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Hello, I just had a wonderful procedure. Their offices were clean, procedures were excellent, and the staff was very accommodating. In 2002 I had 800 grafts done by another group in San Francisco and then again I just did 3500 grafts. The follicles were transplanted throughout my scalp approximately 25 FU/CM2. I have a very nice NW2 hairline. Also, I had a very high number of 4-hair grafts. Over 400 of them! They excised a strip of 3500 grafts and got 3703!!!

Do most of your patients get about 25FU/cm2 and are happy with it? I think it will be ok but just need reassurance.

A normal person will have 1250 hairs or 600 two-hair follicular units. When converted to cm/square, that would extrapolate to 100 follicular units per square cm. If you received 25 follicular units in 1 cm, that would suggest that in one procedure, the doctor returned 25% of your normal density on the transplanted area. This is often not really the case, as some areas will have higher densities put in and other areas lower densities. For a person with average weight hair, olive skin, and brown hair, 50% densities overall should be more than enough to produce a full appearance. If you had a high number of four-hair grafts, then that might mean that your overall densities are higher than average. I generally target 25% density return on the first session, but at times I will go higher or lower depending upon other factors.

I went to a local doctor for a consult and he mentioned that he uses a 2-3 bladed knife with the Haber spreader to insure that no transection occurs. He said that there is less transection with that than with the single bladed knife, when used properly. According to him, with the single blade, you must go down 2-3 times as deep to cut past the follicles, and if you are not right on target there will be some transection. Does this sound correct - does using a Haber spreader with a 2-3 bladed knife sound right?

Thanks…

More than 2 blades with depth may cause hair transection. The use of spreading instruments such as the Haber spreader or a Kelly clamp will also work to minimize transection. If a two-bladed knife is used, it should have a built-in angle to minimize transection. A three (or greater)-bladed knife causes more transection and loss of hair from the donor area.

One vs two blades (with built-in knife angles for the 2-bladed instrument) are about equal to minimize hair loss from the harvest. I use a specially designed (by me) two-bladed knife that has a 30 degree angle built into the holder to minimize transection. Two-bladed knives like the one I use precisely control the width of the strip, so I prefer that to a single-bladed knife.

Hello doctor Rassman,

with all the shady HT docs out there you seem to have a very good record of ethics; but recently I came across the first negative “report” that i’ve ever seen about you.

Quote

“Bobby Limmer presented FU style grafting in 1989. It took 10 years to gain a foothold even though it was clearly better. During this time there was an active movement by the practitioners in the industry to badmouth and prevent the adoption of this new technique. That’s right they were actively stopping the evolution of technique. If a patient asked about these techniques they’d be told false and baseless statistics about transection, etc. if they were lucky. If they were unlucky the doctors wouldn’t even present the option to them. Documented examples of this exist online.

“FUE grafting encountered the same resistance from the industry. Every trailblazing FUE practitioner has had false claims and allegations made against their results. Leading this badmouth charge was William Rassman from NHI. Dr. Woods has recorded evidence of this.

In fact FUE was known by the industry for several years and you couldn’t get any of the top clinics to admit its existence.”

Care to comment?

I originated many of the techniques done today (see medical publications) including the follicular unit extraction (FUE). Dr. Woods and I seem to have evolved it simultaneously, but I published the technique in 2001 and he kept his technique secret. In fact, I am still not sure just what he does, technique wise. I have taken lumps on my head as other doctors badmouthed me in the early 1990s, but after my patients got out to the market, the great results seemed to quiet down the accusations made against me. In 1994, I presented 23 patients with completed results to a group of about 500 hair transplant surgeons at an ISHRS meeting in Las Vegas. I would say that 95% of the doctors at that meeting were doing the old plug technique at the time. I did my presentation with live patients and compared what I did with the poor photography shown at the meeting by other doctors. My patient models spoke reams about the techniques I used, and that meeting seemed to be the actual end of the plugs as the standard of care.

I have been an outspoken critic of misrepresentations by doctors about their skills and techniques. After I announced FUE to the world, one doctor called me to ask how it is done. He had never done anything like it before. Within the week, he announced (over the internet) about the FUE technique he invented and his wonderful results from it. Now, when I meet that doctor I want to puke.

Nobody is without criticism and I am sure that some patients may not have reached their expectations with me as their surgeon, but setting up expectations is what I do and then the surgery is just a fulfillment of meeting those expectations. I show patients off every month at my office in Los Angeles and the experience of sharing has been central to my entire practice strategy.

Hey Doc, generally speaking where does the donar site begin and how much donor hair do I have. It obviously ends in the back of the neck. But where at the back of the head does it start, speacially if your a early norwood recipient.

This answer is going to be a little long and technical, but hopefully some find interest in this…

Donor Area:
The donor area is always the rim of hair that is seen in the Norwood Class 7 patient (see art at right). It starts at the occipital prominence of the skull (back of the skull) and goes up in the midline to a height of about 2 1/2 inches. It runs from the temple prominences by the forehead from one side to the other. The total measurement depends upon the size of the head. Large heads might have a 15 inch measurement from temple prominence to temple prominence and let’s say 13 inches to be safe, of which 1/2 inch on each side is not usable because any hair extraction from that close to the forehead will show as a thin donor area or a scar from the frontal view. So if you were to harvest the donor area (either by strip or FUE) the donor area would measure 12 inches long multiplied by 2.5 inches high or 30 square inches of scalp in a person with a typical size head. Half of that 30 square inch number would produce 15 square inches of usable donor hair. Each square inch in a Caucasian’s scalp with average hair density contains 1250 hairs which if multiplied times 15 square inches (half the donor area) would give 18,750 permanent movable hairs or in theory 9,375 two hair follicular units (grafts). I know this estimate is high, because the side rim of the donor area usually has a lower donor density than hair in the main part of the scalp.

Density:
We must really talk about the amount of hair that must be left behind after harvesting not the hair we are going to take out. In the average Caucasian with average hair density, both residual and donor hair amounts are equal so that we will not be able to ’see through’ the remaining donor area after the maximum number of transplants are taken; however, the lower the donor density, keeping the 18,750 hairs in place (to prevent a see-through look) causes the surgeon a problem and in removing the donor strip, the remaining donor skin will almost certainly stretch, reducing the remaining density.

Hair Character:
When a typical Asian patient comes for a hair transplant, the removable hair is substantially reduced (it will leave behind 80% of 18,750 hairs or 15,000 hairs). Let’s go through the calculations again for a typical Asian patient with 20% less donor density than a Caucasian. The Asian patient would have 15 square inches of usable donor hair and 15,000 remain after the donor strip is harvested. The total supply of the donor area for the hypothetical Asian would be 15,000 hairs or 7,500 grafts. If we then go to a person of African heritage, that number reduces even further (densities in the African can average as low as 60% of a Caucasian’s density). The removable donor area will yield 11,250 hairs or 5,625 grafts. As the donor area is harvested, it will stretch, reducing the remaining density substantially for future procedures.

It should be evident to the reader, that the size of the bald area is a critical determinant (need vs availability), a conundrum of clear proportion as the real donor hair availability becomes apparent. The quality of the hair (thin vs thick) the character of the hair (straight vs wavy or kinky) and the color of the hair and skin (donor contrast between hair and skin color) must play a significant role in the art of the hair transplant and where to put what hair is available. Make no mistake, this is an art form.

Keeping Some Doctors Honest:
By the above calculations, the Asian patient or the African patient has substantially less hair that can be used for hair transplantation. These calculations assume that the looseness of the scalp is not a variable (of course this is not really true) and that scarring is not a problem (everyone scars to some degree and those that scar worse are in a difficult situation for taking larger number of grafts).

Maybe you will understand better why I get so angry when doctors say that they can transplant numbers of grafts that are in the stratosphere. Some of the recommendations I hear smell of dishonesty or a naivety of the doctor to the basic mathematics of the hair transplantation process.

Hi Dr. Rassman,

just wondering if you could place some images or a few examples of actual balding people of all the norwood scales say from 2 to 7, so all us readers can have something to refer to? So we can get a better idea of what stage were at.

Thanks!

There are over 300 different patients posted on the NHI website and they should each have the Norwood class listed. It’s not always easy to tell from just one angle, so be sure to click each to see more photos of that particular patient (and to see their hair transplant results).

Here are examples of each of the main Norwood classes:

Norwood Class 2	Norwood Class 3	Norwood Class 4
Norwood Class 5	Norwood Class 6	Norwood Class 7

Here are some of the variant classes: Norwood 3A, Norwood 4A, Norwood 5A, and Norwood 3V.

To see more patients, check out:

• Full Face Photo Gallery
• Hairline Photo Gallery
• Repair Work Photo Gallery
• Other (Crown, Temple, Female, Eyebrow) Photo Gallery

Hello Dr. Rassman, could you tell me what the difference between “thinning hair”, “Hair Loss”, “Miniaturization”, “Low and High Density”?

Also when people say poor nutrition, e.g. anorexia, zinc deficiency etc, causes thinned hair do they mean the shaft diameter of each hair decreases or hair falls out resulting in low density?

Thank You

“Thinning hair” means a person is losing hair (usually hair that is miniaturized - i.e. thinning of the hair shaft) and does not have as much hair bulk as they once had. “Miniaturization” of hair means that a person’s hair shaft is not as thick in one area when compared to another area as it should be in its normal/healthy state. It is normal to have around 10% of miniaturized hairs for people who are not balding that may reflect what we call vellus hairs, present in every follicular unit.

“Density of hair” describes how many hairs are in a given area of scalp. For example an average Caucasian male can have a hair density of 2 hairs per square millimeter of scalp (which translated to about 100,000 hairs on a typical head size). If it is found that the density is 3 hairs per square millimeter, than the person is said to have a high hair density (born with about 150,000 hairs on the head). Hair density is variable and may depend on the ethnicity or race of a person as much as the inheritance patterns. Caucasians are born with an average of 100,000 hair on their heads, Asians about 80,000, and Africans about 60,000. These numbers are just averages and do not necessarily apply to what you may have on your head.

I have received a job offer that seams to good to be true. I responded to and add for an administrative assistant listing and at the interview they offered me a position as a hair restoration technician. I believe that I am under- qualified with a Bachelor’s Degree in Music Business. Is it customary to only hire women technicians? How do I know if this job is legit?

Training for a hair transplant technician takes considerable time and to become proficient once the skills are learned, may take a few years. If the doctor has experience training technicians and you like the detailed work that is involved, then you can embark on this as a career move. I would hope that the doctor who offered you the position does not let you loose and expect that you will become an instant member of the surgical team, making many mistakes along the learning path. It often helps if you have some medical assistant training so you understand the sterile technique process.

Dr. Rassman. I have noticed that you have a fair amount of threads about bad transplant surgeons such as this one here, but you never say the doctor’s name. What is the point in posting this unless you mention the Doctor’s name so patients in the future will stay clear of this doctor and others? Without mentioning the doctor’s name, other patients will be subject to his horrible results.

I would love to mention the doctors’ names, but that would almost certainly bring me into court, something that I do not wish to spend my life doing (it might bring me to the brink of financial ruin with large lawyer fees just to prove what I said). I get angry when I see the mess created by many of these doctors, but alas, you must use the information in ways to become a knowledgeable buyer, so I use this blog to call people’s attention to what they need to look for when engaging a doctor’s service for a hair transplant.

In 1994, at a medical meeting that easily had 400 physician in the audience, I rose to the microphone and openly referred to the sleaze in this business, with doctors low balling patients and deforming them without telling them the risks to hair transplantation (giving them proper informed consent). The surgical results before 1994 were often deforming and pluggy. These, in hindsight, were very substandard when compared to today’s artfully performed hair transplants. Many doctors would not enter the business to perform hair transplants because of the deforming nature of the surgery at that time. One doctor, in particular, was my target and when I exemplified this sleazy, dishonest doctor without mentioning his name (I called him a “crook” in the true sense of the word), the audience responded with a standing ovation for my being so outspoken, echoing my message. At the end of the session, I was surrounded by many doctors congratulating me on my outspoken comment. One doctor (the one whose name was never mentioned) waited for the crowd to clear and approached me with great anger, saying that he did not appreciate my calling him a crook. As I never mentioned his name, I said “If the shoe fits, wear it” and walked away.

Dr Rassman,
You may or may not have seen this post on the online forums that you visit. Dr Shapiro was the only Dr to answer these questions and as a reader of the forums i wanted to see if you would answer them about NHI?

Do all NHI’s surgical technicians have valid, unrevoked, or unsuspended certificates/licences? Do they place the grafts in the receptor sites during HT surgery? And if they do, Is The surgeon in the room all the time with his HT patient,supervising that process of grafts transplant?

At the New Hair Institute, our technicians were all internally trained by me. They are not certified by any state agency. If you check with Dr. Shapiro, you will find that I was the doctor who trained him in FUT. Our technicians do both cutting and placing of the grafts and the surgeon is either in the room or close by checking on the progress of the technicians frequently. As these technicians have been trained by me, I know what is happening at all times. I am supervising everything that goes on before and during the surgery. Either Dr. Pak or I usually see the patient the next day when we wash the hair and make sure that the scalp is clean of all crusts (mostly done on the day of surgery).

The quality of the technicians determine the results you will get after 8+ months have passed. I recently met with a patient who had over 4000 grafts from an experienced doctor (at another clinic) with what I suspect was a very weak and inexperienced team. When I viewed his results 1 year after his procedure, it was evident that there was easily a 90% failure of the grafts to grow. If the surgeon does not have absolute control over the technical process minute by minute and the technicians and nurses are not very experienced, these large sessions often fail. Here I am just questioning the quality of the technician work in this particular patient. Many doctors have difficulty in hiring experienced people, particularly if they attempt these large sessions and hire inexperienced people. The sloppy work by many itinerant technicians reflects poor training and the patient becomes a victim, never aware of what is happening to him. Even the technicians are victimized by the heavy workload of a very large surgical case and few can manage the tedious work for hour upon hour (e.g. often 7-9 hours for a 4000 graft case with a highly experienced and competent team).

The tragedy here is not just the wasted money (for many people their life savings) but the depletion of the donor hair supply (an invaluable and non-replaceable resource). I warn patients all of the time that as they do their diligence, they should command the ‘team’ nature of this surgery and not go for the least expensive bargain available. This patient paid $2/graft and lost a considerable amount of his donor supply. To say he got what he paid for would be insensitive on my part.

Dr. Rassman,

Thank you for answering my last question. I have one more for you, if you do not mind.

I mapped my own scalp for miniaturization per your instructions, and found it a very useful tutorial, though I took a nod from a recent entry and snipped a few bits of hair from my head instead. I compared 5 locks of hair from all around my head (temples, forehead, crown, donor area) using my donor area as a control, and to be perfectly honest I could not see a difference in the hair shaft width between any of the samples. Unfortunately I do not have equipment to give hard numbers, but my hair does not seem any less pigmented or thinner in any of the areas compared to my donor zone. I examined it under a magnifying glass, but have access to a microscope if that is insufficient.

I’ve also visited a dermatologist. He did not have the equipment to map my scalp but he said I was a NW2 and was fine.

That said, how often do you suggest this process be repeated? Every three months? Six months? Yearly? Is there a certain age after which you can just stop as there is unlikely to be further progression?

I am 26 with no known male-pattern baldness in my family; both grandparents died with Norwood 2 patterns, and none of my uncles have any hints of balding.

Thanks!

I am assuming that the mapping showed no significant miniaturization. If that is the case, once a year mapping or more frequent mapping may have value if you think that the problem may be appearing or getting worse. The mapping exercise is best when comparing:

1. The hair in the back of the scalp (donor area) with hair elsewhere on your head, or
2. Hair within various local areas with hair-by-hair comparisons where the miniaturization shows up well

As for age, some men will lose hair in their teens, some in their 20s and 30s… it can even happen in the 40s and beyond (though it’s less likely). You might be one of the lucky ones and not have any hair loss problems, but I really have no way to tell at this point (and without at least an exam).