Dr. Timothy Carman

The reality of scar formation is that it is most dependent on two things which are actually out of your control. The first is how aggressive the surgeon is in taking the strip. The wider the strip (taller), the more tension on the closure, and the greater the chance of scar formation. The second has to do with the amount of elastin in your tissue. The more elastin, the greater the chance of scarring. The younger you are, the more elastin you have. So, one tends to see better scar results in older patients, all other factors being equal. Vitamin E, in my opinion, is NOT appropriate for wound care until a few months after surgery. It's use during the early phases of wound healing can actually interfere with the normal process and retard normal healing processes. During the immediate post-op period (First 14 days), Bactroban or Neosporin is most appropriate. As previously mentioned. keeping physical activity to a minimum during the first few weeks is recommended as well. I am not aware of any differences in overall wound healing/scar results when dissolvable sutures are used vs non-dissolvable.

As I said on your other similar post- I don't think you have anything to worry about.

2hillpark: In general, 22 years of age is a bit young for a hair transplant procedure, especially when considering lowering your hairline. The main reason has to do with the unnatural appearance which may develop over time as you lose further hair behind that hairline, as well as the lack of adequate supply available to completely and convincingly cover those balding areas in a natural looking fashion. I would recommend considering finasteride to help slow your loss.

All in all as the previous poster noted, everything should be fine. No worries.

Spanker- I will try and reorder the photos so as to make them less confusing- I can see your point. As for the reality of whether or not the way this patient chooses to style his hair does "something" for the result- The fact that he can gel transplanted hair and have an appearance which he was not capable of previously, and thus is quite pleased with the result is what is most important to my interpretation of the result. I do realize that the gelled look can make for "less impressive" results, yet I think I am more interested in showing the diversity of all cases and the individuals they represent, as well as the nuances of, say, as in this example, gelling the results of a single-pass first procedure density. I will try and reorder the photos a little later today. Thanks for the input.

This patient is a 39 YO male who presents with androgenic alopecia, affecting the definition of his hairline, frontal forelock, bilateral temples and lateral anterior hairline margins, as well as causing thinning of density in the frontal and posterior forelock and crown areas. Attention was directed at recreating the anterior hairline as it framed the superior and lateral facial margins and increasing the density in the frontal forelock. This patient had severe recession of his lateral margins/temporal point areas, requiring that a larger than usual proportion of grafts be dedicated to recreating these areas. Graft total: 3,583: 844 one's; 2532 two's; 157 three's; 50 DFU's. p.MsoNormal, li.MsoNormal, div.MsoNormal { margin: 0in 0in 0.0001pt; font-size: 12pt; font-family: "Times New Roman"; }div.Section1 { page: Section1; ThesAttention was

29 yo male with Androgenic Alopecia causing generalized thinning predominantly affecting FF, posterior FF, bilateral temples and crown. Approx 15 x 7 = 105 cm2 total frontal area, plus 40 cm2 in crown. Goals: Recreate new hairline and FF/post FF and bilateral temple recessions, as well as anterior crown. Patient has been on finasteride x 1 year. 4241 total, 1390 1’s; 2523 2’s; 328 3’s. Last photo is of donor scar.

The area covered is approximately 70 cm2. Our plan includes a second session which will focus on the midscalp and anterior crown. The reality of a presenting NW class such as this is the large area of "demand" and the limited amount of "supply" available in such a patients donor reserve. This sceanario requires careful discussion and planning between the patient and surgeon, because, IMHO, trying to spread the supply to BOTH the crown and the frontal hairline leads to a dilution of the supply which results in either a "grafty" look despite the use of FU grafting, or a less than cosmetically significant improvement from baseline. Concentrating on the frontal and midscalp area places the donor in the most cosmetically appreciated areas for improvement, again, IMHO. Again, however, this area of discussion is affected as well by whether the crown is more significant than the frontal view to the patient or not. Should the crown be more important, then the limited donor would be focused there.

Our patient is a 42 YO male with presenting complaint of androgenic alopecia resulting in loss of the frontal hairline, frontal forelock, midscalp and crown. In addition, his donor has a density of an average of 80 FU/cm2. This case illustrates the use of a limited number of grafts to recreate a natural look that is designed conservatively enough so that remaining donor is not utilized solely to support a non-conservative hairline approach. This allows for future use of grafts in the midscalp, along with donor available as needed to address future losses. Patient is currently on finasteride 1mg/day. Total grafts 2176; 1's = 1140; 2's = 1025; 3's = 11. Closure of strip donor site is tricophytic. And remember, at this stage he has about 60% growth present.

Thank you all for the great feedback- It is very much noted and appreciated!!

Most likely, as the folks above have commented, it is due to either new hairs emerging (can occur from 3 months to 12 months post op, usually last no more than 1 week each), or, ingrown hairs (same time period, but may last much longer/become chronic) The drainage that I see concerns me, as this may be due to a folliculitis, which is a more generalized infection, and one which, unlike the others, would require a short course of topical or oral antibiotics. (The others respond to a warm compress, for instance.) Either way, your surgeon should be able to help you with this, either way.

We have added 14 month Follow up Photos to this patients case. There are several views to show the use of ultra-fine follicular unit graftimg in the patients hairline to soften the previous look. As well, his scar revision was accomplished utilizing a modified tricophytic closure technique.

The laser would slowly shrink the follicle, over several treatments, to the point where it would no longer grow hair. FUE is a method wherein the hair follicle(s) is(are) extracted as a single unit- whether that be a group of one, two, or three follicles (which grow as a unit- see follicular unit definition in other posts). This results in a small defect which usually heals without much scarring.

The work that was done , although certainly not stellar, would appear to fall within the category of "standard of care", so the "suing" issue I believe may be a waste of time. The overall result wherein the grafts are placed sparsely more than likely would be the result of "filling in" as many patients request, without attention to the fact that this will be the result not if, but when further hair loss occurs. Following the previous "immature" hairline results in a mismatch between the contour design of the hairline and the density. As for the raised nature of the grafts as they sit on the scalp, while this is certainly less than ideal, hair that is worn at a "normal' (ie not "buzzed") length should hide this poorer result, though i can understand that as this has evolved the low density you have as a result after these years probably doesn't look too good in the "normal" longer style. The scar, as well, is less than ideal. However, it does not appear, at least to my eye, that this is not a scenario worth "giving up", although I understand your frustration. With the exception of grafts that are placed outside the curve of a mature hairline, you should, in the proper hands, be able to: 1. Reduce the scar from the first procedure. 2. Increase the density in the hairline and frontal forelock, and; 3. Have the grafts outside the"mature" hairline removed, either by FUE or laser. I hope this is helpful for you, and I am sorry you ended up with the result you did.

The risks of general anaesthesia ("putting you to sleep") are to great IMO justify it's use in routine hair restoration surgery procedures. In our more invasive procedures, for example, placement of expanders, general anaesthesia or heavy sedation is appropriate. As the others above have pointed out, it's not uncommon to have the fears you express. The good news is, as was stated above, the local anaesthesia procedure, while not painless, is tolerable, and takes only about two minutes to complete. We offer our patients mild sedatives that help sooth those nerves and allow you to relax and "go with the flow".

The human form is an organic shape. In my opinion, to create a geometric shape and superimpose it upon an organic one is asking for trouble, especially in the long run when a patient will age- the "crisp" hairline may "fit" at a young age, but may not later on. I have coined the phrase "Perfectly Imperfect" to describe how we create our hairlines. As for symmetry, take a good look at almost anyone: if you look close enough, you'll notice that one temporal point is probably more anterior than the other; also, it is probably higher on one side than the other- you can see if one were to place a perfectly symmetrical hairline onto this asymmetrical composition, it wouldn't "fit". So, to summarize: organic on organic and keep your eye on the long-term picture.

Put up some photos- I'd be happy to take a look-

Typically by 48 hrs the grafts are well secured. That isn't to say they cannot be dislodged, but it would have to much more than just an accidental "bump" against a hand, pillow, etc, etc- As for those first 48, as per above, most clinics have similar guidelines involving elevation of the head of the bed, post op washing, etc. I've got to say, I myself am still amazed after all these years that the procedure is so consistently, successfully, reproducible! It really is a great procedure!

While it is true that there is a challenge in recreating the temporal points, their artful recreation should not be a problem in the hands of a skilled and artistic hair restoration surgeon and his team. I also do not recommend the use of nape hair, for the following reasons: 1. Taking hair from that area can leave a very noticeable scar as there is a great deal of soft tissue movement in that area; 2. The hair on the male scalp at the inferior borders also is sensitive (to greater or lesser degrees in different individuals) to DHT and may undergo further miniaturization and subsequent disappearance- not a quality you desire in transplanted grafts. I would encourage you to interview another surgeon- one that makes you feel comfortable that they are confident in their opinions, plans, and observations.

@Hairthere- Attached is a photo of this patient at POD#8. @Janna; Thank you very much for your kind assessment - Attached is a "top-down" or "birds' eye" view! (I've also added both to the album as well-) Dr Carman

hairthere- I do- I'll try to get a couple up later today-

Thank you C!! He is!!!!

Second Procedure: Additional photos are one year post op following 2740 FU procedure to address crown, midscalp, and refinement of hairline and previous frontal areas. 2740 Total FU's :470 1's; 2156 2's; 114 3's. Tricophytic closure. They are the last five photos in the series. First Procedure: This is a 60 YO male with androgenic alopecia, with thinning predominantly affecting hairline, FF, posterior FF, and bilateral temples and crown. Our plan was to recreate the frontal hairline, FF, post FF, temples and some crown.. Total area was approx 15cm x 7cm = 105 cm2, plus another 40 cm2 in crown. Decision was made to concentrate on the anterior and midscalp portion, allowing finasteride to work on the crown over the ensuing year, noting any effect at that time. Goals: Recreate hairline and FF and bilateral temple recessions, post FF and anterior crown. Wait to see how finasteride affects crown, possibly place 100 or so FU grafts there at this procedure to decrease severity of appearance. Ellipse 30 cm x 1.0 cm x 110 (est) (in situ). 3099 total, 1029 1’s; 1990 2’s; 80 3’s. Tricophytic closure.Patient will have second procedure of about the same number in January to address crown.

That would be "ISHRS" (International Society of Hair Restoration Surgeons) not "IHARS"- and I must say, I second that vote for Reed!!!

This 50 yo patient presents at 6 months following placement of 3770 Fu grafts in the following distribution: 1007 ones; 2591 two's; 128 three's. The majority were placed in the frontal area, approximately 700 FU grafts were placed in the crown primarily in an effort to decrease the apparent size (diameter) of the crown pattern. There is a bit of asymmetry in the new growth which should even out as the grafts continue to grow and mature; approximately 60% of growth has occurred at this time.