Considering HT - Seeking advice for my situation

[tripleg]

Hello, gentlemen! (and ladies?)

I am considering a hair transplant and want to get some advice.

In the pictures you can see my situation. I’m 38. I started losing my hair in my early to mid twenties. My father is a Norwood 7, but his hair loss was more aggressive at an earlier age. I started finasteride two months ago; plan to stay on it for life. No other treatments. No previous hair transplants. My hair is on the thin side.

I've had online consults with two clinics and I'm now reflecting. It seems I'll need 4,500 - 6,000 grafts to get reasonable coverage. My donor is average based USB microscope eval by an HT surgeon in an online consult.

I'm debating FUE, FUT, or no surgery. Here is the pros/cons summarized:

* FUE
    * Two procedures
    * Shorter hair possible
    * Potentially fewer lifetime grafts
* FUT
    * Possibly one procedure might be enough (for now)
    * Longer hair to mask scar
    * Potentially more lifetime grafts. Higher quality grafts (from prime donor area)
    * No weight training for a few months

Here are my concerns that I'd like some feedback on:

1. Since transplanted hair takes 6-12 month to grow out, there is a period where the top of my head will still be bald, while the scaring in the back will necessitate longer hair on the back. The minimum with FUE seems to be 3mm - 6mm and with FUT 6mm - 10mm. At these lengths the horseshoe pattern becomes more and more prominent. How do I navigate this transition period?
   1. Roughly how long do the donor and recipient areas remain red/noticeable?
2. What is a safe minimum period between two procedures? With FUE I'd need two procedures N months apart. What is the minimum N that would minimize all risks and maximize the chances of a good outcome?
3. Should I wait for finasteride to potentially strengthen and if I’m lucky regrow some of the hairs before the surgery? Or would the surgeon be able to just transplant into areas where there is no chance for strengthening/regrowth. Would having more “mature” finasteride results help the surgeon make better cosmetic decisions?
4. Is FUE even an option for me? Is it possible to safely harvest as many grafts as I would need in my situation?

And and all feedback is much appreciated!

[1978matt]

have you got any photos with your hair grown out a bit?

Knowing the sort of coverage it would offer would help aid the decision. 

[Future Hair Doc]

Welcome to the community! Where are you located? Which surgeons have you consulted with? 

[tripleg]

53 minutes ago, 1978matt said:

have you got any photos with your hair grown out a bit?

Knowing the sort of coverage it would offer would help aid the decision. 

Attached are some photos where the hair is grown out slightly longer. This is the longest I have in the last few years. 

Not sure exactly what you're asking? What kind of coverage I can get from the currently existing hair? Basically that round bare patch that you see offers minimal coverage. The longer I grow it out, the more the barren area stands out.

I keep my hair super short - shaved down to 0.3 mm with a trimmer every ~3 days. Typically don't let it grow longer than the original photos.

[tripleg]

57 minutes ago, qui bono said:

1. The ugly duckling stage. Well Melvin has created a video on it I think, but everyone has a different strategy. Some guys keep shaving it down for FUE, while others grow it out and use concealers (Dermatch, toppik etc). Hats become a good friend. In terms of the recipient area becoming red (the donor, unless it experiences shock loss, bounces back quicker) it really depends on the individual. Some guys its not noticeable at all due to skin tone, fairer complexion guys it can be red for weeks. I think mine was really noticeable for about 1-2 weeks after the shed. Ive read one guy used tanning lotion to hide it, but not sure if thats healthy lol

 

Thanks!

58 minutes ago, qui bono said:

2. Absolute bare minimum time would be 6 months, but I wouldnt recommend it UNLESS you're targeting two distinct areas and ensure you have good growth in the first operation. Ideally you'd wait at least 12 months for the hair to go through enough cycles for the hairline & midscalp, and up to 18 months for the crown. That would allow enough time to assess whether youre happy with the growth/design etc and for your 2nd operation you can go back and tweak the areas youre unhappy with.

Heres a thread https://www.hairrestorationnetwork.com/topic/59182-when-should-you-get-your-second-hair-transplant/?tab=comments#comment-576131

Thanks for that link!

58 minutes ago, qui bono said:

3. You seem to be a pretty advanced NW with some kind of hairline (?) so I think most of what fin is doing is ensuring your donor is safe. Its not that common that fin regrows hair (although it does happen in some cases), so its mostly a drug used to preserve what you have.. 

Yeah "some kind of hairline" 😂 (but hey I'll take it!). I have some "weak" fuzz time hairs on top and I think there is a chance fin might strengthen some of those. Not sure how much that would change the equation for the surgeon, but I'm leaning towards staying on fin for at least a year before doing surgery.

 

1 hour ago, qui bono said:

4. Either extraction is an option, its really about your goals/coverage/expectations and whether you get a good result from the surgeries. You have quite high sides so your donor might be a it larger than most, so it would be worth it to get your donor capacity assessed and that might make your choice between between FUE vs FUT easier. Some guys have a spotty donor with great laxity so FUT is the better option. Other guys completely luck out and have 10k donors so they might want to pursue FUE and avoid the strip scar. Its always a negotiation between what your donor is capable of vs what you want to achieve.

Assessing donor is presumably something that needs to happen in person at the doctors office?

[tripleg]

5 minutes ago, qui bono said:

'coverage' as in the approximate area you want to transplant (the "barren" areas we want to cover up). This would also tell us what NW you are, but its sort of hard to tell with your hair that short. I think youre a NW 5a (?)

The longer the hair is it might help us see which areas are miniaturised (prone to future balding) and which areas are stable.

 

Yeah NW 5a is about right! The area that needs coverage is approximately 90 centimeters squared.

[tripleg]

54 minutes ago, Dr. Suhail Khokhar said:

Welcome to the community! Where are you located? Which surgeons have you consulted with? 

Thanks!

I split my time between Moscow and New York City. I'm targeting Europe for surgery.

I'd rather not mention surgeons right now, unless someone believes some surgeon is particularly well suited for my case.

[BDK081522]

While I think staying on finasteride for a year before surgery is always a good idea I'm not sure in your particular situation it would add much benefit other than strengthening your donor. With the pictures of your hair grown out it suggests you're a NW 5/6. Your crown does not drop too low so finasteride should definitely help keep that where it's at. It would be unlikely you would progress to a 7 as long as you stay on medical therapy. To answer some of your questions it's typical to have redness in the recipient area anywhere from 2-6 months. The donor area isn't usually noticeable with FUE after a few weeks of hair growth. With FUT you can grow the area above the incision longer pre-op and it can camoflouge the donor site. As far as time in between procedures it is generally recommended to wait 12 months to give your recipient area time to achieve full density. 

[Melvin- Admin]

In my opinion, if you want to maximize your donor supply you should start off with FUT, you look to be a Norwood 6. I don't think you'll follow your fathers hair loss pattern. Although, nothing is set in stone. 

Here is my advice, submit as many virtual consultations as possible. Get a general consensus for the price and the number of grafts you'll need. Below is our list, you can start submitting VC's now. 

Forum approved list

https://www.hairtransplantnetwork.com/Consult-a-Physician/hair-transplant-surgeons.asp?sr=HRN

 

Watch these videos, they are from world renowned Dr. Shapiro, Dr. Josephitis, Dr. Nadimi and Dr. Konior. They will help you figure out the differences, and they will explain why getting a personalized consult is ideal.

 

 

[1978matt]

6 hours ago, tripleg said:

Attached are some photos where the hair is grown out slightly longer. This is the longest I have in the last few years. 

Not sure exactly what you're asking? What kind of coverage I can get from the currently existing hair? Basically that round bare patch that you see offers minimal coverage. The longer I grow it out, the more the barren area stands out

I was curoius to see if your natural hair is thick and coarse, or thin and fine.  Obviously the latter requires more grafts to get a dense result on top.

I can only guess but your hair looks like it might be quite fine.

On the positive side, your FUE donor area looks quite big in relation to the bald area.

I actually think you may be better off going FUE.  Scars can be a bit harder to hide if your hair is fine, even if it is a thin scar.

Make sure you go to a top FUE doctor who spreads the extractions out and doesnt leave you with a noticeably 'thin horseshoe zone' at the back.  just do 2500 to start to see how it goes.  I would not recommend trying to do it all in one go, no matter how attractive that sounds.

[tripleg]

1 minute ago, 1978matt said:

I was curoius to see if your natural hair is thick and coarse, or thin and fine.  Obviously the latter requires more grafts to get a dense result on top.

I can only guess but your hair looks like it might be quite fine.

On the positive side, your FUE donor area looks quite big in relation to the bald area.

I actually think you may be better off going FUE.  Scars can be a bit harder to hide if your hair is fine, even if it is a thin scar.

Make sure you go to a top FUE doctor who spreads the extractions out and doesnt leave you with a noticeably 'thin horseshoe zone' at the back.  just do 2500 to start to see how it goes.  I would not recommend trying to do it all in one go, no matter how attractive that sounds.

Thanks, man! Yeah my hair is on the thing side for sure!

Does fine hair mean growing it longer to hide the FUT scar?

[1978matt]

Just now, tripleg said:

Does fine hair mean growing it longer to hide the FUT scar?

Yeah, I've seen some cases where it's still a bit noticeable even at 10mm+.  they just have that fine whispy baby type hair that doesn't provide much volume.

[tripleg]

14 minutes ago, 1978matt said:

I was curoius to see if your natural hair is thick and coarse, or thin and fine.  Obviously the latter requires more grafts to get a dense result on top.

Here's a pic of my hair before I lost too much. Not sure if that helps.

 

Edited March 24, 2021 by tripleg

[1978matt]

Looks on the finer side but not terrible.

[WildBlueberry]

13 hours ago, qui bono said:

Having at least some kind of hairline might help a HT doc know to design the transplanted one around it. The native hair there, if you can retain it, would also add to the naturalness of the result.

You can technically do it yourself, as even knowing a general number might help you

https://baldingblog.com/how-to-quantify-your-donor-area-hair-supply/

Different clinics will give you different answers. Like Lorenzo in Spain and Asmed in Turkey use a graft calculator, although their numbers are usually estimated a little higher. 

 

I should also add there a handful of clinics that are able to do FUE megasessions and would be able to handle your case in one go. Im not advocating it either way as its up to the patient to decide, but Eugenix in India, Hasson and Wong in Canada, and Hattingen in Europe routinely do such sessions with a high level of consistency. 

Are the graft estimates by asmed and Lorenzo a lot higher than what other doctors calculate? Is it significantly higher?

[DrTBarghouthi]

Thanks for posting. I’m not sure I can comment on your donor quality based on those photos. The hair color is making it seem rather sparse. I think it is important to get that part checked properly and then based on that you can have a better plan. I tend to put some patients on finasteride as this can potentially help with the donor as well. 

[Future Hair Doc]

1. Since transplanted hair takes 6-12 month to grow out, there is a period where the top of my head will still be bald, while the scaring in the back will necessitate longer hair on the back. The minimum with FUE seems to be 3mm - 6mm and with FUT 6mm - 10mm. At these lengths the horseshoe pattern becomes more and more prominent. How do I navigate this transition period?
   1. Roughly how long do the donor and recipient areas remain red/noticeable? THE ERYTHEMA LASTS ABOUT 1 WEEK
2. What is a safe minimum period between two procedures? With FUE I'd need two procedures N months apart. What is the minimum N that would minimize all risks and maximize the chances of a good outcome? I RECOMMEND 1.5 YEARS
3. Should I wait for finasteride to potentially strengthen and if I’m lucky regrow some of the hairs before the surgery? Or would the surgeon be able to just transplant into areas where there is no chance for strengthening/regrowth. Would having more “mature” finasteride results help the surgeon make better cosmetic decisions? YES, YOU SHOULD TRY ORAL FINASTERIDE AND TOPICAL MINOXIDIL AND GIVE THIS COMBO ABOUT 1 YEAR TO FULLY REALIZE BENEFITS. 
4. Is FUE even an option for me? Is it possible to safely harvest as many grafts as I would need in my situation? CURRENT RESEARCH SAYS TO DO A COUPLE ROUNDS OF FUT AND THEN DO FUE IN ORDER TO MAXIMIZE THE NUMBER OF GRAFTS YOU CAN GET.

As always, feel free to reach out anytime. I sent you a PM as well.

- Suhail

[tripleg]

5 minutes ago, Dr. Suhail Khokhar said:

As always, feel free to reach out anytime. I sent you a PM as well.

- Suhail

Thanks!

[tripleg]

On 3/24/2021 at 5:54 PM, qui bono said:

I should also add there a handful of clinics that are able to do FUE megasessions and would be able to handle your case in one go. Im not advocating it either way as its up to the patient to decide, but Eugenix in India, Hasson and Wong in Canada, and Hattingen in Europe routinely do such sessions with a high level of consistency. 

It seems I would need a minimum of 4500 grafts to get a decent result. How common are FUE "megasessions" of this size? I would guess you'd need to have above average donor for it?

[tripleg]

On 3/24/2021 at 11:53 PM, 1978matt said:

Make sure you go to a top FUE doctor who spreads the extractions out and doesnt leave you with a noticeably 'thin horseshoe zone' at the back.  just do 2500 to start to see how it goes.  I would not recommend trying to do it all in one go, no matter how attractive that sounds.

Do you mean that if going with FUE trying to extract too many grafts at once is a bad idea or do you mean that with FUT as well?

I believe with FUE the issues are blood supply and donor overharvesting?

[tripleg]

5 minutes ago, qui bono said:

There are a few arguments agaInst megasessions you should be aware of generally;

Thanks a lot! This whole post super-helpful!

[tripleg]

On 3/24/2021 at 11:53 PM, 1978matt said:

I actually think you may be better off going FUE.  Scars can be a bit harder to hide if your hair is fine, even if it is a thin scar.

Was your sole reason for brining up FUE the fact the scar may be harder to conceal with fine hair? In this video Dr. Lindsey says that patients with thin hair in particular should avoid favor FUT because thinner hair doesn't tolerate avulsion with FUE well. But I have seen finer hair FUE results that seem to be looking good. @Rolandas comes to mind.

 

 

[Melvin- Admin]

On 3/28/2021 at 1:10 AM, qui bono said:

the average donor has around 5-6k grafts available for FUE, so no you dont need an above average donor. Guys who go to to Turkish hair mills and fall for the salesmanship of "unlimited grafts" etc get absolutely destroyed by megasessions though. I remember seeing some brutal results there with depleted donors and poor growth etc. I

To get a good hairline and cover the midscalp (basically everything but the crown) you'd need around 4k grafts. You'd need another 1-2k for crown coverage depending on what you have left over - so you see how the average guy (should all things go well with a good clinic), can get a hairline and decent coverage with HT's. With FUT you can add another 2k grafts available (so 6-8k graft donor capacity) and potentially get full coverage and have a safety net should anything go wrong. BHT is an option as well, as that Bisanga case I listed was very smart by doing a 3k donor sessions and a 1k beard sessions with plans to tackle the crown later. Eugenix also use BHT in a similar way

I wrote a list of clinics that do megasessions, those are the safe ones. 

There are a few arguments agaInst megasessions you should be aware of generally;

- The "all your eggs in one basket" problem; if you experience any issues like poor growth, scarring, deleted donor etc your options start drying up, smaller sessions allow you to assess the success of the operation and make adjustments in the future. 

- in terms of survival rate its technically better to do smaller sessions of around 2k grafts (there is a slight drop when you start doing higher number). This has to do with blood supply. Although with those clinics I listed youre not going to see any significant drop in results, and when you compare them to the industry as a whole you'd still be getting a top tier result. A megasession operation would likely be a 2 day operation with these clinics.

- Its better for the donor to do smaller sessions as with FUE you are selecting the best and most robust grafts for transplantation (effectively leaving the less appealing "leftovers" behind). This means the "leftover" grafts now have to do all the heavy lifting in the donor and if you go to a clinic that isnt good at graft selection, or a proper extraction pattern, or causes excess scarring your donor will look crap. 

Everything in his industry is about assessing risk, and as its an elective surgery the choices and risks you take are all on you. So research/ ask as many questions as possible so you know what youre getting into. Although youre already ahead of the curve by joining here

Well said 👍🏼