How long do miniaturized hairs live?

/by William Rassman, M.D./0 /
My question is, can miniaturized hair stabilize? What I mean by that is usually miniaturized hair continues to shrink and get smaller and narrower with each growth cycle until it eventually falls out and stop growing altogether. But can miniaturized hair miniaturize or narrow to just a certain point and then stop/stabilize at that level and not continue to the point where it eventually stops growing? I ask because I believe I have some miniaturized hairs that have been that way for over 10 years and have not changed. Also because I’ve noticed that in a lot of bald men, even those with a Norwood 7 pattern, they often aren’t “slick bald” and have some sporadic hairs remaining on top that seem to remain there permanently.
Also, how do you know when hair loss as whole has stabilized on a particular person? I ask because it’s often stated/recommended for people to wait until their 30’s for a hair transplant so you have an idea of what their final pattern is and when it is stabilized. But from what I read, can’t hair loss stop, start and pick up/ slow down at different intervals throughout peoples lives?
So if a person at 38 years old has a Norwood 3 pattern based on visualizing their scalp/ miniaturization studies with haircheck or whatever, and it hasn’t progressed in a few years so it’s determined for the time being it’s stable and they decide to go forward with a hair transplant; how is it known that in 2, 5, 10 years etc down the road that it won’t pic up again and other areas of the scalp won’t start miniaturizing and end up in a full Norwood 6/7 pattern or whatever?

Great questions.  The concept of miniaturization leading to eventual apoptosis (death) is accepted as the standard process description.   Like you, I have seen some men retain their miniaturized hair for years without growth.  I expect that there is some timeline that these hairs will eventually follow the apoptosis model. With medication, the process can be slowed.  I, too, have seen some Class 7 patients who have some residual both miniaturized hairs and even a few normal terminal hairs.  I remember one man who gave hear of his terminal hairs a name, and when I transplanted him, he was going to check on the welfare of these named hairs.  When he came back the next day, I asked him about his ‘hair’ friends, and he said: “After seeing what you gave me. I don’t care about them any longer”.  

Does miniaturization dictate how many grafts you take out

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

Miniaturization studies help to confirm a person’s expected balding pattern. But let’s say a person is assessed for miniaturization and their hair is miniaturized in a Norwood 3 pattern, how do you know that additional hair beyond the already miniaturized zones won’t also start to miniaturize down the road resulting in an even higher Norwood level?

How I  use the donor area is a balancing act between present balding patterns, evident miniaturization suggesting future balding patterns, and the hidden future potential patterns of balding that are not evident at this time. I always keep reserves from the original donor density calculations I make on every patient. 

What happens to the hairs when you eventually bald?

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

Whatever Norwood balding pattern a person might happen to develop, does every single hair follicle in those miniaturized/ balding zones eventually miniaturize, stop growing and leave those areas (ie the hairline, crown, etc) totally hairless? Or can there be some hairs in those zones that are DHT resistant and don’t ever fall out? It seems that most balding guys I see still have some hair follicles left in the balding areas that have remained there for a while.

In the balding pattern, the hairs may all fall out (Apoptosis) or some of them may remain.  I have seen Class 7 patients with a complete pattern of balding, yet when I look at the balding area, I often see a few remaining hairs here and there. 

I just turned 17

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

I just turned 17, and I have a family history of balding in most members of my family, both my mother’s and my father’s side.  What should I do?

I assume you have genetics in the family, and you are concerned that you MIGHT follow the family pattern somehow. Just keep an eye on your hair by looking for unusual hair shedding, thinning in the front or crown, or recession of the hairline. If you should start developing these symptoms, see a good hair expert and build a complete Personalized Master Plan that you can follow over time as your hair situation changes. A good doctor will care about you, and that is important, in my opinion.

Age for advanced balding

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

 I see you mention several times in your posts that usually people who inherit the genes for MPB typically start showing signs of hair loss by 30. And for those who are destined for advanced Norwood 6/7 patterns, the pattern is usually already established/ complete by the time they are late 20’s. Those who don’t begin balding until after 30 usually develop less severe patterns like a Norwood 3. On the other hand however, I’ve seen several posts where the writer and/ or you gave examples of people who developed balding later in life and some of it to an advanced degree. What accounts for this seemingly conflicting information? Did many of those people likely already have miniaturization starting in their 20’s, but it was just never noticed and as it progressed with the age, the hairloss finally started to become evident?

Specific patients will start balding at any age making it difficult to draw conclusions on any single individual.  Norwood recognized this so he looked at large populations and recorded the incidence of each pattern with respective ages.  That showed most of the advanced balding patterns like the Class 7 pattern men by the age of 30.  I have seen many men who started balding late in life (30s or 40s and even 50s), but those men were more exceptions to the general population statistics. If you are looking for rules to let you know where your balding pattern will go, forget the Norwood statistics and evaluate your pattern by miniaturization and your detectable hair loss 

DHT resistant hair

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

Are hair from the back of your head actually immune to dht or is this a myth?

Yes, Dr. Norman Oreintrich reported this in 1959, telling us that the band of hair reflecting the remaining hair of a Class 7 pattern is resistant to the effects of balding and DHT. That is why hair transplants work so well, as they last the lifetime of the patient.

The meaning of thinning hair

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

I thought I recalled a post of yours somewhere where you said just because a person with AGA is thinning and losing hair in select areas (depending on their Norwood level) that doesn’t mean those areas will end up slick bald. Those areas can thin to a certain percentage of their original density and then stabilize there.

Thinning occurs in three forms:

1- Miniaturization which generally leads to balding.  This never impacts the donor area.

2- Age-Related Thinning: generally hits older people but can hit the younger person as well. This is unified thinning all over the head, including the donor area

3- Moseac Thinning:  Some people have Moseac characteristics that are almost impossible to detect without good genetic testing comparing hair follicles, a very expensive process if it can be done at all.

Meaning of donor density

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

I was surfing the internet on topics related to hair loss and came across your balding blog which is a super helpful resource. I saw you posted on there a math formula on how to estimate the amount of grafts available in the donor area.  When I looked closely with the ultra close up/ zoom option on my phone at a section of my donor and calculated the math, I average about 2.55 hairs per follicular unit which based on your formula would put me at having roughly 7,598 grafts that I can transplant. The only thing is, from what I read the diameter of you hair follicles also factors in. I don’t have a tool to measure but I’m guessing it’s more on the fine side like 45-50 microns. At 2.55 hairs per FU with the hair being more on the fine side, can you tell me how that would skew the available donor and what that would roughly bring my number to?

And, does that formula matter if it is FUE o FUT you plan to do?
  The follicular unit count on the head of a typical male is 50,000 units and constant with all races and in all people.  This is important to understand because the amount of hair per follicular unit is variable.  Simple math would show that if two people measured 2 hairs/per follicular unit in person one and 3 hairs per follicular unit in person two, then clearly, person two would have 50% more hair to transplant.  To make it a bit more confusing, if person two had a hair shaft with half of the volume of person number one, the advantage of person number two would be completely neutralized.  So you see, hair numbers and hair thickness both participate in the “fullness’ we see as we look at a person’s hair volume.  Dr. Marrit, in the 1980s, showed that if he plucked out half of the hairs on one side of the head in a person with black hair and medium-weight hair with an average density, the human eye could not see the difference between the two sides.  This is where the surgeon’s judgment and his/her experience come in, as just a number doesn’t tell you what you must know about grafting a balding area.  I can’t write a book here, but I hope this explanation helps.

Asynchronous hair shedding

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

1 year of finasteride. but in the past month, I am noticing my hair density is decreasing. I think it’s a seasonal shed.  Thoughts?

Humans have asynchronous shedding, unlike most mammals in the animal kingdom who have synchronous shedding. That means that we did not shed to cycles of the weather, or for that matter, for any external factor

22 and thinning

/by William Rassman, M.D./0 /
I am 22 years old, and will turn 23 in September.  I have been experiencing hair loss since I was 20 years old & losing all my hair is my biggest fear.  Getting a hair transplant is something I think I’ll have to get eventually..but before I do that, I have been contemplating starting finasteride 1mg daily for quite some time now but before I do that I wanted expert’s advice on the same.
PS: I have some pimples/inflammation on my donor region (back of my head) & am treating the above already using the keta 2% shampoo 
In short my questions are:

1- What supplements (Multi-Vitamins/Biotin etc..) I should start with?

2- Should I start consuming finasteride 1mg daily now? and start minoxidil too??

Questions on Finasteride:-

1- If I start taking Finasteride, do I have to keep taking it forever?

2- Read online about “shedding phase” that people experience once they are on finasteride 

3- How often does it happen, is it something that will repeat itself over and over again?

Finasteride daily is the best medication for genetic hair loss in a young man.  A few men might get shedding when starting it (not uncommon), but that subsides in a month or two and doesn’t repeat.  Medications for genetic balding, like finasteride, are a lifetime commitment.  I don’t think that most Western men have problems with malnutrition if they eat a reasonable Western diet, so vitamins are not critical for hair loss prevention; however, Vitamin D may be important to men who do not get enough skin, so make sure your vitamin D level is normal, it it can be a cause of hair loss.  

Predicting patterns of hair loss

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

I saw in one of your posts on your blog where you said somebody who is 35 years old with a Norwood 3A pattern has a worst case scenario of reaching a Norwood 5A. How do you know that? I thought the extent of hair loss can’t be predicted and in all of your posts you say that hair loss is progressive.  Also, if you live long enough, will a Norwood Class 3 become a Norwood CLass 7 pattern?

Everyone with balding genetics has a hair loss pattern that will evolve in their lifetime at an age determined by the genetic clock in each hair follicle. That pattern depends upon your inheritance and the progressive nature of hair loss reflects the movement to this “Unknown” pattern that you have. I developed general rules of thumb over 32 years in this business that give me insights into the statistics of patterned hair loss as it reflects the age and circumstances of each patient I examine.  Some balding men, for example, with a Class 3A pattern of balding, may never progress further, so a Class, 6 or 7 pattern for that person, may not be a genuine concern for me with some probability predictions made by me. Every person I examine is different.  For the ‘victim’ of balding, they worry about developing a Class 6 pr 7 pattern, which may be familial, so they rightfully worry. 

About your second question:  No.  If you don’t have the genes for a Class 7 pattern, you will not develop one even if you live to 100.  The problem is that there is no way to tell what genetics you inherited and how that genetics is expressed in your body.  That is why a doctor with great experience, like me, brings some value but still can’t predict the pattern 100%. My grandfather lived to 102 and retained his juvenile hairline and a full head of hair. This proved to me that hair loss is not inevitable for men. My Grandmother lived to 114, and she retained her juvenile female hairline throughout her life.