Cam Simmons MD ABHRS

This 28-year-old man with a Norwood 3 pattern had his hair transplant in 2007. He had fine hair but also had more 3-haired follicular units than average. These photos are from his ???most recent??? visit in 2007 at 5 months after his hair transplant. In an email this week, he wrote that he was ???still very pleased??? with his hair transplant but that he is also still too busy to come in for a follow-up visit. Almost all patients shed the majority of their transplanted hair and wait months for the hair to grow back. We wait a year before judging the final results. Every once in awhile, someone ???gets lucky??? and does not shed much transplanted hair and gets earlier growth like this man. I did not see him but, if he is like other patients with early growth, he probably had close to his final results at 8 months. He did not use Minoxidil (or laser or PRP) but did start Proscar on the day of his hair transplant and has continued to take it. It would be nice to figure out why occasional patients get early growth but it is still a mystery to me.

Hi michaelscott There are pros and cons to 1)hair transplantation into the scars 2)scar revision and 3)opting to do nothing right now. I have already said that I would lean toward waiting if you can currently hide the scars fairly well with hair-styling. If it becomes more difficult to hide the scars later that could be the time to act. If you are leaning toward FUE and transplantation into your scar it is quite sensible to try a small area first. You should not only judge how well the hair grows but whether there is enough hair to hide the wide and raised scar underneath. Unfortunately, I have seen other patients who had FUE into scars and successfully grew hair but not enough to hide the scars or to be able to change their hairstyle. They still had noticeable scars but had some hair growing in them. At the 2008 ISHRS conference, Dr. Martinick mentioned what could be a good idea for transplanting into scars. That is, instead of creating slits, she actually may remove a small circle of full-depth scar tissue that is smaller than the graft that will be transplanted. Going full depth may make it easier for neo-vascularization (i.e development of circulation) of the graft. This would also remove some of the scar tissue while transplanting. I don't think there have been any studies comparing this technique against other techniques for transplanting into scars and I haven't had the opportunity to try it myself but it may warrant consideration. Good luck with your decision.

This man in his early 30s had a Norwood 4A thinning pattern with a persistent but thinning midfrontal forelock. He had average diameter, black, wavy to curly hair. He takes Finasteride but does not want to add Minoxidil. In ( http://hair-restoration-info.c...21087683/m/923103173 ) we showed a patient whose forelock was too dense to transplant initially. That patient's midfrontal forelock may require transplantation later. Whenever possible, we prefer to complete an area in one session. This man's midfrontal forelock was thin enough that there was enough space to transplant it at full density from the beginning. He had 56 grafts per square cm in his midfrontal forelock, 49 grafts per square cm behind his hairline and faded to 42 grafts per square cm.

Hello Babester I understand your frustration but to get good advice you would really need to consult a physician in person or at least to send them photos. Dr. Nusbaum has the advantage that he has seen you and Dr. Charles has the disadvantage that he hasn't. Sometimes the best option is to refine a hair transplant to make it better and sometimes the best option is to not make a bad situation worse. I have not seen you but there are some red flags in your remarks and your reports of Dr. Nusbaum's remarks. You are 20 and had your hairline lowered and your fronto-temporal recessions filled in. Dr. Nusbaum has studied and written about natural female hairlines so if he said that your transplanted hairline had a feminine shape that is very concerning. The extent of future hair loss is very difficult to predict and especially so for young men. My own (conservative) approach is to assume that every 20 year-old man will eventually develop a Norwood 7 pattern and won't take medications for the rest of their life. Of course I do encourage them to use medical treatment but I don't plan hair transplantation as if they will. I also believe that you should plan permanent surgeries based on what can be done now NOT with the hope that someone will get a breakthrough in the future that will rescue bad planning. An appropriate transplanted hairline for someone who has or could have a Norwood 7 pattern is higher and more receded than most 20-year-old's want. They compare themselves to their peers, many of whom still have the same hairline they had as teenagers. There very likely is SOMETHING that can be done to help you, Babester. That may or may not include more hair transplantation. You really need a good long-term plan after a thorough assessment by a dedicated physician and a frank discussion. Best wishes,

Thanks for your informative reply Dr. Lindsey To be clear, how low and how high do your deep sutures go? It looks like you use interrupted deep sutures. I have tried to do my homework but couldn't find a reference describing running double-locked sutures. Are you locking the suture then throwing another loop around the suture before moving on? This would be particularly interesting if it allows for post-op incision swelling.

michaelscott First, I am glad that you have had a full recovery from your accident. A personal consultation with a recommended physician would definitely be worthwhile. As Dr. Lindsey said, these may not be hypertrophic scars but could just be wide surgical scars. If you can style your hair to hide the scars now you may be better off to leave them alone until they can't be hidden any more. Living with medium length hair may not be the worst option. You are 22 and may or may not develop genetic hair loss (Androgenetic Alopecia) later. 50% of men have AGA by age 50. Any plan for transplantation into your scars would have to take into account possible future loss from AGA. A recommended physician can examine your scars and can check for early signs of AGA at the same time. If there is AGA, medical treatment could be started early to prevent a lot of loss. The plate itself would likely not be an issue for transplantation but the skin may be tighter as a result of your previous surgery. One concern about scar revision of your sagittal (front-to-back) scar is that the hair direction could be altered by the revision so that the hair could part along the scar and be directed away from the scar on each side. This is called a slot deformity and more surgery (like a triple-flap procedure) could be required later to fix the altered hair direction. If you later developed AGA and had hair loss in your crown, these scars could become visible. Long-term planning is critical for any 22 year-old and is even more critical for you. To get really good advice you need to see a recommended physician in person. I hope that this helps.

Hi Everyone To get specific personal recommendations you should see your doctor. I hope this general information will be helpful. As Bill said, the angle and direction of the hair is mostly determined by the angle and direction of the original incision. Local skin factors may help to further coordinate the direction of transplanted hair later, if the transplanted hairs are mostly in similar directions to begin with. Longer hair is heavier than shorter hair and longer hair will usually lie flatter than short hair. At 5 months, the transplanted hair is still short. The sebaceous glands also may take some time to recover so transplanted hair can be a bit frizzy in the beginning. Using a styling or anti-frizz cream can make your hair a bit heavier and smoother and can help it stay in place better. You can brush through it after your hair dries to keep the hairs separated and in a "dry look" that makes your hair look fuller. Unlike sculpting gel, wax, or pommade, styling cream doesn't clump your hair into a thinner "wet look". Some patients prefer mousse or medium hold gel that they brush through after their hair dries. You can experiment to find the product that makes your hair look its best. I am not the most experienced FUE doctor but I have used it to reduce older, bigger grafts and to remove and redirect some errant smaller grafts. FUE of virgin (donor) follicular units is easier and probably more reliable than FUE of old grafts. Old grafts may be compressed a bit and the follicles can splay out under the skin. The survival rate of FUE from old grafts may be lower. It seems that FUE would make sense to redirect a few errant grafts that stood out from mostly properly directed grafts. I would not recommend trying to redirect large numbers of old grafts. If you are concerned about your hair direction I would recommend that you first contact your own hair transplant doctor for suggestions. Otherwise a consultation with a recommended physician would be useful. I hope that this helps.

rpachigo It was clear early on in your post that you were a physician. You ask excellent but very technical questions. I hope that I can answer them clearly and well. Let me first state clearly that I am not a plastic surgeon or a researcher so there are others who can probably answer your questions better than me. What I know about donor closure I have learned from others and from experience. I have been doing hair transplantation since 1999 and had always done office and emergency room procedures as a family doctor/emergency physician from 1989-1999. I undermine through the fat layer, above the vessels and nerves that sit just above the galea. (i.e. supragaleal undermining) I usually undermine. Occasionally, I use deep sutures. I rarely do both. So far, I have not scored the Galea to make a relaxing incision. I find that the hair transplant literature is not really clear about the depth of deep sutures. The Dermis, the Galea, and the Pericraneum are strong and can hold sutures. You might as well try to sew a tomato as to try to sew fat. Hair follicles grow through the dermis so sutures placed into the dermis can affect hair follicles. My surface layer reaches into the dermis just above the dermal papillae and below the bulge. Deep sutures coming up into the dermis will reach above the dermal papillae and so will be creating some tension around the papillae. I have no proof or knowledge that this has any affect but I feel like I may have lost a few follicles when I used to carry deep sutures up too high into the dermis. When you look at live surgeries, "subcutaneous" sutures often seem to be going into the Galea. Dr. G. Seery wrote about deep plane fixation where sutures would go from the dermis on one side of the undermined incision to the galea on the other side and vice versa. Dr. Seery also wrote about suturing Galea to Pericraneal flaps as a way to keep the tension away from the skin surface. What he wrote makes sense but I feel like the deeper I work the more chance I have of causing problems. Since I do not come from a plastic surgery background and don't have experience with scalp reductions or flaps, I plan to keep working above the Galea. If there was a clear benefit to doing this deeper work, I would want to train with someone who is experienced before doing it on my own. I don't use locking sutures because they theoretically leave more suture material on top of the skin that can cause pressure when the skin swells. Not locking the suture also allows some movement and equalization of tension along the suture. That being said, I am sure that doctors who use locking sutures have their own reasons for using them and can get excellent results with locking sutures. It is probably more important that there be no tension on the suture than whether it is locked or not. I think Dr. Lindsey used locking sutures in his "2-edged sword" case. Incisions tend to flatten and contract as they first heal. We suture incisions so that the incision sits a bit higher with the edges turned a bit outward in what we call eversion. Mattress sutures pull from further away from the incision so the incision is more everted and sits higher than with simple sutures. Horizontal mattress sutures are like a square with the 2 sides on the skin surface parallel and on either side of the incision and 2 sides that cross underneath the incision. The knot is tied on one of the sides on the surface of the skin. I have not tried using horizontal mattress sutures. I would rather not have the suture travelling too far on either side of the incision in case swelling causes pressure and hair loss under the suture. If that happened the marks would be parallel to the scar and could make the scar look wider. I think the steri-strips wouldn't stick unless you shaved too much hair above and below the incision. You have more experience with scoring the Galea than I do. Thanks for these thoughtful and challenging questions.

Thanks Raphael84 Hair transplantation is a team sport and I am very lucky to have a great team. If this man's midfrontal forelock does get thin, he and I will notice it before the general public does. We won't wait until he goes bald there but will transplant it as soon as there is enough room to put enough hair to finish it.

Thanks very much Bill

Thanks hair_care and rpachigo I am asking that myself! Actually, in Dr. Frechet's original article on trichophytic closures, he said that you could either undermine both edges about 1/2 the width of the donor strip or 1 edge the full width of the strip. Dr. Frechet limits the strip width to 10 mm but I will take a wider strip if the VSL (vertical scalp laxity) allows. If the results were equal, it would be easier and faster to undermine one edge the width of the donor strip than to undermine both edges half the width. I felt the results weren't quite as good so I switched back to undermining both edges. Even when the strip is 10 mm wide, in my hands, the scar is narrower if I undermine both edges. It may be different for other doctors. This patient is content as he is. If he has more hair transplantation in the future, I will remove the donor scar with his strip and undermine both edges.

This 26 year-old man had hair loss in front but still had a strong midfrontal forelock (or 'island' or 'central tuft'.) He also has a strong cowlick which is like an S-whorl in his frontal hairline. He hoped to be able to brush his hair backward without the recessions showing but agreed that a mature hairline would be sensible in view of his potential to lose more hair as he ages. He uses Minoxidil regularly but stopped Finasteride due to side effects after 2 separate trials. He has fine hair but has more hairs per graft than average. We don't keep separate graft counts but did note that he had more 3s than 2s or 4s and had more 5s than 1s. We transplanted 3088 follicular unit grafts in front, excluding his midfrontal forelock, at densities of 56 -> 49 -> 42 grafts per square cm. He had 373 1-haired follicular units in his hairline. We had to follow his natural direction in his cowlick. At that time, I was routinely undermining only the lower edge, whereas I now routinely undermine both edges. He is happy with his trichophytic scar. I think it is OK but undermining both edges works better for me. Patients with acne seem to have a higher risk of getting post-op scalp pimples but using Tetracycline immediately post-op worked well at prevention. Some men keep their midfrontal forelock for life but others eventually lose hair there too. He knows that he will need more hair transplantation if and when he loses the hair in the midfrontal forelock and may want more hair transplantation if and when he loses more hair in his midscalp and crown.

Hi BigBill1234 Dr. Lindsey and Dr. Beehner both made excellent points. I found your original thread: http://hair-restoration-info.c...=201104852#201104852 You must be around 24 now and had hair added to your hairline without lowering it and some hair added to your crown for a total of 1600 grafts. Hopefully, you are using medications to slow hair loss. Drs. Rose and Charles had the benefit of meeting you in person and examining you. To give you really good advice a physician would have to see you in person. This thread gives you some things to think about but can't substitute for a consultation. You may not like this but another option might be to keep your hair long enough to hide your scar now and wait until you need more hair transplantation before addressing your scar. If you lose more hair in the future, you may rather invest grafts in the front or top of your head than in a scar that can be hidden. If you revise the scar now you will get some grafts and those grafts should be spent wisely. If you don't have a weak area now, it would be probably be better to wait. Long-term planning is very important for young men because they have more time to lose more hair and it is impossible to predict how much hair they will ultimately lose. I also feel that young men with simple skin closure (i.e. 1-layer and no undermining) have a little higher risk of getting wider scars than middle-aged guys like me. Maybe it is because younger men have a "better" healing response or older guys lose the elasticity that tends to pull the skin back to its original location or maybe it is because younger guys tend to be more active after a hair transplant. If you don't need more hair transplantation right away, you may also heal better if you wait until you are older. I hope this is helpful.

Thanks for your questions imissthe barber. They relate to Bill's concern so I hope he doesn't feel like his thread was hijacked. These are published numbers. You can get good scars with either staples or sutures. I consider myself fairly tough. For example, I keep playing after I get hit in the face with a soccer ball. I have personally had staples for 10 days each after 4 sessions and they weren't fun. I therefore use sutures for my patients. Patients who had staples when I worked with Dr. Seager then sutures here, always prefer sutures. Even if you left sutures or staples in for 3 weeks then removed them, the scar would ONLY have 30% strength and could stretch. The work to prevent stretching is done below the surface of the skin. You would either need to undermine the edges to cut the elastin fibres that tend to pull the edges apart or leave in deep sutures that retain their strength for months. The skin sutures are just used to make the edges come together nicely. I prefer to remove sutures around 10 days after the hair transplant to avoid getting "train tracks". They are foreign material and the skin will only put up with them for so long. I hope this makes things clearer.

BigBill1234 Every donor scar is different. Unfortunately, I don't think anyone here, including me, can tell you how best to deal with your scar without knowing all the details. Spex was right that you have to first understand why the scar is wide before you can figure out how to improve it. Your scar could be wide because of repetitive stretching with neck movements, how you heal, or surgical technique or a combination of factors. If your scar can be revised, you will get a better result with revision than with grafting. If not, grafting can at least break up the bald appearance. I tell scar revision patients that revision usually makes the scar better but there is a small risk that the scar could end up the same and a very small risk that it could be worse. If I think there is not a good chance of improvement with scar revision then I don't offer to do it. There are many different methods for scar revisions because we haven't found one good way that works for everybody. I am working on a new approach but it is still too early to evaluate it. You have already consulted 2 very bright doctors and got different opinions. You may need to consult other doctors. Dr. Brad Wolf has written and presented a lot about scar revisions and may be worth seeing. I suspect that leaving in sutures or staples longer will not be the answer. The strength of the scar is about 30% at 3 weeks and 80% at 3 months. There are problems with leaving surface sutures or staples too long. I believe that Bill left his staples in a long time after his last surgery so he may be able to prove me wrong with one photo.

Hi NW4 recession The trichophytic part of the closure should not cause any loss of grafts. From the surface downward, the layers of the skin are the epidermis, the dermis, and the fat layer. We are only trimming off the epidermis or surface layer of the skin and the tips of the hairs. The trimmed hairs will keep growing. We are not affecting the stem cells in the hair follicle bulge area in the dermis layer or the dermal papilla stem cells in the fat layer. The hair follicles will therefore be able to keep producing new hairs every 2 to 6 years for the rest of your life. As Dr. Lindsey said, avoiding tension is most important to keep donor scars narrow. First and foremost we have to avoid taking a wider strip than the scalp laxity allows. We can further reduce surface suture tension by using deep dissolving sutures or by undermining the skin edges. Not doing a trichophytic closure allows me to make the donor strip 1 mm wider than if I do a trichophytic closure and that could yield another 250-300 grafts. Some patients prefer getting more grafts than having a trichophytic closure but most don't. We do a trichophytic closure almost all the time but avoid it if the skin edges do not come together easily BEFORE undermining or using deep sutures. I would rather create a narrow scar with no hair in it than a wide scar with hair growing through it. Of course, a narrow donor scar with hair growing through it is best of all. On subsequent sessions, it may take a bit longer to dissect the follicular units out from the old scar than from virgin skin but careful microscopic dissection can still preserve the grafts. In summary, unless a patient prefers a non-trichopytic closure or their skin is tighter than I would like, we do trichophytic closures routinely.

StillHave Hair This thread is 2 years old but is still worthwhile. I don't think I met you but based solely on your posts, I suspect that you could have had both Telogen Effluvium and Androgenetic Alopecia (Male Pattern Baldness). The rapid progression and shedding are typical of Telogen Effluvium but not of AGA. The patterned loss and miniaturization are typical of AGA. These are 2 common conditions and it is not uncommon to have both. For example, I fairly often see women who have AGA and get Telogen Effluvium a few months after delivering a baby. Instead of having the gradual thinning typical of AGA or the rapid thinning then recovery of TE, they tend to get a step-wise hair loss. In medical school we are taught not to try to come up with two diagnoses when one will do. When one diagnosis doesn't fit all the symptoms, it is worthwhile to consider that there could be more than one cause of hair loss. We can't go back in time but may be able to help the future. If you know that you have AGA, it would certainly be worthwhile to try adding Minoxidil to your Propecia. They work in different ways. Most people who start Minoxidil don't get shedding. If you do get shedding it is temporary and is a result of resting hair follicles being pushed into the growing Anagen phase. Despite your past frustrations, it would still be best to see a hair loss physician for a thorough exam, an accurate diagnosis, and to discuss your treatment options.

Swim You are right.

For a video of this patient, go to: http://chtc.ca.devt.back2front...ry/.Video/index.html

Swim I answered this question in a thread on angles: http://hair-restoration-info.c...=599105553#599105553 but have pasted the answer here too: Curly hair also curls under the skin. People with curly hair usually have "C"-shaped grafts. Usually curly-haired grafts are placed so that the grafts exit the scalp at specified upward angles but the hairs tends to curl down toward the scalp. Some doctors have created sites in a curving path with straight instruments and others have used curved instruments. Even if straight tunnels are used, the proper exit angle from the scalp and direction can be achieved if the graft is oriented to curl the right way.

Swim Curly hair also curls under the skin. People with curly hair usually have "C"-shaped grafts. Usually curly-haired grafts are placed so that the grafts exit the scalp at specified upward angles but the hairs tends to curl down toward the scalp. Some doctors have created sites in a curving path with straight instruments and others have used curved instruments. Even if straight tunnels are used, the proper exit angle from the scalp and direction can be achieved if the graft is oriented to curl the right way.

Shanti A recipient site is actually like a little tunnel that has an angle and a direction to it. When grafts are planted they are guided into the tunnel and must follow the angle and direction of the tunnel. If the tunnel is bigger than the graft, the graft can shift within the tunnel. To avoid shifting, hair transplant doctors make sure that the grafts and recipient sites are matched well.

I am certainly not a tattoo expert but I have seen other doctors' patients who tried tattooing donor scars and recipient areas. Some staff members and female patients tattoo their eyebrows and they have to get touch-ups just like Jessica. Black ink turns blue and brown ink fades.

This man in his early 50s had 2 brain surgeries, 8 and 9 years before his hair transplant. This left him with 7 burr holes in his skull and 2 long curved scars near his hairline and on top of his head. His scalp was stretched tight and thin. At first, his hair hid the scars but he also gradually developed genetic hair loss in a Norwood 5-6 thinning pattern. His main goal was to transplant enough hair in front to hide his surgical scars better and to frame his face. He hopes to later transplant his midscalp. He does not plan to transplant his crown because he does not have much scarring there and he would like to accomplish his goals with as few surgeries as possible. He has more 3s than 2s than 1s so he has more hairs per graft than average to compensate for his finer hair. His CT scan confirmed the absence of bone below the skin depressions. Since the skin was quite thin over the burr holes, we elected not to transplant grafts over the holes rather than to try transplanting with strict depth control. He had 2944 grafts transplanted to the frontal area. His grafts were placed at 56 per sq cm in the frontal forelock, 49 behind his hairline then 42 then 36 then we faded out at the back of the frontal area. With the tightness of his skin from his previous surgeries, he had a lot of graft popping, especially near the scars. Popping means placing one graft results in a trampoline effect and 1 or 2 previously transplanted grafts can partially come out. Those grafts have to be gently tucked back in right away before placing another graft. If the ???popped grafts??? are not noticed right away they can dry out or if they are manipulated too much, they can get damaged and either of those factors could lead to poorer growth. Popping slows a case down considerably. Despite taking about 4 hours longer than usual to complete, he had very good growth of the transplanted grafts. We took the maximum safe donor strip that his VSL (vertical scalp laxity) would allow at 10 mm wide on his sides and 14 mm wide in back. Since the edges could oppose but not overlap before routine undermining, we elected not to do a trichophytic closure. He has a 1 mm wide non-trichophytic scar but his donor scalp is still not that flexible after 12 months. His VSL measurements are now between 8 and 10 mm. We could currently safely transplant another 2000 grafts to his midscalp but he is trying scalp stretching exercises to see if he can gain some more flexibility to increase the number of available grafts for his next session.

Thank-you for your replies, Please Grow Please and Bill. If I remember correctly PGP, you usually put some thought into your posts. I don't think you were trying to offend anyone but some would take offence to your remark about "that ridiculous turban." There is nothing ridiculous about a turban just as there is nothing ridiculous about wearing a Yarmulke if you are Jewish or covering your head in some Christian churches. My understanding is that wearing a turban has deep religious and cultural underpinnings and it can be a very difficult decision for a man to decide to stop wearing it. It is even harder when taking off a turban exposes hair loss that had been previously hidden. This man has made the decision to stop wearing his turban and should have no more reason to suffer Traction Alopecia. I saw no signs of miniaturization and he is in his mid-50s so I hope that he will avoid genetic hair loss too. Thanks again for your feedback.