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If a layperson tries mapping out their scalp for miniaturization are they really going to be able to tell the difference from a hair in a certain stage of miniaturization and a new hair growing in? Or from a miniaturized hair getting thicker. I would think it would take a trained professional eye. Especially if someone has already started treatment.


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If you follow the tutorials on mapping your own scalp (see BaldingForum) some of this information is not difficult to get as long as you have the proper tool. Using a video microscope, you take photos of various areas of your scalp and compare those photographs a year later at the same location. Then it will be easy to see what has happened to your hair. You do not have to be a rocket scientist to do this, just a motivated victim of hair loss.

That being said — yes, I can tell much more because of the years of experience I have. I was one of the first ever to do this and it reflected my invention (U.S. Patent 5,331,472), which defined the process for measuring hair density and observing the appearance and thickness of the hair. I then published the same process in various articles written since 1993 (see my CV for a list).

Tags: miniaturization, mapping, hairloss, hair loss, patent


Dr. Rassman,

I read your blog daily and really enjoyed the educational pieces about miniaturization that you recently posted. You made a comment that you have never understood why your colleagues don’t accept the approach you recommend for doing miniaturization studies.

I will probably be looking at getting a hair- transplant within the next 24 months. Because I work 7 days a week due to being self-employed, I cannot afford to miss work and come to see you. Fortunately, I have a very good surgeon about 45 minutes away. When I called his office though to inquire about miniaturization studies, his staff had no idea what I was asking about. I recently e-mailed the doctor to ask him about it. Below is my e-mail and his response to it. Perhaps his response will help to inform you of why some of your fellow surgeons do not embrace the concept. After reading, please tell me what you think in regards to his comments. Hopefully, maybe, everyone can eventually come to an agreement.

This is my e-mail to the doctor in question:

Dear Dr. (name withheld)

I will be looking into getting a possible hair- transplant within the next 24 months. I have been educating myself fiercely. I have become almost addicted to learning about hairloss. I have been listening to Spencer Kobren for the last year and have spent literally hundreds of hours on various hairloss forums. I am also a daily reader of Dr. Rassman’s Balding Blog.

One thing that Dr. Rassman constantly stresses is the importance of getting miniaturization studies done. The miniaturization study serves two important benefits. It predicts your eventual hairloss pattern and gives a baseline to show if, and how, other modalities such as Propecia and Rogaine are working.

I was very concerned when I called your office about 4 months ago to inquire about getting one prior to a transplant to “assess my damage” and to get a baseline, because I want to first try Rogaine and Propecia prior to a future transplant. I was very alarmed when your staff had no idea what I was even asking about. When I pushed the issue with the girl who took my call (she said she’s never heard of such a thing) she said she would check with someone else. She came back on the phone a few minutes later and said she spoke with you and claimed you said miniaturization studies aren’t done or needed because if you are already losing your hair, you don’t need a study to tell you so! This is false and there are several very valid reasons for getting them done.

Is this true that you don’t do them or recommend them?

Please advise.

This is the doctor’s response:

Bill Rassman is a good friend of mine and a top tier surgeon, and we generally agree on almost everything. On the matter of miniaturization studies though, we apparently disagree.

You made the following statement: It predicts your eventual hair loss pattern and gives a baseline to show if, and how, other modalities such as Propecia and Rogaine are working.

I am not aware of any technique that has been shown to reliably predict the eventual hair loss pattern. That would require many years of followup to determine accuracy, and that has simply not been done. Furthermore, there is no evidence that a magnified assessment is superior to a “naked eye” assessment.

While its true that magnified images can be dramatic, and can be helpful to show a patient his or her status, no experienced surgeon needs it to determine who is a good candidate for surgery and who should be rejected, nor to determine where to place the transplanted hairs. If a miniaturization study predicted only a Norwood III pattern, would it be safe to transplant a very low hairline? I would say no.

I was taught early in my medical career to perform a test or study only if the results would change the outcome, and in my opinion a miniaturization study would not give me any information I would not already have. I have no problem with the use of these studies, but they are not part of the “standard of care.” I do perform a magnified view of the donor area with a handheld device to determine density, and to determine how long and wide the strip should be, and obtain high magnification digital photography if a density study is to be performed.

As far as using Propecia and or Rogaine prior to a transplant, I think that’s a great idea, but you will not need the miniaturization study to know if those products are working. Standard photography and self assessments will do that quite well. {END}

I have removed all references to the doctor’s identity, but I can e-mail his name privately if you would like to know. I am very curious as to what you think of his response to the miniaturization studies you advocate.

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Dr RassmanBest if I give you an example of a patient I saw yesterday. He was 39 years old and lost 1/2 inch of frontal hairline above where his mature hairline would be. He wanted it back.

He had no balding to the naked eye and when I mapped out his head for miniaturization, there was absolutely none present anywhere else on the scalp. He was started on Propecia and we arranged for a hair transplant. He asked what his future might look like and I said that based upon no miniaturization on his scalp (even on the leading bald edge where he missing hair was), the use of Propecia and his age, it would be unlikely that he will bald further.

Earlier in the week I saw another patient with a similar presentation. He was 34 years old with no evident balding in the top or back of his head, but when I mapped out the scalp, he had significant miniaturization in its early state impacting 80% of the hair in the front and top and 30% of the hair in the upper crown area. I told him that his future may not be bright and that his balding could progress further back. Only the Propecia will possibly thwart the process. I also told him that in a year we can remeasure his miniaturization and if the drug reversed it, it would be likely that he could control it, but if the drug did not and the process advanced, then he might be into more transplants down the road.

I clearly could not give either patient an absolute guarantee on what might happen to him, but using a metric and a little bit of science, both patients felt that they received value from my opinion and measurements.

Tags: miniaturization, hairloss, hair loss, doctor, physician, propecia, finasteride


I have a hair transplant procedure scheduled with a ABHRS surgeon yet I’m starting to have some concerns due the HLH/HTN websites.

Concern 1) On the HTN/HLH website there are a handful of doctors mentioned often in the forums – shaprio, wong, hasson, fellar and ironically these are the same docs that do most of the advertising – any other doctors basically sounds inferior. I find it hard to believe so many doctors are being excluded and if you mention their name on the forums the immediate majority response is see one the “HLH/HTN” inner-circle of doctors… Are these sites more of a gimmick then a legit source of information and where do you recommend finding a valid source of information regarding a hair transplant surgeon?

Concern 2) How much weight to put on the ABHRS certification. One of the boards member I believe is closely tied to MHR/Bosley – and that company just gets flamed on the HLH/HTN forums?

Thanks In Advance For The Time!

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The advertising websites like Hair Transplant Network (HTN) and Hair Loss Help (HLH) provide a forum for their doctors to “pitch” the public with a storyline about themselves. These sites do restrict doctors to those who they believe perform only follicular unit transplantation and those who are willing to pay a fee to get the endorsements of the HTN/HLH websites. Some physicians do not like the politics of these websites, and certainly the HTN/HLH forums can be harsh on doctors (particularly if they are not paying members). Members are not necessarily spared from harsh criticism just because they pay their monthly fee, though. I have seen firsthand that these forums will try to implement controls on its user audience, but if freedom of speech is what is claimed, clamping down on vocal forum users can be difficult. Some forum users have too much time on their hands, are malicious jerks, or just lonely people who use the forums to obtain an audience. Others like the comradery of the group and provide interesting feedback on a variety of disparate subjects, so their input can be illuminating. If I were to have one criticism of those sites, it would be that many forum participants are out of their league with regard to the medical jargon and what it means, or when the issues of complications of surgery come up, there is a naivety in forum participants that everything is black or white. You need to do your own research — view photos, meet patients — and use these forums as a starting point, but don’t just accept 100% of what is written. As for why some doctors seem to be in the inner circle, I think it has to do with participation. The more these doctors participate, the more fans they gather, and the more vocal those fans become about those doctors. As for me, I tend to devote most of my available time to this site.

With regard to the American Board of Hair Restoration Surgery (ABHRS) certification, what this shows is whether these doctors passed the oral and written examination, and gained a standard of knowledge. The problem with the ABHRS is that the training of a hair restoration doctor is a willy nilly process that does not prove if the doctor is capable of performing the surgery with knowledge or wisdom under any reasonable situations that reflect the reality of the field.

When I took (and passed) the American Board of Surgery examination, it was two years after a five year intensive period of practical training with mentors (expert surgeons) watching me every step of the way. I was judged competent by these professors because they watched me as I made decisions and they followed the outcomes of my patients by direct observations of my results. The ABHRS can not replicate that type of control, so that means to me that their certification may have limited value to book testing alone. There are no great systems out there for quality certification of skill and knowledge as they integrate with each other in the field of hair restoration surgery. As I have said over and over again here on BaldingBlog — let the buyer beware!

Tags: hair transplant, htn, hairlosshelp, hairtransplantnetwork, forum, hairloss, hair loss, surgeon, doctor, abhrs


I am 31 years old. I have always had very dense hair until my 25-26, then I started to loose hair on top and crown while preserving hairline (diffuse pattern hair loss). I had two transplantations of 1000 and 2000 grafts. At the time waiting for the results of the second operation. My question is about estimating my future norwood scale. First of all how can I measure if I am a class 6 or 7? Secondly my rim hair from front to back seems to go down more. Is this common or sign of bad news? I heard that rim hair of 3 inches or less is norwood 7. Is this true? because 3 inches looks like very high.

Best Regards

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The permanent rim usually measures about 2 1/2 inches high in the mid-back of the head, but that does not count neck hair. The rim is measured from the prominence of the bone in the back of the skull upward, and all hair below this in the back is considered neck hair. The rim on the side in the Class 7 patient can be a bit higher (3 inches or so).

Norwood Class 6 Norwood Class 7

Look carefully at the two pictures of the Norwood Classification as shown above. For some bulleted descriptions of each Norwood class, you can check the Assessing Hair Loss page at the NHI site. Also, you and your transplant doctor should have this discussion as part of your long term planning.

Tags: hairloss, hair loss, norwood, balding


Dear Doctor,

I have been doing a lot of reading about hair transplants because I see one in my near future. I have heard enough horror stories to know the importance of choosing a great transplant surgeon.

It just seems to me that the doctor’s role is “overrated.” I certainly do not mean any disrespect by that, but it seems that the transplant technicians have more of a role in the outcome, whether it be good or bad, than the doctor himself.

From what I understand, the doctor justs removes the donor strip, sutures the incision and makes the recipient sites. I may be ignorant of the matter, but this seems like something any general surgeon can easily do. The technicians though are responsible for dissecting and actually placing the grafts. If a transplant’s outcome is judged to be a success or not by the number of grafts that actually grow, then it seems that the technicians were more responsible for the outcome than the surgeon who merely made the holes in the person’s head.

I hope you don’t take anything I wrote as a slight against you or your profession, but if what I wrote is not true, please tell me what am I missing in my thinking?

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The role of the technician is very important. What they do requires special skills that are tedious and at times require years to perfect. The hair that is cut from the strip must be efficiently dissected under the microscope and handled efficiently. Such work is best for a technician who has these functions as their sole activity. It takes a certain type of personality to be able to perform this type of work, great dexterity, and hand-eye coordination. Not to say no doctor has these things, but the complete skill list is honestly not the type that most doctors have. When I started to do the hair transplant procedures in larger and larger sessions, I originally participated in the cutting and placing the grafts, for it was I who defined the standards that the technicians would be held accountable for. So in the early days (1992-1993), I was the fastest graft preparer and the fastest graft placer, but as the graft counts went into the thousands of grafts, the work required more and more labor. Four or five technicians are a minimum number required for a large case of over 3000 grafts in 6-7 hours.

If I was to do this myself without the technicians, it would take me more than 24 hours and I would be exhausted, my eye strain would be incalculable, and the grafts may have died off by the time their turn came to placing them. If a graft is out of the body more than 8 hours, the death rate for the grafts runs 1% per hour. One could say, “Hey, lets get 5 surgeons to replace the 5 or so technicians,” but what that would do is:

  1. Slow the process down, as doctors are generally not good at such disciplines.
  2. Reduce the quality of the work, as doctors can not do repetitive work reliably for they often lack the patience.
  3. Drive up the costs substantially out of the reach of most recipients, as doctors make more money than technicians.

Those reasons, in a nutshell, are why technicians are used throughout surgery. Another example where technicians are used in surgical procedures — open heart surgery. It is the pump technicians that control the patient’s circulation.

Now with regard to what the surgeon does, it is not as simple as you suggest. There is a special skill required in planning the surgery, and I suppose to prove this you’d have to spend a day with me to see the many patients that come in for repairs with results reflecting a lack of strategy in their hair transplant procedure. When a doctor just looks at it as cutting out a strip and putting holes in the head of the patient, the results can be frequently substandard. So while I don’t take what you said as a slight, I hope this helps explain things a little better.

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


Dr. Rassman,
First, let me thank you for the valuable resource your blog provides. I understand that it is in men’s nature to become concerned about hair loss as we age. I also understand that you have answered this question, or at least very similar questions many times. I’ll ask anyway, because you seem like a good guy.

I am a 27 year old white man. I have severe depression and OCD. I recently (past couple of months) started obsessing about my hair. I’ve always been overly concerned about the way I look, and I’ve always been severely lacking in self confidence. When I tilt my head back and look up at the front of my hair line in under direct light from a couple inches away, I can see scalp going back about two inches. When I tilt my head forward, I see no scalp and my hair looks the same as it always has. There are a few long hairs growing below my hairline. I dont notice a change in my hairline when compared with photos taken when I was in my early 20’s. If I pull hard on my hair around my hairline, nothing comes out. Same with the crown. My mom’s dad died with a full head of hair in his 90’s. My dad thinned over the course of his life, but didn’t really go “bald” until he was in his early 50’s. He’s now maybe a norwood 3v or 4. His dad had the same pattern, except it didn’t kick in until later in life. My mom’s brother went bald young. My maternal great grandfather had Homer Simpson’s hair by the time he was 30 or so. My dad’s brother still has a good head of hair in his 50’s. What do you think (and I know you can’t really tell without a miniaturization study)… which leads me to my next question.

Is a miniaturization mapping something that is common among dermatologists? Do most of them (in your experience) properly perform and understand the procedure? Is this something that has been written about in peer-reviewed publications? Will a dermatologist that does not specialize in hair loss be able to correctly diagnose what is going on with my hair (if anything)? Thank you very much for your time.

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If you know you have OCD and are starting to obsess about your hair, I think you answered your own question about what my thoughts are. You’re seeing possible thinning when your head is tilted and you’re under direct light. The hair will generally appear thinner under harsh lighting.

I wrote about this when I applied for a US patent in 1992. I published it in various articles, not suggesting mapping the head, but showing the connection between balding patterns and miniaturization. The rest is not rocket science. It is not exciting to map out the scalp for miniaturization and actually if the doctor is knowledgeable, then a good sweep of the scalp will give the needed information for a well trained physician.

Many doctors now have video imaging systems in their office, like slightly more expensive versions of the USB video microscope mentioned in the Mapping Your Own Scalp series. For around $100, you can buy this microscope for yourself and get the mapping started. One of the biggest reasons that I created was because of comments like yours — that forum gives site visitors the chance to empower themselves by mapping their own hair and making their own diagnosis, following the process over time with aging, drugs, etc. You can share your results with others and get feedback from other site members, not just from me (time is always a problem for me, because I can’t just get to everyone). I believe that the real power will be in the hands of people like you — those who just want to know what is happening to them.

Tags: miniaturization, hairloss, hair loss, mapping


I met with a patient last week who had a spectacular head of hair. On examination of the scalp there was absolutely no miniaturization anywhere, indicating that he had no genetic balding.

He was an obsessive young man who wanted to be sure that he was not going to go bald, as some of his male family members had. Because he needed the advise of a doctor to determine if he was losing his hair and what his future might be, he went to a hair transplant surgeon who determined that he might go bald and needed to do something about it. The young patient showed some maturing of his hairline only in the corners and even that assessment (by me) may be overstated, but because of the power of the doctor’s magnetic personality, the young man was convinced that he needed a transplant and got 800 grafts into the corners of his frontal hairline. The transplant clearly did damage, so he lost hair around the transplant area and many of the grafts did not grow.

Too many young men are receiving hair transplants when they are not indicated, even showing no balding. I would suggest that everyone considering a hair transplant to map out their own hair for miniaturization and if there is none, you can then confidently say that you are not balding and not fall for traps like what this young man fell for. It is unfortunate that many people are preyed upon by surgeons looking to pad their wallets, but you need to be smart about what you’re getting yourself into. Educate yourself and use the tools available online to be able to better understand things. The patient story I described above ended up leaving this young man worse off than before he ever went to see that surgeon. This site is free for anyone to use and learn from, and I am an outspoken member of my community simply because I don’t like to see people taken advantage of. I routinely turn patients down for surgery if I can see they are not candidates or a simple daily pill could be the solution they are looking for.

Tags: scam, hair transplant, hairtransplant, patients, patient, surgery, hairloss, hair loss


Hi there, what type of work can a RN nurse do in this field? and what type of salary is she looking at?

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Registered nurses require considerable training to becoming an expert in the field, but these are skills that must be learned and practice is essential. For example, we can all go skiing, but there are various skill levels of the skiers. Becoming an expert skier takes quite a bit of time and practice. This is the case for hair transplant work on the technical level. Many areas, such as anesthesia, are relatively easy to teach, but practicing with cutting and placing grafts takes time. The average time ranges from 6 months – 10 years. Yes, quite a range. Even at 10 years of experience, some people just never learn what they need to become proficient. Salaries can be competitive with hospital work with proper expertise in the field. We do not employ RNs in our practice at this time.

Tags: nurse, hair transplant, hairtransplant, technician, staff, registered nurse, hairloss, hair loss, surgery


Good Morning Doctor,

My husband is consider hair restoration surgery. We are looking for a qualified surgeon. Are there training programs for hair restoration surgery I SHOULD be asking our doctor if he or she attended? It seems like a lot of dermatologists are doing this surgery, but I don’t see a training program or fellowship in hair restoration in their title or advertisements. Is this something the doctor learns on his/her own? What should I look for to be sure I’m getting a good doctor?


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I’ve written about this many times. The first link below is probably the most comprehensive of the articles I wrote on the subject, but the others should also prove helpful:

Many doctors do learn this on their own and some of those doctors learned it well, while others never learn it. I’ve discussed how to select a doctor and what to look out for in the following posts:

Tags: doctor, doctors, physician, surgeon, hairloss, hair loss, hairtransplant, hair transplant, credentials


Im sure these are some basic questions you’ve answered before, so feel free to direct me to a previous answer. I’m 42, and my hair is starting to both thin and recede, It bothers me quite a bit.

  1. you say very often get examined by a professional. where do i start? is this my regular doctor, or i need to go somewhere else.
  2. What is the difference between rogaine and propecia, and who would be best to recommend what would make the most sense for me?

thanks very much for any help you can provide.

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DoctorYou should go to a good dermatologist with an interest in hair loss. Call his/her office to find out if they are the best one to treat you. Alternatively, you can see a hair transplant doctor (they have an obvious interest in hair), but don’t get yourself rushed into surgery. I see quite a number of men with problems like you describe.

There are huge differences between Rogaine (minoxidil) or Propecia (finasteride). For starters, Propecia is an oral prescription medication and Rogaine is a topical over-the-counter medication. They each have their own set of possible side effects and they both are currently the only FDA approved medications for treating hair loss. I usually recommend Propecia for early hair loss, but as it is a prescription medication, your doctor will be able to give you all the proper information about it. I wrote about this briefly before — “The two drugs work differently. Propecia is more predictable than minoxidil, but they could work together. I have seen hair come back with minoxidil, however I have seen more patients show great benefits from Propecia.

For more, Wikipedia has good info about minoxidil and finasteride.

Please note: the above image is not an endorsement of child doctors.

Tags: hairloss, hair loss, propecia, rogaine, minoxidil, finasteride


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