Male pattern baldness or androgenetic alopecia is caused by the effects of the male hormone dihydrotestosterone (DHT) on genetically susceptible hair follicles that are present mainly in the front, top, and crown of the scalp (rather than the back and sides). DHT causes hair loss by shortening the growth, or anagen, phase of the hair cycle, causing miniaturization (decreased size) of the follicles. The effected hair becomes progressively shorter and finer until it eventually disappears. (See Cause of Hair Loss in Men)

DHT is formed by the action of the enzyme 5-alpha reductase on testosterone. Finasteride is a drug that works by blocking the enzyme 5-alpha reductase Type II that converts testosterone to dihydrotestosterone (DHT) in the hair follicle. Propecia, the brand name for finasteride, is the only FDA approved oral medication for hair loss.

Finasteride causes a significant drop in both scalp and blood levels of DHT and its effect is felt to be related to both of these factors. Finasteride 1-mg/day decreases serum DHT levels by almost 70%. Serum testosterone levels actually increased by 9%, but this is within the range of normal.

It is commonly thought that finasteride was first conceived as a prostate medication and that, only by chance, was found to prevent hair loss. The fact is that in 1974 the researcher Imperato-McGinley described a group of genetically male children from the village of Salinas in the Dominican Republic who were deficient in the enzyme 5-alpha reductase. These male children had very low levels of DHT and throughout their life, their prostates remained small and they did not develop male pattern hair loss or acne.

The objective of the researchers was to find a drug that could block the 5-alpha reductase enzyme and mimic the abnormality found in these men. They could then use this drug to prevent both prostate enlargement (BPH) and hair loss. The decision was made, however, to obtain FDA approval for the medical indication first, rather than the cosmetic one. As a result, in 1992, Finasteride 5-mg was released under the brand name Proscar, for use in men over 50 with prostate enlargement (the prostate also has the type II enzyme). Five years later, in 1997, the FDA approved finasteride 1-mg/day (Propecia) for the treatment of male pattern baldness.

Studies have shown that after five years of treatment, 90% of men taking finasteride maintained their hair or increased hair growth. At five years, 48% of men treated with Propecia demonstrated an increase in hair growth, 42% were rated as having no change (no further visible progression of hair loss from baseline) and 10% were rated as having lost hair when compared to baseline.

In comparison, 6% of men treated with placebo demonstrated an increase in hair growth, 19% were rated as having no change and 75% were rated as having lost hair when compared to baseline.

In the “Hair Count Clinical Study,” hair counts showed an average gain of 277 hairs per one-inch circle at the end of five years. These hairs were significantly larger than the fine, miniaturized hair characteristic of balding. In the “Hair Weight Clinical Study,” a 34% increase in hair weight was observed between Propecia and the placebo at 96 weeks.

Effectiveness on the Front of the Scalp

The indication for Propecia includes the treatment of hair loss in the front part of the scalp. There are published data from a controlled clinical trial of men with frontal hair loss that demonstrates improvement in this region of the scalp.

Before & After Photos of Patients who use Medication Alone to Treat Hair Loss:

Using Propecia

Propecia should be taken once daily with or without meals. Patients must take Finasteride for one year or longer before its effects in preventing hair loss and re-growing hair can be accurately assessed. Finasteride takes up to a year or more to exert its full effects in both preventing hair loss and in re-growing hair. During the first six months you may note some thinning of your existing hair. This may be due to either progression of your hair loss before finasteride has had a chance to work or some shedding of miniaturized hair that makes way for the new healthy anagen hair to grow. It is important to be patient during this period. You should continue the medication for at least one year before you and your doctor can assess its benefits.

Side Effects

Side effects from finasteride at the 1-mg dose are uncommon, but reversible. The one- year drug related side effects were 1.5% greater than in the control group. The data showed that 3.8% of men taking finasteride 1mg experienced some form of sexual dysfunction verses 2.1% in men treated with a placebo. The five-year side effects profile included: decreased libido (0.3%), erectile dysfunction (0.3%), and decreased volume of ejaculate (0.0%).

Most reported cases of sexual dysfunction occurred soon after starting the medication, but there have been reports of sexual dysfunction that have occurred at later points in time. The sexual side effects were reversed in those who discontinued therapy, and in 58% of those who continued treatment. After the medication was stopped, side effects generally disappeared within a few weeks. There have been anecdotal reports where side effects have persisted after discontinuation of therapy.

When finasteride is discontinued, only the hair that had been gained or preserved by the medication is lost. In effect, the patient returns to the level of balding where he would have been had he never used the drug in the first place. No drug interactions of clinical importance have been identified.

Effects on Body Hair

When finasteride is used to re-grow scalp hair, it may also inhibit the growth of body hair. The reason is that DHT stimulates the growth of body hair in adult males and the formation of DHT is blocked by finasteride. However, the genetic variation among people is too great to know how an individual person may respond. For those who may be concerned, finasteride will not increase body hair growth. Read more on the Hair Transplant Blog about the effects of finasteride/propecia on body hair.

Adverse Reactions

Adverse reactions related to the breast, including breast tenderness or breast enlargement (gynecomastia), occurred in 0.4% of men taking finasteride 1-mg (Propecia), but this was no greater than in the control group. Other side effects that were not statistically significant included hypersensitivity reactions including rash, pruritus, urticaria, swelling of the lips and face, and testicular pain.

Effects on PSA

Finasteride causes a decrease in serum PSA (prostate specific antigen) by approximately 50% in normal men. Since PSA levels are used to screen for prostate enlargement and prostate cancer, it is important that your personal physician is aware that you are taking Propecia (finasteride) so that he/she may take this into account when interpreting your PSA results.

Finasteride and Prostate Disease

A study in The New England Journal of Medicine, in 2003, on finasteride 5-mg PROSCAR (not finasteride 1-mg, Propecia) reported that in the Prostate Cancer Prevention Trial (PCPT), men treated with finasteride 5mg for seven years had a 25 percent relative risk reduction for prostate cancer compared to the men treated with placebo. The authors also reported that high grade prostate cancers were found in 6.4 percent of the men treated with finasteride 5mg, compared to 5.1 percent of the men in the placebo group.

The authors were concerned that finasteride 5mg prevents or delays the appearance of prostate cancer and that this possible benefit and a reduced risk of urinary problems must be weighed against sexual side effects and the increased risk of high-grade prostate cancer. With new information, it is now felt that the increased incidence of a higher grade cancer was due to the fact that the finasteride shrunk the non-cancerous part of the enlarged prostate, making the cancerous part easier to detect on biopsy.

In fact, in 2009, the American Society of Clinical Oncology and the American Urological Association issued guidelines that recommend that healthy men consider finasteride to lower their level of the hormone dihydrotestosterone (DHT) with the goal of preventing the development of prostate cancer.

Caution during Pregnancy

Finasteride use is contraindicated in women when they are, or may be, pregnant. Women should not handle crushed or broken Propecia tablets when they are pregnant, or may potentially be pregnant, because of the possibilities of absorption of finasteride and the subsequent potential risk to a male fetus. Propecia tablets are coated and will prevent contact with the active ingredient during normal handling, provided that the tablets have not been broken or crushed.

Exposure of pregnant women to semen from men treated with Propecia poses no risk to the fetus.

Use in Post-Menopausal Women

Merck recently carried out a study to evaluate the efficacy of finasteride in post-menopausal women. After one year there was no significant hair growth and, as a result, the study was terminated. An explanation is that hair loss in women is related more to the action of the enzyme aromatase (which is unaffected by finasteride) rather than DHT. It is also possible that the low DHT levels observed in postmenopausal women are responsible for the lack of significant response to finasteride. (See Causes of Hair Loss in Women).

Long-Term Benefits and Risks

The effects of finasteride are confined to areas of the scalp that are thinning, but where there is still some hair present. It does not grow hair in areas that are completely bald. Although it can regrow hair in thin areas, the major benefit of finasteride seems to be in its ability to slow down or halt hair loss. Results generally peak around one year and then are stable in the second year or decrease very slightly. Although the long-term ability of finasteride to maintain one’s hair is unknown, the majority of men find that after 5 years the medication is still working.

The benefits of finasteride will stop if the medication is discontinued. Over the 2-6 months following discontinuation, the hair loss pattern will generally return to the state that it would have been if the medication had never been used.

Propecia and Hair Transplantation

Propecia (finasteride) has shown to be useful in complementing a hair transplant for several reasons:

1. Propecia works best in the younger patient who may not yet be a candidate for hair transplantation.
2. Propecia is less effective in the front part of the scalp, the area where surgical hair restoration can offer the greatest cosmetic improvement.
3. Propecia can re-grow hair, or stabilize hair loss, in the back part of the scalp where hair transplantation may not always be indicated.

For those who choose not to take Propecia, or who cannot take it due to its side effects, the surgical hair restoration is just as effective. The only difference is that medications can prevent further hair loss whereas surgery cannot. Medications are not needed for a hair transplant to be successful or the transplanted hair to grow and be permanent.

Generic Finasteride

Finasteride 5mg (Proscar) is available in a generic formulation. (Propecia) will not be available generically until the year 2012. For those wanting to take generic finasteride, we recommend buying a pill cutter at the pharmacy and taking ¼ of a 5mg tablet every day. Please be advised that there is no scientific data insuring that this will be as effective as Propecia 1mg a day. Also, remember that there is a potential risk to pregnant women from handling broken or crushed tablets.

Increasing the Dose

We are often asked if one should increase the dose of Propecia. Although we do increase the dose under certain circumstances, there is no scientific evidence that increasing the dose will have any additional effects. There are published data demonstrating that 5 mg is no better than 1 mg from controlled clinical trials. In practice, I often increase the dose when someone has been on the same dose of medication for about three years and then stops responding (begins to lose hair after being stable). When increasing the dose, I generally use generic finasteride 5mg, ½ pill a day.

Prostate Cancer Screening

The American Cancer Society and the American Urological Association recommend the following screening ages:

• Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years.
• Age 45 for men at high risk of developing prostate cancer: African American men and men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer younger than age 65.
• Age 40 for men at even higher risk (those with several first-degree relatives who had prostate cancer at an early age).
• Regardless of age, yearly screening for PSA level if 2.5ng/ml or higher, and every 2 years for less than 2.5ng/ml.

An evaluation should include a rectal examination, a PSA, and other tests that your examining physician feels are appropriate. The above are general guidelines recommended men regardless of whether they use finasteride or not. Specific recommendations for each patient should be based upon the judgment of his own physician.

Common Misconceptions about Finasteride

Myth: Women can’t touch the medication.
Fact: Pregnant women should not handle crushed or broken tablets.

Myth: It only works in the crown.
Fact: It potentially works any where on the scalp where there is some hair, even in the front of the scalp.

Myth: Once you start it you must take it for ever.
Fact: You can stop the medication any time you want – you just lose its benefits when one stops.

Myth: Finasteride lowers testosterone.
Fact: The medication, on average, causes a rise in serum testosterone levels by 9%.

Myth: The sexual side effects are frequent.
Fact: The sexual side effects occur in approximately 4% of patients taking the medication.

Myth: Finasteride causes birth defects if a man takes it when his wife is pregnant.
Fact: Exposure of pregnant women to semen from men treated with Propecia poses no risk to the fetus.

Myth: Propecia was originally a prostate medication that was found to prevent hair loss.
Fact: Propecia is not a prostate medication that was by chance noted to have a side effect of hair growth, it is a medication that was known since its discovery that it could grow hair.

Additional Information

To learn more about Propecia see the Bernstein Medical Finasteride Information Sheet and the Prescribing Information provided by the company.

To hear answers to frequently asked questions about the use of this medication, go to the Drugs (Medications) section of the Bernstein Medical Hair Transplant Blog.

The following are frequently asked questions regarding hair transplantation. For additional entries, please see the Hair Transplant topic at the Hair Transplant Blog.

Q: My hair is fine. Is that a problem for a hair transplant? ~ W.S., Manhattan, NY

A: Fine hair will give a thinner look than thicker hair, but will look completely natural. Thin hair doesn’t prevent one from having surgical hair restoration, providing your donor density and scalp laxity are adequate.

Q: This is my second hair transplant surgery and it seems like it is growing more slowly than my first. Is this normal? ~ H.S., Brooklyn, NY

A: It is common for a second hair transplant to take a bit longer to grow than the first, so this should be expected. It is also possible that there is some shedding from the procedure, or a continuation of your genetic hair loss. Propecia may be helpful in this regard. It is important to wait at least a year for the hair transplant to grow in fully and to give a chance for any hair that was shed to regrow.

Q: I had a hair transplant two weeks ago and I just started noticing that some grafts were in my baseball cap at the end of the day. Am I losing the transplant and what can I do to keep this from happening? ~ Z.K., New York, NY

A: The follicles are firmly fixed in the scalp 10 days following the hair restoration surgery. Hair is shed from the follicle beginning the second week after the procedure. This is perfectly normal and does not represent any loss of grafts. What you are seeing is the root sheath that is shed along with the hair shaft. This looks like a little bulb, but is not the growth part of the follicle and should not be a cause for concern. Two weeks following the hair transplant surgery you may shower and shampoo your scalp as you normally did before the procedure without any risk of losing grafts.

Q: Should I cut my hair prior to the hair transplantation? ~ G.K., Long Island, NY

A: It is easier for the hair transplant surgeon and his team to work when the existing hair in the area to be transplanted is cut short, but a skilled surgeon can work well in either situation. Most experienced surgeons in the New York area are used to working without cutting the hair in the recipient area.

The main advantage of having a closely clipped scalp is that one has better visibility and therefore the hair replacement procedure moves along faster. This has little bearing in moderately sized sessions, but becomes very important in sessions over 2,400 grafts, when working through existing hair can make the duration of the hair transplantation procedure excessively long. Of course, the disadvantage of clipping the hair is that it is more difficult to “hide” the procedure.

I prefer for the patient to arrive the morning of the scheduled hair restoration surgery with his/her hair having some length so that I can better see the demarcation of the area of thinning. Once the area is marked, the hair can be clipped to the appropriate length in the OR. Although hair transplants will be more visible post-op if the hair is clipped short, it is much easier for the scalp to be kept free of crusts.

It is important to differentiate between a closely clipped scalp, which is an advantage, and a shaved head, which makes performing the hair transplant surgery more difficult. When there is some existing hair, the distribution and angle of the original hair is easy to discern and this allows the new grafts to be placed in a direction that follows the existing hair and in a distribution that complements that hair.

Q: How are recipient sites made during a hair transplant? ~ L.F., Manhattan, NY

A: At Bernstein Medical, we use tiny needles of varying sizes. See recipient sites for hair transplants. At the start of the hair replacement procedure, the different size follicular units are fitted to specific site sizes to determine exactly the best size instrument to use for each graft. By custom fitting the sites to the grafts, healing is incredibly fast and patients are able to gently shampoo their scalp the day following hair loss surgery. All recipient sites are made using lateral slits, as these give the most full, natural coverage.

Q: How did Follicular Unit Transplantation and Follicular Unit Extraction get their names? ~ L.G., Long Island City, NY

A: The first paper on Follicular Unit Hair Transplantation was published by Dr. Bernstein and Rassman in 1995 in the International Journal of Aesthetic and Restorative Surgery. The title of the paper used the abbreviated name “Follicular Transplantation.” The longer name “Follicular Unit Transplantation” was formalized by Bernstein et. al. in the paper “Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques.” This paper appeared in Dermatologic Surgery in 1998. Follicular Unit Extraction derived its name from Rassman and Bernstein’s publication “Follicular Unit Extraction: Minimally invasive surgery for hair transplantation” that appeared in Dermatologic Surgery in 2002. Read these publications and more on our medical publications page.

Q: If my hair is just starting to thin, when should l have my first hair transplant? ~ J.K., New York, NY

A: It is best to wait until at least twenty-five years of age before considering surgical hair restoration, although there are exceptions. The most important thing is to wait until you have hair loss that is a cosmetic problem. Hair transplants are a treatment for hair loss – they should not be used as a prevention; that is what medications are for. Some hair loss in the temples is normal for a person in their mid- to late 20s as this represents the progression to a normal mature adult hairline. The hair loss needs to be significant before you should contemplate surgery. This issue is detailed in the publication “Follicular Transplantation: Patient Evaluation and Surgical Planning.”

Q: After a strip procedure, will the scalp’s laxity return to normal and how long after the hair transplant does it take? ~ L.L., Queens, NY

A: Following hair transplantation, the scalp regains most of its laxity in the first eight months, but it will continue to loosen slightly after that. It is interesting that if the scalp is tight prior to hair loss surgery, the scalp is less likely to have its full laxity return than in patients who had loose scalps to begin with. With average or loose scalps, there is usually no difference. However, over time, the patient rarely, if ever, notices any permanent tightness, unless aggressive procedures have been performed or procedures such as scalp reductions and lifts.

Q: Can you get your original density back with a hair transplant? ~ A.J., New York, NY

A: Although the cosmetic benefit can be dramatic, a hair transplant only “moves” rather than creates new hair. In hair restoration surgery, a limited amount of hair from the donor area is transplanted to a much larger area in the front and top of the scalp, so that we can never reach the original density. Achieving a cosmetically appropriate density in the front part of the scalp (which is around 1/3 to 1/2 of the original density) generally takes two sessions and is the goal of most hair replacement surgery.

Q: Can you perform a hair transplant into scar tissue? ~ A.H., Rockland County, NY

A: Yes, hair grows in scar tissue, but not quite as well as in normal tissue. The scar is not as elastic as normal tissue so the grafts are at slightly higher risk of being dislodged; therefore, more care must be taken to protect the grafted area after the hair transplant surgery. In addition, the blood supply in scar tissue is less than in normal tissue, so that area should not be transplanted as densely and the hair replacement should be performed over multiple hair transplant sessions. Finally, grafts do not grow well in thickened scars. If a scar can be thinned using injections of cortisone, it may improve the chance that the transplanted hair will grow.

Q: I have not seen any research in the medical literature that indicates to me that cloning is close at hand. Am I missing something? ~ G.L., New York, NY

A: Possibly the most interesting work related to hair cloning was done by Colon Jahoda in England. Jahoda’s work is significant because he identified an inducer cell i.e. fibroblasts in the outer portion of the hair follicle (the outer root sheath) that can stimulate the skin to produce new hair. It is well known that fibroblasts, unlike many other tissue cells, are relatively easy to culture. Theoretically, a patient’s fibroblasts could be removed from the sheaths of just a few follicles and then cultured to produce thousands of follicles. These fibroblasts could then be injected back into the scalp to induce thousands of new hair follicles to grow. In the study fibroblasts from a man were injected into the forearm of a genetically unrelated woman. The cross-gender aspect of his experiment has received much publicity and is of potentially great importance to burn victims etc., but has little relevance to hair transplant procedures for male pattern baldness, as hair loss patients would probably benefit most from using their own cultured fibroblasts to achieve the best match. So far this important single study has not been reproduced. Read about this topic in our Hair Cloning section, or in the Hair Cloning topic on the Hair Transplant Blog.

Q: What is graft compression? ~ J.J., Brooklyn, NY

A: Graft compression refers to a tufted look resulting from the surrounding skin squeezing a larger graft as the hair transplant heals. This was a common occurrence with mini-micrografting where 5 or more hairs from two or more follicular units were placed into one recipient site. With follicular unit hair transplantation, follicular units won’t show visible compression since they are already naturally compact. One reason why FU’s are valuable in a transplant is that they are compact enough to fit into a very small site. It is important, however to “customize” the site size to the size of the graft so the fit is just perfect. This speeds up healing, enables the patient to shampoo the day after the hair restoration surgery, and enhances graft growth.

Q: What is Follicular Unit Transplantation and how is it different from Follicular Unit Extraction? ~ J.B., New York, NY

A: Follicular Unit Hair Transplantation, called FUT for short, is a procedure where hair is transplanted in the naturally occurring groups of 1-4 hair follicles. During this type of hair transplant, a donor strip is removed from the back and sides of the scalp and then sutured or stapled closed, generally leaving a thin, fine-line scar. Individual units, or groups of hair, are then dissected from this donor strip using stereo-microscopes.

In Follicular Unit Extraction (FUE), the individual units are removed directly from the back or sides of the scalp, through a small round instrument called a punch, so that there is no linear scar. There is, however, scaring from the removal of each follicle. Although the scars of FUE are tiny and round, the total amount of scarring is actually more than in FUT. With robotic FUE now being performed at Bernstein Medical – Center for Hair Restoration in New York City, the accuracy of follicular unit extraction is significantly improved. Read more about the pros and cons of each surgical hair restoration procedure and about Robotic FUE.

Q: I understand that even if you have multiple hair transplants you will only be left with one scar in the donor area. ~ A.J., New York, NY

A: If the closure is performed by the hair transplant surgeon without tension, each procedure should result in the same fine scar. The best-placed incision is in the mid-portion of the permanent donor area. Since there is only one mid-point, there is one best position for the scar. All incisions should lie on this plane leaving one scar. All incisions, therefore, should lie on this plane, leaving only one scar, regardless of the number of procedures.

Q: What are your thoughts on performing hair transplants to the crown first? ~ P.K., Staten Island, NY

A: It depends upon the person’s age, how bald he is likely to become, and the donor supply. As a general rule, the crown should not be transplanted in a younger person (under 30) as the extent of his balding is hard to predict and crown thinning at this age often suggests that the person will become at least a Norwood 6. If a person has abundant donor hair, i.e. good donor density and scalp laxity, so that coverage of the entire bald area can be accomplished if the patient becomes a Norwood class 6 (and it is unlikely that he will become a Class 7) then transplanting the crown before the front is reasonable.

If a person has a family history of baldness limited to the crown, even at an advanced age, and the person in question is following this pattern, then earlier treatment of the crown may be considered. Lastly, if you do treat the crown in a younger person, or in whom the extent of hair loss is uncertain, the crown should be transplanted with light coverage only so that just a limited amount of hair will be used up in this area and there will be enough left over for the cosmetically more important top and front of the scalp. For a complete review of this topic please read: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. A copy in PDF format can be downloaded at our Medical Publications page.

Q: Does dense packing hurt grafts? ~ G.B., New York, NY

A: There is no absolute answer to this question. In hair transplants, dense packing has a risk of decreasing yield if there is a significant amount of photo (sun) damage to the scalp (which alters the blood supply) and if there is a tendency for the grafts to pop (this is difficult to predict pre-operatively). Very closely spaced grafts exacerbates the popping and exposes the grafts to desiccation (drying), hypoxia (lack of oxygen) and mechanical trauma from the necessary re-insertion. That said, the skill of the hair restoration doctor and placing team, the size of the recipient sites, and the way the grafts are dissected and trimmed all play important roles in determining graft survival in dense packing.

Q: Is it possible to have a hair transplant that is totally undetectable immediately following surgery? ~ M.Z., New York, NY

A: Not unless a person has a fair amount of existing hair that can cover the transplanted area. Although surgical hair replacement techniques have improved dramatically over the past ten years, and wounds are so small that patients may shower the morning following the procedure, a hair transplant will be detectable for the first week. During this period, there may be some swelling that settles down on the forehead and some crusting and some residual redness. Please visit our After Your Hair Restoration page for more details on the normal post-op course following a hair transplant.

Q: When a second hair transplant is performed, should there be a second incision or should it be incorporated into the first? ~ J.B., Bronx, NY

A: It is a very common practice to make a second separate scar in the second hair replacement procedure. This is done to maximize the hair in the second session and is the easiest technically to do. If you incorporate the old scar in the new incision, there will obviously be less hair. As long as the upper incision is still in the permanent zone, the hair quality will be good. That said, in my practice I almost always use only one scar during hair transplants that I perform. The subsequent procedure would incorporate the first and extend the scar to one side or the other (or both). I generally use the old scar as one edge of the new strip so that there is only one incision into virgin scalp (rather than two). There are a number of reasons for this hair transplant surgery technique.

1. The hair will always be taken from the mid-portion of the permanent zone, so we utilize the thickest, most stable hair.
2. A line scar in this location is generally the least visible and most easily camouflaged with the persons existing hair.
3. One avoids making a scar too low that increases the risk of widening the scar.
4. One scar will be easier to camouflage with FUE (if this is ever necessary).

Read more about Donor Scars on the Hair Transplant Blog.

Q: What is “shock fall out”? ~ J.S., New York, NY

A: Shedding after hair transplant surgery is also referred to by the very ominous sounding term “shock fall out,” or “shock loss.” The correct medical term is “effluvium” which literally means shedding. It is usually the miniaturized hair — i.e. the hair that is at the end of its lifespan due to genetic balding — that is most likely to be shed. Less likely, some healthy hair will be shed, but this should re-grow. Interestingly, if hair transplants are spaced less than one year apart, one often notices some shedding of the hair from the first transplant, but this hair grows back completely. For most patients, effluvium is not a major issue and should not be a cause for concern.

Typically, when shedding occurs, a patient looks a little thinner during the several month period following the transplant, before the transplanted hair has started to grow. The thinning is often more noticeable to the patient than to others. Shedding is generally noted as a thinning, rather than of “masses of hair falling out,” as the term “shock fall out” erroneously suggests.

In general, the more miniaturization one has and the more rapid the hair loss, the more likely shedding will be from the hair replacement surgery. Young, actively balding patients would be at the greatest risk. Older patients with stable hair loss would have the least risk. In either situation, since miniaturized hair is eventually going to be lost, the effluvium has no long-term effect on the outcome of the procedure.

It is important to differentiate the phenomena described above from shedding of the hair in the graft. This shedding is an almost universal characteristic of a hair transplant procedure and occurs because during a hair transplant a graft is temporarily stripped of its blood supply. As a response to this insult, the graft sheds its hair. This shedding is generally noted beginning a week following the procedure and can continue for up to six weeks. A very small percentage of patients do not shed and the transplanted hair continues to grow. In others, the transplanted hair remains on the scalp for months until a new hair pushes it out. Whether a patient sheds or not has no bearing on the ultimate outcome of the surgical hair restoration.

There are a number of ways to minimize the effects of post-operative shedding: the first is using medication, the second is timing the transplant properly, and the third is performing a procedure using a sufficient number of grafts.

• Medication
  Finasteride 1mg reverses or halts the miniaturization process in many individuals and is thus the logical way to decrease the risk of shedding following hair transplantation. Although many physicians have had the clinical impression that this assumption is correct, there has been no controlled studies to date that prove this.
• Timing and the size of the hair transplants
  It is important to wait until a patient is ready to have a hair transplant, and then to perform one of sufficient size so that if there is some shedding, the procedure will more than compensate for it – and thus be worthwhile. A problem that patients often run into is that they present to their doctor with early hair loss but with a significant amount of miniaturization. The hair restoration doctor performs a small procedure and it does not even compensate either for potential shedding or for progression of the hair loss. The result is that the patient is thinner (or more bald) than he was before the procedure. The doctor rarely blames the problem on the fact that the hair replacement procedure was too small or that the miniaturization was not taken into account, but only that the patient continued to bald. The better solution is to treat early hair loss with medication, but once you make a decision to begin hair restoration surgery, have a procedure large enough to make a significant cosmetic improvement.

As a final point, it is a fallacy that some doctors’ techniques are so impeccable that they can avoid effluvium or those “small” procedures will avoid shedding. Of course, bad techniques and rough handling will maximize effluvium, but effluvium is what hair naturally does when the scalp is stressed and it is stressed during a hair transplant from the anesthetic mixture and the recipient site creation. It is important to note that it cannot be totally prevented. Despite claims to the contrary, Follicular Unit Extraction has no bearing on this process as it is a harvesting rather than a placing technique.

In sum, the best way to deal with effluvium is to treat with Finasteride when hair loss is early, perform a hair transplant only when indicated and finally, to perform a hair transplantation procedure with skill and to use a sufficient number of grafts.

Q: Can you use beard hair for a hair transplant using Follicular Unit Extraction? ~ A.H., Rochester, NY

A: It is possible to use beard hair for hair transplants, but there are three main differences between harvesting from the donor area and harvesting from the beard that should be taken into account. These are: 1) scarring 2) ease of extraction and 3) hair quality.

In Follicular Unit Extraction (FUE), although there is no linear scar, there are small white round scars from where the hair is harvested. Normally these marks are hidden in the donor area and are not visible, even if the hair is clipped very short. However, if the scalp is shaven, these marks will become visible. When the beard is used as the donor source for the hair transplant, the patient must continue to wear a beard after the restoration, even if it is tightly cropped, or the faint white marks will show. The tiny round scars from FUE will generally be visible on a clean shaven face. As each person heals differently, we would perform a test before doing the actual hair replacement procedure to make sure the marks from the extraction are not noticeable at the length that the person wants to wear his beard.

FUE performed on beard hair also differs from the scalp because of the greater laxity of facial skin. This makes extraction with minimal transection more difficult in some cases. A test prior to the hair transplant is particularly important in beard FUE so that the ease of extraction may be determined in advance.

Third, beard hair is coarser than scalp hair. Although the hair seems to take on some of the characteristics of the original hair in the transplanted area, this change is not complete, making beard hair an imperfect substitute for scalp hair. A solution to the problem is to use beard hair behind the hairline for volume and scalp donor hair at the hairline for naturalness.

Q: Should one stay on Propecia after a hair transplant? ~ L.D., New York, NY

A: Yes. Although there is some overlap, medication and hair loss surgery do two different things. Surgery (a hair transplant) is most useful to replace hair that has already been lost. Medication (finasteride) prevents further loss. Surgical hair restoration does nothing to prevent the progression of genetic balding and medication cannot grow hair in areas that are completely devoid of hair. Therefore, one should use hair transplantation surgery to restore hair in areas that medication won’t work, but use medication to retard the further hair loss.

Q: Can you shave your scalp after a hair transplant with FUE without noticing scarring in the donor area? ~ T.C., New York, NY

A: Although there is no line scar in FUE there are tiny round ones. You can clip your hair very short after FUE; however, shaving your head will make the very fine white scarring visible.

Q: Is it true that smoking is bad for hair transplants and why? ~ D.I., Queens, NY

A: Smoking causes constriction of blood vessels and decreased blood flow to the scalp, predominantly due to its nicotine content. In addition, the carbon monoxide in smoke decreases the oxygen carrying capacity of the blood. These factors both contribute to poor wound healing after a hair transplant and can increase the chance of a wound infection and scarring. Smoking may also contribute to poor hair growth.

The harmful effects of smoking wear off slowly after one stops. Particularly in chronic smokers, one is at risk to poor healing even after smoking is stopped for weeks or even months. Although it is not known exactly how long one should avoid smoking before and after a hair transplant surgery, a common recommendation is to abstain from 1 week prior to surgery to 2 weeks after the hair transplantation procedure.

Q: How do you know if you have lost any grafts after a hair transplant and how long after the hair transplant can you still lose them? ~ G.H., New York, NY

A: Each day following the surgical hair restoration, the transplanted grafts become more fixed in the scalp and the hairs in the grafts become more dissociated (loose). At nine days post-op, the grafts are fixed firmly in the scalp – it has essentially become part of the scalp in the new area and can’t be dislodged. The hair, however, has totally separated from the follicle by this time, so that it can easily be pulled out without dislodging the remainder of the follicle that contains the growth center. When this hair is pulled out (or is naturally shed) one often sees a tiny bulb at the end. This is the root sheath of the hair and not the growth center. This is normal and is not a lost graft. If a graft is lost, an event that may occur within the first 3-4 days following hair replacement surgery, it is almost invariably associated with a small amount of bleeding. For details on how to care for the hair transplant visit: After Your Hair Restoration.

Q: Can hair be transplanted from one person to another? ~ Y.R., New York, NY

A: A hair transplant between individuals can only be performed on identical twins, since they are genetically the same. In all other cases, including non-identical siblings, the transplanted hair will be rejected. We are often asked how it is that one can perform kidney transplants from one person to another, but not hair transplants. The reason is that the skin is more antigenic than a kidney, i.e. it is more likely to be rejected. The reason is complex, but this makes sense considering that the skin is the first line of defense against foreign organisms.

Q: What causes graft popping during a hair transplantation? ~ A.B., Long Island, NY

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, and the natural characteristics of the patient’s skin, including the elasticity and stickiness of wound edges. The problem with graft 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 hair transplant surgeon 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.

Q: After bad hair restoration surgery, can you use lasers or electrolysis to remove the transplanted hair? ~ G.A., New York, NY

A: Electrolysis does not work well, because the follicular anatomy is distorted and it is too difficult to insert the needle in the right position. Lasers will work as well with transplanted hair as it will with normal hair but, in either case, it takes multiple treatments. The disadvantage of both procedures is that they destroy the hair that is removed and they do nothing to improve the appearance of the underlying skin (which is often scarred and made more visible when the hair is gone). Graft excision, on the other hand, allows the hair to be reused and can often improve the appearance of the underlying skin. Read more in our Hair Transplant Repair section. View before and after hair transplant photos of some of our repair patients.

Q: If someone doesn’t have enough donor hair, do you ever perform hair transplants using FUE, using donor hair from outside the permanent hair zone? ~ Y.L., Manhattan, New York, NY

A: No. If hair was taken from outside the permanent zone, as the surrounding hair continued to bald, the scars from Follicular Unit Extraction (FUE), although small, would become visible. In addition, the transplanted hair would not be permanent, and over time, would eventually fall out.

Q: Will I be unconscious during the hair transplant procedure and do you use general anesthesia? ~ W.S., New York, NY

A: All of the surgical hair restoration procedures at Bernstein Medical’s facility in New York City are performed under local anesthesia. The fact that general anesthesia is not needed is what makes hair transplant procedures – even though they are long – very safe. Patients are given a sedative to help them relax, but they are not put to sleep. Most patients watch TV, movies or just chat during the procedure.

Q: Is it possible to tell me roughly how many grafts would be left from donor area if one had a hair transplant of 2,500 grafts and had a density of around 2.0? ~ G.H., New York, NY

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 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. Visit the Graft Numbers page for a detailed discussion of this topic.

Q: I have a scar on the top of my head the size of a quarter from an old injury. I would like hair to grow back on the bald spot. Can a hair transplant re-grow hair on the spot and not have any scar on my head at all? ~ J.Y., Trenton, N.J.

A: Traumatic scars are readily treated with follicular unit hair transplantation. The hair generally grows quite well in scar tissue as long as the scar is not thickened (hypertrophic). Several sessions are usually required. Although the hair restoration can make the bald area undetectable, the underlying scar tissue will still be there.

Q: I am taking a baby aspirin to prevent heart disease and I heard that I should stop this medication before my hair transplant. How long should I stop for? ~ J.D., Liberty, New York

A: You should discontinue the Aspirin 10 days prior to your hair restoration procedure. Other NSAIDs (non-steroidal anti-inflammatory drugs) need only be stopped 3 days before the hair transplant. Both Aspirin and other NSAIDs can be resumed three days after surgery. (Reference: Otley CC: Preoperative evaluation and management in dermatologic surgery. J Am Acad Dermatol 2006; 54:119-27.)

Q: I have had 4 hair transplants with strips taken out for a total of 2600 grafts over 15 years. The last one was 1,650 grafts. My doc says my donor site is good for a few more but I think it has been probably stretched to its max. Is it believable that the skin can be stretched to such extremes safely? ~ H.K., Englewood, NJ

A: The scalp is very resilient to stretching, particularly in those with a loose scalp to begin with. After removing a strip, the laxity often returns to normal or very close to it within 6 months to a year. The problem with multiple hair transplant procedures is not only that scalp laxity may decrease, but that the donor density decreases as well. If too much hair is harvested, the donor area may eventually appear too thin. This may happen with either FUT or FUE. Therefore, it is important the doctor not only assess the scalp laxity, but the residual donor density.

Q: I’ll be traveling from New York to Cincinnati the week after my hair transplant. Will I be able to get through airport security if I have staples? ~ O.L., Manhattan, NY

A: Yes, the staples that we use to close the donor area after the hair restoration, although made of stainless steel, are too small to be picked up by the metal detectors. I generally prefer staples as this method is superior to sutures in preserving donor hair.

Q: I have heard that you should take Propecia for 6 to 12 months following a hair transplant. Is this correct? ~ K.L., Forest Hills, New York

A: I would only use Propecia (finasteride) if you plan to continue the medication long-term. That said, Propecia is very helpful in preventing further hair loss and I do recommend that patients who have hair loss stay on the medicine for an extended period, regardless of whether or not they decide to have a hair transplant. See some before and after photos of patients who have treated their hair loss with medication alone.

Q: If I had a hair transplant using FUT, how many grafts would be in a 15cm by 1cm donor strip on average. ~ J.B, Brooklyn, New York

A: In a person with average donor density there are approximately 100 follicular units per square centimeter. A 15 cm long strip would have slightly less than 1500 grafts due to the tapering of the strip ends. Therefore, in a hair transplant of 1500 follicular unit grafts, one should take out a 17 cm x 1cm strip (that includes the tapered ends). This is 15cm2. Visit the Graft Numbers page for more info on this topic.

Q: I have developed a rather large, hard lump beneath the skin at the base of my scalp in the donor area that I first noticed this about two or three weeks after my hair transplant. What is this? ~ K.W., Tenafly, New Jersey

A: You are describing an enlarged lymph node. This is a normal part of healing in response to the surgery. It will resolve on its own in about 3-6 months. It doesn’t require any treatment and it should not be a cause for concern. Read more about what to expect after a hair transplant.

Q: Is it possible to use the strip technique with the extraction technique together? If so, would that hide the scar enough for me to wear my hair really short? ~ G.J., Brooklyn, NY

A: The combination of Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) used the way you are suggesting does make sense and is actually how I originally envisioned the two procedures to work together. The camouflage of the donor scar will probably never be necessary, but if it is desired, it should be postponed until after the last FUT procedure. FUE will make it possible for most people to wear their hair very short.

Q: I have had some surgical procedures on my head that left a fair amount of scar tissue. Can hair grow there? Is it a more difficult procedure? Are there any complications? ~ L.E. New York, NY

A: Transplanted hair will grow in scar tissue as long as the tissue is not thickened. Thickened scar tissue can be flattened with local injections of cortisone. Once the scar is smooth, the hair transplant procedure is relatively straightforward; however a few things must still be kept in mind. Since the blood supply of the scar tissue is less than in normal tissue, the grafts should not be placed as close. As the grafts from the hair transplant grow, new blood vessels are formed in the area.

Additional density can then be achieved in a subsequent session by adding more grafts. After a hair transplant, care must be taken with grafts transplanted into scar tissue, as the scarred scalp doesn’t hold onto grafts as well as normal tissue and they are more easily dislodged. If grafts are packed too closely into scar tissue, poor growth can result. If sites are placed properly and the post-op care is diligent, good growth should be expected.

Q: There is such a big deal made on the chats about people getting Megasessions of over 4000 graft per session. When I look at the pictures on your website, the results look great, but I am surprised that not many grafts were used compared to what is being talked about. ~ K.R., Jersey City, New Jersey

A: My goal is not to transplant as many grafts as possible, but to get the best results possible without exhausting a person’s donor supply. It is important to keep reserves for future hair loss. Unnecessarily large sessions also risk poor growth and have a greater incidence of donor scarring. Read a detailed discussion on the advantages and disadvantages of large hair transplant sessions.

Q: Do you ever see poor growth from a hair transplant? ~ Q.H., New York, NY

A: The situations where I have encountered poor growth are: 1) when hair is transplanted to areas of skin that has been thickened due to the prior placement of larger grafts or “plugs” (this is called “hyperfibrotic thickening”), removal of the larger grafts can somewhat ameliorate this problem. 2) when hair is transplanted into a thickened scar, and 3) when a hair transplant is performed into and area of severe chronic sun damage. In this case, a very modest number of grafts should be used in the first session and if these grow well, additional grafts can be added in a subsequent session. Read about hair growth after a hair transplant in the Hair Transplant Blog.

Take a look at our Hair Loss FAQ.

Or read more Q&A’s with Dr. Bernstein on the Hair Transplant Blog

Before & After Photos
of Medical Treatment

 

 

Propecia (Finasteride)

 

 

Rogaine (Minoxidil)

 

 

Avodart (Dutasteride)

 

 

Aldactone (Spironolactone)

 

 

Oral Contraceptives

 

 

Latisse (Bimatoprost)

 

 

Platelet Rich Plasma (PRP)

This section focuses on FDA-approved medications:

• Propecia (finasteride)
• Rogaine (minoxidil)
• Avodart (dutasteride)
• Aldactone (spironolactone)
• Oral Contraceptives
• Platelet Rich Plasma (PRP)
• Latisse (bimatoprost)

Learn more about these hair loss medications by clicking on the icons to the right and reading information on each medication.

Propecia & Rogaine

Only the first two drugs listed on this page — the oral medication Propecia (that contains finasteride 1mg) and the topical medication Rogaine (that contains minoxidil) — are approved by the FDA for the treatment of common baldness in men (androgenetic alopecia). When the others are used for this purpose, it is considered “off-label” use.

Propecia (finasteride), which inhibits DHT, is particularly helpful in reversing genetic baldness in its early stages. Finasteride still requires a prescription, but is available in the less expensive 5mg generic form that can be divided into smaller 1.25mg doses using a pill cutter.

Rogaine (minoxidil) directly stimulates hair growth, but is significantly less effective than finasteride when used alone. The best results are noted when it is used in conjunction with Propecia. Minoxidil is generic and no longer requires a doctor’s prescription.

Propecia is significantly more effective than Rogaine in treating hair loss, but they have additive effects when used in conjunction with one another. When both are used, over 1/3 of patients can expect visible amounts of hair regrowth. In over 90% of patients, these medications can significantly retard further hair loss.

Use in the Crown

Since both finasteride and minoxidil were approved by the FDA for use in the crown (the back of the scalp), there is a common misconception that these drugs only work in this area. The fact is that both Rogaine and Propecia work in the front and top parts of the scalp. This makes sense, since the process of hair loss is the same in both locations. Both medications thicken fine, miniaturized hair, but both are unable to grow hair in areas that are completely bald.

Since the crown usually has hair in the thinning phase for longer periods of time than the front part of the scalp, there is often a longer window of time for the medications to be useful in re-growing hair in this location. This helps to explain the relatively better response to medication in the back part of the scalp (the crown) compared to the front. That said, for prevention of further hair loss, the medications are equally important in all parts of the scalp, front and back.

Continued Use

Medications take time to work and it usually takes six months to a year to see the results. In the first few months they may cause shedding, so one needs to be patient and continue to use the medication. The effects will wear off if the drugs are discontinued and the patient will soon revert to the degree of hair loss they would have had if they had not used the medications at all.

Medicine vs. Surgery

Medications can be used alone, or can be used as part of a hair loss treatment plan that includes hair transplantation. Medical therapy works well in conjunction with hair transplant surgery since they serve different purposes; the medical treatments work best to prevent further hair loss, whereas surgery is used to regain hair once it has been lost (or when the process is more advanced.) Unlike medication, a hair transplant does not prevent the progression of the balding process, but it is the only hair loss treatment that can restore hair to a completely bald area.

View Before and After Photos of Medical Hair Loss Treatment