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Hello Dr. Rassman,

Thank you so much for the service you provide the public with this site. It must be alot of extra uncompensated work for you, I appreciate it.

I got a 1300 hair graft about 9 months ago to the area that I roughly outlined in red (on both sides of my head of course, I am only showing one side). As you can see it is growing at nearly a 90 degree angle on my head whereas my natural hair falls forward. Even though I cut my hair at the same length, the transplanted area looks twice as long because it is growing directly ‘up’. My two questions are this: 1. Is this a lack of skill on the doctors part that it is growing at an unnatural angle? and 2) if I keep trying to comb it forward can you gradually adjust the natural angle of the hair so that it matches with the rest of my hair as to the angle that it grows (or will the transplanted area permanently be at odds with my natural hair growth angle)?

My doctor recommends a second procedure because as you can see the transplanted area looks quite thin. I am 26, do you see any concerns with having a second procedure done with this doctor, or do you sense a lack of skill and I should look elsewhere? I have minor thinning in the crown area as well, but I do not plan on transplanting anything to that area. I have been on propecia for 9 months, and while it has not totally regrown the crown area, I am hoping that it will prevent further loss in that area.

Many thanks, and feel free to post the picture.

Thank you for permission to post your photo. Please click the photo to enlarge.

You are correct. It seems your hair was transplanted at different angle than your native hair. The surgeon planning for the correct angle and direction of hair is a very important factor in a hair transplant procedure. Unfortunately, this is very difficult to correct and relatively impossible to reverse. Your transplanted hair will always grow in that unnatural direction. One of your options is to have another transplant procedure and make sure that the new transplants are in the correct direction to “blend” in with your hair.

With respect to a second surgery with the same doctor, you need to be able to trust the doctor before having any procedure. Doctors are human beings and they can make mistakes or misjudge the many decisions that are before them in a treatment plan. If you and your doctor have a good trusting relationship, I am sure he/she will see the difference in angle and your concerns and will be more than happy to accommodate accordingly. The key here is to directly discuss this with your doctor first, and then make decisions on the value of the doctor/patient relationship.

At least a few times each week I get emails asking what to do after a surgical procedure was done (not by me), many times with complications. People contemplating surgery should have doctor/patient communication on the top of the list for doctor’s qualities. Having a doctor who is technically competent, but can not support you emotionally, intellectually, or practically, is really of no value.

Sometimes the questions asked of me reflect simple post-operative questions which should be in the written post-operative instructions giving to patients after any surgery. Sometimes the questions reflect simple every day things like washing ones hair immediately after transplantation, or more complex questions like shock loss or hair thinning after surgery. Sometime there are symptoms reflecting possible infection, circulation of the skin, bleeding or vascular problems after surgery. It is becoming clear to me that too many doctors are failing to really connect with their patients. Doing surgery may command the $$$, but good medical care reflects not only competent surgery, but also good support of the patient before the surgery (good education and informed consent issues) and after the surgery, when the patient is clearly off balance while things are healing. Communications start before the surgery, when plans are made such as where the grafts are to be placed and most important in establishing the expectations on what to expect.

The reason for writing this post isn’t to say that I necessarily dislike these types of emails. After all, I’m here to help. You shouldn’t have to seek out post-surgical advice from a doctor that is different from the doctor that performed the surgery. My point is that you’ll want to be sure that the doctor you select has good communication skills during the post-operative period by probing some of his/her patient’s experiences. This is a very key element that it seems many people overlook when choosing their doctor.

Note: This post isn’t related to hair loss or balding, but interesting and worth posting nonetheless.

On my recent trip to the Canadian Rockies, I read an article in the Globe and Mail newspaper about the “latest in sexual enhancement: a collagen injection to swell the elusive G spot”. This was the sub-heading and it caught my attention, not only as an interested reader, but as a physician who practiced some gynecology (as part of my general surgery practice) many years ago. Essentially, a shot of collagen is injected into the spot in the vagina where the G spot is supposed to be, thereby enlarging it and making it less elusive (read the article for the details — link below). This is supposed to produce a “trigger” for the female orgasm. The ‘G shot’ was patented in 2002 by Dr. David Matlock, a gynecologist and plastic surgeon in Los Angeles. The article discusses, in detail, the need for other treatments related to plastic surgery for the vagina “that shorten the plump labias, tighten vaginal muscles, shrink the skin covering the clitoris and reconstruct hymens”.

Many men think that libido and sexual dysfunction are problems that are unique to them, but this article provides some insight into the needs of women, a ‘black box’ for most men whose ignorance on this subject may be helped by reading this article.

Full article: globeandmail.com — Hit me with your best shot

Here’s a cute, brief story that I thought may be interesting to post…

When a patient of mine joined the US Marine Corp many years ago, he lost a great deal of hair, most likely from stress inducing his male pattern balding. His mother did not like the way he looked, so she complained to him that the Marine Corp was bad for his health. “If you get out of the military your hair will come back,” she would say. Eventually he got a hair transplant before leaving the military to restore what hair he lost. He visited his mother some months after getting out of the Marines and he told me she was quick to point out that because he left military service, his hair came back. It proved (to his mom) that mother is always right. She had no idea he had a hair transplant.

It is important for our largely male readership to understand that we will all confront prostate cancer if we live long enough. We can modify our genetics by a dietary focus (e.g. vitamin D & vitamin E may reduce the risk of prostate cancer while diets rich in fat may increase the risks), and the use of such medications as Aspirin (they call this in the class of NSAIDs), and finasteride (we use it as Propecia or Proscar) daily will clearly impact risks.

The following article may will shortly be published in the Journal of the Israel Medical Association: Harefuah. 2006 Jan;145(1):47-51, 76-7. Related Articles, Links [Nutrition and pharmacological treatment for prevention of prostate cancer], Article in Hebrew, by Segev Y, Nativ O., Urology Department, The Bnei Zion Medical Center, Haifa. Isreal.

Here is an abstract of the article:

“Prostate cancer is the most common neoplasm and the second cause of cancer death. It is an excellent target for primary chemopreventive strategies for the following reasons: it is highly prevalent and has a long latency period, there are identifiable risk factors and a precursor lesion and it produces a biochemical marker (serum PSA) which can serve as an intermediate end point in chemoprevention studies. The goal of primary prevention strategies is to prevent development of clinical life-threatening neoplasms in asymptomatic patients with no evidence of clinical disease. Identification of populations at risk for developing cancer is the cornerstone of chemoprevention. Well-established risk factors for prostate cancer include African-American race, older age and family history. Data on diet and obesity are less clearly defined. Since high grade prostatic intraepithelial neoplasia (PIN) is an early predictor of prostate cancer, preventive strategies focusing on men with high grade PIN are being explored. It was demonstrated that finasteride could significantly reduce prostate cancer in asymptomatic men with normal PSA and no abnormalities on rectal examination. Elevated prostaglandin levels, and upregulation of cyclooxygenase-2 (COX-2) are found in prostate cancer cell lines. There is some epidemiologic evidence that regular use of NSAIDs, which inhibit COX-2, may be associated with a lower risk of prostate cancer. In the field of nutrition, data from prospective large-scale studies demonstrated that increased consumption of lycopene-rich tomato-based foods referred to a reduction in the risk for prostate cancer. Vitamin E was also found to reduce prostate cancer risk. Prospective data showed that vitamin D has an inhibitory effect on prostate cancer development while increased calcium consumption, independent from dietary intake, might increase the risk. Dietary fat intake, particularly from animal sources, may also increase the risk for prostate cancer. Whether this effect is strictly due to the already identified compounds or to other compounds, remains to be explored. Further study will hopefully help to establish a core set of nutritional and dietary factors that can positively or negatively affect prostate cancer development, as well as a set of pharmacologic agents that can reduce the risk of prostate cancer development and/or progression in selected patients.”

In the days of Abraham Lincoln, few people actually met or saw the people they voted for. Stock photos in newspapers of the 1700s and 1800s were used, often supplied by the men themselves to reflect the image that they wanted to portray. But today, image is thought to make the man and the images can not be so easily controlled by those being portrayed. In politics, 90% or more of successful politicians have hair (though balding is present in 50% of all men). When focus groups are put together, it is clear that prejudice against balding men is commonplace. We have images of the balding, fat, beer guzzler with a pot belly. What does balding have to do with beer guzzling or obesity? Some people feel that balding men are not trustworthy or dynamic. Why? On my radio show, The Inner Man, we asked Los Angeles listeners to call in and tell us what they thought of the balding man. Between this radio program and other forums I have seen, heard, or participated in, I find these comments humorous, yet sad. Here are a few comments:

1. Balding men are older, right?
2. I would never date a bald man because I don’t date older men!
3. Balding men look shifty; they have beady eyes.
4. Bald men are smarter because they have to be just to survive.
5. Bald men are not good in bed.
6. I don’t find bald men sexy.
7. I find bald men very sexy.

The most interesting comment I heard was from a bald man who called into my radio show responding to prejudice. He said when given the choice in hiring, he would rather hire a man with hair than one without. When we confronted him on this very issue, he said that even though he was bald, it was unfortunately true. We was open about his overt discrimination against balding job applicants, and he was the Senior Vice President of a company.

So in the days of Lincoln (1800’s), men wore top hats to cover their balding, and a bald politician could keep this secret. Today it might be a baseball cap, but there are few secrets to the camera as the paparazzi find their way even into the bedroom. But the real secret is the balding man’s secret. Their views of their balding situation cover a wide range of self esteem issues, inner secrets that are never discussed with anyone. Balding and aging do go together. With 50% of men having some degree of clinical balding by mid-life (45 years old) and balding progressing with age, a look at the man in the mirror constantly reminds him of his aging process, his mortality and his changing body. For some bding bald is a good alternative to the death option. For other more courageous men, they visit me and get their hair back.

What is the story on Donald Trump’s hair? He looks like he is trying to hide something?

As I understand it, Donald Trump was a victim of the old hair transplant process starting in the 1980s. The quality of the work most probably resulted in the pluggy look, and he possibly had scalp reductions (which were popular in those days). Between the two, he might have little donor hair left. There may be significant scarring as well if he had many procedures in the ‘old days’. He apparently found the solution to cover up his hair loss problem, with a creative hair styling that he is now well known for. He knows that his hair is the subject of much focus and with people who just love to talk or make their living hosting entertainment shows. That is the price of today’s celebrity.

What he has done is to exploit a ‘comb-forward’ style, maximizing what hair he has to cover what he wants to hide. Like the comb-over, it layers hair from one part of the scalp to another (comb-forward means that the hair is kept long and combed to the front). I call this the ‘Trump style comb-forward’ in my private office practice, because of his celebrity status. This style uses what many people with frontal balding exploit (see the Norwood Class 3 or 4 pattern balding). The less hair that is lost and the more hair that remains, the more effective is the result of styling to hide thinning or balding in the frontal area. When taken to extreme, whether it is the comb-over or the comb-forward, the appearance does not look good.

When any reasonable amount of hair is transplanted in the Class 3 or 4 balding pattern (those with natural Norwood Class frontal balding patterns), a comb-forward can work even better so restoring all of the missing density is not needed. Nobody ever knew that CBS News sports reporter Steve Hartman was balding and he perfected the combing to the front and side enough to hide his thinning hairline. This canopy comb-forward was very effective for him (a common combing style for many men), but he was slowly losing the battle to preserve his look. Many men tell me that they spend more and more time dealing with their hair, not only in the mornings, but throughout the day as well. One man who comes to mind told me that his comb was like his Mont-blanc pen, always needed wherever he went and he carried hair spray with him to touch up the styling in bathroom breaks that he had to take quite often. Steve’s hair, on the other hand, was very cooperative with a strong character that easily laid down the way he wanted it to. Rather than waiting too long and risking an unnatural appearance, Steve decided to take the bull by the horns and had one transplant procedure (see pictures). Steve went for natural fullness as he did not want to maintain any illusion at all, so we put as much hair as we could safely move in just one transplant session. The point between where Steve came from and a really bad comb-over (the kind that everyone sees on TV or at the airport), is a slow, insidious process — so slow in fact, that the person who is doing it never notices the advancing balding nor the progressive failure of the grooming style. I always wonder why family members do not comment on the failure of this styling process, but maybe they are just not saying anything early enough and now are embarrassed to say anything at all so late in the process.

Some men with bad comb-overs deny their evolving look, putting a mental block on the unnatural appearance they evolved, and others just stop going out into the public arena. Hats and wigs solve the problem for some, a type of cover-up that does not work for everyone and I have seen a few take it to extreme levels, creating a bouffant style with hair that is one or two feet long and combed into a circlular pattern, layered hair by hair to mimic what the person thinks is normal.

I have been asked many times why the rich and famous who can afford the best doctors don’t just get the best surgical hair restoration money can buy. Ignorance is part of the answer. I believe that many men with the old deforming hair transplants find themselves in a difficult situation. They may not know that they were going down that road when the process initially started. When they found out, they may have come to the conclusion that it was too late to do something about it. With luck, men in this predicament may find some solution that they learn to live with when it works (comb overs, hats, wigs, scalp coloring agents, and the like) or they may find their way to a good hair transplant surgeon who can fix the problem.

With today’s modern Follicular Unit Transplant and Follicular Unit Extraction (FUE) techniques, some amazing work can be done. With FUE in particular, it is virtually for all practical purposes scar-less and the procedure is minimally invasive. Not everyone can be brought back to “normal” if too much of the hair has been squandered, or if scarring has gone too far. If Mr. Trump had old type plugs, he can have that hair redistributed so that the big bad plugs are no longer present. Any hair that is moved can be put to better esthetic use in other scalp locations under the guidance of an artistic hair restoration surgeon (see Dean’s Story for an example of this).

Had Mr. Trump been a patient of ours, I could never have written anything about him because patient privacy is central to the way doctors operate their business today. I hope that by writing this piece in answer to your question, I have not offended him in any way.

I saw Bruce Willis on the David Letterman show the other day and he told everyone that he was bald and happy. That could put you out of business so don’t buy your new Mercedes yet doc. What do you think of the balding trend? Is bald beautiful?

I have followed Bruce Willis’ hair loss over the years from his thinning during the TV series Moonlighting, to the present day shaved head look he sports. A while back, I did notice what I thought were hair transplants placed in the front of his head, showing a less than artistic straight line of hair (suggesting a poor hair transplant), but if my initial guess was correct, there would be some signs of it on the front (recipient area) and in the back of the head (donor area). Judging by photos I’ve seen, I can not stand by my original assumption. I do not think Bruce Willis ever had transplant work done. It is interesting that my daughter met him at a party in the mid-90s and engaged him on the balding issue and my transplant services. He commented that he would remember the connection when the time came, so with that knowledge, I have followed his balding over the years waiting for him to come to my office and join others in that line of work that have come my way.

It must be clear to anyone considering hair transplants, that the option to shave the head as Bruce Willis does may be lost if you have the procedure, as some scarring may be present at the donor site (even with the FUE technique). I have seen many patients that had a small-session transplant, which was inadequate to cover the bald area, because less hair is moved to produce the fullness that a reasonable person might expect. Small, delicate follicular units will mimic the normal hair and to get that, the doctors performing the surgery must be adhering to the standards of Follicular Unit Transplantation. Anyone with even a good hair transplant that uses strip harvesting would have a noticable scar if the head was shaved, even if it were 1mm in size. For the unfortunate person who had unsightly or poorly planned hair transplants, they may have no choice other than to live under a hat or a hair piece most of the time.

Some men shave their head as a way to accommodate their balding. This is a style that has more recently been accepted by the ‘hip’ young men today. We see many ways these men deal with their balding/thinning at our monthly Open House events, where a significant number of men who have to deal with balding come to learn more about the hair restoration process. Many men shave or clip their hair short, or are wearing baseball hats or hair systems. Unlike the average guy, Bruce Willis could get away with wearing a baseball hat to the Oscars because of who he is, but I would not recommend interviewing for a high powered job with a baseball hat on your head. With a poorly done or incomplete hair transplant, an interviewer might spend too much time looking at the hairline rather than in the eyes of the interviewee.

Society has stereotypes and a bald head is stereotypically a ‘hard’ look, the man’s man look. In the past, Hollywood actors have gone clearly bald (Yul Brynner, Telly Savalas), and they were tough character actors. Bruce Willis now joins that pack, but if he had transplants, unlike those bald men who could elect to let their hair grow in and not shave their head, Bruce Willis may not have that choice. His options may be limited if he wanted both hair and the opportunity to keep shaving his head.

Now to comment on your last inference, I am not buying a new Mercedes and I fully expect to keep driving my Toyota minivan, which seems to get me from here to there just fine. If it is short hair you want, don’t worry about my car payments as I have accounted for those choices already.

Numerous news outlets have announced a 1 year ban on an Olympic athlete for taking Propecia. The story can be found at NBCOlympics.com, with more info at Yahoo Sports.

“Zach Lund, the top slider on the U.S. skeleton team, was banned from the Torino Olympics on Friday for taking a common hair-restoration pill that can be used to mask steroids.”

Since I have been following this story closely, I felt obligated to share my thoughts on today’s update. The US Anti-Doping Agency originally felt that Lund should receive a public warning and relinquish his medal from the recent World Cup event. However, the World Anti-Doping Agency had another idea and banned him from competition for a full year. It all seems outrageous to me.

Somehow I find it hard to believe that Skeleton athletes rely on steroids to increase performance. I cannot attest 100% that Lund did not use Propecia to mask the use of muscle enhancers but I find the connection unfortunate. He has not been training for the Olympics with me by his side so I don’t think the establishment would take an “elderly” scholar’s opinion like mine. Zach Lund, like millions of men in America, has a justified medical condition. As a 26 year old, he is taking charge of his physical image and obviously desired to reverse his hair loss patterns, which are certainly not helped by the stress of training. His very reasonable, take-charge position to hold on to his hair has now taken his career (4 years of work and passion) down the drain. Lund’s Olympic Dreams are shattered and I would doubt that this drug could impact his muscle mass. Of all the 80 pound weaklings I have treated with Propecia, not one has become a 400 moose (or even a fraction of that). The punishment seems harsh for just wanting to save his hair.

Lund recently was quoted by 1998 Gold Medalist Nikki Stone for Yahoo Sports as saying, “I definitely made a mistake by not staying up with [the updated banned drug list]. I’ve been losing my hair since I was a teenager and I’ve had a prescription for the last seven years and it was never an issue until this year. Whenever I’ve been tested, I always let them know that I was taking [Propecia]. I never had anything to hide.”

In the end, it is up to each athlete to be aware of any banned substances, so Zach Lund is not completely faultless. However, he is not given much choice in the matter. For Lund, as for all athletes, it now a matter of choice: be bald, or try to become an Olympic/professional athlete. I guess the establishment is saying, “Be bald!”

I’ve previously mentioned Zach Lund’s Propecia “problem” last month, Balding Olympic Athletes Promoted.

A few times each month, I will post some random hair-related information, which I’m calling “tidbits”. I spend hours each day writing responses to questions I receive on this blog, so it is a nice change of pace. This one came from guest writer, Dr. Jim Arnold…

Many rastafarians and others with dreadlocks notice that hair which is not in a dreadlock never grows as long as the dreadlocks do. If you have ever examined a person with dreadlocks, you would have probably noticed this yourself — the “dreads” are longer than the the rest of their un-cut hair or beard.

The occurance is related to felting. Felting is the phenomena of hair (or fur as in the making of hats) matted together in a complex entanglement which is almost impossible to separate back to individual hairs. It occurs as a result of the scales on the exterior of each hair. All the scales point in one direction, back toward the follicle. In entangled hair, the rearward pointing scales allows each hair to easily move forward but not backward. With the hairs moving in only one direction, the mat gets tighter and tighter. Beaver hair, which is fine, demonstrates this phenomenon extremely well which is why beaver pelts were of such great value in making hats. Some hats, especially American cowboy hats, still mark the quality of a hat with the amount of beaver fur in the hat, ie “Beaver X” for a little, and a high quality hat having more X’s such as “Beaver XXXX”.

By Dr. Jim Arnold