How many grafts to restore hairline?

[Justin77]

Hello all,

 

I am a frequent lurker on these forums and have learned a ton about hair transplants here. I've been seriously considering a hair transplant and I wanted to get your opinion on approximately how many grafts I would be looking at in order to restore my hairline to a reasonable density.

 

Long story short: I started losing my hair 11 years ago and didn't use anything but Nioxin and Lasercomb for 4 years because I was worried about Propecia side effects. Then, at age 24, started the Big 3 and had remarkable regrowth. A large percentage of my hair came back, to the point where most people don't immediately think of me as a person with hair loss. I believe I've maintained all of this hair for the last 7 years.

 

Now that I'm older, I'm considering a hair transplant to fill in the thin area and see if I can get to a point where my hair doesn't look thin in photos.

 

My biggest problem area is the front of my scalp. I've attached photos so you can see what I'm talking about. The photos were taken under bright bathroom lighting.

 

Two questions:

 

1 - About how many grafts would I need to restore density in this area so that the hairline looks full again?

 

2 - I attached a picture of my donor area. Does it look dense enough to provide a reasonable number of grafts for a transplant?

 

Thank you!

[watch4norwoods]

Between 2000 - 2750 grafts for temple point, hairline, and frontal restoration. Ball park figure.

 

Donor area looks unusually thin.

[Justin77]

Unfortunately I think the donor area is going to look thin in pics now because I just got a new haircut where the sides and back are trimmed down to a 1-2, and the top part is left relatively long. I also took these pictures under a very bright bathroom light which may make it look worse than it is. I'll try to add some new pics under more normal lighting conditions.

 

Photography is not my strong suit

[Spanker]

I'd say about 2000. Hard to tell about your donor.

[Justin77]

Thank you both for weighing in. I think I'm going to try to do an in-person consult with a doctor in NYC. I want to know for sure that I would be eligible for a transplant before getting my hopes up, and after your comments, I'm worried about the donor area.

[WHTC-7706631290]

@Justin77

 

 

Hi. Nearly all of the grafts to restore this area should contain single hairs. These single-hair grafts should be meticulously placed to add at least half of the density that currently exists behind the hairline. What is essentially being recreated is the natural feathered orientation that must be established to maintain a totally soft appearance. Hairline work is by far the most important area merely because it is the most viewed area on the scalp.

 

The measure of your natural hair density would be significant in determining the appropriate number of grafts that are needed to properly treat the area. You may want to consider having more than one session to effectively manage your donor resources. Your donor density and donor hair characteristics will dictate your ability to achieve your defined goal(s). The examination of the donor and recipient area will also affect how cautiously you should approach surgical hair restoration. You can expect to experience more hair loss in the front, and it seems that your recession might advance to a class III A in the future.

 

 

The most important information that you can know is that it's very uncommon to treat this problem by simply having one single surgical procedure. The purpose of surgery is to create the illusion of coverage by minimizing the visibility of the scalp. Where most individuals lose the benefit from their results is when they don’t develop and retain realistic expectations. Individuals who desire surgery should realize that they may not have enough donor hair follicles to treat all of their recession in the future. Hair restoration by all means requires gross amounts of commitment. Each of us will define happiness based on varying degrees of expected results. Adequately maintaining expectations is a very critical part of realizing the benefits of hair transplantation.

 

Your hairline would look great with 1800 grafts. I don't see any benefit to lowering the current location of your hairline. I'd keep it where it is and add conservative density in case you experience significantly more recession in less time than expected.

 

Thank you for sharing the particulars of your case and using the community for its purpose!

[Sean]

This ultimately will also depend on the skill of the surgeon. For example: Some doctors with great yeild rates can fix/treat each norwood level using like 1000 grafts per norwood level. Then there are doctors that classify you as Norwood three, they do 3000 grafts and yet you may still remain a norwood three with very little cosmetic difference due to placement, graft death, etc.

 

In your case, i would tread carefully and see a doc in person. I highly recommend documenting each and every discussion you have with the doctor and ask as many questions you may have.

[Spanker]

I would also consider that you are headed to probably a NW5 eventually IF the finasteride doesn't hold out, so that should affect your plans for placement. I agree that you should see a doctor in person before booking a surgery.

[Justin77]

@WHTC

 

Thanks so much for your extensive reply. I completely agree with your suggestion of leaving the hairline exactly where it is. And I understand that I may need additional surgery in the future to maintain a decent look.

 

@Spanker

 

Why do you think I am headed to a NW5? Can you see that based on the pics? Just curious where you're getting that from.

 

---

 

On a related note, isn't finasteride supposed to work very well long-term for people who responded favorably in their first year? I'm getting that from this link:

 

10-Year Finasteride Study: First to Investigate Long-Term Effects and Safety | Bernstein Medical

 

I believe I've maintained nearly 100% of what I grew back after 7 years. As long as I continue to take finasteride, is it unreasonable to expect that I will keep most of what I have now?

 

I know nothing is guaranteed, and when planning this surgery, I'm definitely going to lean more towards the conservative end to make sure I'm OK for the future.

[Spanker]

 

@Spanker

 

Why do you think I am headed to a NW5? Can you see that based on the pics? Just curious where you're getting that from.

 

 

 

 

Yes.

 

Also, fin could work for you for a very long time.

[gillenator]

Justin,

 

Above all, getting on low dose finasteride was a wise decision IMHO. You have lots of native hair left and anything that you can do within reason to retain it is worthwhile.

 

Now, a couple of things. You have outstanding hair quality. That simply means that it appears that you have outstanding hair shaft diameter to your hair shafts. The better degree of caliber, the better chances of achieving the "illusion of coverage". Density is important but not as important as hair caliber. Why? Because the primary goal of HT surgery is attaining the illusion, not achieving the virgin density levels that you once had there.

 

What are your challenges? A couple. First, your donor density does appear to be on the low side. Even though it is cut down to a short length, it is evident IMHO. Only a closer physical exam and actual density eval will give you a more accurate idea of a range of harvestable grafts in your lifetime both in terms of FUHT or FUE.

 

The other challenge is your wide color contrast of dark hair on a fairer complexion. I have the same as you. Light reflects moreso with dark hair and another reason why your scalp shows more between your hair shafts.

 

How many grafts will it take? That really cannot be answered until you have your comprehensive in person consultation because the surgeon will work with you in drawing your hair line placement, and encouraging you to keep a mature placement and not juvenile. Once the proposed placement is drawn in, then your surgeon can give you a more accurate number.

 

Another thought. IMHO, it does not appear that you will have advanced stages of hair loss, but what is the best barometer is your own family history and how advanced the men on either side have progressed.

 

We all must remember that low dose finasteride is not efficient for the frontal zone where it appears that most of your loss is at this time. But where is it headed in the future? That's what you have to ask yourself and plan for.

 

So again, once your donor density is calculated and you are provided with a estimate/range over your lifetime, the choice you make in how many grafts you will use and where they will go is critical.

 

One last thing. If and I do mean "IF" you have an inkling that you will want to wear a buzzed hair style at any time in the future, "stay with FUE". And with a lower density donor zone, a strip scar would potentially stick out like a sore thumb. And trust me, you don't want that.

 

It appears that you are in NYC? Simply do a search within this community and you will find several examples of good FUE work in NYC.

 

Best wishes to you...

[Justin77]

Thank you gillenator for your very thorough reply! Really appreciate all the information you've given me.

 

It's interesting, I always have been told that I have thick hair from my barbers (except in the front). I wasn't expecting donor density to be an issue, but apparently it is because I've heard it several times now.

 

Either way, I'm definitely going to go see a doctor in person very soon. I'm really hoping that limited donor density won't prevent me from being a candidate for a hair transplant.

[watch4norwoods]

IMO hairline, and temple points are most crucial for aesthetics, and general satisfaction. Forget the conservative approach, and make this your priority. Given the right tools, and surgeon, most doctors will focus on these areas of importance while mitigating the use of grafts on the crown as this area takes up a large portion.

 

 

 

Don't be alarmed, if your hair loss is under control then an aggressive approach can be taken. RU58841 medication in addition to fin will completely halt hair loss.

[Justin77]

Another picture of the donor area close up...

Edited May 23, 2014 by Justin77

[Justin77]

IMO hairline, and temple points are most crucial for aesthetics, and general satisfaction. Forget the conservative approach, and make this your priority.

 

Honestly, if I could just get the appearance that Dermmatch currently gives me on the hairline, I'd be very happy. I'm perfectly content with the hairline shape I have now, including the temples, just not with the density of it.

[1978matt]

Another picture of the donor area close up...

 

I agree with everything Gillenator said. Your picture above also suggests you don't have many multihaired follicular units (3+ hairs).

 

Remember, the density you see at the back of your head is usually more than what you will get in the recipient area (i.e. the follicular units are spread out to cover a greater bald area.) If you wouldn't be happy with that level of density then it is probably not worth getting a transplant.

 

I wonder whether you might just take 1000 FUE grafts to even things out in the hairline and then maybe call it a day since you have a good shaped head for the buzz cut should the fin stop working.

 

Dr Wesley could be a good man to go and see.

[Justin77]

@1978matt

 

Thanks for your input. I actually called Dr. Wesley's office this morning to make an appointment being that I don't live far away, and it would be great to get an in-person assessment of my hair loss. Waiting to hear back from his office.

 

Regarding density, I'd be more than happy with the density from the back of my head in the front. I just got a haircut a few days ago, and within another week or so I won't be able to see through to any scalp at all in the donor area. Unfortunately I don't have recent pics of the back of my head at a longer length, though I will take some in a few days when it's longer to compare.

 

I did attach a photo from last summer of the back of my head at a pool party, when the hair is wet, and I think it looks thicker than the photos I've been posting suggest. I'm wondering if there's any possibility that the pictures just aren't telling an accurate story because of the lighting, skin contrast, and the fact that I have my hair cut very short (1-2) on the sides and back.

 

Either way, I'm definitely going to go for an in-person consultation ASAP. Getting a hair transplant has been a big goal of mine, and I'd rather know sooner rather than later if I'm just not a good candidate. I've been obsessing over this for the last few days and if it's just not meant to be, I'd rather move on.

 

Also, I Iike your idea about getting a small number of grafts for the hairline, if I can get away with it. Crossing my fingers that finasteride continues to work for many years to come.

 

@watch4norwoods

 

Forgot to mention this in my reply to you. I won't take RU58841 because even though I've done a lot of research about it online, it all feels too sketchy for me, and I don't like having to rely on only a couple of seemingly reputable sources for something that would be a large part of my maintenance regimen.

[gillenator]

Thank you gillenator for your very thorough reply! Really appreciate all the information you've given me.

 

It's interesting, I always have been told that I have thick hair from my barbers (except in the front). I wasn't expecting donor density to be an issue, but apparently it is because I've heard it several times now.

 

Either way, I'm definitely going to go see a doctor in person very soon. I'm really hoping that limited donor density won't prevent me from being a candidate for a hair transplant.

 

You're welcome Justin. The reason your barbers think you have "thick" hair is because they are seeing way above average hair caliber and as I pointed out, hair caliber covers the scalp visually speaking far more than density itself. So the tendency is to think, "Wow, what a thick head of hair" and they think in terms of density until the scalp is buzzed down to a number 1 or shorter. That's when the spacing between the FUs are more readily noticed.

 

I used to think that guys of African American descent had the thickest density but what I was seeing was the curl factor which covered more of the scalp surface. So really, density can be defined as the actual hair count within a defined surface area, or the number of FUs within the same surface area.

 

But then you put up another photo and now your donor appears considerably thicker than the first photo. It's probably the difference in the lighting but as I said, a qualified surgeon will do an actual density calculation in your in person consultation. Then you will know for sure what your potential donor reserves are.

 

A quick question. Are there any men on either side of your family history paternal or maternal that have reached Norwood class 5 or higher? Grandfathers, father, uncles, brothers, cousins?

[gillenator]

Forgot to mention after I read your comments about trying to get your hairline as thick as Dermatch could potentially make it. Trust me, you don't want to do that.

 

You have the type of MPB pattern that will decrease your overall density as you age. In other words, your entire scalp is probably going to get thinner verses large amounts of recessionary loss. The recessionary loss will follow the thinning eventually.

 

So if you surgically get your hairline too dense and you end up with more progressive loss, and you will, your frontal zone may look odd when you get into your thirties and forties. Nothing, and I repeat "nothing" stops MPB in its tracks. It's progressive in its genetic nature.

 

In addition you are using up so much limited donor, then where will your reserves come from in the future?

 

So I wholeheartedly agree with 1978matt about approaching FUE more conservatively to begin with. You would be amazed at how much of a difference 1000-1200 grafts to your hairline would make because of your outstanding hair caliber. Then, as you get older, you will have some donor left to draw from...

[Paulygon]

I'd say about 2000-2500.

[Paulygon]

I'd say between 2000-2500.

And I also think the meds can work for a while for you.

I had a similar trajectory (NW6A)

after HT I went on Minox and Finasteride.. still going strong on them.,

[Justin77]

@matt1978

 

I replied to you above but it wasn't until today that the post showed up because it was being approved by the moderators (guess I used a word that triggered a review).

 

@gillenator

 

What you're saying about hair caliber makes a lot of sense. Hopefully I have good hair caliber in the back, and when I go for a transplant, I won't need as many grafts for a good result. I'm still waiting to hear back from Dr. Wesley, but I may also go to visit Dr. Dorin after seeing his info in your signature.

 

Unfortunately there are several men in my family who've gone bald, including my brother, father, and grandfather. And they all went bald early in their 20s, all NW5 or higher.

 

But this brings me to what you were saying about nothing stopping MPB in its tracks. Isn't it true that finasteride has been shown to work long-term? In the 10 year study, it suggests that finasteride doesn't lose effectiveness over time, and in fact a lot of 10 year cases looked even better than they did at the 5 year mark. Also, as you get older, androgen levels decrease, which should mean a decrease in testosterone and DHT. In the 10 year study, it did show patients having better results as they aged, not worse as you might expect.

 

There are no guarantees, though, of course. I'm just hoping I'm in the camp where finasteride works for a very long time.

[gillenator]

Justin,

 

Just curious, how old are you? I mean my word, you still have a good head of hair and although many of the men in your family have reached Norwood 5, my guess is none of them took low dose finasteride for MPB?

 

Please allow me to clarify my prior comments about finasteride. What I meant by my statement that "nothing" stops MPB, is that "nothing stops the progression completely" and it is because of the progressive nature and behavior of MPB.

 

That being said, yes indeed low dose finasteride can have a very dramatic effect in slowing the "rate of progression". I started cutting Proscar in four pieces in 1996 shortly after my first HT procedure and it has stabilized my crown very well for 18 years now! My mid-scalp did further lose but at a very slow rate. And as you mentioned, the ongoing clinical trials of Propecia continue to show many guys realizing long term benefit of retaining their native hair.

 

It's more the frontal zone into the midscalp region that finasteride seems to have the least efficiency. And the manufacturer Merck readily notes that in their pharmacology disclosure that accompanies every package of Propecia.

 

It's interesting because minoxidil also does not seem to have much efficiency in the frontal region. Although some docs may recommend the post-op use of minoxidil in the recipient area for the purpose of "jump starting grafts", long term use in the frontal zone for native hair does not work for most men. Like finasteride, minoxidil works the best in the crown for most men.

 

And you will find Dr. Dorin to be honest and forthright with you. Both he and Dr. Robert True have performed some awesome FUE cases for some time now. I have been especially impressed with their hairline work because both yield and artistry have been very consistent.

 

Dr. Wesley appears to be very passionate about FUE and not sure that he has been doing FUE as long as True & Dorin however he joined this community several years ago and put up several threads regarding FUE. There are more docs doing FUE and some really refining their work.

 

The bottom line is to continue to do your due diligence and you will come to terms with what you want.

 

If I were you, and had the family history of MPB at those advanced classes, I would remain on the conservative side to start. In other words, don't drop your hairline too low, keep the density in the recipient area at 50% or less. I sincerely believe you will have an amazing result and transformation and be happy when everything grows out.

 

You always want to be sure that you have some donor reserves as you get older because you will need them as you get older.

 

And remember, you have outstanding hair quality up and above the average individual. In fact, you would be surprised at the result of keeping the overall density at 40% tops to start with because of your coarser degree of hair caliber. If you feel after one year that you want a tad bit more density, you can always go for more.

 

Anyways, I wish you the best Justin in your journey and final results...

[Justin77]

Thanks so much gillenator, you've been very helpful. I've booked an appointment with Dr. Dorin for next week and I'm looking forward to meeting with him. I researched some of his results on this site and they all look great.

 

Just to answer your questions... I'm 31 years old, and no, nobody in my family who went bald has taken finasteride. I'm the first. And thanks for explaining more about finasteride, it makes a lot of sense to me.

 

I'll keep you updated!

[JimmyNeutron]

Thank you both for weighing in. I think I'm going to try to do an in-person consult with a doctor in NYC. I want to know for sure that I would be eligible for a transplant before getting my hopes up, and after your comments, I'm worried about the donor area.

 

The thing is it's hard to tell because it's shaved. You should let it grow. But an experienced doctor will know by seeing the donor area regardless if it's shaved or not.