Dr. Nakatsui, 2961 grafts to frontal scalp 8 years ago, one session

[Dr. Thomas Nakatsui]

Hi everyone,

This is a patient who came in for a transplant about 8 years ago and his results have been great. He never came in for followup until very recently. At the time of the transplant, he was developing significant miniaturization throughout his frontal scalp. The hairs were very fine and just wouldn't grow very long. We decided to proceed with 2961 grafts, comprised of 623 single grafts, 1430 double grafts, and 908 three hair grafts. This was done in one session using FUT.

He is very happy with his results and feels the HT completely changed his looks. Over the last 8 years, he has lost much of the miniaturizing hair in the frontal scalp and would have looked much thinner than his pre-operative photos had he not had a transplant. Thanks to the HT, he has much more hair than he would have had.

Dr. Nakatsui

https://drnakatsui.com

 

 

PRE-OPERATIVE PHOTOS

 

 

 

EIGHT YEARS POST-SURGERY

 

 

 

[follically challenged]

Can you outline what his regime was regarding medication...?

This looks like fin or dut could help him improve a long way....

[Gatsby]

Did you recommend that he start finasteride and/or minoxidil at the time of his first consultation?

[Dr. Thomas Nakatsui]

foliically challenged and Gatsby,

That is a good question. When I saw him, he had been taking finasteride 1.25 mg daily for 2 years without any benefit whatsoever. Unfortunately, he was not getting any results from the oral medication, and certainly a far cry from what he really wanted to see.

Thank you for the question,

Dr. N

https://drnakatsui.com

 

[GoliGoliGoli]

Do you have pictures of before and after his first op? How many grafts was the first? It looks like a lot did not age well

Edited August 5, 2023 by GoliGoliGoli

[Dr. Thomas Nakatsui]

23 hours ago, GoliGoliGoli said:

Do you have pictures of before and after his first op? How many grafts was the first? It looks like a lot did not age well

Hi GoliGoligoli,

Thanks for the question. He only had one session eight years ago. I'm sorry if it wasn't clear but he only had the one session. The preoperative photos show his hair at its natural, longest look. Some might think his hair was cut to look like this, but the hair on the top of his head was not shaved down. This was as good as it got because the hair on top of his head grew in extremely fine and just didn't grow very long. He combed his hair from the side to cover the thinning area because that was the best he could do.

Not everyone thins following the same pattern (like the Norwood scale suggests). Some people experience diffuse miniaturization of hairs over a large area (ie.g. all the way from the crown to the frontal hairline) before they start losing substantial number of hairs, as in this patient. It is a much more difficult pattern of hair loss to treat than thinning of the frontal hairline and temples for example (in those, you can transplant densely and get dense results). However, some patients even have a worse situation than this patient, diffuse unpatterned alopecia (DUPA), which is not amenable to hair transplantation at all.

I do not have any other photos as this is the first time he came back for follow-up. He has undoubtedly lost much of the pre-existing, miniaturizing hair over the last eight years, leaving only transplanted hair. If you fast forward his hair loss from the pre-operative photos, I suspect he would likely be almost completely bald right now if he hadn't had a transplant 8 years ago and he is very happy he had it done.

This brings up an important point as this was indeed a more challenging case. One of the challenges of transplanting into preexisting hair is that I typically won't damage a preexisting hair to place a new one. As a result, if you have pre-existing hair, I won't place new hairs at full density because I would risk transecting your natural hair.  For example, say you ideally would place 55 follicular units in one square cm, but there is pre-existing hair in 30 of those spaces. Then, I would only add 25 follicular units into those spaces (not 55 as I would ideally have done). Realistically, I might add a bit more than 25 and get in between those pre-existing hairs to try to compensate (e.g. 30-35) but I still wouldn't max out the density for fear of damaging a pre-existing hair. This is one of the limitations of transplanting into pre-existing hair. In some patients, an additional transplant a few years later is necessary to fill in the spaces left by those pre-existing hairs as they are eventually lost. In this case, he likely has lost a lot of the pre-existing hair.

So, if you look at the preoperative photos in this case, you can see that he had a lot of pre-existing miniaturized hair present over a large area. The problem with his hair was not that the numbers of hairs was so low, it was more that so much of his hair had miniaturized and was extremely fine and short from his crown to the hairline.  As a result, the VOLUME of hair was low because of the hair's FINENESS and LENGTH, making it look so thin, not so much the NUMBERS of hairs yet. If the numbers of hairs was much lower at the time of transplant 8 years ago, I would have been able to transplant more densely giving a much thicker and longer lasting result but he also would have required many more grafts.

I suppose an argument could have been made to transplant more densely and risk damaging the pre-existing hair because it looked like it was going to go anyways, but I don't typically operate that way. I would rather transplant safely and my philosophy is to not damage pre-existing hair. Also, an argument could be made that staying on finasteride despite it's lack of effectiveness for two years may have preserved the pre-existing hair, but the patient didn't feel like it was helping so he didn't stay on it.

Keeping these limitations in mind, he has done extremely well. I also think if we combed his hair to shingle it, it would look much denser but he naturally keeps his hair this way, so we did not alter it.

Thanks for the question and sorry for the long reply but I thought it would be helpful to explain my approach to diffuse miniaturizing hair.

Thanks,

Dr. N

[GoliGoliGoli]

Thank you for the detailed response. I understand now, so the first four pictures were 8 years ago, and the last 3 are from today.