Hairline density

/by William Rassman, M.D./0 /

I saw a redditor claim that transplants are very complicated and prone to poor results whenever your native hairline is already dense. In other words, someone like myself could not achieve a natural looking result, even with my long hairstyle, because my current hair is already quite dense and no transplant could hope to replicate that density.  Please tell me this isn’t isn’t true – I am looking into temple transplants in the near future to even out my mature hairline (which rest assured looks quite high from the front).

Thank you for your time, doctor.

Hair transplant density can be whatever you want it to be. To get back to the original density (something I rarely ever do), it takes more than one surgery because follicular units are generally 1mm apart for a typical Caucasian male. I like to use this post to show what I consider a dense hairline; however, this hairline has about 50% of its original density which is usually adequate for most men. See here:  https://baldingblog.com/repair-of-hairline-transplants-photos/

How long will the hair loss last?

/by William Rassman, M.D./0 /

At what age does hair loss usually “stabilize”, asks a Reddit poster?

It’s all tied to genetics. The time it appears, how long it lasts, what pattern of balding you develop and the time it takes to get there. Medications like finasteride and sometimes minoxidil slow it down or stop it for a long period of time. If your lucky, it reverses.

What can I expect with my hair as I get older?

/by William Rassman, M.D./0 /

Since I realized that my hair was getting thinner, I started paying more attention to other people’s hair. Much to my surprise, there are a lot of older folks whose hair receded and thinned, but they are not bald. This includes most of my family and gives me hope.  For example, if you look at my older (>60) relatives, they have pretty much hair, but when I compare their hair to mine, theirs are much more thinner and receded.

I reported a few years ago, a condition we called “Age Related Thinning” which defines the changes in the thickness of all of the scalp hair to become finer.  We see this clearly in many post menopausal women and in men.  In fact, my hair became significantly finer when I became 60.

Taking finasteride

/by William Rassman, M.D./0 /

I’ve been taking it for almost a month now and haven’t experienced any side effects!  Should I expect to see them?

You are typical.  Most men do not see anything wrong with the many side effects reported unless you talk yourself into them.  The real incidence of sexual side effects, for example, is under 4%

A man’s experience with finasteride (from Reddit)

/by William Rassman, M.D./0 /

“If you’ve been prescribed Finasteride by your doctors but you’re scared to take Finasteride, give this a read.

I am not a Doctor, I am not asking you to start Finasteride. If you’ve been prescribed but are afraid to start and/or want to avoid nocebo read this.

https://www.evernote.com/shard/s431/sh/c7b0d8fc-1fd7-9994-a182-feddaca044e6/8488afa8f8d53468ca8f6b59b1ef6048

Read this everyday for 2-3 weeks. Basically will be brainwashing yourself from the fears.

Again do not start because of this report. This collation is to help you start if you’re feeling scared despite being prescribed by your Doctor.

People do get sides. The sides are real but only a small percentage get sides. And even if you get sides, you can stop taking Finasteride / lower your dose.

As pointed in the comments

  • I did get some slight sides after 3 months and 15 days of usage. I took a break for 4 days and they all went away.

  • I tapered down the dose and I’m doing absolutely fine ever since. I now take 0.5mg EOD (Every Other Day)

  • I’ve been considering going down the Topical route too.

  • The point of the post is – Some people do get sides but you mostly will not. *If you’ve been prescribed by your Doctor, I want to reduce the fear you have, that’s all.”

Which is better FUE, Manual or ARTAS?

/by William Rassman, M.D./0 /
I am the doctor who pioneered FUE between 1996-2002, publishing the first journal article on the subject in 2002 as a result of 6 years of experimental work with many cooperative patients. I am the original inventor of he hair transplant robot holding two US Patents on it. I licensed the robot technology to Restoration Robotics, who made the ARTAS and we eventually purchased one, using it for a few years, eventually selling it. We found that the manual systems that were developed after the commercial robot were fully developed allowed us to perform FUE faster and more accurate than the ARTAS.  Speed was important.  Also, we found that the transection rate was higher with the ARTAS than with the good manual systems so we focused on the best of the manual system. We purchase every manual system available to compare one to the other and eventually found that some worked better in some situations and others in other situations. Having many types of manual systems allows us to always use the best system for our patients.

Lost hair comes back brown not white

/by William Rassman, M.D./0 /

Has anyone had this happen? I’m using fin for MPB (obviously) but I noticed the other day, a hair I lost was part grey at the end, and suddenly turned black about halfway thru up to the root. And I just brushed this off, but I noticed the same thing on a couple of other hair today again too. I know for a lot of people fin darkens their hair. Mine is already pretty much black or extremely dark brown.

The change back to the original color may reflect reversal of miniaturization in some white hairs. This means that the drug is working. Not a usual finding however.

My hair loss no longer is responding to treatment

/by William Rassman, M.D./0 /

Dr, if my condition is not just stabilizing but actively accelerating would that indicate the treatment is ineffective? Should I be considering upping the dose of finasteride?

Many times when genetic hair loss accelerates, it can not be impacted by increasing the dosage of medications. Adding options might help. The choices are 1) finasteride dosed at 1mg (higher dosages are not better), 2) minoxidil 5%, 3) add microneedling if you are not doing it. Unfortunately, we don’t have the answer to many of those whose hair loss is moving fast to balding. Keep in mind that the genetically impacted hairs have a genetic life time which is defined by the number of hair cycles they can go through. Balding is the consequence at this time. Maybe soon there will be better drugs or approaches, but unfortunately the hair transplant seems to be the last stop on that train.

Tell me about post finasteride syndrome (PFS)

/by William Rassman, M.D./0 /

Please tell me about post finasteride syndrome, is it real? Is taking finasteride worthy it? Can you havd pfs for taking one to two months of using finasteride? your experience from finasteride? Thank you

If someone complains about permanent sexual side effects, to him it is real. Many doctors doubt the existence of PFS, but from the patient’s perspective, it must be recognized as a risk factor when taking finasteride for any reasonable length of time. I tell young men who have reported sexual side effect that it can’t be fixed with a lower dose, to stop taking the medication and as a result of this advice, I have never seen this in my practice patient population.

What should I look for when taking minoxidil?

/by William Rassman, M.D./0 /

Minoxidil common topical side effects are:

  • severe scalp irritation

  • unwanted growth of facial hair

  • chest pain, fast heartbeats

  • swelling in your hands or feet, rapid weight gain

  • a light-headed feeling, like you might pass out

  • headache, dizziness, confusion

  • flushing (warmth, redness, or tingly feeling)

  • Allergy, flaking of the skin, dry skin

Necrosis (from Turkey Patients)

/by William Rassman, M.D./0 /

The one photos that is labeled one month old, shows the area beyond the necrosis where maybe the scalp skin will survive, but the hair most likely will not.  The necrotic center of this lesion looks ‘angry’ to me which means it might have some infection around it.  The second patient shows a more extensive necrosis and I would expect all of the skin will not survive and be replaced by scar without hair.  Both men will need more work to fix this terrible complication which I believe reflects poor surgical management and anesthetic management with too much epinephrine

Dosing finasteride

/by William Rassman, M.D./0 /

Hi Dr. Rassman, best regards. I recently did a blood test as per recommendation of my doctor before starting fin. I have 0.41nmol/l of DHT (pre fin). Should I reconsider my usage of fin based on these results? 

The blood level of your DHT should not dictate the dose of finasteride that you take.  The dose curve shows that 1mg is the best dose, 1/2 mg is 80% as effective, and .25mg is 50% as effective as the full dose.  See the graphic that demonstrates it here:  https://baldingblog.com/finasteride-competes-with-dht-at-the-receptor-graphic/