Diffuse thinner after dutasteride. Should I continue my transplant plans?

[MisterBreakfast]

Hi all,

I am currently scheduled for a transplant with H&W to do a 5000-6000 graft FUT procedure.  I have talked to Dr. Wong, and he says that he thinks I am a good candidate, and that even though I have an "average to slightly below average donor" he thinks he can safely extract a large strip and cover everything I'm interested in covering.  I have indicated I'd like to leave the crown whirl(s) as is, since dutasteride seems to bring it back.

My question to you is, do you think this would be enough?  My expectations are and illusion of density with a mature NW2.5 hairline up front, and in the back, a balding, or bald crown. Is 5000-6000 grafts enough? I'm suspecting I may need a follow up procedure, maybe FUE.  What do yall think?

Here is my history/progress on dutasteride and oral minoxidil. I'm 37. I have been on dutasteride for about 13 months so far. Oral minoxidil for 8 months.  I've come pretty far... starting here:

to here:

 

to here:

 

and here is my donor:

 

 

Edited May 30, 2023 by MisterBreakfast

[Big Rome]

wow, the medication seems to have worked wonders, is that last pic your donor after the medication for a period of time? looks good not average! 

[TheGreatPretender]

Agreed, your donor doesnt look average at all. I think you could cover up till NW2 possibly and maybe a part of the crown aswell with what you have regrown.

[MisterBreakfast]

33 minutes ago, Big Rome said:

wow, the medication seems to have worked wonders, is that last pic your donor after the medication for a period of time? looks good not average! 

Last pic is after meds.  It certainly has thickened up!

Edited May 30, 2023 by MisterBreakfast

[TorontoMan]

Keep going on meds and delay your hair transplant. We may have positive results soon from HMI-115 and it would be worth knowing how effective it was in the first trial, in the meantime you are likely to continue to get some regrowth from dut and om given how its worked so far

[Melvin- Admin]

3 hours ago, TorontoMan said:

Keep going on meds and delay your hair transplant. We may have positive results soon from HMI-115 and it would be worth knowing how effective it was in the first trial, in the meantime you are likely to continue to get some regrowth from dut and om given how its worked so far

^This you might want to add something else to your regiment, HMI-115, CosmeRNA, Pyrilutimide. I think you should see how much more growth you can get from meds before considering surgery. If you have a good deal of regrowth, you wont need to do FUT, which in my opinion, is risky. A large strip like that could definitely stretch. 

[MisterBreakfast]

4 hours ago, TorontoMan said:

Keep going on meds and delay your hair transplant. We may have positive results soon from HMI-115 and it would be worth knowing how effective it was in the first trial, in the meantime you are likely to continue to get some regrowth from dut and om given how its worked so far

 

54 minutes ago, Melvin- Moderator said:

^This you might want to add something else to your regiment, HMI-115, CosmeRNA, Pyrilutimide. I think you should see how much more growth you can get from meds before considering surgery. If you have a good deal of regrowth, you wont need to do FUT, which in my opinion, is risky. A large strip like that could definitely stretch. 

I'm interested in these, but to my knowledge, these new drugs follow the same mechanism of action of existing drugs like fin/dut.  Since I basically have knocked down my DHT levels to as close to 0 as possible, I don't think degrading my androgen receptors (AR) will do much.  

I will watch closely to new developments.  I'd be very curious if degrading the AR has any impact in users with little to no DHT.  I haven't seen any clinical studies to suggest that may be the case.  I suppose there is a small chance that it may prevent Test from binding to the AR, but that's speculation at this point.  I think test has low binding affinity to the AR already, however.  Will be interesting to see.

Currently I'm booked for December 2023.  I will consider pushing it out, but I have to weigh it against the risk of rescheduling out another 15 months or so for the waitlist.  

[shadowcast]

Why would you want to do a FUT rather than FUE? Why not touch the crown whirl? After 13 months dut/8 months min you will likely not have further growth, certainly nothing miraculous. Forget this "illusion of density" stuff, ~6k grafts with a good doctor would do you wonders. A good doctor will rebuild your whirl, not replace it. Consider yourself lucky that you have good response to medication and a healthy donor, and just go for a big FUE.

[duckling]

after 13 months you had on DUT i think your results are maxed out from it. The changes if any wont be substantial from now on. You have also used oral minoxidil and got the most out of it and maybe 4 months of results for it will remain. But i dont think you need to push surgery date which is in december. 

Other meds which are in pipeline are not going to do anything more than what DUT+oral min did or add anything.  you are on the best stack. The meds in pipeline are supposed to be alternate to Finasteride and dont even come close to what you take or to oral fin+topical min also. example: CosmeRNA instead of being a med is sold as cosmetic product whose safety profile is also not tested. Its a red flag when they try to skip FDA approvals. These products are targeted to people who got sides from FDA approved meds.

HT should be done as you got gains yes but easily your surgeon (who are one of best clinics ) can add grafts in between those hairs and enhance your look more.

FUT or FUE that you should leave to dr wong as he will check your scalp and donor in person and tell you correct answer.

[TorontoMan]

15 hours ago, MisterBreakfast said:

 

I'm interested in these, but to my knowledge, these new drugs follow the same mechanism of action of existing drugs like fin/dut.  Since I basically have knocked down my DHT levels to as close to 0 as possible, I don't think degrading my androgen receptors (AR) will do much.  

I will watch closely to new developments.  I'd be very curious if degrading the AR has any impact in users with little to no DHT.  I haven't seen any clinical studies to suggest that may be the case.  I suppose there is a small chance that it may prevent Test from binding to the AR, but that's speculation at this point.  I think test has low binding affinity to the AR already, however.  Will be interesting to see.

Currently I'm booked for December 2023.  I will consider pushing it out, but I have to weigh it against the risk of rescheduling out another 15 months or so for the waitlist.  

If you do a transplant now, you will deny yourself any chance of regrowth from an upcoming treatment as transplanting into these areas are likely kill off original follicles. I can't say with any real certainty of course that something will for sure change the game but now more than ever there are a few things to look forward too. 

HMI-115 - We should be getting results soon, there is also some guy who was sharing updates on reddit from his participation in the phase 1, apparently a photo circulated from his social media and some claim he was able to recover at least a norwood. Again can't confirm this for sure but I think its worth waiting to see. 

TM5614 - https://www.tohoku.ac.jp/en/press/amish_live_longer_and_healthier.html

Scube3

crispr?

 

[Turkhair]

6k is a lot of grafts, you should be looking at NW1 with that much and full coverage. Maybe even density among hairline. For comparison slick bald NW6 get 3500 for frontal density + coverage and another 2-3k for crown. You’re not NW6. 

FUT is a mistake. When you stop those drugs and you will one day - it will happen - that scar will look really bad all alone when the medicated hairs will fall off.

I will go with another clinic if I was you. FUT is so dated technique and the scars are hideous, it should never be an option. You can not go bald anymore or shave without looking like you had skull surgery. 
 

I have had FUE and nobody can tell I had thousands of grafts taken from me even when I shave bald. 

[MisterBreakfast]

2 hours ago, Turkhair said:

6k is a lot of grafts, you should be looking at NW1 with that much and full coverage. Maybe even density among hairline. For comparison slick bald NW6 get 3500 for frontal density + coverage and another 2-3k for crown. You’re not NW6. 

FUT is a mistake. When you stop those drugs and you will one day - it will happen - that scar will look really bad all alone when the medicated hairs will fall off.

I will go with another clinic if I was you. FUT is so dated technique and the scars are hideous, it should never be an option. You can not go bald anymore or shave without looking like you had skull surgery. 
 

I have had FUE and nobody can tell I had thousands of grafts taken from me even when I shave bald. 

Interesting.  I was pretty sure I was Norwood 6, at least as a final pattern.  I feel like meds brought me back to a NW5.5 ish state.  Maybe a Ludwig 2 pattern?  What do you think I would be?

As for FUT, I'm just not that worried about the scar. I already have a fair number of scars from bike crashes and other things, so I know I typically heal very well. There are plenty of options to deal with it, if it stretches, and I've never been one for bald fades.  I'd also like to leave FUE as an option for the future for either repairs density or maybe the crown or touchups as I continue to age.

As for other things I'm happy to be as conservative as possible.  If Dr. Wong things less grafts are needed I'd be psyched to save them for a rainy day.  I've lived a fast and full life already. I was sure to already enjoy my 20's to the fullest and have no desire to appear as youthful as I did back then. 

I'm happy to have a mature/age appropriate higher hairline with even some thinning in the back. Something that will suit me in my 40's and 50s and beyond (hopefully). I really would just like to frame up my face in the front, as I do video calls, teaching and conferences quite often, where appearance from the front is important. Anything beyond that would put me over the moon.

 

[Turkhair]

1 hour ago, MisterBreakfast said:

Interesting.  I was pretty sure I was Norwood 6, at least as a final pattern.  I feel like meds brought me back to a NW5.5 ish state.  Maybe a Ludwig 2 pattern?  What do you think I would be?

As for FUT, I'm just not that worried about the scar. I already have a fair number of scars from bike crashes and other things, so I know I typically heal very well. There are plenty of options to deal with it, if it stretches, and I've never been one for bald fades.  I'd also like to leave FUE as an option for the future for either repairs density or maybe the crown or touchups as I continue to age.

As for other things I'm happy to be as conservative as possible.  If Dr. Wong things less grafts are needed I'd be psyched to save them for a rainy day.  I've lived a fast and full life already. I was sure to already enjoy my 20's to the fullest and have no desire to appear as youthful as I did back then. 

I'm happy to have a mature/age appropriate higher hairline with even some thinning in the back. Something that will suit me in my 40's and 50s and beyond (hopefully). I really would just like to frame up my face in the front, as I do video calls, teaching and conferences quite often, where appearance from the front is important. Anything beyond that would put me over the moon.

 

You are NW6, the hairs that have been brought back will go back to sleep as soon as you stop minoxidil. After meds it’s hard to judge your Norwood level, I’d say very diffused NW3 with the crown pattern. 

Sounds like the clinic wants to give you density and you don’t have a problem with FUT. 

[TheGreatPretender]

48 minutes ago, Turkhair said:

You are NW6, the hairs that have been brought back will go back to sleep as soon as you stop minoxidil. After meds it’s hard to judge your Norwood level, I’d say very diffused NW3 with the crown pattern. 

Sounds like the clinic wants to give you density and you don’t have a problem with FUT. 

This is what I am talking about. 

Diffuse Thinners are hard to determine for the pattern they take, as one being myself I feel that sometimes I have dropped from 5 to 4.5 and there are moments in which I look like I am 4, probably because I just let the hairs grow out so they cover an extensive part of my scalp with the caliber. 

The thing is that my hair looks horrible when greasy so it easily shows the 5 pattern, when I wash it through is almost as if its regrowing all the way back when its clearly not lol.

But OP seems to be a great candidate for a FUT, im sure it could be a one and done with those numbers. 

[consequence]

You did really well with medications. People have different opinions on this, but I personally had good luck adding 2% keto to my oral dut/minox. 

I wouldn't hold your breath for the theoretical medications as those typically take too long to hit the market and most end up stalling in development. There have been many candidates over the years, RU 58841, CB-03-01, etc. now it's KX826, HMI 115 etc. There is zero long term safety data on any of these in humans. We don't even fully understand the effects of finasteride or minoxidil yet. I wouldn't hold my breath.

I might consider FUE over FUT for you as there is a significant chance that your hair loss will progress to a complete NW7 even with therapy (if you want to have the option of shaving your head). If you could never imagine shaving, then FUT is fine but you never know how long the medication response you've had will last, as follicles become more sensitive to DHT and inflammation with aging.

[Vann]

My personal opinion is… go for FUT if you want to maximize your donor. Considering you had a great response to meds., don’t mind the scar, and have a lot of real estate to cover. If you can yield 6k grafts from one FUT that would be insane. Yes it is a risky procedure but that’s more than 60-80% of donor that people have from FUE alone.

if you still have over 5k graft you can do fue to cover future areas. Essentially you could rock more than just an illusion of a transplant but have a slightly thinning crown and a strong head of hair all around. 
 

do not disregard FUT because others are telling you it’s outdated. There are surgeons who can make that scar extremely pencil thin and you could SMP that or even donor restock (up to you) so consider every option to your disposal! 
 

Just make sure you understand that even getting a hair transplant nothing is guaranteed. The scar could stretch significantly given its large size, you could have complications, etc. but in a perfect world FUT could harvest you significantly more hairs if you have a weak donor and have no body/facial hair. 

Edited June 1, 2023 by Vann

[Z--]

1 hour ago, Vann said:

My personal opinion is… go for FUT if you want to maximize your donor. Considering you had a great response to meds., don’t mind the scar, and have a lot of real estate to cover. If you can yield 6k grafts from one FUT that would be insane. Yes it is a risky procedure but that’s more than 60-80% of donor that people have from FUE alone.

if you still have over 5k graft you can do fue to cover future areas. Essentially you could rock more than just an illusion of a transplant but have a slightly thinning crown and a strong head of hair all around. 
 

do not disregard FUT because others are telling you it’s outdated. There are surgeons who can make that scar extremely pencil thin and you could SMP that or even donor restock (up to you) so consider every option to your disposal! 
 

Just make sure you understand that even getting a hair transplant nothing is guaranteed. The scar could stretch significantly given its large size, you could have complications, etc. but in a perfect world FUT could harvest you significantly more hairs if you have a weak donor and have no body/facial hair. 

I agree with this and would follow Vann's advice. I've done both FUT and FUE now, and I don't regret the scar (though it's quite a painful procedure, and you'll be out a few additional weeks than you would for FUE).

On average, people have between 6k - 9k lifetime grafts (more if you have beard, of course), depending on your Norwood level -- diffuse thinning is usually best captured in the class V, such as 3V and then it jumps to 6 usually, imo. Sadly, the higher the Norwood, the fewer you have to work with. According to many reputable doctors, you can get an additional 1 - 3k grafts if you do a larger FUT and then opt into FUE. Keep in mind that beard grafts have a higher transaction rate than scalp hair, and if used incorrectly, don't look very good (and should only be used for midscalp + crown). You can also use beard grafts to replenish donor or into the FUT scar.

90%+ of the time just FUE is sufficient. BUT in a diffuse thinner's case, who is maxed out on meds and can only really lose hair going forward, preserving these additional grafts is a good idea mate. I don't really understand people who complain that you can't shave afterwards...if you were fine being bald at age 40 or 50, there's no reason to get a transplant in the first place lmao.

Just keep in mind that certain styles (e.g. skin-fades) will reveal the scar. I'd also be a bit wary of all 6,000 grafts coming from FUT -- the benefits of additional grafts don't apply if your scar is stretched, which renders surrounding hair unusable. There was a recent H&W case where that unfortunately occurred, though Wong's FUT has historically been quite good, so not sure what went wrong. 

Edited June 1, 2023 by Z--

[consequence]

It used to be a general rule of thumb that if someone wanted to maximize lifetime grafts, they would "strip out then get the FUE out" or some such cute phrase -- ie strip as much as you can then FUE afterwards. FUE proponents have questioned this over the years, but I think there's a pretty good chance that it's true.

For me this didn't work because I'm a diffuse thinner as well, and I'm hanging on to what I have with a strong regimen like yours. I figured eventually I will want to have kids and probably have to go off the dut (and presumably go to at least a NW5), so I'm just keeping an escape hatch open for a shaved head when I one day just go full hermit as an old man. I didn't want to burn my boats once I crossed the water, so to speak. Everyone has their own preferences with this and it sounds like you've thought your choice through with a careful premortem. Something combination of "What's the most likely scenario? / What's the worst case scenario?" is usually a reasonable approach.

Hasson's FUT yields are some of the best in the world, he's sort of the "Konior of Canada" though every now and again he's had patients post some odd experiences (ie. bizarre hairline designs, lack of f/u, etc.). Regardless of these occasional hiccups, his graft survivals are phenomenal.

Edited June 1, 2023 by consequence