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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).

I had a hair transplant 15 months ago using the strip method procedure. I only had the temple areas done for my receding hairline. I am happy with the procedure, however i would of liked slightly more density. I told this to my surgeon who said he could preform another transplant but i was confused to why he couldn’t of transplanted such two small areas in one session. My worry is that my scar although really well concealed and unnoticeable it is very long. Im worried i dont have enough donor hair now incase i developed into a norwood 7 (completely bald). I know unless you seen me face to face and analyzed my head you couldn’t tell however here is my question. If my transplant surgeon has used alot of donor supply another strip procedure would obviously not be a good idea.

Here is my thinking and i might be wrong so please explain if i am. If i have already had a strip procedure and i wanted another transplant i think FUE would be a better second procedure as you have ability to choose hairs from different areas from the donor area thus being able to use more hairs than you could from a strip procedure. The reason for this is that a strip procedure can only can only be extracted in one long strip which is wasting useable hairs, however with FUE i feel that if someone has had a strip procedure which has used a large amount of surface area obviously another strip procedure would be difficult as theres not enough space for another slit and but with FUE you could extract hairs from all over the donor area. Am i thinking correctly. The doctor told me he transplanted 1464 hairs. is that too much for a receding hair which goes back 2 inches, which means he mustn’t of transplanted that many? Please reply. Thank you NHI team.

I really don’t have a clue as to the size of your recipient area for those 1464 hairs. Assuming that it was 1464 hairs (not grafts), that means that the strip taken should not have been very large (in surface area, that is). The normal person has 1250 hairs (or 625 two-hair grafts) per square inch. At a transplant, you can calculate just what you received by figuring out the square area of the recipient area. Let’s say, for example, that you had 4 square inches of hair transplants in an area that was originally bald. That means that if you had normal hair without balding, the area we are talking about would have had 5000 hairs (or 2500 grafts) in it. If your surgeon put in 183 grafts per square inch, that reflects about 29% of the original density into that recipient area for an average Caucasian density. That is a reasonable number of grafts from a density point of view, but fullness reflects many other factors, including thickness of the hair shafts (coarser produces much more bulk than fine hair), color contrast between hair and skin color (the lower the contrast the better), the degree of wave or natural curl (straight hair is not as good as wavy hair), and the hair styling you use (short requires more density, but long does not unless the hair is fine).

The average donor supply for a typical male is about 20,000 hairs (or 10,000 grafts) and this is dependent upon the laxity (looseness) of the scalp. Based upon the number of grafts you receive as discussed above, you should have a great deal of donor hair left. The scar should be managed by your doctor and removed with the next surgery and a trichophytic closure should be done to manage the scar. Be sure that your laxity is good and do the exercises before the next surgery (see video). There is much controversy to the issue of just how dense one has to make it. I generally shoot for 25% or the original density, but in the very front of the hairline I might go a bit higher (35-40%) if the hair is fine. Transplanting hair into a bald area has mechanical limits that may reflect growth, graft damage and other factors unique to the surgical team and your unique circumstances.

FUE as a unique procedure is not very efficient in most surgeon’s hands. I believe that you are incorrect about FUE vs strip surgery. The strip method may be more efficient in the long term. Once you had a strip, it may be better to remain with it. With regard to your scar, some people just form wider scars than others. The use of special closures like trichophytic will automatically force hair to grow through a wound, but it does not sound like that is the type of closure the doctor used on you.

Progressive balding is something that occurs in every person with genetic hair loss, but fortunately only about 7% of the male population will end up with the Norwood Class 7 pattern. All good surgeons should have a Master Plan for your worse case scenario for balding, so if you should be unfortunate in developing a Class 7 pattern (even with good drug therapy) you should still have a normal appearance. I have been doing this for 18 years, and I admit that did not have the same type of common sense in my first year in practice as I do have now. There is no real substitute for that type of experience, particularly in determining the rate and degree of balding progression.

Dr. Rassman,

You mentioned a couple of weeks ago that with Follicular Unit Extraction Enhanced (FUE2) that you should be able to successfully transplant body hair. When do you expect to experiment with this type of body hair procedure?

Thanks

When a patient comes in and requests it, I will test biopsy him with the FUE² first. No such patient has come forth yet.

Well I am black male and currently shave bald. I want to continue to shave bald. I am thinking of FUE to give me some hair in a thinning area. I have few questions: What does the donor area look like when you shave bald after FUE, does it show scarring? I mean razor bald like MJ. Is it worth doing?

I’m confused as to why you’d want a hair transplant only to shave your head bald. All wounds to the scalp will cause some scarring. With FUE, the scars are tiny dots, instead of a straight line scar like that of the strip transplant and they may have a white color to it that would show up after healing an FUE donor area. With dark skin, that might be a problem and one way to tell that is to have a test FUE session done of just 2-4 grafts and assess the healing at 3 months. These tiny scars allow you to keep your hair very short without noticeable scarring if the whitish scar does not appear, but that being said, completely shaving your head may make these scars visible. Again, a test is worth a try.