Do you count 1,500 grafts? Repair case - Dr Blake Bloxham, Great Neck, NY

[Dr Blake Bloxham]

Another one I thought you guys mind find interesting:

 

We had a repair patient come in today. Well, "repair" may be a bit of a strong word. You might say he needed more of a "finishing" than a repair. The patient told us he had 1,500 grafts transplanted in two separate sessions (one of 700 and one of 800) at another clinic. Despite having 1,500 grafts transplanted into the macro and micro hairline (frontal "band") he was left with a sparse appearance -- and multiple strip scars, for some reason.

 

Let me show you what I mean:

 

Here are his before shots. The area we marked out to work in is where he had 1,500 grafts placed before:

 

 

 

 

 

Doesn't look like 1,500, right?

 

Now we do quite a bit of repair work, and we see scenarios like this frequently. Patients were told they received a certain number of grafts, but the results suggest otherwise. What are the causes of this?

 

Well, there are always the few "classic ones:" they didn't grow; they weren't actually transplanted; they weren't actually removed (eeek!!); or the patients were just, for whatever reason, told a different amount.

 

But every once and a while, something else occurs. This is actually the second case we've seen recently. I'm going to post his intraoperative shot. Tell me if you guys see what we saw:

 

 

A few things:

 

1) If you zoom in on the picture, you'll see that he has a lot of native hairs further back (shaved down). But you'll also note that the transplants are mainly near the hairline and don't seem to add up to 1,500 grafts.

 

2) But there is something else interesting: look at the grafts closely (as closely as you can in that picture). If you zoom in closely, you'll see that they are almost exclusively single haired FUGs.

 

For whatever reason, it looks like his old clinic cut all the FUGs into single hair grafts. This may happen for several reasons: clinics want to increase their graft numbers; or the multi-haired FUGs are large or splayed at the bottom and won't fit into the incision sites; or maybe they don't customize incision sites or vary the size of the needles or blades they use.

 

Regardless, it needed to be fixed.

 

So here's what we did:

 

 

 

 

Standard dense pack! We ended up transplanting 1,500 grafts (ironically), and think it will really make a big difference for this gentleman. We were also able to revise his scar(s) at bit as well.

 

I think the problem cutting the multis into singles here is twofold: 1) obviously the coverage isn't sufficient; 2) Cutting down multi grafts into singles introduces unnecessary risks/damage and decreases yield.

 

What do you guys think? Did they cut down multis into singles? Either way, how many would you say grew?

[88mph]

The coverage from his first op really is sub par. Interesting I thought that cutting down larger graphs was the norm. I had an fue procedure with Dr Path 4 months ago. The doctor used 1s, 2s, 3s, 4s but he said that they never extract singles by themselves as the transection rate was much too high on singles. So they extract 2s and 3s and then cut them down to singles. Does this sound normal?

[Dr. Alan Feller]

Not to me it doesn't. In fact, very often when attempting to get a multi hair follicular unit during FUE one or two of the hairs are avulsed leaving just a single hair graft. That's why I have all my FUE grafts examined under a microscope to see if there are damaged follicles or parts of follicles in a grouping. The techs cut away the injured parts and create a single hair FU out of it. I think I may have cut down the multi grafts of maybe two patients in my entire career to obtain a needed number of single grafts.

[88mph]

Yes Dr Path does the same, all fue grafts are examined under microscope, trimmed and discarded if damaged. I think because of the danger in transection is higher with fue the doctor predominantly aims for 2s. If he gets that and extracts it perfectly, great. If not it may be able to be spliced so as to get a viable single.

[Dr Blake Bloxham]

88,

 

Sounds like he's being very meticulous. I'd expect nothing less from Dr Path! Sounds like you're in the "relax and grow" phase now. I hope you'll keep us updated on your progress.

[Dr Blake Bloxham]

UPDATE:

 

This patient sent me photos of his 4 month progress. He's been lucky to have some early growth of the new grafts and re-growth of the old work we shaved down. He's very pleased with how things are progressing thus far!

 

Here are a few images:

 

Here is an image showing his before (after he had 1,500 grafts in the frontal third from another clinic) and his 4 month progress:

 

 

And here is a comparison showing his before, his immediate post-op, and his 4 month progress:

 

 

It's always nice when patients have early growth. Especially in repair or "finishing" cases like this one!

[bunsenburner]

Dr Bloxham:

 

You mentioned "early growth of the new grafts at 4 months." Should patients generally not expect this type of growth 4 months post-operatively? Did the prior transplants accelerate the growth rate?

[Dr Blake Bloxham]

Bunsen,

 

Sorry for the delay.

 

I don't think most patients should expect this type of growth at 4 months. It truly is early growth. Most people are only around 20% matured at this point (meaning the grafts that have started growing are only about 20% as thick as they will be at 12 months) and many transplanted hairs haven't even broken through the surface.

 

I often see patients grow quicker during their second transplant. I think it has to do with the fact that the body has already grown a better blood supply to this portion of the scalp during the first procedure. I don't know if I've ever seen a study on it, but they do seem to grow a little quicker. I'm not sure I'd say the transplants accelerate the growth for any other reason besides the better blood supply, but they do seem to grow a little faster.

 

By the way, the patient stopped by a few weeks later -- around 5 months post-op -- and we obtained some video footage. It shows how quickly he's growing in, but also shows how the hairs are clearly still immature and how much thickening he still has to look forward to!

 

[voxman]

I think the 4 month photos are actually the result of the 'full moon' effect.

 

The dude is obviously a werewolf.

[mrkellymac10]

This gives us repair patients some hope!!!!

[bunsenburner]

Dr Bloxham:

 

Thank you for the explanation. The vascular theory sounds logical to me. The patient looks good in the video too. I hope to receive updates.

[DeckerG]

Hey Dr Bloxham,

I just want to update you on my progress. You and Dr Feller did a terrific job. I am very happy with the results

[harryforreal]

With regards to the vascular theory, Dr. Bloxham, is it possible that transplanted grafts can get TOO much blood supply and grow super thick?

 

Strange question, I know, but...

[Dr Blake Bloxham]

Decker,

 

I didn't even know you were following the thread!

 

Thanks for adding more images. You look excellent! Truly look forward to seeing more updates in the coming months.

[Dr Blake Bloxham]

Harry,

 

Interesting thought.

 

I don't think you would ever see an overabundance of blood supply to the follicles. The body has mechanisms to shunt blood to other areas when its not needed, and I think you would have some sort of compensation here. What's more, I think you'd also reach a saturation point where the follicles would be as fat and healthy as they could be, but couldn't do much more with additional blood flow.

 

So, I don't think you could ever see "too much of a good thing" with regard to blood flow to the follicles, nor do I think you could grow super follicles with an overabundance of blood supply.

 

But definitely a a great question. I'll update you if anything else comes to mind.

[DeckerG]

Yes Dr Bloxham! I have to clarify about the 6 mos post-op pic; i thought by adding "auto sharpness" would show the details but i noticed it made no justice to your work, so no more sharpness in the future

[bunsenburner]

Decker:

 

Congratulations. The results look great. And it seems you are experiencing early growth and have even more to go.

[DeckerG]

Decker,

 

I didn't even know you were following the thread!

 

Thanks for adding more images. You look excellent! Truly look forward to seeing more updates in the coming months.

 

Hey Dr Bloxham

Here is my 8 mos post-op pics. Everything is going well

[Dr Blake Bloxham]

Decker,

 

Thanks for the update! Still looking very, very good. And you're still only around 60% matured. Definitely one of those lucky "early mature-ers."

 

In fact, I actually made a video about this a few weeks back and used your case as an example:

 

 

 

I hope you can stop by the office for some official photos between the 12-18 month mark.

 

Until then, happy growing!

[DeckerG]

Decker,

 

Thanks for the update! Still looking very, very good. And you're still only around 60% matured. Definitely one of those lucky "early mature-ers."

 

In fact, I actually made a video about this a few weeks back and used your case as an example:

 

 

 

I hope you can stop by the office for some official photos between the 12-18 month mark.

 

Until then, happy growing!

 

Great presentation Dr Bloxham! and I will continue to keep you up to date with my progress. Looking forward in seeing you and Dr Feller in 12-18 months. Keep up the good work!

[Dr Blake Bloxham]

Sounds good! See you then. Look forward to more updates in the meantime.

[SatyamHair]

Yes Dr Krishan Arora does the same, all fue grafts are examined under microscope, trimmed and discarded if damaged.

[pkipling]

These results are fantastic. Good to see that the patient now knows what 1,500 grafts actually looks like, because that first op didn't look anywhere close to 1,500. Great work.

[Dr Blake Bloxham]

Thanks, PK. He's very happy. I'll get him back in sometime between the 12-18 month mark for some official pictures!

[DeckerG]

Hey Dr. Bloxham,

Here are some pictures of my 10 mos post-op. I tried my best to take better pictures; and as always, I'm very happy with the results