Options Abound for Hair Loss

Last Editorial Review: 5/4/2005

Hair Not There?

By Jim Morelli
WebMD Feature

Reviewed By Gary Vogin

Surgery, Drugs -- Options Abound for Hair Loss

One New Product Allows You to Sprinkle on Temporary 'Hair'

By Jim Morelli, RPh
WebMD Medical News

They can range from some of the most delicate surgical procedures to some of the most drastic; from microscopic cut-and-paste jobs to scalpings of horrid dimension. They can be expensive, disruptive, and not without pain -- but that doesn't stop thousands of men each year from undergoing hair restoration surgery -- nor numerous transplantation clinics from luring them in.

But be careful what you ask for, advises a dermatologist. "There are a lot of people who think they need transplants but who are not ready or not suitable candidates," says Michael Reed, MD, who performs hair transplants in New York City. "I just had a 22-year-old come in ready for a transplant and he went out with two prescriptions."

Reed's point: Baldness is progressive. Surgery performed today stands a chance of looking ridiculous 10 years down the road -- picture a nice, healthy island of hair sprouting up from a sea of scalp. "We have to plan ahead," Reed says, no pun intended. "You can't just chase baldness around. It's worse to look unnatural than to look bald."

But even good candidates for transplant surgery can get into trouble -- if they choose the wrong doctor. "The first thing I'd try to avoid is anybody who promises to do a whole head in an entire session," says Walter Unger, MD, a New York-based hair transplant specialist. "Although it's possible to get a very nice looking result, there's good evidence that a good number of hairs have died in the process."

This happens for a couple of reasons, Unger says. First, more hair means a longer surgical session -- sometimes up to 12 hours -- and that means more handling of the grafts. They can become damaged in the process. Second, putting more grafts in means more incisions to the scalp -- and that raises the potential for damage to the blood supply.

The safer route: Plan for more than one transplant. "We routinely do 750 to 1,000 grafts per session. But you can't begin to cover an entire bald area and get good density in one session," Unger says.

He also advises consumers to be wary of multiphysician facilities, as well as those that rely on nonmedical go-betweens to discuss the procedure. And what about those splashy hair transplant advertisers? "If your work is really good you don't have to advertise as much as [you do] if your work is bad," he says.

But clearly, for the right candidates at the right facility, hair transplantation can provide dramatic and extremely natural results -- far beyond what it could achieve in its earliest days. Forty years ago, the surgery consisted of replanting fairly large, circular areas of hair follicles from one part of the head to another. These 'plugs,' as they became derisively known, gave a 'planted garden' appearance to the scalp, similar to what might be found on a doll.

Today, a hair transplant done well is a virtual work of art, with the grafts indistinguishable from surrounding hair. A new surgical technique makes it possible. The grafts used in the new procedure are often natural clusters of about one to six hair follicles taken from the man's head and used as a unit during transplantation.

The more populated follicle units -- the ones with about six hairs -- can be found on the back and sides of the head, which is why those areas serve as the main areas for finding "donor" hairs for transplantation. A strip of hair is removed from this area, split up into follicular units under a microscope, and then replanted into the balding area. The donor site, meanwhile, is stitched up leaving only a thin, 'hairline' scar.

Men with small bald spots and plenty of good, thick hair along the side and back of the head are still considered the ideal candidates for transplantation -- but today, they're not the only ones who can be helped.

"Over the years we have been able to take some candidates who weren't ideal and make them candidates for some kind of replacement surgery," says Daniel Rousso, MD, president of the International Society of Hair Restoration Surgery and a practicing cosmetic surgeon in Birmingham, Ala. "We're finding more and more patients are good candidates. Rarely do you find someone who's not a good candidate for something."

That "something" could mean a standard transplant or a procedure that's a bit more drastic, such as the "scalp reduction."

"You basically remove the area of balding on top of the scalp, then you slide or advance the good thick hair [from the side] to the top," Rousso says. Sometimes doctors will first "stretch" the area to be moved by implanting a balloon under the skin, then complete the operation about two months later.

Then there's the 'flap' procedure. "It's a very efficient operation for certain types of hair loss," Rousso says. "I commonly perform this for patients with hair loss exclusively in the front." Rousso says a 'hotdog-shaped' piece of hairy scalp is loosened and then swung around to the bald area. "If it's designed properly and done properly, the flap is a beautiful operation," he says. "We call it the 'instant hair' operation."

That's to distinguish it from what happens to hair, initially, after transplantation. It falls out, and doesn't return again for about three months. It isn't that the follicles have died -- although there's a chance with any hair transplant procedure that some won't survive -- it's that they've gone into a resting phase.

These days there's little rest for transplant surgeons."[Demand has] really increased. I think the reason for that is we're getting so much better results than we used to," Rousso says.

New grafting techniques are no doubt the major reason, but other advances in transplantation surgery have made it easier to be a patient. "We use lasers to have a less bloody procedure," says Neil S. Sadick, MD. Sadick also points to computer imaging techniques which can, among other things, give the patient a better idea of what a hair transplant can and can't do. He also cites automated devices that assist the physician in placing grafts.

What's to come? "I think you will see, in three to 10 years, cell therapy that will produce unlimited amounts of hair for people," says Unger. It isn't cloning, he says, but rather a technique in which hair-producing germ cells or stem cells are isolated and reproduced.

Of course, surgery isn't the only way for men to get hair. There are some drugs, too. Long-time player minoxidil got a marketing boost when federal regulators approved over-the-counter sales of its 5% solution -- proven in some studies to work far better than the older, 2% product. But it only works for men who are balding on top. Plus, the alcohol solution it's dissolved in can sometimes cause itching.

Propecia, the first oral medication for hair loss, is probably less known for its action on the scalp and more known for its potential action on sex drive. Reed suggests that when it comes to sexual side effects, Propecia may be getting an unfair rap. "The numbers are very, very good. Only 1% to 2% experience a decrease in sexual drive and sexual performance. Of these, greater than 50% will come back to normal [while still on the drug]. There's nothing irreversible."

Because Propecia causes a rise in testosterone levels, Unger is more worried about the possible long-term side effects from the drug. "The younger you are, the more cautious you should be about using this over the long term. You're on this for your life."

At least one drug company is looking at an 'improved' version of Propecia, says John Ertel, editor of the web site Regrowth.com. "The doctors I've talked to said it had really good results ... better than Propecia." The drug is called dutasteride, and is made by the drug company Glaxo Wellcome. No word from Glaxo Wellcome on when, or if, the product might come to market.

Finally, there is an interesting non-drug option tearing up the market: -- electrically charged merino wool fibers sprinkled on as needed. That's the basic recipe behind Toppik, subject of a heavy print advertising campaign. "We wanted to find a simple, inexpensive, low-impact way to improve cosmetic appearance," says Mark Kress, president and CEO of Spencer-Forrest, Inc., maker of the product. "After a lot of research we finally came up with a particular form of keratin protein similar to human hair."

A certain kind of Australian merino wool fit the bill, Kress says. By giving the fibers a positive and negative electrical charge, they bind to existing hair in a strong, but temporary fashion. Toppik will hang on in heavy rain or perspiration -- but don't go swimming on your lunch hour unless you want to reapply it.

Does it look natural? "So much so that a doctor can walk two inches up to your hair and not distinguish where the hair ends [and Toppik begins]," Kress says.


Vital Information:

  • There are many treatment options for men who want to restore hair loss, including surgery, medications, and a sprinkled-on substance that looks like human hair.
  • When opting for surgery, patients should steer away from doctors who promise to do the entire head in one session or facilities that rely on nonmedical go-betweens to discuss the procedure.
  • Those who opt for drug treatments have a wide variety of choices, including minoxidil, an over-the-counter treatment, or Propecia, which is occasionally associated with some adverse sexual side effects.
Originally published April 6, 2000.

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