These people getting these miraculous jobs from Canada – it is a trick, right? They can’t honestly expect to be able to get away with what they’ve done over the course of their entire lives, can they?

A: I think you have better insights into hair loss than many hair transplant surgeons. ABI was the “rare” patient who seems to be a stable Class 3. I made that judgment due to: almost no miniaturization at the border of his Class 3 recession, no crown miniaturization, and his unusual family history. He had several older family members who stayed at Class 3 their whole lives.

Since we only have about 6,000 movable follicular units on average in our donor area, placing 3,000 at the hairline is obviously a joke and/or the doctor is playing “Russian Roulette” with the patient’s future.

As you point out, in most patients the hair loss will progress and the person will be out of luck. It is similar to the way flap patients were stuck without additional donor hair as their hair loss progressed. An additional problem was that the flaps were low on the forehead and very dense. The situation is analogous to placing 100 grafts per sq cm2 to create a low, broad hairline in a young person.

If you do the math you can see how ridiculous this tactic is. A person’s original density is only 90-100 follicular units cm2. Patient with Class 6 hair loss lose hair over an area of about 300 cm2.

This consists of:

• 50cm2 in the front (including a 15cm2 hairline)
• 150 cm2 for the mid-scalp
• 100 cm2 for the crown

Therefore, 6000 FUs transplanted to this area = 6000/300 = 20 FU per cm2. This is the number we often work with. We put up to 50cm2 at the very most in the mid-frontal forelock area and then proportionately less in other areas.

However, if you put 3,000 FUs at the hairline, in a density of 100/cm2, then you have covered only 30cm. This leaves only 3,000 FUs for the remaining 270cm2 of balding scalp for a density of a little over 11 FU/cm2.

Now, transplanting 11FU cm2 over the back part of the scalp is not a disaster EXCEPT if the front was transplanted at 100 per cm2. In this situation (as you have accurately pointed out) the patient will look very, very front heavy, with an aggressively placed, dense, broad, hairline and little hair to support it towards the back.

The gamble is that the patient’s baldness doesn’t progress, that finasteride or dutasteride can halt the process if it does progress, or that hair cloning methods will be available to save the day.

In my opinion, elective surgery should not be performed when its success depends upon these uncertainties – and particularly since a cosmetically disfiguring hair transplant can be so debilitating (and avoidable).

The reality is that doctors who claim to perform these procedures may not even be performing follicular unit transplantation. In FUT, the surgeon transplants naturally occurring intact FUs of 1-4 hairs. The extreme dense packing techniques preclude the use of 4- and sometimes even 3-hair grafts. What happens is that the larger FU are spit up. This doubles the graft counts (and the cost to the patient) without giving the patient any more hair. It also increases the risk of follicular damage and poor growth.

Patients in whom 10,000 follicular units are available to transplant are very rare and when they are shown on the internet, should be viewed as the exception rather than the rule.

A: We generally do not consider hair transplantation until a person is at least 25. There are a number of reasons why hair transplants are not indicated in someone younger than this.

When hair loss starts at an early age, the pattern is unpredictable and the hair loss has a greater chance of being extensive in the future. Also, the permanency of the donor area cannot be determined (see the Diffuse Unpatterned Alopecia (DUPA) page on the Bernstein Medical – Center for Hair Restoration website).

If hair loss is going to be extensive, then the best that one can expect from a hair transplant is to replace hair on the front and top of the scalp. There would usually not be enough hair to fill in the temples or the crown. This look is fine for a person in their 30’s or 40’s who is losing hair, but having a thin or bald crown is not generally acceptable for someone in their 20’s.

Hair transplants are more efficient if performed in relatively large sessions. Multiple, small incisions in the back of the scalp (either by Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE)) consume more hair than when the hair is harvested through a single incision. In addition, when hair loss is early and there is a lot of miniaturized hair in the area to be transplanted, the hair transplants can actually accelerate hair loss in the area in the vicinity of the procedure.

If one were to try and fill in the temples of a young person, a substantial amount of hair would be needed so that the density of the transplanted hair would match the density of the surrounding (already existing) hair. As the person continued to lose hair in the center, the densely transplanted hair in the temples would stand out as two permanent “horns” of hair. Hair placed in the crown would create the same problem, as enough density to satisfy a young person would result in a pony tail as the hair loss in the crown progressed and the bald area expanded around the transplanted area. With advanced baldness, there may not be enough donor hair to connect these areas together, so the result will be a very unnatural look.

In the adult male, the frontal hairline is normally recessed at the temples, so this should not be restored unless the patient’s donor density is very high and the ultimate hair loss pattern limited – two conditions that cannot be determined when a person is young.

On the other hand, medical therapy with finasteride (Propecia) can be very effective in early hair loss by possibly growing some hair back and more importantly by slowing or halting the balding process for many years. The sooner the medication is started the more useful it is, because it works far better in preventing hair loss than bringing it back once the hair is gone. Unfortunately, it will not grow hair back in the temples if this area is completely devoid of hair. Medications work by reversing the miniaturization process, so there must be some existing hair in the area for it to act on.

In sum, it is best to wait until you are a bit older before considering surgical hair restoration. By having hair transplants at a slightly older age, your expectations may be closer to what can actually be accomplished, and your eventual hair loss pattern will be easier to determine. In the meantime, medical treatment with Finasteride, is a good option.

A: The findings that you are describing are well documented; however, it is not clear if these changes are the cause of the hair loss or are the result of having lost one’s hair. Most likely, the DHT causes the hair follicles to miniaturize and eventually disappear. This, in turn, causes the scalp to thin and lose its abundant blood supply (whose purpose is to nourish the follicles). The changes in the scalp are also affected by normal aging, which causes alterations in connective tissue including the breakdown of collagen and other components of the skin. The changes seen with aging are greatly accelerated by chronic sun exposure.

Fortunately, even with long-standing baldness there is still enough blood supply to support a hair transplant, although there are some limitations. One should perform a hair transplant with a lower density of grafts when patients have thin, bald fibrotic scalps since the blood supply is diminished.

The most important factor, however, is photo change. The sun dramatically alters the connective tissue making the grafts less secure in their sites and alters the vasculature, (blood vessels) decreasing tissue perfusion (blood flow to the tissues). When there is bald atrophic, sun damaged scalp, I generally perform two hair transplant sessions of lower density (in place of one) spaced at least a year apart to give time for the scalp to heal and blood flow to increase in the area.

I often have the patient treated with topical 5-flurouracil before the surgery to improve the quality of the skin and to treat or prevent pre-cancerous growths from the sun.

A: How much hair can be harvested in total depends upon a number of factors besides donor density. These include: scalp laxity, hair characteristics (such as hair shaft diameter, color and wave), and the actual dimensions of the permanent zone.

Every person is different, so all of these factors would need to be taken into account to determine the total number of grafts that would be available for the hair restoration.

A: Popping, or the tendency for grafts to elevate after they have been placed into the recipient area, is caused by a number of factors including:

• Packing the grafts too closely, particularly when they are placed on a very acute (sharp) angle with the skin
• Rough placing techniques
• Bleeding
• Poor fit between the graft and recipient site
• Natural characteristics of the patient’s skin, including the elasticity and stickiness of wound edges

The problem with popping is that it exposes grafts to drying (while they are elevated on the skin surface) and trauma (when they have to be re-inserted).

The judgment and experience of the surgeon performing hair transplants is extremely important in minimizing popping. It is important that the surgeon customize the site size to the different size follicular unit grafts and to test the recipient sites as they are made, to make sure that the “fit” is perfect.

Although it is important to place grafts close together to get the best cosmetic result possible, over-packing of the grafts risks popping and other factors (such as overwhelming the blood supply) that may lead to poor growth.

In the end, maximum growth of the transplanted hair should be the primary goal.