Transplanting a Norwood 6 to a Norwood 3 or 4?

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

Hi Doc, Great Blog

If a patient was norwood six on the scale with normal density how many grafts do you think it would take to create a hairstyle similar to that of Tom Ford With strong density. I believe a conservative hairline with more overall density produces a better appearance that that of a lower hairline. Here is a sample of the hairstyle: Photo

I know this is difficult to estimate so even an approximate figure would be interesting. Thanks in advance doc.

You should visit our hair transplant photo galleries, which showcases hundreds of different patients — before and after photos, their starting Norwood class, and the number of grafts it took to achieve their new look. So instead of me just giving you a number, you can see the many examples of hairlines yourself. It is not just about numbers of hairs that we transplant, as factors like hair color, style, texture, and distribution are very important in the overall cosmetic result.

With respect to lower vs higher hairline, that is more of a personal preference for each patient. Some patients choose a higher hairline. We (Drs. Rassman and Pak) do not dictate where a hairline should be. We give each patient a baseline to guide them, so we take a team approach to where the hairline should go.

Tags: norwood, hairloss, hair loss, hair transplant, hairline

How Many FUE Grafts Actually Grew? (with Photos)

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

A man came to see me last week with a problem following his hair transplant at another clinic over a year ago. The surgeon told him that 6600 grafts were transplanted (in three sessions) using the follicular unit extraction (FUE) technique, which he guaranteed has a yield of over 90%. The patient wanted to know if his surgery actually reflected 6600 grafts, so at the patient’s request, we counted the actual grafts that grew. We divided up his head into 1cm square units and then counted the individual grafts inside those squares. The count yielded 2092 grafts of which approximately 50% had only one-hair and 50% had two-hairs, totaling approximately 3100 individual hairs. The hairs did not look very healthy, but the patient had fine hair in his donor area, so I suspect that the fullness reflected the low volume of each hair that survived.

I actually had the opportunity to measure his density before he decided to have his surgery with another doctor. His initial preoperative donor density measured 2.4 hairs per mm square. In my experience this type of donor density usually yielded about 15% one-hair grafts, 65% two-hair grafts, and the rest would be three-hair grafts. Estimating the hair count from the 6600 grafts he expected to grow, he should have had hair growth that would reflect (1) approximately 3960 hairs from three-hair grafts (20% of the 6600 grafts), (2) 8580 hairs from two-hair grafts (65% of the 6600 grafts) and (3) 990 single hairs (reflecting 15% from one-hair grafts)… for a total of 13,530 hairs that would have grown from a 100% successful harvest. Estimating an FUE yield of 90% (a reasonable estimate for FUE and his surgeon’s guarantee of that amount) from a projected successful hair count from the 6600 grafts, I would reduce that count to 12,204 hairs (90% of the 13,500 hairs estimated above). He should compare the actual hair count we obtained in the counting process of approximately 3100 hairs which reflects a loss of 9104 hairs. The hair count therefore reflected a substantial reduction in the hair yield of those grafts that grew when compared to what should have grown. When one would count the grafts that did not grow, the death rate of the hairs was almost three times what did grow.

Where did those missing hairs go? I suspect that they were killed at the time of the FUE either through drying of the grafts during placement, trauma from the technicians placing the grafts, or transection of the grafts (a common problem in those surgeons who really do not have mastery of the FUE technique).

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Hair Transplant After Stopping Minoxidil?

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

Hey Doc,

This is my second post on this Blog. I’ll repeat my initial sentiments with regards to the first-grade work you do on this site. You can’t begin to understand how useful and good this blog is.

I’m 23, and spotted some thinning a few years back. I tried Minox 5% for about 4weeks, and stopped due to skin irritation. I’m convinced that using and then stopping minox has impacted my hair terribly. I’ve been on propecia for about 9months with limited success. It has always been my intention to at some point enquire about a transplant. My question is about the affect of stopping minoxidil on a future transplant.

I understand that upon stopping minox there is a shrinking of capillaries, and consequently blood supply to the scalp. If this is the case, and I were to go ahead with a transplant, would the new grafts be affected? Would it be possible to have a successful hair transplant, after having stopped minoxidil? Have you experience of patients in similar positions?

I hope that makes sense. Your help would be greatly appreciated. Thanks for reading.

The only problem with stopping minoxidil is from the dependencies on the hairs that have been benefited. I tell my surgical patients on minoxidil to continue using it up until the night before the hair transplant and then restart it 2 weeks after the procedure. The blood vessel impact from minoxidil on the scalp will not impact a hair transplant. I’ve had plenty of transplant patients that use minoxidil prior to surgery and have never seen any kind of issues related to using the medication.

If you stop minoxidil at the time of the transplant and decide to never restart it, the withdrawal effects of the drug I have discussed here before will become the risk. It won’t effect the transplanted hairs, but you will lose any benefits you had from the medication.

Tags: hair transplant, minoxidil, rogaine, hairloss, hair loss,

No Room for Optimism for New Hair Treatments?

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

While I don’t disagree necessarily with the premise that doing nothing now, in hopes of treatment in the future, is a course of action that is done at an individual’s own peril — the balance of this response is quite gloomy and alarming. Of course, you are the professional, and we defer to your knowledge — but you truly believe that NO beter treament will be available to the public for decades? That hits many of us prety hard. I am a realist. However, is there no room for optimism? There is a market for this, and certainly a willingness, as evidenced by the research of the past 6 years, in finding better alernatives. Those are my thoughts. Thanks for the site — more so, when it provdies hope, as opposed to narrow courses of expensive, sometimes (not always) unflatering, options.

Half fullHey, I was hoping for flying cars, public space travel, and a cure for cancer by now. I’d even settle for a cure for the common cold. I would like to think of myself as an optimist… you know, a glass-half-full kind of guy… but the cure for balding is not as easy as you may think. Being bald is like the color of your eyes, the way your ear lobes fold, or how tall you are. It is genetics! And as much as gene therapy is the new buzzword in science, it is a long ways off.

In the mean time, for those men who are bald, there are great alternatives. Hair transplant surgeries have evolved to a point where it is almost undetectable when done by the right surgeon and medical group. See my post on selecting the right surgeon. And when combined with medications such as Propecia, it definitely changes lives. So I am not sure what some of you are looking for, but hair transplants really are not unflattering nor expensive. While I agree at face value the cost of a hair transplant surgery may be in the thousands of dollars, remember that it works and it’s for life! It is often less expensive than a good quality wig, which has to be replaced or repaired ever couple of years. What other item can you purchase for a few thousand dollars to make you look younger and you get to keep for the rest of your life? As you say, you are a realist — it may not be the fountain of youth, but for the optimist, its the next best thing.

Tags: optimism, hair transplant, hairloss, hair loss

Trichodynia After a Failed Hair Transplant

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

Hello Dr Rassman,
I would like to start with complicating you on your website. I think that what you are doing, in providing free information with such dedicated professionalism, which must be so time consuming is a testament to you as as a surgeon.

Doctor my question is a simple one. I had a hair transplant almost a year ago and I am living a life of hell since. I am now suffering from Trichodynia and every morning I wake up I say to myself I cannot wait for the day to end. I go to bed hoping the pain will be gone when I wake up each morning. I am emailing you as a last resort. I have been to a pain specialist who has prescribed amitriptyline and lyrica together. I am on this medication for 4 months now and as the dosage goes up there really is no difference in my condition. My transplant was also a failure along with being left with a scar of between 5 and 10mm. Please please help me doc. I did not have any pain pre surgery. Kind regards

BurningFor those readers who does not know about trichodynia, it is a condition where the patient experiences a painful, burning sensation on their scalp. From Wikipedia — “Often there is an underlying psychosomatic cause, such as stress, depression or anxiety.” It also could be caused by trauma to a nerve(s) from the surgical wounds created during a hair transplant.

I do not know the cause of your pain and the answer you desire is not so simple. You state that the pain started after a hair transplant surgery, but I do not know if there is an actual correlation or just coincidence with the hair transplant. You need to find a physician who will listen to you and examine you. I would want to know where the pain is, if there are any sensory defects in the nerve distributions of the major and minor nerves of the scalp. Without a full history and physical, I really cannot offer much help. You are more than welcome to make an appointment to see me or Dr. Pak either in Los Angles or San Jose.

Tags: hair transplant, trichodynia, pain, scalp pain, hairloss, hair loss, hair restoration

Picking Off Transplant Scabs a Month After Surgery

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

Hello, I had a hair transplant early in january, roughly two months ago, it was only a small procedure of about 700 grafts. However I have been reading about the scabbing process and I am very concerned that I may have damaged my grafts. I was very careful after surgery for about two weeks, the scabs were still strongly in place so i followed advice and scrubbed a little harder and let them soak. During weeks 3 – 4 the scabs were still there, not attached to my head but somewhere near the end of the grafts, most of them being lose. The area was very itchy and the scabs looked a mess being very flakey in my hair.

Anyway over 2 or 3 days i used my finger to rub and loosen the remaining scabs, considering it was nearly 4 weeks on i thought this would be ok. When picking the scabs off some of the grafts were still attached to the scabs. I have been told that it is natural for the grafts to come out first with the scabs and that after 2 weeks the grafts are fixed in place so its hard to damage them. However i am very worried that the result i achieve will be poor because I didn’t just let the scabs be, the rate they were going i think it could have been about 5 weeks before they would have gone. I know picking (encouraging) the scabs to come off when the hair is dry is wrong, but i didn’t at the time. Do you think any permanent damage will have been done?

kind regards.

I do not know why your scabs would be there at a month after surgery. Just washing your hair with soap and water should’ve taken them off. I would like to know if the grafts were the large plugs, which used to produce scabs lasting 2-3 months with poor hygiene.

We did a graft anchoring study, which basically concluded that as long as the scabs are in place, the grafts might come out. Pulling scabs and grafts from the scalp just is a set-up for infection (folliculitis). Good hygiene should have started the day after surgery. Where were your post-operative instructions? The surgeon should’ve provided them to you.

Tags: hair transplant, scabs, hairloss, hair loss, grafts

Financing a Hair Transplant?

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

What is the best way to finance a hair transplant? I will be graduating in May and will turn 24 in July. I have done the research and about 2,000 grafts are needed in my frontal hairline. My receded hair line itches at me daily. What is the best way to plan for about 2,000 grafts? Obviously every office is different on pricing, but I want to fix my hairline before I get started in my profession (public speaking and sales) – what is the best way to go about this for a broke college graduate?

MoneyDifferent physicians/clinics will likely have financing available, though some patients opt to pay cash or put it on a credit card. We do offer financing if you elect to have your surgery at New Hair Institute, and that info is available here.

Tags: hair transplant, financing, credit card

Forehead Muscles and Hairlines

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

This is in reference to this response.

You mentioned needing to see the eyebrows and forehead lifted by an individual to see where exactly to construct a hairline. I read a lot of doctors ask the patient to lift their forehead to help construct a hairline as well. My understanding was it showed the extent to where the muscles of the forehead ended which would basically indicate the lowest possible position of one’s hairline. Anyhow, regardless if I was correct or wrong in my understanding, what about individuals such as myself who cannot move or lift their forehead through use of the muscles located there? I was told by my doctor that these muscles were “underdeveloped” or weak and I have never been one either to voluntarily or involuntarily move my forehead in which to show creases or wrinkles. How would a doctor determine where a proper hairline should be located in my case and others? Thank you!

We do not base a hairline on forehead muscle per se, but it does give a generalized reference point. It does not matter if you cannot lift your forehead to delineate a muscle. An anatomically correct hairline is made with the general proportions of a person’s face using the rule of thirds the way artists draw a face. Alternatives that we use are in equalizing the chin to nose distance with the distance from the glabella (groove between the eyes above the nose) and a similar distance upward.

Hairline position is not an exact science — it is an artistic design based on proportions and knowledge of human anatomy and form, and takes into account what the patient believes fits his facial proportions. We often find that this process becomes a negotiation to arrive at the ideal location.

Tags: hairline, muscle, forehead, hairloss, hair loss, hair transplant, artistic

I’m 20 Years Old and Losing Confidence Because of My Hair Loss!

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

i am 20 years old and live in Mi. I started losing my hair since when i was 17 years old and after 3 years that now i am 20 years old i have lost enough hairs that i look 10 times older than my age. I have lost a lot of hairs from and middle and day by day it is increasing due to this reason i am losing confidence and every time try to cover my head with something so people don’t see my baldness and right now i have short hairs which make it more obvious and make me look a 30 year old like man.

Please advice me should i get done hair transplant from your surgical institution or is there any other way to get my hairs back. Because i told you i have almost lost a lot of confidence in myself. Please doctor your advice is required. Thank you

At 20 years old, you’re more than likely not a candidate for hair transplantation. I understand that you’re losing confidence and covering your head — this is common among many men that are seeing hair loss. I don’t know how bad your loss is, but my suggestion is:

  1. Get your hair mapped out for miniaturization to make a diagnosis on the presence and degree of pending hair loss
  2. Talk to your doctor about a prescription of Propecia. I’ve seen this medication work well in younger men with early hair loss like you describe.

There are many doctors that would be more than willing to take your money, but realize that you’re just going to cause problems for yourself in the future if you rush to surgically treat your hair loss today.

Tags: hairloss, hair loss, hair transplant

I’m Holding Out for Future Technology Instead of Getting a Hair Transplant Today!

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


Hi, thank you so much for all your help and knowledge. We greatly appreciate it!

Can you please tell me your thoughts as to when if ever we will see a more progressive approach to fixing hair loss? Such as through stem cells or tissue engineering. i am holding out getting a Hair Transplant in hopes one day this will come. Do you think holding out will be worth any wait?

Thank you for your help!

Imagine that your father and grandfather had prostate cancer and that you run a very high risk of developing the same disease. Rather than get tested to get a diagnosis for you in advance of getting this terrible disease, you decide to just wait until a cure is available. Then you die because the cure never came in time to save you. I realize this logic may be a stretch to bring up the point I am trying to make, but stick with me…

Waiting just means paying the piper of the process as time, whether it is cancer or hair loss, just works against you. Hair cloning or a hair loss cure are still not even close to being available to the public. In fact, I believe it will take decades before some more solid solution to hair loss comes along. People still think that hair transplants can be socially detected on any person who had it done, will always cause terrible scarring, are extremely painful, etc. Well, it may be the perfect solution today. I would challenge you to pick out a hair transplant amongst my patient population (assuming I started the transplant process on the patient being examined myself).

Drugs like Propecia are great at stopping or slowing hair loss with minimal side effects for 99% of men. Why hold out? You could be enjoying your hair now instead of waiting on something that isn’t guaranteed to come in your lifetime. The decision ultimately is up to you.

Tags: stem cells, hair cloning, hair loss, hairloss, cure

Transplanting Between Miniaturized Hairs

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

Hey doc. How are you today?
I have been diagnosed as a Norwood 5 thinning pattern. Originally when I started finasteride I was a Norwood 3 vertex only, but obviously the medication is only slowing the process down. I had a consultation with a reputable Toronto Dr and he said it would not be be worthwhile performing surgery at that time. But now that things have progressed is it possible to perform surgery just to give me more density? I am fine with my hair line. Or is it dangerous transplanting in between miniaturized hairs? I’m 22 and have been on finasteride for 2 and a half years with a gradual decline in my hair count but hairline is still thick for some reason. What do you think ?

I am fine. Thank you for asking.

Transplanting between the miniaturized hairs may likely result in you losing those weak hairs, so you won’t be any better off than you are now (except with less donor hair and less money in your bank account). I can’t say for sure since I haven’t seen you, but based on your description the surgeon you saw might have done you a favor.

Tags: hair transplant, hairloss, hair loss

Temple Hair Loss and Transplantation (with Photos)

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

Hey Doc,great site!
I know people ask about temple thinning a lot, but are usually referring to the corners of the hairline. Well, I have a question about the real temple area (above the sideburns). If this area is thinning does that point to MPB or something else? Thanks!

Losing hair in the area that I call the “temple peaks” may be part of the balding process in some men. Hair transplants to this area takes a special skill to make it look truly natural. I have seen more problems with the transplants done in this area from doctors who have not mastered the hair process. I posted an example of one such patient that came to see me for a repair after he went to a doctor that obviously didn’t understand the art of transplanting to the temple area — Temple Hair Transplanted in the Wrong Direction.

Here’s a patient we did at NHI with 150-200 grafts places into each temple. The before photo is on the left, after on the right. Click the photos to enlarge.

 

And here are even more patient temple hair transplant examples:

Tags: temple, hair transplant, hairloss, hair loss, temples, temple reconstruction, temples

Propecia and Rapid Heartbeat?

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

I am 46 years old, and my baldness can be described as worse than your Class 6 patient. I am not planning on having any more children. I have a rapid heartbeat (mytral valve prolapse). Here are my questions..

1. Would I be a candidate for hair transplantation?
2. Would I be asked to start taking Propecia or Avodart before or after the procedure?
3. Would taking any of these medications aggravate rapid heartbeat?

Thanks

  1. If you have male pattern baldness and your donor hair is in good standing, I would assume that you could be a hair transplant candidate. In fact, patients like you (Norwood class 6) are some of the happiest after a hair transplant, because it can dramatically change your appearance (for the better). See our galleries of hundreds of before/after patients to get an idea of what to expect.
  2. I generally recommend Propecia (not Avodart) for patients with male pattern baldness, but it is not a mandatory requirement. You are asking me about generalizations without an examination, so my answers are generalized.
  3. Propecia would not produce a rapid heartbeat.
Tags: propecia, rapid, heart, hairloss, hair loss, hair transplant

I Want to Get Rid of My Hair Plugs!

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

I had an old fashion hair transplant using the large plug method. Now, I would like to cut my hair short (or shave my head). The plugs on the top of my head are virtually undetectable. I can probably have a laser treatment to completely hide them. No hair really grew anyway. But here is the real question, how do I get rid of the .75 inch high by 4 inch long rows of plugs where the donor area exists? I have spoken to several surgeons and have been told things from FUE to simply cutting around the entire area and sewing it back together. I am no surgeon, but cutting the area out and sewing it back together just seems like a waste of good tissue and hair follicles. Why can’t a surgeon simply re-cut the existing holes and sew them back together leaving the surrounding skin and hair intact. This is similar to the way he/she would do it if removing plugs on the top area of someone’s head? Any thoughts or comments would be greatly appreciated.

There is an art to managing this problem and we published the various methods of repair in distinguished medical journals in the 1990s. One way, when the hairline is too low, is to remove the frontal hairline surgically — and then re-transplant it with modern techniques. This approach leaves minimal scarring and what scar may be developed is completely covered by the hair transplant. Another approach is to remove the big plugs one at a time. Using FUE, we can often just thin the plugs.

As you indicated you’re in the Los Angeles area, you should come in for a free consultation and then allow us to make a recommendation. Also, see past posts about Repair, many of which are about fixing old plugs.

Tags: repair, plugs, hair plugs, hairloss, hair loss, hair transplant

Asymmetrical Hairline After Hair Transplant (with Photos)

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

Hi Doctor Rassman. I had a hair transplant a few years back by a very respectable doctor, and while I’m generally quite pleased with the results, my hairline is a bit asymmetrical. How normal is it for a natural hairline to be higher on one side?

Thanks!

In nature, the hairlines of non-balding males are usually symmetrical, but occasionally they are not. I do not have statistics on this. In the balding hairline that is receding, it is common for one side to recede higher and faster than the other side.

I have, even under the best of conditions, noticed the hairline slightly off balance after the transplant. I routinely draw the hairline and then have the patient (and if he’d like, his family and my surgical staff) provide input and between all of us, we usually hit it correctly. Just this week, I saw a patient who had the hairline higher by 1/8th inch on one side. Here’s his photos — click to enlarge:

Before (left) / After (right):

 

The after photo is 8 months since I did a single surgery of 2328 grafts. Upon seeing the slight unevenness, I offered to fix it the following day at no charge. He was visiting California from across the country and I wanted to address it before he went home. It took 249 grafts on the one side to balance it out. I won’t have photos of the final hairline for a while since the procedure was just done, but here is the area I’m talking about:

 

Tags: hair transplant, hairline, asymmetrical, hairloss, hair loss, symmetrical, photos