Dr Blake Bloxham

Hi Willy, Hope you found the information informative! This should not happen with strip. There will be some "kink" and "wiry" character to the hairs initially. But this will normalize after around the 9 month mark. I do not believe strip extraction puts the grafts under the same level of strain and, therefore, does not cause permanent damage to the internal portion of the follicle. Is it common for this to happen with FUE? Good question. I don't know if I'd call it common. But I also wouldn't call it uncommon. I think it's best described as "under reported." In fact, I first mentioned this on the boards only a few months ago. I don't think most had even heard this phenomenon described before, and many probably still have some doubts. But if you really review the explanation I posted above, it makes physiological sense. I don't think this has anything to do with Dr Diep. It has to do with the nature of FUE in general. No matter how gently the grafts are removed, they will always be subjected to crushing, twisting, crumpling, and pulling, and this is what will cause the permanent deformity of the internal portion of the follicle. Technicians will always be heavily involved. You actually want a lot of technicians as long as the doctor is performing the actual surgery (IE no "technician FUE") and the techs are doing what they are supposed to do -- dissecting and placing. I also don't think this is "split ends" or trichoptilosis. This is an entire different etiology of hair shaft damage/deformity, and wouldn't really occur unless you were doing heavy hair treatments. Here's an example of true trichoptilosis: As you can see, this is either caused by a genetic shaft abnormality or chemical/mechanical damage, but it only affects the ends of the hair. You have this kink throughout the entire hair, so it's not from "split ends."

HT, Thanks again for the reply. I don't want to write too large of a reply, but I'll just re-state my points for the record: -Patients who need multiple procedures are actually much, much better candidates for FUT not FUE. This is because FUE wreaks havoc on the donor and makes future procedures less and less certain. This is different than FUT where all scalp around the scar region is virgin. -BHT has very poor yield (the average of all body extraction sources is around 30-40%), retains it native characteristics in the scalp (beard hair grafts grow like beard hairs, chest like chest hairs, et cetera), and creates the risk of unacceptable scarring in the donor regions. What's more, it should not be attempted until the regular donor is tapped and patients need it for severe repairs. Even then, it still doesn't change the problems with yield, scarring, and unnatural appearance. BHT is not a useful technique for the vast majority of patients and should be a last resort. What's more, because of the poor quality of growth, it really doesn't add a lot of additional grafts that can be used in addition to scalp grafts. This is even truer when the studies published in the text show that yield becomes worse and worse the more BHT grafts are packed on the scalp. -It also really doesn't matter how perfectly the BHT grafts are removed; they can be removed with robotic precision and still won't grow well. They just aren't strong enough, nor are they meant to live in the scalp environment. -FUE will not continue to improve because nothing can be done to remove the detrimental forces FUE places on the grafts. Even if you did create a device to reduce transection, like you describe above, this does nothing to reduce the compression, torsion, and avulsion the grafts experience. Nor does it do anything to reduce the skeletonization that leads to dehydration while the grafts are out of the body or death while the grafts are in the scalp. This is something that I must hammer in again: nothing will improve traditional FUE. Until a doctor or device can remove all of the forces I described above, nothing will change. -The only way to maximize grafts and best treat these high NW patients is to strip them out and then steal more hair with mFUE. FUE + BHT is NOT the best treatment plan for these patients. -Since I mentioned it above, the only true change you'll see with FUE could be modified FUE (mFUE). This is because it removes the forces I described above and provides microscopically dissected grafts with appropriate amounts of supportive tissue that will survive and grow. It also does this with FUE-level scarring. I think if you really read through and research these points, you'll see a lot of what I'm saying is logical and fact-based. It's not as "sexy" as a 20,000 graft BHT case, but it's realistic and the most appropriate plan for a hair loss sufferer. Thanks again. Obviously you're free to disagree, but I do encourage you to research what I've said above.

Willy, Thanks for sharing. So, here's the deal: I'm going to tell you my opinion of what I think happened, and you'll let me know what you think and ask any additional questions. By 18 months post-op*, your grafts are fully matured. By "matured" I mean that the characteristics of your hair follicles and the hairs they produce are set in stone. For the first 3-9 months after a hair transplant procedure, we often see the "kinky" and "wiry" hairs you're describing. The internal portion of the hair follicle is what determines how the hair grows. Straight, curly, thick, thin, wiry, and kinky; this is determined by the internal portion of the follicle. During a hair transplant procedure, this internal portion of the follicle often becomes temporarily distorted. As a result, the hairs grow kinky and wiry until the internal portion of the follicle rights itself and starts producing normal hairs. Now, the information I've described above holds true for strip procedures. However, I've witnessed something different in FUE patients: permanent kinky, wiry hairs that retain these characteristics indefinitely. In my opinion, this occurs because the stresses grafts experience during the FUE extraction process causes permanent damage and distortion to the follicle. This includes the internal portion of the follicle. Which, as I explained above, results in permanently altered hairs. Hopefully you'll see some normalization. But I've unfortunately seen a number of these permanently distorted growth cases in post-FUE patients. Does the hair provide good coverage? What does it look like cut short? This is always an option. Read this over and see if it makes sense to you. Feel free to ask any additional questions. *PS: based on your posting history, it looks like you actually underwent the procedure in early February or late January of 2013. This would make you closer to 2 and a half years, not 1 and a half years post-op? Does this sound right?

Such a dynamite result!

Hi HT, Thanks for the reply. Let me address some of your comments: A NW VI or VII patient will never have enough grafts available to take them back to where they were when they were a teenager. This doesn't matter how you try and steal them. Scalp grafts, body hair grafts, et cetera. Until you have hair multiplication or donor doubling available, it will be a game of covering important areas to create the most restored appearance. And no, BHT does not have a 60% growth rate. Let me share a few interesting pearls from the Unger Hair Transplant text: -Leg hair grafts yield the poorest growth results. As the density of transplanted leg hair on the scalp increased (from 24 leg hair follicles/square cm to 49 follicles/cm^2) yield decreased from 38% to an abysmal 4%. -The studies looking at back, chest, and beard were very, very small -- less than 200 FUGs examined altogether. -Based on the data, however, similar results were seen: the higher density the grafts were implanted and the larger number harvested, the lower the yield. -Technically, chest hair grafts had the highest yield in the study. But the size of grafts they looked at was too small -- in my opinion -- to really form an opinion (28 FUGs) -Beard grafts had a 63% growth rate and back hair grafts had a 47% growth rate -The authors note that the follicles did retain their donor characteristics -- with respect to cycling and hair shaft size/description -They also note that the most common complication was scarring in the donor extraction sites So, here is what's important: average growth yield is low; like 40% with everything averaged out low. And the more grafts you transplant into a certain area, the more the yield falls. I also don't think the experience of the surgeon plays a huge role when it comes to BHT. These grafts just aren't good. And FUE, even when performed by the most experienced hands, damages grafts. Take poor quality grafts and add in a technique that intrinsically damages the grafts, and you're going to get poor yields. Period. And I don't think ACell, or anything else, is going to change this. Even in the study you posted, 0 out of 6 chest grafts treated with ACell grew. BUT, if you look at the research I posted, chest hair grafts had the highest yield. So what does this tell us? The results are unreliable. There is no trend in the data here, which leads us to believe that BHT is unreliable. Yes, I have personally seen bad scarring from BHT. This is not a BHT case, but it's an example of what small, circular, hypopigmented scarring looks like in darker skinned individuals: I would be upset if I did this to a gentleman's face or chest. I'd be even more upset if I did it to get grafts that grew unnaturally in the scalp 30% of the time. BHT is a last resort option for those who do not have scalp reserve left. He may have had 8,000 scored, but it's difficult to say how many were successfully delivered and even more difficult to say how many grew. Let's look at it this way: say he had 6,000 grafts via FUE and 2,000 via BHT. 6,000 at 80% yield is 4,800 (and this is being generous) and 2,000 at 35% is 700, for a total of 5,500 grafts. Now you ask, could I get 5,500 grafts from 2 more strips and an aggressive mFUE session? I think I could. And by definition, traditional FUE and BHT won't improve. The technique, even when performed with robotic precision, puts grafts under torsion, compression, and avulsion strain and yield and quality is lower. There is nothing that can be done to change this with traditional FUE methods. However, we can overcome these issues with modified FUE (mFUE) which is why were are pursuing the technique. However, I would still only recommend one route for this patient: stripping out then stealing what we could with mFUE. Really read this over and tell me what you think. Good discussion! Thanks for participating.

Vox, It will be very interesting to see if you don't shed again. Fingers crossed that you don't! And it's absolutely a bummer to wait. BUT, your coronary arteries and cardiac myocardium are thankful for the nice, thin blood! Trust me! I still can't believe that happened, but relieved to see you recovering and getting back to the important stuff: hair transplants and rock n' roll!

HT, I disagree. Those who are high NW cases should only undergo strip surgery. Allow me to explain, and then tell me what you think: 1) For these patients, hair restoration is a chess game. It's what they have in the donor versus a BIG amount of real estate we must cosmetically cover in the front. In this game, yield is king. Strip gives you about 95%-98% yield on average; FUE average is closer to 80%. Committing to an FUE "mega session" on these patients is akin to removing a strip, cutting off 20% of it right after removal, and throwing it in the trash. We need every graft, so they must be extracted in the most effective manner. This is strip. No question. 2) FUE "mega sessions," which is what high NW patients need, destroy the donor area. If the patient goes in for his first sitting of say 3,000 grafts and gets around 80% yield, the next is going to be 2,000 grafts with 70% yield. Even if you planned for a session of the same size. You're going to get decreasing numbers of grafts successfully delivered and decreased quality of grafts because the donor region is now a net of scar tissue from the first procedure. Like I said above, this is just wasting grafts the patient can't afford to waste. 3) This brings us to "body hair transplants." Why not make up for the phenomenon I described above with body hair grafts? Simple: the growth rate for these grafts is low. And when I saw low, I mean averaging around 30-40% low. Not only that, they retain their natural characteristics. This means they will grow like chest, beard, and armpit hair on the scalp. This is, of course, when they do grow. Extracting body hair grafts also creates hypopigmented scarring in a lot of visible regions, and this often isn't worth the poor grafts obtained from the extraction. Body hair grafts are a last resort after the scalp is exhausted. Period. If you "strip out" a patient with multiple strips and then go in and steal what's left with mFUE (our modified FUE technique), then there is no reason to resort to these body hair grafts. The case you shared is really only an example of one thing: a very poor first surgery. Whether it was performed via FUE or FUT, it was performed poorly. Clearly the grafts were placed too far apart and too deep, and the donor site wasn't closed properly. Sure, this patient was able to salvage with FUE/BHT. And I'm very happy he was able to knock this out and move on with life. But I'm confident that stripping the patient out and then stealing more grafts with mFUE would given him the best "bang for his buck." What do you think?

HTsoon, Remember that this is only half the picture. The other half lies under your scalp. This is where the truly important scarring from FUE lies: subdermal fibrosis. And this is why those who need multiple procedures are actually much better suited for strip procedures.

Irish, It absolutely is! We will check everything out in London and see what we think! Matt, Most will take the old scar with the new strip. In fact, this is standard procedure unless there is a big reason not to take the original scar -- which almost always means the first strip was taken from where it shouldn't have been taken. So yes, almost all second strip procedures will still result in 1 scar. The staples provide us with the best cosmetic scars. However, we use a very specific type of staples. I can only think of 1 other clinic who uses these. Dr Feller experimented with just about everything; deep/internal suturing with external sutures, absorbable sutures, other types of staples, etc. He found the protocol we use now with staples creates the most cosmetically acceptable scars. Much harder for them to stretch initially and eliminates the risk for "train track" scarring with sutures AND eliminates the immune reaction issues and poor breakdown with anything "absorbable."

Tommy, I think a lot of actors actually wear small frontal pieces in movies and at public events. Even guys with good hair. Jackman and Cooper are a few who come to mind.

Hey Irish, How far apart are they? It may work. However, there are two potential issues I see right off the bat: first, we could be taking too large of a strip and risk stretching if they are too far apart; second, we may not obtain any useful amount of grafts to use in the front if the strip contains mostly scar tissue from your two original scars. Now, here's what may be interesting: Dr Feller and I have been toying with using mFUE to create a new method of scar revision. It involves removing some sections with the mFUE punch, reorienting pieces of the scar we don't remove -- to break it up and make it difficult for the eye to pick up, and using the grafts we get from the mFUE punches we took before to fill in some of the reoriented areas of scar we left. It's actually a really novel idea, and I'm talking to a few different patients about trialing it right now. Frankly, I think it will be much more effective than putting FUE grafts into the scar. You may be a good candidate. I'll try to make a diagram to better explain the process this week.

Spanker, I hadn't seen Cruise with short hair in a while. Just googled it; you're right, he does have a bit more maturation than Reagan or Hannity. But I agree with you, no real MPB for sure! While we're on the subject ... Jeremy Renner has great hair too. Great natural density and very thick caliber hairs.

Yaz, I didn't know you were coming in for an mFUE consultation in London. Flag me down when you're in! I want to take a look as well.

Willy, Just to clarify: the procedure was performed in 2013 and you underwent FUE, correct?

Yeah, I think McBurney's hair loss is best described as a FPHL pattern. I would call it "diffuse patterned alopecia," but he really did retain his hairline like a female hair loss sufferer. I'd probably classify him as a Ludwig II-III: Technically, Ludwig pattern I patients don't have any hairline involvement, but I would say his has at least thinned (making him a II or III). Didn't Pegg discuss it publicly once? He's absolutely had one. I've seen Shaun of the Dead and Hot Fuzz way too many times to doubt that. Haha. He was smart about it though. Very, very natural and age appropriate design. I think Tom Cruise is just one of those crazy lucky guys like Brad Pitt, Ronald Regan, and Sean Hannity who simply never had ANY hairline maturation. They still have (or had) the pattern they did as a child.

Great movie, BTW!

Simon Pegg definitely had a transplant. It's a good one! But, like Spank said, our trained eyes pick up on this. I thought the other actor just suffered from more of a FPHL type of alopecia?

Vox, You're very lucky! We see a small percentage of patients -- maybe 2-7% -- who essentially experience no shedding. The theory behind why hairs shed out and the follicles become dormant for a short period has to do with blood supply. The follicles have enough reserve supply to function and cycle somewhat normally for a short period of time after implantation. However, this is temporary and they quickly "go to sleep" without the necessary blood supply. The body naturally creates network of vascular supply to the follicles within the first 3 months and voila, new growth! I have a theory within a theory that some guys don't shed because of a very diffuse vascular supply that latches on to the new grafts before they run out of their own intrinsic supply and go to sleep. It also may be that these guys have the capacity to grow vessels faster than others. Receding, Decreasing graft out of body time is the name of the game! I'm not sure whether or not if affects shedding, but it absolutely affects overall survival and, therefore, yield.

Mag, We will make sure to get some more pictures of the scar when he comes in for follow ups!

I had another patient come in for staple removal recently and noticed something I thought you guys may find interesting: As usual, here is a little background information for reference: I performed a 3,000 graft FUT ("strip," "FUSS," etc) procedure on this gentleman. Here's how he looked during the consultation/pre-operative assessment: And here's what I did: Two weeks later, he came back for his staple removal. What struck me the most was how much his grafts had grown in the two weeks since we did the procedure: As you can see, his grafts grew a significant amount in the two weeks between the procedure and the staple removal. Normally, grafts can grow around 1-2mm a week. Depending on how long before the patient sheds, the grafts, as you can see, can grow a decent amount. And this growth often helps patients get a true "preview" of what lies ahead. This is important because it's sometimes difficult to see exactly what to expect based on the shortly trimmed grafts that are visible right after the procedure. How much do you think this guy grew? I'd say around 4-5mm? Pretty impressive, and more than we normally see! It helped him see "what lies ahead" and got him excited about the upcoming results! Any post-HT guys out there who grew this much before shedding?

I've seen it work too. The only issue I've seen with some guys with short hair is a lot of particles collecting on the scalp. This can be a bit of a "give away."

I take 1,000 mcg of it daily. Makes my hair and nails grow really quickly! Otherwise, don't think it does too much. Haha.

And, in general, thanks for the kind words, guys! So, what do you think? Would a donor scar like this bother you? Is this what you think of when you hear "FUT scar" or do you envision the other end of the spectrum?

London, Thanks! Looking forward to meeting you in-person in a few months. I thought about you earlier today. We had a gentleman come in for a consult, and he revealed he had a total of EIGHT hair transplant procedures in the past 20+ years. A combination of plugs and short, wide strips. His donor was a disaster. However, we mapped it out and realized we could still go in and steal grafts with mFUE. This is going to be his last procedure to finish everything off, and I don't think we could have done much of anything without the mFUE technique. Hopefully we'll be having a similar conversation in October!

Radio, Technically, it matures for a full year. Very much like the results of the HT itself! It often does start off a bit fuller and red-er, and flattens and lightens overtime. Keep me updated on yours!