consequence

I had surgery a few months ago and it was recommended to me to inject PRP after surgery on a schedule of 1 month before, 1 month after then at 3, 6, 9 and 12 months. One question I had for those of you that have done this is where exactly did you have your PRP injected? These are my pics immediately post op and now, a few months later: I think I'll go in for PRP soon but am not sure which level to inject at. If I go directly into the operative bed (circled in yellow), I'm worried about possible damaging the follicles. So I'm thinking perhaps injecting above and letting the fluid diffuse down, though concentration will be lost in diffusion and distribution of PRP won't be as even. I asked Dr. Couto his thoughts about this but he hasn't gotten back to me yet. There's a clinic I came across that also ties a rubber band around the patients forehead for a short period after the injection, apparently to keep the PRP in the region near the follicles. They also use an extracellular matrix to gunk up the area (Acell, or dried pig bladder basically) to keep the PRP around. A red flag with this clinic was they also used stem cell therapy for an added fee which, as far as the research I've read, would have no reasonable mechanism of effect. Why would a foreign stem cell just decide to become a hair follicle after being injected? Also regarding the acell, I'm not sure I want to add a foreign protein to my scalp at a time when blood supply is so delicate. Some people have talked about platelet reduced fibrin as a natural matrix that may have more effect, but there's not even research on PRP in the post-op setting. I think good data on PRF is decades away, which is not a relevant time frame for me. Basically there are a lot of new things being tried but not much in the way of formalized research. So that means I'm left with just asking around and seeing what's worked for you guys. Any advice would be sincerely appreciated.

That's a really good point and I know that's the party line, but as we don't know what actually causes it I don't think this is something we can unequivocally state. For example, it has been reported in association with hepatitis C and sure as heck acts a lot like a skin infection. My hunch is down the line we'll realize there's an underlying bug (or bugs) that some people have an immune response to and others do not. Like it's odd that ketoconazole works for hairloss, and I know there's a mechanistic explanation but it always makes me wonder about occult fungal infections. But yes, I think the "lichen" in it made me stray into broscience more than I intended to in my post -- you are correct, as far as we know it's not infectious in the classical sense. Tinea capitis, on the other hand, is infectious and can cause hair loss, so my caution about sweaty gym benches stands though. 😅😅

Ok thanks guys. Fingers crossed. Couto in Madrid.

I have a similar situation though only at 12 weeks. I figure if it sticks around I can go back for a minor revision. Annoying but what are you gonna do.

Hey guys, I'm 12 weeks out from surgery and there are these persistent gaps in my hairline that are bugging me. Is this normal at this time point? It seems like most of the grafts on the right have come in, just very wispy. On the left it's more like 80-85%. Did any of you have similar situations? And did it work out? I've been trying to stay away from the forums during the healing as this place gets me a bit too much in my head but I just wanted your thoughts on this. If it is abnormal, anything I can do to help it along? Have any of you tried PRP post op?

I'm 3 months out from my surgery with Couto. Very jealous of your incredible results. I feel like I'm lagging next to you. Are you doing anything to help growth? Did you do PRP?

I'm sorry you had to go through all this. What are you going to do now?

Couto did the entire implantation himself. He is extremely meticulous and careful.

This probably isn't an active question for you anymore but in case anyone else has the same -- at around 10 days my scabs became brittle and came off with relatively light pressure for about 85% of them. Over the next few days the remaining 15% came off with just a gentle pressing motion. Melvin has a video floating around somewhere on YouTube where he shows the actual pressing technique to remove the scabs that I thought was helpful.

Also here are the pictures taken by the clinic themselves at the time of my surgery, as I never submitted those with my original post: The crazy stuff we do for our hair, right? 😅

Here are some updates. I'm trying more magnified views for this period as a lot of the changes are subtle and difficult to see from a distance. Also taking pictures with my camera in "outwards facing" mode as selfie mode also seems to blur a lot of the fine detail and nuance. 11 weeks: 12 weeks: From above at 12 weeks: Frontal view further away, 12 weeks: Oblique view at 12 weeks -- the pic below really shows the difference between the frontal line where Couto did denser packing and then the less dense area behind. Hairs have come in for the most part but they're still narrow caliber: Funny that that one hair at the bottom that just took off on his own like Usain Bolt. At this much magnification I know some people might say the density seems sparse, but this may not be the case when the hairs thicken up down the line (hopefully). As I discussed in my previous post above, I think there is a "critical threshold" we have to be cautious of with transplantation to reduce the risk of necrosis. The left side is lagging behind the right and without quite the same yield just yet. There are a few open spots at 12 weeks but it's a work in progress: If these don't fill up I may return to Madrid to "top off" the hairline in the future, but let's see what the next 9 months bring. Not really sure why but it seems to me there was a significant jump between 11 and 12 weeks. I did make some changes to my supplement regimen during this period which I will post on at a later time, but it could also just be the random will of the Hair Gods. In general I'm happy with how it's been coming along. My face is framed much better, and with my hair combed forward you really can't tell I've had any work. As far as post op care, there don't seem to be many hard recommendations in the medical literature or my instruction packet, so I've just generally been trying to stay healthy: I cut out stimulants to large degree (Ritalin, caffeine, modafinil etc) as they are vasoconstrictors and impair sleep -- I want to make sure blood flow is as good as possible. To keep the garden "watered" if you will. Exercising, but not a crazy amount as it is a bit of a free radical inductant. Cleaned up my diet but not doing intermittent fasting until I hit the 1 year mark. Just want to keep my body in a comfortable "growth" environment, and dramatic weight loss is probably not part of that equation. Still keeping my weight healthy and avoiding high blood pressure is also important as hypertension also reduces peripheral blood flow. I did do PRP a month prior and a month after, but instead of directly into the operative bed I went a little above and wore an elastic headband for an hour or two afterwards to let gravity passively draw the injected solution in the operative bed and bathe the dermal papillae. I may do another session now at 3 months but still pondering. I adjusted my job which used to be overnight to evening hours and will be reducing my hours further just to rest more. Basically just doing my best to make the follicles feel as welcome as possible in their new home. 🤗 I sometimes think back to that post about the dude who was asking if it was okay to snort cocaine before his hair transplant because he didn't want to "ruin his New Year's". 👀 Just amazed at the range of patients on this forum sometimes. To be honest I've been keeping away from the forums as viewing posts and getting criticism during recovery can be a bit stressful. Having good sleep and peace of mind are a huge part of healing I think -- perhaps because they impact growth hormone levels. One thing that has become painfully clear in recovery is how lucky I am to have this forum. I tried researching for some other surgeries (one non cosmetic and the other cosmetic) and there is nothing like HRN on the entire planet for either of them. Realself, Yelp, Facebook, Reddit, nothing came close. Certainly no place is perfect but that's just the nature of the beast, especially with techniques in hair restoration being so new in the larger scale of things. We are really spoiled by this place (and its sister foreign language equivalents) and for that I am truly appreciative. Song of the moment -- Mafro's "Alright". Cautiously optimistic and hopeful. To those of you in recovery I wish you best of luck! And a big thank you to everyone else for your advice and insights.

It is really absurd that with so many things in post op recovery with this process (sun exposure, hats, weight lifting, caffeine, alcohol, laser helmets, PRP, growth hormone, etc.) -- no one seems to have a proven answer, so we end up just listening to the most confident guy in the room that matches up to what we secretly would like the answer to be. Really frustrating aspect of recovery -- how in the dark we are and how variable things can be as far as recovery recommendations. And then the ridiculous "ask your surgeon" which means almost nothing because the surgeon is just guessing too. Considering that FUT/FUE has been around for decades, it's pretty pathetic that studies on differing post op recovery regimens haven't been studied essentially at all. For non cosmetic surgeries, things are so much more concrete and studied. Bizarre how under-researched anything in the hair industry is that doesn't directly lead to profit. Trying to research hair dye today and beyond the obvious no ammonia suggestion, I've seen recs range from 2 weeks to 9 months. What. The. F*ck. My lady broke up with me right before my procedure and trying to get back into the dating scene. 6 weeks out and 70% gray which makes me look about a decade older than I actually am. What a sh*t show. Be prepared for that fellas, having flashbacks to how I felt during quarantine. Whatever. Just venting. Probably won't get any response to this post. That's fine too. Good luck to anyone who reads this.

100 grafts per cm2 is just asking for trouble. Does anyone have a link to this case?

Do you have more detailed pics of your journey leading to this point? And any immediate pre op/post op of the surgery itself? Something about this thread and its limited pics comes off so strange.

Very nice! Not sure how you got the clinic to send you their pics at the time of surgery, I asked like 5 times and they never sent me anything, I thought that was a policy they had. 😀 You're coming along great Bobby D. We are very close in timing and age. Saying a prayer to the Hair Gods for you.

I wish there was actual peer reviewed literature on this subject. Most surgeons guess 2-4 weeks. One thing I noticed is that when I had a bit of itching at my donor. When I started back up on keto 2% it went down about 80-90%, I believe because of its anti-inflammatory effect. With the scalp being literally like a petri dish after surgery, I wonder if it killed some bug that had taken up residence.

Those temples definitely looked a bit wonky at first. The revision is better, though if still unhappy can fix with a touch up down the line.

It took a long time, this is true. But I was willing to be patient because a year or two here and there meant nothing when compared to the permanence of a transplant. Part of what makes Couto so good is how much care he takes with each individual patient, as opposed to these Bosley-type Hair Mills that scalp patients by the score like they're reenacting Little Bighorn. Good things come to those who wait.

Wowza. There's almost no part of your scalp that was untouched, either to extract or to place. Almost amoebic in scope. Do you have any pics in outdoor lighting of both recipient and donor?

Make sure you keep your grafts moisturized to avoid cracking. Make sure you keep

I've seen this comment on other cases of his recently and it has been on my mind as well. That being said, here's my head (top) next to another case of his (below): Taking into account the differences in picture resolution, I think the density looks pretty similar. This is how that case turned out: In my opinion a very pleasant result, though I am cherry picking a bit. Here is @Ramsey's recent procedure with Couto that he recently posted: And his comment: Now we can compare to another surgeon that's known for dense packing: Much denser packing but probably with a similar end result, especially when viewed from above. What Couto does is transplant the frontal line more densely but then spaces out behind, presumably to avoid graft loss or necrosis from overdense packing, and to stretch out coverage. The frontal line needs the most density, but it is also usually the oldest place of recession and so has been fibrotic for longer. Remember the blood supply of the scalp: z Too little density and you get corn rows. Too much and you risk necrosis. It's a balancing act. This illusion has seemed to work well for him in the past, particularly with darker haired patients, as long as the frontal line grows -- what another surgeon has referred to as the "illusion of coverage". Also part of the apparent spacing is from increased photo resolution, as historically most people on here don't post pics from so close and with high resolution. Perhaps also because he uses PRP during the recovery period I think hair caliber contributes to this illusion, though certainly I know there are people here that think PRP doesn't make much of a difference. Platelet reduced fibrin (PRF) seems to be the new contender in this aspect of recovery, though almost nothing is known about either in post op recovery medical literature just yet. For me, the main reason I came to Couto was his temple points. Hopefully the density will be sufficient, but if not that can be readdressed with a minor procedure down the line. But yes, certainly in my vulnerable post op state any ambiguous or critical commentary is more than enough to send me down a spiral of analyzing pics across the forums. But beyond adding PRP to my recovery and taking care of my health not much else to do but wait patiently and pray to the Hair Gods.

Here I am at 4 weeks post surgery - shedding has progressed though it seems the temples have held on a little more and the left side is looking less patchy than the right. Good times.

So you posted to look for an echo chamber in where people just tell you everything is going to be okay? Don't demagogue your own health. I'm not going to lie about my personal opinion if you're asking for feedback. Not taking action is not always "anxiety" or "analysis paralysis", it can also be a legitimately good decision. Sometimes the best course of action is not to just do something but stand there. If you're dead set against Europe, the surgeon in North America with the best track record for the softer rounded temples you seek is Konior. Rahal tends to go back straight into patient's native temples without as much rebuilding. Both have similar success rates with FUE, not as good as Hasson or the European folks but better than most North Americans. It is very dangerous to make permanent hair transplant decisions based on geographic convenience. Better to wait till you have the funds and resources to decide based on patient posted cases. Especially as your hair is so fine. Good luck with your procedure regardless of where you go.

It sounds like distance is a massive factor then. I'm not going to link specific cases but some of his patient posted results have caused me serious concern in the past.

If you're not thinking about meds long term, with your diffuse thinning you're essentially gauranteed a NW7 down the line. Any transplant you get should be done with an anticipation that your native hairs will recede behind it. I would be very cautious. It may not be right for you.