Cam Simmons MD ABHRS

I posted a reply on Thana's original post. Thanks for bringing it back hair_me_out and taking _the _plunge. Good Styling always helps transplanted hair look better (and bad styling can make it look worse.)

Thana A new post revisited this one. Thanks for your time and effort in creating this post. Did you post photos before and after your styling regime? They may have been lost in the change-over of the site. I thought you had a blog before but I can't find it. We know that we transplant hair at about half of the original density in key areas and less than that in others but try to make transplanted hair look fuller than it really is. Styling is very important and it is nice to have tips for patients to get the most out of their transplanted hair. I tell my patients they are free to style their hair how they like but transplanted hair looks fuller when it is long enough to layer like shingles on a roof. The "dry look" usually looks fuller than a "wet look" and centre-parting lets more overhead light reflect off the top to make the part look wider. Brushing hair forward, backward or to the side usually makes the hair look fuller and taking advantage of thicker natural hair in your chosen hairstyle is always a good idea. The cuticle of the hair shaft looks like scales on a fish and some products open the cuticle to make the hair shafts wider to give volume while others close the cuticle to make the hair smoother and shinier. Different products work better for different people. Transplanted hair can be dry, especially in the first few months, so I often recommend styling creams to coat the hair and make it smoother, heavier, and shinier and easier to style. I myself use "No more frizz" shampoo and conditioner and a simple anti-frizz styling cream applied to wet hair. I then comb my hair and, because I am usually in a hurry, I just let it air dry then comb it or brush it again after it is dry. These days I just use off -the-shelf Clairol shampoo and conditioner and Dove styling cream. I have experimented with different more and less expensive brands and they all seem to work fine so I am not endorsing any particular brands. Each person has their own hair characteristics and chemistry so it is always good to experiment a bit to find what works best for you. Shampoos, Conditioners, and ordinary styling products do not positively or negatively affect hair growth. I have found that sculpting gels, pommade, and waxes tend to clump the hair together and make it look thinner. Especially when people flip up the front or spike it up, the layering effect is lost. Some patients use these products anyway and say they don't mind a slightly thinner look that is more modern and still looks natural. The first steps of your routine all seem to make good sense and I am sure that the blow-drying helps separate the hairs. I am curious about the "DIRT" because I would have epected it to clump your hair to make it look thinner whereas you feel that it makes your hair look thicker. I would be very interested to see your photos. Thanks again for your post.

The long-haired transplant was presented by Dr. Marcelo Pitchon of Brazil. I believe this was done as a strip FUT procedure. My understanding was that the main purpose was to use it to simulate final density for planning. Patients could look in the mirror as the case progressed and could have input about whether they wanted more density or to cover more area. It was interesting to see videotaped patient's reactions when they saw themselves in the mirror with a sudden improvement. Dr. Pitchon explained clearly that the transplanted hairs would mostly shed then grow back like a typical transplant. It seemed to me that long-hair transplants would be more technically difficult and that the cosmetic recovery would be smoother with short-hair transplants but it was a very interesting presentation. I, like many doctors, transplant slightly longer hairs where it is important to control the direction of the curl, such as in eyebrow transplants.

Thanks RC West Sorry it took me a while to respond. This lady may add some more hair in a year. Her surrounding hair is quite dense but a total of 50-56 grafts per square cm would look fairly full when dry and styled. (I don't use this much hair in the midscalp for a man with genetic hair loss.) If we remove this scar as part of her new strip, she could likely get about another 2300 grafts but she would not need that many. The area is approximately 70 square cms so another 1400 grafts would likely be enough.

This lady in her late 20s suffered from Depression, Anxiety, and Trichotillomania throughout her teens but has made an excellent recovery. She has not pulled her hair for years and this was confirmed by her partner. Trichotillomania is compulsive hair-pulling or twisting. Patients experience an overwhelming urge to pull or twist their hair. The tension builds the longer they resist this urge and there is a great relief after pulling or twisting their hair. This is usually immediately followed by remorse and guilt. Trichotillomania is a psychological condition first and a hair loss problem second. It can be extremely difficult to cure and often requires treatment by family doctors and psychologists, psychiatrists, or other therapists. Patients who still have active Trichotillomania often feel guilty and deny that it is still a problem so, as for this lady, confirmation is needed from a family member, loved one, or room-mate that patients are not still pulling or twisting their hair. From a hair loss perspective, Trichotillomania is a form of Traction Alopecia and can cause permanent hair loss and scarring. Recurrence of hair-pulling would destroy transplanted hair and existing hair alike. She had hair loss over the front and top of her head and scarring in the affected area but her hairline was spared. She could not cover the area with a side part and “always wore a hat everywhere.” There were no signs of current hair-pulling or twisting. She had average diameter, short, brown hair and average donor density but less than average flexibility. Her donor strip was 29.3 cm long and averaged 1 cm in width. She had a single-layer trichophytic closure with routine undermining (but we usually use a 2-layer closure without undermining now.) We transplanted 2681 follicular unit grafts at a density of about 38 grafts per sq cm in the affected area. She had more 1s and fewer 3s than usual and had about 21% 1s, 55% 2s, and 24% 3s, by sampling. With the scarring in the area, dense-packing could cause poor growth so we would not have chosen to transplant at higher densities, even if more grafts had been available. At 10 months, she doesn’t have the densest transplant ever and she may choose to increase the density later. However, she is happy and comfortable keeping her hair short and going without a hat. There is always a risk of relapse of Trichotillomania but if there is good evidence of lasting remission, hair transplantation can be very helpful.

BigBill1234 Stretched scars are usually not raised. The scar may be wider and slightly raised for other technical or healing reasons. Determining why your scar is wider and doing a physical examination of your scar and scalp can help determine how best to fix it. In general the height of the scar is less important than the scar width and the flexibility of the scalp near the scar.

BigBill1234 Louise, Stamos, and Bill have given good answers. If your only concern is the scar, I would usually only revise areas of the scar that have stretched and would leave the good areas alone. The tension on the closure has more to do with the width of the strip than the length. Every scar revision is unique but if the VSL (vertical scalp laxity) is greater than the width of the scar there is a good chance that scar revision would be successful. If it isn't you would need to consider serial partial scar revisions and/or transplanting grafts into the scar.

Monkey You are feeling both. Most of the transplanted hairs and some of the existing hair are shed because of the "shock" of the transplant. They grow back the same way. They will start off fine and tapered and will get wider as they get longer. Eventually your hair stylist will cut off the tapered tops. Happy growth!

Good question Empty Area. Thanks for the posts Mahhong and for the clarification Bill. Using the word “diffuse” is confusing when describing male pattern baldness (Androgenetic Alopecia). A Norwood 6 patient has balding over the front, top, and crown but has healthy donor hair. When someone has thinning over the same areas I describe them as having a “Norwood 6 thinning” pattern. They don’t have diffuse loss; they have patterned loss over a large area. I plan with the expectation that, without medications, thinning areas will go bald and that the area could expand. That is a Norwood 6 thinning patient can go on to become a Norwood 6 or 7 patient. A young man who has a Norwood 3 pattern can also progress through the stages without medical treatment and end up with as much hair loss in his 50s as a young man who started with a Norwood 6 thinning pattern. Propecia and Minoxidil work best on thinning hair and don’t help bald areas. If someone has a lot of miniaturized hair in an area that is contributing to the cosmetic effect it is always best to try medical treatment before considering hair transplantation. Miniaturized hair is more prone to shock loss and end-stage miniaturized hair may not come back. Patients are often surprised how much hair it takes to make a thin area look thicker. Cosmetic improvement depends on perception. Think of the difference you achieve when you add 20 trees to a forest vs. the change you see when you add 20 trees to an empty field. For these reasons, I will transplant hair into an area when there is enough thinning that I can see at least as much scalp as hair in that area. Then there will be enough space between and around the existing hairs that I can add enough hair to make a visual improvement. If the only 3 people who know you are thinning are you, me, and your girlfriend it is too early for hair transplantation to be worthwhile and we could cause more harm than good. For someone with a large area of hair loss it is better to have thinner hair over a bigger area but if the hair is spread out too much it can be like painting an entire room with 1 pint of paint i.e. see-through everywhere and not cosmetically appealing. The trick is to balance coverage and density to get the best cosmetic effect. In a second session hair can be added to increase the density in the first area, to expand the transplanted area, or both. In summary, hair transplantation can be worthwhile for patients who have thinning over a large area as long as they have a stable supply of donor hair, we don’t start too early, and we plan for the long-term.

Usually, micropigmentation is tattooing and should be thought of as permanent. Laser tattoo removal isn't perfect. It looks better from further away than from close up as there is no texture like there is with hair. The micropigmented hairlines are often straight and look unnatural but the artistry could be changed to create more irregularity. As with hair transplantation, creating a low, full, permanent "hairline" on a young man could look terrible after he ages and/or loses more hair. I have been consulted by a man who had a 2nd session of micropigmentation to correct the hairline from his first micropigmentation session. He feels that the hairline looks too straight and smooth and that he has to keep his hair buzzed or the micropigmentation looks unnatural. He is not happy with the results and would like a hair transplant. He would prefer FUT-trichophytic because of the reliability and the lower cost than for FUE but he is reluctant to grow his sides and back long enough to hide the sutures. He is still weighing his options. The choice is yours but you should think of micropigmentation as a permanent procedure that will force you to keep your hair buzzed forever and should plan accordingly. The same rules and guidelines for hairline design for hair transplantation should apply for micropigmentation.

Please allow me to introduce my senior technician, Louise. She has been transplanting hair since 1992 and I am happy to say that we have worked together since 1999. Louise has been following the forum for years. She prepared the following patient album and will be posting more albums and actively participating in the forum in the future. -------------------------------------------------------------------------------------------------------------------- Our patient was 49 years old and had experienced hair loss for the past 25 years. He had a Norwood 3V thinning pattern but also appeared to be developing an isolated forelock. He was mainly concerned with his frontal area. He had average density and average diameter, salt-and-pepper hair. We transplanted 3231 fug to his frontal area, excluding his dense forelock. There were 399 singles, 1932 twos, and 900 threes. Singles were placed along his hairline. Density was created using 56 fug/cm2 , then 49 fug/cm2 , and 42 fug/cm2 . These photos were taken at 8 months. He can expect subtle improvement in the next four months and plans to return to transplant his midscalp and crown.

Campbell Great question. A hair transplant doctor first has to design a hairline that will stand the test of time, particularly if hair loss progresses. We all have rules of thumb and guidleines that we use to determine a safe level and basic shape for a hairline. My guidleines are related to a patient's head and face shape and landmarks that I can see and feel. A natural hairline has irregularities and features such as widow's peaks and lateral peaks. I can add these on my own but do encourage patient input. If a patient asks for a design that I feel won't suit him or her, I will explain why. For example, a V-shaped hairline or a strong widow's peak doesn't usually suit a patient with a broad forehead or a round or squarish face. We can also use old photos to give us ideas for design but should not try to recreate a teenager's hairline. For example, if someone had a strong, low widow's peak when they were 20, we might add a more subtle, higher widow's peak to their transplanted hairline design. In other words, experienced doctors don't need patient input for hairline design but welcome it, when offered.

Haircare99 Most patients shed most of the transplanted hair in the first 2-6 weeks but they don't shed entire grafts. Sometimes patients see hairs going through the crusts that come off and they think they are losing grafts. After a 2 to 4 month rest, the transplanted follicles will start growing new hairs but you won't see the full effect for 12 months. If you are worried the best thing to do would be to collect and take in some of the shed hairs to your hair transplant doctor. He or she can look at them and tell you exactly what you are shedding. Best wishes.

This 29 year-old man had finer than average, dark brown, straight donor hair. He had about 15% 1-haired fugs, 42 % 2s, 38% 3s, and 8% 4s. He had a Norwood 4A thinning pattern with a thinning persistent midfrontal forelock and early thinning in his crown. His larger hat size increased the size of the area to cover. He started Propecia to preserve his existing hair but did not use Minoxidil. We transplanted 3851 follicular unit grafts with 56 grafts per square cm in his midfrontal forelock, 49 behind his hairline then we decreased the density to 42 then 36 grafts per sq cm as we worked further back. At 5 months he has earlier than usual growth of the transplanted hair. His transplanted hair is still short so he brushes it forward in a Caesar cut. Additional photos show his hair brushed back or to the side. He will continue to get some new growth in the months ahead but most of the visual change for him will come from increased width and length of the already growing transplanted hair.

Sparky I don't want to hijack Megatron's thread so I will answer briefly. I pre-make the incisions for the initial hairline but we use stick-and-place for the majority of the transplant. It may be faster to shave the head and do all pre-made incisions but we are confident of our results with this method and our patients have more hair for camouflage afterward. A typical 3000 graft session will start at 7:30 am and we will finish somewhere between 5:30 and 7:00 pm.

markymark Stick-and-place is a technique where an incision is made then immediately filled with a graft. Many doctors make all the incisions first then fill them with grafts later. Both techniques work very well and there are pros and cons for each technique. You can search stick-and-place for more info. azn_guy Pre-operative and post-operative antibiotics, like Cephalexin, are used by some doctors to prevent immediate infections. They don't prevent pimples that sometimes form a month later. We don't know why some people form pimples about 1 month after their hair transplant but presume it is in part due to ingrowing of new hairs. It may also be from a reaction to exposed keratin (hair protein) under the skin from incomplete exogen (shedding) of the transplanted hairs, buried or damaged hair. I have found that people who have had acne elsewhere have a higher risk of getting 1 month post-op pimples. Every hair transplant doctor will get a few patients who get a lot of pimples but Megatron has had the toughest time of any of my patients. Pimples on the face come from increased sebum production, blocked pores, infection, then inflammation. This could also happen on the scalp. I believe that patients who are prone to acne or had a number of pimples 1 month after a previous hair transplant get fewer pimples a second time if they start Minocin at the time of their second surgery. This is only anecdotal and not scientific evidence because the patient numbers are too small. Minocin is used commonly for teenagers with acne and has anti-inflammatory and anti-infective properties. It is more useful to suppress the formation of new pimples than to get rid of old ones. I believe that Megatron got pimples first. The skin barruer was then broken and he got a secondary skin infection called Impetigo. Hindsight is 20/20. If I knew then what I know now for Megatron, I would have started Minocin on or before his hair transplant to suppress the initial pimples. However, Minocin can cause GI irritation and makes someone more sensitive to the sun so I try to use medications only when they are needed. I don't believe that Cephalexin taken in the first 10 days after his hair transplant would have prevented Megatron's pimples or his secondary infection. The Pseudomonas likely came later but neither Cephalexin nor Minocin work against it. On the positive side, Megatron looked much better when I saw him last. I will be following him closely until he has complete resolution. I still expect him to have good hair growth but, as for all hair transplant patients, we have to wait a full year to judge the final results.

This 39 year-old man mostly had a Norwood 4A thinning pattern with wavy, average diameter, dark brown hair. We transplanted 56 grafts per sq cm behind his hairline and in his midfrontal forelock then reduced the density to 49 then 42 then blended with his native hair. He had a single-layer trichophytic closure with conservative undermining of both edges. (I now usually use a 2-layer trichophytic closure without undermining.) He started Finasteride and Minoxidil to help keep his natural hair in his midscalp and crown.

Mario2667 Keflex is the brand name of Cephalexin and it is an antibiotic that works against skin bacteria (not viruses.) Some patients get pimples about a month after their hair transplant and it sounds like that is what you are experiencing. There are different treatment options depending on how many pimples you get but you should contact your own doctor and follow their recommendations. Best wishes for a smooth recovery.

I called Megatron today and have his permission to comment here. Megatron has been prone to acne in the past. He developed a general flare-up of acne over his face, chest, and back as well as extensive pimples of his scalp. When I saw him last at the 6 week mark he had a lot of yellow-brown crusting which suggested that he had a superimposed infection called Impetigo. Impetigo is usually caused by Staph. or Strep. bacteria, just like Folliculitis. These are ordinary skin bacteria that take advantage of breaks in the skin and grab hold and multiply. Impetigo can be spread from one place to another by scratching or rubbing. Minocin is an antibiotic that has both anti-infective and anti-inflammatory properties so it is very good at suppressing the formation of new pimples. There are probably millions of teenagers currently taking long-term Minocin for acne. However, it takes about 2 weeks for the effect to start to kick in and 4 weeks to really settle things down. In the first 2 weeks the pimples can even get worse. While Minocin does work against Staph. and Strep. it is not a first-line treatment for Impetigo. At the 6 week mark we wanted to start the Minocin as soon as possible to settle down the generalized acne as well as the scalp pimples. At the same time as starting the Minocin, we had a choice between starting another oral antibiotic like Keflex or Cloxacillin or a topical antibiotic like Bactroban to get rid of the Impetigo faster. Taking 2 antibiotics at the same time can be hard on the GI tract so we elected to go with a combination of oral Minocin and topical Bactroban, even though the ointment is really greasy. If it had not been for the generalized acne flare-up, we might have started Keflex first then switched to Minocin. Even though Megatron's 7 week photos look pretty scary, they are clearly better than his 6 week photos. The crusting is disappearing and the general acne has settled already. He still has a lot of scalp pimples but they should start to settle down within the next week or so. Megatron is quite confident that he is getting better and we will be meeting again in a couple of days to assess his response to treatment and adjust the plan, if needed. Megatron had a bad case of post-op pimples, general flare-up of acne, and secondary Impetigo. He is the first patient I have seen that got Impetigo after a hair transplant. The pimples and the Impetigo are surface infections and they don't ordinarily cause scarring or affect the final growth. Sometimes post-op pimples can lead to delayed growth but it is rare for them to cause poor growth. Deeper infections like Folliculitis Decalvans i.e. Dissecting Cellulitis can lead to scarring and hair loss but fortunately this is a rare condition and, more importantly for Megatron, he has no signs of deeper infection. Cosmetically, Megatron has had a very tough time. Unfortunately, bad things sometimes do happen to good people. Fortunately, he should be looking more like himself again soon and he should still expect good growth. If Megatron ends up having more hair transplantation in the future, we will likely start prophylactic Minocin on the day of his hair transplant to prevent pimple formation before it happens. I have successfully used this strategy before for others who are prone to pimples. In the first few months after a hair transplant, the hair doesn't look any better and there can be problems like pimples, redness, numbness, shock loss etc. Once we get through this period and he can see some new hair growing around the 4th month, hair transplantation should be a lot more fun for Megatron.

Veteranpatient With your story, I wonder if there is more to your hair loss than AGA. It would be worthwhile for you to consult a hair restoration doctor or a dermatologist to look for clues of other causes of hair loss. A (4 mm) scalp biopsy may even be in order. Best wishes

I really don't think that you can predict the outcome of a hair transplant based on early results. Usually there is little to no growth in the first 2-3 months, noticeable improvement is seen each month from the 4th to the 8th month, then the changes are more subtle until the 12th month. There are exceptions to every rule, however. It is reassuring for patients when they see early growth but some "late bloomers" still get very good results. It is hard for a patient to do but the doctors and experienced posters will all say not to judge final growth until a year after a hair transplant. If transplanting into a previously transplanted or scarred area it is better to judge it after 18 months.

Sorry for any confusion. Follicular units normally have 2, 3, or 1 hair in that order. Sometimes patients with finer hair may have 4s or even 5s. For FUE, the hair is cut short so the 2-haired, 3-haired, 1-haired follicular units can be seen on the surface with spaces between them. Anthony included a link to Follicular Unit Transplantation and there is a photo of follicular units on the surface of the skin there.

CMEPCMEP Further to what Anthony said, follicular units were described by Headington in 1994. Using the high magnification of an electron microscope,one can see the band of connective tissue that holds the follicles together in a group. When we use light microscopes for graft dissection, we can't see the bands but we can see the groups of follicles separated by spaces. With the aid of microscopes we can dissect out the natural bundles so that we get grafts that contain one follicular unit.

This man in his mid 50s was most concerned about his hair loss in front and was not troubled about having a bald spot in his crown. He preferred to wear a left part but brushed his hair forward to hide the recession. He had mostly straight, average-to-fine, brown/salt-and-pepper hair with average donor density and scalp flexibility. We transplanted 3056 grafts in his frontal third at 56 grafts per square cm in his midfrontal forelock and behind his hairline and at 49 behind that then fading and blending in with his hair in the midscalp. His 29.6 cm long donor strip was mostly 10 mm wide on the sides and 14 mm wide in back. He had a single-layer, lower edge trichophytic closure with conservative undermining of both edges. (These days I more often do 2-layer closures without undermining but either method works.) He has lots of donor hair left but he is content as he is for now. He is not keen on using long-term medical stabilization but will likely return to transplant his midscalp, if and when he loses more hair there.

1. I know some patients who have taken Propecia since 1997 (before they met me) who feel that they haven't lost more hair and some who have had a slow decline. 2. Some hair follicles in the donor area may be affected by DHT but most aren't, in most men. Take a look at the seniors you meet or pass in a day. In a few, you can see through their hair on the sides but not in most. Some men can get generalized thinning of all of their hair in advanced age, called senile alopecia. That might be what affected TC17s uncle from age 70 to 85. I just did a touch-up hair transplant for a 68 year-old man who had 4 sessions from 1976 to 1980 and the transplanted hair was still there. His hair was about 2 inches long and his rows and rows of punch graft scars did not show. The punch graft scars made up about half of his 9 mm wide, 30 cm long donor strip and we still got 1408 grafts and he still had about 60% 2s, 25% 3s, and 15% 1s. Hair transplants look much more natural now but transplanted hair from decades ago has stood the test of time.