by Kevin Rands | May 15, 2016 7:52 pm
ISHRS Conference Crossfire. Two transplant surgeons debate whether or not a hairline transplant should be attempted in light of the fact that Propecia and Minoxidil have been shown to maintain hairlines in many people.Presenter: Dr. Marc Avram
Rebuttal: Dr. Matt Leavitt
Dr. Avram’s Published Comments
One of the advantages of hair transplantation is the long term growth of the transplanted hair. Over the past several decades, this advantage has been turned into a cosmetic disadvantage for tens of thousands of men who were transplanted at Norwood stages II and III along a frontal hairline or into a small patch of Alopecia in the vertex, who then progressed over time to a Norwood V-VI resulting in bizarrely implanted grafts in frontal-temporal hairline and vertex of the scalp. Over the past decade, minoxidil and finasteride have gained FDA approval for Androgenetic Alopecia. Both are effective in maintaining existing hair. This has resulted in in some hair transplant surgeons advocating a “more aggressive” hairline design and candidate selection. I believe this should not be the method that surgeons advocate. This approach will obligate patients to a lifelong commitment of medication. All hair surgeons should assume patients will progress to at least a Norwood V and plan surgery with this assumption. This approach will allow increased density from surgery by maintaining existing hair, but also give patients the freedom to continue or discontinue medication and have a long term natural appearing head of hair.
Dr. Avram’s Presentation
Dr. Avram opened with discussion on the statistics covering the percentage of men who are currently losing their hair. He identified hair loss as a progressive process and discussed reasons why. He introduced Minoxidil (Rogaine) and Finasteride (Propecia) as two treatments currently available on the market, and identified them as products that can help stop hair loss and promote hair growth. He pointed out that exact method is still not understood with Minoxidil. He presented the 5 year minoxidil study, and stated that finasteride is considered a safe medication with no blood test required, and no allergic reactions. The use of both Minoxidil and Propecia was discussed. He stated that there were no controlled trials but both are considered synergistic and possibly the “ultimate therapy” for MPB. Maintenance is a key philosophy in treating hair loss today, and regrowth is considered an added benefit. Among hair restoration surgeons, the concept of the hairline is considered an “ill defined transition zone”. Realistic expectations for hair lines based upon today’s technologies is recommended. Natural and undetectable hairlines, based on current technology, are realistic to expect. Hairline location is different for each patient. When it comes to motivating a patient to use Finasteride or Minoxidil after a hair transplant, this should be left completely up to the patient. The use of medications should always remain elective.
Dr. Leavitt’s Published Comments
Hair Restoration remains the only permanent solution to hair loss. However, hair transplant surgeons have always been faced with the fact that there is no way to predict continued hair loss in a patient. Medical treatments such as Minoxidil and Finasteride (Propecia) can help stabilize hair loss but patient long-term usage cannot be guaranteed. This rebuttal will focus on the impact of these treatments in terms of hairline design and the long-term range hair restoration plan for the patient.
Dr. Leavitt’s Rebuttal
Dr. Leavitt feels post transplant patients should be placed on Finasteride and Minoxidil for 6 months to a year to see how they respond. He pointed out that these treatments do not work in everyone, and long term patient usage cannot be guaranteed. Younger patients are most devastated by their hair loss, in the age group of 20-30. Psychologically and Sociologically it can and does affect them much moreso than others. These younger patients are typically much more impulsive, and willing to sacrifice everything for today to avoid what may be coming tomorrow. At the same time, at this point in their lives, the financial stability is not optimum. Setting realistic expectations with younger patients is very important.
The question was raised: Do we arbitrarily do a hair transplant procedure, or do we suggest that they wait? Every person should be evaluated on an individual basis, including taking a history and conducting a physical exam. There are very many variables, including the patients goals, and over time their concerns and expectations may change. Dr. Leavitt suggests attempting to stabilize the patients hair loss in some fashion, using the available proven treatments, and he suggests doing so sooner than later. If this does not work, after a 6 month to 1 year trial, he suggests using the most conservative procedure that will achieve the patients goals. It is the duty of the surgeon to make effective risk-to-benefit judgments. Some patients should ONLY use Propecia and and Rogaine, and not have a transplant. Others should only have conservative transplants, and yes, hairlines can sometimes be lowered via the medications alone.
Surgeons should examine the patient, and educate the patient extensively on their expectations, what’s involved in committing to medical treatments, etc. Finasteride patient satisfaction is upwards of 90%. 277 more hairs per square inch than those not taking it. The ultimate solution then is to treat that patient as an individual, and if you can get that patient started on Finasteride or Minoxidil you can then do an evaluation for potential future surgery or other options for them. You will provide them with hope, and you will have effectively counseled and helped them. You need to listen to the patient, use your experience, and if you do this correctly, you can help them lower their hairline.
In closing Dr. Leavitt asked the audience this: If your son walked in, devastated from no response to Finasteride or Minoxidil, wouldn’t you consider performing a hairline procedure to help lower it for him?
Open Debate
Steven Gaufman: Is there the possibility that donor taken from the back of the head might end up being hair that is being afflicted by DHT.. and might eventually fall out later, after having been transplanted?
Response: No. Donor hair is typically not taken from hair that is too high up.
Steven Gaufman: Yes but with younger patients, we don’t know which hairs are going to eventually be afflicted by DHT. We can’t know how high up is safe to go. On another topic – How do you encourage patients to continue taking the treatment?
Dr. Leavitt: Younger patients are typically very motivated – living in fear of losing their hair. Is it possible that at some point in their lives their enthusiasm may decrease? Yes its possible. They constantly ask if they can take higher doses of Propecia. If they miss a day they get very upset. The slightly older patient is sometimes less motivated, but its really up to them.
Dr. Avram: It depends entirely on the person
Walter Unger: Most of the patients who you would prescribe these treatments to are there because of frontal hair loss. Most people here don’t want to treat the crown, yet the studies I hear at these meetings are all studies done on the vertex area. Everyone should recognize that when you give these drugs for frontal loss, there is little evidence that you’ll affect rate of hair loss frontally or regrow hair in the front. There is a lot of people saying that the use of Minoxidil and Finasteride complement eachother. Where are the studies that show this?
Dr. Avram: There are no studies.
Walter Unger: The audience should remember that.
Dr. Avram: The feeling is based on user experience, and the conclusion seen via user experience is that they are probably synergistic. I tell everyone that I don’t expect them to grow hair in the front, but maintenance is absolutely possible with these treatments. Especially women using Minoxidil. It will help slow down and maintain the hair.
Dr. Leavitt: Finasteride does have some mid-frontal studies done on it as well.
Dr. Bauman: My concern is advocating a lower hairline in a patient who says he will use Propecia and Minox faithfully, and later he chooses not to. How can they commit for life to something like this? I would caution that people shouldn’t get the idea that we can really lower a hairline, because 20 years form now they’ll end up on the complications panel. What patients do you feel comfortable lowering the hairline for, if they are not on these medications?
Dr. Leavitt: There are risks with everything. I would rather take the risk than have someone with permanent scarring for their whole life. There are so many variables involved, you can either turn your back on people who are very good candidates… we don’t know where family history is going to go, and you have to use your experience and judgement.
Bernie Nusman: My main problem with the young patient is the patient who comes in with crown MPB and trying to convince them why they should NOT have a procedure done, and how medical treatment might be suggested.
Dr. Avram: Young patients with that kind of hair loss – they should use medication.
Dr. Leavitt: I try to get patients on medication for 1 year to see what type of result they get. Many times they are satisfied after that. We try to slow down the aggressive nature and concerns. But would I be willing to do the 800 grafts for a person in their mid 20’s who is thinning, absolutely.
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