Dr RassmanI recently met a prospective patient (Asian male) with a very low hair density who kept his hair very short. He wanted a follicular unit extraction (FUE) procedure and I strongly advised against it as in his particular case, the tiny white punctuate scars he would get from FUE might become detectable. His skin was a dark olive color. He did consult with another doctor by phone who told him after seeing his photos that he could easily get 4000 FUE grafts in the first session followed by 3000 in a second session and that he would have a reasonably full head of hair.

We then discussed a strip procedure and I told him that in a single session he might get approximately 1500 grafts, yet still another doctor told him that he easily could get 3500 grafts from a strip session. The prospective patient asked me why these other doctors were so enthusiastic about the surgery they recommended and why I was so low with my estimates on the strip procedure. I told him that I was an ordinary, mortal doctor with human limitations and he needs to understand that this is more than a number difference because the doctors may be talking about different things. I always talk about follicular units which is the graft count that I obtain at surgery. In other words, I’m not going to recommend something to this patient that will ultimately not be in his best interest and I am not one who victimizes patients for what they have in their wallet by charging for something that is not a follicular unit.

There is math and economics in these various estimates. For example, this patient’s graft count could be pushed higher if the grafts were divided so that each graft would have less hair. What one doctor calls a graft (1-3 hairs each) another doctor can cut down into grafts that contain less hair each (shifting to mainly 1 hair grafts) and get the illusion that there is more ‘value’ because the number of grafts is higher. If the amount of hair is say 5000 hairs, one can produce grafts ranging from 1500 to 5000 grafts from this hair count. So first, one has to define what the doctor means by a graft, does he cut them down into small units to get higher number of grafts? Economically for the doctor, it is better to cut these follicular units down (in the number of hairs each) because the fee is based upon the number of grafts. So more grafts means more money for the doctor (and higher fees for the patient). What matters is not just the graft count, but the total amount of hair that is removed in the procedure. Then add to that the way it is divided into small hair units (ideally it should be true anatomical follicular units). In the case of a strip procedure, the value would reflect the ‘area’ of excised scalp. Grafts should reflect the normal anatomy of the follicular unit that G-d created, not one that the surgeon invented (a subset of the follicular unit devised to push up his income).

We are not all equal with regard to the amount of hair that can be moved in a single session because the hair density between people can vary significantly (some people have more than twice the hair density of others). Also the looseness of the scalp may mean than in one patient twice as much scalp can be moved than in another patient. Merging these two measurements, when comparing two people, the maximum safe capacity for moving hair can reflect differences of 4-5 fold. I believe what is ethical from a fee point of view, should reflect the amount of work that the surgeon and his team invest in performing in the surgery. That is why, if true follicular units are what is counted, then the ‘apple for apple’ comparison is appropriate in the calculations for value. A patient should demand knowing that he is receiving follicular units, and not a number reflecting a subset of the follicular units for the purpose of pushing up fees.

We spent some time talking about what he could and could not expect. Expectations really reflect the amount and distribution of hair used in the transplant. The issue of value discussed above, should reflect the number of actual ‘true’ follicular units removed. It is wrong for not educating the patient. A doctor who did not take the time to review what he was going to do, how he was basing his graft count, what constitutes a graft and how he determined the charges for each graft is not doing his job. If you know this information, then you have done the proper research and you have a better chance of getting what you are paying for.

For further reading, plenty of similar links to past blog posts can be found here.

Tags: hairloss, hair loss, hair transplant, doctor, physician, realistic

Dear Dr. Rassman,

In one of your previous posts, you said that a scar from a strip surgery will be at about 80% of healing after 6 weeks. From that logic, I wonder if keeping the staples longer after a strip surgery (for 6-8 weeks, rather than the usual 14 days for instance) would help in getting a better scar…

I know that for practical and cosmetic reasons, keeping the staples longer can be problematic for many people, but in special cases where there is more tightness due to past surgeries (or a history of enlarged strip scar) wouldn’t this be a good solution to help getting a finer scar?

Or, would this in return create other problems such as:

1-skin growth around the staples?
2-Train marks?
3-Shock loss around the scar?

Thanks for your help

Scar formation and wound healing is not that simple. Aside from the technical aspect, everyone heals differently and scars differently. Leaving staples in for about 10 to 14 days is what we generally do. We leave the staples in for up to 21 days in some patients. Sometimes leaving staples in longer will cause the familiar Frankenstein or train track marks (as you state).

In the end there is no universal solution to closing a tight scalp. One solution does not fit all patients and it is up to the physician to address it on his/her individual basis. I know this may not be what you are looking for, but it points to the fact that sometimes there is just no specific answer. Leaving the staples in for 6-8 weeks will cause undo pain in most patients.

Tags: hair transplant, aftercare, staples, suture, scarring, scars, hairloss, hair loss

I was wondering what your opinion is of this study? Thank you!

Treatment of Female Pattern Hair Loss with Oral Antiandrogens

I referenced this article before — Treatments Available for Female Hair Loss

The conclusion of the authors suggest that there is merit in the use of antiandrogens, but the study is not statistically significant. Since my earlier reference 2 and a half years ago, our ability to separate women into two classes (those who are sensitive or not sensitive to antiandrogens) through the use of new genetic tests holds great promise for the future management of women’s hair loss. It is possible that in those women who had the best response to antiandrogens are women who have a high sensitivity to the antiandrogens as determined by genetic test (see HairDX). The study should be repeated with the genetic groups separated.

Tags: antiandrogens, hairloss, hair loss, female hair loss, hairdx, genetic

I have been on Propecia for 2 years; I am 45 years old and have seen no improvement in my hair. I am somewhere between a NW 2 and a NW 3. The fontal forlock has thinned significantly while on Propecia. In your practice have you seen any patients quit Propecia and not get any worse or do most people experience increased hair loss once they go off the medication?

Also, I would do a hair transplant immediately if I was confident that I could go back to work undetected after 2 weeks. It would be a big help to get your thoughts on this as I think this is probably the biggest reason people do not get transplants. Perhaps post some pictures of patients at 14 days. Your blog is great and NHI would be my choice once I decide to take the plunge

Assuming that you have the balding gene and a HairDX finasteride response test indicates that you have an average sensitivity to Propecia, then I would expect that you, like many other men, had their hair loss stabilized on the drug. If that is the case, then you can assume that you may very well lose hair by stopping the Propecia. The series of steps and events are important in the building of a good Master Plan so that whatever happens, it will be planned for. I am sure you can see a series of potential scenarios here, so a good working relationship with your doctor is all important.

Here are some previously posted examples of patients just days after surgery:

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

Hi Dr. Rassman,I have been to two dermatologists about my recent diffuse shedding which I believed to be telogen effluvium and they did very little to help because they said “you look like you have hair”. One dermatologist took some of the shed hairs and said he could not really tell if there was clubs on them because they were somewhat clubbed but had a tail too. When i look at them i can clearly see a white bulb at the end about twice the diameter of the hair but at the end of the bulb there is a very short hair like structure that is much thinner that the hair itself, the hair is very different from the ones i would say “pluck out”. So my question that I and my dermatologist was stumped on is whether they were telogen hairs because they had a tail at the end of the bulb.

Thank You

The telogen effluvium hair often has a white bulb and a mucus debris at the end so this could be the correct diagnosis. Also, the ‘hair pull test’ will show more than 10% of the hairs that are pulled, and will come out between the fingers that pull it. If you do this test, be gentle when the hair is pulled.

Tags: diffuse, hairloss, hair loss, telogen, telogen effluvium

Dr Rassman
If i take 1/4 proscar with breakfast will it get absorbed in my blood streem or is the tablet just too small after it is mixed with food? Do you think it is better to take it on a empty stomach? Thanks

I’ve often said that in my opinion, it is best to take it before breakfast. I generally think that it is best taken on an empty stomach although it probably makes no difference on the absorption issue.

Tags: proscar, propecia, finasteride, hairloss, hair loss, food, breakfast

Can Regaine cause hair growth all over even if i don’t put it on that part of the skin? I think I read something about this happening, but i can’t find the source. thanx

Wolf ManA patient reported last week that when he used minoxidil regularly (also known as Rogaine/Regaine) some years ago, he eventually saw hair grow over the entire face and forehead, giving him a Wolf-Man type look. I wish I had photos, but it was just a story he told me. After stopping the medication, he said the abnormal facial hair disappeared. This might sound ridiculous to some people, but I believed him. There have been similar reports posted before.

I asked some other prominent hair doctors (part of an email group of physicians I am in) about this, and some reported seeing this rare phenomenon in patients as well. We do see facial hair growth in some people that can be substantial, and it’s a particularly rare problem for some women on this medication as well. And when I do have photos, I’ll do my best to get permission to publish them…

Tags: wolfman, wolf, facial hair, minoxidil, hairloss, hair loss, hair growth, rogaine, regaine

I am someone who currently is probably not the best candidate for a hair transplant but may be interested in the future if my pattern of loss continues. While the FUE procedure looks like a desirable option it is expensive for someone on my salary/budget. I’m curious about how much the cost of hair transplantation has gone down or up in the past and what that could mean for the affordability of hair transplants in the future. Also, I understand that the costs of hair transplants vary based upon the quality as well as other factors but Im wondering more from the perspective of the hair transplant industry as a whole. Any thoughts would be appreciated. Thanks!

MoneyHair transplant pricing follow the rules of supply and demand. There are discounters who sell it for less and many of these discounters will not provide the same quality. Quality is defined by the percentage of grafts that really grow and the art of the distribution of the hair. Price ranges from follicular unit transplants range between $15 and $2/graft depending on where you live. FUE (follicular unit extraction), on the other hand, seem to have a slightly higher rate ranging from $20/graft to $7/graft. Because of the recession, prices have dropped. We have dropped our FUT (strip method) pricing by 20% to reflect the hard financial times in the economy. See our fees here.

Tags: hair transplant, fue, pricing, costs, fees, hairloss, hair loss

Hi Doctor. I recently went to my doctor regarding an acne problem I have had for years, and he prescribed me to take propecia for it. He said that acne is caused my the same hormone that causes hairloss. Something called DHT. And that the ingridient in propecia inhibts DHT and thus eliminating acne. What do you thik about this, it seems kind of wierd to me. Please inform me soon because you seem to be an expert on propecia. I wanted to ask him more questions, but he is one of those doctors thats always in a hurry.

He was pretty condfident that propecia treats acne really well

I haven’t heard of Propecia (finasteride) being prescribed for treating acne. Acne is generally caused by bacteria on your skin and certain hormones in conjunctions with a high sebum production. I recently wrote about acne and DHT here.

So while Propecia does inhibit some of these androgens (such as DHT), Propecia is not prescribed for acne as a treatment. I would consider seeking another physician for a second opinion (mine does not count as I am not your doctor) since you are clearly not comfortable with your treatment plan nor your doctor.

Tags: acne, dht, propecia, finasteride, hairloss, hair loss

Snippet from the article:

Researchers in Japan have identified a gene that appears to determine cyclical hair loss in mice and believe it may also be responsible for hair loss, or alopecia, in people.

In a report published in the Proceedings of the National Academy of Sciences, the scientists described how they generated a line of mice that were lacking in the Sox21 gene.

Read the full article: Scientists identify gene that may explain hair loss

I’m sure there will be much more information announced about this, as hair loss is a billion dollar industry and companies will be trying to figure out ways to use this new find to their advantage. So far though, this has only been shown to be valid in mice and “could” be the case for humans, as well.

Here’s some past hair loss genetics news:

Tags: mice, mouse, sox21, hairloss, hair loss, gene, genetic

Hey Doc – I emailed you a while back and wanted to thank you for your response on the blog. I recently upped my dosage of finastride to 2.5 mg proscar after a 10 yrs of propecia (1mg), based on my HT surgeons advice. My hairloss had really progressed so this was a clear course of action. I intially had great results on proetica in my early 20s.

  1. My first question was related to dosing – I lift weights/workout intensely 6 days per week (often twice per day) and wondered if it would behoove me to split this dosage – 1.25 prior to weight lifting in the early evenings and 1.25 first thing in the morning, as recommended in your book.
  2. My second question was, does taking Finastride with a multivitamin, a vitamin C, a vitamin E, vitamin D, Potassium, Magnesium, and Calcium – all in seperate pills, and a protein shake (organic from non hormone cows) in the morning before I do some intense cardio (I eat no real food till I come back from the gym) have any impact on Finastride absorbtion/effectiveness?

I have read your book and realize it is ok to take Finastride with food but this may be a tad different.

Thanks in advance

  1. If you can keep up the regimen of taking a pill twice a day without forgetting, then go for it! Theoretically, it should give you a consistent level. Be sure to talk to your prescribing doctor to clarify this.
  2. I do not believe taking finasteride with your supplements or food or exercise has any real impact on its absorption.
Tags: finasteride, propecia, proscar, hairloss, hair loss, food

Some reports shown that propecia is not suitable for women as it may cause birth defects.Therefore, I want to know if a man is taking propecia continuosly, then will the contents of the propecia transmitted to women during having sex with his partner(which is transmitted via kissing or sperm) and indirectly will it affect women’s health?

thanks for your reply. I do appreciate it.

From a practical perspective Propecia is NOT carried via sperm/ejaculate, when kissing, or having intercourse or oral sex.

Tags: sex, propecia, finasteride, kissing, hairloss, hair loss

I had a transplant in August, 2007. Needless to say it has been over a year and a half, and to my sadness and distress, I have yet to see ANY results. I had a full head of hair going into the surgery, and I went to Mexico with the doctors of a medical institute there, maybe that was my first mistake.. I was 21, and I am a female, and now I find I might not even have been a good candidate to begin with. The doctor just looked at me and told me that I was a good candidate. My hair had a diffuse thinning, but still there was quite a bit of hair stil left, something I wish I would have appreciated before. After the surgery, my hair fell out. I was patient, thinking it was shock loss and it would be temporary, but it has been more than a YEAR and the hair never came back. Fortunately I can use powders like Topikk all over my head to fake a full head of hair, something not necessary before, and my hair is much thinner than before. Does this seem like shock loss and is it permanent? I am upset over this and stressed out, but I would like to know what the future holds for me. Any help given would be greatly appreciated. Thank you.

This is quite unfortunate. Hair transplantation on a 21 year old woman is usually performed by doctors who want the money and do not care about the patient’s welfare. Indeed, about 80% of women with hair loss are not candidates for hair transplants and may suffer the same outcome that you did. You should have had a full medical work-up to include many blood tests for medical conditions that could cause female hair loss. There is even a genetic test for the inherited form of genetic hair loss. This remains a buyer beware market.

It might be worthwhile visiting me in my Los Angeles office. I could then confirm for you what may be going on and possibly give you some insights into what may happen to you in the future. I may even be able to suggest treatments for your hair loss. As your surgery was over 20 months ago, you should’ve seen some growth by now if the surgery was successful.

Tags: hair transplant, hairloss, hair loss, female hair loss

I would like to get your opinion on why I am experiencing relatively sudden thinning. I am 19 years old. I can’t pinpoint the exact time that my hair started getting thinner, but I can say that my hair was completely full a little under a year ago, because of my driver’s license photo.

I have a feeling the hair loss is far too aggressive to be male pattern baldness, because I have had no signs up until recently. I don’t recall before a couple of months ago. In fact I have never seen hair fall out of my scalp or seen actual “hairloss” but i’m sure people rarely do.

I would like to know if you think this hair loss is temporary (based on the photographs) and if you think this is possibly permanent or even male pattern baldness. I have no history of the disease, my grandfathers on both sides died with a full head of hair. So did the grandmothers!

Male pattern baldness (MPB) does not always require a doctor to assess. Look at your hair loss pattern (use two mirrors). Is it thinning mostly at the top, but you still have good hair on the back and sides? If so, chances are you have MPB. We recommend a miniaturization mapping of your scalp hair and you can make the diagnosis that way. You can see how to do this yourself — here. By the way, MPB is not a “disease”. It is a genetic trait that you inherited from one of your parents. It may skip generations so you may not see it in your immediate family tree.

Finally, the aggressive nature as you describe does not surprise me, as men who lose considerable amounts of hair with an advanced balding pattern usually have a more rapid course of hair loss, often starting in their very early 20s. That may not be your case, but don’t fool around with it as there is a good medication (finasteride) to take if you are unfortunately balding. See your doctor and get a correct diagnosis and ask about options.

Tags: mpb, hairloss, hair loss, genetic, finasteride, propecia, balding

Hi Dr. Rassman,
Searching the internet and various websites I always seem to hear/read about women who have severe diffuse hair loss and have developed female pattern baldness when they are around 20-years-old. Is this very common? Some information I’ve come across says it’s very very common while other says it rarely happens. Do you have any statistics on it?

I am not aware of statistics, but from my experience, women often follow the females in the family that have genetic balding in the time of onset and the pattern. There is a strong one-to-one link between mother and daughter in this condition and it is not infrequent to see it in your mother’s mother or aunts. Female genetic hair loss is not common in very young women, but in each decade, the frequency rises until menopause when almost 50% of women experience the problem. We see hair loss after pregnancy in many of these women as well.

Tags: female hair loss, hairloss, hair loss