Category: Other

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Miniaturization Mapping vs Pull Test – Hair Loss Information – Balding Blog

Dr. Rassman,

I’m going to make an appointment to have the miniaturization test in your office, but someone told me about a “pull-test” which measures the ratio of hairs pulled from a sample area on top of your head to hairs pulled in a sample from the donor area. When compared to the donor area, if significantly more hairs come out from the sample area on the top of your head, then you are balding. Is this test accurate to some extent?

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The pull test is not good for diagnosis of miniaturization and genetic hair loss. The degree of shaft thickness change is what mapping will show. Hairs that are in the early phase of miniaturization will not pull out. Those that do pull out, may be the hairs about to go into their telogen cycle.

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Skin Cancer on the Scalp – Hair Loss Information by Dr. William Rassman

In an earlier post, you commented that Toppik can cause skin cancer. Did I read that wrong?

Yes, you read it wrong. Toppik can hide a skin cancer, because it is like a make-up that covers what it is put on. If the scalp is tan, then a tan Toppik would be used to cover the scalp, thereby hiding a skin abnormality like the skin cancer seen here:

I actually picked up this cancer by giving this man a hair wash in the office so I would get off the Toppik and get a good examination of this scalp. He had noticed this spot when his comb got caught on it. It often bleed, but he did not think much about it because he assumed it was from his comb. Wounds that do not heal like this must be examined by an expert to rule out a skin cancer. I found this tumor and was concerned that it was a malignant melanoma (see below), but after excision biopsy was done, it turned out (fortunately) to be a Basal Cell type. The excision alone should cure this particular cancer.

Skin cancers come in three varieties:

  1. Basal cell cancers are the most common and they frequently ‘crater’ and elevate. These tumors are most often the result of direct sun damage and they rarely metastasize and they are slow growing. They will, however, locally invade the surrounding structures.
  2. Squamous cell cancers are the second most frequent cancer and they will invade beyond the confines of the tumor, even spreading to other parts of the body. They can kill.
  3. Malignant melanomas are skin cancers most dreaded by everyone. They often have a black, elevated surface with a spreading out of the tumor like an octopus or an amoeba. Once they invade below the very superficial surface component and break through into the lower structures of the skin (about 1-2 mm below the surface), they can and often spread through the body and they can be deadly.

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Hair Loss InformationHow to Tell if You’ve Found the Right Hair Transplant Doctor – Hair Loss Information – Balding Blog

What is the difference between doctors and the various medical groups performing hair transplants. There appears to be a great deal of competition and as I go between groups, I get confused and overwhelmed.

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If you were looking for a good family doctor or plastic surgeon, you would most likely use certain criteria for selecting one over the other. Fundamentally, you would look for a well credentialed, caring, competent doctor who you like and feel comfortable with. Be sure that the doctor values you as a patient by spending time with you and discussing your agenda freely. Ask yourself if the doctor listened to what you were saying or lectured you about his/her ideas. That doctor must be trustworthy to take on your welfare or your family’s welfare, and not only must you believe in his/her skills, but you should also like him/her as a person. Although the various family doctors and plastic surgeons use physician’s assistants or nurse practitioners to help them manage patient’s needs, the doctor is always ultimately the person in charge, the one whose skills you will eventually depend upon. As most doctors practice in groups, you should feel comfortable with the doctors who work with your doctor in the group that you selected, as sometimes your doctor may be on vacation or off-call when you need him/her the most.

You should expect that physician extenders should be educated as physician extenders (nurses or certified physician assistants, not salesmen). Hair transplantation differs from standard family practice and cosmetic surgery procedures in that there is a team approach to performing surgery. Doing refined follicular unit transplantation takes a team of 3-6 people working together for hours, so the doctor’s team is as important as the doctor is. An old cliché says that a chain is only as strong as its weakest link, so the skills of the doctor as one link of that chain can easily be offset by inexperienced technicians in the surgical team or sloppy processes that are not put together carefully and not focused on the many detailed nuances that produce quality hair transplants. You should feel confidence in the doctor and the team and you should feel ‘integrity’ and trust in soul of that doctor.

In my hair restoration practice, I add many elements to build confidence and establish trust. I have an open practice, where new, potential patients can meet completed hair transplanted patients one-on-one. This offers the opportunity for new patients to probe the process and see up front what they will be getting if we perform the surgery. I focus heavily on patient education, not only by providing copies of some of the important medical articles I have written, but also in spending time with each potential patient (doctor and patient in a private room without a salesman). Then after the visit, I provide a detailed letter summarizing what I learned about the patient’s objectives, and a written Master Plan for what I think will happen to that patient. Fees are openly discussed by the doctor and quotes for surgical fees are put into writing. By far, most of our patients do not have surgery and can be spared surgery with appropriate medications.

NHI is unique in that we have a fully accredited surgical center where all of our surgeries are performed, ensuring safety for patients to the highest national standard. Our surgical center is audited regularly for following hospital quality processes and procedure. Very few (if any) hair transplant facilities adhere to such rigorous standards. Why is that important? Well, it is the patient’s assurance that our sense of quality is judged against the best healthcare facilities in the nation. When you select a medical group for your hair transplant procedure, you should not only know the facility, the staff competence, and longevity of that staff, but also the history of the doctor. Has the doctor been disciplined before the medical board for infractions in any form of conduct? What does the public and his colleagues think about the doctor (available through internet sources)? What is the doctor’s malpractice record? Have you met or spoken to his/her former patients, and if so, what do they tell you about their research prior to taking on this doctor as their doctor-of-choice?

I always tell my patients (and have written on this blog many times before) that there is good news and bad news for the hair transplant patient — simply put, hair transplants are absolutely permanent. Getting it done right the first time is far easier that trying to fix what might not be fixable if it is done wrong. By following this selection process, finding a good doctor should not be difficult. There are many good doctors out there, just be careful not to end up in the wrong place.

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Remember, Actors Change Appearance for Roles – Hair Loss Information by Dr. William Rassman

Dear Dr.Rassman,

I did read your Mel-Gibson story. Please remember that especially actors does a lot of changes in their appearance.

Take Al Pacino. His hair was thinned out for his role in Godfather due to his characters age.

Here’s a snippet from the DVD cover of the Godfather Part III, showing Al Pacino’s aged look that you mentioned.

When a role requires an actor to look older in the theater or on film, stylists (or the actors themselves, perhaps) tend to gray the hair and might even put some balding or thinning appearance to the hair. When the role seeks a younger look, they add more hair and reverse the balding. That is the natural course for the aging man, because half of the male population will have some degree of balding by the time they reach their mid-40s.

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Miniaturization Mapping After Taking Propecia for 3 Months – Hair Loss Information by Dr. William Rassman

I am 39 yrs old male and have been taking propecia for 3 months and 2 weeks (no effect so far). I have been to two doctors in Canada and none of them mapped me for miniaturization (they just prescribed propecia). My question is can I still get mapped for miniaturization or will the 3.5 months of propecia use affect the results. Also, do you know of any doctor in Canada (Toronto) who does miniaturization mapping. You are too far away or I would like to come to you.

Thaknk You and please help out.

Show your doctors the piece on miniaturization that I wrote, Miniaturization: Critical to the Master Plan for Hair Loss. They should easily be able to do what I described. Sometimes, a little push and education from a patient to the doctors goes a long way.

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Hair Loss InformationWhat is Dandruff and Why Do I Have More of It Than My Friends? – Hair Loss Information – Balding Blog

What is dandruff and why do I have more of it than my friends? I can’t wear any dark shirt without snow on my shoulders. What can I do about it? Please help me understand what is happening to my scalp!

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Skin is not static. It changes and we shed it like a snake sheds its skin, but we do this a little each and every hour of the day. In two weeks, the average person will shed their entire skin surface and replace it with new skin. Scalp skin takes about a month to turn over, so the process is a bit longer. To understand dandruff, let’s take a quick look at psoriasis. “Psoriasis is a skin disease that causes scaling and swelling. Skin cells grow deep in the skin and slowly rise to the surface. This process is called cell turnover, and it normally takes about a month. With psoriasis, it can happen in just a few days because the cells rise too fast and pile up on the surface.” (source: NIAMS). Dandruff is like psoriasis in that the skin turnover is faster than normal (not anything as fast as psoriasis) and before it can be shed, it cakes up to form the flakes that you are observing and complaining about (dandruff).

Skin on different parts of the body shed at different rates and as we age, it is the genes in our body that determine how quickly the normal aging process occurs in our skin and the turnover rate of that skin for our age. The rate of aging and the daily changes in our skin can be influenced by extrinsic factors that can act together with the normal aging process to prematurely age our skin. Sun exposure is one of the most important factors that cause our skin to age but the way we use our body also impacts us. Exposure to varying environments will change the rate of skin turnover as well as the moisture that our skin has in it. Other external factors include things we do, like smoking, which has a duel effect, not only aging the skin and changing the water content of our skin, but it also decreases blood flow to some part of our skin anatomy (scalp). Over time, exposure to the sun damages our skin and impacts our ability to repair itself. Much of the damage is probably related to our exposure to ultraviolet (UV) light which damages our skin’s ability to repair itself. The skin which envelops our body becomes loose as we age and this process is accelerated when we do not protect our skin from sun exposure. The rate of skin turnover varies between people and dandruff is probably a reflection of the rate of skin turnover of our scalp skin for the flakes of dandruff are actually pieces of our skin which are shed prematurely. The higher the turnover rate, the worse the dandruff and the more frequent will be our complaints (e.g. itching, dryness) which plagues many of us.

The best way to manage your skin is to develop a sensible skin care routine. The scalp is no different. The use of moisturizers will soften and wet our skin; conditioners made for dry skin and dry hair will help restore moisture that is lost from the shampoos we use, which remove many of the protecting oils made by our sebaceous glands (sebum) that are designed to hold in moisture. Most important of all is the way you protect your skin from sun exposure, which can produce structural changes in your skin that are permanent. Older skin does not hold on to water very well, so older skin dries easily. Our outer skin layer (stratum corneum) may shed less as we age and the normal texture of the skin changes to reflect the loss of the supporting structures below the top skin layer. An older person’s skin appears dry and crinkly and this reflects a slowing down of collagen production as well as the fibrous elements that we call elastin. Elastin brings the recoil that returns the skin back to its normal position if we pull on it. In the typical aging person, the skin does not recoil very well when pulled upon and as such, it stands up after being pulled upon and it is also more fragile to injuries and environmental factors. Aging is a continuous process that normally begins in our mid-20s when most of our skin is healthy and hopefully not yet damaged by environmental factors. Dead skin cells do not shed as quickly and turnover of new skin cells will decrease as we age. The signs of aging are typically not visible for decades and this reflect the fact that our skin can take considerable abuse before it shows its age.

The dandruff on your head reflects many of the elements discussed above and the scalp skin is constantly exposed to drying from air and UV exposure, building up more damage over time.

Our body’s ability to replace itself varies significantly by body part and organ. For example, the outer layer of our skin completely replaces itself in about 2 weeks (scalp 4 weeks), while the lining in our intestine does it every 5 days. Our red blood cells replace themselves every 4 months (about 1/120th per day) and our bones about 10 years. Our chest muscles last 15 years, and our brains, well the part of it reading this blog, is as old as you are. So next time you get frustrated over the dandruff, think about what you have learned here, as it is a lot easier to moisturize and protect your scalp skin from sun damage than to simply ignore it as most of you do now.

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Hair Loss InformationIf You Trash Your Competitors, You Will Get Dirt on Your Shirt – Hair Loss Information – Balding Blog

I read with disgust your piece the other day (Doctors, Crooks, or Con Men — How Do You Tell the Difference?) which attacked doctors in such a way that your readers will get an unfair view of the doctors who do good hair transplants and are honest and caring. There are many doctors with high integrity who try to get the best for their patients. Why don’t you promote them and talk about the wonderful things that we can do today, rather than dwell on the few rotton apples out there?

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From time to time, I just get overwhelmed by some issue and my frustration is shared with all of you. This is my blog, which is like a personal journal that I share with all of my readers. Sure, I answer hair loss questions that are written to me, but from time to time I also treat it as a place to express my thoughts and even vent my anger in hopefully some constructive way. The piece from the other day was clearly precipitated by one particular patient, but unfortunately, it was not such an unusual occurrence for me to see this problem come up. Of the four doctors who gave him opinions, two of them actually do good quality hair transplants that I have seen in my office, but the decisions they made when meeting this poor man were not necessarily driven by his agenda nor his welfare. I know, unfortunately, that many of the doctors in the hair transplant industry spend huge amounts of money promoting their hair transplant expertise. A 2 x 3.5 inch ad in the Los Angeles Times, for example, costs between $1300-2700 for each day it is run (depending on the day of the week and length of the contract), so when ads are run daily, the costs become staggering and the doctor is as much driven by his/her ability to support his ad budget and his staff salaries, as by his/her desire to be honorable and righteous. Does one agenda conflict with the other? I believe that they, unfortunately, do conflict.

To handle a high number of people responding to these ads, these doctors hire salesmen (often disguised as someone with medical expertise) who become physician extenders, often screening callers to find out who has enough money to afford a hair transplant. Salesmen earn commissions, and although commissions are illegal in California, the commissions in some form still are what drives the sales process. Every potential candidate is screened for his ability to pay the large fees, just as the prospective patient was quoted the other day. That patient had the money so I think that the blood hounds sensed it so the price incentives that were offered by one doctor had some sense of urgency to it. The process I just defined is sleazy and it is something that I have written about, much to my detriment in this heavily market-and-sales driven process. Unfortunately, this is not just a California problem, it is an industry-wide cosmetic surgery problem and some doctors from around the world fit well into the amoral mold I have defined here. But there are many good doctors out there as well, so shopping before you buy a hair transplant will probably lead you to a better choice than taking the first doctor you meet. Watch out for sales tactics that look like a used-car sales lot. Do not accept seeing anyone but the doctor who is going to do the work and never, ever accept anything that you are told unless the person is qualified to give you an opinion and can back up what the doctor tells you.

The doctor who wrote the above comment to me today does bring up some very important things. The surgery we can do today is almost miraculous and 6 of my family members who’ve had hair transplants think that I am God-like for how natural the work looks. I think that too many people have expectations of the deforming, pluggy, doll-look with corn rows, so it is a difficult road for today’s doctors to educate the public on today’s high quality reality. A hair transplant was not only good enough for my immediate family, but I also had it done. As I’ve shared before, I have performed surgery on the politicians, billionaires, CEOs of big businesses, celebrities, the Royalty of countries that my readers have read about, and a few probable mafia members from other countries who would not have allowed me to live had it not worked out and met their expectations. I am not the only doctor who can do this type of quality hair transplant, so please forgive me for yesterday’s and today’s diatribe. To complete my answer to the doctor who posed the comment to me, I must remind the doctors who are reading this blog that we have taken an oath to uphold our patients’ interests about our own. If our oath is not enough, most governments that license doctors require doctors to report any infraction in ethical behavior that we observe as a condition of licensure, something that even I do not adhere to, to the spirit and the letter of the law.

I remember in 1994, I spoke before hundreds of doctors attacking those whose ethics reflect the worst of the sleaze in the business. I openly called them ‘sleazy crooks’. I also remember that the audience stood up and applauded my comments because the large majority of doctors were also disgusted with those who dragged down this struggling new industry, making it particularly hard to break the monopoly that had been horded by a select few marketers. I felt good about my comments because I sensed that many of the doctors in the audience fully supported the victimized men we were focused upon helping. After many private congratulations in the hallway over my vocal position, one well known doctor waited on the sidelines. As the crowd that surrounded me thinned and dispersed, that well known doctor came over to me and said, “I did not like the way you talked about me.” He stomped off and I thought for a moment, remembering that I never named a name and the closest I came to identifying anyone was the label “ sleazy crook,” which seemed to have struck a sensitive cord with him. I think I remember saying, “If the shoe fits, its yours,” but I think that he walked away from me too fast to have heard my retort.

I hope that the doctor who posed his query to me here reflects those who supported my position in 1994 and would support this long winded commentary by me as well.

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Hair Loss InformationDoctors, Crooks, or Con Men – How Do You Tell the Difference? – Hair Loss Information – Balding Blog

I just met a patient who, while doing comparative shopping, came to me as the fifth doctor on his shopping list. He was 46 years old and had some thinning in his crown. He lost the first inch of his hairline, but his hairline did not bother him and therefore was not his focus. He was fine with where the frontal hairline was. He was able to see through the crown for the first time in years. Below, is the spirit of what he told me his experiences were, I simulated quotes of a conversation to demonstrate what he described to me —

Doctor #1:
“You are going bald in the crown”, he was told. He was quoted a surgery cost of $12,000 for 1400 grafts.
“Will I lose any hair from the transplant?”, he asked.
“It happens sometimes,” the doctor answered, “but if it does happen, it will grow back”

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Doctor #2:
“I can fix it with 800 grafts for $3,000 and if you do that now, I will throw in another 100 free grafts”.

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Doctor #3:
The man had researched this doctor and found that there were reputation problems evident through industry-specific bulletin boards and in internet reference sites. He felt that the visit to this doctor reeked of sleaziness.

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Doctor #4:
On the visit, he met a patient in the crowded lobby. The patient (who already had surgery) warned him to stay away for his own good. When he visited the doctor, he was told that for $12,000, he could get 2000 grafts into the crown and it would make his crown appear full.

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Dr. Rassman (Doctor #5):
I mapped out his scalp for miniaturization and found that less than 50% of the crown hair was miniaturized (no other doctor did this). The frontal area had 80% miniaturization just behind the balding area, suggesting that his hair loss will continue in the frontal area. I told him that with only 50% miniaturization in the crown, a drug treatment would be the best approach, not surgery. When the hair is 50% miniaturized, there is usually reasonably good cover and surgery runs the risk of causing irreversible hair loss (which usually does not grow back in men). If this happened, it could make his crown more see through than it was now. I recommended against any surgery.

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I was personally frustrated with my colleagues in the hair transplant field, particularly for what appeared to be a lack of moral fiber in managing this man’s problem. I have always believed that doctors should put their own welfare behind the patient’s welfare. What the above cases clearly showed me was that the first four doctors were behaving like used car salesmen, selling this man the car driven by that little old school teacher who never abused it. I have no difficulty condemning the opinions of these other doctors and their behavior. Every one of the four wanted to take this man’s money and preyed upon his vanity.

Of interest, when he first started talking with me, he was at first baffled by the wide discrepancies between the recommendations and the pricing, but after receiving my explanation of the miniaturization assessment (something that none of the other doctors did on his examination), his confusion cleared up. His initial question to me was why was there such a wide descrepency between the estimates of work and price. That was not his focus after the consultation with me. In his case, good comparative shopping saved him from being victimized by doctors who behave like crooks and con men. They are still out there.

Again and again, I warn people, ‘Let the Buyer Beware!’