Dr. Jerry Cooley

This 30 year old man has extensive baldness and was started on finasteride and minoxidil. A follicular unit transplant was performed in such a way as to provide maximum improvement while taking into consideration the possibility of future hair loss. 3,559 grafts were done, including: 1076 (1-hair), 1843 (2-hair), 623 (3-hair), 15 (4-hair) = 6,691 hairs. Only very light coverage was given to the crown. Results are one year post op.

This female in her 70's had fairly typical female pattern hair loss. She had been on finasteride and 2%minoxidil for years with apparent stabilization of her hair loss. The donor area was fairly typical of the females who come to see us: decent density in the mid-occipital (~75 FUs/cm2-first closeup photo) but rapidly deteriorating in the parietal zone (~60 FUs/cm2-second closeup photo). A FUT procedure was performed consisting of 1,832 grafts (1-599; 2-1101; 3-219; 4-13) yielding a total of 3,510 hairs. This was transplanted over an area of approximately 80cm2, giving a transplant density of less than 25 grafts/cm2. The crown was not transplanted. ACell MatriStem was applied to the grafts. Followup photos are at 15 months. In my opinion, the results are better than would be expected than without the use of ACell. We are sometimes asked about doing split scalp studies. In my opinion, this method works well for some studies (e.g. incision type, transection studies, holding solutions) but may not work well for ACell, because of the likely "field effect" produced. The stimulation of angiogenesis and recruitment of progenitor cells likely effects a much larger zone of the scalp due to the interconnected microcirculation. Nevertheless, it would be interesting to see the results of such a study.

This was a strip surgery.

This patient has stage VI loss and very fine, limp hair which contrasts with his very pale skin. On top of this, there is an unusual shape to his skull which magnifies the balding problem. We performed 4,768 FUs (1= 1,431; 2= 2,307; 3=987; 4=43; total hairs= 9,089). The result is one year from the date of surgery. He plans to return soon to graft the crown and add some density to the front.

Hi All I just want to clarify some things. We certainly don't experiment on people without their consent. We do mention ACell when it is used, but we did not emphasize it in this case and it was not part of the controlled studies we did. We had to take a second strip simply because the first strip did not yield our target grafts. By the time we did this case, I had enough experience with ACell to know that it would provide a modest benefit to the result, not changing the overall look, but ehancing the feel by reducing fibrotic scar tissue under the surface. It was not used on the grafts in this case. In my opinion, the problem came in with the running subcutaneous suture. Over the years, my strips have gotten wider as we're doing larger cases (3,000-4,000 vs 1,500-2,500) and I'm always on the lookout for ways to optimize the results and reduce closing tension. A couple of years ago, many of my colleagues were recommending a type of subcutaneous stitch where the stitch runs continuously from one end to the other. When I tried this, the immediate effect was outstanding: it brought the edges together nicely and made the surface suturing easier. Unfortunately, I found that in my hands, the long term results were on average worse than my 'tried and true' interrupted subcutaneous sutures. My feeling is that the running subcutaneous stitch holds the tissue too tight and does not allow the wound to 'breathe' (ie restricts blood flow to the edges) which explains the scars. Interestingly, at our recent conference, a well known surgeon from a respected clinic was telling me about a complication he had with necrosis all along the donor wound. I asked him if he used the running subcutaneous suture, and he replied, "yah, how did you know?" Also, its important to keep in mind that even with the ideal closure technique, some people just heal better than others, and no one can exactly predict how well the scar will look. A trichophytic closure will make the scar look better only if there is adequate blood flow and not too much tension. I always aim for the best results in every patient, and when there are problems, I offer to fix them. Regards Dr Cooley

This young man was in his mid 20's and had evolving type IV hair loss. The donor area had below average hair counts, with alot of 1 and 2 hair follicular units. Finasteride was prescribed and a long term hair restoration plan was made that was based on the possibility of future hair loss. No attempt was made to super dense pack any area but more grafts were concentrated in the front center. 3,606 follicular units by the strip method was grafted, and this included 1s-1,521, 2s-1,690, and 3s-395; this yields an average hair/graft of 1.69, which is below average. Nevertheless, results were good and the patient is very pleased.

This patient underwent FUT with over 2,000 follicular unit grafts. The results are one year after the surgery. Photo 7 shows the scalp after the sites have been made, and photo 8 is taken after the grafts have been placed. Photo 9 shows closeup of the hairline. Photo 10 shows the donor scar.

This patient has type IVA hair loss and had a history of older minigrafts about 10 years ago. We performed 3,168 FU's (6,177 hairs). He came in for a 6 month check and showed good growth. This should continue to thicken up over the next 6 months. Some patients show slower growth but end up with excellent results as well so I try to get patients not to worry too much if they are "late bloomers". The photo taken immediately after the graft placement shows a purplish color because of the dye we sometimes use in darker skinned patients to stain the sites.

Hair loss made this young man look much older than his age. He was started on finasteride and received 3,639 FUs (861-1, 1717-2, 988-3, 73-4), total hair = 7,551. We generally try to create only light coverage in the crown in men in their 30's in order to avoid consuming too many grafts and creating problems should hair loss progress.

This patient has grade II Female Pattern Hair loss. She was started on 5% minoxidil and underwent 3,148 FUT to the front/central scalp, using small needle slits to avoid damaging existing hair (the recipient area was not shaved). The grafts were treated with ACell MatriStem as well. The results are shown at 10 months. To what extent minoxidil or ACell contributed to the result is difficult to say.

Future HTdoc: That's a question I'm asked alot. I do not at this time use PRP as a stand alone treatment for MPB because I want to see more studies first. I believe that PRP reliably effects the healing of HT surgery but in my hands the effect on final outcome is less predictable. My use of PRP got put on hold as I began researching Acell and ATP, which I will be reporting on later this year. As a medical student, you are welcome to attend our conferences. This year our annual ISHRS scientific meeting is in Boston Oct 20-24. Hope you can make it.

In the final seven photos, the time points are: pre-op, immediate post-op, 7 days, 11 days, 6 weeks, 4 months, 14 months.

This patient had an unusual balding pattern, with severe R>L asymmetry. Most patients have more recession on the right side but I have never seen it to this degree. He signed up for 2,000 grafts (as finances were an issue for the patient as well as a fear of damaging existing hair with too many grafts). To promote healing, Platelet Rich Plasma was incorporated into the procedure. 2,270 FUTs were transplanted (4,837 hairs). Followup photos were taken periodically, including the last photo at 14 months.

Patient with Type V hair loss, very fine hair wants frontal coverage with some blending into the crown. Received 3,810 FUs (7,620 hairs). Returned at 6.5 months for followup. Had early growth, more tpical of 8-9 months. Results will continue to improve and blend in with existing hair.

No, the grafts were concentrated in the front center and blended outwards so that should further hair loss occur, it would still look natural. I put him on finasteride to inhibit further hair loss.

This patient has diffuse patterned alopecia with excellent donor hair. He underwent 3,458 grafts (8,080 hairs) and the results are shown 13 months later. We did not shave his recipient area because, like most of our patients, he planned on being back at work in a week and simply would never have had a transplant if he had to shave. We will shave if the patient doesn't care. His donor scar, done with trichophytic technique, was virtually undetectable. Not all patients get this kind of result.

This older gentleman had plugs done 30 years previously and employed a combover to hide them. He underwent one FUT session of 3343 grafts (1-1116, 2-1725, 3-470, 4-32) and many of the plugs were cored out. As often happens, some of the hair in the old plugs regrew. When the patient returns, we will add some hair to the crown and temples, as well as remove what remains of the old plugs.

This man had a transplant about 10 years prior. The result was an abnormal V-shaped hairline, noticeable plugging, and a wide donor scar placed too low. He had a very tight scalp and somewhat below average density (75 FU/cm2) and the most that could be safely harvested was 3,272 FUs (1=811, 2=1406, 3=904, 4=151). The hairline was corrected to produce a more natural shape. About 70 grafts were placed into the old donor scar and many of the old plugs were cored out and recycled. He plans to do another session to give some crown coverage.

This woman was in her mid 60's and had typical female pattern hair loss. As expected, the donor reserves were limited: there was a patch of good quality hair in the back/center of the scalp, but the quality and density deteriorated significantly moving forward. Therefore, only a limited restoration was possible. Results are 16 months after 1,517 grafts (3,741 hairs) to the frontal scalp. The area covered was around 80 cm2 so the density overall was less than 20 grafts/cm, which generally is quite low. However, the density in certain areas was higher (mid frontal) than others (eg temporal hairline), so the overall effect was acceptable improvement, particularly with careful styling. Now that the laxity has returned, she plans to have one more procedure to add some density. This case is fairly typical for my older females with female pattern hair loss.

He is in his 40's. I did a final strip, getting about 600 grafts and the scalp is about tapped out for further strips because of all the prior transplants and scalp reductions. His only options now are FUE (possibly body hair) and the plucking if it works out.

When I say cautionary tale, I mean that I hope young men learn from this case when considering a transplant. Of course routine scalp reductions and plugs at the hair line are a thing of the past, so no one starting out today will have to undergo the extent of repair this patient did. I didn't really go into it, but he had to have plugs cut out and laser work, as well as numerous 'fill in' grafting sessions over the years. As natural as today's grafting is, it should always be done in light of the possibility of future hair loss. For this reason, I usually try to keep a reasonable amount of donor hair in the bank for possible future use, rather than always trying to harvest to the max. Thanks for all the feedback. I rarely do FUE, mostly for repairing donor scars. I am doing research with plucked hair as a source of donor grafts, with some encouraging results. If this research works out, we'll have a viable alternative to FUE in the future.

This is beautiful work by Dr Reed. The quality of the work is evident by the clean post-op look and the excellent growth at six months; it will look even better at a year. Its always amazing to me how a relatively small number of grafts can dramatically improve a man's appearance.

Thanks for the feedback. Scalp reductions aren't done today for regular pattern baldness for several reasons: 1) the scar down the center of the scalp 2) it causes decreased hair density and thinned skin down the sides of the scalp 3) it causes a problem in the back of the scalp called a 'slot' that is hard to correct 4) looks like it helps at first but the benefits disappear due to stretchback. When I trained in the early 90's, scalp reductions were still common and I'm glad I learned how to do it. I still use it for repair work, such as on people who have had traumatic scarring, see http://hair-restoration-info.c...071091493#7071091493. I don't know any of the details on the prior transplants but suspect most of them were quite small, otherwise there is no way I could have still harvested 2000 grafts. This case is a cautionary tale, showing the long term problems of doing hair transplants on a young man without thought for future hair loss.

This patient had numerous procedures in the past including 3 scalp reductions and at least 10 transplants (the patient couldn't remember for sure). I estimated we could get about 2000 grafts to work with from the sides of the donor area. The most pressing need was to bring the temples out to match the low, transplanted frontal hairline. The frontal hairline had already been set too low and raising it was not an option. A session of 2,089 FUT grafts was performed (3462 hairs), resulting in a better balancing of the frontal and temple hair lines. The after photos were taken at the time of a second smaller touch up procedure.

This patient has type V hair loss. Assessment of the donor area showed slightly below average density and significantly below average hairs/follicular unit. Typically we see 1.8 - 2.0 hairs per graft but in this patient, the average was 1.5 hairs per graft. So despite getting over 4500 grafts, his total hair count was more in line with what a 3500 graft session would yield. In addition, he wanted some coverage in the crown, knowing this would take away from overall density. His photos are nine months after one session of 4516 grafts (2448-1s, 1827-2s, 241-3s). He plans to do another surgery soon. He started a blog at http://www.hairtransplantnetwo...-page.asp?WebID=1009.