A: Minoxidil has been prescribed (off-label) in combination with other medications, such as topical retinoic acid (Retin-A), to enhance its penetration into the skin and thus increase its effectiveness. This combination of medications, however, can significantly increase the absorption of minoxidil into the bloodstream and may increase the risk of potential side effects, including changes in blood pressure and severe scalp irritation that has, on occasion, led to scarring.

If person wants to add Retin-A to the minoxidil regime, the Retin-A should be applied only once a day, since the Retin-A will bind to the skin and will last for at least 24 hours.

Applying Retin-A more frequently will not increase its effectiveness (in facilitating the absorption of minoxidil); it will only increase the incidence of side effects. Retin-A can be applied to the scalp at the same time as Minoxidil, or by itself.

Retin-A should not be compounded with minoxidil (mixed together by your pharmacist or your doctor) for the following reasons:

1. Minoxidil works best when used twice a day. Retin-A is best used once a day.
2. Using Retin-A twice a day wastes money and increases the incidence of side effects
3. If you develop side effects from the Retin-A, it is best to stop only the Retin-A. If they are compounded, you would need to stop both and will lose the benefit of minoxidil.

Explore the pro’s and con’s of Minoxidil — also known by its over-the-counter product Rogaine — at the Rogaine/Minoxidil page on the Bernstein Medical – Center for Hair Restoration website or by viewing minoxidil-related posts on the Hair Transplant Blog.

In the past days, there might have been many physicians who did not care much about the importance of the follicular unit and they have only cut the grafts to size. Now, every hair transplant physician believes the importance of follicular unit, and there is no one who cut the grafts to size ignoring each follicular unit.

However, there are some physicians who shout that a hair transplant procedure can be called FUT only when people use all single FU exclusively, and the procedure cannot be called FUT, if mixture of single FU and double FU are used in a session.

I would like to ask you, if you could accept the usage of combination of single FU and double FU under the name of FUT, as long as the grafts were cut according to each FU and intact FU are used throughout the procedure. Could you accept easing of the very strict definition of FUT, which you published about 15 years ago? Could you agree to use mixture of single FU and double FU under the name of FUT?

A: Thank you for the kind words. In thinking about hair transplantation in general, it is important to consider that a hair restoration procedure spreads hair around and, as a result, the transplanted hair will be less dense than the person’s original hair. Therefore, one would never want grafts larger than the largest original follicular units or the results will not look natural. The artificially large grafts will stand out in relatively thin surroundings. If one were to try to fix this by transplanting the doubled FUs very close together (over one or more sessions) one risks running out of grafts for other areas of the scalp. In other words, you can’t fool mother nature.

For example, if a person has thin hair and has only 1-, 2- and 3-hair units occurring naturally in his scalp, then creating 4-hair grafts (by combining two 2’s or 1’s and 3’s) can result in an unnatural, tufted look. Doubling larger follicular units also necessitates larger wounds to receive the grafts which defeats one of the main advantages of FUT, namely to minimize recipient wounding.

That said, it is not unreasonable to place two 1-hair FUs in a single site (if there are extra 1s from the FU dissection) in order to increase density in an area and to eliminate an extra wound.) We do this for crown hair transplants when we are not doing a hairline and there is no need for 1-hair grafts. However, this is the exception.

Technically speaking, anything other than transplanting individual, naturally occurring follicular units is not FUT. However, a physician should make modifications to the procedure for the specific needs at hand. This is the art of medicine. By understanding and applying the underlying principles of Follicular Unit Transplantation, rather than being limited by its nomenclature, the physician will serve his patient best.

The Bernstein Medical – Center for Hair Restoration website is one of the best resources on the internet about Follicular Unit Transplantation. So in addition to exploring the Hair Transplant Blog to learn more on this topic, make sure to visit the Follicular Unit Hair Transplant section of the website to read detailed information about the procedure, follicular units, hair transplant grafts, the donor area, and much more.

A: The crown can be transplanted first in patients who have very good donor reserves (i.e., high density and good scalp laxity). Otherwise, after a hair restoration procedure to the crown you may not be left with enough hair to complete the front and top if those areas were to bald.

Cosmetically, the front and top are much more important to restore than the back. A careful examination by a trained hair restoration surgeon can tell how much donor hair there is available for a hair transplant.

For more information on this topic, see my publication on surgical planning of hair transplants, “Follicular Transplantation: Patient Evaluation and Surgical Planning.”

A: Many scientists feel that adult stem cells house the answer to cloning (regeneration) of hair follicles. One of the problems of hair cloning, however, is that the cells, once duplicated, “forget” that they are hair follicle cells.

It has recently been discovered that the Lgr5 gene, located in stem cells, appears to contain the “global marker” present in all adult hair follicles. If Lgr5 gene is the “calling card” of the cell, it may carry the cell lineage and shoulder the responsibility of signaling to surrounding stem cells what they are actually supposed to do as they multiply.

Recent experiments have shown that these Lgr5 cells maintain the cells ability to differentiate as hair follicles after many generations of being multiplied in the test tube and, therefore, have the potential of serving as the building blocks of entire new hair follicles. The successful exploitation of this gene would eliminate a major barrier to cloning hair.

Reference
Haegebarth A, Clevers H: Wnt signaling, lgr5, and stem cells in the intestine and skin. Am J Pathol. 2009 Mar; 174(3):715-21.

For more on how hair cloning works, visit the Bernstein Medical – Center for Hair Restoration page on hair cloning.

A: In the International Journal of Cosmetic Surgery and Aesthetic Dermatology (Vol. 5, Number 2; 2003), a study on low level laser therapy (LLLT) was conducted which indicated that there was a 55% increase of growth (hair count) in the temporal area as well as 64% in the vertex of the female subjects who were treated with LLLT for hair loss. The study also indicated a 74% increase in the hair counts of the male subjects in the temporal area and 120% in the vertex region. These results would initially indicate that LLLT works better in men than in women, but there were four times as many men in this study so the results might be different in a larger test group.

However, even in this notably smaller female group, the tensile strength of the hair increased dramatically over the tensile strength observed in the male subjects after treatment. This would indicate that, at least in this study, there was not only an increased hair count in women, but the tensile strength of that hair was greatly improved as well. This would be initially indicative that LLLT may be found to be more beneficial to women than to men.

It is important to note that this study was published in 2003. Further studies need to be conducted to confirm the initial results and to further elucidate the possible mechanisms of low level laser light therapy in both men and women with alopecia. As important, long term data needs to be accumulated to show the continued efficacy of this treatment. It had been our clinical experience that LLLT is not as effective as one would assume from the results of the initial studies.

Visit the Bernstein Medical – Center for Hair Restoration page on Laser Therapy for more information on the topic, or read more on laser therapy at the Hair Transplant Blog.