Use of Nape and Peri-Auricular Hair by Follicular Unit Extraction to Create Soft Hairlines and Temples: My Experience With 128 Patients

Background Hairlines and temples can look unnatural due to coarseness of the safe donor area of transplanted scalp hair. Although the thinner caliber of nape and peri-auricular (NPA) hair would be ideal to create softer hairlines, they have not been used mainly because of concerns that they are nonpermanent.

Objective We assessed the outcome of NPA hair transplanted to hairlines and temples in selected patients.

Methods During November 2006 to November 2011, follicular unit extraction (FUE) transplantation using NPA hair was conducted in 128 patients following a shave test involving the visual evaluation of hair density and caliber of shaved head donor areas. The test was used to determine permanent versus nonpermanent donor areas. A questionnaire was sent to patients to assess satisfaction with their restored hairlines, with a follow-up questionnaire sent to those who initially responded.

Results Three-quarters of patients are good candidates for use of NPA hair to the hairlines and temples based on the shave test. Of 128 patients transplanted, 71% responded and reported a mean overall satisfaction of 8.3 (scale, 1-10). Patients saw full hair coverage at the recipient area at a mean of 9.6 months after surgery. Nineteen patients reported lost grafts. Thirty-three patients responded to a second survey and reported a mean overall satisfaction of 8.5 at an average of 4.6 years after surgery; only 5 (15%) new instances of graft loss were reported.

Conclusions Soft, natural-looking hairlines can be created in select patients using NPA hair as a donor source by FUE hair transplantation.

These are just my (Dr. Rassmans’s) opinions (regarding the Press release which may be more exaggerated than he original publication as one reader rightfully points out):

Taking neck hair, which is often finer than scalp hair, has problems with it. These problems include:

(1)  more prominent scarring occurs in the neck and the neck area is very visible so such scars will be detectable as punctate scars

(2) neck hair is often not permanent hair as scalp hair is, so if one transplants the frontal hairline with these finer hairs, they may disappear with age.

This is a warning to those who see this press release. They must know the risks associated with a neck hair donor area.

Actual article is posted here:





Sent by a reader.  This is only Batman’s opinion.

I am 25 years old. I had a couple of questions I wanted to ask and I would really appreciate if you could help me out since I’m really distressed these days cause of my excessive hair shedding.

I started finasteride one month and 20 days ago after extensive research. I had a full head of hair but i could feel my hair density especially at the top of my head and my hairline going down. I also see i lost hair at the top of my temples.

I started finasteride very reluctantly since I didnt wanna lose any more hair and i didnt go on minoxidil because it caused hair to shed. I wasnt aware then that finasteride also causes a shed.

Before starting finasteride, i used to shed around 60-70 hairsin the shower if i took a bath after 2-3 days. But after starting finasteride, almost 2 weeks in, i started noticing around 250-300 hairs in the shower which i take after 2-3 days.

Im really stressed since this started happening. I noticed after this excessive shedding that I lost a bit of density on the front of my hair and the temples.

I read that shedding is common after starting any treatment since alot of hairs go into resting and I accept that.

The thing that is freaking me out is that:

1)  How can i identify if this is a normal shed (250-300 hairs in the shower after 2-3 days ) or a bad reaction to finasteride?
2)  Whether the hair that is shed would grow back, especially in the front of my head?
3) How long can i expect this to go on cause at this rate, im losing hair fast.
4) Have you ever had a case where the initially shed hair didn’t grow back?

I would be grateful if you could ease my mind. I dont know whether to continue with finasteride or stop it.

Thank you very much.

Despite what you may read on the Internet, shedding is not very common after starting Propecia.  You must also understand Propecia does not stop or cure male pattern balding.  Male pattern balding (MPB) is a genetic trait.  Propecia is a medication to treat androgenic alopecia. (not cure it).  Thus, you may notice hair loss even if you are taking Propecia.  You must also note that it takes about 6+ months to start noticing the effects of Propecia but this does not always mean you will not lose hair.

If you are having further issues, you need to discuss this with your doctor who prescribed you the medication.  You may have a false impression or expectation of what Propecia can do for your hair loss.

hello dr rassman, pak, and co,

I am a 33 yo male who may be travelling to the west coast in october and is considering trying to set an appointment for an honest opinion regarding options for my hair loss (if any). if one were deemed a good candidate for either the strip procedure or fue, essentially what is the time investment needed to be in the area for any checkup/followup/aftercare. is there a necessary follow up evaluation a few days or week post op? i ask this now bc if a master plan is suggested i would need to plan around a work schedule. i wasnt sure if a 2 week commitment is recommended to then allow someone to return to work without detection of the surgery. i would be travelling from the pittsburgh, pa area. if it helps i use couvre/dermatch and toppik concealers as part of my daily routine currently. ideally id return to using those products until any results showed from any procedure.I appreciate all you do on this site as well as helping restore patients self confidence. thanks in advance.



We would be glad to meet with you for a consultation.  You can always make an appointment on line at (Look on Bottom Right)

Many people travel from out of town to have a procedure in Los Angeles.  In general you can set aside 1 to 2 weeks depending on your comfort level.  Some people actually go back to work 1 or 2 days after surgery.  The only follow up is the day after surgery. Every person is different.  Many patients also use temporary concealers (Toppik) after surgery to disguise the immediate look after surgery.

Dear Dr Rassman

I am a 31 year old male and around 5 years ago I realised that I had some hairline recession at the corners.  I spent 2-3 years obsessing about this and worrying about whether I would be bald before I was 30 and I also worried about my crown too which looks a bit thinner than the centre of my scalp but remains covered with hair.

As I was so obsessed with this at the time, I tracked my hairloss pattern pretty closely and can safely say that it has not progressed much, if at all since then.  The hairline is exactly the same (as is the crown).  Maybe the corner areas which were thinning are a bit thinner but the actual area has not expanded.  I do not take propecia and would prefer never to take it, for medical reasons.

Recently, for some reason, my hairline has started bothering me again, and feel like I would be more confident if I had it restored slightly so that I could spike my hair a bit rather than have the forelock fall flat over the receded areas.  Actually what bothers me is not so much how it looks in the daytime, but first thing in the morning when I wake up.  I guess the area which I would need transplanting is around 10-11cm squared in total…maybe 6 on one side and 4-5 on the other.  This wouldn’t bring me to a straight juvenile hairline (which I don’t want anyway) but would be enough that I don’t look like I have a receded hairline.

My hair characteristics I am guessing are not great for a hair transplant.  I have pretty good density in all other areas but my hair is brown and very fine.  People are often surprised by how soft it is when they touch it – to give you an idea of how fine it is.

My question is, would having a small transplant (FUE) in these areas be a bad idea?  Is it ever possible to perhaps transplant to these areas at a lowish density, just so that I look like I have a hairline rather than a forelock and so that if/when I lose hair elsewhere then I won’t be left with really dense temples and bald areas elsewhere.  I would be happy with quite a conservative transplant which just gave the appearance of some hair in these areas, maybe just enough to style.  I also think that one day, if I do lose a lot of hair elsewhere, I would shave my head down to a grade 3-4, but if I did this I would still want the appearance of a hairline to frame my face.  With this in mind, maybe it wouldn’t be a terrible idea to get the corners transplanted?  If it is not, roughly how many grafts might a 10-11cm squared area need?

Please let me know your thoughts.  I have seen some very good FUE hair line transplant results online but I am guessing that a lot of these are very dense/’packed’ transplants.


There is a very simple answer to your question.  If you are obsessed with your hair line then you need to make an appointment to see a doctor.

I recently filled a prescription for finasteride at Costco and noticed the manufacturing date was from a year ago (9/2014). The expiration date is 8/2016. Even though it hasn’t expired, should I be concerned that it might’ve been sitting around in a warehouse (either Costco’s or the manufacturer’s) for a year?

It’s Aug 2015 (not 2016) so your propecia has not expired yet.  If you are concerned about the potency, just go back to the pharmacy for a new prescription.  There is a reason why there is an expiration date and a manufacturing date.  As long as you follow direction and use it before the expiration date, you should be fine.

Resveratrol, found in wine, actually in the grape skin, might help in the fight against Alzheimer’s Disease The skin of the grape is a potential treatment for a variety of age related disorders, reported from the Georgetown University Medical Center in Washington DC. In the disease, amyloid-beta protein is deposited in the brain and is associated with this disease, but in a study of 119 people with mild to moderate disease, taking 1 gm of resveratrol twice a day for a year, researchers did not see a significant accumulation of these amyloid-beta deposits. The study is small, so few conclusions can be drawn from this, but there seems to be no harm in taking this drug in these doses, so maybe it is worth a try in those who think that it might help their brain function, particularly if they or a member of their family may have this awful disease.

I am writing this post from the ISHRS annual meeting in Chicago. I have just heard a wonderful and informative discussion on the use of of the drug finasteride. As we know, the hormone DHT is 40 times as powerful an androgen as testosterone. The treatment of genetic hair loss is to address blocking the DHT hormone. One of the worlds experts, Dr. Mohit Khera from the Baylor College of Medicine, told me privately that when DHT levels are in the low normal range, the use of DHT blockers such as finasteride will have little value and may not be effective in the treatment of genetic hair loss. With this as a suggestion, we will now optionaly offer DHT blood tests for any person who wishes to have this test prior to going on finasteride (Propecia). If the blood levels are low, we may not advise the use of this drug as the goal of using this drug is to drop DHT levels, which may already be low. This lecture is based on considerable research both in animals and human studies but it is not absolutely definitive as there was much controversy at the meeting that the doctor may have had a conflict of interest in the opinions he drew.


Hi Doctor, I have been taking 1 mg of finasteride 13 months my hair has become very weak and fine, and still losing hair every time it grows it’s more fine and weak also hair loss at the back of head and facial hair also weak and fine, should i stop this medication? your help would be greatly appreciated thank you.

First and foremost, I am not your doctor so I cannot advise you on your medical treatment. I can tell you that genetic male pattern balding (MPB) is a condition where there is no cure. Propecia is a medication that helps slow down the process. Everyone responds to medication differently. Follow up with your doctor for a recheck and come up with a Master Plan on your treatment goal.

I am curious to know the importance of DHT, post puberty. Is it only significant for men to sexually develop during puberty? Also, is it important for cognitive activity in any way? I ask this second question due to ‘brain fog’ being a reported (although rare I believe) side effect of finasteride.

Thanks for the great site


Dihydrotestosterone (DHT) is one of the many hormones responsible for secondary male characteristics during puberty such as body hair (facial, pubic hair) growth and deepening of the voice. DHT is one of the contributing factors in prostate enlargement as men age. Thus, DHT blocking drugs (Proscar: finasteride 5mg) is sometimes used to treat certain prostate related conditions. DHT is also one of the contributing factors in Male Pattern Balding (MPB) for those who have the genes for MPB. Thus, DHT blocking drugs (Propecia: finasteride 1mg) is used to treat MBP. It is unclear how it may affect cognitive activity but you may read on the Internet that men taking DHT blockers have reported “brain fog” on rare occasions. It is also important to note all drugs have side effects and every patient need to understand the risks and benefits before starting treatment.

I have a question regarding exclamation point hair. Or more specifically thinned proximal shafts (Picture linked at the end). Age:18,Gender:Male

Online sources say that exclamation point happens when you lose hair in patches or in non traditional MPB ways but I am suffering diffuse style MPB (pattern) and the hair that falls off is really thin at the root with a white bulb thick at the top. I also have seborrheic dermatitis. I was prescribed 2% nizoral which then caused me to lose almost 50% of my hair in the span of one year (or maybe it was meant to happen?). Could nizoral cause scalp inflammation that leads to MPB?


The online source of “exclamation point” hair shaft from Am Fam Physician. 2009 Aug 15;80(4):356-362 is describing Alopecia Areata which is a disease process where your body’s immune system “attacks” your own hair causing hair loss.
Male Pattern Balding is a genetically inherited condition where men lose hair in a typical “pattern”.
Seborrheic dermatitis is an inflammatory condition which causes scaly patches on the scalp/skin which may cause hair loss from the inflammatory process.
Nizoral is a shampoo with antifungal properties that is used to TREAT Seborrheic Dermatitis. Some people may have an allergic reaction to this and a rare side effect is hair loss.

All of the above are separate and unrelated causes for hair loss and it is understandable you are searching for a unifying answer.

The simple answer is that Male Pattern Balding is genetic and unrelated to Nizoral, Seborrheic Dermatitis, or Alopecia Areata.

For a more complete answer you need to follow up with your doctor to find out the cause of your hair loss especially if you are having side effects with the medication you were prescribed.

Doc, after years on propecia I reduced the dosage due to sides. Obviously you can’t predict my situation, but what has been your clinical observations in patients who after years of use reduced Propecia dosage due to sides. I’d expect 1mg to .5mg to be the usual reduction. Did your patients experience increasedd hair loss?

BTW after 2 to 3 weeks I chickened out and went back to my regular dosage. Any guess What a 2 to 3 week reduction might do?

It is always a good idea to keep your doctor informed about your side effects and changes to the medications you are taking. It has been reported that half dose of Propecia should be 70 to 80% as effective as the full dose.

Part 1:

I really enjoy the website and find it very informative. I have read on this website many times, that many individuals who are destined to be a norwood 6 or 7 and eventually do become either of those stages, are typically men under the age of 30. Moreover, the final balding pattern is established or completely stops typically between the ages of 40-50.

So, how come there is so much uncertainty regarding hair loss between the ages of 30-40 and what will happen and if further progression of hair loss will occur? I would think if an individual has reached their 30’s with a significant amount of hair, then balding should stop.

Part 2:

My situation is like this, I started balding at 19 and am currently 33. I have been on finasteride for the past the 14 years and have remained a norwood 2-2A. I don’t have much body hair or facial hair and have always felt I have low testosterone. What am I a destined to become then, any ideas?


Thank you for following BaldingBlog!

There is no firm rule on what age you will lose your hair. For most men, genetic male pattern hair loss occurs in their 20s and30s. But it can also happen in their 30s, 40s, and 50s. Hair loss does not completely stop. We don’t necessarily fit neatly into a box. This is why patients go to doctors for an examination.

If your hair loss is a Norwood 2 there would be questions of why you would have needed to be on Propecia in the first place. A Norwood 2 hair loss pattern do not progress to a Norwood 6. Norwood classification is not a chart for “progression” of hair loss. It is merely a pictorial description of your genetic hair loss trait. In the end only your doctor can tell you about your treatment plan. If you suspect a low testosterone level you should discuss your concerns with your doctor and have a test to confirm this (…if it is an issue). Testosterone levels have nothing to do with genetic male pattern balding. You can have a very high testosterone level and have no balding and no beard. You can have a very low testosterone level and be completely bald with a full beard. There is no correlation with facial hair and testosterone levels.

Hello Dr.R. I am an 18 year old. I have been classified as a NW1 by a hairloss center online in London. I however observer minatuirzed thin hairs on the leading edge of the hairline and the leading edge of the hairline corners but the hairs beyond this very forward part of my hairline are very thick. Does this indicate Male Pattern Baldness or future hairloss? If not, till where should miniaturisation exist beyond the leading edge to say that MPB exists.

Other details- I have 12% vellus hair and 88% terminal hair (I checked) and good hair density in general.

I sincerely hope you clear my troubles like you have for several other people on this blog. Thank you for all the information Dr.R.

It didn’t know there was a NW 1 classification. Many non balding men and women have fine miniaturized or vellus hairs on the leading edge of the hair line. This does not mean you are balding. There is no way to determine if you are going bald based on these things. If you see a hair loss “pattern” that develops, then it may be male “pattern” balding.

I get oily skin and increased libido while on zinc 50mg/day. As Zinc increases testosterone so I fear that it may increase the progression rate of my baldness. Considering that I’m also on Finasteride, will the use of zinc negatively affect my hair?


The short answer to your question is that zinc does not necessarily negatively affect hair loss.  Some studies show zinc supplements increase testosterone levels.
There are other studies that show zinc supplements do NOT affect testosterone levels.

For a normal healthy individual with genetic male pattern balding (MPB) taking over the counter supplements such as zinc would not negatively or positively affect their hair loss. It is always a good idea to follow up with your doctor if you have concerns.