Senile Alopecia: How Common Is It?

[corvettester]

Senile Alopecia: How Common Is It?

 

There has been recent discussion on the HTN regarding Senile Alopecia which has caused a lot of alarm. If I understand the phenomena correctly, it is the process of donor or DHT resistant hair in the "safe" zone miniaturizing in a man's fifties and sixties. However, men in their twenties, thirties and forties may experience it too.

 

This is especially pertinent to the HT community considering that the adverse effects of Senile Alopecia can effectively render null and void an otherwise successful HT.

 

In a few recent posts, Dr. Paul Shapiro and Dr. Feller stated that although Senile Alopecia does exist in younger men, it's very rare. Conversely, Dr. Konior stats that he sees it quite frequently.

 

The disparity of opinion comes as no surprise to any of us HT patients. As we all know, if you ask three HT docs the same question, you'll get four different answers! LOL!

 

I'd appreciate it if some other docs could chime in. What I'd like to know is, how common is Senile Alopecia among younger men? Also, how common is it among older men? What percentage of us should expect it in our youth and what percentage of us should expect it in our golden years?

 

Also, is their any viable method, such as microscopic examination of the safe zone, to quantitate the extent of miniaturization, in the hopes of early detection or even predicting Senile Alopecia? Many thanks.

 

 

Corvettester

Edited May 22, 2011 by corvettester

[Dr. Raymond Konior]

Corvettester

Let me clarify that the observation of miniaturized hair within the donor region is not uncommon in many of the patients I examine during consultation; however, the proportion of miniaturized hair versus non-miniaturized hair does vary widely. Unlike pattern loss, where an entire zone will experience progressive miniaturization – thereby leading to the appearance of a balding – miniaturization observed within the donor area tends to be sporadic. The significance of this type of sporadic miniaturization can vary widely from person to person and the occasional detection of donor site miniaturization does not mean cosmetic devastation for every potential or former hair restoration patient. However, this phenomenon must be recognized and appreciated by all potential patients since it can affect the end result. Fortunately, however, the end result will not be adversely affected to any significant degree for the great majority of patients since the “aging” process of individual hairs within the grafts will occur sporadically just as it occurs sporadically within the donor site.

This reminds me of a conversation I had many years ago with one of the all time pioneers of surgical hair restoration. Remember that there was once a time when the primary method of surgical restoration available was “plug” grafting. This particular physician, just like many others during that time period, had his hairline restored with standard 4 mm plugs many years earlier. Despite having what was considered at the time to be a very good result, he still had the distinct appearance of plugginess along his hairline. Years later his hairline appeared to look much better and I asked him if he had undergone any additional procedure to soften the old plugs. He indicated to me that his improved look was a result of sporadic miniaturization within the old plugs – not from additional surgery. He also made it clear that he was experiencing miniaturization in his donor site and he was thankful for it since it helped to soften the contrast of his former too-dense plugs. Because of the randomness of the miniaturization process, both his donor site and his recipient site were thinning in proportion to one another, thereby leading to a balanced appearance between the donor site and the recipient site. This man, a leader of our field with well over 30 year’s experience, was very surprised to discover that the process of miniaturization was a real entity. Once again, although he did experience a density reduction, it was age appropriate and he continued to look natural.

Some members have suggested that this process should be detectable during consultation. However, information obtained during consultation, despite the highest of high-power magnification, is heavily determined by age. I would challenge anyone to examine an entire class of high school seniors and predict with great accuracy the primary factors associated with aging hair, i.e. who will bald, who will go gray and who will develop donor site thinning. However, our ability to predict the future for these parameters of aging hair will increase proportionately as we inspect the same men at their 10, 20, 30 and 40 year high school reunions. Age of presentation makes a huge difference in our ability to forecast the future and thereby recommend a sound surgical treatment plan.

It seems to me that the sudden appearance of a few patients with what may be recipient site thinning has thrown many members into a state of panic with current thinking being that this will happen to everyone. Rare events such as multiple lightening strikes or multiple lotto wins experienced by a single person do occur – but they are very uncommon, if not downright rare. We have recently seen a few isolated cases of this problem, but we also continue to see thousands upon thousands of satisfied patients who get great results and achieve a lifetime of satisfaction following their restoration. Patients are entitled to know all of the risks, limitations and alternatives available for a medical treatment plan, and this is just another factor that has to be considered. Patient presentation at an appropriate age to a skilled, competent and caring surgeon will tremendously increase the odds of achieving a successful outcome.

[NEWHAIRPLEASE]

Corvettester

 

Let me clarify that the observation of miniaturized hair within the donor region is not uncommon in many of the patients I examine during consultation; however, the proportion of miniaturized hair versus non-miniaturized hair does vary widely. Unlike pattern loss, where an entire zone will experience progressive miniaturization – thereby leading to the appearance of a balding – miniaturization observed within the donor area tends to be sporadic. The significance of this type of sporadic miniaturization can vary widely from person to person and the occasional detection of donor site miniaturization does not mean cosmetic devastation for every potential or former hair restoration patient. However, this phenomenon must be recognized and appreciated by all potential patients since it can affect the end result. Fortunately, however, the end result will not be adversely affected to any significant degree for the great majority of patients since the “aging” process of individual hairs within the grafts will occur sporadically just as it occurs sporadically within the donor site.

 

This reminds me of a conversation I had many years ago with one of the all time pioneers of surgical hair restoration. Remember that there was once a time when the primary method of surgical restoration available was “plug” grafting. This particular physician, just like many others during that time period, had his hairline restored with standard 4 mm plugs many years earlier. Despite having what was considered at the time to be a very good result, he still had the distinct appearance of plugginess along his hairline. Years later his hairline appeared to look much better and I asked him if he had undergone any additional procedure to soften the old plugs. He indicated to me that his improved look was a result of sporadic miniaturization within the old plugs – not from additional surgery. He also made it clear that he was experiencing miniaturization in his donor site and he was thankful for it since it helped to soften the contrast of his former too-dense plugs. Because of the randomness of the miniaturization process, both his donor site and his recipient site were thinning in proportion to one another, thereby leading to a balanced appearance between the donor site and the recipient site. This man, a leader of our field with well over 30 year’s experience, was very surprised to discover that the process of miniaturization was a real entity. Once again, although he did experience a density reduction, it was age appropriate and he continued to look natural.

 

Some members have suggested that this process should be detectable during consultation. However, information obtained during consultation, despite the highest of high-power magnification, is heavily determined by age. I would challenge anyone to examine an entire class of high school seniors and predict with great accuracy the primary factors associated with aging hair, i.e. who will bald, who will go gray and who will develop donor site thinning. However, our ability to predict the future for these parameters of aging hair will increase proportionately as we inspect the same men at their 10, 20, 30 and 40 year high school reunions. Age of presentation makes a huge difference in our ability to forecast the future and thereby recommend a sound surgical treatment plan.

 

It seems to me that the sudden appearance of a few patients with what may be recipient site thinning has thrown many members into a state of panic with current thinking being that this will happen to everyone. Rare events such as multiple lightening strikes or multiple lotto wins experienced by a single person do occur – but they are very uncommon, if not downright rare. We have recently seen a few isolated cases of this problem, but we also continue to see thousands upon thousands of satisfied patients who get great results and achieve a lifetime of satisfaction following their restoration. Patients are entitled to know all of the risks, limitations and alternatives available for a medical treatment plan, and this is just another factor that has to be considered. Patient presentation at an appropriate age to a skilled, competent and caring surgeon will tremendously increase the odds of achieving a successful outcome.

 

Dr Konior

Great post!! Thank you for taking time to post on this subject! I truly believe that you are one of the most caring physicians Ive ever had the chance of meeting! All I can ask you as that you do not retire anytime soon as I plan on being back to see you early in 2013.

[corvettester]

Dr. Konior,

 

Thanks for the response. I think I understand what you mean now.

 

Correct me if I'm wrong, but basically, Senile Alopecia occurs frequently, just not enough for most people notice. Whether or not it's in the donor area, or (in the case of an HT) in the recipient area. Since Senile Alopecia is sporadic, it's not likely to have a significant impact on overall cosmetic appearance, either in the donor area or in the recipient area if one has had an HT.

 

It also isn't that noticeable because there isn't a real pattern to it like MPB where one loses all of the hair in a very specific location, thus creating a bald spot.

 

However, there are rare cases where men experience significant Senile Alopecia which actually is disproportionately large and ends up having a very serious impact on the overall appearance of the donor area, or in the case of an HT, in the recipient area. Such cases are so rare, however, that it's like lightening striking the same spot twice.

 

 

Corvettester

[Dr. Raymond Konior]

Corvettester

I believe you are following my thoughts here. Ultimately it will be the percentage of hairs in the donor area that experience miniaturization which will determine whether or not a cosmetically significant change has occurred. A 10% change will probably be insignificant, but a 40% change can be. It is difficult to definitively predict several decades ahead what may happen with respect to donor site hair miniaturization. My lack of a magical crystal ball for prognostication is why I typically advise young men to delay surgery until a reasonably mature age. I do believe that most patients with the potential to develop donor site miniaturization can be identified by the skilled practitioner. However, some will slip through the cracks as the element of time factors into the unpredictability of hair loss. Keep in mind that every class 7 patient had his day in the sun when no one on the planet could have found any trace of miniaturization in the area that would eventually convert into a virtual sea of baldness. Patient selection, patient examination and patient education are key.

[aaron1234]

Good idea for a thread corvettester!

 

And great post Dr. Konior!

 

One question: Could finasteride potentially delay future donor thinning? Could it strengthen donor hair?

[orlhair1]

Thank you Corvettester for this thread. Very informative post Dr. Konior. This is definitely educational and some additional information everyone should consider. While it scared me more when I first read about it, I am not as concerned as I was based on what I have learned here, especially since this is my first HT and I am 53 so my loss is stable and more predictable. I am going to discuss it with my Doc ahead of time which is just wise for anyone to do.

[TC17]

"Keep in mind that every class 7 patient had his day in the sun when no one on the planet could have found any trace of miniaturization in the area that would eventually convert into a virtual sea of baldness."

 

That quote should be read by every prospective patient before undergoing surgery.

 

[Dr. Raymond Konior]

Aaron1234 – My suspicion is that finasteride may help provide stabilization when donor hair miniaturization accompanies a male pattern loss. I proposed your question to our local non-surgical hair loss expert at the University of Illinois who confirmed from his extensive observations of balding men that it can be beneficial for this problem.

Orhair1 – You are at a great age for prognosticating your future risks and your ultimate success. Good luck – you should do great.

TC17 – Your insight and advice for hair loss sufferers are profound. Thanks for emphasizing that single sentence.

[Al - Moderator]

This particular physician, just like many others during that time period, had his hairline restored with standard 4 mm plugs many years earlier. Despite having what was considered at the time to be a very good result, he still had the distinct appearance of plugginess along his hairline. Years later his hairline appeared to look much better and I asked him if he had undergone any additional procedure to soften the old plugs. He indicated to me that his improved look was a result of sporadic miniaturization within the old plugs – not from additional surgery. He also made it clear that he was experiencing miniaturization in his donor site and he was thankful for it since it helped to soften the contrast of his former too-dense plugs. Because of the randomness of the miniaturization process, both his donor site and his recipient site were thinning in proportion to one another, thereby leading to a balanced appearance between the donor site and the recipient site.

 

 

 

That is a load of bull that your friend told you. There is NOBODY who undergoes a HT who is "thankful" that their hair in the donor area is thinning along with the hair that was transplanted. I would bet anything that if his donor wasn't thinning he simply would have had another HT to soften the hairline and even add some density throughout. He can't do that because the donor is thinning, so he has to tell a story about how it's a great thing that the donor is thinning. How else can he keep on selling his HT to potential patients.

 

I have pluggy old transplants too and my donor is also thinning. Yes the plugginess isn't quite as bad as it once was, but it's NOT a good thing. My hair is just thinner all over and will only get worse as time goes by. I'd MUCH rather have a more pluggy appearance and be able to improve it with some available donor.

[NEWHAIRPLEASE]

That is a load of bull that your friend told you. There is NOBODY who undergoes a HT who is "thankful" that their hair in the donor area is thinning along with the hair that was transplanted. I would bet anything that if his donor wasn't thinning he simply would have had another HT to soften the hairline and even add some density throughout. He can't do that because the donor is thinning, so he has to tell a story about how it's a great thing that the donor is thinning. How else can he keep on selling his HT to potential patients.

 

I have pluggy old transplants too and my donor is also thinning. Yes the plugginess isn't quite as bad as it once was, but it's NOT a good thing. My hair is just thinner all over and will only get worse as time goes by. I'd MUCH rather have a more pluggy appearance and be able to improve it with some available donor.

It's not a load of crap! First of all it came from Dr Konior so that's good enough for me. Secondly, look at Joe Bidens early plugs as compared to now, it looks so much better and it's a result of blonde hair and thinning.

[Al - Moderator]

NEWHAIR,

1. I'm not saying Dr. Konior is full of crap. I'm saying his friend is lying to him. Think about it. What would you rather have? Enough available donor to fine tune some older work? Or no available donor left because it's thinning as well as the recipient thinning and you have to worry about how much it's going to keep thinning and how fast knowing you can't ever get any more work done? Which sounds better to you?

 

2. Joe Biden's hair looks better because he had additional work done to soften his hairline and add some density... and that's exactly my point.

[Dr. Raymond Konior]

Behappy

 

In other words, you are calling me a liar or you are stating that one of the most respected physicians in the history of this field is either a liar or confused. I would caution such bold statements since you were not present for the conversation and have no knowledge as to the details of his particular case. I stake my reputation on the accuracy of that statement and can attest to the fact that it is completely factual. I know this man and it is my personal observation that he looks much better with a softer hairline than he did with an obvious line of corn row plugs.

 

It seems as if you have missed the point of the post - that being the issue of long term miniaturization in the donor site and the effect it has on transplantation - not the specific details of how one individual noted that an unexpected thinning of his plugs turned out to be a positive improvement for him. This does not imply that hair loss in plugs is a miracle cure for everyone or that donor miniaturization will be a positive event for anyone who had plugs in the past. He may as well have said that the thinning of his plugs was a devastating experience - this still would have made the point of the post. Fortunately, he did experience a beneficial softening. I emphasize once again that the point here is that long-term donor site miniaturization can affect the final result - sometimes in a positive way, but for the most part is will be unexpected and lead to disappointment from lost density in the graft zone.

Edited May 24, 2011 by Raymond Konior, M.D.
spelling

[NEWHAIRPLEASE]

Well said Dr Konior!

Dr Konior, do you think, YOUR OPINION. that is what happened to Joe Biden? Or do you think he did have additional work done?

[aaron1234]

I can guarantee you that is what happened to Biden. His hairline is much softer now than it used to be. I can bet he is thankful for some donor thinning. It really improved his look, though still not the most pleasant looking hairline.

 

Thanks Dr. Konior for your insight on this thread.

[RCWest]

Well said Dr Konior!

Dr Konior, do you think, YOUR OPINION. that is what happened to Joe Biden? Or do you think he did have additional work done?

 

Joe Biden probably has enough money in his watch pocket to afford the maximum session from the best surgeon . It's a shame things were done back in the plug days.

[Dr. Raymond Konior]

NEWHAIRPLEASE - I believe the improvement you are seeing in his hairline is a result of aging changes associated with additional surgical refinement. He may have experienced some age-related thinning along his hairline, but I also think it is the age-related whitening of his hair that has helped soften his hairline. It is a reduction of density and a lowering of color contrast that helps improve overall appearance in a situation like this.

BeHappy – Here is an explanation as to why a pluggy hairline can improve in the scenario previously described. The unnaturalness of a plug is based on the contrast it creates with the surrounding skin. Factors that increase contrast will make a plug hairline look worse. Some of the things that contribute to increasing contrast include: 1) dark hair on light skin; 2) thick hair shafts; 3) straight hair; and 4) a greater number of hairs per graft. On the other hand, factors that lower contrast tend to improve the appearance of a pluggy hairline. Some factors related to lower contrast include: 1) light hair on light skin or dark hair on dark skin; 2) finer hair; 3) curly or wavy hair; and 4) fewer numbers of hair per graft.

I see many patients who undergo repair of their pluggy hairlines using FUE to debulk excessively large grafts. The FUE technique does nothing more than remove a few isolated hairs from each plug to soften its overall appearance. The random miniaturization of individual hairs within a pluggy hairline will achieve the same effect, i.e. it will reduce density within the plugs so as to soften their appearance. This is not to say that the unexpected miniaturization described here is a definitive solution to a pluggy hairline, but simply that it can have the effect of softening a very pluggy hairline.