hi Mike, Double check with your clinic first, but I would recommend, as LaserCap said above, to scrub harder. I think these are just little "scabs" formed by the dried part of the superficial tissue left on the grafts. You should be able to knock these off and obtain more of the "buzz cut" look we want to see post-transplant.

Interesting topic. I think the biggest issue with using Nizoral (or any ketoconazole-based shampoo) in the post-op is simply how harsh it can be on the scalp. It typically causes a lot of dryness, redness, and irritation, and this is usually why most people only use it a few times a week. A post-op scalp is already pretty raw, so I often discourage using Nizoral too soon in the healing period. Typically I tell patients they can go back to using it on an infrequent basis starting day 10, but ask them to please discontinue it and try again later if it makes the scalp overly irritated or dry. Curious to hear what other clinics recommend.

Dr. Beehner, Very natural transformation. Nice work.

Mike, How are you washing it? The little "bumps" appear to be excessive superficial tissue left on the grafts. This is not uncommon in FUE. It typically drys out like this, and then needs to be scrubbed away.

Thank you for the kind words. Glad they were helpful.

Hi Swish, When you say "full density" are you referring to native density? Meaning that if your non-thinning hair has a density of let's say 80 follicular units/cm^2, then why can't a transplant be done at 80 FUs/cm^2 to match this? If so, Gillenator makes some excellent points above. You do not really need to 100% "match" the native density to achieve a uniform look with the native density. Furthermore, trying to match "pound for pound" like this when the native density is so high is a recipe for disaster. Technically, it is very possible to implant grafts at this density. In doing so, however, you are risking real complications and all but guaranteeing they won't all grow. "Packing" this many grafts into an area destroys the blood supply to the region and often results in localized skin death, AKA the dreaded "necrosis." And even if you don't get necrosis, this is too much damage to the skin. It will heal with some bulky, inflammatory scarring and never quite look right. The goal with dense packing, and I am someone who does this pretty much on a daily basis, is so take the transplants right to the limit of where you know it is safe and you will hit that "sweet spot" where density is excellent, it will all grow in well, and the risk for complications is negligible. This should lead to a nice, thick result and uniformity with the native hairs. Having said all this, it is possible to safely match the native density with hair transplants. However, it will require a second pass. After the first round grows in and does well, a second conservative pass should be well received by the new blood supply and should not cause excessive scarring and will get you up to that "native" level. The real question is whether you "need" to do this to be satisfied with a dense pack pass. As Gillenator expertly noted above, the answer is probably not. You should be content with something that is nice and dense, but not technically at the exact scientific density of your native hair. This is sort of the beauty of a hair transplant. Hope this helps. Best of luck. -- Dr Bloxham

I have used both many times. I feel like staples consistently provide better cosmetic outcomes in the back. They are not quite as comfortable in the post-op, but I think they get the job done a little better in the end. Having said that, I have seen excellent results from many doctors who only use sutures. Most FUT doctors prefer one over the other and use one over the other on a regular basis. I would recommend selecting a doctor based upon the criteria you find important, and then letting them close up in the manner which they believe provides the best results. For example, if you like the way a doctor's incision line scars look and they frequently use sutures, go with what they recommend and you will have the best chance at obtaining the type of scar that drew you to the doctor in the first place. Hope this helps. Feel free to ask any specific questions about using one versus the other and I will try to get them answered.

Beautiful work, Dr. Cooley. The patient must be thrilled. Excellent presentation too. I love the "comb-through" video.

Hi Phil, I always try to make the time -- though I will admit that I am falling behind on answering private messages, and I do apologize to anyone waiting for a reply! I truly like being a clinic that can offer patients both FUT and FUE. And not just in name only. While I think I have made my reputation with FUT and I am a very vocal proponent of it, I perform FUE every single week. We have an OR specifically for FUE; we have a staff cross-trained specifically for FUE (who have been assisting in the FUE process since 2002); and I feel very blessed to have learned manual FUE from my partner, Dr. Feller, who was one of the first three to perform the procedure in North America (the others being Dr. C in Atlanta and Dr. Jones in Canada) and someone who has multiple patients and publications in early FUE development. So, long story short, I think we do have the ability to recommend and offer patients both. I do not think there is a strict, binary decision as to when a patient is a candidate for FUT versus FUE. From a strict mathematical and scientific standpoint, I absolutely do believe there are instances where one should be utilized to the exclusion of another. And in these situations, it will absolutely be my recommendation to use one versus the other. In the real world, however, patients have different long-term goals, different lifestyles, and sometimes what may be the best technique on paper is not the best one in practice. So I do my best to come up with plans and approaches using both methods when patients request it or ask for one above the other. When they simply ask for my opinion, I try to always be objective as described above. Here are some generalizations about when I think you should do one above the other or who is a good candidate for FUT over FUE: Start with FUT: -Young patients with uncertain futures and all but guaranteed progression -People with advanced hair loss -People with limited donor (as long as the limitation is not the density; in patients with very low densities, I actually usually recommend conservative FUE) -Patients who need critical hairline work and cannot risk yield (print models, film actors, etc) - Patients who are likely to want to do more surgeries up the road -Patients with hair types that I do not believe will do well with FUE: very fine, light hair (fragile follicles), certain ethnic groups, etc -Patients with a lot of laxity or very "stretchy" or "mushy" skin -- which I believe will either deform or distort and just not let us accurately score the grafts -Patients who want to do the most possible in a single sitting Start with FUE: -Patients with obviously stable loss only requiring a small amount -Patients who must keep the sides very short (certain military guys; certain actors with crazy film/studio contracts; etc); however, you cannot undersell the scarring to these individuals because it is not a scar-less procedure -Patients with very tight scalps or very low density where the "scarring to graft number" ratio is just not good enough with FUT (IE: taking a 30+cm strip and only getting out 1,200 grafts because the scalp is so tight and the strip was thin or the density was so low) - Patients happy with their prior strip scar who just need a little more work -Patients with prior strips who cannot undergo any more -Patients requiring less than 1,500 grafts (which I now still split up into two days as I like doing everything manual and staying very involved with FUE procedures) - Patients who are not 100% ready to commit to transplants but want to "test the waters" a bit first (again, we need to be careful not to oversell anything to these patients) Surely I am forgetting a few here, and this list is not all inclusive; however, good generalizations. In patients who are not concerned with the scar or want to get as much as possible (the majority of patients) or just want to go with what I recommend, FUT is typically a great starting point. I also offer a "modified" approach to FUT where I break up the strip into smaller 2cm pieces, which are somewhat staggered and broken up. It allows patients to go a little shorter on the sides and the scarring, if it is seen, looks more like trauma than a telltale surgical scar, so it gives people a little more wiggle room up the road. I have probably shared a few of these cases on here before, and I will share more in the future.

Hi Gasthoerer, Thank you for the kind words. Glad the point about hairlines makes sense and is resonating with the community.

Hi jj, Good to hear from you. Thank you for the kind words. The patient's hair loss is pretty stable; I actually saw him a few times for consultation (good time gaps between) and I did not note any changes. So I do not believe there will be aggressive thinning in the back, and his bridge looks great. However, he does have a small, isolated spot in the crown and has expressed interest in getting this filled. So I do not believe this will be his last transplant. However, you never can be too certain with androgenic alopecia. I have seen "stable" patients who look great suddenly thin and need every graft they can get, and I have seen seemly "unstable" patients go years before changing at all. It is very unpredictable, so it always helps to hedge our bets a bit and leave the absolute most available donor for surgeries up the road. If he only needed 1,500 grafts or so, I would have felt comfortable starting with FUE because this level of harvesting (when spread appropriately) typically allows us to stay within the safe donor and does not impede the future too much. For the amount we were doing, however, I felt that FUT was the best bet at not only delivering the results, but also not putting us in a potentially bad situation if he did start thinning more up the road and we wanted to do more surgery.

Thanks, Greg. While healing is physiology-dependent and does absolutely vary between patients, I think some of the "fears" of FUT scars we see online are a bit overblown. With good technique and ethical harvests, the VAST majority of patients heal up with a fine line in the back that is easily hidden. I always tell patients that it will be anywhere from a "pencil line" that is hard to even appreciate if you are a perfect healer, to a "marker line" (1-2 mm of "stretch") if you are a bit of a "stretcher"; anything within this range is perfectly normal and can be easily concealed even with a shorter, cropped hair cut (typically a number 3 on the buzzer). And the trade-off for the scar is fantastic; thousands of the best quality grafts, minimal damage and maximum preservation of the donor, and the ability to do more up the road. While FUT is not for everyone and I totally get that, I think many patients are best served by doing an FUT first and then switching to FUE down the road and I do encourage everyone to tune out some of the noise (which I myself have been guilty of making from time to time!) and really objectively research both techniques from the beginning.