all right here's a marathon series of four lectures from me so we're going to talk about Temple point and lateral hump reconstruction you've seen the slide be before and really know the sub-regions so we're going to talk about dividing those into smaller smaller units today and remember the concept of the head like a box the temporal Point Temple and lateral hump reside on the horizontal sorry the vertical scalp on the side of the head so if we think of it like a spectrum a lot of things what I do or not all or none they're
all Spectrum related I think about the very bald person needing a lateral hump reconstruction to me this is very Advanced it's not just advanced in terms of redesign and reconstruction but thinking about it this guy's that advanced are you going to have a problem because there's going to be ongoing progression you're going to have issues why do I put temporal point for the lease bulb because you can have a very bald guy with really a need for a temporal point and the real reason is that and you're going to hear this in my lecture is
supply and demand wasting so much graph on this area not only the fact that it's very complex in design and then you get what's called a front heavy result where all that sits is in the front so I don't do temporal Point unless I've got great donor capacity and prediction for the future and you shouldn't do it because it's too difficult to do I will be running a three hour temporal Point reconstruction and Crown this afternoon but please understand I rather teach you upper Temple and and then Crown which is moderately Advanced but the crown
is moderately Advanced simply because of prediction of future problems more than anything else so so this is that Spectrum in another in other context of just looking at this thinking geographically where we're going the farther you go forward into that Temple the more difficult advance and the more risk that you have so this lecture is going to be divided into macro and micro meaning how do you design these lines and then how do you make the sites okay so the first thing we're going to talk about is temporal Point reconstruction I emphasize again this is
a very Advanced procedure it is an advanced surgeon and an advanced team because if you do great sites which you brought you will not do I'm sorry and your team will Jack it up because when they Place into these very low sites it's not going to look right so I think it's a person that has mineral hair loss what are you talking about it should be someone that no it's because I'm worried that I'm going to use all these graphs to sit this ahead way up in the front and they're going to be bald back
here and it's going to look like a hair system gone bad it looks weird it's it actually is great for someone with a hair system where they've got such great law said this is the only area that looks artificial I'll build the temporal Point knowing that they're going to wear their hair system in place that's another that's another way that you can do it but great donor capacity that overcomes a lot of evil and other priorities all met because for me I rather do the front the crown everything by the temporal point the other benefit
but the benefit is that it's awesome it looks great there's it's a balanced result and it just looks like a very strong masculine facial frame so how do you design it this the a concept and I'll be honest with you to me practically speaking this is a textbook answer I think this is a little too aggressive and I'll show it to you in lab but essentially what it is you draw a line through the mid pupil through the nose that's one line and then through the earlobe you go to the point that you designed on
your hairline and then you draw that that becomes a self-correcting temporal point I'll be very honest with you this is actually when I've done this in practice it looks more aggressive than it is but it's just a blueprint to start you need to go be once you've drawn this line which I think is a little too aggressive go behind it all right but you need to study natural temporal points you got to see what's out there the funny thing is I always just draw my temporal Point by hand and then I said I'm going to
use this thing and draw it in with this technique oh my God it doesn't look right so but I this is in every textbook including mine as a start Point okay recipient sites they go super insanely flat I use bent needles to create this I have traction I'll show you this I'm very very careful and the trick is in the temporal point which is this thing it goes back why does it go back because if you make them going down they're going to hang over the naked skin and it's going to look Bizarro if they're
sticking out like this okay forget the surprise stuff that Vance talks about this is a real big surprise when you walk in a room with one of these and you can't fix it so I use band needles for this I don't use solid cord needles and I use very small grafts one and then for the frontal Zone and then two hairs when I go farther back in that area I don't use three hair grafts in the zone it looks weird this is an example I showed you yesterday so the right side for a right-handed surgeon
is pretty easy the left side is more difficult to get low sights so I used to bend over and do this I now sit and press upwards into the area I you have to maintain sharp needles because the skin gives so there's two things you have to maintain sharp needles or there's it's going to dull and you're not going to be able to place into those sites and you must have counter traction I now have a dedicated assistant that holds counter traction on my temporal points until I'm done then she leaves and then I continue
this the the procedure so that's counter traction with an assistant I think is mandatory or they've got these clamp devices that hold it back I have used those I just like a person holding it so upper Temple Design This is really what I would have you guys do this is the limit of where I want you to walk home with it's good to know all the knowledge but it's good to avoid problems so I I this this is actually really good the more I teach in lab the more I realize what I'm not teaching so
we heard all the hairline design issues so yes I saw a gentleman uh you know who you are that drew a line that fit all of the rules except one he had the thing didn't tilt down it tilted right he was at the shingle point that was correct he drew his temple line that was actually relatively okay but his hairline sat eight miles ahead of his Temple we didn't talk about that so the problem if you do that I call it the lid effect which is the next slide which is the idea that if you
have a hairline way out here in the temple back here it looks like a hair system it doesn't look balanced so you want those to you think you gotta think of this sort of naturally unzipping now I'll be honest with you when we do hair surgery we've oftentimes got to place the hairline a little bit interior to the temple it's just the nature of supply and demand issues but you don't want that hairline jutting out five miles in front of the temple and that's that if you see that what do you do to fix it
move your hairline back don't move your temple forward especially for the beginner you're going to have problems and that's the idea is when you look at this you don't want on the right the non-grade out area having that hairline sit way in front of the temple it just looks weird this is a reiteration of a point that is uh we talked about yesterday the concept to reiterate how do you think how do you know when to design an upper Temple this is a question I've had for 14 years and it's finally solved in the new
book that's coming out that just came out actually that I I you can draw a line two centimeters and two to the EAC external auditory canal draw you can draw that line in of that lateral canthus when I taught hairline the biggest failure I saw is not getting the lateral canthal position right use that pencil to go up I do it I'm over 20 years in practice I still use an eyebrow pencil to just make sure that I'm in alignment because it's a curvilinear space it's very hard when you see the junction of those two
points if your hairline sits anterior to that when you're designing it you probably don't need upper Temple if if it's gonna if your temple points excuse me if your temple sits behind it you probably need a little bit of upper Temple to match the hairline and we can go over that in lab today if there's any questions to show you that so the Angles and directions they're they're somewhat low in the upper Temple lower the better you can't go too low but it's not as vital when compared to the lower Temple and the temporal um
area in terms of the the the the lowness of it I'm using one or two hair grafts a front one or one to two rows or ones and then twos no threes in this area and I'm talking about three hair follicular units if that would that abbreviation didn't make sense to you just as an example I mentioned to you that there are no abrupt Transitions and you can see I don't fan out that Central hairline they go pretty far forward and then they just slightly curve onto the side so this is something that I came
up with for the new book that I think it's uh hopefully a novel way of simplifying a lateral hump Design This Is Why when the question was asked yesterday I said let's hold it off because I have a lecture today I don't want to mix simple Norwood three to five hair transplants or three to sixes with a how to do a seven because to fix a Norwood seven is a very Advanced concept so the idea is where is this lateral hump remember it looks like an upside down Bowl it's on the side of the head
when that starts to recede you have a Norwood seven that's the definition of a seven now the gentleman I'm going to show you is way too advanced to do actually a transplant he just was a father of a friend of mine that came in so I could photograph them for the books I would never transplant them but I think it's just a good education so how do we Design This remember how we started we started with the anterior Point don't do that with with these Advanced ones because you're gonna by Nature not know how far
forward or back to go you won't make it conservative enough you're gonna make it too far Fort so we need to balance it on the hump what does that mean so I start with a hump so this is the concept is that I start with the hump what does that mean so along that axis of that lateral canthal line I go to the side of the patient and I look at where the Apex of that hump is okay the apex of the hump is this in case I hate using laser laser pointers but let's see
if this thing works there we go that's this is the apex of the hump right here okay that's the apex of the hump so I go from the apex of the hump and go straight North that tells me the Apex of what I'm going to design I do that on the other side and then I I sort of check if I'm midline remember I told you cross check you guys when you're doing hairlines tilt the hair down head down and look if you're midline you guys are not doing that because and then I take a
ruler if you I mean I don't do this anymore but if you need to take a little just measure if you're if your humps are not off because I will tell you as you start you're going to have your humps off you can have everything off your temp frontal temporal Corners are up so I start with that and again I would not design this this is too aggressive you see the loss but it's point of an intellectual understanding so then I finish the hump after I've designed the humps then I TR I create that this
this central island in that area then I know I can balance it either exactly evenly on the on that area or slightly in front now I'll be honest with you a natural no word pattern does not have a hairline that sits anterior to this Design This is not even exactly a natural number pattern but it's as close as thing I can do with an advanced hair loss this is why in general you don't want to be transplanting these but you want to do it in a very careful way that the public cannot see this so
from All Views you're seeing how I've basically centered on that now I would soften those angles so it's not so an Abrupt transition point but this is the concept of balancing it so this is the the New Concept I've delivered in the book which is to balance it so let me show you if what's in green is a very normal uh or regular old transplant for I transmit the front to the back where you if you just transplant the front half of that green and not the back half for example you're going to have a
front heavy result what is a front heavy result what is shown in blue the blue means I've designed the front and not the back I have this aggressive hairline anterior to the loss it doesn't look right you're not going to have the eye to understand this for five years okay maybe seven to ten but you're gonna I want you to develop the idea of balancing the front to the back and not have it especially with the more advanced losses so what's in red is you can see I'm slightly anterior to that vertical line but not
too much you don't want to create hairlines way in the front of a lateral hump recession it looks weird Okay so that's the balance concept on that central line pivoted on the apex of the lateral hump so lateral hump recipient sites they're gonna look like they're cascading forward so they go forward and then down they start falling down and as you go all the way to the back they go vertically downwards so the directions and graphs I I use more threes on the top and then two's farther down now be honest with you that's the
opposite of what exists in nature because as you recede you have a wave of thinner hairs on the top not the opposite so this is a very dangerous way to transplant if you don't know what you're doing if you heard this and say sam uses more threes up high you need to put enough density below it so that it transitions out I'm using the threes to Cascade down to cover my twos using the Cascade principle but if you don't do this right you're going to have these dense graphs sitting up here in this week twos
and it's going to look not like a normal hair loss so I would tell you to reverse it and use more twos up high maybe threes lower down because you're going to mess this up but I'm telling you how I do it and how you can aspire to do it but early on you don't want to do it if that makes no sense to you let's talk afterwards okay because I know this stuff is very confusing so these are just an example of my design and then some quick results this is a frontal temporal temporal
Point Design This is another temporal Point design another temporal Point design another this another temporal Point design so another this is 10 years actually after a temporal Point design um this is a analateral hump build so he stabilized well he was compliant with medical therapy so that's great so sometimes medical therapy is great I went back the reason I saw him 10 years later I went back and added more graphs he's just great he's in his mid 50s he's holding well and so but listen just does that mean I'm a good predictor of future hair
loss no it means I'm probably better than you because I've been doing this 20 years and I'm incredibly conservative of whom I pick I can take a day and just turn every single patient away for surgery it's easier for me at 20 years in practice but I'll tell you it's never easy to say no I don't want it for two reasons I'm losing money and I'm having a patient that is depressed they can't do it but I'll tell you it's the right thing so understand is understand the spectrum of temporal point to lateral hump avoid
temporal point and lateral hunt for beginners so you're doing temporal points to start don't do it you're going to have problems lateral hump seems easy and it is technically easier but I will tell you it's not the fact that you can't make those sites so if you get excited if I show you how to make a lot of in the lab you go I could do this and maybe your staff can place into it the Judgment of dealing with Norwood sevens is very difficult unless you're dealing with a white-haired 70 year old where you're not
worried too much about aesthetic goals and he's pretty happy with some hairs there great but if you're doing a Norwood seven and a 35 year old that guy is going to have a problem in five years that you can't exit on okay just like the story I told you the Norwood 625 year old that decided to go overseas my God he's going to be in a disaster land in 10 years and I won't be able to fix it and he barely can handle things because he has sexual side effects from finasteride it's going to be
difficult so understand when to perform the upper Temple based on those two uh intersections intersected lines again I can go over that with you in lab okay that's the first lecture of four hang on put your seat belts on
