Dear Dr. Parsley,

I tried the microscope test you suggested today. It's definitely a case of miniaturization. Now, the surgeon (a colleague recommended by this site) wants to transplant from front to back (leaving the crown alone), going through a thin front, a 3 inch bridge that is miniaturized to notice it has thinned but is still "cosmetically dense" (you can't see the scalp there at all), and a very thin top. The doctor would be transplanting through the bridge. I had just started Propecia, and the doctor made no mention of Rogaine. When asked if I should be on it, the surgeon I saw didn't think it was important.

Based on what you've said, I feel stuck between a rock and a hard place. If I lose the hair I do have from permanent shock loss, then a transplant will be as you said, three steps forward but two steps back. For me, as for a lot of people, one step forward for this kind of money when three steps are possible is a tough pill to swallow. If I don't have the transplant, well, I stay unhappily where I am (not too many people happy with their situation post on these boards, as you can tell). I can stay on Propecia and hope to stay where I am, but even if I regrow a little, I'm still a 4V. Maybe you think one of the concealer products like Toppik would be the best solution?

Quickly on the idea of a shock loss study, Limmer's article on density as you recall describes a number of different hair counts. Even without a hair count, I would imagine you don't have to do an actual hair count to see if there was significant shock. If they have been on Propecia or Rogaine or both and have stabilized their loss, if they lose hair from a transplant that does not return, I would imagine you could tell they'd suffered shock loss and maybe you and other doctors could identify specific trends (like how miniaturized the hair would have to be in order to be permanently lost). If some trands have been identified, they don't seem to be reliable indicators because you say shock loss is so unpredictable.

This is rather troublesome for a lot of men I suppose. You go to a surgeon to restore hair but find out you will need more hair transplanted than the hair you needed to fill in the thinned out areas. Sort of like when you take your car into an auto shop and they make more work for you than you originally needed. I'm of course not suggesting that HT doctors are happy about shock loss, but the analogy (I hope) illustrates the intense frustration the issue presents given the inability to really nail it down and eliminate it.

At any rate, I hope this provides some food for both thought and study. I don't know what to do. I first thought a transplant could just fill in the areas that were badly thinned out in the front and toward the back of the top. I didn't realize that I might have to be transplanted as if I had already lost hair I still had.

Dr. P and other posters, I'd welcome any suggestions on what to do. I won't hold any of you to your suggestions. And of course, those like Jeff who have similar issues, keep us all posted on your progress.

-AP

yes, the fate of your remaining hair is a real "wild card" in the long term outlook. for a guy that has "balded out" and is stable the bright side , to me, in his situation is he doesn't have the prospect of future losses to complicate everything. for me, i like to simplify issues and take a long term perspective. i believe that all the remaining hair on the top of my head (crown was already bald) is going away. it may have lasted longer without the shock of surgery, but it was destined eventually to go away. so i planned my strategy as if it is already gone. i asked my surgeon to plant the grafts uniformly as if i was already bald. i don't really think it came out quite that way, but mostly it did. (i think the grafts were concentrated mostly in the front and crown, and that mid-frontal area between there and the crown itself is VERY lightly planted. i am not disappointed it was not totally uniform as one has to realize there is a limit to what 2,000 grafts can do in a first session). if i retain any of my original hair a year from now i will just consider it gravy. i do expect to do a second procedure, but will wait until i see if propecia works and how my balding is progressing....that is, mostly how the area around the crown is doing. my feeling for now is to "keep my powder dry" (preserve that donor supply) and wait a while. probably a few years anyway. my point is that for me it was beneficial in planning to just forget the original remaining hair. hope this adds a different view that may be helpful.

It was true that the best idea was to forget the miniaturized hair because it was definitely going to disappear in the near future. However, Propecia (and to a lesser extent Rogaine) has changed that. Until they are used, we don't know what we can accomplish with these hairs. Cutting DHT 65% in some people will result in an explosive regrowth while in others it will only slow the loss. Dutasteride may improve these results but I personally will be reluctant to use this drug on young people when it first comes out. Too many questions about the safety profile for this age group.
AP, if you are going to someone on this site, then I would trust their opinion. I know nearly all the doctors recommended and they have excellent credentials. They have seen you and I haven't. In transplanting, you have to blend the transplants into these areas of miniaturization or it could look a little odd. You need to understand that how to handle areas with a lot of miniaturization is one of our most difficult decisions and most doctors still are working hard to formulate their plan of action. To make it more difficult, these new drugs change the playing field constantly. That is the challenge and the reason you get conflicting advice.
I need to back off a little and let some of the other doctors (who probably have more valuable insight to give than myself) to respond. I hope these discussions are giving you some insight into what we, and you, face with these decisons.
Dr. Parsley

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Dr. Parsley is recommended on the Hair Transplant Network