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Transplanting Hair Before the Loss is Noticeable

Dear Dr. Rassman:

Thank you for your outstanding blog. I have a question about hair transplants. Most of the before/after pictures that I’ve seen show patients with substantial balding who then receive very noticeable new coverage. I wonder, though, whether it is possible to design and begin to execute a H.T. Master Plan beginning in the very early stages of hair loss, so that — rather than suffering noticeable loss and then receiving visible new coverage in that area — the transplants can instead be inserted into areas that are just beginning to thin but still have substantial coverage.

It seems that people who work in the public eye — television anchors, actors, and so forth — must have a way to plan out their transplants so as to seem simply to retain their hair, rather than seeming to lose it and gain it back. Does transplanting into areas that still have coverage make the eventual loss of the remaining hair in that area transpire more quickly? Can transplants be performed BEHIND a fairly solid hairline if the surgeon determines that declining hair counts make it inevitable that this area will eventually go bald?

I’m a 29-year-old male, and I began using 1.25 mg/day of finasteride eight years ago. I still have quite decent coverage — noticeably thin in the vertex when under bright lights, somewhat recessed temples with miniaturized/vellus hairs at the temple hair line, and a decreasing hair count that is only noticeable to me in the first two inches of the frontal hairline. After noticing fairly quick loss in college, the erosion has been very slow during my eight years of finasteride treatment. However, I am aware of the five-year finasteride studies showing hair counts dropping after two years of treatment and continuing down from there.

I understand the need for conservative transplant treatment at my relatively young age, in order to preserve appropriate reserves of potential donor hair. (This is why I know it would be inadvisable to move my hairline FORWARD toward its adolescent location.) However, I am hoping that I can replace hair BEFORE I entirely lose it — including bolstering the hairline and several inches behind it before the inevitable loss there becomes noticeable. So, I wonder if you could tell me: do HT surgeons ever transplant into an area that still has substantial coverage, so that the loss doesn’t need to become noticeable before it is replaced? In other words, can a Master Plan be devised to prepare for inevitable future loss before that loss actually fully occurs, rather than waiting for visible baldness before surgery takes place? (I wonder how else, say, actors and television anchors are able to avoid the appearance of “losing and regaining.”)

Thanks very much for your time! I appreciate it.

I have firmly established a viewpoint to not transplant people before they are ready. Preventing visible hair loss with transplants is performed by some doctors and those happen to represent the doctors who are more in this for money rather than the welfare of their patients.

As good as you think you might be able to predict what will happen to you, you might be surprised to see that the balding will actually occur differently than you expected. As the supply is limited on everyone who will become significantly bald, you could run out and not complete what you will need if you are too aggressive. I am often humbled by the balding process, but I am also the biggest fan of being conservative.


2008-06-24 11:27:33Transplanting Hair Before the Loss is Noticeable

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Transplanting Hair Based on Which Direction I Comb It

If i part my hair from right to left, would it be a good idea to transplant more grafts on the right side compared to transplanting the same amount on each side?

If the balding need exceeds the supply of donor hair, then weighting the hair during a transplant from the parted side makes great sense… something that I do often to get better coverage.

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Transplanting East Indian Men

hello dr.rassman. I am an east indian male, 31 years of age. I have been on proscar for over a decade with decent results. I wanted to know if you or any of your colleagues have had any experience doing surgery on indian men and what has your experience been like? When I mean experience, I mean do they generally require less hair to cover a bald or thinning area, what are the hair characteristics and scalp laxity, hair thickness etc. I know it differs from each patient but there must be a general consensus on what type of hair indian men generally have. I don’t see to many pictures of indian men getting transplants so it is hard to judge.

Mine hair is black and wavy and then generally gets curly when its very long. I guess I am at an advantage because I am assuming I would need less hair to cover up my balding areas because my wavy hair would cover up the areas.

Thank you.

There is no difference to treating men from India than fair haired Caucasians from Minnesota. In fact, Indian men with the darker skin and dark hair have reduced color/contrast between hair and skin, which makes for a better hair transplant. The state of the art for hair transplants in India is not as advanced as in Europe or the US, so perhaps there are less Indian men going for hair transplants in India.

I have done hair transplants on many Indian men and they have done very well, referencing results.

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Transplanting Chest, Leg, and Thigh Hair

I have read some doctors preaching the use of chest and leg hair for hair transplants. I have also read your comments and general lack of enthusiasm for this. What is behind your strong opinions against this?

Scalp hair is better understood and tested for over 50 years. Although the art form has only been reasonable for the past decade or so, the facts concerning hair growth from a scalp source as donor hair are well understood. It is always important for me to inform patients about their risks, expected growth rate, and reasonable results that they should target. We have no body of evidence that hair taken from body or leg parts will work to any reasonable degree, but there seems to be (as P.T. Barnum said) a sucker born every minute. I do not want to be part of such a process, at least until it is clarified as something real.

In the book by Elise A. Olsen, Disorders of Hair Growth, the rest cycles of hair are stated. Although I can not attest for the science of these figures, let’s take them at face value for a moment and see what it means if correct. All hair cycles go through various growth phases, so the length of these growth phases are critically important to understand. For head hair, growth cycles range from 2-7 years, with a sleep period of 3-6 months. Generally it is believed that head/scalp hair is in its resting phase for about 10% of the hair population, which means that of all hairs growing on the head, another 10% is lying dorment awaiting its growth phase.

  • Leg hair has a cycle between 7-12 months, but between 62-88% of these hairs are in their dormant phase.
  • Thigh hair has a cycle of 3-5 months, but between 64-83% of these hairs are in their dormant phase.
  • Arm hair have a cycle of 3-7 months, but between 72-86% of these hairs are in their dormant phase.

With chest, arm, and body hair, the above numbers suggest that there is a large number of sleeping follicles at any one time. If this is true, then there will be questionable value from a hair transplant using these body parts from fullness or coverage point of view. Add to that the pain of hundreds or thousands of small wounds created all over your body might produce. I wonder about the doctors who are routinely performing this type of surgery and ask about their motives. I have concluded that any doctor who offers this must let his patient know that this is not a tested procedure, falling in the experimental rather than the clinical hair transplant offerings. I’d also hope they reveal the figures related to sleep cycle of the hairs from the various body parts as discussed above so that their patients are well informed.

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Transplanting Between Miniaturized Hairs

Hey doc. How are you today?
I have been diagnosed as a Norwood 5 thinning pattern. Originally when I started finasteride I was a Norwood 3 vertex only, but obviously the medication is only slowing the process down. I had a consultation with a reputable Toronto Dr and he said it would not be be worthwhile performing surgery at that time. But now that things have progressed is it possible to perform surgery just to give me more density? I am fine with my hair line. Or is it dangerous transplanting in between miniaturized hairs? I’m 22 and have been on finasteride for 2 and a half years with a gradual decline in my hair count but hairline is still thick for some reason. What do you think ?

I am fine. Thank you for asking.

Transplanting between the miniaturized hairs may likely result in you losing those weak hairs, so you won’t be any better off than you are now (except with less donor hair and less money in your bank account). I can’t say for sure since I haven’t seen you, but based on your description the surgeon you saw might have done you a favor.


2010-03-23 08:51:49Transplanting Between Miniaturized Hairs

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Transplanting a Tight Scalp?

For somebody with a tight scalp is a FUE procedure really the only hair transplant option?

If you have a tight scalp, you can “work” your scalp with an exercise program for 30 minutes per day for 3 months. Most people will succeed in getting more laxity with these exercises. We made a video of this here.

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Transplanting a Patient with VP Shunts?

I have 2 VP Shunts one on either side of the back of my head. Would this be prohibitive to having a hair restoration procedure? Also, does Dr. Rassman have any experience working on patients that have shunts? Any information you could provide would be greatly appreciated.

For those that aren’t familiar with the term, a ventriculoperitoneal (VP) shunt is a tube that takes brain fluid and connects it to the abdomen where it drains for the treatment of hydrocephalus (or water on the brain). And yes, I have done hair transplants on patients who have had VP shunts (see here).

As you indicated that you are from out-of-town, I would have requirements for you if you wanted me to do your hair transplant. First, send me detailed pictures of your hair loss and then I would want to get specific X-rays to locate the shunts. I must know the course of the shunt and how far under the skin it is. With the shunt located, the hair transplant can be done safely. You can call my office at 310-553-9113 and arrange to have a phone consultation with me.


2009-04-24 07:45:51Transplanting a Patient with VP Shunts?

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Transplanting a Patient with a History of Keloids?

If I am prone to forming keloids is it still possible to safely undergo hair transplant surgery w/out forming additional keloids? And have you ever done a hair transplant on someone who has a history of keloids?

Many patients undergo hair transplantation despite a history of keloids, and most of them do well. Keloids can appear on the frontal hairline, but that is relatively rare. Keloid scarring is more likely to form on the donor scar, but the surrounding hairs will cover it so that it’s generally not a problem.

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Transplanting a Norwood Class 2 to a Class 1?

Thank you for all of your informative hard work! I am currently a Norwood 2 & may be progessing to a Norwood 3. I was curious to see if you could post any pictures of patients who’ve went (w/ the help of FUT or FUE) from a Norwood 3 to a Norwood 2 & some pics of those who’ve went from a Norwood 2 to a Norwood 1. Thanks in advance!

Norwood Class 2
Norwood Class 2
 
 
Norwood Class 1
Norwood Class 1

Most people who are young and have frontal recession are experiencing the maturing hairline and are not balding. I do not transplant the frontal hairline in these patients unless there is a reason that it has to be done. I remember an actor who had a lead role in a daytime soap opera TV series. As his hairline was maturing, he got indications that they were going to phase him out of the show because they wanted a person with a juvenile hairline, as the daytime women that watched the show apparently had fantasies about very young men (I’m not kidding). In that case, I did move him back to somewhere between a Norwood Class 1 and 2 and his million dollar a year income kept him secure.

I do transplant women routinely who have lost frontal hair and want their hairline back. Typically, a woman is a Norwood Class 1 and so to answer your question, I’d like to point you to a woman’s hairline reconstruction, which is now a Norwood Class 1. See Female Hairline Restoration After Brow Lift. There is essentially no difference in the process. Creating a female or Norwood Class 1 hairline is not an easy chore. The surgeon must be very experienced when creating it due to the direction of the hair in the corners. Look carefully at your wife, girlfriend, mother, or sister’s hairline and note the direction of the hair in the corners — it flows from the center of the hairline to the temple prominences. That growing process along with the transition from one part of the frontal hairline to another must be done right, or it will look awkward and artificial. If you are an actor or top line male model, I might consider bringing you back to a Norwood Class 1. In other words, I’ll do it, but it’s rare and we must have a meeting of the minds when embarking on this process.