Dr. Cam Simmons – 8787 grafts in 3 sessions for a Norwood 6-7 patient

[Cam Simmons MD ABHRS]

This man had a Norwood 6 to 7 pattern of hair loss. He had average diameter, salt-and-pepper hair and average donor density and laxity. His goal was to work from front to back to cover as much of the balding area as possible. He accepted that he could run out of available donor hair or scalp laxity before covering the whole eventual balding area.

 

So far, we transplanted 8787 grafts in 3 sessions to his front, midscalp, lateral fringes, and anterior crown. He had 3197, 2565, and 3025 grafts. We now plan to transplant about 2400 grafts to build up his temporal hairlines and give better coverage in his crown. He will still have scalp donor hair in reserve for the future.

 

These photos were taken 13 months after his third hair transplant.

[RCWest]

After the 4th session he will have had roughly 11,000 grafts? That's insane for someone with such advanced loss. It gives real hope to people with less loss!

 

That aside, this is really a great case! Starting from nothing to a really nice head of hair for his age. Very natural!

[Davis91]

Excellent case doctor, well done. Lucky guy! Dr. Simmons, can you comment on the graft placement strategy that you took for each session? Cases like this are rare and informative.

[Mick from Farjo]

Dr Simmons,

 

That is one good looking mop of hair that he now has.

 

Mick

[aaron1234]

After the 4th session he will have had roughly 11,000 grafts? That's insane for someone with such advanced loss. It gives real hope to people with less loss!

 

Ditto. Wow! I'm amazed he had that much donor in the tank. Job well done.

[irishsailor]

That is one lucky man

[Mickey85]

Average donor density and laxity and still almost 11,000 grafts? Have Doctors been super conservative in the past in regards to how much they can safely extract without obvious scarring etc?

[Cam Simmons MD ABHRS]

Average donor density and laxity and still almost 11,000 grafts? Have Doctors been super conservative in the past in regards to how much they can safely extract without obvious scarring etc?

 

Thanks everyone.

 

Mickey85, RCWest, and aaron1234:

 

I still work under the assumption that an average man can have 7000 - 7500 scalp grafts with FUT if they go on to develop a Norwood 7 pattern. I think donor closures have improved and that may allow for more total grafts to be transplanted but it is too early to tell.

 

This man started in a similar trend to the past where he got 3197 grafts in his first session then got 2565 grafts after removing that scar as part of a narrower strip. He had routine undermining to prevent skin tension in his first session and had about a 1 mm wide scar but at his 2nd session he had more scarring below the skin than expected. At his 2nd session, I removed the old scar and undermined both edges and used a 2-layer closure to reduce tension. His scar after his 2nd session was still fortunately narrow but his scalp got tighter.

 

I estimated we could get about 1600 grafts in a 3rd session if we removed his scar. Thinking that his 3rd session might be his last but knowing there was still room in the safest donor area, he elected to leave the old scar and remove a new strip. I do not offer to create a 2nd scar for men in their 20s, 30s, or early 40s but in his case, the first scar was narrow and there was room above. I was also concerned about how much more scarring there might be around that scar under the skin surface.

 

He did some scalp stretching exercises and 22 months passed between his 2nd and 3rd sessions. (I usually recommend waiting a year between 2nd and 3rd sessions but life happened.) His flexibility improved and with a new strip and we were able to get 3025 more grafts. That strip was removed with scoring-blunt dissection and closed with a 2-layer trichophytic closure. His scalp flexibility is better now than after his 1st session. We will be able to remove the top scar and he will be left with 2 scars in the safest part of the donor area and will still have strong hair above the top scar. He should keep his hair at least 3/4 inches long to hide both scars.

 

We limit the depth of our donor incisions now more than we did when I started transplanting in 1999 and I believe that reduces scarring, and vascular damage. Minimizing transection along the strip edges gets growing hair closer to the edges of the scar. Since adopting Dr. Tykocinsky's technique of 2-layer closure, I feel that we get narrower scars on the surface of the skin but also less scarring underneath. It also seems that we don't lose as much laxity as before. I suspect that closing the fat layer prevents the scar from tethering down to the Galea. These are impressions and suppositions only and are not tested or proven theories.

 

While I am glad that we stayed within the safest zone and got as many grafts as we have for this patient I cannot promise that many for everyone.

[Cam Simmons MD ABHRS]

Excellent case doctor, well done. Lucky guy! Dr. Simmons, can you comment on the graft placement strategy that you took for each session? Cases like this are rare and informative.

 

Thanks Davis91. I will answer your questions but want to put together a few more photos first.

[Cam Simmons MD ABHRS]

Excellent case doctor, well done. Lucky guy! Dr. Simmons, can you comment on the graft placement strategy that you took for each session? Cases like this are rare and informative.

 

Davis91

 

Thanks for your question.

 

He had a large balding area because of the length and the width. We started with a slightly higher and receded hairline to shrink the area a bit.

 

We try to have a balanced natural pattern after each session but knew it would take 2 sessions to cover the front and midscalp. If he wanted a more gradual approach we could have aimed for lighter coverage over a bigger area in the first session. After it was fully grown we could go back and fill it in more in a second session. He was committed to returning for the 2nd session shortly after the first. We therefore worked from front to back so he would look finished in the frontal view faster.

 

In his first session, we mostly created a frontal forelock that joined to his lateral fringes. we reduced the density gradually as we worked back from his hairline. It went from about 49 grafts per sq cm behind his hairline to 36 then we faded out at the back of the area to blend with his miniaturizing natural hair.

 

He returned about 10 months later for his 2nd session. He decided that he was likely to wear a left part as he did before. We therefore transplanted his midscalp and reinforced the left part. As people naturally may have a bit stronger hair in their midscalp band, we increased the density to 42 then dropped to 36 and faded again. (We went back further than the originally marked area.)

 

He waited about 20 months before his third session. In that session we filled in the back of the first area a bit more then worked further back in his anterior crown at about 30 grafts per square cm and faded again.

 

In a 4th session, we can improve his temporal hairlines. We will also transplant his crown at 30-36 grafts per square cm and can expect light coverage. (Hair grows just as well in the crown as anywhere else on the scalp but it looks thinner at the same density as in the midscalp because of the hair direction from the whorl and because of the vertical angle of the skull.)

 

His hairline and front were finished in the first session. I have attached top view photos of the plans for the 3 sessions and how he looked before each session. I have also attached side view photos after each session.