Dr Blake Bloxham

15 hours ago, BeHappy said:

Welcome back to the forums, Blake. We were wondering what happened to you guys. Excellent results. I'm more impressed with the (lack of) scar line. I can't even see it. people who insist on FUE because they don't want a scar should look at this result.

 

Thank you for the kind words. 

I absolutely think this patient was best suited by the FUT approach, and pleased that he healed with a very good incision line in the back. As you noted, he did not alter his hair style on the sides post FUT and could actually go shorter if he wanted to. Our typical scar is anything between a "razor blade" line if you are a perfect healer to a little bit of a "marker" line (1-2mm) if you are naturally somewhat of a "stretcher," and anything within this realm is very good and can be easily concealed even with shorter, cropped hair (usually a #3 on the buzzer). When possible, I try to include scar comb-throughs for all FUT patients, just to let potentially patients know what to expect. 

Hi Upshall, 

Thank you for the kind words. 

If you truly only needed single hair grafts, then both are technically viable options. In my experience, follicles don't really like being split down beyond the level of their natural follicular unit groupings. Even splitting "triples" into doubles and singles sometimes decreases the yield; but trying to split everything down into singles would likely decrease growth yield. In this instance, it may be better to target singles using FUE. Having said that, "single" grafts are naturally smaller and fragile, so you need to be careful extracting these and there may be some variation in yield depending on how much your follicles tolerate the FUE process. I would recommend someone who takes a very slow, meticulous approach to FUE and would probably request that it be done using manual tools in this instance. 

Are you sure you only need singles? Sometimes "hairline refinement" is really "frontal band refinement" and you may find that you just want to do a pass in that entire region in general. 

Thank you, Melvin. It is good to be back. 

Congratulations on the new position. I know a guy who worked that job for years and thoroughly enjoyed it! 

Hi Everyone, 

I wanted to share a good example of the way I like to showcase hair transplant results: HD video footage with "slick" wet hair. The reason I like this is because there is simply no way to fake it; it is a brutally honest representation of what can be achieved with modern hair transplant surgery. This type of presentation gives the prospective patient a very clear example of how they may look in 6-12 months, and allows them to make an informed decision as to whether or not they would be happy with a hair transplant. 

The patient in this video is male with classic androgenic alopecia (genetic male pattern hair loss) exhibiting a Norwood IV pattern. He takes no hair loss medications. We evaluated the patient and decided to recreate an age-appropriate hairline, perform a dense pack of the frontal scalp, and strategically work into his mid-scalp with 2,500 grafts using the FUT technique. The video shows his pre-operative appearance, the surgical plan, intra-op. and post-op. photos, a comb-through of his 6 month results, a comb-through of his incision line scar at 6 months, and a few "before and after" comparison shots. 

I am only going to share a few "teaser" images here, because I really encourage watching the video itself: 

Thank you for watching. I hope you enjoyed. 

Dr. Blake Bloxham 

Patients bring up diet as a potential cause of their hair loss very frequently during consultations. Some even tell me they are "kicking themselves" because they know the poor diet caused the hair loss. As Bill noted, this is very much not the case. 

In the end, classic genetic patterned hair loss is just that: genetic. It is written in your DNA. It is like your eye color, height, or anything else like that. If I told you that switching to a vegan diet would change your eye color from blue to brown, would you believe me? Of course not! Physical traits like this are genetically pre-determined before you are even born, and there is very little we can typically do to change them. 

Things like excessive stress, very poor diet (IE "crashing dieting"), may slightly exacerbate inevitable hair loss or unmask it a little, but it was going to reach the same conclusion pretty much regardless of what you did; it is written in your genetic code and your genes will win out in the end. 

Now, this does not mean that you shouldn't eat healthy for other reasons, but I just would not expect it to do much for your hair. 

Ancien, 

Dr. Gabel is truly excellent. Congratulations on the procedure. I believe you will be very happy 12 months from now. 

This is what I tell my patients about topical powders in the post-op: 

You can start using them at day 10, but do so sparingly and always wash them off when you are home and done for the day. 

Frankly, I have never seen convincing evidence that they do much damage in the post-op. However, a lot of very respected physicians don't want patients using them for a while afterwards; so it is possible that they have some anecdotal evidence to base this on. My personal belief is that they do cause irritation and a slight inflammation when left on the scalp for a prolonged period. You don't want any extra "excitement" in the recipient area after a transplant, so I think a good "rule of thumb" is to only use sparingly and when necessary, and wash them out thoroughly after you are home. 

And, of course, listen specifically to whatever Dr. Gabel recommends. You should always follow YOUR doctor's post-operative instructions to the letter. 

Hope this helps. 

RD, 

Is it only the donor area or the entire scalp? How many FUEs were removed from back there? 

Hi Upshall, 

It is absolutely possible to achieve a natural, full hairline with coarse donor hair (I believe this is what you are asking). Now, there are a few things a doctor must take into consideration and do a little differently when working with this type of hair; especially if the patient has lighter skin tones as well. The challenge is to take naturally thick, coarse hairs and use them to create a soft transitional hairline. 

As Markee pointed out, using only single hair grafts is a must. Only go to a clinic that utilizes microscopes in all of their procedures -- both FUT and FUE. In fact, demand to see microscopes during your consultation. If you see one small microscope in the corner collecting dust, be concerned that the clinic is not comfortable and practiced using them and be aware that this may lead to an increased chance of misidentified and incorrect grafts in the hairline. 

There are also other "tricks" when it comes to dark, coarse hair. To "bullet point" these: density, the degree and nature of the "irregularity" created, and the number of single grafts used in general play a role. 

Here are a few examples of hairline comb-throughs with thick, coarse, dark hair: 

Hi Helper, 

The scab was dislodged at 3 weeks post-op? What did the staff do to remove it? Was there a dent or sort of "crater" in the skin underneath after it was removed, or did the skin look normal? 

It is normal to see little to no growth at 3 months post-op. It is also normal to see "patchy" grow, and this may very well be a coincidence. And you did not damage the underlying follicles by removing the scab at 3 weeks. Everything is completely "anchored" and essentially a permanent part of the body at that point. 

We know people are busy; we also know people like to view hair transplant results. To try and help, we started a video series called "Quick Vids." And it is exactly what it sounds like: a quick run through of a hair transplant result, only requiring a minute or less of your finite time.

Here is a "Quick Vid" of a 2,500 graft hair transplant I performed on a patient 9 months prior:

Thanks for viewing and commenting,

Dr. Blake Bloxham

Feller & Bloxham Medical, PC

Hi PA,

Thank you for the kind words. He's on minoxidil, but not finasteride. If I remember our initial consultation correctly, he has his reasons for not taking finasteride.

Absolutely it will stand the test of time. His frontal foundation is solid. Regardless of what happens behind it, he will always look good from any reasonable angle. His worst case scenario if he never wants to have another transplant is that he will look like a guy with good hair in the front and mid-scalp, and some thinning in the crown -- which is a pattern found in nature so it does not look odd.

However, he has lots of good donor tissue left because he started as an FUT so he can continue to do procedures to address any changes in the back -- and I believe he may do that eventually.

Thanks for viewing and commenting.

Dr. Blake Bloxham

Great Neck, NY

Almost daily, I see patients with thinning in both the "back" and "front" of the scalp. And while many of these patients tell me the back bothers them the most and they would prefer to do "everything" in one shot or focus on restoring the back first, I almost universally advise them to focus on the front "half" of the scalp first.

This is for a few reasons:

1) Because it is a more visible and cosmetically significant region.

2) A full front with a thinning back is a pattern found in nature and, therefore, looks natural regardless of whether the patient has a second procedure to address the "back."

3) Because the back frequently appears fuller and the overall appearance of the ENTIRE scalp looks fuller when the front is done.

And reason 3 is where today's patient comes into play:

The patient is a male in his 30's with NW VI patterned hair loss. The front is more pronounced than the back, and he's consistent with daily minoxidil usage in the "back" region.

I had the above conversation with him and despite reservations about not addressing the back during the first surgery, he understood "point 3" and trusted that everything would look thicker.

Here is how he looked 6 months after a 3,000 graft transplant. Now, these are not the best "apples to apples" comparison pictures here. Obviously his hair is combed back in the befores and down in the afters. But this is the point of the presentation: he was unable to comb his hair how he wanted before (down) because there was a lack of hair in the front and the thinner hair in the back looked like a "comb over" when he tried to swoop everything down. Now with 3,000 grafts in the front, he's able to "bring it all together" and create a thicker, fuller look in the entire scalp despite having no transplants in the back whatsoever.

 

 

 

 

 

 

 

So, if you have thinning throughout the whole scalp and are somewhat worried about the doctor's recommendation to start with the front first, remember the thickening effect that a single transplant in the frontal half can have.

This patient will continue to see how the back holds up on minoxidil and possibly do a second procedure to address the mid-scalp and crown thinning in the future. He will return at 12 months for a fully matured evaluation.

Thanks for viewing,

Dr Blake Bloxham

Feller & Bloxham Medical, PC

I'd be interested in seeing more pics! And I like that strategy.

 

Thanks for the reply

It tends to work out very well for patients. You can really get solid coverage, a good scar, and the ability to then do FUE for any little improvements they patient may desire over the years.

Here is a picture of the scar. As I said above, it's about 1-2mm. I would consider this my average scar. I tried to blow it up big so you can really get a feel for what I'm referring to here.

This is the little "PSA" I give all FUT patients about the scar during the consultation:

Around 95% of patients fall within what I consider the "normal healer" category. Within this category, the scar will typically heal somewhere between a "pencil line" if you're a perfect healer (harder, thicker skin -- typically with less glide too) to a "marker line" of around 3mm if you're a bit of a natural "stretcher" (more rubbery skin, more scalp glide). Anything within this realm can be easily covered with any reasonable length of hair and most can go as low as a number 3 or 4 on the buzzer before it's noticeable.

This patient fell right in this category and as you can see, it is not affecting this ability to have a clean, cropped hair style in the donor region. And now he has another great strip left to do the back.

Good work but 2 to 2.5 years after a transplant in terms of time is NOTHING. In fact I would venture to guess that 18 months to 30 months post transplant is when one looks the best!

 

Hairloss is progressive and we RARELY see patients that come back for another session 5-15 years later for another and then maybe another after that.

 

Again, good work but this is not a typical example of 'when the other hair falls out' after a transplant.

 

Nope - it isn't. That's why I am replying. Not deceptive but you are stretching it Doc!

 

; )

Thank you for the kind words. And very fair points all around. A patient 5+ years out would be a better example. However, I do believe he has absolutely lost a significant amount of native hair since the original transplant. An examination of his scalp revealed that the front is pretty much completely transplants at this point, and the crown -- where no grafts had been transplanted -- is much more bare compared to before.

But the points you bring up are very important and it's really why I made the thread instead of just posting this as a "before and after" result:

The hair loss is progressive; transplants must be designed and executed with the "long-term" in mind; and transplants can stand alone when the progression continues -- as long as they were thought out and performed properly.

Thanks for viewing and commenting. Good commentary and I really hope others get the chance to read it.

Just shows, if you have reasonable density at the front and a hairline, you can still salvage a hairstyle.

Nicely stated. I spend a lot of time explaining this exact same concept to consulting patients. People are often very self-conscious about the crown, but it is almost universally better to do the front/middle first. Having a strong frontal foundation provides you with a much more natural and cosmetically pleasing result, regardless of what happens beyond it.

Thanks for viewing and commenting.

i’ve had the same question. i have a similar diffusing pattern...

 

this is a great result for only 6months post op. scar is hidden well. I am considering FUT but am nervous about the scar...

 

how did you reach 3200? did he or you suggest to wait to do the crown?

Hi PA,

Thank you for the kind words. His scar is good; 1-2 mm and easily hidden -- even with shorter hair. I have some pictures of it I can put up as well if people are interested. I definitely understand the hesitance with the difference in FUT vs FUE scarring, but FUT is still a much better approach for a big portion of patients and the scarring is typically very manageable in comparison to the huge potential benefits. I would not let the scarring alone completely deter you from researching FUT.

I typically suggest doing these full NW VI cases in two surgeries. In my opinion, The front/middle and then the middle/crown really deserve their own surgeries days. There are always those cases where you can knock it all out in one go -- and I've done it many times; but most people really need two to do everything from front to back. And that's how I like approaching a big case like this: do two big strips, knock it all out, then you can do FUE for any small touch-ups or if you want to put a little into the scar to wear the hair even shorter.

KP,

I would advise your friend to immediately be seen by a doctor in-person.

While some redness and scabbing/flaking around the grafts post-transplant is normal, there are a few concerning things here:

There appears to be a red, swollen, defined area around those small wounds. It looks like it may be somewhat tender and warm to the touch as well. If the entire scalp looked this inflamed, I'd probably think less of it. But the definition of the area and the fact that those small wounds are in the center of it makes it more likely that it could be infection.

This isn't something to wait on. Please seek medical attention.

"What happens when the other hair falls out?"

"What will the transplants look like when the native hair falls out?"

These are two very common questions I'm asked by diffusely thinning or patterned diffusely thinning patients during consultations. What they want to know is what the results of their transplant will look like after the supporting, native hair we work though eventually thins and falls out.

And I tell patients that because modern techniques allow us to carefully work through instead of completely going around these native hairs, the transplants will stand on their own after you lose the hair around the transplants.

And that is exactly what happened with today's patient:

This patient is a very diffuse thinner with NW VI potential. I did a 3,200 graft FUT procedure on his frontal and mid-scalp in 2015 and carefully worked through his native hair at the time. He was worried that it would look thin when these hairs fell out, and I assured him the transplants would stand on their own.

Here is how he looked immediately post-op:

The patient came back 6 months later and looked great. At that point, all his native hair that we worked through came back and was working with the transplant to give a very full look. Here's how he looked then:

I saw him next two years later. He stopped by the office to discuss a planned follow up to address the crown. He looked great. In fact, he was sporting a "gelled and slicked-back" hair style that he hadn't previously been able to wear. At that time he told me that he believed the rest of his original native hair had shed. And based upon an examination of the transplanted area and the rest of his scalp, I agreed that the front was almost all transplants at this point and the back was thinner without any native hair.

Despite this, he looked great and he agreed that my original assessment was correct: the transplants will stand on their own when the native hair thins.

Here's how he looked at 24 months post-op, with loss of the native hair in the transplanted area, and with his hair gelled and slicked-back:

 

 

 

So for those concerned about what a thinning region that will be augmented with transplants may look like after the native hair thins, rest assured; as long as the native hair is carefully worked through the transplants should stand on their own.

Thanks for viewing.

Dr. Bloxham

Feller & Bloxham Medical, PC

Thank you for the kind words.

Indian hair type is a definite "catch 22" in my book.

Altogether, patients of Indian-descent are good hair transplant candidates. And this is good news because hair loss, from how it has been explained to me, is a very big aspect of their culture. Because of this, I do surgery on at least one Indian patient per week -- with good results.

I say the hair type is a catch 22 for the following reasons:

It is true that Indian hair, for the most part, does seem to be somewhat "silky" and the follicles -- though large -- can be fragile -- as jj described above. What's more their donor density tends to be lower on average. I also tend to see a lot of Indian patients with advanced NW patterns. This means a big area to cover with less than ideal donor characteristics.

Having said that, the plus side to Indian characteristics is:

Excellent hair-to-skin contrast ratio. The tanner skin tones with dark hair tends to give excellent coverage. So despite typical lower number procedures and somewhat challenging follicles to work with, patients of Indian descent make excellent FUT candidates.

Today's patient is a male with fairly classic thinning in the hairline/frontal band and "fronto-temporal corners" regions.

Based upon his hair type, pattern and likely progression, I agreed with his request for a strong, defined hairline, a thick rebuild of the frontal band region, and some "corner closure" -- not something I do on everyone.

Presented are the 7 month results of his surgery. While I shared a few key images here, I highly recommend watching the video. The video contains more pre-op, immediate post-op, and "after" images, and it also includes dry hair video and wet comb-through video. The wet comb-through is my favorite because if a hair transplant looks good wet and slicked back, it will look dense and full with pretty much any style.

Video:

Comparison Pictures (wet and dry):

 

 

 

 

 

Thanks for viewing and commenting.

Dr. Blake Bloxham

Feller & Bloxham Medical, PC

Hair Transplant & Hair Restoration Services in New York

never understood the native hair argument. Isn't a transplant only as good as the surgeons ability to dense pack regardless of the native hair?

Native hair can play a role depending on how prevalent it is before the procedure and how well the doctor is able to worth with/through it.

The key with native hair, in my opinion, is to not count on it or create a design that depends upon it in the future. This is because androgenic alopecia is progressive by definition and it is not likely to be there in the future. If you carefully work through it safely (trim it up so you can closely follow the angles, use high magnification, pump the tissue up with some fluid, use very small blades, etc) and create a plan that doesn't need the native hair to be successful, you will should end up with a good result whether or not the native hair sticks around. Maybe it will be very slightly thicker with it, but the transplants will stand on their own and look natural regardless of what happens with the native hair.

Thanks for commenting.

He has weak hair characteristics (typical of Indians) so he needs way more total grafts lifetime for significant cosmetic results.

 

As long as he understands this and has the budget - no worries.

 

He'll never have a wow result 'cause I can tell his native hair isn't even that great compared to many men and he'll be a Norwood 7 without transplants and I am willing to bet he is not on Dut or Fin nor is taking high % minox either to stabilize for a number of years.

 

I'm in the same boat w/wimpy 'native' hair.

 

Bloxham is good (I had a 2250 FUT w/Feller in '04) and tends to represent himself well - though w/a bit of his own agenda.

 

We all tend to do that though. Nice post.

Good analysis. And thank you for the kind words.

I think the problem is that we are all different. You can't actually look at anybody else's before and after picture and say, "I will get that result"....because we all have different patterns and extent of hair loss, our hair characteristics are all different, our faces are all different, and results vary due to other factors like growth rate etc. What makes it worse is that the more research you do the more you can get stuck in an "analysis paralysis" looking at so many good/bad/excellent/indifferent results.....you end up having no idea what you might end up with.

 

This was the biggest problem for me when contemplating a HT. If I'm contemplating buying a BMW I can look at exactly what I'm buying and try it out, so I know exactly what I'm getting before I commit. With a hair transplant your buying "hope" i.e. hope that the final result will meet with your aspirations. The concept of buying hope leaves the door open for the less than ethical doctors to crank the hope up in order to seal the deal.

 

I actually put off having a hair transplant for many years because I believed my expectations were higher than what was achievable. Having such high expectations is definitely a problem if they can't be met, but I was lucky, my pattern of loss and a great clinic/surgeon meant they weren't just met, they were exceeded.

Very nice assessment. Thank you for sharing. I think this will help researching patients in the future.

how does one spend thousands of dollars on something and not know what to expect? I guess typing in google "feller and bloxham before and after" was beyond him.

Fair question. Unfortunately many patients don't find out about resources like this forum or high quality video presentations on YouTube until after they actually "take the plunge." I think a lot of people may start their "research" off with an initial consultation and become hooked in and just go for the surgery. But, as members here know, research in all forms is key.