Planned 3200 FUE with Dr. Rahal - Saving the forelock? Or lose it to "shockloss"?

[Bucky O Hair]

Hello all,

I'm a NW5 (likely going to NW6 in the future) who just booked a 3200 graft FUE with Rahal.

I have a bit of  a "Jude Law" hairloss pattern, with an island of forelock hair surrounded by receded temples and near-bald hair in the vertex (behind the forelock) and am curious about everyone's thoughts around whether to salvage the forelock, or just transplant into the forelock as well (since the forelock is miniaturizing anyway).

I had an in-person consultation and had my donor area measured by the consultant (James), and I had an in-person consult in Ottawa with Dr. Rahal himself.

I am in my mid-40s and have been losing hair for about 20 years (in a slow and steady fashion) starting with the temples, then a balding spot in the crown, then both kinda connecting in the vertex (with a thinning forelock island).
My family history is full of NW5 and NW6 cases, and based on what I am seeing with my hair I will probably be a NW6 as well.
I am pretty skilled with the illusion of creating a full head of hair, and the benefits of being a NW5 over a NW6 is that you can use that thinning hair on your forelock and sides to appear more of a NW3 or even NW2 (with proper hair styles and length).  
However, my vertex and crown are starting to get to near-bald level, making the combovers and coverage harder to achieve.
In a lazy fashion, I would have probably just liked to get a patch of hair transplanted in just the crown area to keep the illusion going, but after reading Hair Loss forums for several years, I am aware that it is "best practice" to address the frontal area of your head first...and then focus on the crown afterward (which makes sense, especially from a long term strategy perspective).

MY HAIR LOSS SPECS

Overall Balding Area: 180cm2

Donor area: above average (7000 expected lifetime grafts)
Hair shaft thickness: above average (56 microns)

Area for first HT (frontal): 80 cm2
Planned FUE total: 3200
Planned Graft Density: 40 FUE/cm2

Area for second HT (crown): 100 cm2
Potential Graft Density: 35 FUE/cm2

Proposed Strategy (discussed with Dr. Rahal):
- Focus on the front half of the head by filling in the temples and vertex (closing off those balding 'laneways' that go from the temples toward the crown).
- Fill in the areas of the forelock that require filling (this part is tricky because the current forelock hairs are miniaturizing, but the hair density is still probably the equivalent of 30 FUE/cm2)
- Don't bother lowering the hairline (just transplant at or behind where it currently is)
- Leave the crown for a future hair transplant

My Plan:
- Get two HTs and continue to wear my hair as I currently do, but with a better framed hairline (with closed off temples) and a filled in crown/vertex area (allowing me to have more hair to work with by using my illusion skills)
- Get PRP sessions for maintenance  (not on any drug regimen)

Worst case scenario (if hair loss progresses significantly in the long run):
- Buzz my head, yet still have a nicely framed hairline (despite losing the density from long term loss); Possibly use BHT (from my thick beard) and SMP to fill in any obvious gaps/areas (in case I go further than NW6)

My Concerns:
- Permanent shockloss in the miniaturizing (but very useful) forelock, making the forelock look worse with the HT than without it

This concern above is the only thing that worries my about my HT plan.  
My forelock is nice enough that it probably doesn't need transplanted hairs, but it being thin also runs the risk of it not matching with the transplanted hairs around it (so it makes sense to connect the templates across the forelock).
I chatted about the prospects of shockloss with James and Dr. Rahal briefly, but will address it further at the pre-operative consultation.
There are (rare) cases where transplanted hairs just don't seem to grow for some people...and I would hate to ruin what I currently have in the forelock (if it goes into shockloss) by hoping to replace it with thicker transplanted hairs that never come.
At the same time, the forelock is thinning and I expect it to last another 5 years before it gets to a point where I would be transplanting hairs into it anyway (in order to address it).

So the strategy will either be going full "Scorched Earth" on the front half of the head (including the forelock)...or just working around the forelock (leaving the forelock with mostly native hairs).
Rahal said he liked my forelock, so he will probably want to salvage some of it (once he gets a better look at it shaved down)...but he did acknowledge that it is miniaturizing and that he'll see where they can add hairs during the procedure.  

However, my assumption (if I am not mistaken) is that adding hairs close to a miniaturizing forelock could actually shockloss that forelock anyway (even if you may not be adding hairs right into it)...I could be wrong in my assumption though.
I expect that this "saving the forelock" discussion will be the main point in the pre-operative meeting, which will drive the strategy.

Looking forward to my HT, and I like my plan, but really curious on what people's thoughts are on saving a forelock and possible shockloss issues that could arise.

Any thoughts, my hair loss brothers?

[Melvin- Admin]

Do you mind sharing some pictures? Looks like you have put a lot into this strategy. It looks like a good one in my opinion. Let me tag @Rahal Hair Transplant to provide more insight.

[Alex98843]

Are you on any meds? that's the biggest question regarding the miniaturizing of your forelock,

[Bucky O Hair]

47 minutes ago, Melvin- Moderator said:

Do you mind sharing some pictures? Looks like you have put a lot into this strategy. It looks like a good one in my opinion. Let me tag @Rahal Hair Transplant to provide more insight.

Yea, I'll take a few and share.  I'll do the greasy, damp hair under a bathroom potlight, just the way everyone likes it. 

I just checked out your HT journey video, and there are some similarities between my loss and yours.  I have a similar large balding crown (like your pre-HT situation) but I don't intend on rebuilding my temple points.  My hair is dirty blonde, so I'm hoping the low contrast plays a nice factor in my results.

Will post something for you guys to tear apart and criticize. 

[Bucky O Hair]

31 minutes ago, Alex98843 said:

Are you on any meds? that's the biggest question regarding the miniaturizing of your forelock,

No.  I'm intrigued by PRP and I'll do that moving forward. 

I've heard that finasteride may prevent shockloss but I'm not sure if there is any data on that.  I have always been on the fence about using fin, but one of my best friends had such bad sides from it that I could never take the plunge.

 

 

[Alex98843]

2 hours ago, Bucky O Hair said:

No.  I'm intrigued by PRP and I'll do that moving forward. 

I've heard that finasteride may prevent shockloss but I'm not sure if there is any data on that.  I have always been on the fence about using fin, but one of my best friends had such bad sides from it that I could never take the plunge.

 

 

Look into topical fin 

[Bucky O Hair]

On 2/20/2023 at 6:09 PM, Melvin- Moderator said:

Do you mind sharing some pictures? Looks like you have put a lot into this strategy. It looks like a good one in my opinion. Let me tag @Rahal Hair Transplant to provide more insight.

Hi Melvin,

I took some photos, with my hair at its greasiest and under a bathroom pot light.   

 

• The first photo shows the receded temple and how the thinning "laneway" goes through the vertex toward the crown. 
• The second and third photos are top and rear shots, showing how bald my vertex and crown are.
• The fourth photo is just my hair wet and slicked back.  The forelock is visibly fuller than the rest of the scalp (with my high sides being the thickest).
• The fifth photo is just a quick side view of how I can just use the length in my forelock and high sides to simply combover the crown, vertex and temples to hide them (and that's a greasy hair photo).

The first HT should cover about the front half of the scalp (closing off those laneways in the temples) giving me a proper hairline and filling in some of the vertex.  

Still wondering if it's worth trying to save the forelock or just transplant over it.  I see a lot of HT cases on this site where the HT surgeon didn't bother working around the forelock and just went right ahead and transplanted into the forelock, regardless if there was native hair there or not.  I used to always think that 'best practice' was to not transplant in areas where you have existing hair...but some of these results are great nonetheless.  

Any thoughts?

 

 

 

 

 

 

[Bucky O Hair]

Sorry the first photo was posted at the bottom.  

I don't see an EDIT option for my post, but I guess you get the point of what I am trying to show.   

[Melvin- Admin]

I would definitely reinforce the forelock, it’s strong, but it may thin over time, it’s always good to go in between hairs so it looks natural as you progress.

[Bucky O Hair]

1 hour ago, Melvin- Moderator said:

I would definitely reinforce the forelock, it’s strong, but it may thin over time, it’s always good to go in between hairs so it looks natural as you progress.

True.  Good point.  Gotta think  both near and long term. 

 

[Rafael Manelli]

Reinforce the forelock. 

If it's weak enough to die to shock loss it was probably weak enough to die to DHT anyway. And if it survives, you'll get extra density. Win either way. 

Edited February 28, 2023 by Rafael Manelli

[Rahal Hair Transplant]

@Bucky O Hair,

I really appreciate you taking the time to document your plan and express your concerns prior to undergoing hair transplant surgery with Dr. Rahal. Firstly let me assure you that you are in the best of hands and I’m not just saying that because I work for him.  I’ve been a member of this forum under a different name since 2004 and I’ve been in the industry for just about 15 years. Dr. Rahal’s professionalism and respect for his patience is only surpassed by his results.

let me address some of your concerns. And also keep in mind that you can always contact me privately if you’d like to talk more. I’m happy to give you my phone number as well.

yes, finasteride will certainly help you keep the existing hair you have. When is your surgery scheduled for?  To be honest, unless Dr. Rahal himself told you not to, I would strongly consider getting on an ASAP which will give you the best chance of helping you keep your natural hair in general and prevent permanent shock loss to any of the miniaturizing hairs.

secondly, in looking at your photos, you remind me of a case that I just presented on the forum. I will post a link and some of the photos but as you can see, this patient had a similar hair loss pattern as you do and it looks like a similar hair color, texture and caliber.   As you can see, 3025 grafts did wonders for him.

 

From the looks of it, you still have a good amount of terminal hair that has not been affected by miniaturization. Finasteride might help thicken up your natural hair especially the miniaturizing ones prior to surgery so I do suggest getting on it unless that advice contradicts Dr. Rahal’s (and if he gave you advice not to use finasteride I’m sure it is for a very specific reason)

Feel free to contact me privately or post any of your concerns or questions publicly and I’ll be happy to answer them. If you want to talk on the phone, drop me a private message and I’ll give you my phone number.

Best wishes,

Rahal Hair Transplant

[Rahal Hair Transplant]

@Bucky O Hair,

just FYI I did send you a private message and provided my phone number if you want to talk. Obviously I’m more than happy to answer any questions publicly, I just thought I would offer additional assistance if you want or need it.

Rahal Hair TransplantI

[Rahal Hair Transplant]

@Bucky O Hair,

I did post the link to the above patient but I thought I would present the hairline pictures as well so you can see how soft and natural it looks.

 

[Bucky O Hair]

Awesome.  Thanks!