Hair Restoration Blog

I saw an 18 year old patient today who was worried about the recession of his hairline. We mapped his scalp hair to analyze the degree of miniaturization using a digital microscope. Here are pictures from the microscopic of his donor hair (left) vs. very frontal hairline (right).

Healthy donor hair (left) vs. significant miniaturization in hairline (right)

You can see significant miniaturization in the frontal area. When we examined a few centimeters behind his frontal hairline the miniaturization rate dropped sharply to less than 20% which was consistent throughout the top and crown area of the scalp. The patient’s father lost his hair at an early age. Patient started taking finasteride a month before his visit with us and topical Rogaine about a week before this visit.

What we observed was the maturation of his hair line, which occurs between the ages of 16-25 in most men. Hair line maturation is when the hair line migrates 1 to 2 cm higher than its normal position as when we are child (kiddy hairline). It is more significant in the corners but could be seen in the midline too. As Caucasian men go through the maturation process, the hairline rises, but many non-Caucasian men never experience hair line maturation and the hairline stays flat and low.

The best way to distinguish the maturation of the hairline from the early stages of baldness is by comparing miniaturization in different scalp areas. If you are experiencing early hair loss, your miniaturization could be seen behind the first centimeter of the frontal hairline, but if the rate of miniaturization drops sharply it could indicate that the hair line is going through maturation and the hair loss may stop shortly after maturation is complete.

We stopped all anti hair loss medications that the patient recently started, and we recommended another miniaturization study in 6 months to a year to follow his hair loss progression.

Dihydrotestosterone (DHT) is a byproduct of the hormone testosterone, formed primarily in the prostate gland and hair follicle cells. Hair follicles contain DHT receptors. Over time as males produce more and more DHT, the DHT molecules cause hair follicles to miniaturize and eventually fall out permanently in people who are genetically prone to baldness. In other words, some males have more hair follicles with these receptors than others.

DHT is the primary contributing factor in male pattern baldness. Unlike men with male-pattern baldness, women with female-pattern baldness are usually not characterized by increased production rates of DHT. Women with increased levels of DHT may develop certain male secondary sex characteristics, including a deepened voice and facial hair. Hair in the Crown and top of the head are usually loaded with these receptors in men with male pattern baldness. But the hair on the sides and the back, termed the permanent zone or donor area, are not affected by DHT. This allows us to transplant hair from the donor area into the frontal area without fear of it falling.

The transplanted hairs keep their resistance to DHT after hair transplant. Propecia is a drug that decrease the production of DHT by blocking the enzyme 5-alpha reductase that converts testosterone to DHT. This is how Propecia is effective in treating hair loss. Hair loss patients will decrease levels of DHT when they are on Propecia and this will help maintain and un-miniaturize hair follicles or even increase the size of hair shaft within the first year of using them.

Dear Dr. Mohebi,

How is everything Dr.? I actually came across something, which might seem a little silly to you. (haha) As the follicle deteriorates, the hair becomes thinner, correct? and this leads to the dying of the hair follicle and hair can’t be grown, right? I have noticed lately that when I shed, the hair is not really thin. Actually the quality of my hair according to my father has improved. Thick hair means that the follicle is still healthy and contains the vital nutrients. Now to sum everything up, even though I still experience hair loss with decent hair quality, does this still mean that my hair follicle is deteriorating or could an internal factor such as stress cause you to lose some hair regardless of its (hair) condition?

The reason I am asking this vaguely put question (sorry) is because earlier when I shed, my hair did get thinner which gave me the signal that it was in poor condition. DHT damages the follicle and causes the hair to become thinner. Sorry to bother you with these questions, it’s just that sometimes I pay attention to little things and I need to find out the answer. Thank you very much.

Answer:
You need to first read one of my articles on hair growth cycle, “The Hair Growth in Good Health and Disease”. The hair that shed is not necessarily miniaturized hair which is in process of balding. Normal hair goes through phases including telogen in which you see normal non-balding hair falls out. If a person is balding he or she may lose a normal looking hair in its telogen phase and grow a finer hair in its place and this process may repeat until your hair miniaturize completely or become non-existant. Loss of miniaturized hair (balding process) is not necessarily sensible, it means that due to the small diameter of hair shafts, you may not even notice your hair falling.

Question:
I am a 22 year old white male with some recession in the corners that has been bothering me in the last two years. Am I eligible for a hair transplant procedure?

Answer:
I generally don’t recommend hair transplant before the age 24 (with some exceptions). We need to have a better understanding of the pattern of your hair loss before coming up with a surgical plan. If you are destined to become a stage VII (advanced stages of hair loss) the plan should be totally different than if you are going to stop at stage III.

We can usually see the final pattern of baldness by the age of 23 or 24 with a microscopic examination of scalp. We should be able to determine whether or not you are going to stop at stage III or if you are heading to more advanced stages such as VI or VII. We can densely pack the corner areas knowing that the patient had plenty of reserve and is not going to lose much more. But if you are supposed to become severely bald, we should be more conservative in repairing your frontal corners knowing that you are going to need a good portion of your hair for the top and crown areas of your scalp in the future.

If I see the evidences of end stage hair loss at an earlier age, I can more safely plan for hair transplant at that age rather than waiting for a more advanced age since the patient is already showing the signs of sever baldness.