Cam Simmons MD ABHRS

In 1996 this patient underwent a “lazy S” scalp reduction and punch grafts to his right hairline at another centre. Although he can’t recall having had flap surgery, it looked like he also had a flap rotation in his right hairline, perhaps as part of the scalp reduction. He went on to lose the hair on the left side and had no choice but to part his hair from right to left. Some of the transplanted hair was directed strongly to the right, however, so his hair was still difficult to style. He had obvious misdirected punch grafts on the right side of his scalp and an area of scarring behind his right hairline that looked like it was caused by tip necrosis from flap surgery. He had punch graft scars that were hidden but higher than ideal in the back. They were at an appropriate level on the sides. He had good donor density where he was not scarred in the back but his scalp was tight. He had finer than average, blond, straight donor hair. After discussing all of his options, we performed fifty 1mm FUE and 2 mm extractions to “thin out” the previous plugs and reuse the hair. At the same time we were able to transplant 2768 FUGs in his frontal area. His grafts were placed with usual density on the left, but reduced density on the right because of the compromised circulation by the scarring. His donor strip went through the punch graft scars on the sides and at the usual level in the back (well below the punch graft scars.) A 2-layer closure was done and it was trichophytic in the new area in back. These photos were taken 7.5 months post-op. He is very happy with the improvement and that it is much easier to style his hair. He continues to take Propecia and Minoxidil and he has donor hair available to transplant his midscalp later.

Thanks Alexdelarge I see your point when looking at these photos. I went back to look at his whole face photos and have attached a photo from his consultation. His whole hairline had receded upward but he had receded upward a little more in the frontotemporal recessions. He is of mixed races and his head shape and natural hairline shape is rounder than for most Caucasian men. You could certainly make an argument that he was between a Norwood 2A and Norwood 3 pattern. In either case, that is not extensive loss ... especially for a 44 year-old.

You can see either a hair restoration doctor or a dermatologist as long as they are used to assessing for miniaturization. First, you may not need hair transplantation if you don't develop AGA later. Alopecia Areata can definitely affect transplanted hair. It is usually a temporary localized condition but not always. Some doctors never treat patients who have Alopecia Areata. Others will advise patients of the risk and will agree to transplant if the Alopecia Areata has been stable for 1-2 years.

Starting-To-Recede I have answered your questions in blue inside one big quote (because I was too lazy to break it up into small quotes.) Right now, your hairline has not receded past a mature level so you may have picked the wrong name. Like most other 27 year-olds, you have about a 50-50 chance that you will develop AGA by the age of 50 and about a 67% chance that you will have at least some hair loss in your lifetime. If you are concerned, it would be best for you to see a doctor to look for miniaturization elsewhere to see if there are any signs of genetic hair loss or Androgenetic Alopecia.

This patient in his mid-twenties mostly had a NW3 pattern but he was receding toward the midline behind his dense midfrontal forelock. He was worried that continued hair loss would leave him with “an island of hair” in front. He had good donor hair characteristics with dark brown, wavy, average diameter hair and average density. We transplanted 2509 FUGs to his frontal area, excluding his existing midfrontal forelock. He declined medical treatment to slow loss and knows he will likely need more hair transplantation in the future – especially if he later loses the hair in his midfrontal forelock. As he was young, we designed a conservative hairline to allow for future hair loss and ageing. These photos were taken 14 months post-op. He feels comfortable flipping his hair up again and he is very happy with the improvement from his hair transplant.

Thanks Newhairplease and RC west

Thanks guys Having more hair made him look younger but his new style makes him look younger still.

This 29-year-old lady had noticed gradual recession in her frontotemporal areas over a few years but did not have hair loss elsewhere. This gave her a Norwood 2 thinning pattern. She had normal lab tests and in particular had no elevation of her androgens. She had experienced Telogen Effluvium after she had her baby the year before but had complete recovery (except for the recessions.) Most women who develop “Male Pattern Hair Loss” have normal hormone levels …. but we always check. She had straight, blond, highlighted, salt-and-pepper hair of average diameter. She had a nice frontal hairline and elected not to lower it. We transplanted 2264 grafts in both recessions. She had about 16% 1s, 41% 2s, 41% 3s, and 2% 4s. These photos were taken 6 months after her hair transplant but she has since moved too far away to return for her last follow-up visit.

At 12 months, he has adopted a shorter hairstyle. Hopefully medical treatment will continue to preserve the hair behind his transplant.

HTGuy and Aaron I think there is some confusion. I almost always do a 2-layer trichophytic closure. Rarely, if the closure is tighter than expected, I will discuss it with my patient and not do a trichophytic closure. HTGuy, your doctor may have felt that getting more hair for you was more important than doing a trichophytic closure. Your doctor may have taken as wide a strip as he or she felt was safe. It doesn't sound like much but when the skin is already snug, taking another 1 mm ledge off one side to do a trichophytic closure can create a lot more tension. Avoiding tension is the most important way to prevent wide scars.

hairgirl08 A trichophytic closure is ANY closure that results in hair growing through the scar. It literally translates to "hair-loving" closure. It can be done with staples or sutures and can have one-layer or two-layers. The tips of the hairs and the surface of the skin can be removed from the upper edge, the lower edge or both and there are many ways to remove that narrow, superficial ledge. If I had to choose between having a narrow scar with no hair or a wide scar with hair growing through it, I would choose the narrow one. Fortunately we can usually create narrow scars with hair growing through them. Some patients have medical conditions that predispose them to make wide scars so doctors ask about that possibility before planning any surgery. To prevent wide scars in otherwise healthy people, it is most important for the closure not to be tight and to avoid taking too wide a strip of skin away with respect to a given patient's scalp flexibility. If a doctor takes a narrow strip then pulls the sutures too tight he or she can still make a wide scar. Other techniques that are used to minimize tension on the surface are to either undermine the edges or to use a layer of sutures to hold the deeper layers together so the outside sutures (or staples) have less tension on them. Different doctors find different techniques work best for them. I have tried many techniques but find that in my hands a 2-layer sutured closure produces narrow scars most consistently. I do a 2-layer closure for all of my patients. After the deep layer, I test how easily the edges come together. If they can overlap, I remove a 1 mm ledge from the bottom edge so that the trimmed hairs will grow through the scar. I then suture the surface layer without tension. If the skin edges ever just come together, I recommend against taking more skin away to get a trichophtyic closure so we can avoid tension and keep the scar narrow. I do a trichophytic 2-layer closure for almost all of my patients. Sometimes when we are trying to get as much hair as safely possible we start out hoping to be able to do a trichophytic closure but change to a non-trichophytic closure if needed. It is always an option to revise a narrow non-trichophytic scar and turn it into a narrow trichophytic scar later. In summary, you don't have to choose between a trichophytic closure and a double-layer closure. You can have both at the same time.

Dr. Lindsey, I wish the best for Julia, you, and your family in this difficult time.

This gentleman came in a few days ago for a follow-up visit, 2 years after his hairline transplant. He commented that his hair has become smoother and easier to style over the last year. He now wears a longer hairstyle and that makes his hair look fuller too. He continues to take Finasteride and has not had side effects or lost more hair. For now, there is nothing for him to do but to continue taking his medication and enjoying his hair.

Thanks everyone for your kind words. We can't count on medications when we design hair transplants because patients may not take them forever (or they may not stop hair loss.) However, medications and hair transplantation together can make a great combination.

Aaron 1234 It is not the turban that causes the Traction Alopecia but the long hair repeatedly twisted into a tight top-knot under the turban. In fact, he probably wore a top-knot in childhood long before he ever wore a turban. He would not get further Traction Alopecia if he kept his hair short and wore a turban but he probably has no plans to do that. I live and work in Toronto, which, like Vancouver, is a multi-cultural city. I also have Seikh patients who have had similar hair loss. I have not met this man and cannot speak for him but some of my patients related how difficult it was to go against their family's wishes and beliefs to adopt a Western look to fit in better in their adopted society. Once they have decided to cut their hair and stop wearing a turban, they had no intentions of wearing it again. In other words, we don't have to tell them anything. They already know!

This 25-year-old man was balding in a Norwood 3A pattern but thinning in a Norwood 4 pattern. His hair was dark brown and average in diameter. At his first consultation in 2009, he started Finasteride and Minoxidil. A year later, his front was unchanged but his crown was clearly better. He decided to have hair transplantation for the front. Although young men would often prefer lower, fuller hairlines like their peers, he accepted the importance of long-term planning. If he stops using the medications or they stop working, he faces many more years of potential hair loss. We transplanted 3245 FUGs in his frontal area in one session from a mature, conservative hairline that would allow for ageing and future hair loss. His donor strip was removed from within the safest donor zone and he had a routine trichophytic 2-layer closure. A year after his hair transplant, he is very happy with the improvement from his hair transplant in front and his medical treatment in back. Hopefully the medications will work for a long time but he is prepared to have more hair transplantation, if and when he does lose more hair.

I agree with Dr. Charles. I tell everyone to expect to shed the majority of the transplanted hair in the first 6 to 8 weeks and not to see new growth for at least 3-4 months. I also warn everyone about postoperative shedding of existing hair. Usually by 4 months the hair starts improving, it looks pretty good by 6-8 months and finished by 10-12 months. I have had a few patients who did not use Minoxidil but had very little shedding and early hair growth. I have had other patients who did use Minoxidil and still got postoperative shedding and regular hair growth. However, on average, there is a tendency for patients who use Minoxidil to get less postoperative shedding and to see earlier growth. I particularly recommend Minoxidil for patients, like you, who have miniaturized hair in the transplanted area as miniaturized hair is most vulnerable to post-operative shedding.

Here are 13 month photos with her hair pulled back to show the transplanted areas better.

Hi Here are updated photos, 13 months after her hair transplant. The main reasons for improvement compared to the 8 month photos are the increased length and strength of the transplanted hair.

Hi Here are updated 12 month photos. He is wearing his hair shorter and it is getting easier to style again.

Dr. Lindsey The deep layer is absorbable and lies in the fat below the bulbs. I use Maxon but others may use Vicryl. The cutaneous sutures have to be removed. I use Prolene but others may use Nylon. Dr. Tykocinsky uses the deep layer to bring the edges closer together so there is almost no tension on the surface. I found that tension in the deep layer caused more post-op discomfort for my patients. Instead I use the deep layer to convert the gap from a "U" shape to a "V" shape then the cutaneous sutures to approximate the edges "U -> V -> l". This 2-layer closure also keeps the hair in both edges and the trichophytic hairs more parallel. You are always generous in sharing your ideas and experience so I hope that this is helpful for you. Ultimately we create techniques and/or adopt other's ideas then adapt them to make them work in our own hands.

Dr. Lindsey Very nice work! Your donor scar is very hard to see. I adopted a method similar to the one Dr. Arthur Tykocinsky developed and presented in Boston and Dr. Parsley published in the Forum. They (and now I) use running horizontal deep sutures in the fat under the follicles and superficial running vertical sutures to close the skin. (These are simple running sutures and not mattress sutures.) I also don't pull the deep layer tight. This technique gives the advantage of a 2-layer closure without any extruded sutures. Your method obviously works well but you might like Arthur's too. Kind regards,

Thanks RCWest, Mahhong, and Mick

Julius Trauma or a major surgery can cause a temporary shedding called Telogen Effluvium (TE). Hair that is already weakened by pre-existing AGA (MPB) may not grow back after a bout of TE. For example, many women notice excessive shedding a couple of months after they deliver a baby and their hair gets thinner. Most women find their hair grows back 6 to 12 months later. Women with AGA (FPB) who have a bout of TE often don't get a full recovery. Some women with AGA find they have a step-wise worsening of their AGA after each pregnancy. I have not met or examined you but if you have AGA (MPB), you have had the genes all along. The trauma could have led to a bout of TE, which in turn uncovered your MPB. Whether it is 3 weeks or 6 months after your hair transplant, the grafts should be established and should not be directly affected by a big surgery. At 3 weeks your grafts will be resting and at 6 months you would have seen some early growth. Most people who have a knee replacement will not get Telogen Effluvium but it is possible to get TE a couple of months after your surgery. If you shed transplanted hair (that came from a safe donor area) it will grow back. If you shed AGA - sensitive hair, most of it will grow back but the weakest hair may not. Medical treatment with Finasteride and Minoxidil may have a protective effect for your native hair. I hope this helps. Ultimately, you should discuss the timing of your hair transplant and knee replacement with the doctors who will be performing the procedures because they will be taking responsibility for the outcome.

Hi SmartGuy You should contact your doctor. There are different types of dissolving sutures with different life spans. Some sutures last longer than they should. Your doctor may be able to remove the remaining irritating sutures.