The following is an email question and answer session conducted with Dr. Cotlar. If some of the questions are not followed up, it is because they were sent in one pass through email.
It’s very rare to find Doctors who practice both transplants and medical treatments for hair loss. It is even rarer to find a Doctor who is active in the on-line community and actually provides informative information to people. Dr. Steven Cotlar from Houston, Texas, is one of those Doctors. I recently had the chance to ask Dr. Cotlar a series of questions about transplants, other procedures, and medicinal treatments for hair loss such as Proscar and Minoxidil 5%. Here’s what he had to say.
Dr. Cotlar, thank you for taking the time to answer these questions. I’m sure my readers will be thankful.
Regrowth: First of all, please tell us about your background. Where did you grow up, go to medical school, and what are your credentials and certifications?
Dr. Cotlar: I was born and raised in Houston, where I now practice. I attended LSU Medical School in New Orleans followed by three and one half years of general surgery residency and then two years of plastic surgery residency at the University of Texas, here in Houston. I am board certified in plastic surgery. I have a faculty appointment with the department of Plastic Surgery at Baylor College of Medicine.
Regrowth: Would you care to share with us some of your personal interests outside your practice?
Dr. Cotlar: I enjoy traveling (who doesn’t). I like the water and related activities such as fishing and scubba diving. I enjoy sports, especially racquetball. I am involved with a few charity organizations in town.
Regrowth: How long have you been performing transplant operations specifically?
Dr. Cotlar: Three and one half years.
Regrowth: How long have you been performing scalp reductions?
Dr. Cotlar: I prefer not to perform this procedure.
Regrowth: How long have you been performing scalp flap operations?
Dr. Cotlar: Any scalp flaps I have performed have been for reconstruction purposes, such as defects of the scalp created from trauma or skin cancer resection. In my hair patient population, I have not had much demand for them.
Regrowth: How many patients would you say you have performed transplant operations on?
Dr. Cotlar: Several dozens for sure.
Regrowth: How many patients would you say you have performed scalp reductions on?
Dr. Cotlar: As mentioned, I don’t do this operation.
Regrowth: Speaking of scalp reductions, some doctors will not perform them and some places, NHI for example, claim they are unnecessary due to advances in grafting techniques for transplants. Why do you perform scalp reductions and who is right?
Dr. Cotlar: My reason for not doing reductions is not because current hair transplantation technique has made them unnecessary (I am not so sure I would agree with that statement). Rather, I am concerned over the unpredictable effects that can occur following the procedure (such as stretch-back, hair loss). Understand that my remarks reflect only my opinion and are not to be interpreted as saying those who did the procedure are wrong in doing so.
Regrowth: Are there many complications with scalp reduction surgeries?
Dr. Cotlar: For sure.
Regrowth: What percentages of your patients who have transplants also have scalp reductions?
Dr. Cotlar: Only those who had them done by other doctors.
Regrowth: How many scalp reductions are usually necessary prior to transplant surgery?
Dr. Cotlar: I do not have the experience to answer that question since I do not do them.
Regrowth: How much does it cost to have scalp reduction surgery?
Dr. Cotlar: Depends on the doctor.
Regrowth: NHI claims that when you perform the scalp reduction that since the scalp is stretched, the amount of hairs available in the donor area is decreased. This seems to make sense. How do you counter their arguments against scalp reductions?
Dr. Cotlar: No need to. Again, I limited my hair restoration to grafting only.
Regrowth: A flap surgery obviously requires an even more skilled surgeon than for transplants. How does someone go about making sure the person they choose to perform a flap surgery is the right one??
Dr. Cotlar: I couldn’t agree more with your statement. First of all, one would hope that proper patient selection would be used, even by a physician experienced in this procedure. Flap surgery is not for everyone with a hair loss problem, who is looking to surgery for improvement. Across the board, most individuals will best be served by transplantation. However for those who are good candidates (and understand the procedure and potential complications, it is mandatory that the doctor have the necessary experience. Board certification is one thing to look at, but still does not guarantee experience. One should make sure that the physician is experienced in flap surgery
Regrowth: How much does flap surgery generally cost?
Dr. Cotlar: Depends on many factors.
Regrowth: Some doctors are skeptical about flap surgery because of possible long term complications, such as eventual necrosis of a flap? Is this really a concern?
Dr. Cotlar: Any potential complication justifies concern, particularly when the surgery is elective. Flap loss, the biggest concern of this type of surgery, can occur. The loss can be minimal or major. Though no doctor can promise this will not happen, the incidence will be much less when the surgery is performed by an experienced doctor. If an individual is not equipt to handle the possibility of this complication, he should think twice before doing it.
Regrowth: What options does someone have if they have a problem with a flap such as necrosis?
Dr. Cotlar: A bad spot to be. In such a case, one must wait for all wounds to heal and see what is left to work with.
Regrowth: What kind of patient is not a good candidate for scalp flap surgery?
Dr. Cotlar: One with advanced hair loss. One who is not willing to accept the possibility of complication. One who doesn’t have the financial resources for undergo this very expensive procedure.
Regrowth: On to transplants. First, do you see many women for transplant operations, and is this number increasing?
Dr. Cotlar: Yes, I see a fair number of women and I do believe the number is increasing as more and advertising for hair transplantation is put out.
Regrowth: Are women more or less suited to transplants than men?
Dr. Cotlar: In general, less suited as their hair loss tends to be more of a general thinning.
Regrowth: Have you ever had a female patient who had a scalp reduction and if so how did it turn out?
Dr. Cotlar: No
Regrowth: How does someone make sure they’ve found the right transplant doctor?
Dr. Cotlar: Credentials and experience.
Regrowth: We hear so many different terms for grafts from different practices. Which grafts do you perform and please describe them.
Dr. Cotlar: Micrografts (one and two hairs) and minigrafts (three or more hairs).
Regrowth: How many grafts or hairs do you transplant in one session?
Dr. Cotlar: Two to five hundred grafts.
Regrowth: Why do you believe transplant mega-sessions are inferior?
Dr. Cotlar: While I personally do not do them, I would not say they are inferior.
Regrowth: How many transplant sessions does your average patient go through?
Dr. Cotlar: Two to four
Regrowth: Some practices offer guarantees that their grafts won’t fall out and if they do that they will replace them. Do you offer any such guarantees, and how could you tell if any of your grafts fell out anyway?
Dr. Cotlar: I believe this is a very moot point and should not influence one’s choice of doctor. With that said, no one can guarantee grafts will not fall out. In my experience, losing a graft or two has no consequence on the ultimate result, particularly when hundreds of grafts are put in. Patients will noticed this when they get in the shower or a graft simply falls out. I simply assure them there is nothing to worry about.
Regrowth: Do you have any idea what percentage of your patients would say they are satisfied with their results once they are finished?
Dr. Cotlar: The vast majority are satisfied
Regrowth: Do you ever turn patients down who seem to have psychological regarding their hairloss? What percentage of patients are these?
Dr. Cotlar: Yes, but not many.
Regrowth: Do you ever turn patients down just because their amount of loss is too extensive for them to get good results? What percentage of patients?
Dr. Cotlar: Definitely-this is a group that will not be satisfied, even with a good surgical result, technically speaking. Perhaps 15%.
Regrowth: Do you ever turn patients down who haven’t lost enough hair yet to know what their final amount of loss will be? What percentage of patients?
Dr. Cotlar: Yes. About 7 percent
Regrowth: How can a patient know when he has lost enough hair to make transplants worthwhile without worrying about further loss causing poor end results?
Dr. Cotlar: The approach to that situation is to plan for future hair loss, no matter what.
Regrowth: What general guidelines do you look for to tell if someone has enough hair left to have a transplant?
Dr. Cotlar: Most depends on what the patient’s expectations are. Then there are considerations such as the hair density, amount of hair loss and patient’s age.
Regrowth: How painful are the shots to the scalp for local anesthetic?
Dr. Cotlar: Varies according to technique. Certain measures can be taken to minimized discomfort and I feel it is important to do this, as is does not add much to the time and it makes things so much better for the patient. I like to freeze the skin prior to injecting.
Regrowth: How noticeable is the surgery immediately afterwards? How soon can someone go out in public without it being obvious that they’ve had the surgery?
Dr. Cotlar: For those who have existing hair in the area of grafting, the surgery can be quite unnoticeable if the hair is combed over it. After ten to fourteen days, the small scabs at the graft sites fall off and it is hard to see any evidence of surgery.
Regrowth: How long does it generally take incision scabs to go away?
Dr. Cotlar: 10 to 14 days (small incisions).
Regrowth: Several people have posted that transplant doctors have told them that transplants would not cause any existing hair to fall out and then it did. Do you warn patients of this and how frequent is it? Are these hairs that have gone into resting phase due to trauma of surgery and will grow back or are they MPB affected hairs that have fallen out early due to surgery and will not grow back?
Dr. Cotlar: Yes I warn patients of this, if the possibility exists. This is why I do not like to transplant into areas where not much thinning exits (even though patients may want it). Both of the causes for the loss you mention exist. It is hard to say for sure the cause.
Regrowth: What do you think of Laser hair transplantation? Why do you not perform them? What are the advantages and disadvantages? Is this just a gimmick to get people who think ‘if its lasers it must be superior’?
Dr. Cotlar: IMO, the laser has yet to prove itself to give superior results. The advantage is said to be less bleeding from the recipient sites and consistent size and depth of the sites. The main disadvantage is said to be the trauma produced at the recipient site (the thermal effect) which may retard graft take. Also laser are not cheap to buy/lease. Someone has to pay. The limitation of hair transplantation is not in the technique; rather it is in the supply of donor hair. Lasers can’t change that.
Regrowth: Have you evaluated ProCyte’s GraftCyte’s moist dressings for preventing newly transplanted hairs from falling out and going into resting phase? Have you used them at all and what have been the results? If you haven’t used them do you plan to evaluate them?
Dr. Cotlar: I have been “detailed” by the company on the product. At this time, I do not think the numbers are out there to prove (or disprove) it’s value. I do mention the product to patients and if they wish to spring for the extra $275 (roughly), they can use it.
Regrowth: Do you recommend Proscar and/or Minoxidil to transplant patients?
Dr. Cotlar: Yes
Regrowth: If someone uses Minoxidil and has a transplant session, how soon can they start using Minoxidil again after the surgery?
Dr. Cotlar: I have them start in a couple of weeks.
Regrowth: Do you recommend any topical treatments such as Iamin or GraftCyte after surgery to promote healing of the grafts?
Dr. Cotlar: No
Regrowth: What do you do if a patient comes back to you and is unhappy with their transplant results?
Dr. Cotlar: Because I selective patients carefully, spend a lot of time with them preoperatively and use careful surgical technique, I really do not have many who are unhappy with their results. However, I will occasionally see a patient who is disappointed in the density. More transplants are offered in such cases.
Regrowth: What advances do you see in the future for transplant surgery and how soon do you think they will be available?
Dr. Cotlar: I think the current technique of hair transplantation is about as evolved as it will get. Any major advances, I see, will be in the way of prevention. We have all heard about cloning and gene therapy. These topics make for interesting reading and offer some degree of optimism, but as far as their practical application, I can’t see it any time soon.
Regrowth: What do you say to people who are concerned about the side effects of Proscar, particularly the possibility of effects on unborn children?
Dr. Cotlar: In my practice, I have not found this concern to exist. It is I who approach this subject during the initial consultation. It is important for people to be aware of the possibility, however minimal (with proper caution exercised).
Regrowth: Do you ever prescribe Proscar to women who are not planning to have children or past their child bearing years? If so, how effective has it been for them?
Dr. Cotlar: No
Regrowth: Have you prescribed Minoxidil 5% to many women and if so how effective was it?
Dr. Cotlar: No
Regrowth: Have you seen any or many women using Minoxidil (2% or 5%) who had the side effect of unwanted facial or body hair growth?
Dr. Cotlar: No.
Regrowth: What do you think of the claim of the woman who is suing Upjohn saying Minoxidil caused unwanted facial growth that didn’t go away after treatment was discontinued?
Dr. Cotlar: I am not aware of the facts.
Regrowth: What percentage of patients you prescribe Proscar alone to would you say have regrown enough hair to be cosmetically significant?
Dr. Cotlar: My experience with the drug has shown the best group of patients to be younger ones who complain mostly of thinning hair, not yet very obvious to others. Most of them report dramatic decrease in the amount of hair loss. Perhaps 15 to 20 percent of patients experience significant regrowth. In patients with advanced hair loss, I caution them that most positive effect comes from slowing of hair loss and any significant regrowth, is a bonus. If regrowth is the objective, I am not real keen on prescribing the drug and tell them that transplantation may be necessary to give them dramatic result.
Regrowth: What percentage of patients you prescribe your Minoxidil 5% formula to alone would you say have regrown enough hair to be cosmetically significant?
Dr. Cotlar: Hard to say as I usually use Minoxidil (2%) in combination with Proscar.
Regrowth: What percentage of patients using both have had cosmetically significant regrowth?
Dr. Cotlar: At least half have significant improvement.
Regrowth: Have you ever had patients using Proscar who it was effective for initially but then it lost its effectiveness?
Dr. Cotlar: I have not yet seen this, but have been using the drug for less than one year.
Regrowth: Some people have a hard time getting their doctors to prescribe Proscar? How would you recommend someone approach their family doctor or local dermatologist about getting a prescription?
Dr. Cotlar: Many physicians have not heard about Proscar’s use in hair loss. In such case, they may not feel comfortable prescribing it. It might help to have some supporting literature if the doctor’s reluctance is due to lack of information. It should be noted, too, that a family doctor may feel this request may be outside his area of expertise and not want to give it for that reason. Personally, I think it is a good idea to not just go to a doctor for a prescription, but to go to one who has an interest in hair loss treatment and will following the patient and monitor his progress (or lack of it). I take photos of my patients to help document things.
Regrowth: What percentage of your patients using Proscar would you say experience side effects?
Dr. Cotlar: About three percent, consistent with the literature.
Regrowth: What percentage of your patients using Proscar who have side effects have them go away?
Dr. Cotlar: With or without stopping the drug?
Regrowth: What do you tell people for whom Minoxidil 5% and Proscar is ineffective who don’t wish to have transplants or use a hair system?
Dr. Cotlar: I can only offer them what I can provide for them. In the situation you ask, if I sense they are very disturbed by the situation, I would suggest they talk to a psychiatrist or therapist. I have been very impressed with how distressed some of the hair loss patients I see are.
Dr. Cotlar, thank you for taking the time to answer these questions. Dr. Cotlar practices at the Medical Center Plastic Surgery and Hair Transplantation in Houston, TX ( 713-791-9885 )