How do doctors predict future hair loss?

[notsosure]

Is there a specific way that they can predict how rapidly and where you'll likely lose your next hair? I'm almost 35 and am receding in the temples and starting to slightly in the very front. Considering a transplant for years, as you can see by when I registered on the forum, but have held off.

 

Thanks

[xtatic5]

Miniaturization pattern and family history. I was advised that I won't likely lose hair (even though it runs in the family) because I have no miniaturization at age 29. I am skeptical but two surgeons independently stated this.

[notsosure]

Can they predict the speed of hair loss and how far it will go?

[Jotronic]

The speed at which one loses hair is completely unpredictable. It can be slow at times then kick into overdrive and accelerate at a shocking pace and it can happen at any time. That is where family history comes into play as well as just eye-balling it from a birds eye view. Sometimes a seemingly full head of hair can actually show indications of future loss in very distinct patterns. I can't count the number of times someone came in for consultation seeking minor hair line work only to be shocked to learn they have a slight outline of a diffused NW5A developing.

[Wes310]

Consider yourself fortunate for holding off. You are soon approaching the age will you will know whether or not it is a good decision based on what native hair you have and can make a more age appropriate hairline.

 

Best way to predict is family history/genetics.

[Dr. Michael Beehner]

Your question is one that hair surgeons wrestle with constantly and are always trying to figure out in their daily practices. We have several things that help us an awful lot though.

Most important is the patient's age. If the patient is in his late teens, twenties, or even early thirties, then all bets are off and a surgeon could be very wrong in telling the patient he will never bald. And the absence of miniaturization in the younger ages, though a little reassuring, is no guarantee that they won't bald some day. I agree that the family history is helpful to know, but no guarantee either way. Exceptions are very common.

I agree with one of the notes above that looking over the various areas of the scalp with high magnification (30-60x power) for miniaturization is very valuable. I feel it gives me a peek at perhaps the next 15-20 years of the patient's life. So if I have a 45 or 50 year old man in front of me, I usually will tell him that it's highly unlikely that he will lose his hair on top if I see no miniaturization. If a hair surgeon sees more than 5% miniaturization in an area, then that usually means that eventually they will go on to thin in that area over the years, and, if they live long enough, reach shiny baldness in that area. One very helpful sign for me is whether or not, when I view the patient's scalp from above, if I see even the slightest hint of a U-shaped difference in density near the fringes, no matter how subtle, I almost always find miniaturization on magnified exam and feel very confident they will eventually probably end up a Norwood VI. The age at which that will happen can vary drastically from one man to another. And of course, if they take finasteride, their hair loss will often be stalled at least another ten years. To me, whether a man is a Norwood 3-v, IV, or a class V means very little to me in terms of what my plan will be; I treat them all as I would a Norwood VI patient (U-shaped baldness). The progression of a Norwood IV to an advanced Norwood VI can be easily seen by simply watching Seinfeld re-runs. In the early years of the show Jason Alexander was a Norwood IV. Halfway through he was a Norwood V, and near the end of the show's run he had reached a Norwood VI. So I can turn on the show and tell about what year it was just by looking at "George Costanza's" head.

I certainly would not tell the 29 y/o patient above that he probably will never bald, nor even a 35 year old. A now-retired doctor from out west used to include in his lectures photos of several famous Hollywood types who seemingly had full heads of hair up to the age of 40 and then went on to be nearly bald by the age of 60. Some of them, as best as I can recall, were Johnny Carson, Clint Eastwood, Don Ameche, Paul Newman and several others.

Ironically, even though it's nice to be on finasteride to preserve your hair longer, it does somewhat "mask" what is really going on when evaluating your heredity's affect on your hair-loss status. 35 is my cutoff age for starting to feel confident about where a man is heading the rest of his life. I'm sure I will make an occasional mistake, but I think 95%+ of the time, I will be pretty accurate. After 35 I usually will agree to do the temples, bring the recessions further forward and fill in the vertex - providing there is a generous cushion of donor supply present.

In summary, I think most patients in their late 20's and early 30's should be looking mainly for a framing of the face in front and not looking to have the crown/vertex in the back filled in.

 

Mike Beehner, M.D.

[xtatic5]

I appreciate your medical opinion, Dr. Beehner, and I hope my surgeons are correct.

 

I saw a graph somewhere on the Web which showed the statistical likelihood of starting hair loss in each decade of a man's life. The largest peaks were in the 20's and 50's, 30's was one of the lowest. Are you aware of this? I've also read that Africans are 75% less likely to bald than Caucasians. Has this been your observation?

[MAGNUMpi]

Your question is one that hair surgeons wrestle with constantly and are always trying to figure out in their daily practices. We have several things that help us an awful lot though.

Most important is the patient's age. If the patient is in his late teens, twenties, or even early thirties, then all bets are off and a surgeon could be very wrong in telling the patient he will never bald. And the absence of miniaturization in the younger ages, though a little reassuring, is no guarantee that they won't bald some day. I agree that the family history is helpful to know, but no guarantee either way. Exceptions are very common.

I agree with one of the notes above that looking over the various areas of the scalp with high magnification (30-60x power) for miniaturization is very valuable. I feel it gives me a peek at perhaps the next 15-20 years of the patient's life. So if I have a 45 or 50 year old man in front of me, I usually will tell him that it's highly unlikely that he will lose his hair on top if I see no miniaturization. If a hair surgeon sees more than 5% miniaturization in an area, then that usually means that eventually they will go on to thin in that area over the years, and, if they live long enough, reach shiny baldness in that area. One very helpful sign for me is whether or not, when I view the patient's scalp from above, if I see even the slightest hint of a U-shaped difference in density near the fringes, no matter how subtle, I almost always find miniaturization on magnified exam and feel very confident they will eventually probably end up a Norwood VI. The age at which that will happen can vary drastically from one man to another. And of course, if they take finasteride, their hair loss will often be stalled at least another ten years. To me, whether a man is a Norwood 3-v, IV, or a class V means very little to me in terms of what my plan will be; I treat them all as I would a Norwood VI patient (U-shaped baldness). The progression of a Norwood IV to an advanced Norwood VI can be easily seen by simply watching Seinfeld re-runs. In the early years of the show Jason Alexander was a Norwood IV. Halfway through he was a Norwood V, and near the end of the show's run he had reached a Norwood VI. So I can turn on the show and tell about what year it was just by looking at "George Costanza's" head.

I certainly would not tell the 29 y/o patient above that he probably will never bald, nor even a 35 year old. A now-retired doctor from out west used to include in his lectures photos of several famous Hollywood types who seemingly had full heads of hair up to the age of 40 and then went on to be nearly bald by the age of 60. Some of them, as best as I can recall, were Johnny Carson, Clint Eastwood, Don Ameche, Paul Newman and several others.

Ironically, even though it's nice to be on finasteride to preserve your hair longer, it does somewhat "mask" what is really going on when evaluating your heredity's affect on your hair-loss status. 35 is my cutoff age for starting to feel confident about where a man is heading the rest of his life. I'm sure I will make an occasional mistake, but I think 95%+ of the time, I will be pretty accurate. After 35 I usually will agree to do the temples, bring the recessions further forward and fill in the vertex - providing there is a generous cushion of donor supply present.

In summary, I think most patients in their late 20's and early 30's should be looking mainly for a framing of the face in front and not looking to have the crown/vertex in the back filled in.

.

Thank you for this very open and informative post Dr Beehner. I have been wondering about this. Your post is very helpful.

[lucldh]

Your question is one that hair surgeons wrestle with constantly and are always trying to figure out in their daily practices. We have several things that help us an awful lot though.

Most important is the patient's age. If the patient is in his late teens, twenties, or even early thirties, then all bets are off and a surgeon could be very wrong in telling the patient he will never bald. And the absence of miniaturization in the younger ages, though a little reassuring, is no guarantee that they won't bald some day. I agree that the family history is helpful to know, but no guarantee either way. Exceptions are very common.

I agree with one of the notes above that looking over the various areas of the scalp with high magnification (30-60x power) for miniaturization is very valuable. I feel it gives me a peek at perhaps the next 15-20 years of the patient's life. So if I have a 45 or 50 year old man in front of me, I usually will tell him that it's highly unlikely that he will lose his hair on top if I see no miniaturization. If a hair surgeon sees more than 5% miniaturization in an area, then that usually means that eventually they will go on to thin in that area over the years, and, if they live long enough, reach shiny baldness in that area. One very helpful sign for me is whether or not, when I view the patient's scalp from above, if I see even the slightest hint of a U-shaped difference in density near the fringes, no matter how subtle, I almost always find miniaturization on magnified exam and feel very confident they will eventually probably end up a Norwood VI. The age at which that will happen can vary drastically from one man to another. And of course, if they take finasteride, their hair loss will often be stalled at least another ten years. To me, whether a man is a Norwood 3-v, IV, or a class V means very little to me in terms of what my plan will be; I treat them all as I would a Norwood VI patient (U-shaped baldness). The progression of a Norwood IV to an advanced Norwood VI can be easily seen by simply watching Seinfeld re-runs. In the early years of the show Jason Alexander was a Norwood IV. Halfway through he was a Norwood V, and near the end of the show's run he had reached a Norwood VI. So I can turn on the show and tell about what year it was just by looking at "George Costanza's" head.

I certainly would not tell the 29 y/o patient above that he probably will never bald, nor even a 35 year old. A now-retired doctor from out west used to include in his lectures photos of several famous Hollywood types who seemingly had full heads of hair up to the age of 40 and then went on to be nearly bald by the age of 60. Some of them, as best as I can recall, were Johnny Carson, Clint Eastwood, Don Ameche, Paul Newman and several others.

Ironically, even though it's nice to be on finasteride to preserve your hair longer, it does somewhat "mask" what is really going on when evaluating your heredity's affect on your hair-loss status. 35 is my cutoff age for starting to feel confident about where a man is heading the rest of his life. I'm sure I will make an occasional mistake, but I think 95%+ of the time, I will be pretty accurate. After 35 I usually will agree to do the temples, bring the recessions further forward and fill in the vertex - providing there is a generous cushion of donor supply present.

In summary, I think most patients in their late 20's and early 30's should be looking mainly for a framing of the face in front and not looking to have the crown/vertex in the back filled in.

 

Mike Beehner, M.D.

 

 

Nice detailing. Much appreciated Dr. Mike Beehner.

[MAGNUMpi]

The age at which that will happen can vary drastically from one man to another. And of course, if they take finasteride, their hair loss will often be stalled at least another ten years.

 

Ironically, even though it's nice to be on finasteride to preserve your hair longer, it does somewhat "mask" what is really going on when evaluating your heredity's affect on your hair-loss status.

 

A quick question Dr. Beehner. Are you suggesting here that finasteride has a finite amount of years that it will potentially work? Does it sometimes lose it's effectiveness over the years in your experience? or could a person take it for the rest of their life and never make it to a NW5 even if they would have without it?

[gillenator]

Can they predict the speed of hair loss and how far it will go?

 

No one can accurately predict how fast the progression of MPB will be for the individual however considering family history of MPB on both sides of family history is the best barometer of assessing how extensive one's hair loss might be in the future.

 

The progression of hair loss can occur at varying degrees of progression over time and this is why so many HT doctors advise the use of effective hair loss meds. The meds never completely halt MPB nor do they cure it, but the meds can in fact buy us time over the long haul.

 

The doctor can potentially use high powered instruments to examine the entire scalp for signs of miniaturization to see where DHT is impeding. Many times this cannot be seen by the naked eye especially to the areas just beginning to be affected by DHT.

[gillenator]

Magnum,

 

I have been taking low dose finasteride since 1996 and it is still working for me, especially my crown.

[BensonTT]

Miniaturization pattern and family history. I was advised that I won't likely lose hair (even though it runs in the family) because I have no miniaturization at age 29. I am skeptical but two surgeons independently stated this.

 

Why are you on a hair loss forum then? lol

[Dr. Michael Beehner]

In reply to Magnum's question about whether or not finasteride gives lasting insurance against hair loss, I can definitely assert that it does not halt the balding process. One lecture I heard a few years ago by an expert in this area stated that a majority of men taking the drug have an increase in "hair mass" for 4 1/2- 5 years, and then thereafter there is a gradual diminishment in hair mass. Hair mass is determined by a combination of both hair diameter and hair length. Obviously, if one's barber cuts it short, then increased diameter is the only way hair mass will increase. A man is still ahead of the game by staying on the medication, even after 5 years, because the rate of hair loss is still less than if one went off the drug.

Mike Beehner, M.D.

[MAGNUMpi]

In reply to Magnum's question about whether or not finasteride gives lasting insurance against hair loss, I can definitely assert that it does not halt the balding process. One lecture I heard a few years ago by an expert in this area stated that a majority of men taking the drug have an increase in "hair mass" for 4 1/2- 5 years, and then thereafter there is a gradual diminishment in hair mass. Hair mass is determined by a combination of both hair diameter and hair length. Obviously, if one's barber cuts it short, then increased diameter is the only way hair mass will increase. A man is still ahead of the game by staying on the medication, even after 5 years, because the rate of hair loss is still less than if one went off the drug.

Mike Beehner, M.D.

Very interesting Dr. Beehner. Thank you.

 

I have been taking low dose finasteride since 1996 and it is still working for me, especially my crown.

Thanks Gillenator, I hope I remain lucky with the Fin for a while too. What dose do you take? Edited November 5, 2013 by MAGNUMpi

[Dr. William Lindsey]

Good comments above. Here are my 2 cents.

 

For me, future hair loss is all genetics and luck, which is actually just some as yet undetermined genetic issue that accounts for hair loss patterns not explained by family associations.

 

If a person is young and has good hair but everyone else is bald....I tell them to proceed with surgery only after long and careful contemplation. Meaning if they have a little frontal triangle loss and everyone else is a class 7...they probably ought to wait and rebuild an acceptable framing of the face when they have significant hair loss. OR if they decide to proceed, I suggest that a very conservative hairline be designed and that they really need to plan for future surgeries when and if there is more loss. I saw a 24 year old submariner yesterday and we had exactly this discussion.

 

If someone is 50ish and has a little loss and nobody loses much hair in the family, I think they can likely spend their donor hair without any reservation...fix that crown, or that frontal thinning as they'll likely never run out of hair.

 

For everyone else its an educated guess at best. We discuss other men and women in the family, what happened to them, what ages they lost hair, and what the patient's specific goals are...and do they have enough hair in case their "luck" is worse than they expect...for future work so they don't wind up a hair "criple".... Even with all of this discussion and planning nobody can predict the future. Just look at the weather channel on any given afternoon and you'll see that despite satellites, hurricane hunters, and powerful computers, forecasts still remain an educated guess.

 

That being said, if a reasonably conservative plan is made, and the patient and doctor allow for the chance of future loss and the need for future surgeries...HT can offer even younger guys a nice option for dealing with this cosmetic problem. And as I've posted numerous times...I personally believe that sleeping on a big decision, not jumping at an impulse buy, is the best way to proceed. Finally I encourage younger guys to bring their parents with them to the consultation. While parents and kids may not always agree, often times a mom or dad can give a little different perspective than a prospective patient's buddies or girlfriend can.

 

Bottom line, doctors can make reasonable educated guesses...but they remain educated guesses for the time being. Plan conservatively and spend your donor hair frugally.

 

Dr. Lindsey McLean VA

[Spanker]

Here is my 2 cents, most good doctors are always going to play it safe, for the patient and themselves. No doctor wants to be the guy on the forum that has a "repair" patient that is a NW5 with a NW1 hairline. However, most people "know" a LOT of people. I shaved my head when I was 32 to check for miniaturization and did not have any high NW pattern. Does that mean I am totally safe? No. But, how many people do you know that had a pretty good head of hair at 30 that were bald as a goose at 40? Very very few. It just isn't common. If you carry decent hair into your 30's, that doesn't mean you won't lose hair, it just really increases your chances of not being an aggressive and early balder. Dr. Beehner is basically reiterating the studies that show that after 5 years on fin (I am at 3 right now), your hair loss starts to catch up with you, but you will pretty much always be ahead of the game and lose at a slower pace then if you were not on fin. You hair count increases on fin but so does your mass, allowing an increase in length and diameter, which really makes a big cosmetic difference (pi*r2). For the majority of people that live long enough, it isn't IF you are going to lose hair, it is how much are you going to lose and how fast? 50% of men in their 50's, 60% in their 60's and so on have visual hair loss. This means less than 3 in 10 men will make it out of this world without noticeable hair loss. My personal goals is to always look good for my age when it comes to hair and always look natural. I think my small procedure will give me many years of feeling more confident, and by slowing my progressive hair loss down with fin (everybody's is progressive, only the rate is in question), hopefully I can stay ahead of the game.

 

My only caveat to this is that I am a major worry wart and I do sometimes wish that I would have planted the very front of my hairline a little higher and I encourage people to err on the side of conservative, because you can always drop it in the future. I would have been perfectly happy in having my hairline a cm higher, but didn't know it until it had grown out. To me, the grown out hairline felt like it moved a cm forward from when it as initially planted. Or my face is starting to sag

[MAGNUMpi]

If the effectiveness of finasteride decreases over time, in 10+ years a person could end up not really being able to halt his MPB and would absolutely need lots of healthy donor hair. I suppose the only answer then is being super conservative and knowing how much donor hair you have in the bank. Also have a very natural placement that takes into account the idea that eventually there may not be any supporting natural hair around the transplanted hairs to help out (even if you stick to finasteride use).

Seems its all about the quality/quantity of donor in the end.

I must admit I am a little saddened to learn that finasteride isn't going to work forever. This kind of changes the game.

[lucldh]

If the effectiveness of finasteride decreases over time, in 10+ years a person could end up not really being able to halt his MPB and would absolutely need lots of healthy donor hair. I suppose the only answer then is being super conservative and knowing how much donor hair you have in the bank. Also have a very natural placement that takes into account the idea that eventually there may not be any supporting natural hair around the transplanted hairs to help out (even if you stick to finasteride use).

Seems its all about the quality/quantity of donor in the end.

I must admit I am a little saddened to learn that finasteride isn't going to work forever. This kind of changes the game.

 

Since the time this universe is formed, mankind has tried to find answers in binary: 0 or 1; however, the answers always lied between 0 and 1. If finasteride suits you and you do not have any side effect, the good part is that you will have an edge in wake of future treatments such as Histogen's HSC that may do better in rescuing dying follicles than died follicles. And yes, you can be conservative about your donor supply when you consider HT such as by not lowering hairline way too much.

[MAGNUMpi]

Since the time this universe is formed, mankind has tried to find answers in binary: 0 or 1; however, the answers always lied between 0 and 1. If finasteride suits you and you do not have any side effect, the good part is that you will have an edge in wake of future treatments such as Histogen's HSC that may do better in rescuing dying follicles than died follicles. And yes, you can be conservative about your donor supply when you consider HT such as by not lowering hairline way too much.

Yes finasteride has been working for me for 7 years now. Maybe it'll just keep on going. Fingers crossed.