Dr. Raymond Konior

StaggerLee123 – The test grafts were placed because the patient was not sure what route of repair to pursue when I first met him. He was upset with the appearance of his original scar and was reluctant to use another strip because of his first experience. Initially he was leaning toward an FUE-only approach. Although he did experience good regrowth in the scar with the test grafts, the several month wait that was required to evaluate the success of his healing helped him solidify his overall goals. He felt that we would be able to get to the finish line quicker and with a better overall result using the final plan that was decided upon. The scar is still there – as one should expect – it’s just that it is now thinner and easier to camouflage with a relatively short length of hair. Aaron1234 – I also wish I could have seen him for the one year follow-up so that I could have taken postop photos using the same perspective and lighting that were used for the preop photos. However, that was impossible as he and I are now 2000 miles apart. I was happy to receive the photos he forwarded to me and felt that they were sufficient to present his interesting story. HARIRI – I do not have a precise hairline density, but it is relatively low based on his overall graft distribution. Our primary goal was not density, but rather naturalness. He had relatively strong, high caliber hair shafts which helped maximize his apparent density and coverage. I believe his hair characteristics are primarily responsible for the high volume appearance he achieved. This would never have been possible with fine, lifeless hair. RCWest – You make a great observation in recognizing what appears to be a happy appearance in his postoperative photos. My greatest satisfaction with this case has been witnessing his transformation from being someone he wasn’t - an unhappy, hat-wearing, hair transplant failure - to becoming himself again – that being a positive, upbeat, and fun-loving guy. I have long recognized how “bad surgery” can alter or devastate one’s sense of self and diminish the quality of one’s life. His attitude and personality transformation has been very inspiring. Thanks to all for such positive feedback.

This presentation is the summary of a five year journey that began when my patient underwent a failed hair restoration at the age of 21. Since his multi-staged repair with me, he has moved back to his home in California. He has been very open about his experience and was kind enough to forward me recent photos of his repair restoration. He has also been gracious enough to allow his photos and story to be presented. His initial procedure was performed at the age of 21. That procedure, which consisted of 1200 grafts, failed to yield the density and appearance he had hoped for. Rather than getting the hairline of his dreams, he was converted into an obligate hat-wearer to hide the stigma of his mistake. The following is a chronological description of my patient’s long journey. April 2008 – The photos from this time were first presented by the patient to this community in 2008. His original 1200 graft procedure occurred about 15 months earlier at the age of 21. He saw me in consultation in September 2008 as which time we discussed his options and concerns. His concerns included: 1) the grafts looked unnatural; 2) the grafted area lacked density; 3) his hairline was placed too low on his forehead; and 4) the donor scar was wide and difficult to hide. I agreed that his hairline was too low and that he would develop an even more unnatural look as his balding progressed with age. We discussed correcting the low hairline using one of two options: 1) a direct hairline excision via a forehead-lift approach; and 2) thinning out the unnatural frontal and temporal grafts via FUE removal. We agreed that the FUE approach was more suited to his needs and concerns. That approach would not only help raise the hairline, but it would also selectively eliminate unnatural grafts from the hairline and temporal regions. Following the staged removal of unsightly grafts, the surgical plan would be finalized with a hairline graft session to enhance frontal density, soften the hairline and revise the donor scar. August 2009 – A small FUE test session was performed. The purpose of this “test” session was to determine: 1) if unsightly grafts could be removed intact; 2) how the exposed hairline extraction sites would heal, i.e. detectable or undetectable; and 3) what the survival and appearance characteristics of the transplanted grafts would be. Photos at this time show unsightly grafts at the hairline and in the temples. Also shown is the original donor scar. The test consisted of 14 extractions. These were placed in the right donor scar. March 2010 – The initial test session was successful in demonstrating acceptable healing characteristics. A more aggressive extraction session which included the removal of low hairline grafts, large grafts, and misdirected grafts was performed. Small extraction sites were left open to heal on their own while larger sites were sutured closed. The goal of the extraction component of the repair plan was not to remove every graft from the low hairline, but rather to remove just enough grafts to adequately soften the hairline and assure a natural end-result. A total of 112 grafts were created from the extracted tissue and these were placed further back in the right frontal region. September 2010 – Wound healing and graft regrowth were determined to be successful from the March 2010 session and another extraction session was performed to further soften the area. A total of 139 grafts were created from the extracted tissue and these were placed in the central frontal zone. October 2010 – A final extraction session was performed to fine-tune the restoration zone of any remaining large, low or misdirected grafts. A total of 55 grafts were created from the extracted tissue and these were placed in the central frontal zone. December 2010 – Restoration Day. Preop transplant photos show how the proposed graft zone has been soften by the removal of large, low and misdirected grafts. The dilemma at this time consisted of the fact that scar revision was a priority for the patient. His wide scar, in combination with limited scalp flexibility, limited our ability to obtain a large harvest without taking the risk of leaving another unacceptable scar. The patient was informed of his density limitations. We established a goal to take a conservative strip and strategically distribute the limited harvest in the most efficient way possible so as to maximize the “illusion” of density. A total of 2377 grafts were used to complete the restoration. A total of 306 grafts had been relocated into the frontal region from the prior graft extraction sessions, thereby giving the restoration zone a final total of 2683 grafts. May 2011 – Five month postoperative photos reveal respectable early growth with a homogeneous graft distribution, softening of the frontal and temporal regions, and good camouflage of the donor site. December 2011 –These are one year postop “about-town” photos which were forwarded to me. They reveal his current hair style. March 2012 – These are 14 month postop photos which were most recently forwarded to me. A final comment – A valuable lesson to learn here is that no one, particularly young men, should venture into surgical restoration without achieving a full understanding of the process they will be undergoing. Many debates have transpired over what age surgical restoration is considered safe. There is no clear cut answer, but technical and planning mistakes are much more likely to occur in young men. I.E. – young men take caution before jumping into the chair.

RichFrog He had an average hair caliber and the graft density was approximately 50 grafts per square centimeter. Spanker The temple density is lower to keep a soft transitional appearance. Although I do not think his pattern will advance to any significant degree, there is no way to be absolutely certain. Grafting with too high a density could then lead to a leading zone of too dense hair. ManinSpace His examination revealed a very isolated frontal thinning with no evidence of miniaturization in the crown or midscalp. Although this is not a guarantee against the future appearance of miniaturization, his history and examination were very encouraging to permit the restoration that was implemented. Thanks to everyone for their kind works.

This is a 27 year old patient who desired high density frontal hairline restoration. Examination revealed miniaturization limited to the frontal hairline region. He underwent a single dense-pack session of 2953 grafts to restore his recessed frontal hairline. Postoperative photos were taken one year after surgery. Representative photos include a one-week postoperative view that highlights his graft placement.

ManinSpace – You pose an outstanding question regarding his decision to aggressively fill the frontotemporal recessions. I believe that the strategy of how one approaches hairline design in terms of location and density is based on several key parameters – each of which must be factored into the final decision as to what should or should not be done with respect to designing the frontal restoration zone. Here are some of the key components that I factored into his plan. A prediction as to the final hair loss pattern – Although there is no way to assess the definitive final pattern for many patients, an educated prognosis can often be made based on age, examination for presence or absence of miniaturization and family history. Analysis of these factors for this case suggested that his final pattern would support the long term aesthetic benefit of the restoration that was performed. Personally, I spend much more time trying to convince patients to be conservative with respect to hairline location and density as there seems to be more patients presenting to my office with the potential for progression to an advanced pattern that would not support aggressive hairline restoration. Fortunately this patient appeared to have just the right combination of factors to allow for the restoration performed. Stabilization therapy – This patient has been on stabilization therapy with finasteride for over 10 years. His examination showed advanced miniaturization confined to the frontal region and very limited miniaturization in the crown. He stated that he had maintained a good response over the treatment period and that he had no plans to alter the treatment regimen. Donor site availability for future treatment – Careful assessment of graft availability within the donor site must be completed to generate a treatment plan that includes planning for any potential future grafting needs that may arise from progression of a pattern. This particular patient had ideal donor characteristics – excellent density, elasticity and healing characteristics. His graft “reserve” was factored into a treatment plan that should allow his overall long-term goals to be fulfilled if his pattern progress. Patient goals – Both short-term and long-term goals need to be prioritized in developing such a grafting scheme. With the understanding that the donor site is finite and that a full head of thick hair is impossible for patients with advanced patterns, a discussion of what would be done in the event of pattern progression must be undertaken with all patients prior to committing to any hairline restoration plan. A patient who has no concern about crown restoration in the short-term or the long-term has the ability to do more in the frontal region than someone who prioritizes coverage from front to back. With respect to this case the front was defined as the highest priority from both a short-term and long-term perspective. Thanks to everyone for their positive comments. This patient had absolutely wonderful hair characteristics which contributed significantly to his final result.

This is a 39 year old male who requested frontal hairline restoration. He presented to my office with a history of previously undergoing a frontal restoration that did not accomplish his density goals. A total of 3165 grafts were placed in his thinning frontal tuft and empty frontotemporal recessions. Two year postoperative photographs demonstrate his final hairline. A comparison view uses arrows to identify several skin markers so as to provide a perspective of the lowering that was achieved.

Two very enthusiastic thumbs up for Dr. Beehner!!

Patients with highly sensitive skin can purchase LMX topical anesthetic cream and apply it over the suture line 30-45 minutes prior to the suture removal. I prefer that the area be cleaned prior to application so as to facilitate absorption into the local skin region. This cream will numb the superficial skin and make the removal process more comfortable.

Thanks for all of your positive comments. I agree that fine hair usually limits the appearance of higher density when grafting over a large area, but this patient had an exceptional hair texture which allowed for the very nice coverage that is seen in the video.

This is a 50 year old patient who hoped to obtain as much coverage as possible for his balding pattern. He was accustomed to wearing long hair and felt that full coverage would provide the best look for his preferred style. Based on a relatively snug donor site it was recommended that he undergo two staged sessions – the first to address his hairline and midscalp regions and the second to manage his bald crown. His first session utilized 3331 grafts to establish a frontal hairline and to restore the midscalp region. The second procedure was performed one year later at which time 1722 grafts were transitioned from the midscalp into the crown. A total of 5053 grafts were used to provide a relatively homogeneous final graft distribution throughout the front, midscalp and crown regions. Representative photographs demonstrate his hairline refinement and the final density obtained along his central part. A video link below best demonstrates the coverage obtained throughout the scalp and the details of his crown restoration. YouTube VIDEO ///

This is a one year postop result for a 35 year old patient who underwent hairline restoration using 3496 grafts in a single session. Multiple views are presented which include a part view through the central graft zone to help demonstrate the density which was gained.

This is a 10 month postop presentation of a 27 year old patient who underwent placement of 4016 grafts. The patient was bothered by thinning in his frontal, midscalp and crown regions. Graft distribution was planned to enhance density throughout these three regions. Images presented here include an immediate postop view which depicts the graft distribution and 12 day postop views which demonstrate early graft growth.

This is a 47 year old man who requested restoration of his frontal hairline. In addition to the usual requests for naturalness and acceptable density, he was especially focused on having a “quick heal” so that he could return to work and social interaction in a short period of time without any evidence of having undergone a procedure. The risk of detectability was discussed in great detail and it was decided that the goal of rapid healing, so as to minimize shock and recipient site pinkness, was to have a higher priority over density. The patient underwent placement of 2622 grafts. Graft placement was performed using a non-shave implantation technique so as to assist immediate postoperative camouflage using his preexisting native hair. Presented are one year postoperative photos.

This is a 3 1/2 year postop result on a 42 year old patient who presented to my office for hairline repair from a prior transplant. The patient was mostly concerned about the low density and unnaturalness which resulted from that prior procedure. He believed that his grafted area had a pluggy appearance and he was concerned that people had a tendency to stare at his hairline. He indicated that his primary goals were to enhance density and reduce unnaturalness in the hairline. Various options which included selective excision and debulking of large grafts were discussed. It was decided to proceed with a dense-pack strategy to fill the residual gaps and to camouflage the unsightly grafts within his hairline. A total of 2247 grafts were placed to produce a densely packed frontal hairline. Multiple views and angles are shown to demonstrate the appearance of his current hairline.

This is a 41 year old male who underwent a two stage hair restoration to treat his frontal and crown balding. He gave a history of previously undergoing a prior hair transplant session that failed to yield the density he had hoped for. He wanted to avoid shaving the recipient site and use his existing thin hair to camouflage the effects of surgery. His initial goal was to restore the frontal hairline and this was accomplished using a total of 2775 grafts. Session 1 photos demonstrate his eight month result for the frontal restoration procedure. Ten months following the frontal restoration he underwent a 2112 graft crown restoration. As with the first session, the treatment zone was not shaved to assist postop camouflage. The final photo reveals his full scalp coverage nineteen months following the second session.

This is a 60 year old male who requested frontal hairline restoration. His goals were very conservative and a total of 2500 grafts were used to establish a hairline. The graft zone was transitioned into the midscalp and stopped short of the crown. Presented are 6 month postop photos. He experienced very good growth at this early mark and is expected to see further density enhancement over the next six months.

Thanks to all for your positive feedback. Spanker, I performed his first procedure based on these original hairline photos. He developed some subsequent miniaturization over the next few years which thinned the region just behind the original graft zone. Although I was content with his appearance, he was looking for a very tight hairline, which prompted the secondary density enhancement procedure.

This is a 31 year old patient who had a total of 2635 grafts placed to restore a high density frontal hairline. He originally had 1529 grafts placed into the hairline region which led to a satisfactory restoration. Progressive miniaturization within the frontal region over the following three years prompted him to undergo a secondary density enhancement procedure to achieve his goal of a very solid hairline. The patient expressed a desire to use different styling options which included using a gel product to spike his hair. Presented here are two hair styles – dry hair with a traditional style and gelled hair with a spiked style. Video can be viewed at

NEWHAIRPLEASE - I believe the improvement you are seeing in his hairline is a result of aging changes associated with additional surgical refinement. He may have experienced some age-related thinning along his hairline, but I also think it is the age-related whitening of his hair that has helped soften his hairline. It is a reduction of density and a lowering of color contrast that helps improve overall appearance in a situation like this. BeHappy – Here is an explanation as to why a pluggy hairline can improve in the scenario previously described. The unnaturalness of a plug is based on the contrast it creates with the surrounding skin. Factors that increase contrast will make a plug hairline look worse. Some of the things that contribute to increasing contrast include: 1) dark hair on light skin; 2) thick hair shafts; 3) straight hair; and 4) a greater number of hairs per graft. On the other hand, factors that lower contrast tend to improve the appearance of a pluggy hairline. Some factors related to lower contrast include: 1) light hair on light skin or dark hair on dark skin; 2) finer hair; 3) curly or wavy hair; and 4) fewer numbers of hair per graft. I see many patients who undergo repair of their pluggy hairlines using FUE to debulk excessively large grafts. The FUE technique does nothing more than remove a few isolated hairs from each plug to soften its overall appearance. The random miniaturization of individual hairs within a pluggy hairline will achieve the same effect, i.e. it will reduce density within the plugs so as to soften their appearance. This is not to say that the unexpected miniaturization described here is a definitive solution to a pluggy hairline, but simply that it can have the effect of softening a very pluggy hairline.

Behappy In other words, you are calling me a liar or you are stating that one of the most respected physicians in the history of this field is either a liar or confused. I would caution such bold statements since you were not present for the conversation and have no knowledge as to the details of his particular case. I stake my reputation on the accuracy of that statement and can attest to the fact that it is completely factual. I know this man and it is my personal observation that he looks much better with a softer hairline than he did with an obvious line of corn row plugs. It seems as if you have missed the point of the post - that being the issue of long term miniaturization in the donor site and the effect it has on transplantation - not the specific details of how one individual noted that an unexpected thinning of his plugs turned out to be a positive improvement for him. This does not imply that hair loss in plugs is a miracle cure for everyone or that donor miniaturization will be a positive event for anyone who had plugs in the past. He may as well have said that the thinning of his plugs was a devastating experience - this still would have made the point of the post. Fortunately, he did experience a beneficial softening. I emphasize once again that the point here is that long-term donor site miniaturization can affect the final result - sometimes in a positive way, but for the most part is will be unexpected and lead to disappointment from lost density in the graft zone.

This is a 10 year follow-up of a patient who initially had 2100 grafts placed to reestablish his recessed frontal hairline. He presented 3 years later with progressive miniaturization in his midscalp region and had 1000 additional grafts placed to solidify the core of his hairline. Presented here are his 3 year and 10 year postop photos. I believe these comparison views demonstrate the stability of grafted hair quite nicely for this individual in that the 10 year views have maintained their original appearance from the initial procedure.

Aaron1234 – My suspicion is that finasteride may help provide stabilization when donor hair miniaturization accompanies a male pattern loss. I proposed your question to our local non-surgical hair loss expert at the University of Illinois who confirmed from his extensive observations of balding men that it can be beneficial for this problem. Orhair1 – You are at a great age for prognosticating your future risks and your ultimate success. Good luck – you should do great. TC17 – Your insight and advice for hair loss sufferers are profound. Thanks for emphasizing that single sentence.

Corvettester I believe you are following my thoughts here. Ultimately it will be the percentage of hairs in the donor area that experience miniaturization which will determine whether or not a cosmetically significant change has occurred. A 10% change will probably be insignificant, but a 40% change can be. It is difficult to definitively predict several decades ahead what may happen with respect to donor site hair miniaturization. My lack of a magical crystal ball for prognostication is why I typically advise young men to delay surgery until a reasonably mature age. I do believe that most patients with the potential to develop donor site miniaturization can be identified by the skilled practitioner. However, some will slip through the cracks as the element of time factors into the unpredictability of hair loss. Keep in mind that every class 7 patient had his day in the sun when no one on the planet could have found any trace of miniaturization in the area that would eventually convert into a virtual sea of baldness. Patient selection, patient examination and patient education are key.

Corvettester Let me clarify that the observation of miniaturized hair within the donor region is not uncommon in many of the patients I examine during consultation; however, the proportion of miniaturized hair versus non-miniaturized hair does vary widely. Unlike pattern loss, where an entire zone will experience progressive miniaturization – thereby leading to the appearance of a balding – miniaturization observed within the donor area tends to be sporadic. The significance of this type of sporadic miniaturization can vary widely from person to person and the occasional detection of donor site miniaturization does not mean cosmetic devastation for every potential or former hair restoration patient. However, this phenomenon must be recognized and appreciated by all potential patients since it can affect the end result. Fortunately, however, the end result will not be adversely affected to any significant degree for the great majority of patients since the “aging” process of individual hairs within the grafts will occur sporadically just as it occurs sporadically within the donor site. This reminds me of a conversation I had many years ago with one of the all time pioneers of surgical hair restoration. Remember that there was once a time when the primary method of surgical restoration available was “plug” grafting. This particular physician, just like many others during that time period, had his hairline restored with standard 4 mm plugs many years earlier. Despite having what was considered at the time to be a very good result, he still had the distinct appearance of plugginess along his hairline. Years later his hairline appeared to look much better and I asked him if he had undergone any additional procedure to soften the old plugs. He indicated to me that his improved look was a result of sporadic miniaturization within the old plugs – not from additional surgery. He also made it clear that he was experiencing miniaturization in his donor site and he was thankful for it since it helped to soften the contrast of his former too-dense plugs. Because of the randomness of the miniaturization process, both his donor site and his recipient site were thinning in proportion to one another, thereby leading to a balanced appearance between the donor site and the recipient site. This man, a leader of our field with well over 30 year’s experience, was very surprised to discover that the process of miniaturization was a real entity. Once again, although he did experience a density reduction, it was age appropriate and he continued to look natural. Some members have suggested that this process should be detectable during consultation. However, information obtained during consultation, despite the highest of high-power magnification, is heavily determined by age. I would challenge anyone to examine an entire class of high school seniors and predict with great accuracy the primary factors associated with aging hair, i.e. who will bald, who will go gray and who will develop donor site thinning. However, our ability to predict the future for these parameters of aging hair will increase proportionately as we inspect the same men at their 10, 20, 30 and 40 year high school reunions. Age of presentation makes a huge difference in our ability to forecast the future and thereby recommend a sound surgical treatment plan. It seems to me that the sudden appearance of a few patients with what may be recipient site thinning has thrown many members into a state of panic with current thinking being that this will happen to everyone. Rare events such as multiple lightening strikes or multiple lotto wins experienced by a single person do occur – but they are very uncommon, if not downright rare. We have recently seen a few isolated cases of this problem, but we also continue to see thousands upon thousands of satisfied patients who get great results and achieve a lifetime of satisfaction following their restoration. Patients are entitled to know all of the risks, limitations and alternatives available for a medical treatment plan, and this is just another factor that has to be considered. Patient presentation at an appropriate age to a skilled, competent and caring surgeon will tremendously increase the odds of achieving a successful outcome.

Corvettester - Your points are well taken. We all make judgments on this site based on photos, and I am certainly not a fan of most photo presentations. Once again, it would be very beneficial for trooper to follow-up with Dr. Feller so that hopefully we could evaluate high quality preop and postop photos with comparable lighting, positioning, and styling. I also appreciate your comments about the rash of patients with recipient site thinning and the possible implication of miniaturization as to the cause. However, debate here is relatively subjective in nature since all of the pertinent details that are contributing to this case are not available. I would be very interested in having Dr. Feller perform a microscopic examination of trooper’s scalp so as to quantitate the extent of miniaturization throughout the area where the harvest was performed. Only with this objective evidence can we move forward with educating ourselves and the hair loss community. Thanks for your comments and contribution to this discussion.