Repairing Plugs

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

I had a hair plug transplant back in 1989 when I was in my mid-20s and desperately worried about going bald. My own hair is now thinning around where these were placed and they are beginning to show. I also have a scarring at the back of the head from the donor site. Is there any way back from this big mistake I made (the original treatment was for three sessions but I only had one after I realized fully what i had let myself in for). I’m now not bothered about being bald as such, so long as i can have a natural look. However, I am worried about these plugs (I did have electrolysis on them a few years back; is that the answer?). There is also the problem of the donor site. I can’t cut my hair short because the ‘holes’ would be exposed. Is a strand-by-strand hair transplant on a hair plug donor site possible? Is there any way of solving this??

Most of the tens of thousands of men who had these procedures prior to the early 90s are in exactly the same place you are in. We have developed techniques to fix these which I would recommend that you read in our publications in medical journals, particularly Art of Repair, Part 1 and Art of Repair, Part 2 . These articles and other material that can be seen on the NHI site have great illustrations of folks like you with similar problems. There are some wonderful solutions, but totally undoing the mistake may not be one of your options. If you are in California or near New York, we can arrange for you to be evaluated. Otherwise, look at the hair society website ISHRS.org for the names of doctors in your area that may be worth investigating. If you would like to send me photographs, I would be willing to give you an opinion. If you want to take me up on this, send photos and write to me at the email address on the Contact page.

Hair Loss in Young African American Man

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

Dr. Rassman;

As hard as this may seem to believe (especially for me), I am a 20 year old African American male who started losing my frontal hairline at the young age of 18. I am a sophmore in college and only started losing hair a few months after my first year. I am foolishly hoping that there is some other unknown cause to my early hairloss besides MPB (i.e.-I wore tight cornrow braids for a year, have heavy dandruff, and am also a heavy marijuana smoker) but I know this is unlikely. I have not had any tests done. I am wondering what my best options are considering that I am a college student with low income. I do not want to only stop hairloss, I really need to re-grow the hair I already lost. I am well into a Norwood class type III and have been for about a year now. I also cannot shave my head completely bald because of dark spots on my scalp and the weird shape of my dome. My situation is devastating due to my age and lack of money. I feel that NHI is really the most sincere and genuine hair transplant program and would be the most truthful and accurate with any advice they could offer. Thank you in advance for your time, patience, and assistance.

Robbed of Youth

Returning lost hair may be impractical for genetic hair loss. If you had your hair in tight braids when you were young, what you may be experiencing is some impact of traction alopecia modified by the genetic process. Whatever the cause, you do need to be examined by a competent doctor to make a diagnosis. The drug Propecia can return hair that has been lost, usually not as much in the front as elsewhere on the scalp. This is a prescription item, so again you need to be seen by a good doctor. A good Dermatologist should be able to do this. We have offices in California and and an affliated office in New York, so if you can get to one of our offices, we would be happy to examine you. Otherwise, look for a doctor in your area at ISHRS.org. You are too young for transplants, so be sure that no one does a hair transplant on you and stay away from anyone that pressures you to do surgery.

The Lion’s Mane

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

Sir, my age is about 23 years i am the student of information technology where hairs are the main part of human personality which make a man live and active every here. when ever i use to set with my friends and compare my hair i feel some shame. My hair are falling with a big speed what should i do.

I use the metaphor that hair to men is like the ‘lion’s mane’ is to a lion. It is what creates his majestic look. You are like the lion, and are confronting a real problem- that your age and your hair do not conform with the overall image that the world expects. At your age, I understand that confidence in your appearance does count for your ability to feel comfortable with others. The shame you feel is clearly not of your making but you feel it nevertheless. None of these feelings are abnormal behavior and I have seen it in many men of all ages-from all walks of life. No one wants to look old and our society has been less than fair to the balding men out there, many times cruel.

There is good news for people with hair loss. The drug Propecia can slow, stop or possibly reverse hair loss in young men and it has been on the market for 8 years with good results reported by millions of men. I would advise you to seek out a competent doctor in this field (your dermatologist or family practitioner), then seek his advice. I am certain that this drug will help most young men with hair loss, but you need a diagnosis and you need a doctor to manage you. If you are in California or New York, you can make an appointment with me or one of my associates (see newhair.com) or if you are not near by, visit ISHRS.org where other doctors who focus on this field can be found in your area.

Most 23 year olds are not good candidates for hair transplants for it may be too early, but the future is bright. Good luck.

MFG, MUG, and FUT

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

I have been reading about Multiunit Family Groups (MFGs) and Multi Unit Groups (MUGs) which are felt by those who do them to be as good as Follicular Unit Transplants. These claims are very confusing. I met with a doctor last week who does MUGs and he stated that they are essentially the same as Follicular Unit Transplants. Is that true?

The reason that many people use MUGs or MFGs is that they can not or will not put the effort in learning or mastering the Follicular Unit Grafting techniques which are clearly more difficult and more expensive to deliver. There is a great movement to show equality between MUGs and MFGs and the golden standard Follicular Unit Transplants, which is absolutely not the case. At the ISHRS convention these past few years, some doctors showed off patients with MUGs and MFGs. They were at the same session as patients with final results from Follicular Unit Transplants and they are clearly not as good on close inspection. Like the “Emperor’s New Clothes’ , the MUGs and MFGs proponents want to believe that it is something that it is not.

Clearly, the use of MUGs and MFGs are better, much better than the old large plugs of yesterday. But they are just smaller plugs made up of groups of Follicular Units which when placed into MUGs and MFGs, tend to become compressed and look ‘stalky’. Real Follicular Unit Transplants are more difficult to do, but the quality on close inspection with Follicular Unit Transplantation can not be told from God’s work in the best of hands, most of the time.

William Shakespeare said, “A rose by any other name would smell as sweet“, but the MUGs and MFGs doctors might modify this famous quote by declaring that a synthetic paper rose with perfume on it is exactly the same as a real rose for all practical purposes because it may (from a distance) look like a rose.

I think that Shakespeare was talking only about real roses and I am talking only about what God had designed in his original plan for us. We are naturally put together with Follicular Units, not MUGs and MFGs. Sorry if I offended anybody here.

Graft Density

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

How many micrografts are there per cm2?

The density on the human scalp is 193.75 hairs per square cm or 1250 hairs per square inch. The average human head has 80 square inches to it which translates to 100,000 hairs on a typical Caucasian. Asians have about 80,000 hairs and Africans have about 60,000 hairs. Assuming the average follicular unit has 2 hairs each (typical Caucasian), that would put the numbers at 100 follicular units per square cm in a typical non-balding Caucasian. Doctors can transplant (with modern dense packing techniques) about 50 follicular units per square cm (100 hairs on average) when indicated. Clearly there issues that logically should point to how much coverage can one get. The higher the density, the smaller the area of coverage (assuming supply limitations which are always a factor) In a very bald person, it would be virtually impossible to transplant such high densities to cover the entire balding area as the supply would clearly not meet the needs. So the artistry of the doctor becomes important to maximize the characteristics of the patient’s hair.

Propecia and Liver Disease (Follow-Up)

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

I just heard back from the manufacturer of Propecia, Merck, concerning the question raised on April 29th (see: Propecia and Liver Disease). The question related to a person with a liver disease called Primary Scholerosing Cholangitis (PSC) and the safety issues with using Propecia.

A detailed three page answer was forwarded to me (with quotes from many scientific publications), so I will summarize it as simply as I can. The drug experience comes from Merck’s experience with Proscar (5mgs of Finasteride) and Propecia (1mg of Finasteride). A liver adverse effect has not been listed in the clinical trials of the drug for hair loss treatment. The drug itself is broken down by the liver, so decreased liver function will directly impact the rate at which the drug is metabolized by the liver and will keep serum levels higher in people known to have decreased liver function. In other words, the ability of the liver to clear this drug from the body may cause the serum levels to be higher than on someone without liver disease. There has been no study performed on the effects of hepatic insufficiency for Finasteride pharmacokinetics. Also, a search of the medical literature did show a rise in liver enzymes in one of 14 subjects studied in healthy volunteers (Shimazaki and Nose). One case of hepatitis induced by Finasteride was reported in a patient with many organ problems including a high alcohol intake. The inability to find another cause for the hepatitis on this patient led the doctors to believe that this drug may have been the cause for the liver disease on this one patient. When the drug Finasteride has been used with Flutamide, there was some impact possibly inducing liver disease.

In conclusion, I would strongly suggest that if you have known liver disease, that you use this drug with caution. Follow the use of the drug as prescribed in the literature and have a doctor follow your liver function tests periodically with the use of this medication. Liver disease in healthy people has not been reported (based upon the Merck communication with me). I would not consider liver disease as a significant risk in the typical patient’s routine use. But as a caution, every medication that anyone takes has potential risks associated with it. Even vitamins and Aspirin have their problems, yet we seem to continue to use them as well. The challenge is to balance reasonable risks against the alternative hair loss that might be slowed, stopped or reversed on this medication.

Hair Lasers

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

I have seen ads all over the newspapers on hair lasers. What is the deal on them?

When you probe what these devices actually do, you often hear either unjustified claims (which are not legal from an FDA or FCC point of view) or that “studies are being done” and naming prominent people involved in these studies (as if to justify their premature endorsements). We never hear about the final results of negative studies! Reports from prominent doctors in my community tell me that they have seen a very high disappointed group of early adopters who participate in these modalities, but then again, my community of doctors are not experts in these lasers and they may have been negative from the start, not keeping an open mind. Some doctors, on the other hand, have become enthusiastic about them, but most of their observations are based upon subjective observations. A small number of people report some gain from the lasers and some segments of the European medical community seem to be enthusiastic for its value.

I personally believe that the literature I read does suggest that there is some stimulation to the vasculature of the scalp and that this impacts hair regrowth, but if so, then the question should become “, Growth? By How Much?”. I really think we should wait for final results on hair growth with good scientific trials before the medical community endorses this modality. I am supportive, however, of all uses of this modality on an experimental basis. What concerns me is if a doctor focuses upon money-making add-ons with any less than proven value defined scientifically like questionable creams and potions (like having a large display of hair conditioners, shampoos, “scalp cleaners,” etc as a focus on their medical practice that claim to make the hair grow), then the objectivity of the doctor as a consumer advocate will be questionable when it comes to these modalities. Sorry to be such a curmudgeon, but I will have to wait until I see some convincing proof of value before endorsing such approaches for saving my patient’s hair.

Hair Sales Questions

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

I loved the question about the salesman and the consultation [see: Hair Salesman]. I am a professional salesman selling high end cars, and I fully understand this issue. When one is selling a car or a service, the businessman asks: how many people does one have to go through to get a sale? Now with that said, How many prospective candidates do you go through to make a sale?

We call this conversion rates. Taking 100 people coming through, how many will sooner or later (within 2 years) make the decision to have a surgery. I have found that the number for my practice is between 33-40% and for other doctors working for me it is about 25-30%. My ‘conversions’ are higher because most of the people who come to see me know about my reputation in advance and often have made up their mind in advance of the visit. I am often the last doctor that they will visit. Still, my conversion numbers are low because I turn down most women (they often can not be helped), young men (who are too young and therefore too early in the process), people with unrealistic expectation, etc.. A salesman would view that the right conversion rate should be the majority of people coming through the door-whether they truly needed the surgery or not. When I had worked for another medical group who had employed a full time sales force, the conversation rates ranged between 50-95%! They would have fired me for my low conversion rate if I was one of their salesmen. That tells me that those doctors who employ salesmen, insulate themselves from the patient. These doctors build more a money focused practice than a people focused practice. My style is to use the medical forums and meeting, my website, the internet and activities like this BaldingBlog to communicate and educate, then have the prospective patient come to see me after they are informed. I have built a boutique practice where I have Hollywood stars and heads of state or CEOs of large companies as often as blue collar workers.

Propecia Patient Results (with Photos)

/by William Rassman, M.D./18 /,

Dr. Rassman, I saw one of your comments on Propecia on the balding blog. You are welcome to use my pictures to show your bloggers what the drug can do. As you remember, I am 39 years old and I got these results in just 8 months on the drug. Contrary to what some say about the sex drive, the drug did nothing to suppress it. Sometimes I wish it did. I saw a couple of other doctors before I started Propecia and one had a salesman who tried to sell me 1500 grafts. He said Propecia would not work. Glad I did not have the surgery and listened to you guys.

Thanks for coming forward on this very important issue. The young man can get an outstanding response from Propecia, especially the ones under 30. You are an exception to the rule and a lucky one at that. Although sometimes I feel like a Merck salesman, because I suggest this medication for many of my patients, it is because of people like you that I have become an enthusiast for Propecia. Although the corners did not return, the fullness you wanted was achieved and you are happy. That is what this is all about. You were wise to seek out other opinions and I applaud you for such persistence. There is no “A” given in school for such decisions, and in the real world, the hairy guy you look at in the mirror every day is better than that “A” on a report card.

The below photo on the left is before Propecia use (scanned from a Polaroid, so please forgive the quality); below photo on the right was taken about 21 months after continued Propecia use. He’s had no hair transplant surgery. Click the photos below to enlarge.

 

Tags: propecia, finasteride, hairloss, hair loss, merck

Hair Loss and Accutane

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

Dr. Rassman,
Thanks for taking the time to review my circumstance. i am 35 yrs old and have been thinning for the last 5-6 years. I currently use minoxidil and the lost has seemed to stop. A dermatologist said it was MPb after a brief exam. There are a couple of reasons why i disagree with this. first there is not one case of any member of my family even thinning much less losing their hair. second my hair doesnt look like a typical MPB patient. i have a real good hairline and decent coverage all over the top its just thin, much thinner than the sides which are quiet full. i also visited a Hair center to discuss some options and the interviewer was agreed that it didnt fit the normal profile. I am wondering if it is a hormonal issue. I took accutane when i was younger if that has any bearing. Also around the time i started losing my hair i started to sweat a bit more than usual Any help would be greatly appreciated

Genetic variations are wide and family patterns do not always show balding. Now with that said, I would want to see you to map out the miniaturization in the head and then determine if this is one of the variations we see in genetic hair loss. Accutane clearly does participate in the process and if you are genetically prone, it may contribute to the genetic hair loss.

Send me pictures as a start (my email address is on the Contact page). You clearly need a diagnosis. Let me know which city you are in and if you are not near one of our offices, I may be able to refer you to someone who can help make a diagnosis.

Female Hormones and Hair Loss

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

I was prescribed topical estradiol shampoo .05% for hair loss (Bout with TE spring 2004, Hair wasn’t growing back in very well in some areas). Within 3mos. of using this hair is now falling out. Do you have any information on this. My Dr. says that it does not cause hair loss suppose to maintain growing phase longer. Came across a study that says that it can induce hair into telogen. Who’s right? Any help would be greatly appreciated!!!!

Yes, hormones can cause hair loss. Female hair loss is a strange ‘beast’ because our understanding of it is very poor. The best indication of the hair loss impact of your estradiol is the observation that it caused hair loss in your situation. I would suggest stopping it and seeing if it returns. You might have to wait 6 months for reversal.

Hair Salesman

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

I went to a hair transplant facility the other day and had a consultation. Most of the time I was there was spent with a salesman. Is this usual? Do they generally get a commission of I sign up.

Your question is a good one. Unfortunately, many doctors in this field do use salesmen as communicators for their patient interactions. Although I have never done this, I do understand the huge costs involved in patient education and communication. The salesmen do perform that role well, but in the ending part of the question, you raised the most important issue, the one which defines whose interests are being weighed during the consultation process. The laws of all states generally forbid the payment of commissions to ‘communicators’, but I have no doubt that most salesmen have incentives to sell the hair transplant process. The doctor, on the other hand, is sworn by oath to put your needs ahead of his financial interests. There is clearly a conflict between selling you the transplant and watching out for your needs. You might judge the doctor by how much of his time you are worth.