I’ll Be Bald By 25 — How Can All I Get All My Hair Back?

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

Hello Doc,
I have a very vague question for you. Im a 20 year old male who is thinning very fast and probably will be completely bald by about 25 (Class 6). What would you have me to get all my hair back to the way it was in high school in the best method possible.
I understand i can’t get it back completely, but what would be the best possible recommendation from your standpoint. I have been on propecia a bit over a year now and I feel it has done nothing for me, and Im looking to buy minoxidil to help me, but I’m also considering Dutasteride. What do you say?

I want to have the body I had when I was 40, but at 60 I can’t get there. Reality is that everyone loses youth and I accept that for myself. You need to stop gambling and start being smart about your hair loss. Once your hair is mapped out for miniaturization, you can be checked for the change of miniaturization over time. If the Propecia does not work, then transplants with a Master Plan is the right way to go, but you need a good doctor first and foremost. Following the advice in this blog site will at least help you to become a smart buyer.

Is a Photo Consultation Enough Before a Hair Transplant?

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

Dr. Rassman,
2 questions please:
1) A while back you answered a question about a substance that some doctor in another country claims to use to prevent transplanted hair from falling out as is common. Do you have any more info on that? Is there any truth to it or is it just unsubstantiated claim? I certainly hope that it is true.
2) Is it ever justified in getting a hair transplant from a doctor without actually visiting with him in person first? For example, I live in Texas. It would be a big expense to go there for a consultation and then return later for the operation. If a doctor seems to have a very good reputation (like yourself) would a photo consultation be enough for someone to have confidence in the outcome? Thanks so much for your time in doing this Blog.

  1. Some doctors recommend FDA approved drugs such as topical minoxidil or oral 1mg finasteride (Propecia) for hair loss. These drugs may benefit recently transplanted hair from falling out. In my opinion, to claim that a drug or a product will be prevent the natural shedding of recently transplanted hair seems too good to be true.
  2. A photo consultation is certainly a good start and in healthy men, I have been known to draw conclusions on the course and take on a patient coming in from a distance. Generally it is a good idea to meet with a hair transplant doctor and establish a patient-to-doctor relationship first. You should feel comfortable and 100% certain that your hair transplant doctor will meet your expectations. I appreciate your trust in my reputation. I will be more than happy to start a phone/photo consultation with you. Anything is possible from there.

Medications or Transplants?

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

Dear Doctor Rassman,
Since the medications Propecia and Rogaine will eventually lose their efficacy, would it be advisable not to take them and address hair transplantation instead?

I believe that we have no way to determine if and when the medications that are working will lose their effectiveness. Sometimes it will last a very long time and if the medications are not producing problems for you, then it would be generally my preference to stay on the medications and exploit them until they become less effective. Supplementing the benefits of the medications with hair transplants may be appropriate in some situations.

There is also the issue of how far the hair loss will progress if you stop the medication and start losing hair very quickly. If that progression gets very advanced, then transplants may not be something that will solve the problem either. I discuss the supply/demand balance between your donor source and the advancing balding pattern. When the pattern exceeds your donor supply’s ability to give up the hair, you will not look normal unless you and your doctor had a Master Plan devised when the process started.

Transplanted Hairline at 3 Months (with Photos)

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

I am concerned about transplants in the front of my existing hairline. Will they be noticable if I lower my hairline 2/3rds of an inch?

Here are some 3 month follow-up photos of a patient with dark hair. He had received about 700 grafts in front of an existing hairline. Since it is only a few months after the transplant, only some of the hair is growing and I expect much more to grow out in the subsequent months.

What is important to note is that the patient styles his hair forward so there is no way to tell that these little hairs are growing. Even if he did not do that, it was not clearly evident that these transplants are even there. The point is, it is easy to ‘hide’ transplants even in the front of the existing hairline, because these hairs grow from nothing (bald forehead) to something (fine hairs) very slowly. Most men are very sensitive to having their hair transplants seen by anyone, so I thought that these pictures would show a ‘worst case’ where the hair is growing directly from the forehead (its future home).




Please click the photos to enlarge.

How Much Transplantable Hair Does A Person Have?

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

How many grafts can be transplanted in a person in his lifetime?

Simple Answer: It depends.

From my personal experience at NHI with over 18,000 hair transplant surgeries from the various clinics I have managed, the most transplanted hair grafts on a single patient done under my care was about 10,000 (over several surgeries). There are many patients between 8,000-10,000 grafts. These are often the exceptional case in which the patient had a very high density donor hair supply. Most Norwood Class 7 patients are happy with about 5,000 to 7,000 grafts.

We are born with 100,000 (average) to 200,000 (exceptionally high) hairs. Of those, only the back and side part of your scalp is considered permanent hair if you have male pattern hair loss. If you roughly estimate the back part of your scalp to be 30% of your total scalp area, then you can argue that 30,000 to 60,000 hairs in the back part of your scalp can be considered permanent, leaving with about half (theoretically) able to be moved somehow. For a typical hair transplant to be undetectable (so that your donor area scar is not noticeable) I suspect you can safely get 8,000-10,000+ hair grafts over several hair transplant procedures provided that the donor supply can be maintained healthy and scarring is minimal and able to be controlled.

Some doctors love to push the numbers. The push to high numbers are for money (to the doctor as he charges per graft), his ego (he can say he has patients with high numbers putting him in the ‘mile high club’), or the agenda of his patient. Please be careful that you as a patient know what you are getting into and best be sure that your doctor has the experience by personally meeting some of those patients who have these numbers actually done successfully.

At Age 19, Do I Need to Take Propecia Before a Transplant?

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

hello im 19 from london, i want a hair transplant, but dont want telogen shock, i would like to have a hair transplant as soon as possible, but do i need to be taking a drug eg propecia to avoid it long before my operation or can i start just before, also would it be worth having the operation w/out drugs and hopeing telogen shock did not occur

At 19, I would be hesitant to have a hair transplant. You need to have your hair loss measured and should absolutely be on Propecia for a trial of at least a year. Have measurements for miniaturization taken prior to starting Propecia so that they could be compared after a year on the drug, and a good doctor can then determine if you have the hair loss under control. The last thing you should be considering at this time is a hair transplant. As I say all the time, Let the Buyer Beware. No one will protect you other than you. Look at my website and become familiar with what we do and the field of hair transplantation in general.

Propecia’s Major Side Effects

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

Hi Dr., I am a 20 year old male who is goin bald and is considering a hair transplant. I was wondering what you recommened to maintain hair after a transplant, other than propecia because i have heard of major side effects. What is your opinion on rogaine and other topical treatments ?

I often receive questions on finasteride (Propecia) from patients like you quoting “adverse” or “major” side effects. All drugs have side effects (even Tylenol), but when used correctly under the supervision of a qualified medical doctor it serves its purpose. I often find people are misinformed from the mass amounts of uncorroborated information available on the internet or just word of mouth. It is the source of folk legends and superstition. It is one of the reasons why these medications can only be prescribed by a medical doctor.

Propecia has been well studied for male pattern hair loss in men. The following is taken directly from the Healthcare Professional Information Label for Propecia (finasteride 1mg).

Drug related adverse experience for healthy men taking Propecia during a 12 month period:

  945 men on
Propecia		 934 men on
placebo (sugar pill)
Decreased Libido 1.8 1.3
Erectile Dysfunction 1.3 0.7
Ejaculation Disorder 1.2 0.7

Rough translation: 1 in 100 (1%) patients had some form of sexual dysfunction. “Resolution occurred in men who discontinued therapy with Propecia due to these side effects and in most of those who continued therapy”.

There have been incidence of breast enlargement or tenderness (gynecomastia) reported. This occurred in 1 in 200 (0.5%) patients taking Proscar which contains 5mg finasteride (5 times the dose of Propecia) in a 12 month period. There is probably less than a 1 in 300 chance of gynecomastia from Propecia (which is 1mg rather than 5mg finasteride). This is also reversible.

Please note inb my practice experience there is a 1 in 10 chance of INCREASED libido (some may call this an “adverse” or “major” side effect for married men). I experienced this when I started taking it myself.

I believe the take home message for anyone who is serously concerned about their hair loss is to be make an appointment with a medical doctor (primary care doctor, dermatologist, or a hair transplant doctor) to discuss possible medical causes and its treatment options.

With regard to your second question, some doctors recommend the use of Rogaine (minoxidil) with a hair transplant on the belief that it accelerates the hair growth. I have used it on patients (half of the head with minoxidil and have without anything) and there was no difference with the use of minoxidil. The beauty of the hair transplant process, with the robust donor hair from the back and sides, is that no matter what you do or do not do with additional medications, the transplanted hair grows.

Hair Too Thin For Transplant?

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

my son who is 24, and african american went for a consultation this morning for possible hair transplantation, and he was told his hair was too thin. does that make any sense to you? too thin to transpant?

Being turned down for a hair transplant because of thin hair does not make sense to me, but I do not have the benefit of examining your son’s scalp to map his hair for miniaturization. Sometimes hair transplant doctors who are not experienced in the field are reluctant to perform hair transplant on African Americans because of their unique hair characteristics. African American hair can be very fine and thin naturally and it can also be very coarse as well. That does not mean he cannot have a hair transplant and someone like your son is just as much a candidate as anyone else, provided that he meets reasonable criteria standard for ALL men. The race card is not in play here. You or your son should research hair transplant doctors who are willing to show pictures of their patients. At NHI, anyone has the opportunity to come to one of our monthy Open House events to meet many of our hair transplant patients and see an actual surgery in progress. Everyone coming in can have their scalp mapped out for miniaturization as part of the basic diagnostic process we carry out for everyone.

Using Grafts from Other People

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

I am a 49 year-old African-American female. My mother and her two sisters suffer from female pattern balding. They are all in their 60’s. None of them have balding to the degree that I have. My two sisters still have the very thick hair we all had as children. I have general thinning all over. The top of my scalp and the sides have very thin, and in some cases bald spots. I never permed my hair. I am now wearing my hair in dread locks. Short of shaving my head, I don’t know what else to do. I would like to see if I am a candidate for transplant. Not the strip kind. Maybe the very small graft units. Do you have any experience in using hair grafts from other people. Or is this science fiction. I do not know if I have enough hair to transplant.

I do have experience transplanting hair from different people but they were identical twins. Otherwise, the difference in our individual genetic makeup will reject the ‘foreign’ hair.

Suicidal Thoughts After Hair Transplant

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

I am devastingly depressed from my strip procedure…I made a very very bad mistake by doing a “fill in” procedure when I was 27 (something I regret more than anything) not realizing I would eventually get 2 other procedures of over 1000 grafts later and have a scar that I can not cut my hair short or shave my head…

I am having suicidal thoughts and wish I never did this at all..Id give anything to have no scars and just shave my head like I should have done. I was too young, uneducated and stupid at the time I made the decision for the first procedure. Now my friends with less hair than I have, Im jealous of.

Is there anyway to cover up this strip scar with FUE? DOes the donor area have to be shaved to do this? Will it cover it enough to cut my hair short again? Should I wait for potential hair multiplication someday?

Your opinion and expertise is appreciated. Im overwhelmed here..please help

Thoughts of suicide are a major red flag for me. When depression leads to such thoughts, then medical intervention is needed. You need to connect to your family doctor and discuss these thoughts, so that he/she can help you deal with a far more important issue than what is going on on the top of your head.

I do empathize with the trauma that you describe. From a medical and surgical viewpoint, these problems are not difficult to deal with, but they should take a back seat to your mental health. Just to list a series of options that may apply to your scar, they include: fascial techniques to reduce scars, transplants with FUE to fill in scars, and a Trichophytic closure technique that allows hair to grow through the scar, and camouflaging the scars to reduce their detectability. This is not meant to be a comprehensive listing, but just enough to tell you that once you get your mind clear and focused and can manage your suicidal thoughts, there are many options that can be considered for you.

With regard to things like hair multipication and cloning, I am disheartened when I read the rumors on the web telling that these technologies are around the corner. They are still quite a ways away from becoming a reality. See the Hair Cloning category for more.

Is Hair Transplantation a Slippery Slope?

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

hi there . my question is why every time i have had transplant work done it has caused the hair around the transplanted hair to permantly go to sleep or fall out. i have even met doctors over the years who stopped doing tranplants for this reason.it seems like a slippery slope getting transplants done. thanks

I do not understand what your situation is, so before I dive in, let me make some general observations and pass on particular messages that I feel are relevant.

  1. I don’t like the idea that you used the term ‘every time I had transplant work’. Why is there so many times? That is not the modern approach used today and something that I would not want to hitch my wagon to. Was your work started many years ago? How many procedures did you have?
  2. Hair loss in previously transplanted hair is very, very unusual. Generally its incidence is 1 in 500 people who may temporarily lose previously transplanted hair. For men, hair loss in non-transplanted hair often does not grow back if it is well along in its miniaturization process. In women, it usually grows back when it does happen and it is present in less than 10% of women transplanted.

What you are describing in non-transplanted hair is a well known phenomenon called shock loss after a transplant. In men, it only happens once, usually after the first transplant on young men not on the drug Propecia. This can be minimized by taking Propecia and it does not happen to all patients who undergo hair transplants, particularly men over 40. Hair loss may also have occurred even without a hair transplant if there is an accelerated phase of hair loss, or the hair transplant may have just accelerated it (again, more common in young men not on Propecia). It is very troubling to me that the doctors you met have stopped doing transplants for this reason, because it signifies that they do not know the intricacies and the physiology of the hair transplantation process. Or there is possibly other factors that you’re not mentioning.

Smoking Cannabis After Hair Transplant

/by William Rassman, M.D./2 /, ,

First off let me say I find your answers to be very informative.

My first question is: Will cannibus affect my hair transplant I had on Feb 08/06? I don’t smoke cigarettes but cannibus helps me deal with my occasional back pain.

Secondly when can I resume my normal jogging of a couple miles in the morning? As well as doing chin ups and push ups? I have been told exercise of these sorts will only expand the the donor scar.

Thank you and i appreciate your advice.

Cannabis Medically speaking, smoking cigarettes (even the cannabis / marijuana kind) promotes poor wound healing by decreasing blood circulation. It may have an impact on your hair transplant, however, I do not know how much of an impact it will have.

Exercises such as sit-ups that may have a potential to stretch the back of your scalp will also have an impact on your donor scar. Running 1 week after surgery is not a problem. Although you can probably resume most of your regular activity after one or two weeks post surgery, the scar takes about 6 months to a year to completely set and in the first 3-6 weeks, the wound structural elements that make for good solid healing change and build. I generally tell my patients not to do the type of exercises that stress the neck muscles like body press or sit-ups for up to 6 weeks. A few of my patients even ran marathons a few weeks after surgery without any negative effects.

Angry and Depressed Strip Surgery Patient

/by William Rassman, M.D./2 /,

Dear Dr William!!!
I have to say that I’m very sorry doing FUSS on my 6-7 scale bald head. It does not give me chance to cut my hair short and the stripe is from one ear to another, very ugly. Doing a stripe more than 10cm should be forbidden. When I came for surgery i thought “if something went wrong i’m gonna shave”. Dont you think that is better to have a procedure with less FUE and be able to cut hair short, to make a nice hair line. if the vertex is bald it doesnt look bad when the hair is short. I’m sorry I realized that after my surgery. Cant you people see how many people suffer from this frankenstein scar? it is a sin to cut somebody like that. Besides that all the pictures lie about fullness of hair and also nobody ever mentions that the hair above and under the scar can have a big difference in fullness which looks very ugly.

I’m a very depressed and mentally destroyed 33 year old man. I had one chance for HT and I lost it with one of the greatest doctors that could not evaluate me and give me right advice . I signed all these scary papers just because I was trusting him, after all this I see it was all about the money. I would give now everything I have just to go back to normal. Please start up with some medical law to stop doing FUSS. The papers I signed are too scary to be offered to humans.

Unfortunately I will have to wear a hat in public for the rest of my life, probably at home too because I dont want my poor mother looking at me like this. People have done the HT for last 40 to 50 years and still do not realize that strip is wrong technique. To sign so many scary papers, like for FUSS, means that doctor still doesnt know what he is doing. I’m sure it is about the time when FUSS will be forbidden. God bless

First, it must be pointed out that this man is not one of my patients.

I sympathize with your predicament and I’m sorry for your situation. The truth is, though, that there are many patients for whom a scar is much less of an issue than the alternative of having a Norwood Class 6 or 7 bald head. For those readers who are unfamiliar, there are some doctors that refer to the Follicular Unit Transplantation (strip procedure) as “FUSS” (Follicular Unit Strip Surgery). I don’t know what your scar looks like, and the fact that it bothers you so much means that it is unacceptable to you, yet these are issues that one needs to deal with before the surgery.

A few points that I want to highlight:

  1. The hair transplant procedure happens on your head, so you must think about every option and its possible consequences carefully.
  2. Never, ever sign anything that you do not understand. If you thought “these scary papers” were too much for you, you should’ve taken a step back and perhaps re-evaluated what you were doing before you agreed to it! This goes for anything you sign your name to. No matter how “trusting” you are, there is no excuse for signing any contract or papers without knowing what you are signing. What you most likely signed was an Informed Consent. According to the American Medical Association:

    Informed consent is more than simply getting a patient to sign a written consent form to protect the doctor when something goes wrong. It is a contract between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical or surgical intervention. In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with you:

    • The diagnosis, if known;
    • The nature and purpose of a proposed treatment or procedure;
    • The risks and benefits of a proposed treatment or procedure;
    • Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
    • The risks and benefits of the alternative treatment or procedure; and
    • The risks and benefits of not receiving or undergoing a treatment or procedure.

  3. How could you call the doctor who did your surgery “one of the greatest doctors” if he never gave you the “right advice” and you are so dissatisfied with the surgery? You should go back to your doctor to discuss your concerns.
  4. All surgical procedures will leave a scar. Most hair transplant scars can be easily covered by your hair, even with a short haircut. Note that if you shave your head, it will show. I had two hair transplants, and rarely can anyone find my scar unless they work my hair with a comb and use a very bright light, but if I shaved my head (something I do not ever plan to do) one would see a ‘smile’ on the back of my head reflecting this scar, though again, it would be very hard to find when I have hair grown to any length. Finally, if your scar is more than 5mm thick, you may have a keloid formation or may be a candidate for a scar revision (a type of fix that good doctors can do). All of this should have been covered in your Informed Consent.
  5. You state that you are “very depressed and mentally destroyed” and just want to go back before the transplant was done. You condemn your doctor who you have suggested just showed you pictures that lied about the fullness you were going to get. We have open house events in my practice to allow prospective patients to meet actual patients. I do agree that pictures are often not adequate, because they show you what the photographer wants you to see, but by meeting patients, it gives you a good chance to see the quality that you are going to get. As the expression goes, hindsight is 20/20, and hopefully knowing what you know now, you would’ve asked to meet patients in person. This should also be an important lesson for the readers considering a hair transplant (or any cosmetic procedure, really).
  6. Depression is a serious matter and you should think that about getting help directed to what is inside your head, not just addressing the subject of hair loss or scarring. Every human being would love to undo some decisions in their lives, but that is just not reality. As I’ve mentioned on this blog before, I always tell people that the good news and the bad news about hair transplants is that they are permanent. Going back in time is therefore not an option.

I have compassion for you, but you must take charge of your own situation by doing something positive about it. If you can make it to the Los Angeles area and would like me to judge what you have going on, come visit me or send me a good set of photos. At least that would be a small ‘baby step’ in the right direction by starting to take charge of your problem the correct way.

Transplant Risks, Stopping Propecia After Hair Transplantation

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

  1. What are the risks of hair transplantation?
  2. Will I keep balding after a hair transplant?
  3. Can I stop my hair loss with Propecia?
  4. I am 35 years old and a Class NW 3V, will I get very bald (like a Class 7)?
  5. A Doctor told me that I needed 3500 grafts, Is this a reasonable goal for a NW 3V?

  1. Hair transplantation is a surgical procedure and entails all of the risks of an outpatient procedure. The risks of death and severe complications (in good hands) should approach zero. The usual risks such as infection, drug side effect/overdoses, and the like are rare. Scarring risks for strip surgery are about 5% for a scar measuring greater than 3mm. Folliculitis (local infection/cycts of hair follicles) is not an uncommon problem in the post operative course over the first few months as the sebum builds under the skin and can not get out (this is easy to treat). Most people do not have much of a problem with things that go wrong from the surgery. The biggest problem is for the patient to match his/her expectations with what the surgeon can deliver. Miscommunication here is the biggest problem of all because either patient or doctor often oversell the results.
  2. Male patterned genetic hair loss is a life long process, but most people stabilize or slow down the progression by the time they are 35. From that time forward, hair loss is usually slower. This is what a good doctor will cover as he develops a Master Plan for your hair loss with you.
  3. If you take Propecia (for men only), then hopefully if your goals are achieved with the drug alone, surgery may not be necessary. If Propecia alone does not solve your problem (typical for the NW 3V or more advanced balding patterns), then transplants may be necessary to achieve your goals. Again, that is where the Master Plan is customized to your needs.
  4. A Class 3V varies in size and degree. The ability to supply enough hair from the front and crown depends upon your densities, scalp laxity, hair characteristics, shaft thickness ,and color/contrast of hair to skin. Each person is different so the actual answer to your question is that each person is different and what is good for one person may not be food for another.
  5. It is not unusual for me to perform a session of 3500 grafts, but that depends upon what is safe and what is in the best interest of the patient according to his Master Plan. If you are 25, I would probably not consider the crown transplant. If you were 45 with good density and scalp laxity, then this may be a reasonable option depending on other factors that would be defined in an extensive consultation.

I Want an FUE Procedure After Already Having 3 Strip Procedures

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

I had 3 strip hair transplants in the late 1990s, they came out OK but being that I’m around a 5-6 on the Norwood scale and got only a little more than 3,000 grafts total, it’s just too dang thin. All-in-all I’ve never quite decided for sure whether going the HT route was worth it or not, sometimes I think yes, sometimes I should have just shaved my head.

Anyway I’ve researched FUE quite a bit over the past year or so and have signed up for a 1,000-1,200 FUE procedure over 2 days with a doctor who is known as being one of the best in the business at FUE. My goal is fairly modest I think — no crown work or lowering the hairline or anything, just adding grafts on top towards the front to make it look less thin (I won’t even say thicker, I’ll settle for less thin). I’m hoping this final result meets my expectations (which I truly believe are realistic and not at all grandiose).

Does my plan sound reasonable to you? Or would you say there’s a big chance I’ll end up in the same unenthusiastic place about the whole thing, minus $8-$10K and a few more weeks of my life?

You put me in a very precarious position with your question. While it is understandable that you are seeking a second opinion on your decision to have an FUE procedure, you are asking me if the clinical judgment made by your doctor was correct without a formal examination from me. If you would like a second opinion, please make an appointment to see me.

That being said, if your doctor cannot answer the same questions you are posing to me then there is a communication issue. As a Class 6 pattern with 3000 grafts already in, I would expect (assuming that a complete pattern balding was your ‘before’ status) that the addition of 1000 grafts now to the 3000 that is already there may make only a marginal impact on the thin appearance. There are tricks in the art of this process that can make 1000 grafts act like 2000 grafts. Of course, what I am saying does not reflect the characteristics of your hair or its thickness, or the surgeons plan or in particular what you look like now and where these grafts are going to be put.