Preserve or replace the existing hair with a hair transplant

[Understanding Hair]

While we use the Norwood stages to categorise hair loss patterns, reality often differs due to the residual hair growth, for instance, a strong, but isolated forelock, separated hair growth through the mid-scalp, or an opening but covered crown.

When planning the hair distribution, a doctor will consider the existing hair coverage, including the potential for the hair to thin or shed. There are two differing policies doctor´s employ, one, to simply ignore the remaining hair, and place new hair directly over it, or two, keep the existing hair and place around or in between if necessary. Each policy has pros and cons.

If the doctor wants to use the existing hair, they will want to consider the hair quality and quantity, including the risk of hair loss. They may suggest using a hair loss treatment, with age a big consideration. Using the existing hair will potentially reduce the number of grafts, and or enable increased hair coverage with same number of grafts, good donor hair management. However, there is a risk if the existing hair thins or sheds, leaving an unnatural pattern of hair growth. While it should be possible to address further hair loss it´s not an ideal situation, having to decide when it´s too noticeable and impossible to ignore, the additional downtime, and cost.

Conversely, doctors decide the blanket approach, ignoring the existing hair growth and placing directly over it with the transplanted hair. The pro to this approach is it´s simpler to achieve a solid, even hair coverage. It´s also easier and faster, to place over the old hair cutting/transect the hair follicles. The downside to this fatalist approach is you are killing off the best part of the old hair, you don´t benefit from the improved graft distribution. There may be an initial increase in hair fullness as old and new hair grows, however, this will result in a slight drop in density as the old hair permanently sheds. While this doesn´t create thin areas, it can be worrying for the individual.

There´s an argument for either approach, dependent on the hair loss pattern, age, and the family hair loss history. If there´s enough existing hair and the quality is good, then having it is an advantage, especially if the overall hair loss pattern is advanced, or the donor hair only average.

Saving the maximum amount of existing hair is best. Be it a strong, albeit isolated, central forelock or a separated mid-scalp region. However, if there is a risk of further hair loss, and the risk increases the younger the candidate is, then the argument to place over the old hair makes sense. While it´s an aspect of hair restoration that may not be obvious it plays a significant role in the planning. It´s important therefore to know how the doctor approaches the planning of your hair restoration and the reasons why.

 

[josh145]

Great post. I do have a question. What donor density would be considered too low to extract from?

 

[Understanding Hair]

Thanks @josh145.

The hair density naturally varies depending on ethnicity and hair characteristics, so there can be allowances.

With FUE, 60 FUcm² hair density is about borderline and depending on the potential for hair loss to advance, as to reach high numbers (five thousand plus) would mean removing around 50% of the donor.

Once you get down to 50 FUcm² donor hair density you aren´t going to be talking about removing significant numbers unless you overharvested. Removing 2700 grafts is around 30%, not a small percentage.

You can change the numbers, +/-, but I would suggest this is an average, based on working within safe parameters. Not overharvesting, spreading the extraction, so on.

A good donor is a combination of follicular unit (FU) hair density, a natural number of hairs per FU around the donor, and the safe donor surface area, FUE. You could for instance have a decent hair density and surface area, but the hair count being low, with more single and two hair units, or a higher % miniaturisation. Or the density being fine, but donor surface area small due to the hair loss pattern.

There are exceptions when a hair transplant could be considered, but it becomes especially important to discuss the limitations and ensure expectations can be in line with what is possible, often, best not to do.

 

[L64]

This post really resonates with me @Understanding Hair !

In my first transplant, implantation was arranged in a way hoping that the native forelock would hold up well:

Because my hair loss wasn't stable and I wasn't prescribed Finasteride then, it thinned completely.

I am now looking for another transplant, but many of the surgeons seem to assume that they need to transplant the frontal area as if no grafts had taken, even suggesting to create a hairline as if the job hadn't already be done.

 

[Understanding Hair]

Hello @L64 ,

Sorry to hear of your problem, it is a real issue when the consequences are not fully recognised. Keeping the existing hair can work very well on the right candidate but as you have experienced comes with complications if not managed well.

I hope your hairline has not been placed too low in relation to your progressive hair loss pattern. The picture posted is obviously days post-op, how far along with the hair growth are you, what is your age, and do you use minox and or finasteride now? Your next step is important to ensure you can maintain a natural hair coverage long-term. Your donor is no longer untouched and the number of grafts reduced, so planning the next procedure and graft distribution is important, you may need to temper your original expectations.

 

[L64]

Hello @L64 ,

Sorry to hear of your problem, it is a real issue when the consequences are not fully recognised. Keeping the existing hair can work very well on the right candidate but as you have experienced comes with complications if not managed well.

I hope your hairline has not been placed too low in relation to your progressive hair loss pattern. The picture posted is obviously days post-op, how far along with the hair growth are you, what is your age, and do you use minox and or finasteride now? Your next step is important to ensure you can maintain a natural hair coverage long-term. Your donor is no longer untouched and the number of grafts reduced, so planning the next procedure and graft distribution is important, you may need to temper your original expectations.

Check out my case here

 

[Understanding Hair]

Check out my case here

Unfortunately even for 4200 grafts, as they spread the hair the result was not solid. Your donor hair looks a little patchy in areas, that is going to reduce what can now be safely removed. You need to see a few Dr´s in person to have your result properly measured, donor density etc, only then will you know what´s possible and formulate a plan.

You´re 30 years of age, and your hair loss pattern already advanced, it would have been the best assumption that any residual hair would also recede, so place directly over it.