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I had a visit last week from a Merck executive and while talking with him, I realized that I could ask some sensitive questions about why they hold the price for Propecia (1mg finasteride) much higher than Proscar (5mg finasteride). It is not uncommon for a Merck representative to visit various physicians’ offices, and because of my position in creating this website I had an executive pay a visit so he could meet me face to face. His focus as an executive of the manufacturer of Propecia is clearly focused on maximizing the value to the company (as it should, of course). These are their arguments for taking Propecia, rather than cutting Proscar into quarters:

  1. Propecia gives you a certainty on the dose. 1mg is 1mg, but if you cut a Proscar into quarters, you are never completely sure of what the dose that you are taking might be.
  2. Some people try to put Proscar through their insurance. This is not only illegal (if hair loss is not a covered benefit), but the insurance company can come back on you for the money they laid out for Proscar if they wish to enforce their rule that hair loss is not a covered benefit.
  3. If you get a prescription and process it through your insurance, you may be deemed to have a pre-existing condition (Prostatic Hypertrophy is usually the reason that a Proscar prescription is written by the doctor). If your insurance company puts that in your medical record, this pre-existing condition may impact your ability to get insurance if you switch your employment. Once you get a ‘pre-existing condition’ label, it is often near-impossible to get the diagnosis reversed in the insurance company database records. I don’t know if this is a real concern, but it is something that people who process Proscar through their insurance should be aware of.
  4. The FDA has only authorized Propecia for treating hair loss, not Proscar.
  5. The cost of Propecia is subsidized by Merck at $25/3 month supply, which means that there is a $100 rebate per year. They feel that these incentives make the drug more affordable.
  6. There is a one year full money back guarantee if you feel that you did not get a benefit from Propecia. See their website for details.

I asked about the problem with women handling Proscar and cutting it in quarters for their husbands. I was given the example that if a woman who handled finasteride, then gave birth to a male child with a genitalia defect (e.g. hypospadias), Merck could be held accountable for the birth defect if they did not take a legal position on this subject beforehand. I probed them one more time about doing a study on touching the pill, cutting a 5mg pill into quarters and seeing what level of absorption of the drug would occur through the fingers. Essentially though, there is no reason for them to do this. The 1mg dose pill is already available on the market and all this would do is undermine the sales of Propecia.

With all this being said, Proscar and Propecia are still the same drug — finasteride. They are just in different dosages, obviously. If you want to ignore Merck’s perspective and stick to Proscar (or the generic Proscar) for treating your hair loss, and your doctor will prescribe it to you, that is your prerogative. I’m just showing both sides of the coin — the benefits of taking cut Proscar tablets (price) vs the benefits of sticking to the actual Propecia (as outlined above). I’m all for a drug if it is proven to work… and finasteride works.

Tags: proscar, propecia, finasteride, merck, hairloss, hair loss


This is a follow-up of the blog entry from the other day, What Happens When a Doctor’s Car and Mansion Payment Is More Important Than You?

First, lets get to the photos. The photo on the left was taken this week in my office. The photo on the right was taken 18 months ago, also in my office (forgive the quality — it is scanned from a Polaroid). Click the photos to enlarge.


The above photos are of a man in his mid-50s. Note that the progression of his hair loss has been very significant. Some of the medications he uses may be promoting hair loss rather than saving his hair. He tried Propecia (finasteride), but he had wiped out his sexual drive from it. He went to another doctor for a second opinion and then came to see me with that second opinion. He was a good note taker and is fastidious about medical records. His father had prostate cancer. The doctor who offered him the second opinion suggested that he have 3000 graft placed all over this head. He would then have a “full head of hair”. Even though he saw a doctor, it was the salesman inside the doctor who was talking. That has to be the worst recommendation he can get, because shock hair loss is almost a certainty and this patient would be like the fellow I showed you the other day. To make matters worse, his donor supply was low so that the probability of getting 3000 grafts would have failed.

This patient did the right thing — he got a second opinion. In this case, he checked up on me. Transplanting the corners and making a hairline is an option, but he should stay away from transplanting into the thinning area. Because of the steroids he is taking, I advised him to stop some of the medications and try to take a smaller dose of Propecia, for if he undergoes a hair transplant (or even if he does not) and would want to see his hair loss stop first. Propecia may be the only good option for him and worth a try again at half of the dose. With the family history of prostate problems, Propecia is a good medication to reduce this risk. The other doctor only talked about selling him 3000 grafts and the benefits of such a procedure for him. Why am I alarmed? Simply, this man is losing hair in ‘gangbusters’ and as he is in his mid-50s — that is not supposed to happen. He is clearly an exception to the rule that men over 50 don’t usually go through accelerated balding. With low densities, any doctor who put hair into his crown will deplete his donor supply. He is also losing frontal hair now, so what is the Master Plan when he runs out of donor supply and money?

I showed him photos of his hair, and explained how the miniaturization of the hair was throughout the top and crown and if this area was transplanted, the hair he would lose would be more than any benefits he would have if he was transplanted. I am personally appalled at the desire of a doctor to try to push him into getting thousands of grafts and to make matters worse, he was never told that he may accelerate his crown loss with a transplant. Patients have every right to know such potential side effects and the probability of that happening. Doctors are legally obliged to inform patients of such risks. My only place to vent this frustration is on this site. I don’t mean to scare you and I don’t want you to think that every doctor out there is trying to screw you. There are many good and honorable doctors that do hair transplants, but again and again, I tell patients, Let the Buyer Beware.

Tags: hairloss, hair loss, finasteride, propecia, cancer, prostate, photo, steroid, steroids


First, please read the article from the Associated Press here: Wife Files Suit After Husband’s Dies During Hair Transplant Operation.

Scales of justiceHere’s my in-depth 2 cents:

This is a tragic and unnecessary death and my heart goes out to the family. According to the article, this actually occurred a year ago today (April 27, 2006), but the case was just filed in Los Angeles Superior Court, and thus made public. From what I could get out of the court filing I read, there was an overdose of some medication (I believe it was Lidocaine) and the response of the professionals in attendance was inadequate to address either the medication that was overdosed or the proper management of the critical emergency with basic life support activities. Why did it happen? Is it a real risk for people wanting to undergo a hair transplant procedure? Are hair transplant procedures any more risky than other plastic surgery procedures or even a dental office procedure? These questions have been raised because of this news release and I would be remiss not to discuss this at some level of detail.

Why this happened is something that we will not know until all of the facts of this case are revealed in the legal proceedings, but I can tell you that I am unaware of any death other than this one (in anybody’s hands, anywhere in North America) that has occurred in the years since I have been a hair transplant surgeon (1991 – present). Hair transplantation, or any surgical procedure, has its greatest risk associated with the anesthetic used. If the patient only has local anesthesia, then the risks should be almost minimal, yet this patient apparently died from the simplest form of local anesthesia. But, like any medication, there are known risks of Lidocaine. eMedicine says, “If untreated, local anesthetic toxicity can result in seizures, respiratory depression or arrest, hypotension, cardiovascular collapse or cardiac arrest, and death.” This begs answers to questions which have not yet been posed. I am resolute in stating that local anesthesia is absolutely safe, provided that the person administering it does so in a competent manner. Tylenol, aspirin, vitamins, alcohol and other such substances should be absolutely safe, but on very rare occasions, each of these can kill. When used in ‘overdose’ and untreated, these medications (including Lidocaine) can be lethal.

How does an ordinary person know if the doctor he chooses, the facility the doctor practices in or the track record of the doctor’s previous history is ‘clean’? You can go to the medical board of the state and find out if the doctor has a clean record (available online in most states). You might be surprised to find that your doctor has been in trouble and has a well ‘marked up’ record of infractions. Doctors who are known drug addicts, who had sexual misconduct, or who have been disciplined by the medical board for any reason, create a public record which you can get access to. If the doctor practices in a certified surgical facility or hospital, you can assume that the doctor’s work is overviewed by a ‘peer review’ process which holds the doctor accountable for his actions and his surgical results. Doctors who confine their work to their offices or those who do not seek out national certification and peer review are not accountable to an official ‘body’. Just because they are not reviewed by impartial third parties does not necessarily mean that these doctors aren’t any good. It means more that those doctors who are reviewed and are held accountable for the quality of the medical care they administer, may reflect upon the style of their practice which is open for criticism by accrediting organizations. I personally welcome such a review, as it gives me a check on my own personal belief that I am doing everything possible to deliver the best medical care that I can. Had I unknowingly used doses of medications that were dangerous, for example, the reviewing physician who checks my use of medications during an inspection would have identified a problem in my drug use routine and notified me of the need to re-examine what I was doing.

Sudden death:
People die in their sleep, when exercising, running a race, working under stress, having sex, going to the toilet, etc. Many of these spontaneous deaths are caused by a heart rhythm problem where a heart stops beating from something called spontaneous ventricular fibrillation (SVF). As this can happen anywhere and at any time, each of us should be prepared to act, to save a life, because that life could be your father’s or mother’s or your child’s. The EMS (or EMT or paramedics) know how to maintain an open airway, administer cardiac massage and perform more advanced life support, which would be appropriate in such SVF situations. Many lay people are also trained at performing cardiac and airway life support at the most basic level and death can be delayed and possibly prevented as more sophisticated care is administered. For those of you reading this, you should be able to perform basic life support services just in case someone near you undergoes SVF. This means that you can pump a chest (perform external cardiac massage) in a person whose heart stopped and you can administer respirations while keeping the airway open. Simply calling 911 (at least in the US) can bring you sophisticated life support services (in most cities) within 5 minutes. We should expect that your doctors, nurses, medical technicians and every person working in your medical office will know the fundamentals of at least basic life support. Certainly, when a doctor gives any anesthesia, that doctor must be able to manage a worst case scenario and direct the entire process where life support services meet the standards of care for a medical facility. That doctor should also be intimately familiar with the drugs he/she uses, in case some rare side effect should occur.

If what was reported in the case filing of this death is correct, the doctor and all of the support people on his staff failed to meet the fundamental standards for basic cardiac life support. Still worse, is the suggestion that the responsible medical personnel may not have been what the patient who died had expected. John Lord (referred to as a “doctor” in the court action) is not a medical doctor. I personally have complained to the Medical Board of California on a number of occasions about Mr. Lord’s activities that were reported by ‘patients’ of his, his credentials, and his practice. Anyone can check online records to find that there is no licensed MD or DO named John Lord in California and the suggestion that he was a licensed physician performing surgery as claimed in the civil suit purports possible criminal activity [Update: John Lord plead guilty to a felony count of practicing without a license]. Many things are claimed in the legal action, much of which (if proven in court) makes this case unique and beyond a simple case of malpractice. If he was a doctor, Mr. Lord could be tried for malpractice — but he’s not. Does that mean that this is a matter for the ‘state’ attorney and if so, is it a criminal matter (practicing medicine without a license)? We must, of course, let the legal process work its course and basic to the constitution, these defendants are innocent until proven guilty. But the more basic question that must be asked is, “What is being done to protect the public now if these accusations are proven true in the months or years yet to come?”

I have reviewed the medical literature on the subject of death in a doctor’s and dentist’s office to try to find out what the experience has been across the United States. None of the improprieties of possible criminality are discussed in the brief review I have put together here. I have focused on the data which address the risks of death in an outpatient setting. Florida, Oregon, and Texas have provided a review of some of their experience over many years. These reviews, in part, have included dental office procedures as well. Most patients who died had preexisting conditions, such as gross obesity, known cardiac disease, epilepsy, chronic obstructive pulmonary disease, and liver disease that can significantly affect anesthesia dosage and care. In the dental office, while under sedation/anesthesia, insufficient or inadequate oxygenation arising from airway obstruction and/or respiratory depression was the most common cause of life threatening events. In all of these cases most of the adverse events were determined to be avoidable with skilled medical care. When age is factored into the risk formulae, risks go up significantly in patients who fall outside the healthy, young adult category typically treated in the surgical/dental outpatient setting. In the death under discussion here, the patient appeared to be a healthy man, so his risk of death should have been negligible.

In the state of Florida (over a 6 year span), a total of 46 deaths related to office procedures were reported. Twenty of those were “plastic surgery procedures” and 11 people died in the immediate treatment period (first 24 hours). The most common cause of death reported were from blood clots (most probably from the legs). Most of the deaths involved non-board certified plastic surgeons. The 46 deaths were among over 600,000 surgeries. This puts the risk at 0.00077 of patients. Unfortunately, the one who dies has a risk of 100%.

44,000 Americans reportedly die annually as a result of medical errors. Medical mistakes are the eighth leading cause of death in the United States. When surgery is performed in an office-based setting, the risk for serious injury or death comprises a 10-fold increase when compared with a certified ambulatory surgical facility. At the New Hair Institute, we have maintained a certified ambulatory surgical facility since 1996. I am proud to say that we may be one of very few hair transplant centers that is fully AAAHC (Accreditation Association for Ambulatory Health Care) accredited. To be accredited and certified, the doctor and facility must meet the highest standards for safety, cleanliness, and the use of proper standardized procedures. The facility must undergo inspections by highly trained physician specialists to determine (by independent medical record review) that all of the standards are met, and that the complication rates (infection and surgery) fall within national standards. The doctors and staff must be trained in life support and at least one physician must be trained in Advanced Cardiac Life Support (all of our doctors are so trained). I must reflect on the Hippocratic Oath: primum non nocere (“first, do no harm”). Patient safety must be the foremost priority in any surgical procedure and that means:

  1. That the doctors are trained and retrained at least every two years in Advanced Cardiac Life Support (ACLS) and know how to respond to emergencies.
  2. That the doctors fully understand the risks of what they do and all of the potential complications of the medications that they administer and how to respond to such complications.
  3. That the doctors and their entire staff are adequately trained in the procedures that they perform and oversee, including life support activities.

Update on Friday Evening, April 27th:
ABC News just announced that John Lord plead guilty to a felony for practicing medicine without a license.

Tags: hairtransplant, hair transplant, death, crown, medical, los angeles, surgery, procedure, hair restoration, hairrestoration


Received two semi-related questions, so I’ll answer them as one —

Several years ago I had tunnel graft surgery and I’m now in need of the clips. Can you advise me on a source where I can find them? It’s been rather difficult to locate them

Block Quote

Someone told me that you could sew a wig into the scalp. Is that true and does it work?

Block Quote

Unfortunately, I do not know who might sell these clips.

For those of you who do not know what a scalp tunnel is, it is described in PubMed as:

A new procedure for attaching a hairpiece to the scalp is described. Two skin-lined tunnels in the anterior and posterior scalp are built, using a strip of free full-thickness donor skin fron the postauricular area. Silicone-coated metal clips, suitably fashioned from .062” Kirschner’s wire, are then attached to the hairpiece. The metal clips are inserted into the skin-lined tunnels and thereby anchor the hairpiece to the scalp.

These permanent tunnels (more like bridges made of scalp skin) are created to hold a wig (also known as hairpiece or hair system) in place instead of glues or tape. It is a barbaric and deforming process, not considered anyone’s standard of care today. Note that the description on PubMed is dated October, 1976.

There have been many things that people have done that are (in hindsight) a little nutty. There are three ways that I have seen the wig attached to the skull.
Sew scars

  1. The picture on the right was of a patient who went to a company in New Jersey who hired retired doctors to actually sew wigs through the scalp skin directly (see photo at right of patient with scars from this procedure). These almost always got infected and when the patient came back to the doctor, the stitches were switched to a non-infected part of the scalp. As you can see from the pictures, the scalp was heavily scarred from the infections. At one point, I was hired by the New Jersey Medical Board to prosecute the doctor, but the doctor was replaced by another who then went through the same legal process. When the State tried to shut this company down, the company closed down and opened under another name. I do not know if they are still playing this ‘cat and mouse‘ game with the State of New Jersey.
  2. A doctor actually drilled a metal connector into the skull. The wig had a male like clips that connected with a mechanical fit to the part that was drilled and cemented in the skull. The wig could be buttoned in and out with great ease.
  3. The art below shows skin tunnels (an old procedure that required a skilled surgeon to fashion in the scalp) which are use to tie ‘shoe laces’ that were attached to the wig. The process was promoted as simple as putting on and taking off your shoes (except you just did it with your wig).
Tags: scalp tunnel, surgery, wig, hairpiece, hair piece, hair system


Shell gameThere was a movie named Network that came out over 30 years ago and contained a great line that became a very memorable quote:

“I’m mad as hell, and I’m not going to take this anymore!”

Well, this line came to mind and I want to tell you, my readership, how mad I am and why. Unfortunately, I can not directly act on what is making me mad, except by speaking my mind through this blog. There is a new scam going on in the hair transplant industry, which plays off uninformed patients who come to visit a doctor for hair restoration surgery and who want to rightfully trust that doctor. The scam is simply to get a young man or woman to trust in the doctor through skilled sales and presentation skills, and then when they make up their mind to have a hair restoration procedure, they get what they would not have expected.

The fee structures in the hair transplant industry is based upon a fee per delivered graft. Usually, the prices run all over the place. I have seen three people in the past week alone who received over 2800 grafts, supposedly in their ‘balding’ area. They get poor densities transplanted into the balding area and many more grafts are placed into normal hair. One of the three patients was sold 3300 grafts at $4/graft, and I calculated that he could have never gotten that many grafts because the density of his donor area and the tightness of his scalp would never have allowed that number. Add to that was that my examination only saw about 400 grafts that grew and I suspect that the patient was swindled. Worse than the financial loss, was that valuable donor hair was lost and damage was inflicted in the recipient areas that were transplanted.

I am certain that this scam is being perpetuated all across the world, as I have seen patients coming to visit me from throughout the United States and Europe. All I am addressing here is the intent to defraud. I am not addressing the second class work performed by doctors who try to deliver first class work.

What can you do to protect yourself? The answer to this question is to do careful research. Read the blog entry Patient’s Guide — How Many Grafts Will I Need?, which teaches you how to determine the number of grafts for a given balding area. When I wrote this piece, I did so to explain the economics of hair distribution to arm those prospective patients with enough information to be well informed about the pending purchase of hair transplant grafts, but now it seems that doctors are reacting to the competitive challenge by dropping the price per graft and raising the numbers, many time a multiple of what is needed. Many times the doctor does not even transplant the numbers he/she commits to (I believe this is less common, because their staffs would see that). If you understand the process of calculating the number of grafts, you will be able to determine for yourself how many transplanted grafts you need, so if you (for example) calculate 1000 graft needed and the doctor recommends 3000 grafts, then you know that the doctor is in for the ‘SCAM’. Never forget (that like any service business, even a doctor’s cosmetic surgery activities) that it is a Buyer Beware business.

There is nothing that I can do except to vent here on my blog. I am appalled at the behavior of this group of scum doctors, for they are not only crooks, but they dishonor the good doctors who are in the hair restoration field. If I come out publicly and identify the doctors who I am certain are involved in this scam, I will be open to legal actions by those involved. The medical board has no power to deal with it, as the decisions on what to do falls outside their domain and the doctors would withdraw into the practice of medicine. The only place where these doctors can get attacked is in the courts on a malpractice action. I can play a role as an expert witness to those that wish to take action and would offer my services to the victims of these crimes and their lawyers.

Tags: scam, hairtransplant, hair transplant, fraud, grafts


I’ve put together a nice list of things to consider if you’re interested in having a hair transplant, particularly when comparing the Follicular Unit Extraction (FUE) technique and the Follicular Unit Transplant (FUT / strip) technique.

FUE pros

  • There will not be a detectable scar in donor area. Of course the scar will be present after every skin incision, but since scars are very small and scattered in a larger area, they are not detectable even on a head with a close crew cut.
  • There are no sutures or staples to be removed. The small pointy wounds on the back of the head will be left to be closed on their own with no sutures or bandages.
  • There is minimal or no pain in donor area after the removing the grafts.

FUE cons

  • Not everyone is a good candidate for this procedure. We always test our patients before doing the actual procedure with several biopsies with different methods and view the grafts under microscope to see whether we can harvest them without damaging the hair follicles. If we see a lot of transected (damaged) follicles, we can not proceed with this procedure.
  • It is more expensive (almost double the cost compared to the strip procedure). Follicular Unit Extraction is very tedious and every graft should be individually extracted by the surgeon as opposed to the strip method where skin is removed first and grafts are harvested under a microscope.
  • It takes more time, sometimes up to twice the time when compared to a strip procedure for the same number of grafts. A procedure to harvest one thousand grafts may take six to eight hours.
  • A large area of the scalp needs to be shaved or clipped very short. This is not acceptable for many patients.

There are a few issues that are important to look at and understand. Hairs within a graft can be killed by improper harvesting (e.g. drying, cutting it at a critical point in the anatomy of the hair follicle within a follicular unit). This can happen if there is poor cutting techniques in strip harvesting, or in actual transection of hairs within a follicular unit during an FUE procedure. I personally do not believe most of the doctors who claim 95+% successful hair counts from FUE and I would love to pay a visit to some of these doctors and actually do the hair count from their FUE extracted grafts.

Thick grafts (those that are transplanted with fat around the follicular unit) can tolerate air exposure longer than a skinny graft (which can dry in seconds when exposed to the air). But tolerating air exposure for longer than 10-20 seconds suggests to me that hair follicle death may occur and the staff do not have strict quality control process implemented. What is important is not how many hairs are extracted successfully and anatomically intact. The important question to ask is, “Will they grow?”

The best part about strip harvesting is that there is a very high yield with the experienced team. The risks of scar formation that is detectable (greater than 3mm wide) is about 5% with the first procedure, 10% with a second procedure, and higher with a third procedure. Other than the scar possibilities and a slightly more painful recover period of a day or two, the strip procedure is more cost effective and more efficient from a time and yield point of view.

Tags: fue, follicular unit extraction, strip procedure, strip, hairtransplant, hair transplant, hairloss, hair loss, hairrestoration, hair restoration


I just read a complaint about me on the internet from a former patient. I figured out who he was and reviewed his medical record. He originally came to me angry with hair transplants by another clinic that left him a bit pluggy (from older type of work) and scars in the donor area (also from many years earlier). Some 7 months after I performed his surgery, I found a post on a bulletin board, which said: “Dr. Rassman does truly exceptional work…. Dr. Rassman helped me with the money and is honest and was generous to me. … never lied or exaggerated. I am disappointed, however, because I evidently had unreasonable expectations.”

‘Unreasonable expectations’ are the Achilles’ heel of cosmetic surgical procedures. In hair restoration surgery, unhappy patients are often running out of both money and hair. Some patient will continuously look for new doctors to improve their situation, or sets up the expectations in hope that their situation will be better than reality will allow.

Patients come to cosmetic surgeons with a vision of what they want. Unlike a photographer, the cosmetic surgeon is more like a portrait painter who tries to create the image, the ‘look’, that the client wants. Patients undergoing cosmetic surgery of any type need to establish realistic expectations for what the process can accomplish, so the burden on the surgeon is to help the patient get a dose of reality. Reality, in hair restoration surgery, can be challenging when it is offset against:

  1. sub-standard work the patient might present with (deformities common in the old type of hair transplant surgery)
  2. the supply/demand issues of hair
  3. the many attributes of hair (a white skin color with black hair, straight hair, a fine hair shaft thickness)
  4. the costs of the process

When repairing some of the old sub-standard work, there is an added challenge when the patient starts off angry. Anger (often with passive aggressive behavior) can be transferred to each downstream doctor and distort expectations. To address this problem, I have created a format where we have Open House events (which I have held monthly for over 14 years) and this has been an exceptional opportunity for prospective patients to see what their results will be like by meeting other patients who had gone through the process. Even for those patients who have the deformities from the old plugs, these Open House events allow prospective patients to examine subjects who have had repair work as well and see the nuances associated with these repairs. This becomes a large dose of reality. I find that patients who go that extra-step to come to an open house event are more reality based, so if they do participate in this event, disappointment is rare.

After I see a patient, I always write a letter summarizing the visit and send that letter to the patient. I have come to learn that despite these efforts, I can not satisfy 100% of the people I work on 100% of the time. I do not always read people well enough and when I think that we communicated, I may be the one with unrealistic expectation.

Tags: hairtransplant, hair transplant, surgery, surgeon, doctor, hairloss, hair loss


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

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.

Tags: hairloss, hair loss, hairtransplant, hair transplant, newhair, nhi, rassman


White knightI often wondered why so many people crowd dentists offices to get their teeth worked on. Today I had the chance to speak with a very prosperous dentist who told me it was due to the fact that most people starting with a dentist come when they have a tooth ache. It is the pain that drives them to the dentist’s office. At the time of the visit, they get loved (by the good dentists who understand nurturing patient loyalty) and the plan to end pain is defined. Short term relief is given and any relief brings on appreciation. The more the love that the patient senses, the more the loyalty. The dentist then checks his teeth and most people who were less than ‘good’ about dental care, get diagnosed with a variety of cavities, get recommendations on that chipped tooth that they had for some time and as they might even have dental insurance. They get a good dental hygiene program and then get educated on the need for regular dental care. They may start off with 800-DENTIST to find the dentist, that white tooth knight that will make their pain go away. With most people who have tooth decay (because of bad gum management and no flossing), constant dental care is critical and thousands of dollars goes from the patient’s pocket to the dentist’s bank account. The pain from a tooth ache is often precipitous, and emergency care often starts the process.

Imagine Joe Smith, coming into the emergency room. He says: “Doctor, my head aches”. “Well,” says Joe, “the pain came on this morning when I was about to shave. I put lather on my face and realized that the dome of my head was empty. Then I knew that the pain which has been building for some time, caused my hair dome to shine. Doctor, what can I do about my hair ache? It now bothers me all of the time.” The doctor probes his head, asks more and more about his symptoms and then finds out that what he is actually describing is a hair ache.

As the doctor who first meets him, I find out that his insurance does not cover hair aches (it is not a known, defined benefit of health insurance). “But,” says Joe, “I have the best insurance that money can buy!” Now Joe is in a quandary — does he have to go into his wallet and pay real cash to fix that hair ache? Does he put off his new car, that vacation he is planning for next summer? Joe thinks about it and he realizes, unlike a tooth ache which keeps him from sleeping, his hair ache can be ignored. That baseball hat seems to work well and his hair does not ache as much when he wears it. He could wear his hat when he shaves in the morning and maybe the hair won’t hurt. Joe finds out that the costs of putting back the hair on the front of his dome will be about the cost of some veneers on the frontal teeth that his dentist recommended, or a tuneup on his Jag (and he loves his Jag). The only good news about Joe’s hair costs are that once the hair is put back, the hair lasts forever. Best of all, he doesn’t have to worry about brushing his hair after every meal, hair decay or even flossing his new hair. Those veneers, however, need to get replaced from time to time and they may fall off once the tooth behind them decays again.

Tags: ache, hair, hairloss, hair loss, dentist


Here’s a story about a dermatologist who had a hair transplant when he was 25 years old, in 1975. Forgive the blurriness of the photo below.

What is particularly important about this first picture is the amount of hair that he actually had when the transplant process was started. He was clearly thinning his hair in the Norwood Class 6 balding pattern and if he were treated today, he would have been put on finasteride (Propecia) to halt the hair loss and hopefully lock in the Norwood Class 6 pattern. When he had the plugs put in, the hair was still there, although clearly heavily miniaturized. The photo above was taken in the first month after the surgery and the hideous looking islands reflected grafts that contained between 20-30 hairs and crusting after the surgery. The crusts which are shown here are only a few weeks old, but in those days, the patients were deformed for months after the surgery as the healing progressed very slowly. The only good news for this man was that many of the hairs failed to grow, reducing the pluggy appearance, simply because of the failure of hairs to grow. His first procedure put two lines of plugs in the frontal hairline, which were followed up with many more plugs at another surgical session.

Norwood Class 6He eventually lost all of his hair native in the Norwood Class 6 pattern. The grafts were taken out of his donor area with hollow drills measuring slightly under 1/4 inch which left him with white spots about 1/4 inch round that could easily be seen through the thinned out donor area. After he completed his surgery, he developed a comb-over to hide the plugs, but the hairline was still deforming and even with a comb-forward style, he could not hide the hideous grafts.

In 1988, he went to Denver and had a few hundred micrografts placed in front of the hairline by the inventor of the micrograft. The focus was to put camouflage in front of the plugs. This surgery did much to soften his look. Still, on meeting people in his dermatology practice, eyes focused on his hairline and the top of his head. That convinced him that he needed to find a better solution. Eventually, he had grafts removed, received dermabrasion to smooth out the bumps and cobblestoning, and had about 8 laser hair removal procedures to kill off the hair that he worked so hard to put there. To deal with the deformities created by the harvesting techniques, he had finely stippled tattoos created to look like hair and this hides most of the scars on the side and back of his head. His final look, one of a bald man, seems to work for him. His approach to his problem was creative and it showed me the value of the old saying: “Necessity is the mother of invention”. This doctor, armed with a unique set of skills (dermatologist) and facing his deformities every day in the mirror, applied his talents to solve his problem. He got there and now people who see him as a doctor, look straight into his eyes, not at his head. Congratulations!

Note: Most people see someone just like this man walking down the street, at a movie, in a restaurant, or at an airport. There is a perception that this pluggy look is the look of a hair transplant, but this type of procedure, if done today, would be clear malpractice and not acceptable in this litigious legal climate. Unfortunately, tens of thousands of men had this awful surgery done worldwide years ago. The victims were many — far too many. Personally, I can not imagine why a doctor would ever perform such a surgery. Fortunately, there are many ways to treat this problem and becoming bald is just one option (see Repair – Dean’s Story for an example of using hair transplantation to correct the old plugs).

For even more information on repair, please see:

Tags: repair, hairtransplant, hair transplant, hairloss, hair loss, horror, victim, plug


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