TakeAction

Looks great, how many grafts and what was the distribution between the front and crown?

I think you're on track. You should see a lot of improvement in the next couple months.

No side effects, some regrowth but nothing crazy. Hair loss stopped. I take 1.5 mg dutasteride and 5 mg oral minoxidil daily. But you don't need more than 0.5 mg dutasteride.

Also concealers work very well in the crown because it's completely surrounded by hair (if you have hair in the midscalp). So if someone focuses on the front 2/3 and adds a small amount in the crown, they can use concealers and have the appearance of a full head of hair.

I don't see much of a downside to adding in dutasteride once or twice a week. Most studies show no significant difference between dut and fin side effect incidence but dut works better. I never took fin, went straight to dut.

Final result is very dense. How do you avoid shock loss when the patient has this much native hair?

I lost my hair similarly, the crown lost 80 percent of the density in a NW6-7 crown pattern and my hairline and midscalp were still pretty intact.

Yeah 100%, I never noticed Joe Rogan's FUT scar and I'd been watching MMA for years before I got into HT research and learned he'd had one. Not the end of the world. And exactly no matter how good the technique, you simply cannot extract 100 percent of the donor from any subsection of the donor with FUE like you can with FUT. Unless of course you're just gonna leave a massive bald scarred area visible. Yeah I think either way it'll cost a lot though. I will say, PIttella is 4-5 dollars per graft which is not much higher or the same as several of the surgeons you mentioned. Only thing is he has a massive waitlist of 1.5 years now and it's expanding fast. But with Pittella FUE + beard you probably will get full coverage in one session. He also uses a TON of grafts. You'd probably get 9k minimum from him.

Also check out Melvin's podcast with Ted Miln that just came out. Another FUT guy who seems solid. His IG has some great results.

Yeah it's far from insignificant. I think people are too afraid of the scar because most people are not high norwoods and don't need extra grafts so they don't benefit much from FUT. But for those of us who are higher norwoods and need 6k grafts or more, there's a massive benefit. I personally don't mind trading a linear scar for 3k extra grafts. My donor is quite good in the occipital region but not so great on the sides, so it makes even more sense to use FUT to get all of those thicker grafts. Most people have stronger occipital hair than temporal, but for me it's a pretty significant difference. I probably need about 6k total and I might not be able to get that with FUE alone, but I probably can with FUT. I actually met a guy last year at brunch who had a haircut that exposed his FUT scar. It didn't look bad, and I brought it up later and we talked about transplants. The scar was pretty thin and honestly I wouldn't have thought much of it if I didn't know about transplants. It wasn't some disgusting frankenstein scar, and if he had let his hair grow another two weeks it would've been covered. We can always talk about worst case scenarios i.e. "what if the scar stretches" --> then you grow your hair out longer. Everything comes with some risk. Not everyone has the luxury of being able to do just FUE and get the result we want. And some people say "just use beard hair" which I don't agree with. Scalp hair is far superior in terms of appearance for obvious reasons. Beard hair is something I'd only use when I've maxed out FUT and FUE. Like I've said before I wouldn't do FUT if I were a NW3 or even a NW4. But FUT has it's place, especially for high norwoods.

Don't get me wrong, if I were a full blown NW7 I'd go to Pittella. I mostly agree with you. But I don't think it's true that a patient would be lucky to get only 1000 more grafts with FUT. Assuming a strip 25 cm long and 1.8 cm wide most patients can get 45 cm^2 in their first strip, with around 75 FU/cm. That first strip can easily yield 3000+ grafts, and the vast majority of patients who don't have abnormally bad laxity can get a second strip of similar caliber. Conservatively most patients can get 5000 or more lifetime FUT grafts (with two strips). Most surgeons won't take more than 50 percent of the donor, so that entire area would only have yielded 2500 grafts with FUE only. So the average patient can easily get another 2500 or more grafts by combining FUT and FUE. This is where I get the 25 cm strip length from. 30 cm is also used as an example.

I have to disagree, the FUT could be the difference between getting good coverage and not. With FUT (plus FUE) he could get an extra 2000-3000 grafts from his donor. Of course nobody wants a linear scar. I would never advise anyone below a NW4 on meds to do FUT, the benefit just isn't there. But in order to maximize the donor in these high norwood cases, especially someone who's not on a 5AR inhibitor, FUT + FUE is the best way to get enough grafts. Those several thousand grafts are the difference between covering the crown and leaving it bare. So it's either start with FUT, do several procedures and probably get good coverage over a lifetime or do FUE only, not get enough coverage over time and then have to shave. That wouldn't apply if he went to Zarev or Pittella to be fair. But that's out of reach for many people and his goals can be accomplished with FUT + FUE.

TRT is probably the single worst thing you can do to your hair. 400-500 ng/dL is not nearly as bad as some people will have you believe and your libido should be fine at that level. You're probably better off hairwise natty and not on meds than on TRT and dutasteride. TRT destroys SHBG and spikes up free testosterone through the roof. That means much higher scalp DHT. Dutasteride only lowers scalp DHT by about 50 percent. In many cases, TRT + dut is worse than natty and nothing. There are many factors to libido and TRT clinics and marketing have made people believe that a testosterone level in the 400s means you will have zero sex drive. Couldn't be further from the truth. Make some basic lifestyle adjustments and see if that helps.

Nice density and growth. Do you have any pictures of the exposed hairline?

Really impressive. Does the patient have laxity for a second strip? And if he chose instead to do only FUE in the future how much donor hair would he have left in reserve approximately?