Dr. Michael Beehner

One other comment on graft survival that I forgot to include is the orientation of the slit in the recipient site. Dr. Wong deserves credit for showing us that excellent density can be achieved with the "perpendicular" (erroneously referred to as "coronal" by some) orientation of the site, and I agree with him as long as the size of the site is relatively small. I do feel strongly that there is some critical "divide" or threshhold of recipient site size, past which one has to switch to a "parallel" orientation ("sagital") in order to not embarass the vascular support to the grafts and risk necrosis in a central area. I'm not totally sure where that cross-over point is, but my guess is that the 0.6, 0.7, and 0.8mm sites are fine when made perpendicular, and I think the 0.9's are probably ok too, especially if confined to the deep hairline area only. But, I think once you get to 1.0mm and wider, that it is wise to stay with the parallel orientation. There is a mixed blessing with this orientation:As Victor Hasson points out in the Haber/Stough textbook, the opening of the site will actually be a tiny bit wider than the actual 1.0mm size of the blade which makes it easier for entry placement of the graft, especially the 3-hair and 4-hair FU's. The down side is that, because the opening is that little bit larger, not as many sites can be placed in 1cm2 of area as with the perpendicular sites. I will try and attach a drawing from the text which shows this: Mike Beehner, M.D.

I was asked to update my comments from what I said before about hair follicle survival in high densities, but for the most part would pretty much say the same thing now in late 2008. There was a nice study published in the journal, Dermatologic Surgery, by Dr. Tom Nakatsui and Dr. Jerry Wong about a year ago or so, in which they used small lateral slits and created study boxes of between 23 and 72 slits per square cm of surface area, and obtained a 95.6% survival in the 23/cm2 box and 98.6% in the 72/cm2 box. These results are outstanding, although we have to keep in mind that the study was done on ONE patient and the same results may or may not occur with another person. Also, as I recall, these boxes were around the periphery of the area transplanted and I don't believe any were actually in the center, which I would think would be the area most at risk for possible less-than-ideal growth. I have noticed in past studies I have conducted that, even though I did everything exactly the same, I often would see marked variation in hair follicle survival a year out. Every hair surgeon that I have spoken with acknowledges that there is an individual patient "X factor" that we can't totally put our finger on, but does in fact exist. There are a number of factors that I think definitely play a role in worsening the survival of densely packed grafts: Among these are: cigarette smoking; a very thin scalp with little subcutaneous tissue; a scalp that has had a lot of past surgery performed on it; Another factor that I think makes a huge difference in a hair surgeon's ability to create density and obtain good growth at the same time is the SIZE OF THE RECIPIENT SITE. There is no question that the custom-made lateral slits allow us to place a larger number of recipient sites in a given square area than ever before. Then the limiting factor becomes the safety with which the placers can insert the grafts without traumatizing them. With extremely dense sites, this is much more difficult with the hair left long. I will again make the statement that I believe the biggest factor in getting good dense growth is not necessarily the density with which the sites are made, but rather the skill and conscientiousness of the assistants who are placing the grafts. If they do their work in a rough, slipshod manner, there is going to be terrible growth. If they are gentle and meticulous with each placement, then the growth will probably be wonderful. I haven't gotten around to doing any further survival studies on 1-hair FU's but would welcome others doing so, to see how they compare. The 3-4 studies I have performed comparing 1-hair grafts with 2-hair grafts would suggest that there is 10-15% less growth with the 1-hair grafts. This is simply a function of their slim build and inherent vulnerability to dessication (drying) and trauma with handling. Mike Beehner, M.D.

My experience over the years from seeing cases like this occur at various clinics, and a couple times at ours years ago, is that the cause of permanent hair loss above or below the donor scar is ALWAYS a closure that is too tight. I think the epinephrine plays a small if inconsequential role in this final cell death, provided it is used in the usually dilute concentrations that most hair surgeons use. I think the epinephrine CAN be a factor in the temporary telogen fallout cases, which can occur in the recipient area and rarely along the donor scar. I think it is wise to wait around 15 months before deciding that an area of hair loss near the donor scar is not going to grow back. This loss of donor border hair, if it occurs, almost always is located at the two rear corners, where the strip turns the corner in the parietal area behind and above the ears. The two most important ways to avoid this are: one, for the doctor to have excellent judgement on how wide he can go on a given patient after examining him or her, and two: the patient and the doctor not being too greedy concerning how many grafts are harvested, given the above exam. This is particularly the case for those patients the doctor does feel is "tight" but, because the patient has his heart set on a given target number of grafts, the surgeon goes ahead anyway, assuming he'll yank it together somehow. I think things are much better in recent years, as I don't see this or hear about it hardly ever. Mike Beehner, M.D.

My own experience, especially with regards to female patients, has been that, if shocking did occur, it was much more likely on the first session and much more unusual on the second one. My way of understanding this has been that I assume the more vulnerable hair follicles, which are on one of their last life cycles, get bumped off with the first insult (the first session) and then at the second session, the transplanted hairs from the first session plus the presumed stronger surviving "native" hairs are less resistant to shocking. I agree that it can happen both ways, but in my experience has been much more likely with the first session. Mike Beehner, M.D.

Just a couple of comments relative to your question about the hairline: First of all, DaVinci's "rule of thirds" for most males places the hairline too low. It is fine for females, although many female hairlines would actually start a bit lower than the DaVinci upper mark. There are a few key things that factor in to where to place the hairline. The most important are: a) What does the patient want? (assuming it's reasonable) b) Where is the temple hair? If it is far back near the ears, then the hairline should be a little higher, unless the patient has unlimited donor hair and wants a major temple area restoration along with the work on top. If the temples are far forward, then a lower hairline will be "held up" nicely by this temple hair and is more acceptable. c) How old is the patient and what is the potential for a "worst case scenario" later on? For a man in his early 20's, I would be a little conservative in the hairline height, and, even more importantly, on where the lateral arms of the front hairline intersect the side fringes. Some doctors want an easy, fool-proof method for determining every patient's hairline height. In the early days of hair transplantation, some used "two fingers above the top forehead crease" or "four fingers above the eyebrow." If I was forced to recommend some simplistic method, it would be this: imagine a horizontal line going across the top of the head and projecting out and also imagine a vertical line coming upward along the front surface of the face. This would form a right angle. Intersect that right angle with a line directed 45 degrees downward onto the upper forehead and this would be the point. It would be the perfect median between horizontal and vertical for that particular patient. As I mentioned above, I think the decision should be more nuanced and individualized than that. I agree with the above comments that the hair surgeon's artistry and use of micro and macro contouring is key to a natural look. A smooth-edged, dense hairline should never be created. Mike Beehner, M.D.

We use blue colored 3-0 Prolene (nylon) running sutures to close virtually all of our donor harvest areas for two reasons: First, they are comfortable and don't hurt when you lay on the pillow at night, etc. Second, they are easy for a spouse or family member to remove. We simply describe it as a "seam stitch," a "baseball" stitch, and they readily understand. We give a suture removal kit to them and an instruction sheet with a drawing of the steps involved. We have had a couple of rare instances where someone wants staples used and we then order a kit or two. I think the scars are equally good with both. I used staples for many years when I was in practice and did C-sections and mini-lap tubals and they were great for their time-saving feature. I just feel that the discomfort with them in place and the fact that the person who takes them out has to do it just right with the removal tool or that too will be painful experience. If a doctor did all patients who lived in his immediate geographic area who could come back, then that would make the argument for staples a little easier, since they could all return to the office. At least half of my patients are from far enough away that that is not practical. And I must admit that I have had many occasions where my patient went into a clinic or "regular" doctor's office (even occasionally a plastic surgery office) and the doctor would look at the wound on the back of the head and think it was something from the planet Mars and wouldn't want to touch it, not knowing what was under the wound. Mike Beehner, M.D.

DB, From the description you give, it is almost certain that the "cyst"/bump on your head is a sebaceous cyst (a "wen"). These are easily removed and the resulting scar should be barely visible. It is important that the entire wall of the cyst is excised or it can come back. I have never heard of one of these causing discomfort though. My strong hunch is that in the next 2-3 weeks you will see this pain gradually go away as you get further from your surgery. There is one very unusual cause of pain called a "neuroma," which is a bundle of nerve tissue which is in the donor scar and involves usually a suture that trapped a small nerve branch, causing radiating pain from that spot up onto the top of the head. It can usually be reproduced by pressing on an area of the donor scar and then the pain comes on. I highly doubt this is what it is, but it must be kept in the differential, especially if it does not improve. One last note is that sometimes you be so focused and upset about some cosmetic problem, such as this "lump" being exposed, along with the numbness up there which occurs in virtually every transplant procedure, that you can work yourself up into interpreting the whole thing as pain. This is also unlikely to be your case, but I mention it for completeness. Mike Beehner, M.D.

The photo almost looks like a mild seborrheic dermatitis reaction of the skin to the transplant. I see this commonly in patients who have a history of some mild occasional seborrhea (dandruff)in their past, and the transplant procedure kicks it into high gear. The other factor that often plays in this appearance of a whitish layer over the transplanted area is a hesitancy on the patient's part to wash the scalp at all. They will be so afraid of knocking grafts loose that they basically don't wash the scalp at all, and over several days some of the more seborrheic ones will get a layer of "crud" that looks unsightly and smells similarly. We had one patient a few years ago who went a month and a half without washing the scalp and literally had a quarter inch buildup all over the scalp that could be peeled off. Using an anti-seborhheic shampoo and, in more severe cases, the application of a steroid lotion at night I find clears it up nicely. Mike Beehner, M.D.

DUPA, which stands for "Diffuse Unpatterned Alopecia", affects all of the potential donor hair on the back wall and on both side walls. By definition, it is the presence diffusely through these hairs of MINIATURIZED HAIRS, which are hairs with a limited number of life cycles left before they disappear. Sometimes this can be picked up early with an in-office magnification device by an expert in hair loss diagnosis. Oftentimes it is obvious to the patient and his family by simply looking at these areas, in which you can "see through" to the bare scalp when it is moderately advanced. As to why you only get those two views, my guess is that he feels the right and the left views would be identical and he's giving you a representative view. Some clinics only take a side view of one side and don't photograph both unless there is a difference. We used to only take a left view when we used film, to help save on photographic costs, but now do both sides with the less expensive digital modality. Mike Beehner, M.D.

I think some of the above comments are way too conservative and restrictive. I'm not sure anybody knows the exact answer. In my own practice, I have my patients not do any STRENUOUS exercise (wind sprints, lifting heavy weights, full court basketball, etc.) for 5 days and then I don't have any restrictions, as long as the activity does not include wearing a tight-fitting helmet for 7-10 days after surgery (skiing, motor bike, hockey, etc). I do allow golf, brisk walks, playing catch, etc the very next day. I keep my patient's head out of water for at least a week, for fear some maceration may occur to the grafts and skin. Why do we have any limitations? Some of it comes under the category of "C.Y.A." - so that if something went wrong of any sort, the doctor doesn't want to be in a position of the patient pointing to something like that as the cause - which would be pretty unlikely, barring a head-on collision during the activity. For my own part as a patient, I once took a 10 mile run the very next day after a large transplant session 20 years ago with no ill effects. There are three reasons I can think of theoretically that exercise could pose a remote threat: One, with vigorous exercise many of us sweat a great deal. I'm not sure this is a problem of any sort and a brief shower after the activity certainly cleans this up. Number two, as I already mentioned, there would be the risk of a head injury in a team sport such as soccer or basketball. And, number three, which is probably MY main reason for holding things off for 5 days, is that with strenuous activity the blood pressure does go up quite a bit as a normal reaction - and if there was a tiny scalp artery that was clotted off but located right at the edge of one of the many tiny recipient sites or the donor wound, then this could suddenly start bleeding. I have seen this only twice in 19 years. So, the answer is that nobody knows for sure, but it certainly is overkill to restrict it for months. The one suggestion about not flexing the neck a lot after the donor stitches come out is a good one - as extreme stretching at the back of the neck could put some stretch on the donor scar in its early formative weeks and cause a wider scar. Mike Beehner, M.D.

All good points above. Just wanted to add that the density of FU's (and hairs) can vary at different heights of the rear donor wall of hair. This is particularly true in my female patients. Sometimes the maximal density is actually in the lowest part of the occipital hair, which is usually an area we try to avoid taking donor strips, as scars can stretch down there. I can imagine a case in which the surgeon correctly placed the scar around a third of the way up the rear donor area, with the scar resting somewhere around the occipital notch, but the donor density in that patient perhaps wasn't maximal there. On the next surgery, in going above that scar (or, less frequently, below the scar), where the density may be greater, a larger number of FU's per square area could be obtained. The more common scenario, which has already been mentioned, is for the measured density of FU's per cm2 to very slightly diminish at each subsequent session. This is important for calculating how big a strip to take for a given number of grafts, but is not important from a visual perspective. What I mean is that you cannot tell, in looking at the patient, that his hair is thinner back there. Mike Beehner, M.D.

The answers above by Bill and Dr. Paul Shapiro are excellent and I agree with everything they have said. I just wanted to add that a very important factor in blade size (or needle size) selection is the COARSENESS of the hair (the hair shaft diameter). Very fine 1-hair FU's can be placed into 0.6mm blade incisions, whereas coarse ones require a 0.8mm one. Same goes for 2-hair and 3-hair FU's. The blade width is significantly larger for these grafts when the hair is coarse. And one more factor that is significant. Some patients have FU structures in which the hairs are very straight, parallel to each other, and situated "tightly" together. Other patients have what we term "teepee-ing" of the grafts, with the hairs curving off from each other in various directions. This affects what size blade is chosen also. Mike Beehner, M.D.

When we harvest FUE grafts, I find that there is a great deal of variability in them. Some do have more extra tissue around them that does need to be trimmed and probably 60% of them are just fine the way they are and can be placed in small recipient sites. Obviously, you would only use a 1-hair FUE FU on the edge of the front hairline. As I harvest them, one of the assistants give them all a "look over" under the microscope and only trims skin (epidermis) or tissue if it is too much. Occasionally an FUE 2-hair or 3-hair FU will have a split down the center from the bulb up, somewhat like a pair of pants. These are a little difficult to place, and, in those few instances, we have the assistant divide it into two separate grafts for the ease and safety of placement. Mike Beehner, M.D.

I have seen those exact photos of that same fellow over the years and can tell you on good authority they are simply describing a hairpiece that is either woven into the side hairs or, more likely, glued onto the bare or shaved scalp. It is possible to add more hair gradually, since the "net" that is used with most modern hairpieces is a mesh through which more or less hairs can be woven. "HRS" refers to a corporate line of hairpieces and materials that certain salons use in their businesses. I am familiar with such a salon in upstate New York that has used these for years and their results actually are wonderful. It's just that it is NOT your hair. So, since you are so impressed with those photos, you should therefore choose to have a non-surgical hairpiece and not a tranplant. I must confess I thought your comment was a joke also, until you persisted in later remarks. Mike Beehner, M.D.

Charlie 08, When reviewing the "negatives" regarding transplants, I usually touch on the following for the patient to know about: First of all, the general tone of my comments is that fortunately hair transplant surgery is a remarkably complication-free area of surgery. Much of this has to do with the rich blood supply of the scalp. Here's the list: a) 20% chance in males (probably 30-40% in females) of forehead swelling, which comes on the 3rd day and is gone by the 6th day after surgery. The more work is done in front, especially if temples are included, the higher the incidence of this. Most clinics give Prednisone or a steroid to decrease the incidence of this. b) Most important one of all: 5-15% chance of mild "shocking" to some of the existing native hairs. (Incidence is higher in females, probably near 30%). Most of these follicles affected by this will start to regrow in 3-4 months. Thin vulnerable ones may not return. c) Small cysts on scalp. These have become very, very rare in our own practice compared to 10 years ago, when they seemed much more common. They are usually caused by "piggybacking" of a graft on top of another, or a hair that grows inward and curls up. d) Very small area of numbness in the rear, central scalp, which happens in nearly 100% of patients and returns to normal in 3-8 months after surgery. This is caused by cutting some of the branches of the superficial sensory nerves when the donor cut is made. They grow back and full sensation almost always returns. e) Some soreness and discomfort in the donor scar area, especially when lying on a pillow. This is usually quite minimal, especially if sutures aren't placed too tightly. f) That's about it in the real world today. Bleeding, infection, pitting, cobblestoning - these simply shouldn't happen and are extremely rare in a good modern hair transplant practice. Mike Beehner, M.D.

JW334, You didn't mention your age. As Bill mentioned, it is normal to lose 50-100 hairs a day simply from the random rotation of the hairs on your head through the growth and resting cycles. So on any given day, you will have that many hairs falling out and that many hairs starting up growing out from the follicle again. The number you mention, assuming you've proved this by counting them - that's a hard thing to "eyeball" - and you are losing that many, then one of two things is going on. Either you are really in an accelerated phase of male pattern baldness, or you have experienced a "telogen" reaction from one of many causes. These phases are very common and usually occur around a few weeks to a couple of months AFTER the incident or exposure that actually caused it, which makes it a little harder to figure out. Common causes of telogen reactions are some of the following: a surgery or general anesthetic; a severe psychiatric event such as a death of a close one or a sudden divorce breakup; a crash diet of very low caloric total; various medications; a viral illness or pneumonia; and there are quite a few others. If this were the cause, then after the 3-4 month period of time passes after most of the hair falls out, there should be a rebound of hair growth gradually back to what it was. It won't happen quickly, because these hairs won't grow faster than a half-inch a month. If you are in the midst of this experience, there is a valuable diagnostic test that a physician does, which you could actually do yourself. Simply take two fingers (thumb and index finger) and pinch a wad of your hair (perhaps 100 strands or so) and simply pull on them. If more than five hairs come out, that may indicate a telogen reaction had occurred. Don't worry, you won't lose those hairs. They have already separated from the underlying follicles, which is what occurs in telogen. Mike Beehner, M.D.

I can think of two good reasons to call the crown (vertex) a "black hole." Number one, it is always larger than what the patient thinks, and, most importantly, it virtually always increases in size in all young and middle-aged men (and even in a lot of the older ones!) and the area increases almost logarythmically, not in simple direct proportion to the increase of the diameter. The second reason is that, because of the "whorl" or swirl arrangement of hairs, there isn't a lot of overlap in this area with most styling patterns compared with how transplanted hair looks thicker in the areas on top and in the temples. I'll throw in two more observations: The crown is almost never the most important area of hair loss, the front half of the scalp is, and it is important, especially if your budget is limited, to spend your money on this area. The frontal area is what frames your face and directly affects your appearance to people. The second observation I would make is that, if you persuade your doctor to fill in the entire top of the head and also the crown - this is assuming that much donor hair can be found on that given day - it is my very strong hunch that the grafts placed in the crown don't grow as well as the grafts on top when that much work is done. My best guess is that the donor scar behind the area and all the recipient sites made in front of it combine to slightly deprive these grafts of blood supply. I don't think this happens in all men, but in a good percentage. Light crown coverage (say, 300 FU's) probably isn't affected. Mike Beehner, M.D.

Shock loss above and below the donor scar should be a fairly rare occurrence. It doesn't happen everyday - or at least shouldn't. It is well known that the cause of telogen hair loss around the donor scar is too tight of a closure, which usually is related to taking too wide a strip in that particular section of the head. This is most commonly a problem at the two "corners" behind the mastoid bone. Fortunately, in the great majority of cases, after a few months the hair starts to regrow again, but in severe cases it can be a permanent loss. Bottom line: it shouldn't happen. Mike Beehner, M.D.

Yskhleif, I think the most important key to your problem is whether you have already existing hair down to the area you want your new transplanted hairline to be or not. If your existing hairline now is way up high and it will be brought down an inch or so, then you will have a slightly noticeable situation, although in 8 of 10 patients, it is fairly unnoticeable two weeks later. The redness and scabbing will most certainly be gone in two weeks. The problem sometimes are the persistent hairs that stay at the transplanted length and just sit there, or the ones that actually do take off and start growing. They will appear somewhat different from your pre-transplant appearance. You could shave them as they grow. If you do have some hair, no matter how miniaturized or scant in the same area you want transplanted, then either Toppik or Dermmatch (or both) can do a nice job of camouflaging things until the hair starts growing out. Assuming the hairline or temple areas will have transplants that you want no chance of someone noticing, then the temporary hairpiece is an option; but I should warn you that it is very difficult to get one that matches your present look of thinning hair. You will need a very skilled salon to pull this off. Most will put something on you that looks considerably more than what you want and will be a give-away as a non-surgical addition. If you do get a hairpiece, be sure and get a clip-on attachment, and, if you use if for more than a very few months, have the salon every few months change the location of the clips so that they are not pulling on the same clump of hairs, which can lead to little bald spots. One last suggestion, ask your HT surgeon for a Graftcyte kit. I have seen several miraculous healings, even within a week with all FU transplants, in which you can barely tell any surgery occurred. Mike Beehner, M.D.

Mrkneed, If your pulse truly did reach 230 that is not directly from the epinephrine, but almost certainly has to be a brief supra-ventricular arthythmia. There's a good chance that the presence of some epinephrine in the numbing solution was a stimulus to help it occur though. I would recommend that you check with your personal physician, who in all likelihood may arrange for a Holter monitor (24 hour tracing of your heart rhythm) and/or a cardiac stress test. I wouldn't just go into another hair surgery until you checked this out from a cardiology standpoint. Panic attacks and reactions to epinephrine can make the pulse go up to the 130-150 range, but do not directly cause a pulse that fast. The reason that these types of tachycardias occur frequently in the dentist's office is that the mouth area is rich in blood vessels and it is very easy for the dentist to have the tip of the injecting needle within the lumen of a vessel, but I find this is extremely rare in hair transplant surgery in my experience. Perhaps this is partly due to the fact that we inject our Lidocaine and Marcaine with an extremely small needle (30 or 27g), which makes that possibility much smaller. Mike Beehner, M.D.

Emperor, I have been reading and going to meetings for years and have never heard Rogaine (minoxidil) described as an anti-androgen. I think you have mixed it up with finasteride. We know that minoxidil is a vasodilator and may increase blood supply in the skin. In fact, some surgeons stop it a few days before surgery to avoid excessive bleeding. I don't, and have never been impressed bleeding was increased with it being used right up to the time of surgery. Also, we know it has an effect on potassium in the cells, but most of its action is relatively unknown, and some have simply described it as a "growth factor" for hair, although in reality it is much better at preventing hair loss than in actually growing hair. It probably works best in growing hair when used in conjunction with finasteride (Propecia), as it is synergistic with the other medication. Mike Beehner, M.D.

One thing you have to keep in mind is that minoxidil (Rogaine) is probably the strongest blood pressure drug in the world. If put on too soon, while all these fresh open sites are present on the scalp, the potential for the drug on the skin being absorbed into the system and dropping the blood pressure is a real risk. A person who is older or who has low blood pressure to start with would be at risk for fainting or passing out. For that reason, I wait till around the 4th day to restart it. The other reason I wait those few days is that the physical act of applying the drug might disrupt some of the grafts' physical positioning in their sites. We don't fully understand all the ways minixidil works to help hair growth (and prevent hair loss), but it is considered a "growth factor" for hair, and I do use it for 3-4 weeks before and after surgery in situations in which I am more concerned about the outcome of the surgery or worried about shock loss (such as in my female patients). If a person has had a lot of past scalp surgery - scalp reductions and multiple HT's - I will start if a month before surgery and then re-start it on the 4th post op day and have the patient take it another month. The evidence that this helps is so far anecdotal and not based on a good scientific study that I know of. Mike Beehner, M.D.

BeHappy, From what you say, you very well may be one of these DUPA patients (Diffuse Unpatterned Alopecia). There are a couple of ways to approach your scar problem. First of all, if the scar is wider than usual (3mm or more wide), and providing you have good laxity left, I would first do a scar excision, which could get it down to 1mm or so. Then, assuming it still showed through the thinning hair, I would use FUE grafts into the scar. These FUE donor sites would be undetectable, even with a DUPA donor hair type. If you did not have the laxity to do an excision, then I would simply go right to using FUE into the scar. I find this sometimes has to be done a couple of times to get good camouflage of the scar. Mike Beehner, M.D.

Bill, In reply to your question, I think it's probably unfair to at least finasteride to say "in rarer cases it stimulates some hair growth." My experience and that of most of my colleagues I talk with, is that a good half of the men we put on finasteride (Propecia or generic Proscar) experience some added hair growth, at least in the first 4-5 years. Minoxidil (Rogaine) works synergistically with finasteride and the results are better than with only finasteride for the single patient who chooses to use both. After 4-6 years, there is a slow gradual drop-off in hair mass in most patients with finasteride treatment. This period of potential hair growth seems to parallel the length of time of the normal anagen (growth) cycle of the hair follicle. My point in including that in my comments on diffuse thinning was to make sure that someone with such a hair pattern didn't think there was a possibility he would just stay in that stage the rest of his life, as that is virtually never the case, medical treatment or no medical treatment. Our genetics inexoribly calls us home, so any planning that involves transplants has to take into consideration that there will be more future hair loss. The man with male pattern baldness who probably can say he's near the end of his hair loss is the male over 45 with a Norwood VI pattern of shiny baldness on top and a strong fringe border of hair. Even in these men, the vertex "scoop" in the back tends to sag a little lower over the years....and then there's "senile alopecia" which causes a mild gradual thinning as most men age. Final thought: medical treatment is great, but it's not a miracle worker and doesn't prevent eventual balding down the road in life. Mike Beehner, M.D.

Photo showing Diffuse Unpatterned Alopecia attached. Mike Beehner, M.D.