Category: Physician training

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Hair Loss InformationPredicting Hair Loss – Hair Loss Information – Balding Blog

Hey Doc,
I got a question for you. Im 26 years old with no definitive loss yet although i do have the mature hairline. My question is has do with genetics. What is the likelyhood that a male will either take after their father or mothers father in terms of Male Baldness, is it almost 100% that you will take after one or both of them or could you concievably not follow either one’s baldness pattern and instead follow inherit MPB pattern as that to your cousins, uncles, great uncles, grandfathers.

This is the reason i ask my father started to bald by the time he hit age 25 and was completely bald by around 35, my mothers father started balding in his late teens and was completely bald by 30 yet here i am at 26 with no apparent loss. With this family history i always figured i had no chance to keep my hair because both my father and mothers father have excessive MPB, so i assumed by the time i graduated High School, i would have some sort of loss.

Also the reason i ask is because generally many of the male family members on both sides (father and mother’s side) namely uncles and cousins have fairly good hair, is it possible i was fortunate enough to escape the MPB gene from 2 of the closest male members (dad, mothers father) and somehow instead inherited the hair of the more distant male relatives?

IN you encounters as a derm, do you think most males take after either their father or mothers father, or is it common for a male to not follow either one of their patterns and instead have a hairloss pattern that of a more distant relative.

Thanks for your response

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Basically, we can take after either parent or neither parent. We can inherit genes and not have them expressed, yet pass the balding genes to our children or future grandchildren. I tell all of my patients that the best way to know, is to have a good microscopic examination of your scalp periodically. By the age of 27, you should have an idea of what your possible hair loss pattern is. In your particular situation, the appearance of a mature hair line has no significance for your balding pattern. It is possible that your pattern may have skipped generations or was inherited from others in the family that do not express the gene.

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Hair Loss InformationMaximum Number of Transplanted Hairs – Hair Loss Information – Balding Blog

HI DOC, what is the average number grafts a person has to transplant from the donor area???

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This is a difficult question, because it depends upon donor denity and donor laxity (assuming the strip method of harvesting). On average, I would suspect that the total number of transplantable hairs is between 15,000 – 20,000 assuming an average density and average laxity. Those with high density and laxity may push these numbers to double (30,000-45,000 hairs). I gave this answer in hairs not grafts, so based upon an average of two hairs per follicular unit, that number may be half in grafts.

If the FUE technique is perfected, then this number might change, but without more clinical experience, I could not answer this part of the question as the technique changes.

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How Many Grafts Per Procedure? – Hair Loss Information – Balding Blog

Hi Dr Rassman,
I have lost my hair since i was 25. I had 2 procedures so far with xxxx Medical Group for a total of about 1700 grafts and it seemed like every time after i had a procedure, my hair fell out even more. I am class 4 now and i am not really happy at all with my results. I am now interested in another procedure and I wonder how many grafts you can do per procedure? Please respond and thank you for your time.

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Hair transplants in young men, often accelerate hair loss unless they are on some protection like the drug Propecia. The hair loss associated with a hair transplant impacts the original hair and is called an Anogen Effluvium. After the first transplant, an Effluvium rarely occurs again provided the second transplant is performed in the next 2-5 years.

In my practice, we can perform as many as 5000 grafts in a single session provided that the scalp is loose and the densities are very good. We routinely perform at least one procedure each day in excess of 2500 grafts, but this is a matter of matching donor supply and recipient area need. The correct balance between these two, will minimize just how many surgeries one might need. We do like to put the highest densities in each session to minimize the number of sessions. Most people get what they want in one or two sessions, unless they are really extensively bald.

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Microscopes in Hair Transplantation – Hair Loss Information – Balding Blog

There is a lot of talk about the need / not the need for microscopes in hair transplantation, but as I visited various groups performing transplants, only a few use the microscope. Is it really important?

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We published an article about 7 years ago, (Dissecting Microscope versus Magnifying Loupes) which showed that using microscopes reduces waste, which means that more viable donor hair is available from every square inch of scalp that is harvested. The wastage is not a minor issue; those with white hair may find as much as 40% more hair can be obtained by using a microscope for dissection. The average person gets 20-25% more usable donor hair if a microscope is competently used in the dissection process. For those who are very bald, once hair is lost or damaged through inefficient dissection, that precious hair is never retrievable.

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Do Linear Donor Scars Widen? – Hair Loss Information – Balding Blog

Do linear donor scars stretch (widen) over time?

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You are asking about hair transplant scars from the rim of permanent hair that is found around the back and sides of your head. This area (donor area) is generally not prone to stretching if the incisions are made in the horizontal plain (side to side). The scalp has some degree of redundancy so that there is ‘extra’ scalp which you can easily slide up and down on the back of your head. This makes the scalp loose in most people so when some of it is removed, there should be enough excess scalp to close without tension on the wound. When there is minimal tension on the wound, it usually will close without stretching in people with normal healing tissues. If either the scalp is tight, or the body’s tissues are not strong, then these wounds may stretch. The more surgeries you have, the more the potential to develop stretched scalp scars.

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Calculating Future Hair Loss – Hair Loss Information – Balding Blog

Hi Dr. Rassman,

I have two questions. Is there any standard rate at which MPB occurs or is it completely unpredictable? I am 27 and would like to be able to look out 5-10 years and calculate where my hairline will be. I have been on Propecia for 3 months and am waiting to start a Rogaine program, but I am shedding so much that I would like my scalp to stabilize before I start.

I am also considering a FUE HT through my hairline. I have thinning in the front of the hairline but it hasn’t recessed yet. I’ve read that a FUE HT causes the hairs around the implants to thin out. Is this true? Is there any way to impant FUs in this thinning patch to make it appear thicker?

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You have raised many issues here so I will try to separate them and address each of them.

Predicting hair loss is difficult. It is best done by looking to your family, finding the various forms of balding there and trying to identify one person that matches the timing of your hair los. Generally, those people who will become very bald, show their balding pattern well before the age of 30. You appear to be in the group where anything is possible, so look to your family patterns.

With regard to Propecia and Minoxidil, I like to start off with one drug (usually Propecia) and then after 8 months, add the second. In this way I get an idea of the value and effectiveness of both drugs and can separate them out. Propecia shows much of its impact in 8 months. Minoxidil, when it works, kicks in within 4 months.

With regard to Follicular Unit Extraction, when it is well done by those who really have a great deal of experience and expertise, it should not damage the surrounding hair. What often happens, is that when the experience is not there, the surrounding hair may be directly damaged in the transplantation process.

Putting in transplants to make hair appear more dense is done when there is reduced risk of damaging the thinning area. Good judgments are required here to be sure that the degree of miniaturization that is present does not reflect ‘active’ hair loss in one of its accelerated modes.

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Hair Loss InformationRacial Differences in Hair Loss – Hair Loss Information – Balding Blog

Are there racial variations in hair loss. Which races have the most hair loss and which have the least?

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Male and female hair loss is common to all races. If you separate the races, the American Indian whose ancestors came from the Alaskan bridge have no balding. The more advanced hair loss patterns appear to impact Caucasian males most frequently. There are different distributions of balding that may favor one race or another. Asians often do not have the very advanced hair loss patterns, but then again, I have seen such patterns in some from these ethnic backgrounds.

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Hair Loss InformationHair Transplant Growth Success Rate – Hair Loss Information – Balding Blog

What is the growth success in 100 grafts that are transplanted?

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This is a good question. We really do not know exactly. I suspect that the growth rate success in our hands is over 90%, but it is almost impossible to count the transplanted hairs and compare their numbers to what was moved.

I have had opportunities to transplant a limited number of hairs in a scar, or an area of the head that was easy to separate from the rest of the areas and when I counted them, they all grew. I do test grafting in people with Alopecia Areata when I believe that the disease is inactive. In those patients who have inactive disease, I put in about 20 grafts into various areas of a bald patch of scalp. If the disease is really inactive, all 20 grafts are counted after some 6 months. I do the same for some burn patients where the scars may not support the grafts. When the scars can support the grafts, all grafts are then counted and if one grows, they all grow. This experience does show what is probably the case in our typical hair transplant sessions.

What we stress is a quality control process to minimize those factors that can cause hair loss in the transplant process. For the natural hair that is still present, we use drugs like Propecia before surgery. Various technical systems are enforced which guarantee that the grafts do not dry out (the leading cause of graft death), gentle handling (the second most common cause of graft death) and very experienced technicians (we have no turnover of clinical staff). A good transplant with a high success rate depends upon good team work with employees that know how to work together. Just like a good football team, every player in every position must work at peak efficiency to win the game. Winning the game in hair transplantation is a combination of 100% growth and good esthetics. This is why we show off our patients after their procedures at our open house events and also have a live surgery so that you can see, first hand, what will happen to you both in surgery and then 8 months later.

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Hair Loss InformationDo Hair Doctors Still Use Plugs? – Hair Loss Information – Balding Blog

Are doctors still using the plugs that I see on the street, in the malls and at airports all of the time?

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Not as a rule. The old plugs that gave this industry a bad name in the 1970-80s have largely been replaced with small grafts that are called follicular units. But there are some doctors that use ‘combination grafting’ which is a mixture of larger small grafts and naturally occurring follicular units. Only the follicular units are undetectable in bright light or close inspection.

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Hair Loss InformationJournal Articles on Propecia (Finasteride) – Hair Loss Information – Balding Blog

Two articles are summarized below which address the drug Finasteride (Proscar 5mg and Propecia 1mg).

These article are very technical and may not be good reading, but I have put them here as part of my effort to educate the readership. Both of these articles discuss what we have learned on preventing prostate cancer with finasteride (very important as most men who live long enough will develop prostate cancer) and the cost/benefits of taking finasteride over time. In medical circles, these are controversial articles in many ways. I have included the comments of one doctor in the hair restoration field. Dr. Bill Reed, states: “An oversight on the author’s part that would probably negate the need to reduce the price of finasteride is the enhanced quality of having more hair! With regard to the authors’ basic approach, it’s an awkward premise to attempt to attribute a monetary value to quality. For example, is the real quality and value of treating BPH (enlarged prostate) with finasteride [to produce a] better sleep and absence of urgency or the money saved from a TURP? I’ve always loved how a healthier prostate and more hair probably go together with this drug [How does one quantify this value?]”

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European Journal of Cancer. 2005 Jul 29; The article addresses the finasteride prostate cancer prevention trial (PCPT) and asks: What have we learned?

Author: Mellon JK., Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, United Kingdom.

In 2003, the first of two large NCI-sponsored prostate cancer chemoprevention trials was reported. The prostate cancer prevention trial (PCPT) demonstrated a 24.8% reduction in the prevalence of prostate cancer in men taking finasteride 5mg/d for 7years. However, despite the overall reduced risk of prostate cancer, men in the finasteride-treated arm of the study were more likely to develop high-grade disease. This article examines some of the controversies aroused by the PCPT and evaluates some of the arguments that have been advanced in an attempt to explain some of the unexpected outcomes of the study. In addition, some of the recent studies assessing the potential impact of an effective chemopreventive strategy on population mortality are reviewed. To conclude, there is some discussion of factors, which need to be openly discussed with male patients who might be considered for finasteride therapy.

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The American Journal of Medicine. 2005 Aug;118(8):850-7. The article addresses the lifetime implications and cost-effectiveness of using finasteride to prevent prostate cancer.

Author: Zeliadt SB, Etzioni RD, Penson DF, Thompson IM, Ramsey SD., Fred Hutchinson Cancer Research Center, Seattle, Wash.; Health Services Department, University of Washington School of Public Health and Community Medicine, Seattle, Wash.

PURPOSE: We estimate the lifetime implications of daily treatment with finasteride following the results of the Prostate Cancer Prevention Trial (PCPT). In this trial, prostate cancer prevalence was reduced by 25%; however, an increase in the number of high-grade tumors among the treatment group necessitates the long-term projection of the likely benefits and costs. METHODS: We use a Markov decision analysis model with data from the trial, the SEER program, and published literature. The model measures the cost per life-year and cost per quality-adjusted life-year (QALY) gained for a cohort of men age 55 years who initiate preventive treatment with finasteride. RESULTS: Finasteride is associated with a gain of 6 life-years per 1000 men treated at an incremental cost of $1,660,000 per life-year gained. The quality-adjusted analysis results in 46 QALYs gained per 1000 men treated at an incremental cost of $200,000 per QALY gained, due primarily to the favorable effects of finasteride on benign prostatic hyperplasia. Under the assumption that the increase in high-grade tumors observed among finasteride treated men is a pathologic artifact, the incremental costs are $290,000 per life-year gained and $130,000 per QALY gained. CONCLUSIONS: The cost burden associated with finasteride is substantial, while its survival benefit is small and only realized many years after initiating treatment. To achieve an incremental cost below $100,000 per QALY gained, the price of finasteride must be reduced by 50% from its current average wholesale price and finasteride must be shown to prevent high-grade as well as low-grade disease.