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What Is the Real Extent of the Donor Area Hair (Permanent Hair That Lasts Your Lifetime)?

The photo below shows a man with an advanced balding pattern (Norwood Class 7 pattern). This is the pattern that is a risk for every man having a hair transplant. Everyone runs this risk. They could lose all of their hair except for this 2½ inch rim of hair around the back and sides of the head. The white line shows where the neck hair begins and the arrow is 2½ inches long. The neck hair below the white line is not permanent hair. So if your surgeon takes hair above this rim area (where it is bald) or below the white line (neck hair) in any FUE surgery, you run the risk of eventually showing scars all over your head where the hair used to be before the balding happened. Not good!

This is why strip surgery is a better surgery for people with advanced balding patterns. If the density of this rim hair is good, then the area immediately above the white line can be harvested over and over again, decreasing the density of this rim with each successive harvest. I have harvested as many as 10,000 grafts from this rim in Class 7 patients and still left enough hair to keep the rim area covered when the density was very good. I have also been able to harvest routinely 6000-7000 grafts in people with average donor hair densities. If this area is harvested with FUE, the surgeon must stay away from the upper border or the FUE scars would show as balding progressed (https://newhair.com/donor-area/). The depletion of the donor area with FUE is not uniform so the number of grafts taken from this area is more limited than with the strip which is always harvested and re-harvested just above the white line if the surgeon does it correctly. The density of the residual hair after a strip surgery is always uniform. Of course, the scarring risk from repeated strip surgeries is real, but because there is always hair above the scar and Scalp Micropigmentation can address the scar so this is a manageable problem if it should happen (https://scalpmicropigmentation.com/scar-covering/).

The other important issue is the size of the bald area, which in this man is 80% of the original hairy scalp. So, this rim must supply hair to cover the entire bald area. The math is a real challenge and that is why your surgeon must be both an artist and a mathematician. Your surgeon must calculate what you need now and what you might need later as your balding progresses. This donor area is limited to about 50% of the original donor density. EVERY balding man will develop more hair loss over time, so a great surgeon understands this and should always be able to give you a status report of your reserves for future hair loss. Maybe you will not progress to a Class 7 pattern but rather a Class 6 pattern as only 7% of the population ever progresses to a Class 7 balding pattern. Poor planning by the doctor or patients who are in a rush to satisfy their immediate goals (particularly when they are early in the hair loss process) at the expense of your future needs, is not good. You and your surgeon must always develop a Master Plan for your future hair loss. Always think long term so that your decisions will be calculated to address the problem you have now and the problem that you will almost certainly have in the future.


2018-06-07 08:57:48What Is the Real Extent of the Donor Area Hair (Permanent Hair That Lasts Your Lifetime)?

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Readers Respond to Suicidal 18 Year Old

We received a lot of emails about last week’s post — I’m Suicidal Over Losing My Hair at 18 Years Old! — and I wanted to share this one with the rest of the community.

Dr. Rassman,

I read this blog regularly and when I read your post yesterday about a young man dealing with suicidal thoughts, I had to write in.

Young people out there need to understand that they have options but doing something drastic (like a transplant at 18) years old or worse (harming yourself) only eliminates options. I came to your office last year young, scared and anxious about hair loss myself. I was convinced that things were only going to get worse, but a year ago there wasn’t a hair bulk analyzer or A Cell. Imagine, just a year later and suddenly I am hearing about all these innovations. Maybe I overreacted?

It is amazing what happens when you take a deep breathe, research your options and gain a little perspective. I was given great advice by the doctors at NHI and they were words I needed to hear. Hair loss still bugs me but I now have every option open to me because I did not jump into a rash decision and young guys (I am 25 and empathize with you) need to understand that, just because you are not happy with what the mirror is showing, it doesn’t mean you can’t be happy ever again.

This is not the end of the world. Balding doesn’t rob you of your vision, your hearing or your overall health. This young man still has eyes to see the world, ears to listen to wonderful music and a capable body that can laugh, love and live. Getting a quality doctor to help you deal with your problem will keep you from being a slave to your hair and will help you get on with living.

While most of the emails (and comments) had positive messages of support, I felt the above email perfectly expresses what many compassionate people relate to. Thank you for writing.


2010-12-12 12:54:57Readers Respond to Suicidal 18 Year Old

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Reader’s Minoxidil Theories About Side Effects

I just wanted to see what your thoughts were about my “theories” in regards to Minoxidil 5%.

Firstly, I have read online about how it has caused erectile dysfunction, anxiety, heart palpitations, etc.

Are there any studies that show that these are legitimate side effects, or are they just symptoms listed by individuals? I think it is highly possible that these individuals could be effected by the listed side effects due to psychological issues due to their hair loss, and assuming the minoxidil is causing these physiological symptoms.. What do you think?

Secondly, do you think that the failure rates of minoxidil are due to people who stop using the solution too early on, rather than the minoxidil not “working”?

What you read on the web isn’t always true.

The official reported side effects are listed on the minoxidil insert and the drug profile (see here). Minoxidil taken orally in pill form is a blood pressure lowering mediation, so it is conceivable you can get lightheartedness and heart palpitations if your body absorbs too much of the topical. Chest pain and fainting are also possible if you’re sensitive to the medication. Erectile dysfunction is more likely to be due to a psychological issue or an underlying medical issue, rather than minoxidil.

With respect to the failure rates of minoxidil, I believe it is partly because of compliance issues. Many men and women have a hard time adhering to a twice a day schedule, and therefore do not get the full benefit of the treatment.

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Reader Tells Others to Calm Down Over ACell Inquiries

Hey Dr Rassman i hope your day is treating you well.

Being a hairloss sufferer myself i can relate to the extraordinary anticipation and hype surrounding the new buzz word in the field of hair restoration ”Acell”. However i also realize that this is far from establishing itself as a practical solution to genetic alopecia(if it even makes it that far). As a hair restoration physician i imagine you grow tired of those ”cure” type perennial questions. In my opinion readers need to recognize that when the hairloss community is equip with innovators like yourself Dr Rassman it provides us with the best chance possible of making the most out of these types (Acell) situations.

Being a daily reader of this blog i have nothing but good things to say about it. There is not a doubt in my mind that Dr Rassman and the other physicians that contribute to the blog will be efficient at posting occasional updates. So for a lack of a better term just ”chill out” time will tell…..

Thank you for your support! I don’t mind the large amount of emails I’ve received with ACell questions, as I kind of expected that… but I don’t want to give anyone the wrong idea about what it can do (we’re still trying to figure it all out).

We will most definitely update the readers of this site on our progress as we can.


2010-12-07 11:03:21Reader Tells Others to Calm Down Over ACell Inquiries

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Reader Shares His Daily Hair Routine

Dear sir,

I first of all thank you for taking your time out to answer this question. I’m sure you’re quite busy…I’ve seen more balding heads on the streets than ever.

I’ve been losing my hair since I was 17. I just turned 21.

I went through all the usual stages. Denial, loss of confidence, etc. I still have as much left as many men RECIEVE in their procedures, but it will only get worse. I had a solution in Spring 2006, while I still had enough that no one knew – Propecia. My (completely bald) doctor recommended it for me.

But I was an idiot.

In December 2006, I stopped taking it. I felt it hadn’t made any difference. No further thickening, no regrowth. Everything seemed fine until summer 2007, when it started becoming frighteningly apparent that it HAD kept some hairs in (I washed many long, luxurious strands of Marc Bolan-style hair down the shower drain). I didn’t know why this was happening all of the sudden – I did not know that stopping Propecia not only stopped the positive effects of Finaesteride on DHT, but also allowed the MPB held back to return with a vengeance.

Within six months, my hair loss had become worse and more apparent than it had since it began. It happened quite quickly.

I went to the barber’s in October 2007 and cut my long hair off. I could tell where the hair loss was hitting hard; the hair cut from the sides and back was thick and Roman, while the hair cut from the top and front was lighter and frizzy. Not enough hair was growing to create curls or waves, so it looked like it was damaged.

Immediately I began a plan of action. This time, I wasn’t going to hit MPB with just one drug. I was going to have an armory full.

In November, I began a treatment which gathered supplements, drugs, and shampoos over the course of those following months. It has come to finally include the following daily routine:

Propecia (1X)
Rogaine Foam (2X applications)
Saw Palmetto (supplement, 400 mg each; 2X)
Nioxin 3-part System (no.2; in the shower)
Neutrogena T-Gel (1X; shower)
Nizoral (1x; shower)

The anti-MPB effects of Propecia and Rogaine are known to you. Saw Palmetto is reputed to have anti-androgen effects, as is coal tar (1% found in the T-Gel) and ketoconazole (1% in the Nizoral). Nioxin is proven only to thicken the APPEARANCE of the hair, but claims to clean away “environmental residues like DHT” on the box. Reviews and hearsay seem to back this up, so I’ve been trying it.

Why go through all the bother, you ask? Simple.

I am a musician. A player, a writer, a performer. Not just a musician, either. A damn good one, with artistic vision and a damn good shot at making it.

But this is the one thing holding me back.

1: Toupee/Wig – Will not. Don’t want to be playing a windy outdoor show or find myself in the throes of lust with someone I fancy when the proverbial “rug” falls off.

2: Shave – The aesthetics of being a performer on stage in the rock/pop medium require a youthful, attractive appearance. This I know firsthand; people who knew me when I had a large rockabilly pompadour or a healthy tangle of curls suddenly looked at me with sad shock when my receding hairline and thinning temples were revealed. I have an odd-shaped head, and that doesn’t help either. So nix the Telly Savalas look for me.

3: Hair Transplant – This is the most promising option. I have read all sorts of “breaking news” regarding WNT proteins and new solutions for this age-old bastard curse, and they may eventually pan out. But not in the next five years, and certainly not soon enough to take advantage of my youth and hit the big time. But I do not have tens of thousands of dollars to spare (especially in the midst of the economic recession), and I know that (sparing a new cure) my situation is only going to get worse.

I have read on many forums that Propecia (or finaesteride at all) loses it’s effectiveness on most men after 5 years of use. This rumor is widespread and greatly troubling; if true, the backbone of my (and many other men’s) MPB treatments will be null and void in 5 years or less, leaving us to lose all the remaining hair in a fast, depressing way (as I did much of my hair last summer).

I am at ends. While one’s self-worth should not be based on looks alone, appearance is crucial to the formation of identity. And when that tool, that weapon of good looks is taken away from a hopeful star, what is there to do?

Again, your time is most sincerely appreciated and I truly thank you for reading this.

You are incorrect with regard to Propecia (finasteride). It continues to work for years and does not simply stop at the end of the 5th year. What usually happens is that hair loss continues to progress and eventually (around the 5th year), you may go back to your baseline hair loss pattern — but if you stop the Propecia altogether, you will be far worse.

You need to get a good doctor to build a Master Plan for you. It is said that the person who treats himself may have a fool for a doctor. You’re throwing everything at your hair loss, and while it may not be a bad thing (unless you count the expense of money and time involved), it might be excessive and unnecessary. Please, discuss this with a doctor — the physician that prescribed your Propecia is probably a good place to start. Thinning hair can be devastating to one’s self esteem, and many people will do whatever it takes to not let that happen.

I wish you good luck and thank you for sharing your story with us.


2008-03-18 10:01:57Reader Shares His Daily Hair Routine

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Reader Says — Patents Stop Innovation

This is a comment left by a reader in response to Propecia being under patent protection…

And that is exactly why we need to see the end of Patent laws as we know them today, companies are given way too much time to bleed us. Its evil. Especially when medication has been Government funded or approved.

The real issue is that patents stop other companies from innovating. In fact while I’m thinking about, we should all be lobbying against the company that tried to sue Histogen. Because that company only cares about your money not your hair. There is nothing more criminal then these companies slowing down the discovery process – its anti human and we want our hair back

USPTOMaybe you are right, but we live in a capitalist society. I’m not going to make excuses for it. These are for-profit companies and they spend millions (if not billions) of dollars on research and tests to develop new products and new drugs. Some drugs fail, some succeed. When one succeeds, it makes up for all the R&D and failures that still had to be paid for.

Do you think they should just give that away for essentially nothing? Patents form the backbone of what built our country into an industrial giant. In time though, the patents on these drugs will expire and generic versions will be legally available in the US… so there’s no stranglehold forever.

We all have the right to our own opinions, but hair loss is seen as a cosmetic issue. I have a hard time believing that the government would fund hair loss issues when its hard enough to have HIV or diabetes or heart medicines funded. But hey, maybe you can lobby the government and try!

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Reader Says He Discovered the Hair Transplant Miracle-Gro!

Hello! I’m a 55-yr-old guy who’s had several HT procedures over the past 20 years. My last two were performed by different surgeons (both well-respected in this field), and both times I was surprised and delighted to note astounding growth of newly-grafted hair which I believe resulted from my coincidental use of a unique nutritional supplement. At six weeks following surgeries, I already had a solid half-inch crop of thick, colored new hairs which continued to grow like crazy. My current HT doc is starting a small trial with this supplement next week. Would you be interested in hearing about this? I think I accidentally discovered HT Miracle-Grow!

Sure, please keep me in the loop. I try to keep an open mind.

Update:
The person that sent me this email has told me that he’ll send me updates when he can, so I’ll post more information as it becomes available. In the meantime, take the above for what you will. Anyone want to wager a guess as to what this supplement could be?


2008-04-10 08:46:47Reader Says He Discovered the Hair Transplant Miracle-Gro!

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Reader Response to Using Rogaine Foam

A reader wrote in with a quick review of his experience using the Rogaine Foam, and I thought it was worthwhile to post for those that are still looking into trying this newly released product…

It’s easily available now without a prescription and the foam does have some advantages. It doesn’t run, so it’s easier to apply. And it contains no propylene glycol as does the Rogaine XS solution. However, I have some reservations about its use. The beneficial actions of topical minoxidil are dose related and the Rogaine foam is only a 5% compound. The foam by its sheer volume deposits a large amount of each application on the hair shafts, where it cannot be absorbed and remains ineffectual.

Out of curiosity, I recently bought a bottle of Rogaine foam ($29.99). It seems to be more inconvenient to use than the Rogaine XS solution. Unless your hands are cold, the foam will immediately liquefy. You should also be aware of the fact that the foam contains both butane, isobutane and propane, so it is highly flammable. But, if the Rogaine Foam fits your needs, this might be a good alternative product for topical minoxidil use.

These are the inactive ingredients listed for the Rogaine Foam: butane, butylated hydroxytoluene, cetyl alcohol, citric acid, fragrance, glycerin, isobutane, lactic acid, polysorbate 60, propane, purified water, SD alcohol 40­B, stearyl alcohol. See product warnings.


2006-11-16 15:36:51Reader Response to Using Rogaine Foam

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Reader is Not Convinced That Bulk Analysis is Worthwhile

I’ve seen you mention many times that bulk analysis is a good way to determine if someone is balding and that density should be the same everywhere for a non balding patient.

But I’m not convinced by this – I recently saw a well known hair transplant surgeon and he said that people typically have less density around the crown and temple areas anyway. He didn’t believe in bulk analysis for analysing hair loss.

Today I saw a male child who must have been around 8 years old. His hair was shaved short and sure enough, his temple/corner areas were noticeably less dense than the rest of his hair and this went quite a way back (I suppose to the point where someone might have suggested he was between a NW2 and NW3 on a balding scale if he was an adult).

HaircheckYou may not be convinced of the value in measuring hair bulk, but I am not going to try to convince you.

In a non-balding man, the bulk analysis shows that the hair in the 4 areas we measure (down the midline: front, top, crown and donor area) are all within 10% of the measurement of each other. I do not measure the hair at the sides of the head, because that is not where the balding will be. I would therefore possibly agree with you that the side densities are not as high as the midline densities.

Out of curiosity, I will measure a non-balding man’s sides and see if we are both correct.

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Reader Doesn’t Think ACell Will Work

I don’t believe that A-Cell will work. Is there actually any proper evidence of this technology working anywhere? It seems to be just that guy with the finger which I am unsure whether has been exagerrated/fabricated. Other than this it feels like all hype.

Also, it seems like when you pluck these hairs, you have to take out so much of the hair that logically thinking I’m not even sure if they will grow back the same thickness (if at all). Now I know people will come back with how they wax their legs, chest, arms or even their head regularly and they always grow back, but I seriously doubt that when a normal person plucks/waxes, they are extracting the amount of tissue required to perform the A-Cell procedure.

In addition, Jerry Cooley states in his presentation on one slide: “you can see the thicker FUE grafts vs the thinner plucked hairs” – so this really isn’t what it is being hyped up to be?

This unfortunately to me feels like just another method of doing a standard hair transplant. Maybe it will infact become the common way as it appears to allow it to be done without any scaring at all, but right now it looks like you would actually be worse off using A-Cell method over current methods, as the hairs at the donor and recipient region will grow back thinner, that is if they grow back at all.

I don’t know of Dr Cooley’s reputation, but from watching his presentation this just doesn’t seem that impressive. The only way it might work is using beard hair that thinned out during the process and ended up like scalp hair, but even then if this worked perfectly is it really a cure? You can’t do whole units and can you control the direction?

Perhaps you are right, but in the spirit of scientific research we have to try. That is one reason why we are trying to conduct formal IRB approved clinical research. It will either prove or disprove the concept.

The hope is that the plucking approach will yield more hair than moving the hairs around with traditional transplantation. The fact is that not only us (NHI), but the entire hair transplant surgeon community needs to be able to replicate this technique to stand up to the test.


2010-12-10 09:08:40Reader Doesn’t Think ACell Will Work