QUESTION TO DOCTORS AND VETERAN TRANSPLANT PATIENTS

[Guest]

if a HT patient was in a slow ongoing balding situation, then had a good HT (including light crown coverage), what is the likelihood and what have you seen in terms of a patient like that continuing to bald, thereby complicating the good result of the HT? thats basically my situation.....47 yrs old, norwood 4 to 5, had 2100 all FU HT on Nov.7 (about 1300 in front, 700 on crown), been on propecia about 3 months, my hair type is fine and thin, with a lower than avg. donor density. my concern is mainly concerning the crown. i read a paper by HT surgeons...they make the point that attemting the crown can make large demands on the donor supply if the patient continues to bald after the HT (see "follicular transplantation: patient evaluation and surgical planning" by bernstein/rassman in the research library).

i worry that at my age, with ongoing slow balding, that if the propecia does not work for me, i could get into a situation like a dog chasing his tail. of course, one can always get another procedure to address future balding, but there is a limit to your donor supply. i am wondering if i should grafted my crown at all. what about it doctors, patients....have you seen much of this kind of problem?

[Guest]

if a HT patient was in a slow ongoing balding situation, then had a good HT (including light crown coverage), what is the likelihood and what have you seen in terms of a patient like that continuing to bald, thereby complicating the good result of the HT? thats basically my situation.....47 yrs old, norwood 4 to 5, had 2100 all FU HT on Nov.7 (about 1300 in front, 700 on crown), been on propecia about 3 months, my hair type is fine and thin, with a lower than avg. donor density. my concern is mainly concerning the crown. i read a paper by HT surgeons...they make the point that attemting the crown can make large demands on the donor supply if the patient continues to bald after the HT (see "follicular transplantation: patient evaluation and surgical planning" by bernstein/rassman in the research library).

i worry that at my age, with ongoing slow balding, that if the propecia does not work for me, i could get into a situation like a dog chasing his tail. of course, one can always get another procedure to address future balding, but there is a limit to your donor supply. i am wondering if i should grafted my crown at all. what about it doctors, patients....have you seen much of this kind of problem?

[Dr. William 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

[Guest]

it sounds to me that propecia may be more successful for people than i had thought. and maybe, as arfy said, dutasteride or something yet unknown may do better. i have to admit i'm a little skeptical of drugs long term.

[Dr. William 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

[Guest AP]

Dr. P and other posters,

 

This is a good topic and a good discussion. I have some concerns about Propecia as it relates to having a transplant. I'm really concerned about permanent shock loss (I could live with temporary loss). Like Jeff, I'm a Norwood 4.5 with fine hair and crown loss (I think by the "crown" we are talking about the area back behind the high point on the skull where the hair changes direction?). I am now taking Propecia to try to keep from becoming a full 6.

 

I have hair that I would probably keep if I keep taking Propecia, which I started three months ago. But what I read about shock loss is that you lose hair that is genetically programmed to fall out. The hair I'm trying to keep has thinned a bit and will fall out without the Propecia. But the surgeon I saw wants to transplant through that thinning hair because it's in front and on top. So I'm worried that the shock loss will negate the benefit I hoped to gain from the Propecia--to keep existing hair so that it can help make a transplant look good given my unfavorable hair characteristics.

 

I don't know what to do about it. I know a permanent frame for the face is priority #1 but it will look really silly if there is too little behind it on the top of the head. I think most people who haven't gotten to full stage 6 yet or who are losing hair a bit younger feel the same.

 

Anyway, I look forward to your intelligent comments. This "thread" has been a good one.

 

Best wishes to all,

AP

[Guest]

it sounds like we are in a similar situation. i also thought my hair characteristics were unfavorable as they sound a lot like yours. i wished i had thick hair as it seems to be better than fine. but any more, my thinking is that fine hair might not be such a bad thing to have for HT's in some ways...if after my HT i have a fairly thin coverage (i also hope to retain whats left of my front hair) which might blend well with the sides and back which are naturally fine and thin. my surgeon did transplant through the front to the crown. i'll report back if i lose the original ones there. my feeling is that if i retain it and with the added grafts, maybe i can end up moderate in front and thin on the crown. i guess a guy could wait until the propecia really has had a chance to work before surgery. i did my after 2 months on propecia.

[Dr. William 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

[Guest AP]

Dr. Parsley,

 

Thank you for your post. I was just reading another thread and I realize these forums become heated sometimes, but don't let that deter you from participating. I wish more doctors would.

 

Just in response to your suggestion on using a microscope to determine whether areas have suffered hair loss or just very visible

miniaturization, would a densitometry reading actually be the most accurate way to tell?

 

I have read that shock loss can affect miniaturized hair even if you are transplanting into other areas. I wish there were some real clinical studies on shock loss rather than just anecdotal evidence. I hope you and your colleagues would consider embarking on such a study. It would be of great value to many patients. Merck commissioned a study on Propecia's effects on transplant to MHR but I think I speak for a lot of other patients and potential patients in saying that MHR, like Bosley, carries little credibility on these boards and I am disappointed Merck chose them rather than one or several of the doctors on Spencer's or Pat's list(s).

 

Thank you,

AP

[Dr. William 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

[Guest AP]

Dear Dr. Parsley,

 

I tried the microscope test you suggested today. It's definitely a case of miniaturization. Now, the surgeon (a colleague recommended by this site) wants to transplant from front to back (leaving the crown alone), going through a thin front, a 3 inch bridge that is miniaturized to notice it has thinned but is still "cosmetically dense" (you can't see the scalp there at all), and a very thin top. The doctor would be transplanting through the bridge. I had just started Propecia, and the doctor made no mention of Rogaine. When asked if I should be on it, the surgeon I saw didn't think it was important.

 

Based on what you've said, I feel stuck between a rock and a hard place. If I lose the hair I do have from permanent shock loss, then a transplant will be as you said, three steps forward but two steps back. For me, as for a lot of people, one step forward for this kind of money when three steps are possible is a tough pill to swallow. If I don't have the transplant, well, I stay unhappily where I am (not too many people happy with their situation post on these boards, as you can tell). I can stay on Propecia and hope to stay where I am, but even if I regrow a little, I'm still a 4V. Maybe you think one of the concealer products like Toppik would be the best solution?

 

Quickly on the idea of a shock loss study, Limmer's article on density as you recall describes a number of different hair counts. Even without a hair count, I would imagine you don't have to do an actual hair count to see if there was significant shock. If they have been on Propecia or Rogaine or both and have stabilized their loss, if they lose hair from a transplant that does not return, I would imagine you could tell they'd suffered shock loss and maybe you and other doctors could identify specific trends (like how miniaturized the hair would have to be in order to be permanently lost). If some trands have been identified, they don't seem to be reliable indicators because you say shock loss is so unpredictable.

 

This is rather troublesome for a lot of men I suppose. You go to a surgeon to restore hair but find out you will need more hair transplanted than the hair you needed to fill in the thinned out areas. Sort of like when you take your car into an auto shop and they make more work for you than you originally needed. I'm of course not suggesting that HT doctors are happy about shock loss, but the analogy (I hope) illustrates the intense frustration the issue presents given the inability to really nail it down and eliminate it.

 

At any rate, I hope this provides some food for both thought and study. I don't know what to do. I first thought a transplant could just fill in the areas that were badly thinned out in the front and toward the back of the top. I didn't realize that I might have to be transplanted as if I had already lost hair I still had.

 

Dr. P and other posters, I'd welcome any suggestions on what to do. I won't hold any of you to your suggestions. And of course, those like Jeff who have similar issues, keep us all posted on your progress.

 

-AP

[Guest]

yes, the fate of your remaining hair is a real "wild card" in the long term outlook. for a guy that has "balded out" and is stable the bright side , to me, in his situation is he doesn't have the prospect of future losses to complicate everything. for me, i like to simplify issues and take a long term perspective. i believe that all the remaining hair on the top of my head (crown was already bald) is going away. it may have lasted longer without the shock of surgery, but it was destined eventually to go away. so i planned my strategy as if it is already gone. i asked my surgeon to plant the grafts uniformly as if i was already bald. i don't really think it came out quite that way, but mostly it did. (i think the grafts were concentrated mostly in the front and crown, and that mid-frontal area between there and the crown itself is VERY lightly planted. i am not disappointed it was not totally uniform as one has to realize there is a limit to what 2,000 grafts can do in a first session). if i retain any of my original hair a year from now i will just consider it gravy. i do expect to do a second procedure, but will wait until i see if propecia works and how my balding is progressing....that is, mostly how the area around the crown is doing. my feeling for now is to "keep my powder dry" (preserve that donor supply) and wait a while. probably a few years anyway. my point is that for me it was beneficial in planning to just forget the original remaining hair. hope this adds a different view that may be helpful.

[Dr. William 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