This is an example of one procedure to create a hairline that would not be appropriate for many men, especially younger men. This man is only 34 years old. I would be reluctant to graft this low a hairline in most men under age 40 and reluctant even then if their crown were more than minimally balding. This case, in my opinion, shows that “black and white” rules are fine for some and certainly make life easier for all involved (but leave some patients with the verdict of “not being a candidate” for whatever concerns their aesthetics had them visit the surgeon for in the first place). This gentleman is very smart and understands the consequences of future balding in the crown which, if extensive, could result in there not being enough donor hair to keep up a natural distribution of hair on his scalp. He states, however, that he has complete confidence that there is no crown balding on either side of his family. His crown (see photo) both with regular and 30X photography shows no evidence of male pattern balding. I agree with his assessment that the risks of insufficient donor hair are sufficiently small that surgery would be a reasonable option. He is not taking finasteride and would prefer not to. The absence of miniaturization or loss of density in the crown makes it reasonable not to use finasteride at this point. He can revisit this issue if miniaturization appears in the crown. A surgical plan should not be devised that requires a person to use ( with successful results) medicines for the rest of his life.

Looks superb, and the documentation is really great for getting a feel for the result! You've given this guy a flawless head of hair. There was a prospective patient with a very similiar situation (more receeded temples) who stumbled onto the forum recently; I'll definitely refer him to this case.

The work does look amazing Dr. Reed, great result. Would you please elaborate a little on what you meant where you said that "A surgical plan should not be devised that requires a person to use...medicines for the rest of his life."?

Very natural, great job, I am sure this patient is happy.

1301 grafts?

Thank you, TC17, for the compliment. You ask that I elaborate on " a surgical plan should not depend upon the successful use of medicine". I'll try not to be too verbose, but I think it's an important point to be clear about since male pattern balding is a progressive condition and since medication can stop the progression and even regrow some hair mass. A key question is if a person and his surgeon decide upon a pattern of grafting that addresses only his current pattern of hair loss or do they limit themselves to a more conservative pattern that can be created with the donor that remains and the amount of balding present in the distant future after balding has progressed for several decades. At times the decision is probably based upon the present degree of balding and larger amount of donor area because the person says he is going to take finasteride for the rest of his life. This is probably a false premise since how does he know he can take finasteride that long and that it will be effective? The "90% of people that have their balding arrested" is based upon a study that followed patients only five years. The informal nine year followup with this group of patients suggests the progression of balding is still arrested then and theoretically the progression will probably stay slowed down (although we, men and women, all lose hair over our entire scalps to some degree) after nine years. Nevertheless, the stakes of balding more than surgically planned can result in a social discomfort that is worst than the balding that had him decide on surgery. So I'm opposed to making a surgical plan whose success of having enough donor depends upon taking medications for the rest of ones life. Please feel free to follow up with questions if I'm not clear. I find a common misunderstanding of inquiries that I get from HTN is about this point. Young men in their twenties don't seem adequately clear on how bald they may go and what this means. I don't want to rain on any parades or enthusiasms about the refined techniques that have arisen in the last 15 years, but that is not a very long followup period and we have not yet begun to see the results of poor surgical planning whether it be because the person planned to take finasteride for the rest of his life or for some other reason. Male pattern balding is patient!

Looks incredible Dr Reed. Im highly impressed

Dr. Reed,

Thank you for your reply. Just to clarify, is the gist of your post that you always look at what the patient will be in the future when transplanting? If so, how do you predict the final pattern with any accuracy?

Yes, grafts. Sorry for the typo.

Dr. Reed,

The results look great. Nice hairline refinement with a low number of grafts.

I've taken the liberty of changing the topic to "1301 Grafts with Dr. Reed" so it's more sensical to those viewing it :-)

Best wishes,

Bill (Falc)

Hi TC17, I've flagged your question and hope to respond soon. Best regards.

This is an interesting discussion IMO Dr. Reed, although I am a little confused. To follow up on tc17's question, which is a good one, are you saying that propecia usage after 9 years in the study you referenced had arrested or considerably slowed their hair loss? I'm still confused on how you base propecia's effectiveness into your surgical plan, or are you saying you don't?

To follow up on that, I read on the baldtruth message board something interesting in regards to propecia and making sure it still works over time. From IAHRS Reccomended Hair transplant surgeon Dr. Mark Baxa

"But I will tell you that in my practice I find Finasteride to be VERY effective.. especially at maintaining the patients current hair count. But alas, usually after about 6 -7 years ... I do see that it either loses some of its effectiveness ~or~ I believe that you just can not stop the stronger 'genetic' factors from taking hold.

So what you are seeing is probably the best results you can get from Finasteride alone!

You may want to also add both Selenium & Biotin as a supplement to your finasteride!!!

I started doing this about five years ago with my patients and I have seen less of this 'genetic' decrease in effectiveness of Finasteride alone.

Therefore, I started compounding a formulation of Finasteride, Biotin & Selenium for my patients."

I have also read about people taking a two week break from the drug every year or two or so, so the body doesnt get used to it. Have you heard of this? I remember reading some saying that propecia "wasn't working like it used to" so he stopped the drug for a few weeks, started back up again, and it "started working like new."

Finally, do you think spiro cream has any benefit for hair loss?

Thanks for your time and thoughts, I look forward to your answers.

looks great would never know that he had a transplant. Is patient on propecia also to stop further hairloss?

This man is unusual. He has absolutely no evidence of male pattern balding anywhere except in his hairline and has a family history showing the same pattern of balding. He doesn't want to take finasteride any sooner than he has to. That seems reasonable to me. The low hairline is a surgical decision that has to be able to stand as a reasonable decision without his taking finasteride for the rest of his life mandatory as we've touched upon earlier.

hdude46, welcome to the club of confusion with regards to hair restoration. It means you are looking at the data critically. Let me respond to your points with my best impression of what is accurate at the moment.
1. Re finasteride. The preliminary, informal, nonpublished results of the group that gave us the impression of what finasteride can do (and this was based upon only 5 year's usage) was looked at after nine years and seemed to be holding their own. 2. I do not think it appropriate to devise a surgical plan that depends upon successful results from lifelong use of finasteride and/or minoxidil. I recommend their use enthusiastically and enjoy seeing their results but this must be considered "frosting on the cake" for as long as the medicines are used. In my opinion the foundation of the permanent balding pattern that the surgery establishes must be from surgery only and not be a foundation dependent upon lifelong use of medicines. 3. I have no opinion upon your quotes from Dr. Baxa except that changes that we would be talking about are subtle enough that they would have to be derived from carefully designed and executed studies and not from anecdotal observations. I'm not clear on how Dr. Baxa arrived at his conclusions. Regarding biotin and selenium, I only go by discussions with one of the foremost basic hair researchers who says that there is no evidence that they are effective. She works as an independent researcher for the major pharmaceuticals and it seems to me that if these substances were effective, the pharmaceutical companies being what they are would be adding them to their proprietary chemicals to boost their effectiveness. 4. I don't particularly like the idea of a 2 week holiday from finasteride but it think there is little harm done in doing this and could be a reasonable idea if a person starts seeing evidence of loss of effectiveness.

quote:

Posted July 01, 2009 03:03 PM
This is an interesting discussion IMO Dr. Reed, although I am a little confused. To follow up on tc17's question, which is a good one, are you saying that propecia usage after 9 years in the study you referenced had arrested or considerably slowed their hair loss? I'm still confused on how you base propecia's effectiveness into your surgical plan, or are you saying you don't?

To follow up on that, I read on the baldtruth message board something interesting in regards to propecia and making sure it still works over time. From IAHRS Reccomended Hair transplant surgeon Dr. Mark Baxa

"But I will tell you that in my practice I find Finasteride to be VERY effective.. especially at maintaining the patients current hair count. But alas, usually after about 6 -7 years ... I do see that it either loses some of its effectiveness ~or~ I believe that you just can not stop the stronger 'genetic' factors from taking hold.

So what you are seeing is probably the best results you can get from Finasteride alone!

You may want to also add both Selenium & Biotin as a supplement to your finasteride!!!

I started doing this about five years ago with my patients and I have seen less of this 'genetic' decrease in effectiveness of Finasteride alone.

Therefore, I started compounding a formulation of Finasteride, Biotin & Selenium for my patients."

I have also read about people taking a two week break from the drug every year or two or so, so the body doesnt get used to it. Have you heard of this? I remember reading some saying that propecia "wasn't working like it used to" so he stopped the drug for a few weeks, started back up again, and it "started working like new."

Thanks for your time and thoughts, I look forward to your answers.

Dear TC17. How do we figure out the future of balding with any accuracy? That's a great question and one that every person should answer before undergoing hair transplantation. I think you and I know that there is no way to be accurate and that accuracy is worse the younger and more bald the person is.
So if I can't be accurate, I can at least be conservative. The basis of this conservative approach is that it is safest to place hair in a 3 vertex distribution. The more forward you come with the bridge that connects the grafted oval on top of the head to the hair on the sides of the head to result in a hairline with less temporal recession, the more risk you are assuming long term (because at some point it is no longer a pattern that occurs in nature, ie the 3 vertex). The wider the bridge you make that connects the top to the sides, the more risk you assume. The bigger the oval of hair on top, the more risk you assume. More than light grafting into the crown cannot be considered conservative earlier than perhaps age 40 (depending perhaps upon family history, styling, hair characteristics and balding elsewhere). A major concern is that the younger a person is the more likely he is to lose density in his donor. If he has fine caliber hair or low density hair to begin with he is particularly at risk of having donor scars show through at an older age, especially when the hair is wet. I think this explanation is clear to you, TC17, since you are obviously very advanced in your understanding. I'm sorry if it confuses others but perhaps this can serve as a question to ask surgeons that you interview if you are a perspective patient.

Excellent hairline, very dense and natural looking.