Ingrown Hairs / Pimples Months After Hair Transplant

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

3 months after my transplants i’m still getting ingrown hairs (pimples on my scalp). also i see no hair growth as of yet. do i have anything to worry about yet? also i was told the ingrown hairs is a good sign because it suggest there is growth beginning under the scalp. is that true?

Ingrown hairs are caused by three factors:

  1. Leftover remnants of the hair transplant inside the recipient site, which then go on to produce reactive pustules
  2. Hair grafts that are piggybacked one on the other as a result of a technical problem during surgery
  3. Folliculitis that evolves into abscess formation

Usually, the third one comes about with less than skilled technicians or technicians with poor eyesight. The other two are just the risks of the process. We see an occasional eruption and on some patients more than a few eruptions. The may come from a progressive folliculitis (infection of a hair follicle) or from one of the other causes listed above.

On very rare occasions, the follicular remnants will act like a foreign body and stimulate an autoimmune process (folliculitis decalvans). Fortunately, we have seen less than a half dozen such reactions in the 20 years history of this practice, but when they occur they are very difficult to treat both in time and visible problems at the wound sites.

Tags: hair transplant, pimple, acne, ingrown hair, hair restoration, surgery

How Do I Know if My Donor Area is Depleted?

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

How can someone figure if their donor region has been depleted? Is it evident by the appearance and volume of the donor region; would someone who has a depleted donor region have somewhat of a see through look in that area? I have had two FUHT both around the same size, 1350 grafts each, totaling 2700 grafts. Both of the strips were about six inches long and 5/8 of an inch wide and were remove from the exact same region of my scalp, second strip removed from the previous scar. My doctor says he could easily get another strip totaling 1300 grafts if not more from on top of my now existing scar. I’m a little skeptical of this. Although my donor area still appears just as thick as it ever was, that seems like a lot of grafts from just that small region. I would have totaled 4000 grafts and barely even touched either of the sides of my donor region, having just used the back region. Is this plausible? Side note my donor density is slightly above average

Usually 2700 grafts will not deplete the donor area. You need to have expertise in examining a donor area to make that assessment. If you do not trust your doctor’s opinion, get a second opinion. The depleted donor area usually has a see-through appearance, especially when the hair is lifted up.

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

Is There a Part of the Scalp More Likely to Have Shock Loss?

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

hello.
My question is, if shock loss is one of the side effects with a HT would the doctor insert more graphs in a particular area knowing that shock loss would occur? This way a patient doesn’t feel as if he or she didn’t get a proper procedure done and it looks as if more hair is there then the patient originally began with.

As well, are the hair line and frontal areas more susceptible to shock loss versus the back, top part (Crown) and sides of the head?

Shock!The areas most likely to have shock loss are the areas where miniaturization is present. There isn’t one part of the scalp that is more susceptible than another. The more miniaturized the hair is, the greater the risk over time.

Shock loss doesn’t occur for all patients, and taking finasteride prior to surgery usually protects the body from hair transplant induced shock.

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

Doesn’t the Scalp Still Shine with SMP?

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

Hey Dr Rassman. i hope your day is treating you well. As i am a frequent reader of this ever informative blog of yours a few questions have sparked my interest over the last week. It is in regard to the new micro pigmentation service NHI is offering. Now in the past i have noticed you were quite the skeptic about this type of procedure. I recall reading a few comments made by yourself which made me think they were: wouldn’t the scalp still shine? The lack of a ”sandpaper feel due to there being no actual stubble on the scalp and hair is 3 dimensional a tattoo is not.

However I was doing some thinking and this came to mind. If a patient were to come and request to have as many grafts that their doner supply would allow then have the tattooing procedure done in between those grafts and also had the scar camouflaged in the back of the scalp wouldn’t it be nearly impossible to tell the persons head of hair from a non balding person ? It would eliminate all of those issues i previously mentioned. Like for those individuals with high donor densities if someone had 10,000 grafts placed on their scalp then had the micro pigmentation procedure done i would think they would be able to get close to their juvenile hairline back and they would also be able to grow their hair out to probably a number 1 clipper with out it looking to odd. What are your thoughts on this ?

as I presently support the shaved head look but my hairloss is progressing i like the look i would just like more coverage. I have been on finasteride for 3 years when i first started it i was 20 and an early norwood three now my hair is really thin through out the top half of my scalp. I totally anticipate being completely bald by the time im 25 whether im on the medication or not.

HeadlubeYour scalp can shine with the oil that your scalp produces, so scalp micropigmentation (SMP) patients often use matting products available at cosmetic stores. There’s various brands of shine control lotions for the scalp, including HeadLube.

SMP has a use with some negatives and some positives. There is a natural symbiosis between hair transplants and SMP in some individuals. SMP is far less expensive than hair transplants, but you can not have it both ways (SMP in part with a limited hair transplant) unless the Master Plan takes into account what is happening to you now and later. There is a balance between SMP and hair transplants, but I can not give you an opinion over the internet.

It sounds like you need a Master Plan (I know I talk about that a lot), because you are changing with regard to your hair loss. Whatever you do, it should fit into the life plan; if you do go really bald, you’ll want to have a plan for what you’ll look like in the future if you make decisions about today’s problem. Come see me.

Tags: scalp, shine, smp, pigmentation, hair transplant

Could SMP Damage Previously Transplanted Hair?

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

Dear Dr. Rassman,

I am interested in your new SMP process. I have had approximately 3000 grafts in the past and am running low on donor area.

My question is, will the SMP damage the hair that I have already had transplanted? The purpose of SMP in my case is to make the hair look thicker when it grows out.

The SMP (scalp micropigmentation) process works really well for this problem (low on donor hair), provided that you have enough hair to take advantage of the reduced contrast between scalp and skin color. SMP will not damage the previous hair transplants or any naturally growing hair that is present.

Tags: scalp micro-pigmentation, micropigment, hair transplant

Histamine Positive Skin and Hair Transplantation

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

Hi,
I would first like to thank you for this very informative site. My question has to do with post operational side effects. Specifically, I had FUE/FUT 1.5 months ago. Unfortunately I have something my doctor called histamine positive skin. As a result there is redness in the recipient area. My first question is related to that.

How long would it take for such redness to fade away and what can I do to reduce that amount of time? Additionally, in the donor area, there is a significant amount of redness and the hair growth appears limited. Is this to be expected? And what is the time frame for full recovery of the donor area? My doctor is quick to say it will all be fine in a few months but I wanted a second opinion as well as anything I should keep an eye on to better facilitate the recovery of that area.

This was my first surgery and I only had 1000 grafts transplanted.

If your doctor was helpful enough to explain a histamine reaction to you, how is it possible that you were not told how long it would last? I often do a scratch test to the scalp or forehead to preselect those patients who are histamine positive. In general, every patient is different and the redness can last several weeks to months. 1 to 2 months would seem on the long side.

Unfortunately this is not a place for second opinions as I do not know what you are really experiencing. All hair transplants are not the same, especially FUE, as there are many variables such as size of punch, techniques of extraction, the drugs you take, the allergies you have, etc, etc.

Tags: histamine positive, redness, hairloss, hair loss, hair transplant, surgery

I Am a Bad Scar Former — Would FUE Be an Option?

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

I have hypertrophic scars from numerous cutaneous surgeries, and even under modest tension my scars tend to spread quit a bit. None of them have an adequate cosmetic result in my mind for a hair bearing region. As a result, harvesting grafts with a strip is something I am not considering. Given my propensity for making ugly scars, am I likely to have abnormally visible scarring from follicular unit extraction at the harvest or transplant site, or are these so small that hypertrophy and spreading are of little concern?

Nobody wants a bad scar, but for hair transplant surgery (or any surgery on the scalp), the scar should always be hidden under the hair if you keep it at a normal length (more than 2 inches). Even a bad scar can still be hidden after a haircut with a #3 clipper most of the time. I also realize many men would like to cut their hair very short in the back where the scar may be visible, and that’s when follicular unit extraction (FUE) may be a better option. However, if you have a tendency to have hypertrophic scars, then even the FUE may leave you with hundreds of noticeable dots.

As with everything in life, you need to have some perspective on what you are doing and what you are willing to give up. Nothing is perfect. There is no such thing as scar-less surgery. There are men who choose to have hair in the front and top, but sacrificing the gain with a scar in the back of their head. There are men who do not want any scars on the back of the head (linear or otherwise), and for them surgery is simply not an option. There has to be some give and take that you have to be comfortable with.

Think about cosmetic surgery on women: Women who want larger breasts will sacrifice their gain in cup size with a scar under the breast, around the areola, in the armpit, or in their belly button. Women who want a face lift will sacrifice a youthful face for a scar along the back of their ear and behind their front hairline.

Remember, keeping your hair very short after a hair transplant will not give you the best cosmetic results no matter how many grafts you transplant. A very short hair style will look much thinner than a longer hair style, which covers more of your head. This is because the surgeon is working with a limited number of grafts to cover a big area.

Tags: scarring, hair transplant, hairloss, hair loss, hypertrophic

Removing Only Part of the Follicle

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

Hello Doctor

There is a dutch clinic that advertizes the following method

“The most significant difference between the HST method and traditional hair tr*nspl*nt techniques is that with HST, only a tiny part of the hair follicle is removed, leaving the majority of it in the donor area where it will produce a new hair. This preserves the donor area for future treatments, which is why this technique should actually be referred to as hair multiplication, rather than tr*nspl*ntation.”

A very famous dutch soccer player ( Snejder ) supposedly undergone this procedure . Anyone who saw the Bayern Munich – Inter Milan game this week definately noticed the difference on his head

I’m not sure why “transplant” is censored on that clinic’s site…

I know who you’re referring to and I have heard this doctor speak on the subject of partial unit extraction. One of the problems — there was never any physicians actually looking at what he was doing, and as such, there is no peer review or comments by other qualified academic doctors that could back up the claims that he actually has growth of full healthy hairs from fragments of hairs. This very subject has been extensively studied by other physicians and the ability to grow full, healthy normal hairs is clearly not possible. I do not believe that what this doctor is reporting is real.

Past posts about this here and here.

Tags: hair transplant, partial unit, hairloss, hair loss

Would Cosmetic Eyebrow Tattooing Cause Further Loss?

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

Hello dr,
I was considering getting my eyebrows filled in with a tattoo. I have a decent amount of hair but have some sparse areas due to overplucking as a teen. I was wondering if tattooing the area will make the hairs fall out? I hear that it doesn’t from the techs who perform it but not sure if they are just saying that to get more business. I would love your thoughts as a hair loss expert on this matter. Thank you

The use of hair transplantation is probably the best solution available today for eyebrow restoration. Take a look at this post from last month and you will see the absolutely natural appearance of an eyebrow transplant.

I wouldn’t expect the tattooing to cause eyebrow loss, but I’d be more concerned about the tattooed eyebrows looking natural, particularly on close inspection. I guess it depends on the color of your brows and how sparse they currently are.

Tags: eyebrow, tattoo, hairloss, hair loss, eyebrow transplant

If I Can Only Afford 1 Transplant Procedure, But I Might Need More?

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

Hello Doctor,

I am a hair loss sufferer, but my hair loss is more of a diffused type, with thinning across the scalp. I am considering hair transplant but would like to get your opinion before I make the decision since I am living in India and will be traveling to US for the transplant and want to make sure the trip is worthwhile.

I have been saving for a hair transplant for the last few years and at this point I can afford a little more than 2000 grafts. Do you think hair transplant is the right option for someone if they cannot afford any follow up procedures after the first transplant? Do you think I should keep saving for some more time so that I can get maximum amount of grafts in one go that can last me for a much longer period without having to go for a second surgery for a very long time?

All my calculations are based on $5 per hair graft that I got from your site for prior fixed appointments. Also is the $5 per graft inclusive of all charges or are there some overheads as well.

Thanks

MoneyAt NHI, our fees are fully inclusive without any additional charges. The $5/graft fee you mentioned is for Dr. Pak’s standby rate, so you’d need to be a little flexible with the scheduling. We do offer a travel discount, too.

Indians generally have lower hair densities than Caucasians by about 20%. Assuming that you take the pill finasteride and you are under 30 years old, the following may apply:

  1. Class 3 pattern — may work well with between 1300-1800 grafts, depending upon hair shaft bulk. Coarse hair is better than fine hair.
  2. Class 4A pattern — can be filled nicely with about 2000 grafts.
  3. Class 5, 6, and 7 patterns — you may not have enough hair to cover the crown.

Many men elect to have one surgery and be done with it, or have multiple surgeries over time. It’s up to you. I haven’t seen you, so keep that in mind. I’m not sure how many grafts you’d actually need or what your hair loss pattern even is. You should send me photos if you’re considering surgery and I’ll be able to hopefully tell you a little more.

Photo credit: Origami artist Won Park

Tags: hair transplant, fees, hairloss, hair loss

SMP for High Contrast Scalp and Hair

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

Dr. Rassman,

For patients who have high contrast scalp and hair (ie. dark hair and fair skin). Wouldn’t a combination of SMP and surgery help minimize some of that contrast and maybe achieve a more fuller look?

Yes! It would be advantageous to complement the scalp micro-pigmentation (SMP) with a hair transplant for a full and realistic (3-dimensional) look. No one treatment is perfect. Hair transplantation can never give you the complete fullness you once had, since it is just rearranging what you currently have. But hair transplants can give you a good hairline, adequate coverage, and even almost normal densities if the area covered is small.

SMP can give you the look of fullness but it will not be real hair, since it is like using concealers (think DermMatch or Toppik) but without the daily applications because it is permanent.

Tags: smp, scalp micro-pigmentation, pigment, hairloss, hair loss, hair transplant

Auditing a Hair Transplant?

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

Hey Doc,
I had an FUE procedure last week of 2400 grafts. The procedure lasted 9 hours (10 if you include lunch, etc.).

My question is as follows: How can one verify that the doctor (a well respected FUE doctor)actually gave you the number of grafts that you paid for? The work seems fine, but it just doesn’t seem like there are 2400 scabs on my head representing the number of grafts, and im now skeptical that i really got that amount. I do not have much of a way to verify my hunch as its too difficult to count.

I know the obvious answer is to pick an honest surgeon. But beyond that — any thoughts, tricks or advice for those of us whose eyeballs seem to underestimate the number of grafts on our heads? Is it tpically more or less than it looks like to the human eye?

Thanks!

Magnifying glassIf you feel the need to verify that you got what you paid for or what the doctor represented to you in regard to the follicular unit extraction (FUE) transplant, then you can get a second opinion. I have done that on a number of patients, but if the transplant was more than a week old, my accuracy in counting them is compromised. What I do is count the wounds (holes) on the back of your head.

If you had 2400 grafts, then you should have 2400 holes reflecting the FUE extraction sites. If the doctor charged by the number of follicular units, sometimes a single FUE site can have more than one unit if the doctor used a large punch or if your density is very high. Or maybe less than 2400 were taken, but the grafts were split (see here for more on that). I am not saying this is what happened, but I am giving you a skeptic’s point of view, reflecting your uncertainty.

Finally, if you trust the doctor ask for your surgical records and count sheets, which may show the doctor’s actual numbers (where the technicians keep track of all the “successful” FUE grafts pulled out and all the “unsuccessful” FUE grafts pulled out). This is what we do on every FUE case.

Tags: audit, hair transplant, fue, graft count, hairloss, hair loss, follicular unit extraction

Does FUE Mean Less Total Donor Hair Available?

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

This analogy on the subject of FUE really hit home:

…Your donor is like a grid of marbles. FUT is basically a line through the middle (strip) which is closed up leaving the grid uniform and balanced but when using FUE, you are removing marbles at random from all over. It is much harder to keep the grid “balanced” with FUE…

So Doctor…..when a patient elects the FUE procedure to restore their hair, is there considerably less total donor hair available?

I have heard only half as much as with FUT. Say it ain’t so!

“It ain’t so!”

I suppose your donor area can look patchy with little white dot scars if you have 3000+ FUE grafts extracted. This occurs when your original density was average or less than average. People with high density hair often will not show the white scars (dots) at all. Even with 1000 FUE grafts, you will notice these patchy white dot scars if you shaved your scalp, but in general, even with 3000+ FUE grafts, the scars and the less hair volume will be hard to notice (depending how close you cut your hair).

Remember — not all FUE or FUT (strip surgery) is the same, and not all patients are the same with healing. I have seen awful FUE scars and great FUT scars and vice-versa. Each and every patient needs to talk with their doctor and understand the unique advantages and disadvantages along with the risks and benefits of the surgery. This may sound like generic advice, but many patients who seek out FUE choose to go ahead with a FUT procedure after understanding the limitations of FUE and FUT.

With regard to your main question about which procedure will get you more hair (strip vs FUE), I think that the answer is probably strip surgery. Many doctors now doing FUE surgery actually get the hair outside of the fringe area, which means that the hair is not permanent. Some doctors (who think about $$$ above all else) will push the FUE harvest area to meet the projections given. The donor area has about 20,000 hairs in it and if an FUE procedure harvested 1/3rd of the available supply (assuming average density of the hair in a Caucasian male), that would be about 6,500 hairs or 3,200 grafts on average. All of the higher number we are reading about reflects, most probably, non-donor (non-permanent) hair.

Tags: fue, hair transplant, donor hair, strip procedure, follicular unit extraction

Transplanting Nape Hair at the Hairline to Soften the Look

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

A prominent HT doctor recommends using transplanted nape hair at the hair line to soften the look of the hair transplant and make it look more natural. This seems to make sense as often hair transplants look like the hair strands are too thick where transplanted and not natural. You mentioned that nape hair is not permament. Does this mean it might fall out over time and even if it does is it still worth it for the cosmetic effect in creating a more natural hairline?

I recently saw a patient in my office who asked me this same question and asked about the doctor. In case you are the same person, my answer was as you correctly state — nape of the neck hairs are not permanent. Some patients actually come to have hair transplants to the nape of the neck, as they are completely bald from below the ear level.

Thus, your nape of the neck hairs that are transplanted elsewhere may fall out over time and it is not worth the surgery. More importantly, even with the FUE technique there will be scarring that may show at the neck with white pale dots if the nape hair falls out over time. If you are considering this type of surgery I would ask that doctor if you can meet with a patient who has had it done to see what it looks like. When the donor area is from the nape of the neck with strip surgery, most of the time the scars are prominent and wide. Scars like these are not amenable to repairs and even with FUEs placed into them, they can not really look normal.

If you want a softer hairline, regular donor hair should be sufficient if done right with single follicles that are finer and grow naturally that way. If the staff and the doctor are good, they will pick out the smaller caliber single follicles for the very front.

Tags: hairline, hair transplant, nape of the neck, hairloss, hair loss

Could My Scalp Reductions Be Preventing Transplanted Hair From Growing?

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


I’ve previously had scalp reductions and a flap hairline performed in the early 1990’s.

I recently in Feb 2010 had a 2000 hair (not graft) procedure performed by the same doctor who was responsible for the scalp reductions and flap hairline in the 90’s to address the lack of hair behind the flap which looked strange. It is now 12 months since the procedure and it appears only half of my hair in the triangular area behind the flap has grown, it is very patchy and is more scalp than hair. Could the fact that the previous scarring from the scalp reduction and flap hairline be causing this skin zone to not grow transplanted hair properly?

The funny thing is that several of the hairs transplanted into the actual scars have grown quite well and show thick well developed hair shafts. But as mentioned before the triangular shape of bald scalp behind the flap is completely surrounded (an island of forelock scalp) by scarring from the old surgery. Could this zone be of limited blood supply due to these scars or does the scalp still get enough blood supply anyway? Also could 12 months be too soon for me? The island of scalp behind the flap hairline has sensation although somewhat reduced sensation but the skin goes white than straight back to pink when pressed. I have compared my post op photos with my current photos and it appears that only half of the hair has grown. I can email a couple of photos if you wish, I have not been back to the doctor since my 1 week post op check up (for personal reasons). it was about 1000 grafts I think. I will get back to him when I feel ok about it, thanks

Prior scalp reductions are not a reason why a hair transplant surgery would not work. Many patients that had scalp reductions in the 1980s and early 90s followed them up with hair transplantation with relative success (growth was fine, but they were the pluggy look from back then).

I think the best thing for you is to follow up with your doctor when you are ready. Maybe you took pre-operative photos, but your doctor should have one (or more) as well and it may be useful to compare what you have now and what you had then. There are many factors that can be the cause of a hair transplant failure and that is why you need to see your doctor for a better understanding.

Tags: scalp reduction, hair transplant, hairloss, hair loss