Month: May 2005

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Undetectable Hair Transplant – Hair Loss Information – Balding Blog

Dear Dr. Rassman,
I will like to know if you can you tell that someone had a hair transplant by looking at it?

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Hair grows naturally in units of 1, 2, and 3 hairs each. The frontal hairline always has single hairs and a transition zone of these single hairs starts at the forehead (more widely spaced) and they then get closer together as you look further back into the actual denser hair. Within ¼ of an inch, these single hairs get noticeably denser and then groups of 2 hairs start appearing. I say this because to make a hair transplant look like God’s work, God’s design must be copied. The single hair leading edge of a non-transplanted person is erratic and disorderly. It is not heavy, so the idea that there is a ‘line’ with a hairline is a misconception. The transition zone makes the hairline imperceptible. If the pattern is created by the transplant surgeon with enough hair to mimic the normal transition zone, an observer should not be able to see a hairline nor a hair transplant. At our open house events (which we hold every month at each office) the people are amazed that they can not pick out those who had hair transplants from those that did not.

So simply answered, in 95% of all cases, a hair transplant should not be detectable as a hair transplant if there is enough hair to address the needs of the patient. Look at this video of a completely transplanted frontal hairline worked with a comb. Please note that this patient has a high contrast black hair against a light skin color (the most demanding combination). If there is anything abnormal looking about a hair transplant, it will always show up in someone with black hair and light skin.

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Libido and Hair Loss – Hair Loss Information – Balding Blog

My husband is considering a transplant operation as one way to address his waning male libido – and yes, he has thinned quite a bit since he turned 50. A friend told him that since he (the friend) had hair transplants he was feeling more confident in ALL areas of his life, including his sex drive. Is this true? Better than Viagra?

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Libido is a complex characteristic of the human male or female and is not related to just one factor. Clearly, what men think of their manhood, their attractiveness, their self-esteem, the influence of the woman in their life, directly impacts their libido. One of the important determining elements for libido has to do with a man’s emotional state and sense of well being. The second, is a man’s reaction to his hormonal influences and brain regulators that drive libido. We know that Testosterone is the most potent hormone that in determining the sex drive in men (and in women). Third, is the physical ability of a man’s penis to react to his sexual wants and needs. Penile function is another complex process and the failure of a penis to become erect, even in the motivated sexually driven male, will perpetuate (or make worse) sexual dysfunction.

With regard to your comment on the increased confidence of men who have had a hair transplant, well, this is a very common message my patients pass on to me. For example: One well known, rich, successful and happily married businessman came to me with a Class 6 (fairly bald) pattern. He had two transplant sessions totaling about 5000 grafts. He was dynamic and was known for his charismatic style in public – but there was a piece of the inner, sexual man what was influenced by his hair loss. His wife came to me a couple of years after I had finished his hair restoration process. When he told her of his decision to have a hair transplant, she was outwardly supportive, but secretly did not feel it was necessary. She told me that after her husband had his hair back, the man she married came back and her confession brought tears to my eyes. She told me that her love had never diminished as he was balding, because he was still the same man she fell in love with and married. Now she wanted me to share her joy in the decision and to thank me for my role in his restoration two years earlier.

This story should shed light on the secret inner man which is in every man. The inner man does not like aging, Balding is a reminder of the aging process that men hate. The problem for most men, however, is that the transplant route is imbued with negative connotations and men tend to be averse to the idea that their vanity is a problem for them. Facing their vanity without the support of a loving and understanding wife, can be a difficult decision for a married man. For the recently divorced man, on the other hand, hair transplantation is a common process during the post divorce period and with the change in their image (even the possibilities of a potentially painful surgery), a hair transplant is often moved to the forefront. With a change in the physical appearance that comes with a normal looking head of hair, comes a confidence and a libido to match provided the plumbing is in good condition.

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Hair Loss InformationBridging the Generation Gap – Hair Loss Information – Balding Blog

I’m 22 and my dad is very very bald. When i look in the mirror, I see my dad and his dad. I love my dad and grandfather, but i dont want to look like them. Much of my front hair line is gone and I am starting to look far older than i am. When I spoke to my dad about a hair transplant, he told me that I should just accept my fate and go on with life. He also said I was being immature and going bald was just a natural thing. I’ve lost my confidence with women and have become shy and less social in general. What can I do to change my dad’s opinion?

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There is a generation gap here. I can not change what your father thinks, nor the years of whatever the relationship is between you and him. First, I would ask you to look at how the two of you relate on other issues. IF this communication situation is unique to the balding problem, I would be surprised. Good communication is important. I have seen these problems often. Sometimes it reflects cultural issues. Many young men who are first generation Americans, see a different world than their parents who still may have a foot in another culture.

Many times I ask the young man to bring his father or both parents into the office to meet with me. I will sometimes work it out that I see them just before an open house, where the parents can get some sense of what other people can do and how they can change their balding appearance. These open house events serve to tell those that attend, that the people who get hair transplants are normal people, working people, lawyers, doctors and professionals of all sorts. Meeting other transplant patients that come from such a world does a great deal to bridge the communication gap between generations. The key here is not to confront your dad, but to ask for his help in evaluating the modern day alternatives to balding. Controlling what he sees, meeting with a good doctor (not a salesman) and meeting successful transplant patients might change his mind, or make him slightly more open minded. As you are still young, take your time in the process for a transplant at this time may not be the right thing for you to do. Consider taking the drug Propecia and see if it stops or reverses the hair loss. That approach, may be the best approach for you, as it will show to your dad that you have maturity on your part and a cautious skeptical approach to the problem and the solution. He can be a good friend and assist your decision making in more ways that you might think. Be optimistic, and approach the entire process cautiously.

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Hair Loss InformationYoung Male Model’s Hairline – Hair Loss Information – Balding Blog

I’m 22, a model who has just recently hit it big. The clients seem to love my look, but I worry that my hairline is receding and my hair seems thinner, just like my older brother’s hair. It hasn’t been a problem yet on the job, but the competition is intense and I want to stay on the top as long as possible. My brother uses a scalp coloring agent which seems to cover the thinning, but I don’t think that will work for me under the lights. What are my realistic options? I have been extremely busy and don’t have much time between bookings. Are hair transplants an option ?

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As young men age, the normal hairline does rise about ½ inch in the front and about 1 – 1 ½ inches in the corners. I call this the mature male hairline. This is not what the advertisers want in their young male models. Like with male actors, low hairlines are a sign of virility and youth, and no one wants to get cast as an older man before their time. This patient’s hairline is a great example of the youthful look (Patient RA, after 7,147 grafts). I have had the wonderful opportunity to work with many daytime actors during their off-season hiatus, to put back their adolescent hairline and they, like you, were afraid of being replaced with a more youthful ‘would be’ competitor. The best thing for you to do is to use Propecia and possibly consider Rogaine as well if you are really balding. A good evaluation by a competent doctor is an important first step. I would strongly suggest that you make an appointment to see me in my Los Angeles office. Having worked with so many actors and others in the public eye, I understand the sense of urgency, since your earning capacity can be affected.

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Hair Loss in Children – Hair Loss Information by Dr. William Rassman

I just found an article on the subject of hair loss in children which may have interest to my readers. See yesterday’s question from the young girl with possible genetic hair loss. This article is a bit technical but it does address the problem.

Androgenetic Alopecia in Children: report of 20 cases by Tosti A, Iorizzo M, Piraccini BM.
Research performed at: Department of Dermatology, University of Bologna,
Via Massarenti 1, 40138 Bologna, Italy. tosti@med.unibo.it

SUMMARY: Androgenetic alopecia (AGA) is the most common type of hair loss in adults. Although there are differences in the age at onset, the disease starts after puberty when enough testosterone is available to be transformed into dihydrotestosterone. We report 20 prepubertal children with AGA, 12 girls and eight boys, age range 6-10 years, observed over the last 4 years. All had normal physical development. Clinical examination showed hair loss with thinning and widening of the central parting of the scalp, both in boys and girls. In eight cases frontal accentuation and breach of frontal hairline were also present. The clinical diagnosis was confirmed by pull test, trichogram and dermoscopy in all cases, and by scalp biopsy performed in six cases. There was a strong family history of AGA in all patients. The onset of AGA is not expected to be seen in prepubertal patients without abnormal androgen levels. A common feature observed in our series of children with AGA was a strong genetic predisposition to the disease. Although the pathogenesis remains speculative, endocrine evaluation and a strict follow-up are strongly recommended.

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Hair Loss InformationHair Loss in Teenage Female – Hair Loss Information – Balding Blog

I am an active 17 year old high school cheerleader and my hair which used to be thick, is now falling out and becoming thin, like my mother, my grandmother and two of my aunts. They tell me it is in the family, but not when they were my age. What should I do? If I go to a doctor, how do I find one?

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Genetic causes of hair loss in a 17 year old female, is unusual. You were correct to ask your female relatives at what age the condition first appeared with them. I would first have a good doctor see you and look for medical causes of hair loss (there are many). The following problems are amongst those that should be considered: anemia, thyroid disease, connective tissue disease, various gynecological conditions and emotional stress. It is also important to review the use of medications that can cause hair loss, such as oral contraceptives, beta-blockers, Vitamin A, thyroid drugs, coumadin and prednisone if you are taking any of these. Many other medications can also contribute to hair loss so if you are taking any drugs of any type, then that should be looked into as well. The following laboratory tests may be useful if underlying problems are suspected: CBC, Chem Screen, ANA, T4, TSH, STS, Androstenedione, DHEA-Sulfate, Total and Free Testosterone.

It is possible that a medical condition may be the cause of your hair loss, so before you jump to conclusions that you are following your female relatives’ fate, I would have you checked out for these conditions. Also, please read my previous blog entry, Female Hair Loss.

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Hair Loss InformationTrichotillomania – Hair Loss Information – Balding Blog

I have been picking my hair for years. I would like to think that I stopped, but I know that I keep picking at it. I now have a series of bald areas where the picking has taken out some hair. Is this permanent? Will it come back if I stop picking at it? Can it be transplanted if it does not grow back?

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The medical condition is called trichotillomania. Children or adults sometimes twist or pull their hair, brows, or lashes until they come out. This hair pulling is sometimes a coping response to unpleasant stress and occasionally is a sign of a serious problem of an obsessive disorder. If the picking stops early enough, then the traction alopecia that results will reverse. However, this is not what usually happens as most of the people with this disorder continue to pick on the hair until it eventually becomes lost permanently. The best way to determine permanence is to look at the area with a high-powered microscope. Active areas of trichotillomania show blunted, short hairs which are signs of recent regrowth of plucked hair. When these short hairs do not show up under microscopic examination, the traction alopecia is probably permanent.

Yes, hair transplants can put the hair back in the area of alopecia produced by trichotillomania, but the problem with doing it is that the person will just pluck out the same hair again and again and produce the bald spot. What is the point of transplanting the area of alopecia only to have it returned? The key is to address the trichotillomania from a medical/psychiatric medication or therapy approach and solve the underlying problem. Once the patient knows that the cause of the trichotillomania has been fully addressed, then the reward can be a hair transplant to put their hair back.

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Hair Loss InformationMalpractice Information – Hair Loss Information – Balding Blog

I had a hair transplant that deformed me a number of years ago. I have been depressed and angry, hiding under a baseball hat much of the time. Now, I want to get back at the doctor and make him pay me for my suffering. He had no right to do this to me and had I know what I was getting, I would never had the surgery done. How does one find a lawyer to represent me in a malpractice case against the doctor?

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This is a hard question for many reasons. First, you are angry and I understand the anger, but you did make the choice to have the procedure and must recognize your role in enabling the doctor, even though you feel that you were a victim. The old axiom, ‘buyer beware’ holds for anything you buy, even a hair transplant. I am not sanctioning what happened to you, for I have seen hundreds of men in your situation and I have great compassion for someone who wanted to take charge and improve their appearance, and find themselves going south when they wanted to go north. Unfortunately, the old procedures did not meet the standards of many people. Today’s surgery is much better and the standards are good enough to meet even the most critical buyer.

First, I must qualify my credentials by saying that I am not a lawyer, just a well informed doctor. Every State has a ‘Statute of Limitations’ which means that you must file an action within (usually) 2-3 years of the point when you realized you were damaged. I will assume that your surgery goes back to the old days when big plugs were done (10 + year ago). You can, of course, go back to the doctor who did the work and ask him to fix it. A good doctor should try to make things right, but with your degree of anger, you must first address your anger and try to determine just what you want to do about the problem that you are living with. Alternatives to a malpractice suit include: (a) Complaints to the State Medical Board (which in California are always investigated by representatives of the State Attorney General’s office), and (b) Complaints to the Better Business Bureau (this is a place that new patients will often go when checking out a doctor).

Focus on the positive! I generally tell patients who have had the older work to put together a priority list of things that bother them. The more that they are bothered, the higher on the list these complaints should be. If you direct your energies to fix your problem and make it right (overcome the problems) then you can go on with your life. I have written extensively on repairs for the older type of work (see Medical Publications) and have many examples of repairs done on our website (see: Repair Work Photo Gallery).

There are many problems with going the malpractice litigation route that you are asking about. I do know a little about the difficulty in a hair malpractice suit, as I have been an expert witness in the past. I am familiar with two cases that ‘succeeded’, one was settled for less than the cost to fix the work, and the second (poor outcome from scalp reductions) got one of the largest awards in California $140,000 (to be paid over 20 years). He took it all in cash up front (which meant that it was discounted to less than half) and he had to pay his lawyer. The patient ended up with less than $20,000 for himself. Considering the time and energy he put into it, it may have been a poor decision to go that route. The crime here was that he suffered a second time, living the nightmare in court activities for a number of years starting from the time he filed the case. Malpractice cases (particularly in the cosmetic hair business) rarely succeed. The problem for litigation is:

  1. The ‘Standard of Care’ is what the plaintiff must prove was not practiced. In the old days when plugs were the standard quality and although the standard was a ‘sub-standard’, litigation was rarely successful as the sub-standard was the standard that had to be met.
  2. Even if a surgical procedure fails to work, the ‘victim’ must prove that they were damaged by that failure. Assume that a modern hair transplant is done and it failed 100%, the question might be asked what was the damage? Other than the money, anger and the humiliation, there may be no damage that can be demonstrated.
  3. Juries have been less than sympathetic to the balding man’s plight. The patient starts from an ‘underdog’ position and any anger he has (particularly with no real evident and obvious damage) the less sympathetic may be the jury. Remember, the jurors really want to be home, on vacation or someplace other than listening to a bald man’s problems.
  4. Jury decisions in hair transplantation malpractice cases have not produced the larger monetary awards that make it worth the the lawyers’ time. As such, the lawyers are generally reluctant to take them on.

The burden must therefore be on the patient to do his homework, to find a reputable doctor who is known for his good work and whose past performance that can be verified. Becoming a victim today with all of the information on the internet, and the open house events at offices like ours, make it easier for today’s transplant candidate to practice by what is suggested in the phrase “Buyer Beware”. With the power of information at his command today, such problems can and should be avoided.

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Does Blow-Drying Accelerate Hair Loss? – Hair Loss Information – Balding Blog

Dr. Rassman,
Does blow-drying your hair accelerate hair loss? If so, is it worse if you use a brush attachment? Can you blow-dry transplanted hair?
If the plan is to transplant, say, 1200 follicles, how does the patient know that many were actually transplanted? Thanks, Doctor.

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Blow drying does not accelerate the hair loss, but as the hair becomes miniaturized, the hair is more fragile and if one pulls too much or handles the hair roughly, then the hair may break off, giving the illusion that the hair loss is accelerating.

I really do not believe that you need to worry about the number of grafts you are paying for in our office. My finance office reconciles the patient accounting daily and routinely refunds money to patients who did not receive the targeted number of grafts. One of my patients, a well known actor, paid for 2500 grafts at my personal rate of $10/graft. When the accounting was finalized that day, he only got 1400 grafts, so we sent him a refund check for $11,000. After he got the check, he called me and argued with me, telling me that he did not care about the money and that I should keep the money. I refused to do so, saying that if he did not care about the money, he should give it to a charity, but that I had not earned it, so it was not mine to keep. He did make a donation of $11,000 to his favorite charity with my name on the donation. Integrity is either in a person or it is not and I was raised to believe that you can often tell the integrity of a man by his business dealings.

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Hair Loss InformationRemoving Scalp Tattoo – Hair Loss Information – Balding Blog

I have tried hair systems, weaves and all of these newest innovations in this field. Then I started getting transplants in 1987, with 5 scalp reductions and 7 hair transplant procedures. The more I did, the worse I looked. So I came up with the idea that I could tattoo my scalp and make it look like hair by putting brown dots the color of my dark hair. I then shaved my head. The tattoos were done on my scars as well. For a while they looked OK, but then the brown color started to turn green. Now I have a green head. Do you have a solution for this? Can the tattoo color be returned or can they just be removed? What would you suggest?

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I have seen problems like this in the past. Creative people come up with creative answers to problems, but when the solutions fail, the consequences are sometime profound. I have had two such patients: The first had terrible scars that were treated with a balloon insert to stretch the normal scalp so that the tattooed scalp could be removed. The balloon was in inflated 2-3 times each week for 10 weeks before the scar was removed. It worked nicely and he was fortunate to have enough normal scalp to stretch the excised scalp defect. The second patient went through the same thing you did. He did not have a great deal of hair left, but he did have enough to start to cover some of the most prominent balding areas . The bad scars were improved with some scar surgery and the transplants did help. This second patient and his girlfriend were very grateful for the improvement and remain amongst the most happy of my patients. It was an important lesson for me – that working through problems with the patient as a partner with realistic goals, is the best way to make the best out of a bad situation.