Dr. Timothy Carman

Complains of Frontal Forelock Thinning!! 😉

45 yo male c/o FF thinning with loss of hairline and central crown over last 20 years. No significant medical history. No medications. Donor: average laxity with 70 FU/cm2. Linear strip excision surgery, strip 24 x 1.3 cm. 1936 total FU's: 606 one's; 753 two's; 577 three's. Reconstruction goal: creation of natural-appearing, age appropriate hairline with frontal forelock density and softening of crown thinning. High quality strip excision to produce consistently robust FU grafts which ensure the quality growth potential of the donor hair.

The challenge with this patient was a relatively low yielding donor and large area "needing" grafts. Appropriate placement of grafts in a design pattern that will mimic nature, while maximizing their full potential for growth as non-DHT-sensitive follicular units is a cornerstone in creating artwork that appears natural. 2291 FU grafts were harvested via a conservative strip excision procedure, which assures consistent high quality graft survival and growth for the long-term performance benchmark. The photos are from his 9 Month Post Op visit, wherein approximately 80% of the hair has grown in.

This patient is a 54 YO male who presented with stabilized crown thinning, not on preventative medical therapy. Plan is to reconstruct the crown and add some density to the posterior midscalp. Total FU Grafts: 1576: 285 one's; 954 two's; 337 three's. Last two photos illustrate typical donor closure result utilizing simple plastics closure.

Thank you!!!

History: This patient is a pleasant 29 year old male who experienced thinning of his fronto-temporal hairline since the age of 20. He is generally very healthy, with no medical history or previous surgeries. He has become progressively more and more pre-occupied with his hair loss as it has affected his self-esteem, limiting his social activities. The frontal thinning becomes especially apparent after exercise, as the thinning becomes more noticeable when his hair is wet. His family history is significant for fronto-temporal thinning in a similar pattern in his father, 64, that has progressed about midway into his midscalp, with no apparent crown involvement. The patient has decided that he does not want to utilize finasteride as a medical therapy now or in the foreseeable future. Physical Exam: The patient has brownish-blonde (“dirty-blonde”) colored hair with strands of medium thickness that has a mild curl at lengths greater than 4- 5 cm. He presented with total loss of the fronto-temporal hairline and frontal forelock area, and significant loss of density (due to miniaturization) in the anterior midscalp area. His donor area showed a density of 80-90 follicular units per square cm, which is considered average. Based on the anticipation of future losses, a “conservative” hair line was designed. (A “conservative” hairline is one which has some bilateral recession built into it; it is a design that is “forward-looking”, in that it will age with the patient and conserve grafts for use later on down the road for other areas that may thin.) We planned to rebuild the frontal forelock area and the anterior midscalp as well. Our plan was centered around 1800 FU grafts. Procedure: On the morning of the procedure, our surgical plan was revisited, and the hairline was drawn according to the surgical design which was discussed with the surgeon in detail during the initial consult on his previous vist. The safe donor area was then identified, and the appropriate length and height of the strip determined based on the number of follicular units (which will become our “Grafts”) decided upon previously. In most all cases, the hair is preferably left at a length of an inch or more, as the hair will completely cover the area where the donor was removed following excision. The strip is typically about one to one and a half centimeters in height, (about1/2 inch) and it’s length dependant on the number of grafts needed. In this case the length was 15 centimeters (about six inches). The patient is sitting upright in the surgical chair, and small amounts of lidocaine are instilled in a circle around the patients head. This takes about two minutes, and is the “uncomfortable” part of the procedure due to the slight burning of the medication. Once completed, the entire donor area as well as the area to be transplanted is completely numb. The donor was then removed, and a plastic surgery style closure was utilized to create a very minimal appearance upon healing. The typical donor scar result we obtain in our practice is shown in the last photo. The donor site is then placed in the care of the surgical team that will create the 1, 2 and 3 hair grafts from the naturally occurring 1, 2 and 3 hair follicular units, by dissecting them under direct visualization utilizing microscopes. During this time, the patient was placed in the reclining position to enjoy a movie, music, or simply snooze. While the grafts are being prepared, the recipient sites were created, by hand, by the surgeon. This step is essentially sculpting, and an eye for artistic detail is critical. Angulation of the sites, dispersal of the various types of grafts, and varying density are all elements the surgeon addresses in order to create a natural, organic pattern which will be undetectable as manmade. At La Jolla Hair Restoration Medical Center, all blades utilized for this step are created on the spot to specifically fit the individual tissue characteristics of the specific patient on the day of surgery. Creation of sites should only be performed by the surgeon. Following this, the grafts were placed by three members of the surgical team, in order to decrease the “out-of the-body” time of the grafts. The procedure took about 7 ? hours total. Results: A total of 1829 FU grafts were obtained as follows; 743 one hair grafts (utilized as the leading edge of the hairline); 1086 two and three hair grafts (to add density behind the hairline and in the midscalp area). The result shown is at the 9 month mark. At this stage there is typically about 80% growth seen, so there will be some additional subtle filling in over the next 3- 4 months. Discussion: This case illustrates several points. Most importantly, the planning which needs to go into the surgical design. There is a limit to the amount of donor all patients have over their lifetime, and in a young patient it is critical they understand how this fact directly affects the artwork that can be accomplished according to the surgical design. This is why in our practice philosophy at LJHR it is critical that the surgeon perform the surgical consult in detail well in advance of the procedure, as the surgical design is the blueprint upon which the current and future procedures will be built. This is also in line with standard of care practices in Plastic as well as General Surgery. The case also illustrates the typical close cooperation between the surgeon and surgical assistants; experience and ethical standards are the cornerstone of a successful practice, and this, in our opinion, can only be found most consistently in practices dedicated solely to the practice of treating hairloss via transplantation and other adjunctive medical and surgical therapies. As with all hair transplant procedures, this case also illustrates the artistic nature of the process. To me, as a surgeon, the creation of the sites is an absolute pleasure, and as an artist there is no detail too small, especially when it comes to making custom-sized surgical blades specific for each patient. This is often overlooked in many practices, as utilizing commercially made blades which are available are the norm. I borrowed this concept from my habits as an oil painter. I create my own brushes for detailed work- and have done so for decades. It allows me to address the specific needs of the project I am working on at that time. In hair transplant, although there are generalities across all patients that provide the “basics” of the hair transplant procedure (observing these makes for consistent results), there are details specific to each patient that makes each case unique. It is the recognition of those details and addressing them that elevates the procedure from one of rote repetition to one of true artwork. Hence, my preference for making custom blades for each patient. The patient presented here, through a successful transplant procedure, has regained his confidence and self-esteem as a result of the surgical team’s dedicated and conscientious work. There is no greater reward than being able to contribute to an improvement in the quality of life of our patients, and this patient, as with all our patients, illustrates this last point as very well.

This patient is a 36 year old male with loss of definition of the frontal hairline and frontal forelock density. Our plan was to recreate a delicate, healthy appearing hairline that will stand the test of time as he continues to lose subsequent hair due to MPHL. His FU grafts were harvested by strip so as to guarantee long lasting, natural results. His donor scar, which is shown in the last photo, shows typical results of conservative surgical plastic closure technique.

This gentleman is a 54 YO male with MPHL affecting his frontal hairline, frontal forelock, midscalp and crown area. His donor area presented a challenge as his donor reserves are less than most men due to a tight scalp and low density of FU's. Average density in most men's donor is about 85-90 FU/cm2. This patient has a density of about 65-70.cm2. It is especially important in cases where donor numbers are low to not "dilute" the effect of the grafting by trying to spread the available supply over too large an area. This is a challenge when that recipient area is large. This case shows the critical need for healthy transplanted hair growth in creating a natural result, despite low donor yield. Note the typical donor scar which again, is a non-issue when keeping hair a cm or longer in the donor.

Patient is a pleasant 64 yo male who presents with thinning and temporal recession of the hair line as well as midscalp and crown thinning. Patient underwent traditional strip donor harvest which yielded 2745 FU grafts. He presents at 14 months post op very happy with his result. Note the last couple of photos which demonstrate the very minimal effect a properly planned and executed strip donor harvest can and should achieve.

Thank you all for your kind words of appreciation for our team's hard work!!!

Patient is a 25 YO male experiencing MPHL affecting the frontal hair line. A conservative hairline was recreated utilizing 1498 FU grafts obtained from a conservative donor strip closed utilizing time-honored plastic surgery closure technique. Donor scar appearance is shown at the 14 month post op mark.

This patient is a 32 YO male who experienced loss of definition of the frontal hairline which is consistent with his fathers pattern. There is no family history nor clinical evidence in this patient of crown thinning. Two procedures of 1601 FU grafts and 1609 FU grafts were performed a year apart, to obtain the final hairline shape, location and density. Graft design pattern and robust long term growth were achieved from conservative donor strip harvest, leaving the cosmetic quality in the donor virtually unchanged.

Countinghair- As Harin says, waaaay too early to see anything except the way your scalp looked prior to the transplant. All the hair fibers have been ejected, the follicles are resting, and only a few will begin growing at about month 3 post procedure, then a few more at month 4, etc etc, until roughly only about 50-60% have started to grow at the end of month six. We tell our patients to wait until about 14 months to assess the overall results, as the last group of transplanted follicles that just begin to grow at post op month 12 need a couple of months to gain length and mature. Hope this is helpful.

NewHare- Scar revision can be successful, but that success is individualized and also very dependent upon how many previous procedures have been performed. That option should be available in any State of the Art surgical practice, given an experienced surgeon. As for the trychophytic closure, IMHO that closure was more of a trend to address poor technique which characterized well-intentioned but less than Standard of Care donor closures. Adherence to sound plastic surgery techniques when harvesting and especially closing the donor area virtually eliminates the need for any type of tricophytic manipulation. Whats more, with short, straight hair, the tricophytic method can leave a tell-tale pattern in the hair as hairs along the incision are angled in an unnatural direction due to the mechanics and geometry of hair growth through the scar tissue. I hope this is helpful.

Patient is a 26 yo male with MPHL manifested as a loss of frontal hairline, frontal forelock, crown and midscalp density. The hairline was recreated in a conservative design, frontal forelock and midscalp density were addressed, and the crown underwent a conservative reconstruction. Total FU grafts used: 3092. Donor and graft quality preserved using "FUT" excision.

Transhair- In general, folliculitis as a clinical entity generally will occur over a larger area of grafts. There is a band of erythema (redness) along the hairline which is suspicious, yet the singular area depicted appears isolated to some extent. These singular localized infections typically respond to warm moist compresses for resolution. Never squeeze those puppies!. If there is a global folliculitis present, that would be an indication for antibiotic treatment. Your surgeon is the best judge, of course.

Very nice result, especially at this early stage!!!!

Pavan- You are headed for a good degree of loss as your MPHL progresses; Propecia and Rogaine are good choices to address this issue. The reality of any procedure is that the artwork must respect the amount of grafts your donor will provide in the hands of a conservative, forward (looking toward and considering the future) thinking surgeon. The ultimate question of "how many grafts do I need?" must be tempered with the realities of working with tissue in a manner that reproduces consistent, reproducible natural looking results. Numbers are important, and more hair is always good, yet numbers need to take a back seat (IMHO) to the overall goals of good and appropriate tissue management plan geared to the ultimate goal of judicious use of the patients precious and limited donor supply. That said, your donor appears average, and most patients (assuming average density, head size, and tissue laxity) in your situation have anywhere from 2500-3000 FU available at any one time. I hope this is helpful. Dr Carman

Hi Johnboy. This patient, specifically because of his low donor density would be a poor candidate for FUE in our opinion. The use of that technique in this patient would have led to a cosmetically significant thinning of the donor area, creating a new "hair problem" to satisfy his presenting one. Also, because in general FUE grafts grow with less hair mass than grafts made from a strip, that would cosmetically affect the transplanted area as well. In hair transplant surgery, there are many factors the surgeon should consider, and with the overall goal being a natural, undetectable (as man-made) result, one must weigh many factors carefully for the patients benefit. Thank you for taking the time to chime in!!

This patient is a 62 YO male who presented with loss of frontal hair line and frontal forelock density. His donor had lower than usual density, about 60 FU/cm2 (vs average of 90 FU/cm2). This resulted in a donor yield of approx 1900 FU grafts. Patient returns at about 15 months post op very happy with the improvement. Note the last photo which demonstrates the typical donor scar from a strip excision when conservative, plastic surgical techniques are employed as standard procedure.

Patient is a 42 yo male who presents with an advanced degree of MPHL. Patient had thinning of the HL/FF/Midscalp and crown early in life with stabilization over last ten years without medications. Total 3757 FU total.

Patient is a male in his late twenties who has been slowly thinning due to Androgenic Alopecia affecting his hairline, frontal forelock, midscalp and bilateral temporal points in a Norwood 5 pattern since his early twenties. He has mild crown involvement as well. Understanding he will continue to have further losses, he understands the need to manage his limited donor in such a fashion that initial transplantation occurs in a limited area which can be addressed in the future without fear that grafts are spread out over too large an area, which would result in a "grafty" appearance later on in life. At one year post-op, the qualitative change in the appearance of his hair in terms of hair shaft caliber, distribution, shine and coverage are greatly improved over the pre-op baseline. The conservative hairline will work well into his 50's and 60's, and precious donor graft reserves have not been squandered on an unnecessarily dense frontal hairline, freeing those reserves for the midscalp and anterior crown as needed as he ages. The last photo illustrates the 1 mm donor scar which should be the normal expected result using conservative, state of the art surgical technique. 2200 Total FU grafts.

This 42 yo male experienced extensive balding through his twenties and thirties, yet was blessed with a very good donor density. 3088 total FU grafts.

Patient is a 33 yo male with very mild recession of the hairline and crown area. His family history is similar on his fathers side, with no hair loss history on his mothers side. Patient has had this condition which has stabilized since about 26 years of age. Our goal was to recreate a very subtle change in his frontal hairline, as well as address the minor thinning in the crown which was a concern to him as well. A total of 1617 FU grafts were obtained via strip excision; 730 one's; 779 two's; and 108 three's. A photo of the donor incision is included to illustrate the type of donor scar which should be most anticipated in the great majority of patients, given the current state of the art techniques we as Hair Transplant Surgeons utilize when performing conservative surgical methods.

Delancey: Strip donor harvest.