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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 Consequences of Trichophytic Closure in FUT Hair Transplant and Infection of Donor Area?

Q: Could you tell me in case there is an infection at the donor area following a hair transplant, will it prevent the hair to grow after healing if the donor area closed by Trichophytic Closure? What are the problems which may the infection cause? — S.S., Park Slope, NY

A: Infection may cause the donor incision to heal more slowly or with a widened scar after a hair transplant. It may affect any closure, Trichophytic or not.

The risk of infection after a hair restoration procedure is made worse by a tight closure, but not necessarily a Trichophytic closure, unless too much skin was removed at the edges leaving the dermis (deeper part of the skin) exposed.


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Hair Restoration Answers

Can Second Hair Transplant Repair Pits in Scalp from Prior Procedure?

Q: I recently had a hair transplant procedure done in Florida and it has been about 8 months. When I am in direct overhead light and when sunlight is behind me, I see many tiny holes that are not visible under normal light. I know these are where they placed the transplanted hair but need to know if there is a way to remove these tiny holes. I am obviously not getting any answers from the doctor that performed the hair restoration. I am wondering if dermal fillers, dermabrasion, or laser treatment would work to fix this and if so, do you offer these treatments?

A: This condition is often referred to as pitting and occurs when grafts are placed below the surface of the skin. It is more common with large grafts rather than small ones and is almost never seen in Follicular Unit Transplantation (FUT).

In general, visible holes can result from mini-micrografting hair transplant procedures where the grafts (and thus the recipient sites needed to hold them) are larger than approximately 1.2mm. Recipients sites smaller than 1.2 rarely leave any mark. In follicular unit hair transplant procedures, the grafts will fit into sites smaller than 1.2mm so surface changes are generally not seen (even if the grafts are not placed flush with the skin).

It is difficult to fix the holes directly with the methods you listed as fillers do not fix well defined holes and laser-abrasion and dermabrasion may destroy the surrounding hair.

A properly performed second procedure that places follicular unit grafts in the area should correct the problem.


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Hair Restoration Answers

Which is More Effective: Rogaine or Propecia?

Q: Will Propecia and Minoxidil reverse some of the miniaturization going on with someone with thinning hair? If I do need a hair transplant will I have to stay on these medications? — C.C., — Fairfield County, Connecticut

A: Yes, both minoxidil (Rogaine) and finasteride (Propecia, Proscar) affect the miniaturization of the hair follicles and help restore the shrunken follicles to cosmetically viable hair.

Minoxidil works by directly simulating miniaturized follicles to grow, whereas finasteride blocks DHT, the hormone that causes hair to miniaturize and eventually fall out.

Finasteride is much more effective than minoxidil in preventing or reversing the miniaturization process and it is so much more convenient to use that we generally suggest finasteride after a hair transplant procedure, but rarely recommend minoxidil.


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Hair Restoration Answers

Can Hair Loss Accelerate Due to Non-steroid Nutritional Supplements?

Q: Some non-steroid athletic nutritional supplements claim to increase testosterone. Assuming they worked, would increasing testosterone increase DHT and hair loss?

A: Yes, if they were effective in increasing testosterone then they may accelerate hair loss.


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Hair Restoration Answers

Can Hair Loss Increase During First Four Months of Treatment with Propecia?

Q: I am a 22 yr. old male and have been on Propecia for exactly 4 months. When I started taking the medication, I was in the beginning stages of hair thinning/loss in the front and crown areas, with no change in my hair line. During the time I have taken Propecia, my hair loss has increased drastically. Is it that I just have to bite the bullet and am one of the few unlucky individuals that do not respond to Propecia? Could it be that I am taking the medication incorrectly? Wrong time of day? With or without food? Or, do I just need to give it more time? Is there still a chance I could at least regain the hair I’ve lost over these past 4 months? — A.B., St. Louis, Missouri

A: You are probably experiencing an accelerated phase of hair loss that is possibly made worse by the finasteride. The shedding from finasteride is common during the first few months of treatment and is temporary. The full effects of Propecia are not seen for 6 to 12 months.

I would continue to take the medication for at least a year before you judge if it is working. It does not matter the time of day or relationship to food.


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Hair Restoration Answers

After Hair Transplant, Can Hairline be Lowered Further with Second Procedure?

Q: In my first hair transplantation procedure, I wanted to be as conservative as possible and focus on thickening the thinning hair on top of my head and lowering the hairline minimally. Is it still possible to lower the hairline further in a second hair restoration procedure? Is there an “ideal” time period for a second hair transplant after the first? — B.B., Meatpacking, N.Y.

A: It is possible to lower the hairline with a second hair transplant, but the doctor must be certain that you have enough donor hair so that the transplanted pattern will look natural long-term.

Unless there is some pressing reason that you had to have a second session sooner, I would wait a minimum of 10-12 months between hair restoration procedures so that you can see the full cosmetic impact of the first session.

As a hair transplant matures and thickens, the hairline will look lower as the eye doesn’t see as far into the scalp.


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Hair Restoration Answers

Is Pulsing or Cycling Hair Loss Medication Dosage Effective?

Q: First off thank you for providing this Blog, it is extremely informative and gives people the opportunity to ask questions of one of the most knowledgeable hair transplant surgeons in the world. You are considered the consummate researcher in the field of hair loss, so I ask this question of you. It appears that all the current hair loss drugs, at one point or another, begin to lose their effectiveness. Have you ever entertained the idea of cycling these drugs, or reducing the dosage for a period of time, to prevent the body from becoming acclimated to these drugs and subsequently making adjustments to receptors causing this? This method is commonly used by bodybuilders and others in the sports profession to elicit the maximum effect from the drugs they employ. Though I have not found any studies along these lines, I believe there are valid reasons why this may work. I hope you may be able to share any information on this subject. — Z.Z., Chicago, I.L.

A: Excellent question. I can answer it only indirectly.

It has been our experience that when you discontinue finasteride (Propecia), or decrease the dose to a degree that it no longer works, the patient will begin to shed hair. When the drug is re-started or the dose increased again, the medications will begin working, but the patient now maintains his hair at a lower baseline. He doesn’t seem to regain the amount of hair he has before the medication was stopped. For this reason, we don’t stop and start finasteride. The same argument applies to dutasteride, although we have less experience with this medication. This experience would speak against using pulse therapy for hair loss.

On the other hand, the hair loss medications finasteride and dutasteride do not necessarily need to be used once a day. Although the serum half-life of finasteride is around 6 hours, the tissue half-life is felt to be around two days. Therefore, alternate day dosing with 2 mg of finasteride (or approx. 1/2 of a 5mg tablet) should work just as well as 1mg a day. An average daily dose of less than 1mg, however, does not seem to be as effective. Dutasteride has a half-life of 5 weeks and is found to bind to scalp tissue for many months, so with dutasteride, a dosing of even once a week will most likely be just as effective as once a day.

Note that this regular alternate day dosing is different than pulse dosing. In pulse therapy, the body is given a chance to recover. The principle here is to take advantage of the persistence of the drug in the scalp even after blood levels drop and not to let the scalp recover (which we have found to result in a net loss of hair (as discussed above).

When patients do become acclimated to these drugs (which seem to be common after 3 to 5 years) we increase the daily dose of finasteride gradually up to 5mg and then consider switching to dutasteride 0.5mg a day.


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Hair Restoration Answers

Can Hair Transplant Treat Hair Loss from Traction Alopecia?

Q: I am a Caucasian female that has experienced hair loss on the sides of my head from the height of the eyebrow to the ear due to traction. The hair loss has been present since my teen years. My job requires me to wear my hair up most of the time. Although I don’t wear it nearly as tight, I seem to continue to lose my hair in the front and on the top of my head. My hair also used to be very thick as a child and is now quite thin. I’m not sure if this is normal or something else is going on, but I am definitely interested in a hair transplant. — M.H., Larchmont, NY

A: It sounds like you are experiencing continued traction alopecia. Unless the underlying cause is corrected (the traction), you can expect to continue to lose your hair. People that have traction alopecia can have thinning even from mild pulling that might not be a problem for others. Once you stop the pulling, it can take up to two years for the hair to return, although there may be permanent hair loss.

Surgical hair restoration is the treatment of choice for permanent hair loss from traction. If you have significant thinning on the sides, you may not be a candidate for hair transplantation since in this procedure we often need to harvest hair from the permanent area in the sides of the scalp as well as the back.

An additional problem (that you allude to) is that you may have underlying female pattern hair loss. This would further complicate the surgical treatment.

A careful examination (including densitometry) can sort these problems out and allow for more specific recommendations.


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Hair Restoration Answers

After Hair Transplant, How Should I Care for Scalp Scab?

Q: I had a follicular unit hair transplant 5 days ago and my scalp is very scabby. Is there something that I can do to make it look better? — N.D., Pleasantville, N.Y.

A: Before you go to bed, take a long shower and shampoo during the shower for at least 5 minutes, with a very thorough rinsing. As soon as you get out of the shower, while your hair is still wet, put on a shower or bathing cap that will hold in the moisture. Sleep in this cap and then take a long shower/shampoo when you awake. This will remove some or all of the crusts. The process should be repeated each night until all the crusting is gone.

At 10 days post-op the grafts are permanently in place, so any residual crusts can be scrubbed off. However, I wouldn’t scrub before 10 days following the surgery. For your next hair restoration procedure, I suggest that you are more vigorous with showering, particularly the day following the hair transplant, to remove any exudate (oozing) so that the crusting can be prevented. This is much easier than having to remove them after they form.


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Hair Restoration Answers

Do You Recommend Loniten as Hair Loss Medication?

Q: Is Loniten good for treating hair loss? — N.V., East Hills, N.Y.

A: Loniten (oral minoxidil) is not useful for treating hair loss. The reason is that it stimulates hair growth all over the body (hypertrichosis) and has a number of serious side effects.

Even when used to treat blood pressure, for which it is FDA approved, it is a medication reserved only for severe hypertension, used after at least three other types of blood pressure medications have been tried and are unsuccessful.

In addition to increased body and facial hair growth, it can cause fluid retention and heart disease. When used topically (topical generic minoxidil or Rogaine) the medication generally does not cause any significant problems other than local skin irritation and occasionally increased facial hair (which can be real nuisance for women).


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Hair Restoration Answers

Can Hair Transplantation Correct Hair Loss From a Facelift?

Q: I have had a minor facelift operation and have lost a bit of hair. Have you heard of this before? The areas around the scars are the most effected. What treatments are best for this? — N.D., Westport, C.T.

A: Hair loss after a brow, or face lift, is quite common. If it is cosmetically bothersome, a localized hair transplant can correct the problem.

The hair can be transplanted directly into the scar (if the scar is flat) and into any surrounding areas of thinning. The complete correction may take more than one hair restoration session.


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Hair Restoration Answers

Do You Recommend Avolve Hair Loss Medication?

Q: My friend just came back from Paris and said that his cousin was taking Avolve for hair loss. Can you tell me what that is and is it available in the U.S.? — N.W., Portland, Oregon

A: Avolve is the European trade name for dutasteride 0.5mg made by GlaxoSmithKline for prostate enlargement. In the U.S. dutasteride 0.5mg, under the brand name Avodart, is FDA approved to treat prostate enlargement (BPH). It has not been FDA approved for hair loss.


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Hair Restoration Answers

In FUT Hair Transplant, How Important Are Microscopes?

Q: I went to a hair transplant doctor for a consultation for my hair loss and he said that it was not that important to use microscopes for hair transplants. I had heard that it was. What’s the deal? — V.F., Hell’s Kitchen, N.Y.

A: It is extremely important to use microscopes when performing hair transplants. It is the only way that follicular units, the naturally occurring groups of hair follicles, can be isolated from the donor tissue without damaging them.

Other techniques, such as magnifying loops and back-lighting are not as precise. Using microscopically dissected follicular units in hair transplants has been the main advance that has allowed doctors to move away from the older mini-micrografting hair restoration techniques to the current procedure that can produce totally natural results.

See the Graft Dissection page.


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After Hair Transplant, How Long Before Grafts Permanently Root?

Q: I had hair transplant surgery 10 days ago and have since developed what looks like big, dry flakes in the transplant area. How long does it take for the grafts to root, and is it okay that some of the grafts fall out when brushing my hair back carefully at this point? Also, the area that was worked on has not fallen out yet, so should I shave this area before the new hair comes in or should this be a natural process? — N.N., Easton, C.T.

A: Grafts are generally permanent 9 days following a follicular unit hair transplant procedure, so you may shampoo the flakes off at this time. If larger grafts were placed (with correspondingly larger recipient sites), the grafts will be subject to being lost for a slightly longer period of time. After 9 days, you may shave or clip the hair in the transplanted area if you like, but this will not affect the success of the hair restoration one way or the other.

Visit: Graft anchoring following a hair transplant


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Can Hair Loss in Women be Caused by Pregnancy, Prozac, or Hyperactive Thyroid?

Q: I had a baby 12 weeks ago and have recently been diagnosed with a hyperactive thyroid, although only slightly. I was also taking Prozac for 7-10 days. I am 27 and have been experiencing a significant amount of hair loss from all over my scalp. What are the chances that this would be permanent?

A: Based upon your history, you have three possible reasons for having a type of hair loss called telogen effluvium; thyroid disease, medication induced (Prozac) and pregnancy.

Telogen effluvium is diagnosed by a hair pull test and observing club hairs under the microscope. It is generally a reversible condition, regardless of the cause. Telogen effluvium most often occurs 2-3 months after the inducing event, so your pregnancy is the most likely cause. Prozac would less likely be the problem since you have only been on it for a short time. Besides causing Telogen effluvium, thyroid disease can also alter your hair characteristics, which can make your hair appear thinner.

Other causes of hair loss, such as genetic female pattern hair alopecia, must be ruled out. Please see the Hair Loss in Women page on the Bernstein Medical – Center for Hair Restoration website for more information.


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


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