Month: November 2014

I have been reading various blogs and posts on hair transplants before I take the dive. Many doctors are using PRP, is this a valuable thing to use?

At the recent International Society of Hair Restoration Surgeons (ISHRS annual meeting), the subject of the use and value of using Platelet Rich Plasma (PRP) came up. Over the years, there have been many poorly researched reports on the use of PRP. Not only at the meeting did the papers reinforce the lack of value for using PRP, but the uses by those who advocate it make me wonder if this is a money thing for the doctor’s income. In performing PRP, the doctor draws blood from the patient and then spins the blood down to reveal the part of the blood that is known to be rich in platelets. It is not a complicated or a costly process. Platelets are the part of the blood that allows blood to clot when you cut your arm, or your beard when you shave. Not only is it valuable in clotting, but it supplies important elements for the healing process. The theory goes from there that if it helps healing from when you cut your face or arm, it must have strange healing powers, including stem cells that are derived by the platelets http://baldingblog.com/2013/05/30/lots-of-questions-about-prp-platelet-rich-plasma-and-acell-use/. I cannot say the results of any of the newest papers impressed me in any way.

So you might ask: Why do the doctors recommend using it? I really have a problem with answering this the way I feel, but I will tell you that most doctors who use it charge about $1,500 for a treatment of taking and returning your own platelets back to you. That is a good motivation for the doctor, but not necessarily for the patient (unless the patient don’t care much about the $1500).

I am personally not sure if I would try it on myself or even offer it for no significant expense since I have not been convinced of it’s scientific value. Anecdotal results are mostly what is out there.

Dear Dr. Rassman
I’m a 54 years old male. I had a hair transplant operation on 30 June 2014 by FUT method followed by FUE method on 1st July to complete the transplantation. From the second day after operation I noticed that a big area in recipient part between crown and front of my head, the skin is so irritated (fig.1) and after 1 week it became completely black and was necrosed (fig.2).

Photos: Figure 1, Figure 2

I rang to my surgeon to consult on this issue. He said at your age this problem sometimes happens and I should wait until the skin being repaired and to speed up this procedure I should put warm towel on the necrosis area as well as making it oily by Vaseline to avoid dryness. I really don’t believe in the opinion of my doctor to relate this problem to my age, so I would highly appreciate if you let me know your opinion regarding the reason of this problem, is there any special treatment for such necrosis?

As the recovery procedure of the skin is so slow as shown in figs 3 and 4, I’m not sure that the transplanted follicles are not damaged. I thank you so much if receiving your valuable comments.

Photos: Figure 3, Figure 4

Sincerely yours

I am not clear on your history as you note a FUT (as in strip surgery) and fue (as in Follicular Unit Extraction Technique). There are some doctors who combined FUT and FUE (called FIT by one particular surgeon).

In my 23 years in this industry, we have performed hair restoration surgery in over 15,000 patients (with as many as 8 doctors working for the New Hair Institute at one time), so my experience is in the thousands of patients we have treated at NHI. Although I have never personally seen this complication in any of our patients, I have been aware of this complication in patients who have either consulted with me or I have heard about it through other doctors’ reports at medical meetings. At the recent meeting at the beginning of this month, one doctor presented 5 cases like this so your experience has been replicated at other clinics. This problem was more common in the 1993-1996 time frame, as doctors were increasing the number of grafts they were performing and not reducing the size of the punch or slit equipment. These doctors devascularized the scalp because their wound areas were too large or put too much epinephrine with the Xylocaine that negatively impacted the blood supply to the mid-scalp.

The central area of the scalp (where your problem is demonstrated) was the place where this complication has been seen most commonly, although I have seen patients referred to me where the finding was present in the donor wounds from FUT (strip) surgery. The least vascular area of the head is probably at that exact location because it reflects the end of the blood vessels that come from the side, back and front of the head. As you may know, balding produces an atrophic skin that is thin and not vascular with little infrastructure (fat) under the skin (where a normal scalp would be rich in blood supply, with many nerves per follicle, many hair follicles, considerable amounts of fat, etc..). The reason that the skin becomes atrophic in balding men is because the bald scalp does not need a rich blood supply, so the body withdraws the blood vessels in response to lack of demand. When a hair transplant is done, the demand of the new hair increases the blood supply and eventually the scalp is no longer atrophic and becomes rich in blood supply again.

I am certain that age is not an issue. Smoking may contribute to this problem. My oldest patients have been in their 80’s and we routinely operate on men in their 60s and 70s. I have done surgery on diabetics and in these people, I have not seen vascular problems either, but I often do not ‘dense pack’ these diabetic people for fear of such a complication. I personally had a hair transplant two year ago (at the age of 70) with no issue. I had an atrophic scalp resulting from 3 scalp reductions done in 1991-1992 that left my skin very, very thin and atrophic, yet I suffered no vascular effects from the transplant into my atrophic skin.

Some doctors believe that there is a risk for people who smoke, so if you are an active smoker, then this could be a contributing factor. If your surgeon used instruments that were larger than 18 gauge needles, then this could be a contributing factor. I have also seen necrosis when the doctor accidentally switched the routine medications used for anesthesia from a benign medication to a toxic medication; however, yours does not appear drug induced, because the necrosis would have been more immediate and more wide spread than your earlier pictures showed.

My educated guess is that there was a blood supply issue to the top of the scalp where blood supply is reduced in atrophic skin (something that you probably had based upon the photos you sent). How that happened is unclear. There are reports of necrosis in the donor area from FUE recently, and this is probably caused by taking the extracted hair follicles out too close to each other.

The treatment for this type of complication could be a problem. Usually, small areas of necrosis shed the dead skin and the wounds heal from the sides; however, large areas of necrosis puts you at risk for damage to the bones of the skull, so an experienced surgeon who knows of such risks should be consulted. Skin grafts may be necessary to protect the bone.

Please note that what I have stated here is NOT to be taken as a second medical opinion, but just an informational view from a well informed and experienced hair restoration surgeon. To evolve this into a formal second opinion, I would have to personally see you and examine you. If you would like a second medical opinion, please find and see a physician in person.

A saw a very beautiful woman today in consultation. She wanted me to lower her hairline. She noticed that the hairline she had, appeared on the part of her skull that was not perpendicular to the ground just and the hairline was about 2cm above the point where the rounding of the skull started. This made her sensitive to what looked like a longer than normal forehead.

I did see what she saw. Based on today’s examination, her hairline was clearly in the same place as it was when she was 10 years old. I judged this from it location at the highest crease in the furrowed brow and the complete concave shape of the hairline. Also the distance from the tip of the chin to the tip of the nose is the same distance as the middle part of a line drawn from the pupils of her eyes to the lowest hairline point in the midline. This shows balance and symmetry.

We discussed the two methods of lowering the hairline (1) and surgical lowering procedure and (2) a hair transplant. After considerable discussion, I think that we both came to the decision not to do it, as it might impact her work and her modeling schedule from a visibility point of view. With the hairline on the upper crease, moving it down with a hair transplant to the 3/8ths inch she wanted, would show hairs that moved when her brow wrinkled or her eyebrows were lifted in any emotion she might express. This ‘moving’ hair would occur if the hair was placed below the furrowed brow of her normal existing juvenile hairline.

How many procedures does it take to lower a women’s hairline?

There are two types of procedures for lowering a woman’s hairline. One, is a surgical excision of the upper forehead followed by the downward advancement of the hairline up to an inch from where it was prior to the surgery. To accomplish this, the entire scalp from the frontal hairline to the very back of the crown, is lifted up and pulled forward. When this is done by an experienced surgeon, the hairline can often be advanced about 2/3rd – 3/4 inch as there is enough looseness when this lifting process is done. This procedure is often complete in one surgical session; however, it may not address receded corners of the hairline if the corner recession is significant. A great advantage of this surgical approach is the immediate impact of the procedure on hairline location with healing usually complete in a week or so. Sometimes this procedure produces a scar in front of the hairline, and if this is this is the case, a hair transplant in front of the hairline can address the scar. Hair transplants take 7-8 months to fully grow out.

The second type of hairline lower procedure is done through hair transplantation. The number of sessions varies by the thickness of the hair, were women with thicker hair, might do this in a single session. With finer hair, it often takes two sessions. The time to see the impact of a hairline lowering hair transplant procedure is 7-8 months and if a second session is required, it will take another 7-8 months to wait for full growth.

Janis C. Kelly, September 8, 2014, Medscape reported that Liver Injuries From Supplements are Up 3-Fold in 10 Years
There is an association for Liver Toxicity in the use of herbal or dietary supplements (HDS).

“The liver injury cases included 45 attributed to bodybuilding supplements, 85 attributed to nonbodybuilding supplements, and 709 caused by medications. During the 10-year study period, the proportion of cases linked to HDS increased from 7% to 20%.”

Beware of supplements you take if you think that you will be healthier or may lose weight, when these supplements may be destroying your liver. Ref: August 25 in Hepatology.

We have discussed that Erectile Dysfunction (ED) is a known side effect of Propecia (finasteride) and Avodart (dutasteride) in the range of 2% of men taking Propecia (finasteride). The side effect occurs in 1-2% of men. We have also stressed that ED is common in men not taking these drugs. In general ED affects 20% of men in their 20s, 30% of their men in their 30, 40% in their 40s, 50% in their 50s, 60% in their 60s and so on with an impact on 150 million men. ED can also be a sign of vascular disease or other systemic diseases such as high blood pressure or diabetes. Outside of the hair loss topic in BaldingBlog, many medication (other than Propecia) can cause ED or other sexual related issues. Vitamin D deficiency is one of the causes of ED that is easily treated. More notable are the anti-anxiety or anti-depressant medications as well as blood pressure medications. There is also a psychological component to ED where the lack of erection can be attributed to the mind. This is the reason that doctors are needed to diagnose and prescribe the medication.

When a patient is so worried or express anxiety that they may have ED from taking Propecia I can almost predict that they WILL have a side effect as the mind can be a powerful motivator. These patients I tend to generally not recommend Propecia (despite my effort at educating them) since they would be more preoccupied with the side effect than its benefit.

When on occasion a patient report back with some side effect, we decide on the course of action together. They can stop the medication or consider other options such as lowering the dose or taking a medication that may help with the erection problem. We also explore other extraneous causes such as their health, other medications that they may be on, and other emotional factors in their lives. To some, hair loss in it of itself can be a horrible and debilitating emotional trauma. On a few occasion, I have referred patients to a psychiatrist because hair loss affected them to a point of clinical depression and thoughts of suicide.

When a patient is in good mental capacity with extraneous factors accounted fand the patient still expresses the desire to take Propecia, we explore the option of medications to help with the ED. The following medications are used in general to treat ED (irrelevant of Propecia or its side effects).

Tadalafil Mylan (Generics UK Ltd) is used for the treatment of men with erectile dysfunction (ED) and benign prostatic hyperplasia (BPH). It is a generic of Cialis (Lilly), which has been available since mid-November 2002. All of these drugs that I will discuss below require sexual stimulation to work. It is reported to last 48 hours with a slower onset. Some doctors recommend a daily dose of 5mg and this may have positive effects on your prostate as well as your ED.

Avanafil has been approved by the FDA for ED as early as about 15 minutes before sexual activity, although the official time to use it might be 30 minutes which makes the onset much faster than the other drugs.

Viagra was the first drug introduced for ED. It may be the strongest of the medications and many men report that when these other drugs fail, this one works.

There is no good scientific study reflecting men with ED from finasteride using the above treatments, but my personal appraisal and my experience prescribing these medications, these approaches can satisfactorily treat ED even while on finasteride.

My daughter and I went on a diet together. Within the first 3 months, I lost 40 lbs and she lost 30 Lbs. We went off our diets for the summer. Enjoyed the sun and baseball games, but both got minor sun burns on our heads as our hair was thinner. By July we noticed too much hair coming out in our brushes. Our heads were itchy and dry and it is now October and our hair continues to come out too fast. In the shower and on our combs and brushes we get balls of hair. We had blood work done, we are fine. We are going to see a dermatologist but they are booked up until the spring. By that time, we could be bald. We were using Pantene shampoo, and recently we are trying Infusium shampoo. I am 42 and she is 15. My husband and 12 year old son are fine. They also aren’t itchy and dry and my son who was overweight, also went on a less restrictive diet. We tried extra virgin olive oil more in our diet. We are taking salmon oil pills. We rubbed aloe vera on our heads and wash our hair every two days. I dont know what else to do. What could this be and what can we do, why are our heads dry and itchy and what can we use. We don;t have dandruff or any other problems. Anything you can tell me would be really appreciated. Thank You.

Diet can cause hair loss and if you lost too much weight too fast (this is what is sounds like). Extremes and stress on your body could be a cause of your hair loss. Caloric restriction in conjunction with a balanced diet is the way to lose weight and not lose your hair (assuming that you have this connection). Some women have a genetic propensity to hair loss with stress of any kind. Considering that your daughter followed your course, I would suspect that the hair loss factors connects with genetic factors. Has your mother, aunt, sister have a propensity for hair loss like you? Without examining you in detail, I can not offer you other advice here but one modality we have to address thinning hair is Scalp MicroPigmentation (SMP). See HERE.

Taken from Huffington Post:

Eating hair is common in animals in their grooming process and they normally create Hair Balls which are either vomited up (those of you with cats see this all of the time) or they pass through the intestine and come out through defecation, Eating hair is part of a neurosis found in some people who will have the same problem as in other mammals. It is interesting to note that it does happen with humans.

This patient received 1287 grafts in 2008. At the time of his surgery, he and I discussed the location of the leading edge of his hairline. He loved my hairline (Dr. Rassman) and he wanted it exactly as my hairline appeared. I suggested as I was in my 60s, he might want to lower the corners a bit, but he wanted to remain conservative so my hairline was what he got. Just yesterday 10/29/14, he came in asking to lower the corners of his hairline and we both laughed. It would have been nice to have it all done in one session in 2008, but tastes and desires changed. So we scheduled him for another 1200 grafts to move his hairline a bit lower.

I just recently quit taking finasteride due to experiencing some sexual side effects that did not decrease when trying a smaller dose. My doctor advised me to stop finasteride for six months to see if my sexual symptoms improved. I took my last pill a month ago.

I was on finasteride from age 24 to 27, and, while not improving my hair loss, it at least kept further loss from occurring. I’m starting to feel anxious about the catch-up hair loss that could come within the next few months. Would minoxidil help prevent this catch-up loss from occurring, or is it more or less inevitable?

Finasteride (Propecia) and minoxidil (Rogaine) works in different ways. Rogaine will not necessarily stop catch up hair loss that sometimes occurs after stopping Propecia.

There is no cure for genetic hair loss in men (Male Pattern Balding). These medications (and even surgery) help address the balding. Medications can postpone the hair loss to varying degrees in individuals and each individual has different results and experiences with Propecia / Rogain / and any medication for that matter.