Q: It seems that some doctors offer only FUT and others only FUE. What is your opinion on that? — D.E., Portland, M.E.
A: Both FUT and FUE are excellent techniques, but have different indications. To deliver the best care for our patients, hair restoration physicians should have expertise in both procedures, and they should offer both in their practices.
Update: I have expanded the answer to this question in a new Answers post.
Q: Hi. I am 52 years old and wish to know if Propecia will work for people my age. I have started losing some hair a couple of years ago and it’s thinning out. Thank you very much for your help. — K.E., Boca Raton, FL
A: Propecia (Finasteride 1 mg) can hold on to hair at any age, but works best to re-grow hair in those who are younger.
The reason is that finasteride works to reverse miniaturization (the thinning and shortening of hairs due to DHT). Younger patients, with early hair loss, generally have more hair in the early stages of miniaturization where the changes are readily reversible.
Older patients are more likely have more advanced miniaturization or areas that are totally bald and will thus not regrow with medical therapy.
Q: Does finasteride need to be taken every day? — M.B., Atlanta, GA
A: Finasteride (Propecia) is a competitive inhibitor of Type II, 5 alpha-reductase (5AR is the enzyme that converts Testosterone to DHT which then causes hair to miniaturize and eventually be lost). Finasteride is 100x times more selective in inhibiting the Type II enzyme (present in hair follicles) than the Type I enzyme (present in other body tissues). The turnover (T1/2) of the finasteride/5AR Type II complex is 30 days and the finasteride/5AR Type I complex is 15 days. This explains why finasteride does not need to be taken every day and why, after stopping finasteride, the effects may take a month or longer to begin to disappear.
Q: Why is using the robot to create recipient sites useful in a hair transplant? — S.K., Jersey City, NJ
A: The ARTAS® Robotic Hair Transplant system eliminates the inconsistencies inherent in creating large numbers of recipient sites by hand. The robot can create sites at a rate of up to 2,000 per hour. Although there is more set-up time compared to sites made manually, once the physician specifies the parameters such as punch depth, punch angle, and site direction, recipient site creation is precise and rapid.
One of the benefits of robotic site creation is that the distribution of grafts over a fixed area of the scalp can be exact. For example, if one wants to transplant 1,000 grafts evenly over 50cm2 of area, this can be done with great precision and with uniform site spacing. In addition, the physician can vary the densities in select regions of the scalp and the robot will adjust the densities in other areas so that the total number of sites remains the same.
Another benefit of the new technology is that the robot can be programmed to avoid existing hair and select which specific hair diameters to avoid. The robot is programmed to keep a specified distance from the existing hair to ensure that the resident follicles will not be damaged and that the distribution of new hair is even and natural. This computerized mechanism appears to be more accurate than what can be done by hand and, importantly, does not sacrifice speed in the process.
Q: How do recipient sites get made in Robotic FUE? And how does the robot know where to create the sites? — K.K., Bergen County, NJ
A: In performing recipient site creation, the ARTAS Robotic Hair Transplant system automates another part of the hair transplant process that is repetitive and prone to human error. In robotic site creation, the physician first designs the hair restoration and then specifies the angle of hair elevation, hair direction, site depth, average density, and total number of the recipient site incisions. The robot then creates the sites according to these specifications.
During site creation, the robot automatically uses its image-guided technology to avoid hairs of a certain diameter (specified by the doctor). The robot creates sites at a minimum distance from hairs of the specified diameter (the distance is also specified by the physician) and will do so randomly throughout the areas where the hair is finer or the scalp is bald. With this important feature, the new distribution of sites can be made to complement the distribution of existing hair. Observation of the ARTAS System suggests that it performs recipient site creation with greater precision and consistency than can be accomplished manually.
Q: What is the main difference between hair transplants using the robot versus other procedures? — M.P., Flatiron, NY
A: There are two basic types of hair transplant procedures, Follicular Unit Transplantation (FUT or strip surgery) and Follicular Unit Extraction (FUE).
In FUT, donor hair is harvested by removing a long thin strip from the back of the scalp. Individual follicular units are then obtained from this strip using stereo-microscopic dissection. In FUE, individual follicular units are harvested directly from the donor area using a sharp, round cutting instrument.
The ARTAS Robotic System performs the follicular unit isolation step of an FUE procedure and can also create recipient sites according to specifications determined by the hair restoration surgeon. In performing each of these steps, the robot uses its image-guided technology to locate the next target and position the cutting instrument, and it does so with precision and speed that cannot be accomplished using manual FUE techniques or instruments.
Q: Can Propecia (finasteride) completely halt androgenic alopecia for the duration of your lifetime, or does it just slow down the progression of androgenic alopecia? — L.B., Scarsdale, N.Y.
A: In many patients we have found finasteride to hold on to a patient’s hair for at least 15 years. We don’t have much longer data than that since it was approved for hair loss in 1998. Although finasteride will usually continue to work as long as you take it, it may lose some of its efficacy over time. Generally after about 5 years we may notice that the patient’s hair is starting to thin again and we will increase the dose slightly. It is important to understand that even if someone thins on finasteride it doesn’t mean the medicine is not working, because they might have thinned much more without it. To my knowledge, there are no studies that have looked at the effects of finasteride for such an extended period of time.
Q: I have been reading about Robotic FUE and have seen some photos on your website of you operating the ARTAS robot using what looks like a remote control. What is that thing and how does it control the robot? — C.B., Greenwich, CT
A: The ARTAS robot uses a dual operating system when performing follicular unit extraction. One station consists of a desktop computer adjacent to the robot. This station is used to establish the basic parameters of the transplant such as the spacing of grafts, the angle and depth of the harvest, which size follicular units will be targeted, and a host of other important variables.
The hand-held pendant is used by the operator situated next to the patient. The remote has more limited options – the main ones being depth adjustment and to immediately suspend the action of the robot. Many of the parameters are determined automatically by the robot’s computer to maximize the accuracy of the harvesting. The robot also makes real-time adjustments to these variables during the hair restoration procedure.
The physician sets the parameters at the computer monitor and, once the settings are determined, he/she sets the tensioner grid on the patient’s scalp. The tensioner determines where the grafts will be harvested. The grid is moved approximately every 130 harvests. The robot can be operated at the computer terminal and through a mobile pendant. The physician often alternates with a trained assistant between that station and using the pendant.
Besides the involvement in the operation of the robot, there are many other important physician-dependent steps to the hair transplant including the planning and design of the procedure, and recipient site creation. Other steps, such as the microscopic sorting and trimming of harvested follicular unit grafts and graft placement, are often performed by trained staff, but require the physician’s close supervision.
Q: How does the ARTAS robot control the depth of the incision in Robotic FUE? — B.V., Old Greenwich, CT
A: The ARTAS robotic system is equipped with advanced sensors that determine the precise depth of the sharp and blunt needles used both in the graft harvesting step and for recipient site creation. The robot automatically adjusts to the precise depth needed for the non-traumatic extraction of the grafts. The tip of the punching mechanism contains depth markings so that the physician can visually override the punch when he wants to fine-tune its action. While monitoring the procedure in real time, if it is observed that the punches are too superficial or too deep, punch depth can be modified using the robot’s computer system.
The physician can also use the ARTAS system to precisely control the depth of recipient sites. As with harvesting, the robot automatically adjusts the depth based on parameters set by the physician and the doctor can then make further adjustments, in real-time, during the procedure.
Q: I’m a 42 year old African-American woman and I’m losing hair on the crown of my head. Would I be a good candidate for a hair transplant? — E.E., Philadelphia, P.A.
A: Hair loss in the crown of an African American female can have several different etiologies, so the first thing to do is to make the right diagnosis. The most common causes of hair loss are androgenic alopecia (AGA) and scarring alopecia, also called ‘Central Centrifugal Cicatricial Alopecia,’ or CCCA. A biopsy is often useful to differentiate these two causes of hair loss when the diagnosis is unclear. A biopsy can also identify other, but less common, causes of crown hair loss.
AGA presents with a history of gradual thinning in the front and/or top of the scalp, a relative preservation of the frontal hairline, a positive family history of hair loss and the presence of miniaturization in the thinning areas. Miniaturization, the progressive decrease of the hair shaft’s diameter and length in response to hormones, can be identified using a hand-held device called a densitometer. If the diagnosis is AGA, then a hair transplant can be very successful provided there is enough donor hair.
CCCA presents as a progressive form of scarring alopecia that occurs almost exclusively in African American women. The onset of CCCA is very slow, typically developing over the course of years. CCCA starts near the vertex or top of the scalp and spreads in an outward direction. The involved area is usually smooth and shiny with decreased hair density.
Central Centrifugal Cicatricial Alopecia is diagnosed with a scalp biopsy performed in the area of hair loss. Those patients with CCCA are generally not candidates for a hair transplant procedure since the body may reject the transplanted hair. This condition is better treated with oral and injectable anti-inflammatory medications. Surgical treatment for cosmetic benefit may be an option in some cases after the disease has been inactive for many years.
Hair loss has a variety of causes. Diagnosis and treatment is best determined by a board-certified dermatologist. We offer both in-person and online photo consults.
Provide your email to learn more.
