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Dr. Rassman;

As hard as this may seem to believe (especially for me), I am a 20 year old African American male who started losing my frontal hairline at the young age of 18. I am a sophmore in college and only started losing hair a few months after my first year. I am foolishly hoping that there is some other unknown cause to my early hairloss besides MPB (i.e.-I wore tight cornrow braids for a year, have heavy dandruff, and am also a heavy marijuana smoker) but I know this is unlikely. I have not had any tests done. I am wondering what my best options are considering that I am a college student with low income. I do not want to only stop hairloss, I really need to re-grow the hair I already lost. I am well into a Norwood class type III and have been for about a year now. I also cannot shave my head completely bald because of dark spots on my scalp and the weird shape of my dome. My situation is devastating due to my age and lack of money. I feel that NHI is really the most sincere and genuine hair transplant program and would be the most truthful and accurate with any advice they could offer. Thank you in advance for your time, patience, and assistance.

Robbed of Youth

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Returning lost hair may be impractical for genetic hair loss. If you had your hair in tight braids when you were young, what you may be experiencing is some impact of traction alopecia modified by the genetic process. Whatever the cause, you do need to be examined by a competent doctor to make a diagnosis. The drug Propecia can return hair that has been lost, usually not as much in the front as elsewhere on the scalp. This is a prescription item, so again you need to be seen by a good doctor. A good Dermatologist should be able to do this. We have offices in California and and an affliated office in New York, so if you can get to one of our offices, we would be happy to examine you. Otherwise, look for a doctor in your area at You are too young for transplants, so be sure that no one does a hair transplant on you and stay away from anyone that pressures you to do surgery.


Dr. Rassman,
Thanks for taking the time to review my circumstance. i am 35 yrs old and have been thinning for the last 5-6 years. I currently use minoxidil and the lost has seemed to stop. A dermatologist said it was MPb after a brief exam. There are a couple of reasons why i disagree with this. first there is not one case of any member of my family even thinning much less losing their hair. second my hair doesnt look like a typical MPB patient. i have a real good hairline and decent coverage all over the top its just thin, much thinner than the sides which are quiet full. i also visited a Hair center to discuss some options and the interviewer was agreed that it didnt fit the normal profile. I am wondering if it is a hormonal issue. I took accutane when i was younger if that has any bearing. Also around the time i started losing my hair i started to sweat a bit more than usual Any help would be greatly appreciated

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Genetic variations are wide and family patterns do not always show balding. Now with that said, I would want to see you to map out the miniaturization in the head and then determine if this is one of the variations we see in genetic hair loss. Accutane clearly does participate in the process and if you are genetically prone, it may contribute to the genetic hair loss.

Send me pictures as a start (my email address is on the Contact page). You clearly need a diagnosis. Let me know which city you are in and if you are not near one of our offices, I may be able to refer you to someone who can help make a diagnosis.


I was prescribed topical estradiol shampoo .05% for hair loss (Bout with TE spring 2004, Hair wasn’t growing back in very well in some areas). Within 3mos. of using this hair is now falling out. Do you have any information on this. My Dr. says that it does not cause hair loss suppose to maintain growing phase longer. Came across a study that says that it can induce hair into telogen. Who’s right? Any help would be greatly appreciated!!!!

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Yes, hormones can cause hair loss. Female hair loss is a strange ‘beast’ because our understanding of it is very poor. The best indication of the hair loss impact of your estradiol is the observation that it caused hair loss in your situation. I would suggest stopping it and seeing if it returns. You might have to wait 6 months for reversal.


Dr. Rassman:
I am a 25 year old male who over the past 2 years has begun to see hairloss (receding hairline starting at the front middle forehead and working its way back). I am using rogaine 5% and Propecia daily. Its been 12 months and I swear it doesnt seem to be working. Now I never noticed hair on the pillow, etc, but the loss was becoming apparant, and I am still not seeing it on my pillow. I can not go bald (many many nasty scars on the old dome). At 25 is it reasonable to get a transplant if I want to keep from getting to stage 3, 4, etc. My mother’s father was almost entirely bald, but no one else seems to have problems. What else should I try or do? Suppliments? I live in Florida and noticed you are only in California. How can I get an idea of cost, etc without flying to California? Please help!

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At 25, with your history, it is most likely that your genetics are dictating the hair loss process. With both Rogaine (weak medication) and Propecia (strong medication) your ability to stop frontal hair loss appears improbable. You must assume that you will be like your family hair loss pattern (worst case scenario) and if you elect to go the transplant route, then starting in the front and working backward is the best way to go about it. It is possible that the medications you are taking may stop the hair loss short of your full family pattern, but I suspect the frontal hair will be lost. These medications work better on the back of your head than on the front. This makes you a wonderful hair transplant candidate, something we do on young men of your age all of the time.

First, take some good digital pictures of your balding head from front, top and sides, wet and dry then email them to me (my address is on the Contact page. If you are not technical, call my office 800-NEW-HAIR and we will send you a disposable camera. Then the next step will be a telephone consultation with us. From that point on, at the least, we can talk from ‘the same page’ knowing what is really happening. If you elect to come to California, then there is air fare subsidization of your trip and a night in a hotel (on us) once you arrive for your surgery. More info on the NHI Travel Program available at this page. When we speak, I can give you a cost estimate, best and worst case.


Another Propecia question, this time from Thomas…

I have been on propecia now 9 months and have receded more and gotten thinner on top. Propecia either accelerated my mpb or did nothing for it. I am worse off now then when i started. I never used to have hair in the shower, on my hands, or in the sink..Ever since the 3rd month on propecia, it has not stopped. My head even itches now sometimes when it NEVER used to before. My question is can Dutasteride help me or because i had no response to Propecia, is it a waste of time?

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I do not know your age or family history, when you started balding, or what pattern you are heading to. This information is critical. Already you know that Propecia has not helped you (slowed or stopped the hair loss) so this is already atypical. It is possible that you have other than a genetic cause for hair loss. Thyroid disease and some other medical conditions can produce hair loss that will not respond to Propecia.

With regard to Dutasteride, there is no doubt in my mind that it is a better DHT blocker than Propecia, but it has not been proven to be by appropriately controlled studies. A few doctors who I respect have used it for genetic hair loss and they tell me there is significant benefit in some patients that do not respond to Propecia.

First and foremost, you need to have a competent doctor make the assessment. If it proves to be genetic hair loss, then using a non-FDA approved medication (called off label use) has implications for both you and your doctor. If you are in the California area, I would be happy to see you personally and make that assessment.


I am a 23 year old male with an extensive family history of balding. I am well on the way to follow my father and grandfather’s pattern. What can I do?

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I just had a patient of the same age and with the same problem in my office, so I thought it might be worthwhile to read what I wrote to him. I send comprehensive letters like this to all of my prospective patients out of respect. It is always an honor to be able to play such an important role in the life of a patient.

Here’s the letter:

You have an unusual problem found in less than 1% of balding men. Your donor hair density in the rim of ‘permanent’ hair around the side and back of your head is higher than average (300 hairs/cm2 while the average is 200 hairs/cm2) but 1/3rd of these hair show miniaturization. This is the same process that goes on in the balding area on the top of your head and it should not occur on the side and back. When it does, it reflects a condition we have defined in the medical literature which we call Diffuse Unpatterned Alopecia. In essence, you have a process going on throughout the hair on your head, even the ‘permanent’ zone. Now with that said, your effective donor density of 200 hairs/cm2 (which reflect the sum of your hair count less the miniaturized hairs) is from a practical point of view, normal. But the fact that you have this process going on in the permanent zone means that the future of your permanent hair is uncertain. In my fairly wide experience, people who have had Diffuse Unpatterned Alopecia, have not experienced progressive extensive balding in the ‘permanent’ zone, but there is not certainty in your future. In determining your predicament, I would like to call your attention to some of the other elements of the examination I performed on you. Your hair is more coarse than most people, which means that the value of each hair is much higher than a normal person. There is a slight wave to your hair which means that it grooms and covers well with its strong character. Your hair is black and your olive colored skin provides moderate contrast between your hair and skin color, and although your olive skin offsets the dark hair a bit, it still calls attention to a lighter background which might require more coverage to get a full look.

Your biggest problem is the extent of your balding, which appears well on the way to becoming a Class 7 balding pattern (the most advanced pattern) and one that runs in your family. At the age of 23, you have a typical early appearance of this advanced balding process, but that balding process although mild in the top and crown of your head at this time, may respond well to the drug Propecia. You indicated your objection to using this medication to slow down or arrest the hair loss in the top and crown area. Your objections are over the side effects of the drug (rare and unusual). Considering your age, you have a good chance to get some reversal of the balding process in the top and crown area. With the diagnosis of Diffuse Unpatterned Alopecia that we found our your examination, I see even more reason to use the drug. I have seen fully half of the men who take Propecia see some reversal of the diffuse hair loss process in the ‘permanent’ zone, giving you two reasons to reconsider your position against taking this drug.

When dealing with a young man, I tend to be conservative, leaning on the drug treatment to slow down the balding process and for the maturity of the patient to line up with the extent of the problem. By saying this, I do not mean to be offensive, but young men are driven for now answers and often do not see themselves through the entire balding process which may take years. Transplantation, although a wonderful solution when appropriate, is the wrong answer for those who have not worked out a Master Plan with a good doctor that accounts for the worst case scenario of the balding process as modified by a transplant program. That is the dilemma before you and I at this time. You have to convince me that you understand what I know about your hair loss and what can be and can not be done about it. I must understand your maturity in dealing with a transplant program that will be with you the rest of your life. A good doctor/patient relationship is what I am talking about, something that is not easy to obtain in an hour visit to my office.

I am not firm against a transplant solution for your balding but because of the Diffuse Unpatterned element of your Alopecia, I need some comfort that whatever we plan is going to be the right plan for you. I want to speak with you again about the Propecia option and dive more into depth on the various subjects we discussed. We spent a great deal of time discussing the safety issues with Propecia, hopefully giving you more comfort in considering this drug as part of the long term treatment of your progressive hair loss problem.


In the interest of keeping things as private as possible, I have removed the Doctor’s name from this email I received…

Hi Dr. Rassman,
I read your recent comment about young guys under 30 years old who get an HT and are not on Propecia. I fit into that profile. I recently had a HT with [another doctor] and its 4 months post -op now. had a lot of shockloss of original hair post op and am really concerned now that I read your comment online [see: Hair Loss After Transplants]. Since I had sexual side effects when on Propecia, I had to quit it and cannot tolerate being on it.

I received a total of 3366 grafts in total. Am attaching Before Hair transplant pictures with this email and 6 weeks post op pictures. According to [my hair transplant doctor], he feels that the shockloss will mostly come back and eventually I will have good results. He recently asked me to take Saw Palmetto and see if I can tolerate being on it. Started taking 320 mg of Saw Palmetto twice a day recently.

Please advice what I can expect from the procedure. Do you think that I will permenantly lose a lot of original hair that has fallen due to shockloss for good? Or will it mostly come back?

I’m seeing growth in the 4th month but not sure if the shockloss hair is coming back or it is the new grafts that are growing in. To highlight my case, I mostly had diffuse thinning in frontal 1/4 of my scalp. The hair that was there was strong and had a thick shaft, there might be other miniaturized hairs, but looking at my pre-op pictures you will get an idea of the state of the existing hair follicle.

Thanks a lot for your time and effort.

My current regimen includes : minoxidil 5%, topical Spironolactone 5% cream from Lee’s, 3000 Mg of MSM, 2% Nizoral trice a week, Recently added : betnovate topical lotion, 320 mg Saw palmetto twice a day, Folligen lotion.

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I have had an opportunity to review your questions and photographs. For our general audience who are reading this, I will summarize the salient points.

You appeared to have a large surgical session with dense packing based upon the number of grafts reported by you. The frontal area appears to have been shaved for the procedure and the growth of the hair does not reflect the normal growth that one would expect in 3 months. This is a case of hair loss transplant shock in a young man, just as my previous responsive email reported to another young man. There is a possibility that the hair that you lost may come back. Most likely though, it will not return. Other medications have not been shown to be effective (like Propecia). In people like you, I generally try to cover the short term transplant period with half of the Propecia dose, even if it causes some drop in sexual performance just to protect the hair.

The good news however is that the new grafts that you had done should (hopefully) more than offset any loss you may have. You will know reasonably well at about the 7-8th month by comparing the two sides. The left side that seemed to suffer more of the reactive hair loss needs to be compared to the right side. If the hair loss was reversed, the densities of the two sides will be the same. Please drop me a line or send me photographs at the 7-8th month and I would be happy to give you further insights. Good luck.


Rick asked…

Unlike the 62 year old man, I’ll soon be 48 & my loss started about the age of 25, gradually. Now, I am about a VI hair loss on this website’s Norwood Scale & will this new minimal hair transplant I saw on Ch. 4, Bruce Hensel, work for me ? I think the root cause(no pun intended !) is primarily stress. Many thanks in advance.

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Stress is one of the four causes of hair loss in the genetically prone individual. Yes, the minimally invasive surgery, the FOX™ Procedure (Follicular Unit Extraction) can work, but before embarking upon that route, plan on a visit to a competent doctor’s office. If you are in California or the New York area, we have easy access. I assume that since you referenced NBC Channel 4 News, you are local to the Los Angeles area. If you would like more information from me directed at you and your condition, please call for a free consultation or at the very least, send me a photo of your hair loss from a series of views. A good digital camera will work, or call my office at 800-NEW-HAIR or fill out the form on my website and we will send you a disposable camera.


Essie writes…

I have discord lupus and the scarring on my face I know can not be repaired. I also have hair loss in the very front top of my head and where there was hair, there is now scarred scalp. I just want to know if it is possible for even a little encouragement for this head of mine.

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If your disease is not active, then it is possible to use hair transplants to address the balding area. If the disease is active, it will attack the transplanted hair as it had the original hair. Sooner or later, the disease will burn out and then a transplant might become a good option for you.


Dr. Rassman,
I am considering hair transplant but have a question that I cannot find the answer to on any website. What are the long term cosmetic issues associated with a younger person (I am 26) who has hair transplant surgery?

In other words, my hair has begun to recede to an NW 3 (approx.). If I was to have transplants, and several years later my hair line continued to recede, wouldn’t that make an unnatural and strange looking hairline? I.e. there would be transplanted hair at the very front, then further up the scalp there would be a zone with thin or non-existent hair, then there would by my natural hairline.

I hope I have adequately explained myself. Any info you could provide would be great.


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This is a great subject, one that is important to everyone who undergoes a hair transplant. In essence, JX is asking, “How does the hair transplant fit into the changes that keep producing more hair loss?” Much of this material is covered in a book I wrote, The Patient’s Guide to Hair Restoration. You can get a free copy of it by calling my office at 800-NEW-HAIR, or visting our website.

Everyone will lose hair to whatever their genetic pattern will eventually be. Those with advanced balding, usually develop indications of their pattern by the mid-twenties. Most will have their pattern evident by the time they reach 30. It is rare that people will start with hair loss beyond their 30th birthday so a good examination by a competent doctor will show the signs of ‘miniaturization’ on microscopic examination of the hair throughout the head. JX reports a Class 3 pattern hair loss at 26 years of age. Assuming that the pattern will not progress much further (that there is no ‘miniaturization’ of the hair in the mid head or crown), it would be safe to assume that he will not develop an advanced hair loss pattern and that a hair transplant program will never make him abnormal as he progresses slightly from this pattern. If he wishes to get the hair transplanted in the front to return his hair to its normal mature position, he can do this easily. If he uses the drug Propecia, his ability to slow down or stop the hair loss is good. There is now 8 years of good data on Propecia’s ability to slow the hair loss down, but only time will tell us if the medication can continue to be effective in the long term.

I generally tell my patients to create a Worst Case Master Plan which assumes that progressive hair loss will occur. With that Master Plan, you can estimate what might happen and plan for it both economically and socially. The one evident thing to point out is that once a hair transplant process is started, it should be followed with more transplants until the loss stabilizes or it takes you to another hair loss pattern that is found normally in nature. Frontal hair loss only commits the patient to frontal work, not to crown work. Worst, worst case is that with transplants in the front, the balding in the back will reflect what many men have naturally: a full-haired frontal look and a balding or thinning crown. This last scenario is JX’s worst case. If he wishes to see his worst case, he can visit me and look at my before pictures. I had a normal full front of thick hair (naturally) and a bald crown (which I elected to transplant but could have left it alone as an alternative option).


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