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Raising the eyebrows gets the forehead to wrinkle and this shows the anatomy of the muscles under the skin. The distances between the Glabella (the bridge of the nose) and the highest wrinkle on the forehead tells me a great deal when measuring the leading edge of the hairline. A normal mature hairline is usually one finger breadth distance between the highest wrinkle and the midline hairline. A picture of your entire face allows me to judge general proportions, chin to nose, nose to Glabella and Glabella to hairline. Michaelangelo in his status of David, put the proportions of these distances 1/3rd, 1/3rd, and 1/3rd however most normal people find that the distance between the chin and the tip of the nose is equal to the distance between the Glabella and the leading edge of the midline hairline.

Say you are 19 with male pattern baldness. How do you figure out who’s pattern he will be following?

Hi Doctor Rassman,
I am 26 yr old guy having hair thinning since past 10 months. I recently started on a regimen of propecia and Minoxidil 5% since past 1 month. I plan to have an elective surgery next month which will involve Anesthesia with IV sedation. I am worried this could accelerate my hairloss/ thinning. From what I have read any surgery can cause Temporary hairloss or telogen effluvium more so due to psychological stress than light anesthesia. How true is this ? Does any surgery always result in hairloss ? Will the fact that I will be 2 months on propecia and Minox help or decrease the hairloss/thinning that might be caused because of the surgery ? Please advise whether its too risky to go for surgery as I do not want to mess up with my hair. I have had a surgery (accident fracture) before under general anes. 4 years back and did not notice any hairloss but that was because I was not having any hair issues back then.

If you have genetic hair loss, then any stress (like anesthesia and surgery) can accelerate the hair loss process in a young person. Men are less likely to have this happen and your approach wtih Minoxidil and Propecia should reasonably protect you, as much as possible. I have rarely seen hair loss in men with anesthesia and surgery outside of the scalp, but in women with genetic hair loss it is not uncommon. Many women who lose hair will regrow it, but for the few men that lose it with ongoing genetic hair loss, the return of hair is rare. Your approach seems aggressive and well-timed and would encourage you to continue on that track.

I am 40 years old. I have bald areas corresponding to Norwood 3 Vertex but thin (but stable) hair corresponding to NW6 according to two doctors. I am not taking Propecia for 18 months.

1. Can I still progress to a NW6?
2. If you (Dr. Rassman) were to transplant me, would you fix the NW3 regions or the NW6 regions or both?

Generally, when doctors assess patients with a Norwood scale, it is meant to categorize your eventual balding pattern. You may not look like a Norwood class 6 right now, but it seems two doctors that have examined you think you are going to eventually be a Norwood 6. This likely means you are not a Norwood 3V, but you have a pattern leading to a class 6.

Many men on finasteride may never lose all of the hair in the end pattern, but no one really knows. Best to get good baselines with bulk measurements along with some good pictures, and then repeat them serially year after year to know where you are actually going.

So a good doctor should recognize this and transplant the hair with both a short term focus to address your immediate needs and a long term focus leaving enough donor hair available to address the evolving situation as it unfolds. In short, this is what I always stress about on this blog and in my private practice. This must be a Master Plan for each patient before going forward with the first hair transplant in what may become a course you will follow over your lifetime.

I have decent coverage but low hair density and when I push it around I can see it’s a bit thin up top especially under super bright light. Will fin alone help with thickening up the top and increasing the density? I really don’t want to take min bc it’s not extremely bad. Thanks.

Yes, it can, especially in a young man under 25. That is why I do HAIRCHECK tests to see the differences in density before and after treatment with finasteride.

I started receding when I was about 18 but it stabilized and never went past what I now understand to be a “Norwood 2.”

However, now that I’m in my early 40s, and particularly over the last year, I’ve noticed a substantial thinning on top (still no bald batch in the back). I can clearly see scalp.

Could this be a medical issue (hormone changes with age) or is there something I should be tested for to correct the situation?

My grandfather (mother’s side) was bald; my father had his hair, as did his father. My uncle (on mother’s side) lost most of his hair in his 40s-50s. I have two older brothers and both are receding but nothing dramatic.

This is called getting old. Maybe you always had some thinning but as you get old it is showing more. Maybe you were genetically programmed to be a Norwood 2V/ 3V. I do not know.

The best test to find out if you are balding, is to get a hair Bulk Analysis or a Miniaturization Test in a doctor’s office. We do these routinely. Just yesterday, a 27 year old male came in with hair loss in the frontal hairline, but when I did the hair bulk analyses, I found that he was losing hair in the top and crown where he could not see it. There really is no blood test other than establishing a diagnosis by a competent doctor in the office setting. I realize there are genetic blood test for androgenic alopecia but the results will not give you a clear cut yes or no with regard to whether you are balding or not. Even if the answer to the genetic test is that you do or do ot have genetic balding genes, you still have the hair loss issue that is something that only a doctor can tell you once he examines you for hair bulk around your entire scalp.

In the end if you want to do something about it, you are left with (1) drugs (Propecia or Rogaine) (2) hair transplant surgery if you can see the hair loss (3) scalp micropgimentation (4) different hair style. Finally it is rare for men to have other medical issues that would cause a “pattern” balding. The “pattern” you are describing may be Male “Pattern” Balding. See a doctor if you want to do something about it.

My dad is 55 and is still a NW2 with good density, but unfortunately I don’t think I got his hair genes. Looking at my maternal grandfathers pictures I have a really similar hairline to him and the same big forehead. He said he didn’t start losing hair until 40 and was a nw7 around 60. However I think he started earlier than 40 he just didn’t really notice it getting bad until then. I was an NW2 at 20 and have been on fin since then (am 23 now) and am still an NW2, but my overall density has thinned a little bit. Do people usually follow an exact pattern as certain people in their family or is it sometimes a combination of multiple people?

Many men who are balding can find someone in their family line that have a balding pattern and rate of balding that they can identify with.

I recently noticed my hair thinning and it has put me in a state of sadness. There are times during the day where I can’t bring myself to do anything because of how upset I am about my hair loss. I am a 23 year-old Asian male with what I suspect to be diffuse thinning. However, I have not seen any hair fall out on my pillow and just a few fall out when I shower. Would it be possible for you to look at some pictures of me to give me a confirmation? I want to take Finasteride but I am scared to death of the sides.

I don’t think that you are balding. Asians often have lower than average hair density and with your black hair and light skin, the see-through of low density reflects the high contrasts between skin and hair color. To find out if you are balding, you need to see a doctor who has an instrument called HAIRCHECK which will tell you if you lost hair bulk in any part of your scalp. In men, this is caused by genetic hair loss. I suspect that if you get this test, it will show that you do not have hair loss but to be sure get the test. Even if you are not balding but your hair appearance is not satisfactory, you can get Scalp MicroPigmentation and reduce the contrast between your scalp and your hair. See https://scalpmicropigmentation.com