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Robotic Hair Transplants & Hair Restoration
Flagship: 110 East 55th Street, New York, NY
212-826-2400 - [email protected]
Bernstein Medical - Center for Hair Restoration
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Hair Restoration Answers

Why Should Hair Transplant Doctor Measure Miniaturization in Donor Area Before Transplant?

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.

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Hair Restoration Answers

How Do You Treat Diffuse Hair Loss in Donor Area?

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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Hair Restoration Answers

Which Contributes More to Hair Loss: Stress or Genetics? [Updated]

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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Hair Restoration Answers

Is Asymmetrical Hair Loss from Telogen Effluvium or Androgenetic Alopecia?

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

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

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

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

Hair cuts do not affect either condition.

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

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

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Hair Restoration Answers

How Does Densitometry Help Diagnose Hair Loss?

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

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

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

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

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

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

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Hair Restoration Answers

Can I Treat Hair Loss Using Rogaine and Propecia Together?

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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Hair Restoration Answers

Is Success of Hair Transplant Affected by Age or Scalp Fibrosis?

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.

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Hair Restoration Answers

Should I Increase Dose of Propecia if Hair Loss Continues During Treatment?

Q: I recently turned 22 and have been on Propecia for about 2.5 years. The amount of hair that de-miniaturized with daily 1 mg peaked about a year ago and I have seen steady thinning since. I feel that I am too young for a hair transplant. My question is whether or not an increase in dosage of Propecia is indicated here or if I should seek other options entirely? — N.W., Portland, Oregon

A: At 22 years old, I would increase the dose of Propecia before considering hair restoration surgery. However, it is important to realize that there is no scientific evidence that increasing the dose will have any additional effects. There are published data by Roberts et al in the JAAD in 1999 demonstrating that 5 mg is no better than 1 mg from controlled clinical trials.

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Hair Restoration Answers

Do You Recommend Hair Transplant for Hair Thinning Over Entire Scalp?

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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Hair Restoration Answers

How Does Hair Transplantation Work?

Q: Why does a hair transplant work? – L.L., Salem, Massachusetts

A: Hair transplantation works because hair taken from the permanent zone in the back and sides of the scalp maintains its original characteristics when transplanted to a new place in the balding area in the top of the head. This property of hair is called “donor dominance” and is the reason why hair transplants are possible.

The hair follicles in areas that go bald are genetically susceptible to DHT, a breakdown product of testosterone. In response to DHT, these hair follicles miniaturize (decrease in size) until they eventually disappear. When follicles from the permanent zone, that are resistant to the effects of DHT, are moved to a balding area, they maintain this property and continue to grow.

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Hair Restoration Answers

What is "Shock Fall Out" After a Hair Transplant?

Q: What is “shock fall out”? – D.B., Chappaqua, N.Y.

A: Shedding after a hair transplant is also referred to by the very ominous sounding term “shock fall out.” The correct medical term is “effluvium” which literally means shedding. It is usually the miniaturized hair (i.e. the hair that is at the end of its lifespan due to genetic balding) that is most likely to be shed. Less likely, some healthy hair will be shed, but this should re-grow.

Interestingly, if transplants are spaced less than one year apart, one often notices some shedding of the hair from the first transplant, but this hair grows back completely. For most patients, effluvium is not a major issue and should not be a cause for concern.

Typically, when shedding occurs, a patient looks a little thinner during the several month period following the transplant, before the transplanted hair has started to grow. The thinning is often more noticeable to the patient than to others. Shedding is generally noted as a thinning, rather than of “masses of hair falling out,” as the term “shock fall out” erroneously suggests.

In general, the more miniaturization one has and the more rapid the hair loss, the more likely shedding will be from the hair restoration surgery. Young, actively balding patients would be at the greatest risk. Older patients with stable hair loss would have the least risk. In either situation, since miniaturized hair is eventually going to be lost, the effluvium has no long-term effect on the outcome of the procedure.

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Hair Restoration Answers

How Do You Recommend Treating Early Hair Loss?

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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Hair Restoration Answers

Should I Consider Hair Transplant if I Have Early Hair Loss in Crown and Donor Area?

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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