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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.

So what prompted me to write a new FUE guide? A while ago, I had the opportunity to view a well known doctor extract approximately 20 FUE grafts under my direct observation. While he boasted that he had mastered the procedure, what I saw reflected far less than such mastery and the doctor obtained a significant transection/amputation rate of the hairs in the graft. That doctor is prominently offering FUE today.

The surgeon’s technical skills take years to acquire and perfect, and although there are now some very fine doctors who I believe have truely mastered the technique and can deliver a quality service, I believe that they are in the minority of those offering it. There is a substantial worldwide demand for this minimally invasive hair transplant (virtually painless during the post-operative period, the patient can return to full activities in a week including all types of exercises, and there is no linear scarring). The problem for the patient, however, is in selecting a doctor where the FUE technique does not produce a “follicular holocaust” causing a substantial loss of donor hair and a failure of the procedure. This insight seems to be hidden from most buyers, because prospective patients want to believe in the marketing hype that is prevalent on the Internet and they are sold the technique by professional marketing pitches. There is no way to determine in advance, the skills of the doctors offering to perform the surgery.

In our new FUE guide, we have defined a way for patients to examine the various doctors offering this procedure, giving them an idea of what questions to ask and what things to look for. There is no site to offer guidance in the doctor selection process so the consumer must arm himself with the knowledge and skills to make the proper judgments themselves. Hopefully, our writings will appropriately arm the readers interested in this technique.

• Article link: Patient’s Guide to Follicular Unit Extraction

Hair Transplant Forum International is the official publication of the International Society of Hair Restoration Surgery (ISHRS), and I’m pleased to announced that I was just named the Pioneer of the Month (Volume 18, Number 1)! The article, written by Dr. Jerry Cooley, is presented below. It serves as part biographical, part information that hasn’t been found elsewhere on the Internet until now. I hope it gives you an insight into my background and goals for the future.

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As a young man, Bill Rassman had “one focus in life, to make a difference.” To say he’s made a difference to the specialty of hair restoration may be one of the greatest understatements ever. Creative and controversial, Bill has made his mark and it’s hard to imagine how hair transplantation would have evolved without him. Because of Bill, our lives are very different indeed.

Bill was born in 1942 in New York. He grew up in Brooklyn, the son of Russian immigrants. After medical school in Virginia, he entered general surgery residency at the University of Minnesota and Cornell. This was interrupted by military service in Viet Nam. Before military service, he did a cardiovascular fellowship where he played a key role in pioneering and commercializing the intra-aortic balloon pump. After returning, he finished his surgery residency at Dartmouth. Bill entered private practice in Vermont where he practiced for six years. He then relocated to Hawaii, practicing surgery there for four years.

Feeling bored and in need of adventure, Bill left medicine and became an entrepreneur, starting a company that developed commercial applications for windmills. After this became a multi-million dollar business, he sold the company. With the money he made, Bill funded his next adventure, a start-up computer software company, which did not progress the way he wanted. After four years of working to develop this, he decided to reenter medicine.

Bill joined Bosley where he soon became its president. Unhappy with the state of hair transplantation at that time, he left Bosley and in 1991 began visiting prominent surgeons, such as Walter Unger and Emmanual Merritt. During this time, he developed his ideas about procedures with large numbers of small grafts, the “megasession.” Bill began doing hair transplants, which in the beginning meant only 400-500 grafts where he did all the cutting and placing himself.

With increasing staff came increasing session sizes. More staff also allowed Bill to focus on further innovations, such as the Densitometer to quantify donor hair and help estimate the number of grafts that could be harvested. It also allowed him to open more offices, including one in New York where he met Bob Bernstein. Together, they developed the concept of using naturally occurring follicular units as the fundamental building block of hair transplantation.

In the mid-90s, Bill’s practice was booming and he was very busy. One issue that became obvious in the “megasession” era was the dependence on large numbers of well-trained staff. To give the surgeon more control over the procedure, Bill began experimenting with follicular unit extraction and new tools to automate the procedure. His interest in FUE continues and he reports that he may introduce a new tool that “reflects a completely new paradigm” for FUE. His interest in automation led to the development of the Carousel Implanter (1997), and instrument he still thinks works great. Unfortunately, he was unsuccessful getting a company to manufacture a reliable instrument.

Bill’s current activities include maintaining his Balding Blog on the Internet, he he daily gets 5,000 visitors and 700 emails. Bill also enjoys writing and is currently working on a book entitled “Hair Loss for Dummies,” which is part of the popular consumer book series.

Another current interest is completely outside the field of hair restoration. Bill is founder of a company (Maven Technologies) focused on “personalized medicine,” with proprietary technology used in a diagnostic instrument to rapidly assay thousands of abnormal proteins, glycoproteins, and disease markers in patients for early disease detection and staging. Eventually, he hopes that this technology will become a backbone instrument used by pharma for the development and testing of new drugs. He refers to this project as one of the most exciting things he’s ever done, which is quite a statement in light of all his career accomplishments.

When he has free time, Bill likes to scuba, ski, read, and compose music on the piano, as well as spend time with his four grown children.

Joe Penny, perhaps best known for his starring roles in hit 1980s television series Riptide and Jake and the Fatman or more recently his guest spot on the popular TV show CSI: Crime Scene Investigations and the Hallmark Channel’s Jane Doe TV movies, has agreed to let me show his results from a repair job started years back. Due to a variety of professional obligations, we were unable to schedule more work until about a year ago. When his old, ugly plugs from another doctor showed, I was reluctant for him to tell people that I was his doctor (even if only for repairs, because I did not finish the repair job)… but now things are very different as these two month old pictures show.

He tells me that on many occasions he’s overheard fellow actors talking about hair transplants, expressing fear of taking charge and doing something about their thinning hair. As Joe puts it, “It takes a great deal of courage to make the decision to get a hair transplant, especially when you see so many bad jobs out there in Hollywood. You get gun shy after making a bad decision and it took me some time to make the decision to fix my bad hair job. But now, when people talk about a hair transplant for their balding and struggle with the hair loss problem, they don’t look at me as an expert any more”.

Update 2/1/08 6:00 pm:

Joe just wrote to me. He did not know that I put him on the blog today, even though he gave me permission to do this over a month ago. This is what he said: “I want to thank you again for your kindness and your generosity in my case. The last procedure I had..even after seeing you a couple of months ago..has still continued to grow and thicken. Also the donor area…because of the expert surgical job you did… is so loose I cannot believe it! It is truly astounding to me. I mean…I new you were good but WOW! The results speaks louder than words. I have recommended several people to come and see you. I know that some of them have already come. They called me and were very angry at me, meaning…well the dialogue went something like this…”Why the hell didn’t you tell me about the NEW HAIR INSTITUTE BEFORE” My response was “I DID…YOU WERE NOT LISTENING”. They are extremely satisfied, as I have been for years. So I will keep spreading the word about the fantastic work you and you Doctors are doing at NHI.

After I received this email, I wrote to him asking for permission to use the above email. His response came in at 9:00pm and this is what he said: “Yes, you have my absolute permission to post my email. Please consider this communication as my acknowledgment that it is absolutely OK with me to post it. Not a problem Dr. Rassman. If there is a group oif men or if there is an open house going on at the office with people who are considering it and might feel a little shy or afraid of a surgery, just let me know and IF I, AM…AND IN TOWN….I WILL DO MY BEST TO ATTEND AT AN OPEN HOUSE!

Your fan forever, Joe Penny
God Bless You And Keep You

Joe is not atypical for someone who has gone through a type of hell with the old type of hair transplant plugs done years ago. I am absolutely humbled by his comments. For as long as I have been in this industry, I have been pleased to be able to help men like Joe and there have been hundreds of them, but it is even better to put hair back on a new patient who would never have to experience Joe’s type of pain.

Click photos to enlarge.

After repair:

Before repair (scanned photos):

I am concerned about the loss of sex drive from taking propecia. I took propecia for about 6 months and my sex drive was non existant. I stopped taking it over a year ago and it has returned, some what, but not nearly where it was before. Is there a product that will help it return, or anything that can be done? I would rather be bald with a strong sex drive, than a head full of hair without one.

You need to go see your doctor for a physical examination and possible testing. While Propecia can cause a decreased sex drive (in 1 to 2% of men), it is temporary since the drug only lasts in your blood stream for about one day. After one year, I hardy doubt your sexual problem is due to Propecia. You need to see a doctor for further evaluation. In fact, erectile dysfunction may be one of the first signs of an underlying medical problem.

Here are a few facts about sex drive / erectile dysfunction / impotence that I found at Minnesota Men’s Health Center:

• One in 10 men (10%) in the world have erectile dysfunction.
• 30 million men in the United States have erectile dysfunction.
• 50% of men with diabetes have erectile dysfunction, frequently within 10 years of diagnosis.
• The likelihood of erectile dysfunction increases with age: 39% at age 40, 65% over the age of 65.
• Smokers have a higher likelihood of erectile dysfunction.
• Men who smoke more than 1 pack per day have a 50% higher chance of impotency than nonsmokers the same age.

And from the Mayo Clinic:

Nonphysical causes:

• Psychological problems. The most common nonphysical causes are stress, anxiety and fatigue. Impotence is also an occasional side effect of psychological problems such as depression.
• Negative feelings. Feelings that you express toward your sexual partner — or that are expressed by your sexual partner — such as resentment, hostility or lack of interest also can be a factor in erectile dysfunction.

Physical causes:

• Nerve damage from longstanding diabetes (diabetic neuropathy)
• Cardiovascular disorders affecting the blood supply to the pelvis
• Certain prescription medications
• Operations for cancer of the prostate
• Fractures that injure the spinal cord
• Multiple sclerosis
• Hormonal disorders
• Alcoholism and other forms of drug abuse

The physical and nonphysical causes of erectile dysfunction commonly interact. For instance, a minor physical problem that slows sexual response may cause anxiety about attaining an erection. Then the anxiety can worsen your erectile dysfunction.

Dear Dr. Rassman,

I have heard from people on the Internet, especially from the following two websites, that the sexual side effects of Propecia can be permanent, along with many others. Can you dismiss all the information on these websites?

propeciasideeffects.com and propeciahelp.com

Anyone can write and publish anything on the Internet. You can you find contrary evidence to those sites you listed at Propecia.com. I can’t dismiss everything on these anti-Propecia/finasteride websites, because I simply don’t have time to go through every post made there. I’m sure some of the claims made there are based in fact and might have some validity — and those have more than likely been addressed here before (search for “Propecia side effects”). I’m also sure that much of the info on those sites is created by people that have no medical background and simply write what they believe to be true based on FUD (fear, uncertainty, and doubt).

The people that speak the loudest are usually the people that want their complaints to be heard. In other words, you don’t necessarily see a lot of people visiting message boards just to tell others that Propecia works great for them, but you certainly will see the unsatisfied few going to every website they can find to make their opinions known. When doing your research online, try to find out if you’re getting information from fact-based sources. Are these other sites just shills for the various snake oil products on the market today? What better reason to shoot down a proven treatment like Propecia than to promote your non-proven treatment that sells for double the price. I’m not saying that this is 100% the case, but anything is possible. Take BaldingBlog (this very site), for example — I’m a hair transplant surgeon, yet I’m not trying to “sell” people on hair transplantation procedures. I write a lot about Propecia because I get asked a lot about Propecia, and because I’ve seen first hand what this medication can do to treat hair loss. I don’t want to see anyone go through an unnecessary surgery when a simple daily pill could be the answer to their problem. I, along with the other doctors that write here, are just trying to help.

It seems what you really want is a doctor’s reassurance. Although I am a doctor, I am not your doctor… and you need to discuss these concerns with your doctor. You may not even be a candidate for Propecia.

Hi Dr Rassman

I have read your blog for some time and find it an oasis of sensible, factual information in the desert of hair loss websites.

I am writing to you to ask about the BX 3.4 helmet. I know you have mentioned it before but I wanted to draw your attention to a paper written by Dr Tony Chu, a consultant dermatologist in the UK. I have seen Dr Chu for years for my acne and he has managed it amazingly well, and he pioneered a laser therapy for acne which he proved with rigorous studies and research.

When I mentioned my (minimal) hair loss to him, he alerted me to the BX 3.4 helmet, and I did some research. I found a paper he wrote somewhere on the internet, to the UK Advertising Standards Authority, pulling together all the various studies and research on the subject of electromagnetic treatment of hair loss. IT looked very persuasive to me as a layman, and suggested room for further studies. I can’t find the paper now, which is annoying, but know it exists.

What are your thoughts? Have you seen the paper he wrote? If not, do you have some way of getting it and looking at it? If not, are you aware of all the studies he cited concerning this subject, and what are your thoughts on them?

I did buy the helmet from ebay at greatly reduced cost (£750 is a lot of money) and it does *seem* an insane idea to me, but then so did laser therapy for my long standing acne problem, and that worked, so I never like to say never.

Thanks

I’ve received a few emails over the past year and a half about this BX 3.4 helmet, and as I wrote before, there is no science that I can see behind claims that electromagnetic waves can have a positive impact on hair regrowth. I was just reading on their website that this helmet requires a monthly purchase of “essential oils” from the helmet maker, although the prices aren’t listed. What are these magic hair-regrowing oils, you wonder? The site lists Bay Saint-Thomas, Laurel leaf, Rosemary, Patchouli, Thyme Borneol, Cedar, Sage, Clary Sage, Myrtle, and Ylang-Ylang. So there’s extra costs on top of the nearly $1500 hair helmet.

A number of years ago, a professor from one of the local universities had developed electromagnetic treatments for diabetic ulcers of the legs and suggested that there was some data indicating an application for bringing back hair in a situation where hair loss occurred. The work to find out if it would work would’ve been an enormous task (and one which I just didn’t have time for), so I decided to pass on an opportunity to get involved to determine the value of this treatment modality.

As many regular readers of this site will probably know, I am a skeptic of most of the new treatments for hair loss, as most of them are not based on science, but motivated by commercial and monetary gain. I have not read Dr. Chu’s paper (I looked for it online and was unsuccessful), but since you’ve purchased one of these helmets, I’m guessing that you believe in it. Please keep us informed of your progress.

Consumers spend collectively millions, if not billions, of dollars on products for that allusive hair loss cure and as long as we are willing to spend the money simply to “give it a shot”, these products (including this electromagnetic helmet) will continue to entice people. I suppose the reasoning is that if the price is right, it may be worth the gamble, and to many people, the price of hair has no limit. On the other hand, the savvy entrepreneurs will keep selling these products for the “right” price and make their fortune.

Note: Image is for illustrative (and humor) purposes only. This is not the actual BX3.4 helmet.

How dangerous is a hair transplant? The news about Kayne West’s mom dying after surgery has me scared. What happened to her and could it happen to me after surgery?

This is certainly a big news story this week, but for those that haven’t followed it, please read the following links:

• CNN - Autopsy planned for Kanye West’s mom
• Wired - American Academy of Cosmetic Surgery President Discusses Kanye West’s Mom’s Death

What is there to say that the above references did not already say? Crossing the street can put you at risk of death, but the risks will go up if you’re running across the street with your eyes closed. Good planning, thorough research and common sense is central to the lessons here.

The presence of heart disease, by itself, may not be a contraindication for elective cosmetic surgery, but the heart disease risks must be defined and appropriate steps must be taken to minimized these risks. I have done surgery over my career on many patients with heart disease and these surgeries were done safely. Clearly from the references here, there is a strong suggestion that these risks were not defined for Donda West’s heart condition.

The doctor is ultimately responsible not to do surgery when risks have not been mitigated. I would ask if there was a rush to the surgery. Decisions that are made before surgery, during anesthesia, and even after the surgery is completed, account for most of the risks. Donda West doctor’s legal problems (medical board history, history of DUIs, and court appearances for malpractice) are suggestive of a problem for this doctor. It has been reported that the plastic surgery (tummy tuck and breast reduction) was performed by Dr. Jan Adams, who is probably best known as the host of the Discovery Health channel’s show Plastic Surgery: Before and After, or from his appearance on the Oprah show, or even from when he co-hosted a daytime talk show with Dick Clark a few years back. So here we have a doctor performing cosmetic surgery that has been on TV for a number of years and is known to many viewers. Does he promote himself as a “Doctor to the Stars” due to his Hollywood connections? Did Kanye West’s mother research the doctor’s history and credentials adequately? Did she have heart disease and if she did, was it adequately evaluated. I don’t know the answers to these questions.

To my knowledge, there has been only one death from a hair transplant anywhere in North America, as previously reported (see Death During Hair Transplant Surgery). This death reflects what appears to be completely incompetent medical care. The clinic where this death occurred, known for bargain basement prices, is still performing surgery and it appears that the patients that go there do not focus on risks of death or complications from a hair transplant or they would not be so popular. One might ask those who continue to even consider this place for surgery, “Why try to save a few dollars and place your life on the line?”

Yesterday, I received some sad news when I learned about the passing of one of our hair transplant patients just 5 months after his procedure. He had complained to his local doctor about chest pain and was told that it just was indigestion. This patient complained a number of times about the chest pain to his physician and each time he was tagged with the diagnosis of reflux. He recently had a heart attack and died.

Although the outcome was different, this reminded me of a similar case that I wanted to share. A female hair transplant patient had complained of periodic chest pain when I took her medical history. It sounded like cardiac pain (angina), so I had her see her doctor. He took an electrocardiogram (ECG — also known as an EKG) and told her that the pain was reflux (stomach type pain), not heart pain. She came back to me for a hair transplant, but I did not like her doctor’s diagnosis since it sounded like classic angina (pain coming on with exertion, climbing stairs, and fast paced walking), so I sent her back to her doctor. Again, he reassured her that the pain was not cardiac in nature, as her ECG was normal. I then got into her medical care and called her doctor, suggesting that he perform a stress ECG. He told me that it was unnecessary and again insisted that the pain was not cardiac. This lady wanted a hair transplant and was unable to persuade her doctor to get further testing, so because her doctor had cleared her and she wanted to proceed, I transplanted her.

During the surgery, she began experiencing chest pain, which I then treated with nitroglycerin, fortunately relieving her discomfort. This happened twice during the procedure. After surgery, I called her doctor and told him of the events at surgery. He saw her again after the transplant procedure and told her that she did not have cardiac pain and was upset with me for interfering with his medical care of her. I suggested to her that she see another doctor for a second opinion, but she liked her doctor and wanted to stay with his opinion. Three weeks after the surgery, she had a heart attack, and fortunately for her, she survived.

Being right is not a consolation from my point of view. We know from the anesthesia literature, that for people with heart disease and outpatient surgery, the risk of a heart attack in the 30 days after the surgery is higher than in the average person without surgery. Undergoing any surgery is no small matter and although I have never experienced any cardiac problems with my patients that I could not manage in surgery, risk clearance for anyone over the age of 45 years old, a good and thorough physical examination should be a medically necessity. We must all be on guard for detecting heart disease early and there are many good ways to do this today. The sad reality, however, is that in nearly 50% of cases, the first sign of heart disease is death.

I received this email from a patient of mine and I have reposted it below with his permission (removing any identifying information, of course). This was not solicited, and it serves as an example of those men out there that are looking into hair systems (otherwise known as wigs or toupees). The price chart at the end of this post could be a wake-up call to many that think hair systems are cheaper than hair transplants.

In the end, transplanted hair is YOUR hair and the only maintenance you might need to do for it is to use shampoo and perhaps even use a comb. Oh, and visit a barber from time to time, if you’d like. You know, the things you did when you had hair the first time.

And now, the patient email…

Dr. Rassman:

As usual, it was good to meet with you to discuss my case. It is amazing that what we (operative word here) will accomplish in 21 months negates over 13 years of living with worry and dread about my hair loss! On some level I am certain you understand the value of your work; on the other hand, it is impossible for you to fully comprehend what you and your great staff at NHI have done for me and your other patients!

Here is a breakdown of my costs from a hair replacement salon in Los Angeles from June 2000 through January 2006. I wore a competing hair system from 1995 through 2000, but did not keep thorough records of those costs. Therefore, the $16,000+ indicated on the spreadsheet does NOT include the previous five years, so the total amount I spent on hair systems is actually higher that what my spreadsheet shows. In fact, I am certain I spent more on hair “replacement” than what I will spend on 5000+ transplants with NHI.

To be fair when you reprint this spreadsheet, post the the following as well:

1. This spreadsheet is ONE PERSON’S experience with hair systems. It was my reality and should be viewed as such. Your costs will vary from my mine.
2. The price for a hair system included two of them: wear one while the other gets service or cleaned.
3. The months where there is no dollar amount were the times I did not go to the salon for servicing.
4. I work in an industry that required my systems to look absolutely real at all times. The months where you see me spending $200-$400 were instances when the unit had to be colored or have hair added. Again, in my case it was a necessity. If you are in, say, another profession like a machinist, you may not have to obsess over your hair system. You WILL have maintenance, though, perhaps not as much. Also, to be fair, some people do most of their own maintenance, so their costs would be lower as well.
5. In June 2000 the systems were just over $3000. Flash forward to 2004 and they were over $5000. I got 4 years use out of mine before they were replaced, and that was on the higher end of the average life cycle because of my meticulous maintenance. They might have had to be replaced before that if I did not treat them so well.

I wonder what systems cost today in 2007?

Bottom line: I spent $16,000+ over five years wearing hair. Sure, the initial costs for systems were cheaper than surgery, but their VALUE quickly fades over time. It costs more upfront for a high quality transplant, but its VALUE over the course of your lifetime is incalculable.

Thanks again for everything. Looking forward to my next transplant session.

Here’s the spreadsheet he sent me with the costs incurred for purchasing and maintaining his hairpieces.

Last week we attended a lecture at Cedars-Sinai Medical Center in Los Angeles on the topic of hair stem cells. Dr. Robert Hoffman (speaker) is a professor at the University of California, San Diego. He and his colleagues have done several studies on hair stem cells and its application in different fields of medicine.

Dr. Hoffman’s team extracted special cells from the bulge area of hair follicles (above the lower generative center of hair) that are known to be easily accessible and a good source of actively growing, pluripotent cells (cells that have capability of differentiating to different cell lines). They found the protein markers of the neural stem cells in this group of cells (Nestin). They performed several projects to evaluate the final cell lines that could be harvested from growth and differentiation of these stem cells. Among those were using these cells to produce nervous system and blood vessel cells. In one study, Dr. Hoffman’s team applied these stem cells on mouse severed sciatic nerve. The animals that were treated have recovered from nerve injury and could resume the function of affected limb faster in comparison to the control group that never received any treatments.

Dr. Hoffman and his colleagues also performed similar study on a mouse with spinal cord injury. The animal with spinal cord injury gained the function of its paralyzed limb following application of these cells to transected part of spinal cord. The findings can bring about hope for treatment of patients with ‘fresh’ spinal cord injuries. Currently, there is no effective treatment for spinal cord injury and those patients are doomed to lose the neural function of some part of their body, commonly their lower extremities for the rest of their lives.

Although Dr. Hoffman was optimistic about application of hair stem cells in regeneration of cells in nervous system, when asked about his opinion on hair multiplication, he did not believe that it would be that easy. Dr. Hoffman believes that the necessity of interaction of this dual stem cell system (cells from bulge area and cells from dermal papilla of hair follicles that produce hair formation) makes it more complicated for producing hair with a method similar to what is described (in producing nervous system or blood vessel cells).

It is most interesting that Dr. Hoffman and many others working in this arena, find that producing the hair organ (which contains skin, hair elements, blood vessels, fat, and other supportive tissues) is far more difficult than producing just one of these elements (nerves, blood vessels). For those of you who are anxiously waiting for hair multiplication results to be available in the clinical world, I would not postpone the more standard treatment for hair loss (e.g hair transplantation), as your balding will inevitably progress as you will wait, and wait, and wait for the breakthrough that may not occur in the time frame when you can enjoy having hair on your head.