Dr. William Parsley

48 y/o WM with NW6 pattern transplanted with 4,000 FUT grafts. Results at 15 months.

55 y/o WM with history of mini-grafts in the past wants more thickness but mainly to hide the plugginess. One session of 1,100 FU grafts via strip were placed. Results are at 9 months but patient would benefit from a second session. He had moderate scarring from earlier transplants, so dense packing was not done.

48 y/o WM first presented as a NW VI. At that time I felt he was a borderline candidate for hair restoration due to his extensive loss. However, he had an impressive improvement with the medical treatment of finasteride, minoxidil, Head & Shoulders/ Nizoral shampoo. A single transplant was performed over the top of the scalp with a predominance of grafts going to the frontal zone. Results at 6 months. Would like to do a 2nd session to give it more fullness.

This 67 y/o NW 6-7 male had 2 sessions of FUT grafts (4500 total) 8 months apart. He had reasonably good donor hair but lessened by retrograde hair loss in the lower occiput. Results are shown at 18 months.

50 y/o WM with a 15 year history of progressive baldness, treated by follicular unit strip harvesting with 4,000 grafts. Follow up at 2 years.

It is hard to tell how much more progress will occur. I'm guessing another 20% over the next 5 months.

Agree. Hair characteristics are key for all good results and need to be seriously considered during consultation and accepting patients for surgery.

42 y/o caucasian male had hair loss primarily of the frontal zone which was transplanted with one session of 1800 FUT grafts. Results are at 7 months.

Pt is a 52 y/o caucasian male with one FUT session of 2700 grafts. Results are at one year.

The patient is a 10 y/o girl who had surgery followed by irradiation for a brain tumor. The treatment went well but she was left with a significant amount of alopecia. She was wearing a hair piece at the time of her first visit, but her classmates teased her and tried to pull off her hair piece. She had a very limited amount of donor but we were able to get out 3,000 grafts over 3 sessions. While she was much improved, it still looked quite thin. We then demonstrated Toppik with a little Fullmore spray (pictures 5 & 6) allowing her to go out without the hairpiece and without being to self conscious. This case demonstrates the need to use everything at your disposal at times.

Patient is a 32 y/o WM with one session of 1800 FUT grafts to the frontal half of his scalp. Follow up is at 23 months.

80 y/o caucasian female lost her lower temples during facelift surgery. A total of 600 FU grafts by FUT were used to repair these zones. Results at 3 years post op.

This 53 y/o WM is a NW6 and has reasonably good donor density. The grafts were placed in one session and the results posted are at 10 months.

Excellent work with great attention to the little details that give a natural result.

The patient is a 38 y/o caucasian male 7 months postop 3,500 FUT grafts to the frontal half of the scalp. Hasn't reached its full maturity yet but is still giving good coverage.

Dr. Parsley,

 

Yet another of your patient's has received a huge improvement with a small number of grafts. Well done!

 

Has he reached is hair restoration goals or is he planning a second pass for added density?

He is happy at present. The density could be improved with a second session but I am not pressing for it as the improvement would be limited and at his young age I feel it is advantageous to conserve his donor for the future.

36 y/o male NW 4 was transplanted into the frontal zone with 1350 FUT grafts.

45 y/o male presented 7 yrs ago with rapid generalized thinning of the hair on the top of his scalp. Finasteride and minoxidil were recommended but at that time were more expensive and never used. 4 yrs ago he returned with a surprisingly rapid loss of his hair. Finasteride and minoxidil were started (and used this time) followed by 2,000 FUT grafts to the frontal half of his scalp. The back of his scalp was responding nicely to meds and were not transplanted at the time. The donor site was repaired with a double layered trichophytic closure.

Nearly every patient I see has some degree of miniaturization in the donor area. I look for coverage that the donor hair is giving and I also look for the number of follicles in each follicular unit. If there are a predominance of 1 and 2 hair FUs, then that is beyond miniaturization and goes into actual loss of hair. I don't transplant these patients.

I expect the donor hair to weaken with age as it will with all patients. HRS doctors generally try to transplant with the worst case scenario on our patients as we can't predict confidently the ultimate hair loss on our patients.

The age of the patient when starting hair restoration is critical- in design and also in final outcome. But there are no guarantees at any age, particularly young patients.

Dr. Parsley,

 

Thank you for responding. I'm certain that you did a thorough examination of this patient before agreeing to perform surgery on him, and that you made the decision to operate only after careful consideration. I'm not trying to impugn your credibility or throw you under the bus here with these questions, I'm just curious.

 

Isn't the fact that this patient is already showing some signs of donor site problems a big red flag? Granted, it may not be severe (yet), but how is it that you can be confident that his donor site won't turn into a bigger problem in 10 or 20 years? Perhaps my own observations have clouded my judgment, but I look at my own dad who had MUCH more hair than many people I see getting transplants on this site at comparable ages, and yet at age 60 he is still losing hair and he is almost a NW 7. Obviously I don't know what his hair looked like upon magnification, but I can see that when he was 40, he had more hair than this gentleman.

 

Should I take from this patient that at age 40 it is possible to accurately predict the extent to which a man will bald? Or, was this transplant done not knowing the future, but planning for a worst case scenario of NW 7?

TC17

Good question. This fellow has some miniaturization but most of the follicles are terminal follicles and he has a predominance of multi-haired grafts. When deciding on surgery, I look at the occipital and parietal zones to determine the coverage. If see-through, then he is not a candidate. If I think I can remove 50% of this hair without cosmetic problems, then he might be a candidate. I also look at the total area of the good donor zone, look for retrograde hair loss and possible future extension of loss into the occipital zone and the parietal humps. I don't want to do a transplant that has an expiration date.

For this patient the design is conservative- relatively high hair line and transplanting only into the frontal zone, midscalp and parietal humps. I feel he has enough donor hair to accomplish this task. No doubt his hair will thin with age- as will all of our patients- but I feel his hair design will continue to be a positive.

Let me know if this answers your question. Thanks.

The patient is a 40y/o white male with less than average density in the donor area. Attached picture shows a 5x5mm area of the donor strip preop, revealing less than 70 follicular units/cm2, also showing some miniaturization. Hairline and planted density were conservative to preserve donor supplies.

48 y/o caucasian male before and after 1400 grafts to frontal scalp. Follow up is at 7 years.

The brand of ketoconazole shampoo is Nizoral 1%. The brand of pyrithione zinc is Head and Shoulders 1%. Both can be purchased at pharmacies or grocery stores over the counter. These are the only shampoos of which I am aware with studies showing hair growth. Even so I think they are not strong hair re-growers (the combo of finasteride and minoxidil is much more important). They have in common that they kill Malassezia Globosa, a spore that lives in the upper hair follicles of nearly all adults and feed on the sebum. This makes the sebum more and more acidic, which is irritating and a major factor in dandruff. I generally have my patients alternate their use on a daily basis but some use both at the same shampooing. In addition to killing the spores, ketoconazole might block DHT at the follicle receptor. Zinc has the ability to increase vascularity.

I particularly like patients to pretreat their scalps with these shampoos before surgery as I don't want 3,000 blade/needle sticks causing acid oil to spill into the tissues.

I used 5mg Proscar on this patient, divided into quarters for a dose of 1.25mg daily. I Recently I have been more commonly using Propecia 1mg divided into quarters (0.25mg daily). It reduces side effects and seems to work just as well.

Pt is a NW4 with rapidly developing hair loss, taking him toward a NW6. Pt is in his late 30's. There was abundant miniaturized hair in the frontal and midscalp. My feeling was that this case required medical treatment before considering surgery- and that surgery might not be required at this time if the response was good. His treament consisted of finasteride 1.25mg daily, minoxidil foam 2x daily, ketoconazole shampoo and pyrithione zinc shampoo. Happily, he had a great response showing that surgery is not always the only or best option. he still has a little thinness over the vertex but it is cosmetically acceptable. I usually don't like to transplant the vertex until the patients is 45 years old and has enough donor to adequately treat any future hair loss.

It was interesting to see that Dr. Brad Limmer just posted a case, showing that medical treatment can be impressive in good candidates. It should be noted that I have had equally impressive results with 0.25mg of finasteride daily.

50 y/o WM with vertex pattern of hair loss. 1850 FU grafts were transplanted in a single session. Before and after pics at 7 months are presented. Also presented is a presurgical macro photo of his donor zone. The circle is 8mm in diameter and encloses 0.5 square cm. I measured him at 80FUs/cm2. We like to see closer to 100FUs/cm2; however, he has mostly multi-hair FUs with good hair diameter.