Cover only frontal 1/3 in first surgery vs. full scalp with less density?

[tripleg]

Hello,

I haven't yet had any hair transplants and I started finasteride 2 months ago. My donor is okay, but nothing spectacular and my hair is on the thinner side, but not super-thin. Currently I shave my head very close.

It seems I'll need 5000-6000 grafts to get good coverage (see pics below). I am currently leaning toward FUE. I don't think I want to attempt an FUE megasession of 5000 grafts, nor am I sure any surgeon would attempt it in my case. 

In cases like mine it seems common to cover the frontal 1/3 of the scalp in the first surgery and the rest of the scalp in the second surgery. If I were to do that I think I would not be inclined to grow my hair out until the result of the second surgery would begin to show. This is because the first surgery would still leave my mid-scalp and crown bare and I'm not too keen on trying to comb over that area. I know some people do it successfully, but for some reason it doesn't feel right. I'm open to have my mind changed on this, but I don't know...

Walking around with a hair line would be nice, but considering the mid-scalp and crown are still bare, I would feel less exposed and more secure with short hair. Like if a girl were to run her hand through my hair the whole situation would become immediately apparent with a comb-over. Most likely after the first surgery, I would be shaving my head to 3mm-6mm or whatever the minimum length required to cover the scarring from FUE. (It seems FUE scars take some time to "mature" meaning they're not as noticeable at first, which means I may be able to get away with shorter hair in the early months after surgery #1).

So here is my question: Would it be possible to take say 2500 grafts in the first surgery and spread them out more or less evenly throughout the scalp instead of concentrating all the grafts in the frontal 1/3? I believe this would offer a better intermediate aesthetic result while I'm keeping my hair short until surgery #2 is completed. Would the resulting density be too thin to make any noticeable improvement even with short hair? Would it somehow complicate surgery #2 because the surgeon will need to insert new grafts in between previously transplanted grafts (Could the scarring in recipient area make it more difficult or less likely to succeed?)

Alternatively, if the grafts from surgery #1 are concentrated in the frontal 1/3 and I cut my hair short, maybe it would still look better than spreading the grafts all over the scalp. What do you think?

Edited April 25, 2021 by tripleg

[gman849]

It would seem to me that the best immediate option is to do the frontal 1/3 1st. You would be establishing a hairline and framing the face. Future procedures would jump of from there. 

[j1mmy]

You can essentially do whatever you want, if your Dr is on board. By that, I mean that in a first procedure you could make a plan with your Dr to achieve a reasonable coverage at the hairline (you already have a hairline which is helpful), reasonable coverage in the mid-scalp, and feather in less grafts going backwards from there. Agreeing with gman, the typical advantage of frontal work is that at the very least you have facial framing and the largest cosmetic difference, when you had an untouched donor to source from. As time goes on, and the 2nd or 3rd procedure occurs, density in the mid-scalp/crown is subject to the availability of the remaining donor. That is a very logical approach, compared to if someone decided to work from the back forwards, and potentially running low on graft availability when it comes to really building the frontal third.

Firstly, consider having a consultation with someone reputable to gauge a better assessment of your donor supply, the entire plan hinges on that.

Secondly, understanding your concerns about a mega session, and given an average donor supply, I would favour a 2-stage approach. 1st step could be bigger and provide a significant cosmetic difference, but allow you to not feel like you just restored half of your head. Say 3000-4000 grafts with a bias towards the mid-scalp and frontal third. The second procedure, depending on your donor, address a bias towards the crown, but touch-up areas based on the results of your first procedure. I would say this is a typical approach, so you are not reinventing the wheel there.

[Future Hair Doc]

Is your hair loss stabilized? Are you on finasteride/minoxidil? I would focus on the frontal 1/3 and this will frame your face well and serve as a barometer for the rest of your scalp. 

[Britanium]

I would also be interested to know which clinics your considering ? I would also aim for at least 4000 grafts like @qui bonohas mentioned. 

[tripleg]

30 minutes ago, JohnAC71 said:

I would also be interested to know which clinics your considering?

 

43 minutes ago, qui bono said:

What clinics are you considering?

I'm early in the process of researching clinics. I'm targeting Europe for my HT.

Currently on my radar:

Hattingen - more so if I end up going the FUT route, but currently leaning FUE. FUE with them would probably be more expensive and while I feel they're a top clinic, I get the sense that there are other European clinics are just as good at FUE.

Next on the list are the Belgians in alphabetical order:

Bisanga, Devroyem, Feriduni, Lupanzula

Also on the list: Bruno Ferreira

That's my shortlist at the moment. I've also considered Dr Zarev from Bulgaria. But he seems to be a FUE megasession specialist. I know there are also great options in Spain and in the U.K. and other places in Europe.

I plan to travel to Europe and visit the as many clinics as I can in person to get an assessment and meet the docs. For me it's very important to meet the doc beforehand.

In the mean time I'm waiting to see how I respond to finasteride, which I've only been on for two months so far. For me, I don't think HT surgery makes sense unless I can stay on finasteride for life.

[tripleg]

1 hour ago, qui bono said:

Can you give anymore info about your donor i.e. have you had it assessed and do you know the donor capacity and hair calibre?

I haven't had any in person assessments yet, but planning on it. I've had an online assessment by Dr. Muresanu of Hattingen. He had me point a USB microscope at different points on my donor. Based on this he said my donor was okay, but nothing spectacular (paraphrasing). No mathematical calculations were done. Same for hair calibre - exact calibre unknown, but on the thinner side, though not super thin. So basically a lot of grafts required.

 I also attempted a self-assesment following the instructions you supplied to me in another thread:

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

It seemed my donor was slightly below average, but I wasn't always sure if FUs were singles/doubles/triples and I was erring on the lower side. It was tedious to try counting/classifying all the FUs and making sure I don't miss any. I may attempt this process again more carefully. 

In mean time I'm hoping to receive at least some benefit from finasteride. Perhaps it can strengthen my donor a bit. I did see a couple of miniaturized hairs in donor as well under the microscope.

[Britanium]

Your consideration list of clinics/Drs is spot on ! Your research is certainly going to give you the best chances of a good result 🙏

[tripleg]

1 hour ago, Dr. Suhail Khokhar said:

Is your hair loss stabilized? Are you on finasteride/minoxidil?

I am on finasteride for two months, waiting to see how I respond. I may add topical minoxidil after I've been in on fin for a year, but I worry I will not stick to the routing of applying daily. I'd rather not "get my hair hooked on minoxidil" right now.

If I get some sides from fin (highly unlikely) or if I continue to lose hair despite fin, I will postpone surgery and likely not do it all unless I can find a way to stabilize (with something like dutasteride or minoxidil). But statistically speaking I will most likely at least stabilize on fin with no side effects and be able to move forward with surgery.

[tripleg]

2 minutes ago, JohnAC71 said:

Your consideration list of clinics/Drs is spot on ! Your research is certainly going to give you the best chances of a good result 🙏

Thanks! And thanks for the help you've given on this an other threads.

[j1mmy]

44 minutes ago, tripleg said:

 

I'm early in the process of researching clinics. I'm targeting Europe for my HT.

Currently on my radar:

Hattingen - more so if I end up going the FUT route, but currently leaning FUE. FUE with them would probably be more expensive and while I feel they're a top clinic, I get the sense that there are other European clinics are just as good at FUE.

Next on the list are the Belgians in alphabetical order:

Bisanga, Devroyem, Feriduni, Lupanzula

Also on the list: Bruno Ferreira

That's my shortlist at the moment. I've also considered Dr Zarev from Bulgaria. But he seems to be a FUE megasession specialist. I know there are also great options in Spain and in the U.K. and other places in Europe.

I plan to travel to Europe and visit the as many clinics as I can in person to get an assessment and meet the docs. For me it's very important to meet the doc beforehand.

In the mean time I'm waiting to see how I respond to finasteride, which I've only been on for two months so far. For me, I don't think HT surgery makes sense unless I can stay on finasteride for life.

You're the man @tripleg! Where are you based, out of curiosity? That is of course a factor with where to go should you decide to go this route, even with Europe as your net, as it was for me. 

Don't be afraid of online/video consultations, imagine how that has been performed and improved over the past 12 months. I don't know this for a certainty, but I think the people who you are considering have a decent idea of your donor and hair caliber from good pictures. They may not know your hairs/graft, or your donor size as a measurement but you are already equipped to gauge that. Should you be unable to meet them in person, you will have a good idea of what is the best plan and who to go with, and the plan will be fine tuned once the consultation happens in person. 

It also helps with a photo of the back, your occipital area is your density bullseye of your donor. 

Edited April 25, 2021 by j1mmy

[tripleg]

1 hour ago, j1mmy said:

Where are you based, out of curiosity?

I am currently living in Moscow, Russia where I'm originally from. I split my time between NYC and Moscow, but HTs are more expensive in the U.S. and the surgeons in Europe are just as good IMO, especially for FUE.

And here is a pic of the back of my head. This is 6 days of growth after shaving to zero.

Edited April 25, 2021 by tripleg

[j1mmy]

54 minutes ago, tripleg said:

I am currently living in Moscow, Russia where I'm originally from. I split my time between NYC and Moscow, but HTs are more expensive in the U.S. and the surgeons in Europe are just as good IMO, especially for FUE.

And here is a pic of the back of my head. This is 6 days of growth after shaving to zero.

Ok cool, nice to see someone from Russia!

Hard to photograph I know, but try to capture the bottom of it too, so we/Dr's can see if there is any visible miniaturization at the nape.