Do Hair Transplants Debunk The Scalp Tension-Hair Loss Hypothesis?

Does a tight scalp cause pattern hair loss? This question recently resurfaced in hair loss forums… sparking heated debate from scalp tension supporters and opposers.

The supporters: scalp tension must contribute to hair loss. Why? Because balding men and women tend to have chronically tight scalps. This tension tends to match the pattern and progression of hair loss. And when we look at the effects of chronic tension in other tissues, we see near-perfect overlap with the biomarkers of a balding scalp: increased androgen activity, excess collagen deposition, tissue degradation, and hair loss.

Thus, scalp tension must be involved in pattern hair loss. Scalp tightness not only fits within the current androgenic theory, but also helps to answer many questions that the androgenic theory can’t – like why dihydrotestosterone (or DHT) increases in balding scalps… why DHT leads to hair loss in the scalp but hair growth in the chest and face… and why androgenic alopecia occurs in a specific pattern and progression.

But there’s one thing scalp tension advocates can’t explain: hair transplantation results. In fact, hair transplantation studies are the strongest opposition against the scalp tension theory. They’re also the rallying cry for the theory’s opposition.

The opposers: the entire idea that scalp tension contributes to pattern hair loss hangs on one major assumption: that our scalp environment influences our hair follicles’ ability to grow hair. However, this assumption is false. It was disproven in 1959 with the first study on hair transplantations. This study showed that…

  1. Non-balding hairs transplanted to balding regions will keep growing normally.
  2. Thinning hairs transplanted to non-thinning regions will keep balding at the same rate as other balding hairs in the scalp.

These findings, according to critics, demonstrate that androgenic alopecia has nothing to do with our scalp environment (or scalp tightness). Rather, pattern baldness must be genetically programmed within the follicles themselves. In other words, it’s the interaction between androgens and genetics that likely determines our hair follicles’ predisposition for hair loss and our baldness “clock”… not scalp tension.

So who is right? Who is wrong? And do these hair transplantation studies overturn the scalp tension-hair loss hypothesis… or are we missing something in our logic?

That’s what this article is for.

This is part two of a three-part series on scalp tightness and androgenic alopecia.

In the first article, we explored the science behind how scalp tension might contribute to androgenic alopecia. Now it’s time to build the scalp tightness counterargument.

First, we’ll dive into the scalp tension theory’s opposition and uncover the hair transplantation studies that changed the trajectory of hair loss research. Then we’ll reevaluate those studies in light of new evidence… and see if the conclusions from 1959 still hold today.

Finally, we’ll present new evidence to suggest that our scalp’s environment might influence our hair follicle’s ability to grow. In doing so, we’ll revisit the concept of donor dominance… and list some discrepancies in its theory.

By the end, we should have a firm understanding of the arguments for and against the scalp tension theory of androgenic alopecia. That way, you can decide what to believe. After all, hair loss research is always up for reinterpretation.

If you have any questions, I’m happy to address them in the comments.

The argument against the scalp tension theory: hair transplantation studies

In 1950, the scalp tension theory of androgenic alopecia had picked up steam in scholarly journals. But it wasn’t until 1959 that researchers figured out how to test its plausibility.

That year, a researcher named Dr. Orentreich set up an experiment to understand which factors influence why we go bald. His major question: is baldness due to a hair follicle’s environment (i.e., its surrounding tissue)… or is it due to the hair follicle itself?

Dr. Orentreich thought of an ingenious way to test this. Hair transplantations. Specifically, he wanted to see if a balding hair transplanted out of a balding scalp would continue to bald… and if a healthy hair transplanted into a balding scalp would continue balding. He figured that if balding had anything to do with our scalp environment, healthy hairs moved to balding regions would start to bald – and balding hairs moved to healthy regions would stop balding.

So he gathered patients with androgenic alopecia (AGA) and performed his tests:

  1. He took skin grafts (6-12mm punch biopsies) of balding scalp regions and transplanted those grafts into non-balding parts of the scalp.
  2. He took 6-12mm punch biopsies of non-thinning scalp regions and transplanted those biopsies in balding parts of the scalp.

So, he got busy observing (and waiting). Years later, he published his findings. What were the results?

Balding hairs keep balding, and non-balding hairs keep growing… no matter where we put them

That’s right. After 2.5 years of observation, Oreintreich found that…

  • Non-balding hairs transplanted to balding regions will keep growing normally.
  • Balding hairs transplanted to non-thinning regions will keep thinning at the same rate as balding hair at the top of the scalp.

Thus, he concluded that our scalp environment had no influence over a hair follicle’s determination to start thinning. To quote directly from his study…

“…The determinants of growth of strong scalp hair or of baldness lie within the local skin tissues of a full-thickness graft and suggest that the pathogenesis of common male baldness is inherent in each individual hair follicle. Probably each individual follicle is genetically predisposed to respond or not to respond to androgenic and/or other influences that inhibit its growth”

Dr. Orentreich referred to scalp hair follicles as donor dominant – meaning that scalp hairs retain all of their characteristics regardless of where they’re placed. In his words…

“…The transposed grafted skin maintains its integrity and characteristics independent of the recipient site.”

These findings undermined the scalp tension hypothesis entirely. But this was just one study. In order to be sure, we’d need to see these results occur again… and again.

Over the next two decades, that’s exactly what happened.

Follow-up studies confirm Dr. Orentreich’s hair transplantation findings

In 1979, a researcher took composite skin grafts of balding, non-balding, and bald scalp regions from a 29-year old patient, then transplanted those skin grafts to the forearm and observed their hair growth over the next several months.

His findings? When those scalp skin grafts were moved to the forearm, bald hairs stayed bald, thinning hairs continued to thin, and non-thinning hairs remained thick and healthy.

Then in 1982, doctors from the Oregon Regional Primate Center used a similar skin graft procedure to transplant the hairs of balding primates from the backs of their scalp (i.e., where hair was healthy) to the front of the scalp (i.e. where these stump-tailed macaques were experiencing human-like pattern hair loss).

Eight years later, the primates’ donor hairs were still alive – despite the fact that their surrounding follicles had succumbed to baldness. Again – the evidence confirms that transplanted hairs don’t miniaturize – and that hair follicles aren’t affected by their environment.

So… is the scalp tension theory officially debunked?

Well, let’s review the evidence:

  • Early hair transplantation studies show that transplanted hairs don’t miniaturize… even when they’re transplanted into “tense” (i.e., balding) scalps
  • Some of those studies show that balding hairs keep miniaturizing… even when they’re removed from a balding environment and placed on the forearm.

Based on these findings, it’s completely rational to assume that the scalp tension theory is invalid. In other words, our scalp environment does not influence a hair follicle’s growth. Hair transplantation studies confirm this belief. And as such, the scalp tightness theory is debunked. Right?

Well, not so fast.

We’ve really only built a straw-man’s argument against the scalp tightness-pattern hair loss hypothesis. Why? Because we’ve yet to address the two elephants in the room.

Elephant #1: relieving scalp tension improveAGA outcomes

There’s evidence that relieving scalp tension – either through mechanical offloading or Botox injections into “tight” scalp muscles – improves hair counts in AGA sufferers… and on-par with the effectiveness of finasteride. We discussed these findings in our original scalp tension article.

So if scalp tension doesn’t contribute to AGA… for some reason, relieving scalp tension helps reverse it. Go figure.

Elephant #2: hair transplant studies don’t answer every question needed to refute the scalp tension-AGA hypothesis

Let’s look at these studies’ conclusions again. What are they saying?

If we take a chunk of skin from the back of our heads and insert it into a balding region, that skin’s hair will continue to grow for several years.

But if we’re to refute the scalp tension hypothesis, that’s not what we should be testing.

This is because we haven’t yet isolated the variable to which we’re making inferences… the actual hair follicle.

Rather, these studies evaluate how entire landscapes of skin behave when moved to different locations of the body. Accordingly, here’s how the conclusions of those studies should’ve read:

When harvesting 6-12mm skin punch biopsies, the 20-80 hair follicles within those biopsies retain their growth characteristics regardless of where they are transplanted on the scalp, even in men with AGA.

Now, what does this conclusion not tell us?

  1. If a hair follicle’s immediate environment (i.e., its skin tissues and surrounding hair follicles) influence its growth characteristics.
  2. If older hair transplants “strip” techniques achieve the same lasting results as individual hair follicle transplants
  3. If transplanted skin experiences the same tensile environment as surrounding skin

Again, these hair transplantations are incredibly important. But they don’t answer these questions. And if we’re to refute the scalp tension hypothesis, we need to evaluate each of these questions carefully.

That’s what the rest of this article is going to do. And in doing so, we’ll see issues in using early hair transplant studies as evidence against the scalp tightness theory.

1. Does a scalp hair follicle’s surrounding environment influence its growth characteristics?

Contrary to what those initial hair transplant studies suggest, a hair follicle’s environment does influence its behavior. We’ve seen this demonstrated in three major ways:

  • Scalp hairs change growth behaviors depending on where they’re transplanted
  • Balding human hair, when transplanted on mice, can regenerate in one hair cycle
  • Hair follicles directly next to each other can coordinate / hair growth

Let’s take these one-by-one.

Scalp hairs change growth rates depending on where we transplant them

In 2002, a team of researchers published a study that revised aspects of Orentreich’s “donor dominance”. The team’s first research question: over a three-year period, what happens if we transplant scalp hairs from the back of our heads to our lower leg?

The results: 60% of transplanted hairs survive, and the ones that survive grow at about half the speed of regular scalp hairs.

Their second research question: what happens if we re-harvest those scalp-hairs-turned-leg-hairs and move them back to the scalp (or more specifically, the nape of the neck?)

The results: those re-transplanted hairs – which were once scalp hairs, then leg hairs, and now are neck hairs  – grow at a slower speed than non-transplanted scalp hairs. However, they grow at the same speed of hairs transplanted directly from the scalp into the neck.

The takeaways: scalp hair follicles adapt to growth rates set by their surrounding environment. Thus, scalp hair follicles can be influenced by the location in which they are transplanted.

Moreover, a follow-up study showed that chest hairs, when transplanted into balding scalps, grow longer to match the length of surrounding (but still balding) scalp hairs.

Together, these findings suggest that scalp hair follicles are not 100% donor dominant… and that scalp environment can influence the behavior of its recipient hairs.

As for why? The investigators weren’t sure. But they hypothesized this could be due to “recipient site characteristics such as vascularity, dermal thickness or skin tension.”

Again — that’s not to say that donor dominance is invalid — or that scalp hairs transplanted into balding regions won’t grow. We’re just highlighting that recipient sites of scalp hairs can influence that hair’s growth characteristics — which goes against the idea that scalp hairs are 100% donor dominant.

This begs the question… just how much influence can a recipient site have on a hair?

Apparently a lot. And here is where things get more interesting.

Balding human hairs can regenerate when transplanted onto a mouse

A 2002 study from the Orentreich Foundation for the Advancement of Science (yes, the very same Dr. Orentreich) transplanted both balding and non-balding human hairs into the backs of mice. 22 weeks later, what were the findings?

The balding human hairs had regenerated just as well as the healthy non-balding hairs… and this regeneration happened in a single hair cycle.

In fact, those balding hairs continued thickening through the duration of the study… whereas the non-balding hairs, for reasons unknown, plateaued after 17 weeks.

How is that possible? Aren’t balding human scalp hairs supposed to continue to thin – like they did in that case study of the 29-year old whose balding scalp hairs were transplanted to his forearm?

Again, the researchers couldn’t explain their results with 100% certainty. They thought the regeneration might be due to lower androgen levels in mice – similar to how finasteride (an androgen reducer) might improve hair loss in men. But the hairs regrew just as well on male (higher androgen) and female (lower androgen) mice — which they couldn’t explain.

Even odder – the balding hairs regenerated in a single hair cycle – much faster than hair recoveries seen from finasteride in humans. To the researchers, this suggested the influence of non-androgenic factors in the recovery of those hairs. Yet that was as far as they could extrapolate.

Again, this contradicts the original hair transplant studies. Balding hair follicles should keep thinning no matter where they’re placed. Except this study shows that’s not always true.

So, are there any other examples of hair follicle regeneration from environmental influence?

Yes. And this next study even gives us insights as to what may explain the discrepancy in newer findings versus the original hair transplantation studies.

Hair-plucking increases hair follicle proliferation five-fold… but only if many hairs are plucked from a small region

In 2015, researchers wanted to see if hair follicles could communicate with each other to coordinate behaviors – like making new hair follicles. So they set up a test…

They plucked 200 hairs from the backs of mice… but did so while controlling for the diameter of a plucking region. In some cases, 200 hairs were plucked in a 2.4mm region. In other cases, 200 hairs were plucked from an 8mm region. The smaller the region, the higher-density the plucking – and vice-versa.

The goal: to see if hair follicle behavior changed on how closely hairs were plucked from one another. So they measured hair growth over the next several weeks.

The results were fascinating.

With low-density plucking, hair follicles either didn’t grow back at all… or grew back to its normal pre-plucking density. That’s what we would expect to happen.

But with higher-density plucking, additional hair follicles were created… to the tune of a five-fold increase.

What’s more interesting is why this happened. The researchers theorized that higher-density plucking created more inflammatory signaling, which led to more cross-communication between hair follicles directly next to each other, which signaled to hair follicles to start regenerating – regardless of whether they’d been plucked. The end-result: a huge increase in hair.

What does this show? Two things…

  1. A hair follicle’s immediate environment can influence its ability to grow. We saw this in changing the hair’s environment (i.e., transplanting balding human hair onto a mouse)… and by augmenting that environment (i.e. plucking many hairs from a small region). In both cases, hair recovery ensued.
  2. The immediate environment that hair follicles use to cross-communicate can be very small.

Let’s elaborate on that second point. For reference, those plucking “zones” the investigators used ranged from 2.4mm to 8mm – yet researchers only observed hair follicle proliferation in plucking zones of 4mm and smaller.

Now let’s reflect back to those original hair transplantation studies.

These studies used skin punch biopsies of 6mm to 12mm – each of which contained up to several dozen hair follicles. Yet our inferences from those transplantation studies were that scalp hair follicles are donor dominant – they retain their characteristics wherever they are transplanted.

Do you see the irony?

We’re saying that hair follicles can coordinate to make new hair follicles across distances of 4mm distances or smaller… while simultaneously saying that scalp hair follicles aren’t influenced by the environment, as demonstrated by transplanting 6-12mm chunks of skin containing dozens of hairs and watching them not change their behavior.

So… does the amount of tissue transferred alongside hair follicles influence hair transplant results?

This is actually the second question we need to answer in order to refute the scalp tension hypothesis. And while nobody’s actually fully answered this question… preliminary evidence suggests that yes -the amount of tissue transferred alongside a hair follicle transplant does influence its survival.

2. Does the success rate of a hair transplant depend on how much adjacent tissue is transferred alongside the hair follicles?

In both Orentreich’s original study and the primate transplant study, hairs from skin punch biopsies of 6-12mm retained their original characteristics when transplanted into balding regions – and for 2.5 to 8 years.

But again, these punch biopsies contained dozens of hair follicles and their surrounding tissue. As we’ve just learned, surrounding hair follicles and tissues communicate with each other to react to environmental influences.

But do these tissues also help hair follicles maintain their original growth characteristics?

In other words, if we strip away these tissues, isolate a hair follicle unit to just a single hair follicle, and then transplant that into a balding region, what happens?

Interestingly, those hair follicles don’t always survive.

Hair follicle transplant survival rates decrease if individual hairs – rather than full hair follicle units – are transplanted

This is exactly what these researchers discovered when investigating hair transplant survival rates for individual hairs versus hair follicle “clusters” – known as hair follicle units.

Specifically, these researchers were exploring a new hair transplantation technique known as follicular unit extracts (or FUE). This is when, rather than taking larger punch biopsies or “strips” of skin containing hundreds of hair follicles – a surgeon instead takes a series of 0.6-1.2mm “punches” containing individual hair follicle units (usually 4-8 hairs) spread throughout the donor area. This allows for less scarring from a transplant.

Their findings: if a hair follicle is separated from its follicular “unit” – its survival rate decreases. In fact, single hair follicles are 25% more likely not to survive… at least in the 26-week period of the study.

In the words of the study:

“Extremely high survival rates of micrografts are obtainable by transplanting intact follicular clumps with protective tissue around the micrograft, and preserving the follicular clump’s sebaceous gland. These survival rates were not achieved when micrografts were produced by splitting individual hairs away from a naturally occurring follicular clump.”

Do hair transplantations always last forever?

With 6-12 punch biopsies and “strip” transplantations, these hairs certainly last for a very long time. Certainly long enough to validate the surgery (if you’re considering doing it).

But as with these techniques – and with newer techniques, like follicular unit extractions (FUE) – survival rates seem to depend on how much connective tissue is also transplanted alongside the hair follicle, and if a hair follicle unit is transferred altogether.

I haven’t found any studies investigating the long-term efficacy of FUE transplantations. But it seems like there’s enough preliminary evidence to suggest that the less surrounding tissue transplanted alongside the hair, the less successful the hair transplant.

In FUE literature reviews, researchers address these concerns by acknowledging that, over time, even donor regions of a scalp can still succumb to miniaturization from pattern hair loss. In other words, over the years, the loss of transplanted hairs is perhaps to be expected.

“While the follicular units in the optimal donor area of the occipital and parietal scalp are ″relatively″ protected from androgenetic hair loss, even those follicular units may be somewhat affected with time.”

For the record, this is absolutely true. In many cases of androgenic alopecia, regions beyond the galea aponeurotica will succumb to hair follicle miniaturization – especially in advanced stages. And the truth is that regardless of an FUT or FUE procedure, hair follicle survivability is likely dependent, in part, on how much tissue the surgeon trims away from each follicle prior to transplanting it.

Additionally, as more surgeons transition to FUE, many now mandate to their patients to take finasteride. In fact, a lot of surgeons won’t even perform FUE surgery unless their patient agrees to this.

Obviously, this is to the interest of the patient. Finasteride is incredibly powerful at stopping hair loss – and as more FUE patients commit to taking it, it will improve their odds of their hair transplant sticking and looking great for years to come.

At the same time, mandating finasteride use post-FUE transplantations will make it harder to grasp how individually transplanted hair follicle units (and sometimes, just single hair follicles) behave over decades in a balding environment. The FUE studies bank on these follicles behaving the same way as they did in the original hair transplantation studies. But again, I’m not sure this is the case.

Perhaps unsurprisingly, a lot of readers here who did an FUE and then stopped taking finasteride have reported that their transplanted hairs are falling out. That’s concerning – especially as these readers have also reported that the regions from where those transplanted hairs were taken have not had any noticeable miniaturization.

While many surgeons claim this only happens if a transplanted hair is taken too close to the vertex (where thinning might later occur) – this seems to happen far too often to explain all cases.

Again, here’s a 2013 literature review suggesting these newer, smaller “micrograft” techniques might not match up to Orentreich’s hair transplant findings with larger punch biopsies…

“Micrograft survival rates in hair transplantation have been frequently described in private conversations by hair transplant doctors as variable at best. References in medical literature may grossly underestimate the prevalence and magnitude of poor growth. This is probably because most hair transplant surgeons are concerned that publication of a significant incidence of poor growth would reflect negatively on their practice.”

In my conversations with other AGA researchers, a few have stated – contrary to popular belief – that transplanted hairs do thin. There’s even a hypothesis that transplanted hairs simply restart their “balding clock” post-transplantation – meaning that in 5, 15, or 25 years, we can expect transplants to start thinning as well.

Only time will tell.

In any case, there at least appears preliminary evidence that a hair follicle’s surrounding environment influences its growth characteristics… that this includes both balding and non-balding scalp hairs… and that hair transplantation success might depend on how much of the surrounding environment is transplanted along with the hair.

Do transplanted hairs experience the same “tensile” environment as recipient site hairs?

Another thing we’d need to confirm for hair transplantations to refute the scalp tension hypothesis is that after an operation, transplanted hairs experience the same tension as the recipient site hairs.

Unfortunately, this hasn’t yet been studied. But based on what has been studied, we can infer that this might or might not be the case.

Interestingly, in that eight-year transplant study on balding primates, investigators biopsied the transplanted skin periodically after the procedure – to see what was going on underneath the skin.

They found that after one week, transplanted tissues fused with surrounding tissues. Soon after, the transplanted hairs fell out, and then began regrowing a number of weeks later as underlying tissue began to merge toward the transplanted tissue. At four months, the underlying transplant tissue looked nearly identical to the surrounding tissues – minus the larger hairs.

This might suggest that these hairs do experience the same tension as surrounding hairs, but it’s really hard to say. What isn’t studied here is the differences in tensile readouts between transplanted hair follicles and their surrounding environments. As another researcher mentioned in his critique of the balding scalp hair-to-forearm transplant study we mentioned earlier…

“…According to the approach of the present paper, it would be necessary to know the strain supported by the forearm skin and to realize that the hair follicles close to receding hairline have already started a countdown toward the miniaturization, but not the occipital follicles. In hair transplantation, the grafted follicles start a new “balding clock,” but hair growth would be guaranteed for many years even without preventive pharmacotherapy.”

What also isn’t studied is the role of epigenetics in these transplants – or in other words, the changes in gene expression pre- and post- hair transplantation. When these transplant studies were conducted, epigenetics wasn’t even a field of scientific study. So again, there are just a lot of unknowns here… so we need to exercise caution with how we interpret these studies and apply implications.

In any case, we can now summarize why hair transplantation successes might not refute the scalp tension-AGA hypothesis.

Summary: why hair transplants might not refute the scalp tension-hair loss theory

Hair transplantations are overwhelmingly successful. Early transplant studies suggested that scalp hairs transplanted into balding scalp environments retain their original characteristics and keep growing forever – a concept known as donor dominance. Many people use these studies to refute the scalp tension hypothesis – and with good reason.

At the same time, relieving scalp tension appears to improve androgenic alopecia (for references, please see the first article). So we should probably try to make sense of these paradoxical findings.

Reevaluating the original hair transplantation studies, we see that the investigators transplanted 6-12mm skin punch biopsies containing dozens of hair follicles per transplant. This might create a few problems when trying to use these studies as evidence against the scalp tightness-AGA theory:

  • Studies show hair follicles communicate with each other to maintain or increase hair follicle counts in regions of 4mm and smaller. Thus, we can’t conclude that baldness is determined within each hair follicle if these transplant studies use punch biopsies large enough to allow for inter-follicular communication.
  • There’s preliminary evidence that as we trim away surrounding tissues, hair follicle transplantation survival rates decrease. This is most obvious in FUE micrograft studies of single hair follicles – where researchers separate a hair follicle from its hair follicle unit, and then observe worse survival rates post-transplantation into balding regions.
  • Moreover, recent studies demonstrate that human scalp hair follicles do take on characteristics of their recipient sites… and that balding human hairs can regenerate in a single hair cycle if transplanted onto the back of a mouse. In other words, human scalp hairs are susceptible to their environment – which refutes aspects of Orentreich’s original findings.

These findings, along with many anecdotes from patients with failed FUT and FUE transplants (despite no miniaturization observed from where the hairs were transplanted), have led some AGA researchers to conclude transplanted hair follicles might eventually thin. Rather, it’s just that after transplantation, their “balding clocks” are set back to zero… and thus we might need to wait 5, 15, or 25 years to begin to see the effects.

Again, this is not to say hair transplants aren’t long-lasting. In most cases, they certainly are. It’s just to say that there’s evidence that transplanted hairs might also be susceptible to AGA with time… and that recipient sites of transplanted balding scalps have a bigger influence on their growth than we initially thought.

How can transplanted hairs grow in fibrotic scalp environments?

According to some models of the scalp tension hypothesis, fibrosis (or scar tissue) is a rate-limiting factor for hair recovery. This has led some to ask, “If regular hair can’t grow in fibrotic tissues, how come transplanted hairs can?”

Interestingly, we can use the findings of a recent (and fascinating) study to help answer this question. It was conducted, in part, by one of the biggest names in hair loss research: Dr. George Cotsarelis.

Dr. Cotsarelis and his team wanted to understand the role of the hair follicle during wound-healing. It has been long understood that where there is scar tissue, hair cannot grow. We see this in burns, scleroderma patients, and in advanced stages of androgenic alopecia (pattern hair loss) where scar tissue is present in skin tissues, thus preventing the proliferation of hair follicles (and thereby hair growth).

What Cotsarelis and his researchers discovered: if we can regenerate a hair follicle first, that hair follicle will begin to signal to its surrounding tissues to regenerate other cell types normally lost to scar tissue – like adipose tissue (or subcutaneous fat).

What does this have to do with hair transplant survival rates? Well, think about it:

  • In AGA, fibrosis (scar tissues) restricts hair follicle growth space, leading to hair loss.
  • Hair transplants take hair follicle units from the backs of our scalps and transplant them into balding areas where there is scar tissues
  • In doing so, they provide scarred tissues with newer, healthy hair – and in a way, “force” the regeneration process of nearby tissue – thus partially resolving fibrosis in surrounding tissues and allowing for the transplanted hairs to grow.

Interestingly, this might be why some hair transplant surgeries observe transplant survival rates of over 100%. This was originally believed to be the result of hidden telogen (resting) hairs moved during the hair transplant. Now it’s possible that these extra hairs are actually bald vellus hairs regenerating as a result of cellular signaling from the transplanted hairs.

In fact, this study might not only explain why transplanted scalp hairs survive in balding environments… but also the mechanisms behind why they reset the baldness clock – if we choose to believe that concept at all.

Final remarks: scalp tension and hair transplants

The scalp tension-AGA hypothesis is far from proven, but it’s also far from debunked.

At face-value, older hair transplantation studies refuted the scalp tension theory and led researchers to believe that hair follicle miniaturization was programmed within the hair follicle itself – not its environment.

However, these transplant studies were conducted using 6-12mm skin punch biopsies. A 6-12mm biopsy contains dozens of hair follicles and a lot of surrounding tissues. That’s a far cry from a single hair follicle. Resultantly, 6-12mm punch biopsies don’t really tell us much about what happens if we transplant an individual hair follicle into a balding region – absent of its surrounding tissues.

New research suggests that surrounding tissues do influence the regulation and proliferation of the hair follicles they support. And interestingly, survival rates for transplanted hairs decrease as we trim away surrounding tissues and transplant just singular instead of entire hair follicle units (4-8 hairs), strips, or punch biopsies.

This suggests the conclusions of the hair transplant studies from 1959-1982 actually should attribute more of their success to the surrounding tissues transplanted alongside the hair follicle – and the fact that entire hair follicle units were transferred (not just single hairs) – which likely allowed these tissues to maintain follicular communication and regular their growth and proliferation even in their newly transplanted environment.

Given all of this, and the potential variability in success with FUE transplants, several AGA researchers now believe that transplanted hairs simply reset on a balding clock – and that given enough time, they eventually will thin.

On top of that, newer studies show that healthy transplanted hair follicles actually help to signal to surrounding tissues to regenerate – just explaining why they can proliferate in balding regions (or maybe even support the proliferation of surrounding balding hairs).

All of this isn’t to say that the scalp tension hypothesis is irrefutable. On a personal level, I don’t think that scalp tension explains all aspects of AGA (more on this later). This is just to say that hair transplantation studies don’t necessarily refute the scalp tightness theory – especially in light of newer evidence.

At the end of the day, relieving scalp tension – either through botulinum toxin injections or mechanical offloading – seems to improve AGA outcomes. So if scalp tension doesn’t contribute to pattern hair loss… relieving scalp tension seems to still help regrow hair.

Is the scalp tension theory true? I don’t know. Maybe. Maybe not. But I don’t think these original hair transplant studies refute it. And in the next article, we’ll discuss where this “scalp tension” might originate.

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    141 thoughts on “Do Hair Transplants Debunk The Scalp Tension-Hair Loss Hypothesis?”

    1. Really interesting read, thanks for that.

      I was considering a transplant in a few years, once I really give mechanical stimulation a solid effort though and (hopefully) see results which means I wont have too.

      I always considered FUE to be approach I would go for, due to no scaring and the fact it is the more ‘modern’ and recommended approach . But as you’ve described it seems like FUT, although leaving scaring, may a much better survival chance in comparison to FUE. FUT is also cheaper!

      • Hey Hooj,

        I’ve heard that the costs of FUE in Turkey are just a tenth of the price in the US or UK! So that might be an option for you.

        I realize I might not have been clear enough in the article — but even if you do FUT, a transplant surgeon will still take that strip and then cut it into smaller parts to transplant into thinning regions. There’s less mid-follicle “slicing” with FUT, since the surgeons get a better view of where to cut the hair follicles, and that also might explain aspects of the improved survival rates. If you go the FUE route, just be sure that your FUE surgeon is 1) taking high-quality micrograft punches, and 2) not separating out individual hair follicles from their hair follicle units. It’s that latter part that seem to dramatically reduce survival rates versus FUT.


        • Hi Rob,

          All the evidence seems to point to FUT giving better results than FUE, do you agree? If so, is the only disadvantage of FUT the fact that it leaves a scar? Couldn’t that scar be covered up in the future with, say, hair from your chest/arms, for instance, making FUT the unequivocally superior solution?


        • Hey Joao — it’s tough to say with certainty which technique is better in terms of survival rates (I’m not aware of a study comparing FUE vs. FUT survival rates beyond 3 years). The information covered within the article suggests that FUE might not be the best in terms of survivability — but we just don’t know.

          There’s also someone’s personal preference for scarring and costs. People who wear their hair longer don’t always mind the scar and also like the lower costs of FUE.

          In any case, heavy scar tissue can be a bit tricky to transplant into — since the vascular networks of that tissue are compromised. However, there are plenty of cases where people cosmetically color the scar with a tattoo and/or transplant body hair near / within the scar site to lessen its appearance.



        • Hi Rob.
          If the hairs communicate with each other that are very close as you say. Well how come the hairs on the perimeter of the punch biopsies put into the balding scalp didn’t start balding? They would be communicating with balding hairs right next to them, just outside the punch biopsy.

    2. Hey Rob, this is Elliott from South Carolina. You might remember me? How have you been? Great article on transplants, btw. You might remember I had several transplants before I found your program. I have always wondered about transplanting into fibrotic tissue, and if the hair will continue to grow. So, far mine has.

      I actually just connected with a good DO in my area 3 weeks ago, who ran some blood tests on me. I sent you an email attached with the results for you to see.

      I found it interesting how low my DHT levels were (basically so low they didn’t even show up on the test). As you know, the universal answer for hairloss in western medicine is transplants and DHT blocking finesteride. I’m still taking finesteride, but my DO wants me to get off it.

      My iron and iodine are also kind of low, and my theory about being sensitive to eggs was correct (As well as a few other foods like dairy, processed grains, garlic, and a few others). I wonder now if these things have been contributing to the inflammation cascade, and are possibly why my hair won’t reach the next level. My DO gave me a plan to implement in addition to everything else I already do(many things inspired my your ebook).

      My theory is the things I mentioned above are what is causing my hair to not reach the next level.

      What is you opinion, and when is the revised book coming out?


    3. Thanks dude for ur great articles

      You have suggested some vitamins for the diet، k2,E,A,D3,mg,zinc….
      Ok now i want to know one thing(as always you suggested us use natural resources for get vitamins) can I use carrot for the source of vitamin “A” and Sunflower seed for vitamin “E”?

    4. Thank you Rob for another excellent article. I love the way you’re not afraid to challenge mainstream ideas and even your own!
      May I please humbly request something? I have joined a few female hair loss forums and see a lot of members complaining about the increased prevalence of AGA in women. We are often being misdiangosed with TE when we actually have AGA or being dismissed because our doctors think hair loss is not a big deal. Added to that alot of us with AGA were on some form of contraception like the Pill before we noticed our hair thinning which is making us question the role of oral contraceptives in triggering AGA.
      For me personally, I was on an anti-androgen Pill called Diane 35 since my teens to my mid 20’s during which I enjoyed the really thick hair of my childhood. I then switched to a low estrogen Pill which contains gestodene as a progestin and then started noticing slow hair thinning for 10 years. Doctors scoffed at my concerns and my gynaecologist laughed when I said I think the new Pill triggered my hair loss. My dermatologist recently did a scalp biopsy and finally confirmed, that at the age of 35, I have AGA with inflammation, mild fibrosis, and perrifoliculitis present. I also want to add that the lab only picked up one vellus hair out of the entire sample of thick hairs. The recommendation is that I go back on Diane 35. I should mention that my insulation is quite high though I’m not diabetic.
      That aside, I’m humbly requesting:
      A) if you can please research if there is a link between oral contraceptives and AGA in women and post it on your site? It may be a very female specific issue but i think your mainly male readers will find it interesting if they have female family members and loved ones also struggling with hair loss.
      B) Can you please comment if after 10 years of hair loss, would it be normal for the pathologists to only identify one vellus hair from a scalp biopsy? My biopsy report came back saying I have a normal hair count of dark hairs but I believe that this is so because i had very thick hair to begin and my hair loss is slow so that to average person I look like i have normal thickness hair. At which stage of AGA should miniaturisation be showing?

      • Thank you, Anna! And I’m sorry to hear about all the troubles you went through with your doctors and diagnoses.

        I will certainly make it a point to write an article on contraceptives in the future. In terms of the vellus hair — as you eluded, the relationship between vellus:terminal hairs in AGA progression is all highly individualized, so we can’t say with certainty how many vellus hairs someone should observe a decade after the onset of AGA.

        There’s a debate over whether the miniaturization in AGA happens slowly or as a single step-process. There’s strong evidence on both sides, and at the end of the day, it might just depend on the individual how they express their hair loss. For instance, 99% of your hairs might not meet the qualifications of vellus in your biopsy; however, all of your terminal hairs might be at 50% of their thickness from years prior — likely from the inflammation / fibrosis present. This would explain why the results might be confusing. It might just boil down to semantics, and how doctors characterize terminal vs. vellus hair. We need major revisions to all of these approaches if dermatologists are going to better serve female AGA patients. And I’m sorry again for all of your troubles!


    5. Hi Rob. Great articles this week, thanks! This one was really relevant to me, as I’d had the strip procedure about 6-7 years ago, but need to check up on that as time flies so fast it might be 10 years by now. Anyway, the first thing that struck me like a bolt was that I had a very wide strip removed from the back, and it basically runs from ear to ear, tapering towards the ears of course. However, I can clearly remember the surgeon telling the ladies to split every single hair once that strip was removed, so that I could get more coverage. I was basically bald, so they had to space it out. Firstly, can you imagine the tension created when a one inch wide strip is removed and your scalp is pulled back together!?! I never thought about this until today. I was happy at the time, I looked about 5 years younger 🙂 However, now it totally makes sense why my hairline has moved back about an inch or more from where I had transplants, my scalp is super tight! I’ve lost about 50-60% of my transplanted hairs around the horseshoe region I reckon, and I’ve had to battle so hard to keep the remaining few. The surgeon said I absolutely had to be on finasteride and mixoxidil forever from that day on, though I’d already been on minoxidil for many years prior with very limited results. So who knows what would be left if I hadn’t gone straight onto finasteride? Where the hair hasn’t fallen out is basically the area under the least tension on the top of my head, right in the middle of the scalp between the crown and hairline. So I think the tension theory sits well with this, and the simple fact that people generally have transplants at an age where their scalp has already fully expanded, so they can’t be putting the new hair into that same environment during the miniaturization period when it’s still expanding can they? Not sure on that as people obviously thin out into their later years. I’m sure that reason, and using both finasteride and minoxidil, has allowed me to keep that one portion, but the rest is under extreme tension and has simply died out over the last 3 or so years. So exactly as you said, the strip method might be great when done as you’ve mentioned, but it’s basically a fail when done like mine, individually. Hence this whole article has just blown me away, it’s 100% accurate to what I’m going through since I had mine done. I’m off minoxidil now, and about 5 months into this programme, so let’s see how things look in a few months. I did lose that crown hair minoxidil gave me, it was pretty damn lame after 25 years of twice daily application though. Not like I could style it, I had to use toppik and other products to blow it out. But it might also have been the finasteride 100% creating that, hence I’m still using that, but slowly weening off as I get more into this method. This update might just be the most important one I’ve come across to tie this approach together, so thanks again Rob!

      • Hey Richard,

        Thanks for reading! And thank your for taking the time to write about your experience. I’m sorry that 50-60% of your transplanted hairs have already thinned… it’s something that happens more often than hair transplant anecdotes suggest! Please keep us posted on everything — and best of luck with all things health and hair.

        All my best,

        • I think Richard’s experience is a plus 1 for the tension theory. I believe a lot of people who had transplants get poor yield, especially after some time goes by. It seems the before and after pics of successful hair transplants, are always within a year of having the procedure.
          It seems that a patient still needs to keep good health , and a lax scalp to improve the transplant outcomes long term.

      • Hello Richard,

        I hope you don’t mind if I jump in a little. Perhaps I’m prying, but I’m curious why you would wean off of finasteride if that’s what has possibly kept your hair somewhat intact over the past few years. Medical reasons? If so, then I understand, but you might have to emotionally prepare yourself for the mother of all sheds. Even worse, you could leave yourself with less hair than before your surgery and a scar to conceal.

        Are you taking generic finasteride or brand name Propecia? I’ve heard (anecdotally) that:

        1) Although more expensive, brand name could yield better, more reliable results.

        2) If your taking generic and your pharmacy changes the manufacturing company their buying from, then the lack of consistency of the medication could effect your results.

        Consider doing the exercises while continuing to take the meds. After all, it’s almost impossible to tell if somethings working if your making multiple changes at once. If you gain ground from the massages while still on meds, great. If not then no harm no foul and your exactly where you were.

        I’m just giving you some things to think about since it sounds like your in a delicate position having already taken the surgical/medication route. If staying on the medication is something you’d consider, you could talk to your doctor about tweaking the dosage. Like quartaring a Proscar so you’d be taking 1.25 mg of brand name Propecia a day.

        As a fellow hair loss sufferer, I’d hate to see you lose ground that you’ll never recover from.

        In your position, making a couple of small medication changes could be your best bet.



    6. Wow Rob, two fascinating articles. Firstly I want to say thank you. It’s refreshing when you challenge the status quo of the experts and even your own previous assumptions. I feel that a holistic approach is the best approach in fighting hair loss. I myself was on Roaccutane twice during 1995. This was over an 8 month period and I have photos of before and after and it’s amazing that my hair went from thick and strong to thin and I lost from the hairline. I have never looked at these pictures from hair purposes as it was always for skin purposes. It’s amazing when you try and correct one issue that it effects another. These two articles have made me look at everything again. I always wondered why my hairline loss was not the M shape. Looking at the old photos show my loss started right in the middle of the hairline. Thanks again, Rob.

      • Alan, these are great insights! Please follow up with me through email. There might be some things we can test to see if past Roaccutane use might’ve contributed to your hair loss. I look forward to connecting!


        • Hi Rob, again, great article! I am also interested in having more information about a possible link between my hair loss and the time I took roaccutan.


    7. Thank you Rob. I have lost 50% of my original thickness so I was really expecting to see more vellus hair which I haven’t yet. I was totally unaware of the ongoing debate around miniaturisation. This is interesting as hair loss doctors like the Canadian Dr Jeff Donovan regularly uses the Terminal: Vellus ratio to determine if you have telogen effluvium, chronic telogen effluvium or AGA. Maybe yet another topic for you to sink your teeth into?

      • Thanks Anna! It’s certainly something I mention in the new book. Basically, you can go to three different dermatologists and walk away with three different hair loss diagnoses. It all depends on…

        1. The diagnosis strategy (visual inspection vs. scalp biopsy vs. photographic counting for anagen:telogen ratios vs. a combined approach)

        2. How your doctor defines each hair loss type (this is always changing!)

        3. How far behind your doctor / dermatologist is on the latest literature (in general, it’s safe to assume 10-15 years).

        What’s worse, most don’t bother doing a full health examination to uncover confounding factors with hair thinning — like underlying chronic conditions (heavy metal toxicities, hypothyroidism, etc.) or medications (NSAID’s, birth control, etc.) that can manifest as diffuse hair loss. It’s certainly frustrating for patients.


      • Thank you Ben! It’s going to be a while. Right now, my focus has shifted entirely to the book rewrite. Hopefully the last article will be ready in a month or so.

    8. hello Rob, i do agree that scalp tension is the cause for hair loss. its really obvious that balding people have more tight skin and healthy non balding areas have loose light coloured skin. but what triggered the scalp tension in the first place? couldn’t it be the underlying bones? you know what i am talking about,right? yes its all about skull expansion. i just happened to buy paul taylor’s ebook on skull expansion and i definitely agree with what he says. “scalp tension casused by skull structure is the true cause of androgenetic alopecia”. but the reason why most people dont wanna believe it is because if skull structure was the cause then there is not much they can do.whats your view on this?

      • Hey Henric,

        The third article will cover, in detail, some potential sources of tension. However, I touch on three likely factors in the first article, which you can read here:


        The issue with skull bones exclusively causing tension is that with bone growth, our skin adapts and reforms to maintain homeostasis. So the tension needs to be derived from additional sources. It’s likely that if skull bone enlargement is involved in AGA onset, it has more to do with skull suture closure and foramina fusing. My bet is that most of the tension is derived from fascia and muscle.


    9. Hi, Rob! Not sure if this has been asked already, but when will the book update be available? I bought a year or two ago, will I need to do something special to update it? Thanks

    10. Thanks Rob, will keep you updated of course. It will be a slow process for me, and I’m very realistic, not expecting to go from near nothing to a full head of hair. Much like Alan I was also on roaccutane, around the time I was 16 or17 if I remember right. Started losing my hair around that time too, started coming out in clumps. But only in the typical balding regions, so doubtful of a direct connection. But who knows? Cheers Rob

    11. H Rob,

      If this theory is proven to be right, then what do you think about potential future treatments that use cutre of stem cells taken from the back and sides of the scalp (like what Replicel and Tsuji Lab are planning to do) ?

      • Hey Kevin,

        My current understanding of progress in stem cell research is that we can grow new hair follicles, but we have a much harder time getting those hair follicles to re-enter anagen after they cycle into telogen and shed. In any case, I think Replicel and Tsuji certainly have a place in AGA treatments… but a multi-targeted approach to reversing AGA is likely going to be even more effective.

        We’ll have to wait for both companies to release their latest clinical data. From my understanding, these solutions are still a few years from being market-ready.


    12. Hey Rob! Awesome and informative articles by the way. The really give a deeper, newer insight and understanding to hairloss and why, when, how and to whom it happens. But anyways I found an article about a drug called WAY 316606 and it’s been reported to show impressive results in terms of hair regrowth and maintenance. What’s your input on it?

    13. Hey Rob!
      Very nice read. I’m doing microneedling and found that people who previously didn’t respond to Minoxidil started seeing results after they began microneedling, which leads me to believe that microneedling helped by making a better environment for Minoxidil to do its effects while promoting growth by itself too. What do you think?
      By the way, I’m doing microneedling and following your massaging protocol (2 mm two times a month). Would you say it is recommended to skip the massages in needling days?

    14. Hey Rob,

      I bought your book in April 2018 and have been doing the massages since. Unfortunately my hair loss has continued and it looks noticeably thinner than a year ago.

      Admittedly I have not done massages twice a day. Normally I do once a day focusing across the top of the scalp. I realise this isn’t exactly as prescribed in the book. However I’ve been doing the massages for 9 months now yet have not even stalled my hair loss.

      My hair is thinning diffusely and evenly across the top including at the front of the scalp. Is twice daily massaging absolutely necessary to see regrowth or is there possibly some other cause behind my hair loss which is not fibrosis/dht related? Would appreciate any advice you might have.

      • Hi Lorcan, it’s been noted before that the best responders gave necessary diligence to massaging back and sides. I think it’s worthwhile to follow the regimen as intended. When you consider scalp tension theory etc, it becomes apparent how important back and sides are, even though visually they may not be an area of concern.

    15. Hi rob
      I’m a little worried because i usually have 5 to 12 number hair loss during a massage session,now ihave a few questions
      1_how many hair loss is normal during massage?
      2_ those hairs that we losing in while scalp massage come back?
      3_can this deep massage(pinching,pressing, stretch) keep our hairs always, I mean, the same number of hairs we have?

      • 5 to 12 hairs is completely fine and stated as normal by Rob is his book. Remember that even people without hairloss shed many, many hairs a day. I woulnt worry about it.

        When I first began the massage I was shedding 60+ hairs each time. I’m now on month 3 and that number has reduced dramatically (around 10-15).

    16. Hi Bill Russo. I take it you don’t have Rob’s book? Microneedling with minoxidil is quite old news now, Rob’s approach is for people trying to get off minoxidil. But yes, microneedling and minoxidil is supposed to be a great combo, however it did nothing for me and many other guys. Luck of the draw like anything hair growth related. Good luck

    17. Hi Lorcan. I lost a fair bit of hair in the first 3-4 months, I’m now 5-6 months in and it’s slowed down I think. I think i was going too hard in the massages and also skipping odd sessions, and focusing mainly on the top. What I’ve discovered is that the sides are actually the most important for me, the ridge area on my scalp is incredibly tight, so the top doesn’t stand a chance unless I can really loosen the lower back and sides. I’m also 100% following the diet and lifestyle the last month. So in reality I might be 6 months into this approach, but really only 1-2 at close to 100%. I don’t massage as hard to be sure I’m totally good to go 36 hours later, just enough to be reddish. I think I’m finally seeing improvements, but it’s scary losing lots of hair. As Rob says in the book, can you only do it 50% – 60% and still get the results, probably not. Good luck!

      • The main benefit of detumescence massages is to break down calcification/fibrosis. If we massage the area with hair loss – the area where calcification is a problem – then it should work if the massages work at all. Massaging the sides or back of the scalp isn’t going to break down calcification on the top. Massaging only the top could break down 99% of the calcification in the problem area, if the massages actually work.

        I stopped doing the massages around January because I was losing too much hair doing them. I don’t think it’s possible to break down calcification in the scalp by massaging it without causing further hair shedding. My hair loss wasn’t that noticeable before starting the massages but it became noticeable during the timeframe I was doing them. My hair is much thinner now than it would have been if not for the massages. There was a significant change in how much hair I have during the time I was doing the massages and that change has been entirely negative. I don’t know if detumescence works but in my case it definitely caused more harm than good.

        I started using minoxidil 5% foam at the end of January. Haven’t been using it long enough to say for sure how good it works but I do notice a lot of sprouts. If calcification and fibrosis are blocking off the blood supply to the hair follicles then this explains why minoxidil – a vasodilator – works so well for many people. Minoxidil may not reverse calcification but if blocking off the blood supply is the problem caused by calcification then minoxidil at least stops that being a problem. Just over 2 months in and I feel like I’m seeing improvement.

    18. Hey Richard!
      I don’t have the book, as you said. I’m microneedling without Minoxidil. It’s a mechanical manipulation only approach.
      We’re doing a “community trial” in HairLossTalk and a lotnof people there are seeing results. I’m 2 sessions in and, while this doesn’t mean much, it has improved my hair quality.
      Sorry it didn’t work for you… Thanks for replying and best of luck with the massages.

      • Hi Bill could you send a link to the hairloss forum you’re talking about? Would love to see the comments on the results of micro-needling. I’m going to a trichologist for 10 needling sessions to my scalp but also want to continue with the PHH massages.

    19. Hi Bill , Richard and others.

      The sides are very important, make sure that you are able to pinch the sides to the extent you can grab the ridge by fingers alone.

      The scalp ridge is also thee tightest of all.

    20. Hi Bill. Oh right, didnt realize it was without minoxidil, that’s good to hear. I have done a couple of microneedling sessions again the last month or so, my concern is that it takes about 3 days before I can massage again, so not sure which approach to fully concentrate on? If it doesn’t hurt the PHH method then I might do one every couple of weeks, it’s all just a trial and error thing isn’t it. Great to hear you’re having positive results. I’ve lost a fair bit of hair after ending minoxidil, but I’ve got fine little hairs coming through, they just need a push as they’re staying small and very fine at this stage. Even on my crown, which was totally gone about a month ago, really had no hope of ever growing hair there again without topicals or surgery. Cheers Bill

    21. Hi Paz. My sides and ridge around my ears are pretty good, but the ridge and lower crown area around the back is still super tight after 5 months, no chance of pinching with one hand around there yet. As mentioned in an earlier post, probably because I had a strip removed years ago. The scar is like an arc weld, really big and long. Going to take a few more months, but I’m really working extra hard there now. Cheers!

    22. Hello Richard! Yes, I’m wondering if it’s fine to skip them for those 3 days. Or perhaps just focus on the sides? I know of people who have combined them and had results. It wasn’t Rob’s routine though, but similar. My hair loss is mild and very slow, I don’t need much regrowth. My worst hit area is the temple recession (NW3). Crown is the second, but nothing bad. Mostly thinning that still provides somewhat decent coverage under certain lighting. Rest is okay, would improve a lot with just thickening.
      It is indeed a trial and error. Hopefully we don’t have much of an error!
      I’m happy to hear that! It also gives me hope, since there are still little baby hairs where my hairline used to be around the temples. If I can get those to grow it’ll be life changing. Cheers, buddy.

    23. Hi Bill. Lucky you, I’m basically starting from about 500 hairs on my whole scalp. This method alone should be perfect for you I think, seems to work great for guys with slight to moderate thinning. If it works for me it will be amazing, it will definitely prove the method works. I was searching for microneedling topics on hairlosstalk yesterday and came upon one which has worried me, that using a roller could actually be more damaging by tearing the follicles as you roll over the scalp at a fast speed. Hmm, might explain my poor results as I really raced over the scalp pressing hard. The thought of rolling a 1.5mm needle over at snail pace to full depth is a bit frightening though, you’d really need to have good quality sharp needles. I’m wondering about the difference between really intense deep massage vs microneedling, any thoughts on what the difference might be? Is it the needle itself which is the component stimulating hair growth, or the aggravation it causes? I’ve still got a lot to learn! One strange thing that’s happening at the moment to me is that I’ve got a really good tan on my face, southern hemisphere summer, but my scalp is totally white in the balding areas, even after being in the sun almost as much. Strange things afoot on my head at the moment. Thanks Bill, keep me informed about those baby hairs 🙂

    24. Hey Richard .

      The consensus I took from the book was to do microneedling if massages don’t work. In my case they did.

      But dermarolling is a very abrasive approach which seems to work by regenerating cells , however wound healing alone.

      If these articles are to be considered, then scalp tension relief through massages are the best beginning approach which should loosen scalp and improve tissue.

      But I believe both methods take time in results.

    25. Hi Paz

      Thanks! So you’ve had good results from the massages alone? Can I ask what your hair loss was like when you started? I’m going to skip the dermarolling, I’m just too uncertain about using it in combination with massages and whether it’s more damaging. There are too many people with different ideas about needle length, pressure, and length of time between sessions. I can’t afford to lose any more hair, it’s already thinned out a fair bit the last few months, I’ll stick to this alone until there’s conclusive evidence and a standard approach to needle usage. Thanks for your message 🙂

    26. You ever gonna comment on platelet rich plasma treatment? Thinking about pricing it out. I’ve had some success with detumesence and dermarolling, but I suspect PRP might more quickly heal some recession that I can then maintain with ongoing detumesence massage.

      • Thank you Bill. I’m going to have a read. Are any of your guys using needling with LLLT therapy? And if so what are the results? As mentioned below I just started both with a hair loss clinic and wondering how successful they are together?

    27. Hey Richard.
      I actually use a dermapen; 2 mm. You should probably look into it!
      About the differences between deep massage vs needling; the needle penetrating is what activates the growth factors related to Wnt signalling.
      I hope you have success with your hair loss journey. Will try to keep you posted, but my attention span isn’t the best these days, sadly…
      Best wishes.

      • Hi Bill. Thanks for the info! Will look into things further, so many different stories and techniques out there regarding needling. I read 2 long articles yesterday, one saying it had to be 1.5mm minimum needles, another swearing 0.5mm was the perfect length, and detailing why just as well as the other article. Today I’m reading they’re developing 5mm devices. More info required for me as I’m far too scared of losing more hair, so I’ll stick to this approach for now. But thanks for putting those links up. Cheers

        • Hi Richard, I suspect why there are different opinions regarding needle length is dependent on the pressure that is being applied to the scalp when rolling or stamping. I have been derma-stamping with a 0.5mm needle length at home for a short while and at the most I had a sore scalp and no results yet. I just started a 10 microneedling + LLLT therapy session package with a hair loss clinic on Saturday and they insisted on using the 0.5mm needle. I thought I would just have a sore scalp and nearly regretted going there thinking I could have done it myself. However the therapist who derma-stamped my head applied so much pressure I bled with every stamp to my head. It’s Monday and my head still feels a bit bruised. She mentioned that 0.5 is fine to start with but you need to ensure you apply enough firm pressure to bleed.

    28. Hi Rob,

      what I am really curious about after reading all your (very well written and researched!) articles:

      What is the number of people who got back to you reporting positive results, in total? And, if you can tell, how many of these were on your book’s regimen only and doing nothing else?

      From your website I can gather:
      – you
      – Trent
      – JD Moyer
      – Jared (problem with him though: he was vitamin D deficient so that might have played a big role, rather than typical AGA)
      – Joseph
      – Peter
      – Damir
      – Chris

      Leaving Jared out of the equation, that would make 7 people. Knowing how desperate people with AGA are and how they like to combine a lot of things at the same time though, I am not sure all of them did your book’s regimen only and nothing else. Do you know anything on this?

      Also, what is the total number of people that got success by following your book’s regimen? And how many of those did not follow any other treatments at the same time?
      Maybe you could even write a blog post with some statistics and rough numbers?
      This would certainly also convince more people to buy your book if you can give some statistics on success rates!

      I’m really interested in buying your book, but if the “responder sample size” is small and if it’s not clear they only followed the book and nothing else, it’s a bit of a gamble.

      Thanks & I really appreciate your work!

      • Benjt, I’d like to support this! Especially given that the only two studies we have as evidence of the success of massage techniques are both quite problematic. The one by Choy appeared in a suspicious Journal, there is not much photographic evidence, the success rate claimed is way too high to be legit (or so it seems), and the author apparently does not respond to any questions. Hm… The other study had a small sample size, and it found that massages actually DECREASE the number of hairs (while increasing their thickness, however).
        Given these caveats, I’d also really like to see more case studies presented by Rob. If so many people have contacted him over the years, that should not present any problem.
        Why is that so important?
        – the suggested regimen is quite hard on the scalp, and one would want to know how many people experienced regrowth before inflicting any potential damage to the hair
        – it may be that only a fraction of people actually suffer from lower perfusion in the scalp, and that only to those the massages are a cure (while for all the rest it’s just genetics or other factors at work). The only way to rule that out is having large sample sizes. This includes: knowing how many people actually reported NO success. So far, we know of 8 who had success. How many did not?
        – 40 minutes per day is a big commitment, and most people would not want to waste this time if there is not enough evidence
        – there are thousands of “hair-panaceas” outside there. Rob aims to make a difference by tackling the issue scientifically. He does a terrific job, but at this stage (a few years in!), this should also include more case studies
        – finally, as already mentioned in the above post, it is vital to exclude all other factors (fin, minox, etc.) in the success rates!

        So, Rob, please give us some more evidence / pictures / case stories / statistics. You are onto something there! Thanks!

        • Benjt and Wayne,

          Thanks for taking the time to comment. I agree with both of you. The effects of these massages need to be quantified. And while I (and others) have experienced improvements from massaging, we can’t take the data presented within the Detumescence Therapy study seriously. The paper was published in a predatory journal, the author doesn’t reply to emails, and full-hair recoveries (i.e., from NW6 to NW0) in ten months (as the author suggests) have yet to be replicated by a single person.

          The good news is that we DO have data on AGA sufferers doing these massages. Specifically, we have data from our readers. And this data was recently accepted as an original research article in a top-20 dermatology journal. I’ve been dying to share it with everyone — and I’ll be able to do so very soon. Here’s a bit of background:

          In late 2017, I worked with two statisticians to design and implement a survey on past readers of the second book release. Beyond demographic data, Norwood gradients, and hair loss region / patterning — our questions centered around assessing each reader’s adherence to the massages as well as their perceived hair changes. We also collected data on diets and concomitant uses of AGA-related supplements, topicals, FDA-approved drugs, or other stimulation-based therapies like microneedling.

          After collection, we spent several months analyzing the data to determine a relationship between massage adherence and perceived hair changes — particularly when controlling for variables like age, gender, AGA gradient, hair loss regions, and concomitant treatments like finasteride, minoxidil, or microneedling.

          The results were incredibly promising. Months, minutes daily, and total massage effort (minutes daily x months) were all significantly associated with improved perceptions of hair change. And the biggest predictor of someone’s hair change was simply the time they spent massaging. Not gender, diet, concomitant finasteride use, etc.

          We also found differences in response rates between hair loss regions. Those with temple or vertex recession responded differently than those with diffuse thinning. It was really fascinating stuff and all explainable with the literature.

          We then spent three months writing up these findings into a study. This was a pretty involved process. There are a lot of things we had to do from the outset of data collection to mitigate any conflicts of interest. For example, since I run this website, and since data are from past readers, I wasn’t allowed to analyze the data at all. Independent statisticians had to do it. As such, our study design, execution, and analyses were a tightly regulated process involving methodology reviews from an independent Institutional Review Board, qualifying for exemption statuses for non-human subjects, de-identifying data, etc.

          The long-story short is that our study was just accepted into a top-20 dermatology journal. It’s something I’m really proud of. The study will be open access, so anyone can read it and benefit from the information. Our goal here is to maximize everyone’s chances for success, and this study was a big next step toward quantifying this data.

          The other good news is that in becoming more involved in the academic side of AGA research, a few research partnership opportunities have opened up with universities. One of these (that we’re currently negotiating) might very well overturn much of what we think we know about AGA pathology. I’m really excited to share that with everyone when the time comes — but there won’t be much to share on that front for at least another six months.

          In the meantime, I’ll be sharing that original research study very soon. Hopefully within the next 20 days.


    29. Rob, This is so exciting!! I can’t wait to read the study! I hope so much that because of your tireless efforts, everyone would be made aware of where “conventional wisdom” is wrong in regard to hair loss and treatment efficacy. I also hope you would have the opportunity and resources to investigate all of your outstanding ideas and theories. Thank you again for never giving up.

    30. Thanks for the update Rob. So unless there’s something dramatic to alter we just continue with the second book theory? Makes sense if there’s been success. I’m sticking with the diet and massages anyway, but those cold showers!!! One question I have for anyone in the know is whether anti-inflammatory medication would affect this system? I’ve been using Diclofenac pills for back and tennis elbow injuries daily for years, and being that it’s in my system 24/7 I wonder whether that is helping, doing nothing, or hindering because there’s not enough inflammation from massages? So complex! Cheers

    31. Dear Rob,
      thank you very much for replying! This is great news – exactly what we need at this stage (also, as you say yourself, to assess the influence of massages vis-a-vis the dietary adjustments you propose)! If you can pull that off, your case will be much more convincing. Your first journal paper was already great, and I enjoyed reading it a lot. Actually, it was this paper that brought me here. It proposes a mechanism, and the obvious next step would be to propose a tailored cure, given the apparent reversibility of this mechanism, accompanied by some statistical evidence. I am very pleased to hear that you are in the process of getting this published!
      Being in academia myself, I know how time consuming these things are, especially since one has to avoid so many pitfalls if the research is to be accurate and the findings waterproof. If your second paper sparks interest – which I am sure it will – then you should consider conducting a proper double-blind study (I also wanted to write ‘placebo-controlled’, but how does one introduce a placebo for massages?! 😉 I’ll have to think about that). Such studies are obviously costly and time consuming, but if, as you wrote, some cooperations with universities are already on the horizon, all this may not be impossible.
      Rob, keep up the good work! I am really looking forward to your next paper. Best wishes!

    32. Hi Rob,

      as I stated before I was already seriously impressed with your previous work, both your first paper and also your blog posts here. Another paper with proper (!) statistical evaluation of a good sample size – if the data supports your proposed therapy to actually work, this could be really big. I assume the data gathering and sanitization was a big PITA, as you had to gather this data retrospectively and it was not a properly monitored study. Hope the amount of data you were able to use was still sufficient.

      As you mentioned though, the detumescence therapy paper was utter BS. You might want to be more open about this on your website and in your articles, for the sake of transparency – just as a suggestion. People who check out this study seeing how you use it as a supportive argument might disregard your hypotheses completely based on the fact that the study was really bad.

      Asking for a small spoiler: How big was your new paper’s group size in the end, i.e. the number of individuals whose data you could actually use? Is the open access version going to be a preprint or the journal version?

      Congrats again on your next paper, keep up the good work! And celebrate it properly once it’s published – I know from experience how hard it can be to be accepted into one of the top journals of one’s field! Looking forward to reading the actual paper!

    33. Rob, reading all this, it makes sense that the regenerative capacity that comes from wound healing is just as important as reducing scalp tension.

      While scalp tension is the likely culprit behind most AGA, reducing the tension that caused the loss will not by itself trigger regrowth, but wounding could spark that regrowth, after reducing tension. In light of this, minutes, frequency and massaging with the most force, seems the best bet.

      I’m reminded of the bald old man who split his scalp open after a fall and subsequently regrew his juvenile hairline, that’s the power of wounding (and possibly reduction in tension at the same time due to the cut). I’ll stick with the intense massages, but there’s a fine line to causing damage and I don’t want to hurt myself to regrow hair, lol.

      The question is, could the intensity of the wounding limit the level of regrowth? The 7 month regrowth photos you show are impressive, but do those individuals get further recovery after those pictures, or does their progress then stall? If recovery doesn’t progress to pre-AGA, perhaps we need to wound more intensely.

      • Hey Steve. Wondering the same thing. I’m 6 months in and have lost most of my crown hair since I stopped minoxidil and finasteride, but I do have some tiny hairs on the area. Very tiny, basically invisible except under a double magnified mirror. I’ve seen them for 2 months and they’re still tiny, so not sure if they’re coming or they’re miniaturized from stopping those products and on the way out? Anyway, my scalp is a bit looser, but it seems to need a jolt to kick into gear if those hairs are new, and maybe I just haven’t inflicted enough inflammation. From today I’m going much harder, I’ve actually used a small wooden board and pressed it around my crown pretty hard instead of doing the usual second phase of pressing and knuckling with hands alone, and for the first time in a while I’m actually a bit sore. Not crazy sore, but it’s still a bit tender an hour later. If it’s not sore at all in 36 hours I’ll continue like this. I’m wondering how else we can replicate the inflammation and potential regrowth of a 1.5mm dermaroller , there has to be a real hard session at some point. Maybe not every time, but one full on session a week where you’re really inflamed. Thoughts?

        Also, I guess my hair loss means either minoxidil or finasteride did something, just no idea which one as I used both for a decade together. It was never a lot at it’s peak, hundreds more than thousands, but enough to use concealers. Not worth the side effects though

    34. Hey Rob,

      I got a question:
      Have you tried or looked into cupping on the scalp to induce stress, increase blood flow and to break up calcification?

      Could it help or work?

    35. Hi Rob

      I bought your book a while back and just finished reading it. Very detailed and exciting information. In the Q&A section of your book re: topical oils, you mentioned that pig lard worked for one vs not working for another and made the comment that people with diffuse thinning seemed to have less subcutaneous fat and less calcification than those with typical MPB. What do you think accounts for the loss of the fat and will your protocol still work for those with diffuse thinning? Is this the reason that it takes women longer to see results using your protocol and would minoxidil further reduce subcutaneous fat due to its affect on collagen?


    36. I can’t agree with the scalp tightness theory personally because the areas on my scalp where I have the least hair are also the loosest.

      – 5 months into scalp massaging (using various methods) and seeing thicker hair and reduced hair loss

    37. If a good responder to mechanical therapy also incorporates dermarolling will it speed up his hairline recovery even more? Your book states that dermarolling regimes should only be tried if the person is non-responsive to ~10 months of massages as instructed. But perhaps even for good responders to the massages, adding dermarolling can speed regrowth up even more. Just a thought. Are you saying that if someone responds well to massages, dermarolling will have no additional effect?

    38. This might be a bit random, but can having laser hair removal on the back, arms, or any part of the body, contribute to hair thinning/loss on the top of the head?

    39. Hey Rob ,

      I’ve read the book and I have a question to make about the DHT paradoxes .

      In your book , you claim that increased tissue DHT on the face and body , equals to more body and facial hair . But there is also a paradox in that point. As we age , we develop more body and facial hair, but at the same time our testosterone and DHT levels are gradually dropping . My question is why we develop more facial hair towards our elder ages , while its proven that DHT levels drop as we age.

      Finally , I want to make a final question.

      I’m currently using an Ayuverdic Shampoo for my hair x3 times a week . This shampoo has :
      No sulfates , No alchohol , No artificial colours , No silicon , No paraffin + mineral oil , No perfume.

      Taking into account , that you are against shampooing , my question is , will this shampoo affect negatively my hair regrowth ?

      • Hey Alexander,

        Thanks for reaching out. The literature shows that as we age, testosterone declines, but DHT tends to remain stable or even increases in certain tissues (up until around 80 years of age).


        You can certainly try that shampoo. As long as someone isn’t chronically shampooing (1+ times per day), they tend to be out of the danger zone in terms of promoting sebum overproduction.


        • Dear Rob,

          I have had no reply to my messages I sent to you recently, what’s happened? I am two years still practicing massages and not missed a single day and not missed a session. Not one session.

          Hope to hear from you.



    40. Hey Rob, great work. Can you please put up a post on dermarolling and one on how to reverse seborrheic dermatitis induced hairloss? Thanks!

    41. Hey Rob , back with another question , concering to cold showers.

      I’ve done some personal thinking and research for cold showers , because I was curious why would I do something that feels so bad. It seems that sea water temperature (at summer season) is the best and most ideal water temperature for the human body. I will explain why. However , I can’t deny that cold showers help to build discipline , by doing something that is not comfortable . But healthwise , I think it is not beneficial. It might be actually harmful.

      When you take cold showers , your body produces more white blood cells than normal. That means that , there is an IMMUNE RESPONSE to what you are doing and in my opinion , the body doesn’t like it.

      That’s why when cold water makes contact with your skin , your body automatically “cringes” and your genitalia shrinks significantly , because as I said it seems that the body doesn’t like it.

      Moreover , it seems that chronic cold showers , deplete nutrients from your bone marrow because of that immune response . That’s why many people after taking cold showers for months or years will say ” I don’t get sick anymore .. WOOW ” .

      I think that people were meant to live in the climate , that they were born , the tropical one. The oceans in a country with a tropical climate are not ice cold and freezing.

      I have to point out that this is my personal opinion with only a few researches backing up what a claim.

      I want your personal opinion on this topic , Rob 🙂

      Thanks , Alex 🙂

      • Also , there is a huge difference between cold ocean swimming and cold showers . When you swim at cold oceans , your body temperature is steady because simply your body is constantly inside the water.

        However , at cold showers your body temperature is fluctuating because your body is not under water. I think that these constant alternation of body temperature is dangerous . Same applies with hot steaming showers. Probably , the best way to go is room temperature water.

    42. Hi Rob

      I just wanted to know if it’s ok to be consuming white rice every day, as I’m having a hard time finding what to replace it with.

      Also, are almonds and oats fine to add to the diet?

    43. Hi Rob,

      Fantastic website, I only came across it a couple of weeks ago but I am thoroughly convinced you’re light years ahead of most of the so-called professionals in this field. You’re doing a fantastic thing. I just bought your book today and I’m looking forward to reading it.

      This question may be answered in the book at some point, but it’s a bit obscure so it may not, but basically I was just wondering your opinion on whether or not Collagen supplements would contribute to fibrosis, and to a lesser extent calcification? I have been taking a marine collagen supplement for a couple of months, for reasons other than hair growth. It has been helping me a lot with joint pain, digestive issues and sleep funnily enough (Glycine). So I am keen to continue it, but not if it’s going to be detrimental to my hair, which has been thinning for a number of years, although strangely has been seeming better the past few months coinciding with the collagen. My thinking is that it may be making the follicles healthier in the short term, but could be contributing to more fibrosis in the long term?

      Also as collagen does have a somewhat large calcium content, would it also contribute to calcification? And should we be limiting our calcium intake in general, or just making sure we’re getting enough Vit D, K2 and Magnesium to make sure it’s stored properly? Apologies if these have been answered before, I did try to find them on other articles.

      Finally, on an unrelated note, what is your opinion on a device such as this one

      It seems viable and logical to me, for tackling scalp tension, fibrosis and calcification. However, I think most of what this product does would be covered in the scalp massages anyway, and the scalp massages would go beyond what this product can do. Anyway just wondering your opinion.

      Sorry for all the questions, no stress if you don’t get around to answering for a while. Thanks in advance!

      Cheers from Australia,


    44. Hey Rob !

      The SCALP RIDGE PINCHES on the video , are pretty hard to do in my scalp , with the technique you use. Can I do double-hand scalpe ridge pinches instead?

    45. What is the rationale behind cold showers against hairloss? I have read quite a bit on this site, JD Moyers site and others, but i cant recall to have read anything that makes sense about how cold showers should prevent hairloss. Can someone elaborate or send a link to a good source on this?
      Also, i find it hard to get greasy hair clean without warm water, so i tend to use warm water and shampoo for that, but i usually only shower and wash my hair once a week or even rarer. For me this is sufficient, no smell or nothing. ( I think that everyday showering is a very recent thing in history of life, and not necessarily a good one )

    46. Hey Rob, does water quality play a role in hair loss? I use broewell water. I have MPB (diffuse thinning) and seborrheic dermatitis (both confirmed by a dermatologist). I’ve been using minoxidil and ketoconazole shampoo for a year now with no improvement. But I had to go out of town last week for a couple of days and my dandruff, itchiness and flakiness miraculously disappeared. They’ve returned now.

    47. Hi rob

      I’ve just finished your book and have some question :

      – shampoo

      When you do water only do you massage your scalp ? If yes what technique do you use ?
      Personally I have hard water… do you use or recommend a filter for this ?

      – breakfast

      What would you recommend as a breakfast ?

      – blood donation

      Are you still donning your blood every two months ?

      Finally I think posture can play a big role at Hair loss. Do you think the same ?


    48. Hi Rob. Any update on the release of your research you mentioned here in January, or when it will be published in the scientific journal? I am at week 22 of the massages and am seeing impressive improvements that I can truly attribute only to them. I had confided only in my immediate family up until a few days ago when I saw my hairdresser. My previous trim was 2 weeks prior to beginning the massages, and I (once again) lamented my noticeable thinning. She attributed it to heredity and the aging process but I told her I was committed to finding the real cause and a drug-free treatment. About 2 weeks afterward, I found your website after countless hours of disappointing and contradictory other findings and immediately began the massages. Fast forward 22 weeks. When she saw me Wednesday, she was astonished at the amount of regrowth she found and confirmed that it is way above “normal”. I am going to wait a few more months before I start shouting from the mountaintops but I would prefer additional data to back up my claims.

    49. Really need that forum, and the book update

      Well done Lisa, hope it keeps improving. I’m at the 8 month mark but not having any regrowth yet. Not losing lots of hair, but not growing any at all. I’ll wait on the new book and hope to unlock a few new techniques or changes I can make

    50. Dear Rob,

      I have had no reply to my messages I sent to you recently, what’s happened? I am two years still practicing massages and not missed a single day and not missed a session. Not one session.

      Hope to hear from you.



        • Hi Steve,

          I would say there is a lot of new very, very fine hairs and, noticed recently little sharp black hairs developing which has encouraged me greatly. In the two years my hair has thickened, dozens of little vellus hairs sprouting but, regrowing it is hard, very hard. Still, my scalp has a degree of thickness (especially on vertex) to be removed and, I know once that is completed maybe, just maybe the platform is set for new hair regrowth?

          How has your progress developed?

    51. Hi Jon,

      Sounds like you are getting there, slowly but surely. Thick fibrotic tissue is going to take some time to break down. I’d be pressing it very hard with the knuckles to encourage that break down. How much hair did you have before you started the massages?

      It’s too early to tell here, but when committing to massages every 12 hours, I notice the itch stops, the scalp feels less tense, and recession freezes. So I can only imagine it is doing very good things.

    52. Hi Steve,

      I’d say I have Norwood 3 in regards to how much hair I had and there does appear to be a degree of improvement. Hair has thickened considerably and. looking at an angle on the scalp there appears a lot hair follicles in the bald patches so, something is emerging.

      The key to all this is perseverance. My scalp has a spongey effect. Is this calcification softened? Also I’m if skin cells get trapped in fibrosis/calcification.

      How long have you been doing massages?

      • I restarted the massages in earnest a couple of weeks ago. I did this for many months last year but never committed to the 12 hr frequency, which I believe may be the key to success. As Rob said recently, the most important factor in getting results is total minutes daily. So, massages have to be every 12 hrs.

        Norwood 3 here. Possibly 3.5. My scalp feels thin and tight over the skull bone. No sponge. I’ve felt the sponge in Norwood 6’s with the dome shaped thickened scalp, and I think it’s definitely fibrosis. That’s only going to clear up with hard massages. I don’t think calcification can be felt as that is microscopic, but fibrosis definitely can be felt as it is a build up of scar tissue mass, making the scalp thicker and spongy.

        Have you tried Rosemary? Rob said 10% Rosemary oil diluted in a carrier can improve regrowth outcomes with message therapy. It basically dilates the blood vessels in the scalp to allow more oxygen to the follicles, and has a 5AR blocking effect. I’m considering it, but I burned my scalp with undiluted Rosemary oil (not recommended) and it caused a massive shed, so I am cautious about trying it again in case I created a sensitization issue.

        • Hi steeve,

          I am suffering from MPB since last 7 years, till now i am not fully understand i am suffering from whether it is dandruff or flakes or any other thing, while i am doing massages my hair has been falled with some small white spices comes along with every single hair root, what is it? is it dandruff? or is it related to Male patteren baldness, and my hair also itching. Also fully not understand why hair loss is very less if i shave my full hair and growing back exiting hair till two months, after the hair growing long till 3 months, again the hair fall is increasing with that white spices(it is dandruff or something?).

        • Earlier this year I suffered a really bad flu, didn’t really want to pursue massages but, I still carried on regardless. Had a bad fall from attic and damaged my shoulder but, still carried on. You just cannot take a break the intensity must remain the same.

          I read that a Magnesium topical is good for softening the scalp to help your massaging that bit easier. What carrier can you use with Rosemary oil. I didn’t like the sound of your method 100% Rosemary…sounds lethal!

          Do you attempt inverse technique? I tried this with my head sitting on an acu pressure ball. That may help break processes in scalp.

          Let me know if you find out what carrier is needed for rosemary.

          If you don’t persist the massages according to method, you’ll regret later on in years not doing it.

    53. Agreed Jon. There’s no substitute for consistency.

      If you go to the Rosemary page on this site (I’ll copy the link below) there is a form to enter your email to receive Rob’s Rosemary guide. Very good information in there. I wish I had used his protocols before trying undiluted.


      He essentially recommends fatty vegetable oils, like pumpkin seed oil, borage oil, coconut oil. It doesn’t seem to matter which. Rosemary has good dermal penetration, it doesn’t really need a carrier they’re just used for dilution.

      Thanks for the heads up about inversions. I am going to work that in to a daily routine. The more blood flow to the scalp, the better. After all, follicle miniaturization is a blood flow issue. No oxygen and the follicles shrink, hair shafts get thinner and they drop out. Fibrosis also constricts these blood vessels and starves the follicle.

      I have also started supplementing with beta carotene, vitamin D, magnesium, selenium, biotin and silica. This is the best nutritional support for hair growth. Rob said that a limiting factor in regrowth success is low levels of vitamin D and nutritional cofactors. So I have that covered with the above supplements. Magnesium is important but it is required internally as it is a vitamin D cofactor. Biotin and silica aren’t necessary for regrowth, but they do thicken hair strands so could help appearance.

      Papanna – white flakes are normal for heavy massage sessions.

      • Hi Steve

        Have you attempted cold showers? Stepping into a shower for five minutes forces the blood in your body to circulate the organs for immediate protection survival mechanism then once you step out of the shower the blood immediately returns to normal and, consequently flushes out toxins and lympth glands.

        Have you heard of a powerflush to clean a boiler system in order to remove clogged up waste in pipes? That’s my analogy on the cold shower.

        I tried this practice 25 days but, I had to stop due to a flu. I wanted to do a straight 30 days for maximum effect. Do you think Aloe Vera would be a good carrier? Jojoba oil? I’ve already ordered a Rosemary oil 50ml bottle.

        When you mentioned the oil dilates the blood vessels that was music to my ears! Blood in full operation is so essential to re-set your scalp and clear away the debris it’s the fuel much needed in supply.

        Talking about Magnesium, do you take Magnesium chelated? I believe that is best Magnesium to consume a bit expensive too.

        Do you know anything about fibrosis release on scalp and what it feels like? if there is knowledge on substance.

        • Hi Jon,

          Cold showers are a good idea, but I’m not sure if I can take it! Will try and see if I can get used to it.

          Jojoba oil would be a great carrier. I’m using Fractionated Coconut Oil (FCO) which is very thin and light, like Jojoba. I’m going to try 10% Rosemary in carrier today, and see how it feels. I’ll massage it into the scalp for some minutes, then wash it out. In my opinion, leaving Rosemary on your scalp for hours may be counterproductive. It’s very strong stuff. If you feel any stinging or burning sensation, dilute it further and leave it on for less time. I believe it will work well for regrowth when used carefully.

          Yes, all the minerals I buy are chelated. I take Magnesium Citrate. Make sure you’re also getting enough vitamin A (Beta Carotene is the best form of Vit A because the body can regulate the level of it better). Vitamin D can only work for regrowth when you also have adequate levels of Vit A and magnesium. If the body is deficient or imbalanced in these it will slow or even prevent regrowth.

          Fibrosis is scar tissue within the scalp, it’s collagen based. So you have to physically break it down through hard massages, which slowly disintegrates the fibrosis over the long term. The fibrotic cells that break down will be removed by the circulation. It’s like grinding away at a stone, it takes a long time to wear it down. It won’t release any substance. The more oil / sebum you get rid of, the better. But that’s not related to fibrosis.

          You must also loosen the scalp, alleviate the tension / tightness. The body responds to chronic scalp tension by releasing DHT, which causes blood vessel calcification and fibrosis. Our hair follicles are under attack in many ways, there’s a whole host of things cutting off blood supply, but we can beat it!

          Let me know how you get on with the rosemary.

    54. Hi Jon,

      Please help me ,my hair is falling and almost it was thinned on the top of head due to I think seborrheic dermatitis, because when I rake my top hair skin with my finger nails, inside nails filled up with white powder, is it seborrheic dermatitis??

      Please suggest me

      Thank you so much

      • Papanna,

        How long have you been doing these massages? a substantial amount of dandruff is expected to be released from scalp. Have you been doing massages twice a day rotational. Do let me know.


    55. I believe Aloe Vera is water-based. What is best to carry Rosemary oil is oil based and Jojoba oli is oil based which I have at home. By all accounts the oil has to be used continuosly after say a four to six month trial. \stil the underlying matter is to remove fibrosis which is very hard to do.

      I treat the massages as second nature to get through the days when I don’t want to do them knowing success may prevail.

      I tested my hair the other day and it does appear to have thickened somewhat. There does appear to feel more hair and that’s a little victory. Keep persisting and surely more hair will grow.

      Do you have a method to measure Rosemary oil? I’m thinking of starting at 10% and remain there till I know when to up or down the level.

      There’s a psychology behind massaging scalp and that is not wanting to beat hair loss but it is beaten. With that mentality you don’t question yourself…never.

    56. Thanks for your response job, I am doing massages as per Rob video, but I didn’t follow it’s protocol.

      Please suggest me how to do protocol?

    57. Good thoughts Jon.

      I measure it out in a small clear measuring cap.

      I make a combination of 90 ml fractionated coconut oil and 10 ml rosemary and apply to scalp with a short massage, leave it on for a time then wash out.

      Tried 10% yesterday for 30 minutes. That duration felt more than enough. Didn’t have any negative effects, so will continue with this concentration.

      • That’s the spirit, Steve,

        I bought a hydrometer jar today for measuring correct quantity for Rosemary and Jojoba combination this evening and, again I’m following a new path thanks to you!WhaThe t I like to know is if 10% Rosemary is one solution surely the other part must be 90%?

        Obviously those two figures add up to 100%. The correct balance would be 1:10 ratio?

        Anyway, I’m curious how one could arrive at spongey scalp being fibrosis and calcification being microscopic. And, here’s me thinking I’m removing mostly calcification! Like you say you have to keep battering away removing fibrosis. How long have you been doing massage before stopping?

        Is fractionated coconut the best for Rosemary you think?

    58. Hey just wondering if you’re next artical is close to being done.
      I’m really curiuse for it.

      By the way i thank you a lot for you’re work it’s outstanding work.
      Thanks Rob.

    59. Hey Jon

      Yes a 10% strength solution could be 10 ml Rosemary and 90 ml carrier, of the total 100 ml 10% is Rosemary. But you can make any amount with the same ratio.

      I believe that layers of fibrotic scarring builds thickness to the scalp tissue over time. There’s a lot of it which builds into a thick section of flesh, which feels kind of spongey because the layers cushion and are naturally hydrated.

      The calcification is different, it is a calcium deposit within the tiny blood vessels in the scalp (narrowing the flow of blood), it cannot be felt and is viewed under microscope. Think of it like the calcium plaques that build up in your arteries.

      I did it for about 5 months then stopped. But never committed to the 12 hr thing, which is absolutely necessary I’m thinking.

      I like fractionated coconut because it’s easy to wash out, and doesn’t feel very oily or messy. Well absorbed by the skin too. In terms of Rosemary effect, any oil carrier will do, just a matter of preference.

      I really don’t think I can do these cold showers. Truly hate them, lol.

    60. Scalp tension theory is the one which explain most of the pattern and paradoxes in AGA . but your emphasis on transplanted hairs seem to be far fetched and useless or could it be that finasteride use after transplant may reverse the fibrosis?

      • Hi Mandar,

        It’s hard to form a counter-argument to your comment, since it’s unclear which part of the article you’re talking about. If you have any specific aspects of the evidence I’d laid out that you disagree with, I’m happy to have a conversation about that. Just provide your counter-points and links to the relevant studies.

        In terms of finasteride use, the evidence that I’ve read suggests that finasteride only seems to inhibit DHT-induced TGF-B1 and thereby stop fibrosis in balding scalps, but not reverse it. However, the more relevant point is the study done by Cotsarelis’ team which showed that if a hair follicle regenerates, it can reverse the fibrotic material surrounding it. That would explain why transplanted hairs survive in a new environment. This is all discussed in the article.

    61. Hi Rob,

      I recently read an article about the frontalis muscles having to do with recession, so I started massaging above my eyebrows and it felt good because there is a lot of tension there usually. I recently bought a Heeta scalp massager and used it on my forehead and after 2 days noticed there was no longer tension, just phantom feeling in the area which was now much smoother and the muscles more taut and less reactive. I also noticed that a ridge above my eyebrows was gone, so it must have broken up a lot of calcification that was causing a lot of tension. this was 2 weeks ago and since, there has been a huge difference in blood flow to my face and scalp, with a much more even skin tone. The exfoliation from the massager while washing plus the penetrating massage has broken up all the calcification in the scalp and sides and front of the head. Just putting this note here for you and others to see. The tool massaging plus regular exercise and scalp massages has completely halted fallout (seriously, completely) and any scalp peeling that was happening. The skin is now clear and with good circulation. hoping for the best over the coming months as these changes push the system towards a homeostasis!

      • Dear Ralph,
        Dear fellows,
        thank you for sharing your experience. This is a very good point. As I read your comment I just included some extra 5 min (2/2/1 split) into the frontal area session just tackling the frontalis muscles at the forehead between eyebrows and hairline. In my opinion this part is quite underestimated and as important as the side and ridge parts of the head. In the past I only massaged the hairline when doing the frontal area session. Oh dear, there has been tension. I can’t even believe how I did not catch this in the past. However, just after not even 2 weeks the difference in terms of bloodflow is like day and night. The tension has decreased quite quickly day after day. And there is some kind of peeling skin or dandruff just as at the top of the head. I really believe that there is something bigger behind this. I will continue to include this extra 5 min into my routine just as the extra 5 min of the side part area session. Thank you.

        • Gernot – great insights! One reader here experienced little to no results from the massages for six months. We had a Skype consult and he switched almost exclusively to focusing his energy on his scalp perimeter and forehead. Six months later, he saw some significant improvements.

          Ben's Before-after

          So, keep with these additional five minutes and please let us know how it works out!


    62. Rob,

      You write in your topical rosemary email guide that coconut oil would be a good carrier. After doing some research I’ve found a major red flag with this. 7% of coconut oil is caprylic acid (and forms the majority of fractionated coconut oil). Caprylic acid is a potent phytoandrogen with higher androgen receptor affinity than DHT. Since applying coconut oil to my scalp as a rosemary carrier my MPB itch has returned with a vengeance. I recommend people stay away from it. I’m switching to EVOO, a much safer option which has the benefit of high oleic acid content that should help subcutaneous fat density, which is likely why some of the topical animal fats work.

      • Hey Richard,

        Yes! Just like the last book release, I severely underestimated how long it would take to rewrite everything. But this new book release also comes with much more than the book: 20+ case studies, dozens of ultimate guides, an interactive survey to guide people to an evidence-based hair loss regimen based on their age, gender, hair loss type, comfortability with drugs, and time availability, and a forum (as you’ve been asking for a long time). All of that is almost ready to go, and I should have an announcement for you in the next few days.


    63. My previous comment can be disregarded. I was using the wrong coconut oil. Raw, extra virgin, cold pressed coconut oil is perfect on the scalp, and a good carrier for Rosemary, at 5 drops or so per teaspoon of oil. Feels wonderful, with or without the Rosemary. I love topical fat absorption for diffuse thinners. Coconut is also very good at blocking DHT and reducing inflammation, just not in the Fractionated form I was using before (avoid that).

      Jon, there is no propylene glycol in oil. I use a few drops of propylene glycol to emulsify Rosemary oil in water based mixes. I make a spray this way, with up to 10% Rosemary in water, just spray occasionally through the day. Much less messy than a fat based topical which I do when time allows. I’m buying a hat for when I use coconut oil.

      Scalp is getting very pliable with the 12 hr massages, so very pleased about that. Looking forward to some new hair growth in a few months.. fingers crossed.

      • Steve,

        I read that Propylene Glycol (Rogaine has this property in its product) penetrates very well into scalp. Would Propylene Glycol be a good safe to other to other fat-based oils? bearing in mind Rogaine contains 2% Propylene Glycol.


      • Steve – this is great to hear! I’m glad the new coconut oil carrier is helping. And you’re right. I’ll absolutely make a note of avoiding fractionated coconut oil in the write-up. I saw your email about this and appreciated you sending the information my way.

      • Wayne, thank you! I have been checking the phh website/articles/comments several times a week for months for news about Rob’s paper!

        • Wayne,

          Thank you for the kind words! I wanted to announce the study shortly after it was published, but my daughter was born and I spent the next 8 weeks in a time warp trying to figure out when I’d find time to write a supporting article. I’m just surfacing for air now, and I’ve written an article about the study here:


          Lisa, thanks for checking in about this, and I’m sorry for my lack of communication on the article’s release. How is your hair coming along?


    64. Jon, not sure what you’re asking.

      PG is used to emulsify essential oils in water based mixes. I make a water based rosemary spray with PG, as I said above. Without PG, the rosemary oil would just sit on top of the water which is no good. You do not need PG in an oil based mix. Rosemary is an oil and mixes into any other oil, such as coconut or jojoba. Fat based oils absorb + penetrate into the scalp. Rogaine is not fat based, that’s why they add 2% PG and alcohols, for mixing and penetration.

      If you’re asking about using pure PG + rosemary, I don’t see the point. There are many benefits for hair regrowth with fat based oils that you will not get from using PG.

      • Hey Steve,

        I know I sent you a mesage previously, I just found how to reply to you directly.

        Could you tell me exactly where the scalp’s perimeter is located?


    65. Brilliant updates Rob! Thanks for the reply. I’m about 9 months in now, but have realistically only done the massages at 60% of what I should have based on your new article. Probably ok time wise if I was maintaining hair growth, but too many skipped sessions and random days off for a beginner with advanced hair loss. I can 100% say that removing minoxidil 7 months ago, after 25 plus years, has absolutely made no difference to my hair. What a waste of thousands of dollars that was unfortunately. My hair loss has stabilized for a couple of months now, so hopefully only positive results going forward. Looking forward to the forum, great news. Cheers

    66. Very interesting article Rob! I was thinking if efficiency of these massages or even more needling has something to do with this “inflamation radius” of 4mm from the study. I understand that a “single hair” can sense what is going on in the skin within these radius. This could explain why some guys get regrowth in stripes on the folds of the massaged scalp. What do you think?

      • Hey Julia,

        This is a great question. The short answer is, I don’t know!

        We have case studies like Trent (who have seen regrowth in lines, like you’ve described). And it seems like people see better success when varying the angles in which they pinch (and thereby the directions in which the skin folds).

        On that note, maybe the folds create “additional” stimulus to the follicles, thus stimulating better thickening / regrowth versus the surrounding areas. But I just don’t know. It’s certainly something worth looking into further, and if I find any answers, I’ll be sure to reach back out here in the comments.


    67. Hi Rob
      Greeting from China. I think hair transplantation may do change the environment of the scalp, considering the process of hair transplantation, some tiny holes are created on balding area in order to transplant the follicle unit, which may work in a mechanism similar to microneedling, but it affects much deeper tissues, which may also cause acute inflammation and remove the fibrosis and calcification if the doctor is doing this in the correct way, therefore, transplanted hair can preserve much longer or maybe “lifelong”, that is my opinion, hope it’ll help.

    68. Hi ,

      according to this :

      “In my conversations with other AGA researchers, a few have stated – contrary to popular belief – that transplanted hairs do thin. There’s even an emerging theory that transplanted hairs simply restart their “balding clock” post-transplantation – meaning that in 5, 15, or 25 years, we can expect more FUE transplants to start thinning.”

      there is nothing in the indicated article ‘https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4639964/’ shows that the FUE transplants starts thinning , i saw that ” In hair transplantation, the grafted follicles start a new “balding clock,”

      So , they didn’t mention if the FUE or FUT , they said in hair transplantation , and that article show the Involvement of Mechanical Stress in Androgenetic Alopecia….

      best regards,

    69. Hi Rob,
      I had a couple of questions regarding the scalp tension theory.
      1.Where does diffuse pattern hair loss fit in all of this ?

      2. If scalp tension is the main cause of AGA then why do some people lose their hair at the temples and the nape? Such as in Retrograde Alopecia.

    70. “in the next article, we’ll discuss where this “scalp tension” might originate”

      Rob I saw you mention that your attention shifted to the book but did you ever get around to visiting this topic in the third article? The root causes of scalp tension are probably of the most interest to me.



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