"How to Beat Hair Loss" is a source of information for men and women suffering from hair loss. It describes in detail and in an easy-to-read format the latest surgical, medical, and alternative treatments for hair loss.
how to beat hair loss third editionAntonio A. Armani, M.D. University of Toronto redom books inc. 233 Carlton street toronto, ontario Canada M5a 2l2 telephone: (416) 363-6655 1-800-365-6220 Fax: (416) 363-1589
about the author Dr. Antonio Alvi Armani has written this book as a sourceof information for men and women suffering from hair loss.He is a hair transplant surgeon who graduated from the Uni-versity Of Toronto. Dr. Antonio Alvi Armani is dedicated toresearch and development of new medical, surgical andalternative therapies for hair loss. His hair transplant practiceand research centre is located in the city of Toronto, Canada,where he is the director of Cosmetic Surgery Spa.He graduated from the University of Toronto Medical Pro-gram with M.D. Honours, after which he went on to per-form his residency at the Toronto Hospital. He is a memberof the American Academy of Cosmetic Surgery, the Inter-national Society of Hair Restoration Surgery, member of theAmerican Society of Hair Restoration Surgery, Italian Soci-ety of Hair Restoration Surgery, the Ontario Medical Asso-ciation, the College of Physicians and Surgeons on Ontario,and the Canadian Medical Association.Dr. Antonio Alvi Armani has won numerous awards in-cluding the: J.W. Billes Admission Scholarship, University ofToronto, W.K. Mc Gillis Trophy, Gold Medallist, Yetive HeardMemorial Trophy and Steven Clarfield Trophy, Italian Soci-ety of Hair Restoration Surgery Award, Toronto Sun Read-ers Choice Award 2002, for Best Cosmetic Surgeon, XTRAMagazine Readers Choice Award 2002 for Best CosmeticSurgeon.He has written articles and books on various aspects of hairloss, dieting, weight loss and fitness, and is conducting clini-cal research in the fields of hair transplantation and clon-ing of hair.
to my patientswho have allowed me to assist them
Acknowledgments I owe gratitude to many people who along the wayof my career have helped in supporting and guiding mywork. I cannot possibly list all those who deserve creditbut I must mention the names of a few that have beenmost instrumental in producing this book. I owe special gratitude to my main mentor in thefield of hair loss Dr. Dow B. Stough Jr. Dr. Stough trainedme in hair transplantation surgery and was the majorinfluence in my development as a hair loss surgeon.Dr. Stough has produced a masterful reference bookthat have been a constant source of reliance to me. Ithank him for this. I must also thank the following individuals who haveprovided technical assistance in the production of thisbook: Dr. Shaheen Azmi who edited it and helped to de-velop its design; Fernando Andrejin who photographedthe pictures and was a constant source of technicalassistance; and Alex Vasolla who drew its illustrations. Last but not least I must thank my parents and familymembers who have nurtured me and who have alwaysbeen there to support me in my every venture.
Table of ContentsIntroductIon ........................................ 1SectIon 1: KnowIng your type of haIr loSS ......... 5chapter 1: genetIc haIr loSS ................................................ 6chapter 2: other typeS of abnormal haIr loSS ....................... 25 a. dIet related haIr loSS ...........................................................25 b. drug related haIr loSS ..........................................................26 c. dISeaSe related haIr loSS .......................................................27 ¨ skin diseases of the scalp ........................................................ 28 ¨ telogenic and anagenic alopecias ........................................... 28 ¨ sudden unexplained hair loss (alopecia areata) ........................... 29 ¨ thyroid diseases ..................................................................... 30 ¨ psychological diseases .......................................................... 31 ¨ cancer related hair loss ........................................................ 31 ¨ saha syndrome ..................................................................... 32 d. haIr loSS due to external InjurIeS to the Scalp ........................ 33 e. haIr loSS cauSed by poor haIr care ........................................34SectIon 2: treatment for genetIc haIr loSS ....... 39chapter 1: medIcal treatment ...................................... 41 a. rogaIne .............................................................................41 b. propecIa .............................................................................44 c. comparIng rogaIne and propecIa .........................................47 d. other emergIng drugS ..........................................................52chapter 2: SurgIcal treatment ...................................... 55 a. baSIc queStIonS about SurgIcal treatmentS .............................55 b. follIcular unIt StrIp Surgery (fuSS) .........................................65 c. follIcular unIt extractIon (fue) ............................................75 d. comparIng fuSS and fue methodS ...........................................83 e. goalS of haIr tranSplant Surgery ..........................................89 i
ii table of contents f. rISKS aSSocIated wIth haIr tranSplantS ..................................109 g. repaIr caSeS.......................................................................111 h. caSe StudIeS .......................................................................125 I. the future of SurgIcal treatment ...........................................182chapter 3: alternatIve treatmentS ............................... 192chapter 4: haIr replacement treatment .......................... 200SectIon 3: about your haIr......................... xxchapter 1: anatomy of the haIr and haIr follIcle .................. xxchapter 2: ruleS for good haIr care .................................... xxa fInal recommendatIon ....................xxappendIx a: Sample conSent form ..........................xxappendIx b: Sample pre-operatIve InStructIonS ........xxappendIx c: Sample poSt-operatIve InStructIonS ......xxgloSSary .........................................xxIndex ...............................................xx
KNOWING YOUR TYPE OF HAIR LOSS 5 1 knowing your type of hair loss1. genetic hair loss ................................ 62. other types of abnormal hair loss...... 25 a. diet related hair loss ................................................... 25 b. drug related hair loss ................................................ 26 c. disease related hair loss .............................................. 27 ¨ skin diseases of the scalp ........................................................ 28 ¨ telogenic and anagenic alopecias ........................................... 28 ¨ sudden unexplained hair loss (alopecia areata) ........................... 29 ¨ thyroid diseases ..................................................................... 30 ¨ psychological diseases .......................................................... 31 ¨ cancer related hair loss ........................................................ 31 ¨ saha syndrome ..................................................................... 32 d. hair loss due to external injuries to the scalp ................ 33 e. hair loss caused by poor hair care .............................. 34
6 KNOWING YOUR TYPE OF HAIR LOSS The first thing everybody with hair loss must know iswhat type of hair loss they have. Some people suffer fromcertain types of hair loss that are temporary, which may resultfrom a variety of causes. While these may be very stressful,many of these ailments can be corrected without resorting tomajor treatments. On the other hand, most men and womenwho suffer from hair loss are predisposed to genetic patternhair loss. This type of hair loss is hereditary and progressive.Many people who suffer from this turn to medical, surgicaland alternative treatments to combat their hair loss. In this chapter, you will learn about the different typesof hair loss so that you may classify your own type and beginthe task of finding proper treatment. You should, of course,have your problem confirmed by a trained professional.But you know yourself best, and only you can help yourprofessional by providing accurate and relevant informationabout your hair loss based on the information that you findhere.NOrMal haIr lOSS Normally, each person will have around 100, 000hairs on his or her scalp at any given time. Some of thesehairs routinely take a rest from growing every few years andeventually fall out. These same hairs re-grow from their roots.as a result, the average person can expect to shed 50 to 100hairs everyday. however, this type of normal hair loss shouldbe spread out over the whole head and should not result inany balding or excessive thinning of hair on any particularpart of the scalp.aBNOrMal haIr lOSS abnormal hair loss is the falling out of excessive hairthat leads to unusual thinning or balding at specific spotson the head, which is probably the type of hair loss you areexperiencing. Medical professionals call abnormal hair lossalopecia. alopecia can be caused by many factors but the
KNOWING YOUR TYPE OF HAIR LOSS 7most common factor is your own genes, meaning that youinherit the tendency to lose your hair. This type of alopeciaaffects over 95 per cent of all cases of balding or thinninghair for both men and women. This type of genetic hair lossis given many names, including “male pattern baldness” or“female pattern baldness” because of the consistent patternthat the hair loss tends to follow in both men and women. Itsmedical term is “androgenic alopecia” because it is believedthat hereditary hair loss is associated with changes in theamount and activity of male hormones called “androgens”.I will be referring to this type of hair loss as “genetic hair loss”because it is the easiest to remember and because it doesnot suggest that it only applies to one sex or the other. It is important to remember that your hair loss may bethe result of a combination of factors. Other factors mayspeed up or increase your hereditary balding. Keep this inmind because it is a major error that many people makewhen determining their own type of hair loss and respondingto it. That being said, since hereditary balding is the mostcommon type of hair loss, I will be discussing it first, followed bya brief discussion of the other types of abnormal hair loss.ChaPTEr 1: GENETIC haIr lOSShOW COMMON IS IT? Genetic hair loss affects almost 50 per cent of allmales and almost 40 per cent of all females as they age.This means that if people lived long enough, almost halfof the population would show significant hair thinningor balding. Some ethnicities are more affected thanothers are. People with European origins show morehereditary tendency to hair loss than other ethnicities,though other groups are affected to a degree as well.
8 KNOWING YOUR TYPE OF HAIR LOSSHOW dOES IT OCCur aNd CaN IT BE CurEd? like so many ailments that afflict us, medical professionalsare not certain as to what directly causes genetic hair loss.It is something that is programmed into your genes, but whatcauses the genes to act and what they cause your body todo, it not entirely known. as a result, there is no sure, full-proofcure for this kind of hair loss that we know of. researchershave different theories about the way genetic hair loss worksand they are working on various possible solutions based onthese clues. The most common explanation for how genetic hair lossworks suggests that it works through a complicated chemicalprocess operating in your body. Most researchers associateit with the chemical changes that occur with the malehormone testosterone as you age. Both men and womenhave this male hormone but the level of testosterone isdifferent for the sexes and changes with aging. There arealso other chemicals, which react with testosterone, thatchange as you age and may influence hair loss. Because most researchers believe that genetic hair lossis caused by chemical reactions in your body, most of theresearch being done in the field has focused on findingchemicals that can reverse the chemical causes of genetichair loss, and then forming them into medical drugs suitablefor usage. recent discoveries have found that an enzyme called“5-alpha reductase” is excessively produced by the hairfollicles of people with genetic hair loss. The enzymecombines with testosterone, one of the male hormonespresent in both men and women, to form a new chemicalcalled “dihydrotestosterone” (dhT), which is known to causehair to fall out. This chain of chemical reactions is one amongmany possible chemical chains that researchers are currentlyinvestigating in relation to genetic hair loss. In the last few years, researchers have been working onmany different drugs for combating genetic hair loss, but sofar only two have shown success in doing so. This first drugis called minoxidil, and it is currently being marketed by the
KNOWING YOUR TYPE OF HAIR LOSS 9upjohn Company under the name rogaine as a topicalsolution for both men and women. The second drug is calledfinasteride, and it is currently being marketed by Merck & Co.under the name Propecia in a tablet form for men only. Theadvantages and drawbacks of both these drugs, along withother drugs that are being tested and that show promise,will be outlined later in the chapter on medical treatmentsfor hair loss.WhaT dOES IT lOOK lIKE? Males with genetic hair loss often become at least partiallybald and the hair loss follows particular patterns. The mostcommon pattern of genetic hair loss for men is characterizedby a thinning of hair at the hairline and/or the crown area.Over time, the thinning expands, receding from the hairlineand in a circular fashion from the crown, until the two areas ofbaldness meet in the middle. The final result is a completelybald scalp except for a strip of hair along the back of thehead above the nape of the neck. Though this is the most common pattern that male patternbaldness follows, there are many other variations as well.Norwood’s classification describes this most common patternbut it is somewhat limited in addressing the other possibilities,including the one that applies to women. In the followingsection, I will outline the new patterns of genetic hair loss thathave been identified, giving you a better understanding ofthe variety of ways in which genetic hair loss occurs. Norwood’s classification has been used to classify malepattern hair loss for many decades and has been usefulin many cases. however, it is not complete. Norwood’sclassification only describes one pattern of male genetichair loss on a scale of seven degrees of severity. Therefore,a reclassification of genetic pattern hair loss is necessary toaccount for the other possible patterns of male and femalegenetic hair loss.
10 KNOWING YOUR TYPE OF HAIR LOSS Genetic Pattern Hair Loss. Progression of hair loss for men according to Norwood’s classification Alternative male 1 patterns 2A 2 3 3A 3v 4 5A 5 6 6A 7
KNOWING YOUR TYPE OF HAIR LOSS 11Another depiction of the progression of genetic pattern hair loss according to Norwood’s classification 1 2 3 3 Vertex 4 5 6 7
12 KNOWING YOUR TYPE OF HAIR LOSS Another depiction of genetic patterns of hair loss according to Norwood’s classification 3A 4A 5A 6A 7A
KNOWING YOUR TYPE OF HAIR LOSS 13Progression of hair loss for womenaccording to Ludwig’s classification
14 KNOWING YOUR TYPE OF HAIR LOSSdrug-related hair lossMany prescription drugs can cause varying degrees ofhair loss for some people. It is likely that you have seencancer patients who have lost hair after undergoingchemotherapy. In fact, most cancer-fighting drugs Class 1 Class 1 Class 3 mild to mild hair moderate no hair loss hair loss loss Pattern 1 Pattern 2 Pattern 3 Pattern 4 Pattern 5
KNOWING YOUR TYPE OF HAIR LOSS 15cause hair loss. In addition, close to 300 more commonlyemployed drugs are known to be associated with hair loss.drugs commonly associated with hair loss Class 4 Class5 Class 6 Class7 mild to mild to large complete moderate large hair loss hair loss hair loss hair loss
16 KNOWING YOUR TYPE OF HAIR LOSS New classification of genetic hair loss: Pattern 1 Examples of pattern 1 genetic hair lossNorwood’s traditional pattern where hair loss progresses fromthe back and the front, and meets in the middle.
KNOWING YOUR TYPE OF HAIR LOSS 17 New classification of genetic hair loss: Pattern 2 Examples of pattern 2 genetic hair losshair loss progresses only from the front hairline and recedesbackwards while maintaining the crown area.hair loss occurs mainly in the crown area and moves forward.
18 KNOWING YOUR TYPE OF HAIR LOSS New classification of genetic hair loss: Pattern 3 Examples of pattern 3 genetic hair lossThe frontal hairline remains intact.“ludwig’s Pattern of hair loss” – Commonly seen in female
KNOWING YOUR TYPE OF HAIR LOSS 19 New classification of genetic hair loss: Pattern 4pattern hair loss, though it occurs in men as well. hair lossstarts in the center and moves sideways towards the ears.This type of hair loss rarely results in total baldness.“Crescent-shaped hair loss” – This pattern is common in men
20 KNOWING YOUR TYPE OF HAIR LOSS Examples of pattern 4 genetic hair loss in a female Examples of pattern 4 genetic hair loss in a male
KNOWING YOUR TYPE OF HAIR LOSS 21 New classification of genetic hair loss: Pattern 5 Examples of pattern 5 genetic hair lossfrom the Mediterranean and the Middle East, although itdoes occur in other ethnic groups as well. hair loss begins atthe two temples and moves in a circular pattern backwards,leaving a small forelock of hair at the frontal hairline.
22 KNOWING YOUR TYPE OF HAIR LOSS Tom K.: Male Pattern Baldness Age: 38 Occupation: Construction Worker Medications: None Medical History: No significant illness Family History: Father and two brothers all have significant hair loss It was one year ago that Tom went to see a surgeon concerning his hair loss. He had tried a number of herbal products with no change in hair growth. Based on his family history and on detailed examination of his scalp, it was clear that Tom had male pattern baldness. His surgeon discussed his options with him, including medications like Rogaine and Propecia and hair grafting surgery. Tom and his surgeon decided that hair grafting surgery was his best option to replace his lost hair. In addition, after surgery his surgeon suggested that he employ medications to slow further hair loss and help retain his new full head of hair. The hair grafting surgery went well, and Tom feels rejuvenated with his restored hair.
KNOWING YOUR TYPE OF HAIR LOSS 23FemALe ANdRoGeNIC ALoPeCIA (FAGA) As has already been discussed, women can suffer fromgenetic pattern hair loss just like men do and both forms of genetichair loss are caused by similar chemical factors. The difference isthat it is much less common for women than it is for men, and thehair loss follows a different pattern. Women with female genetichair loss tend to experience a progressive thinning of the scalphair only around the crown area. It is also usually more diffuseand central than male genetic hair loss; and it is often referred toas a ‘widened part’. Less commonly, women may have a recedinghairline similar to that seen in balding men. It is unlikely thatfemale genetic hair loss will result in total baldness, though it doesoccur. Aside from female genetic hair loss, there are other waysthat women may suffer from hair loss that will be discussed in thenext chapter. Female pattern baldness frontal view Female pattern baldness top view
24 KNOWING YOUR TYPE OF HAIR LOSS Mary L: Female Pattern Baldness Age: 42 Occupation: Marketing Consultant Medications: None Medical History: No significant illness It was two years ago that mary L. went to see a surgeon regarding hair loss. She was anxious that she was losing too much hair too quickly. She was afraid that all her hair would fall out and felt desperate that something had to be done. on examination, it was clear that mary was losing hair diffusely in the centre “widened part” of her scalp. This type of hair loss is a typical form of female pattern baldness. Her surgeon reviewed her medical and family history and performed a physical examination and laboratory testing. After this detailed review, it became clear that mary was losing hair as a result of her genetic makeup. Weighing all factors it was decided to start her on Rogaine treatment. Shortly thereafter mary’s hair loss slowed down.
KNOWING YOUR TYPE OF HAIR LOSS 25Chapter 2: OThEr TYPES Of aBNOrMal haIr lOSS hair loss can be triggered by many factors other thangenetic predisposition. While these other types of hair lossonly make up five per cent of abnormal hair loss cases, theycan be more severe in their effects. however, the goodnews is that these other types outlined below are almostalways temporary or are often treatable. I will briefly discusseach of these common types of hair loss as well as the maintreatments usually given for them.dIET-rElaTEd haIr lOSSProtein: There are a number of nutritional deficiencies thatcan cause hair loss by altering your hair’s structure or haircycles. among these, protein deficiency is one of the mostcommon. Your hair is composed mostly of proteins, the samematerials that your nails are composed of. If your food doesnot provide you with enough protein then both your nailsand your hair may be negatively affected. Protein is foundin common foods like meats, poultry, fish, beans and dairyproducts. If a protein-deficient diet persists then your hairwill go into a premature resting stage and will start to fall outwithin a few months. unfortunately, many people simply donot eat well, or they become caught up in some fad diet.The kinds of things to watch out for are poor eating habitsthat lack in protein, vegetarian diets, or fad diets that restrictthe amount of protein you consume.Iron: another possible cause of diet-related hair loss is alow level of iron in your blood, which might result from aninadequate amount of iron in your diet. foods that arecommon sources of iron include potatoes, dried beans,liver, beef, fortified cereals, raisins, spinach and broccoli.an inadequate amount of iron in your blood may also resultfrom some difficulty your body has in absorbing iron, whichis commonly linked with the condition anemia.
26 KNOWING YOUR TYPE OF HAIR LOSSVitamin A: another nutrient that can affect your hair isvitamin a, which can be found in whole eggs, milk and liver.Both an inadequate and an excessive amount of vitamina can cause hair loss. Too little of this vitamin can resultin a condition called hyperkeratosis. It occurs in your hairfollicles and in the sebaceous glands (the small glands inyour skin that secrete oil into your hair) and it can complicatehair growth. Conversely, too much vitamin a can preventproper keratinisation (the process by which a protein calledkeratin builds your hair and nails), resulting in a kind of hairloss referred to as ‘toxic alopecia’. Other nutritional deficiencies that can affect your hairgrowth include deficiencies of: essential fatty acids, zinc,copper and vitamin C. fortunately, the damage done tohair by this type of diet-related hair loss is only temporaryand can be corrected by simply improving your diet. Yourdietary history is one of the first things a medical doctor whospecializes in skin and hair would ask when assessing your hairloss problem. Before considering anything else, you shouldassess your own diet in relation to any hair loss problems youmay be experiencing.druG-rElaTEd haIr lOSS Many prescription drugs can cause varying degrees ofhair loss for some people. It is likely that you have seen cancerpatients who have lost hair after undergoing chemotherapy.In fact, most cancer-fighting drugs cause hair loss. In addition,close to 300 more commonly employed drugs are known tobe associated with hair loss.drugs commonly associated with hair loss: Birth control pills heart disease and high blood pressure pills, especially betablockers and ace inhibitors, like captopril Blood thinners, like heparin drugs for gout and arthritis, like allopurinol
KNOWING YOUR TYPE OF HAIR LOSS 27 antidepressants, like lithium carbonate diet drugs, like phentermine Cancer-fighting drugs hormone replacement therapy drugs used to treat Parkinson’s disease, like levadopa Performance-enhancing steroids acne medications derived from vitamin a, likeisotretinoin anti-inflammatories, like naproxen Cholesterol-lowering drugs anti-convulsants anti-fungals drugs used to treat thyroid disorders ulcer medications, like Pepcid dermatologists always ask about drug histories, inaddition to your dietary history, before diagnosing hair lossproblems. Even drugs that are not currently associatedwith hair loss may cause you to lose hair, so you should takeyour drug consumption history into consideration no matterwhat. fortunately, drug-related hair loss is easily treated bysimply discontinuing use of the drug causing the hair loss.There are usually several drug options to treat every condition,so you should be able to find an alternative that does notcause you to lose your hair.dISEaSE-rElaTEd haIr lOSS There are dozens of diseases and conditions that canresult in some type of hair loss. In this section, I will outlinethe major classes of diseases that cause hair loss, the kindof hair loss that they cause and possible treatments that areavailable. Since so many common ailments and conditions cancause you to lose hair, your recent and long-term health
28 KNOWING YOUR TYPE OF HAIR LOSShistory is one of the first things a medical doctor wouldquestion when assessing a case of hair loss. You should alsoquestion your own medical history to determine if disease isa factor in your own hair loss.Skin diseases of the scalp There are a number of different conditions that canaffect the scalp and cause varying degrees and types ofhair loss. These include: infections like syphilis and ringworm;infestations like pediculosis, which is caused by lice;inflammatory diseases like folliculitis; genetic diseases likedarier’s disease and other syndromes of the skin like psoriasis.The hair loss in each case is usually only partial and can betreated.Ringworm: ringworm is a contagious disease that is causedby the infection of fungus. It results in small, scaly patcheson the skin and, when it occurs on the scalp, is also followedby a loss of hair. It can be treated effectively with a topicalsolution.Darier’s disease: darier’s disease is a genetic disordercharacterized by dark, crusty patches on the skin, sometimescontaining pus, which results in the hair becoming rough anddry with patches of baldness.Psoriasis: Psoriasis is a chronic skin disease characterized byscaling and inflammation. It is a disorder of the immunesystem that occurs when cells in the outer layer of the skinreproduce faster than normal and pile up on the skin’ssurface. The hair loss is reversible with treatment.Telogenic and anagenic alopecias To understand this type of hair loss, you first need tobe familiarized with the hair growth cycle. all human hairsgo through a natural cycle beginning with growth, calledthe anagen phase, followed by a period of rest, called the
KNOWING YOUR TYPE OF HAIR LOSS 29telogen phase, and ending with the hair falling out. Whenonly the hairs that belong in a particular phase fall out, we callthis either anagenic alopecia or telogenic alopecia. dozensof factors can cause either of these alopecias, includingstress, chronic diseases and nutritional deficiencies. Many ofthese different factors send anagen hairs prematurely intothe resting stage and result in excessive shedding monthsafter. This is called telogenic alopecia. In this section we willdiscuss some of the more common telogenic and anagenicsyndromes.Loose anagen syndrome: This condition generally affectsyoung, Caucasian blonde girls, although anyone issusceptible. The characterizing symptom is the ability ofanagen hairs (hairs that are in the anagen, or growth, stageof the hair cycle) to be pulled out easily and painlessly. Inchildren ages 2 to 5 years with loose anagen syndrome, thehair is usually unable to grow past the ears, though the densityis otherwise unremarkable and the hair is not particularlyfragile otherwise. Treatment is usually unnecessary becausealthough loose anagen hair grows slowly, it does grow andif it is accidentally pulled out, it grows back quickly.Pregnancy and childbirth: The stress of childbirth, similar tothat of a severe fever or chronic illness, can prematurely pushanagen hairs into the resting stage, resulting in excessiveshedding some months later. hormonal changes that occurduring pregnancy also play a part in this telogenic alopecia.The slight hair loss should fix itself within 6 to 12 months.alopecia areata hair loss may sometimes affect otherwise healthypeople with good eating habits, no notable diseases orinjuries to the scalp that can explain such a loss of hair.When this occurs, it is referred to as ‘alopecia areata’. Thisunpredictable but common disease affects 1.7 per cent ofthe world’s population. although it can affect men andwomen of all ages, onset most often begins in childhood.In most cases, the hair falls out in round patches all over the
30 KNOWING YOUR TYPE OF HAIR LOSSscalp and body. In some extreme and rare cases, the hairloss may lead to a complete loss of hair all over the head andbody. alopecia areata that causes complete hair loss of thescalp is called ‘alopecia totalis’ and when it causes hair lossover the whole body it is called ‘alopecia universalis’. It is believed that alopecia areata is caused by theimmune system unexpectedly, and usually temporarily,attacking the hair follicles, causing them to fall out andpreventing re-growth in some cases. however, it is not knownwhy this occurs. Cases of alopecia areata usually disappear on theirown and never occur again. If this type of hair loss persists,however, medical treatment is a possibility. Various steroids,Propecia, rogaine, and various immunogens (drugs thatinterfere with the immune system) have been found to beeffective in combating alopecia areata. although alopecia areata is not life threatening, it isso dramatic in its effects that it often damages the mentaland emotional states of its victims. for this reason, manysupport groups have been established to help people copewith alopecia areata. You can find a local support group inmost countries around the world by contacting the Nationalalopecia areata foundation via their website at www.alopeciaareata.com.Thyroid diseases Your thyroid gland resides in your neck and isresponsible for producing hormones that are involved inmany of your body’s functions, your metabolism in particular,making its proper functioning vital to your overall health. hypothyroidism occurs when your thyroid is under-active, meaning it is producing inadequate amounts ofhormones. When this occurs, there is a slight shedding ofthe hair on the scalp, and possibly of the armpits and pubicarea. an under-active thyroid gland may become enlargeddue to a bombardment of thyroid-stimulating-hormones (TSh)produced by the pituitary gland, which occurs in order to
KNOWING YOUR TYPE OF HAIR LOSS 31entice the thyroid to produce more hormones. The result isthe creation of ‘goiter’. The most common cause of hypothyroidism is aprevious (or ongoing) inflammation of the thyroid gland thatleaves a large percentage of the gland’s cells damagedor dead. This kind of inflammation is most likely the result ofautoimmune thyroiditis, which is caused by the patient’s ownimmune system. hypothyroidism may also be caused bycertain medical treatments that, indirectly or directly, affectthe thyroid gland. The hair loss that results from thyroid disease canbe reversed by treating the condition that is affecting thethyroid gland. There are many other symptoms of thyroiddisease, including fatigue, weakness, weight gain, dry skin,intolerance to the cold, constipation, memory loss, muscleaches and/or depression. The proper functioning of yourthyroid gland is very important and is worth seeing a medicaldoctor if you think you may be experiencing some or all ofthese symptoms.Psychiatric and psychological diseases The most common type of psychological conditionthat can cause hair loss is stress. Excessive stress can causetelogenic alopecia, which is described above.Anorexia nervosa: anorexia nervosa occurs when someonerestricts their diet to such a degree that there are nutritional,endocrinal and psychological impairments. The hypocaloricdiet (meaning there is an insufficient amount of caloriesbeing ingested) may result in a loss of hair. This may also beaccompanied by an increase in lanugo (the fine, light hairsthat cover the body) on the face, trunk and arms.Cancer-related hair lossNeoplasic alopecias: This term refers to hair loss that resultsfrom cancer spreading from one area of the body to thescalp. The word ‘neoplasic’ comes from the word ‘neoplasm’,which means ‘tumor’.
32 KNOWING YOUR TYPE OF HAIR LOSSThe susceptibility of the scalp to neoplasic alopecia ishigher for women with breast cancer and for men with lungcancer in particular, as opposed to other types of cancer.It is believed that mucines, a certain kind of protein createdby breast and lung carcinoma, degenerate the cells of theouter root sheath of the hair follicle. however, not all casesof breast or lung cancer will cause hair loss. Ovarian and adrenal tumors are also likely to causehair loss. Both types of tumors can cause hyperandrogenism,which is the excessive production of androgens (malehormones). androgens are known to play a key role in maleand female pattern baldness. Once the tumor has beenremoved, however, the hair loss should go away.Cancer-fighting drugs: Most cancer-fighting drugs, likechemotherapy, attack the body, including the hair follicles,and cause considerable hair loss. The hair should grow backafter the treatment has stopped.Saha syndrome Saha syndrome is a skin condition that only affectswomen and is caused by hyperandrogenism, which is theexcessive production of male hormones (androgens) andwhich occurs in the whole body (cases of hyperandrogenismaffecting only particular parts of the body are considereddifferent conditions). The four main symptoms of this syndrome make up theacronym ‘Saha’: seborrhea, acne, hirsutism and alopecia.These four manifestations appear in this order, although not allwomen suffer from all of them. all sufferers of Saha syndromedo experience seborrhea, however. Seborrhea is a skin condition characterized byinflammation, dry or oily scaling, crustiness and/or itching. Itis so called because of the excessive production of ‘sebum’(the oily secretion of the skin) that causes the condition.The acne associated with the syndrome is considered partof the condition because the increased sebum productionthat causes acne in this case is caused by androgenicaction. hirsutism, the third symptom, is the excessive growth
KNOWING YOUR TYPE OF HAIR LOSS 33of male-pattern hair in women, also caused by an increasein androgens. The hair loss that accompanies Saha syndrome is alsocaused by excessive amounts of androgens and results intypical female pattern baldness. a uniform clearing of thescalp of the crown occurs, though total alopecia is unlikelyand the frontal hairline remains intact. Treatment of Saha syndrome includes several drugoptions, including the use of antiandrogens and estrogens(female hormones).haIr lOSS duE TO ExTErNal INjurIES TO ThE SCalP hair loss commonly occurs as a result of something assimple as physical stress being put on the hair, the destructionof the hair follicles themselves or excessive amounts of hairbeing pulled out of the scalp. In these cases, we say that thehair loss is due to ‘external injuries to the scalp’ as opposedto a skin disease or disorder.Cicatricial alopecias hair loss may occur due to the destruction of the hairfollicle. In this case, the skin of the scalp is somewhat likescar tissue and is therefore unable to produce hair, meaningthat the hair loss is permanent and the only option is surgicaltreatment. This destruction of the hair follicles can result frommechanical, physical or chemical trauma (which mayinclude the use of acids, chronic traction, electrical or thermalburns, or freezing), as well as tumors, special skin diseases orsevere infections such as syphilis. The destroyed hair folliclesmay not necessarily cover the entire scalp, depending onthe method and type of damage. again, the only optionfor this kind of hair loss is surgical treatment.Trichotillomania hair loss among children can occur as a result of
34 KNOWING YOUR TYPE OF HAIR LOSSa usually unrecognized behavioral disorder known astrichotillomania. It is characterized by uncontrollable hairpulling, similar to impulsive disorders such as pyromaniaor kleptomania. The disorder usually appears in males atthe age of 8 and in females at the age of 12 and has aprevalence of about one per cent. Sufferers of trichotillomania generally spend aboutone hour per day pulling their hair out. This can last for a fewseconds or minutes, or it may last for prolonged periods oftime. Some may try to resist the urge, while some are unawareof its occurrence, pulling hair absent-mindedly while driving,reading or watching television. While the disorder itself is a stressful condition, the hairloss that results is an unfortunate additional complication thataffects many children and teenagers psychologically andemotionally. The hair loss that occurs is usually focused on thescalp, but it may also occur among the eyebrows, eyelashesand pubic region. hair loss is usually patchy, irregularly-shaped and occurs most often on the side of the body thatcoincides with the person’s predominant hand. Most sufferersof trichotillomania are likely to feel embarrassed aboutthe disorder and may try to hide their hair loss, prolongingdiagnosis and complicating treatment. Treatment for trichotillomania involves behavioraltherapy and/or medication. Possible drugs include moodstabilizers, anxiolytics (drugs that work on the centralnervous system to relieve anxiety), neuroleptics (also knownas antipsychotics) and topical agents including steroids.however, behavioral therapy has been found to be moreeffective than drug therapy, especially if the hair pulling hasonly been occurring for less than 6 months and because thereare no clear guidelines for how drugs should be used to treattrichotillomania. With therapy, sufferers of trichotillomaniacan overcome this disorder and resume their normal liveswithout worry of uncontrollable urges or hair loss.haIr lOSS duE TO POOr haIr CarE The effects of poor hair care on hair loss are significant.
KNOWING YOUR TYPE OF HAIR LOSS 35unfortunately, there are many styling habits and treatmentsthat are bad for the overall health of your hair and thatpromote hair loss. hairstyles that require unusual pulling, dyingor conditioning may severely stress the natural workings ofyour hair and may lead to unusual balding. When a high degree of physical stress is constantlybeing put on the hair for styling purposes, hair loss may occur.This condition is referred to as ‘cosmetic alopecia’. It is usuallycaused by the constant use of curlers, brushes and othertools used to style hair as well as hairstyles that pull the hair.The alopecia appears as a slight shedding of the hair andoccurs because the strain that the hair is put under leadsto reduced blood flow in the capillaries at the bottom ofthe hair follicles. The hair’s growth is stunted and eventuallyleads to a slight loss of hair a few months later. This usuallyaffects the triangular areas above and in front of the ears,though it is dependant on the direction in which the hairstyleis aimed. It is also possible to damage the hair follicles and/or the scalp itself with the constant use of chemicals usedto curl or dye the hair. In most cases of cosmetic alopecia,the reduced blood flow that causes the hair loss disappearsafter the pressure is removed, although the shedding maytake a few months to return back to normal.
36 KNOWING YOUR TYPE OF HAIR LOSS Anna S. : Losing Hair Due to Iron Deficiency Age: 32 Occupation: Receptionist Anna S. initially saw a surgeon three years ago, complaining of ongoing hair loss over six months. A history and medication review indicated no significant findings. No one in her family had lost significant hair before. On physical examination, it was discovered that her hair was thinning mainly on the crown area of her head. Her blood tests showed an iron deficiency, and she informed her surgeon that she had been experiencing unusually heavy periods over the last year. It was diagnosed that her hair loss could be related to this. Anna started on iron therapy and it was recommended that certain dietary changes be made to support this. Within three months Anna’s hair loss had stopped. Within six months Anna’s hair was back to normal, and she was much relieved. She has had no recurrence of hair loss ever since.
KNOWING YOUR TYPE OF HAIR LOSS 37Julia B. : Losing hair because of HypothyroidismAge: 27Occupation: HomemakerJulia B. went to a clinic complaining of fatigue, increase inweight, and sparse hair on the scalp and on the eyebrows. Shewas not taking any medications. Julia had no family historyof hair loss. Physical examination showed dry skin, diffusehair loss, and noticeable loss of hair on both eyebrows.Lab testing revealed that Julia’s TSH levels were elevated.Julia was suffering from hypothyroidism (the slowing of thethyroid gland). often such a condition causes the unusual lossof hair not only on the scalp but on other parts of the body.Julia was started on a thyroid replacement medication. In sixmonths not only was her hair restored to normal, but Juliafound herself less fatigued and in better overall health.
38 KNOWING YOUR TYPE OF HAIR LOSS Peter K. : Losing Hair Because of a Medication Age: 40 Occupation: Accountant Peter came to see me after having suffered ongoing hair loss for over three years. He had no family history of hair loss, but Peter did have high blood pressure for the last five years. He had been on a drug called Propranolal, a type of beta-blocker medication, that is often used to control high blood pressure. A physical examination showed his hair to be thinning diffusely at the center. It was suspected that Peter’s hair loss was caused by his blood pressure medication. The Propranolal that he was taking was replaced with another medication, and He was monitored for the effect this would have. Slowly but surely Peter’s hair loss was reversed. After one year all his hair was regained.
KNOWING YOUR TYPE OF HAIR LOSS 39 Many people with other types of hair loss aggravatetheir situation by poor hair care habits. for example, thereare many genetically balding people who are losing morehair than they should be and at a faster rate because ofpoor hair care habits. In these cases, people can forestallthe appearance of baldness for years by maintaining goodhair care. You can learn how to properly take care of your hairand prevent, or forestall, the appearance of balding later inthis book in the section regarding ‘rules for good hair care’.
2 treatment options for hair loss1. medical treatment ...........................41 a. rogaine (minoxidil) ................................................... 41 b. propecia (finasteride) ................................................ 44 c. comparing rogaine and propecia ............................. 47 d. other emerging drugs ............................................... 522. surgical treatment ..........................55 a. basic questions about surgical treatment ..................... 55 b. follicular unit strip surgery (fuss) .............................. 65 c. follicular unit extraction (fue) ................................ 75 d. comparing fuss and fue methods ................................ 83 e. goals of hair transplant surgery ............................... 89 f. risks associated with hair transplants ....................... 109 g. repair cases ........................................................... 111 h. case studies ........................................................... 125 i. the future of surgical treatment ................................ 1823. alternative treatment ....................1924. hair replacement treatment ............200 39
40 DRUG TREATMENTS FOR HAIR LOSS Over 90 per cent of all hair loss cases fall under the categoryof genetic hair loss. For this reason, all the treatment optionsdiscussed in this section, with the exception of hair replacementtherapy, are meant only for the treatment of genetic hair loss. Forall other types of hair loss, you should contact a qualified medicaldoctor to discuss treatment options. And while this section is meantto guide you in treating your hair loss, you should always contacta medical doctor before beginning any treatment program.
DRUG TREATMENTS FOR HAIR LOSS 41 chapter one: medical treatment The treatment of genetic hair loss with medication,taken either orally or applied topically on the scalp, haslong been the dream of people suffering from this type ofhair loss. But until recently this hope has been nothing but adream. During the last couple of decades researchers havebeen developing two drugs that have proven effective incombating genetic hair loss. First the drug minoxidil, which isnow marketed as Rogaine, was approved by the Food andDrug Administration and later on the drug finasteride, whichis now marketed as Propecia, was also approved for use infighting genetic hair loss. There are also many other drugs and combinations ofdrugs that are now being tested and which may be availablein the coming few years. It should be noted, however, thatthere is always the risk of side effects with any medications.Also, it takes decades to completely understand the fulleffects of any drug and many of these drugs have not beenaround long enough to determine these full effects.RogAIne (mInoxIDIl) Rogaine was introduced as a new drug for promotinghair growth by the Upjohn Company in 1988. It is sold as atopical solution, which means that it is a rubbing solutionmeant for the balding areas of your scalp. It comes in eithera 2 per cent or a 5 per cent solution depending on how much
42 DRUG TREATMENTS FOR HAIR LOSSminoxidil the solution contains. Rogaine is available over thecounter and should be applied on the balding area(s) twicea day, every day.How does Rogaine work? Although there is only a small percentage of minoxidilin Rogaine, it is this drug that makes it work. minoxidil is knownas a hair growth stimulator. It was originally marketed in atablet form for the treatment of high blood pressure andunwanted hair growth was one of the common side effects.It is unclear why it is able to do this.How effective is Rogaine? While the Food and Drug Administration recognizesthat Rogaine works, it is well known that it doesn’t work foreveryone. Recent studies show that when the 2 per centsolution is used properly, it can stimulate hair growth 30 percent of the time, with a slightly higher rate in females. And thenew 5 per cent solution has shown only slightly more successthan the weaker solution. Rogaine is most effective when used at the first signsof balding and in relatively small areas of hair loss. It is alsomore effective in the center of the scalp than on the frontalhairline. Rogaine can inhibit further hair loss and can be usedto supplement hair transplantation. It should be noted, however, that if you stop usingRogaine you will lose any hair re-grown while you wereusing it. This means that once you start using Rogaine, youmust continue to use it for the rest of your life to enjoy itsbenefits.Are there any side effects to using Rogaine? every drug has some side effects. In the case ofRogaine the drug that makes it work, minoxidil, has adangerous effect on the body (and the heart in particular) if
DRUG TREATMENTS FOR HAIR LOSS 43taken orally. When it is diluted in a solution for topical use, asit is in Rogaine, the side effects are less severe because theamount of minoxidil entering the body is much less. However,even in small doses the use of minoxidil does have some minorand major side effects that should be noted.Minor side effects: These include skin irritations on the scalpsuch as dry red skin, flaking and itching; nausea and vomiting;and diarrhea. These are short-term, temporary side effectsthat should go away when your body adjusts to the use ofRogaine.Major side effects: These include back and chest pain;cold-like symptoms; rapid heartbeat; fluid retention; difficultybreathing; weight gain; worsening of hair loss. These are veryrare, extreme side effects that are similar to the effects ofminoxidil taken orally. Also, Rogaine is not safe for people who: Show allergicreactions to minoxidil; have heart disease; have high orlow blood pressure; have skin diseases like dermatitis; arepregnant; or who are nursing mothers.What improvements can we expect in the near future? The most likely advancements in the use of Rogainewill come from two different approaches:Increasing the amount of minoxidil: like the addition of the5 per cent solution to the 2 per cent solution, researchershave been trying to improve the effectiveness of Rogaineby increasing the amount of minoxidil in the solution.Increasing the ability of minoxidil to enter the skin: Researchershave also been trying to make Rogaine more effective byincreasing the ability of the minoxidil in the solution to enterthe skin and cause hair growth. Tests have shown that if
44 DRUG TREATMENTS FOR HAIR LOSSminoxidil is mixed with certain other substances it may beable to enter into the skin better and cause more effectivehair growth.Final recommendations for Rogaine only use Rogaine if your health is good, if you arewilling to test how it works for more than one year whileaccepting the possibility of failure, if you are disciplined intaking medications and following detailed instructions, andif you are prepared and able to pay to use Rogaine for therest of your life.PRoPeCIA (FInASTeRIDe) In late 1997, the Food and Drug Administrationapproved Propecia for distribution in the United States as ahair-restoring drug. It is sold by the company merck in 1 mgpill form by prescription only. It is the first pill that effectivelytreats genetic hair loss. The active agent in Propecia is a drug calledfinasteride. It was originally used in a prostate medicationcalled Proscar that was found to grow hair. Propecia is alower-dose form of Proscar developed specifically to fighthair loss. one of the main differences between Rogaine andPropecia is that Propecia should only be used by men. It isdangerous for women of childbearing age and can causesevere birth defects in women that have handled Propeciain any way. Possible dangers aside, Propecia does not workfor any women of any age.How does Propecia work? Finasteride is the active agent in Propecia. It worksby manipulating the underlying chemical causes of genetichair loss. We know that men with genetic hair loss haveincreased levels of a hormone called dihydrotestosterone
DRUG TREATMENTS FOR HAIR LOSS 45(DHT) in their scalps and it is believed that the presence ofDHT in the scalp is related to the thinning of hair follicles andthe resulting genetic hair loss. DHT is a by-product of the malehormone testosterone, which is converted to DHT when itreacts with a natural enzyme that is found in human skin cellscalled 5 alpha-reductase (5AR). Propecia does not directlycounteract DHT itself, but rather blocks the action of 5AR toindirectly reduce the presence of DHT.How effective is Propecia? Propecia seems to be at least as effective as Rogaine.It is particularly potent in preventing further hair loss but is notas successful in stimulating new growth. Studies suggest that about 80 per cent of baldingmen can stop any further hair loss by taking Propecia. Inaddition, two out of three men may see some re-growth ofhair. However, Propecia only works for men who have mildto moderate hair loss. Balding men with major or completehair loss will not benefit from Propecia. Like Rogaine, Propeciais more effective in the center of the scalp and less so alongthe frontal hairline. Propecia must be taken for at least three monthsbefore seeing any results. Because hair generally grows at arate of about ½ an inch per month, it usually takes betweenthree to six months to see the full effects of Propecia. If there isno significant growth after 12 months it is unlikely that Propeciawill ever work. Also like Rogaine, Propecia is effective only for as longas it is taken. This means that all benefits of using Propeciawill be lost if you ever stop using it.Are there any side effects to using Propecia? Contrary to the dangerous effects that Propecia hason women, it is generally well-tolerated by men. The Foodand Drug Administration described Propecia as having onlyinfrequent side effects that affected only a small number ofmen.
46 DRUG TREATMENTS FOR HAIR LOSSGeneral side effects: These include allergic reactions such asrash, hives, itching and swelling of the lips and face; breasttenderness and enlargement; and testicular pain.Sexual side effects: Less desire for sex, difficulty in achievingan erection; decrease in the amount of semen; and problemswith ejaculation. These side effects occurred in less than 2per cent of men and were only temporary. Some men in particular should not take Propecia.These include men who have allergies to finasteride or arelated drug or who have liver function abnormalities. menfor whom the noted side effects are unusually severe or long-lasting should only continue using it with caution and underthe direct guidance of a medical doctor. As has already been mentioned, Propecia is also notsafe for women and may cause severe birth defects. Womenshould not even handle broken or crushed tablets, althoughall Propecia tablets have a protective coating when intact.Also, men taking Propecia pose no danger to women or theirfetuses. Although there are no known dangers in mixingPropecia with other drugs, the use of this drug has been linkedto decreases in levels of prostate-specific antigen (PSA).Though this decrease is insignificant in itself, PSA levels areoften measured for diagnostic reasons in the case of mensuspected of prostate cancer or other prostate problems.Because of this, all patients taking Propecia, especially thosewith prostate illnesses of any kind, should inform their doctorsof the usage.What improvements can we expect in the near future? Although Propecia is relatively new on the market,there have been several novel approaches to obtaininggreater results from its use.Using Propecia as a topical solution: one approach has been
DRUG TREATMENTS FOR HAIR LOSS 47to formulate finasteride as a topical solution, like Rogaine. Thisapproach is more common outside of the United States, butsome American companies are already selling finasteride inthis form. At this point, however, a topical form of finasterideremains experimental as there have been no clinical studiesthat have shown the effectiveness of a finasteride topicalsolution.Combining Propecia with Rogaine: It is believed by somethat Rogaine and Propecia can complement each otherby combining Rogaine’s ability to stimulate new growth withPropecia’s ability to prevent further hair loss. This, however,is a relatively new approach and little has been done in theway of scientific studies to verify its effectiveness.Final recommendations for Propecia Rogaine Propecia Comment About $30 USD About $50 to Rogaine is a Cost per month $60 USD per little cheaper Safe for both Safe for men men may sexes, except for only choose those with heart, either, but Safety women can blood or skin problems only use Ro- gaine Topical solu- Single tablet Propecia tion, twice a taken once ev- is easier to U s - day every day ery day continu- use but both continuously ously must be used for life
48 DRUG TREATMENTS FOR HAIR LOSSCOmpAring rOgAine And prOpeCiA, COntinued Rogaine Propecia Comment extra strength Can help 2 Propecia is (5 per cent out of 3 men more effective solution) can regain minimal in preventing help 2 out to moder- further hair of 3 people ate amounts loss. Rogaine is regain minimal of hair in the more effective to moderate central bald- in stimulating amounts of ings areas new growth. effect- hair in the cen- of the scalp. Propecia i v e - tral baldings Almost 90 per shows results in areas of the cent effective less time than ness scalp. There is in preventing Rogaine. a 10 to 40 per further hair cent chance loss. There is that your hair a 30 to 60 per regrowth will cent chance be significant. that your hair It may take up regrowth will to one year to be significant. see full effects. It may take 3 to 6 months to see full effects. Temporary Temporary Side effects are side effects: side effects: rare with either skin irritations rash, hives, drug. long-term on the scalp; itching and effects are un- nausea and swelling of known for both vomiting; and lips and face; drugs. Side diarrhea. Rare breast ten- effects side effects: derness and back and chest enlargement; pain; cold-like testicular pain; symptoms; rapid sexual impair- heartbeat; fluid ment including retention; dif- problems with ficulty breathing; ejaculation weight gain
DRUG TREATMENTS FOR HAIR LOSS 49examples of crownal hair loss helped by propecia
50 DRUG TREATMENTS FOR HAIR LOSS examples of crownal hair loss helped by propecia
DRUG TREATMENTS FOR HAIR LOSS 51Anterior mid-scalp hair loss helped by propecia
52 DRUG TREATMENTS FOR HAIR LOSSoTHeR emeRgIng HAIR gRoWTH DRUgS Although Rogaine and Propecia are the only two drugscurrently approved by the Food and Drug Administrationto combat genetic hair loss, there are several other drugsthat have shown great promise in restoring hair loss. Theseare not likely to be miracle cures but they may be moreeffective than current versions of Rogaine and Propecia,and they may display features more suited to your needs.You should know what other drugs may soon be availablebesides Rogaine and Propecia. All of these drugs are stillbeing tested and some are being seriously investigated bylarge pharmaceutical companies that are investing millionsof dollars to make them work.Dutasteride Dutasteride is another 5 alpha reductase inhibitorlike the finasteride used in Propecia but it is currently beingmarketed as Avodart for the treatment of benign prostatichyperplasia. Researchers are trying to formulate a form ofdutasteride that can be used for the treatment of genetichair loss. Like finasteride, it will likely have side effects on malesexual functioning.Antiandrogens Antiandrogens are drugs that prevent androgens(male hormones) from working. These drugs have shown themost promise in being able to provide a cure for genetic hairloss, as androgens are known to play a key role in causingthis kind of hair loss. Antiandrogens are used to treat many differentailments and one of the side effects commonly seen duringtheir usage has been the stimulation of hair growth all overthe body. Because male hormones are important to the properfunctioning of many male bodily functions, possible sideeffects of using antiandrogens include impairment to male
DRUG TREATMENTS FOR HAIR LOSS 53physical characteristics and sexual desire and potency. Work has been done to develop antiandrogens thatare safe for men to use to combat hair loss while avoidingthe unwanted side effects. Finasteride, the drug in Propecia,is an example of one such drug because it does not directlyinhibit male hormones but rather inhibits an enzyme thatinteracts with male hormones. Because antiandrogens target male hormones,antiandrogens are generally safer for women. Since womenare less damaged by the side effects of antiandrogensthey are more effectively treated by them. In europe,antiandrogens have been officially used to treat genetic hairloss in women for years. one of the two drugs approved by the Food and DrugAdministration for the treatment of genetic hair loss is Rogaine,whose active agent minoxidil is not an antiandrogen. So itwould not be surprising to discover that the most effectivedrug treatment for genetic hair loss might emerge from atype of drug that is also not an antiandrogen. outside of the antiandrogens, there have beenseveral drugs that have shown some promise as a treatmentfor genetic hair loss. The most prominent of these that arecurrently being developed and tested include the drugs listedbelow. look for these drugs to emerge in the near future tocomplement Rogaine as a drug treatment for genetic hairloss.Tricomin The American pharmaceutical company ProCyte istesting this drug in France. It has shown some effectivenessin increasing new hair growth by 40 per cent for three outof four of the balding men who used it in testing. Tricomin isa compound chemical that helps restore the health of skintissue. The compound drug is applied on the skin like Rogaineand is believed to restore a healthy skin base for new hair togrow.
54 DRUG TREATMENTS FOR HAIR LOSSCyclosporine In several scientific studies conducted over the lastfew years, this drug successfully re-grew hair for at leastsome of the balding men who used it in testing. It is a typeof drug called an immunosuppressive, meaning that itfights the body’s immune system. Immunosuppressives areusually given to patients to prevent organ rejection after akidney, liver or heart transplant. Some experts believe thatthe ultimate cause of genetic hair loss is the immune systemreceiving the wrong messages that hair on certain parts ofthe scalp are foreign to the body, causing the immune systemto attack them. In tests, cyclosporine was applied on the skin in thesame way as Rogaine. This is done to localize the suppressionof the immune system to the scalp and protect the rest ofthe body from the effects of the drug. The partial successof cyclosporine is fueling great interest in researching anddeveloping immunosuppressive treatments for genetic hairloss.Cyoctol This drug has shown enough promise for Squibb, amajor pharmaceutical company, to work on developingand testing it as a treatment for genetic hair loss. It isbelieved to combat hair loss by binding itself to the rootsof hairs and protecting them from the negative effects ofdihydrotestosterone (DHT), which is linked to genetic hairloss.Diazoxide The Food and Drug Administration is currently testingthis drug for approval. It is usually used to treat symptoms ofdiabetes, such as abnormally high blood sugar. When it isused orally for this purpose, it has the side effect of causinghair growth all over the body. Recent research on diazoxidehas been focused on developing it for treatment of genetic
DRUG TREATMENTS FOR HAIR LOSS 55hair loss by trying to control and direct the hair growth to thescalp.
chapter two: surgical treatment Like medical drug treatments, surgical treatments forhair loss have developed significantly in the last couple ofdecades. However, unlike medical drug treatments that arestill years away from being able to provide a full head of hair,recent advancements in surgical treatments have made itpossible to achieve the appearance of a full head of naturalhair. At this point in time, surgical methods are the surest andmost effective way for most balding people to restore naturalhair to a balding head.BAsic questions ABout surgicAL treAtmentsWhat are surgical treatments? There are several types of surgical treatment for hairloss. They all involve the movement of hair from areas of yourscalp that normally never go bald, such as the back and sidesof your head, to the balding areas of your scalp, usually thecentral area on top and the frontal hairline. What is important to recognize about all surgicaltreatments for hair loss is that no surgical method can giveyou new hair or restore any of your lost hair. They canonly redistribute what you still have. It is also important to 55
remember that surgical treatments for hair cannot preventfurther balding. When deciding to employ any surgicaltreatment you must consider the possible progression of yourhair loss as well as what you have already lost.Who is a good candidate for surgical treatment? Because surgical treatments of hair loss can onlymove existing hair from one area to another, it can only workproperly with people who have enough remaining hair tocover the balding areas, and who are likely to retain it forsome time. With recent advances in hair transplantationeven people who have lost up to 50 per cent of their haircan get the appearance of a full head of hair with surgicaltreatment. But even with less than half your hair left, you canstill benefit from hair transplantation and have your remaininghair redistributed in a way that looks natural and attractive.When is surgical treatment appropriate? there are several different situations in which hairtransplantation is the best method to treat your hair loss.To produce a natural hairline: A hair transplant is alwaysrequired to produce a natural looking frontal hairline. thefrontal hairline is the most important part of hair restorationbecause it is the most prominent part of your hair. Thecreation of a natural looking frontal hairline requires therestoration of a delicate pattern of hair lengths at variousangles, which leaves little room for error.To fill in thinning hair: When hair only appears to be thinning,short of complete balding, then hair transplantation canprovide the restoration of a full set of hair. small grafts of one,two or three hairs can be precisely placed amidst thinninghair to restore a natural looking density.To implant on scars left by surgical cuts to the scalp: scars leftfrom surgical cuts into the scalp or physical traumas can beeffectively concealed by transplanting hair into the scarred 56
skin tissue.What are the different types of surgical treatments? Currently, there are two methods of hair transplantationthat offer the best and most natural results possible. Theseare follicular unit strip surgery (FUSS) and follicular unit extrac-tion (FUE). Both the FUSS and FUE procedures involve the extractionof follicular units from a donor area on the head. Follicularunits are small groupings of one, two or three hairs that grownaturally on the scalp. These follicular units are taken fromareas on the head where hair is genetically programmednot to fall out. They are then implanted in the balding areasof the scalp, where the transplanted hair will continue togrow naturally. The FUSS and FUE procedures approach thismethod differently, but both provide exceptionally naturalresults and are by far the most popular methods with surgeonsand patients.How much does surgical treatment cost? The cost of hair transplantation can vary enormouslydepending on who is performing it. Typically a doctorwill transplant 1000 to 4000 grafts in one session that canlast anywhere from two to twelve hours. The cost of theprocedure is based on a price per graft. The grafts used inthe FUSS procedure range in cost from $5 to $8 USD each.The grafts used in the FUE procedure range in cost from$12 to $25 USD each. Depending on the number of graftsbeing transplanted, the cost of the procedure can run intothe thousands, but patients should remember that a hairtransplant is a permanent and life-long investment. 57
58 SURGICAL TREATMENTS FOR HAIR LOSS Alex: Male Pattern Hair Loss Candidate for Surgical Treatment Age: 52 Occupation: engineer Medications: none Family history: brother has similar hair loss Alex had been losing hair for 10 years. He was losing his hair slowly but progressively over that time. Each year seemed to get worse and worse. It began to effect his self- image. Since his brother had also displayed signs of male pattern hair loss it was clear that Alex had genetically- related male pattern baldness. His surgeon outlined for Alex all his treatment options. He could start on hair growth medications like Rogaine or Propecia to decrease further hair loss or he could undergo surgery with follicular unit micrografting to replace his lost hair. He thought about if for several days and discussed this with his wife and friends. In the end he felt that he needed to restore his hair to its former glory. He opted for surgery. Alex and his surgeon decided together that he needed about 1500 grafts
SURGICAL TREATMENTS FOR HAIR LOSS 59 Ideal candidates for surgical hair transplantCrownalhair loss:top view
60 SURGICAL TREATMENTS FOR HAIR LOSS Ideal candidates for surgical hair transplant Frontal and central hair loss: Front view Frontal and central hair loss: front view
SURGICAL TREATMENTS FOR HAIR LOSS 61 Ideal candidates for surgical hair transplantFrontal hair loss: Front view Frontal andcentral hair loss: Front view
62 SURGICAL TREATMENTS FOR HAIR LOSS Ideal candidates for surgical hair transplant Temporal hair loss: front view Temporal hair loss: Side view
SURGICAL TREATMENTS FOR HAIR LOSS 63 Ideal candidates for surgical hair transplant Temporal hair loss:front view Temporal hair loss: side view
64 SURGICAL TREATMENTS FOR HAIR LOSS Ideal candidates for surgical hair transplant Central hair loss: Front view Central hair loss: Side view
SURGICAL TREATMENTS FOR HAIR LOSS 65 Ideal candidates for surgical hair transplant Frontal andcentral hair loss: Top view Frontal andcentral hair loss: Side view
66 SURGICAL TREATMENTS FOR HAIR LOSSFOLLICULAR UNIT STRIp SURGERy (FUSS) The FUSS procedure involves the extraction of follicularunits from narrow strips of scalp taken from donor areas onthe back and sides of your head. The removal of these stripsresult in virtually undetectable scars. The follicular units arecut out from these strips and implanted into the balding areasof your scalp in pin-sized, surgically created holes. These siteswill also heal in just a few days, leaving nostep three: making the grafts the strips of skin taken from the scalp are cut into smallgrafts. Each of the small units is called a graft because it isintended to be placed in the bald portion of your head whereit is supposed to literally ‘graft’ or meld into the existing skin.step four: making the recipient sites Following the plan previously sketched on the scalp,small holes are cut. A thin gauge needle is used to preventdamage to the skin while making the holes needed fortransplanting into the bald areas of the scalp. First, anesthetic and extra fluids are injected into theskin, causing the surface area to increase. the needles areinserted into the skin to make the holes. With small enoughholes, there is no tissue damage.Step five: placing the grafts Each graft is carefully placed according to the planinto specified holes. Usually 1000 grafts are more implantedin a single transplanting session. Mega sessions may involvethe transplanting of 1500 to 4000 grafts in one session.FOLLICULAR UNIT ExTRACTION (FUE) The follicular unit extraction (FUE) method, like the
SURGICAL TREATMENTS FOR HAIR LOSS 67session that can be performed in a single day. Each of thesesessions of hair transplantation involves the following steps:step one: making a plan A careful plan is made to design and mark a hairtransplant map on the patient’s scalp. In making this plan,the hair transplant surgeon is using the principles that governa natural head of hair to design a transplant that will lookappealing and go undetected.step two: Harvesting the hair using local anesthesia, a small strip of skin is cut outfrom a selected hairy portion of your head. The selection ofthis area as a source of hair is based on a few considerations.First, the portion of the scalp to be stripped should not besusceptible to balding. Otherwise, the transplanted hairwould eventually fall out of its new location, defeating thepoint of the transplant. Also, the selected portion of thescalp should be selected on the basis that after stripping andharvesting the donor grafts follicular unit strip surgery (fuss)
68 SURGICAL TREATMENTS FOR HAIR LOSSharvesting the donor grafts follicular unit strip surgery (fuss)
SURGICAL TREATMENTS FOR HAIR LOSS 69harvesting the donor grafts follicular unit strip surgery (fuss)
70 SURGICAL TREATMENTS FOR HAIR LOSSFUSS method, involves the transplantation of follicular unitsfrom donor areas on the back and sides of the scalp to thebalding areas. The difference between the two is that theFUE procedure extracts follicular units directly out of the scalp,one by one, using precise instruments and a high-poweredmicroscope. this second and newer method of follicular unit The two different cuts: The top shows the ellipse cut where the skin with hair is removed by cutting around the edges. The multi-bladed cut shown below often transects many hair follicles.
SURGICAL TREATMENTS FOR HAIR LOSS 71The strip is removedfrom the donor area.The strip will be dis-sected into the follicularunits under a micro-scopeThe individual folliculargroups of 1, 2, and 3hairs will be transplant-ed to the balding area
SURGICAL TREATMENTS FOR HAIR LOSS 73transplantation has the advantage of requiring no majorsurgical excisions. But while the FUSS procedure allows a largenumber of follicular units to be removed from a single stripof scalp, a fewer number can be removed during a singlesession of the FUE procedure because each unit must beremoved one at a time. However, a session can be repeatedone or two days apart. The FUE method of transplantation is particularlygood for those who do not have a lot of hair in their donorareas, those who are afraid of the surgical aspect of hairtransplantation and for those who do not want any surgicalscars in the donor areas. Due to the lack of cutting involvedwith the FUE procedure, patients retain the option of wearingstep four: making small holes
74 SURGICAL TREATMENTS FOR HAIR LOSStheir hair very short without worrying about the appearanceof minor scarring. The grafts used in the FUE procedure are thinner thanthe ones used in the strip technique. this is an additionaladvantage because grafts can be placed closer together,which means that more grafts can be implanted to maximizethe density of the transplant. Thinner grafts are also more Small gauge needles used to expand the recipient area for the grafts.
SURGICAL TREATMENTS FOR HAIR LOSS 75step six: Allowing the grafts to settle the grafts are left to settle in their new places andthe scalp is allowed to heal for several months. During thishealing process, the skin closes around the grafts. the hairfrom the transplanted grafts usually falls out as a result of theshock of transplantation. However, after a few months theroots of the hair usually recover and the hair re-grows.
76 SURGICAL TREATMENTS FOR HAIR LOSSeasily inserted amidst thinning hair to improve densityand they reduce the effect of shock, which causes hairin the transplanted area to temporarily fall out after theprocedure.then the skin with the hair follicles was removed and cut intosmaller hair grafts.In the first operation 586 grafts from AA were transplantedin FA and in the second operation 594 grafts from FA weretransplanted in AA. the transplants were performed on thetemples of both subjects, giving us a clear observation of hairgrowth. Also, the identification of hair growth was facilitatedbecause AA’s hair was black and FA’s hair was brown.postoperative hair growth was measured at 9 months andat 14 months, and pictures were taken at different intervalsto monitor growth at various stages.* pictures of AA and FAResults: postoperative hair growth was measured at 9 monthsand at 14 months. At 9 months, 45 of the 586 grafts on FAwere considered surviving grafts. The number of survivinggrafts was not determined on AA. At 14 months there wereno surviving grafts on FA.* chart of resultsConclusion: This study shows that allo-hair transplants donot work in the traditional format. However, there is reasonto believe that the hair itself is not antigenic but the tissuesurrounding the hair follicle is the reason why the hairwas unable to survive. It will be necessary to introducemodifications to the method of transplantation to changethe structure of the surrounding skin so it does not rejectallo-transplanted hair follicles. if the antigenic nature of theskin can be limited, this may present a new approach to thesurgical treatment of hair loss.
SURGICAL TREATMENTS FOR HAIR LOSS 77harvesting the donor grafts follicular unit extraction (fue)
78 SURGICAL TREATMENTS FOR HAIR LOSSharvesting the donor grafts follicular unit extraction (fue)
SURGICAL TREATMENTS FOR HAIR LOSS 79Follicular units are extracted with the use of
80 SURGICAL TREATMENTS FOR HAIR LOSS Donor area for Follicular Unit Extraction (FUE) one day after surgery. Donor hair has been extracted one at atime.
SURGICAL TREATMENTS FOR HAIR LOSS 813 weeks post-Follicular Unit Extraction (FUE) surgery No scalpel, sutures or staples results in a donor area with no scars.
82 SURGICAL TREATMENTS FOR HAIR LOSS The FUE technique does not require any stitches or staples because there is no traumatic surgery involved with the harvesting of the donor hair. This non-scalpel technique also allows for a faster recovery because there is no major surgery involved as there is with the usual
SURGICAL TREATMENTS FOR HAIR LOSS 83 These pictures were taken on the day after 395 grafts were transplanted using the Follicular Unit Extraction (FUE) technique. The small dots in the donor area represent the follicular units that have been extractedone-by-one and transplanted to the front of the patient’s head.
84 SURGICAL TREATMENTS FOR HAIR LOSScomparison of fuss and fue methodsfollicular unit strip surgery: Hair is harvested by extracting a strip from the donor area. Requires scalpel surgery Requires sutures or staples Minimal scarring in the donor area
SURGICAL TREATMENTS FOR HAIR LOSS 85comparison of fuss and fue methodsfollicular unit extraction: Individual follicular units are extracted one-by-one. No major scalpel surgery involved No suture or stapling involved No scarring involved
86 SURGICAL TREATMENTS FOR HAIR LOSScomparing needles gauge for fuss and fue
SURGICAL TREATMENTS FOR HAIR LOSS 87comparing fuss and fue grafts
88 SURGICAL TREATMENTS FOR HAIR LOSScomparing density for fuss and fue 50 to 60 grafts per square centimeter using 18 - 20 gauge needles in FUSS transplants. 70 to 80 grafts per square centimeter using 21 - 23 gauge needles in FUE transplants, achieving greater density in the hairline. than with the FUSS procedure.
SURGICAL TREATMENTS FOR HAIR LOSS 89comparing advantages and disadvantages for fuss and fue Follicular Unit Follicular Unit Strip Surgery extraction (classic method) Generally limited to this method allows 750 to 1500 grafts per up to 3500 to 4000 day, though sessions Number can be repeated grafts to be trans- of grafts over 2 to 3 days in a planted in one session row for more grafts, up to 2500 to 3000 grafts major surgical component, large minor surgical com- excision and ponent with no major bleeding. Staples excision. skin closes Surgical or sutures are very quickly requiring compo- required for 1 to 2 no staples or sutures, weeks to close the meaning minimal opening, meaning surgical risks surgical risks Who those who do not medium to large is best wish to have any baldness suited scarring at all Aver- $5 to $8 USD/graft $10 to $25 USD/graft age
90 SURGICAL TREATMENTS FOR HAIR LOSSGOALS OF HAIR TRANSpLANT SURGERynatural appearance The artistry of hair transplantation begins with the properdesign of the frontal hairline. It is vital that the hairline be de-signed to suit the patient’s face so that the transplant appearsnatural and goes undetected to the casual observer. The hairline must be carefully placed in relation to therest of the face to ensure this natural appearance. LeonardoDa Vinci’s formula for the face produces the best results forthis purpose. the formula is as follows: the distance from theeyebrows to the hairline is half the distance from the eyebrowsto the bottom of the chin. By following this formula, each hairtransplant should be unique and suited to the patient. Thismay be age-adjusted so that younger patients have lowerhairlines and older patients have slightly higher ones. A combination of follicular unit micro-grafting is the onlyway to perform the precise manipulations needed to pro-duce this natural-looking hairline. An irregular pattern of hairdistribution is created with a combination of one-, two- andthree-haired follicular units for a natural look. A soft frontalzone is made with single-haired follicular units and then thetransition to high density is made with the placement of two-and three-haired follicular units farther back. The crown and temples are other areas that must beproperly designed. If transplantation is needed in the crownarea, the hairs should follow the natural swirling pattern char-acteristic of this particular region. Also, the way the hairlinemeets the temples requires correct angling and blendinginto the rest of the hair behind the ears.
92 SURGICAL TREATMENTS FOR HAIR LOSS In the following cases you will see pictures of younger patients. The restored hairlines are lower and the temple angles are closed in order to give the patients their youthful look back. BeFOre AFTer
SURGICAL TREATMENTS FOR HAIR LOSS 93In the following cases you will see pictures of the restoredhairlines of middle-aged men. The hairlines are generallyhigher and the temple angles remain open to better reflect theage of the patients. BeFOre AFTer
94 SURGICAL TREATMENTS FOR HAIR LOSS BeFOre AFTer
SURGICAL TREATMENTS FOR HAIR LOSS 95One way of restoring a natural hairline is by closing the temple angles as demonstrated in the diagram above. Exposed temple angles indicate a receding hairline.
96 SURGICAL TREATMENTS FOR HAIR LOSSMaximum density It is important that your hair transplant provide enoughdensity to cover the balding areas of your scalp. This shouldbe discussed in the initial consultation with your doctor asyour financial investment in your surgery is dependant onthis. the hair transplant surgeon can, and should, outlinethe density you should be able to achieve with a certainnumber of grafts. The average person, before the onset of balding occurs,has 100 to 200 follicular units per square centimeter of thescalp. For a hair transplant, a density of 50 to 80 follicularunits per square centimeter is optimal and is possible for anexperienced surgeon in a single session. Future sessions canbuild on this density. Follicular unit extraction (FUE) has contributedsignificantly to the achievement of greater density. Byextracting the follicular units one by one using the FUEtechnique the grafts are thin enough to pack them in closertogether and thus achieve maximum density.density per square centimeter Normally, a person would have 100 to 150 grafts per square centimeter. Today, a maximum density of 70 to 80 grafts per square centimeter can be achieved with follicular unit transplantation.
SURGICAL TREATMENTS FOR HAIR LOSS 97natural density
98 SURGICAL TREATMENTS FOR HAIR LOSSdistribution of densityregions of the scalp:1, 2 60 - 70 grafts per cm square centimeter (high density)3 70 - 80 grafts per cm square centimeter (maximum density)4 50 grafts per cm square centimeter (medium density)5 30 - 40 grafts per cm square centimeter (light density)
SURGICAL TREATMENTS FOR HAIR LOSS 99the following pictures demonstrate densityin transplanted patients BeFOre IMMedIATeLy AFTer grAFTIng
100 SURGICAL TREATMENTS FOR HAIR LOSSthe following pictures demonstrate densityin transplanted patients After transplant: 70 to 80 grafts per square cm
SURGICAL TREATMENTS FOR HAIR LOSS 101the following pictures demonstrate densityin transplanted patients BeFOre
102 SURGICAL TREATMENTS FOR HAIR LOSSthe following pictures demonstrate densityin transplanted patients AFTer After transplant: 60 to 70 grafts per square cm