Cam Simmons MD ABHRS

Well Done Dr. Keller. How are you doing each layer?

Thanks B spot, hair_me_out and Bill for your kind words. I will follow your advice the next time I update patient photos.

This is a great question and I unfortunately don't have the answer. More often than not, people with more subcutaneous fat have more laxity and people with less have less. There are exceptions though. On the other hand, people who have gone on crazy diets and lost a lot of weight quickly may have very loose skin. From a purely selfish standpoint, I am thrilled when I see a layer of subcutaneous fat. I can get under the bulbs easily while still staying well above the nerves and vessels and the skin glides together more easily. I have to take my time and be quite careful when people's dermal papillae come very close to the Galea. Maxxy is right that your general health is most important so I would never recommend that a thin person gain weight or that a not-so thin person go on a starvation diet for the sake of increasing their laxity. Scalp stretching exercises are definitely a safer way to go. Some plastic surgeons or dermatologists inject patients' own fat (from other areas) as fillers and I have wondered if pre-operative fat injection would help people with tight scalps. Of course, the fat could just liquify and may not help at all. I have no knowledge about or experience with fat injection and the risks could outweigh the benefits but I would be interested to hear the thoughts of a doctor who has used fat injections elsewhere.

Top View P.S. I would appreciate it if someone could suggest a better way to add updated photos. I will add them to the gallery too.

Donor Scar

3/4 Left

3/4 Right

Tilted Down

This man has returned for his 12 month photos with shorter and darker hair. His donor scar has also faded and his hair around and in the scar has grown back. He is happy that he has the option to change his hairstyle, if he likes.

This man in his early 50s had fine, salt-and-pepper hair and had micros transplanted (elsewhere) to his hairline in the mid 1990s. In his first CHTC session of 3099 fug, his goal was to increase the density of his hairline and front and to add a little hair in his temporal hairlines. He had some scarring in the recipient area so we could not ???super dense pack??? the way we might for someone with fine hair and a smaller area to cover. He was happy but elected to increase the density along his left hairline and to get some light coverage of his crown in his second session of 2338 fug, 11 months later. For someone with fine hair, 42 -> 36 grafts per square cm in the crown gives light coverage, whereas it would give reasonable density in the crown for someone with coarser hair. He has just 1 narrow donor scar and lots of donor hair left and his scalp flexibility is returning. In a third session he may add more hair to increase the density of his transplant on top and in his temporal points. Fine hair can look very natural when transplanted but more transplanted hair is required in an area to give a look of fullness than with average or coarse hair.

Pros: 1. Minoxidil can decrease shedding of transplanted hair so that more of the transplanted hair grows sooner 2. Minoxidil can decrease shedding of existing hair in a transplanted area (i.e. reduce shock loss) Cons: 1. The scalp is more sensitive after a hair transplant so about 10% of people have to stop it because of: a. redness b. itch c. dry skin d. possibly increased pimples 2. After stopping Minoxidil it can take 2 weeks or more for the side effects to disappear. Minoxidil is more effective at preventing shedding if it is used before and after a hair transplant. If used, I ask patients to stop it a week before their hair transplant and start it 3 days later. Some patients want to wait until the scabs are off before starting it but it is most effective when used early. Patients can continue Minoxidil indefinitely if they want to maintain existing hair. If they want to just use it short-term, I recommend using it twice daily for 3 months, once daily for 2 weeks then once every other day for 2 weeks to avoid a second shedding by stopping it abruptly. The transplanted hair will look the same a year later with or without Minoxidil but patients usually have more hair 4 months later if they use Minoxidil. I discuss the pros and cons with my patients and they can choose to use it or not use it, as they wish.

Thanks Future, orangehair, and Bill I think Traction Alopecia is much more common than we realize. I have been noticing it more and more when walking around downtown. Often, women try to hide the Traction Alopecia with heavy hair extensions sewn in to tight braids and accidentally make their problem worse.

Dr. Limmer I think that you have used the grafts your patient allowed you to work with to create a natural and balanced look. Your patient had more modest goals and you have achieved them for him and allowed him to turn back the clock.

The decision to revise an old scar or to take a new strip depends on many factors. I prefer to revise scars whenever possible because it usually allows improvement in both recipient and donor areas. Particularly for younger patients or patients who could face donor hair limitations, I usually recommend revising the scar and getting fewer grafts in this session so that there will be less donor scarring and more hair available in the future. There are times when it does make sense to remove a new strip, away from the old scar. Usually slow and steady wins the race but decisions must be made on a patient-by-patient basis. A new narrow scar created too close to an old scar can create the appearance of a wider scarred area. The old scar can tether the skin and cause the new scar to be wider. Usually 1 cm is a safe distance away from the old scar but the hair between the 2 scars becomes unavailable for future hair transplants because it is needed to hide the lower old scar. Successful scar revision depends on the location of the old scar, the width of the scar, the scalp laxity, the patient's own healing characteristics, and the surgical technique. A mobile area, a very wide scar, or a very tight scalp may make it so that there is not a good chance for successful one-time scar revision. Sometimes serial revisions may work or sometimes it is best to abandon the old scar and take donor hair from elsewhere. Fortunately, with the advancements in donor closure in the last 5 years, fewer patients in the future should have to deal with wider scars but it is important that we do our best to help patients who already have wider scars from past procedures.

Joeysi If you are getting more than a couple of pimples at a time, please contact your doctor. Pimples don't usually affect the final results but they can be a nuisance. There are some simple measures that your doctor can recommend to reduce the number of pimples you get. These could include such things as warm salt-water soaks, topical antibiotics or other lotions, or oral antibiotics (like acne medications for teenagers.)The treatment your doctor will choose would depend on the severity of the pimples. I would recommend against squeezing any pimples. If they break inwards instead of outwards you could get inflammation and scarring under the skin. Big or painful pimples can be punctured with a sterilized needle to release the pressure but you should follow your own doctor's recommendations. Ironically the pimples tend to be at their worst before the transplanted hair has grown enough to hide them. Hopefully your pimples will disappear and you will see some good hair growth soon. Good luck.

Hi Julius There are many different guidelines, including Da Vinci's Rule of Thirds, that you described. The glabella is the ridge between the eyebrows that is one of the reference points. I actually find that the distance from the glabella to the tip of the nose is often a little less than the distance from the nose to the chin or the glabella to the hairline. ( I don't use Da Vinci's rule as a starting point but do use it as a rough check of the drawn hairline.) Guidelines are just guidelines and not rules. In the end someone's hairline has to match the shape of their face and their head and their facial features. It should also be adjusted to reflect their projected future hair loss. While I may start by using a guideline, I always fine-tune the hairline by eye. If you are happy with a slightly higher and more receded hairline and it would suit you, go for it. You are absolutely right that you would require fewer grafts if you started higher. It is always safer and easier to deal with a transplanted hairline that is higher than you would like than one that is too low. Of course it is best to get it right the first time.

This lady in her late 20s had hair loss from wearing tight braids for many years. She stopped wearing braids and heavy extensions. She used light and loose extensions, created bangs from hair above her hairline, and wore scarves or headbands to hide her hairline. Patients with coarser, very curly hair usually do not have dense donor hair. She could not safely transplant enough grafts in one session to cover the whole area well. While I would usually recommend building her hairline forward in 2 steps, she preferred to commit to 2 sessions from the beginning, start with her hairline, and to continue wearing scarves to cover the gap until the hair from her second session grew. She had 1 session of 2166 grafts transplanted at about 45 grafts per square cm in her frontal hairline and 42 in her temporal hairlines. She had planned to have her second session sooner but it was a year later that she had 2240 grafts transplanted at 36 grafts per square cm to close the remaining gap. I was concerned that the extensions could cause further Traction Alopecia but they are actually very light weight and are fastened to loose twists. She did not include the transplanted hair in the extensions and plans to stop using the extensions after her transplanted hair grows longer.

Ronald I think that there may be rare Norwood 8 patients out there. I have been doing hair transplants for 10 years and have not seen one in my office. In my 47 years of life, I do recall seeing a couple of older men who had a narrow, thin fringe of hair in the back with no hair on the sides of their head but if course I did not have the chance to examine them to see if there were other causes. There are also rare men who have diffuse unpatterned hair loss (DUPA). I am a believer in cautious planning but I don't think men should worry that they could go on to develop unpatterned hair loss or a Norwood 8 pattern unless there are already signs. If Norwood 8 exists, Norwood 8 and DUPA would both be quite rare for men.

Hello Poorgrowth I think Acrobaz,Jotronic, and Bill have given you excellent advice. If any of my patients were unhappy with their results, I would hope that they would first give me the opportunity to make things right. Most hair transplant doctors truly want to help their patients and strive to improve their skills and knowledge to be the best hair transplant doctors they can be. Before deciding on the fairest solution, it is important to figure out what went wrong. When there is poorer than expected growth there can be problems with expectations, growth, or both. If the grafts truly did not grow well, your doctor would need to figure out why they didn't grow well before undertaking any more hair transplantation. I hope that you and your doctor can work together to find a good and fair solution for you. If you meet and can't come to an understanding, that would be the time for a second opinion.

Ventuoguy You make some escellent points and Bill is right on with his reply. "Scalp geometry" not only affects the area to be covered but should also affect the shape of the transplanted hairline, which further affects the area to be covered. Those patients with a broad forehead also need a broader hairline to look natural. A narrower hairline often suits a patient with a more conical head but the higher dome-shape still increases the surface area.

That is the point. You don't have to shave your head to get the best results. Look at photos from centres that don't shave patients' heads and judge for yourself. If you can get the best results and not lose your natural camouflage in the process wouldn't that be better?

If a doctor pre-makes the incisions, it makes sense that shaving the recipient area would allow faster placement and it would be easier to make sure that every "hole gets filled." If there is an abundance of natural hair in an area, it is too early to do a hair transplant there. I think Bill probably meant that he feels that shaving is important when there is obvious thinning but still a significant amount of natural hair. At CHTC, when we use a stick-and-place technique, there is not much advantage to shaving the area. We know that the incision will be filled with a graft right after it is made. Shaving might make things a little faster for us but our patients would lose more of their natural camouflage. I therefore don't ask any patient to shave their recipient area. Whether the recipient area is shaved or not, it is critical to follow the natural angle and direction of the existing hair to avoid transection.

This 27 year-old man had balding in front and thinning in a Norwood 5A pattern but had a residual thin midfrontal forelock that came lower than a recommended level for a transplanted hairline. Coverage was more important for him than density and budget was a concern. Most of the area was transplanted at 42 grafts per square cm but we used 56 per square cm in his midfrontal forelock and 49 just behind his hairline. We could have easily transplanted 3000 grafts in the same area at higher density but that would have used up more donor hair (and money) in front. He started Proscar and Minoxidil at the time of his hair transplant and will likely see the full benefits next year. He knows he does not have the thickest hair transplant in the world but he is happy that he no longer has to keep his hair so short and that his transplanted hair blends well with his natural hair.

Thanks Forrest Gump It looks like I may not get to see the final results until he loses more of his original hair. I am sure that he hopes the Proscar will delay that appointment for a long time.

Baldboy I think you have had some great advice here. I am concerned about some of the posts that may validate FUE as a viable option right now. I think you need to be just as cautious about starting FUE transplantation as you would be of starting FUT by strip. FUE is still a relatively new technique and it is too early to know all of the long-term consequences. There are not a lot of photos of patients who have had thousands of FUE grafts transplanted. I have not seen one photo of a Norwood 7 patient treated by scalp FUE alone. I have been quite disappointed by the results I have seen on-line and in conferences of extensive body hair FUE. More and more I hear the notion that it may be OK for someone to have FUE transplantation into their hairline then shave the head later if they lose their hair and don't want or can't do more hair transplantation. I believe that this is wishful thinking that has no basis in reality. Has anyone seen any good photos of anyone who has actually done this? FUE scars are small but not invisible. If a patient comes in with medium or long hair I can always find the FUE or trichophytic scars with back-combing and careful examination. I can always see the scars from either method if someone has shaved their head. I have seen patients who had lots of FUE with grafts taken from well outside the safe donor area. I have also seen the start of a moth-eaten look in the donor area after extensive FUE. This is not to overlook the effects of strip surgery but just to state that FUE is not perfect either. If you had a hair transplant then went quite bald and buzzed your head or shaved it slick, you would still have a five o'clock shadow in an unnatural pattern. The texture of the skin in the recipient area may be better than it would have been in the old days of the bigger graft but it won't be perfect. To make a good decision it is important to have realistic expectations. FUE transplantation requires just as careful planning as strip transplantation ??“ especially for someone who could lose a lot of hair. I believe that hair transplantation of any kind should be considered a permanent step with long-lasting benefits and long-lasting consequences. You cannot undo any hair transplant. The trade-off for having more hair on top is that the donor area will have some hair missing and some scarring. This can be minimized but not eliminated. Not everyone can get the coverage or density they would like but with careful planning they can have natural looking hair in a natural pattern that is better than they would have had without hair transplantation. Generally speaking, men in their early 20s have a more unpredictable future and higher expectations to look like their peers. You seem to have a good understanding of how much hair you could lose. In my experience, intellectual understanding does not equate to emotional satisfaction. A conservative approach for someone who already has a Norwood 7 pattern makes a noticeable difference and can be quite satisfying. The same approach for someone who is headed toward a Norwood 7 pattern will have less visual impact and will be much less satisfying. Decisions must be made on an individual basis but I would encourage you to explore every other option instead of hair transplantation right now. I hope that this helps and that you excuse me for my little rant.