My guess is that even a great FUE session won't make much of a dent. Believe it or not, probably the best thing to do is to punch out 3mm plugs from the donor area then refine them under the microscope to minigrafts and then implant into the alopectic area of the donor and the top. This patient needs VOLUME. Thankfully he has very curly hair which will cover the plug donor sites AND provide him with the serious volume he needs.

Ironically, if his surrounding hair were thinner, then FUE might be useful, but the contrast in density would make FUE pointless, not to mention very expensive.

Dr. Bernstein is probably the world leader in punching out old plug work so he is the number one main for this job as this experience will serve him well in performing the old syle plug work this patient needs.

This would be a VERY RARE approach, but probably the best one:
My approach would be to punch out as many plugs as possible from the donor area with as much space between them as possible. Then I would suture or staple each wound closed. That will minimize the visible scarring. Then refine the grafts (on purpose) only down to minigrafts, NOT FUs. Then implant in both areas. That gets around the non-stretch skin problem AND allows for maximum yield. Sometimes you have to look to old techniques to get around rare problems. Dr. Bernstein would probably be the best in the world for this approach in my opinion. His results should then be posted on the web for all to see.

Thanks for the suggestions. I did consider FUE, however the limitation he has is not only the donor scarring, but the very low donor density. I don’t feel that FUE would offer any significant improvement in volume because of this and would just leave additional scarring. Although punch harvesting is an interesting suggestion, I am concerned that punch excision of the donor area would also leave unacceptable scarring. If you could examine him it would be apparent.

The grafts that Dr. Rassman placed were quite small. In his note, he said the maximum was 4-hairs and the patient does not look pluggy, rather the hair loss is patchy – so graft excision with re-implantation would offer little. A main concern was the poor growth from each procedure, which is why I am reluctant to do additional surgery. A diagnostic biopsy would be a reasonable next step, but the other issues remain. It is a very difficult problem.