Dr Blake Bloxham

Giant, I think it means something is happening -- meaning you are a "responder." Like I, and KO, said earlier, however, I don't think there is any conclusive evidence showing a correlation between body hair changes and how well it will work for you in the long run. But I do think it means "something is happening." And I also think the shedding means you will likely see a response in the scalp. I agree with KO: watch closely and see what happens! Best of luck!

Custar, Stopping the preventive medications will only have an effect on the follicles that needed the drug in the first place. What does this mean? The only hair follicles really affected by medications like minoxidil (Rogaine) and finasteride (Propecia) are ones already miniaturizing from the androgenic alopecia (genetic pattern baldness) process. Once the medications are stopped, these follicles will continue progressively miniaturizing -- which essentially means thinning out -- as they were before. The transplanted hairs, on the other hand, aren't prone to androgenic alopecia and, therefore, don't require the medications. You could start, stop, or vary the preventive drugs and it wouldn't affect the transplants. It may thin out regions surrounding the transplants -- which can then make the transplants appear thinner as well -- but not the transplanted follicles themselves. Hopefully this makes sense! Haven't had my coffee yet!

I agree with Spanker. Based upon some of the thinning you have in the back part of the crown and the temples, a NW 5-6 is a realistic possibility. However, 7 is actually a fairly rare pattern. I think Unger showed that only something like 3% of hair loss sufferers actually hit a NW 7 within a realistic time period. Things to look for: thinning in the temple region regressing past the ear, dropping lateral humps (the top of the sides), and any aggressive retrograde alopecia (thinning in the donor region that starts on the neck and actually moves upwards). I don't see much of this on you. Your lateral humps look strong and no real sign of retrograde regression in the back. Glad you're giving preventive medications a try. This could be huge in a young guy like yourself!

Giant, As you probably know, DHT affects scalp and body follicles differently. In sensitive scalp follicles, DHT causes miniaturization; in sensitive body hair follicles, it causes robust growth. Cruel joke, right? Because of this, many people do see changes -- usually a reduction -- in body hair while taking finasteride. However, I don't think it correlates with how well one is responding to the medication. It likely means that it is affecting your DHT levels. So this is good. However, I haven't seen anything conclusively showing a correlation between body hair changes and positive scalp response. But, the fact that you are shedding and seeing a change in your body hair means you are probably a positive responder to the medication. Let's hope this is the case! Grow well and keep us updated!

Replicel, the makers of the RCH-01 injectable, have been around for quite some time. It actually looked like they were going to give up on the product for a while (and focus more on a similar injectable solution that was actually aimed at healing tendons), but they received a 4 million dollar grant from a large Japanese company a few years back and started working more on releasing the product in Asia. And many were actually surprised by this because they did release some preliminary data about safety earlier that -- although it was focused on safety and not efficacy -- showed somewhat underwhelming results from the injections. The RCH-01 is similar to what some others have tried in the past in that it's essentially injectable hair follicle stem cells. This is meant to do a number of things, the most important would be waking up telogen follicles -- IE conquer androgenic alopecia (AGA). What Replicel did differently, however, is derive their follicle stem cells not from the dermal papilla at the bottom of the follicle, but instead from the dermal sheath cup (DSC) that actually surrounds the bottom of the follicle. Frankly, this was a pretty bold move. I think the most relevant data shows us that the DSC can be a reservoir for dermal papilla stem cells, but really needs a functional dermal papilla from a healthy hair follicle to do much. In AGA scalp, this just isn't the case. Because of this, it may function as more of a short term booster like PRP or other growth factor serums. Regardless, the Japanese company is still -- as far as we know -- working on the product in Asia. There are talks as to whether they could release it in Asia earlier than expected because of a new Japanese law regarding stem cell treatments and releasing commercial products only after 2 phases of clinical testing. However, the original release date was 2018 and there hasn't been a whole lot of talk to make it seem like it is on schedule for a release around that time. What's more, I've always thought most of these injectable cures involving growth factors or stem cells would have a BIG problem obtaining FDA approval in North America. So is it a cure? I think that may be a bold word. Could it have some benefit? Possibly, and Replicel is hoping this is true when a lot of injections are used (that's how they've been trialing it). Will it be out soon? I don't have a crystal ball, but I'm not too confident about it. I think a true "cure" will come when you can safely and effectively create DHT-resistant follicles in a lab and then transplant in a fashion somewhat similar to what we do today. However, this is light years away. The follicle is a surprisingly complicated organ! I think the closest "cure" we may see will be donor doubling (IE splitting of the follicle into it's two regions of stem cell activity and growing two follicles from one). However, this has proven more difficult than expected. It's one of those things that makes perfect sense and works in the lab, but hasn't panned out in clinic practice.

Lucky, Excellent outlook! Obtain as much knowledge as you can and go into your consultations well informed. For you, I really think the biggest 'question mark' is the stability of the donor region. I truly hope it does look solid in person and you are a better candidate for surgery than it may appear online. Best of luck! Keep us updated and do feel free to ask any additional questions!

Lucky, Yeah, it's not the most fun to hear -- or to say. However, it is very important to be realistic. A lot of people will provide advice, opinions, and even offer services that are simply unrealistic. This can land you in a worse situation than where you even started to begin with. In fact, a number of these big cases that involve things like BHT are done on guys who were lured into something years down the road that they shouldn't have been. It takes things like these last ditch efforts just to get them back to an acceptable level. However, I've read too many stories online -- and seen patients in person -- where they wished they could just go back in time, obtain the cold hard truth, and make a more informed decision. The difference between you and that gentleman comes down to the surface area that needs to be covered and the donor. I know it probably doesn't look like it because he's buzzed down so closely, but I think the shape of his head actually creates a smaller surface that requires covering and his donor appears more robust -- and stable. Again, however, these things are very hard to gauge online. They have to be determined in person by someone who has experience doing it. Once you know where you stand and what you have in reserve, you can review your options -- attempt surgery, SMP, et cetera.

Lucky, Based on your very aggressive hair loss, which may be creeping (or will eventually creep) into 'safe donor region' on the sides, I would proceed with the utmost caution. Frankly, I would be surprised if you were a good candidate for hair transplant surgery. And the first step to determining whether or not you are a candidate is by undergoing evaluations in person. Your case is too complex for online consultations. Your donor needs to be evaluated by a hair loss specialist in the flesh. And I highly, highly doubt body hair transplantation (BHT) will be a viable option for you either. This is normally a last ditch effort for complicated repair cases, and you still need a very large amount of regular scalp hair to essentially camouflage the body hair grafts. I'm not sure you have the scalp hairs to fill around the body hairs to create a natural look. For most patients, BHT isn't a viable option. Sorry to be a bit grim, but I would hate to see you rush into any surgery in your situation. Like I said before, this is something that MUST be approached very cautiously. And don't do anything with anybody unless they have evaluated your donor in person. Best of luck. Feel free to contact with any questions.

My alter ego, huh? Now things are getting interesting ; )

911, I think you may be looking at the pictures from his second surgery. The ones from the first (where the hairline was redone by Dr Feller) are on the first page.

Hey Vox! He's coming in Monday for staple removal. We'll ask him about the radio silence! Haha. In the meantime, here are some of the intra-op and post-op shots: Here's a picture of his donor region. You can see the FUE sites on each side of our strip scar (and his skin is a bit red/irritated from cleaning the area with an alcohol pad): And here he is after placing 850 (approximately) grafts in the area behind where we worked previously. Unfortunately, his donor was very depleted and we were only able to harvest a limited number of grafts. However, we think we can steal some more out with mFUE in the future. More to come Monday!

Nevada, I think Dr Gabel, in the Northwest, is performing temporary SMP now. You may want to send him an email. If you do want to travel, I know of an excellent place in NY where we send our guys as well. Best of luck! Keep us updated on the progress.

Greatest thread of all time! I've never laughed so hard reading something on the forums. Bravo, newbie!!! I officially nominate this for a "sticky." Do I have a second?

Petchski, Correct! The goal was to address the micro and macrohairline alone during the first procedure. The patient's donor was extremely depleted from the past FUE, and it was clear that he would not get a lot per strip, so spreading the grafts at all really wasn't an option. The overall gameplan was then to address the area in the frontal scalp directly behind the macrohairline with whatever grafts could be obtained from a final strip, and then to see if mFUE was an option down the road.

Congratulations! You really grew great!

Pup, Good questions! Yes, the yield should be absolutely the same. The grafts in the mFUE punches are beautiful, and we dissect them in the same microscopic protocol that we do traditional FUT. We've done both very sporadic spreading (like traditional FUE) of the punch sites, and more of a linear plan like Dr Lindsey outlined above. There are advantages and disadvantages to both, but it does seem to be advantageous to create an "organized chaos" sort of game plan with respect to harvesting. What this means is that it is not a completely random spread, and it does have some overarching linearity to it. BUT, you can still create a very random pattern within this overall design and make it look very scattered. When you do this, it's very difficult for the eye to pick up any patterns or focus in on any continuation of the scar. And it results in the wide spreading of the sites like I've described before. This seems to be the key to a really successful mFUE: punches larger than traditional FUE, spread far apart, with lots of healthy tissue between -- to break up any scarring, facilitate good growth, and leave us with lots of healthy donor to utilize in the future.

Newbie, I think the best way to describe the scars is "little dashes" spread throughout the donor. That's how Dr F and I have been discussing it, at least. I call the scarring from mFUE "FUE-like" because it is non-linear scarring spread throughout the donor. But the scarring itself is actually a bit different: FUE produces thousands of small, circular, scars tightly packed and spread all over. Each mFUE "dash" (and this shape is especially true when we've been closing the circular punches -- opposed to the elliptical ones Dr Lindsey is using here) is larger than an individual FUE scar, BUT they are spread MUCH farther apart and there are a hell of a lot less of them. This not only creates, from what I've seen thus far, a very nice result cosmetically, it doesn't compromise the donor in the same manner. Here are a few examples:

Dr L, Awesome video! Seems like this was a good mFUE candidate and a great case. Look forward to seeing the results mature!

Hairthere, Thanks for the shout out! I love doing those mFUE cases! And, as always, you were a great patient. PK, Yessir. I've discussed when I will start sharing results -- on here -- with Bill a bit. It'll likely be in the not too distant future. Stay tuned!

Congrats, esrec! Nice write up too. Can't wait to see this grow and mature!

Wwizz, Sorry for the hijacking!! Haha. Best of luck in your research and future surgery. I think this thread will be really helpful for guys researching down the road. Thanks for starting it!

Delancey, You too!

Delancy, I think we could go back and forth forever here, but I don't think it's fair to say a statement is "unequivocal" when he uses terms like "may" or "close to" in the same sentence. His point with the yield is that it's less of an issue than lifetime graft potential. What he's saying is that FUE clinics are using yield as a detractor to get FUT clinics to argue that their yield is better and ignore the problem with lifetime potential grafts -- which he argues is the bigger issue. He says that FUE clinics draw FUT clinics into a debate about yield; the FUE clinics then post results with good yield; it takes the wind out of the FUT surgeon's sails; and the result is that the FUE clinics look like they know what they are talking about so when the real problem -- in his opinion -- is brought up by the strip clinics, they look like they've already been defeated so no one takes them seriously. It's just an example of either a classic "straw man" or ad hominem argument depending on how you want to look at it. And he confirms it in the quote: “FUE only clinics will emphasize that they can get the equivalent result in one session with more or less the same yield. They emphasize this so that you forget about this very important concept of lifetime hair potential. It is a deception. Because the strip surgeons fall into it as the opponents. They say no, our yield is better. And then the FUE surgeons come in and show excellent yield, and then the strip surgeons are busted.” And note how he doesn't say it's strip level yield. He just says it's "excellent." And, again, he uses vague language by calling it "more or less" the same yield. And he actually makes no comments about consistency. And this is the biggest problem with FUE: consistency. Dr Ron himself brought this up earlier: depending on the source you use (the patient he spoke with versus the video we saw) 2-5 out of every 10 patients don't grow the same. Who will be the 20-50%? Why does it happen? Could we have predicted it? Would it have happened if the grafts weren't strained during extraction? The reason the numbers are being contested is simply because it's not popular opinion and people don't want to hear it. But that's not my fault! Haha. I'll go against the grain here. I know what I'm saying is correct, and this has been confirmed by pretty much every source that has been listed in this thread if you really read through it. The fact that Dr K started off with FUE only and felt the need to add both to his practice speaks volumes to this point. And even he himself -- and the host -- state that it's not driven home enough (or heard enough) online. And you absolutely bring up an important point: nothing in medicine or surgery is guaranteed. But there are ALWAYS ways to optimize your chances of success. If you goal is to move as much quality hair from the back to the front, I, and many, many others, believe there is one specific way to optimize this. Not saying it's the right thing for everyone, but it's the most effective way to really "get the job done." And remember that medicine isn't a traditional merchant:consumer business model. Just because something is becoming more popular doesn't mean it's equally effective. This is a timeless tale in medicine. Ask a bariatric surgeon about gastric banding or a cosmetic breast surgeon about trans-umbilical saline breast implants. It's not a doctor's job to sell or make a patient believe they can select a procedure or treatment like a menu item. It's the doctor's job to evaluate and offer their expert opinion on the best possible treatment. Not always sexy and popular, but it's technically the job. Even in a cosmetic field. "Pencil thin" refers to a line drawn by a standard pencil. Not any part of the pencil itself. It's like this: And I'm not commenting on the scale there, but simply showing the line they are referring to. I would consider 3mm "stretched" in a guy with normal skin. I wouldn't consider this really normal either. Like you said, so much of this process comes down to physiology. However, it's a myth that stretching is completely unpredictable or that good surgical protocol plays no role. I feel like most guys fall into a "normal healer" category and the "3 guard" rule applies. Keep in mind that you can see FUE scars around the 2 guard level as well. Seems like we've pretty much covered it here! Plenty of good info for those researching to dissect. Again, you've really provided some excellent content here. Thanks for discussing this in a civil and educational manner. It's really going to help some guys out down the road. We need more of this on HTN!

Delancy, Just watched that interview; it's actually quite good. And Dr Karadeniz makes a few very similar points to what we've seen before: FUE megasessions are damaging to the donor region and complicate future procedures, it's most advantageous for patients to start with strip and then go FUE (he states that he likes this scenario because he's able to obtain a lot of grafts and a very good scar with one procedure and then finish off with FUE without overthinning the donor), and that single procedure clinics (FUT only or FUE only) are really missing a critical component by only offering one or the other. And he does say you can obtain good yields with FUE when the characteristics are good. And I don't disagree with him either. But it's also clear, based upon the above quote I shared, that he doesn't think it's for everyone nor does it happen every time.

Hi Delancy, Again, really look at what Dr K is saying here: "when an experienced FUE surgeon does FUE and takes care of all nuances, you may get and do get a close or equivalent result with strip surgery." "you may get close" I don't think this is inaccurate. You very well may get close. And you also very well may not. Here's something else he posted about an ISHRS presentation he did this year at the conference: "FUE does not work on every patient and this may be evident only after doing an FUE test. Is it ethical to actually be an 'FUE-only clinic' [and] offer and do FUE on every patient?" Seems like he's actually being pretty straightforward about it to me. I've actually always like most of what I've heard from him. And this is how it should be: clinics able to offer both and make appropriate recommendations to patients. I agree that all the contrasting information is confusing. However, it's inevitable if we really want all the information out there. Allowing for only one viewpoint on a forum like this -- be it pro FUT or FUE -- is dangerous to the newbies you mentioned above. That's why we must have these discussions and really get all this out here. Thanks again!