NORWOOD 6 members who have had HT surgery

[delancey]

jotroic, as a life long strip monger, i'm not surprised that you refuse to recognize that there is something called the illusion of coverage. i guess that when you perpetuate the myth that strips in your hands don't leave disgusting, ugly scars, you can also perpetuate the concept that "coverage is coverage" and obviously erroneous myth you spread for years that strips produce better results than FUE. in fact, it is possible to cover the entire scalp with a single hair that is grown long enough. that is not coverage, however. that is an illusion of coverage.

you may refuse to face the fact there there is rarely enough hair to give the illusion of coverage in a nw 5 and never enough hair to give the illusion of coverage in a nw 6, but his is the simple God's truth. one is never going to cover 225 to 250 sq. cm of bald skin with 5000 to 7000 follicular groups. it is simply mathematically impossible. now, i know you guys sometimes do 5000 grafts in one session and then do more, but you fail to explain that you typically split the natural follicular groups into smaller segments so that you actually place the same follicular group more than once and then bill double or three times for that same group.

i'm no fan of discussing any specific patient whose had a hair transplant. i also, have no taste in my mouth for salesmen that pick guys who are just trying explain their perspective of hair transplant surgery. Since you did it, i'll be frank. there is something quite different from a photo result and a real result and you are a master of the photo result. that my friend is also called an illusion of coverage.

Dr Cole,

how many grafts do you believe a Norwood 5/6 needs (blonde hair/fair skin) to get a good result? Let's assume an area of 200 cm2 to cover. Hair characteristics: medium-fine. How many grafts?

[hairquestions]

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.

Thank you Dr. Cole.

[John P. Cole, MD]

A NW 5/6 has a ton of hair loss.

Let's assume a 5 has up to 180 cm2 and a 6 has up to 225 cm2. Multiply these surface areas by an average of 80 fu/cm2 and you have the total number of missing follicular units. Complicate this by noting follicular unit densities often approach 100/cm2 in the crown.

We always need more hair in a crown/vertex/or back of the scalp. We often need more than 50% of what was lost to look full.

I don't think we can get the illusion of full coverage in the crown beyond a NW 3V. If you have home run hair, you might approach a full look in a NW 5 with a higher hairline, but you can't fully reach the goal. We can change the equation using beard hair or body hair that grows, but it's an uphill battle beyond a NW 3V. Recognize that beard hair has a yield of about 60%. Other forms of body hair give good coverage in only 25% of patients and the degree of coverage in this 25% is variable.

I really don't think physicians acknowledge the limitations of hair replacement surgery. I know the ones I met over 20 years ago led me to believe the donor area was nearly limitless. It's not. We can obtain good coverage with less than 50% of what was there originally in the front, but not the back. Of course larger diameter or coarser hair changes the scenario, but not enough to change the possibilities in NW 5 or 6. So....imagine you have 200 cm2 of hair loss. You have lost 16,000 FU. we need more than 50% in the rear 100 cm2. 50% in the rear could be 5000 FU but you lost 10,000 FU. Maybe you need 8000 in the rear alone. 3500 should do it in the front, but you have only an average of 15,300 in the safe donor area. You can't cover the rear with the remaining 4000 FU so the answer is impossible. you can't do it. You have to accept a thinner look in the crown or use concealers like toppik or SMP.

[hairquestions]

A NW 5/6 has a ton of hair loss.
I don't think we can get the illusion of full coverage in the crown beyond a NW 3V. If you have home run hair, you might approach a full look in a NW 5 with a higher hairline, but you can't fully reach the goal. We can change the equation using beard hair or body hair that grows, but it's an uphill battle beyond a NW 3V. Recognize that beard hair has a yield of about 60%. Other forms of body hair give good coverage in only 25% of patients and the degree of coverage in this 25% is variable.

This is upsetting. I talked to someone at your office who told me that I was a NW 5. I had a HT 10 years ago that I think damaged the donor area. I can't shave my head because I would have scars in the back, possibly holes in the front and a HT won't give me coverage. So I feel stuck.

Will more hair fall out on the sides after a HT? Then I'd really have a mess.

The cost is also a concern.

[hal]

Some excellent advice and observations, Dr. Cole. I'd add that of course expectations are the key.

I was a Norwood 5A moving in to Norwood 6 territory 4 years ago when I went for my first hair transplant procedure. I had a 3,700 graft FUT with Dr. Ron Shapiro. The focus was to rebuild my front hairline/frontal 3rd. I could not be happier with the result.

I was 47 years old at the time, had no hairline, and had a dying "island" at the front of my head. I am blond, with fair skin and somewhat fine hair.

Many younger patients seem to be looking for, or have expectations of, a full restore. My goals and expectations were more modest, and have been fulfilled in spades.

Which brings me to your comments-- I have a bald spot on my crown the size of a softball. No hair at all. With a cover product and bringing hair down from the top of my head I can actually cover this spot. But the fact remains I'm basically painting my bald scalp. And I hate it.

I am planning a procedure of 2,500 grafts or so for the crown this spring with Dr. Shapiro. My expectations are that this *might* give me something like 20-25% density. Maybe a little higher if I'm very lucky and graft harvest level is in the 3,000 range.

The point is that I will have hair back there for the first time in years. I will have to use a lot less cover product and will not have to use my current styling techniques to conceal the bald spot. I will also have a few other overall styling options for my hair in general that are not open to me now.

If the planned procedure can get me to the above, than I am a happy camper. I think my expectations are in line with what is possible.

So I agree with your comments 100%-- but there are happy mediums which will leave the patient with better alternatives.

Hal

[FearTheLoss]

I think the real power of propecia is in slowing the rate of hairloss down. In other words if you're norwood 3 and get 3000 grafts in the frontal third you could be happy for 5 or 6 years before you have to consider another session. Without propecia you may get 2 or 3 years before it progresses. I think the real benefit is that it keeps you out of the chair for longer.

However if you have aggressive hairloss and a norwood 6 pattern in the genes I think most get to norwood 6 eventually with or without propecia. I know Jotronic stills takes it as he is concerned that the lateral humps may drop over time.

I know that Jason Gardiner does not use meds as he has lost all the hair across the top and Dr. Ziering must feel the lateral humps are not miniturising.

It really is a case by case basis. Everyone is different. There's actually a really interesting case that Dr. Feller posted here a number of years ago about a 24 year old norwood 3 that began the restoration process. His hair continued to thin over the years and his norwood 6 pattern eventuallly stabilised. Dr. Feller I believe did 3 transplants in total over the years and the patient always looked better than he did before the first session. He also has more in the tank in case of any further unforeseen loss. I don't recall the exact number of grafts he had transplanted but I think he had 7300-7500 with more than 2500 left in the tank by strip.

In other words you can sweep against the tide but you need:

1) The money
2) The donor
3) The patience & perseverance
4) The right doc who will use your donor wisely over time

http://www.baldtruthtalk.com/showthread.php?t=2326

It's a lifetime commitment. It's almost never one and done.

That case is absolutely unreal. It looks to me like that is real density, rather than just a combover allusion.

[Alpine]

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.

My surgeon only does FUT and he is the best in the world. He teaches the best doctors in the world. He is the one who is usually sitting on your oral board exams when you are trying to get membership into an elite organization like IAHRS or ISHRS (member of both and founding member of the latter). He is one of the very few who actually did their residency in hair transplant surgery and he was Chief Resident at that. He is Clinical Professor at USC Medical School, is the main hair consultant for Merk (maker of Propecia), the main hair consultant for Pfizer (maker of Rogaine), and is either the president or senior member of just about every hair organization there is. So he is wrong when saying that FUE is not good compared to FUT because in FUE you lose so much donor supply? And btw the scar from my first FUT was almost non-existent and I can't even feel the scar from my second FUT done 8 days ago (can't even feel a thin line), so the whole scar thing is mute if you are talking about competent surgeons.

[fred970]

My surgeon only does FUT and he is the best in the world. He teaches the best doctors in the world. He is the one who is usually sitting on your oral board exams when you are trying to get membership into an elite organization like IAHRS or ISHRS (member of both and founding member of the latter). He is one of the very few who actually did their residency in hair transplant surgery and he was Chief Resident at that. He is Clinical Professor at USC Medical School, is the main hair consultant for Merk (maker of Propecia), the main hair consultant for Pfizer (maker of Rogaine), and is either the president or senior member of just about every hair organization there is. So he is wrong when saying that FUE is not good compared to FUT because in FUE you lose so much donor supply? And btw the scar from my first FUT was almost non-existent and I can't even feel the scar from my second FUT done 8 days ago (can't even feel a thin line), so the whole scar thing is mute if you are talking about competent surgeons.

This is complete BS.

[Alpine]

How can any of this be BS? All this stuff is easily verifiable by merely looking it up. The only thing I said that you can't look up yourself is what I said about my scar. And yes like it or not my scar was virtually invisible with hair growing out of it from my first surgery, and after my second surgery the same scar is developing the same way. So what exactly is BS?

I'm starting to believe that many of you deserve these horrible HT's you get.

[fred970]

How can any of this be BS? All this stuff is easily verifiable by merely looking it up. The only thing I said that you can't look up yourself is what I said about my scar. And yes like it or not my scar was virtually invisible with hair growing out of it from my first surgery, and after my second surgery the same scar is developing the same way. So what exactly is BS?

I'm starting to believe that many of you deserve these horrible HT's you get.

I'm quite happy with my (scar-free) HT, thank you.

I'll just repeat what someone else intelligently said on this forum:

Anyone who gets FUT in 2015 is a certified bozo.