Need advice - Suggest plan and which doctor to consult with (NW5/6)

[4chanhrn]

Hello,

I need advice on my pattern of loss and which doctor I should go for. Lighting is super strong. Sunlight+bright indoor light directly overhead.

Front view:

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Top view:

Side view:

Back view:

Personally I feel I am diffuse NW5/6, heading towards a NW6/7. I am 27, with relatively stable hair loss since it started 5 yrs ago, although I have lost more ground recently. Family history is mixed bag. Dad, paternal uncle NW1/2. Paternal grandpa NW7. Maternal uncle diffuse like me, but has OKish hair at mid 40s.

I am on Oral Minoxidil 5mg/day, which I increased from 2.5mg/day very recently. Also on LLLT+keto+microneedling. I cannot tolerate finasteride(or topical finasteride/dutasteride). My plan is to go for FUT only, since I really need the grafts longer term as I expect native to shed. Hopefully Verteportfin+FUE by then should work out. I am planning to consult few doctors for FUT. 

• Dr. Wong - Close to me. Started consultation with rep. Quoted 4000-4500 grafts. Worried about recent misses.

• Dr. Bloxham - Honestly felt results weren't spectacular. But his methodology is good and he has good reputation for FUT.

• Dr Nakatsui - Close to me. Half the cost of Wong? Doc/techs trained by Dr. Wong. Less waiting times. Not many results posted by patients and results posted by him weren't spectacular.

• Dr. Laorwong - Much cheaper. Great results. Bit far. Not sure if he still does FUT. 

• Dr Path - Great surgeon. Expensive(especially for Thailand). Bit far.

• Hattigen - About the same price as H&W, great clinic. Hard to get to for me, would need visas.
  
  Cost is a significant factor for me. I'm open to taking a flight to elsewhere vs having to pay higher costs if results don't directly justify it. But I don't mind spending more if really needed. But I'd rather save that money towards FUE later.

What do you think? Is my donor OK enough? I feel it's thinning looking at the pics. I have extremely coarse/strong beard/body hair so those are options too. My plan is to not do much of crown, focus on front/mid, keep same hairline.

Thank you.

Edited April 10 by 4chanhrn

[Melvin- Admin]

What types of topicals have you tried? I seriously think you need an effective DHT blocker before proceeding with surgery.

[4chanhrn]

37 minutes ago, Melvin- Admin said:

What types of topicals have you tried? I seriously think you need an effective DHT blocker before proceeding with surgery.

Topical finasteride 0.1% 0.5mg 3x/week. Tried Xyon topical dutasteride. Both give me side effects. Insomnia/nightmares, ED, loss of libido. I've tried Alfatradiol as well. No sexual sides but terrible nightmares. 

Planning to try Pyrilutamide soon.

I know medication is recommended, especially for someone like me, but I just can't tolerate 5AR blockers at all.

[Bucky O Hair]

You are a NW6 and still in your 20s.  

I get that money may be tight, but you cannot cheap out on a hair transplant especially with this level of loss.

Don't get a procedure if you cannot afford one, and do not get a procedure if you're not willing to travel a few hours for a good one.  If I were you, I would reach out to Dr. Zarev for your level of loss, and do what I could to save up money in the meantime (while you are on the waiting list).

Personally, I would advise against an FUT procedure.  You have many more decades of life, and you will experience further loss.  You may want to one day buzz your head (when you're in your 40s or 50s) and you'll regret the linear scar on the back of your head.  
 

Edited April 10 by Bucky O Hair

[Melvin- Admin]

19 minutes ago, 4chanhrn said:

Topical finasteride 0.1% 0.5mg 3x/week. Tried Xyon topical dutasteride. Both give me side effects. Insomnia/nightmares, ED, loss of libido. I've tried Alfatradiol as well. No sexual sides but terrible nightmares. 

Planning to try Pyrilutamide soon.

I know medication is recommended, especially for someone like me, but I just can't tolerate 5AR blockers at all.

How often did you apply the Xyon? 

[TakeAction]

48 minutes ago, Bucky O Hair said:

You are a NW6 and still in your 20s.  

I get that money may be tight, but you cannot cheap out on a hair transplant especially with this level of loss.

Don't get a procedure if you cannot afford one, and do not get a procedure if you're not willing to travel a few hours for a good one.  If I were you, I would reach out to Dr. Zarev for your level of loss, and do what I could to save up money in the meantime (while you are on the waiting list).

Personally, I would advise against an FUT procedure.  You have many more decades of life, and you will experience further loss.  You may want to one day buzz your head (when you're in your 40s or 50s) and you'll regret the linear scar on the back of your head.  
 

I have to disagree, the FUT could be the difference between getting good coverage and not. With FUT (plus FUE) he could get an extra 2000-3000 grafts from his donor.

Of course nobody wants a linear scar. I would never advise anyone below a NW4 on meds to do FUT, the benefit just isn't there. But in order to maximize the donor in these high norwood cases, especially someone who's not on a 5AR inhibitor, FUT + FUE is the best way to get enough grafts. Those several thousand grafts are the difference between covering the crown and leaving it bare.

So it's either start with FUT, do several procedures and probably get good coverage over a lifetime or do FUE only, not get enough coverage over time and then have to shave.

That wouldn't apply if he went to Zarev or Pittella to be fair. But that's out of reach for many people and his goals can be accomplished with FUT + FUE.

Edited April 10 by TakeAction

[mr_peanutbutter]

hdc cyprus, eugenix, pittella

 

@Doron Harati

[4chanhrn]

  

1 hour ago, Melvin- Admin said:

How often did you apply the Xyon? 

Got sides after single application. Tried 2 applications 3 days apart for sides to fully kick in. Sides went away after around 1.5 weeks of discontinuation. This is consistent with other 5AR blockers I have tried(topical/oral fin). Topical fin microdosing sides came in after few weeks. I stayed on it for a month hoping it would improve and had complete limp dick.

I am very sensitive to 5AR blockers. My parents are medical doctors and their recommendation was not to use 5AR blockers when my body does not like it. Every body can react completely different to medication. What works for you may be poison for you. It sucks but you can't do anything. Oral Min is complete opposite for me. It feels like it gives me so much energy and has improved my cardio.

Maybe Pyrilutamide can help. I'm waiting for it to arrive in mail.

1 hour ago, Bucky O Hair said:

Personally, I would advise against an FUT procedure.  You have many more decades of life, and you will experience further loss.  You may want to one day buzz your head (when you're in your 40s or 50s) and you'll regret the linear scar on the back of your head.  

I'm completely fine with the scar. Like you said it's a personal decision to make. I want to maximize grafts and I do not mind the scar at all. Even if I at all need to buzz it down, I don't think I would mind it, especially in 40s/50s.

1 hour ago, Bucky O Hair said:

I get that money may be tight, but you cannot cheap out on a hair transplant especially with this level of loss.

Don't get a procedure if you cannot afford one, and do not get a procedure if you're not willing to travel a few hours for a good one.  If I were you, I would reach out to Dr. Zarev for your level of loss, and do what I could to save up money in the meantime (while you are on the waiting list).

I'm not trying to cheap out, but I do not have unlimited money and would like things to be cost efficient. There are excellent surgeons(on HRN recommended list/recommended by patients) that are very good, but still not prohibitively expensive. I'm thinking I may have to get a little expensive large FUT, because there aren't a lot of good FUT surgeons(and most of them are in North America). I've listed the ones I'm considering above. And then I can get cheaper FUEs down the line. Laorwong, Nader, Pekiner, Keser, Eugenix(I often travel to India so would be easy to get done) are all good enough options for FUE without breaking the bank. There are many surgeons that charge much more, but are subpar in quality.

As for travel, it's a similar story. H&W is 4 hours drive for me. Hattigen would be a long flight+like a week worth of trip+arranging visas well ahead of time. Visas for Schengen countries can be super hard to get sometimes(depending on your passport). It adds inertia to the whole process. I can do it, but if costs, quality of surgeon aren't that much better, it is harder to justify.

Dr. Zarev is very good, there is no doubt about it. For me, his costs and availability make it a non-option.

Edited April 10 by 4chanhrn

[4chanhrn]

38 minutes ago, TakeAction said:

I have to disagree, the FUT could be the difference between getting good coverage and not. With FUT (plus FUE) he could get an extra 2000-3000 grafts from his donor.

Of course nobody wants a linear scar. I would never advise anyone below a NW4 on meds to do FUT, the benefit just isn't there. But in order to maximize the donor in these high norwood cases, especially someone who's not on a 5AR inhibitor, FUT + FUE is the best way to get enough grafts. Those several thousand grafts are the difference between covering the crown and leaving it bare.

So it's either start with FUT, do several procedures and probably get good coverage over a lifetime or do FUE only, not get enough coverage over time and then have to shave.

That's my thinking. I also think Verteporfin+FUE would likely work out for better donor management. The trials are very promising. FUT now gives me the option to use Verteporfin for FUE later when it's better studied.

I'm OK with a bare/bareish crown. Looking for front/mid coverage. I don't have high expectations because of my level of loss+not using 5AR inhibitors. Also I don't think I would care as much in 40s/50s.

[4chanhrn]

23 minutes ago, mr_peanutbutter said:

hdc cyprus, eugenix, pittella

 

@Doron Harati

Yea all good options..

[Melvin- Admin]

16 minutes ago, 4chanhrn said:

  

Got sides after single application. Tried 2 applications 3 days apart for sides to fully kick in. Sides went away after around 1.5 weeks of discontinuation. This is consistent with other 5AR blockers I have tried(topical/oral fin). Topical fin microdosing sides came in after few weeks. I stayed on it for a month hoping it would improve and had complete limp dick.

I am very sensitive to 5AR blockers. My parents are medical doctors and their recommendation was not to use 5AR blockers when my body does not like it. Every body can react completely different to medication. What works for you may be poison for you. It sucks but you can't do anything. Oral Min is complete opposite for me. It feels like it gives me so much energy and has improved my cardio.

Maybe Pyrilutamide can help. I'm waiting for it to arrive in mail.

I'm completely fine with the scar. Like you said it's a personal decision to make. I want to maximize grafts and I do not mind the scar at all. Even if I at all need to buzz it down, I don't think I would mind it, especially in 40s/50s.

I'm not trying to cheap out, but I do not have unlimited money and would like things to be cost efficient. There are excellent surgeons(on HRN recommended list/recommended by patients) that are very good, but still not prohibitively expensive. I'm thinking I may have to get a little expensive large FUT, because there aren't a lot of good FUT surgeons(and most of them are in North America). I've listed the ones I'm considering above. And then I can get cheaper FUEs down the line. Laorwong, Nader, Pekiner, Keser, Eugenix(I often travel to India so would be easy to get done) are all good enough options for FUE without breaking the bank. There are many surgeons that charge much more, but are subpar in quality.

As for travel, it's a similar story. H&W is 4 hours drive for me. Hattigen would be a long flight+like a week worth of trip+arranging visas well ahead of time. Visas for Schengen countries can be super hard to get sometimes(depending on your passport). It adds inertia to the whole process. I can do it, but if costs, quality of surgeon aren't that much better, it is harder to justify.

Dr. Zarev is very good, there is no doubt about it. For me, his costs and availability make it a non-option.

Sides after one application sounds like a nocebo. Xyon by design doesn’t penetrate immediately. It takes several applications without washing your hair before it could even get absorbed. 

[4chanhrn]

Just now, Melvin- Admin said:

Sides after one application sounds like a nocebo. Xyon by design doesn’t penetrate immediately. It takes several applications without washing your hair before it could even get absorbed. 

I left it on for a day without washing. Its hard for weird dreams/nightmares, sleep issues for few days after applications, complete lack of morning wood for 1.5 weeks to be nocebo, especially when I am normally opposite to this.

[Shadman]

3 minutes ago, Melvin- Admin said:

Sides after one application sounds like a nocebo. Xyon by design doesn’t penetrate immediately. It takes several applications without washing your hair before it could even get absorbed. 

^ I agree, this could be due to nocebo

Got sides from oral fin even after using 1 mg three times in a week. Recently switched from oral to topical fin solution. I feel like I'm having nocebo effect. I think for every medications using for few months would give an idea how it's responding. 

[Fox243]

I do not think it is worth the medication as a NW7, especially if your body doesn't tolerate it. There's not much more you can save and there is a risk-reward tradeoff -- meds aren't a "free" option. I instead think its more important to find a doctor who also uses beard hair and be conservative in your expectations (maybe a NW3).

[4chanhrn]

15 minutes ago, Fox243 said:

I do not think it is worth the medication as a NW7, especially if your body doesn't tolerate it. There's not much more you can save and there is a risk-reward tradeoff -- meds aren't a "free" option. I instead think its more important to find a doctor who also uses beard hair and be conservative in your expectations (maybe a NW3).

I'm on oral minoxidil, which is supposedly a mild AR blocker. I'm going to try pyrilutamide. Also use saw palmetto tablets sometimes+keto/SP shampoo. So I'm not completely off medication. It would have been nice to use a 5AR inhibitor, but I can't seem to tolerate it.

Yes, I have super strong beard/body hair and I do not have high expectations. I can grow a beard like Bin Laden(maybe not the best person to compare to but you get the idea) and have body hair as thick as bear fur if I don't trim it down.

This is my hair 4 years back at 23 before starting minoxidil and after bit of TE. It's not a whole lot worse today(may actually be better), but it was better little later after TE improved and minoxidil worked for sure.

Edited April 10 by 4chanhrn

[Fox243]

4 minutes ago, 4chanhrn said:

I'm on oral minoxidil, which is supposedly a mild AR blocker. I'm going to try pyrilutamide. Also use saw palmetto tablets sometimes+keto/SP shampoo. So I'm not completely off medication. It would have been nice to use a 5AR inhibitor, but I can't seem to tolerate it.

Yes, I have super strong beard/body hair and I do not have high expectations. I can grow a beard like Bin Laden(maybe not the best person to compare to but you get the idea) and have body hair as thick as bear fur if I don't trim it down.

This is my hair 4 years back at 23 before starting minoxidil and after bit of TE. It's not a whole lot worse today(may actually be better), but it was better little later after TE improved and minoxidil worked for sure.

I think your best shot is to go with Dr. Pittella and see what he says.

[Melvin- Admin]

20 minutes ago, 4chanhrn said:

I left it on for a day without washing. Its hard for weird dreams/nightmares, sleep issues for few days after applications, complete lack of morning wood for 1.5 weeks to be nocebo, especially when I am normally opposite to this.

Lack of morning erections is correlated to poor sleep. I don’t think you can claim dut causes nightmares. Correlation doesn’t equal causation. Poor sleep and insomnia can be correlated to stress, presumably from losing hair. Something that medication would help.

[4chanhrn]

1 hour ago, Fox243 said:

I think your best shot is to go with Dr. Pittella and see what he says.

That's a good idea. I will consult with him as well. He's a great surgeon for sure. Not sure about price/location, but I can try to make it work if he's much better option.

58 minutes ago, Melvin- Admin said:

Lack of morning erections is correlated to poor sleep. I don’t think you can claim dut causes nightmares. Correlation doesn’t equal causation. Poor sleep and insomnia can be correlated to stress, presumably from losing hair. Something that medication would help.

I don't want to beat a dead horse, but hormonal changes can cause sleep disturbances. From my understanding fin/dut can mess with HPA axis, which can lead to nightmares/sleep disturbances. Fin/dut can also affect neurosteroids.

It is possible that it was placebo, because placebo effect can be strong, but I have used 5AR blockers for more than a month and everytime I end up with prolonged similar effects. From people's posts on the forum, Xyon's topical dut still had significant effect on blood DHT levels. I am hopeful for Pyrilutamide, because their press notes say one of their primary markets is as a hair loss medication for people that can't tolerate 5AR inhibitors and safety trial data looks good.

Like I said I was closely monitored by my parents who are both MDs and their strong recommendation was to discontinue use of 5AR blockers. I also consult with a dermatologist who also told me not to take 5AR blockers because I can't tolerate them. 

Edited April 10 by 4chanhrn

[bigmistake]

I'm currently 30, your hair loss is very similar to mine when I was 27, I am now NW6-NW7, your hair can still be revived with dermarolling + oral minoxidil + topical finastride. You can almost become a NW2. 

Don't get a HT without Fin. 

[Bucky O Hair]

4 hours ago, TakeAction said:

I have to disagree, the FUT could be the difference between getting good coverage and not. With FUT (plus FUE) he could get an extra 2000-3000 grafts from his donor.

Of course nobody wants a linear scar. I would never advise anyone below a NW4 on meds to do FUT, the benefit just isn't there. But in order to maximize the donor in these high norwood cases, especially someone who's not on a 5AR inhibitor, FUT + FUE is the best way to get enough grafts. Those several thousand grafts are the difference between covering the crown and leaving it bare.

So it's either start with FUT, do several procedures and probably get good coverage over a lifetime or do FUE only, not get enough coverage over time and then have to shave.

That wouldn't apply if he went to Zarev or Pittella to be fair. But that's out of reach for many people and his goals can be accomplished with FUT + FUE.

 

That's just it.  It's all about the doctor.

IMO, it's better to just save up and go with the better doc, than to put a scar on your head and maybe get an extra 1,000 to 2,000 grafts (if you are very lucky) when you have the top FUE doctors pulling record numbers of grafts from NW7s without seemingly affecting the appearance of the donor area.

 

 

 

 

[TakeAction]

4 minutes ago, Bucky O Hair said:

 

That's just it.  It's all about the doctor.

IMO, it's better to just save up and go with the better doc, than to put a scar on your head and maybe get an extra 1,000 to 2,000 grafts (if you are very lucky) when you have the top FUE doctors pulling record numbers of grafts from NW7s without seemingly affecting the appearance of the donor area.

 

 

 

 

Don't get me wrong, if I were a full blown NW7 I'd go to Pittella. I mostly agree with you. But I don't think it's true that a patient would be lucky to get only 1000 more grafts with FUT.

Assuming a strip 25 cm long and 1.8 cm wide most patients can get 45 cm^2 in their first strip, with around 75 FU/cm. That first strip can easily yield 3000+ grafts, and the vast majority of patients who don't have abnormally bad laxity can get a second strip of similar caliber.

Conservatively most patients can get 5000 or more lifetime FUT grafts (with two strips).

Most surgeons won't take more than 50 percent of the donor, so that entire area would only have yielded 2500 grafts with FUE only. So the average patient can easily get another 2500 or more grafts by combining FUT and FUE.

This is where I get the 25 cm strip length from. 30 cm is also used as an example.

 

[mr_peanutbutter]

how much does @Kulakarncharge for fut?

 

ive noticed they posted a fut result recently

 

 

[4chanhrn]

46 minutes ago, TakeAction said:

Most surgeons won't take more than 50 percent of the donor, so that entire area would only have yielded 2500 grafts with FUE only. So the average patient can easily get another 2500 or more grafts by combining FUT and FUE.

This is also a good video I found.

 

If their calculation is right, then it's 40% more grafts for avg person from safe donor areaby doing FUT first? That's not insignificant.

Edited April 10 by 4chanhrn

[TakeAction]

36 minutes ago, 4chanhrn said:

This is also a good video I found.

 

If their calculation is right, then it's 40% more grafts for avg person from safe donor areaby doing FUT first? That's not insignificant.

Yeah it's far from insignificant.

I think people are too afraid of the scar because most people are not high norwoods and don't need extra grafts so they don't benefit much from FUT. But for those of us who are higher norwoods and need 6k grafts or more, there's a massive benefit.

I personally don't mind trading a linear scar for 3k extra grafts. My donor is quite good in the occipital region but not so great on the sides, so it makes even more sense to use FUT to get all of those thicker grafts. Most people have stronger occipital hair than temporal, but for me it's a pretty significant difference. I probably need about 6k total and I might not be able to get that with FUE alone, but I probably can with FUT.

I actually met a guy last year at brunch who had a haircut that exposed his FUT scar. It didn't look bad, and I brought it up later and we talked about transplants. The scar was pretty thin and honestly I wouldn't have thought much of it if I didn't know about transplants. It wasn't some disgusting frankenstein scar, and if he had let his hair grow another two weeks it would've been covered.

We can always talk about worst case scenarios i.e. "what if the scar stretches" --> then you grow your hair out longer. Everything comes with some risk. Not everyone has the luxury of being able to do just FUE and get the result we want. And some people say "just use beard hair" which I don't agree with. Scalp hair is far superior in terms of appearance for obvious reasons. Beard hair is something I'd only use when I've maxed out FUT and FUE.

Like I've said before I wouldn't do FUT if I were a NW3 or even a NW4. But FUT has it's place, especially for high norwoods.

 

Edited April 10 by TakeAction

[TakeAction]

Also check out Melvin's podcast with Ted Miln that just came out. Another FUT guy who seems solid. His IG has some great results.