Need advice - Considering First HT at age 43

[thanatopsis_awry]

"Just because some doctors may recommended 3,000, 3,500, 4,000 or even more does not mean that you cannot achieve the same results with less grafts."

 

I'd have to disagree. If *any* doctor -- let's just plug in Alexander for now -- can deliver "the same" result as different doctor -- let's say Hasson, for example -- while using a dramatically lower number of grafts, I have yet to meet him, in any way/shape/form.

 

In theory, this logic has a certain appeal: I love Dr. A and Dr. B --> Dr. A recommend less grafts --> I wil go to Dr. A and save grafts and miraculously get just as good a result.

 

However, how often is this ever *actually* the case. For all intents and purposes, extrordinary outliers aside, people either get the grafts they really need and get satisfied, or they fall prey to a low # and end up disillusioned and shocked that after all the $, emotional investment, and time they are left utterly lacking and need to brave more surgeries to hopefully get what they could have had initially.

 

These scenarios happen countless times, and when you go back through the threads -- just like this one -- you will see history repeat itself time and time again, and more times than it should.

 

And ya, hair caliber should always be taken into account, but cmon, JS could have the hair of a thousand stallions transfused into one strand and it wouldn't make 2700 right. The # of grafts is *not* "merely one of many factors"; it is hugely important, and when dealing with otherwise skilled surgeons, it is the #1 reason *by far* for patient dissatisfaction.

[TC17]

It is difficult to compare any patient with another because of the differences between any two people. Obviously, you cannot make a genuine apples to apples comparison. With that being said though, it seems to me as though there are a few physicians on here who achieve consistently great results, yet use less grafts than some of the other physicians. The analogy I think of in my head is that to a group of great chefs. Every chef, if allowed to use heavy amounts of salt, fats, creams, and other unhealthy ingredients (large # of grafts), can create a gourmet meal that is a pleasure to eat. But eating such an unhealthy diet can lead to a myriad of health problems down the road, so it should be avoided (possibility of running out of donor and looking silly). It's not a challenge to the chef to use the unhealthy ingredients to create the gourmet meal, and frankly you will leave the restaurant happy as a clam after eating it. But what about when you're older and you're suffering from the health problems? Will you still feel that the unhealthy eating habits were worth it merely because it tasted good in the moment? On the other hand, if you tell the chefs that they must keep the meal healthy, the true skill of the chef will come out. With these limitations in place, can the chef still cook a meal that knocks your socks off? My opinion is that a number of chefs (doctors) can, and I will go on step further and say that their healthy meals taste just as good as the unhealthy meals of some other doctors. The discomfort of a possible second surgery will pale in comparison to the lifetime of looking freakish if too much is done too soon. Until baldness can be accurately predicted, count me as firmly in the corner of those doctors that do not touch a crown on a younger patient, do not use more grafts than are absolutely NECESSARY, and do not cater to the whims of the immature patient.

 

I've attached some links of some work that I feel is absurdly good by some of the doctors that seem to be more "conservative", as well as that article written by Dr. Paul Shapiro on their basic guideline for graft numbers. I believe my main point stands without contention though. Find a doctor whose work it is that you like, and say to hell with graft number. If you like the work, you like the work. (unless of course the doctor recommends too many grafts, at which point you'll be screwed in the future)

 

http://hair-restoration-info.c...=615103223#615103223

 

http://hair-restoration-info.c...=158100281#158100281

 

http://www.hairtransplantnetwo...tientID=1879&DrID=16

 

http://www.hairtransplantnetwo...tientID=1621&DrID=16

 

http://www.hairtransplantnetwo...tientID=1437&DrID=16

 

http://www.hairtransplantnetwo...tientID=1648&DrID=18

 

http://www.hairtransplantnetwo...tientID=1707&DrID=18

 

http://www.hairtransplantnetwo...ientID=1579&DrID=263

 

http://65.36.174.14/Consult-a-...tientID=1864&DrID=54

 

http://65.36.174.14/Consult-a-...tientID=1718&DrID=54

[TC17]

Oh, and thana, I am not saying go for low graft numbers. I am merely saying that I believe our perception as to how many grafts are required is somewhat skewed. Because Dr. Paul wrote the article I will use him as my example. Dr. Paul produces excellent results. Dr. Paul uses the graft numbers that he believes to be necessary to produce those great results. Therefore, the next step is that Dr. Paul's graft numbers will be sufficient to give us excellent results.

[Old Baldy]

JS: My surgeries hurt for the first few days in the donor area but weren't that bad. You'll probably be just fine in that regard.

 

Yes, the first 3-4 months are not great but it isn't as bad as you are thinking IMHO.

 

Most likely, you'll be fine going with the doctor you are choosing.

 

I've had three surgeries, the most recent about 10 days ago.

 

Overall, total grafts equalled about 7,600 and I was about a NW5 when I began this HT journey in September, 2004.

 

If I can handle it I'm sure you, or any of the other guys, can handle it also.

 

It's basically minor surgery that won't leave you inactive for very long.

 

But the "doldrum" period can be a pain in the butt. Not the end of the world though.

 

Good luck, I'm sure you will be able to handle the "hassle" part very well!!

[Rachmunas4life]

Here is 2,700 grafts on an NW5-6 male (estimated). Dr. Charles just posted it.

 

http://www.hairtransplantnetwo...-page.asp?WebID=1053

[thanatopsis_awry]

I agree, all of those cases look good in their own right, though as you say they don't necessarily approximate what JS is in store for; and thus, most importantly, what may very well be *best* for JS.

 

Many of the very links you posted I would actually use as support for my cautionary urge that JS *not* go to a doctor who is *shooting* for 2700 as a *target*. Out of the 9 case links (the first link not being a result): #9, #8, #6, #4, #3 I would say explicitly support my argument that JS at the very least *shoot* for more grafts than 2700.

 

With regard to the other case links:

 

#2 http://www.hairtransplantnetwo...tientID=1879&DrID=16 isn't a great example for JS (or most anyone) to compare, without more information. Nice result, either way, but I would love to see the post-op photos, as I suspect this is mainly hairline work utilizing 2k grafts, and the before/afters represent this, as well as meds or simply lighting and longer hair. Again, a nice result, no doubt, but I don't think even SMG would actually use this as a prime example of what 2k can do for someone's *entire* head and produce *that* transformation. It seems SMG themselves classified the patient as a NW2, so....

 

#5 http://www.hairtransplantnetwo...tientID=1648&DrID=18 is a pretty good comparison, but again, it utilizes 20% more grafts than what JS has been prescribed, and if you asked Dr. Parsley -- let alone the patient -- if he wished he had been able to magically get more that day I'm sure he would say "hell yes".

 

#7 http://www.hairtransplantnetwo...ientID=1579&DrID=263 (even with the given lighting, and no true top-down) is actually a pretty good supporter of my position. I guess this is all subjective, so if JS would be content with reaching that + 700 grafts thrown in, then all the best. Most wouldn't, particularly in light of the options available.

 

The final example, #1 http://hair-restoration-info.c...=158100281#158100281

is of a guy much younger than JS, with a *much* *much* smaller area of balding, who also got more grafts used.

 

2700 grafts done by God would not be optimal. Will 2700 be good? Probably, but again, I don't really think that's the most important question. We're talking about what should be sought after, as a realistic ideal for JS.

 

Maybe it's my old age setting in, but I'm just calling it like I see it. If JS, or anyone, thinks "Dr. Alexander" can deliver the goods unlike anyone else, fine....the Dr. in question should *still* shoot for a max-like session to whatever their capabilities are and not target 2700. Merely my opinion, but I *know* patients who went into their HTs who *didn't* hear talk like this wish they did beforehand. If JS is not destined to be one of these people, all the better, for sure, less grafts for the same level of contentness is undoubtably the best route to go.

 

I personally don't believe *any* doctor exists who can work virtual magic and make grafts work better than they can in the hands of any number of solid, let alone elite, surgeons.

 

Ultimately the approach of --> "If you like the work, you like the work." is just far too narrow for my tastes. The innumerable # of patients who get inferior jobs (ranging from not optimal, to OK, to horrible) almost always go in "liking the work" of whatever doctor is in question.

 

Granted, on this site, we rarely deal with cases of poor surgical work; which is a truly terrific thing. I feel like session sizing is the #1 thing that can often be improved, and flexibility in this area is for the general population of patients' benefit.

 

Either way, I think we have both given JS more than enough info to chew on. So while I disagree with you I'm glad JS and any1 else can decide what makes the most sense for them personally.

 

*this isn't to target Dr. Alexander, whose work I have consistently praised, and whom I've often recommended, as I'd apply what I've said univerisally to any doctor and clinic.

 

**also, JS, don't worry, you won't be confined to a "LIFETIME" of looking like a "FREAK" if you get 4k (or 9k) done by Dr. Alexander or Dr. Spok.

[thanatopsis_awry]

Rachmunas, nice find. Also, to repost the Dr. Hasson case, who actually has a fairly similiar pattern to JS, though, again, more native hair and much higher laterals: http://hair-restoration-info.c...66060861/m/862106743

[Ron J]

JS,

 

you appear to have a NW6 pattern w/ *some* thinning native hair. Using the graft calculator on HTN ( http://www.hairlosslearningcenter.org/mm/calc.html ) even if we only calculate that you want a meager 30 out of a total of 50 on the density scale, it would still require that you gte 4,252 grafts; if we put '50' as the required density the # goes up to 5,110. 2,700 grafts isn't even enough for a gimp hairline. You would look extremely un-natural and 'FREAKISH' if you only got 2,700 grafts IMO. I really don't think your going to be happy w/2,700 grafts REGARDLESS of which dr. you choose. A ht is a 12 month process, and if you go the 'less is more' route, your going to commit yourself to a 12 month wait/window w/each successive procedure you get; it will also cost you more money. You'd be hard pressed to find ANY NW6 who received 2,700 grafts and was content w/it. Best of luck.

[Ron J]

Originally posted by TC17:

The analogy I think of in my head is that to a group of great chefs. Every chef, if allowed to use heavy amounts of salt, fats, creams, and other unhealthy ingredients (large # of grafts), can create a gourmet meal that is a pleasure to eat. But eating such an unhealthy diet can lead to a myriad of health problems down the road, so it should be avoided...

 

This is a complete disanalogy & uses extremely poor reasoning. We're dealing w/a question of quantity of 'ingrediants' not quality. All dr.'s have the same 'ingrediants' (grafts) at their disposal. No dr. can (significantly) make 'x' grafts go further than another, just like no chef can turn 2 eggs into 10; some dr.'s get poor yield, by destroying grafts but that's another issue. To claim otherwise, w/respect to grafts needed, is merely another form of snake oil chains/hacks like bosley sells to the uneducated. It's simple math. Quite simple really.

 

Maybe a chef could satisfy the appetite of a three year old boy w/a 2 egg ommelet, but that same ommelet wouldn't satisfy a grown man; likewise JS, w/all respect, is no 20 yr old hair line case. He's going to require a lot of eggs. If the question becomes saving ample donor hair for future loss, then this is a simple prerequisite for all dr.'s and no dr. in the coalition is going to use too many grafts for future loss. That would be unethical, are there any dr.'s in the coalition that you think use such unethical principles TC?

[JS]

I've been following along on all the posts and thank everyone for their input as it helps set the expectations. I was never hoping for a miracle of complete coverage. I had told the doc that I wanted the hairline to stay about where it is now so as to save more graphs for the top of the head. I didn't want him dropping my hairline down another inch towards the front. And he agreed, although he still wanted to bring it down about a quarter inch. So that is one thing. The other is there was going to be no work done on the crown, of course, so no expectation there. But you are all pretty passionate about 2700 being way too low. I will look into this further and maybe have another consult to see about upping the graph number to see what he says. Thanks all.

[TC17]

Ron J,

 

Either you did not properly understand the analogy, or I did not do a good job of conveying what I meant. Either way, here is the explanation.

 

If an infinite supply of grafts existed, the major impediment for a successful surgery would disappear. EVERY coalition doctor can produce 100% natural, top notch results, if they are given unlimited resources. (focus on the term resources, and don't let the fact that the resources I speak of happen to be a # of grafts, throw you off) Likewise, if you give a top chef like Joel Robuchon any ingredient he wants, he will cook you a meal that is out of this world. But, if you tie Chef Robuchon's hands by saying that his dish can only have X amount of saturated fat, or that he cannot use black truffles, or that his meal must come in under $75 per person, the true skill of the chef comes out. Granted, arbitrarily limiting access to a chef is different from the limitation placed upon every surgeon, but watch Master Chef on TV and you will see that the chefs are given random challenges to test their skill. It doesn't matter if the limiting factor is a quantity or a quality, all that matters is that a limiting factor exists.

 

If you believe that every doctor produces the same results with the same number of grafts, then so be it. If that is your starting point, then anything I say will never be in agreement with your beliefs. If that's the case, that's OK, but I do not share that same belief. I believe that some doctors accomplish more with less. I believe that some doctors place grafts in such a way as to maximize their cosmetic value.

 

You asked if I believe if some doctors on this site are unethical? I would say sure, why not? I have no idea if Dr. X cheats on his wife, steals, doesn't report his taxes, etc., but I don't care about those things. Ethics and risk are two different things. I don't care if a doctor is ethical in his personal life, provided he is proficient in his professional life. I do not believe that any doctor on this site would KNOWINGLY do anything to harm a patient. However, I do worry when I see doctors touching the crown on 22 year olds, or taking a scar so long and high that future loss can expose it. For what it's worth, I don't believe that Dr. Armani perceives what he is doing as risky though either, but most of us agree that it is.

 

Analogy number two, and hopefully this will quell any questions into my personal beliefs. If your plane crashes in the middle of the desert, and you only have 1 gallon of water, how do you ration the water? Are you going to chug the first 1/2 gallon within the first hour, are you going to use it wash your hands, are you going to drink 1/16th per day? You may be rescued within 10 minutes, you may find a stream on day two, or you may be stuck in the desert for a week with no water other than what is in your canteen. The point is that you do not know how long you will be in the desert, just as you do not know how bald you will go. If you're the type of person who decides to drink a lot in the beginning in the hopes that you'll be rescued or find water, cool. But, I'm not that person. I'll figure out exactly how much water I need per day to survive, and ration accordingly. Maybe by day 4 I'm rescued, and my canteen still has 1/2 a gallon left. In that case, I may look back and say "damn, all those times that I was thirsty I could have had more". But because I didn't, and COULDN'T know when I would be rescued, I did the smart thing and kept enough to survive a little while longer.

 

The "average" patient only has 6,000 grafts available for transplantation. I would venture a guess and say that the average NW 6 and 7 has FAR less available, as evidenced by the graft counts of the NW 7's on this site. Assuming that JS possesses the average of 6,000, the 2,700 recommended by Dr. Alexander is 45% of his total number of grafts. To me, that's a relatively large percentage, even if it is admittedly, a seemingly small number of grafts.

 

Just remember, family history, meds, current loss, and any other barometer of future loss are merely guides. Someone in your family is already, or will be someday, the baldest in your family. Who knows, it could be you.

[Vollow]

Hello guys, mind if I jump in with some questions?

 

TC17, you previously said "average" patient only has 6,000 grafts available for transplantation."

 

I'm a bit confused,as I was just told today on this forum by 4 or so people that hairs in the donor regions do not have limited lifespans. However if most people only have 6000 available grafts in the donor region, surely that must mean that an immense number of hairs in that region have indeed died out. Is this is the case?

 

2ndly you mentioned the danger of a making a scar on a 22 year old being exposed in the future when further hair loss occurs. Is it then commonly the case that even in a 22 year old, such as scar will not heal? Are these scars for the average HT patient permanent?

 

Thanks! looking forward to your response.

[TC17]

No, the hairs have not "died out", it's just that you cannot access all of the available grafts in the area with strip or FUE. Strip surgery involves cutting a long (24 to 30cm), relatively narrow (1 to 2cm) strip from the back of the head, and then microscopically dissecting the individual grafts from the strip. The skin is then pulled together and sutured, usually leaving a thin scar that is well hidden by existing hair. Essentially all you are doing is taking a strip of hair and transplanting it to other parts of the head.

 

The average patient has around 80 follicular units per square centimeter. So, assume that you take a strip that is 28cm x 1.6cm, you will get a total area of 44.8cm. If you have the average 80 fu's per sq/cm, that will give you around 3,600 grafts. After the skin heals, you can take another strip, but you will probably not get as many grafts because the skin has tightened somewhat. All in all, the average person has around 6,000 grafts available for transplantation using strip methods.

 

However, in some patients, the donor area does thin. Say your donor area thins to around 65 fu's per sq/cm, and you take the same size strip, you would get get around 2,900 grafts. The safe zone is usually impervious to balding, but there are men who have minor, moderate, and even severe thinning in that area. The thing that I have found very useful is to look at the hair of men who are 60+. In a sizable number of those older bald men, a strip scar would be visible. I just keep thinking to myself what would have happened if that 65 year old man had undergone a transplant when he was my age? (26)

 

I personally think that FUE is the better approach for younger patients with uncertain balding patterns because the linear scar is a non issue. I started a topic a few weeks ago that considered the pros and cons of both FUE and strip surgery for the younger patient. I think it might prove helpful for you.

 

You will hear it a million times on this forum, but really let it sink in - RESEARCH. You can never know too much about this field, after all, we are talking about your appearance for the rest of your life.

 

http://hair-restoration-info.c...=702109833#702109833

[TC17]

Also, please read this response to a similar question that Dr. Paul Shapiro answered. His third point addresses the possibility of donor thinning.

 

 

Originally posted by Paul Shapiro, MD:

This is a very good thread and has brought up a lot of good issues. It is important to remember that balding is a complex multi-genetic trait, and the balding genes are expressed very differently in each individual. What age these 'balding genes' turn on, the rate of balding, and how sever the balding will be is difficult to predict early on. Your family history and how much hair loss you have in your 20's is a guide to future hair loss, but not a predictor. The only thing I can say for sure is that if someone has significant balding in their early 20's they are likely on their way to be a Norwood type 6 or 7. But the opposite is not true. I have seen many patients in which their hair loss did not start until they were in their 30's, some do become a Norwood type 6 or 7 and some do not. I come from a family of 4 boys (my poor mom). Two of us have a full head of hair and two have significant balding.

 

Secondly, I do think that it is very rare to find someone who will have 10,000 FU donor grafts over a lifetime. If my memory servers me correctly I have seen only a few patients posted on the HTN who have had 9,000 to 10,000 grafts total. I am concerned that to get so many grafts we may push the limits of taking hair from the safe donor area. I have seen some transplants in which to get such a large amount of donor hair, the donor is taken from outside the 'safe' donor area. Not only is there a potential to see the scar, but there is the potential that this is not permanent hair. So the hair that is transplanted may fall out like all the other hair with male pattern balding. I have spoken privately to some on the HTN about this. These hair transplant patients say they are aware of the risk they are taking, and would rather look good today and take a chance on tomorrow. This is a personal choice for each patient to make, but I do think the risk/benefit ratio should be made clear prior to the surgery so each patient can make an educated decision. I do like to point out that we are living longer, and the US divorce rate is over 50% so there is a good chance a lot of us will be single in our 50 or 60's and back on the dating seen. I also like to point out that we can get a very good cosmetic look with less grafts then a lot of the HTN patients seem to think they need.

Please look at my post 'How Many Grafts are Needed in a Hair Transplant'.

http://hair-restoration-info.c...66060861&m=615103223

Third is an issue that is hardly mentioned on the Hair Transplant Network. As we age our safe donor area does lose hair and becomes less dense. I have not seen any good studies on this phenomenon but there is a general consensus in the hair transplant medical community that this does happen. I have notice that most of my older patients have less donor density then my younger patients. I believe this is a process of aging just like we get wrinkles in our skin due to less collagen in our skin. This thinning does not seem to be hormone related like the hair loss in male pattern baldness because the donor area never becomes completely bald like in male pattern baldness, but just thins out. If there is a hormonal component to this thinning of the donor area it is different then the male pattern balding process. The amount of thinning varies with each individual. So if you your donor density is 90 FU/sq.cm when you are 20 it may thin out to 80FU/sq.cm when you are 50. So I don't think one can count on having the same donor density thought out ones lifetime.

I hope this information is helpful.

Dr. Paul Shapiro

[Ron J]

Originally posted by TC17:

The "average" patient only has 6,000 grafts available for transplantation. I would venture a guess and say that the average NW 6 and 7 has FAR less available, as evidenced by the graft counts of the NW 7's on this site.

There is zero correlation between NW level and total donor available, to the extent that all grafts are taken from the "safe zone"; and is evidenced by cases such as these:

http://hassonandwong.com/patie...ansplant_type=normal

 

http://hassonandwong.com/patie...ansplant_type=normal

 

http://hassonandwong.com/patie...ansplant_type=normal

[Ron J]

Originally posted by TC17:

Assuming that JS possesses the average of 6,000, the 2,700 recommended by Dr. Alexander is 45% of his total number of grafts. To me, that's a relatively large percentage, even if it is admittedly, a seemingly small number of grafts.

 

 

He's: 43, almost bald (no offense JS), and has a NW6 pattern; just *where* & *when* are you saving these (*55%*) grafts for? You'd rather have him have a *thin* hair line, be bald on top and crown, and then when perhaps he's in his sixties go in for a "touch up" (?)

[Ron J]

As for your analogies, honestly there just so off the mark there's not much to say. The distinction is quantitative not qualitative. If you truly believe that ANY dr. can magically make 2,700 grafts appear like 4-5K, on a patient who TRULY needs the latter, well then...that's just wonderful, but your in for a big surprise.

 

Can you show us some cases of these magical houdini dr.s who take a case like JS and use such minor amoutns of grafts and make them "go *far*" ? I'm sure we'd all love to see them. If not,then I don't think you should be selling this snake oil and leading people astray.

patiently waiting.

[HairHope]

Glad your researching.

 

4000-5000 grafts, bare minimum - don't under estimate the downtime of a HT, it sucks and is a long and psychologically draining process.

 

Best of luck and you will fullfill your objecives I am sure.