Part 2
Medications and Hair Transplants
Interviewer: Do you recommend that patients continue using treatments like minoxidil and finasteride even after they’ve had a hair transplant?
Dr. Bernstein: I don’t usually encourage people to use minoxidil. The reason is that it is irritating and it’s pretty fussy. People often get tired of applying it and stop using it after a couple of years, or they only use it once a day so it doesn’t really work well. And I find that minoxidil doesn’t offer a lot of benefit to someone who has had a hair transplant. I usually use minoxidil if someone wants to do everything they can to prevent hair transplant surgery. If one has early hair loss and they’re already on Propecia, we will suggest Rogaine.
On the other hand, we suggest Propecia for almost everyone that we consider for hair restoration surgery. Those that have really extensive hair loss would be the exception. The reason for that is twofold; one, is that it prevents the extension of the hair loss so that hopefully they’ll need less hair restoration surgery, second, if they have existing hair in and around the area of the hair transplant, the finasteride will help to hold that, because some of that hair can sometimes be shed as a consequence of the hair transplant procedure.
Interviewer: Do you recommend any of the hair loss treatments, like dutasteride for example?
Dr. Bernstein: I generally do not recommend dutasteride (also known as Avodart) because we do not have enough information about its long-term safety. Although it has been approved to treat prostate enlargement, the trials with dutasteride for the treatment of hair loss were discontinued. We know it is more effective than finasteride, so one would assume that the incidence of side effects was much greater – but we don’t really know. I think that in special circumstances, it may be appropriate. But, in general, we use Propecia. Over time, if Propecia doesn’t seem to be working well, we will consider increasing the dose.
Hair Transplant Megasessions
Interviewer: Getting back to hair transplantation, in your own practice, do you perform these so-called “megasession” hair transplants and, if so, how many grafts do you use in one hair restoration session.
Dr. Bernstein: It depends upon the patient. We always try to complete the hair restoration in one or two sessions. However, once you get to very high numbers of grafts, there is a point of diminishing returns where you risk having a greater donor scar and you risk poor graft survival. The concept of “megasessions” was coined by Dr. Rassman about twelve years ago and it initially started as a 1,000-graft procedure, then megasessions were 1,500 grafts, then 2,000, then 2,500. Now people talk of megasessions as 4,000-graft procedures. In my view, for most patients, that is often too many grafts to do in one hair transplant session.
A procedure around 2,500 grafts is enough to cover most Norwood Class 6 patients and you don’t have any significant risk of a wide scar. You don’t have a risk of what we call central necrosis where the grafts outstrip the blood supply. And the grafts are not out of the body too long. Once you get to a session of three, four thousand grafts, the hair transplant procedure takes twelve, fourteen hours. And we know that the survival of grafts kept outside of the body for over about eight hours starts to decrease.
The other issue is that that there’s often a lot of variability in the hair transplantation surgery. Sometimes patients are more vascular i.e. they tend to bleed more than others. I this situation, the grafts have a tendency to elevate when you put them in and they can try out and die. And all those factors can be dealt with when you’re performing large sessions. But when you’re doing very, very large sessions and pushing the envelope, if things don’t go flawlessly, then you’re going to have problems with hair growth. And you can’t always anticipate those problems before you take out that strip.
What we try to achieve is to have a one-to-one correspondence between what we take out of the donor area and what ultimately grows.
Our goal for the first hair transplant session is always to cover the entire area that you want to cover, try to minimize scarring and maximize hair growth. And for most patients, we can usually accomplish that in a hair transplantation session of about 2,500 grafts, although we will do more if a person has high density, a very large bald area.
Another thing that is very important, but often overlooked, is that sun damage very often will compromise the blood supply and so people with long-standing baldness also have chronic sun damage on their head and that will really limit the amount of grafts you can do safely in one hair restoration session. So it’s really important for the physician to assess the patient carefully before they do large hair transplant sessions.
Interviewer: Right. Sun damage matter was something that I hadn’t considered.
Dr. Bernstein: It is something that’s actually very significant. Most people think that it is important not to get sunburns or sun after the hair transplant surgery. That is important, but the most important thing is the chronic sun damage and it’s not always presents with growths on the skin. It presents as a fine wrinkling or a change in skin texture or color. This is called elastotic change where the sun actually changes the dermis, the connective tissue, and alters the blood vessels. It makes the blood supply much more tenuous than in a healthy scalp – and less able to nourish large numbers of closely packed grafts.
Interviewer: What was the name of the condition that this can lead to?
Dr. Bernstein: It is called central scalp necrosis. The blood vessels to the scalp come from the sides. So the more sites you make, the more interference there is with this blood supply. And if the scalp is already compromised from sun damage, then it is possible for the grafts not to get enough oxygen into the central part of the scalp and you can get poor growth. And it’s not always an all-or-nothing phenomenon. Sometimes you get sub-optimum growth and the hair transplant doctor just doesn’t know what it’s from.
Interviewer: That’s a fairly rare situation, though, correct?
Dr. Bernstein: It’s rare to actually get necrosis where the skin dies, but it’s actually relatively common in surgical hair restoration to get poor growth in the central part of the scalp from when dense packing is done in areas of sun damage.
Interviewer: And then you take that into consideration when you do a hair transplant?
Dr. Bernstein: Yes, I think people often get obsessed with these numbers and their focus is on getting 3,000, 4,000 plus grafts in one session – rather than a great looking hair transplant. I like to underscore this issue by retelling the story of Pinocchio where he wants the nickel because it is bigger than the dime. You know, more is not always better. And I think that a hair transplant is serious business and you only have a limited amount of donor hair. I think that what you want to do is to always minimize scarring and maximize growth. These things are not always accomplished when hair restoration surgery is pushed to the limits.
That said, small hair transplant procedures that sometimes are performed only because the doctor doesn’t have enough staff or doesn’t have adequate technique is also bad and is on the other end of the spectrum. Multiple procedures lead to more scarring and it’s just an inefficient use of the donor area.
There is an optimal size and it’s different for each patient. We really want to get the hair transplant surgery done as quickly as possible, but not so aggressively that you risk growth.
Interviewer: Right. And you mention that the number 2,500 grafts is typically enough for someone at a Norwood Level 6?
Dr. Bernstein: A Norwood 6, yes.
Interviewer: That’s actually pretty encouraging because that’s obviously very high up on the Richter scale of hair loss –
Dr. Bernstein: Right. And again, that’s in one pass. Generally, for a Norwood 6 patient, what we would do is 24, 25 hundred grafts in the first hair transplant session and then you let that grow in and then a year later you do a second procedure of maybe 1,800 or 2,000. And that person is now getting 4,400 grafts and they’re pretty well set.
If you look on our website, you can see hundreds of hair transplant patients that have been treated like that who look fabulous. And these patients will have very fine donor scars and they’ll also have some grafts in their back pocket in case they lose more hair down the line so they’re not exhausting the donor supply. And I think that hair transplant patients often get their donor supply tapped out very early on and then as they have hair loss down the line they’re going to be stuck.
Another issue is that in order to do very large sessions, 3000+ grafts in one session, a person must have a completely bald area or their hair must be shaved so that the procedure can be completed in a reasonable amount of time – so that the grafts are not out of the body too long. Most hair transplant patients, particular in the New York area, just can not go around with their head shaved. I can readily to a procedure of 2500 grafts working though a persons existing hair.
So I think that the idea is to make someone look as good as possible with the smallest number of grafts, not with the most – and to maximize graft survival. And this should be the goal of the hair transplant surgery.
Interviewer: Right. Good point, actually. You know, it really puts things in perspective.
