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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 ?

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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.

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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?

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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.

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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 .

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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


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