general-etwan

Exactly. Better to be conservative and leave areas being "treated" by medication a chance to respond to that medication for a good while first. As a doctor, you don't want to be transplanting into areas that could naturally strengthen from medication and topical treatment. You can always address more areas in future procedures, but you only have a limited number of grafts to work with that first go because you want to make sure you don't over-harvest the scalp donor area.

I disagree that it's as easy as saying that. Without knowing the area of coverage needed, density desired, and number of donor grafts available, it's impossible to say whether it is proper to implant in lateral ridges immediately or not. It's not wise to implant heavily into an area of still-native-growing hair, especially when medication + topicals need more time to see if they are going to improve the area or not. If they are, then you definitely shouldn't be implanting into that area so soon. Bald areas should always be addressed first, and thinning areas second, in my opinion.

I have to say I don't recall ever seeing that large of an area done on a patient before all at once. If you can find me an example, I'd be very impressed with the work. Would you have done the area outlined in red all in one giant procedure? That would have taken an outrageous number of grafts, would have taken 4 or 5 days, and density would have been lower and unacceptable. Also, the lateral ridge areas were still covered with some hair and transplanting into hairy areas isn't usually advocated for because it could do damage to native hair there. Medication is almost always recommended a solid try first. At the time of this picture, I was only on finasteride for 7-8 months, and it can take 10-12 months to sometimes see progress from finasteride in those areas of thinning hair. So our agreed plan was to wait and see if I'd get any regrowth or strengthening. If so, then transplanted hair to that area wouldn't be ultimately necessary. 5300 grafts is a lot for one procedure. The consensus is usually play it safe and don't let doctors jump the gun with too many grafts too quickly and massacre your donor area. You can always have more procedures. The only alternative that actually would have been feasible is this: Is that what you would have endorsed? This makes more sense. That would have required even more grafts still, probably 6,000+ and we didn't want to take any more than 4,000 from scalp donor. And at the time, I probably wouldn't have liked the idea or agreed to it. I highly, highly doubt I have 10,000 grafts available for use. Slicking back is a realistic strategy for extremely high Norwoods and middle-aged to older men who have traditionally done that anyway. The reason to not implant entire lateral ridges on a first procedure is because medication may improve the area, and at that time we were still waiting to see if I would get satisfactory improvement from medication + topicals. In my case, anyway. And, 4,000 was a ton of grafts to be taking from my scalp donor on first-observation and first-procedure, so it wouldn't have been proper to jump the gun so much from the start. I disagree completely that there's anything shady about it. We pay for grafts. I'm not paying any more depending on if the lateral ridges were addressed 1st or 2nd. Hair = hair in the end. And I haven't lost any hair due to damage that I otherwise would have kept. Nothing "luring" about it at all. And Eugenix didn't initially want to schedule me this early for a 2nd procedure. I essentially made them because I feel confident enough to keep the ball rolling and want to get it done now. Dr. Das and I spoke ALL about this before my first procedure. Let me make that VERY clear. Not sure where this idea of it being "hidden" or "secret" comes from.

Never said I wouldn't care, just that it will be less than at 28. Guaranteed That is indeed a great explanation by Dr. Muresanu. Very clear, very informative. Unfortunately as he stated exactly, it's a difficult decision whether or not to do temple reconstruction in patients with severe hair loss with side hair that may continue to regress. You say here to consider skipping the lower rear crown region entirely but don't provide any alternative. If you'd like to be clearer, where are you saying to do the work if not doing any work there at all? The problem is still there is a severe contrast between the lower back of the head (thick, dense hair) and right above it (severely thinned, light hair). Even if just a few hundred are placed in the lower rear crown area, it will help a lot with visual redistribution and will not leave such a severe line of hair characteristic change. I agree most of focus should go to side lateral ridges and front. Yes. I have been using pyrilutamide since the beginning of this year in addition to finasteride. Seemed to have been giving positive results. Stopped because of this upcoming procedure. What's left? Pretty much just dutasteride. Everything else is unproven experimental.

Thanks for all of your contribution and you’re welcome to discuss any time. You don’t have to declare that any given comment will “be your last.” Notice I stated DHT resistant a few comments up; we fully understand. But the fact is the pattern of hair loss is already almost entirely visible. The end of the road already came for me, and it’s about battling back. Each person should prioritize what they value most. I know that personally, I’m not going to care as much what my hair looks like at 50 as I do right now. Youth is fleeting. And this isn’t meaning that I don’t understand the proper way to plan HTs out over the years. I’ve spent hundreds of hours since I began this journey thinking about all of this. I think about it every day. Niko1’s design looks proper for the situation he faced. We’ll make sure we put together a realistic and proper plan next week.

@Niko1 Any feelings or advice on my 2nd HT next week? You and I have a very similar hair loss pattern and also very similar HT design strategies. I see the way they wrapped around with your remaining horseshoe pattern and took care of your ridges and lower crown with 2,000 grafts.

Following! Looking to your case and situation for inspiration for my own. I, too, am having the lateral ridges and lower crown addressed in my 2nd HT next week, after it was not addressed in my first HT. Really difficult situation for us NW7s. You are looking better and better and I think with this last redistribution, it's going to look really good.

I agree most grafts will need to be concentrated along the middle lateral ridge areas. But the transplantation zone has to follow the line of the pattern of hair loss. This is NW 7 patterning - the "game over" pattern is there; if anything it will dip very gradually over the rest of life, but it's already 90%+ of the way there. So you have to fill the area appropriately in order to be able to let hair grow for a few weeks and not have an unnatural disconnect in the mid-to-high ridge regions. It's a good time for a reminder that we notice every little detail as HT-invested people whereas the vast majority of regular people do not think about hair loss patterns very much and they will not notice minor issues. The goal, in my perspective and what I teach to others, is always as much redistribution as possible (without massacring donor area) to the top and lateral ridges of the scalp, as that is where hair needs to be for appealing presentation. There are multiple different ways to handle issues on the sides of the head, SMP for example, that I don't endorse for top-of-scalp use because people focus on the tops of our heads and they usually look too unnatural when used there. Here's another visual representation of what I believe it should look like. Lower crown will need some grafts, but less than lateral ridge areas.

Balding is close to done. NW7 by mid 20s. 4000 grafts not needed for my goals here. 2,000-3,000 can still make a big improvement. The goal must be to close the disconnect. And if someone holds a gun at your head and forces you to choose where you want the disconnect to be, you should choose lower on the sides of the head because it's more typical to shave and fade that area, meaning the top and lateral ridge areas of your head can be grown longer as they should be. You don't want choose disconnect where it is right now, higher up, with longer hair below it. There is no lesson here other than perhaps you're inserting your own inaccurate perspectives into this a little too much. My process of doing research did not just involve looking at some other good cases and then going with it. The current situation I have was predicted and discussed by me, Dr. Das, and team last year. None of what you said is representative of me or my process.

Respectfully disagree. Do you understand the extent and difficulty of what my situation was? I knew and agreed to our first HT covering the entire top, hairline to upper crown, knowing the lateral ridge and lower crown areas would continue thinning and would need to be addressed somehow, some way in the future. What would your planning have been? I didn’t hear any alternative. To rip away 9,000 grafts in one procedure, massacre donor area, and implant all over an area that would have then suffered shock loss? That can't be done. And I don't have that donor. The most important areas to get hair first are the top, midscalp to front hairline. I don't need 4,000 more grafts. That might be your opinion but you're not me so you don't get to decide what my goals are. If we can get 2,000-3,000 (which I think we can with beard hair used again if necessary) redistributed to lateral ridge areas, that is going to make a massive improvement of overall uniformity. My situation has already improved tremendously thanks to the job the team at Eugenix did the first time. I could never afford that.

Remember the entire goal of hair transplants is supposed to be hair redistribution. It doesn't matter if the horseshoe area isn't as dense as it would ideally would be. It simply has to have more DHT-resistant hair than it does right now, and match the top and lower sides as closely as possible, so that constant haircuts are not required. The entire reason for thi second procedure is so I don't have to get a faded buzz every 3 days to look good. Nobody got time for that. The horseshoe area is the only the target of this procedure. Otherwise I wouldn't be going back. That said, I agree with these specifics here, of course. Priority should be front to mid lateral ridge area, with gradual less focus on the lower crown. The lower crown will need some grafts, though, as the upper crown has already been worked on, so the lower crown cannot be completely ignored or there will be an unnaturally low bald spot. They're going to have to put some grafts there, guaranteed. Maybe less dense than the upper crown; but it has to pass as not having a huge visual distinction. Remember there isn't much more balding to go for me. I was already a NW 6/7 in early 20s, which in part makes it at least a bit simpler in terms of future-proofing than someone who is unlucky enough to suffer from slow hair loss continuing all the way to NW7 over decades.

Another pic just from today in somewhat natural lighting.

Interesting idea. I’ll keep everything on table. Not sure if due to slightly different hair beard hair characteristics, if that’s something they would ever do. Lower on the list of priorities, sides of head not too important to me.

How many more grafts estimated? I’d love to get more density throughout the top because my hair is very thin, but I have to address the side ridges first and foremost in my situation. You look like you have a good bit of donor still available before any real visible thinning would even occur.

What’s the plan for 2nd procedure? Edit: read it’s for more density. Will they be buzzing your entire head?

It’s you. From time to time the site will reference cases from here in an Instagram post to recognize good work and results. I have Dr. Das and Dr. Somesh collaborating. Next Thursday June 8th.

Will be watching!

This is an absolutely fantastic result. I saw you first on Instagram and asked whether your hair was naturally curly or if you got a perm. It’s naturally wavy/curly. I think that helps a good bit towards the whole illusion of density concept too. You’re looking fantastic! I haven’t seen anyone else perm their hair after a HT, but I will probably try it a few months down the road after my 2nd HT with Eugenix next week. It’s a popular cut, makes you look younger, and helps visual density.

She said this to me, too. The reality is I think it’s just too much to do all in one procedure. And the reality is also that the lateral humps and lower crown will not regrow even with the best meds on the planet for 99% of people. If you look at my case, I’m now going back for work on the lateral ridges and lower crown, and I always knew that was a future possibly. And now the time is here. You’re looking good so far I think!

Also, I'm assuming and hoping they can leave the top at this length (or at least some length) through the procedure. Kinda don't want to buzz my whole head right now. 🙃

Thanks for the input here everyone. One more thing I wanted to state which is pretty much common sense though: those thinning lateral ridge areas, which have been that way for many years...they look okayish when everything under them is buzzed super short. But when grown out, that's where the obvious disconnect appears because the hairs on the lateral ridges literally stop growing at a certain length. I've gone 2+ months without a haircut now and the hair there just won't grow any longer. It won't keep up with the top or lower sides. So this is what I'm thinking now: 1st priority: lateral ridges (humps as you guys call them) all the way to the front of the hairline 2nd priority: lower crown area to match upper crown density (which is already done) as closely as possible. No temple reconstruction; no grafts will be available for that most likely Some more pictures (I hate the look on my face in these so I'm not sharing it with y'all lol). Also this was straight out of the shower with no styling or anything, so hair looks pretty meh. But you can see where the lateral ridge work is absolutely needed. I want to compare to someone who has a similar hair pattern to mine: Dustin Johnson. Age: 38, hair loss def started in 20s. If you look closely, you can see he's lost a significant amount of temple-area hair too. But despite suffering from hair loss at a young age, his look is still quite okay, mainly because he's been able to hold onto the middle portion of the front, and the lateral ridge areas aren't too bad. I'm looking at his situation for inspiration for my case. So, I'm going to go in with this plan: I will tell them to use some sideburn hair (circled blue #2) because if you go back and look at my pics from 1st procedure, they marked that area as usable for donor if needed but then didn't end up using it. Plus, since the temples have already thinned, it will look better if the hair underneath them in the sideburns thin more similarly anyway. I don't ever plan to wear my sideburns all wild like I have them in this picture. I'm just not touching anything until next week so Eugenix can see everything as it is. Here, the black dotted line is just an imaginary line of where the temples would go to, if I were to have work done there. But since it's so minor, and it's more important to focus the hair on the lateral ridges/top/lower crown, really not worried about that at this time.

On finasteride since Jan 2022 so nothing has changed there. What has changed is I stopped using minoxidil and pyrilutamide several weeks ago in leadup to this 2nd surgery. And that picture I posted the other day is literally like 2 feet directly underneath three bright bathroom lightbulbs. Yes. So super harsh lighting and angle.

I agree, SMP always available for back and sides if it gets too thinned out. Yeah, so we knew going back from the first procedure those lateral humps and lower crown were significantly thinned out areas; they wouldn't address those all in the same 1st procedure. It's an illusion indeed that when the sides and back are buzzed and faded super short, lateral humps and lower crown look passable from a distance but they never actually have been in reality, with hair grown out longer. Also to clarify for everyone else too: Yes I am on finasteride and have been since Jan 2022. But like it has been said, it probably doesn't even really do a whole lot for me. And once hairs lose over 50% of their original natural density, it's game over. I have also stopped using Minoxidil and Pyrilutamide; they told me to stop use 1 month prior to surgery and honestly I got lazy and stopped using both about 2 months before next week. I suspect minoxidil + pyril was keeping some illusion of thickness in the lateral humps that is lost as soon as I stop use. For sure, I agree completely with your analysis: lateral humps are the #1 priority, and lower crown 2nd. I don't have plans to grow out the sides super long, no. But I definitely would like a medium length hairstyle on the top and upper sides, which means those lateral humps are super important for creating that framing. The lower sides and back can always be buzzed down.

For sure, I will make sure the plan is to first attack the lower crown and side ridge areas. Get that all uniform so I can grow hair out to some length and still have it look OK without any big thinning areas. And if that uses up all the available donor grafts I have left, then so be it. I can always keep the sides of my head buzzed super short or shaved; not a big deal at all. The temples would be so tricky like you said. I don't doubt that we could find the grafts to use from some donor, but the big risk would be creating too dark/thick hairs at the front of the temples with hairs that may thin over the years right behind, closer to the ear. I wouldn't want to deal with that visual issue. I absolutely want to go all-in on getting rid of all the disconnect of natural hair on top/sides/crown. I'll make sure to plan with Dr. Das and Dr. Somesh that that thinning ring is 100% taken care of so that all the hair looks uniform. Thanks for this input. I expect the side ridge areas will be a bit tricky. But as Mr. Cross told me on Instagram, it's super important to get some hair as far forward as possible on the side ridges. Will help with visual appearance of thickness from the front if I want to be able to grow a medium-length fluffy hairstyle. Something like this?

Ok everyone, reading over some of your comments. Here are some more pics to share at 8 months of the area to be addressed next week. I am mostly satisfied with the hairline, though I wish I had a little more temple-area coverage to help with the presentation from the front. I of course would like the hairline to be 1 cm or so lower, but I understand that may not be realistic at this point and that it's not bad at all for a mature hairline height going forward. As for the temples, if I were to get them done, I'd guess it would look something like this? ^Option 1: temple reconstruction straight up to meet hairline ^Option 2: Temple reconstruction curved to meet hairline (not sure about this...this is natural for a young male with no hair loss, but Eugenix doesn't really like to do curved like this. They believe straight to hairline is more appropriate for aging.) ^Option 3: Temple reconstruction + hairline lowered by 1 cm. Not sure if this is even an option. Might require too many grafts and be messy and risky at the front. Below are marked-up areas of what I believe absolutely needs to be covered: I expect that the procedure may end up being more than the 2,000 grafts they've estimated at first glance. If we do the lower crown, plus the entire side ridges all the way to the front (basically what I need due to that area thinning), plus the temples, it's probably going to be more like 3,000, assuming we can get that many. What do you think? The middle of my donor area is still looking pretty solid, so I hope we can do at least 2,000 straight from that. Even some sideburn-area hair could be used (originally planned for my 1st procedure but then not used). And I guess some beard if needed again (500-1,000?). Feel free to offer specific advice on the temple areas. I don't want to end up having unnatural looking temples.