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Dear Doctor,

I have been doing a lot of reading about hair transplants because I see one in my near future. I have heard enough horror stories to know the importance of choosing a great transplant surgeon.

It just seems to me that the doctor’s role is “overrated.” I certainly do not mean any disrespect by that, but it seems that the transplant technicians have more of a role in the outcome, whether it be good or bad, than the doctor himself.

From what I understand, the doctor justs removes the donor strip, sutures the incision and makes the recipient sites. I may be ignorant of the matter, but this seems like something any general surgeon can easily do. The technicians though are responsible for dissecting and actually placing the grafts. If a transplant’s outcome is judged to be a success or not by the number of grafts that actually grow, then it seems that the technicians were more responsible for the outcome than the surgeon who merely made the holes in the person’s head.

I hope you don’t take anything I wrote as a slight against you or your profession, but if what I wrote is not true, please tell me what am I missing in my thinking?

The role of the technician is very important. What they do requires special skills that are tedious and at times require years to perfect. The hair that is cut from the strip must be efficiently dissected under the microscope and handled efficiently. Such work is best for a technician who has these functions as their sole activity. It takes a certain type of personality to be able to perform this type of work, great dexterity, and hand-eye coordination. Not to say no doctor has these things, but the complete skill list is honestly not the type that most doctors have. When I started to do the hair transplant procedures in larger and larger sessions, I originally participated in the cutting and placing the grafts, for it was I who defined the standards that the technicians would be held accountable for. So in the early days (1992-1993), I was the fastest graft preparer and the fastest graft placer, but as the graft counts went into the thousands of grafts, the work required more and more labor. Four or five technicians are a minimum number required for a large case of over 3000 grafts in 6-7 hours.

If I was to do this myself without the technicians, it would take me more than 24 hours and I would be exhausted, my eye strain would be incalculable, and the grafts may have died off by the time their turn came to placing them. If a graft is out of the body more than 8 hours, the death rate for the grafts runs 1% per hour. One could say, “Hey, lets get 5 surgeons to replace the 5 or so technicians,” but what that would do is:

1. Slow the process down, as doctors are generally not good at such disciplines.
2. Reduce the quality of the work, as doctors can not do repetitive work reliably for they often lack the patience.
3. Drive up the costs substantially out of the reach of most recipients, as doctors make more money than technicians.

Those reasons, in a nutshell, are why technicians are used throughout surgery. Another example where technicians are used in surgical procedures — open heart surgery. It is the pump technicians that control the patient’s circulation.

Now with regard to what the surgeon does, it is not as simple as you suggest. There is a special skill required in planning the surgery, and I suppose to prove this you’d have to spend a day with me to see the many patients that come in for repairs with results reflecting a lack of strategy in their hair transplant procedure. When a doctor just looks at it as cutting out a strip and putting holes in the head of the patient, the results can be frequently substandard. So while I don’t take what you said as a slight, I hope this helps explain things a little better.

Doctor,

What do you think of minoxidil products sold by doctors with little or no propylene glycol? Do you think they’re still effective as long as minoxidil is the main active ingredient? (Tried Rogaine foam, very hard to apply through hair to the scalp)

It appears on the internet a large number of people are only using minoxidil once a day. Usually at nite. Do you see that at your practice? Are they having results or developing dependency?

Also, it appears I can only handle .5mg of Propecia due to side effects. I think you’ve stated it’s about 80% effective at that dose. Have you seen that 80% result in your clinical practice?

Thanks for taking the time everyday to answer everyone’s questions. I’ve learned more than anywhere else on this blog.

I don’t see why the lack of propylene glycol would make minoxidil ineffective. The propylene glycol is supposed to help the minoxidil penetrate the scalp better, but it isn’t used in the Rogaine Foam or in the Women’s Rogaine liquid (which is good for those that may have allergies to propylene glycol), so I’d expect that other delivery mechanisms, such as alcohol, work relatively well. I really have no opinion on the various ways the doctors make their minoxidil formulas. The recommended use is twice a day, but many people do use it once a day. I can not tell if once a day works across the board.

My comments on the 80% effectiveness of 1/2 mg of finasteride came out of a conversation I had with Dr. David Whiting (and might’ve been in something I read), not my own clinical study.

Dr. Rassman

You have always been against the idea that propecia side effetcs may be permanent, and I saw you telling many people that the side effects as released by Merck are temporary and have been approved by the FDA. now it seems that there is an updated Prescription Information for Propecia. you can check it yourself at this link

among the most important changes are (in section 4, “Possible Side Effects”): “Persistent difficulty having an erection after discontinuation of treatment.”

Anything to comment? Thanks

Interesting, but the information lists that under the heading “Frequency unknown“, which leads me to believe it must be extremely rare. I have no information on this and have never seen it in my practice. I wonder about psychological impact on those that are affected.

The PDF you linked to appears to be for the Austria, Denmark, Finland, France, Germany, Greece, Iceland, Italy, Luxembourg, Netherlands, Portugal, Spain and Sweden markets… and Merck doesn’t seem to have the same information in their US pamphlet. I really could only speculate as to why that is the case, though.

Can hair really be restored? Most of the things i have read say its impossible unless its implants and that’s not certain to work? I also wish to now how much it would cost to treat. roughly? Due to not being well off. regards

Hair transplants will work for most, but each case is different and costs will vary depending on how much hair you need. You’re never going to be able to get 100% of your hair back. Medication like Propecia or minoxidil does work for many men, but again, each case is different — no two people will respond to medication exactly the same. Since you are asking about general costs, they can be from about $10/month for some medications (generics), to the $3,000-$10,000 range for surgery.

Hello Dr.,

I have mild gyno since I was 15, nothing to be worried, just my nipples are larger than those from other guys. Now I’m 21, and I’ve just started using Propecia (2 weeks ago). My questions are:

1. How many are the chances to make even worse my breast condition?
2. When I should see that my gynecomastia is getting worse and what are the signs to alarm me?
3. If it’s getting worse what are the alternatives for me (to save my hair), cause I know propecia is the only DHT blocker approved by the FDA? (I’m a NW2)

1. Your chances of Propecia producing gynecomastia problems is about equal to the regular population (one in about 500 men).
2. If you develop breast enlargement or breast pain, it usually comes on in the first month, but sometimes I have seen it delayed a year or so.
3. There are no FDA approved DHT blockers other than finasteride for treating hair loss. I only recommend FDA approved and proven treatments, which are limited to minoxidil and finasteride at this point.

Snippet from the article:

Researchers spanning three continents have pointed the finger at nine flawed genes after carrying out the largest-ever trawl through human DNA to search for inherited risks of a heart attack.

Variants of genes located in chromosomes 2, 3, 6, 12 and 21 boost the risk of myocardial infarction, according to five studies published online on Sunday in the latest issue of the journal Nature Genetics.

Identifying the culprits could open up new drug targets for people at risk, targeting inflammation by the immune system, adhesion between cells and other molecular mechanisms.

Read the full article — Nine gene clues found in risk of heart attack

No, it’s not a hair loss related news item… but it could potentially be huge news and I found it worth sharing.

Hi Sir, i want to ask u if i apply minoxidil and left it there for the night w/o washing it will it cause hairloss?

There should be no problem with it causing hair loss. I do not believe it should be washed off when you go to sleep.

Are you bald and want to be on national syndicated TV to talk about it with your wife or girlfriend in front of a studio audience? Well, now’s your chance!

The following is an open casting call announcement for those that wish to appear on The Doctors TV show. I believe they are looking for people for a show taping this coming Friday in the Los Angeles area, but they’ll be able to provide the actual details (see their contact info below). I won’t be able to participate in the show due to scheduling conflicts, but Dr. Pak may be able to move some things around to be at the taping. Here’s the notice:

—

“The Doctors” Talk Show (www.thedoctorstv.com) is looking for couples to appear on the show! They are doing a fun, light segment about Male Pattern Baldness. They are looking for men who have begun to bald and are wondering why they lose hair on the top of their head first, yet still have a crown of hair along the outside. If you are interested in appearing on the show and asking a question about the balding process with your spouse, we’d love to hear from you! Please contact Julie at julie.laplaca@cbs.com or 323.956.8653.

Hello Doctor,
I have been using propecia for close to 2 years now with great results. The hair got thicker and I am very thankful for it. But for last 6 months I have been getting hives over my entire body, initially I thought it was food. So I kept track of what I ate but it showed no consistency. I had hives almost every other day. Then I stated taking an antihistamine but the hives continued to get more severe and my lip started swelling up. I went to allergist and everything (got blood test). Nothing showed. Recently I started getting swollen eyes as well. I finally tried stopping propecia and no hives, swollen lips or eyes for almost 10 days now. What can I do now? I really think propecia works great and I want to keep taking it but the side effect is really bad. The lip swelling is really disfiguring. How can I get around this problem? Thanks

It sounds like you have developed an allergy to Propecia if your hives and swollen lips go away upon stopping the drug. I would like you to go back to your doctor or possibly your allergist and give them the information about stopping the drug, asking for an opinion. You are on a timeline here, as you can expect to see hair loss after stopping Propecia for about 2-3 weeks, so get those opinions in hand ASAP.

You may not be able to manage the allergic reaction which has dangers of progression and even more side effects. I am not your doctor, so this is just a general opinion not based upon an intimate knowledge of you and your situation other than what you wrote here.

Hi Dr Rassman

My question it’s about new approach of treatment. Have you heard about Zymo Hsor (used in Kaidax), or the options to use lotions with finasteride and flutamide with liposomes to enlvolve the drugs? Well, let me start describing the Zymo Hsor. It’ s a enzyme able to destroy DHT on the scalp. It’s manufactured on Italy. A brazilian Dr, that I know, likes Zymo Hsor and have formulas that use in liposome.

A transdermic gel aor foam with finasteride and flutamide in liposome forms it’s also used to reduce topical DHT. This brazilian Dr recomends to first use Zymo Hsor to destroy topical DHT, and then apply the gel of Finasteride an flutamide. The finasteride topical would reduce the DHT formation, and the remaining DHT would compete with flutamide for the androgens receptos. As the final result the DHT that would link to androgen receptors would be much less.

There are studies suggesting that retioic acid enhance minoxidil effect, and also studies that clains B-12 vitamin increase the effect of minoxidil. One study show that minoxidil with retinol and 0,1% of finasteride resulted in a much higher percentage of people with regorw, when compared to people that only used minoxidil. Propecia reduces more DHT on blood, but not much topical DHT. So I believe would be a fine approach if we use topical lotions to attack DHT, combined with the oral propecia.

I would like to heard your opinion about

Regards

I haven’t heard of Zymo Hsor, but lots of claims are made of various products and I am posting your comments to show the general inexhaustible approaches to the balding problem, your Brazilian doctor in particular. There is no evidence that topicals will work as you suggested here, but let the reader beware as he reads your post and researches it to his heart’s delight. I have no further knowledge to base an opinion on.

There’s this post at HairLossHelp about Zymo Hsor that doesn’t reveal much more than what you described in your email above, and I’ve written about flutamide gel before.