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Hi Doc

i had previously done a minor HT of 500 grafts onto the thinning mid scalp. Shock loss was bad and now at 8 months post HT, my hair looked thinner than before.

my question is is it advisable to plant the hair grafts onto the thinning mid scalp or is it more advisable to plant only onto the bald area and leave my thinning mid scalp until more serious before i start to tackle them.

I would have hoped that you were on finasteride prior to getting a hair transplant, as this drug minimizes the shock loss some young men experience. Were you warned ahead of time about the possibility of shock loss?

Everyone is different and you certainly have a unique problem, though I don’t know much about your case (age, hair loss pattern, hair character, etc). I would have to see you, or at least you should email some good photos that show your scalp, and we might be able to setup a phone consultation.

Hey, i just want to know if the hair that its pulled out from the root grows back up?

Also can harsh brushing of the hair lead to hair loss?

Hair pulled out from the root will regrow, but continuous pulling could eventually lead to permanent loss. Same goes for harsh brushing. If it’s ripping the hair from the scalp over and over, it’s possible that it could eventually cease to grow. I guess it depends on how harsh we’re talking… but generally, brushing your hair won’t cause a problem.

Dr. Rassman,
I enjoy your blog! One questions I had was if any hair transplant surgeons use level 2 sedation? I recently found a blog where a surgeon uses level 2 sedation instead of injection. What are the differences or risks for each one? Is one more preferred than the other?

Regards

Level 2 sedation scale is considered: “cooperative, tranquil, and oriented” according to the Ramsay scale. To some this can be achieved with no drugs. To some this can mean a shot of Vodka. In the doctors office this can be a shot of a sedative or a pill (like Xanax). It can also be breathing in laughing gas.

Level 2 sedation is not anesthesia.

At NHI we have evolved our sedation and anesthesia routine. We offer nitrous oxide (laughing gas) for sedation. In addition we also offer a single shot for sedation or a Xanax pill to take by mouth. Some patients choose all of the above and have a great Level 2 sedation experience. The laughing gas has the most immediate on/off response, followed by the injection. Finally the oral Xanax takes the longest for a patient to reach the Level 2 sedation.

We do monitor the breathing, oxygenation status, and cardiac status during the procedure, and if the breathing slows down, an alarm goes off. Level 2 sedation can quickly turn disastrous if the physician or the clinic is not prepared to handle the consequences of the medications.

To achieve Level 2 sedation your surgeon should be certified in ACLS (Advanced Cardiac Life Support) and the facility should be equipped to handle emergencies. Luckily Dr Pak is also Board Certified in Emergency Medicine so we are well prepared for any medical emergencies.

For Level 2 sedation we also take an additional voluntary step to be accredited by the AAAHC (Accreditation Association for Ambulatory Heath Care) as an out patient surgery center. Very few hair transplant clinics have this AAAHC rating (something to ask about when doing your research).

So that’s what we do. I can not comment on other doctor’s drugs and uses.

Hi. I have been taking proscar cut into 4 for two and a half years, with excellent results. For about 4 months I have had pain under my right nipple and a small lump has developed. The nipple is puffy and the areola is swolen. In the last week the same has happened under the left nipple. Reading the blog has made me realise gynecomastia is a rare but well known side effect of finasteride. I am seriously worried about continuing the medication. But I am also reluctant to stop due to the success on the MPB. Could you advise a course of action. If I gave up the meds for two/three weeks, to give the gyno a chance to subside, and started taking a reduced 0.5mg of fin would this be suffiecient to prevent catch up hairloss and maintain the benefits in the future?
Thanks for a great blog

This is a question you need to ask to the doctor who is prescribing you the medication and treating your androgenic alopecia. Gynecomastia is a possible side effect of Propecia (finasteride). From my recollection, there have been 3 patients who have reported gynecomastia to me, but it reversed when they stopped taking the medication. Sometimes you need to consider the risks and benefits of taking a medication.

Finally, while the gynecomastia may be a side effect of Propecia (finasteride), it may also be a unrelated issue which some men experience. No matter what the cause, you need to follow up with a physician and have a complete examination.

Hello Dr,
I over tweezed my brows and now that the hair is growing in, it is growing in one eyebrow in different and odd directions. I was wondering if I tweezed them out in the right direction if they would start growing that way the next time they sprout out? I don’t want to pluck them out if they won’t. Thanks for your help!!

That’s an interesting question. I don’t have personal experience with eyebrow plucking and I do not know the answer to this one. I am sure you will know the answer when they fall out (go into telogen, part of the normal hair cycle) and then regrow.

Keep in mind that continuously tweezing of the hair could eventually result in permanent loss.

Should a person who says he is a specialist on the FUE procedure with the neograft machine who is not a plastic surgeon, be providing the procedure?? He is a surgical tech that works with a very reputible plastic surgeon. Im very cautious of this bc I know that the science is not regulated by the medical board and anyone with a machine can perform the procedure? I would rather find a doctor who is experienced with this type of procedure.

I would agree with you. FUE performed by non-physicians is a grey area and illegal in most states. Legally, a procedure where there is a cut on the skin requires an MD to do it. There are cases where a registered nurse or a PA (Physician’s Assistant) can perform certain tasks, but it has to be supervised by the physician. A surgical tech performing FUE is a dark grey area.

As I’ve mentioned before, I’m a part of an email group of hair transplant doctors that share information amongst each other. The other day I received an email from a well respected doctor (let’s call him Doctor A) reporting that he’s now had two patients in the past 12 months who had persistent erectile dysfunction (ED) even after they stopped finasteride (traditional 1mg dose). These are two patients out of thousands that this physician has prescribed to, and I have no knowledge of other potential health factors or even full details on the cases.

Other doctors in the group chimed in:

1. Doctor B in the email group responded that he had been prescribing finasteride from even before it was approved to treat hair loss and he has never seen one case in this situation.
2. Doctor C wrote about two patients who had the problem in some 1500-2000 patients.
3. Doctor D said that he’d also seen two patients in his 18 years of practice that talked about ED permanence.
4. Doctor E who has also been practicing about 18 years has seen no cases of ED permanence.
5. And then there’s me (I’ll be Doctor R). I echo that from the thousands of patients I have prescribed finasteride to, I have never seen nor heard of such a complaint after the patient has stopped the drug.

So while I don’t have specific case info or medical history of those claiming permanent side effects, it seems that there are 6 cases out of maybe between 6,000-10,000 prescriptions (estimated). Unless you’re one of the 6, the risk is extremely limited (if it is shown that the medication is the cause). I’ve always maintained (my opinion) that these side effects are reversible upon stopping the medication, as this has been reported in peer-reviewed studies and in thousands of my own patients. However, I make it my job here to educate our readers as I become more informed. I’m not writing this post with the intent to scare anyone, but do whatever you’d like with the information. We still don’t know for sure that the “permanent” ED cases are even related to finasteride. Remember, I do not sell finasteride to make Merck profitable. If that were the case, I wouldn’t tell patients (or readers of this site) how to cut into Merck’s Propecia profits by buying the generic 5mg and splitting the pills when discussing alternative suppliers.

The incidence of low testosterone in men is high. There are reports that 44% of men have low testosterone levels. We know that 20% of men have ED, 30% of men have ED, 40% of men have ED and so on. That is the market that Viagra sells to. Can we be confusing the ED observations from Propecia and the ED resulting from low testosterone levels? There are many causes of ED, so we should be careful not to state that the ED we are seeing was from the Propecia/finasteride that these men were taking.

I still believe in this medication fully for treating genetic male pattern baldness, and I must point out that these reports are still extremely rare. The alternative for the balding male is to continue to go bald. For some, that small risk of sexual side effects may not be worth abandoning their hair. Sill, the consumer (you) must make his own decisions on what to do with such reports. I fully expect my inbox to be flooded with “See, I told you so” emails from forum trolls, but if anything, this should show you that I’m not disregarding the claims outright. As I’ve always said, I’ve never seen any case and the medical literature supports that. I do, however, appreciate respectful discussion.

Also, keep in mind the study we mentioned yesterday about common everyday pain relievers like aspirin and ibuprofen being linked to erectile dysfunction. Who knows what else is in the systems of those claiming permanent ED.

Hi Dr. Rassman. How are you?

I don’t know if you have heard of Dr. Richard Lee from Regrowth LLC (www.minoxidil.com) but apparantly the FDA shut him down for selling what they consider ‘dangerous and illegal drugs’ aka: his Xandrox Line of specialty Minoxidil Products. I wonder how he could be forced out of business since he is a medical doctor, and correct me if I am wrong, but can prescribe drugs for off label usage. And why after 25 years of doing this they all of a sudden come after him???

What is your opinion on this and do you think it is the shape of things to come with regards to the FDA cracking down on buying drugs online or do you think that the makers of Rogaine saw him as a threat and applied pressure on the FDA to shut him down? (Conspiracy theory thinking I know! LOL)

Just curious as there are other MD’s doing the same thing as he did and yet they haven’t been touched…yet..Knock on wood!

Personally I think the FDA, in this particular case, are doing the public (balding men in general) a huge disservice because I believe thousands of patients relied on his products to keep their hair.

I believe the issues the FDA had are with claims that Dr. Lee made about his products. Claims are under FDA control and every claim has to be backed up with good science, effectiveness, and safety testing. I think that playing by the rules just serves the public, helping to limit false representations and scams which are on the internet by the bucket full. Just because a doctor says it is legal, does not necessarily mean it is.

Minoxidil in itself is available in generic form, so I’m not sure the makers of the name brand Rogaine would make a stink about Dr. Lee selling it. Perhaps it had something to do with mixing prescription finasteride into a topical and selling it online? Perhaps it was the other ingredients and the claims attached that the FDA didn’t like? I have no idea. The shutdown isn’t a total shocker to me though, as I even mentioned that I thought there was a violation of the FDA rules well over 2 years ago (see here).

HI,
I had car accident recently.I am 40 year old female. I did pass out after the accident due to stress but other then that there was no injury to my physical body. My car is at total loss. Later when I came home and had shower I lost about one fourth of my hair while washing my hair. This kind of sudden hair loss was strange. Only thing I can think is we did end up gently vacuuming the hair to remove glass pieces from my hair which was in fact advised by the hospital. Are you aware of any reports like this? Would it grow back?

I have never heard of losing 1/4 of your hair after a car accident from stress. It is indeed very strange. Perhaps your perception of losing 1/4 of your total hair is a bit exaggerated or the accident just called your attention to something already going on? I do not think gentle or even harsh vacuuming the scalp to remove glass debris would pull out that much hair (it would really hurt). I think only time will tell if your hair will grow back (about 6 to 12 months).

Hi Dr,
I’m currently taking both Propecia (1 mg) and Avodart (0.5 mg) daily and am noticing good results. However, I’m wondering if this combination has the potential to be unsafe - can it mess with hormonal levels? Does taking more of these enzyme inhibitors leave more testosterone in the body?

I am not sure if what you are doing is safe or unsafe, but I would never recommend it to any of my patients. I would follow up with your doctor who is treating you and ask for his/her opinion. Did the same doctor prescribe both medications? Do you have prostate issues or are you strictly trying to treat hair loss?

The sexual side effects are more common with Avodart (dutasteride), but when you add Propecia (finasteride) to your routine, I wonder if you have any sex life left.