When Would Shock Loss Occur?

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

I’ve been reading your blog and find it a great probable one of the best sources on the web for transplant facts! Thanks!

You recently replied to one user about Shock loss. I’m considering a transplant for my receding hair line at the temples. Though am worried it may damage my surrounding hairline which is healthy and in abundance. If shock loss were to occurr, is there a high risk it could be permanent? When would it kick in – immediately after the operation? And would propecia help several wks after the op?

Shock loss is a dilemma for some of the hair transplant patients. It usually happens in the first 1 to 3 months following the procedure and usually is not reversible in men. Bear in mind that shock loss happens mostly to the hair follicles that have some degree of miniaturization to them and the strong terminal (normal) hairs are quite resistant to shock loss. Several methods have been suggested to eliminate this problem. Many physicians say that topical agents like minoxidil and GraftCyte prevent shock loss, although there is no supporting evidence for this and no such claims in the manufacturer’s product inserts or claims. I had actually studied this use of these two medications on one side of the head many years ago and found no difference between the two sides.

Finasteride (Propecia) would perhaps be the most advantageous medication for reducing shock loss, if patients start taking it before the time of surgery. My recommendation to you is to start finasteride if you haven’t already. It is not well documented in any formal literature, but I believe starting the medication at least two weeks before the procedure is most valuable. If you miss the two week window, starting it anytime will be better than not taking it. The rate of shock loss has significantly dropped in our practice in the years since we have used Propecia, and I believe it has to do with us strongly recommending its use before surgery to all of our male patients.

Tags: finasteride, propecia, hairloss, hair loss, shockloss, shock loss, hairtransplant, hair transplant

Unlimited Donor Supply (or Follicular Unit Multiplication)

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

Hair multiplication has been a hot topic in hair restoration field in the last few years and many patients with severe hair loss hope that using this technique they can get back a full head of hair without worrying about donor supply limitation.

I think it would be helpful to review a recent article in the journal of dermatologic surgery on a similar subject: In Vivo Follicular Unit Multiplication: Is It Possible to Harvest an Unlimited Donor Supply? Ergin ER, MD, Melike Kulahaci, MD, and Emirali jamiloglu, MD 32:11:NOVEMBER 2006.

The article discusses a method for multiplication of hair follicles without a need to culture them. The authors have removed hair follicles using a FUE technique and cut them in different levels, trying to see if two hairs can be obtained out of one hair follicle. The researchers implanted the upper parts of these partial grafts in recipient area and the remnants back in donor site. The procedure was done on five male patients. Hair follicle counts and thickness analysis were performed after 1 year by a third party investigator.

Results of the hair count and thickness analysis showed that the growth could be seen in both the upper and lower parts of the cut follicle. From the grafts that were cut in upper one third, only 20 percent showed growth in the recipient site, while 84 percent of the remnant that were left behind, grew in the donor area. There was 29% growth rate in recipient area in the grafts, which were cut in halves vs. 68% growth of the remnants of these same grafts in donor area. Finally 41% of the grafts cut in upper two third grew hair in recipient area vs. 53% growth in the remnants of the same hair follicles in the donor area that they were taken from.

The authors concluded that hair follicle growth is complex and hair follicle contains stem cells in different levels, which could participate in the growth of new hairs. We know that stem cells are located in the bulb of hair follicles and in the outer sheath, in the middle of the hair shaft where the sebaceous gland is located. The authors assumed that each half of the follicle contains a stem cell reservoir that would potentially allow the growth of a new hair. The rate of the growth in a new hair follicle is reported to be 41 percent at best. All of the partial hair follicles grow thinner hair in comparison with intact hair follicles that were transplanted in the same patients.

The authors suggest that these sub-units of hair have value but they provide a lower yield than growth of hair from intact grafts both in numbers of viable hairs as well in the actual thickness of the hair that do grow. They also suggested that FUE is a promising technique is a mechanism to get the hairs for an eventual hair multiplication process once it is worked out, but it should be avoided if the transaction rate is higher than 10 percent.

Of course, this is not the only study on this subject and some other studies reported comparable results. As we have suggested in our previous publications over and over again, FUE is a great technique for the patients who have small donor area requirement, a limited balding area, a tight scalp and the ones with a contraindication for removing a strip. FUE should not replace strip technique in standard cases.

Tags: fue, hairtransplant, hair transpant, multiplication, donor

Tips to Keeping Newly Transplanted Hair from Going Dormant for Months?

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

Thank you for your Great Blog! I was wondering if there are any “tips or Tricks” to keep from losing the transplanted hair to dormancy?

There are many claims by some doctors that medications like Graphcyte or minoxidil do just what you are asking, but I studied both of these medications and find that neither have stopped the recently transplanted hair from going dormant. Sorry.

Tags: hairtransplant, hair transplant

Is an FUE Procedure a Less Successful Hair Transplant?

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

What do you mean by saying “FUE can be done in one surgery (our group did as many as 2600 in a single patient in a single session) or it can be done multiple day surgeries”? You said that this does not mean that FUE produces viable hair, so does that mean that you see less success in FUE procedures???

Anyone can claim that they are an expert at a procedure, but where is the credibility? The results of an FUE procedure in good hands will be as good as the standard strip procedure, but yet all FUE grafts are not equal. In our original article, we talked about the candidacy of patients, where some patients were better suited for FUE than others. Now the non-candidacy group is smaller, but the quality of the grafts may become an even more important issue.

For the future, we can look to the past, as Dr. Jae P. Pak’s engineering work led to a robotic application and a U.S. Patent granted for the FUE technique in 2003 (U.S. Patent 6,572,625). We can expect to see a robotic application coming out in a year or two.

In brief, Follicular Unit Extraction (FUE) can produce damage that range from transection (cutting) of the hair follicles to avulsion of vital elements of the graft. The percentage of such damage should be under 10 percent. When compared to the traditional strip surgery, the follicular units taken under the microscope from the strip excision are mostly perfect. The FUE procedure is not as time efficient as the strip either. Local damage to each individual follicular unit depends upon:

  1. the skill of the doctor
  2. the instruments and techniques used
  3. the tissue characteristics of the patient

Most doctors do not classify the quality of each individual FUE graft nor do they calculate the transection rate, so the integrity of the doctor in making this assessment is just as important as his/her skills. Please note that nothing is 100% and always be wary of doctors or salesmen promising you 100% success rates, or a willingness to take on any patient for an FUE, or flippant comments like ‘our grafts’ do not get damaged. Always ask the doctor how he/she knows. Look at the picture of the three grafts below. The graft on the left is a normal FUE three hair graft with good fat and fibrous tissue surrounding the follicular unit, the one in the middle shows transection of one out of two hairs (only one hair may grow, but it is denuded of skin so it may not grow to its full bulk), and the one that is on the right is a three hair follicular unit which shows that the follicles have been stretched and the surrounding supportive tissue has been stripped away (these grafts will ‘probably‘ grow, but they may not have their normal width when they grow out). If this patient had coarse hair normally, the graft on the left would be coarse when it grows (like his normal hair), the one in the middle might be less than coarse (less than his normal) and the one on the right may be ‘finer’ hair. A coarse hair has better bulk and better coverage for this patient than a ‘fine’ hair and the results of the fine hair graft when and if it grows will almost certainly disappoint the patient when compared to what it should have been. Click the photo to enlarge.


For further reading about the FUE process, please see What Doctors Don’t Want You to Know About FUE.

Tags: fue, follicular unit extraction, hairtransplant, hair transplant, hair loss, hairloss, success
Errors: https://baldingblog.com/wp-content/uploads/2019/03//photos/061214_fuegrafts.jpg is not accessible or supported filetype.

I Want To Harvest Facial Hair for Transplanting Into My Scalp

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

i am a 25 year old male with some male pattern baldness. I still have quite a bit of hair, but just want to have a full head of hair. I am interested in harvesting from the donor area near the back and sices of my head, but also was interested in hair from my beard (my chin). do facial hair transplants have just as low hair regrowth as body hair. also how many hairs can be transplanted from your chin with just one prcedure.

It would be malpractice for a surgeon to do beard to scalp hair transplants in a 25 year old. If you are committed, please do the standard thing and do not invent your own surgery. The price you will pay will have nothing to do with money.

Tags: hairtransplant, hair transplant, face, scalp

Exercising After a Hair Transplant

/by William Rassman, M.D./3 /,

First of all, a great blog – so thanks and I hope you get lots of patients from it!

I’m a 35 year old male. I had a hair transplant 10 days ago (1400 grafts) and am due to have my stiches out on day 12 (the doctor said that 10 days is ideal – but today’s a Saturday).

I’m a regular gym-goer and would like to know when I can hit the gym to my usual intensity. My doctor said that I should exercise only lightly initially. But I’d like to get back to my usual heavy weights. When would you generally say is safe to lift heavily?

Many thanks!

Exercise after hair transplant surgery is a concern for many people who are physically active and want to get back to their normal routine. You are facing two risks after a hair transplant:

  1. The risk of losing new hair grafts from scratching or rubbing the skin of the recipient area. If the hair and scalp are washed well after surgery, the risk of graft loss after 3-5 days is small, as the risk occurs as long as the scabs are present.
  2. The incision in the donor area, which is primarily closed by sutures or staples. The body takes 3 weeks on average for the wound to be reasonably secure. The healing of the incision of the donor area follows a general wound healing process that is standard no matter where the wound occurs. The process of healing starts from the moment the wound is closed. The body lays down the supportive infrastruture of fibrin from which the stroma for a secure would builds. Any vigorous activity should be avoided within the first week and then any aerobics can be done as long as the wound is not stressed (no heavy weights at all). After 2 weeks, the strength of this newly healed skin is not anywhere close to its final level, but between weeks 5 and 6 it reaches better than 80% internal strength. You can probably start your regular aerobic activities after the first week (the sutures should hold the wound together), but no weight lifting should be undertaken for 4-6 weeks. The process of wound maturation takes up to six months after the surgery.
Tags: hairloss, hair loss, hairtransplant, hair transplant, exercise

Is Shock Loss Always Certain Without Taking Propecia?

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

Hi Doctor, im a 20 year old male and am going to get a transplant in a couple of weeks. The doctor is in India and seems to be pretty good. But my main question is regarding shock loss. in one of your posts you said that without taking propecia, shock loss could be permanent in the transplanted or balding area. is that a 100% case. If it’s temporary,what can be done to prevent or lessen it because if suddenly after shock loss there is nice coverage then people would be able to tell that something has been done. that defeats the whole purpose of a transplant. your opinion….

Shock loss, as was referred to in previous posts, is a state of losing miniaturized hair in the recipient area that could be seen after hair transplant surgery. It also can accelerate hair loss that occurs in prone individuals who are young (like you). Its occurrence is multi-factorial and may have to do with the patient’s individual susceptibility, degree of miniaturization, type and extent of surgery, and clearly, age. Some patients may never show shock and the loss may be negligible. As stated previously, using Propecia (finasteride 1mg) significantly reduced the rate of shock loss in our practice, and we recommend it to all of our male patients before surgery.

I have concerns that at the age of 20, without taking finasteride daily for a year or so, a hair transplant is something you may regret. I would strongly recommend that you not have a transplant without giving the medication a year to see what it would do. You have your whole life to do a transplant, but you can not undo it once it is done.

Tags: hairloss, hair loss, shockloss, shock loss, hairtransplant, hair transplant

If I Lower My Hairline Now, I Won’t Have Enough Hair for the Top When It Balds

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

Hi Mr. Rassman,

A very worried man is writing to you. I am a Sikh and used to ties a turban for 8 years, but last year I decided to cut my hair. My hairline has receded considerably, and the hair on top is not thick, when light shines then alot of my scalp can be seen. However, there is too much hair on top for HT.

My worry is that if i lower my hairline, and dont have enough hair for the hair on top when its bald, then i will be left in a huge predicament.

You need a Master Plan for your hair loss. First I would need to know your age. Then I would want to know to what degree other men in your family have lost their hair. Next, I would want to determine your available donor hair supply so that I understand what you can depend upon for hair transplantation. I totally agree you need to balance the supply of donor hair with the worst case demand you might see from the balding. I would map out your head for miniaturization to determine where you are in the balding process and if you have your family pattern. Then, and only then, if you meet all of my requirements for a hair transplant candidate, I would plan out a ‘look’ with a hairline that will respect your long term ‘worst case’ scenario for hair loss. I generally like to put the hairline back where it belongs in a mature male hairline, but this does not include male Indians who have unusually youthful hairlines like what they had when they were 8 years old. Your concern of a hairline put too low for long term donor supply has not happened for me in all of the years I have been in this business and it should not happen to any competent doctor in the field either.

Tags: hairtransplant, hair transplant, hairloss, hair loss, hairline

Diabetes and Hair Transplant Complication

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

I have a related diabetic question and would like your opinion… I am diabetic, and I had a 1000 graft procedure done at a reputable shop. I had a severe complication, my scalp ulcerated, the “skin” just disappeared and left me with a large hole. I then had to have balloons placed under my scalp to stretch the skin and two surgeries under general to close the hole. Do you have any knowledge or experience with such a disaster?

I generally tell my diabetic patients that they are no more at risk from a hair transplant than any other person. I would want to know more about the surgery and what happened at the time of the surgery. This complication is one I have seen before when poor decisions were made at the time of the surgery by inexperienced doctors. I am not saying that this is your situation, but if your doctor was a good and experienced hair transplant doctor, I would probe more about why this happened to you.

Tags: hairloss, hair loss, hairtransplant, hair transplant, diabetic, diabetes

Swelling After a Hair Transplant

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

I had really bad swelling three days after my hair transplant. My right eye closed completely. Is this usual?

The swelling we see three days after a hair transplant is dependent swelling, working its way down from the scalp to the face. Clearly it takes time to work its way down.

The other day, a patient called me on the evening of the third day telling me that one ear was an inch away from his head, had shifted in position and was pointing downward. I told him that I did that intentionally so that he would be able to hear ground termites in his older house. I’m joking! Actually, I found out that he slept on the side where his ear had the problem. I blessed him, told him to take two aspirin and it would be better in the morning. Indeed, by morning his ear was fine. Dependent edema!

A few years ago, we did a study on the use of steroids, with small, medium and large dosages used. As the dose went up, the swelling came down both in frequency of occurrence as well as the amount of swelling seen. At the dose we use today (40mgs prednisone daily starting the morning of the surgery and going out 4 days) swelling is rare and significant swelling is even rarer. It was so obvious, the study was stopped and the higher dose became our routine.

Tags: steroid, prednisone, swelling, hairtransplant, hair transplant, swell

I Think 2-Hair Grafts Look Too Thick in the Frontal Hairline

/by William Rassman, M.D./1 /,

Hi Dr Rassman! If I pay for lets say 1000 grafts, do I have the right to achieve 2000 hairs (placed in the front) if I only want 1-hair graft in the front? 2-hair grafts don’t look good in the front (by front i mean about 1 inch), it looks too thick. My hairdoctor and I have different thoughts about this! Your opinion?

Thanks and God Jul “Merry Christmas” as we say in sweden.

I generally put a wide transition zone of single hairs in the frontal line. I believe that the ‘line’ is not actually a line, but a zone where there is a transition from the bald forehead to the thicker hair about 1/2 to 1 inch behind. The thicker area should have two hairs each, but that is a negotiation between doctor and patient. Generally, if you make single hairs from two and three hair grafts, there is a hair death rate, as not all of the hair will survive the break-up of the follicular unit. Great skills are necessary to accomplish this with the greatest success rate possible. I realize you are not in the US, but if you do make it out to California or if any other readers come to one of our open house events, you can look closely at the hairlines we have created and I think you will see what I am talking about in person. Alternatively, you can take a look at the Patient Photo Gallery on the NHI website.

Tags: transition, grafts, hairline, hairtransplant, hair transplant, hairloss, hair loss

FUE Scarring, Healing, and Other Questions

/by William Rassman, M.D./1 /, , ,

  1. will FUE transplanted grafts grow in donor strip scar tissue?
  2. Do you recommend GraftCyte for healing of graft recipient sites?
  3. If a person wanted to have as much hair as possible and not care about having any hair at all on the back and sides of thier head, simulating a rock musician look or marine type cut. Can one successfully FUE that entire area artistically and move it all to the top?
  4. would the tiny dot scars left by the FUE punch eventually be able to tan or blend as not to be too noticeable in person?
  5. And finally if one is nearly totally bald on top – say a 5 vertex – how many grafts will give a thick head of hair on top, not the 50% theory but rather full density, 8000 10,000 or more?

thank you

I will answer your diverse questions in the order you wrote them:

  1. Yes, and it is a good method of revising scars of the scalp and can also be used for bad scars in donor area.
  2. Yes, GraftCyte contains copper peptide with a mild cleansing effect and we recommend using it for post operative patients who have a tendency to hold on to the red color after the surgery. It may enhance the healing of the recipient and donor area (claimed by the manufacturer) and it may be helpful to control scabbing and crusting of incisions.
  3. This is not practical and I doubt that any doctor would do this. We generally FOX-test most of our patients and the result dictates whether the patient would be a good candidate for FUE procedure or not. We do not recommend FUE for the patients with negative FOX (having high transaction rate).
  4. The scar of FUE is usually not noticeable, but it is there and does not contain pigment cells (as a rule) so the hairless spot will be noticed by discriminating eyes if the scalp is shaved.
  5. As a general rule, you need 3000+ grafts (about 6000 hairs if you are Caucasian with average density), to cover an area of the size of an adult hand with a reasonable density. For more density, for those with dark hair and light skin, or very fine straight hair, a redo procedure may become necessary.
Tags: fue, hairtransplant, hair transplant, hairloss, hair loss, healing, scar, pigment, graftcyte

Can Eyebrow Hair Grow Through Scar?

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

I have a four inch skin lacerasion on my forehead. The skin was cut very deep and stitched back together. The scar extends right under my right eyebrow. I was wondering if my eye brow hair can still grow under the skin that was torn by the accident and stitched back together.

Hair may grow in the scar. I have performed eyebrow transplants in people who had terrible facial deformities with considerable success. Hair transplants work well at hiding scars when properly done in the hands of an expert.

Tags: eyebrow, transplant, hairtransplant, hair transplant, scar

T-Gel Shampoo and Recent Hair Transplant

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

20 days post operation.

I am a 24 year old male and just had a hair transpant (2000 grafts). Everything seems to be going OK, however, I used a Tar Shampoo (T-Gel) for direct shampooing on the recipient area (twice) before reading that this may interfere with the growth of the grafts. I have switched to another shampoo, however, I am wondering if this has already affected the transplanted area in a negative way.

You can burn the hair below the skin. For a description of the product and its risks read MedicineNet. It would be unusual to negatively impact the new transplants at 20 days. You should go back to the doctor who did your transplants and ask him/her. I generally advise that after a transplant, you use gentle shampoos like baby shampoo, which is safe and will not burn the skin.

Tags: skin, shampoo, hairtransplant, hair transplant, hairloss, hair loss, tar

Recreating the Hairline

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

my hairline seems to be moving back about an inch.. I know you describe this as a maturing hairline.. It seems that my hairline is now more of a zone. where if you pull back my hair the scalp slowly dissapears over the course of another half inch. It seems more of a zone. Have you done treatments where you recreate the line.. I dont wish to move the hairline back down but to just make it more of a line. Can transplants be placed that close together? If so, would you normally do this procedure on a 27 yr old? or would I have to wait until I’m older

There are many patients who have slight thinning of the frontal hair line. Hair transplantation to the thinning frontal line works well, but a correct diagnosis has to be made and the surgeon and the patient would be wise to make a “Master Plan” for future hair loss. At 27 years old, I would suggest that you have your scalp mapped for miniaturization to assess the current health of your hair and possibly determine your future hair loss scenario.

Assuming that the diagnosis of genetic balding is correct, you can increase the fullness of hair in your frontal area by having hair transplants. I generally tell my transplant patients to put the hairline where it belongs, not to shoot for a higher hairline. When high hairlines are created 1-2 inches higher than normal, they do not look natural because a strong higher-than-normal hairline is not normally found in nature.

Tags: hairline, hairloss, hair loss, hairtransplant, hair transplant