From Reddit: So, I recently did a AMA on hair transplant, answered many questions and reacted to several people’s stories. I want to make something clear to everybody interested in or planning a HT. Fin is mandatory. Unless you just want to correct a shitty natural hairline and have solid reasons to believe you have no MPB in your genes, finasteride is a must do. I mean, use common sense here: if you have receded from NW1 to NWX over the years, what do you think is going to happen over the next decade? Hairloss doesn’t just stop at 30, 40 or whatever. At best it slows down.
So, if you do a transplant, especially at young age as I did, and don’t prevent further loss you are at risk of being in a situation aesthetically far worse than just balding. You are literally at risk of getting thinning or bald spots behind your transplanted area. And you cannot work you way around it:
You cannot do surgery after surgery over the years to maintain a decent set of hair. I mean, you can… but this is totally sub-optimal. First, because you only have a certain amount of donor hair. At top density with no diffuse you have in between 9 000 and 10 000 donor grafts. That’s a a lot. But if your crown balds and get diffuse thinning all over (which is usually the case of people considering HT) this easily drops down by 50 or 60%. You cannot fully compensate it with body hair. Unless you are a gorilla you don’t have tons of body hairs and their regrowth rate is way poorer than actual hair (around 60% for chest hair). Second: because you would have to wait to get significant balding/thinning to perform another operation (see point below) so you would look stupid in the meantime. And third: it would cost you a fortune, especially if you are planning several op because you would want a top doc that would take extra care of your donor zone.
You cannot merge grafted hair into the native hair to give you some leeway in case hairline recedes further back. This is not how it works. Unless you have a severe lack a density you cannot plug follicles between the original ones. There is too much risk of damaging the latter, so no decent surgeon will agree to do that.
That being said, I think HT are great. I also think it is okay to have it young and potentially have several transplants if required, but imo that can only be done once you max-out the preventive treatments for hairloss.
I suggest the use of finasteride in most men who do hair transplants with us under the age of 35. That is when the hair loss is most at risk, more the younger you are. A condition called Shock Loss occurs after a hair transplant in younger men who find that they often lose a great deal of their miniaturized hairs after the transplant, thereby accelerating the loss factor. Finasteride usually prevent this from happening. Many men who refuse to take finasteride, have never tried it and assume that they will get sexual side effects, which of course if they believe that, they will. I also noted more recently that sexual side effects are more commonly reported, but I am not sure if that is because of the power or the market focus on sexual side effects and Post Finasteride syndrome which frightens many potential users away, or it is real. We may never know but in the first 10+ years of prescribing thousands of young men this drug in my practice when the drug was introduced (prior to the introduction of PFS as a potential syndrome in 2011), the incidence of sexual side effects were consistent with the Merck study of between 2-4% in my practice from 1997-2010. That experience has been echoed by many of my colleagues.