Dr. Timothy Carman

Patient is a 37 YO asian male who presents with loss of frontal hair line, frontal forelock, and midscalp/anterior crown thinning. The cornerstone of long term success in hair transplant surgery is understanding the supply/demand inequity which is a factor in over 90% of candidates: there is a limited/finite supply of follicular units available in the patients lifetime, so the artwork design and subsequent placement must respect this overriding concept. This generally translates into higher, more receded/diffuse hairlines and less aggressive crown reconstructions in order to constrict the total area to be transplanted in a pattern that mimics those naturally occurring thinning patterns in nature. Her we see a diffuse, receded hairline created along with good density realized in the midscalp and anterior crown area. This allows for future loss to be successfully addressed as the patient experiences any further progression of his hair loss. Total: 2184; Ones: 849; Two's: 1082; Three's: 253.

Patient is a 32 yo Male with loss of definition of the frontal hairline, frontal forelock and midscalp area. We are looking to recreate the hairline and the density in the Frontal and midscalp areas. Patient has elected not to take medications to slow loss. The last photo demonstrates a typical donor incision at one year post surgery.

This patient is a 51 YO male with a history of thinning frontal hairline with bilateral recessions. He wanted to recreate the frontal hairline and receded areas to enhance his appearance in an age appropriate manner. We transplanted a total of 2017 FU grafts into a new frontal hairline design, along with increasing the central frontal forelock density to support that hairline. The last phot in the series shows the donor scar appearance at this one year post op date.

Patient is a 47 YO male with an initial presentation that featured severe bilateral recessions and loss of posterior frontal forelock with a diminished definition of the midline frontal hair line. He underwent a total transplantation of 5845 FU's over two procedures. His graft distribution included an unusually high proportion of three and four FU's, which adds to the total hair mass and cosmetic result.

This is a 42 YO who presented with loss of his frontal hairline and frontal forelock. He had been wearing his hair longer in order to cover the areas of hair loss, but this was becoming too much for him, maintenance-wise. This is a shot of his results at the early stage of four months. He was very pleased as for the first time in "forever" he was able to style his hair shorter. Total FU grafts: 592 ones; 2101 two's; no three's or fours. At this stage he probably has about 35% in growth.

This patient is a 36 YO male who experienced slow loss of his frontal hairline, showing bilateral recession associated with thinning in the frontal forelock and central midscalp. His family history and physical exam were negative for significant crown loss. We were able to rebuild these areas over two procedures, advancing the hairline from procedure one through procedure two. Graft Counts: 1228 ones; 2744 twos; 583 threes.

At four weeks out that seems a bit red, but as someone pointed out, that may just be your skin type and its healing characteristics. Really, the issue is whether it feels tender to the touch or warm to the touch. It would be unusual to have any sort of infection or reaction this far out, unless of course your surgeon used dissolvable sutures. If that is the case, the redness should decrease as that process resolves.

Biased "study", to be sure. My primary concern has always been whether or not the laser comb is safe in terms of not "waking up" a latent melanoma skin cancer. Skeptical still at the "results" reported/observed.

Toubey- I would agree after looking at the photos you may have larger grafts placed in a fashion that would indicate multi-follicular units were used. While the density and arrangement certainly are more reminiscent of techniques of days gone by, by no means does this signal as great a disaster as one would think. Hopefully the grafts were placed in appropriate angles- that somewhat mimic the "whirl" pattern in the crown. We'll just have to see. This will all unfold over the next years time. IMHO it would be premature to assess prior to at least a year- especially for further transplant planning. Remember, should those grafts grow, they ARE adding hair mass to that area. Although possibly less than natural looking once this procedure has grown in, it is my opinion that a second procedure done artistically with exclusively FU grafts will be able to camouflage those grafts quite nicely with an acceptable result. So yes, do your research before the next one, but chin up, this looks totally fixable to my eye. -Dr Carman

This 60 yo Gentleman presented with loss of definition/thinning of his frontal hairline. At 7 months post-op he presents very pleased with his results to date. At seven months post surgery, we tell patients that in general they can expect about 70% of the grafts to have grown in, ie, they can expect another 30% to grow in in the next five months. This case is no different. Graft count: One's = 1040; Two's = 967; Three's = 10.

This hairline reconstruction emphasizes the importance we place on subtlety in the recreation of a natural result. The new hairline must take into account the patients bone structure, pre-existing hair, and most importantly, the anticipated future losses. We feel it is also critical that the improvement not change the overall facial character, as this can drastically affect the perception of a natural look. This gentleman had been experiencing hairline recessions only, with no other features of male pattern balding in other areas. Importantly, as there is a limit to how densely one can "pack" hair into a square centimeter, on bare skin (due to blood supply limitations), further conservative design is essential so as to not create an aesthetic tension between the placement and shape of the new hairline and that limiting density.

Patients is a 53 YO male with AA affecting his hairline, frontal forelock, midscalp and crown. In addition, patient has hair of very thin caliber, which translates as less total hair mass than similar graft counts with larger diameter hair shafts. 2424 total grafts; 683 ones, 1506 two's, 133 three's, and 102 DFU's. In addition, this case is challenging as the patient has a larger than normal surface area due to a larger than average head size. His good scalp laxity in the donor made up for his lower than average density of 75 FU/cm2. The result is at 14 months post op.

Staples by far are the most uncomfortable type of closure for the patient. This should all become a non-issue once they are removed. And yes, things can feel "tighter" as well as healing progresses. You should be fine once they are out. Grow well!!

To all- Thank you for your comments and observations. First, yes, 951 ones were used in this delicate hairline/frontal forelock reconstruction. (That is unusual; 600 is the average in our practice.) This, along with the fact that the patients natural/healthy donor hair is on the fine side, is what contributes to the soft look. Second, yes, there has been additional loss due to AA, which was anticipated and again is but one of the reasons for the graft numbers, sizes and densities. As if that were not enough, the patient prefers to utilize heavy hair products in his hair, which can pose a cosmetic challenge under these circumstances. I think this affects the look as well, as anyone with fine hair using "heavier" hair products may have come to realize. Again, thank you to everyone for taking the time to look and comment on our patient.

GBU- Actually no, there is no toppik or any other camouflaging agents present on his post op visit.

This pleasant gentleman in his late twenties has been experiencing MPHL affecting his frontal hairline, midscalp and crown. He decided he would prefer to not take finasteride, and does not use any topicals as well. Grafts harvested through strip excision. The result shown was at 15 months post-op. Total FU grafts: 2423; 585 ones; 1710 two's; 128 three's. Tricophytic closure.

This patient in his mid forties noticed thinning in his frontal forelock along with loss of definition of his hairline over the last five to seven years. 1522 FU grafts were placed in this region in order to address his concerns, in the following distribution: 627 ones; 795 two's; 100 three's. The posterior view is of the donor area immediately after closure. All other views are one day post op.

Patient is a 28 year old male with a significant family history for MPHL. We post this case to reinforce the concept of lifetime donor/supply vs lifetime loss/demand, as well as illustrate "what it looks like" seven days after surgery, with short hair; we get that last question very often. Here, our plan includes a conservative hairline with recession, placed behind the existing one, and reinforcement of the midscalp area. It is critical in this patient category to plan for the future by anticipating future losses and NOT attempt to "fill in everywhere". There is a limited donor in every patient that must be respected, and this is usually concurrent with a much larger lifetime demand (area of potential loss requiring transplant). Understanding this lifetime imbalance and creating realistic surgical plans is key to long term transplant success. Also, note the look at seven days post op- if the hair is about 1/2 inch longer, the transplant would be fairly undetectable. It is however, some patient's choice to keep their hair short, so this example is for those considering that option. We are able to accommodate any hair length at surgery. Total: 2528 FU grafts; 728 one's; 1345 two's; 455 three's.

This is a patient in his late twenties that presented with a request to re-establish a hairline he had lost due to androgenic alopecia. He had undergone a previous procedure of about 6-700 grafts which were placed in his frontal forelock area only. Those were beginning to show as his hair continued to recede. His familial history has only frontal loss patterns, with no crown patterns seen on either side of his parental tree. Total FU grafts: 1983; Ones: 951; Two's: 903; Three's: 129.

I just read the initial post of this thread- and the section on "graft selection" is nonsense, and misleading. Saying that as a surgeon my selection of grafts is "left to chance" when utilizing strip harvesting is ridiculous. Moreover, as can be seen in your photo, titled "Surgeon can target specific grafts" transection rates are higher in FUE procedures (regardless of the hype), again as CAN PLAINLY BE SEEN in your photo. I would not expect ANY of those grafts to grow, as they are ALL transected. Amazed this post has withstood scrutiny, really. Granted, I have not gone through the ensuing 25 pages!!!!

Has anyone ever seen the disheveled homeless gent on the street, in obvious poor health, with a great head of hair? Yes. Bottom line, your genetics are at play here. The vascular neogenesis (formation of blood vessels) must necessarily occur in the first few hours after transplantation, otherwise the follicles would not survive. That being said, the vasoconstrictive activity and decreased oxygen supply along with carbon monoxide presence may or may not affect your hair's lifespan, again, depending on your genetics. My perspective on this would be; Why, after putting in the effort to improve the quality of your life by improving your appearance would you partake in utilizing an acutely addicting behavior such as smoking which clearly has been shown to play hell with not only your health, but your appearance as well? Just a thought, and my two cents. Grow well.

It's impractical to make ANY assessment at this early stage. Your surgeon should know that. Rest easy, it is simply too early to tell.

Patient is a 27 YO female who presented with a congenitally high hairline. Cosmetically, the hairline location ideally should be about 1.8-2.1 cm below her presenting location. Options discussed included the option to place an expander with serial expansion followed by advancement 1.8- 2.1 cm. As her schedule would not allow the significant interruption of daily activity that an expander would entail, we elected to recreate a new hairline through FUT. Our plan estimated 1200-1300 FU (30cm2 total area x 45 FU/cm2 density). At surgery, the graft count was as follows: Total: 1346 FU; 532 one's; 640 two's; 174 three's. Tricophytic closure. It should be noted this is stage one of a two stage procedure; in a year, a second procedure will be performed to increase density.

Spanker- Thank you for the kind words- As I alluded to in my post- the most important factor is estimating (based on age, current pattern, familial history, etc-) projected future loss and establishing a safe total area of transplant that can be supplied by the always limited amount of donor. I like to call this the patient's "lifetime supply-demand" ratio, as best can be determined, and it guides each and every patient case as to what is possible design-wise, which will look natural not only a year from the transplant, but into the distant future as well. Once that is established, the contour/ shape/density all have to be designed so as to "fit" the variables involving bone structure, hair type, ethnic background, and overall facial character.

I agree.