How to plan future hair restoration when you can't take meds(finasteride)?

[RandomGuy]

Hi everyone, this is my first post in the forum. I'm 24 and first noticed some hairloss last year. I've been lurking on various forums related to hairloss(including this one) and had a few questions regarding hair restoration which I wanted to ask. I'll first be giving some details about my case and my experience with meds.

Status of my hair and family history-

I currently notice some recession and thinning of my temples, with my right temple being more receded than my left. My father is a NW6 and started losing his hair pretty early on(he says earlier than me). But it kind of progressed slowly and he only reached NW6 by age 36. He is the only male from his side who has a NW6 pattern though. My grandfather is a diffused NW3 at the age of 79 and my uncles are probably NW3 at the age of 40(approx). From my mom's side, my grandfather is 80 years old and a clear NW4.

My history with finasteride and side effects-

So the moment I noticed the thinning last year, I immediately got on finasteride. I took it for around 2 months at the dosage of 1 mg/day. Tbh, I would have been ok with the mild sexual side effects, but I started getting this horrible foggy feeling in my head after I took the drug which then started effecting my performance at work. I also got some sensitivity in my chest. I tried powering through the side effects thinking it would resolve(reason I took it for 2 months), but then it got too much for me to handle and I stopped it. Then after doing some research online, I decided to start it at a lower dose- 0.5mg on alternate days. I was fine for a while, but then I started getting the chest sensitivity and cognitive side effects again. I then stopped taking the drug completely. I guess I'm just too sensitive to the drug🙁 .

My questions-

1. I'd read online that you can kind of predict your final norwood pattern based on analyzing the miniaturization. Is this correct? And when is the minimum age when you can do this? I'd read that (ethical) surgeons don't generally operate on patients unless they're above the age of 25/26. So is this like the minimum cutoff age in general to analyze your miniaturization and final pattern?
2. If the final NW pattern can be analyzed and found out, is it also possible to get an analysis and estimate of your donor area and its characteristics for the future like the number of grafts you'll have, hair shaft thickness, number of multi hair grafts etc?
3. I see a lot of cases where people with just some temporal recession get a large number of grafts like 2000 grafts etc dense packed and just on the hairline. But why is this so? I also see higher NW patients get a similar number of grafts, but it's more spread out across the bald areas. And their results look pretty natural too. Isn't it dangerous/risky in the long run to use so many grafts just on the hairline? What would someone who got such a dense packing do if they lost more hair in the future?
4. Related to the question above. If a higher NW case can get a pretty amazing result with a similar number of grafts but spread out more across a larger balding region, then why is dense packing done/needed?
5. I'm a bit confused with the terminologies used to describe the regions of the scalp. Eg: frontal half, frontal third, midscalp etc. Is there some diagram or something which can help me understand this?
6. I understand that the crown should be left alone in higher norwood patients. So how many grafts on average for some someone with avg. hair characteristics would be needed for covering the other regions(assuming the patient is NW5/6)?
7. How would you go about planning future hair transplants if you were in my state and knew that you would probably reach a high norwood state of hairloss at some point? Wait till you reach your final norwood and then do a transplant? Or keep doing hair transplants as you keep balding? What type of surgeries would you get? FUT then FUE?

Sorry for the long post and asking so many questions. But I'm new to this and want to plan for the future and not just jump into getting a transplant too early and regret it later.

[Future Hair Doc]

First, welcome to the forum. It's a great community we have here. Have you tried a topical solution of finasteride/minoxidil? I'll get to your other questions in a moment, but wanted to ask that beforehand. 

[RandomGuy]

1 hour ago, Dr. Suhail Khokhar said:

Have you tried a topical solution of finasteride/minoxidil?

Thanks for your reply!

No, I haven't tried minoxidil since it isn't effective in the long run. My dad had used it when he was losing hair. He said that it was effective for a while but then he started losing hair again. He then stopped using it after which he had even more hairloss(which I guess will happen if you stop any hairloss medication).

Regarding topical finasteride, I did consider it, but couldn't find any product here in India which didn't have minoxidil. I also had a concern with its effectiveness and if it truly doesn't go systemic. I guess I was also fed up with finasteride at that point and didn't want to take any more chances with the drug.

Also had a question about topicals- they're only effective in the area you apply it on right? So if you're balding in a large area(diffuse thinning) and have to apply it all over, doesn't that increase the chances of it getting into your system(since you'll be forced to use a larger amount)?

Edited April 10, 2021 by RandomGuy

[RandomGuy]

Hi @qui bono, thanks for the detailed reply!

I guess I'll get a consult with a surgeon when I turn 25 to evaluate my pattern and donor then.

1 hour ago, qui bono said:

Depends entirely on the patient and their goals/expectations. If you think it would be a benefit now then thats your choice. If it improves your quality of life then it doesnt make much sense to wait 10+ years until you fully bald. 

I think what I'm worried about is that I don't want to just get a transplant to fix my hairline and then later struggle to fix it if I lose more hair(which would be likely if I don't use meds). So what I mean is that I'd rather prefer a long term improvement in my quality of life rather than just a short term one. I think that@Melvin-Moderator had mentioned something similar in one of his videos- that if he had gotten his hair transplant when he was younger, then he would have gotten a hairline that was too low. But waiting for his hairloss to progress proved better for him in the long run.

So something like say if there's no hair left in the frontal region (NW4?), then it's the right time to get a hair transplant and then easier to play catch up rather than if you're NW3/2 and get a hair transplant to rebuild your hairline and play catch up if you lose more hair.

Edited April 10, 2021 by RandomGuy

[Richie888]

I think there is a brand of topical fin/min which is purchasable in India, I think it's Morr F?? I think Dr Suhail can vouch for its efficiency. I would definitely consider this route before you write off using all meds.

 

To answer your origional question, a HT is achievable without meds but I would not commit to it until you are past 30. Whilst that is still a risky age, it gets you past you initial spike of hormones in your late teens and early 20s and should give you a rough indication of where you're heading. 

[RandomGuy]

Hi @Richie888, thanks for your reply. I know that there are a couple of Minoxidil+Finasteride topicals like Morr F sold in India. Wasn't too keen on trying it out because it has minoxidil, it seemed a bit shady(don't understand how a topical version of finasteride is allowed to be sold without a prescription when finasteride tablets need one), and was concerned whether it truly doesn't go systemic. Are there any options for topical finasteride without minoxidil which you're aware about?

29 minutes ago, Richie888 said:

 

To answer your origional question, a HT is achievable without meds but I would not commit to it until you are past 30. Whilst that is still a risky age, it gets you past you initial spike of hormones in your late teens and early 20s and should give you a rough indication of where you're heading. 

Thanks for the advice! What norwood level were you when you got your surgery?

[Rolandas]

Hey man,

First of all let me tell you this: I admire your willingness to research more and approach future hair restoration with caution. Remind me of myself when I started doing the research. I'm sure you're setting yourself for a success (if you keep being curious).

I think @qui bono replied very well to all your questions.

I will add few things:

3. Low Norwood levels tend to dense pack hairline quite a lot, so it visually matches native density (as an example forelock being strong and need of rebuilding temples, which will require quite high amount of grafts). On another hand if someone has lost most of his hairline, then overall lower density will still achieve great coverage as there's nothing to directly compare to. Hope this makes sense
Also worth mentioning that hair thickness in my opinion plays key role how dense your final result will look like. You can transplant 3000 hairs with hair thickness of 45 microns and it will look much worse worse than 3000 hairs with 80 microns. Illusion of density could be almost double.

If I were you I would try following:
- Topical Finasteride
or
- Topical Dutasteride
or
- Dutasteride Mesotherapy

I won't go into detail about Dutasteride, but recent studies and mostly anecdotal evidence shows it doesn't penetrate deep enough to go systemic (as it's molecular structure is denser than the one required to penetrate the skin properly) while reaching "just enough" depth to be effective.

And of course I suggest to go and see a really good surgeon who could check your whole scalp and estimate your final pattern (keeping in mind future loss). Of course this won't be 100% correct, but could give you an idea if you're heading towards NW6. If that's the case, then I'd strongly suggest to look into FUT rather FUE. 


Best of luck!