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Thread: FUE Transplant

  1. #21
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    The normal sequence of events following a hair transplant is for the transplanted hairs to elongate for about 2 weeks. Then the elongation ceases and over a period of weeks the hairs should shed. Occasionally, the hairs do not shed. They stay in their state of elongation following the first two weeks after hair transplantation without falling out. These are dead keratin and they should be removed because the body will attempt to wall off the dead keratin or form a cyst, pustules, or "black head" around the non-growing hair. You can pluck them with tweezers and they will come out like a pin out of soft, warm butter.

    Then about 3 months following a transplant the hair resumes growth. You will see about 10% more growth each month so that at 5 months you have 50% and at 8 months 80%.

    Your situation is far different as i understand it. Your hair resumed growth and then fell out. Looking at the high mag. photo of your scalp, i see a follicle that is bent over in a C shape. The follicle is quite coarse. The follicle is dark.

    Often times follicles will look similar to this when they resume growth right after a transplant with the exception that the distal tip tends to be fine and lighter in color. Following a transplant a few transplanted hair might continue growth with the exception that they will show the trauma of the procedure (donor removal and re-transplantation). They usually start fine and light at the tip and then the hair becomes coarse and bends over like this one. They are phul pinkus hairs and represent trauma. over time they turn out normal.

    your bent over hair is a little different. it might represent a follicle that was an ingrown hair. I think it represents trauma and i would expect that follicle to fall out temporarily and then resume growth.

    The history is really bizarre. A proper transplant will follow the coarse that your transplant seems to take. Nothing about a transplant has any influence on what happens to the follicles after 9 months other than how the grafts appear. By this I mean natural appearance, proper hair growth direction, etc. Fall out following regrowth suggests something else.


    The other hairs in this photo look ok. the other follicles are finer and lighter in appearance. did these follicles fall out too or just this one that looks like it would fall out. Follicles can look like this without the procedure necessarily being performed poorly.

    So, are you saying that all the grafts fell out after they resumed growth? If so, something is going on. Some sort of medical condition and it should be evaluated and biopsied.

    Follicles can be damaged by both strip procedures or FUE, but I really feel there is a greater risk to the follicles with FUE because the only tissue around the follicles is the dermal sheath. You don't have adipose. You really have to be more careful when placing FUE grafts. I think it is up to the surgeon to monitor the graft placement and insure that FUE and strip graft placement is atraumatic.

    Ok, let me know if I understood your case properly.

  2. #22
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    Hi Dr. Cole,

    Firstly, thanks very very much for your reply. I'm ecstatic to get your opinion on my case, as no one have been able to give me any answers, as my case is a little tricky.

    Quote Originally Posted by drcole View Post
    The other hairs in this photo look ok. the other follicles are finer and lighter in appearance. did these follicles fall out too or just this one that looks like it would fall out.
    The hairs around the dead 'C' hair in that magnified picture are all native hair. The 'C' hair definitely looked like a transplanted hair to me, as it was so much thicker/darker than the surrounding hair. The dead 'C' hair was one that re-grew at around month 5.

    Quote Originally Posted by drcole View Post
    So, are you saying that all the grafts fell out after they resumed growth?
    Yes. How do i know this, 2 reasons. Firstly, i watched grafts RE-grow from months 3-9 and then fall out with my USB scope. Please see the 1st pic i've attached, called 'Graft growth at month 6.png'. I've circled what i believe to be two grafts growing, as they're thicker than the surrounding native hair. It was very easy for me to identify these two grafts consistently, due to the permanent red mark i have on my hairline, which you can see in the pic. I watched these two grafts grow for about 2 weeks (albeit they grew very slowly), then one day they were gone. I'm assuming they became loose like the graft in my first pic and then fell out. The second reason i know my grafts grew and fell out, is because i visited my HT surgeon at 9 months post op and he pulled some of my transplanted hairs out with tweezers. They were just loose on my scalp and weren't holding properly. This, in my opinion, has happened to about 80-85% of my grafts. I've had some growth, but no more than 20%. It's easy to identify transplanted hairs with a USB scope, as they're reasonably thicker/darker than surrounding native hair and you can see some inflammation at the root of the follicle, which isn't present with native hair. I've attached a picture of my hairline, 2 weeks post op.

    Here are a few points that may also be relevant.

    1) 2 months pre-op, i foolishly started minoxidil on my hairline only. Before my surgery, i had a massive shed on my hairline, due to the minoxidil. My HT surgeon was stunned at how much hair i'd lost from the minoxidil, as he had seen me 4 weeks prior at our consultation and estimated 800-900 grafts. On the day of surgery, we agreed on 1,250 grafts, due to the shed. On retrospect, i should have delayed the surgery. I'm worried existing native follicles were damaged during placement of my grafts, as i had shed so much hair on my hairline.

    2) I had a lot of nerve damage post op. I didn't get full feeling back in my crown area for almost 4 months.

    3) My grafts were out my scalp for 5-6 hours, as there was only 1 technician working that day. The grafts were in Hypothermosol. I was in surgery for almost 15-16 hours.

    4) After the HT, i experienced huge amounts of shedding. This continued for 9 months post-op. My HT surgeon said it was telogen effluvium, but when i went to a dermatologist at 8 months post op, he did a hair biopsy and told me it was just aggressive MPB. 60% of the hairs on the top of my head were in shedding phase, compared to 8% in my donor area. I've NEVER experienced a large shed before the surgery, so something from the surgery must have triggered my MPB. I've had hair miniaturizating on my hairline since i was around 17, but at a snails pace. But i've never shed huge amounts of hair like i did post op. I was losing hundreds of hairs daily for almost 9 months. Me and my HT surgeon agreed that I should stop the minoxidil, as we thought I may be experiencing a bad reaction to it.

    My HT surgeon believed that the grafts were falling out because of the intense shedding i was going through. He said they would eventually regrow. My shedding has stopped for almost 2.5 months now, after the 9 months of intense shedding. I'm guessing it will take another 6 months for all my hair to grow back. Will the grafts re-grow again.....i hope so. But i think that's just wishful thinking. I'm sceptical as to why aggressive MPB would cause grafts to fall out. I've seen a couple of other surgeons and the general consensus is that the transplanted grafts appear to be damaged.

    Would you recommend a biopsy in 6 months time, if i still have no re-growth ?

    FYI: I was an NW2 pre-op with hairline thinning only. Still had reasonable density in my hairline, it's just the hairs were fairly minituarized with no colour.

    Thanks again for your reply Dr. Cole and sorry for the length of the post. I really appreciate your input.
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  3. #23
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    The follicles you circled at 6 months are non-growing hairs from the original hair transplant. When hair begins to grow following a transplant, it will start off finer with a pointed tip. The hair will gradually increase in diameter. Note that the hairs you circled are sharply demarcated at the distal end as a result of cutting the hair.

    Shedding following a transplant is often due to shock loss. I have no doubt that a transplant can accelerate hair loss.

    Your post is long and it needs time. I'm currently in route to Cyprus to work with the team there for a week. I have a number of comments to add, which i will shortly.

    What i would like to see is a view of your frontal area today. The immediate post transplant view shows where the grafts were placed, but does not show what you look like today.

    Hypothermosol is a fine solution, but it must not rise above 12 degrees Celsius. Most physicians store grafts on ice, but the ice can melt abruptly exposing the grafts to a dangerous elevation in temperature. To combat this, I designed and sell a graft chiller to physicians that allows the physician to set a constant temperature to store the grafts in over the entire duration of a procedure.

    One tech is limited staff for a procedure over 1000 grafts.

  4. #24
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    Quote Originally Posted by drcole View Post
    The follicles you circled at 6 months are non-growing hairs from the original hair transplant. When hair begins to grow following a transplant, it will start off finer with a pointed tip. The hair will gradually increase in diameter. Note that the hairs you circled are sharply demarcated at the distal end as a result of cutting the hair.
    I've attached another image of the two grafts, which shows the pointed tip you mentioned. You commented: 'The follicles you circled at 6 months are non-growing hairs from the original hair transplant.'. Do you mean these grafts never shed after surgery and didn't grow ? If that's the case, it's strange because i took the image almost 6 months post op.

    Quote Originally Posted by drcole View Post
    Shedding following a transplant is often due to shock loss. I have no doubt that a transplant can accelerate hair loss.
    I have noticed my MPB since 17, but everything has been minituarizing at a snails pace. My surgery has accelerated my MPB tenfold. Not something that is mentioned during consultations. I was told at my consultation that the risk of shock loss is less than 5%, which i don't believe to be ture.

    Quote Originally Posted by drcole View Post
    Hypothermosol is a fine solution
    I have been told from another consultation that grafts being out of the head for 5-6 hours is not good, regardless of the medium used. However, i was told at another consultation that this shouldn't have caused graft 'death', so i'm not sure what to make of it !!

    Quote Originally Posted by drcole View Post
    What i would like to see is a view of your frontal area today. The immediate post transplant view shows where the grafts were placed, but does not show what you look like today.
    Please see the attached picture of my hairline currently, which is 11 months post op. It may appear that i have had some growth, but most of the hairs in the front 2.5 cm (transplanted area) are my native hairs. I was told by my HT surgeon that the first 3-4 rows of the hairline would contain single hairs and the rows behind these would be multiple FU. In the area circled red, i can see with my USB scope that the majority of hairs are thin (minituarized) single hairs. I can also see a double haired FU, which is very thick and appears to be a transplanted hair. In my 2 week post op picture which i attached in my last post, it looks like i have little native hair in my transplanted area, but that was not the case. I had shed most of it due to the minoxidil. The native hair on my hairline has now grown back. I cannot see many multiple FU in my hairline, which i was expecting to see as a result of the tranplant. I can attach a magnified USB image of my hairline if needed.


    Quote Originally Posted by drcole View Post
    One tech is limited staff for a procedure over 1000 grafts.
    All the follow up consultations i've had with other surgeons/reps agree with this point.

    Quote Originally Posted by drcole View Post
    Your post is long and it needs time. I'm currently in route to Cyprus to work with the team there for a week. I have a number of comments to add, which i will shortly.
    I really appreciate your help, as i know you're extremely busy. Have a safe flight.
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  5. #25
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    It is common for patients to see hair shedding following the initial application of minoxidil. Personally, I think it is an indication that you are responding to the minoxidil. It really frightens some patients who then stop using it. Minoxidil works by stimulating anagen. When you force hair into anagen, the resting telogen hairs are pushed out of the way and they are replaced by anagen hairs. It may take 8 to 12 months for these new anagen hairs to reach a stylable length.

    When grafts are transplanted, they will elongate for about 11 days and then stop elongating. Then the hair is usually shed. Some patients are very scarred to wash their scalps aggressively following a procedure. When they are frightened, they often have far more non-growing hairs that are not shed. You really want to get rid of these because they can cause pimple and cyst formation. I honestly worry that when you keep these non-growing transplanted hairs too long that you might develop an allergic reaction to them and it might affect your graft growth going forward.

    Yes, I'm saying that the hairs you have circled are the original grafts. The hair in the grafts did not fall out. They do need to be removed if there is still some residual stubble from your transplant.

    Shock loss will begin after 2 or 3 weeks and only last for about a month. Shedding for 9 months means you were loosing more hair due to androgenic alopecia or some other sort of scalp medical condition. Shedding for 9 months is not a result of your transplant. I agree with your dermatologist that it was male pattern baldness.

    The greatest fear for any physician is to do a hair transplant on a patient and then have the patient enter into an aggressive phase of male pattern baldness. You see MPB happens in phases. It stabilizes, rests for many years sometimes, and then aggressively resumes. It’s like falling off a series of cliffs followed by a long plateau that only leads to another cliff. The duration of plateaus is variable and sometimes for years. If you do a hair transplant on someone who is at the edge of the cliff and they fall off it a month later, they will have marked loss that may exceed the grafting procedure you did for them. It has rarely happened to me, but it has happened.

    I recall one patient who was going to have a transplant, but wound up getting shipped to Iraq instead. He came back to see me a year later. I could not believe how much hair he had lost. I was very thankful that I did not do a transplant on him because he went from a 3V to a 5 in one year. I think the transplant might have left him very discouraged because he went from losing 30% of his hair to loosing 50% of his hair in one year.

    The new hair you circled looks like a transplanted hair. It’s not a new growing hair. The other finer hairs around this one with a very fine point could be new graft growth. This is what new hairs that are transplanted look like initially. They continue to elongate about 0.4 mm per day.

    I think you did get graft growth looking at your follow up photo at 11 months. You indeed might have lost more than you had transplanted, which has left you thin. You are going to need some additional grafting to add density. I really did not see much native hair in the transplanted area on your recent post surgery photos so it’s hard to imagine that the hair on your hairline is pre-existing hair.

    Side by side images are the best way to evaluate growth. Also, doing a cross sectional trichometry can help evaluate growth. The best way is to see it in person because as you mention, grafted hairs look much coarser and darker than native hair that is undergoing MPB.

  6. #26
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    Hi Dr. Cole,

    Thanks again for your reply. I agree that i was probably on the edge of a massive shed due to MPB, which unfortunately happened right after the HT. I believe the HT triggered it, but it was probably due anyway.

    Currently, i'm very unhappy with the results, but i may still grow in the coming months. I was told that a density of 50 FU/cm^2 would be achieved at the front, which is way off. I'm still confident that my grafts regrew and fell out. My HT surgeon pulled out half a dozen transplanted hairs on my hairline at 9 months post op and was puzzled. I'm sure he would have known if these were original transplanted hairs that didn't shed after surgery. He said they were grafts that REGREW and have fallen out due to my intense shedding. If my growth is poor in another 6 months, i'll arrange a biopsy. I won't risk another surgery without ruling out if i have an underlying issue.

    Are you still on course to open a clinic in London this year with HDC, which is where i live? Finally, us guys in the UK won't have to travel across the world to find a reputable HT surgeon !!

    Also, will/do you provide 'patch test' sessions for CIT (in London or Atlanta) ? Say 150-200 grafts? I would love to have a small patch test done to see if i can have a successful FUE procedure or not. Maybe my physiology is poor for FUE, although i don't think that's the case. However, it would be great to rule this out with a patch test.

    Sorry last question, but do you have patients whose physiology doesn't support FUE ? Or is poor growth from FUE almost always caused by a surgical blunder ?

    Thanks again Dr. Cole !!

  7. #27
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    Quote Originally Posted by sausage View Post
    Is the possible:

    2500 FUE over 2 days then.....

    in 6-12 months time another 2500 FUE over 2 days ???


    In terms of graft numbers is this ok for FUE?
    As being stated in thread, Yes Cole can do this at a very high quality. It's also a very high price. 5000 is probably neighborhood of 40-50k, although i'm sure you might get a bulk discount. That said, you could do a mega strip and 800-1000 with Cole and get a great result for around 25-30k.

    I'm hoping the law of accelerating returns gives us 10-15 FUE docs with speed and skill of Cole, which should drive the price down considerably, as competition almost always does (8-10 a graft as of now to my knowledge)

    I've got one FUE on the near horizon, luckily since my last HT in 08' my hairloss has been minute at the worst.

  8. #28
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    Yes, still on track to open in London. Sorry for the delay. i returned from Cyprus and then went to Hot Springs, Arkansas to visit with Dr. Dow Stough and his fine staff.

    FUE can be pricey. I always encourage those who need a discount to let me know so i can see what all i can do. For example today i added 40% more at no charge. It's all about proper planning.

    All the best.

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