Bernstein Medical - Center for Hair Restoration - Early Hair Loss
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Q: What is the problem with transplanting the crown too early? — P.L., Newark, NJ

A: If a person’s hair loss continues – which is almost always the case – the crown will expand and leave the transplanted area isolated, i.e. looking like a pony-tail. The surgeon can perform additional hair transplant procedures to re-connect the transplanted area to the fringe, but, as one can see from the photo below, this is a large area that can require a lot of hair. It is often impossible to determine when a person is young if the donor supply will be adequate. If there is not enough donor hair, then the island of hair may remain isolated. Most importantly, it uses up a lot of hair that might be better transplanted to the front and top of the scalp – areas that are far more important cosmetically.

Patient who visited us who had an early crown transplant

The front and top of the scalp are more important to one’s appearance than the crown, and these areas should be the first priority when planning hair restoration surgery.

As an exception, 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 one with whom the extent of hair loss is uncertain, the crown should be transplanted with light coverage only. That way a limited amount of hair will be used up in this area and there will be enough left over for the more cosmetically significant 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, and other hair transplant publications, can be downloaded at the Bernstein Medical – Center for Hair Restoration Medical Publications page.

View the Crown (Vertex) topic, the Age topic or see posts tagged with Early Hair Loss for further reading.

View Before and After Photos of some of our crown hair transplant patients

Read about candidacy for a hair transplant in young patients

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Crown Balding and Heart Disease Linked in British Medical Journal Study

A new meta-analysis of six studies, published in the British medical journal BMJ Open, has found a linkage between balding at the crown and coronary heart disease. While the top-line result of the study may be alarming, let us look first at some of the key facts.

  • While the study showed a modest link between crown balding and heart disease, the link was not as strong as for other heart disease indicators such as smoking, obesity, cholesterol levels and blood pressure.
  • There was no link established for men with a receding hair line.
  • Key indicators of heart disease — high blood pressure, high LDL cholesterol, and smoking — are present in about half of Americans, according to the Center for Disease Control in America. So this is a health issue faced by many Americans, hair loss or not.
  • Importantly, the most appropriate response if you have balding at the crown (and particularly crown balding at an early age), is not to worry first and foremost about your hair, but to concentrate on basic heart health and maintaining a healthy lifestyle. Discuss these issues and any concerns with your primary care physician.

Researchers at the University of Tokyo in Japan compiled information from six different studies with a combined total of almost 37,000 male participants. The studies were published between 1993 and 2008. Although one of the six studies did not find a link between baldness and coronary heart disease, the other five studies did find a link with the strength of the association differing in each study. In general, the more severe the balding at the crown, the more likely there was an association with heart disease. In addition, early onset of vertex balding — i.e. early balding at the crown — was found to be associated with the early development of more significant heart disease.

More research needs to be done to investigate the actual medical causes of the linkages shown.

An article on the BBC News website quotes a cardiac nurse from the British Heart Foundation discussing the findings:

“Although these findings are interesting, men who’ve lost their hair should not be alarmed by this analysis. Much more research is needed to confirm any link between male pattern baldness and an increased risk of coronary heart disease. In the meantime, it’s more important to pay attention to your waistline than your hairline.”

Image c/o BBC online

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A study of Australian men between the ages of 40 and 69 suggests that men who were mostly bald by the age of 40 were more likely to develop prostate cancer in their 50s or 60s. The Melbourne Collaborative Cohort study of about 10,000 men showed that men who have high levels of testosterone may be more vulnerable to cancerous prostate tumors.

The team of scientists that conducted the long-term study, which was published in the journal Cancer Epidemiology, Biomarkers and Prevention, reported that both baldness and prostate cancer are age-related and androgen dependent conditions, so these findings are not surprising. The statement said, “We found that baldness at the age of 40 might be a marker of increased risk of prostate cancer.”

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The central finding of a 2004 study led by Italian researcher Dr. Antonella Tosti, in which he and his team investigated sexual dysfunction in hair loss patients being treated for androgenetic alopecia, was that there was no statistically significant change in sexual function after four to six months of treatment with finasteride 1mg (Propecia).

The researchers used a questionnaire, called the abridged 5-item version of the International Index of Erectile Function (IIEF-5), to measure sexual function in the men in the study. The questionnaire, which is considered an internationally valid diagnostic tool for distinguishing between men with and without erectile dysfunction, asks the patients 15 questions on the topics of: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall sexual satisfaction. By administering the questionnaire both before and after treatment with finasteride, the researchers were able to determine if sexual function was impaired by the treatment.

The result of this investigation in the sexual function of 186 patients was that, “the erectile function of all patients remained stable after 4 to 6 months of treatment with finasteride 1 mg.”

Interestingly, the research team found that sexual side effects were actually less common than reported in the clinical trials of the drug. They suggest that this difference was potentially due to the fact that subjects in the clinical trials were made aware of the potential for sexual side effects, and were asked about these side effects upon each visit, which led to higher reporting of side effects than what would otherwise be the case.

Reference:

Tosti A, Pazzaglia M, Soli M, Rossi A, Rebora A, Atzori L, Barbareschi M, Benci M, Voudouris S, Vena GA. Evaluation of Sexual Function With an International Index of Erectile Function in Subjects Taking Finasteride for Androgenetic Alopecia. Arch Dermatol. 2004;140:857-858.

Download the Tosti study of erectile function and finasteride

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The 2011 study published by a research team led by Dr. Alfredo Rossi, is the first comprehensive investigation on long-term safety and efficacy of finasteride 1mg (Propecia).

In “Finasteride, 1 mg daily administration on male androgenetic alopecia in different age groups: 10-year follow-up,” the Italian research team sought to fill a gap in our understanding of the long-term effects of treating hair loss with Propecia. The study tracked hair growth in 118 men between the ages of 20 and 61, with mild to moderate hair loss, who were treated with 1mg finasteride. These patients were evaluated before treatment and then again at 1, 2, 5, and 10 years on treatment.

The result of testing found not only that Propecia works and is safe for use, but there were some other interesting findings as well. Only 14% patients experienced a worsening of hair loss, while 86% benefited from the treatment over this extended time period and efficacy of the drug was found not to reduce over time for the majority of patients.

One of the most interesting findings is that patients who had hair growth in their first year of treatment are more likely than others to have better hair growth after 5 years. About half of patients experienced good hair growth in their first year, and about 53% of those patients went on to see improved growth over time. However, of the group with unchanged or worse results in their first year, only 25% saw improved hair growth after 5 years. After 10 years, almost 69% of patients who experienced growth in their first year experienced continued growth. Only 32% of those who saw unchanged or worse results after their first year had growth at 10 years.

The authors concluded that a patient’s response to finasteride in the first year is a pretty good indicator of how effective long-term treatment will be for the patient. The better growth he experiences in his first year, the more likely he will have continued growth beyond 5 years of treatment.

Among other findings, the age of a patient did have a statistically significant effect on the outcome, as patients older than 30 years had better hair growth in the long term. On the topic of side effects, 7 subjects (5.9%) experienced them, and some of those patients remained in the study because of what they perceived as the benefits of the treatment.

In conclusion, the authors found that Propecia is a safe and effective hair loss medication, even when used long-term. It is effective in patients older than 40 years and it is particularly beneficial for patients over 30 and who are in early stages of hair loss. Perhaps the most important finding is that a patient’s response to finasteride after the first year of treatment can be an indicator of the patient’s success with the drug in the long-term.

Reference:

Rossi A, Cantisani C, Scarnò M, Trucchia A, Fortuna MC, Calvieri S. Finasteride, 1 mg daily administration on male androgenetic alopecia in different age groups: 10-year follow-up. Dermatol Ther 2011; Jul-Aug;24(4):455-61.

Download the Rossi study of finasteride long-term effects

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Led by Dr. A. Sato, a Japanese team of medical researchers published the largest finasteride study ever performed, “Evaluation of efficacy and safety of finasteride 1mg in 3,177 Japanese men with androgenetic alopecia.” It investigated the effects of finasteride over a 3 1/2 year period in men with androgenetic alopecia, or common baldness.

The study found that patients who had experienced hair loss for an extended period of time and were treated with finasteride exhibited notable hair growth. While a fairly small proportion of patients with a hair loss duration over 10 years exhibited “greatly increased” growth, 85% of patients with hair loss duration of more than 15 years experienced “moderate” or “slightly increased” growth. Physicians have thought that people with advanced hair loss do not respond as well as patients in the early stages of hair loss. However, in light of the results of this study, that determination should be reconsidered.

Further, the same study found that the initial age of a hair loss patient at the time of commencing treatment has little to no effect on the outcome. While the efficacy studies that are included in the Propecia package insert were conducted in men 18 to 41 years old, men over 41 appear to respond as well as the younger group. Adverse reactions occurred in only 0.7% of the study population and the Sato study found no increase in adverse safety events over time.

In summary, the Sato study showed an increased response rate to finasteride 1mg with increasing duration of treatment. In addition, it is effective in a larger portion of the male population with androgenetic alopecia than previously thought.

Reference:

Sato A, Takeda A. Evaluation of efficacy and safety of finasteride 1mg in 3,177 Japanese men with androgenetic alopecia. J Dermatol 2012; 39: 27–32.

Download the Sato study on finasteride

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Q: I am 24 years old and just starting to thin. I was told by another doctor that it was too early to have a hair transplant, but the hair on the back and sides of my scalp seems really thick. Shouldn’t I have a hair transplant now, just in case I am not a candidate in the future? — A.S., Cherry Hill, NJ

A: The most important criteria in determining who will be a candidate for a hair transplant is the presence of sufficient permanent donor hair. When hair loss is early, it is often hard for the doctor to determine this, since early on the donor area can appear very stable. It is not until the front and/or top of the scalp has significant thinning that the donor area may also show thinning. Therefore, it is only at this time that the stability of the donor area can adequately be assessed.

It has been argued, that one should have a hair transplant early, before the donor area can thin. This is not a reasonable argument, since doing a hair transplant early, does not make the donor hair more permanent. If the donor area is not stable, the transplanted hair will continue to thin after it has been moved to the new location. This will cause the hair transplant to gradually disappear and also risk the donor scar from becoming visible as the hair covering it continues to thin. This problem can affect patients undergoing both FUT and FUE procedures.

Age itself is another factor to consider. The donor area in young people almost always appears adequate. However, the older a person is, the more likely he/she will show donor changes. Therefore, the older a person is, the more confident we are of donor area measurements being accurate. In very general terms, it is very difficult to assess the permanency of one’s donor area in patients under 25 year of age.

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Dr. Bernstein on CBS - Eye on NY

Dr. Bernstein was interviewed by Dana Tyler, host of the television program “Eye on New York” on CBS, for the show that aired on April 17th. The wide-ranging interview was the feature in a 9-minute segment on hair transplantation and hair loss.

Below is a partial transcript from the interview.

Hair Loss – Men vs. Women:

DT: How big a problem is it, men versus women? We heard the statistics but is it worse for one group or the other?

RB: It seems to be worse in women emotionally. Statistically it’s obviously more common in men, but the pattern is very different. When men lose their hair they lose it mostly in the front. And they can start in two different patterns. One is in the temples and in the crown or it can just go front to back. That’s called patterned hair loss and it’s pretty obvious. Women have a more diffuse pattern so it would be many years before you even notice it.

DT: What about the influence we hear, if it’s your mother’s father or your mother’s grandfather was bald then therefore, men, you will be. Is there any truth to that?

RB: Like many myths there is a little bit to it. There is a slight predominance coming from the mother’s side of the family. There is something called an androgen receptor gene, that has been found on the X chromosome, which accounts for the slight difference between inheritance from the mother’s side versus the father’s side. But most of the genetics is on the regular chromosomes, called the autosomal chromosomes, which is the same from both sides. So you can get it from either your mother or your father or your uncles or grandparents.

Early Hair Loss:

DT: Age-wise. Are there certain times – I mean, we talked about earlier in the 30s, but some young men it happens earlier.

RB: It seems that when people start to lose their hair early, it has a tendency to be much more severe. So the people who start to thin around 16, 17 usually become very bald. Time is usually on your side if you have hair into your 30s and 40s, [it’s] more likely you’ll have a full head of hair.

Hair Loss in Women:

DT: Speaking about women and the reasons behind women’s hair loss. A little different than for men.

RB: It’s genetic, as with men for the most part, but there are two different systems. Where in men it’s related to androgens directly, which causes the front-to-back pattern, in women they have another enzyme pathway which kind of evens it out and keeps their hairline longer. Also, because women have a tendency to thin all over, their genetic hair loss can be mimicked by other things, such as diseases that cause hair shedding or thinning — so anemia, thyroid disease, medications such as birth control pills — all those things can also contribute to hair loss, and it seems that those factors are much more common in women than in men.

DT: And then in trying to determine if a woman is going through that, because there are more factors is it hard to figure out why there is the hair loss?

RB: It’s a little bit more difficult [in women]. The main thing that you do is to look at the hair diameters. In genetic hair loss the hairs have different diameters. In [conditions] like anemia, or where there is shedding on medication, the hair comes out at its root. Where people think of hair loss as losing hair, most of hair loss is thinning because the hairs are actually thinner in diameter.

Preventing Hair Loss:

DT: Preventing baldness… is there anything that can be done?

RB: There are… But it’s not what you think. It’s not hats and combs.

DT: Fertilizing your head. (laughs)

RB: There are two medications, main medicines. One is Propecia, or the generic term is called finasteride, and what that does is it blocks DHT. And DHT is what causes these hair follicles to gradually miniaturize, or get smaller, and disappear. And the other is Rogaine, which actually stimulates hair follicles directly. Unfortunately, Propecia can’t be used in women because it can cause birth defects during child bearing years and it can also stimulate breast tissue, but it is very effective in men.

DT: So what does a woman do?

RB: Well, Rogaine will help a little bit. Lasers can help a little bit, perhaps not as much as the initial studies have suggested. And then, once you’ve lost your hair, surgical options are available.

Hair Transplantation:

DT: Hair transplants. I know that’s a complicated procedure. And Dr. Max [Gomez] was talking about the art of it, too, when you’re finding someone. Tell me a little bit more…

RB: The main thing in hair transplants is really to determine who is a good candidate. And the interesting thing is that because of the pattern of [hair loss] in men, men usually have a very permanent area on the back and sides of the scalp. So when you move that to the front and top, it will continue to grow. Because women’s hair loss is more diffuse, the back and sides are not always stable. So, when you’re trying to decide if a woman is a good candidate, you have to make sure that the hair, where you get it from, is going to last their lifetime. And only a small percentage of women are really good candidates for that transplant.

The Future of Hair Restoration – Medications & Cloning:

DT: What about the future? Are you optimistic about new options on the horizon?

RB: First of all, new medications are coming out. Latisse is a medication that can grow eyelashes. And we’ve just started studying it in eyebrow hair, and it seems to grow eyebrows as well. There are studies to see if you can grow hair on the scalp. And it certainly will, it’s just whether it’s practical and how well it works. It probably will be of some benefit.

DT: There always is progress, right?

RB: Right. And then [there are] hair transplants where we can take individual follicles rather than having to take a long thin strip, although that still seems to give you the best volume. And then we’re trying to multiply hair. In other words, the limitation of transplants is always that we don’t have [as much] hair as we’d like. So we’re working on cloning. We’re working on multiplying hair that can actually be plucked from the scalp. So that [the original hair] will regenerate, and you then can get the plucked hair to grow into new hair follicles.

For more interviews with Dr. Bernstein, and other media appearances, visit our Bernstein Medical “In The News” section.

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It has long been thought that the genes for common baldness come from the mother side of the family – explaining why a male whose maternal grandfather is bald is more likely to lose his hair than if his own father were bald. This observation was recently supported by the discovery of the androgen receptor (AR) gene which resides on the X-chromosome.

Remember, there are two sex chromosomes; X and Y. Females have two X chromosomes (XX), while males have one X and one Y chromosome (XY). This means that a male must get his X chromosome from the mother.

But we all have seen that some bald sons have bald fathers, even when no one on the mother’s side of the family has any hair loss. This suggests that the genetics of male pattern alopecia is more complicated, with multiple genes influencing hair growth. And it is likely that the inheritance of baldness is polygenetic, with relevant genes coming from both the x-chromosome of the mother and non-sex chromosomes of either parent. So where are the other genes?

Two independent research groups, one from England and the other Germany, both published in the journal Nature Genetics, have identified a gene locus p11 on chromosome 20 that seems to be correlated with male pattern hair loss, and since the gene is on a non-sex chromosome, it offers an explanation for why the inheritance of common baldness can be from either side of the family. It is important to emphasize that like the AR gene, the chromosome 20p11 locus has only been shown to correlate with hair loss. It is not been shown that either of these genes actually cause baldness.

Unlike many genes whose expression is one or the other (i.e. blue eyes or brown), the 20p11 variations tend to be additive; therefore, men with one affected copy will have a 3.7 fold increase in the chance of having early hair loss and those with two copies a 6.1 fold increase. Men with both the chromosome 20p11 variation and the AR gene will have a seven-fold increase of developing male pattern hair loss at an early age. This gene combination occurs in about 15% of Caucasian men.

The mainstay of predicting future hair loss is with a Densitometer – an instrument used by physicians to measure changes in hair shaft diameter (miniaturization). According to Dr. Robert Bernstein, “Looking at hair shafts under a microscope can spot shrinkage years before it is apparent – we can pick it up when kid are still teenagers.” Early diagnosis is important in androgenetic alopeica because medication is useful only if the hair loss is not too advanced. The genetic studies are significant in that they supply the physician with one more piece of information when developing a master plan for treating a person’s hair loss. See the article in the Wall Street Journal titled, Hair Apparent? New Science on the Genetics of Balding.

While researchers consider these latest discoveries to be of significant merit, caution must be made since these genes are felt to be associated with hair loss, but not yet shown to be causative. More importantly, the associations are not absolute. A clinical evaluation is still the most reliable indicator of future hair loss. Finally, the ability to identify associated genes does not suggest that a “cure” for male pattern baldness is imminent.

Reference
“On the Genetics of Balding,” Wall Street Journal, Vol. 4 – October 1, 2008.

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Dr. Bernstein, pioneer of Follicular Unit Hair Transplantation, was a featured guest on The Oprah Winfrey Show. In addition to discussing his hair transplant technique, Dr. Bernstein showed Oprah and Dr. Mehmet Oz the results of a hair transplant on one of his patients. They also showed a video montage of Dr. Bernstein performing a hair restoration procedure.

Please read the full Bernstein Medical – Center for Hair Restoration press release below:

New York, NY (PRWEB) October 7, 2008 – The Oprah Winfrey Show features Dr. Bernstein discussing his pioneering follicular unit hair transplant procedure, focusing on the newest diagnostic and treatment techniques for hair restoration. The Oprah Winfrey Show aired Tuesday, October 7th at 4:00PM EST on ABC.

Dr. Bernstein is a Clinical Professor of Dermatology at the College of Physicians and Surgeons of Columbia University in New York. He is recognized world-wide for his pioneering work in the treatment of hair loss. Dr. Bernstein is known for developing the revolutionary Follicular Unit Transplantation procedure for hair restoration.

Dr. Bernstein with Dr. Oz and a Patient on the Oprah Winfrey ShowDr. Bernstein with Dr. Oz and a Patient on the Oprah Winfrey Show

After introducing Dr. Bernstein to Oprah, Dr. Mehmet Oz (health expert on The Oprah Winfrey Show) presents video footage of Dr. Bernstein performing a hair transplant and then invites the patient live onstage to be inspected by Oprah. In addition to engaging with the audience about baldness and hair transplant procedures, Dr. Bernstein examines a person from the audience who is experiencing early hair loss using an instrument known as a densitometer.

The densitometer is a self-contained, portable, device that houses a magnifying lens for viewing hairs close to the scalp. The idea behind densitometry is to determine the degree of miniaturization, or shrinking of the hair’s diameter, which contributes to hair loss. This information is used to evaluate whether the patient is a good candidate for hair transplant or medical treatment, as well as to predict future hair loss.

“Follicular Unit Transplantation is a procedure where hair is transplanted exclusively in its naturally occurring groups of 1-4 hairs. It is the logical end point of over 30 years of evolution in hair transplantation surgery,” explained Dr. Bernstein. “However, this by no means implies our work is complete. We are obsessed with making the procedure as perfect as possible.”

View the original press release at PRWeb.

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Q: I am 25 year old who just started going bald. My doctor confirmed that I have pattern baldness and put me on Propecia and Rogaine. I don’t want to go bald at any age. So, instead of prolonging the process for 5-10 years and then having a hair transplant, isn’t it easier to just let the hair loss continue and then have a HT, so that I can save the money on drugs for years. — Z.B., Greenwich, C.T.

A: It is far better to keep your own hair using medical therapy. The medications (i.e. finasteride and minoxidil) are relatively inexpensive if use the generic forms and will be far less expensive than surgery – even on the long-term. Keeping your own hair will look fuller than a hair transplant, since a hair transplant just re-distributes a diminishing amount existing hair. When the ability to multiply hair (cloning) is available this, of course will change, but this technology is still years away.

Read about the Candidacy for a Hair Transplant

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Q: I am 26 years old, have had two successful hair transplants, but am still losing hair in the crown area. The doctor I have worked with told me that he does not do crown work on anyone until they are at least 40 (due to lack of donor area). I have very thick hair and the transplanted area looks as if nothing was lost. Would you do work on someone my age in their crown area if they have enough donor hair? — A.W., Brooklyn, N.Y.

A: Although I am hesitant to start with the crown when transplanting a younger person, if you have good coverage on the front and top of your scalp from the first two sessions then extending the hair transplant into your crown may be reasonable. It depends upon your remaining donor supply and an assessment of how bald you will become. I would need to examine you.

If it is likely that you will progress only to a Norwood Class 6, then transplanting your crown can be considered. If you will progress to a Class 7 then you should not since, in the long term, hair that was placed in the crown might be better used for other purposes, such as connecting the transplanted top to receding sides.

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Q: I’m male, early thirties and in the early stages of hair loss, too early for hair transplants. I am experiencing extreme shedding. I took Avodart for 6 weeks, but because of the shedding I stopped. Now, it still continues as strong as ever. I’ve been losing about 200 hairs every day in the shower. 3 months ago I had so much more hair, what is going on? I heard that shedding can happen, but not like this. Could this have caused telogen effluvium, or something else? — M.M., Boston, Massachussetts

A: Since Avodart (dutasteride) is a more potent medication than Propecia (finasteride), the shedding (telogen effluvium) may be more dramatic. If you have made a decision to use Avodart, then you need to tolerate this short-term effect. It should subside within the first 6 months on the drug.

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Q: I am 22 yrs old and I started shedding hair in a very limited form since I was 20. I have now been on Propecia for nearly 8 months. To date I have not experienced any benefit. In fact, I have seen my hair continue to thin. Is it possible that this thinning is a result of Propecia? — M.M., Boston, Massachussetts

A: Usually the shedding associated with finasteride will subside by 6 months.

If you are still losing hair at 8 months, most likely the medication is not working. Unfortunately, it is not effective in about 15% of patients.

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Q: I am in my early 20’s and I was told my hair loss pattern is a Norwood Class 6, on its way to becoming a Class 7. My hair is brown in color and medium to coarse and I was told I have high density in my donor area. Although I was told I could have hair transplants, do you think that I should based upon what I have told you? — D.W., Pleasantville, N.Y.

A: The main concern I would have is that when someone is already a Class 6 by their early 20’s, he may eventually be left with only a very thin see-through fringe as he ages. A high donor density now does not ensure that this will not occur – and coarse donor hair at age 22 does not ensure that it will not become fine over time. In fact, there is a significant chance that it will.

Since the hair restoration would require one or more large sessions, there is a risk that the donor scar(s) will not be hidden over time. If you had a widened linear donor scar from an FUE-strip procedure, you would need to grow your hair longer on the back and sides to cover it (if that is even possible). And this look of longer hair on the back and sides would not be a good one for a young person, especially if there was not enough donor hair to fill in the crown.

On the other hand, large FUE sessions leave a very wide band of small round scars in the back and sides of the scalp that can become visible if the anticipated permanent donor zone was not truly permanent and narrowed over time.

When we are younger, our decisions are often more emotion-based and impulsive. When one is older, and our tastes change, we may change our mind about having had surgical hair restoration, but the hair transplant, once performed, is not reversible.

Read about the Candidacy for a Hair Transplant

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Q: If I’m 20 years old and haven’t lost any hair yet, should I start using a laser comb now?

A: One should not treat hair loss until it actually occurs.

That said, once there is clear evidence that a person is thinning, non-surgical treatments are best started early to prevent further hair loss.

It is important to keep in mind that finasteride (Propecia) is still the most effective treatment for early hair loss and has a good record for at least some long-term effectiveness. It is not clear what additional benefit the laser-comb will have.

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Q: I am a 21 year old male experiencing the first signs of hair loss as of late. I looked at your before and after pictures of hair transplant patients and honestly right now I have a lot more hair than the patients, even in the after photos. By no means do I intend to criticize your work at all, but I noticed that they still had a receding hairline. I myself am an artist and pay close attention to detail. What I want out of a hair transplantation procedure is to basically have the full head of hair that I had even before puberty. Is it possible for this to be done? — P.N., New York, NY

A: Your concerns and goals, although understandable, are impossible to achieve through hair transplantation and is exactly the reason why we don’t perform hair transplants in young persons.

Surgical hair restoration can never give you your original density back since we are just redistributing a smaller amount of hair.

In addition, your original hairline should not be restored since a transplanted hairline is permanent and will not evolve naturally as you age. A mature hairline must be built into the design of the first hair restoration procedure, regardless of a patient’s age.

Read about the Candidacy for a Hair Transplant

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Q: I believe I am an “early” IIIA or IVA. I am not losing any hair on the back of the scalp. There is no substantial hereditary hair loss on either side of the family, but I began taking Propecia four months ago and recently noticed a dramatic thinning of hair on the top (front) of the scalp, extending back to the rear of the head. — B.M., Lower East Side, N.Y.

A: Often people experience some shedding the first six months on finasteride as the new hair essentially pushes out some of the old. I would wait a full year before making any judgments about a hair transplant since you may see significant regrowth from finasteride in the second six months and may not need surgery at this point, particularly if the hair loss is early.

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Q: I have some early thinning in my crown and the doctor said I am too early for a hair transplant. I don’t want to take Propecia, but using Rogaine twice a day is a big nuisance. Can I use Rogaine once a day? — L.B., Cleveland, Ohio

A: The tissue half-life of minoxidil is 22 hours.

This means that 22 hours after it is applied, about 1/2 of the compound is still bound to the skin and exerting some effect. Because of this, once a day dosing is probably OK.

Please note that this is hypothetical and that there have been no controlled studies to confirm this.

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Q: I am 22 and losing my hair all across the top of my head. How can I thicken my hair to its level a few years previously? — I.L., Kentfield, CA

A: If medication, such as finasteride, is successful it can thicken hair by increasing the diameter of the existing hair shafts. Although the cosmetic benefits can be dramatic in a person with significant hair loss, a hair transplant can not restore hair to its original density, since it only moves the existing hair around and does create new hair.

When hair cloning technology is available, this will change as a person’s donor supply will be increased.

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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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Q: I have early thinning on the top of my scalp and I was told to use Propecia, but I heard that is was only for men. What do you think? — T.G., Staten Island, NY

A: Women can’t take Propecia during the child-bearing years because, if ingested, it can cause birth defects in male offspring.

In post-menopausal women, where we see the greatest frequency of hair loss, it doesn’t seem to be effective.

In pre-menopausal women who do not plan to become pregnant or who already have children, we are still cautious about using the medication, since there effectiveness has not been proven and its long-term safety in this population has not been tested.

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Q: I am 19 years old and seem to be thinning all over, including the sides. My father has all of his hair but my grandfather is totally bald. Should I have a hair transplant now or wait until I am older? — T.K., Garden City, NY

A: Most likely you have a type of androgenetic alopecia called Diffuse Unpatterned Alopecia (DUPA). In this hereditary condition, hair thins all over rather than just on the front, top and back as in the more common male pattern baldness. The fact that the back and sides of your scalp are thinning (the donor area) precludes you from being a candidate for surgery. The diagnosis can be made by observing a high degree of miniaturization (fine hair) in the donor area under a magnifier. This instrument is called a densitometer.

For further information, please read the article:

Bernstein RM, Rassman WR: Follicular Transplantation: Patient Evaluation and Surgical Planning, published in the journal Dermatologic Surgery in 1997. Specifically, read the last part of the article.

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Q: Should you perform a hair transplant on a crown that is just starting to thin? — R.R. Philadelphia, Pennsylvania

A: A “thin” crown should first be treated with Propecia, as it may thicken the hair to a cosmetically acceptable degree without the need for surgery. If Propecia is ineffective in restoring enough hair, then surgical hair restoration can be considered.

The surgeon must also factor whether or not the patient has enough donor reserves to transplant the front and top part of the scalp if the patient becomes very bald. This is hard to predict in patients who are still in their twenties.

See the paper Follicular Transplantation: Patient Evaluation and Surgical Planning for a more complete discussion.

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Q: I am 27 years old and have a Class 3 degree of hair loss. Should I do a hair transplant or consider non-surgical methods of hair restoration? — Y.B., Lake Forest Illinois

A: At age 27 with early hair loss, you should consider non-surgical options first.

Propecia is the most important medication, but you need to be on it for one year at the full dose of 1mg a day to assess its benefits.

If you have done this and other parameters are OK for a hair transplant, such as adequate donor hair density and scalp laxity and you have little evidence that you will become extensively bald (i.e. no donor miniaturization and no family history of extensive baldness), then hair transplantation can be considered.

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Q: I’m currently 24 years old. Ever since turning 20, my hair on top began to thin little by little. I have noticeable thinning on the top part of my scalp and on my crown, but have no recession at the temples. My hairline looks amazingly young and hair on the donor areas seems quite thick. Am I in the early stages of male patterned baldness? I cannot place myself in the Norwood scale since my thinning doesn’t seem to follow the classic pattern. I just started on Propecia. Should I be considering a hair transplant? — B.R., Landover, MD

A: From the description, it sounds like you have typical Diffuse Patterned Hair Loss or Diffuse Patterned Alopecia (DPA). In this condition, the top of the scalp thins evenly, the donor area remains stable, and the hairline is preserved for a considerable period of time. Please see: Classification of Hair Loss in Men for more information.

Propecia would be the best treatment at the outset. When the hair loss becomes more significant, patients with DPA are generally good candidates for surgical hair restoration. It is important, however, that your donor area is checked for miniaturization to be sure that it is stable before a hair transplant is considered.

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Q: If my hair is just starting to thin, when should I have my first hair transplant? — T.O., Bayonne, NJ

A: It is best to wait until at least 25 before considering hair transplant surgery, although there are exceptions. The most important thing is to wait until you have hair loss that is a cosmetic problem. A hair transplant is a treatment for hair loss — it should not be used as a prevention. When hair loss is just starting, medical therapy is generally a better choice than surgery as it can both regrow hair and prevent future loss.

This issue is detailed in the publication Follicular Transplantation: Patient Evaluation and Surgical Planning.

Read our page on Hair Transplants in Young Patients

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Q: I was wondering why you chose two years as the amount of time one should wait to judge the effectiveness of Propecia. Have you had patients who only saw results after that long? Why does Merck say 3-6 months and Dr. Rassman at New Hair say 6-8 months? I know these numbers aren’t arbitrary, but I’m just wondering what the logic is behind this and how does this relate to planning a hair transplant? — I.P., Hempstead, Long Island, NY

A: The Merck data showed that over 90% of patients had peak response at 1 year and this has been my experience as well.

Most patients show the most dramatic response between 6 to 12 months with some getting additional benefit up to two years. Prior to 6 months, the results are quite variable and there may even be a net loss due to shedding during this period, as the Propecia (finasteride) stimulates a new anagen cycle.

If one is planning to go on Propecia before a hair transplant to minimize any shedding from the surgery and to prevent future hair loss, one should start the medication at least one month prior to the procedure.

If one wants to use Propecia for the purpose of possibly avoiding hair restoration surgery, then one needs to wait at least a year to see if there will be enough regrowth.

Finally, if one is younger (i.e. in the 23-25 age range) one should be on Propecia for at least two years to give it every possible chance of working and see its maximum benefit before considering a hair transplant.

Read more about taking Propecia before a hair transplant
Read more about Propecia (finasteride)

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Q: I am twenty and think that I am starting to thin. I am also experiencing a slight tingling in my scalp. Are these related? — T.N., Philadelphia, PA

A: Most likely. Early androgenetic alopecia can be associated with a slight tingling or slight tenderness of the scalp.

You should see a dermatologist for evaluation and, if you have early male pattern baldness, consider starting finasteride (Propecia).

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