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Do you ever reject a patient for plastic surgery?

I have seen a small number of patients who seemed dissatisfied with so many of their features (inappropriately), that I’ve recommended self-evaluation and/or psychotherapy instead of cosmetic surgery. Some of these patient admit to being harshly criticized by a parent during childhood, and may have severe self-esteem issues that will not be addressed by the cosmetic surgery process. It is important for patients to be mentally sound, able to understand what cosmetic surgery will and will not do for you. I try to probe the person behind the request to understand if what I can do will truly meet the objectives of the patient. This is a difficult process for the plastic surgeon because each patient does not undergo an extensive psychological analysis, so I have to trust the instincts I have developed over the years. I do reject patients who do not have realistic expectations or those who are psychologically imbalanced.

This question was answered in conjunction with Jon Perlman, M.D.

what is premature genetic balding…?why is my hair falling out at age 14?

Assuming you are male, genetic balding can be seen in the early teens, although it is unusual. There are other causes of hair loss as well. I would have your scalp mapped out for miniaturization to make the diagnosis. See a good dermatologist to get this done. If it is early genetic balding, the drug Propecia may help, but clearly you need a good doctor to manage your hair loss.

I saw you on Extreme Makeover last year. I was wondering if many patients become addicted to plastic surgery once they start doing it?

I find plastic surgical addiction to be extremely rare in my practice. Most patients are genuinely made to feel better and become happier when “flaws” are improved or fixed.
My Extreme Makeover (ABC Network) experience has shown me how for some, a “makeover” can be more effective in improving self-esteem (and be longer-lasting) than psychotherapy.

This question was answered by Jon Perlman, M.D. Dr. Perlman appeared on Extreme Makeover many, many times.

A couple of months ago, I began to notice the top of my scalp more prominently after getting out of the shower. Not balding per se, but certainly thinning. I finally went to see a PCP (who took a thorough history and performed the hair pull test) and he felt it was Telogen Effluvium and not MPB, but that we should give it six months and reevaluate then with a blood panel to determine DHT levels before prescribing Proscar.

I’m conflicted about this diagnosis. I did admit I had been feeling some anxiety lately, since my wife and I are expecting our first child in November, and that the stress may be triggering the TE. But on the other side of the debate, my father started experiencing his MPB around my age (my mother’s father left this earth at 90 with a full head of hair, however).

Is this a common approach for a PCP to take?Should I get a second opinion, possibly from a specialist, or should I attempt to be an adult and patiently wait the six months?

Thanks in advance for your time.

I would recommend that you get a second opinion about your hair loss and in that second opinion, I would get your scalp mapped out for miniaturization, which will show if it is genetic balding as seen in your family line. A hair specialist and dermatologist are in a better position to diagnose your hair loss than your primary care physician, because they see men with the balding process all of the time. Assuming that you do have genetic hair loss, the earlier you get on Propecia, the faster you can save your hair. Time is of the essence and the stress of fatherhood may be a precipitating factor.

I have been diagnosed with HIV which is now under reasonable control. For a period of time I was very sick, but now with the proper balance of medications, I am healthy and active. The problem is that I lost a great deal of hair from the time I got sick 2 years ago to the present. I am 54 years young and I do not like looking 80 whic is what I feel I look like when I saw a recent picture of myself. Can I have hair transplants or does the my HIV status impact either my candidacy for surgery or the results of hair transplants? Will the doctors turn me down for surgery because I am HIV positive?

A healthy person who is HIV positive may be a good a candidate as an HIV negative person. Your sickness probably caused the ‘expression’ of your genetic balding process on an accelerated timeline. At your age, I would be surprised if it continued to progress, but after mapping out your hair for miniaturization, I would go on Propecia to protect you hair from further loss and then be evaluated for a hair transplant if you want to change your look.

Under most state laws, doctors can not discriminate against someone who is HIV positive. Some doctors fudge on this and do what I call ‘closet’ discrimination where there are convenient reasons to turn down patients, but not only is this against the law, it is against the oath we as doctors are supposed to adhere to. If you are healthy, you can expect that you should be a reasonable candidate, certainly one worth evaluating. I perform hair transplants on many such patients each year.

I was looking at your photos of the blog “Alas, Bald Again”. That is what I am considering. I have had about the same amount of hair transplants and in the same area. I want to have the transplants removed and not have any more work done. I was wondering if this could be done and be able to not have a bunch of scarring and divits left on my scalp? I had the work done about 14 yrs ago and wish I just would have went bald. Thank you.

You’re referring to: Alas, Bald Again.

Each case is different. Scars, plugs, pits, color changes in the skin of the plugs, cobbling of the skin — all of these things must be analyzed. This type of question is not an easy one to manage over the internet. I have many posts on this subject and this one shows a long cure time and an expensive process. Based upon a direct examination, I might be able to give you advice.

Do I have Ringworm, that is scarry? Where are the worms? I looked very carefully for them and did not see them. Are they like earthworms? Here is a picture of what my doctor called Ringworms as the cause of my hair loss.

Ringworm is a terrible term and I apologize for the medical profession’s use of it. A better term is tinea capitis and it is not a worm at all, but rather it is a fungal infection of the skin. For more info on this, please read:

• BBC News - City ‘ringworm epidemic’ warning
• eMedicine.com - Tinea Capitis
• MedlinePlus - Tinea capitis

This is one cause of localized hair loss that is relatively easy to treat and diagnosis is easy in the hands of a good family practice doctor or dermatologist.

Here’s a photo of what tinea capitis (better known as ringworm) infection looks like on the scalp:

Dr. Rassman,
Thank you so much for your answer concerning the two shoulder injections of cortisone!
I also have acid reflux,& had taken nexium, but stopped it after noticing hair loss more accelerated than usual. Are you aware of any hair loss associated with Nexium, as this drug seems to work best with GERD, & will regrowth occur after suspension? Also does regrowth generally occur with hair lost to seborrheic dermatitis, if treated? Thank you again for your prolific insight!

Nexium can cause hair loss, though it is a rare side effect. Seborrheic dermatitis rarely produces hair loss unless you scratch it and produce traction alopecia by continuously pulling at your hair.

1. I am 57. Over the last 5 years I have suffered hair loss. I have consulted with three hair-loss experts. Two have said I should be on Propecia, one said at my age it will make no difference. Will it?
2. I have four elevated liver counts. I do not drink or smoke, nor have I ever smoked or drank. Will taking Propecia have negative effects on my liver?

The value of Propecia should be determined after you have a diagnosis in hand for the balding process. How much miniaturizationdo you have as compared to balding? Propecia works well if the miniaturization process is well underway, but the hair still should have substantial volumes. With regard to your liver, what is your diagnosis as the cause of your liver problem? Doses of Propecia must be reduced when people have liver disease. I do not like internet medicine, because I like to see and bond with my patients. That is why you need a good doctor first, then a Master Plan to determine what to do next. Propecia may make a difference in the crown hair, even in a 57 year old.

Have you considered, or would you consider body hair transplants to the scalp? I was a patient of yours once, but my donor hair is depleted. And since I have had 4 scalp reductions, you could not do the FOX (I believe its called) procedure on me because the folicals were stretched or deformed from the stretching of the scalp. I have resorted to having to wear a hair “system” because even if I shaved my head, the scarring from the donor area would be quite apparent.I am hoping for cloning or multiplication, but these seem to be far in the future, and I am not getting any younger. Do you have any ideas, or have you ever planned to experimetnt with body hair?

Thank you.

Body hair transplants have problems, including the long sleep cycles of body hair. That means that up to 80% of transplanted body hair is sleeping and not present at any one time. Body hair transplants therefore give you efficiency factors, possibly in the range of 20% — in other words, they do not provide much value. Before you go into way out treatments, come see me in Los Angeles, as Phoenix is not that far away.