View Full Version : Video-Dr. Feller in consultation

Dr. Feller
06-13-2013, 05:31 PM
One of the most important topics discussed during consultation is where to put the hairline.
Today a patient visited and allowed me to video some of our consultation. I made my suggestion as to the best placement for the hairline and why.
For those who are interested please chime in and give us your opinion. Maybe you agree with me and my reasons. Maybe you don't, but I look forward to your views, as will this patient who will go by the alias "Questionable Hairline Guy".


06-13-2013, 06:30 PM
I think you're giving him great advice. I'm also wondering if he is on Propecia? It seems with his relatively minimal hair loss, Propecia could really help the guy maintain what he has, which is actually pretty good.

06-16-2013, 12:31 PM
He still has quite a lot of hair. Im jealous :)
How many grafts would you give him at this stage? Would you have to shave around the receiving area?
As for his hairline, sounds good, as marty would say, "you're the doc, doc".

06-18-2013, 02:30 AM
I think these videos are really great. Of course inevitably the same old questions will pop up on these forums again and again as new people start to look into surgery and do thir research and I think these videos a a great way of answering lots of questions at one! So please keep them coming!

From a young guys point of view it's a question I have thought of (and to be honest one I would be still do worrying about) if it were me getting surgery. Personally I would like a slightly straighter hairline, just because I've seem looks of pictures of people (of varying ages) with quite a straight hair line when their hair is combed back. Which for me would be a style id like to have and would feel less comfortable doing if I Felt I had what looked like a receding hairline. In fact that's exactly why I don't currently wear my hair like that! That's just me though.

On the other hand I also appreciate that depending how extreme your loss is, it maybe more sensible to be conservative so more donor hair is saved for future surgery.

Is a lower hairline an option if the donor hair supply is good?

Dr. Feller
06-18-2013, 05:19 PM
Pay: Yes, he's on propecia. A regular user. But even with that his hairline is deteriorating so the writing is on the wall. Thank you for the input.

Bighair: I think I would limit it to no more than 1800 grafts. Could I do more? Yep, but I want to keep the hair in the bank for when he really needs it up top in the future. Same plan I used on myself over the past tweny years.
As Joe Black said: "You fit the Bill, Bill."

UKCali: You hit on the main part of our consultation and the answer is NO. Unless he unlimited donor hair I would not drop that hairline nor would I flatten it in the corners. In fact, that's what hairpieces look like and why they are so obvious. In the past few years, though, the hairpiece industry has learned to create non-straight hairlines and have saved their business in doing so.

UPDATE: This patient called today because he read these reviews and decided to go with my plan. My thanks to everyone for their input. With his permission I will post his results as we go along.

Follicle Death Row
06-20-2013, 09:01 AM
I agree 100% with the rationale behind the choice of hairline. To my eye it looks just right. I don't think even Rahal would go much lower with a 28 year old.

For those that always want to push the boundaries I often think of it this way:

A doctor thinks you have x amount of grafts by strip over say 3 procedures and this is the hairline he is willing to give you and still have enough if you get to norwood 5 or 6.

Now if the patient is willing to dip into FUE after being stripped out or is willing to have a small bald spot in the crown or less density, what type of hairline can we design with x + 1000 grafts? i.e. place 1000 more grafts in the frontal third with the idea in mind that these 1000 grafts can be made up for in the crown via FUE or a small bald spot is left.

Anymore aggressive than the later that is wreckless imo.

Btw, what density would you propose for this patient's hairline doc?

Dr. Feller
06-22-2013, 07:42 AM
I'd say the 40-50 grafts per cm2 would be about right. I don't remember the caliber of his hair, if it is thinner than your average Asian hair, then I might go a tad higher.
But the idea is to make sure there is enough donor left to fill in the front top if that time should ever come. Hopefully not, but his age hmmmmmm......

Dr. F

Follicle Death Row
06-22-2013, 12:14 PM
I was wondering what your opinion is doc on the efficacy of finasteride in those who have a strong family history of baldness. I'm not convinced that it can maintain hair for very long in a patient whose genetics have him set on a path for norwood 5, 6 or 7.

What has been your experience with your patients and finasteride usage over the last 15 years? Will it only slow the process down in this cohort?

Dr. Feller
06-30-2013, 06:10 AM
I was wondering what your opinion is doc on the efficacy of finasteride in those who have a strong family history of baldness. I'm not convinced that it can maintain hair for very long in a patient whose genetics have him set on a path for norwood 5, 6 or 7.

What has been your experience with your patients and finasteride usage over the last 15 years? Will it only slow the process down in this cohort?

Let me start by saying I bill myself as a "hair surgeon" and not a "hair loss specialist"- the latter of which dabble in various questionable concoctions and merely state the obvious just before sending the patient a stout bill. In other words, by the time someone comes to me they have already tried the FDA stuff (that have SOME true beneficial effects), and the quack remedies as well.

That said, since you are asking specifically about finasteride, most patients who come to me have tried finasteride and believe it helped keep their hair longer than they otherwise would have. But ultimately the treatment window closed and so they moved to the next step up the ladder which is a surgeon.

I believe there is an inverse correlation between finasterides efficacy and the destined level of hair loss. That is no doubt why efficacy varies across the entire patient population and why finasteride is not the "magic bullet" for the extreme majority.

I have seen norwood 5,6,7s grow what I call "finasteride hair", but this hair is often fine and light in color and of little to no cosmetic signfiicance in and of itself. However, combine it with something like Toppik and you can achieve an impressive cosmetic improvement indeed.

But is it worth the physiological price? I have been hesitant to push finasteride because in the end it messes with the DHT biochemical axis which can lead to issues like erectile dysfunction, enlargement of the breasts, decrease in sex drive and others that have been discussed online for years.

But I intuatively believe that the side effects and physiological disruption may run far deeper than that. Like so many chemicals in the body, DHT likely has more than one use throughout the body. For example, it may be used as PART of another completely non hair related chemical process needed to sustain proper health. In fact, that's likely. So I've never been a big fan of messing with it.

We all remember learning about "homeostasis" in junior highschool. Our chemical mechanisms are in balance. And when you thrust them out of balance through illness or introduction of a foreign substance the body will attempt to compensate. But that compensation OFTEN comes at a price and may not last indefinitely.

That price may be well worth it when the body is in a PATHOLOGICAL state. HOWEVER, MPB hair loss is NOT pathological. It only seems that way to us. Quite the opposite, it is as normal a state is it comes. Hair follicles do not rot out of our head, they were designed from conception to literally commit suicide at a certain point in our lives. Hair loss is an ACTIVE process the body engages in for reasons known only to it. This process consumes energy, which the body, through a complex mechanism, willingly provides. Rarely does the body waste energy as it is THE most efficient machine known to mankind in the universe to date.

If a patient in their 20s and 30s has a significant amount of crown hair or vertex hair but completely lost the front third of the hair, finasteride is a fair option to help maintain what's left, but I would hesitate to offer it for the same patient in his 40s and beyond because the sexual side effects will likely be more pronounced.

There is a percentage of patients who benefit greatly from finasteride by keeping an almost full head of hair with no obvious or subtle side effects. Spencer Kobren is an excellent example of this kind. Why or how his body "threaded the needle" to seemingly enjoy all the benefits and not suffer any of the consequences is a riddle that is well hidden in his DNA for now.

And so it goes for ALL hair loss sufferers attempting to use finasteride to treat their hair loss. Genetics will dictate failure, success, or the inbetween.

Dr. Feller

06-30-2013, 06:43 AM
great post