disappointed

[mitchjohnson1]

I had folical transplants by Paul Shapiro 3 years ago. The transplanted area is thinning! They told me this would not happen. I was already not pleased with the results, now I'm mad as hell. $9,200 bucks down the drain!

[Sigildark]

Here is my opinion and i'm far from being an expert but i have learnt alot from reading these forums.

 

Are you losing transplanted hair or hair that was already in the area? (hard to know for sure, aka where you totally bald in the transplant area or still had hairs?)

While transplanted hair is supposed to be genetically DHT resistant, DHT is not the only cause of hair loss. Also it might not be the only hair in the area. One isn't immune to losing DHT resistant hair to stress or scalp diseases for instance. And non DHT resistant native hairs can still very much go over time.

 

Sucks to be sure, but there are no guarantees in life. Some people have many transplants. I assume that's especially the case for people who do not use or do not respond well to finasteride and continue to lose non transplanted hair post proceedure.

 

Keep your head high, hang in there and plan your next strategic step.

Edited May 18, 2011 by Sigildark

[corvettester]

I had folical transplants by Paul Shapiro 3 years ago. The transplanted area is thinning! They told me this would not happen. I was already not pleased with the results, now I'm mad as hell. $9,200 bucks down the drain!

 

 

What an interesting first post!

 

Welcome to the forum Mitch Johnson!

 

Would you please provide the community with before and after photos as well as the details of your procedure, i.e. FUT/ FUE, Graft Count, NW Level, Age, Family History, etc...

 

I'm not trying to accuse you of anything, and I really hate to sound cynical, but I just see too many of these "drive by" first time posters complaining, attacking, denouncing or berating well-reputed doctors. No offense, but your post has all the hallmarks of a phony / duplicate account: it's your first post, it's negative, potentially maligning, critical, it's very vague, you have no supporting documentation, no B&A pics, virtually no details, etc...

 

So if you don't mind, please show us that you're committed to transparency and provide us with more details concerning your case. I'm sure the community is very interested to hear your story.

 

 

Corvettester

[Mp96]

Some people should be removed from this forum. We don't even know if this is genuine or any details about this case and some just can't wait....

[lorenzo]

This is turning into a pattern lately.

[Dutch]

The existing hairs are falling or the transplanted ones are? I know it's tough to tell.

But please show pics & provide info otherwise no one can give you any advise.

Plus, it can also be 'seasonal' shedding

[TakingThePlunge]

mitch,

 

Welcome to the community. I am truly sorry to hear that your hair transplant did not meet your expectations. However, as has already been pointed out, statements such as these should be accompanied by photos and details regarding the procedure.

 

I see by your profile that you are taking finasteride. How long have you been on it? While finasteride is the best medication for slowing the progression of hair loss, there's no guarantee that it will work. There is always the possibility of further hair loss.

 

Dr. Paul Shapiro has an excellent reputation, not only for consistently producing stellar results, but also for his ethics and patient care. Have you discussed your concerns with him? If you haven't then I highly recommend doing so.

 

Best of luck!

[Bill - Seemiller]

MitchJohnson,

 

Welcome to our community. While it's unusual for transplanted hair to fall out, it's not entirely unheard of. The best course of action at this point would be to contact Dr. Shapiro and if possible, arrange an in-person consultation. After 3 years of solid results, the hair transplant itself was an obvious success. But if you're right and it's the transplanted hair permanently falling out (and not just a seasonal shed or the natural progression of hair loss continuing), then a medical professional should perform a full diagnosis of your scalp in an attempt to determine why this is happening.

 

Like others have said, I do encourage you to post any photos you have showing your scalp before surgery, one year after, and how it looks now. Additionally, more information such as when you had the procedure and how many grafts you received would help the community provide you with more helpful advice.

 

Best wishes,

 

Bill

[RCWest]

With SMG, $9200 won't even get you 2000 grafts via strip. That's not much hair if you have a lot of loss.

[Dr. Paul Shapiro]

To all who posted:

I do think this is a real patient I performed surgery on three years ago. I reviewed his chart and we have not heard from him since his surgery. We always send a six month and one year follow up letter to all our patients to see how they feel about their results. In that way we can address any issues head on within the year of the surgery. We do stand by our results and when a patient has results that are less than expected we do work with them. I have sent a pm to Mitch and hope to hear from him so we can go over his concerns.

I would just like to review some reasons why after three years a patient’s hair transplant may starts to thin. As mentioned already, sometimes we are transplanting between existing hairs. And as this native hair starts to thin, it looks like the transplanted hair is thinning. Also there is the phenomenon of seasonal shedding in which more hair then average goes into the resting stage which last about three months. After three months this hair should start to re-grow.

There are factors besides DHT that can contribute to hair thinning. Many medications can cause hair thinning. So I always ask about new medication when I see unexplained or sudden hair loss. Also some supplements, such as creatine, have been connected with hair thinning. Too much selenium or zinc can cause hair thinning. There was a product that the FDA took off the market recently, called Total Body Formula, which had very high levels of selenium and cause hair thinning. I always tell patients if they are taking supplements not to exceed the FDA recommended dosage. Taking products that cause the Testosterone level to rise or taking testosterone can cause hair thinning. Also, having a high prolactin level has been linked to hair loss. Sometimes there are dermatological conditions that are hard to diagnose without a skin biopsy. If a patient is having unexplained hair loss, or poor transplant growth, I sometimes recommend having a skin biopsy done of the thinning area.

Although transplanted hair is permanent, it can thin over time. Transplanted hair will retain the characteristics of one’s donor hair. We tell our patients that some men’s donor hair will thin over time. The donor thinning is not the same as Androgenetic Alopecia. No matter how bald one gets, there is always a strip of donor hair left, but with time most men’s donor hair will decrease in caliber and sometimes the actual Follicular Unit Density will decrease. We call this senile alopecia. Usually we don’t see this until one turns 50 or 60, but it can happen at an earlier age. So the transplanted hair will permanently cover the area it is transplanted into although it can thin with time.

Finally, all hair transplant doctors report an occasional case in which the hair transplant grows well in the first few years and then a lot of the transplanted hair will shed. This is rare, but can happen. It is discussed in hair transplant meetings but so far we cannot predict in which patients this will happen and why it happens.

I hope this information is helpful

[Dr. Alan Feller]

I agree with Dr. Shapiro's post. Some patients tend lose the cosmetic effect two years or more after a successful surgical procedure. Most times it's due to the miniturization of native hair between the grafts that was destined to fall out, but very rarely it can be due to miniturization of the hair transplants themselves.

 

As Dr. S. noted, this has been the topic of discussion at several hair transplant conferences and is a well known phenomenon that occassionally visits patients of all clinics. The simple answer is just to increase the volume by doing another transplant. Most clinics will do it at a massive discount if the issue is truly graft miniturization. This is easy to diagnose if the patient's recepient area was totally bald prior to surgery. If there was native hair at the time of surgery, then the diagnosis requires an in person visit or REALLY good camera work.

 

If you go through the archives on this site I documented the case of Dai Vernon in whom I had performed two procedures with great effect on totally bald skin. He had wonderful results and was quite happy for about two and a half years, then all of a sudden he lost the bulk of the transplanted hair. On exam the hairs were still in the grafts but they had in fact miniturized. So we did a third procedure on him to fill in the gaps and that did the trick.

 

Mitch, I don't think you wasted your money, but rather experienced a physiological set back that does affect some patients unpredictably. You may find even a moderate "fill in" does the trick

 

Best of luck to you and your paitent Dr. S.

 

Dr. Feller

[Jotronic]

Dr. Feller,

 

Dai Vernon is a good guy and was a valued forum member so long ago. I'm glad his case has turned out well.

[RCWest]

It was not until I came to this site that I found out that some peoples DHT resistant donor hair can still miniaturize. Until about a year ago, I always thought that the hair on the sides and the back all the way down the neck was permanent until death. This is obviously not the case! This is also another reason why it is important to not do a transplant young or do one until a pattern is stabilized.

[Bill - Seemiller]

Guys,

 

Because I'd like to reserve this topic to discuss MitchJohnson's concerns, I've moved all discussion of TheEmperor's hair transplant (including "TheEmperor's" first post on this topic since most of the content discussed his own case rather than the topic starter's concerns) to another discussion topic. To discuss theEmperor's results or ask him questions about his procedure, visit the discussion topic I created for him about a month ago entitled "Discussion about TheEmperor's Hair Transplant Results".

 

Thanks,

 

Bill

[TC17]

These questions are for any doctor who wishes to answer.

 

1. Assuming that it was transplanted hair that was lost, wouldn't a "fill in" procedure simply be a temporary fix? It would seem as though if the donor hair is destined to fall out, the only thing planting more of it would accomplish is delay the inevitable, while costing the patient time, money, and pain.

 

2. Once again, assuming it was trasnplanted hair that was lost, wouldn't there have been evidence of that inevitability upon examination of the donor area prior to surgery? I realize predicting the future is impossible, but this patient is saying it has only been three years since the surgery. I was under the impression that you can foresee changes in the hair upon microscopic analysis at least a few years in advance.

[Dr. Paul Shapiro]

TC17

You raise a good question. Since there are many reasons why transplanted hair might thin, the answer is not straight forward.

If the transplanted hair is only thinning, but still present then as Dr. Feller pointed out, another transplant may add the density that will make it look good. Remember that there is always hair in the donor area, even if it thins out.

If the transplanted hair is falling out that is another story. And sometimes a second transplant will help and sometimes not. Sometimes there are vascular or immune system issues we don't understand and they are temporary. Sometimes a second transplant will take, and sometimes it won't. So in those rare cases it is difficult to decide what to do. I would always take a skin biopsy in a patient like this to rule out unusual dermatological conditions.

But these types of cases are very rare. In most cases the donor hair is just thinning and miniaturizing, not actually falling out.

I hope this is helpful

Dr. Paul

[TC17]

Dr. Paul,

 

Thanks for taking the time to respond. I still have some follow up questions that I hope you can answer. Assuming it is simply the hair "thinning" and not falling out, wouldn't removing additional donor hair increase the risk of the strip scar showing on these types of patients? It seems like in effect one would be robbing Peter to pay Paul, and perhaps look worse in the long run.

 

And second, again assuming it is the hair simply thinning and not falling out due to an illness or other problem, generally speaking, if a doctor examines the donor area thoroughly, is he capable of foreseeing the donor area thinning in the future, and if so, how many years out? I realize all patients are different, but as generality, upon microscopic examination, can a doctor say with confidence that a patient's donor area is secure for 3 years, 5 years, 10 years, 15 years? Or, is that prediction not possible for any period of time, and we should view that possibility as simply another risk of surgery?

 

Thanks again Dr. Paul, and I look forward to your answers!

[aaron1234]

Great questions TC17. I often see men in their later years (maybe 70's, 80's) and their donor zone is completely gone. I wonder if they had some sort of diffuse alopecia, or I wonder when their donor area started to disappear. I guess that is senile alopecia and wonder if finasteride could prevent it or at least fight it.

 

Unfortunately Mitch, no one can help you out if you don't present the forums with good quality before and after pics. If there is any clinic that looks out for its patients it is SMG so do yourself a favor and contact them for a follow up. Like you said, 9K is a lot of money. So you owe it to yourself to get to the bottom of this.

[Dr. Paul Shapiro]

When I evaluate a patient for a transplant there are some indications that the patients donor hair may thin at an early age in the future and in these patients I am very cautious. I am cautious with the following patients: patients with diffuse thinning and miniaturization throughout their scalp, patients who are significantly bald before they are 30, patient in which there is already miniaturization in the donor area, and patients who have significant thinning in the lower crown near the safe donor area.

Most other patient’s donor hair is secure for many years. That is why we see most of our transplant patients happy and with good results holding for 10 15 years. The senile alopecia that happens in the donor area usually does not show up until a patient is in their 50’s or 60’s. All transplanted patients have the risk of senile alopecia. This is a thinning, not a total loss of hair. Usually this thinning is minor and it can be accompanied with some minor thinning of the transplanted hair. Sometimes it is more significant and the transplanted hair can look very thin and the donor can thin out. We cannot predict when this will happen or to what extent. But most patients have enough donor hair that if they want to they can thicken up the transplanted hair with another transplant and still hide the donor scar.

There are few patients who have good donor and no miniaturization in the donor are and despite good growth after their transplant, will start to thin 2 or 3 years post operatively. We do not know why this happens. There may be more than one reason for this type of patient and fortunately this is a very rare phenomenon.

In answer to your question about the donor scar, even if the donor hair thins, we leave enough hair to hide the donor scar. That is why it is important to leave about 50% of the donor hair to hide the scar. Aaron1234 pointed out that some men in their 70’s their donor area is completely gone. I don’t see that often. But it can thin significantly. But if the scar is minimal and they wear their donor hair at the proper length, even in these men the scars are not easy to spot. This usually only happens in Norwood type 7 patients. And by the time a patient is 30 we can usually tell if they have a good chance of progressing to a Norwood type 7.

I hope this answers your questions.

[JustAGuy]

I'm a little confused. Dr. Shapiro said:

Finally, all hair transplant doctors report an occasional case in which the hair transplant grows well in the first few years and then a lot of the transplanted hair will shed. This is rare, but can happen. It is discussed in hair transplant meetings but so far we cannot predict in which patients this will happen and why it happens.

Then Dr. Feller said:

I agree with Dr. Shapiro's post.

But in another thread when I mentioned that I my transplanted hair seemed to start falling out aggressively at 15 months post-op, Dr. Feller said:

In all my years of practice I have NEVER had a patient whose grafted hairs grew only to fall out 15 months later. Some miniaturizing, yes, but actually falling out, no.

and also:

He claimed the hair grew and then fell out. An unheard of claim...

So, Dr. Feller, I'm not sure I understand your opinion. Is the loss of transplanted hair some time after surgery heard of or unheard of? I'm not trying to start any fight, I just want to understand your position better. Based on your earlier comments, I thought you were saying that such loss was pretty much impossible, but now it seems like you're saying it's actually possible. However, maybe you were agreeing with Dr. Shapiro only on miniaturization and not on actual loss, I'm not certain. I just want to understand this better.

 

And for everyone else, as I've stated consistently, I believe that any failure of my transplant was much more likely to be due to my own biology than to be the fault of Dr. Feller, who performed my surgery. Also, he hasn't had the opportunity to inspect my head since this loss started occurring in order to come to a professional conclusion about what actually happened to me. (But personally, I've lost so much hair that it's hard for me to think that I *didn't* lose a huge amount of transplanted hair.)

[Dr. Paul Shapiro]

JustAGuy

I think what is confusing is that we are talking about transplanted hair miniaturizing, not completely falling out. Those are two different issues. Sometimes when we use the term shed, we are talking about miniaturizing, not completely losing the whole follicle. Sorry about the confusion and the term shedding is not a very accurate term. As I said there are some rare cases in which the results initially look good, but then the transplanted hair thins prematurely. This is very rare, but can happen. I have never seen a case in which the results were good and then 15 months later the transplanted hair permanently fell out. The only cases I have seen in which transplanted hair actually fell out are from some older cases in which the old large grafts were taken from the unsafe donor area. Thus these hairs finally succumbed to the affects of DHT. And in these few cases the transplants were done 15 to 20 years ago.

When the hair miniaturizes the decrease in volume of hair is much greater than the decrease in diameter of the hair. This is because the volume of the hair follicle is 3.4X the radius squared x the length of the follicle. So it may seem like the transplanted hair has fallen out when it has just miniaturized. I have done transplants on patients who have see through hair and one would guess they have a density of 10 or 15 FU’s/sq.cm. But when I took an actual photo of their hair after I cut it short, I measured a density of 50 or 60 hairs/sq.cm. but the area looked bald because the hair was so thin and miniaturized.

You ask if there are reported cases like yours. I have not heard of a case like yours with such significant hair loss after 15 months of surgery. You did mention that Dr. Feller has not had the opportunity to examine you in person. Without examining you he is most likely giving you an array of possible explanations and that is why you may be getting some contradictory information. Even with photographs, it is difficult to evaluate miniaturized hair unless one is looking at the hair under magnification. Sometimes under magnification we can tell if you are experiencing loss of existing hair or miniaturization of transplanted hair, but that can be difficult.

Because what you are describing is unusual, I do think it would be a good idea for you to get a medical work up for both endocrine and dermatological causes for your sudden hair loss. I am not sure how long this hair loss has been going on but you may be experiencing some form of chronic telogen effluvium. This can look like permanent hair loss. Also there is a condition of diffuse alopecia areata which can look like what you are describing. If for some reason you are having fluctuations in your Testosterone, or thyroid hormones that could cause hair loss. Also there is some evidence that high prolactin levels can cause hair loss. As I mentioned in a previous post some supplements can cause hair loss and even heavy metal in ones diet can cause hair loss. If all medical explanations are exhausted there may be something unusual with your biology as you pointed out that may never be diagnosed.

In summary the cases I have heard of that are similar to yours, are cases of donor hair miniaturization, not actually complete hair loss. I have also had cases when I have gone between existing hair and when that existing hair thins, the transplant looks worse. There are some patients whose donor hair will get very thin and decrease in density with age, but this happens 10 or 20 years down the road, not 15 months down the road. Usually, this does not happen until the patient is in their 60’s. There have been a few cases I have seen reported of significant donor hair loss 10 years after surgery, but not 15 months after surgery. And usually there are other medical factors that may explain some poor circulation or other medical conditions.

I hope this is helpful

Dr. Paul

[JustAGuy]

Thank you, Dr. Shapiro, this is very helpful, and was exactly what I was looking for.

 

It's not convenient for me to get to New York any time soon for Dr. Feller to examine my head, but I'll try to see if I can find a more local surgeon in the meantime who can at least try to verify whether I've had actual loss or miniaturization.

[TC17]

Thank you for taking the time to respond, Dr. Shapiro. Based upon what you said, I tend to think that propecia, at least with respect to younger men, might be a doubled edged sword and could perhaps lead to major problems down the road.

 

I have a hypothetical to better illustrate what I mean.

 

Take two patients, each having begun losing hair at age 20. The first one, Patient A, got on propecia at age 25 while a NW3. The second one, Patient B, also a NW3 at age 25, decided against using drugs. Fastforward 10 years and each patient is now 35 years old. Patient A is still faithfully taking the propecia and is still a NW3, while Patient B, who still does not take medication, is now a NW5. Each now wants their hair restored. Who is in the better position? (assume hair caliber, density, balding pattern, etc. is identical in both patients)

 

Is it Patient A? If so, why? Is it because he obviously has stablized his hair loss, has less surface area to cover, which means he needs less grafts, thus meaning his surgery is cheaper. One would think, based in large part on the advice given by many on this forum that Patient A has done everything correctly and is in a great position for hair restoration.

 

That's fair, but hasn't Patient A, by virtue of taking propecia, also artifically altered his balding pattern? Obviously he has, so doesn't that make the doctor's job of trying to predict just how advanced the patient's hair loss will become that much more difficult? I've heard from quite a few surgeons that MOST NW 7's can be predicted when a patient is 25 or 30 years old. I hope that's the case, but I cannot imagine that holds true if the patient is taking propecia.

 

Bringing it back to the hypothetical patients, if Patient A had never taken drugs and would have also been a NW 5 at age 35, then shouldn't he be transplanted as though he is a NW 5? That way, if life happens, and he's unable or unwilling to continue taking drugs, he can get off of them without the risk that he would look foolish. But, if the patient is hiding his true pattern behind drugs, the doctor now not only has the inherent risk of continuing hair loss in all patients, but the added risk that his patient is actually a much balder man than he actually appears to be. And that says nothing of the fact that some patients might not even be candidates for surgery, but appear to be because they're on drugs.

 

I'm curious as to a doctor's philosophy when he finds out that his patient is taking propecia, and how that knowledge subsequently affects the analysis and examination of that patient. My first meeting with a highly respected doctor on this forum was when I was 26 and on propecia for one month. He looked at my scalp and told me that I was a NW 3v, but that I had thinning in a NW 5 pattern. I'm sure I'm the exact same now, but if not for the drugs, who knows.

[bonkerstonker]

I have spoken this issue with quite a few doctors and they all say the same even with 10 years of propecia you would still see thining of some sort in areas that are dht sensitive.

 

I my self am not a hypothetical i am a real patient obviously. I started propecia 10 years ago when i had aggresive hair loss over the space of 6 months i became a nw5 diffuse but i still had decent coverage if styled right and my hair cut short at the sides, anyway over the last ten years of using propecia and minoxidil my diffuse thining continued to thin very very slowly over the last ten years and i gained a little bit of retrograde alopecia which is in the donor above your ear also my hairline started to become weak in the last year but my nw5 barriers were never broken and stand there still as solid as it was ten years ago.

 

My point is finasteride does not holt hairloss completely for numerous years it does lose its grip as time goes on even if you don't notice it your self it can be seen under a microscope and what doctors do is assess your hair for slight miniturization in bigger nw patterns and how long you've been using propecia to get the answer to your future loss obviously like anything else there is a margin of error but it is not much.