Frequently Asked Questions

about Hair Loss and Hair Transplants.

FAQ

What can be done to minimize the effects of post-op shedding?

The first is using medication, the second is timing the transplant properly, and the third is performing a procedure using a sufficient number of grafts. Finasteride 1mg reverses or halts the miniaturization process in many individuals and is thus the logical way to decrease the risk of shedding following a transplant. Although many physicians have the clinical feeling that that this assumption is correct, there has been no controlled studies to date that prove this. Timing and the size of the transplant are the most important issues. It is important to wait until a patient is ready to have a transplant, and then to perform one of sufficient size so that if there is some shedding, the procedure will more than compensate for it – and be worthwhile. A problem that patients often run into is that they present to their doctor with early hair loss but with a significant amount of miniaturization. The doctor performs a small procedure and it doesn’t even compensate either for potential shedding or for progression of the hair loss. The result is that the patient is thinner (or more bald) than he was before the procedure. The doctor rarely blames the problem on the fact that the procedure was too small or that there the miniaturization was not taken into account, but only that the patient continued to bald. The better solution is to treat early hair loss with medication, but once you make a decision to begin surgery, and then have a procedure large enough to make a significant cosmetic improvement. As a final point, it is a fallacy that some doctor’s techniques are so impeccable that they can avoid effluvium or those “small” procedures will avoid shedding. Of course, bad techniques and rough handling will maximize effluvium, but effluvium is what hair naturally does when the scalp is stressed and it is stressed during a transplant from the anesthetic mixture and the recipient site creation. It cannot be totally prevented. In sum, the best way to deal with effluvium is to treat with Finasteride when hair loss is early, perform a transplant only when indicated and finally, to perform a procedure of Follicular Unit Transplantation with skill and with a sufficient number of grafts.

My doctor rubbed the back and sides of my scalp and told me I have plenty of hair. Can I trust this opinion?

We are all born with a finite amount of hair. Whatever the approach, no new hair is created. Scientific measurements, such as densitometry, provide the surgeon with much greater accuracy than subjective assessments when estimating your total supply of permanent hair. Accurately estimating your total donor reserves for proper long-term planning cannot be over emphasized.

My doctor told me try a few and see if hair transplantation is for you! Is this reasonable to do?

Hair transplantation should only be started after a long-term master plan has been established. The “try a few” mentality is totally inappropriate for it does not fully inform the patient of the potential problems involved with starting a process which they may not wish to complete.

What are the reasons for male pattern balding?

The tendency towards male pattern balding is genetic and can be inherited from either the mother or father. Balding is actually triggered when dihydrotestosterone molecules chemically bond with special receptor sites on hair follicle cells. This causes the hair follicle to weaken (miniaturize) and eventually to die.

Why do hair transplants work?

Even in the most extreme balding patterns, a permanent ‘wreath’ of hair exists on the sides and back of the head. This hair is unaffected by the balding process. In Follicular Unit Hair Transplantation, a thin strip of skin containing this permanent hair is removed from the back of the head (because the skin of the scalp is flexible, the scalp can be sutured together again after the strip is removed leaving little trace that anything was done). The hair follicles are then carefully removed from that piece of skin and placed in very small surgical sites made in the thinning or balding areas of the scalp. Once transplanted, this hair behaves as it was programmed to behave in the original area it came from and will grow naturally for the rest of your life.

How do I know if I’m a good candidate for hair transplants?

Most men in good general health are candidates for hair transplantation. In order to determine your candidacy, you should arrange to have a private consultation with a NHI physician. During your consultation, the physician will measure your donor density and scalp laxity. He will also determine your balding pattern and take your individual hair characteristics such as color and wave into consideration to develop a plan for your hair restoration.

Why start now?

If you have been determined to be a candidate for restoration by a NHI physician, and if you are uncomfortable with your hair loss, why not start now? With your restoration completed, you can get on with life without this distraction.

Is it better to begin early?

A hair transplant should begun when your degree of hair loss is unacceptable to you. Not when you are only worried about future loss or “So no one will notice.” Starting early will often require multiple small sessions, and your expectations may be unrealistic.

How much hair do I have?

The Norwood classifications were adapted from the patterns described by Dr. O’Tar Norwood. There are seven classes of hair loss in the main series and five variations of these classes called the ‘A’ series. If you compare your hair loss pattern with these diagrams, you can probably see the pattern you are in now. Discussion with one of NHI’s knowledgeable physicians can help you determine how extensive your hair loss may become.

How much hair do I need?

When you have your consultation with a NHI physician, he will suggest how many grafts may be available for your first procedure (and subsequent procedures if they will be needed). This number will be based on your present balding pattern, what it may become in the future, and how much donor hair is available. When an individual has high donor density, the follicular units usually contain multiple hairs, and when an individual has low donor density the follicular units often contain only one hair. If an individual has a very loose scalp, a larger donor strip can be removed, while an individual with a tight scalp will have a smaller donor strip. When an individual has a relatively small amount of hair that can be moved, our physicians take great pains to distribute the available hair in ways that produce the best coverage.

What is the difference between density and fullness?

The word fullness rather than density, more accurately describes the visual phenomenon in what we perceive as thick hair vs. thin hair. The concept of fullness is broader and more inclusive. Density, the number of hairs/cm2, is only one of several contributing factors that are responsible for the visual impression of hair that appears “thick”. Other factors include hair shaft diameter, color, texture, and curl, which may be of equal of even greater importance than density, in contributing to the visual appearance of a “full” head of hair. In the early stages of balding the “thin look” is caused by a process called “miniaturization” where hair is reduced in size, but not actually lost. Therefore, the density (the counted number of hairs/cm2) remains the same, although the persons look of fullness can be dramatically reduced.

Will smoking affect my hair transplant procedure?

Smoking causes constriction of blood vessels and decreased blood flow to the scalp, predominantly due to its nicotine content. The carbon monoxide in smoke decreases the oxygen carrying capacity of the blood. These factors may contribute to poor wound healing after a hair transplant and can increase the chance of a wound infection and scarring. Smoking may also contribute to poor hair growth. The deleterious effects of smoking wear off slowly when one abstains, particularly in chronic smokers, so that smoking puts one at risk to poor healing even after smoking is stopped for weeks or even months. Although it is not known exactly how long one should avoid smoking before and after a hair transplant a common recommendation is to abstain from 1 week prior to surgery to 2 weeks after the procedure.

Will senile Alopecia affect my hair transplant procedure?

Diffuse un-patterned and patterned alopecia is uncommon. The medical descriptive term ‘senile’ appears in literature; unfortunately, the word implies that it impacts only the old and senile, which is not the case. It has appeared in almost every age group somewhat equally, but as each carries the malady throughout its life, the frequency increases as the population ages. However, Senile Alopecia is a more commonly accepted diagnosis for the younger population, potentially skewing population data. As a guess, its incidence amongst men is 1%. Prior to the advent of Propecia, recognizing the malady did nothing more than eliminate surgical candidacy. Now with Propecia, effective treatment is available for some. Approximately 50% of affected individuals that saw doctors at NHI have realized benefits from the drug. Most saw reduced miniaturization and a subjective appearance of additional fullness. Despite these desirable drug benefits, impacted alopecia patients seem to finish with less than desirable surgical results.

How long should I wait between hair transplant procedures?

At NHI we routinely schedule a second surgery 8-12 months after the first for the following reasons: At 8-12 months, hair length is adequate to see the effects of styling. With that in mind, the patient can work concomitantly with the surgeon to make many of the decisions regarding further distribution of grafts, and the process is more ‘owned’ by the patient. Occasionally, when hair first begins to grow, its texture may be slightly different from your original hair. After 8-12 months this generally returns to normal making decisions about the grooming easier, and grooming preferences may affect the way the next procedure is planned. Some patients have cyclical growth, which means that all of the growth may not be in and of adequate length at 4 or 5 months. Waiting the few extra months gives the person enough time to see hair growing and this can be a psycholigical advantage for the patient. Seeing the hair allows the surgeon to clearly see where to place the new grafts. For those patients with tighter scalps, the skin has a greater time to restore some of its previous laxity.

Most consumers and patients take for granted that board certification implies some level of expertise and qualification of a doctor. What does it ultimately mean to you? Why do we even bother with it? Is it to advertise achievement reflecting doctor’s credentials?

In the United States there are 24 approved medical specialty boards that are overseen by The American Board of Medical Specialties (ABMS), a not-for-profit organization. Certification by an ABMS Member Board has long been considered the gold standard in physician credentialing. To be ABMS board certified means that the physician has undergone formal educational and clinical training with adequate supervised activities a medical institution AFTER earning their medical degree. After this training, they must successfully pass a level of competence through written and oral examinations. Hair transplant surgery is not a part of the ABMS so there really is not a board certified hair transplant surgeon in the traditional sense the public thinks of. Learn More

Do women have problems with balding?

Women experience hair loss, too, and it is quite common, although not as common as in men.

How can I find out about female hair loss?

Some women have genetically determined hair loss, while others may experience hair loss from surgery or injury. Depending on their type of hair loss, women may or may not make excellent candidates for surgery. For more information on candidacy you should consult a NHI physician.

What causes hair loss in women?

Some women have genetically determined hair loss or hair loss from a series of medical conditions or genetic inheritance. Others may experience hair loss from surgery, or injury. Still others experience hair loss from wearing very tight hairstyles that exert constant pull on the hair. Because some hair loss in women can be caused by underlying medical conditions, it is important that women with undiagnosed hair loss be evaluated by their own physicians. If clinically appropriate, the following disease processes should be considered: anemia, thyroid disease, connective tissue disease, gynecological conditions and emotional stress. It is also important to review the use of medications that can cause hair loss, such as oral contraceptives, beta-blockers, Vitamin A, thyroid drugs, coumadin and prednisone. The following laboratory tests are often useful if underlying problems are suspected: CBC, Chem Screen, ANA, T4, TSH, STS, Androstenedione, DHEA-Sulfate, Total and Free Testosterone.

Why are some women not candidates for hair restoration surgery?

Hair transplantation involves the movement of hair from an area of greater density and fullness in the back of your scalp to an area of hair loss in the front, top or crown. Women who have generalized thinning (Diffuse Unpatterned Alopecia) have hair that is thin all over the head, and it may not be beneficial to transplant hair that has been weakened by the balding process. When hair is transplanted into a part of the scalp that is thin, but not completely bald, there is a risk that some of the hair that is weak will not regrow in its new location. There is also the possibility that the hair in the recipient area is more fragile and some or all of the original hair in this area may be lost. This process is called “telogen effluvium” and when it occurs, it is usually reversible in a 3-6 month time frame when the hair that has been lost has been weakened by balding. Also, when the donor area continues to thin, then the transplanted hair will also thin over time, since it came from the same area. In hair transplantation, as in all surgical procedures, it is important to balance the potential gain against the possible risks when making a decision to go forward with the treatment.

What is Follicular Unit Transplantation?

Follicular Unit Transplantation, a technique pioneered at NHI, is the transplantation of very small, individual, naturally occurring groups of hair called follicular units. Follicular units are comprised of one, two, three and sometimes four hairs each. These units are placed in thinning/balding areas following carefully studied natural hair growth patterns. The results are incredibly natural in appearance.  Learn More

What is Follicular Unit Extraction?

Follicular Unit Extraction is a technique used for harvesting individual follicular units during hair transplant surgery.  Each naturally occurring group of follicles, or hair grafts, can contain up to four individual hairs.   The hair transplant surgeon uses a special manual surgical punch to remove the grafts from the donor area of the scalp.  Robot-assisted surgery can also be used to perform an FUE procedure. Learn More

What is the primary difference between FUE and FUT?

During an FUT procedure, the hair transplant surgeon will cut a strip of skin from the donor area in the back of the patient’s head. The strip is dissected into individual follicular units and prepared for transplantation. The open wound left from the removal of the strip is sutured together and ultimately results in a linear scar once the donor area is healed. Visibility of the scar is dependent upon the skill of the surgeon, the patient’s ability to heal and the length of hair worn over the donor area. During an FUE procedure, the hair transplant surgeon will remove individual follicular units from the donor area using a special surgical punch. This approach leaves small punctate scars on the scalp once the donor area is healed. These scars are the size of a small ballpoint pen. The surgeon will remove the follicular units in a random pattern throughout the donor area thus leaving the patient with an even distribution of punctate scars. This uniform distribution technique eliminates the potential for the donor area to end up looking moth-eaten. The patient can confidently wear his hair long or very short over the donor area since the FUE scars are not noticeable to the naked eye.

Do I have to shave my hair from the donor area before my FUE procedure?

The donor area should be cut in buzz cut style in order to maximize the number of grafts extracted during a single FUE session. For patients with long hair, FUE can be performed by shaving multiple layers of three to four millimeters separated by flaps of longer hair that can cover the donor area. It is important to note that performing FUE in this manner may require additional FUE sessions. Long Haired FUE is an option invented and regularly performed at NHI. Ask your doctor about Long Haired FUE during your initial hair transplant consultation.

Do all hair transplant surgeons use the same tools when performing FUE?

Different doctors use different tools. The diversity of instruments among doctors is so varied that many surgeons develop their own specialized tools. For example, some doctors use a sharp surgical punch while others use a dull one or even a combination of both. Some FUE surgical instruments resemble a dental drill that rotates at a specific speed and others vibrate like a cast cutter used to remove a plaster cast from a broken arm. All of these tools produce similar results that suggest that no specific tool or technique works for every surgeon. Regardless of the types of surgical tools used to perform FUE, the most important factor is the survival of the hair graft once it is removed from the donor area. Ask your hair transplant surgeon what type of FUE instrument he uses when you meet with him at your initial hair transplant consultation.

How do doctors get qualified to perform FUE?

There is no formal training or certification available for manual FUE. Many doctors train with other experienced surgeons and then return to their own clinics and continue to learn by trial and error. In surgery, there is no substitute to human learning. The key is to learn from a hair transplant surgeon who has a long history of successful hair transplantation and who has a highly skilled surgical team with proven quality control mechanisms in place.

Is it better to pre-make recipient sites or to use the stick and place method?

We prefer to pre-make recipient sites for the following important reasons: Control of transplant design By making all the sites himself, the physician has complete control over the aesthetics of the surgery i.e. the angle of distribution of each follicular unit and the overall design of the transplant. If the physician is highly skilled, this is an extremely important advantage. Less popping When sites are pre-made there is less popping, since the act of making the sites (in stick and place) puts pressure on the surrounding skin causing adjacent grafts to pop. Popping can be a significant cause of graft warming and desiccation, which can decrease graft survival. Because there is less popping, grafts can be placed closer together, increasing the density. Easier sorting of Follicular Units When all of the sites are pre-made it is easier to sort follicular units so that you can use the larger units to create central density and the 1-hair units for the frontal edge of the hairline. In stick and place, sorting is much more difficult since the grafts are placed as they are cut. Pre-made sites can be made the day before the surgery. Less bleeding The body’s natural coagulation has a chance to work so that there is less bleeding and better visibility during the surgery. In our opinion, the purported advantages of stick and place (i.e., less chance of piggy-backing and missed sites) do not out weigh the many advantages of pre-making sites. In addition, these small advantages can be compensated for by appropriate techniques.

Do large grafts produce a better, denser result than smaller grafts?

Can a portrait painter create a better portrait with a house painter’s equipment i.e. by using a roller rather than a brush? The use of an artist’s brush is analogous to the use of very small grafts. High-quality hair transplants require fine instruments and delicate, small grafts. These grafts must be distributed in a way that balances the facial features, hair characteristics, and goals of the individual patient. Large grafts simply can’t offer sufficient flexibility to allow this “customizing” and their unnaturally high density doesn’t take into account the progressive nature of hair loss, placing the patient at great risk of having an unnatural appearance in the future. You can see for yourself what large plugs create. I don’t believe anyone today wants them. Learn More

Is removing large amounts of donor hair unsafe?

This is a statement commonly made by doctors who lack sufficient experience, or technique, in performing large sessions. The amount of hair needed for the average large session is well within the safe limits of what can be moved, provided that the procedure is done properly. It is the experience and judgment of the surgeon that will insure that the amount of hair that is harvested from the donor area is safe and appropriate. This is discussed in the following section: Learn More

Is it true that the blood supply of the scalp cannot support a large session?

No. People who make such comments don’t understand the oxygenation process in the transplanted grafts or the anatomy of the scalp’s circulatory system. The issue is one of oxygenation, not blood supply. By their very size, large grafts over 2 mm, will result in oxygen deprivation to the hair located in their center. This has been proven over and over again by observing the phenomenon called donuting (the loss of hair follicles in the center of larger grafts). In contrast, oxygen diffuses easily into grafts 1 mm or less in size. The blood supply of the scalp is among the richest in the entire body, enabling it to support the growth of large numbers of grafts, provided that they are kept very small. The Follicular Transplantation procedure performed at the New Hair Institute insures that these implants are kept to their optimum size. With this said, there can be problems if a doctor doesn’ know what they are doing as reported cases of gangrene (scalp necrosis) has been reported when a doctor used the wrong anesthetics or needles that were too large to make recipient sites.

Do scalp reductions save hair for future loss?

No! Hair is a limited resource. It is used up regardless of how it is moved and scalp reductions are just another method of moving hair around. Scalp reductions move hair to the crown at the expense of the front of the scalp, the cosmetically more important area. As a result of the reduction, the hair in the sides and back of the scalp is reduced in both density and looseness (This is why the procedure is appropriately called a “reduction”). The hair on the sides and back of the head thins considerably through the process and this, together with the tighter scalp, makes it more difficult to move the hair to the cosmetically important areas such as the frontal hairline and front part of the scalp. After a scalp reduction, the surgeon may never be able to harvest enough hair to complete the transplant. In addition, the scalp reduction can cause problems such a scarring, a thin scalp, altered hair direction, and a host of other unwanted effects. No wonder that the use of this procedure has dropped so dramatically in recent years! Learn More

Are lasers state-of-the-art technology?

No! Lasers are used by some hair transplant doctors to make the recipient sites. The laser works by using a beam of very high energy to burn a hole in the skin. But, regardless of how precise the laser, it still works by destroying tissue i.e. by making a hole. The beauty of Follicular Unit Transplantation is that the tiny follicular unit grafts can fit into very small sites that are made with a needle poke rather than by an instrument that removes healthy tissue. In Follicular Unit Transplantation, the blood vessel rich tissue that it is to receive the grafts does not need to be destroyed, so the growth is maximized.

With new surgical techniques, is it possible to restore a full head of hair?

No! All hair transplantation procedures move hair around to make you look better, but none create more hair. However, if performed properly and on the right person, it can make an incredible improvement in your appearance. The actual amount of hair you need may be as little as 25% if your original hair density. Those people with less severe balding can get a far higher density and come closer to their original look as long as the supply of donor hair is enough to meet the demands of the recipient balding area. This is something that you must speak with one of the doctors about.

If I am unhappy with a transplant performed by another doctor, can I have repair work done at NHI?

Of course, it is always better to do things right the first time. Unfortunately, many individuals have had hair restorations with less than satisfactory results. NHI has been able to develop strategies that can effectively camouflage many of the mistakes caused by less sophisticated procedures. Individuals have come to NHI from all parts of the world for repairs. To determine if you are a candidate for repairs, you should arrange a private consultation with a NHI physician.

Will new medications make surgical hair restoration obsolete?

No! New medications work best by retarding or preventing future hair loss. There are no known medications that can significantly regrow hair once it has been lost.

On what parts of the scalp do Propecia and Rogaine actually work?

Although their mechanisms of action are different and although Propecia (finasteride) is far more effective than Rogaine (minoxidil) they both work on similar “targets.” Both drugs work ONLY on miniaturized hair by increasing their diameter. Neither medication will work on areas that are totally bald i.e. that have no hair. Both work in any areas on the scalp that are subject to androgenetic changes i.e. the front top and crown. The medications work best in the crown where the miniaturization period is more prolonged. However, if there is miniaturization in the front of the scalp (this is particularly seen in younger persons with early hair loss) the medications can regrow hair in this part of the scalp as well. As far as preventing hair loss, they work in all parts of the scalp subject to androgenetic changes. Both medications are far more effective in preventing hair loss rather than “regrowing hair” (i.e. thickening hair once it is extensively miniaturized). Remember that finasteride is far more effective than minoxidil for both regrowing hair (i.e. thickening miniaturized hair) and preventing hair loss. Their actions do appear to be synergistic and their use together may be advantageous, particularly in young people, although on the long-term it is probably too much of a nuisance to use both. I generally just recommend finasteride for older people or for those considering hair restoration surgery. Much of the confusion stems from the FDA requirement that claims of pharmaceutical companies regarding their products must be limited to things that were actually tested clinically. Both Upjohn (Rogaine) and Merck (Propecia) did the testing in the crown since this is generally the area of greatest miniaturization and the area most likely to show the most dramatic response. I think that in trying to show effectiveness (a requirement for FDA approval) the drug companies overlooked the importance of frontal hair to a person’s appearance. In retrospect, they probably should have done studies both in the front of the scalp and in the crown, even if though the response of the frontal scalp would be less pronounced.

Why can’t Propecia be used in post-menopausal women?

The studies using finasteride 1-mg have shown that it is not effective. It may be useful at higher doses, but good studies showing its efficacy and safety still need to be done.

There are so many non-prescription hair loss products on the market. The ads sound so promising, surely some must work?

Remember, a prescribing physician “usually” has no financial interest in the drug he prescribes. He receives office visit fees from the consult or from performing a surgical procedure. When non-physicians sell products for hair loss they always have a financial interest. There is no other reason for them to manufacture, market and sell their product. More importantly, claims of effectiveness of non-prescription medications are not as strictly regulated by the FDA.

I was told to use an herbal 5-alpha reductase inhibitor since it is safer. Is that true?

Unlike food that is best taken as a “natural” substance, medications are taken for a specific problem. Therefore, one should take a form that is pure, where the exact dose is known, where controlled scientific studies have been performed and published in reputable medical journals to show its efficacy and safety, and where other ingredients of unknown safety are not included. It is generally not understood by the lay public that if a herbal form of a medication is taken at a dose that is as effective a medication then the same side effects have the potential to occur.

If a pregnant woman can’t even handle the pill how can Propecia possibly be safe?

Since the absorption through the fingertips can’t be measured, the FDA considers it all to be absorbed, regardless of how infinitesimal the absorption actually is. If there were really a concern the FDA would require men, taking Propecia to wear condoms when their wife is pregnant, but they do not even recommend this.

Once I start Propecia won’t I have to use it for life?

Not necessarily. You use it only as long as you want it to work to hold onto your hair. And there will even be better treatments in the future. However, regardless of future medical advances, it will always be much easier to hold onto your hair than to grow it back.

I heard that Propecia doesn’t work in older people, so why should I bother?

It is true that it is less effective in growing hair in older individuals, but a main benefit of Propecia, that of prevention of further loss is just as important.

I heard that Propecia works only in the back of the head?

No. It can work all over, as long as the balding is not complete. It has the potential to work wherever there are miniaturized (fine) hairs. It is just that the crown has a longer phase where the hairs are in their transitional state. That is why it is important to treat the front early on.

Why did Propecia get off to a bad start?

Propecia launched around the same time as Viagra (jokes and media coverage), which is unfortunate since Propecia can benefit a much larger percent of the population and is very safe.

My doctor gave me a combination of Minoxidil and Retin-A in a single solution. Should I use it?

We are generally against the physician-based practice of combining Retin-A with minoxidil. The reason some doctors do this is to get around the law that prevents a doctor, who sells medication in his office, from marking up the price of an individual medication more than 10%. The doctor, however, has the ability to charge anything that he/she wants if he makes his own formulation. If the formulation benefits the patient that is OK, the price might be justified, but in the case of Retin-A/Minoxidil, it is often a scam that actually harms patients. Here is why: Retin-A only needs to be applied once a day to exert its effects on the skin. That is why Retin-A is prescribed only once a day for acne, where all the other acne medications i.e. topical antibiotics and benzyl peroxide must be used multiple times. Retin-A works by altering the follicular epithelium (the outer layer of skin) so that it doesn’t keratinize (form a hard compact layer). This is helpful in acne because it keeps the opening of the follicles from clogging. By preventing keratinization, Retin-A also decreases the protective barrier of the skin and makes it more able to absorb medications (like minoxidil) and more sensitive to chemicals (like the propylene glycol and alcohol base of Rogaine). Since Retin-A binds well to the skin and exerts it influence over 24 hours, it only needs to be applied once a day. Using it more than once a day causes unnecessary irritation, without increasing its effectiveness. Minoxidil, on the other hand, needs to be used twice a day to be effective. Since the base of minoxidil (the propylene glycol and alcohol) is irritating, minoxidil should not be used more than twice a day. We are not overly enthusiastic about minoxidil because we do not think that it works well over the long-term and think that it is too fussy. We find that finasteride is far more effective both on the short and long-term. We will occasionally prescribe both to patient with early hair loss that are not yet candidates for a transplant, but for the most part, we use Propecia alone as our mainstay of medical treatment. That said, if patients are set on using minoxidil and want to increase its effectiveness, we suggest that they apply it to damp scalp as soon as they get out of the shower. Applying medication to hydrated (damp) skin can increase the absorption up to 5-fold, without introducing another medication and without causing excessive irritation. It also makes the hair more groomable. For patients who insist on using Retin-A and minoxidil, we would use them separately and stop the Retin-A as soon as there was any sign off irritation. Remember, irritated skin has very little barrier to absorption, so when you apply medication to irritated skin you are essentially dumping it directly into the blood stream. We know that oral minoxidil is a very potent blood pressure medication that can have very significant adverse side effects of the cardio-vascular system. That is why it is not used either as a first line, or even second line blood pressure medication, but only as a medication for patients with severe hypertension that don’t respond to other medications. If a person were not getting irritation, the only local damage would be that the Retin-A would make one more sensitive to the sun (and cause increased facial hair in women). The possible long-term systemic consequences, although probably remote, are unknown. Cardiac enlargement from minoxidil had been reported in a single animal study a number of years ago in England, but did not get much press here. To our knowledge, it has not been duplicated in humans. However, we are always concerned when minoxidil is used with medications that increase its systemic absorb ion such as Retin-A, since we know that minoxidil orally is a very potent and potentially dangerous medication. The main problem with the combination is that when patients begin to get irritation, they are afraid to stop using the minoxidil for fear of losing their hair. Since the Retin-A and minoxidil are mixed, they are forced to continue both, i.e. they are in a Catch-22. When they call the prescribing doctor, they are often advised to do things to decrease the irritation, even sometimes to use steroids…but not stop the medication. The doctor doesn’t generally give the proper advice and say to simply use over-the-counter minoxidil alone until the irritation subsides and then gradually re-introduce Retin-A as a separate medication a little at a time, since this would uncover the doctor’s scam. Therefore, the doctor sticks to his speech about the importance of the combined mixture and the patient is sometimes left with scarring (if the inflammation is not treated properly) and always left with a jacked up bill. (Minoxidil is over-the-counter and very inexpensive and Retin-A just needs to be used very sparingly, no more than once a day. So the cost is very modest.) We have seen patients that have been given a doctor’s mixture of an expensive, in house combination of Retin-A solution (which is very potent) mixed with minoxidil 4%, and told that they must use the combination four times a day. When they got irritation, they were not advised to stop the medication. They continued using this potent medication on an irritated scalp, with the risk of both local scarring (which some actually got) and the risk of systemic toxicity from the increased absorption into the bloodstream. In sum, the reason we do not like the combination is that it has some potential risk, it increases the irritancy and fussiness of a medication that we do not think is that effective to begin with, and most importantly, it is often abused.

But I don’t want to use the medication for a year and then have to stop and have all my hair fall out.

In the occasional case where there are side effects, they seem to mostly appear in the first month or two, long before the effects on the hair begin, so it is easy to stop it without a problem.

What about the dutasteride?

Combined blockers knock out over 90% of circulating DHT and may have increased side effects as a result. It is not yet approved for hair loss.

What is the medical term for shock loss?

The medical term for the very onerous sounding “shock hair loss” is “effluvium” which literally means shedding.

It would be very disconcerting to go through a transplant procedure only to have a high number of currently perfectly good hairs fall out through the process. Is this possible from shock fall out?

It is usually the miniaturized hair i.e. the hair that is at the end of its lifespan due to genetic balding that is most likely to be shed. Less likely, some healthy hair will be shed, but this should regrow. Rarely, but sometimes, we notice some shedding of hair from a prior transplant when transplants are spaced less than one year apart. However, this hair grows back completely.

How much fallout typically occurs?

For most patients, effluvium is not a major issue and should not be a cause for concern. In the typical case, a patient looks a little thinner during the several month period following the transplant, when the transplanted hair is in its latent phase. It ends when the transplanted hair begins to grow. The thinning is often more noticeable to the patient himself, than to others. Shedding is generally noted as a thinning, rather than of “masses of hair falling out”, as the term “shock fall out” erroneously suggests.

On what variables does the degree of fallout depend?

In general, the more miniaturization one has and the more rapid the hair loss, the more likely will be shedding from surgery. Young, actively balding patients would be at the greatest risk. Older patients with stable hair loss would have the least risk.

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