Dr. Michael Beehner

The term, "diffuse thinner," can refer to two different types of patients. One group - and the more common one referred to this way - is the man with homogenous thinning throughout the typical male pattern baldness area on top (horseshoe-shaped), in whom there is some degree of miniaturization going on with some of the follicles/hairs, allowing someone to see the scalp through the hair. The second group are those who have the acronym diagnosis, D.U.P.A. - which stands for "diffuse unpatterned alopecia. These men, though usually much thinner on top, also have diffuse miniaturization throughout the donor area also. Many of these men present for transplantation in their 20's and it is difficult to tell them they are NOT candidates for hair transplantation. If you look around in a crowd of older men, you can spot some of these. They have hardly any hair on their head anywhere. It is a somewhat rare diagnosis fortunately. The reasons for not transplanting them are twofold: One, the "donor" hair is of uncertain quality and will not last that many years in all likelihood. Second, because the sides and back are thinnish, a donor scar would easily be seen and would draw attention to itself. Basically, a surgeon is raising false hopes and stealing the patient's money in such situations. With the more commonly described "diffuse thinning" patient, in whom there is an equal degree of thinning throughout the top, the patient certainly should be told that he will eventually lose all the hair contained within that area, unless he is in his 50's or 60's at the time of examination. Even medication, such as finasteride and minoxidil, will not prevent it from eventually being lost. It may delay that day by 10 years though. If they are transplanted, the advantage for the patient is that the hairs that remain on top help serve as camouflage while the patient is recuperating and healing those first couple of weeks and makes the whole process more undetectable. It certainly is possible that some of those more vulnerable, miniaturized hairs will be "shocked" and possibly lost forever; but it's a minor point, since only 4-5 months later the new transplanted hair will be gradually growing and dominating the area on top. I will try and attach a photo of a young DUPA patient, confirmed with 30x power magnification exam of the scalp showing a significant percentage of miniaturized hairs. Mike Beehner, M.D.

Chris, I would hang in there till a full year has passed before making any final judgements. I have seen some remarkable improvements in quite a few of my patients between the 8 month and the 12 month points. This is especially true for the possible benefits of finasteride (Propecia). Mike Beehner, M.D.

Abby, I would agree with Bill that hats do not have a negative effect on hair growing, either your natural hair or grafts that have been transplanted. The only thing that goes on the head that I DO know can have a negative impact on some patients is wearing a hairpiece. Over the years, I would say that approximately 15-20% of my hairpiece-wearing patients have had slight to moderate diminishment of hair growth compared to my normal non-hairpiece-wearing patients. A few years ago I had a discussion about this with some other very experienced doctors, including Dr. Bobby Limmer and Walter Unger, and they had noted this also in their practices. Their recommendation to me at the time, which I have followed, is to not have a hairpiece worn during the week after a procedure, and then to have the patient have the hairpiece off as much as possible, wearing it only for essentials such as work and social engagements - but wearing a ballcap around the house or nothing on the head. I have noticed a slight improvement since switching to this policy, but still see an occasional patient with diminished growth. The reason for this is not fully understood. Most feel it has to do with a close "shuffling" of the piece on the newly implanted grafts, perhaps somehow preventing them from "taking root." Increased temperature or bacteria present would be other wild guesses that probably don't apply. Most of us have people who wear motorcycle helmets, ski helmets, and hard hats NOT wear their headware for at least 7-10 days. Mike Beehner, M.D.

My sense is that in the majority of cases of donor shock loss, the hair mostly returns. I have had this happen three times in my career, none within the past 8 years, as I have gotten smarter with age, I hope. In all three cases the hair grew back and there did not appear to be any permanent loss. I have personally seen four cases of extensive permanent loss above and below the donor scar in work done at other clinics, and have heard of many others that colleagues of mine have seen come to them for repair. One thing I have learned over the years is that, if at least one attempt has already been made by anybody to try and cut out the bare area, whether it's from permanent shock loss or a wide scar, it is fruitless to attempt another excision procedure. FUE into the scar is then the best option, even though the survival of grafts into this kind of tissue is less than the usual 90% we enjoy elsewhere. Mike Beehner, M.D.

Dear TomD, I see that I commented over 6 years ago on this thread - so I might as well help finish it up. Its pretty much a given among hair transplant doctors that, whenever shocking happens in the donor area above and below the donor scar, it is virtually ALWAYS the result of too much tension in the closure of the wound. It is one of the important reasons for a surgeon not to take too wide of a donor strip for a given patient. Each patient is different. Some patients can easily have a 1.5cm wide strip taken and for another, 1 cm might be too much. The scalp is clinically evaluated by the surgeon before each procedure. Needless to say, when you go to a second or third strip harvest, the width you can take becomes less than with the first session. The most precarious stretch of the strip is that portion where the rear parietal corner is turned in back, somewhat behind the ears and above the mastoid bone area. Many of us narrow the strip here, in order to avoid problems with wide scars or telogen hair loss. Incidentally, Dr. David Seager, who passed away a year or so ago, was the one that taught all of us that, if for any reason you do find yourself in a situation where you can't bring the two edges of the wound together, it is far better to place the suture as usual but leave a gap between the two edges, and over time it will granulate and heal in fine. This is far preferable to "yanking" the two sides together with brute strength. One other event in surgery that theoretically could make a sloughing of hair loss along the donor scar would be cutting some of the arteries that feed the scalp, either in a prior surgery or in the current one. The wonderful thing about the donor area scalp is that, after you let 10 months or so go by, the scalp almost returns to the same laxity it had before the previous surgery. Having the patient do scalp stretching exercises(pushing and pulling the scalp together and apart in an up-and-down plane direction) can help a lot also. Mike Beehner,M.D.

Chris, You are still much better off staying on the drug. The great majority of men taking finasteride realize an increase in "hair mass" during the first 4-5 years; then there is a very gradual loss of same, but not nearly at the steep curve and rate as if you weren't taking the drug. At one conference I attended a couple of years ago, the speaker said that after 5 years, 30% of men look better than when they started, 50% look about the same and hold their own, and 20% look thinner. My gut feeling is that the last group would still look far worse had they not been taking the drug. My own personal experience is that 80% of the men I give it to have a positive result and look better when seen back in 2-3 years. When pinned down on exactly how long a given man will have to take the drug, my reply is "until the next wonderful thing comes along!." Mike Beehner, M.D.

Dear Robert Madison, I had an 18 year old young man in my office yesterday with that exact same complaint. The best way to be certain it is not an early sign of male pattern baldness is simply to have your nearby hair specialist (medical or surgical) examine the area under high magnification for any signs of miniaturization. If there is none (or less than 2-3%, which is pretty much normal), then there is no sign that you are going to lose hair in that area probably for the next 10-15 years. In a person with a single tone of dark hair and a fairly light scalp, any place where there is a change of direction of the hairs pattern, it will appear in good light that it might be thinning. This happens often with women who have a change of hair direction up the center of their front scalp and think they are losing hair, when it is only the divergence of hair revealing the skin a small amount. When we look at hair and it looks "full", part of the reason it does so is because of the overlap of hairs over one another. In performing hair transplantation, where we never come close to restoring the original density of hair someone had at age 15, we depend upon this overlapping of hair to help us create the illusion of full density. Mike Beehner, M.D.

I use disolvable sutures on occasion if the patient strongly wants them. There are two kinds of disolvable sutures: there is everyday "chromic catgut" or "plain catgut," both of which start disolving pretty quickly, even as soon as 6-8 days. Then there are the longer staying sutures such as the clear Monocryl. These can stay in for several weeks and almost seem to act like permanent nylon sutures. Most of the patients are looking around about two weeks after surgery for someone to take them out because they feel tight and are uncomfortable and the patient expected them to be "disolving." If I am closing a donor wound in a patient who is the slightest bit tight or who has really stretchy, hyperelastic skin, then I really try hard to convince him/her to accept nylon sutures (or staples would be equally appropriate in such a case). But for those men who will be in a geographic situation or are so busy they just don't want to bother with making a trip to a physician's office or back to our office, I usually use the chromic catgut suture. I give the patient a stitch kit anyway and tell him that in around ten days he can nip and cut any thread he feels back there and try to pull out what he can, as it will lessen the amount of inflammatory reaction that occurs in the skin due to the disolving process that goes with these sutures. In most cases, 90% of patients have a girlfriend, spouse, mom etc who can easily take the sutures out if they live too far from our office. Staples work fine, but we don't use them because they tend to be more uncomfortable for the patient, especially at night sleeping. Mike Beehner, M.D.

Dear Bearsfan1, For many years we took the sutures out at around 7 days. Around 6 years ago we switched to taking most patients' sutures out at 10 days after a first session, 12 days after a second session, and if a patient had a third procedure, 14 days for that surgery. The more important point is that for any patient with a slightly tight closure or who had "hyper-elastic" scalp tissue, we have the sutures taken out at 14 days, even for the first session. On rare occasions I have gone to 16 days, but the trouble with going past 14 is that the stitch material (or staples( start to become imbedded with skin tissue creeping over it, which makes the removal more difficult and more painful). What is actually happening when you go those extra 4-6 days with the sutures in place, you give time for the hair-bearing scalp above and below the suture line to start to relax and stretch out. In this process the remaining hairs become infintismally further apart, which the human eye can't detect. Keeping the sutures in keeps the wound scar from being pulled apart on from above and below during those early days when the tension is the greatest. Mike Beehner, M.D.

Worried girl: The way you describe your "full head of hair" presently, it sounds like you might not be too bad off, and maybe that area that was examined in the donor area that showed 30% miniaturization wasn't representative of most of the areas. I am fairly certain you don't have 30% miniaturization on top from your description of your hair. On another note, you will be in excellent hands with Dr. Kabaker. He's one of the best. One of my old patients from 10 years ago moved to San Francisco and had his last two procedures with Dr. K and was very pleased with the results and how nice of a guy he is. Regarding miniaturized hairs, each life cycle (usually 5-6 years in a woman) they become skinnier in diameter and will grow to a shorter length until they finally disappear. This whole process is very slow over many years in a woman, but it is generally somewhat progressive over many years so there is an actual change. It also varies from one woman to another, just as in males. Stay on the Rogaine faithfully. I highly doubt any "DHT blockers" work in a female, as that isn't the hormonal mechanism behind female pattern hair loss. As long as you've had a thyroid test (TSH is the best one) and an iron level (Ferritin level) at some time in the past 5 years or so, you are covered on that front. If your periods have been normal and you had normal fertility, then the hormonal blood tests usually aren't necessary. Good luck. Mike Beehner, M.D.

Dear "Worried Girl," 30% is a fairly high percentage of miniaturization to be present in the occipital donor area, usually the best hair on most women's heads who have female pattern alopecia. Most of the time I wouldn't transplant a woman with that high of a percentage, simply because it also portends that a lot of the other hairs will probably be following in the same footsteps of miniaturization a life-cycle or two away from now. The good news is that hereditary female pattern hair loss is a very SLOW process for most women, and almost never occurs as rapidly as its counterpart in males. The most curious part of your history is the fact that you described being thin in the temple areas only. Usually a woman with 30% miniaturization in the donor area will have an even higher percentage of miniaturization in the top recipient area behind the hairline, and yet you didn't seem to complain about that at all. What degree of miniaturization did your doctor find in the top recipient area? Even if the hair on top was the same and no worse than the back, that degree of miniaturization would still be easy to see through and I would expect that would have been your main complaint ir at least mentioned along with the other temple problem. Regarding the decision as to whether you should be transplanted or not, you certainly could, but your expectations would have to be lowered and realistic, especially concerning the number of years of your life you may get to enjoy this additional hair you gain by transplantation. For some women entering a critical period of their lives from a social or career standpoint, even 10-15 years of having increased density of hair could be valuable to them and worth it. I have been fooled in a few cases in which I initially didn't want to transplant a particular woman, she insisted on going ahead despite my low expectations for her, and she went on to do well over at least a 5-10 year period up to the present (and still doing well). In some others I can think of, it seemed like a high percentage of the hairs from the donor area, even the seemingly strong appearing ones, when they emerged in the recipient area one life-cycle later (after going through the normal "shock" reaction all transplanted follicles undergo), an even higher percentage of them grew out "wispy" and the overall experience was not a forward step for the patient. Theoretically, one additional step that could be taken would be to "cherry pick" only the follicular units that contain at least one strong "terminal" hair and only use them, putting aside the severely miniaturized ones, as the injury to the scalp of the recipient incision is almost not worth the tradeoff for placing a hair that is unlikely to add to the cosmetic appearance and theoretically could hurt the chances for the good follicles to grow. I have transplanted hundreds of women and must confess not having used this method yet. As per the other suggestions you received, Rogaine will certainly slow down the hair loss process if taken faithfully. The comments about other medical diagnoses is important for completeness and can be ruled out with a couple of simple blood tests and a good history, but I must emphasize that they are very rare in most of our clinical hair practices. The bottom line is this: if your expectations are not too high and are realistic and your hair surgeon feels that a positive result is possible, then you have a chance of being reasonably happy with your result for quite a few years. Mike Beehner, M.D.

Albal Smith, The total number of grafts planted in a hair transplant procedure simply refers to the number of "building blocks" used in that case, whatever their size or composition. In modern hair transplantation, that usually can range from a 1-hair follicular unit graft up to usually a double follicular unit graft of 4-5 hairs, both dissected under microscopes. Ordinarily the number of grafts equals the number of recipient site incisions with two exceptions: One, if extremely tiny incisions are made over the entire planting area and the physician feels that 3 or 4-hair FU's are too large to use and instructs the assistants to split them into two smaller grafts each. Actually, two 2-hair grafts made by splitting a 4-hair FU will still count as two grafts, because the work was taken to cut them into separate units and two separate incision sites are made to place them in. Two, if a patient has a larger percentage of naturally occurring 1-hair FU's in the donor tissue, often two 1-hair FU's will be "paired up" and placed into a single incision, which then becomes a 2-hair site, as opposed to making two separate sites and placing 1 hair into each one. Fortunately most patients have around 20% 1-hair FU's, which works out to about the number needed to create a natural front hairline, and rear border. From the viewpoint of minimizing injury to the scalp and creating density, if there is an excess of 1-hair grafts, placing two into a single incision is probably preferable. Whether one charges for 1 or for 2 grafts for the grafts placed in such sites can sometimes be problematic, as you have carried out the work to dissect two separate grafts, but only one placement act is performed, as they are usually gripped together as they are placed. In our practice we prefer to keep 3 and 4-hair FU's intact and simply make sure that a few of the micro-slits are slightly larger than the others in order to accomodate them. An earlier commentator spoke of minigrafts and micrografts as both being over 4 hairs each. That is true of the definition of a "minigraft," which was a cut-to-size graft cut under loupe magnification in the past. But a "micrograft" is a different animal and has always simply been a 1 or 2-hair graft, which in the "old days" was split off from a larger graft usually. The concept of the naturally occurring follicular unit wasn't appreciated back in the 1970's and early 1980's. Many of us still use the term "micrograft" to refer to a 1-hair graft that is the result of splitting up a 2-hair FU to make two single 1-hair grafts. This is sometimes necessary when a patient has hardly any naturally occurring 1-hair FU's and they are needed for either eyebrow work or for the edge of the front hairline. Many people, including myself, feel that giving the NUMBER OF HAIRS transplanted is a more accurate way to describe what was accomplished in a single transplant procedure. My experience is that most patients require somewhere around 10,000-12,000 hairs on the top of the head (frontal and midscalp regions) to look relatively full. Persons with extremely fine hair sometimes require more. Mike Beehner, M.D.

Hair loss in women IS a little different than in men, and the approach for transplanting is often different for most physicians. In our practice, women make up about 15-20% of our patients. I find that around 70% of the women who present for consultation are able to be offered hair transplantation. The two key requirements are sufficiently dense, high-quality donor hair AND realistic expecations. First of all, hair loss is far more psychologically devasting for a woman than for a man. Part of their body self-image is to have a full head of hair. Many men look fine without hair on top and it doesn't bother them at all. Somewhere around 20% of women will eventually have significant thinning of their hair. Their rate of hair loss, compared to the typical male who has hair loss, is much more gradual and over many years. There often are other females in the family history with similar hair loss. They also have a somewhat higher incidence of medical factors causing hair loss, which have to be carefully looked for before assuming it is hereditary "female pattern hair loss." Scalp biopsies are done much more often in women. There are a few different patterns of hair loss in women, but the commonest is for the front hairline hairs to be preserved and for there to be a general thinning all through the top, central area. This thinning often extends to the side areas of the scalp in the temples and above the ears. Fortunately, the majority of these women retain good density in the rear occipital region of their scalp, and this can be used for hair transplantation if there isn't too much miniaturization present. Another common pattern, present mostly toward the front, is the "Christmas tree" pattern, which is loss down the front-center of the scalp. Women's hair loss doesn't seem to be that related to DHT's presence as in men, and finasteride is not usually of benefit. We know women have higher concentrations of the enzyme aromatase in the front hairline area. In transplanting women, expectations are important. How they will style their hair later is a key factor. Normally the priorities have to be filling in the front-central "frontal core" area with hair so the front view of a woman is a "full" appearing one and the scalp can't be seen through the hairs. Depending on which side or down the center that they intend to part their hair, this area will be transplanted more densely. These hairs will then be styled off to either side, which creates overlap and the illusion of density. Perming the hair is another option that works well to create a fuller appearance. In transplanting women, one of the key pieces of information that must be communicated and accepted by the patient is that there is greater incidence of "shocking" to native hairs present in the area being transplanted. I would say it occurs to some extent in 30-40% of the women we transplant. It is severe in only 5% and in the others it is mild or moderate. The majority of the shocked hairs will after a few months, regrow and contribute to the hairs present on top. But a lot of the more vulnerable hairs, especially the wispier ones on their last life-cycle, will not return. For many years we used multi-FU small slit grafts in the center and FU's all around. This gives a wonderful density result, but I am presently trying to determine if the larger slits in the middle have anything to do with the 30-40% incidence of shockin, and so we are now taking a two year period in which we are going to transplant most of our females with 2000-2500 FU's, using a dense-packed stick-and-place method in the front center for "instant density" there, and we will see if the density results and perhaps reduced incidence of shocking comes about. If not, I would return to my former way of tranplanting, as it is more economical for the patient and gives very predictable density results. The good news is that as early as 5-6 months after the procedure, the area transplanted has the strong donor hairs from the occipital area growing and appearing filled in. Paradoxically, I find that the women who are very early in their hair loss and don't actually appear that bad are the ones who are most sensitive to shocking and are much more distressed when it happens. The women with moderate to severe hair loss are almost always happy they went through with it, especially at the 15 month point after the second session. Mike Beehner, M.D.

Bill, In answer to your question, my answer would have to be that I don't know, but would like to like to know what it is. The few tests that have been done give us only glimpses into what it might be. An important thing to remember is that there is huge patient variability in how hair grows and even survives, and I'm not simply talking about coarseness of hair or how curly it is. I suspect there are large patient-to-patient differences in blood supply and immune factors that allow grafts to grow better in one person than in another. Almost every hair surgeon I have ever talked with in depth privately acknowledges seeing this in their patient results. I have a strong hunch that FUE survival has to be lower than with microscope-dissected strip FU's, but I can't even vouch for what that survival might be at this time, since most of my FUE grafts go into scars, which is a notoriously poor blood-supply bed for grafts to grow in. Even with the best, microscope-dissected FU's and technique, 60-80% is probably the best we can expect in thick scar tissue - and that's if they are spaced far enough apart to get some vascular support. Since any one doctor can only conduct a study on one to three patients at a time because of time and financial restraints, any one study is thrown off a little by how good those factors I alluded to above happen to be in that small group of patients. The more studies that are done, the more certain we can be. By the way, all the comments I made were about virgin first sessions. The whole issue of what percentage of follicles survive in second or third sessions, when you are making recipient sites in close quarters between previously placed grafts is a whole other story. Six years ago, when larger recipient sites were used (18g), I conducted a study on a single individual and obtained survivals at one year of 108% and 94% after the first session; 71 and 76% cumulative survival after two sessions; and 56.9 and 57.6% survivals cumulatively after three sessions. These were planted at 25 FU/cm2 the first session, 19 FU/cm2 the second session, and around 16 the third. The density decreased in order not to damage previously placed grafts. Whether the principle involved in this study still applies I don't honestly know. I do know that the 18g needle is too large to use when dense packing FU grafts, so the study may be flawed from that standpoint, but I am still strongly suspicious that second and third sessions don't do as well as the first time around - which also backs up Dr. Seeger's "one pass" theory he gave to us years ago. Also, I should comment that, except for the two studies I mentioned, all of my studies have been on 2-hair FU's. So, in answer to your question, I don't know the absolute truth as to survival averages. I am pretty darn sure it isn't 95-98% in the average practitioner's hands, nor probably even in the best practitioner's hands, but feel pretty sure that on our good days with the right patient, we maybe hit that high mark, but my gut feeling is that it is the exception. I look forward to learning from others in the years to come which combination of methods will work best to insure high graft survival. Mike Beehner, M.D.

Bill, I won't presume to answer your question as to whether FUE or strip harvest surgery is better. I did, however, want to respond to the numbers that were thrown out (or possibly quoted from some source) regarding FU survival from strip and FUE. Your note quoted FUE grafts having "approximately" a 90% survival and strip-harvested FU's having a 95-98% survival. In point of facat, there have been no published studies on FUE survival to date that I know of in the usual publications that most hair surgeons read and contribute to. Regarding FU's obtained from strip harvest, I have done approximately 10 separate research studies over the last few years which looked at FU follicle survival and I am also familiar with several other studies by reputable hair surgeons, and I can assure you that they do not average out to 95-98% survival. They are skewed all over the place, from the low 80's to over 100% (in "chubby" FU's). My overall impression is that FU's average in these studies to around 90%. In 2003 at the annual ISHRS meeting in New York City, Dr. Kim from South Korea and I presented two separate, independent studies of FU survival and coincidentally or not so coincidentally, we both obtained a 90% survival of follicles. In two recent studies I conducted, the follicles contained within 2-hair FU's survived in the mid 90% range, whereas 1-hair FU's survived between 65-75%. The 2-hair FU's were placed in 19g needle sites and the 1-hair FU's into 20g sites. I strongly suspect that the lack of protection and physical buffering around a skinny 1-hair FU makes it far more vulnerable to both trauma and drying. Furthermore, these studies and most of those that have been done have always been done in a separate, isolated area where blood supply is probably most ideal and not in the center of thousands of other FU grafts as most transplanted grafts usually find themselves. Obviously, these numbers you mentioned are given by doctors to their patients because it is their IMPRESSION, on looking carefully at the hair growth they obtain a year after an FU transplant, that this is what they think they see growing. I don't disagree that some of the results we see on the internet are impressive. I am simply adding the caution that when you throw enough mud against a wall, a lot of it will stick. If you place 3000-7000 FU grafts in a single person's scalp, you are placing a large number of hairs and it will look like a lot of hair a year later, especially if they are put in as they are found in the donor area and not dissected into smaller half-FU's of 1 or 2 hairs. Unfortunately,no one as yet has studied growth of FU's in the midst of such dense, large sessions. It's probably not a good idea for me to do such a study, as sessions that size are not my usual way of doing surgery and I would be rightly criticized on that basis. I have spoken to several of the doctors who do large dense-packed sessions, asking them to conduct such a study, but to my knowledge none have been done to date. There is no doubt in my mind that there easily could be a 30% difference in survival when comparing a top-notch surgeon and his/her staff to the results of a mediocre operation that one day adopts this method and tries to do the same number of grafts without having gradually worked up skill-wise to that level of task. Assuming that everyone gets the donor follicles into the recipient area within 8 hours and that they are stored in cooled saline until that time, the critical, life-threatening step for the individual follicle's survival is the grasping of the graft by the assistant (or physician) and the ENTRY of that graft into the small site. If the bulb is pinched or if part of the bulb is lopped off trying to be pushed through a skin opening that is too small and tight, then the chances for that follicle's survival drop precipitously. So, whatever we find the percentage to eventually be in the hands of a skilled, conscientious surgeon and staff - regardless of what the number is - it is obviously still a good thing to use follicular unit grafts and to try and get them safely into the smallest sites possible, simply because they give a very natural appearance that cannot be obtained at the hairline or visible areas by larger grafts. I just don't know how, just looking at an area you transplanted, you can tell 80% survival from 98% survival. The ideal approach is to tattoo an area off, put a thin 1mm wide moat around it of bare skin and count the follicles that are placed within that box at the start and then the number of hairs that grow out a year later. One final comment about FUE grafts. I certainly don't claim to be one of the experts in FUE, but have done around 50 cases, mostly with harvesting scalp hairs to help camouflage donor scars or post-surgical scars from other surgery such as neurosurgery. My point is that, in my experience, the grafts obtained from FUE are not of the same quality as those dissected carefully under a 10 power stereoscopic microscope from a strip. Many of the FUE grafts are a little "scraggly" and missing some or much of the surrounding protective subcutaneous tissue structures. The bulbs at the bottom are often denuded, making insertion of the grafts hazardous. Many of the 2-hair FU's resemble a pair of pants, in that the two follicular structures are hanging down separately from the epidermis/dermis connection at the top. These are difficult to insert into a small recipient site and are sometimes more easily and safely placed as two separate 1-hair grafts. This isn't because any doctor is bad, but just because the nature of the beast is that the final removal of the graft from the donor area is a gentle "tug" of the graft from its connections. Many of us use a two step technique (initial superficial sharp cut, followed by a deeper dull one). I use the SAFE method published by Dr. Jim Harris. Dr. Feller's point that everyone is not a good FUE candidate is certainly true. Dr. Rassman, one of the early pioneers in this technique, submitted patients to a FOX screening test before taking a patient on for FUE, and many a time, when removing the graft from its moorings was tough, I wish I had tested the waters first. So the bottom line is that the slightly uneven, rough way we harvest the FUE graft is offset by the wonderful advantage of not creating a horizontal scar or worsening an already present one. As with the large 3000+ FU session graft survival studies, it would be ideal if an FUE graft survival study was done by someone who does these frequently on a regular basis. Hopefully a year or two from now we'll have better answers to these questions, which will help both doctors and patients to choose wisely how to proceed. Mike Beehner, M.D.

Thank you for some of the kind comments above. Per the request of a couple of the readers and Bill, I will submit some photos of our recent work under "Patient Photo Albums," with one section showing some "forelock" type projects in extremely bald men, and the nother section including some more routine male and female cases. Over the past 7-8 years that I have been a part of the HTN, I have enjoyed the "give and take" of trying to help educate the public about hair transplantation and sharing some of my personal, slightly more conservative views regarding this wonderful field. We are so lucky at this time in history to be able to offer such natural results to the great majority of our patients, using the various techniques that are available. When Pat visited our office a few months ago and reported on a dense-packed, all-FU trans-gender surgery session we did that day, he asked me if I would at some point try to explain for the readers some of the pro's and con's for including MFU grafts within certain transplant projects. I promise to do this at some point in the next few weeks when I get my thoughts organized and a few pictures to help make my points. Best wishes, Mike Beehner, M.D.

KulMD, When you say "with side effects discussed," I assume you are experiencing some sort of sexual side effects and are looking to reduce your dosage in hopes that you will not have the side effects but still get some benefit from inhibiting DHT. In men over 30, my commonest dosage regimen is 1/4 of a 5mg tablet M-W-F. If you are having side effects at that does (which is 1.25mg every 2-3 days), then I would advise that you switch to Propecia 1mg tablets and cut them in half and take a half a tablet every other day for a month or so and see whether things get better. Remember that studies with as little as 0.2mg per day showed significant suppression of DHT. I agree with you that if the goal is to use these lower doses, you can't be cutting a 5mg tablet into fragments, as it is impractical. You still will have significant cost savings in comparison with the usual recommended dose. Mike Beehner, M.D.

When someone looks into an area of thinning scalp hair under magnification and looks at an area with a significant number of "miniaturized" hairs, there obviously are also present some fairly normal, residual full-diameter hairs. Usually in future hair growth cycles, these follilcles will later start to produce instead hairs that are narrower in diameter ("wispier") and not capable of growing to full length. Why do some hairs die off early and others stay around longer? It's important to remember that the genetic programming within each follicle is still the most important determinant for what is going to happen as the years unfold in that person's lifetime. That probably is a little different in each follicle, thus explaining the fact that all the hairs don't thin and become lost at exactly the same time. I like to think of DHT having a PERMISSIVE role for the genetic pre-determined course to occur. When DHT is suppressed with finasteride or dutasteride, it appears it DELAYS the day the genetic end-result occurs, but does not prevent it. As most of you know, as a man (or woman) becomes older, especially in the 60's, 70's, etc., there is a thinning of the hair density with loss of some hairs which we refer to as "senile alopecia," which is not thought to be under the influence of DHT. Mike Beehner, M.D.

If one of the various well-known patterns of male pattern baldness expresses itself in its early stages, it is virtually unheard of for it not to progress gradually to a more severe degree of hair loss. About the only exception to this might be the man who only has a minimal fronto-temporal recession (Norwood II category). Occasionally one of these will "lock in" and stay there. It is true that many men have periods of their life during which it seems the hair loss progression accelerates and other periods in which it seems to stabilize, but in my 19 years of following men with hair loss, when you see any man 5 years later who was not on medication or transplanted, there is progression of hair loss. The two age plateaus where I see most men start this process is first in the early 20's when many, including myself, start to recede in the front corners and at the same time thin in the crown. The second is in the 40's, when a fair number of men, who previously thought they were immune to hair loss, also start to thin in front and in back. Dr. Marritt, a well-known now-retired hair surgeon from Colorado, was a movie buff and used to follow the careers of many actors who fell into this category, including Clint Eastwood, Johnny Carson, Alan Ameche, Paul Newman, and many others. The person who replied concerning "diffuse thinning" was right on, as this one always progresses. A good way to tell at the time of a consultation if an area is going to progress later to hair loss is simply to look for miniaturization under magnification (we use 30x power in our office).If one sees more than 5% miniaturized hairs, you can be fairly certain that area is someday eventually going to clear out. There are basically 5 main pathways of hair loss progression: (#2 is probably the commonest) 1) Diffuse thinning all over on top 2) Recession in front along with crown thinning, with eventually a band of hair across the top (mid-parietal bridge) and a weak frontal tuft of hair, with eventual disappearance of these and a resulting U-shaped area of baldness. (Norwood Scale basically follows this pattern) 3) Norwood "Variant" hair loss pattern: in which it erodes away at the front hairline edge and progresses backwards, usually sparing the rear crown/vertex. 4) The reverse, with the crown balding and then the hair loss progressing forward behind an intact front hairline (see Al Gore) 5) Residual frontal forelock pattern of strong hair with loss to both sides and all behind it. Mike Beehner, M.D.

If you recall, I didn't say that finasteride didn't work at all after 4-5 years or after 10 years. It is still helping; the rate of hair loss is still s trickle compared to how much would be being lost if a man stopped using it. It's just that you are on the "down-curve" instead of the "up-curve" regarding the amount of "hair mass" on your head. You're still helping yourself staying on the medication; it's just that the dramatic response of the first 4-5 years won't still be there. As to Dutasteride, I know that a lot of my colleagues have used it on their patients and I have seen some photos showing impressive results. I am a little more conservative than most with new drugs like this. Dutasteride can raise the testosterone level in some men up out of the normal levels. If side effects, such as libido or erection problems, occur, they can last for months because of the long half-life of the drug. It is true that you can sort out these people who will have problems by first having them take Propecia and seeing how they respond to that. The FDA hasn't approved dutasteride for hair loss for another thing. Lastly, it suppresses DHT almost too well, over 90%. I'm one of those docs that believes that most of the hormones and chemicals floating around in our body have a purpose for being there, for the balanced health of your body. To put a young man on a new drug for the next 20 years of his life without the knowledge of what might happen down the road while suppressing this body chemical that happens to also work in our brain tissue, is a leap I'm not comfortable taking. That having been said, I am pretty sure it works a little better than finasteride in working against hair loss. Mike Beehner, M.D.

Byehair, What you are describing with finasteride treatment, namely increase of hair the first 5-6 years followed by some decrease, mirrors the timetable I described above. You are still better off staying on it, as the "curve" or rate of hair loss almost certainly would be greater if you abruptly went off it as opposed to staying on it for a few more years. As to whether or not you would be helped by transplants, this is almost always the case, as long as your expectations are not unrealistic. The decision on how much can be tackled on a man like yourself depends on two things primarily: your AGE, and the PROJECTED RATIO OF "SAFE" DONOR HAIR COMPARED WITH THE EVENTUAL BALD RECIPIENT AREA. Even in extreme projected Norwood VII patterns of hair loss, a frontal forelock pattern frames the face nicely and appears almost like a full head of hair from most views. For_Indai, With regard to breaking Propecia tablets in half, you use an ordinary "pill cutter" (around $3.20 at Wal-Mart or any drug store). The official line you will sometimes hear is that the medication is not evenly distributed throughout the 1mg (or the 5mg) tablet, so the dose is not predictable, but I think this is overdone, and, besides, most doses are probably more than you need and do work to suppress tissue DHT for nearly 3 days, so I wouldn't worry about that. You are right: women cannot take this medication, because of the danger of a male infant having birth defects and also because it really doesn't work for most female pattern hair loss. If you indeed will never be worse than a Norwood IV, then your hair surgeon can certainly be a little bit more aggressive. Normally, the area transplanted is not only the bald or very thin areas, but the surgeon projects over the next 10-20 years where the edge of the hair loss will probably recede to and places FU's into this area too, so that when the day comes that your native hair is gone there, these transplanted hairs will already be there growing to prevent a bald "stripe" of scalp from showing. And Yes, many men do come back 10 or more years later to fill in areas of new male pattern baldness that were not evident earlier, especially with a pattern like you have. Mike Beehner, M.D.

With regard to the point you made about having side effects with Propecia, you might want to try a much smaller dose regimen, which is likely to still help you prevent hair loss, and at the same time possibly reduce or remove the side effects. I have had many male patients of mine, especially those over 45, use a half tablet every other day. This averages out to 0.25mg/day. Merck's own research showed a 62% reduction of DHT with only 0.2mg/day. Mike Beehner, M.D.

For Indai, When my new transplant patients ask me whether or not they should also go on finasteride, I use the following two scenarios to explain thedifference: Imagine that you and I have a brief consultation visit in around 4 years to see how your hair is doing; If you have both the transplants AND go on finasteride, we will see the ADDITION of two things: the transplanted hair PLUS the increase in hair mass that occurs in a majority of finasteride-treated patients. On the other hand, if you only have the transplants, then 4 years from now we will be looking at a SUBTRACTION, namely, the positive effect of the new transplanted hair, MINUS the progression of male pattern baldness that occurred during that time. There is an enormous visual difference between those two scenarios. The ironic part is that in the first scenario the doctor gets more credit than he deserves for his transplant efforts, whereas in the second scenario, the patient often blames the doctor for having had NO EFFECT on his hair loss with the transplants! There are exceptions to the above: If the man is of a reasonably mature age, say 38 or 48, and is shiny bald on top with his side fringe borders pretty well set, which means that male pattern baldness has essentially reached its end-stage, then finasteride is unlikely to make much difference. The more "native" hair that exists on top and the younger the patient is, the more beneficial and important is the combining of transplants along with finasteride treatment. The majority of patients who benefit from finasteride treatment have a net gain in hair mass (increase of hair shaft diameter and increase in the potential length hair can grow to) in the first 4-5 years of therapy. After that there is usually a very gradual diminishment in hair mass, such that many patients end up ten years later around where they started. So the medication "buys" 10 years of time, usually during socially critical years of a young man's life. If you are destined to someday have a Norwood VI or a Norwood VII level of baldness, finasteride therapy taken your entire life will not prevent that, it will in most cases greatly delay the day when it happens. There are obviously individual variations in how any one man will respond to finasteride treatment, but the above picture describes the great majority of the men I have treated over the past 10 years. As others have stated many times on this Forum, Rogaine (minoxidil) topical therapy along with finasteride does have a synergistic effect. Unfortunately, castration is about the only therapy that will almost completely arrest your hair loss, and there understandably aren't many men lining up for that. Mike Beehner, M.D.

John M, You have to understand what is happening at the microscopic level under the skin. After hair transplant surgery, probably 95% of the follicles that have been moved to the recipient area are "shocked" into a 3-4 month "telogen" phase, during which the follicle structure "shrivels" up, shrinks, and takes a nap for a few months. While it does this, it totally disconnects from the little stub of hair above it, leaving it sitting in its little superficial hole. Oftentimes, a shower, brushing, or rubbing your scalp will cause these to fall out of their tenuous hold in your scalp and cause panic. Don't worry. The follicles that don't shock, which is usually a small percentage, but occasionally can be quite a few of them in some patients, you can tell because the hair grows from the get-go and from week to week you can tell this is happening. In many cases, a lot of the short hair stubs will fall off along with the scab at the 1-2 week mark and cause alarm in patients, thinking that they have lost the translanted hair, when it is just a shedding of this dis-attached hair, which is dead, just like a finger nail that has been separated from its bed but still sits in position at the end of your finger. Interestingly enough, when one uses multi-follicular grafts of 4-5 hairs each, almost all of the hair stubs DO fall off with the scab, whereas in areas where all FU's are used, I find it common for the hair stubs to sit in place for many weeks as you have described. When the follicle finally comes out of its "slumber" and starts creating a new hair shaft, this new shaft quickly displaces the other one. Mike Beehner, M.D.

Occasionally I will notice what you are talking about in a returning patient - where one or two hairs near the front hairline are extrememly kinky and can even start off at a different angle, but more commonly exit their site at the proper angle, but then take sharp turns in different directions, almost resembling part of a broken pretzel. While it is true that many men with coarse, slightly wavy/curly hair will have more general "kinkiness" of the hair in the first year and that it can "settle down" and be much less noticeable after a year, I think the really bizarre ones like I described are most likely due to trauma to the follicle during the insertion phase of the procedure by the forceps or by repeated attempts to place the graft. If they are out front and noticeable and unlikely to be improved by new grafts around them, etc, my preference is to FUE (core) them out at that subsequent session and put a very fine suture in to close the tiny hole, or to leave it alone to heal by itself if it is back behind at least a couple of hairs. The presence of one of these hairs certainly doesn't mean you have a bad hair transplant surgeon. They happen to the best ones. If they were all over the place, or accompanied by a lot of pitting also, then I would worry about the quality of your doctor's assistants and I would look for a new surgeon. Mike Beehner, M.D.