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Hair Loss InformationTerrible Scarring from Hair Transplant – Hair Loss Information – Balding Blog

Doctor; I had my 4th hair transplant last October with the same surgeon who had done the prior 3. No complaints the first 3 sessions; I had decided to do a final “touchup”, filling in the front a bit more and adding to the crown.

Big Mistake.

My donor area on the left side was totally butchered; a patch about 1 1/2X 1 1/2 inches totally barren and badly scarred. I knew something was wrong immediately after surgery. The hair was gone the next day-immense pain and tightness was in the wound and there was redness also there. On the left side, there was a scab in the middle of the patch that took 2 months to heal.

The right side was similar but not quite as bad. The hair eventually grew back on the right side around 2 1/2-3 months. Its now been over 7 months; I do not expect anything will ever grow on the left side. The sutures seemed placed extremely high above the edges of the wound, also suspicious. I was told by the surgeon that everything was fine; these things “always resolve”.

Finally a month ago, after seeing my predicament, he tepidly agreed that re-growth wasn’t in the cards. He said he would do “Scar revisions”? This did not seem right, so I sought 2 other opinions, both saying scar revision considering the circumstance was definitely the wrong way to go, and that transplanting hair into the area, in 2 small sessions, was the best way to handle it.

Do you have any advice for me?

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Scars from any surgery are unavoidable. When I performed general surgery, people would judge the surgeon by the appearance of the scar after the surgery. If the scar was barely detectable, then the surgeon was great, but if the scar was stretched or obvious (for example) the surgeon was terrible. If I did 100 appendectomies, about 10 would have a widened scar and 90 would have a barely detectable scar. Was I a great surgeon 90% of the time? How did I select who got the bad surgery? The question sounds silly, but as a surgeon I am humbled all of the time that anything ever healed and I live in a constant state of awareness that there are many things that I can not control. Scarring is just one of them, but I do not abdicate on the awesome responsibility upon me to try to get perfect scars 100% of the time.

I want to know how the scar impacts your styling and your ability to function daily. Since we are talking about visible scars in most situations, we are talking about the ability for the hair around the scar to cover it adequately. The thinning of the hair in the donor area is unavoidable and as more surgeries are done, more thinning can be expected and the scarring risks rise (non-visible and visible scarring are separate issues here). Think of it as follows:

  1. the donor area has extra skin when the process is started (you can feel this if you put your hand behind your head and move the scalp up and down as it should move at least ½ inch)
  2. each time you have a procedure, some of the extra skin is removed and eventually the skin may get tighter
  3. as everyone is different, some people’ skin just gets thinner and not tighter, others get tighter and not thinner, most are a combination of the two. When the skin does not get tighter, the ‘extra’ skin probably re-grows
  4. every surgery produces more scars below the skin making the skin less mobile to some degree and the amount of this mobility (and binding of the skin to the deep structures of the scalp area) varies in each patient.

Some patients have poor healing wound characteristics in their collagen and as such, become set-up for stretching scars. Unfortunately, these patients may not be obvious in advance of a surgery. For a repair, the surgeon has to decide just how far to push the skin removal process; in other words, he must determine with each surgery just how much skin to remove. If the surgeon takes out too much skin, then the wound may be too tight to close without tension. High tension wound closures are the greatest cause of scarring and reactive hair loss. Sometimes, people just get reaction to the sutures, or the surgery, or they might even get an infection (clinically evident or sub-clinical). Sometimes, scars just happen, not on the first procedure, possibly not the second, but maybe the third. When the scars form, then each patient has to be assessed by a skillful surgeon, hopefully one you trust. I always tell my patients that a surgeon and a patient have a partnership. A good partnership means that the partners stick together in good or hard times. I tell my patients that if anything ever goes wrong with a surgery done by me, any complication from infection to scarring, I am the best partner that they can have because I take full ownership of the responsibilities of the partnership. Money or time has no meaning for me if things went wrong, so I tend to be there to stand by the patient and do whatever is necessary to manage the process. As a general surgeon, I lived with death from accidents and the outcome of cancers that were incurable, but I was a dedicated partner to each and every patient I took on as a surgeon.

First, ask yourself if your doctor is a real partner with you in this process. Then, if he is, discuss the issues so that you understand his thinking. His analysis and what he will do should depend upon the ‘tension’ on the wound when it was closed (at the last surgery) and the dimensions of the strip of skin that was removed. Decisions on how to repair such problems vary with the conditions of the donor area and the scarring above and below the surface. Does you surgeon suspect a reason that the scar formed? If it was very tight and immobile, then removing the scar may not work as a primary surgery for the repair process? How is the hair around the donor scar? If it is good, then the approach will be different than if it is poor. What are the dimensions of the donor scar (the wider it is, the harder it is to remove)? What is the proposed surgical correction and if it is done, why would the surgeon expect a better outcome for the repair than he had on the surgery that produced the problem? What are the alternative approaches to removing the scar? Transplanting the scar may work, but where will the hair come from and what is the risk of the removal of still more hair? Is a balloon a better approach (definitely for the very bad scars) and what about FUE surgery?

It is impossible for me to determine your exact situation without examining you and seeing (and feeling) the status of your donor area. Be sure that the doctor you have is experienced in these repairs and can show you what type of results his experience with such repairs have produced (like showing you other patients who have had such repairs). I can tell you that the only surgeons that never see scarring in surgery are those that do not perform any surgery. Every surgeon sees scars. In standard hair transplants with today’s newer closure techniques, obvious scarring should be present in less than 2% of those undergoing a standard strip excision transplant. Solutions to transplant scarring are there almost all of the time. An alternative solution for you to consider are FUEs (Follicular Unit Extractions) where each hair grouping is removed one at a time and then transplanted into the scar. The use of balloons can produce miracles for the worst of the scars. Both FUE and balloon use require specialized skills, not common to most hair transplant surgeons.

For more info on FUE, please view the FOX Procedure.

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Hair Loss InformationReplacing Hair System with Transplant – Hair Loss Information – Balding Blog

I read with great interest, your answer to the person who wore a hair system that stunk. Systems stink and it’s not only the smell that I am talking about. This is only one of the problems I am faced with. I don’t have a lot of money. If I did, the place where my system is serviced would take care of me as often as I want. They suggest once a week, but they want $60 for a full service. Frankly that is alot of money when you consider that I have to take off from work to have it done. In the past 10 years, I have spent over $10,000 in hair systems and the costs of replacing the one I have now will be another few thousand dollars. It really does need to be replaced. I want to know how much will a hair transplant cost me and how many transplant procedures will I have to suffer through? I am 35 years old.

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Most people who are 35 have already established a mature pattern of hair loss, so first you need to find out what Class of hair loss you have. Read Assessing Hair Loss and then get back to me with photos of yourself with wet hair and dry hair, showing the full extent of the hair loss. A phone consultation with me will be specifically focused on your individual needs. Generally, the less the balding, the less expensive will be the process. A Class 3 reconstruction might run between $3000-$6000 and if your hair loss is stable, then more surgeries may not be necessary. For the very bald person, the cost can climb to range between $10,000-$15,000 (these prices are based upon our least expensive Standby program). Please see Fees and Financing for more information.

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Hair Loss InformationFemale Hair Loss – Hair Loss Information – Balding Blog

I am 25 years old and I have thinning all over, I’ve been to two dermatologists and both of them just tugged on my head and told me to use Rogaine. I want to know how to find out what the cause is and if there might be an underlying health condition. I have never taken ANY medication including birth control but I may have some other symptoms, only slight but possible indications of something medical or hormonal. There is also no baldness in any women on either side of my family, but there are men on both sides. This is absolutely destroying me and I just want to figure out how to get some answers because Rogaine is not working, I’m running out of hope. Do you know where I can go or what I can do? Thank you for your time and consideration to my question, I would appreciate any suggestion you might have.

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There is not a great deal understood about women’s hair loss. First, many women have hair loss secondary to a medical condition. You need to be check out by a competent doctor to rule out the conditions that cause hair loss. Thyroid disease, for example, seems to have hair loss associated with it. In addition to thyroid disease, hair loss can be a sign of a medical problem from anemia, connective tissue disease, gynecological conditions, polycystic ovaries and other androgen stimulating hormones. While you do not currently take any medications, some medications can cause hair loss including: oral contraceptives, beta-blockers, Vitamin A, thyroid drugs, coumadin and prednisone so at any time in the future, this awareness may have significant value to you.

The treatment of women’s hair loss with hair transplantation must be approached differently than men’s hair loss, as most women rarely develop patterned hair loss and it is much more widely distributed. In fact much of the hair remains, but the thickness of the hair shaft is smaller than normal hair and the areas that get impacted by this process can be localized or generalized. This reduction of hair thickness (miniaturization) causes the hair to appear thinner. Because a relatively large area has been subject to this thinning, for hair transplants to have any value it is important to place the hair in areas where it is cosmetically most significant and where it can augment a specifically “defined” styling plan to increase the appearance of fullness. Also, the ‘donor’ area might also be impacted so careful measurements of the donor density and distribution of miniaturization in the donor area is important before a transplant decision is made. For this reason, we generally confine the entire transplant process in women to a localized part of the scalp such as behind the “frontal hairline” or “along the part” in a plan that fits the way the woman combs her hair.

Since hair will be transplanted into a part of your scalp that is thin, but not completely bald, there is a risk that some or all of the original hair in this area may be lost. This process is called “telogen effluvium” and is usually (but not always) reversible in women. In addition, if the donor area continues to thin, then the transplanted hair will also thin over time, since it came from the same area. The progressive hair thinning may be improved by subsequent procedures, but with significant loss, there is a limit to the improvement that can be achieved. In hair transplantation, as in all surgical procedures, it is important to balance the potential gain against the possible risks when making a decision to go forward with the treatment.

Once you rule out a medical problem, then a doctor with knowledge about hair transplantation may be considered. The problem here is that too many women are so desperate for hair that any doctor wanting to offer a hair transplant to a balding women, set up a woman as an ‘easy mark’ for a sale. You must find a doctor who understands who can be helped and who can not be helped; a doctor who is honest and has a good reputation. There is an easy test to give to a doctor. Ask him/her, “What is the percentage of women patients who get hair transplants in your medical practice?”. If he reports significantly more than 5% of patients are women, you can generally assume that he is doing more transplants on women than he should be doing. Some doctors claim that half of their patients are women and that puts me on an alert that this doctor may doing more hair transplants on women than he should be doing. Women have different aesthetic challenges than men, so patient selection is critical and when a doctor elects to do a woman’s hair transplant, he/she has to fully understand the art. The thing that makes women’s hair loss different is that their donor area is frequently not healthy and the recipient area is very diffuse. Moving bad hair to another area just moves the problem around without helping, unless the goals and expectations reflect the reality of that woman’s particular problem.

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Hair Loss InformationFemale Traction Alopecia – Hair Loss Information – Balding Blog

I have a full head of hair which is shoulder length. However due to many years of wearing a pony tail, I have developed a mild traction alopecia around the neck line and slightly behind the ears. Because of this, I am not able to wear my hair up, or side swept which limits my hairstyles. I was wondering if I may perhaps benefit from follicular hair transplant?

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Tight pony tails or ‘pig-tails’ can cause traction alopecia (hair loss from constant pulling). Of interest, the ‘falls’ that women use to add fullness to hair are a frequent cause of hair loss in women who use them to make their hair appear fuller. The more the use, the thinner the hair gets and the cycle of more use to treat thinner hair produces more thin hair.

With that said, the traction alopecia may not be permanent, that is, if you stop putting the traction on it. To find out, you would need to stop using a ‘pony tail’ for at least 6-8 months. What hair does not come back is probably permanent. There is a difference in the hair at the nape of the neck (which often has a different genetic ‘permanence’) then other scalp hair. Hair in the nape of the neck is generally more fragile and can be lost with stress (like traction).

We have extensive experience with treating temple hair and hair at the nape of the neck. The neck transplants were usually secondary to scarring from flap procedures which were surgically induced. The temple hair has been done in many, many patients wanting to move the temples forward or replace them from thinning. Send some pictures to me and I would be happy to give you an opinion. My email address is on the Contact page.

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Hair Loss InformationHigh Hairline in Women – Hair Loss Information – Balding Blog

Hi I am a 24 year old blonde female. I am not experiencing hair loss, but I was born with a weak/receded hairline. Is it possible to correct something like this? I have very fine hair in two spots on either side of my hairline but you can’t see the hair unless you look closely. Let me know if there is any hope. Thanks

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High hairlines in women or thin hairlines are very common. Many women who have them would like to have them fixed, but not many come to people like us who have the expertise that might apply. Without discussing which one is better, they are:

  • Moving the entire hairline forward with a surgical procedure, similar to a brow lift but with a focus to bring the hairline down. This gives a very fast result and healing is fairly fast as well.
  • Transplanting the hairline. This has great value in many cases, particularly when the hairline is weak in an identified area as you seem to be describing. This may be one of the most popular hair restoration procedures we do in women.

Send pictures in digital format to me via email and I can give you an opinion.

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Hair Loss InformationHirsute Men and Head Hair Loss – Hair Loss Information – Balding Blog

As a writer focusing on men’s health issues I would be interested in your comments on two areas of my research.

  1. I have read a number of reports that suggest that hirsute men (those with a lot of body hair on chest, shoulders etc) are more prone to lose hair from their heads.
  2. I have also seen reports that the American Red Indian does not suffer from hair loss.

I do not believe these issues have been dealt with by you before.

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I too have seen claims that men with heavy populations of body hair have more balding than their hairless or less hairy counterparts. I can say that in my medical practice, the balding men routinely say: “I wish you can take it from my chest or back”. But then again, I do not have the type of interchange with non-balding men to probe the same issue. There is generally a belief that DHT (the evil hormone that ‘causes’ hair loss), also brings on the body hair, the nose hair and the ear hair along with the balding on those genetically inclined balding men. I believe that in the discovery of Finasteride, the people who ingested large amounts of this drug through their dietary intake of a food stock from the rain forest, did not bald, nor do the men born with a genetic defect where they can not make the enzyme that produces DHT. I recently probed a large number of doctors asking if anyone has found evidence of a reduction of body hair, nose or ear hair with Propecia. Everyone liked the question and told me that although they believed it might just do that, there is no evidence that Propecia or Proscar actually blocks or reverses these less than ideal hair locations.

With regard to the American Red Indian, I am fully aware of this observation. His ancestors came from the Alaskan bridge and they had the balding trait, so it is strange that this particular ‘race’ (the great grandchildren of the migrating Alaskan ancestors) is unique amongst all humans as they do not have balding. Of interest, I am not aware that these people are missing any enzymes for making DHT. Could it be that a primitive people actually wiped out balding genes in their brothers in a relatively short time frame of less than a couple of thousand years?

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Smelly Hair System – Hair Loss Information – Balding Blog

I have a hair system and it smells. I am compulsively clean and I used to wash my hair once or twice daily. Now, with the hair system on, I can not wash frequently. A close friend told me that the colognes I use do not help hide the smell, so when I heard this, I was devastated. Now I think that everyone is smelling me, my dates, the ladies around the office and strangers I meet, but I am so embarrassed that I do not know what to do. Any suggestions?

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Just in case you weren’t sure, the term hair system is another term for a toupee, a wig or in local slang, a rug. Systems have been around for centuries. They have been found in Egyptian tombs, on frozen mummies from Alaska’s Eskimos, and on your late night TV showing quick fixes for hair loss. My saddest story reflects a less than ethical wig-salesmen (only some are bad folks), who introduced a 21 year old with early frontal balding for a free trial. Before he knew what was happening, his head was shaved and then a ‘mop’ was put on this poor soul’s head, glued to his shaved scalp. Of course, he could have walked out and not purchased one, but alas, with the front of his scalp shaved bald and the back of your head with long luxurious hair, he knew he was going to look kind of funny walking into the office in the morning. So, like a few fixes of Heroin, he got hooked on a ‘system’ and found it part of his persona for years. Worse still is the hidden reality that these systems promote hair loss from traction, accelerating the genetic hair loss and promoting the addiction even further. Hair piece cripples are created and they live their hell almost every day.

When a poor self image is perpetuated in the mirror every morning, the smell may be less of an issue. This emaiiler’s main point is the smell. To deal with the smell, the only satisfactory solution is to have a series of wigs, use clips to attach them so that they can be taken off at night and then wash the wig often. Daily washing of the scalp is not a problem when the wig is off the head. Washing the wig will cause it to wear out sooner and the result will be more frequent replacements. The use of clips are not promoted by those who sell these systems. For reasons I can not fully understand, glues and tapes are more popular, and weaves are gaining in popularity. These last three fastening methods keep the soap and water away from doing a proper cleaning of the scalp, despite what the wig salesmen say. If you can’t wash the scalp with the system off, the scalp will smell and if you do not wash the wig, it will smell. I have rarely seen a person in my office with a system that does not smell, but sometimes I can not tell if it is the system or the patient. Does it matter what smells?

Today, the cost of a hair system properly fitted and maintained in a 5 year period of time will often run more than the cost of a hair transplant procedure.

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Accelerated Loss from Propecia? – Hair Loss Information – Balding Blog

HI Dr. William Rassman. I read in many places that propecia can make the frontal hairline/temples recede. Is it true or is it a myth? Coincidently my temple was a NW 1.5 2 month before propecia. Now it’s diffusing in a strange way. thanks

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I am unaware of any reports that Propecia will accelerate temples recession. I am assuming that you are a young man (Norwood 1.5-2) and one of the things that you must recognize is that 95% of Caucasian young men (also true of other races but a smaller percentage) will change their hairlines as they mature. This maturation process certainly moves in the direction of a Norwood 2 – 2.5 range. This is not balding, but normal maturation which occurs between the ages of 18-29 in men. The other 5% or less of Caucasians are like Bill Clinton, where they keep their childhood hairline and remain as they were at 12 years old. Best to be sure that you understand the difference between normal maturation of the hairline as seen in your genetic family connections and the balding process itself.

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Hair Loss InformationHair Coloring After Transplant – Hair Loss Information – Balding Blog

Hi Dr. Rassman.
First I would like to thank you and Dr. McClellan, for doing such a great job. It has only been a week since my surgery 1,700 grafts. 5 Years ago I had 1,100 grafts. Healing is occurring quite rapidly, and I feel the positive results around the corner.

I have somewhat fine, and curly hair age 38. Auburn brownish is my natural color. Redhead when I was younger. My father grayed heavily in his thirties, as did my brothers & I. I use either “Grecian Formula”, or “Just for Men” 5 minute hair coloring. (Light Brown to get as close to my natural color as possible). About a month prior to surgery, I had my hair highlighted bleach blonde, and the results were fantastic. I looked a lot less bald, with wonderful full blonde curls, and my brown underneath. It looks so natural and subtle that everyone thinks I have just been in the sun for a week. I am very pleased with this coloring. Because I only highlighted, the brown color treated area remains, its brown status.

The main question becomes at this point, is when can I use the “Grecian Formula”, or the “Just for Men 5 Minute Hair Coloring again as my base?

And, when can I “bleach” highlight again?
A) My regular area.
B) Donor, and Transplanted area.

Thanks again to Dr. McClellan for doing such a great job last week.

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Thank you for your kind words! I am hesitant to post this for fear that readers may think this is a ‘planted’ question, but you do raise some issues that have not been addressed in this blog. You can begin to color or bleach your hair once there is no more scabbing present and the skin is smooth. This usually happens within the first after surgery (in some people in days). I generally advise people to dye their hair immediately prior to the surgery so that there is no significant disruption to their schedules.

You also bring up an important point on the value of hair coloring. Lightening the hair always adds the look of fullness. In a question posed to me on April 21st (see: Platinum Blonde Patients), the question of blonde hair came up in a different context. That question has bothered me since it came in and as I looked through hundreds and hundreds of patient photos, fewer blondes were in my hair transplant group than non-blondes. Then I realized that the lack of blondes in my database of photos came about for two reasons:

  1. There are fewer blondes in the population (estimated at less than 10%). We are led to believe that the actual number is higher because there are many, many blonde women. Could it be that because ‘Blondes have more fun” women are becoming blonde far more frequently than men are?
  2. A platinum blonde man can lose 85% of the hair on the front, top and crown without knowing that he is going bald. This is because of the low color contrast between hair and skin color and that the shiny hair platinum blondes have makes balding less prominent.

In conclusion, men who are balding should think more like you and consider taking charge of coloring like some of the women out there are doing regularly. Maybe, just maybe, coloring can solve the hair thinning problem without a hair transplant for those who are not quite bald yet.

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Propecia’s Effectiveness in Front and Sides – Hair Loss Information – Balding Blog

Just wondering if it is known why Propecia is often not effective around the front/sides ? Is there any hope for a new drug in the works that may address the front/sides?

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When Propecia works, it works where the hair loss is relatively newer. The frontal area is often the first place the hair loss starts but often it is not noticed until the hairs are fully miniaturized or lost and at that point Propecia is not effective. Propecia can work well in preventing rapid hair loss in the frontal areas when the drug is started early enough. There is clearly a difference between frontal balding and crown balding, which tends to start later, in the way the genetics are expressed.