Dr. Jerry Cooley

Yes, testosterone replacement can accelerate hair loss because it is converted to DHT. If the patient is on finasteride, there will be much less DHT and hence the hair is protected. I actually prefer dutasteride in this situation because it gives more DHT suppression. I also talk to men about considering an aromatase inhibitor to prevent a build up of estrogen in this situation. Most men can get the benefits of testosterone replacement without hairloss by managing their hormone levels intelligently. I work with their other physician (who is giving them their testosterone) to make sure we're on the same page.

This patient is in his mid 50's and wanted 1) thickening of the entire scalp and 2) frontal restoration. He was doing testosterone replacement, which is becoming more common nowadays. Despite my recommendation, he did not initially want to do finasteride. About six months post op, he did decide to start taking it and has had no side effects. We performed FUT of 3,421 grafts (1-749, 2-1,591, 3-856, 4-225; total hairs= 7399 hairs). We put about 2,500 grafts in the frontal scalp and 1,000 in the back. We also performed PRP/ACell to provide some overall thickening. As usual, we did not shave the recipient area, so he could return to work in 7-10 days. He is shown 10 months post op. Also of note, he had some very low hairs in the front central area, going down to 6cm above the eyebrows. If we had built the hairline off this point, it would have created a very front heavy result, as well as requiring an inordinate number of grafts. What I do is design a hairline as if they were bald, and use electolysis to eradicate hairs below this line. In the op photo, the small red spots can be seen where we did this. After electrolysis, a certain number of hairs will always grow back. He was trimming these (see arrow) but plans to come back for another electolysis session to clean these up.

Thanks for the comments. I should point out that this guy is about as good a candidate for hair restoration as we could hope for: middle age guy with frontal loss, with good hair and donor density. With younger patients, we have to worry more about the progression of hair loss. Some patients won't have enough donor hair to completely fill in the balding area. So each person has to understand their individual situation so they can have realistic expectations.

This patient is in his mid-50's with 4A hair loss pattern and wanted to restore his frontal zone. We started him on finasteride and performed 2,682 graft FUT (1-877, 2-1156, 3-540, 4-109; 5,245 hairs). He is shown 16 months post op. He healed very nicely and the donor scar was almost undetectable.

Good question. Dosing studies show that 0.5mg finasteride is almost but not quite as good as 1mg in suppressing DHT. I think everyone is different so some people will do well at this low dose. They haven't done large studies on hair loss with different dosages/dosing intervals so we have to base our opinions on how the drug is metabolized. We know that a single dose of finasteride reaches peak DHT lowering after 3 days and the DHT doesn't come back to normal till after 7 days. So twice weekly dosing of 0.5mg will keep DHT suppressed significantly and inhibit hair loss for most people. How does it compare to 1mg every day? No one knows but it might be 70% as good, just a guess, and a whole lot better than doing nothing. Over the years, I have had patients who have had side effects at 1mg daily who did not have side effects with lower/intermittent dosing and still seemed to benefit in terms of their hair.

Finasteride only lowers DHT 65-70% because it only blocks one of the enzymes converting T to DHT, regardless of how often it is taken. Most people (not all) get the same results taking it every other day as they do every day and there is no significant benefit taking more than 1mg. Rather than increasing the dosage of finasteride, I will consider putting the patient on dutasteride which can lower DHT by 94%. Regarding the PRP/ACell, you're right that it is temporary. How long it lasts depends on 1) genetically how fast someone is balding and 2) what other hair treatments they are on (e.g. fin/min). It might need to be repeated yearly for some patients, but may last 3-5 years in others. It is not a miracle treatment but it can be very helpful in certain situations: Many females who are not or are just barely surgical candidates; men with early crown thinning; young men (<23yrs) who should usually put off doing surgery. The results can be variable but as part of an overall treatment plan, it can be very useful.

This patient is in his mid-40s and wanted to address his hairline and fill in the rest of the scalp. We started him on finasteride and performed FUT of 3,933 grafts (7,275 hairs, 1.85 hairs/graft). He didn't return until 5 years later. Overall, he was very pleased but noted that he thought his hair looked thicker a couple years prior (ie 3 years after the procedure). I explained that the grafts were not thinning but that he was seeing the natural progression while on finasteride. I see this all the time, and unfortunately patients sometimes think this means the medicine has 'stopped working'. Referring to the chart, the 'average' patient who starts finasteride will see thickening for about 5 years and then will begin to decline below where they started, but they are always much better than if they had never taken it, the difference becoming greater with every year. Options at this point include: adding minoxidil (if they are not already using it), doing another transplant, and/or doing a PRP/ACell procedure to regain some of the thickening. It is important to have an understanding of this process to set realistic expectations and make a long term plan.

Also, grafts were only placed in the front half of his scalp. Thickening in the back occurred from the ACell/PRP treatment.

ACell/PRP does have regenerative properties, but only in the presence of transected follicles. We have known for many years that transected follicles can regenerate into intact, healthy follicles but this is not 100%. I believe that the presence of ACell makes this natural process more likely to happen, but it too is not 100%. We always have some degree of transection when we do FUE, and if ACell is used properly, the transected follicles that remain have a higher chance of growing back. If a graft is extracted with no transection, there is nothing left behind to serve as a starting point for regeneration and I don't believe that ACell can make hair grow from nothing. Likewise when we use ACell on the grafts, if there is any transection or damage during placement, regeneration is more likely. In this case, we had very low transection as his grafts extracted very easily. I'm sure ACell helped whatever transects there were grow back, but there weren't many. ACell also helps the skin heal better with less scarring. This creates a softer feel but more importantly makes the skin healthier for future FUE sessions. I think my photo lights kind of make the donor look thinner than it really is; in real life it does not look depleted but I understand why you would think that. Good question. Thanks for all the comments too.

This patient has type V hair loss. He has been on finasteride + minoxidil for over ten years. Because he often likes to wear his hair very short, he opted for FUE. We performed FUE consisting of 2,746 grafts: 1-490, 2-993, 3- 1246, 4-18; total hairs= 6,284. We also performed ACell/PRP to the entire scalp. He is shown one year post op.

Because he has such fine hair, grafting the crown with good density in the first procedure would have taken away from the density in the midscalp and front. In fact, he's on the schedule to graft the crown next week. The way he has been wearing his hair, you don't really see the crown. We did put some grafts in the crown, which takes away the 'slick' bald look. Everyone is different: age, donor density, hair quality, hair length and style preference, meds or no meds,etc. This is why its important to come up with an individualized plan for each patient.

The patient is in his mid 40's but looks older due to hair loss. We recommended finasteride and performed FUT of 4,600 FUs (1-1491, 2-2385, 3-724; 8,433 hairs) and distributed the grafts mostly to the front half, with some very light coverage to the crown. We did not see him again until nearly five years later when he returned to discuss filling in the crown. He was sporting a youthful long hair style (although with significantly more graying!). He had not taken the finasteride but we recommended it again, especially with plans to do more grafting in the crown. Of note, he has baby fine hair and the result is more in line with what we see with 3500-4000 grafts in someone with normal hair.

Sorry, forgot to take them. Scar was barely discernible.

I would estimate that he has another 4-5 thousand grafts in his donor via strip/FUE. And by that, I mean that given his hair and donor characteristics, this could be safely removed without leaving him visibly thin with his current hair style.

This patient presented several challenges. He is in his mid 40's and has type IV evolving into a type V hair loss. He did not want to take finasteride despite my recommendations. His donor density was average but the hairs/FU count was below average. Given that future loss will occur, we came up with a conservative plan to give him nice improvement but also buffer the expected future loss. We did FUT 3,205 grafts ( 1-1123, 2-1538, 3-544; 5,831 hairs) and covered the front with medium density and the back with lighter density. Making the hairline lower and putting all the grafts in the front might have looked better in the short term but would have resulted in an unnatural front heavy look as hair loss progressed in the midscalp and crown. Overall, he was very pleased with the outcome, shown at 9 months.

This patient first saw us over ten years ago when he was in his late twenties. We prescribed finasteride and did not see him again until five years ago, when he wanted to restore his hairline. We did about 1,500 grafts at that time but did not see him again until about one year ago (middle three photos). He was happy with his procedure but he had stopped finasteride several years ago and was continuing to lose non-grafted hair. We performed another session consisting of 1,609 grafts (1-606, 2-648, 3-320, 4-26; 2,993 hairs) and PRP/ACell to his entire scalp. He is shown one year after this (last four photos). He did not resume finasteride and doesn't plan to, but will do more PRP as necessary.

This african american female in her late 50's had long standing traction alopecia and androgenetic alopecia. She had been stable for many years and was wearing a wig. We did 2,153 grafts (1-631, 2-1309, 3-193; 3828 hairs) primarily to the hairline and some scattered in the midscalp. Given the large area covered, only light density was achieved. The patient uses camouflaging fibers on the top of her scalp, behind the hairline, to add visual density. This combination allowed her to get out of the wig and to wear the short hair style she desired.

This guys is in his 30's and has deep frontal recessions. We performed 1,502 grafts by the FUE method (1-446, 2-653, 3-403; total hairs= 2,961). We also performed PRP/ACell treatment throughout the scalp. He did not take finasteride despite our recommendation. He is shown 11 months post op.

Thanks for all the feedback. It's often the guys in their 40's and 50's who come back with their hair much longer. I guess it has something to do with growing up in the 1970's !

I presented this case at 5 months and am now reposting with two year results. The patient is in his early forties with 3A loss. We performed 2,612 FU grafts (1-417, 2-1,336, 3-716, 4-143; 5,809 hairs). We simultaneously performed PRP+ACell treatment and used ACell on the grafts, and liposomal ATP spray post op. He had early robust growth. Not all patients grow in at this rate but we are seeing more of them with our 'bio-enhanced' protocol. Most of our patients are unable to shave any area as they need to get back to work in a week or so. He's loving the new 'Fabio' look!

This patient has type IV loss and wanted frontal restoration. We did FUT of 3,042 grafts (1-1215, 2-1325, 3-502; 5,321 hairs). We also performed PRP/ACell to try to provide some overall thickening. He is shown at 9 months. Some comments: his hairs/graft were below average but the quality of his hair (caliber, curl) made up for this, providing nice coverage. There is mild thickening in the mid scalp and crown from the PRP despite the patient not being on finasteride (we recommended it, but he decided against it). He plans to do periodic PRP's to keep up with any future loss.

This African American lady has long standing frontal alopecia due to traction. We performed FUT 2,283 grafts (1-460, 2-1463, 3-319, 4-31; 4,467 hairs). She is shown one year later.

This older gentleman is evolving into type VI hair loss.We prescribed finasteride to preserve existing hair. We did FUT consisting of 4,020 follicular units (1-807, 2-2059, 3-1064, 4-90; 8,477 hairs). He is shown two and half years later.

This patient is in his early 30's. He had the "A" pattern of hair loss, with frontal recession only and no crown loss. Thank you for the comments.

Thanks for the comments. I should have mentioned that the patient had excellent hair characteristics and a higher than average hair/graft count.