This article says the FUE surgery using the Artas® robot is actually cheaper, which goes against what you said about higher costs. Thoughts?

LA Times: Robot-assisted hair restoration?

The cost of the ARTAS robot is $200,000 and the doctor must pay a fee of $1/graft for its use. That cost must be factored into the doctor’s overhead for the procedure (rent and surgical supplies). The robot will not lessen the cost of a highly skilled staff, so I am not sure if the overall cost will be lower financially or not. I see in the article from the LA Times that a discount for follicular extraction (FUE) pricing will be offered for the substitution of Dr. Harris’s time, but as many of the other costs remain fixed, the discount may be relatively smaller (in the range of $1-2/graft). This is the opinion of one doctor and one doctor only.

In the past, I have said that the robot might actually increase the costs, especially in its early phases (today’s form) where it can only core the graft (FUE style), not remove them or place them into the scalp. When the robot is capable of doing the entire process — including the graft placement, which is still years away — I am relatively confident that the overall cost to the patient will be less. I hesitate to comment on Dr. Harris’s pricing formulae and I am not sure that he will be able to maintain lower prices with the robot without some history of working with the robot occurring.

Besides the financial aspect, the real cost for the patient in FUE procedures is graft damage during extraction which causes less graft growth, a common problem for FUE in all but a few highly skilled doctors. I see patients in our office quite frequently who have had FUE procedures with significant failures of the grafts to grow, so the robot will assure the patient that (at the least) the grafts will not be damaged during the extraction phase. Damage of the grafts can also occur when the grafts are exposed to air for more than 10-15 seconds, if they are mishandled during placement, or if they are killed off during storage while awaiting placement (now a manual, not a robotic technique).

So to answer your question, the charge for the present technology may or may not really be significantly lower, but for the less-than-very skilled surgeons who do not have a great deal of FUE experience, the cost to the patient in successful extractions will be leveraged with better results. From a quality point of view, the robot levels the playing field for FUE, making the inexperienced FUE surgeon possibly as good as the skilled FUE surgeon. It will absolutely level the playing field once the robot can perform the entire mechanical process from extraction to placement of the grafts in one smooth process. That functionality is not at hand now or anytime soon.

After discussions with the president of Restoration Robotics (the makers of the robot) last week, I was told that the full functionality of the robot with FDA approval will not be available for 4-6 years. Pricing something that is worked into our daily process will take time.

Tags: fue, artas®, restoration robotics, hair transplant, follicular unit extraction

Hi Dr. Rassman,

I was wondering if you had read the recent posting concerning Replicel’s technology and initial results that will be released Q12012.

Link: RepliCel’s cell-based solution to hair loss

The reason that I ask this question is to see if you had any ideas or guesses as to who (of the companies performing research in this area) might have the best odds of delivering a viable solution? I had heard that a few of the companies presented at ISHRS-Alaska and it appears they realized the initial approach (followed during the past 5-10 years) was the wrong route. Aderans is using the dermal papilla cells while RepliCel is employing the dermal sheath cup to produce the replicated cells for later injection into the patient’s scalp. Guess that we will have to wait until Feb. 2012 for the clinical trial results. One good sign is that they filed their protocols on the FDA website which allows their approach/results to be a bit more “transparent”.

Thanks for bringing this to our attention! This is a good read for our audience.

I really have no best guess as to which path will be the most successful, but like everyone else, I’m hoping at least one of the paths turns out to be successful. The more proven treatments available for those with hair loss, the better. I guess we’ll know more early next year when the early results are released, though the article says the study won’t conclude until August 2013.

Tags: replicel, stem cells, hairloss, hair loss

Snippet from the non-hair loss article:

People who struggle with insomnia appear to be more prone to heart attacks than those who typically get a good night’s sleep, a large Norwegian study has found.

In the study, published Monday in the American Heart Association journal Circulation, researchers conducted a comprehensive health survey of more than 52,000 adults, which included questions about sleep quality. Over the next 11 years, roughly 5% of the participants had a heart attack for the first time.

Compared to solid sleepers, those who had trouble falling or staying asleep nearly every night were 45% and 30% more likely to have a heart attack, respectively, even after the researchers took into account age, blood pressure, cholesterol levels, and other factors that can contribute to heart disease. People who reported feeling tired or unrefreshed after waking up at least two mornings per week were also at greater risk.

Read the rest — Insomnia May Boost Heart Attack Risk

You can find the abstract of the study here. While the study concludes that the risk is moderate, it this is an important health issue that many of us just do not take into account.

Tags: insomnia, heart attack, ami, heart, health

In a recent blog post you wrote about sexual side effects associated with propecia use, “These side effects are reversible withing one to two weeks after you stop the medication.” You then went on to say that Dr. Irwig’s study in Journal of Sexual Medicine was not a scientific study.

When you read through the FDA hearing on Propecia (FDA link) Keith Kaufman of Merck talks about the 3.8 percent of finasteride users experiencing side effects versus 2.1 percent of the placebo. He then goes onto say that these patients then completed a validated sexual function questionare. I am not a doctor but Merck basically based these figures on self reporting, should those numbers not be considered scientific?

In July the Dr. Irwin Goldstein the Editor-in-Chief of the Journal of Sexual Medicine wrote “I think of the frequent phone calls I receive from distressed men with varying degrees of hair loss who have used 5 alpha reductase inhibitors and now have newly manifested sexual and cognitive complaints that often persist despite discontinuation of the 5 alpha reductase inhibitor. Often such 5 alpha reductase inhibitor users have sought help only to be belittled, betrayed, misdirected, and sometimes misinformed. In general, these patients feel deceived becuase of the lack of information warning them of the potential side effects.”

I am one of the individuals suffering from persistent sexual dysfunction after stopping propecia and it appears pretty certain to me that in a small subset of men the persistent sexual dysfunction is due to the medication.

I am not going to get roped into an anti-Propecia agenda. I will leave that up to those who regularly comment on almost every post where the word “Propecia” appears.

My heart goes out to you if you actually have long-lasting sexual side effects, but the questions of validity ring true to your cause of sexual dysfunction. I am not in a position to judge your problem or to put the pieces together for you. That must be between you and your doctors. I am a doctor, but the posts here are just my opinions on my blog. Some may not agree with me, but that is OK! As the disclaimer on every page says, BaldingBlog is not a place for treatment advice or diagnosis. If the readers want to discuss their issues on a professional basis, they can always make an appointment and see me.

I will post an interesting excerpt from the 1997 FDA Drug Evaluation Hearing that you quote (the last sentence particularly worth noting):

We attempted to obtain followup on all patients reporting sexually-related adverse experiences. Of the 36 patients on finasteride reporting these adverse experiences, 21 reported resolution of the adverse event while continuing finasteride therapy. Seven reported resolution following discontinuation from the study, and seven had persistence of the adverse event while continuing in the study on finasteride therapy. The pattern for patients on placebo was essentially similar, with most patients resolving either on or off drug, four patients reported persistence of the adverse event while remaining on placebo therapy.”

Tags: propecia, finasteride, hairloss, hair loss

I am a 23 year old male seriously considering a hair transplant. I am a norwood class 2 w/a naturally high hair line and diffuse thinning in the temples about an inch back and slight thinning in the front (minor). I have been on finasteride for 2 years and rogaine foam (on the hairline) for 2 years. I have a few uncles on my mom’s side who are norwood 5’s and some uncles on my dad’s side who are norwood 2’s and 3’s. My dad is a norwood 2a.

I have been to two hair transplant surgeons who both said I was a good canidiate because I have good donor hair and I’ve halted/slowed my hair loss with finasteride. The surgery would be a conservative approach to establish a mature hairline. I’m not trying to get my adolescent hairline back. They each recommended btw 800 and 1000 grafts via the strip technique.

I know I am young but what do you think? Will I regret this in 10-20 years? Is shock loss a major concern in my case?


You need to find a great doctor that is known to be honest — not one that wants your money instead of giving you what you need. A good relationship with a doctor you trust will be critical to the decision making process. I cannot say the recommendation you got was good or bad, as I haven’t seen you. Some 23 year olds are excellent candidates, some are not. If you do go through the surgery, hopefully the Propecia will limit or prevent shock loss, but there’s no guarantee.

It seems you are having doubts and that raises a red flag for me. Unfortunately I cannot give you a diagnosis, recommendation, or prognosis here.

Tags: hair transplant, age, hairloss, hair loss

I am a 21 yr old male diffuse thinning in the NW6 pattern. I am currently on finasteride but I know it will not last forever.

Is this look possible with SMP? It is pretty much the only hope I have left.

Yes, this is a good option… but you must get educated on the facts that go along with it. Remember, this is a permanent decision so it needs to be thought through carefully.

Here is a 22 year old in your similar situation — Client 17. He started losing his hair when he was 16 years old and had worn a hat everywhere he went. After the SMP procedure he told us he went out for the first time without a hat on! SMP is not for everyone, but it does have its use in certain segments of the balding men.

Tags: smp, hairloss, hair loss, pigment, scalp micropigmentation

Good morning Doctor Rassman,

I would like to know if washing my hair every day with a gentle shampoo could cause a hair loss ?

Many thanks for your great blog.

If you are gentle when massaging the scalp in the shampooing process, especially if your hair is miniaturized and in the balding process, I would doubt that shampooing would cause hair loss.

Tags: shampoo, hairloss, hair loss, massage

Dear Drs,

I was wondering which is the difference between “scalp DHT” and “serum DHT”. I guess “scalp DHT” needs “serum DHT” concentration to reach the scalp; am I right? Then, what means in the dutasteride/finasteride studies the differentiation of “scalp DHT” and “serum DHT”?

I know Avidart inhibits, 90% of serum DHT and 55% of scalp DHT, what it mean? The 55% is inhibited from the total DHT or from the 10% (respect the 90% serum inhibit)?

Thank you.

When a drug like finasteride is introduced into the body, it works its way through all of the fluid systems of your body. In theory, almost every cell in your body gets exposed to the drug and some of the cells will do something to the drug. So when you take this finasteride pill, 50% of it will remain in your blood stream after 4-6 hours, and every 4-6 hours the concentration halves.

The drug then works its way into the body fluids around the cells, and it may (finasteride does) attach to the hair follicles and the skin of the scalp. Slowly this process reverses (probably about a week), as the drug does its job on the individual hair follicles, minimizing the DHT. This DHT working, becomes less effective because of the competition for the sites in the cell. That is a very simplified way to explain how it works.

As I’ve said before, I am not a biochemist. I really do not know how scalp DHT or serum DHT are measured.

Tags: scalp dht, serum dht, dht, hairloss, hair loss, finasteride, dutasteride

I, like another member on here recently, was prescribed Finasteride in the 5mg tablet once a week by my dermatologist. I’ve researched here that it’s better to take it daily for the most effective treatment, however, the pills that I picked up at the pharmacy are very, very small. They are circular shaped, blue in color and have an ‘H’ on one side, and a ’37’ stamped into the other side. Are you guys familiar with this pill and is this the size that I am expected to cut into fifth’s?

I need to know if I should try and get a larger size, go ahead and cut them (into at least thirds?), or just stick with the once a week treatment. Thank you!

This is a problem that I’ve heard about before, depending on the generic maker. I’m not familiar with that exact pill you’re describing though. Some generic makers use various excipients to size the pill larger, making it easier to cut. Some may even add scores into the tablet to make it easier to break. You can either go back to your pharmacist and see if they have a different generic size available or try to cut the pill carefully.

It really makes no difference if the 5mg pill breaks apart, provided that the entire 5mg pill is consumed over a 4 day period. I am assuming that even with some crumbs lost in the cutting process, it will still amount to 4mg consumed. Taking 1mg every day is better than taking 5mg once every 5 days, but I’m not your prescribing doctor.

Tags: finasteride, generic medication, propecia, proscar, hairloss, hair loss

I would like to know if you have to necessarily shave a part of the donor area to perform FUE ? Can it be done if you keep your hair at normal length ?

If you have to shave it how long do you have to keep the rest of the hair in the donor area to camouflage the part that’s shaved ? Is it noticeable ?


It depends on the number of grafts you need through follicular unit extraction (FUE). A large number of grafts will require an area to be shaved. When we see you and give you a quote, we can tell you the answer to that question.

Take a look at the patient example on our FUE page. We kept his hair long and clipped small areas that were easy to cover with his existing hair. We can often get 500 or so grafts from such an area.

Tags: fue, follicular unit extraction, hair transplant

Dr Rassman,

What ever happened to FUE2? When it first came out it was marketed like the next big thing in hairloss but know never gets a mention.

Was it a failure? Or are you still working on it?

We still use FUE2 in selected patients. The system in not automated, so it is more difficult to do it by hand, but we do use it. When I finally get it automated, I suspect that I will use it all of the time.

Tags: fue2, fue, follicular unit extraction, hair transplant

Is it true that Finasteride in Humans would reduce important Neuroactive Steroids like for example allopregnanolone? I know there was already a post about this in the past but that was about rats. In rats, Finasteride blocks both type I and II 5α-reductase whereas in humans inhibits only type II which it seems is not present in the brain unlike type I. I would appreciate your opinion about the following two studies:

Link 1: Finasteride Treatment and Neuroactive Steroid Formation (PDF file)

Link 2: The influence of low dose finasteride, a type II 5α-reductase inhibitor, on circulating neuroactive steroids

I do not think I can add much here, as I am not a biochemist. Mood changes have been associated with finasteride and depression has been reported, but I’m unclear on specifics beyond that.

The 1st link is a study of 20 men with an average age of 69.5 years that took 5mg finasteride. The 2nd link is a study of a dozen men that took the 1mg finasteride with no listed ages that I see. Both studies are small and offer nothing definitive, using words like “probably” and “might”.

This should go without saying, but finasteride is an elective medication with some rare side effect possibilities and is available by prescription only. Hundreds of other medications also come with side effect risks, and you must talk with your doctor about these risks and benefits so you can make an informed decision.

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

Could you tell me more about Laminins-511 please and whether you think it is a promising ‘solution’ to hair loss? I had never heard of it before reading this article, but i’m now very intrigued.

Link: Mens Health

I do not know much about laminin-511 besides this press release from 2008. These are studies performed on mice and the research is disseminated to the popular media, grabbing the interest of readers such as yourself. I don’t see a date on that article, but I’m guessing it was from back when the laminin-511 mouse findings were first announced. It says they’ll have trials in 2 years… so I’d assume there should be info already if it was successful, but I can’t find anything new.

These news stories create a definite interest, but the implications on hair loss treatment remains to be seen. We get these types of stories sent to us almost on a weekly basis.

Tags: laminin-511, laminins-511, hairloss, hair loss

Here is a question on the Scalp micro Pigmentation. Once a patient decides to do a cosmetic pigmentation especially on certain parts of the scalp, but not the full scalp, how is he going to look when his real hair will become gray eventually? Do you use a permanent or a temporary pigment?

I think we’ve answered this before, but in general, we do not perform SMP to certain parts of the scalp since as you point out, it would not blend in with the changing of hair color. For example, we sometimes leave the areas around the ears and neck.

Scalp Micropigmentation is permanent. If you want a temporary solution, I’d try Toppik or DermMatch.

Tags: smp, hairloss, hair loss, pigment, scalp micro-pigment

I have had two procedures in the past at Dr. Rassman’s NHI facility. The first about 8 years ago, the second about 6 years ago. I have used Propecia, or Finasteride as a substitute, religiously since before the first procedure.

About a year ago I started to notice substantial thinning in the areas that had become filled in from the procedures. I have assumed this to be loss of original hair. Is it common for Propecia/Finasteride to stop working at some point? Does substituting Finasteride have a negative effect?

Last, I have read that Propecia (Finasteride) dosage can be reduced from 1 mg a day to .2 mg per day with no negative effect, and that it may be possible to take the med every other day. True?

Hair transplants are permanent and lifelong, but those remaining hairs you had in the balding areas (not the transplanted grafts) will continue to fall out. When you have surgery, we transplant the hairs in between any existing hair to blend it in so that if the existing hairs fall out years down the line, you will still have the transplanted hairs to keep things looking natural without an abrupt demarcation.

Propecia is just a brand name for the finasteride (in 1mg dose). There should be no difference between generic and brand name other than possibly the strength in dose of the active ingredient. It’s possible that there are different fillers. Propecia/finasteride does help hold on to the existing thinning hair as long as possible, but eventually your genetic predisposition catches up with you. This does not mean it just stopped working, but rather, you are getting older and your predestined hair loss fate is winning the battle.

The medication is about 70 to 80 percent as effective at half the dose of the recommended 1mg daily, so you can theoretically cut the pill in half (0.5mg) and still see some benefits. There have been some patients who have seen side effects, and cutting the dose in half has allowed them to experience good results without the side effects.

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