Dr Blake Bloxham

Nimrod, Most won't tell you to stop the medication if you aren't having side effects. As you've seen here, many individuals never experience any issues. Even if you did stop the finasteride and lost your native hairs, remember that the strip scar resides in the permanent donor region and wouldn't show unless you shaved this region. Who prescribed the finasteride? Remember that you can always talk to your personal physician about this and have him or her monitor you for any side effects. But I don't think you need to worry about scar treatments and lasering off the transplanted hair.

Broncos, This may sound like a strange recommendation, but I suggest "pumping the brakes" and slowing down a bit. Spend some time on the forums doing research. This site is a great resource. Ask questions; send emails; and undergo consultations. Make sure you're informed and ready before jumping into any hair transplant procedure. Feel free to ask any questions here or by private message. Most of the members here are very well informed and very helpful. Good luck!

Yiddo, It looks like you're researching and considering a large FUE procedure in Turkey. So I understand that a lot of what we're saying conflicts with your research. This is obviously a bit jarring, but it's actually a good thing. Integrate the information we're providing into your research. Ask the Turkish FUE clinics about it. See what they say. After you get the entirety of the information on hair transplant surgery, review it and make an informed decision. That's all anyone is trying to do here. No personal slights or subjectivity intended. Just sharing information that really hasn't been out there before. Read it, digest it, and then use it to help guide your decision. Even if you don't agree, at least you're now aware and are more capable of making the best decision for you. I really do wish you the best of luck. If you do have any questions as to why this information conflicts with what you've read on other forums, feel free to send me a private message or email at any time. I'm happy to discuss anything we've shared here, objective information about FUE, etc. Hope this helps!

Willy, No. This shouldn't have any effect. Congratulations on the procedure! I hope you'll keep us updated.

HTsoon, Again, I must disagree. Tension on the wound or elasticity has nothing to do with donor shock loss. This has much more to do with either damage or overwhelming the blood supply. And, again, both are more common in FUE. But permanent donor shock loss is very uncommon in hair transplant surgery in general. So this shouldn't be a big concern for either FUT or FUE. But I get what you're saying overall, and I don't inherently disagree with it. All I'm saying is that patients need to be presented with all the facts before they make a decision. This is the definition of informed consent. And it's every physician's responsibility to provide informed consent to patients. Once they are fully aware, they are free to pursue a procedure. I don't see anything controversial in this. But remember, all the facts must be presented to really make it informed consent. And we can't get upset with the objective facts. This is fair, right?

HT, I disagree that decreased elasticity in FUT is akin to subdermal scarring in FUE. If you lose elasticity during multiple FUT procedures, you could theoretically risk scar stretching. Elasticity is actually a multifactorial issue and more complicated that you're discussing here, but I digress. Regardless of what happens with the scar, the tissue around it is unchanged. That means all this tissue is still available for extraction. This includes taking it via FUE or mFUE. With subdermal scarring, however, you actually decrease the yield you can take during subsequent procedures. As you can see, two very different issues. And all the "FOX" test does is check for angulation. Even if you "pass," you still put torsion strain, compression strain, avulsion strain, and risk dehydration and non-growth post-implantation secondary to skeletonization. Like I said before, transection is the least of FUE's problems.

Bogger, We do have an affiliation with Spex. He's a rep for us in the UK. However, he's his own man, and he's allowed to have his own opinions on FUE. Clearly, they differ in some respects. But we're not here to force anyone to say or do anything. Ironically, Dr Feller did his repair work a number of years ago via FUE. Grew fantastic too! To further explain our professional affiliation, and one that's not hindered by a hierarchy or anything like that, you'll note that he actually works with a number of doctors. Some of who feel differently about large FUE sessions. Again, I think this kind of works against the arguments some are making about Dr Feller trying to exert his philosophy on others. But I digress. Lileli and HT, Remember that it's not just about a little less growth in the front. This is a proven reality, but it could be fixed if not for the bigger issues at hand: the subdermal scarring in the donor region that reduces future successes and the higher potential for unnatural ("wiry" or "kinky") hairs in visible regions of the scalp. But like Dr Feller said, feel free to undergo FUE if you understand these facts and still weigh this above the linear scar. But in order for patients to have full informed consent and make a proper decision, they must have the facts. They can't think that there are no consequences to an "FUE mega session" or that growth and quality is on par with strip. Telling patients this is true informed consent. And it's something all doctors, FUE and FUT lovers alike, need to tell their patients. The problem is that these things aren't said online. Just the opposite in fact. And there seems to be an interesting phenomenon where people are taking personal offense to the sharing of facts. This is the opposite of what should occur! These facts are out there now. And all patients considering strip or FUE should read and understand them before committing to a surgery. If they review them and still chose FUE. Great! Best of luck. And why is that? Because they are now fully consented and have the ability to make the choice. That's all. No controversy; nothing personal.

Wow. Excellent work. Thanks for sharing!

Hairsgone, Excellent question! The theory behind topical finasteride is twofold: 1) you will get more inhibition of the 5-a-R enzymes directly in the scalp by applying it ... directly to the scalp; 2) you will have less systemic absorption of the medication and, therefore, less systemic side effects. Now, the real question is whether or not we can get it to effectively absorb through the scalp. It's actually very, very hard to get medication to absorb through our skin. It requires crushing it down to microscopic sizes and using a series of "vehicles" to help it pass through the skin and into the tissues. In fact, there are pharmaceutical companies and pharmacist researchers dedicated solely to finding vehicles for topical drug absorption. It will be interesting to see what happens with topical finasteride absorption. We do, however, have one interesting comparison: the topical anti-DHT drug RU58841. It's a topical anti-androgen that has been trialed by a number of hair loss sufferers online. The theory behind it was similar: apply it to the scalp, get the anti-androgen properties locally, and avoid systemic effects. Unfortunately, many still suffered the same systemic side effects as they did with other anti-androgens (namely finasteride). This means there is still a good amount of systemic absorption -- probably because the scalp is just so damn vascular!

Mikey, Good point. However, there are actually ways to test whether or not erectile dysfunction (ED) is psychological or physiological. Back in the day, they would test this by affixing tissue paper around a man's penis at night. If he was able to achieve a physiological erection at any point during the night, the tissue paper would be ripped in the morning. If it was ripped, the doctors would suspect a psychological cause. If not, they would look into other potential causes. The biggest culprits being: poor vascular supply, poor nerve supply/function (usually secondary to a disease that causes vascular and nerve damage like diabetes), hormonal imbalances, and age. But this test fell out of favor because too many men were ripping the paper when they moved naturally throughout the night. Now doctors essentially ask men if they ever wake up with any semblance of a regular morning erection. If so, then a psychological cause may be to blame. If not, then the other causes must be evaluated. The gentleman I discussed earlier had no semblance of a nocturnal or morning erection in the 10 years after stopping the finasteride.

Spanker, Fear. He feels burned by the first procedure and worried to do anything -- be it medical or surgical -- after the Propecia issues. He's actually been researching another procedure for years and still can't quite bring himself to pull the trigger. It's hard to blame him too.

BMW, It definitely doesn't happen to everyone. And when I see a patient doing well on it, I never specifically advise them to get off of it. This is because despite the potential for serious side effects, it is probably the most efficacious preventive hair loss medication.

Mav, You're dead on. I've said it dozens of times, but it doesn't seem to resonate. We could cut our overhead costs in half (at least), charge 2-4x per graft, and make MUCH more money doing FUE. What's more, we have the patients to do it. So the economic argument for why anyone would advocate strip above FUE is bunk. In general, I also must refer back to my old comments about BHT as well. It's not a realistic solution for the vast majority of patients. And it also has the potential to scar up very visible regions in the body (IE, the face). Please proceed very, very cautiously.

Bill, I applaud you for writing this piece! I'm never the guy who doubt studies, and I think side effects are many times amplified by things like the internet, TV ads for class action lawsuits, et cetera. However, I don't feel this way about the side effects related to finasteride. Frankly, I've seen far, far too many cases of patients with persistent sexual side effects years and even decades after stopping the medication. And the important thing to understand is this: for many men, experiencing reduction in libido or erectile dysfunction as you age isn't necessarily pathological. So some men will naturally begin to experience these issues while taking Propecia, but it isn't necessarily from the finasteride itself. It would have happened as they aged regardless. But I've seen numerous, numerous scenarios where this was not the case. I'll give you a recent example: I consulted with a man in his 40s two weeks ago. He underwent a hair transplant procedure with another clinic in his mid 20s, and was also started on finasteride at the same time. The procedure was a small case to lower the corners of his hairline, and the theory was that the finasteride would help him retain the rest. He then began experiencing sexual side effects closer to his late 20s. This was unfortunate because, thus far, the planned worked; the patient kept his existing hair and the temple corner case still looked natural. He stopped the finasteride, and two things happened: his existing hairs in the frontal and midscalp shed, and the grafts from the fronto-temporal corner case were now surrounded by bald scalp and looked unnatural. And, the side effects from the finasteride never went away. By the time he came to see us, he was 10 years off the finasteride. In these 10 years, he had not seen a reversal of the side effects and still had severe erectile dysfunction. Very sad case.

Whoa, Seth. Need to clarify one thing: the strip scar is taken with the new strip each time. So you'll always only have 1 scar. Not 3-4. And the theory behind stripping out and then stealing more hair IS the absolute best way to maximize your grafts. You don't thin out any areas of the donor unnecessarily. What you do is take follicles from areas that can't be reached by strip and are, therefore, still virgin. You then take an appropriate amount of grafts from here and you don't thin anything. If what you're saying is true, then FUE, by definition, thins out the entire donor every time. I don't think this is what you're saying or meaning to say. HT, You're not a customer. You're a patient. Cosmetic, life saving, elective, you're still a patient receiving care from a doctor. I'd never refer to any patient undergoing a procedure with any healthcare professional as a customer. And despite what procedure you're undergoing, the relationship is unchanged: you're still a patient coming to a professional asking for their expertise and help fixing the problem. Whether it's your heart or your hair, the doctor is still trained to evaluate the scenario, recommend the appropriate course, and do his or her best to carry out the procedure. No different. And don't let anyone convince you otherwise. You're still a patient. And I hate to be so blunt, but you're incorrect in saying that patients who need more than one procedure should opt for FUE. It's the exact opposite, in fact. If you need virgin donor for more procedures down the road, keep as much of it virgin as you can. It's simple anatomy. FUE2014, Result looks good. Patient characteristics played a role without a doubt. Send the same patient I shared from Dr Alexander to the same physician who performed that procedure, and the results would not be the same. Even if everything else was -- the surgeon, the procedure, and the area being filled. And, it would have looked thicker and fuller as a strip. But you guys are right, not a single FUE doctor has come on here to refute these claims. Two ways to look at this: every single FUE only doctor in the world is so busy that they can't take the time to post once; or the "other" reason. Hmmm. Haha.

HT, Again, thanks for posting. But I wanted to share the following: remember that when you go to a doctor for a consultation or a procedure, you aren't choosing a procedure based on what you feel. Medicine and surgery are not retail businesses. You can't walk into a medical clinic and say: "I feel like I have a herniated spinal disc, and I choose to take oxycodone for it, please." The doctor would look at you like you had two heads! He/she would rightfully tell you that based on their professional training, you have X diagnosis and you need Y treatment. Any doctor that didn't do this and let a patient get away with this isn't doing their job. And this is harmful to only one person: the patient. That's why the doc said "it's your scalp." Because the only people being harmed by misinformation or the misconception that you can order a HT procedure like a fast food item are the patients. And that's why we do come on here to act as true patient advocates. We could cut about 50% of our overhead and make roughly 2-4x as much per procedure just blindly performing FUE on everyone who asked for it. But that's not our job and it's absolutely not the right way to do things. Do some people think it's the "wrong way," as you stated above? Of course. But you don't stop doing the right thing just because it's unpopular. So, I ask you this: Say you walk into an emergency room with a complaint of chest pain. The cardiologist sees you, performs tests, and says: "you need bypass surgery." Would you tell him: "nope, I don't want that. Do cardiac stenting -- the less invasive option. And don't try to tell me the benefits of the procedure you recommended or you're not a patient advocate and you don't respect my choice." Of course you wouldn't! And you would have no respect, nor should you, for a cardiologist who caved and said: "Ahh shucks. Okay, we'll do the other one." Hopefully this analogy clears things up a bit. No need to go back and forth with this and detract from the thread, so I'll leave it at that. Again, very pleased you found a solution for your hair loss.

Mon, It can happen with both. But really only in FUT if the grafts weren't handled or placed correctly. In my opinion, it's much more common in FUE for the reasons I outlined above. Best of luck!

HT, I agree. Give the patients the facts and encourage them to do their research! Right on.

Monaba, Sorry to hear this, man! Glad you found a doctor to help you out. Keep us updated on your progress. I'm always here to answer questions. I don't care if they are about surgery, hair loss in general, FUE, FUT, et cetera. I just like helping you guys out! Send me a private message here or feel free to email me. Now, back to your question: This is actually a phenomenon I feel is very under reported. Did you have an FUE or strip procedure? It occurs in FUE versus FUE/FUT for two different reasons: The characteristics of the hair shaft is determined by the internal portion of the follicle. Kinky, wavy, straight, thick, and fine, this is determined by inner portion of the follicle right above the "hair bulb." If this part of the follicle becomes distorted, it produces hairs that are distorted as well. Hairs grow "kinky" and "wiry" for the first 9(ish) months after hair transplant surgery because the inner portion of the follicle is still re-orienting and correcting itself after being transplanted. When it does re-orient itself back to the normal position, it begins producing normal hairs. However, I believe the excessive forces put on grafts during FUE procedures can cause permanent damage to the inner portion of the follicle. When this occurs, the inner portion of the follicle is never able to orient itself correctly and it creates kinky, wiry hairs indefinitely. Doesn't happen every time, but it can -- and does -- happen. Now, there is another way this can occur in both strip and FUE surgery. If for any reason the grafts are crushed during placement or placed into incision slits that are too small, a similar phenomenon occurs and you see the kinky, wiry hairs. The difference is that when this occurs during implantation, it was a surgical error. But, it can occur in FUE even when everything is done correctly.

HT, First, I'm very pleased you were able to find a procedure that fit your needs. However, you say we need to let patients make up their minds. I ask, how do they do this? They need to be given the facts. Plain and simple. If we don't have these very important conversations -- which you're a part of, patients won't be able to make the right decisions. Like I've said before, telling the truth isn't always popular or sexy. But it needs to be out there. Having said that, let me address your points: 1) Your challenge is to find a roughly 1,800 graft strip case on a diffuse NW 4a to 5 patient that rivals your results. I timed myself. I spent 1 minute and 30 seconds reviewing the "results posted by physicians" category of the site and came up with the following: Patient with a similar pattern; 2,000 grafts (very close to yours); done via strip: All credit goes to the very talented Dr Scott Alexander for that one. 2) Your point about people noticing your friend's scar. Here's the problem with this answer. You say you have 1 friend who had strip and now has an issue with the scar. Your "sample size" is 1. I had a patient in today who had 2 previous strip procedures with a chain clinic, scarred poorly, still cuts his hair the exact same way he always has, and has never had one issue, comment, or problem with the scar. He's not happy with the growth in the front, but has never even thought about the scar. Now my sample size is 1 as well, and our arguments have the same validity. What if I told you that I see that same patient in the OR and consultation room 10 times a week? See why my opinion of the gravity of the scar may be a bit different? 3) Your donor. Yes, your scars -- though still visible -- are cosmetically acceptable on the surface. But imagine taking all those little dots you see on the surface, multiplying it by two, and pushing this network of scar under your skin. This is what your scalp is like now post-FUE. What would happen if your results didn't grow as planned? Now we have to go in and try to steal another 1,800. But now the grafts are ripping, transection is increasing because we aren't getting the right tissue feedback, and you're absolutely not going to get another 1,800 growing. 4) Which brings me to this point: the "crippled argument." I stand by this. FUE cripples your race horse right out of the gate. No two ways about it. The grafts are twisted, ripped, crushed, skeletonized and grow around 20% less than the same grafts taken out by strip. If you have a horse with 4 legs, and I tie one of them off and make him run on 75% capacity before the gates even open, what do you call this? Crippled before the race even starts. Again, I'm not going to win any friends here. But it's the truth. And I'm okay with that. 5) I'd actually have a lot less headaches and more money if my practice was all FUE. But it's not the right way to do things. And you're right, there is a time and a place for strip and FUE. But I don't think FUE's place is ever for sessions this big. Here's my philosophy: If you need some small patchwork, some refinement somewhere (and BTW, I really don't like using FUE for hairline refinement because I don't think the quality of the hair growth is suitable for the most visible region of the scalp), sure, FUE is fine. If you need a lot of grafts that will actually grow and may need procedures down the road. FUT is your man. Spoiler alert: you will have a scar. Unfortunately, I don't have a magic wand. I'd love to give guys Brad Pitt's hair with no signs I ever touched their scalp daily, but my dark arts magic isn't at that level yet ; ). HOWEVER, you bring up a very valid point: some guys just absolutely can't live with the strip scar. And I get it. I'm not here to bully these guys into a procedure that will leave them unhappy. So here's what I tell them: the only reason to do an FUE over a strip is the linear scar. Otherwise, strip pummels FUE without question. Better growth, better quality, and virgin donor left for more procedures. So, this should be your go to. If you cannot deal with the scar, do the procedure as a modified FUE (mFUE). This way, you won't have the scar, BUT we have grafts we can rely on AND the donor is less wrecked. For those who really want to "have their cake and eat it too," this is THE option. 6) Those FUE results. Yes, those results look good. And I'd never stand here and say you cannot get a good result with FUE, because that's not true. We've all seen examples of it. However, the problem is that for every 10 ANY doctor -- let me say that again: ANY doctor -- does, you'll get 1-2 that are great, 5-6 that are okay, and 1-2 that just flat out don't work. This is why FUE patients are screened and selected carefully. Now, back to those results: they look good, but they would have looked fuller and thicker as a strip. And I'll go tit-for-tat with you on FUE versus strip home run cases all day long. For every 1 FUE "wow" result you find, I'll show you 5 "wow" strip results. I hope this is taken in the spirit in which I intended. Like I said before, the things I'm saying aren't hip, fun, sexy, or exciting. But neither is science or medicine/surgery. And as a doctor, I feel the need to say these things. Patients need all the facts available to them before making a decision. And I think we can all respect that. Thank you for participating in this discussion. Hopefully you find it as fascinating as I do. And believe it or not, we really are helping some guys make the right decision here. Keep it up!

Seth, When I do a consultation, either online or in person, I generally see two very broad categories of patients: Category 1: This is about 98% of patients I see. These are guys who say: "I've been bald or thinning for X number of years. I'm going through Y in my life right now, and finally have the opportunity to fix this. Please put as much reliable hair in the front as possible." These guys get it. They understand what we are trying to do with a hair transplant procedure. They also understand that surgery is just that: surgery. Any time a scalpel, needle, or punch touches your skin, it leaves a scar. If we do our job right, the trade off is a cosmetically acceptable scar buried under good donor hair and nearly 100% growth of healthy hair in the front. These guys are focused on the actual hair in the front and want the most "bang for their buck." Category 2: The other small minority of patients. These are the patients who mention the donor scar within the first few lines or few minutes of a consultation. These gentleman, unfortunately, often fall prey to a "self fulfilling prophecy." They want the "back up" option to shave their head. So they opt for a procedure that's crippled from the starting line that all but ensures they won't be happy with the results and will, indeed, shave their heads at some point. I usually tell these patients the following: "if you're really considering this option, try shaving your head now. You may like it, and it will save you the hassle of having any surgical procedure. It will also actually allow you to shave down without the risk of any scarring, because your barber will see the punctuate FUE scars if you chose to shave down low enough as well." But the bottom line is that no one sees, is thinking about, or cares about any sort of scar on your scalp. 99.9% of the world, including barbers, has no idea what a hair transplant scar looks like. No "prying eyes." UNLESS you do opt to undergo a procedure that could leave poor growth and wiry/kinky hairs in the front of the scalp. Now this people may actually notice.

Depaul, Congratulations! You made an excellent decision coming to the forums too. You'll be able to get a lot of good information here and go into surgery informed and ready! Luckily, yes. Nerves and blood vessels do grow back after FUT -- or "FUSS" or "strip surgery." The small blood vessels severed during the procedure will heal. New blood vessels and new nerves will also naturally form and grow. This leaves you with a strong vascular and nerve supply in the back of the scalp. What does this mean? Good, healthy growth and normal sensation in the scalp. Best of luck! Feel free to ask any additional questions. Hope you'll keep us all updated on your progress.

Post, Very interesting. I personally don't think minoxidil would create or speed up new vessel growth. However, I'd be interested in reviewing the papers if you can find them.

Receding, I actually thought about adding VEGF a number of years back. The problem, like we see with all "growth factors," is that it's a powerful, but non-specific vascular growth agent. This means injecting it may lead to good, early blood growth to the grafts. But it could also lead to fast, strong growth to ANY cells. Even an abnormal cluster of cells that shouldn't have this good blood supply. This abnormal cluster of cells could also be described as a small tumor. This is the risk with injecting almost anything with growth factors into the body. I don't think the FDA would ever let us do this. And I think they'd be right in doing so. And even if they did, I don't think I'd risk it.

Dave, It can occur in either procedure if the graft is crushed during placement or if it's forced into slit sites that are too small. However, it can only really happen during the extraction process with FUE.