Grafts in frontal 1/3

[SpaceBetween]

Is getting around 3,000 grafts in the frontal 3rd too agressive for a guy whose loss will further progress? I'm thinking that its just about right, and I am going to ask to keep the hairline more conservative to compensate for my future loss. I just want to play this as safe as possible.

 

Also, since the doc is shaving, do you think they can leave a small little tuft to help in the aid of a rad comb over post op so you don't have to buzz your whole head? Similar to what petschki did? I'm talking just a small little section.

 

Thanks in advance

[SpaceBetween]

Is getting around 3,000 grafts in the frontal 3rd too agressive for a guy whose loss will further progress? I'm thinking that its just about right, and I am going to ask to keep the hairline more conservative to compensate for my future loss. I just want to play this as safe as possible.

 

Also, since the doc is shaving, do you think they can leave a small little tuft to help in the aid of a rad comb over post op so you don't have to buzz your whole head? Similar to what petschki did? I'm talking just a small little section.

 

Thanks in advance

[Acrobaz]

Hi Space

 

First and foremost - if you have chosen a top doc you should go with his advice. The doc will make a recommendation that involves a sensible plan for dealing with future hair loss. Given that approx 10,000 FUs can be harvested overall across several procedures (although it differs from person to person), 3,000 in the frontal third should leave plenty in the tank to deal with further hair loss progression behind the front and towards the crown.

 

Personally I would be hesitant to go much over 3,500 in the frontal third. Much better to have a mature hairline IMO. I've always been worried when I see dense packing in the hairline, particularly for youngsters. So, yes, I agree with you completely.

 

Also, while I appreciate the short-term cosmetic attraction of leaving a tuft up front, you need to plan for the long-term. How robust is it? My doc did my whole front third, rather than transplanting around the tuft. It will hopefully thicken up in due course. As you can see in my blog, I went for the all-over buzz and it was fine to go back to work within 20 days or so.

 

Again, go with the advice of whichever doc you've chosen - I know you've done your research, so it will be a top doc I'm sure.

 

Good luck.

[Dr. Paul Shapiro]

SpaceBetween

It is difficult to know the answer to your question without knowing your age, donor density, door laxity, what Norwood type you are, and what degree of balding you have on your crown.

In patients with good donor density (greater then 80 FU/sqcm), good donor laxity, and good health, who I don't think will progress to Norwood type 6 or 7 balding, 2,500 to 3,000 FU in the front 1/3 can be appropriate. So a 3,000 FU graft case may be good for you.

 

I do not think the average patient has 10,000 FU over their lifetime. I would say that few patients have 10,000 FU over their lifetime. Many have 8,000 FU over their lifetime. And some have as little as 6,000 FU over their lifetime.

 

Remember that one has to leave enough donor hair in the donor area to cover up the scarring left by either strip or FUE technique. Most patients end up with very minimal scarring, but everyone scars differently.

 

Studies show that 20% of the male population will have balding in the Norwood type 6 pattern by age 60. In these patients, when the hair recedes in the temporal areas and at the bottom of the crown, that leaves less of a 'safe donor area'. There are textbook measurements of what is considered the safe donor area for most patients. I think it is important not to go beyond that safe donor area in young patients and patients who most likely will become a Norwood type 6 or 7. Some of the aggressive hairline and frontal one third cases I have seen, the doctor takes donor beyond the textbook definition of safe donor area. If those patients progress to a Norwood type 6 or 7 we may be transplanting hair that is not permanent and we may be at risk of a see through scar as one ages and/or running out of donor hair that may be needed for later surgeries.

 

So as you can see, your question does not have a straight forward answer. It would be wise to get a few consults, and ask questions about the density of your donor, your donor laxity, and possible future progression of hair loss.

 

I hope this is helpful

Paul Shapiro, Md

[hdude46]

Thanks for that Dr. Shapiro. If I may ask, what factors do you use to determine whether or not a patient may progress to a NW6-7? What hair characteristics would you deem are to be the "ideal" candidate? Is there a way one can measure their own donor density (or have an idea of it)?

 

Its interesting to hear different clinics comment on available donor hair. While everyone is different, I'm seeing more and more patients approaching the 10,000 graph mark.

 

Just from looking at some of the pictures on Dr. Shapiro's page as well as his brothers, the amount of coverage and naturalness of their transplants is second to none IMO. I don't think if I have ever seen them use more than 6,000 and change on a patient. Plus with FUE, you can get more graphs now safely than ever. Will be interested to hear Dr. Shapiro's response...

[Dr. Glenn Charles]

I agree with Dr. Shapiro more information is necessary to answer your question properly. Another important factor is where is the hairline going to be placed. You should definitely be a little more conservative on the first procedure and not start off with to low of a hairline. Remember this has to look good now and 20 years from now. I often will give my potential patients the worst case scenario. What happens if we do a large procedure in the frontal area and as the years go by you have more hair loss in the mid and crown regions? The patient may only have enough donor hair to finish the front and middle zones. They have to be comfortable with the fact that at some point they may have a very nice hairline with good coverage in the frontal and middle zones, but have thinning or balding in the crown. Most patients are ok with that possibility because it probably won't happen until they are much older. They talk about how the hair loss is much more important to them now while they are still younger.

[Acrobaz]

The docs' answers show why you need your doc's advice!

 

Up to 10,000 FUs might have been optimistic, but it remains the case that your chosen doc should take note of your physiology and recommend a sensible approach for dealing with potential future loss.

[Ron J]

Originally posted by SpaceBetween:

Is getting around 3,000 grafts in the frontal 3rd too agressive for a guy whose loss will further progress?

 

Barring any unique mitigating conditions (your: 55+, have no extensive family history of loss, & have demonstrably stabilized loss via meds) ANY Dr. is going to assume your loss will progress w/time, because hair loss is a progressive condition. Assuming proper hair line placement and average + donor density, anything LESS than 3K grafts in the frontal third would be unsatisfactory to most in that it would fail in creating an illusion of density. By allocating an uneven distribution of grafts, skilled surgeons create an illusion of greater density than that which is actually achievable to the entire head, & the hair line/frontal third is the constitution of this illusion as they are the most conspicuous areas.

[Dr. Bernardino Arocha]

Agree with Drs. Shapiro and Charles, and Ron J. These are all important points to consider in the hair restoration planning. The frontal third is pivotal in the creation of a nice hair restoration outcome after all it is what everybody including the patients sees the most while framing the face. The density in the mid scalp does not need to be created as high. A pivotal factor in the determination of the final outcome rests with the hair characteristics, here is a link to an article on this: http://www.regrowhair.com/hair...-transplant-results/

The ???black hole??? of hair restoration is the crown, in which the area grows exponentially with increases in the crown radius. Extra caution needs to be employed before undertaking to restore this area.

[Ron J]

Originally posted by Dr. Bernard Arocha:

The ???black hole??? of hair restoration is the crown, in which the area grows exponentially with increases in the crown radius.

Dr. Arocha, could you elaborate on this? I've heard that it is due to the crowns unique angulation, as opposed to the flatter surface areas of the hair line/mid scalp, which make it require so many grafts to create an adequate illusion of density. Is this true? We've all seen cases where copious #'s of grafts have gone into the crown, and yet the density is still lacking; I have seen a FEW cases where density was achieved w/a modest # of grafts. If a larger 'whorl pattern' is created does this exponentially aid in the illusion of density, to the extent that more layering/shingling is possible?

[Ron J]

Originally posted by hdude46:

Plus with FUE, you can get more graphs now safely than ever. Will be interested to hear Dr. Shapiro's response...

I used to think this as well, but I no longer do. If a patient is truly 'stripped out' by an excellent surgeon, then how could ANY dr. obtain more grafts via FUE *WITHOUT* going outside the safe zone (?). In addition, even in FUE cases where patients have had zero strip procedures, I've seen MANY Dr.s' go well outside what is considered the "textbook safe zone". I'd be very interested to hear Dr.s takes on both of these issues.

[Dr. Bernardino Arocha]

Ron J,

Those are some very interesting and insightful questions. Please use this link to answer your questions about crown hair restoration: http://www.arochahairrestoration.com/en/art/157/

 

FUE can be a source of additional donor harvesting to provide further numbers of grafts if necessary. I agree with you that there is overzealous FUE donor harvesting in non-permanent donor zone, hence some transplants may prove to be temporary ones in those with the advance MPB genes.

 

I have treated some severe stage 7 NW patterns with good results after only one session of course without addressing the crown. However, this patient was able to return for a second mega-session to address the crown and further refine the first transplant if need be. Here it is: http://www.regrowhair.com/hair...patterned-hair-loss/

[Dr. Paul Shapiro]

Back to the original question: is 3,000 FU too much for the frontal 1/3. As you can see from all the comments there are a lot of factors to consider when determining how much donor hair to use for each hair transplant. One factor I did not mention is how much surface area needs to be covered. When you are asking about the frontal 1/3 of your scalp I am not sure how much surface area is in the frontal 1/3 of your scalp. Here is a link to a thread on the average surface area of a Norwood type 7:

 

Surface Area Norwood Type 7

 

So when you are asking about your frontal 1/3 of scalp are you talking about 50 sq.cm of surface area or 70 sq.cm of surface area? It might be helpful for you to measure the area of coverage rather then thinking is it the frontal 1/3 and then look at the projected density for that transplant. I estimate that the frontal 1/3 scalp in the average patietn is 60 to 70 sq.cm. of surface area. At SMG we usually plant 2,000 to 2,500 FU in the frontal 1/3. Depending on the surface area we are covering this can give us an average density of 30FU/sq.cm up to 40 FU/sq.cm. Ocassionally we will plant 3,000 FU in the frontal 1/3 if a patient is older, has great donor density, and we do not think he will become a norwood type 6 or 7. This will enalbel us to plant at higher densities.

Dr. Arocha's links also show how ones hair characteristics play an important role in hair transplant planning and his approach to a Norwood type 7 with average donor is very useful. As you can see in the type 7 patient he needs some hair to raise the lateral hump to meet up with the temporal alleys and hair line. Also to make this transplant look good he did transplant hair further back then the frontal 1/3. If one only transplants the frontal 1/3 in Norwood type 7 patients the hair transplant looks weighted to far forward. In this patient it looks like the frontal ?? to 2/3, not the frontal 1/3 was transplanted. As Dr. Arocha noted he needed 500 FU to raise the temporal humps and then used the remaining 3,000 FU to plant the rest of the scalp. Thus 3,000 FU was used to cover more then the frontal 1/3. I think there may be varying definitions of what the frontal 1/3 of a patients scalp is.

In answer to Ron J's question about safe donor area; I have seen some cases posted on the internet where the donor hair is taken outside the traditional textbook safe donor area. In some patients there is the potential that this hair is not permanent and may thin or fall out as we age. Below is a photograph of a Norwood type 7 patient. You can see how the lateral temporal area has eroded, and how the neck hair line has been raised. I have outlined the safe donor area in this patient.

With the advent of FUE we may be able to increase how much donor can remove, but I am not sure how much. It may be 500 to 1,000 FU in a patient. But remember that FUE is not scar less, but just leaves a less obvious scar. One still has to leave enough donor hair to cover up the scar. Also FUE is a tedious expensive procedure and may not be an option for a lot of patients.

In young patients I do not believe we can accurately predict future hair loss. But in older patients the degree of balding, the rate of balding, their family history, and how they respond to propecia, all may help predict future balding. There is one tool I find very helpful in predicting the patient's safe donor area. I will wet the patient's donor area and then look for what areas become see through. You can see how this works in the photo below.

When the hair is wet you can see much more of the crown and I assume that this hair will fall out in the future and is not safe to remove as donor hair.

 

I hope this is helpful in answering your questions

Dr. Paul Shapiro

[hdude46]

"In young patients I do not believe we can accurately predict future hair loss."

 

So does this mean you don't operate on younger patients? Isn't family history and degree of loss as well as rate of loss enough to get aguage of where they might be headed?

[Dr. Paul Shapiro]

In predicting hair loss, ones age, family history, the degree of hair miniaturization is helpful, and as you said can give us a gauge of where they may be headed. But knowing all this it is still difficult to accurately predict hair loss in patients less than 30 years of age. I come from a family of 4 boys. My brother Dr. Ron Shapiro and myself have little hair loss at age 56 and 54. My other two brothers have Norwood type 6 to 7 hair loss. One of my brothers started to show significant hair loss in his 20's but the other did not start to show much hair loss until he was in his 30's. If someone came in to my office at 30 with very minimal hair loss, no miniaturization of his hair, and a great family history, then I would say he most likely won't have much hair loss. But this type of patient is rare to see in our practice.

We can do hair transplants in younger patients. I have done hair transplants in patients as young as 21. But the planning has to be conservative and I plan my case as if they are going to become a Norwood type 6 or 7. If a young patient has realistic expectations and is OK with a conservative first surgery, we can help them out a lot.

In patients who are over 30, if they are Norwood type 3 or 4, I feel more comfortable planning a lower hairline, and planting more hair in the hairline, and frontal 1/3 of the scalp. But these patients have to know we are still taking a risk that we may run out of donor to cover the crown if his hair loss progresses. Most importantly we need to make sure that in patients who seem to be on their way to Norwood type 6 or 7 that we are not overly aggressive. These patients may lose the hair in their temporal humps and we need to make sure we design the hairline and have enough donor hair to build the temporal humps back up to meet the hairline.

I hope this answers your question.

Dr. Paul Shapiro

[hdude46]

Thanks Dr. Shapiro that definitely helps. It seems that rate of loss plays just a big a role as age. I have seen a lot of patients who start to lose their hair in their twenties but at a slow rate who actually by the time they are in their 30's have more hair then someone who starts losing in his thirties but quickly.

 

In your experience, how much do meds like propecia really help? All I see on these forums is people complaining sides or having the drugs stop working after a few years. Is this what most of your patients experience? Thanks!

[TC17]

hdude46,

 

Why do you say that rate of loss plays such a big role? I can see how if you have slow loss the transplant will look better for a longer period of time due to more native hair in the area, but eventually the hair that is destined to fall out will do so. You're then left with the same bald area as if you were to lose all of the hair in 5 years as opposed to 20 years.

[hdude46]

yeah, but if you are losing your hair at a rapid rate, you are more likely to aggressive loss, whereas if you are losing slowing, TYPICALLY its not going to progress as far on the nw scale. just my two cents tho.

[Dr. William Lindsey]

This is a great topic and I think the doctors above have given excellent advice. I tell patients there are 3 common mistakes in hair surgery.

 

First, bringing the hairline too low. This is a particular challenge in young guys who want to look like all of their friends with regard to a youthful hairline. But if you get a 25 year old's hairline, a: you will look goofy at 45 years of age and b: you will likely not have enough hair to cover other areas of the scalp as you lose more hair with age.

 

Second, you can get a really bad scar. This can often, but not always, be minimized with good closure technique; but sometimes a scalp that would give a great scar at 2500 grafts, is pushed beyond its limits to have a good scar and the patient and doc go for 3500 grafts. Scalp stretchability is best "guestimated" with an office consultation but even then, I have been surprised (for good and bad) at the difference in stretchability in real surgery compared to my guestimation. That is one reason I often opt for longer, skinnier strips and sometimes we do a bit smaller cases than others would suggest. A thorough preop discussion with the patient is helpful. If we know the patient wants a great scar and a bit smaller case if needed, we strip for that. If we know the patient has less concern about the scar, we'll go a bit bigger....with the caveat that we try to avoid really bad scars. Even if the patient said he didn't care, he may not post that desire when showing pics to others or online.

 

And third, you can put too little donor hair to try and cover too much bald scalp. I think the doctors above did a good job discussing "planning for the worst" and informing patients that they may need to accept a crown with minimal hair in order to really fix the front.

 

The one variable I didn't see discussed above ( and I skimmed this fairly quickly as we are in a case) is hair shaft thickness. If you are a thin haired asian with white skin and dark fine hair, the amount you need is WAY different than if you are a medium pigmented black guy with really thick, coarse curly hair.

 

Remember, the doctor and the patient have limitations. The goal is to give good coverage in a desired area with what is available. The doctor has a knife, not a magic wand. Hence, a good preop consultation and open communication is key to a desired outcome.

 

Dr. Lindsey McLean VA

[Dr. Paul Shapiro]

Originally posted by hdude46:

Thanks Dr. Shapiro that definitely helps. It seems that rate of loss plays just a big a role as age. I have seen a lot of patients who start to lose their hair in their twenties but at a slow rate who actually by the time they are in their 30's have more hair then someone who starts losing in his thirties but quickly. S

 

In your experience, how much do meds like propecia really help? All I see on these forums is people complaining sides or having the drugs stop working after a few years. Is this what most of your patients experience? Thanks!

 

Hdude46

Propecia is a great medication for a lot of men. The information I have on propecia comes from two sources. One is the medical literature and the other is personal experience. The medical literature studies only go out for 5 years. What it shows is that 90% of men who take propecia have a positive effect. Of that 90%, half get new hair growth and half only stop further hair loss but do not get new growth. Outside 5 years we do not have any scientific studies to go on.

In my experience we see a wide variance on hair loss in patietns on propecia. It works in most men and seems to work best when started young and in men who are Norwood type 2 to Norwood type 5. Some men stop it because of side effects but that is a small number in our practice. I would say less then 1%. Most men tolerate it well, or the side effects are very minimal and worth the hair growth. We do see that propecia losses its efficacy with time in a lot of men. In how many I am sorry I can't tell you. That would be a good study to do. I would say that maybe 20% to 50% of men start to see a loss in efficacy after 5 years. In some of these men Avodart seems to help. I would like to hear what other physicians have noticed.

The rate of hair loss is an interesting topic. I agree that if someone at a young age has rapid hair loss I think they have much more probability of becoming a Norwood type 6 or 7. But I have seen some men in which they have a period of rapid hair loss, and then it stabilizes for many years. So like all other factors. It is a guide to predicting hair loss but not an exact predictor of hair loss.

[hdude46]

In my experience we see a wide variance on hair loss in patietns on propecia. It works in most men and seems to work best when started young and in men who are Norwood type 2 to Norwood type 5. Some men stop it because of side effects but that is a small number in our practice. I would say less then 1%. Most men tolerate it well, or the side effects are very minimal and worth the hair growth. We do see that propecia losses its efficacy with time in a lot of men. In how many I am sorry I can't tell you. That would be a good study to do. I would say that maybe 20% to 50% of men start to see a loss in efficacy after 5 years. In some of these men Avodart seems to help. I would like to hear what other physicians have noticed.

The rate of hair loss is an interesting topic. I agree that if someone at a young age has rapid hair loss I think they have much more probability of becoming a Norwood type 6 or 7. But I have seen some men in which they have a period of rapid hair loss, and then it stabilizes for many years. So like all other factors. It is a guide to predicting hair loss but not an exact predic

 

Thanks for taking the time to answer that Dr. Shapiro. Makes sense to me. As far as propecia and loss in efficacy, I have read some people cycle off the drug once every say 18-24 months for a period of a few weeks so as to make sure the body doesn't build up a tolerance to it. I remember reading a few guys doing this after the drug stopped working for them as much and then after a few weeks off started back up and it started working anew for them. Do you think this is something worth trying?

 

On something unrelated, but how much does mpb and scalp itch correlate to each other. I have been to several derms and they say nothing is wrong with my scalp but have given me anti-inflams, medicated shampoo, topical steroids, ect.. but nothing seems to work. I also notice that my itch is right in the spots where I seem to be losing hair. It's so annoying and I have yet to find a remedy. Some say propecia could help with this but I guess I have to try it to find out. Going to get thyroid and diabetes tests to rule those out but just wondering if you think the two are correlated at all. Sorry for all the questions and thanks again Dr. Shapiro. SMG does great work and if/when I decide to have a procedure, I already know where to go.

 

Also well said Dr. lindsey, I agree 100 percent.

[Ron J]

Originally posted by Paul Shapiro, MD:

We do see that propecia losses its efficacy with time in a lot of men. In how many I am sorry I can't tell you. That would be a good study to do. I would say that maybe 20% to 50% of men start to see a loss in efficacy after 5 years.

Even in the crown/vertex area or hairline mid scalp alone? I've heard quite the opposite from a leading clinic who have been prescribing it for 10+ years.

[Dr. Paul Shapiro]

hdude64

I have not seen mpb correlate with an itchy scalp. Most likely your skin is sensitive to something and in the areas where there is no hair, there is more sensitivity.

I would try hard to think of any products such as soap, shampoo, conditioner, laundry soap, etc??¦ which might be the cause of the problem. I also have seen some patients being sensitive to hard water and getting a water softener installed helped. I have also seen the opposite where the chemicals in water softener has made a patients skin itchy.

If you have any sort of rash with the itchiness you may need a skin biopsy to get the proper diagnosis.

I have not had a patient stop propecia and then go back on it as you mentioned so I really can't comment on whether this works. It may work in some patients but not in others. If porpecia seems to be losing its efficacy I don't see the harm in taking a drug holiday and then restarting it.

Dr. Paul Shapiro

[Dr. Paul Shapiro]

Originally posted by Ron J:

Originally posted by Paul Shapiro, MD:

We do see that propecia losses its efficacy with time in a lot of men. In how many I am sorry I can't tell you. That would be a good study to do. I would say that maybe 20% to 50% of men start to see a loss in efficacy after 5 years.

Even in the crown/vertex area or hairline mid scalp alone? I've heard quite the opposite from a leading clinic who have been prescribing it for 10+ years.

We also have patient who have been on propecia for 10 year and for some it seems to continue to be 100% effective, for others it starts to lose its efficacy. Unfortunately we don't have any good studies to know the percentage of men in which propecia stops to work or the percentage of men it continues to work for.

And most likely there are many men who even if they are having some hair loss, propecia still retards the rate of hair loss.

What I do think is important is to not count on propecia to halt all hair loss, especially if you are young. So I would still be conservative in a young patient regardless of if they are on propecia or not.

Now if 10 years down the road that patient choses to have a second surgery and has not had any progession in their balding on propeica, I would plan a different surgery then if they continued to progress even on propecia.

Dr. Paul Shapiro

[hdude46]

Thanks Dr. Shapiro,

 

As far as the itchiness goes I have no rash or anything like that (and there is still hair in these parts of the scalp minus the temples) and have tried to figure out and what the source may be but just can't. I guess I do have a bit dry and sensitive skin but it just seems weird to me that the spots that itch on my scalp are the spots I'm losing hair. Every time i run my hand through my hair i get a few hairs coming out. After taking a shower, while combing my hair an unusual amount of hair comes out. Hair consistantly falls out throughout the day. I also need to add that my hair over the past few years seems to has thinned a bit and gotten more coarse on the sides (I can also rub my hands on the sides and get lots of hair to fall there too). Not only that, but there are lots of grey hair popping up not only along the sides, but also a few on top of my head. To me this seems extremely weird given that I am only 25. I feel like something is wrong given all these factors put together. Could it be thyroid, hormonal, something else? Does your clinic perform biopsies and blood work and would you guys be able to diagnose if I have mpb or something else if I flew in for a consultation? hair loss is in my extended family but most of it is pretty subtle and there are definitely no cue balls. I'm just at a loss right now...