Dr Blake Bloxham

Hi Plz, Thank you for the kind words. He is very pleased with the results and I think the approach worked well and will continue to serve him well for many years to come. The second video was taken at 12 months, and I would say he is pretty well grown. In fact, he was a bit of an early grower. Probably almost everything has "popped" and he will likely only see small changes from here up through the 18th month mark (I think hair transplants really do continue to thicken up and mature through 18 months).

Hi Lenney, Thank you for the kind words. I think you are referring to the area in the frontal hairline I started behind? I like doing this when possible. The patient has a standalone transplanted hairline built behind it. So if and when he does lose it, he will not have a hole or anything like that. It will just look like the center part of his hairline is a little higher and in line with the rest. And you can see it is miniaturizing and will likely thin completely -- leaving him with the scenario I described above. In the meantime, however, we can use it to his advantage as it adds extra irregularity to the hairline and takes advantage of those very fine singles which are often even softer than those we select for the frontal line during a transplant. It adds an extra degree of naturalness to the result. You could use this tuft as the starting height for the hairline. However, I think it may have been a little low for his specific case. In other patients, no problem; for him, however, we want to err on the side of caution and start high with the hairline. Once everything is settled, we could always do some more frontal work and bring this down to that level. But remember: you can always go a little lower with a higher hairline later, but it is very, very difficult to raise a hairline started too low -- not to mention the number of grafts used to create it that low which are much better spent elsewhere and may not survive the "raising" and redistributing process.

One of the more debated topics on the forum is whether or not "young" patients should undergo hair transplant surgery. The controversy revolves around the fact that these patients are very early in the hair loss process and have an unpredictable future ahead. Using too many grafts now or starting with an "aggressive" plan may set a patient up for a lifetime of multiple surgeries or deplete donor resources before acceptable coverage can be achieved. There is also controversy surrounding the donor area in young patients: Will it thin aggressively and end up only providing a small "strip" of safe donor in the future? Are grafts taken from the "expanded" donor area in a young patient actually safe or will these thin in the future? For these, and other, reasons, many hair transplant doctors do not like to perform hair transplants on "young" patients. While cutoffs vary, many do not like to take patients under the age of 25 and others want to wait until their hair loss pattern has really revealed itself -- which can often take decades. My philosophy on young patients is a little different. I frequently perform hair transplantation on appropriate "young" patients as long as a few absolute "musts" are understood and accepted by the patient. If the patient is mature thinking and accepts the "long term" reality of hair transplantation at a young age and the potential for future surgeries up the road, I feel like they do quite well. In order to successfully undergo hair transplantation at a young age, I feel a patient must acknowledge and really feel comfortable accepting the following: 1) We must start conservative with the hairline. Many young patients remember a very low, flat, immature hairline from only a few years prior. And sometimes it is hard to get them to understand that this is not advisable. If a young patient insists on rebuilding an immature hairline, I do not think they should have a hair transplant. However, if the patient understands that hair transplants are permanent and the hairline must "age well;" if they understand that starting conservative now will allow us to get coverage from front to back as they continue to thin and we can go lower later once things cool off and the majority of the scalp has been treated with hair transplants; and if they understand that the lower we go now, the more grafts we use in the front that we now cannot use in other areas, then I think they are good candidates. 2) We must start with FUT Not to stoke the flames here at all, but I insist on starting all young patients as FUT. Not only is this the only way to truly maximize the amount of donor grafts available over a lifetime, but it is also the only way to really take continuously from the small true safe donor area (SDA) zone. We never know how these patients may thin up the road, and grafts taken from even slightly outside the safest part of the donor area may be susceptible to hair loss and fall out in the future. We need to maximize donor potential and only work where we absolutely know it is safe until these patients are older. Then we can usually augment with FUE. 3) The patient must accept that he will very likely want/require more procedures up the road Androgenic alopecia is a progressive process and while hair transplants do thicken and restore thinned areas, the procedure does not treat the progressive hair loss. Patients who are thin enough to seek hair transplantation at a young age will likely continue to thin in the future. With a hair transplant plan "started" in one area, the patient will likely want more. We never design anything that would absolutely require a patient to have more surgery up the road, but chances are that you will want to address additional thinning regions at a later date. The patient needs to accept that this is likely not a "one and done" deal. 4) We really should (maybe not "must") start in the front and work back The frontal third (hairline, frontal scalp, and slight transition into the mid-scalp) is the most visible region of the scalp. It also is responsible for re-framing the face and really creating the appearance of thick, full hair from the perspective of how most of the world sees you (IE "front on" or from the sides). Furthermore, if this region is done properly the rest of the scalp can thin and still look natural. For these reasons, we really should address this area first in young guys. Many times younger patients are focused on the "bald spot" in the back, but starting in the front and working back if and when necessary creates the greatest cosmetic impact and prevents creating anything that may look unnatural up the road. To better demonstrate this philosophy, I want to share a case: The patient in this video is a young guy in his early 20's; he's in that transition between college and the rest of his life. He has aggressive thinning for his age and is likely to become a NW VI up the road. I discussed all of the above with him and he completely agreed and wanted to move forward. We did a 3,000 graft FUT and everything went very well. I saw him back at 6 and 12 months. The first video features an explanation of how I approach young patients (similar to what I wrote above) and a detailed 6 month result video. The second video is an update at 12 months. 6 month results: 12 month results: As a final note: I do think all young patients considering hair transplant should do their research carefully. If you do it as out outlined above, I think you will be happy for many years to come; however, there are some potential "pitfalls" for younger patients. So do your research, ask your questions, and remember to start conservative and keep the long-term in mind. Hope everyone enjoyed the presentation. Look forward to the discussion. Dr. Blake Bloxham Feller & Bloxham Medical, PC

Always a good topic. Very good replies as well. As a few of the other doctors have pointed out, we are dealing with an influx of repair cases right now from "cheap" clinics. The ISHRS, as Dr. Barghouthi alluded to, has labeled this phenomenon the hair transplant "black market;" this label usually applies to a new, start-up, tech-run, FUE-only clinic. They pull out all the stops when it comes to luring patients in and then leave them out in the cold if and when things go wrong. Now, I think it is important not to stereotype or imply that paying a lot of money for a procedure automatically equates to a good result; however, I think almost any established clinic today can share at least a few sad stories of patients they have met who have been forever impacted by this new model. It is hurting patients and it gives the entire field a black eye. Something else patients MUST remember too -- and I do not think I saw it mentioned here previously: remember that the donor area is a very finite resource. You are only gifted with a certain number of scalp grafts in the donor area and once they are gone, you're done. One big FUE pass from a tech clinic and you can wipe out the entire donor. I have seen it with my own two eyes multiple times. And let me tell you, it is awful having to tell these patients who are there for repair that there is nothing you can do aside from removing grafts and referring to a good SMP practice (shout out to Erik at Ahead Ink!) because the "bank" is empty.

Augusta, I pretty much agree with Dr. Barghouthi; I would estimate around 200 grafts total for that little area. This may seem a little high, but keep in mind that you are lowering the hairline there so it must be dense. You may also need some multis behind the tight packed singles to make sure the corner is nice and dense -- as you appear to comb from left to right. I would advise you not to use body hair grafts in that area. This will arguably be the most visible region on your entire scalp (with the left to right comb) and you want nothing but the highest quality scalp grafts there. Like Dr. Barghouthi said, please share some donor pictures if possible. I would be shocked if you could not steal out 200 or so more from your donor. I have taken 200 - 300 many times from donors patients believe were "tapped."

Also ... Please do not rush into getting a procedure. I understand the urgency to get it done; trust me, I do. However, it is far better in the "long term" to take your time now and make the best decision possible opposed to rushing into a procedure and being dissatisfied or spending more time and money (and irreplaceable donor follicles) to fix or augment things up the road. It is a common tale we see and something that you should do your best to avoid.

Hi Wendell, Thank you for sharing. I thought this is what your donor may look like. Very classic for that type of hair we see in certain patients from the Dominican. These patients tend to have thick, coarse, hairs which typically equate to very large follicles. This usually means a decreased donor density because the large follicles take up more space and tend to be spread further apart. You appear to have advanced hair loss and a lower than average donor density due to the large, spread apart follicles. Now, the good news is that this type of follicle tends to give EXCELLENT coverage; the not as good news is that you are limited in the number of grafts you have available and scarring may be more difficult to conceal. If you came into my clinic for a consultation with this presentation, I would recommend two planned FUT procedures: the first to re-establish the hairline, densely pack the frontal scalp, and strategically work into the mid-scalp; the second would address the remainder of the mid-scalp and strategically address the crown. I see why FUE would be an appealing option with your donor area. While I think scarring from a 1,600 graft case would be reasonable if it were spread out properly, you will have noticeable "dot" scarring (especially with your nice tan skin tone) if you keep it very short, and I also think you are greatly reducing the number of lifetime grafts available if you start with FUE. Your hair type also tends to be a tricky one with the FUE approach. I believe you would likely have a fairly unpredictable curve to the follicle under the skin, and this can be challenging to get around. Doesn't meant that it cannot be done -- and some even have tools aimed specifically at addressing this issue; but it will make FUE even more challenging and the grafts will likely be a little more traumatized. As far as the estimate of 1,500 grafts to the crown: Keep in mind that I have not evaluated you in-person so I defer to whomever has; however, I have a sneaking suspicion that this amount may not achieve your goals in the crown. My guess is that to do the crown to the level at which you would like it filled, you are probably looking at closer to 2,000 grafts minimum, but likely closer to 2,500. I would also think about addressing the front first -- as it appears this region is thinning and will likely reach the level of the crown. I hope this helps. Dr Bloxham

Wendell, Can you share a picture of the donor area on the sides and back of the scalp? This should be evaluated first.

Great answers. One thing I would add: when you visit a clinic for consultation, make sure they can show you examples of different types of hairlines. Hairlines are not a "one size fits all" type of thing. Just because a hairline looks amazing for one patient, does not mean it would look right for you. Hairlines must be customized for each patient. Things like: hair type, facial structure, forehead shape, level of hair loss, and overall goals must be taken into account.

I find that patients are always understandably nervous as to how friends and family will react. However, I cannot think of one instance where they were not very supportive and typically fascinated by the process. Good friends and family just want you to be happy; once they understand that it is a good solution and it will help you, they are generally very supportive of a hair transplant. In fact, we often later see those very friends and family members for consults and surgeries once they see how it transformed their own loved ones.

MrNuit, Are you combing or manipulating the hair vigorously while it is still wet? Hair strands break a little easier when they are wet. You will notice more hair on the comb if you run it through wet hair compared to dry hair. This is not hairs "falling out" or shedding, but the hair shafts themselves snapping off or breaking mid-shaft.

PA, Kiwi, and Det, Thank you for the kind words. Glad you enjoyed the presentation.

Thank you for the kind words. Great post. This is exactly what I recommend for my patients who I believe will be in this for the "long run." It is nice to know you always have FUE in your back pocket once you are "stripped out."

It may be unsurprising to many long-time readers of the forum, but one of the most popular topics right now seems to revolve around FUT versus FUE. However, this topic is not an "FUE vs. FUT" debate, but is a very good question revolving around which technique a patient should start with and the best way to utilize both. Specifically, in patients looking to maximize donor potential and future surgeries, which technique should be used first: FUT or FUE? As many may know, I am an advocate of clinics who can offer and regularly perform both, and I typically advise patients who have uncertain or advanced levels of hair loss and may want multiple procedures to start with FUT. Because I am a "fan" of this approach, I wanted to share a presentation of a patient who went this route. The patient first presented to the clinic with classic frontal hair loss several years ago. He wanted to "test the waters" a bit with hair transplantation, so I did a very conservative frontal band procedure via FUT. He did very well and after seeing that hair transplant surgery really works, he decided to "dive in" and undergo a more aggressive hairline lowering and dense pack frontal band procedure. I did this via FUT as well. After two strip surgeries he was fairly confident with the scalp in general except for a small spot in the crown -- which had been static for years -- that he wanted to address. This procedure only required 500 - 800 grafts and he decided that since the bulk of the work was done via FUT and he was happy with the incision line (which was still very good after two harvests), he wanted to now switch to FUE. Because we started with FUT, I was happy to do a conservative pass via FUE and address the crown. Here are a few "before and after" comparisons after the two strip procedures: And here is a very thorough walk-through video I encourage all those wondering which technique they should start with to watch. Not only does the video include comb-through of the results, it also features a discussion about the approach, video of his incision line after FUT #1 and FUT #2, video of me performing the FUE procedure, and a post-op of the FUE crown surgery. Also, as a little "bonus" here: I have included video from his 6 month visit, just in case any members need reassurance that results do change from the 6 to 12 month mark: Thank you for watching. I hope this sparks some good discussion and I look forward to the conversation. Dr. Blake Bloxham Feller & Bloxham Medical, PC

Hi SprayPaint, All clinics have slightly different recommendations. It is important to follow your specific clinic's post-operative instructions as closely as possible. In my office, I recommend that patients be "careful" in the sun for the first 3-6 months (usually putting more emphasis on 6). Now, this does not mean you need to avoid the sun; we have many patients return to sunny Florida or make a "recovery" trip to the Caribbean right after surgery; but what it does mean is that you need to avoid a sunburn or excessive sun exposure to the scalp. 15 minutes walking to your car is not going to hurt anything, but six hours laying in the sun on the beach could. A good rule of thumb to use is: if you are putting sunblock on and have a concern about burning the rest of your skin, it is probably a good idea to protect the scalp -- if you are less than 6 months out from surgery. Just bring a hat with you; if you are in the sun and you feel things heating up, put it on; if you go under an umbrella or go inside the beach bar, you are free to take it off. No need to avoid getting a transplant around Summertime just because of this. Just be a little more aware and cautious and you will do fine. I have heard varying explanations as to why this occurs. Some seem to believe it has to do with adaptation based upon where the donor follicles come from; some believe it has to do with the melanocyte cells that surround the base of the transplanted follicles; others seem to think it has more to do with follicle stem cells being closer to the surface in the first few months after a transplant before things really mature; regardless, it is probably a good idea to just be a little careful and protect your investment. Hope this helps. Dr Bloxham

Good replies from Melvin and Sean. Yes, you can remove grafts via FUT after having an FUE. The issue is not so much getting the grafts out of the strip. As Sean stated, it can make dissecting more difficult but a trained FUT staff should have no problem with this; the issue with doing FUT after FUE is simply that you will get a lot fewer grafts out of the strip. Let's say you have a virgin density of 80 graft/cm^2 in the donor region. If I take a strip of 30cm x 1 cm, I will obtain approximately 2,400 grafts (remember that this is just a simple example and not precisely reflective of nature). Now let's stay you had an FUE first and a responsible doctor took around 25% of the grafts throughout the area which will be strip harvested later on. This means your density now dropped from 80 grafts/cm^2 to 60 grafts/cm^2 -- because in FUE you have a drop in grafts without a change in surface area; and keep in mind that this would be a responsible harvest. So if we now took a 30cm x 1cm strip after the FUE harvest, you would only yield 1,800 grafts with the same incision line scar (IE damage in the donor). The other issue would be if the first doctor was not responsible with the FUE harvest. When this happens, the yield from the strip becomes very low and there may be issues with covering the incision line because the donor has been significantly over-harvested. The beauty of strip is that you remove both grafts and surface area in one attempt, so you do not reduce the global density of the donor. This is what allows you to do multiple strip procedures with a minimal amount of scarring and then still do good FUE harvesting from all around the incision line (assuming you are not going to be an extremely high NW patient). It is typically best to do it this way -- FUT and then FUE -- if you are looking to do a combination of both. You absolutely can start with FUE, but just make sure you are not harvesting too aggressively and reducing the benefits of a potential strip up the road. Hope this helps. Best of luck with your decision. Dr Bloxham

Do you mean by day 6-7? In my mind and per my post-operative instructions, no. I let people start scrubbing at day 4 (only pouring with water and shampoo for the first 3 days). Although it probably could use another update because the study looked at slightly larger grafts than what we use today, the best data says grafts are essentially permanent by day 10. Before they become permanent, however, they anchor pretty darn well. It would be hard to dislodge a graft after day 4 or so, but they are technically not a permanent part of your body like the rest of the follicles until day 10. I bring this up because some clinics rely on this more than others and pretty much don't want much washing until closer to this mark. If this is what they recommend, then I suggest following their specific instructions closely. If you were my patient, I would tell you there is really nothing you could do while washing to dislodge a graft after day 4. And I would not worry if you did not see a very specific flow of blood from that area -- a little speck of blood here or there while cleaning is not uncommon.

My pleasure. Glad it was helpful. Hair shafts often have what appears to be a white "bulb" on them when they fall out. It is really just indicative of the shape of the most inner layer of the hair follicle itself. Typically any hair that naturally sheds is in a release or a resting phase, so the entire hair shaft is released and it would be common to see the little "bulb" on the bottom -- opposed to a broken or pulled hair which may snap in half and you would not see the bottom of the hair shaft itself. Glad you are able to see the dermatologist.

The dreaded "cracking." I think I receive at least one email per week from an understandably nervous post-op patient. Rest assured that this is expected. You did not lose an entire row of grafts, nor did you some how dislodge a perfect row or "chunk" of grafts. I have heard differing explanation as to why doctors think this occurs. I believe these cracks occur because the skin contracts as it heals. When you have thousands of small wounds covering tissue that has been stretched and swollen, you will get contractions that will appear like little rivers, canyons, cracks, or roads in the grafted area -- I have heard it described using all these different illustrative analogies. It happens even more frequently when dense packing is utilized. It can also appear more dramatic when you are scabbed up and a larger region of superficial scabbing (with or without some hairs attached) falls out. Rest assured, however, that even if you see these "cracks" or missing "chunks" above the surface, the grafts are safely anchored below the skin. They may be temporarily displaced from where they will eventually settle, but they are secure. Many people also assume that areas were missed during the transplant itself, and this is typically not the case. Just part of the healing process. Graft dislodging is a pretty specific event that happens within the first 3 days (when true follicular units are used). If you did not see an active bleed accompanied by an event within the first few days post-op, it is very unlikely that you lost a graft. And this to me just appears like the classic contraction from healing. Of course you should always keep your doctor in the loop and run this by him/her as well. Hope this helps. Dr. Blake Bloxham Feller & Bloxham Medical, PC | Great Neck, NY

Bonkling, Seasonal shedding is a real thing. I have seen it many times in transplanted and non-transplanted patients. I previously thought it mostly occurred during the "cold" months, but I have seen a number of people experience it when the weather changes from colder to warmer as well. It typically lasts about the same time as a normal hair follicle telogen resting cycle -- which is 3-4 months, and should really look improved by around 5-6 months when the regrowing hairs have some length. I would still have a doctor take a look in-person if you get the chance. It could be some progression or it could be due to something else the doctor picks up on during your visit. Hope this helps.

Good replies. While scarring from both methods -- FUT and FUE -- can be very subtle and hard to pick up even with a short haircut, you should not go into any scalp surgery with the mentality that you can completely "shave" it off if you are not happy. Of course this does not mean you can't possible go short in the future or camouflage the scarring further with things like SMP or grafting into the scars (as Cosmo noted), but remember that any cutting in the back (be it with a scalpel or a punch) will create a scar which will be noticeable to some degree if you shave down low enough. I hate to harp on this, but we are seeing a big influx of patients who underwent hair transplantation at clinics where they were told the procedure was "scarless" and they could simply shave their head if they did not like the results. The patients then did try to shave their head, saw the scarring, and were upset. So it is good to see this topic being discussed openly and honestly.

These are definitely some important things for all patients to know before surgery. Some other frequent ones that come up during consultations: 1) You will have some level of scarring regardless of how the procedure is performed. No hair transplant is "scarless" and you are unfortunately being set up for some level of disappointment if you are sold on this bill of goods. 2) Follicles do not regenerate. Anything that is taken from the back is permanently displaced from one area to another and will not "regrow" in the donor. While on the subject of donor: remember that, in line with the above, the donor area is finite. You only have so much available and -- as Melvin correctly stated here -- hair loss is progressive and you may want more up the road. Use it wisely. And also remember that you can only use your own follicles. I think one of the most frequent questions I am asked during an initial consultation is whether or not we can take hair from other people. Unfortunately, at this time, we can only use follicles from your own body. 3) Hair transplant surgery is done under local anesthesia ("numbing medication"). So while you really will not feel anything during the surgery itself, we do not put you "out" for a hair transplant. 4) Remember that hair transplants are designed to be permanent. Any hair that we move is going to stay there forever. The transplanted hairline we build at 25 still needs to look natural at 55, 75, and 95, so always try to keep the "long term" in mind and maybe lean a little more towards the conservative (remember you can always go a little lower later, but it is difficult to reverse things and go "higher" if a previously low, flat hairline begins to look unnatural as you age). 5) To end on a lighter note: remember that modern hair transplant surgery when done properly is an extremely effective procedure. These are not the "plugs" of yesteryear. Results via follicular unit grafting with high density "packing" (when appropriate) can be extremely impressive, so hair transplantation may be a good treatment (or adjunct treatment) for your hair loss.

Det, Do you know the cause of the arthritis? Is it more of a "wear and tear" osteo-arthritis from usage or do you have an immune-related rheumatoid-type arthritis? Frankly, I do not believe either would really affect the growth of a transplant. The only theoretical caveats in my mind would be: 1) If you have either, you likely take medications which may thin out your blood and the doctor (HT) will likely want you to stop these for a little while around surgery. This is something the rheumatologist will need to sign off on. 2) If it is an immune-mediated type of arthritis like rheumatoid arthritis, there is a chance you may be prone to other autoimmune conditions. Some of these can affect hair follicles and they can sometimes be "set off" by the stress of a surgery. Now, this is a very slim and likely only theoretical scenario; however, it is probably worth discussing if you do have a history of autoimmune conditions. Hope this helps. Look forward to your reply. Dr Bloxham

Thank you for sharing. Based on your age and the fact that it sounds like it is progressing (as it almost always does), I would likely advise one of my potential patients in this situation to start with FUT. It is not clear what will happen up the road and you will have more lifetime grafts and more certain surgeries in the future if you keep the donor in good shape with FUT. Hope this helps.

Plz, To be honest, family history and androgenic alopecia is a mixed bag. Genetic male pattern hair loss is poly-genetic with variable penetrance, which is a fancy way of saying that it can come from pretty much anywhere in the family and can "express" itself in all types of different ways. Just because your mother's father was a NW VI does not mean you are destined to experience aggressive hair loss. In the same sense, if every single male member of your family was a NW VI by age 32 and you have signs of aggressive loss in your late 20's (thinning in front of and above the ear, "sides" of the donor dropping, diffuse hair loss throughout the entire scalp, etc.) then it is more likely than not that you will go this route. There are also certain strong familiar hair loss traits -- such as a persistent frontal forelock -- that I like to explore because it helps with surgical planning. But I think it is best to just get a general dense of what the family history of hair loss is like and keep it in mind while developing our long-term plan. I really don't rely on it too heavily and I always try to put the patient in the best situation "up the road" regardless of how I believe they may or may not progress. Hope this helps.