Bernstein Medical - Center for Hair Restoration - Miniaturization
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Q: I have heard that shock loss can occur after a hair transplant. Do women experience less shock loss than men? — N.R. ~ Mineola, N.Y.

A: Actually, the risk of shock hair loss is usually greater in women than in men since women generally have a more diffuse pattern of thinning. This is because females often have more miniaturized hair, the hair that is most subject to post-op shedding.

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What are the chances that I will go bald? How bald will I be? Can I know for sure? These are among the most common questions we get from patients in our hair loss consultations. Despite extensive knowledge about the mechanisms and causes of androgenetic alopecia (common baldness), the answers to these questions have been a bit hazy. New research has sharpened the focus on the genetic mix that results in hair loss and has enabled more accurate predictions. A study published in February 2017 in the journal PLoS Genetics identified over 250 gene locations newly linked to hair loss. Using this information, researchers more accurately predicted severe balding compared to previous methods.

Background

We know that susceptibility to hair loss is driven by genetics. One in two men in their 50s experience some degree of balding, with that proportion increasing to over 60% of men aged 60 and over. We also know that one of the most important genes in hair loss, called the androgen receptor (AR) gene, is located on the X chromosome. Outside of that, knowledge of the precise genetic makeup resulting in baldness is sparse and there is wide variation in balding patterns. Some genetic tests, such as the HairDx test, have been developed to predict a patient’s risk of balding, but lack the ability to determine its severity. To date, the best method for predicting the extent of future hair loss is to have an experienced physician take a personal and family history and perform a physical examination that includes an assessment of miniaturization of scalp hair.

Developing a more thorough understanding of the complex genetic relationships that result in hair loss will be important in clinical practice as these relationships may help predict future hair loss and guide methods of treatment.

The Study

Researchers selected a pool of more than 52,000 men with male pattern baldness from UK Biobank. This is a massive database of over half a million people aged 40-69 years with information accumulated from 2006 to 2010. This pool was over four times the size of the previously largest hair loss study. Researchers applied a genome-wide association study (GWAS) to a cohort of about 40,000 men and identified 287 statistically important gene locations (loci) linked to varying degrees of baldness — more than 35 times the eight genetic signals found in the previous largest study.

Using this set of 247 loci on non-sex, or autosomal, chromosomes and 40 loci on the X chromosome, the researchers analyzed the remaining 12,000 men for predictive patterns. The results indicated that the predictive value of using this set of gene loci was 0.78 for severe hair loss, 0.68 for moderate hair loss, and 0.61 for slight hair loss. When the subject’s age was added, the predictive score improved to 0.79 for severe hair loss, 0.70 for moderate hair loss, and 0.61 for slight hair loss. Subjects whose individual scores, based on their genetic makeup, were below the mid-point of the range of scores were significantly more likely to have no hair loss than severe hair loss. By contrast, almost 60% of subjects whose individual scores were in the top 10% of the range of scores were moderate to severely bald.

While the predictions were not extraordinarily accurate – the authors characterized the accuracy as “still relatively crude” – they did show a distinct improvement in predictive accuracy over prior studies.

Summary

Hair loss is a serious concern for many people. Research shows that men with extensive hair loss may experience significant psychosocial impacts such as reduced self-image and reduced social interactions. Some studies have associated baldness with increased risk of prostate cancer and heart disease.

Understanding the complex factors that comprise the genetics of hair loss can help physicians potentially customize treatments based on a patient’s genetic profile and their risk of balding. Beyond that, diagnosing the potential severity of hair loss may help doctors get a head start on treating what could be related life-threatening conditions.

With large databases like UK Biobank, researchers can now drill down into this information and develop increasingly clear, highly granular data sets that can identify complex systems and potentially lead to improved treatments.

References

Hagenaars SP, Hill WD, Harris SE, Ritchie SJ, Davies G, Liewald DC, et al. (2017) Genetic prediction of male pattern baldness. PLoS Genet 13(2): e1006594. doi:10.1371/journal.pgen.1006594

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NYCityWoman.com

Dr. Bernstein was interviewed for an article in NYCityWoman.com that ran the gamut of available treatments for hair loss in women. Read below for some select quotes on a wide range of topics related to hair loss in women and treatments for female patients with androgenetic alopecia (common genetic hair loss).

On the fading stigma of hair loss in women:

“Women today are more comfortable talking about their hair loss.”

On indicators of hormone-driven female hair loss:

“It is typical to have a positive family history of hair loss and the presence of miniaturization (short, fine hairs) in the thinning areas.”

On minoxidil for regrowth of thinning hair:

Rogaine (minoxidil) can increase the quality (length and diameter) of hair that is just starting to thin.”

On the different strengths of Rogaine (minoxidil):

I generally recommend the 5 percent for women and men. Although it’s sold in separate packages for men and women, the basic ingredients are essentially the same.”

On Rogaine Foam:

“It is an elegant mixture, made for compliance,” says Dr. Bernstein. “It is an aerosolized foam, so it is less irritating than liquid Rogaine, but can be more difficult to get directly on the scalp.”

On LaserComb vs. cap-based Low Level Laser Therapy (LLLT) devices:

“The cap is both easier to use and more effective for very thin hair, due to the greater number of lasers. But for higher-density hair, a laser comb or the LaserBand82 may be more effective, as it’s probably better at getting the laser therapy beam to the scalp.”

On Follicular Unit Transplant (FUT) surgery:

FUT hair transplants allow many women to have a completely natural hair restoration, producing a dramatic change in their appearance.”

On Robotic FUE hair transplants:

Robotic FUE allows for unparalleled precision, without any line scars in the donor area and no post-operative limitations on physical activity.”

See before and after photos of some of our female hair transplant patients
Read about the causes, classification, diagnosis and treatment of hair loss in women

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Q: I have done a lot of research over the past year including seeing a dermatologist and receiving consultation from a surgeon. Both recommended Propecia and Rogaine. After my consults I researched these products online and read that they do not work on the front of the scalp to improve my receding hairline, only to regrow hair in the crown area. Can you settle the issue once and for all? Do Propecia and Rogaine work on the front of the scalp? Can they improve my receding hairline? — J.S., Great Falls, Virginia

A: Both Propecia and Minoxidil definitely can work in the front of the scalp as long as there is some hair in the area. Although their mechanisms of action are different, both Propecia (finasteride) and Rogaine (minoxidil) act to thicken miniaturized hair regardless of where it is on the scalp. In fact, there are published data ((Leyden, James et al. “Finasteride in the treatment of men with frontal male pattern hair loss.” J Am Acad Dermatol. 1999 Jun;40(6 Pt 1):930-7.)) demonstrating this improvement with finasteride in a controlled clinical trial of men with frontal hair loss.

The source of the confusion is that the FDA limited the application of the drugs to the crown on the package inserts for both Propecia and Rogaine. The FDA did this because Upjohn (the company that introduced Rogaine) and Merck (Propecia) only tested the medications on the crown in the clinical trials. Logically, the fact that DHT causes frontal hair loss and Propecia works by blocking DHT gives a reasonable explanation for the efficacy of the drug on the front of the scalp. Also, a side effect of the use of minoxidil is facial hair, so how could it not also work on the front of the scalp? It is regrettable that some doctors and many patients think that these medications won’t work on the front of the scalp. Unfortunately, many hair restoration surgeons have done little to educate the public and dispel this myth.

To reiterate, yes, both of these medications can work on the front of the scalp to prevent hair loss and thicken a thinning hairline. However, it is important to note that neither of these medications can grow hair on a totally bald scalp or lower an existing hairline. Hair follicles must exist for the medications to work. It is also important to stress that the best results come from using both finasteride and minoxidil together.

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Q: I have seen through forums that a hair transplant gives severe shock loss in the donor zone (especially behind ears) after the surgery. Doctors say it is temporary and can last about six months or more. Frankly, do you believe in this? Will the donor shocked hair recover? — M.D., Darien, C.T.

A: It depends if you are speaking about follicular unit hair transplantation using strip harvesting (FUT) or Follicular Unit Extraction (FUE). With FUT, it is extremely uncommon to have any shock hair loss in the donor area. This could occur if the hair transplant procedure was done improperly, i.e. the donor area was closed too tightly. In this case, some hair loss may be permanent. This is one of the reasons that very large hair transplant sessions are unwise. Shock hair loss in FUE is more common, but is generally not significant and should eventually recover completely.

That said, some shock hair loss in the recipient area is quite common with either hair restoration procedure (FUT or FUE). This is particularly the case if there is a lot of existing miniaturized hair (hair that is starting to thin) in the transplanted area.

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Q: What is female androgenetic alopecia?

A: Female androgenetic alopecia, also called female pattern hair loss, is caused by the shrinking of susceptible hair follicles in response to normal levels of hormones (androgens). It is the most common type of hair loss in women, affecting perhaps 1/3 of the adult female population. It is seen as a general thinning over the entire scalp, but can also present in a more localized pattern i.e. just limited to the front and top. The condition is characterized by a gradual thinning and shortening (miniaturization) of individual hair follicles, rather than their complete loss and, although the condition tends to be progressive, it rarely leads to complete baldness.

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Q: A while ago I saw you and you recommended FUT hair transplantation, but my friend came in and you recommended FUE. How come? — C.T., Hackensack, N.J.

A: I think that both procedures are excellent, which is why I do them both. My recommendations are determined by the individual patient. His or her age, desire to wear hair cut very short, athletic activities, donor density and miniaturization, extent of hair loss, and potential future balding are all important aspects in the decision process.

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Q: What is Lichen planopilaris? — G.S., Pleasantville, NY

A: Lichen planopilaris (LPP) is a distinct variant of cicatricial (scarring) alopecia, a group of uncommon disorders which destroy the hair follicles and replace them with scar tissue. LPP is considered to have an autoimmune cause. In this condition, the body’s immune system attacks the hair follicles causing scarring and permanent hair loss. Clinically, LPP is characterized by the increased spacing of full thickness terminal hairs (due to follicular destruction) with associated redness around the follicles, scaling and areas of scarred scalp. In contrast, in androgenetic alopecia (AGA) or common baldness, one sees smaller, finer hairs (miniaturization) and non-inflamed, non-scarred scalp. Complicating the picture is that LPP and AGA can occur at the same time – particularly since the latter condition (common baldness) is so prevalent in the population (see photo). And LPP can involve the frontal area of the scalp, mimicking the pattern of common genetic hair loss. Interestingly, the condition is more common in women than in men.

For those considering a hair transplant, ruling out a diagnosis of LPP is particularly important as transplanted hair will often be rejected in patients with LPP. In common baldness, the disease resides in the follicles (i.e., a genetic sensitivity of the follicles to DHT). Since the donor hair follicles remain healthy, even when transplanted to a new location, we call common baldness donor dominant. It is the reason why hair transplantation works in persons with common baldness. In contrast, LPP is a recipient dominant condition. This means that the problem is in the recipient area skin, so if healthy hair is transplanted into an area affected by LPP the hair may be lost.

Because it is so important to rule out suspected LPP when considering a hair transplant and because it is often hard to make a definitive diagnosis on the physical exam alone, a scalp biopsy is often recommended when the diagnosis of LPP is being considered by your doctor. A scalp biopsy is a simple five minute office procedure, performed under local anesthesia. Generally one suture is used for the biopsy site and it heals with a barely detectable mark. It takes about a week to get the results. The biopsy can usually give the doctor a definitive answer on the presence or absence of LPP and guide further therapy. If the biopsy is negative, a hair transplant may be considered. If the biopsy shows lichen planopilaris, then medical therapy would be indicated.

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Q: Dr. Bernstein, can you please comment on leg and body hair transplants? — J.R., Ridgewood, NJ

A: I’ve tried the technique in the past but have been dissatisfied with the results. Scalp hair, unlike the rest of the body, has multiple hairs rising out of each follicle. With leg and body hair, you have only one hair per follicle, not follicular units of multiple hairs. Leg hair is also very fine. It might thicken up a little bit after it is transplanted, but not enough to be clinically useful. In men you want full thickness hair, so fine hair can make it look like it is miniaturizing, as it does when you’re losing it.

Body hair has been successful in softening hairlines, but most people have enough scalp hair to due this, since it often requires very little if properly placed. Another issue is that because leg hair emerges from the skin on a very acute angle, more wounding of the skin occurs as each hair is individually extracted and this leaves marks.

Body hair, from the chest or back, does hold better potential for success than leg hair, particularly if it is plentiful, but it still is extracted one hair at a time and can leave significant scarring when done in large numbers.

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Q: Can shock loss be eliminated by using special surgical techniques? — R.P., Short Hills, NJ

A: Although there have been no scientific studies proving this, shock hair loss can most likely be minimized by keeping the recipient sites parallel to the hair follicles, by not creating a transplanted density too great in areas of existing hair, and by using minimal epinephrine (adrenaline) in the anesthetic. We implement all of these techniques. Finasteride may also decrease shock hair loss, or at least help any (miniaturized) hair that is lost to re-grow. That said, some shock hair loss from a hair transplant is unavoidable regardless of the technique as it is a normal physiologic response to stress.

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Q: I have been reading various articles and forum postings and it would seem that a person utilizing Propecia might experience increased “shedding” of hairs (outside of the normal hair cycle) around the 12 week mark after a hair transplant and lasting around 2-4 weeks. The forum postings suggest that one will not only see the miniaturized hairs being lost, but also normal terminal hair in greater than expected levels. Does an explanation exist to explain this increase in shedding hairs? — B.T., Manhattan, NY

A: Our understanding is that finasteride only affects miniaturized hairs — i.e. hair affected by DHT — and that this is all that should be shed. Remember, however, that much of the thinning a bald person experiences is due to thousands of partially miniaturized hair, and these can look very much like a full terminal hair in its early stages.

See our page on Shedding After A Hair Transplant.

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Q: What does the hair transplantation process do to your existing hair? — R.V., London, UK

A: When we perform hair transplant surgery, we transplant into an area that is either bald or has some existing hair. The hair that is existing is undergoing a process called miniaturization. What this means is that the hairs are continuing to decrease in size – both in diameter and in length. When we perform a hair transplant, we don’t transplant around the existing miniaturized hair on your scalp, we transplant through it. And the reason why we do that is because the miniaturized hair, the fine hair that is being affected by DHT, is eventually going to disappear, so you don’t want there to be any gaps.

So the question is, does the hair transplant actually destroy the existing hair? The answer is that it doesn’t destroy, but it can “shock” it. In other words, creating recipient sites (that the grafts are placed into) will temporarily alter the local circulation of the scalp and this can cause some of the hair in the area to be shed. The reason why hair may be shed is that hair is naturally cyclical. In other words, hair is normally growing, shedding, and then regrowing again. When you stress the scalp, the growing hair may be shed prematurely, but then it regrows.

If you think about the process of electrolysis, it makes sense that you don’t damage follicles from making recipient sites during a hair transplant procedure. In electrolysis used to treat unwanted hair, you stick a needle in the follicle, and you turn on an electric current. And you burn it. And then what happens to the hair? It usually comes back and you need to do it a few more times, even though we are applying an electric current via a needle placed directly in the follicle. So it makes sense that by just inserting a fine needle – the tool commonly used to make a hair transplant site – into the skin, one would not destroy hair follicles. However, the cumulative effect of making hundreds or thousands of recipient sites does shock the follicles and, as a result, some may shed their hair.

It can occur with general anesthesia – when the scalp is not even touched – and it can occur with oral medications, from pregnancy, or after psychological stress. So if you have hair restoration surgery and there is shedding, and it takes six months to a year for the transplanted hair to grow in, during this time hair transplant patient will experience some thinning. Since miniaturized hair is going to eventually disappear anyway, some of the miniaturized hair that is shed may not return. But if it is healthy hair, and it is shed, it will grow back. And, of course, the transplanted hair will be growing in as well during this time.

I am often asked to describe how much can be expected to be shed. The answer is that it is an amount that is often noticeable by the patient, but not noticeable by anyone else.

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Q: Scalp Med is supposed to unclog pores. How does this prevent hair loss? — O.P., Trenton, NJ

A: The active ingredient of Scalp Med is Minoxidil, which will help reverse miniaturization, the process that causes androgenetic hair loss. Hair loss is not caused by clogged pores, so unclogging them will not prevent going bald. Minoxidil, which is also the active ingredient in Rogaine, is over-the-counter so it is a less expensive way to use the active ingredient.

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Q: I am about 3 months post-op after my hair restoration procedure. I have noticed some hair shedding in the frontal part of my scalp. I have continued both Propecia and Minoxidil. Is there anything I can do and should I be concerned? — M.B., Chicago, IL

A: Shedding of some of the patient’s existing hair in, and around, the area of a hair transplant is a relatively common occurrence after a hair transplant and should not be a cause of concern. The mechanism appears to be a normal response of the body to the stress of the hair restoration surgery -– i.e., site creation, adrenaline in the anesthetic etc. Some doctors claim that their hair transplant techniques are so “impeccable” that their patients do not experience shedding. This is a false claim. Although using very small recipient sites and limiting the use of epinephrine may mitigate shedding somewhat, shedding is a normal part of the hair transplant process and the risk is unavoidable.

It appears that a person’s normal, non-miniaturized hair, as well as transplanted hair, is somewhat less subject to shedding than hair that is actively miniaturizing (thinning from the effects of DHT). In addition, if transplanted hair or non-miniaturized hair is shed, it will grow back. If miniaturized hair is lost, however, it may or may not return.

Since both finasteride and minoxidil reverse the miniaturization process, they should decrease the amount of hair at risk from shedding after hair transplant surgery. This has been our clinical experience, but it is important to note that as yet there have been no scientific studies to support this view.

At this time there is not much you can do except to be patient and wait for the newly transplanted hair to grow in and for the shed hair to return. Of course, make sure you continue to take finasteride and/or minoxidil if the doctor has prescribed it for you.

Read more on the topic of Shedding After a Hair Transplant.

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Dr. Eric S. Schweiger - Associate at Bernstein Medical - Center for Hair RestorationDr. Eric S. Schweiger, board-certified dermatologist, is quoted in a few recent articles on the effects of chemotherapy on hair, genetic testing for hair loss, and protecting a balding scalp from the sun.

“Coping with Chemo-Induced Hair Loss” was published in a recent issue of Energy Times, a publication focused on wellness and nutrition. Dr. Schweiger commented on the way hair follicles can react to chemotherapy treatment for cancer patients:

Expect changes like “chemo curl.” Eric Schweiger, MD, explains that chemo shocks rapidly dividing cells like hair follicles in the scalp, causing the hair loss. “When the follicles grow again, the shock sometimes changes how they grow, temporarily resulting in a different hair texture and color, which eventually normalizes,” explains Schweiger.

In the article, “Genetic Testing to Predict Hair Loss,” published on HairLoss.com, Dr. Schweiger and Dr. Bernstein discussed the efficacy of genetic tests for hair loss:

[Dr. Schweiger] explains, “I think the test has probably identified a predictor of hair loss but not the only predictor. There is science behind the test and some published research studies; however, the longitudinal, larger studies have not been done, because this testing procedure is just too new.” Dr. Robert Bernstein, M.D., director at Bernstein Medical Center, agrees and adds, “These tests focus on one particular dominant gene, but what is becoming apparent is that hair loss is a complex genetic condition most likely involving several different genes.” He further notes that age, stress, hormone levels, disease and many other factors also are at play in determining factors for hair loss. “Just because a person has the genes for baldness, it doesn’t mean the trait will manifest itself. The truth is the cause and effect have not been proven and differ from person to person, and the association is not anywhere near 100 percent.”

[…]

“Right now, we predict future hair loss based on follicle miniaturization, using advanced microscopic equipment,” says Dr. Schweiger, “and I advise a man to do this at around age 25. If someone presents with more than 25 percent miniaturization, then it’s time to start a hair loss prevention regimen.”

Lastly, Dr. Schweiger contributed featured commentary to an article on HairLoss.com on a topic of importance to those suffering from hair loss, namely, protecting your scalp from the dangerous radiation given off by the sun. In “When You Lose Your Hair, Protect Your Scalp,” Dr. Schweiger encourages bald or balding individuals to take important steps to protect their scalps:

…if you notice your hair thinning or you have baldness of any kind for any reason, it’s important to protect your scalp from sun damage, precancer and skin cancer,” says Dr. Eric Schweiger, M.D., a board-certified dermatologist and hair transplant surgeon at Bernstein Medical — Center for Hair Restoration in New York City. That’s because 100 percent of the surface area on top of your head directly faces the sun’s burning rays when the sun is strongest, between 10 a.m. and 2 p.m. “In general, a mild sunburn on your scalp won’t harm your hair follicles. But any exposure that causes blistering can cause scarring and pre-cancer cells, which will harm hair follicles permanently, so you need to take special care of your scalp when exposed to the sun, even for only a few minutes,” explains Schweiger.

Set up a hair loss consultation with one of our board certified physicians.

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Q: I have been on finasteride for about 7 months. After my latest haircut I can see that my scalp is shiny. I read that is from sebum buildup and it can cause a layer that clogs the growth of hair. I was wondering if this is true and, if so, how can it be treated? — T.C., Philadelphia, PA

A: It is not true. Hair loss is caused by the miniaturizing effects of DHT on the hair follicle, not by blocked pores.

For more on this topic, view our pages on the causes of hair loss in men or the causes of hair loss in women.

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Q: I am currently taking Avodart and have done so for around 8 months. Last night I had a significant loss of hair after taking a shower, nothing like I have ever seen before and found it very distressing. Can you tell me if this is hair loss or could it be something known as shedding and could you please tell me what is the difference between hair loss and hair shedding? — M.S., New York, NY

A: Hair loss is a very general term that can refer loss of hair for any reason. Genetic hair loss is caused by the effects of DHT on hair follicles that result in miniaturization -– i.e. a slowly progressive change in hair diameter that starts with visible thinning and that may gradually end in complete baldness. Hair shedding is more sudden where hair falls out due to a rapid shift of hair from its growth phase into the resting phase. The medical term for this is telogen effluvium. This process is usually reversible when the offending problem is stopped. It can be due to stress, medication, or other issues. You should see a dermatologist to figure out which process is going on. Dutasteride can cause some shedding when it first starts to work, but it would be unusual to do this after being on treatment for eight months.

Read more about the Causes of Hair Loss in Men, view our Hair Loss Glossary, or read more about Avodart Hair Loss Medication.

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Q: You mentioned that the hair at my crown and other areas where I now have baldness hasn’t really fallen off but has thinned to a great extent and that taking Rogaine and Propecia might help increase their thickness. If the medications do restore the hair thickness, I’m curious why you said that I could look like how I was 1 to 2 years ago. Technically, shouldn’t I be able to regain much more of my hair (and look like how I was longer than before that) since the follicles are all still there? — H.D., Park Slope, NY

A: Although Propecia is much more effective than Rogaine, even when used together, the medications are just not that effective in reversing the miniaturization process. They may bring you back to the way you were a few years ago, but will not restore your adolescent density.

Read more about hair density and miniaturization, Propecia, Rogaine, and other hair loss medication.

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Q: What happens to hair diameter when you age? — K.L., Greenville NY

A: From infancy to puberty, hair gets progressively thicker. From adulthood to old age the hair becomes thinner again and this is exacerbated by the effects of DHT in susceptible persons. The later process is called androgenetic alopecia (common baldness) and is characterized by miniaturization – the progressive decrease in hair diameter and lengths as a result of DHT.

However, even without the effects of DHT, hair gradually thins over time in many people.

Read more about hair growth and hair loss in men and women.

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Dr. Angela Christiano of Columbia University in New York and a team of scientific researchers have identified a new gene involved in hair growth. Their discovery may affect the direction of future research for hair loss and the diagnosis and ultimate prevention of male pattern baldness.

The condition which leads to thinning hair is called hereditary hypotrichosis simplex. Through the study of families in Pakistan and Italy who suffer from this condition, the team was able to identify a mutation of the APCDD1 gene located in chromosome 18. This chromosome has been linked to other causes of hair loss.

According to Dr. Christiano, “The identification of this gene underlying hereditary hypotrichosis simplex has afforded us an opportunity to gain insight into the process of hair follicle miniaturization, which is most commonly observed in male pattern hair loss or androgenetic alopecia.”

The mutation of the APCDD1 gene inhibits the Wnt signaling pathway. Although this recently discovered gene does not explain the complex process of male pattern baldness, the importance of this discovery lies in the Wnt signaling that the gene directs, has now been shown to control hair growth in humans, as well as in mice.

Reference: Nature 464, 1043-1047 (15 April 2010) | doi:10.1038/nature08875;

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Losing one’s hair can be an uncomfortable topic of conversation for any adult, but, given the importance many women place on their appearance, hair loss in women is an especially taboo subject of conversation. Whether it is a bald patch, diffuse thinning, balding from a medical condition, or scarring from an accident, hair loss can be upsetting or even traumatic for many women.

The good news is that hair restoration pioneers like Dr. Bernstein are bringing the treatment of women’s hair loss out of the cosmetics bag and into the modern era of hair restoration. What a better way of squashing the taboo once and for all than for Dr. Bernstein to appear on national television and confront the issue head-on. Dr. Mehmet Oz invited Dr. Bernstein to appear on his show, the Dr. Oz Show, to discuss the causes and diagnosis of hair loss in women.

As seen in the image above, Dr. Bernstein used a densitometer to evaluate the hair loss of a female member of the audience. The device enables a physician to determine the amount of miniaturization, or genetic thinning, present in the patient’s scalp. Dr. Bernstein also commented on the treatment of hair loss with low level laser therapy (LaserComb).

Dr. Oz and Dr. Bernstein are colleagues at The New York Presbyterian Hospital of Columbia University. They first appeared together on the Oprah Winfrey Show where Dr. Bernstein explained his new hair transplant techniques to Oprah.

See before and after hair transplant photos of some of our female patients.

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Q: Why does a hair transplant grow – why doesn’t the transplanted hair fall out? — J.F., Redding, C.T.

A: Hair transplants work because hair removed from the permanent zone in the back and sides of the scalp continues to grow when transplanted to the balding area in the front or top of one’s head. The reason is that the genetic predisposition for hair to fall out resides in the hair follicle itself, rather than in the scalp — this idea is called Donor Dominance. This predisposition is an inherited sensitivity to the effects of DHT, which causes affected hair to decrease in diameter and in length and eventually disappear — a process called “miniaturization.” When DHT resistant hair from the back of the scalp is transplanted to the top, it will continue to be resistant to DHT in its new location and grow normally.

Read more about Miniaturization
Read about the Causes of Hair Loss in Men

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Note from Dr. Bernstein: This article, by my colleague Dr. Rassman, is such important reading for anyone considering a hair transplant, that I felt it should be posted here in its entirety.

Areas of Unethical Behavior Practiced Today
William Rassman, MD, Los Angeles, California

I am disturbed that there is a rise in unethical practices in the hair transplant community. Although many of these practices have been around amongst a small handful of physicians, the recent recession has clearly increased their numbers. Each of us can see evidence of these practices as patients come into our offices and tell us about their experiences. When a patient comes to me and is clearly the victim of unethical behavior I can only react by telling the patient the truth about what my fellow physician has done to them. We have no obligation to protect those doctors in our ranks who practice unethically, so maybe the way we respond is to become a patient advocate, one on one, for each patient so victimized. The following reflects a list of the practices I find so abhorrent:

1. Selling hair transplants to patients who do not need it, just to make money. I have met with an increasing number of very young patients getting hair transplants for changes in the frontal hairline that reflect a maturing hairline, not balding. Also, performing surgery on very young men (18-22) with early miniaturization is in my opinion outside the “Standard of Care”. Treating these young men with a course of approved medications for a full year should be the Standard of Care for all of us.

2. Selling and delivering more grafts than the patient needs. Doctors are tapping the well of the patient’s graft account by adding hundreds or thousands of grafts into areas of the scalp where the miniaturization is minimal and balding is not grossly evident. I have even seen patients that had grafts placed into areas of the scalp where there was no clinically significant miniaturization present. Can you imagine 3,000-4,000 grafts in an early Class 3 balding pattern? Unwise depletion of a patient’s finite donor hair goes on far more frequently than I can say.

3. Putting grafts into areas of normal hair under the guise of preventing hair loss. There are many patients who have balding in the family and watch their own “hair fall” thinking that most of their hair will eventually fall out. A few doctors prey on these patients and actually offer hair transplantation on a preventive basis. This is far more common in women who may not be as familiar with what causes baldness and do not have targeted support systems like this forum. They become more and more desperate over time and are willing to do “anything” to get hair. They are a set-up for physicians with predatory practice styles.

4. Pushing the number of grafts that are not within the skill set of surgeon and/or staff. The push to large megasessions and gigasessions are driven by a limited number of doctors who can safely perform these large sessions. Competitive forces in the marketplace make doctors feel that they must offer the large sessions, even if they can not do them effectively. A small set of doctors promote large sessions of hair transplants, but really do not deliver them, fraudulently collecting fees for services not received by the patient. Fraud is a criminal offense and when we see these patients in consultation, I ask you to consider your obligation under our oaths and our respective state medical board license agencies to report these doctors.

5. Some doctors are coloring the truth with regard to their results, using inflated graft counts, misleading photos, or inaccurate balding classifications. False representation occurs not only to patients while the doctor is selling his skills, but also to professionals in the field when the doctor presents his results. Rigging patient results and testimonials are not uncommon. Lifestyle Lift, a cosmetic surgery company settled a claim by the State of New York over its attempts to produce positive consumer reviews publishing statements on Web sites faking the voices of satisfied customers. Employee of this company reportedly produced substantial content for the web.

The hair transplant physician community has developed wonderful technology that could never have been imagined 20 years ago. The results of modern hair transplantation have produced many satisfied patients and the connection between what we represent to our patient and what we can realistically do is impressive today. Unfortunately, a small handful of physicians have developed predatory behavior that is negatively impacting all of us and each of us sees this almost daily in our practices. Writing an opinion piece like this is not a pleasant process, but what I have said here needs to be said. According to the American Medical Association Opinion 9.031- “Physicians have an ethical obligation to report impaired, incompetent, and/or unethical colleagues in accordance with the legal requirements in each state……”

Rassman, WR: Areas of unethical behavior practiced today. Hair Transplant Forum Intl. Sep/Oct 2009; 19(5) 1,153.

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Q: It’s a question that greatly concerns me because I’m investigating getting a transplant sometime next year. I’m 28 and thought I started balding at 26, but photographic evidence suggests it had started somewhere around age 24. I’m roughly a Class 2 now, and thanks to finasteride, I’ve stayed almost exactly where I was at 26 with some improvement (not really cosmetically significant though). However, I am convinced I have some crown and top of the scalp thinning too, but not to a visible degree.

These people getting these miraculous jobs from Canada – it is a trick, right? They can’t honestly expect to be able to get away with what they’ve done over the course of their entire lives, can they? — L.M., Great Falls, V.A.

A: I think you have better insights into hair loss than many hair transplant surgeons. Patient ABI was the “rare” patient who seems to be a stable Class 3. I made that judgment due to: almost no miniaturization at the border of his Class 3 recession, no crown miniaturization, and his unusual family history. He had several older family members who stayed at Class 3 their whole lives.

Since we only have about 6,000 movable follicular units on average in our donor area, placing 3,000 at the hairline is obviously a joke and/or the doctor is playing “Russian Roulette” with the patient’s future.

As you point out, in most patients the hair loss will progress and the person will be out of luck. It is similar to the way flap patients were stuck without additional donor hair as their hair loss progressed. An additional problem was that the flaps were low on the forehead and very dense. The situation is analogous to placing 100 grafts per sq cm2 to create a low, broad hairline in a young person.

If you do the math you can see how ridiculous this tactic is. A person’s original density is only 90-100 follicular units cm2. Patient with Class 6 hair loss lose hair over an area of about 300 cm2.

This consists of:

  • 50cm2 in the front (including a 15cm2 hairline)
  • 150 cm2 for the mid-scalp
  • 100 cm2 for the crown

Therefore, 6000 FUs transplanted to this area = 6000/300 = 20 FU per cm2. This is the number we often work with. We put up to 50cm2 at the very most in the mid-frontal forelock area and then proportionately less in other areas.

However, if you put 3,000 FUs at the hairline, in a density of 100/cm2, then you have covered only 30cm. This leaves only 3,000 FUs for the remaining 270cm2 of balding scalp for a density of a little over 11 FU/cm2.

Now, transplanting 11FU cm2 over the back part of the scalp is not a disaster EXCEPT if the front was transplanted at 100 per cm2. In this situation (as you have accurately pointed out) the patient will look very, very front heavy, with an aggressively placed, dense, broad, hairline and little hair to support it towards the back.

The gamble is that the patient’s baldness doesn’t progress, that finasteride or dutasteride can halt the process if it does progress, or that hair cloning methods will be available to save the day.

In my opinion, elective surgery should not be performed when its success depends upon these uncertainties – and particularly since a cosmetically disfiguring hair transplant can be so debilitating (and avoidable).

The reality is that doctors who claim to perform these procedures may not even be performing follicular unit transplantation. In FUT, the surgeon transplants naturally occurring intact FUs of 1-4 hairs. The extreme dense packing techniques preclude the use of 4- and sometimes even 3-hair grafts. What happens is that the larger FU are spit up. This doubles the graft counts (and the cost to the patient) without giving the patient any more hair. It also increases the risk of follicular damage and poor growth.

Patients in whom 10,000 follicular units are available to transplant are very rare and when they are shown on the internet, should be viewed as the exception rather than the rule.

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Q: Hi! I wanted to ask if after hair restoration surgery the transplanted hair will eventually fall out? Because the surgery is to restore hair mainly for people with genetic hair loss which results from DHT, won’t the DHT make the new follicles implanted fall out as well? — B.C., Stamford, C.T.

A: Hair loss is due to the action of DHT (a byproduct of testosterone) on hair follicles that cause them to shrink and eventually disappear (the process is called miniaturization). The follicles on the back and sides of the scalp are not sensitive to DHT and therefore don’t bald (miniaturize).

When you transplant hair from the back and sides to the bald area on the front or top of the scalp the hair follicles maintain their original characteristics (their resistance to DHT) and therefore they will continue to grow.

Read about Miniaturization

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Most medical conditions can best be addressed with early diagnosis. Genetic hair loss is no different. A test now has the ability to identify whether or not you may be genetically predisposed to hereditary male pattern baldness (Androgenetic Alopecia).

The HairDX genetic test offers information that can aid you and your doctor in making an informed decision about the treatment of your hair loss.

This test is not a substitute for an examination by a physician experienced in the diagnosis and treatment of hair loss. It offers one more bit of information that, in the context of other data (such as hair loss pattern, scalp miniaturization and family history) can help guide you and your doctor to formulate an appropriate treatment plan.

How does this test work?

This new genetic test examines genetic variables (SNP) which are responsible for recognizing Androgen hormones in our bodies. These specific genetic variants of the X chromosome (the Androgen Receptor or AR gene) are found in 95-98% of bald men.

These genetic differences are associated with Male Pattern Baldness (MPB) and by identifying them; the onset of MPB might be better predicted. If a person is predisposed genetically to these chromosomal variations, they may be more likely to develop male pattern baldness prior to age forty.

The test consists of a simple swab of the inside of your mouth. The skin cells are then sent to the HairDX clinical laboratory for a confidential analysis.

How accurate is the test in predicting baldness?

HairDX tests for a genetic variant of a gene (the androgen receptor gene) found on the X-chromosome that is present in more than 95% of bald men. Sixty percent of patients with this variant experience male pattern baldness before the age of 40. Therefore, if a person has this gene, they would have an increased risk of significant pattern baldness.

Another, less common genetic variant of the same gene (present in about 1 in 6 men) indicates a greater then 85% likelihood that a person will not experience early onset pattern baldness. If a person is found to have this gene, they are unlikely to become very bald.

Why is the genetic test not 100%?

The androgen receptor gene identified thus far is only one of a number of genes that affect hair loss.

How does the test compare to information obtained from a history and physical exam by your physician?

An assessment of scalp miniaturization by an experienced physician using a densitometer, combined with a history and physical, appears to be a far more reliable way of predicting future hair loss. The genetic test can complement this information, but does not replace it.

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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 heard that there is a new drug on the market called Avodart for prostate enlargement which might help with hair loss as it blocks the conversion of testosterone to DHT better than Finasteride and is more effective than Propecia. Do you recommend taking it and if so what is the dose? — Y.B., Orlando, Florida

A: I am currently not recommending that patients take Dutasteride for hair loss, although it is more effective than Propecia, finasteride 1mg. (Dutasteride 0.5, the dose generally used for hair loss, seems to be slightly more effective than finasteride 5m in reversing miniaturization.)

The reasons that I am hesitant to prescribe it at present are outlined in the Hair Restoration Answers question, “Is Avodart Safe?

In addition to the reasons that I listed in that response, I would also consider that: Dutasteride, unlike finasteride, decreases sperm counts, it can result in persistent decreased sex drive and the incidence is greater than with finasteride. Finally there are a significant number of alpha-type 1 receptors in brain, those affected by dutasteride, but not finasteride.

However, since Dutasteride is approved for older men with prostatic disease, using it for hair loss in this age group (usually in a lower dose) is reasonable.

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Q: My first hair transplant was a breeze. Will a second procedure be any different than the first? — B.B., Murray Hill, N.Y.

A: Generally in a second procedure, a patient can expect less swelling post-up although the reason for this is not known.

There will also generally be less shedding in the second hair transplant session since the weak miniaturized hair that will be shed is often lost in the first session and the previously transplanted hair is generally more resistant to shedding.

In a second session we generally, but not always, transplant fewer numbers of grafts.

If the old scar in incorporated into the new incision, then there will be slightly less hairs per graft since the density in and around the scar will be slightly altered.

For those who are bald, the second hair restoration is sometimes less dramatic than the first since the second is used for fine tuning rather than taking the person from completely bald to having hair.

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Q: Can stress produce diffuse unpatterned hair loss (DUPA), or was it bound to happen anyway? — D.D., Park Slope, Brooklyn

A: Both DPA (diffuse patterned hair loss) and DUPA (diffuse unpatterned hair loss) are genetic conditions, unrelated to stress and would have happened anyway. These types of hair loss are characterized by a high percentage of mininiaturized hair in broad areas of the scalp. See the Classification of Hair Loss in Men and Classification of Hair Loss in Women pages on the Bernstein Medical – Center for Hair Restoration website for more information on this topic.

In contrast, stress generally presents as increased hair shedding, a reversible condition referred to as telogen effluvium. It is called this because the normal growing hair is shifted to a resting (telogen) phase before it temporarily falls out. Increased miniaturization is not associated with telogen effluvium.

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Q: I have been using Propecia since it was released to the public in 1998 and have found it to work very well. Recently, its effectiveness has stopped and my hairs are miniaturizing again. I am going to increase the dosage to 1/2 a pill Proscar every day. How long will the increased dosage take to stop the miniaturizing process? — T.U., Chappaqua, N.Y.

A: It seems to take the same time to work as when you initially started Propecia.

When patients increase their dose, I rarely see re-growth, but rather the expectation is that further hair loss will be decreased. When it does work to actually re-grow hair, we sometimes see an initial period of shedding, similar to when finasteride was first started.

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Dr. Bernstein took part in a PRWeb podcast about hair transplantation in June 2007. Stream the discussion below or read the transcript:

Announcer: PRWebPodcast.com, visiting with newsmakers and industry experts.

Mario: This is Mario from PRWeb, and today it is a real pleasure to have with us Robert M. Bernstein, M.D. Dr. Bernstein is Associate Clinical Professor of Dermatology at Columbia University, and founder of New York City‑based Bernstein Medical – Center for Hair Restoration. Dr. Bernstein, it’s a pleasure to have you here on PRWeb.

Dr. Bernstein: Nice to be speaking with you.

Mario: Give us some understanding, sir, of your practice, the Bernstein Medical – Center for Hair Restoration. How long have you been around, where you guys are located, what is it you do there, please?

Dr. Bernstein: Bernstein Medical has evolved over the last ten years. It was set it up to do a specific procedure that I pioneered called “follicular unit hair transplantation.”

In this procedure, we dissect out hair follicles from the back of the scalp, exactly the way they grow in nature, so we are now able to perform hair transplants that essentially mimic nature.

This procedure is used by doctors around the world in hair restoration procedures. Our NY Hair Transplant Center is in midtown Manhattan and has been specifically designed for performing this hair transplantation technique.

Mario: You recently co‑authored an article, Dr. Bernstein, that appeared in the “Medical Journal of the International Society of Hair Restoration Surgery”. Now, you are well read and interviewed all over. This must be a bit exciting, something that was positive for you and your clinic. Tell us about the article, what it touched on, and some of the things that would be important for our listeners.

Dr. Bernstein: It sure was very exciting. The hair transplantation procedure has been around for many years, but a lot of it has been too much of an art and not enough of a science. What we’ve found is that doctors sometimes make these very general judgments about how bald the patient is going to become, how much hair they may need for the hair transplant or for the restoration.

We’ve found that by using a procedure called “densitometry”, where the hair is looked at under high magnification, we are able to get much more specific and useful information, both on the extent of how much someone is going to lose their hair, and also whether they are going to be a good candidate for hair restoration surgery.

One of the things that we’ve found is that when people start to thin, the hair first changes diameter before it’s lost, and this change in diameter may not necessarily be seen by the naked eye or be observed by another person.

But if you clip the hair very short and look at the base of the hair follicles under very high power, 30X magnification, you can actually see these very subtle, early changes, and these changes will anticipate future hair loss.

When we’re trying to decide whether a person should have hair transplant surgery, we can actually look at the donor area in the back and sides of the head, and see how stable these areas are. For example, someone that is becoming very bald, if the back and sides of their head show no change in the hair diameter, or no miniaturization, then we know that they may have very good hair for hair transplants; where a person with a similar degree of hair loss, whose sides and back are not stable, may not be a good hair transplantation candidate.

In a sense, by being able to measure things now, we’re able to have a much better sense of whether people are going to become very bald, possibly the rate of change of their hair loss, and then if they do need surgery, such as a hair transplant, we’re able to give much more specific information about what actually might be done.

Mario: We’re speaking to Dr. Robert M. Bernstein, M.D., an Associate Clinical Professor of Dermatology at Columbia University, and founder of New York‑based Bernstein Center for Hair Restoration.

Dr. Bernstein, give us some contact information where we can learn more about your services, and be able to end up taking advantage of them.

Dr. Bernstein: The best information can be found on our web site. The web address is www.BernsteinMedical.com.

Mario: Dr. Bernstein, it’s been a pleasure having you here on PRWeb podcasting with us. The best of luck to you, and congratulations again for that article in the “Medical Journal of the International Society of Hair Restoration Surgery.”

Dr. Bernstein: Thanks a lot, nice talking to you.

Announcer: Produced by PRWeb, the online visibility company.

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Q: I have read that in the evaluation of a patient for hair restoration surgery some doctors use a densitometer to measure miniaturization – the decrease in size of hair diameters. I read that miniaturization is a sign of genetic hair loss, but when there is miniaturization of greater than 20% in the donor area, a person may not be a good candidate for hair transplants. Is this correct and does 20% miniaturization mean that 20% of the population of terminal hairs have become fine vellus-like hairs or that there is a 20% decrease in the actual diameter of each of the terminal hairs? — B.A., New Albany, Ohio

A: Miniaturization is the decrease in hair shaft length and diameter that results from the action of DHT on healthy, full thickness terminal hairs. The hairs eventually become so small that they resemble the fine, vellus hair normally present in small numbers on the scalp and body. Miniaturized hairs have little cosmetic value. Eventually miniaturized hairs will totally disappear. Twenty percent miniaturization refers to the observation, under densitometry, that 20% of the hairs in an area show some degree of decreased diameter.

In the evaluation of candidates for hair transplantation, we use the 20% as a rough guide to include all hairs that are not full thickness terminal hairs. Of course we are most interested in the presence of intermediate diameter hairs — i.e. those whose diameters are somewhere between terminal and vellus and are clearly the result of DHT. I don’t know if one can tell the difference on densitometry between vellus hairs, fully miniaturized hairs and senile alopecia. The partially miniaturized population is most revealing.

Miniaturization in the recipient scalp (i.e. the balding areas on the front top and crown that we perform hair transplants into) is present in everyone with androgenetic hair loss. Miniaturization in the donor area, however, is less common (in men). It means that the donor area is not stable and will not be permanent. Men with more than 20% of the hair in the donor area showing miniaturization are generally not good candidates for hair transplant surgery.

Read about Miniaturization
Read about Candidacy for Hair Transplant Surgery

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Q: I heard that Rogaine only works on the crown and not on the front or top of the scalp. Is this true? — D.D., New Haven, Connecticut

A: Rogaine (Minoxidil) has the potential to work where ever there is miniaturized hair, either the front, top or crown (however, it will not work in areas that are completely devoid of hair).

The reason for the misconception that it will not work in the front is because the clinical trial performed by Merck in the 1980’s, that led to FDA approval, only studied the vertex (crown) and thus the company was limited to this labeling. Several years later, Merck realized that this was a misjudgment in the design protocol and ran a new study (approximately one fifth the size of their Phase III vertex trial) to document effectiveness of the drug in the front of the scalp. This allowed them to avoid the vertex restriction in their label.

Another reason for the confusion is that since the hair in the crown seems to have a longer miniaturization phase than hair in the temples, there is a greater window of time in which the medication can act on these hairs. This goes for both minoxidil and finasteride (Propecia).

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Q: I am a 33 year old woman and have been told my hair is too thin on the sides for me to have a hair transplant. Could I benefit from laser treatments?

A: Although the long-term benefits on hair growth are not known, Low Level Laser Therapy (LLLT) is able to stimulate hair to become fuller in appearance in the clinical trials that have been carried out for six month periods.

Since the laser light serves to thicken fine, miniaturized hair, it is particularly suitable to areas of diffuse thinning, rather than areas of complete baldness.

Since hair loss in women commonly has a diffuse pattern, because women can’t take Propecia (finasteride), and the fact that women are less often candidates for surgery (as compared to men), laser therapy in females is particularly appealing.

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Q: I heard about the laser comb and other lasers for hair loss, how do they work?

A: Low Level Laser Therapy (LLLT) is based on the scientific principle of photobiotherapy. Photobiotherapy occurs when laser light, absorbed by cells, causes stimulation of cell metabolism and improved blood flow.

Although the exact mechanism by which lasers promote hair growth is still unknown, they appear to stimulate the follicles on the scalp by increasing energy production and partially reversing the miniaturization process leading to thicker hair shafts and a fuller look.

Read more about Laser Therapy for Hair Loss

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Q: I seem to be thinning, but I never shed hair as such in the shower. I cannot see my hair falling out. Can it be androgenetic hair loss? — R.C., Cambridge, MA

A: In androgenetic hair loss one rarely sees hair falling out in mass, but rather the thinning is due to the hair decreasing in diameter and length (a process called “miniaturization”).

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Q: Can the laser comb grow hair back in bald areas of scalp?

A: The HairMax LaserComb only works in areas where there is still some hair.

It will not bring back hair that has been lost. You need hair transplantation to do this. The laser comb works by thickening fine, miniaturized hair.

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Q: How effective is the HairMax Laser Comb?

A: It is difficult to tell since there are no long-term studies using the LaserComb.

From the data we have available, it seems to be about as effective as Rogaine (Minoxidil). As most who have used Minoxidil know, it only works in areas where there is a fair amount of miniaturized hair and over time loses its effectiveness.

The HairMax LaserComb is not as effective as Propecia (Finasteride) and, of course, is not a substitute for surgical hair restoration.

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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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Q: Why should a doctor measure miniaturization in the donor area before recommending a hair transplant? — E.B., Key West, F.L.

A: Normally, the donor area contains hairs of very uniform diameter (called terminal hairs). In androgenetic hair loss, the action of DHT causes some of these terminal hairs to decrease in diameter and in length until they eventually disappear (a process referred to as “miniaturization“). These changes are seen initially as thinning and eventually lead to complete baldness in the involved areas.

These changes affect the areas that normally bald in genetic hair loss, namely the front and top of the scalp and the crown. However, miniaturization can also affect the donor or permanent regions of the scalp (where the hair is taken from during a hair transplant). If the donor area shows thinning, particularly when a person is young, then a hair transplant will not be successful because the transplanted hair would continue to thin in the new area and eventually disappear. It is important to realize that just because hair is transplanted to another area, that doesn’t make it permanent – it must have been permanent in the area of the scalp it initially came from.

Unfortunately, in its early stages, miniaturization cannot be seen with the naked eye. To detect early miniaturization a doctor must use a densitometer, or an equivalent instrument, that magnifies the surface of the scalp at least 20-30 times. This enables the doctor to see early changes in the diameter of the hairs that are characteristic of miniaturization. If hairs of varying diameter are noted (besides the very fine vellous hairs that normally occur in the scalp), it means that the hair is being affected by DHT and the donor area is not truly permanent.

In this situation, a person should not be scheduled for hair transplantation. If the densitometry reading is not clear, i.e. the changes are subtle and the doctor is not sure, then the decision to have surgery should be postponed. By waiting a few years, it will be easier to tell if the donor area is stable. Having surgery when the donor area is miniaturizing can be a major problem for a patient, since not only will the transplanted hair eventually disappear, but the scar(s) in the donor may eventually become visible. This problem will occur with both follicular unit transplantation (FUT) and follicular unit extraction (FUE).

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Q: I underwent hair transplant surgery several years ago and was pleased with the results. However, over the last 2-3 years I’ve lost hair in the donor area with subsequent loss of hair in the transplanted area. Is this type of hair loss especially difficult to treat? What accounts for hair loss from the back of the head that is typically considered “permanent”? — F.D., Laude, Missouri

A: Less than 5% of patients have unstable donor areas, i.e. where the back and sides thin along with the front and top. We call this condition Diffuse Unpatterned Alopecia or DUPA. It is best to identify this condition before hair transplant surgery is contemplated as people with DUPA are not good candidates for hair transplantation. The diagnosis is made using densitometry by noting high degrees of miniaturized hair in the donor area.

At this point, I would use medications such as finasteride. I would not do further hair restoration surgery.

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Q: Can stress accelerate hair loss? I am 25 and there is balding on my dad’s side of the family. I never had any thinning or hair loss till this year. I guess you can say I’ve been under a lot of stress. When I did notice shortly after my 25th birthday I started stressing even more, which led to more hair loss. It is thinner up front and it is thin on top. I have heard of some hair docs mapping your head for miniaturization, do you do this too? — E.W., Miami, FL

A: Yes. The presence of miniaturization (decreased hair diameter) in the areas of thinning allows us to distinguish between hair loss due to heredity (i.e. androgenetic alopecia) — in which hair progressively decreases in diameter under the influence of DHT — and other causes. The degree of miniaturization can be assessed using a hand-held instrument called a densitometer.

The pattern of hair loss and the family history are also important in the diagnosis.

Stress more commonly produces telogen effluvium, a generalized shedding that is not associated with miniaturization and is often reversible without treatment.

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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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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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Q Do Rogaine and Propecia work synergistically? — N.W., Chappaqua, N.Y.

A: They are synergistic, since the mechanisms of action are different.

Rogaine directly stimulates hair growth, while Propecia is permissive for hair growth by blocking DHT, the byproduct of testosterone that causes hair to miniaturize and eventually disappear.

The important thing to remember, however, is that for most people, Propecia is far more effective.

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Q: It is my understanding that as a person loses his or her hair, the skin of the scalp undergoes a number of changes, namely there is a loss of fat, an increase in cellular atrophy, and of course the dreaded perifollicular fibrosis (now that’s a mouthful). It seems to me that these changes, in particular the fibrotic scarring, are the main obstacles in the way of regrowth, and the reason Propecia does not work for extensively bald men. What can be done about this demon we call fibrosis? Can it be slowed, stopped, prevented, reversed? If we could somehow counteract collagen formation, wouldn’t our baldness problems be solved for good? If a bald scalp is atrophic, how does it have the capacity to hold a whole new head of transplanted hair? Is there a limitation to the number of hairs we can transplant (outside of donor limitations)? — R.L., Rivington, C.T.

A: The findings that you are describing are well documented; however, it is not clear if these changes are the cause of the hair loss or are the result of having lost one’s hair. Most likely, the DHT causes the hair follicles to miniaturize and eventually disappear. This, in turn, causes the scalp to thin and lose its abundant blood supply (whose purpose is to nourish the follicles). The changes in the scalp are also affected by normal aging, which causes alterations in connective tissue including the breakdown of collagen and other components of the skin. The changes seen with aging are greatly accelerated by chronic sun exposure.

Fortunately, even with long-standing baldness there is still enough blood supply to support a hair transplant, although there are some limitations. One should perform a hair transplant with a lower density of grafts when patients have thin, bald fibrotic scalps since the blood supply is diminished.

The most important factor, however, is photo change. The sun dramatically alters the connective tissue making the grafts less secure in their sites and alters the vasculature, (blood vessels) decreasing tissue perfusion (blood flow to the tissues). When there is bald atrophic, sun damaged scalp, I generally perform two hair transplant sessions of lower density (in place of one) spaced at least a year apart to give time for the scalp to heal and blood flow to increase in the area.

I often have the patient treated with topical 5-flurouracil before the surgery to improve the quality of the skin and to treat or prevent pre-cancerous growths from the sun.

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