Bad Hair Loss or Bad Hair Lighting?? | Dr. Bloxham | 2,400 Graft HT| F&B (NY)

[Dr Blake Bloxham]

"My hair looks fine in the bathroom mirror in the morning, but awful when I check it in the car!"

 

"My hair always looks okay when I see my reflection walking into the office, but thin when I see my reflection in my computer screen."

 

"What gives?"

Sound somewhat familiar? Spend a few minutes searching the forums and you'll read a similar story: someone who isn't sure why their hair looks different in certain scenarios and hates the way it looks in one particular setting -- bathroom mirror, at the office, etc.

 

The most common explanation is the lighting; light simply affects the way hair looks.

 

And this was exactly the conversation I had with the patient I'm sharing today. He is a diffuse, patchy thinner in his 20s who came in for a consultation after being fed up with the way his hair always seemed to look different in different settings. And although the lighting played a role, he truly was experiencing diffuse hair loss. This frustration with his hair loss and the patchy appearance forced him to cut his hair short. However, his goal was to have some length and stop worrying about whether or not he was going to be caught in bad lighting!

 

So I performed a 2,400 graft HT to rebuild his frontal scalp and strategically fill some of the mid-scalp -- though graft numbers were limited by his below average donor.

 

He came back 7 months later looking great. I remembered our initial conversation with the lighting and decided to do a little lighting experiment of my own.

 

I shot photos of him in two different settings: my office with harsh, inconsistent LED lighting to mimic an indoor/office type of lighting; and in our video studio with him seated below our overhead back light in order to mimic the brighter, more direct, and more natural outdoor lighting.

 

Here are the comparisons:

 

Indoor:

 

 

 

 

 

 

 

 

 

To me, the indoor lighting looks a little more flat, dull, and much less consistent.

 

Outdoor:

 

 

 

 

 

To me, even though the outdoor lighting can be a little more "honest" and may even cause more of a "see through" effect, I think it provides a more vibrant, natural, consistent look. And this is how I do prefer to take images when I can.

 

Either way, the patient is no longer having issues in either type of lighting setting and I'm very happy to have helped him achieve this. But I think it's an interesting and relevant topic about how things like lighting -- along with hair length, styling, etc -- can affect the appearance of transplanted and non-transplanted hair.

 

So, which do you think looks better? Which works better for your hair personally?

[Gasthoerer]

Wow, Dr Bloxham. This looks like a great result in a difficult case. Fom these pictures it looks like a perfect full head of hair. If you ever have a video with you combing through it, I would love to see it as I am also a diffuse thinner.

Edited June 15, 2017 by Gasthoerer

[Dr Blake Bloxham]

Gas,

 

Thank you for the kind words.

 

I actually did film a full comb-through video, but it came out very dark and grainy for some reason -- somewhat ironic considering that the presentation is all about lighting!

 

I'll see what I can do with it and post any parts worth salvaging.

[mikeyhwk]

very nice work Dr Bloxham! very natural. You mention just a ht, was it fue or fut, given the clinic im assuming fut but seeing as his donor was naturally low maybe that made it more necessary to cherry pick grafts with fue.

[hairlosscpa]

Looks great! Any overhead/top down shots?

[BadBeat]

I honestly can't tell the difference in the indoor and outdoor pics. But the result from the before/afters looks fantastic.

[Dr Blake Bloxham]

very nice work Dr Bloxham! very natural. You mention just a ht, was it fue or fut, given the clinic im assuming fut but seeing as his donor was naturally low maybe that made it more necessary to cherry pick grafts with fue.

 

Hi Mikey,

 

Thank you for the kind words.

 

You're absolutely right with regard to the donor. Because this patient is a diffuse thinner, FUE was initially discussed and seriously considered. However, I did think he had a good, dense piece right in the "sweet spot" of the safest donor area, so we moved forward with FUT -- which is what he initially requested in the first place.

[Dr Blake Bloxham]

Looks great! Any overhead/top down shots?

 

Thank you. Yes, I do have some "tilt" shots. The patient was experimenting with some permanent concealing methods in the crown only, and it does look a little thicker with things he's tried so I purposely omitted these because I didn't want to showcase anything that wasn't a gain from a transplant. However, he ended up wanting more transplants and now we're going to do the crown at some point in the near future. I'll put the tilts up if people would like to see them.

[Dr Blake Bloxham]

I honestly can't tell the difference in the indoor and outdoor pics. But the result from the before/afters looks fantastic.

 

Interesting. Maybe I'm too "honed in" to the lighting because I take dozens -- if not hundreds -- of patients pictures on a daily basis.

 

Thank you for the kind words.

[Justin77]

Because this patient is a diffuse thinner, FUE was initially discussed and seriously considered.

 

Hi Dr. Bloxham.

 

First of all, amazing job on the transplant, the hairline is perfect and the results look incredibly natural. You mentioned that because this patient is a diffuse thinner, FUE was seriously considered. Would you mind elaborating on that, and why diffuse thinners should consider FUE over FUT?

 

Asking because I'm a diffuse thinner myself and still haven't completely decided yet between FUT and FUE. Thanks!

[Bill - Seemiller]

I honestly can't tell the difference in the indoor and outdoor pics. But the result from the before/afters looks fantastic.

Ironically, either can I and I'm usually very good at discerning the difference. Blake, I think it's obvious that the results of this hair transplant look great. I also think your post on lighting is crucial and very true. But I don't think the above pictures do a good job showing differences in lighting between the indoors and outdoors. The "outdoors" pictures still look like they were taken inside, to be honest. And the "before" pictures in the "inside" and "outside" pictures still seem to show the same painting/picture on the wall in the background? I'm confused.

 

Best wishes,

 

Bill

[Dr Blake Bloxham]

Hi Dr. Bloxham.

 

First of all, amazing job on the transplant, the hairline is perfect and the results look incredibly natural. You mentioned that because this patient is a diffuse thinner, FUE was seriously considered. Would you mind elaborating on that, and why diffuse thinners should consider FUE over FUT?

 

Asking because I'm a diffuse thinner myself and still haven't completely decided yet between FUT and FUE. Thanks!

 

Thank you for the kind words. And excellent question.

 

I don't think diffuse thinners need to immediately do FUE over FUT. However, I do believe there are situations where FUE may be a better choice for significantly diffuse thinners. Let me explain a little further.

 

Patients who have general diffuse thinning, but still have a stable, safe area in the best part of the "SDA" (safe donor area) are good candidates for FUT. In fact, taking a strip from the "sweet spot" of the donor is kind of the crux of FUT surgery. These patients have good donor, they should have no issue concealing the incision scar, and taking a strip from this spot is very likely going to yield the most grafts.

 

However, there is another type of diffuse thinner. Sometimes diffuse thinners are broken down into two categories: diffuse patterned thinners (DPA) and diffuse unpatterened thinners (DUPA). However, like most scales used in hair loss/hair restoration, I find that its often difficult to put patients into "boxes" like this. But the second type of diffuse thinner would probably fall more into the "DUPA" category. This is the type of patient that has fairly aggressive thinning in the traditional recipient and donor region, and there really isn't an identifiable area to take a good, unified section (IE a strip).

 

Now, there are two very important aspects to this scenario that must be established before a procedure is scheduled:

 

1) The doctor must determine that the patient is a candidate for any type of surgery to begin with. If the donor is so thinned out that the grafts probably aren't going to do well or will continue to miniaturize and disappear soon (or if the patient isn't truly suffering from genetic male pattern hair loss), then hair transplant surgery probably isn't advisable at all. This is pretty rare, but it does happen. But, if a thorough evaluation of the donor and the patient's medical history indicates that surgery is an option, you can proceed. However, it must be understood that:

 

2) Patients who fall into this category and are better suited for FUE must understand that the plan isn't for thick, full, restoration; it is to get some light, overall coverage. The point of doing FUE over FUT in these patients is because the donor is very thin and an incision line scar may be more apparent compared to punctuate circular scars. This is because the donor is usually kept pretty short in these patients. And usually the recipient will be kept the same short length post-surgery. It's difficult to obtain enough grafts -- without really making the donor appear odd -- to really create a thick, "dense pack" sort of appearance in these patients. But you usually can extract a decent amount to recreate a hairline, and give a thinner amount of coverage. This tends to give the patient a more uniform look and it also gives the patient the opportunity to do some SMP all over the entire scalp (including the donor) and sport a clean, 3-D, "cropped" look.

 

Now, scenario 2 is pretty specific and really only occurs in the worst "diffuse thinners." Much more of a "last resort" scenario. This is really the situation where I think FUE is the better option. And, again, it's somewhat rare. If you'd like to share some images, I'd happily take a look and let you know whether or not I think you'd fall into category 1 or 2.

[Justin77]

Thanks so much for your detailed reply Dr. Bloxham, that was very informative and super helpful. I believe I have a strong donor area and crown so I don't believe I fit the category of hair loss you describe.

 

I appreciate you offering to review my photos, but I've done several online consultations and have received graft estimates anywhere from 500-3000 grafts, so I get the sense that my photos don't really provide a very accurate depiction of my loss (probably due to bad hair lighting). I'm seeing Dr. Konior next week for an in-person consultation which is where I hope to get a much better idea of my candidacy for a hair transplant operation, and will also discuss FUT vs FUE with him. Thanks again!

[Dr Blake Bloxham]

Thanks so much for your detailed reply Dr. Bloxham, that was very informative and super helpful. I believe I have a strong donor area and crown so I don't believe I fit the category of hair loss you describe.

 

I appreciate you offering to review my photos, but I've done several online consultations and have received graft estimates anywhere from 500-3000 grafts, so I get the sense that my photos don't really provide a very accurate depiction of my loss (probably due to bad hair lighting). I'm seeing Dr. Konior next week for an in-person consultation which is where I hope to get a much better idea of my candidacy for a hair transplant operation, and will also discuss FUT vs FUE with him. Thanks again!

 

My pleasure.

 

Yes, online consultations are tricky and can be quite inaccurate. It's very difficult to get a good grasp based upon these type of pictures alone.

 

I'm pleased you're seeing someone in-person. Best of luck with everything.

[hairthere]

Nice work here Dr. B! Lighting is certainly a HT patients' best friend or worst enemy. Same goes for SMP. I could write a book on the subject at this point.....

[BadBeat]

I think the other advantage to FUE and diffuse thinning is that a lot of times, the diffuse thinner won't ever be satisfied with the density and the hair will still look really thin. The patient might then opt for a much shorter haircut, perhaps paired with SMP to at least create the look of good coverage and a chosen buzz/shorter haircut. The FUE scarring can usually be fairly well hidden with this type of haircut where a FUT scar would likely need longer hair to be concealed.

[MattyNJ1]

What Norwood scale was the patient in the before pics? And could explain exactly what a diffuse thinner is? Great results either way the patient should be very happy with those results, awesome job.

[Dr Blake Bloxham]

What Norwood scale was the patient in the before pics? And could explain exactly what a diffuse thinner is? Great results either way the patient should be very happy with those results, awesome job.

 

Thank you for the kind words.

 

It's tough to put this patient on the traditional Norwood scale because he has more a diffused thinning pattern compared to the classic true "patterened" genetic hair loss. It's worth noting, in my opinion, that many, many patients with genetic patterned hair loss don't fit well on the NW scale. And he's one of them.

 

A diffuse thinner is a patient who is thinning all throughout the genetically prone regions of the scalp and not just in the classic "pattern" areas you see on the Norwood scale. This can involve patients who have more of an underlying pattern and would be considered "diffuse patterned thinners" (DPA) or more everywhere on top which would be diffused unpatterned thinning (DUPA). There can also be some donor involvement, which complicates things and may be indicative of different types of alopecia.

 

Hope this helps.

 

Dr Blake Bloxham, NY