Your hair loss questions, answered daily.


The hair in every person’s scalp grows in tiny bundles called follicular units. Although this had been recognized for some time by histologists (doctors who study human tissue), the existence of follicular units was largely ignored by physicians performing hair restoration surgery.

The follicular unit of the adult human scalp consists of 1-4 terminal (full thickness) hair follicles. In areas of the scalp affected by genetic balding, the healthy terminal hairs are gradually replaced by hairs of smaller diameter and length called “miniaturized” hairs.

In addition to the full terminal hairs, the follicular unit contains 1-2 fine vellus hairs, sebaceous (oil) glands, a small muscle, tiny nerves and blood vessels, and a fine band of collagen surrounding the unit (called the perifolliculum). The follicular unit is thus the hair bearing structure of the skin and should be kept intact to insure maximum growth.

The follicular unit is seen on the surface of the scalp as a tiny group of hairs that appear to be growing together. They are best viewed under a microscope where they are seen as well-formed structures in the skin but if you part your hair (say in the middle) and look at with a bright light

A close-up view showing the hair actually emerging in small groups called Follicular Units.

With the hair clipped the natural hair groupings are visualized on the surface of the skin at 30x magnification through an instrument called a densitometer.

A histologic view of the corresponding Follicular Units seen in cross-section within the dermis.
What is Follicular Unit Transplantation?

Perfectly intact 1-, 2-, 3-, and 4-hair Follicular Units removed from the donor strip using a dissecting stereo-microscope.

Follicular Unit Transplantation is a technique, pioneered by the Physicians at the New Hair Institute, in which hair is transplanted from the permanent zone in the back of the scalp into areas affected by genetic balding, using only the naturally occurring, individual follicular units.

In order to remove Follicular Units from the back of the scalp without damaging them, the donor tissue is removed in one piece. This technique, called Single Strip Harvesting, is an essential component of follicular unit transplantation as it not only preserves the follicular units, but it prevents damage (transection) to the individual hair follicles. It differs dramatically from the mini-micrografting technique of using a multi-bladed knife that breaks up follicular units and causes unacceptable levels of transection of hair follicles. Another harvesting technique, Follicular Unit Extraction, allows the surgeon to remove individual follicular units without a linear donor incision.

Another essential component of Follicular Unit Transplantation is Stereo-Microscopic Dissection.

In this technique all of the follicular units are removed from the donor tissue under microscopic control to avoid damage. Complete stereo-microscopic dissection has been shown to produce an increased yield of both the absolute number of follicular units, as well as the total amount of hair, (upwards of 25%). (This procedure differs from mini-micrografting in which the grafts are cut with minimal or no magnification.)

A major advantage of follicular unit transplantation, (besides preserving follicular units and maximizing growth) is the ability to use small recipient sites. Grafts comprised of individual follicular units are small because Follicular Units are themselves small, but also because the surrounding non-hair bearing tissue is removed under the microscope and doesn’t need to be transplanted. Follicular unit grafts can be inserted into tiny needle-sized sites in the recipient area, which heal in just a few days without leaving any marks.

When performed by a skilled surgical team, Follicular Unit Transplantation can provide totally natural looking hair transplants that make the full use of the patient’s donor supply to give the best possible cosmetic results in the fewest possible sessions.

A Norwood class 6 patient with position of new hairline marked just prior to surgery.

Results after two sessions of Follicular Unit transplantation. Note the perfectly natural appearance of the frontal hairline.


I realize that individuals vary greatly, but is possible to determine, from measuring a person’s facial proportions, where their natural hairline, prior to any hair loss, should be? i.e. how far up the forehead should it be located.

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Each and every patient is different but in general a male hair line usually starts around 1cm or so above the highest crease of the furrowed brow. To see this, look in the mirror and lift your eyebrows. That crease will show up well unless you had Botox done. We can go in to facial geometry and proportions and there are books and papers written about this. But you can start with the basic. We’ve also written about the Juvenile Hair line regarding this topic over the last several years here on Balding Blog. Use the search bar (upper right corner).


Hi doc. I have a thick donor area but the side of my hair in my opinion are a bit thin. Would I still be a good candidate for a surgery?

I have read on a few forums and websites that say a person in my situation would be better suited for FUE rather then strip because they can just go to my donor hair in the back and pick the healthy hair out instead of doing a strip and leaving my side even more thinner. But, I wanted to get a more expert opinion from you to see what you think. Thanks.

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Reading forums and searching the Internet for personal health or cosmetic surgery related questions will probably cause more confusion. Each and every case is different. So when you are ready to see a doctor for options regarding a “possible” surgery, your situation will be better served with a doctor sitting in front of you.

Sorry if this is not answering your question in detail but that is really my “expert” opinion. I can’t give an expert opinion without a diagnosis or a physical exam. There have been plenty of patients who have had thinning and done well with a strip surgery. There also have been plenty of patients who I recommend no surgery at all.


Is propecia effective against DUPA hair loss? Do you prescribe propecia to patients diagnosed with DUPA?

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Propecia works for genetic androgenic alopecia not DUPA (Diffuse Unpatterned Alopecia). Some patients may have both DUPA (hair loss throughout the entire scalp) and androgenic alopecia and in this case it may help (for the androgenic cause). Each and every case is different and as always you need to have a good diagnosis and a Master Plan with a doctor.



This young man has very thin see-through hair. Near completion of the first session, the SMP procedure shows the difference between the non-pigmented scalp and the pigmented scalp as it is being performed. The first session uses lighter strokes than subsequent sessions which may be darker in the next session if the patient makes that choice as many often do. The dots are slightly lighter than his hair color. Click on the photo to see what we are talking about.


Dr William, in order to prevent hairloss and to regrow some hair in androgenic alopecia patients , can one take finsteride 5mg daily instead of finisteride 1mg?

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The recommended dose for finasteride for the treatment of androgenic alopecia is 1mg daily. Taking more than the recommended dose will not be of benefit for hair.


The drug melatonin, a potent antioxidant and growth modulator, was identified as a promising candidate for the topical treatment of hair loss. The study was conducted in 2003 at the Forenap Centre Hospitalier in Rouffach, France. The drug was found to be well tolerated. Approximately 80% of people found that it reduced hair loss during the short 90 day trial. The study concluded that there was a positive effect of melatonin on hair growth in patients with AGA. The authors recommended more studies have to be done to confirm the benefits for both short and long term hair loss treatment. The drug melatonin may behave similar to a topical drug which was marketed by a French pharmaceutical company which was known as a “morning after” abortion pill (as it was/is known and marketed some 20 years ago) and no longer on the market. A topical form of melatonin is commercialized in Spain (a topical solution called Lambdapil solution) but according to a colleague there, it is weak and no better than minoxidil.


Dr. Rassman,
I’m currently preparing a Master Plan, and I’m considering the merits of combining ARTAS FUE and SMP, but I have a query: Can the ARTAS system robot differentiate between a normal hair follicle and an SMP replica follicle?

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There have been patients who have had SMP first then subsequently had FUE with the ARTAS with no issue.


I have followed the finasteride-sexual impairment debate on this blog with interest and found the following review published this month in a reputable journal to be highly informative and with new information (to me). The full article, by Singh and Avram, was published in the December issue of the Journal of Clinical and Aesthetic Dermatology and is freely available to the public at:

As a clinician-scientist, I have observed that the most fervent proponents of the belief that finasteride results in permanent sexual side effects do not fully appreciate the minuscule and uncontrolled amount of evidence of this phenomenon. Further, their comments (often more of a personal nature directed toward those they disagree with) usually reflect significant difficulty distinguishing between well-controlled studies, which can be done, and letters to the editor, case studies, and anecdotal reports that seem to be from the same author.

Sigh and Avram nicely summarize the current “state of the art” and the need for controlled investigations in the last section of their paper:
“In summary, the findings by Irwig et al. are quite disconcerting; however, even if the findings in these three articles by Irwig et al. are accurate, this clearly only effects a small proportion of finasteride users. As stated above in the Prostate Cancer Prevention Trial, none of the more than 17,000 participants experienced persistent sexual dysfunction or depression. In addition, the authors were able to demonstrate that finasteride only had a minimal effect on sexual dysfunction. They advised that these sexual adverse effects should not affect prescribing practices. Once again, given the data from the hundreds of randomized, controlled trials, finasteride should still be considered a safe and well-tolerated medication. It is essential that further research is performed, in the form of randomized control trials, to further evaluate if there are any unique characteristics in these individuals suffering from prolonged sexual dysfunction and severe depression after using finasteride. These future double-blind, placebo-controlled trials are necessary to conclude if these findings by Irwig et al are “a red herring” or a potentially rare but serious side effect about which we should counsel our patients.”

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Thanks for sharing your thoughts!
The topic of sexual dysfunction with use of Propecia (finasteride) here on BaldingBlog as well as the Internet in general is something that will likely be a heated debate.
It is unfortunate that understanding clinical research (with randomized control trials) will be out shadowed by the “hysteria”. Interesting point about the 17,000 participants. Alas… let the debates begin…


Dr Rassman ,does side effect of weight gain always occur in all male patients who uses 5% topical minoxidil? After how many days/months of discontinuation of topical minoxidil 5%, will the patient reach to his original /actual weight?

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As far as I know, weight gain is not a side effect of Rogain.

The main source of hair loss in men is genetics.

The main source of weight gain is generally over eating.


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