Cam Simmons MD ABHRS

This 28-year-old man had a Norwood 6 thinning pattern with a low thinning forelock. He had average diameter, black, straight hair with average donor density and flexibility. His goal was to achieve a finished look in front then to return to transplant his midscalp in a second session. We transplanted 3219 grafts from a conservative hairline. We keep an accurate total graft count but do sample counts to estimate the graft ratios. His calculated ratios were 22% ones, 44% twos, 28% threes, and 6% fours. His breakdown would therefore be about 721 ones, 1399 twos, 896 threes, and 203 fours. When his schedule allows we will transplant his midscalp. As he is still just 29, it is not possible to predict how much lateral recession he might develop in the future. We will therefore reserve some donor hair in case he later develops a gap between his transplanted and natural hair on the sides. For now, he is happy with his hair in front.

Thanks Everyone I agree that his previous doctor did high quality work, considering it was done in the 1980s. His old punch grafts were not compressed and there was good hair growth within the grafts. He had some smaller grafts in his hairline as well. The punch grafts would have been more noticeable when his hair was still black but his grey hair helped make them look more natural. His past results allowed us to just refine his hairline and fill in the gap without having to reduce the old grafts and reuse the hair.

This man in his early 30s had past cranial surgery for an eye tumour. The surgery was successful but he was left with irregularity of his skull and hair loss in and around his surgical scars. He also developed a Norwood 3 pattern from AGA. He was most concerned that the recession was making his skull changes and scars more conspicuous. He had tightly curled, black, average to coarse donor hair, good scalp flexibility (despite his past surgery), and average donor density for an African American man. His donor density was about 85 fu per sq cm in the occiput and 75 fu per sq cm on the sides. After his neurologist cleared him for surgery, we transplanted 2774 follicular unit grafts, focusing on his left and left temporal hairlines. We intentionally brought his left temporal hairline a little further forward than his right to hide the depression better but the design was still within the range of normal hairline asymmetry. We also transplanted grafts into his scars. Transplanted hair does not grow as well in scarred or thinned skin as in “virgin” skin, especially if dense-packed. We therefore reduced the transplanted density in those areas to optimize the survival of the grafts that were transplanted. 13.5 months after his hair transplant, he is happy with his hairline and that it is easier to hide his past surgery. He does take Finasteride but is prepared to return for more hair transplantation if and when his genetic hair loss progresses.

Here is a patient were we needed to reduce his old grafts: http://www.hairrestorationnetwork.com/eve/162633-dr-cam-simmons-%96-1-session-repair-scalp-reduction-hairline-flap-punch-grafts.html

Jesse This is good creative thinking but it probably wouldn't be my first choice for you. Without seeing photos, I can't give precise recommendations. You get tiny dot scars from extraction and those scars may not be the exact colour of your natural skin. Those dot scars would be in a very visible area. If an eyebrow transplant is a good solution for you and your current eyebrows are quite sparse, you may be better to transplant matching eyebrows then repeatedly pluck or use electrolysis to get rid of the unwanted hairs outside of the newly shaped eyebrows.

Here is an example, where we transplanted in front of and between punch grafts without reducing them. We could do this because he had grey hair and his old grafts weren't compressed: http://www.hairrestorationnetwork.com/eve/165228-dr-cam-simmons-%96-hairline-restoration-man-old-plugs-depleted-donor-hair.html#post2299480

This man in his early 60s would have had a Norwood 6 pattern but for his scalp reduction and 4 sessions of punch grafting in the 1980s. He initially hoped to both improve his hairline and fill in his crown but his available scalp donor hair was limited. He had multiple narrow scars in his donor area but had thinning around the scars. A strong fringe of hair above the top scar hid everything. I felt we had to leave that fringe alone to ensure that the donor area would remain concealed. FUE was an option but he preferred to remove one of the old scars and simultaneously transplant about 600 grafts. 600 grafts would be a drop in the ocean in his midscalp and crown but could allow us to refine his hairline. As he was committed to a left part, we concentrated on his left hairline and the left gutter (lateral hump). We removed a 31.3 cm by 5 mm donor strip that contained a 1 mm wide scar and obtained 607 grafts. We also extracted 18 FUE grafts as a little test. We know that FUE can be an option for the future. With his grey hair, we did not need to reduce his old plugs but could fill in around them. If he had black hair, we would have needed to reduce them first. We purposely used the single-hairs and whiter hairs from the sides of his head in the leading edge of his hairline to create a softer transition. 12 months later, he is happy with his new hairline and that the gap has been filled. By leaving his strong fringe at the top of his donor area alone, he can hide all of his past work. He still has some hair available for the future, which he likely won’t need. Finally, sometimes going grey can be a good thing!

Thanks Everyone Blake, I almost always do pure follicular unit transplantation and use the grafts as they come. A usual patient might have 55% 2s, 30% 3s, and 15% 1s but some with finer hair have 4s or even 5s. My mentor, Dr. Seager, called these combination grafts "follicular family units" but they could also be called "double follicular units" or "dfus". I really only use them when someone has the unfortunate combination of fine hair and small natural follicular units (and when we can create these "ffus" and still get enough grafts to cover the area.) It is important that only small follicular units that are close together get combined so that you don't end up with a minigraft that requires a big slit for planting. We didn't keep an exact count but I would estimate that of 3155 grafts no more than 300 were follicular family units. It was a way to bump up his "3s" and reduce the number of "1s." Fine 1-haired grafts are great in a hairline but don't give much coverage in the dense zone of the transplant. I should also mention that what you see first is his thinning natural hairline which is below the level of the transplanted hairline. His natural hairline was lower than where a mature hairline should be (imo) but it will eventually recede up to the transplanted hairline, which will be denser than his current hairline.

Either approach can work in the right situation. For example, if you have dark, coarse hair, light skin and big compressed plugs with 18 - 30 hairs per plug, it would be very difficult to camouflage the plugs with small grafts alone. In that case, you would need to debulk the old plugs and transplant more grafts. There are different techniques to reduce and recycle old plugs too. If you have finer, lighter coloured hair and the plugs aren't too big you may be able to just fill in. One more caveat: If you have already had 2 older method surgeries in the same area, the scarring may limit how densely the new grafts should be placed. Dense-packing into scarred skin can lead to poor growth.

Martin84 You do have miniaturization over a big area. You may have recession in a Norwood 3 pattern but you have thinning in a Norwood 6 pattern. As you are just 26, we unfortunately can't promise that it will stop at Norwood 6. Using both Finasteride and Minoxidil together is the best treatment but if you are going to use one or the other, Finasteride is usually much more effective than Minoxidil alone. There is a warped perspective about Finasteride on the internet. Ultimately you get to choose what you take or don't but please first discuss the real risks and benefits with your doctor so that you can make an informed decision. Best wishes

This 32 year-old man had thinning for 8 years. He had finer than average, dark brown hair and light skin. In addition, he had fewer 3s and more 1s than average. These hair characteristics make it challenging to achieve good visual density without using up too many grafts in too small an area. Fortunately, he had good donor density. We transplanted 3155 grafts from a mature hairline that starts just above his natural hairline. Where possible, we combined two small follicular units that were close enough together into one graft, as long as that graft would still fit into a regular incision. These combined grafts were counted as one graft and have been referred to as follicular unit family grafts. He was fortunate that he had enough donor density that we could reach the target graft number (3000) despite combining a few hundred follicular units into “family” grafts. We could have used only follicular unit grafts and placed them closer together but then he would be paying for more grafts and his hair would not have looked any denser. He uses Minoxidil but declined to take Finasteride. One day he will lose the natural hair below his transplanted hairline so the transplanted hairline will take over. For now they blend together.

This 40 year-old man had a Norwood 4 pattern of hair loss with fine, black, straight hair. His donor density was average but his scalp was flexible. We transplanted 4169 grafts in front at higher than average transplanted density to compensate for the fineness of his hair and his smaller follicular unit size. He had about 55% 2s, 20% 3s, 20% 1s, and 5% 4s with about 2.1 hairs per graft. He had a routine 2-layer trichophytic closure without tension. These photos were taken 12 months after his hair transplant. Although we did not transplant his crown he can now partially conceal the thinning there by styling. He has more hair available to transplant further back if he chooses but he is content for now as he is.

This gentleman had a scar in his lateral (outside) right eyebrow that was stretched wide but was flat and fairly soft. He had no other hair loss and wanted to transplant hair to conceal the scar. We discussed FUE vs. FUT with trichophytic closure (FUT-T) as options. With FUE, we could have cherry-picked natural single-haired grafts but I would have had to trim the hair shorter to see the angles for extraction. FUT-T did leave a short, narrow trichophytic scar but allowed me to keep the hair longer so we could direct the curl toward his face. He had 95 single-haired grafts and 19 grafts with 1 terminal hair and 1 parallel vellus hair transplanted into pre-made flat-angled lateral slits. We use skinny grafts in eyebrows, as recommended by Drs. R. Bernstein and J. Epstein. Left-over 2s and 3s were transplanted back into the donor incision. Many of the transplanted hairs were still visible at 10 days but by 1 month most had fallen out. At his 6.5 month follow-up most hairs had grown back. He does need to trim his eyebrows weekly. His eyebrow will still fill in a little more but he is content now that his scar is hidden.

First let me say that I do not have a lot of experience with CVG. After seeing a CVG patient in consultation and seeing email photos of another a couple of years ago, I realized that I had done a hair transplant a couple of years ago on someone with very mild CVG. He had 2 sagittal slight indentations that could be felt at the time of his hair transplant but not really seen. I wondered at the time if he had a couple of childhood scars he didn't remember. I since saw him in follow-up and his hair transplant grew well. I believe that his hair loss was caused by male pattern baldness. He had a classic Norwood 5 pattern and the indentations were most easily felt where his hair was thickest in the band across the midscalp. His CVG likely had not progressed. For patients who see thinning in an area affected by CVG, it is possible that hair is being spread apart more in the ridges and not spread apart in the furroughs. Also the way the skin thickens, the hair direction will tend to fan out from side to side on the tops of the ridges and will criss-cross in the bottom of the furroughs. That will also make the hair look thicker in the furroughs and thinner in the ridges. I could not find much about treatment for CVG. There was a report about subcision to reduce the depth of the furroughs, which is basically undermining under the furrough with a needle through multiple entry points. In the accompanying photos there was some evening out of the skin but it wasn't perfect. There were other reports of scalp reductions and flap rotations to remove more pronounced ridges and furroughs. My patient had barely noticeable CVG and his hair transplant grew quite well. I don't know about the effect or more pronounced CVG on hair transplantation. If I find some colleagues with experience with CVG I will ask them to reply.

This gentleman's hair has continued to fill in. He is quite happy with his hair when parted on the left. We knew that the right hairline would not look as full or natural as the left side because we had to reduce the transplanted density on the left because of the extensive scarring. He is content that reducing the old punch grafts and filling the hairline in a little makes his right hairline much better if the wind should blow his hair from right to left. He may see a little improvement in the scarred area over the next 6 months because there can be some delayed growth when transplanting into scar tissue. He is content now but does have more hair available to strengthen his left part and transplant further back.

Thanks. He is happy.

This 44-year-old man had a Norwood 5A pattern but also had receded temporal points. His facial frame was very important to him so he wanted to address the front and temporal points first and to leave the midscalp for later. (Others may have chosen to transplant the front and midscalp first then to return for the temporal points later.) He had fine, wavy, brown, salt-and-pepper hair. He had a large head and therefore a large area to cover but he had good donor density and good flexibility. We transplanted 4037 grafts with about 1000 in his temporal hairlines and points and about 3000 in front. We used score-blunt dissection and a 2-layer trichophytic closure. His donor strip was 34.5 cm long and well within the safe donor zone. The was narrowest at 12 mm wide in the mastoids and widest at 15 mm in the occiput. He had about 18% 1s, 46% 2s, 22% 3s, and 14% 4s with an average of 2.3 hairs per graft. At 8 months he is very happy with his early results. The transplanted hairs will still get a bit longer and stronger. He plans to transplant his midscalp in a second session and may slightly lower his frontal hairline at the same time. He still has good flexibility and good donor hair to work with.

Sorry for the previous video. I uploaded a better quality one and edited the link.

Here is the video of his results: http://www.youtube.com/user/DrCamSimmonsCHTC?feature=mhee#p/a/u/0/YabdfOkIsK0

Thanks Superfinehair. I do recommend Minoxidil after hair transplantation to reduce postoperative shedding and to jump start the new growth. However, he did not use it. Fine hair can look very natural when transplanted but it takes more fine hair to achieve fullness than coarser hair. This man had finer than average hair but it was not "super" fine. He was also fortunate that he had more 3-haired grafts than usual and fewer 1-haired grafts. His approximate ratio was 8% 1s, 46% 2s, and 46% 3s so he would have had an average of 2.4 hairs per graft.

This man was concerned about hair loss but was opposed to medical treatment. He had a Norwood 3 - 3A pattern but had early thinning in a Norwood 5A pattern (that is most visible in the top_plan photo.) He had light brown, finer than average, straight hair with average density and average flexibility. We transplanted 3580 grafts from a mature hairline and covered more than the frontal third of his scalp. He is prepared to have more hair transplantation when he loses more hair. At 5 months post-op, he has good early growth but he can expect his hair to fill in, get longer, and stronger over the months ahead.

Thanks everyone. Good point David!

This 71 year-old active man enjoyed good health but didn’t enjoy his gradual hair loss. Tired of combing his hair across, his only goal was to get more hair in front in one session. He had a Norwood 5 to 6 pattern and finer than average salt-and-pepper, wavy hair with average density and good flexibility. Apart from his temples and the remaining hair in front, his hair was mostly dark. He had 3915 follicular unit grafts transplanted in front. He had about 15% ones, 45% twos, 32% threes, and 8% fours. He had a 2-layer trichophytic closure. A year later, he has lots more hair to transplant further back but he is happy that he has achieved his goals and his hair transplant career is finished.

Thanks Jotronic He has already seen a huge improvement.

Thanks everyone.