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HeartYesterday, 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.

Tags: hairloss, hair loss, chest, pain, indigestion, outpatient, surgery, heart attack, heart disease, disease, procedure, transplant


HaircutI 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.

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

Hair System Costs By Month

2000 2001 2002
Jul $3031.00 *
Aug $65.73
Sep $199.80
Oct $95.00
Nov $120.72
Dec $139.38
* Initial cost for 2 systems
Jan $135.14
Feb $125.00
Mar $91.73
Apr $110.06
May $402.52
Jun $13.50
Jul $145.59
Aug $179.42
Sep $113.70
Oct $197.80
Nov $91.20
Dec $270.00
Jan $258.69
Feb $153.07
Mar $156.21
Apr $103.49
Jul $175.93
Aug $162.62
Oct $131.90
2003 2004 2005
Jan $101.12
Feb $105.00
Apr $146.25
May $183.27
Jul $87.86
Aug $138.69
Oct $176.39
Dec $282.35
Jan $204.58
Mar $172.63
Mar $2796.00 **
Apr $142.64
May $2589.06 ***
Jul $216.69
Aug $233.68
Sep $272.27
Oct $131.00
Nov $130.84
Dec $120.26
** 1/2 Deposit on a new system
*** Remaining balance on new system
Jan $240.89
Feb $120.98
Apr $112.00
Apr $128.05
May $78.50
Jun $155.29
Sep $113.41
Oct $209.50
Nov $99.50
2006 Grand Total (after only 5.5 years)
Jan $99.50



MouseLast 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.

Tags: stem cell, stemcell, hair multiplication, cloning, hair cloning, spinal cord, hoffman


Da Vinci RobotMy first cousin just had a diagnosis of prostate cancer. With my help, we explored his options. He is 67 years young and his father lived to 96, and many on both sides of his family lived into their 90s and 100s. This is important, because the decision on which treatment to take for the cancer depends upon your life expectancy. Many men over 70 are pointed to non-surgical treatments, because their life expectancy is in the 10 year range so the value of surgery over radiation (radioactive seeds) or “watchful waiting” is not clearly defined compared to the risks of surgery. You don’t want your surgeon to use actuarial tables alone in deciding whether surgery is right for you.

In my cousin’s case, we selected a radical prostatectomy with a new technique using the da Vinci robot directed surgery. The surgeon does surgery from another room, all through the use of telemetry and robotics. The surgeon most skilled in this technique is Mani Menon, MD, based at the Henry Ford Hospital in Detroit (my cousin flew from Washington DC for the surgery and will fly back out for the post surgery follow-up). Dr. Menon has personally done over 2,000 such surgeries and his complication rate is the lowest in the world. His extensive pioneering research and experience on nerve sparing techniques results in a lower incidence of complications, such as erectile dysfunction (ED), in particular, and incontinence. My cousin could have had the surgery done locally at much less cost with surgeons who had some experience (20 – 200 surgeries) with the robot. There is no substitute for experience. For more information on the da Vinci surgical robot, see

He just had the prostate surgery yesterday and said it was easy with no pain. He thought that the entire process was first class. Of interest, his older brother had the same surgery with a local doctor just a few weeks before and did not have as smooth a course with the surgery. I don’t know and can not say that this is an apples to apples comparison, but my cousin thinks it is. He is now 24 hours from his surgery and is already walking around and being discharged from the hospital as I write this blog. Had finasteride been around for 20 years and had he taken it, it may have reduced his risk for developing prostate cancer (better than a slick surgery, of course).

What does this have to do with hair transplantation? Unfortunately, hair transplant surgery is fast becoming a commodity as more and more doctors enter the business and drop prices to lure patients into their practices. If you were my cousin, would you accept a discount from a local, less experienced surgeon rather than pay higher fees and endure travel expenses and associated inconveniences? Does it pay to travel to get the surgeons who are the leaders in the field? My cousin thought that some years ago when he traveled cross country to California to have his hair transplant surgeries done at NHI.

Here are some questions you should ask yourself when choosing your hair transplant surgeon:

  1. What are the complications that one can experience from doctors who do not have experienced teams performing this type of surgery?
  2. Do you really know what you are getting and what you are paying for?
  3. Are the graft counts accurate?
  4. Do the doctors maintain a high standard on quality control while performing these surgeries?
  5. How many surgeons have you met with that show the results of the ‘local’ doctor’s surgery? It is better than seeing some of their “failures” walking around the city.
  6. Do you have the discipline that my cousin had to ensure that the surgeon that you select will do the best job the first time around? Unlike prostate surgery you never see the patient’s incontinence or impotence, but on a poorly done hair transplant, you have to face it in the mirror every day and if it is bad enough, so will everyone else (and few will tell you what they see).

Case in point, I just met with a patient who had a terrible hair transplant. I asked him about the doctor who did it and he told me that the plastic surgeon who did the procedure was a relative of his and was willing to do the transplant at no cost to him. He thought he got the deal of a lifetime. This is a family connection that is now in trouble. Some plastic surgeons who do not have substantial training in hair transplantation and do not have an experienced team working with them, will fail at getting the results that are possible. There are no real bargains out there, and often, the old saying ‘that you get what you pay for’ is hard to learn.

Tags: prostate, davinci, da vinci, robot, prostatectomy, menon, nhi, hairtransplant, hair transplant, surgery, surgeon, hairloss, hair loss


I am a 52 year old woman with thinning hair since I was 30. I died my hair blonde and it seemed to cover the thinning. Now it is clearly getting worse and I can see through the hair to my scalp and even the blonde color does not help. In fact, the scalp really stands out. Is there something wrong with me?

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The cause of hair loss in women is not as straight forward as it is in men, who usually follow a specific male pattern balding. Male pattern balding involves hair loss only on the front, top, and crown of the scalp. Male pattern balding spares the hair in the back and sides of the scalp, which is often referred to as permanent hair. This is the area where hair is harvested for hair transplantation.

Unlike men, adult women with typical female androgenic alopecia often have significant levels of miniaturization in the donor area (back of the scalp). Miniaturization is part of the balding process where hair shafts become thinner over time before falling out. The mere presence of miniaturization is not necessarily a contraindication to surgery. However, miniaturization does indicate an unstable donor supply and one has to make a judgment regarding the risk/reward of the procedure. One needs to consider the absolute number of full terminal hairs that are available for the hair transplant, the risk of further miniaturization, the area that needs to be covered, and the risk of the surgery accelerating the hair loss (since in women, hair is often transplanted into an area that has a considerable amount of existing hair –- some of which is at risk of being shed from the surgery).

Before further discussing the phenomenon of clinical (“socially” visible) hair loss, here are a few basic facts for your general knowledge. It is normal to lose 100 to even 150 hairs a day. As hair falls out there are hairs that are also starting to grow. Hair may also grow in cycles and you may notice more hair falling out at different phases and seasons of the year. Hair follicle cells have three phases of growth:

  1. Growth phase (Anagen phase) which lasts anywhere from 2 to 6 years. This is the phase where your hair is actively growing at approximately 10cm per year. 85% of hair is at this phase at any given time.
  2. Transitional phase (Catagen phase) which lasts about 2 weeks. This is the phase where the hair follicle shrinks and prepares to enter the resting phase.
  3. Resting phase (Telogen phase) which lasts about 1-6 months. This is the phase where hair does not grow, but stays attached to the follicle. Some hairs are shed at this phase, but at the end the hair follicle re-enters the growth phase to start the cycle over again. 10-15% of hairs are at this phase at any given time.

The first step in evaluating hair loss in women, after a detailed history and physical exam, is to rule out any underlying medical causes of hair loss which can be treated. If clinically appropriate, the following disease processes should be considered: anemia, thyroid disease, connective tissue disease, gynecological conditions and emotional stress. Furthermore, over 50% of women going through change of life hormone fluctuations (menopause) experience significant hair loss. It is also important to review the use of medications that may cause hair loss, such as (but not limited to) oral contraceptives, beta-blockers, Vitamin A, thyroid drugs, coumadin, and prednisone. The following laboratory tests have been recommended to rule out the aforementioned medical conditions:

Some common blood tests for female hair loss:

  • Sex Hormone tests
  • SHBG (Sex Hormone Binding Globulin) used to test status of male hormones
  • Estradiol is a sex hormone
  • FSH (Follicle Stimulating Hormone) *not hair follicle but follicle in the ovary*
  • LH (Luteinizing Hormone) is a sex hormone
  • Free Testosterone
  • Total Testosterone
  • ANA (Anti Nuclear Antibody) used to test for Lupus or other autoimmune diseases
  • TSH (Thyroid Stimulating Hormone) used to test for hyper or hypo-thyroid disease
  • Test Iron status
  • TIBC (Total Iron Binding Capacity)
  • Ferritin
  • Iron

These laboratory tests are a good starting point to medically rule out underlying medical conditions. If there is an abnormality in your test results, we can proceed to address these medical issues. It is important to note that even after a medical condition has been corrected, your hair loss may still persist to some degree. It is thought that this is due to a “switch” in your genetic makeup that has been turned on when the medical insult had occurred. Once the hair loss starts, it is difficult to turn off this “switch”. At the very least, your hair loss may slow down and your medical condition addressed.

The only medicine that seems to work for women (who do not have a medical cause of the thinning or hair loss) is minoxidil.

Now with all of what I said above, there is a small subset of women who have what appears to be the ‘male’ form of alopecia with front to back balding and no miniaturization in the donor area. These women may be helped by Propecia and certainly get the types of excellent results from frontal hair transplants.

Tags: women, woman, female, hairloss, hair loss, minoxidil, tests, genetics, genetic


Re: Are Doctors Promising More Grafts Than Can Possibly Be Delivered?

Hi Dr. Rassman, I appreciate you addressing this very important issue. However, I think you missed the questions on this post. It seems to me the poster is asking if there is really 10,000-15,000 grafts available for transplant in the average male rathar than how many can be transplanted in a single session. I have noticed an increasing number of doctors who are saying this and using it as a basis for giving young men very aggressive hairlines. Can you expound on the issue of how many grafts are typically available?

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The available number of hair follicles for a hair transplant is different in each person. Some of the factors that affect the number of hair grafts are:

  1. Density of hair in donor area. Average density is 2.0 hairs per square millimeter. It could vary significantly from person to person and between different ethnic groups. The actual donor area may represent 30% of your original hair (the rim around the head) of which half are possibly harvestable (in theory). This would reflect about half of the 30% of the original or 15,000 hairs (reflecting about 8000 grafts).
  2. The size of the head also affects the size of donor area. Bigger heads with similar hair density have larger numbers of donor hair. Unfortunately, bigger heads have larger baldikng areas.
  3. The average number of hair in each follicular unit is also important. People with higher density will have less single hairs and more groups of three and four hairs. In those who may have densities of 3 hairs per mm2 (150,000 hairs on such a head) the harvestable hair will be higher and may run as high as 45,000 hairs or 22,000 grafts (theory of what can be harvested). Actually harvesting these high numbers is more the exception than the rule.

Considering all these above factors, you can calculate the possible number of grafts and add to it the effectiveness of those hairs in producing appearance of fullness. It is true that in an average man with an average sized head, with average hair density (2.0 per mm2), and an average number of hairs per each follicular unit (~2), you can remove about 10,000 grafts safely, but this number can vary significantly and other factors should be considered in this equation.

This number is driven from a simple calculation that needs to be done for every patient when planning a hair transplant. Obviously since there are a lot of variables involved, this number can vary significantly, but is still easily assessable.

You asked about using such numbers for justifying an aggressive hairline. I occasionally have to create a thinner hairline due to scarcity of donor hair considering all of the above factors. I strongly believe that normal placement of a hairline in the ‘mature position’ is the correct location for a hairline. The Master Plan I keep talking about determines the distribution of harvestable hair in a worst case scenario, so that no matter what happens to the patient, no matter how much hair loss occurs with age, the patient will ALWAYS look normal. The quality of the donor hair is also very crucial for making the decisions in the Master Plan. I will, once again, list the factors that make up the elements for calculating transplant grafts in a solid Master Plan:

  1. Hair thickness (the thicker the hair, the more volume it will produce, so less hair is needed for a given result).
  2. Hair curliness (the curlier hair generally appears fuller and less hair is needed to produce the same appearance).
  3. Contrast of the hair color and skin tone (the higher the contrast the more hair is needed to produce the appearance of fullness).
  4. Donor density and scalp laxity will determine the ‘number of grafts’ that are available at any one point in time.

As you see, decision making is complex and many factors are involved. So available hair follicles are only part of this and other factors, including hair quality, should be taken into account. I also have to mention the importance of patients having a real expectation and is involved in making decisions on how aggressive we should design the Master Plan. See Medical Publications on the NHI site for more.

Tags: hairloss, hair loss, doctor, physician, hairline, surgery, hairtransplant, hair transplant



It appears that most of the hair transplant examples I’ve seen have tended to be transplants around the hairline (and hair combed back in most cases too) versus crown transplants. If one suffering from MPB were to undergo a hairline transplant and be on Propecia (for the crown) indefinitely, there will inevitably come a time (5+ years) when even the finasteride will wear out in terms of its effectiveness in keeping the crown hair. Does that mean that a series of hair transplants are required to “keep up” with the rate of hair loss overtime?

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To give this question the respect it deserves, one needs to understand the natural progression of genetic male patterned balding. This is a progressive process that will eventually lead to a final pattern consistent with your genetically predetermined pattern. Look at the Norwood classification chart for hair loss and you will see a series of patterns. These can be the ‘end stage’ of the hair loss or they may be intermediate stages leading to a more advanced stage along the progression indicated in the Norwood scale. The problem is that you really do not know (for sure) where you will end up, but there are many ways to estimate where you might be by looking at:

  1. Your miniaturization map of your scalp. The final pattern may very well show some degree of miniaturization, even if you are not frankly balding yet.
  2. Your family pattern and see if you can identify (a) the worst case in the family or (b) the person whose pattern you believe you are following. Then you might be able to ascertain your final pattern (an educated guess).

If your final pattern is not the more advanced patterns (demand for hair) and if your hair density is adequate (supply), then you might be able to keep up with the progression of your balding as it is happening. If, however, the final pattern will be a Class 5, 6 or 7 pattern, you might not be able to keep up with the balding process with additional transplants because you may run out of donor hair (supply). The one clear point I wish to make is that you need to have a Master Plan to take in your worst case scenario and you must have a doctor who you can trust to work with you on that plan. The Master Plan has one objective and that is that no matter what happens, your hair restoration surgeries should always leave you with a natural appearance. Too many patients and doctors think in the short term, and think that the hair transplant will solve the problems of balding. That may not be realistic, so the relationship between the patient and the doctor is all important.

If you are having your first surgery when you are 24 years old and you are supposed to become a class 6 or 7 in the future, even though you are only a class 3 now, it is likely to assume that you need more than one surgery. On the other hand, if you are 35 and have almost reached the end of your hair loss process, you may be done with just one procedure and may never need another surgery. You have to understand that Propecia is not a permanent solution, but it does slow down the loss process in most men. Sooner or later, your hair loss will catch up until that final hair loss pattern is reached. Taking Propecia (Finasteride) may prolong the outcome, but the final pattern is probably inevitable.

Tags: finasteride, propecia, hairtransplant, hair transplant, hairloss, hair loss


Everyone has seen those awful comb-overs and wonder how people get there. First, it is important to note these men did not wake up one morning, see that they were bald and then decide to grow out the hair above their ears to comb back to the other side. Politicians are frequently seen with these bizarre comb-overs. They develop insidiously over time. First a little hair loss, and the person starts combing their hair from one side to the other. The ‘part’ moves down over time as the hair by the ‘part’ grows longer and longer. For the first few years, this trick of styling with the patient’s own hair works well, even as the hair loss progresses, but sooner or later, the comb-over starts to become obvious as the balding area enlarges so much that the hair can not cover it. Because the change occurs each and every day over years, the person who uses the comb-over doesn’t notice it. Even their wives don’t see it, nor do many of those in a close family. If the comb-over is really bad (I see them at the theaters all of the time), friends and family don’t want to touch the subject, so these poor men just don’t know how they look. This is a classic psychological term called “denial”. These men think hairs, and they are hairy, no matter what anyone says.

Norwood 6 and 7Alternatively, some men create bouffants, a puffed up hairdo which is made up by very long hair that is wrapped around the top of the head to look like a normal head of hair. Some of these bouffants are truly amazing and they have often fooled me when they came into the office. Most of these man are either Class 6 or 7 patients and they work the frontal hair, hair by hair, to stick to the upper part of the forehead and combing the hair from behind to a forward direction so that the actual hairline does not show. I remember one man who took it one step further — he cut his hair and let it settle on his bald scalp. I am not sure how it started, but when I saw him, he had a pile of loose hairs, held by the dirt and grime of Los Angeles, to the bald area of his scalp. It worked, at least for the top and crown of his head, but not for the front of his head. This poor man never washed his hair, because the hair would all go down the drain. He used a type of perfume to neutralize any odor from his hair, which actually smelled musty.

So styling, which works for slight hair loss and is very commonly used, is modified over and over again as the hair loss progresses. As over 50% of women over the age of 60 have significant hair loss, the use of puffing up styles, allow the appearance of more as their balding becomes worse. Just go to a retirement community and you will see what I mean. If you realize than almost 50% of men and women over 45 have hair loss, most of them are using styling tricks to make their hair look fuller. Hair thickeners, gels and special hydrating shampoos will increase the thickness of each hair shaft.

It should be clear to regular readers of this site that hair transplantation rarely brings back the hair to normal densities. So the same tricks that are used in those with thinning hair are used by those people who have had hair transplants. On very rare occasions, I have returned the transplanted area to an almost normal density, but that is more the exception to the rule than what I normally do. Many hair transplant doctors would like you to think that you really get your hair back, but that is not the case. I have selected four patient examples with estimates of the actual range of density that they have obtained from hair transplantation. The reason that one might get a higher density return is because the supply is more than adequate to address the balding area demand.

Patient #1 has returned about 80% of his original density at great cost to his donor supply, which has become a bit depleted. His hair is very fine, so more density was necessary for his to get his crew cut hair style.


Patient #2 uses a puffed up hair style to create the illusion of hair (he has less than 15% of his original density replaced and is a full Class 6 patterned balding patient).


Patient #3 is a full Class 6/7 balding pattern and combs his hair backward to cover the balding in the crown.


Styling is part of a hair transplant process which you and your doctor should discuss as part of his informed consent. It is a process that balding men, sooner or later will adopt if they want to look hairier.

Tags: hairtransplant, hair transplant, photos, results, hairloss, hair loss, style


George Bernard Shaw in his preface to his play ‘The Doctor’s Dilemma’, said: “If we pay doctors to take legs off, would it not stand to reason that we will then see more men with less legs?” Shaw clearly held physicians in poor regard.

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Hair transplant surgeons are trained and compensated to do hair transplants. Unfortunately, these doctors are the most knowledgeable doctors who understand hair loss and much of its nuances. Why do I say unfortunately? To answer that, I pose another question: Why is there no group of doctors who specialize in hair loss and get compensated for it? Think about it and you understand the dilemma for the hair loss patient.

1) Why would anyone pay a doctor to diagnosis genetic male patterned hair loss when you can do it yourself and treat it with internet acquired finasteride or grocery store purchased minoxidil? That is what is done today for many hair loss sufferers.

2) Only the hair transplant surgeon has the potential to profit from the diagnosis and treatment of hair loss because a few of the many balding men followed by a good doctor will eventually become hair transplant patients. As a good will gesture, our clinic has waived clinic charges for consultations.

3) I generally tell patients that a doctor’s ethics may be determined by how he ‘sells’ his service. Find out if your doctor uses a salesman to front for him or does he/she invest his own quality time to diagnose your problem and communicate his suggestions to you?

So to answer my own question, a good doctor must always be able to put his patient’s welfare above his own interests. How common is it that doctors can put their patient’s interest above their own? We can not answer this question because we can not easily count those with missing legs (metaphorically speaking). I have taken from memory an old Jewish proverb which states that you can tell the fabric of a man by one who treats his business clients in a manner that he treats his own family. That applies equally to cutting off legs or doing hair transplants. Integrity can be a rare commodity, even amongst doctors who took the Hippocratic Oath to serve his patient’s interest above everything else.


Why is there such a difference between these two previous post’s photographs. They are both, by your report, Class 7 patients.

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Norwood class 7 Thanks for asking this great, insightful question.

The rim of hair in a Class 7 balding pattern contains about 30,000-35,000 hairs. Considering that the normal total hair count of an adult is about 100,000 hairs, the only permanent hair that is never lost in any balding man, is the 3 inch high rim of hair schematically shown on the right (Norwood Class 7 pattern). The art of hair transplantation that I will show you below, reflects the way the surgeon redistributes these 30,000 (or less) hairs so that it looks like more than it is. The surgeon needs all of the help he/she can get from the characteristics of the hair on the patient’s head, including the quantity that can be safely moved.

The texture of the hair in these two patients is very different. The white/grey haired man (let’s call him ZU) has a hair shaft thickness that is easily three times the hair bulk (weight) as the blonde fellow (and for the sake of consistency, we’ll call him BF). The hair of ZU has a good character to it and holds a wave nicely, while BF has hair that lies limp and wimpy. Also, the donor supply of ZU is easily twice as good as BF and has a loose scalp which allows the surgeon to redistribute more hair from the permanent rim of hair around the sides and back. ZU received almost 10,000 grafts with easily 23,000 hairs in these grafts, while BF had only 4500 grafts (about 8,000 hairs). BF’s scalp was tight and his hair density was not as good as ZU. With that understanding, re-read the blog post titled Patient’s Guide — How Many Grafts Will I Need?, and it should be easy to see that we are not all created equal and the surgeon’s hands are ‘tied’ by patient’s hair characteristics (weight, texture, color, quantity) and therefore the hair transplant surgeon is not in control of every variable he/she needs. When putting the patient’s final results side-by-side, ZU has easily 8-9 times the amount of hair bulk (# of hairs and bulk) as BF. What is very important for you, the reader, to recognize here is that even BF is thrilled with his results. The thinly covered crown in BF (both men use a comb-back hair styling technique) is not of a concern for BF, because he looks at the man in the mirror and does not see his hair from behind. ZU also has a comb-back (which I showed in these photos by allowing the hair that is combed back to separate so you can see the scalp) with much better coverage of his crown area. ZU also had a considerable amount of hair transplanted into the crown, making his grooming easier and his crown looking fuller. From BF’s point of view, that man he sees in the mirror has a full head of groomable hair, just like ZU.



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