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I have ceased to be amazed by the vast amount of information this site provides to all of us hair-obsessed patrons–Kudos to you balding blog!

My question is pretty simple (i think):

How soon is one able to tell what Norwood class he will develop into? Put another way, if you’ve been mapped for miniaturization, how accurate an assesment is this of your final balding
pattern?

I think I understand your question. You want to know if the mapping of your scalp for miniaturization will indicate your eventual hair loss pattern? The mapping of miniaturization will show you more about your balding pattern than you can see with your naked eye. Most likely, you would progress to a higher Norwood classification if there is miniaturization in the areas which appear hairy and the more miniaturization present, the more likely your balding will extend to those areas. You may not completely bald in the areas where miniaturization is present and if you took drugs, that may be more likely then if you let nature take it course. If you did nothing to arrest the process of MPB, the likelihood that you will see a more advanced pattern is high. But if you use medications like Propecia, you will be slowing down the process. If you’re looking for a numerical value to show the accuracy of a hair loss pattern, I unfortunately don’t have one for you.

Hi, I believe I asked a question some months back but you only responded by asking me to come in for a consultation. So, let me try to get into specifics before considering coming in. I have been undergoing some stress lately and noticed thinning of my vertex. My hairline is completely unchanged… same as it has been since high school. I am also underweight for my height. Male, 28 years old 6′2″ 160-165 lbs. I have been underweight for the last 4-5 years. My average weight was 180 lbs in the past but have been eating less due to shortage of time and decreased appetite from work, plus I exercise 5-6 days a week. Also, my protein intake has fallen drastically.

I am contemplating whether I am experiencing MPB or Telogen Effluvium. Few months back I noticed a lot more shedding from the vertex area, mostly in the shower. I would pull at my hair and more than 4-5 strands would come out at a time and would not stop until I have pulled out an average of 10-15 strands. This happened every morning in the shower. It has somewhat slowed down, but now I am seeing some hairs come out that underwent miniaturization. Maybe I am experiencing a combo of both Telogen Effluvium and MPB. But has there been cases where men only experience balding in the vertex only?

My father is balding at the age of 59 (typical horseshoe). My mother’s side shows no signs of hairloss from anyone. He informed me that he experienced loss in the front first. If I inherited his baldness, would I follow his pattern?

Detailed feedback would be appreciated. Is consultation by appt only?

Yes, consultations are by appointment only. Your case, like many, are not as cut-and-dry as you’d like it to be, so it would be difficult to just make random assumptions about your hair loss without an exam. I’m not trying to “rope” you into coming in, but I’m also not trying to steer you in the wrong direction. This does require an exam, which can and should be done locally. When I see a patient for the first time (let’s say you, for example), I would plan on spending an hour with you, which gives me time to:

• Get to know you
• Listen to the problem you will be defining
• Examine your scalp and hair in detail
• Discuss a ‘plan of attack’ based upon a Master Plan we would setup to manage your hair loss problem

MPB can be limited to only the vertex (crown), or it may start in the front and progress backward. Genetic hair loss generally occurs in patterns (see Norwood Chart). Telogen effluvium, on the other hand, would be diffuse and not only limited to a patterned area.

If you’d like to setup a free consultation, you can either call my office at 800-NEW-HAIR or fill out the form on my site to Request Additional Info and someone from my staff will get in contact with you.

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.

Dear Dr Rassman, with respect to the miniaturization mapping, it seems that many of the dermatologists I’ve visited in Canada don’t know what it is or if they have heard of it they think it’s hogwash. What’s a guy with MPB to do in this situation? I REALLY want to find out how much and where the miniaturization has occurred on my scalp! Is there another method beside using the densimeter to get an accurate assessment of my balding?

Thanks!

I can’t force doctors to use microscopic evaluation of the scalp to determine degrees of miniaturization, but the mapping is certainly the best way to determine degrees of hair loss, rather than having your doctor essentially just eyeballing the problem. Perhaps you could/should print out our this page — Miniaturization and Hair Loss - More Than Meets the Eye — and give your dermatologist a copy of it.

You might even suggest your dermatologist buys a pocket hand-held microscope (see photo at right for an example) so that he/she can can make a diagnosis. Between the hand microscope suggestion (which runs about $8-15 and is sold at Radio Shack in the US or various online stores) and the sheet of paper you will bring your dermatologist, he/she should be appreciative.

Most charge by the graft. I was wondering how much hair is a graft? Or is it just one hair? I was also wondering if you can transplant hair in places where it previously didn’t exist and how does that process work. I mean when you put the hair in a certain part, how does it just start growing? Also, is it permanant. And if you have no facial hair, can you transplant hair there? Will it grow like normal facial hair or after the first shave would it not return? Also, what happens to the hair that were taken from the back of the head, does that return to normal?

“Graft” can be defined as: living tissue surgically transplanted from its normal location in one part of the body into another part of the body in the same individual (an autotransplant, like hair or bone marrow transplants) or from one individual to another individual (like a kidney or heart transplant) and is expected to grow and function normally in its new location.

In hair transplantation surgery, a graft refers to a unit of hair or a group of hair follicles which naturally cluster together (a follicular unit) consisting of one, two, three, or sometimes four hairs. Typically, a graft equals or averages to about 2 hairs (see photo at right of average density, from the article Follicular Transplantation: Patient Evaluation and Surgical Planning?), but in individuals with very high densities, it might average as many as three hairs per follicular unit.

Hair (usually from the donor area of the scalp) can be transplanted to any part of the body, including the bald part of the scalp, beard, mustache, or eyebrow. It can even be transplanted to the tip of your nose and it will grow to as long as 6 feet (assuming that the growth phase of the hair lasts as long as 6 years or so)! The donor hair that was taken from the back of the scalp will not regenerate and you will then have either a small linear scar from where the strip of scalp was taken, or a series of small dot scars from where the graft was removed by FUE.

Prior to the 1950s, people incorrectly thought that the balding process was a result of a loss of blood supply, because the skin of the bald scalp was not flush with blood vessels, though that notion was killed by clinical scientists who showed that it was a genetic process, not a blood supply process. It was a relatively simple proof. If there was a blood supply problem, the transplanted hair would have died. Instead, the transplanted hair placed in the bald scalp grew well and the blood supply returned to supply the needs of the new hair at its new location.

Dr. Rassman, I’m surprised no one else has raised this issue with you given the activity on various hair transplant discussion boards during the last few months. My question concerns the quantity of grafts in the donor reserve.

On these boards, I see a new trend of very young men wanting high density transplants to restore their juvenile hairlines and being transplanted under the assumption that they have, *on average*, 10K-15K grafts available via both strip and FUE. When the blarney of the clinic(s) making these graft count claims is questioned by more critical posters, the young men in question usually get very defensive and end up expressing their confidence in their doctor(s), and say that even if such estimates are exaggerated, surely some new drug, or hair maintenance, will come along to help them by the time their balding progresses to the point of making their transplants looks unnatural.

Since you believe in documenting scientific findings and have published the pathbreaking papers in this field, do you feel that these young men are being sold a false bill of goods? Can any clinic in good conscience be promising to be able to harvest twice as many grafts as we previously believed available? Has there been some breakthrough in graft harvesting capabilities that the laymen has yet to hear about? And should hope about the availability of future technology being able to benefit patients ever be part of a Master Plan?

You raise a very good point and concern. A typical hair transplant procedure of an average male with good scalp laxity will yield 3000 to 3500 grafts in Caucasians (who often have higher densities than Asians). The most that we were able to yield in one single surgery was about 5800 grafts from a patient with a very high donor hair density and good scalp laxity. This was the exception to the rule, of course. Some doctors split the ‘follicular units’ into smaller units and then charge the value of the ’split’ number. So if a doctor got 3000 grafts, by dividing the grafts into smaller units, he/she may be able to charge for 5000 grafts and give the patient a feeling that he got more than he really did.

Thus, I very highly doubt that any clinic can yield 10,000 to 15,000 grafts in one procedure. They may be cutting all these grafts (which contain one, two, three, or four hairs) into single hair grafts. See my recent post titled How Do I Know I Am Getting the Number of Grafts I Am Paying For?. I feel strongly that splitting grafts to make money from patients is highly unethical and desperate patients are ultimately paying a price -– not only in financial terms, but in a lifetime of potential disfigurement from a depleted donor supply.

Hello doc,

over at the hairlossadvances.com I read the following lines from one of the most serious posters over there:

“The actual surival and yield percentages of the strip compared to the FUE will vary from patient to patient based on pysiological characteristics but, strip will out-yield fue every time”.

If this is true, how much weaker is the FUE?

It depends on what this poster means by “yield“.

If the question is strictly about the number of grafts (yield), then you’re correct — the strip procedure is far more efficient in the yield when compared to FUE. If you mean long term survival, then I would say that the answer is tied to the organization of the team of technicians and surgeon. If you mean the ability to come close to 100% hair by hair yield, I believe that strip harvesting yields 95%+ hair for hair yield, while FUE is often less than that. In other words, transection rates with strip harvesting are usually very low (under 5%), whereas FUE transection rates can run as high as 90% and as low as 5% (depending on the skill of the doctor and the collagen make-up of the patient).

Looking at the old school method doctors used to perform hair transplants, with those really “pluggy” looks, Im curious as to why ANYONE in their right mind in the eighties would go in for that procedure! Was it ever done well?? I mean it really looks like crap and nothing like natural hair. Do you have any photos of one of those procedures done relatively well? Just curious. Thanks, really enjoy the blog!!!

They didn’t know any better back in those days. I know we’re only talking about 20-25 years ago, but technology is an interesting thing. One might say that there was so much excitement to get hair on a bald head, that men did not use their brains. Or that doctors were so trusted in those days, that when a doctor recommended hair plugs, everything was followed like the sheep to the slaughter. It may seen archaic now, but it was the state of the art back then and most men had plugs put into thinning hair so that they only saw more fullness — that is, until the hair all fell out around the plugs. There was a logic put together by the doctor that one could put the hair back in quarter sections, like a checkerboard with four squares. First you transplanted one square than the second, then the third, and then the last. In theory, the doctors and the patients wanted to believe that when all four squares were filled in, the hair was full. But reality took on another face, and the doctors started to push ‘touch-ups’ to fix the pluggy appearance of the rows of corn that grew on the head. It was not unusual for a patient to have 10 surgeries to get their hair back, but that was never a real possibility. I don’t know where common sense played a role and the men walking around with ‘doll’s hair’ were becoming more and more prevalent. Celebrities were leading the way and people like Frank Sinatra became the model that everyone wanted to follow (he had a pluggy transplant), but he really looked awful so he wore a wig and people thought that was his hair transplant, an illusion that doctors profited from and patients wanted to believe. It was an embarrassing con game perpetrated by the medical profession.

Have you seen the old Atari video games back in the 1980s? It was the best back then! Unfortunately, just like the Atari video games of the 80s, the results of the old plugs are not as impressive when viewed today.

Doctor Rassman,

Two years of immersing myself in your blog and other medical literature has cultivated in me a real passion for the study of hair loss. I am still a college student and would like to know what academic decisions would be important for me in laying out a career path in hair research.

To be in the field of hair loss treatment and hair transplantation, you can either be a nurse, technician, or be a doctor. To be a hair transplant doctor you need to go to medical school (4 years). Afterwards, you need to finish residency (3-6 years). You can choose any residency such as dermatology or surgery. After the residency you would need to finish a fellowship (1 year) specializing in hair transplant surgery. If you wish to get into the field after college, send us an application. We train technicians, which can earn you a very good living when you are good at it. If you are considering pure research, you can major in biological sciences and pursue a graduate degree and specialize in the stem cell research and cloning.

Reprinted from the New Hair News, Vol. 12, 2007.
Click here to request your free copy, included with the “complete information package”.

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People always ask, “How many grafts will I actually need to have transplanted?” Time and time again, that graft number answer will vary by doctor. When a doctor recommends a certain number of hairs/grafts, the doctor’s experience and his/her artistic skills are used to estimate what it might take to fill in the balding area with enough fullness to meet the person’s needs. I have seen estimates that could be a four fold difference and when you are shopping for a hair transplant, the differences in the estimating abilities of the doctors can be very unsettling. Who do you believe? Clearly you want to believe the doctor who has the lowest estimate for hair moved (transplants are priced by the graft), but then you are locking yourself into what might become a never ending series of hair transplant surgeries with an unrealistic amount of hair transplanted that may not meet your goals.

Does your doctor have the necessary artistic ability, not just to estimate the number of hairs/grafts, but also to take advantage of the hair supply to create a distribution that maximizes the value of the transplants for the most fullness? We have put some factors together to address how a surgeon actually calculates the numbers of grafts. These factors may not apply equally to all people. No two people are the same. The various factors like the thickness of the individual hair shafts (coarse vs. fine hair), the character of the hair (curly vs. straight hair), the color of the hair and the skin (the closer the match, the more full appearance of the hair), and any special needs defined by the patient, make us very different. On white skinned people, those with blonde hair have a fuller look while those with black hair will have a more ‘see through’ appearance. The blonde haired man, the very fine haired man, or the very bald man who has a hair supply that might not be adequate to cover the bald area will be different in their needs for fullness. When the calculations are not clearly evident, it is the doctor’s art that saves the day to maximize the value of the hair transplants that are received. We generally try to restore 25% of the original hair density in a ‘typical’ patient. Some people may require more than 25% of the original density and if you are one of these people, you should understand what you need and why you need it. Even if the overall achieved density is 25%, some areas may require more and some less than 25%. In people with fine or dark hair and light skin, a higher density than 25% of the original density is often required. In blondes with fair skin, less than 25% of the original density might meet the ‘fullness’ requirement. This is critical, because you look for fullness in the end result of the transplant process and it is the doctor’s art that addresses just how that fullness is to be achieved. Keep this in mind as you look to the analysis below.

The math for estimating number of grafts needed for a bald area:
We have proposed a 25% rule, which means that the balding person can go from a completely bald area to 25% of the original hair density that was there prior to the balding. The following calculation also assumes that the person used in this example has an average density of 2 hairs/mm2 (average density of a Caucasian). Every person is different, so the final number of grafts that will produce the fullness that a person wants to achieve (and can afford to purchase), are independent variables. These calculations were originally defined in a classic medical journal article written by Rassman in 1993 (Rassman, W.R.; Pomerantz, M.A. Minigrafts, the art and science. International Journal of Aesthetic and Restorative Surgery. 1(1): 27-36; 1993).

by William R. Rassman, M.D. and Jae P. Pak, M.D.