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We’re taking a week off from posting new content — our first break in almost 6 years — so we’re using this opportunity to repost some older articles that didn’t get the attention they deserved the first time around.

(Originally published on October 3, 2008.)

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I wanted to call your attention to yesterday’s announcement relating to follicular unit extraction (FUE). As the ‘inventors’ of the procedure, publishing the first authoritative article in the Journal of Dermatologic Surgery in 2002, I have taken a keen interest in the way this procedure is delivered throughout the world. Much of what I have been observing has been disturbing. Too many doctors with little experience, and skills that have not been refined, have entered the field with heavy marketing programs offering FUE. My experience, however, has shown that some patients are not good candidates for this procedure and damage to the harvested grafts can be substantial in most surgeon’s hands. The key here is graft yield and unfortunately, this is an assessment made either after the procedure is performed with careful surgical monitoring and record keeping (by recording hair damage within each graft), or 8 months after the procedure when the patient can judge the success or failure of the results on his or her head.

I realize there is a delicate balance between what we want and what we buy. Our progress in reinventing the FUE process is discussed here — new FUE breakthrough. I really hope everyone considering having an FUE surgery (or anyone just curious about how it works) will read our new guide to evaluating Follicular Unit Extraction Techniques.

Announcement:

This week, we’re going to take a break from publishing new content so that we can re-feature some of our favorite archived posts that didn’t get the attention we thought they initially deserved. We’ll post 2 or 3 longer articles from the archives each day.

For nearly six years, we’ve posted new blogs every weekday (excluding holidays)… and we don’t intend to stop. Not to worry, we’ll have new content again starting next Monday, February 14th, otherwise known as Valentine’s Day.

As always, thanks for visiting! The first archived post will be up in just a bit…

Good day Doctor. Are there any ways to minimize bleeding during a hair transplant? I know there are a lot of incisions involved, so I am curious. In the two procedures I have had both at 1200 grafts several years ago, the doctor mentioned that I was a “bleeder.” Now I have never passed out in my life, but 1-2 days after both procedures I came very close before I placed my feet in an elevated position as told by the office nurses. I assumed it was from losing blood. I know you must have had similar patients and would very much appreciate it if you could provide insight. Thank you for your time and your blog!

Bleeding is almost never a problem with a hair transplant in the hands of good surgeons. For controlling bleeding throughout the scalp, the surgeon will include a solution that contains adrenaline — and it is the adrenaline that reduces the bleeding from the recipient sites and even the donor wounds.

With regard to the donor area, if a strip is the method for donor area harvesting, then bleeding will be in the hands of the surgeon. There are many blood vessels in the back of the head which must be carefully managed during the surgery. I became aware of a surgeon whose patient lost so much blood during the surgery (when a major scalp blood vessel was cut) that the patient developed a stroke from hypotension. I only heard about this situation once.

When I trained as a surgeon, I always knew to look over the head for bleeding areas when a person came into the emergency room. Sometimes a small gash in the head can bleed heavily, enough to lose a unit of blood (or more). The scalp is very vascular, so your question is quite appropriate.

Hi Doctor. Thank you for having this great site!!

About 25years ago I had a HT using the hobby drill method. Now I have 3 rows of white plugs. I am like most of the others on this site and want to shave my head. I was wondering if you have ever considered a procedure to re-drill the plugs and suture them closed similar to the way you show it being done to patients for the top of their heads. I have spoken to other doctors and they want to cut the entire area out and suture it closed. They also state that it would take two or three procedures. Why can’t someone just re-drill and suture shut the area?

We have done what you described — taking each of the old style hair plugs out one-by-one and suturing each wound closed. We have also cut out the entire row and sutured it all closed. And we’ve even done a combination of both. Here’s a step-by-step story of the process one man took to repair his pluggy hairline. It took multiple surgeries to complete his repair, with the first procedure being a removal of a row of plugs, and the second procedure being individual removal of some of the remaining plugs.

My point is, everybody is different and every treatment plan for each individual is unique. In the end, find the doctor that you trust and ask to see some before after results of these repair procedures. You may even ask to speak to their former patients or meet them. Good luck.

You’ve said before that balding comes from both sides with a tiny bit more weight on your mother’s side. When looking through a family tree for traits and patterns of hair loss (which I’m sure every visitor to this site has done over and over), how far back or in to your extended family should you look (cousins, uncles, great uncles, etc.), or can it spring up out of anywhere? I understand there are many environmental factors as well, but I ask because I have some unique traits I can’t attribute to anyone I have photos of in the past two generations or my second cousins even.

Genetic hair loss will likely be visible somewhere in your family tree, but I really cannot give you a definitive way to predict if you have the hair loss gene just by looking at your family members. The best way to know is look in the mirror… or see a doctor for a miniaturization study and/or hair bulk analysis.

The genes can be determined by genetic testing to 70% accuracy (see HairDX), but the test doesn’t tell you at what point the genes will be expressed, if at all.

Snippet from the article:

Now 55-year-old Joseph Fox Batista sits in a Miami-Dade County jail, accused of scamming his yogurt cream investors and spending their money on a luxury apartment in the Flamingo condo on South Beach, fancy dinners, alcohol, and, one victim says, drugs.

In a jailhouse interview with the Miami Herald, Fox dismissed charges of grand theft and organized scheming to defraud as persecution from “shady forces, possibly members of the powerful and very jealous hair transplant industry.”

Read the full story at MSNBC — Man accused in scam blames hair transplant industry

According to the article, people invested thousands of dollars into the idea that yogurt could supposedly regrow hair, reverse aging, and turn gray hair dark again. Wow. I don’t even know what to say…

Hello Dr. R and all.

Thank you for your blog, I’m sure everyone would agree with me that it’s a venerable resource. With regard to strip surgery in a typical male who is losing hair to a NW5 pattern at 40 years of age (eg. William Hurt like) when would you anticipate the donor scar to become potentially visible due to senile alopecia?

The reason why hair transplants work in men is because men don’t usually bald in the donor area (back of scalp). And since men don’t bald in the back of the scalp, the scar from strip surgery isn’t shown.

Senile alopecia does NOT occur in all men. It is a rare entity where the hair thins considerably in the elderly. If you end up with senile alopecia in the donor area, I suspect the donor scar will still be well hidden, because you likely wouldn’t bald completely and the donor scar is very minimal. Of course, this depends on how this area thins out.

We must all look at the pros and cons of anything we do in life. Having a hair transplant surgery is a great option for balding men. The donor scarring, possible senile alopecia, or even balding from chemotherapy is something to think about, but in most men the benefits outweigh the risks. The other option is do nothing. It is like staying home locked up on a perfectly sunny beautiful day because you are afraid it may rain (despite a beautiful forecast).

I have a question. I have a son who is about to turn 16 years old and he is loosing hair. Not that much but he is afraid it can get worst since a bald spot is getting more visible. At that young age what treatments are recommended? and if this gets worst can he evaluate hair transplant or he is too young for that? Please answer me. Thanks a lot.

It needs to be determined if what he is seeing is genetic male pattern baldness (MPB)… and assuming that is the case, we need to establish baseline metrics on the degree of his hair loss to follow it over time. With a proven diagnosis of MPB, the use of Propecia might be indicated, though at 16 years old the prescribing doctor may have reservations. See here for more on teens and Propecia.

Yearly monitoring of the progression of the balding is critical. Many young men will stop and possibly reverse the impact of genetic balding at his age, but caution in the diagnosis is important.

I’m planning on having hair transplant surgery this year but am concerned about post-operative itching in the scalp, which I understand it to be expected. Can betamethasone dipropionate 0.05% cream be applied to the scalp to control itching post-operatively?

Thanks.

Talk to your surgeon about how he/she best treats post-operative issues (including itching). What you are asking about is a steroid that can be used on a limited basis, but your doctor will want to know what he/she is treating.

There’s a lot of other things that could go wrong with the surgery that I’d think most patients would by concerned about before even thinking about the itching. You’re about 20 steps ahead of yourself. Many men do not have excessive itching, and the use of good conditioners can keep the scalp moist enough to avoid it.

Good Evening Dr Rassman,
I have posted before and found my post from 5 yrs go!!! I have triangular alopecia and have tried to treat it using Steroids (Dermovate Scalp Application) and even stronger injectable steroid, all via a qualified dermatologist. Unfortunately, there has been no response to treatment even after 1 yr.

Will a HT work or is that area programmed to always minaturise the hair present in just that part? Also, would you be prepared to carry out such a ’small’ HT as i not so bothered by my normal balding?
Many thanks

Triangular alopecia can be treated with a hair transplant surgery. Be warned that when you select your surgeon, they should have prior experience with this type of transplant. Hair transplantation to the side temple areas are very tricky and unforgiving, and they can look unnatural if the surgeon does not have the skills that are required.