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Two articles are summarized below which address the drug Finasteride (Proscar 5mg and Propecia 1mg).

These article are very technical and may not be good reading, but I have put them here as part of my effort to educate the readership. Both of these articles discuss what we have learned on preventing prostate cancer with finasteride (very important as most men who live long enough will develop prostate cancer) and the cost/benefits of taking finasteride over time. In medical circles, these are controversial articles in many ways. I have included the comments of one doctor in the hair restoration field. Dr. Bill Reed, states: “An oversight on the author’s part that would probably negate the need to reduce the price of finasteride is the enhanced quality of having more hair! With regard to the authors’ basic approach, it’s an awkward premise to attempt to attribute a monetary value to quality. For example, is the real quality and value of treating BPH (enlarged prostate) with finasteride [to produce a] better sleep and absence of urgency or the money saved from a TURP? I’ve always loved how a healthier prostate and more hair probably go together with this drug [How does one quantify this value?]”

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European Journal of Cancer. 2005 Jul 29; The article addresses the finasteride prostate cancer prevention trial (PCPT) and asks: What have we learned?

Author: Mellon JK., Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, United Kingdom.

In 2003, the first of two large NCI-sponsored prostate cancer chemoprevention trials was reported. The prostate cancer prevention trial (PCPT) demonstrated a 24.8% reduction in the prevalence of prostate cancer in men taking finasteride 5mg/d for 7years. However, despite the overall reduced risk of prostate cancer, men in the finasteride-treated arm of the study were more likely to develop high-grade disease. This article examines some of the controversies aroused by the PCPT and evaluates some of the arguments that have been advanced in an attempt to explain some of the unexpected outcomes of the study. In addition, some of the recent studies assessing the potential impact of an effective chemopreventive strategy on population mortality are reviewed. To conclude, there is some discussion of factors, which need to be openly discussed with male patients who might be considered for finasteride therapy.

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The American Journal of Medicine. 2005 Aug;118(8):850-7. The article addresses the lifetime implications and cost-effectiveness of using finasteride to prevent prostate cancer.

Author: Zeliadt SB, Etzioni RD, Penson DF, Thompson IM, Ramsey SD., Fred Hutchinson Cancer Research Center, Seattle, Wash.; Health Services Department, University of Washington School of Public Health and Community Medicine, Seattle, Wash.

PURPOSE: We estimate the lifetime implications of daily treatment with finasteride following the results of the Prostate Cancer Prevention Trial (PCPT). In this trial, prostate cancer prevalence was reduced by 25%; however, an increase in the number of high-grade tumors among the treatment group necessitates the long-term projection of the likely benefits and costs. METHODS: We use a Markov decision analysis model with data from the trial, the SEER program, and published literature. The model measures the cost per life-year and cost per quality-adjusted life-year (QALY) gained for a cohort of men age 55 years who initiate preventive treatment with finasteride. RESULTS: Finasteride is associated with a gain of 6 life-years per 1000 men treated at an incremental cost of $1,660,000 per life-year gained. The quality-adjusted analysis results in 46 QALYs gained per 1000 men treated at an incremental cost of $200,000 per QALY gained, due primarily to the favorable effects of finasteride on benign prostatic hyperplasia. Under the assumption that the increase in high-grade tumors observed among finasteride treated men is a pathologic artifact, the incremental costs are $290,000 per life-year gained and $130,000 per QALY gained. CONCLUSIONS: The cost burden associated with finasteride is substantial, while its survival benefit is small and only realized many years after initiating treatment. To achieve an incremental cost below $100,000 per QALY gained, the price of finasteride must be reduced by 50% from its current average wholesale price and finasteride must be shown to prevent high-grade as well as low-grade disease.

 

I am 20 years old and I was born with a very high hairline. I have always hated it. It makes my face look less feminine. Can you help me?

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Hairline location is a genetic factor. If you look at ethnicity and family patterns, you will see wide variations in hairline location. I have always noticed very low hairlines of women from the Indian sub-continent, and I have seen family patterns where the hairlines on men were just as low. My own daughter has complained about her very high hairline, but is not at the point of wanting to do something about it.

What is a high hairline and how do you know you have one that can be fixed? If you look at the profile of the forehead, you will see a vertical part of the forehead where it is perpendicular to the floor. A transition takes place as the skull curves back, changing from a vertical to more of a horizontal position. The hairline is located at the point where the transition zone occurs from vertical to ‘horizontal’. The hairline can be located at any point along this zone. The higher it is located with respect to its location in this transition zone, the larger is the forehead. I have seen foreheads where the hairlines are located on the horizontal (top, flat) side of the head. In women, this rarely reflects balding or natural recession and most women see this pattern throughout their youthful days. The hairline is part of their unique look.

There are two approaches to deal with the hairline, both producing outstanding results. These two approaches are to (1) put hair transplants into the bare forehead, essentially putting hair where it never existed before, bringing it lower to the more vertical part of the forehead, and (2) move the hairline down surgically by excising a portion of the upper part of the forehead. The two approaches are both surgical and they are distinctly different, but the end point is about the same.

Hair Transplants to Create a New Hairline Location:
The transplant approach is a slower approach, putting hair into the upper forhead and waiting until it grows out. Generally, I like to wait between 7-8 months before judging if the thickness is enough to meet the need for fullness. These transplants will look just like the normal hair. While waiting for the transplants to grow, most women will style the hair to cover the hairline until the results meet their needs. Sometimes a second procedure is necessary. Not much risk involved in this procedure, but I would suggest that those interested in the risks of hair transplant review my book (click here) for a very comprehensive overview of hair transplantation. Although much of the book reflects hair transplantation in men, there is little difference between the risks in men or women.

Lower the Hairline with Surgery:
Moving the hairline down is a reasonable goal if the scalp of the patient has some reasonable laxity (looseness) to it. People with tight scalps are generally not a good candidate for this type of surgery. The best part of this approach is that the end results are obtained at the end of the surgery (you do not have to wait for the hair to grow out) and within a week, much of the swelling and ‘black and blue’ from the surgery is gone. We call this ‘instant gratification’ which gives this approach a clear advantage over the transplant route. The surgery requires heavier anesthesia than the hair transplant approach, but it still can be done under local anesthesia. There is more numbness after the surgery than with hair transplants and the numbness can last 6 months or more. Eventually, most people return normal sensation to the hairline area.

Scars are treated with a type of incision called ‘trichophytic’ which tends to force hair to grow through the scar for camouflage purposes. The greatest risk of this surgery is the risk of scarring. Most people who have this surgery do not develop socially noticeable scars, but for a small number of people, the scar may be noticeable. If the scar becomes an annoyance, it can be covered with cosmetics and it could even be treated with hair transplantation, which is very effective to cover such scars. Any transplants that are desired to treat the scar would be relatively unnoticeable. Few people seek hair transplants for treating the scar.

Moving hairlines down in women is a very different process than moving them down in men. Women generally have a stable hairline. It is very rare for women to recede with age from genetic causes. In men, it is completely another story because in addition to a genetically high hairline which we see in boys and young men, genetics may create a progressive process of further recession. For this reason, lowering the hairline in men with a hairline advancement procedure is not a viable option, but transplants can follow a receding hairline as age and genetic factors force the hairline further back.

Framing the face is critical to beauty and balance. For those individuals with disproportionably high hairlines, the upper part of the frame is not proportionally balanced to the distance between the nose and the chin. Just like the man with a receding hairline, a disproportionably high hairline in the female impacts the youthful appearance and beauty in the western view of beauty. By moving the hairline to a position that is more proportional, the results can dramatically change the proportions of the face.

 

I recently had a hair transplant and I hate to tell you how much I paid. What I am writing about is that after the surgery, the the instruction sheet they gave me is very poorly constructed and when I tried to call the doctor to ask questions, I got a message telling me to go to my local emergency room. Is that an acceptable way to do business or are there standards that doctors must adhere to with regard to giving patients the information they need?

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There are no standards other than the Hippocratic Oath which is: I swear by Apollo the physician, by Æsculapius, Hygeia, and Panacea, and I take to witness all the gods, all the goddesses, to keep according to my ability and my judgement, the following Oath. “To consider dear to me as my parents him who taught me this art; to live in common with him and if necessary to share my goods with him; to look upon his children as my own brothers, to teach them this art if they so desire without fee or written promise; to impart to my sons and the sons of the master who taught me and the disciples who have enrolled themselves and have agreed to the rules of the profession, but to these alone the precepts and the instruction. I will prescribe regimen for the good of my patients according to my ability and my judgement and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death. Nor will I give a woman a pessary to procure abortion. But I will preserve the purity of my life and my art. I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art. In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with men, be they free or slaves. All that may come to my knowledge in the exercise of my profession or in daily commerce with men, which ought not to be spread abroad, I will keep secret and will never reveal. If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all times; but if I swerve from it or violate it, may the reverse be my lot.”

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Why can’t you just buy on price? All that a hair transplant surgeon does is puts hair follicles into holes, so what’s the big deal?

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Great question and an important one as well. We are all sensitive to price and there is no doubt that if you can buy the ‘car’ cheaper from one dealer, why pay the higher price from another dealer. The higher price dealers try to sell service, but the reality is that a Lexus is a Lexus and you can get maintenance from any authorized dealer so you could buy the car over the internet and save thousands of dollars. A better question to ask: Why is a hair transplant (or any cosmetic procedure) different from buying a Lexus at the lowest price you can get?

I think that you now might understand where I am going with this question. How does one value cosmetic surgery services by particular doctors in a comparative shopping viewpoint? When you are buying the services of a surgeon for cosmetic surgery, you are buying:

  1. Unique surgical training
  2. Artistic judgments, experience and talents
  3. facilities and skilled staff

In a major cosmetic procedure (like a face lift for example), it often takes years to get the experience ‘under your belt’ to make a great cosmetic surgeon. Doctors just starting off are taking their skills from training and finely honing them, often ‘practicing’ the techniques that they accumulated in training. For a hair transplant surgeon, the same is true. I see hairlines that are not quite right, that are not well placed, that are not balanced, not distributed properly or placed in the proper alignment and/or are not delicate or subtle. So putting hairs into holes without skills and artistic judgments may give you an Edsel rather than a Lexus and everyone (unfortunately) knows what an Edsel looks like.

In a hair transplant, there are issues of ethics and judgments on the extent of surgery, the indications when to do it and when not to do it, how much to do, how often to do it, what is the particular variables of each patient when it comes to planning, and what risks should be taken for what gain, etc… Doctors who cut corners in recruiting patients have to employ people who sell for them and substitute their expensive time to the more cost effective time of a salesmen. As long as you have the money, a salesman will tell you that you need the surgery in order to take your money. In my practice, I turn down more work than I perform because I know when to do surgery and do not value the almighty dollar over what is best for my patient. This is not a plug for me, but a statement that a doctor’s value is in his knowledge and honesty in placing his patient’s interests above his financial interests.

In modern hair transplant surgery, the team is as important as the surgeon. Experienced team members are critical to producing a successful hair transplant. Novice doctors get hair transplant failures on a significant scale, but unfortunately, the consumer only learns of these failures 6-8 months after the surgery was done because it takes that amount of time for the hair to grow no matter who does the surgery. By the time a patient may find out that the transplant was a failure, his check has cleared the doctor’s bank and the doctor may not be in business anymore.

Take a look at newhair.com, read our history, our publications, and request a free copy of the book we wrote on transplantation. Look at the pictures of our patients and their results (over 200 on our site). We have written the authoritative articles for the repair of hair transplant problems. Be sure to thoroughly check out your doctor. With our medical group, you can meet a dozen or more patients at our monthly open house events and judge for yourself the value of what your dollar buys. There is no need to overpay, just to get real value and that is the power you, as a consumer, hold.

 

This was a busy day. I started early this morning – today’s surgical patient (Patient A) had a Class 6 balding pattern. He had great donor and scalp laxity- we transplanted 5069 grafts in 7 hours! Patient A’s “before” photo is just below, on the left — his “after” photo was taken immediately post-op and is below, on the right.



My clinical staff is amazing; they are so efficient and focused on the needs of the patient. I hope Patient A enjoyed his shrimp cocktail, his Thai lunch, and the movies he watched.

I got to see the patients from earlier this week, when they came in for their hair washes. They are healing really well. I wonder if I could talk the staff into doing my hair every morning.

Starting mid-afternoon, I saw a series of consultations, some new patients and a few old patients coming in for follow-ups.

 

Patient B came in today. He has had 5870 grafts with us in three sessions many years ago. He told me an interesting story today. A friend of his came over to him, looked at his hair and said, “I know that you probably don’t follow this hair transplant stuff, but I have just seen a doctor about getting one. Do you think that I am foolish?” Patient B confided in his friend, “Well that is one funny question. Didn’t you know that my entire head is transplanted?” His friend had no idea. They both laughed.

Here is Patient B’s before (on left) and after (on right). He had a procedure in 1997, 1998, and 1999. Six years later, his hair is still looking great. Please note that the quality of the “before” photo is from a scanned photo, so it is not as clear as the “after” photo, taken with a digital camera.



 

Then I saw Patient C. He had a total of two surgeries with us, the first being only about 7 months ago to repair an old hair transplant. Many years ago he had the older technique of large plugs done by another clinic, and had been wearing a hair piece to help cover them. Every morning he had faced himself in the mirror and saw this:



I removed many of the big plugs, dissected them into follicular units and then relocated the hair. I replaced his frontal hairline zone with 1501 grafts of single hair units. The entire frontal presentation is what you see here:


After his first NHI surgery he tossed away the wig once the new grafts grew out. His second and last surgery was just a couple of months ago. The photos below were taken less than two weeks after this second procedure. I was able to place 992 grafts into his frontal hairline. The hair is still very short and beard like in length. I told him that I expect this last surgery will finish his reconstruction. He now sees a normal man in the mirror every morning and he is pleased. So am I.



I love it when my previous patients come in to see me and to show me their results. Prior to surgery they are often anxious, and frequently during surgery they are so relaxed that they sleep through some of the movies they selected. These follow-up visits really give me chance to bond with them and share in their ‘hair happiness high’.

 

This is Patient D. He had three procedures with us totalling 4391 grafts and he stopped by to say “hello”. The “before” photo is on the left, the “after” is on the right.



 

Also, four new patients were on the schedule and it is the adventure in meeting new people that is most fun. Today I was able to spend at least 45 minutes with each of them. In my career I have personally consulted with tens of thousands of hair loss patients and their families. They are each unique, but they share so many of the same concerns. It is a pleasure to discuss their options, to encourage them to research, to seek out the best!

At the end of my day, I got a call (on my cell phone at about 7pm) from a very successful LA area businessman who was 4 ½ months out from his surgery. He just wanted to tell me that now his favorite activity is shaving in the morning. He said “Each and every morning there is more and more hair. It is exactly the reverse of what I saw when I was losing my hair. Back then, my nightmare started in the morning when I looked in the mirror to shave- all I could see was me getting older and older. Now, the mornings are the bright spot in my day.” His thanks and appreciation was a nice way to end my long day.
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I had a hair transplant that deformed me a number of years ago. I have been depressed and angry, hiding under a baseball hat much of the time. Now, I want to get back at the doctor and make him pay me for my suffering. He had no right to do this to me and had I know what I was getting, I would never had the surgery done. How does one find a lawyer to represent me in a malpractice case against the doctor?

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This is a hard question for many reasons. First, you are angry and I understand the anger, but you did make the choice to have the procedure and must recognize your role in enabling the doctor, even though you feel that you were a victim. The old axiom, ‘buyer beware’ holds for anything you buy, even a hair transplant. I am not sanctioning what happened to you, for I have seen hundreds of men in your situation and I have great compassion for someone who wanted to take charge and improve their appearance, and find themselves going south when they wanted to go north. Unfortunately, the old procedures did not meet the standards of many people. Today’s surgery is much better and the standards are good enough to meet even the most critical buyer.

First, I must qualify my credentials by saying that I am not a lawyer, just a well informed doctor. Every State has a ‘Statute of Limitations’ which means that you must file an action within (usually) 2-3 years of the point when you realized you were damaged. I will assume that your surgery goes back to the old days when big plugs were done (10 + year ago). You can, of course, go back to the doctor who did the work and ask him to fix it. A good doctor should try to make things right, but with your degree of anger, you must first address your anger and try to determine just what you want to do about the problem that you are living with. Alternatives to a malpractice suit include: (a) Complaints to the State Medical Board (which in California are always investigated by representatives of the State Attorney General’s office), and (b) Complaints to the Better Business Bureau (this is a place that new patients will often go when checking out a doctor).

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Doctor; I had my 4th hair transplant last October with the same surgeon who had done the prior 3. No complaints the first 3 sessions; I had decided to do a final “touchup”, filling in the front a bit more and adding to the crown.

Big Mistake.

My donor area on the left side was totally butchered; a patch about 1 1/2X 1 1/2 inches totally barren and badly scarred. I knew something was wrong immediately after surgery. The hair was gone the next day-immense pain and tightness was in the wound and there was redness also there. On the left side, there was a scab in the middle of the patch that took 2 months to heal.

The right side was similar but not quite as bad. The hair eventually grew back on the right side around 2 1/2-3 months. Its now been over 7 months; I do not expect anything will ever grow on the left side. The sutures seemed placed extremely high above the edges of the wound, also suspicious. I was told by the surgeon that everything was fine; these things “always resolve”.

Finally a month ago, after seeing my predicament, he tepidly agreed that re-growth wasn’t in the cards. He said he would do “Scar revisions”? This did not seem right, so I sought 2 other opinions, both saying scar revision considering the circumstance was definitely the wrong way to go, and that transplanting hair into the area, in 2 small sessions, was the best way to handle it.

Do you have any advice for me?

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Scars from any surgery are unavoidable. When I performed general surgery, people would judge the surgeon by the appearance of the scar after the surgery. If the scar was barely detectable, then the surgeon was great, but if the scar was stretched or obvious (for example) the surgeon was terrible. If I did 100 appendectomies, about 10 would have a widened scar and 90 would have a barely detectable scar. Was I a great surgeon 90% of the time? How did I select who got the bad surgery? The question sounds silly, but as a surgeon I am humbled all of the time that anything ever healed and I live in a constant state of awareness that there are many things that I can not control. Scarring is just one of them, but I do not abdicate on the awesome responsibility upon me to try to get perfect scars 100% of the time.

I want to know how the scar impacts your styling and your ability to function daily. Since we are talking about visible scars in most situations, we are talking about the ability for the hair around the scar to cover it adequately. The thinning of the hair in the donor area is unavoidable and as more surgeries are done, more thinning can be expected and the scarring risks rise (non-visible and visible scarring are separate issues here). Think of it as follows:

  1. the donor area has extra skin when the process is started (you can feel this if you put your hand behind your head and move the scalp up and down as it should move at least ½ inch)
  2. each time you have a procedure, some of the extra skin is removed and eventually the skin may get tighter
  3. as everyone is different, some people’ skin just gets thinner and not tighter, others get tighter and not thinner, most are a combination of the two. When the skin does not get tighter, the ‘extra’ skin probably re-grows
  4. every surgery produces more scars below the skin making the skin less mobile to some degree and the amount of this mobility (and binding of the skin to the deep structures of the scalp area) varies in each patient.

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I am a 23 year old male with an extensive family history of balding. I am well on the way to follow my father and grandfather’s pattern. What can I do?

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I just had a patient of the same age and with the same problem in my office, so I thought it might be worthwhile to read what I wrote to him. I send comprehensive letters like this to all of my prospective patients out of respect. It is always an honor to be able to play such an important role in the life of a patient.

Here’s the letter:

You have an unusual problem found in less than 1% of balding men. Your donor hair density in the rim of ‘permanent’ hair around the side and back of your head is higher than average (300 hairs/cm2 while the average is 200 hairs/cm2) but 1/3rd of these hair show miniaturization. This is the same process that goes on in the balding area on the top of your head and it should not occur on the side and back. When it does, it reflects a condition we have defined in the medical literature which we call Diffuse Unpatterned Alopecia. In essence, you have a process going on throughout the hair on your head, even the ‘permanent’ zone. Now with that said, your effective donor density of 200 hairs/cm2 (which reflect the sum of your hair count less the miniaturized hairs) is from a practical point of view, normal. But the fact that you have this process going on in the permanent zone means that the future of your permanent hair is uncertain. In my fairly wide experience, people who have had Diffuse Unpatterned Alopecia, have not experienced progressive extensive balding in the ‘permanent’ zone, but there is not certainty in your future. In determining your predicament, I would like to call your attention to some of the other elements of the examination I performed on you. Your hair is more coarse than most people, which means that the value of each hair is much higher than a normal person. There is a slight wave to your hair which means that it grooms and covers well with its strong character. Your hair is black and your olive colored skin provides moderate contrast between your hair and skin color, and although your olive skin offsets the dark hair a bit, it still calls attention to a lighter background which might require more coverage to get a full look.

Your biggest problem is the extent of your balding, which appears well on the way to becoming a Class 7 balding pattern (the most advanced pattern) and one that runs in your family. At the age of 23, you have a typical early appearance of this advanced balding process, but that balding process although mild in the top and crown of your head at this time, may respond well to the drug Propecia. You indicated your objection to using this medication to slow down or arrest the hair loss in the top and crown area. Your objections are over the side effects of the drug (rare and unusual). Considering your age, you have a good chance to get some reversal of the balding process in the top and crown area. With the diagnosis of Diffuse Unpatterned Alopecia that we found our your examination, I see even more reason to use the drug. I have seen fully half of the men who take Propecia see some reversal of the diffuse hair loss process in the ‘permanent’ zone, giving you two reasons to reconsider your position against taking this drug.

When dealing with a young man, I tend to be conservative, leaning on the drug treatment to slow down the balding process and for the maturity of the patient to line up with the extent of the problem. By saying this, I do not mean to be offensive, but young men are driven for now answers and often do not see themselves through the entire balding process which may take years. Transplantation, although a wonderful solution when appropriate, is the wrong answer for those who have not worked out a Master Plan with a good doctor that accounts for the worst case scenario of the balding process as modified by a transplant program. That is the dilemma before you and I at this time. You have to convince me that you understand what I know about your hair loss and what can be and can not be done about it. I must understand your maturity in dealing with a transplant program that will be with you the rest of your life. A good doctor/patient relationship is what I am talking about, something that is not easy to obtain in an hour visit to my office.

I am not firm against a transplant solution for your balding but because of the Diffuse Unpatterned element of your Alopecia, I need some comfort that whatever we plan is going to be the right plan for you. I want to speak with you again about the Propecia option and dive more into depth on the various subjects we discussed. We spent a great deal of time discussing the safety issues with Propecia, hopefully giving you more comfort in considering this drug as part of the long term treatment of your progressive hair loss problem.

 

What type of training does a hair transplant doctor need?

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This is a difficult question to answer properly, so as I have lots of room and time to consider the question thoroughly, I will answer it in great detail. Read as much as you wish.

The Hair Restoration industry has a society called the ISHRS (International Society of Hair Restoration Surgeons) and they are trying to provide both the public and the doctors who ‘specialize’ in hair restoration a way to define this, both for those who call themselves specialists and those doctors who want to enter the field and learn how to become a hair restoration surgeon. As you may notice the way I started answering this question, I have divided the answer into two categories: The existing doctors who call themselves specialists (like myself) and the new doctors wanting to get into the field.

Existing Restoration Doctors: The existing group of hair restoration surgeons come from a wide diversity of specialties. Dermatology was the field that produced the original hair transplant process in the late 1950s, so this specialty has officially hosted the field ever since. The text books are largely written by Dermatologists and the leading medical journals in Dermatology have articles about advancements in the field with great frequency. In fact, most of the articles written by New Hair Institute doctors have been published in Dermatologic medical publications.

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