This case study follows a composite patient profile based on common clinical outcomes for a Norwood 4 FUE transplant. The timeline, complications, and results represent realistic expectations rather than best-case marketing scenarios. Every data point aligns with published clinical ranges and the factors covered in our graft survival rate factors guide.
Patient Profile
Demographics:
- Age: 34
- Hair type: Medium-thick, slightly wavy (Caucasian)
- Norwood stage: 4 (further recession with enlarged vertex area)
- Duration of hair loss: 8 years of progressive thinning
- Previous treatments: Minoxidil 5% for 2 years (moderate response), no finasteride
Pre-Assessment Data:
| Metric | Measurement |
|---|---|
| Norwood stage | 4 |
| Donor density | 195 FU/cm2 |
| Donor area | 175 cm2 |
| Available donor grafts (45% safe limit) | 15,340 |
| Target graft count | 3,000 |
| Procedure type | FUE |
| Hair shaft diameter | 75 micrometers |
Consultation and Planning
AI Pre-Assessment
Before the consultation, the patient used an AI assessment tool that estimated his Norwood stage at 3.5-4 with a recommended graft range of 2,500-3,500. This matched the truth database range for Norwood 4 (2,500-3,500 grafts).
Surgeon Recommendation
The surgeon recommended 3,000 grafts distributed as follows:
| Zone | Area (cm2) | Target Density | Grafts Allocated |
|---|---|---|---|
| Hairline (first 2cm) | 15 | 40 grafts/cm2 | 600 |
| Frontal zone | 30 | 30 grafts/cm2 | 900 |
| Mid-scalp | 25 | 25 grafts/cm2 | 625 |
| Crown/vertex | 35 | 25 grafts/cm2 | 875 |
| Total | 105 | 3,000 |
The patient's AI estimate of 2,500-3,500 aligned with the surgeon's 3,000-graft recommendation, providing confidence that the plan was appropriate for his stage.
Procedure Day
Surgical Details
- Duration: 8 hours (extraction: 3.5 hours, site creation: 1.5 hours, placement: 3 hours)
- Punch size: 0.85mm
- Anesthesia: Local with mild oral sedation
- Graft storage: HypoThermosol at 4 degrees C
- Transection rate: 4.2% (126 grafts damaged during extraction)
- Total extracted: 3,126 grafts (126 replacements for transected grafts)
- Total placed: 3,000 intact grafts
Intra-Operative Graft Survival Factors
Several factors during the procedure influenced expected graft survival:
Positive factors:
- Low transection rate (4.2% is within the excellent range of under 5%)
- Advanced storage solution (HypoThermosol outperforms saline)
- Total out-of-body time under 5 hours for all grafts
- Experienced surgeon (12 years, ABHRS certified, 200+ procedures annually)
Risk factors:
- Vertex grafts were placed last, meaning those grafts spent 4-5 hours outside the body
- Slightly wavy hair required careful angle matching for recipient sites
- Crown area has lower blood supply than frontal zones
Recovery Timeline
Week 1: Critical Phase
Day 1: Moderate swelling across the forehead. Prescribed medications included antibiotics, anti-inflammatory, and pain management. Slept at a 45-degree incline. The clinic performed the first wash with gentle saline solution and demonstrated the technique.
Days 2-4: Swelling peaked on day 3, then began resolving. Small crusts formed around each graft site. Patient followed the clinic's washing protocol of gentle warm water with low-pressure application twice daily. No grafts were visibly dislodged.
Days 5-7: Crusts began loosening naturally. The patient returned to the clinic for a check-up on day 7. The surgical team confirmed healing was progressing normally. All recipient sites showed intact grafts with appropriate crusting.
Weeks 2-4: Early Healing
Days 8-14: Most crusts fell off naturally during gentle washing. The donor area showed small pink dots at extraction sites. The patient resumed light walking but avoided any exercise that raised heart rate.
Day 14 follow-up: Surgeon confirmed normal healing. Recipient sites had closed. Some mild redness persisted in the transplant zone, which is expected for 4-6 weeks. Patient was cleared for light cardio.
Days 15-30: Redness gradually faded. The patient started finasteride (1mg daily) on the surgeon's recommendation to protect existing hair.
Months 2-4: Shock Loss Phase
Month 2: Transplanted hairs began shedding. This is normal shock loss and does not indicate graft failure. The follicle remains alive beneath the skin while the shaft is shed and regrows. Approximately 85% of transplanted hairs fell out by the end of month 2.
Month 3: Minimal visible progress. This is the most psychologically challenging phase because the transplanted area can look similar to or worse than pre-surgery. The patient reported anxiety, which is common. The AI tool was used to compare monthly photos against the pre-surgery baseline for objective reassurance.
Month 4: First signs of new growth appeared. Fine, light-colored hairs emerged in the hairline zone. Growth was patchy and uneven, which is normal at this stage.
Months 5-8: Growth Phase
Month 5: Approximately 30% of transplanted area showed new growth. The hairline showed the most progress, consistent with frontal grafts typically growing before crown grafts.
Month 6: Hair density measurements at the 6-month follow-up:
| Zone | Grafts Placed | Surviving Grafts (estimated) | Survival Rate |
|---|---|---|---|
| Hairline | 600 | 570 | 95% |
| Frontal | 900 | 846 | 94% |
| Mid-scalp | 625 | 581 | 93% |
| Crown | 875 | 788 | 90% |
| Total | 3,000 | 2,785 | 92.8% |
The crown showed the lowest survival rate, consistent with published data showing vertex grafts survive at slightly lower rates than frontal grafts due to lower blood supply and longer out-of-body time during the procedure.
Month 8: Growth reached approximately 60% of final density. Hair texture began to normalize from the initial fine, wispy growth to thicker, more representative strands.
Months 9-12: Maturation
Month 9: Visible improvement was significant. The patient reported positive reactions from friends and family who noticed fuller hair. Coverage across the frontal zone looked natural under normal lighting.
Month 12: Final assessment. Hair had reached full maturity with natural texture and growth direction.
Final Results at 12 Months
| Metric | Pre-Surgery | 12 Months Post-Surgery |
|---|---|---|
| Norwood classification | 4 | 2-3 (visual appearance) |
| Total grafts placed | - | 3,000 |
| Estimated surviving grafts | - | 2,785 (92.8%) |
| Estimated surviving hairs | - | 6,127 (at 2.2 hairs/graft) |
| Patient satisfaction (1-10) | - | 8/10 |
The patient rated his satisfaction at 8 out of 10 rather than 10 because crown density, while improved, was not as thick as the frontal zone. This is a common outcome and a realistic expectation for single-session Norwood 4 cases.
Key Takeaways from This Case
What Went Right
- AI pre-assessment matched surgeon recommendation: The patient entered the consultation informed, which built trust and confirmed the plan was appropriate.
- Low transection rate: The experienced surgeon's 4.2% transection rate meant minimal graft waste.
- Structured aftercare: Professional first wash and regular follow-ups prevented complications.
- Finasteride post-procedure: Starting medical therapy protected existing native hair from further loss.
What Could Have Been Better
- Crown grafts placed last: Earlier placement of vertex grafts could have reduced their out-of-body time and potentially improved survival beyond 90%.
- No PRP therapy: Adding PRP at the time of surgery might have boosted overall survival by 2-3%.
- No pre-operative finasteride: Starting finasteride 6-12 months before surgery could have thickened miniaturized native hairs, improving the overall visual result.
Realistic Expectations
This case produced good results at 92.8% graft survival, but it was not perfect. The crown needed additional density, and the patient may consider a follow-up procedure of 500-800 grafts in 12-18 months to improve vertex coverage. This is a common and expected outcome for Norwood 4 cases.
Be cautious of clinic red flags including clinics that promise 100% graft survival or show only their best-case results.
Get Your Assessment
Know your Norwood stage and estimated graft needs before your first consultation. Visit myhairline.ai/analyze for a free, instant AI assessment.
FAQ
How do I find a reputable hair transplant clinic?
Start with board certification (ABHRS in the US, ISHRS internationally) and check the surgeon's documented experience with your specific Norwood stage. Review before/after photos for patients with similar hair type and loss pattern. Consult with at least 2-3 surgeons and compare their graft recommendations, technique preferences, and aftercare programs before committing.
What credentials should a hair transplant surgeon have?
ABHRS board certification is the gold standard for US surgeons. It requires both written and practical examinations specific to hair restoration. ISHRS membership is a positive indicator internationally. Beyond certifications, evaluate procedure volume (150+ annually), years specializing in hair restoration, and willingness to share outcome data including graft survival rates.
How do I know if before/after photos are real?
Authentic photos maintain consistent lighting, angle, distance, and camera settings between before and after images. They show the patient from multiple angles. Ask the clinic if they can connect you with the patient in the photos or provide video documentation. Be skeptical of photos that are only shown from one flattering angle or where the lighting changes dramatically between shots.
Medical disclaimer: This case study represents a composite patient profile based on typical clinical outcomes. Individual results vary based on surgeon skill, patient health, and hair characteristics. This article is for informational purposes only and does not constitute medical advice. Consult a board-certified hair restoration surgeon for personalized recommendations.