Hair Restoration Blog

Q:

I was told that a spot has opened up for my hair transplant surgery. I told them to slot me in, but now that I’ve jumped into the deep end I’m a bit nervous. My nerves don’t have to do with what it will look like six months or a year from now, but for the weeks following the surgery.
I need to take the next day to really meditate on this. Although my hair loss does bother me, it’s not as if I’m noticeably bald. So I’m deciding if this is something that makes sense for me.

A:

It is completely normal to have a touch of nervousness prior to this elective surgery. Since it is an elective procedure, it is common to have questions and/or
reservations. We need to remember that it is simply hair and not some life threatening procedure! Many patients have this reluctance and there is never a clear or definitive answer aside from your intuitive feelings.

Your particular situation is for the enhancement and detailing in order to complement what you already currently have. Your hair loss is probably going to progress in the future but again, it depends on when you want to address the issue.

Having experienced seeing many other patients who had similar feelings before their hair restoration procedure, I think you will very happy you did it!! Either way, I support whatever decision you make. US Hair Restoration is always going to be a resource for you with whatever questions or concerns you have regarding hair loss and the treatment options available.

Meditate  on that assurance and clarity will present itself!

Q:

I am planning to have my hair transplantation with you soon and I have a few questions about the few days after hair transplantation.  I’ve been letting my hair grow so that I’ll be able to push it forward to cover the frontal work, but I’m concerned with how much swelling there might be, or if there’s a lot of shock loss, so that the hair I was going to use to conceal, fell out.
How many days is it again that the scabs usually persist? And how long would it be until I could get back into the gym or doing some other kind of exercise?

Also, I have been taking finasteride (1mg) and cutting the tablets into quarters. Is that correct? I haven’t kept up with the scalp massaging though. It was taking so long I was starting to wonder if was going to happen at all. But I could start doing that again now.

Thanks in advance, for your answers!

A:

These are great questions and I will be happy to answer them!

• Swelling
  Generally speaking, swelling after hair transplant surgery may occur 1-5 days following the procedure. It is usually moderate with certain exceptions which might be more noticeable and involve some area around the eyes as well. Not everyone experiences swelling, but I must always describe the worst case scenario: you may have an elevation (due to fluid) on your forehead which is alleviated by the medication we provide and elevating your head during the first few days after hair transplant.
• Bruising
  You may have some bruising or discoloration on the transplanted area, forehead, and occasionally around eyes which is even less likely, but necessary to mention. Wearing a baseball cap usually conceals your hair transplant for the following week. I’m sure your existing hair will do an adequate job as well (of course that is only for individuals who have some existing hair to cover the transplanted area).
• Shock loss
  The medication finasteride, or minoxidil in women, will help to lighten the shock loss (acceleration of the loss of native hair in balding area). Most of those shocked hairs usually go into a temporary resting phase and come back with your new transplanted hair.
• Scabbing
  The scabs are simply tiny crusts that dry up and flake off within a week.  They are hardly noticeable, and if you wear a cap no one can see anything.
• limitations in physical activities
  Exercise can be resumed two days following your surgery. Try to keep the blood pressure down (no squats, dead lifts, bent rows, etc) for the first four days after hair transplantation. If you can do some light machine work for a week, that would be best. Try to keep your head elevated/upright. You can do the treadmill or cycle, but just keep the intensity moderate. After 4 days post op, the grafts are pretty much locked in.

Rub your scalp before the hair transplantation. It helps! Your procedure size is rather small so scalp laxity will be a minor issue. However, do the scalp exercises! They are good for the delts also! And yes, you are correct in dividing the finasteride into 1/4′s!

Q:

I am on my day 4 after my hair transplant surgery. I’m a little concerned that I may have pulled out a few grafts accidentally. They sure look like grafts. But then, the hairs are all dry and brittle, with no moisture at the ends, and that gel-like substance is also dry. Could they have just broken off, or are these grafts that didn’t take?

Thanks again for all of your help and support. I really appreciate it.

Best wishes,

A:

That is an excellent picture! The most important question is whether you lost a graft or hair with scabbing after or before day 4 from your hair transplantation.  Looking closely at the photo you submitted shows that you may have lost the entire graft and it may have happened before then and you have found it now.

Remember that follicular units (a unit of one or a few hairs and their appendages) are very fragile in the first 4 days after hair transplantation.  If you accidentally scratched or rubbed the transplanted area during the first few days you may have dislodged the grafts and lost it completely.  However, any loss of hair after day 4 might be just a telogen (resting) hair with its attached scabbing and you still will grow normal hair from the remaining follicle.

Dihydrotestosterone (DHT) is a byproduct of the hormone testosterone, which is formed in different areas such as the prostate gland and hair follicles.  Hair follicles which are susceptible to genetic male patterned baldness contain DHT receptors.  Over time as males produce more and more DHT the molecules affect hair follicles and cause them to become decrease in size, and eventually fall out permanently.

DHT and having the gene of male pattern baldness are the primary contributing factors for male pattern baldness. Women with female-pattern baldness, unlike men with male-pattern baldness, are usually not characterized by increased production rates of DHT due to their low levels of testosterone.  However if for any reason a woman has increased testosterone, she may develop female patterned baldness just like a man does with the same mechanism.

Hair in the areas that are prone to male patterned baldness such as corners, top and crown areas are loaded with DHT receptors in men with Androgenetic Alopecia.  However, the hair on donor areas such as back and sides do not have as much DHT receptors.  This is why hair is more permanent on the sides and back as opposed to the top and front.

The distinction in hair quality on different areas (donor vs. recipient) allows a hair transplant surgeon to remove hair from one area and transplant it to the balding portions of the scalp.  These transplanted hairs are permanent and won’t be affected by circulating DHT. Finasteride (Propecia) is a drug that blocks the conversion of testosterone to DHT by blocking the enzyme alpha reductase.  DHT levels in hair loss patients decrease when they are on Propecia and this helps maintain healthy hair, and this helps some of the miniaturized hair become stronger.

We recommend medical treatment with DHT blockers in many of our patients who undergo a hair transplant procedure to help maintaining their own hair in addition to restoring the balding areas with hair restoration surgery.

I am back from our summer vacation and we will be posting on the site regularly again. We have several visits to local California attractions and as always I took a whole lot of pictures.

This bald Lego-Man in LegoLand (San Diego, CA) looked very sad and reminded me of the article we published a few years ago on Hair Transplant Forum International “Psychology of Hair Transplant”.  In the article we discussed how hair transplant can affect changing people’s mood and energy level and make them feel happier.

I guess anything with hair loss is a subject for my photography and a topic for my blogs these days.

Avodart (dutasteride) and Propecia (finasteride) have recently been in the news for the report of some studies regarding their role in increased or decreased risk of prostate cancer.  Avodart and Propecia are both 5-alpha reductase inhibitors (5-ARI), which help prevent production of DHT (dihydrotestosterone).  This class of medications is indicated for the treatment of benign prostate (BPH) hypertrophy.  These DHT blockers also help with the prevention of male patterned hair loss and have been recommended and prescribed for hair loss treatment, for many years.

On one hand, several studies have indicated that DHT blockers could decrease the rate of prostate cancer.  On the other hand,  there are some studies that indicate they may increase the incidence of high-grade prostate cancers.  Those studies performed on both finasteride (7 years study) and dutasteride (4 years study).  It has been concluded that the patients who take DHT blockers should have prior knowledge of whether they have a lower risk of prostate cancer.  However, if the patient gets prostate cancer it might be in a category which is more advanced.

Doctors should be aware DHT blockers can decrease the levels of PSA artificially, so a small increase in PSA levels might reflect a higher activity of prostate tissue in comparison to patients who are not on DHT blockers. Overall, it is good practice to make sure all patients age 50 and older have a baseline PSA reading before they get started on finasteride.  This will determine their PSA levels before they begin taking medications, and the doctor will be able to monitor changes in PSA with greater precision.

Turban Alopeica due to chronic use of turban and knotting hiar - Bottom: hair line design before hair transplant surgery

Turban Alopecia is a type of traction alopecia that is seen in people who wear tight turbans, such as Sikhs.  Turban Alopecia can also occur as a result of knotting and braiding long hair which results in hair being pulled continuously for long periods of time.  This can cause hair loss with the same mechanism as many other types of traction alopecia – chronic pull on hair follicles can destroy them permanently.

Prognosis of Turban Alopecia is similar to other types of traction alopecia.  It might be reversible to some degree only in some patients.  However, if re-growth is not seen after a year of stopping the use of the turban and tight hair braiding, it is unlikely that new growth will occur at all, leaving the affected areas of the scalp with permanent hair loss.

Turban Alopecia is generally seen in the frontal area of the scalp and in some cases in temple areas.  Those are the areas that are directly affected by the traction effect of the turban and hair braiding.  (This could be seen in most members of a Sikh family.)  Unlike the more common androgentic alopecia, which is a genetic predisposition to hair loss, Turban Alopecia is not genetic, but being predisposed to familial male patterned baldness is an accelerator factor and can cause occurrence of male patterned hair loss prematurely.

The risk of traction alopecia in Turban Alopecia type could be reduced by not knotting or braiding the hair and by wearing turbans more loosely. But for those who have experienced permanent hair loss due to Turban Alopecia, there is a natural and proven treatment option available through surgical hair transplantation. (It will be important to control hair braiding and tight turbans following hair transplantation to insure continued hair growth in these areas.)

Also see: Hair loss for cap

Q:

Dear Dr. Mohebi -

There is an article in the LA times about a doctor practicing in LA who treats women’s pattern hair loss by injection of progesterone into the scalp, as well as prescribing Finasteride and applying minoxidil-plus solution onto the scalp.

As an expert in the field, I appreciate your opinion about this hormonal method of hair loss treatment.

Thank you.

____________________

A:

Thank you for your question and your kind words. Although there are many practices regarding the treatment of female pattern hair loss, we try to remain evidence based in our recommendations. This means that we only use treatments and methods that are proven to work through scientific studies or peer reviewed publications.

There is no proof that the injection of progesterone to the scalp can treat typical female pattern hair loss. Minoxidil is a known hair loss medication that can help women who have significant miniaturization (thinning of hair shafts) experience some increased density (thickening of hair shafts). Candidacy of the patients needs to be determined by a doctor after microscopic evaluation of the scalp before starting on minoxidil.

Finasteride should only be prescribed to women who are not pregnant or planning on becoming pregnant, and are losing their hair in a “male pattern” due to increased levels of testosterone, due to a variety of potential factors. This needs to be tested and documented before starting a woman on finasteride. I should mention that finasteride is FDA approved under the name Propecia as a potential treatment for certain types of hair loss in men, not women.

Some doctors may use different methods of hair loss treatment. They may also promote themselves and their “innovative methods” in the media and on the internet. That does not make their case any stronger or provide a shred of evidence that their treatment methods will work. We are in an era of evidence based medicine, and the research, history, safety and potential treatment benefits are readily avilable to everyone.

I strongly encourage everyone to agree to treatment recommendations accepted and practiced by the medical society through scientific research or those through published peer reviewed journals.

Hair restoration surgery is a blending of science, skill and artistry. But there is also a mathematical component to this equation that can help us better understand what it is we’re seeing, experiencing and can expect from hair loss and hair restoration. So here’s a little information that puts numbered averages to the process.

On average, Caucasians and some African-Americans are born with around 100,000 hairs. This number may be slightly lower in Asians and Hispanics and slightly higher in those of Middle Eastern descent. The density of hair varies throughout the scalp, but in the donor area (in the back and sides) hair density averages around 2 hairs per square millimeter.

On average, people do not notice that they are losing their hair until they’ve lost around 30% of their overall hair density on any area. However, they have to lose more than 70% to look bald. The maximum hair density one should expect from a (“strip method FUT”) hair transplant procedure is about 40% of original density, which is quite good. Hair loss need, continued loss of native hairs, surgical technique, surgical skill, donor area quality and availability will all play a factor in this as well.

With a qualified surgeon and staff and good donor quality, “giga-session” procedures of 3,500 and more grafts can be transplanted in a single (“strip method”) surgery, when appropriate and warranted. These giga-sessions can translate over 10,000 hair follicles.

Follicular Unit Extraction (“FUE”) procedures are much more labor intensive and require a great deal more surgical time than strip method procedures. The maximum number of grafts, on average, per procedure utilizing FUE techniques is from 1,500 to 2,000 in each session. Patients who need larger number of grafts need to undergo more than one session of hair restoration.

Although the vast majority of men and women who undergo modern day surgical hair restoration are completely satisfied with the results, with the aesthetic and emotional benefits far exceeding their initial desires, it’s important to understand that there are limits to what hair transplantation can do. And for each patient, there are unique variables that play a major role in the outcome.

> Hair loss (androgenetic alopecia) is a progressive, ongoing genetic disorder that first manifests itself as thinning hair and ultimately results in hair loss, in those pre-determined hair follicles effected.

> You should never expect to retain the same hair density or the same hair line placement you had as a teenager, nor should you want to. Hairlines and overall hair density evolve as we age.

> You may have already lost up to 70% of your hair density before you’ve even realized your hair was thinning.

> Hair transplantation simply relocates natural hairs, it does not produce new hair.

> Hair transplantation does not stop affected native hair from thinning and future loss. The transplanted hairs are permanent, as they are genetically different from the thinning hairs, but hairs that are pre-disposed to thinning and loss will continue on that course.

> If warranted, in addition to hair transplant surgery to replace lost hairs, your physician may recommend finasteride or minoxidil in an effort to stabilize existing thinning hairs.

> Since beauty is in the eye of the beholder, and hair loss is progressive, somewhere down the road, you may elect a second hair transplant procedure to help you achieve your hair restoration goals.

Here are some factors that directly impact surgical results and should be considered when setting realistic expectations:

1) The ratio of supply (donor hair) and demand (area of hair thinning and loss). In essence, the more significant the hair loss and/or the larger area of scalp affected by hair loss, the more donor hair required. Hair density following one surgical procedure will be based on limits to donor hair extraction.

2) The caliber (diameter) of each hair shaft. Thicker hair will provide greater coverage and volume than fine hair.

3) The body of hair. Curly or wavy hair tends to create greater coverage than straight hair, resulting in greater hair density.

4) The contrast between the scalp and the hair. Hair density, or at least the perception of greater hair density, increases as the contrast (or visibility) of the scalp through the hair diminishes. For patients with dark hair and a light scalp, this contrast is greater, giving the appearance of thinner hair, or less hair density.

5) The density of the donor area. The donor area is the source of the hairs utilized in surgical hair transplantation. The greater the natural donor hair density (hairs per square millimeter), the more available donor hairs for possible future procedures.

6) Scalp elasticity. Mega-session and giga-session hair transplant procedures are becoming more common. For a surgeon to safely perform a procedure of this size (4,000 to 5,000 grafts or more), there has to be a need for it, the donor area has to have sufficient density, AND the scalp has to have enough elasticity to accommodate the donor removal, allowing the surgeon to close the area safely, leaving nothing more than an undetectable scar.

7) Future thinning and loss. Unless a patient is a Class 7, having lost most of the hairs in the affected area, it’s important to anticipate future, continued loss and recession. A secondary procedure and/or the use of finasteride or minoxidil may be recommended to achieve the hair restoration objective.

It’s important to review all available information, to make an informed decision. And when considering hair transplant surgery, or any surgery for that matter, it’s good to remember that the most critical decision is the surgeon himself… his training, his artistry, his skill, his compassion, his surgical techniques, his results.

If you are looking for answers to hair loss and are considering hair transplant surgery, we encourage you to visit a good hair transplant surgeon. In the right hands, you too can experience the life-changing benefit of hair transplantation, exceeding all of your expectations.