Food for thought/ Various approaches

[Guest Brad Limmer, MD]

This gentleman was seen in consultation yesterday. Classic Norwood VI with donor density of ~84 fu/sq cm and slightly finer than average hair shaft diameter. I present him because I think his case demonstrates some of the classic options available to guys with similar patterns of loss.

 

As most know there is a limit to donor availability / funds patients want to spend, that needs to be balanced with a persons desired goals. Educating patients with regards to the pros/cons of various patterns of planting/ number of grafts needed to accomplish each is paramount to a patient's decision making process.

 

This gentleman has two primary options. First, he could be very conservative and stay within the dotted pattern using between 1500-2000 grafts. We would basically be planting in the area that still has a few remaining hairs. While conservative (11cm mid-frontal hairline), it would look 100% natural (as we are using the pattern he naturally has as our guide), require the least cost to produce a significant cosmetic change (total reframing of face and planting of the bridge zone) and could always be modified in the future.

 

The second approach (solid lines) has a ~9cm mid-frontal hairline and covers a much larger area. At a minimum he should plan between 3000-4500 grafts. Using any less will result in very low density over a very large area that while not absolutely wrong, won't produce the cosmetic change guys are typically looking for. If he can't afford this, I would encourage him to follow the first approach and modify it later when he has the funds.

 

I present him to help some of the new visitors to the forum better understand various options and approaches available to them. While these two approaches could stand on their own (without the need of additional grafting), each could be modified and additional grafts place a year down the road to cover additional areas or increase density. While he has 7000 + grafts available, harvesting more than ~4000 in one sitting is going to risk a wider than desired donor scar.

 

Brad Limmer, MD/jac

 

 

 

[Guest Brad Limmer, MD]

This gentleman was seen in consultation yesterday. Classic Norwood VI with donor density of ~84 fu/sq cm and slightly finer than average hair shaft diameter. I present him because I think his case demonstrates some of the classic options available to guys with similar patterns of loss.

 

As most know there is a limit to donor availability / funds patients want to spend, that needs to be balanced with a persons desired goals. Educating patients with regards to the pros/cons of various patterns of planting/ number of grafts needed to accomplish each is paramount to a patient's decision making process.

 

This gentleman has two primary options. First, he could be very conservative and stay within the dotted pattern using between 1500-2000 grafts. We would basically be planting in the area that still has a few remaining hairs. While conservative (11cm mid-frontal hairline), it would look 100% natural (as we are using the pattern he naturally has as our guide), require the least cost to produce a significant cosmetic change (total reframing of face and planting of the bridge zone) and could always be modified in the future.

 

The second approach (solid lines) has a ~9cm mid-frontal hairline and covers a much larger area. At a minimum he should plan between 3000-4500 grafts. Using any less will result in very low density over a very large area that while not absolutely wrong, won't produce the cosmetic change guys are typically looking for. If he can't afford this, I would encourage him to follow the first approach and modify it later when he has the funds.

 

I present him to help some of the new visitors to the forum better understand various options and approaches available to them. While these two approaches could stand on their own (without the need of additional grafting), each could be modified and additional grafts place a year down the road to cover additional areas or increase density. While he has 7000 + grafts available, harvesting more than ~4000 in one sitting is going to risk a wider than desired donor scar.

 

Brad Limmer, MD/jac

 

 

 

[Bill - Seemiller]

Jessica,

 

Very nice post.

 

Personally...

 

I would think that there would only be three reasons for this particular patient to go with the more conservative approach:

 

1. Lack of donor laxity preventing a larger session

2. Funds

3. The patient simply desires this better.

 

The reasons for being more liberal would be:

 

1. Age

2. Level of hair loss

3. Available donor - if he has it

 

But I noticed your use of the word "primary" relating to options. Certainly patients might want to do the front third/half of their scalp first, going with the conservative but slightly lower hairline but not going back as far.

 

Would you consider this a secondary option or even an option at all? Certainly other clinics have done this - but every clinic works differently. Why would or wouldn't this approach be an option? And if it is an option, do you feel your primary options are better and if so why?

 

Thanks for the discussion Jessica on behalf of Dr. Limmer.

 

Bill

 

P.S. I want to take you up on your offer for a phone conversation as well. I'm thinking in the next couple weeks I might have some time if you are interested.

[MrJobi]

Hi

 

Good post. Last factor determining which strategy would be if hairloss was stabilized with meds or not at this point.

[Bill - Seemiller]

Mrjb,

 

Being that his hair loss pattern seems pretty well established and the fact that he looks older - I wonder if medication is as much as an issue here or not.

 

I would THINK, and this is ONLY speculation...

 

That his NW6 pattern won't get any worse at this point since there doesn't appear to be any miniaturization outside of the balding area. Perhaps this patient never used medication...or it didn't work for him?

 

Of course...there IS the possibility that this patient was heading for a NW7 and that medication has prevented that fate (whether temporary or permanent).

 

Anyway...since I am speculating entirely...I'm curious to know if this patient is on any medication to prevent future loss.

 

Bill

[spoon]

I would think that there would only be three reasons for this particular patient to go with the more conservative approach:

 

1. Lack of donor laxity preventing a larger session

 

That depends on what you interpret to be a "graft".

 

Let's face it, the consistent average number of hairs per graft in different clinics ranges from about 1.6 or 1.7 to about 2.2 or 2.3, and that's a pretty big swing. Anyone who says otherwise is welcome to provide evidence. Based on the numbers I've been able to find, that is my conclusion.

 

I suspect that at the Limmer clinic it's closer to 2.2. So yes, taking more than 4,000 of those grafts would risk a wide scar.

But I noticed your use of the word "primary" relating to options. Certainly patients might want to do the front third/half of their scalp first, going with the conservative but slightly lower hairline but not going back as far.

How is this different than the second option presented in the post?

[Guest]

Jessica, thank you for presenting this case.

 

If I were advising this gentelman, I would say to go for option # 2.

 

I know funds can be a hindering factor, however I believe it would be in his best interest to go for option #2.

 

Assuming he has adequate donor supply.

 

This is a tough case given his degree of hair loss & his donor characteristics.

 

These are the cases I would like to see come to frutition, not the NW 2 that gets 3,000 grafts with optimal donor characteristics.

[Guest Brad Limmer]

Thanks for the comments and questions. He is 62 years old and never been on medical therapy. Below is and exact quote from the patient:

 

"I first noticed my hair receding when I was in my early 20's. By the time I was in my early to mid 50's any additional loss or recession had stopped. My goal is to look natural for a man that turned 60. Something to comb and give my face some definition would be great. I have had no previous hair restoration procedures and have never used any hair restorative medications. Loss of hair has been one of the greatest disappointments of my life. Now that transplant technology has reached the current level I would like to put hair back on my head. I'm sure every bald person will tell you the same thing; the only bad looking bald person is the one in the mirror."

 

This sets the tone for what he is desiring to do: Reframe his face and create a natural look for someone over sixty. He is accepting of many approaches and understands the limitation on graft numbers that can ultimately be harvested. Recreating a Norwood pattern 3-V or 4-V should accomplish his goals.

 

As for medicatiions, he is not currently on them. While he will not see any profound improvement and is unlikely to see much future loss, I would still recommend low level therapy. Primarily 1/2 tablet of Propecia per day and even a little Rogaine in the donor zone/grafted area. While his pattern is unlikely to change, as men move into their 70's and 80's they typically show some thinning of the donor zone(primarily decreased hairs per f.u.). I would like to prevent this in both the donor region and transplanted zone.

 

I too would encourage option 2, but option 1 could meet his goals and gives him food for thought. Ultimately it is my responsiblity to educate him as to all his options so he is able to choose what best fits his needs/desire/budget.

 

Hope this answers all the questions raised. If not, let me know.

 

Brad Limmer,MD

[Bill - Seemiller]

Spoon,

 

That depends on what you interpret to be a "graft".

 

Let's face it, the consistent average number of hairs per graft in different clinics ranges from about 1.6 or 1.7 to about 2.2 or 2.3, and that's a pretty big swing. Anyone who says otherwise is welcome to provide evidence. Based on the numbers I've been able to find, that is my conclusion.

 

I suspect that at the Limmer clinic it's closer to 2.2. So yes, taking more than 4,000 of those grafts would risk a wide scar.

 

quote:

 

Any clinic that is doing true follicular unit transplantation should come close to the same average number of hairs per grafts. The variable should ONLY come when comparing patient to patient as some patients have varying numbers of 1s, 2s, 3s and 4s.

 

Anyhow...I'm not exactly sure how this was relevant to my post.

 

How is this different than the second option presented in the post?

 

 

Read my post again. Dr. Limmer's second option covers a larger area, where what I posted suggests an alteration of the first option. Instead of moving the hairline back and covering a smaller area, one could move the dotted lines forward, giving the patient a slightly lower hairline, but simply not moving back as far.

 

Of course, this should be dependent upon both what the patient desires and what is possible to achieve while minimizing risk.

 

Dr. Limmer,

 

Thank you for giving us a glimpse into the specifics of his case.

 

It's interesting to me that you would recommend medical therapy at his age - and though I'm not against this, if I were the patient, I'd probably opt out at that point simply because it appears his level of loss has been the same for a long time, not to mention, it appears there aren't many studies (that I'm aware of) that Propecia is as effective at his age. This is only based on the fact that I haven't seen them...but if they are out there, please direct me to the studies so I may read them.

 

Thanks again.

 

Bill

[Bill - Seemiller]

Everyone,

 

Please understand that I am not disagreeing with the two options provided by Dr. Limmer.

 

My only point is, though two options have been posted by Dr. Limmer, I'm suggesting that there are other options that may be considered if the patient isn't satified with those two.

 

It all depends on what the patient wants verses what is possible/achievable with minimal risk.

 

If the patient wants a lower hairline (like in the solid lines), but can only achieve a lower number of grafts - the attached picture below may be considered as an option (see between the red lines) - though personally, I don't know if I'd go for it.

 

On the other hand, a larger area can be covered like in the solid lines with a lower number of grafts IF the patient is wiling to sacrifice density.

 

Of course all the options should be discussed in detail between doctor and patient so the patient understands what his/her final result will look like.

 

Bill

[spoon]

Originally posted by Bill:

Any clinic that is doing true follicular unit transplantation should come close to the same average number of hairs per grafts. The variable should ONLY come when comparing patient to patient as some patients have varying numbers of 1s, 2s, 3s and 4s.

Not trying to be flippant or 'start trouble' but you are seriously kidding yourself if you think this is true. The evidence says otherwise.

 

The reason I mentioned it is because my interpretation of your comment was that the 4,000 grafts suggested by the doc could be increased, assuming sufficient laxity. If that wasn't what you meant then sorry about that.

[the B spot]

I think clinics have been taking wider strips for a long enough time to say that IF the patient is qualified properly, "going wide" should not present any additional risks, other than the risks associated with strip surgery in general.

 

If this patient possesses enough laxity to go 1.5-1.7cm wide, then I believe he should do so, but only if his laxity qualifies him to do so. That is simply the doctors call and responsibility.

This is one of the reasons donor should be taken in sections----- closing a 10cm section "tight" is much easier than closing the entire 28-30cm incision.

 

This patient will need 2 sessions, so I believe it is perfectly fine to be a "tad" conservative. I do not believe the extremely high hairline will make him happy.

 

I would go for 3000-3500 grafts and transplant the frontal half (100-125cm) at 25-35 fu's cm/2 with the understanding that an additional 3000+ graft surgery will be done, in order to get the frontal zone to 40-50 fu cm/2 (average) and any additional grafts will be used to go further back (should have 1000-1500 grafts to go further back.

 

 

I think 6000 grafts will end up satisfying him, giving him a very appropriate hairline and provide him with a tremendous cosmetic improvement.

 

Should he feel the need to dip into the well for any additional grafts it will be a combination of hairgreed and a desire to complete the process to his maximum potential.

 

Frontal Zone: 125cm--(3500 grafts/density of 28 fu's cm/2) (1st session)

 

Second session same 125cm (2125 grafts to get to 45 fu's cm/2 average)

 

Leaves 900-1200 grafts to go further back to provide some coverage.

 

This guy is an ideal candidate for a great transformation.

 

6000-7000 grafts will do the trick.

[NervousNelly]

Shouldn't the patients age be more of a consideration. Although we all want as much hair and as low of a hairline as possible, at 62 I would think that it might not be as much of a factor.

 

I like the input that Bspot has made and think that this approach should satisfy him. However, I disagree slightly in that I think that the chosen hairline would be fine for this patient.

 

NN

[the B spot]

NN--let me add that I believe the hairline at 9mm could be brought down a half cm or so, possibly to 8cm.

However, given his age, you might be correct in your assertion.

I wonder if we could get a measurement on his entire balding area and the measurement of the front half (with a 8 and 9cm hairline)

 

J

[Gorpy]

62 is not that old guys.

[Bill - Seemiller]

Spoon,

 

The reason I mentioned it is because my interpretation of your comment was that the 4,000 grafts suggested by the doc could be increased, assuming sufficient laxity. If that wasn't what you meant then sorry about that.

 

Actually that's not what I meant at all.

 

I was making a general statement that donor laxity would play a significant role to the number of grafts that can be obtained period.

 

BUT...

 

Generally speaking again...

 

Are you saying that you don't believe more than 4000 grafts can be obtained in a single session given the proper donor laxity and density?

 

There are some clinics (not just Hasson and Wong) who have achieve greater numbers than this in a single session - IMO, this is proof that it can be done.

 

Again, a general statement.

 

Not trying to be flippant or 'start trouble' but you are seriously kidding yourself if you think this is true. The evidence says otherwise.

 

 

I'm not sure we are talking about the same thing. If we are, then I'm not sure where you are getting your data.

 

I'll state it again, and feel free to dispute me with evidence.

 

I agree that each patient will have a varying average of hairs per graft. Patient A may be at 1.7 whereas patient B may be at 2.3 hairs per graft.

 

What I am arguing is...as a whole...when combining all the patients from one clinic, and if a clinic does NOT split FUs, and then comparing clinics...

 

The average number of hairs per graft including ALL patients should come out CLOSE to the same number.

 

Clinic A shouldn't have an average of 1.5 hairs when combining all their patients while Clinic B has an average of 2.1, etc.

 

One could ascertain that a clinic with too LOW of a number could be splitting FUs, while a clinic with too HIGH of a number might be combining them.

 

Bill

[Bill - Seemiller]

Back to topic,

 

I think what the patient wants truly is what matters.

 

Whether or not we think he'll be happy or not is less relevant than what the patient thinks...though of course we are here sharing our opinions which is the whole point.

 

I agree that this patient will need 2 sessions to accomplish both decent coverage and density - so I agree with B that there is nothing wrong with the first session being a bit more conservative.

 

But given an evaluation by the doctor and if it's determined that there are no additional risks - then extracting a wider strip to obtain more grafts might be the best way to go.

 

Bill

[NervousNelly]

Gorpy,

 

Anything over 50 is ancient. LOL There comes a point when you are glad it is the surgeon and not mortician working on your hair.

 

NN

[Guest Brad Limmer]

Guys,

 

Thanks for the input. Obviously there are many options available to him and while we all have our opinion, it is ulimately his that matters.

 

While I presented two options, I did tell him we could put his hairline lower or somewhere in between. These were just the hairlines that I drew to give him the ablity to see various possiblities. One thing to remember is that the surface area of coverage begins to rapidly increase as the hairline is lowered. It is more or less, in simple terms, as half circle. As the diameter of a circle increases, the square cm of surface area increases exponentially. This means you will need a lot more grafts or sacrafice density.

 

Basically, in his case, lowering his hairline from 9cm to 8cm could easily swallow up an extra 1000 grafts. Not a problem, just info he needs to help make an informed decision. Also, it can always be lowered later. This would allow him to see what he looks like with hair(remember he has been without it for 30+ years) and then if he desires it to be lower, you can move it down. It is always ealier to lower a hairline than try to move it up.

 

As stated, he easily has over 7000 grafts to move. It is just his decision on how best to use them to meet his goals. I think at times we all get caught up in the more is better approach, when in reality many don't always want that. That's when the physician needs to be listening to what the patient is saying.

 

Thanks for the input. I was out of touch this past weekend at state time trials and unable to respond.

 

Brad Limmer, MD

[Guest Brad Limmer]

One last comment that I failed to touch on is that of medical therapy in a 60 year old. I saw a patient minutes ago that reminded me of this topic.

 

He is 64 years old and had his transplant surgeries in 1997 and 2001. He felt he had done well, but in the last 2-3 years feels both his donor zone and transplanted hairs have thinned out a bit.

 

What I feel is happening in these cases is something I have commented on before. That is while the fu density might not have changed much, the hairs per fu are decreasing. I don't know of a specific study looking at this, but strongly feel after 15 years of dermatology that this routinely happens to men in their late 60's through their 80's.

 

This loss is the reason I institute low level therapy, even in my older patients, or at least discuss it with them as an option.

 

Brad Limmer, MD

[spoon]

Originally posted by Bill:

 

Generally speaking again...

 

Are you saying that you don't believe more than 4000 grafts can be obtained in a single session given the proper donor laxity and density?

I think it's entirely possible to get more than 4,000 in a session.

 

I'm not sure we are talking about the same thing. If we are, then I'm not sure where you are getting your data.

From cases published on internet boards, from the reports of visits to clinics, from conversations with doctors, and from interpreting numbers after a long time of studying transplants.

 

I'll state it again, and feel free to dispute me with evidence.

The evidence is there. What were your hair counts in your surgeries?

 

I agree that each patient will have a varying average of hairs per graft. Patient A may be at 1.7 whereas patient B may be at 2.3 hairs per graft.

 

What I am arguing is...as a whole...when combining all the patients from one clinic, and if a clinic does NOT split FUs, and then comparing clinics...

 

The average number of hairs per graft including ALL patients should come out CLOSE to the same number.

 

Clinic A shouldn't have an average of 1.5 hairs when combining all their patients while Clinic B has an average of 2.1, etc.

 

One could ascertain that a clinic with too LOW of a number could be splitting FUs, while a clinic with too HIGH of a number might be combining them.

 

 

Very diplomatic. If that's what you believe then that's fine but from what I can see, if you could send the same patient to different clinics, the different clinics would come up with very different hairs-per-graft counts. Incidentally it doesn't mean that some clinics split grafts, per se, in order to jack up the price. I think it does mean that certain clinics have concluded that the smaller the grafts the more natural the result, or the smaller the incision, or the better the perceived surgical skill, or whatever...although I notice that when "less trauma from smaller incisions" is mentioned, it is not mentioned that you have to make that many more incisions...but I digress.

[Bill - Seemiller]

Spoon,

 

I think it's entirely possible to get more than 4,000 in a session.

 

 

Glad to hear it.

 

From cases published on internet boards, from the reports of visits to clinics, from conversations with doctors, and from interpreting numbers after a long time of studying transplants.

 

 

Can you provide the information please? Remember, we are talking about the average number of hairs per graft for every patient from that clinic. Please post hard evidence.

 

The evidence is there. What were your hair counts in your surgeries?

 

 

I don't know how this could prove or disprove your point. I am one patient. Cleary my results will vary from another clinic. I'm talking about clinical averages here, not patient averages. However, I don't have the numbers handy...but will try to find them and post them in the near future.

 

Very diplomatic. If that's what you believe then that's fine but from what I can see, if you could send the same patient to different clinics, the different clinics would come up with very different hairs-per-graft counts. Incidentally it doesn't mean that some clinics split grafts, per se, in order to jack up the price. I think it does mean that certain clinics have concluded that the smaller the grafts the more natural the result, or the smaller the incision, or the better the perceived surgical skill, or whatever...although I notice that when "less trauma from smaller incisions" is mentioned, it is not mentioned that you have to make that many more incisions...but I digress.

 

 

Maybe...but how is that different than splitting FUs?

 

If certain clinics believe that smaller grafts yield a better result, than natural FUs must be "split" into sub-FUs in patients who have large numbers of 3 and 4 haired FUs. Period.

 

The argument of whether or not a clinic splits FUs to make extra money is not being debated here. I know these clinics are out there.

 

All I'm saying is, if the averages of hairs per graft of all the patients from a clinic differs significantly from that of another, it can be safe to assume that the clinic has sub-divided FUs (regardless of their motivation).

 

Cheers!

 

Bill

[Bill - Seemiller]

Dr. Limmer,

 

He is 64 years old and had his transplant surgeries in 1997 and 2001. He felt he had done well, but in the last 2-3 years feels both his donor zone and transplanted hairs have thinned out a bit.

 

 

This makes sense. Thank you for the explanation!

 

Bill