Category: Favorites

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Hair Loss InformationRobotic Controlled Hair Transplants – Hair Loss Information – Balding Blog

There’s a doctor in the bay area that is claiming to do hair transplants with robots. What is this about? Robots??? Can you tell me more about this?

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Robot“Restoration Robotics, Inc. (Mountain View, CA) is a company using image-guided robotic technology to perform hair restoration by emulating the FUE technique. The robotic technology is in development. Currently, it is not approved by the FDA and the technology is not for sale”, said a company spokesperson when I contacted them. I also found this press release about Restoration Robotics from 2003, here.

I can imagine the scene of a movie with robots doing hair transplants, starring 3-CPO from Star Wars. I am sure that we will be hearing more about robotic-assisted hair transplants in the future and I doubt that it will be as frightening as I just made it sound. This is an exciting conceptual solution to the Follicular Unit Extraction (FUE) quality problem.

There is also the Medicamat Punch Hair Matic, first announced in late 2004 in this press release — Punch Hair Matic rescues baldies — which says: “Medicamat of France will be launching its new robot for hair transplantation”. I have been familiar with this company, which purchased the technology from a long term friend in the mid-1990s, Dr. Pascal Boudjema, one of the brightest inventors that the hair transplant community has ever had.

Their press release goes on to say: “The Punch Hair Matic (which is patent-protected) is a robot using micro-instruments to remove follicular units, which makes surgery simpler, faster, and less debilitating for the patient, with more convincing aesthetic results.” They report a very fast surgical time (2 hours to do 700 grafts) for the transplant (appears to be an FUE technique).

In many ways, Medicamat has been doing small punch grafting longer than I have, considering that they have been using smaller and smaller punches for many years. The evolution to smaller punches has been slow and methodical.

Today, the shoppers for FUE transplants pass through a mine field (a ‘buyer beware’ business for sure) where doctors from all over the world (with little or no training) are using manual techniques with varying degrees of success. Regardless of their expertise, they are telling the public that they specialize in FUE and are experts in the technique. At least, the robot approach promises to standardize the technique and the quality of the output. So we have a horse race now between two companies offering what may turn out to be competing technologies. Only the public can benefit here, so I sincerely hope that one or both of these companies succeed in making the business for automated hair transplants work.

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Miniaturization: Critical to the Master Plan for Hair Loss – Hair Loss Information – Balding Blog

Miniaturization occurs in men and women who are balding. Miniaturization is the process where a normal thickness hair shaft becomes thinner and thinner over time due to the genetically determined effects of aging and/or androgenic hormones on the terminal (normal) hair follicle. The process of miniaturization is a slow process in genetic balding. Hair shafts may lose 10% of their diameter, then 20%, then 30% and so on. Each degree of increased miniaturization reflects further progression of the genetic balding process. The instruments that measure miniaturization were invented (and patented) by me in the early 1990s (patent ) and they are in wide spread use today. Socially detectable hair loss is not evident until more than 50% of average weight hair has been lost (more with fine, high contrast skin/scalp color hair and less with coarse, low contrast skin/scalp color hair) and as a result, many men do not seek out expert help until they see some evidence of balding (which they too often deny).

When a doctor views the scalp hair with high magnification, the degree of miniaturization and the location of the miniaturization are both critical to establishing (1) the diagnosis and (2) the rate of the process, which progresses over time. Because miniaturization is a relative measurement at any one time (comparing finer hair to the thickest hair), it takes substantial experience before this measurement can be useful to the individual clinician. In our experience, from examining and following tens of thousands of patients with the hair densitometer (video microscope), we have found that assessing the degree of miniaturization has useful predictive value when evaluating the risks of hair loss and in establishing hair loss patterns. The amount of miniaturization in each section of the scalp tells the physician just how far the balding is progressing or has progressed. In men who show more and more areas of miniaturization over time, the genetic balding can be considered active. In men treated with finasteride, if the miniaturization is reduced or the hair count is increased, it can be assumed that the balding process is coming under medical control.

We know that hair loss occurs in patterns (see Norwood Chart), but these patterns are what the eye can see. When the naked eye picks up these patterns, the miniaturization is always in a more advanced state. The balder the patient is, the worse is both the absolute hair count (density or healthy hairs) and the relative fullness of the miniaturized hair shafts. Clearly, miniaturized hairs that have a reduced hair circumference of 10% will have more bulk value than a hair circumference reduction of 70%.

In our practice we use a video densitometer to map each patient’s scalp. We typically map and digitally photograph a series of discrete areas on the scalp that reflect the balding and non-balding areas. The non-balding donor area (back and sides of the head) reflect the numbers of hairs per square inch the patient was probably born with. By comparing the donor area with other areas that might be balding, we will have very relevant numbers that will reflect the eventual balding that the naked eye will pick up as the balding progresses.

As an exercise in thinking out the process that the skilled doctor performs, follow the thinking on the following case example: Miniaturization in the recipient area (front, top and crown) can often delineate which areas of the scalp are most likely to bald and which are stable, anticipating the patient’s future Norwood hair loss classification. If a 38 year old man has most of the miniaturization in front and very little in the mid-scalp and none in the crown, then the physician may safely assume that the eventual hair loss pattern will probably not go much beyond a Class 3A or 4A pattern (worst case scenario). View the diagram below and click the button for a view of the degree of miniaturization of the patient illustrated here. From this, a Master Plan can be derived depending upon how the existing hair loss is bothering the patient. If the hair loss is just showing some thinning, it may be logical to treat it with finasteride alone, while if the hair loss is more advanced, looks like it is balding and it bothers the patient, then it could be treated with a hair transplant. Because the doctor knows the miniaturization pattern and the age of the patient, he may confidently predict this patient’s worst case and with that information, the patient can budget his time and money to do or not to do a hair transplant. That is why I say that the future management of hair loss needs a Master Plan. In Patient QQ, this is just what happened. He had one hair transplant procedure 10 years ago and because he had limited miniaturization to the frontal area, I could predict that he would probably not need further work for some time. If his situation was to evolve differently (such that he lost more hair than I had predicted) then he could always have had another transplant (if he needed and/or wanted it). He was close to 50 when he came to see me, near the end of his hair loss process. Now his experience with me is just a fond memory of a difficult time in his distant past.

We feel that predicting the short-term loss (the extent of miniaturization in the recipient area, as well as the rapidity of the loss) is critical in establishing the guidelines for treatment, whether it is a hair transplant or drug intervention. In the very early stages of hair loss (the man in his early-mid twenties), findings of increased miniaturization can anticipate future balding even before any loss can be seen to the naked eye. Often, the reason a person seeks a consultation from a hair restoration expert is that there is some change in the “rate” of his hair loss (often more hair seen on the pillow or in the shower). A patient who is very gradually losing his hair is less likely to seek help, compared to a patient who suddenly has acceleration in the rate that he is losing hair. Usually large numbers of hairs undergo miniaturization before any are actually lost and the time the drugs are most effective is in this early phase. In men, DHT is the hormone responsible for these changes.

Ideally, if you are balding, you should take finasteride after mapping your scalp to identify if you have male pattern baldness. The focus upon mapping for miniaturization is to (1) estimate the pattern of hair loss, and (2) measure the starting point for miniaturization so that changes caused by finasteride can be measured over time. Although it takes around 6 to 8 months before you can see the effect of finasteride visually from hair length, it is highly possible that the impact of finasteride on the emerging hair will be earlier than the projected 6-8 months. The measurements are very fast and easy to get from a hair transplant physician and it is today’s Standard of Care that should be available to every balding patient wanting a Master Plan for their future hair loss and hair loss management (medical or surgical).

With successful medical (drug) treatments like finasteride, the miniaturization may be reversed (partly or completely). The responsiveness of each patient is different, so each patient must be diligent in acquiring follow up measurements of the degree of miniaturization and the location of the miniaturization by scalp location. The same diagnostic criteria should and must be followed in women. Without good, reproducible measurements for miniaturization, there is no clinical science in the treatment of hair loss, just hocus-pocus and blustering, a problem that is far too frequent today.

Click each zone or area in the image below to see a microscopic view of the miniaturization (or lack thereof) in a typical balding male:

PZ = Permanent Zone
T1, T2 = Temples
F1, F2 = Frontal
M = Middle
V = Vertex

The below image is a guide to see examples of normal, moderately miniaturized, and advanced miniaturized hair. Click to enlarge.

 

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Analyzing the Results of the HairMax Laser Comb – Hair Loss Information – Balding Blog

I have added a link to some of the before and after pics of people who have apparently used the lasercomb.

What do you think?

http://www.lasercomb.net/beforeafter.htm

Thanks again Dr! I’m addicted to your site now!!!

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Ah, the HairMax LaserComb by Lexington International. It’s worth noting that lasercomb.net and hairmax.com both go to the exact same site, so the link you sent is the official site of this product. The page you sent (linked above) has 2 groups of photographs, each with multiple before/after sets. The 1st group is apparently patient results, and the 2nd group is of clinical trial macro photos.

So let’s start with the first group of photos — the patient results. I looked carefully at these, and there is a real question in my mind as to what I am seeing. A few of these pictures have longer hair that is possibly responsible for the changes that I can see. I wanted to get an enlarged version of the photos to see the details that would tell me what I was looking at, but they are not available on the site. The first before/after set in the group are a good example to start with. There is a suggestion that the scalp has coloring to it (Dermatch or something similar), but as I can’t enlarge the photos, I can’t try to determine what it might be. Could the difference be lighting or combing style? I don’t know, honestly. Many of the photographs suggest styling differences. In no case was there any significant change in the hair coverage, though. Either the person had plenty of hair when they started or there was not enough hair when they finished treatment.

Moving on to the 2nd group of pictures, the clinical trial macro photos —

We analyzed two sets of the before/after high-powered magnification photos, which also includes the data that they based their research upon. The actual hair counts as they did them are well presented and can be seen by magnifying the circular areas of hair density assessments. Each hair grouping was identified, numbered, and the authors put the actual count on each follicular unit as they made the measurement. They did not separate or identify those hairs that were miniaturized. Because all of the information is present in the material presented on their website, it was easy for us to repeat their measurements and to ascertain if their numbers corresponded to an independent assessment.

Here’s a breakdown of what I found in the macro photos that Hairmax presents on their LaserComb site.

Macro Photo Set 1 – Before picture:

  • HairMax’s hair count: 107
  • My hair count: 115
  • Of these hairs, 12 were miniaturized

Macro Photo Set 1 – After picture:

  • HairMax’s hair count: 148
  • My hair count: 128
  • Of these hairs, 10 were miniaturized

See the image on the LaserComb site

Statistically, the percent difference between the before and after photos (according to my count) is insignificant. Therefore, in the first set of photos the LaserComb made no real difference.

In the second sequential set of photos, I discovered that the after photo actually had less hair than the before photo —

Macro Photo Set 2 – Before picture:

  • HairMax’s hair count: 147
  • My hair count: 161
  • Of these hairs, 12 were miniaturized

Macro Photo Set 2 – After picture:

  • HairMax’s hair count: 184
  • My hair count: 159
  • Of these hairs, 10 were miniaturized

See the image on the LaserComb site

Yes, I actually counted three fewer hairs after the LaserComb was used. My measurements of the data on their official site do not support the findings they offer.

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I am comfortable saying that I am one of the world’s experts in hair densitometry. I can prove this as I am the inventor of this technology and hold the U.S. Patent on the instruments used by HairMax (or Lexington International) to demonstrate their findings (see: USPTO.gov). With that being said, I reviewed our findings and agree with our counts. I believe that HairMax’s photos do not show any objective evidence of hair growth on the first two sets of data and that the numbers that they derived do not correspond to the assessments made by us. Lots of good hype if you’re into it.

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Hair Loss InformationStandard of Care Consultation for Hair Transplantation – Hair Loss Information – Balding Blog

I just had my consultation at your office last week. I want to congratulate you with a professional way of managing your practice.

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This blog entry is a little lengthy, but it is important to retell this man’s tale as he told it to me. For the purposes of privacy, I’ll refer to him as Joe.

Joe had received three opinions from different doctors over the past few months. The one with me was the last of the consultations. After receiving the nice note from him, I asked him for a competitive analysis. Joe had planned to get multiple opinions over a three month period and he had already attended one of our open house events prior to seeing me privately.

He had some comments about our practice, some of which were not flattering. He criticized the quality of our video as tired and out of date (it is 14 years old) and our brochure was not nearly as fancy as the ones that he had seen elsewhere. He might not have been aggressive at pursuing us if it were not for the generally less than professional presentation of the other two practices. With the two previous groups he had met, both were front-ended with a professional salesman who went through well-scripted processes, each recommending what the salesmen thought Joe might need to address his balding problem. Both of these groups applied considerable pressure to get him to schedule a hair transplant. At one of the two clinics, the doctor came into the office, but spent very little time with him, only confirming what the salesman told Joe about his needs. When he left each of the two previous groups, he was somewhat impressed, but skeptical of their sales process. Later, he did some internet research and found considerable legal problems with one of the groups and many generally negative comments on internet chats. Both groups were eventually crossed off his list.

Our office was his third stop. He came by an open house event and met with many patients that had been through the same thing he was now facing. Three patients came in without notice and they showed results that he felt were normal looking. He was impressed with the openness of the patients attending the open house. He met two patients with the exact balding pattern that he had, both in their 40s and they had Joe’s hair and skin color as well.

Joe went into the operating room and talked to the outgoing fellow who was having the hair transplant that day. When we eventually met, he was impressed that I had committed a full hour to the interview. The night of the consultation he went to the internet and found that every claim that NHI had made on its website (reflecting their authority as a pioneer in the field) was easily validated. This was quite different than the claims made by the other groups which he felt were over-hyped in their representations. The very next day, he got an email from me with what he said “was an amazing and thorough summary” of the conversation we had on his visit the day before. I had included a full fee schedule for the quoted estimate of work. None of the other transplant office took the time to produce such a document, not even the doctor who performed surgery on his broken nose a few years ago.

I developed my hair restoration practice as I did when I practiced a more traditional ‘general surgery’. I’ve always believed that a medical practice should be classy and that means to me that the doctor should take every effort to provide what he would want to see if he or a member of his family were a patient — and that would include an honest, open communication. Unfortunately, too many medical groups who are now dominating the field of hair transplantation, have applied heavy sales tactics (which I believe is either immoral or unethical). The patient can easily become a victim if critical information is held back. As a case in point, throughout this blog, I discuss the need for assessments with mapping of the scalp hair for loss looking for miniaturization, and even with multiple articles written by me on this subject, the metrics in this field have not been incorporated into the standard of care. I would never transfuse a unit of blood without knowing the hemoglobin of a patient who was bleeding, nor would I use potentially toxic medications without understanding the working efficiency of the liver or kidneys, yet many hair transplant doctors seem to constantly offer extensive hair restoration surgery without measurements of the patients existing hair status or in giving the patient some help in predicting his future hair loss.

We need a standard of diagnosis for the consultation process and we need to exclude the salesmen who dominate the process and make recommendations that should be in the exclusive domain of the doctor. We need to incorporate such processes as mapping of the scalp for miniaturization, in order to give the patient a fighting chance in understanding what he is agreeing to when he undergoes a hair transplant. We need to provide educational material about what the patient may experience, including all of the risks (not sugar coated) associated with a transplant process. If we don’t do these things, then I will continue to speak out about our standard, hoping that the consumer will press those in this industry to discard shoddy sales tactics.

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Hair Loss InformationI Want to End This 15 Year Nightmare – Hair Loss Information – Balding Blog

Hello Dr. Rassman. I received my first hair transplant when I was 22. I received several procedures which gave me a horse shoe shape of plugs in my hair line. At that time my social life shut down completely and I wore a hat until 1996. At the time I located a new doctor and he doctor recommended removing only the plugs at the outer edge of the hairline and focusing on hiding the plugs with follicular grafts after three procedures I was able to take my hat off again although the plugs were somewhat hidden the hair line was very hard like a wall. I was never able to accept how unnatural it felt and behaved when groomed. The density behind the hair line would never match the horse shoe in my hair line. I have had two procedures to thin out the plugs and with each procedure it looks and feels better, but the camouflage came with a tradeoff. I now have a large donor scar ear to ear 5/8 wide I had two procedures to remove the scar. It did not work and the scar soon returned. I am currently having FUE extraction procedures to camouflage the scar and thin out the hair line. I believe this combination of procedures can get me the result I am looking for. I refuse to have any more linear procedures due to my healing qualities and the fact I find them way to invasive. Enter new problem — it has been harder to talk to my doctor. I believe he is tired of me and I have trouble communicating with him since I believe it will take three more procedures to get a natural result. Enter problem two — my last procedure was extremely painful. Each injection of local anesthesia was unbearable and very traumatic. I believe I am so close to having a hair line that looks and feels natural and a scar that is difficult to detect so I can finally go out and have a social life again before I reach forty. My goal is to end this 15 year nightmare before I reach 37. I just turned 35. I am still single.

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The old plugs can be a real nightmare and I really feel for your pain. It sounds like your current doctor has kept up with the correct treatments and has brought you a long way. Life is full of trade-offs and it appears that the downside of your present nightmare is the pain associated with each anesthesia and the scar from the strip surgeries, so I will address these first.

Anesthesia: There are ways to handle the pain associated with the anesthesia. For the audience who is reading this, I will explain that when a great deal of scar is present, the anesthesia gets to be very difficult and the more scar, the more difficult will be the anesthesia. But with that said, there are ways to reduce the pain you are having by using such systemic medications as Versed and Ketamine in combination, which will wipe out any pain that you might experience with further surgeries. If you doctor is not comfortable with this approach, you might have him/her bring in an anesthesiologist to monitor you through the initial injections to set up the anesthesia. I have offered this option to a few of my patients.

Scars: Scars come with all types of surgery (100% of the time) and when you have many surgeries, there is a scar of sort associated with each, even if they are in the exact same place. I tend to separate the scar issues of the donor area (which can be covered with long hair) with the other important priorities, your appearance to the public who can often not see what lies below. The goal is, of course, a normal looking hairline and a decent head of hair without obvious plugging or abnormalities. Then when the normalcy is reached from a social point of view, I tackle the scars as my primary and last set of activities using FUE if it is needed to finalize the best end point that is socially undetectable. There are many good tools that are available to treat the scars that were created by the varying older techniques and FUE is one of the newer ones. For some people with very extensive scars, balloon expanders are a reasonable option, but these often require wearing a hat to hide the balloon expanders for the 10-14 weeks it takes to stretch the normal hairy scalp so that the scars can be removed. The good things about balloon expanders is that they often will yield a good deal of additional transplants which can nicely refine the last of the corrective work.

“Socially undetectable” means that the work is repaired so that in normal situations any person will look reasonably normal. This may require a styling adjunct with the the reconstructive work. Apparently, this is what your doctor has successfully addressed and from the little you wrote here, you did admit that “I believe I am so close to having a hair line that looks and feels natural and a scar that is difficult to detect so I can finally go out and have a social life again before I reach forty.”

Repairs: This is a nightmare which I have shared with too many patients over the years. From the articles we wrote, we have developed a sizable repair practice as doctors and patients from around the world have found us as a resource. We are a team made up of good caring doctors and focused patients who we educate on the realities of their situations. The rewards, from my point of view, have been very worthwhile. Sometimes you have to look back and see from ‘whence you came’. A good doctor goes through much anguish because he/she wants the process to end as fast and as soon as the patient does, but the doctor must be realistic and keep an objective hat on his head at all times, even when the patient gets antsy and frustrated. Those times are the tests that doctors and patients have to struggle through. I suggest that patients like you should try to understand that progress is slow at times. The tortoise beat the hare in the race, because the tortoise was steady, making consistent progress towards the goal. Some of the horribly deformed patients I have seen over the years have become normal people, leaving their freaky look as a nightmare past. With the techniques which we have developed today, almost every patient can be helped, provided that they have suitable donor hair to relocate.

Reality: When I say almost every patient can be helped, what I really mean is that I will give an honest opinion as to what can be done and if the patient will hear what I’ve said, I can usually come close to the target that I outlined in the initial consultation. I always put my opinions into an extensively written report outlining the goals that I think are reasonable and which are not. Most of the patients with the old style plugs suffer greatly because of the deformities created by these old techniques. Many feel that they have been abused, taken advantage of, and become victims. They often have lost trust in all doctors. Anger is part of the problem that stands in the way of getting the best out of a good doctor/patient relationship. The key for the doctor embarking on such a project is to try to establish trust and confidence, a sense of teamwork, and a genuine feeling of caring. I have helped people who I could not bring back to a normal looking full head of hair, but I have made a point to communicate with them (in advance) the reality of what we can accomplish. The greatest problem I have seen is that some patients have run out of donor hair, so that even using the old plugs as a source of donor hair by harvesting with FUE techniques, there may still not be enough hair to get it all fixed.

See Dean’s Story for a complete repair process from plugs to a normal looking head of hair.

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Hair Loss InformationWhat Procedures Has Dr Rassman Had? – Hair Loss Information – Balding Blog

Hi Dr. Rassman,

I’m wondering if you could tell us a little about what you’ve personally gone through? I’ve managed to gather, based on reading about half of all your entries (i’m aiming to get through all of them!) that you’ve had a full transplant and that you’re currently on Propecia, but I was wondering if you could elaborte.

Cheers

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In the early 1990s I had three scalp reductions for balding in my crown. I realized after the third (about 8 months had passed) that I was worse off after the three surgeries than before I had them done. Worse off because:

  1. my bald spot returned larger than before I started the first procedure
  2. the skin was fragile, bleeding easily
  3. the scar looked like a Mercedes emblem on my head

I was not angry with my doctor because he had done what others were doing, practicing a standard of medical care that was sub-standard. What angered me was a phone call I had made. I called the authority on this surgery, explained what happened to me and found out that it was a common outcome for many patients. I remember clearly that when I asked him one simple question: What was this outcome not published? His answer was: It would be bad for business. I was sickened. I had personally performed 8 of these surgeries myself, one of them on my first cousin. He was the only one who had the complications of scars and the emblem on his head. We joke about it today and he never loses the opportunity to be dramatic about the impact of the scar I gave him. I transplanted his crown three times to try to make amends, and although he now has great results, he still teases me over his suffering.

Like him, I had hair transplants performed into the scar in the back of my head. I no longer belong to Mercedes and am a free man with a good head of hair. My crown (1600 grafts later, see below) is still slightly thin, but few people notice it unless I call their attention to it. I use a comb-back and the hair in front of the thinning hair covers the bald spot reasonably well.

 

Click the photo to enlarge.

Because of the scalp reductions I had, it was not reasonable to replace the swirl in my crown so I accepted a change in hair positioning for each of the grafts to enhance the comb-back styling that I had gotten used to. I often do this in people who have a supply/demand mismatch, where the supply is short and demand is high. On some patients where there is no demand mismatch (like with Patient CL and Patient OR), we can replace the swirl.

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Hair Loss InformationNon-Doctors Doing Hair Transplants? – Hair Loss Information – Balding Blog

Can a Non-doctor Do a Hair Transplant?

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In some countries (more so in third world countries, but some non third world countries may be included here), non-physicians can legally do a hair transplant. In Western Europe, Australia, Canada, Mexico and the United States, I believe only licensed medical doctors can legally perform hair transplant surgery.

What is legal and proper, however, is not always what happens. I was an expert for the State of California in an action against a non-licensed physician passing himself off as a hair transplant surgeon. He was prosecuted along with the doctor who promoted him.

In 1992, a doctor in Cook County was charged by the State of Illinois, stating “…the business has allowed non-doctors to perform surgery on clients, including one non-physician who claims expertise as a muskrat skinner and who was first employed by Dr. [name removed] planting trees on his farm.” Illinois Assistant State’s Atty. Robert Lyons, supervisor of the consumer fraud division, said “We’re not saying the guy can’t stand there and hold gauze, but we are saying he can’t stitch a wound”. (from Chicago Tribune, July 26, 1992)

In another situation, I was a aware of a doctor in New York that was charged by the State for allowing garbage collectors to perform surgery at his clinic. Their training was apparently done after they finished collecting garbage as extra-help for the doctor. It appeared that they were coming in after hours as well, performing surgery themselves without the doctor present. It was not clear if the doctor knew of this activity but it was done in his office. I doubt that the patients were aware that these men were not physicians. I know of one business that was set up in Virginia where the technician opened their own business and hired ad-hoc doctors to cut along the dotted line and the doctors did not know anything about the field of hair transplants. I was told that sometimes the doctor did not show up so the technicians went ahead anyway. In one clinic located in Pittsburg: they hired residents from one of the universities and told them where to cut and what to do, paying them a nice hourly wage for their service. A class action suit was instituted against the poor doctors for mal-practice (I believe that they became poor). I was an expert for the plaintiff on that case and agreed to participate because the results were hideous and many, many people were deformed permanently. This Pittsburg clinic was owned by the sleazist salesman you can imagine, who must have convinced the doctors that they were doing a real service for these patient. The clinic gave the names of over 500 patient references. That was impressive, but when I got that list from one of their victims, I started down the list to call the patients and went through about 20-30 of those on the top of the list. I found that not one person on that list had anything nice to say about the clinic, the experience or the results. In fact, most people complained about their deformities and the emotionally angry conversations I had over the phone with them is what I remember most.

Non-physician clinics are opening everywhere, even if the various state laws were intended to restrict non-physicians from profiting from the practice of medicine. There is a legal work-around that has not yet been challenged in any state. Hair Club for Men (which is owned by Regis International, a $5 billion company) and Bosley (which is owned by Aderans, a Japanese hair piece manufacturer) have medical groups which are owned and run by a competent doctor who commands the hair transplant elements of the practice while the complex process of running the ‘sales driven business’ is managed by businessmen from the non-physician entity. I am not saying that a physician-owned hair transplant business is any guarantee of quality, as there are some sleazy licensed doctors out there who are as bad as the Pittsburg clinic I referenced. I have seen many results of bad non-physician and physician-owned clinics over the years and know that the victims have little recourse against the non-physician owned clinics because the state license authorities have little contol over the business entities (only the doctors who work for these clinics are controlled by medical practice agencies and laws).

Some States can not enforce the laws against non-physician owned medical clinics fast enough as entities change their names and identities as soon as the States get ready to put them away. I was hired by one State prosecutor as an expert witness against such a business entity, but the owners of the company closed down one corporation just before trial and opened a new corporate entity with an almost identical name with the exact same service. The prosecutor had to start from square one all over again. The doctor who ran that particular clinic was over 80 (he was a figure head leader with a valid medical license) and he lost his license to practice medicine because he could not change his name or protect his license. He was easily replaced with another figure head physician. Over the past few years, I have been told many times of ‘doctors’ who turned out not to be doctors doing surgery on them. It is happening all of the time (most recently a month or two ago in Los Angeles not far from my office). What is the difference between sleaze (like the Pittsburg entity) and the class act hair transplant entities? How do you know what to do, who is good and bad, how to pick a doctor and what to spend for a hair transplant? Is the bargain you are getting really a bargain? The good news is that today’s hair transplants can be absolutely first class and undetectable. The bad news is that they can be disastrous and deforming. You have to do your research to protect yourself in order to find your way through this complex maze.

One might ask, why not let a non-doctor operate on you after they’ve learned how to perform a hair transplant? Perhaps it could save you money? I won’t argue that the technical issues of the surgery are not difficult and everything goes well. The person doing the surgery would have to train a good team and teach the nuances of the surgery. But I would then ask where is the proper diagnosis, planning, and treatments that require knowledge of surgical planning, medications and how to treat a side effect of a medication or a complication if that should occur. When Xylocaine is given, can it precipitate a heart attack or a seizure? Absolutely, yes! A simple fainting episode in the operating room which slows down the heart rate to dangerous levels, can bring on a stroke or a heart attack (usually in older susceptible people with heart disease). What do non-physicians know about the treatment of such events? How do non-doctors treat run-away high blood pressure that occurs during a hair transplant (not-uncommon) in a hypertensive prone person? Or bleeding? If an inexperienced physician does a hair transplant, can he/she produce permanent nerve damage if they are not intimately familiar with the anatomy? Absolutely, yes! I can go on and on, but I hope that my readers get the message. Surgery can be safe, if it is done by a skilled, experienced and competent physician lead team, or it can kill you without such expertise. I have said many times that hair transplants are permanent and maybe I should add that death in the hands of a ‘would be surgeon’ is permanent as well. It is a buyer beware situation, as always.

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Hair Loss InformationBarry Bonds, Batting Averages, and Hair Transplants – Hair Loss Information – Balding Blog

Hi Doctor. Thank you for this blog and your honest responses. The fee that you charge to perform a procedure yourself is nearly double the fee to have one of your other doctors perform the procedure. I am sure that you are in high demand and as the laws of supply and demand go you are able to command double. What I really want to know is if the QUALITY of the results of a procedure performed by you would be noticibly better than that of a procedure performed by one of your doctors? I also see that there is only one other doctor and if I’m correct he is new to your practice. Bottom line is that when it comes to something such as a hair transplant, Quality and not Price would be a deciding factor as to who I went with. To use a baseball analogy, If you and John were baseball players would you both be batting .350 or would you be batting .400 and John .250 :)

Thanks again!

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BaseballGreat question! Like any good baseball team, you need to have the team work together to get a winning result. What I have consistently said is that a great hair transplant doctor can not produce great work without a great team. In 1991, the quality of the work performed by the hair transplant industry was not acceptable to me, so I had to redesign the surgical techniques to make them acceptable. I have published a massive amount of work defining the standards in hair transplantation techniques (see: Medical Publications).

If you took me out of the team today and moved me to a 2nd class team, I might produce 2nd class work if I would allow myself to do just that. Back in the late 1980s and early 1990s, the quality of the work done by all hair transplant doctors was poor because the techniques were crude. The pluggy ‘dolls’ head appearance was the standard of care. So, on the first day I started to do hair transplants, I changed the technique I offered to one that allowed for delicacy of the transplants with a larger and larger number of smaller grafts, but this took manual techniques that had yet to be invented and lots of labor to produce and place these smaller grafts. Since I have never allowed myself to produce 2nd class work in anything I do, I had to build a 1st class team that understood all of the nuances that made for great hair transplants so that I could increase the number of small grafts in a single session so my patients would not have to have a surgery many times to get their hair back. You can not imagine the number of things that are controlled by the processes we developed and implemented at NHI. If I had to start all over again, I am one of the few physicians worldwide capable of doing every single part of the transplant process and I have been teaching process and techniques (one on one) to dozens of doctors and many, many medical assistants over the years. I have personally trained and retained the best people with me over the years. I pay them well and create a festive and positive work environment for the team and they return to me a diligent focus on quality and an attitude that most patients feel is imparted to them when they experience a hair transplant from this team. When I have ‘terminated’ a staff member, they always find work with other hair transplant doctors (many doctors want a medical assistant trained by me), but as I would never ‘fire’ someone great, these doctors get medical assistants that could not meet or sustain my first class standards.

In my practice, there is no such thing as a batting average of less than 1000 (400 just does not cut it, because it means that the doctor and team get great results only 40% of the time). Barry Bonds does not bat 1000 when he is at the plate, but I can bat consistently at 1000 with the NHI team and a batting average in a hair transplant reflects great results consistently. Without the team, particularly in these larger session transplants, I doubt that I would bat 1000, unless I reduced the size of the sessions to meet what I could do alone in a single day, as I did in 1992 as I evolved the megasession.

Simply put, my fees are higher because of supply and demand issues competing for my time (as you discussed).

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Hair Loss InformationMiniaturization or Gimmick? – Hair Loss Information – Balding Blog

Dear Dr. Rassman.

I have a 3-in-1 question for you. Thanks for answering my previous question about Propecia. I am trying to cover my loss by all available means (Propecia, supplements, Minox and finally a transplant.)

First, I noticed you talk about getting one’s head mapped for miniaturization. I have spoken to five dermatologists here in Arizona, including two who specialize in hair transplants, and none of them have an idea what “mapping head for miniaturization” is. One of them even went as far as suggesting it was just a gimmick to get people to go on with the surgery. (Which I doubt.) I absolutely need to know to what degree my loss might be, so I can plan for the future, transplant and money-wise. The dermatologist who prescribed Propecia for me only took a 30 second look at my hair and gave me the prescription. I think that was a bit wrong, as it might be something else what’s causing my loss, though there is a history of it in my family. So…

Is there a doctor you can refer me to, who can perform the mapping, here in Az? The doctor who mentioned the “gimmick” said such analysis is pointless, as one miniaturized hair might be non-miniaturized by the next cycle. (I doubt it.)

Second. Another concern is how much it can evolve. I know balding is a progress, but I would like to know if a mapping can ascertain if I’ll be a say, class 4 for the rest of my life as it can be obvious some hairs are not affected by DHT, or if it will only tell me what class I am at a certain point in time, with the potential for more balding.

Third. I am concerned I might not have enough hair to leave me satisfied with my appearance even after a transplant. My main concern is thinning, as the recession is not that noticeable. I am curious to know if you can transplant hair from other parts of the body like chest or belly. I have long enough hair there that looks identical to my head hair, save for not growing longer than 1 or 1 1/2 inches. I wonder if this hair can be successfully transplanted to provide thickness, or work as “guard hairs” for the frontal hairline. I noticed my brother’s frontal hair is just like that. Other doctors in Australia (Who happen to follow your procedures and credit you with the techniques they use) have been successful in patching people up with body hair, with amazing results.

Sorry for the long post, and if some of my questions are not too clear. Keep up the good work, doctor, and hope to be stepping up into one of your offices soon.

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I just answered a similar question a couple of weeks ago, but I’m going to get a little more in depth this time…

The hair transplant medical field is not as standardized as one may think. There is the International Society of Hair Restoration Surgery (ISHRS), but not all hair transplant doctors belong to the society or practice the same way. Some doctors do not use microscopes for dissection. Some doctors do not use hair densitometers to determine miniaturization. Some doctors do not use follicular units. These should be the standard of practice in my opinion, but there is really no way to enforce these practices. Unfortunately, hair transplantation is not a highly regulated medical field. There are doctors who coin new terminology to promote their expertise. There are doctors that even claim that they were the ones who invented certain procedures by subtly changing minor details. It is alarming, but these things happen. To be fair, it happens in other industries as well. It is the basic theme of “buyer beware” that I often state in my posts here.

Your question on minaturization is an example of such variation in clinical practice. Hair generally loses its shaft thickness as it is lost. This thinning of the shaft is called miniaturization, a standard term in modern dermatology. Miniaturization occurs at different speeds in different areas of the scalp and over time it is (in men) often progressive. By getting a picture of the degree of miniaturization by area (a snapshot of the health of your scalp hair in each area), it allows the physician to determine not only the health of the hair in each paticular area, but it allows the physician the ability to follow the progression of the miniaturized process by area caused by the genetic process — or the improvement when a person is treated with drugs like Propecia.

Miniaturization measurements do not predict your future hair loss or the rate of that hair loss with certainty, because there are many factors involved in hair loss. It does give a trained doctor an extra set of vital information on the progression of the individual’s hair loss by monitoring and quantitatively documenting the effectiveness of medical treatments such. There is no science or measurement in when a doctor runs their fingers through your hair. Contrary to popular belief, mapping for miniaturization is often used to deter what is going on and allows the doctor to refine the diagnosis. Women have unique miniaturization patterns that differ from men and men each have different miniaturization patterns depending upon the extent and speed of their hair loss. Men who are not balding should show no miniaturization present (see example here).

With respect to body hair transplants, I am fully aware that there are internet advertisements and post-operative pictures with doctors proclaiming success. My reservation is that pictures do not always tell the truth. You need to meet these patients face to face and see their results and see the scars from their donor sites. At NHI we have monthly Open House events where we encourage all potential patients to come and see actual patients and learn and see a real hair transplant surgery. Furthermore, body hairs grow at different rates and have different (longer) dormant cycles where its transplantation may not be of clinical benefit (see Transplanting Chest, Leg, and Thigh Hair). Finally, hair transplants and even body hair transplants will NEVER restore your hair back to its childhood densities. It may be hard to believe, but you only need about 30 percent of your original hair density to preserve the same appearance.

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Hair Loss InformationAngry and Depressed Strip Surgery Patient – Hair Loss Information – Balding Blog

Dear Dr William!!!
I have to say that I’m very sorry doing FUSS on my 6-7 scale bald head. It does not give me chance to cut my hair short and the stripe is from one ear to another, very ugly. Doing a stripe more than 10cm should be forbidden. When I came for surgery i thought “if something went wrong i’m gonna shave”. Dont you think that is better to have a procedure with less FUE and be able to cut hair short, to make a nice hair line. if the vertex is bald it doesnt look bad when the hair is short. I’m sorry I realized that after my surgery. Cant you people see how many people suffer from this frankenstein scar? it is a sin to cut somebody like that. Besides that all the pictures lie about fullness of hair and also nobody ever mentions that the hair above and under the scar can have a big difference in fullness which looks very ugly.

I’m a very depressed and mentally destroyed 33 year old man. I had one chance for HT and I lost it with one of the greatest doctors that could not evaluate me and give me right advice . I signed all these scary papers just because I was trusting him, after all this I see it was all about the money. I would give now everything I have just to go back to normal. Please start up with some medical law to stop doing FUSS. The papers I signed are too scary to be offered to humans.

Unfortunately I will have to wear a hat in public for the rest of my life, probably at home too because I dont want my poor mother looking at me like this. People have done the HT for last 40 to 50 years and still do not realize that strip is wrong technique. To sign so many scary papers, like for FUSS, means that doctor still doesnt know what he is doing. I’m sure it is about the time when FUSS will be forbidden. God bless

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First, it must be pointed out that this man is not one of my patients.

I sympathize with your predicament and I’m sorry for your situation. The truth is, though, that there are many patients for whom a scar is much less of an issue than the alternative of having a Norwood Class 6 or 7 bald head. For those readers who are unfamiliar, there are some doctors that refer to the Follicular Unit Transplantation (strip procedure) as “FUSS” (Follicular Unit Strip Surgery). I don’t know what your scar looks like, and the fact that it bothers you so much means that it is unacceptable to you, yet these are issues that one needs to deal with before the surgery.

A few points that I want to highlight:

  1. The hair transplant procedure happens on your head, so you must think about every option and its possible consequences carefully.
  2. Never, ever sign anything that you do not understand. If you thought “these scary papers” were too much for you, you should’ve taken a step back and perhaps re-evaluated what you were doing before you agreed to it! This goes for anything you sign your name to. No matter how “trusting” you are, there is no excuse for signing any contract or papers without knowing what you are signing. What you most likely signed was an Informed Consent. According to the American Medical Association:

    Informed consent is more than simply getting a patient to sign a written consent form to protect the doctor when something goes wrong. It is a contract between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical or surgical intervention. In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with you:

    • The diagnosis, if known;
    • The nature and purpose of a proposed treatment or procedure;
    • The risks and benefits of a proposed treatment or procedure;
    • Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
    • The risks and benefits of the alternative treatment or procedure; and
    • The risks and benefits of not receiving or undergoing a treatment or procedure.
  3. How could you call the doctor who did your surgery “one of the greatest doctors” if he never gave you the “right advice” and you are so dissatisfied with the surgery? You should go back to your doctor to discuss your concerns.
  4. All surgical procedures will leave a scar. Most hair transplant scars can be easily covered by your hair, even with a short haircut. Note that if you shave your head, it will show. I had two hair transplants, and rarely can anyone find my scar unless they work my hair with a comb and use a very bright light, but if I shaved my head (something I do not ever plan to do) one would see a ‘smile’ on the back of my head reflecting this scar, though again, it would be very hard to find when I have hair grown to any length. Finally, if your scar is more than 5mm thick, you may have a keloid formation or may be a candidate for a scar revision (a type of fix that good doctors can do). All of this should have been covered in your Informed Consent.
  5. You state that you are “very depressed and mentally destroyed” and just want to go back before the transplant was done. You condemn your doctor who you have suggested just showed you pictures that lied about the fullness you were going to get. We have open house events in my practice to allow prospective patients to meet actual patients. I do agree that pictures are often not adequate, because they show you what the photographer wants you to see, but by meeting patients, it gives you a good chance to see the quality that you are going to get. As the expression goes, hindsight is 20/20, and hopefully knowing what you know now, you would’ve asked to meet patients in person. This should also be an important lesson for the readers considering a hair transplant (or any cosmetic procedure, really).
  6. Depression is a serious matter and you should think that about getting help directed to what is inside your head, not just addressing the subject of hair loss or scarring. Every human being would love to undo some decisions in their lives, but that is just not reality. As I’ve mentioned on this blog before, I always tell people that the good news and the bad news about hair transplants is that they are permanent. Going back in time is therefore not an option.

I have compassion for you, but you must take charge of your own situation by doing something positive about it. If you can make it to the Los Angeles area and would like me to judge what you have going on, come visit me or send me a good set of photos. At least that would be a small ‘baby step’ in the right direction by starting to take charge of your problem the correct way.