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A female reader asks…

I have Hashimoto’s Syndrome and diagnosed alopecia areata. The hair on the crown of my head is not diminishing as fast as that around the face and all around the back of my head. What options do I have? I feel I will shortly have to wear a wig permanently. Is there anything that can be done?

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Hashimoto’s Syndrome and diagnosed alopecia areata are autoimmune diseases which are attacking the hair follicles in your situation. If the disease can not be controlled, then the hair will continue to fall out. Sometimes, these diseases are self limiting, but your doctor will be in a better position to judge this for you.


I’m considering hair transplants, but my wife saw a talk show recently with a hair expert. In the segment, the expert said that a significant number of transplanted hairs fall out in both the short and long terms following the procedure. He said figure five years before you return to your original look.

How is loss of transplanted hair measured, and is the permanency guaranteed in some way?

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Most transplants fall out within a month of being put into their new location. The new hair goes through a rest phase and some 2-5 months after the transplant was done, they start to grow and will continue to grow for the rest of your life. Hair grows at about ½ inch per month so you can calculate the hair length from the point the hair starts to grow multiplied by the number of months the hair has been out. The hair growth is not like a horse race, where every hair starts to grow at the exact same time. The growth comes in waves, some earlier and some later. We generally expect that 100% of the hair that is transplanted, will grow. Some if it may start immeciately, some in a month, two or three, and some may not start to grow for 6 or more months. Good growth reflects a skilled surgical team who does this all of the time. Less than a skilled team may take a toll on less than 100% growth.

You asked about measurement of hair. I invented and obtained a patent for a device I called the ‘densitometer’ over 10 years ago. This invention covers almost all of the measuring devices presently used today. What it allows is the direct visualization of an area of scalp. If you cut the hair (an area about the size of a pea), you can actually measure hair densities by counting hairs in the cut pea sized area. This measurement is performed on every patient we analyze prior to a hair transplant. This measurement tells me what the total supply of hair is in that particular patient (hairs per square mm) or the overall thickness of each hair shaft in the field of view. Caucasians, have the highest densities, African hair is usually the lowest and Asian hair is somewhere in between Caucasian and African hair. But within the races, there is a wide variation of densities so there is no substitute to good measurements. After a transplant is done, the same measurement process can be performed to reassess the donor area or even the recipient area. It is, however, impractical to take such measurements in the recipient area because it would require shaving too much of the scalp (a pea sized area may not be representative of the entire recipient area). The judgment of a good honest doctor and the results that you saw on other patients may be your best guide to determine what the yield of the transplant procedure actually was.

The 5 year statement you asked about is difficult for me to answer as whoever gave this opinion may have been looking at a very advanced balding pattern and looking at the native hair in the recipient area, not the transplanted hair.

Since you are in Northern California, I would suggest you and your wife may want to come to our Open House (at our office on Wednesday, May 18th in San Jose) where you can see a surgery and meet former patients. They will share their experience with you. There is no substitute to meeting patients directly.


I am considering getting a hair transplant, however, I read a comment you made that hair transplant can accelerate hair loss if the process of hair loss is active? what does that mean? So what’s the point to get hair transplant? Maybe I didn’t understand what you said.

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Every person who has genetic hair loss continues to have hair loss throughout their lifetime. Hair loss is accelerated as time moves forward and as we are stressed. A hair transplant is another stress. If you are a young man and in rapid hair loss, the added stress of a hair transplant may increase your genetic rate of loss for a few months. With women it is different. With drug protection (Propecia in men only) you can slow down the rate of loss that is programmed into your genetic clock. Those over 30 are less reactive to the stress of a hair transplant (less likely to get telogen effluvium, the medical term for stress loss) than are those under 25. The hair transplant (1) in the right patient performed (2) by a good doctor (3) with the proper modern procedure (4) placed in the right location (5) in the best distribution (6) adjusted to your hair color (7) hair character (8) hair shaft thickness (9) hair density (10) balding pattern (11) with a proper plan catered to your individual needs diagnosis, age and (12) adjusted to meet your financial situation may replace some of those already lost hairs. I could keep going on and on, but I hope that you understand that there is more to getting a world class hair transplant than just having a doctor put holes in you head and then plugging those holes with hair. All hair transplant doctors are not equal, nor is each hair transplant patient. The drug Propecia generally protects men from surgically induced hair loss, so we use that drug with great frequency.


I am a 26 year old male, who has had two hair transplants in my frontal area. The density of hair in my transplanted regions is much lower than that of my natural hair, and hence looks a bit unsightly. I want to know if there is a limit to the number of FU grafts one can transplant in order to improve density. If so, what are the dangers of exceeding this limit?

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The normal hair densities of non-transplanted hair are measured at 193 hairs per cm squared (97 follicular units per cm square). A transplant doctor can put in densities of half of that in a single session. If you have thinning hair, then your density is not up to a level adequate to appear full. There are no inherent dangers in dense packing the hair in a transplant surgery provided that the doctor’s team is able to do it.

Dense packing, a technique we defined in 1993, makes for less surgeries and more fullness. If the wounds are over a particular size (more than 1.7mm each) then the risks start impacting the patient, for example, with regard to blood supply. If the wounds are smaller than 1.7mm, then the risks of dense packing of the grafts all but go away. We use wound sizes of about 1mm (the size of the wounds vary with each patient). The smaller the wounds, the faster the healing. Healing in this context means that the wounds on the skin become almost impossible to see, something that usually takes a day or two on most of our patients. Wounds greater than 1.7 mm, tend to show for longer periods. Some transplant patients in the old days saw wounds measuring 3-4 mm each (the old plugs), and they were visible for weeks after the surgery.


My original blog entry (found here) detailed a reader’s thinning hair, possibly due to taking Accutane when he was a young man. The following is my response to him along with one of his photos, which I was given permission to post.

Thanks for sending your pictures. I am using one of these for the Balding Blog to make good reading for our audience, showing only a top down view without anyone able to identify you. What I see in this photograph along with the other you sent, is that you seem to have miniaturization throughout the Norwood Class 6 pattern. The frontal hairline looks stronger than the area behind it (a good surprise), suggesting that the frontal line has different and stronger genetics than the hair behind it. I can not determine the amount of miniaturization that is there, but a good baseline is needed to determine change over time and any response to medications. Also, the donor area around the back and sides needs to be assessed to determine if you have a condition called Diffuse Patterned Alopecia, a diagnosis that is important to make prior to considering what to do about your problem.

With such an extensive area of thinning, your donor supply, skin laxity, and varying hair characteristics need to be determined before any treatment recommendation can be made. You may be a good candidate for Propecia and/or Rogaine. The pictures help, but I would think that you need to be managed by a competent doctor before going forward from here.


I am a 22 year old African American female. I very curly, short, and extremely dry frizzy hair. Due to experimenting with different hairstyles I have managed to pull out some of my hair from the root and now I have bald spots all over my head, which i have fortunately managed to hide with my other hair. I have tried many produts to see if I could regain the hair lost in these particular areas, but nothing has worked thus far. My hair is also particularly thin around my forhead and basicly non-existent around the temples/edges of my head. I want my hair to be longer, thicker, more healthy all while still looking natural and not too “fake” What would be the best hair procedure for me to opt in my particular case and what are the estimated costs for this/these procedure(s)?

Note: Just so that you know the extent of my hair damage. It is so bad that I have had to resort to wearing hair weaves, wigs, and other hair pieces.

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I would want to see you before rendering an opinion. Your history is one I hear with great frequency, but the cause of the hair loss needs to be determined before making any plan to fix it. Different diagnoses would include traction alopecia and a variety of autoimmune alopecias. You need to be careful with wigs, because they can induce traction alopecia, compounding your problem. If you are in the California or New York areas, you can meet with an NHI affliated doctor. If not, visit to find a doctor specializing hair restoration in your area. Or you can find a local qualified Dermatologist to get the diagnosis you need.


I was an NHI client. Considering all factors, I would rate the experience as “average”. I am very close to being back to the point where I will need either more surgery, or I will have to shave my head and call it a day. Some of this was genetically predisposed, but some of it may have stemmed from the fact that the grafts did not “take” as well on the crown of my head, the place where I would need them if I have the procedure done again.

My question to you is twofold: Is there any or a better chance of the grafts “taking” in this area a second time? If so, is there a way to schedule the surgery with you without offending the doctor who did it? I think he did a fine job, but it is my understanding that you are the best – and if I do this again, I want it to be for the last time regardless.

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Your question may be clear enough for you and I to understand, but for the average reader, the problem you are pointing to is the progressive nature of hair loss. The crown of the head always takes more hair per square inch than the frontal area, so as we tend to favor the front, the crown often gets less hair than it really needs. Add to this the large area the crown represents and that compounds the problem. The swirl and the absence of good layering because of the swirl, added to the very large area make the crown a ‘hair hungry’ area. If we do a hair transplant and any of it does not take, we will replace any hair that did not grow at no charge. However we sometimes find that it is not a failure to grow, but the progressive hair loss that one has. Most complaints, when they are given, are the results of further hair loss. In our medical group we have no pride that supercedes the interests of the patients, so the answer is yes, if you want me to personally look at you and we decide to do more transplants, then I would be honored to be your doctor. To deal with the progressive nature of hair loss and to hopefully put an end to recurrent surgeries, the drug Propecia would be an important additive to your treatment protocol, particularly for the crown in someone like you.

I’ve had crown surgery, having made the mistake of having three scalp reductions to reduce the size of the bald area. By bald spot was a 3 inch diameter circle before the scalp reductions and a 3 inch diameter scarred circle after the scalp reductions. I eventually had 1600 grafts put into my crown and now I am normal. When I am in bright sunlight and my hair is web, my crown appears thinner than I would like. My bald spot used to get a sun burn before the transplants were done, but since the transplants there have been no more sunburns.

I look forward to speaking with you.


Hello Dr. Rassman,
Well I am 23 year old student and I have been experiencing hair loss since I was about 22. My question is regarding dutas or the generic avodart that is made in India. Do you believe that this is a legitimate form of .5 mg dutasteride? Furthermore, I just order procerin and was going to take it in conjuction with the .5 mg dutas as a supplement as well as revivogen and tricomin. Do you recommend this and if not what do you recommend that I take to supplement the dutas. Thank you for your time.

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I can not advise you on medications made off shore (India). The other supplements you discussed are not scientifically proven to my satisfaction. That does not mean that they do not work, just that I can not advise you that they do work. I generally stick to what I know works and that is limited to two approved medications Rogaine (or the generic form of it) and Propecia. The rest is up to you, the buyer.


I just answered a question about transplanting in older men, so I’ll answer one on the other side of the age scale. “Youngtoo” asks…

Why exactly is 20 too young if the hair is taken from the permanent growth zone? I am 23 and a doctor also told me that I was too young without giving a real justifiable reason. thanks for your time.

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There are many reasons why transplanting a very young man is not a good idea. I will list some of them:

  1. The final balding patterns start to become evident on a men in his mid-20s. Earlier than that, one may not be able to determine the final pattern so that surgical planning becomes difficult. If a 20 year old is destined to become very bald (e.g. the most extreme Class 7 pattern) then he may not have enough hair to tackle the balding pattern, so planning is critical. On the other hand, a man with only mild balding can be aggressively treated after the pattern is clear without putting him at significant risk for placing his limited donor supply in the wrong places.
  2. The ability to slow or halt the balding process with Propecia needs to be determined. For those men in their early 20s who do not respond to this drug and continue to bald, the future prognosis is far more bleak than for those who are drug controlled. I generally like to get a ‘feel’ for the aggressiveness of the balding process.
  3. This is a life-time decision, a decision that many people at age 20 are either not equipped for or do not have the financial follow-through capabilities to manage. Maturity on a 20 year old is different than a 30 year old.
  4. We change as we get older and along with that change, our priorities change. Once the decision to start a surgical hair restoration course has begun, there is no going back.

I never make absolute rules and each person is different. I have done transplants on some men around the age of 20, but when I have, I was able to get to know and become comfortable with them, their maturity and their decision process. I also ask men of that age to bring in a parent, a girlfriend or good friend to listen to the consultation and become involved in the decision process like a “brick wall” to bounce ideas off of.

I hope that this answers your question. With more time, I will add to this list of ‘reasons’ to slow down the transplant process for a 20 year old.


My wife passed away early last year and I just started to date on the internet. There are a lot of ladies out there, but my bald head makes me look too old, more like someone’s great grandfather. I want to be a lover and to be that, I got to look like that. Is there an age limit to get a transplant? I am essentially totally bald (except for my sides and back and scattered hairs in the front that seem to be holding on for dear life). Can hair transplants work for me at 84 years old?

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Your question brought a smile to my face. I have done hair transplants on many men in their 80s and they were driven to have a hair transplant after either divorce or the death of their spouse. Men of all ages want to look young and looking young makes you feel young, so why not get your hair back and get your youth back? I have done surgery on many people with the most advanced hair loss pattern. Clearly, we are not all equal and some balding men just don’t have the supply, while others do. I always start by suggesting that you come in to the office to be evaluated. Rather than overwhelm you with lots of text, I thought I would point you to two patients who allow me to use their photographs. The first is a very bald man in his late 60s (happily married), before and after a hair transplant and the second is a man now in his 80s, that had one transplant procedure and started dating in his late 70s. The photos show his hair loss progression since the 1940s.


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