ISHRS 2009I just got back from the 17th annual scientific ISHRS meeting (basically a hair transplant doctor’s convention), which went on from July 22-26. Lots of information was presented… lots of lectures, presentations, and discussions. This year’s meeting was in Amsterdam, so I had quite a long flight back to California when it was all over and I was able to do a write up on the plane of what I learned. I thought I’d share…

If you missed yesterday’s post, check out part 1 of my ISHRS meeting notes! Here’s part 2…




Hair transplant failures:
Hair transplant failures are often due to undiagnosed scarring (cicatricial) alopecias, so the need to detect them is critically important in advance of the procedure. The skin is often white and shiny and their activity may be in spurts, active at some times and inactive at other times. In my opinion and from my experience, women suffer more undiagnosed scarring alopecias than men and reflecting abnormal patterns of balding may be a clue to their presence. The doctor usually makes the diagnosis when these abnormal balding patterns appear and then the doctor will take multiple skin biopsies in the identified areas. Biopsies are the traditional approach, but the tissues that are taken for biopsy must have some active disease going on to affirm a diagnosis. When the biopsy approach to diagnosis is made, they are made with sizable tools (usually a series of 4 mm punches along the edge of the abnormal balding pattern). Alternatively, test transplants (which are limited procedures) can be done to see if growth occurs at 6-8 months. I have been performing test transplants over the years in such suspicious cases, as this is a more certain way of making the anticipation of success or failure of a traditional hair transplant. Failures of transplants in patients with such scarring alopecias are common.

Hairline design:
This is an area that I find most interesting. My philosophy is very different than most other doctors in the field. I tend to place hairlines in the mature position while most other doctors place the hairlines higher with more recession. There is a belief by many doctors that eventually a traditional mature hairline normally found in a non-balding man will not look normal as a man ages, so the hairline designs offered by many of my colleagues leave portions of the Norwood Class 3 and 4 frontal pattern into the end design of the hairline. Most men, however, want the man that they see in the mirror to reflect the mature hairline, not an “older” looking hairline, so I recommend the mature hairline almost all of the time. This is easily seen at our monthly open house events or online in our Hairline Photo Gallery. As my design of a hairline differs from many of the designs of my colleagues, the art form of a hair transplant surgeon will be evident to all.

Graft trimming:
Graft trimming by the surgeon and his team seems to reflect the robustness of the hair growth. A study was performed by Dr. Michael Beehner, where he trimmed the grafts from chunky to very skinny. The grafts that were made very skinny did not grow as well as those grafts that were made more chunky with more fat surrounding the hair grafts. Dr. Beehner believes that making grafts very skinny seems to:

  1. Open them up to the damage from drying and being out of the body for any prolonged period.
  2. Critical elements of the growth centers where stem cells exist, may be trimmed away during graft preparation.

New Hair Institute has always produced chubby grafts for these obvious reasons giving us a good growth track record. There is a direct relationships between the size of the graft and the ability to make recipient sites and place them well. The need to match the graft thickness with the recipient site holes are critical for good graft stability and growth.

Four devices were shown to improve the FUE (follicular unit extraction) process. Each claimed that their product was the only one that worked. Every one had a mechanical rotation associated with it one with vibration, others with partial twists of varying diseases. Costs for these devices run as little as $60/each for a disposable device, to as high as possibly $200,000 for robotic controlled FUE soon to be available on the market. Clearly when there are so many options offered, the suggestion is that none really work well. Time will tell which are the best instruments by next year’s ISHRS meeting in Boston.

Saturday morning held a series of sessions called “Breakfast with the Experts”. My session on FUE seemed to have the highest audience. The concerns by the participants were the wild and unsubstantiated claims in performing high numbers of FUEs in a single procedure and a very unrealistic view of damage to the FUE graft from transaction and stripping the grafts in the process of extracting the grafts.

Wound closures:
Would closures from strip surgery were discussed in great detail by many doctors, each promoting their own prejudices. There was clearly no technique that was better than others to prevent scarring. Suggestions on trichophytic closures were one of the few bright spots, but the differences in the techniques used by the various doctors, in my opinion, ranged from effective to completely ineffective. In other words, getting a trichophytic closure is no guarantee of a great result from the technique and a trichophytic closure in one doctor’s hands may be a radically different technique than the same procedure in another doctor’s hands. Results ranged anywhere between wonderful and a complete failure.

Tags: ishrs, fue, surgery, hair transplant, hairloss, hair loss, amsterdam

Since there’s obviously a ton of money in hair loss products, why hasn’t anyone done a conclusive study on the effects of saw palmetto on hair loss? It seems like if it’s believed to help, a conclusive study would (if it’s found to slow loss) help products containing saw palmetto off the shelves

I agree that a better controlled study would help us understand the impact of saw palmetto on hair loss, provided it was dose response oriented. The reason that this is probably not being done is that there is no patent coverage available for this drug, so when a study comes out, anyone can profit from the sale of the drug (in this case it is an herbal remedy not a drug). So there’s money to be made if it shows the herb is effective… but one company financing the study will potentially open the floodgates for other companies to profit. This does not make for a good business proposition if you were paying for the study. In other words, studies are not cheap and who is going to finance it if the money can’t be made back?

There have been limited studies on this very subject in the past. One such study from 2002 contained only 19 men. Of those men, 60% showed “improvement”, but I don’t know if that means their hair looked thicker, darker, or there was actually more hair. Plus, it was just a pilot study and too small to be worthwhile in proving effectiveness.

Tags: saw palmetto, herbal, herb, hairloss, hair loss, study

Why do dandruff shampoos like Nizoral and pyrithione zinc supposedly help MPB? Perhaps there is indeed a connection between dandruff and MPB after all. Remember when everybody thought the world was flat, or that the universe revolved around the sun, or that DDT was safe for humans? ;-)

Oak treeTo my knowledge, there are no good scientific studies to prove that Nizoral (ketoconazole) or zinc pyrithione help prevent balding, but they seem to be valuable for the treatment of dandruff. If I told you that eating a branch from an oak tree 15 times a day helped with MPB, would you blindly accept what I said? (For the record, oak trees will not cause your hair to grow.)

I get your comparison, but science and study have improved quite a bit since the “world is flat” days.

Tags: hairloss, hair loss, oak, nizoral, ketoconazole, dandruff, shampoo, zinc, science

i was in a car crash 4 months ago and got a bleed to the brain that needed to be operated just wondering seen as im only 18 wil hair ever grow back on the scar if not is there anyding else i could do?

Incisions from brain surgery often produce scars because they widen slightly (about 1/4 inch on many people). If they are located in the hair baring scalp, then these scars are easily treated with hair transplants, quite successfully. The hair will not grow back on its own in the scar.

Tags: incision, hair loss, hairloss, wound, injury, brain surgery, scar

Does finasteride make you put on weight?

No. Eating too much causes you to put on weight. I’ve answered this question previously — here and here.

Tags: finasteride, weight gain, weight, hairloss, hair loss, propecia

ISHRS 2009I just got back from the 17th annual scientific ISHRS meeting (basically a hair transplant doctor’s convention), which went on from July 22-26. Lots of information was presented… lots of lectures, presentations, and discussions. This year’s meeting was in Amsterdam, so I had quite a long flight back to California when it was all over and I was able to do a write up on the plane of what I learned. I thought I’d share…




Review of the Korean study for this drug indicates that it is safe and effective drug with side effects consistent but slightly higher than those in the finasteride study. The tests, however, did not study the impact of this drug on sperm count. One doctor present at the meeting reported two patients who had become sterile while on the drug (one being his son). Both men, upon stopping the drug, found their sperm count returned to normal. The failure to study sperm count is, in my opinion, a major oversight in the Korean study from a safety point of view. Based upon this private report, I will not prescribe dutasteride without at least 2 years of treatment on finasteride or a frank failure of the finasteride. I will require that anyone getting a prescription from me (each case would be individualized) would have to sign a legal document that states they recognize that sterility is a possible side effect and risk of the drug.

Finasteride limits Type 2 receptors for 5 alpha reductase, which reduces the incidence of cancer of the prostate… not the risk of developing prostate cancer. The information available only covers a 7 year period and longer term studies are not available. It is unknown if this drug will reduce the risk of prostate cancer.

The use of platelet rich plasma (PRP) was a theme for many scientific papers. We have known that for topical use on skin wounds, this PRP has shown value in accelerating healing when applied. Studies for its application for alopecia areata was suggested by one doctor and a few doctors have started to soak the grafts in the plasma of patients to see if the grafts grew sooner, looked more robust and had a high “take” rate. I would not trust the conclusions of these doctors without a good scientific study to back up their observations. For the moment, I would call this “human experimentation”.

Dr. Bessam Farjo presented a paper on prostaglandin receptors in the stimulus of hair growth. The drug latanoprost has been successfully used to grow eyelashes and is now FDA approved for this (in the form of bimatoprost), but the actual mechanism for what has been observed is unknown. It clearly increases the hair length, rate of hair growth and pigment in the treated lash, and there is a suggestion that there may be applications of this drug in the treatment of hair loss with a bit more research. Some early research by Dr. Farjo suggests that this may very well work as a stimulant for hair growth and in future treatments for hair loss.

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Dear Doctor,

Now i’m using Finasteride for 7 months and the results are good. Hair is regrowing and i’m losing less hair then before. (average 10 hairs a day). I’m a 20 year old caucasian male.

But now I started with Minoxidil (2%). I noticed that I’m losing more hairs than before (25-30)(Only when I comb my hair!!) I’ve been using Minoxidil for 2 weeks. But I don’t know if i have to continue this procedure, because it doesn’t guarantee any regrowth and now i’m losing more hair then before… I’ve read that you can lose more hair in the beginning with minoxidil, but now i’m losing 20-30 hairs more each day(!)then normal, how will the benefits compensate that on the long term?! Continue or not continue the procedure, that’s the question!

I hope you understand my question.

I do understand your question, but you need to understand that it’s normal to lose 100+ hairs a day. 20 to 30 hairs on your comb each day shouldn’t be a cause for concern. The hair loss from minoxidil is documented for the first two months when hair cycling is accelerated. There is good science to this effect. Likely what happens is there is a “resetting” of the hair cycle as the hairs fall out to get ready for new, stronger hair to grow.

Most patients tend to stop using minoxidil because they are worried that the hair loss will continue. Some patients do continue with the minoxidil and should see the loss stop after 2-3 months as the new hair cycle takes over. It takes patience of at least 6 to 12 months of using minoxidil for benefit and at least 1 year for maximum benefit. Ultimately the decision to use it is yours.

Tags: minoxidil, rogaine, propecia, finasteride, hairloss, hair loss, hair cycle, shedding

What is the minimum amount of time someone can use finasteride and then stop and see “catch up loss”? I am 35 and have very minor hair loss and I am afraid if I start, and get sides, et, or am not comfortable with the pill, and can’t tough them out, that my hairloss will accelerate much faster than it was previously. What would you consider an appropriate amount of time to use the drug, quit, and get catch up loss?

Also, what do the shed hairs say about my MPB or loss? Is there a difference if I am shedding long/thick hairs vs wispy ones? In normal shedding and accelerated/catch up shedding, should a “bulb” be attached?


Catch up hair loss takes about 1 to 3 months after stopping Propecia. Hair loss will accelerate to “catch up” to the point where you would have been if you never had taken Propecia in the first place. You will NOT have more hair loss than if you’d never taken Propecia.

The bulb at the end can be normal and isn’t a concern. I’m not sure what you’re seeing as far as the long/thick hairs, but you might just be describing normal hair cycling.

Tags: hairloss, hair loss, propecia, finasteride, catch up hair loss

My boyfriend has just started using the generic Rogaine from Costco in liquid form, and I have been helping him since depositing a dropperfull of liquid on the bald spot is not an easy thing to do alone. I use the dropper to distribute the liquid around the spot, but no matter what we do it seems that much of it runs off down his neck or forehead. The rest sits in the few hairs he has left in little droplets.

My questions:
– are we doing this wrong somehow?
– should I be putting on a latex glove and trying to spread the solution around with my fingers?
– would the foam work better? He has the typical bald spot at the crown of the head, with just a few fine hairs and mostly just scalp. But I have found in my research that an awful lot of guys say the foam just melts from your body heat and runs off anyway…

Suggestions or pointers to articles would be much appreciated!

Your problems are well shared by many users of liquid minoxidil, thus Rogaine Foam was created so that the medication stays on the area you want to treat. It may “melt” and run off as you say, but it is better than the liquid in my opinion. If you still want to use the liquid (or your boyfriend does, more precisely), you can apply the liquid with a gloved hand. That might be best anyway, since you’re not using the medication.

Tags: minoxidil, rogaine, foam, liquid, hairloss, hair loss

Hi I’m a female and only 16 but my question is about my widow’s peak. Well, it used to be the same length as the rest of my hair but after messing with it for the past few years its gotten shorter and shorter and now its become a habit and I can’t stop messing with it. I just want to know if it will ever grow out again if I stop twirling it with my fingers? Or is there anything else I can do to make it grow out again? It’s become so short that if I dont use serum or other products like hairspray to keep it down it just sticks out. Please help!

If you play with the widow’s peak, it may produce some level of traction alopecia and that could cause you to lose your widow’s peak. Even if you don’t play and tug on it, it may still disappear. The shape of hairlines may change as you get out of your teenage years.

Tags: hairline, widow’s peak, female hair loss, hairloss, hair loss, teen

I have been losing my hair since i was about 17 and a half and i have found it deeply depressing and i am sick of the smell of hairspray! I was just wanting some helpful advice …

I have been taking Propecia for about 4 months and i am yet to notice any results and i am beginning to consider but as i am only 18 i will probably be denied such treatment. I just want something to tide me over until hair cloning is made public. Do you have any idea when this may be?

Any Advice you have i would be very grateful to receive.

Yours sincerely

I just got back from the annual ISHRS hair doctor convention (this year was in Amersterdam), and that very same question about cloning was asked to the experts who where on a panel that I chaired. The answer is that there is no cloning in the near future. I’ll write more about the ISHRS meeting in a future post this week.

My honest opinion is that cloning is still a decade away from being available to the public. They’re making progress, but even the clinical trials seem not to be working as hoped. If you follow message boards, some believers will tell you to give it another year or two… but that’s a moving timeline. I’ve been reading it’ll be available in “5-10 years” for at least the past decade. If you believe that someone has the answer, please let me know as it might just be good marketing hype.

You won’t see results in just 4 months of Propecia use, but stick with it. The most common question I get from 18 year olds on Propecia is about hair loss in the hairline. I don’t know what your hair loss is like, but keep in mind that full regrowth isn’t a benefit of the medication that you should be expecting. Just stopping the hair loss where it’s at is benefit enough. The peak benefits of Propecia takes 2 years and the gain in the second year slowly appears.

Tags: propecia, finasteride, age, teen, cloning, hair cloning

My hair density has decreased since I have started this medicine. Even my front hairline started decreasing. I masturbate 2-3 times a week. Is this loss permanent? What should I eat to decrease my DHT level. Suggest me some food not medicine plz. thank you.

Not sure why you would include your masturbatory habits with the hair question. Masturbation does not cause hair loss, regardless of how many times you might’ve heard that myth.

There is no specific diet that decreases DHT levels and high or low DHT levels in the blood stream do not reflect a cause for hair loss. Hair loss is caused by genes that you were born with and the DHT that we are talking about (which is blocked by the drugs like finasteride) are active inside the cells of the hair follicle, not in the blood stream. I would suggest you eat a normal, healthy diet and masturbate all you want.

Tags: hairloss, hair loss, masturbation, dht, diet

Hello Mr rassman

Why does almost everyone all over the internet claim propecia causes the hairline to recede and bald even faster? is this true. can it be because of the testosterone rise. because we all know testosterone does bind and hair thinning just like dht

Where are you getting your source of information? Hair loss from genetic male pattern baldness (MPB) cannot be stopped forever, but it is not accelerated by Propecia. In other words, you can be using Propecia, but still have receding hairline. Propecia does work mostly on the top/crown area and not so much on the hairline, so I suspect most people you are referring to are just noticing their recession and blaming it on Propecia.

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

lol Dr. Rassman,you say that masturbation has no effect on mpb but then how do you explain that when i stop masturbation for 3 days,my hair feels and looks stronger and thicker and the longer i dont masturbat,the better it gets..but when i do masturbate,my hair looks and feels weaker and asked for a controlled study,im your controlled father is bald,my brother balded so im geneticaly set for mpb but using certain methods and limiting masturbation to a minimum,i seem to have some control over my genetic mpb..i think someday you will see that we are right

I think you should go back and look up the what a controlled study actually is. I am posting your email because some other men may feel as you do, but there is no evidence for your thesis. Everyone is in control of what they do with their body, like when they choose to use non-approved topicals on their hair or the frequency of masturbation. If you think your hair is better now, congratulations.

Tags: masturbation, hairloss, hair loss

Note the importance of buying legit Propecia from a real pharmacy!!

Couple years old but a UK Press Release about fake Propecia rings true today.

Press release: Counterfeit medicines gang convicted

Thanks for sending this in. Yes, it is from late 2007, but it goes to show that counterfeit Propecia does exist and is a problem. One crackdown (no matter how large it was) in the UK doesn’t eliminate the problem altogether. Buyers need to use common sense when buying prescription drugs off the internet without a prescription.

Tags: propecia, finasteride, counterfeit, fake, crackdown, hairloss, hair loss, uk