Dr. Houssock (00:04):
You are listening to another episode of Perfectly Imperfect. Hey Linds.

Lindsey (00:09):
Hey, Dr. Houssock,

Dr. Houssock (00:11):
Welcome to Perfectly Imperfect Podcast.

Lindsey (00:14):
Thank you for having me.

Dr. Houssock (00:16):
I'm sure you've been very excited to take your turn to be a part of this. I know you have been.

Lindsey (00:21):
Yes, I've been waiting anxiously. I don't know why I wasn't first. I dunno. It's fine.

Dr. Houssock (00:26):
<laugh>

Lindsey (00:27):
It's fine though.

Dr. Houssock (00:28):
So Lindsey and I, we joke, but not really that we need those old school telephone cup to string ways to speak because we speak through the wall. Our offices are literally next to each other and the wall is thin enough where we just talk right through the wall and we're doing the same thing right now,

Lindsey (00:49):
But the opposite wall.

Dr. Houssock (00:50):
But a different wall.

Lindsey (00:52):
It's weird. Now you're on my other side, but

Dr. Houssock (00:54):
I just feel like this is just our usual day. So this is Lindsey's first time on the podcast and she has a wealth of knowledge, so you're going to see her a lot, but she's going to tell us a little bit, Linds, about what you do here and kind of your training history and whatnot.

Lindsey (01:14):
Yeah, so I do a lot of things here. I do the hair transplant surgeries a few days a week with you and I'm part of the harvesting and I assist with the strip. I do all the non-surgical hair, so the platelet rich plasma. I also do platelet rich plasma for the face, so all the microneedling, the cool peel, CO2 laser, and all the injectables that I can get my hands on. So kind of all over the place with everything that I do, which makes the day go by and it's a little more fun. I get to do a variety of things every single day, which I really enjoy. My background, I trained at Hopkins and my background's actually in women's health. I did labor and delivery and postpartum and the whole mother baby world for about six years while I was going back to school for my nurse practitioner degree. That's where I started.

Dr. Houssock (02:04):
That was like the best when we were all pregnant here at the practice because Lindsey has this amazing background in labor and delivery and anytime any of us who were pregnant had any issues, it was the easiest thing. Quite frankly, I said that I wasn't worried about going into labor during surgery because if worst case scenario, Lindsey was already here so.

Lindsey (02:24):
We had a plan.

Dr. Houssock (02:26):
<laugh>

Lindsey (02:27):
Continue on.

Dr. Houssock (02:28):
Yeah, we totally did. And it's true. Lindsey does a little bit of everything here and I would say she's kind of runs our non-surgical practice. I mean, our practice is comprised of a surgical side and a non-surgical side, and Lindsey really has started here as a recovery nurse in the OR when Dr. Vogel was still here and then really has just taken off and really has been very passionate about what we do here and has built just an amazing non-surgical practice. And a big part of that because it's a big part of our practice is hair restoration. And so today in particular, we're going to focus on female hair because quite frankly it's not focused in most places very much. And it's kind of shocking to us who are in it and to see how many women suffer and it's just not talked about the same as men.

Lindsey (03:26):
It's not, and it's a totally different animal. It is not the same as men. Women struggle because it's part of their identity when they're doing their hair and then suddenly they can't or they have to spend an obscene amount of time doing their hair to cover an area that they feel like they can't show anymore. So it's very frustrating.

Dr. Houssock (03:45):
Definitely frustrating and also very complicated. We tell our patients that women in particular are complex beings and our hair loss is no different and our hair loss is definitely more complicated than the male population. And because of that, whenever we see someone for a hair thinning or hair loss in the female population, we have to treat them very, very differently. What are the kinds of things, Lindsey, when you get your first consult, they've never seen anybody for hair before, they're really concerned about their hair thinning. What are the starting points that you go through with some of our women in the nonsurgical world?

Lindsey (04:27):
Sometimes I really start with what's been going on with you because many times I find they've either just had a baby and that could be a factor or they've got something hormonally going on, maybe they're starting menopause or they're just post menopause. They might've had surgery, they might've had a recent diagnosis of a hypothyroidism that's affecting their hair. So sometimes my opening really is what's happening with you, not just your hair, because I find that many times there's something that you can pinpoint as to what may be a possible cause or something you need to look at. What do you start with?

Dr. Houssock (05:02):
So I mean I would say I'm the same, right? What's happening? What happened recently? We definitely noticed that more than ever during the pandemic, we were seeing a ton of patients who were coming in with hair thinning after covid. So we talk about have you been sick? And the truth of the matter is all those questions that you just mentioned, most of the women have multiple of them. So they either have just gone through pregnancy or are going through menopause at the same time they've been sick, they've had covid stressors, mental stressors, though that can certainly affect men and women alike, we see a significantly more sensitive response in the female population. So fancy words for that are called telogen effluvium where they lose hair temporarily due to a stress or mental or physical. And so same thing, it's a broad stroke when it comes to women. Before our recent findings in hair thinning, Vogel would talk about how he would just have tissues at the table for his female population because he didn't have a whole lot of options for them. There really wasn't an assurance that they would be able to have their hair improved because at the time they were just using what we used for men. And unfortunately we both know that doesn't work.

Lindsey (06:24):
We're different.

Dr. Houssock (06:25):
So talk to me about what are the first, so let's say the woman comes in, she does have a few of those stressors, kind of talk about how you address those just to begin with. How do we get the ball rolling with treating their hair thinning?

Lindsey (06:40):
So a lot of times we talk about ways that we can mitigate the stress of what's going on or is it coming to an end soon? I've had a number of people who have a husband that's ill, what's going on with that? Well, he's doing very well in his treatment and things are looking better. So this stressor may be relieved as things improve or children having issues with school or anything like that. And so sometimes we use actually the neutrophil vitamins to help because they've got the ashwagandha in there and that can help with stress and it's an herbal, and sometimes I'll start with that as kind of a let's get you on something to kind of help.

Dr. Houssock (07:16):
Simple supplementation, basically a simple supplement.

Lindsey (07:19):
Simple. Because I'll tell you sometimes when you're stressed you're also not eating. And so their diet is all wonky and they're like, well, normally I don't do this, but now I'm doing. And so sometimes they do need a little bit of vitamin supplementation just to get them through that initial period of time. And then we've also got two medications that work great in Minoxidil and spironolactone for women.

Dr. Houssock (07:38):
Talk a little bit about, break them down a little bit and what they're treating.

Lindsey (07:42):
So Minoxidil is basically the active ingredient in Rogaine, which everyone's familiar with as a topical except no female, very few females to put a topical on their hair because it does not do you any favors when you're trying to style your hair. I actually used to laugh because Dr. Vogel would say, I use it and it's like foam and gel. And I'm like, no, no,

Dr. Houssock (08:03):
No it's not, it's sticky.

Lindsey (08:05):
No females find that it's gel for their hair. But so the oral version of that has actually been fantastic for our women. And so it started off as a blood pressure medicine and they were dosing people for blood pressure and miraculously their hair was improving and they're like, Hmm, there's something to this. And so here we go, we lower the dose and we tend to not affect blood pressure. I find that sometimes my older population, like 75 and up can sometimes have some blood pressure effects. So we tend to be a little more cautious as you are as well with dosing people slowly. And so sometimes we start them on a quarter or a half a tablet and slowly increase just to make sure they don't have any blood pressure related side effects. But that's actually putting the hair in the growth phase and so it's causing the hair to continue to grow rather than going through its normal resting shedding phases. Probably the hardest part for women, and I'm sure you see this too, is that initial shed period that causes a panic. So it does happen and you get through it and then that hair regrows and it's like the hair is kind of jumping off the cliff. It doesn't know to just stay in the growth phase. So any of those hairs that are already growing just kind of reset and go, oh, alright, great, but you see it in the shed.

Dr. Houssock (09:23):
Yep, definitely. And definitely preparing patients for that is really important because it can be really scary. And we both see patients who say that they started minoxidil and stopped it because they've started shedding and they weren't educated by their practitioner. That, and quite frankly, if you're doing it over the counter, if you're doing over the counter rogan, it doesn't talk about that either. People don't know to look out for that.

Lindsey (09:45):
No, and that can be very disheartening when you come into us looking for more hair and I give you a medicine that makes you lose more, at least in the short term. Yeah, it's frustration.

Dr. Houssock (09:53):
So minoxidil would you argue is basically a great medication for most types of hair loss, whether it's stress related, whether it's androgenic alopecia or the testosterone induced, which yes, women get, it's not just men really anybody across the diagnoses would benefit from minoxidil?

Lindsey (10:12):
Yeah, I use it across all of my patients for the most part, unless they've got a heart condition and then I'm a little more cautious just because of the blood pressure and heart related side effects, generally.

Dr. Houssock (10:24):
So great starter medication. I would also say that in the female population I am more likely to see minoxidil actually improve how the hair is looking. So I would say that's less common in my men. We always hit the bar low when it comes to these medications. Ultimately any medications and primary goal is to stop losing more hair, but we certainly can see in certain populations an improvement in hair. Are you finding that with Minoxidil sometimes with our female population as well?

Lindsey (10:58):
Yeah, I find it really affects that hairline, especially for people that have got thinning at the hairline. They get those little baby hairs and it really does a nice job by itself.

Dr. Houssock (11:09):
So what other medications do you have in your back pocket when it comes to that female population in general?

Lindsey (11:15):
Back pocket would also be spironolactone, so it's also a blood pressure medicine. And so sometimes I start minoxidil by itself to monitor for side effects and then I'll add spironolactone in because I just think sometimes you can't tell what medication is having the side effect as the root cause. So I'll start one and then add the other in a few weeks and that way we can identify if there's any issues. The weird thing with spironolactone that I've seen in people with eczema is that it can cause eczema flares, which is an odd one. So I usually try to ask people if they've had any eczema issues in the past. I've had a lot women who have complained of that.

Dr. Houssock (11:56):
Population, is it the women in general that seem to benefit from spironolactone or is there a particular population that generally?

Lindsey (12:03):
It's interesting in women, I feel like the combo of minoxidil/spironolactone is really key and that works really good across the board. Do you use it across the board when you're seeing patients too?

Dr. Houssock (12:14):
Yeah, for the most part.

Lindsey (12:15):
What do you favor?

Dr. Houssock (12:17):
I would say premenopausal for sure. So when I start thinking about it, it depends on the patient population again, but when I think about spironolactone, I think about the hormone induced hair thinning and hair loss that we see. So it works on the adrenal glands and for whatever reason it's kind of that estrogen component of our hair thinning and hair loss, which again is that ebb and flow of estrogen as we are going through the stages of life, whether it be motherhood or postmenopausal, I really think that women benefit from it. And I would say the only population that I may not put on spironolactone is if they come in and say that there's a real, like you said, the first thing you say is what's going on. If they've got a moment in time and it has nothing to do with something hormonal such as pregnancy, if it is that stress related, I had covid and my hair fell out, I may hold off on that patient population from starting spool lactone until we really give minoxidil a chance, not for any particular reason except for the fact that I think that because we have a moment in time where it doesn't seem to be related to their hormonal changes, I may hold off.

Lindsey (13:33):
Well and also nobody wants to take a bunch of medications. So I think that's a component of that too, is keeping it more simple sometimes. Keeping it simple works great.

Dr. Houssock (13:43):
Oh, absolutely. And talk about simple, I mean dermatologists have used spironolactone for hormonal acne forever, so we're kind of just catching up. It's the same idea. The hormonal changes that produce acne are no different than the hormonal changes that you can see that produce hair thinning and hair loss and hair shedding. So of course we just plastic surgery just like any other medical specialty or aesthetic medicine borrows from other practices because it works and it's worked for them forever. And so why wouldn't it work for us? Which brings us really to the next topic, which is really the meat of what Lindsey does and that's really when it gets to do something a little bit more invasive for hair thinning. So Lindsey, talk a little bit about your hair injections and what exactly they are and what would be the help with them and why people would use them.

Lindsey (14:41):
Sure. So we do P-R-P, P-R-F, platelet rich plasma, platelet rich fibrin. So we're using all components of your own blood. Basically we spin down and we get the growth factors and then we inject those back into the scalp. The role of that growth factor is to go in and thicken up each individual hair diameter. So when I see someone for this, I'm looking for thin hairs, I'm looking for miniaturized hairs, and usually it's not all over. Usually they're sprinkled in. And so there's an area of concern and typically there's some that are regular thickness or even thick hairs in that area. And then there's a lot of miniaturized hairs. And so as long as there's hair there, I can act upon it. With the PRP when I have an area that's slick, bold, PRP really isn't going to grow hair. And so differentiating between the patients that will have the best response is really based on how much thin hair they have. If they've got an area that's just a lot of thin hair, that's a lot of hair I can act on to thicken up. And you can imagine how that helps when you thicken up the hair, you really have more coverage in that area.

Dr. Houssock (15:47):
Yeah, definitely. And it's so interesting because historically PRP is not new to the medical world. We talk about it really being commonly utilized in orthopedics for joints to grow cartilage. You see it a lot in athletes, the dentist using it around dental implants to grow bone. And so it's a very nonspecific growth factor. I mean that is what it's called. And wherever you produce it and wherever you inject it in a concentrated fashion, it will induce growth. And so why not hair? And the answer was, yeah, it's going to work, but it has to have something to work on. Just like Lindsey said, it's a great adjunct to patients who have hair thinning, but it isn't going to bring back hair that is no longer present. It's the downside of the injections and neither are these medications. So really everything we've talked about up until this point have been things that work on current hair that still has a stem cell that's still viable once you've lost hair, none of this magic is going to do anything.

Lindsey (16:57):
No.

Dr. Houssock (16:58):
That's hard though. I think that's unfortunately due to advertising, a lot of patients don't understand that. Wouldn't you say you see a lot of people who expect more than that?

Lindsey (17:07):
Yes, the expectations are very high and I try to be very realistic with what they can expect based on what I'm seeing. The other thing I'll say is there's a lot of data that talks about hair counts and hair numbers increasing. When we do our measurements, we measure hair diameter because that's more appropriate of what we would expect for it to do. But in some of the studies they talk about hair counts increasing and I usually tell people when they've heard that or seen that maybe what's happening there is there's hair that's there, it's just dormant and it can reawaken. So for example, if you had three hairs coming out of a single follicle and now there's only two, but that third one is under there, it could reawaken it. Sure it's a growth factor, but I have no way to know how many of those there are. So it's not something you can count on. It's a bonus. It's a bonus, but really what you're looking at is hair diameter.

Dr. Houssock (18:02):
And really the cool thing about that is Lindsey does it in a really awesome objective way. So it's very easy to subjectively take a photo and do a before and after treatments, but Lindsey actually measures the diameter. How do you do that in your whole process when you are setting somebody up for a PRP?

Lindsey (18:23):
So we use a computer assisted measurement program, and what we do is we take a tricoscope, which is basically a little camera that zooms in about 25 times on the hairs. And I take a small 25 square millimeter area and I measure each individual hair in that area and it gives me a diameter measurement and then it gives me a mean diameter that I can use to compare and it actually will break out the percentage of thin, regular and thick hairs. And what we're looking for is not only a change in the mean diameter over time, but we're looking for those thin and regular hairs to convert down to regular and thick. And so some people will say, well, my diameter didn't change that much, but I've changed a lot of my hairs from thin to regular. That's still a win because it's starting. And usually I see them for follow-up yearly to do that measurement again. And it's at that point that we see the change in the diameter. So it's something that I find gets better over one to three years for people, whether they're the person that jumps diameter and they still got some thin regular thick hairs and it's not distributed evenly, or they have that where their diameter's kind of similar, but they see the shift in the percentages. So there's no right or wrong there. The goal is that you're improving.

Dr. Houssock (19:36):
Yeah. And not losing. I mean, again, stage one of any, whenever someone comes in for a hair consultation for hair thinning or hair loss, number one win always is to stabilize hair loss. I mean it's always going to be. And then can we then thicken what they have or improve what they have over time? It's always the goal, and I wish we had more in our back pocket, but right now we have to deal with what we have. And right now the best way is a long-term plan, combining those medications at home with injections in the office. And we've seen really great success with that. We've seen life-changing success, especially in our female population. I think because we're so sensitive, we also respond better to these particular treatments. So I'd argue that some of the females actually see results sooner than are men. When it comes to PRP, would you agree?

Lindsey (20:29):
I would. And I don't know how much of that is just that we are constantly doing our hair, so my hands are always in my hair every day. It's true. And so I'll have women that'll say to me, you said it would take six months, but really we're month four and my ponytail's different or my hair texture is different. My guys will come in at eight months and I'll say, how are you doing? They go, I don't know. And I'm like, well have you run your hands through their hair. I'm like, my wife says it's good. I'm like, oh, okay. Because they're not doing their hair. It's just the truth. I had a patient who never wore her hair down, never. It was always back because she hated how it looked down. And at eight months she walked in the door, I'd never seen her with her hair down. And I took a moment and I said, welcome. And she's like, I'm bring my hair down for you. I can wear it down now. And I was like, this is so amazing. And now she's always got it down and it's awesome.

Dr. Houssock (21:22):
It's so awesome. It's like one of our biggest goals. And I would say one of the biggest complaints for women when they come in is that they cannot style their hair the way they want to. And their goal is to style it however they want to. And they're so used to camouflaging it in whatever way they do, whether it's with the part that they style it or the way that they wear it, like you said, wearing it up or wearing a hairpiece. They all are unfortunately tied into a style that they would really like to get out of. Yes, agreed. That's a huge win. To have them walk in and wear their hair in a certain way, whether it's just like you said, a different way or down or without a hairpiece is our biggest win.

Lindsey (22:06):
Agreed.

Dr. Houssock (22:07):
For sure. There are two other, just want to touch on a couple other hair loss reasons or phenomenon that we didn't touch on that are definitely a little more complicated. One of them being patients who suffer from traumatic hair thinning or hair loss, whether it be due to hairstyles or from previous surgeries or burns that we do certainly see. And generally speaking, those patients have to be treated a little differently because their issue isn't necessarily the hair follicle, but it's the medium in which the hair grows, which is the scalp. We definitely work in conjunction with dermatology when it comes to the certain patient population because we may have all these plans for the hair follicles themself, but if the scalp is not in a position to take the grafts, well they won't do well, especially if we start to talk about surgery. So that's a complicated group that unfortunately may not benefit necessarily from our typical treatment regimen, but we certainly do have options for them surgically and injection wise depending on where they are in their stage of healing.

Lindsey (23:23):
And sometimes we combine the two, sometimes we're doing PRP to kind of get that bed a little healthier for then you to come in and do transplant in that area, especially in an area of scar. We've done that a number of times.

Dr. Houssock (23:34):
Absolutely. They're some of my favorite patients. We see because of where we are in the world, we see a lot of skin cancer patients and because a lot of us are pale but yet still love being in the sun. And so we've seen plenty come over from Hopkins where they've had skin cancers taken from the scalp, and then Lindy and I are left with a big scarred skin grafted area in the middle of their hair, and all they want to do is wear their hair normally. And we have to treat the scar with those PRP injections where Lindsey can prepare that bed to maximize the growth of the surgical transplant we may do in the future. So the great news is is that there's very few patients that come in now to our practice that we don't have a really positive outlook and an optimistic plan for them.

Lindsey (24:30):
I don't see the tissues anymore when you're in the room. That's not the only thing we have.

Dr. Houssock (24:35):
Yeah. Yeah.

Lindsey (24:36):
It's really cool.

Dr. Houssock (24:37):
Yeah, I mean it's so cool. And before we really did struggle with that, and particularly the scarring alopecia where they have a autoimmune disease where their scalp is not growing hair in the way that it typically would transplants before couldn't be offered because they wouldn't take transplant. And now we're finding that in conjunction with our colleagues at the right time planning for a medical treatment combined with some PRP injections, we can successfully transplant those patients. Which I think Lindsey and I would probably agree is probably some of our most miraculous changes in the last few years. Patients with lupus patients who have had any of the scarring alopecia that we unfortunately witness. And if they're not diagnosed appropriately and they go to a hair restoration specialist and they attempt a surgery, it will not be successful. So great. And we didn't even touch on surgery today. We'll do that on a completely separate podcast episode, but surgery is an absolute option for our female population. You don't have to have a disease process in order to have a hair restoration surgery. I will see a lot of patients who want surgery just because they've always had a high hairline and they would prefer a lower hairline, but generally speaking, the women in our hair restoration population are probably some of the most happy patients because there really are changes that can be made these days.

Lindsey (26:12):
Yes, absolutely. And I think having options is something that people do appreciate when they come in, it's no a, well this is all you have. It's, well, we can do this or this and this, which is so nice.

Dr. Houssock (26:29):
Yeah.

Lindsey (26:29):
For people to be able to choose.

Dr. Houssock (26:31):
Yep. You just have to be patient. It's not one of those immediate gratification portions of the practice. You do have to give us time. It's literally watching grass grow can be successful for sure.

Lindsey (26:43):
Yes, definitely. And I usually tell people, it really is a process and you are going to have to wait years, but it's progressive. And so we're starting now and we're going to prevent that progression. And that's the goal.

Dr. Houssock (26:57):
The sooner the better, right? I mean, we want to get you in as soon as you are seeing any of the symptoms that you're seeing. Don't wait until it gets too vigorous, because then it's always harder to treat.

Lindsey (27:07):
Yes. Because it does take time. Definitely takes time.

Dr. Houssock (27:12):
Well, Lindsey, thank you. Today was wonderful.

Lindsey (27:14):
Oh, you're so welcome.

Dr. Houssock (27:15):
I learned a ton.

Lindsey (27:16):
Did we cover everything?

Dr. Houssock (27:17):
Yeah, I think so. I mean, I think ultimately teaching that we have options for patients in this current times for women specifically, is a very positive thing. And we love seeing our female patients for hair restoration so.

Lindsey (27:32):
Yeah. I think we covered a lot and thank you so much. Carry on, Dr. Houssock.

Dr. Houssock (27:32):
Carry on, Lindsey.

Dr. Houssock (27:33):
Perfectly Imperfect is the authentically human podcast, navigating the realities of aesthetic medicine. JEV Plastic Surgery is located in Owings Mills, Maryland. To learn more about us, go to JEV plastic surgery.com or follow us on Instagram at Dr. Care Houssock, spelled D-R-C-A-R-E-H-O-U-S-S-O-C-K, or just look in the show notes for links. If you enjoyed this episode, please share it and subscribe to Perfectly Imperfect on YouTube, Apple Podcasts, Spotify, or wherever you'd like to listen to podcasts.