A: Both Propecia and Minoxidil definitely can work in the front of the scalp as long as there is some hair in the area. Although their mechanisms of action are different, both Propecia (finasteride) and Rogaine (minoxidil) act to thicken miniaturized hair wherever it’s location. Neither of these medications can grow hair on a bald scalp. I would ignore the package insert in this case, because the FDA limits the indications only to the areas tested in the clinical trials. That is why doctors have the liberty to prescribe medication the way they see fit.

I suggest to stay on the medications for at least a year – results can take this long. If you have not gotten satisfactory growth by that time then a hair transplant can be considered.

Areas of Unethical Behavior Practiced Today
William Rassman, MD, Los Angeles, California

I am disturbed that there is a rise in unethical practices in the hair transplant community. Although many of these practices have been around amongst a small handful of physicians, the recent recession has clearly increased their numbers. Each of us can see evidence of these practices as patients come into our offices and tell us about their experiences. When a patient comes to me and is clearly the victim of unethical behavior I can only react by telling the patient the truth about what my fellow physician has done to them. We have no obligation to protect those doctors in our ranks who practice unethically, so maybe the way we respond is to become a patient advocate, one on one, for each patient so victimized. The following reflects a list of the practices I find so abhorrent:

1. Selling hair transplants to patients who do not need it, just to make money. I have met with an increasing number of very young patients getting hair transplants for changes in the frontal hairline that reflect a maturing hairline, not balding. Also, performing surgery on very young men (18-22) with early miniaturization is in my opinion outside the “Standard of Care”. Treating these young men with a course of approved medications for a full year should be the Standard of Care for all of us.

2. Selling and delivering more grafts than the patient needs. Doctors are tapping the well of the patient’s graft account by adding hundreds or thousands of grafts into areas of the scalp where the miniaturization is minimal and balding is not grossly evident. I have even seen patients that had grafts placed into areas of the scalp where there was no clinically significant miniaturization present. Can you imagine 3,000-4,000 grafts in an early Class 3 balding pattern? Unwise depletion of a patient’s finite donor hair goes on far more frequently than I can say.

3. Putting grafts into areas of normal hair under the guise of preventing hair loss. There are many patients who have balding in the family and watch their own “hair fall” thinking that most of their hair will eventually fall out. A few doctors prey on these patients and actually offer hair transplantation on a preventive basis. This is far more common in women who may not be as familiar with what causes baldness and do not have targeted support systems like this forum. They become more and more desperate over time and are willing to do “anything” to get hair. They are a set-up for physicians with predatory practice styles.

4. Pushing the number of grafts that are not within the skill set of surgeon and/or staff. The push to large megasessions and gigasessions are driven by a limited number of doctors who can safely perform these large sessions. Competitive forces in the marketplace make doctors feel that they must offer the large sessions, even if they can not do them effectively. A small set of doctors promote large sessions of hair transplants, but really do not deliver them, fraudulently collecting fees for services not received by the patient. Fraud is a criminal offense and when we see these patients in consultation, I ask you to consider your obligation under our oaths and our respective state medical board license agencies to report these doctors.

5. Some doctors are coloring the truth with regard to their results, using inflated graft counts, misleading photos, or inaccurate balding classifications. False representation occurs not only to patients while the doctor is selling his skills, but also to professionals in the field when the doctor presents his results. Rigging patient results and testimonials are not uncommon. Lifestyle Lift, a cosmetic surgery company settled a claim by the State of New York over its attempts to produce positive consumer reviews publishing statements on Web sites faking the voices of satisfied customers. Employee of this company reportedly produced substantial content for the web.

The hair transplant physician community has developed wonderful technology that could never have been imagined 20 years ago. The results of modern hair transplantation have produced many satisfied patients and the connection between what we represent to our patient and what we can realistically do is impressive today. Unfortunately, a small handful of physicians have developed predatory behavior that is negatively impacting all of us and each of us sees this almost daily in our practices. Writing an opinion piece like this is not a pleasant process, but what I have said here needs to be said. According to the American Medical Association Opinion 9.031- “Physicians have an ethical obligation to report impaired, incompetent, and/or unethical colleagues in accordance with the legal requirements in each state……”

Rassman, WR: Areas of unethical behavior practiced today. Hair Transplant Forum Intl. Sep/Oct 2009; 19(5) 1,153.

A: This is a question that should be addressed to the doctor that operated on you.

If a doctor is charging by the graft, then you should know exactly how many grafts you are receiving. It is possible that he/she hit the number (2500) exactly on the head, but statistically that is extremely unlikely. In a Follicular Unit Hair Transplant (FUT) procedure, a strip is removed from the donor area and then dissected into individual follicular units, so although an experienced surgeon can remove a strip that contains close to the desired number of follicular units, it would be very rare to hit that number precisely.

More importantly, it is impossible to perform follicular unit transplantation properly without knowing both the exact number of follicular units harvested from the donor area and the exact number of hairs in each unit (i.e. the number of 1-, 2-, 3-, and 4-hair follicular unit grafts). This information is essential in determining both the distribution and density of the hair transplant and in creating transitional zones such as the frontal hairline, where single-hair follicular units are required.

In all hair transplants, the number of grafts harvested should equal the number of recipient sites, so the doctor must know the exact number of grafts so that he can make the appropriate number of recipient sites. An exception to this rule is the stick and place technique, where each graft is inserted as soon as the site is made, but this technique is much less common than first making the recipient sites. The surgeon also needs to know the number of grafts so that he can make the sites in the appropriate distribution. For example, if the number of grafts harvested was less than anticipated, the doctor can space the sites further apart, cover less of an area (for example, not extend the restoration as far back into the crown) or harvest additional donor tissue – each option having advantages and disadvantages.

It is equally important to know the exact composition of follicular units, so that different densities can be created in different areas, producing the most natural appearance. For example, the 3- and 4- hair follicular units should be placed in the central forelock area as this area normally has the most density. On the other hand, if these larger units are placed near the hairline, they will look distinctly unnatural.

So how can the patient really know? Obviously, trust in your doctor is the most important insurance. If you are skeptical about the way the doctor conducted the consult (i.e. used a salesman to encourage a sale), if he or she skipped over important options such as medication, or if you felt pressured or rushed into making a decision to have surgery; you should be skeptical about other aspects of your care as well – such as an accurate graft count.

Although just a very general guide, here are some things you can do at your consult when trying to decide if a doctor can be trusted to give you accurate information regarding the number of grafts you receive.

1. Ask to see the operating room – see if there are plenty of microscopes (the larger the session, the more are needed).
2. Ask the doctor how he keeps count of the grafts that are dissected and how does he record how many hairs in each follicular unit graft.
3. Ask the doctor how he keeps track of the number of recipient sites that are made.
4. Ask to see how all this information is documented in the patient’s medical record.
5. Ask the doctor if he refunds money to the patient if he transplants less grafts than scheduled.
6. Speak with other staff members to confirm the use of dissecting microscopes for the entire surgery and confirm the procedure for tracking grafts.

In sum, knowing the exact number of grafts and their composition is extremely important, not only to ensure that you are being charged fairly, but in maximizing the aesthetic results of your follicular unit transplant procedure.

Be certain that this information will be available to you (and of course your surgeon) before scheduling a procedure.

So you have become reacquainted with your scalp (a place on your body that you hoped to remain strangers with), and it looks like you’re about to see a lot more of it if you don’t find a solution soon. You’ve tried a few “cures” already; Rogaine, Propecia, Saw Palmetto oil, and vigorous scalp massage, you are now considering having a hair transplant.

Surprisingly, people generally spend more time researching a new car purchase than they do choosing a surgeon, but researching the right hair transplant doctor is not something you want to rush through. There are a couple of things you will want to be mindful of when seeking a surgeon for a hair replacement operation. Here are a few tips to help you when interviewing a doctor for your hair loss.

Starting Your Research
Hair transplantation has become a fairly large field with many doctors performing these procedures. There are some great surgeons out there and some lousy ones (evidenced by some of the unnatural looking hair transplants that we have all seen). How do you start your quest to find the best physician for you?

In general, the best way to find a physician is through a referral either from your dermatologist, GP, or from another patient. The worst way to choose a doctor, who may be performing surgery on your head, is via infomercials or aggressive marketing campaigns. You should be wary of any medical practice that is spending lots of money on marketing, rather on patient care.

The internet can also be helpful in your research because, unlike infomercials and TV ads, where the doctor can make any kind of claim they want to, online message boards and user forums make it difficult for a doctor to control what is being said about them. But remember that on the internet you have to take any medical advice you might read with a grain of salt.

The Doctor’s Background
The first thing you will want to know is what the doctor’s specialty is. Ideally, he or she is a board certified dermatologist or plastic surgeon. If they do not specialize in these two fields ask them why they have chosen to work in hair restoration. If they are trained as a gynecologist or an internist, why are they doing hair? You are within your rights to know the answer and you should be concerned that they are only in it for the money.

Doctors to consider should be members of the International Society of Hair Restoration Surgery (ISHRS) and be Diplomats of the American Board of Hair Restoration Surgery (ABHRS). The ABHRS is the only board in the United States that certifies hair transplant surgeons.

There are a number of non-physician consumer advocacy groups that help consumers find the best doctors in the field. The most popular are the Coalition of Independent Hair Restoration Physicians and the International Alliance of Hair Restoration Surgeons (IAHRS).

The most coveted awards in the field of hair restoration are the Golden and Platinum Follicle Awards given by The International Society of Hair Restoration Surgery (ISHRS) for outstanding achievements in science or clinical research relating to hair restoration. If the prospective doctor is the recipient of either of these awards, this would certainly show the confidence that their peers have in their skills and abilities as hair restoration surgeons. Each of these is given to only one outstanding physician a year.

Lastly, feel free to inquire if the doctor has helped contribute to the science of hair restoration by performing some research in the field and publishing his or her findings. Publishing medical papers shows that the physician is sharing ideas and experience with other doctors in order to promote patient care. If the publications are in peer reviewed medical journals, the medical community holds them to be of significant value.

Techniques and Approach
You are going to want to ask the Doctor what techniques they use and how long they’ve been performing them. Follicular Unit Transplantation, or FUT for short, is the procedure that has made modern hair transplantation completely natural – if performed correctly that is. If they do perform FUT, ask the doctor where they learned it. It is preferably that they learned the procedure from one of the technique pioneers, like Dr. Robert Bernstein, Dr. William Rassman or Dr. Bobby Limmer. This will give you a sense of whether they really know the nuances of this procedure.

When conducting your interview, ask whether the surgical staff uses microscopes for dissection, loop magnification, or simply the naked eye. Using the naked eye does not allow the optimal harvesting of the follicular units and loop magnification is only a tad better. Stereo-microscopes allow the surgeon and his team to perform the most accurate graft dissection and best preserve donor hair. Take a look at the operating room to make sure it has clean up-to-date equipment, and that there are plenty of microscopes on hand, as each clinical staff member will need one.

Questions to Ask

• What percentage of patients do you recommend surgery for? (People may not be candidates for a hair transplant for a variety of reasons. If the doctor recommends surgery for most patients that he sees, then something is wrong). Many men with early hair loss should be first treated with medication and the majority of women is actually not good candidates for surgery (because of their generalized thinning) and will never be.
• What about shedding? (If the doctor says “my techniques are very good so my patient’s never shed existing hair after surgery” then run out the door because that is simply not a realistic prediction of the surgical outcome of a hair transplant).
• What did my examination show? (The doctor should be able to tell you exactly what he ascertained about your hair loss condition after examining you).
• What age do you start treating patients? (Anyone under 25 has yet to display the traits used to predict their hair loss in say 10 years, for that reason a good surgeon will not perform a hair transplant on anyone too young).

Red Flags
Here are a few red flags to tip you off that a medical practitioner may not have the patient’s best interest at heart:

• Are you being evaluated by a salesman or a doctor? (Though it is fine for a medical assistant to answer general questions, and a salesman to answer financial ones, any examination should be conducted by a doctor and he should be the one making the recommendations. The doctor should not come in as the finisher; he should be the starter and the only one practicing medicine.
• Is your consultation focused on your long-term plan for your hair loss problem or is it just about quickly getting a “hair fix”? (A good doctor will be thinking about where your hair loss is headed many years from now.)
• Is the doctor examining you thoroughly? (He or she should not take a cursory glance at the back of your head and exclaim “oh you’re a great candidate for a hair transplant!” Make sure that you are examined very carefully, having your density checked, with a diagnostic tool called a densitometer, and your scalp assessed for laxity.)
• Is your doctor at the office all the time or does he travel from office to office with some other person doing the follow-up care?
• Are you getting the feeling that you are being rushed? (Hair restoration surgery, or any cosmetic procedure, is not right for everyone. It is important that the doctor not rush you into surgery, but rather discuss all options, emphasizing the importance of medical therapy with, or without, surgery.)

When choosing any kind of health care practitioner a patient should always go with their gut. If you feel uncomfortable with a doctor, it is usually a sign that you are in the wrong place.

What to Focus On
Surgical hair restoration has made some remarkable advances in the past 5-10 years and a hair transplant might be a solution for your hair loss, but only an experienced doctor can determine the likelihood of your benefiting from this option. You should find a health professional specializing in the diagnosis and management of hair loss. Make sure his or her focus is on finding the optimal course of action for treating your future hair loss for the long-term – be it medical or surgical. And resist the dangerous temptation toward self diagnosis and, of course, don’t rush any decisions. Good Luck!

A: I perform all the consults myself. I invariably start with a very open ended question as this allows the patient to really express what his/her concerns are and I am often surprised by what I hear.

I agree that the doctor should not have pre-conceived notions about what a patient wants or what he or she is feeling. This doesn’t mean that the doctor can’t advise a patient on what we believe to be the best course of treatment, but we must listen first if we are gong to really help you.

Once the patient has told his story, a thorough history is important to rule out medical conditions – this is essential with women where the diagnosis of androgenetic hair loss is not often clear. A careful exam will enable the physician to see if the patient has sufficient hair resources to match his/her goals.

The specific aesthetic needs of the patient, particularly with respect to hairline design, should be discussed in detail and, most importantly, there should be a long-term plan in the event of further hair loss.

For more extensive information, please read the Follicular Transplantation: Patient Evaluation and Surgical Planning page of the Bernstein Medical – Center for Hair Restoration website.