Covid-19 Update

Due to the COVID-19 (coronavirus) outbreak, our office will be closed through Thursday, April 30.

During this time, existing patients can reach us at [email protected].

We invite new patients to use our Online Physician Consult Form or call 212-826-2400.

Robotic Hair Transplants & Hair Restoration
Flagship: 110 East 55th Street, New York, NY
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Bernstein Medical - Center for Hair Restoration
Hair Restoration Answers

How Long After Facelift Can I Have Hair Transplant?

Q: I am having a facelift next month and also want to have a hair transplant soon after. How long should I wait between procedures? — S.H., Boston, M.A.

A: Although it would be possible to do a hair transplant as soon as a week after a face or brow lift, ideally one should wait at least three months between procedures for the following reasons: 1) there will be less tension in the donor area and, therefore, it will be possible to harvest more grafts, 2) if there is any shedding from the facelift it will make the planning of the hair transplant more difficult, 3) it will leave the option of adding hair, in or around, any problematic surgical scars, and 4) will provide the ability to add hair to any area of thinning that might result from the facelift.

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Hair Restoration Answers

Why Am I Losing Hair Despite Taking Avodart For Hair Loss?

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.

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Hair Restoration Answers

Why Am I Shedding From Higher Dose Of Finasteride?

Q: I have been taking one tablet of Propecia daily for the past 5 years, with good results, until May of this year. At that point I started to experience some hair loss and so you recommended that I switch from Propecia to generic finasteride and increase the dose to 1/2 of a 5 mg pill per day. I started taking the 1/2 tablet of finasteride daily one month ago, and for the past 2 weeks I have seen a lot of hair in the bathtub and on the towel after taking a shower. I have not made any other changes in my diet or my shampoo, and I do not have any conditions on my scalp. Please advise me on what needs to be done. — C.C., Floral Park, New York

A: Just continue the medication at the higher dose. Either the finasteride hasn’t started working yet or you are getting temporary shedding from the medication (which means that it is working).

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Hair Restoration Answers

After a Hair Transplant Will Hair Fall Out At The Root?

Q: I had a hair transplant 10 days ago and I lost some hair that looks like the hair fell out at the root. — R.A., Bronxville, N.Y.

A: When there is shedding after a hair transplant, it is the hair that is lost, not the follicle that contains the growth center (the follicle eventually produces the new hair).

Since the “hair” usually consists of a hair shaft and the inner and outer root sheaths, which creates a little bulb at the end of the hair, it looks like the hair is “falling out at the root.” Do not be concerned as this is not the growth center.

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Hair Restoration Answers

Can A Hair Transplant Cause Thinning?

Q: If you transplant grafts in between the thinned out areas, is there a risk of cutting previously normal roots, even if one is cautious? — J.S., Upper Saddle River, N.J.

A: Healthy hair can be temporarily shocked from a hair transplant and then shed (the process is called telogen effluvium) but it will not be permanently damaged.

Any healthy hair that is lost in this shedding process should re-grow.

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Hair Restoration Answers

Why Is Hair Loss In Women Harder To Treat With A Hair Transplant Than Hair Loss In Men?

Q: Why is hair loss in women harder to treat with hair transplants than hair loss in men?

A: The majority of women present with diffuse hair loss (i.e. thinning all over) rather than the patterned hair loss seen in men (where the hair loss is localized to the front and top of the scalp).

Diffuse thinning presents two problems for a potential hair transplant candidate.

The first is that there is no permanent area where the hair can be taken from. If hair is taken from an area that is thinning, the transplanted hair will continue to thin after the procedure, since moving it doesn’t make it more permanent.

The second problem is that since the areas to be transplanted are thin, rather than completely bald, the existing hair in the area of the hair transplant is at some risk to shedding as a result of the procedure.

When women have a more defined pattern (i.e. more localized thinning on the front part of the scalp with a stable back and sides), they can make excellent candidates for surgery. This pattern occurs in about 20% of women. A small percentage of men have diffuse thinning and are, therefore, poor candidates for a hair restoration surgery as well.

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Hair Restoration Answers

Hair Transplant Using Shedded Hair?

Q: Can a hair transplant be done using the hair which has fallen out? — G.O., Gramercy, N.Y.

A: A hair transplant is really a misnomer, since it is the follicle (or root) that is transplanted not the hair itself – although the transplanted follicle usually contains a hair.

Hair, like fingernails, are dead and cannot grow once detached from the root.

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Hair Restoration Answers

Can Stress Cause Diffuse Unpatterned Hair Loss (DUPA)?

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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Hair Restoration Answers

Can Stress Cause Hair Loss or is that a Myth?

Q: I’ve been dealing with daily mental stress for the past few months. I’ve noticed that during that time, I’ve experienced a lot of frontal hair loss and thinning. I thought stress was a myth for causing hair loss. — R.P., Upper East Side, Manhattan

A: Stress may cause temporary shedding, but it generally does not affect the long-term course of genetic hair loss.

It seems that women’s hair is affected by stress more commonly than men’s hair, but the reason is not clear.

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Hair Restoration Answers

Can Avodart Hair Loss Medication Cause Shedding?

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

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

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Hair Restoration Answers

Can My Hair be Thinning Without Shedding?

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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Hair Restoration Answers

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

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

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

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

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Hair Restoration Answers

Is Pulsing or Cycling Hair Loss Medication Dosage Effective?

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

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

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

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

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Hair Restoration Answers

Can Hair Transplant Treat Chronic Telogen Effluvium?

Q: I am a 36 year old female who has been diagnosed with Chronic Telogen Effluvium. Although I do not have any bald spots yet my hair is much thinner on both of my temples as well as in the back of my head. Is a hair transplant an option for me or am I just going to shed the new hair as I am shedding my current hair? — R.K., Providence, R.I.

A: Since Chronic Telogen Effluvium is a generalized condition, it is not amenable to correction by a hair transplant. The reason is that there is no stable area to take donor hair from. Chronic TE is generally self-limited, so try to be patient.

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Hair Restoration Answers

Which Contributes More to Hair Loss: Stress or Genetics?

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

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

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

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

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

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Bernstein Medical In The News

NPR Interviews Dr. Bernstein on Hair Transplantation and Hair Loss

Here is one exchange from the interview:

Moderator: How one can tell the difference between hair loss from hormonal imbalances and common baldness?

Dr. Bernstein: Measuring hormone levels alone, although important for medical management, does not necessarily reveal whether the cause of the hair loss is actually hormone related or is genetic. The diagnosis is made by examining the scalp and looking at the hair under close magnification using an instrument called a “Densitometer.”

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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

Does Hair Grow More Slowly After a Second or After a First Hair Transplant?

Q: This is my second hair transplant and is seems like it is growing more slowly than my first. Is this normal? – J.D., Port Washington, N.Y.

A: It is common for a second hair transplant to take a bit longer to grow than the first, so this should be expected. It is also possible that there is some shedding from the procedure, or a continuation of your genetic hair loss.

Propecia may be helpful in this regard. It is important to wait at least a year for the transplant to grow in fully and to give a chance for any hair that was shed to regrow.

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Hair Restoration Answers

When Can I Judge the Effectiveness of Treatment with Propecia?

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

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

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

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