I often see hair restoration forum members scorn young people in their early to mid-twenties who are considering a hair transplant. I’ve seen young guys who’ve had them and they dont “look bad.” Is it discouraged because the hair (both native and transplanted) continues to fall out post surgery due to genetics?
I will try to give a hair transplant surgeon’s point of view of this problem of “what age is too young to transplant?” For me personally, 23 is my somewhat “unofficial” cut-off age for transplanting a young man. I have made a couple of exceptions in recent years and done a 21 and a 22 year old, but only with very conservative framing of the face with a front-central forelock of hair to help out their appearance. Two other unofficial “rules” I follow in my practice is not to transplant the rear vertex or the side temple (sideburns) areas in men under the age of 35. This is because, if the man goes on to extensive hair loss, then these grafts will be sitting out “high and dry” by themselves without hair to support it in the temples and, even worse, will look like a “bulls-eye” in the vertex. Then you have a patient who is a social recluse and very bitter about ever having done it.
I would start by saying that a 19 or 20 year old is almost never mature enough to appreciate the whole situation. He knows one thing: his peers have full heads of hair and he is afraid he is losing his. At this age, when your social life and dating are so important, that young man will have blinders on to everything else. In such a situation, if he is a man who, because of family history or already extreme miniaturization, you fear he will someday be a Norwood VII, he is not going to appreciate the fact that any transplanting has to stay out of the rear crown area and out of the recession/temple areas, or that a “forelock” type of pattern is perhaps the best one for him in terms of avoiding an abnormal look later in life.
The second obvious reason is that androgenic alopecia or male pattern balding is progressive throughout life and you have no idea, when looking at a 19 year old or even a 21 year old, how bald he will be when he is 40 or 50. We do start to get some hints of where he will end up as the patient gets into his middle and late 20’s. For that reason, when I do transplant a 23 year old, I am always conservative and assume the worst case scenario will develop. I use a forelock design, which does connect to the sides, but with a definite gradient of density stronger in the front-central and tailing off as it approaches the sides. What I am trying to do is mimic a natural stage of hair loss that a significant number of males normally pass through on the way to balding. That way, anyone looking at them, even 20 years later, will not pause and wonder if what they see on his head is normal or not.
The corollary of not knowing how bald someone will be is not knowing how much “safe” donor hair will be available over the long haul. A lot of men also have what we call “nape thinning”, which is a loss of hair from the neck up into the lower occipital hair in back.
One final point: Like everyone else, I try to put all young men on Propecia (finasteride) for all the obvious reasons. It does not hold off the eventual hereditary pattern that man will get however, some of us think it puts it off by 8-12 years or something on that order. So, when a young man presents to see me at 23, 24, or even 26, who has been on finasteride for a few years, it is even harder to tell where he is heading because the finasteride masks what would normally be happening if the patient weren’t on it. Some people on these forums comment as though going on finasteride somehow confers some permanent benefit for the young man. That is not true. It’s great for holding on to or even increasing the “native” hair for several years more than it would normally be around, but it doesn’t change the eventual long term picture.
Mike Beehner, M.D.