Dr. Jerry Cooley

Yes, improvement in the crown was just from finasteride.

This patient is in his late 20's and presented with Type III pattern hair loss. We started him on finasteride and performed FUT of 2,691 grafts (1-551, 2-1206, 3-861, 4-73) to the frontal hairline, as well as some in the mid-scalp. We did not graft the crown and usually avoid doing this for men in the 20's and early 30's because of the increased risk that further progression of hair loss will leave the grafts looking unnatural. He is shown 18 months after the procedure. His wavy hair definitely adds to the result.

This patient has typical fronto-temporal thinning and received 1,677 grafts (1-438, 2-865, 3-303, 4-74; total hairs 3151). He stopped in at 7 months for a check and was progressing nicely.

This case was posted a year ago, seven months after the first procedure. She is a woman in her 70's and is fairly typical of older females with hairloss. There is diffuse alopecia throughout her scalp except for a band of slightly denser hair in the lower border of her back and sides. Normally she would not be considered a good candidate for a hair transplant because of her weak donor (approx 50 FU/cm2). Her donor hair is shown with comparison to a male with excellent quality donor hair. The first procedure yielded 2391 grafts with 4304 hairs, and the second surgery yielded 1,948 FUs (3,446 hairs) for a total of 4,339 FUs (7,750 hairs) to the entire thinning scalp (<25 grafts per cm2). She is shown 8 months after the second procedure. ACell MatriStem was used on the grafts. This is better than I normally expect and I attribute this to the use of the ACell. There is no way to prove this just as there is no proof for any of the techniques we use as hair restoration surgeons, other than accumulated clinical experience. I believe that the benefits of ACell are most apparent on those patients with below average hair characteristics and low density grafting.

This patient has type IV hair loss. We performed 3,509 grafts (1-1,047, 2-1,871, 3-535, 4-56 = 6,618 hairs). The patient returned at 9 months for followup with a much shorter hairstyle. Further thickening is expected over the next 3-6 months. The improvement can be tracked by comparing the location of the hairline in relation to the freckle on the upper right forehead.

This patient came to us in 2003 at the age of 26 and had type IV hair loss. Although not very apparent in the pre-op scanned photo, he had signs of miniaturization all the way to the crown. He was started on finasteride and we did 2.800 grafts to the front of the scalp. He sent us photos in 2004 and was very pleased. We did not hear from him again until 2010 when he came to see us for another transplant. He had stopped taking the finasteride several years prior and had begun losing hair slowly at first, but then more rapidly. He reported no side effects or problems with the finasteride, just that he had neglected to keep it going, not being sure how much he needed it. We performed another transplant: 3,278 FU's ( 1-889, 2-1624, 3-705, 4-60) covering his entire scalp, including crown. Photos are 15 months later. This case illustrates some important points, the first being the value of finasteride, and the importance of staying on it! The other point is that we try to plan our transplants in such a way that it will be relatively natural even if the patient stops finasteride. The transplant from 10 years ago held up relatively well and when he came in last year, virtually the only hair in the frontal scalp was in fact the transplants from 2003. It also shows the value of keeping hair in the donor bank for future use, especially for guys in their 20's, where future needs cannot always be accurately predicted. The first row of pictures shows the progression from 2003 to 2004, off finasteride in 2010, and post transplant 2011. The next pictures are of the pre-ops for the 2010 case and the next series are the 2011 pictures at 15 months.

It is complicated because there are many factors to consider including the patient's age, hair characteristics, current baldness, rate of hair loss, whether they are on finasteride, donor supply, etc. The goal is to produce not only a look that satisifies the patient in the short term, but also one that will stand up over time. It is best to be evaluated in person to get an individualized recommendation for you.

Thanks for the feedback. The area covered was 90 cm2 which included the entire thinning border of the baldspot. So the avg density was about 35/cm2 but certain areas would have been much higher, and the border areas would have been much lower. We don't generally graft at higher densities in the crown because it can consume alot of grafts and deplete the donor area, as well as having a higher chance of causing esthetic problems if the surrounding areas thin.

This patient consulted with us about his hair loss in the crown. He was happy with his frontal hair and did not want anything done to the hairline. We started finasteride and performed an FUT of 3,035 grafts (1-880, 2-1516, 3-649; 5,829 hairs). ACell was used in the grafting. Results are one year later. His hair is a little longer in the after photo and he had been on the finasteride, both of which likely contributed to a fuller look, but overall, it was judged to be an excellent result.

This patient underwent sex reassignment surgery (male to female) and wanted correction of a receding male hairline to appear more feminine. A procedure of FUT with 3,083 grafts (6, 015 hairs) was performed. Results are 18 months later. The patient was extremely pleased.

This patient has IVA hair loss, has typical Asian donor density of 70 FU/cm2, and desired the lowest hairline possible. Over two sessions, 4,426 grafts were transplanted (1=1279, 2=2163, 3=847, 4=137; total hairs= 8,694). Result is one year after last session. The patient wears his hair down, but is gelled up and parted to show the hairline and grafted area.

Jessie We graft areas with existing hair all the time. Shaving is a nice technique, but fewer than 5% of our patients are willing to do this. People are willing to take a week off to recover but expect to be almost undetectable at that point so they can go back to work. Grafting into existing hair requires special techniques including 1) taking time to make incisions using high magnification 2) tumescent anesthesia 3) control over size and depth of incisions. We still see some post procedure thinning from time to time but it is usually very mild in most cases. Using the ACell may trigger anagen growth in existing hair, so we actually see a little more shedding 3-4 months after the procedure but this is well worth it considering the robust regrowth and thickening of existing hair. Regards Dr Cooley

This patient had one previous small transplant. He was not on therapeutic doses of finasteride so there was ongoing loss. We performed 2,970 grafts (1-966, 2-1278, 3-693, 4-33; 5,733 hairs). We used ACell on the grafts and throughout the recipient area. He experienced thinning after the 3 month time point, suggesting a 'telogen effluvium', which is different than the typical shock loss which can occur after the procedure. We have seen this in other patients where we have used ACell on, and is followed by vigorous regrowth and excellent results. The after photos are taken at 15 months, and there was still some shorter hairs growing in and had not reached full length, so we anticipate continued thickening over the next few months. The growth was considered excellent, considering the above, and that the patient is not on therapeutic doses of finasteride. This patient has a blog at Hair Restoration Site for kiwicut.

Exactly.

This patient had undergone numerous mini-micrograft procedures in the past. There was some tufting and detectablility particularly at the hairline. Also, the hairline was too low in the corners. We performed FUT with a total of 2,690 grafts (1-601, 2-1485, 3-569, 4-35; 5,814 total hairs). We also thinned out some of the hairs below the new hairline using electolysis. Results are at 10 months. ACell was used on the grafts prior to implantation.

This woman in her 50's has classic female pattern hair loss. We performed an FUT procedure consisting of 2,203 grafts (1-664, 2-1006, 3-409, 4-124). Results are before, immediately post op, and 16 months later.

This patient has type IVA hair loss and was started on finasteride. We performed 3,760 FU grafts (1-935, 2-1,827, 3-758, 4-240) totalling 7,823 hairs. His hair is extremely fine which has the benefit of looking very natural when transplanted but requires more grafts to look full. ACell was used on the grafts, which we find makes growth more consistent and predictable. Photos are before, immediately post-op, and one year later.

This patient had received two prior transplants at other clinics in the past, with a total of 4000 grafts, but was not happy with the density he obtained. We performed 3,524 FU grafts (1-874, 2-1,632, 3-865, 4-153; total hairs 7,345). Photos show before and 13 months later, as well as immediate post op and 1 week post op.

This patient has IIIA pattern hair loss, with significant recession of the frontal-temporal hairline. He underwent 2,614 follicular unit grafts to create a conservative restoration (430-1, 1030-2, 782-3, 372-3; total hairs = 6324). Because of an unusually high amount of 3 and 4 hair grafts, his results are more like a 3,000 graft case.

Sorry for the confusion. This was a standard FUT strip procedure, in which we coated the FU grafts with ACell. In fact I did do about 50 plucked hairs to the frontal core, which are growing, but did not mention it because its hard to document these compared to the standard grafts. I'm accumulating the hair duplication (formerly known as 'autocloning') cases for presentation later this year when I can give a more accurate summary of my findings. In this case, neither all plucked or FUE would have been appropriate as the thin band of good hair would have been thinned to the point of creating a cosmetic problem in the months after the procedure. A strip on the other hand allowed her to easily hide the incision. I think that each procedure will have a place in the hair surgeon's armamentarium. Dr Cooley

This woman in her 70's is fairly typical of older females with hairloss. There is diffuse alopecia throughout her scalp except for a band of slightly denser hair in the lower border of her back and sides. Normally she would not be considered a good candidate for a hair transplant. We harvested the maximal amount we could, which yielded 2391 grafts with 4304 hairs to the entire frontal 2/3ds of her scalp (<25 grafts per cm2). ACell MatriStem was used on the grafts. She is shown at 7 months. This is better than I normally expect and I attribute this to the use of the ACell. Her donor hair is shown with comparison to a male with excellent quality donor hair. She is thrilled and scheduled another procedure. I believe that the benefits of ACell are most apparent on those patients with below average hair characteristics and low density grafting.

This 58 year old man has type V hair loss and was started on finasteride. He underwent 3,331 FUT including 1-772, 2-1605, 3-548, 4-406 (7250); many of the 3's and 4's were probably very close 1's and 2's, but with his curly fine hair, we opted to keep these together. Rather than provide light coverage to the entire crown, we transplanted medium densities only to the periphery of the crown and none in the very center. This creates a more natural look if he decides to not do anymore grafting for awhile.

This type IV patient consulted us about restoring a natural hairline, adding frontal density with some light coverage in the crown. He was started on finasteride. We performed 3,814 grafts (1-773, 2-1851, 3-984, 4-206 = 8251 hairs). Photos are one year post op.

This posting leaves out some important information. I was consulted by this patient to 1) improve the old donor scars from numerous procedures and 2) add hair to the front which was very thin despite all the work he’d had done. It was my understanding that these were equally important. I suggested FUT to fill in the front and described the new plucking procedure. Because it was so new and we did not have a clear idea of the success rate, there was no charge for the plucked grafts or use of ACell. The only fee was for 2,000 FUT grafts. This was not planned as a ‘one and done’ and there was discussion that multiple procedures would be necessary to fully correct his old donor scarring. No results were promised or guaranteed but I certainly did give him an optimistic assessment based on the early results I was seeing in other patients. Looking at the results: 1) Plucked beard grafts in old donor scars: The patient’s scalp had extensive wide donor scarring from old procedures. We performed about 600 plucked beard grafts throughout this area. I have not seen the patient in person but from the photographs it appears that virtually none of them grew. We have since learned that plucked grafts do not grow well in scars and that the wider and denser the scar tissue, the lower the success. I understand the disappointment and upset by the patient as I too am extremely disappointed by the failure of the plucked grafts to grow in scar tissue. Looking at the photographs, there appears to be an improvement in the texture of the old scars from the multiple recipient sites made and implantation of ACell coated grafts. I believe this will make the area even more receptive to FUE grafts in the future (see below). 2) New donor scars: The patient had minimal donor reserves and minimal scalp laxity. Yet he desperately needed some density in the front central region of his scalp. Despite all the work he’d had done, there was a lack of density which was the primary factor contributing to his balding look. I identified 3 areas which I thought we could harvest from. We were able to obtain over 2,000 FUs which we used to transplant the frontal core. Because all the good, safe areas of his donor area had already been harvested, I had to go to areas that I would normally avoid. I wrongly assumed that ACell would ensure scarless healing of these donor strip sites. Two of the three sites stretched due to their location and are now creating a cosmetic problem. I have since learned that ACell doesn’t prevent stretching of donor scars, but it does eliminate the thick, dense scar tissue that would normally result. The texture of these new “hairless gaps” is softer and feels like normal skin, according to the patient. I believe that these areas will be very receptive to FUE grafts. I take full responsibility for creating this result and have offered to fix it (see below). 3) FUT results: It seems unfair to judge this case without looking at the results of the grafting to the frontal scalp. The patient had already been committed to longer hair to cover all his old donor scars, yet this made the lack of hair in his frontal scalp even more apparent. From what I understand, the 2,000 FUs have grown in well, yet no before and afters are presented. Also, on top of everything, the patient had an unfortunate incident in the post op healing phase where a relative accidentally slammed the car trunk down on his grafted area, creating a full thickness laceration. I have offered to fix this as well. It’s easy to second guess in retrospect and question whether the patient should have had strip FUT. Yet, he desperately needed more hair in the front and it seemed like the best option at the time. Moving forward: 1) I believe that a combination of beard and scalp FUE will correct the two donor ‘scars’ I created. 2) Beard and scalp FUE will be even more effective in the old donor scars as a result of the area being ‘rejuvenated’ by wounding and ACell. 3) Plucked grafting should work well in his frontal scalp and to fix the area where he had the accident and to add some more density overall. I have been in communication with the patient for two months now and have repeatedly offered all of this at no charge. I sincerely hope the patient takes me up on it. I am as anxious as he is to see this turn out well. Dr Cooley

No plans at present. Since he is really quite satisfied with his current hairline, we are going to let it be for awhile.