Thank you for the time and effort you put into answering all of our questions. My question regards scarring. I have heard some people say that scar tissue forms where the hairs are implanted during a transplant, and that this can result in bumps or raised spots on the hairline. Is this true? If so, is it common? If not, why don’t scars form where the hairs are implanted? After all, a wound of sorts must be made to implant the hair, so how would do you prevent hundreds or thousands of scars from forming after a hair transplant?

With the technique we pioneered, we do two things that minimize recipient site scarring —

  1. We make very small wounds in the skin, essentially slits that approximate the size of the grafts. These heal very fast.
  2. When preparing the grafts for implantation, we cut off the skin disk at the skin level. To minimize the skin disk, we remove the top layer of the graft skin from the surface of the graft. This prevents the skin from surviving the transplant which could, in some individuals, produce the bump seen in recipient areas. The same process is done with grafts taken from strip surgery.

When doctors use grafts that have a larger surface area than what I described above, the bumps you referenced get more prominent. We have seen from the old days when plugs were done and the graft sizes ranged from 3-5 mm across, the skin always was deformed. Clearly the more skin that survives at the top of the graft, the more detectable will be the existence of the transplanted graft.

Tags: hairloss, hair loss, hair transplant, scarring

Dear doctor how are you? In terms of demographics, I have read on this site the older you become the more hair loss you see. For example, when somebody hits their 30’s, 30% of the people are bald when somebody hits their 40’s, 40% of the people are bald etc. etc.

Could there also be a reversal of those statistics? For example, once a person hits their 30’s and they are not bald or only have minor thinning, 30% chance that they will not go bald and once in their 40’s, 40% chance they will not go bald etc. etc. I know its really hard to judge because everybody is different, but I just wanted your input and wanted to share it with the rest of the readers.

Thank you for a wonderful website site. Take care.

Most balding occurs in men when they’re in their 20s, especially if they are destined for a more advanced hair loss pattern (Class 5 and higher). I can try to predict your pattern during an office visit by measuring your hair bulk and comparing it throughout the scalp. Early patterns that can not be seen with the naked eye can be measured and followed as you get older.

It is important to make your question personal, as none of us fall in any particular percentile, as it is just a statistical process.

Tags: hairloss, hair loss

My fiance and I are planning on trying to start a family in a few months (after the wedding). I’ve read in some places that Rogaine can lower sperm quality or affect an unborn fetus somehow, but I can’t find it anywhere that looks official. Is there any truth to this? If I do stop using it, will a large portion of my hair fall out within weeks? I’ve never gone more than a day without using it.

I’ve been on Rogaine for about three years now and it appears to have slowed my hair loss. If the choice is between keeping my hair and the health of my unborn child, obviously I’ll pick the latter. But I’d rather not have to choose. Thank you!

Rogaine (minoxidil) should have no effect on your sperm, nor have I have read anything supporting what you read about it affecting the fetus. Of course, if you’re concerned you should talk to your doctor.

Perhaps you’re confusing it with Propecia (finasteride), which has rare side effects related to ejaculate and fertility (but not change sperm count).

Tags: rogaine, minoxidil, sperm, hairloss, hair loss

Hello Doctor

I’m a 27yo male with a full head of hair yet. I comb my hair a couple of times a day after my minoxidil application with a wide tooth comb. As I have medium length hair sometimes knots are formed and even if I’m gentle sometimes I feel little painful pulls.

Should I be worried about those? I doubt any hairs are being pulled out by the root because I try to be gentle, but if some hair does, will it grow back?

Thank you very much.

If you’re being gentle, I don’t know what to tell you. You could try switching to the foam instead of the liquid solution and see if it helps.

Tags: minoxidil, rogaine foam, hairloss, hair loss

Hi Doc,

Nice blog.

My question is kinda odd, but please humor me. I can tell there’s some sort of relationship of importance between cause-driven itchy scalp and hair loss.

I really think someone in the hair loss research field, such as yourself, should look further into what I’m saying. I am a statistician by background; I have a PhD in my field, and I am by no means bringing up a crazy idea here. It’s a theory. We all want a cure for baldness, and the best bet is to hear out every conceptual idea or theory. If you could learn the connection here, I believe you would not only make a lot of money, but you’d also help a lot of people.

So, here goes… I noticed about a year or two ago – when I eat something spicy, my head itches. Ok, big deal. Sometimes when I workout, my head also itched. However, the spice aspect, is more noticeable, regular and I can even predict it. When I eat something spicy, I know I’ll have an itch shortly “only in the area of my head that’s thinning or balding”. It’s really strange, and my statistics background tells me there’s got to be a connection there.

The questions I think need answering are:

-Why do humans feel itching?
-What in a spice could cause itching at distant location?
-Could it be something from the spice goes into the bloodstream right away and effects DHT?

I seriously think a dermatologist should be able to answer this. I know I’m not the only one to bring this up.

Hot peppersI am not a dermatologist, so I will try to answer to the best of my capacity. I do know from personal experience that one of the consequence of eating spicy foods is sweating on the scalp, which can make your scalp itch. It also makes my nose run and sometimes my eyes water depending on the heat level. This may be due to a histamine reaction from the capsaicin, the chemical which makes it spicy. But I do not see how this is related to hair loss.

Most male hair loss is due to genetic causes, which is known as androgenic alopecia (AGA) or male pattern baldness (MPB). It is really not a DHT issue in and of itself. In other words, if you do NOT have the genes for hair loss, you will not go bald no matter how much DHT you have.

As far as why humans have to feel the sensation of itching, that is like asking why humans have to feel the sensation of pain. I think that is a bit beyond the scope of BaldingBlog. Sorry.

Tags: spicy food, hairloss, hair loss, itch, scalp itch

First of all I, among many other really appreciate your work in helping people out with hair loss questions.

My condition, starting at 18 (two years ago) began abruptly with hair falling out at all parts of the scalp. This includes the “donor area”, sideburns, the top, the crown, the sides…everything. I researched and thought it may have been telogen effluvium but it never stopped which led me to the unfortunate conclusion that i was losing ALL of my hair. Two years later it is still going strong with all parts of my scalp significantly thinned but no receding hair line at all. This past year alone I have been having constant, very serious dandruff ( to the point where I don’t even understand how my skin cells keep up with all the skin shedding) and toward my hairline it almost looks like a rash where the dandruff begins. I feel like either the dandruff is causing hair loss or the hair loss is causing dandruff.

Anyway, I am just wondering if you have any knowledge of this and if there is any sort of treatment just to at least give me some extra tie with my hair since I’m am not even 21 yet! My mother’s father lost all of his hair by 30 but since much time has passed there must be some sort of working treatment other than minoxidil and propecia. I am also 100% Italian if that helps at all. Any thoughts at all will be extremely helpful since I am too scared to tell my parents or anyone because I am so young!

Thank you

You need to see a good doctor. If you are losing hair in the donor area and the sides (as well as elsewhere on your head), you might have diffuse unpatterned alopecia (DUPA)… or there could be something else entirely (allergy? fungus?). It would be foolish to treat yourself and second guess what is going in.

You’re 20 years old, but you’re never too old to lean on your family for support if you need it. I’d start with a doctor to help determine what is causing your hair loss.

Tags: dupa, diffuse unpatterned alopecia, hairloss, hair loss

Hello Dr Rassman.

Want to start by thanking you and all the others who helped and contributed to this awesome forum!

I have been depressed for a while now. But then I’m very critical of antidepressants. So i have decided to test ST. John’s wort, who according to studies can be just as effective as antidepressants while it has much less side effects than conventional antidepressants.

But St. John’s wort has a tendency to affect the metabolism of other drugs.

My question is, do you know if St. John´s wort will affect propecia

I am not much of a herbal expert, but I do know that some herbs can interact with medications. In particular, St. John’s Wort is listed as having interactions with Propecia (finasteride 1mg), though I do not know if this will have a clinically significant affect on the efficacy of Propecia. You may run the risk of increase side effects, however.

I would consult with your doctor.

Tags: st johns wort, hairloss, hair loss, propecia, finasteride, herbal

Joe RoganI was listening to the Joe Rogan podcast and was really surprised when he mentioned that he won’t shave his head because he had a transplant a few years ago and has a scar. I always wondered why he DIDN’T have a transplant when I would see him on TV but was kind of surprised that he says he had one. Do you think he was misinformed as to what his eventual loss would be?

Your guess is as good as mine. I do not know the circumstance of actor/comedian/host Joe Rogan’s hair loss or the treatment he had. It’s possible that he had the surgery many years ago and had continued hair loss, but I really don’t know.

Someone might mention to him that we can treat his scar with either a scar revision or Scalp MicroPigmentation (SMP).

Tags: joe rogan, fear factor, hollywood, hairloss, hair loss, hair transplant

IDOC.. let me see if I have this correct. Having a transplant in an area where there is still a fair amount of hair increases the odds of shock loss? if i want to get a head start and restore my hairline as its thinning but still have hair, the trauma from the surgery will most likely cause shock loss to the existing hair in that area. Is that right? So the best candidate is one who has little hair in the area to be transplanted?

Is anyone still testing A Cell therapy for hair restoration?


Broken recordThose who are at the highest risk for shock loss include:

  1. Patients with noticeable hair loss that is active at the time of surgery
  2. Patients that are younger than 30 years old
  3. Patients that have significant miniaturization of hairs in the balding pattern.

When such patients are on finasteride, the risk for shock loss is reduced.

I know I sound like a broken record at times, but everyone is different and every individual case is unique. There is no universal answer to this question. Some wait until they are bald before they have hair transplant surgery. Some have surgery as they are balding (to maintain their existing look). Shock hair loss is always an issue, but not an overriding one after all the factors are considered… as long as you and your doctor are realistic about shock hair loss. Some overreact or misinterpret what shock hair loss really is, and make it out to be an overbearing issue. But this is a generalization. Please read this recent post on shock hair loss. We do take it seriously, but we also take it on a one-on-one basis. That is why we have a real doctor- patient examination and consultation before any surgery.

With respect to ACell, we have conducted the one year study for hair restoration, but it was a failure. As far as I know, no doctor has been able to reproduce the results claimed by Dr. Hitzig or Cooley on hair multiplication. That is probably why you are not reading about it in scientific journals or in the mainstream media as the next great breakthrough. I don’t know which doctors are still experimenting with it, though.

Tags: shock loss, hairloss, hair loss, acell

Can I use hair removal if I decide my transplants just aren’t looking right? I am just trying to figure out what my options are to undo the surgery.

I met with a patient a couple years ago who had frontal hair transplants at a clinic with results that did not meet his expectations. He responded by going through electrolysis and removing the grafts. He came to my office to figure out what to do with the linear scar.

The results of the tedious electrolysis was very good, but in our experience, electrolysis is very dependent upon the skill of the person doing it. The means the results from this process can vary considerably. The use of hair removal lasers also can be a problem particularly if the grafts are large since they leave an abnormal “foot print” in the skin once the hair is gone.

Tags: electrolysis, hair removal, hair transplant, hairloss, hair loss

Some of my eyebrows are gray

those eyebrows have two colours on them. they are dark at the end and then they drastically turn white towards the root. what would it mean? also, the new little eyebrows seem to be dark.

Eyebrows gray like other hair. There is little you can do about the graying other than using pencils designed for graying eyebrows or hair.

Tags: gray hair, grey hair, eyebrows

The following post is by UK-based physician Dr. Bessam Farjo:

Written by:
Dr Bessam Farjo, United Kingdom
Dr Bessam Farjo
United Kingdom

I recently came across a poll on, which reveals that one in four Americans would consider having surgery if it wasn’t so costly. With this in mind, it’s not surprising that people seek a lower cost option and consequently consider having surgery in a country where it’s cheaper. While the discounted price tag may be very appealing, there are some important things to bear in mind when it comes to having surgery abroad.

The same website outlines some of the dangers associated with medical tourism. It describes how it can be difficult to check if a foreign physician’s credentials are genuine, suggesting that the International Society for Aesthetic Plastic Surgery is a good place to start. It also flags up that you may not be covered by your travel insurance if something goes wrong in another country. Another issue concerns recovery, which can sometimes take longer than expected after surgery and there can also be a danger of clotting if travelling by plane.

Similar considerations apply to our own field of hair transplant surgery. The website of the International Society of Hair Restoration Surgery provides a list of members as a reference not necessarily recommending anyone in particular. It is down to the individual patient to do their due diligence whether online or in person.

There are clinics that try to take advantage of potential patients who consider surgery at home too. We’ve seen a growing number of men come to us after opting for surgery via an offer on a discount website such as Groupon or KGB deals. These ‘deals’ are usually limited to 1,000 grafts which is only around 2,000 – 2,500 hairs. To anyone with a significant amount of hair loss this would be nowhere near enough to provide a suitable result.

The small print in these offers often dictates that only one discount is available per person, meaning that anyone requiring further treatment would have to pay the full cost or more likely, above the odds.

There certainly are some serious dangers involved with having surgery both abroad and at home and I would strongly recommend considering these should patients be tempted by low-cost surgery options. As always, I must stress the importance of thorough planning and research when contemplating any type of surgery, make your decisions based on what’s right for you, not on the price it costs.

Learn more about the author of this article, Dr. Bessam Farjo, on his BaldingBlog profile or at his website.

Dr. William Rassman’s Comments:

    I can speak to having surgery in the United States, Canada or Europe. The issue of recourse comes up. What recourse do you have if the doctor misrepresented himself (or herself)? Or if there is medical malpractice involved in the delivery of the surgery? Or if the “doctor” really isn’t a doctor?

    I know the laws in California are made to protect the patient at all times, and California lawyers are waiting enthusiastically to represent those who are harmed. The legal recourse in many foreign countries may not be there, which means that if you become a victim of the surgeon, there is little you can do about it. This, to me, is a good reason to have the surgeries in the United States, Canada or European countries that have strict laws that control doctors’ licenses and the way they use their licenses.

Tags: hairloss, hair loss, hair transplant, travel, surgery, farjo


Your blog is wonderful, an excellent information source. You are also one of the few who mentions the mature hairline in a significant amount of detail. So many people get mislead by the classical Norwood 1 image, which is actually a juvenile hairline, as you said. (Many sources claim that only NW 1 means a full head of hair, and everything else is a sign of balding..)

That said, there is something you haven’t mentioned, but seems to be relevant: the size and shape of the head, especially the forehead.

NW 2 hair tends to look more dramatic on people with round faces and large foreheads than on oval heads, for example. In addition, I have noticed that some foreheads tend to have a more rounded shape, while others look more like a V (when viewed from above).

Do you agree on this?

ConeheadThe Norwood hair loss classification describes the variations in male hair loss patterns. It is not the progression or stages one goes through. You can look like you have a full head of hair, but still be a Norwood 6 if you show the thinning pattern. Some may be a Norwood 3 and be that way for the rest of their life. In other words, Norwood 3 rarely, if ever, progresses to a Norwood 6.

With respect to the shape of one’s forehead or even the shape of their head, I agree it may exaggerate the look of a Norwood pattern, but forehead shape and hair loss are not directly related. Perhaps there should be a forehead classification.

Tags: norwood class, forehead, hairloss, hair loss, hair pattern

Hi Dr. Rassman and Dr. Pak
I recently had an FUE procedure done at your Los Angeles office and I want to thank Dr. Pak and his stuff which are very knowledgeable and really smart! And most of all very carring and are willing to go the extra mile to make the surgery the most pleasant one, I even had I conversation with Dr. Rassman while waiting for the elevator to arrive, he’s so down to earth and very polite.

I just wanted to let you guys know that at Costco warehouse store I recently got my finasteride medication for the whole year for only $16 dollars, before I used to pay $63 dollars per month for propecia, big savings, Once again thanks to Dr. Pak, Dr. Rassman and all of your staff (nicest people that i’ve been around so caring!) and sorry that on the day of the procedure I didn’t shave my head off and for being a little late to the appointment.

Thanks for everything you guys do for us and keep up the great work.

Thanks for your kind words!

And thank you for sharing your Costco information. It seems they lowered their pricing. That’s great news! For anyone looking to save some money, I should note that you do NOT need to be a member at Costco to use their pharmacy (or buy liquor, for that matter)… but you do need a prescription for the 5mg finasteride (and cut the pills for treating hair loss).

Tags: costco, hairloss, hair loss, finasteride, propecia, proscar

I am interested in using a dermaroller to enhance topical absorption. How long can the needles be before there is a risk of damaging the follicle and the surrounding vasculature?

We do not use or have experience with a dermaroller. I had one on my desk to play around with, but it never got use on the scalp, so I am the wrong person to ask about this one. I wrote about that years ago. It still looks painful.

In general, anything with a sharp point or a needle that you use on yourself (or others) should be sterile and used with caution. If there are readers out there that use this product, I’d be curious to know what you think about it.

Tags: dermaroller, derma roller, hairloss, hair loss