**VIDEO** Working out after hair transplant? Feller and Bloxham, Great Neck, NY

[Melvin- Admin]

IMO he didnt need an hair transplant, maybe few years down the line. I think he was better of having FUE than FUT.

 

Yea I agree, his hairloss was minuscule depending on his age I'd say his hairline was actually normal if he's in his late 20's early 30's. It's interesting Blake you've stated that scar stretching is unpredictable, that's the very reason why a lot of men stay away from FUT so I'm glad you've addressed this concern with sincerity, I made the same point several times before but it was never addressed.

[Dr Blake Bloxham]

2014,

 

A poster who shall not be named?? How intriguing. Haha. Does this poster's name start with a J?

 

If so, not the gent you're thinking of. I don't think the patient in this case series posts online.

[Dr Blake Bloxham]

Bobby and HTSoon,

 

Again, thanks for commenting!

 

Definitely an interesting perspective on what patients want and how they perceive their own hair loss. I get patients in all the time who have excellent hair, but can't help but focus on a little spot here or there that no one would ever notice. Usually, the best thing to do with these guys is tell them you don't recommend surgery. Other times, we will see a very high NW patient who only wants to address his crown or something along these lines!

 

Again, HTsoon, I must correct your statement a bit: there will always be some variability that is up to the patient's own physiology. However, I do believe we have enough screening tools to identify a broad category of patients who I have every reason to believe will be "normal healers." Take a look at the post I just shared with Mag as well. It will explain more of the in depth analysis we can do as well, and how this helps us identify and classify patients. Probably less of a unknown that you'd think!

[MAGNUMpi]

Magnium,

 

No, I don't think Calvin went to a bad doctor necessarily. I don't know anything about his strip surgeon, to be honest! I was merely commenting on the importance of doing your research. I always recommend this!

 

You bring up two important points that I do want to address. Frankly, I think one deserves its own thread and I may make it in the future. But I'll discuss it a bit here:

 

1) Are bad/stretched scars a rarity or a common occurrence?

 

Frankly, I really should bounce this question to my good pal Dr Lindsey. He's a facial plastic surgeon and scar healing is a bit of an obsession for him. The man even grades his own scars and openly reports the winners and less-than-winners to the community! Impressive.

 

Dr Lindsey does a very meticulous layered closure and stands by the fact that somewhere around 28 out of 30 of his incision sites heal up nice and thin. He says the other two stretch a bit and he's not as happy. But I don't think I've ever seen him share a big disaster case -- and he's the kind of guy who absolutely would share it. And the ones that don't heal the way he wants ("A" grade) are still very easily concealed with the "3 guard" level I tell all my patients.

 

We close with staples and I believe get the same ratio/effect. The worse stretching I've seen thus far has been a few millimeters, and it's still very easily concealed.

 

Do I think it's the 25% Dr Shapiro claims, or closer to the 2 or so cases out of 30 Dr Lindsey claims? I suppose it's going to vary all over the place, but I see similar results to Dr Lindsey's assessment. I think if you limit the width of the strip (which sometimes means not doing the 6,000 graft HUGE FUT cases, and I know this isn't as sexy or fun), and close it up nicely, I usually feel very confident with the way the patients heal and give them the same speech about "fade cuts and 3 guards."

 

I also think the disaster scars we see online have something in common, and it brings me to your next question:

 

2) What role does laxity play?

 

I really should make another thread about this, and it's actually something Dr Feller and I are experimenting with at the moment, but there are two types of "laxity" and each plays a role in closure (and it's different than what you'd assume):

 

There are two types of laxity: the intrinsic stretch or laxity in the skin, and the "give" in the scalp caused by how the entire scalp is attached to the deep layers and the bony skull itself. Both are going to affect how the scalp will stretch during and after closure. If the scalp is loosely attached to the deep layers, the skin is going to have a tendency to separate further from the wound. There is also the intrinsic stretch in the skin (which has more to do with the collagen we discussed above). This is different than the first type of laxity, but still allows for more natural stretching.

 

So imagine the following two scenarios: You remove a 1.5 cm (wide) strip from two patients. One has a scalp that is very loosely attached to the deeper tissues and, because of this, doesn't stay in place when the strip is removed and, instead, tends to creep away from the incision site. This same patient also has a lot of natural laxity or "stretch" in his skin. When we close this gentleman, we have two things working against us: 1) the scalp doesn't have firm deep attachments and will naturally drift away from our staples. and 2) the intrinsic qualities of the skin itself let this happen! This isn't going to scar well.

 

Now imagine patient two: he's locked down to the deep layers, and taking a strip from one portion isn't going to affect the areas around it because they are locked down. He also has hard, "non-stretchy" skin that won't allow for pull away from the staples either. This guy's closure is like stacking cinder blocks. He comes right together and doesn't move a millimeter!

 

Now, most people are somewhere in between and therefore the results are somewhere in between as well. The scar won't be an invisible seam like it will be on the second patient, but it also won't look like stretched silly putty like the first (and I don't mean to make light of this issue here). It will end up being a thin line across the back of the scalp. Maybe 1-2 mm if he has one quality a little worse than the other? So in this sense, I think my opinion may differ from the norm. But I do feel like an increase in both types of laxity leads to increased potential for scar stretching.

 

Does this make sense?

Awesome and very informative reply. Thanks Blake. Yea, this does makes sense. I had never even heard about ""the give" in the scalp caused by how the entire scalp is attached to the deep layers and the bony skull." being a factor. Interesting stuff.

[destorius]

James/Des,

 

Thanks for the kind words! People seem to like the video format, so we'll keep making them! And let me apologize, in advance, for those who don't want to see our mugs that many times a month!

 

I agree that your comment is fair game and I'll absolutely address it. Unfortunately, Dr Feller feels the same way. And I wish it wasn't the case. But, it does make sense if you think about it: we, based on experience, studies, et cetera, believe that the quality and quantity of FUE growth is less reliable. The hairline is your money shot. Frankly, it's everything in HT surgery. I tell high NW guys daily that If I only recreated a solid hairline and re-framed your face, you essentially wouldn't look like a "bald guy" any longer. Obviously I don't actually recommend creating a floating hairline on these guys, but it's a good example of the power of the hairline. And this is why we need the powerhouse grafts here. I just can't risk missing pieces or unnatural growth up here

 

So, where and how do we do it? Despite the controversy, we actually do quite a bit of FUE. It's done in small sessions and meticulously done with all manual scoring, manual delivery, and microscopic inspection before anything is implanted. Don't tell anyone either, because I don't want it to ruin my rep, but I actually really enjoy doing it too!

 

Most of the cases we do are on patients who had FUE before and are looking to add density to certain areas. Again, not a jab at the procedure, but the reality of what we see. Because of this, we invariably end up placing some in the frontal scalp from time-to-time. We also have patients who are coming back for another pseudo-planned small session and end up doing the same. However, we never really start off this way. Most of where we end up placing FUE grafts are in the areas behind the hairline -- as this is more camouflaged and where you need more density than anything else. But we also place in the midscalp, vertex/crown, et cetera.

 

Frankly, I do think I have an answer to this problem. But that's another thread for another time. Hahah. PM me if you'd like to discuss it further.

 

Hope this helped!

 

Thanks for such an honest and informative reply. I can understand why you would take this view following your view on possibly variable yields on FUE. Bit disappointed from a personal perspective as this is where Dr Feller put 1010 FUE grafts into me in 2011! perhaps this view has evolved in the last 4 years.

 

Thanks again for giving me your input.

 

James

[mav23100gunther]

Magnium,

 

No, I don't think Calvin went to a bad doctor necessarily. I don't know anything about his strip surgeon, to be honest! I was merely commenting on the importance of doing your research. I always recommend this!

 

You bring up two important points that I do want to address. Frankly, I think one deserves its own thread and I may make it in the future. But I'll discuss it a bit here:

 

1) Are bad/stretched scars a rarity or a common occurrence?

 

Frankly, I really should bounce this question to my good pal Dr Lindsey. He's a facial plastic surgeon and scar healing is a bit of an obsession for him. The man even grades his own scars and openly reports the winners and less-than-winners to the community! Impressive.

 

Dr Lindsey does a very meticulous layered closure and stands by the fact that somewhere around 28 out of 30 of his incision sites heal up nice and thin. He says the other two stretch a bit and he's not as happy. But I don't think I've ever seen him share a big disaster case -- and he's the kind of guy who absolutely would share it. And the ones that don't heal the way he wants ("A" grade) are still very easily concealed with the "3 guard" level I tell all my patients.

 

We close with staples and I believe get the same ratio/effect. The worse stretching I've seen thus far has been a few millimeters, and it's still very easily concealed.

 

Do I think it's the 25% Dr Shapiro claims, or closer to the 2 or so cases out of 30 Dr Lindsey claims? I suppose it's going to vary all over the place, but I see similar results to Dr Lindsey's assessment. I think if you limit the width of the strip (which sometimes means not doing the 6,000 graft HUGE FUT cases, and I know this isn't as sexy or fun), and close it up nicely, I usually feel very confident with the way the patients heal and give them the same speech about "fade cuts and 3 guards."

 

I also think the disaster scars we see online have something in common, and it brings me to your next question:

 

2) What role does laxity play?

 

I really should make another thread about this, and it's actually something Dr Feller and I are experimenting with at the moment, but there are two types of "laxity" and each plays a role in closure (and it's different than what you'd assume):

 

There are two types of laxity: the intrinsic stretch or laxity in the skin, and the "give" in the scalp caused by how the entire scalp is attached to the deep layers and the bony skull itself. Both are going to affect how the scalp will stretch during and after closure. If the scalp is loosely attached to the deep layers, the skin is going to have a tendency to separate further from the wound. There is also the intrinsic stretch in the skin (which has more to do with the collagen we discussed above). This is different than the first type of laxity, but still allows for more natural stretching.

 

So imagine the following two scenarios: You remove a 1.5 cm (wide) strip from two patients. One has a scalp that is very loosely attached to the deeper tissues and, because of this, doesn't stay in place when the strip is removed and, instead, tends to creep away from the incision site. This same patient also has a lot of natural laxity or "stretch" in his skin. When we close this gentleman, we have two things working against us: 1) the scalp doesn't have firm deep attachments and will naturally drift away from our staples. and 2) the intrinsic qualities of the skin itself let this happen! This isn't going to scar well.

 

Now imagine patient two: he's locked down to the deep layers, and taking a strip from one portion isn't going to affect the areas around it because they are locked down. He also has hard, "non-stretchy" skin that won't allow for pull away from the staples either. This guy's closure is like stacking cinder blocks. He comes right together and doesn't move a millimeter!

 

Now, most people are somewhere in between and therefore the results are somewhere in between as well. The scar won't be an invisible seam like it will be on the second patient, but it also won't look like stretched silly putty like the first (and I don't mean to make light of this issue here). It will end up being a thin line across the back of the scalp. Maybe 1-2 mm if he has one quality a little worse than the other? So in this sense, I think my opinion may differ from the norm. But I do feel like an increase in both types of laxity leads to increased potential for scar stretching.

 

Does this make sense?

 

Dr, quick question, does this mean you do not recommend performing scalp laxity exercises in advance of a strip surgery?

[Sethticles]

Seth,

 

Haha. Good point, my friend! I'll try to keep my ADD-esque posting to a minimum! Haha.

 

i really do enjoy your good cop role, in the F&B camp, don't every stop

[gbhscot]

Very informative! Do you feel there might be some benefit in HT patients beginning supplementation with collagen in advance of a FUSS procedure?

[Dr Blake Bloxham]

Seth,

 

Will do! ; )

 

Mav,

 

Excellent question. The point of the scalp laxity exercises is just that: increase the stretch in the scalp in order to take a wider strip on surgery day. And to an extent, they do work. However, it bounces back to what I said above: in our observations, decreased attachment to the deep layers (the first type of laxity) will allow you to take a bigger strip, but this may also increase your risk of stretch. What's more, we really have cutoffs for strip widths because we've found a "sweet spot" where we are able to maximize yield while minimizing scarring and really avoiding any issues with wound healing. So we rarely need patients to stretch themselves out more than the width we normally take. However, all clinics are different and I do recommend discussing this with your surgeon personally -- if you do go down this route.

 

GBH,

 

First, I did receive your email and I'll reply this AM. Second, great question! I'm not really sure if there is a way patients can supplement collagen themselves. But I absolutely do think increasing the amount in certain areas would enhance the phenomenon I described above.

[MAGNUMpi]

Excellent question. The point of the scalp laxity exercises is just that: increase the stretch in the scalp in order to take a wider strip on surgery day. And to an extent, they do work. However, it bounces back to what I said above: in our observations, decreased attachment to the deep layers (the first type of laxity) will allow you to take a bigger strip, but this may also increase your risk of stretch. What's more, we really have cutoffs for strip widths because we've found a "sweet spot" where we are able to maximize yield while minimizing scarring and really avoiding any issues with wound healing. So we rarely need patients to stretch themselves out more than the width we normally take. However, all clinics are different and I do recommend discussing this with your surgeon personally -- if you do go down this route.

Are you saying that laxity excercises help to take a bigger strip but may increase the chance for poor scarring? That kind of makes them useless right? Or am I misunderstanding?

[CalvinJR]

The type of laxity I know I have is the type where the skin is loosely attached.. Don?t know about the collagen. Actually I got a protein powder with collagen peptides...

[Dr Blake Bloxham]

Mag,

 

No, you're not incorrect here. But it's more a matter of how you and your surgeon look at it:

 

Doing the scalp laxity exercises helps decrease the adherence of the deep scalp attachments (increasing the first type of laxity I described above). By doing so, it allows for a wider strip to be taken without having to overdo the closure. In my opinion, however, people with this type of increased laxity have a greater tendency to stretch.

 

We tend to use set strip widths (and increase length when needed) to avoid all of this.

 

So yes, it allows for a wider strip but it may also increase the chances of stretching.

 

BUT! Your surgeon may feel differently about the "sweet spot" of increasing laxity to a certain point to optimize the balance between cosmetically acceptable scar and a high number of grafts. In this instance, they may recommend more laxity exercises and feel comfortable harvesting a wider strip.

 

So I wouldn't call them useless. It may be more accurate to call them a component of a fine balancing act. And I think it is absolutely something you need to discuss with your surgeon. Obtain their philosophy on laxity, exercises, width, et cetera. My thoughts come from our protocols and experiences. I feel passionate about them because I really do think they lead to great strip yields with very, very acceptable scarring. However, other doctors have their own experiences and practices based on these. So I definitely recommend discussing it thoroughly with any doctor you're considering doing FUT/FUSS with.

 

Does this make sense?

[Dr Blake Bloxham]

While I'm on the subject ...

 

Would people be interested in some sort of rough checklist or scoring system they could go through to get a vague idea of how they may scar?

 

This is actually something I worked on in the past, but kind of put on the back burner because of a few other projects.

 

However, it could be a good motivator to finish it if I really thought it would help some guys out!

[destorius]

While I'm on the subject ...

 

Would people be interested in some sort of rough checklist or scoring system they could go through to get a vague idea of how they may scar?

 

This is actually something I worked on in the past, but kind of put on the back burner because of a few other projects.

 

However, it could be a good motivator to finish it if I really thought it would help some guys out!

 

I think that is a great idea. In my mind, the next breakthrough in the field is working a way with or without something like ACELL (or whatever is flavour of the month at that time) to produce "grade a" strip scars each time. If you could get strip yield and still shave to a grade 2 in 99% of the attempts, we would be at the sweet spot until we can get donor regen. I know you will mention MFUE but you yourself still say this is detrimental to donor.

[Dr Blake Bloxham]

Dest,

 

Sounds like I'll have to get back to work on it!

 

What you're describing would be excellent! We will see what the future holds.

 

And yes, you're correct that mFUE would still cause more subdermal donor damage compared to strip.

[destorius]

Every innovation should be welcomed, it could be that MFUE is the bridging step. Time and results will tell.

[gbhscot]

Seth,

 

 

 

GBH,

 

First, I did receive your email and I'll reply this AM. Second, great question! I'm not really sure if there is a way patients can supplement collagen themselves. But I absolutely do think increasing the amount in certain areas would enhance the phenomenon I described above.

 

Hi Dr B,

 

Got your reply - thanks a lot, very informative and enjoyably positive about my prospects of a decent HT outcome had been getting a bit down about it all.

 

Had occurred to me as I take collagen peptide based protein in order to soften up some scar tissue I have from a hamstring tear (physio suggested it)...just wondered if the mechanisms might be similar. Thanks for the reply!

[Dr. William Lindsey]

Blake, this is a pretty good thread. Good job on picking up on this commonly asked question.

 

Interestingly scalp laxity seems to occur in at least 2 different ways. First is the "normal" scalp laxity which allows strip removal and tension free closure. And if someone has this kind of scalp and is tight from a previous case, they can do exercises and loosen it up enough to make a second or third case still fairly easy to close.

 

Then there are guys with really lax scalps..almost connective tissue disease-like, but with no other findings that would suggest a congenital abnormality in their healing (no double joints, extreme height, heart defects...) just really stretchy skin. I've seen it in zillions of facelift patients too.

 

The thing that these guys have that impacts hair is that they almost always are the guys who wind up with a crappy scar, which then surprises me as my op notes say "very easy closure". (For clarification, the really stretchy facelift skin patients of mine fortunately don't get scar stretching...it must be some pathophysiology unique to the scalp).

 

I was talking with Dr. Kabaker recently about just this issue.

 

The trouble Blake is that even after 20 years...I can't tell which group the lax scalp guys are in. Statistically most are in the first group and wind up with good scars...but a small percentage (white black middle eastern and asian patients of mine) are easy closure patients and wind up with a 3mm wide hairless scar from stretching...despite a perfect 2 layer trichophytic closure and a fairly narrow strip excision.

 

I'm not trying to take over this thread but you hit on strip width and length and I agree with you completely on it. I just posted a little video, and I devote a minute or 2 to just this, so I'll put the link up here too.

 

 

 

Lastly, at my office I tell people they can do any exercise on day 7, right after the sutures come out, EXCEPT things that stretch my scar...crunches, behind the neck lat pull downs, and bench pressing while arching on my scar. I've had 2 or 3 guys do distance running events on day 10 and they healed as well as anyone.

 

Again, good topic.

 

Dr. Lindsey

[Dolph1969]

How soon can you work out after a FUE procedure?

[MAGNUMpi]

Would people be interested in some sort of rough checklist or scoring system they could go through to get a vague idea of how they may scar?

Yes! that would be great.

 

As far as laxity goes does someone with good laxity have a better chance of a small scar after 2-3 procedures compared to the same guy if he had a tight scalp (and normal "inner" laxity)?

Thanks.

 

The trouble Blake is that even after 20 years...I can't tell which group the lax scalp guys are in. Statistically most are in the first group and wind up with good scars...but a small percentage (white black middle eastern and asian patients of mine) are easy closure patients and wind up with a 3mm wide hairless scar from stretching...despite a perfect 2 layer trichophytic closure and a fairly narrow strip excision.

Bingo. This is more along the lines of what I've read over the years of my research.

Blake, I'm sure you and Dr Feller get great scars in general but minimizing this reality (above) does a disservice to the community by potentially leading to some unhappy people who were made to believe they would get a "pencil thin" scar. I'm not saying you are doing anything wrong but your initial posts really hint that a stretched scar shouldn't happen with good technique etc. I don't mean to put you on the spot. Im just looking for the reality here

[Dr Blake Bloxham]

Dr Lindsey,

 

Thank you for sharing that info! I was bragging about your scar expertise earlier, so I'm glad you stopped by!

 

Mav,

 

I'm not sure if I'm following the comparison correctly, but I would say the guy with the increased laxity has an increased risk of scar stretch (despite the number of procedures).

 

Also, thank you for sharing the above statement. I absolutely do NOT want to make it seem like I'm downplaying any aspect of the procedure. Patients need objective information from this site, and that's what I seek to give. I do apologize if it seemed like I was glazing over any details or looking at things through "rose-colored lenses!"

 

However, I do want to address the above: I think if you read through what Dr Lindsey wrote, we are actually very much on the same page. He states that statistically, most guys fall into the "first group and wind up with good scars." This is akin to my "normal healers" category I discussed initially. I still do feel like the majority of patients fall comfortably within this group. This people heal with the simple "line." If they do "stretch," it's usually 1-2mm.

 

What's more, Dr Lindsey actually described a few variables that always go through my mind as well: laxity during testing and ethnicity. As he said, these patients tend to heal with a bit wider of a scar, and this does reference back to the people I think we can somewhat identify as counsel appropriately.

 

He also does discuss those who surprise you or seem to heal up less-than-ideal despite okay characteristics and a good closure. This does have to do somewhat with physiology, which I touched on above, but I do want to state the following -- and maybe this is where I should have been clearer before: there will ALWAYS be a degree of variability and unpredictability with medicine and surgery. No way around it! Call it whatever you'd like, there will always be some patients who don't heal up as expected, some who don't grow as expected, some who experience more swelling than you'd expect; and then there are always the "nice surprises" that you wouldn't expect either: guys with grafts that never actually shed, people who look like they just had a perfect "buzz cut" on day 3, very early growers, and, of course, beautiful scarers.

 

Having said all that, I do still feel the following holds true: there are more ways to identify and classify patient scarring than we usually do read online; most fall into the "normal healers" category -- which I define as a thin line in good scenarios and a few mm when they "stretch;" and there are certain patients with certain characteristics that indicate they may not heal as well as others; however, I do believe these are a minority and good closure technique has a lot to do with keeping these guys in the minority; and I firmly believe limiting strip widths has a lot to do with this as well.

 

I hope this seems more direct! Like I said before, I don't want to sugarcoat any of this. That's not what our community is all about!

Edited September 2, 2015 by DrBlakeBloxham
added something I forgot to mention.

[Dr Blake Bloxham]

Dolph,

 

First, epic name and avatar.

 

Second, I recommend a roughly similar timeline for FUE patients. The working out issue comes down to more than just scar stretching. It also creates increased risk of bumping your head or utilizing machines that could -- accidentally or purposefully -- rub the scalp, and the activity builds up a lot of sweat on the scalp. Unfortunately, bacteria love to hang out in warm, sweaty environments, and we would prefer to keep these puppies away from new grafts and open wounds (slit sites, FUE punch wounds, and closed up FUT incisions).

 

Like I said above, I'd give it a good 7-10 days. Unless of course you're training for a boxing match and the pride of your country hangs in the balance; and you're afraid your competitor will best you because you killed his best friend in the ring during an earlier bout. Then all bets are off ; )

 

If that reference makes absolutely no sense to others reading the thread, I recommend watching Rocky IV.

[gbhscot]

Dolph,

 

First, epic name and avatar.

 

If that reference makes absolutely no sense to others reading the thread, I recommend watching Rocky IV.

 

If you do go ahead with a.HT then we are gonna need a Video Montage of before during and after to the tune of Burning Heart by Survivor....

[Td06]

Can someone with extra laxity still get a good scar? I had two FUT procedure with two different doctors, first left me with a great thin scar, i was able to cut my hair to a grade #3. The second one not so much so, i cant even do a grade #5.

 

I was told i had lose scalp during my recent 1 year follow up consultation. The clinic used a normal closure method on me but said a scar revision with a double layer closure should get me back to a #3 guard like before. Is that possible with my current scar and laxity?

 

 

Also i haven't done any type of exercises after having my second procedure.

[home1212]

nice video and case study Doctors, thank you, very informative as always.