Donor Area Question

[VeeDub]

Hey All, I'm new to this forum and it's my first post. I'm going back for another surgery in a few months (I've had maybe 5000-6000 grafts implanted by Dr. Cole over about a 5 or 6 year period of time).

I'm just asking a general question about Donor Area. I know most doctors who perform FUE usually cherrypick the best grafts from around the circumference of the head. It seems like after that area has been relatively depleted, the next course of action is to use body/beard hair.

In the picture attached (which is not of me, just used as a visual), can hair still be harvested above and blow the "U" shaped donor area? I still feel like I have a fairly large amount of transplant-able hair outside of the meaty safe-zone "U" shape, and fairly large amount of hair in the area above my ears and behind my temples too.

Thanks All!

[drybone]

You make an interesting point dude.

I have no idea how much donor hair you have left. Can you put up some pics of your hair?

[VeeDub]

Sure, I'm at work and just thought about this. I'll post some pictures of my donor area when I get home....it'll be a few hours though.

[John P. Cole, MD]

It's the million dollar question. Can we harvest outside the traditional safe zone. The answer is yes in a NW 6 or better. I think we run into a problem with the future NW 7. We also have to be careful in the NW 6 who may drop into the safe zone in the middle of the donor area. One can typically see this coming, however because the hair begins to miniaturize at an early age so when I see this, I avoid this area.

There are other reasons to consider going outside the traditional safe zone. One is an effort to make the density of the surrounding thicker areas more similar to the thinner areas that were harvested before.

Now what happens if we harvest outside this zone and you later loose this hair? You will be fine in the long run. The hair was going to fall out anyway, but you had good use of it when you needed it, in the thinning areas, when you were young.

The flip side to this argument is that the hair may not be permanent so you don't want to transplant it. My counter argument to this is that most of the time this hair will be permanent or at least long lasting. Only about 3% of men advance to a NW 7 by age 60 so why not use the hair to look and feel attractive when you are young.

I've take up to 9500 scalp hair grafts by FUE in some patients. That's alot more than you can get by strip surgery. The bottom line is that when the cross sectional trichometry in your donor area equals that in your thinning areas, you are then tapped out. The goal is to make them all equal in FUE. FUE reduces CST far less than strip surgery. The mean FUE CST is 68, while the mean strip CST is 51. You need more hair to cover the strip scar and strips thin the donor area more than FUE. thus, you are finished far sooner when you have strip surgery done. You have to leave the hair longer in the donor area with a strip to cover the scar (s) than you do with FUE following maximal harvest. I've collected a ton of data on this over the years. The good news is that our new equipment is so fast that we can really get pricing down closer to strip surgery these days. that's a huge bonus for patients wishing to get the maximal coverage out of their donor area and have more options with hair style following surgery.

[didi]

It's the million dollar question. Can we harvest outside the traditional safe zone. The answer is yes in a NW 6 or better. I think we run into a problem with the future NW 7. We also have to be careful in the NW 6 who may drop into the safe zone in the middle of the donor area. One can typically see this coming, however because the hair begins to miniaturize at an early age so when I see this, I avoid this area.

There are other reasons to consider going outside the traditional safe zone. One is an effort to make the density of the surrounding thicker areas more similar to the thinner areas that were harvested before.

Now what happens if we harvest outside this zone and you later loose this hair? You will be fine in the long run. The hair was going to fall out anyway, but you had good use of it when you needed it, in the thinning areas, when you were young.

The flip side to this argument is that the hair may not be permanent so you don't want to transplant it. My counter argument to this is that most of the time this hair will be permanent or at least long lasting. Only about 3% of men advance to a NW 7 by age 60 so why not use the hair to look and feel attractive when you are young.

I've take up to 9500 scalp hair grafts by FUE in some patients. That's alot more than you can get by strip surgery. The bottom line is that when the cross sectional trichometry in your donor area equals that in your thinning areas, you are then tapped out. The goal is to make them all equal in FUE. FUE reduces CST far less than strip surgery. The mean FUE CST is 68, while the mean strip CST is 51. You need more hair to cover the strip scar and strips thin the donor area more than FUE. thus, you are finished far sooner when you have strip surgery done. You have to leave the hair longer in the donor area with a strip to cover the scar (s) than you do with FUE following maximal harvest. I've collected a ton of data on this over the years. The good news is that our new equipment is so fast that we can really get pricing down closer to strip surgery these days. that's a huge bonus for patients wishing to get the maximal coverage out of their donor area and have more options with hair style following surgery.

I never bought into 'permanent safe zone' theory for the reasons you mentioned above. This non-permanent hair will last till the person turns 50-60 at least, if the guy is 28 yo and NW6 nothing wrong harvesting outside zone and let him enjoy next 30 years or so..by that time even strip clinics will be multiplying hairs. No brainer.

Maybe this myth is perpetuated by STRIP clinics, they cant really go outside safe zone they way fue can...



Dr Cole.

Have you solved the issue of white dots with FUE? We need something like pilofocus. Say there no scar/white dots, would it be possible to remove 30-50% of NW6 donor area and implant it on top, patient shaves sides and grows top, marine look, in theory it should work?

[John P. Cole, MD]

We have not solved the problem of white dots, but we are getting better at it with Acell. It does seem that if we can eliminate the leakage of Acell, we can get excellent healing.

I really don't think the permanent zone is really permanent in all patients either. I know that strip patients do tend to thin out in their donor area over time and this can make their concealed scar obvious later on.

The goal to eliminate white dots is important. We know that you can wear your hair much shorter following maximal harvesting following FUE than you can with strip surgery. White dots simply preclude your capacity to shave your head. Then again, not all individuals get white dots.

In our follow up 1 sq cm study on Acell, we are comparing a non-acell side to an Acell treated side. We eliminated two additional ingredients to the Acell treated side this time, however. So far at 6 weeks are are holding steady at three sites growing a single hair on the Acell side. None of those sites had a transected hair follicle. On the non-Acell treated side, we have on extraction site growing a single hair and there was a single transected follicle in that site. We want to compare healing at 3 months on each side. It should be interesting. So far, the growth is a little slower than the last study on the Acell treated side, which suggests that the other two ingredients might be important. We will keep studying the growth and then follow up with another comparative study by adding the other two ingredients again.

I did spend a good bit of time with Dr. Nigam in San Francisco. He talks a good game. I need to go there to evaluate the results, however. Other physicians in India are no so sure about his claims. We shall see.

[John P. Cole, MD]

Also, recognize that Pilofocus is a long way off if ever technology at this point. The device harvests tiny plugs deep in the scalp. This will fill in with scar tissue so it's absurd to suggest that it is scarless. If anything there will be more scar. What we don't know is what all this subcutaneous and intradermal scarring will do to the donor area. Right now, it is more theory than substance. They are quite fortunate to have financial backing. What we do have with our techniques and donor are treatment is proven results and improved healing. Proven is a whole lot better than unproven theory. Pilofocus also removes all of the deep stem cells. Thus, it is highly unlikely you will have any follicle regeneration. Instead, you will have a thin donor area with lots of gaps and tons of deep fibrous scar tissue.

[crafter]

Also, recognize that Pilofocus is a long way off if ever technology at this point. The device harvests tiny plugs deep in the scalp. This will fill in with scar tissue so it's absurd to suggest that it is scarless. If anything there will be more scar. What we don't know is what all this subcutaneous and intradermal scarring will do to the donor area. Right now, it is more theory than substance. They are quite fortunate to have financial backing. What we do have with our techniques and donor are treatment is proven results and improved healing. Proven is a whole lot better than unproven theory. Pilofocus also removes all of the deep stem cells. Thus, it is highly unlikely you will have any follicle regeneration. Instead, you will have a thin donor area with lots of gaps and tons of deep fibrous scar tissue.

that makes sense.

[gillenator]

We have not solved the problem of white dots, but we are getting better at it with Acell. It does seem that if we can eliminate the leakage of Acell, we can get excellent healing.

I really don't think the permanent zone is really permanent in all patients either. I know that strip patients do tend to thin out in their donor area over time and this can make their concealed scar obvious later on.

The goal to eliminate white dots is important. We know that you can wear your hair much shorter following maximal harvesting following FUE than you can with strip surgery. White dots simply preclude your capacity to shave your head. Then again, not all individuals get white dots.

In our follow up 1 sq cm study on Acell, we are comparing a non-acell side to an Acell treated side. We eliminated two additional ingredients to the Acell treated side this time, however. So far at 6 weeks are are holding steady at three sites growing a single hair on the Acell side. None of those sites had a transected hair follicle. On the non-Acell treated side, we have on extraction site growing a single hair and there was a single transected follicle in that site. We want to compare healing at 3 months on each side. It should be interesting. So far, the growth is a little slower than the last study on the Acell treated side, which suggests that the other two ingredients might be important. We will keep studying the growth and then follow up with another comparative study by adding the other two ingredients again.

I did spend a good bit of time with Dr. Nigam in San Francisco. He talks a good game. I need to go there to evaluate the results, however. Other physicians in India are no so sure about his claims. We shall see.

Very informative and truthful post!

[gillenator]

Veedub,

Very good questions that Dr. Cole answered.

Terminal hair (DHT resistant) can vary through the scalp and why as you discovered, can be potentially harvested with FUE.

I have especially encouraged multiple HT patients with depleted donor reserves to consider having their entire scalps microscopically examined for differences and comparisons in hair shaft diameter. You already know that a potential FUE surgeon is able to cherry pick these more ideal grafts, but few docs examine for miniaturization and diffusion. Actually, all potential HT patients should have this exam before any surgery is done IMHO.

FUE allows the surgeon to move outside the primary donor zone (occipital) in the back of the scalp. This is a good thing because some patients do experience donor zone thinning especially in their later years. The fundamental challenge is that most guys in their younger years do not display donor zone thinning so most HT docs approximate what they see as the safe zone. It's ambiguous at best because the zone can decrease or become compromised as we get older. Thank goodness donor zone thinning is not rampant.

Only periodic microscopic exams will tell all. And if there are signs of miniaturization/diffusion in the primary donor zone, than moving to the other donor sources like some of the areas you mentioned and in the parietal zones, can be proven viable for use. More beard grafts are being used for transplantation with good yields as I am sure you have been reading about.

But due to the high average degree of coarseness, it may have some visual compatibility issues when placing beard grafts in a highly visible impact area like the commencement of the hairline.

[John P. Cole, MD]

That's a great observation, Gillenator. Not many people recognize miniaturization as a precursor of future loss. The smart ones, such as you do. One thing I look for is an increase number of telogen hairs in the donor area. When i see this, I begin to consider the potential for future hair loss. One area i see them often is in the superior, non-permanent zones. Then i also see them in the non-permanent lower zones. When i see an increase in telogen hairs in these non-permanent zones, I anticipate future loss. What i really worry about is when i see them in the traditional safe donor area. We all know that the safe donor area is not safe. An increase in the telogen to anagen ratio is the true precursor to future hair loss. Unfortunately, you have to look under the hood to see them.

[baldymcgee]

Also, recognize that Pilofocus is a long way off if ever technology at this point. The device harvests tiny plugs deep in the scalp. This will fill in with scar tissue so it's absurd to suggest that it is scarless. If anything there will be more scar. ... you will have a thin donor area with lots of gaps and tons of deep fibrous scar tissue.

This might be technically true, but the only scars that people (myself included) really care about are the visible ones.

So just as FUE leaves scars that are less obviously visible than FUT, Pilofocus (if everything works out) will leave scars that are *even* less visible than FUE. Internal damage notwithstanding.

As regards regeneration: that's just a bonus. We don't have (practical, repeatable, predictable) regeneration today so saying that "Pilofocus won't have regeneration" is largely irrelevant.

[gillenator]

That's a great observation, Gillenator. Not many people recognize miniaturization as a precursor of future loss. The smart ones, such as you do. One thing I look for is an increase number of telogen hairs in the donor area. When i see this, I begin to consider the potential for future hair loss. One area i see them often is in the superior, non-permanent zones. Then i also see them in the non-permanent lower zones. When i see an increase in telogen hairs in these non-permanent zones, I anticipate future loss. What i really worry about is when i see them in the traditional safe donor area. We all know that the safe donor area is not safe. An increase in the telogen to anagen ratio is the true precursor to future hair loss. Unfortunately, you have to look under the hood to see them.

And this is why every patient with MPB should seek this type of evaluation both initially and then continuing intervals due to the progressive nature of MPB. And thanks for the clarification of the telogen to anagen ratio Dr. Cole.

Only this type of evaluation can identify these variations and as you say, the traditional zone is not always as permanent as it appears, especially to the naked eye.