Hair Loss From A Hair Transplant

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

Thanks again for your rapid reply. I have a question regarding “telogen effluvium” mentioned in an article authored by yourself and Dr. Bernstein, ‘Follicular Transplantation, Patient Evaluation and Surgical Planning’. (This was a very informative and helpful read) In the article you mention that existing hair in the recipient area could potentially be shed as a result of transplant surgery due to telogen effluvium. You conclude that “it is probably important to transplant enough hair to overwhelm any possible telogen effluvium that might occur so that the net effect of the transplant will be a positive one.”

My question is what exactly causes “telogen” effluvium? And whether there is anything one can do before, during or after the surgery to reduce this side effect and hence achieve better denser results. Since
this article was published in 1997, I was wondering if there has been more studies in this area and if anything can be done to prevent or reduce it.

The telogen effluvium that we have seen with what we used to call ‘Hair Transplant Shock Hair Loss’ can be largely prevented today with Propecia, with which we had little experience in 1997 when the articles were written. We have found that this drug will protect much of the hair that is impacted by genetic balding against the ‘shock hair loss’ we used to see. If the hair that falls out is the permanent hair (which happens rarely), it will usually come back. If “shock hair loss” occurs in women, I have never seen it not return. The cause of telogen effluvium is not known. Most of my views on it are empirical ones that, from a scientific viewpoint, are not proven but it allows me to explain the process to patients and to myself.

Polycystic Ovarian Syndrome

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

i have pcos, i have hair loss in the front of my skull, there are still some left but only a pathetic few. what should i do , i used to have this long black great hair. can i get it back.. thank you for your time.

Dr. Robert Bernstein (Hair Restoration Surgeon in New York) was kind enough to supply a thorough answer to this question for you…

Polycystic Ovarian Syndrome (PCOS), originally called Stein-Leventhal disease, represents a number of conditions where ovulation is inhibited and, as a result, the ovaries become cystic and secrete more androgens than normal. The most significant of these androgens is testosterone, but other related androgens such as dihydroepiandosterone (DHEA) may be produced as well. Testosterone is converted to a hormone called dihydrotestosterone (DHT). If women have a genetic predisposition to balding, this hormone will cause the follicles on the scalp to shrink (miniaturize) and eventually disappear.

There are a number of treatments for hair loss related to PCOS. The first is the drug finasteride. Although not FDA approved for women, finasteride blocks the production of DHT (this is the same medication that has been approved for treating hair loss in men under the name Propecia) and thus will decrease or reverse the process of miniaturization. Weight loss (if this is appropriate) may also be helpful as this will decrease the body’s production of testosterone. Spironolactone, a diuretic, blocks testosterone and can also be useful. Finally, birth control pills, because they contain estrogen, will lower testosterone in the blood stream and thus decrease the amount of DHT produced. Please remember that these treatments should only be used under a doctor’s supervision.

Scalp Reductions

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

I met with a doctor last week who suggested that I take out the bald area. I am very bald so the bald area is very big. Is this a good idea?

Removing the bald area (scalp reductions) were very popular surgeries 10+ years ago. Thousands of men have had it done. You might even see them at airports, where they have a scar down the middle of their head, like they had brain surgery. Starting with that as my answer, I think that you will see (from everything else I am about to write here) that I am not open minded about this surgery. First, I should state that I am a victim of this surgery, having had three such surgical procedures to remove my bald spot (much smaller than yours, I suspect). I was scarred, but I got lucky in that I did not pursue more than the three surgeries, for had I done so, I would have been really deformed.

These surgeries have many, many problems associated with them and they have been largely abandoned over the past 10 years, largely because of the efforts of myself and a small handful of other doctors who have brought the complication of this surgery to the public. The most important issue to remember here is that when you are considering a hair restoration procedure, you want low risk and high certainty in the outcome. These scalp reductions produced many, many risks and the outcome was only occasionally successful. This is not a good procedure to do. For more information, please see Scalp Reductions on the NHI website.

Pain with a Hair Transplant

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

I don’t like pain so I have stayed away from hair transplants. If I take the plunge, how much will it really hurt?

Pain is relative. When I discuss pain, I always discuss safety at the same time, for it is not worth putting someone’s health at risk to wipe out pain. Some people handle pain better than others so there are no absolute rules here. Most people tell me that it is like having your dentist making an injection in your gums, but the pain comes in two flavors:

  1. The pain from the administration of the anesthesia itself (like what the dentist does to numb your gums and nerves)
  2. The post operative pain. There is no pain once the local anesthesia takes effect, most patients either fall asleep or just relax and watch a movie during the procedure.

If the hair transplant is performed completely under local anesthesia, the risks to your health are almost non-existent. You almost never hear of a person dying from filling a cavity in a dental office, but many die crossing the street. Laughing gas, prior to the local injections of Xylocaine, helps with reducing the pain from the injections but doesn’t eliminate it. In some cases, the doctor will administer stronger medications that will block even more pain and will allow the patient to more fully relax. The risks to health of being “put out” completely are slightly higher than putting up with subdued pain with laughing gas. The choice is made between you and the doctor. I have found varying reactions to the injection pain, from “no big deal” to the other extreme. The pain from the injection rarely lasts more than a minute. During the surgery we make sure that you are kept pain free, and the medications given last for about a four hour period after you leave the office.

If there is pain following the transplant, it occurs the first night. To deal with that pain, we do give you medications to take with you that will block the pain. These medications are strong and I recommend that they be used for night use only. A sleeping aid is also given for you to use. The use of simple over-the-counter pain medications will work during the daytime. Rarely are there many complaints of pain after the first night.

Getting hair is far less painful than the emotional pain of going bald– at least, that is what my patients tell me. I feel that pain is a non-issue since we have effective ways to deal with it, most of them pleasantly.

Hair Attachments for Women

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

My girlfriend and I don’t think that we have hair loss problems (at least not yet), but we would LOVE to have fuller hair so that we wouldn’t need to use hair extensions (which I assume all the celebs use because no one has hair like that!). Could transplants do this for us too?

Historical Perspective: It is important to understand that many of the accoutrements that adorn our bodies arose from earlier, less sophisticated times. The use of wigs date back to the Egyptians in the years between 4000-300 BC. They were used extensively by men and women. The Greeks were the first to popularize wigs and braids and that began the long torturous route to hair styles that cycled in popularity for the next few thousand years. In the middle ages (1200-1400 AD), single women showed their health and vitality by demonstrating full heads of hair, much of the hair manufactured from animals. Once married, only the husband could see the head uncovered, so it was the young single, female that had to appear healthy and capable of producing healthy children. Even back then, women were packaging themselves for the marriage process. As the populations started to concentrate more and more in the cities, the disease tuberculosis, took its toll. For the malnourished females whose heads were uncovered, their hair showed a window into their core health. Those women who were not sick but had the misfortune to have a fine hair, appeared sickly. So women with a thin head of hair wore a wig or used braids to increase the fullness of their hair, thus appearing healthier. Sexual attractiveness and a healthy appearance were inextricably linked early in our evolving society. Paintings since the late renaissance, showed women with abundant body fat and full heads of luxurious hair. As tuberculosis is blind to socioeconomic conditions, the successful artisans were engaged by wealthier clients to create the illusion of health with abundant hair and lots of braids. The concepts of portrait art, showed what the person wanted to look like, not what they actually looked like. As the hair became thicker, it hid signs of illness or malnutrition. Braids became common place and the use of wigs and other hair extensions remain part of our cultural heritage, as our question suggests.

No, hair transplantation should not be used to increase the fullness of a normal head of hair, but the use of hair extensions and other such devices comes with a hidden cost for some people. That cost can be progressive hair loss. When it happens, it is caused by the continuous pulling that these devices produce on the hair at the point where they are attached. If you weave your existing hair into the matting of the extension to hold it, then the constant pulling from the attachment can produce Traction Alopecia (hair loss from pulling) and it can be permanent if the process continues. I have seen women with patches of hair loss or hair thinning from these extensions. What they do to manage the proble, is put in more extensions around the thinning area. This successfully masks the thinning area while it damages the healthy area nearby. Eventually, these damaged areas become confluent. My advice to you is to respect your hair and watch carefully for any signs of Traction Alopecia. Make sure that you are not starting a cycle that worsens with time.

Undetectable Hair Transplant

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

Dear Dr. Rassman,
I will like to know if you can you tell that someone had a hair transplant by looking at it?

Hair grows naturally in units of 1, 2, and 3 hairs each. The frontal hairline always has single hairs and a transition zone of these single hairs starts at the forehead (more widely spaced) and they then get closer together as you look further back into the actual denser hair. Within ¼ of an inch, these single hairs get noticeably denser and then groups of 2 hairs start appearing. I say this because to make a hair transplant look like God’s work, God’s design must be copied. The single hair leading edge of a non-transplanted person is erratic and disorderly. It is not heavy, so the idea that there is a ‘line’ with a hairline is a misconception. The transition zone makes the hairline imperceptible. If the pattern is created by the transplant surgeon with enough hair to mimic the normal transition zone, an observer should not be able to see a hairline nor a hair transplant. At our open house events (which we hold every month at each office) the people are amazed that they can not pick out those who had hair transplants from those that did not.

So simply answered, in 95% of all cases, a hair transplant should not be detectable as a hair transplant if there is enough hair to address the needs of the patient. Look at this video of a completely transplanted frontal hairline worked with a comb. Please note that this patient has a high contrast black hair against a light skin color (the most demanding combination). If there is anything abnormal looking about a hair transplant, it will always show up in someone with black hair and light skin.

Libido and Hair Loss

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

My husband is considering a transplant operation as one way to address his waning male libido – and yes, he has thinned quite a bit since he turned 50. A friend told him that since he (the friend) had hair transplants he was feeling more confident in ALL areas of his life, including his sex drive. Is this true? Better than Viagra?

Libido is a complex characteristic of the human male or female and is not related to just one factor. Clearly, what men think of their manhood, their attractiveness, their self-esteem, the influence of the woman in their life, directly impacts their libido. One of the important determining elements for libido has to do with a man’s emotional state and sense of well being. The second, is a man’s reaction to his hormonal influences and brain regulators that drive libido. We know that Testosterone is the most potent hormone that in determining the sex drive in men (and in women). Third, is the physical ability of a man’s penis to react to his sexual wants and needs. Penile function is another complex process and the failure of a penis to become erect, even in the motivated sexually driven male, will perpetuate (or make worse) sexual dysfunction.

With regard to your comment on the increased confidence of men who have had a hair transplant, well, this is a very common message my patients pass on to me. For example: One well known, rich, successful and happily married businessman came to me with a Class 6 (fairly bald) pattern. He had two transplant sessions totaling about 5000 grafts. He was dynamic and was known for his charismatic style in public – but there was a piece of the inner, sexual man what was influenced by his hair loss. His wife came to me a couple of years after I had finished his hair restoration process. When he told her of his decision to have a hair transplant, she was outwardly supportive, but secretly did not feel it was necessary. She told me that after her husband had his hair back, the man she married came back and her confession brought tears to my eyes. She told me that her love had never diminished as he was balding, because he was still the same man she fell in love with and married. Now she wanted me to share her joy in the decision and to thank me for my role in his restoration two years earlier.

This story should shed light on the secret inner man which is in every man. The inner man does not like aging, Balding is a reminder of the aging process that men hate. The problem for most men, however, is that the transplant route is imbued with negative connotations and men tend to be averse to the idea that their vanity is a problem for them. Facing their vanity without the support of a loving and understanding wife, can be a difficult decision for a married man. For the recently divorced man, on the other hand, hair transplantation is a common process during the post divorce period and with the change in their image (even the possibilities of a potentially painful surgery), a hair transplant is often moved to the forefront. With a change in the physical appearance that comes with a normal looking head of hair, comes a confidence and a libido to match provided the plumbing is in good condition.

Hair Loss in Children

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

I just found an article on the subject of hair loss in children which may have interest to my readers. See yesterday’s question from the young girl with possible genetic hair loss. This article is a bit technical but it does address the problem.

Androgenetic Alopecia in Children: report of 20 cases by Tosti A, Iorizzo M, Piraccini BM.
Research performed at: Department of Dermatology, University of Bologna,
Via Massarenti 1, 40138 Bologna, Italy. tosti@med.unibo.it

SUMMARY: Androgenetic alopecia (AGA) is the most common type of hair loss in adults. Although there are differences in the age at onset, the disease starts after puberty when enough testosterone is available to be transformed into dihydrotestosterone. We report 20 prepubertal children with AGA, 12 girls and eight boys, age range 6-10 years, observed over the last 4 years. All had normal physical development. Clinical examination showed hair loss with thinning and widening of the central parting of the scalp, both in boys and girls. In eight cases frontal accentuation and breach of frontal hairline were also present. The clinical diagnosis was confirmed by pull test, trichogram and dermoscopy in all cases, and by scalp biopsy performed in six cases. There was a strong family history of AGA in all patients. The onset of AGA is not expected to be seen in prepubertal patients without abnormal androgen levels. A common feature observed in our series of children with AGA was a strong genetic predisposition to the disease. Although the pathogenesis remains speculative, endocrine evaluation and a strict follow-up are strongly recommended.

Bridging the Generation Gap

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

I’m 22 and my dad is very very bald. When i look in the mirror, I see my dad and his dad. I love my dad and grandfather, but i dont want to look like them. Much of my front hair line is gone and I am starting to look far older than i am. When I spoke to my dad about a hair transplant, he told me that I should just accept my fate and go on with life. He also said I was being immature and going bald was just a natural thing. I’ve lost my confidence with women and have become shy and less social in general. What can I do to change my dad’s opinion?

There is a generation gap here. I can not change what your father thinks, nor the years of whatever the relationship is between you and him. First, I would ask you to look at how the two of you relate on other issues. IF this communication situation is unique to the balding problem, I would be surprised. Good communication is important. I have seen these problems often. Sometimes it reflects cultural issues. Many young men who are first generation Americans, see a different world than their parents who still may have a foot in another culture.

Many times I ask the young man to bring his father or both parents into the office to meet with me. I will sometimes work it out that I see them just before an open house, where the parents can get some sense of what other people can do and how they can change their balding appearance. These open house events serve to tell those that attend, that the people who get hair transplants are normal people, working people, lawyers, doctors and professionals of all sorts. Meeting other transplant patients that come from such a world does a great deal to bridge the communication gap between generations. The key here is not to confront your dad, but to ask for his help in evaluating the modern day alternatives to balding. Controlling what he sees, meeting with a good doctor (not a salesman) and meeting successful transplant patients might change his mind, or make him slightly more open minded. As you are still young, take your time in the process for a transplant at this time may not be the right thing for you to do. Consider taking the drug Propecia and see if it stops or reverses the hair loss. That approach, may be the best approach for you, as it will show to your dad that you have maturity on your part and a cautious skeptical approach to the problem and the solution. He can be a good friend and assist your decision making in more ways that you might think. Be optimistic, and approach the entire process cautiously.

Young Male Model’s Hairline

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

I’m 22, a model who has just recently hit it big. The clients seem to love my look, but I worry that my hairline is receding and my hair seems thinner, just like my older brother’s hair. It hasn’t been a problem yet on the job, but the competition is intense and I want to stay on the top as long as possible. My brother uses a scalp coloring agent which seems to cover the thinning, but I don’t think that will work for me under the lights. What are my realistic options? I have been extremely busy and don’t have much time between bookings. Are hair transplants an option ?

As young men age, the normal hairline does rise about ½ inch in the front and about 1 – 1 ½ inches in the corners. I call this the mature male hairline. This is not what the advertisers want in their young male models. Like with male actors, low hairlines are a sign of virility and youth, and no one wants to get cast as an older man before their time. This patient’s hairline is a great example of the youthful look (Patient RA, after 7,147 grafts). I have had the wonderful opportunity to work with many daytime actors during their off-season hiatus, to put back their adolescent hairline and they, like you, were afraid of being replaced with a more youthful ‘would be’ competitor. The best thing for you to do is to use Propecia and possibly consider Rogaine as well if you are really balding. A good evaluation by a competent doctor is an important first step. I would strongly suggest that you make an appointment to see me in my Los Angeles office. Having worked with so many actors and others in the public eye, I understand the sense of urgency, since your earning capacity can be affected.

Hair Loss in Teenage Female

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

I am an active 17 year old high school cheerleader and my hair which used to be thick, is now falling out and becoming thin, like my mother, my grandmother and two of my aunts. They tell me it is in the family, but not when they were my age. What should I do? If I go to a doctor, how do I find one?

Genetic causes of hair loss in a 17 year old female, is unusual. You were correct to ask your female relatives at what age the condition first appeared with them. I would first have a good doctor see you and look for medical causes of hair loss (there are many). The following problems are amongst those that should be considered: anemia, thyroid disease, connective tissue disease, various gynecological conditions and emotional stress. It is also important to review the use of medications that can cause hair loss, such as oral contraceptives, beta-blockers, Vitamin A, thyroid drugs, coumadin and prednisone if you are taking any of these. Many other medications can also contribute to hair loss so if you are taking any drugs of any type, then that should be looked into as well. The following laboratory tests may be useful if underlying problems are suspected: CBC, Chem Screen, ANA, T4, TSH, STS, Androstenedione, DHEA-Sulfate, Total and Free Testosterone.

It is possible that a medical condition may be the cause of your hair loss, so before you jump to conclusions that you are following your female relatives’ fate, I would have you checked out for these conditions. Also, please read my previous blog entry, Female Hair Loss.

Trichotillomania

/by William Rassman, M.D./9 /,

I have been picking my hair for years. I would like to think that I stopped, but I know that I keep picking at it. I now have a series of bald areas where the picking has taken out some hair. Is this permanent? Will it come back if I stop picking at it? Can it be transplanted if it does not grow back?

The medical condition is called trichotillomania. Children or adults sometimes twist or pull their hair, brows, or lashes until they come out. This hair pulling is sometimes a coping response to unpleasant stress and occasionally is a sign of a serious problem of an obsessive disorder. If the picking stops early enough, then the traction alopecia that results will reverse. However, this is not what usually happens as most of the people with this disorder continue to pick on the hair until it eventually becomes lost permanently. The best way to determine permanence is to look at the area with a high-powered microscope. Active areas of trichotillomania show blunted, short hairs which are signs of recent regrowth of plucked hair. When these short hairs do not show up under microscopic examination, the traction alopecia is probably permanent.

Yes, hair transplants can put the hair back in the area of alopecia produced by trichotillomania, but the problem with doing it is that the person will just pluck out the same hair again and again and produce the bald spot. What is the point of transplanting the area of alopecia only to have it returned? The key is to address the trichotillomania from a medical/psychiatric medication or therapy approach and solve the underlying problem. Once the patient knows that the cause of the trichotillomania has been fully addressed, then the reward can be a hair transplant to put their hair back.

Malpractice Information

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

I had a hair transplant that deformed me a number of years ago. I have been depressed and angry, hiding under a baseball hat much of the time. Now, I want to get back at the doctor and make him pay me for my suffering. He had no right to do this to me and had I know what I was getting, I would never had the surgery done. How does one find a lawyer to represent me in a malpractice case against the doctor?


This is a hard question for many reasons. First, you are angry and I understand the anger, but you did make the choice to have the procedure and must recognize your role in enabling the doctor, even though you feel that you were a victim. The old axiom, ‘buyer beware’ holds for anything you buy, even a hair transplant. I am not sanctioning what happened to you, for I have seen hundreds of men in your situation and I have great compassion for someone who wanted to take charge and improve their appearance, and find themselves going south when they wanted to go north. Unfortunately, the old procedures did not meet the standards of many people. Today’s surgery is much better and the standards are good enough to meet even the most critical buyer.

First, I must qualify my credentials by saying that I am not a lawyer, just a well informed doctor. Every State has a ‘Statute of Limitations’ which means that you must file an action within (usually) 2-3 years of the point when you realized you were damaged. I will assume that your surgery goes back to the old days when big plugs were done (10 + year ago). You can, of course, go back to the doctor who did the work and ask him to fix it. A good doctor should try to make things right, but with your degree of anger, you must first address your anger and try to determine just what you want to do about the problem that you are living with. Alternatives to a malpractice suit include: (a) Complaints to the State Medical Board (which in California are always investigated by representatives of the State Attorney General’s office), and (b) Complaints to the Better Business Bureau (this is a place that new patients will often go when checking out a doctor).

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Does Blow-Drying Accelerate Hair Loss?

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

Dr. Rassman,
Does blow-drying your hair accelerate hair loss? If so, is it worse if you use a brush attachment? Can you blow-dry transplanted hair?
If the plan is to transplant, say, 1200 follicles, how does the patient know that many were actually transplanted? Thanks, Doctor.

Blow drying does not accelerate the hair loss, but as the hair becomes miniaturized, the hair is more fragile and if one pulls too much or handles the hair roughly, then the hair may break off, giving the illusion that the hair loss is accelerating.

I really do not believe that you need to worry about the number of grafts you are paying for in our office. My finance office reconciles the patient accounting daily and routinely refunds money to patients who did not receive the targeted number of grafts. One of my patients, a well known actor, paid for 2500 grafts at my personal rate of $10/graft. When the accounting was finalized that day, he only got 1400 grafts, so we sent him a refund check for $11,000. After he got the check, he called me and argued with me, telling me that he did not care about the money and that I should keep the money. I refused to do so, saying that if he did not care about the money, he should give it to a charity, but that I had not earned it, so it was not mine to keep. He did make a donation of $11,000 to his favorite charity with my name on the donation. Integrity is either in a person or it is not and I was raised to believe that you can often tell the integrity of a man by his business dealings.

Removing Scalp Tattoo

/by William Rassman, M.D./6 /

I have tried hair systems, weaves and all of these newest innovations in this field. Then I started getting transplants in 1987, with 5 scalp reductions and 7 hair transplant procedures. The more I did, the worse I looked. So I came up with the idea that I could tattoo my scalp and make it look like hair by putting brown dots the color of my dark hair. I then shaved my head. The tattoos were done on my scars as well. For a while they looked OK, but then the brown color started to turn green. Now I have a green head. Do you have a solution for this? Can the tattoo color be returned or can they just be removed? What would you suggest?

I have seen problems like this in the past. Creative people come up with creative answers to problems, but when the solutions fail, the consequences are sometime profound. I have had two such patients: The first had terrible scars that were treated with a balloon insert to stretch the normal scalp so that the tattooed scalp could be removed. The balloon was in inflated 2-3 times each week for 10 weeks before the scar was removed. It worked nicely and he was fortunate to have enough normal scalp to stretch the excised scalp defect. The second patient went through the same thing you did. He did not have a great deal of hair left, but he did have enough to start to cover some of the most prominent balding areas . The bad scars were improved with some scar surgery and the transplants did help. This second patient and his girlfriend were very grateful for the improvement and remain amongst the most happy of my patients. It was an important lesson for me – that working through problems with the patient as a partner with realistic goals, is the best way to make the best out of a bad situation.