First of all, many thanks for this great blog. I’m a regular reader.

My question is about mild shampoos. I often read contradictory comments about whether or not washing your hair on a daily basis could cause hair loss particularly when these extra mild shampoos contain ingredients like Sodium Lauryl Sulfate, Sodium Laureth Sulfate and all parabens, that may cause skin irritation, drying, and hair loss due to follicle damage. So if someone has to wash his hair every day, is using a shampoo without those ingredients is better for the scalp and the follicule ?

Shampoos and washing your hair does not cause hair loss in general. In men genetic traits (androgenic alopecia – male pattern balding) causes hair loss. In women hair loss can also be genetic or hormonal (example: menopause).

Shampoos have ingredients that can irritate the skin/ scalp in some people and that can be an issue, but it is not the main cause in terms of hair loss. Sodium Lauryl Sulfate and its likes are just detergents that wash way dirt in the most basic sense. Some believe these chemicals may be too harsh and there are other alternative (more expensive) shampoos that do not contain such chemicals. If you believe your shampoo has something to do with hair loss then it is rather easy to change your shampoo over reading through blog posts and conflicting Internet information.

In general, if you have the genes for hair loss (male pattern hair loss) washing your hair with or without the Sodium Lauryl Sulfate as it’s ingredient will likely not be a factor. There is, however, a multi-billion dollar industry that will try to convince you otherwise.

Doctors generally want to help people and doctors use what tools are available to do just that. Unfortunately, the hair transplant technology that was available prior to 1992, was a very limited technology. It was used by hundreds of doctors over decades and consisted of two types of surgical procedures. The scalp reduction, which removed the balding scalp on the top and back of the head, and hair transplant plugs that were removed from the back of the head and placed in the front of the head. As these patients grayed, their plugs became less detectable so time worked in favor of the patients who were deformed by some of the old technology.

The Scalp Reduction: Conceptually, removing the bald scalp behind the hairline from front to back might have made sense if the hair on the sides could be stretched to cover the removed scalp. As the hair on the sides never balded, this side hair might theoretically have done the trick. This, however, was not what really happened. I, for example, had three of these procedures done on my head in 1992 and this caused me no end of grief. A scar was present in the center of my head and my scalp was paper thin, bleeding from the slightest touch. That alerted my perception of that this procedure that it was a bad procedure and I made it a personal campaign to stop it from being done. I even went as far as to publish an article and present it before the international society telling all the doctors that this was a bad procedure and if any patient wanted to take legal action against any doctor performing it, I would act as an expert witness when asked. That did not make me popular, but I succeeded in stopping this procedure from being done. Thousands of people had been victimized by it. The doctors; however, did not really understand the consequences of this procedure and as it was the “Standard of Care” at the time, they just continued to offer it and did in on those people who seemed, to them, to be good candidates. The lesson here is that doctors must always think twice about what they are doing and listen to their patients. Anyone, like me, could have told their doctors about the evils of the scalp reduction. Unfortunately, there is a herding instinct in people and doctors are just people, but doctors are special people who are intrusted to be better than the ‘herd’, and must always think twice, or more than twice about what they are doing. Maybe I was responsible for stopping the scalp reduction from being done, but it should have happened well before I became a victim of it.

The Hair Plug: What a marvelous innovation it was. A hair from the back of the head would live as long as the patient lived, even if it was moved elsewhere. It started in 1959 on a commercial level and doctors and the public quickly became enthusiastic about it. Imagine hair in front of a bald mans head! As a person started to thin from genetic balding, doctors became aggressive as patient wanted to stop the balding process and surgery seemed to be the answer, so doctors put these plugs behind the hairlines to make it look fuller, and it worked, at least for a while until the progressive nature of balding continued and the thin hair disappeared, leaving the large plugs behind. Doctors quickly picked up on this and started to fill in between the plugs so more plugs were needed. Some doctors used parts of a plug, so that they were smaller to fit better into the large white spaces created by the original surgery, but no matter what was done, it was never perfect because the plugs just could not be disguised for what they were. Many doctors tried to fix the problem, but they nevertheless continued to create more of the same problems.

Innovation to fix this problem really started in the late 1980s. I am not sure why it took so long considering that hair transplants were going gang-busters since 1959. A friend of Frank Sinatra who I performed hair transplants on in 1994, told me of the hatred that Sinatra had for his hair transplant surgeon. He was ‘plugged’ and had to wear a hair piece, a wig, for his entire life because of it. He could never graciously accept balding once he started the hair transplant process. In the late 1980s, Dr. Manny Marritt figured out that smaller grafts could look more natural and that if these smaller grafts were kept to the forelock area, even a very bald man might look good. He spoke at medical meetings about his idea. But just how small? That was the problem. Dr. Ubel in Brazil offered small grafts in larger sessions in about 1990 along with the Mosher Clinic in Germany and patients flocked to their doors. After doing my research, I entered the hair transplant field in late 1991 and knew that small grafts in large quantities were the way to do this surgery. But how small and how many were the questions I had to answer. So I visited Dr. Marritt and saw what he was doing and I knew that they had to be smaller than he created them. That required a completely new technical skill that I had to develop and perfect, so that is how it all started. By 1992, I was doing 1000 grafts, by 1993-4 I had gotten to as many as 4000 grafts of very small grafts, essentially the follicular units that we use do today. Publications by Dr. Bobby Limmer in Texas helped me focus on graft size. Once I got going, the line-up at my office was massive and bingo, I became a successful hair transplant surgeon. Other doctors saw my success and they quickly adapted the techniques that I published in medical journals along the way. The old plugs had died.

Can you imagine that you go see a doctor because you are losing your hair. You are young and you believe in modern medicine and in doctors. You take the courageous step to improve your look and get your hair back to look younger. You have already lost too much hair and fear that you will lose it all. Then you go to the doctor’s office who advertised with the strong suggestion that one can get their hair back by having a hair transplant. Then he sees pictures in the newspapers, even a few ads on TV and in magazines. He went to one of those advertised doctors and met a man in a white coat that he thought was the doctor, but he quickly finds out that he is not a doctor. The man tells him that he came to the right place. “Dr. T can give you back all of your ‘luxurious’ hair and you will never have to worry about it again” says the man. The year is 1990, before Propecia was available (which means that his hair loss would continue even more rapidly after the transplant). This man in the white coat introduces him to the doctor and he seemed personable enough. After all, with his white coat and his name clearly displaying ‘Herbert T, M.D.’ he clearly presents with authority. He recommends hair transplants and a series of simple surgeries called scalp reductions (removing the bald spot from the back of his head).

Then he starts the process and after one surgery he starts doubting that this is going to work out so he go back to Dr. T three weeks from the date of surgery and he tells him how nicely he are doing and the scabs on his head will disappear in a few weeks. He then tells him that he scheduled you for your first scalp reduction surgery, two months later that while he is waiting for the hair to grow out which normally takes 8 months. “After all, he only transplanted the front of his head and had to deal with the top and crown area”, said the doctor. At this new scalp reduction surgery, the removed part of the bald area in the top and back of his head. That simple surgery is not quite as simple as the doctor said and he has a lot of pain following the surgery. He got to a mirror and saw the scar down the middle of his head and now became more concerned than ever. So again, he goes to visit Dr. T. This time 4 1/2 months following his transplant surgery, the doctor tells him that he is doing fine but that there was still more bald scalp that had to be removed, so the doctor schedules him again for another scalp reduction surgery. He agrees. Then after 2 more months, he noticed a red scar down the middle of his head that seems to have stretched, so he goes back to Dr. T again and he tells him that he still needs a third surgery to remove the rest of the bald area along with scar that formed. After that third scalp reduction, he is now starting to get concerned. Four surgeries (one hair transplant and 3 scalp reductions). Now he waits anxiously until 8 months later when the hair starts growing. At first he gets excited, but then the pluggy nature of his dark brown hair grafts start showing. So again, he goes back to Dr. T who then tells him that it will take two to four more hair transplant surgeries to fill in between the brown hair plugs so it does not look so pluggy. Now he is not trusting the doctor anymore because he never told him that he would look pluggy and needed more surgeries. Where was that luxurious hair that was represented? So he gets a second opinion and he meets Dr. Fredrick W who confirms that he needs at least 4 more surgeries to makes the original work look normal.

Between the terrible plugs of the early 90s, and the three scalp reductions, he had a pluggy look created by his dark brown hair spaced by bare white scalp skin, like a corn field. The scalp reduction scar ran down the middle of his head, the scar stretched and anyone could see it. Over and over again, he repeats this process with Dr. Y and then Dr. Z and a few other doctors until he reached 13 surgeries in 4 years. Imagine 13 surgeries and having to wear a hat to hide the deformities on his head. Can you believe that his faith in doctors allowed him to go down the garden path created by immoral doctors who took his money and cared nothing about him? I am ashamed of those doctor who were nver honest with him and continued to rip him off for money and worse, continue the deforming surgeries repeatedly over and over again, making promises they could never meet. No one ever told him where reality was.

I asked him why he had so many doctors and why he put up with failures upon failures. He said there was no internet in those days and each time he saw a new doctor and they looked at him, they told him that they could fix him because other doctors messed him up. Just another false start here and there. He even flew to Chicago to see another ‘experienced’ doctor. He found that during the surgery a doctor doing his first hair transplant procedure did the surgery, supposedly supervised by the senior doctor at the Chicago office who never came into the surgery room.

If I were him, I would have sued all of the doctor, everyone of them, but the statue of limitations had expired and he was left to live his life under a hat. It impacted him in every social setting one can imagine. He couldn’t go swimming because he would have to take his hat off. He felt shame, but it was the doctors who should have felt shame. It must have cost him a fortune as his doctors made off like bandits. Patients like this just don’t sue their doctor because they feel so much shame and going before a jury of his peers would make them feel even more shame.

Now with that said, last week we put together a plan on how to fix him. The plan was simple. I told him what I wanted to do but there was a risk that I could not implement the plan I wanted because his donor hair was very depleted. The goal was to try to rebuild a normal hairline and put hair into and around the scar and also place it to the sides of the scar if we got out enough hair to accomplish this goal. It was risky and we both knew it. But he agreed to take the risk. Then, after the surgery, with great surprise, we succeed beyond what I had expected and harvested 1550 grafts, enough to produce a normal hairline with enough hair left over to sparsely cover the scar area going down the center of his head (from the three scalp reduction).

Over the past 24 years that I have been in this business, I have had well over 1000 patients like this man. I was able to fix many of them (see: and but not all of them. In eight months, I am planning to perform scalp micropigmentation on him to hide all of the scars and give him a good base for a totally new look. Scalp micropigmentation (see: gives me a tool that I have never had before so now I am more confident than ever that I can help him achieve a normal look with only some minimal styling modifications. I am anticipating that for the first time in 25 years, he will take off his hat and even go for a swim if he want to. In 10 months, I anticipate that I will post his before and after pictures here on along with a reference to this post and a statement from him (which he indicated he would make about his view of his result).



Have a good laugh

“Study shows that children exposed to smoking at home have more deposits in the carotid artery as adults. Passive smoking is known to endanger health. This is particularly so for the offspring of smokers. Children who are exposed to their parents’ smoking have a considerably higher risk of developing cardiovascular diseases as adults. That is the main result of the “Cardiovascular Risk in Young Finns Study” presented in the Journal “Circulation”.”

I am a 26 year old male with vertex hair loss only. My hairline and frontal hair is very strong, yet my vertex is almost slick bald for a few years now. I was thinking about having a hair transplant, yet I am not sure whether I will lose my hair in the front or not.

I have been to a hair transplant surgeon and he was very surprised with my unusual pattern of loss and suggested that I get a hair transplant (I strictly do not want to use any medication).

I am left confused here. I do want to replace the hair that I lost in my crown, however I certainly do not want to have a weird loss pattern if I start losing frontal hair in the future. My question is, how long should I wait to find out my eventual hair loss pattern or should I cross my fingers and go forward with the process now? I know a diagnosis without a physical examination is impossible, but a second opinion cannot hurt I guess.

There seems to be a disconnect between you and your doctor. If he recommend surgery what is the problem? What is the “weird” hair loss pattern? Is your doctor a novice where he has never seen a person like you before? Maybe you need a second opinion from another doctor (in person). Some people do not fit into a classic Norwood balding pattern. Some people only bald on the top vertex area just as Dr. Rassman had (no frontal or top balding and only a bald crown). You definitely need a good diagnosis and a Master Plan of action. What we do in such a situation for someone of your age, is that we perform a bulk analysis of your hair in front and on top. then compare the hair bulk from the same sized area in back of your head (the permanent zone used for hair transplants). Most people your age, will show some decreased hair bulk in the frontal area and on the top of the head if they have any balding present elsewhere in their head.

A person with a balding crown may increase the size of the balding area as they age. If they have a hair transplant and they the crown balding area enlarges, you must transplant the wider balding area or you will be left with a hair ‘island’ in a larger balding area. The implications of transplanting the crown should be known to you, of just research it on the internet or our website (, purchase our book ‘Hair Loss For Dummies’ which can be ordered through Amazon or our office, or visit one of our badlingblog editors if you are in Los Angeles, Koream or England.

I have recently had a sperm analysis done and have seen that I have abnormal sperm morphology, pretty much close to 100%. I have been taking Propecia for close to 9 years. Does Propecia increase the effects of abnormal sperm morphology?

There is a report in Fertil Steril. 2013 Dec;100(6):1542-6. doi: 10.1016/j.fertnstert.2013.07.2000. Epub 2013 Sep 4. that state Propecia (finasteride) can cause reduced sperm counts in some men. It goes on to state: “In this population, counts improved dramatically for the majority of men after finasteride discontinuation. The hormone parameters, sperm motility, and sperm morphology were unchanged after cessation. Finasteride should be discontinued in subfertile men with oligospermia, and used with caution in men who desire fertility.

In your case, we do not know if your sperm morphology was abnormal even before taking Propecia. It would be difficult to establish Propecia may have cause it. I simply do not know. Your question is better left to your urologist or reproductive specialist.

My 5yr old son had a staph infection in his scalp .. It left a bald spot on scalp. My concern is will his hair grow back in that area.

It generally take up to one year to assess if hair will grow back in an area that has been traumatized.

Hi Dr. Rassman , Please help me on this one .
I have been taking Plant Sterols 1000 MG. siad to contain 375 MG Beta Sitosterol per Tablet … combined with Generic Finasteride 1 MG. every DAY !

My Question is :
Can I combine the two i.e. Plant sterols and Propecia ( Finasteride )? Will that Harm my Health in anyway ? as Both are known to Lower DHT , so will that very Low DHT cause some imbalance in my Body ? Please Advice .

Let’s be reasonable here. You know better than to ask personal health and medication questions on the Internet. You really need to see your doctor for these issues. I am not your doctor and cannot give you medical advice. Baldingblog is a not a place to check for medication interactions.

Beta-sitosterol is a substance found in plants and I am sure you can find plenty of information on the Internet.
Propecia (finasteride 1mg) is a medication that needs to be prescribed by your doctor for the treatment of androgenic alopecia.

I personally am not too familiar with the use of Beta-sitosterol and it’s interaction with other medications. So I would defer this to your doctor.

We are seeing more and more problems with Scalp Micropigmentation in our office from other facilities that offer SMP. These services are not only offered by inexperienced doctors, but also many tattooists have entered the business because there is money to make. What we are seeing are blotches of pigments, not microdots as we do. Where we might spend over 20 hours doing a full head, these facilities do it in a few hours. Clearly, this it is not an apples to apples comparison. Blotches on the scalp that everyone can see are deforming. Even if they are hidden below the hair, they can be seen in bright light when you go outdoors and just don’t look good. Many doctors are just addressing the scars from previous strip surgeries and as most of these scars are hidden by hair so the blotchy work may not show up unless the person goes swimming, takes a shower and is intimate with another person. Just because it is done by a doctor or in a doctor’s office, does not mean that it will meet the standard of care that we have established. Many doctors hire a tattooist or cosmetologist with no training in SMP just because they know how to do a tattoo. Many of the pigments they use turn green so that they stand-out even more. Would you like a green head?

There are temporary tattoos which seem to be adopted by many doctors and tattooists. Although these tattoos last only two years or so and they fade over these two years, the temporary nature of the tattoo means that constant touch-ups are needed. The temporary SMP pigments have been adopted by doctors usually unskilled in the art, so they know that their bad work will eventually fade. As they get their money ‘up-front’ they pass the problem to their patients for the two years that the ink remains on this scalp.

Be sure to ask to see the patients of those people who you are considering when you interview the provider for the SMP services you are going to get. Seeing their patients and looking at them in a discriminate manner, will tell you all you need to know. We still have open house events every month and you can meet many of our SMP patients and see the quality of the work that has become the world’s standard of care.

Tags: scalp micropigmentation, scalpmicropigmentation, SMP, Complications, Turning Green, tottooist, temporary tattoo

“Men who engage in a high level of physical activity report better erectile and sexual function regardless of their race”. The study seems to cross all racial groups (March 20 in the Journal of Sexual Medicine). The threshold seemed to point to at least 2 hours of strenuous exercise such as running or swimming, 3.5 hours of moderate exercise, or 6 hours of light exercise.

“A new study reported that children exposed to their parents’ smoking may have a higher risk of developing heart disease in adulthood than those whose parents didn’t smoke. Findings from the study are published in the Journal Circulation.

The research included childhood exposure to parental smoking in 1980 and 1983 and testing with carotid ultrasound data in adulthood was collected 2-25 years later. Blood cotinine levels were collected and frozen in 1980. In households where the parents did not smoke, the cotinine levels were less. Carotid plaques, a major cause of stroke in adulthood was nearly double when one or two parents smoked.

It is clear that parents who smoke expose their children to the risk of possible early strokes. Considering that the study only went 25 years from childhood, I would suspect that the incidence of stroke will significantly increase as more years are studied in these families.

Source of Information Taken From:

According to the article in Circulation, March 18 “Most US children start life with optimal cardiovascular health (CVH), but it declines substantially over time.

“Our findings indicate that, in general, children start with pretty good blood pressure. But if they have a horrible diet, it will drive a worsening body mass index (BMI) and cholesterol levels,” senior author Donald M. Lloyd-Jones, MD, said in a news release. Dr Lloyd-Jones is professor of preventive medicine at the Northwestern University Feinberg School of Medicine in Chicago, Illinois. “The better we can equip our children to make healthy choices, the more cardiovascular health will be preserved into adulthood. And those who preserve their heart health into middle age live much longer and are much healthier while they live,” he added.

I remember a study where autopsies were done on Korean war dead. The finding, to the best of my memory, was that there was advanced cardiac atherosclerosis in most of them (most under the age of 21). When correlated with more modern times, a new study “shows that the rate of American service members with signs of coronary artery disease has declined sharply in the last half century, falling to roughly 1 in 10 military personnel today from about 8 in 10 during the Korean War. The findings came as a surprise to some researchers, who expected that the nationwide rise in obesity and Type 2 diabetes, including among young people, might have led to a similar trend in heart disease in the military. But instead it appears that national reductions in other risk factors for heart disease, like hypertension, smoking and high cholesterol, have had a greater effect on cardiovascular health.”

What is the lesson here. Start your children with a conscious focus on a proper, healthy diets. It may not be reversible if they eat poorly for years, so the best gift you can give your children is the gift of a good diet and hopefully a long life.

Hi Doc, Here is an interesting msg I ran into in Craigslist, a guy who is job hunting, might be good for the blog sfo Help! I am bald and cannot get a job! “Recently, people interviewing me have been staring at my bald head. I used to have a receding hairline (a la George Costanza) so I keep my hair shaved bald now. Nobody used to stare before, now they do a lot. I notice that a lot of IT guys are bald and does not seem to keep them from getting hired. Am I being discriminated as a bald (I mean “follically challenged”) man because people in sales/marketing are supposed to be cool looking (unlike IT nerds) so they are not hiring me because of my looks? Should I do the hair transplant thing? I always thought that the bald-shaved look was cool, sort of like the no-collar shirts used to be.

Myths exist about men with hair loss reflect the superficial nature of our society which judges a “book by its cover’. These myths, at times, cut deep into the psychology of our culture. About 9 years ago, I ran a radio talk show called “The Inner Man”. It ran an hour once a week. We covered many subject from sex to religion and became fairly popular because of the controversial subject material. One show, in particular, discussed discrimination targeting bald men. The switchboard went crazy with many call-in listeners. I remember one man who called in and told us that he was a Vice President of Sales for a very large company and he was very bald himself. Then he told me that generally bald men can’t be trusted and he never hires balding men because of that. As a bald many, he must have known something about himself with that comment because it made no sense, particularly in his case.

The image of trusting men by their appeearance, however, is common issue in politics. Full header hairy men win more elections than balding me across the nation. Every elected president after Eisenhower, has had a full head of hair and many pundits infer that men with a full head of hair are trustworthy. That is not to say that a bald man is not trustworthy, but prejudices go back centuries. Women, for example, have preferred full haired men well before the 1900s because men who lost their hair often had some disease like tuberculous, making them undependable marriage candidates because they may die early leaving them with children and no support. Although tuberculous is uncommon today and we understand that balding is a genetic condition that has nothing to do with health in 99%.9 of men, but the cultural hangovers of history probably left a mark through our present time.

From what my patient’s tell me, I can assume that getting hair back, produces a man who is more self confident. I have heard this from men who have made it in their careers after I have restored their hair, particularly those who eventually became successful actors (we are in Hollywood so we get a fair number of actors). I remember an African American who wanted to be America’s first black president and believed he could not do it without hair on his head. I have heard these stories for the 24 years I have been in practice and those who have had their hair restored have reported that this surgery and this change in their appearance was a milestone in the development of successful careers. Hair does bring: freedom from the fear of the unknown, freedom from the fear of looking older, and a general feeling of more confidence for the man we all see in the mirror

What should you do? the above poster asked. Clearly this is an issue for him. He should become educated about hair restoration as the first step he might consider. He could come to one of our Open House events as he is in Southern California and he can meet many of the men who have had their hair put back back and ask them the questions he asked on Craigslist. He should research the internet and the many forums that address hair loss. He should interact with the community through social networks. He might find the answer by probing the world around him.

There is little doubt that the ARTAS robotic System is less stressful for the surgeon than than the manual Folliclar Unit Extraction (FUE). Some of our patients are driven by the technology as we have seen some of them ask for the ARTAS robotic system. We offer both the manual and the ARTAS FUE for our patients at the exact same price of $8/graft at this time. From a quality perspective, both techniques are identical. We have been doing FUE since the mid-1990s, so we are pretty good at it. The manual FUE in Dr. Pak’s hands is a faster procedure when compared to the ARTAS system making for a shorter surgery.

Please comment in our comment section and ask more questions about these two FUE procedures. If we are doing an ARTAS FUE on the day you visit us, ask if you can see it in action and if the patient agrees to allow visitors, we will let you observe the ARTAS in action. For more about the ARTAS robotic system go here: