Cam Simmons MD ABHRS

This 35 year old man mostly had a NW 3A pattern but he was developing a Norwood 5 pattern with early thinning in his crown. He kept his hair short to make his hair loss less obvious. His hair was black, coarser than average, and straight. It was not surprising, given his hair quality, that he had fewer 3s and more 2s than average. We transplanted 3041 grafts in front in one session. By sampling, he had about 19% 1s, 66% 2s, and 15% 3s. Medical treatment may preserve his hair in his midscalp and crown. He has available donor hair to transplant further back, if and when he loses more hair in the future.

Thanks. Here is his video. (He was smiling before and after the video but I guess we all get a bit nervous in front of the camera.) http://www.youtube.com/watch?v=5qn6FN-GVn4&feature=channel_video_title

Deitel130 Just to clarify. These plans were drawn for 3000 grafts in the first session but you chose to safely transplant 3500 grafts. With either option we would cover a larger area with 3500 grafts, than drawn in either photo. The area drawn for the second session in the first photo was for 2500 grafts. We usually aim for fewer grafts in a second session than the first because we remove the old scar and take a slightly narrower donor strip. You have a Norwood 6 thinning pattern with miniaturizing hair over a big area. Medical treatment can help preserve that hair but we can't count on you using medical treatment forever or medical treatment working forever. Our goals were to cover the front and midscalp, while keeping a narrow scar in the safe donor area, and donor hair in reserve for the future. You are young enough that we still have to be cautious about transplanting your crown until we see how your future hair loss unfolds. Your donor density and scalp flexibility allow you to transplant a lot of grafts but not enough to cover your whole front and midscalp to a finished density in one session. We would need 2 sessions to achieve these goals. Those 2 sessions can be done in 2 basic approaches. In the "front-to-back" approach you would see a finished look in front after one session and could return as soon as 9 months later to transplant your midscalp. You still have hair in your midscalp and we would fade out the transplant so it wouldn't look (between sessions) like your hair suddenly stopped at the back of the transplant. There is a higher chance of postoperative shedding when we "dense-pack" the area but each area would be finished after each session. In the "spread out" approach, we would give you a more gradual restoration and would cover a larger area less densely. We can spread the hair out a little but if we try to cover too big an area with too few grafts, I can guarantee that you will be disappointed. Spreading the grafts out would not give as dramatic a change after one session but would give a more balanced look if you postponed the second session. You would have to wait at least a year after the first session to see the full growth before adding more hair. We could fine-tune the plan for the second session based on the results of the first session. There are advantages and disadvantages to either approach but either is acceptable. You can think of the "front-to-back" approach as the more direct route and the "spread out" approach as the scenic route. Either path can take you to the same destination after 2 sessions. Youger men who still have some hair on top usually prefer a front-to-back approach and older men who are bald on top tend to prefer a spread out approach .... but not always. I hope that this helps with your decision. You can certainly solicit other opinions here but feel free to contact me directly with other questions. I will follow this thread with interest.

Let me expand on Tsakalos' accurate and concise answer. The human eye is very good at noticing colour differences. A scar is almost always a slightly different colour than the skin beside it. Even a 1 mm wide scar with hair growing through it will be visible if the hair is shaved right down. It is more important for the scar to be narrow than hair-bearing but a narrow hair-bearing scar is easier to hide with shorter hair than a narrow bald scar. I routinely do 2-layer trichophytic closures but tell my patients to expect to have to keep their hair at least 1 inch long for the first 6 months until the pinkness fades then at least 1/2 inch long. A number 4 clipper cuts hair 1/2 (4/8) inches long. Occasional patients are comfortable going down to a #3 clipper (3/8 inch) but they are the exception and not the rule. I usually see patients 10 days, 1 month, 5-6 months, and 10-12 months after their hair transplants. At 1 month there is usually some hair growing through the scar but there is more at 5 months.

This man in his early 30s had black, average-fine, straight hair. He was balding in a Norwood 3 pattern but had miniaturization and thinning in a Norwood 3A pattern. Rather than just restoring his hairline, he wanted to be more preemptive and to finish the front. His hair on top and in his crown is great and hopefully Finasteride will keep it that way. We transplanted 3082 FUGs to the frontal third of his scalp. His frontal hairline was newly created at a mature level so that it would look appropriate now and later in life. We reduced the density while working further back from the hairline, so that the transplanted area would blend with his existing hair further back seamlessly and would not stop abruptly if he lost more hair. He has plenty of donor hair available to transplant further back if he loses more hair in the future These photos were taken 5 months after his surgery. He is happy with his current growth and looks forward to further growth in the next few months.

I have not found any clinical studies so far but have contacted the manufacturers to see if they have published studies. Studies are not required for makeup, shampoos, conditioners, or stying agents the way they would be for medical treatment. Many recommendations for post-op care are based on experience and not on scientific evidence.

Joe Thanks for this post. It raises an important question about using concealers post-op. With respect, I would like to discuss your conclusions. It may be hard to say with certainty that he had a low-grade infection. In the video, his scalp does not look particularly red and there are not a lot of pimples or pustules. Mostly what appeared on the end of the comb was a clump of pigment. The white spots on the end of the comb looked more like skin than pus. Plugged pores or comedones are not necessarily infected. With Dr. Hassan seeing the patient outside the office, he likely could not do swabs or a biopsy to confirm his suspicion that there was a low grade infection. Dr. Hassan, of course, can get a much better clinical impression in real life than we can from a video. It is also hard to say with certainty that the concealer caused the poor growth. The clumps demonstrated were mostly at the bases of growing hairs. In fact they looked biggest where there were the biggest grafts. It may be that the pitting around the graft and the hairs in the graft caused it to be more difficult to clean the concealer with regular washing but that the concealer did not harm the transplanted hairs. It would be more concerning if the clumps of concealer were found in pits where grafts were transplanted but didn't grow. The patient noticed poorer than expected growth and the concealer may have played a role. However, there are many other factors that could have influenced the growth and the concealer might not have been a factor. You have raised an important question because many patients rely on fibers or concealers to give them some camouflage while they are waiting for their hair to grow. I have not noticed ill effects on the end results but you don't look as hard for a relationship when you don't suspect it. I ask patients not to start using concealers or fibers until the scabs are all gone and they can wash their transplanted hair normally. I usually recommend fibers over concealers. This is just my recommendation and is not based on science. I will certainly look closer at the results of patients who choose to use concealers. It will also be worthwhile to see if there are already studies on the effects of concealers and fibers on hair growth. If it hasn't been done already it could be useful to do a study where concealer is applied regularly to a small test area and not applied to a similar control area and to see if the growth is different. It is not easy to recruit patients for studies and it is time-consuming and expensive to do them. There is always a problem getting a large enough sample to make definitive conclusions. I would be eager to hear about the experiences of forum members who have had hair transplants and used concealers post-operatively. Thanks again for raising this question and posting the video. It is certainly worth considering.

We can't know for sure but I suspect that hairs that responded to medications are more likely to grow back. Medications tend to work best on hair follicles that are early in the miniaturization process. It is the weakest hairs that have been miniaturizing for many growth cycles already that are the most vulnerable and the least likely to return. If the hairs were strong enough to respond to medical treatment I suspect that they are strong enough to return after postoperative shedding. When there is a blanket of peach fuzz over a large area that is to be transplanted, postoperative shedding can have the greatest toll.

The honest answer is we don't know exactly what happens when Minoxidil is used after a hair transplant. In a few patients some of the transplanted hair just keeps growing and is not shed. Most patients still shed 90% plus of the transplanted hair but it has a shorter resting phase and grows back faster. Finally, some seem to grow their hair back at the same pace as those who don't use Minoxidil. Overall, patients see their results faster if they start Minoxidil in the first few days after their hair transplant but some respond better than others. We can't predict in advance how much Minoxidil will help any individual. Minoxidil can also reduce but not eliminate postoperative shedding of existing hair in a transplanted area.

For the second part of your question: Doctors would simply make more incisions if there were grafts left after the first incisions were made and filled.

Michael5577 As long as the transplanted hair came from the safe donor zone, you should expect it all to grow back. You can usually see improvement in the 4th month when some of the transplanted hair and the "shocked" hair gets long enough to see. Best wishes

Megatron gave me permission to post cropped photos and comments. I showed these photos to Megatron after his 12- month follow-up visit and he agrees that they accurately demonstrate his usual appearance. First and foremost, I want to say that Megatron went through an ordeal with extensive post-operative pimples and secondary Psuedomonas infection that none of my patients have gone through before or since. Megatron has always been patient and fair (and was calmer than I would have been if I were the patient.) I am glad that despite his bumpy start, he is happy with his results. Megatron knows that I don’t feel the photos he posts represent his hair well. He posts these photos to try to be candid but other patients don’t post photos of wet, short, spiked-up hair. Hair is deliberately transplanted at lower than naturally-occurring densities and so we depend on some illusion to make it look fuller than it actually is. Transplanted hair will always look fuller when 2-3 inches long, dry, separated, and styled to layer like shingles on a roof. It will always look thinner when cut short, spiked up, parted through, wet or clumped with product. At his follow-up visit, Megatron’s hair was shorter than I would recommend but he did not use product and brushed it forward so the transplanted hair would overlap. His hair would look fuller if it was a bit longer but Megatron is free to style his hair how he likes. Megatron has had delayed growth (likely due to the infection) and at 8 months was behind the curve for expected results. Usually changes are subtle between 8 and 12 months but his hair has continued to improve in the last 4 months. Sometimes, when transplanting into scar tissue, there can be delayed growth and continued improvement for up to 18 months. Megatron may already have his full results now but since his hair has been improving at a faster than normal pace for 8-12 months, he may still see more improvement in the months ahead. He has had a flare of facial acne and has a few pimples in his donor area but thankfully has none in his recipient area. He will be resuming treatment and will likely see a dermatologist. Megatron is happy overall with his results but would like more density in some areas. He has been describing the area of concern as his temples but that was not the correct terminology. Megatron does have thinning temporal points but we did not transplant any grafts there as we focused on the front. The area that he is concerned about is actually the second cm in his right and left frontal hairlines, close to the fronto-temporal recessions. When combing through those areas, the hair there does look less dense than the hair in the hairline and the hair in the midline. There are scattered small spots that look empty to the naked eye but have small hairs when seen with magnification. Those hairs could either be growing transplanted hairs or shrinking natural hairs but grafts would have been placed near them. If those spots fill in over the next few months, the overall density will increase. These days, when transplanting hair around thicker natural hair in the midline, we do increase the transplanted hair density behind the 1st cm by either using more 3s and 4s or increasing the graft density or both. In summary, Megatron does have good results overall but could have expected a little better density in the 2nd cm from the hairline on the left and right. This could be due to decreased or delayed growth, secondary to infection, and to a design that did not account enough for the fullness of his natural hair in the midline. I have offered to touch up the areas of concern at no charge now or in 6 months, if they don’t improve on their own. However, Megatron prefers to wait until he needs or wants more hair transplanted in other areas (like the midscalp or crown.) If and when we do more hair transplantation we will suppress his acne before, during, and after his next hair transplant and will be vigilant about early recognition and treatment of pimples/infection. Thanks again to Megatron for his patience and for letting me add my 2 cents to his thread.

His video was added to the videos page: Hair Restoration Social Network - Hair Loss and Transplant Videos

Mahhong It is good that you are planning for the future. After Finasteride, Minoxidil 5% has the most evidence for fighting hair loss. You have given Finasteride 2 fair trials. Usually Minoxidil slows hair loss but doesn't stop it. While most patients find that Finasteride alone works better than Minoxidil alone, a few respond better to Minoxidil. The better hair you have to begin with the better your chance that Minoxidil will help slow your loss. Some doctors believe in laser and/or PRP but I am sitting onthe fence until better studies are done. Perhaps the most difficult task in hair transplantation is predicting someone's eventual hair loss pattern. I tend to plan for the worst and hope for the best. Usually, the younger the patient notices hair loss, the more rapid their hair loss tends to be and the longer they have to lose more hair. That is why most hair transplant doctors tend to be cautious and conservative about hair transplantation for young men. If a man has kept a lot of hair into their 40s or older they are much less likely to lose a lot of hair and to need a lot of grafts. Some men use a combination of hair transplantation and medical treatment, others choose to use medications alone, others choose hair transplantation alone, and others let nature take its course. With modern hair transplantation, Norwood 6 or less patients can usually get good results if they transplant enough grafts. Norwood 7 patients who choose hair transplantation most often do not have enough scalp donor hair to cover the entire balding area well and have to either sacrifice some density, some coverage, or some of each. If you are comfortable sharing your age and some photos, people here will be better able to guess where you might end up without medical treatment. You can then plan backwards from there.

Here is a video of his results and his trichophytic scar: http://www.youtube.com/user/DrCamSimmonsCHTC?feature=mhum#p/a/u/1/j7lc0_pbBOo

Megatron You had the worst case of post-op pimples that I have seen and I truly feel bad that you went through such a rough post-op course. I had not seen a patient get a secondary infection like yours before and haven't seen it since. You had mentioned having had severe acne in your history and I wish in retrospect that I had started preventative treatment for you. Usually pimples do not affect hair growth but in your case the infection may have caused either delayed growth or worse growth than usual. Like you, I am waiting to see how the final results turn out. As I have told you personally, if you do not achieve the usual expected results, I will touch up your hair transplant at no charge. In consultations, I routinely say that we transplant hair at about half the density of a teenager in some areas and less than that in others. Otherwise we would use up too much hair in too small an area. We depend on styling and the human eye to fill in some spaces for us. Transplanted hair will always look thinner when wet, spiked up, cut very short, or clumped together with gel or pommade. There is more space between follicular units than in a teenager's head and more light will be reflected under harsh lights. Transplanted hair will look fuller when dry, separated, long enough and styled to layer, and in natural light. Taking photos with wet hair, spiked up, and exposed to harsh light is not a fair way to judge transplanted hair. It is kind of like having a nose job then taking photos with a fish-eye lens. Neither is it fair for people to deliberately take photos in dim lighting or to compare photos that are taken at different angles. As much as possible, lighting should be consistent from one visit to the next and the hair should be styled as you would normally wear it to make it look as good as possible. When I saw you last at the 8 month mark, your hair transplant was not as dense as expected. It has seemed to improve each month since then in your journal but may still not be where it could or should have been. Sometimes there can be delayed growth where there can be continued improvement for up to 18 months. I have seen this happen when transplanting hair into scar tissue. However, if your hair is not as full as expected at 12 months I will offer to touch it up ... and to start acne prevention treatment beforehand. See you next month.

Mac1 This topic has been discussed a few times. Forum By and for Hair Loss Patients - Search Results I am no expert on micropigmentation or tattooing but I believe that black ink can turn blue and brown ink can fade. As Sparky said, black (or blue) dots may look unnatural when your hair turns white.

Here are updated photos from 13 months after this man's hair transplant. His hair is combed left to right and back to reveal his transplanted hairline. He has natural hair below the transplanted hairline in his existing widow's peak. He is happy with his transformation and continues to use Finasteride to preserve his native hair. Happy New Year to all!

Natural Hairlines have what Dr. Bill Parsley called Macro-irregularities and Micro-irregularities. There are peaks and valleys in the basic shape and finer irregularities in the leading edge of the hairline. Dr. Ron Shapiro's concept of a Transition Zone before the Defined Zone of the hair transplant is also very important. A strongly defined saw-tooth pattern looks as unnatural or more unnatural than a strongly defined straight hairline. I believe that to make a natural-looking transplanted hairline, it is a good idea to build-in some peaks, mounds, or notches in the defined zone and soften that further with irregularly placed 1 haired grafts in the leading edge and 2-haired grafts in the transition zone.

This lady in her mid-30s had a Ludwig 2 pattern of thinning. She had fine, straight, brown but highlighted hair and had a stable donor area. She has an S-whorl and naturally parts her hair on the left. Usually, we would focus on her midfrontal forelock and the first portion of her left part so the hair there could look better and she could style that hair to make other areas look better. She preferred to transplant along the length of her part. At her consultation and pre-op, she consistently parted her hair at exactly the same place. We focused on a much narrower than usual area along her part, knowing that parting her hair outside this zone would eliminate the cosmetic benefit. With her fine hair, we knew it would take a higher density to give her the results she wanted. Transplanting at higher density increases the risk of shock loss but could give her a finished result in one session. Transplanting at lower density would reduce her shock loss but she would likely need a second session to get enough density. She chose the former plan. She had 2725 grafts transplanted in her midfrontal forelock and along her left part in a narrow area. Her hair was fine and her grafts were small so they were transplanted at 64 grafts per sq cm. (This is a much higher density than I would recommend for someone with average-sized grafts.) In anticipation of shock loss, she switched to a right part until the transplanted hair grew in. She used 2% Minoxidil lotion then 5% foam but by 3 months, she reported that she did have significant shock loss. At her 5 month follow-up, her hair was finally starting to fill in but she still needed to wear a right part. At 10 months she neared her final results and when she returned at 18 months, her hair was longer (and highlighted more). Both times, she came in with her hair parted right down the middle of the transplanted area. She will be the first to admit that the shock loss was tough but is very happy with her final results. Despite the shock loss, she is still happy that her results were achieved in one visit instead of two.

Dr. Griffin You clearly paid a lot of attention to his hair direction. I look forward to seeing his final results.

Mick Nice transformation and a great trichophytic scar. It was good to meet you in Boston and to see the patients Dr. Farjo brought to the meeting.

Big Bill It is uncommon for a scar to stretch after 3 months. As a rule of thumb a scar has about 30% tensile strength at 3 weeks and 80% at 3 months. We used to think that scars became stronger than skin but they may never get to 100% strength. I advise patients to avoid forcefully stretching their scalp for the first 3 months and discourage active scalp stretching exercises until they have reached 5 months.

Hello Nick When you say down do you mean forward? The hair naturally grows mostly in a forward direction and is angled more down toward the scalp than upward. Depending on the area of the scalp the hair is usually angled between 30 and 40 degrees up from the scalp. If someone's transplanted hair is better in front than their natural hair behind it, some men choose to brush the transplanted hair back to cover the thinning area. Patients can brush their hair forward, backward, or to the side. They can centre part their hair but it tends to make the transplanted hair look thinner. Spiking hair up also tends to make transplanted hair look thinner. Here are a couple of patients who brush their transplanted hair forward: http://www.hairrestorationnetwork.com/eve/137441-dr-cam-simmons-norwood-5a-3288-fug-front.html http://www.hairrestorationnetwork.com/eve/135304-dr-cam-simmons-norwood-3-2001-fug-short-hair.html

StuPitt You are right. Temporal points are one of the more challenging areas. The angle and direction of the hair are critical. The very flat angles required means we can't put the grafts as close together as we could on the top. The transplanted hair is directed away from the incision so the bases of the grafts near the incisions are visible whereas in the front, you see the tips of the hairs first. Even if you brush the frontal hair back, you see the bend in the hair and not the base. Larger grafts can stand out like a sore thumb in the temples so we will not get as much density when we are using 1s and 2s. I think most hair transplant doctors would rather achieve the look of thinning natural-looking temporal points than having denser less natural-looking temporal points. Subtle temporal points can make a difference even if they aren't dense. Temporal points are still the icing on the cake for most patients. Usually we have to focus on the cake first. Hopefully, you will consider this "good, not great, but good" temporal point transplantation: http://www.hairrestorationnetwork.com/eve/158034-dr-cam-simmons-%96-norwood-3v-man-%96-part-2-2295-grafts-better-frame.html