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I recently had a FUE procedure-just one week ago. I am experiencing heightened sensitivity and slight pain located above the donor strip where the occipital area is and up to near to the top my head. This is particularly noticeable when I rest my head or touch it slightly. Is this normal after one week of surgery or is it a possible symptom of occipital nerve damage? If this is the case, how can this be diagnosed and treated? Or are these symptoms normal or all much to early to tell and I should wait it out? I understand numbness can take months to heal but it’s the sensitivity and pain that concerns me. Thank you.

There are two major nerves that feed sensation to the back of the head (greater and lesser occipital nerves). There is also a large major nerve above the temples. These nerves branch are like a tree and any punch that is placed in the path of a small nerve could transect (cut) it. It could also bruise the nerve. If you look at the image here, you will see that these small nerves are all over the scalp so it is inevitable that one or more can be damaged. As long as it is not the major nerves, bruising or transection should not be a problem, as the other nerves that cross over the same skin area will substitute for any damaged ones. But there is always some damage and few complaints that last more than a month or two. If a major nerve is cut, then there will be anesthesia (numbness) over the distribution of that nerve. Be patient and wait this out.

I have followed this site for a few years now and I am so impressed. First off, your integrity seems to be apparent in how you run this site. There is none of the cheap salsmanship common to some of the hair replacement surgeons with whom I have spoken. You provide so much disclosure that it is obvious that you truly want educated patients. It seems to me that the medical hair replacement industry was crying for someone like you.

With that, I am happy to share with you my story and ask you my questions. I am a 45 yr old male who began losing his hair at 19. I was told early on by a few surgeons that I was an excellent candidate for hair transplantation because my donor hair was so good (it was rated a 9 out of a possible 10). I believe that I am a Norwood 6 but I know that I have long lost all the hair that I was to lose. I have had 13 hair transplant procedures with Dr. X [editor's note: name removed] and 2 scalp reductions with another doctor. The procedures were performed between 1989 and 2001. In total, I had 1679 “large” grafts, 379 “medium” grafts, and 321 “single” grafts. My hair provides decent coverage for someone who by this time would have been left with only what I call “clown fringe” (I am sure the visual will resonate with you) but I do use a concealer (Fullmore) to hide some small patches of my crown which show, and some of the scarring. My goal is to surgically get more coverage - or at least more uniformity in my existing coverage - so that I can stop using the concealer. I would like a good evaluation on what surgical options may be open to me, as I have already had so much work already performed and donor hair is not so plentiful. These are my questions:

1. Do you ever do any work in NYC/LI?
2. If the answer to #1 is no, can you recommend any good and caring surgeons in the NY/LI area?
3. It seems like FUE2 would be a natural choice for someone who has had so much work performed already and where so much donor hair might not be harvestable in one strip. Is this a correct assumption?
4. Is it possible to do many smaller strips so as to increase yield for someone who has had so much work performed already? Does it matter from where the strips are taken? I think that I may have some donor hair on the high sides.
5. I have not heard of too many people having as much work as I have had. Does the work I describe sound like it is so much? Are you aware of many people who have had more work?
6. I have been using a concealer for 15 years - just during the week and just during the day. Are there any health affects of such prolonged use?
7. How does the cost of the FUE2 compare with the normal strip method?

Any of these questions which you can answer would be appreciated.

Keep up the site.

1. At the moment, I only have offices in California and do not plan on going to New York.
2. Dr. Robert Bernstein is a caring and competent doctor with a Manhattan location.
3. Follicular unit extraction (FUE) is less productive when donor densities are down from multiple surgeries and when there is lots of scarring.
4. With regard to taking high strips, it is generally not a good idea as high strip scars tend to show and they may not be in the permanent zone, so the hair may not last your lifetime.
5. I have seen many patients that have had more than a dozen surgeries plus scalp reductions. One patient I met had 27 procedures, of which I believe most were sham surgeries. Without seeing you, I can not comment on what you did and did not get.
6. Your approach with the use of concealers is well defined in my new book, Hair Loss and Replacement For Dummies, for the readers who do not know much about them.
7. FUE costs are high compared to the strip method, but more important, they may not be very productive. FUE costs roughly 2x the amount of strip procedures, per graft.

The problem with your situation is donor scarring and your donor area must be a mess. It’s difficult to make any real advisable points without first seeing what I’m dealing with, but you might be able to excise the highly scarred donor area (probably using a balloon expander) if that is bothersome to you. Good luck.

Hi Doctor,

If one were to get a FUE or FUE2, and in the future decide to shave it all, will there be left over dotted scars in the back from the donoring?

What kind of scarring can one expect from FUE or FUE2?

Thanks

Yes, any incision made to the scalp will result in a scar of some kind. It is not an entirely scarless procedure and any doctor that tells you there are no scars is feeding you a load of bull. Scarring for FUE will be a small pinhole… like a pencil mark. If your density is low, scarring can be a problem with the follicular unit extraction (FUE) procedure, because the amount of hair to cover the donor excisions will be less. If the density is high, it hides well. Shaving your head like your facial hair, will leave ‘dots’ of white circles measuring between 0.7 - 1mm wide, or if your surgeon used a wider instrument, it will be even wider.

I just saw a patient who had 3300 grafts with a FUE technique by another doctor and the back of the head looked like he was shot with 3300 holes from a pellet gun; few of the grafts grew after a year. Your skin and other factors will determine how visible these scars are with your head completely shaved to skin level — but why would you bother getting a transplant if you’re just going to shave your head anyway?

Story time! Although I can’t provide photos (by patient request), I’ll do my best to paint the picture…

A man in his early 20’s flew to Los Angeles from Alaska to see me last month. He already had two hair transplant procedures using the follicular unit extraction (FUE) technique — one surgery of 1,000 grafts, and another of 3,000 grafts — by two different doctors (that I won’t name) who each claim expertise in this process. The 1,000 FUE case by the patient’s estimate was about 50% successful, while the 3,000 FUE case had, according to the patient, no growth after a year. The donor area was heavily scarred from the FUE extractions and were easily seen by lifting up the hair. A strip procedure would have produced less scarring than this patient showed now. To compound the problem, those hairs that did grow from the first surgery were placed in a radial direction (like the spokes of a bicycle wheel) and the hair pointed to the sides, not the normal frontal position. So not only was he dealing with a huge failure of growth, but now he had to deal with poor placement for those grafts that did grow! Imagine a person with hair growing out of his head like the spokes of a bike?

This patient most certainly had a low donor density to start. I recommended a strip surgery to harvest the most grafts he can get and with the reduced donor density, I recommended about 1,300 grafts, which is possibly the most I can harvest. Fortunately, his hair loss was only in the first 1 1/2 inches of the hairline and by taking Propecia he might hold the rest of his hair in place, although there is miniaturization behind the frontal 2 inches, suggesting that he might bald further over time. He wanted to look normal, but I could only suggest that I would try to make him look better.

FUE is not a panacea for scars. As I have said here before, the follicular holocaust that is seen in FUE is substantial, even in the hands of those who claim success. This is a buyer beware market. You should always ask to see a number of patients who had the procedure and look carefully at the donor area. Another FUE procedure on this patient will be disastrous (even in my hands), as scarring is clearly a problem.

Dr. Rassman

What is the largest number of grafts you recommend to be transplanted in one session using FUE? What is the maximum number you guys at NHI have done in one shot using this technique?

Thank you and Happy Holidays to you and your staff.

The largest case we did was 2,800 grafts. The large follicular unit extraction (FUE) cases require high densities of the hair in the donor area. Those individuals who have lower densities generally have from 20-40% less hairs per square inch, so one could expect that yields may be as low as 700 - 1,000 grafts for most — and that is generally people from Asia (like Indians), many from the middle east, and those with African hair. In a Caucasian with an average density, we have done 1300-1500 FUE grafts.

I think that many of you have seen comments made by me — comments of disbelief about the number of FUE grafts claimed to be performed by some dishonest doctors. I’d like to see some more honesty in the industry, but the almighty dollar is more important to some.

Hey Dr. Rassman, I have a question regarding a recent curiosity about FUE post op care. Would it damage the grafts if i buzzed my head down to a 2 in about a month from now? I had a 3500 FUE procedure for zones 1 and 2 in Canada about a month ago. I just want to be sure and have been trying to contact my doctor but he is currently unavailable. If you could answer this question that would be great!

Shaving the head or clipping it after FUE procedure is OK after a month.

Considering that you must have paid a pretty penny for 3,500 FUE grafts, I am distressed that your doctor can not be reached by you. I would like it if you take good photographs of your head now and then more photos again in 8 months. I have been seeing a number of patients with FUE grafts in the 3000+ range that have had very poor results in terms of growth. So don’t forget to keep me in the loop — if for any reason you don’t get good growth, I might be able to help you.

Do you have an opinion of Dr. James Harris and the Harris Safe System located in Colorado? Thank you.

His method of doing follicular unit extraction (FUE), which he calls the Surgically Advanced Follicular Extraction / SAFE, works well in his hands. Dr Harris is a creative person and a competent hair surgeon.

Hi

I have recently undergone an FUE procedure. I had about 2500 hairs placed in total. One week after the procedure, The grafts have taken really well and the scabs have fallen off. All swelling on my forehead has subsided. There is only slight swelling on the vertex. I still have numbness in the recipient area on the top of my scalp, behind the hairline.

When I run my hand over the new implanted hairs, I feel slight twitching on the skin on the scalp. I am concerned about nerve damage in the recipient area. Is it possible that a nerve was pinched, poked or disturbed in the recipient area ? What is the corrective action to take if this was the case ?

regards

Whenever there is a cut on the skin it may cause numbness or tingling or pain. This should subside after several weeks (sometimes months). This should have been thoroughly explained to you before the surgery in your Pre-Operative Consent form and by your doctor. The follicular unit extraction (FUE) technique still involves a cut on your skin. Cut nerves in the donor area is more of a problem, because there are major nerve trunks there, but your question was about the recipient area.

Hello, and thank you for this wonderful blog!

Now, down to the point. I’m an 18 year old experiencing slight SLIGHT recession. I went to my Dermatologist and was put on Propecia and Regaine to control and halt hairloss. I understand that with time, these medications will eventually stop working. Now, the question is, in your professional opinion, do you think that I will be one of those lucky ones who can benefit from future hairloss treatments such as Hair cloning, or will FUE still be my future hairloss friend? I have no problem with FUE, as I live so close to your office to have the procedures done. My only quarrel with it is the success rate and donor patch areas. Can you see any advancements in 5-10 years, such as Hair Cloning and Gene Therapy?

It’s not that the medications will stop working — it’s that your body tries to fight the meds. So usually around 5+ years of taking finasteride, some people will report that they’re seeing a little more hair loss than they’d been used to, but its not that case for everyone. I’ve got patients that have been taking finasteride for a decade and their hair still looks great.

As for FUE, with our latest FUE advancement (FUE2), we’ve eliminated the problems that most doctors will experience with the technique.. which is what lead to poor success rates. Check out www.newhair.com/fue2 for more on that.

Hair cloning is still in its infancy. There are some people that were saying 5 years ago that we’d be seeing cloning available by now, and that is obviously not the case. I couldn’t really speculate on the availability of cloning a decade from now. I hope it does work, but hoping for things and seeing the reality are two very different things. Personally, I think it will take more than 10 years because of FDA issues in releasing any advancement that may come up.

I just did a small fue procedure into my scar, I asked to be sedated but during the procedure I scratched away some of my grafts unconsciously. The operating team choose to put some of the grafts back in the scar, can you please tell me something about the grafts survival chances?

For starters, I do not know what, where, and how your surgery was performed. Generally, an FUE procedure may have lower yield and is HIGHLY variable with different medical groups and doctors; the procedure is almost never the same from one doctor to another. Moreover, hair transplantation to a scar may not have a high growth yield when compared to hair transplanted to normal skin.

Graft survival depends on how long it was out of your body with the real issue of graft drying. Grafts that are left in the open hair for 20 seconds will generally die and that is why we are compulsive in keeping the grafts moist as we move them. As you can start to see there are numerous variables at work here and it is not a question I can answer, but most of the time if the grafts come out, they dry and die. Your surgeon is the best person to address your concern (as it always should be).