32y/o - crown-mid scalp balding - hairline is pretty good. What to do?

[blufforfold]

Hey all looking for some guidance,

I am 32 y/o and mostly balding in the crown and some mid scalp. I had no idea what so ever I was balding until I had some friends show me a pic from the rear and was like woah wtf is that! Nobody ever said anything to me. It was pretty mild back then. just a small spot on either side of the center of my crown. Since then basically nobody has seen my bald spots and nobody even knows im balding since my front hair line is pretty strong and they thought I just "handled it" so to speak. Nobody has mentioned it to me other than a handful asking what supplements i took to help my hair.

This was at around 27-28 but dont think I have great photos of it back then but its been a solid 5+ years or so and now im at where im at. I started oral fin reluctantly about 8 months ago. Part of me feels like the sides of my hair are thinner than they were prior to getting on Fin. My balding areas are probably about the same as 8 months ago. But my hair loss was fairly slow so im not sure if its actually helping or not. I just started HappyHead which is topical fin + minox 8% and retinol acid. Tbh I think im gonna stop & go back to oral fin because I dont think im going to be willing to take meds for life and I have a small fear that meds and then stopping has a chance to accelerate my hair loss (i made a thread about this with only a handful of replies), I plan to ask the physicians this during consults.

I know some of you will say, youre 32 and your youve still got a lot of hair especially in the front so relax and just use some minox and microneedle etc and youll be fine and reacess a HT later, dont waste your grafts on the crown at only 32. The truth is I like to do a lot of sports, hiking, beach etc and its just not realistic to keep going covering it up for that much longer. Id say I have like 2 years max where its going to be pretty hard to cover up from those type of actives which sweat and water will naturally take away fibers + dermatch and as of right now basically nobody I know knows that I am losing hair and none of the women I meet know I am losing my hair.

I had a few consults in December of 2020 mostly online but I really knew nothing. Now I realize how many questions I didnt ask but I spoke to only members of IHRAS so I assume most here will think they are at least pretty ethical and everyone I spoke to was willing to work on me but most people just said my hair looked good so why get a HT and nobody cares about the crown haha.

Since then I have learned about the more complexities about crown restorations and how I need to also think about the future HTs and "island" of hair in crown. My initial gameplan was to just get around 2-2.5k total grafts mostly to the crown and then maybe 250-350 in the mid scalp. I wanted FUE because I didnt want the scar and that was more important to me than the cost. Now I am learning about how if you want to maximize grafts going FUT into FUE is ideal? I dont know what level I will bald to and hoping for some analysis on that. My dad is hard to tell he shaves his head and had a HT like 20-30 years ago and he doesnt even remember specifics of it. If I had to guess hes around a Norwood 5. My brother is 36 and around a Norwood 3.5 he was also much further along than I was at 32 and always had hairline and temple recession and I really dont have a lot (IMO). One doctor looked at my hairline in a microscope which was Dr. Benham in Santamonica, CA. He didnt seem to be too concerned about my front hairline miniaturization that he was seeing at the current time (this was pre-meds). He said I probably have 7000+ grafts lifetime and Dr. Yazdan in Newport Beach, CA told me I have a fairly strong donor (his microscope was broken however that day) and that I have 7000 or maybe 8000 in his opinion eyeballing it.

Im trying to give as much info about me, my goals and my priorities so those who want to help are able

1) I am not naturally someone who likes pharmaceutical drugs. Ive been into fitness and health for my whole life basically so even taking fin is pretty hard for me mentally. I have very low feeling I will be able to perm take Minox which is why im scared to keep going and have it backfire when I stop. Fin Im on for now but to be totally frank its not a guarantee I will be willing to do it for 10-15-20 years.

2) I am more concerned about my hair from today until my early 40s than I am having a thick head of hair at 45+. I am single still and I dont want my hair to be the reason my confidence goes down and my lack of getting some women to be my hair. This is one issue with me now realizing that all the best docs for crown are going to be 12 months out and then another 12-18 months for it to come in full. Huge bummer now that Im realizing all this. I shoulda done this back in Dec 2020 and kept going on my research id be getting my transplant right now.

3) Crown results - I think I have a higher expectation than reality is going to have for me. I would want to basically have nobody tell im thinning unless they really were looking for it. I know this makes me sound like a snob as HTs are not perfect science and im not trying to be but the main thing that really gets me is that when im seeing a woman and they have NO CLUE i am balding because I wear fibers or dermatch. I just wanna get beyond the point of wearing any concealers 

4) I am willing to travel anywhere I would say. That doesn't bother me have a lot of flexibility work-wise and can make just about any time and any place happen. Cost is going to be tough to swallow but depending on the advice I get, I willing to pay for "the best" if everything else checks out and is making sense.

 

So now some questions I have moving forward

1) How do we rate my donor area? How concerned should I be about harvesting too much donors for this current crown + mid scalp procedure

2) How do we rate my hair loss in general and how bald do we think I will go in our best guesses?

3) Who are the doctors I should be considering, for this I would love to get "the best" in your opinion and then maybe 1-2 options that you still highly recommend that will have lower than a 12 month wait time? As of right now this is my list I want to consult with but still open to adding and removing based on feedback here:
Dr Wong, Dr Konior, Dr Ahmad, Dr Bisanga, Dr Wesley, Dr Bloxham/Feller, Dr Sethi

4)  If I am concerned about longevity should I be going for FUT first or is FUE fine? 

5) Should I be concerned with shockloss, is the doctors skill level relevant here? I have a good amount of native hair in my recipient area, both crown and mid scalp

6) As I said, almost nobody in my life knows I am having significant hair loss. What would be my best way to try and conceal this transplant? I would love to keep as much hair as I can long and immediately go back to wearing fibers soon after to conceal. Will some Drs be better at this and more comfortable? Im okay with shaving my donor area, but its mostly from the bottom of my balding area up that I would want to shave as little or none as possible. Not sure if anybody offers this, seen a little about it.

Currently I am doing:
LLLT Every other day
Oral Fin 5x a week 1mg

Biotin

Let me know if I need l better pics, the last 2 crown photos one is on a cloudy day outside Dec 2020 and the other one is a few days ago with harsh noon sun beaming right on me, so the worst possibly lighting. Id say its pretty similar and hasnt moved much since Dec 2020? What is weird tho is it does feel like I need to use more fibers and more dermatch than I used to. Especially dermatch. The bathroom photos are all from tonight.

Edited April 21, 2022 by blufforfold

[hairman22]

I wore fibers dating. 

After 2 months i said i used fibers. No issue was made about it. 

She even helps me put in the fibers on my crown. 

Crown loss isnt going to be an issue for most woman.

[Gatsby]

If you can tolerate Finasteride then I would stick with this. It can take up to two years to see the benefits. Surgery is a last resort and you could face shock loss, etc. your frontal area is incredibly full. All the best. 

[1978matt]

Your hair qualities are really quite great (wavy).  Density is probably about average in the donor.

If you go to one of the goats of HTs (Konior, Shapiro, Wong etc) you could probably get away with 1500-2000 FUE.

 

[blufforfold]

31 minutes ago, Gatsby said:

If you can tolerate Finasteride then I would stick with this. It can take up to two years to see the benefits. Surgery is a last resort and you could face shock loss, etc. your frontal area is incredibly full. All the best. 

Thanks, this is what most people told me in my consults in Dec 2020. They felt my hair was good enough and a lot of balding men would be plenty happy with my current situation and they dont think I need a HT but were okay with operating on me if thats what I wanted.

I am tolerating Fin I believe, my mental has gone down since then but its also possible it is unrelated. Sex drive is still there.

Is shock loss risk at all relevant to skill of surgeon?

27 minutes ago, 1978matt said:

Your hair qualities are really quite great (wavy).  Density is probably about average in the donor.

If you go to one of the goats of HTs (Konior, Shapiro, Wong etc) you could probably get away with 1500-2000 FUE.

 

Genuinely asking, do you rate my donor as average mostly because of the side shots? I really feel my sides have thinned since starting Fin, it could be that I pushed out some weaker hairs, not sure, its been almost 9 months. I didnt pay attention to the sides that strongly but I never felt I thought they were even remotely thin but I do feel they like just a tad thin these days

I had online consults with a handful of people with photos and the lowest graft quote I got was 1500 from Dr Yazdan and the highest I got was 2500 from Dr Scott Alexander in AZ.

As I asked above, is there more risk associated with shock loss the less skilled the surgeon is and the equipment they use? Not much discussion took place with my previous consults about shock loss but its definitely something I will discuss in my newer consults.

EDIT:
one last question about FUE vs FUT total grafts available vs how many I will need down the road. Do we have any guesses as to my final advancement of hair loss with my age, my current hair loss, and my dad/brothers hair loss? They both had a lot of front hairline loss and I dont yet so IDK doesn't feel like I am following their pattern. I also had a huge trauma to the back of my head as a child, could have been the beginning of why my thinning at crown first. I had surgery and nearly broke my skull.

Edited April 21, 2022 by blufforfold

[1978matt]

7 minutes ago, blufforfold said:

Genuinely asking, do you rate my donor as average mostly because of the side shots? I really feel my sides have thinned since starting Fin, it could be that I pushed out some weaker hairs, not sure, its been almost 9 months. I didnt pay attention to the sides that strongly but I never felt I thought they were even remotely thin but I do feel they like just a tad thin these days

I had online consults with a handful of people with photos and the lowest graft quote I got was 1500 from Dr Yazdan and the highest I got was 2500 from Dr Scott Alexander in AZ.

As I asked above, is there more risk associated with shock loss the less skilled the surgeon is and the equipment they use? Not much discussion took place with my previous consults about shock loss but its definitely something I will discuss in my newer consults.

I was looking mostly at the back shots where you parted the hair.  Even though it may be average density, the natural hair wave more than compensates.

I would treat the thin areas as if there is no hair left to save.  I mean, the hair that is left does not produce a lot of coverage so it's probably little more than 10 hairs per sq cm.  With that in mind I would not worry too much about shockloss.  You are bound to look a bit worse after 3 months post surgery anyway, even if those remaining hairs survive and grow back. 

 

[Curious25]

It doesn’t really make sense for your sides to have thinned since starting finasteride - after 8 months, existing hair quality is usually thicker and healthier, and if it were to be from a shed of miniaturised hairs, that would suggest you to have had a considerable amount of donor miniaturisation, which going off your pics . . I don’t feel would be a very likely reality. Your donor looks good to me anyway - I think when Matt says it looks average, he probably mean average density wise (between 70-80 follicular units per cm2). 
 

Your hairline looks surprisingly strong, given the level of crown loss you present with, slightly further recessed on the right hand side, which is very common, but the frontal density still seems pretty strong. If you wished to restore this area in anyway, I would probably advise at looking to bring the right hand a little more level with the left, and lowering it in a widows peak style, as I’ll take a stab in the dark and predict you naturally had somewhat of a widows peak?

Your temples also look good, creating a narrow looking forehead, which is very advantageous in terms of facial framing, so all of this combined with your wavy hair characteristics, puts you in a pretty strong position, in terms of being a hair transplant candidate. 

Meds wise - try topical fin, if you feel uneasy with taking it orally - this can be microdosed via different concentrations and/or taking on a less frequent basis than daily. I wound recommend derma rolling - and I would also recommend oral minoxidil. However first of all, I would recommend speaking to multiple and relevant dr’s about these recommendations first of all - rather than just taking my, or anyone else’s word on here, with what to do with medicines 😉

Personally the only two doctors I’d feel comfortable with visiting for a crown restoration would be Dr Wong or Dr Konior, but that’s just from my observations over the years, I admittedly haven’t ever looked into crown restoration too deeply. 

[blufforfold]

39 minutes ago, Curious25 said:

It doesn’t really make sense for your sides to have thinned since starting finasteride - after 8 months, existing hair quality is usually thicker and healthier, and if it were to be from a shed of miniaturised hairs, that would suggest you to have had a considerable amount of donor miniaturisation, which going off your pics . . I don’t feel would be a very likely reality. Your donor looks good to me anyway - I think when Matt says it looks average, he probably mean average density wise (between 70-80 follicular units per cm2). 
 

Your hairline looks surprisingly strong, given the level of crown loss you present with, slightly further recessed on the right hand side, which is very common, but the frontal density still seems pretty strong. If you wished to restore this area in anyway, I would probably advise at looking to bring the right hand a little more level with the left, and lowering it in a widows peak style, as I’ll take a stab in the dark and predict you naturally had somewhat of a widows peak?

Your temples also look good, creating a narrow looking forehead, which is very advantageous in terms of facial framing, so all of this combined with your wavy hair characteristics, puts you in a pretty strong position, in terms of being a hair transplant candidate. 

Meds wise - try topical fin, if you feel uneasy with taking it orally - this can be microdosed via different concentrations and/or taking on a less frequent basis than daily. I wound recommend derma rolling - and I would also recommend oral minoxidil. However first of all, I would recommend speaking to multiple and relevant dr’s about these recommendations first of all - rather than just taking my, or anyone else’s word on here, with what to do with medicines 😉

Personally the only two doctors I’d feel comfortable with visiting for a crown restoration would be Dr Wong or Dr Konior, but that’s just from my observations over the years, I admittedly haven’t ever looked into crown restoration too deeply. 

Yeah I dont know its pretty weird, maybe its not the case. Im not saying definitively it has, I never had thin sides so didnt pay attention to them but these days they do randomly look thin?

Tbh IDK but I do suspect I had a natural slight widows peak. The left might be my natural and the right went up a little bit is my guess, but ive had this hairstyle for something like 10 years now and just never really looked as I had no signs of losing hair so never thought twice about it. I can try to find some old photos of me as a later teenager with long hair I tied back a lot and see how my temples look there.

Why do you say oral minox over topical? Id probably feel less comfortable taking oral. I definitely plan to talk to the Drs about the meds and also the risk of stopping them and acceleration occurring. Dont think theres literature on it but Drs may know.

Dr Wong is who I was originally looking at the 2nd research round when I was looking for crown results and then learned about Dr. Konior on here. Both are going to have incredibly long waits which is a big bummer and really expensive but Im starting to think that might be what I need if my goals are to be achieved, hopefully Ill get more feedback from people on other Physician options as well in my situation

Edited April 21, 2022 by blufforfold

[blufforfold]

Just editing a post I made about PRP that was way too long. I was seeing a sports pysician who advised me to get PRP on the scalp with him which IMO was a mistake and caused my hair to get worse about 3-3.5 years ago. We did like 8 injections in an 8 week period or so. Way too much and IMO he didnt know what he was doing cause you guessed it he was a sports physician. Im sure PRP done by a hair clinic wont make things worse but the pattern of my hair loss followed the exact pathing he used for his injections. I had no mid-scalp at all prior to the injections which were on my crown + mid scalp and my crown got worse too, certainly didnt decrease my hairloss thats for sure, at best it did nothing

Edited April 21, 2022 by blufforfold

[Mike10]

I would just stick to  the medication and maybe add the hair fibers. I tink that the way to go for you

[DrTBarghouthi]

Thank you very much for your detailed thread. It really helps us in understanding more about the case. It seems to me that the crown area is something that is really bothering you and that the use of concealers is something that you’d wish to move away from. Nonetheless, you realize that donor maximization is important. I agree that the crown ranks lower in terms of priority- in fact you didn’t even realize the loss there in the first place. It’s a good thing you are on meds for now, but the fact that you may consider stopping them in the future is not reassuring- especially if a good amount of grafts will be used in the crown- which i estimate to be of at least 3000 going into the mid scalp area too. 
You also raised an important point about the importance of having it covered in these couple of years. I totally understand that but It’s important to know that you would still care about having decent hair well into your 40s and beyond. We see that all the time. 
If you really want my genuine opinion, I strongly believe that a good hair system might tick most of your goals. You would have fast results, great coverage, save your donor and would guarantee coverage even if meds were to stop in the future. At least your donor (which is fairly good imo) will be utilized to any future loss in that case and should be enough to restore any future thinning in the hairline, frontal or mid sections. Some of these systems are so well made that they are technically undetectable. They are well fixed to allow for a very active lifestyle, and would only require a once a month quick maintenance. They are great for crown cases and for cases similar to you in terms of expectations.

I do apologize if this may be slightly different to what you’re looking for in terms of opinion, but I am honestly trying to guide you towards fulfilling your desired expectations yet addressing your concerns and fears about undergoing crown surgery at this stage- both of which are completely reasonable and justified. 

[blufforfold]

On 4/21/2022 at 4:23 PM, DrTBarghouthi said:

Thank you very much for your detailed thread. It really helps us in understanding more about the case. It seems to me that the crown area is something that is really bothering you and that the use of concealers is something that you’d wish to move away from. Nonetheless, you realize that donor maximization is important. I agree that the crown ranks lower in terms of priority- in fact you didn’t even realize the loss there in the first place. It’s a good thing you are on meds for now, but the fact that you may consider stopping them in the future is not reassuring- especially if a good amount of grafts will be used in the crown- which i estimate to be of at least 3000 going into the mid scalp area too. 
You also raised an important point about the importance of having it covered in these couple of years. I totally understand that but It’s important to know that you would still care about having decent hair well into your 40s and beyond. We see that all the time. 
If you really want my genuine opinion, I strongly believe that a good hair system might tick most of your goals. You would have fast results, great coverage, save your donor and would guarantee coverage even if meds were to stop in the future. At least your donor (which is fairly good imo) will be utilized to any future loss in that case and should be enough to restore any future thinning in the hairline, frontal or mid sections. Some of these systems are so well made that they are technically undetectable. They are well fixed to allow for a very active lifestyle, and would only require a once a month quick maintenance. They are great for crown cases and for cases similar to you in terms of expectations.

I do apologize if this may be slightly different to what you’re looking for in terms of opinion, but I am honestly trying to guide you towards fulfilling your desired expectations yet addressing your concerns and fears about undergoing crown surgery at this stage- both of which are completely reasonable and justified. 

Ty for the reply Dr, means a lot to have a physician reply. A few questions

1) A little surprised to hear you say 3000 as that is the most I have heard and I did about 4 online consults and 2 in person. You also said "at least" which sounds like 3000 is more towards your bottom number.
2) In your experience with my type of hair loss, what do you think my future hairloss will be like or do you find my hairloss pattern to be too strange to tell? Would love input from someone who sees as many patients as you have.

3) Im not sure you interpreted my point about maintaining my hair, what I meant to get across is I care a lot more about my hair from now at 32 until my low 40s than I do about my hair after that. I would hope that I have found my woman in the next 10-ish years and after that I am not as concerned. Not because all there is in life is finding and getting women but more so that once you start to have a family etc naturally your priorities shift and how you look to friends and colleagues matters less and at that age it also simply is more common and acceptable.

4) In your experience do you have patients who have started meds and then their hair accelerated upon stopping those meds?

5) Can you point me into a few hair piece companies? I didnt even look at that route. I still find this similar to concealers but I will not say I am 100% opposed to it. 

Edited April 25, 2022 by blufforfold

[DrTBarghouthi]

8 hours ago, blufforfold said:

Ty for the reply Dr, means a lot to have a physician reply. A few questions

1) A little surprised to hear you say 3000 as that is the most I have heard and I did about 4 online consults and 2 in person. You also said "at least" which sounds like 3000 is more towards your bottom number.
2) In your experience with my type of hair loss, what do you think my future hairloss will be like or do you find my hairloss pattern to be too strange to tell? Would love input from someone who sees as many patients as you have.

3) Im not sure you interpreted my point about maintaining my hair, what I meant to get across is I care a lot more about my hair from now at 32 until my low 40s than I do about my hair after that. I would hope that I have found my woman in the next 10-ish years and after that I am not as concerned. Not because all there is in life is finding and getting women but more so that once you start to have a family etc naturally your priorities shift and how you look to friends and colleagues matters less and at that age it also simply is more common and acceptable.

4) In your experience do you have patients who have started meds and then their hair accelerated upon stopping those meds?

5) Can you point me into a few hair piece companies? I didnt even look at that route. I still find this similar to concealers but I will not say I am 100% opposed to it. One thing I really do not like however is I think a lack of sun on our hair is definitely increasing hair loss in general in men & women. We are all vitamin D def and not seeing enough sunlight, a hair piece would make the area receive literally 0 sun which I think might accelerate the hairloss under the hair piece. Not really a point to discuss it but it is one of my considerations. 

Thank you for your reply. I do prefer to over estimate what is needed in the crown. The reason being is that it usually takes more to fill than other areas due to the continuous change of direction that needs to be done when transplanting it. I also saw that there is some extension into the midscalp anteriorly and hence do not want to underestimate what might need to be done. It does seem that you might have some extension into the Midscalp resulting in a NW 5 pattern at some point. This ofcourse is only an educated guess. 

The reason i suggested a hair system is that I did sense that you wanted the coverage sooner than later. I totally understand that need. I also feel it helps you achieve this good dense look so that if you decide in your 40 s to go for a more conservative crown coverage, you will have the donor area for it and you might not look for a full density by then as you highlighted. Nonetheless, from experience, I know that even with a family and all, you would still care a lot about your hair. This is why donor preservation is important. If your crown is covered with a system and you develop MS thinning or frontal thinning in your 40s, you can simply do a very good coverage at that point. Always a good option to have. 

Yes some men tend to accelerate their loss once meds stop. I find that mostly with minoxidil more so than finasteride. Mainly due to the mechanism of actions of both. 

I can send you a name of some hair system companies. I am not sure I am allowed to disclose names publicly or only through DM. Maybe @Melvin- Moderatorcan let me know if allowed and I am happy to do so. 

[blufforfold]

On 4/23/2022 at 1:12 AM, DrTBarghouthi said:

Thank you for your reply. I do prefer to over estimate what is needed in the crown. The reason being is that it usually takes more to fill than other areas due to the continuous change of direction that needs to be done when transplanting it. I also saw that there is some extension into the midscalp anteriorly and hence do not want to underestimate what might need to be done. It does seem that you might have some extension into the Midscalp resulting in a NW 5 pattern at some point. This ofcourse is only an educated guess. 

The reason i suggested a hair system is that I did sense that you wanted the coverage sooner than later. I totally understand that need. I also feel it helps you achieve this good dense look so that if you decide in your 40 s to go for a more conservative crown coverage, you will have the donor area for it and you might not look for a full density by then as you highlighted. Nonetheless, from experience, I know that even with a family and all, you would still care a lot about your hair. This is why donor preservation is important. If your crown is covered with a system and you develop MS thinning or frontal thinning in your 40s, you can simply do a very good coverage at that point. Always a good option to have. 

Yes some men tend to accelerate their loss once meds stop. I find that mostly with minoxidil more so than finasteride. Mainly due to the mechanism of actions of both. 

I can send you a name of some hair system companies. I am not sure I am allowed to disclose names publicly or only through DM. Maybe @Melvin- Moderatorcan let me know if allowed and I am happy to do so. 

Thanks for the reply again Dr. 

At a Norwood 5 should my donor be sufficient to have decent coverage into my 40s and 50s? I still consider myself a bit of a newbie but it seems like as long as I went with a good surgeon I would have enough grafts, maybe not for a super low hairline if it got worse than expected but at least something reasonable.

You can DM me some hair piece companies, I will look into it.

I am not comfortable going on minoxidil if you think that the risk of accelerated loss is not unrealistic. I really doubt I will be on it for life and I totally get what you mean by mechanism of action, it makes sense why minox would happen more than finasteride. Would you think that natural products would also cause a similar thing if they happened to work for an individual? I know we consider most natural products to be snakeoil but lets say someone used something like Revivv and it worked for that individual, would you see a similar risk of accelerated loss when continuing to minox or minox specifically

As far as shockloss, like someone above commented, should I basically consider all my native hear in my crown dead and a surgeon would basically totally disregard it and implant as if that hair doesn't exist at all and wont be there?

Lets say I didnt want to do the hairpiece and I wanted to move forward with a surgery, what would your advice be to me? Do you think I could achieve something decent with 2000-ish grafts with a good surgeon, stay on fin and see what happens? I am also new to LLLT which might thicken up the hairs some as well.

 

[CaliforniaLiving]

I would def not focus on the crown. Fill up the mid-scalp and plan for having to use most of your future grafts done on the hairline.

You can always use fibers on the crown and it will look good. The hairline is 100% the most important, so considering we all have finite grafts I would plan on using most of them in the frontal third (not yet but later in the future maybe) and some in the mid scalp. The crown is a black hole for grafts from what I have seen.

 

Edit:

Also, if you care about your hair now it won't change when you are in your late 40s. With that in mind you need to temper your expectations, because hair loss is a progressive condition and transplants only give you the illusion of coverage. We will never be able to get the same thickness in our youth, so the goal should always be a solid hairline w/ decent coverage throughout the rest. 

 

 

Edited April 25, 2022 by CaliforniaLiving

[AlexMeister21]

I think you'd do good with FUE. Spain has great FUE surgeons with Dr. Freitas and Dr. Couto, but they you may need to wait more than a year to see them.