Dr. Timothy Carman

I have always found it a bit interesting when anyone makes estimates based on photos. There are varying sizes available in human heads, and they all have about the same proportions- So making any specific numbers statement really is premature (for me at least) until the actual area can be measured. I think those should be qualified with statements like "assuming an average head size, donor, etc. The issue of predicting your loss, as pointed out earlier, may mimc your dads, gfs, etc, but it may not. However, just because you MAY lose crown hair in the future does not IMHO prevent you form addressing your concerns via a small transplant. I have always been of the opinion in plastic surgery that less is more- even in hair. It is not (again, IMHO) the amount of transplanted hair you have, it's the design and planning that goes into creating a long term natural effect that utilizes your donor to it's greatest advantage. I am of the opinion, in your case, that no more than 800-1000 grafts could create a healthier, natural looking hair line in your receded areas (again- assuming you have an average size human head and average donor- your donor if low would adjust the design and hence the number, that's why it is important) and leave you in fine shape for whatever comes down the pike in the coming years. As for meds- I feel that is a very personal decision, one that every patient should think about but not feel pressured to take. I personally do not alter the design of any of our transplant approaches whether the patient is on meds or not. One must be conservative with donor usage regardless. My two cents.

Addressing the question of asymmetry- In general, most folks facial features are slightly asymmetrical- we can be fooled since there are pairs of eyes, pairs of ears, two nostrils to the nose- etc., the casual look sees "symmetry". While taking measurements may be helpful, we have found that designing a hair line must take in the total "gestalt" of the persons facial features, as well as an artistic appreciation of facial "character". For most patients, precise symmetry in a hair line would produce an unnatural look, as this amounts to placing a geometric shape on an organic form- not a good match. Above all, taking into account future hair loss and familial patterns should guide the placement as well as the shape (degree of recession) of the hairline. Density should vary as well along a hairline, as it does in nature. It is the art of respecting these subtle variations which occur in nature that leads to the recreation of a natural, non-man-made appearing result. As for the hairline above, I think, from what can be determined at this stage, that it designed just fine.

This patient is a gentleman in his fifties with gradual loss over the last 2 1/2 decades, with androgenic alopecia affecting the frontal hairline, midscalp and crown. Our plan is to recreate a conservative hairline while increasing the frontal forelock and midscalp density. CIn the preop photos he camouflagesthe midscalp by a comb-over of sorts, and as such is not able to style his hair shorter, as he would prefer. The posted results show the very early stages of regrowth which began at around month three, and are posted here to answer a frequent concern by patients regarding the naturalness of the regrowth phase. At this early phase, only about 25% of the final growth is observed, yet it is enough to allow him to style his hair with a shorter cut already. The hair grows in as very fine initially, and will appear quite natural, as long as the design is not overaggressive for his age, bone structure, and the pattern of loss in his crown. Our preference in any reconstructive case is to add a subtle yet definable change to the preexisting condition. Total FU grafts: 2424; Ones- 683; Two's- 1506; Three's 133; DFU's- 102. Tricophytic closure.

Pretty much as per previous posters- the hair lost due to shock loss will start to return around month 3 to 4, and will continue over the next 8-10 months in a gradual fashion, in the same manner as the transplanted follicles. As was noted above, some of the finer pre-existing hair may not recover from shock loss. Understanding this observation allows your surgeon to vary the appropriate graft placement density depending upon whether he or she thinks the pre-existing recipient hair will survive or not. Good question.

It appears as though you would be a suitable candidate................

Hey Steve- The entire case itself was small enough that we just went ahead without the test case. Because the nature of the scarring was not a scarring alopecia, we weren't concerned about growth issues relative to that issue, only that of adequate blood supply. At the time of surgery, the vascular potential of the skin is judged based on blood flow response to the incisions made, and density adjusted accordingly. Her blood supply was judged as excellent at the time of transplant, and the results bear that out. Thanks Steve.

One of the more satisfying cases to do as a Hair Transplant Surgeon are those involving repairs or reconstruction following injury/accidents. This patient suffered third degree burns to two areas in the frontal scalp region, each about 6 cm2. Grafts were placed at a maximum density of about 50 FU/cm2. The results are showing grafted hair parted in the center of each of the scarred areas following growth of the grafts. Success in these cases really brings a smile to the patient's face!!!

This patient is a 26 YO male with AA affecting the bilateral temples, hairline, frontal forelock and Midscalp. In addition, there is significant miniaturization affecting the crown as well. The patient has elected not to utilize finasteride. Our plan is to recreate a conservative hairline with significant recession so as to accommodate future loss and reserve grafts for the reconstruction of the midscalp area. 2402 FU total, 828 one's; 1489 two's; 85 three's. Tricophytic closure.

This 48 YO gentleman has experienced mild bilateral recessions and thinning of the frontal forelock over many years due to androgenic alopecia. Patients requiring subtle work such as this often wonder and ask, "What will I look like right after surgery? A week after?" Here ya go. The first eight show his presenting preop condition, the next three his appearance at post operative day one, and the last four at post operative day eight. The small scabbing present will usually all be gone by post operative day 12 - 14. Total grafts: 1821; 799 one's; 990 two's; 32 three's.

Very frequently we are asked what things will look like the day after- this is a one day post op example. Our patient experienced limited male pattern hairloss in the crown area over a total of roughly 35 cm2. When transplanting the crown it is important to follow the patients pre-existing whirl pattern so that the finished result blends seamlessly with the surrounding hair. Total grafts: 1678; 357 ones; 1246 two's; 75 three's. Tricophytic closure, single layer.

Beautiful work!!!

Pt is a thirty two year old male with a family and personal history of androgenic alopecia affecting the frontal hairline/frontal forelock area. The patient's complaint was an inability to style what was left of his frontal forelock/hairline to anything that even closely resembled strong healthy hair.... Our goal was to reinforce the existing frontal forelock area while recreating a conservative advancement of the temporal recessions while further defining the frontal hair line. Note we have maintained some recession so that should this patient experience further loss, this can be addressed successfully as we have not "set the bar too high" by creating a less receded hairline. 1848 total FU grafts; 1075 one's; 581 two's; 192 three's.

Patient is a 36 YO male experiencing Androgenic Alopecia with thinning predominantly affecting crown, central core posterior to FF, midline frontal forelock, and bilateral temples and temporal points. Patient does not wish to utilize medications to slow loss. Graft counts: 3457 Total; 1’s = 1129; 2’s=2166; 3’s=163.

Pt is a 36 YO male with one previous transplant procedure in hairline area. His goal was to bring down the temporal recessions a bit more while at the same time we worked to conceal two and three hair FU's that were used in that previous surgery in the hairline so that his final result would look more natural on close scrutiny. We also placed grafts in the frontal forelock area as well, to increase density and allow him to wear his hair in a different style, something he could not do previously due to lack of density. Photos 1-3 are preop; photos 6-8 are postop; photos 9 and 10 are pre and post op, respectively; and photos 11-13 are closeups to show refined hairline work. 2373 FU grafts total; 687 one's; 1320 two's; and 366 three's. Tricophytic closure.

Patient is a gentleman in his early fifties who experienced a gradual thinning of the posterior frontal forelock and midscalp over the last 25 years to the point where he refers to this area as the "barren wasteland" behind "this little mountain" (referring to the retained anterior frontal forelock seen). We placed a total of 2375 FU grafts as follows: Ones: 800; Twos: 1434; Threes: 141. Note how we choose to recreate a new hairline just slightly in front of his current one: this is done so that, as he loses that hair over time, he doesn't develop a central defect which would certainly be quite noticeable. Here, at 5 months post op, he has about 50% of his grafts grown in.

Patient is a 39 YO male. Preoperative Diagnosis: Androgenic Alopecia with generalized thinning predominantly affecting bilateral temples, hairline, anterior lateral humps, central core posterior to FF and anterior to crown has miniturization/thinning. Plan 2500 Total. Ellipse 23 x 1.0 – 1.8 cm. Actual total at time of surgery 2757 FU's; 1035 1’s; 1665 2’s; 51 3’s. Acceptable closure tension; Tricophytic. These results are Post Operative day #1. They are posted in response to the large number of consult patients who ask "What will I look like the day after surgery?" These are typical results.

When initially evaluated in our office in early 2010, this 29 YO patient was concerned about density in his frontal and midscalp area. Although on propecia, he felt he was continuing to experience loss. He had a previous procedure done about a year prior wherein grafts were placed so as to recreate his younger hairline. Although happy with the result, he was concerned about the generalized thinning. On exam, the most striking feature was the tightness of his scalp- his laxity was very low, and his donor density only about 70 fu/cm2. In addition, his scar from the previous procedure was 4mm in some areas. The concerns we discussed were the low donor to recipient ratio (a supply demand picture that was low on supply and high on demand!), as well as concerns regarding future loss. We also discussed my concerns with a recreated hairline as low as it was, as that created a larger area of "demand" both on numbers of grafts as well as density (lower hairlines, in general, are denser when naturally occurring). A factor in his favor is a hairloss familial history that does not include thinning in the crown. After discussion of these concerns, we agreed on focusing on increasing the core density in the frontal and midscalp areas, cautiously utilizing the donor area, aware of the low yields available, and the scar excision required on our first procedure. The first three photos are at consult. The next three are 1.3 years post procedure one with us: Ellipse 24 x 0.9 cm. 1271 Total, 885 1’s; 717 2’s; 181 3’s. The last five photos are 5 months post procedure two with us: Ellipse 12 x .5-.6 (right); 9.5 x .5-.7 (Left). 1239 Total. This is an example of subtle yet satisfying results that may be seen with slow, conservative planning. Because of the thinner strip size, his second two procedures were not complicated by large scarring areas, and his donor should be able to accommodate one future procedure if needed.

Absolutely, without question. Long overdue.

Patient is now one year post second procedure of 2740 grafts (See description update) for a total of 5839 total FU grafts to address the thinning seen in presenting consult photos of two years prior. The last five photos in the series here are post procedure number two.

This patient had concerns regarding the irregular appearance of his hairline as well as some mild thinning in the crown. We reinforced the anterior hairline to eliminate a midline "dent" that was troubling him, as well as increased the definition and density of the bilateral temporal areas. We also placed about 300 FU's in the crown area to address his concerns there. The results are subtle, yet make for all the difference in the world for this patient. i apologize in advance for the quality of some of the photos..... .

Patient is a 52 YO male with androgenic alopecia affecting the hairline, frontal forelock, bilateral temples, midscalp and crown. Approximately 100 cm2 of area is to be grafted, and in this patient with Diabetes we decreased the recipient area density to allow for possible vascular compromise secondary to that condition. Our average density to be approx. 30 FU/cm2. Final count 2715 FU; 874 1's; 1764 2's; 77 3's. Tricophytic closure. This example of growth at the beginning of month 5 is typical, and is presented as patients often want to know what to expect after growth commences at about post op month 3. As can be seen, the growth comes in natural, without any unusual appearance, as some patients are concerned about.This patient has about 25-30% of his grafts in the growing phase at this point.

This patient is a 37 YO male who presented with androgenic alopecia, with thinning affecting FF, frontal HL, anterior lateral humps, and crown. Plan 2700, mostly into recreation of frontal portion, namely frontal hairline, FF, bilateral recessions, and central core. 2742 total grafts. 854 ones; 1736 two’s; 152 three’s. Acceptable closure tension. Tricophytic closure.

This patient is a 30 year old male with a familial history and chief complaint of AA predominantly affecting the bilateral temporal areas, resulting in recession. 912 Total FU grafts, 372 1's; 482 2's; 58 3's.

Rizwan- Welcome to the forum. From your photos, I would concur that you appear to be heading toward advanced hair loss as you age. At 21, and with this advanced degree of loss, it is my opinion that you are too young for a transplant procedure. The artistic creation of a natural, long term solution depends upon the surgeons ability to optimally utilize the limited supply side of the "lifetime supply-demand balance" as I like to call it. Although you want to restore a lower hairline, with an advanced degree of loss behind that hairline would require more supply than you have available in your lifetime. I realize you think that in a few years you "won't care" about any short-sighted surgical plan, but believe me- you will. There is only one thing I see that is worse than the feeling patients have when they are facing thinning/loss of their hair: that is having "something" done on their heads from years ago that looks anything but normal. These patients are very distressed. Be wise, take finasteride (the side effects are very very low indeed) and give that a year to judge the results. At your age conservative medical management is all I would recommend for you so that you and your surgeon can get a better idea of your long term prognosis.

Again, the follicles should be undamaged, and the results unaffected.