These people getting these miraculous jobs from Canada – it is a trick, right? They can’t honestly expect to be able to get away with what they’ve done over the course of their entire lives, can they?

A: I think you have better insights into hair loss than many hair transplant surgeons. ABI was the “rare” patient who seems to be a stable Class 3. I made that judgment due to: almost no miniaturization at the border of his Class 3 recession, no crown miniaturization, and his unusual family history. He had several older family members who stayed at Class 3 their whole lives.

Since we only have about 6,000 movable follicular units on average in our donor area, placing 3,000 at the hairline is obviously a joke and/or the doctor is playing “Russian Roulette” with the patient’s future.

As you point out, in most patients the hair loss will progress and the person will be out of luck. It is similar to the way flap patients were stuck without additional donor hair as their hair loss progressed. An additional problem was that the flaps were low on the forehead and very dense. The situation is analogous to placing 100 grafts per sq cm2 to create a low, broad hairline in a young person.

If you do the math you can see how ridiculous this tactic is. A person’s original density is only 90-100 follicular units cm2. Patient with Class 6 hair loss lose hair over an area of about 300 cm2.

This consists of:

• 50cm2 in the front (including a 15cm2 hairline)
• 150 cm2 for the mid-scalp
• 100 cm2 for the crown

Therefore, 6000 FUs transplanted to this area = 6000/300 = 20 FU per cm2. This is the number we often work with. We put up to 50cm2 at the very most in the mid-frontal forelock area and then proportionately less in other areas.

However, if you put 3,000 FUs at the hairline, in a density of 100/cm2, then you have covered only 30cm. This leaves only 3,000 FUs for the remaining 270cm2 of balding scalp for a density of a little over 11 FU/cm2.

Now, transplanting 11FU cm2 over the back part of the scalp is not a disaster EXCEPT if the front was transplanted at 100 per cm2. In this situation (as you have accurately pointed out) the patient will look very, very front heavy, with an aggressively placed, dense, broad, hairline and little hair to support it towards the back.

The gamble is that the patient’s baldness doesn’t progress, that finasteride or dutasteride can halt the process if it does progress, or that hair cloning methods will be available to save the day.

In my opinion, elective surgery should not be performed when its success depends upon these uncertainties – and particularly since a cosmetically disfiguring hair transplant can be so debilitating (and avoidable).

The reality is that doctors who claim to perform these procedures may not even be performing follicular unit transplantation. In FUT, the surgeon transplants naturally occurring intact FUs of 1-4 hairs. The extreme dense packing techniques preclude the use of 4- and sometimes even 3-hair grafts. What happens is that the larger FU are spit up. This doubles the graft counts (and the cost to the patient) without giving the patient any more hair. It also increases the risk of follicular damage and poor growth.

Patients in whom 10,000 follicular units are available to transplant are very rare and when they are shown on the internet, should be viewed as the exception rather than the rule.

A: Although I am hesitant to start with the crown when transplanting a younger person, if you have good coverage on the front and top of your scalp from the first two sessions then extending the hair transplant into your crown may be reasonable.

It depends upon your remaining donor supply and an assessment of how bald you will become. I would need to examine you.

If it is likely that you will progress only to a Norwood Class 6, then transplanting your crown can be considered. If you will progress to a Class 7 then you should not since, in the long term, hair that was placed in the crown might be better used for other purposes, such as connecting the transplanted top to receding sides.

A: The main concern I would have is that when someone is already a Class 6 by their early 20’s, he may eventually be left with only a very thin see-through fringe as he ages. A high donor density now does not insure that this will not occur – and coarse hair at 22 does not insure that it will not become fine over time.

Since the hair restoration would require one or more large sessions, there is a risk that the donor scar will not be hidden over time. If you had a widened donor scar, you would need to grow your hair longer on the back and sides to cover it (if that is even possible).

This may not be ideal for a younger person who would have otherwise been able to wear his hair short, and now would not have that option. Regardless of the maturity and good judgment you may feel you have now, your thinking may change as you age.

Hair transplants should generally not be performed in those under 25 because:

• Very short hair/or a shaved head can be an acceptable look
• Receded temples and a thin crown is not a good look for a young person
• When hair loss begins at a young age, the course is unpredictable and will more likely than not result in extensive hair loss
• Young persons tend to have worse/more stretched scars than older patients
• When we are younger, we generally tend to think more short-term
• When we are younger, our decisions are often more emotion-based
• When you get older, you may change mind about having surgical hair restoration, but the hair transplant procedure, once performed is irreversible.

A: Laser treatments, as with other medical treatments for hair loss, only work when there is some existing hair in the area.

A: If a person is to become a Norwood Class 6, the hair that we have available for us to transplant is only about 12% of what was there originally. This, of course, will vary from patient to patient depending upon one’s donor density and scalp laxity and a host of other factors.

We make the hair restoration look good by restoring 25-50% in the front, and proportionately less in the back. Logically one cannot restore 1/2 of ones original density to an entire bald scalp with only a thin strip of donor hair – there is just not enough hair, even with multiple sessions.

I transplant 25-35 FU/mm2 in one session, but this is the density created in the front, not overall.

Due to follicular unit graft sorting (placing the larger follicular units in the forelock area) this provides even more density than the actual numbers suggest. If someone is relatively certain to have more limited hair loss, then the numbers can be increased, but it is risky if you underestimate the degree of eventual hair loss.

Please carefully read the article on Hair Transplant Aesthetics.

It will answer your excellent question in greater detail. The article is a bit old, but the principles are the same.