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I thought it would be nice to share a 2 month post surgical donor wound (still a bit light pink) with hair growing out of the wound from a trichophytic closure. By the 4th months, this wound will become virtually invisible.

For more information about the trichophytic closure technique, see Techniques to Minimize Donor Area Scarring.

Click the photos to enlarge.

Many of my younger readers of this blog are seeing changes in their hairlines and are worrying about becoming bald. The problem is made worse when there is balding in their family line. I have placed three diagrams taken from the Norwood Classification for hair loss. By conventional wisdom, the Class 1 pattern is proposed not to be balding, the Class 2 pattern suggests that this is the beginning of the balding pattern (it may actually be the beginning of the mature hairline, just not named as such), and the Class 3 pattern is thought of as early balding, possibly worthy of transplants in some men. The line between the Class 2 and 3 patterns are fuzzy, at best. The reality, however, is not quite as simple as I believe that Dr. O’Tar Norwood had documented. In most men (more so in Caucasians), the hairline of youth rises to a hairline of maturity. The mature hairline is about 1/2 to 3/4th inch higher in the middle than where the youthful hairline is and as one moves away from the midline to the corners of the hairline, the gap between the mature hairline location and the youthful hairline location is slightly over 1 inch, changing the overall shape of the hairline to its characteristic ‘V’ shape.

You can tell where your youthful hairline is/was by lifting your eyebrows up so that you can see your forehead wrinkle. I call this the furrowed brow, and the wrinkles you see reflect a muscle below the skin (the frontalis muscle which is present in everyone). The youthful (juvenile) hairline touches the top of the highest wrinkle and has a concave frontal shape to it. In the mature hairline (with its almost convex frontal shape that extends from the temple prominences), shows a gap where there are no wrinkles and no hair present. None of what I just wrote is male pattern balding, yet many of our young readers panic when they see the rise in this hairline and they look to the Norwood Chart to identify where they are in the progression of their hair loss. It is particularly bothersome to the young men when the change occurs slowly and asymetrically. It is even worse when the change produces ‘chewed’ look. This maturing process occurs between 17 and 29 years of age and it is not uncommon to find one side go up faster than the other side. Not all men get a mature hairline (for example, former US President Bill Clinton retained his juvenile hairline — see photo at right) and retention of the juvenile hairline is more common on non-Caucasians as seen in many people from Asia and the middle eastern region.

They say a picture is worth 1000 words, so look at the pictures and labels below for clarity of this. Women almost always retain their juvenile hairline through their entire lives, while 95% of Caucasian men develop a mature hairline.

Set 1 (below): Photo on the left is of a patient with the “mature” hairline drawn in. The photo in the middle is of that same patient with the “juvenile” hairline drawn in (the lowest line). Note the gap between the highest wrinkle and the proposed mature hairline. That ‘gap’ should probably not be transplanted. The photo on the right is of my hairline — the mature hairline. Click photos to enlarge.

Set 2 (below): Photos on the left (Korean) and middle (Hispanic) are of adult males with the juvenile hairline (non-transplanted), photo on the right is of an adult female (Cambodian) hairline (non-transplanted). Mr. Clinton’s hairline takes on the shape of the female hairline shown here. Female Hairline = Juvenile Male Hairline. Click photos to enlarge.

Weekend homework assignment: Check out the hairlines of your sibling, parents, spouse, neighbor, and meter maid. It’s worth looking at a variety of hairlines so that you can see what I’ve discussed above and determine the difference between a juvenile hairline and a mature hairline.

This 27 year old man came to see me with this interesting hair loss pattern worthy of sharing with the BaldingBlog readers. Note that the first 3/4 inch of the frontal hairline is normal, but the thinning picks up just behind it and goes all the way back. If he let his hair grow longer, he might have been able to cover it with his hair combed back. Sooner or later he would lose more of it. Of particular interest, that frontal hairline may last his lifetime, while he could be completely bald behind that hairline if he does not treat it with finasteride. In taking the drug, he may actually return the thinning hair behind the frontal hairline, and if successful, no surgery would be required to accomplish this goal.

Once you have a follicular unit transplant (FUT), if the procedure was done with care, there is no question that the results can’t be detected in any casual encounter, or even on close inspection in most circumstances. Yet with that said, there is still a difference between patient results that go beyond the characteristics of (1) hair shaft thickness, (2) hair character, and (3) hair color.

Let’s take a look at a patient who had two hair transplant procedures. The patient is Dr. Jon Perlman, the well-known Beverly Hills plastic surgeon that has been featured on ABC’s television show, Extreme Makeover. After his first session, he had good results that nicely framed his face when his hair was groomed. But on close examination, his hair was somewhat see-through. Dr. Perlman has very fine hair, so the bulk of each hair shaft was lower than average. By undergoing a second procedure, the bulk was doubled and the results shown in the pictures below say a great deal about the change he experienced. He was more-than-satisfied after the first procedure and thrilled after the second one. A good transplant became a great transplant.

Sometimes patients will tell me something like, “I don’t want it too thick and I am afraid if I put too much hair there, it will look unnaturally thick.” In all of the years of doing this surgery, I have never, ever had a patient who told me that I had made the hair too thick in a single session. We have seen many of our patients (initially satisfied, but wanting more hair) receive another transplant and become transformed back in time to their youthful look. By performing NHI’s pioneering dense packing procedure, we can increase the density of hair in a single procedure, often reducing the number of procedures needed to obtain results like the one shown here, but when the hair is super fine (like the example below) then two sessions may be needed. For many people, hair is like money — the more you have, the better it is.

Click the photos to enlarge.

Before and After 2 procedures (2890 grafts total):

For more photos, click “read more” –

Dr. Rassman:
I noticed that my hair transplants are not blonde like much of my head hair. You transplanted my head 1 year ago (1500 grafts) in the front and the hair has grown darker where the transplants are. Much of the other hair is blonde, that is, except my beard which has red hair. Now I have a three toned hair color. I can come to your office if that will help!

(This patient subsequently visited my Los Angeles office; see photos below).

The transplanted hair came out of the back and sides where you hair is brown (today). This is the dense area that does not get sunlight and you clearly need sunlight to have the sun bleach out the brown color and turn it blonde. I call this phenomenon the ‘Summer Blonde’. My three sons are all Summer Blondes who have brown hair in the winter. When we met in the office today, you did tell me that the brown color was evident this fall, after the surfing season was over for you and you had to spend more time indoors. You then deprived your hair of the sun that it needs to turn to blonde. That is why the problem was not evident this summer when you ‘lived’ on the beach and in the surf.

The red beard is kind-of funny looking coloring, as long as you keep your goatee. If you like the three tones, then keep at what you are doing. The fact that you grew the goatee means to me that you like the red color. If you want that blonde color to show up all year around, you must either spend more time in the sun, or hit the bleaching bottle.

The photo on the left shows the brown roots of the transplanted hair in the center of his hairline; the photo on the right shows the blonde non-transplanted hair from the corner of his frontal hairline. In the summer, the area that is now light brown will become blonde like the hair on the sides. Please click the photos to enlarge.

Dr. Rassman, I saw one of your comments on Propecia on the balding blog. You are welcome to use my pictures to show your bloggers what the drug can do. As you remember, I am 39 years old and I got these results in just 8 months on the drug. Contrary to what some say about the sex drive, the drug did nothing to suppress it. Sometimes I wish it did. I saw a couple of other doctors before I started Propecia and one had a salesman who tried to sell me 1500 grafts. He said Propecia would not work. Glad I did not have the surgery and listened to you guys.

Thanks for coming forward on this very important issue. The young man can get an outstanding response from Propecia, especially the ones under 30. You are an exception to the rule and a lucky one at that. Although sometimes I feel like a Merck salesman, because I suggest this medication for many of my patients, it is because of people like you that I have become an enthusiast for Propecia. Although the corners did not return, the fullness you wanted was achieved and you are happy. That is what this is all about. You were wise to seek out other opinions and I applaud you for such persistence. There is no “A” given in school for such decisions, and in the real world, the hairy guy you look at in the mirror every day is better than that “A” on a report card.

The below photo on the left is before Propecia use (scanned from a Polaroid, so please forgive the quality); below photo on the right was taken about 21 months after continued Propecia use. He’s had no hair transplant surgery. Click the photos below to enlarge.

Update: For those that are crying foul about the line drawn meaning it was a transplant, please see comment #10 below.