Peter Mac

"1 What exactly is a densitometry and how will it be conducted?" Densitometry is measuring the grafts and hair follicles per sq cm using a handheld densitometer or a video electron microscope. For the guarantee we will use the video electron microscope so you can see your results on a computer screen. "2 What assurances will a patient have that the test is valid at the outset?" You will watch the densitometry reading on a computer screen and see for yourself. Every part of the guarantee is open to inspection by the patient. "3 Why is it available only in Greece? Does this relate to the actual surgeon performing the surgery?" Because Greece is the DHI corporate headquarters. In some places hair transplant clinics are not allowed by local agencies to make any sort of guarantees about graft count in the results while in Greece we can. "4 Why should it be necessary to express a request for this guarantee in advance? Should the results not be the same in any event?" Yes they should absolutely. However, some patients accept the possible outcomes of the surgery and are not interested in a guarantee. With the guarantee we need to take several steps to ensure all proper images and densitometry readings are taken. "5 How can a patient be expected to know the extent to which regrowth occurs? While they will have a general idea about the overall improvement in appearance, they can't physically count the grafts/hairs and will be reliant on DHI to tell them what's grown and what hasn't." DHI will use video electron miroscopy for the analysis. The patient could go to any high quality dermatologist and have measurements taken if he feels the yield is not what it should be. "I'm sorry if I appear negative about what may very well be a genuine offer. It's just that I've been sold a pup before and I've grown to be more cautious about "special offers"." The difference between this offer and others is patient education. We're advising patients up front about the growth cyles of body hair and the lack of definitive and peer reviewed scientific evidence. The offers you should be cautious of are those that try to pull the wool over your eyes and don't explain the science behind the procedure. We are fully explaining the science up front. This offer is intended to help those who want to try body hair, understand the possible outcomes, but don't want to take a financial risk if the growth isn't ideal. It helps them get started on a body hair transplant without any financial risks. The fact that we want you to watch our densitometry readings on a computer and see the graft count for yourself speaks volumes about the legitimacy of the offer. PeterMac@dhi.gr www.dhimedical.com

As many of us know body hair has different growth cycles than scalp hair. Scalp hair has been shown to be in anagen (growth phase) 90% of the time while body hair is only in anagen 30-50% of the time. While many of us believe that a transplanted body hair resets resets its growth cycles once moved to the scalp, there are very few scientific studies performed to verify this belief completely. On behalf of DHI I am pleased to announce the following. DHI guarantees all body hair transplants performed at DHI will have an 80% growth rate on the scalp. Terms of guarantee: 1. Patient must allow at least 24 months for transplanted body hair to change its growth cycle to match that of the scalp hair. 2. If any area has less than 80% of body hair follicular units in anagen after 24 months DHI will replace any body hair grafts not in anagen with head hair FUE grafts at no cost to the patient. Replacement grafts are limited to the total number of transplanted body hair FUE grafts minus 10% as 10% of head hair grafts are expected to be in the telogen phase even with normal scalp hair. 3. The patient will be responsible for transportation expenses to return to DHI, but lodging and any surgical costs will be provided at the DHI Plastic Surgery Hospital at no charge. 4. A densitometry reading will be taken before and after surgery to determine total number of body hair grafts placed. If the patient feels the body hair yield at 2 years is not 80% then DHI will perform another densitometry reading to determine growth percentages and replace any grafts that didn't grow or that are not in anagen up to the total number of grafts transplanted minus 10%. 5. Patients will be allowed to view the densitometry reading on a computer screen to see the results for themselves both before and after their surgery. 6. Patient must advise DHI before surgery that he/she is interested in the body hair guarantee program to ensure the density and growth measurements are recorded and documented. 7. At this time the DHI body hair guarantee is only available at the Athens, Greece office. Now patients interested in using body hair, but worried about their return on investment in terms of visual yield, can undertake the procedure and have peace of mind with the DHI guarantee. PeterMac@dhi.gr www.dhimedical.com

As many of us know body hair has different growth cycles than scalp hair. Scalp hair has been shown to be in anagen (growth phase) 90% of the time while body hair is only in anagen 30-50% of the time. While many of us believe that a transplanted body hair resets resets its growth cycles once moved to the scalp, there are very few scientific studies performed to verify this belief completely. On behalf of DHI I am pleased to announce the following. DHI guarantees all body hair transplants performed at DHI will have an 80% growth rate on the scalp. Terms of guarantee: 1. Patient must allow at least 24 months for transplanted body hair to change its growth cycle to match that of the scalp hair. 2. If any area has less than 80% of body hair follicular units in anagen after 24 months DHI will replace any body hair grafts not in anagen with head hair FUE grafts at no cost to the patient. Replacement grafts are limited to the total number of transplanted body hair FUE grafts minus 10% as 10% of head hair grafts are expected to be in the telogen phase even with normal scalp hair. 3. The patient will be responsible for transportation expenses to return to DHI, but lodging and any surgical costs will be provided at the DHI Plastic Surgery Hospital at no charge. 4. A densitometry reading will be taken before and after surgery to determine total number of body hair grafts placed. If the patient feels the body hair yield at 2 years is not 80% then DHI will perform another densitometry reading to determine growth percentages and replace any grafts that didn't grow or that are not in anagen up to the total number of grafts transplanted minus 10%. 5. Patients will be allowed to view the densitometry reading on a computer screen to see the results for themselves both before and after their surgery. 6. Patient must advise DHI before surgery that he/she is interested in the body hair guarantee program to ensure the density and growth measurements are recorded and documented. 7. At this time the DHI body hair guarantee is only available at the Athens, Greece office. Now patients interested in using body hair, but worried about their return on investment in terms of visual yield, can undertake the procedure and have peace of mind with the DHI guarantee. PeterMac@dhi.gr www.dhimedical.com

Josh, As someone who has watched both Epstein and Rose in surgery I can say both are exceptional and either one will do excellent work for you. I suggest you have a consult with both and get a feel for each doctor. I feel having a good rapport with your surgeon is paramount. Since Epstein and Rose are both superstar surgeons, the deciding factor might be the surgeon you feel most comfortable with. PeterMac@dhi.gr www.dhimedical.com

<BLOCKQUOTE class="ip-ubbcode-quote"><font size="-1">quote:</font><HR>What are the chances that FUE'd grafts will continue growing and not fall out? Maybe this is just wishful thinking. I know that the follicles have to go through the same traumatic journey from donor to recip but wouldn't it be great if they could just keep growing? Yes, it would be great and that is our common goal. Every surgeon in the hair transplant world should have a goal of 100% growth in 100% of patients with no post transplant effluvium. Many in the industry are working hard to accomplish this mission. In the near future we will likely have better storage solutions that will eliminate post transplant effluvium. For small sessions we are also moving the grafts directly from the donor area to the recipient area. In theory this would minimize the time out of the body and thus increase the likelihood they continue growing. Sometimes they still shed however just from the trauma of being extracted. We will continue to experiment and work daily to find the best methods to eliminate post transplant effluvium. Shedding has many factors including time left in Lactated Ringer's solution or chilled saline, each patient's own healing characteristics, and trauma to graft during extraction and placement. So, to give even a rough estimate for any give patient is challenging. All we can do is quote statistical averages. We brought this patient in the pictures with us to the DHI London FUE seminar and everyone attending was able to see him close up. His grafts have yet to shed. They'll probably begin the first shed within a couple of weeks. We'll keep a close eye on him to see how many grafts he keeps. I had around 50 body hair FUE grafts placed into my crown to show the seminar attendees how the grafts look 24-48 hours immediately post op. I am now 1 week post op. Since my session was so small I'm not sure how many of my grafts will shed. I suspect I'll keep a higher percentage of them than someone would on a mega session since the session was so small. El Guapo, you are welcome to e-mail me at any time if you have any additional questions. PeterMac@dhi.gr www.dhimedical.com

A few men in the Merck study did get their partner pregnant while on finasteride. To date no birth defects have been recorded as being caused by the sperm from a man on finasteride. However, the pregnant woman can't even touch the pills as finasteride might interfere with development of the male fetus if absorbed through her skin. PeterMac@dhi.gr www.dhimedical.com

What are the best ways to keeping "shock loss" to a *minimum* before and after surgery? I heard that I should make sure that my exisitng hair is cut real short when the doctor is putting in the new transplanted grafts and to apply lots of Rogaine to the transplanted area. Shock loss is always a possibility, but we can try to minimize it. Helpful suggestions: 1) Use Propecia pre and post op: Helps to strengthen hair, increase weight, and helps follicle grow deeper into hypodermis 2) Use smallest tools possible ( donor and recipient): On the donor site, use FUE extraction tools of 0.5 mm if possible. A 1.0 mm FUE tool has over 4 times the surface area of a 0.5 tool. For recipient, use the smallest blades or needles possible. 3) Minimize transection: perfectly follow the angle of every hair follicle to minimize hair transection during making of the slits. 4) Use minox like you suggested. Minox is good for shock loss recovery and graft growth as well IMO. Some people are more prone to shock just like some are more prone to scarring just like I can't get a date with a Greek girl no matter how hard I try. Some things we just have to live with.

Ideally grafts should be placed into the hypodermis of the skin aka the subcutaneous fat. This usually extends about 3-4 mm deep. Not only does this depth vary by individual, it varies on different parts of the scalp. It's a very fine line. The surgeon wants to enter the subcutaneous fat with his slit or needle, but if he goes even slightly deeper he might nick or completely sever the subdermal vessels which nourish the scalp and provide the blood supply for new grafts to grow. If he does too much damage to the subdermal vasculature it could impede growth. Interestingly, we've seen body hair follicles don't usually grow out of the hypodermis. They are often found in the dermis which makes them much more difficult to extract. I've been watching body hair FUE extractions vs. head hair extractions lately. Head hair FUE is a walk in the park compared to body hair FUE which is why the surgeon can extract twice as many head hair grafts per day. It could be your surgeon placed the graft extremely deep, below the hypodermis and in the area of the subdermal vessels. It could be that the follicle somehow tangled itself around a subdermal vessel. When the scab came off the hair pulled through and severed the vessel. Imagine if you tied a sharp chain around a thin garden hose and yanked really hard, severing the hose. Water would start to spray everywhere. That's kind of a bad example, but you get the picture. A hair follicle is only 100 microns in width. I think it's highly unlikely that it could tangle up with and sever a subdermal vessel, but still possible I suppose. Blood vessels run all through the dermis so it's more likely that the follicle ripped through quite a few dermal vessels on its way out and that's why you had so much bleeding. Or your dermal and/or subdermal vessels hadn't fully healed yet from the transplant and the hair that came out simply aggravated pre-existing injuries to these vessels. It's impossible to know precisely since we didn't stick a camera inside the skin to watch In skin, the easiest way to think of your blood vessels is like a tree. The SUB-dermal vessels are like a tree trunk and the smaller DERMAL vessels are like branches. You stop the tree from bearing fruit by doing one of two things: 1) chopping the tree down at the trunk or 2) cutting off all of the branches. You can generate a lot of bleeding (killing the fruit) by damaging the subdermal vessel (chopping the tree at the trunk) or damaging many dermal vessels (cutting off the branches). Both will have the same cumulative effect on how how much blood you see. I could wax my chest which would cause a lot of bleeding too, but the hair would all grow back. I waxed my back once and that happened (don't ask me why I was stupid enough to think that would work). But I bled a lot and all of my hair grew back. Once the matrix cells of the follicle are safely in place in either the lower dermis or the Hypodermis (Subq fat), the hair will likely regrow. Interestingly, some dermatological studies have shown dying follicles reach deeper into the Hypodermis once the patient started Propecia. It could be theorized that some grafts may attempt to work their way into the Subcutaneous Fat even if their initial placement was only in the lower dermis. Perhaps like tree trunk roots reaching the right depth. I don't know of any dermal scans to prove the theory however post transplant, although it sounds like an interesting study. If the follicle was damaged during the transplant (i.e. left out of storage solution too long, transected, inserted with too much force) it might also affect the growth. Many transplant patients see their hairs come out with scabs and panic. There is no reason to. The follicle is not the hair matrix cells that generate a new follicle. If you lose the graft replete with all of it's sebaceous glands and other surrounding skin cells immediately post transplant, then you've probably lost the hair. If that happens I must ask what on earth you are doing. Immediately post op your follicles are held in place by fibrin, the body's natural glue, which is created by a chemical reaction in the blood serum during the graft placement. The Fibrin helps to protect your grafts from displacement while your bodies wound healing agents generate new skin and repair the damage of the graft incision. If you are at the 12 day point you should expect to start seeing more and more shedding every week for a few weeks. However, this discussion is probably overkill. We're only talking one follicle right? I hope I've answered your questions. Feel free to contact me via e-mail if you have anything else you'd like to ask privately. PeterMac@dhi.gr [This message was edited by Peter Mac on December 15, 2003 at 12:36 AM.]

that reminds me of the song: "I know an old lady who swallowed a fly...she swallowed a spider to catch the fly...I guess she'll die." This game will never end as you will keep upping your doses of everything. My opinion is you should not be taking testosterone injections unless you have a serious medical need. If you have a serious medical need, then hair loss is likely the least of your problems.

Yes, the grafts are held loosely in place for a few days. By day 8 or so they are fully secure. If you lose a graft at day 12 the matrix cells have been planted and the follicle will regenerate. A large percentage of transplanted follicles shed between 2-8 weeks. That is normal and expected. Did you spray your scalp with a solution like saline or Graftcyte every hour or two post op for a few days? I share the opinion that scabs should not be allowed to form on recipient sites. If some scabs did form, it means a few recipient sites were allowed to dry out and they formed scabs to protect themselves. Perhaps a few of them didn't get enough of the spray. That's why you are bleeding. You popped a scab where the body hadn't finished healing the skin underneath. Regardless, the follicle will likely regenerate so I don't think there's anything to worry about.

what are your testosterone levels (free, DHT, etc)? Why are you on injections?

Balding doesn't always go to the fringe stage of Norwood 7. I've seen many men including some in my family that went to Norwood 6 and stabilized for many years. However, perhaps if they lived really long they might have progressed to a Norwood 7. I do believe you should assume that you will go to at least a Norwood 5 or 6 with your hair loss pattern and plan your treatment accordingly, especially if there's a history of this in your family. Avodart is a serious drug and should be treated as such. At present Glaxo Smith Kline has been unable to determine how 55% of dutasteride is metabolized by the body. It's half life is quite long as it is not fully purged from your body for up to 5 months after you stop taking it. If you stop taking finasteride it's pretty much purged from your body after about a week. Finasteride has been analyzed for over a decade and has an excellent record so far for safety and effectiveness. Remember that Propecia (finasteride) is working if it stops your hair loss. Regrowing any hair is only a bonus. You only tried Propecia for one week. You need to try any treatment for 6 months to evaluate effectiveness. Side effects may sometimes resolve themselves within a month. At a Norwood 3 stage medication can be much more beneficial than a transplant. It should be given a chance to work before you go through with a transplant. You are only a Norwood 3 after 4 years of loss. That's a slow rate of baldness. There is no need to rush anything. [This message was edited by Peter Mac on December 13, 2003 at 01:23 AM.]

A Norwood 1 is a normal adult hairline. You should NEVER have a transplant at this stage. Even those with no other hair loss at all usually become Norwood 1's--like 99% of the population. I've met only a handful of people in my life that kept their teenage hairline into their 30's and they looked really odd too.

>Are there test that can tell you if you DHT or testosterone levels are too high. < Just about any lab can test your serum testosterone levels measuring both DHT and free testosterone quite easily. it takes about five minutes to draw the blood. I think I spent about 30 minutes in the waiting room though. I'd see your primary care physician as he might recommend some other tests too to get a better understanding of your condition.

>Is my body creating more DHT now? I'm not sure if I should continue working out or not. Also, are the white bulbs at the ends of the hair that fall out the follicle or just scalp build up? Any help would be greatly appreciated< You should continue working out. We have some studies that show that abdominal obesity increases DHT production 10 times in the body. Ever noticed how many fat, bald guys you see? Is there a correlation being being fat and balding? Most likely. Focus on being fit and lifting weights. It will reduce your DHT in the end. The body is of course extremely complex, but being fit and eliminating your abdominal body fat is one of the best things you can do to reduce DHT in your body. Please feel free to e-mail me at: petermac@dhi.gr if you want further information.

Has it kept the hair you have? That's the goal. Anything else is a bonus. I was on a topical formula (Proxiphen) for 18 months. I thought it wasn't working because I didn't grow any more hair. So I stopped using it. YIKES! Within 6 months I lost a ton of hair. The product HAD been working and keeping my hair. It was stopping further loss so it was working very well. So I basically lost 2 years worth of saved hair in six months. Stopping Propecia is a big decision. Proceed with extreme caution.

Remove? probably not. Lessen? maybe. An extreme measure is balloon tissue expansion. A balloon is inserted into your scalp and gradually inflated. The pressure creates more skin and elasticity. The surgeon then removes the extra skin (and scars with it) and sutures the remaining skin together with normal tension. If done properly it combines all scars into one pencil line scar like a strip transplant should give you to begin with. However, you have to be prepared to live with a balloon inflated in your head for many weeks. I wouldn't do this unless you have some really bad scars. You will always have at least one linear scar no matter what you do. If your scars are both thin, I like Arfy's suggestion of putting FUE grafts into the scar to help conceal it.

The findings are curious, but I for one wouldn't blame Propecia just yet. According to the clinical pharmacology from Merck: "Finasteride had no effect on circulating levels of cortisol, thyroid-stimulating hormone, or thyroxine, nor did it affect the plasma lipid profile (e.g., total cholesterol, low-density lipoproteins, high-density lipoproteins and triglycerides) or bone mineral density. In studies with finasteride, no clinically meaningful changes in luteinizing hormone (LH) or follicle-stimulating hormone (FSH) were detected. In healthy volunteers, treatment with finasteride did not alter the response of LH and FSH to gonadotropin-releasing hormone, indicating that the hypothalamic-pituitary-testicular axis was not affected. Mean circulating levels of testosterone and estradiol were increased by approximately 15% as compared to baseline in the first year of treatment, but these levels were within the physiologic range." You might be an anomaly, but finasteride is known to lower DHT only. The body actually compensates for the reduction of DHT by increasing testosterone production. I suggest you proceed with extreme caution. It would be ill advised to go off Propecia only to discover something else is causing your problems. I'd look into this a little more and see if something else is causing your problem.

Grafts may still come in around the 9 month mark. Do yourself a favor and stay out of the sun for at least a year. You probably spent a lot of money on your transplant. Don't do anything to jeopardize it.

>Would 1450 grafts on the hairline be considerd somewhat dense packing?< What is your definition of the hairline? How many cm or inches back and how wide is your forehead. Take a fabric tape measure and take some measurements on your scalp of the area you are thinking of Once we know the square centimeters we'll have a better idea of how dense it is.

>BUT THEN ISNT IT POSSIBLE: That by rubbing the grafts you may dislodge the actual hair root in your scalp thus popping the hair out.< It's all right if the hair follicle itself sheds as the matrix cells have taken root at this point. Hair goes through cycles of shedding normally. >ARE THEIR ANY DISADVANTAGES OF HAVING THE SCAB? i AM WILLING TO LET IT HEAL naturally < YES! A scab is NOT a good thing. A scab means that a wound was allowed to dry out. To protect the area the body forms a scab to allow healing to occur underneath. This offers no advantages and there are no published studies that I know of that show it's beneficial to let scabs form after a hair transplant. Moist healing offers no scab, retains moisture, cushions nerve endings, heals faster, reduces scarring, and reduces pain. I encourage everyone to spray saline or a commercial product like Graftcyte every 2 hous as the grafts heal to keep them moist and PREVENT scabs. SCABS equal SCARS. that's an easy way to remember it. Here is an excellent web page on wounds. http://www.robinsoncare.com/MoistWoundHealing.htm

>Thank g-d i didnt go threw it by them... Well what im trying to get at is... Do you think at my age and hair loss (NW-4 working on a 5) I should go under the knife?< Absolutely not and no ethical surgeon would operate on you either. If you are a Norwood 4 at your age, you need to rely on medical treatment for a while.

You have some excellent questions. Let's evaluate them one by one. >Can this be 'solved' by graduations of density? i mean if you would go for 80 grafts/cm2, would it be better to put 50g/cm2 in the first 2mm, than put 65 in the next two and go to 80 behind that or will that look stupid? < The density isn't the issue. Transition zones are. It also helps to create a slightly irregular pattern transitioning with single hair follicles. >Couldnt it be possible to get the finer hairs with FUE in the neck-area and behind and above the ears, and like that create the appearance of a natural hairline when you go for high density?< Interesting idea, but be careful. The neck area has many muscles in frequent motion and is more subject to scarring, even with FUE, than other areas. There are "soft" 1 hair follicles from other parts of the head you can use. >I find this a critical point when you are doing hairline AND temple-work. If you have very thick hair, that might look a little weird when it goes from thin hair to thick hair at once.< Yes, it would look strange which is why it's good to create gradual transition zones. Many surgeons recommend using all 1 hair follicular groups for the hairline and using the 2-3 hair follicular groups for added density behind the hairline. >Check out the pic. You can easily see where the HT begins. Cant this be taken care of with those finer hairs? Or i am trying to be too optimistic?< Yes, you could soften up the hairline with single follicles.

>The positive side effect is it actually makes your hair thinker and healthier because of allowing more blood flow (including the scalp). < I'm glad you had a positive experience, but for most of us poor blood flow is not the problem. I watched an FUE surgery for a patient two days ago who was an excessive bleeder. His crown was completely bald, but he was bleeding quite a bit during graft placement. Increasing blood for him isn't going to help any of his hair. A hair follicle demands blood and nutrients from the surrounding tissue. As the hair follicle miniaturizes due to MPB, it demands less blood from the scalp's circulatory system. You can increase the blood flow in your scalp, but the hair follicle isn't going to benefit much from it.

You could hire a local lab to test them, but you might end up paying more than it would cost just to buy Propecia outright after you pay for the testing. I used to work for a vitamin manufacturer several years ago. We tested several of our competitor's products and found they didn't include the dosages of the labels they said they did. The bigger the company, the more likely they are to be accurate because they have a brand to protect. The longer they've been around and the bigger they are the more likely you can trust them because they are more subject to scrutiny. Good companies send their products off to independent labs for testing voluntarily. Your hair is worth a lot of money. I wouldn't risk my hair just to save a few bucks. There is a company called ConsumerLab.com that tests vitamins and supplements. The founder hired a former FDA chemist and they now test and certify vitamins and supplements. They are completely independent and make their money from user fees. You might be able to see if they can recommend a good lab or if they're willing to test your product. I just did a who is lookup on this company: http://www.networksolutions.com/en_US/whois/results.jhtml;jsessionid=Q5IK33C3CGANWCWLEALSFEQ?_requestid=922624 they opened only 6 months ago, but haven't disclosed their information in the whois. That seriously concerns me. PeterMac@dhi.gr [This message was edited by Peter Mac on November 22, 2003 at 06:00 AM.]