Dr. Timothy Carman

Philitron- Welcome to the HTN!! Although there are treatments in acupuncture that address the energy systems related to hair growth, I have seen no credible evidence that acupuncture alone can regrow lost or thinning hair. Acupuncture, in as much as it contributes to overall health and balance, can help to keep your scalp/hair healthy in general however. Good choice utilizing the medical options (Propecia)- this certainly will help in slowing or halting the process. Perhaps you could upload some photos so the members of the forum may help you better. Timothy Carman, MD

HTGT- You can expect the wound to be tender to palpation thru the first 7-10 days. After that, the discomfort should subside- especially following suture removal. So yes, this would appear normal. BTW, sutures or staples? (Staples tend to be more uncomfortable than sutures..) Timothy Carman, MD

HTGT- Following the initial 14 days, wherein you can use neosporin to keep the wound moist, after this just a light coating of vaseline or Aquaphor once a day should be fine. The saline spray is fine, that just seems like a bit of work compared with a once daily app of the above- Timothy Carman, MD

Dewayne- I read the link posted- Wound healing is actually a very interesting process that can be broken down into overlapping stages that occur initially in the first 14 days following wound creation. (Specifically 1.Tissue injury phase; 2)Coagulation phase; 3)Early inflammation phase; 4)Late Inflammation phase; 5)Fibroblst Migration/Collagen Synthesis; 6)Angiogenesis; 7)Epithelialization; and 8)The Remodeling Phase.) Those processes stabilize at around day 14, but the "remodeling phase" continues thru the next 6-12 months as the synthesis and breakdown of collagen within the wound. Interestingly enough, the ultimate goal of all these processes is to actually shrink the size and appearance of the scar. Since the normal process of scar formation is dependent upon the body's ability to organize a complex matrix of organized tissue, and the end goal is an eventual reduction of visible scar, I would suggest that scar massage PRIOR to the completion of this process may just interfere with this organizational process, leading to a poorer cosmetic result. Again, unless the individual patient suffers from unusual wound healing processes, such as hypertrophic or keloid formation, wounds are best left to "do their thing" as it were, though it is generally accepted that keeping the wound moist hastens epithelialization of the wound and therefore may contribute to a better cosmetic outcome. Good question. Hope that helps. Timothy Carman, MD

Ah yes, the power of Van Halen!!

More_Hair- Thank you for the complement. Yes, I will be posting patient progress/updates on all cases presented. I liked the idea of showing forum members examples from the start; I think it allows for a better understanding of the entire process one might expect to go through should they elect to go ahead and have their own hair restoration procedure. Timothy Carman, MD

You're welcome!!

HTGT; Neosporin is an antibacterial agent that helps promote healing in the first 10 to 14 days by decreasing the bacterial counts along the suture line. Mederma is a topical agent whose active ingredient is Allium cepa, or onion extract. The facts are as follows: Scars form on the skin through a three-stage process and this process can last up to two years after an injury. Many scientists are studying this wound-healing process in an attempt to find something that will make scars less visible. It is widely recognized that wounds heal best under moist conditions -- the skin fills in faster and scars are less visible. In 2001, a study showed that onion extract used on rabbit ear scars improved collagen organization but didn't lead to a difference in scar appearance. So far, there have been three major controlled clinical studies in the United States evaluating the effect of onion extract on human wound healing. In all three, scars treated with onion extract did not show any improvement compared to scars treated with petroleum jelly. In fact, scars treated with petroleum jelly improved better than those treated with onion extract. Here is an abstract of that reference: http://www.ncbi.nlm.nih.gov/pubmed/12087249 In general, keeping the donor incision site moist following the initial 10-14 days should be all that is necessary, if anything at all. The issue of "hypertrophic scar" development is a separate matter; usually a patient will know if their wound healing will have this tendency from previous wounds/scars. In that case, use of steroid injections into the scar by your physician can help decrease this process. To summarize then; in general, unless you have other underlying medical conditions that would affect wound healing, your wound should heal without any special treatment on your part. Sincerely, Timothy Carman, MD

Johnson- I am familiar with fluridil. Without going into too great a detail, this preparation acts TOPICALLY to inhibit the effects of DHT on the hair follicle. Current studies show that, similar to finasteride, there is an increase in the total percentage of hair in the active (vs resting) stage (from 76% to 87% at nine months.). I happen to personally know the clinical investigators (Dr. M Sovak, UCSD) and the clinical research facility (UCSD). Their results are clinically significant, and their research work and ethics are highly respected in the scientific research community. At this time however, fluridil is not licensed for use in the US. The main advantages fluridil boasts of are that it is a "hydrophobic" compound; that is, fat soluble. In addition, it is deactivated when coming in contact with water (a "hydrophilic" environment). This last fact makes so that IF it is absorbed into the bloodstream from the scalp, it is deactivated as soon as it hits the blood (an aqueous or "hydrophilic" environment). Hence, since it doesn't enter the circulation, there reportedly are none of the (normally low incidence anyway, 5%) sexual side effects. Hope this helps- Timothy Carman, MD

Mike- Regarding the procedure itself; 1. No, it is not necessary to shave the recipient (in your case, the crown) area. 2.There is a fairly well described area where grafts are removed, it is the posterior area and lateral areas of the scalp which, in general, is resistant to the effects of DHT. 3. FUE as a "better" option? FUE extraction, although dispensing with the linear scar that strip donor harvesting creates, has it's downside in that it does not make for the most efficient use of your available donor area; once you have done FUE in a given area, there is no going back to that area for grafts as that would lead to a less than satisfactory density cosmetically. It is hard for me to assess your "need" based on just a verbal description. I could best assist you if you could upload a few photos. This would also help a great deal to give you a "ballpark" on the number of grafts required for the goals you have in mind. If you need help posting photos, Bill can assist you. Best to you- Sincerely, Timothy Carman, MD

Mike in Houston- Unfortunately, utilizing someone else's hair grafts would present the same medical issues which are addressed when transplanting any organ or tissue from one person to another. Any time an organ or tissue is transplanted into a new recipient, the recipient will begin to make antibodies to the donated tissue. (Hence M&M's comment). These patients are therefore routinely placed on immunosuppression medications to prevent the rejection. There are many risks associated with these meds, not the least of which is a greater susceptibility to infections. Now when we are talking about life saving transplants; e.g., kidney, heart-lung, liver, etc., the benefits outweigh the risks. It would certainly be the case that in hair restoration, in terms of medical ethics, the use of "other than self" donors would create a situation in which the risks far outweigh the benefits. It really isn't an option. Hope that helps. Best to you- Timothy Carman, MD

Sea- I think that the breakthrough will occur when we are able to first clone SKIN. This will revolutionize the manner in which patients who have experienced large amounts of skin surface deficits (eg, burn patients, trauma patients, patients with congenital deformities). Traditionally, these patients are treated utilizing autologous (their own) skin, which is taken from another part of the body (usually the thighs), thus leaving a significant scar. The quality of the grafted skin, though functional, leaves much to be desired, cosmetically speaking. The ability to clone skin would truly be a miracle to many patients who suffer from the above conditions. I think it would be considered a milestone in "modern" medicine, on par with Penicillin and the introduction of surgery. That said, the process of cloning specific types of skin is simply dependent on the type cloned. Hence, the cloning of hair bearing scalp should present no additional boundaries, per say. This would also make logical sense, I think, as I would believe that trying to create the complex structure of the hair follicle would necessarily involve it's inception as a structure created from a specialized type of skin. How far away? I'll go out on a limb and say 10 years. Timothy Carman, MD

Tragedy86- Welcome to the HTN forum! Bill has given you excellent advice. In general, one should proceed with caution when considering hair restoration at your young age. Although based on your family history one can "kind of" predict your future hair loss, that prediction process is not an exact science by any means. In light of this, it is risky to aggressively transplant any areas of hair loss, as, should you be (genetically) predisposed to lose a substantial amount of hair as you age, those transplanted areas would become fairly obvious and become much more of a problem than the problem you were trying to correct in the first place when you elected to have the procedure done. So again, trying the medication (finasteride at 1mg/day) for 9 months to a year and then revisiting with your surgeon for re-evaluation is, in my opinion, the more prudent path to take at this stage of your plan. Also, Rogaine, which works to help slow the hairloss process (and possibly regrow hair) works by a different mechanism than finasteride, and it's effects are synergistic (1 + 1 = 3) when used with finasteride. Also, I believe Bill meant to say the Rogaine foam was LESS messy than the liquid, and also may be more expensive. I would say it is worth it though, as, prior to the availability of the foam preparation, one of the biggest complaints patients had with using Rogaine was how messy and sticky it was, and hence, patients weren't as likely to use it consistently, and, well, the product does even less well if your aren't using it.... Also, if possible could you post a few photos? This will go a long way in helping members give you "ballpark" estimates based on what we can actually see. Good luck, and hope to hear more from you as time progresses. Sincerely, Timothy Carman, MD

Avin701- Hello and welcome again to the HTN website. The above forum members have given you sound advice; do a good amount of research into all the technical aspects regarding hair restoration, as well as consulting with as many surgeons as possible to come up with the practitioner that, along with excellent recommendations, you personally feel comfortable with. I also agree that geographic location should be less of a factor, as this is a relatively small amount of money compared with the total cost of the procedure (as Dewayne points out). What's more, as with our practice, many surgeons offer a travel discount which makes this expense even less of an issue. Hairthere also makes an excellent suggestion in proposing that you consider taking finasteride (Propecia) in 1mg amounts daily as this has been shown to halt the progression of androgenic alopecia in 90% of men taking this medication. At your relatively young age, this is a powerful tool indeed to have at your disposal. Although from your photos it does not appear that your crown is an issue at this time, the addition of finasteride can help insure that hair loss at least will not progress as quickly in that area, if it progresses at all. And although there is less chance of hair regrowth in the frontal and temporal areas (on finasteride as opposed to that possible in the crown), as pointed out by hairthere it is a good idea to get on that medication 9 months to a year before any planned surgical decisions are made, as the effects of that medication may significantly alter the surgical plan in terms of total amount of area transplanted, required density distribution, etc. As far as the specifics, eg, # of grafts needed, etc; while a "ballpark estimate" can be generated by looking at photos, the best evaluation for you personally would take place in the individual consult with your surgeon. At that same time, your surgeon can also rule out less common, but other possible causes of hairloss. Hope this helps. Best of luck to you, and you are already ahead of the game in discovering this forum/website; it is an invaluable source of information and a great way to get honest, well intentioned opinions and insight from forum members. Sincerely, Timothy Carman, MD

As pointed out by Bill, the amount of donor is related to 1)The length of the donor strip (cm); 2)The density of the hair (Follicles/cm2); and Scalp Laxity (cm) (which ultimately determines the width of the donor in cm). The way Bill calculated in his example addressed these points, but you must remember to keep all measurements in the same units (cm). For the example Bill gave, the yield would actually be 12,000 follicular units (The width of two inches = approx 5 cm). (5cm X 30cm X 80 FU/cm2) (BTW, I'm sure Bill meant 2 cm, not 2 inches) In assessing the donor, there is an "eyeball" estimation made with respect to the donor density. In general, "normal" density of the donor area is about 100 follicular units/cm2. While there are more formal ways to measure hair density, this step is usually done as an "eyeball estimate" based largely on the surgeons previous experiences, and, at least in our practice, that estimate tends to be very accurate indeed. The donor length available is pretty straight forward; one needs to assess how far forward on the lateral portions of the patient's head the incision can be brought to, and this depends on the density of the hair and whether or not (in the surgeon's opinion) that density is great enough to cover the resulting scar in that area. Those endpoints form the line "A" to "B", which is then measured. Finally, a judgment as to how wide the donor can safely be is made based on the surgeons impression of the laxity the scalp on the sides and back of the head. And yes, this estimate is usually made as part of the initial consult interview. Timothy Carman, MD

HT55- I read your link. And allthough the story states: "Federal laws bar drug companies from paying doctors to prescribe medicines that are given in pill form and purchased by patients from pharmacies. But companies can rebate part of the price that doctors pay for drugs, like the anemia medicines, which they dispense in their offices as part of treatment. The anemia drugs are injected or given intravenously in physicians' offices or dialysis centers. Doctors receive the rebates after they buy the drugs from the companies. But they also receive reimbursement from Medicare or private insurers for the drugs, often at a markup over the doctors' purchase price.", it's still technically "money given to the doctors". So, I stand corrected. I guess I'm just outside the loop. That said, on topic, I don't believe any "kickback" phenomena occurs in the everyday HT surgeons practice prescribing propecia/proscar. Timothy Carman, MD

Jotronic- Thank you for your comment. The information which I passed on to the forum members is qualified as follows; those figures and results were presented at the Annual International Society of Hair Restoration Surgeons (ISHRS) Meeting and was based on longitudinal investigations involving a sizeable group of patients (I apologize that I don't have a recollection of the exact number) not just an anecdotal patient or two, and it was performed by physicians well known in our practice community to have the expertise and skill to conduct techniques involving dense packing. That said, I agree that there can be a wide variability in what individual practitioners report regarding this phenomena. Also, please bear in mind the context in which my remarks are made. I was speaking in broad generalities (the exception proves "the rule") in order to communicate to the original poster the rationale behind the use/benefits of larger grafts (including DFU's) in general. I do appreciate your observations, however. Timothy Carman, MD

THINinHOUSTON- That is an excellent question. As Bill has pointed out, hair occurs naturally on the scalp in what are termed "follicular units". These are groups of individual hair follicles that average two hairs per follicular unit. They can vary, therefore, from a "group" of only a single follicle, or two, three, or four follicles. As pointed out, one typically only utilizes one hair grafts for hairline reconstructions, but within regions where there is no specific need such as this, two, three and four hair grafts are completely acceptable, and are utilized commonly. There are situations where a graft which is comprised of TWO follicular units, called a "DFU" (di-follicular unit) are also appropriate to be utilized. An example of a location where "combination grafting" (referring to the use of intermixed follicular unit grafts and DFU's) are used with excellent results is the frontal forelock area and the midportion of the scalp directly behind it. To appreciate the rationale for this, one needs to consider the following. In general, the limitation to packing in density (measured as the # of grafts per square cm) is the blood supply of the scalp itself. It has been demonstrated that a density of 40grafts per square cm will give near 100% graft survival, all other things being equal. It has also been observed that when grafting at higher densities than this, the survival rates of the grafts decreases. So, while it may be technically possible to make and place 60 grafts per square cm, the survival rate is in the low 90-93% range. So in essence, above 40/cm2 one is simply "throwing away" perfectly good grafts. It has to do with the 40 little stab wounds one makes, and the available blood supply to nourish those follicles. Now, in the case of the area above, the FF area and immediately behind, one may be able to place more hair mass using combination grafting as follows: The DFU's, being slightly larger than a single follicular unit graft, require a slightly larger recipient site accordingly. Yet we found you can "cheat" a little, making some of those 40 stab wounds DFU sites. Still 40 sites, but some of those sites (the DFU's) have double the hairs (on average) that the follicular unit sites have. This way, one can move more hair mass per unit area utilizing combination grafting than simple all follicular unit grafting alone. In our practice we have found that this technique yields excellent results. Good question, I hope this explanation, long-winded though it may be, helps. Timothy Carman, MD

diamondlight- Perhaps you can upload some photos (preferably pre- transplant and current stage) so that we might better assess your situation. A "birdseye" view would best help assess the area behind the frontal hairline and forelock portions. I have had a few patients that were "late bloomers", so don't despair- Also, remember that hair grows slowly- about a cm/month- and if you are just beginning a bit later than most, some of those hairs may only be just at the scalp surface. At any rate I would be happy to look at any photos you upload, I'll check back in a few days. Best regards- Timothy Carman, MD

Dewayne- Oh I wasn't addressing your quote specifically- I apologize if I came off like I was responding specifically to your point- I could tell from your comment as a whole that you already understood where I was coming from- I was mostly addressing the comment by Dakota3- it sounded like from his experience he had come to a conclusion that, as you know, simply isn't accurate. Sorry for the confusion. And yes, they do provide a sandwich or pizza every now and again..... Timothy Carman, MD

Currently, there is a great deal of research in this area. After the donor strip is harvested, it and the grafts which are dissected from it are placed in what is called a "holding solution". This medium can be as simple as normal saline, or it can be made up of a number of ingredients whose purpose is to maintain the health of this living tissue. The addition of glucose, amino acids (which make up proteins), and other "growth factors" are being studied in relation to graft survival while out of the body. While certainly not common practice, I am aware of an incident wherein an exceptionally large case was actually carried over to the next day, the grafts being stored overnight!! Those grafts had about a 75% survival rate when transplanted the following morning!! In general however, our experience has been that even in large cases (4000 or more grafts), survival rates are not significantly affected even after 8-10 hours following removal and before placement. That being said, in general in most practice situations, grafts are not held prior to placement any longer than 6 hours at the most. Good question.

I just thought I would set the record straight- As a practicing hair restoration surgeon, I do not receive, nor have I (or any other of my hair restoration colleagues for that matter) EVER received any "kickbacks" or the like. Also, in general, those days of "wining and dining" by the pharmaceutical companies are long gone- The best we as physicians today see in that regard are pens, keychains, and the like. Truth is, even the best dinner back in the day never affected my choice of prescription medication to use in a given clinical situation; my decisions have always been based on sound clinical-based medical assessments. Hope this clears the air. Timothy Carman, MD

I agree with djdennis. Uploading some clear photos showing your areas of concern would help us help you answer that question with at least a "ballpark" figure. Like they say, "a picture is worth a thousand words"... Best Regards- Timothy Carman, MD

HLDB- I have reviewed your photos and the comments submitted by forum members. They have provided you valuable input. You raised some important questions in your last post regarding personal hair loss history, family hair loss history, age, and use of medications shown to be effective in slowing the process of androgenic alopecia. All of these areas are pertinent to making an informed decision regarding the appropriateness of entertaining a hair restoration procedure. They are a standard part of the initial consult, along with information regarding any relevant medical history (such as thyroid conditions, diabetes, etc.). From your initial post I have gathered that you have been taking advantage of medical therapy, and that alone is a very powerful tool. As you have been utilizing finasteride for 2 years and Rogaine for 6 months, I would venture to say that it would be an appropriate observation that you have achieved your maximum results, and that you could anticipate continued maintenance of you current condition. In addition, your personal and family history suggest to me that you would certainly be a candidate for a future procedure, especially given the observation that your donor area is "beautiful..!!". As for the number of grafts needed, this is best ascertained most accurately in the personal consult. The amount of grafts required depends on the design of the hairline you and your physician decide upon in that consult. Given the apparent good density of your remaining hair, it appears that a highly refined follicular unit grafting procedure would be appropriate. I am going out on a limb here, but, on the basis of the photos you provide, I would estimate that you would require no more than 2000 grafts. Please understand, however, that this estimate is just that, and again, is based on a photo only. This estimate can vary by 2-300 grafts, based on your actual head circumference, the need to "reinforce" the current hairline of your frontal forelock area, the frontal forelock area itself, etc. I hope that this helps. As recommended by our forum members, take your time, do your research, and, with the forum's support and your due diligence, I'm sure you will find an appropriate surgeon with whom you are comfortable so that your experience and surgical outcome are both positive and productive. Best of luck to you. Sincerely, Timothy Carman, MD

Rahul; Have got to agree with Bill. At the very best, "splitting" a follicle will simply yield two weaker hairs, and that in itself would not be a consistently reproducible result. I have seen this "procedure" and it's description from another post regarding another website with similar claims, (in the Netherlands, I believe),and I must say that my impression is that the claims are all in that "shady" zone of less-than-full disclosure. As for what they do show, it most closely approximates a simple FUE procedure. As I said, were they to extract "partial" hair follicles there will be consequential growth and survival issues (Graft and Donor) which, in my opinion, would limit the viability of this as an effective and/or prudent procedure. Hope this helps- Sincerely, Timothy Carman, MD La Jolla, California