Lateral Slits and Transplanted Hair Direction

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

Suppose a patient has had two non-lateral slit transplants by doctor A (who is reputable), and goes for a third operation with doctor A (who now advertises use of lateral slit)–should doctor A perform a lateral slit transplant on the same patient, or continue with the same method of the previous two surgeries? Also, does the lateral slit method deserve the positive “hype” it receives on hair transplant sites? Or, is the difference slight and subtle and even overrated? Finally, when a transplant has been completed and the required one year waiting period ends, if hairs appear to grow straight up from the scalp, would you deem this to be a poor transplant? In my case, it appears that the hairs come straight out of the scalp, but lean or lay down–perhaps because of the weight of the hairs and also because of how I comb the hairs.

Switching between lateral and vertical slits are not a problem, but the learning curve for staff is a problem and those with experience in vertical slits will not just simply become experts in lateral slits without some experience.

I like the idea of lateral slits because it forces a bend of the hair as it exits the scalp forward and downward. In addition, the concept of fencing (where hair within a follicular unit appear like a fence/wall) should enhance the value of the grafts. Now with that said and the great theory, the realities are that no one has really demonstrated the value of lateral vs vertical slits, side by side. I have massive experience transplanting with vertical slits beyond 4 years ago, however I do lateral slits because it makes sense and it is in vogue, not because I am convinced that the results are better than those of the vertical slits.

If transplanted hairs grow straight up or to the sides, it usually reflects the way the surgeon put them in. I have seen people who had radial placement of hair with straight, strong hair and the hairlines look like bicycle spokes — not a normal hairline. Last week, I saw a patient where the hair was put in pointing to the right. The patient wanted to comb his hair back but because of a strong hair character, it always pointed to the right creating an unnatural appearance. This is a problem of strong haired people, not soft haired people. Hair characteristics tend to dominate in some people, impacting the way hair can be groomed.

Natural Looking Hairlines

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

Dr. William Rassman,
is it possible to restore the original hairline through hair transplant since my hairline had receded so much but not completely bald & its really affecting my self confidence. is it too early for me to undergo this procedure or should i go ahead? whats the best hair transplant method that gives a more natural looking hairline? thanks

You did not state your age and without a photo it is impossible to go into detail about whether a procedure is right for you or not. Hair transplantation today can be and should be undetectable and able to produce a completely natural hairline. The appropriateness of the surgery depends on the individual assessment of each person. There are hundreds of patient hairlines on our website, and you are invited to come to one of our open house events in Los Angeles and San Jose to meet patients directly, so you can see for yourself what can be achieved.

For a great example of what is possible in hair transplantation, please see the Steve Hartman feature on the NHI site. There are larger photos available on the previous blog entry, Where Are the Celebrity Transplant Photos?.

I’m 21 and Balding — What To Do?

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

Dear Sir:
I’m 21 years old , i’m suffering from hair loss , its not that much till now but i have a feeling that if i just ignored it , it will be very bad later , & i realy care sooooooooooo much about my Look. So please tell me what can i do , Do you prefer surgery for me , or Drugs ( if yes mention one ) i used to use REGAIN EXTRA STRAINGTH . but i stopped. because i wanted a faster solution . please reply as soon as possible . thanks so much

It is very difficult to evaluate hair loss without at least pictures, and an in personal consultation is better. I don’t recommend hair transplantation as the first option to solve your balding problem. First, you would have to be evaluated to map out your hair loss as it progresses by determining the degree of miniaturization that is in every part of your scalp. Then, providing you are a male, I would likely have you on Propecia for a year or so, then reassess the miniaturization and your observable pattern of hair loss (if any) or reversal of hair loss. From there, transplantation might be right for you, but only an in-person evaluation will be able to determine this. If you’d like to email photos to me, please use the email address on the contact page.

No Improvement After Two Hair Transplant Procedures

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

I am a 42 going into 43 years old. I have been losing my hair slowly but steady for a good 12 years now. Only about 5 years ago clear spots started to become more and more evident. I had 2 transplants. Both of them about 1300 grafs. The count of insertions was about 270 so I figure it must be in groups of 3 and 4 grafts. In the areas where I had the transplants done I dont see any improvement.IF any I see it getting more and more bald. I don’t know if is that I am just not holding the transplanted graffs. Is there such a possibility. My operating physician said that that was imposssible. That they will never come out. The first procedure was in October 2001 and 2 and 3 weeks after I had a lot of dry roots and hairs come off. I asked the Doctor that operated and he said that was normal. I was doubtful specially because of the roots being dry and out. Then last year I had another procedure. And I dont see any improvement from that either.I dont smoke , dont drink. I exercise, and I tried to eat healthy. I am contemplating a 3rd procedure but I am concern that I may not be holding it.

It sounds to me like you are having confidence problems with your present doctor and certainly have not adequately communicated on the problem as you’ve presented it to me. Before you go at it a third time, get a second opinion. This is not something I can do over the internet, and since you indicated that you are on the east coast, I can recommend Dr. Robert Bernstein in New York and New Jersey at 866-576-2400 to get that second opinion from. If you are willing to make a trip out to California, I have offices in Los Angeles and San Jose and can be reached at 800-NEW-HAIR if you’d like to set up a free consultation.

Some of the things you are saying do not leave me comfortable. Clearly, that is your view as well. I would advise you to not rush into a third procedure if the other two did not work out. I find that we always get results and rarely have I heard of one of my patients have the issues that you’ve mentioned.

Bio Matrix, Extreme Hair Therapy, and High Pressure Sales

/by William Rassman, M.D./10 /, ,

I have recently turned 21 years old, and have been out of school last semester saving for some kind of solution to get my hair back. I have visited Bosley and Hair Club for Men (HCFM). Bosley was very cordial and did not pressure me or get me to sign a contract during my consultation or anything. They answered my questions at the time and left me with info and the consultant’s card. HCFM on the other hand views me more as a walking dollar sign rather than someone with a concern. I visited them 3 weeks ago and I still get calls from the consultant or salesman, I should say 2 to 3 times a day. I walked in, watched a tape, and then he told me I was too young for transplant surgery and he recommended the all new “Bio Matrix Transplant”. Within minutes he hustled me into signing a 3500 dollar contract. I called the next day and cancelled after reading more about it. Its basically a wig, which disgusts me. Anyways, then I met with him again to talk to him about EXT Extreme Hair Therapy. He said it was the same price as the Bio Matrix thing, which I think is a lie because I can’t imagine vitamins, shampoos, and monoxidil can cost over 3000 dollars for a years supply!!! It is my firm belief that he works on commission, and that is why my voicemail has 10 messages on it right now.

I tell you all that to say this: I need a good doctor to speak with to give me honest answers and someone who can give me the best route to go with this thing. I go to you because I read from this site and see how much knowledge you have and know you are trying to help and educate people, and I appreciate that.

My hair loss started probably at age 17 or so. I have no “bald” spots but my hair is thin on top now and would like to get it back to the way it was. I believe doing something now will help since it is still early. People can see through to my scalp. I used to spike the front of my hair and now I comb it forward and cut it short to try to hide the thining. Is hair transplantation out of the question, is hairgenesis an option, and perhaps is HCFM’s EXT an option? Please give any help you can as I am looking to act now with whatever solution necessary. Also if you can direct me to a good ethical doctor in my area that would be awesome!!! I will supply before and after pics in another email another day when I have access to a computer. I am typing this on my sidekick2. I am also curious about your thoughts on procerin. Looks like a good product. Thank you for your time and I appreciate what you are doing on this site!!

I have heard horror stories about hair salesmen in the past and yours is, unfortunately, very typical. Commission sales are the driving force for the free enterprise system we live with. Car salesmen also get to me in a similar way, so I hate buying a car just because I do not want to deal with the saleman. I absoletely believe that salesmen should not be turning men into victims and certainly salesmen have no place, absolutely no place, in a medical practice.

Take a look at my post yesterday titled The Truth About Cheap Hair Transplants, for it goes into the entire process of shopping for hair restoration. Also, see the post on Hair Club for Men from earlier today. As you are aware, you need a good doctor, but to be more specific, you need one who can map out your scalp and give you a good diagnosis. Young men often can reverse genetic hair loss by using Propecia. Go to the ISHRS site to find a good doctor in your area.

Hair loss from age 17 to 21

We generally do not like to transplant young men, but according to your pictures (thank you for granting me permission to post them), the pattern you show is classic male patterned genetic hair loss. Your scalp needs to be mapped out for miniaturization. If you do have genetic hair loss, this is best treated with Propecia first. Allow the drug 8 months to have a good chance to reverse or at least stop the hair loss. With a good doctor managing you and understanding where you are coming from, a hair transplant is possible if you do not respond to Propecia, but you must have a good assessment of your donor supply and your final pattern should be estimated prior to considering a hair transplant. Also, the issue of your maturity, your financial ability to follow the process, and a worst case look at your Master Plan must be commanded by you in advance of such decisions. I would love to get to meet with you, so if you plan on a trip to California on a discounted airline, you might be surprised at what you will learn and find it of great value for the trip. The consultation is free.

Oh, and in regards to Procerin, please see my previous comments here.

Good luck.

Wigs and Hair Club for Men

/by William Rassman, M.D./32 /, ,

Just wanting some info, I am thinking of doing hair club and getting a piece. Do you know the cost and is it cheaper than hair transplants? I would rather do something that will grow mine back, but I am skeptical and weary of trying something like this, especially if the cost is what is rumored.

Costs for wigs (hair systems) are much higher than most people think. I met Sy Sperling and the executives of Hair Club for Men in the late 90s and I was informed that the average price that they got from people with ‘systems’ over a 5 year period was around $12,500. That price included the hair system and constant repairs, replacements, and adjustments with frequent visits to their offices. When washing one wig and letting it dry, you need a second to wear. These hair systems are expensive and they do wear out. These cost figures I presented here are not based upon anything other than the cost quotes given to me in about 1998. I suspect that with inflation, the costs will be higher today, but that is only speculation on my part. The problem with hair systems is that they tend to accelerate and/or cause hair loss (traction alopecia) from the glues and tapes that are used.

Most hair transplants can be obtained for less than that figure (for the early balding man) and the transplanted hair will last a lifetime and grow as long as you want it to be. If you also take Propecia, the progressive hair loss may stop. This approach is far less expensive and totally natural. Men with hair systems are always afraid of other people touching their head. If the hair is attached to the existing hair, then cleanliness becomes a problem and odor becomes very distinct when you get close to men who use them. When romance opportunities appear, you might have a no-touch / no smell zone around your head if you are wearing a wig. Most people who have these systems, hate this no-touch zone more than any other single factor in hair systems but few men realize the odor that surrounds the systems that are attached, particularly if they do not come off at night so that you can wash the scalp and remove the dead skin than normally sheds every day.

Is Bosley the Best Hair Transplant Place?

/by William Rassman, M.D./5 /, ,

Hey doc, I have just found your website and have enjoyed it tremendously. I am 23 and have noticed my hair thinning since I entered college at 18. I tried Propecia but grew impatient. I wish I would have stuck with it but I chose to stop. I have lost enough hair now that I am fairly thin on top and towards the front. I was curious if you would recommend a transplant for someone so young. I am on the bubble about this, but I think that for my mental well being and career that really it is my only option. I am constantly unhappy with my looks and miss dating a lot. Truly the only real thing holding my back is the price, I would do it tomorrow but I just truly do not have enough saved. I think I would need extensive graphs to restore what I have lost. I have only looked into Bosley because it is the most popular and respected name. Would you recommend them or should I look elsewhere? I am very afraid of a poor surgery where I come out looking like a fool for the rest of my life because of some doctors weak job on my head. Thank you so much for your time.

You must be careful that you are not body dysmorphic. Dating and hair loss relate with regard to self-confidence certainly, but losing your hair should not be an excuse to stop living. Your points about career, mental well being, dating, happiness, (I can go on and on) are good reasons many people try to either hold on to their hair, or if they can not or have lost it, they can get it back with good medications or hair restoration surgery. Now with that said, you need to first get a diagnosis established, your scalp mapped out for miniaturization and the pattern of hair loss that you may develop. Many good medical hair restoration practices, such as Bosley or NHI, can supply a good working diagnosis for you. It is important that you find a hair restoration clinic that you feel comfortable with, and that you feel will give you the results you are looking for. I would not go somewhere based solely on marketing. Do your research.

There is much in this blog about how to shop for hair transplants (my lengthy post from earlier today, The Truth About Cheap Hair Transplants, is a good start), because budget minded people need to understand the entire shopping experience. With a diagnosis in hand, you may find out that you can reverse it (if you have it) with something as simple as Propecia (one pill a day), which works well for many young men. Be careful of the sale pressures to make you buy a hair transplant before you do your comparative shopping and before you know what is wrong with your hair. Knowledge is power, and you as a buyer are very powerful in determining your fate and the status of your hair for much of your life.

Multi-Bladed Knives and Dilators

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

I just visited a doctor who took me into a surgery and showed me nails in the head of a patient. He said that these kept the wounds open and makes the graft placement easier and produced less damage to the skin and hair. He also told me that he used a multibladed knife to harvest the grafts. I thought I read somewhere that these instruments cause damage. Can you explain what I am being told?

These nails that you are describing are something that was invented by Dr. Manny Marritt in the mid-eighties to make the placement of smaller grafts easier. Within a year, he abandoned the use of these dilators as his staff built the skills to not need them anymore. He concluded that these dilators did not have great value to anyone other than the novice. I did try them early on in my practice, but I quickly abandoned their use within a month. For more information on dilators, including a photo of what they look like, please see this dilators page.

After I designed the 2 bladed knife with the offset of 30 degrees, I built a multi-bladed knife with variable settings to it. I eventually found that when I used the final design on the first 9 patients, the results were decent (I estimated the loss at about 15%). Then on the 10th patient, I had a follicular holocaust with a loss factor of 70%. Fortunately, on these first 10 patients, I only used it on a limited area, but the high transection rate on this 10th patient said to me that inconsistency was going to be the problem. If I could do it 9 times right and then 1 time wrong, the technique was flawed.

This clinical research was done by me in 1992-1993 when cutting was a manpower problem that I eventually solved with a larger and better trained staff. The multi-bladed knife was the wrong answer to this problem and that is my final opinion on the subject. With multi-bladed knives, the labor that the doctor saves does not offset the hair that is killed off. I believe anyone who uses such instruments today are subject to the same type of variables.

Do Cage and Travolta Have Hair Transplants?

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

I heard nick cage and travolta have hair transplants ,does anyone know what doctor they used? I want to find the best hair transplanter? I heard brazil?

I can not tell a good hair transplant patient from a normal person 95% of the time, even on a close up examination. The best hair transplant surgeons are those that use Follicular Units and adhere to the standards that have been set for Follicular Unit Transplantation. We have published those standards and they are available to read on the New Hair Institute website on the Medical Publications page.

As to your celebrity hair transplant questions, I can only speculate, as I have no first-hand experience with either actors. I would assume that Nicolas Cage was transplanted, because it appears that what he has on his head are the older type of smaller grafts, not the follicular units we use. Some times, people look transplanted even when they are not. If he was transplanted, then I did not do them (if I did, I could not comment on it because it would violate doctor/patient confidentiality). With regard to John Travolta, I have not done transplants on him either, so my best guess is that he found another great hair transplant surgeon, or never had them transplanted in the first place. I have only seen these two actors in films and some interviews that were public, so I might change my mind if I examined either of them in person and they then asked me to make that information public, a doubtful scenario at best.

The Truth About Cheap Hair Transplants

/by William Rassman, M.D./4 /, ,

Note: My answer to this question is very extensive and detailed, almost like a consumer guide for shoppers needing hair transplants. Please take your time in reading it and try to read between the lines, for there is much I did not say. The answer took me over a week to write, because the question was so pointed and so appropriate to what I am asked almost daily.

I am very confused about prices that are charged in your field and the associated estimates in what you guys want to do for me. I believe in capitalism so the wide range of prices does not bother me as much as the wide range of recommendations I get when I see a hair transplant doctor. This clearly impacts costs. My Norwood Classification is a Class 6. I have had recommendations as low as 1000 grafts in one or two sessions. That doctor told me that more than 1000 grafts in a single session could not be supported by the blood supply of the balding area. I have also been told by you earlier this year, that I could have as high as 4000 grafts in one or two separate sessions. No matter what the prices are, the difference between one session of 1000 grafts and two sessions of 4000 grafts is a huge cost differential. On one hand, I want to believe that 1000 grafts will work for me as it is easy to afford (the doctor charges $5/graft, or $5,000) but on the other hand, your estimate of between 4000-8000 grafts is so out of line with the lower estimate, I am a bit put off about having hair transplants at all. I have also seen other doctors and the wide range of estimates continue to amaze me. I want to be a good buyer so I want to compare apples and apples. Who should I believe?

Hair transplant costs are one thing and ethical practices by the physician are another. You must know what you are buying to value a hair transplant’s real cost to you. Add to that, the expectations you have and the probability of meeting them. Bottom line, a meeting of the mind between you and your doctor addressing your goals is what matters and only in the final results will you really know what you purchased.

In your particular case, the more of a perfectionist you are, the more hair you will want. If I projected 4000 to 8,000 grafts, I would have anticipated your desire for fullness is far greater than the average person. Then there is still another factor, your donor supply. If your donor density is high, then you can get more hair moved and more hair placed in the balding pattern you describe, but if it is not very high, then you will be hair limited and 4000 grafts might be out of the question for you. Some doctors will tell you exactly what they think you want to hear (rather than what is really best for you) – to make sure that you will proceed with the surgery.

Read more

Removing a Hair Transplant

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

hi, i’ve had two hair transplant procedures in the past. over the last couple of years i have just been shaving my head. i feel very uncomfortable going anywhere without a hat because of my scars. i would just like to be able to shave my head without the scars being so obvious. they are mostly right at my front hairline. can i go to a physician to have the transplants removed? and if they are removed will my scalp where the transpants are taken out heal so those little puncture holes are not as noticible? or could a procedure such a dermabrasion or laser help to smooth out the area? thank you

Without seeing you it would be difficult to make an assessment. Please send photos to the email address on the Contact page.

Generally, it is difficult to put you back in time to the days before you had your hair transplanted. With that said, we can reverse it in many ways, and sometimes it might be brought back to the “before” status. I like to tell my patients that I have good news and bad news about hair transplants: they are permanent, so get it done right the first time. If you are amongst the unfortunate that did not time your procedure correctly with current technology, then the good news is that there is a great deal of experience now in removing or hiding the ugly plugs of the older types of hair transplants.

Transplanting Hair Into Burned Tissue

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

Dear Dr.
I am a recovered burn patient from childhood with forehead scars that extend to my left temple area. I was able to grow my hair to cover it as a young man until my late 30’s. My hair started to thin and I now wear a hair system to cover and blend the non hair scarred area. Are hair transplants now being able to be transplanted into scarred areas that are cosemetically acceptable. I have been told that bloodflow below my scarred areas is still good. Thank you for your response.

If your skin is what we call a full thickness, hair may be able to grow from it. If it is covered with a split thickness of skin and scar, it may not support hair growth. There are things that can be done today to bring your hair-baring skin here and may include a variety of surgeries like flaps, and balloon-stretching the normal scalp and rearranging it to cover the bare area. Some of the results are remarkable. I would be happy to give you an opinion and as you’ve indicated that you are in Southern California, I would suggest that you make an appointment with me and maybe together, we can address your problem. Please call my office at 800-NEW-HAIR to set up a free consultation.

Balding Fast, Even on Propecia

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

I am 22 years old and have been taking Propecia for 2 years. Although the hair loss slowed a bit, I now see the rim of hair that my dad has around the back and sides of his head. What can I do? Are hair transplants the only option left for me?

You situation reflects that there will be progression of hair loss over a period of months/years, probably taking you to your father’s pattern sooner or later (sounds like sooner, rather than later). The variable response to finasteride speaks to the complexity of the factors at play. Included in these factors are variables like the sensitivity of your androgen receptors, as expressed by androgen receptor gene polymorphism. Simply stated, we can not come up with one treatment for all people, as each of us are different and have different sensitivities to the hormone environment in our body. We make androgens in our adrenal glands as well, and these androgens impact the hair end organ as well as DHT.

It is possible that you might respond better to Avodart, but even that medication may not do what you want. Avodart is not approved by the FDA for hair loss, so if you find a doctor willing to prescribe it, you should weigh the disadvantages of taking it (see previous blog entries) and the safety factors that may relate to having children when you are on the pill.

If you can already see the Class 7 pattern in the mirror that your father is showing, much of what you have lost may not be reversible. You should be checked out for other diseases, but in the probable event that your hair loss in only genetic, then hair transplantation is an option that you might consider. If your densities are good, if you have blonde hair or become blonde, if your hair thickness is reasonable, if you are willing to style your hair to take advantage of hair redistribution, you might have an amazingly good response to hair transplantation. As a general rule of thumb, most good hair transplant doctors do not take on young men prior to 25 years old, but with good support from your family, adequate financial planning, and a maturity that can allow you (best with the help of a parent) to make an informed decision, then you should explore the hair transplant option with an ethical and experienced hair transplant surgeon if you do not try the Avodart option or if the Avodart option fails to solve your problem.

FUE After Strip Surgery

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

I had a few strip surgeries, decent results but still a bit thin for my liking. I have realistic expectations and don’t think I need that many more grafts to achieve satisfaction (about 500 3-hair grafts perhaps?), but I’m done with strip (my doc said I shouldn’t have any more and I wouldn’t want to anyway). My donor hair on sides and back is decent, not real thin or see-through. Given my thumbnail profile does it sound like FUE can get me to the promised land of being satisfied? Have you seen cases of other guys who could only get down to the 10 yard line with strip and FUE got them into the end zone? I know you’d have to examine me for a full and accurate assessment, but I would appreciate your best answer based on the info I have provided.

When the scalp is too tight, the only option to extract hair is by using the FUE technique. I have done some patients with FUE as the last option with good results, but it is very difficult to evaluate you without at least some photos (personal consultation is always best). Since you’ve indicated that you are in New York, I highly recommend that you contact my colleague Dr. Robert Bernstein in Manhattan at 1-866-576-2400.

Sudden Hair Loss Years After Transplant

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

I have had 6 procedures. four smaller (elsewhere) and my last two (more substantial) with NHI. You performed my last procedure about 6 years ago. I started the restoration process early, so I never went through a noticeable hairloss phase. I have been on proscar for about 5 years and it halted my hairloss. Obviously, I still have a significant amount of hair. I normally kept my hair cut short, but recently I let it grow a bit longer and got a trendy razor cut hairstyle. I towel dry my hair and put a manipulator cream (bed head brand) to keep the style. I have never looked so good! Then one week before my next haircut I started to notice hairloss. From Oct. 13-Nov 12 I have lost all the hair behind and between my frontal-most grafts(about a half inch deep, from the front hairline and extending all the way across the front and into the corners. Is this normal? I’m beside myself. I have done everything through the years to combat my hairloss with unbelievable results and now this. It’s as if somebody just flipped a switch and Pow! Can proscar just stop working? I would appreciate any information(based on my brief description). I diligently keep track of my hair–the hairloss happened that quick. Also, I am now 41(a very young looking 41!!) I am on 3 medications. One is allegra D, the other is an acid reflux medication (both prescribed for allergies/cough) and finally, a cortiosteroid nose spray (nasonex). Can any of these be compromising the effects of the proscar? Thanks again.

I am also alarmed. I will try to call you as I know you are not local to California. The corticosteroid nasal spray could cause this, if you are using it regularly and heavily. Loss of transplanted grafts after they have grown is very, very unusual. It could be caused by other medical conditions which you will have to get checked out. The Proscar should not be the problem.

As I think back about hair loss in transplanted grafts, they are rare. I have seen them in some men who have developed a type of senile alopecia where the donor area is thinning. If this was happening to you, your donor area should show signs of miniaturization and that would point to this diagnosis.

We need to talk and get you to a good doctor locally who can map out our scalp for miniaturization and attempt to clarify the cause for the hair loss.