Anemia and Hair Loss

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

I started researching on the web what I can do to prevent additional hair loss and ways to restore hair loss and found your website.

I was wondering if you could answer a question for me. Here’s a little history – I have had a medical condition which involved being on non-inflammatory steroids (prednisone) for 4 years and have had 3 surgeries. During each surgery I have noticed that my hair had gotten thinner. I also have a problem with being anemic due to the result of my prior medical problem and surgeries. I am supposed to be cured now, however, I have hair loss which is visible on the top of my head (easily to see my scalp). I’m only 34 years old and am very discouraged. Can my hair loss be restored by taking vitamins and/or iron pills? If not, what would I be facing to restore it? Can it even be restored at this point? Help!

You need to be examined to be sure that there is no other medical problem that is producing hair loss at this time. Anemia is just one of the causes of hair loss. Generally, vitamins and / or iron pills will have no effect. I am not sure if you are a man or woman from this question and this would be an important factor for men with hair loss that is genetic and precipitated by a medical condition will usually not get the hair back. You need to make an appointment with a competent doctor, who is familiar with hair loss.

Excess Sebum After Transplant

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

Hello! I had a transplant at NHI with Dr. Mcclellan in February 2005 (2000 grafts). After the growth, and then fall out, I am starting to sprout :) What I have developed the past 3-4 weeks is a horribly itchy scalp that feels slightly greasy and is covered with a layer of sebum.

I have tried Nizoral and Head & Shoulders, but am afraid they will make my hair fall out, and dry/damage it. Is this a normal occurence after a transplant? I am itching so badly, that I am starting to shed.

You will have to experiment with different shampoos and conditioners, to find out what works for you. Remember, a hair transplant is a series of organ transplants and each and every one of the follicular units are full organ. It appears from your question that the glands of the new hair are producing excess sebum. Possibly twice daily shampoos during this period might help. You are nearing the 8 month post operative period, so please make an appointment with me so that I can see where you are, and maybe give you a more personalized suggestion.

High Hairlines in Women

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

I am 20 years old and I was born with a very high hairline. I have always hated it. It makes my face look less feminine. Can you help me?

Hairline location is a genetic factor. If you look at ethnicity and family patterns, you will see wide variations in hairline location. I have always noticed very low hairlines of women from the Indian sub-continent, and I have seen family patterns where the hairlines on men were just as low. My own daughter has complained about her very high hairline, but is not at the point of wanting to do something about it.

What is a high hairline and how do you know you have one that can be fixed? If you look at the profile of the forehead, you will see a vertical part of the forehead where it is perpendicular to the floor. A transition takes place as the skull curves back, changing from a vertical to more of a horizontal position. The hairline is located at the point where the transition zone occurs from vertical to ‘horizontal’. The hairline can be located at any point along this zone. The higher it is located with respect to its location in this transition zone, the larger is the forehead. I have seen foreheads where the hairlines are located on the horizontal (top, flat) side of the head. In women, this rarely reflects balding or natural recession and most women see this pattern throughout their youthful days. The hairline is part of their unique look.

There are two approaches to deal with the hairline, both producing outstanding results. These two approaches are to (1) put hair transplants into the bare forehead, essentially putting hair where it never existed before, bringing it lower to the more vertical part of the forehead, and (2) move the hairline down surgically by excising a portion of the upper part of the forehead. The two approaches are both surgical and they are distinctly different, but the end point is about the same.

Hair Transplants to Create a New Hairline Location:
The transplant approach is a slower approach, putting hair into the upper forhead and waiting until it grows out. Generally, I like to wait between 7-8 months before judging if the thickness is enough to meet the need for fullness. These transplants will look just like the normal hair. While waiting for the transplants to grow, most women will style the hair to cover the hairline until the results meet their needs. Sometimes a second procedure is necessary. Not much risk involved in this procedure, but I would suggest that those interested in the risks of hair transplant review my book (click here) for a very comprehensive overview of hair transplantation. Although much of the book reflects hair transplantation in men, there is little difference between the risks in men or women.

Lower the Hairline with Surgery:
Moving the hairline down is a reasonable goal if the scalp of the patient has some reasonable laxity (looseness) to it. People with tight scalps are generally not a good candidate for this type of surgery. The best part of this approach is that the end results are obtained at the end of the surgery (you do not have to wait for the hair to grow out) and within a week, much of the swelling and ‘black and blue’ from the surgery is gone. We call this ‘instant gratification’ which gives this approach a clear advantage over the transplant route. The surgery requires heavier anesthesia than the hair transplant approach, but it still can be done under local anesthesia. There is more numbness after the surgery than with hair transplants and the numbness can last 6 months or more. Eventually, most people return normal sensation to the hairline area.

Scars are treated with a type of incision called ‘trichophytic’ which tends to force hair to grow through the scar for camouflage purposes. The greatest risk of this surgery is the risk of scarring. Most people who have this surgery do not develop socially noticeable scars, but for a small number of people, the scar may be noticeable. If the scar becomes an annoyance, it can be covered with cosmetics and it could even be treated with hair transplantation, which is very effective to cover such scars. Any transplants that are desired to treat the scar would be relatively unnoticeable. Few people seek hair transplants for treating the scar.

Moving hairlines down in women is a very different process than moving them down in men. Women generally have a stable hairline. It is very rare for women to recede with age from genetic causes. In men, it is completely another story because in addition to a genetically high hairline which we see in boys and young men, genetics may create a progressive process of further recession. For this reason, lowering the hairline in men with a hairline advancement procedure is not a viable option, but transplants can follow a receding hairline as age and genetic factors force the hairline further back.

Framing the face is critical to beauty and balance. For those individuals with disproportionably high hairlines, the upper part of the frame is not proportionally balanced to the distance between the nose and the chin. Just like the man with a receding hairline, a disproportionably high hairline in the female impacts the youthful appearance and beauty in the western view of beauty. By moving the hairline to a position that is more proportional, the results can dramatically change the proportions of the face.

Transplanting Identical Twins

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

I just saw pictures of identical twins, one transplanted with 3000 grafts and the other not. The twin who had transplants, also took Propecia at less than the recommended dose, while the non-transplanted twin did not take Propecia at all. The difference between the two was dramatic, of course.

I have seen many identical twins over the years. These two were done back in 1993, when one twin had 3300 grafts removed, and gave 800 of those grafts to his identical twin brother on that same day (on the house of course). The twin who had lost his hair had genetic MPB and wore a hair piece which pulled out most of his remaining hair and he became balder than the twin that had done nothing. Eventually, they both got transplants, and one more procedure was done where the recipient twin had to pay back the donor hair to his twin brother. The piece in the video is short, but you can see the dynamics between the two.

I also remember twins that had been done years apart. The first was done with the old plug technique elsewhere, and the second was done by me with FUT just 7 years ago. The one with the plugs does not like to talk about his hair transplant, while the patient who was done by me has been trying to get his brother to fix the old work. Unfortunately the “pluggy” twin has been gun-shy about surgery since he was plugged years ago and has not yet had repairs done.

From my experience, only a minority of twins go the transplant route. I wonder if it is because my focus is not to ‘sell’ hair transplants but to be a physician hair loss advisor and I do not exert pressure on my patients to go for the surgical solution.

Shaving the Recipient Area

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

I came into your office for a hair transplant in September of 2004. It was very successful and I now scheduled to come in for a second transplant to add density in a few weeks. When I came in for my first transplant I was surprised to hear that the doctor wanted to shave the recipient site of head to about 1/4″ in length. At the time it did not bother me, because I was able to wear a hat where I work. I am now coming in for a second session and things have changed. I need to be able to go back to work within four days of the surgery. I have spoken with several staff members at your office and they all have stated that there is no reason for the doctor to have to shave my head except in the donor area, but if my hair is long enough it will cover it up. I wanted to ask you personally if it is true that I don’t need to have the recipient site cut or shaved at all. My hair now is about 1 1/2″ long and I would like to leave it at that. If so I would also like to know why I had to do it the first time or was it just a personal preference of that doctor.

The recipient area does not have to be shaved for a hair transplant, but there are some doctors that prefer to make the recipient sites in a shaved area. When I am the physician I do not have the recipient area shaved.

Avodart and Mixing Shampoos

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

Hello Dr. Rassman.
Thank you for taking the time to respond. I also wanted to ask you about going on Avodart (Dutasteride) or it’s Generic Dutagen. I have been on Propecia since 1999, and I think it is no longer working. I read Merck’s official report on Propecia’s 5 year efficacy, and it looks like after 5 years Propecia stops growing any hair at all, and it’s ability to keep hair is weakened. Dutasteride appears to block 93% of DHT production, where Propecia can only block 38-45% DHT. Can I get a prescription form you or Dr. McClellan? I am noticing that my “own” non-transplanted hair is thinning, and hopefully the Dutasteride or it’s generic version can stop any more loss.

Also, I am using Nizoral shampoo (Ketoconazole) 2 times a week, and Head and Shoulders shampoo (Pyrithione Zinc) on the other days. Is it safe to mix the Ketoconazole and P. Zinc? A friend told me that the P. Zinc can cause miniaturization of the hair follicle, and mixing the 2 shampoos can have disastrous results. Then on the the other hand, many people on online hair loss forums are saying it is fine to mix the two shampoos. Only using Nizoral 2x a week does not stop my newly acquired incessant itching. It would be great if I knew it was safe to use Ketoconazole and P.Zinc.

Thank you so much for you time, I’m sure you hear all these worries all of the time. Now that I see my new hair sprouting, I want to keep it growing, and keep or grow more of my own.

Here is a link to some of my other posts with my comments on Avodart. I will make a decision with regards to prescribing Avodart in early September, after I return from the International Society of Hair Restoration Surgery meetings in Sydney, Australia.

With regard to the various questions you had concerning the shampoos you mentioned, I really do not know the answer, as many people respond differently to each. Experiment with each and when you find something working, then stick to it. Mixing shampoos should not be a problem.

Cost of Donor Scar Repair

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

I’m a former NHI patient with a bothersome donor scar. Say I came in and it was determined a certain repair treatment was indicated — would you charge full freight as if I were from another clinic?

Scars come from either the patient’s healing traits or the techniques used. For this reason, we have not charged any of ‘our’ past patients for a donor scar repair, providing that we did not have to transplant the scar. I believe that the new surgical techniques we have developed where scars can be removed, can improve scars that come about for failings of the older techniques. I believe that we should take care of our patients and that is part of our responsibility.

If we have to resort to an FUE for the repair, we have a charge between $1000-2000 per surgery (much less than our going rate) and most of these can be done in one or two sessions. In the past year, most of our patients have successfully improved their donor scars with this new technique and as a result we have not needed to do any FUE repairs in the past half year or so.

FUE Doctor Recommendation

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

I started my research on the fue procedure about six months ago and have come accross an organization known as DHI. My cousin had an fue transplant from them last year and recommended their work, their website is full of info and they have numerous locations. BUT, until I stumbled upon your website, I didnt know half the things I know now, for example the fact that a Doctor is best trained to perform such procedures and that one should look for endorcements from pioneers in the field. While browsing their section on what doctors say about their procedures, I found that your name was listed. PLEASE could you tell me if DHI is a good choice for my procedure, as after studying your credentials I graetly value your opinion. If I dont go with DHI, your organization will be next on my list. I thank you for your time in advance and will greatly appreciate your proffessional advice.
Thank you.

With regard to FUE, the field is still new and most of what I read/hear is through the advertising of particular doctors who promote FUE. From an insider point of view, I suspect some doctors who promote their skills in this area are not able to do a competent job at FUE, but I am not willing to name them because of possible slander issues and my lack of good solid information. This site is not put together to police the profession, but to give good advice to people like you on questions covering the entire range of subjects with regard to hair care. In searching out a doctor, you should always meet patients that they have done to be assured of the skills of that doctor. You would want to get good vibes on that doctor.

A while ago, I got a list of 500 patient references (source was a doctor who I knew was terrible and unethical). I picked up the phone and called the first 20 references that the doctor listed. Every one of the references (all had surgery with that medical group) told me horror story after horror story. I then realized that by publishing such a list, that particular doctor knew that few patients would make the effort to actually call these people and that the list of 500 references was enough to produce the credentials he wanted. This shows that when you do your research, you MUST follow the threads until you have clarity on the inquisition. This is a buyer’s market and as a buyer, please beware.

For information on FUE, please see:

What is the Cause for My Female Hair Loss?

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

34y/o female, on birth control, no visible medical conditions that I am aware. Started losing hair about 7 years ago once graduated from college and ended a three year engagemenet under stressful lconditions. Hair loss has progressedandrecentlynoticed the amount of thinning as I had a head full of thick hair. Now thinner, and every night shwer, there is always some hair in drain. Ihave tired multivitamins, Kevis, Advecia, and Hairgenesis….the vitamins helped but still falling out. I dont knowwha tto do….I am 5’2″, weight about 115-120 pounds. I was addicted to laxatives at one time but have since recovered. Could I have a vit. deficiancy? hormone problem dueto birth control? My thyroid checked out fine. I dont want to be 40 and bald. I have no children, no otehr medications.

It is hard to know exactly what the cause and solutions might be via email without first meeting you. My suggestion would be to please read my many answers to women with hair loss. I discuss the medical work-up required for women, plus the causes for it. A good doctor to check you out and a good hair doctor will go along way to help you focusing upon your hair loss problem. I am sorry to sound evasive, but hair loss in women is a difficult differential diagnosis.

Hair Becoming Minoxidil Dependent

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

Dr Rassman
I have heard anecdotal reports that the use of Minoxidil for diffuse thinning in men can cause the good terminal hair one currently has to become Minoxidil dependent and change the “good hair” into a fuzzier Minoxidil produced hair—any truth to that? Thank you

Minoxidil dependence does occur for the thinning hair associated with balding in both men and women. When it works, it can be dramatic, but the dependence is a reality that you must face, for if you stop the drug, you will lose all of the benefits including the hair that is preserved. Those men and women with normal hair do not have to worry about minoxidil dependence.

Can You Transplant the Widow’s Peak?

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

I want to have a widow’s peak like I did when I was younger. Can you transplant a widow’s peak?

Yes, you can transplant the widow’s peak. People have different types of widow’s peaks, with some having different directions. Any of them can be made. Here’s a widow’s peak that is 100% man made, along with the entire frontal hairline. The “before” photo is on the left, followed by the “after” on the right. The “after” photo was taken after two sessions totalling 3,702 grafts. Click the images below to enlarge.



This patient is also featured on the NHI website:

Taking Propecia While Starting a Family

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

I am consuming propecia for the past 6 month and i can see good results. My question is, i and my wife would like to have a baby. Is it safe to have a baby while i am on this medication because i have been told by a pharmacist that i should stop consuming propecia for at least 1 month before planning to do so. He said that it will probably do damage to a newly born child.

The half life of Propecia is 4 hours. That means that in 4 hours, there is 50% of the dose remaining, in 8 hours 25% remaining, in 12 hours 12.5% remaining, in 16 hours 6% remaining, in 20 hours, 3% remaining and in 24 hours 1.6% remains in your system.

Now the official answer from Merck is that you can continue to take Propecia while you are trying to get you wife pregnant. Different opinions from different doctors who are generally skeptical, tell their patients the following:

  1. Stop taking the drug while you are trying to get your wife pregnant.
  2. Stop taking the drug while your wife is pregnant.
  3. Stop taking the drug the month you are trying to get your wife pregnant and when successful, go back on it.
  4. Stop taking the drug for the one week a month when your wife is in her fertile period.

Clearly, this is your decision. I tend to recommend #4, not because I believe it, but because it is reasonably safe and will minimize the time off the drug. I am always concerned about losing the benefits of the drug, and running the risk of a dramatic hair loss.

Long Term Propecia with More Hair Loss

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

Please read and comment: Propecia (Finasteride) has been available since 1997 and is the first oral medication to ever be approved by the F.D.A. specifically for the prevention of hair loss. A physician’s prescription is required. The overwhelming majority of men using this drug experience some benefit from its use, sometimes dramatically. It takes a full year before the full benefits can be fully seen and appreciated. The recent 5-year research studies show that, for most patients, there is a substantial increase in the number and quality of hairs growing on the patient’s scalp for around 4 years. After that, the patient’s overall hair mass on top very gradually starts dropping ever so slightly each year, so that at the end of around 10 years, the patient is back to where he started 10 years earlier. So, in effect, for most patients it holds off the hereditary expression of hair loss for around 10 years. There also are many clinicians and investigators who believe that finasteride works nearly as well when administered in dosage amounts substantially lower (and cheaper) than that recommended by Merck.

Much of my opinion is projection and conjecture. Propecia hair loss curves show that hair loss continues, albeit slower, with the drug than without the drug after an initial gain in hair volume, but Propecia is still not the magic bullet for hair loss. After 5 years, the hair may return to the level that it was at prior to starting the drug, but that varies with patients. I had a discussion some years ago with researcher David Whitting, who told me that the Merck studies showed that Propecia was just as effective at 1mg, 5mg, 10mg and higher. The effectiveness dropped by 20% at ½ mg. So all I know is what the 7 years data shows (hair loss continues at a slower rate) and that lower doses than the recommended 1mg level are less effective. You are using generalities on what may happen at the 10 year mark. It may or may not happen. Avodart may be more effective than Propecia, but as of this moment, the data is not in my hands and the FDA has not ruled on safety and effectiveness issues.

Hair Transplant Horror Stories

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

As i am concerened by hairloss, I have looked at your site and read some useful information. The one question I had was, while going through the Horror Stories link [note: on our sister site, TheBaldMan.com], are there any horror stories which have occured after about the year 2000, and the development of FUE and FUT. I can understand that an operation which cuts a large chunk of skin out of a persons head is going to run the risk of causing a large scar and other related complications, but has the development of new techniques like those above which allow the removal of single hairs got away from these problem or has got other ones? Also why do so many people choose to keep the name of a bad doctor to themselves?

Thank you

You are correct that fewer and fewer horror stories are appearing because today’s techniques are much better than those of the 80s and early 90s. Certainly, the quality of the work of the top notch surgeons has improved to produce virtually undetectable transplants. The focus of those surgeons is now on improving the growth of transplanted hair. There are still some failures with these modern techniques because today’s FUE and FUT techniques require exacting methods which, if not followed, will cause the transplant not to grow.

Well trained doctors using modern techniques should produce not only undetectable transplants, but a very high survival rate. Still, there are some doctors who do not know what they are doing, and I still see some terrible complications which reflect a doctor’s lack of training, skills or ethics. I am also seeing more and more patients who are being transplanted that should not have been transplanted and those who being sold more grafts which are put in beyond the balding area and into the permanent hair zone, just to increase the fees. Find yourself an ethical doctor who uses modern techniques and be sure to meet with some of his patients before you take him/her on.

I often ask the same question that you did in this email: “Why are the names of bad doctors kept secret?” The answer here is that men are generally not confrontational, and they do not like to be reminded that they made a mistake. They do not want to relive a bad experience over and over again. Just sharing their stories to prevent others from making their same mistakes is not a pleasant experience for these victims.

Hair Transplant Questions

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

I am 20 years old and very nervous about losing my hair. Since about my senior year in highschool ive seen the front of my hair line recide. This is a very stressfull and private thing for me so I only talk to my family members about it. When I ask if it looks like im going bald the answer is always no. But my hair line from my senior pictures to now has deffinately changed. Its seems to be going back on the sides, right above the eyebrow.(im sure you know what im talking about. So I do have a couple of questions.

  1. Am I to young to get a hair transplant?
  2. How much hair do I have to lose to actually be able to get one. Im always reading different sites and all kids my ages ask almost hte same questions but everyone always says wait till you go more bald… Well I dont want to wait, I want to prevent it before it starts. I dont want any sign of thining hair or a reciding hairline. Its like my petpeve.
  3. Do hair transplants look like real hair, or can you tell the difference? Ive seen about 2 people in person that got them done..and one person It was pathetic he had like 3 strands of hair growing out of one section. Then about a 1/4 inch space and then more hair. If I get a transplant I want it to look so real that even I cant tell it was doen.

Also I was reading a question that someone posted on your site. And I read an answer by some John Doe. He said that there were scars from his transplant. This is the first time that ive ever heard anyhting about scars. Can you tell me more about that?

You have many questions, all good ones, but not easy to answer without writing a book. I actually wrote a book, The Patient’s Guide to Hair Restoration, which you can get by clicking here. The entire book is available in PDF format, but you can also order a complimentary print copy complete with photos at the Request Additional Info page. Many of these questions will be answered by the book or even in the previous blog questions from other young men about your age. No matter what I tell you, you must have a visit with a competent, caring doctor. Although I have performed hair transplants on patients as young as 18 years old, it is not my usual case, but before I would do this, I would want to know what is happening to you. Make an appointment with a good doctor who specializes in hair loss treatments. Dr. Robert Bernstein in New York is such a doctor, if you can handle the 5 hour drive to visit him. He is at (201) 585-1115.