Dr. William Parsley

Rogaine added to Propecia is definitely helpful. I have seen some dramatic cases in my office of a great response when the response to these drugs individually was weak. In my experience Rogaine, while still worthwhile, is only somewhat helpful by itself. When used along with Propecia, it can be quite remarkable. Rogaine is so inexpensive now that I recommend it to everyone. If the brief oily appearance to the hair in the morning is a problem, I tell patients to use it once daily in the evening. It's half life in the skin is 22 hours so it should still be helpful. Generics can be good or bad so I recommend the Rogaine brand just to be certain that the drug is good (just my opinion).

I basically agree with Dr. Feller, but if the scar is below the nuchal ridge, I feel that stretching the neck can contibute to widening of the scar. You can locate the nuchal ridge by feeling with your hand. It is the horizontal ridge about halfway up the back of your head. I ask my patients to avoid situps or forceful stretching of the neck during the first 30 days. Best to be on the safe side.

I would be extremely cautious about going back to the doctor if the situation is worse, even if it were done for free. I would sit down and talk to him about the reasons and, if I weren't satisfied, go elsewhere. Keep in mind that you only have so much donor hair. You certainly don't want to waste any of it. Also, scarring in the recipient area builds up with each procedure. More scarring is layed down with poor techniques than with good techniques. This double whammy is a good reason to take your decision to start transplantation very seriously and pick someone you trust. Visit several offices before you start and get educated. Your efforts will be rewarded.

It is not uncommon for grafts to grow in slowly after being transplanted into a scar- sometimes after 8 months. The cause and type of scar are important. It is my experience that the thicker the scar, the slower the growth and the worst the yield. Grafts into radiation scars and skin grafts grow well. The worse for me are thickened scars around old plugs, perhaps because the bulbs of the grafts sometimes don't reach into the fat layer where they normally lie.

Matt This is common and almost never permanent. I would expect that over the next 2 months you will have nearly all of your sensation back. Cutaneous nerves are small and hook up again; but it takes time.

It usually looks the worst right before it starts to grow in- which means you are there. With FU grafting you usually notice the start of growth at 3 1/2 to 4 months. It is pretty pitiful at the start, but by 5-6 months it is gaining strength and starts to contibute to your appearance. Improvement will continue for another 6 months or more beyond the start of growth.

Dr. Kabaker is an excellent transplant doctor. Even though he has done many alopecia reductions with excellent results, his practice is almost all grafting. To his credit, he was one of the first AR specialists to say that grafting is the gold standard and to drastically reduce AR surgery once FU grafting was developed. Before you discount AR as totally without merit, you should see the Mexican kid with severe traumatic scarring hair loss he did (gratis). Those skills gave this kid back his life. Dr. Kabaker has my utmost respect. The best way to evaluate any doctor is to visit him in person and see his results. Don't take any of these web messges as gospel, including mine.

I agree with Arfy in that you can't look at one at credentials only. You must look at all these factors. It is extremely difficult to separate fluff from substance - that is why these web sites are badly needed. That said, I think that Dr. Haber looks good in light of these questions. I don't send messages like this, especially about a regional competitor, unless I have some conviction. But even so, one needs to study any doctor closely.

As a transplant surgeon I feel that I can give some input. Dr. Haber is a co-author of one of the major textbooks in our field. Next year he is going to be President of the ISHRS. He is as solid as they come. While there are many good hair surgeons out there, one would be in excellent hands with Dr. Haber.

It would not hurt to shave your head. Putting tape over the recipient area is another matter. Nobody knows for sure that tape would hurt, but chronic occlusion and rubbing from a hairpiece is felt to be detrimental by many top hair transplant doctors (but there is no hard evidence). I would recommend leaving the hairpiece off as much as possible and try to avoid taping over the grafts. If this is not practical, at least use as little tape as possible and move the tape the different locations frequently.

It is true that a person with a full head of hair loses about 100 hairs per day - however, the loss varies greatly from day to day. It is probably not worth your time to count hairs. Good pretreatment photos to compare with follow-up pictures is the best way. The gains generally peak out at the scalp level at 1 year and peak out cosmetically at 2 years. Be patient. It is my impression that Rogaine, while helpful, is pretty weak when used alone. However,when combined with a more powerful agent like Propecia it can become impressive. I strongly recommend using both. Be sure to use the X-strength Rogaine. Make no mistake about it- these drugs are not of minor help. They can make a huge difference when continued several years. 90% of people have as much or more hair at 5 years than when they started treatment- and that is with Propecia alone. The percentage is even better when combined. Don't stop these medicines.

There has been not link of finasteride to any type of heart condition. A few years ago there was a study on the prostate gland that gave some worry. The study showed an increased incidence of carcinomatis changes in a small group after one year of use compared to controls. Further review indicated flaws in the study including the small number of patients. The opposite of these results may be the truth. In lab animals, several studies have show finasteride to reduce prostate cancer. There is a large 7 year study in humans to determine if the incidence of prostate cancer might be reduced with the use of finasteride. The study is about 2 years from being concluded and the results opened. It is thought by some that finasteride will not help if someone already has prostate cancer, even early. But it may help prevent the onset.

Propecia is about 65% effective in growing new hair in the midscalp and vertex (crown), and about 38% effective in growing new hair on the frontal scalp. It should be in the range of 90% effective to preserve the hair in both areas - at least for 5 yrs, which is as far as the studies go.

Women can benefit from hair transplantation but I have not found it to be a rewarding as working on men. Women are much more prone to shedding, but usually the grafted hairs and a lot of the shed hairs will start coming in at about 4 months. At that time you will start seeing the benefit so just hang in there a little longer. I transplant a number of women but try to create low expectations. It seems that you take at least one step back for every 3 steps forward. Also a result that would please a man does not necessarily please a women as they expect thicker hair. Add to this the fact that the donor area is usually weaker than that of a man. Hair loss is women is very different than for men and the reasons are poorly understood. A lot of hair surgeons are enthusiastic about transplanting women but I don't consider myself in this group. Still, you don't want to deny women a procedure that often brings a very satisfactory result. Women just need to understand that results can be very unpredictable and need to accept this problem. Spironolactone and other feminizing drugs are very weak hair preservatives and are generally considered not helpful in hair regrowth. The effective dose for spironolactone is high (about 200 mg per day} and its usefulness is questionable. For the hair experts, Rogaine is about the only real treatment.

There is a very large 7 year study to determine if finasteride can reduce the incidence of prostate cancer. The study was started 5 years ago so it will be opened in about 2 years. Finasteride significantly lowered the risk of prostate cancer in lab animals after they were exposed to chemicals known to stimulate prostate cancer. It doesn't appear to have much effect if prostate cancer has already developed so its use, if the study shows an effect, will probably be in the area of prevention. Dr Parsley

The shock loss should be minimal. This isn't a large number of grafts and the previously transplanted hair is relatively resistant to shock. Dr. Parlsey

Sharp, the question you ask is very legitimate and certainly is not a dark secret among transplanters. It is debated at every meeting. As you know hairs grow from the scalp in clusters known as follicular units. The units may contain 1-5 hairs. FU grafting usually means a single blade created strip from the back of the scalp followed by microscopic preparation of the strip which means removing the considerable amount of "hairless" skin in between them. Here are the numbers. About 20% of the hairs in the donor area are single hairs. If resting or empty follicles are part of a follicular unit (FU) then they will almost certainly be moved with the FU graft. So we are mainly concerned about the single hair units. Anagen (growing) hairs are very visible and would not be overlooked. 10% of hairs will be in a resting phase, where they are retracted up to the skin and lose pigment in the bulb, at any given time. With the micrsocope they can be seen and transplanted. So this involves 2% of the grafts and less than 1% of the total hairs because, even though 20% of the grafts are single hairs they only represents 8% of the the total hairs - FU's generally average 2.5 hairs. So 10% of 8% is 0,8%. Now if the hairs has been shed from follicle, the follicle is an "empty" follicle (exogen follicle). These will be missed and discarded but fortunately probably represent 0.1 % of the hairs. This % will vary with the skill and conscientiousness of the assistant. There was a study by Dr. Kolasinski that reported significant growth in discarded skin. However, he did not use a microscope during the study so it is hard to know the significance. More work needs to be done. Some survival studies show as good or better survival from FU grafting vs minigrafting - the payoff is the naturalness. The other controversy is transection. Some studies show that it is very detrimental to grafts and other show that is is not damaging. In my experience it is highly significant. There is always some transection with the strip excision, but is minimized with the single bladed knife. Very little occurs with the use of a micoscope to separate out follicular units. One last thing. Bald epidermis (top layer of skin) is removed right up to the hair shaft with most FU grafting. With this technique, no bald skin is removed from the recipient area in creating sites. If the bald skin is left on the graft, you can't obtain the desired density because you are adding more bald skin to an area where none has been removed.

The longest duration till start of growth in my practice has been 12 months. Normally they have started by 4 months and a few continue to come in up to 7 months. People that are elderly, have gray hair, and have fine weak hair have been the ones to grow later, at least in my experience. I would venture a guess that you grafts are probably growing but are being hidden by the more vigorous hair from the previous sessions. I see this frequently - it is hard to find these fine early hairs in a forest.

Carlos, When Rogaine was being tested, they picked the crown (vertex) as a uniform control area. When they went to the FDA, I understand that they were slightly surprised that the FDA told them they could only say it grew hair in the crown. Some complained that if they had done testing on the right side of the head that the FDA would tell them they could only claim growth on the right side. The truth is that it is capable of growing hair anywhere. In fact a problem that it is capable of increasing facial hair, particularly in women (reversable). I have seen pictures of hair regrowing quite nicely in the frontal scalp with Rogaine use. My personal opinion, from experience and a lot of before and after photos, is that used alone it is a weak hair regrower in men. When combined with Propecia, I believe it is far more effective and have photos to back it up. It is my unproven opinion that all these agents work better over the midscalp and crown because the hairloss starts later there. Areas of untreated hairloss become unsalvageable hairloss in a few years. As each hair miniaturizes there comes a point that it can't be saved. Hairloss on the frontal scalp usually begins before loss over the crown. There may be more to it than my explanation, but believe this point is valid. Carlos - my main concern with the use of Propecia and Rogaine is for the top and crown areas. You need to try to preserve these areas and possibly regrow them to get the result you want - whether you ever do a transplant or not.

I am sure that if you asked several transplanters you would get several different answers. Depending on where you put the hairline, I would guestimate that you would need 2 sessions - the first being 800-1000 grafts and the second at least 8 months later and probably a smaller number. As an extra suggestion, I would add Rogaine extra-strength to your regimen. By itself, it is not too strong, but in combination with Propecia, it appears to me to be more effective. Plus, it is pretty inexpensive now.

Although I appreciate Jebster's comments, I would be very cautious. You appear to me to be right on the border of transplanting. I would not blame someone for encouraging you or discouraging you. Keep the following in mind- once you start, it is a lifelong committment. Are you unhappy with your hair as it stands or unhappy with what you think it will become? If you would be happy if the loss would just stop, then I would hold off. About 6 months ago I did a procedure on a fellow who 25 yrs ago had some punch grafts placed into an area of frontal recession. His hairloss virtually stopped and he wished he had not had the procedure -fortunately it was correctable. You mentioned that you don't like it as it is now - in that case, I would lean more for a transplant. The frontal "V" can easily be widened and should look very good. But then you are committed. Your hair looks pretty good right now but it is obvious that you have had a moderate degree of recession. You are no doubt an excellent candidate for this procedure - if and when it is proper for you. Only you can answer that question. Just go into it with a good knowledge of the committment - and don't let anyone talk you into or out of anything. It is your decision and you need to be comfortable with it. No need for rushing. Dr. Parsley

Unfortunately, the definition of the crown is a little vague. Whereas, vertex means "highest point" or "top of the head" - in reality it is considered synonymous with crown by nearly all transplant doctors. You are right, in my opinion, that it starts at the area where the skull starts sloping downward. If you follow this area with a pen, you will get a curved line that is concave when looking from behind the person. Normally this line, the "vertex transition zone" is about an inch or more in front of the middle of the center of the whorl for the crown. Usually this center of the whorl is about the center of the crown. The purpose of the vertex transition zone is it is a useful area for ending the transplant for people who don't have enough hair to transplant the crown. Of course, this zone changes in people so it is not a hard and fast ending place. Nearly all agree, however, that you don't transplant below the center of the whorl unless you are going to continue to transplant he crown. Personally, I line to stay safely anterior to this point. Hope this helps. I may try to post a picture of these landmarks sometime in the near future. Dr. Parsley

I would advise against transplanting the crown area at your age. Even though Propecia is a valuable drug, you never know what the future will bring. Maybe it will stop working for you, maybe side effects will develop, maybe you just want to quit. If you stay in the frontal and midscalp area, you are relatively safe- but if you work on the crown, you could be asking for trouble later. I tell my people that losing hair in the front hurts your appearance, but losing in over the crown just hurts your feelings. You should never forget the number one goal - keep it natural. The crown can become the "black hole" for grafts because it can get surprisingly large. If you stay in front of the area in the anterior crown where the scalp changes from horizontal to vertical (we call it the vertex transition zone) then you will be much safer and still have a nice looking head of hair. In my opinion it is still a little early to trust Propecia protecting you for the rest of your life.

To Harve, Sometimes they never fall out and at 3 months patients are looking pretty good. At the other extreme, I have had patients that didn't start growing well until after 8 months. From some of the recent studies, it appears that many patients still have new hairs coming in at 7 months. Personally, I don't tell my patients to expect anything until 4 months because it just causes needless worry when it comes in later than 3 months, which is common. Sounds like you took good care of the grafts, so hold off any concern. Dr. Parsley

The amber colored buildup on your scalp probably represents serum that has oozed from your skin. In all likelihood you have one of two situations: 1) a primary irritant rash or 2) an allergic contact dermatitis. If you have an allergic contact dermatitis then you will not be able to use Rogaine because even small amounts of the substance you are allergic to can keep the dermatitis going. You would need to see a dermatologist specialized in contact allergy so you can be tested. Possibly a pharmacist could specially mix a minoxidil preparation without the offending agent once it is identified. If you have a primary irritant dermatitis, this means that less frequent use or lower concentrations might allow you to use it. Propylene glycol is a common irritant and can also be a contact allergen. The 2% Rogaine has less of this ingredient so may solve the problem. Possibly once daily use could also help. First of all you need to stop the Rogaine until your scalp settles down and consider restarting it later. You should check with a dermatologist if possible. I do think the combination is helpful but Propecia is the more important of the two. If you have a lot of irritation, it could even make your hairloss worse. Dr. Parsley