Is Epinephrine the Cause of Shock Loss?

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

There has been some discussion on the Hair Transplant Network about the relationship between the amount of Epinephrine used during surgery and shock loss in the following months. I know that Epinephrine is used to control bleeding and constricts the blood vessels, but is it the main culprit in shock loss?

Shock loss is prevalent in younger men who are actively (rapidly) losing their hair. In simple terms, any shock to the weak/dying hairs will accelerate the hair loss. While we can hypothesize epinephrine as the culprit, it is probably a combination of the surgery itself, the drugs that are used, and where you are in the hair loss process that all contribute to shock loss.

Young men (under 28 years old) in rapid hair loss with unstable hair in the balding area are more likely to experience hair loss than older men (greater than 40 years old), regardless of the medications used. High doses of epinephrine, when used by less experienced surgeons, increase the risk of shock loss. Men on finasteride, on the other hand, are likely more protected against shock loss than men not taking this drug.

I suppose the one way to tell would be to inject epinephrine on one side of the scalp and saline in the other side of the scalp (without hair transplant surgery) to see if that causes shock hair loss. Any volunteers?

Tags: epinephrine, shock loss, hairloss, hair loss, hair transplant

Could Androgel Cause Transplanted Hair to Fall Out?

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

In one of your answers to a post you mention that if the man had been receiving testosterone injections, that the new hair could fall out. Did I understand you correctly? I was under the impression that the hair taken from the area on the back of the head that normally never falls out would not fall out if it was transplanted as long as the surgery was successful. Can you please straighten me out on this? I have been taking Androgel for 10 years and had a HT about six months ago. Is it possible that all my new hair will fall out because of the Androgel?

Also, I’ve noticed that on the back of my head,the area that first showed balding years ago isn’t being filled in by new hair but the front of my head has,although there isn’t much thickness in front. I was given 2400 grafts.Do you think the testosterone could be causing any of this thin hair in front as well as little or no growth in the back area? Thanks once again for sharing your knowledge about hair transplants.

If Androgel (an androgen that may increase your body’s DHT levels) causes hair loss, it will only affect the genetically susceptible hairs. The transplanted hairs taken from the donor area are not affected by androgen (DHT).

Tags: androgel, androgen, hairloss, hair loss, testosterone, dht

Does Any Surgeon Do the Entire Transplant Without Techs?

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

I’m looking for a hair transplant surgeon who does both harvesting and transplanting. I don’t want a doctor who harvests only and lets technicians do the transplanting, as happened in my wife’s case.

Surgical staffIn the United States, virtually all hair transplant surgery is done with a doctor and his staff of technicians. The doctor harvests the donor hair grafts and makes the recipient sites. The technicians process the donor grafts (under a microscope) and feeds it into the recipient sites that that doctor has premade. Without this teamwork the entire surgery would be too cumbersome for one doctor to accomplish. There is a misconception that the technicians are controlling where the hairs are implanted, but the direction, the angle, and the distribution of hair is predetermined by the doctor.

In short, the planning is more important than the execution and to succeed you need great teamwork. Thus, the consumers (patients) should be aware that when they choose a hair transplant doctor, they should also ask about the staff/technician and the overall reputation of the clinic (not only the doctor).

Here are some past articles that might be of interest to you, related to technicians in hair restoration surgery:

Tags: hair transplant, hairloss, hair loss, surgery, technician

I’m a Class 2 Right Now, But What If I Have Surgery and The Loss Progresses?

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

I am 31 years old, and have Stage 2 hair loss. It’s not major yet. I am missing maybe one inch on each side.

My question, if I get a hair transplant – and fix those two small spots, what happens if my hair recedes further? Won’t it look horrible to have two spots of hair up front and continual loss behind it? how is this situation remedied without further surgery?

Again, I’m stage 2 – not bad at all, maybe an inch pushed back so far. Thank you!

This is why a Master Plan is needed before you have your hair transplant surgery, so you can build a plan with your doctor about how to address a worst case scenario of further progression of your hair loss.

I will usually recommend that my male patients stay on finasteride to help prevent the loss from continuing (or at least slowing it down considerably), but ultimately, progression of the hair loss is a risk and probably a reality for balding men sooner or later.

Tags: hairloss, hair loss, hair transplant

Transplanting Pubic Hair to the Scalp

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

If pubic hair is transplanted on the scalp will it grow due to the fact the nourishment and exposure will become different. Does apocrine gland still remain active when transplanted on head? A doctor in Delhi does carry out such procedure FUE technique and is affordable. However I still want to have all the facts..If any one has done then it will be good?

If pubic hair were transplanted to the head, it would grow and be very curly. I actually performed a pubic hair transplant to a patient. The pubic hair was mixed in with scalp hair and placed into the crown in a person who had a very limited donor area. It worked well. I have also done beard hair to the scalp that has worked well, particularly when mixed with regular scalp donor hair. These are rare and special circumstances, though. Many doctors are transplanting body hair from the abdomen, chest, and back with mixed results.

But while these procedures are technically possible, surgery on your body should NOT be driven by costs. If there is good donor hair from the scalp that is available (as it most probably is), this should be the first source… not the pubic area. The hair that is transplanted will usually retain its original characteristics so pubic hair on the scalp will be very curly, underarm hair will bring with it an odor from the accompanying apocrine glands, and body hair will usually be characteristically fine and not grow out to be very long. One of your goals should be to have the results look as natural as possible, and body hair transplants (BHT) make that difficult.

Remember, any decision you make will be with you for the rest of your life, so be careful what you choose.

Tags: body hair transplant, bht, hair transplant, hairloss, hair loss, pubic hair

Is the Donor Hair Really Permanent?

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

My grandfather’s has what you call a Class 7 pattern and the hair around the back and sides is very thin. I asked him if his hair was always that thin and he replied that when he was my age, his rim hair was much thicker. He became bald in his later 20s. Is the donor hair really permanent?

The donor hair around the sides and the back of the head in some men is not permanent.

I have seen men like your grandfather in my office and their donor density is very low, but as they are usually coming for a hair transplant assessment, I, of course, turn them down. There is some miniaturization in the donor hair in these men and I suspect that the miniaturization process that impacted their original frontal hair extends to the donor region. These men are clearly not surgical candidates.

On very rare occasions (about once every few years) I see someone who lost hair bulk in the transplanted hair. These men have a drop in donor density as well, so I must assume that these men are losing this sacred donor hair. This introduces two more risk for patients who have transplants: (a) the loss of some of the transplants over time as the donor hair dies off, or (b) the hair becomes finer with age (a common finding). The few who I have seen that reported transplanted hair loss to me, fortunately did not lose all of their transplanted hair, but it is a risk. I have only been doing hair transplants for 20 years, a relatively short period of time in the life of my patients.

Amongst those men I have transplanted above the age of 70, they never showed miniaturization in the donor area and they behaved like the young men I transplanted. One of my most unusual patients who came to my office frequently during our Open House events, was a Class 7 patient who received 9900 grafts over 9 years and he maintained his donor density through the entire process without miniaturization. He was 74 years old.

Tags: hairloss, hair loss, donor hair, hair transplant

Hair Regrowth vs Thickening

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

hello, I’m a little confused about what hair regrowth is and what hair thickening is. is regrowth when hair grows where it isn’t or is it when a small hair thickens?

Regrowth is when hair grows where it once was. It’s all a matter of semantics. One can thicken the appearance of a head of hair by increasing the number of hairs in the head (regrowing new hair), moving the hair around (transplant), using camouflage (pigments), or increasing the thickness of existing hair (products). This is done by:

  1. Reducing the degree of miniaturization with drugs like Propecia (finasteride) so that each miniaturized hair will become less fine and more coarse (closer to your normal hair in the donor area).
  2. Increasing the thickness of the individual hair shafts with thickening agents that are applied to the hair which cause them to take on more water, or coat the hairs with some product that makes them appear thicker (this is done by applying a product to the hair that will usually wash off when shampooed).
  3. Increasing the thickness of an area can be done through hair transplantation. This is a relatively permanent solution until you lose more hair (it’s progressive).
  4. By playing with color, someone can bring their hair color closer to their scalp color with chemical dyes or the use of scalp micropigmentation (a medical tattoo). The use of agents such as Toppik (adds fibers to the hair and scalp) or DermMatch (a crayon type application to bring color to the scalp.

So you see, there are many ways to get a fuller look that may not be the results of a full head of hair, but if it fools the eye, then many people will be satisfied using these approaches.

Tags: hairloss, hair loss, hair thickening

My Transplanted Hair Keeps Falling Out

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


Doctor, I’m having the worst time of my life and I’m hoping you’d take the time to answer my question.

I’ve had 5 HTs over the past decade all in the frontal area totalling around 4000 grafts including one at NHI back in 2000. The problem is I keep losing more hair in the area and it keeps getting thinner. My last 2 HTs were done by a very reputable doctor here but when I went to see him last time to get his opinion he said I am apparently one of the rare cases where transplanted hairs end up dying over time. This was a complete shock to me. From what I see, there seems to be very gradual loss -in an area that I think is totally made of transplanted hairs- over time but then at one certain time I lose a whole bunch of hair in a period of 1-2months. I am told that there’s no point of getting more HTs because they’ll end up dying. I am devastated and don’t know what to do. Am I really out of luck ?? Is there anything left for me to do?? I’ve been using Fin and minox for a long time.

I’m going crazy looking for an answer. I’m thinking about FUEs to fill in the thin areas but don’t know if I should do it. I hope that you have the time to reply to this as this doesn’t seem to be a common problem here. I appreciate it.

As a former patient, I feel compelled to answer your question. There are rare cases where transplanted hair is lost over time. On the few times I have seen it, I really do not have an explanation.

It is possible that you could have a telogen effluvium or a more diffuse type of hair. Your donor hair should be having the same process going on so the presence of miniaturization in the donor area may point to a clue for a diffuse type of hair loss like diffuse unpatterned alopecia (DUPA)… but without examining you, I can not tell you much.

There may be other options, as there may be other causes (metabolic abnormalities, dietary deficiencies, the existence of hormonal problems, etc), and these are things that I would want to know and would ask that if you visited me in Los Angeles.

Tags: hairloss, hair loss, hair transplant, diffuse

Did My Surgeon Possibly Damage a Nerve During My Transplant?

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

Hello Dr:
I had a HT done about 8 months ago and 1 month after my surgery I started experiencing really really bad headaches. i thought it was something else, so I was tested for pretty much everything and nothing came up. My only one explanation is that the Dr who did my HT damaged a nerve inside of me.

My question to you is, I would like to know what nerves were damaged and if the problem can be fixed?

In general if a nerve was damaged after a normal hair transplant surgery, it would cause numbness and not pain. If in the rare instance a nerve damage causes pain, it can be very point specific (to a certain spot on the back of the scalp where your scar is). I have in the past addressed the certain area with a scar revision (removing that specific point) to address the pain.

I have not seen a standard hair transplant cause headaches months after surgery.

Tags: nerve damage, nerve, hair transplant, surgery

I Scratched My Fresh Transplant Area While I Slept!

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

hello doctors,

im 21 yo this year and had my hair transplant 3 days ago. when i was sleeping last night, i accidentally scratched the area where it was transplanted and soon it started to bleed, i went to check in the mirror, and noticed significant blood and a single hair was dislodged on my forehead. i just want to know if there were more then just one hair graft dislodged? as i have checked and seems that theres only 1 hair graft that is missing. will it affect other hair graft too?

I remember a patient who had 3 transplants and seemed to love to scratch his head while he was sleeping. He lost some grafts (as did you). I told him to wear a boxing glove, which seemed to stop the late night scratching as he fought with himself at night.

Tags: hair transplant, hairloss, hair loss

Does Not Shaving the Recipient Area Cause a Greater Shock Loss Risk?

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

Is there any truth in the statement on the Hasson and Wong website about not shaving the recipient site. They say that by not shaving you risk causing permanent shock loss to certain hairs?

If this is not true then is it still fair to say that you can do a more artistic job and get better looking end results that achieve greater density IF you shave the recipient area. Based on that what is your perfect scenario when performing HTs.

There is no doubt that shaving the recipient area makes the job for the surgeon much easier, but I rarely do it because my patients do not want to deal with the social disruptions in their life that would occur with shaving the head. It takes considerable experience working with the hair on the head and often this can slow down the work on the recipient site.

Concerning shock hair loss, shaving the recipient site can not (in my wildest imagination) reduce the risk of shock loss. The use of finasteride is the best preventive measure a man can take to prevent shock loss.

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

If FUE Doesn’t Satisfy My Hair Needs, Can I Then Have a Strip Surgery?

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

Im a 58 year male who is seriously considering transplant surgery to restore my frontal hairline area. Im interested in the FUE procedure. My question is if Im not satisfied with the results can I still undergo strip harvesting in the future

I realize your question is very limited and I don’t know anything about your hair loss, but based on what you are asking I think you are going about this completely wrong. First, you need a Master Plan for your hair loss.

Follicular unit extraction (FUE) is a great surgery, but it has limitations. One of the main reasons you should have an FUE procedure is because you want to cut your hair short in the back without seeing a linear scar. If you don’t mind the linear scar (which I assume to be the case if you’re considering the strip procedure), I’m not sure why you’d want to go with FUE to start with. There’s a list you might find to be an interesting read — The Pros and Cons for FUE / Strip Harvesting.

So while the short answer to your question is “yes”, I think you should seek a good hair transplant surgeon to discuss your overall goals and expectations.

Tags: fue, hair loss, hairloss, hair transplant

Why Was My Daughter Born with a Large Bald Spot?

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

My now 2 year old daughter was presented at birth with a large bald spot on her scalp (from the frontal part to the vertex part) its about 2-3 in long and 1.5 in wide. plz help I dont know what treatment to decide since I dont even know exactly what kind of congenital defect/disorder of the scalp/hair it is

There are multiple possible causes for this, but there is little information supplied. Most bald spots are acquired, unlike your daughter’s situation. Bald spots in children can be treated with a variety of modalities, including hair transplantation and balloon expanders. These expanders work best when the bald spots are large (like what you described with your daughter).

The best age to treat the child needs to be discussed with the surgeons that have the experience. Generally, that will be a special type of plastic surgeon who can do expanders if the bald area is very large. I don’t have any personally recommendations on the east coast (where you indicated you’re from), but if you’d like I can ask some of my colleagues in that area if they can recommend someone.

Tags: bald spot, child, hairloss, hair loss

Megasession vs Multiple Smaller Sessions?

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

Dr Rassman

Let’s assume someone’s donor area may yield, say, 5000 grafts using the strip technique. Is it better to have 1 mega session or 3 smaller ones? Is the yield better when cutting the skin only once (or twice) with megasessions compared to 3 or 4 times with in smaller operations?

I have always believed that less surgery is better than more surgery in people with more extensive balding patterns. If you can get 6,000 grafts in two sessions, why go for 6 sessions of 1000 grafts each? If the density and laxity allow for it, most of my patients prefer to have one larger session and hopefully just be done with the surgical process quicker. This means in a practical sense that 6-7 months after the first session of 3000 grafts, you can see results which will impact your ability to style your hair.

Alternatively, I can make an argument against the large session. Multiple FUE procedures or smaller strip sessions have a relatively short recovery time, but for FUE, the shaving of the donor area can be a problem unless you elect to keep your hair short, so regrowth of the donor area usually occurs in about 10 days. Smaller strip cases will have their donor scar covered by the existing donor hair.

Incremental surgeries have really no downside other than the length of time from the point you start to the time you finish. It is possible that more surgeries could give you wider scars, but this has never been studied with any direct comparison. Few patients approach me with a desire for multiple smaller surgeries and prolonged benefits, as they want the benefits quickly and would like to say goodbye to me and the hair transplant process altogether. I am, however, open to performing multiple smaller surgeries.

Tags: megasession, hair transplant, surgery, hairloss, hair loss, hair restoration

Does My Head Need to Be Shaved for FUE?

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

Dr. Rassman,

Thanks you for the informative site; I have been following for years.

I am 27 years old and thinning on the crown and top of my scalp. I have been on finasteride for 4 years and, while I have had success slowing the process, it definitely did not stop it. I have been in to see Dr Hasson in Vancouver several times, since I live in Vancouver. I did not make the decision to do a HT, and he recommended that I didnt, but that I increase my finasteride does to 2.5mg/day. But like I said, it has not reversed any loss. And while I hold my breath for a permanent cure, I realize that may not be any time soon as well – 5 years ago it was allegedly supposed to be available in 5 years!

Anyways, the reason for my email was to ask a few questions regarding FUE. If I am going to get a HT, I want to ensure that I get the best possible treatment/option for myself.

1. Do you have to shave the donor/recipient areas for surgery? It is important to me to keep any surgery I have quiet…to the best of my ability.

2. What cost would I be looking at? From past consultations it was estimated I would need 2500-3000 grafts

3. What timeline would I be looking at? Like I said, I live in Vancouver, so there would be travel involved.

4. What impact would the transplant have on my native hairs in the area?

I realize it is next to impossible for you to answer most of these questions without seeing me, but Im just wondering in general, from your past experience. Thank you again for all your hard work and dedication. It is much appreciated.

Considering that you had an opinion from a good doctor who recommended not having surgery, you should take such advice into your thinking. I don’t quite follow how you can be told you need 3000 grafts but that you shouldn’t have surgery. So unless I read your email wrong, then pursuing a hair transplant is probably not a good idea at this time. I will nevertheless answer your questions:

1. You need only to shave the donor area. For small procedures, shaving can be striped as shown here.

2. Costs of FUE at NHI is $8/graft.

3. You need to set up an appointment to be examined. Send us good photographs with frontal views and top down views. Be sure to wrinkle your brow (lift your eyebrows) on the frontal view. The waiting list extends some weeks. There is travel reimbursement available.

4. If you are using finasteride, a hair transplant most likely will not have an impact on your existing hair, unless there is extensive miniaturization present. This is clearly a real risk.

Tags: hairloss, hair loss, fue, hair transplant