Dr. Michael Beehner

Joanne, By 15 months one can usually see almost the full "flowering" of the transplant's results. The fact that you feel certain it is worse would indicate that you probably did have some permanent shocking of some of the vulnerable hairs on top that were partially miniaturized. My guess is that a fair percentage, possibly 15-30% of the hairs on the back donor area of your scalp were miniaturized also. Do you recall if the doctors there did a microscopic exam of the hairs in back to make sure there wasn't a lot of miniaturization present? That is the biggest risk factor in my experience for a poor result in a female. The fact that you have evidence of female pattern hair loss at only the age of 19 is significant also. Then there is the whole matter of the technique used and whether the recipient sites were kept small and the grafts were cut correctly and placed in a safe, non-traumatic manner. All of the above having been said, I have seen two females in my 20 year experience of transplanting females in whom the growth of hair was rather stunning around 15-20 months out. I had no good explanation for the delay in them, except that one of them had Sjogren's Disease, an auto-immune condition. I wish you the best, but it may turn out that a lightweight, natural appearing hair piece may be your best answer. Mike Beehner, M.D.

Crow1, I have no idea what percentage of the patients shown with "befores and afters" owe some of their "fullness" to finasteride or dutasteride. My guess is that it probably plays a role in at least 10-20% of those shown. That is probably true for the ones I show, except for the "shiny bald" ones. Mike Beehner, M.D.

Andyman, "Attacking" is probably not the best way to think about what is happening. A better way to picture it is that the presence of DHT (which virtually every man has) PERMITS the genetic expression of each individual follicle to occur. The follicles on the sides and back of our heads have no genetic programming for miniaturization and eventual loss, whereas the follicles on the top of the head of men with hair loss do have this genetic programming. An experiment was done around 50 years ago, I believe by a Dr. Hamilton, in which he followed the paths of around a dozen pairs of identical twins, one of which was institutionalized and castrated (yes, those things occurred back then!) and the other was mentally normal and out in the world. The twin who was not castrated went on to lose all his hair on top, but the twin brother in the institution kept all of his hair because he there was no DHT present, since the testicles which produce testosterone, which breaks down into DHT, weren't present. My recollection is they then gave testosterone to the institutionalized twin (cruelty on top of cruelty) and he then went on to lose his hair. Regarding the question of whether a man who has had a transplant is better off taking finasteride after his transplant or not, I believe he is - providing he has native hair on top that can still be salvaged and reversed from its miniaturization. If he is middle ages and a Norwood Class VI (shiny bald on top), then I generally don't advise taking it. I don't believe good proof has ever been shown that transplants do better with finasteride. A good way to picture the benefit of adding finasteride to the treatment package along with transplants is this: imagine two men with a similar hair loss pattern have a transplant and then return to see their doctor 4-5 years later. One takes finasteride and the other does not. The majority of men using finasteride, in my experience, have a net gain of hair mass during those first 5 years of treatment. When the doctor and the patient who had transplants plus finasteride looks at his results, he is looking at an ADDITION of two things: the newly moved transplanted hair PLUS the increase in hair mass from the medication. The other fellow who didn't take finasteride is instead looking at a SUBTRACTION on his head: the addition of the transplanted hair on top MINUS the increase in male pattern baldness that occurred during those years. That difference is a huge one. The man who doesn't take finasteride often unfairly blames his hair surgeon for not bringing about the transformation he envisioned, whereas the patient who did both often gives undeserved credit to the transplant for creating such a great result when half of the credit is probably due to the finasteride. Mike Beehner, M.D.

The higher 100/cm2 density you refer to was from some of the earlier work and was mostly taken from the rear donor area, where the hair is usually the densest. More recently, with several doctors looking closely at their average measurements in that rear donor area, that 100/cm2 number is considered on the high side, and most now say they on average see donor densities of 80-95. There are occasional men with densities up over 120, so there is a wide range that is seen. Mike Beehner, M.D.

Bill, Her study was published on the front page of the International Forum in the March/April 09 issue and was on 14 men. She initially tried to do 50, but excluded a bunch of them because there was some early crown thinning and she didn't want anyone with androgenetic alopecia evidence. Thus it is not absolutely statistically significant but does give a good glimpse into what is a realistic density on normal men's heads. The 60 FU per cm2 is certainly not the practice of the majority of hair transplant doctors. In our ISHRS Journal (the Forum) 2 issues ago, a doctor from Europe showed a high survival rate of 100 FU's in a cm2, but the grafts were put in absolutely perpendicular, which is about the only way you can accomplish that - but the aesthetic result of grafts placed in an upright angle is horrendous and very abnormal. Mike Beehner, M.D.

First of all, it should be noted that a very good recent research study by Dr. Sharon Keene from Tuscon showed that in "normal" men without male pattern baldness, the average FU density at the front hairline was 51 FU/cm2 with a range of 38-78. The average density in the temple apex region (behind the recession) was around 44 FU/cm2 with a range of 25-64. The biggest factor in predicting whether or not the 35-40 FU/cm2 density you mentioned would look "dense" is the diameter of the hair shaft. In a man with coarse hair, that could indeed look dense. In a man with fine hair, it would probably be "see-through." The other factor besides just stating an FU number per cm2 is the number of hairs that the FU's average out to. Obviously, at the very edge of the front hairline you would want all 1-hair FU's, but I think it's important to switch to 2-hair grafts fairly quickly as soon as you get 2-3 grafts deep into the hairline zone. What a person should be looking for, at least as far as the hairline is concerned, is the artistry of the hair surgeon, not how many FU's he can cram in a single CM2. If you get maximal density right up to the edge of the hairline, it looks very fake and has a tendency to look straight and unnatural, almost as if you were wearing a hairpiece. A whole host of other factors also play a role. How steep of an angle is the hair going to be placed at? With extremely acture angles it is more difficult to achieve real high numbers, but often the steep angle looks more natural. Is the scalp thick or thin? If it is a thin scalp, the surgeon will want to decrease density so as to get enough vascular support to the grafts that are planted. It doesn't do any good for a surgeon to heroically place 60 grafts in a square cm if only 60% of the follicles survive. So the gist of my answer is that it is a nuanced, complicated question, not a simple one. Mike Beehner, M.D.

Mick Reno, Your photo sure looks like early male pattern baldness caused by heredity and the normal presence of DHT (which every male has). In males a pattern of hair loss like you have is 99.9% of the time the above diagnosis. There are some rare "zebras" out there. One is a condition called "diffuse alopecia areata," but I have only seen one case in a colleague's practice and it was a female. If your history was a rather recent one within a matter of several months, then one thing to rule out would be a "telogen" reaction, which can occur in response to a number of things: certain medications, an acute illness such as pneumonia, a general surgery or general anesthetic during surgery, chemotherapy, a severe crash diet, a stomach-stapling procedure, and a host of other things. The best way to diagnose this is, during the shedding, to do a simple "hair pull" test on a bunch of hairs on top. Normally, you don't pull any out or maybe 1-2. During a telogen reaction, you will pull out 5-10 with each pull. They are sitting there, unattached to the follicles, which have shrivelled as a response to the inciting cause of the telogen. The other best way to make this diagnosis is to just wait several months (assuming you are not continuing the offending behavior or agent) and the hair will fill back in again. Then you can look back on the event and it is easy to determine it was a telogen shock event. There is a genetic over-the-counter test for hereditary hair loss, which you may also want to try. I believe there are a certain number of false-positives and false-negatives though. Mike Beehner, M.D.

I would call him an "advanced Norwood VI" but very close to being a Norwood VII. Also, my experience is NOT that the side fringes stabilize in the patient's 30's but rather they stabilize in the mid-40's. The rear vertex/crown can go on to recede even into the 50's lower and wider. Again, because your grandfather followed a certain pattern is no guarantee that you will follow suit. You may have a totally different amount of hair loss and on a totally different timetable than he did. In the real world, it's rather academic whether your grandfather is called a Norwood VI or VII. The main issue, if he were to present to me for a transplant, is: what is the ratio of good, safe donor hair available for what he needs? Can I fill in the whole bald area for this man? The answer to the last question is obviously "no," so it is then the surgeon's job to picture in his mind how much hair he CAN obtain in 2-3 sessions and then draw a pattern that will make the patient happy while using his realistic hair reserves to do it. Mike Beehner, M.D.

Combatinghairloss, We offer the Graftcyte to our patients, but it is probably overpriced ($155). Many people think that the simple act of frequently spraying a moist vehicle to the scabs is the key to speeding up the healing and falling off of the scabs. If so, there is a Biotin spray, which only goes for $15-20, which we keep around at times, which is obviously a lot cheaper. Also, and possibly even better, is the constant application of some oily or ointment vehicle. It could be Vitamin E oil, Bacitracin Ointment, or even plain Vaseline from a clean new jar. The downside is that it is the messiest way to go, especially on the pillow at night, but I think it is the fastest way to get scabs off. With this regimen, the patient applies a thin layer of any of these greasy compounds to the transplanted area. It is usually nice each AM to wash off the stuff applied the previous day. If an ointment was used, the best way is to use baby oil to first liquify the ointment, and then use Dawn detergent or a similar grease-cutting soap. Then you could finish with your favorite shampoo and conditioner. When you have toweled off, blotting the area and not rubbing it, you then apply that day's first thin application of the oil or ointment of your choice. The only problem with starting right off with this stuff applied immediately after surgery is that it sometimes inhibits the coagulation at the graft site and the grafts remain "slippery" and can even slide out, so sometimes a few hours wait is in order before beginning the regimen. I should finish by saying that I have seen a few "miracles" with the Graftcyte, where people came back 6-8 days later and it was almost hard to tell they had surgery. Whether it was the copper peptide or they just responded well to the moist environment created by the packs and the spray I don't know. Mike Beehner, M.D.

To "I miss the barber": First of all, there's a huge difference between a Norwood III and a Norwood V. With a Norwood V, you are essentially looking at the outline of that patient's future Norwood VI pattern. All Norwood V patients go on to become at least Norwood VI's. So then you have good insight into how wide that man is likely to go, especially if he's in his mid-30's or his 40's. The family history is a nice piece of information to have tucked back in your brain, but it should never give a hair surgeon a confident feeling with a man in his early 20's that that patient cannot possibly go on to become a Norwood VII simply because his male relatives two generations removed didn't do so. As to the "how wide the sides are," I had mentioned in previous notes that when a patient's certain width of baldness reaches 15cm, the surgeon should be thinking about a forelock type of pattern, with maximal density in the front-central area and a gradient of density between that and the sides, whatever distance that is. As far as the rear area of baldness goes, it is good in these situations of mismatch between available donor hair and massive areas of baldness to stay out of the rear vertex region - that is, the circular or oval area of the rear scalp that is behind that point at which the slope of the head starts heading downhill. I hope that helps answer your question. Mike Beehner, M.D.

Be Happy, You have summed up the dillemma of the young patient in a nutshell. The surgeon (nor the patient) really, really doesn't know how bald he is going to be 20 years down the road. I do think, however, if you stay out of the rear vertex, don't put the hairline too low, and - most importantly - don't go too wide in front or try to close the fronto-temporal recession areas, that you will be safe in the long run, and even with borderline donor supplies, you can find some FU's to blur that space between the front-central forelock mass of hair and the side fringes. As I have said before, styling the hair backwards makes it look the best and the fullest. Some men have hair that "travels" well and can be taken back, while some men have wavy, stiff hair that doesn't lay over each other that well. A few of these maybe shouldn't be transplanted. But you're right - once a hair surgeon gets you started with a low, aggressive hairline, you are stuck on the hair transplant merry-go-round, and unless you can remove all of them or at least the offending ones off to the side, you have no choices but to make the best of a bad situation. One solution that works great, but not many men actually do it, is to invest the transplants into the front half and get a small clip-op hairpiece for the back half and vertex. Mike Beehner, M.D.

Our choice of whether to use needles or custom-cut lateral slit blades is identical to what Dr. Cooley stated. When I want to "dense pack" in a limited area, which is usually up front or in the temples, I like the small custom blades, but when making FU sites amongst existing native hairs, we also prefer the solid core needles for the exact reasons Dr. Cooley stated - the fact that they are more precise than the blunt, squared end of a lateral slit blade and they push the hairs away from the path of the needle. Also, there is the benefit that they slightly dilate the hole more than a lateral slit does, which facilitates in visually seeing the site when the tech or I are placing grafts. Mike Beehner, M.D.

To mmhce, First of all, it is very difficult to tell whether or not a NW3 is going to progress to a NW7, since by definition the hair all through the central area of the scalp would be thick. I am assuming you are referring to a male in whom you could see early thinning in a wide area throughout the top of the head and can project that the eventual area of baldness is going to be very large, and, in the case of a NW7, that the side fringes are going to reside down along the side of the head. I agree with Bill's comments above. There is not magic presently that allows a hair surgeon to come anywhere close to filling in the entire bald area. So that leaves two choices as extremes: One, to place small grafts all over the balding scalp with rather sparse density, or two, to choose rather to place hair in a limited area that strategically does the most good and elect not to place hair in some of the scalp areas that are of less importance in styling. The main thing that hair transplantion does for a man losing his hair is that it FRAMES THE FACE. A forelock type of pattern can do this for a man who has a severe degree of baldness (as the man in the link below with a before and after photo from my practice) and can also be used as a design template for a younger male who hasn't quite lost all this hair, but one is fairly certain this is what is going to happen. The forelock pattern seeks to place the relatively densest area in what we call the "frontal core" area at the front center, and then all the other hairs along the side hairline and behind the forelock are gradients of lesser density. This type of pattern is best styled backwards, either straight back or toward one of the rear corners. Using this type of design, either the "shield" shaped one or the oval shape, almost every man who presents for hair transplantation can be helped. The only ones that can't be helped are those who can't lower their expectations enough to accept this type of design. Mike Beehner, M.D.

The interval between surgeries will be different for different types of patients, and will certainly be a little different from one physician to another. However, to help understand the decision, there are basically four important reasons in my opinion for waiting 10-12 months between surgeries in most cases as a minimal interval: 1) As Bill mentioned, you want the donor laxity to return, so that a second donor strip can be taken and closed with a resultant thin donor scar. 2) The blood supply of the scalp has to recover from the insult of surgery and be capable of adequately supplying blood and oxygen to the second crop of tranplants. 3) The hair from the first session must be growing, so that the hair surgeon doesn't directly damage previously placed hair follicles. While it is true that most of these first session hairs will make their appearance between 3 and 6 months, sometimes there are stragglers and in some patients the initial appearance of the first transplants is a little longer than average. 4) It helps for the patient to see the evidence and be impressed with the growth of the first session before making the commitment of money, time, inconvenience, and donor hair to doing it all over again. The longer the hair surgeon waits, the happier the patient that is in his chair that second time. With all of the above said, there are still some exceptions. I know that several years ago, when I did sessions 8, 6, and even 4 months apart, that the hair did in fact grow - but the big unknown factor is that our present day sessions are much larger than 10 years ago and the issue especially of whether or not the vascularity (blood supply) of the scalp has returned to an adequate level is the big factor for me in waiting. Two examples I can think of in which I will do the sessions 8 months apart are the patient with a hairpiece who is very anxious to get out of it and rely on transplanted hair alone; and the second one is a patient who has unusual time constraints, such as one of my patients who was from China and teaching at an American university, and wanted to get his second session in before heading back home. Other than these types of exceptions, in my own practice 10-12 months as a minimal interval works well. Mike Beehner, M.D.

Over the past few years Bill and Pat have asked me to share with the reading audience my rationale for using MFU grafts (multi-follicular grafts, 4-6 hairs each) in the hair transplant planning for some patients. I will try to do so here. First of all, in order to get our terminology straight, the difference between a "minigraft" and a MFU Graft, is that the minigraft is cut with less magnification, usually with "loupes" and are "cut to size" and often have a little transection in the cutting process. A MFU graft is cut, at least in our practice, under a 10x stereoscopic microscope and the nurse in our practice who specializes in cutting them each case that we use them, under high magnification dissects out a graft that encompasses two (or sometimes three) FU's that are in close proximity to each other. Incidentally, MFU grafts can be placed into either a small slit (usually made in what we call a "parallel" orientation) or into a small, round hole (usually 1-1.3mm in diameter; about the size of pencil lead) I'll attach a photo of some Double-FU Grafts at the end of this note. ADVANTAGES: 1) In most research studies performed looking at hair growth/survival in follicles within MFU grafts, the survival has been 100%. It is presumed that this is because of the fact that they are buffered and protected by the tissue around and between them, and thus are less susceptible to trauma and drying. Also, hidden "telogen" stage (hibernation) hairs are often present and grow out later, which with FU disssection might be stripped away. 2) Their use makes the hair transplant more affordable, as a smaller number of overall grafts are used, and thus less work is necessary and the charge is correspondingly less. 3) In a unique way they help create the illusion of density. The best description of what I am referring to was made by Ron Shapiro in the Unger textbook of 2004. Ron may feel differently now, but I want to quote his words in the text, as I've never heard it described better: "For approximatley 2 years, I have considered the possibility that, in selected patients, the addition of multi-FU grafts to the less scrutinized central recipient area may improve the final illusion of density I can achieve without sacrificing naturalness to a clincally significant extent. This central recipient area includes the mid-scalp region and the posterior aspect of the frontal region.......I asked myself the question: Are there some properties of multi-FU grafts that create a greater illusion of density than FU's used alonge? My current answer to this question is yes. I believe that at the lower than normal mathematical densities created during hair transplantation, multi-FU grafts jave tje abo;otu tp create a greater illusion of density with the same amount of hair than when FU's are used alone......When multi-FU grafts are used, the space between the FU's within these grafts is at normal density (or higher than normal density if a degree of contraaction occurs). Light has a more difficult time passing between the FU's within the multi-FU grafts at these specific points of higher density. Thus, an equivalent amount of hair placed as multi-FU grafts gives one the ability to create an optical effect that lends a greater illusion of density than FU's alone." These words express wonderfully what I have believed for many years to be true of the use of MFU grafts in hair transplantation. They enable me to tackle a larger area than I could otherwise do with only FU's. DISADVANTAGES AND CAUTIONS: 1) There are some men in whom they should not be used: a) Someone who says he is only going to have ONE procedure. Using MFU grafts requires at least two, and preferably three, sessions to complete the hair transplant project. b) Someone is whom, after examining the hair/scalp characteristics, one judges that the MFU grafts would be detectable. The commonest instance is the man with dark, coarse hair and a pale colored scalp. Only FU's should be used here. I have noticed over the years that men with a golden-brown colored hair and oily, hyper-elastic scalp have an unnatural look with MFU's and I use all FU's in these. c) All females: For two years now I have been using only FU's (average of 1600 per case) in my female cases and have put a hold on using slit-MFU grafts which I used for a great many years. In that time I have noticed that the incidence of shocking to residual native hairs is much less. It seems the hair on top in females is much more vulnerable to shocking and that larger recipient sites seem to bring this on easier. I have not noticed a similar effect in males. 2) MFU's should only be used in the front-central regions. I don't even use them in the posterior midscalp anymore, to avoid any possibility of their being detectable. They should be placed closely together, in a random distribution (not rows), and placed at an acute angle, which helps them overlap and ride over each other to magnify the illusion of density and minimize detectability. Placing them in a perpendicular orientation (straight up) totally ruins the naturalness of their appearance. Doing so with FU's doesn't look so good either. Thanks for hearing me out. That pretty much covers the topic. I have to admit that in the past 3-4 years, in most of my patients who have a relatively small area that needs transplanting (frontal area or smaller), I have switched to usually recommending the dense-packing of FU grafts as the initial approach. The lateral slits have made a huge difference in our ability to place grafts close to one another and minimize blood supply damage. I would just ask that people be open-minded and realize that there is more than one way to skin a cat, and that, if used artistically and wisely, MFU grafts can help some men achieve their goals and do so at a cost they can afford. Mike Beehner, M.D. Saratoga Springs, New York

Over the past few years Bill and Pat have asked me to share with the reading audience my rationale for using MFU grafts (multi-follicular grafts, 4-6 hairs each) in the hair transplant planning for some patients. I will try to do so here. First of all, in order to get our terminology straight, the difference between a "minigraft" and a MFU Graft, is that the minigraft is cut with less magnification, usually with "loupes" and are "cut to size" and often have a little transection in the cutting process. A MFU graft is cut, at least in our practice, under a 10x stereoscopic microscope and the nurse in our practice who specializes in cutting them each case that we use them, under high magnification dissects out a graft that encompasses two (or sometimes three) FU's that are in close proximity to each other. Incidentally, MFU grafts can be placed into either a small slit (usually made in what we call a "parallel" orientation) or into a small, round hole (usually 1-1.3mm in diameter; about the size of pencil lead) I'll attach a photo of some Double-FU Grafts at the end of this note. ADVANTAGES: 1) In most research studies performed looking at hair growth/survival in follicles within MFU grafts, the survival has been 100%. It is presumed that this is because of the fact that they are buffered and protected by the tissue around and between them, and thus are less susceptible to trauma and drying. Also, hidden "telogen" stage (hibernation) hairs are often present and grow out later, which with FU disssection might be stripped away. 2) Their use makes the hair transplant more affordable, as a smaller number of overall grafts are used, and thus less work is necessary and the charge is correspondingly less. 3) In a unique way they help create the illusion of density. The best description of what I am referring to was made by Ron Shapiro in the Unger textbook of 2004. Ron may feel differently now, but I want to quote his words in the text, as I've never heard it described better: "For approximatley 2 years, I have considered the possibility that, in selected patients, the addition of multi-FU grafts to the less scrutinized central recipient area may improve the final illusion of density I can achieve without sacrificing naturalness to a clincally significant extent. This central recipient area includes the mid-scalp region and the posterior aspect of the frontal region.......I asked myself the question: Are there some properties of multi-FU grafts that create a greater illusion of density than FU's used alonge? My current answer to this question is yes. I believe that at the lower than normal mathematical densities created during hair transplantation, multi-FU grafts jave tje abo;otu tp create a greater illusion of density with the same amount of hair than when FU's are used alone......When multi-FU grafts are used, the space between the FU's within these grafts is at normal density (or higher than normal density if a degree of contraaction occurs). Light has a more difficult time passing between the FU's within the multi-FU grafts at these specific points of higher density. Thus, an equivalent amount of hair placed as multi-FU grafts gives one the ability to create an optical effect that lends a greater illusion of density than FU's alone." These words express wonderfully what I have believed for many years to be true of the use of MFU grafts in hair transplantation. They enable me to tackle a larger area than I could otherwise do with only FU's. DISADVANTAGES AND CAUTIONS: 1) There are some men in whom they should not be used: a) Someone who says he is only going to have ONE procedure. Using MFU grafts requires at least two, and preferably three, sessions to complete the hair transplant project. b) Someone is whom, after examining the hair/scalp characteristics, one judges that the MFU grafts would be detectable. The commonest instance is the man with dark, coarse hair and a pale colored scalp. Only FU's should be used here. I have noticed over the years that men with a golden-brown colored hair and oily, hyper-elastic scalp have an unnatural look with MFU's and I use all FU's in these. c) All females: For two years now I have been using only FU's (average of 1600 per case) in my female cases and have put a hold on using slit-MFU grafts which I used for a great many years. In that time I have noticed that the incidence of shocking to residual native hairs is much less. It seems the hair on top in females is much more vulnerable to shocking and that larger recipient sites seem to bring this on easier. I have not noticed a similar effect in males. 2) MFU's should only be used in the front-central regions. I don't even use them in the posterior midscalp anymore, to avoid any possibility of their being detectable. They should be placed closely together, in a random distribution (not rows), and placed at an acute angle, which helps them overlap and ride over each other to magnify the illusion of density and minimize detectability. Placing them in a perpendicular orientation (straight up) totally ruins the naturalness of their appearance. Doing so with FU's doesn't look so good either. Thanks for hearing me out. That pretty much covers the topic. I have to admit that in the past 3-4 years, in most of my patients who have a relatively small area that needs transplanting (frontal area or smaller), I have switched to usually recommending the dense-packing of FU grafts as the initial approach. The lateral slits have made a huge difference in our ability to place grafts close to one another and minimize blood supply damage. I would just ask that people be open-minded and realize that there is more than one way to skin a cat, and that, if used artistically and wisely, MFU grafts can help some men achieve their goals and do so at a cost they can afford. Mike Beehner, M.D. Saratoga Springs, New York

Take a Chance, If you are up near 29 or so, AND your side fringe where it defines you as a Norwood VI is fairly "strong," meaning that on magnification hardly any miniaturization is seen among those hairs, then you are pretty safe having the front 2/3-3/4 of your balding area filled in. The side areas, if they recede a little more over the years, which they probably will, can usually be blurred in with some FU's as you get older, providing you have a reasonable amount of donor hair. This whole matter is a judgement thing and your hair surgeon is in the best position to make this decision and advise you. Mike Beehner, M.D.

Willhair, There are no numerical measurements or guidelines that I know of related to which Norwood category you fall into, although, as a general rule in my experience, if your width of baldness on top measures across greater than 15cm in distance, you are probably close to or in fact a Norwood VII. One good way to determine a Norwood VII is to look at a photo taken from straight above the head. If you see only bald scalp and don't see the fringe, that patient is a Norwood VII for certain. If a young man is in his 20's or early 30's and is wondering if he will possibly become a Norwood VII, there are several clues that can help: One is family history, particularly older brothers, father, and maternal grandfather. Another one, at least for the man in his 30's, is the quality of the side fringe. If it has any miniaturization, which is seen by the layman's eye as very early thinning, then you can be fairly certain that the fringe is going to drop further as that man ages. A hair surgeon can tell that by using strong magnification. Anything over 5% miniaturization should arouse suspicion that the area may clear out some day. As for the men in his 20's, I am on the conservative side and feel that all of these candidates should be transplanted as if they were going to progress to a Norwood VII. The worst errors of judgement are filling in the rear crown and filling in the fronto-temporal recessions aggressively. Some of these 20-ish transplant patients who are transplanted in this manner are someday going to have a very abnormal, freakish appearance. In two large studies performed around 25-30 years ago, Norwood found that 10% of men in their 60's became Norwood VII's, and Walter Unger found that 20% of men in their late 60's became Class VII's. Mike Beehner, M.D.

If you even suspect that you might end up a Norwood VII class of hair loss (side fringe borders partway down the side of the head with a narrow fringe of donor hair), you shouldn't even be thinking about "filling in" the bald area. Rather, you should be thinking in terms of using the little donor hair you have to frame the face along with some natural blurring with sparse hair in the alleys between the forelock density of hair and the side fringes. The downhill vertex (crown) in back should almost always be excluded from transplanting if you are to use the donor hair available wisely. Rather than thinking in terms of uniform density over a large area, the goal is to create GRADIENTS of hair density, with the maximal density being created in the front-central region, which we term the "frontal core." Then the density gradually tails off to each side and toward the back. Sometimes "tacking hairs" are placed in the rear vertex in line with the planned styling pattern of the patient, so the hairs swept back have some other hairs to help "fix" them in position. Needless to say, a styling pattern that sweeps the hair back either straight or, better yet, toward one of the corners, is the ideal one for a man with this much baldness. A good example of a little bit going a long way is Joe Biden. He doesn't have all that much hair up in front, but the way he sweeps it back makes him look from most vantage points as if he has a lot more hair than he actually does. When you see a back view of Biden, you realize how much bald, shiny skin is still there. If a man is young (20's or early 30's) and there is reason to suspect that he might be heading for a Norwood VII pattern, then it is very foolish to embark on any kind of transplant plan that tries to fill in the bald area. Mike Beehner, M.D.

If you are in your 20's or 30's, have a fair amount of residual "native" hair on top, and want to do EVERYTHING possible to hold onto it and remain as thick as possible, then I would recommend using both minoxidil topically and finasteride orally. It sounds like your scalp may be reacting to the Propylene Glycol preservative that is used in the topical minoxidil solution. The new Rogaine Foam, though more expensive, doesn't have this chemical in it and may be more friendly to your skin. There is a synergistic effect from using both of these drugs. The problem with minoxidil is that you have to be religiously faithful about using it. If you take little "breaks" from using it, your gains will be lost quickly and such a strategy doesn't make any sense. Mike Beehner, M.D.

Blazed, It sounds like you are fortunate in that your scars, even though "stacked" on top of one another, are relatively thin and cover without too much hair length. The problem still remains that, if you remove much of that hair that exists between the "railroad tracks" of two adjacent scars, it has a way visually of merging the two scars (even though they're narrow ones) into what looks like a wider scar. You are much better off having your next strip, if you elect that donor harvest method, taken from on top of the very highest scar or adjacent to the bottom of the lowest scar. This assumes that there is an adequate amount of good quality donor hair in either of these places, so that you don't take hair that may later be lost from the progression of male pattern baldness. I still would caution that the best way to obtain any of the hair between these old scars would be by FUE. I'll attach a photo of a patient I saw recently who had previous work done elsewhere, showing a "stacked" pair of horizontal scars in back. The photo on top shows him with his hair long and the bottom one is shaved. I believe we did FUE in this case. You can easily imagine, looking at the photos, how important those hairs are between the two scars. If you were to take a strip which removed the great majority of them, the scar would appear to be three times as wide, because you brought them closer together and took away the shingling of those hairs in between. Mike Beehner, M.D.

It's all well and good to talk about taking out both scars and the hair in between and ending up with one scar, but in reality that almost never is possible. When patients have had old "stacked scars," they are spaced apart just enough and with enough hair in the space between the two scars that that overall vertical width cannot be bridged by simply cutting everything out. It will look like one very wide four-lane highway along the side of your head. A far better way to approach this situation is to leave every one of those hairs between the scars, because you will need them desperately to shingle down over the scar - and instead use FUE in whatever areas you want, including the hair between the scars, and plant FUE grafts into the scar. Another approach is to add tattoo dots along with the FUE FU's to further help camouflage these scars. Mike Beehner, M.D.

Dear "Take a Chance," First of all, not all Norwood Class VI's go on to become a Class VII. If you can see some thinning in that top fringe area, and if your male relatives tended to drop their fringes down that far, then you might be right to expect to go to a Class VII. (For those that don't know, a Norwood Class VII, the most severe degree of hair loss, is one in which the entire top of the head is bald and the border of the side fringes is down along the side of the head and not up near the top) Assuming you're in your 20's and that you are going to become a Class VII, you still can be a good hair transplant candidate. Your hair surgeon almost certainly will have to exclude the downhill vertex/crown in back from transplanting, and will need to create a gradient effect of hair, which is densest in the front-center and then tails off as it approaches the sides and back. Adopting a styling pattern of bringing the hair straight back or toward one of the rear corners would be a big help also. Two other big factors that will be important for your hair surgeon to consider are: first, how dense is the area of donor hair you do have - is it densely populated and with a lot of 2 and 3-haired FU's, or is it thin with lots of 1's and 2's? Second, what are your hair characteristics. It would be a big help if your hair was not curly and "flowed" well so it could be brought straight back and cover some of the crown area. With decent density in your "safe" donor area and with realistic expectations on your part, you could receive a very natural looking transplant result. Mike Beehner, M.D.

I tend to be a little conservative with new drugs, but will share with you the reasons that I don't prescribe dutasteride (Avodart). First of all, it is only FDA approved for prostate gland problems, not for hair loss. Secondly, it does a very good job of suppressing both DHT1 and DHT2, whereas finasteride (Propecia/Proscar) works primarily on DHT2, which is in the hair follicles and prostate gland. The problem is that DHT1 is found in the brain and in nerve tissue, and it bothers me that I would be giving a young man a drug for many, many years that has unknown effects in such important areas of the human body. Thirdly,if the patient does get side effects (sexual, etc) those effects can lock in for a few months because of the long duration of the drug. All the above having been said, I certainly have heard colleagues of mine share that they have had patients respond to dutasteride who didn't respond all that well to finasteride. Also, I have heard that if a patient tolerates finasteride without side effects, they will usually do ok on dutasteride without side effects also. I will want a lot of years of proof that it is safe to use before I will include it in my recommendations. Mike Beehner, M.D.

Here's the other drawing, showing the effect on the size of the opening of the site using perp or parallel orientation. Mike Beehner, M.D.