Hi Dr.Rassman,
I’d be very grateful if you could reply to the following questions:

1. How do the technicians slivering the donor strip record the Follicular Units. Is this done as a running total on a sheet of paper for type 1, 2, 3 units? Is the total of these units then recorded?

2. How do the placers, placing the Follicular Units record the Incisions created. Is this similar to Q.1 above.

3. Is it true that each incision site created can only contain ONE Follicular Unit graft? Otherwise, more than one would be compressed, traumatized and die??

4.If the Incision count is LESS than the Grafts extracted from the donor strip, what would that indicate.

5. What would increase a hair transplant procedure between 2 patients having the same amount of grafts transplanted and the same number of medical staff in attendance? For example, if one of the patients had blond hair, would it be more difficult to see such grafts under a stereomicroscope?

I often get these type of questions asked in different ways. It is a very good question that also can be seen as a trust between doctor and patient. In other words, how do you know if you are receiving the number of grafts agreed up on (which relates to how much you paid for).

It is also a great question merely from purely a technical point of view of how one keeps track of thousands of grafts and incisions on one’s head.

I cannot speak for all the hair transplant doctors in the world as there is no standardization on how one keeps track of grafts. I will try to explain your question from a general perspective as well as what I personally have been doing in my practice for the last 23+ years.

1. Our staff keeps track of each graft dissected on a paper as they cut about 25 to 50 grafts at a time. They record and sort out single hair to multiple hair grafts individually as they dissect the grafts. A team leader then double checks the numbers as the day progress and add up the total number of grafts on a master sheet. Finally when all the grafts are dissected, another accounting in made on a computer Excel spread sheet. Usually we double check numbers with another staff individually adding up the numbers separately.

2. The placers do not keep track of the grafts being placed. Instead the doctor keeps track of how many incisions were made. If there was 1000 grafts cut, the doctor makes 1000 incisions and the placers have to find individual incisions to place the grafts. It sounds tedious and difficult but that is why the experience of a good staff and the reputation of a medical practice is important. This is one of the critical steps in the hair transplant surgery where this task need to be completed as fast and most efficiently as possible to accomplish a successful surgery. Longer this takes, your hair grafts may not grow to its full potential as it is kept out of your body and handled by an inexperienced staff trying to find the incision.

3. One incision usually has one graft. Sometimes where there is an over abundance of single grafts, the doctor instructs the staff to place two single hair grafts in one incision (or one single hair and one double hair grafts in the incision). If the staff is experienced there should be no issue with compression (we call it “piggybacking”) and trauma to the grafts. If the staff is inexperienced they may inadvertently place on graft on top of one another and cause trauma and poor growth. If the doctor is planning on “doubling” grafts he appropriately makes less incisions than the grafts that are being cut. He also makes the incision differently with a different needle to indicate to the staff where the double grafts should go. This a very subtle thing that has huge implications and requires a very well trained staff.

4. If the incision count is less than the grafts extracted, then more incisions have to be made. Or if the grafts are less than the incisions made then more grafts have to be harvested or you have to leave the incisions empty. Another subtle thing that takes coordination between staff and doctor.

5. Every patient is different even when the same number of grafts are planned (even with same colored hairs). In general curly hair and white hair is more challenging. Some patients have different textured scalp which cause the grafts to “pop” out and not stay in its place.

Tags: accounting, hair transplant, counting, trust, reputation

I have had several transplants over the years and have lost about 30-40% of them due to thyroid related conditions. My main concern is if this continues will the transplant scars at the back of my head become visible. Some of the pictures posted on your blog shows promising ways of disguising these scars using SMP. Is this a one-time procedure or something that has to regularly undertaken?

NHI_SMP_to scar

NHI_SMP_to scar

The photo here is an example of what is possible with SMP on hair transplant scars.
SMP is generally a one time procedure and the longevity is similar to any tattoo. As with any tattoo you may want to have it touched up after several years.
If you would like more information, you can always give us a call to speak to our surgical staff or one of our doctors.

Tags: smp, scalp micropigmentation, photos, information

I am 24 years old and now have advanced my balding to include the front and the crown. I don’t want to be bald like my dad who is probably has a Class 6 pattern of balding. He said he got most of it when by the time he was 35. What if I started taking Propecia when I was 18, would that have preserved my hair?

That is a great question. Most advanced balding pattern patients have their pattern established in their 20s. Despite that almost 20 years that Propecia has been on the market, we really do not know if the progression could have been stopped had you taken the drug when you were 18. There would have had to be controlled clinical trials where one group who had advanced balding in their families were put on Propecia and the other group not. In that situation, we would know the answer to your question, but no such study has ever been done.

I suspect, however, that had you taken the medication when you were 18, you would have slowed down the progression of the balding and most of such young men in the 18 year old bracket, would not develop their final balding pattern for many years. i doubt that the final pattern would have been thwarted, but for such men, delaying into their 30s could give them the benefits for possibly another decade of so. We will probably never really know the answer, but for many men who I placed on finasteride (Propecia) I have seen the process slow, stop or occasionally reverse. Better to do it than not to take the drug if you are one of these 18 year old men. At 24, it can’t hurt and probably will help.

Tags: family history, balding, finasteride, propecia

There are many such cards being sent out to get your detailed health records that will invade your privacy. Here is the pink from the Better Business Bureau. Here’s the URL for the BBB’s page on Script Relief

The US patent office just issued Dr. Rassman and Pak a new US Patent called “Apparatus and Method for Mapped Hair Metric” Publication number US20120148127 A1

We continue to innovate in the field of hair restoration and this device is another diagnostic tool that may come to market in the near future.

patent Dr. Pak, Dr. Rassman

Prior art systems are available for obtaining measurements of hair to determine the degree of hair loss in areas measured. U.S. Pat. Nos. 5,331,472 and 6,253,771 and 4,807,163 and 7,098,910 and 7,006,657 and 6,993,851 are examples of such systems. Commercial software packages are currently available (TrichoScan by a Germany company Tricholog, and Folliscope by a Korean company Hairscience) for such purpose. But in order to provide a reliable metric by which to evaluate hair loss and even the effect of treatment, the status of hair loss has to be determined at different times over the same geographic area.

The prior art systems, even those employing imaging systems, determine the status of hair loss that is difficult to compare at different time intervals because the area of interrogation is not well defined geographically. Generally the areas under interrogation are in the order of 10 to 50 square millimeters. Since the total area of scalp is 50,000 square millimeters, the need for accurately accounting for the geographical location of individual measurements that only covers 10 to 50 square millimeters is paramount.

The prior art incorporates relatively small static images over a relatively large area for analysis. The present invention is based on the recognition that a streaming video analysis can also be incorporated to provide more data points in the algorithm.

The present invention is based on the recognition that a metric for hair loss can be produced by imaging areas of any hair bearing skin which are sufficiently large (i.e. 50,000 square millimeters of the human scalp) that the focal areas can be later revisited reliable where any offset in positioning would introduce only acceptably small errors. A map of the hair bearing skin or scalp can be generated by a compilation of the images to provide a reliable metric of hair loss status for comparison with the metrics previously generated. The invention provides a method and apparatus for geographically mapping user defined locations of hair bearing skin area with a bulk metric output. The metric values may be used to compare different user defined locations to quantify relative differences by location. The metric values may also be used to compare user defined locations at different time intervals to quantify relative differences over a period of time. The mapping and the metrics can be achieved more specifically by automated means by the analysis of multiple static pictures or the analysis of a live video covering a larger area than a single, static field of view. It also provides a method and apparatus for sorting and characterizing the relative diameter of a hair shaft by automated means in which the total cross sectional area of all the hair shafts in the interrogated field can be calculated. The automated method of obtaining this metric can be effectively used to acquire the bulk of hair over user defined locations and time intervals.

Hair on the scalp that is susceptible to androgenic influence may exhibit a relative decrease in shaft diameter and number. This phenomenon is sometimes described as miniaturization of hair as is described above. Miniaturization of hair may also be due to various disease states as well as the natural life cycle of hairs. The present invention incorporates a device to interrogate an area of hair bearing scalp. The image(s) are digitized and processed by a pre-programmed algorithm to differentiate the hairs against its background. This differentiation is quantified by automated means to express a value of number of hairs per area and Density (D). Furthermore, the aforementioned image is processed by another pre-programmed algorithm to differentiate the differences in hair shaft diameter (or its thickness) within the image field(s). This differentiation is also quantified by automated means to express a value of Miniaturization (M).

For the purpose of simplicity in demonstrating aforementioned concept, the Density (D) may be expressed as a relative number that is the sum of the area that all the hair (?H) occupies in an image divided by the total area (A) of the image field (D=?H/A). The Miniaturization (M) may be expressed as a relative number that is the sum of the areas occupied by hairs with a smaller diameter (?h) divided by the sum of the area that all the hair (H) occupies in an image (M=?h/?H)

In effect, this automation produces metrics for Density (D) and Miniaturization (M). It also provides metrics for the bulk (B) of hair that is expressed as the total cross sectional area occupied by hair divided by the area under interrogation. This provides a quantifiable value in assessing the state of hair density, miniaturization, and bulk for the purpose of diagnosis. The variation of (M), (D), and (B) over different location and at different times will provide valuable information to the end user for the diagnosis and progression of hair loss or hair gain. The pattern of hair loss can also be determined with the aforementioned metrics. It is this ability to map out a metric based system for the status of hair loss at multiple locations sufficiently large to be accurately revisited and in a relatively short time window (seconds or minutes) that is the essence of this invention. When longer time intervals are used (weeks. months and years) an assessment of change in hair bulk can be measured. This method and apparatus would be particularly useful for documentation of hair loss or gain progression over time and/or hair gains in bulk after treatment regimens have had time to work. Drugs like finasteride (Propecia) are but one example of such a treatment regimen.

Another embodiment of the invention consists of a hand held device which a user moves from front to back along the scalp to establish a path of sufficient size to permit accurate measurements. The end user points the sensor end to the location of interest to obtain readings as the sensor is moved. The bulk of hair may be expressed in many ways depending on the aforementioned metrics and may incorporate the cross sectional area the hair shafts occupy in a field of interrogation. In this particular embodiment, a relative ‘hair bulk’ number may be expressed so that the end user can compare the value to the value at other locations or compare the value to other references on the individuals anatomy over time. This embodiment would conveniently have a recording and analysis function to keep track of the different data and reference points with dimensional locations mapped out. It could represent various static images or a ‘video like’ device that enables a person to sweep the hair bearing area along a series of tracks in a pattern that will, in effect, produce a more detailed map of hair bulk in the scalp, by area. In practice the device may be adapted to keep track of the velocity of movement and reference of a user defined location and record the time of data acquisition.

Another embodiment of the device utilized the same instrument without cutting the hairs to a small length. By using a combing device. The hair can be separated (parted) such that the scalp is exposed with hair on both sides, visualizing only the point where the hair exits the scalp before it is combed aside by the separating comb-like element. Standardization of the combing process is necessary in any one person and this can be accomplished by mechanical (comb) or pneumatic (air blowing) means.

Another embodiment of the device incorporates a miniaturized probe, like a ball point pen, which can be advanced over a section of scalp, separating the hairs as the probe moves through the ‘forest’ of hair shafts by mechanical or pneumatic (air blowing) means.

Tags: US Patent, Rassman, Pak, mapped hair metrics

Just spoke to a man named Mike who had his 69 year old grandfather ‘Henry’ in the hospital for for a possibly flu type syndrome. When he was visiting Henry, we walked into his hospital room and saw that his grandfather was having severe difficulty in breathing. He ran out to the nursing station and told the nurse at the desk who commented: “He is not my patient, go to the next nursing station”. He then ran about 40 feet to the next nursing station saw a nurse and ask for help for his grandfather. “Please help my grandfather, he can’t breathe, he is in Room 305”. The nurse replied: “I don’t take care of that area, try to find the nurse who does”. He was now in a panic, so he ran around looking for help ending up back in Room 305 without anyone to help and found his grandfather, in bed, dead.

Maybe this is an exceptional situation, but this is manslaughter and the nurses should be held accountable. The young man and his entire family bonded around Henry’s death, just grieving. There was no follow-up with the hospital authorities, no lawyer, no attempt to make people accountable. So, although Mike and his family were not litigious, accepting Henry’s death, the same people who ignored his grandfather’s distress were still there to repeat their abysmal performance. Maybe Mike and his family did not do anything other than bury Henry, but I certainly am outraged and would tell anyone in such a situation to get a lawyer and write to me to ask me to become an expert witness in a legal action against all parties involved in what appears to be clear malpractice. We can never stand by to such outrageous, irresponsible behavior.

Tags: good medical care

I am 25 years old.my father is norwood 6. and i am also thinning in norwood 6 like pattern.i am taking dutasteride and minoxidil to stabilize my hair loss.its all started three years ago when i first noticed increased shedding.is it the case of advanced balding??if so,i wouldn’t respond to medication??i am on the medications since last 3 years and had switched 2 times from finasteride to dutasteride.currently on dutasteride.

Genetic hair loss for men can starts with puberty and most men who lose their hair to a Norwood 6 or 7 pattern will see that in their 20s. There is no cure for genetic male pattern balding. Drugs such as Propecia or Rogain can help but over the long term you will continue to lose hair in your genetically predisposed pattern. Taking Dutasteride does not mean it will stop hair loss and it is not an approved medication for genetic male pattern balding. It works in similar ways as Propecia and many Internet readers believe a stronger medication may work better. But it does not.

Before you switch back and forth on medications and read confuse yourself with Internet source of hair loss information, please see a doctor to establish a clear diagnosis and come up with a Master Plan for treating your hair loss.

Tags: shedding, finasteride, dutasteride, stabilize

I have been taking Propecia for 2 years than stopped for roughly 1 year.

I recently started to taking the medicine again for the last four month, but it seems I am losing a lot of hair.

I am wondering if one experience initial shed again if one stops it for long time and take it again?

We occasionally hear about it with Rogain use but there is no “shedding period” with Propecia.

If you stop taking Propecia for several months (6+ months), you will experience “catch up” hair loss where you lose the hairs that benefited from Propecia. Catch up hair loss basically means you will catch up to where your hair loss would have been if you never took Propecia in the first place.

When you restart taking Propecia at this point, you will never regain the hairs you lost (the benefits it provided a year ago). You are basically starting from a new set point. It will also take about 6+ months for you to see some benefit or slowing of hair loss.

Tags: rogain, rogaine, propecia, finasteride, stopping medication

I’m 21 years old, and I fear I may be losing hair. About a year and a half ago I noticed that my temples were a little thinner in the corners. Now my hair is getting longer, and there are thinner hairs that hang down at my temples. Also, the shallow edge of the scalp is visible. Am I definitely balding? Is there anything I could do about that, and should I even worry? I checked with that chart, and my hairline looks like an NW2, but even with it getting longer, the temples are somewhat visible. I know people way older than me with a
hairline like this, but if I’m already noticing at 21 (almost 22) that seems like a bad sign right?

Genetic Male Pattern Balding (MPB) can start in the teenage years after puberty. Norwood 2 is not really balding, but if you are noticing other patterns of hair loss, then it may be an early sign. Without an examination, anything is possible.

Hello Dr Rassmann,this blog is great.
Sir suppose a person has genetic hairloss for around last 3 years. If he also has abdominal pain for around last 6 months, so is it possible that his abdominal pain can increase/accelerate his genetic hairloss but without causing acute/chronic telogen effluvium?


I am not sure how you can make a correlation between abdominal pain and hair loss. Abdominal pain is not related to genetic hair loss or any other type of hair loss from my experience.

Tags: propecia, abdominal pain

I’ve have consistent diffuse hairloss universally around my head for about a year and a half, to the point where I believe I’ve lost about 60-70% of my hair. Many of the hairs that fall have large white plugs attached to them (see pictures), which I believe may be sebum.

Is this in fact sebum? Can these plugs cause diffuse hairloss? Any idea what may cause them or what might treat them? So far, I’ve tried zinc, ketoconazole, salicylic acid, coal tar, and other “sebum reducing” shampoos. I have also been on propecia for 6 months, but with no noticeable reduction in the pace of my loss.


Sebum is a waxy substance from the production of oil from your sebaceous glands. It can be seen on ends of hair follicles that fall out but this does not mean you have a hair loss condition or disease process (because of the sebum). There are products that claim better control of sebum and Internet posts that claim the sebum is the cause of hair loss. It generally makes for great marketing campaign to sell a product to those who are looking for a hair loss cure. Sebum does not cause hair loss, if it did, the many men and women on skid-row would be balding as they often do not shampoo their hair and reduce their sebum buildup. If you are experiencing diffuse hair loss, I doubt sebum is the root cause (no pun intended). You need to see a doctor for your hair loss condition to establish a good diagnosis.

Tags: defuse hair loss, sebum plug, hairloss

Do Indian heads undergo maturing? My father started going bald at the age of 35 and my grandfather at 40. However my mother’s side is devoid of any kind of MPB. My question is my temples have undergone receding corresponding to the MATURE hairline that I read in this website. Is this normal for an Indian male like me? Also there is no further thinning, as far as I know and my hairline has remained the same for the past 1-1.5 years. Can I safely call it a maturing hairline and put all my mental worries and tension aside? This is killing me and I hope you read this and help me and my case.

Almost all men have some form of maturing hair line as they transition into adulthood. About 5% of Caucasian men maintain part of all of the child;s hairline well into maturity (former presidents Reagan and Clintoon). Maturing hair lines are not considered balding. Balding in the form of androgenic alopecia (AGA) also called Male Pattern Balding (BMP) is genetic and is inherited from your mother or father (close to 50/50); however, it does not always follow a predictable pattern and you may have the balding pattern where your immediate family members do not. There is no specific cure to reverse genetic male pattern balding or maturing of a hair line and even the drug Propecia (finasteride) which works so well on genetic balding does not stop the maturing hairline from appearing.

I was taking name brand propecia for one year with fantastic results. After one year (July of 2013) I switched to generic finasteride. In July of 2014 i didnt notice any difference in the Generic version. recently (janurary 2015 – present) I have experienced significant hair loss (My thinning has progressed to its worst point ever). I am attributing the sudden and significant hair loss to stressful events that occured around july of 2014 and have been ongoing till present day. If I obtained by generic finasteride from my doctor and through
my local US pharmacy. Am i guaranteed my dose was legitimate and my significant hair loss can be contributed to stressful events? I am currently blaming the Generic finasteride for the massive hair thinning.

In general brand name drugs and generic drugs are the same. The difference is the cost, color, or shape of the pill. The active drug ingredient is the same. I personally cannot guarantee this but most of the patients use the generic form of Propecia and do well. I hear (rather read) on occasion on the Internet and this blog that some have noticed a change when switching from a brand name to a generic. If you are noticing something different, I would follow up with your doctor and consider other options (such as switching back).

Tags: generic propecia, hairloss, hair loss

Am 25 yrs old. I am suffering from hair fall since 3 yrs. Am not bald but scared that i might get bald in next 2-3 yrs. wen i suffer more hair fall, shortening and regrowing hair gives me good result, but as the hair grows longer,again i suffer more hair fall..over these 2 yrs, i can say my hair has thinned and reduced in density .consulted dermatologist and i was suggested to use minoxidil topical solution(mx-10) + finasteride. I don’t have hereditary. As my dad and grand dad has good hair… so using minoxidil + finasteride is a good move?. after gaining hair back, can i stop using minoxidil as i don’t have hereditary?

Genetic male pattern balding is hereditary but it does not always follow a specific inheritance pattern. If you have the gene for male pattern balding there is no definite cure. There are medications such as Propecia and Rogain to help slow down and even reverse some hair loss but in the long term it is not a complete solution. The first thing you must do is establish a good diagnosis by your doctor and come up with a long term Master Plan and treatment plan. We have written many times that even those people who appear not to be balding but have balding in their families, can be balding and would not know it unless they lost more than 30% of their hair. We can detect that level of hairloss in our office with a special instrument that measures the hair bulk in various parts of your scalp and compares it to the back of the head where balding never really occurs. IF you should have clinically detectable hair loss with out instruments, then taking drugs like finasteride work great to slow it, stop it or reverse it.

If you don’t have genetic male pattern balding, Propecia will not help. This is why you need to talk with your doctor and have a good understanding of your long term goals and plans.
Rogaine and Propecia are long term medications. You don’t just take it to try it you come to a doctors’s office and get your hair bulk measured.

On the day of my surgery I took an lozenge for my sore throat. Later I realized in horror it contained a NSAID (Flurbiprofen 8.75mg).

There was no excessive bleeding during or after the surgery. However I’m afraid that the NSAID caused just enough bleeding to dislodge many grafts and they popped out without any signs during the first hair wash 18 hours after the procedure.

I do not understand the basis of your “horror”. Please follow up with your doctor.

In general many patients take pain medication on the day or even during surgery. This includes NSAIDS. In general NDAIDS have a slight bleeding risk.