Microscope for Follicular Unit Transplantation

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

What is so great about using a microscope for hair transplantation? I read some ads in the Los Angeles Times which stated: “Dr. X set new standards in hair restoration through the use of the ‘X’ Scope [Doctor’s name removed], an advanced microscope that allows more healthy hairs to be transplanted than ever before”.

At the same time, a second ad appeared which said: “Dr. Y’s new Mantis Microscope allows for greater single-hair dissection accuracy, significantly less donor hair for wastage, high hair growth success and better, denser and more natural results.”

Are you keeping up with Dr. X and Dr. Y?

Dr. X and Dr. Y somehow just came into the modern era in hair transplantation. Please look at the many articles I authored on the use of microscopes for hair transplantation which address the use of the microscope and its value. Most of what Dr. X and Y said is true. The industry standard was set by us in an article written in 1998 which conclusively showed the value at minimizing damage in harvesting grafts by the use of the microscope. What we reported was that the hair yield produced without the microscope was 25% less than the yield with a microscope. These numbers were even more dramatic in individuals with white or gray hair, where the advantages of the microscope showed hair yields from harvested strips were 40% higher than those without the microscope. The lost hairs in the count have almost certainly been tossed into the discarded tissue and were lost value to the patient. In a common idiomatic expression, ‘The baby was tossed out with the bath water’.

The focus for Dr. X and Y in claiming a breakthrough is one of ‘grandstanding’, bringing something to the forefront of importance and trying to take credit for discoveries where none is due. Microscopic dissection has been around since the 1980s’ (first introduced by Dr. Bobby Limmer). We applied the microscope to the follicular units which we defined and published in 1995 to define the standard which is now universally accepted as the golden standard for hair transplantation in everyone’s hands. The ads are largely correct, the use of the microscope is critical for significantly less donor hair wastage, high hair growth success and better, denser and more natural results. This is just what we have been doing for the past 10 years, so there is nothing new here.

So maybe the answer to your questions is: Dr. X and Dr. Y have now finally understood the standard of care and are moving into using it. It’s about time.

FYI: I changed the names of the doctors to Dr. X and Y. Buyer Beware remains the quote for the day.

DHT, Hair Lasers, Chemotherapy, and Finasteride

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


I have a few questions about androgenic alopecia and I’d be very happy if you could answer them for me:

1. What is a bigger factor for hairloss the quantity of DHT in the serum or in the scalp? If the scalp had levels of DHT at 0% would this stop hairloss? If that is the case is there a topical drug like Rogaine with finasterid instead of minoxydil and would it decrease scalp DHT levels better than oral tablets?

2. What is your opinion on the Lasercomb device that uses lasers to improve blood circulation in the scalp? Since minoxydil also improves blood circulation and is supposedly ineffective on the frontal area of the head would this device have the same downside?

3. Father of a friend of mine had cancer and had to undergo chemotherapy. My friend told me that chemotherapy improved his hair and even made it grow darker than before. Could there be any truth in this?

4. With propecia losing its effect over time I often see that people increase the dosages of finasteride up to 5mg per day. Would these higher doses really help or are you just putting your health at risk?

This is not really a question just observation on my part: everytime I see the after and before pictures of hair transplants the comparisons aren’t realy fair since the before picture usualy has more intensive lighting and hair combed straight forward or back and is often greasy while after picture has less intensive lighting and different position of lights and hair is combed to the side and it looks like it has just been washed. It would be nice if all pictures would be made with people having wet hair combed straight forward or back so people could really see the difference.

Thank you for your time and answers.

Whew! You need a whole hour-long cosultation with a hair doctor to answer all of these questions, but I’ll try to give you some short answers in the meantime.

  1. DHT and genetics are the biggest factors in hair loss. DHT is a hormone that is present in your blood (which flows through the scalp but does not reside there). There are no topical formulations of Finasteride (the molecule is too big). Any topical medication for hair loss would need to be a small enough molecule to penetrate the skin and have an effect. Minixodil does penetrate – which is why it works. Rubbing Finasteride on your head will not help and it will waste the Finasteride.
  2. Do a search for “laser” here. To reiterate, there is no conclusive data on the effectiveness of laser therapy for hair growth.
  3. Chemotherapy can occasionally change the character (color, curliness, thickness, etc) of hair in addition to many other unusual side effects. However, the idea of taking chemotherapy just to improve your hair is ridiculous. Chemotherapy drugs can kill you, they are used when the alternative is death. Hair changes post chemotherapy are absolutely the truth, though.
  4. Propecia may lose its effectiveness over time (the data presently now goes out only 7 years), and some patients continue hair loss, hopefully at a slower rate. There is no evidence that higher doses will reverse this, but neither is there evidence that higher doses of finasteride pose an increased risk to health.

Finally, your observation is correct – there are methods of taking photos which will give the misleading impression of increased hair density/thickness/coverage. To really compare, similar photos need to be taken in similar lighting conditions with duplicated angles and styles. Wetting hair before and then showing dry hair after is an especially obvious tip-off that the comparison is invalid!

Hair Loss Homeopathy

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

Dear Doc,
At 18, i used minoxidil solution for about 6 months.I had some help and then suddenly it stopped growing and started falling again.I stopped after six months and shifted to homeopathy. By then I had already lost a lot of hair.For the past 2 yrs i have been trying homeopathy but to no avail.I keep losing to male pattern baldness. No family history except for some thinning on moms hair.Pls help.

It sounds like you are going through rapid genetic hair loss. If the minoxidil was working initially and then after 6 months you stopped it, you probably experienced shedding of hair from the minoxidil withdrawal of the dependent hairs that you built up on the drug. You need to have your scalp and hair mapped out for miniaturization and if the results of that mapping show male patterned genetic hair loss, then you should go on Propecia. You need to block DHT with a therapeutic dose of the correct medication. Homeopathy does not offer powerful DHT blockers that are proven as safe and effective as a good prescription of Propecia. For your own good, do not waste your time, for time amounts to irreversible hair loss in those with rapid hair loss. You are using a water pistol to put out a fire that is consuming your valuable hair resources. Take command of your problem.

Propecia, DHT, and Sperm

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

Hello Doctor:

Thanks for you candid forum. I have three questions for you. If I’m a male on Propecia to prevent hair loss, will taking protein supplements for body building militate against the benefits of reducing DHT by Propecia? And, how can I reduce the sexual side effects of Propecia; namely, the reduced sperm volume? Finally, is there any evidence yet that taking Propecia and its active agent long term will cause permanent side effects or potential diseases?

Thanks again

I’ll answer your questions in order and they are all good questions;

  1. Protein supplements will not change how Propecia works, namely, by blocking DHT formation. I WOULD warn you against taking any steroids which conceivably could alter hormone levels and diminish the benefits of the Propecia.
  2. The sexual side effects of propecia are often temporary, but if they persist for you, I usually recommend trying a half-tablet twice daily or even just once a day. You will get less than the full benefit (I am led to believe that 1/2 tablet may give you 80% of the benefit), but you will at least get SOME benefit and that is the important thing.

    Sperm volume and ejaculate volume are two different things. Ejaculate contains several body chemicals and fluids, not just sperm, and decreased ejaculate does NOT mean less sperm at all – as a matter of fact sperm levels for those with decreased ejaculate are usually still within normal levels, possibly higher. Decreased ejaculate volume was shown to occur in 0.8% of people taking propecia versus 0.4% of the placebo group in the initial studies (that decimal point is correct, it is LESS THAN one percent). Although the frequency of reduced ejaculate volume is reported small, in my experience after probing many men on this issue, it is far more frequent than the literature seems to suggest. If you are worried about potency or having problems with conception, I’d see a urologist and get your sperm count done.

  3. Finally, the long term data for finasteride (~15 years of data) does not show any permanent side effects or potential disease. As a matter of fact, the data so far indicates that there is less prostate cancer in those taking it. So there you go!

Is a Balding Man Shallow?

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

I am sorry to say that I am a shallow 28 years old former male model who has believed over the years that my looks were everything. I never had a problem with women until I started to lose my hair. The more the hair came out, the more my dating life and my sex life went downhill. Then after a while, the dandruff started and now, not only am I balding, but I drop snow from my head all over the place, leaving a trail of white flakes everywhere I sit. Is this all connected? Is god making me pay for my pretentious and shallow life of the past? I am suffering, really suffering, so please do not laugh at my email and help me.

Ken DollYou are in the sensitive years when hair loss appears if you are genetically predisposed to it. If the hair loss is early, Propecia usually works nicely, but if you lost much of your frontal hair, then some of the loss may be too late for Propecia and only hair transplants can help. In any event, Propecia works well to prevent your future loss and help restore more recent loss. You may also have some skin disorder causing the flaking (or as you describe it, “snow”) that you are talking about. See a good dermatologist and find out what you have and what else it might be. It could be something simple — or something severe like psoriasis. Get a good doctor to help with a diagnosis and get your hair mapped out for miniaturization.

I can not judge what is in store for you. I do believe that each of us has the power to take command of our lives. You can elect to go bald, spread “snow” everywhere you go and withdraw into some closet, or you can address your hair loss properly, get the dandruff diagnosed and treated, and get your mental state into a place where a woman may find that you are a man of substance. I suspect that you recognized that the old, shallow you now understands that depth of character in women or men is what makes us what we are. I do not mean to lecture you, just to tell you to stop suffering, resolve your hair and scalp problem, and then face who you are by starting to look beyond the mirror, at the man who stares back at you. Hopefully when you were a model, women saw more than a hollow shell of a Ken doll. Become that person!

ISHRS Australia Meeting 2005

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

I recently read on one of your previous blogs that you would be attending a international hair restoration conference at the end of the month and would comment further on avodart, mainly if you would begin prescribing it. I’m just curious if you have any further comments?

I apologize for not posting this response sooner. There were too many exciting events happening at the ISHRS 13th Annual Meeting for me to describe everything to you. For those that may not be familiar with this event, it occured in late August 2005 in Sydney Australia. I do recall there was some discussion about Avodart which may appear to have better result than Propecia. Unfortunately, there was concerns about whether Avodart persists for a significant amount of time in semen, which may have an unwanted affect on development in the male fetus. Currently, there is no FDA approval for Avordart to treat male pattern hair loss. I am somewhat perplexed about why GlaxoSmithKline, the drug company producing Avodart has suspended further tests for treatment of male pattern hair loss, but that would be a better question to ask the drug company.

Cortisone Shots and Hair Loss?

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

Would cortazone shots cause hair to fall out in large quanities? I had a shot about 2 weeks ago, would this cause it. or maybe my age 55 in mentapause time something to do with it?

On occasion, cortisone shots into the head can precipitate hair loss. In women who are predisposed to genetic hair loss (in those who do not have an autoimmune cause of the hair loss), cortisone may add to the many precipitating factors for hair loss, which occurs more frequently in post menopausal women. Any stress can precipitate the process. Although some doctors use steroids to treat hair loss, I do not understand the rationale for such use, unless there are autoimmune influences suspected as a cause of hair loss.

Hair Loss from Wigs

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

Hi,

I am a 52 year old African American female, who has had the struggle of being bald most of my life. When I was 12 I had a severe case of chicken pox, and left me scarred all over. Fortunately, I recoved with the skin, but the disease left large bald spots all over my scalp. I have worn wigs .. seems like forever.

The problem is no one has ever been able to help me through the years, and the wigs that I always wore, are taking out the remaining hair I have left on my head.

Is there someone I can see, to help me with this problem. I have used medications, hair weaves, etc to no avail.

Thanks

Wearing a wig for many years can cause further hair loss as a result of the traction caused by the wigs. Traction Alopecia is common in wig wearers, those who wear turbins, and even in those women who pulled their hair into tight pony tails. Send your photos or if you are planning a trip to Los Angeles, visit my office so that I could better evaluate your situation. There are a few questions I need to answer, but can’t do so until I can see your hair loss. These questions include: What is your donor supply like? Is there enough hair for redistribution with hair transplants?

Bald After Radiation for Brain Tumor

/by William Rassman, M.D./12 /,

Had breast cancer, surgery, chemo, radiation. Then had a brain tumor that they thought could be taken out without radiation (kills follicles, and absolutely left me BALD! I was a hairdresser that went to graduate school with beautiful long blond hair. I CAN NOT find another woman that is as bald as I am. My whole head is permantently BALD. I tried every product on the market and nothing helped because the follicles were killed by total head radiation. I can not work, stay away from longterm partner that I knew since 1973 that I was in love with. I don’t work, have no friends left (my move, because I could not stand their pity). Stopped going to my support groups, and have tremendous stress now. My son is alone too, diagnosed with diabetes after given a medication for bi-polar disorder. I was adopted, and my family has never called me. So I am left completely bald – wear wigs w/pajamas if I have to go out. Thank you for letting me write this since I feel like a grieving “bald” widow !

I was left totally bald 4 years ago from head radiation after removal of a brain tumor. I cannot find another woman as young as I am, or ever older that me, that this happened to. Totally stressed out and won’t go out of the house. Probably will lose my house. Have NO self esteem. Tried everything, creams, lotions with no results. Hair Club for Men and Women (HCMW) are hostile to women, could not afford permanent program. Have alot of wigs, but NO SELF CONFIDENCE/ SELF ESTEEM and have just about given up on the hope of a solution.
Thank you.

Have no pictures/ HCMW took pics of top and back ! I kept asking to talk to someone that had my extent of permanent hair loss that they kept telling me about – but did not for a year. Instead they had me talk to a potential client. Very sad.

There is no cure for what you are describing. You had bouts of cancer and beat it. That should tell you that your glass is half full, not half empty. We are the writers, directors, and actors in our own lives. Sometime we need help to do that job and a good psychiatrist/psychologist or counselor may help you direct your ‘play’. Get the help you need and make your life come out they way you want it to be. I have seen many handicapped people who have overcome many liabilities. A relative of mine died from breast cancer and she went through hell trying to beat it. Her life was taken and yours was gifted to you. Do you think that there was a purpose to your survival? Take a look at National Alopecia Areata Foundation. What this should show you is that there are many people working on your type of problem and many people managing their lives with it. Their glass is half full.

I met a lady with alopecia universalis (no hair on any part of her body from genetic causes) who wore a wig and used make-up for eyebrows and lashes for her eyes. Her alopecia could not be detected at all (she chose to look like a hairy woman), and she was fashionable and dynamic in her social and professional life (radio show host and former spokesperson for the alopecia afflicted). She told me that she made a decision that her alopcia was just a handicap and she quickly came to deal with her life when she was young. Living life for life’s value was more important than obsessing over a problem for which there was no cure. She was victorious, something I wish for you.

Transplant Hair From My Back

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

My question is about donor sites. I have a rather extensive amount of back hair and, if possible and practical, I would like to transplant said hair (in conjunction with hair from other, more typical, donor sites) as part of a transplant to correct my scalp baldness. While I still have hair on the sides and the back of my scalp, I do have a lot of baldness all across the top of my scalp, which I assume will require lots of grafts. Can back hair be considered donor hair?

Body hair is not a productive source for hair as traditional sources from the sides and back of your head. Unless you have significantly depleted the donor hair from the traditional source, I would not recommend hair from the body (an experimental procedure of questionable value). I have performed hair transplants on the baldest of men with great results. They have gotten hair from back and sides in each case. For example, see Class 7 Patient ZU from the NHI site.

I Don’t Want to Play Doctor with My Hair Loss

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

I’m 22 and over the last year my hair has been thinning fast. Thinning, really bad itching all over my scalp and a receding hair line. This last year i have had three major surgerys and one minor one. Also I have been under extreme stress. Plus both my grandfather and father are bald or going bald. So i really dont know were it could be coming from. I have been to hair loss clinics and doctors and been told and given different things. 5% Minoxidil, Enhanced anti-androgenic pill with saw palmetto and other herbs, some shampoo, laser light therapy and just yesterday i got propecia. What should i do? I’m scared that I am starting to play doctor with all these products. PLEASE HELP

It sounds like you are grasping for straws and may or may not find a solution. First you need to KNOW if you have genetic hair loss, like what is in your family. With measurements on miniaturization made, you can then establish a base line from which drugs like Propecia can be valued by comparing the changes in miniaturization over time. I would drop everything else, and focus on getting a diagnosis before the Propecia gets going too far, just for comparisons. Propecia may be your best approach, but you still need a Master Plan to know what is going to happen to you.

What Type of Dermatologist Should I See?

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

Hi,

First, thank you for your wonderfully informative blog.

1) I’d like to see a dermatologist about my scalp. Would any dermatologist be okay or should I make sure it is a dermatologist specializing in hair loss? (I’m currently between III and IV on the Norwood chart. Also, I my skin seems unnaturally dry in those areas, and there are two tiny red sores that I discovered about the same time my hair loss began three years ago which have never gone away; so I think there may be a correlation.)

2) I’m in San Diego. Do you (or your associates) or anyone you can recommend in my area accept Blue Cross/Blue Shield health insurance?

Thank you very much for your time.

Insurance for medical work-ups for hair loss is covered by many insurance companies, but you will have to investigate your benefits from your present carrier. Hair transplants, on the other hand, have not been covered by insurance companies unless there is a burn or accident associated, and again, the benefits are defined as ‘covering’ those injuries for cosmetic surgeries.

If you are a male or female with hair loss, then your doctor should be able to make miniaturization mapping of your scalp. Some dermatologists do this, so you should ask their staff before you set up a visit. People who call themselves hair experts can be found in the physician search on ISHRS.org in your local area. My closest office is 120 miles from you, in Los Angeles.

Taking Supplements with Propecia

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

Hi Dr,
I’ve learned a great deal from your site. I have two questions — one general, one specifically for me.

1. I read that you encouraged the use of propecia in the AM. I take a multivitamin and calcium citrate in the morning, and therefore I take propecia at night to offset the risk of an interaction. I also take creatine pills at various times in the day. I’m on no other drugs or supplements. Is there any problem with taking any or all of these pills/supplements together? I’m especially concerned about the creatine and its potential role with testosterone.

2. Some background info:
– I’m in my early 20s
– I’ve been using propecia for about 16 months because of a maturing hairline at the temples.
– My hair is black, extremely thick and curly, and my facial hair is extremely coarse as well — Before 2 years of laser surgery I had 5 o clock shadow 24 hours a day. In terms of facial hair, I made Richard Nixon look like a backstreet boy!

That being said, I’m under the impression that I have more testosterone than most guys, and that 5 MG Proscar pills (which I will cut in half) might work better than 1 mg Propecia. The only reason I contemplate doing this is that I think –although it’s hard to tell — I’m still losing ground on my hairline. I’m also going to reinitiate minoxidil-use at night.

Avodart sounds very promising, but I’m willing to wait until it gets FDA approved for hairloss. I’m under the impression that will never happen.

Basically, I’m looking for your input on this matter. In addition to 2.5 MG of finasteride daily and minoxidil, is there anything else you can recommend to keep as much — if not all — of my hair as I can?

I look forward to your response

The medications you are taking should not be negatively impacted by Propecia, so I would still suggest taking Propecia in the morning.

I am not certain that you have more or less testosterone than others to explain losing hair on the top of your head — probably just strong genetics. The strong beard again points to strong genetics and the DHT effect on those genetics. Male pattern balding is caused by DHT (so is your beard). Taking 1.mg vs 2.5mg of finasteride may or may not make a difference in terms of reducing hair loss, because there is no conclusive data for better results with higher dosage of the drug. If you find that 2.5mg of finasteride works better for you, then you should continue doing it, but you must be aware that the higher dose does correlate with more negative sexual side effects. I recommended that to stay healthy, eat a balanced diet and exercise. Crash diets may accelerate hair loss. I would like you to email some photos of your hair for further evaluation. If you truly have hair loss, I would be happy to email back more insights.

Discoid Lupus and Hair Loss

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

Female. I was diagnosed with Discoid Lupus Erythematosus about 4 years ago. It started out as a little bald spot, now most of my hear on the top is gone. I am not sure what to do, I have at the cortizone shots, I have used the clobex shampoo,noting is working. I am constatly getting new bald spots it appears to always be active. Is there anything I can do to slow down the hair loss? I have kept my hair short for almost 20 years. I am tryin to let it grow back enough to be able to push the front part of my hair back to cover up the spots.

Autoimmune diseases are a known cause of hair loss and a difficult problem to control. To get control of the hair loss means getting control of the autoimmune disease. This requires the expert hands of a doctor specializing in such diseases, such as a dermatologist with a particular interest in this.

Hair transplantation works if the disease in the scalp has been inactive for a number of years and this is best determined by biopsies along the edge of the bald area where normal hair may exist. The presence of inflammatory cells may show active disease (from your history this is your case) so a number of areas must be biopsied (must wait until the disease becomes inactive). When the disease become inactive in the scalp (it may remain active elsewhere), biopsies will show that it is inactive. With inactivity present for at least 2 years, a series of test hair transplants will show if the skin will support hair transplant. Representative areas must be selected for the test transplants and FUE can be the source of the transplanted donor hair. Before embarking on this process, however, a supply/demand assessment must be made with goals clearly defined. With a disease only 4 years old, it is probable that you will have to wait some time before undergoing any type of restoration assessment and hopefully when it reverses, you will see some hair return in the affected areas as an indication that inactivity in the scalp may be on the horizon for you.

I have successfully transplanted a series of patients with inactive alopecia areata with nice results. I would suspect that you might be a candidate some day if you are fortunate enough for the process to stop progressing in your scalp. I have no other suggestions for the moment other than continue with your treating physician and have hope.

Hair Transplant After Alopecia?

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

I have several bald spots at the back of my head.I went to see an MD and a blood test was done all are normal and MD said that i am having alopecia. What is the approximate price of hair transplantation? i am only 26 years old / female and i don’t want to be bald this early in life. please respond. thanks

There are many types of alopecia. If you have one of the autoimmune causes of hair loss (that is what it sounds like), then hair transplantation does not work until the disease has burned out (generally you must wait for at least a couple of years and be certain that the autoimmune process has ended often requiring a biopsy). I need more information on the type of alopecia you have. See the Female Hair Loss category for the answers to your concerns that may have already been written.