Cam Simmons MD ABHRS

Thanks TC17, dakota3, hair_me_out, Megatron, Forrest Gump, and Fingers Crossed.

I am looking forward to his second session to get more coverage and will update the photos after that.

Clinton

Please, please, please do NOT get a hair transplant now. I can say with 100% certainty that you will regret it later.

Even if you don't lose more hair later, your dream hairline would look unusually low when you got older. If you do lose more hair later, it will be impossible to keep your hair pattern looking balanced and natural after you use up a lot of hair in a full, low hairline up front and lose more hair behind it.

I have heard young men say many times that they won't care as much how they look when they are older but nobody wants to look strange at any age. If you proceed with this plan, you WILL look strange later.

I think that Bill has answered this quite well.

It is difficult to compare these techniques. Each technique has its own advantages and disadvantages. There are many theoretical arguments why one method may be better than the other but they are not supported by real science. It would be difficult to do an accurate comparison study of the two techniques because each doctor is most comfortable with the method that he or she uses. If I did a comparison study I am quite sure I would get better results with stick-and-place than with pre-made incisions and if, for example, Drs. Hasson or Wong did a comparison study they would get better results with pre-made incisions than stick-and-place. Unless we both operated on the same patient at the same time (in our own offices), there would not be a real comparison. If done well, you can get excellent results with either technique. The best way to judge a technique is not by theoretical arguments but by the final results that are produced.

Thanks Megatron, aaron1234, and Phil

I will preemptively give a long answer to Phil's short question.

Hair transplantation is a team sport. No doctor can prepare every graft, make every incision, and place every graft alone. Every step is equally critical for a successful outcome. Different doctors divide the resposibilities among the team differently but no doctor can do a good hair transplant without a good team.

I map out the entire transplant plan in the morning, including the densities by area and the hair direction. After I have given the medications and administered the local anaesthesia and done the donor strip excision and closure, I pre-make the slits for the leading edge of the hairline. After that, my experienced staff fills in the 1s in the pre-made slits and does the stick-and-place. From about 11 am onward, I am in and out of the room, spot-checking, and adjusting the plan as needed. I am always immediately available.

I can do stick-and-place but my staff do it much more than I do and they are more adept and faster planters than I am. We have worked together for 10 years and I have great confidence in them. I stand behind their work just as I stand behind my own.

This patient had a Norwood 6 pattern with a thinning, low persistent midfrontal forelock. He grew the hair there long and mixed it with the hair in his bonded hair system. He wanted to get rid of his hair system because he didn't like the cost and time to maintain it or the look of the hairline.

Often a Norwood 6 patient would choose to start with lighter coverage over a bigger area and to start with a higher, more receded hairline. However, patients who are used to wearing a hair system rarely choose this approach. He preferred to get a denser look in front in his first visit with the idea that he would return for a second session to work further back at gradually decreasing density. He knew that he could not expect the density or coverage of a hair system but that hair transplantation would be less expensive in the long-term, would not require special maintenance, and could give him a more natural-looking hairline.

He had good donor density and flexibility and while he had finer than average hair he had many 3-haired follicular units. He elected to transplant his hairline and midfrontal forelock denser than usual at 56 grafts per square cm then we reduced the density to 49 then 42, knowing that he would not be able to cover as big an area. His hairline was placed at a mature level so that it would blend in with the back of his midfrontal forelock but would eventually take over after he lost the hair in the forelock. His plan was designed for 3000 grafts but we were able to get 3245 so we could transplant a bit further back after all.

He could wear his hair system with tape for 8 hours per day on the 5th day after his hair transplant. I usually instruct patients to start thinning their hair system gradually so there is less of a change in density when they get rid of it. Many hair system patients have their second session 6 to 9 months after their first and keep wearing their hair systems until 4 to 6 months after their 2nd hair transplant but he stopped wearing it 8 months after his first session and hasn't had his second session yet. He plans to return to transplant his midscalp and anterior crown at 36 then 30 grafts per square cm.

Originally posted by splitting hairs:

1) There is now post marketing data to show that Finasteride can cause erectile dysfuction which persists after stopping treatment. If anyone mentioned such a thing in the past, I always shrugged it off because there was no clinical evidence to back it up - but now there is.

 

splitting hairs

Thank-you very much for posting this link. I have read through the full statement.

There appears to be a possible but very small increase in breast cancer. The baseline incidence of male breast cancer was said to be 3.8 per 100,000 patient-years and this increased to 7.8 per 100,000 patient years. This implies that for each year that 100,000 patients took Finasteride, 4 more would develop breast cancer than in a similar group who didn't take it. This is still a very small increase overall but there will be closer scrutiny.

The only mention of erectile dysfunction was this:

Section 4.8 Undesirable Effects

In addition, the following have been reported in postmarketing use: persistence of erectile dysfunction after discontinuation of treatment with PROPECIA;

This is reporting. It is NOT clinical evidence.

I worked briefly in a men's sexual health centre. Erectile dysfunction is a very common problem that has both physical and psychological causes and often has combined causes. If an 18 year-old has too much to drink on a Friday night and can't get an erection, he may get anxious the next time. The adrenaline released from his anxiety may make it harder for him to get an erection and he will then be even more worried the next time. Viscious cycle. I have seen young guys come in who said they hadn't had an erection for months who took Viagra, Levitra, or Cialis and were fine. Patients would come back later taking just a fraction of a pill. This was not a case of a medication "curing" erectile dysfunction it was a case of someone getting their confidence back. After they realized the dose of the pill was too low to make a difference and that they were really getting erections without medical assistance, they stopped taking pills and were fine on their own.

It doesn't make sense to have permanent erectile dysfunction from using a medication that has a temporary effect unless it is psychological. The more anxiety caused by posting about it, the more the anxiety will lead to prolonged erectile dysfunction. I have had patients in my practice who had erectile dysfunction while taking Finasteride but they all got better after they stopped it.

Originally posted by Megatron:

dr. simmons - while I think you did a great job on that patient and I agree that it's a huge improvement, I'd still rather choose to go bald than have that hair. again, just my opinion.

Megatron

It is great to have a choice and I respect yours. Some of my own family members don't mind going bald but my patient is thrilled to have hair again. Despite having lots more donor hair available, he is satisfied as he is.

For other people to post that Norwood 6 patients require multiple sessions to only get a whispy comb-over look is obviously patently false.

There is a mixture of good and bad information in this thread.

Transplanted hair does not need medical treatment but existing hair can benefit from it.

You can preserve existing hair for a long time with medical treatment. Few men get side effects and, contrary to what some people have posted in other threads and websites, in the studies and in my experience those side effects have always been reversible. We only have study data for 5 years of Finasteride use. I have patients in my practice who have been taking Finasteride for 15 years (since before they met me) and they feel they have not lost hair. I have other patients who have lost hair slowly while taking Propecia.

A Norwood 6 patient can usually cover their whole head reasonably well with 7000 to 7500 grafts, with denser hair in front and lighter coverage in the crown. I can only post photos of my hair transplant patients from this office (since 2006) so for now, I can link to a Norwood 5 patient who was on his way toward a Norwood 6 pattern. http://hair-restoration-info.c...?r=78710849#78710849. He could have returned to cover his crown in one more visit and had lots of donor hair to spare but he felt he looked fine after 2 visits and 5220 grafts and he didn't mind having thinner coverage of his crown, in his 50s.

Currently, someone who will go on to develop a Norwood 7 pattern will not be able to cover the whole balding area well with scalp hair. Someone with potentially aggressive hair loss should be encouraged to take medications but they should not count on taking them forever or for those medications to work forever. If they choose to have hair transplantation, it is safer for them to start higher, use lower densities, always leave some donor hair "in the bank" and to accept that they will be left with a bald or balding crown.

If we plan ahead, patients may need to have more hair transplantation later but nobody should ever look like a "freak."

RajToor is right. Shock loss is most noticeable in the first 1-3 months. By 4 months, the transplanted hair and the shocked hair will usually be starting to grow back.

Sorry I misread your HT date. That is good news because you will likely get fewer pimples as you get further from your hair transplant date.

Originally posted by Jotronic:

... Let it run its course and it will go away. If it comes to a white head then you can squeeze it out to relieve the pressure then put a bit of Neosporin on it to be safe.

Hi Phil

You had your hair transplant on January 18 and may get a few pimples in the next few months. I usually tell my patients that they can ignore a few pimples or ingrown hairs as they will usually break in the shower or resolve on their own. If you get too many, you can contact Dr. Hasson as there are treatments that can be used to suppress pimples (like antibiotics for acne).

Jotronic usually gives very good advice but I would check with Dr. Hasson before squeezing the pimples. I usually tell my patients not to squeeze pimples. They would probably break outwards but if they break inwards that can cause inflammation under the skin. If they are too big or sore, I advise my patients that they can puncture the whitehead with a sterilized needle to release the pressure. (A new pin or needle can be boiled in water for 5 minutes.)

If in doubt it is always best to check with your doctor.

Originally posted by TC17:

Wonderful result Dr. Simmons, but how far back did the grafts go? Is there anyway you can draw a line on one of the photos to show where they were placed since we can't see from the photos presented?

Long, curly hair covers well! If I had been smart enought to have clipped his hair back in the before photos it would have been easier to see how receded his hairline was.

I can't see how far back I went either but this is my best guess according to my notes and what I can see.

Originally posted by bighosedragger:

Very nice result indeed! Was wondering if 2539 graphs is to aggressive considering his age and family history. Is there enough donor left to properly cover the rest of his scalp if he follows his father and ends up norwood 6? I know he is using meds but what if they lose efficiency....that is my biggest fear! I hope for both of us the meds keep working! He does seem to have good characteristics.

Thanks BHD and ..

The 2539 grafts go further back than you can see in the photos and he has a good donor supply.

It is good that he is using meds but I don't design hair transplants based on the assumption that he will take them forever. If he goes on to develop a Norwood 6 pattern, he would need 2 more sessions for coverage and he will have the donor hair and the scalp flexibility to do this.

This 27 year-old man had Norwood 3 recession. His father apparently now has a Norwood 6 pattern but had similar hair loss when he was in his late 20s. My patient was already taking Proscar and using Minoxidil before he met me.

He had black, coarse, curly hair with average donor density and scalp flexibility. We transplanted 2539 FUG to his hairline and recessions. At that time, I only undermined the bottom edge and performed a trichophytic closure. (These days, I either do a 2-layer trichophytic closure or undermine both edges and do a 1-layer trichophytic closure.)

Although it may not be easy to tell in these cropped photos, his transplanted hairline is at a mature level so that it won't be too low or full after he ages or if loses more hair.

The photos were taken 9 months after his hair transplant.

Originally posted by foreheadgump:

Hi guys

 

I just got thinking. I was told I would need around 1000s grafts to the hairlin/temples.also that I have alot of 2/3 hair donar grafts. but they would be placed in singles. QUOTE]

 

Foreheadgump

 

I do not know your personal situation but, in general, 1000 single-haired grafts is a LOT of 1s. It is good to have 1s in the leading edge of the hairline but if you split every graft into 1-haired grafts, the results won't look as dense as they would if you transplanted the same number of grafts but had intact 2 or 3-haired grafts too.

 

There is no rule for how you will be charged so you should clear that up with your doctor.

Originally posted by Cole:

I had the procedure performed with approximately 1700 grafts in the crown and the hairline ... Dr. Siporin ... set my expectations from the onset that I may require another procedure to increase the density. ... I also consulted with Dr. Rahal and Dr. Cam Simmons (Recent member of the coalition) and they all averaged 1500 grafts. Dr. Simmons also mentioned that he can also perform scar reduction. ... This second procedure must be perfect as my financing would be exhausted and I would NOT be in a position to afford a third go-around.

Hi Cole

We have consulted by email and by phone but not in person. I have looked very closely at your "blown-up" photos again.

As before, I suspect that the main reason for your current result is that a large area was covered with a small number of grafts. In your before photos, you appear to have AGA (male pattern baldness) and I don't see signs of scarring or other conditions. As you can see in your natural hair on the sides of your head, your hair is quite curly and tends to clump into tufts.

The uneven appearance may be due at least in part to:

1. a low density hair transplant that is weighted more toward the front of the hairline.

2. clumping of your curly hair

3. some loss of existing hair in the back of the transplanted area and in your temples

To assess how well your transplanted hair grew or didn't grow would require direct inspection. My best guess is that this is more of a planning issue than a physiology or growth issue. I think it is reasonable to assume that further hair transplantation has a good chance of success. My recommendation would be to revise your scar and get as many grafts as safely possible to add to your frontal hairline. You should be able to get at least 1500 grafts with this approach and possibly many more.

I don't know Dr. Siporin personally but he seems to have a very good reputation here. I hope that he offers you a good solution.

I don't think that you can get a perfect result in one more session but I hope that you will see a big improvement.

Best wishes,

Originally posted by Dr. Cam Simmons:

... Rarely, patients get less than satisfactory results when there is no obvious explanation.

 

Bill is right that rare patients get disappointing results when everything seemed to have been fine and this has been called the "X factor." Every hair transplant doctor who has done a lot of hair transplants, including me, will have a couple of patients whose results did not meet expectations.

We can't always figure everything out but we need to try hard. The danger lies in attributing the cause to X factor too quickly and so missing an opportunity to fix a correctable problem.

Originally posted by thanatopsis_awry:

... I get the sense that you do not believe the mysterious "lame-ass-physiology" truly exists; and that even if it did, which would be quite a big "if", it is certainly something that should be aggressively attempted to decipher and combat prior to surgical operation? ...

Phil's reply was sarcastic and funny. By repeating his terminology I could have caused some confusion.

There are certainly patient factors that can affect how transplanted hair grows.

As an extreme case, if a doctor decided to do a hair transplant for a patient who had smoked 3 packs per day, had poorly controlled Diabetes for 30 years, had vascular disease, and diabetic skin ulcers, impaired scalp circulation could very well lead to poor growth. That truly would be a question of bad patient physiology.

More commonly, patients with fine, straight donor hair and small follicular units will not get as dense results as someone with coarser, wavier hair and more hairs per follicular unit, if the same number of grafts are transplanted into the same area. That is more a question of anatomy and math.

Rarely, patients get less than satisfactory results when there is no obvious explanation.

As a doctor, it is my job to try to assess how good a candidate a patient is before offering hair transplantation and to offer realistic expectations for each patient, based on their medical status, hair loss, and their hair characteristics etc. (By the way, having complete coverage and the density of a hair system or a teenager is not a realistic goal for the vast majority of my patients.) Sometimes I need to turn away patients who are not good candidates or who have goals that cannot be met.

We do our best but no doctor is perfect. Hair transplantation is a very reliable procedure but it isn't perfect either. Almost all of my patients achieve or exceed their expected results. For that to happen, the goals have to be realistic, the plan has to be correct, and there has to be good execution of every step of the hair transplant process. If patients don't achieve the expected results, whether it is because I don't incorporate patient factors well enough in my plan or our execution of the transplant isn't perfect enough or the reason is unclear, it is up to me to make it right. I am the team leader and make all of the decisions and therefore have to accept the responsibility if a hair transplant is not satisfactory. If there is a great result, the credit properly belongs to the whole team.

Going back to the title of the thread, fortunately almost all of the surgeries "work." For the rare ones that "don't" it is best to first figure out why and then to fix it.

If you have a bad result it's because you have a lame ass physiology and it is clearly no fault of the doctor.

... but it would be up to the doctor to figure out that the patient had a lame-ass physiology and shouldn't have had a hair transplant in the first place!

Unless a patient goes out of their way to knock out and abuse their grafts, he or she gets no blame.

Hair transplantation is a multi-step process and is only as good as the weakest link in the chain. A great result is due to the whole transplant team and a poor result is the responsibility of the doctor. Simple.

D-1234

We have advised thousands of patients since 1999 that it is safe to rub the remaining scabs off in the shower from the 10th day on. By then the skin has healed under the scabs and the scabs are separating from the skin.

For others reading this post I would still recommend that it is safer to rub the scabs in the shower, when there is less friction. I also feel that rubbing is safer than picking. To soften the scabs, patients can leave baby oil or baby oil gel on the scabs overnight before rubbing them off in the shower on Day 10. They can also use oil or gel between showers until the scabs are off.

However, because you didn't start picking until Day 13, you are likely still OK. The pain was most likely due to pulling on your existing hair, to which the scabs were probably stuck.

Thanks Bill, future_HT-Doc, hair_me-out, and raphael84.

Originally posted by N-6:

...what I'm truly interested in is a physician's medical justification for shaving or not shaving pre-op. Does it really make a difference in the ultimate outcome of the patient? Any info on this topic, especially from physicians themselves, is greatly appreciated.Thank you!

I am a "non-shaver" but I will try to give you a balanced answer.

For docs who use the method made famous by Drs. Hasson and Wong, I think it makes sense to shave the recipient area. Pre-made lateral incisions are usually made fairly quickly and it is easier to see where to make the incisions and the angle and direction of the hair when the hair in the recipient area is shaved. Shaving the recipient area makes it easier and faster for the techs to find and fill the small incisions. Particularly for patients having very large sessions, shaving the recipient area could "shave" hours off the procedure time.

Using a stick-and-place technique does not require shaving the recipient area. We continuously part the hair and use hair clips and thus can also see the hair direction and angle well. As recipient sites are created then filled immediately, we do not have to fear that we will miss incisions and leave them unfilled. Shaving the recipient area could make stick-and-place faster too but not shaving it provides better camouflage in the first days and weeks after the transplant.

You can easily see patient results in this forum that demonstrate that you can get good final results with either technique ... provided you do that technique meticulously.

Hello domma_85

What you are describing look like transplanted hairs that have not been shed yet.

I tell my patients they should expect almost all of the transplanted hairs to be shed in the first 6-8 weeks. It can even look like the transplanted stubble is growing before it falls out.

The follicles will remain and rest 2-4 months before making new hairs. You will likely feel the short new transplanted hairs before you can see them. By 4 months, you will see some growth and it will get better each month. You won't likely see the full effect until 10-12 months after your transplant.

This man in his early 40s first lost hair in his crown but was most concerned about his frontal hair loss. He had short, light brown, finer than average hair. His donor supply was good but his scalp laxity limited how much could be transplanted in one day. He wanted to get a finished look in front then likely to return later to transplant further back.

His VSL was 12 above his ears, 10 in his mastoid areas (behind his ears) but only 10 in back (occipital). We harvested 2992 follicular unit grafts from a 31.8 cm long donor strip that averaged 1 cm in width.

We transplanted 64 grafts per square cm in his midfrontal forelock, 56 behind his hairline then 49 then 42 as we worked further back in the frontal area, blending into his natural hair across his midscalp.

He is happy with the results in front. We just recently removed the old scar with a new strip and continued from where we left off with 2062 grafts to his midscalp. He may choose to stop there or to return to later transplant his anterior crown.

I hope to add more photos as he progresses.

Happy Holidays.

Originally posted by ultimate:

... Im wondering once i have a scar at the back if it will stretch due to tension (because of the shape of the skulp)...

Hello Ultimate

The area you are talking about is called the "Nuchal Ridge". It is the base of the skull, where the neck muscles attach. With FUT, a donor strip is often removed right above this bump. We usually test the scalp flexibility for each individual to determine the safe width for a donor strip. The skull shape may have an influence but there are many other factors.

You very likely can have FUT with a trichophytic closure as long as the donor strip is not wider than your flexibility allows. As Dr. Charles noticed, even a very narrow scar would show with your hair at your current length.

Finally, you do seem to have thinning over a big area in the 3rd view. If you are not already using medical treatment it would be good to consider it.