Hair Restoration Blog

Q:

Hi Dr. Mohebi,
I was at your hair restoration clinic a few months ago asking about hair loss. I was curious, have you heard of anything regarding Avodart (Dutasteride) causing significant thinning just in the front of the hairline? I got on it a month ago and I’m shedding a whole hell of a lot. Any idea how long the sheds last? I heard that the hair from the hairline actually does not grow back. Have you heard anything about that?

A:

Dutasteride (Avodart) although not FDA approved for hair loss treatment is prescribed by some physicians for treatment of male patterned baldness.  The effect of Dutasteride on slowing down the process of hair loss is documented through several studies.  Dutasteride blocks both isoenzymes (Type I and II) of 5 alpha reductase inhibitor and for that reason can help hair loss even more effectively than finasteride (Propecia).

Hair loss patients who start taking any dihydrotestosterone blockers may initially experience more hair shedding that is assumed to have to do with an increase in the turn over of miniaturized hair follicles.  The shedding and hair loss is usually temporary and new and stronger hair shafts will grow from the same follicles in a few months after the initial shedding.

Q:

It is now 4 days following our procedure and everything seems to be going quite smoothly.

I have been taking care to wear a hat during the day outside and shampoo as I was instructed twice a day.  I have experienced no bleeding thusfar and the swelling has dissipated and gone.  The redness is diminishing and I now have sensations back in the back of the head.  Actually, the sensitivity there was back within 12 hours or so.  The pain is minimal and I have only taken generic Tylenol twice for it.

I am VERY happy with your work thus far and please feel free to quote any of my questions on the blog, anonymously.  I have attached two pics for you to see my status: 1 from last night and 1 from today with my hair styled.  No swelling!

Now, for my questions:

1) I go back to work tomorrow, the 5th day post op.  You instructed that I can begin to shampoo and normally style my hair then, correct?  Does this apply to any leave-in conditioners or should I wait on those?

2) A few pesky blood-caked scabs aren’t washed off and dry, flaky skin is forming around the middle of the sagittal.  I believe this is all normal and part of the mitosis process.  Right?

3) Can I start applying over-the-counter ointments like neosporin to my hairline to aid with the elimination of the tiny red dots of incision?

4) The back of my head feels quite tight.  Will the procedure on Saturday help with this or is this just a process of healing?

5) And finally, I know this is a really really silly question, but it seems fairly obvious that the grafts are growing.  I know more than likely this is actually just them getting ready to shed and go into dormancy.  But, I wonder, if you think, given that I have been on finasteride since the beginning of December and the hairline and temples were the first areas worked on, if there’s a good chance I get to keep most of them?  I also hope that I will experience little to no “shock loss” with the ‘native hairs’ so they should not theoretically go into a ‘dormant’ phase, correct?  The problem is that it would be very hard to conceal the growth I have with my longer hair if it wasn’t for something to work with, as it were.  The tiny hairs provide an anchor to rest longer hairs on.

I apologize for the length and perhaps detail of my questions but as I’m sure you know, this is a VERY personal procedure.

THANK YOU SO MUCH.

A:

I am glad you had a smooth post-operation period after your hair transplant surgery.

Here are the answers to your questions in the order you asked them:

How to use shampoo and conditioner use after hair transplant?

Yes,  anytime after day 4 you can go back to your normal routine in terms of using shampoo and conditioner and combing your hair normally.

How to deal with scabbing, dried blood removal after hair transplant?

Flaky skin could be seen any time in the first few days to weeks following a hair transplant surgery.  Dried blood due to some oozing in the first few hours after hair transplant should be dealt with carefully for the first 4 days and if still present after your instructed hair wash in the immediate post op period, it needs to be washed off more efficiently.  After day 4, you can shampoo your scalp and keep the foam for about 10 minutes each time.  This will allow the dried blood to become loose and come off easily with the soft brush that was provided to you after your hair transplant.

Do I need antibiotic ointment after hair restoration surgery?

Neosporin and any other antibiotic ointments are not necessary after hair transplant.  You have medications that were provided to you after your hair restoration which are used to help minimize the redness following surgery.  The small red spots that have been seen from the incisions or local anesthesia injections will be gone in 4 to 7 days following the day of surgery.

How about tightness of scalp after hair transplant?

The donor area is closed with staples that might be felt a little bit before we remove them at day 10 after hair transplant.  We also removed a strip from your scalp with significant number of grafts.  That stretches the skin, but the tightness that you feel know will be gone in a week or two after hair transplant.

Am I going to keep the hair or lose it?

I hope you are among the small group of people who does keep their transplanted hair and begins growing from the day of surgery.  However, the general rule is “Don’t count on them”.  We put most of our patients on finasteride after their hair transplant, but still about 80-90% shed all transplanted hair.

What is the chance of shock loss after hair transplant?

Shock loss is a different story and considering that you have been on finasteride before and will continue it after hair transplant, you have a good chance to prevent and significantly reduce the chance of shock loss.

I look forward to seeing you soon for your post operation visit at day 10 after hair transplant.

Q:

I had a hair transplant surgery a month ago.  As it turns out, I have a huge amount of shock loss right now.  As i’ve never taken propecia before, do you think it’s too late to combat this shock loss with propecia?  Any suggestions on how i could eliminate this shock loss from further damage?  I hope my hair will return.

A:

To prevent shock loss, it is never too late for Propecia (finasteride) if you really need it. You may not get the maximum benefit as if you started on the medications before your hair transplant, but your shock loss may not have been completed yet.

We generally start our patients on Propecia a few days prior to their hair transplant so the medication is in the system at its therapeutic level on the day of surgery.

Many people choose to continue the medication after hair restoration surgery and we encourage that. We continue the medication for 6 to 8 months after the hair transplant, depending on the degree of miniaturization for patients who do not want to be on finasteride for the rest of their lives or the ones who have minimal miniaturization. After the first few months, the chance of shock loss due to the hair restoration surgery is very minimal but it still may occur.

Q:

Thanks Dr. Mohebi,

Your input is much appreciated.  The shock loss you had mentioned has been my concern, as a few of my frontal hair seem lighter than before.  You had mentioned that the shock loss might be visible for a few weeks to months – will it be the case that after that shock loss stage, the hair will likely return back to original form?

There’s a very important question that i would like to ask you, and was thinking the it would be great for the blog to have.  Basically, when you saw my before and after picture, i feel like i changed a bit.  The “after” picture seems like i have more redness, and i’m hoping it’s not the case where the hair transplant affects the circulation (e.g., tight donor area/scalp affecting the blood flow to my head).  My surgeon told me before the procedure that i will eventually be back to the way i was before (i.e., the “before” picture), but just have a new scar and more gafted hairs.  That’s the ultimate question: would you agree that a patient who does a hair transplant will relatively return to the condition that he was before the particular sugery (w/ of course, a new scar and more hair)?  This is what keeps me up at night, thinking perhaps my scalp has worsened, or i am now more prone to lose hair.  I hope that’s not the case, and every patient should be aware about before she or he gets a hair transplant done.

Thanks again for your help.  If I see you in person at your office, I might be interested in discussing about future scar work.

A:

What is hair transplant shock loss

Some of the hair shafts that fall off due to shock loss might come back. Especially if the shock loss happens in an area with permanent hair like back of the head. However, losing hair in the frontal area because of shock loss might not be completely reversible. But, you have to understand that falling hairs are the ones that were supposed to fall off anyway and a hair transplant just accelerates the loss.

How to prevent shock loss

Again, using finasteride can significantly reduce the extent of shock loss. After surgery, in the transplanted area, the tightness should not affect the circulation of the scalp. After a few days to weeks, on the donor area, the tightness goes back to normal.

Donor scar in strip hair transplant

And to answer to your last question, I do not agree you go back to the condition before surgery with only a new scar and some more hair. What I personally do in a repeat surgery is remove the old scar; the patient at the end has only one scar that at times may be even better than the initial scar.

How to improve the appearance of the scar

I perform trichophytic closure when I think it is the final surgery that the patient may need.  Trichophytic closure is when we close scalp skin on the back in a way that hair can grow through the scar.  Trichophytic closure reduces the contrast between donor scar and surrounding areas that eventually improve the appearance of the scar, so you are not more prone to hair loss because of your hair transplant.

In some cases and when we are looking for even less visible scar, the scar may get filled with FUE into the scar in a few months from the initial surgery.

Be patient and you should be able to see results in the coming months.

The effectiveness of medical hair restoration alone with hair restoration medical options that are currently available such as finasteride or Rogaine has always been questioned.  Medical hair restoration without the surgical option (hair transplant), might work for some people, but should not be recommended to all as a cure-all solution, as you may find in some advertisements.

The available FDA-approved medications for hair loss prevention are finasteride and minoxidil.  Although both are effective, they may have different indications for male and female patterned baldness. They might not be considered a complete treatment for male patterned baldness, as pharmaceuticals may try to show.

Medical hair restoration should be seen as a preventative measure which should be considered, along with the surgical options, as part of a master plan. Most people are prone to shock loss that may happen after a hair transplant surgery and they need to be on preventative measures such as finasteride at least a few months around the time of surgery. Shock loss after a hair transplant used to be one of the biggest problems that hair transplant patients had up until the last few years. Now, most hair transplant patients go on finasteride after a hair transplant surgery.

What is Saw Palmetto?

Saw Palmetto is an extract of the fruit of Serenoa Repens. It is rich in fatty acids and phytosterols. It has been used in alternative medicine for a variety of indications, most notably benign prostatic hyperplasia (BPH).

Indications:

Prostate treatment

Saw Palmetto has also been used in treatment of benign prostatic hyperplasia (BPH), a condition known by enlarged prostate size to the degree that it makes urinating difficult.

Hair loss prevention

The role of Saw Palmetto in hair loss prevention has also been documented. Saw Palmetto is one of the few effective herbal treatments that can reverse hair loss process in some people to some degree and slow down the process of  balding in men. Saw Palmetto bio active ingredients prevent conversion of testosterone into dihydrotestosterone (DHT).

That is how Saw Palmetto helps to stop the process of balding on the hair follicle level. It can help increase the thickness of miniaturized hair and make them grow longer. The Saw Palmetto effect is comparable to finasteride or other DHT blockers by mechanism. Saw Palmetto is available in oil extract for topical use on scalp or as pills used for prostate enlargement treatment.

Q:

Hope you had a great weekend, Just a quick question.

After how long usually I would see the result of those pills (finasteride)? Will it grow like baby thin hair and it thickens over time or should I like shave my head to help it? J just wonderin‚
Regards,

A:

Be patient,

It is unlikely that you grow new hair from the areas that you lost hair follicles. The medication finasteride can help increase the thickness of your miniaturized hairs that normally do not give you any significant cosmetic effects. You should not see the effect of medication before 3-6 months from the time you started it.

Remember, the purpose of medical treatment is not to grow your hair back as it was when you were 17. The goal of medical hair restoration treatment with either minoxidil or finasteride would be to stop or at minimum slow down the progression of hair loss. Shaving your head should not change the progress of hair loss or gain either. When you manipulate your hair whatever you do, you are dealing with external part of the hair, which is not alive. The follicle does not sense what is going on outside at hair shaft level. To restore it more permanently in front and top of your scalp, you would need a hair transplant.

Best,
Dr. Mohebi

Q:

Hi Doctor,

Some doctors prescribe Dutasteride (Avodart) for hair loss prevention. I know you do not recommend Dutasteride for hair loss for obvious reasons, but based on available research findings on this medication, what do you think are the most likely possible side effects from using Dutasteride if worse come to worse. Would it be like multitude of finasteride side effects? Again, I know your view of non-FDA approved drugs.

A:

Dutasteride (Avodart) is one of the selective inhibitors of the type I and II of the enzyme 5-alpha-reductase, the enzyme that converts the male hormone testosterone to 5-alpha-dihydroxytestosterone (DHT). In comparison with dutasteride, finasteride (Propecia) acts as an inhibitor of just type II of the enzyme 5-alpha-reductase, which is more specific. Studies around dutasteride mechanism of action shows that, blocking both type I and type II enzyme can be more potent that only one in reducing the levels of DHT in the body.

If you are taking dutasteride for other indications, you may get some hair growth as a good side effect. As you may guess cannot recommend dutasteride solely for prevention of male patterned hair loss; not until it is approved for hair loss treatment by FDA. Other than not being FDA approved my other reasons are:

1. The optimum dose of dutasteride for hair loss prevention is not determined.
2. The side effects of dutasteride are much more prominent comparing to finasteride.  That include the negative effect of the medication on sex drive in men.
3. If you are considering the cost effectiveness of dutasteride, with new price reduction of finasteride that should not be in the picture any more.

Dear Dr. Mohebi,

I was doing a quick research on the hair loss solution, that I came across your weblog. I wanted to ask you regarding my hair loss problem. I am 28, with history of hair loss in male members of my family. My hair loss started more than 10 years ago, and I started using Minoxidil (first 2% and then 5%). At the time, I was told that Minoxidil will just postpone the total hair loss. Well, I never went bald that much. About four years ago, I started taking Finasteride 1mg, and I think it worked out really well. But the concerns regarding the side effects for men made me stop it about a year ago. Now, I am seeing more hair loss. I was just wondering how careful should one be in taking Finasteride, especially when all the researches are doomed to an inherit uncertainty, and that the side effects might prove much more severe only in future.

So, I would appreciate if you please advise me and let me know about the solutions that is out there for my case.

Thanks very much,

Patient’s name

A:

I understand your concern. You have stopped finasteride (Propecia), despite of experiencing good results. Finasteride has been out in the market and widely used for prevention of hair loss in past 10 years. Finasteride has a few side effects that they are all reversible with discontinuation of the drug. The most problematic side effect of finasteride is decreased libido that if occurs should go away in about 3-7 days after stopping the medication. I have seen this side effect mostly in elder patients who recently start taking finasteride. I have never seen any patients who won’t recover from this side effect within a few days. In fact, instead of stopping the medication, I usually change the dose to half or prescribe it in alternate days and that way I have been able to manage the side effects in the most cases.

You are concerned with delayed Propecia adverse effects that may have not been discovered or reported and could potentially be a cause for concern in the future. That could be brought up for almost every medication, but I believe we had better stick to the proven facts. All medications that are used in the United States are regulated by the FDA after thorough evaluation of solid results from extensive clinical research.

There are other medications that are prescribed by some doctors for hair loss treatment. Some are currently being evaluated for hair loss prevention such as Avodart (dutasteride), which works through a mechanism similar to Propecia. Avodart is even more effective for hair loss prevention in comparison with Propecia, but it also causes more side effects and that is why the FDA has not yet approved it for hair loss treatment. I do recommend Propecia to most of my patients with male pattern baldness because even if you want to treat your hair loss with hair transplant, you are still better off doing a lesser number of sessions and preserve your own natural hair as much as possible.

hey doctor!

As I read through forums and articles, people mention that propecia works better in conjunction with something else, such as rogaine for exmaple. At the moment, the vertex area of my scalp seems emptier than than the crown and minoxidil works well with the vertex. Do you recommend me go back on minoxidil for the vertex, or should I just focus on propecia?

Answer:
I generally prescribe finasteride to most of my patients who have significant miniaturization whether they are getting hair transplants or not. There are several studies on using Rogaine (minoxidil) and Propecia (finasteride) as single therapy and in combination with each other or with other medications.

Comparing minoxidil and finasteride for treatment of male pattern baldness clearly shows that treatment with only finasteride is more effective than treatment with only minoxidil. Combination of finasteride with minoxidil and with some other medications shows improved outcome, but the rate of improvement is not significant enough that I can convince myself to prescribe combination therapy to all my patients for the rest of their lives, considering difficulty of using topical minoxidil (topical spreading of medication twice a day on the balding area of scalp).

If you want to do everything possible to prevent or slow down further hair loss and maybe grow some, you can consider combination therapy, but remember when you start minoxidil you are committed to continue it for the rest of your life or until there are better alternatives.