Dr. Bernardino Arocha

TC17 thanks for the interesting questions. It is correct that the evolution of Norwood patterns fallows a bell shaped distribution curve. Indeed, miniaturization may be less prominent at an earlier age, it usually is. Only about 20% of men become bald in their twenties, it is for these younger patients that the crystal ball is cloudiest. So to answer your question, I assume that all my patients will develop the advance stage male pattern baldness. It is important, to fallow sound surgical planning for both the recipient area as well as the donor. Of course, I examine the scalp carefully looking for miniaturization, but the absence of it does not guarantee that it will not develop in the future. Remember that Androgenetic alopecia is a two prone process, in which we inherit a pattern of hair that is sensitive to the DHT. When the sensitivity develops varies amongst the afflicted, and is contained in their genes. Sensible treatment should employ surgery to restore the hair, which has been loss, and pharmacologic treatment to prevent the progression. The fallowing article discusses the treatment of the most advanced MPB in a patient with limited donor, here it is: http://www.regrowhair.com/hair...patterned-hair-loss/ Please copy and paste unto your browser if it is not active.

mmhce, good job that is an excellent roster of questions. veeru, Finasteride is definitely the most efficacious therapy, fallowed by topical minoxidil 5% twice per day, and also nizoral 2%. The addition of these topical agents can have synergistic benefit, with probable more complete DHT blockade.As for diet, here is a link to an article:http://www.arochahairrestoration.com/en/art/99/ Please copy and paste unto your browser if not active.

umz2009, If you are having recurrent thoughts about hurting yourself or others, then you need to seek medical or psychiatric attention as soon as possible. There are many excellent hair restoration surgeons that can do an outstanding job, but if you are depressed,this needs to be addressed first.

That is correct Bill, it does take 6-12 months for scars to mature. Subjecting the immature scar to tension forces during this period will result in widening of the scar and increase collagen production.

jonrctim, Congratulations on your hair transplant with Dr. Feller.It is wise to use rogaine post op, especially to help prevent shock loss and maybe accelerate the growth of your transplant.I would recommend that you increase the dosing of rogaine to twice per day, and that you also apply it to the donor area. The shock loss in the donor area should grow back within a few months. Good luck.

For the patients already on Rogaine before surgery, I ask them to discontinue use 5 days before the procedure. Rogaine is a vasodilator so it tends to increase bleeding during surgery. Regarding the post surgery use of Rogaine, it depends on which Rogaine you are using. The older Rogaine solution containing propylene glycol can be used sooner after the procedure; I used it on the day of myself without problems. The new Rogaine foam, however, I would recommend waiting 5 days since it is alcohol based and will cause stinging in the fresh wounds. While Rogaine is not as effective as Propecia, slowing or stopping progression in about 35%, and re-growing in only 10%. There is some synergism when Rogaine and propecia are used in combination, and it can be of benefit in preventing post-surgical shock loss.

Its_Going_Fast, you have been given some excellent recommendations. Your hair is a little thin, I would recommend consideration of maximal medical therapy. That means propecia, rogaine 5% bid, and nizoral shampoo 2%. This regimen will likely slow or stop the progression, and there is 5% chance that you might get a strong re growth in the crown, and a 21% chance of medium re-growth. The front half will not likely respond to the medical regimen less than 2% do. So if that is of concern, then a thorough evaluation of your donor is necessary to determine where you are. I do not think that you need too large a session. Mmhce neither Drs. Gionnatto nor Karamikian are ABHRS diplaomats.

Both Drs. Lindsey and Epstein make valid points about trichophytic closures. I agree, and have written about this in prior blogs, the two-layer closure is pivotal in minimizing surface tension, hence rendering finer scars. It takes a scar 6-12 months to mature, if tension is applied before the scar matures then it is subject to widen. The deep layer loses strength rapidly after a few weeks so minimizing activities that weight or pull on the neck are important until the scar has matured. Usually, I reserve the tricophytic closure for the last procedure, since the yield may be decreased in future surgeries because of distortion of the follicular alignment along the scar.

Thank you all for the opportunity, it is my pleasure to be of service. Happy New Year!

It is very important to maintain the integrity of the follicular units. That, is follicular units should be kept intact. It is difficult to put hair as close as they occur in these follicular units. The more 3,4, and 5 hair follicular units the thicker the hair, there are more of these in the back of the head than there are on the sides or temporal area. The temporal area has a higher percentage of 1 and 2 hair follicular units. One and two hair follicular units make up over 50% of the total. So it is never or very rarely necessary to breach the follicular unit's integrity to soften a hairline. What permits mega sessions is the harvesting of wider and longer donor strips! How wide a strip is possible to harvest is dependent on the tissue elasticity. This elasticity is greater in the back and less in the sides. Usually, I harvest the widest part of the strip in the back where the density and elasticity is greatest and a narrower strip on the sides where the density and elasticity is less. Recently, I worked on a patient with advanced stage hair loss,who desired to restore as much as possible in one session. He had excellent hair characteristics with very good density and elasticity. We obtained 6166 FU, the strip was 38 cm long, 2cm wide in back (20 cm) and 18 cm long sides x 1.5 cm wide. Note the strip is narrower on the sides to close without tension and obtain a nice and narrower scar. Is this possible in every patient? Of course not, but it is more possible than some people will have you belief. Even in someone with an advance stage hair loss pattern a NW 7 with thin donor, it is possible to do a mega session of 3500 FU, see my hair loss article titled 'Surgical Hair Restoration of Advanced Stage Male Patterned Hair Loss.' http://www.regrowhair.com/hair...patterned-hair-loss/

Hello Hair Brewer, Would like to help,can you post some jpegs?

Congratulations Bill, the hard work will pay off,may legions of hair loss sufferers benefit from your wisdom and humanistic counseling.

One of the most important factors in determining how wide a strip can be harvested has to do with tissue elasticity. The greater the tissue elasticity the wider the strip that may be harvested. Elasticity varies across the strip; it is greater in the back, less in the sides, so the width of the strip varies across the strip. The donor density also varies across the strip as does the per cents of the break down of hair number follicular units, that is there are more 1 and 2 hair fu in the temple area and more 3,4, and 5 hair fu's in the occipital area. I do not routinely measure tissue elasticity before surgery, but after thousands of surgeries I have a very good feel from just the tissue response to my tumescence procedure. The volume the tissue can accommodate is proportional to the tissue elasticity.

It is nice to have options, occasionally I employ cut to size blades especially in the patients with advance stage hair loss and little remaining hair. As I stated previously, the solid core needles, are very useful in creating sites between existing hairs, since the only part that can cut the follicle is the point, once pass this sharp point the needle shaft is blunt and will not transect the hair. When carefully introduced between hair follicles the needle wedges between the follicle creating the site without damaging the adjoining follicles. Dr. Mohebi, I too employ solid core 21g, 20g, 19g and 18g needles a lot, what a great value they are too. Dr. Lindsey, while the size is getting most of the attention, it is not all that matters. As a matter of fact, equally important is how deep. Dr. Arnold designed his Minde blades with this in mind. It is pivotal that the depth be controlled to prevent injury to the microvasculature, which lies below the follicles. When not using Minde blades I use my finger to minimize the depth of the incisions.

Zhiangde, This is highly unusual.It is impossible to render an opinion without the benefit of a good history and of course a thorough examination. Have you had a scalp biopsy? There is a secondary cicatricial alopecia that occurs in a male pattern distribution. Consult with your physician, but this might be something that should be entertained.

Marko Ramius, Please do not valsava when you lift. Yes it can raise your blood pressure, but more importantly it will decrease the return of blood to your heart and subsequently the blood pump out by the heart drops off causing you to become light headed or past out. Please use good breathing technique and breath out as you exert never hold your breath.

Do all the cardio you want, it has no detrimental effect on the scar. I ask my patients to wait one week, but I have caught some jogging in the local park a few days after surgery. Latinlotus that is correct, just limit the ones that can put tension on the neck muscles. There are many other alternative lifting exercises that can accomplish the same benefit.

Good thread guys, right on. Sometimes it's best to use a larger blade to accommodate families to create density, like the forelock area or behind the hair line. Other times it's best to not use a blade, and use a solid core needle instead like when working to increase density in a diffuse thinner with a lot of remaining hairs.

latinlotus, Avoid any exercise that loads your shoulders downward as to pull on the neck, squats, weighted shoulder shrugs,etc...

Hello SETT, usually the nose surgery will not conflict with the hair transplant, but it can. Hair loss after surgery can occur in two ways:1. Post-surgical telogen effluvium which is a diffuse hair loss ; 2. Post-operative localized hair loss due to pressure-induced ischemia if you are in a position that produces pressure on a spot for a prolonged period.

Sorry, latinlotus I was busy. That is correct, using the .75mm punch is better with regards the scar, but it is far more difficult to extract the whole follicular unit, hence traumatizing it or even transecting. If it is so important to employ microscopes to sliver the donor, then again to trim the slivers into the ultra-refined follicular units, that is one of the hallmarks of many if not all of the practitioners recommended on this network, then why would we think that it is equally good to attempt to extract these same follicular units using such a small punch blindly. It is my opinion that many products of these extractions are fractional follicular units rather than ultra-refined whole ones. I occasionally will do FUE, more often in corrective procedures to remove improperly placed grafts.

FUE is not always scar less and FUSS does not always leave visible scars. FUE done with a .75 mm punch to score, then using the Safe scribe to blunt dissect is less likely to leave a visible scar, but using a larger sharp punch will leave the characteristic "shot gun pattern" scars." Anytime the skin is wounded, ie surgery , there is always a scar. With good 2 layer closure these scars are usually faintly visible if at all. The critical fact is that after surgery, the FUSS patient's wound is more sensitive to tension vectors applied to the wound margins, ie weight lifting, until this wound matures. The wounds can take 6-12 months to mature. It does not mean that you cannot weight train, just that caution is necessary to avoid loading the shoulders so as not to pull on the neck. Here is a link to one such example: http://www.hairrestorationnetwork.com/eve/showthread.php?t=151565

readyand40 At Arocha Hair Restoration 100% of our surgeries are done without shaving. Most of my patients are already concerned about how they look, the last thing I want to do is make them more uncomfortable, albeit for 4-6 weeks. The other day, I was doing a mega session on a patient with a lot of hair remaining, he offered that we can shaved his hair. I almost took him up since his blood was a bit thin, he had curry for dinner the night before.I reviewed your photos, depending on your desire for density, I would recommend between 2500-4000 FUT. Thanks for the opportunity to review your case.

Well done Bleachcola12,it is proving to be much more effective in the treatment of hair loss. My concern with prescribing it is that the t1/2 (half life) is 30 days). Hence, it takes 5 months for the complete elimination of the dose you take today. The t1/2 of propecia is only 7 hours. Thus it is eliminated within 35 hours. Also, remember that we have been prescribing finesteride for nearly thirty years. One can feel safer that no major dire consequences have yet been reported. I am looking forward to the latest data update at the ISHRS meeting in Montreal, as I have some patients that have been propecia non-responders.

Interesting topic. It used to be that all transplanted hair would fall out within 30 days post op. We are now finding that most of our patients are retaining varying percentages of the transplanted hair from day one. Smoothy good point, the use of both propecia and minoxidil 5% bid seem to be synergistic in aiding the transplanted hair to remain. Also, this combination helps to protect the native intermediately miniaturized hairs.TheBeatles were right on, "I do believe it's getting better all the time."