Megasession Healing Time (with Photos)

/by William Rassman, M.D./0 /

The idea of a Megasession frankly scares the hell out of me. I am an executive of a large company and fairly bald. I want to keep my vanity problems to myself. If I have a Megasession, how long will it take me to look normal so that I can go back to work. Will everyone ask me where all of the hair care from?

The healing is best answered by looking at two patients with megasessions. The photos here on the left and middle are of Patient A (3,628 grafts) immediately after the procedure; the photo on the right is Patient B (4,676 grafts) one day after his procedure.





Most patients will have no sign of a transplant within a week or so. Some will have no sign of a transplant in a day or so. There is a difference in the way we heal, but with that said, today’s good clinics use very small needles so that the “tracks” of a transplant heal with amazing speed. I tell the patients that they can resume full activities in 5 days (except for heavy lifting, sit-ups and body presses). I have had one patient enter a 120 mile bike race on the 5th post operative day.

The average patient returns to a normal look in about a week, then the hair stubs that are there fall out and by the 3-4th week, most patients look totally like they did the day before their hair transplant. Then in 2-5 months, the hair starts to grow, very insidiously. It is rarely picked up by anyone, even by those who sees the patient daily, much like watching a child grow (never sees it happen). The two examples shown above are two different examples, one with some hair (Patient A) and one almost completely bald (Patient B) except for hair in the middle of his head. A famous celebrity (who shall remain nameless), told me that after his hair transplant, everyone knew something changed, but no one, not one single person pegged the hair as the cause of his change. He was 48 years old when I did his hair transplant and people thought he had a face lift because he looked so much younger. He told everyone he just lost some weight after working out a bit more and no one questioned that.

Funny Patient (with Photos)

/by William Rassman, M.D./0 /

The photos below are of a patient who came to my office yesterday, now 11 months after his transplant of 2403 grafts. When he saw his before pictures, he asked me to cremate them because that man no longer existed. We had a great laugh together as he shared his own amazement of the transformation which he had not fully appreciated until he viewed those old photographs. The humor took another step as he put on the Groucho Marx mask that we bought to give to his grandson. It was one of those joyous experiences that I see day after day. For me, it’s the impact on peoples’ lives that really makes my day.





This patient is a Norwood Class 6 with salt & pepper, medium fine hair. “Before” on the left; “After” in the middle and on the right.

Propecia and Liver Disease

/by William Rassman, M.D./0 /

I have been taking propecia for about 6 years. I also have Primary Scholerosing Cholangitis (PSC), a liver disease. Do you know of any studies or have any other knowledge about the impact of propecia on the liver? Thank you.

There are warnings on the use of Propecia for those people with liver disease, however, it is not clear if the drug can negatively impact the liver directly in those with active liver disease. What I suspect is that the metabolism of the drug may be affected by active liver dysfunction. I will ask Merck, the makers of Propecia, about it and get clarification from them, getting back to you in the very near future. They are usually responsive to my questions.

UPDATE (May 3, 2005): Please see the response from Merck here.

Use Minoxidil After Transplant?

/by William Rassman, M.D./1 /

Hi,
I am 6 weeks post op. I received 1500 fu’s and earlier punch graft work repaired. Other than some minor shock loss in the donor area, I seem to be healing fine for 6 weeks. My question is this; I have never used Propecia or Minoxidil before. I am curious if 5% Minoxidil would speed up and/or enhance grafts. It states that Minoxidil only works in the vertex area. Would that not apply to recipient area on the top of my head? After all, the grafts were taken from below the vertex. Also, I’m using Mederma for scarring from old plug extraction on crown. Is it wise or safe to use Mederma and Minoxidil at the same time? I have purchased the Minoxidil, but have not used it yet. Any information would be appreciated. Thank you.

The donor hair will not be affected by Minoxidil so I do not recommend its use after a hair transplant. I generally put people on Propecia if they are young and in the balding process at almost any stage, as hair transplants can accelerate any hair loss process that is active. Mederma is an over-the-counter herbal medication that is recommended for (1) old scars, and (2) new scars. Its claims include that it softens the scars. It has no defined scientific benefit that I know of. I suspect that it is safe, but I do not have first hand knowledge about it.

Hair Transplant Advice

/by William Rassman, M.D./0 /,

Dr. Rassman:
I am a 25 year old male who over the past 2 years has begun to see hairloss (receding hairline starting at the front middle forehead and working its way back). I am using rogaine 5% and Propecia daily. Its been 12 months and I swear it doesnt seem to be working. Now I never noticed hair on the pillow, etc, but the loss was becoming apparant, and I am still not seeing it on my pillow. I can not go bald (many many nasty scars on the old dome). At 25 is it reasonable to get a transplant if I want to keep from getting to stage 3, 4, etc. My mother’s father was almost entirely bald, but no one else seems to have problems. What else should I try or do? Suppliments? I live in Florida and noticed you are only in California. How can I get an idea of cost, etc without flying to California? Please help!

At 25, with your history, it is most likely that your genetics are dictating the hair loss process. With both Rogaine (weak medication) and Propecia (strong medication) your ability to stop frontal hair loss appears improbable. You must assume that you will be like your family hair loss pattern (worst case scenario) and if you elect to go the transplant route, then starting in the front and working backward is the best way to go about it. It is possible that the medications you are taking may stop the hair loss short of your full family pattern, but I suspect the frontal hair will be lost. These medications work better on the back of your head than on the front. This makes you a wonderful hair transplant candidate, something we do on young men of your age all of the time.

First, take some good digital pictures of your balding head from front, top and sides, wet and dry then email them to me (my address is on the Contact page. If you are not technical, call my office 800-NEW-HAIR and we will send you a disposable camera. Then the next step will be a telephone consultation with us. From that point on, at the least, we can talk from ‘the same page’ knowing what is really happening. If you elect to come to California, then there is air fare subsidization of your trip and a night in a hotel (on us) once you arrive for your surgery. More info on the NHI Travel Program available at this page. When we speak, I can give you a cost estimate, best and worst case.

Procerin Info

/by William Rassman, M.D./7 /

Dan wrote…

a website called consumer-review.net/hair-loss.html rates a product called procerin higher than propecia, procerin’s website, procerin.com elaborates on their product. I was getting ready to order some procerin, when my wife heard your ad on the radio and I checked out your website, and read about dutasteride. Are you familiar with procerin ? Also could a dermatoligist prescribe dutasteride to patients before it has fda approval ? please advise

The product you described, like many other similar products, adhere to a very loose standard for the health food additives which are naturally found in the environment. There are many natural herbs that are poisonous as well. There is no requirement for any of these products to prove effectiveness or safety, unlike those that go through the rigorous FDA process. This is the reason that I maintain what I believe is a healthy skepticism for these ‘natural’ products. The same is true for my attitude for prescribing dutasteride for hair loss, which has not been shown to be both safe and effective for hair loss. I am familiar with hearsay reports that the libido impact is greater for dutasteride than with Propecia and the drug has a very long half life, which means that it takes months to get out of your system. If you should take dutasteride and develop a libido problem (for example), it may take 6-12 months for it to rectify, while with Propecia is would disappear in days. I personally would not be against prescribing dutasteride, but I have not done so yet. My motto, like any good doctor’s philosophy must be “Above all, do no harm”.

Also, it should be noted that the link on that consumer-review.net site you mentioned is an affiliate link to the Procerin site, meaning that Procerin pays that site if people use their link to buy the product. In that regard, it would seem that it’s in that site’s best interest to highly recommend Procerin.

First Course of Action

/by William Rassman, M.D./0 /

I am 34 years old and I have a receding hairline. Now, I am getting a bald spot on the top of my head. What should be my first course of action to save my hair?

The first course of action should be to see a competent doctor who understands the male pattern balding (MPB) process. He will examine the hair on different parts of your scalp and look for the amount of miniaturization that you are showing in various locations. The things he will identify will not be the level that you can see with the naked eye as balding occurs slowly and insidiously and can not be picked up without high powered examination of the hair. Based upon a proper examination, he should develop a master plan for you that will cover your worst case scenario and probably include the use of medications for MPB if that is your diagnosis.

Transplanting Into Scalp Scars

/by William Rassman, M.D./3 /

i have an unsightly scar on the side of my head approximately 4 inches long and 1/4 inch wide. is there anyway of repairing this? i tend to wear my hair short and i am fairly conscious about it.

Scars of the scalp can be difficult to deal with. I am assuming that the scar you are talking about is not related to a hair transplant. The management of scars is not well understood by many doctors because they generally do not look at the hair solutions that are, at times, critical in the final repair of the scars. Neurosurgery scars, accident scars, burn scars and the like require specialized knowledge of the scalp’s ability to heal in the area treated and the direction and location of the scar determine much of the outcome. Many scalp scars may have come with good medical care, so one has to think differently about scalp scars: what will make the next treatment better than the last one?

Send me a photo (preferably digital) and be sure that the scar location is clearly shown. Your confidentiality will be assured. My email address is on the Contact page.

Hair Cloning

/by William Rassman, M.D./17 /

Benjamin asked…

Are there any doctors who can clone donor hairs so that the amount of available donor hairs is no longer an issue with transplants?

The hair cloning issue keeps coming up because it seems to be promoted by some unscrupulous people who use the cloning ‘card’ as a way to elevate their own position of authority in this business. There is no cloning on the short-term horizon for hair, despite claims to the contrary. If and when the cloning problem for hair is solved from a research perspective that can be replicated , it will take legislation to make that reality into a clinical tool. Hair was first cloned by Jahoda in Scotland in the late 1980s. Since then, there is been a relatively long silence in the industry on repeating his work. His report stands alone as a successful cloning experiment. Attempts to do this in mice and other animals have produced many dead animals in at least one study I have been told about. Attempts to do this in humans have met with failure after failure. Fortunately, no deaths have occurred. I would urge all of my readers to be cautious about the cloning option and look skeptically at anyone who promotes it at this time.

Pigment Loss After Laser Hair Removal

/by William Rassman, M.D./1 /

I am 22 years old. I underwent 3 treatments of laser hair removal and believe that I have made the biggest mistake of my life. It was after my third treatment that I realized that the results I had in mind were not feasible at all. I have since stopped the treatments and am now trying to determine how much permanent damage was done to myself. My last treatment was in September of 2004. For many months there were lots of spots that were bare, but in the last couple of months I’ve noticed lots of hairs growing in. It seems as though it is filling in almost as thick as how it was before I started treatments. Although none of the hairs are growing in white, some of them are growing in light with hardly any pigment at all. Is this permanent or will the pigment fill in with time? Basically this question is leading into my next one which is the most important to me. Have I damaged the melanocytes in my hair or my in skin?

In response to your multiple questions, I can simply say that lasers do cause damage to the pigment cells both in the skin and in the hair. Hair has an amazing ability to come back, so maybe the changes in color that you noticed, may return after the hair goes through another cycle. There is nothing to do here other than wait it out. Be patient.

Appropriate Graft Numbers

/by William Rassman, M.D./0 /

I was told by my doctor that I need 3000-4000 grafts, but it would take at least 3 surgeries. He said that their maximum per day is 1000-1200 grafts. He said that limiting the number of grafts is better for graft growth and for patient comfort, since each surgery will take 7 or 8 hours. What do you think?

In your doctor’s hand, if his comfortable number is 1000-1200 grafts, than that is what he should do. Seven hours of surgery is a lot, so the number he is quoting is reasonable for him. In our practice, we often perform 3000-4000 grafts in a single session and it takes usually about 5 hours or so. The reason we can do this is because:

  1. We have been doing megasessions for 13 years, originating the technique back in 1992.
  2. We have very experienced team members who do this every day. Many of our staff have been with us for up to 10 years.
  3. Our staff is very efficient. Having enough efficient staff allow us to do more work in less time than most medical groups.
  4. Better growth reflects the issues of quality control and the time it takes to get the grafts into their recipient site. Keeping them out of solution for more than a few seconds, damages the grafts during the placement process.

In conclusion, three sessions of 1200 grafts moves the same amount of hair as one session of 3600 grafts, but it would not be in your best interest to push your doctor’s estimate of what he will transplant in one session for it will, almost certainly, reduce graft growth in his hands.

Suture Scarring

/by William Rassman, M.D./0 /

I have a couple stretch marks in my back donor area performed years ago from older methods of harvesting graphs.

My new HT doctor has revised these stretch marks by suturing into the subQutaneous. What is your opinion on this?

Thanks,
Tony

I am having difficulty understanding your question. I think you are saying that there are ‘rail road tracks’ where you were stitched years ago. If widely spaced sutures are placed a bit of a distance back from the wound, they tend to produce ‘hash marks’. Today’s suturing with very fine sutures close to the edge of the wound does not produce ‘hash marks’. Is this what your doctor is suggesting?

Dutasteride vs Propecia, Round 2

/by William Rassman, M.D./2 /,

Another Propecia question, this time from Thomas…

I have been on propecia now 9 months and have receded more and gotten thinner on top. Propecia either accelerated my mpb or did nothing for it. I am worse off now then when i started. I never used to have hair in the shower, on my hands, or in the sink..Ever since the 3rd month on propecia, it has not stopped. My head even itches now sometimes when it NEVER used to before. My question is can Dutasteride help me or because i had no response to Propecia, is it a waste of time?

I do not know your age or family history, when you started balding, or what pattern you are heading to. This information is critical. Already you know that Propecia has not helped you (slowed or stopped the hair loss) so this is already atypical. It is possible that you have other than a genetic cause for hair loss. Thyroid disease and some other medical conditions can produce hair loss that will not respond to Propecia.

With regard to Dutasteride, there is no doubt in my mind that it is a better DHT blocker than Propecia, but it has not been proven to be by appropriately controlled studies. A few doctors who I respect have used it for genetic hair loss and they tell me there is significant benefit in some patients that do not respond to Propecia.

First and foremost, you need to have a competent doctor make the assessment. If it proves to be genetic hair loss, then using a non-FDA approved medication (called off label use) has implications for both you and your doctor. If you are in the California area, I would be happy to see you personally and make that assessment.

Propecia and Prostate Cancer

/by William Rassman, M.D./0 /

I am almost 30 years old and just started propecia. My general practitioner advised against taking it due to the risk of prostate cancer. I’ve tried to research this and have not really found any evidence to support this other than the increased risk at the 5mg level.

I’ve been told by a few doctors that I should take propecia and not necessarily have a hair transplant at this time given that my hair is only beginning to thin; and that propecia should help.

Additionally, I’ve heard recently that I should not be surprised if “hair cloning” becomes available in the next few years. Would appreciate any comments.

Best Regards

Propecia, according to a recent article in the New England Journal of Medicine, reduces the risk of Prostate cancer by 25% in the men who were studied. I personally believe that it is a good medicine for this. There is some general argument on those who may develop cancer while on the drug, that the drug may have made the tumors look more aggressive. I think that the evidence amongst most knowledgeable people points to safety and Propecia is not a carcinogen. Your doctor is misinformed.

Hair cloning, I believe, will not be addressed in the next decade.

CNN released the following news in 2003: In the study, which was funded by the National Cancer Institute and published in the online version of the New England Journal of Medicine, researchers at 221 sites nationwide followed nearly 19,000 men older than 55 for seven years. About half of them were assigned at random to take either finasteride, a drug that lowers male hormone levels, or a placebo. By the end of the trial, those taking the drug reduced their risk of prostate cancer by nearly 25 percent over those on placebos.

Also, give the following reference to your doctor: New England Journal of Medicine Volume 349:2387-2398, December 18, 2003, Number 25, The Long-Term Effect of Doxazosin, Finasteride, and Combination Therapy on the Clinical Progression of Benign Prostatic Hyperplasia, John D. McConnell, M.D.,et. al.

Hair Pieces and Advancing Hair Loss

/by William Rassman, M.D./2 /

I live in Brasil, I’m 41 year old and my grade of baldness is 6 / 7. I use a hairpiece for 18 year and i want to get free of this, but i have a problem, because when i started using , i was able to avoid peolple noticing that was a hair piece, as was very natural and my baldness was class 2/3 and as i used to travel a lot i didn4t see people so frequently. My case i believe is needed a scalp reduction for a start, but i’m afraid of procedures go wrong and i cannot remove the hairpiece to much in advance. Please help me . I can travel to NHI if necesary but I can forward photos to a better evaluation of my case
Thanks

Your story of how one starts with a hair piece and then gets caught in a cycle of more and more dependence as the hair loss advances, is a common story. Many of our patients have been where you are now. The problem for advanced hair loss patterned people is the availability of supply. The basic point is to find out if there is enough donor hair, when combined with good styling, to produce the type of coverage you want or need. That depends upon many factors, of which the number of hairs available for transplants is only one of these factors:

  1. A better match of hair and skin color will work to your advantage, wavy hair and coarser hair also will work to your advantage if that is what you have. What is your skin and hair color?
  2. How loose is the skin in the back and sides of your scalp. For those who have loose skin, the availability of donor hair is generally higher.
  3. Is your hair wavy or straight?
  4. Is your hair coarse or fine?

Sending me a good set of pictures is important for me to establish a good baseline. Please answer the questions above for me in your responsive email. You can use the form or my email address on the Contact page.

In answer to your other point, the idea of using scalp reductions, I will just say that this procedure has fallen into a bad reputation and most good surgeons do not do them anymore. The problems are that there is severe scarring on many patients and thinning of the donor hair to such a degree that there is not enough donor hair to restore the frontal area. Although there are some patients that may do well with them, there are far too many risks for the average patient. I know about these risks because I had three scalp reductions in the early 90s and was left with scars and a return of my entire balding area. I eventually got transplants and had enough donor hair to fill in the crown defect. Best of all for me was that I had no frontal hairloss. Had I been a Class 6-7 balding pattern, I would have been in trouble. So in conclusion, cutting out the bald spot is a risky surgery with many things that could go wrong. The key to a good hair restoration procedure is low risk and a normal, hairy outcome in a reasonable time-frame.