Adding density with 2nd HT - successes or failures?

[mcr7777]

Has anyone had any success or failure with a second HT to add density?  Mine is the frontal area - temples and forelock. I am concerned about permanent shock loss of hairs transplanted in the first HT. 

?  Did you have shock loss of hairs from the first HT or not?  Did shock loss hairs grow back?   Interested if people are satisfied with the result - or has it barely improved or made things worse?  

There seem to be few examples of these cases on the forums (although seem to be plenty of examples where people are unhappy with density after the first HT!)
My background:
First HT was in January 2020 of just under 1200 FUE grafts to fill in temples and at front. I'm convinced not enough grafts were planted - result is see through in many lighting conditions unless I keep my native hair longer to cover.

I have been quoted 1200-1500 grafts by another doctor to add density.  

 

Also considering FUT after my first FUE although don't know if it would be worth it for 1200 additional grafts.

Thanks for any advice.

 

[Richie888]

I would think after 11 months you should have a rough idea by now if the hair was growing back, is if possible it's just not a gap from poorly placed grafts maybe? 

Where did you get it done and are you happy to post any pics for the more seasoned members to elaborate on?

[yalla8]

Can you share photos please?

[mcr7777]

Photos attached. First one of showing the day after my HT.  

Others are showing the result after nearly 10 months under harsh lighting - i have tried to highlight the issue rather than hide it away for the purposes of this post. 
 

when my hair is arranged properly the gaps in density can sometimes be relatively hidden or harder to spot - as in the final photo taken outside with no product.  Essentially my native hair can help hide the problem. But under harsh lighting it is nearly impossible to hide. 

any advice from people who have had a 2nd transplant to add density in the front -  and if it helped or not - would be especially helpful to hear.

 

[mcr7777]

The HT was at a UK clinic (not recommended on this site). I had 1200 grafts implanted into the area as shown in the first photo.  I think a big part of the problem is not enough grafts were planted.  However, I'm concerned about shock loss and permanent shock loss to existing grafts and looking worse if I go for a 2nd HT.

On fin for 1 year and seems to be working.

 

[deitel130]

Do you have pre op pics? Pics seem like there was very little native hair with existing forlock. May not have been enough grafts to cover frontal third. Who did the surgery?

[mcr7777]

photos before ht attached. Yes I think not enough grafts were placed.  Another clinic has quoted 1200-1500 grafts to create a dense result.  
 

But I am concerned about losing existing hairs due to permanent shock loss. Has anyone had experience of adding density in between existing hairs? Success or otherwise? 
 

I am waiting for a face to face consultation with the uk clinic so don’t want to name them until that has happened. 

[UnbaldEagle]

I think your case is very similar to mine, I too had a first procedure of 1200 grafts to fill in my temples and hairline a bit and yes, I still had some patchy native hair in those areas prior to the first procedure, however you've got way better coverage now. 

I think the real challenge is finding a clinic that would be willing to transplant through the thin areas, I'm a bit stuck there too. 

 

[UnbaldEagle]

Also, how's your temple points? Couldn't see that from your pictures. If you would lower your hairline a bit more or add extra density to your existing, you'd need some solid temple points too to have a natural look.

[Mycroft]

3 hours ago, mcr7777 said:

photos before ht attached. Yes I think not enough grafts were placed.  Another clinic has quoted 1200-1500 grafts to create a dense result.  
 

But I am concerned about losing existing hairs due to permanent shock loss. Has anyone had experience of adding density in between existing hairs? Success or otherwise? 
 

I am waiting for a face to face consultation with the uk clinic so don’t want to name them until that has happened. 

There are plenty of cases on here where grafts were placed into thinning areas successfully, but it is a risk because shock loss does happen and there are a few stories on here about that as well.

One factor is your unique physiology and unfortunately that's something that's hard for you or the doctor to gauge. No way to know how your body will respond, although being on Finasteride helps reduce this risk.

The other is skill of the surgeon. If a surgeon transects an existing follicle trying to transplant a new one, that transected follicle won't grow any more hair.

If you're referring to transection of previously grafted hairs that shouldn't be an issue as long as the surgeon doesn't mess up because those hairs weren't miniaturizing.

 

[deitel130]

If you go to an experienced well reviewed doctor the transection of existing healthy or previously transplanted hair should not be an issue. Its always advised that to avoid damaging existing hair the recipient area would need to be shaved down to allow a clear vision for the incisions.

 

There are many well reviewed and recommended doctors here and you should consult with a few and go with who you feel comfortable.

[Melvin- Admin]

It doesn’t look bad IMO. It could use more grafts, but with a low graft count a second procedure is almost a requirement. Have you consulted with Reddy? 

[mcr7777]

Thanks Melvin - yes I think it will need more grafts to get me happy.  Shaving the recipient area and shockloss will be the hardest part.... Dr. Reddy seems solid but I understand he is booked well into next year. I'm looking at options in Europe (not Turkey though).

[mcr7777]

Yes Unbald Eagle - I think too few grafts were used on both of us. Not really wanting to lower my hairline - so curious as to whether doctors would place grafts just in front of the hairline and not really lower it or just transplant in between hairs.  Temple points would need to be strengthened. I'm most worried about them placing grafts in between existing hair as I don't want transection.

I have heard shaving the recipient area is best and some docs mandate this. Although really not looking forward to that (I didn't have to shave completely last time).

[Melvin- Admin]

5 minutes ago, mcr7777 said:

Thanks Melvin - yes I think it will need more grafts to get me happy.  Shaving the recipient area and shockloss will be the hardest part.... Dr. Reddy seems solid but I understand he is booked well into next year. I'm looking at options in Europe (not Turkey though).

Check out Bisanga, Feriduni, HDC to name a few. May want to look Dr. Bargouthi as well, he’s not in Europe, but  not too far.

https://www.hairtransplantnetwork.com/Consult-a-Physician/surgeon-list/BEL/Belgium

https://www.hairtransplantnetwork.com/Consult-a-Physician/surgeon-list/CYP/Cyprus

[Raphael84]

@mcr7777

I have read through your thread. I may be wrong, but I do not think that there has been any mention of your age and if you may be using any hair loss preventative medication? 

The two main considerations in regards to permanent shock loss will be transection (in either donor or recipient), or miniaturisation levels of your current hair (be that native or previously transplanted). If you are not on medication and your hair loss is not "stable", then the risk of shock loss will likely be higher.

When discussing the risk of shock loss whilst transplanting amongst native hair, there are a few things to consider, some which have been touched on above.

As with any procedure, the most important factor will be the surgeon. This includes a thorough consultation to check for levels of miniaturisation, and to discuss your objectives and providing you are a candidate for surgery, then providing an appropriate graft count. 
If you were to then proceed with surgery, of course the quality and skill of the surgeon will be paramount. When working within existing hair, especially when the concern and motivation for surgery is a lack of density, I would thoroughly recommend shaving down your recipient as you have mentioned. With longer existing hair, the need to constantly manipulate and move this existing hair for improved visibility to be able to make recipient sites, and again when placing ensuring that native hair does not "stick" to the newly placed grafts, adds further challenging factors to the surgery. Shaving down will allow your doctor to clearly see exit angles and direction of current hair (both native and previously transplanted), to be able to make sites as close as appropriate for improved/optimally appropriate density whist avoiding transection below the scalp.

In all "repair" patients, or patients who will be revisiting the same recipient area, it is important to remember that the quality of your previous surgery, may impact the result of your subsequent surgery, even when proceeding with a quality doctor. As with skin on any area of the body, "cutting the skin" will normally leave some kind or scarring. It may be small or even not particularly visible on the surface, but it is fair to say that the tissue has been compromised to some degree.
We see incredible results for extreme repair patients, and they are often able to achieve impressive yield and growth when revisiting the same recipient area that may be damaged or scarred, and more commonly now, we see great results when adding FUE into previous FUT strip scarring.
But it is important to understand that revisiting the same recipient area can present challenges and is not the same as working on a virgin scalp.

@mcr7777
I wish you the best of luck. My advice would be not to proceed with any surgeon without meeting them in person for consultation beforehand. 
This is not to put you off in anyway as your photos suggest that you could really benefit from some additional grafts and density and this is common, but is just to say, do you due diligence and select the right surgeon for you.

Edited November 21, 2020 by Raphael84

[alex1985]

Take a look here: https://www.realself.com/question/amsterdam-nl-hair-transplant-challenging-due-scar-tissue-de-recipient-area

The general consensus of the surgeons is that a second hair transplant is not really more challenging.

Edited November 22, 2020 by alex1985

[Raphael84]

@alex1985

Thanks for the link. It is always very interesting to appreciate other surgeons approaches and points of view on elements of surgery.

What is also interesting is the differing views and opinions that have been expressed.
Responses included -
* "if the skin in the front of the scalp (recipient area) healed well after surgery"
* "However, talk with experience surgeon that is capable of the redo procedure. The second surgery can be a challenge"
* "Sure there is some scar tissue in the scalp, but no - it does not have huge impact for most"

We can all interpret these as we prefer.

I would agree with the above responses. As I mentioned previously, we see incredible results with challenging repair patients and into previous FUT strip scarring, which is essentially complete scar tissue, and in most cases, growth and yield is positive. If healing from previous surgery is good, without ridging, tenting or pitting in the recipient for example, then concerns would be much less and the probability of successful growth would be high.

What I believe is also fair to say is that if after a subsequent surgery, growth was poor or non optimal, the explanation from the surgeon would be that your recipient area was non virgin scalp, and this has influenced yield. From an educational perspective, I as a patient would certainly like to have a better understanding of all possible scenarios.

Another very good and valid point that was touched on in some of the responses, was regarding if density concerns are due to previous surgery placing at a lower density, or because yield was poor. If yield was poor with a respected surgeon, then it is always prudent to try and understand why this happened. In such cases, a biopsy may be recommended to rule out any inflammatory concerns or underlying scalp issues before proceeding and utilising more of the patient´s limited grafts. This doesn't seem to be the case for @mcr7777as his result looks "appropriate" in terms of growth based on his 1200 graft count, which based on photos and being able to see surface area covered, was honestly never going to be enough to achieve high density.

Edited November 22, 2020 by Raphael84

[Mycroft]

22 hours ago, Raphael84 said:

Thanks for the link. It is always very interesting to appreciate other surgeons approaches and points of view on elements of surgery.

What is also interesting is the differing views and opinions that have been expressed.
Responses included -
* "if the skin in the front of the scalp (recipient area) healed well after surgery"
* "However, talk with experience surgeon that is capable of the redo procedure. The second surgery can be a challenge"
* "Sure there is some scar tissue in the scalp, but no - it does not have huge impact for most"

We can all interpret these as we prefer.

I would agree with the above responses. As I mentioned previously, we see incredible results with challenging repair patients and into previous FUT strip scarring, which is essentially complete scar tissue, and in most cases, growth and yield is positive. If healing from previous surgery is good, without ridging, tenting or pitting in the recipient for example, then concerns would be much less and the probability of successful growth would be high.

What I believe is also fair to say is that if after a subsequent surgery, growth was poor or non optimal, the explanation from the surgeon would be that your recipient area was non virgin scalp, and this has influenced yield. From an educational perspective, I as a patient would certainly like to have a better understanding of all possible scenarios.

Another very good and valid point that was touched on in some of the responses, was regarding if density concerns are due to previous surgery placing at a lower density, or because yield was poor. If yield was poor with a respected surgeon, then it is always prudent to try and understand why this happened. In such cases, a biopsy may be recommended to rule out any inflammatory concerns or underlying scalp issues before proceeding and utilising more of the patient´s limited grafts. This doesn't seem to be the case for @mcr7777as his result looks "appropriate" in terms fo growth based on his 1200 graft count, which based on photos and being able to see surface area covered, was honestly never going to be enough to achieve high density

This is a very thoughtful and detailed response. I think we don't often touch on scalp issues in this forum because honestly most of us are simply dealing with androgenetic alopecia, and this is good information. With that said, I agree 100% that the first thing to look at is simply the fact that the graft count was likely insufficient to meet patient goals and expectations so there were bound to be issues from the start.

Edited November 22, 2020 by Mycroft

[mcr7777]

Thanks for these comments - very helpful.

Raphael 84 - it's great advice to have the surgeon see me beforehand - this is what I intend to do. My scalp doesn't show signs of scarring/bad work from the HT but I would like it examined properly. I'm 41 and on fin for 1 year which seems to be working.

Really interesting that you mention scalp condition.  I have been suffering from an intensely itchy scalp on and off (no dandruff) for over a year and half now - maybe longer - well before the first HT.  The itching comes and goes but at times it's felt like burning  and feels very tender  e.g. in the shower when water gets  on it. I had put the itching down to MBP itch or dermatitis.  After researching more, two weeks ago I mentioned it to my my GP and she ordered a test for Tinea Captis (ringworm - which is not actually a worm but a fungal infection).  She said the actual results may take a few weeks and in the meantime prescribed me Betascalp steroid drops (bethamesanone) and the itchiness has stopped and it's not tender and inflamed anymore.  Strangely, my hair loss accelerated significantly around the time the itching condition got bad  a couple of years ago.  In retrospect I wish I'd researched the condition (and clinics!) before the HT - I was in too much of a rush at the time.

Nevertheless I'm still thinking my disappointing result is mainly down to the clinic using too few many grafts in my case.  However, there is also a nagging doubt now about my scalp condition and whether that could have interfered at all.

I'm thinking of getting a full biopsy before my next surgery just to rule out any scalp condition.

I've also read about scarring alopecia (lichen planopilaris) and seen some horrible results with HT.  I'm pretty sure I don't have scarring alopecia but the tinea captis would explain a lot. 

Really interested if anyone else has any experience with  intense itching/burning scalp and tinea captis out of curiousity?  I haven't seen it mentioned much on these boards.