Dr. Arvind stated the following regarding my case:

"Hairytale is a forum poster whose hair restoration procedure is being carried out at our clinic.
As per his request, and also because he has a preferred interesting plan for his HT, we are discussing his procedure.
I think numerous forum readers may find hairytale’s approach and choice very informative.

History -
Hairytale is a Caucasian. Fitzpatrick skin type 3.
About 17 years earlier, at the start of his hairloss, he received a plug graft HT on his temple and hairline areas.
That time he was a NW 2 or early NW 3.

He has used Toppik successfully to conceal hairloss over the years.

A few months ago, he decided to shave his scalp.
Shaving the scalp, in hairytale’s words, was liberating and he felt very comfortable with his new image.

When I met him a few months earlier, he had cobblestoning on the previous plug grafts. That is a common problem with plug grafts.

I advised him electrofulguration to level the cobblestoning and a major portion of the cobblestoning has been treated following the electrofulguration.


His present procedure involves -
1. the use of scalp and body hair FUSE/fue grafts,
2. Thinning out or totally removing the hair from the plugs that were placed inappropriately low in the temples.


Aim
Hairytale plans to buzz cut and shave his scalp post HT.

Therefore, we plan to thin out the donor scalp and thicken the recipient.
This approach is to reduce the contrast of density between the two areas.
Keeping a buzz cut or shaven scalp requires that the hair density not be too different in separate areas of scalp.
Hairytale used a very apt phrase for this.
"To pixelate the recipient area and dipixelate the donor".

I am posting some pictures and shall post some details of the procedure over the coming few days.

The above pictures show the marked difference in density that is visible in the different areas even after a buzz cut.

Scalp donor area picture

This is what is termed the shotgun harvesting method and was common decades earlier.
Bunches/plugs of hair were extracted using 4mm diameter punches.

Recipient area

This picture shows a close up of the recipient area where the plugs were placed.
When the plug used to be too large, sometimes, the hair follicles in the centre of the plug did not survive as the revascularisation could not occur in time.
That gave rise to a donut like appearance in the grafted plug.
That is, hair growing in a circle, near the periphery of the plug, but not near the centre.

Hairytale plans to go for a slightly rounded hairline, parallel to the ground when he stands upright.

These pictures depict the markings.

Day 1

Total # of grafts = 1073.

Scalp = 508
1 hair FUs = 155,
2 hair FUs = 265,
3 hair FUs = 88.

Chest = 177
1 hair FUs = 118,
2 hair FUs = 59.

Beard = 29
1 hair FUs = 25,
2 hair FUs = 04.

Pubic = 259
1 hair FUs = 136,
2 hair FUs = 123.

Left armpit = 100.
1 hair FUs = 68,
2 hair FUs = 32.

The grafts, thus obtained, were used to create a bridge of hair on top of the vertex akin to the one seen in NW 4 individuals.

This is the intraoperative picture of the recipient area taken intraoperatively during Day 1.
The recipient slits were made while taking care of the surrounding pre existent terminal hair in the area.

Day 2 with recipient pictures

Hairytale has some of his own hair growth on top centre of the vertex area.
The recipient sites in those areas were made parallel to the surrounding hair follicles and only where there was a lack of a terminal hair.
A close up of this is shown in the second picture.

Scalp Donor picture

Day 3 and 4 - plug thinning and healing

On day 3, we initiated the extraction of FUSE grafts from the plugs to thin them out.

Close up view of the extracted untrimmed grafts from the previous plugs.

This is the area on Day 4.

Day 3 - recipient area picture and grafts

Total grafts = 1155.

Scalp = 896.
1 hair FUs = 273,
2 hair FUs = 464,
3 hair FUs = 149,
4 hair FUs = 10.

Abdomen = 130.
1 hair FUs = 85,
2 hair FUs = 45.

Armpit = 129.
1 hair FUs = 74,
2 hair FUs = 52,
3 hair FUs = 03.

Some pictures of the grafts.

Cobblestoning accompanied by hypopigmentation are 2 important factors that cause the plugs to stand out as sore thumbs.

If not for these two problems, and the pitting (if and when it occurs), a person with plugs could simply shave off the plug hair and look almost normal.

Electrofulguration carried out by the electrocautery is a very helpful, albeit simple approach to tackle cobblestoning.

Electrofulguration, like laser, leads to transient erythema and Hairytale is applying cortisone ointment to reduce the same.

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Once the hair in the plug are removed (in this case by FUSE/fue), any remaining cosmetically unacceptable hypopigmentation can be overcome by the use of split thickness skin micrografts.
(Similar to the way post burn hypopigmented scars are treated).
I think you may like to try that instead of the excimer laser.
We have found it to be a very effective and permanent method of addressing the hypopigmentation.
I had a chance to use this approach while treating post burn scars while in Army.
Its also commonly used in treating vitiligo. I think you have also read up about the benefits of this approach of using micro skin grafts.

http://www.hairsite4.com/dc/dcboard.php?az=show_topic&forum=12&topic_id=21930&mode=full

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By holes, I think you are reffering to the extraction sites left after the hair were taken out from the plugs.
We have not closed/sutured them. We utilized the expanding needle method to minimize the amount of epidermis extracted alongwith the hair grafts.
We hope to remove the remaining hair of the plugs as soon as the healing from the first phase of extractions is complete.

Day 4 - pictures and grafts

Total grafts = 947.

Scalp = 513.
1 hair FUs = 154,
2 hair FUs = 284,
3 hair FUs = 72,
4 hair FUs = 03.

Beard = 109.
1 hair FUs = 98,
2 hair FUs = 11.

Chest = 325.
1 hair FUs = 297,
2 hair FUs = 28.


Apart from placing grafts in the recipient areas, some of the grafts were used to break up and camoflage a row of the shotgun scars left in the back of the scalp as the relic of the previous plug graft HT.
The blue arrows in the picture point to the scars that were transplanted into. We did not densely transplant these scars. The aim is to camoflage them rather than to fill them with high density hair growth. Only 40 of the precious grafts were used to accompllish this.

Following is the picture of the recipient area taken intraoperatively on Day 4.

Day 5

Total grafts = 578.

Scalp grafts = 335.
1 hair FUs = 125,
2 hair FUs = 163,
3 hair FUs = 47.

Chest = 138.
1 hair FUs = 130,
2 hair FUs = 08.

Beard = 105.
1 hair FUs= 87,
2 hair FUs = 18.

Beard hair extractions, in my opinion, is a litmus test of FUSE and has been possible due to the use of the expanding needle technique.
The extraction is performed in a manner that minimises the loss of the pigment containing epidermis.

Following is a picture of some untrimmed 2 hair FUs obtained from the beard area.

These are the pictures of the recipient area at the end of Day 5.
The first one, as per my specifications, (to show the details), and the second one as per Hairytale's wish, viz., that a man should be photographed with his head upright and not in a manner where he has to bend his head down.

I respect his sentiments. In heart, I agree with him to a large extent. Hair restoration is something that a man should undergo as a choice, not out of shame or guilt. There is something important here that every person who has hairloss (not SUFFERS from hair loss, but just HAS hairloss), would do well to remember.

Do not let hairloss consume you. Treat hair restoration merely as an option.

Dipixelating

As I mentioned before, in Hairytale's procedure, we are also harvesting/ thinning/ depixelating the area that does not fall in the orthodox strict safe donor area, as per hairytale's wish. That is what is shown in the following picture.
The area towards the top of the donor zone is the one that has been thinned out or depixelised.

One for the mathematicians

There has been certain observations pertaining to body hair growth and its cycles.
During our discussions in these past few days, I exchanged some of those observations with Hairytale.

Hairytale has a passion for mathematics.
He presented those observations in a mathematical form.
I would present the same to you.

I know there would be many mathematicians among the readers, and I would request their input on this.

(I can not take credit for the beautiful mathematical language that follows. Its hairytale's).

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In a given body hair zone (GBHZ), supposing Xa% and Xt% hair are in, respectively, anagen and telogen with Xa% + Xt% = 100%.

Supposing Xa has a duration Da and Xt has a duration Dt (measured in weeks and days), and,

Dt > Da

It ensues that from a given moment that you shave a GBHZ, after a duration of Da, Xa% will go into telogen, whereas Xt% is still in telogen, since Dt > Da.
Which results in, (Xa + Xt being = 100%), that all hair in GBHZ will be in telogen until we reach complete duration of Dt. That is, a no hair growth in a GBHZ.
This has not been observed on anyone even as soon as 1 day after shaving the GBHZ.

Thus, ad absurdum, we can not have Dt > Da.

In other words, telogen cannot be longer than anagen. Or else, there will be a time when all hair will be in telogen.
And, as time passes, and hair cycles continue, Xt% will keep increasing and Xa% decreasing.

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Mathematicians, please contribute your thoughts.

An experiment for the readers

There is an observation that I feel tempted to share at this juncture.
As you know, we advise patients to preshave the body donor areas, 4-5 days before their procedure, to pick the growing hair and leave those that are in the resting phases.

I would request forum readers to contribute with their findings by conducting a small experiment.

The experiment

Please wetshave, with a razor, hair over a small part of the body. 1 sq inch over the thigh or the forearm would be ideal as these areas can be observed very closely.
2 days later, you will be able to see, distinctly, that some of the hair are growing while the others are not.

Please observe, and, if possible, take high resolution pictures of the area on a weekly interval.
You have to observe the non growing hair.

There will come a time when the last nongrowing hair in that sq inch also starts growing.

The period starting from the time of wet shaving to the time when the last non growing hair starts to grow will give you an idea of the duration of telogen of the body hair in that area.


Please note that taking serial weekly digital pictures and examinimg them on the computer screen will help this process.


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We have performed this observation on many patients and volunteers and have found the time to vary from 6-10 weeks.

I think the previously held assumption of the telogen duration being 9-12 months long for body hair, is not supported by these observations.

Please let me know your thoughts as well as the result of your observations.

This little experiment can also be used by patients to tabulate the telogen duration for the hair in different parts of the body and choose the hair with a shorter telogen v/s one with a longer telogen.

Hairytale’s approach – an interesting HT option

On the final day, a total of 724 grafts were extracted and transplanted.
237 from the scalp (nape areas), 373 from the legs and a further 114 from the pubic areas.

The scars left from the shotgun extraction of the plugs were left unfilled, except for the one row on each side.
Crown, too, was filled at a low density.

These areas we plan to transplant at a later date, using the robust chest hair once the presently dormant hair in those areas reach their growth cycle.

A total of 5726 grafts were transplanted in the procedure of which 3103 were scalp grafts."

Detailed forum discussion for these pics can be found at:

http://www.hairsite4.com/dc/dcboard.php?az=show_topic&forum=12&topic_id=48094&mode=full