One procedure results with 2713 FUGs by Bill Reed, MD

[Dr. William Reed]

These results with a 24 yo man and after about a year following the one procedure of 2713 (666,1717,330) from a strip measuring 20 cm x 1.4 cm. This procedure represents concerns I have and have expressed about hair transplantation in men in their 20s (and even in some cases and to some patterns of balding to men in their 30s). Specifically, the strip length is only 20cm out of concern that we don't really know how stable the hair in a young man is going to be in the area above and forward of the ear. If this hair thins as is often the case in men showing balding in their early years, then the grafts will thin as well. Extreme cases of this thinning revealing the donor scar, no matter how well done, is another concern. The other issue concerning the young patient is that he is early in his relationship with male pattern balding and it isn't clear how bald he will become. It may be that he will become too bald for the amount of donor that he finds himself to have at that more advanced stage of balding and will be faced with a distribution of hair that does not occur in nature, i.e., an unnatural, potentially embarrassing situation with poor solutions available. This is why I favor treating the balding (some would say "inadequately treating") by restricting the donor pattern to fortifying a variant of the 3 vertex pattern: a frontal tuft of varying diameter that attaches to the hair on the sides by a bridge of hair of varying width. How wide the diameter of the frontal tuft (roughly aka the "widow's peak") and wide the bridge depends upon the degree of balding and the amount of donor. I am not opposed to a light density of grafting in the more posterior areas including the crown as this occurs in nature and often gives enough coverage with the pre-existing hair to give good short term satisfaction to the balding going on in those more posterior areas. The results are of one procedure and this gentleman recently had another procedure of roughly 2000 fugs to broaden the widths of the frontal tuft and bridges. He began finasteride shortly prior to the first procedure.

 

[hdude46]

Dr. Reed,

 

I'm just a little confused here. You gave a very nice write-up about the concerns and cautions that you have in transplanting men in their 20's, yet you still gave this young man over 4,000 grafts despite those concerns. Why?

 

I'm not sure what exactly constitutes 'significant balding' or at what age a balding pattern emerges, but from your post it seems you think no one in their 20's should be a candidate for a ht. Being only 25 myself, I am concerned about future loss but have no where near the level of balding this young man who is younger than me has, and have been told I have above average donor density and hair thickness by the top clinic in this coalition imo. I would also say that the rate of my loss is fairly slow as well. Does this mean i should hold off until I'm 30 (btw I'm taking propecia)? Do you believe propecia will hold onto most of this patients native hair and that's why you performed the surgery?

 

I'm just trying to figure out why you would use over 4,000 grafts on a 24 yr old after your write up would suggest rarely should a dr perform a ht on someone in their 20's, especially when this particular case seems like he isnt exactly to be the ideal '20 something yr old candidate.' I would say over 95% of the blogs of people I read on here say their hair loss began in their late teens or early twenties, and almost all of them say they wish they would have had a ht procedure and jumped on propecia sooner. So I'm just looking for a little clarity on this based on your statements above.

[Dr. William Reed]

Dear HDude46,

 

Good questions. 4000 grafts is: 1. a quantity of grafts that does not deplete his donor and 2. they were placed into the 3 vertex pattern such that if everything else falls out he will have, probably with the help of the remaining donor hair, a pattern of hair that is found naturally occurring in nature, i.e. the 3 vertex pattern. It's less coverage than most of us would prefer but the amount of permanent donor hair we have is genetically determined. Delaying this genetically determined degree of balding with finasteride and/or minoxidil is "frosting on the cake", so to speak. The improvements resulting from the use of these medicines is very satisfying short term but should not alter the surgical plan since none of us can be sure how long we will or be able to use the medicines.

 

In my opinion, there is little difference in a cautious surgical plan for a 21 year old and a 35 year old except that there is a somewhat better idea of how bald the 35 y.o. might become. Having said that, many, probably most, 35 year olds should not have their crowns grafted with very many grafts for exactly the same concerns that exist for the 21 year old.... We don't know that well how bald that 35 yo will become.

 

I did not intend my post to say that I think "no one in their 20's should be a candidate for a ht." If it were to have made a statement along those lines, I would like my post to have been interpreted as saying that the same concerns exist for the 35 yo as the 21 yo and, therefore, in most cases the plan that is appropriate for a man in his mid 30s is often the same that would be appropriate for the 21 yo, i.e. mimicking the 3 vertex pattern with perhaps light coverage more posteriorly.

 

It seems that it is all about risk/benefit ratios: What is the magnitude of the long term risk for whatever the short term benefits? There are actions that can increase the size of margin of error should the patient and I find ourselves having miscalculated and having lost the risk/benefit assessment. Examples of such are styling (basically using styling much as we do as we go bald) and laser hair removal. Nobody wants to talk about this, but nobody can calculate the unforeseeable future of male pattern balding. I think mimicking the 3 vertex pattern of balding is the safest pattern for avoidance of complications long term. Divergence from this pattern by grafting bigger areas or the crown can increase short term satisfaction but at the cost of the assumption of an unknown amount of long term risk.

 

This issue ceases to exist as one gets into his late 40s since it is more "in your face" about what can be done because the ultimate sizes of the donor and of the balding are much more ascertainable. But it is not until well into ones 40s that such confidence can be had with any high degree of certainty.

 

I have just reread your post to see that I've covered your questions. Do you see why it makes no difference to wait until 30 to do a ht? Nothing will be different than it is now for you. If anything you will be misled by how little your balding progressed because you have been using finasteride.

 

I would consider this young man to be a good candidate based upon his donor density and good hair fiber diameter. I would consider most young men to be reasonable candidates if they have good hair fiber diameter and average density with no evidence of miniaturization of their donor by microscopic evaluation. (Such miniaturization may be a yellow flag about how permanent the supposedly permanent hair is in his donor.)

 

The last point I see in your post relates your situation to this patient. I don't see, on the surface at least, any difference between you and this gentleman. He may be more bald than you and, therefore, may look like an emerging 3 vertex before you will but each of you would be making a mistake, in my opinion, to graft into any pattern other than that which mimics this variant of a 3 vertex.

 

I'm afraid I'm going to be out of touch with emails for the next week, but I would be happy to continue this thread upon my return. I hope I've helped to clarify the vagaries of my post. Good questons.

[hdude46]

Thanks Dr. Reed.

 

I must say though, part of your response directly contradicts the response to similar questions of some of the very very top clinics in this coalition. Saying that this young man, or every young man, is no different than someone who is 35 (when planning surgically) I have to disagree with based on what I have heard from other top clinics I have consulted with.

 

It seems you do a one size fits all on the 3v pattern on every patient who is under 35. I will agree that it is safe, but what about the 22 nw5 and the 35 yr old nw3? I don't see why the two would have the same surgical plan. Its obvious the 22 yr old would have a a significantly greater chance of advancing to a 6-7 than the 35 yr old. Isn't rate and aggressiveness of the balding a huge factor in where one ends up? What about hair characteristics, family history, donor density, ect. Are Hasson and Wong or Shapiro Medical, arguably the two leading clinics in the field, making mistakes by planting hairlines not in the 3v pattern in patients under 35? I'm very skeptical of your claim there is no difference between two patients such as the ones described above.

 

Moreover, I dont understand how using finasteride is misleading. Every clinic I've consulted with swears by its effectiveness and longevity. I can understand and appreciate your philosophy, however there are simply some clinics out there who can simply do more with the same amount of grafts than others.

 

You are right in that no one can predict the future of mpb, but it would seem the risks would be far greater for someone in their early 20's than mid 30's, instead of seemingly the same, especially if the level of loss is greater for the younger patient. To say there is no difference from myself to this patient SEEMS a bit absurd based on my conversations with other clinics. Is a 25 yr old nw2 the same as a 25 yr old nw5? Again, does every 25 yr old have the same hair characterisitcs, family history, rate of loss, use of medication, ect? No.

 

I appreciate your explanation, but it goes against a lot of leading clinics on here you don't transplant in the 3v pattern in patients under 35.

[hdude46]

Originally posted by hdude46:

Thanks Dr. Reed.

 

I must say though, part of your response directly contradicts the response to similar questions of some of the very very top clinics in this coalition. Saying that this young man, or every young man, is no different than someone who is 35 (when planning surgically) I have to disagree with based on what I have heard from other top clinics I have consulted with.

 

It seems you do a one size fits all on the 3v pattern on every patient who is under 35. I will agree that it is safe, but what about the 22 nw5 and the 35 yr old nw3? I don't see why the two would have the same surgical plan. Its obvious the 22 yr old would have a a significantly greater chance of advancing to a 6-7 than the 35 yr old. Isn't rate and aggressiveness of the balding a huge factor in where one ends up? What about hair characteristics, family history, donor density, ect. Are Hasson and Wong or Shapiro Medical, arguably the two leading clinics in the field, making mistakes by planting hairlines not in the 3v pattern in patients under 35? I'm very skeptical of your claim there is no difference between two patients such as the ones described above.

 

Moreover, I dont understand how using finasteride is misleading. Every clinic I've consulted with swears by its effectiveness and longevity. I can understand and appreciate your philosophy, however there are simply some clinics out there who can simply do more with the same amount of grafts than others.

 

You are right in that no one can predict the future of mpb, but it would seem the risks would be far greater for someone in their early 20's than mid 30's, instead of seemingly the same, especially if the level of loss is greater for the younger patient. To say there is no difference from myself to this patient SEEMS a bit absurd based on my conversations with other clinics. Is a 25 yr old nw2 the same as a 25 yr old nw5? Again, does every 25 yr old have the same hair characterisitcs, family history, rate of loss, use of medication, ect? No.

 

I appreciate your explanation, but it goes against a lot of leading clinics on here that don't transplant in the 3v pattern on all their patients under 35.

[Dr. William Reed]

I like your style of argumentation; it is polite, but candid and forthright, well thought out and clearly articulated. What frustrates me with email is that even with such good style, the nuance of the dialogue seems to get lost. In our case the loss results in your not unreasonable conclusion that my approach is "formulaic" when I stated that my concerns are as valid for the 35 yo as the 21 yo. Further consideration, perhaps looking at my case examples on HTN and elsewhere as well as talking with any of my patients (or actually all consults even those who don't become patients) about the lengthly planning sessions and consideration of a wide range of possibilities, should make it clear that although there are fundamental principles that should guide a ht, my approach is anything but formulaic.

 

In fact, I am strongly opposed to any "formula" or guiding principle that applies to all patients. For instance, the hairline that is established by the "bridge" I describe as being a fundamental element of the 3 vertex generally comes more forward than the standard 3V cartoon in almost all of my cases. The guiding principle is an intuitive one where the patient and I feel out how far forward a hairline can come in a so-called 3 V pattern while still looking acceptable in the worst case, long term scenario on the profile view when it will exist with the large bald crown. Where this anterior border of the bridge is located on the skull is as important for short term satisfaction (for instance the case that started this thread) as it is for long term "naturalness" and congruence with the large bald crown. Skulls and facial proportions come in all sizes and combinations. One formula would be doing a disservice to the beauty to be found in Nature, yet certain fundamental principles and concerns persist as points of departure. It is in this sense that I should be called formulaic with it the risk/benefit that results (and which is influenced by a wide range of factors: age, perhaps family history, amount of area chosen to receive the grafts, range of what is considered "acceptable styling", hair fiber diameter, waviness, color contrast of hair with skin, donor skin thickness, distensibility, donor hair density, etc.).

 

I doubt that the doctors to whom you allude and whom I'm certain we both respect differ with these opinions and, in fact, I would assume they spend the necessarily lenghtly amounts of time needed to educate the prospective patient so that they can ultimately make their decision based upon the risk/benefit ratio that they feel comfortable with. I would very much like to hear opinions of agreement or disagreement from my esteemed peers in the Coalition. I think it would help clarify the presence of the inevitable risk/benefit ratio that is an inseparable part of any action, surgical or otherwise. I still get too many inquiries from HTN from men under 25 who seem oblivious to the risk/benefit dialectic. It would be valuable to have a rich thread to refer these young men to.

 

Reviewing your email you mention something about number of grafts needed to achieve density. I think you are alluding to the 4000 grafts that I used over two procedures (the photos posted are after the first procedure) and to your original query that it be too big a number. If you assume that the donor area in this case is somewhere more than 100cm2 and probably less than 150cm2, and divide that into 4000 grafts, you will see that the pattern is less than 40 grafts/cm2. If fugs average 2/fug and there is 90% survival you arrive at about 70-75 hairs/cm2 after all of the pre-existing hair falls out. With dense hair being somewhere in the low 100s/cm2, it feels right to me to go into the central core of the long term pattern, i.e. the 3V, with this number of grafts. Hopefully it will give more short term satisfaction while the pre-existing hair persists and will be about the right density after the pre-existing hairs fall out. (I would disagree with the opinion you alluded to that the surgical plan can take into account the results of finasteride, but I know other reputable surgeons disagree with me; this is a good topic for its own thread.)

 

I would conclude by reminding us that none of us have seen the bad outcomes of refined follicular unit transplantation. They will occur but the procedure has only been practiced for at most fifteen years and that would be insufficient time for even some large plug sessions of yesteryear to show their unfortunate long term outcomes. In both cases, planning, caution and, almost certainly, dumb luck are key in delaying or avoiding the chronic embarrassment that results when balding outruns the ht plan's ability to mimic what occurs in Nature. There will be a larger margin of error with small grafts vs the large plug: the ability to remove them and to have the associated skin be smooth instead of revealing the large grafts' "cobblestone" appearance, the even homogeneity of small grafts vs. the "pluggy" heterogeneity of large grafts, the existence of FUE to smooth out defects and to tap further the depleted donor areas result in this larger margin of acceptable error. This present absence but inevitable certainty of some outcomes that will be a daily embarrassment to those of us who underwent or participated in ultra-refined FUG should at least give each of us a moment's pause.

 

I would be happy to continue our discussion next week and would very much like to hear from other respected surgeons of the Coalition to support, refute or refine my thinking.

[hdude46]

Thanks Dr. Reed, this makes more sense to me. I think I just misunderstood your original post a bit. thanks for the nice writeup.

[TC17]

I agree with everything you said Dr. Reed, wonderful write up.

 

I can understand why patients would want crown treatment, low hairlines, and dense packing, but I cannot understand why any physician would do those things in the face of such an uncertain future. Unfortunately, it seems as though few people truly understand the potential for bad outcomes down the road, and put "conservative" physicians on the defensive far too often. Until there is something more precise than merely guessing as to the future hair loss pattern, count me as one person who will not jeopardize his future physical appearance for the present.