Diffuse patterned hair loss (DPA) is characterized by hair loss (thinning) across the top of the scalp while the hair on the sides and back of the scalp remain intact. Because donor hair is taken from the sides and back of the scalp, those with a DPA hair loss pattern are often good candidates for surgical hair transplantation. Diffuse unpatterned hair loss (DUPA), on the other hand, is characterized by hair loss not only from the top of the head but also from the sides and back of the scalp. Because persons with DUPA hair loss have thinning on the sides and back, they are usually not good candidates for a hair transplant. DUPA is relatively uncommon in men but it is the most common type of hair loss in women. Both DPA and DUPA in men respond well to medical treatment using minoxidil and finasteride. Unfortunately, finasteride is not indicated for the treatment of hair loss in women.
Since 1993, minoxidil has been the most successful topical treatment for hair loss in both men and women, yet its exact mechanism of action remains unknown.
A 2004 review of minoxidil’s possible mechanisms of action (A.G. Messenger & J. Rundegren, 2004) suggests that the best evidence supports the idea that minoxidil causes hair follicles in the later phases of their resting phase (telogen) to shift prematurely into an active growth phase (anagen) sooner than they otherwise would; this causes rapid increase in hair growth. They also found good evidence that minoxidil works to thicken the hair by increasing hair diameter.
While minoxidil’s effects on other critical factors known to affect hair growth — such as cell proliferation, collagen synthesis, vascular endothelial growth factor and prostaglandin synthesis — remain uncertain, more recent research has found evidence that it may also suppress the androgen-androgen receptor responsible for androgenetic alopecia (Cheng-Lung Hsu, Jai-Shin Liu,An-Chi Lin, Chih-Hsun Yang, Wen-Hung Chung, & Wen-Guey Wu, 2014).
Understanding minoxidil’s exact mechanism of action remains today an important line of research both for the development of better hair loss treatments and for a better understanding of the biology of hair growth.
Q: I’ve heard that FDA added a description of reports of male infertility to the side effect labels of both Propecia and Proscar (finasteride). Is this a likely side effect in your experience? — S.S., Rolling Hills, California
A: Propecia (finasteride 1mg) may, uncommonly, lead to male infertility by changing the consistency of the male ejaculate as well as decreasing the sperm count.
Ejaculate is a combination of sperm produced by the testes and a viscous fluid made by the prostate. Since finasteride shrinks the prostate it make the ejaculate less viscous (more watery).
Most patients taking Propecia and trying to conceive have no issues.
If one is trying to conceive for 4-6 months and having difficulty, then it is reasonable to stop taking Propecia.
It is important to know that taking Propecia while trying to conceive will not lead to congenital deformities or issues with the fetus as long as the women does not come in direct contact with the medication.
Plug procedures, popular in the 1960s and 1970s, often resulted in an unsightly “pluggy” or “dolls head” look. In the past we tried to work around the plugs with fine grafts in order to camouflage them, but this proved ineffective. At Bernstein Medical, we now find it best to totally remove the old plugs, put them under a microscope, dissect them into smaller follicular units and then re-implant them. This process is called Combined Hair Transplant Repair. In this way, many of the cosmetic defects created by hair plug procedures can be partially or completely reversed.
Q: I have a significant amount of hair loss. Can a hair transplant make me look exactly the way I did before I lost my hair? — V.S., Fairfield, C.T.
A: In most cases, the answer is no. All surgical hair restoration procedures move hair – they cannot create new hair. Specifically, surgical hair transplantation takes existing hair from the donor area (located in the back and on the sides of the scalp) and moves (transplants) them to the part of the scalp that has lost hair. It is usually the case that there is not enough hair in one’s donor area to replace all lost hair. That said, in persons with extensive hair loss, the restoration can often produce a dramatic improvement in one’s appearance.
Q: How is robotic FUE different at Bernstein Medical compared to other practices?
A: The ARTAS robot assists in the first part of the follicular unit extraction procedure: separating the follicular unit from the surrounding tissue. The rest of the hair restoration procedure is done manually. Once follicular units are removed from the scalp they need to be trimmed prior to implantation, recipient sites need to be created, and the grafts must be placed in them – a time consuming, delicate process.
Because we are highly skilled in microscopic dissection, we are able to produce the highest quality grafts. In addition, all the other aspect of the procedure, including the long-term planning and design will be performed with the same high standards. With respect to the actual robot at Bernstein Medical, we use smaller instruments that result in less wounding to the scalp, it promotes faster healing time, and it improves the appearance of the donor area. We also have our computer programed to select the larger follicular units to obtain more hair with less wounds (holes) in the donor area – ultimately achieving a better cosmetic result.
Q: My hair is thinning, but I’ve been told I have too much existing hair to warrant a hair transplant. I heard that transplanting new hair into my thinned areas will lead to a loss of existing hair follicles. I was told to delay a hair transplant procedure until my density has further decreased. Is this true? — M.S., Maple Glen, P.A.
A: It is possible that you simply don’t need a hair transplant at this time one. If you have early thinning, it may be best treated with medication, or not at all. As you age, we will have a better idea of your thinning pattern and, at that time, a hair transplant may be more appropriate.
A hair transplant does not cause loss of hair follicles in the recipient area. The procedure may cause a temporary “shock” loss of the hair. Shock hair loss is a physiologic response to the trauma to the scalp which is caused by a hair transplant. Hair that is healthy is going to come back after some period of time – generally 6 months. Hair that may be near the end of its lifespan may not return. When a hair transplant is performed at the proper time, in the proper candidate, shock hair loss should just be an incidental issue.
Q: Is robotic FUE different in the number of follicular unit grafts one can extract compared to manual FUE? — R.V., Stamford, CT
A: We can extract (and transplant) the same number of follicular unit grafts robotically as we can manually.
The goal of a hair transplant is not to simply transplant as many grafts as possible but to achieve the best possible cosmetic result given the number of hair follicles in your donor reserve. Remember, this is always a limited supply.
While there is no difference between robotic and manual FUE in terms of the number of follicular unit grafts that each can extract, robotic FUE does differ from manual FUE in several important ways.
First, there is generally less transection of the hair follicles with robotic FUE, since the method is more precise. This enables us to obtain follicular units with less trauma to the grafts.
Second, while the robot is not necessarily faster than the human surgeon, the robot is much more consistent since, unlike the human surgeon, it never fatigues and the accuracy is maintained throughout the entire procedure.
Dr. Bernstein discusses how FUE instrumentation has evolved from the hand held follicular unit extraction punch to automated robotic follicular extraction.
The ARTAS Robotic System uses a small, window-like device called a tensioner to help hold the scalp in place and to help guide the 3D optical technology that locates and extracts follicular units.
