Dr Blake Bloxham

Irish, That's what I generally tell patients: you should be able to buzz to a 3 guard before the scar is noticeable. However, the most popular option right now seems to be the fade cut. Guys tell us they want to buzz it to a 1-2 on the lower part of the sides and fade up to a 3-4 higher up. I've seen a few that look really, really good. We're even able to pull the sides of the incision line up a bit if guys want to sport this cut.

Two weeks ago, I performed a 2,400 graft FUT ("strip," "FUSS") surgery on this patient. Before we dive too deep into the real discussion, here's what I did: Plan: Shaved up and getting started in the OR: Post-op: Now here's where the real discussion begins. The patient came today at the 14 day mark for his staple removal. We asked him how everything was going, and he said all was great. He then joked about not being able to even see the staples. We turned him around to take a look and "low and behold," we couldn't see the staples! Here's how he looked at 14 days: And here's a shot of the donor region as he walked in. And he was right! We couldn't see the staples: So this got us thinking: if we couldn't even see the staples with the patient's hair grown the way he normally wears it, what would his strip scar look like at 14 days? We dug in, and this is what we found: We removed the staples and finally got to it: THE STRIP SCAR!!! And here it is, boys: Zoomed in closer: As you can tell, this patient's strip scar is excellent. Not only will it never be noticeable with his hair at any length he would reasonably want to wear it, but it's barely noticeable when the hair around it is shaved and the wound is flanked by staple holes. With all the discussion surrounding the "smile face" FUT scars lately, I thought this would be a good example of the reality of what we see from our strip scar patients daily. A lot of scarring and wound healing is dependent on patient physiology. And there is only so much we can do as doctors to create a cosmetically acceptable scar. However, I think the majority of scars we see from real patients, in the office each day fall into this category. Clearly, this patient is going to be one of them. Hopefully you guys find this interesting! Discuss!

Vox, I don't personally have a hard numerical limit. But the more cases we do with mFUE, I look at it this way: - If you need a large number of grafts, something greater than 1,500 -- for example, strip IS the way to go. At this level, the patient clearly needs a lot of follicles moved and will likely continue thinning in the future. He/she needs the 98% yield. What's more, the patient is now at the level where diffuse fibrosis in the donor could be a "game over". If a patient needs say 1,500 grafts now and probably a few more sessions -- of similar size -- down the road and we go in, really reduce the quality of the donor with FUE, and then the yield -- of the FUE procedure -- isn't what we needed, this patient is in trouble. Where are we going to get these grafts from now? He needed 1,500 from session one, and maybe 2 other sessions. Now only 1,000 of the 1,500 he needed grew, and each time I enter the donor to do more FUE the yield is decreasing and decreasing. This guy will be BEST served by being "stripped out" and then going in and stealing hair from other parts of the donor we couldn't reach with a non-strip method. Which brings me to mFUE. -If a patient fits the above criteria but absolutely CANNOT have a linear scar, then do it as an mFUE. By using this technique, we get strip-quality grafts we can depend on and still leave large areas of virgin scalp in the donor -- as we only have to do a fraction of the punching in the scalp at much further distances apart to get the grafts -- to work with later. AND we do it with FUE-level scarring. Win, win! -If for some reason the patient can't do the stitches AND only needs a small number of grafts for little touch ups, then we can go traditional FUE. However, I'm actually starting to like using this for small touch-ups in the hair line -- which is generally where guys ask for it -- less and less because I get concerned about the permanent kink/wiry appearance in the hairs -- that can sometimes occur -- and how this would look front and center in the hairline.

You will see decreased return with each session because of the decreased quality of the donor. Yes, mFUE and FUT are both possible after FUE. Still less donor to take, but it's a more effective way to take it (opposed to traditional FUE).

Lil, How many per sitting? You can always get them out by shear force, but good luck with the growth. Also, 10k would be an exceptional donor AND way, way over the rule of thumb that 50% extraction of the total donor capacity should generally be the limit -- because everything over that causes obvious thinning. 10k FUE procedures aren't realistic for 99% of patients.

Wwizz, The fibrosis of a 5,000 graft FUT case and a 5,000 graft FUE case would not even be comparable. No matter how large of a strip you take, your fibrosis is still limited to a small line across the back of the scalp. Most surgeons today take skinny, long strips to avoid excessive visible scarring, so your fibrosis is just that: a few mm directly around the line. Doesn't matter if it's 2,000 or 5,000; still just a thin line of scarring with vast amounts of virgin donor above and below. The same cannot be said about FUE. 5,000 graft FUE would essentially be donor death. DIFFUSE fibrotic scarring all over the entire donor region. Diffuse; everywhere; you are not getting healthy grafts out after that. Absolutely no doubt. Exponentially more donor damage compared to a strip of similar size. I haven't personally noticed this change of direction along the linear scar. I've seen one picture of it online, and I don't know who closed that wound or how they closed it. I also wouldn't recommend extracting donor follicles via FUE from right around the strip scar. And yes, there is always damage to tissue and scar formation any time you cut or poke the skin. You form a scar and experience tissue changes from needle pokes and paper cuts. Obviously on a much smaller scale, but these changes occur anytime you cut the skin.

Wizz, Yes, there would be a very, very small amount of fibrosis on the superior and inferior boarder of the strip scar. Imagine it like the FUE example I gave above. If your strip scar is 2 mm thick, maybe you'll have 1.5mm of fibrosis above and 1.5mm of subdermal fibrosis below the scar. The beauty of the donor area post-strip, however, is that all the other skin above and below this is virgin. Untouched and reliable for future procedures.

Notso, Congrats on the procedure! Did your doctor give you a timeline for restarting the lifting and supplements? Clinics generally vary in their recommendations. I've heard everything from: you're good to get right back into lifting after the sutures/staples come out (assuming this was strip), to: don't do certain exercises that flex the head or strain the traps for months. It's difficult to make a general recommendation because of this variation. I always recommend following your clinic's post-operative instructions "to a T." This takes any unwanted variables out of the scar healing process. Heal well, bud!

Athena, Huge change! Thanks for sharing. Hope you guys are all doing well!

HairJo, Thanks for the kind words! Seth, You wouldn't notice this scarring by touching the surface of the skin. It's "sub-dermal," so it is scarring that occurs underneath the skin by definition. Most patients wouldn't realize this was occurring during and post-FUE. However, ANYONE who tries to penetrate the scalp afterwards will notice. It's actually amazing when performing a second FUE case on a patient. You could close your eyes and still tell when you are in a spot of virgin scalp versus post-FUE scalp just by the feel of the punch after you penetrate the epidermis -- this is, of course, with a manual punch. For those who are interested, IE science geeks like me, here is an explanation of how this occurs: ::taken from a post I made earlier:: Dr Feller isn't really referring to the environment of the deep dermis/superficial subcutaneous layer itself or transection of surrounding follicles during FUE extraction. He's talking about the "confluence of scarring" that occurs from making multiple insults to the skin mere millimeters apart from one another. Let me explain (and I'm sure you're already aware of a lot of this): Anytime the skin is injuried, a predictable cycle of wound healing occurs. This starts off with a general and non-specific inflammation, followed by a period of cellular proliferation, maturation, and eventually remodeling into what we consider a scar. What isn't frequently discussed, however, is that there is far more to wound healing that what we see above the skin. The inflammation phase of wound healing, as I said above, is very non-specific. This means that when you make a cut of X length on the surface of the skin, the area of inflammation under the skin is actually much larger - think 2(X), 3(X) etc. This initial period of inflammation creates signals that determine the area of wound healing under the skin. Because it's much larger than the cut/scar we see on the surface, the remodeled, matured scar tissue under the surface is much bigger as well. Take a look at this image: Note how the area of initial inflammation is much bigger than the cut itself. Also note how the scar tissue made from the fibroblasts (fibrosis) ends up cover this entire area. So, as you can see, a small cut on the skin led to a larger area of fibrosis. Now, think of the cut shown in the image as a 1mm FUE punch. As you can probably see, 1mm punch through the skin actually ends up being 2mm, 3mm, etc, of fibrotic scarring under the skin. Now image that you do this 3,000 times with your spacing between the punches being less than your area of inflammation under the skin. What's going to happen? You're going to get a much larger, diffuse sheet of scarring underneath. If this encroaches into the area of other follicles -- which it most certainly will -- extraction becomes much less certain from here on out. Now, I've heard lots of people simply reply to my example with "nope, doesn't happen; the donor area is unchanged after large FUE procedures." To me, this just doesn't make sense. It's pretty basic physiology, and I don't really see the controversy. Now, saying it decreases yield of future procedures or makes future extractions more difficult/variable is more of a theory than the above scientific facts, but it's not a hard conclusion to draw based on the known physiology.

Vox, How can we have an open and intelligent discussion if we refute data and evidence? This isn't good science. I also don't think it's fair to say that a lack of response from practitioners indicates that there are world class results flying under the radar everyday. This would be akin to saying that there are patients fully restoring their hair with lotions, potions, and lasers all over the world daily simply because no one is coming on the forums saying they aren't doing so. See what a slippery slope this can be? This is why it's important to rely on data and facts, and not feeling when it comes to these manners. And laying out some data and facts isn't an attempt to discredit the process. In fact, it's what we need to actually have the intelligent and open discussion you referenced earlier. Objective data is never as fun, interesting, or sexy, but it needs to be put out there.

Hi Cali, I have no doubt Dr Bhatti has honed his technique very well. Despite the skill of the surgeon, however, you'll never see "great" yields from BHT for two reasons: 1) the intrinsic forces FUE extraction puts on grafts, and 2) these forces being applied to FUGs that are much weaker to begin with. You could build a robot to perform the procedure -- and they have -- and still not see yields on par with other extraction techniques. This is simply because even when performed perfectly, this extraction method damages grafts. When this is applied to grafts that are naturally more fragile, like I said above, you'll see yields in the 30%-60% range like those quoted in the textbook. As far as that patient is concerned: it's very, very difficult to tell the exact yield of a procedure just by looking. If I didn't have any prior information, I think somewhere around 2,000 - 2,500 grafts would have been a reasonable estimate. So maybe the rough average wasn't too far off. What's more, he's actually a good example of the type of hypopigmented scarring you see with darker skinned patients. Like you said, however, Dr Bhatti clearly knows where to extract to minimize the visibility of the scarring. BUT, BUT all of this is really just semantics when you consider the following: if patients are in a tight spot and understand the risks thoroughly, BHT can be discussed. I still think it's something that should only be integrated after the traditional donor is exhausted and it shouldn't be put anywhere near the hairline. In the end, I'm very glad Dr Bhatti was able to help this patient and I'm sure he feels the same. That's what is important.

Matt, Thanks for the updates! I tell patients they'll be able to hide it as you described every day, but I think it's hard to believe until you're actually doing it! I'm going to reference your post when trying to hammer this point home in the future. Happy growing! Look forward to more updates. As usual, the good doc's work looks perfect.

Hey Radio, Always good to hear from you. The general consensus seems to be pretty consistent and helpful. I did want to add, however, that I would use scalp grafts in the crown before investigating alternative sources -- IE nape and body hair grafts. Too far off in the future at this point to worry about, however! Enjoy the growth in the front! Haha.

Vox, You mixed up the "6" and the "4" there. Clearly, you are 46, not 64 ; ) Just to keep the thread interesting ... My age range for consultations last week spanned from 19 years of age to 73 years of age! The 73 year old was looking to undergo his first transplant! He also asked if he was too old. The gentleman was blessed with a very solid hairline, a good -- and side effect free -- response to finasteride, and some characteristic thinning in a few areas in the frontal and mid-scalp that could be easily addressed with surgery. He was looking to have the procedure done and then go on vacation to China with his wife! I suppose age is truly just a state of mind!

Cali, Thanks for sharing! You actually inspired me to go to the Unger hair transplantation text to get some exact percentages on body hair transplant success rates. The authors admit that studies investigating BHT are limited, but they do share a few interesting things: -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 I am glad you were able to share some examples. I've talked to Dr Bhatti a number of times over the years, and always found him to be very genuine and dedicated to helping others. Clearly his patients are no exception. Like you said, he absolutely tries to help these people out. In the examples you provided, there are a lot of scalp grafts mixed in with the body grafts. This is clearly the right way to do it. However, it's also going to camouflage the true characteristics and yield of the body hair grafts -- meaning that the results will still generally resemble scalp hairs and the yield will be most dependent on the scalp hair grafts. It would be interesting to see what we would get from a case of pure body hair grafts. You also brought up the "food for thought" comment about patients who would otherwise have no other options without BHT. This absolutely does give them a shot, but allow me to play devil's advocate for a moment: Let's say you have a patient with poor donor and ample body hair supply. You are able to transplant 1,000 grafts from the scalp and 1,000 from the beard, axilla, and legs. Using some ROUGH estimates from the numbers I quoted earlier, let's say you got and average yield of 49%. (mean of 47% for back, 63% for beard, and 38% for leg hair -- which is the highest yield the authors noted for leg hair). You're now seeing slightly less than 500 of these BHT follicles growing. Now, the cosmetic difference 500 grafts would make in the scalp would probably be mediocre at best. Now, this wouldn't be that big of a deal IF it didn't expose the patient to scarring in the extraction zones. If he -- especially if he has darker-toned skin -- experienced decent subdermal fibrotic or superficial hypopigmented scarring in his face, chest, and legs, was the coverage obtained from the 500 graft yield worth it? So, again, this would be playing "devil's advocate" but it's all important discussion when considering BHT in a patient. As usually, Cali, thanks for sharing!

Tav, When Dr Feller said "if you need greater than 1,000 grafts -- now or in the future -- you would be better served going with FUT (strip) procedure" he did not seem to be referring to this patient specifically. I believe the "you" was a generalization based upon his years of surgical expertise. This is a very different thing than telling a patient to start a specific medication. It's more akin to saying "there are medications out there for this issue." I thought you attorneys lived to read through these fine lines! Haha. ; ) PS: I've been following your own personal thread and I'm glad the necrosis post-FUE is resolving. Very glad!

Esp, Initially, I was going to go with "whorl." However, that spot lower down near the superior boarder of the donor region is suspicious. TE could be, could be playing a role here. However, temporary TE does not exclude underlying androgenic alopecia (AGA). In fact, it often unmasks it. If it's true TE, you should see a resolution. If it never seems to improve, it could be underlying AGA and you may want to start looking into your options a bit more closely. Regardless, don't worry about this for now. If it's truly TE, you're fine and it'll come back; if it's AGA, you have to wait a bit to differentiate it from TE either way and there is nothing to do for now. Focus on dominating the bar and worry about this later. It'll all be far less important and manageable after you're a bit shot attorney ; ). Best of luck, buddy! Feel free to ask any additional questions. But I would try to just put it out of your mind for now.

HTsoon, Agreed. Patients will always get more "bang for their buck" with scalp grafts. BHT tends to yield much lower growth rates and retains its native characteristics -- IE: beard hair grows like beards hair in the scalp, chest hair like chest hair, et cetera. It also leaves scarring in the extracted regions, but that's another discussion altogether. I don't advocate for purposeful donor thinning either, but it's generally advised to use up everything you have on the scalp -- safely -- before considering other potential donor sources. It would also likely be better to cover up in the donor region opposed to implanting these grafts into the recipient scalp too (as you said previously).

Needing, I'm wondering if the doctor didn't take out the first scar simply because it was taken quite low and he/she didn't think you'd get much better if it was revised. The area where the first scar is located looks like it is probably prone to higher scalp tension and more scar stretching. I agree with Spanker's assessment. Since you've already had prior FUSS procedures, another strip -- which would include your most recent scar -- surgery focused on really beefing up the density in the previously transplanted areas would likely make the biggest difference. Most probably would not recommend putting body hair grafts in the frontal 1/3rd of the scalp either. Hope this helps! Best of luck. Feel free to ask more questions.

Worried, Big breath in ... and big breath out! Relax. You're okay. The only time you'd truly see a follicle from a dislodged graft is after it popped out and was followed by a small amount of bleeding. This would also generally be within the first 3 days. At 12 days post-op, those grafts are locked down. There really isn't much you could do to hurt the follicles themselves at this point. What you see there is normal crusting and scabbing coming off with the grafts. The small white dots near the end of the hair shaft are normal as well. You'll likely see a lot of shedding in the near future. Most of the grafts will probably look similarly to this. But you're too far out and there was nothing indicating that you actually lost any grafts -- AKA no bleeding. Always try to double check these things with your clinic as well. They may have specific post-operative instructions for situations like this, and you always want to follow these as closely as possible. I really hope this helped! Happy growing.

Quasar, Unfortunately, there is no "cure" to stop the hair from thinning. This is an unfair reality of progressive androgenic alopecia (male pattern hair loss). The closest you can get to stopping the process is, as KO pointed out, finasteride. However, it looks like you're already on this medication. Female pattern hair loss is usually a different animal altogether, so it's very unclear whether this treatment would have any effect on you. I don't think a vitamin deficiency is to blame either. It's simply that the androgenic alopecia process continues onward, and it's very hard -- if not impossible -- to stop once it's really started. Finasteride works in some individuals for a period of time, and there are always side effect issues to consider with this drug as well, but the process almost always continues and the finasteride eventually loses hold. You may be able to continue maintaining somewhat with the preventive medications and determine whether or not you're a candidate for the next option -- hair transplant surgery. Good luck! Feel free to ask any additional questions.

Matt, Tenderpoints and myofascial pain is something covered in medical school. However, London's pain sounds far more consistent with neuropathic pain very likely secondary to the FUE procedure. I highly recommend he discusses this with his surgeon and the physician who prescribed the neuropathic medications.

Hey London, Glad you're pleased with the results! Definitely makes the situation a more positive one all around. I don't think you have any sort of dermatitis either. I posted that pic to show you what true seborhetic dermatitis looked like. If you had this -- at any point -- you'd know it. It sounds most consistent with FUE neuralgia. I think talking to the surgeon and the doctor who prescribed the neuropathic pain medication is a good idea. Best of luck!

Baldy, It could be either an ingrown hair or small inclusion cyst as stated above. Ingrowns occur in the donor region after FUE when grafts are transected or ripped, the top portion is removed, the bottom part of the follicles remains and grows, but it now has to grow against a healing/scarring area above it (where the other portion of the graft was transected or ripped away). I wouldn't try to "pop" it. Many recommend running hot water over a wash cloth, ringing it out, and placing it over the area until it cools. This should help an ingrown rupture and drain naturally without having to pop it -- which just pushes a lot of unnecessary bacteria from your fingers and surrounding skin subdermally.