Dr. Raymond Konior

I agree with Jotronic and others who stress that wet and gelled hair will augment your thinning appearance. Wet hair binds individual hair shafts, thereby producing a much greater see-through effect. You have a very harsh contrast situation with dark hair and very light skin. Keeping your hair dry will produce a more diffuse distribution of the individual hair shafts to help provide better scalp camouflage. I believe TC17 is correct in saying you look much better with dry hair and in his suggesting Propecia as an additional component to your overall treatment plan. You have an aggressive balding pattern that certainly could benefit from stabilization therapy. Hairthere is spot on with his comment regarding 4000 grafts – it sounds like a lot, but there are multiple variables that influence how that number is affecting your final appearance. It is very clear from the graft distribution that is shown on your postoperative photo that gradients of density were used to optimize your result. A much higher graft density was used along your actual frontal hairline to maximize the aesthetics of your frontal appearance. The bulk of your transplant zone was grafted at a much lower density – perhaps 10-15 grafts per square centimeter. This is why you look so much better from the frontal view than from the top down view with wet hair. Additionally, we know nothing about the hair counts that you had available for the procedure, i.e. are you an individual with a preponderance of one and two hair grafts, or did you have a large number of 3 hair grafts available. Also, what is the status of your donor area with respect to miniaturization? You show a side-view photo in your postoperative collection that clearly reveals a see-through effect in your temporal region. While your hair is wet in that photo, it is also long enough to have provided better coverage of your scalp. What is the reason for this see-through effect – an intrinsically low baseline hair density, reduced hair shaft caliber or the coexistence of miniaturization in your donor site? Any progressive miniaturization within the donor area will compromise transplant density as the years roll on. Corvettester has stated his doubt about the process of transplant miniaturization, but the fact is that it does exist. Transplanted hair will maintain the genetic code of its previous neighbors in the donor site. Donor site graying and donor site miniaturization will be realized years later in the recipient site if the genetic code happens to be programmed that way. I observe donor site miniaturization quite frequently during consultation examinations and can attest to the fact that this process does occur. I also do not understand where the comment about a pluggy hairline came from. It seems clear that your frontal hairline is loaded with single hair grafts and I can not identify any plugginess whatsoever. I am curious as to which photo or photos are being referenced with that statement. Trooper, you really need to visit Dr. Feller for a follow-up examination. I have great respect for the doctor-patient relationship and would be extraordinarily discouraged if I did not have the opportunity to personally discuss a situation like yours with a patient of mine. I believe you and the rest of the community will gain a greater depth of knowledge regarding your situation by scheduling an appointment with your surgeon. Good luck.

Orangehair - I have added a postop day 6 photo. As you can see, she still had some light crusting at that time. Thanks to all for your comments.

I emphatically echo the words of Dr. Feller. The fact of the matter is that we are dealing with a surgical procedure - and with it all of the risks that are associated with surgery. Many assume hair restoration to be such a straight forward procedure that little else other than density and undetectability are taken into serious consideration prior to entering the operating room. However, all surgical procedures involve risks, and those risks need to be carefully considered by each and every patient who decides to undergo the scalpel. Unfortunately, infection, bleeding, nerve damage, scarring, cyst formation, and low graft yield are just a few of the realities of what may transpire following surgical intervention. Dr. Feller’s reference to patient physiology is extremely important. This vital component of the overall surgical process must be clearly appreciated by all potential patients since it is this variable that can compromise even the most perfectly implemented procedure.

This is a 49 year old female who requested hair restoration to lower her high hairline and strengthen her thin frontotemporal recessions. The patient claimed to have been bothered by what she perceived as a large forehead. A dense-pack procedure which utilized 2141 grafts was performed to fill the frontal and temporal regions. Ten month postoperative photographs are presented. A part view demonstrates the density match between the graft zone and the preexisting hair.

Multiplier – It is logical to defer placing grafts in the crown if the final pattern is not apparent and there is a possibility that an advanced pattern may emerge. I am definitely not suggesting that all donor hair should be concentrated in the front, but rather that the front and midscalp are a higher priority if the donor supply is not sufficient to treat the entire scalp. Staying away from the crown and restoring only the front and midscalp should leave a very natural look it the procedure is implemented correctly. I commonly evaluate repair patients who are a decade or more out from surgical restoration. Many of these patients are trying to correct a “freakish” appearance not because the crown was left alone, but rather because grafts were inappropriately placed in their crowns. These patients are the victims of a mismanaged graft supply and a flawed grafting plan which did not take future thinning into consideration. Their common finding is an unfinished looking transplant and limited or no donor reserves to work with.

TC17 – You introduce an excellent point regarding the placement of grafts into the crown. As you know, the crown has been described as the black hole of the scalp. Based on that I believe a very large percentage of patients seeking hair restoration should avoid grafting into the crown region, especially young men in whom it is often impossible to determine how far the pattern will progress. This recommendation is based on the finite nature of donor supply and on the progressive nature of male pattern hair loss, i.e. there is an imbalance between supply and demand. The fact of the matter, however, is that despite prolonged and detailed consultative discussion relating to the risks and limitations of grafting the crown, many men are still adamant about obtaining some crown coverage. Although it is difficult to predict with absolute certainty everyone who is a rock solid candidate, it is possible to weed out the majority of poor candidates and to institute a safe grafting strategy which will avoid future problems for most patients This particular patient was originally advised during consultation to focus grafting into the front half of the balding zone - more in an attempt to maximize density in the cosmetically important frontal hairline than out of fear of his future progression to an unmanageable advanced pattern. On the morning of surgery, however, he requested some crown coverage after deciding that an overall greater coverage of the entire balding region with lower density was more acceptable to him than focusing exclusively on the frontal region. His examination indicated to me that he was a decent candidate for a conservative crown restoration. The grafting strategy took into consideration his potential for future fringe thinning by managing the graft size and density distribution so as to create a relatively low net density in the crown – one that should never look out of place if the surrounding hair happens to miniaturize. He has excellent hair characteristics in terms of hair texture, color and caliber which facilitate the “illusion” of density and produce a nice cosmetic change in the crown. He also has a tremendous donor area - great density, excellent elasticity, ideal healing properties and plenty of graft reserves. Multiplier - I would never recommend any grafting strategy based on the hope of future treatments or speculative technological advances that “may” emerge someday to patch up the problems left from an incomplete or poorly planned restoration. I believe that surgical planning should be based on whatever an individual donor supply is capable of providing over the lifetime of a patient. Thanks for all of your positive comments.

This is a 7 1/2 month postop result for a 34 year old male who underwent a 3665 graft hair restoration which extended from the frontal hairline into the crown region. The proposed hairline and graft zone are revealed in some of the preop photos by the blue surgical marking pen lines. He appears to demonstrate a very good density response for 7 1/2 months.

This is an eleven month postop result for a female hairline restoration that consisted of placing 1267 grafts into the frontal hairline and fronto-temporal recessions. The patient’s primary goals were to improve the appearance of her hairline recession and strengthen density within her thin temporal recessions.

Presented here is a nine month postoperative result for a 57 year old patient who underwent a single session of 2512 grafts. This frontal/midscalp restoration was performed without shaving the recipient site.

This is a 28 year old patient who received a total of 4086 grafts in three sessions over a six year period. The patient began his hair replacement journey six years earlier at the age of 22 when he presented to my office concerned about progressive thinning in the frontal and crown regions. He was on finasteride at that time and felt that it was helping to keep his hair loss process under reasonable control. An initial session of 1800 grafts was performed to enhance density in the frontal hairline and temporal recessions. Over the following years he showed progressive miniaturization despite a continuous attempt at medical stabilization with DHT inhibitors. He was bothered by the progression of diminished density and underwent two additional fill-in sessions at two year intervals to keep pace with his thinning process. An additional 2286 grafts were place over that time span to enhance the density that was lost due to progression of his male pattern balding. The staged restoration approach has resulted in a near complete replacement of hair in the frontotemporal regions.

Thanks for the comments guys. I have included two graft placement photos as requested by TC17.

This is a 37 year old patient who hoped to reinforce his hairline and enhance density within his thinning frontal scalp. He underwent a relatively conservative procedure of 1862 grafts which were placed without shaving the recipient zone. Presented are 16 month postoperative photos of his final result.

This is a 30 year old male who desired reestablishment of his frontal hairline and conservative density enhancement in the frontal region. He was not willing to shave the recipient area and feared shock loss amongst his preexisting hair population. He had 2041 grafts placed using a non-shave technique to restore his frontal hairline and thicken the frontal zone.

jonathanb - I believe that this patient is an excellent candidate for stabilization therapy and he does take finasteride. He has a significant amount of residual hair in the traditional male pattern zones that is at risk for progressive miniaturization and balding. We hope that his continuing finasteride will allow him to maintain the appearance of a relatively full head of hair.

Thanks to all for your positive feedback. orangehair - I have added a couple of intraop photos that were taken just prior to the completion of the procedure. Thanks for your comments.

This is a 43 year old patient who underwent a single session of 3252 grafts for restoration of his frontal hairline. Presented are 10 month postoperative photos which include comb-back views that detail the hairline.

Patients occasionally ask if they will be subjected to certain styling limitations following surgical hair restoration. Presented is a 12 month result of a patient who underwent 2912 grafts into his thinning frontal and midscalp regions. Several styling options are shown which include: 1) hair combed straight back; 2) hair combed toward the back from the left part side; and 3) hair combed to the side from his normal left part.

This 47 year old male requested restoration of his frontal hairline recession. His primary goal was to lower his hairline into a more youthful position. Examination of his scalp revealed an isolated frontal loss without evidence of a progressive thinning pattern in the crown or midscalp regions. He underwent a single session of 2237 grafts. Representative photos of his preop hairline, postop results, surgical plan and graft placement are presented.

Sonia – Her hair caliber was relatively smaller than average. This was ideal for allowing a soft appearance at the hairline. Aaron – A total of 1040 grafts were used. These were evenly distributed between the four zones. Thanks to all for the kind words.

This female patient presented to my office with a history of having undergone a facelift which resulted in unsightly scars and displaced sideburns. The facelift technique that was used pulled her original sideburn hair tuft upwards and backwards thereby leaving her with hairless sideburn regions. Her surgeon also used incisions behind her ears at the base of the lower hairline which healed with unsightly linear scars and multiple stitch marks. She was extremely disturbed by the lost sideburns and the visible scars because of her preference to wear her hair pulled back. She was offered the option of repair using follicular-unit hair restoration to rebuild the lost sideburns and to camouflage the harshness of the lower hairline scarring. She was told that the scars would not disappear, but rather they would be “lost” in the new transplant zone. Grafts in both regions were meticulously oriented to follow the native hair directions so as to provide for a seamless integration and undetectable result within the respective zones.

This young man presented with a history of progressive miniaturization in the frontal region. He had been on Propecia for some time and felt that the thinning process had stabilized, but he was disappointed in not recovering any of his lost density. A 2152 graft session was performed to restore continuity of his recessed frontal hairline and to enhance density in the thinning frontal forelock region. This limited graft number was utilized to minimize the risk of shock loss and to accommodate the patient’s request to avoid shaving the recipient area in order to provide postoperative camouflage of the procedure. A preoperative photo with lightly damp hair details the magnitude of his miniaturization and highlights the surgical treatment plan.

This is an 18 month postoperative result of a 2810 graft hairline restoration in a 42 year patient. This man lives out of state and he recently emailed a few photos to me for review and discussion. I have attempted to match his postop photos with those I took preoperatively in the office. His graft harvest was limited by an extremely snug donor region. The main goal for this patient was to reestablish a natural frontal hairline with coverage throughout the frontal and midscalp regions. The surgical plan photo identifies three zones: 1) a narrow frontal zone where 1 hair grafts were exclusively utilized; 2) a large central zone where 2-3 hair grafts were placed; and 3) a zone at the back edge where more single hair grafts were placed for a soft transition into the balding crown. The patient is satisfied with the restoration and now hopes to complete a second procedure to fill the crown. I will post more photos when he returns for that visit.

This is a nine month postoperative result for a 52 year old patient who underwent 3008 grafts in a single session. The patient initially expressed an interest in reestablishing his frontal hairline and boosting density throughout his entire thinning scalp. His donor region was found to be relatively snug and it was advised that he focus restoration on the frontal hairline and midscalp region to accommodate the limitations of graft availability. The surgical plan was designed to use a relatively small number of the available grafts for creating a subtle transitional density gradient from the thicker midscalp into a thinning crown.

This young man requested density enhancement in his thinning frontal scalp region. His family history and physical exam suggested that crown balding would become an issue with age, but he was willing to accept thinning in the crown region and did not desire treatment in that area. His goals were quite conservative in that you did not want to alter the location of his existing hairline and simply wanted to focus on improving his frontal appearance. He underwent 2249 grafts which were distributed into the frontal and midscalp regions. This is an 11 month postoperative result.

This is a 57 year old female with extensive thinning which extended from the frontal scalp to the crown region. Although the hair count in the thinning region was relatively high, the hairs were severely miniaturized and provided little cosmetic coverage. Her goal was to thicken the thinning scalp and improve her styling options. She was concerned about shock loss in the transplant zone and was not willing to shave for the procedure. She received a total of 2338 grafts over two sessions which were performed with an 11 month interval (1175 grafts in session one and 1163 grafts in session two). Staging was utilized in an attempt to minimize the risk of shock loss within the miniaturized hair zone. Preoperative and 21 month postoperative photos with wet hair demonstrate the density enhancement that was achieved. The patient did not experience any demonstrable shock loss following either procedure.