Hair Restoration Blog

Q:

Dr. Mohebi, this may seem like an unusual question, but I’ve been hearing a lot about Prince William’s hair loss and wondered if you wouldn’t mind letting me know what treatment option(s) you’d recommend. Rogaine? Propecia? Hair transplant surgery, and if so, how many grafts?

Thanks so much!

A:

Prince William is a class IV hair loss in Norwood classification with significant thinning on the top area that indicate he will be heading toward class VI if he does not use any treatment for his hair loss.  Looking at Prince William pictures, you can see that he has had the initial signs of hair loss in his early twenties that is typical for Caucasian hair loss.

Although you may argue that wearing the crown will eventually cover the balding areas on the top, he may still have a few more viable options.  Prince William needs to be on some sort of medical treatment, either Propecia or Rogaine, to minimize his hair loss or at least to prevent or slow further thinning.  He should also consider a hair transplant surgery to reinforce his hairline and add density to his corners.  Restoring his crown balding spot will be the next priority and I think if his donor quality is good all of those goals could be achieved in one session.

I think with one hair transplant he can eliminate the appearance of balding while he might need another procedures to thicken up the frontal density and add more to the volume of top and the crown area.

Q:

Before and after hair transplant repair procedure with removing frontal pluggy grafts and increasing density of the front and top. Please click on the photo to zoom in.

I am a patient from another facility who had the ” old style” circular plug grafts place in two straight lines across the front hairline. I have read on your website about you performing hair repairs? I am very interested in the various options on how a repair may be done to address my particular situation.

Can smaller follicular unit grafts be placed in front and between the large plug grafts to make it appear more natural?  Is removing the large plug grafts a more cosmetically pleasing approach?  Do you utilize the old grafts by subdividing them into individual grafts? Finally, would it be to my advantage to keep the old plug grafts and doing landscaping work around them?

Thank you,
-

A:

We do perform repair hair transplant surgery for old and pluggy hair transplants on a regular basis.  But, you have to be seen and evaluated before we know what is the best plan for you.  Here is a general guideline of what needs to be done for pluggy hair transplant surgeries:

• If the hairline is high enough and patient has enough donor hair, we do not need to remove the plugs.  We can just lower the hairline and create a transitional zone in front of the hairline followed by a more dense area to cover the visibility of the plugs.
• Many patients may not have enough room in front due to placing their initial hairline too low.  In that case we cannot lower the hairline and need to remove the plugs.  Plug removal is done either by thinning them out (for larger plugs) or removing them completely (for mini and micrografts).
• We also need to put follicular units between the plugs to even out the transplanted area.  That generally gives adequate density to the transplanted area and can minimize the plugginess.

I have to emphasize that you need to be evaluated by a good hair transplant surgeon and only after a close examination a surgical plan for a hair transplant repair should be designed.  Repair might seem easy, but in some cases it may be challenging and patient may require more than one hair transplant for the best result.

Q:

I had a 2850 graft hair transplant surgery 3 years ago in New York. I’m a 46 year old, Class 6. I’ve seen what procedures that size have done for others, but my hair growth seems about 40% less. Why do some procedures seem to yield more hair growth than others? Is it the patient? The hair? The doctor?

Thanks.
_

A:

You should never compare the result of your hair transplant surgery with other people only based on the number of grafts.   Every time I educate a patient before a hair transplant, I go over those facts as of what they should expect after their hair restoration procedure.  Although I promise wonders to some patients who have better quality of donor hair (thicker, waiver and denser), to others I emphasize that they need more than one surgery for the best result. The final result could vary drastically based on the donor hair qualities such as hair thickness, waviness and hair to skin color contrast in addition to the number of grafts.

If you compare two patients with the same characteristics of hair, but with one having a ticker hair twice as the other one, you see that the cross section of the hair in the one with thicker hair is 4 times (A = r2) and the expected final hair volume is 4 times.

There are other factors that can lead to a poor result from a hair transplant procedure.  Some of those are patient related and others have to do with the technique of the hair restoration and maintenance of hair follicles in the outside environment.  You can read more on that on: Unsuccessful Hair Transplant.

Q:

Dear Dr. Mohebi,

I have recently learned that Finasteride injected into scalp and or taken orally not only stops hair loss but makes hair growth as well.  What is your opinion on the use of this  medication for female with hereditary pattern hair loss?  Is it safe, is it effective, do you use this method of treatment in your office?

 Thx.

A:

Finasteride injection is not approved nor recommended for male or female patterned hair loss and we do not recommend it.  Finasteride is prescribed for male patterned baldness in men and also it could be beneficial for women with hair loss secondary to hyperandrogenism (increased levels of male hormones) in women* to prevent or minimize the process of hair loss.  Finasteride (Propecia) is prescribed for typical forms of female patterned baldness without elevation of testosterone levels by some doctors.  However, there is no evidence to support its effectiveness on women with hair loss without elevated testosterone.

* The use of finasteride for women should be under a physician supervision and it is contraindicated in pregnant women.

Q:

Dear Dr. Mohebi,

I’m in my sixties and  consulted with you a year ago at your clinic, and had tests done, all normal.   I have had hair loss ever since I was nineteen years old.  The onset  was when I traveled to Europe, and it never stopped until in two cases:

1. With each pregnancy my hair loss almost completely stopped and gained a lot of hair back, but fell out after a few months during the period I was nursing my babies.

2.  About twenty years ago, I saw Dr. XX XX in Beverly Hills who prescribed Rogaine a solution that at the time wasn’t available over the counter.  After six weeks of application, I saw results, and after about four months I gained abundance of hair back, but started itching of scalps, and discontinued it.  When after being out of town for a while, I started seeking help, he had moved away, and couldn’t find that doctor.

For the past ten years or so that Rogaine has been readily available, I attempted using it even at the strength of male 5%, but have had no results.

Hair loss has been in my family, from my grandfather, on mother’s side, to my mother, and to me and now to my children.

My main questions are:

1. What was in the initial solution of Rogan that worked, and then over the counter ones didn’t work?
2. What is the latest preventive measures/solutions/hopes for this type of hair loss at least for my children’s generation?

Thank you kindly for your response,

A:

Hair loss medications such as Rogaine work only if you have active hair loss.  The effect is mostly preventative, but since it may make some of the miniaturized hair (finer hair that is in process of balding) thicker, patients may experience some enhancement in their hair bulk only for the first year of its use.

Some women with genetic female patterned hair loss may be good candidates for hair transplant surgery as long as they have protected (Permanent) hair on their donor area on the back and sides of the scalp.  Hair transplant in this group of patients should be done only if they are trying to reinforce a limited area of scalp.  However, a hair transplant is not a good idea if their goal is to increase hair density throughout a large area or entire scalp.

To be able to say what options are out there for your children, they need to be individually evaluated by a good dermatologist or a hair transplant surgeon and treatment options should be tailored to their individual needs.

Q:

Dear Dr. Mohebi,

What follicular unit trimming technique does USHR employ? Is there a survival rate difference between the different trimming techniques (chubby vs skeletonized)?

Are there any distinguishing characteristics of the follicular units, once they are grown out, between the chubby trimmed versus the skeletonized trimmed follicular unit grafts?

Dr. Mohebi, is there a size difference between a a follicular unit containg one hair and a multi-hair follicular unit?

Thank you for sharing your expertise and opinions.

Sincerely,
–

A:

These are great questions and we will use them for blog posts too. Here are the answers to your questions:

We are committed to the gold standards of hair restoration in our hair transplant procedures. We perform exclusive follicular unit transplants to maximize the natural appearance of the hair while increasing the survival of hair follicles. We only skeleton single hair follicular units that are needed to be used for frontal hairline to minimize the chance of growing anything but single hairs which mimics a normal hairline.  For anything else 2s, 3s and 4s we use chubby grafts to maximize their viability.

Chubby grafts can result 100+% result because of the growth of hidden hair follicles in telogen phase.  They also have more supportive tissue to support the follicles.  It has been studied and documented that chubby grafts have a higher survival rate than skeletonized ones (proven in two different studies done by Dr. Beehner 2010 and Dr. Seager 1997).

Even transplanting two single hair follicular units in one site have higher survival rate in comparison to two individual single hair that are transplanted separately.  That is why we combine the single hairs with other singles in one site to increase the final density and also enhance survival of hair grafts.  The only exception is for the single ones that we have to use the way they are on hairline area to minimize the chance of growing more than one hair on the hairline.

• So here is my recommendation for hair transplant surgeons: Make the hairline single hair grafts skeletonized and the rest keep them chubby for the best result.

For more on that please read the Skinny Vs. Chubby follicular unit transplants article on our website.

Faculties: Drs. Suddleson, Mohebi and Perez in OLSW-17

Orlando Live Surgical Workshop (OLSW 17) of International society of hair restoration surgery (ISHRS) was held one more time in beautiful city of Orlando last month.  Hair transplant surgeons participated from different parts of the world.  We had many great lectures from the leaders of hair restoration surgery to cover basic information about hair restoration methods for new hair transplant surgeons and to refresh and update the more experienced ones.

We had lectures every morning and in the afternoon went to surgery center for hands on procedures to teach the techniques of hair transplant surgery.  I have to congratulate the the whole staff involved with this workshop for the great work they have done this year, coordinating a large group of doctors from all over the world and putting together a great set of lectures to cover a wide variety of subjects about modern hair restoration procedures and medical treatments.

Dr. Mohebi and Dr. Leavitt in OLSW-17

We had lectures about new methods of hair restoration surgery such as robotic hair transplant surgery.   The most updates on robotic surgery was shown to the audience.  There is a hope that the practical model of robotic hair restoration be available within a few months.

There is a woman behind every successful EVENT - Dr. Mohebi and Valarie Montalbano

I had two lectures that were both emphasizing on the techniques of removal of follicular units in hair transplants with large number of grafts using Laxometer.  I also demonstrated the applications of Laxometer in sequential strip removal techniques in live surgical workshop.

Technician training: Patrick Tafoya teaching hair transplant technicians

My second lecture was on Scalp Scars and the methods to revise them.  The lecture was focused on making surgeons more familiar with the proper techniques of scar revision and indications of each particular technique.

I went over trichophytic closure methods for a variety of different scars.  I discussed the implications of Follicular Unit Extraction (FUE) to revise scalp scars.  I presented a variety of several scalp scars treated with FUE methods.  I went over the pros and cons of FUE to revise scalp scar and provided a guideline that hair transplant surgeons can decide what method should be used for each type of scar.