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This discussion summarizes the 14 year journey of a patient who presented to my office in 2003 complaining of a very unnatural hairline. He had previously undergone hairline restoration using large plug-type grafts. The large size of those grafts, in combination with highly contrasting skin/hair characteristics, left him with an unnatural, surgical-looking hairline. His primary objective was to improve his frontal appearance without using an aggressive hairline excision, as has been discussed here previously (http://www.hairrestorationnetwork.com/eve/143279-advanced-plug-hairline-repair-dr-raymond-konior.html ). His secondary goal was to enhance density in the area behind the frontal plugs using front-to-back prioritization. The chosen strategy for accomplishing these goals was one that would debulk the offending large grafts, which would then be dissected into follicular units and redistributed in the thinning areas behind the grafted frontal region. Additional follicular unit grafts would be obtained using strip harvesting to further supplement density in the thinning midscalp, working back over time toward the crown. The patient was aware that the limitations of extraction and donor supply would require the use of several staged procedures to accomplish his goals. Large punches were used in the early years to perform macro-debulking of the plug-type grafts. As FUE punch technology evolved and improved, small FUE punches were subsequently implemented beginning in 2011 at which time micro-debulking was utilized to selectively remove higher-caliber, darker-hair follicular units from the remaining objectionable plug-type grafts. Over 14 years the patient transformed from having an extremely unnatural hairline that required creative styling for camouflage, to having a natural hairline that allowed him to fully expose it without concern of detectability. Additionally, large-graft redistribution, along with follicular unit grafting from supplementary donor harvests, provided respectable coverage throughout the thinning midscalp and crown regions, despite the progression of his balding over 14 years.

 

Chronological Highlights:

2003 – Patient presents with unnatural, pluggy hairline. The plan was to debulk the largest grafts (some marked with purple) and to add single-hair grafts to the hairline for softening the harsh appearance. Top view shows extent of thinning in the midscalp and crown regions. Grafts dissected from the extracted large grafts and additional strip harvest grafts were placed into the midscalp.

2004 – Hairline softening is observed one-year postop. Additional debulking and grafting were performed as in the 2003 session.

2006 – Hairline shows further softening from the 2004 session. Additional macro-debulking of large grafts (purple surgical marker) was performed.

2011 – Hairline is looking better, but continues to show some tuft formation. Midscalp density has improved from prior sessions. Further refining of the hairline is now accomplished with micro-debulking using FUE from the remaining large grafts. Extracted grafts and follicular units obtained from a small donor harvest are placed into the crown region.

2014 – Hairline shows more refinement following the FUE micro-debulking session. Additional micro-debulking is performed.

2017 – End result after 14 years of macro-debulking, micro-debulking, and follicular unit grafting. Patient can fully expose the hairline and sports decent midscalp and crown coverage.

 

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Very intriguing case and I would choose no other surgeon in the world to boost naturalness in the hairline than yourself Dr. K.

Due to the patient's frequent procedures he is also apparently very fortunate to be in close proximity to your clinic.

 

In addition to the naturalness transformation the patient has also maintained extremely well for his advanced age (deducted from the greying progression).

Is he on Propecia or other medications for maintenance?


go dense or go home

 

Unbiased advice and opinions based on 25 plus years of researching and actual experience with hair loss, hair restoration via both FUT & FUE, SMP, scalp issues including scalp eczema & seborrheic dermatitis and many others

 

HSRP10's favorite FUT surgeons: *Dr. Konior, *Dr Hasson, Dr. Rahal

HSRP10's favorite FUE surgeons: *Dr. Konior, *Dr. Bisanga, Dr. Erdogan, Dr. Couto

(*indicates actual experience with doctor)

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How do you avoid "higher-caliber, darker-hair" contrasts when moving hair from the back/sides of the head to the hairline?

 

I feel this is the biggest problem with my hair transplant, along with multi-haired grafts.

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How do you avoid "higher-caliber, darker-hair" contrasts when moving hair from the back/sides of the head to the hairline?

 

I feel this is the biggest problem with my hair transplant, along with multi-haired grafts.

 

Depending in your donor, it can be difficult. But most people have some lower caliber hair. For instance, when my transplant was done, they were broken into 3s, 2s, 1s, and F1s. F1s are fine ones. They are used in the front to soften the hairline.

 

This is an attention to detail that top docs use. So, if you have multi follicular units in your hairline, I'm pretty certain they didn't go to the trouble soften it.


I am an online representative for Dr. Raymond Konior who is an elite member of the Coalition of Independent Hair Restoration Physicians.

View Dr. Konior's Website

View Spanker's Website

I am not a medical professional and my opinions should not be taken as medical advice.

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This is an attention to detail that top docs use. So, if you have multi follicular units in your hairline, I'm pretty certain they didn't go to the trouble soften it.

 

I would agree with your assessment. But Spanker you had FUT, correct? Does Konior do much in FUE? I do like his hairlines - very natural.

 

I mean, let me qualify my question. I know Konior does FUE, but does he prefer FUT/strip? I consulted once with a coalition doctor who officially did both, but in private consultation stated strongly that best results were obtained with FUT/strip.

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harryforreal – You ask, “How do you avoid "higher-caliber, darker-hair" contrasts when moving hair from the back/sides of the head to the hairline?”

 

My statement discussed something different than your question, i.e. using an FUE punch for micro-debulking plug-type grafts with the selective removal of the most contrasting, higher-caliber, darker-hair follicular units from those grafts. The ability to target specific follicular units for removal within a large objectionable graft allows the surgeon to strategically soften the appearance of detectable plug-type grafts.The same principle of selective extraction can be applied to your question regarding moving hair from the donor area, i.e. the FUE process allows the surgeon to select specific follicular units based on size, color or hair shaft characteristics.As an example, the surgeon can target low-caliber nape-of-neck hairs using FUE and place them along the leading edge of a detectable surgical hairline.This strategy will soften an unnatural, detectable hairline, as you seem to indicate being your concern.Without having your pictures available for review, your comment about an unnatural hairline with multi-hair grafts suggests you may benefit from selective graft reduction within the hairline, along with placement of lower caliber nape hairs in front of any higher caliber hairline hairs.

 

hsrp10 – He is one of the lucky few who has maintained decent density over time without the use of supplemental medications. He has extraordinary donor characteristics with high caliber and good texture, which definitely helps with coverage in the graft zones.

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Doc has ultra-high-end pricing but I can't disagree with any of his philosophy.

 

Can create a custom plan for now and long-term future. Can't argue with that.

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Thank you for replying, Dr. Konior,

 

It's a bit late so I'm not thinking as thoroughly as I normally do, so I may leave something out.

 

I have asked previously of my HT doctor about the softer nape hairs, and his response was that nape hairs were not stable for long term and that they had a different growth rate from other hairs - a longer .dormancy between growth and rest stages?

 

But, yes, if I were to complain about my HT, the darker, thicker, coarser hairs - even when singles, is not something I was expecting. I regularly pluck these darker hairs from my hairline in order to soften my hairline like it used to be - I actually keep the plucked hairs in sandwich bags labeled by month to see if the constant plucking has reduced their caliber, coarseness, kinky-ness, and possibly lighten them a bit. I THINK it might have affected them some, but it's difficult to say, and if the hairs are a wee bit lighter and less coarse (and less kinky), I can't say it's because of plucking - could just be the passage of time. But in any event they still don't look like or act like the soft hair I once had along my hair line - and perhaps it is unrealistic to expect transplanted hairs to have such soft characteristics. The test for me is if I hold the plucked hair strand up between my finger tips, does the hair strand fall back down around my hand or remain standing up? Native hairs almost always fall softly, while many transplanted hairs almost always remain standing.

 

But on the other hand, I actually wonder if my FUE procedure could have caused the donor hairs to become darker and thicker and kinky - a sentiment commonly expressed in general following both FUT and FUE hair transplants, and I would be curious to know your opinion about this. The concern about hair transplants resulting in transplanted hairs becoming more coarse and kinky, is it possible? Does it or can it really happen this way or is it simply that the hairs from the donor region generally are thicker and darker? I swear my transplanted hairs are thicker, darker, coarser, and kinkier than my native hairs. I don't like the "wooly Einstein" look at the front of my head! In a vain society looking like an airhead Justin Bieber is better than looking like a brilliant man sadly! xD

 

In any case, while I'm confident that grafts can be implanted into my hairline and they will grow, I'm not confident that adding more will soften my hairline - just the opposite. My concern is that adding more grafts at the front will further add "wooliness" when ideally I would like my hair to fall softly about my face like it once did.

 

That being said, I have been admiring your hairlines on this forum for several years for their soft and natural look!

 

And sorry for hijacking the thread, but when you specifically mentioned "using an FUE punch for micro-debulking plug-type grafts with the selective removal of the most contrasting, higher-caliber, darker-hair follicular units from those grafts," it resonated with me. I mean, I was on a date, and my date specifically reached up and touched the darker, coarser, wooly hairs in my hairline.

 

Not happy. :/

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From the pics it Looks quite clear to me:

 

You have quite some multis in your hairline which are also very thick.

Also the disctance beween your hairs is too big.

 

Low density, with thick Multis = Pluggy look and wiry feel.

 

Sorry,to say that, but I think there is quite some potential for improvment. Not only because of growth but mainly due to poor craftmanship. Which clinic was this?

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Hairforreal quote - “I have asked previously of my HT doctor about the softer nape hairs, and his response was that nape hairs were not stable for long term and that they had a different growth rate from other hairs - a longer dormancy between growth and rest stages.”

 

It is quite common to find more telogen (resting) follicles when harvesting from the nape. However, who cares? These are excellent, soft hairs that can refine the front. I would venture to bet that most natural small hairs along the leading edge of a young male or female hairline have the same growth and rest characteristics. I would simply place more small hairs in any given area to compensate for the higher percentage of resting follicles – if this proved to be an issue.

 

Although some men do go on to develop retrograde alopecia in the nape, most do not, and there are often signs of stability or instability that would allow the surgeon to make a calculated decision on the logic of using these hairs. And, although there is the possibility of some nape hairs thinning over the long haul, I would rather see a 25 year old get 30 years of softening rather than dealing with 30 years of misery such as your date “reaching for wooly hairs”. If this did occur, the solution is the same as above - place a few more small hairs in the problem zone.

 

Hairforreal quote – “But on the other hand, I actually wonder if my FUE procedure could have caused the donor hairs to become darker and thicker and kinky - a sentiment commonly expressed in general following both FUT and FUE hair transplants, and I would be curious to know your opinion about this.”

 

A small percentage of patients show textural and even color changes following the implantation of follicles, regardless of harvest method. I believe this to be a healing phenomenon. I do not believe this is your issue.

 

Hairforreal quote – “In any case, while I'm confident that grafts can be implanted into my hairline and they will grow, I'm not confident that adding more will soften my hairline - just the opposite. My concern is that adding more grafts at the front will further add "wooliness" when ideally I would like my hair to fall softly about my face like it once did.”

 

The comment by Gasthoerer regarding thick multiunit grafts and wide spaces is spot on correct. You are a straight-forward fix, if done correctly. 1) Debulk heavy front units. 2) Enhance density within graft zone to match adjacent zones using appropriate size grafts and meticulous placement. 3) Add low caliber grafts to immediate front zone. Attached is a hairline restoration from last week that used approximately 1650 grafts in the frontal zone. Approximately 200 grafts were harvested specifically from the nape to provide a softer appearance to the leading edge. The pic is limited in detail as it was taken while the patient was still on our operating table, but I believe you can sense a more balanced frontal fill with a transition from soft at the edge to thicker as the graft zone moves back. Also attached is a very minor selective extraction of heavy grafts from another patient where even a small number of selective debulking extractions has made a difference. He subsequently underwent a fill-in session to finalize the restoration. The bottom line is that you have options to achieve your goals.

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I agree completely with Gasthoerer's analysis, and in fact my HT surgeon added 300 more grafts later on at no cost to try and reduce the pluggy look caused by multi-unit grafts. Even so, while I remained awake during the second procedure, and watched the doctor target single grafts or try to divide double grafts into singles, I STILL ended up with multi-unit grafts in the revised hairline! xD

 

But I agree with your philosophy regarding nape hair, Dr. Konior - at least that's what I felt at the time which is why I pressed my HT doctor on the use of nape hair. Are you commonly using nape hair in the hairline? Is that your secret at such great hairlines, Dr. Konior? :)

 

I am of course just kidding a bit, as I know artistry is never dependent solely upon a single criteria!

 

But it is reassuring to hear you say I have options, and if Chicago were closer - and not so freaking cold! - I would be interested in further discussion at your clinic so as not to take over your thread.

 

I have considered some extractions or electrolysis, but I am worried about how the skin would look afterwards. The photo you provided of debunking definitely looks better, though! Have you published the results of the two patients in the two thumbnail pictures? I would definitely be interested in seeing the final result.

 

A couple last questions, and then maybe I should just schedule a time for a consultation, but what do you use for your FUE extractions, and then once extracted, do you examine the FUE extractions under a microscope to insure that the extractions will be singles? I mean, I watched as the FUE extractions were placed in a holding solution and then sorted in a tray based on singles, doubles, etc., but still these multi-unit grafts ended up in the revised hairline. Also, are you using implanter pens to implant the grafts? I have been truly shocked at how beat up (bumpy and red) my recipient zone was after my transplant and have wondered if the type of implanting tool might have made a difference. Beyond my concerns regarding "wooly" hair, I have serious concerns about my forehead looking like "plucked chicken skin" in the recipient zone! xD

 

Thank you, Dr. Konior for your responses!

 

And Gasthoerer, at this time I would prefer to not publicly name the clinic where I had my transplant done. It is true I have not been especially pleased with the outcome, but there are simply too many variables for me to cast public aspersions onto the doctor and his clinic. In any case, when I first agreed to the procedure, there wasn't much information or examples of the doctor's work available in the public forum; now, however, there are multiple examples of the doctor's work online and, since my initial procedure, on this forum, actually. Also since my initial procedure and subsequent revision, my standards of hair design have matured significantly - most certainly because of my own personal experience. To this degree I can say I have been continually impressed with Dr. Konior's published work - at the very least Dr. Konior's aesthetic sense is appealing to my aesthetic sense. But clearly there are differences in approach - as evidenced by Dr. Konior's willingness to employ nape hair versus my HT surgeon's reluctance to use it; also I suspect there may be a difference in price. Therefore, given these variables in patient needs and goals, I don't feel it fair to publicly name my HT surgeon within the context of this specific discussion. I hope you understand. :)

Edited by harryforreal

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Hairforreal quote “I agree completely with Gasthoerer's analysis, and in fact my HT surgeon added 300 more grafts later on at no cost to try and reduce the pluggy look caused by multi-unit grafts. Even so, while I remained awake during the second procedure, and watched the doctor target single grafts or try to divide double grafts into singles, I STILL ended up with multi-unit grafts in the revised hairline!”

 

Approximately 10% of one’s scalp follicle population resides in a dormancy state, meaning that one out of ten apparent single-hair grafts may harbor a second follicle that is difficult to detect because of the dormancy state.

 

Hairforreal quote “Are you commonly using nape hair in the hairline?”

 

Not always, but this is not uncommon for those with dark, high caliber hair.

 

 

Hairforreal quote “Have you published the results of the two patients in the two thumbnail pictures? I would definitely be interested in seeing the final result.”

 

These are recent patients who will take up to a year for the final result to be presented.

Hairforreal quote “What do you use for your FUE extractions, and then once extracted, do you examine the FUE extractions under a microscope to insure that the extractions will be singles? I mean, I watched as the FUE extractions were placed in a holding solution and then sorted in a tray based on singles, doubles, etc., but still these multi-unit grafts ended up in the revised hairline. Also, are you using implanter pens to implant the grafts?”

 

Punch design, cutting methods and specific insertion techniques can vary depending on local conditions. All grafts should be checked under high-power magnification to determine their individual characteristics. Because I place all grafts, it is not uncommon for me to see a small two-hair graft that had been placed in a single-hair pile by one of the assistants. Thus the importance of using proper magnification for dissection, sorting and placing.

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Dr. Konoir,

 

Do you have some results (grown out) with nape hair or cherry picked fine hair from the sides which you can share with us? I have a dicussion with a well known "hair advicer" who claims that no (!) clinic ever has shown grown out results with nape hair and cherry picking with FUE for fine singles doesn't exist.

 

Thanks in advance.

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Dr. Konoir,

 

Do you have some results (grown out) with nape hair or cherry picked fine hair from the sides which you can share with us? I have a dicussion with a well known "hair advicer" who claims that no (!) clinic ever has shown grown out results with nape hair and cherry picking with FUE for fine singles doesn't exist.

 

Thanks in advance.

 

Joe T?

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Do not say the word in here ;-) but yes!

 

There are a few Umar results specifically mentioning signifcant usage of nape hair in the hairline (and they didn't look particularly aesthetic to me), would be interesting to know the specific graft numbers involved in Konior's cases of nape useage and see them pointed out. Probably true that none specifically involve only nape hairs or a particularly high percentage of them.

 

I do agree with his point that there is no such thing as cherry picking grafts on an individual basis via FUE, but obviously the area of scalp it is being selected from is relevant in regards to texture and there are a higher percentage of singles and thinner hairs in the temporal region than the occipital etc. I think he's just saying that as a non-specific means of advocating for microscopes because the surgeons he supports use them tbh. Stretching the truth a bit.

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I think he's just saying that as a non-specific means of advocating for microscopes because the surgeons he supports use them tbh. Stretching the truth a bit.

 

bingo.

 

I don't know how many guys have written me asking if they should get their deposits back or cancel their ops with excellent docs cause this advisors scared them into thinking their hairlines are going to be all multi hair grafts. He's found a talking point and he's exploiting it... there is some degree of truth to what he says which I guess frees his conscience of thinking he's acting in a self serving manner.

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bingo.

 

I don't know how many guys have written me asking if they should get their deposits back or cancel their ops with excellent docs cause this advisors scared them into thinking their hairlines are going to be all multi hair grafts. He's found a talking point and he's exploiting it... there is some degree of truth to what he says which I guess frees his conscience of thinking he's acting in a self serving manner.

 

Funny you mention that about messages you're getting, same in my case about and around the forum in general, he created some huge waves with only a few videos on the issue.

 

I do find it somewhat annoying because despite nothing changing industry-wide regarding results or in basic judgements of hairlines over the past few months, it seems to be all some people focus on now. Many are seeing multi-grafts where they're clearly singles, or pointing out multis centimetres behind the hairline and complaining despite this being the norm, even among microscope users. Also the idea that the only criteria of a natural hairline is singles at the very front, for example I can guarantee you no Caucasian man ever born has a hairline as high and perfectly rounded as Joe Tillmans that's simultaneously lacking in miniaturised hairs.

 

To be honest I don't think there's anyone in his position more trustworthy in the industry overall, but its no doubt a selfserving form of marketing despite it being helpful to a broader cause.

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bingo.

 

I don't know how many guys have written me asking if they should get their deposits back or cancel their ops with excellent docs cause this advisors scared them into thinking their hairlines are going to be all multi hair grafts. He's found a talking point and he's exploiting it... there is some degree of truth to what he says which I guess frees his conscience of thinking he's acting in a self serving manner.

 

 

Funny you mention that about messages you're getting, same in my case about and around the forum in general, he created some huge waves with only a few videos on the issue.

 

I do find it somewhat annoying because despite nothing changing industry-wide regarding results or in basic judgements of hairlines over the past few months, it seems to be all some people focus on now. Many are seeing multi-grafts where they're clearly singles, or pointing out multis centimetres behind the hairline and complaining despite this being the norm, even among microscope users. Also the idea that the only criteria of a natural hairline is singles at the very front, for example I can guarantee you no Caucasian man ever born has a hairline as high and perfectly rounded as J's that's simultaneously lacking in miniaturised hairs.

 

To be honest I don't think there's anyone in his position more trustworthy in the industry overall, but its no doubt a selfserving form of marketing despite it being helpful to a broader cause.

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You are both right. One of my favorite hairline clinics is (as far as I know) not (!) using microscopes. But I still believe there has to be improvement.

 

And there are different cases which require different solutions.

I do have a very uneven hairline with soft baby baby hair on one side.

This baby hair was always there and is lost on one side.

 

If I want to even the hairline I need to work with fine hair on the "bad" side.

Nape hair might be one solution (at least I think so).

That is why I am so interested why Konior promotes the usage of it, and Joe T denies it.

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