Month: May 2005

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Scalp Psoriasis and Transplants – Hair Loss Information – Balding Blog

Does a history of scalp psoriasis (assuming it is under control with treatment) rule out using minoxidil or transplants to offset hair loss?

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Psoriasis is an autoimmune disease that has a genetic preference in its victim selection. It comes in all degrees of activity. Simple dandruff may be a very low active state of psoriasis and as it becomes more severe, it takes on more of the characteristics of the disease state, where scaling of the skin and red areas in the affected area can become painful. Flaking of the skin can be easily seen when psoriasis affects the scalp. Baldness is also a genetic process but it is unrelated to psoriasis. Both processes can co-exist in the same person and both can be treated independently at the same time.

People with psoriasis often ask about transplanting the disease from one area of the scalp to another. Can, for example, skin taken from the area where psoriasis is active, move the disease to areas in the recipient area that are not showing signs of the disease? The answer here is no, as the disease seems to be localized in the area where the scaling exist and moving the hair from the scaling area does not impact the normal recipient area, assuming the recipient area is normal. Psoriasis can be aggravated in the area where the disease is active by any trauma and surgery is a trauma. Some people who tend to pick at their skin and hair can develop traction alopecia (hair loss) if they persist on picking over a prolonged period of time.

I generally tell my patients to use a topical treatment (steroids) on any active area of psoriasis prior to a hair transplant so that the scaling that occurs will be less bothersome during the transplant process. I try to get good control of any scalp psoriasis prior to a hair transplant.

With regard to minoxidil, if this medication does not produce skin side-effects, then one can use it with psoriasis. If side effects should appear or the psoriasis should become worse with minoxidil, then the medication may not be a good choice.

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Photos – Day After Hair Transplants – Hair Loss Information – Balding Blog

I have thin hair in front. I am in the public eye and can not take off more than a day or two. What will I look like after a hair transplant?

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To answer your question, I took some pictures of a person who is 50, who had a hair transplant (1,046 grafts) and came in for a hair wash by us the next day. He has enough hair to cover the transplants. Good washing will guarantee, as much as possible, that any scabbing is removed. With the use of medications, we can keep swelling on most people to undetectable levels. He can go out in public the day after surgery without any real detection.

The photo on the left was taken before his procedure — the photo in the middle and the photo on the right are 1 day after.





Update: Oops, I originally posted the wrong patient photos with this entry. I apologize for the confusion. The correct photos are what you see above.

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Hair Loss InformationUsing Cover-Ups After Transplant – Hair Loss Information – Balding Blog

How soon after a transplant procedure can you resume using cover ups such as, Couvre or GLH, until your newly transplanted hair grows in?
Thank You!

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The use of Couvre and other scalp coloring agents, which tend to be powdery, can be safely used after the scabbing is gone. Scabbing is gone as early as 1-2 days on the short side, and 5-9 days on the long side. The difference between the short and long side reflect two controllable variables and one non-controllable one. The controllable ones are (1) size of the wounds, the smaller the wounds the shorter the healing time, and (2) the washing technique used at the surgery, the end of the surgery and the next day or two after the surgery. Good aggressive washing gets rid of scabs (in many of our patients) in a day or two. We offer hair washes for all of our patients after the surgery and as often as they feel that they are helpful. Patients are rightfully afraid to be too aggressive with the wash, out of fear that the grafts will be washed out of their recipient site. The non-controllable variable is the patient’s individual and unique reaction to the surgery. Some patients tend to exude more ‘transudate’ from the wounds (the yellowish fluid that brings blood-coagulating elements will often form scabs) and some patients may have microscopic bleeding at the wound site after the surgery (forming clots). All of these scabs and clots can be washed off the next day with properly administered washing techniques.

After the scabs are gone, these powdery agents can be used until the new hair wipes out the need for them (usually 5-8 months after the surgery).

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Scalp Flap Experience – Hair Loss Information – Balding Blog

I am a patient of yours and I read a previous blog question and response from you the other day where you worked the problem out with the patient. I came to you 13 years ago with a problem that others could not help me with. After I explained the problem to you (which you listened carefully) I went into my solution. Although I prefer you not to use my name, you might want to tell your audience my story. I have been forever in your debt and grateful.

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I remember you very well. You came to me after having done two flap procedures where sections of your scalp were moved from the back and sides of your head to cover the front (like a banana peel). This was an operation invented by a man from Argentina (Jury Flap) that was popular amongst certain surgeons in the late 1980s. This left the patient with an unnatural hair line, hair lying in the wrong direction and a hair line that (on my particular patient in question) was located far too high. You had gaps in many areas of your frontal hairline and there was no hair behind the flaps, leaving you bald in the mid-head. The donor area was depleted of substantial amounts of good movable hair so the supply was very limited and you lost much of your native neck hair as a result of the stress of the procedure.

I remember our first conversation and what you told me. You said (out of context): “I have been thinking about this problem for a few years now. I have met with doctor after doctor and when I finally figured out a way to manage the problem, none of the doctors who I visited would do what I asked them to do.” You went on to explain that your hair had a very strong wave and character to it (Italian hair of medium weight) and that if some hair was placed in front of these flaps, far in front of the flaps, then you could style your hair with a comb-back and a pompadour (like Elvis but much more subtle) and an angled combing style would hide your problem. You told me that you used gels and blow drying to achieve your looks; and you were convinced that this solution could solve your problem if I could find enough hair to transplant. After the first surgery (which was experimental on my part) and the ensuing 12 months it took for the hair to grow out to a good styling length, the results were fantastic. Your creative styling did wonders for the 600 grafts we put into your frontal hairline area. The good news was that we performed four surgeries over the 8 years we worked on you and you got enough hair to address, not only the frontal defects, but also the balding in your neck hair, which was a complication of the flap procedure. Today, you still must spend a few minutes every morning styling your hair, but even my eye can not pick out any defect on you- you looked great when last we met for dinner at one of your restaurants! Thanks for allowing me to share your experience.

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Hair Loss InformationHair Piece Blues – Hair Loss Information – Balding Blog

My earlier post about smelly hair systems generated a lot of good responses…

I loved yesterday’s question on the smelly hair system. It does not even compare to my problem. I have already found the secrets to keeping it from smelling decent, but that does not deal with the ladies when they want access to my head. I am working the internet dating scene and this problem is killing me. I find myself fearing the intimacy that I fantasize about. Now it is not fantasy, but a pending nightmare each and every time I start up a new relationship. If I do not wear the hair piece, I can not be myself. How does one deal with the no-touch zone that puts the fear of God into the rug wearer when a woman wants to run her fingers through the piece?

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When a man embraces a woman, there is a tendency for the woman to want to run her fingers through her man’s hair. This is a deal breaker for hair system wearers and it puts them on-guard every time they establish a new relationship, often impacting behavoir as the wearer tenses up during intimate moments. I have spoken to many men and this is a common problem. The answer is that the rug wearer needs to keep one hand free at all times to fend off the roaming hands of the woman. It does put the kybosh on the freedoms one wants in real intimacy and it excludes such activities as bathing, swimming and the like. I have found that these problems are not addressed well in long term relationships either. I have done hair transplants on men whose wives have told me that they have never seen their husband without his wig on, not even after 30 years of marriage. I am afraid there is no real answer. Every hair system can be felt, even with the best of weaves. The only real answer to this question is a good hair transplant.

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Hair Loss InformationWhy Did I Create This Blog? – Hair Loss Information – Balding Blog

I was wondering why you are running this baldingblog.com site rather than participating in one or more of the many chat groups on the internet?

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The chat groups have a scattered agenda. Many are using it as a magnet for doctor advertising, charging doctors a fee for participation and favoring those that participate. Some of these sites have a combination of content focused on hair loss and chat activities. These sites are frequented by many of the same people who dominate the chat agenda, so it is less focused upon subject content and more focused upon selling something. With the anonimity of the internet, you can not always be sure which of the posters are honestly trying to help and which are trying to line their own pockets. Some of these sites thrive on things that go wrong. In our practice, things rarely go wrong, so a site that focused on the exceptions rather than the rule, gives a false impression of the process to the new inquirer who wants to learn about the reality of today’s modern hair transplant process. I have always liked to have free forums where new people can get answers without intimidation or salesmen hawking their every move. In my office, I started having open house events and hotel seminars 13 years ago with patient participation long before a hair transplant recipient ever came ‘out of the closet’ where he hid his hair transplants. We never used a salesmen anywhere in our business model. In those days, the ‘standard of care’ was the pluggy graft, so showing off a patient without plugs made our seminars and open house events very successful. Those who came, expected to see pluggy patients and what they saw were normal looking people where the hair transplant could not be seen. At these events, I always held an open forum, allowing interruptions as the audience fell into the tempo of the subject material and conversations. It was the audience that ran the ‘show’ not me. The BaldingBlog.com site allows the type of freedom that I have in our seminars and it put the agenda into the hands of the questioner. I am more a responsive participant as a content expert. I have had many emails that I do not put on the BaldingBlog because I am frequently responding to a follow-up question that may not have a public interest.

I have in the past experimented with participating in these chats, but many of the aggressive participants love to go after a doctor who is not paying his ‘right of way’ for immunity in the for-profit sites. Some of the comments have been tasteless. Hearsay comments dominate. If I go down in the mud with those that are hair obsessed or angry, I generally get frustrated. Arguing with an irrational person is akin to a Jerry Springer milieu rather than an educational and informative framework. The worst part of anonymous free speech is that some of these chat groups don’t care if any statement can’t be proved to be true. One can say that Dr. X is a murderer, a heartless transplant mutilator, a mercenary who is driven by the almighty dollar, and if there is no recourse to identify the person who sends out such comments, then you can not necessarily believe anything you read. I have seen people say that they have personally seen patients of Dr. X …. Or that they are a patient of Dr. X and certifies to the crime personally. Defending oneself from baseless attacks are pointless and a wasteful use of time. I would doubt that any of this audience would want to read the JerrySpringerBaldingBlog.

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Hair Loss InformationBody Hair Transplantation – Hair Loss Information – Balding Blog

In reply to my post titled Hirsute Men and Head Hair Loss, Duke writes…

That is fascinating but it prompts a few thoughts. Why not use body hair for transplant processes?

More research into the Red Indian genetic heritage us surely required.

And why does the balding gene only impact on the top of the head and not the sides.

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This is a fun question. First, why the top of the head. Leonard Shlain’s book, “Sex, Time and Power: How Women’s Sexuality Shaped Human Evolution,” had an interesting insight into the cause of balding. He postulates that our tribal heritage arose when man lived amongst his peers constituting 100-150 people. When looking at that the hunters (the healthy and fit men) in the light of certain qualities, there was a distribution of 4 traits that would pencil out to an 8% rule. He believed as animals learned to be afraid of man, the 8% of the hunters who were bald did not frighten the animals because they did not have the typical framed face of a hairy man, so animals would not run from them. They fulfilled the role of the spotter in the hunting party. Likewise, 8% of men were color blind and could see the animals in the bush missed by normal color visioned men, 8% were left handed and they threw the spear from the left side of the hunting group and 8% were gay so that they would stay home with the women and become more involved in their activities yet retain the strength to protect them. Fathering of children, while the heterosexual man were away hunting, was therefore not a concern.

If you take the 100-150 tribe hypothesis into the Red Indian, it would be relatively easy to see that with a small band of Indians that moved over from the Alaskan Bridge and down the Canadian countryside (they initially migrated to what would become the western American territory) it is possible that selective extermination of a sub-set (based upon the balding trait for example) of Indians over some generations during hard times, might have wiped out that genetic characteristic. This hypothesis for the Red Indian has been made by some, but without the presence of a written language or other documentation of their history, such assumptions might be a dangerous precedence to be proposed by a hair transplant surgeon.

Now, regarding body hair transplantation:

Experimentation is presently occurring on the use of body hair in some transplant centers (they just do not call it experimentation). As body hair grows in singular numbers (not follicular units of more than 1 hair each as in scalp hair) and length is not as long, and the hair cycle is possibly much shorter and the sleep cycle much longer, the use of body hair for transplantation might leave much to be desired.

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When Will I Go Bald? – Hair Loss Information – Balding Blog

i am 20 yrs old,and my dad is bald,although he started losing his hair only when he was 37 yrs old,i just have the fear that i may also get bald like my dad,so far now,my hair is ok,just that i have some dandruff .is there any specific age that i wil start balding,or how can i keep my hair healthy and ever long lasting.is it mandatory that i may also lose hair as well as i grow old

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Balding almost never hits men under 18, so I have set up a model for the balding process to give some insights into men on the balding process. If you imagine that we are born with different types of baby hair that changes as we get into our first year. Then it changes again through childhood and then again around puberty (11-13). I suspect that these changes are influenced heavily by the hormone DHT. The hair undergoes another change between 18-29 years old.

The changes are two fold. The first part of the process is the advancement of the frontal hairline into the mature position. The typical juvenile hairline of the 12 year old boy is no different than the hairline of the 12 year old girl, but as men (typically 95% of Caucasians) move into a mature pattern with the central area rising about ½ – 3/4th inch above the central crease and the sides move up about 1-1½ inches, giving a slightly receded corner. A small percentage of men (Bill Clinton and Ronald Reagan) keep their 12 year old hairlines through life. Many young men mistake the mature changes in the Caucasian hairline for balding. Such changes are normal, but for the soap actors who must retain their baby face, such changes are devastating, so on rare occasions I have restored this juvenile hairline on famous actors.

Secondly, the balding process may start anytime after this change starts (about 18 years old). Since real balding starts at about 18 years old (caused by the impact of DHT on the susceptible genes associated with genetic hair loss) the faster the fall out occurs, the worse the prognosis. There is some protection against DHT that holds until 18, but when that protection is gone, the faster the fall out, the more is the indication that balding will be severe. On a visit to my office, I will put the hair of the patient on a TV, so that they can look at the hair shaft diameter variability. Normal (non-balding) hair has equal diameter while genetically impacted hair starts to become finer and finer, reducing the diameter to smaller and smaller sizes (miniaturization is the term that doctors use) until it becomes threadlike and just disappears. The drug Propecia blocks the impact of DHT on these impacted hairs, often slowing, stopping or reversing the process over time. The best way to change the course of this hair loss is to take Propecia which means that you must stay on the drug for life. Short of that medication, there is no effective proven medication or treatment. There is no doubt that the hair loss will still pick up again (even on the drug) but it will be a slower process.

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Hair Loss InformationTerrible Scarring from Hair Transplant – Hair Loss Information – Balding Blog

Doctor; I had my 4th hair transplant last October with the same surgeon who had done the prior 3. No complaints the first 3 sessions; I had decided to do a final “touchup”, filling in the front a bit more and adding to the crown.

Big Mistake.

My donor area on the left side was totally butchered; a patch about 1 1/2X 1 1/2 inches totally barren and badly scarred. I knew something was wrong immediately after surgery. The hair was gone the next day-immense pain and tightness was in the wound and there was redness also there. On the left side, there was a scab in the middle of the patch that took 2 months to heal.

The right side was similar but not quite as bad. The hair eventually grew back on the right side around 2 1/2-3 months. Its now been over 7 months; I do not expect anything will ever grow on the left side. The sutures seemed placed extremely high above the edges of the wound, also suspicious. I was told by the surgeon that everything was fine; these things “always resolve”.

Finally a month ago, after seeing my predicament, he tepidly agreed that re-growth wasn’t in the cards. He said he would do “Scar revisions”? This did not seem right, so I sought 2 other opinions, both saying scar revision considering the circumstance was definitely the wrong way to go, and that transplanting hair into the area, in 2 small sessions, was the best way to handle it.

Do you have any advice for me?

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Scars from any surgery are unavoidable. When I performed general surgery, people would judge the surgeon by the appearance of the scar after the surgery. If the scar was barely detectable, then the surgeon was great, but if the scar was stretched or obvious (for example) the surgeon was terrible. If I did 100 appendectomies, about 10 would have a widened scar and 90 would have a barely detectable scar. Was I a great surgeon 90% of the time? How did I select who got the bad surgery? The question sounds silly, but as a surgeon I am humbled all of the time that anything ever healed and I live in a constant state of awareness that there are many things that I can not control. Scarring is just one of them, but I do not abdicate on the awesome responsibility upon me to try to get perfect scars 100% of the time.

I want to know how the scar impacts your styling and your ability to function daily. Since we are talking about visible scars in most situations, we are talking about the ability for the hair around the scar to cover it adequately. The thinning of the hair in the donor area is unavoidable and as more surgeries are done, more thinning can be expected and the scarring risks rise (non-visible and visible scarring are separate issues here). Think of it as follows:

  1. the donor area has extra skin when the process is started (you can feel this if you put your hand behind your head and move the scalp up and down as it should move at least ½ inch)
  2. each time you have a procedure, some of the extra skin is removed and eventually the skin may get tighter
  3. as everyone is different, some people’ skin just gets thinner and not tighter, others get tighter and not thinner, most are a combination of the two. When the skin does not get tighter, the ‘extra’ skin probably re-grows
  4. every surgery produces more scars below the skin making the skin less mobile to some degree and the amount of this mobility (and binding of the skin to the deep structures of the scalp area) varies in each patient.

Some patients have poor healing wound characteristics in their collagen and as such, become set-up for stretching scars. Unfortunately, these patients may not be obvious in advance of a surgery. For a repair, the surgeon has to decide just how far to push the skin removal process; in other words, he must determine with each surgery just how much skin to remove. If the surgeon takes out too much skin, then the wound may be too tight to close without tension. High tension wound closures are the greatest cause of scarring and reactive hair loss. Sometimes, people just get reaction to the sutures, or the surgery, or they might even get an infection (clinically evident or sub-clinical). Sometimes, scars just happen, not on the first procedure, possibly not the second, but maybe the third. When the scars form, then each patient has to be assessed by a skillful surgeon, hopefully one you trust. I always tell my patients that a surgeon and a patient have a partnership. A good partnership means that the partners stick together in good or hard times. I tell my patients that if anything ever goes wrong with a surgery done by me, any complication from infection to scarring, I am the best partner that they can have because I take full ownership of the responsibilities of the partnership. Money or time has no meaning for me if things went wrong, so I tend to be there to stand by the patient and do whatever is necessary to manage the process. As a general surgeon, I lived with death from accidents and the outcome of cancers that were incurable, but I was a dedicated partner to each and every patient I took on as a surgeon.

First, ask yourself if your doctor is a real partner with you in this process. Then, if he is, discuss the issues so that you understand his thinking. His analysis and what he will do should depend upon the ‘tension’ on the wound when it was closed (at the last surgery) and the dimensions of the strip of skin that was removed. Decisions on how to repair such problems vary with the conditions of the donor area and the scarring above and below the surface. Does you surgeon suspect a reason that the scar formed? If it was very tight and immobile, then removing the scar may not work as a primary surgery for the repair process? How is the hair around the donor scar? If it is good, then the approach will be different than if it is poor. What are the dimensions of the donor scar (the wider it is, the harder it is to remove)? What is the proposed surgical correction and if it is done, why would the surgeon expect a better outcome for the repair than he had on the surgery that produced the problem? What are the alternative approaches to removing the scar? Transplanting the scar may work, but where will the hair come from and what is the risk of the removal of still more hair? Is a balloon a better approach (definitely for the very bad scars) and what about FUE surgery?

It is impossible for me to determine your exact situation without examining you and seeing (and feeling) the status of your donor area. Be sure that the doctor you have is experienced in these repairs and can show you what type of results his experience with such repairs have produced (like showing you other patients who have had such repairs). I can tell you that the only surgeons that never see scarring in surgery are those that do not perform any surgery. Every surgeon sees scars. In standard hair transplants with today’s newer closure techniques, obvious scarring should be present in less than 2% of those undergoing a standard strip excision transplant. Solutions to transplant scarring are there almost all of the time. An alternative solution for you to consider are FUEs (Follicular Unit Extractions) where each hair grouping is removed one at a time and then transplanted into the scar. The use of balloons can produce miracles for the worst of the scars. Both FUE and balloon use require specialized skills, not common to most hair transplant surgeons.

For more info on FUE, please view the FOX Procedure.

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Hair Loss InformationReplacing Hair System with Transplant – Hair Loss Information – Balding Blog

I read with great interest, your answer to the person who wore a hair system that stunk. Systems stink and it’s not only the smell that I am talking about. This is only one of the problems I am faced with. I don’t have a lot of money. If I did, the place where my system is serviced would take care of me as often as I want. They suggest once a week, but they want $60 for a full service. Frankly that is alot of money when you consider that I have to take off from work to have it done. In the past 10 years, I have spent over $10,000 in hair systems and the costs of replacing the one I have now will be another few thousand dollars. It really does need to be replaced. I want to know how much will a hair transplant cost me and how many transplant procedures will I have to suffer through? I am 35 years old.

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Most people who are 35 have already established a mature pattern of hair loss, so first you need to find out what Class of hair loss you have. Read Assessing Hair Loss and then get back to me with photos of yourself with wet hair and dry hair, showing the full extent of the hair loss. A phone consultation with me will be specifically focused on your individual needs. Generally, the less the balding, the less expensive will be the process. A Class 3 reconstruction might run between $3000-$6000 and if your hair loss is stable, then more surgeries may not be necessary. For the very bald person, the cost can climb to range between $10,000-$15,000 (these prices are based upon our least expensive Standby program). Please see Fees and Financing for more information.