Can Rogaine Cause Miniaturization?

Q: Can Rogaine Cause Miniaturization?

When I am on Rogaine it seems – to my untrained eye – that I am having hair miniaturization and when I stopped briefly, I had shedding. Does this seem accurate based on what you have seen? Can Rogaine cause miniaturization? Is there a point you would recommend I stop Rogaine or is it something that likely can’t cause a negative impact on hair? — B.T., Brooklyn, NY

A: Minoxidil reverses miniaturization. It does not cause it. Shedding can occur after starting use of Rogaine but this means the medication is working should resolve with continued use. New miniaturized hairs are either from the progression of your genetic male pattern hair loss or newly forming hair that was stimulated by the minoxidil which can mimic miniaturized hair.

• Read more Medical Treatment Options at Bernstein Medical
• Read our Rogaine Tips

In What Cases Do You Think Scalp Micro-Pigmentation (SMP) Is Most Useful?

Q: In what cases do you think Scalp Micro-Pigmentation (SMP) is most useful?
— M.O., Greenwich, CT

A: Scalp Micro-Pigmentation (SMP) is used in patients who want to make their thinning hair look fuller and want to avoid the nuisance of daily application of cosmetic concealers, powders or fibers. It is for patients who want a permanent solution, but who do not want, or who are not candidates for hair transplant surgery. It can achieve a variety of looks such as a buzz cut by tattooing hundreds of microdots that appear like follicles or it can reduce the contrast between generalized dark hair that is thinning over a pale scalp. It can even give the appearance of hair over a scar that has now become noticeable.

• Read more about Scalp Micro-Pigmentation

How is Scalp Micro-Pigmentation (SMP) Performed?

Q: How is Scalp Micro-Pigmentation (SMP) Performed?

How is SMP done? — B.P., Long Island, NY

A: Scalp Micro-Pigmentation (SMP) is applied with tiny microneedles that mimics the appearance of hair in an area of the scalp that looks thin. It requires the use of local anesthesia and is performed in a doctor’s office. SMP is typically performed over a series of three or more sessions spaced at least 2-4 weeks apart. The length of each session varies depending on the area to be tattooed and can last from a few hours to a full day.

To perform successful SMP, the hair length and color must be analyzed in consultation along with a discussion of cosmetic goals and the potential techniques that could be implemented for the patient’s hair type. The procedure is performed under local anesthesia and is generally well tolerated with very few post-op limitations.

• Read more about Scalp Micro-Pigmentation
• Read about our practicing SMP physician, Dr. Christine M. Shaver

What is Scalp Micro-Pigmentation (SMP)?

Q: What is Scalp Micro-Pigmentation (SMP)?

What is SMP? — M.O., Greenwich, CT

A: Scalp Micro-Pigmentation (SMP) is a medical-grade scalp tattoo. It is a form of permanent cosmetic camouflage that can mimic the appearance of hair in locations such as scars or balding areas. SMP gives the appearance of fullness of hair without actual hairs being present. Although permanent dyes are generally used, semi-permanent materials can be substituted that will purposely fade over time.

Dr. Shaver is our dedicated in-house physician for Scalp Micro-Pigmentation procedures.

• Read more about Scalp Micro-Pigmentation
• Read about Dr. Christine M. Shaver

Why Is My Hair Dry And Kinky After My Hair Transplant?

Q: I had a hair restoration procedure and the hair grew, but after one year the hair was kinky and dry. It has remained like this ever since.

From what I have read Dr Bernstein says this is uncommon but can happen. I understand there is no definitive explanation for this but I would like Dr Bernstein’s opinion on why this happens. My theory is that DHT is more prominent on the top of the head and is changing the structure of the transplanted hair. The hair is so dry and unmanageable it looks like I am wearing a wig. I await his response. — P.O., Greenwich, CT

A: Some dryness and texture changes can occur after a hair transplant and this usually self-corrects over 1-2 years during which time the transplanted hair gradually regains its original luster and texture. These changes are most likely due to the unavoidable trauma that takes place as follicles are removed from the scalp and placed into recipient sites. Excessive dryness can occur if the sebaceous glands had been stripped away from the graft. In FUT, this can be due to over dissection (i.e., grafts that are trimmed too much). In FUE, this can be due to loss or damage to the sebaceous glands in the extraction process. Persistent kinkiness may represent either damage to grafts from the procedure (improper handling, crush injury) or effects of scarring in the recipient area (usually from older procedures which used larger recipient sites) that distort the growth of follicles.

• Read about post-op care following an FUT hair transplant
• Read about post-op care following a Robotic FUE hair transplant
• Read more Q&A about post-op care

Can Anyone Tell Me Why Dr. Bernstein Is Still Bald?

Q: Can anyone tell me why Dr. Bernstein is still bald? — N.H., Brooklyn, NY

When Dr. Bernstein was younger and started to lose his hair, it really didn’t bother him. After medical school, he began his career as a dermatologist and became aware of surgical hair restoration. It was then when he realized that he would not be a good candidate for a hair transplant procedure, even if he wanted one, because his donor area is very thin. In the years since, he has gotten used to being bald. But his not being a candidate made him keenly aware of who is and who is not a good candidate for surgery, and this insight has helped earn him a reputation as an honest and ethical practitioner of hair transplantation.

What is the Difference Between “Hair Transplant Reversal” and “Hair Transplant Repair”?

Q: I have read a lot on the forums about hair transplant reversal and hair transplant repairs. Are they the same thing, if not, what is the difference? Can you reverse a hair transplant? — K.J. ~ Park Slope, N.Y.

A: A “hair transplant repair” refers to techniques that improve the appearance of a poorly executed procedure or one performed with outdated methods. A “hair transplant reversal” refers to techniques that enable the individual to appear as if no hair restoration surgery had been performed. Although the techniques in attempting to perform a repair or a reversal may be similar, the ultimate goals of each are quite different. It is important to understand that although significant improvement can often be achieved, perfect repairs and/or full reversals are generally not possible.

The main reasons for seeking a repair include; large grafts transplanted to the frontal hairline giving an unnatural, “pluggy” appearance, a frontal hairline placed too far forward, hair placed in the wrong direction, and donor and recipient site scarring. Outdated procedures such as scalp reductions and flaps also need to be repaired.

If the transplanted grafts are large (“hair plugs”), it is possible to surgically excise these grafts, microscopically dissect them into smaller follicular unit grafts, and re-transplant them into the scalp in a more natural-looking, aesthetic way. After these large grafts are removed, the sites are sutured closed and heal with very fine, often imperceptible, white scars. Hair plug removal is often followed by one or more sessions of FUT or FUE in order to harvest additional hair for use in camouflaging any remaining plugs or improving the appearance of the region where the plugs had previously been. These combined repairs can lead to excellent outcomes.

If the grafts at the hairline are not large but are placed too low or too broadly, it is possible to use laser hair removal and/or tweezing to remove these hairs. Repeated treatments may be necessary until the hair ceases to grow back at these locations. Additionally, hair which was placed in a direction different from the way hair naturally grows will usually need to be removed.

Another challenge in hair transplant repair is fixing widened donor scars that had resulted from poorly performed FUT/strip procedures. These scars are permanent and may be visible if the hair is not worn long enough. Scars from FUT procedures can be repaired by harvesting hair from the surrounding donor area (using FUE) and transplanting these follicular unit grafts into the scarred tissue.

Scalp micro-pigmentation (SMP), a permanent micro-tattoo, may be useful to further camouflage these linear scars. SMP can also be used to improve the look of the stippled scars of FUE in patients. This can occur with overharvesting, when patients wear their hair too short, or when the balding is more extensive than anticipated and extends into the harvested area.

A hair transplant reversal, in theory, has the goal of having the person look as though a hair transplant had never been performed. While reversing a hair transplant completely is not possible, the techniques previously discussed can be utilized to achieve a number of important things. The donor site scarring can be minimized and/or camouflaged and the smaller follicular unit grafts in the recipient zone can often be removed without leaving behind any visible scarring of the underlying skin. What is not possible is to restore the person’s density to a pre-procedure level as improperly performed transplants always result in wasted hair.

• Read about Hair Transplant Repairs
• See Hair Transplant Repair before and after photos

What is your Opinion of Nutrafol?

Q: What’s your honest take on Nutrafol? It is a product my dermatologist has recommended for my hair loss. — N.S. ~ New York, N.Y.

A: The traditional thinking is that that male pattern alopecia (androgenetic alopecia) is due to follicular sensitivity to DHT causing miniaturization and eventual loss of hair. The premise of Nutrafol is that hair loss is multi-factorial with an important inflammatory component and that it is important to address the inflammation as well as the DHT sensitivity.

This is a relatively new and important concept (I would like to stress this point!). However, the big leap is their conclusion: Since hair loss is multi-factorial, then broad, rather than targeted treatments would be most beneficial, and since naturally occurring “phytochemicals” are broader in action than targeted, FDA approved drugs (like and minoxidil), they should offer benefit in the treatment of hair loss and Nutrafol is the elixir that can accomplish this.

Although this makes sense in concept, there is no scientific evidence that Nutrafol can actually reverse or/mitigate androgenetic alopecia or any other type of hair loss. We need independent, blinded, controlled studies to show that Nutrafol actually works. Until then, it is very difficult to recommend this product and, more importantly, to recommend it over other treatments known to be effective.

• Read about treatments for men’s hair loss
• Read about treatments for women’s hair loss
• Discover the causes of hair loss

When is it Best to Feather in Robotic FUE?

Q: I thought that FUE extraction is performed in a way that it cannot be detected. Therefore, it is best to distribute the pattern evenly starting from the safe zone and fading out on the sides. The ARTAS results often show a smaller extraction area and harder edges (no transition from extraction to non-extraction area). Does this lead to a higher risk to detect the surgery? — H.K. ~ Chicago, I.L.

A: Feathering of the extraction zone in FUE is a technique where the distance between the extractions gradually increases as one reaches the border of the extracted zone. When this technique should be used depends upon the short- and long-term goals of the patient. If the patient’s main goal of the FUE procedure is to wear their hair very short, then the technique of feathering and rounding the edges to have a less distinct border is appropriate, as this will decrease the visibility of the harvested area.

However, if a person does not wear his hair very short (nor plans to) and maximizing the donor supply is paramount, then a more organized pattern, with less feathering, will give a greater long-term yield and a more even distribution. The reason is that the healing of FUE wounds distorts adjacent follicular units making subsequent extraction in the same regions more difficult and increases the risk of transection. For this reason, in subsequent procedures we generally prefer to harvest in new areas. If we need to harvest more hair from the same area, we rarely go back more than once.

When one feathers extensively in the donor area, this utilizes a larger surface area of the scalp with less graft yield, so it may become necessary to go back over the same area to obtain additional grafts, often multiple times. This risks increased transection and an uneven, mottled appearance to the donor area.

If a person wears his hair very short, then feathering is critical (even though it makes subsequent extraction more problematic). It is very easy to feather and round edges with the ARTAS robot, but we make the decision to do so based upon the specific needs and goals of the patient.

• Read about Robotic FUE
• See examples of healing of FUE donor sites

Are Topical DHT Blockers as Effective as Oral Finasteride?

Q: What is more important against baldness, decreasing DHT in serum with oral finasteride or decreasing DHT in the scalp with topical finasteride? — A.G. ~ Brooklyn, N.Y.

A: Decreasing serum DHT with oral finasteride is more effective in combating hair loss, as the decreased blood levels also lowers the DHT in follicles and seem to do it better than finasteride applied topically.

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Q: I was thinking of having an FUE hair transplant procedure done in Turkey, but I am concerned that it will be done with just technicians. Any thoughts? — E.E. ~ Mount Vernon, N.Y.

A: I do not have first-hand information on the clinics in Turkey, but there is a recent “Letter to the Editor” in Hair Transplant Forum International, the official publication of the “International Society of Hair Restoration Surgery” that you might find informative. From the article:

“In Turkey, there are 300 FUE clinics in Istanbul alone but, unfortunately, at only 20 of them are operations are done by doctors. We do not exactly know how many of those 300 clinics have legal permissions, but we know very well that an average of 500-1,000 FUE operations are done per day.”

If you would like to read the entire article, the reference is: A Report from Turkey – the situation in a top FUE destination. Hair Transplant Forum International July/August 2017 p 162.

Do Women Have Less Shock Loss Than Men?

Q: I have heard that shock loss can occur after a hair transplant. Do women experience less shock loss than men? — N.R. ~ Mineola, N.Y.

A: Actually, the risk of shock hair loss is usually greater in women than in men since women generally have a more diffuse pattern of thinning. This is because females often have more miniaturized hair, the hair that is most subject to post-op shedding.

Is Manual FUE Better Than Robotic FUE Because The Physician Can “Feel” The Follicle During Extraction?

Q: Is it true that manual FUE hair transplant procedures are better than robotic hair transplants because the physician can adjust and feel the follicle when extracting? — M.H. ~ Great Neck, N.Y.

A: The ARTAS robot is a physician controlled, computerized device that uses a three-dimensional optical system to isolate follicular units from the back of the scalp in a hair transplant. The robotic system assists the physician in the extraction of grafts with precision and speed. Although there is some advantage to having “human feel” for the tissue, this is far outweighed by the fact that repetitive procedures performed manually thousands of times lead to operator fatigue and result in increased transection and damage to grafts. With the ARTAS robotic system, the quality of the first and the last graft harvested will be the same.

Read about advantages of the ARTAS Robot over manual FUE procedures

What is Trichophytic Closure After An FUT Hair Transplant?

Q: I have read that some doctors perform something called a trichophytic closure. What is this? — M.S. ~ Thornwood, N.Y.

A: Trichophytic closure is a way to minimize the appearance of the donor scar in a hair transplant using a strip incision. The technique provides improved camouflage of a linear donor scar in Follicular Unit Transplantation (FUT). Normally, in FUT, the surrounding hair easily covers the scar. For some patients with very short hairstyles, the resulting donor scar may be visible. With the trichophytic closure technique, Dr. Bernstein trims one of the wound edges (upper or lower), allowing the edges to overlap each other and the hair to grow directly through the donor scar. This can improve the appearance of the donor area in patients who wear their hair very short.

The trichophytic donor closure can be used on patients who have had previous hair transplant procedures and are looking for improvement in the camouflage of their donor scar. It is particularly useful in hair transplant repair or corrective work. Trichophytic closures work best with sutured incisions. Stapled closures have their own advantages. The doctor will recommend which type is best in your case.

• See the Donor Area page for more on closures
• Dr. Bernstein summarizes research on trichophytic closures

What Is The Difference Between The ARTAS 9x And The Earlier Versions Of The Robot?

Q: What is the difference between the ARTAS 9x and the earlier versions of the robot? — T.J. ~ Washington, D.C.

A: The differences can be grouped into four broad categories:

1. Speed: The 9x is 20% faster than the 8x. This is achieved through the ARTAS robot’s ability to more quickly and accurately align with the follicles, faster movement from follicular unit to follicular unit while harvesting, and a shortened dissection cycle (less than 2 seconds). In addition, the 9x uses white LED lights instead of red, which permits an increased work flow from the ability to simultaneously incise and extractions grafts. The decreased strain on the eyes from the white lights (compared to red) makes this possible.

2. Accuracy: The 9x uses smaller needles that minimize wounding and donor scarring. It is especially useful for patients with fine hair or those who want to keep their hair short.

3. Functionality: The robotic arm on the 9x has a 1-inch base extender that gives the machine a longer reach and decreases the need for the patient to be repositioned. The ARTS 9x also has a smaller robotic head allowing the robot to harvest the grafts at a more acute angle. The ARTAS 9x also allows for more site making options due to the universal blade holder and the ability to program a change in the orientation of the incision in different regions of the scalp. The ARTAS 9x also uses a new harvesting halo to secure the tensioner (the grid-like device that indicates where the robot should harvest) which is faster to apply and more comfortable for the patient.

4. Use of Artificial Intelligence: The technology notifies the physician early-on if the harvesting is not precise, so that action can be taken to ensure most effective results. The ARTAS software can now detect areas with low (or no) hair density and prevent those areas from being over-harvested. This also decreases human error and saves time by automatically blocking these areas with low density. Finally, the ARTAS Hair Studio, can now create a 3-D image of the patient’s head with only one photo (as opposed to the prior requirement of 3 to 5).

• Read more on Robotic FUE
• Schedule a Consultation at Bernstein Medical

Why Visit a Practice That Specializes in Both FUT and FUE?

Q: Why go to a hair restoration practice that specializes in both FUT and FUE? — L.P., Bayside, NY

A: This is a great question, but the answer may be counterintuitive in today’s age of specialization. The answer is that you should always go to the practice that offers both. To deliver the best care, hair restoration physicians should have expertise in both Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) techniques and should offer both in their practices. There are at least five good reasons why:

1. FUT and FUE are both excellent techniques, but have different indications for their use; therefore, a patient might benefit from one technique over the other. If the doctor offers both procedures, the physician will be able to choose the best one for the specific patient rather than treating everyone with a single type of procedure.

The main advantage of FUT is that it typically gives the highest yield of hair. Therefore, when the patient’s primary goal is to achieve maximum fullness, FUT should be performed. There are many well-described reasons for this, including the precision of stereo-microscopic dissection (which helps preserve follicles and the protective tissues around them) and the ability to harvest efficiently from a more select area of the donor zone.

The main advantage of FUE is no linear scar. Therefore, when the patient’s primary goal is to be able to wear his hair very short, FUE should be performed. FUE is also indicated when there is an increased risk of a widened scar or when scalp laxity does not permit a strip excision. The patient may sometimes choose FUE simply to avoid the stigma of a linear donor scar.

2. The same patient may benefit from both procedures

There are situations in which both procedures are useful in the same patient. For example, FUT may first be used to maximize yield, but then, after several sessions, the scalp may become too tight to continue to perform FUT, or the donor scar may become wider than anticipated. In the former case, the physician can switch to FUE to obtain additional grafts; in the latter case, FUE may be used to camouflage the scar of the FUT procedure.

3. There is a cross-over set of skills from FUT to FUE

To do an FUE procedure well, the follicular unit grafts that are extracted should be examined carefully under a stereomicroscope and, when needed, trimmed and sometimes subdivided into individual hair follicles (such as for hairlines, eyebrows, temples, etc.). Stereo-microscopic dissection is basic to FUT and is a skill that is second-nature to the staff of hair restoration practices that regularly perform FUT procedures, so this critical step will not be hit or miss. A doctor and staff who perform only FUE will often lack this skill.

4. Practices that offer both procedures are usually more experienced

It is easier to learn and train one’s staff in just one hair transplant technique. In particular, FUE procedures require a smaller staff than FUT and, thus, many doctors entering the field of hair restoration surgery will perform FUE, but not master the skill or make the commitment (financial, time, and infrastructure) to hire and train the staff to perform FUT.

5. Better decision making

One could argue that if a doctor performed only one procedure, but the patient needed the other, then he/she would refer the patient to a colleague. Although this sounds nice in theory, it is very rare for a doctor to refer a surgical case to a colleague if it is a condition that he/she actually treats. More likely, the doctor will convince the patient (and probably himself) that the procedure he offers is the appropriate one, even though it may not be the case.

• Read more about Choosing A Hair Transplant Surgeon
• Read about FUE Pros and Cons

Can Hair Transplant “Plugs” be Repaired by Lasers or Electrolysis?

Q: After an old hair transplant using plugs, can you use lasers or electrolysis to remove the transplanted hair? — N.C. ~ Newark, N.J.

A: You can remove the hair in plugs with electrolysis, but it is difficult since the scarring distorts the architecture of the hair shaft and makes it hard to insert the electrolysis needle. Laser hair removal is a far more efficient way of removing the hair but takes multiple treatments. However, the problem with either of these techniques is that the hair is destroyed and the underlying scarred scalp is not improved. In fact, it is made more visible when the hair has been removed.

Our preferred method of repair is to completely remove the plugs, dissect out the individual follicular units from those plugs and then re-implant them in the proper location and direction. In this way, the hair can be reused and the appearance of underlying scarred scalp can be improved, as well as camouflaged with new hair.

• Read more about Plug Removal
• See before and after photos in our Hair Transplant Repair gallery

Does Frequent Combing Cause Hair Loss?

Q: Is it ill-advised to comb one’s hair more than twice a day, especially hair that has been transplanted? Will frequent combing induce hair loss? — G.K. ~ Paramus, N.J.

A: Combing or brushing one’s hair does not cause hair loss – no matter how many times a day you do it. However, constant traction with braids or hair extensions can cause hair loss and this loss can be permanent.

• Discover the causes of hair loss
• Read about how grafts become permanent at 10 days after a hair transplant

Do You See An Impact Of Your Involvement With Restoration Robotics In The Development Of ARTAS?

Q: As a medical advisor and an end-user of the ARTAS Robotic System, do you see any impact of your involvement with Restoration Robotics? — J.V. ~ Miami, F.L.

A: Restoration Robotics has been very responsive to the needs of its physicians and to their patients. Because I work closely with Restoration Roboticsin the development of new improvement and advances they are often introduced first in our practice.

• Read about the latest version to the ARTAS Robot, the ARTAS System 9x
• Read about the ARTAS Robotic Hair Transplant System

What Are Alternative Medical Treatments to Propecia?

Q: Dr. Bernstein, I am experiencing side effects on Propecia, are there alternative treatments? — J.D. ~ Roslyn, N.Y.

A: Yes, minoxidil (Rogaine), and low level laser therapy (LLLT). Unfortunately, none of these will be as effective as finasteride.

Hair Restoration Answers

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Q: What do I do if I start experiencing side effects on finasteride? — L.L. ~ Riverdale, N.Y.

A: Don’t panic, just stop the medication and let your doctor know. He or she will give you guidance based on your symptoms.

• Read more about Propecia (finasteride) and side effects

If I Am Starting to Thin, Should I Have A Hair Transplant Or Try Medication First?

Q: My hair is starting to thin in the front, but it is not yet bald. I have been going back and forth about whether to get a hair transplant or use Propecia. I’m not sure what my first step should be. What do you think? — N.K. ~ Pleasantville, N.Y.

A: In general, patients who are thinning, but not actually bald, should begin with combined medical therapy (finasteride and minoxidil) for at least a year prior to considering surgery. In many cases, with this regiment, surgery can be postponed or even avoided completely. Unfortunately, some patients cannot tolerate finasteride or choose not to take it due to concern about potential side effects. Minoxidil, although useful, does not significantly alter the long-term course of hair loss when used alone.

In Hair Transplant Repair, Do You Always Harvest Additional Hair Via FUT or FUE? Which is Better for Repair Procedures, FUT or FUE?

Q: In hair transplant repairs do you always harvest additional hairs to give the hair restoration a better result? Which is better for repair procedures, FUT or FUE? — E.Z. ~ Fairfield, C.T.

A: We do not always harvest additional hair in repair procedures, but we do if possible because it can improve the aesthetic outcome by adding additional density and camouflage. This is called Combined Repair. As for whether we use FUT or FUE in repair procedures, the answer depends on the clinical situation. For example, a loose scalp favors FUT. If the person wants to wear their hair short, that favors FUE. If donor scars from the plugs need to be removed, that favors FUT. If scarring in the donor area needs to be camouflaged rather than removed, that favors FUE.

• See Patient ETI’s before/after repair photos
• Read about Combined Repair techniques

In Hair Transplant Repair, Can You Remove Plugs By Follicular Unit Extraction?

Q: I was wondering if it was possible to use Follicular Unit Extraction (FUE) on the old plugs instead of graft excision. — N.B. ~ Westport, C.T.

A: Graft excision generally works better than FUE in removing old plugs and mini-grafts. The reason is that, in these grafts, the hair is not aligned due to the scar tissue that tugs on, and bends the hair. Because the hair direction is altered from the scar tissue, there is much more damage when the grafts are removed with the tiny FUE punches. In addition, FUE only removes a very small part of the plug. If the hair in the plug is pointing in the wrong direction or the plug is in the wrong location, the entire graft needs to be removed.

Another benefit of graft excision is that we can remove the underlying scar tissue and improve the appearance of the underlying skin. In FUE, only a tiny bit of the scar tissue is removed and, since FUE holes are left open, FUE actually causes its own scarring. With graft excision, the sites are sutured closed so some scar tissue is removed and the quality of the underlying skin looks more natural.

• Read about Hair Plug Removal
• Before/After Photos of a Plug Repair Patient

In Hair Transplant Repair, What is Hair Follicle Survival Rate for Re-implanted Grafts?

Q: When you remove hair plugs and re-use the hair from the grafts, what is the survival rate for those follicular units? — W.B. ~ Upper West Side, N.Y.

A: The survival rate is close to that when grafts harvested via FUT or FUE. However, if the grafts are placed into a significantly scarred scalp, this can have a negative impact on growth.

• Read more about Hair Plug Removal

After a Hair Transplant Will Scars Be Visible in the Recipient Area?

Q: I’ve read some information on your website about donor area scarring from FUT and FUE. Since I wear my hair longer in the back, I am not really concerned about that. But what about the recipient area where my hair is thin? Are any scars visible in the recipient area after a hair transplant? How long after a hair transplant will you be able to see redness, marks, or scars on the top of my scalp? — A.N., Chicago, IL

A: The marks and redness from a hair transplant should fade in about 10 days, although there is significant patient to patient variability. The tiny recipient sites that we use prevent visible scarring, pitting, or other surface irregularities as a result of the procedure.

• After FUT Hair Transplantation
• Read about Recipient Sites

Are Lab Tests Required Before Starting Propecia?

Q: I had a good friend get a transplant at your practice and it seems that your practice is the industry leader in hair transplantation. I may one day be looking for one. That being said, my friend said I shouldn’t trust anyone else. I wanted to know if you may be able to tell me what tests/specific labs you have your patients do prior to starting Propecia. I am having my doctor put me on it but he does not recommend any labs but I don’t trust this. So I’m not looking for medical advice, just what your practice may advise a patient to get (in terms of labs/blood tests) prior to starting Propecia. I’m really hoping you can help as I have already contacted a number of other sources and can’t seem to get an answer. — M.B. ~ Upper East Side, N.Y.

A: Blood tests are not required before starting finasteride and we do not routinely perform them. If a patient requests test then Total and Free Testosterone, DHT, and Prolactin are reasonable to obtain, but there is no consensus on what the appropriate tests might be. If a patient requests tests because he has symptoms (i.e. such as lack of energy associated with low T), he should see his internist, urologist, or GP. That said, patients 50 and over (40 and over in patients with a high risk of developing prostate cancer) should have a PSA before starting finasteride.

• Read more about Propecia (Finasteride)

If I Have Shock Loss After a Hair Transplant, How Long Until Hair Grows Back?

Q: I had an FUE hair transplant three weeks ago and some of my existing non-transplanted hair has fallen out. I was a Norwood 3V, but now I look more like a 4 or 5 without the hair that used to help cover up my thinning area. Am I destined to look balder for the next few months? When can I expect to look like before? — T.M., New Haven, CT

A: You are describing shedding that is pretty typical following a hair transplant. The hair which is shed generally grows back together with the transplanted hair beginning at about three months. You should expect hair that is shaved for the FUE procedure to grow back right away at the normal rate of 1/2mm per day.

The shedding (also called shock hair loss) doesn’t mean permanent damage to the hair follicles. What it refers to is a physiological, or normal, response to trauma to the scalp which is caused by the hair restoration procedure. In general, only miniaturized hair (the hair that is affected by androgens and that has begun to decrease in diameter) is shed after a transplant. This hair would be lost in the near term anyway. Existing healthy hair is unlikely to shed, but if it were to shed, you could expect it to grow back as the transplanted hair grows in.

• Shedding After a Hair Transplant
• What to Expect After Robotic FUE

Why Is It Important to Wash My Scalp After a Hair Transplant?

Q: Is it harmful if I do not rinse or wash my recipient area for 5 to 7 days after the hair transplant? — T.E., Yonkers, NY

A: The purpose of showering the day after the procedure is to remove scabs and dried blood. This will allow for quicker healing, less inflammation (redness), and a reduced incidence of infection. It will also shorten the time post-op where the procedure might be detectable. In our practice, patients are instructed to start showering and gently washing the recipient area the day after the surgery. The first day after surgery the patient will shower three times, and for the remainder of the week, showering will be twice daily. When showering, patients can clean the transplanted area with a special medicated shampoo that is gentle on grafts. The follicular unit grafts are made to fit snugly into the recipient sites and will not be dislodged in the shower, as long as the patient washes gently.

• Read about post-op care following an FUT hair transplant
• Read about post-op care following a Robotic FUE hair transplant
• Read more Q&A about post-op care

Can I Have Robotic FUE If I Have Gray Hair or Curly Hair?

Q: I have read that the ARTAS System works best on straight black hair. Is this an option for gray hair? How about wavy or curly hair? – P.W., Fort Lee, NJ

A: The ARTAS robotic system can be used in patients with any hair color although in order for the robot to visualize white hair (or very light blond hair) the hair must be dyed. Curly hair is also not a problem as the donor hair in a robotic procedure is shaved to approximately 1 mm in length so a wave or curl is eliminated. In patients of African descent, where the hair below the surface of the skin may be curved, a slightly larger punch can be used. we have patients dye their hair the evening before or the day of the procedure. For convenience, only the hair in the donor area (back and sides) where the robot will be doing the harvesting needs to be dyed.

In patients who prefer not to shave or dye the entire back and sides of the scalp, we can perform the ARTAS robotic FUE using the long-hair technique. With this technique, you will grow your hair on the back and sides of the scalp a bit longer so it can cover the harvested area. On the day of the procedure, we will lift up the hair, clip a long thin band of donor hair and then extract follicular units from this limited region of the scalp. After the procedure, you can simply comb down your hair to cover the donor zone. The area that has been harvested (and possibly dyed depending on your hair color) will not be visible.

• Read about the ARTAS Robotic System
• Read about dying white hair in advance of Robotic FUE
• Read about the long-hair Robotic FUE technique

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Q: I have a diagonal scar in the middle of my donor area that I got during a childhood accident and I am concerned that it will limit my options for hair restoration. Will this type of scar prevent me from having either FUT or FUE? Do you recommend one or the other? — R.F., Upper West Side, NY

A: Traumatic scars in the donor area do not preclude us from performing a hair transplant. With an FUT/strip procedure, we can remove all or part of the scar when we excise the donor strip. In Robotic FUE, the ARTAS Robot can be programmed to avoid a scar during harvesting. In either procedure, we can improve the appearance of the scar by implanting follicular unit grafts directly into the scar tissue. The hairs will grow permanently in the scar, just like ones we implant in the recipient area, and the scar will become harder to detect.

It is important to note that transplanted hair will not grow in a thickened scar. If your scar is thickened, the doctor can thin it out (soften it) with injections of cortisone. They are usually repeated at 4-6 week intervals in advance of the procedure. The number of injection sessions required depends upon the thickness of the scar and your individual response to the medication.

The presence of a traumatic scar should generally not determine which type of transplant you have. That should be decided in consultation with your physician based on factors such as how much volume you need, how you intend to style your hair, how short you would like to keep it, how soon you need to return to strenuous physical activity, and other general considerations for a hair transplant.

We recently posted photos from a patient who had a robotic hair transplant with a scar in his donor area. The photos include images of his donor area (with scar) before his procedure, immediately after robotic graft harvesting and 11 days post-op. View this patient’s before after photos.

• View Patient RSI’s hair transplant photos
• Read about techniques used to fix scars
• Video: How Does the ARTAS Robotic Hair Transplant System Locate and Dissect Follicular Units?

Q: Why is using the robot to create recipient sites useful in a hair transplant? — S.K., Jersey City, NJ

A: The ARTAS® Robotic Hair Transplant system eliminates the inconsistencies inherent in creating large numbers of recipient sites by hand. The robot can create sites at a rate of up to 2,000 per hour. Although there is more set-up time compared to sites made manually, once the physician specifies the parameters such as punch depth, punch angle, and site direction, recipient site creation is precise and rapid.

One of the benefits of robotic site creation is that the distribution of grafts over a fixed area of the scalp can be exact. For example, if one wants to transplant 1,000 grafts evenly over 50cm2 of area, this can be done with great precision and with uniform site spacing. In addition, the physician can vary the densities in select regions of the scalp and the robot will adjust the densities in other areas so that the total number of sites remains the same.

Another benefit of the new technology is that the robot can be programmed to avoid existing hair and select which specific hair diameters to avoid. The robot is programmed to keep a specified distance from the existing hair to ensure that the resident follicles will not be damaged and that the distribution of new hair is even and natural. This computerized mechanism appears to be more accurate than what can be done by hand and, importantly, does not sacrifice speed in the process.

Q: I’m a 42 year old African-American woman and I’m losing hair on the crown of my head. Would I be a good candidate for a hair transplant? — E.E., Philadelphia, P.A.

A: Hair loss in the crown of an African American female can have several different etiologies, so the first thing to do is to make the right diagnosis. The most common causes of hair loss are androgenic alopecia (AGA) and scarring alopecia, also called ‘Central Centrifugal Cicatricial Alopecia,’ or CCCA. A biopsy is often useful to differentiate these two causes of hair loss when the diagnosis is unclear. A biopsy can also identify other, but less common, causes of crown hair loss.

AGA presents with a history of gradual thinning in the front and/or top of the scalp, a relative preservation of the frontal hairline, a positive family history of hair loss and the presence of miniaturization in the thinning areas. Miniaturization, the progressive decrease of the hair shaft’s diameter and length in response to hormones, can be identified using a hand-held device called a densitometer. If the diagnosis is AGA, then a hair transplant can be very successful provided there is enough donor hair.

CCCA presents as a progressive form of scarring alopecia that occurs almost exclusively in African American women. The onset of CCCA is very slow, typically developing over the course of years. CCCA starts near the vertex or top of the scalp and spreads in an outward direction. The involved area is usually smooth and shiny with decreased hair density.

Central Centrifugal Cicatricial Alopecia is diagnosed with a scalp biopsy performed in the area of hair loss. Those patients with CCCA are generally not candidates for a hair transplant procedure since the body may reject the transplanted hair. This condition is better treated with oral and injectable anti-inflammatory medications. Surgical treatment for cosmetic benefit may be an option in some cases after the disease has been inactive for many years.

• Click here to read more about Scarring Alopecias