NORWOOD 6 members who have had HT surgery

[3rd time]

Fred970
It seems like you are in a similar category to me. You are correct in wanting to get your front hair line looking good. Wish you luck with your final results.
Unfortunately if your crown is completely bald the concealers will not work well.
However, if you have a little hair in the crown you can use toppik and dermmatch very well. I also liked couvre but eventually I stopped using it because I hated the smell.
Toppik is good if you still have some hair as it makes exisiting hair look thicker but i found it came off very quickly. IMO if you have a party or wedding that is going to be inside then toppik is good.
On the other hand if you have a big day ahead of you and you will be outside I would recommend dermmatch as it stays on for longer and in harsher weather.

[didi]

Fred970
It seems like you are in a similar category to me. You are correct in wanting to get your front hair line looking good. Wish you luck with your final results.
Unfortunately if your crown is completely bald the concealers will not work well.
However, if you have a little hair in the crown you can use toppik and dermmatch very well. I also liked couvre but eventually I stopped using it because I hated the smell.
Toppik is good if you still have some hair as it makes exisiting hair look thicker but i found it came off very quickly. IMO if you have a party or wedding that is going to be inside then toppik is good.
On the other hand if you have a big day ahead of you and you will be outside I would recommend dermmatch as it stays on for longer and in harsher weather.

3rd time,

You said you had 7500 grafts and your crown is still completely bald and hairline is non existent under light and now you ran out donor?

Good number of grafts you had for NW6 but as 35yrsafter pointed out it all comes down to math, simple math that is , you lost 25 000 units and 7500 will not cut it.

I would suggest you buzz cut your head down to .5cm to make it appear thicker but I think strip scars would be visible at that length.

This is why I think strip sucks on NW6s, what if you get stuck in the middle, poor coverage to grow hair out and cant shave due to strip scars.

[fred970]

Fred970
It seems like you are in a similar category to me. You are correct in wanting to get your front hair line looking good. Wish you luck with your final results.
Unfortunately if your crown is completely bald the concealers will not work well.
However, if you have a little hair in the crown you can use toppik and dermmatch very well. I also liked couvre but eventually I stopped using it because I hated the smell.
Toppik is good if you still have some hair as it makes exisiting hair look thicker but i found it came off very quickly. IMO if you have a party or wedding that is going to be inside then toppik is good.
On the other hand if you have a big day ahead of you and you will be outside I would recommend dermmatch as it stays on for longer and in harsher weather.

My crown is thin but still holding pretty well thanks to minoxidil. Thanks man, it's just so hard for me to find solutions. I was told I was too blond for a scalp micropigmentation, too bald for a HT (yeah apparently, hair transplants are not meant for bald people) and even to get a wig by a clinic in Belgium. How nice of them.

[35YrsAfter]

My crown is thin but still holding pretty well thanks to minoxidil. Thanks man, it's just so hard for me to find solutions. I was told I was too blond for a scalp micropigmentation, too bald for a HT (yeah apparently, hair transplants are not meant for bald people) and even to get a wig by a clinic in Belgium. How nice of them.

We had a patient in yesterday in his 50s who was somewhere between a Norwood 5 and a 6. He had never had any hair restoration surgery before and his donor was somewhat thin. He had 2148 grafts placed in his frontal area to frame his face. He had a shaven procedure and he looked great with his head shaved. He has the perfect head for it. I told him he looked great with his head shaved when he got our of surgery for photos and he looked at me like I was crazy.

35YrsAfter also posts as CITNews and works at Dr. Cole's office
Cole Hair Transplant Atlanta
Phone 678-566-1011

[35YrsAfter]

Our patient this morning came in for 2,000 grafts to his crown for added density. I didn't think he had previous surgery because the work in his crown and frontal area was outstanding. After I was finished taking photos, I asked our patient if he had any previous hair restoration surgery. He answered, yes, he had a strip surgery. At that point I asked him if he was happy with his strip scar. He said he never paid any attention. He wears his hair long and has plenty of donor hair to cover the scar. I suggested we take some photos of his scar so he could decide whether he wanted Dr. Cole to place any grafts into it while he was here. He told me he wanted to focus on his crown. Our patient doesn't want to wear his hair short so the scar is not an issue. A scar like this can be successfully repaired allowing a shorter haircut but as you can see, a scar 10mm wide will not work with shorter hair.

[3rd time]

Didi, I will explain the best i can.
I had a big area to cover 209 square cm of measured bald area, the plan for the first HT was to transplant 4000 grafts in 114 sq cm approximately. I was told I had an average density of 38% The doc advised that if we went for a lower, square hairline we could not cover a decent area as too many grafts will be used to fill the temple and not enough for mid scalp. So we decided on a bell shape hairline. Hair was placed In a way where I got coverage but a very thin front hairline. Needed more work.
The second HT was about 3 years later. I had more hair loss (had to stop FIN as sides did not improve but got worse) The Doc said we would need to add more grafts to improve the front and rest in the crown. Ended up getting around 2000 grafts. This made a big improvement but again under bright light the front was not great.
(New Doc)Third HT which I had less than a month ago was about 1500 grafts. Reconnecting the hair transplant with native hair and adding some grafts behind the hairline to combat the see through look and more into the crown.
A lot of 1 hairs were placed at the front hairline in my first 2 HTs.The Doc said it looked more natural but the final result was a thin wispy hairline.
With this last HT a lot of 3 hairs were placed behind the hairline for more density. The first Doc didn't really do this.
Regarding the crown I did start with a completely bald crown as a Nw6 but grafts were added there just enough to give me a little coverage. I still use concealers for crown only. Hoping to see a difference once this HT grows. It's amazing how quickly the crown continued to go without FIN. I know the crown will never look great but I knew that going in.
In regards to depleted donor. The doc did save a small amount of grafts for any future work but i don't have many after three strip surgeries and further hairloss. This is what I was told.

[Follicle Death Row]

This is an example of what I always say about Norwood 6; they need 9000 grafts or more. 2000 more by FUE in select areas can make a big difference. You could put 1000 in the frontal third and then build up parts of the crown laterals with another 1000. Would probably be the best use of the remaining donor. Might get you up over the threshold of density in the most important spots.

[Follicle Death Row]

The area below the scar is the area prone to retrograde alopecia so even though we can harvest more hair here, the hair is more prone to loss over the next 10 to 20 years. This is why I'm no fan of combining strips and FUE. It's just better to do FUE from the beginning.

I guess it depends on where the strip is taken from. I notice Dr. Hasson goes slightly higher than most but still within the boundaries. He gets the best hair which is not vulnerable to retrograde alopecia. I agree that with lower strips the amount of grafts below that can be harvested by FUE is low. The way Dr. Hasson takes strips allows the donor to be maximised not just with strip but with FUE afterwards.

It would be interesting to see you debate the pros and cons with Dr. Bisanga since he developed his skills under your guidance yet he feels FUE is more restrictive in terms of restoring Norwood 6s than you feel.

How many grafts can we extract after stripping out in your opinion Dr. Cole? I've seen some docs come out with some high numbers which I don't really buy. My own opinion is 1500-2000.

I guess one of the bigger drawbacks with FUT imo is that 5-10% of follicles are dormant and end up in the bin with any strip.

[35YrsAfter]

This is an example of what I always say about Norwood 6; they need 9000 grafts or more. 2000 more by FUE in select areas can make a big difference. You could put 1000 in the frontal third and then build up parts of the crown laterals with another 1000. Would probably be the best use of the remaining donor. Might get you up over the threshold of density in the most important spots.

Don't forget beard grafts. Dr. Cole has taken up to 5,000 from a single patient. The area below the jaw heals remarkably well. Beard hair is often twice the caliber of scalp hair and twice the caliber offers four times the coverage. Beard hair must be placed carefully for it to look natural. Styling is an important consideration as well. It makes a great filler and looks good cut short.

[3rd time]

Follicle death row
Thanks for the info about FUE. I'll keep that in mind for the future.
35yrsAfter
I've heard beard hairs don't always get a good yield. For someone like me who needs extra crown work it would be ideal to get this done. How successful have results been for Dr Cole? also do you get a lot of patients after 12 months with no growth?

[John P. Cole, MD]

FDR, it is funny how your name matches a president of the USA. Your questions are good ones.

Dr. Bisanga worked for me about 4 years. In our last year together we took one or two days off each month and we did around 800 strip procedures that year. When I returned to my hometown in Atlanta, he elected to remain in Washington. He spent only a few days with me after that. I showed him an early version of my FUE about a year later. His FUE is built upon that because prior to this he had never been involved in FUE.

In 2004 I began to train a team in Cyprus for strip surgery, but they mostly saw FUE. In 2005, I suggested that Dr. Bisanga would be a good fit in Cyprus for them. Dr. Bisanga elected to go there. Soon after arriving, Dr. Bisanga decided that he would open a practice in Belgium so he began encouraging the patients from the Cyprus clinic to go to his new Belgium clinic. It was not the most ethical thing to do. I had no financial interest in the Cyprus clinic at that time so it did not impact me. However, financial ethics are the most important reflection on a man as far as I’m concerned. He did not hurt me, but he did damage a good friend of mine who employed him without malice. My opinion of Dr. Bisanga has not been high since then. This does not reflect on his talent. His talent is good. That I respect. I think you can get a good result with him.

Since the origin of FUE, there have been physicians who claim they offer FUE. These are well-respected physicians. I could name them if you like, but that really does not matter. What matters is that any good physician can offer FUE. When you arrive for a consultation with such capable physicians, you are generally told that you are not a candidate for FUE. Rather, you need a strip procedure. You might ask, why a strip procedure? You are met with the same argument. You can get more grafts with a strip. You will get a better result with a strip. You should have a strip procedure.

In their hands, they might be accurate. You see, one is never going to be great at anything that they do not love, respect, and practice. All of these physicians do not love the procedure so they do not respect it and they do not practice it. One can never become great at anything they do not practice. I think we all know that we do not practice anything that we do not love and respect. I could make my son play tennis every day. I could push him. He could become very, very good. However, if he personally did not love it, he would burn out eventually and stop. With adults it is different. We can’t force them. They have to recognize the benefits and accept it as a labor of love. If adults don’t love it, they will never be great at it.

Now why would a strip physician refuse to get more involved in FUE? Well, for one thing, FUE takes more effort. FUE is far more taxing on the physician’s body, especially his neck and back. That’s one reason, but there are perhaps others. Suppose you never really get behind the procedure. Will you ever be great at it? Most likely not. In such, you should stick with what you like such as strip surgery.

The farthest one can push a donor area is to the point where the cross sectional trichometry (CST) matches the CST in the recipient area. If one must also leave enough hair to conceal a strip scar, one might not be able to reach this point. It is far easier when one does not have to worry about a strip scar.
Then there are other variables to consider. Most physicians will continue to tell you that the safe donor area is permanent. It is not always. When patients headed to NW 6 enter their early 50s, the donor area begins to thin and so does the recipient area. Would it surprise you to tell you that many strip patients I have refuse to allow me to take any more hair from their donor area simply because it is already too thin?

That leads us into the final question. How many grafts may be obtained after “striping a guy out”? Well, that depends. How old is he? How much hair do we think he will loose long term? What are his hair characteristics such as diameter, follicular density, and hair density? How wide is his strip scar? How many strip scars does he have? This is an individual question and often based on patient age as the donor area gets worse over time though physicians will rarely tell you this.

One must also define striped out. I had a patient from Spain in this week. He was striped out after two procedures though he clearly could have done a third strip. He had a fine strip scar after the first procedure and he was happy. Then he had the second and Walla, he had a ½ cm scar. He could have done a third strip taking the original scar or done a third strip making a second strip scar and then done FUE. However, he is now stripped out.

So the number varies based on the patient, the age of the patient, the characteristics of the donor area, etc. It might be 3000 in some and 500 in others or 0 in yet others.

When I evaluate a patient, I record a ton of data. I can tell you how many follicular units are in your donor area, how many hairs you have per follicular unit, your hair diameter, your surface area of hair loss, your CST in multiple locations, how many grafts we harvest from each zone, your transection rate, your telogen ratio, your average hair per graft, your strip scar surface area, and so forth. All of this data helps me define what I can and what I cannot do short term and long term. Data is the most compelling objective influence on what we can and what we cannot do.

What I cannot do is debate the pros and cons of FUE with a physician who predominately does strip surgery. Those of us who do FUE daily already know the benefits of FUE over strip surgery. Today we debate other factors such as how to approach a donor area. The debate of strip Vs. FUE is over. Now more than 50% of all hair restoration surgery procedures are FUE. We no longer think in terms of converting strip patients to FUE. Patients are doing that themselves just as they converted themselves from plugs to micrografts and from micrografts to follicular units and single hair grafts. Patients determine the flow based on results.

In 2003, there were two physicians in the world advocating FUE over strips, Ray Woods and myself. Today, there are many. I went from a strip surgeon who had done over 8000 strip procedures to a FUE surgeon over night simply because I recognized the benefits of FUE. Now that I’ve done over 5000 FUE procedures and closing in on 6000, I am probably the most experienced FUE surgeon on the planet. It is impossible for me to debate FUE vs strip with a surgeon who does a handful of FUE procedures each month. We would be talking on different wave lengths.

Now in regard to Dr. Hasson, yes, he directs his incision more vertical in the lateral aspect of the donor area. This allows him to harvest a longer length and as such obtain more grafts. I’m no fan of this simply because a vertical incision in the donor area lends itself to a wider scar. This was first documented by Dr. Brandy back in 2003 when he noted that his vertical incisions to ligate the occipital artery prior to a scalp lift resulted in a wider scar. The lateral scalp is the location where all sorts of different types of hair exist (fine vs. coarse) and where hair growth angles vary the most (anterior to posterior). Vertical incisions here marry coarse hair with fine hair and also marry anterior directed hair with posteriorly directed hair. All it does is create a new set of problems to deal with long term without allowing for an increased number of grafts.

I know of very few patients who can pass beyond 7000 natural follicular units via strip. I think that a safe FUE number is the same. Still one can pass this number via FUE more readily simply because one does not need to worry about leaving enough hair to cover a strip scar. Strip scars are finer after one procedure, but the risk for a wider scar increases exponentially with each subsequent procedure. It’s best simply to avoid them altogether. If you surgeon predominately does strips, I would not trust his opinion on FUE. If you surgeon predominately, does FUE, I would not ask him to do a strip. In the hands of a good FUE surgeon, one can obtain more grafts via FUE than a good strip surgeon can obtain doing strips because maximal FUE leaves a better overall aesthetic donor area than maximal strip surgery.

[Bobman]

Wow...pretty long thread.

First off...Thanks Joe (jotronic) for clarifying my response to the "sunlight" photo. And appreciative of having the good fortune of "giving back". Many have met with me in the first 5 or so years who were considering having a procedure done. I was happy to do so and from what I've gathered, they all appreciated my open, honest and no bullshit responses to their questions. And of course...they all dug my results...as the results speaks for itself.

Artista: I've been enjoying my hair transplant from H&W for 9 years now...fyi.

Wow...when you say it like that.

Anyway...All I can say is I'm very VERY happy. I'm no longer "obsessed" with it since I've been able to conquer that issue and have embraced my new chapter most comfortably.

To clarify once again...I'm very happy and am told I look great. In the end, no matter how it's achieved...isn't that the idea. Looking good, feeling good.

[Artista]

Bobman my friend,,THANK YOU for adding to this discussion.
Might I say, the reason why we dont see you as active here is because GOOD FUT work to your then NW6 scalp did the job and you are no longer obsessed with how your scalp looks to this day. You are HAPPY.
Decent coverage of the scalp if one is a good candidate for it.
REALISTIC expectations= common sense.

[topcat]

I suppose there are plenty of ways to explain it especially to younger guys who really don’t understand and I like this example. You have 100 marbles and you have lost 50 of those marbles. Regardless of what you conjure up in your mind you will never have 100 marbles again and to plan on having 100 marbles again is very foolish so you need to come to terms with this reality. Out of the 50 marbles you may have 15 marbles you can use to cover the area where the 50 marbles use to be. That is providing you don’t waste the marbles and lose some along the way as you replace them. You can arrange those 15 marbles any way you like to cover that area but it’s only 15 marbles. So you will end up trying to move those marbles strategically to really make it look like you have the area covered maybe even use some spray to hold them in place and you know in the right light it might just look like you have those 50 marbles back again. When someone turns the lights up guess what chances are the illusion will be up and this applies to the greater percentage of patients regardless if a very few can still keep the illusion going. If someone tells you something different they are lying to you plain and simple.

My experience having had several different types of procedures and not being in the business of having to sell you something and has taught me a few things. When I had a large chunk of flesh excised from the back of my head I had a tightness that seemed to last forever probably close to 20 years before it finally felt normal again. I also had numbness for equally as long with an area that itched but impossible to relieve by scratching it. I had the shooting pains which I found bearable but I did sometimes say to myself wow as the nerve connections started to come back. If I wore my hair long it wasn’t a problem to cover up the scar but if I went swimming the hair could easily part in such a way that it would be exposed and easily seen. Same thing for resting your head anywhere you always needed to have access to 2 mirrors to check that everything was in place and the scar was not exposed as the hair had a natural tendency to part in that area. So if you are a young guy doing the sleep over thing than does become an issue that needs to be constantly dealt with. Chances are very good if you are a NW6 and you have a procedure you will become a slave to your hair plain and simple and it becomes very tiring much worse than being bald.

If I were a Norwood 6 today with a virgin scalp I would only consider reversing the balding process a few years by way of fue. High thin mature hairline with the hairs all angled in the right direction. It frames the face and you can keep it short to medium length and look good. You will not become a slave to your hair because you tried to do something about it. If it goes well you will have nothing to hide. Don’t really need to make the explanation sound too technical because when it comes down to it, it really is common sense when it’s all pointed out.

If you are a NW6 and are considering a procedure just take a look at others around you with similar hair loss. Look at that donor area and if you can visualize how you are going to take a small percentage of that area and use it to cover the bald area and you really can see it and it makes sense than it’s your choice. But chances are reality will kick in.

Most NW 6 guys cannot grow their hair long in the back because it looks ridiculous so that does become an issue when trying to cover up a scar. In reality strip is probably best left for someone that is going to be a NW3 or 4 for the rest of their life and they can deal with some of the issues involved with having that procedure. As far as FUE if you are going to keep you hair short and neat it can be an ideal procedure. If you want to shave to the bone depending on how much you have had extracted from the donor region and the size of the punch along with the skill of the doctor it can become an issue. But guess what if you want to shave to the bone don’t have a hair transplant. You have unrealistic expectations and you should be told that flat out at the beginning.

A good example of what a NW6 can achieve in my opinion would be a look like Jason Straham. Maybe you could do better and maybe not but it’s a good gauge in my opinion. Have a little bit more hair, look normal without issues of having to constantly hide something and get on with your life.



If you are a NW 6 find a picture of yourself from 5 years ago or so and chances are that it what you can bring back and maybe you will be happy with that which is okay just be realistic. And yes if your beard hair is a very close match you might be able to do a little better just fully understand what you are getting into and only stick your toe in the water.

[fred970]

Excellent post topcat. I loved the marbles analogly .

This is exactly what I plan to do. Restore my NW5 as much as possible with FUE. If for some reason, I don't achieve what I want, I'm ready to use dermmatch which had worked amazingly well for me in the past.

I know I won't be able to treat the crown but it seems to be holding very well with minoxidil alone. I'm reaching the point on no return, almost no frame at all to my face. I'm a good looking guy but I'm really starting to look very odd without a frame to my face. I've never known the horror of a receding hairline (my hair just faded equally in the NW5 area), but in a few months, I'll be a full-blown NW5.

I think I've done my homework. I've seen an IAHRS surgeon who told me I won't be happy without a crown. Another clinic told me to go get myself a rug. And finally Dr. De Reys who truly understood what I wanted. Anyway this is my only option left, besides accepting looking like an old man at 24 years old.