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How to Beat Hair Loss By Dr. Antonio Armani
how
  to beat
 hair loss third edition




Antonio 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
© Copyright 1999 by antonio alvi armani, M.d.

All rights reserved. Printed in Canada. No part of this
book may be used or reproduced in any manner
whatsoever without written permission except in the
case of brief quotations embodied in articles and
reviews.



     How to Beat Hair Loss does not offer medical ad-
vice to replace the services of a physician or surgeon.
The information provided here is collected from various
sources and represents an effort to inform you about the
options available to treat hair loss. It is intended to assist
you to work with a trained medical and other hair care
professionals. The author assumes no responsibility for us
of information provided here or any other manner. For
information address:


                       redom books inc.
                       233 Carlton street
                        toronto, ontario
                       Canada M5a 2l2
                  telephone : (416)363-6655
                        1-800-365-6220
                      Fax : (416)363-1589
                     info@alviarmani.com




    ISBN 0-9683898-1-3
about the author

     Dr. Antonio Alvi Armani has written this book as a source
of 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 to
research and development of new medical, surgical and
alternative therapies for hair loss. His hair transplant practice
and 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 member
of the American Academy of Cosmetic Surgery, the Inter-
national Society of Hair Restoration Surgery, member of the
American 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 of
Toronto, W.K. Mc Gillis Trophy, Gold Medallist, Yetive Heard
Memorial Trophy and Steven Clarfield Trophy, Italian Soci-
ety of Hair Restoration Surgery Award, Toronto Sun Read-
ers Choice Award 2002, for Best Cosmetic Surgeon, XTRA
Magazine Readers Choice Award 2002 for Best Cosmetic
Surgeon.
He has written articles and books on various aspects of hair
loss, dieting, weight loss and fitness, and is conducting clini-
cal research in the fields of hair transplantation and clon-
ing of hair.
to my patients
who have allowed me to assist them
Acknowledgments

    I owe gratitude to many people who along the way
of my career have helped in supporting and guiding my
work. I cannot possibly list all those who deserve credit
but I must mention the names of a few that have been
most instrumental in producing this book.

     I owe special gratitude to my main mentor in the
field of hair loss Dr. Dow B. Stough Jr. Dr. Stough trained
me in hair transplantation surgery and was the major
influence in my development as a hair loss surgeon.
Dr. Stough has produced a masterful reference book
that have been a constant source of reliance to me. I
thank him for this.

    I must also thank the following individuals who have
provided technical assistance in the production of this
book: Dr. Shaheen Azmi who edited it and helped to de-
velop its design; Fernando Andrejin who photographed
the pictures and was a constant source of technical
assistance; and Alex Vasolla who drew its illustrations.

   Last but not least I must thank my parents and family
members who have nurtured me and who have always
been there to support me in my every venture.
How to Beat Hair Loss By Dr. Antonio Armani
Table of Contents
IntroductIon ........................................ 1
SectIon 1: KnowIng your type of haIr loSS ......... 5
chapter 1: genetIc haIr loSS ................................................ 6
chapter 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 ........................................34




SectIon 2: treatment for genetIc haIr loSS ....... 39
chapter 1: medIcal treatment ...................................... 41
   a. rogaIne .............................................................................41

   b. propecIa .............................................................................44

   c. comparIng rogaIne and propecIa .........................................47

   d. other emergIng drugS ..........................................................52

chapter 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 ...........................................182



chapter 3: alternatIve treatmentS ............................... 192

chapter 4: haIr replacement treatment .......................... 200


SectIon 3: about your haIr......................... xx

chapter 1: anatomy of the haIr and haIr follIcle .................. xx
chapter 2: ruleS for good haIr care .................................... xx




a fInal recommendatIon ....................xx

appendIx a: Sample conSent form ..........................xx
appendIx b: Sample pre-operatIve InStructIonS ........xx
appendIx c: Sample poSt-operatIve InStructIonS ......xx


gloSSary .........................................xx

Index ...............................................xx
KNOWING YOUR TYPE OF HAIR LOSS                     5




                                             1
       knowing your type
                   of hair loss

1. genetic hair loss ................................ 6
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 .............................. 34
6   KNOWING YOUR TYPE OF HAIR LOSS


        The first thing everybody with hair loss must know is
what type of hair loss they have. Some people suffer from
certain types of hair loss that are temporary, which may result
from a variety of causes. While these may be very stressful,
many of these ailments can be corrected without resorting to
major treatments. On the other hand, most men and women
who suffer from hair loss are predisposed to genetic pattern
hair loss. This type of hair loss is hereditary and progressive.
Many people who suffer from this turn to medical, surgical
and alternative treatments to combat their hair loss.
        In this chapter, you will learn about the different types
of hair loss so that you may classify your own type and begin
the 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 your
professional by providing accurate and relevant information
about your hair loss based on the information that you find
here.

NOrMal haIr lOSS

        Normally, each person will have around 100, 000
hairs on his or her scalp at any given time. Some of these
hairs routinely take a rest from growing every few years and
eventually fall out. These same hairs re-grow from their roots.
as a result, the average person can expect to shed 50 to 100
hairs everyday. however, this type of normal hair loss should
be spread out over the whole head and should not result in
any balding or excessive thinning of hair on any particular
part of the scalp.

aBNOrMal haIr lOSS

       abnormal hair loss is the falling out of excessive hair
that leads to unusual thinning or balding at specific spots
on the head, which is probably the type of hair loss you are
experiencing. Medical professionals call abnormal hair loss
alopecia.
       alopecia can be caused by many factors but the
KNOWING YOUR TYPE OF HAIR LOSS     7

most common factor is your own genes, meaning that you
inherit the tendency to lose your hair. This type of alopecia
affects over 95 per cent of all cases of balding or thinning
hair for both men and women. This type of genetic hair loss
is given many names, including “male pattern baldness” or
“female pattern baldness” because of the consistent pattern
that the hair loss tends to follow in both men and women. Its
medical term is “androgenic alopecia” because it is believed
that hereditary hair loss is associated with changes in the
amount 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 does
not suggest that it only applies to one sex or the other.
         It is important to remember that your hair loss may be
the result of a combination of factors. Other factors may
speed up or increase your hereditary balding. Keep this in
mind because it is a major error that many people make
when determining their own type of hair loss and responding
to it. That being said, since hereditary balding is the most
common type of hair loss, I will be discussing it first, followed by
a brief discussion of the other types of abnormal hair loss.


ChaPTEr 1: GENETIC haIr lOSS


hOW COMMON IS IT?

      Genetic hair loss affects almost 50 per cent of all
males and almost 40 per cent of all females as they age.
This means that if people lived long enough, almost half
of the population would show significant hair thinning
or balding. Some ethnicities are more affected than
others are. People with European origins show more
hereditary tendency to hair loss than other ethnicities,
though other groups are affected to a degree as well.
8   KNOWING YOUR TYPE OF HAIR LOSS


HOW dOES IT OCCur aNd CaN IT BE CurEd?

    like so many ailments that afflict us, medical professionals
are not certain as to what directly causes genetic hair loss.
It is something that is programmed into your genes, but what
causes the genes to act and what they cause your body to
do, it not entirely known. as a result, there is no sure, full-proof
cure for this kind of hair loss that we know of. researchers
have different theories about the way genetic hair loss works
and they are working on various possible solutions based on
these clues.
      The most common explanation for how genetic hair loss
works suggests that it works through a complicated chemical
process operating in your body. Most researchers associate
it with the chemical changes that occur with the male
hormone testosterone as you age. Both men and women
have this male hormone but the level of testosterone is
different for the sexes and changes with aging. There are
also other chemicals, which react with testosterone, that
change as you age and may influence hair loss.
      Because most researchers believe that genetic hair loss
is caused by chemical reactions in your body, most of the
research being done in the field has focused on finding
chemicals that can reverse the chemical causes of genetic
hair loss, and then forming them into medical drugs suitable
for usage.
       recent discoveries have found that an enzyme called
“5-alpha reductase” is excessively produced by the hair
follicles of people with genetic hair loss. The enzyme
combines with testosterone, one of the male hormones
present in both men and women, to form a new chemical
called “dihydrotestosterone” (dhT), which is known to cause
hair to fall out. This chain of chemical reactions is one among
many possible chemical chains that researchers are currently
investigating in relation to genetic hair loss.
      In the last few years, researchers have been working on
many different drugs for combating genetic hair loss, but so
far only two have shown success in doing so. This first drug
is called minoxidil, and it is currently being marketed by the
KNOWING YOUR TYPE OF HAIR LOSS    9

upjohn Company under the name rogaine as a topical
solution for both men and women. The second drug is called
finasteride, and it is currently being marketed by Merck & Co.
under the name Propecia in a tablet form for men only. The
advantages and drawbacks of both these drugs, along with
other drugs that are being tested and that show promise,
will be outlined later in the chapter on medical treatments
for hair loss.

WhaT dOES IT lOOK lIKE?

  Males with genetic hair loss often become at least partially
bald and the hair loss follows particular patterns. The most
common pattern of genetic hair loss for men is characterized
by a thinning of hair at the hairline and/or the crown area.
Over time, the thinning expands, receding from the hairline
and in a circular fashion from the crown, until the two areas of
baldness meet in the middle. The final result is a completely
bald scalp except for a strip of hair along the back of the
head above the nape of the neck.
  Though this is the most common pattern that male pattern
baldness follows, there are many other variations as well.
Norwood’s classification describes this most common pattern
but it is somewhat limited in addressing the other possibilities,
including the one that applies to women. In the following
section, I will outline the new patterns of genetic hair loss that
have been identified, giving you a better understanding of
the variety of ways in which genetic hair loss occurs.
    Norwood’s classification has been used to classify male
pattern hair loss for many decades and has been useful
in many cases. however, it is not complete. Norwood’s
classification only describes one pattern of male genetic
hair loss on a scale of seven degrees of severity. Therefore,
a reclassification of genetic pattern hair loss is necessary to
account for the other possible patterns of male and female
genetic 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   11



Another 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   13




Progression of hair loss for women
according to Ludwig’s classification
14   KNOWING YOUR TYPE OF HAIR LOSS


drug-related hair loss
Many prescription drugs can cause varying degrees of
hair loss for some people. It is likely that you have seen
cancer patients who have lost hair after undergoing
chemotherapy. 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   15

cause hair loss. In addition, close to 300 more commonly
employed 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 loss




Norwood’s traditional pattern where hair loss progresses from
the 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 loss




hair loss progresses only from the front hairline and recedes
backwards 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 loss




The 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 4




pattern hair loss, though it occurs in men as well. hair loss
starts 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 loss




from the Mediterranean and the Middle East, although it
does occur in other ethnic groups as well. hair loss begins at
the 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       23

FemALe ANdRoGeNIC ALoPeCIA (FAGA)

         As has already been discussed, women can suffer from
genetic pattern hair loss just like men do and both forms of genetic
hair loss are caused by similar chemical factors. The difference is
that it is much less common for women than it is for men, and the
hair loss follows a different pattern. Women with female genetic
hair loss tend to experience a progressive thinning of the scalp
hair only around the crown area. It is also usually more diffuse
and central than male genetic hair loss; and it is often referred to
as a ‘widened part’. Less commonly, women may have a receding
hairline similar to that seen in balding men. It is unlikely that
female genetic hair loss will result in total baldness, though it does
occur. Aside from female genetic hair loss, there are other ways
that women may suffer from hair loss that will be discussed in the
next 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    25



Chapter 2: OThEr TYPES Of aBNOrMal haIr lOSS

      hair loss can be triggered by many factors other than
genetic predisposition. While these other types of hair loss
only make up five per cent of abnormal hair loss cases, they
can be more severe in their effects. however, the good
news is that these other types outlined below are almost
always temporary or are often treatable. I will briefly discuss
each of these common types of hair loss as well as the main
treatments usually given for them.
dIET-rElaTEd haIr lOSS

Protein: There are a number of nutritional deficiencies that
can cause hair loss by altering your hair’s structure or hair
cycles. among these, protein deficiency is one of the most
common. Your hair is composed mostly of proteins, the same
materials that your nails are composed of. If your food does
not provide you with enough protein then both your nails
and your hair may be negatively affected. Protein is found
in common foods like meats, poultry, fish, beans and dairy
products. If a protein-deficient diet persists then your hair
will go into a premature resting stage and will start to fall out
within a few months. unfortunately, many people simply do
not eat well, or they become caught up in some fad diet.
The kinds of things to watch out for are poor eating habits
that lack in protein, vegetarian diets, or fad diets that restrict
the amount of protein you consume.

Iron: another possible cause of diet-related hair loss is a
low level of iron in your blood, which might result from an
inadequate amount of iron in your diet. foods that are
common 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 result
from some difficulty your body has in absorbing iron, which
is commonly linked with the condition anemia.
26   KNOWING YOUR TYPE OF HAIR LOSS


Vitamin A: another nutrient that can affect your hair is
vitamin a, which can be found in whole eggs, milk and liver.
Both an inadequate and an excessive amount of vitamin
a can cause hair loss. Too little of this vitamin can result
in a condition called hyperkeratosis. It occurs in your hair
follicles and in the sebaceous glands (the small glands in
your skin that secrete oil into your hair) and it can complicate
hair growth. Conversely, too much vitamin a can prevent
proper keratinisation (the process by which a protein called
keratin builds your hair and nails), resulting in a kind of hair
loss referred to as ‘toxic alopecia’.

        Other nutritional deficiencies that can affect your hair
growth include deficiencies of: essential fatty acids, zinc,
copper and vitamin C. fortunately, the damage done to
hair by this type of diet-related hair loss is only temporary
and can be corrected by simply improving your diet. Your
dietary history is one of the first things a medical doctor who
specializes in skin and hair would ask when assessing your hair
loss problem. Before considering anything else, you should
assess your own diet in relation to any hair loss problems you
may be experiencing.

druG-rElaTEd haIr lOSS

        Many prescription drugs can cause varying degrees of
hair loss for some people. It is likely that you have seen cancer
patients 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 to
be associated with hair loss.

drugs commonly associated with hair loss:

 Birth control pills
 heart disease and high blood pressure pills, especially beta
blockers 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, like
isotretinoin
 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, in
addition to your dietary history, before diagnosing hair loss
problems. Even drugs that are not currently associated
with hair loss may cause you to lose hair, so you should take
your drug consumption history into consideration no matter
what.
       fortunately, drug-related hair loss is easily treated by
simply 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 not
cause you to lose your hair.

dISEaSE-rElaTEd haIr lOSS

        There are dozens of diseases and conditions that can
result in some type of hair loss. In this section, I will outline
the major classes of diseases that cause hair loss, the kind
of hair loss that they cause and possible treatments that are
available.
        Since so many common ailments and conditions can
cause you to lose hair, your recent and long-term health
28   KNOWING YOUR TYPE OF HAIR LOSS


history is one of the first things a medical doctor would
question when assessing a case of hair loss. You should also
question your own medical history to determine if disease is
a factor in your own hair loss.

Skin diseases of the scalp

        There are a number of different conditions that can
affect the scalp and cause varying degrees and types of
hair loss. These include: infections like syphilis and ringworm;
infestations like pediculosis, which is caused by lice;
inflammatory diseases like folliculitis; genetic diseases like
darier’s disease and other syndromes of the skin like psoriasis.
The hair loss in each case is usually only partial and can be
treated.

Ringworm: ringworm is a contagious disease that is caused
by the infection of fungus. It results in small, scaly patches
on the skin and, when it occurs on the scalp, is also followed
by a loss of hair. It can be treated effectively with a topical
solution.

Darier’s disease: darier’s disease is a genetic disorder
characterized by dark, crusty patches on the skin, sometimes
containing pus, which results in the hair becoming rough and
dry with patches of baldness.

Psoriasis: Psoriasis is a chronic skin disease characterized by
scaling and inflammation. It is a disorder of the immune
system that occurs when cells in the outer layer of the skin
reproduce faster than normal and pile up on the skin’s
surface. The hair loss is reversible with treatment.

Telogenic and anagenic alopecias

      To understand this type of hair loss, you first need to
be familiarized with the hair growth cycle. all human hairs
go through a natural cycle beginning with growth, called
the anagen phase, followed by a period of rest, called the
KNOWING YOUR TYPE OF HAIR LOSS    29

telogen phase, and ending with the hair falling out. When
only the hairs that belong in a particular phase fall out, we call
this either anagenic alopecia or telogenic alopecia. dozens
of factors can cause either of these alopecias, including
stress, chronic diseases and nutritional deficiencies. Many of
these different factors send anagen hairs prematurely into
the resting stage and result in excessive shedding months
after. This is called telogenic alopecia. In this section we will
discuss some of the more common telogenic and anagenic
syndromes.

Loose anagen syndrome: This condition generally affects
young, Caucasian blonde girls, although anyone is
susceptible. The characterizing symptom is the ability of
anagen hairs (hairs that are in the anagen, or growth, stage
of the hair cycle) to be pulled out easily and painlessly. In
children ages 2 to 5 years with loose anagen syndrome, the
hair is usually unable to grow past the ears, though the density
is otherwise unremarkable and the hair is not particularly
fragile otherwise. Treatment is usually unnecessary because
although loose anagen hair grows slowly, it does grow and
if it is accidentally pulled out, it grows back quickly.

Pregnancy and childbirth: The stress of childbirth, similar to
that of a severe fever or chronic illness, can prematurely push
anagen hairs into the resting stage, resulting in excessive
shedding some months later. hormonal changes that occur
during 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 healthy
people with good eating habits, no notable diseases or
injuries to the scalp that can explain such a loss of hair.
When this occurs, it is referred to as ‘alopecia areata’. This
unpredictable but common disease affects 1.7 per cent of
the world’s population. although it can affect men and
women 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 LOSS


scalp and body. In some extreme and rare cases, the hair
loss may lead to a complete loss of hair all over the head and
body. alopecia areata that causes complete hair loss of the
scalp is called ‘alopecia totalis’ and when it causes hair loss
over the whole body it is called ‘alopecia universalis’.
        It is believed that alopecia areata is caused by the
immune system unexpectedly, and usually temporarily,
attacking the hair follicles, causing them to fall out and
preventing re-growth in some cases. however, it is not known
why this occurs.
        Cases of alopecia areata usually disappear on their
own 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 that
interfere with the immune system) have been found to be
effective in combating alopecia areata.
        although alopecia areata is not life threatening, it is
so dramatic in its effects that it often damages the mental
and emotional states of its victims. for this reason, many
support groups have been established to help people cope
with alopecia areata. You can find a local support group in
most countries around the world by contacting the National
alopecia areata foundation via their website at www.
alopeciaareata.com.

Thyroid diseases

       Your thyroid gland resides in your neck and is
responsible for producing hormones that are involved in
many 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 of
hormones. When this occurs, there is a slight shedding of
the hair on the scalp, and possibly of the armpits and pubic
area.
       an under-active thyroid gland may become enlarged
due to a bombardment of thyroid-stimulating-hormones (TSh)
produced by the pituitary gland, which occurs in order to
KNOWING YOUR TYPE OF HAIR LOSS    31

entice the thyroid to produce more hormones. The result is
the creation of ‘goiter’.
       The most common cause of hypothyroidism is a
previous (or ongoing) inflammation of the thyroid gland that
leaves a large percentage of the gland’s cells damaged
or dead. This kind of inflammation is most likely the result of
autoimmune thyroiditis, which is caused by the patient’s own
immune system. hypothyroidism may also be caused by
certain medical treatments that, indirectly or directly, affect
the thyroid gland.
       The hair loss that results from thyroid disease can
be reversed by treating the condition that is affecting the
thyroid gland. There are many other symptoms of thyroid
disease, including fatigue, weakness, weight gain, dry skin,
intolerance to the cold, constipation, memory loss, muscle
aches and/or depression. The proper functioning of your
thyroid gland is very important and is worth seeing a medical
doctor if you think you may be experiencing some or all of
these symptoms.

Psychiatric and psychological diseases

       The most common type of psychological condition
that can cause hair loss is stress. Excessive stress can cause
telogenic alopecia, which is described above.

Anorexia nervosa: anorexia nervosa occurs when someone
restricts their diet to such a degree that there are nutritional,
endocrinal and psychological impairments. The hypocaloric
diet (meaning there is an insufficient amount of calories
being ingested) may result in a loss of hair. This may also be
accompanied by an increase in lanugo (the fine, light hairs
that cover the body) on the face, trunk and arms.

Cancer-related hair loss

Neoplasic alopecias: This term refers to hair loss that results
from cancer spreading from one area of the body to the
scalp. The word ‘neoplasic’ comes from the word ‘neoplasm’,
which means ‘tumor’.
32   KNOWING YOUR TYPE OF HAIR LOSS


The susceptibility of the scalp to neoplasic alopecia is
higher for women with breast cancer and for men with lung
cancer in particular, as opposed to other types of cancer.
It is believed that mucines, a certain kind of protein created
by breast and lung carcinoma, degenerate the cells of the
outer root sheath of the hair follicle. however, not all cases
of breast or lung cancer will cause hair loss.
         Ovarian and adrenal tumors are also likely to cause
hair loss. Both types of tumors can cause hyperandrogenism,
which is the excessive production of androgens (male
hormones). androgens are known to play a key role in male
and female pattern baldness. Once the tumor has been
removed, however, the hair loss should go away.
Cancer-fighting drugs: Most cancer-fighting drugs, like
chemotherapy, attack the body, including the hair follicles,
and cause considerable hair loss. The hair should grow back
after the treatment has stopped.

Saha syndrome

        Saha syndrome is a skin condition that only affects
women and is caused by hyperandrogenism, which is the
excessive production of male hormones (androgens) and
which occurs in the whole body (cases of hyperandrogenism
affecting only particular parts of the body are considered
different conditions).
        The four main symptoms of this syndrome make up the
acronym ‘Saha’: seborrhea, acne, hirsutism and alopecia.
These four manifestations appear in this order, although not all
women suffer from all of them. all sufferers of Saha syndrome
do experience seborrhea, however.
        Seborrhea is a skin condition characterized by
inflammation, dry or oily scaling, crustiness and/or itching. It
is 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 part
of the condition because the increased sebum production
that causes acne in this case is caused by androgenic
action. hirsutism, the third symptom, is the excessive growth
KNOWING YOUR TYPE OF HAIR LOSS    33

of male-pattern hair in women, also caused by an increase
in androgens.
       The hair loss that accompanies Saha syndrome is also
caused by excessive amounts of androgens and results in
typical female pattern baldness. a uniform clearing of the
scalp of the crown occurs, though total alopecia is unlikely
and the frontal hairline remains intact.
       Treatment of Saha syndrome includes several drug
options, 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 as
simple as physical stress being put on the hair, the destruction
of the hair follicles themselves or excessive amounts of hair
being pulled out of the scalp. In these cases, we say that the
hair loss is due to ‘external injuries to the scalp’ as opposed
to a skin disease or disorder.

Cicatricial alopecias

         hair loss may occur due to the destruction of the hair
follicle. In this case, the skin of the scalp is somewhat like
scar tissue and is therefore unable to produce hair, meaning
that the hair loss is permanent and the only option is surgical
treatment.
         This destruction of the hair follicles can result from
mechanical, physical or chemical trauma (which may
include the use of acids, chronic traction, electrical or thermal
burns, or freezing), as well as tumors, special skin diseases or
severe infections such as syphilis. The destroyed hair follicles
may not necessarily cover the entire scalp, depending on
the method and type of damage. again, the only option
for 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 LOSS


a usually unrecognized behavioral disorder known as
trichotillomania. It is characterized by uncontrollable hair
pulling, similar to impulsive disorders such as pyromania
or kleptomania. The disorder usually appears in males at
the age of 8 and in females at the age of 12 and has a
prevalence of about one per cent.
        Sufferers of trichotillomania generally spend about
one hour per day pulling their hair out. This can last for a few
seconds or minutes, or it may last for prolonged periods of
time. Some may try to resist the urge, while some are unaware
of its occurrence, pulling hair absent-mindedly while driving,
reading or watching television.
        While the disorder itself is a stressful condition, the hair
loss that results is an unfortunate additional complication that
affects many children and teenagers psychologically and
emotionally. The hair loss that occurs is usually focused on the
scalp, but it may also occur among the eyebrows, eyelashes
and pubic region. hair loss is usually patchy, irregularly-
shaped and occurs most often on the side of the body that
coincides with the person’s predominant hand. Most sufferers
of trichotillomania are likely to feel embarrassed about
the disorder and may try to hide their hair loss, prolonging
diagnosis and complicating treatment.
        Treatment for trichotillomania involves behavioral
therapy and/or medication. Possible drugs include mood
stabilizers, anxiolytics (drugs that work on the central
nervous system to relieve anxiety), neuroleptics (also known
as antipsychotics) and topical agents including steroids.
however, behavioral therapy has been found to be more
effective than drug therapy, especially if the hair pulling has
only been occurring for less than 6 months and because there
are no clear guidelines for how drugs should be used to treat
trichotillomania. With therapy, sufferers of trichotillomania
can overcome this disorder and resume their normal lives
without 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     35

unfortunately, there are many styling habits and treatments
that are bad for the overall health of your hair and that
promote hair loss. hairstyles that require unusual pulling, dying
or conditioning may severely stress the natural workings of
your hair and may lead to unusual balding.
        When a high degree of physical stress is constantly
being put on the hair for styling purposes, hair loss may occur.
This condition is referred to as ‘cosmetic alopecia’. It is usually
caused by the constant use of curlers, brushes and other
tools used to style hair as well as hairstyles that pull the hair.
The alopecia appears as a slight shedding of the hair and
occurs because the strain that the hair is put under leads
to reduced blood flow in the capillaries at the bottom of
the hair follicles. The hair’s growth is stunted and eventually
leads to a slight loss of hair a few months later. This usually
affects the triangular areas above and in front of the ears,
though it is dependant on the direction in which the hairstyle
is aimed. It is also possible to damage the hair follicles and/
or the scalp itself with the constant use of chemicals used
to curl or dye the hair. In most cases of cosmetic alopecia,
the reduced blood flow that causes the hair loss disappears
after the pressure is removed, although the shedding may
take 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        37


Julia B. : Losing hair because of
            Hypothyroidism
Age: 27
Occupation: Homemaker

Julia B. went to a clinic complaining of fatigue, increase in
weight, and sparse hair on the scalp and on the eyebrows. She
was not taking any medications. Julia had no family history
of hair loss. Physical examination showed dry skin, diffuse
hair 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 the
thyroid gland). often such a condition causes the unusual loss
of hair not only on the scalp but on other parts of the body.
Julia was started on a thyroid replacement medication. In six
months not only was her hair restored to normal, but Julia
found 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 aggravate
their situation by poor hair care habits. for example, there
are many genetically balding people who are losing more
hair than they should be and at a faster rate because of
poor hair care habits. In these cases, people can forestall
the appearance of baldness for years by maintaining good
hair care.
         You can learn how to properly take care of your hair
and prevent, or forestall, the appearance of balding later in
this book in the section regarding ‘rules for good hair care’.
2
         treatment options
           for hair loss

1. medical treatment ...........................41
   a. rogaine (minoxidil) ................................................... 41
   b. propecia (finasteride) ................................................ 44

   c. comparing rogaine and propecia ............................. 47

   d. other emerging drugs         ............................................... 52
2. 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         ................................ 182
3. alternative treatment ....................192
4. hair replacement treatment ............200


                                      39
40    DRUG TREATMENTS FOR HAIR LOSS




        Over 90 per cent of all hair loss cases fall under the category
of genetic hair loss. For this reason, all the treatment options
discussed in this section, with the exception of hair replacement
therapy, are meant only for the treatment of genetic hair loss. For
all other types of hair loss, you should contact a qualified medical
doctor to discuss treatment options. And while this section is meant
to guide you in treating your hair loss, you should always contact
a 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, has
long been the dream of people suffering from this type of
hair loss. But until recently this hope has been nothing but a
dream. During the last couple of decades researchers have
been developing two drugs that have proven effective in
combating genetic hair loss. First the drug minoxidil, which is
now marketed as Rogaine, was approved by the Food and
Drug Administration and later on the drug finasteride, which
is now marketed as Propecia, was also approved for use in
fighting genetic hair loss.
        There are also many other drugs and combinations of
drugs that are now being tested and which may be available
in the coming few years. It should be noted, however, that
there is always the risk of side effects with any medications.
Also, it takes decades to completely understand the full
effects of any drug and many of these drugs have not been
around long enough to determine these full effects.


RogAIne (mInoxIDIl)

       Rogaine was introduced as a new drug for promoting
hair growth by the Upjohn Company in 1988. It is sold as a
topical solution, which means that it is a rubbing solution
meant for the balding areas of your scalp. It comes in either
a 2 per cent or a 5 per cent solution depending on how much
42    DRUG TREATMENTS FOR HAIR LOSS



minoxidil the solution contains. Rogaine is available over the
counter and should be applied on the balding area(s) twice
a day, every day.

How does Rogaine work?

         Although there is only a small percentage of minoxidil
in Rogaine, it is this drug that makes it work. minoxidil is known
as a hair growth stimulator. It was originally marketed in a
tablet form for the treatment of high blood pressure and
unwanted 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 recognizes
that Rogaine works, it is well known that it doesn’t work for
everyone. Recent studies show that when the 2 per cent
solution is used properly, it can stimulate hair growth 30 per
cent of the time, with a slightly higher rate in females. And the
new 5 per cent solution has shown only slightly more success
than the weaker solution.
        Rogaine is most effective when used at the first signs
of balding and in relatively small areas of hair loss. It is also
more effective in the center of the scalp than on the frontal
hairline. Rogaine can inhibit further hair loss and can be used
to supplement hair transplantation.
        It should be noted, however, that if you stop using
Rogaine you will lose any hair re-grown while you were
using it. This means that once you start using Rogaine, you
must continue to use it for the rest of your life to enjoy its
benefits.

Are there any side effects to using Rogaine?

     every drug has some side effects. In the case of
Rogaine the drug that makes it work, minoxidil, has a
dangerous effect on the body (and the heart in particular) if
DRUG TREATMENTS FOR HAIR LOSS        43


taken orally. When it is diluted in a solution for topical use, as
it is in Rogaine, the side effects are less severe because the
amount of minoxidil entering the body is much less. However,
even in small doses the use of minoxidil does have some minor
and major side effects that should be noted.

Minor side effects: These include skin irritations on the scalp
such as dry red skin, flaking and itching; nausea and vomiting;
and diarrhea. These are short-term, temporary side effects
that should go away when your body adjusts to the use of
Rogaine.

Major side effects: These include back and chest pain;
cold-like symptoms; rapid heartbeat; fluid retention; difficulty
breathing; weight gain; worsening of hair loss. These are very
rare, extreme side effects that are similar to the effects of
minoxidil taken orally.

       Also, Rogaine is not safe for people who: Show allergic
reactions to minoxidil; have heart disease; have high or
low blood pressure; have skin diseases like dermatitis; are
pregnant; or who are nursing mothers.

What improvements can we expect in the near future?

       The most likely advancements in the use of Rogaine
will come from two different approaches:

Increasing the amount of minoxidil: like the addition of the
5 per cent solution to the 2 per cent solution, researchers
have been trying to improve the effectiveness of Rogaine
by increasing the amount of minoxidil in the solution.

Increasing the ability of minoxidil to enter the skin: Researchers
have also been trying to make Rogaine more effective by
increasing the ability of the minoxidil in the solution to enter
the skin and cause hair growth. Tests have shown that if
44    DRUG TREATMENTS FOR HAIR LOSS


minoxidil is mixed with certain other substances it may be
able to enter into the skin better and cause more effective
hair growth.

Final recommendations for Rogaine

        only use Rogaine if your health is good, if you are
willing to test how it works for more than one year while
accepting the possibility of failure, if you are disciplined in
taking medications and following detailed instructions, and
if you are prepared and able to pay to use Rogaine for the
rest of your life.


PRoPeCIA (FInASTeRIDe)

        In late 1997, the Food and Drug Administration
approved Propecia for distribution in the United States as a
hair-restoring drug. It is sold by the company merck in 1 mg
pill form by prescription only. It is the first pill that effectively
treats genetic hair loss.
        The active agent in Propecia is a drug called
finasteride. It was originally used in a prostate medication
called Proscar that was found to grow hair. Propecia is a
lower-dose form of Proscar developed specifically to fight
hair loss.
        one of the main differences between Rogaine and
Propecia is that Propecia should only be used by men. It is
dangerous for women of childbearing age and can cause
severe birth defects in women that have handled Propecia
in any way. Possible dangers aside, Propecia does not work
for any women of any age.

How does Propecia work?

       Finasteride is the active agent in Propecia. It works
by manipulating the underlying chemical causes of genetic
hair loss. We know that men with genetic hair loss have
increased levels of a hormone called dihydrotestosterone
DRUG TREATMENTS FOR HAIR LOSS         45

(DHT) in their scalps and it is believed that the presence of
DHT in the scalp is related to the thinning of hair follicles and
the resulting genetic hair loss. DHT is a by-product of the male
hormone testosterone, which is converted to DHT when it
reacts with a natural enzyme that is found in human skin cells
called 5 alpha-reductase (5AR). Propecia does not directly
counteract DHT itself, but rather blocks the action of 5AR to
indirectly 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 not
as successful in stimulating new growth.
         Studies suggest that about 80 per cent of balding
men can stop any further hair loss by taking Propecia. In
addition, two out of three men may see some re-growth of
hair. However, Propecia only works for men who have mild
to moderate hair loss. Balding men with major or complete
hair loss will not benefit from Propecia. Like Rogaine, Propecia
is more effective in the center of the scalp and less so along
the frontal hairline.
         Propecia must be taken for at least three months
before seeing any results. Because hair generally grows at a
rate of about ½ an inch per month, it usually takes between
three to six months to see the full effects of Propecia. If there is
no significant growth after 12 months it is unlikely that Propecia
will ever work.
         Also like Rogaine, Propecia is effective only for as long
as it is taken. This means that all benefits of using Propecia
will be lost if you ever stop using it.

Are there any side effects to using Propecia?

       Contrary to the dangerous effects that Propecia has
on women, it is generally well-tolerated by men. The Food
and Drug Administration described Propecia as having only
infrequent side effects that affected only a small number of
men.
46    DRUG TREATMENTS FOR HAIR LOSS




General side effects: These include allergic reactions such as
rash, hives, itching and swelling of the lips and face; breast
tenderness and enlargement; and testicular pain.

Sexual side effects: Less desire for sex, difficulty in achieving
an erection; decrease in the amount of semen; and problems
with ejaculation. These side effects occurred in less than 2
per cent of men and were only temporary.

        Some men in particular should not take Propecia.
These include men who have allergies to finasteride or a
related drug or who have liver function abnormalities. men
for whom the noted side effects are unusually severe or long-
lasting should only continue using it with caution and under
the direct guidance of a medical doctor.
        As has already been mentioned, Propecia is also not
safe for women and may cause severe birth defects. Women
should not even handle broken or crushed tablets, although
all Propecia tablets have a protective coating when intact.
Also, men taking Propecia pose no danger to women or their
fetuses.
        Although there are no known dangers in mixing
Propecia with other drugs, the use of this drug has been linked
to decreases in levels of prostate-specific antigen (PSA).
Though this decrease is insignificant in itself, PSA levels are
often measured for diagnostic reasons in the case of men
suspected of prostate cancer or other prostate problems.
Because of this, all patients taking Propecia, especially those
with prostate illnesses of any kind, should inform their doctors
of 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 obtaining
greater results from its use.

Using Propecia as a topical solution: one approach has been
DRUG TREATMENTS FOR HAIR LOSS        47


to formulate finasteride as a topical solution, like Rogaine. This
approach is more common outside of the United States, but
some American companies are already selling finasteride in
this form. At this point, however, a topical form of finasteride
remains experimental as there have been no clinical studies
that have shown the effectiveness of a finasteride topical
solution.

Combining Propecia with Rogaine: It is believed by some
that Rogaine and Propecia can complement each other
by combining Rogaine’s ability to stimulate new growth with
Propecia’s ability to prevent further hair loss. This, however,
is a relatively new approach and little has been done in the
way 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 LOSS


COmpAring 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   49



examples 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   51




Anterior mid-scalp hair loss helped by
              propecia
52    DRUG TREATMENTS FOR HAIR LOSS


oTHeR emeRgIng HAIR gRoWTH DRUgS

       Although Rogaine and Propecia are the only two drugs
currently approved by the Food and Drug Administration
to combat genetic hair loss, there are several other drugs
that have shown great promise in restoring hair loss. These
are not likely to be miracle cures but they may be more
effective 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 available
besides Rogaine and Propecia. All of these drugs are still
being tested and some are being seriously investigated by
large pharmaceutical companies that are investing millions
of dollars to make them work.

Dutasteride

        Dutasteride is another 5 alpha reductase inhibitor
like the finasteride used in Propecia but it is currently being
marketed as Avodart for the treatment of benign prostatic
hyperplasia. Researchers are trying to formulate a form of
dutasteride that can be used for the treatment of genetic
hair loss. Like finasteride, it will likely have side effects on male
sexual functioning.

Antiandrogens

        Antiandrogens are drugs that prevent androgens
(male hormones) from working. These drugs have shown the
most promise in being able to provide a cure for genetic hair
loss, as androgens are known to play a key role in causing
this kind of hair loss.
        Antiandrogens are used to treat many different
ailments and one of the side effects commonly seen during
their usage has been the stimulation of hair growth all over
the body.
        Because male hormones are important to the proper
functioning of many male bodily functions, possible side
effects of using antiandrogens include impairment to male
DRUG TREATMENTS FOR HAIR LOSS       53

physical characteristics and sexual desire and potency.

        Work has been done to develop antiandrogens that
are safe for men to use to combat hair loss while avoiding
the unwanted side effects. Finasteride, the drug in Propecia,
is an example of one such drug because it does not directly
inhibit male hormones but rather inhibits an enzyme that
interacts with male hormones.
        Because antiandrogens target male hormones,
antiandrogens are generally safer for women. Since women
are less damaged by the side effects of antiandrogens
they are more effectively treated by them. In europe,
antiandrogens have been officially used to treat genetic hair
loss in women for years.

       one of the two drugs approved by the Food and Drug
Administration for the treatment of genetic hair loss is Rogaine,
whose active agent minoxidil is not an antiandrogen. So it
would not be surprising to discover that the most effective
drug treatment for genetic hair loss might emerge from a
type of drug that is also not an antiandrogen.
       outside of the antiandrogens, there have been
several drugs that have shown some promise as a treatment
for genetic hair loss. The most prominent of these that are
currently being developed and tested include the drugs listed
below. look for these drugs to emerge in the near future to
complement Rogaine as a drug treatment for genetic hair
loss.

Tricomin

        The American pharmaceutical company ProCyte is
testing this drug in France. It has shown some effectiveness
in increasing new hair growth by 40 per cent for three out
of four of the balding men who used it in testing. Tricomin is
a compound chemical that helps restore the health of skin
tissue. The compound drug is applied on the skin like Rogaine
and is believed to restore a healthy skin base for new hair to
grow.
54    DRUG TREATMENTS FOR HAIR LOSS



Cyclosporine

        In several scientific studies conducted over the last
few years, this drug successfully re-grew hair for at least
some of the balding men who used it in testing. It is a type
of drug called an immunosuppressive, meaning that it
fights the body’s immune system. Immunosuppressives are
usually given to patients to prevent organ rejection after a
kidney, liver or heart transplant. Some experts believe that
the ultimate cause of genetic hair loss is the immune system
receiving the wrong messages that hair on certain parts of
the scalp are foreign to the body, causing the immune system
to attack them.
         In tests, cyclosporine was applied on the skin in the
same way as Rogaine. This is done to localize the suppression
of the immune system to the scalp and protect the rest of
the body from the effects of the drug. The partial success
of cyclosporine is fueling great interest in researching and
developing immunosuppressive treatments for genetic hair
loss.

Cyoctol

       This drug has shown enough promise for Squibb, a
major pharmaceutical company, to work on developing
and testing it as a treatment for genetic hair loss. It is
believed to combat hair loss by binding itself to the roots
of hairs and protecting them from the negative effects of
dihydrotestosterone (DHT), which is linked to genetic hair
loss.

Diazoxide

        The Food and Drug Administration is currently testing
this drug for approval. It is usually used to treat symptoms of
diabetes, such as abnormally high blood sugar. When it is
used orally for this purpose, it has the side effect of causing
hair growth all over the body. Recent research on diazoxide
has been focused on developing it for treatment of genetic
DRUG TREATMENTS FOR HAIR LOSS       55

hair loss by trying to control and direct the hair growth to the
scalp.
chapter two:

       surgical treatment

         Like medical drug treatments, surgical treatments for
hair loss have developed significantly in the last couple of
decades. However, unlike medical drug treatments that are
still years away from being able to provide a full head of hair,
recent advancements in surgical treatments have made it
possible to achieve the appearance of a full head of natural
hair. At this point in time, surgical methods are the surest and
most effective way for most balding people to restore natural
hair to a balding head.


BAsic questions ABout surgicAL treAtments


What are surgical treatments?

        There are several types of surgical treatment for hair
loss. They all involve the movement of hair from areas of your
scalp that normally never go bald, such as the back and sides
of your head, to the balding areas of your scalp, usually the
central area on top and the frontal hairline.
        What is important to recognize about all surgical
treatments for hair loss is that no surgical method can give
you new hair or restore any of your lost hair. They can
only redistribute what you still have. It is also important to

                              55
remember that surgical treatments for hair cannot prevent
further balding. When deciding to employ any surgical
treatment you must consider the possible progression of your
hair loss as well as what you have already lost.

Who is a good candidate for surgical treatment?

         Because surgical treatments of hair loss can only
move existing hair from one area to another, it can only work
properly with people who have enough remaining hair to
cover the balding areas, and who are likely to retain it for
some time. With recent advances in hair transplantation
even people who have lost up to 50 per cent of their hair
can get the appearance of a full head of hair with surgical
treatment. But even with less than half your hair left, you can
still benefit from hair transplantation and have your remaining
hair redistributed in a way that looks natural and attractive.

When is surgical treatment appropriate?

       there are several different situations in which hair
transplantation is the best method to treat your hair loss.

To produce a natural hairline: A hair transplant is always
required to produce a natural looking frontal hairline. the
frontal hairline is the most important part of hair restoration
because it is the most prominent part of your hair. The
creation of a natural looking frontal hairline requires the
restoration of a delicate pattern of hair lengths at various
angles, 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 can
provide the restoration of a full set of hair. small grafts of one,
two or three hairs can be precisely placed amidst thinning
hair to restore a natural looking density.

To implant on scars left by surgical cuts to the scalp: scars left
from surgical cuts into the scalp or physical traumas can be
effectively 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 transplantation
that offer the best and most natural results possible. These
are follicular unit strip surgery (FUSS) and follicular unit extrac-
tion (FUE).
     Both the FUSS and FUE procedures involve the extraction
of follicular units from a donor area on the head. Follicular
units are small groupings of one, two or three hairs that grow
naturally on the scalp. These follicular units are taken from
areas on the head where hair is genetically programmed
not to fall out. They are then implanted in the balding areas
of the scalp, where the transplanted hair will continue to
grow naturally. The FUSS and FUE procedures approach this
method differently, but both provide exceptionally natural
results and are by far the most popular methods with surgeons
and patients.

How much does surgical treatment cost?

        The cost of hair transplantation can vary enormously
depending on who is performing it. Typically a doctor
will transplant 1000 to 4000 grafts in one session that can
last anywhere from two to twelve hours. The cost of the
procedure is based on a price per graft. The grafts used in
the 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 grafts
being transplanted, the cost of the procedure can run into
the thousands, but patients should remember that a hair
transplant 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 transplant




Crownal
hair 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 transplant




Frontal hair loss:
   Front view




  Frontal and
central 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 and
central hair loss:
    Top view




  Frontal and
central hair loss:
    Side view
66    SURGICAL TREATMENTS FOR HAIR LOSS


FOLLICULAR UNIT STRIp SURGERy (FUSS)

        The FUSS procedure involves the extraction of follicular
units from narrow strips of scalp taken from donor areas on
the back and sides of your head. The removal of these strips
result in virtually undetectable scars. The follicular units are
cut out from these strips and implanted into the balding areas
of your scalp in pin-sized, surgically created holes. These sites
will also heal in just a few days, leaving no

step three: making the grafts

         the strips of skin taken from the scalp are cut into small
grafts. Each of the small units is called a graft because it is
intended to be placed in the bald portion of your head where
it 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 prevent
damage to the skin while making the holes needed for
transplanting into the bald areas of the scalp.
        First, anesthetic and extra fluids are injected into the
skin, causing the surface area to increase. the needles are
inserted into the skin to make the holes. With small enough
holes, there is no tissue damage.

Step five: placing the grafts

        Each graft is carefully placed according to the plan
into specified holes. Usually 1000 grafts are more implanted
in a single transplanting session. Mega sessions may involve
the 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    67

session that can be performed in a single day. Each of these
sessions of hair transplantation involves the following steps:

step one: making a plan

       A careful plan is made to design and mark a hair
transplant map on the patient’s scalp. In making this plan,
the hair transplant surgeon is using the principles that govern
a natural head of hair to design a transplant that will look
appealing and go undetected.

step two: Harvesting the hair

         using local anesthesia, a small strip of skin is cut out
from a selected hairy portion of your head. The selection of
this area as a source of hair is based on a few considerations.
First, the portion of the scalp to be stripped should not be
susceptible to balding. Otherwise, the transplanted hair
would eventually fall out of its new location, defeating the
point of the transplant. Also, the selected portion of the
scalp should be selected on the basis that after stripping and


harvesting the donor grafts follicular unit strip surgery   (fuss)
68     SURGICAL TREATMENTS FOR HAIR LOSS



harvesting the donor grafts follicular unit strip surgery   (fuss)
SURGICAL TREATMENTS FOR HAIR LOSS     69


harvesting the donor grafts follicular unit strip surgery   (fuss)
70    SURGICAL TREATMENTS FOR HAIR LOSS




FUSS method, involves the transplantation of follicular units
from donor areas on the back and sides of the scalp to the
balding areas. The difference between the two is that the
FUE procedure extracts follicular units directly out of the scalp,
one by one, using precise instruments and a high-powered
microscope.
       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   71




The strip is removed
from the donor area.




The strip will be dis-
sected into the follicular
units under a micro-
scope




The individual follicular
groups of 1, 2, and 3
hairs will be transplant-
ed to the balding area
72   SURGICAL TREATMENTS FOR HAIR LOSS
SURGICAL TREATMENTS FOR HAIR LOSS   73
transplantation has the advantage of requiring no major
surgical excisions. But while the FUSS procedure allows a large
number of follicular units to be removed from a single strip
of scalp, a fewer number can be removed during a single
session of the FUE procedure because each unit must be
removed one at a time. However, a session can be repeated
one or two days apart.
        The FUE method of transplantation is particularly
good for those who do not have a lot of hair in their donor
areas, those who are afraid of the surgical aspect of hair
transplantation and for those who do not want any surgical
scars in the donor areas. Due to the lack of cutting involved
with the FUE procedure, patients retain the option of wearing
step four: making small holes
74    SURGICAL TREATMENTS FOR HAIR LOSS


their hair very short without worrying about the appearance
of minor scarring.
       The grafts used in the FUE procedure are thinner than
the ones used in the strip technique. this is an additional
advantage because grafts can be placed closer together,
which means that more grafts can be implanted to maximize
the 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   75

step six: Allowing the grafts to settle

       the grafts are left to settle in their new places and
the scalp is allowed to heal for several months. During this
healing process, the skin closes around the grafts. the hair
from the transplanted grafts usually falls out as a result of the
shock of transplantation. However, after a few months the
roots of the hair usually recover and the hair re-grows.
76    SURGICAL TREATMENTS FOR HAIR LOSS


easily inserted amidst thinning hair to improve density
and they reduce the effect of shock, which causes hair
in the transplanted area to temporarily fall out after the
procedure.


then the skin with the hair follicles was removed and cut into
smaller hair grafts.

In the first operation 586 grafts from AA were transplanted
in FA and in the second operation 594 grafts from FA were
transplanted in AA. the transplants were performed on the
temples of both subjects, giving us a clear observation of hair
growth. Also, the identification of hair growth was facilitated
because AA’s hair was black and FA’s hair was brown.
postoperative hair growth was measured at 9 months and
at 14 months, and pictures were taken at different intervals
to monitor growth at various stages.

* pictures of AA and FA

Results: postoperative hair growth was measured at 9 months
and at 14 months. At 9 months, 45 of the 586 grafts on FA
were considered surviving grafts. The number of surviving
grafts was not determined on AA. At 14 months there were
no surviving grafts on FA.

* chart of results

Conclusion: This study shows that allo-hair transplants do
not work in the traditional format. However, there is reason
to believe that the hair itself is not antigenic but the tissue
surrounding the hair follicle is the reason why the hair
was unable to survive. It will be necessary to introduce
modifications to the method of transplantation to change
the structure of the surrounding skin so it does not reject
allo-transplanted hair follicles. if the antigenic nature of the
skin can be limited, this may present a new approach to the
surgical treatment of hair loss.
SURGICAL TREATMENTS FOR HAIR LOSS    77


harvesting the donor grafts follicular unit extraction   (fue)
78   SURGICAL TREATMENTS FOR HAIR LOSS



harvesting the donor grafts follicular unit extraction   (fue)
SURGICAL TREATMENTS FOR HAIR LOSS   79




Follicular 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    81



3 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 extracted
one-by-one and transplanted to the front of the patient’s
                          head.
84     SURGICAL TREATMENTS FOR HAIR LOSS


comparison of   fuss and fue methods

follicular 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   85

comparison of   fuss and fue methods
follicular 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 LOSS



comparing needles gauge for   fuss and fue
SURGICAL TREATMENTS FOR HAIR LOSS   87

comparing   fuss and fue grafts
88      SURGICAL TREATMENTS FOR HAIR LOSS


comparing 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      89

comparing 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 LOSS



GOALS OF HAIR TRANSpLANT SURGERy


natural appearance

     The artistry of hair transplantation begins with the proper
design of the frontal hairline. It is vital that the hairline be de-
signed to suit the patient’s face so that the transplant appears
natural and goes undetected to the casual observer.
     The hairline must be carefully placed in relation to the
rest of the face to ensure this natural appearance. Leonardo
Da Vinci’s formula for the face produces the best results for
this purpose. the formula is as follows: the distance from the
eyebrows to the hairline is half the distance from the eyebrows
to the bottom of the chin. By following this formula, each hair
transplant should be unique and suited to the patient. This
may be age-adjusted so that younger patients have lower
hairlines and older patients have slightly higher ones.
     A combination of follicular unit micro-grafting is the only
way to perform the precise manipulations needed to pro-
duce this natural-looking hairline. An irregular pattern of hair
distribution is created with a combination of one-, two- and
three-haired follicular units for a natural look. A soft frontal
zone is made with single-haired follicular units and then the
transition 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 be
properly designed. If transplantation is needed in the crown
area, the hairs should follow the natural swirling pattern char-
acteristic of this particular region. Also, the way the hairline
meets the temples requires correct angling and blending
into the rest of the hair behind the ears.
SURGICAL TREATMENTS FOR HAIR LOSS   91

hairlines
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          93

In the following cases you will see pictures of the restored
hairlines of middle-aged men. The hairlines are generally
higher and the temple angles remain open to better reflect the
age of the patients.




           BeFOre                   AFTer
94   SURGICAL TREATMENTS FOR HAIR LOSS




               BeFOre                    AFTer
SURGICAL TREATMENTS FOR HAIR LOSS      95




One 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 LOSS


Maximum density

     It is important that your hair transplant provide enough
density to cover the balding areas of your scalp. This should
be discussed in the initial consultation with your doctor as
your financial investment in your surgery is dependant on
this. the hair transplant surgeon can, and should, outline
the density you should be able to achieve with a certain
number of grafts.
     The average person, before the onset of balding occurs,
has 100 to 200 follicular units per square centimeter of the
scalp. For a hair transplant, a density of 50 to 80 follicular
units per square centimeter is optimal and is possible for an
experienced surgeon in a single session. Future sessions can
build on this density.
          Follicular unit extraction (FUE) has contributed
significantly to the achievement of greater density. By
extracting the follicular units one by one using the FUE
technique the grafts are thin enough to pack them in closer
together 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   97


natural density
98     SURGICAL TREATMENTS FOR HAIR LOSS


distribution of density




regions 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   99

the following pictures demonstrate density
in transplanted patients


                             BeFOre




              IMMedIATeLy AFTer grAFTIng
100     SURGICAL TREATMENTS FOR HAIR LOSS


the following pictures demonstrate density
in transplanted patients




          After transplant: 70 to 80 grafts per square cm
SURGICAL TREATMENTS FOR HAIR LOSS   101

the following pictures demonstrate density
in transplanted patients

                             BeFOre
102     SURGICAL TREATMENTS FOR HAIR LOSS


the following pictures demonstrate density
in transplanted patients

                             AFTer




           After transplant: 60 to 70 grafts per square cm
SURGICAL TREATMENTS FOR HAIR LOSS   103

the following pictures demonstrate density
in transplanted patients

                             BeFOre




           After transplant: 70 to 80 grafts per square cm


                             AFTer
104     SURGICAL TREATMENTS FOR HAIR LOSS


the following pictures demonstrate density
in transplanted patients

                            BeFOre




           After transplant: 50 to 60 grafts per square cm

                             AFTer
SURGICAL TREATMENTS FOR HAIR LOSS   105

the following pictures demonstrate density
in transplanted patients



                 BeFOre                      AFTer
106     SURGICAL TREATMENTS FOR HAIR LOSS


the following pictures demonstrate density
in transplanted patients


                              AFTer




         After transplant: 50 to 60 grafts per square cm

                              AFTer
SURGICAL TREATMENTS FOR HAIR LOSS   107

mega-sessions

       With new advances in hair transplantation, mega-
sessions are more common. these sessions allow for large
amounts of grafts to be transplanted in a single procedure.


world record: largest session done over two days
       Currently, the world record for the most amount of
grafts completed in one session over two consecutive days
is:


                     6, 298 grafts
             BeFOre                    AFTer
108     SURGICAL TREATMENTS FOR HAIR LOSS


world record: largest session done over two days

        Before and after pictures of the patient can be seen
in the previous two pictures. this patient wanted the whole
head covered at once from the front hairline to the crown.
The whole procedure turned out to be the largest session
ever done over two consecutive days.
        The results (also shown below) were exceptional
considering the high degree of difficulty associated with a
hair transplant session of this size. The patient was extremely
pleased with regaining his youthful look and achieving
excellent density. The growth in this patient was excellent,
with over 95 per cent of the follicular units transplanted
surviving.

             Age:                  33
             Profession:           Import/Export
             One Session:   6298 grafts


                  BeFOre             AFTer
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How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani
How to Beat Hair Loss By Dr. Antonio Armani

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How to Beat Hair Loss By Dr. Antonio Armani

  • 2. how to beat hair loss third edition Antonio 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
  • 3. © Copyright 1999 by antonio alvi armani, M.d. All rights reserved. Printed in Canada. No part of this book may be used or reproduced in any manner whatsoever without written permission except in the case of brief quotations embodied in articles and reviews. How to Beat Hair Loss does not offer medical ad- vice to replace the services of a physician or surgeon. The information provided here is collected from various sources and represents an effort to inform you about the options available to treat hair loss. It is intended to assist you to work with a trained medical and other hair care professionals. The author assumes no responsibility for us of information provided here or any other manner. For information address: redom books inc. 233 Carlton street toronto, ontario Canada M5a 2l2 telephone : (416)363-6655 1-800-365-6220 Fax : (416)363-1589 info@alviarmani.com ISBN 0-9683898-1-3
  • 4. about the author Dr. Antonio Alvi Armani has written this book as a source of 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 to research and development of new medical, surgical and alternative therapies for hair loss. His hair transplant practice and 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 member of the American Academy of Cosmetic Surgery, the Inter- national Society of Hair Restoration Surgery, member of the American 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 of Toronto, W.K. Mc Gillis Trophy, Gold Medallist, Yetive Heard Memorial Trophy and Steven Clarfield Trophy, Italian Soci- ety of Hair Restoration Surgery Award, Toronto Sun Read- ers Choice Award 2002, for Best Cosmetic Surgeon, XTRA Magazine Readers Choice Award 2002 for Best Cosmetic Surgeon. He has written articles and books on various aspects of hair loss, dieting, weight loss and fitness, and is conducting clini- cal research in the fields of hair transplantation and clon- ing of hair.
  • 5. to my patients who have allowed me to assist them
  • 6. Acknowledgments I owe gratitude to many people who along the way of my career have helped in supporting and guiding my work. I cannot possibly list all those who deserve credit but I must mention the names of a few that have been most instrumental in producing this book. I owe special gratitude to my main mentor in the field of hair loss Dr. Dow B. Stough Jr. Dr. Stough trained me in hair transplantation surgery and was the major influence in my development as a hair loss surgeon. Dr. Stough has produced a masterful reference book that have been a constant source of reliance to me. I thank him for this. I must also thank the following individuals who have provided technical assistance in the production of this book: Dr. Shaheen Azmi who edited it and helped to de- velop its design; Fernando Andrejin who photographed the pictures and was a constant source of technical assistance; and Alex Vasolla who drew its illustrations. Last but not least I must thank my parents and family members who have nurtured me and who have always been there to support me in my every venture.
  • 8. Table of Contents IntroductIon ........................................ 1 SectIon 1: KnowIng your type of haIr loSS ......... 5 chapter 1: genetIc haIr loSS ................................................ 6 chapter 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 ........................................34 SectIon 2: treatment for genetIc haIr loSS ....... 39 chapter 1: medIcal treatment ...................................... 41 a. rogaIne .............................................................................41 b. propecIa .............................................................................44 c. comparIng rogaIne and propecIa .........................................47 d. other emergIng drugS ..........................................................52 chapter 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
  • 9. 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 ...........................................182 chapter 3: alternatIve treatmentS ............................... 192 chapter 4: haIr replacement treatment .......................... 200 SectIon 3: about your haIr......................... xx chapter 1: anatomy of the haIr and haIr follIcle .................. xx chapter 2: ruleS for good haIr care .................................... xx a fInal recommendatIon ....................xx appendIx a: Sample conSent form ..........................xx appendIx b: Sample pre-operatIve InStructIonS ........xx appendIx c: Sample poSt-operatIve InStructIonS ......xx gloSSary .........................................xx Index ...............................................xx
  • 10. KNOWING YOUR TYPE OF HAIR LOSS 5 1 knowing your type of hair loss 1. genetic hair loss ................................ 6 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 .............................. 34
  • 11. 6 KNOWING YOUR TYPE OF HAIR LOSS The first thing everybody with hair loss must know is what type of hair loss they have. Some people suffer from certain types of hair loss that are temporary, which may result from a variety of causes. While these may be very stressful, many of these ailments can be corrected without resorting to major treatments. On the other hand, most men and women who suffer from hair loss are predisposed to genetic pattern hair loss. This type of hair loss is hereditary and progressive. Many people who suffer from this turn to medical, surgical and alternative treatments to combat their hair loss. In this chapter, you will learn about the different types of hair loss so that you may classify your own type and begin the 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 your professional by providing accurate and relevant information about your hair loss based on the information that you find here. NOrMal haIr lOSS Normally, each person will have around 100, 000 hairs on his or her scalp at any given time. Some of these hairs routinely take a rest from growing every few years and eventually fall out. These same hairs re-grow from their roots. as a result, the average person can expect to shed 50 to 100 hairs everyday. however, this type of normal hair loss should be spread out over the whole head and should not result in any balding or excessive thinning of hair on any particular part of the scalp. aBNOrMal haIr lOSS abnormal hair loss is the falling out of excessive hair that leads to unusual thinning or balding at specific spots on the head, which is probably the type of hair loss you are experiencing. Medical professionals call abnormal hair loss alopecia. alopecia can be caused by many factors but the
  • 12. KNOWING YOUR TYPE OF HAIR LOSS 7 most common factor is your own genes, meaning that you inherit the tendency to lose your hair. This type of alopecia affects over 95 per cent of all cases of balding or thinning hair for both men and women. This type of genetic hair loss is given many names, including “male pattern baldness” or “female pattern baldness” because of the consistent pattern that the hair loss tends to follow in both men and women. Its medical term is “androgenic alopecia” because it is believed that hereditary hair loss is associated with changes in the amount 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 does not suggest that it only applies to one sex or the other. It is important to remember that your hair loss may be the result of a combination of factors. Other factors may speed up or increase your hereditary balding. Keep this in mind because it is a major error that many people make when determining their own type of hair loss and responding to it. That being said, since hereditary balding is the most common type of hair loss, I will be discussing it first, followed by a brief discussion of the other types of abnormal hair loss. ChaPTEr 1: GENETIC haIr lOSS hOW COMMON IS IT? Genetic hair loss affects almost 50 per cent of all males and almost 40 per cent of all females as they age. This means that if people lived long enough, almost half of the population would show significant hair thinning or balding. Some ethnicities are more affected than others are. People with European origins show more hereditary tendency to hair loss than other ethnicities, though other groups are affected to a degree as well.
  • 13. 8 KNOWING YOUR TYPE OF HAIR LOSS HOW dOES IT OCCur aNd CaN IT BE CurEd? like so many ailments that afflict us, medical professionals are not certain as to what directly causes genetic hair loss. It is something that is programmed into your genes, but what causes the genes to act and what they cause your body to do, it not entirely known. as a result, there is no sure, full-proof cure for this kind of hair loss that we know of. researchers have different theories about the way genetic hair loss works and they are working on various possible solutions based on these clues. The most common explanation for how genetic hair loss works suggests that it works through a complicated chemical process operating in your body. Most researchers associate it with the chemical changes that occur with the male hormone testosterone as you age. Both men and women have this male hormone but the level of testosterone is different for the sexes and changes with aging. There are also other chemicals, which react with testosterone, that change as you age and may influence hair loss. Because most researchers believe that genetic hair loss is caused by chemical reactions in your body, most of the research being done in the field has focused on finding chemicals that can reverse the chemical causes of genetic hair loss, and then forming them into medical drugs suitable for usage. recent discoveries have found that an enzyme called “5-alpha reductase” is excessively produced by the hair follicles of people with genetic hair loss. The enzyme combines with testosterone, one of the male hormones present in both men and women, to form a new chemical called “dihydrotestosterone” (dhT), which is known to cause hair to fall out. This chain of chemical reactions is one among many possible chemical chains that researchers are currently investigating in relation to genetic hair loss. In the last few years, researchers have been working on many different drugs for combating genetic hair loss, but so far only two have shown success in doing so. This first drug is called minoxidil, and it is currently being marketed by the
  • 14. KNOWING YOUR TYPE OF HAIR LOSS 9 upjohn Company under the name rogaine as a topical solution for both men and women. The second drug is called finasteride, and it is currently being marketed by Merck & Co. under the name Propecia in a tablet form for men only. The advantages and drawbacks of both these drugs, along with other drugs that are being tested and that show promise, will be outlined later in the chapter on medical treatments for hair loss. WhaT dOES IT lOOK lIKE? Males with genetic hair loss often become at least partially bald and the hair loss follows particular patterns. The most common pattern of genetic hair loss for men is characterized by a thinning of hair at the hairline and/or the crown area. Over time, the thinning expands, receding from the hairline and in a circular fashion from the crown, until the two areas of baldness meet in the middle. The final result is a completely bald scalp except for a strip of hair along the back of the head above the nape of the neck. Though this is the most common pattern that male pattern baldness follows, there are many other variations as well. Norwood’s classification describes this most common pattern but it is somewhat limited in addressing the other possibilities, including the one that applies to women. In the following section, I will outline the new patterns of genetic hair loss that have been identified, giving you a better understanding of the variety of ways in which genetic hair loss occurs. Norwood’s classification has been used to classify male pattern hair loss for many decades and has been useful in many cases. however, it is not complete. Norwood’s classification only describes one pattern of male genetic hair loss on a scale of seven degrees of severity. Therefore, a reclassification of genetic pattern hair loss is necessary to account for the other possible patterns of male and female genetic hair loss.
  • 15. 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
  • 16. KNOWING YOUR TYPE OF HAIR LOSS 11 Another depiction of the progression of genetic pattern hair loss according to Norwood’s classification 1 2 3 3 Vertex 4 5 6 7
  • 17. 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
  • 18. KNOWING YOUR TYPE OF HAIR LOSS 13 Progression of hair loss for women according to Ludwig’s classification
  • 19. 14 KNOWING YOUR TYPE OF HAIR LOSS drug-related hair loss Many prescription drugs can cause varying degrees of hair loss for some people. It is likely that you have seen cancer patients who have lost hair after undergoing chemotherapy. 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
  • 20. KNOWING YOUR TYPE OF HAIR LOSS 15 cause hair loss. In addition, close to 300 more commonly employed 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
  • 21. 16 KNOWING YOUR TYPE OF HAIR LOSS New classification of genetic hair loss: Pattern 1 Examples of pattern 1 genetic hair loss Norwood’s traditional pattern where hair loss progresses from the back and the front, and meets in the middle.
  • 22. KNOWING YOUR TYPE OF HAIR LOSS 17 New classification of genetic hair loss: Pattern 2 Examples of pattern 2 genetic hair loss hair loss progresses only from the front hairline and recedes backwards while maintaining the crown area. hair loss occurs mainly in the crown area and moves forward.
  • 23. 18 KNOWING YOUR TYPE OF HAIR LOSS New classification of genetic hair loss: Pattern 3 Examples of pattern 3 genetic hair loss The frontal hairline remains intact. “ludwig’s Pattern of hair loss” – Commonly seen in female
  • 24. KNOWING YOUR TYPE OF HAIR LOSS 19 New classification of genetic hair loss: Pattern 4 pattern hair loss, though it occurs in men as well. hair loss starts 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
  • 25. 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
  • 26. KNOWING YOUR TYPE OF HAIR LOSS 21 New classification of genetic hair loss: Pattern 5 Examples of pattern 5 genetic hair loss from the Mediterranean and the Middle East, although it does occur in other ethnic groups as well. hair loss begins at the two temples and moves in a circular pattern backwards, leaving a small forelock of hair at the frontal hairline.
  • 27. 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.
  • 28. KNOWING YOUR TYPE OF HAIR LOSS 23 FemALe ANdRoGeNIC ALoPeCIA (FAGA) As has already been discussed, women can suffer from genetic pattern hair loss just like men do and both forms of genetic hair loss are caused by similar chemical factors. The difference is that it is much less common for women than it is for men, and the hair loss follows a different pattern. Women with female genetic hair loss tend to experience a progressive thinning of the scalp hair only around the crown area. It is also usually more diffuse and central than male genetic hair loss; and it is often referred to as a ‘widened part’. Less commonly, women may have a receding hairline similar to that seen in balding men. It is unlikely that female genetic hair loss will result in total baldness, though it does occur. Aside from female genetic hair loss, there are other ways that women may suffer from hair loss that will be discussed in the next chapter. Female pattern baldness frontal view Female pattern baldness top view
  • 29. 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.
  • 30. KNOWING YOUR TYPE OF HAIR LOSS 25 Chapter 2: OThEr TYPES Of aBNOrMal haIr lOSS hair loss can be triggered by many factors other than genetic predisposition. While these other types of hair loss only make up five per cent of abnormal hair loss cases, they can be more severe in their effects. however, the good news is that these other types outlined below are almost always temporary or are often treatable. I will briefly discuss each of these common types of hair loss as well as the main treatments usually given for them. dIET-rElaTEd haIr lOSS Protein: There are a number of nutritional deficiencies that can cause hair loss by altering your hair’s structure or hair cycles. among these, protein deficiency is one of the most common. Your hair is composed mostly of proteins, the same materials that your nails are composed of. If your food does not provide you with enough protein then both your nails and your hair may be negatively affected. Protein is found in common foods like meats, poultry, fish, beans and dairy products. If a protein-deficient diet persists then your hair will go into a premature resting stage and will start to fall out within a few months. unfortunately, many people simply do not eat well, or they become caught up in some fad diet. The kinds of things to watch out for are poor eating habits that lack in protein, vegetarian diets, or fad diets that restrict the amount of protein you consume. Iron: another possible cause of diet-related hair loss is a low level of iron in your blood, which might result from an inadequate amount of iron in your diet. foods that are common 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 result from some difficulty your body has in absorbing iron, which is commonly linked with the condition anemia.
  • 31. 26 KNOWING YOUR TYPE OF HAIR LOSS Vitamin A: another nutrient that can affect your hair is vitamin a, which can be found in whole eggs, milk and liver. Both an inadequate and an excessive amount of vitamin a can cause hair loss. Too little of this vitamin can result in a condition called hyperkeratosis. It occurs in your hair follicles and in the sebaceous glands (the small glands in your skin that secrete oil into your hair) and it can complicate hair growth. Conversely, too much vitamin a can prevent proper keratinisation (the process by which a protein called keratin builds your hair and nails), resulting in a kind of hair loss referred to as ‘toxic alopecia’. Other nutritional deficiencies that can affect your hair growth include deficiencies of: essential fatty acids, zinc, copper and vitamin C. fortunately, the damage done to hair by this type of diet-related hair loss is only temporary and can be corrected by simply improving your diet. Your dietary history is one of the first things a medical doctor who specializes in skin and hair would ask when assessing your hair loss problem. Before considering anything else, you should assess your own diet in relation to any hair loss problems you may be experiencing. druG-rElaTEd haIr lOSS Many prescription drugs can cause varying degrees of hair loss for some people. It is likely that you have seen cancer patients 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 to be associated with hair loss. drugs commonly associated with hair loss:  Birth control pills  heart disease and high blood pressure pills, especially beta blockers and ace inhibitors, like captopril  Blood thinners, like heparin  drugs for gout and arthritis, like allopurinol
  • 32. 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, like isotretinoin  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, in addition to your dietary history, before diagnosing hair loss problems. Even drugs that are not currently associated with hair loss may cause you to lose hair, so you should take your drug consumption history into consideration no matter what. fortunately, drug-related hair loss is easily treated by simply 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 not cause you to lose your hair. dISEaSE-rElaTEd haIr lOSS There are dozens of diseases and conditions that can result in some type of hair loss. In this section, I will outline the major classes of diseases that cause hair loss, the kind of hair loss that they cause and possible treatments that are available. Since so many common ailments and conditions can cause you to lose hair, your recent and long-term health
  • 33. 28 KNOWING YOUR TYPE OF HAIR LOSS history is one of the first things a medical doctor would question when assessing a case of hair loss. You should also question your own medical history to determine if disease is a factor in your own hair loss. Skin diseases of the scalp There are a number of different conditions that can affect the scalp and cause varying degrees and types of hair loss. These include: infections like syphilis and ringworm; infestations like pediculosis, which is caused by lice; inflammatory diseases like folliculitis; genetic diseases like darier’s disease and other syndromes of the skin like psoriasis. The hair loss in each case is usually only partial and can be treated. Ringworm: ringworm is a contagious disease that is caused by the infection of fungus. It results in small, scaly patches on the skin and, when it occurs on the scalp, is also followed by a loss of hair. It can be treated effectively with a topical solution. Darier’s disease: darier’s disease is a genetic disorder characterized by dark, crusty patches on the skin, sometimes containing pus, which results in the hair becoming rough and dry with patches of baldness. Psoriasis: Psoriasis is a chronic skin disease characterized by scaling and inflammation. It is a disorder of the immune system that occurs when cells in the outer layer of the skin reproduce faster than normal and pile up on the skin’s surface. The hair loss is reversible with treatment. Telogenic and anagenic alopecias To understand this type of hair loss, you first need to be familiarized with the hair growth cycle. all human hairs go through a natural cycle beginning with growth, called the anagen phase, followed by a period of rest, called the
  • 34. KNOWING YOUR TYPE OF HAIR LOSS 29 telogen phase, and ending with the hair falling out. When only the hairs that belong in a particular phase fall out, we call this either anagenic alopecia or telogenic alopecia. dozens of factors can cause either of these alopecias, including stress, chronic diseases and nutritional deficiencies. Many of these different factors send anagen hairs prematurely into the resting stage and result in excessive shedding months after. This is called telogenic alopecia. In this section we will discuss some of the more common telogenic and anagenic syndromes. Loose anagen syndrome: This condition generally affects young, Caucasian blonde girls, although anyone is susceptible. The characterizing symptom is the ability of anagen hairs (hairs that are in the anagen, or growth, stage of the hair cycle) to be pulled out easily and painlessly. In children ages 2 to 5 years with loose anagen syndrome, the hair is usually unable to grow past the ears, though the density is otherwise unremarkable and the hair is not particularly fragile otherwise. Treatment is usually unnecessary because although loose anagen hair grows slowly, it does grow and if it is accidentally pulled out, it grows back quickly. Pregnancy and childbirth: The stress of childbirth, similar to that of a severe fever or chronic illness, can prematurely push anagen hairs into the resting stage, resulting in excessive shedding some months later. hormonal changes that occur during 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 healthy people with good eating habits, no notable diseases or injuries to the scalp that can explain such a loss of hair. When this occurs, it is referred to as ‘alopecia areata’. This unpredictable but common disease affects 1.7 per cent of the world’s population. although it can affect men and women of all ages, onset most often begins in childhood. In most cases, the hair falls out in round patches all over the
  • 35. 30 KNOWING YOUR TYPE OF HAIR LOSS scalp and body. In some extreme and rare cases, the hair loss may lead to a complete loss of hair all over the head and body. alopecia areata that causes complete hair loss of the scalp is called ‘alopecia totalis’ and when it causes hair loss over the whole body it is called ‘alopecia universalis’. It is believed that alopecia areata is caused by the immune system unexpectedly, and usually temporarily, attacking the hair follicles, causing them to fall out and preventing re-growth in some cases. however, it is not known why this occurs. Cases of alopecia areata usually disappear on their own 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 that interfere with the immune system) have been found to be effective in combating alopecia areata. although alopecia areata is not life threatening, it is so dramatic in its effects that it often damages the mental and emotional states of its victims. for this reason, many support groups have been established to help people cope with alopecia areata. You can find a local support group in most countries around the world by contacting the National alopecia areata foundation via their website at www. alopeciaareata.com. Thyroid diseases Your thyroid gland resides in your neck and is responsible for producing hormones that are involved in many 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 of hormones. When this occurs, there is a slight shedding of the hair on the scalp, and possibly of the armpits and pubic area. an under-active thyroid gland may become enlarged due to a bombardment of thyroid-stimulating-hormones (TSh) produced by the pituitary gland, which occurs in order to
  • 36. KNOWING YOUR TYPE OF HAIR LOSS 31 entice the thyroid to produce more hormones. The result is the creation of ‘goiter’. The most common cause of hypothyroidism is a previous (or ongoing) inflammation of the thyroid gland that leaves a large percentage of the gland’s cells damaged or dead. This kind of inflammation is most likely the result of autoimmune thyroiditis, which is caused by the patient’s own immune system. hypothyroidism may also be caused by certain medical treatments that, indirectly or directly, affect the thyroid gland. The hair loss that results from thyroid disease can be reversed by treating the condition that is affecting the thyroid gland. There are many other symptoms of thyroid disease, including fatigue, weakness, weight gain, dry skin, intolerance to the cold, constipation, memory loss, muscle aches and/or depression. The proper functioning of your thyroid gland is very important and is worth seeing a medical doctor if you think you may be experiencing some or all of these symptoms. Psychiatric and psychological diseases The most common type of psychological condition that can cause hair loss is stress. Excessive stress can cause telogenic alopecia, which is described above. Anorexia nervosa: anorexia nervosa occurs when someone restricts their diet to such a degree that there are nutritional, endocrinal and psychological impairments. The hypocaloric diet (meaning there is an insufficient amount of calories being ingested) may result in a loss of hair. This may also be accompanied by an increase in lanugo (the fine, light hairs that cover the body) on the face, trunk and arms. Cancer-related hair loss Neoplasic alopecias: This term refers to hair loss that results from cancer spreading from one area of the body to the scalp. The word ‘neoplasic’ comes from the word ‘neoplasm’, which means ‘tumor’.
  • 37. 32 KNOWING YOUR TYPE OF HAIR LOSS The susceptibility of the scalp to neoplasic alopecia is higher for women with breast cancer and for men with lung cancer in particular, as opposed to other types of cancer. It is believed that mucines, a certain kind of protein created by breast and lung carcinoma, degenerate the cells of the outer root sheath of the hair follicle. however, not all cases of breast or lung cancer will cause hair loss. Ovarian and adrenal tumors are also likely to cause hair loss. Both types of tumors can cause hyperandrogenism, which is the excessive production of androgens (male hormones). androgens are known to play a key role in male and female pattern baldness. Once the tumor has been removed, however, the hair loss should go away. Cancer-fighting drugs: Most cancer-fighting drugs, like chemotherapy, attack the body, including the hair follicles, and cause considerable hair loss. The hair should grow back after the treatment has stopped. Saha syndrome Saha syndrome is a skin condition that only affects women and is caused by hyperandrogenism, which is the excessive production of male hormones (androgens) and which occurs in the whole body (cases of hyperandrogenism affecting only particular parts of the body are considered different conditions). The four main symptoms of this syndrome make up the acronym ‘Saha’: seborrhea, acne, hirsutism and alopecia. These four manifestations appear in this order, although not all women suffer from all of them. all sufferers of Saha syndrome do experience seborrhea, however. Seborrhea is a skin condition characterized by inflammation, dry or oily scaling, crustiness and/or itching. It is 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 part of the condition because the increased sebum production that causes acne in this case is caused by androgenic action. hirsutism, the third symptom, is the excessive growth
  • 38. KNOWING YOUR TYPE OF HAIR LOSS 33 of male-pattern hair in women, also caused by an increase in androgens. The hair loss that accompanies Saha syndrome is also caused by excessive amounts of androgens and results in typical female pattern baldness. a uniform clearing of the scalp of the crown occurs, though total alopecia is unlikely and the frontal hairline remains intact. Treatment of Saha syndrome includes several drug options, 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 as simple as physical stress being put on the hair, the destruction of the hair follicles themselves or excessive amounts of hair being pulled out of the scalp. In these cases, we say that the hair loss is due to ‘external injuries to the scalp’ as opposed to a skin disease or disorder. Cicatricial alopecias hair loss may occur due to the destruction of the hair follicle. In this case, the skin of the scalp is somewhat like scar tissue and is therefore unable to produce hair, meaning that the hair loss is permanent and the only option is surgical treatment. This destruction of the hair follicles can result from mechanical, physical or chemical trauma (which may include the use of acids, chronic traction, electrical or thermal burns, or freezing), as well as tumors, special skin diseases or severe infections such as syphilis. The destroyed hair follicles may not necessarily cover the entire scalp, depending on the method and type of damage. again, the only option for this kind of hair loss is surgical treatment. Trichotillomania hair loss among children can occur as a result of
  • 39. 34 KNOWING YOUR TYPE OF HAIR LOSS a usually unrecognized behavioral disorder known as trichotillomania. It is characterized by uncontrollable hair pulling, similar to impulsive disorders such as pyromania or kleptomania. The disorder usually appears in males at the age of 8 and in females at the age of 12 and has a prevalence of about one per cent. Sufferers of trichotillomania generally spend about one hour per day pulling their hair out. This can last for a few seconds or minutes, or it may last for prolonged periods of time. Some may try to resist the urge, while some are unaware of its occurrence, pulling hair absent-mindedly while driving, reading or watching television. While the disorder itself is a stressful condition, the hair loss that results is an unfortunate additional complication that affects many children and teenagers psychologically and emotionally. The hair loss that occurs is usually focused on the scalp, but it may also occur among the eyebrows, eyelashes and pubic region. hair loss is usually patchy, irregularly- shaped and occurs most often on the side of the body that coincides with the person’s predominant hand. Most sufferers of trichotillomania are likely to feel embarrassed about the disorder and may try to hide their hair loss, prolonging diagnosis and complicating treatment. Treatment for trichotillomania involves behavioral therapy and/or medication. Possible drugs include mood stabilizers, anxiolytics (drugs that work on the central nervous system to relieve anxiety), neuroleptics (also known as antipsychotics) and topical agents including steroids. however, behavioral therapy has been found to be more effective than drug therapy, especially if the hair pulling has only been occurring for less than 6 months and because there are no clear guidelines for how drugs should be used to treat trichotillomania. With therapy, sufferers of trichotillomania can overcome this disorder and resume their normal lives without 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.
  • 40. KNOWING YOUR TYPE OF HAIR LOSS 35 unfortunately, there are many styling habits and treatments that are bad for the overall health of your hair and that promote hair loss. hairstyles that require unusual pulling, dying or conditioning may severely stress the natural workings of your hair and may lead to unusual balding. When a high degree of physical stress is constantly being put on the hair for styling purposes, hair loss may occur. This condition is referred to as ‘cosmetic alopecia’. It is usually caused by the constant use of curlers, brushes and other tools used to style hair as well as hairstyles that pull the hair. The alopecia appears as a slight shedding of the hair and occurs because the strain that the hair is put under leads to reduced blood flow in the capillaries at the bottom of the hair follicles. The hair’s growth is stunted and eventually leads to a slight loss of hair a few months later. This usually affects the triangular areas above and in front of the ears, though it is dependant on the direction in which the hairstyle is aimed. It is also possible to damage the hair follicles and/ or the scalp itself with the constant use of chemicals used to curl or dye the hair. In most cases of cosmetic alopecia, the reduced blood flow that causes the hair loss disappears after the pressure is removed, although the shedding may take a few months to return back to normal.
  • 41. 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.
  • 42. KNOWING YOUR TYPE OF HAIR LOSS 37 Julia B. : Losing hair because of Hypothyroidism Age: 27 Occupation: Homemaker Julia B. went to a clinic complaining of fatigue, increase in weight, and sparse hair on the scalp and on the eyebrows. She was not taking any medications. Julia had no family history of hair loss. Physical examination showed dry skin, diffuse hair 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 the thyroid gland). often such a condition causes the unusual loss of hair not only on the scalp but on other parts of the body. Julia was started on a thyroid replacement medication. In six months not only was her hair restored to normal, but Julia found herself less fatigued and in better overall health.
  • 43. 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.
  • 44. KNOWING YOUR TYPE OF HAIR LOSS 39 Many people with other types of hair loss aggravate their situation by poor hair care habits. for example, there are many genetically balding people who are losing more hair than they should be and at a faster rate because of poor hair care habits. In these cases, people can forestall the appearance of baldness for years by maintaining good hair care. You can learn how to properly take care of your hair and prevent, or forestall, the appearance of balding later in this book in the section regarding ‘rules for good hair care’.
  • 45. 2 treatment options for hair loss 1. medical treatment ...........................41 a. rogaine (minoxidil) ................................................... 41 b. propecia (finasteride) ................................................ 44 c. comparing rogaine and propecia ............................. 47 d. other emerging drugs ............................................... 52 2. 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 ................................ 182 3. alternative treatment ....................192 4. hair replacement treatment ............200 39
  • 46. 40 DRUG TREATMENTS FOR HAIR LOSS Over 90 per cent of all hair loss cases fall under the category of genetic hair loss. For this reason, all the treatment options discussed in this section, with the exception of hair replacement therapy, are meant only for the treatment of genetic hair loss. For all other types of hair loss, you should contact a qualified medical doctor to discuss treatment options. And while this section is meant to guide you in treating your hair loss, you should always contact a medical doctor before beginning any treatment program.
  • 47. 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, has long been the dream of people suffering from this type of hair loss. But until recently this hope has been nothing but a dream. During the last couple of decades researchers have been developing two drugs that have proven effective in combating genetic hair loss. First the drug minoxidil, which is now marketed as Rogaine, was approved by the Food and Drug Administration and later on the drug finasteride, which is now marketed as Propecia, was also approved for use in fighting genetic hair loss. There are also many other drugs and combinations of drugs that are now being tested and which may be available in the coming few years. It should be noted, however, that there is always the risk of side effects with any medications. Also, it takes decades to completely understand the full effects of any drug and many of these drugs have not been around long enough to determine these full effects. RogAIne (mInoxIDIl) Rogaine was introduced as a new drug for promoting hair growth by the Upjohn Company in 1988. It is sold as a topical solution, which means that it is a rubbing solution meant for the balding areas of your scalp. It comes in either a 2 per cent or a 5 per cent solution depending on how much
  • 48. 42 DRUG TREATMENTS FOR HAIR LOSS minoxidil the solution contains. Rogaine is available over the counter and should be applied on the balding area(s) twice a day, every day. How does Rogaine work? Although there is only a small percentage of minoxidil in Rogaine, it is this drug that makes it work. minoxidil is known as a hair growth stimulator. It was originally marketed in a tablet form for the treatment of high blood pressure and unwanted 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 recognizes that Rogaine works, it is well known that it doesn’t work for everyone. Recent studies show that when the 2 per cent solution is used properly, it can stimulate hair growth 30 per cent of the time, with a slightly higher rate in females. And the new 5 per cent solution has shown only slightly more success than the weaker solution. Rogaine is most effective when used at the first signs of balding and in relatively small areas of hair loss. It is also more effective in the center of the scalp than on the frontal hairline. Rogaine can inhibit further hair loss and can be used to supplement hair transplantation. It should be noted, however, that if you stop using Rogaine you will lose any hair re-grown while you were using it. This means that once you start using Rogaine, you must continue to use it for the rest of your life to enjoy its benefits. Are there any side effects to using Rogaine? every drug has some side effects. In the case of Rogaine the drug that makes it work, minoxidil, has a dangerous effect on the body (and the heart in particular) if
  • 49. DRUG TREATMENTS FOR HAIR LOSS 43 taken orally. When it is diluted in a solution for topical use, as it is in Rogaine, the side effects are less severe because the amount of minoxidil entering the body is much less. However, even in small doses the use of minoxidil does have some minor and major side effects that should be noted. Minor side effects: These include skin irritations on the scalp such as dry red skin, flaking and itching; nausea and vomiting; and diarrhea. These are short-term, temporary side effects that should go away when your body adjusts to the use of Rogaine. Major side effects: These include back and chest pain; cold-like symptoms; rapid heartbeat; fluid retention; difficulty breathing; weight gain; worsening of hair loss. These are very rare, extreme side effects that are similar to the effects of minoxidil taken orally. Also, Rogaine is not safe for people who: Show allergic reactions to minoxidil; have heart disease; have high or low blood pressure; have skin diseases like dermatitis; are pregnant; or who are nursing mothers. What improvements can we expect in the near future? The most likely advancements in the use of Rogaine will come from two different approaches: Increasing the amount of minoxidil: like the addition of the 5 per cent solution to the 2 per cent solution, researchers have been trying to improve the effectiveness of Rogaine by increasing the amount of minoxidil in the solution. Increasing the ability of minoxidil to enter the skin: Researchers have also been trying to make Rogaine more effective by increasing the ability of the minoxidil in the solution to enter the skin and cause hair growth. Tests have shown that if
  • 50. 44 DRUG TREATMENTS FOR HAIR LOSS minoxidil is mixed with certain other substances it may be able to enter into the skin better and cause more effective hair growth. Final recommendations for Rogaine only use Rogaine if your health is good, if you are willing to test how it works for more than one year while accepting the possibility of failure, if you are disciplined in taking medications and following detailed instructions, and if you are prepared and able to pay to use Rogaine for the rest of your life. PRoPeCIA (FInASTeRIDe) In late 1997, the Food and Drug Administration approved Propecia for distribution in the United States as a hair-restoring drug. It is sold by the company merck in 1 mg pill form by prescription only. It is the first pill that effectively treats genetic hair loss. The active agent in Propecia is a drug called finasteride. It was originally used in a prostate medication called Proscar that was found to grow hair. Propecia is a lower-dose form of Proscar developed specifically to fight hair loss. one of the main differences between Rogaine and Propecia is that Propecia should only be used by men. It is dangerous for women of childbearing age and can cause severe birth defects in women that have handled Propecia in any way. Possible dangers aside, Propecia does not work for any women of any age. How does Propecia work? Finasteride is the active agent in Propecia. It works by manipulating the underlying chemical causes of genetic hair loss. We know that men with genetic hair loss have increased levels of a hormone called dihydrotestosterone
  • 51. DRUG TREATMENTS FOR HAIR LOSS 45 (DHT) in their scalps and it is believed that the presence of DHT in the scalp is related to the thinning of hair follicles and the resulting genetic hair loss. DHT is a by-product of the male hormone testosterone, which is converted to DHT when it reacts with a natural enzyme that is found in human skin cells called 5 alpha-reductase (5AR). Propecia does not directly counteract DHT itself, but rather blocks the action of 5AR to indirectly 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 not as successful in stimulating new growth. Studies suggest that about 80 per cent of balding men can stop any further hair loss by taking Propecia. In addition, two out of three men may see some re-growth of hair. However, Propecia only works for men who have mild to moderate hair loss. Balding men with major or complete hair loss will not benefit from Propecia. Like Rogaine, Propecia is more effective in the center of the scalp and less so along the frontal hairline. Propecia must be taken for at least three months before seeing any results. Because hair generally grows at a rate of about ½ an inch per month, it usually takes between three to six months to see the full effects of Propecia. If there is no significant growth after 12 months it is unlikely that Propecia will ever work. Also like Rogaine, Propecia is effective only for as long as it is taken. This means that all benefits of using Propecia will be lost if you ever stop using it. Are there any side effects to using Propecia? Contrary to the dangerous effects that Propecia has on women, it is generally well-tolerated by men. The Food and Drug Administration described Propecia as having only infrequent side effects that affected only a small number of men.
  • 52. 46 DRUG TREATMENTS FOR HAIR LOSS General side effects: These include allergic reactions such as rash, hives, itching and swelling of the lips and face; breast tenderness and enlargement; and testicular pain. Sexual side effects: Less desire for sex, difficulty in achieving an erection; decrease in the amount of semen; and problems with ejaculation. These side effects occurred in less than 2 per cent of men and were only temporary. Some men in particular should not take Propecia. These include men who have allergies to finasteride or a related drug or who have liver function abnormalities. men for whom the noted side effects are unusually severe or long- lasting should only continue using it with caution and under the direct guidance of a medical doctor. As has already been mentioned, Propecia is also not safe for women and may cause severe birth defects. Women should not even handle broken or crushed tablets, although all Propecia tablets have a protective coating when intact. Also, men taking Propecia pose no danger to women or their fetuses. Although there are no known dangers in mixing Propecia with other drugs, the use of this drug has been linked to decreases in levels of prostate-specific antigen (PSA). Though this decrease is insignificant in itself, PSA levels are often measured for diagnostic reasons in the case of men suspected of prostate cancer or other prostate problems. Because of this, all patients taking Propecia, especially those with prostate illnesses of any kind, should inform their doctors of 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 obtaining greater results from its use. Using Propecia as a topical solution: one approach has been
  • 53. DRUG TREATMENTS FOR HAIR LOSS 47 to formulate finasteride as a topical solution, like Rogaine. This approach is more common outside of the United States, but some American companies are already selling finasteride in this form. At this point, however, a topical form of finasteride remains experimental as there have been no clinical studies that have shown the effectiveness of a finasteride topical solution. Combining Propecia with Rogaine: It is believed by some that Rogaine and Propecia can complement each other by combining Rogaine’s ability to stimulate new growth with Propecia’s ability to prevent further hair loss. This, however, is a relatively new approach and little has been done in the way 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
  • 54. 48 DRUG TREATMENTS FOR HAIR LOSS COmpAring 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
  • 55. DRUG TREATMENTS FOR HAIR LOSS 49 examples of crownal hair loss helped by propecia
  • 56. 50 DRUG TREATMENTS FOR HAIR LOSS examples of crownal hair loss helped by propecia
  • 57. DRUG TREATMENTS FOR HAIR LOSS 51 Anterior mid-scalp hair loss helped by propecia
  • 58. 52 DRUG TREATMENTS FOR HAIR LOSS oTHeR emeRgIng HAIR gRoWTH DRUgS Although Rogaine and Propecia are the only two drugs currently approved by the Food and Drug Administration to combat genetic hair loss, there are several other drugs that have shown great promise in restoring hair loss. These are not likely to be miracle cures but they may be more effective 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 available besides Rogaine and Propecia. All of these drugs are still being tested and some are being seriously investigated by large pharmaceutical companies that are investing millions of dollars to make them work. Dutasteride Dutasteride is another 5 alpha reductase inhibitor like the finasteride used in Propecia but it is currently being marketed as Avodart for the treatment of benign prostatic hyperplasia. Researchers are trying to formulate a form of dutasteride that can be used for the treatment of genetic hair loss. Like finasteride, it will likely have side effects on male sexual functioning. Antiandrogens Antiandrogens are drugs that prevent androgens (male hormones) from working. These drugs have shown the most promise in being able to provide a cure for genetic hair loss, as androgens are known to play a key role in causing this kind of hair loss. Antiandrogens are used to treat many different ailments and one of the side effects commonly seen during their usage has been the stimulation of hair growth all over the body. Because male hormones are important to the proper functioning of many male bodily functions, possible side effects of using antiandrogens include impairment to male
  • 59. DRUG TREATMENTS FOR HAIR LOSS 53 physical characteristics and sexual desire and potency. Work has been done to develop antiandrogens that are safe for men to use to combat hair loss while avoiding the unwanted side effects. Finasteride, the drug in Propecia, is an example of one such drug because it does not directly inhibit male hormones but rather inhibits an enzyme that interacts with male hormones. Because antiandrogens target male hormones, antiandrogens are generally safer for women. Since women are less damaged by the side effects of antiandrogens they are more effectively treated by them. In europe, antiandrogens have been officially used to treat genetic hair loss in women for years. one of the two drugs approved by the Food and Drug Administration for the treatment of genetic hair loss is Rogaine, whose active agent minoxidil is not an antiandrogen. So it would not be surprising to discover that the most effective drug treatment for genetic hair loss might emerge from a type of drug that is also not an antiandrogen. outside of the antiandrogens, there have been several drugs that have shown some promise as a treatment for genetic hair loss. The most prominent of these that are currently being developed and tested include the drugs listed below. look for these drugs to emerge in the near future to complement Rogaine as a drug treatment for genetic hair loss. Tricomin The American pharmaceutical company ProCyte is testing this drug in France. It has shown some effectiveness in increasing new hair growth by 40 per cent for three out of four of the balding men who used it in testing. Tricomin is a compound chemical that helps restore the health of skin tissue. The compound drug is applied on the skin like Rogaine and is believed to restore a healthy skin base for new hair to grow.
  • 60. 54 DRUG TREATMENTS FOR HAIR LOSS Cyclosporine In several scientific studies conducted over the last few years, this drug successfully re-grew hair for at least some of the balding men who used it in testing. It is a type of drug called an immunosuppressive, meaning that it fights the body’s immune system. Immunosuppressives are usually given to patients to prevent organ rejection after a kidney, liver or heart transplant. Some experts believe that the ultimate cause of genetic hair loss is the immune system receiving the wrong messages that hair on certain parts of the scalp are foreign to the body, causing the immune system to attack them. In tests, cyclosporine was applied on the skin in the same way as Rogaine. This is done to localize the suppression of the immune system to the scalp and protect the rest of the body from the effects of the drug. The partial success of cyclosporine is fueling great interest in researching and developing immunosuppressive treatments for genetic hair loss. Cyoctol This drug has shown enough promise for Squibb, a major pharmaceutical company, to work on developing and testing it as a treatment for genetic hair loss. It is believed to combat hair loss by binding itself to the roots of hairs and protecting them from the negative effects of dihydrotestosterone (DHT), which is linked to genetic hair loss. Diazoxide The Food and Drug Administration is currently testing this drug for approval. It is usually used to treat symptoms of diabetes, such as abnormally high blood sugar. When it is used orally for this purpose, it has the side effect of causing hair growth all over the body. Recent research on diazoxide has been focused on developing it for treatment of genetic
  • 61. DRUG TREATMENTS FOR HAIR LOSS 55 hair loss by trying to control and direct the hair growth to the scalp.
  • 62. chapter two: surgical treatment Like medical drug treatments, surgical treatments for hair loss have developed significantly in the last couple of decades. However, unlike medical drug treatments that are still years away from being able to provide a full head of hair, recent advancements in surgical treatments have made it possible to achieve the appearance of a full head of natural hair. At this point in time, surgical methods are the surest and most effective way for most balding people to restore natural hair to a balding head. BAsic questions ABout surgicAL treAtments What are surgical treatments? There are several types of surgical treatment for hair loss. They all involve the movement of hair from areas of your scalp that normally never go bald, such as the back and sides of your head, to the balding areas of your scalp, usually the central area on top and the frontal hairline. What is important to recognize about all surgical treatments for hair loss is that no surgical method can give you new hair or restore any of your lost hair. They can only redistribute what you still have. It is also important to 55
  • 63. remember that surgical treatments for hair cannot prevent further balding. When deciding to employ any surgical treatment you must consider the possible progression of your hair loss as well as what you have already lost. Who is a good candidate for surgical treatment? Because surgical treatments of hair loss can only move existing hair from one area to another, it can only work properly with people who have enough remaining hair to cover the balding areas, and who are likely to retain it for some time. With recent advances in hair transplantation even people who have lost up to 50 per cent of their hair can get the appearance of a full head of hair with surgical treatment. But even with less than half your hair left, you can still benefit from hair transplantation and have your remaining hair redistributed in a way that looks natural and attractive. When is surgical treatment appropriate? there are several different situations in which hair transplantation is the best method to treat your hair loss. To produce a natural hairline: A hair transplant is always required to produce a natural looking frontal hairline. the frontal hairline is the most important part of hair restoration because it is the most prominent part of your hair. The creation of a natural looking frontal hairline requires the restoration of a delicate pattern of hair lengths at various angles, 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 can provide the restoration of a full set of hair. small grafts of one, two or three hairs can be precisely placed amidst thinning hair to restore a natural looking density. To implant on scars left by surgical cuts to the scalp: scars left from surgical cuts into the scalp or physical traumas can be effectively concealed by transplanting hair into the scarred 56
  • 64. skin tissue. What are the different types of surgical treatments? Currently, there are two methods of hair transplantation that offer the best and most natural results possible. These are follicular unit strip surgery (FUSS) and follicular unit extrac- tion (FUE). Both the FUSS and FUE procedures involve the extraction of follicular units from a donor area on the head. Follicular units are small groupings of one, two or three hairs that grow naturally on the scalp. These follicular units are taken from areas on the head where hair is genetically programmed not to fall out. They are then implanted in the balding areas of the scalp, where the transplanted hair will continue to grow naturally. The FUSS and FUE procedures approach this method differently, but both provide exceptionally natural results and are by far the most popular methods with surgeons and patients. How much does surgical treatment cost? The cost of hair transplantation can vary enormously depending on who is performing it. Typically a doctor will transplant 1000 to 4000 grafts in one session that can last anywhere from two to twelve hours. The cost of the procedure is based on a price per graft. The grafts used in the 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 grafts being transplanted, the cost of the procedure can run into the thousands, but patients should remember that a hair transplant is a permanent and life-long investment. 57
  • 65. 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
  • 66. SURGICAL TREATMENTS FOR HAIR LOSS 59 Ideal candidates for surgical hair transplant Crownal hair loss: top view
  • 67. 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
  • 68. SURGICAL TREATMENTS FOR HAIR LOSS 61 Ideal candidates for surgical hair transplant Frontal hair loss: Front view Frontal and central hair loss: Front view
  • 69. 62 SURGICAL TREATMENTS FOR HAIR LOSS Ideal candidates for surgical hair transplant Temporal hair loss: front view Temporal hair loss: Side view
  • 70. SURGICAL TREATMENTS FOR HAIR LOSS 63 Ideal candidates for surgical hair transplant Temporal hair loss: front view Temporal hair loss: side view
  • 71. 64 SURGICAL TREATMENTS FOR HAIR LOSS Ideal candidates for surgical hair transplant Central hair loss: Front view Central hair loss: Side view
  • 72. SURGICAL TREATMENTS FOR HAIR LOSS 65 Ideal candidates for surgical hair transplant Frontal and central hair loss: Top view Frontal and central hair loss: Side view
  • 73. 66 SURGICAL TREATMENTS FOR HAIR LOSS FOLLICULAR UNIT STRIp SURGERy (FUSS) The FUSS procedure involves the extraction of follicular units from narrow strips of scalp taken from donor areas on the back and sides of your head. The removal of these strips result in virtually undetectable scars. The follicular units are cut out from these strips and implanted into the balding areas of your scalp in pin-sized, surgically created holes. These sites will also heal in just a few days, leaving no step three: making the grafts the strips of skin taken from the scalp are cut into small grafts. Each of the small units is called a graft because it is intended to be placed in the bald portion of your head where it 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 prevent damage to the skin while making the holes needed for transplanting into the bald areas of the scalp. First, anesthetic and extra fluids are injected into the skin, causing the surface area to increase. the needles are inserted into the skin to make the holes. With small enough holes, there is no tissue damage. Step five: placing the grafts Each graft is carefully placed according to the plan into specified holes. Usually 1000 grafts are more implanted in a single transplanting session. Mega sessions may involve the transplanting of 1500 to 4000 grafts in one session. FOLLICULAR UNIT ExTRACTION (FUE) The follicular unit extraction (FUE) method, like the
  • 74. SURGICAL TREATMENTS FOR HAIR LOSS 67 session that can be performed in a single day. Each of these sessions of hair transplantation involves the following steps: step one: making a plan A careful plan is made to design and mark a hair transplant map on the patient’s scalp. In making this plan, the hair transplant surgeon is using the principles that govern a natural head of hair to design a transplant that will look appealing and go undetected. step two: Harvesting the hair using local anesthesia, a small strip of skin is cut out from a selected hairy portion of your head. The selection of this area as a source of hair is based on a few considerations. First, the portion of the scalp to be stripped should not be susceptible to balding. Otherwise, the transplanted hair would eventually fall out of its new location, defeating the point of the transplant. Also, the selected portion of the scalp should be selected on the basis that after stripping and harvesting the donor grafts follicular unit strip surgery (fuss)
  • 75. 68 SURGICAL TREATMENTS FOR HAIR LOSS harvesting the donor grafts follicular unit strip surgery (fuss)
  • 76. SURGICAL TREATMENTS FOR HAIR LOSS 69 harvesting the donor grafts follicular unit strip surgery (fuss)
  • 77. 70 SURGICAL TREATMENTS FOR HAIR LOSS FUSS method, involves the transplantation of follicular units from donor areas on the back and sides of the scalp to the balding areas. The difference between the two is that the FUE procedure extracts follicular units directly out of the scalp, one by one, using precise instruments and a high-powered microscope. 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.
  • 78. SURGICAL TREATMENTS FOR HAIR LOSS 71 The strip is removed from the donor area. The strip will be dis- sected into the follicular units under a micro- scope The individual follicular groups of 1, 2, and 3 hairs will be transplant- ed to the balding area
  • 79. 72 SURGICAL TREATMENTS FOR HAIR LOSS
  • 80. SURGICAL TREATMENTS FOR HAIR LOSS 73 transplantation has the advantage of requiring no major surgical excisions. But while the FUSS procedure allows a large number of follicular units to be removed from a single strip of scalp, a fewer number can be removed during a single session of the FUE procedure because each unit must be removed one at a time. However, a session can be repeated one or two days apart. The FUE method of transplantation is particularly good for those who do not have a lot of hair in their donor areas, those who are afraid of the surgical aspect of hair transplantation and for those who do not want any surgical scars in the donor areas. Due to the lack of cutting involved with the FUE procedure, patients retain the option of wearing step four: making small holes
  • 81. 74 SURGICAL TREATMENTS FOR HAIR LOSS their hair very short without worrying about the appearance of minor scarring. The grafts used in the FUE procedure are thinner than the ones used in the strip technique. this is an additional advantage because grafts can be placed closer together, which means that more grafts can be implanted to maximize the density of the transplant. Thinner grafts are also more Small gauge needles used to expand the recipient area for the grafts.
  • 82. SURGICAL TREATMENTS FOR HAIR LOSS 75 step six: Allowing the grafts to settle the grafts are left to settle in their new places and the scalp is allowed to heal for several months. During this healing process, the skin closes around the grafts. the hair from the transplanted grafts usually falls out as a result of the shock of transplantation. However, after a few months the roots of the hair usually recover and the hair re-grows.
  • 83. 76 SURGICAL TREATMENTS FOR HAIR LOSS easily inserted amidst thinning hair to improve density and they reduce the effect of shock, which causes hair in the transplanted area to temporarily fall out after the procedure. then the skin with the hair follicles was removed and cut into smaller hair grafts. In the first operation 586 grafts from AA were transplanted in FA and in the second operation 594 grafts from FA were transplanted in AA. the transplants were performed on the temples of both subjects, giving us a clear observation of hair growth. Also, the identification of hair growth was facilitated because AA’s hair was black and FA’s hair was brown. postoperative hair growth was measured at 9 months and at 14 months, and pictures were taken at different intervals to monitor growth at various stages. * pictures of AA and FA Results: postoperative hair growth was measured at 9 months and at 14 months. At 9 months, 45 of the 586 grafts on FA were considered surviving grafts. The number of surviving grafts was not determined on AA. At 14 months there were no surviving grafts on FA. * chart of results Conclusion: This study shows that allo-hair transplants do not work in the traditional format. However, there is reason to believe that the hair itself is not antigenic but the tissue surrounding the hair follicle is the reason why the hair was unable to survive. It will be necessary to introduce modifications to the method of transplantation to change the structure of the surrounding skin so it does not reject allo-transplanted hair follicles. if the antigenic nature of the skin can be limited, this may present a new approach to the surgical treatment of hair loss.
  • 84. SURGICAL TREATMENTS FOR HAIR LOSS 77 harvesting the donor grafts follicular unit extraction (fue)
  • 85. 78 SURGICAL TREATMENTS FOR HAIR LOSS harvesting the donor grafts follicular unit extraction (fue)
  • 86. SURGICAL TREATMENTS FOR HAIR LOSS 79 Follicular units are extracted with the use of
  • 87. 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.
  • 88. SURGICAL TREATMENTS FOR HAIR LOSS 81 3 weeks post-Follicular Unit Extraction (FUE) surgery No scalpel, sutures or staples results in a donor area with no scars.
  • 89. 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
  • 90. 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 extracted one-by-one and transplanted to the front of the patient’s head.
  • 91. 84 SURGICAL TREATMENTS FOR HAIR LOSS comparison of fuss and fue methods follicular 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
  • 92. SURGICAL TREATMENTS FOR HAIR LOSS 85 comparison of fuss and fue methods follicular unit extraction:  Individual follicular units are extracted one-by-one.  No major scalpel surgery involved  No suture or stapling involved  No scarring involved
  • 93. 86 SURGICAL TREATMENTS FOR HAIR LOSS comparing needles gauge for fuss and fue
  • 94. SURGICAL TREATMENTS FOR HAIR LOSS 87 comparing fuss and fue grafts
  • 95. 88 SURGICAL TREATMENTS FOR HAIR LOSS comparing 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.
  • 96. SURGICAL TREATMENTS FOR HAIR LOSS 89 comparing 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
  • 97. 90 SURGICAL TREATMENTS FOR HAIR LOSS GOALS OF HAIR TRANSpLANT SURGERy natural appearance The artistry of hair transplantation begins with the proper design of the frontal hairline. It is vital that the hairline be de- signed to suit the patient’s face so that the transplant appears natural and goes undetected to the casual observer. The hairline must be carefully placed in relation to the rest of the face to ensure this natural appearance. Leonardo Da Vinci’s formula for the face produces the best results for this purpose. the formula is as follows: the distance from the eyebrows to the hairline is half the distance from the eyebrows to the bottom of the chin. By following this formula, each hair transplant should be unique and suited to the patient. This may be age-adjusted so that younger patients have lower hairlines and older patients have slightly higher ones. A combination of follicular unit micro-grafting is the only way to perform the precise manipulations needed to pro- duce this natural-looking hairline. An irregular pattern of hair distribution is created with a combination of one-, two- and three-haired follicular units for a natural look. A soft frontal zone is made with single-haired follicular units and then the transition 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 be properly designed. If transplantation is needed in the crown area, the hairs should follow the natural swirling pattern char- acteristic of this particular region. Also, the way the hairline meets the temples requires correct angling and blending into the rest of the hair behind the ears.
  • 98. SURGICAL TREATMENTS FOR HAIR LOSS 91 hairlines
  • 99. 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
  • 100. SURGICAL TREATMENTS FOR HAIR LOSS 93 In the following cases you will see pictures of the restored hairlines of middle-aged men. The hairlines are generally higher and the temple angles remain open to better reflect the age of the patients. BeFOre AFTer
  • 101. 94 SURGICAL TREATMENTS FOR HAIR LOSS BeFOre AFTer
  • 102. SURGICAL TREATMENTS FOR HAIR LOSS 95 One 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.
  • 103. 96 SURGICAL TREATMENTS FOR HAIR LOSS Maximum density It is important that your hair transplant provide enough density to cover the balding areas of your scalp. This should be discussed in the initial consultation with your doctor as your financial investment in your surgery is dependant on this. the hair transplant surgeon can, and should, outline the density you should be able to achieve with a certain number of grafts. The average person, before the onset of balding occurs, has 100 to 200 follicular units per square centimeter of the scalp. For a hair transplant, a density of 50 to 80 follicular units per square centimeter is optimal and is possible for an experienced surgeon in a single session. Future sessions can build on this density. Follicular unit extraction (FUE) has contributed significantly to the achievement of greater density. By extracting the follicular units one by one using the FUE technique the grafts are thin enough to pack them in closer together 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.
  • 104. SURGICAL TREATMENTS FOR HAIR LOSS 97 natural density
  • 105. 98 SURGICAL TREATMENTS FOR HAIR LOSS distribution of density regions 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)
  • 106. SURGICAL TREATMENTS FOR HAIR LOSS 99 the following pictures demonstrate density in transplanted patients BeFOre IMMedIATeLy AFTer grAFTIng
  • 107. 100 SURGICAL TREATMENTS FOR HAIR LOSS the following pictures demonstrate density in transplanted patients After transplant: 70 to 80 grafts per square cm
  • 108. SURGICAL TREATMENTS FOR HAIR LOSS 101 the following pictures demonstrate density in transplanted patients BeFOre
  • 109. 102 SURGICAL TREATMENTS FOR HAIR LOSS the following pictures demonstrate density in transplanted patients AFTer After transplant: 60 to 70 grafts per square cm
  • 110. SURGICAL TREATMENTS FOR HAIR LOSS 103 the following pictures demonstrate density in transplanted patients BeFOre After transplant: 70 to 80 grafts per square cm AFTer
  • 111. 104 SURGICAL TREATMENTS FOR HAIR LOSS the following pictures demonstrate density in transplanted patients BeFOre After transplant: 50 to 60 grafts per square cm AFTer
  • 112. SURGICAL TREATMENTS FOR HAIR LOSS 105 the following pictures demonstrate density in transplanted patients BeFOre AFTer
  • 113. 106 SURGICAL TREATMENTS FOR HAIR LOSS the following pictures demonstrate density in transplanted patients AFTer After transplant: 50 to 60 grafts per square cm AFTer
  • 114. SURGICAL TREATMENTS FOR HAIR LOSS 107 mega-sessions With new advances in hair transplantation, mega- sessions are more common. these sessions allow for large amounts of grafts to be transplanted in a single procedure. world record: largest session done over two days Currently, the world record for the most amount of grafts completed in one session over two consecutive days is: 6, 298 grafts BeFOre AFTer
  • 115. 108 SURGICAL TREATMENTS FOR HAIR LOSS world record: largest session done over two days Before and after pictures of the patient can be seen in the previous two pictures. this patient wanted the whole head covered at once from the front hairline to the crown. The whole procedure turned out to be the largest session ever done over two consecutive days. The results (also shown below) were exceptional considering the high degree of difficulty associated with a hair transplant session of this size. The patient was extremely pleased with regaining his youthful look and achieving excellent density. The growth in this patient was excellent, with over 95 per cent of the follicular units transplanted surviving. Age: 33 Profession: Import/Export One Session: 6298 grafts BeFOre AFTer