Dr Blake Bloxham

Recession and Cosmo, Thank you for the kind words. That was absolutely the strategy here: natural, conservative, and a smart use of grafts to achieve a satisfying result in the "long term."

PA, Thank you.

Biceps, I think the advice to seek doctors who perform both FUT and FUE is wise. Sometimes patients are good candidates for one and not the other. And many times patients with "weaker" donors are much better served with FUT. I pretty much perform a large FUT procedure daily and have a pretty good eye for evaluating donors via pictures. If those images were sent to me, I too would be a little be concerned and want to evaluate closely in person before recommending anything. However, FUT might not be the right answer here either. Melvin's advice to see, in-person, a few doctors who perform both is spot on. How much do you need up top? The "right" answer in the end may be conservative FUE and augmenting with something like SMP.

Good topic. I often have patients ask me during consultations if it is "worth it" or if they "should do it." I tell them that I never tell a patient they should do surgery; that is always a decision that must be made by the patient. I often tell people they should not do surgery, but never that it will be "so worth it" for them or that they "should do it." As I said before, this is a personal decision and one that, in the end, you have to make for yourself. You are doing the right thing; have doctors evaluate to determine whether or not you are a good candidate for surgery, and then ask patients about their experience and how they dealt with the decision to "take the plunge." What I will say is that at the end of the surgical day, most of these patients who had doubts like this are typically very happy and feel relieved. It feels good to make a proactive decision and do something to better yourself or address something bothering you. And thankfully, modern hair transplant work pretty darn well! Best of luck with your decision. Looks like you are getting some great feedback from members here.

Today I wanted to present what is likely our most common and most "classic" case: the 2,500 graft -- or 2,600 graft in this instance -- FUT case. While we see patients with all types of hair loss, it seems like the most common are males with advanced -- or advancing -- hair loss, and we typically say they will likely want to do two procedures over time: a 2,500-ish graft FUT mega-session now for the hairline, frontal scalp and transition into the mid-scalp; and another 2,500-ish graft FUT mega-session later to finish the mid-scalp and address the crown. Doing two large FUTs tends to, in my opinion, provide good coverage from "front to back" and leave patients in the best situation for the long-term. They should have a good incision line scar and plenty of grafts left for more potential work (done via FUT or FUE) if needed. So here is one of those "classic cases:" Male physician in his late 20's headed to a NW V-VI pattern; we recommended two planned FUT procedures of approximately 2,500 grafts a piece; he did the first (hairline, frontal scalp, and mid-scalp transition) in winter of 2017, and the second (finished the mid-scalp and crown) in winter of 2018. Here are a few comparison pictures of his 10 month results from the first procedure. As usual, I highly encourage all to watch the video. Video is the ULTIMATE way to present a hair transplant result. This video includes the result, detailed comb-through (HD), and footage of the incision line (FUT scar). Photos: Video: Thank you for reading and commenting. Dr. Blake Bloxham Feller & Bloxham Medical, PC (www.fellermedical.com)

PA, There are almost always things that can be done to improve the incision line scar. Typically the best approach is a combination of FUE and SMP. Some doctors like using beard grafts, but I've found that the largest multi-haired follicular units (sometimes trimmed a little less than normal) work best. It is important to remember that FUE growth is more variable from the get-go, and growth of any kind into de-vascularized, altered tissue like scar is variable as well. So sometimes FUE into scar works well and other times it simply does not. I tell all my patients this, and I have absolutely had instances where it really does not work as well as we want or we need a few "passes" to make it work. I find that SMP is an excellent approach, regardless of whether or not you are adding FUE. Check out Erik at AheadInk for some good examples. Most people benefit from a combination of both, and using both typically results in a pretty darn good improvement in the incision line. Since you were asking for examples of FUE into scar, I'll post my personal favorite here: this is a guy who had multiple surgeries where the doctor took different strips each time and poor results. He then started to come to us and achieved great results in the front, but the back was always a challenge because of the previous surgeries. However, he was always more interested in growth in the front -- as he wore his hair long in the back -- so he asked us to always be as aggressive as we could with the harvests and not worry that the back was a bit of a bit of a jungle. So, after all was said and done, he decided that he wanted to do some FUE into several of the scars in the back. The worst was a scar was a patch on the right where a few scars sort of came together and the vascular supply was pretty decreased around the area. I did a fairly dense pace with multi-haired follicular units into the scar, and here is how it looked 9 months later: Excellent growth for the tissue we were working in, and a great cosmetic improvement all around. I think the important take away from the "FUE into FUT scar" discussion is: there are always options to minimize and improve the scar if you want to go shorter, but, believe it or not, most FUT patients don't feel the need to do anything after. Most don't focus on the scar at all, and most are left with neat, discrete lines that are perfectly covered back there. But it is reassuring to know that the scar can always be further concealed down the road if you want to. So it is great to have this option for those who want the best growth and best usage of the donor AND the ability to go a little shorter down the road. Dr Bloxham

Rope, I have seen many "good responders" to finasteride continue to enjoy the benefits at doses as low as 0.5mg daily and even 0.25mg daily. It does not mean your body will respond the same way, but it is not uncommon to be on a lower than recommended daily dose. However, you should ask the doctor who prescribed the medication and follow his/her advice to the letter. Hope this helps.

Elduterino and Mr S, Thank you for viewing and commenting.

Hairtargeter, No, touching the grafts in this manner at 8 days post-op will not harm anything. The grafts are very secure by day 4 and a permanent part of your body by day 10. The only thing to take into consideration with "touching" at this point is excessive touching or scratching, which may lead to a superficial infection or prolonged inflammation.

Kramer, The "rule of thumb" is that it takes approximately 1,000 grafts to densely lower a hairline by 1 cm. Looking at your design here (including what includes to be some slight corner work) and hair characteristics, I would estimate around 1,200 - 1,400 grafts.

Dev, While it is unfortunate you had to stop the preventive medication, I do not think you are in bad shape here. The approach you took with the hair transplant was perfect for someone in your situation: FUT mega-session with a conservative hairline. You -- and the clinic -- put yourself in the absolute best position for the "long term," and this is regardless of whether or not you are on preventive medication. You are set to continue with surgical restoration if you do lose more hair, and this is probably what you will need to do. Not a bad position to be in at all. Just continue with FUT until you cannot do any more, and then switch to FUE if you need or want more work (including putting some grafts into the scar). I frequently work on patients who cannot or simply will not utilize preventive medications, and the goal with these patients is to start with the approach you took here and move forward as I outlined above. So while more surgery may be in your future, I think you are probably in pretty good shape here. And, by the way, the work looks great as well. I hope this helps. Dr. Blake Bloxham Feller & Bloxham Medical, NY

Friar, Are you noticing thinning in any other regions of the scalp -- particularly the hairline and "corners" of the hairline? What is your family history of hair loss like? Dad's hair? Any brothers? If so, what does their hair look like?

All individuals experience hair loss differently. We frequently see patients with small changes or confined areas of thinning who almost feel guilty coming in to see a hair transplant doctor because their friends, partners, and family continually tell them that the hair loss is "nothing" and they should just "forget about it and move on." However, it is a big deal to these patients and the psychological stress and distraction from the hair loss often prevents them from focusing on bigger, better things. The patient in today's presentation falls into this category; he is a male who, most outsiders would probably agree, had quite "good hair" in general. I do not think the average person on the street would ever think he was thinning. However, he came from a long family of males with "perfect" hair, and, although his hair was still "good," his hair was simply not as "good" as it used to be. He had some pretty classic thinning throughout the entire frontal band, and really just wanted to thicken it. Long story short: despite the minimal amount of hair loss he had, this was bothering him and he was ready to take care of it. I discussed the reality of the situation with him thoroughly and I did believe he could "beef up" that area, and I also felt confident that it was unlikely (though not certain) he would progress to advanced hair loss. Regardless, we decided to start him off as an FUT to hedge our bets and leave his donor in good shape in case he did need a significant amount in the future. We ended up utilizing 2,100 grafts to place his hairline back where it originally was (frontal hairline only, no temporal hairline work needed) and densely pack the frontal band. He visited us 6 months later, and I was very pleased to see that the worry and distraction his hair loss caused him had vanished. Here are a few "comparison" shots of his case. Below is a detailed comb-through video which includes footage of his incision line. I highly recommend all interested patients watch the video. Remember, hair loss is about identity; if you feel off, distracted, or stressed by any changes in the scalp, it is okay to see a hair restoration doctor and discuss your options. There is nothing wrong with taking care of this, despite how some may make you feel. Thanks for reading and watching. Dr. Blake Bloxham Feller & Bloxham Medical, PC

Bonkling, It is definitely a good idea to have the donor evaluated locally. It will be useful information to use on future consultations, and it is always good to get multiple opinions.

Dr. Pathomvanich, Beautiful work! Thank you for sharing.

Thanks, Melvin. Yes, I get asked questions about my hair all the time. I have been lucky genetically, and there really just is not much hair loss in my family. I have 3 younger brothers and all of them AND my father basically have mops; perfect density but all with wavy, thick, coarse hairs (opposed to my much finer hair) which looks great. My dad now has a little bit of bilateral temporal recession, but very slight and hard to even appreciate with his hair type. The only real hair loss in my family was my paternal grandfather who had very unique isolated crown hair loss -- perfect hair in the front. Now, that isn't to say I don't have other genetic things in my family I would like to avoid (heart issues, dementia, etc), but I have been lucky on the hair front. However, I would absolutely have a hair transplant if I needed one. And not just because I am in the field; I would get one because they work and work well. I presume I would lose in the front, so I would do a dense pack frontal band via FUT aimed at pretty much keeping my hairline where it is now and allowing for some temporal recession.

Good post thus far. I think this is an important topic, albeit one that many do not want to discuss. I don't think anyone wants to go into any medical procedure thinking it may not "work" as expected, but this is even more true for an elective and cosmetic procedure. Although it is elective, it is important to remember that it is still surgery; there will always be variables and human physiology is unpredictable. Thankfully, hair transplant surgery is an EXCELLENT procedure. When you compare it to the entire gamut of cosmetic surgery, it is probably the most consistent, effective, and natural when performed by an experienced team using modern techniques (IE: true follicular unit grafting, appropriate dense packing, small tools and proven placement protocols, et cetera). However, it still can "fail" or not work as well as we would hope. And I think it is important for all patients to understand and truly accept this before "taking the plunge." There is always an aspect of "risk" in life, and the results of an elective procedure are no different. A lot of very good reasons for sub-par growth are listed above. A few important ones that come to mind: -Inappropriate graft handling This includes the grafts being physically mishandled during removal, preparation, and placing, and grafts sitting out for too long. This is typically avoided by using a clinic that has highly trained in-house technicians who have performed a LOT of surgeries together. -The wrong procedure for the wrong patient I do not want to turn this into an "X vs Y procedure" situation, but some patients are simply not as well suited for FUE. Certain follicles are just more fragile and less resilient than others, and they will not do as well with the FUE process. - Inappropriate surgical technique or too much delegation Making recipient sites using too large of tools or putting them too close together in certain patients (inappropriate dense packing) can overwhelm blood supply and result in poor or no growth; making recipient sites too small or not trimming grafts properly and trying to place "chunky" grafts into small slits can do the same. Handing important aspect of surgery off where they should not be handed off can play a role as well. -Physiology This one is likely the "hardest pill to swallow," but some people simply grow better or worse compared to the average. The good news is that touch-ups typically take care of this.

Love the graft placing footage. Great result too.

Great case. I like the discussion in the video as well. Good stuff all around. Thanks for sharing.

I have performed surgery on many patients with controlled (no insulin) type-II diabetes and hypertension. I typically like to speak with the patient's physician before officially scheduling the procedure, ensure they are taking all medications as instructed, I use a little less of any medication which can raise blood pressures (and monitor pressure throughout the day), and really pay attention to how the skin is responding to the density at which we are transplanting; by doing all this, it always seems to work well. I do not believe this would preclude you from FUT or FUE surgery. As Dr. Charles said, have the doctor evaluate to determine that you are a good candidate for FUE in general. Best of luck.

The average width of a strip is probably around 1.0 - 1.5cm (so 10-15mm). Sometimes you can and do go wider; other times it is more advantageous to go more narrow; and there are certain areas of the scalp where you always want to "taper" it down a little regardless of how wide you are going on the strip in general. Scar healing is typically good, but much of it is affected by your own physiology. Some people are simply prone to healing a little wider than others. I would say the average FUT scar is 1.5 - 2mm. Many times we get the perfect "razor blade" line or "pencil thin" scar; other times you get more of like a "marker line" (2mm or so) in patients who are just prone to a little more "stretch." I tell my patients that anything within this range is considered normal healing and can be concealed all the way down to a #3 on the buzzer -- which is around 1/4th of an inch or 6mm.

I find that temporary shock loss in the donor -- with both FUT and FUE -- is very common. Thankfully, it is almost universally temporary. Sometimes it can "linger" a bit and make patients nervous, but everything should grow back. Permanent shock loss in the recipient zone should be pretty much avoidable. If you do not work in hair that is inappropriately thick, use small tools, use high magnification, and pump the tissue up with a little saline, then you should significantly decrease your chances of experiencing shock loss. Remember it is surgery and anything can happen, but it is typically avoidable. I also believe trimming the hair helps, but I know others do feel differently.

FB, How many grafts were transplanted and where? Do you have any "before" pictures and/or immediate post-operative pictures showing where the grafts were placed?

Hi UpShall, Here is a topic I created on how hair transplants "grow," "pop," and "mature." These three elements make up the cosmetic "results" of a hair transplant. Hope you find it helpful:

Augusta, You're welcome. Thank you for sharing the detailed video of your donor. You have absolutely been "hit;" no question about that. The donor is thinner than it should be. However, I still think you can get 200 grafts out of it. Go to someone who will use a manual (non-motorized) punch, go very slow, and promise you that they will stop the case and not cause more donor thinning if the grafts are not coming out (opposed to doing 400 - 500 attempts just to get out the 200 grafts). If they stop, then at least you tried; but do not let anyone go aggressive back there. Like a few others stated, I would highly discourage you from doing BHT in the hairline. As unhappy as you may be with a higher and slightly thinner hairline (it still looks great, by the way), I can all but guarantee you will be more upset with an unnatural looking appearance in the front that draws attention. Just as a point of reference, I want to share a very abused donor I was still able to get around 300 grafts out of via FUE. His donor had been essentially destroyed (by a well-known clinic only performing FUE), but I was able to very carefully (took me basically a full surgical day) go around to unused or less "hit" areas (the sides) and safely remove about 300 grafts. So if he can get a few hundred, I think you can get a few hundred.