Burns to the Scalp

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

I have researched your website and I am curious as to whether or not any of these procedures would work for me. I suffered from 3rd degree burns resulting from being trapped in a burning car after a MVA. My scalp was burned past the follicle in a large area ( mainly the top). I have been undergoing burn treatment for the past few years. My surgeon and have been using tissue expanders to restore my hair. I am concerned that this is a long process and involoves a few surgeries every 6-9 months. So I am looking for options and short-cuts. Any suggestions?

What you said sounds like your doctors know what they are doing and have developed a good, sound strategy. If you would like a second opinion, it would be very difficult to do it over a long distance. Sending photographs of good quality would help and I would be willing to take a look and verify the plan, but it sounds like you are in good hands. Why are you writing to me now? How far have you gone with your present medical team? Are they responsive to your questions and do you have confidence in them? These are basic questions that may speak to your overall comfort and the communications you have with your medical team. When you have the confidence in the team, then you should stay with the winning team. There are no shortcuts to problems of your type. Be sure that when transplants are the refining step, that your transplant surgeon knows how to manage a case like yours, as the transplant surgeon will frequently have different skills than the team of plastic surgeons who are managing your ’tissue expanders’.

Tidbits: Balding in Indians and Asians

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

A few times each month, I will post some random hair-related information, which I’m calling “tidbits”. I spend hours each day writing responses to questions I receive on this blog, so it is a nice change of pace. For example…

American Indian

The American Indian (or Native American, if you prefer) has no genetic balding if their ancestry is from the Alaskan Bridge. American Indians that came to North America from Central America can have genetic balding. There has been no explanation why the American Indian does not have genetic balding, making him unique amongst all men (except those born with genetic defects in the DHT making enzyme or those who eat large amounts of DHT blockers in their diets, a group of primative people from the Central American rain forest).

The observation that men from Asia, India, or China have less balding is certainly not a reality today where the wig business is thriving. A theory put forward by Dr. Masumi Inaba in his 1996 book “Androgenetic Alopecia” claimed that there was more baldness in the post WWII Japanese men than in the earlier generation to which he belonged. I think that he attributed this to dietary change and in particular, to more saturated fat in the Japanese diet. The same theory, if true, could apply to Indians, who have only a small meat intake back in India (strict Hindus eat no meat at all). Dr. Inaba’s theory never gained any credence then or since, but history shows that if his theories are proven correct, he would not be the first scientist to be proven right a decade or more after his death.

History points to insights as we get further away from the facts as we see them. Dr John Snow back in the mid 19th century proclaimed that Cholera came from contaminated water while most other “experts ” believe it was transmitted by bad smell (the “miasma”). The entire London sewerage system was designed to get rid of the stench that permeated the city every summer (and coincided with cholera outbreaks) . The sewerage system was an engineering marvel with the worlds largest pumps and miles of brick lined tunnels. It got rid of the smell and coincidentally got rid of the source of water contamination and cholera became very rare. The cholera organism and its lethal effects were not discoved until many years after Snow was dead and buried. (This last paragraph was written by Dr. Richard Shiell of Sydney Australia)

Considering Future Hair Loss

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

i am 56/m, bald at the crown. with general thinning on the top and front. because my hair is still falling out i would expect to be compleatly bald in the norwood 6 area in 1 to 2 years. my hair is very fine. can i get a transplant that will also take into consideration my future hair loss, or will i have to repeat the process as my natural hair reduces to zero. if this is a stupid question please forgive my ignorance.

p.s. can you recommend a surgeon in the u.k. who is of your standard both ethically and medically. also i am a blue coller worker, so i would need a to get a loan, can you give me a estimate of a average price for a norward 6 transplant.

p.p.s. GREAT SITE.

At 56, it would be unlikely that you will complete your expected Class 6 pattern, because at your age, the hair loss is often very slow (almost to a stop) in most men. If you want to fill in the frontal and top areas, that would be the best place to start. The crown often takes a great deal of hair to fill in. With regard to a hair transplant surgeon in the UK, consider the physician search at ISHRS.org for a place to look and be sure to read The Truth About Cheap Hair Transplants as a buyer’s guide to selecting a doctor. Both the NHI site and my book also cover different aspects of the buyer’s challenge. Loans vary with the doctor, where some have arranged credit sources. Many of our patients put the hair transplant on a credit card.

Hair Loss from Tuberculosis?

/by William Rassman, M.D./5 /, ,

My 17 years old daughter was diagnosed with inactive tuberculosis about 8 months ago and has been taking INH. However, about 18 months ago she started losing her hair. Could this be caused by the tuberculosis alone?

I have written on this medication with tuberculosis before (see Tuberculosis Drug and Hair Loss). The disease itself is a wasting disorder which is known to produce hair loss, as with other wasting disorders. The same recommendations I made before apply: good diet and appropriate vitamin therapy. A full work-up for female hair loss is in order here as there are many diseases that cause hair loss in women (see Female Hair Loss category). Read these pages carefully and seek out a good doctor to follow through with a thorough examination of your daughter. Also, you might want her to see a hair specialist who will study her for female genetic hair loss and assess the miniaturization of her hair to see if the pattern is typical of female genetic hair loss.

Female Hair Loss — What to Do?

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

I have been losing my hair for years. I’ve been a sucker for many high priced hoaxes and am now to the point where the comb over is barely hiding it anymore. I’ve lost so much of my hair on the front/top and am ashamed to even look in the mirror, I feel like crying each morning when I style my hair. When people look at me I can’t help but feel like they are laughing, I’m only 30. I had asked my doctor awhile back (when I was about 22-23), but his advice to me was to learn to live with it, there’s nothing that can be done for hair loss. Please, is there any product out there that you would recommend for me to research, (I know in the medical world you can’t recommend a product for me to try), so all I’m asking for is a point in the right direction. Every time I try I just feel more defeated, there are so many products out there, I know most of them are little more than snake oil. Please please help–I don’t know where else to turn for an unbiased recommendation.

I hesitated to write an answer to you because I did not want to contribute to the many failures of treatments you have experienced. It sounds like you are accepting your balding without having a medical work-up. Please review the many pages of answers in the Female Hair Loss category, and then get a good doctor who will work as a professional in helping you to surround the diagnosis and treatment for your hair loss. Good luck.

Spironolactones and Minoxidil

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

Dr. Rassman,
I read your comment on Spironolactones.

However, some doctors argue that combined application of Spironolactones with minoxidil significantly enhances the regenerative effect of minoxidil. Would you please make a comment on this? Thank you

I am always concerned that some doctors speak because they have to differentiate themselves from the crowd of doctors trying to sell you something. If I believed that these two medications added value, I would be at the head of the crowd recommending and using them.

Coverage with FUE

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

I’ve heard that 20 to 40 fue per centimeter is recommended.Is this true? Does this give someone enough coverage? What do you recommend? I hope I asked the question correctly.

Thank You

This is a good, but difficult question to answer. What you are really asking is: “What density of follicular units is enough to give you good coverage?” Whatever the harvesting mechanism used, (FUE or standard strip harvesting) the amount of density achieved reflects fullness as modified by hair and skin color, hair thickness of each hair shaft, and the character of the hair (curly or straight). The health of the scalp determines just how close you can place the grafts (for scalp that is atrophic and lost its infrastructure of blood vessels, glandular structures and fat less densities are often better).

The normal density of a person is 100 follicular units per square centimeter (200 hairs), so clearly the amount that is placed will depend upon what you buy, the size of the balding area, etc. For blonde people, low density is often able to look full, while in a black hair person with white skin, higher densities are often needed.

Genetic Code Catching Up

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

In a previous post you said “Remember, hair loss is progressive and either with Propecia or Avodart, sooner or later your genetic code will catch up with you.”

What do you mean about genetic code catching up with you even if you take Propecia or Avodart?

Thank you for drawing attention to my cryptic medical speak. This is best explained by using an example.

First, it is important to show the Norwood Classification chart, so that the readers here can see what I am referring to.

Norwood Classification

Now, let us assume that your genetics will eventually take you to become a Class 6 patterned hair loss, but now you show only a Class 4 pattern because you are still losing hair and have not arrived at the final hair loss pattern you may have inherited from your family. In some people, their hair loss is so slow that they progress from the Class 3, to a Class 4, to a Class 5 and so on. The change can take years and be very slow to occur. In other unfortunate people, the loss may first show as thinning in the Class 6 pattern and then advance to a complete Class 6 pattern within a couple of years. If you are that Class 4 pattern person and take Propecia, the size of the bald spot in the back of your head may become smaller and the hair in the top may fill in a bit. You may go backward on this chart from a Class 4 to a Class 3 Vertex pattern, or you may regrow your thinning Class 6 pattern to a full head of hair with Propecia alone. If you stay on Propecia for life, maybe you will stay at a Class 3 Vertex, or you may slowly progress to a Class 4 or 5 or possibly 6 pattern over your lifetime (it could take 20-30 years or so to get there). If you got back the thinning hair in the 8 months that it takes for Propecia to act, you could lose it again, finding yourself back to ‘square one’ as the progressive nature of the hair loss continues to take its toll on you. We do not know if drugs like Propecia will stop the Class 6 pattern that you were destined ‘genetically’ to become, but it is not unreasonable, with what we know of today’s medications and what we know about Propecia, to actually see the value of this medication decrease with time. That means that the drug may eventually become less effective in preventing the progressive nature of the hair loss.

Avodart is a stronger medication for blocking DHT, and maybe by the time Propecia stops working for you, the FDA will clear Avodart for use in preventing hair loss. More likely, however, some new medication that is more effective than either of these drugs may come to market. It is my hope that medical research will continue to improve the effectiveness of medications for hair loss prevention or regrowth. What we must do now is to be patient, use what is there and what is safe, keep our fingers crossed and use the transplant ‘card’ when you are not satisfied with what you can achieve with drugs.

For people who have a Class 6 pattern and do not like it (or a lesser pattern hair loss which can be seen in over two hundred patient pictures at newhair.com), for example, they can become more hairy and reduce their balding appearance to a Class 3 or possibly even a Class 2 pattern if they have the donor hair to do it. That is what I mean by the hair transplant ‘card.’ We live at a wonderful time, where a simple outpatient surgery can transform a patient from a Class 6 to a Class 3 pattern in just a single surgery (under the right conditions). That means, between modern medications or hair transplantation, you can take charge of your life and your ‘hairy’ appearance. Remember, you are in the driver’s seat, so drive carefully.

EXT: Extreme Hair Therapy & Hair Club

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

Please give me information about the Extreme Hair Therapy program Hair Club for Men tries to sell at exorbitantly high prices. Do you know of these products, i.e., shampoo, conditioner, vitamins, etc.?

I can not comment on the exact program offered by Hair Club for Men (and women), but I have previously commented on many of the alternatives available for treating hair loss, thinning, and the like.

Comprehensive programs generally offer hair thickening agents, which may make thin hair appear to be thicker as they swell and take on hydration. The agents that cause hair to grow back stronger or where there is balding present are limited to Minoxidil (for men and women) and Propecia (for men only). Anything else may be hype if there are no FDA clearance in the claims for hair growth and I do not believe that product claims which reflect new hair growth have much validity (other than minoxidil and Propecia) in the real world of clinical science. It is interesting to note that some products may use minoxidil as the active ingredient, so it is the burden of the buyer to find out if that is what he is paying for, and if it is, consider buying it at one of the discount drug stores if cost is a factor.

Eyebrow Transplant Cost

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

just want to get a ball park figure for eyebrow transplant. I am a 38 year old male and want more thickness and shape to my brows, like had when I was younger.
thanks.

Generally, we have a $3,000 minimum fee that will cover the eyebrows easily. On occasions we can reduce the fee if the work is really minimal.

Ranking Doctors

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

I am considering a hair transplant procedure. would you rank the following doctors based on the quality of their work (detectable transplant and actual results):

Five names were suggested by the sender but omitted by me:

Thank you.

I feel that it would be wrong of me to pass judgments on doctors in this forum. I would rather ask you to look to my blog posting, The Truth About Cheap Hair Transplants. Although the article appears on the surface to be about cheap hair transplants, it actually is a piece about the very subject you asked about. I took a great deal of time to focus upon physician integrity and the quality of the transplants that are delivered, linking ethics and results of what is done, to the doctor and the medical practice. Essentially I provided the basis of a buyer’s guide to selecting a hair restoration surgeon. I also wrote a book, which you can get by download or mail. Our newhair.com site extensively makes points on how to educate yourself on becoming a smart buyer. I always suggest that you ask any doctor to attend something like our open house events so that you can determine first hand what the doctor is actually doing and what his patients think of him. The hidden benefit of such events is that most of the attendees, like yourself, have shopped around a great deal and they share stories about their experiences, so the shopping process becomes like a consumer report with first hand reports obtained from sources you could never get otherwise.

Hair Thickness Changes by Seasons

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

I had really thick hair up until I was 16 years old. Since then it is about 1/3 the thickness. I have tried vitamins and have tried to eat alot of protein etc to help. I am 52 (female) and after all these years I cannot help but notice a pattern. During the winter months after December my hair will have regrowth with new hair and actually thicken to the point that my scalp is not visible. Is is possible that cold and sinus medicines such as sudafed, cough syrups, and antibiotics [non penicilin] have ingredients that would contribute to hair growth? As soon as the weather heats up in the summer my hair starts falling out again by the brush full. What do you think? Thank you for your time and consideration.

What you say is logical, it is just not what we normally see in humans. Why humans have developed asynchronous hair growth, why we do not grow and shed hair all at once and the evolution of this is not known. What you are suggesting is that in you there is some seasonal variation in your hair density and that shedding may occur as the seasons get warmer, I do not doubt your observations, but I do not have a basis for understanding it. I am convinced that in the summer when we sweat a great deal and get our hair wet from sweat, we may actually produce more friction when we brush or comb the hair. That might account for the hair that comes out when you brush your hair in the summer. Also, some people wash their hair more frequently in the summer when they are out and about because they get it ‘dirty’ more easily. That might explain what you are observing. Clearly, there is a suggestion that there is some middle ground in your history and that some climate problems do occur in the summer in your situation. Do you live in a warm/hot climate?

Safe Steroids for Hair?

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

I am 22. I have always have had thin hair. Three years ago I was thought to have alopecia areata, and was given kinacrt injections for about 4 months. They helped a bit, then I took natural cream for a while. How do you find out what you have and if you have the MPG gene? Does body building itself (without the use of steroids), given the fact you have a ok diet,impair your hair or help hair loss? There is talk about some steroids being safe for your hair. Does this include people that have thin hair or are suffering from MPB? Thank you

Steroids are not always safe to use, and that is why it is regulated by prescription administration. I think that your question is: Will body workouts where muscle mass is built cause hair loss without taking exogenous steroids? If that is the question, I would think not. But if you had Alopecia Areata, then there is much going on that requires an expert to understand your questions. Please address them more specifically either with your doctor or to me if I did not answer what you had on your mind.

Non-Propecia Recommendations?

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

Dear Dr. Rassman,
I am a 17 year old and have been losing my hair for about a year and a half. I started losing it while I was taking Accutane, and it hasn’t stopped since. I went to a dermatologist and he said that it was MPB, and he recommended I take Propecia. Is there anything else I could take or use that you would recommend, such as Revivogen or the LaserComb instead, as I am frightened of the possible side effects, considering that my cousin took Propecia and had sexual side effects?

If you have MPB, then Propecia is the appropriate medication for you. Although the other things MAY have value (I am not saying they do), Propecia is in your best interest in that it WILL have value to you. Don’t gamble with your hair, for unlike a slot machine where you can always win more money, the hair gamble is irreversible; you can’t go out there and win more.

FUE Yield

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

Happy New Year Dr. Rassman, thanks for your great work on this site and in real life. Baldingblog is not only informative, but it’s usually fun to read too.

My question is about your reference (in a previous blog answer) to the conference about FUE this past year. Who was the one doctor who you said showed good FUE yield?

Thanks for your kind words. To be honest, I am not comfortable with identifying doctors that are better (by rumor) than others, unless I personally observe them myself over a few difficult cases. It can be easy to get close to 100% yield from an FUE in a “FOX positive” patient, but as I do not know the classification of the patients presented at the conference, I can not rate any doctor based on their yield unless they were classified on the FOX system that we defined. If I recommended one doctor who has 100% yield on a FOX 1 class patient and then if you went to him and were a FOX 5 class patient with a poor yield, then I would have done a disservice to you (see Follicular Unit Extraction: Minimally Invasive Surgery for Hair Transplantation for full details about the FOX test). Your best bet is to challenge the doctor by asking for his yield. If he does not want to address this or did not understand your question, then you should get out of there. I always classify my patients before doing the surgery.