Author: Dr. William Rassman

Many times the transplant does not provide enough hair to cover an extensive balding pattern because the donor supply density is too low for the high demand of the balding pattern. When that happens, the surgeon who is skillful with both hair transplants and SMP will know how to use the transplants to form a good foundation so that the SMP will make the hair look much fuller.

Here is an example: The picture on the right has the exact same amount of hair as the picture on the left except that SMP was added to fill in the thinning hair.

This man built a frontal hairline with 2300 grafts and 1600 grafts on his temple peaks. He has since added another 2300 grafts to double up the density of his frontal area. The goal here is to use a hair system behind the hair transplant to cover his Class 7 pattern of hair loss. Hair systems can often be detected, but with a transplanted hairline in front of the hair system, it will not be easily seen. He, unfortunately, has fine hair. That is why it will take a lot of grafts to create a thick frontal hairline. If his hair was medium or, even better, coarse in character, he might have achieved his goals with far less grafting and with thicker-looking results. Fine hair has limitations, especially compared to a hair system. The photo on the right shows a hair system behind his leading-edge transplant with his hair pulled back. I have been involved in many such attempts; however, most of the men who started the process didn’t like the lower density of the transplant when compared to the hair system. That can be overcome with more transplanted hair in the frontal 1 inch.

We have been using SMP (with our classic stippled pattern) and microblading, resulting in a nice effect as shown in this photo (before on top, after on bottom). This patient still has a very thin look, so to obtain a fuller look, he should get a hair transplant.

Before (Above), After (Below)

Thank you for posting my comment on your blog this week. I re-read my comment and thought it may have been unclear so I wanted to clarify a point.

Haber’s original data set showed some peculiar results for the finasteride (F) group versus the control (C). It is very widely accepted that finasteride impairs sexual functioning compared to the control but that was not what Haber found in his study due to the research design. I don’t really know how to put it any more nicely unfortunately. According to the ASEX score, (F) had only 24.3% with some sexual dysfunction versus 38.4% for (C). Libido was similar between groups with (F) showing 22.8% with libido loss and (C) at 22.2%. Reduced sexual functioning was much lower for (F) at 17.8% versus 24.2% for (C).

Keep in mind there is a small amount of missing data in the fin group but it shouldn’t matter that much. Because of the way they excluded patients who stopped taking the drug, likely due to side effects, the data appears to show that on average finasteride improves sexual functioning but that isn’t true because the data isn’t properly randomized. Everybody basically knows that finasteride causes sexual side effects and the data is growing ever stronger that a small group gets persistent side effects. When their data showed the opposite effect and they didn’t stop to question why, they decided to completely ignore the data and conclude “there was no difference in loss of libido, reduced sexual performance, or the number of men with an ASEX score indicating sexual dysfunction.” I’m really not sure how this article got published but the authors appeared to have willfully distorted the data and study design to meet their presumed conclusion.

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My experience parallels Dr. Haber’s experience as well as another few dozen doctors with lots of experience. From a first hand perspective, I take it and don’t have ED or libido issue and my son took it and got an increased sexual drive. My patient’s parallel the official reports with about 2-4% ED and libido issues, possibly slightly higher. I have written thousands of prescriptions for finasteride and that makes me more of an authority than those who look in from the sidelines.

I was advised by a dermatologist NOT to have a hair transplant because of the reasons mentioned above: shock loss and possible acceleration of hair loss.

If the reader is over 26 and is willing to take the drug finasteride, the risk of acceleration of the hair loss and shock loss are mitigated.

Well you should never have had a transplant that young especially with this much hair loss. Any good doctor would never do this because the potential for you to keep going bald is too high. In other words, you only have 6000-7000 transplantable grafts total. You may not have grafts to cover future loss later. The sad fact is the best age for a hair transplant is in the 30s. Now you may be faced with shaving your head and if you have fut, you will have a scar. It’s possible you can have scar revision if it’s bad. You can also have what’s basically a hair tattoo where they take a shaved head and place tiny dots to simulate hair follicles as well as hide the scar. You have other options but not everyone has the correct head or hair for a transplant.

This man is right on!

I realize that everyone is looking for the magic treatment that is not expensive, but the point of my post was that there are risks that most of the users do not appreciate. I have no first-hand experience with such risks. Infection risks are theoretical, and they could occur with disastrous consequences in the ‘worst case’ I can think of.

I figured I would offer my opinion here since the reader asked for a reply from somebody who had a similar experience and the response doesn’t really answer the question. I used Propecia about a decade ago and developed general sexual dysfunction (not just ED) that continues to this day.

Unfortunately nobody can provide you with the reassurance that you say you desperately need. You won’t know for sure if the side effects will be permanent unless you stop taking the drug. The doctor highlights that you risk “catch up hair loss” which provides an incomplete picture to the decision you need to make. On the other hand, if you continue taking the drug you risk “catch up side effects” because the side effects can get worse than they are today. You need to think about what is most important to you and how much you value your general health versus your hair in order to make a smart decision. There is uncertainty in making a decision like this which is stressful but the right decision is different for everybody.

In my practice, when a new patient goes on finasteride and has sexual side effects, I tell him to stop the medication. I have them report back to me about their sexual side effect which usually goes away within a month or so. I have not seen any patient tell me that after stopping the drug, the side effects continued.