Hair Restoration Answers - Bernstein Medical Center for Hair Restoration

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Dr. Bernstein and Dr. Shaver answer frequently asked questions about hair transplantation, hair loss, and medical treatment for hair loss.

Q. Many hair loss products contain Biotin and/or Saw Palmetto. Do they work?

A. Both Biotin and Saw Palmetto are totally useless in growing hair or slowing the progression of hair loss. Unfortunately, they sound important and are naturally occurring, so they are great for marketing products that contain them. Unfortunately, a lot of desperate people with hair loss will be duped. Worse, they will postpone seeking a doctor’s advice and getting prescriptions that do actually work.

As usual, myths often start with some basis in fact. Saw Palmetto does offer some benefit for older men with prostate enlargement and both prostate enlargement and hair loss are due to the same chemical, DHT. And biotin deficiency can cause thinning hair.

However, Biotin deficiency does not occur in those eating a healthy American diet, as Biotin (vitamin B7) is a vitamin found in many foods such as eggs and milk. For vegans, bananas, peas, beans, peanuts, lentils, and soy are all rich in Biotin.

Q: What are your thoughts on topical finasteride? I am hesitant to use this because I cannot find any good studies on this let alone what the potential side effects may be with prolonged use.

A: Although there are no controlled studies to date, our sense is that topical finasteride in the right formulation may be a good therapeutic option. Long-term it should be at least as safe as the oral formulation.

However, presently, we don’t use topical finasteride for the following reasons:

  1. The dosing and efficacy have not been worked out.
  2. The topical formulations are not regulated and therefore not consistent in dose.
  3. In order to be effective, topical finasteride must be absorbed to some extent in the bloodstream and so a similar side effect profile may exist as with the oral version.
  4. It is not clear that using it topically can increase the efficacy/side effect ratio (i.e., depression of serum DHT levels may be important for its effect).
  5. It may inadvertently be used by pregnant women.

Q: How do you best manage the irritation that comes with minoxidil? I have patients that report burning, and this causes them to stop treatment prematurely.

A: We start with minoxidil solution and if the patient gets irritated, switch to the foam (which doesn’t have the propylene glycol that is contained in the solution).

If he/she can’t tolerate the foam, then we consider oral minoxidil. We rarely use a topical steroid in conjunction with the minoxidil (a practice of many doctors).

As an aside, once a day use is all that is necessary and this seems to be less irritating than bid.

Q: Can you use a hair transplant to treat radiation-induced permanent hair loss in pediatric patients?

A: Yes, but there are a number of things to consider:

  1. As in adults, if the hair loss from radiation is extensive, or involves the permanent zone of the scalp, there would not be enough donor hair to make the procedure worthwhile.
  2. Depending on the nature of the scarring, it may not take grafts well and always will require multiple procedures to achieve adequate density.
  3. Hair transplant procedures (both FUT and FUE) leave scarring, so future treatments for tumor recurrences that cause hair loss (radiation or chemo) may expose these scars and be an additional cosmetic problem.
  4. There is a concern that the younger patient may eventually develop androgenetic alopecia and this would be a problem if extensive and occurring early. Family history, of course, is important, but there is no way to tell with certainty the prognosis of AGA in a young person.
  5. For those that might develop AGA, finasteride is not indicated in males under 18 and there is no way to tell in advance if the person can tolerate this medication.
  6. The hair transplant procedure is long, so local rather than general anesthesia is used. That said, 12 y/o is generally the minimum age that a patient can tolerate the procedure and a 12 y/o needs to be mature and motivated. Certainly, waiting until the patient is older makes it easier surgically.

Q: Does donor area hair thin with age? – T.W.

A: Hair taken from the donor zone is considered to be permanent and should resist changes related to androgenetic alopecia also known as genetic patterned baldness. In other words, it will not be lost. Through the natural aging process, hair diameters may decrease over time making the donor area appear thinner.

Q: I am an African-American woman who had a unsuccessful hair transplant. Should I have another one? – S ~ Boston, MA

A: A common cause of a failed hair transplant in African Americans is the surgeon missing a diagnosis of primary scarring alopecia. In this case the scalp is literally attacking the transplanted hair and a repeat hair transplant would also not expected to be successful. This condition is recognized by scaling and redness around the follicles and diagnosed by biopsy. The condition is treated medically rather than by surgery. However, if the cause of the failed transplant was poor surgical technique, then a repeat procedure would be warranted as long at the remaining donor supply was adequate. In all cases, a repeat procedure should not be contemplated unless the cause of the failure can be identified and corrected.

Q: I am preparing for FUT surgery and read about scalp laxity exercises. Will they better prepare me for my hair transplant? – O.U.

A: For the majority of patients, there is enough scalp laxity so that exercises are unnecessary. If a patient’s scalp becomes too tight for FUT, we would switch to FUE. On occasion, after multiple FUT procedures, if the scalp is snug and FUT is still desirable, then scalp laxity exercises can be useful.

Q: Is it safe to implant 6,000 grafts in 2 days with an FUE procedure? — L.P. ~ Port Washington, N.Y.

A: A 6,000-graft procedure would be a very large hair transplant. Transplanting this many grafts at once would necessitate grafts being placed very close together. In this situation, the blood supply may not be adequate to support the growth of the newly transplanted grafts.

Another reason for concern is that when harvesting, FUE yields about 20 grafts/cm2. A 6,000-graft procedure would require 300 cm2. Since the donor area is about 30 cm long, this would require a donor height of 10 cm, clearly extending beyond the permanent zone of the scalp of most patients.

Q: Can a woman who is breastfeeding have a hair transplant? — M.R. ~ Long Beach, N.Y.

A: Since surgical hair restoration is an elective procedure, I would wait until 1 year after delivery and once breastfeeding has completed before considering a hair transplant. Often after pregnancy, there is a post-partum shedding that occurs as the hormones fluctuate and then return back to their normal levels. This active period of shedding can cause a few issues. The first issue is that active shedding can make it difficult for the surgeon to determine where best to place the grafts for the optimal long-term cosmetic result. Additionally, medications may be used during and after the procedure that can potentially appear in breast milk.

Q: What is your opinion of the companies that advertise hair loss solutions like Hims and Keeps?

In searching the web and riding the subway I’ve seen many ads for a company called Hims that offers hair loss medicine and other medical solutions for men’s problems. What are the medications used for hair loss and how do they compare to Propecia and Rogaine? — V.T., Long Island, NY

A: Hims and Keeps are digital wellness companies that are geared toward men. They prescribe the same hair loss products that you can receive from a doctor or from online stores like Amazon, such as minoxidil, finasteride, biotin, salicylic acid shampoos and other topical and oral medications. The patents on the most commonly used prescription medications have expired within the last few years, opening the door for companies to distribute their own generic versions. The online system that Hims uses allows people to get prescriptions without seeing a doctor. Although this might be convenient, receiving an in-person evaluation from an experienced physician is important to ensure that you receive the proper treatment. Medical treatments for hair loss are most effective when started early. Therefore, making sure the diagnosis is correct and that the medications are optimized, will give you the best chance of re-growing your hair and preventing future thinning.

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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.

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