Explanatory Photos

The following explanatory pictures are referenced in the The Procedure and Common Question and Answer pages.

Figure 1

Hamilton/Norwood classification of MPB

Figure 2

Ludwig classification of female pattern hair loss

Figure 3a

Close up photo of a strip excised from the hair-bearing scalp: note that scalp hairs most often grow in naturally occurring groups of 2-4 hairs we refer to as Follicular Units (FU). A minority of scalp hairs grow as single hair follicles.

Figure 3b

(Left photo) FU obtained with Follicular Unit Extraction. Note minimal protective fatty tissue surrounding the hair bulbs (“roots”). (Right photo) FU microscopically prepared from a donor strip. Note fatty tissue has intentionally been left around the hair bulbs, leading to currently better hair survival rates than with FUE grafts.

Figure 3c

An excerpt from an Artas robot promotional brochure. The author does not agree with the statement “appear similar to standard strip surgery grafts”. (See Figure 3b)

Fig 4a.

The more frontal hairline outline is the one suggested by some owners of Internet sites the patient had reviewed and one seen personally. The higher line was the one I recommended. (b) An intraoperative photo. The patient had taken my advice. His before and after photos are shown in Figure 20.

Fig 4b.

A patient before treatment (top photo) and nine months after the second of two transplants; the first to the frontal area and the second to the mid-scalp area with a total of 3864 FU and a relatively low density of approximately 20 to 25 FU/cm².

Fig 4c.

Explanatory Photos

A frontal view of the same patient taken at the same time as Fig. 4b. Note that the hair appears thicker in this view than in Fig. 4b. Always look for comparable views in "before" and "after" photos.

Figure 5

(a) A patient who underwent the old round graft hair transplanting from 1980 to 1995 and who initially had very good cosmetic results in both recipient and donor areas. (b) By 2005 however, some scars in the donor area fringe, adjacent to the balding crown area, had become noticeable, especially when his hair was wet. This was due to the fringe hair gradually becoming less dense and finer textured, thereby decreasing camouflage of the scars by their surrounding hair. (c) Twenty-nine years after starting transplanting, the fringe hair had become sparse enough and fine enough that the problem also involved the temple areas. The hair has been parted in this photo to clarify the extent of scarring. The patient had unsuccessfully tried to improve the appearance in this area with inexpert tattooing. (d) This photo was taken at the same time as (c). Very little hair was left to camouflage the problem scars that were clearly noticeable with the hair dry or wet. In retrospect, too much donor hair had been harvested from the upper borders of the originally assessed fringe hair because the severity of hair loss had not been foreseen. At this point he was only 53 years old and could reasonably anticipate many years of a very serious and worsening cosmetic problem.

Another patient whose donor area looked excellent for many years but as the hairs within the highest portion of the fringe hair gradually became sparser and finer textured the donor scars became easily visible beginning approximately 20 years after his last hair transplant (his recipient area luckily had continued to look quite good at this point!). It is best to stay within the SDA (Figure 6) when harvesting grafts – whether by strip method or FUE.

Figure 6

Unger's "Safest Donor Area (SDA)" for 80% of patients under the age of 80 years, as determined from studies of 328 men aged 65 years or older.

Figure 7

(a) Immediately after strip wound closure. The sutures will be easily camouflaged completely, immediately after the surgery, by combing the hair above the suture line down over it. (b) The same site 8 days after surgery when the sutures were removed. (c) The same site 6 months after surgery. Approximately 80% of our patients heal with a scar similar to this one.

Figure 8

(a) A donor area strip scar similar to those produced in 10% to 15% of patients. It was approximately 0.1mm to 0.2mm wide. The hair has been lifted to expose it. (b) A photo taken at the same time as that shown in Fig.8a with the hair combed as normally worn. There is no noticeable scarring despite a very short hairstyle.

Figure 9

Some hair restoration surgeons believe that while strip harvests can produce a very fine scar line following the first donor area excision, each subsequent excision that includes the preceding scar will lead to an increasing scar width. As the above photos before a 5th small session demonstrate, this is not necessarily the case. As long as each subsequent strip width does not create a tighter closing tension in the wound (which usually requires a narrower strip and therefore fewer grafts), subsequent scars typically remain quite narrow.

Fig 10

(a) 1000 FU were extracted by another physician via FUE, 3 years prior to this photo, leaving the donor area with an unnatural moth-eaten appearance with the hair worn at the length shown here. The patient had undergone FUE in the hopes of being able to shave his donor area without scar noticeability. (b & c) Punctate oval/round FUE scars are obvious with the donor area buzzed very short for an additional FUE procedure just above the original donor sites. This time the FU were harvested by me, with a smaller punch and wider site spacing than the prior surgeon had employed. The grafts obtained in the second FUE session were placed into the worst scars from the first session. FUE is not scarless.

This is a copy of a page from a promotional brochure for the Artas robot. While there is minimal noticeability of the scars 7 days post-procedure, the photo also reveals how high the grafts have been taken and very close to the border of a balding area that is destined to get larger in most patients as they age (the younger the patient, the more likely that will occur). Hairs transplanted from areas that eventually lose their hair will result in loss of those hairs in the recipient area in which they were placed, as well as donor scar noticeability. This type of harvesting unfortunately is too common when FUE is carried out, whether by hand punch, motorized punch or robotic punch.

Some FUE operators have referred to FUE harvesting as “minimal excision surgery”! Compare the above intra-operative photos showing a strip wound immediately after surgery in the left upper corner and FUE in the other photos; then decide for yourself which method is more minimal. Note also in the photos on the right hand side, how close an obviously balding area’s border is to areas that were harvested. (The photos on the right are again taken from an Artas Robot promotional brochure.)

Figure 11

(a to d) "Before" (left) and "after" (right) photos of a Type VI MPB patient transplanted at 30 FU/cm2 in frontal and midscalp areas in 2 sessions totaling 2808 FU.

Figure 12

(a) Before HT-1 (2534 FU at 30 FU/cm2) in 2009. (b) 3 years after HT-1. (c) Close-up 2012 - 3 years after HT-1. (d) Different view, before HT-1. (e) Different view before HT-1. (f) Three years after HT-1; Before HT-2 (2012) further back on head. Note in Figure 12a: the recipient area included an area that still had persisting hair that I thought would eventually be lost (an "evolving" area). By including that area, one attempts to avoid the need to have to do another session at a later date in that "evolving area" (in order to avoid being left with a bald "alley" lateral to the previously transplanted area - or put differently, avoiding a never ending chase after an enlarging bald area. I have strongly encouraged that approach to hair transplanting; especially in younger patients.

Figure 13

(a) Patient before transplanting. (b) Patient after one FUT session to the frontal area (1947 FU at 30 FU/cm2). This patient was an exceptional candidate because of particularly good hair characteristics—most patients do not get such thick-looking results. Nevertheless, he demonstrates excellent results using what likely is often thought of on the Internet as being too low an FU density.

Figure 14

(a) Female patient before HT-1 to frontal recessions. (b) 8 months after HT-1 (1573 FU at 30 FU/cm2).

Figure 15

(a) Female patient before HT-1 to very severe frontal recessions. (b & c) 13 months after HT-1 (1981 FU at 30 FU/cm2).

Figure 16

(a) Before HT-1. (b) one year after transplant, demonstrating the substantial cosmetic effect of adding transplanted hair to existing hair (2037 FU at 30/cm2). This patient’s result will eventually look similar to that shown in Figure 11 or 12 when all or most of the original hair is lost, but offers the advantage of thicker hair until then.

Figure 17

(a) Male patient before transplanting – hair dry. (b) Male patient before transplanting – hair wet to clarify extensiveness of hair loss. (c) 10 months after HT1 (2367 FU at 30 FU/cm2).

Figure 18a

(a) Before HT-1; wet with antiseptic solution just before surgery, which clarifies the extensiveness of his hair loss, and dry in (b). (c & d) 7 months after HT-1 (2282 FU at 30 FU/cm2). Full growth of transplanted hair typically takes 12 to 18 months from the time of surgery, so these are not full results.

Figure 18b

(a,b and c) "Before" and (d,e and f) "after" at 30 FU/cm2. The patient was an actor and because he did not wait until the treated areas were very sparse or bald, nobody noticed the substantial, but gradual increase in his hair density in the treated areas.

Figure 19

(a) A 52-year-old female patient before hair transplanting to a frontal midline area. (b) 7 years after a hair transplant consisting of 843 FU and 113 double FU (a total of 1069 FU). The patient was being seen for possible transplanting further back from the first recipient area. (c) A photo taken at the same time as (b), with the hair combed back for critical evaluation. A little hair placed properly and with good hair survival can go a long way cosmetically—especially because hair is nearly always being added to some persisting original hair in women. The fear of relatively soon loss of transplanted hair is also misplaced if the donor area has been appropriately chosen.

Figure 20

(a and c) a 29-year-old patient before and (b and d) 17 months after his first frontal FUT (2611 FU) at 20-30 FU/cm2. This is the same patient shown in Figure 4.

Figure 21

(a) Before transplanting. The objective was more hair in the treated area but subtle enough to increase the likelihood of the change possibly not being noticed by others. (b) One year after one session (1677 FU at 15-20 FU/cm2). The patient was also able to treat nearly twice the area that he would have if we had instead used 30 FU/cm2 (nearly twice the graft density).

Figure 22

A schematic drawing demonstrating the various zones of the head, the frontal area (F) running from the hairline zone to a line drawn more or less perpendicularly from the ears to the mid-scalp area (M) from that point back to where the head changes its orientation from more or less parallel to the ground to more or less vertical; the crown or “vertex” area (V) behind that area. Areas labeled FE, ME, and VE are zones that still contain hair but can be anticipated to lose that hair over the patient’s lifetime. These areas are in general best treated at the same time as the more obvious areas are transplanted, in order to avoid a constant chasing of an enlarging bald area.

Figure 23

(a) A young man before transplanting. Note that the supra-temporal areas have been outlined and will be treated at the same time as the more obvious areas of thinning medial to it. (b) Nine months after treatment with 2137 FU at an average density of 30 FU/cm².

Figure 24

(a) A young man with severe (for his age) hair loss in the frontal area before transplanting. (b) One year after a single session to the frontal area consisting of 2246 FU transplanted at an average density of approximately 30 FU/cm². The hair has been parted in the same area as it was in the before photo for critical evaluation. (c) The same patient shown in Fig. 24(a) before his first session but with the hair wet with an antiseptic solution prior to the surgery. The photo demonstrates considerable hair loss in the mid-scalp area as well as in the frontal area. The mid-scalp was treated with 1998 FU at an average density of approximately 30 FU/cm² six months after the frontal area had been transplanted. (d) 19 months after the second session of FUT. This individual had very dense hair in his donor area. Primarily because of his age, the average number of hairs/FU was greater than the typical 2.3/FU, hence the denser than average results. As he gets older and the number of hairs/FU in the original donor tissue decreases, the recipient area hair density will also decrease. Younger patients should proceed with transplanting with more caution because of the greater uncertainty of the ultimate extent of hair loss in both recipient and original donor tissues. However, emotional factors must also be taken into account when a physician decides how long one should wait before starting transplanting in a young man.

Figure 25

(a) A patient with apparently very limited hair loss in the fronto-temporal corners of his hairline. (b) The same patient as shown in Fig. 25(a) nine months after his first transplant. (c) The same patient as shown in Fig. 25(a), and at the same time, which demonstrates that he had diffuse thinning through the entire frontal area and that the hair loss was not limited to only the hairline zone, as might at first have seemed to be the case. (d) The same patient as shown in Fig.25(a) nine months after a session of 2211 FU. One does not have to wait until an area has experienced the loss of the majority of its hair before the area can actually be treated. However, the hair density shown above will not persist for the patient’s lifetime because it is a combination of the transplanted hair and the original hair in the recipient area at the time the surgery was carried out. As the patient loses his original hair, the hair density in the transplanted area will become more like that shown in the "after” photos in Fig 11.

Figure 26

Adding hair to hair: Left Side: Various views before 1st hair transplant. Right side: 12 months after 1st hair transplant at 30 FU/cm2.

Figure 27

Adding hair to hair: Left side: Various views before 1st hair transplant. Right side: 12 months after 1st hair transplant at 30 FU/cm2.

Figure 28

Adding hair to hair in white haired patient: Left side photos: before 1st hair transplant. Right side photos: 12 months after first hair transplant at 30 FU/cm2

Figure 29

Low graft density transplanting: Left side photos: before transplanting. Right side photos: after one frontal session (2237 FU at 20 – 30/FU/cm2).

Figure 30

Before and after hair transplanting at 30 FU/cm2 in a female with moderately severe frontal and recession hair loss.

Figure 31

A lady who underwent a facelift during which the roots of her temple hairs were accidently destroyed leaving only a mixture of skin and scar tissue. a) Before transplanting. b) Intraoperative hair transplanting graft sites. c) 6 months after the transplant at 30 FU/cm2 (a very unusually rapid growth of hair!)

Before, immediately after and 6 months after linear scar repair. The hair has been clipped very short for critical evaluation, before what is to be a second scar revision.

Figure 32

(a) Scars after a car accident, before transplanting. (b) After transplanting at 20 FU/cm2.

(c) Scar following a facelift. (d) After hair transplanting.

Fig 33a.

A patient who had been in a car accident and had severe scarring alopecia in the temple area.

Fig 33b.

The same patient nine months after a single session of grafting into the temple area. Hair transplanting into scar-bearing tissue can produce substantial improvements. See also Fig. 21.

Figure 34

a) Before transplanting in the midscalp and a half hemispheric area extending into the crown area (that I refer to as a “bump”). b) After transplanting those areas (at 30 FU/cm2) in which much of the hair easily fell backwards or was directed backwards, and therefore produced a substantial cosmetic improvement to the crown that was not transplanted.

Figure 35

(a) This 56-year old gentleman had undergone hair transplanting 15 years prior to seeing me in 2002. He had fine-textured, reddish-to-blonde colored hair. The transplanted area was moderately pluggy-looking and would have appeared much worse had his hair not been so fine and relatively light-colored. The density in the transplanted area was also relatively low. In addition to the preceding, his MPB was obviously extending further laterally and he had lost all of the hair behind the transplanted zone. He was basically left with a pluggy-looking, unsatisfactory "isolated frontal forelock", as is shown in the photo. I designed lateral "humps" for completion of the frontal-third of the area of MPB and a new hairline zone in front of the old one. The black crayon line delineates these objectives (b) The same patient shown nine months after first repair session that consisted of 1270 follicular units, 105 double follicular units, and twenty-one 2 mm2 grafts. While I rarely used grafts other than FU, after 2005, in this individual the preceding mixture of grafts best solved his problem in a single session.

Figure 36

a and b) This young man was likely to become a Type VII MPB eventually but wanted at least some hair in his midscalp to “break-up” the large bald expanse at the top of his head that would evolve. A midscalp + “bump” hair transplant was designed for him into which I transplanted 2260 FU at 20 – 30 FU/cm2 in a single session. (35c and d) Show the results 21 months later while (e and f) show the results in his donor area.

Figure 37

(a) Old donor scars before repair. (b) After scar revision.

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