DrTBarghouthi

It is true. There is no right or wrong really. It is hard to be accurate with photos especially that the exact hairline height, shape of temple recessions can vary and thus require less or more grafts. This is the reason for some variations mostly.

Thanks a lot for that. It seems you do have a great donor. Your hair is somehow find and straight. I would probably thing you will need more than 2300 to match the density of your forelock. Based on photos I would probably say 2800 grafts and strict maintenance will be better in my opinion.

Please feel free to share some photos here of your hair loss and donor areas. That would help a lot. Also what age are you? Any family history?

FUT can create good hairline grafts as we need to dissect all follicles individually and may need to refine single hair ones similar to FUE. The scar in an FUT is definitely more obvious then the FUE gun shot scarring ( which in most cases the eye does not fixate on). Shaving on #1 can be quite risky at times with FUT. I’ve seen some nice scars that show on #1 still. It is just the linear nature of it that makes it obvious. Recovery post FUT can also be slower in terms of pain and precautions. I guess the main thing is the type of hair loss you have. What stage is it?

I do in certain cases. The truth is that the majority of clients are opting for FUE nowadys for reasons you probably know. Limited donors are really the ones going for FUT nowadays. I find that people could be more appreciative of FUT as they grow older. I therefore always try to leave a nice central portion of the donor untouched while doing FUE, as I would know if down the line an FUT is chosen, then I or someone else will be thankful for leaving that unharvested.

I do agree that hair systems are advancing a lot. They are utilizing 3D printing nowadays to make a perfect customized fit of the client’s scalp. I do believe that they cater to clients with higher expectations or those who need a full dense coverage or even in then unfortunate event of depleted donors with unsatisfactory results. I certainly like them for the crown at a younger age when a HT is not yet advised. Saves you grafts and at the same time gives that fullness.

Thanks @Rossybop Yes I did my undergraduate medical degree and surgical training in Dublin before heading to the US for a hair restoration fellowship. Thanks a lot for your kind words. I certainly miss Ireland. I lived there for 15 years so I really know my way around and I do visit whenever I can. I think HRBR is a good facility with good doctors. I haven’t worked with them to comment on their work unfortunately but I am aware that Dr Collins and his team have a long track record in this field. As for prices, we do charge 3 usd for the first 2000 grafts and 2.5 usd for anything after. Most steps are done by me apart from implantation which I would supervise.

Hi @Rossybop Yes I am. I think something needs to be clarified here. There are two techniques for “non shaven” fue out there and both are being marketed in a similar way but the techniques are different. What some doctors do (i do it myself at times) is shaving thin random strips across the donor whereby the longer hair over those strips will cover the fue extraction sites. This is technically a shaved fue but is more concealed. It is useful for smaller touch ups or smaller sessions or what became to be know as a VIP or celebrity FUE. You can plan multiple small sessions like that and eventually reach the number needed over 3-4 sessions. The newer trend I was referring to is Long hair FUE, which extracts the hair with a long shaft. No shaving done at all.

Long hair FUE is getting some momentum certainly. A recent study showed that the transection rate with this technique (which has a learning curve ofcourse) can be higher. In contrast, by keeping the hair in the donor long, the extracted numbers can be higher than the shaved technique, because the surgeon has the visual effect of long hair in the donor, which might allow him or her to extract a higher percentage per cm2 than if shaved. It is ofcourse a new area that some are getting into. I see the attraction to some patients. However, I think there is a learning curve and shouldn't be done by anyone or offered to everyone.

There has been an interesting talk by Dr True recently at the world congress about possibilities of extracting grafts from the upper and lower intermediate zones of the donor area or what may be considered out of the safe zone. These areas as he demonetised could be separated and used in areas that are non critical in case they thin out with time despite of medical therapy. He suggested using them in the crown or in the hairline so as not to cause diffuse thinning if used all over the scalp. Ofcourse this is still an ongoing observation and is not a suggestion to adopt this. Interesting enough though.

Beautiful result!

Thank you all for your positive feedback. It is really a tough decision when you feel you’re getting someone to commit to a hair piece for long. Definitely a case by case scenario. Nonetheless, I often tell patients that there’s a fine line between being happy or not with a hair piece and this is almost always the hairline. What we have to understand is when a hair piece is put on, the transition-unlike a transplant- is immediate and sudden. Psychologically our brain might not accept any exaggerated changes especially if there is a slightly unnatural appearance. A transplanted section in front of a hair piece serves both to make the hairline natural but also puts the patients mind at ease as he knows he has nothing “fake” in front.

Dear community, This is a rather unusual case to share but the aim is to highlight some possibilities in hair restoration for patients with depleted donors or higher expectations of density or both. This 45 year old gentleman had two failed FUE procedures starting in 2011. He had around 5500-6000 FUE grafts harvested elsewhere leaving him with an obviously depleted donor and near zero growth. He even tried SMP but that even ended up fading and color migration, leaving a blue/green discoloration. The patient desired full coverage and although reasonable regarding his failed procedures and accepting of the fact that his options are very limited, I suggested a combination approach of both a Hairline and defined zone transplant along with a custom made hair system for the remainder of the hair loss area. I do believe that hair systems are evolving nicely, however, I still think that the hairline part of it can look unnatural and awkwardly dense and that mainly due to manufacturing technicalities. I often refuse suggesting a full hair system without having an existing soft or natural hairline. This technique involves good planning in order to take the measurements for the hairsystem a month or two after the transplant is done, making sure that we have recorded measurements before, during and after the procedure. The donor area was clearly depleted for a decent FUE or even FUT. He had no interest in getting any FUT scars so that reduced the options further. We managed to cherry-pick around 1400 FUE grafts from the entire donor. Although he had a good beard, we were reluctant to harvest from it since all of these grafts are going on the hairline and did not want to risk any unsightly grafts. 440 single hairs were placed in the transition zone and the remainder in his defined zone. We covered around 1.5 cm area with the transplant and the measurements of the hair system were then taken 6 weeks after bearing in mind these measurements. 6 months later, the transplanted hair started growing enough to cause a nice blend in the front. We decided to go ahead with applying the system at this stage, knowing that he will still get even better camouflaging when all transplanted grafts grow. The photos of the final results are taken 6 months after the HT and at the time of application of the system. I just thought that this case can probably provide some additional insight to what can be done to ensure as close to natural results as possible even given the limitations of donor depletion or even having demanding clients who need full and dense coverage. In a typical scenario, such patients will be usually refused surgery, but in those who understand their case well, such options can be very rewarding and pleasing. Before Surgery: Immediately after: 6 months of HT growth: Combined application of hair system:

Transplanted hairs should not be affected by minoxidil or get sensitive to it on the longrun. Nonetheless, even if they do, it will only go back to it's normal cycling pattern without any fear of thinning etc as in the case of native hair. Remember that minoxidil keeps hairs in a growth stage rather than them entering into a resting stage, which is what we fear with thinning hairs. So even if minoxidil becomes ineffective on transplanted hairs on the longrun, it will just be a normal cycling pattern.

Thanks @EgyCorrect. I only recommend the foam personally, at least for the initial phase. Nonetheless, I actually push for people to only use foam.

We usually stop it two weeks before to reduce potential heavier bleeding. We resume it 2 weeks after by the time the healing is well underway and shedding starts and the scrubbing of grafts is completed.

Thank you @JohnAC71 Yes he does have great potential going forward, despite his limited donor, tight scalp and slightly low hair/follicle averages and calibre. I believe he could get a decent number next time and also along with some beard extraction if he prefers that. I think he can be in an even better position over 1 or 2 further sessions. The best thing is that he got rid of his caps and toupees, which is a huge psychological step.

Dear Community, This is a 40 year old gentleman with a previously done FUT in 2010 that unfortunately hasn't been successful. His scar has been slightly wide and sensitive and he refused undergoing further FUT as he had an unpleasant experience with post operative recovery/pain. He has a Family Hx of NW 6/7. He himself is a NW6 with a low dipping crown and a limited donor area total surface area. His hair calibre is average. The patient has been using toupees for the last 9 years as his original growth was unpleasant and too obvious. His post operative photos show his shaved pattern but you can clearly see the obvious grafts with the low density and obvious appearance. We had no set number in mind, but we managed to extract 3200 FUE grafts to reconstruct the frontal and Midscalp areas in July 2019. No crown work was done as patient felt that should he have any future work done, he will rather wait for the initial result/ density. The patient is currently satisfied and is planning another density session and possibly some limited crown work in the same setting. I believe we can harvest another 2000-2500 grafts. Would be ideal if he would allow for another FUT/combination procedure. Total grafts: 3200 464 single hair refined grafts in Hairline. Average hairs/follicle: 2.04 Presurgical photos: After surgery: 12 months photos:

Dear community, This gentleman is 39 year old with a NW4-5 Family history. he has been on finasteride for few years before presenting to us. His main concern is an obvious recession along his hairline/mainly temple recessions that are extending into his Mid scalp zone. His frontal tuft is strong and intact. He underwent surgery 9 months ago to add density to his frontal zone. 2322 FUE grafts were transplanted. His average hair/follicle was 2.85. 400 single hair follicles (refined) were used for the hairline. The latest photos I have personally for him are those 9 months after surgery. Pre surgery or shaving: Immediately after: 9 months results:

Thank you guys for the feedback. I guess in some of these cases, depending on the future prospects, level of current hairloss, age of patient etc, it is important to be cautious with numbers. Try to lay down a very good foundation and then proceed accordingly. As we all know, sometimes “less is more”

Dear Community, This is a 31 year old gentleman with a NW 6 pattern and a strong family history of the same. He underwent a HT procedure 10 months ago. He has been put on finasteride every other day just prior to his HT. He had a total number of 2900 grafts done over two days. The areas transplanted were his frontal and mid scalp zones. The plan is to transplant the crown once his pattern stabilizes. We were quite conservative with the numbers due to his advanced pattern, dipping crown and the fact that he is considering a beard transplant too in the future. We though we would try and reduce the numbers needed. His hairline design went above his native hair also to reduce preserve the numbers. His old native hair in his hairline gave a nice additional naturalness to his hairline. Nonetheless, if those native hairs go, then he will still have a natural and realistic hairline. Single hairs: 460 (400 ultra refined in hairline) Hairs/follicle 2.55 Punch diameter: 0.8 mm Pre surgical photos: Surgical planning: Immediate post op: 7 months results: (No more recent photos yet as he is out of the country) Zoomed in hairline photos- combed back to show transition zone of hairline with ultra refined single hairs. Donor 7 months after: Harsh lighting photos:

Thanks @Melvin-Moderator To be honest I did expect to have some with a combed back hairline as we usually do so for patients. Unfortunately when I went back to the backed up photos I couldn’t come across any. I’m not sure if the person taking the photos that time was following strict social distancing guidelines and forgot to have a combed photo taken 😂😂

Indeed. His wavy hair and an above average hairs/follicle certainly served him well. He is 46 so I wasn't reluctant in allowing him to delay further work needed in the mid scalp (not a lot needed). It seems his hair is holding well on finasteride and he utilized all 2800 to the frontal zone which turned out to be good for him.

Dear community, This is the case of a 47 year old male- fit and healthy otherwise, who had 2000 FUE grafts transplanted 18 months ago. He has a Fhx of NW 5 and his exam showed some recessions in his hairline and some mild thinning in his mid scalp region. We had originally planned for him to have around 3200-3600 Grafts to address both areas, but was reluctant to proceed with more than a one day session of around 2500 grafts. We opted to delay any further Mid scalp work for another session but commenced him on finasteride to slow down any progression. In total he had 2800 FUE grafts. He had on average 2.8 hairs/graft. 400 refined single haired grafts were utulized for the hairline. The remaining were placed in the frontal zone and anterior midscalp to blend things in. He has always been shaving his head so apologies for not having pre-op photos with his hair long. Pre surgery: Planning: Immediately after: 18 months after:

@AnimaII think the gel is better to apply and control and has a better cooling effect. Do not have much experience with people using the juice itself.