Category: Physician training

Dr. Rassman, I’m surprised no one else has raised this issue with you given the activity on various hair transplant discussion boards during the last few months. My question concerns the quantity of grafts in the donor reserve.

On these boards, I see a new trend of very young men wanting high density transplants to restore their juvenile hairlines and being transplanted under the assumption that they have, *on average*, 10K-15K grafts available via both strip and FUE. When the blarney of the clinic(s) making these graft count claims is questioned by more critical posters, the young men in question usually get very defensive and end up expressing their confidence in their doctor(s), and say that even if such estimates are exaggerated, surely some new drug, or hair maintenance, will come along to help them by the time their balding progresses to the point of making their transplants looks unnatural.

Since you believe in documenting scientific findings and have published the pathbreaking papers in this field, do you feel that these young men are being sold a false bill of goods? Can any clinic in good conscience be promising to be able to harvest twice as many grafts as we previously believed available? Has there been some breakthrough in graft harvesting capabilities that the laymen has yet to hear about? And should hope about the availability of future technology being able to benefit patients ever be part of a Master Plan?

You raise a very good point and concern. A typical hair transplant procedure of an average male with good scalp laxity will yield 3000 to 3500 grafts in Caucasians (who often have higher densities than Asians). The most that we were able to yield in one single surgery was about 5800 grafts from a patient with a very high donor hair density and good scalp laxity. This was the exception to the rule, of course. Some doctors split the ‘follicular units’ into smaller units and then charge the value of the ‘split’ number. So if a doctor got 3000 grafts, by dividing the grafts into smaller units, he/she may be able to charge for 5000 grafts and give the patient a feeling that he got more than he really did.

Thus, I very highly doubt that any clinic can yield 10,000 to 15,000 grafts in one procedure. They may be cutting all these grafts (which contain one, two, three, or four hairs) into single hair grafts. See my recent post titled How Do I Know I Am Getting the Number of Grafts I Am Paying For?. I feel strongly that splitting grafts to make money from patients is highly unethical and desperate patients are ultimately paying a price -– not only in financial terms, but in a lifetime of potential disfigurement from a depleted donor supply.

Looking at the old school method doctors used to perform hair transplants, with those really “pluggy” looks, Im curious as to why ANYONE in their right mind in the eighties would go in for that procedure! Was it ever done well?? I mean it really looks like crap and nothing like natural hair. Do you have any photos of one of those procedures done relatively well? Just curious. Thanks, really enjoy the blog!!!

They didn’t know any better back in those days. I know we’re only talking about 20-25 years ago, but technology is an interesting thing. One might say that there was so much excitement to get hair on a bald head, that men did not use their brains. Or that doctors were so trusted in those days, that when a doctor recommended hair plugs, everything was followed like the sheep to the slaughter. It may seen archaic now, but it was the state of the art back then and most men had plugs put into thinning hair so that they only saw more fullness — that is, until the hair all fell out around the plugs. There was a logic put together by the doctor that one could put the hair back in quarter sections, like a checkerboard with four squares. First you transplanted one square than the second, then the third, and then the last. In theory, the doctors and the patients wanted to believe that when all four squares were filled in, the hair was full. But reality took on another face, and the doctors started to push ‘touch-ups’ to fix the pluggy appearance of the rows of corn that grew on the head. It was not unusual for a patient to have 10 surgeries to get their hair back, but that was never a real possibility. I don’t know where common sense played a role and the men walking around with ‘doll’s hair’ were becoming more and more prevalent. Celebrities were leading the way and people like Frank Sinatra became the model that everyone wanted to follow (he had a pluggy transplant), but he really looked awful so he wore a wig and people thought that was his hair transplant, an illusion that doctors profited from and patients wanted to believe. It was an embarrassing con game perpetrated by the medical profession.

Have you seen the old Atari video games back in the 1980s? It was the best back then! Unfortunately, just like the Atari video games of the 80s, the results of the old plugs are not as impressive when viewed today.

Dear sir,
I underwent hair restoration surgery last year in the month of Octobar. All the transplanted hair fell and i didn’t get them back.what could be wrong? doctor not skilled enough to do it or what,Is it possible to redo surgery?

When the entire transplant fails, then it is possible that something major went wrong at the time of the surgery. This could be a disastrous mistake that killed the grafts or even an unskilled surgical team. Was the team skilled? Did you check out the doctors first? Did you see patients of theirs? If you decide to redo it, be sure that you have these questions answered… or do some more research and find a different doctor.

For more on what could go wrong during a hair transplant procedure, please see Things That Can Go Wrong in Hair Transplant Surgery.

I just saw a person that had a hair transplant by a man claiming to be a doctor (who actually wasn’t). This fake doc opened up a practice for doing hair transplants, and I decided to write a brief note here to hopefully serve as an important reminder about verifying your doctor’s credentials.

So what does one do to verify if the person who claims to be a doctor is really a doctor? It may sound ridiculous, but you could ask to see his/her state identification (like a driver’s license, for example) to get the correct spelling of the first/last name and then look the physician up at the state medical board database. For California, check here — for other states in the US, I found this Medical Board Directory, and if you can’t find what you’re looking for in there, I’m sure a Google search will turn up results by state/country/region. Try using the keywords “medical board” followed by your state/country/etc. Granted, fake state identification might be relatively easy to get, so maybe then you need to get his/her licenses to practice medicine and their narcotic number, both of which are harder to falsify.

The particular phony doctor that prompted this blog entry had rented another doctor’s office to give himself some credibility and had a line-up of patients for surgery. I won’t get into how wrong it was for the doctor to have rented him the office, but what was particularly significant to me is knowing what would have happened if something went wrong with a surgery. One of the most common complications I see is a fainting spell brought on when the Vagus nerve is stimulated from the excitement of the procedure, slowing the heart down to possible unsafe levels. When the heart slows, there is often a temporary drop in blood pressure, but if this very simple process is not addressed quickly and the patient had atherosclerosis of blood vessels to the brain or heart, a simple drop in blood pressure can lead to or cause a stroke or a heart attack. This complication is easily prevented by lying the patient back with the head down and the feet elevated. In a few minutes of careful observation with the patient in this position, the heart rate usually goes back to normal on its own. If this is not done, what may have been simply practicing medicine without a license might turn into some murder prosecution if the patient died.

Thank you for this illuminating website. I would like to know that when you are doing a hair transplant, what are the things that can go wrong and what can the surgeon do to prevent them?

I can write a book answering this question. Everything seems so simple. When a visitor comes to one of our open house events, they are amazed as to how simple it appears to be (we have a closed-circuit television setup where visitors can see the procedure as it happens). Alas, the beauty of what we do accounts for many of the things that you asked about and it is buried into the process. I will make a list, but the list may not be inclusive of every nuance. I will not discuss anesthesia right now, but will commit another blog entry to address that subject at some future time.

1. For donor area harvesting using the strip method, the issues are (1) damage to the important structures of the scalp (nerves, blood vessels, attaching muscles must be carefully avoided in the incision process) and (2) damage to the hair follicles as the strip is removed which can occur along the blade that is used to incise the scalp. When the wounds are closed, the tension at the time of the closure reflects the size of the donor strip. High tension closures tend to cause a higher degree of scars.
2. The hair follicles are dissected from the donor strip under a microscope and great care must be exercised to avoid damaging them as they are separated into 1, 2, 3, and 4 hair follicular units. The use of a microscope with a skilled staff guarantees the least amount of damage. The grafts must be kept moist at all times, as drying for even less than a minute will kill the delicate follicular units. Graft placement must be timely, for if the grafts are kept out of the body for more than 6 hours the survival decreases with each additional hour. The use of cold solutions can keep grafts alive for longer periods of time.
3. Graft handling is critical, because crush injuries are common if the grafts are not handled very gently. The long term tenure of our staff is what minimizes graft damage during placing the grafts.
4. Graft placement is critical. These grafts must be placed so that the top of the graft is flat to the skin. Placing them too deeply will kill the grafts.
5. Recipient site distribution, direction, and the type of instrument used dictate which direction the hair will grow and if it will be normal in texture. The graft direction and distribution reflect the experience of the surgeon. Improper direction or distribution will produce less-than-ideal aesthetic results. The closeness of the grafts vary between patients. Those with less blood supply should not have close packing of the grafts, while in some patients close packing densities can easily and safely be achieved.
6. Great care must be taken to fill each and every empty site with an appropriate size (# of hairs) graft. Stacking one graft on top of another graft is a common problem (piggybacking) in a less than experienced staff and it is the cause of folliculitis in many practices.

I hope this helps.

Thank you for taking the time to maintain this website. I met with a hair loss consultant last week for the first time. He recommended that I have 2500 grafs on my forehead area and a second transplant a year from now on the top of my head. Why not just have it all done at once? He claims that they dont charge per graf, but a flat fee regardless of how many transplants they do. Is this just a opportunity to make more money for a second procedure?

If the consultant you spoke with was not a doctor who does the surgery him/herself and is trained in hair transplantation as a specialty, then he/she is practicing medicine without a license and I would run for the hills. There are some clinics that promote consultants to recruit patients and I have seen some people get recommendations that are way out of line with their need. Doing more than 2500 grafts depends upon:

1. The size of the bald area being treated
2. The donor density
3. The looseness of the donor area skin (laxity)
4. The skill of the surgical team (only some teams are capable of performing 5000 grafts at one session)

Fees are generally priced per graft, but that is not a hard and fast rule. Whatever the basis for the charge, it should be both competitive to what a quality medical group would charge and show value for what you are going to receive (result focused of course). Selecting a doctor should follow the science I have outlined in How to Tell if You’ve Found the Right Hair Transplant Doctor.