Dr. Jerry Cooley

This patient came for frontal-temporal restoration. We started him on finasteride and did FUT consisting of 2,636 grafts (1-518, 2-1438, 3-680; 5434 hairs total). He is shown 17 months later.

Great question. In my practice, helping a patient decide on FUE vs FUT involves weighing several factors. Most of my patients wear medium length hair and place a premium on being able to get back to work in a week, and since we generally don't shave donor or recipient, this is very realistic. If my patient wears their hair very short anyway and wants to avoid any chance of a noticeable linear scar, then FUE is the best bet. For someone who has had prior procedures, scalp laxity is a big factor. Minimal scalp laxity may push us toward FUE. On the hand, if you healed well from the last procedure, and have decent remaining laxity, another strip FUT would be the way to go. And maybe when everything from this procedure grows in, you'll be satisfied with the results and you'll forget about your hair and this will be a non-issue! Good luck.

The after photos are with wet hair and the lights exaggerate the thinning as he looks thicker in real life. However, in answer to your question, we were shooting for medium coverage of the crown which is what we achieved. As the patient is in his late 30's, there is a lot of uncertainty as to future hair loss. Dense packing the crown may look better but uses up more grafts (which may be needed later elsewhere) and if further thinning occurs at the original borders of the baldspot, it will stand out more as a thin halo around a dense center. Thanks for your question.

This man is in his mid 30's and already has type VI hair loss. We performed FUT of 3481 grafts (1-981, 2-2074, 3-426 = 6407 hairs)) providing medium coverage to the front and light coverage to the crown. We plan to do a second procedure to add more density to the crown. He is shown one year post op. He was using an interesting styling trick when he returned, where he took braided hair from the back and sides and pulled the braids over the front of his scalp. This gave an appearance of a nearly full head of hair, but I did discuss my concerns over traction alopecia.

This woman is in her forties with almost ten years of progressive hair loss. We usually do blood tests in our female patients and her iron and vitamin D levels were extremely low. We corrected these and prescribed spironolactone and topical minoxidil. We performed PRP/ACell and FUT consisting of 2541 grafts (1-1227, 2-1172, 3-142 = 3997 hairs). Of note, her hair counts were fairly typical for the females we see: only 1.6 hairs per graft compared to most of our male patients which are closer to two hairs per graft. Close examination showed excellent growth of the grafts down the center of her scalp, but the global improvement was a combination of the grafting, PRP, and medical treatment. She is shown one year later.

This patient had been on finasteride over 5 years and felt he was beginning to lose a little ground. We did PRP/ACell and performed FUT consisting of 2,336 grafts (5,819 hairs) focusing on the hairline and crown. He is shown 15 months later.

Thanks for the comments, Spanker. He's in his mid 30's (I'm getting old so he seems really young to me). I think he has another 1000-1500 grafts by FUE.

This patient wanted extensive coverage and to be able to wear his hair short. We performed FUT first: 3,935 grafts (8,126 hairs); one year later, we performed a much smaller FUE session of 1,201 grafts ((2,444 hairs) to fill in more on the top as well as any areas of the strip scar that might show with short hair. In total, we did 5,136 grafts (10,570 hairs). He is shown one year after the last procedure.

This young man came to us requesting even coverage of his entire scalp. He had done a transplant of 1000 grafts about 10 years prior with significant hair loss since then. He had excellent quality hair but below average density. We performed FUT, with maximal harvesting giving us 3,782 FUs (1-998, 2-2006, 3-694, 4-84; 7428 hairs). Rather than dense pack the front only, we did medium coverage of the front and lighter coverage of the crown. We also performed PRP/ACell to stimulate existing hair and got him on finasteride. He is shown one year later.

This patient had fronto-temporal recession that he wanted to correct. We prescribed finasteride and performed FUT 2,648 grafts (4,986 hairs). He is shown one year later. In patients with very curly hair, the grafted hair is often a bit unruly in the first year of growth, but later it settles down and syncs up with surrounding hairs to create more natural looking curls.

He easily has another 2,500 by FUT and then more by FUE. He's going to hold off for now as he's happy with it. As he said to me, 'I've forgotten about my hair'. That's my goal!

I think finasteride is safe and effective for most guys even when taken for many, many years. Is it perfect? No. A small number of guys will have side effects when taking it, and will decide to stop it. We may have much better medical/biologic/cell based treatments in the future, but for now, it is the most effective way to save your hair.

This delightful lady is almost 80 years old and wanted to restore her eyebrows. We did 370 grafts using scalp hair (1-282, 2-88) to both brows. She is shown 6 months later. In the first year, transplanted brows can be a little wiry and have to be trained flat. Of course, they also have to be trimmed periodically because they will grow longer than normal brow hairs.

This patient is in his 40's and has type V/VI hair loss. We started finasteride and performed FUT of 4,361 grafts: (1-865, 2-1946, 3-1166, 4-384 = 9,791 hairs). The results are almost two years after the surgery.

This patient is in his late 50's and has primarily frontal loss ('A' pattern). He has excellent donor density and hair quality. We performed FUT 3,046 grafts (6079 hairs) to the frontal zone, blending into the midscalp. His shown at 8 months. He decided against taking finasteride, understanding that some ongoing thinning may occur behind the transplants,

This patient had a prior transplant elsewhere with disappointing results. He had been on finasteride for some time and his hair was stable. We did 1650 grafts (2999 hairs) and a PRP/ACell treatment. He is shown one year later. Because he had been on finasteride for several years, the improvement in the crown and midscalp is entirely due to the PRP treatment.

This 30 year old man had a prior transplant with disappointing results. He was very specific about how he desired his hairline to look. We first did FUT 1571 grafts (2438 hairs) and a year later a smaller FUE session of 1000 grafts (1475 hairs). He is shown 18 months after the last session.

This patient presented with very irregular hairline recession, with much more loss on the left. Usually some asymmetric recession is seen, but when that is the case, it is usually the right side that is higher. On top of that, he has a rather large skull, so he wore his hair longer, and pulled it down. His goals were to rebalance the hairline so he he could wear his hair shorter, but without being too aggressive. We did FUT 1696 grafts (1-352, 2-812, 3-468, 4-64; 3636 hairs). He is shown 15 months later.

Yes, I see less shedding and earlier regrowth. Whether or not this happens varies by individual. It's the final result that counts. Don't worry!

In my opinion, using it for a week, then intermittently afterwards should not cause any problems. But you can check with your surgeon to make sure they approve.

I generally prescribe clobetasol 0.05% solution nightly till the dermatitis is gone and then used periodically as needed for flare ups. A shampoo called Aqua Glycolic does a great job of getting rid of scaling. Tar shampoo can be helpful for maintenance.

That is certainly possible but I don't think so. I realize that without a large blinded clinical study (which is impossible to perform), people will be skeptical. And they have every right to be that way. But then again good clinical studies don't really exist in our field and yet tremendous progress has been made. How can that be? Doctors observe their results, make small changes, and observe the result of these changes. If I had started using post op ATP 8 years ago, and used it on every case since, and my results got better over this time, I really couldn't know whether improved results were from the ATP or from experience. But that's not what happened. Early on, I didn't know whether it was helping, and usage was intermittent over the first 6 years depending on availability. Reviewing my results, ATP usage was a significant factor explaining the difference in observed results. Like many experienced clinics, we go to great lengths to protect our grafts from any trauma. Assuming a perfect graft is placed perfectly into the recipient site, why wouldn't it grow? I believe the biggest reason is ischemia (lack of oxygen = lack of ATP). Doctors who do other skin grafting will tell you that blood flow (ie oxygen and ATP supply) is the major predictor in graft survival. I'm a dermatologist and in the past, I did alot of skin cancer surgery which often required skin grafts to close the wounds. If we do a skin graft on to the face (where blood flow is good), it usually takes and survives. If we do a skin graft on the lower leg (where blood flow is much lower), it often sloughs off and merely acts as a biological bandage until new skin is produced to fill the wound. Years ago, I removed a large melanoma from an elderly woman's lower shin. She had poor circulation and I had every reason to think the skin graft I placed wouldn't survive. However, I rigged up an IV bag with ATP solution that continually dripped over the graft for several days. The graft completely took and after it healed, the only sign we had ever done a graft was a faint circular scar at the margins. The skin in the graft looked like the surrounding skin, which was a much better than expected result. This is one more piece of evidence in my mind. Numerous top hair clinics have started trying post op ATP spray on their patients. I have gotten feedback from many of these (eg Shapiro, True, Harris) on how quickly their patients are healing now. It will take a couple years before these doctors are convinced it is improving survival but that is the nature of our field. The best way for a doctor to be convinced that ATP is doing something is to use it on their toughest cases, eg densely packed grafts into areas with low blood flow (eg scar tissue, areas of previous transplants) and see if their results are better than what they would predict. Dr David Seager, the father of dense packing, would try to finish an area in one pass because he believed his survival was lower in previously transplanted areas. Why? You guessed it: lower blood flow = lower oxygen = lower ATP. Most experienced clinics get good growth. If I get less than expected growth in 10% of my cases, then for me, that is too high. I want every case to turn out perfect and every graft to survive. That is why I use post op ATP. Thanks for your comments!

I will add my comments to this thread on ATP since I was involved in its development and application in hair restoration. In 2005, Dr Bill Parsley introduced me to Dr Ehringer after he learned about his ATP research. We were going to study its effect as an additive to holding solutions for hair grafts. Our in vitro work (lab work, not on patients) showed that ATP increased the viability hair follicles kept outside the body using special cellular stains and cell culture. This led to my study in 2008 where I kept a patient's grafts in the refrigerator (4C) for 5 days in a solution of HypoThermosol/ATP and obtained good growth. This is far longer than any researcher has ever done. In the attached photo, the patient's left temple was hairless due to radiation from a skin cancer. We put in 1200 grafts that had been stored for 5 days, achieving over 70% growth, compared to 45% growth for HypoThermosol without ATP and 0% for grafts stored in saline (grafts placed elsewhere in scalp). Prior studies had shown that survival drops to near zero after 3 or 4 days in storage in various solutions. This shows that ATP increases survival during long term storage. But is HypoThermosol/ATP necessary for an average case where grafts are out of the body for several hours? Furthermore, even if HypoThermosol/ATP was the perfect graft holding solution, would this be the end of the story? I think not. After twenty years performing hair transplants, it is my opinion that the two most important factors predicting graft survival are 1) graft trauma and 2) Post operative ischemia (low oxygen = low ATP). I would put storage injury/ischemia-reperfusion injury (what the holding solution would protect grafts from) as less important, so even a perfect holding solution will not correct for graft trauma and ischemia post operatively. So it dawned on me a few years ago that we should be putting ATP in the post op graft spray. The hair transplant procedure is at its core a transplant procedure, specifically a 'free graft' procedure. Unlike an organ transplant in which blood vessels between the graft and body are reconnected, we put these tiny grafts into the scalp and wait several days for the body to build a capillary network around the graft and to supply it with oxygen. So how does it survive? It passively absorbs left over oxygen which is diffusing through the tissue. Normally, this works well enough for the graft to survive and grow. But everyone has different amounts of blood flow, and therefore oxygen, flowing through their scalps. If someone has had prior transplants (unless it was with ACell), they will have even less oxygen due to fibrosis. So applying post op ATP is a way to 'feed' the grafts until they have their own capillary network about 5 days post op. Remember, oxygen is only needed so it can combine with glucose in the cell to make ATP, which is the universal fuel source for cells. In my opinion, the biggest explanation for poor growth at an inexperienced clinic is graft trauma (transection, crushing, dehydration). At an experienced clinic, where graft trauma is minimized, I think the biggest explanation for suboptimal growth is ischemia. So where is the clinical research to prove this claim? To answer that question, you have to step back and consider what kind of a study would be necessary to provide this proof. If post op ATP spray (or HypoThermosol/ATP as a holding solution) improves graft survival, that should be easy to prove with a study, right?. All surgeons (and I mean ALL surgeons) have results that vary. There are so many variables that effect graft survival that even with perfect technique, claiming 100% survival in 100% of cases is ludicrous. So if you draw a bell curve to represent a doctor's graft survival (assuming it was even possible to know this, which it isn't) and assume that ATP pushed this curve to the right 10% (just for the sake of argument). We would need to study 50 patients where we treated half the scalp normally as a control, and the other half with post op ATP. We would need to get all 50 patients to come back in a year (which we never get) and be able to do accurate hair counts over large areas (which is not feasible) and make sure the post op ATP wasn't effecting the control side (which would be impossible since it is a vasodilator and improves blood flow to the whole scalp). So in another words, a proper study is virtually impossible to perform. Furthermore, all of my patients want the best growth possible, not just on one half of their scalp. I'm confident that post op ATP improves the consistency of my results because when I look back over the 8 years of usage, my 'consistency curves' were much tighter when I used it. There were long stretches of time when I could not get it because Dr Ehringer wasn't producing it. It only became apparent to me over time what an important role the post op ATP was playing. Dr Ehringer's liposomal formula is unique in its ability to get ATP into the cell. I tried another liposomal formula of ATP and it did nothing. My colleagues often ask me why they should bother with ATP (or ACell, etc) and my reply is that if you and your patients are happy with your graft survival, then you don't need to worry about it. I'm not telling any doctor they need to start doing this; I am saying that my results have improved by doing this. I have no financial interest in the sale of Dr Ehringer's ATP. If BioLife is able to develop with Dr Ehringer a freeze dried version of his ATP, this will make it more commercially accessible worldwide, and I will have a small financial interest in that product. If a prospective patient wants to use post op ATP spray after their transplant, they can simply ask their doctor to order some from Dr Ehringer. I think they will notice an improvement in healing time, but that is really secondary to the main goal of optimal graft survival. Sorry for the long winded post....

The patient is not on meds. He had been on finasteride for a few months in the past and had a physical complaint (which I do not think was related to the medicine) and opted to discontinue it.

That's great to hear. We look forward to having you as our patient.