Hair transplant with only 1,500 grafts implanted. What are my options to fix the new 5cm hairline? (photos)

Question

I am 22 years old male with aggressive hair loss. I have been using propecia since I was 17 but the hair loss has not stabilised. I got a transplant at a reputable clinic in the local area. 1500 grafts were implanted. All the men in my family are NW6. I was told that I could use 10,000 scalp grafts and 6-8 thousand beard grafts. Since then I have been told that this is not a viable option. Right now my new hairline is at 5 cm. What are my choices? Was this ethical abuse?

Jae Pak, MD · Answer

If you had surgery already and you are concerned about future hair loss, it is best to see a doctor in person for a consultation and Master Plan of what can be done.

Sanusi Umar, MD · Answer

At your age, any transplant done should take into account the fact that your hair loss would progress beyond what is presently evident. You should understand that future hair transplants would be necessary for this reason. The hair transplant should not be undertaken until you are very reconciled to this idea. Your transplant must be very conservative at this time. Where these not discussed with you prior to your hair transplant?

Parsa Mohebi, MD, FISHRS · Answer

I usually plan a much more conservative hairline for patients with any young patient who has the following:Family pattern of advance class of hair lossSignificant scalp hair miniaturization in a large area of scalpMy hairline designs may have been more generous in recent years.  That is thanks to the advancements in bears to scalp hair transplant as it present a new reserve of hair for some patients. You need to be evaluated with full face pictures to see what options you have in the future.

Amiya Prasad, MD - Account Suspended · Answer

Thank you for your question. You’re 22-years-old, and recently underwent 1500 hair grafts in what appears to be the frontal hairline based on your photo which was apparently strip or FUT surgery. You state you’ve had hair loss since age 17, and have been on finasteride since that time, and say it hasn’t stabilized your hair loss. Men in your family are Norwood 6, and you were advised you would need about 10000 more grafts from your donor area, and 6000-8000 from your beard. You’re getting conflicting opinions, and now you’re concerned if the procedure was done ethically.
I can discuss a little my strategy for patients like yourself who we see in our practice. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Hair transplant has been a very big part of my practice. I am the founder of TrichoStem™ Hair Regeneration Centers, a system we developed to help men and women with genetic pattern loss using a non-surgical approach for hair thinning we developed over the past 7 years, which actually evolved from improving hair transplant surgery.
We’re dealing with a controversial area with transplantation in younger men. My perspective is the unfortunate reality of hair loss treatment as it is generally practiced, is if you go to a hair transplant center or clinic, you’re essentially judged as to whether or not you are a good candidate for transplant. I would say the overwhelming majority of transplant clinics, you aren’t going to be someone who they will want to manage and take care of in the long-term, as it becomes more of a transactional approach. If you’re a transplant candidate, they’ll do a transplant; if you’re not a transplant candidate, they’ll tell you, go somewhere else. In the medical side, patients typically go to dermatologists who offer them finasteride and minoxidil, then the rest is basically limited. 
For many years, we’ve had this treatment called Hair Regeneration which evolved out of our desire to help people with hair transplant. What you’ve probably learned from your own experience is the donor area is limited, and the frustrations with hair transplant are also transplanting so many hairs from this donor area at one given time, and the survivability of the transplanted hair. We use a material called Acellullar matrix to help improve the survival and viability of transplanted hairs, as well as improve the appearance of the donor scar. A fortunate side-effect was thinning hairs became thicker. Based on that observation, we’ve spent many years developing a process of injections in a way that can stop progression, or at least significantly slow it down, prolong the growth cycles, thicken thinning hair, and reactivate hair that’s not growing. This has been a significant improvement in our approach to helping people with genetic pattern loss.
For younger males, by definition, having a younger onset of hair loss, you fall into a more aggressive hair loss pattern. Men in your category are more sensitive to dihydrotestosterone or DHT. You’ve been on finasteride and feel it hasn’t stabilized, but consider in actuality that you probably slowed down your progression by reducing the level of DHT. Unfortunately, the nature of your hair loss is such that the growth cycles are shorter. Therefore, even with the prolongation of the benefit of a DHT blocker, your hair growth cycles are stopping earlier than before puberty, and resulting in this progression which is different from your contemporaries. The question we always have to ask is why 80% of your contemporaries still have hair. As you enter your 30s, 40s and beyond, the percentage will grow of male pattern hair loss. 
It has been my observation that there are two groups of men in their late teens to early 20s who develop hair loss. One group has a more highly aggressive and more advanced hair loss, which I think is likely the category you fall in, and the other group has an early onset, but with moderate progression with diffuse thinning. They may still hold onto hair longer and get into their 30s, and still have significant hair loss, but it will happen more slowly. In your category you may lose hair faster because of your early age of onset. 
With Hair Regeneration, we’ve been able to help people in your category prolong the growth cycles, and get past several years, and up to 5 years of benefit. Differentiating the highly aggressive to the moderately aggressive, I would say the moderately aggressive tends to last longer with our injection treatment compared to the people who are very highly aggressive, which we discuss in consultation. 
For the options you have moving forward, I would say you are almost stuck because you now have taken that first step of doing a transplant. I expect you would maximize or continue taking your finasteride on a regular basis. As far as future transplantations are concerned, it depends a lot on how much more hair you lose, and in what timeframe. 
Generally, from my training in facial plastic surgery and studying hair transplant, and for the decades that followed, it is the general standard in our community to not operate on someone who is young because of their relative rate of progression, and what is the desirable outcome and acceptable outcome.  When we think of someone who comes in in their 40s and want a hair transplant, they can handle a relatively smaller grouping of hair that can look appropriate for their age group. We’ve seen patients in our practice well into their 30s who have had 4 transplants, and the top of their scalp looks like they barely have any hair, and they have very wispy hair. 
There are options that exist beyond these numbers, especially with the beard hair option of body hair transplantation. Although we don’t currently offer that in our practice, I have seen very good results, and it might be a strategy that will help you maintain a certain amount of coverage as you get older. 
The question about ethics is not appropriate for me to give you an opinion on. From my perspective, it’s not about ethics, but about what kind of results I can deliver to my patients. I think it’s critical you get the maximum benefit of your current treatment strategy. There may be a value for you to consider something like Hair Regeneration to help enhance the benefits of finasteride. We also help people who have gotten transplants elsewhere, and we’ve been able to improve the quality of their hair transplant results. 
Learn more about these other options, and discuss your concern with your surgeon. Hopefully, finasteride will continue to work for you. We’ve had history from patients where they said they’ve lost a lot of hair in terms of their progression, then were stable for a while, then started losing again. One can hope that may be the case for you so you can go into your 30s without significantly more loss, but it’s very difficult to predict the future. A lot of these patterns I’m describing: young highly aggressive, young moderate progression, are based on reviewing the patients’ history and looking at their scalps at different stages, as opposed to trying to predict from one point forward. The early age of onset is certainly an aggressive pattern. I hope that was helpful, I wish you the best of luck, and thank you for your question.This personalized video answer to your question is posted on RealSelf and on YouTube. To provide you with a personal and expert response, we use the image(s) you submitted on RealSelf in the video, but with respect to your privacy, we only show the body feature in question so you are not personally identifiable. If you prefer not to have your video question visible on YouTube, please contact us.

William Rassman, MD (retired) · Answer

At 22, I would not consider you a candidate for a hair transplant because your final hair loss pattern will not have evolved.  I generally wait until a patient is at least 25 before recommending a hair transplant and would often try medications first to try to stop it or reverse it. 10,000 grafts from a donor area is a high number of grafts that requires a very high donor density to be present; however, since you started the process, you should slow down and wait for the transplant to grow out, Consider getting another opinion. Below is a picture of a young man on the drug finasteride with a  complete reversal of his balding. Even at this stage, you might consider this

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