Why Can’t We Move the Entire Permanent Zone to the Front?

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

Hi Doctor,

My understanding is that when you remove hair from the permanent zone, you want to leave enough so that the permanent zone does not look “thin.”

But what about sacrificing the permanent zone, especially in the back of the head?

Why not remove most of the hair there — so that the back may indeed look thin — while moving it to the top front and crown as desired by the patient?

Bad faceliftI suppose you can do anything you want if you find a surgeon willing to cause you tremendous scarring in the back/sides of your head. I can’t say I know of any patients that would want to be the first candidate.

Doing what you suggest would leave a patient with a very wide and long scar on the back of the scalp as the scalp became tighter and tighter, stretching the scalp skin in the area of the excision. Even if the surgeon used follicular unit extraction (FUE), it would still not look natural, as the donor zone will be very depleted and look unhealthy (not to mention the tiny pinhole scars all over that may be visible). I have seen many patients with depleted donor hair, as too much hair was used by their surgeon for the front and top. These patients are not very happy with how their donor area (scalp) looks.

Keep in mind the entire point of doing any cosmetic surgery is to look natural (like there was no surgery done), meeting the enhancements and goals that the patient desires. Doing something extreme as you suggest is like an overly done facelift surgery, where it looks like someone is pulling one’s face back.

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

Length of a Strip Scar

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

Hi Doctor, thanks for your site

I am keen on getting a hair transplant, but i am a little bit worried about the scaring that will occur.

I was just wondering, say i only want a small amount of grafts done, is it possible to get a procedure which will only produce a small scar in length, say one 5cm long on the back of the head rather than one from ear to ear?

Thanks in advance for your reply.

You need to talk with your surgeon, and ask these specific questions and convey your wishes. You do NOT have to have an ear to ear scar. There are options for hair transplantation, such as the FUE procedure, which produces no linear scar.

A shorter length linear scar (5cm long) is possible though, and would obviously yield less grafts than a longer strip. It all depends on how many grafts you are expecting or require. A 5cm length strip might yield anywhere from 300 to 600 grafts (depending upon height of the strip and the density of your donor hair), but this is a VERY general estimate and will vary with each individual.

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

Can I Have a Hair Transplant Months After Other Surgeries?

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

Hi Dr Rassman,

I am thinking of having a hair transplant FUE approx 2000 grafts in 2 months time.

My concern is I have just recently had multiple surgeries to fix a broken jaw, rhinoplasty (broken nose) and scars suffered in a recent accident. I was told I would be able to resume normal activities in a few weeks and exercise in 6 weeks. Just wanted to know if the success of the transplant (2 months after the multiple surgeries) would be hindered at all.

ps: the surgeon who performed the multiple surgeries said it should be fine but to consult with a transplant specialist.

The ultimate answer will be from your hair transplant physician, who can examine you and determine if they feel comfortable going ahead with the surgery. In general though, it should be fine.

Tags: hair transplant, surgery, surgeon, accident

Reader Upset By Criticism of Wig Costs

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

Dear Dr. Rassman,

I’m a fairly young hair loss sufferer (23), and I’m currently evaluating my options. Finasteride gave me side effects, despite two trials (one low dose). As you’re no doubt aware, the remaining topical and internal treatments are either even more side-effect prone (dutasteride) or simply not very effective (almost everything else). I’m too young for transplants, and if my loss does progress to NW6/7 – which is fairly likely having started losing at 19 – I would be a poor candidate anyway. I have tried the shaved look, and it doesn’t work for me.

By process of elimination, I’m coming round to the idea of trying wigs. I’ve done a fair amount of research on them, and I have to say I’m fairly dismayed by your reports on the topic. You present the costs as astronomical, which they don’t have to be. Many use them for approx. $1000 a year very easily. You also critique them because of the shadiness of the industry. There’s no denying that it’s a dodgy business, but that’s precisely why you have to do research and shop around.

I’d contend that most of the criticisms you lay at the door of the wig solution could also be leveled at HTs. They are both only good options when you go to GOOD providers. Your posts are akin to someone posting about HTs saying that they’re overpriced, operated by con-artists, leave people butchered, and give poor results. These are true for bad HTs, but it’s not a legitimate reason to criticize the industry. I’d say the same of wigs.

I only write this email because, had I come to you before I’d done all this research, I might not have looked any further into them. I’m concerned that some for whom it might be a legitimate solution will be similar put off, given the exposure of your blog.

No big deal really, I’d just prefer it if you qualified your criticisms with the fact that while the wig route CAN be bad, it isn’t always like that.

MoneyI am not against wigs / hair pieces. My point has been that it can be relatively expensive in the long run when comparing it to a hair transplant. In your case, if you pay $1000 a year, after 20 years you would have spent $20,000… which is much more than most people would spend for a hair transplant that lasts a lifetime without all the maintenance that wigs/hairpieces would require. Let’s say your hair transplant only costs $4000. That’s 4 years of wigs vs a lifetime of transplanted hair. To me, it seems like a waste of money. Of course you may not get the same density and fullness as a wig with a hair transplant, but that is one’s choice.

There are many people who live with a wig and there is nothing wrong with that. If you want to go that route, try it! In the worst case scenario, if you do not like it, you have other options. Some however get stuck on the wig system and find it hard to stop wearing it, as it becomes a drastic change in appearance. Some even do a combination of both wig and a hair transplant. They have a hair transplant in the front to achieve a natural looking frontal hairline and wear a wig to cover the top/back area. You also need to be aware of the traction alopecia risks, depending on how the hair system is attached.

At 23 years old, you may not be too young for a hair transplant. Each case is unique so I can’t say 100% without seeing you, I’m just pointing out that you’re not automatically disqualified based on your age alone. I don’t know what your pattern looks like at this point, but just because your loss started at 19 years old doesn’t mean you’re for sure heading towards a Norwood 6 or 7.

Tags: wig, hairpiece, hair system, hairloss, hair loss, hair transplant

Density and Hair Transplantation

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

I was reading this ‘Understanding Density’ article [PDF file] and it states that thinner ‘see-through’ hair has a density of about 20 cm2. It also says that areas with a pre-op density of 20-25 FU/cm2 could achieve a post-op density of 40-50 FU/cm2.

Then, in the ‘Determining Number of Follicular Units’ article [PDF file] on the same web page, it says that: with a pre-op density of 20 FU/cm2 and a transplant of 20-25 FU/cm2, a post-op density of 40-50 FU/cm2(20-25 FU/cm2 x 100 cm2 area) could be achieved with a total of 2000-2500 grafts.

I’ve had 2 transplants to the frontal half area as shown in the picture in the article, but I still have a ‘see-through’ appearance to some degree. My doctor has confirmed the 20-25 cm2 density was the goal, although it was never made clear to me that was his intention. Anyway, I’m assuming I have about the 20-25 cm2 density and I’d like to have another procedure to increase the density to 40-50 cm2. So, based on all this I’m estimating that I should get 2000-2500 grafts in my next procedure.

My question is: Do you agree with the info presented in these articles and do you think this is an accurate way to calculate how many grafts are needed? Also, are there methods/tools a doctor should be using to check scalp laxity and density to help with determining what can be harvested for another procedure?

Thanks

CalculatorA hair density of 30-50% can produce a good look depending upon the coarseness of your hair and the color contrast of your skin and hair color. I have never believed that a hair transplant should bring you to 70% of your original density. The difference between people, based upon color/contrast and the coarseness of the hair, can be dramatic. A return of 50% of the original density in a person with fine hair will have a more see-through look than a return of 25% of the original density if the hair is coarse. So you see how difficult it is for me to understand your situation as the blanks (color/contrast and coarseness) are not filled in for me to include in the assessment.

The calculations are easy. The original density in a person with “average” hair density is hair is 2.1 hairs per mm square. That amounts to 1250 hairs per square inch (or 650 follicular units per square inch). You need to know the area we are talking about to do the calculations correctly, yet that is not really the answer as the variables which are not included will dictate the presence of a see-through appearance.

Tags: density, hairloss, hair loss, hair transplant, calculation

Avoid the Scam – Hair Transplants That Do Not Grow

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

Scam AlertI’m often outspoken about the problems with ethics in our industry, and I know I just wrote about transplant failures a couple months ago… but I continue to see a large number of patients who are unsatisfied with the growth after their hair transplants. Part of me really hates writing these types of posts, because I just know I am turning some people off to the idea of surgery altogether. But really, these posts should serve as a way to educate yourselves. Transplant failure is a problem that can not be denied and an increasing number who received surgery from various doctors all over the world are visiting my office to ask for help as to why they aren’t seeing the growth they were promised. I’ve even received emails about the same issue. Although there are a number of reasons why a transplant could fail, it seems that these failures are mostly technical in nature and related to the hair transplant staff. In other words, the problem is avoidable.

So how does one avoid losing donor hair or paying for grafts that aren’t going to grow? Finding a surgeon with a staff that knows what they’re doing is a good start. An experienced staff is hard to hire, and I have been training my own technicians for years. The drop-out rate from training is high, but for those that we retained, the high quality of our work reflects the quality of our staff. I know what I am about to say is self-serving, but I do very limited promotion here and wanted to point out that we have a travel reimbursement program which offsets the cost of travel and hotel for those patients coming from out-of town. With our standby rates, it is hard to compete with the value NHI offers and in 8 months, few worry about what actually grew out.

Tags: hair transplant, failure, hairloss, hair loss, hair growth, scam

What Happens When a Class 7 Patient Has No Master Plan?

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

BlueprintWithout a Master Plan, a Norwood Class 7 patient can be exposed to the worst of the problems in planning. An unfortunate example of this is a patient with a complex surgical history that I just saw who had three procedures with three different doctors over the past 10 years. His balding pattern was heading to a Class 7 and none of his doctors seemed to understand where he was going with his hair loss problem. This man had transplants that were spread all over in a most unnatural look, with areas left completely untouched. Some hair was placed in areas that should not have received transplants (they weren’t beneficial to the appearance), and he now has a massive scar in the donor area with no significant donor hair left. He asked I not post his photos here, but what are the options for a case like this?

  1. Use beard and body hair transplants to fill in the areas that do not look normal. Fill in the scar with beard hair transplants as well. Learn to use transplants as an aide to styling and hair length needs to be planned. I’m not a fan of body hair transplants (BHT) in the great majority of cases, but his options are extremely limited.
  2. Use cosmetic camouflaging such as Toppik or DermMatch.
  3. Consider scalp tattoos.
  4. Get a wig.

Some people still don’t get why a Master Plan is even important, so think of it as a surgical blueprint that plans for the worst case scenario of your hair loss progression. I can not stress the importance of a good Master Plan. Some doctors made a lot of money from this man, but did him no favors. And as I sound like a broken record, never forget — let the buyer beware!

Tags: hair transplant, bht, hairloss, hair loss, master plan

Avoid the Scam – Gangrene After Cheap Hair Transplant

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

Scam AlertI just saw a man that had two hair transplant procedures done a decade ago and then a third procedure done at a clinic just south of Los Angeles, which caused major surgical complications like gangrene of the scalp. This was probably from the use of lasers during the surgery to make the holes, which produced burns all over his head. The patient now has a deformity in the frontal area of his scalp which is incredibly difficult to cover with styling alone. His options to hide this include using Toppik and/or DermMatch, but he doesn’t like using these camouflaging agents. There may be some value with using FUE into the immediate areas, but then he would have to use use beard and body hair to get the value to this patient as his donor supply is markedly depleted. This is one of those rare cases where using body hair transplantation is acceptable.

This is a prime example of a patient who tried to save a few dollars on a hair transplant, but it ended up costing him more in the end. He told me that he even knew that someone died at that clinic, but their low pricing was enough to get him to go anyway! I can’t stress this enough — researching both the doctor and the clinic is critical. If he’d met with patients from that clinic and saw the type of results they had, he might’ve stopped right there. The Medical Board of California has allowed that place to continue to operate even though it is owned by a non-physician (which is against the law). So if the authorities can not really protect you from these criminals, you must protect yourself by doing the right type of research to avoid this type of problem. This applies to all types of doctors, not just hair transplant docs… but all types of surgeons and really, doctors of all specialists.

Tags: gangrene, hair transplant, nightmare, hairloss, hair loss, scam, bad hair transplant

Hair Transplant Results with No Detectable Scar (with Photos)

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

This patient stopped by my office to show off his remarkable results from his single hair transplant less than 8 months ago of only 1336 grafts in the frontal area. Before photo on the left, after photo on the right; click to enlarge:

 

He also had no detectable linear scar as shown in the photos below. The absence of the linear scar really reflects the patient’s healing ability as much as the surgeon’s skills. I usually don’t take credit for great scars as I always do the same procedure with the same precision on every patient. Interestingly, we elected not to use a trichophytic closure on this patient and the donor scar is still undetectable. Some people just heal better than others. Why didn’t we use that closure technique? Well, he planned on having a 2nd surgery in the future, but his results were so impressive that he won’t need another procedure. Click the photos to enlarge:

 

Tags: hair transplant, hairloss, hair loss, scarring, hair restoration, patient photos

Finite Number of Hair Cycles?

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

Dr. Rassman,
Thanks for an amazing blog. I check it daily for updates. I wish I could fly to the US for a consultation one day, but it’s far away from Australia.

I have seen in a number of blog entries that you refer to hair going through a finite set of cycles (one cycle being Anagen, Catagen, Telogen). Is this based on research and/or from experience? Does all hair have a limit or does it not apply to the donor area?

Kind regards

The anagen, catagen, and telogen phases are the well known life cycle of any hair. I think it is even taught in high school biology. For human scalp hair, the anagen (growth) cycle can last several years. This is followed by the resting phase (catagen/telogen), lasting several weeks to months. The length of time of the anagen cycle widely varies in people, but it is estimated to be anywhere from 2 to 8 years. If you take 3 years to be an “arbitrary” average, you can calculate your lifetime of cycles. If you have genetic balding or other hair loss conditions, the cycle of hair is obviously shortened (see apoptosis). The hair cycles apply to all hairs, but the pre-programmed genetic life of certain hair is variable. You really do not need research to see this… just look at all the bald men out there!

Norwood 7Now, I am not sure if I have completely answered your question, as I believe there may be some misunderstanding. For men most of the hair on the back of the scalp is considered “permanent” hair which will cycle and live on (see the Norwood 7 diagram at right). The hair you see in that diagram is considered the donor hair and this is a basis of hair transplant surgery for men. The research and experience you are asking about is evident on thousands of men who have had hair transplant surgeries. For example, see the hundreds of examples posted on our site showing patients we have performed surgery on over the last 18 years — the transplanted hair is still growing and cycling. Now the aesthetics and the natural appearance is what is highly variable, depending on who performed the surgery.

Tags: hair loss, hair transplant, hair cycle, anagen, catagen, telogen

Help with Craniotomy Scar?

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

Hi there,

I’m hoping I can get some guidance on craniotomy scar issue I am having. I am a 27 year old male, and about 6 months ago I had a craniotomy for the removal of a benign tumor which was discovered shortly before the procedure. The surgery went well and all is good now health wise. However, I now have a 6″ long scar that is about 5/16″ wide in the back of my head.

I would now like to address how I can improve the aesthetics of the scar, as I prefer to keep my hair short. The good news is with longer hair (shown in the photo), I am able to cover the scar, but I’d really like to wear my hair shorter. I have visited 2 cranial plastic surgeons and one hair doc in the Bay Area, California. Here is summary of their recommendations on how to improve the scar:

– UCSF plastic suregon: Scar Revision and change scar to a zig zag shape.
– Stanford plastic surgeon: Standard Scar Revision. Advised against doing a zig zag as it would change hair growth directions and “make it look weird”.
– Hair Doc: Standard Scar revision and possibly hair transplant on scar if scar needs additional improvement.

Is it true that changing the scar to a zig zag shape would change the hair directional growth? If that is the case, why would the UCSF surgeon recommend that? Do any of you have any recommendations on the best way to improve aesthetics of the scar? My end goal is to not get rid of the scar completely, but to at least improve the aesthetics of it. I’d appreciate some feedback!

I really cannot give you good, personal medical advice via the internet, so I’d suggest if you’re interested you can see us at our office in San Jose or Los Angeles (the consultation is free). We have transplanted hair into craniotomy scars with very good success. Many of these patients have had scar revisions that failed to resolve the cosmetic issues. You may need more than one transplant depending on the case, the size of the scar, and the location of the scar. Dr. Pak recently performed a FUE/FOX transplant into a craniotomy scar where a zig zag attempt was made. Sometimes a zig zag revision can make the scar worse.

Ask your surgeons for examples with before and after photos. Maybe it will help disguise the scar, but it’s still a scar nevertheless. Hair transplants to the scar does not mean the scar will be removed, but at least there is hair growing “ON” the scar and if there is enough hair in the proper direction, the scar will not easily be seen.

Tags: hair transplant, craniotomy, scarring, scar, tumor

FUE Megasessions?

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

if this is answered in your blogs forgive me and just send a link. i am clear i want a ht. i have done much research and am still meeting with docs. i can do in thailand, uk, usa. my one reservation has been the scarring and after effect, plus temporary nerve damage on the head. after realising FUE could be done in a megasession i feel this is it for me, (told i need 3-4000 hairs/grafts). as i research so many are careful, sceptical of it. i have come across you (dr. Rassman) and dr. cole. i understand a skilled physician is necessary. will FUE of 3-4000 grafts megasession handle it for me (norwood 3v to a 4)? do you recommend it more than strip or not? is it a very viable option? with dr. cole or you? thank you.

A skilled physician is necessary for any surgery you have, and one that specializes in the cosmetic surgery you’re looking into is absolutely something I’d recommend. If you’re asking me whether you should go to me for your hair transplant or go to another surgeon, well, I think the answer would be pretty obvious. However, I cannot recommend surgery options for you at this point, as I have not examined you or know of your medical history. Everyone is different and all surgery has its risks and benefits (FUE vs strip, etc).

What I can tell you is that I have never performed a 3000 to 4000 graft follicular unit extraction (FUE) procedure in one session. I think I can say this with some authority, as I was the one who introduced the FUE technique to the international community in 2002, but an FUE procedure of that size will likely lead to a higher transection rate due to physician fatigue.

I realize it has been 8 years since the technique was introduced and other physicians have performed and tried to perfect the technique, but there are factors that the general public do not know of in such surgery. To the general public, FUE sounds slick and the best of all worlds (you get hair with minimal scarring). But there are some thing you need to look out for. Please read about these in my post from a few years back — What Doctors Don’t Want You to Know About FUE.

Tags: fue megasession, hairloss, hair loss, hair transplant, fue, follicular unit extraction

Am I Losing My Transplants After a Shower?

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

Hi Dr Rassman,

I had two transplant done. One in aug2008 and another one in January 2010. Total about 5000 grafts altogether. Sometimes after showering I see 2 to 3 hairs in the towel with a bulb. the hair that falls out is also thick. Do you think I am loosing a root? or its normal hair cycle. Please advice. I am not sure if the hair that is lost will grow back .

thanks

TowelEveryone goes through normal hair cycling, meaning every hair will fall out and then after a few months in the telogen phase, it will regrow. I can not comment on any particular hair loss that you are reporting, because I don’t know exactly what you’re seeing. Both transplants would’ve taken hold by now, so those 2-3 hairs on the towel are likely nothing to worry about. You should go back to your surgeon for his/her confirmation of that. Hopefully, the transplanted area will hold its overall fullness and that will be the best indicator of the permanent nature of those hairs.

Tags: hair transplant, hair cycle, hairloss, hair loss

My Transplanted Hairs Don’t Look Like My Natural Hairs!

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

Hi Doc,

I am 27, and stupidly got two procedures (~800 grafts each) done about three years ago. Have been taking propecia since the age of 18 and just started on rogaine a few months ago. I guess I’m about a Norwood 3, moving towards a 4 (except no thinning on crown).

Anyway, the problem is that the transplanted hairs came in much thicker and more wiry than the natural hairs, and they were not always individual hairs, so I’m about a year into getting them removed as best I can via electrolysis. The skin is slightly scarred, but I’m unsure exactly how it will end up looking once it gets time to really heal and start to fade.

I’m trying to weigh my options for proceeding as my hairline continues to recede, and am deciding if I should continue to get the rest of the plugs removed as my natural hair goes or if it’s worth more transplantation but done with more care. The question is really do you have any knowledge about different types of hair responding differently to transplantation? My hair is dark brown and curly, would it be more susceptible to coming in thick and kinky than someone with finer straight hair? Because the last thing I want to do is get more transplants and have them be obviously fake and just compound my problem!

Thanks a lot, and I love your site.

As I’ve said many times before, the good news about a hair transplant is that it is forever… but if you have a bad hair transplant, then you probably aren’t looking at that news as being too good. Even removing the hairs may still leave a scar and cause an unnatural hairline, as you’re noticing with the electrolysis. Something concerning me though is that you’ve had 2 procedures at 27 years old of what you describe as “plugs”. I hope you aren’t referring to the ugly, old hair plugs that you commonly see in men that had surgery decades ago. Perhaps you’re just using the wrong term and you meant “grafts”, which are made up of 1-4 hairs. Modern hair transplants will look natural and the hair shouldn’t change character or color.

There are still options even though you may have a bad transplant, but BaldingBlog is not a place for second opinions. You’ll need to have an evaluation to see what options are available to you since each repair case is unique, so you should see a hair transplant physician (just don’t go to the one you already had two surgeries with, obviously). If you want to come out to Los Angeles, our consults are free and we have plenty of experience with patients who are in your situation. We have performed corrective procedures on many sub-par hair transplants.

See Dean’s Story for an example of a repair process, and check the Repair category for even more posts about this.

Tags: hair transplant, hairloss, hair loss

Should I Trust This New Hair Transplant Surgeon?

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

Hello,

I an from India and wish to get a HT done. I approached [a doctor] but I found out that the medical trip could be quite above my spending capacity and also I cannot find enough time fo the same. There is a new surgeon in India who is a ISHRS fellow and incidentally also happened to work under [the other doctor] (according to his website). I have also seen her results and I find them better than what others in India have produced.

The only thing that stops me from going to her is that she is into practice less than a year(but i don’t have any information about her past experience). Can I trust her bald head to this new doctor or should I wait for a while and get it done abroad?

Regards

I can’t tell you who to trust. I’m not familiar with that doctor or her work, so you might want to use Google to research the doctor a bit more or ask around in various hair loss forums. Be sure to ask the doctor herself for any information about her past experiences that you wish to know. Also, ask to meet with live patient models so you can see the quality of her work in person (this is better than just seeing photos).

Don’t rush into surgery because the price is cheap. Go with whichever doctor you’re most comfortable with (and results that you like), and if it means you have to wait to save up your money, then you should do that.

Tags: hair transplant, trust, surgeon, hairloss, hair loss