if a HT patient was in a slow ongoing balding situation, then had a good HT (including light crown coverage), what is the likelihood and what have you seen in terms of a patient like that continuing to bald, thereby complicating the good result of the HT? thats basically my situation.....47 yrs old, norwood 4 to 5, had 2100 all FU HT on Nov.7 (about 1300 in front, 700 on crown), been on propecia about 3 months, my hair type is fine and thin, with a lower than avg. donor density. my concern is mainly concerning the crown. i read a paper by HT surgeons...they make the point that attemting the crown can make large demands on the donor supply if the patient continues to bald after the HT (see "follicular transplantation: patient evaluation and surgical planning" by bernstein/rassman in the research library).
i worry that at my age, with ongoing slow balding, that if the propecia does not work for me, i could get into a situation like a dog chasing his tail. of course, one can always get another procedure to address future balding, but there is a limit to your donor supply. i am wondering if i should grafted my crown at all. what about it doctors, patients....have you seen much of this kind of problem?

if a HT patient was in a slow ongoing balding situation, then had a good HT (including light crown coverage), what is the likelihood and what have you seen in terms of a patient like that continuing to bald, thereby complicating the good result of the HT? thats basically my situation.....47 yrs old, norwood 4 to 5, had 2100 all FU HT on Nov.7 (about 1300 in front, 700 on crown), been on propecia about 3 months, my hair type is fine and thin, with a lower than avg. donor density. my concern is mainly concerning the crown. i read a paper by HT surgeons...they make the point that attemting the crown can make large demands on the donor supply if the patient continues to bald after the HT (see "follicular transplantation: patient evaluation and surgical planning" by bernstein/rassman in the research library).
i worry that at my age, with ongoing slow balding, that if the propecia does not work for me, i could get into a situation like a dog chasing his tail. of course, one can always get another procedure to address future balding, but there is a limit to your donor supply. i am wondering if i should grafted my crown at all. what about it doctors, patients....have you seen much of this kind of problem?

Jeff's concerns are very real and one that is considered by transplanters. Transplanting the vertex(crown) at an early age can lead to a halo of hairloss around it later, leaving a "nest" of hair in the center. As opposed to the frontal hairline where we have a defined border, in the crown we are working inside the hairline with a border that moves. As a loose rule, I don't work on the crown until someone is past 40 yrs of age -but you have to judge each patient differently.
Jeff, I think you have little to worry about. You are 47 and and are on Propecia. The 5 yr studies are back on Propecia and show that 65% of people taking this drug have more hair than when they started. Compared to people not taking the drug, the difference is huge. Even the 35% who had less hair still had 151 hairs/sq inch more hairs than the controls. It's help has been far greater than I had imagined. For many patients, it appears that Propecia will severely reduce the number of transplants over their lifetime and dramatically improve what can be accomplished. I have many patients that I am hopeful might never need another transplant.
I would suggest adding 5% minoxidil to your regimen. It is supposed to be used twice daily but I have some who do very well using it only at bedtime. It works in a different way than Propecia and adds about 20-30% more improvement according to the experts. Someone on another thread mentioned that they stopped Rogaine after starting Propecia because they didn't think they needed it anymore. Predictably, his hair started shedding. This is because Rogaine holds hair longer in a growth phase. On stopping Rogaine a huge number go into the resting phase at the same time. Even without restarting Rogaine he will get some of the thickness back. But why stop it? It is safe, fast, and relatively inexpensive now. Certainly worth using, even though it is not in the same league as Propecia.
Another problem that comes with aging can be your blessing - gray hair. With old plugs, there was a saying: "Pray for Gray". Gray hair can make even old plugs look smoother. I don't think that will be necessary with you anyway since you had a thin pattern and you hair is fine (another bonus for the crown). It looks like you and are in good hands and that your treatment is conservative. You will do fine.
Dr. Parsley

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it sounds to me that propecia may be more successful for people than i had thought. and maybe, as arfy said, dutasteride or something yet unknown may do better. i have to admit i'm a little skeptical of drugs long term.

Propecia is more successful than we at first thought and I admit that I was one of the skeptics after seeing so many things that fizzled with time. It's biggest problem, as Arfy pointed out, is that it works slow. You will be lucky to see results within 6 months and its benefits peak out at 2 years. I have had so many patients tell me that they used it for 4 months and stopped because it didn't work. It shouldn't be started if the person doesn't plan use it for at least a year. Also, just stopping hair loss is still a good result if you compare results to controls over 5 years.
I agree with your concerns of long term use of any medication. However, finasteride has been out around 10 yrs and at doses 4 times higher than hair doses. It appears to be safe and all side effects appear to be reversible, but it is still being watched. Because the benefit-to-risk ratio looks good, I encourage (but don't push) all my patients to consider it.
Dutasteride, which blocks both Alpha Reductase type I & II, will be out on the market soon and will probably be a stronger hair regrower than Propecia. It lowers DHT 90% to Propecia's 65% because Propecia only blocks Alpha Reductase type II. It will have to be used off-label by the transplant doctors if it is to be used. While the safety profile of Propecia has been pretty well worked out, the profile for dutasteride still leaves some questions. Still it looks promising for future use. It may be 4 years before it is approved for hair.
Dr. Parsley

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Dr. P and other posters,

This is a good topic and a good discussion. I have some concerns about Propecia as it relates to having a transplant. I'm really concerned about permanent shock loss (I could live with temporary loss). Like Jeff, I'm a Norwood 4.5 with fine hair and crown loss (I think by the "crown" we are talking about the area back behind the high point on the skull where the hair changes direction?). I am now taking Propecia to try to keep from becoming a full 6.

I have hair that I would probably keep if I keep taking Propecia, which I started three months ago. But what I read about shock loss is that you lose hair that is genetically programmed to fall out. The hair I'm trying to keep has thinned a bit and will fall out without the Propecia. But the surgeon I saw wants to transplant through that thinning hair because it's in front and on top. So I'm worried that the shock loss will negate the benefit I hoped to gain from the Propecia--to keep existing hair so that it can help make a transplant look good given my unfavorable hair characteristics.

I don't know what to do about it. I know a permanent frame for the face is priority #1 but it will look really silly if there is too little behind it on the top of the head. I think most people who haven't gotten to full stage 6 yet or who are losing hair a bit younger feel the same.

Anyway, I look forward to your intelligent comments. This "thread" has been a good one.

Best wishes to all,
AP

it sounds like we are in a similar situation. i also thought my hair characteristics were unfavorable as they sound a lot like yours. i wished i had thick hair as it seems to be better than fine. but any more, my thinking is that fine hair might not be such a bad thing to have for HT's in some ways...if after my HT i have a fairly thin coverage (i also hope to retain whats left of my front hair) which might blend well with the sides and back which are naturally fine and thin. my surgeon did transplant through the front to the crown. i'll report back if i lose the original ones there. my feeling is that if i retain it and with the added grafts, maybe i can end up moderate in front and thin on the crown. i guess a guy could wait until the propecia really has had a chance to work before surgery. i did my after 2 months on propecia.

AP, you asked a very important question and one I can't completely answer - no one can. That is, what about transplanting into thinning hair? I consider thinning hair divided into 2 groups: 1) thinning because the number of follicle units/sq cm is severely reduced - say down to 5-15 units or 2) thinning because the hair is miniaturizing severely and uniformly yet the FU's/sq cm is 40 or more. Case (1) is fine for transplanting as there are not that many hairs to shed and there is space to transplant. Case (2) is a problem because the hairs are weak and there is not much room to transplant. You may move 3 steps forward but also 2 steps back as a result of transplanting. Shedding is somewhat unpredictable - some people are more prone to it - and also the return is unpredictable. When to transplant into case (2) is very much a matter of judgment. Until it thins enough, I generally only go into those areas to blend that area with transplants into a more forward area that I transplanted heavily.
The good news is that case (2) is where Propecia does its best work. Also Rogaine. I do push these medications a little to those patients.
If you want to determine your FU counts, there is a simple way. Radio Shack sells a pocket microscope (30x) for about $7. Scissor clip your hair in a 4-5mm circle down close to the scalp. Look through the pocket microscope and you will see clearly the different FU's. Count the groups, not the individual hairs, and multiply it by 10. That number will be your FU's/sq cm in that area. It will help you be part of determining whether you are right for transplanting that area.
Good luck.
Dr. Parsley

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Dr. Parsley,

Thank you for your post. I was just reading another thread and I realize these forums become heated sometimes, but don't let that deter you from participating. I wish more doctors would.

Just in response to your suggestion on using a microscope to determine whether areas have suffered hair loss or just very visible
miniaturization, would a densitometry reading actually be the most accurate way to tell?

I have read that shock loss can affect miniaturized hair even if you are transplanting into other areas. I wish there were some real clinical studies on shock loss rather than just anecdotal evidence. I hope you and your colleagues would consider embarking on such a study. It would be of great value to many patients. Merck commissioned a study on Propecia's effects on transplant to MHR but I think I speak for a lot of other patients and potential patients in saying that MHR, like Bosley, carries little credibility on these boards and I am disappointed Merck chose them rather than one or several of the doctors on Spencer's or Pat's list(s).

Thank you,
AP

Densitometry will help you quantify the loss of FU density but, no you don't have to have it. I just look generally at the total amount of miniaturized hair. It is possible Propecia might help reduce the shedding but there are some studies to suggest that Rogaine might help. I generally start Rogaine 5 days after the transplant. Some studies suggest starting Rogaine 3 wks before the transplant helps but we need more studies to confirm it.
Some people seem to be extremely prone to shedding. I suspect just anesthetizing the scalp in some people can bring it on. Because on this, I warn patients of these unpredictable risks and let them decide if they are willing to accept them. Of course, if a patient has really large numbers of miniaturized hair I won't tranplant them regardless of their motivation. Fortunately we have Propecia which is tailor-made for these situations where there is a lot of miniaturization.
You are right in saying that we need better studies on shock loss. However, these are very tough things to study. Counting hairs is difficult.
Dr. Parsley

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