We now know that there is a gene that contributed to Alzheimer Disease. It is called ApoE4 and is found roughly in 15% of the population. Although males carrying the gene are only slightly more likely to get the disease, women had a 180% increase in the incidence of those carrying the gene. The gender specific nature has not been explained. Why am I writing this for a Hair Loss Blog is because we all have parents and you might find that this information becomes valuable if your parents are over 60 year old.
I was looking at Dr. James Harris’s website and noticed some research he has done with new instrumentation for his SAFE System. I e-mailed him and asked if he planned to try to get this published and I have not heard back from him. Is there any data on the industry average of transection rates? Here is some of what his research stated according to his website:
“In the study by Rassman, Bernstein, et al, 20% of patients were “not” good candidates for FUE due to the high rates of follicle damage. Dr. Harris’ Safe System is being used by many doctors as a tool for FUE. It uses blunt dissection. It was this technology, that was adopted by the Artas® system and incorporated into their FUE protocol.
“Discussion/Results: Over 40 patients have been subjects of this new methodology and instrumentation. The range of grafts extracted in this series has been between 50 and 1400 grafts. Transection rates of hair follicles have ranged from 0% to 8% thus far. All patients so far would be considered candidates for FUE using the SAFE System, as the follicle damage rate is less than 20%. The rate of follicle extraction has been as high as 300 grafts per hour. A test case on the extraction of 20 grafts each on an African American patient and a gray haired patient revealed a 0% transection rate.”
Conclusion: The SAFE System has the capability to expand patient candidacy for FUE to virtually 100% of patients, including African Americans and those with gray hair.
Dr Harris is my friend and he is a great surgeon. He has devised a powered blunt punch technique which seems to solve the transection problems in the hands of many doctors. There is no data on the industry average of FUE transection rate. My publication with Dr. Bernstein is the only publication I know of and in my opinion the true industry average for transection is probably more than 10%. It’s just that nobody will ever admit to it since it will kill their business. In my practice with Dr. Pak (in which he performs most of the FUE procedures), our transection rates range from 3 to 10% (depending on the individual patient’s hair/scalp characteristics). In the past, we have disqualified patients who were poor candidates (produced transections above 10%) as we test them prior to the scheduled FUE surgery.
In my humble opinion, there is no such thing as 100% success or 0% transection rate. Only thing 100% in this world is death and taxes. Transection rate is not necessarily the golden standard, as damage to the hair grafts occur when they are removed and probably cause more damage than a transection rate of 10%.
I have a question about DHT that just occurred to me.
DHT is, at this time, considered to be the main cause of male-pattern baldness. If this is really the case, could you please explain the following …
DHT levels are highest in early adulthood and gradually decline with age, yet most men do not suffer from hair loss until later in life (when their DHT levels are much lower).
If DHT is really the culprit of hair loss, why does most hair loss in men seem to occur about the same time that DHT levels are declining and stabilizing? It really makes no sense to me.
Your statement is false in that GENETICS is the main cause of male-pattern baldness (MPB) otherwise referred to as genetic balding or androgenic alopecia (AGA) and when you have the balding gene, it is the hormone dihydrotestosterone (DHT) that causes the hair loss process when the gene for hair loss is present. There may be other undiscovered hormones and mechanisms but DHT is the one hormone that we know about at this time.
In addition, if you have the genes for balding, most men lose most of their hair in your 20s and early 30s. Of course there are exceptions to the rule, but chances are if you ask a bald man (e.g. Class 7 pattern of balding) when he started to lose his hair, he would likely say in his late teenage years or his early 20s.
DHT is a byproduct of testosterone metabolism and it is true that young men have more testosterone and DHT than older men but testosterone or DHT levels don’t cause the balding process… GENETIC predisposition does. Perhaps many people are confused on this fact because it’s sort of like a chicken or the egg dilemma. Does DHT trigger the balding, or does genes trigger the balding? (Answer=genes) Men start balding process in their 20’s and 30’s mainly because that is when their genetic destiny is triggered by DHT. If a man did not have testicles, he would not make DHT and therefore, he would not bald even with the gene for balding.
It is thought that about 50% of men have the genes for some degree of male pattern balding. About 7% of the men have total Norwood 7 balding. The life of a hair is dependent on the genetic timing of each hair’s life and in the pattern of genetic balding. In some patterns, the frontal hairs my die first (in men), in other like me (Dr. Rassman) the hairs in my crown died and my frontal hairline was never impacted (because that was the results of the genes I inherited). The life of a hair follicle relates to how many cycles it has (probably programmed genetically) and the death of that hair follicle occurs when the number of hair cycles is reached. So, for example, if a hair located in the front of the hairline has a 3 year hair cycle and the genetics have programmed 10 hair cycles, then that frontal hair will die when that person reaches 30 years of age. This is impacted by the presence of DHT in genetic “death” of a hair follicle (apoptosis). Without DHT (which can be partially blocked by finasteride), the number of hair cycles may actually increase beyond its programmed death. This is probably a simplistic way of explaining the number of hair cycle that exist for all hairs on your head, but the main point is that GENETICS determines hair loss and DHT is the precipitating cause when the number of genetically programmed hair cycles are reached. Because it is the genes that cause hair loss, the presence of DHT impacts only those genes when the per-programmed hair cycle is reached for each hair.
For men without a genetic inheritance of male pattern baldness, it does not matter how much DHT you have (or don’t have), balding will not occur. The classic case that exemplifies this is a case of twins, where one of the male twins was castrated in his youth for mental illness (a situation that shamefully occurred in the early part of the 20th century). The story goes that the non-castrated twin (who was bald) came to see his brother in the mental institution and saw his ‘hairy’ counterpart. The doctor was amazed and performed an experiment on the hairy, castrated twin. He was given testosterone (which was turned into DHT by the hairy twin’s body). Guess what? He lost his hair just like his bald brother. This final story may spawn new questions on why we don’t take medication that block DHT 100% or take stronger DHT blocking medications such as avodart (Proscar) to treat male pattern balding. It is mainly because once the genetic switch is turned on, you cannot stop it and blocking DHT 100% might slow the process down and may give you unwanted adverse side effects. I doubt anyone would volunteer to be castrated. The only exceptions are transgender males going through hormone therapy and sex change operation/ castration.
Another patient with SMP to the old hair transplant scar. While the scar itself is not the worst we’ve seen, it defiantly shows when the hair is cropped very short. You can see the SMP results after the 2nd SMP procedure. Note the slight redness since the photo was taken immediately after the SMP.
I recently performed beard and sideburn transplants on this African American man who did not have complete facial hair due to a genetic issue. I have been asked many times about this problem, so I thought I would show photos from the day after surgery. He received a total of 769 grafts (each side got about 380 grafts) to create what you see in these pictures. His natural curly hair made the results look better than if his hair was straight. Black hair on dark skin also helped.
This is a comment from our regular reader/ occasional contributor -BiotechMD- (who is actually a medical doctor involved in many clinical trials and research) I thought I’d post a third party opinion since so many readers and patients are concerned about Propecia and sexual side effects and are quick to blame a side effect over a common issue (that they may not want to admit).
While conducted a number of years ago, one of the largest studies of the incidence of erectile dysfunction (reference below) puts the rate at 40% for men in their 40?s. Given the multiple causes of erectile dysfunction (atherosclerotic disease, diabetes, medications, psychogenic) and the increasing risk of these factors with age, this is not too surprising. There is no scientific evidence in the published medical literature that the erectile dysfunction associated with finasteride is of a different “quality” than other types of erectile dysfunction or that the “whole sexual response is diminished”. Decreased sex drive can be a side effect of finasteride in a minority of patients and even fewer still (<2%) will have both erectile dysfunction and decreased libido. Feldman HA, Goldstein I, Hatzichristou DG, et al: Impotence and its medical and psychosocial correlates: Results of the Massachusetts Male Aging Study. J Urol, 1994;151:54–61.
Hello docs! Thanks for an interesting site.
I’ve been wondering: Will finasteride have any effect in use when someone has passed the age of – lets say 50 or 60, if one at that age has a full head of hair, or is only slightly thinning? I mean – is thinning at that age also related to dht miniaturization or is there a different mechanism then at work, just the ‘age cause’, but without the dht playing any crucial part? Or is mostly all thinning, whatever age (also diffuse thinning) caused by the effect of dht.
Propecia is a medication that is prescribed by your doctor for the treatment of androgenic alopecia. You can be 20 years or 70 years old as long as you were diagnosed with male pattern balding or androgenic alopecia. The doctor should be able to prescribe the medication for you. The key to determine when the drug Propecia (finasteride) might have value, is the presence of recent hair loss. I’ve had patients who start the medication at between 50-70 years of age who recently lost hair as a result of a delayed appearance of some undiagnosed hair loss pattern that took that long to makes its appearance. When there is recent hair loss, the results can still be good, even for a 70 year old.
I have thinning at the crown and can cover up with a concealer quite nicely. I was wondering how effective would a permanent concealer like SMP compare to say Toppik? It seems SMP would be much less of a hassle but would it look comparable?
Scalp Micropigment is a permanent concealer similar to the temporary concealer like Toppik or Dermmatch. SMP goes on the scalp but Toppik and Dermmatch also goes on both the scalp and on the hair. Toppik and Dermmatch will make you hair “feel” thicker. SMP will not. But the overall coverage and cosmetic value will be about the same. SMP is permanent and it will not rub off on your hands or pillow. If you want to see people who have had SMP to cover the top, just visit our monthly Open House Events.
Taken from MPR Daily Dose: “Previous research has suggested that regular aspirin use may lower the risk of certain cancers like pancreatic and colorectal cancer, but it could take as many as three years for this beneficial effect. An Annals of Oncology review of the effect of aspirin for site-specific cancer incidence, mortality, and cardiovascular events found that the effects of aspirin on cancer were not evident until at least three years after aspirin initiation. Some of the benefits were even sustained for several years after cessation in long-term users. Higher doses of aspirin did not appear to lead to additional benefits, nor were differences between low and standard doses observed. Individuals 50–65 years of age with average risk who took aspirin for 10 years saw a relative reduction in risk of 7% for women and 9% for men in the number of cancer, myocardial infarction, or stroke events over a 15-year period and an overall 4% relative reduction in all-cause mortality over a 20-year period. Additional research is needed for optimal dosage and duration of use and identification of individuals at greater risk of excess bleeding (the most important harm linked to aspirin use).“
I have been taking daily Aspirin for over 25 years. No cancer yet!
Over and over again, we see the value of Aspirin for such diseases as heart disease which is protective against a heart attack, prevention of cancer and here the prevention of stroke. I am amazed how few people pay attention to this simple use of one pill per day. This is not rocket science, it is just common sense.
I am suffering from hairfall problems for over one year…recently I suffered from chicken pox, after which my hairfall problem aggravated…kindly suggest some for how long the hairfall will continue after chicken pox??
I doubt chicken pox caused the hair loss (hairfall). Certainly medical illness and stress can cause hair loss, but after the stressful event that caused your hair loss pattern to appear, I would expect some stabilization of your hair loss pattern after a year. If you are male, the most common cause of hair loss is genetic androgenic alopecia and the stress of chicken pox may accelerate your genetic pattern.
Hello Dr. Rassman,
I was wondering whether you thought that there was any merit in the following theory which explores the relationship between hair loss and progesterone/cortisol levels.
Thanks and keep up the good work!
Theories that reflect excess free radical damage are abundant. We really do not know enough about the free radical impact on hair. I would ask why some hair is impacted and not other hair. If the genetic issues that relate to defects in the formation of the hairs is explained by the missing progenitor cell theory, maybe there is more logic in the application of the theory. It makes for interesting reading and I would let the readership make up their own minds (read here: https://journal.frontiersin.org/Journal/10.3389/fcell.2014.00010/full).
I have a lot of thick dark hair on the nape area of my neck. If I were to have a large strip procedure, could I then have the nape hair planted via fue into the strip scar so I could wear my hair short?
You can do this, but you will have to wait until the scar forms and heals (6+ months). If you are worried about wearing your hair short and scarring, why not just do the FUE procedure instead of the strip as that will obviate a linear scar? Keep in mind that neck hair does not behave like scalp hair as it is not permanent in many men as they get older. Anatomically, the neck starts below the skull, so if your feel the scalp and the skull beneath, and then move down, the nape of the neck is encountered without the skull underneath it, just muscle. As I said above, ask your doctor about doing an FUE for the entire hair transplant.
I’ve tried taking Fin twice now and both times have developed chest pain, I wonder if this is coincidence or an actual side effect. Unfortunately I live abroad in a rural village, and don’t have access to medical care.
The first time I took 1.25mg each day for about 2 weeks, and then stopped because of the chest pain. The second time, about 3 months later, I took .625mg every other day, and developed pain after a week (4 doses).
The pain can appear at any point on my ribcage, most usually along the outside of my sternum where the pectoral connects. Commonly under my pec, just inside of my nipple as well.
I’m wondering if this could be the onset of gyno, although I haven’t experienced any nipple sensitivity or pain.
Finally, it’s worth mentioning that I go to the gym 4x/week and am taking a generic version of Fin produced from a pharmacy in Costa Rica.
What you are describing is very unusual and I don’t have the luxury of examining you in person or taking a detailed medical history. You need to talk with a doctor as the cause of your chest pain may be something more serious than a simple side effect of a drug. Finasteride can cause gynecomastia in rare cases but that should not cause chest pain.
This blog is great for answering questions always and thank you for that. Im a 30 year old male with thick hair wavy hair. I slicked back my hair the other day and saw that theres a part were it looks thinning. I went to the dermatologist and he told me that its a part that I’ve always have had and sometimes the parts look like there thinning because the hair going in different directions. Is this true what my dermatologist told me? He is one of the top in the state to let you know how good he is. I also took pictures with my iphone and parted my hair to look if the diameters are different in the hair from others I saw some that were diameter of hair thinner looking and most were not.. I told him and showed him and he said this was completely normal on non-balding man and that I was stressing out about nothing. Does taking pictures with iphone close up prove that if you see some hairs different form others you have miniaturization or could it be normal? Is it more accurate to do it with a digital microscope ? He told me I had no signs of male pattern baldness or thinning and I have a full head a hair. I was happy with the visit. I also told him about the Haircheck device and he said that he heard that device can be accurate but it could be normal even if you had a small amount different from the back donor hair like 6% could be normal for a non-balding man too. What percentage would be normal for a non-balding man with the hair check device from the donor hair to the hair in the front region? Thank you so much for always reading as many emails as you can and I hope to hear back from you soon! You can post this on your blog too.
You can always take photos with any good camera to see if there is a change in hair but that would be very subjective on how you take the photo and over a relatively short period of time, it may not have much value. Things like combing style, hair length, the lighting, the style or part of hair, the angle, etc. are significant variables that ten to confuse an objective viewer. We try to objectively quantify potential true thinning with the Hair Check device which will give a clear measurement when compared with the donor area, Microscopic devices to determine the degree of minaturization for comparison purposes, with analysis also helps region by region. These measurement are also variable and about 10% difference is within the margin of error but as the areas are very small, finding the same spot over and over again over months is not reasonable to document change. I don’t think most people would care about 1 to 2 % change in hair density or hair bulk. What meaning would it really have when no one can see it?
Finally when you part your hair, you will naturally see scalp when the contrast between your hair color and your skin color is high (e.g black on white). This present in normal, non-balding adults when you comb your hair. Many people comb their hair to take advantage of the natural part and if they are balding, exploit comb-overs to hide thinning. Yes, your dermatologist is correct, that a subtle change in hair growth direction usually shows the scalp.
Thanks for donating your time to this great site! I have been taking proscar for ages side affect free but lately I’ve noticed a few. I’m also in my 40’s now too mind you. Question is, how long would I have to stop to see them possibly go away? Also if you say a month or something, would that be enough time for me to start a catch up hair loss phase? Please let me know your opinion. I really appreciate it
This is something you need to bring up to your primary doctor or the doctor who prescribed you the medication. Side effects you are attributing to the medication may be something totally different and you may have other health related issue. If it is a sexual side effect, many men in their 40’s have sexually related issues just due to age itself – as high as 40% of men who are not on Propecia (finasteride).