Dr. William Parsley

The mini vs FU debate has been going on among transplanters for some time. Personally I put myself in the FU group but appreciate the points that many of the mini proponents (no pun intended) bring up. Let me first say that speed and cost savings do not hold water. Most patients could care less how fast the procedure is performed. The cost savings are rarely passed on to the patient significantly. The procedure is tough enough without compromising it by doing something less than optimal. Most of the mini grafters I know do it for one reason - they feel that they get better results. Truthfully, there are some cases where it makes some sense - patients with fine hair and patients who have a disproportionate number of 1 and 2 hair FUs. FU grafters usually try to handle this problem by coupling some FUs by placing a 1 and a 2 hair FU into a single site or placing two 2 hair FUs into a site. Is this now a minigraft? I don't know. There are some similar issues with mini and FU unit grafts that are important: placing the graft at the proper level, angling the graft correctly, aligning the graft properly, putting the graft in the proper size site, avoiding transection in site creation, creating proper density, etc. Whether the graft is a mini or FU is only one part of the technique. Rassman and Shapiro, for example, got beautiful results with minigrafting before going to FU grafting. Of course, as you know, FUs are just a specially prepared type of mini graft. The main problem with many grafts, in my opinion, is that you are transplanting too much bald skin. With needle stick site creation, no bald skin is removed (as opposed to a punch) so you don't want to bring in the bald skin between FUs with the grafts. It prevents you from getting proper density. Dr. Beehner uses mainly FUs but uses some mini grafts, but only because he feels there are advantgages to the patient, not to himself. He gets beautiful results. I use almost all FUs for the same reasons - because, in my hands, I feel I get better results this way. In the long run, give me a person who know how to handle and place the grafts properly - i.e. someone with talent. At our international meetings, Dr. Beehner, Drs. Rassman & Bernstein, Dr. Shapiro, Dr. Limmer, and Dr. Seager constantly bring their transplanted patients for critical observation. You don't do this unless you know your results compare well to the best out there. The results are all excellent even thought techniques are somewhat different. Either technique can be done well or badly so don't get too thrown off by terms. All of these doctors use FUs as their dominant graft. If you only want FUs, just tell them and they will be happy to accommodate you. Dr. Parsley

I enjoy Arfy's comments and would not like to see him back away. However, I am not sure Hair Transplant Tech's comment was meant to be as negative as it was taken. It is easy to misunderstand someone's printed text so I give them the benefit of the doubt. Personally, I would have considered it flattering that they asked. Even though I don't always agree with anybody, Arfy seems to have a good handle on the present information and is well worth reading. Knowlege is the best way for anyone to avoid problems. You have every right to question the clinics as to their techniques. Regardless of what many think, transplanters have plenty of disagreement on the same topics I see debated by potential patients. But the physicians I know are far more conscientious than are portrayed here and would be more than happy to answer any questions. Forgive me for getting off thread, but I would like to take a bit of Lou Holtz's philosophy in order to advise someone as to how to pick a doctor or clinic. There are 3 things you should always ask yourself: 1) Are they competent? 2) Are they committed to their trade? That is, do they attend meetings, interchange with other doctors, keep up with current techniques,etc.? 3) Do they care about me? If any of these are "no", keep looking. I may be different from some of the other doctors, but I feel shedding is a big concern. First of all I worry about shedding because I realize that some of the shed hairs will not return. I feel the baldness has to be progressed enough that real gains can be made without the backsliding caused by shedding. Secondly, some of this hair may be salvageable with medication. I personally don't know of any good studies on this problem. It needs to be done but will be very difficult. In my opinion, shedding is a major cause of dissatisfaction with transplantation, particularly the first session. I frequently see people in my office with early hair loss ready to start transplanting. This is an area where real caution should be exercised. If there is a reasonable chance they can be satisfied without transplanting, then they should wait and try medications. If a person is a good candidate for transplanting, they will still be a good candidate 3 yrs or 6 yrs later - no need to rush. Once the decision is made to transplant, realize that shedding is not predictable. Use of minoxidil and GraftCyte can help. More questionable are finasteride and lysine. Surgical technique is important - avoiding transection, not overly dense packing, possibly reducing epinephrine concentration, etc. But the best way reduce the problem of shedding is to make sure that there is enough hair loss before embarking on transplantion so that shedding is not able to detract significantly from the positive gains. Dr. Parsley

To norwoodthree: It depends on how long it has been since your transplant. If it has been about 2-3.5 months, then this means the hairs are starting to get active. In this case it is fine to take a small needle such as a sewing needle, clean it with alcohol, and pick the pustules. They can then be gently expressed. This is what we do and it does not hurt the hair - but prolonged inflammation from the foreign body (hair shaft) can occasionally be a problem. If you have a lot of redness, swelling, or tenderness around them then you should consult your doctor. Now if the pustules are a few days after the transplant, leave them alone and call your doctor. Expressing these can possibly extrude the graft. Hope this helps. Dr. Parsley

It was true that the best idea was to forget the miniaturized hair because it was definitely going to disappear in the near future. However, Propecia (and to a lesser extent Rogaine) has changed that. Until they are used, we don't know what we can accomplish with these hairs. Cutting DHT 65% in some people will result in an explosive regrowth while in others it will only slow the loss. Dutasteride may improve these results but I personally will be reluctant to use this drug on young people when it first comes out. Too many questions about the safety profile for this age group. AP, if you are going to someone on this site, then I would trust their opinion. I know nearly all the doctors recommended and they have excellent credentials. They have seen you and I haven't. In transplanting, you have to blend the transplants into these areas of miniaturization or it could look a little odd. You need to understand that how to handle areas with a lot of miniaturization is one of our most difficult decisions and most doctors still are working hard to formulate their plan of action. To make it more difficult, these new drugs change the playing field constantly. That is the challenge and the reason you get conflicting advice. I need to back off a little and let some of the other doctors (who probably have more valuable insight to give than myself) to respond. I hope these discussions are giving you some insight into what we, and you, face with these decisons. Dr. Parsley

Densitometry will help you quantify the loss of FU density but, no you don't have to have it. I just look generally at the total amount of miniaturized hair. It is possible Propecia might help reduce the shedding but there are some studies to suggest that Rogaine might help. I generally start Rogaine 5 days after the transplant. Some studies suggest starting Rogaine 3 wks before the transplant helps but we need more studies to confirm it. Some people seem to be extremely prone to shedding. I suspect just anesthetizing the scalp in some people can bring it on. Because on this, I warn patients of these unpredictable risks and let them decide if they are willing to accept them. Of course, if a patient has really large numbers of miniaturized hair I won't tranplant them regardless of their motivation. Fortunately we have Propecia which is tailor-made for these situations where there is a lot of miniaturization. You are right in saying that we need better studies on shock loss. However, these are very tough things to study. Counting hairs is difficult. Dr. Parsley

AP, you asked a very important question and one I can't completely answer - no one can. That is, what about transplanting into thinning hair? I consider thinning hair divided into 2 groups: 1) thinning because the number of follicle units/sq cm is severely reduced - say down to 5-15 units or 2) thinning because the hair is miniaturizing severely and uniformly yet the FU's/sq cm is 40 or more. Case (1) is fine for transplanting as there are not that many hairs to shed and there is space to transplant. Case (2) is a problem because the hairs are weak and there is not much room to transplant. You may move 3 steps forward but also 2 steps back as a result of transplanting. Shedding is somewhat unpredictable - some people are more prone to it - and also the return is unpredictable. When to transplant into case (2) is very much a matter of judgment. Until it thins enough, I generally only go into those areas to blend that area with transplants into a more forward area that I transplanted heavily. The good news is that case (2) is where Propecia does its best work. Also Rogaine. I do push these medications a little to those patients. If you want to determine your FU counts, there is a simple way. Radio Shack sells a pocket microscope (30x) for about $7. Scissor clip your hair in a 4-5mm circle down close to the scalp. Look through the pocket microscope and you will see clearly the different FU's. Count the groups, not the individual hairs, and multiply it by 10. That number will be your FU's/sq cm in that area. It will help you be part of determining whether you are right for transplanting that area. Good luck. Dr. Parsley

Propecia is more successful than we at first thought and I admit that I was one of the skeptics after seeing so many things that fizzled with time. It's biggest problem, as Arfy pointed out, is that it works slow. You will be lucky to see results within 6 months and its benefits peak out at 2 years. I have had so many patients tell me that they used it for 4 months and stopped because it didn't work. It shouldn't be started if the person doesn't plan use it for at least a year. Also, just stopping hair loss is still a good result if you compare results to controls over 5 years. I agree with your concerns of long term use of any medication. However, finasteride has been out around 10 yrs and at doses 4 times higher than hair doses. It appears to be safe and all side effects appear to be reversible, but it is still being watched. Because the benefit-to-risk ratio looks good, I encourage (but don't push) all my patients to consider it. Dutasteride, which blocks both Alpha Reductase type I & II, will be out on the market soon and will probably be a stronger hair regrower than Propecia. It lowers DHT 90% to Propecia's 65% because Propecia only blocks Alpha Reductase type II. It will have to be used off-label by the transplant doctors if it is to be used. While the safety profile of Propecia has been pretty well worked out, the profile for dutasteride still leaves some questions. Still it looks promising for future use. It may be 4 years before it is approved for hair. Dr. Parsley

Jeff's concerns are very real and one that is considered by transplanters. Transplanting the vertex(crown) at an early age can lead to a halo of hairloss around it later, leaving a "nest" of hair in the center. As opposed to the frontal hairline where we have a defined border, in the crown we are working inside the hairline with a border that moves. As a loose rule, I don't work on the crown until someone is past 40 yrs of age -but you have to judge each patient differently. Jeff, I think you have little to worry about. You are 47 and and are on Propecia. The 5 yr studies are back on Propecia and show that 65% of people taking this drug have more hair than when they started. Compared to people not taking the drug, the difference is huge. Even the 35% who had less hair still had 151 hairs/sq inch more hairs than the controls. It's help has been far greater than I had imagined. For many patients, it appears that Propecia will severely reduce the number of transplants over their lifetime and dramatically improve what can be accomplished. I have many patients that I am hopeful might never need another transplant. I would suggest adding 5% minoxidil to your regimen. It is supposed to be used twice daily but I have some who do very well using it only at bedtime. It works in a different way than Propecia and adds about 20-30% more improvement according to the experts. Someone on another thread mentioned that they stopped Rogaine after starting Propecia because they didn't think they needed it anymore. Predictably, his hair started shedding. This is because Rogaine holds hair longer in a growth phase. On stopping Rogaine a huge number go into the resting phase at the same time. Even without restarting Rogaine he will get some of the thickness back. But why stop it? It is safe, fast, and relatively inexpensive now. Certainly worth using, even though it is not in the same league as Propecia. Another problem that comes with aging can be your blessing - gray hair. With old plugs, there was a saying: "Pray for Gray". Gray hair can make even old plugs look smoother. I don't think that will be necessary with you anyway since you had a thin pattern and you hair is fine (another bonus for the crown). It looks like you and are in good hands and that your treatment is conservative. You will do fine. Dr. Parsley

Sorry about my comments on Dr. Woods being placed on a different thread. I am relatively new to these discussions but am catching on. I don't seriously entertain a notion at this time that Dr. Woods' technique is the future. It is the technique of the past, with smaller donor plugs. On the conspiracy theory - can anyone give me one good reason that transplant doctors would have a conspiracy against him? He is certainly not a competitor of mine nor of many doctors in the States. We are happy to embrace any new techniques if they prove out. It is a characteristic of any good doctor. Improving keeps us motivated. Scarless? That is totally wrong. You replace a long thin scar with hundreds or thousands of little scars that add up to more than the sum of the strip scar. Another point- of all the problems we deal with in transplanting, I would say cosmetically problematic donor scars are low on our list. I have had extremely few complaints in this area on a patient that I started with. This is not to say I don't deal with problems. Everybody does. But donor scars are not the thing that should worry you unless you plan to have a burr haircut. Don't confuse FU scars with scars from scalp lifts or scalp reductions. There is a big difference in tension and complications. Arfy,I agree that no one should take my statements as the final word. Just take it as from one person's perspective. There are serious problems from my vantage point. Don't expect many doctors to take up this procedure even if he comes out of his shell of "secrecy". Most of the doctors feel we generally know his technique, it is just that we don't care for it. These are probably my last comments on Dr. Woods. I just thought some might want to know the general feelings of most transplant surgeons. Dr. Parsley

Dear pmac, The chances are almost zero that the shingles would be reactivated. It is usually only a one time problem even though I have had a few rare people with more than one episode. I would not worry at all. Besides, there are antiviral drugs to stop it if an attack occurred. Dr. Parsley

Dear AP, Densitometry readings measure FU's/sq cm - it does not measure hair diameter. Actually the diameter of the hair only slightly changes the distance between FU's. Usually the spacing is about 1 mm. You can imagine how hard it would be the remove a graft without transection using a 1mm punch. If your hair was dense when you were younger it may be you are considering your hair fine by looking at the balding area. If so, that represents miniaturization. When I mentioned fine hair, I was talking about the donor area. It is possible that your donor hair isn't fine if, in fact, your hair was dense when you were younger. Usually the donor area hair is similar to the hair on top of your head before it started to bald. So maybe your donor hair is better than you think. You are right about staggering the grafts. If you dense pack an area this isn't too much of a worry. Dr. Parsley

To AP, I will be interested to hear what the other doctors have to say about this. In my opinion, if you have fine hair you will not have significant density from a transplant. In most cases, people with fine hair never did have significant density. That does not mean that they cannot have significant improvement in their situation. The face can still be framed and they can eliminate their bald look. Mathmatically, if their hair shafts average 50 microns in diameter then they will only have 1/4 the hair volume from a transplant compared to someone who has an average shaft diameter of 100 microns. If a patient has 50 grafts/sq cm the density is going to be about as good a that patient is capable of having. I must caution you however to be aware of the graft size. Are the grafts 1-hair, 2-hair, 3-hair, or 4-hair grafts? Obviously 40 1-hair grafts will not be as thick as 40 3-hair grafts. However, you can get more 1-hair grafts into a sq cm than you can with 3-hair grafts - partly, because of the size of the needle slit required. If you have fine hair just be aware that the ultimate volume won't be as thick as with other transplant patients. Dr. Parsley

To pdm68 Usually 15-40 grafts/sq cm are placed depending on the density desired in a given area. Density can be accomplished 2 ways with any given transplant: 1)place more grafts/sq cm 2)place grafts with more hair, such as 3 or 4 hair grafts, into each site. These variations of density are important to the outcome and their use varies from transplanter to transplanter. Dr. Parsley

Dear Ratan. Usually the grafts are not very noticeable after a week if one shampoos and keeps the area free of crusts. I have had many patients where it is not that visible the next day. The two things that can be noticeable are general redness and crusts over the grafts. I have found that frequently spraying the scalp with a light saline solution during the transplant reduces the redness while keeping the grafts free of crusts. Frequently spraying the scalp after the transplant with water or GraftCyte also can help. If a person has light skin and dark hair, the little hair stubbles can be a little noticeable. When possible, start wearing a cap a couple of weeks before the transpant so that wearing one afterwards won't draw so much attention. Forget scarring after the hairs fall out. This is virtually unnoticeable as visible scarring is rare. Hope this helps. Dr. Parsley

Light non-burning sun exposure should not be a problem. While it is true that sun rays do not penetrate to the depth of the growth areas of the hair, a sunburn even mild can cause inflammation. The inflammation definitely penetrates to the growth areas. Because of this, you should really restrict your unprotected (without cap) activities for a couple of weeks after the transplant. I have seen many patients so enthusiastic to get back to their routine that they don't take care of their investment with the transplant. Be smart. Dr. Parsley