Photo evaluation - 42 year old male - second transplant

[BJ47]

Hi all,

I had a transplant 10 years ago with Dr. Cooley.  Great experience.  Time marched on and I'm on board for a second transplant to fill in behind the hairline and restore the temple areas. I've been given a few options and was curious as to what your thoughts are?

1) 2500 to 3000 grafts to frontal 2/3 (depending on donor)

2) 2500 to frontal 2/3 + 500 grafts to crown

3) leave crown alone, no grafts but do exosomes

4) any of the above options + exosomes to crown and/or frontal 2/3

My main area of concern is the frontal 2/3 but I would honestly love to address the crown area in some way.  Even a sprinkling of grafts would give my Toppik more to grab onto.  Having a tough time visualizing what 500 grafts would look like in that sized area.  Also wondering if exosomes would be a good alternative to the grafts, a good option to supplement the grafts, or if the improvement to the crown area would be minimal to the point that going with the option of grafts makes more sense.  Thanks! 

Edited October 6, 2021 by BJ47

[bostonguy]

Hi @BJ47 , welcome to the forum. With your first transplant, how many grafts did you have and where were they placed?

Are you currently on finasteride to prevent further loss? 

The reason I ask is because if you had a previous transplant in the frontal area that is concerning. A prior transplant even 10 years ago should hold up, but without understanding your specific situation I can only assume. 

2500-3000 grafts will add a noticeable impact to the frontal 1/3rd of your head and 500 into the crown would at least allow Toppik to grab on, but you will probably want more down the road. We all want more. 1500 into the crown later on may give you enough to be content if your hair characteristics are favorable. 

As for exosomes the jury is still out. There are many clinics claiming great results but fail to deliver evidence or photos. They talk a big game, but do not deliver. I have seen some clinics state how great Exosomes are, but time and time again fail to show proof. I'd hold off on Exosomes and invest as much into the Hair transplant instead. 

Edited October 10, 2021 by bostonguy

[aaron1234]

7 minutes ago, bostonguy said:

A prior transplant even 10 years ago should hold up, but without understanding your specific situation I can only assume. 

Not necessarily.  Dr. Bisanga did recently say that if your transplant remains good for 10 years you should be happy. 

@BJ47 Was your first procedure FUT or FUE?  Depending on your laxity you might be able to have another strip megasession (2-4k grafts).  The more grafts you can harvest the more likely you can address both the frontal third and crown with your next procedure.  I would take a serious look at Hasson & Wong for round 2. 

[JDEE0]

56 minutes ago, aaron1234 said:

Not necessarily.  Dr. Bisanga did recently say that if your transplant remains good for 10 years you should be happy. 

@BJ47 Was your first procedure FUT or FUE?  Depending on your laxity you might be able to have another strip megasession (2-4k grafts).  The more grafts you can harvest the more likely you can address both the frontal third and crown with your next procedure.  I would take a serious look at Hasson & Wong for round 2. 

Whilst I agree with the 'not necessarily' caveat to your point, I certainly agree with the other posters point that a transplant from 10 years prior should hold up, especially under the use of a reductase inhibitor during that period.

I also watched that live with Bisanga (who is one of my favourite doctors for clarity, not questioning his knowledge) but I was unsure if something got lost in explanation along the way as he made that point. The general wisdom from clinical evidence/studies/data and so on is that donor hair (assuming it was actually taken from the patients individual safe zone) should indeed act as it would had it never been relocated to the front of the scalp (as I'm sure you know).

Most doctors who I've ever spoken to and have queried this with have all agreed and said that this is generally the case. To suggest otherwise is to suggest that the individual follicle itself isn't what's influenced by MPB or what caries the genetic trigger that sparks it so to speak, but instead that the specific area of the scalp is the underlying culprit. As such, the whole theory of donor dominance suddenly becomes contestable, but we know that there is a scientific consensus that this is not the case and that at the very least it is widely accepted that transplanted follicles do indeed retain their genetic resistance to DHT/androgens (other things such as hair characteristics in terms of waviness etc have been observed to change). 

Because of this, and the fact that the instagram live conversation in question was heavily intertwined with the use of meds and age related thinning of all hairs (including donor hair) if I recall correctly, I generally attributed what Bisanga was saying to mean that, should someone not use any meds after a HT and have just generally aged a bit, then they should be happy if it still looks good in comparison to their initial results 10 years later. It would be good to get some clarity on what he meant here though as it would seem his stance goes against conventional wisdom and I'd be interested to hear why he thinks so.

Either way, there are countless surgeons who suggest these transplanted hairs should grow for life if everything was done correctly, but note that they will in all cases thin (shrink in diameter, but unrelated to MPB/androgen exposure) with age and that without the use of meds both they and your native hair have the potential to thin (directly from MPB/androgen exposure) over time leaving you with a lacklustre result down the road. Here's a video of Dr. Sethi saying as much: 

 

Edited October 10, 2021 by JDEE0

[aaron1234]

@JDEE0 Dr. Ron Shapiro and Dr. Wong also recently stated that transplants can thin over time.  Dr. Shapiro said we shouldn't refer to the donor region as the permanent zone anymore.  Dr. Wong even wondered out loud if there might be something in the bald area of the scalp that attacks transplanted follicles.  It appears there's been a shift in the conventional wisdom, and the speculation coming from reputable/ethical docs of late definitely got my attention.

Regarding the OP, we would need to see pictures of his results from 10 years ago and know the number of grafts he received to determine if his transplant thinned or if it was more native hair loss (or both).  If it did thin then he might want to get a scalp biopsy done to see if he has any scarring alopecia condition that might effect the transplant.  

Edited October 10, 2021 by aaron1234

[JDEE0]

4 minutes ago, aaron1234 said:

@JDEE0 Dr. Ron Shapiro and Dr. Wong also recently stated that transplants can thin over time.  Dr. Shapiro said we shouldn't refer to the donor region as the permanent zone anymore.  Dr. Wong even wondered out loud if there might something in the bald area of the scalp that attacks transplanted follicles.  It appears there's been a shift in the conventional wisdom, and the speculation coming from reputable/ethical docs of late definitely piqued my curiosity.

Regarding the OP, we would need to see pictures of his results from 10 years ago and know the number of grafts he received to determine if his transplant thinned or if it was more native hair loss (or both).  If it did thin then he might want to get a scalp biopsy done to see if he has any scarring alopecia condition that might effect the transplant.  

Yeah, I saw both of those lives too. It is indeed interesting, I'm with you there! Personally, I think for the most part that most people are fine and thinning indeed only occurs as it would have in the donor, but that it seems a select few do have issues where the transplanted hair does inexplicably thin for some reason. There probably is something that happens fairly rarely that we don't yet understand. Seeing as you are a HT vet, have you noticeably seen anything with your own transplanted hair over time? I know your hair looks damn good still, but would be interested to hear if you have personally noticed anything?

And yeah, OP, pictures as Aaron has pointed out would be very helpful.

[Mike Flaherty]

I can say with 100% authority that transplanted hair can and most likely will thin again and fall out beyond the 10-year mark. My surgeon told me a few months ago that transplanted hair will continue  to fall out along with native hair. It was quite distressing to hear this as myself and my mother asked the surgeon at the time how long transplants last and the response then was they "last forever,"

Edited October 10, 2021 by Mike Flaherty

[JDEE0]

Can is a given, yes. That it 'most likely will' is a fairly preposterous, strong statement.

In your case just like this one, we really need to see before/baseline pics to have any idea of what's going on. 

[Mike Flaherty]

1 minute ago, JDEE0 said:

Can is a given, yes. That it 'most likely will' is a fairly preposterous, strong statement.

In your case just like this one, we really need to see before/baseline pics to have any idea of what's going on. 

My surgeon used the word "will."

[JDEE0]

Just now, Mike Flaherty said:

My surgeon used the word "will."

All hair will continue to thin as you generally age and your follicles go through more and more cycles, your body just overall begins to decline and also as they are continually exposed to the processes that trigger gene expression/genetic baldness. This includes the donor area; no one should ever say that it's immune to androgens/DHT, just that these follicles are far more resistant (it's extremely normal for a very healthy donor area to have a small % of active miniaturisation under a microscope for example, so we know this).

Most reputable doctors will tell you to take a 5ar inhibitor not only to protect your native hair from thinning, but also your donor. So whilst I agree with your statement on a literal basis, I feel like, based on your comment here on this specific post of a severely thin looking result and also those in your own thread, your take is more of a "I can say with authority that your transplanted hair will heavily miniaturise/fall out after 10 years and leave you with a poor result" which is not the case. If that's an assumption and you weren't inferring that at all, then my bad. But there are countless examples of guys who's hair still visually looks the same a decade later although I would indeed wager that it has undergone some sort of thinning in this time.  

As said in your post, it would be very helpful if you could just post some pics to show what you're talking about, at least some showing the difference from pre and post fin that you say has ravaged your hair so we can get some idea. 

[BJ47]

7 hours ago, bostonguy said:

Hi @BJ47 , welcome to the forum. With your first transplant, how many grafts did you have and where were they placed?

Are you currently on finasteride to prevent further loss? 

The reason I ask is because if you had a previous transplant in the frontal area that is concerning. A prior transplant even 10 years ago should hold up, but without understanding your specific situation I can only assume. 

2500-3000 grafts will add a noticeable impact to the frontal 1/3rd of your head and 500 into the crown would at least allow Toppik to grab on, but you will probably want more down the road. We all want more. 1500 into the crown later on may give you enough to be content if your hair characteristics are favorable. 

As for exosomes the jury is still out. There are many clinics claiming great results but fail to deliver evidence or photos. They talk a big game, but do not deliver. I have seen some clinics state how great Exosomes are, but time and time again fail to show proof. I'd hold off on Exosomes and invest as much into the Hair transplant instead. 

@bostonguy Yes, I am currently on finasteride.  I started finasteride at age 19, and had a period of a couple years in the time after my first HT that I stopped taking it. 

For the first HT,  Dr. Cooley recommended 2000 grafts and we ended up at almost 2200.  It was a FUT procedure and the grafts were placed into the hairline and frontal 2/3 or so.  I had some thinning in the crown area, but Dr. Cooley said he did not feel comfortable transplanting into that area until age 40 or later once the hairloss had stabilized a bit more.

My hair is slightly damp in the photos I shared in the original post.  These are the images I sent to Dr. Cooley's office as part of the initial conversation for a second procedure and wanted to show the extent of the thinning.

My instinct is that what we're seeing from hairline back in the middle are transplanted hairs, and the natural hairs have continued to thin from age and discontinuing finasteride for a time.  My dad and two younger brothers are all slick bald on top and in the crown area.

I very religiously and agressively use Toppik, so I'll try to see if I can find some "post HT 1" photos that were taking during the time that I was able to give it up.  I know there were a few years in the time after the first HT that I was able to give it up completely, then continued it back up once I noticed the thinning was progressing.

I do have a bit of peach fuzz in the crown area.  Enough for Toppik to cling to.  That makes me hopeful about the exosomes if they really do work as "advertised."  I want to be smart about using the donor grafts that remain, but I also want to be realistic about what's possible and definitely want to do something to address the crown in my second procedure.  Lollie said something along the lines of "I'd recommend putting off transplanting into the crown as long as possible and focus on the frontal 2/3." 

UPDATE:  I was able to locate the photos that I sent for my first evaluation in 2008.  These were pre-op and what Ailene used to make recommendations prior to an in-person visit.

Also, in looking for photos I realized that my first procedure was in December 2008.  So almost 13 years ago.

 

 

 

Edited October 10, 2021 by BJ47
added photos

[aaron1234]

@BJ47 You had a strong frontal tuft 13 years ago, so I assume Dr. Cooley transplanted around it at the time?  I would most certainly go with FUT again since you already have.  Do you believe the transplanted hair for your first procedure has thinned out?  You still have a strong bridge (between the frontal third and crown), so definitely stay on fin. 

[JDEE0]

Looking at your newly posted photos pre HT, I would have to assume that your transplanted hair has indeed thinned out - I mean, I imagine most of your grafts went either side of the forelock which were slick bald and at least visually had the illusion of matching its density once the result came in. Unless the result was never really satisfactory and didn't grow in well, but considering you said it was a great experience, I doubt that.

Do you have any photos of how things looked when the result was at it's best in the years following the procedure (no Toppik or anything obviously) so we can see an honest comparison of then vs your pics now posted in this thread. As Aaron said earlier in the thread, if its clear it has thinned, it would be prudent to check for any potential underlying scalp conditions before going for round 2, just in case. 

As far as your original question: I would either visit H&W for a larger session to fill in the front and the back, probably totalling 4000-5000 grafts all in, or hit the frontal third/half in one procedure of around 3000 grafts and then revisit the crown with what's left a year later. Obviously this is all dependent on donor, but yours looks in good shape still from what (albeit little from your pics) I can see.

Edited October 10, 2021 by JDEE0

[Curious25]

I have to reiterate the concern that has already been expressed, as to what happened to the 2200 grafts over the last 13 years - there doesn't seem to be a very high survival rate at all, going off your current pics. 

[BJ47]

I managed to find the drive that has my photos from the day of the procedure.  Here are the pre-op photos that Dr. Cooley took.  I'll do another comment below this one with post-op photos to show graft placement.

[BJ47]

And here are the post-op photos (I also included one of the hairline that Dr. Cooley drew right before the procedure).

[BJ47]

And day 1 post-op.  Back home.

[BJ47]

Here's what I came up with in the way of post-op, no Toppik photos.  I realize these aren't the greatest quality.  Some inside, some in the sun.  These are mostly a couple years post-op.

[JDEE0]

Hmm, it's an interesting one. I've been looking at the different pics and trying to compare and have come to the conclusion that it's mostly the result of your native hair thinning, but there has to be some thinning of the transplanted hair at play also. Certainly so in fact.

However, looking at your pics from 2010 where you're outside in them, your hair is sort of pushed forwards and over to one side and it is still clear even with this style that the hairline isn't particularly dense or full and it still looks fairly weak in this area. Don't get me wrong, there is definitely improvement from pre-op, but it doesn't seem like a very dense hairline and I can obviosuly tell it's not as if your 2000 or so grafts gave you a result even close to something along these lines of this: https://www.hairrestorationnetwork.com/topic/58568-dr-couto-2000-grafts-10222020/page/5/

Yes, I know this guy has got outstanding donor characteristics yada yada, I'm not trying to compare him or his results to you directly, I'm just saying that it's not as if your transplanted hair has deteriorated from a result such as that to how yours is now if you understand me. I think it has thinned a bit as I say, but that it was already pretty thin and you have additionally since lost maybe 70 percent of the density and or diameter/coverage of your native hairs up top which makes it look the way it does now.

It still seems slightly concerning in general though as I feel the transplanted hair has thinned out a fair bit more than I would expect - would be interested to hear what others think.

You say you've been on fin for a long time but have had some fairly lengthy breaks - did you notice most of your loss in general happen during these times, or has it just slowly happened over the past 10 years or so?

 

Edited October 10, 2021 by JDEE0

[bostonguy]

After viewing the pre-op photos and comparing them to the other photos it's evident the transplanted hairs did not hold up well. Based on the 2010 photos it's hard to tell how successful the initial transplant really was. What appears to have happened, as others have pointed out is more native hair loss and significant thinning of transplanted hair. I'm not sure if this comes down to the doctor or intrinsic factors but would definitely have the scalp looked at prior to a second HT. 

Did the clinic have anything to say when you sent over your photos for review? I would love to hear their explanation. 

Edited October 10, 2021 by bostonguy

[asterix0]

OP, How long did you stop taking finasteride for?

[BJ47]

I took some time after showering tonight to comb through my hair and inspect after studying my post-op photos for graft placement from 13 years ago.  I can tell that part of that front "tuft" is still there, probably the middle 1/3 or so.  From the pics it doesn't look like many/any grafts were placed in this area and today it's noticeably thicker than the right and left sides of it. 

The hairline is still in place and I can make out the shape of my hairline now as compared to the post-op photos.  There may have been some thinning of the transplanted hairs themselves, but the majority of the grafts appear to be there and still growing.

I think this is mostly a case of my original hairs continuing to thin and recede.  Sure, graft thinning could come into play as well but I don't think it's as significant as the former.  @asterix0 I was off finasteride for about 2 years.  I feel like it was a slow and gradual thinning over the last 13 years rather than a rapid loss scenario.

I wonder what it would look like now if I had 2200 grafts, with that placement, on a slick bald head?

@JDEE0 I don't know if it's fair to compare to a procedure that some are calling a "unicorn" and "YouTube worthy."  LOL  My results never looked as good as his.   I wouldn't have considered my results at their best to be super dense but they provided coverage I was happy with for a time.

@bostonguyI didn't ask Lollie what she thought about my current day photos.  I didn't think anything was going on beyond original hairs continuing to fall out.  Should I follow up with any specific questions?

Some of you have mentioned having my scalp checked out or tested.  In what way?  Who could do that for me, and what would they be looking for?   

[asterix0]

From what I can tell, your hair looked great in your pictures from 2012. So, I can only guess that while you were off finasteride is when the majority of your thinning occurred. Remember, finasteride very rarely regrows anything, it's more a preventative hair loss drug.

We can only really say for certain if you have some more pictures right after you got back on finasteride, and then do a side-by-side comparison. 

 

[JDEE0]

17 minutes ago, BJ47 said:

I took some time after showering tonight to comb through my hair and inspect after studying my post-op photos for graft placement from 13 years ago.  I can tell that part of that front "tuft" is still there, probably the middle 1/3 or so.  From the pics it doesn't look like many/any grafts were placed in this area and today it's noticeably thicker than the right and left sides of it. 

The hairline is still in place and I can make out the shape of my hairline now as compared to the post-op photos.  There may have been some thinning of the transplanted hairs themselves, but the majority of the grafts appear to be there and still growing.

I think this is mostly a case of my original hairs continuing to thin and recede.  Sure, graft thinning could come into play as well but I don't think it's as significant as the former.  @asterix0 I was off finasteride for about 2 years.  I feel like it was a slow and gradual thinning over the last 13 years rather than a rapid loss scenario.

I wonder what it would look like now if I had 2200 grafts, with that placement, on a slick bald head?

@JDEE0 I don't know if it's fair to compare to a procedure that some are calling a "unicorn" and "YouTube worthy."  LOL  My results never looked as good as his.   I wouldn't have considered my results at their best to be super dense but they provided coverage I was happy with for a time.

@bostonguyI didn't ask Lollie what she thought about my current day photos.  I didn't think anything was going on beyond original hairs continuing to fall out.  Should I follow up with any specific questions?

Some of you have mentioned having my scalp checked out or tested.  In what way?  Who could do that for me, and what would they be looking for?   

I purposely pointed out that I wasn't comparing your procedure with his as he likely has above average donor characteristics and you likely do not...

As I said, I was making the point that although I do believe your transplanted hair has thinned, it doesn't look like from your photos from 2010 you results were super dense as they were in the linked scenario and were in fact somewhat underwhelming from what I can see. as a result, they probably haven't thinned that much, it's more a case of the surrounding hair has, exposing the weaker transplanted areas sort of thing.

Although I do think they have thinned a decent amount more than I would expect.

[aaron1234]

You've definitely lost native hair since your procedure 10 years ago, but this is really not a surprise.  Your transplanted hair likely thinned out during that time as well.  This would be important to discuss with any prospective surgeon before round 2 in determining the cause - because if it happened to you before it could very well happen again.  Some patients do have inflammatory conditions that negatively impact graft yield/survival.  A scalp biopsy would help to determine if that's the case for you.