Dr. Paul Shapiro

hdude64 I have not seen mpb correlate with an itchy scalp. Most likely your skin is sensitive to something and in the areas where there is no hair, there is more sensitivity. I would try hard to think of any products such as soap, shampoo, conditioner, laundry soap, etc??¦ which might be the cause of the problem. I also have seen some patients being sensitive to hard water and getting a water softener installed helped. I have also seen the opposite where the chemicals in water softener has made a patients skin itchy. If you have any sort of rash with the itchiness you may need a skin biopsy to get the proper diagnosis. I have not had a patient stop propecia and then go back on it as you mentioned so I really can't comment on whether this works. It may work in some patients but not in others. If porpecia seems to be losing its efficacy I don't see the harm in taking a drug holiday and then restarting it. Dr. Paul Shapiro

Hdude46 Propecia is a great medication for a lot of men. The information I have on propecia comes from two sources. One is the medical literature and the other is personal experience. The medical literature studies only go out for 5 years. What it shows is that 90% of men who take propecia have a positive effect. Of that 90%, half get new hair growth and half only stop further hair loss but do not get new growth. Outside 5 years we do not have any scientific studies to go on. In my experience we see a wide variance on hair loss in patietns on propecia. It works in most men and seems to work best when started young and in men who are Norwood type 2 to Norwood type 5. Some men stop it because of side effects but that is a small number in our practice. I would say less then 1%. Most men tolerate it well, or the side effects are very minimal and worth the hair growth. We do see that propecia losses its efficacy with time in a lot of men. In how many I am sorry I can't tell you. That would be a good study to do. I would say that maybe 20% to 50% of men start to see a loss in efficacy after 5 years. In some of these men Avodart seems to help. I would like to hear what other physicians have noticed. The rate of hair loss is an interesting topic. I agree that if someone at a young age has rapid hair loss I think they have much more probability of becoming a Norwood type 6 or 7. But I have seen some men in which they have a period of rapid hair loss, and then it stabilizes for many years. So like all other factors. It is a guide to predicting hair loss but not an exact predictor of hair loss.

In predicting hair loss, ones age, family history, the degree of hair miniaturization is helpful, and as you said can give us a gauge of where they may be headed. But knowing all this it is still difficult to accurately predict hair loss in patients less than 30 years of age. I come from a family of 4 boys. My brother Dr. Ron Shapiro and myself have little hair loss at age 56 and 54. My other two brothers have Norwood type 6 to 7 hair loss. One of my brothers started to show significant hair loss in his 20's but the other did not start to show much hair loss until he was in his 30's. If someone came in to my office at 30 with very minimal hair loss, no miniaturization of his hair, and a great family history, then I would say he most likely won't have much hair loss. But this type of patient is rare to see in our practice. We can do hair transplants in younger patients. I have done hair transplants in patients as young as 21. But the planning has to be conservative and I plan my case as if they are going to become a Norwood type 6 or 7. If a young patient has realistic expectations and is OK with a conservative first surgery, we can help them out a lot. In patients who are over 30, if they are Norwood type 3 or 4, I feel more comfortable planning a lower hairline, and planting more hair in the hairline, and frontal 1/3 of the scalp. But these patients have to know we are still taking a risk that we may run out of donor to cover the crown if his hair loss progresses. Most importantly we need to make sure that in patients who seem to be on their way to Norwood type 6 or 7 that we are not overly aggressive. These patients may lose the hair in their temporal humps and we need to make sure we design the hairline and have enough donor hair to build the temporal humps back up to meet the hairline. I hope this answers your question. Dr. Paul Shapiro

Back to the original question: is 3,000 FU too much for the frontal 1/3. As you can see from all the comments there are a lot of factors to consider when determining how much donor hair to use for each hair transplant. One factor I did not mention is how much surface area needs to be covered. When you are asking about the frontal 1/3 of your scalp I am not sure how much surface area is in the frontal 1/3 of your scalp. Here is a link to a thread on the average surface area of a Norwood type 7: Surface Area Norwood Type 7 So when you are asking about your frontal 1/3 of scalp are you talking about 50 sq.cm of surface area or 70 sq.cm of surface area? It might be helpful for you to measure the area of coverage rather then thinking is it the frontal 1/3 and then look at the projected density for that transplant. I estimate that the frontal 1/3 scalp in the average patietn is 60 to 70 sq.cm. of surface area. At SMG we usually plant 2,000 to 2,500 FU in the frontal 1/3. Depending on the surface area we are covering this can give us an average density of 30FU/sq.cm up to 40 FU/sq.cm. Ocassionally we will plant 3,000 FU in the frontal 1/3 if a patient is older, has great donor density, and we do not think he will become a norwood type 6 or 7. This will enalbel us to plant at higher densities. Dr. Arocha's links also show how ones hair characteristics play an important role in hair transplant planning and his approach to a Norwood type 7 with average donor is very useful. As you can see in the type 7 patient he needs some hair to raise the lateral hump to meet up with the temporal alleys and hair line. Also to make this transplant look good he did transplant hair further back then the frontal 1/3. If one only transplants the frontal 1/3 in Norwood type 7 patients the hair transplant looks weighted to far forward. In this patient it looks like the frontal ?? to 2/3, not the frontal 1/3 was transplanted. As Dr. Arocha noted he needed 500 FU to raise the temporal humps and then used the remaining 3,000 FU to plant the rest of the scalp. Thus 3,000 FU was used to cover more then the frontal 1/3. I think there may be varying definitions of what the frontal 1/3 of a patients scalp is. In answer to Ron J's question about safe donor area; I have seen some cases posted on the internet where the donor hair is taken outside the traditional textbook safe donor area. In some patients there is the potential that this hair is not permanent and may thin or fall out as we age. Below is a photograph of a Norwood type 7 patient. You can see how the lateral temporal area has eroded, and how the neck hair line has been raised. I have outlined the safe donor area in this patient. With the advent of FUE we may be able to increase how much donor can remove, but I am not sure how much. It may be 500 to 1,000 FU in a patient. But remember that FUE is not scar less, but just leaves a less obvious scar. One still has to leave enough donor hair to cover up the scar. Also FUE is a tedious expensive procedure and may not be an option for a lot of patients. In young patients I do not believe we can accurately predict future hair loss. But in older patients the degree of balding, the rate of balding, their family history, and how they respond to propecia, all may help predict future balding. There is one tool I find very helpful in predicting the patient's safe donor area. I will wet the patient's donor area and then look for what areas become see through. You can see how this works in the photo below. When the hair is wet you can see much more of the crown and I assume that this hair will fall out in the future and is not safe to remove as donor hair. I hope this is helpful in answering your questions Dr. Paul Shapiro

SpaceBetween It is difficult to know the answer to your question without knowing your age, donor density, door laxity, what Norwood type you are, and what degree of balding you have on your crown. In patients with good donor density (greater then 80 FU/sqcm), good donor laxity, and good health, who I don't think will progress to Norwood type 6 or 7 balding, 2,500 to 3,000 FU in the front 1/3 can be appropriate. So a 3,000 FU graft case may be good for you. I do not think the average patient has 10,000 FU over their lifetime. I would say that few patients have 10,000 FU over their lifetime. Many have 8,000 FU over their lifetime. And some have as little as 6,000 FU over their lifetime. Remember that one has to leave enough donor hair in the donor area to cover up the scarring left by either strip or FUE technique. Most patients end up with very minimal scarring, but everyone scars differently. Studies show that 20% of the male population will have balding in the Norwood type 6 pattern by age 60. In these patients, when the hair recedes in the temporal areas and at the bottom of the crown, that leaves less of a 'safe donor area'. There are textbook measurements of what is considered the safe donor area for most patients. I think it is important not to go beyond that safe donor area in young patients and patients who most likely will become a Norwood type 6 or 7. Some of the aggressive hairline and frontal one third cases I have seen, the doctor takes donor beyond the textbook definition of safe donor area. If those patients progress to a Norwood type 6 or 7 we may be transplanting hair that is not permanent and we may be at risk of a see through scar as one ages and/or running out of donor hair that may be needed for later surgeries. So as you can see, your question does not have a straight forward answer. It would be wise to get a few consults, and ask questions about the density of your donor, your donor laxity, and possible future progression of hair loss. I hope this is helpful Paul Shapiro, Md

cd3po As you can see there are many options available to you mentioned so far. To find out which is the best option for you it is a good idea to educate yourself as much as possible. Most hair transplant clinics give free consults and it would be a good idea for you to have some consults and see some photographs just to see what can be done. You should also get some advice from reputable hair piece companies. Whether a hair transplant is right for you depends on your donor supply and what your expectations are. Also whether to use strip of FUE is not straight forward. It is incorrect to say that FUE does not leave a scar, and when doing large sessions over 3,000 grafts the scar left by FUE is noticeable, but different then the scar left by the traditional strip method. I am not sure in your case that FUE would be the way to go. Dr. Feller wrote an excellent comment about using FUE for large procedures and you can read it on the following thread. Dr.Feller on FUE Here are a few photographs of patients who are between a type 6 and type 7 and what can be accomplished in one strip session using 3,400 FU. Here is what the strip scars look like: As you can see they do not have a full head of hair. But they have gone from looking bald to looking as if they have hair. Of course the crown in these patients were not addressed at all. This may be acceptable to you or it may not. Both of these patients have enough donor for a second session. I hope this information is helpful Dr. Paul Shapiro

Hair transplants can be done with or without the head shaved and at SMG we do transplants both ways. When doing a megasession of 3,000 grafts or more, or in cases in which we plan to do dense packing, I think it is important to be able to shave the head. Our goal in these megasessions is to get the patients total hair density (the patients native hair plus the hair we transplant) up to at least 40 FU sq.cm and in some cases we even get their total hair density up to 60 FU sq.cm. If I we are going to plant hair at these densities I believe it is important to shave the head in order to avoid transection of existing hair and get the high densities desired. I do agree with Dr. Charles that it is easier to perform the surgery when the head is shaved. For the sake of hair survival when doing a meagassession I think it is important to do everything possible to make the surgery as easy as possible and to keep the time the follicles are out of the body as short as possible. Now that we are doing cases up to 4,000 FU it is important we do everything we can to make the surgery go smoothly. Studies show that the hair survival decreases the longer the hair is out of the body. The most sited study shows that at 4 hours out of the body, FU survival decreases to 95% and at 6 hours it decreases to 90%. After 6 hours out of the body, FU survival continues to decrease by another 2% every hour. In all my hair transplant cases I try to have the FU's planted within 4 to 6 hours of removing the strip. That is why when I do large sessions I take the strip out in two pieces and have the FU's from the first strip planted while the second strip is being divided into Follicular Units. I tell patients that we can perform a surgery with or without shaving the head, but that we can pack more densely and the amount of hair we transplant will be greater if we can shave the head. In general I use the following guidelines: In transplanting the frontal 1/3, if the patient has existing hair and will not allow us to shave the head I will transplant 1,500 FU. If the patient has little hair or allows us to shave the transplanted area I can transplant 2,000 to 2,500 FU. In transplanting the frontal 1/2, if the patient has existing hair and will not allow us to shave the head I will transplant 2,000 FU. If the patient has little hair or allows us to shave the transplanted area I can transplant 2,500 to 3,000 FU. In transplanting the frontal 2/3, if the patient has existing hair and will not allow us to shave the head I will transplant 2,500 FU. If the patient has little hair or allows us to shave the transplanted area I can transplant 3,000 to 4,000 FU. Of course this is just a guideline and the numbers varies depending on donor, quality of hair, patients health status, patients goals, etc??¦ I do not perform surgeries in the 5000 FU range. I am not sure the benefits of such a large case out weigh the risk. In these large cases we still can not cover the total crown area and many patients will still need a second surgery to achieve their goals. I am concerned the survival may decrease in these cases because they take so long. Unfortunately it is difficult to accurately measure survival and I am not saying for sure the survival is compramised but it is a concern of mine. I also find that many patients have a difficult time sitting in a chair once the surgery goes greater then 8 hrs. Remember even if one gets 85% survival on a 5000 case that still gives a final yield of 4,2500 FU and will still look better then a 4,000 case. But there is a potential for depleting donor that may be needed in later years. In summary, what I tell patients is that we can do a lot in one session without shaving ones head, but the remarkable dense packing one sees on the internet can only be done with shaving the head. So it is up to the patient to decide which way they want to go. Some patients can not shave their head and we can still get very good results. But if they want to get the maximum density possible and the biggest bang for the buck it is better to shave the head. I hope this information is helpful Dr Paul Shapiro

TC17 In my experience the average patient head can be divided into two areas. The frontal 2/3 of the scalp on average measures 100 sq.cm. On average the crown loss is 80 to 100 sq.cm. The area of the crown will vary by how low and wide the crown loss is. On average I would say that to cover the total bald area in most men who are type 6 or 7, I cover an area of 200 sq. cm. But there are men with very large scalps in which the area is more like 250 to 300 sq.cm and men with smaller areas. A total area of 170sq.cm.is in the realm of a normal area to cover. Since the area of scalp I am transplanting is not a box, it is hard to get a measurement by measuring just the length and width of the balding area. So your measurements may not accurately estimate the area balding in your scalp. The way I measure the recipient area is as follows. I went to Kinko's and had them copy some one sq.cm. graph paper onto clear plastic overhead sheets. To measure the recipient site area I place this clear plastic sheet on the scalp and draw the recipient site with wax pencil. Then I count the number of intersections inside this drawing on the sq.cm. grid. The number of intersections counted should closely approximate the area inside the tracing. This method is mentioned in some of the textbooks on hair transplant surgery. Try this method and see what area you get for your recipient area. I hope this is helpful Dr. Paul

Chancy From your description of having a red, itchy scalp, with hair shedding I would suggest you see a dermatologist. There are other causes of hair loss and/or hair shedding besides Male Pattern Baldness. You may have a simple dermatitis like seborrheic dermatitis, or may have an allergy to some hair product you are using. If you have actual pustules on your scalp you may have a low grade staph. infection. And there are other rare skin conditions that can cause skin redness and hair to shed. Without a diagnosis it is difficult to know if your condition is related to the Hair Transplant at Bosley or not. Regardless, you should have this your scalp looked at by a dermatologist. I would continue using the propecia. If your hair loss is from Male Pattern Baldness both propecia and rogaine can help, but the studies show that these medications sometimes do not help in the front half of the scalp but sometimes they do. So it is worth staying on the medication unless you are experiencing side effects. Dr. Paul Shapiro

Marie32 From your description of your hair loss it does sound like you have female pattern hair loss accelerated by a hyper-androgen (high testosterone) state. We do transplants on many women like you. The reason hair transplants work in women is the same as in men. The hair we take from your donor area is not affected by the genetic factors which are causing your female pattern hair loss. So when we transplant that hair onto the front of the scalp, it is permanent. Prior to considering a hair transplant I would recommend you have a thorough medical work up and possible medical treatments for your condition. There are medical treatments that can help lower your testosterone level, but most are not FDA approved. There is some evidence that porpecia which blocks the formation of DHT may help slow down some women with hair loss, but it is very dangerous to take if you are considering pregnancy. I usually do not give propecia to pre-menopausal women. Have you seen an endocrinologist? There are some medical treatments for hyper-androgen states which may help slow down your hair loss. It is also recommended that you make sure your Thyroid hormones are normal and the your Ferritin level (which measures the Iron in your blood) is in above 70. We are seeing more women come in for hair transplants and I would say 10 to 15 percent of my patients are female. Hair transplants in women are very different then men. The sessions are usually smaller and what we can achieve in one session is limited. If you are considering a hair transplant it is important you see a doctor who is experienced with female hair transplants. I have attached a previous thread so you can see some examples of what you can realistically expect to achieve in one transplant.Female hair transplant

Babs3h It is possible to perform succesful transplants on female patients. Hair tranplants in women are very different then in men and what is considered successful is also different. The most common cause of Alopecia in women is the one that is inherited and we call it Androgenetic Alopeica. But there are many other types of Alopecia and as Bill pointed out it is important to know the exact diagnosis of your Alopecia. From your comments it sounds like you may have Androgentic Alopecia which is a diffuse thinning. Because of the amount of thinning and the limited donor supply our goals of a succesful transplant in most women is to get more density so that it is easier to style your hair. I have included two photos of a female with moderate diffuse thinning and a female with sever diffuse thinning and what you could expect in one hair transplant. Most female patients take more then 1 year to get the maximum results from a transplant. This can be seen in the 2'd photo taken at 1 and 2 year post op FEMALE PATIENT WITH MODERATE HAIR LOSS at one year post op FEMALE PATIENT WITH ADVANCED HAIR LOSS at 1 and 2 years post op I hope this is helpful Dr. Paul Shapiro

Bananas HK500 is right to point out that what you are seeing may be due to technician placing, but there are also other factors that may have influenced the phenomena you are seeing. If you notice everyone seems to bald asymmetrically. I am not sure why this happens but obviously one side of the head is acting different then the other. It may be the side of the head you sleep on, it may just be genetic factors. So, hearing that your shedding is not symmetrical would not worry me. Now you are going into the hardest part of a Hair Transplant. Waiting for the hair to grow back. Like HK500 suggested, wait to see what it looks like when it grows out. At 6 months you will have a good idea of what the results are going to look like, but it takes a year for the final results. Dr. Paul

Thanatopsis_awry: The answer to your question is that sometimes smaller blades are more optimal, and sometimes not. It depends on many factors. What is more important then the size of the blade is how the Follicular Unit fits in the incision. The graft should fit snugly, but not too tight to cause compression. Also, the incision size should be such that the FU grafts can be planted into the skin with as little trauma as possible. The texture and thickness of ones skin and the size of the graft determine what size blade should be used to make the incisions. Some patients have tough, non-forgiving skin that does not have much stretch to it. In these patients I would usually cut my blades a bit larger. Some patients have follicular units which splay at the bottom. I find they get squashed a bit if the incision size is too small and I have to use larger incisions for this type of FU. A person who has thin blond hair will have much smaller FU's then a person who has thick, black hair. Persons with very curly or kinky hair will have a curve to the FU and will need larger incisions. Also, a FU with 4 hairs will be larger then a one hair FU and will need a larger incision to fit properly. At Shapiro Medical Group we cut our blades and they usually range in size .6mm to 1.2 mm. On average we use a .7 or .8 mm blade when we are making incisions for the one hair FU in the hairline. For the 2 hair FU we usually use .8 to 1.0 cm. For 3 and 4 hair FU we usually use .9 to 1.2cm blades. What I do is estimate what size blade I will need for a 1,2,3, and 4 hair FU. Then I make about 10 incisions and place some FU's into the incision. Sometimes the fit is perfect. Sometimes I need increase or decrease the width of my blade. I would say that in half my patients I use a .7mm blade for my one hair FU's. The other times I use a .8 and sometimes even a .9mm blade. Very rarely I have used a .6mm blade for one hair FU's. The smaller blades are great. We can make incisions closer together when we want to do dense packing. In patients with existing hair in the area of the transplant, the smaller the blade the easier it is to get between the existing hairs. Also, the smaller the blade, the less trauma there is with each incision. But also the smaller the blade, the more chance it will be difficult to place the FU without any trauma. So as you see, ONE SIZE DOES NOT FIT ALL. I hope this answers your question Dr. Paul

readyand40 At Shapiro Medical Group (SMG) I would say that about 40% of our patients shave their head. We do not require it, and as GrayFox stated, we get excellent results without shaving the head. I did review your photos and personally I would not do a case larger then 2,000-2,500 without shaving your head. That would allow for increasing the density in the front two thirds and filling in the hair loss in your frontal-temporal alleys. I would not lower your hairline much because you may have future hair loss. This would give you a very good cosmetic result. We did not even shave patient's heads at SMG until 2 years ago when we started to do large cases or dense packing in some areas. If you look at the photos in either mine (Paul Shapiro MD) or my brothers, (Ron Shapiro MD) profile on HTN, none of these patients shaved their heads. The difference in your case if you shaved your head would be that I could place the FU's a bit closer together to increase your density. Sometimes this increase density shows up as a significant cosmetic benefit, but many times it does not. Once we hair transplant doctors get use to making incisions and placing in shave heads it is difficult to go back to unshaved heads because the field of view is so much better. But we can do the whole procedure without shaving and get great results! So don't worry. You can get a great cosmetic result without shaving your head. I hope this is helpful. Dr. Paul

UK Lad As Bill said testicular pain is one of the side effects of finasteride. I used the PDR.net drug interaction search to see if there is any know interaction with Finasteride and Thyroxine and it came up negative. Possibly the fact that you were having a side effect from the finastieride which sounds upleasant to me caused some anxiety and thus a fastened heart beat. Hopefully, if you go back on Finasteride with the small dose you won't have any testicular pain. There is some evidence that Finastiride works if you take it less often(such as every other day) and that may also help decrease any possible side effects. Good luck Dr. Paul

Eman Rest assured it is very uncommon to have a patient touch or rub their head at night while asleep and damage the newly transplanted grafts. I agree with Dr. Feller's answer about the subconscious taking over. If you have ever had any other surgery or injury you may notice that it is very uncommon to hurt it in your sleep. Your body knows there is an injury and knows it will be painful to touch it. What we do see in our practice is a patient will accidentally hit their head when they are awake and dislodge some grafts. This is a much larger concern for us then anyone hurting their grafts while asleep. I would not recommend putting any type of dressing on the grafted area. My concern is that grafts could stick to the dressing and come off when removing the dressing. When hair transplants consisted of larger grafts, many doctors use to put on occlusive dressings after a hair transplant. But with the small follicular unit grafts most doctors got away from using the dressings. Bandaging of the scalp is often more uncomfortable then the pain from the surgery, and it can sometimes block venous and lymphatic drainage. Also, we like to use a spray called "Grafcyte" on the transplant starting right after surgery. "Grafcyte" has copper peptite which can aid in healing and keeps the transplanted area moist. If you insist on a dressing, let your doctor do it. There is a special non-stick bandage call Telfa which would prevent the grafts from sticking onto the bandage. As for sleeping on your back: We ask patients to sleep on their back with the head propped up on a few pillows to help the fluids that have accumulated in the scalp during the surgery to drain. If one lays on their face or side, the fluid may not drain well and noticeable swelling can occur. Laying on ones back with their head propped up helps reduce the possibility of swelling, but does not eliminate it. If it is difficult for you to sleep on your back or you toss and turn, you may have a greater chance of some post operative swelling, but this does not affect the outcome of the surgery. As for hitting the grafted area while tossing and turning it is very difficult. Just try to position yourself in bed so that the typical surgical area is touching the bed/and or pillow and you will find that unless you are a contortionist it is very difficult. Lastly, there are many medications available to make your first few post operative days comfortable. We give all our patients Vicodin, a strong pain medication which also has a sedative effect. Most patients sleep very well when they take Vicodin. For patients in which anxiety may make it difficult for them to sleep I will prescribe Xanax, or Valium. Lastly we always offer our patients a follow up visit the next day. We will do the first hair wash and make sure all the grafts are snugly in place. I hope this inormation is helpful Dr. Paul

If you are having dizziness and palpitations on Minoxidil I would advise you to stop it right away. Minoxidil is a vasodilator which means it relaxes the veins and arteries in the body. It was first used as an oral medication to lower blood pressure. The fact that Minoxidil stimulates hair growth was an accidental finding. In fact, it is no longer used to lower blood pressure, partly due to this side effect. When used topically (applied directly to the skin) usually the amount absorbed into the blood stream is minimal. In most people it does not cause systemic (affecting the body ) side effects. Dizzy spells and palpitations are known side affect of Minoxidil and you may just be extra sensitive to the medication. But there also may be a medical reason why the minute amount of Minoxidil absorbed into your blood system cased palpitations. I would see your primary care physician and/or a cardiologist to do some simple testing to evaluate your heart. Another possibility is that you have a skin condition on your scalp which allows more Minoxidil to be absorbed into your body,(i.e. bad psoriasis) but I think you would know of such a condition. I hope this is helpful Dr. Paul

HotToStop The studies on Propecia, (Fenasteride 1mg pill) for hair loss treatment were done at the 1mg dose so we do not have any good medical studies to suggest the .5mg will or will not work. I always suggest that anyone taking Fenasteride for the first time do it as suggested: at the 1mg dose and keep constant for 1 year. Then after you and your physician have a good idea of how effective the Fenasteride has been you can start to adjust the dose if need be. If you start on the .5mg dose and do not have a good response how will you be able to tell if the poor response was due to the low dose or you are just one of the few (10%) of men it does not work for? As for the side effects: They are so rare at the 1mg dose I don't think there would be a statistically significant difference between the 1mg and the .5mg dose. Prior to doing hair transplants I worked as a Family Doctor until 2000. In my practice we used Proscar, (Finasteride 5mg) and it was rare to see side effects even at the higher 5 mg dose. At the 1mg dose in our practice at SMG we see the sexual side effects rarely. I have had a few patients stop it because of sexual side effects. As for the possible gynecomastia (breast enlargement) I have only had one patient who may have had the beginning of gynecomastia. He had some breast tenderness and we stopped the Propecia immediately and the pain went away. I have never seen any actual breast enlargement while a patient was taking Fenasteride. I hope this information is helpful In Health Paul Shapiro, MD

Hair transplants can be very successful in women and I previously posted a photo album of some of my female hair transplant patients. Female Hair Transplants The most common cause of hair loss in women is what we call Androgenetic Alopecia, also called Female Pattern Hair Loss (FPHL). This is an inherited condition in which you have certain genes which makes your hair susceptible to hair loss when exposed to the normal, small amount of androgens (male hormones) which all women have. Occasionally there are other causes of hair loss in women such as hormonal imbalance, medication side effects, or other dermatological conditions. A dermatologist or hair loss specialist should take a complete history and exam to determine if your hair loss is the result of FPHL, or if any testing is needed to rule the other rare causes of hair loss. The video of Dr. Meja's patient is very instructive and shows a good example of a successful female hair transplant. It is obvious from the video that Dr. Meja spent time educating this patient, so that she knew what results to expect. Most women with FPHL have poor donor, and a large area to cover. As the women said in the video she was told that she would have more hair, but not a full head of hair. It is important that you have realistic expectations of what can be done in one surgery if you decide to go ahead with hair transplant surgery. A lot or women are satisfied after one hair transplant, but many female patients need more then one surgery to meet their goals. If you have FPHL, hair transplantation may be a great option for you. It is important to get several consults from surgeons who have experience with female patients. Look at as many before and after photos as you can and ask to surgeon to speak to some of his female patients. Also try to find photos with the hair styled and not styled to get an accurate idea of what the surgery accomplished. Are you presently using Rogaine (minoxidil)? If not I find that most women with FPHL benefit from Rogaine, and it also lessens the chance of post surgery shedding (telogen effluvium) which is very common in women. I hope you find this information helpful. In health Paul Shapiro, MD

Hatrick There have been studies done on the ratio of 1,2,3,&4 hair FU grafts found in a typical donor strip. And you are correct in saying there is a "fairly standard" ratio. I have never seen a study or a case in which the 2 hair FU are not the dominant number, and usually around 50% of the total FU's. There is greater variance in the ratio of 1,3, and 4 hair grafts which depends a lot on hair type and ethnic background. I have come up with the fallowing ratio I use because the numbers are easy to remember and fall within the range of studies I have seen. 1 hair FU 20% 2 hair FU 50% 3 hair FU 25% 4 hair FU 05% Your surgery seems to fall within the standard ratio in which half the FU's are 2 hair grafts and considering we see a wide variance in the percentage of 1 and 4 hair grafts from case to case. I hope this is helpful In health Dr. Paul

Slick, Thanks for posting your photos. I am glad you are so pleaed with my first transplant. About cutting the hair short.. In a second hair transplant I there are many times when I do not have to cut the hair short, and Slick shows how every case is different. Slick has a diffuse thinning pattern at a young age and very fine hair When I look at his hair under magnification there is still a lot of fine, thin, hair between the transplanted hair. Without cutting his hair short it would have been almost impossible to make incisions at the density I wanted to without transecting these fine hairs. As Jana said in her post he will need more gafts/hair to get his desired density becasue of his fine thin hair. On a positive note I did notice that his tranplanted hair from his frist session was daker and had more density to it. That is one of the reasons his first tranplant took so well. Dr Paul

I would like to thank all the patients who gave me positive comments and I am glad that Dmoor is still confident that he will have excellent results with my surgery. Dmoor is correct in saying that I do strive for perfection and that any time my results are less then this, such as in TomR's case, I do review the case and try to see if there was anything I could do better. One thing I know I could do better in TomR's case is communicate better. It is very important to me that all my patients go into surgery fully understanding the surgery, my approach to their specific case, and that the patient fully understands the risk and benefits of the surgery. From TomR's comments I can tell he understands that a scar like his can occur in hair transplant surgery and that even the most skilled surgeons can not bat 100% of the time. But I could have done a better job describing his specific risk and letting him know about his tight closure. In many hair transplants, the removing of the strip is a very straight forward process. In a case like TomR's the strip removal is not straight forward and some decisions need to be made. Usually I review this carefully with my patient, explain the pros and cons of different approaches to the strip removal, and together, we come up with the best plan for a strip removal. Some how this was not done in TomR's case and I am take full responsibility for that. In TomR's case he had already had two previous surgeries. The first surgery was in 2000 at a different clinic then SMG, and the second was at SMG in 2006. His donor laxity was not great, but not terrible. Usually in a case like this I discuss different options with the patient. I discuss that if we try for the maximum number of FU I can get, the closure may be tight which increases the risk of a larger scar. I always assure the patient that if they do end up with an unacceptable scar I will do a scar revision at no cost. As a side comment I have had many tight closures in which there was no unusual scarring. I also usually discuss that if I go along the old scar line, the yield will be less. It is just common sense that there is no living hair in scar tissue and often the tissue around the scar has fewer hair follicles. TomR is correct in saying that I made a judgment call when I decided how wide a strip of donor tissue I should remove for his surgery. I take out a piece of tissue that I think will close with no tension. In his case I judged that a 1cm wide strip would close easily. Unfortunately it was a bit tight, resulting in tension. All hair transplant surgeons end up in this situation at one time. In patients with a tight donor area, the difference of only 1mm, or .045 inches can make the difference between an easy or tight closure. I like to use the analogy of packing a suitcase. Many of us have had the experience in which we pack a suitcase to the max and it closes. Then we add just one more shirt and it is difficult to close. In summary, when a patient has had previous surgeries and/or a tight donor area, there are some difficult decisions to be made. If we want to maximize FU yield then we may chose to not go along the old scar and this results in two scar lines. I we choose to maximize yield then I need to take out a donor strip with a width that has a chance of resulting in a tight closure. I am always thinking of what is best for the patient and in these difficult cases try for the best yield with the least risk for additional scarring.

Some answers to qeustions about Paul Shapiro MD,s surgeries Thank you for your positive comments. In the future with new patient postings I will be giving more information. But the photos I have posted were just a way to give the community an idea of what my results look like. I am going to give a brief answer to the questions of what type of densities I strive for and what goals I attempt to achieve in hair transplantation. As Bill and Cousin-It pointed out, there are many factors that go into deciding what density a doctor will chose to use in a surgery. I also need to point out that when speaking of density there are two types of densities to consider. The density of FU/sqcm and the density of actual hairs/sqcm. If I plant a density of 30FU/sqcm of 2 hair FU's I will get 60 hairs/sqcm. If I plant the same density with 3 hair FU's I will get 90 hair /sqcm. All this said and done, I would say that in a typical surgery my density ranges from 25 to 45 FU/sqcm. In general my goal is to recreate a density gradient that looks natural and imitates nature. The same density throughout the entire recipient area often creates a diffuse unnatural look that is see through. I try and create higher densities in areas of greater aesthetic significance such as the frontal tuft area, the area right behind the transition zone of the hairline, and in the central core. To accomplish this goal I plant one hair FU's in the hairline at lower densities to give a soft, natural look. Behind the hairline, in the temperal area and the beginning of the central core area I plant the two hair follicular units with a density anywhere from 30 to 45 FU/sqcm. Behind the 2 hair FU's I will plant the 3 and 4 hair FU's in the central core. The 3 and 4 hair FU's differ in size depending on each patient's hair and skin quality. In some patients the 3's will fit into a .8mm incision and I can plant them closer together. In other patients the 3's need a 1.0mm incisions to fit properly and I have to place them further apart. The 4's usually need a blade .1 to .2 mm larger then the 3's. I would say in general I plant the 3 and 4 hair follicular units in a density form 20 to 35 FU/sqcm. Remember, if I plant 4 hair FU's at 25FU/sqcm that is 100 hairs/sqcm as opposed to 2 hair FU's at 25FU/sqcm which would be 50 hairs sq/cm. To put it another way by planting 4FU hairs at a density of 25FU/sqcm I am getting the same number of hairs as planting 2 hair FU at a density of 50FU/sqcm. As you can see I create the higher densities by placing incisions closer together( i.e my incision density can ranger from 25-45 or more), and by selectively choosing to use a greater population of the 3-4 hair grafts in areas I want the greatest density I know you all will be wondering how many 1,2,3 and 4 hair follicular units I usually get in a session. It varies from patient to patient. I will post my numbers of 1,2, 3, and 4 hair FU's in my future. The patient I transplanted last Friday will give you an typical example of distribution. On Friday's patietn I got a total of 2595 Follicular Units. That broke down as follows: Type # Grafts # Hairs 1 Hair FU 510 510 2 Hair FU 1465 2930 3 Hair FU 818 2454 4 Hair FU 175 700 Total 2959 6594 For the hairline in this patient I used 400 one hair FU's. I doubled the rest of the one hair FU's to make them into 2 hair FU's to get more density behind the hairline. I hope this helps answer your questions.

To all members of the coalition: I have been preparing a response to Cousin_It and Bill question last week. I am sorry the response took so long but the subject of density and my goals in surgery is complicated These are topics of chapters in textbooks and hour long lectures at the ISHR surgery meetings. It has been difficult for me to give a concise answer that seems to hit all the important points but does not go on for pages. The following answer is the result of many re-writes over the last week. I was going to post this answer on Monday. In the meanwhile Pat posted his announcement that I am accepted into the coalition. I am honored of Pat's confidence in me but at the same time I was not aware of his decision until I received an email form him. I just think that Pat is very busy and thought that the members of the coalitions concerns had been met. If the members believe that their concerns have not been answered then maybe Pat should wait to put me in the coalition. I am not sure how Pat plans to run the process of allowing a new member into the coalition and I will comply with all and any request. The main reason I would like to be a member of the coalition is to establish a profile for myself so potential patients can see my work. I know there has been confusion in the past about who is Dr. Paul Shapiro and it will help establish my identity. As for the financial aspect. At SMG the price of surgery with my brother, Dr. Ron Shapiro, has always been higher then the other doctors working there, whether it be Dr. Rose, Dr. Keen or Dr. Charles. It just makes sense that a price with Dr. Ron Shapiro would be greater due to his reputation. I will send Pat a copy of this email and let him decide on what to do about my membership to the coalition. I am sorry if anyone thinks they have been deprived of enough information to make an informed decision and I think the best action at this time would be to delay my membership until your concerns have been met. I will send the answer to the questions about densities and my goals in another post. I think this one is long enough.