Dr Blake Bloxham

Hi jj, Thank you for commenting. Yes, I would say this patient is on the earlier side. As you noted, his 6 month images and video showed a result that was closer to what I would expect around 9-10 months. Still not the full thickness and naturalness you achieve between the 12-18 month mark, but "ahead of the curve" for sure. Sometimes I hesitate to put up "early grower" cases because I feel like it propagates the stereotype that everyone should look great at 6 months or that you will not have a good result if it does not already look good at 6 months. This is not true. Remember that for the average patient, 6 months is the half way mark. If you do not look as matured as the "early growers" at 6 months, it is no reason to panic. We see a bit of bias with people who put up results at 6 month because if they are good, people will want to put them up. But please do not get discouraged if you do not look like this at 6 months. Everyone matures a little differently and "all's well that ends well" if you end up looking just as good at 12-18 months.

Thanks to all for the kind words. I am going to jump into the individual questions below.

I have heard them described as "snowflakes;" I have heard them described as individualized "works" like paintings; regardless of how they are described, one thing is for certain: hairlines are not a "one size fits all" type of situation. All patients are different. Things like hair characteristics, facial structure/head shape, level of loss, and projected future loss all come into play when designing a hairline. Some situations call for a lighter, more broken-up and irregular "transition" hairline; in other situations, patients may benefit more from a stronger, denser, more symmetric hairline. No two hairline should be alike and a doctor should customize the design for each particular patient. And remember, just because a hairline looks good on another patient does not mean it is the right one for you. Today's case is an example of a specific hairline created for a specific patient. The patient is a male with darker, coarser hair, and seemingly more limited and stable loss for his age. He requested a strong, dense frontal hairline (he was happy with the corners), and I thought this made sense for him. In his situation, a more striking, strong, less irregular hairline made sense for him. I performed a hairline rebuild, a dense frontal band pack, and also a little bit of fill behind it using 2,400 grafts removed via the FUT technique. He returned at 6 and 12 months, and was very pleased with the direction we took for the hairline. Here are a few "teaser" shots of his 12 month results from the video: And here is his 12 month comb-through video, which features much more detail and also a look at his FUT incision line at 12 months: And here is his 6 month video for comparison: So I hope this helps explain that hairlines are not a "one size fits all" approach, and you must visit a clinic which will spend time creating a specific hairline for you and you alone. Make sure to see lots of examples of different hairlines from any clinics you are considering, and speak with the doctor about their hairline philosophy. Look forward to the discussion, Dr. Blake Bloxham Feller & Bloxham Medical, PC http://www.fellermedical.com

Hi Anthony, I apologize. I read "father's brother" as "brother." Skipped over the "father's" part entirely for some reason. Regardless, I still think this is likely the beginning of genetic male pattern hair loss and would recommend undergoing an evaluation in-person if possible. Typically it is best to identify this early, intervene quickly, and slow the process down to preserve as much hair as possible for as long as you can. Good luck.

Hi Sam, Definitely resist the urge to Google. At best, you will find some pseudo-related information that will scare you; at worst, you will find absurdly unrelated things which will make you panic. And in the end, it will probably be nothing even closely related to what you find. Not worth the stress. Just try not to focus on it too much and wait for the doctor's reply. Good luck.

It is mind-boggling to see this technique make a comeback. However, I can confirm that is is happening. I have repaired probably about half a dozen or so of them over the past 2 years. All following the same pattern you describe: a clinic taking a strip, cutting it into something between a mini-graft and what I consider a small plug, making gigantic holes spread very far apart, and implanting these under the guise that this is a special technique which provides superior results. And while I am always interested in different approaches, I think this method was surpassed by follicular unit grafting for a reason and I have been very unimpressed with that I have seen in person. A very important video with some good recommendations; particularly about looking for comb-through HD video results. I highly recommend all patients ask to see these. It is so easy to film and upload quality video in 2019. All smart phones essentially have the capability to capture excellent video and this can be uploaded to YouTube, Vimeo, etc, with the clinic of a button. There really is no excuse not to have this. Do yourself a favor and ask to see it!

Hi Anthony, Thank you for sharing this additional information. 21 is definitely still the "uncertain" age where it could be either. The fact that your brother had the same receding corners and the degree to which yours have progressed, however, does lead me to believe this may be male pattern hair loss. Can you consult with a trusted hair loss doctor? He/she should be able to evaluate, determine what may be going on, and make some treatment recommendations.

Hi Sam, No need to panic now. You did the right thing by contacting your doctor. He/she will be able to advise you most accurately on what may be happening and hopefully see you in the office for evaluation and treatment (if necessary). Have you noticed any other changes? Does the area feel warm? Any cold-like symptoms (fever, headache, chills, et cetera)? This could be something as simple as normal healing for your physiology. It also could be inflammation from a variety of causes. I would not do anything for now aside from checking for the response from your doctor and then following his/her advice carefully. Keep us updated.

My pleasure. Question as well: Do you use the hybrid punches to remove grafts from the frontal region like that or sharp punches?

Dr. Devroye, Excellent presentation of a very interesting case. I love the "corner(s)" results from the first surgery as well. I am sure the second pass will look just as natural. I do hope you will update when he comes back. Again, great work.

Kvn, At a young age with a somewhat disappointing response to preventive medications (you are not alone here), you should look at hair transplantation as a strategic and long-term game. You have limited grafts to use from the back --- and it looks like you will progress to an advanced pattern -- and a large and expanding area to cover on the top. I think you can do this with transplantation only, but you need to work smart and not waste any precious donor. If you came into my office, I would likely recommend the following: Do an FUT mega-session now of around 2,500 - 3,000 grafts aimed at addressing the "frontal 1/3rd" of the scalp. This would involve carefully (as you are a diffuse thinner and we would not want to damage the existing hair) rebuilding or reinforcing an appropriate hairline, densely addressing the frontal scalp behind it, and strategically transitioning into the "bridge" of better hair you have in the middle. I completely understand the urge to jump into the crown now, but I would highly advise against it. It is rapidly evolving and we do not know how it will end up yet. Use your grafts now to build a strong foundation in the first 2/3rds of the scalp (this is assuming the bridge will thin and you will want a second hair transplant to rebuild this) and then come up with a strategic plan for the crown later. This is where you may get into FUE and other clever approaches to obtain coverage back here or build up enough "tacking" hair where you can use a little bit of concealer, when warranted, to really make it look full. I would really push starting with FUT because I do believe your donor is limited. Likely enough to get 6,000 or so grafts out of with a combination of both methods (FUT and FUE), but I do not think it is sufficient for FUE alone. It also looks like you may have some thinning in the bottom region of the "donor" (retrograde alopecia) as well, so it is best to stay away from anything along the fringes of the donor for now. Hope this helps.

Anthony, You probably will not garner too many responses because this was posted in a previously existing thread and not a new one you started yourself. It could be either depending on your age. How old are you? Having said that, the recession in the corners looks more aggressive for classic hairline maturation. This, in my opinion, is more likely the early start of male pattern hair loss. Are you noticing changes anywhere else? What is the family history of hair loss like?

Alin, I tell patients they can resume alcohol intake starting post-operative day 4. The real reason to avoid alcohol is because it thins the blood. You do not want thin blood during a procedure, nor do you want it with thousands of open incisions and possibly excisions (FUE) in the few days after surgery. Each clinic is different, however, and you should follow your doctor's post-operative instructions as closely as possible.

Thank you for the kind words. And you are 100% correct about the aggressive "sloping" or very "boxed in" hairlines we are seeing on younger patients today. I completely understand the temptation and why young patients to want this; however, it is often not in their best interest and will not age well. Start a little conservative with the hairline, make sure everything from front to back is uniform and taken care of, and then consider going a little more aggressive in the front down the line if and when the entire top is full and natural.

While planning a procedure, patients frequently ask if we can "close the corners." What they mean by this is whether or not is is appropriate and possible to close in the angles in the fronto-temporal corners and rebuild some of the temple region. Working in these regions often results in a very aesthetically pleasing result. A frontal rebuild including these regions is a little more aggressive and often recreates a nice balance. And while a lot of patients request work in these areas, it is important to note that it is not for everyone. It takes a specific hair loss pattern, hair type, and the right clinic to pull this off. Those with thick, coarse donor hair (even the singles), a stark contrast between the hair and skin color, and those with advanced or uncertain hair loss should likely not transplant in these areas. As tempting as it may be, it may not look correct and grafts may be better used elsewhere. In the right patient, however, the results can be great. The patient in today's case is a male in his early 40's with moderate frontal thinning but somewhat significant thinning in the "corner" regions. He really wanted to address these areas, and based on his hair loss pattern, history, and hair/skin type, I thought he would be a good candidate for him. We utilized 2,500 grafts to densely rebuild the superior portions of both temple triangles, the anterior portion of the parietal "humps" (the vertical portion running from the temporal triangles to the fronto-temporal corners), close the frontal temporal-corners, and pack the entire frontal band. The patient returned only 6 months later and was very pleased with the results (as were we). The decision to "close the corners" was a good one for him, and I believe we achieved the desired balance in the frontal region by closing in and rebuilding these areas. Here are a few select "teaser" images showcasing the result (both wet and dry). Attached are more before and after comparisons (both wet and dry), and below is the detailed comb-through video. As usual, I highly recommend that all patients watch the video. Video is the most honest way to display a transplant result, and it is what you as a prospective patient should look for. Look forward to the discussion. Dr. Blake Bloxham Feller & Bloxham Medical, PC www.fellermedical.com

Hi Ali, Who diagnosed the Telogen Effluvium? Based on these images here, your hair looks healthy in general. I think most of the "thinness" you are seeing here is due to lighting and focus on specific areas than it is due to an actual condition. Do also keep in mind that it is common to first notice male pattern hair loss (androgenic alopecia) at this age. I am not saying I see evidence of that, but it is something to keep in mind. There is likely no treatment required at this time. Most of the treatments available are for diagnosed androgenic alopecia, which it is not clear that you have. And if this is Telogen Effluvium, it should reverse on its own. The only way I could see treatment being necessary is if you had a medical condition that set off the Telogen Effluvium like a thyroid problem, vitamin deficiency, etc.

Maltese, Let the warm water in the shower loosen them up a bit, and then scrub with your fingertips -- not fingernails -- and some shampoo. This should remove the majority of them. Sometimes you do get one or two stubborn scabs that are not ready to come off. It is okay to leave these for a bit until they are ready to break free. However, typically this should only be one or two. If you have a lot of these left, you probably have not scrubbed hard enough. Also, please share some images here if you can. This will allow the community to provide more accurate advise as to whether or not you are washing hard enough.

Perfectly stated. I think there is a picture of the Norwood Hamilton scale in the dictionary next to the definition of "unpredictable." One of the most common questions I am asked during consultations is: how is my hair loss going to progress? And, like you said here, there is very little way of knowing. While you do pick up on some very general patterns and timelines after seeing it so many times, I am continually surprised by how the hair loss progresses in different patients. I have seen people in the office whom, I believed, showed ominous signs of advanced hair loss, only to see them back years later in the office and not a thing changed (no medical therapy either). I have also seen patients whom I believed only had isolated hair loss with great hair behind and around it show up 6-12 months later with significant thinning and signs that they would progress to an advanced level. So I think the takeaway here is that everyone is different, it is a progressive condition, and you should always think in the "long term," especially when it comes to surgery. Use your grafts wisely and do not put yourself in a bad position up the road.

I have viewed this presentation multiple times now, and I am still impressed with it each time. Very important topic and I am glad it is receiving the attention it deserves. Be careful!

While you may want to triple check with your clinic, I cannot think of how this would be an issue. At all. Also, best to check out the issue at hand. Good luck!

Very important issue. Thank you for sharing.

Huge transformation. Great work!

I encourage patients to wait 12 months. Sometimes they are very anxious to address another area of the scalp and you can go in a little sooner. I typically require 6 months at the least in these situations.

A lot of patients start them simultaneously. The argument for starting both at the same time would be: overlapping the initial shedding phases (each drug carries a 3-4 month initial shedding phase) so you do not need to go through this twice, and increasing the strength and efficacy of your preventive regiment. The argument against this would really be that if you did experience some sort of negative effect, it is difficult to tell where it is coming from and how to make adjustments if you started two medications at the same time. If you are looking to stagger them, I think most patients would start with Propecia -- which will likely be the most effective as well.

Excellent point, and one that I always try to impress upon patients during the consultation. The hairline always appears about 0.5 - 1cm lower than the "line" we draw the morning of surgery because the hair grows forward. Furthermore, patients must remember that, as you pointed out here, transplants are permanent. The hairline we place on a 25 year old patient must age well and still look natural at 45, 65, and, God willing, 95. And, as you correctly pointed out, we can always go a little lower later once the stop is stabilized with transplants and age. This is easy. What is not easy, however, is raising a hairline that was started too low and now looks unnatural or is eating up huge graft numbers to maintain. Thank you for the great commentary. I know this will help researching patients out.