Dr Blake Bloxham

From time to time, we see a disconnect between hair transplant "expectations" and the "reality" of modern hair transplant surgery. Most of the time online, it seems like patient expectations were outside or above the -- excellent -- reality of hair transplant surgery. However, sometimes in practice, I actually see the opposite; an instance where a patient actually had lower expectations and accepted a less than satisfactory outcome because they thought this was the reality of modern hair transplantation. And I think it is just as important to discuss this because it helps patients understand what they can expect in general. When expectations match reality, patients tend to be happy and achieve good cosmetic outcomes. What's more, by knowing what they should expect from a transplant, otherwise unsuspecting patients reading this thread will hopefully avoid being taken advantage of. The case today is a patient with advanced hair loss -- essentially a NW VI -- who underwent an FUT procedure in India. The doctor recommended doing a 2,600 graft "mega session" to rebuild a "dense pack" frontal band and do some fill behind to create a smooth transition in the mid-scalp. The patient liked the plan and moved forward. Here's how he looked 12 months after that procedure: As members of this forum know, this result is not an accurate representation of the reality of a modern mega session with dense packing. But when the patient presented for the consultation, he was under the impression that this type of result was the norm. I informed him that his expectations did not match the reality of what hair transplant surgery can offer. And I recommended proving this to him by essentially doing precisely what the first clinic claimed: a 2,600 graft mega session with a dense packed frontal band and a strategic mid-scalp fill that transitioned into his open crown. Here's how he looked 12 months after the surgery at our clinic: Now I believe this is a realistic representation of what a modern hair transplant mega session with dense packing via FUT should look like. And while the final result may have benefited slightly from the existing grafts (which, for whatever reason, did not amount of what 2,600 grafts should look like), I still think this is about right. Always keep in mind that results will vary, but this is something I would feel comfortable showing to the average patient to help create realistic expectations. I'm happy to report that this patient is very pleased with where he is at now. I recently did 1 more FUT (this is when the "after" pictures were taken) to fill a little more in the posterior mid-scalp and anterior crown (which is what the patient actually thought he wanted to do originally before understanding how much thicker the front could look). He's likely stripped out now and will probably return in the future for some FUE to finish up. Hope this presentation is helpful to those researching HTs and wondering what they can expect. Here are some comparison shots: Dr. Blake Bloxham Feller & Bloxham Medical, PC

Thanks, Spex.

Hairthere, He absolutely does. Worked very well for him and happy to be a part of his transformation. Thanks for viewing and commenting.

One of the most common requests I receive at the office is: "Doc, I want to cover 'everything.'" In other words, patients want to try and cover from hairline to full crown in one procedure. And while this is possible for some patients -- and I have done it before -- it's usually not the best/most realistic approach for most. Instead, I usually tell patients the best way to really knock "everything" out is in two procedures: one FUT mega-session to rebuild the hairline, densely pack the frontal scalp, and strategically fill the mid-scalp (past the "horizon"); and a second FUT to really do the crown correctly and feather up into the mid-scalp. I particularly like doing this method because a true "crown surgery" really deserves it's own day and a good graft number. I've also found that the FUT scar usually heals roughly the same between surgery 1 and 2, so you get total coverage with very minimal damage in the back and lots of donor left to address any issues in the future -- including some non-strip surgery to camouflage the scar further if the patient wants to go shorter on the sides later on. And that's precisely what this patient did: The patient is a male in his 50's with advanced NW level V-VI hair loss. We planned for two FUT procedures as described above. The first was a 3,200 graft HT aimed at the frontal and mid-scalp. Here are his results from that surgery: And here are his immediate post-operate results from the second surgery -- 2,000 grafts to the crown: And here is a video with more pictures, explanations, and some detailed "comb-through" footage. I highly encourage all members to watch: Thanks for reading. Look forward to comments and questions. Dr. Blake Bloxham Feller & Bloxham Medical, PC

Today's case is a male in his 30's with a diffuse and evolving Norwood VI hair loss pattern. We performed a 3,000 graft hair transplant via the FUT technique. His results are presented at 12 months post-op. Please see the images and video below. I encourage all members to watch the video. It contains more pictures, a detailed video of his immediate post-op, and a more thorough video of his 12 month results. Video: Images: Thank you for reading. Look forward to comments and questions. Dr. Blake Bloxham Feller & Bloxham Medical, PC

Thanks, Matt. He's very happy and thankfully he understood the long-term planning required when doing a transplant on a younger patient, and I think this transplant will serve him well for many years to come.

Research, I say the following from the perspective of a medical doctor and not with any intent to stoke the flames of this situation: Several of those dark patches appear to be necrosis. Even in a healing state, necrotic skin often requires prolonged antibiotic therapy, possible surgical wound debridement, and usually follow-up wound care. I advise you in the strongest terms to make an appointment with an outside doctor who focuses some aspect of their practice on wound management and have an evaluation. Best of luck, Dr Blake Bloxham

David and Spex, Thank you for the kind words. The patient is very happy with his progress, and even happier to discover that he's really only half way done maturing. Growth in repair/finishing patients is always interesting. Some seem to grow ahead of schedule; my guess is that this would be secondary to the increased vascularity in the scalp from the prior transplant. Others seem to grow noticeably slower; and my guess here would be that this is from the increased scar tissue in the area which is less hospitable to healthy follicle growth. So a bit of a "catch 22" I suppose. Second round patients may grow quicker (like this patient) or they may grow slower.

Today's case is a younger patient who presented with classic "frontal band" thinning. After discussing the patient's long-term best interests, we proceeded with a 2,000 graft (via FUT) surgery to rebuild a hairline that will age well and densely fill the frontal band area. Attached are a few images of his 12 month results. I highly encourage members to watch the video as well. The video contains many more images (including post-ops), an explanation of the case, and a dry and wet video comb-through. Video: Look forward to comments and questions. Thank you, Dr. Blake Bloxham Feller & Bloxham Medical, PC

There are a few cardinal "sins" in the hair transplant field. And while I doubt a standard list of these deadly sins exist, the general consensus is that they include things like: wasting/not respecting the donor, going too low/flat with the hairline in a patient with future loss, etc. This patient presented after undergoing a "mega session" at another clinic where I believe two of these "HT sins" were committed. The outside clinic attempted a large session on the patient to treat his Norwood VI pattern hair loss. In my opinion, however, two things were done that should not have been: 1) An inappropriate amount of grafts were spread way too far all over the entire scalp 2) The donor was harvested (FUT) in an awkward manner (likely an attempt to to a mega session harvest by a clinic that doesn't do a lot of them) and this limited the available donor for future surgeries. Here is how he looked after his procedure at the outside clinic: He was completely gone on top before the first surgery, so all the hair you see on top is the result of the transplant. As you can see, too few grafts spread too far. But what really made this case a "repair" is the state of the donor. The first clinic started the FUT incision high in the back of the donor area, and almost pointed it downward (opposed to naturally curved upwards) on the sides. This meant in order to obtain a good harvest (which was now limited off the bat) and leave the patient with one acceptable linear scar in the back, I had to harvest above the old scar on the sides and below it in the back. Despite the donor challenges, I was able to obtain 2,500 grafts from the donor. And instead of spreading these all over the scalp in a less dense manner (like previously done), I used these to dense pack the frontal scalp and strategically fill the mid-scalp as much as possible. Obviously this doesn't result in as much area being covered, but it's what gives us those dense, natural results. And here is how he looked only 6 months after surgery: And here are some with surgical lines to demonstrate the plan and where we worked: Now the patient has an appropriate result and a framed, natural look. And while it's always nice to get as much coverage as possible on high Norwood patients, it's rarely a good idea to to it at the expense of cosmetically significant density or the state of the donor. Thankfully the patient still has laxity so he is planning on doing one more large FUT session aimed at filling the rest of the mid-scalp and crown. After that he will likely be a good candidate for FUE to finish off any little areas. Thank you for reading. I will update this thread when the patient comes back for a 12 month follow-up -- especially because the camera wasn't being overly cooperative during his appointment and a lot of the pictures didn't come out. But I hope this case serves as a reminder to those with high levels of hair loss looking to undergo big procedures; make sure good, strategic density is utilized and make sure to keep the donor is the best shape possible for future surgeries -- because you may very well not be able to do everything in one shot. Dr Blake Bloxham Feller & Bloxham Medical, PC

Forgot and David, Thank you for the kind words.

Like many other procedures in this field, SMP is a great tool with the potential to help a lot of patients when done correctly by a skilled practitioner. However, like just about everything else in life, not all SMP clinics are the same and not all practitioners work with the patient's best interest at heart. And that is where our story begins; and it's a little bit of a different case, so I hope members enjoy and I really hope it lets others know there are almost always options to improve upon old or bad work, so don't be afraid to consult and discuss your possibilities. The patient here is a male in his early 40s who initially presented to an outside hair transplant clinic for a consultation years before. He consulted with the hopes to have a hair transplant to treat his Norwood level V-VI patterned hair loss. At that time, he was told that he did not have the donor for surgery and was not a candidate. Discouraged, he looked into other options and found SMP. So he decided to go to an SMP clinic and have permanent SMP done on the entire scalp. Unfortunately, the clinic initially went very low and flat (and somewhat crooked) with the hairline, and the permanent ink partially faded into an unnatural blueish hue overtime. He watched some of our YouTube videos where we had repaired previous bad SMP work and decided to come in for a second opinion about a transplant. Here is how he looked during the consultation/before surgery: His donor was definitely below average. In fact, the gaps and spread nature almost made it looks like he had prior surgery. Initially, we discussed doing an FUE to try and create a "haze" of thinner hair on top to blend with the SMP and give him a more 3-D cropped look. But I didn't think his pseudo-afro hair follicle type would do well with FUE, and he had great characteristics otherwise for an FUT approach. I also thought he would received excellent coverage with his follicle type. Here is how his donor looked: So we decided on an "AMAP" or (as much as possible) FUT procedure aimed at rebuilding a more appropriate hairline (above the previous SMP hairline) and filling as much as possible with a slight emphasis on coverage over density. Despite his well below average density, I was able to harvest 3,103 grafts via FUT and use them as described above. Surgery went beautifully. Here's a surgical overview: He came back for a 6 month follow-up and looked great. Even with his hair cut quite short (and the patient cuts his own hair so that is why there is some unevenness in the 6 month pics), he clearly achieved his goals. This is precisely how the patient wanted to style his hair from the get go, though he is going to try growing it a little longer in the future: Based on the patient's excellent laxity and healing in the donor, we're going to do the rest of the mid-scalp and crown in the not-so-distant future. And although he was concerned initially about starting the hairline above the SMP, I explained that I've done this many times in the past and it usually blends quite well. Particularly when he grows his hair out a bit. But a very satisfying result on a challenging case, and an end to the daily worry about the bad SMP for this patient. Hope you enjoyed. Look forward to your comments. Dr. Blake Bloxham Feller & Bloxham Medical, Hair Transplant Institute Hair Transplant & Restoration Services in New York

Everyone is entitled to their own opinion. That's fine. But I'll say it again: I would not change a thing about this case. This patient presented with a very challenging donor -- with respect to both the hair and skin-type -- and both traditional FUT and FUE were off the table. I was able to go in, remove FUT-quality grafts, achieve an excellent result in the front, and leave him without a long FUT scar in the back -- which, trust me, would have been the real issue with the overall nature of his donor. If any doctor would like to come on and discuss the merits of my approach or what they would have done differently, I'm happy to have that discussion. The images and video I presented are 100% accurate. Like I stated before, this is the same environment I use to take all my pre and post-op photos. What you see there is what the public sees. Period. If NJ feels the need to revise his scars, then, again, that's fine. I spoke with him about this and really do not believe it is necessary. With the thin, spaced nature of his donor, I simply don't think they are overly noticeable or look surgical. And I believe the result in the front was an absolute worthy trade-off. Like I said before as well, this approach is really just a middle ground between procedures. I've presented it to many patients who are worried about a connected strip scar, and they happily opt for it. Works great too. I'll present more cases of it soon. And for the record, it would be much easier and more convincing to do something like SMP or grafting into a small area like this than it would be a full FUT scar. So if NJ does opt for this, I'm sure it will work well. And to NJ, I'm still more than happy to discuss this with you further. You have options to address the scars if you really feel the need. I had thought we had discussed this thoroughly during your last appointment, but I am here if you would like. And if you chose to seek treatment elsewhere, I wish you nothing but the best.

Edited video has been put back up. I made every possible attempt to make sure identity was completely blocked.

If the patient were to lose more hair, the same scar lines would be used in the exact same manner that they would be with an FUT scar. He wouldn't have additional scars.

I thought the patient's face was sufficiently blocked in the video. But I'm going to pull it right now, review it again, and then put it back up if I see any areas where it wasn't blurred enough.

Also, just for clarification purposes: this case was actually 971 grafts.

Here are the before/after photos and video showing how NJ744 actually appears in reality. These include the hairline results of the procedure itself, which he chose to omit. These results are shown with the patient’s hair buzzed to a # “1.5” guard, which is below the #2 guard the patient was informed (verbally and in writing in the consent form) would be the minimum he would need to successfully cover the scars. If the goal of a hair transplant is to cover bald skin with growing hair, then by any rational standard this procedure was an unqualified success. And I expressed this to the patient during our 12 month follow-up. I was extremely pleased with the results in both the recipient and the donor. Having said that, I understand that the patient is not happy about the scars. And he went to great lengths in his photographs to present the scars in a manner that exemplifies his point. If he left his hair at the length agreed to prior to surgery, then the casual observer would never know they were there. A lot of thinking, planning, and discussing went into how the donor area would be harvested. NJ744 was involved in every step. All hair transplants leave scars. There are no exceptions. What’s more, these scars represent something very important in hair transplant surgery: a trade-off. This patient rejected FUT. And probably rightfully so. With African American skin type, the chances of hypertrophic and keloid scarring are higher. And a large connected FUT scar that is stretched to this level could have been unacceptable in the donor. However, the trade-off for this would have been excellent yield. Dr. Feller rejected FUE for this patient because he simply didn’t have the characteristics for it and it would have likely resulted in unacceptable transection and a cancellation of surgery after only a few test attempts. He would have had smaller and more frequent scars in the back, but the trade-off would be the almost guarantee of damaged grafts and poor yield. So what we offered this patient was the best and most carefully considered trade-off: let us take small (2cm) “hits” from very strategic areas in the donor. This will leave you with scars like this – which were discussed and known to the patient far beforehand. In return, you will get minimal scarring in the back that is well broken up and eliminates the chances of a long, connected bad scar, but you will get quality grafts and good growth. And as you can see, this is precisely what was delivered: excellent results and very reasonable scarring in the back. So much so, in fact, that I have done this approach now on many patients and it’s a hit. Ironically enough, I’m in the process of actually renaming this approach and creating a video sharing the technique and this patient’s specific case is one that inspired me to keep pursuing it. Knowing everything I know now, I still would not do anything differently on this patient. He has excellent results in the front and can even cut his hair down to a 1.5 with obscured scarring that looks more like trauma than it does surgery -- although a #2.0 or greater was recommended. Despite a rejection of pretty much all my recommendations during the post-operative period – which were given over the course of dozens of email exchanges and several in-person consultations -- his results are undeniable. In the end, he is my patient and I want nothing but the best for him. I want him to be happy. There seems to be this growing idea online that doctors and patients are “adversaries,” but nothing could be further from the truth. I treated his scalp in the same way that I would treat my family members, my personal friends, and ask my own to be treated. We all want a procedure that gives great growth with tiny scars but today's technology demands a trade-off between the two and is a reality all potential patients must recognize and understand. Dr. Bloxham

I was just made aware of this thread. I will post more information including pictures and video of this patient with a 1.5 guard hair cut and and explanation of why larger pieces (and not the traditional smaller mFUE pieces) were taken in this patient specifically. I'm starting a surgery in a few minutes, but will update as soon as I get the chance. As this patient knows, my door is always open to him.

Thank you for viewing the thread and commenting. I'll absolutely post updates at 12 months when these patients come back in for their year follow-up.

Thank you.

Thank you. And yes, I do hope this helps some of the patients worried around the 6 month point. While this is just my complete subjective observation, I believe the crown maturation lags by at least 3 months. Usually I see it just waking up around 6 months (the same way the front starts to wake up at 3 months) and it takes at least 15-16 months to say that it's "fully matured." Having said that, I usually don't fully evaluate a crown until 18 months because a lot of people do mature even slower in the crown.

I've recently had several community members reach out concerned with their 6 month "results." Despite a lot of information online reassuring HT patients that 6 months truly is the half-way point as far as maturation goes, there does seem to be this underlying idea that if it doesn't look good at 6 months, you're in trouble. And to make things worse, we do frequently see examples of 6 month patients who are ahead of schedule on the community -- furthering the misconception that if things aren't "looking good" by 6 months, it won't look good at 12 -- or 18 -- months (which is untrue). So what should an HT look like at 6 months? What does it mean to be "on schedule?" What things should you see? And what does it mean if you're not there yet? To try and help, I decided to share a few examples of 6 month follow-ups who have come into the clinic over the past several weeks. I think each of these are a good example of what an HT should look like at 6 months. So I'm going to share 4 different cases; describe where these patients "fall" on the 6 month average ("ahead of schedule, "on schedule," etc); and point out some classic 6 month characteristics. I hope this thread provides some comfort to those patients around the 6 month mark nervous with their progress. You are probably right where you should be, and look somewhat like these patients: Case #1: 6 months post-op, 2,200 grafts VIA FUT 6 month rating? I would say this patient is slightly above average. Not only is his density solid and fairly uniform at only 6 months, but you can also see in the "top-down" shot that he has good growth in the more posterior regions where I worked -- and generally the further you go back in the scalp, the slower the maturation. Classic 6 month characteristics? Note the texture differences (still a little "wiry"), the shorter length, slightly slower maturation of the singles at the hairline compared to the multi-FUGs behind them, and the slight color difference of the transplanted hair. This is all normal and expected for 6 months. Case #2: 6 months post-op, 1,200 grafts via non-strip technique 6 month rating? I would rate this patient as "on target" or "on schedule" for 6 months. Classic 6 month features? The classic "wiry" or "kinky" appearance to the hairs; the patient is also exhibiting some very classic 6 month styling. Not only is he doing the very common "side part" at 6 months (this usually suits patients best at 6 months), but he's also starting to get enough new transplants to style them with his existing hair (you can see him combing these together in the left side shots), and he's experimenting with newer styles in general (he complained about not being able to ever style before and his hair always "sticking up" like seen in the pre-op pics -- though it's exaggerated in those images). If you find yourself with much easier styling options, using less concealer, or finally being able to work with your existing hair, you're right on track for 6 months. Case #3: 6 months post-op, 3,500 grafts via FUT 6 month rating? Slightly above average. I say above average simply because the patient has maturation very far back in the scalp. I was able to work all the way from the hairline into the crown on this patient. I usually tell patients that the crown noticeably lags compared to the frontal regions, and very little progress (or subtle, vellus-like growth) is normal at 6 months. This patient, however, had fairly impressive growth in the crown region at 6 months. And while I didn't get great top-downs, you can see the immature growth in the crown (short, "frizzy," hairs standing up) in the right-side shots. Classic 6 month characteristics? A lot of noticeable texture differences and the side-part styling; but what I find most "classic" on this patient is the loss of the "comb over" he was using before surgery. 6 months is usually the point where patients start to rid themselves of these crutches. Comb overs are cut, concealer use decreases dramatically, and they begin to rely on the cosmetic effect of the transplant. If you find yourself changing these things around 6 months, you're on target. Case #4: 6 months post-op, 2,500 grafts via FUT 6 month rating? Ahead of schedule. Although there are some very classic 6 month traits here, this patient looks more like what I would expect at closer to 8 or 9 months. However, all patients do mature differently; so I did want to include one of the "ahead" 6 month examples we often see online and confirm that he is ahead of schedule. Classic 6 months characteristics? Although well-matured, the patient still has some classic texture changes -- he noted that his naturally "wavy" hair was extremely curly and wavy. He also has some lack of uniformity across the front. As you can see, some follicles are growing slower than others and the hairs are, therefore, slightly shorter, thinner, and lighter in color. The top-down shot also shows something very classic for 6 months: a growth gradient. I was fortunate enough to work all the way back through the mid-scalp and into the anterior crown on this patient. And as you can see in the 6 month shots, the hair in the frontal regions is more matured compared to the hairs in the mid-scalp and crown. The frontal hairs are thicker, have more of a "wave," and provide more coverage when compared to the hairs behind which are thinner, less dense, and provide less coverage all around (even with the strategic styling). This is normal. There is no reason to be concerned if the frontal portion of your transplant looks better than the more posterior portions at 6 months. So I hope this presentation helps those who find themselves around the 6 month mark and feeling slightly concerned. And even if you find yourself "behind" these mostly "on par" 6 month cases, there is no reason to panic; everyone matures at different rates and "slow growers" are a real thing. But chances are that you somewhat resemble at least one of these patients and are right where you should be for 6 months. Thank you for reading. I look forward to your comments. Dr. Blake Bloxham, Great Neck, NY Feller & Bloxham Medical, PC

Yes, I liked the overall design but the density was simply lacking for an area of that size -- particularly in the frontal band. But smart approach with respect to the overall design. There were some multis that crept close the the hairline. I didn't have to remove any, but instead camouflaged them with single hair grafts in the hairline.

I've received several requests to comment on the study Tofur shared and his assessment in general. To keep this brief: Yes, I completely concur with the data on finasteride. As he noted, what needs to be observed is the trend with respect to the X axis (traditionally time). The efficacy of finasteride absolutely decreases overtime. I've personally noted that patients really start to return to noticeable progressive shedding after 7-10 years. And if we extrapolate the 5 year data, this makes sense. As previously stated: there is no such thing as "stable" androgenic alopecia, even on a 5-alpha-reductase inhibitor. And while preventive medications, including finasteride, are very helpful in certain instances, it is a "kick the can down the road" type scenario. This is why donor management is crucial. And there is no such thing as donor management when it comes to FUE megasessions and young patients. Sorry to be blunt, but no such thing. It's truly an oxymoron. Don't kid yourself and wind up in a bad situation in the road. I'm already seeing this too much in the office. Dr. Bloxham