Donor Dominance Theory Revisited

[asterix0]

Hi all,

I was hoping there could be a calm and rational discussion on this topic, as I think it is valuable for prospective patients. Certainly, undergoing a hair transplant is an expensive and emotionally taxing procedure, with many ups and downs. 

Due to certain posters here, and other places online, claiming that their transplanted hairs were falling out after a certain period of time, I wanted to see if there was evidence to be found either for, or against, the donor dominance theory of hair transplanted. 

Namely, does the donor hair take on characteristics of the recipient hair after a certain period of time after being placed in the recipient area.

And in addition, can the usage of finasteride/dutasteride, minoxidil, and other drugs prevent this effect?

So, I have found one recent study published just a month ago showing some skepticism:

https://www.jcasonline.com/article.asp?issn=0974-2077;year=2020;volume=13;issue=4;spage=292;epage=297;aulast=Kumaresan

Abstract

Background: The longevity of the grafted hair follicles is still debated and there are limited literature available on this topic. Aim: To assess the longevity of transplanted hairs after follicular unit transfer (FUT). Materials and Methods: A total of 112 patients who had undergone FUT were included in the study and their results at the end of 4 years were compared with the 1 year post surgery results by standardized images. The reduction in the density of the grafted hair follicles was graded by a blinded observer in a grading scale. Results: Among 112 subjects 50.89% had grade 4, 46.42% had grade 5, 2.67% had grade 6 alopecia respectfully. The 4 year follow up grading of hair loss showed moderate reduction in transplanted hair density in 55.35%, slightly reduced density in 27.67% greatly reduced in 8.03% and no change in the density in 8.92% subjects. Conclusion: The hair grafts transplanted may not last permanently for all the subjects. Recipient site influence might affect the growth and long-term survival of the transplanted hairs.

 

Here are some more examples:

https://pubmed.ncbi.nlm.nih.gov/16931898/

Abstract

Pathogenetic mechanisms in androgenetic alopecia are not yet fully understood; however, it is commonly accepted that androgens like testosterone (T) and 5alpha-dihydrotestosterone (5alpha-DHT) inhibit hair follicle activity with early induction of the catagen. Thus, we investigated the influence of T and 5alpha-DHT on proliferation, cell death and bcl-2/bax expression in cultured dermal papilla cells (DPC) from nonbalding scalp regions of healthy volunteers. T and 5alpha-DHT induced apoptosis in DPC in a dose-dependent and time-related manner; in addition a necrotic effect due to T at 10(-5) M was found. Interestingly, bcl-2 protein expression was decreased in T- and 5alpha-DHT-treated cells, leading to an increase in the bax/bcl-2 ratio. In addition, T and 5alpha-DHT induced proteolytic cleavage of caspase 8 and inhibited proliferation of DPC at 10(-5) M. High concentrations of T and 5alpha-DHT were needed to induce apoptotic effects in DPC. These data suggest that DPC from nonbalding scalp regions do have the capacity to undergo apoptosis, but need a high androgen stimulus. The present study provides an interesting new pathogenetic approach in androgenetic alopecia.

Even Dr. Bernstein, a respected surgeon, raises suspicions about it with evidence:

https://www.bernsteinmedical.com/research/donor-dominance-revisited/

My hope is that this thread can be an open and fair discussion about this topic, as certainly the last thing anyone would want is to be blindsided by loss of transplanted hair after investing so much time and money into a procedure.

[TrialAcc]

This study findings are through a person observing? How does the observer know that a NW4 didn't just progress in the 5 years while the slight reduction people are just the NW6s who were mostly stabilized? I understand they would be looking at the visual appearance of the transplanted area but surely the rest of the head would factor into it even at a subconscious level.. This study seems pretty useless without actual measurments of graphs per sq.cm over the entire period. 

I have been asking this question myself though, because I do not see many images posted of people 10+ years removed from their work being done. I'm okay with the look of well done HTs, but if the work were destined to be gone in 10-15 years anyways but you also have scaring, it's something I'd rather avoid all together. Tough to know because the improvements in techniques have come so far in even the last decade that it's hard to compare.What you could be describing here could easily be work done by poor doctors who's damage to the FU's caused early cellular death. 

I also see that you have experienced severe thinning in your transplanted areas in as little as 3 years, which is 100% not the norm. I think you could be approaching this from a place of bias. 

 

Edited December 26, 2020 by TrialAcc

[asterix0]

37 minutes ago, TrialAcc said:

This study findings are through a person observing? How does the observer know that a NW4 didn't just progress in the 5 years while the slight reduction people are just the NW6s who were mostly stabilized? I understand they would be looking at the visual appearance of the transplanted area but surely the rest of the head would factor into it even at a subconscious level.. This study seems pretty useless without actual measurments of graphs per sq.cm over the entire period. 

I have been asking this question myself though, because I do not see many images posted of people 10+ years removed from their work being done. I'm okay with the look of well done HTs, but if the work were destined to be gone in 10-15 years anyways but you also have scaring, it's something I'd rather avoid all together. Tough to know because the improvements in techniques have come so far in even the last decade that it's hard to compare.What you could be describing here could easily be work done by poor doctors who's damage to the FU's caused early cellular death. 

I also see that you have experienced severe thinning in your transplanted areas in as little as 3 years, which is 100% not the norm. I think you could be approaching this from a place of bias. 

 

What are you talking about? I haven't even had a transplant yet.

If the work was poor, wouldn't the yield be poor right off the bat? Do you have some evidence to show that poor work can show early graft death years down the road?

[asterix0]

Further, the pictures, while not the best, clearly show a slick bald temporal area originally where the transplanted hair was placed, followed by fullness post transplant.

The 4 year pictures show deterioration in that same spot that was slick bald, so it could not have been native hair.

I welcome any and all open discussion, I do not claim that these data points are complete by any measure. They are simply "some" data points for evidence for one claim.

Contrary evidence is necessary and encouraged, that is the whole point of the discussion.

[Ron5566]

I posted a thread here about a month ago:

I spoke with multiple patients in other forums and also here who lost their transplanted hair.

It has nothing to do with donor miniaturizion in those cases, Norwood 2/3 and even 4 won't even donor miniaturizion when he is 35-40 years old and even if he does, it won't get his transplanted hair destiny lower by 30-70% within 2-8 years.i

It's really upsetting that this topic is not being raised often, people are speaking what's better FUE vs FUT or other bs questions but ignore the most important thing, Does HT is permanent?

 

It does for any people that's for sure, however for the major people I think unfortunately it's temporary. I wish rep docs could actually aim in and let us know their opinion regarding this, I have no doubt that ALL the doctors who preformed over 1k surgeries encountered at least 20% cases over the years that their patients lost their transplanted hairs.

 

If I know personally 2 people (Out of three that done HT) then they should know hundreds if not thousands.

 

Donor miniaturizion definitely impact, no doubt, but the latest posts I have seen here about people complaining have no donor miniaturizion and again, even if they had, they are not supposed to lose 50% of theirs Destiny in two years unless their donor looks like hell now.

[TrialAcc]

13 minutes ago, asterix0 said:

Further, the pictures, while not the best, clearly show a slick bald temporal area originally where the transplanted hair was placed, followed by fullness post transplant.

The 4 year pictures show deterioration in that same spot that was slick bald, so it could not have been native hair.

I welcome any and all open discussion, I do not claim that these data points are complete by any measure. They are simply "some" data points for evidence for one claim.

Contrary evidence is necessary and encouraged, that is the whole point of the discussion.

I just think that none of those look like particularly well done transplants from the get go, which would indicate that the extraction methods and surgeon skills are probably lacking as well. There is more to transplants then just "donor dominance", because most of the men in the photos have incredibly poor donor to begin with. When you couple this with more stress/damage to the FU during surgery then a quality surgeon would inflict you probably have some cell death rather then miniaturization. This is why the study is useless, because to disprove donor dominance you would need to prove that these hairs are actually miniaturizing due to DHT, not damage. 

[asterix0]

Just now, TrialAcc said:

I just think that none of those look like particularly well done transplants from the get go, which would indicate that the extraction methods and surgeon skills are probably lacking as well. There is more to transplants then just "donor dominance", because most of the men in the photos have incredibly poor donor to begin with. When you couple this with more stress/damage to the FU during surgery then a quality surgeon would inflict you probably have some cell death rather then miniaturization. This is why the study is useless, because to disprove donor dominance you would need to prove that these hairs are actually miniaturizing due to DHT, not damage. 

So I am not misrepresenting your point, do you mind if I rephrase it? Since I am confused.

Do you believe that the 12 to 18 month period of the finalization of the hair transplant result (this is the universally accepted time period that hair transplant surgeons use to assess one's result) is insufficient in determining the quality of the transplant result received?

 

[asterix0]

@Ron5566 In your communication with these patients, or just researching their cases, do you know what number of them were also on an anti-androgen, such as finasteride or dutasteride?

I am positing that for patients with particularly high androgen sensitivity, these medications are very important in preserving the transplanted hairs. Even if these hairs appeared healthy in the initial donor analysis when analyzed through microscopic means.

How do I know this? Well, I have yet to see donor miniaturization examples where a doctor carefully analyzed the grafts microscopically in the donor, to see their miniaturization stage and assess it properly, only to have the surrounding area where the graft was taken from also miniaturize and thus render the analysis void.

More simply stated, it is highly, highly unlikely that a patient's transplanted hair can be labeled as "failed due to selecting a miniaturizing donor graft" if the surrounding follicles around that graft appear healthy and robust post operation.

That would almost imply that the surgeon deliberately selected miniaturizing grafts versus healthy ones, which we know no surgeon would do.

 

 

[TrialAcc]

1 minute ago, asterix0 said:

So I am not misrepresenting your point, do you mind if I rephrase it? Since I am confused.

Do you believe that the 12 to 18 month period of the finalization of the hair transplant result (this is the universally accepted time period that hair transplant surgeons use to assess one's result) is insufficient in determining the quality of the transplant result received?

 

No I think the 12-18 month period is fine for determining your result, however I think there is more to it then this. Without world class technique, I have to imagine the FUs sustain some extent of damage in the transplant process. This is why some die off and don't take right away, but I think even the ones that grow yet were damaged could lose proper function over a period of time. 

What I am saying is that this study is useless in disproving donor dominance because there is 0 effort to determine that the donor hair is dying in the same fashion as hair susceptible to DHT. 

[Ron5566]

1 minute ago, asterix0 said:

@Ron5566 In your communication with these patients, or just researching their cases, do you know what number of them were also on an anti-androgen, such as finasteride or dutasteride?

I am positing that for patients with particularly high androgen sensitivity, these medications are very important in preserving the transplanted hairs. Even if these hairs appeared healthy in the initial donor analysis when analyzed through microscopic means.

How do I know this? Well, I have yet to see donor miniaturization examples where a doctor carefully analyzed the grafts microscopically in the donor, to see their miniaturization stage and assess it properly, only to have the surrounding area where the graft was taken from also miniaturize and thus render the analysis void.

More simply stated, it is highly, highly unlikely that a patient's transplanted hair can be labeled as "failed due to selecting a miniaturizing donor graft" if the surrounding follicles around that graft appear healthy and robust post operation.

That would almost imply that the surgeon deliberately selected miniaturizing grafts versus healthy ones, which we know no surgeon would do.

 

 

From what I remember non used any anti androgen medication.

However one of those who lost his transplanted hair started to take oral Minoxidil and it did grew a lot back (Transplanted hairs only).

It won't let me send a link to another forum so I assume this is against the rules.

 

I have no doubt hair transplant does works wonders for many but maybe this is truth and without Propecia it will eventually fall (Although I know and see people here who did HT 8 years plus ago without any medication and still kept their results).

[TrialAcc]

5 minutes ago, asterix0 said:

@Ron5566 In your communication with these patients, or just researching their cases, do you know what number of them were also on an anti-androgen, such as finasteride or dutasteride?

I am positing that for patients with particularly high androgen sensitivity, these medications are very important in preserving the transplanted hairs. Even if these hairs appeared healthy in the initial donor analysis when analyzed through microscopic means.

How do I know this? Well, I have yet to see donor miniaturization examples where a doctor carefully analyzed the grafts microscopically in the donor, to see their miniaturization stage and assess it properly, only to have the surrounding area where the graft was taken from also miniaturize and thus render the analysis void.

More simply stated, it is highly, highly unlikely that a patient's transplanted hair can be labeled as "failed due to selecting a miniaturizing donor graft" if the surrounding follicles around that graft appear healthy and robust post operation.

That would almost imply that the surgeon deliberately selected miniaturizing grafts versus healthy ones, which we know no surgeon would do.

 

 

For FUE, sure, no argument. But this study is FUT. There is absolutely no way these men had FUT hair taken from above the donor area when most are NW6/7 to begin with. 

[asterix0]

10 minutes ago, TrialAcc said:

No I think the 12-18 month period is fine for determining your result, however I think there is more to it then this. Without world class technique, I have to imagine the FUs sustain some extent of damage in the transplant process. This is why some die off and don't take right away, but I think even the ones that grow yet were damaged could lose proper function over a period of time. 

What I am saying is that this study is useless in disproving donor dominance because there is 0 effort to determine that the donor hair is dying in the same fashion as hair susceptible to DHT. 

Dense packing, where blood flow may be compromised, can certainly play a factor in grafts dying out over time. 

While the study is sub-optimal, I disagree that it is useless, as the evidence from the photographs is indisputable of hair (transplanted) that has deteriorated from the 1 year mark to the 4 year mark.

I just think it is highly unlikely that, if blood flow was compromised, this would not show itself after the 1 year mark. Many of the transplants shown in the pictures look very typical for 1 year results, I would not categorize them as poor. We do not have specific graft counts in the paper so it is incomplete of course. 

[asterix0]

Are they world-class, home run results? Well no, but that isn't the point. 

Suppose they extended the duration from 4 years to 8 years in the paper. Would you still attribute surgeon error as the primary cause for the deterioration of the transplant?

And disregarding that particular paper for a moment, how do you explain the aptosis observed in non-balding scalp regions with increased androgen exposure?

Edited December 26, 2020 by asterix0

[asterix0]

18 minutes ago, TrialAcc said:

For FUE, sure, no argument. But this study is FUT. There is absolutely no way these men had FUT hair taken from above the donor area when most are NW6/7 to begin with. 

That gives further credence to my initial suspicion. Because it is FUT, it is highly unlikely that these grafts were taken from a "non-safe" region, such as many FUE cases do.

Therefor, the idea that the grafts failed because they were initially miniaturizing is highly unlikely. So, another explanation is needed.

Surgeon error, I am positing, would reveal itself within the 1 year results. So, I believe that is unlikely as well.

[TrialAcc]

9 minutes ago, asterix0 said:

That gives further credence to my initial suspicion. Because it is FUT, it is highly unlikely that these grafts were taken from a "non-safe" region, such as many FUE cases do.

Therefor, the idea that the grafts failed because they were initially miniaturizing is highly unlikely. So, another explanation is needed.

Surgeon error, I am positing, would reveal itself within the 1 year results. So, I believe that is unlikely as well.

No, it would not. Much as organs can sustain damage on transplant, take immediately, and start to fail again in a few years, damage sustained to follicles and the surrounding tissue probably act in the same way. The cells are probably damaged and the lifespan is reduced. 

Edited December 26, 2020 by TrialAcc

[asterix0]

3 minutes ago, TrialAcc said:

No, it would not. Much as organs can sustain damage on transplant, take immediately, and start to fail again in a few years, damage sustained to follicles and the surrounding tissue probably act in the same way. The cells are probably damaged and the lifespan is reduced. 

I would like to believe this, but a single study or piece of evidence that surgeon error can be responsible for such prolonged damage would be appreciated. 

You are also claiming that surgeon error can be responsible for long term damage of the transplantation of other organs? Meaning, after the generally understood settling period, as in the case of hair transplantation of 12 to 18 months, but specific to that particular organ in question. I admittedly have not researched this, so any studies on that would be appreciated as well. 

[TrialAcc]

2 minutes ago, asterix0 said:

I would like to believe this, but a single study or piece of evidence that surgeon error can be responsible for such prolonged damage would be appreciated. 

You are also claiming that surgeon error can be responsible for long term damage of the transplantation of other organs? Meaning, after the generally understood settling period, as in the case of hair transplantation of 12 to 18 months, but specific to that particular organ in question. I admittedly have not researched this, so any studies on that would be appreciated as well. 

With all due respect, the study you presented is hardly any sort of evidence or scientific validity against donor dominance, a well established principle that was verified using much more comprehensive measures then some hairs being gone 5 years later on a few guys. It makes more sense to look at a broad variety of reasons for why these hairs are not permanent, especially when this study didn't actually examine the follicles to see if DHT initiated inflammation was present (which is the entire reason donor dominance was accepted, they actually examined the cellular structure for signs of damage). 

[asterix0]

Let's stick to hair transplants though as that is the point of this forum.

And let's assume for a moment what you are saying is true. 

Then, the following should also be true:

At best, they can only claim we have no way to give an accurate time period of when your "permanent" transplant will actually settle, because your result may change for the worse after 12 - 18 months.

They must also say we have no tools to use, either through scalp biopsies, microscopic analysis of donor, any tool you can think of, to ensure that the transplantation process after this 12 - 18 month period will be successfull.

If they did have these tools, they should have used them prior to performing the surgery, and informed the patients of the findings beforehand. 

 

[lovinitl9]

100% some grafts that have been transplanted will fall out

[asterix0]

3 minutes ago, TrialAcc said:

With all due respect, the study you presented is hardly any sort of evidence or scientific validity against donor dominance, a well established principle that was verified using much more comprehensive measures then some hairs being gone 5 years later on a few guys. It makes more sense to look at a broad variety of reasons for why these hairs are not permanent, especially when this study didn't actually examine the follicles to see if DHT initiated inflammation was present (which is the entire reason donor dominance was accepted, they actually examined the cellular structure for signs of damage). 

You keep on repeating proof of donor dominance? Where is it? Can you provide links?

This is just one paper. That other forum poster showed many other examples. I can give you anecdotal examples from this forum and others of this occurrence. 

The point is, I have provided evidence for one claim, and you keep on repeating your claim, but you have not provided any evidence. 

Remember what you are claiming though. 

You need to show evidence that donor dominance is proven. What I am claiming is that it is just a theory and has not been proven.

So, showing a transplant example of a patient with an enduring transplant of 10+ years, or however long, without finasteride, does not help your claim. 

How does one examine the donor follicles to see if DHT initiated inflammation was present? Isn't this just word scrabble for checking for signs of miniaturization?

Edited December 26, 2020 by asterix0

[lovinitl9]

there will always be some donor miniaturization that can contribute to this. also I believe if a surgeon traumatically made the holes for the grafts, I have seen many times the graft falling out in about a one year range

[caricatura]

1 hour ago, Ron5566 said:

I posted a thread here about a month ago:

I spoke with multiple patients in other forums and also here who lost their transplanted hair.

It has nothing to do with donor miniaturizion in those cases, Norwood 2/3 and even 4 won't even donor miniaturizion when he is 35-40 years old and even if he does, it won't get his transplanted hair destiny lower by 30-70% within 2-8 years.i

It's really upsetting that this topic is not being raised often, people are speaking what's better FUE vs FUT or other bs questions but ignore the most important thing, Does HT is permanent?

 

It does for any people that's for sure, however for the major people I think unfortunately it's temporary. I wish rep docs could actually aim in and let us know their opinion regarding this, I have no doubt that ALL the doctors who preformed over 1k surgeries encountered at least 20% cases over the years that their patients lost their transplanted hairs.

 

If I know personally 2 people (Out of three that done HT) then they should know hundreds if not thousands.

 

Donor miniaturizion definitely impact, no doubt, but the latest posts I have seen here about people complaining have no donor miniaturizion and again, even if they had, they are not supposed to lose 50% of theirs Destiny in two years unless their donor looks like hell now.

I agree that there should be more discussion and documentation of this. HT has become a massive industry and I wouldn't be surprised if $ has propelled (and preyed upon) a false optimism bordering on recklessness. There's little incentive for surgeons and industry leaders to discuss the potential long-term pitfalls of HTs and so everyone goes around saying it's permanent and to just get on Fin. for life "to protect the remaining native hairs," when in fact it may be the relocated donor hair that needs to be protected. Meanwhile, squabbles about FUE, FUT, surgeon choice, etc. can distract from the more important questions about the efficacy of the procedure itself.

Edited December 26, 2020 by caricatura

[asterix0]

To give an example for another topic.

If I claimed that gravity on earth was proven, and that it was always 9.8 m/s^2, only one example of an apple floating in the air would invalidate my claim. It is now only a theory that has flaws due to an exception.

 

[asterix0]

8 minutes ago, lovinitl9 said:

100% some grafts that have been transplanted will fall out

You are talking about yield. This is a separate topic, and it should be observable within the 12-18 month time period post surgery, which is the universally accepted time frame for the finalization of one's hair transplant results. 

Edited December 26, 2020 by asterix0

[lovinitl9]

no, I'm talking about hair that has grown