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See this remarkable result on this 80 yer old patient who has had his live transformed by 2400+ FUE with Dr Bhatti. See the video and the timeline of results as they come in at different stages.
A remarkable result and so great to know this gentleman life has been transformed.
See the pictures below to also help you see the remarkable transformation.
Unknown loss is truly a moot point, surgeons can test for miniaturisation in these areas. Its not as if this is any different for someone in their 30s either, hairloss is progressive by nature, this risk doesn't magically change because you're a 20 year old NW3 rather than a 30 year old NW3. There's also absolutely no evidence that balding younger means you're more likely to hit a higher norwood pattern. No matter the age of balding, there is no evidence that your chance of being NW6 or NW7 is higher. Donor management beyond this is again unrelated to age, and donor miniaturisation tests are common and simple. The often rapid speed of loss is the only issue that doesn't also concern those in their 30s, so chasing losses can be a problem, which makes meds almost a very worthwhile first consideration like you say. I don't think anyone heading to NW5+ in their twenties that refuses to take finasteride is mature enough or in a good position for surgery.
Imo its mostly fear of higher expectations + most guys this age aren't prepared financially or mentally for a bad result, and clinics don't want to bear that burden. I think this is a fairly good reason to avoid it for most guys in their early twenties, most don't have 10 grand for a surgery with a good surgeon and a further 10 grand for future surgery due to progressive loss or potential corrective work. At least in my case I first booked surgery right after turning 22 and what made it a success was that I was stabilised on meds, was very aware of risks and expectations, and had the money for multiple surgeries. It was absolutely the best time for me to have surgery and I'm sure for many others in the situation. Once you move out from home, work full time, start paying rent/saving for property etc the ability to take two weeks off and drop 10 grand on a hair transplant goes out the window to some degree.
I'd also look at a result like Melvins (who admittedly has good hair and donor characteristics) as emphasising that even if you're quite far gone, its still possible to get a sizeable improvement. It just takes a lot of money, time and proper research to achieve that. But I'm sure that for many guys in their early twenties with a similar hair situation to his starting point, they could handle it and its a hell of a lot better than living through your early twenties as a bald guy. For many its not a possibility, but its not a black and white cut off. By 21 someone should be able to make the decision and take on the responsibility. Should be emphasised that finasteride is a lot more important and helpful than transplants are too as a first point of action.
There are doctors out there that will not touch a patient until they are in their 30's. I find this a bit ridiculous, but I understand the basic concept.
I believe that the main reason why doctos prefer not to move forward with a procedure on someone in their late teens and early twenties is because (and there are many exceptions), the doctor is unable to tell the pattern in which the patient is thinning. Say an 18 YO shows up and he is maturing his hairline. The current hairline is in the middle of his forehead and you can see the corners starting to recede. After pleading with the doctor, the procedure is done and the corners are filled in. It becomes evident, 6 years later, that the patient is going to be a class 7. The patient experiences rapid thinning and the only thing that remains are two "horns" the doctor placed years ago.
There are stories like this out there, plenty of them.
That's not to say that the doctor can, perhaps, discuss medical therapy with that 18 year old.
I think the best way to approach this is to have the parents involved and discuss all options and possible outcomes. Educate everyone involved so they can decide. In my view starting someone at 18 on preventive meds for a year, let's say, is appropriate. Depending on the outcome, the patient can then decide if it is worth it for them to continue treatment. For transplants....it all depends on so many factors.