Author: Dr. William Rassman

I am a medical student and was wondering how finasteride works to give people a fuller appearance of hair.

In the Journal of the American Academy of Dermatology July 2006, Volume 55, Dr. Vera Price summarized the action of finasteride as follows:

“Long-term finasteride treatment led to sustained improvement in hair weight compared with placebo. Hair weight increased to a larger extent than hair count, implying that factors other than the number of hairs, such as increased growth rate (length) and thickness of hairs, contribute to the beneficial effects of finasteride in treated men.”

This is important, because what she implies is that the miniaturized hairs reverse. That is why it is so important to map out the scalp for miniaturization and to perform bulk measurements with the HAIRCHECK instrument. These two approaches used prior to starting finasteride (Propecia) gives us a baseline metric to determine the value of the treatment. I have seen people with miniaturization in the 80% range, reduce substantially to almost normal levels (under 20%). This is why everyone taking finasteride should be evaluated prior to starting the treatment by a doctor who understands this process clearly.

A recent article in the International Journal of Cardiology showed that baldness is tied to Heart Disease (coronary artery disease, the metabolic syndrome,hyperinsulinemia,insulin resistance. higher cholesterol, higher triglycerides, and higher systolic and diastolic blood pressures (high blood pressure). The article summarized 31 studies involving 29,254 subjects with alopecia and found these relationships. They pointed out that such measures such as weight loss, smoking cessation, and other modified risk factors should be the way patients fight for their health.

I started to lose your hair this July. About that time I also went on hormones, DHEA, and antibiotics. Could these medications have caused my hair loss. I recently stopped taking these medications and think that the loss may have slowed and some reversal may be going on. Is this possible

I believe that considering the short period of use and the known relationships between DHEA and hair loss, it is reasonable to expect that the hair loss you had might be related to the medication. You think that the hair loss is reversing upon stopping the medication so it is reasonable to expect that your progress will continue. You need to determine the status of your hair in and around your head, get the hair and scalp mapped out for miniaturization and hair bulk with the HAIRCHECK instrument. From changes in hair thickness (in bulk) you will know where you are going with your hair loss and if it has stabilized. Good hair transplant doctors’ offices will do these test for you.

I have FUT surgery scheduled in late late December. I am planning on taking propecia in Mid-November..so is this long enough to prevent shock loss. I do not want to go through this shock loss that others have reported.

The longer the better, but 4-6 weeks should cover you. Even a shorter period will work, but taking it is critical particularly if this is your first hair transplant and you are under 30 years old. Shock loss is most common in young men and after the first hair transplant. Stay on the medications until all of the results are achieved and then consider staying on the drug for life. Talk with your doctor about this.

I would like you to write a how to-guide on the topic “MINIATURIZATION”. I have a tool to zoom in on my scalp and hair. I was hoping to self-diagnose my miniaturization but I have no clue how to do it or what to look for. Please help!

Clip your hair to a pea size spot in different areas of your head:

1. frontal area in midline
2. corners – one inch behind both
3. top of the head (area determined by a line from between the ears)
4. the crown area (where the swirl is) including one inch in front of the swirl and one inch behind the swirl
5. to the sides of the head about 1-2 inches from the midline

Using a video microscope, count the total hair population in the visual field no matter what the shaft thickness of the hair. That number will give you a density of the hair, particularly if you can measure the size of the visual field.

For a miniaturization map of the area, count the hair shafts that have a smaller diameter than the large hair shafts.

Use this formula:

Miniaturization Factor = small hair shafts÷total hair shafts

The mapping is done by recording the miniaturization factor for each area of hair you cut.

The projection for balding in the future will be determined by the area where miniaturization exceeds 20 percent (there are about 20 percent normal vellus hairs that look just like miniaturized hairs but are not). Miniaturized hairs have arrows pointing to them in the middle picture. Click to enlarge.

.

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 https://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.

QUESTION FROM THE PAST Please help me – I’ve been suffering from hair shedding since Aug 2007. I was on the pill for 12 years and came off in august just after my wedding to conceive. I concieved straight away and am now 7 months pregnant. In Dec 2006, I was in hospital for a day with an infection which caused a hemorrhage. The shedding does seem to have slowed down now so losing about 25 after washes and I feel spiky bits all over my head. This has lasted about 7 months now and just wanted to know how long it usually last for and if it will stop? Will I ever get the thickness back in my hair?

I’m so depressed about this and would be grateful if you could help me. Thanks

You have many potential causes for hair loss, including:

• Pregnancy, which can cause hair loss that should reverse after about a year
• Changes in your hormones from the withdrawal of birth control pills
• Illness from the infection that put you into the hospital

It is likely that this process will reverse. You are not alone and the experience of others with this problem have been far from hopeless.

I just met with a Asian man with very low density, even for an Asian. He was considering the different harvesting techniques FUE vs strip surgery. He met with other doctors who represented that they could transplant 4000-5000 grafts in a single strip session and 3000 FUEs in a single FUE session. This poor man was confused when I suggested that his yield would be less than 2000 grafts with a strip surgery.

There is a great deal of hype on the Internet that people need to have a single large session of 6,000 grafts to get coverage and that is preferable to 3000 grafts in each of two sessions. I would agree if I did not know better. First let me state my qualifications for what I am about to say. I was the first doctor in the world to do 2000 grafts, then 3000 grafts than 4000 grafts in a single session back in 1992-4 and I have been doing larger sessions longer than anyone in the world starting back in 1992. I was using follicular units in large sessions before most of the doctors heard of the follicular unit, let alone the megasession. That would make me an expert on the subject of large sessions hair transplants and I doubt that anyone would challenge my expertise (see references below from prior to 1995). Add to that the fact that I practically invented the large session of small grafts. You may not know my training in surgery, but I am a board certified general surgeon who did everything from war surgery (in the Vietnam war) to extensive trauma, vascular and cancer surgery. That would make me more than qualified to perform a large session harvesting technique for modern hair transplantation.

Of course, if I could harvest 6000 grafts in a single session safely, I would do it more often. I have always had the supportive staff to carry out this type of surgery. But as safety is my guide in all circumstances, my judgments tell me often that taking out a strip which would yield 12,000 hairs (6,000 grafts) is often dangerous and would put the patient at risk to develop some complication. Please note that I clarified that a 6,000 graft harvest should yield about 12,000 hairs, so if a 6,000 graft harvest yielded substantially less than 12,000 hairs, then I might start thinking that smaller grafts were produced by sub-dividing follicular units which is a sin in my ‘ethical’ book. What makes it a sin is that as the fees are directly related to graft counts, sub-dividing follicular units as a routine accomplish two things (1) it raises the surgeon’s fee, and (2) they damage follicular units which tends to produce decreased hair survival.

A hair is not a hair. Fine hair has low bulk and when someone states that they can completely cover a bald man’s head with 6,000 fine hair grafts referencing a ‘gorilla’ result, they are just plain lying. Dr. Feelgood may market his god-like qualities, but Dr. Feelgood just ‘ain’t’ god.

I get rattled when someone tells me through the various internet forums that I should have given someone 6,000 grafts to manage his bald head and that if it was done by Dr. Feelgood, everyone knows that Dr. Feelgood always achieves high graft counts (no mention of the hair count of course). I would ask two questions, (1) what are the hair counts in such large sessions as a matter of routine, and (2) what do the donor wounds look like as a matter of routine. I know more than most what is possible and what is safe, and I know what is not. I use my judgment to ascertain safety and I really don’t believe for one minute that Dr. Feelgood would get 6,000 grafts (12,000 hairs) when I could only get 3,000 grafts (6,000 hairs), never, never, never. If a graft count in the 5000-6000 range is possible, I do them with the agreement of my patient.

The forum chat ‘folks’ who are not knowledgeable about the subtleties of a safe strip harvest and who believe in the marketing hype of some of the internet doctors can talk from their ‘armchair’ all they want. Either my patients are not typical and have tighter scalps and lower densities than Dr. Feelgood’s patients, or some of the doctors who claim these high numbers routinely are either lying to push up the numbers and claim a ‘mighty’ superman deed rewarded (of course) by making more money, or I am a monkey’s uncle.

Published References from prior to 1995 when almost every hair transplant doctor in the field was doing small sessions of large plugs:
# Rassman, W.R.; Bernstein, R.M. One of our greatest problems – lowballing! Hair Transplant Forum. 2(6); 1992.
# Rassman, W.R.; Pomerantz, M.A. The Art and Science of Minigrafting. International Journal of Aesthetic and Restorative Surgery. 1(1): 27-36; 1993.
# Rassman, W.R. A buyers guide to hair transplantation. Los Angeles, CA: NHI; 1993.
# Rassman, W.R. The minigrafts’ revolution, can we keep up ethically? Publication Journal of Cosmetic Surgery.
# Rassman, W.R. Everything you wanted to know about hair transplantation but were afraid to ask. Los Angeles, CA: NHI; 1993.
# Rassman, W.R. The fast track option: a common sense approach to hair transplantation. Los Angeles, CA: NHI; 1994.
# Rassman, W.R. Megasessions: Dense Packing. Hair Transplant Forum 4(3); 1994
# Rassman, W.R Concern about quality. Hair Transplant Forum 4(4); 1994
# Bernstein, R.M.; Rassman, W.R.; Szaniawski, W.; Halperin, A. Follicular transplantation. International Journal of Aesthetic and Restorative Surgery. 3:119-32; 1995.
# Rassman, W.R.; Carson, S. Micrografting in extensive quantities, the ideal hair restoration procedure. Publication to Journal of Dermatology, Surgery and Oncology, 1995
# Rassman, W.R. Follicular Unit Transplantation Megassessions, Hair Transplant Forum Intl. 5(5); 1995

Dr Rassman,

My question is: does finasteride play any role in maintaining minoxidil dose-dependent hair?

I got started on 5% minoxidil topical in early Feb, 2009. My derm prescribed Finasteride oral 1mg/day too, but I did not pursue that medication due to the usual side-effects related concerns. There was an initial minox-induced shed: not a massive one, but scalp showed. Things started looking up 4 months later but then again in July/August a bout of minor shedding ensued. Survived that too. In November yet another shed started and this one was bad; short fine hairs all over the pillow in the morning. Scalp showed yet again, as bad as after the first shed in March. In December, I panicked, decided that Minox wasn’t working for me, and got started on Finstaride 1mg.

By mid-Feb this year, there was a sort of minor miracle on the top of my head. My hair is looking its best in maybe two years. I hope you agree with me that it’s unlikely that Finasteride started growing hair within 10 weeks of beginning its use. My (semi-literate) guess is that Minox first grew “peach fuzz”, which gave way to intermediate hair, which then was replaced by terminal hair. I suffered synchronized sheds, the last one being the shedding of intermediate hair. Maybe more sheddings are in store for me, maybe not.

To get to the point, I am so pleased with the result that I’ve gotten greedy: I want Finasteride growth too. No sexual side-effects so far. I’d like to press on with Fin, and reserve the option of discontinuing it in future if side-effects show up. I understand that that would result in catch-up loss, but then probably I’d be content with the hair that Minox grew for me.

Hence the question: do minox and Fin have a cumulative beneficial effect on the same hair follicle? Will minox-dependent hair too be lost in catch-up loss if Fin is stopped? If the answer is in the affirmative, I’d probably be better off stopping Fin right away, since I’ve been using it only for 3 months.

Thank you for a patient reading, and thank you for your time.

You would have to poll each hair follicle and ask them what they liked better. If you can not communicate with them, then you are like me who frankly does not know the answer to your question. My best guess though (keep in mind I could be mistaken) is that because the medications work in different ways and finasteride will not keep hair grown from minoxidil and vice versa, that the benefits are independent of each other. Many men do use both medications concurrently, and as long as you can afford both (and maintain the regimen) I say go for it! It’s ok to be greedy and want your hair to look as great as possible. If the meds work well for you, that’s great news!

While it is unlikely that any major hair growth you’ve seen in just 10 weeks occurred from finasteride, you could’ve seen benefits from the medication that have helped your hair look better overall. The two drugs work differently. Minoxidil will grow new hair but the quality of the new hair varies in individuals from thin and poor, to strong and good (less than 15% of people). Finasteride probably does not grow new hair, but most likely works on the miniaturized hairs that we see in male pattern balding as it progresses. This is why finasteride (Propecia) will have no effect on the new minoxidil produced hairs. Minoxidil has not been shown to work on miniaturized hairs, at least that is what is presently understood.

Dr. Rassman,

I have been a patient of yours for over three years now and I recently visited your office back in August. After seeing you again it was established that my hair loss had not progressed from last year and had possibly even improved. Unfortunately, over the past month, I have been experiencing non characteristic loss. When I am in the shower, I have never ending clumps of hair coming of my head and clogging the drain. Also, when brushing my hair there is even more loss. Dr. Rassman, this has never happened before and I have no idea what to do. Is it possible that the Propecia that I have been taking since November of 2005 has stopped working for me and my genes are taking over?

All of the loss has been occurring since I have been out of town on a job. I seem to even have some kind of infection on the corners of my lips. I am sure the two things are not related, but I figured I would tell you.

Anyway, is this a normal experience for someone on the drug as long as I have been? Should I take more of it? Is it possible for a person to lose all of his hair immediately? Could this be a possible hair cycle or allergy? Again, I have no idea what to do and what to expect. I appreciate you taking the time to read this and your advice/help would be greatly appreciated.

Thank you and looking forward to hearing from you soon!

Hair loss can increase from stress amongst many other things, such as the normal progression of hair loss that occurs in some men (even those on Propecia). As one of my patients, please come see me and let me see if your miniaturization has increased. We can get a baseline on the HAIRCHECK instrument by measuring your hair bulk now and then repeat it in a year to see, for future purposes, if you are continuing to lose your hair.