Minoxidil responder with finasteride (photo)

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

First picture was in feb, 2nd picture was in June. Have been on topical min since 1 year with no results, decided to upper the dose from 1x to twice a day. Was followed by a shed but I think you can see new hair in the hairline now. Also I added fin 2 months ago, but i think that didn’t had any impact yet. I’m just extremely scared that I’m a non responder or something.

The changes show that a lot of new hair is growing, just short hair at this time. It will get longer and from what I see, you will return your hairline. Keep it up.

FUE vs FUT comparison of results

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

My question is. Picture a hair transplant candidate, wavy dark hair on light olive skin. Needs about 3.000 grafts and is on 1mg of finasteride/day.

Two options : A FUE operation, let’s say all 3K grafts may be extracted from the safe zone. Or, a FUT operation instead. All other factors (healing time, discomfort, price, scar) excluded. Sole criterion is the final cosmetic result. Given that FUT extracted  grafts are considered ,  generally, healthier , bustier and less damage prone, could you give an (enen rough) estimation, on how much  better would the FUT cosmetic result be? (A percent % number would be helpful, like 15% better result from FUT , or something like that)

I have seen publications where patients had FUE on one side of their head and FUT on the other, and I respect the doctors who did this because they know how to do both competently.  The reports indicated that there was no difference between the two.  The issue you may be missing is that the hair thickness (fine, medium, or coarse) is more important a determinant of what you would look like than FUE vs FUT.  Also, the need for 3000 grafts is very dependent upon hair thickness, as men with coarse hair often require a lesser number of grafts than a man with fine hair, and even with a change in the number of grafts, the man with the coarser hair will have more fullness than the man with fine hair. 

Transplanted Crown (photo)

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

I wanted to share this fantastic photo of a patient transplanted in the crown by Dr. Kavish Chouhan from Delhi, India (tap on the image to enlarge).  For a patient with enough donor hair, this photo shows the details of the graft design, following the swirl in exquisite detail.  Congratulations to Dr. Chouhan. 

Was this transplant appropriate? (photo)

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

I received 1500 grafts in the frontal hairline and 500 in the temple peak area.  

Was this balding? If it was, you almost certainly lost miniaturized hairs elsewhere on your head from the surgery. If you were not on finasteride and didn’t lose any hair volume, that clearly suggests you were not balding. I question the use of 2100 grafts for such a small area. Do you know if the surgery was necessary? Will it look as natural as it did before the surgery? Using 2100 grafts reflects 25% of your total lifetime donor supply (assuming your donor density was average). I am questioning the depletion factor here if you have balding.

A taste of Hair Transplant History 1994

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

Richard Shiell’s and Dr. O’tar Norwood’s comments were screenshots discussing my use of Megassions, transplanting between 2000-4000 graft. At that time, I was the only surgeon in the world performing 4000 grafts/sessions, publishing further on my early work in article #2 below. What I see in the screenshot of the photos of my patient, even meets my standards today, when most surgeons of the time were still performing plug surgery. You should know that performing such large procedures came at a great price to me, as I was relentlessly attacked at hair meetings because most other surgeons were still stuck in the “Plug Mentality,” performing 50-100 plugs per procedure. My surgeries could run 10 hours, but theirs ran about 1-3 hours, so it is easy to understand that they didn’t have the staff nor the skill to adopt these larger sessions with tiny grafts. The last article showed a compromise between an extensive session of plugs with some tiny grafts in the leading edge of the hairline (that wouldn’t work well for these patients, even at that time).  Click to Enlarge the article you want to read, below. 

Why isn’t minoxidil enough for hair regrowth?

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

I’ve been reading a lot about male pattern hair loss lately(androgenetic alopecia). Most often finasteride is said to be a requirement for hair loss and if you don’t use it, it’s an uphill battle.

From my understanding (if nutrition, hormones, exercise, etc is good) DHT causes hair loss due to reduced blood flow and shrinking of the hair follicle. If so, why wouldn’t minoxidil which increases blood flow and even brings back hairs from a baby state to a terminal hair during usage, be enough? Microneedling has a very similar effect, with great backing.

DHT blockers cause issues for many with varying effect. It changes your hormone levels, there’s no question about it. Most doctors I spoke to were against that as a young male, because of the terrible repercussions. I did however take Min + Fin solution for 3 weeks (local treatment, no pills). Did blood work and have higher estradiol. Will get further testing, but not interesting on messing myself. Off fin and will retest myself again after stabilization (month later).  This question was taken from Reddit 12/15/2024 with my answer below. 

I can’t write a textbook for you in answering your questions, so I am going to discuss only two classes of drugs, (1) DHT blockers and (2) Minoxidil. 

DHT blockers work effectively at the hair follicle level blocking DHT in a competitive inhibition with the enzyme 5 alpha-reductase with 70% effectiveness for finasteride and greater than possibly greater than 90% with dustasteride. DHT works in many body organs, so blocking at the hair follicle level, will lead to blocking at other organ systems as well.  Dutasteride blocks more receptors than finasteride and it has not been approved for hair loss by the FDA in the US. Finasteride was the first drug to be approved for DHT blocking hair loss drugs around 1996-7 timeframe.

Minoxidil was developed as an antihypertensive drug, which did not work consistently at controlling blood pressure; however, many women complained about hair growth on the face and body when taking it.  When it was applied topically, it grew hair and less was absorbed systemically to impact blood pressure significantly. The mechanism of action is not that is increases blood flow as most people believe, it has its effect: by stimulating “ASC motility and increases paracrine growth factor signaling. Minoxidil-stimulated secretion of growth factors by ASCs that may enhance hair growth by promoting Dermal Papilla proliferation.”  Further, “Minoxidil directly promotes hair growth via the stimulation of dermal papilla (DP) and epithelial cells. Reference: https://pmc.ncbi.nlm.nih.gov/articles/PMC5877552/

So, as you see from above, both classes of drugs have different modes of action to get to hair growth. Minoxidil has been around much longer, and in countries like India, it has been used well before finasteride was even discovered as a drug for treating hair loss in genetic balding.  So if one drug doesn’t work, switch to the other, or sometimes take both. 

Minoxidil does not work like microneedling, see here for mechanism of action: https://baldingblog.com/does-microneedling-really-work/

 

9 months on finasteride, topical minoxidil, estrogen, spironolactone (M to F)

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

TI was starting my transition and noticed my mpb was beginning to progress faster, even though I was blocking my testosterone. On top of my temples receding, I also started showing signs of retrograde alopecia. My doctors still don’t know if it was telogen effluvium with an unknown cause or my androgenic alopecia worsening from stress. I got bloodwork done and my DHT levels had actually risen from when I first started my transition. So that’s why we added finasteride onto of the spiro. 

I have seen minoxidil do this as well. The hairs are growing fairly forward on your hairline, too forward to reflect more than your original juvenile (female) hairline. I suspect this is a side effect of minoxidil reinforced by Estrogen. Do you have new hair growth in any other place on your body? If so, it suggests a minoxidil effect; if not, it would reflect a combined minoxidil and Estrogen effect. It would be interesting to see your 10-year-old hairline. That would shed light on where your hairline should be with all the changes you are precipitating.

New Allergy report by patient

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

I’ve observed that I am definitely allergic to Finasteride, and my symptoms; 1- As soon as I wake up,I start sneezing, and I have a stuffy nose (not so bad but definitely stuffy) 2- I feel like I need at least one hour to wake myself up. The sneezing is the worst one, it starts at the morning and continues until around evening. Normally, I was having these symptoms every day, but I started taking EoD 1mg, it helped but not the way I wanted it to be. I am desperate for any suggestions or alternatives. 

This is the first time I heard symptoms like your report; however, based upon your report, I would consider that this is possibly some allergic reaction. If you stop the oral finasteride, do the symptoms go away? You can switch to a topical liposomal finasteride in which as much as 82% of it stays in the scalp.

I’m worried about the density

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

I had a hair transplant 21 days ago, and as I looked closely, I saw many gaps where there are no grafts.  Did my surgeon not give me what I bought?

By the 21st day, I expect that many grafts will fall out in the ordinary course of healing. You didn’t mention how many grafts were put in, but these spaces probably had grafts in them. As they are shed after a hair transplant between 2 and 5 weeks after the procedure, they will grow when they go into their growth phase, usually 2-4 months from the day of surgery. You will know the fullness at 5-7 months from the surgery date.  Don’t worry about this, as it should be okay if your surgeon’s team did it well.

Do patients ask you to create a mature hairline?

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

As title asks, I feel like I can spot a transplant almost instantly because they get a juvenile hairline, and it gives it away straight away and unless your Ronald Reagan is unrealistic for most guys past the age of 25 . Im just wondering how a transplant surgeon would react if you asked for a mature hairline and how it would look.

Most people don’t know what normal is, so they unfortunately leave the final design of a hair transplant to the surgeon. Mature hairlines are slightly different in different men. The most striking difference is when the hairline independently recedes while they retain a persistent forelock in the juvenile location. This is where most surgeons make their mistakes because the retained forelock in the juvenile position may not be permanent, so decisions have to be made to account for the changes in the forelock position with age. Your surgeon must have a sense of art and balance and imagine how your hairline will change as you age.
Like Bill Clinton, a small percentage of the population retains their juvenile hairline into adulthood. When his hairline slightly receded, he still retained most of the juvenile hairline.  For such men, I might restore the recession; however, I would never put back a juvenile hairline in an adult who doesn’t have one. 
You must have a conversation with your surgeon BEFORE you agree to a hair transplant that you will be stuck with for the rest of your life. It is the most important decision when getting a frontal hair transplant. My hairline is the perfect mature hairline. Its location is the same distance from my glabella (the grove on the upper nose between your eyes) as the tip of my nose is from my chin. This rule is often broken by me when I do a hair transplant when I deal with a persistent forelock, but that is always a discussion I have with the patient before the surgery. (you can write to me at williamrassman33@gmail.com if you want a second opinion or just want to talk about your hairline situation).