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

Hair Restoration Answers

What are your thoughts on topical finasteride?

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.

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Hair Restoration Answers

How do you best manage the irritation that comes with minoxidil?

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.


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Hair Restoration Answers

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

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.

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Hair Restoration Answers

Is Hair from the Donor Area or Zone Permanent or Will It Thin with Age?

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.


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Hair Restoration Answers

I am an African-American Woman with a Failed Transplant. Should I Have Another Hair Transplant to Correct the First One?

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.


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Hair Restoration Answers

Will Scalp Laxity Exercises Better Prepare Me for FUT Surgery?

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.


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Hair Restoration Answers

Is it Safe to Implant 6,000 Grafts in 2 Days Using FUE?

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.


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Can Women That Are Breastfeeding Have A Hair Transplant?

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.


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Hair Restoration Answers

What is your Opinion of the Companies that Advertise Hair Loss Solutions like Hims and Keeps?

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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Can Rogaine Cause Miniaturization?

Q: Can Rogaine Cause Miniaturization?

When I am on Rogaine it seems – to my untrained eye – that I am having hair miniaturization and when I stopped briefly, I had shedding. Does this seem accurate based on what you have seen? Can Rogaine cause miniaturization? Is there a point you would recommend I stop Rogaine or is it something that likely can’t cause a negative impact on hair? — B.T., Brooklyn, NY

A: Minoxidil reverses miniaturization. It does not cause it. Shedding can occur after starting use of Rogaine but this means the medication is working should resolve with continued use. New miniaturized hairs are either from the progression of your genetic male pattern hair loss or newly forming hair that was stimulated by the minoxidil which can mimic miniaturized hair.


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In What Cases Do You Think Scalp Micro-Pigmentation (SMP) Is Most Useful?

Q: In what cases do you think Scalp Micro-Pigmentation (SMP) is most useful?
— M.O., Greenwich, CT

A: Scalp Micro-Pigmentation (SMP) is used in patients who want to make their thinning hair look fuller and want to avoid the nuisance of daily application of cosmetic concealers, powders or fibers. It is for patients who want a permanent solution, but who do not want, or who are not candidates for hair transplant surgery. It can achieve a variety of looks such as a buzz cut by tattooing hundreds of microdots that appear like follicles or it can reduce the contrast between generalized dark hair that is thinning over a pale scalp. It can even give the appearance of hair over a scar that has now become noticeable.


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How is Scalp Micro-Pigmentation (SMP) Performed?

Q: How is Scalp Micro-Pigmentation (SMP) Performed?

How is SMP done? — B.P., Long Island, NY

A: Scalp Micro-Pigmentation (SMP) is applied with tiny microneedles that mimics the appearance of hair in an area of the scalp that looks thin. It requires the use of local anesthesia and is performed in a doctor’s office. SMP is typically performed over a series of three or more sessions spaced at least 2-4 weeks apart. The length of each session varies depending on the area to be tattooed and can last from a few hours to a full day.

To perform successful SMP, the hair length and color must be analyzed in consultation along with a discussion of cosmetic goals and the potential techniques that could be implemented for the patient’s hair type. The procedure is performed under local anesthesia and is generally well tolerated with very few post-op limitations.


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Hair Restoration Answers

What is Scalp Micro-Pigmentation (SMP)?

Q: What is Scalp Micro-Pigmentation (SMP)?

What is SMP? — M.O., Greenwich, CT

A: Scalp Micro-Pigmentation (SMP) is a medical-grade scalp tattoo. It is a form of permanent cosmetic camouflage that can mimic the appearance of hair in locations such as scars or balding areas. SMP gives the appearance of fullness of hair without actual hairs being present. Although permanent dyes are generally used, semi-permanent materials can be substituted that will purposely fade over time.

Dr. Shaver is our dedicated in-house physician for Scalp Micro-Pigmentation procedures.


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Why Is My Hair Dry And Kinky After My Hair Transplant?

Q: I had a hair restoration procedure and the hair grew, but after one year the hair was kinky and dry. It has remained like this ever since.

From what I have read Dr Bernstein says this is uncommon but can happen. I understand there is no definitive explanation for this but I would like Dr Bernstein’s opinion on why this happens. My theory is that DHT is more prominent on the top of the head and is changing the structure of the transplanted hair. The hair is so dry and unmanageable it looks like I am wearing a wig. I await his response. — P.O., Greenwich, CT

A: Some dryness and texture changes can occur after a hair transplant and this usually self-corrects over 1-2 years during which time the transplanted hair gradually regains its original luster and texture. These changes are most likely due to the unavoidable trauma that takes place as follicles are removed from the scalp and placed into recipient sites. Excessive dryness can occur if the sebaceous glands had been stripped away from the graft. In FUT, this can be due to over dissection (i.e., grafts that are trimmed too much). In FUE, this can be due to loss or damage to the sebaceous glands in the extraction process. Persistent kinkiness may represent either damage to grafts from the procedure (improper handling, crush injury) or effects of scarring in the recipient area (usually from older procedures which used larger recipient sites) that distort the growth of follicles.


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Can Anyone Tell Me Why Dr. Bernstein Is Still Bald?

Q: Can anyone tell me why Dr. Bernstein is still bald? — N.H., Brooklyn, NY

When Dr. Bernstein was younger and started to lose his hair, it really didn’t bother him. After medical school, he began his career as a dermatologist and became aware of surgical hair restoration. It was then when he realized that he would not be a good candidate for a hair transplant procedure, even if he wanted one, because his donor area is very thin. In the years since, he has gotten used to being bald. But his not being a candidate made him keenly aware of who is and who is not a good candidate for surgery, and this insight has helped earn him a reputation as an honest and ethical practitioner of hair transplantation.


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Updated: 2019-11-15 | Published: 2009-07-02


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