DrTBarghouthi

Absolutely. Irregularities are one component. Microscopically sorted Single haired grafts, direction and angulation are among the other things that matter. Also paying attention to the various facial geometry.

You're welcome!! Well I understand your view on it and it is always an advantage having some realistic goals and expectations and a plan B. I dont think given your current maintenance regimen that filling the recessions is unreasonable. I think you can reach with your surgeon for a good plan whereby you achieve the hairline you like and at the same time preserve as much as needed for any future work needed. There might be compromises in the future, but again you seem like someone who understands this quite well.

Thanks for the info. Honestly, If I were you, I would wait a bit. It seems to me that you could potentially end up with the crown extending quite low and that would eat out into the donor area in the middle. This ofcourse will reduce the total possible donor numbers. Another problem is that you frontal midline is still quite low compared to the recessions and this will require a bigger surface area of the temple recessions to be closed in order to keep the hairline looking natural. I would say you will need around 2000 grafts to get a homogenous hairline that follows your low forelock. The question is should you invest these right now? I would be reluctant myself because your overall look right now is good. You definitely have some thinning in the crown that is of concern to me as to how low will it extend into the donor and it is advisable that you wait for that with the medications until it stabilizes a bit more or until we know that the pattern is fairly well controlled on meds.

Thanks for posting. Yes your pattern is still fairly controlled. May I ask what age are you and what your family history is like ?

Micro and macro irregularities in the transition zone of the hairline is a very essential step in hairline creation. In fact it is a standard of practice. I doubt that top docs would avoid such a step. It might not be obvious on photos immediately after surgery, but I am quite sure the docs mentioned follow the same standards of practice when it comes to that. Of note, these irregularities dont have to look so obvious on photos but just enough not to have very obvious perfectly aligned side by side hair follicles. Important thing also is not to over do the irregularities as this can also look obvious when hair grows or is combed backwards.

I usually recommend olive oil on both the recipient and donor areas for the first 5 days and upto before the 10 days scrub. Helps soften the crusting. After that, I use Aloe vera gel on both areas as this is usually when the itching and redness peaks. Highly recommended.

Definitely the first time I encounter such a question! Congrats @AB2000 So extended water fasts can surely induce a state of shock loss or telogen effluvium as our body would consider hair cycling as non essential function. This however should go back to its norm within around 6 months after completion, provided you go back to a healthy balanced diet. Transplanted hairs should not really act differently. There most likely will be a delay in cyclin and the initial dormant stage might be extended to beyond the first 3 months. However, there is no reason that transplanted hairs will act differently to normal cycling hairs once implanted beyond a certain period of time. My assumption is that there will be delayed growth nonetheless. Again this is just my opinion based on what I know about extended fasting and hair loss. I dont believe there is solid evidence yet in literature about this in particular.

Doesn’t seem you need much work done. Maybe few hairs to be extracted from the hairline and if anything some softening with single hairs will probably do. You can also leave it be.

i dont believe there is a certain age for that. I think it is always good to start off with a strict safe zone. Further follow up over the years and for any subsequent surgeries, one can evaluate the unextracted areas and extend a bit beyond. Maybe a simple rule of thumb (not always applicable) is to stay safe for thos ein their 20s and 30s. Be a bit more open about extending the area in the 40 age group and beyond.

Very nice documentation of your journey. Congratulations!

1. I strongly believe that hair restoration- just like hair loss is a dynamic process. Therefore, Restoration should in most cases be seen on a patient by patient basis. It is important to start off with the safest region first, extract a decent number that will greatly fulfil expectations . These patients are then followed up and if the donor pattern is leaning towards a less aggressive pattern, then that donor area extraction can be extended gradually if no significant miniaturization is seen on dermoscopy. I’m not in line with utilizing the entire donor limits from the first go unless the final pattern is clearly reached. 2. Vaccum assisted extraction adds further stress on the follicles. It is hard to judge the effect of vaccum on drying up grafts. Remember that dryness is more significant than partial transection when it comes to survival. 3. I have numerous patients who have had surgeries in clinics that claim new and secret techniques. One of them is a clinic that claims only partial extraction of the follicles to preserve your donor. Unfortunately they end up having 2-3 procedures before noticing any significant growth in the recipient area. When we do one session for them after that, they realize how different their results are and the huge improvement they get after only one proper transplant. 4. I am on the members selection committee of the ISHRS. I therefore go through the new applications. According to the ISHRS guidelines, naming new techniques that are not backed by evidence for the sake of marketing is a questionable thing and can lead to a member being refused membership or even for an existing member to be asked to provide further explanations about this technique.

Looks as expected. Can you share some before and immediately after photos?

@transplantedphilofcourse there are well researched patients and those who mention their areas of concern or at least those who have been to several decent clinics for second opinions. I’m not talking about this group of sensible, well read up candidates. In fact those are a real pleasure to have in a consultation. The ones I’m talking about can be spotted instantly. They usually send a photo by email or social media, mention that they need an x amount of grafts and in certain areas. There will usually be an immediate question about pricing for this x amount too. They usually have other more important areas to address but they are just fixated on a certain region such as the crown for example. This group of patients is what I consider to be bad candidates.

Spot on and great points @Melvin-Moderator In addition to those, may I add that I personally consider patients who come in demanding a certain amount of grafts and dictating where they should go- as bad hair transplant candidates.

Hi @JohnCasper I’m sorry I jumped into here. To be honest given the patient’s age and family history we thought i will be appropriate to only close of part of his anterior crown/ posterior MIdscalp region and not go into the actual crown just yet. So there was a small area in front of his crown that used to cause him styling difficulties and that’s the one we decided to cover. The crown we thought best to delay altogether, keep him on finasteride and hopefully tackle it in the future with a decent amount if need be. 🙏🏻

This can and will be a never ending mess. 😂 First of all the scars will most likely be linear as adjacent FUE punches will form continuous scars. Therefore the whole area will be scarred/burnt looking or similar to some forms of scarring alopecia. Now the risk with that is that SMP might not hold well , might fade in an unpredicted way or might even lead to complications with color as the skin texture is different.

Craig Bottomley @scalpmicrouk is excellent too imo

Thanks @Melvin-Moderator it’s a tough battle at times when you’re surrounded with all these “shops” just using any marketing tool possible to book clients. They employ all possible strategies from price cuts to fake results and unreasonable expectations. Becomes very easy for average un researched person to believe it and think that an honest opinion is rather a sign of incompetence. The dangerous part is when some doctors start following these strategies to keep up with the competition even if unintentionally.

Great post. While you have an excellent result @Melvin-Moderator, transplants need to give a great “illusion” of density. The challenge is to try and convey this in the consultation as a doctor and accepting those clients that have realistic expectations and no red flags regarding unrealistic expectations or outcomes. Unfortunately, the marketing scams that some practices employ gives people the impression that hair will be restored like teenage years. A really big problem!

Sounds like a generally good plan. I prefer delaying the crown. However, I think the front and mid sections will likely need a bit more than 2200. You will get good contrast And coverage with that figure since your hair to scalp contrast will help but I think 500-700 more grafts for the front and mid section will be a home run.

Hi @azza786 I understand how tough this has been, especially that everything has been beyond anyone’s control. Don’t give up, techniques in hair restoration have evolved and I think you can get a really good outcome with SMP in good hands. Another thing I really like for cases like yours or for botched up cases that I see a lot of in my practice is a custom made hair system or prosthesis. They are now becoming extremely natural and of a high quality. I can recommend some in private if you wish. I usually do a small hairline FUE to make it look more natural and make the measurements for the system right behind the hairline. I think your existing hairline can work well to blend with a system right behind it. I can share some photos with you too. The point is there will always be something that can be done to get you moving on. Don’t give up!

Beautiful result! Congratulations!

May well be. It’s just hard to tell with all the harvesting done. Although the miniaturization in the donor doesn't seem quite diffuse as in DUPA. You can see a thicker segment of donor in the middle that is uniform. Probably dermoscopy of that Region can show if they are thinning better.

Yes indeed. I still think this is quite unusual. I think looking at it in depth is quite important. Maybe a biopsy with a dermatopathologist can reveal something?

How come all the surgeries yielded low results? Have you investigated this through biopsies etc? A hair system with a naturally transplanted hairline is currently my preferred choice for cases similar to you.