NORWOOD 6 members who have had HT surgery

[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.

[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.

[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.

[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?

[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.

[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.

[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.

[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.

[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.

[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

[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.

[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.

[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.

[3rd time]

Dr Cole, thank you for this information its very interesting to read. I have had three strip HT and have noticed thinning around the nape of the neck making this hair unusable for future treatments. Both docs told me this hair was thinning.
I always had thick hair around the donor area but not anymore. I can defintely say my hair has declined in quality after these three procedures and no meds to halt further losses.

I may have to try avodart as a last alternative.

Dr Cole
For someone like me who has basically depleted their donor do you think FUE would be an option? I was told by another Doctor it's not a good idea for me as it may do more damage than good.

[John P. Cole, MD]

it's really interesting. some individuals who had side effects to Propecia did not have them to Avodart. You'd expect more with Avodart. I prescribed it for years. I never noted an increase in side effects with Avodart.

A short hairstyle can make a person with fine hair appear to have more hair.

I did a study over the past two years with cross sectional trichometry. I studied donor areas in patients with no previous surgery, patients after FUE, and patients after strip surgery. What I found was that the average virgin donor area was a 74. After my version of FUE, the number dropped to 66. After a similar number of grafts done by strip the number was 52.

This number reflects the cross sectional surface area of a bundle of hair from 4 square cm. What it means is that the surface area drops significantly more following a strip procedure than from a proportional number of FUE grafts, at least harvested my way.

Why does this occur? In a strip, we remove a section of tissue containing hair. We then must close this void with the surrounding skin. We now have to use the remaining hair to cover a larger portion of the scalp or the portion that was removed. In that you have the remaining number of hair must now cover more surface area, the density is reduced. The traditional safe donor area is about 203 sq cm. Thus, if you remove 40 square cm, the remaining hair in the remaining 163 sq cm must now cover 203 sq cm of scalp. The number of remaining hair is the same, but the surface area they must cover is larger. The density goes down and so does the cross sectional trichometry.

In FUE, the surface area remains the same or decreases. Density is reduced by the removal of follicles. The remaining follicles are not stretched out to cover a void, however so the cross sectional trichometry is reduced, but not as significantly was with a strip procedure.

In a strip procedure, the remaining hair must also cover a scar. This is why you cannot remove as many grafts via strip as with FUE. With FUE, you can take more because you don't have to worry about covering a scar.

Now guess where the cross sectional trichometry is reduced the most following a strip. Is it above the strip scar or below the strip scar? It is reduced more above the strip scar. Which hair is more important to cover a strip scar? Is it the hair above the strip or below the strip? It's the hair above the strip unless you want to walk around on your hands. Thus, where you need the hair the most is where the hair density is reduced the most following a strip procedure.

As an example, I had a patient in today who had two strips done by a well known and well respected physician. I think he does good work. The patient had a CST of 42 above the scar and 56 below the scar. What does this mean? We can't harvest as much hair above the scar as we can below the scar even if we correct his 5 mm wide scar, which was his primary concern. 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.