Category: Physician training

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Why Would a Doctor Limit to 1000 Grafts Per Session? – Hair Loss Information by Dr. William Rassman

hi Dr,
i am considering getiing FUT done in the near future. i am from Ireland and there are limited surgeons here. one surgeon, has an excellent reputation, and an impressive bio, but limits his sessions to 1000. I would need about 2500 to 3000. what would be the reason for the limitation, and do you know of Doctors that also limit their sessions?

The limitation on the number of follicular units transplanted may be due to the limitations of the doctor’s staff and time. For example at New Hair Institute, we are capable of transplanting 3000-5000+ grafts in a day. This is possible because of our experienced staff, mastery of the tools we use, and techniques we have refined over many, many years. We were the first medical group in the world performing sessions of 1000, 2000, 3000 and even 4000 grafts (in 1994). The key to doing these larger sessions must address reasonable limits based upon each patient’s dynamics, skin laxity and supply/demand considerations. Then, the doctor’s team should become a focus and one should never push a doctor or his team to do more than they can competently handle. The level of competence with these large sessions varies between doctors.

If you are referring to Follicular Unit Extraction (some doctors may use different terms) where individual hair follicles are harvested one at a time, 1000 may be a reasonable number because it is a very laborious process, but here too, as the originator of the FUE process, we have performed as many as 2200 grafts in a single session in appropriate candidates. It is all a matter of experienced teams of doctors and staff working together after years of training. If your doctor is unwilling to perform a larger session, either stick with him/her and do more surgeries with smaller numbers of grafts or find another surgical team able to perform larger sessions with lots of experience doing them.

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Free Hair Transplants from Trainees? – Hair Loss Information by Dr. William Rassman

my question is, do medical students do hair transplants for free. For experience, like a dentist in trainning would give free cavity fillings if the patient let them work on them. i ask this because i dont make alot of money and is hard for me to save up due to bill. also i dont want to go bald, so im trying to find out other ways to not go bald. thanks for reading my question.

Surgery is not something that is legally allowed in any ordinary hospital or clinic for a non-physician to do and that includes medical students. Teaching hospitals have special waivers for medical students (who are not licensed medical doctors), so it is possible that medical school hospitals can offer this, but I am not familiar with this service being offered at any medical school in the United States. We do not have a medical school affiliated with New Hair Institute.

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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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Where Do Doctors Get Hair Transplant Training? – Hair Loss Information – Balding Blog

Where do doctor’s get hair transplant training? What credentials should I look for?

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Since I wrote this extensive answer to a similar question in the past, the International Society for Hair Transplant Surgeons have attempted to address the problem with little success. Although standards are now known, training is still an unsolved problem.

Please see my post from April 2005, Hair Transplant Doctor Training for the previous response.

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Buyer Beware – Hair Loss Information by Dr. William Rassman

Are all balding men transplant candidates?

BaldJust the other day, a 31 year old man came to my office wanting a hair transplant using the Follicular Unit Extraction (FUE) method. He had already seen 3 other doctors and I was 4th on his shopping list. I’m not knocking that — it’s a good idea to meet with more than one doctor before chosing your surgeon , even if you feel comfortable during your first consultation because comparison shopping in this industry is the best way to protect yourself. Whether I was 1st on his list or 4th on his list — I’m just glad he eventually made his way to my office. During the examination I noticed that his balding was more prominent in the front, but there was thinning everywhere, even in the donor area. His hair was light brown and his skin had moderate skin tones and people with this contrast usually show a good fullness in the ‘donor’ area, so I was immediately concerned that something was wrong with this picture. I mapped out his scalp for miniaturization and found that the hair groupings in the front, top, and crown rarely had two hairs per follicular unit, averaging half of the normal healthy hair population. The donor area had a density of 1 hair per mm square (normal for a Caucasian is 2) and there was significant miniaturization throughout the donor area, worse on the sides, but bad enough in the back of the head.

I asked him about the three doctors he had visited and he went on to tell me about their surgical recommendations and how many grafts each had suggested was the appropriate number. I asked him if they mapped out his scalp and he said each had put their hand over his donor area and told him that his donor supply was good. None had used magnification in examining the donor area, certainly not mapping out his scalp. In one pf the doctor’s offices, he only met with a salesman, who recommended the largest number of grafts of all three offices.

This patient had a disease called Diffuse Unpatterned Alopecia (DUPA) and if there is ever a contraindication for hair transplants, this is one of them. I found it more than interesting that all three of the other doctors recommended surgery and I told him that he was not now or ever going to be a hair transplant candidate. Had he undergone surgery, his donor area would have been wrecked and he would’ve had an awful result, losing more hair than any gain he could’ve possible had. The only advantage to having surgery was that the doctors who recommended it could adequately pay for that new house and car they are driving. Let the buyer beware.

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Avoiding Hair Salesmen – Hair Loss Information by Dr. William Rassman

SalesmanI just saw a 23 year old man come back to see me after he had a hair transplant with another medical group known for ‘overselling’ hair transplants using pressure tactics with an aggressive sales force. He had seen me just a few months earlier and I told him that I felt that he was not a good candidate for a hair transplant at this time, because he was too early in the hair loss process. I further told him that if he had a surgery without a course of Propecia, he might accelerate the hair loss. I thought we had agreed that he would go on Propecia in an attempt to slow down the hair loss he was experiencing and then return in 8 months for further evaluation.

He went to another doctor for another opinion and then, under pressure by their salesman, he had a hair transplant. On his visit with me yesterday, it is now 5 months after his surgery and he looked fairly bald now, with a reactive hair loss. Prior to his surgery he was a Class 3 pattern balding and now he showed a full Norwood Class 6 pattern. The 1000 grafts he received at the surgery were insignificant in view of the hair loss he had. The patient never took the Propecia (which might have protected him from the loss he experienced).

Some clinics still exist today who ’sell’ hair transplants like a used car. This young man is now hooked on the hair transplant process, like it or not. Will he ever be normal? Will his supply of donor hair meet the demands of his progressive balding? Will he have enough money to follow the course he is now on? Did he ever really have Informed Consent offered to him? What are his options?

I am not going to answer these questions, because by posing them I have in a way brought the purpose of this blog entry to your attention. For those shopping for a hair transplant today, it is still appropriate to warn: Let the buyer beware!

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Analytical Questions From a 21 Year Old Balding Man – Hair Loss Information by Dr. William Rassman

Respected Sir,
I am very happy to see the service you are providing. My name is nabeel hussain .My age is 21.5 years. I have started getting bald when I was of eighteen. Now on THE NORWOOD/HAMILTON SCALE I am at 3V position. I have met a dermatologist he recommended me genesis and minoxil2%. I was told that initially I will lose hair + I have to use these medicines for whole of my life. Sir please answers my following questions I will be highly thankful to you.

  1. I don’t want to do this hectic and frustrating job of using medicines. As it is temporary and as I will stop using them my hair will lose more rapidly. Apart from that they have side effects also. Am I right? Will medicines have some negative effect on my donor area?
  2. I want to go for hair transplantation. but one doctor told me that doing so at an early age of 21.5 is not a good option because I will continue losing my hair and I will be again bald at a age of 30.and the previous transplantation will become fruitless. Is it right?
  3. I want to transplant hair because I have a concern about my donor area that it might not diminish if I postponed my transplantation. Is it could be the case?
  4. Can we take hair from the side of our head as donor hairs?
  5. What is period of complete bed rest after transplantation?
  6. At what age should I go for transplantation?

I have asked you a lot of questions but I hope and am certain that you will answer them all as you are very co operative.

Kindly recommend a better solution for me.

  1. If you are balding from genetic causes, then there is a good reason to be using finasteride 1mg (marketed as Propecia), which you must take for the rest of your life ( that is, until a cure for balding is discovered).
  2. The doctor who told you that you are too early for transplants is probably correct, but I have not seen you so I am drawing this conclusion based upon no objective findings, just the average 21 year old who is in the early stages of the balding process.
  3. Hair transplantation may not be the answer for you because you do not know how bald you will become and if the supply of your donor hair will meet the demands of your eventual balding pattern. You could end up depleting your donor hair for the short term gain at the expense of your long term look without a Master Plan for hair loss in your hands.
  4. The donor area is on the side and back of the head as you indicated.
  5. Hair transplantation does not require any bed rest after the surgery. You can walk around and within 5 days, even run a marathon.
  6. Generally, balding patterns are clearly evident by the age of 25-26. The later you can delay the decision, the more mature the hair loss pattern will be.

You are asking good questions. Take the advice of the good doctor you have already seen.

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Hair Loss InformationDishonest Doctors and FUE – Hair Loss Information – Balding Blog

I have published an article recently in the Hair Transplant Forum International (an industry newsletter, see below) that warns of doctors who perform Follicular Unit Extraction and produce a Follicular Holocaust, killing off many of the hair follicles and then charging the patient as if all of the follicles were actually transplanted. This process is unfortunately more the rule rather than the exception, because doctors just do not count what they actually deliver. This is a double ‘insult’ to the patient who pays for 100% of what the doctor says he is transferring and actually receiving something in the order of 25-50% of that quantity. The second part of the insult is the loss of the hair which may be irretrievably lost from the patient’s limited donor supply for life. So, the surgeons who engage in this process are cheating the patient and at the same time destroying valuable donor hair.

I have just participated in a Regional Workshop for the International Society for Hair Restoration Surgeons where I was one of the faculty, teaching the FUE technique on patient volunteers to some 25 doctors from around the world. A few of the better known self promoted doctors were invited to attend, but they did not take up the invitation. Most of the doctors who attended the course came with an open mind to learn state of the art FUE technology from more experienced physicians who have been doing FUE successfully for years. I learned that the reports of dishonesty that I reported in the article I wrote continue to be a real problem. I received confirmation of what I discussed in the article, which appears to be widespread, over much of the world. I applaud doctors who take formal approved courses to learn or enhance their skills for new technologies by spending the time and the money to come from Korea, Japan, Western and Eastern Europe, North America and the Middle East, but I continue to be disgusted by physicians who would rather develop experience by experimenting on patients and damaging/cheating fellow human beings. I admire the courageous balding people who want to get the benefits of new technologies, but when dishonest doctors promote their expertise with no real basis, they behave like hucksters, only distinguishing themselves from other crooks selling products or services by having an M.D. after their name and a ‘doctor’ for a title. Clearly, for the FUE buyer, the buyer must beware!

Here is the editorial I wrote addressing problems of ethics in hair transplantation surgery, which was published a few months ago in the Hair Transplant Forum International, January/February 2006, Volume 16, Number 1:

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How Does a Doctor Get FUE Training? – Hair Loss Information by Dr. William Rassman

I see that many HT docs are offering FUEs and claiming how great they are. Where did they learn this and how can the consumer know what we’re getting is really quality work and not just a publicity scam?

It is best to ask to see the doctor’s patients and meet them directly. Do not accept photographs alone, for they may not be what they appear to be. FUE is becoming the ‘hip’ thing to offer patients to start to build a practice. It takes about 8 months from the time of the surgery until the results are known. For the dishonest doctor, that could become the ‘funding’ for a new venture and claims of expertise are easily made throughout newspaper ads and internet websites. Training is almost impossible to obtain unless you have a large hair transplant practice and are willing to practice on a dozen or so FUE grafts on every patient you perform a strip surgery upon. That is how I learned how to do them, 1-2 at a time per patient over 9 years. The main difference between me and others is that today’s self proclaimed expert can reference the standard I set and published. For me it was more complex than that, because I never knew it was really possible to obtain consistency until I had been doing it for years. The question you did not ask is about claims of success are measured. Self-proclaimed success in harvesting is clearly dependent upon ’self reporting’ without audits. Trust is everything and integrity is at the core of the surgeons being. I can not advise upon this point for the buyer has responsibilities to research it heavily (please see The Truth About Cheap Hair Transplants for more info). As I always end these types of comments, let the buyer beware.