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How soon for second procedure


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  • Regular Member

If you are talking about FUT, one reason is to allow your scalp elasticity to return to normal so another strip can be taken. Also, it's a good idea to allow time for all your grafts to grow out from the first procedure. A year time period usually satisfies both of these.

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Full healing and stretching of the scalp to allow another excision and limited tension closure takes a while. 12 months is better than 6 and easy to remember, and since some people are slower healers than others, most doctors probably wait 12 months to be on the safe side. I do.

 

Also, I prefer the patient to know that the first one "worked" before paying for a second procedure. They are more relaxed and it just goes more easily than a second "leap of faith".

 

That said, we have done roughly 1 second case at 6 months per year, always in someone who was leaving the country for an extended time frame and who wanted to have a second surgery with me rather than wait 4 or 5 years. Interestingly all of those have promised to send pics...and only one has. Several send a thank you email or card but it would be nice to have a bit more followup from my selfish perspective.

 

Bottom line, waiting 12 months is likely the standard of care currently.

 

Dr. Lindsey McLean VA

William H. Lindsey, MD, FACS

McLean, VA

 

Dr. William Lindsey is a member of the Coalition of Independent Hair Restoration Physicians

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  • Senior Member

There are two issues with this topic. Regaining adequate scalp laxity as stated, and then maturation of the previous procedure.

 

From the previous posts, scalp laxity was addressed. And I agree that regrowth needs to take place before scheduling a follow-up procedure.

 

The truth of the matter is that most men and women suffering from MPB will need or should I say will want more work done as they continue to lose hair. Or they have experienced some level of stabilization from various hair loss meds and they desire to add coverage and/or density. Very few people will get by with a single procedure in their lifetimes. I sometimes hear from guys who say I just want to do this one procedure and get my hair loss done with. They realize later that MPB is indeed progressive and not curable.

 

So the question at hand is, "How soon should I go back for the next one?"

 

Providing adequate scalp laxity has been regained and tested, the regrowth should not only be fully completed but also the wait for caliber maturation. That can potentially take up to 15 months or so post-op. That's the ideal, not necessarily the industry standard.

 

Why do I say that? Because IMHO, hair shaft diameter (caliber) is the single most critical factor to be considered when attaining the "illusion of coverage". Let me explain. HT surgery should never and I repeat never be a goal of replacing what once was there in terms of density. Most of us do not need that but rather if the average patient can attain approximately 50% of that original density, then they will appear or look restored.

 

Then is there any other variable? Oh yeah! It's hair caliber. Too many times we get hung up on the graft count/numbers when IMHO, it should be the matured result. As with anything else, we all respond differently. Some grow and mature quicker, some slower.

 

I remember after my third procedure of 2417 strip grafts. Most went to the frontal third zone yet even after one year I could still some see light reflecting off of my scalp. I also have a wide color contrast. My conclusion? More surgery!

 

Then something magic happened after I was approximately 15 months post-op. My wife noticed it first. One day just like that, it appeared that I had better coverage. Notice I did not say more coverage. The magic was that you could not see "any" light reflecting off my scalp. It looked fuller and healthier.

 

My doctor confirmed this when he did my routine exam for the procedure and also for miniaturization in other areas of my scalp. All along the way they took digital shots of my recipient area and saved them. Each follow-up my doc kept telling me that there would be visual improvement. He showed me the transplanted hairs under a scope and at my 18 month follow-up, they were all just as fat (degree of caliber) as my other terminal hair in the donor zone where they were harvested from.

 

Then he said, "this is why you cannot see your scalp anymore". He also said another procedure was not necessary based on my goal of looking restored.

 

I became a believer in waiting for each and every procedure to "fully" mature. As long as we remember that there are some slight variations in the post-op timetable...;)

Gillenator

Independent Patient Advocate

I am not a physician and not employed by any doctor/clinic. My opinions are not medical advice, but are my own views which you read at your own risk.

Supporting Physicians: Dr. Robert Dorin: True & Dorin Medical in New York, NY

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  • Regular Member

I agree with Gillenator's statements entirely. Month 6-12 is where you see the most dramatic change with your transplanted hairs surfacing, but it's not until the 14 to 18 month mark where the transpalnted hairs fully mature with greater texture and calibur. This held true on my first procedure and I am hoping the same holds true for my second procedure as I am almost 15 months post op from the second. Everyone is usuallly a bit different, but the 12 month timeline is an average. The true "final" result isn't until the 18th month in my situation.

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  • Senior Member

I agree with the comments made above. Like Dr. Lindsay, we also encourage patients to put 12 months between sessions. I also make one or two exceptions with shorter intervals, usually for the same reason - namely, that someone is returning to their native country and won't be able to get back to see me a year from then.

Two other reasons that weren't mentioned are that waiting the year is necessary for the blood supply (vascularity) of the scalp to return to normal to support the new grafts and to be able to respond to the new added injury that all these recipient sites bring about. The second additional reason is to make sure almost everything is growing, so that we don't trample on a graft that has already been placed.

There are good studies showing that the diameter of the new hairs increase over the first 15-18 months. I also, as the commentator before me above said, encourage the men and women we transplant to wait till 18 months to make a decision as to whether or not they think they need another procedure. This applies to those patients who are trying to accomplish their hair replacement in the fewest number of sessions. Twelve months is too early to judge the final results.

A fifth reason for the one year wait, and a selfish one on my part, is that I am much more likely to get some "wow" pictures if I see the patient then, rather than at 9-10 months.

Mike Beehner, M.D.

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  • Regular Member

Dr Beehner:

 

Can you please expand on the blood supply issue. If I understand what you are saying its that when you do the first procedure it puts starin on the blood supply in the scalp to support the new grafts and thus you need to give it some time adjust. If you do another proceudre to early there will simply be too much strain on the blood supply to support the additional grafts.

 

Does your opinion change however if you are doing smaller procedures so that the first procedure does not cause a major strain on the blood supply allowing a second proceudre to be done in a quicker interval. How about if the seocnd procedure is done in a completley different area of the scalp than the first.

 

I have heard some doctors claim that in a perfect world it woud be better to do several samller sessions than one big one. It seems to me that one viable startgey would be to do several small proceudres over a 12 month period rather than one large session as it wouldd allow for the patient to be evaluated in his/her reaction to the grafts, scarring , healing etc. Obvioulsy the receipient areas would have to be in diferent areas of the scalp and each procedure would probbaly require going into a different part of the donor area to avoid scalp laxity issues but it seems (assuming the patient had the time for it) to be a vaiable way to go.

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  • Senior Member

Regarding the blood supply to the scalp, we know a couple of things: One, there is a limit to how much injury you can do to the scalp before bad things happen. Most hair surgeons have seen or heard of cases of localized scalp necrosis . This is basically a "black hole", or more accurately, a black scar. Scalp necrosis is like a full-thickness burn, in that the damage if "full thickness" and cannot heal "from the bottom up,"but rather has to heal from the edge inward, for which there is only a limited distance this can cover. Some of these patients require skin grafts to get skin coverage. That's one extreme.

On the other hand we know that the blood supply of the scalp is awfully good. There are ten separate arteries that supply arterial, oxygenized blood to the scalp and they cross-circulate or collateralize - the two most important ones being the paired occipital arteries in the back and the superficial temporal arteries just in front of and above the ear in the temple area. These latter two are the most important ones.

Obviously, the blood supply is totally "virgin" at the time of the first transplant, which means a doctor would have to really brutalize the scalp to have necrosis following that first surgery. Most hair surgeons accept the fact that some degree of "micro-scarring" occurs following any surgery. Also, in taking a donor strip, a surgeon could transect one or more of these arteries. When enough time, usually several months or more, elapses, the body has the ability for the arterial supply of an area to develop a tremendous increase in "collateral" circulation, which means that other small vessels enlarge and increase their flow to an area that was partly damaged. On a microscopic scale, this happens in the scalp. As an arbitrary figure, 12 months is the interval most of us like to have as a minimum between transplant sessions. Doing things such as not cutting arteries, using "depth control" in making the sites, and avoiding excessive use of adrenaline in the injected solutions all help protect the scalp's circulation. The main network of small arteries resides deep in the subcutaneous layer (fatty layer) of the scalp where the lower part of the follicles are. Limiting the depth of the sites to 4-5mm usually avoids hitting these small arteries and arterioles.

In the old days before 1990 or so, it was common to do sessions of 60-100 large grafts 4-5 months apart, even as few as 3 months apart. This was partly due to the fact, as you suggested, that the sessions were very small with regards to the square area the grafts covered. Whatever injury occurred was confined to a relatively small area. If a second follow-up surgery is done in a totally different area, such as the rear crown when the first session was in the frontal area, one certainly could make an argument for being able to safely do that second surgery at 5-6 months, which I have done on rare occasions.

I think we are all trying to follow the "better safe than sorry" rule of thumb, and we all live in dread of ever having a patient of ours develop a necrosis area in the scalp.Respecting the scalp's circulation also helps avoid poor growth of the grafts planted.

Mike Beehner, M.D.

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