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Robotic Hair Transplants & Hair Restoration
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Dr. Bernstein answers frequently asked questions about hair transplantation, hair loss, and medical treatment for hair loss.

Hair Restoration Answers

Can a Hair Transplant Restore Frontal Hair Loss in Women?

Q: Although I read that women are supposedly protected from hair loss in the frontal hairline by the enzyme aromatase that is exactly where I am losing hair. My hairline has receded and I have developed a widow’s peak. What can be causing this, and how can I fix it? It seems to have been happening gradually for a few years.

A: Less than 10% of female hair loss is in a frontal pattern that is similar to the pattern of genetic hair loss seen in men.

Women with this pattern can often be good candidates for hair transplant surgery, particularly if the donor area is stable. View our Women’s Hair Transplant Gallery for some examples of the kind of results we can achieve for women at Bernstein Medical – Center for Hair Restoration.


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Hair Restoration Answers

Why is Propecia Not Stopping My Hair Loss?

Q: I have been on Propecia for a year and my hair loss has not stopped or slowed down. How much longer should I give the drug? Can Propecia speed up hair loss in some patients? — N.V., East Hills, N.Y.

A: If you have not responded to Propecia in one year, it is unlikely that you will.

Finasteride may cause shedding in the first 6 months of treatment, but should not accelerate hair loss long-term. It is most likely that you have progression of your hair loss.

In addition, be sure that you have a correct diagnosis i.e. that you actually have androgenetic alopecia.


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Hair Restoration Answers

Is Avodart Hair Loss Medication Safe for Male with Early Hair Loss?

Q: My query is prompted by your answer to another query “Is Avodart Safe?” My son, who is in his mid-20s, has been taking Dutasteride for hair loss for about two years now. He had tried Finasteride earlier but without much benefit. Medical supervision regarding Dutasteride is not available in Australia as the drug has not been released here yet. — N.V., Melbourne, Australia

I am concerned by your remarks that there is no biologic model to show the long-term safety of Dutasteride (as opposed to Finasteride). Would you suggest that he goes back to taking Finasteride? We would be grateful for your advice.

A: It is a tough call as I have never met or examined your son, so I can only offer an opinion based on limited information. If you feel your son will be emotionally or socially debilitated by the hair loss, then I think that it may be worth the risk (if there is any) of taking the medication; otherwise, I would use Finasteride.

Please keep in mind that you don’t need to make the final decision now. You may want to defer the decision until he is 28 or so, at time when he is more mature. It is a tough call. Please let me know what you decide.


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Hair Restoration Answers

Can Hair Loss in Women Come from Hair Dye?

Q: I am a 48 year old woman. Since I have used a new hair dye, I seem to be going bald. Is this possible?

A: Dying hair is a very common practice and hair loss in women who are 48 years old is also very common. The fact that the two have occurred together does not necessarily imply that there is a cause and effect relationship.

Women who are already losing hair often go to a great deal of effort to disguise this fact with dying, bleaching, and perming. These procedures, particularly if too aggressive, or done too frequently, can cause weakening and increased fragility of the hair shaft and increased hair breakage may result. This is more common if the hair is already fine in texture. This breakage is frequently interpreted as “hair loss” and it certainly does result in a significant loss of hair bulk, although the follicle itself is not damaged.

When there is a relationship between hair dye and hair loss in women, it is usually an inflammatory/allergic or irritant reaction. If severe, there may be an actual burn. In these cases, there would be a history of redness and swelling. An inflammatory reaction could cause hair loss but it would be unusual to damage follicles enough to produce scarring – although this occasionally does occur. A scalp biopsy is often helpful to sort out these cases.


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Hair Restoration Answers

Is Finpecia a Viable Hair Loss Medication?

Q: A friend of mine is taking Finpecia, is this the same as Propecia?

A: Both Propecia and Finpecia contain the active ingredient Finasteride 1mg. Finpecia is manufactured in India by the company Cipla. It comes in packets of 10. Finpecia contains the same chemical ingredient as Propecia, i.e. 1mg of Finasteride, but it is manufactured differently and it is less expensive. — A.B., St. Louis, Missouri

Indian patent law allows companies in India to make medications that are patented by drug companies in other countries, since Indian law protects only the processes by which drugs are made and not medication itself. Therefore, if an Indian company finds another way to make a drug, it can legally do so.

Cipla has not published any studies showing that their generic Finasteride is identical or as effective as Merck’s original product in treating hair loss. These alternative processes and drugs are not regulated by the FDA, so there is no assurance that the medication manufactured in India has the same biologic activity or potency as the FDA approved counterpart made in the United States.


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Hair Restoration Answers

Is Asymmetrical Hair Loss from Telogen Effluvium or Androgenetic Alopecia?

Q: Over the past three months, my hair seems to be thinning more on one side. Is it common in male pattern hair loss for it to be more on one side? I had a lot of stress about three months ago and have heard that this could be the cause. Is this possible? Should I use Rogaine to treat it? — B.R., Landover, MD

A: Regardless of the cause, hair loss is usually not perfectly symmetric. This applies to male pattern hair loss as well.

In your case, it is important to distinguish between telogen effluvium (shedding that can be due to stress) and hereditary or common baldness. The three month interval from the stressful period to the onset of hair loss is characteristic telogen effluvium, but you may have androgenetic alopecia as an underlying problem.

The two conditions are differentiated by identifying club hairs in telogen effluvium and miniaturized hair in androgenetic alopecia. In addition, a hair pull will be positive in telogen effluvium (when a clump of hair is grasped with the fingers, more than five hairs pull out of the scalp at one time) and will be negative in common baldness. The hair loss diagnosis can be made by a dermatologist.

Hair cuts do not affect either condition.

Rogaine (Minoxidil) is only effective in androgenetic hair loss and only marginally so. Finasteride is the preferred treatment if your hair loss is genetic when it is early and a hair transplant may be indicated if the hair loss progresses.

Shedding from telogen effluvium is reversible and does not require specific treatment.


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Hair Restoration Answers

What Causes Patch of Hair Loss in Women?

Q: I am a 34 year woman with a patch of hair loss by my temple. I went to the salon to have my hair done and to my surprise my hairdresser told me that I have Alopecia? First time I’d heard of it, my G.P is not very concerned about it but having read so much about it on this site I am becoming a bit concerned. The rest of my hair is healthy any suggestions and diagnosis? — M.V., Williamsburg, Brooklyn

A: “Alopecia” is just a generic term for any kind of hair loss.

It sounds like you have a specific condition called alopecia areata. Alopecia areata is an autoimmune disease that presents with the sudden appearance of well localized bald spot(s) on the scalp or other parts of the body. The underlying skin is always normal.

The treatment is injections with cortisone. Hair transplant surgery is not indicated for this condition.

You should see a dermatologist to confirm the diagnosis and treat.

Other diagnoses to consider are triangular alopecia (which would have been present since childhood) and traction alopecia (that is cased by constant tugging on the hair).


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Hair Restoration Answers

Is Hair Loss Treatment with Avodart Safe?

Q: My friend is taking Avodart, he bought it over the internet. Is it safe to take? — T.G., Denver, Colorado

A: Avodart (dutasteride 0.5mg) was approved by the FDA for the treatment of prostate enlargement in men in 2002. Avodart has not been approved for the treatment of androgenetic hair loss, although physicians can use an approved medication in ways other than for which it was specifically approved. That said, the use of dutasteride certainly requires a doctor’s supervision.

Like finasteride (the active ingredient in Proscar and Propecia), dutasteride blocks the enzyme 5-alpha reductase that converts testosterone to DHT (DHT is a key hormone that causes hair loss). However, unlike finasteride, which only inhibits the Type I form of the enzyme, dutasteride inhibits both the Type I and Type II forms. This combined effect lowers circulating DHT more with dutasteride than with finasteride, but also increases the incidence of its side effects.

The Type II form of the enzyme (blocked by finasteride) is found predominantly in the hair follicle. The Type I form of the enzyme has been found in the scalp and sebaceous glands, and many other parts of the body, but its exact role in hair growth has not been determined. It is felt that dutasteride’s ability to dramatically lower serum levels of DHT is what makes it a more potent medication in hair loss.

When considering the safety of dutasteride, one should consider the following:

  • It acts on other parts of the body besides the hair follicle.
  • Unlike finasteride, where families that had a deficiency of the Type II 5-alpha reductase enzyme were followed for years without any adverse effects, there is no natural biologic model to show the safety of dutasteride.
  • Dutasteride has been approved for prostate enlargement in an older male population. It is not approved for hair loss and, in fact, the clinical trials for hair loss were discontinued, so there is no safety data for its use in younger patients. There is a greater incidence of sexual side effects with dutasteride compared to finasteride.
  • The 1/2 life of dutasteride is 5 weeks compared to 6-8 hours for finasteride. Serum concentrations of dutasteride are detectable up to 4-6 months after discontinuation of treatment.

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Hair Restoration Answers

What is Cost of Hair Plug Removal?

Q: I was looking at your prices for repair work and you mentioned that you charge $85 per graft removed. I had a hair transplant and received follicular unit grafts (one-hair follicles) but I think my hair loss is going to continue so I might in the future want to remove them. Am I interpreting your fees correctly, or does this price apply to people who have had the plug like transplants?

A: The fee applies to the removal of plugs and includes graft (plug) excision, suturing of the site, dissection of the plug into individual follicular units and re-implantation.

Generally the best way to reverse a procedure of follicular unit transplantation is with laser hair removal. This is particularly true if the hair restoration was done properly and the underlying skin is normal. Alexandrite and diode lasers are the best for hair removal. Typically, there are too many small grafts in FUT procedures to make excision practical.

Removal via Follicular Unit Extraction (FUE) will leave scars in a cosmetically important area. As an aside, if you received all “one-hair follicles”, your procedure was NOT follicular unit hair transplantation and may explain why you are unhappy and want to reverse it.

Visit Hair Transplant Costs & Consultation Fees for more information.


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Hair Restoration Answers

Is Hair Loss in Men Caused by Elevated Testosterone Levels?

Q: I was told that if men have a lot of testosterone that that’s when they lose hair. Is this true? — Y.B., Lake Forest, Illinois

A: Although androgenetic hair loss is dependent upon normal levels of testosterone, it is not due to increased testosterone. It is caused by a sensitivity of the follicles to normal levels of testosterone.

So someone that is bald doesn’t have extra levels of male hormones and is not necessarily over-sexed.


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Hair Restoration Answers

Was Propecia Originally for Treatment of Prostate Enlargement?

Q: I heard that Propecia was being used originally for shrinking the prostate, is this true? — M.D., New Hyde Park, N.Y.

A: Propecia (finasteride 1mg) is not a prostate medication that was serendipitously noted to have a side effect of re-growing hair, it is a medication that was known all along that it might be able to slow hair loss and/or to grow hair.

Although finasteride was first approved for the treatment of prostate enlargement, the researchers at Merck knew, at the outset, that there were families whose members were deficient in the 5-alpha reductase Type II enzyme and that the men in these families neither developed prostate disease nor went bald. In addition they had no long-term problems from the lack of this enzyme.

Merck used this natural model to develop a medication that could block the 5-alpha reductase Type II enzyme – the result was finasteride. Because the only approved treatment for symptoms related to prostate enlargement at the time was surgery, Merck developed finasteride as a medical treatment for this condition prior to developing finasteride as a potential treatment for men with male pattern hair loss.

This also meant that Merck would understand the safety profile of finasteride, and have it approved for a medical disease (symptomatic prostate enlargement), before developing it for a cosmetic condition.

The drug was first submitted to the FDA for the treatment of prostate enlargement as Proscar (finasteride 5mg) in 1991 and it was approved for this use in 1992. The drug was submitted for the treatment of men with male pattern hair loss as Propecia (finasteride 1mg) in 1996 and was approved for this use in 1997.


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Hair Restoration Answers

Can Women Experience Hair Loss from Hormone Replacement Therapy with Testosterone?

Q: Dr. Bernstein, a lot of older women are taking testosterone to restore libido, but are they going to experience hair loss as a consequence?

A: They can. In women there is a delicate balance between the androgens, i.e. testosterone and estrogens. Estrogen is protective to some degree against hair loss in women, which is why most women don’t experience such severe hair loss as do men.

When a woman takes testosterone supplements it upsets that balance and can cause hair loss. However, hair loss in post-menopausal women is usually due to age related changes. Typically, the hair decreases in size in a genetically determined progression that seems not to be directly related to changes in the levels of hormones.

For more information, please see the Causes of Hair Loss in Women page on the Bernstein Medical – Center for Hair Restoration website.


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Hair Restoration Answers

How Does Densitometry Help Diagnose Hair Loss?

Q: Dr. Bernstein, I was reading about a densitometer on your website. What is it and what is it actually used for? — Z.A., Westchester, NY

A: The hair densitometer was introduced to hair restoration surgeons by Dr. Rassman in 1993. It is a small, portable, instrument that has a magnifying lens and an opening of 10mm2.

To use it, the doctor clips the hair short (~ 1-mm) and the instrument is then placed on the scalp. The doctor counts the total number of hairs in the field, looks at the number of hairs per follicular unit and assesses the diameter of the hair, looking in particular for abnormal levels of miniaturization (decreased hair shaft diameter caused by the effects of DHT).

The densitometer can increase the accuracy of the diagnosis of genetic hair loss by picking up early miniaturization.

It can also better assess a person’s donor hair supply, thus helping to determine which patients are candidates for a hair transplant.

Densitometry has helped us define the conditions of diffuse patterned and unpatterned hair loss (DPA and DUPA) and help to refine the diagnosis of hair loss in women.


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Hair Restoration Answers

Can Hair Loss be Caused by Thyroid Problems or Fluctuations in Hormones?

Q: One of the things that I have noticed as a person who has needed to take thyroid medication for a long, long time, is that when my thyroid gets a little bit out of balance – when I’m not getting quite enough, I begin to notice is that my hair starts falling out. What about the role of thyroid for hair loss? — T.K., Mineola, NY

A: Both increases and decreases in thyroid levels can cause hair loss and changes in the levels of thyroid hormone can change the consistency of one’s hair. Elevated hormone levels cause scalp hair to be fine and soft, with diffuse thinning being relatively characteristic.

When thyroid hormone levels are low, the hair becomes dry, coarse, and brittle. Hair loss can be either patchy or diffuse (involving the entire scalp).

Low levels of thyroid hormone are associated with the loss of the outer 1/3 of the eyebrows and a decrease in body hair. When changes in thyroid hormone levels are abrupt, there can be dramatic shedding (telogen effluvium).

The most important thing to do if you have thyroid disease is to try to keep the levels within a normal range and keep them as steady as possible. If you are taking thyroid medications, try to use them on a regular basis, because alterations of ones in hair can be caused by large fluctuations in the levels, as much as by the absolute values.


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How is Rogaine for Women Different from Men’s Formula? [2020 Update]

Q: What is the difference between Rogaine for men and Rogaine for women? — G.K., Hawthorne, N.Y.

A: Rogaine, the brand name of generic minoxidil, comes in formulations for both men and women. The men’s versions come in a 5% solution and a 5% foam while women’s products are the 5% foam and 2% solution. Of these, the strongest and most effective is the 5% men’s solution. This is due to the inclusion of propylene glycol, which is a vehicle that helps the active ingredient, minoxidil, to more readily penetrate the scalp. As the other products do not contain propylene glycol, they may be slightly less effective.

Instructions for use also differ on the label between the men’s and women’s products. All products (5% men’s solution, 5% men’s foam, 2% women’s solution) recommend twice daily use, except for the 5% women’s foam which recommends once daily application. In reality, a thorough once daily application seems to be nearly as effective as twice daily for all version of topical minoxidil.

While the 5% solution may be stronger, it is more irritating to the scalp and more difficult for some to tolerate. Some people have a sensitivity to the added propylene glycol and will experience redness, burning, itching, and irritation. If this occurs, patients should switch to the 5% foam or 2% solution. We also recommend that patients use enough of the medication when they apply to adequately cover the treatment area of the scalp. Often, this means using 2 or 3 capfuls of foam or 2-3 droppers full of the solution (2-3mL).

It is important to understand, that contrary to the more restrictive package indications, it works in all areas of the scalp where there is thinning. It is not only for use in the crown. Many patients find that evening application allows the full 4-6 hours of contact time necessary for absorption and that the product will dry overnight and no longer look greasy in the morning. Results can appear as early as 3-6 months, but we often advise using minoxidil for a full year before judging its efficacy. As the hair is always cycling and growing, the product will need to be continued daily for ongoing benefit.


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


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