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Hair Replacement Surgery

Hair Replacement Products

Hair Replacement Options

It is not surprising that hair replacement options has become a multi-billion dollar industry worldwide. Unfortunately, while there are dozens of hair replacement options vying for a piece of that consumer attention, few hair replacement options actually deliver on promises.

The effectiveness of hair restoration treatment options vary widely, from no discernible effect to a reasonably full head of hair. As you might expect, the cost of these hair replacement options varies widely as well, from a few dollars to many thousand. Given this variation in effectiveness and cost, it is important to thoroughly research the various hair replacement treatment options before you embark on a costly endeavor with little cosmetic benefit. This article describes the most popular (and useful) hair replacement options and the evidence (or lack thereof) of clinical benefit.

Why bother with hair replacement options?

Pattern baldness or pattern hair loss affects more than 50 % of men over the age of 50 and nearly as many women, but what's the big deal if it's so common? With statistics like that, why would you even bother going looking for hair replacement options at all?

Well, hair loss can seem like a cruel joke, hair is leaving the places where you would like it to be, but growing in places that you do not. While hair serves only minor biological functions, the presence or absence of hair can dramatically influence a person’s appearance and, by extension, a person’s self-esteem. Hairloss replacement also allows us to counteract the obvious aged appearance that hair loss causes, and hair replacement often gives the person a look that is many years, if not decades, younger. I don't think many people like to look in a mirror and see an aged person looking back at them.

In general, there are three broad hair replacement options:

Non-medical, medical, and surgical hair replacement options.

In fact, during the battle of hair loss, many people attempt treatments in each of these three categories (and usually in the order listed).

Non-medical Hair Replacement Options

Most people begin to combat hair loss by experimenting with “volumizing” shampoos, conditioners, or other hair products that claim to create the appearance of fuller hair. This type of hair replacement option may slightly change the way that existing hair appears on the head, but these products do not grow hair or prevent hair loss in any way—they do not claim to—but even their claims of providing fuller, thicker hair to people with pattern hair loss are unsubstantiated.

People with hair loss also tend to experiment with certain supplements and herbal medicines. This type of hair replacement option is available without a prescription and are relatively inexpensive to try. While these pills and creams may be inexpensive initially, the costs can add up over time, especially if results are said to occur over months to years. This author is not aware of any direct to consumer supplement, homeopathic, or herbal remedy that can reliably grow hair that has been lost. Many of the most popular or most tried hair replacement options in this category are biotin, nioxin, Procerin tablets or topical serum and Tricomin shampoos—none of which has been shown to be able to replace hair in clinical trials to date.

Having said that, one herb, saw palmetto (Serenoa repens), was shown to increase hair growth in 6 out of 10 men with hair loss of a particular type.¹ This evidence was gathered in a randomized, double-blind, placebo controlled clinical trial, which is the gold standard clinical trial. Perhaps one of the reasons that saw palmetto is effective at hair regrowth, is because of its proposed mechanism of action, that is, the supplement blocks the conversion of testosterone to DHT - DHT is a primary cause of hairloss and baldness in men. So this hair replacement option may be considered worthy of consideration.

There are several devices for hair restoration that have been tried (and sold). One of the more popular hair replacement options in this category of devices is the LaserComb produced by a company called HairMax. This hair replacement option has received FDA approval—not for efficacy, but for safety. Of note, this 501k clearance means that the FDA confirms the safety of the LaserComb for patients but does not make any statement that the product works for its intended purpose. The device (and others like it) use either laser light or simply incandescent light on the scalp with the goal of stimulating hair growth of the hair follicles. While it is unclear whether this type of hair replacement options actually works (there is one published study that is favorable²) the science related to it has been demonstrated decades ago, at least in mice. In the 1960s a European researcher by the name of Mester demonstrated that he could increase the rate of hair growth in shaved mice by applying ruby red laser light energy for extended periods of time. While this light energy can actually help in several medical conditions, it has not yet been demonstrated convincingly as a hair restoration technique. In other words, this hair replacement option may or may not work.

Hair Replacement Options: The Medical Treatments

One hair replacement option that is now available over-the-counter is minoxidil (Rogaine).

Minoxidil was originally an oral agent used to treat high blood pressure. However, people treated with minoxidil for high blood pressure grew significant amounts of hair, unintentionally. Unlike the anti-hypertensive form of the drug which is still available, minoxidil that is used as a hair replacement option is topical meaning that it is applied to the scalp one to two times per day and is intended to act directly on hair follicles.

There are several proposed mechanisms for why minoxidil applied to the scalp helps regrow hair and prevent further hair loss, but the real answer is that no one knows for sure why this hair replacement option works. What is known is that minoxidil appears to be nominally effective at regrowing lost hair and that effect peaks at about one year of use. Also, most dermatologists agree that the 5% solution is more effective than the 2% concentration that is also available. While minoxidil is a reasonable hair replacement option, it must be used consistently and routinely to bring hair follicles that are about to be lost back to full health. Also, new research seems to indicate that a medicine called tretinoin may enhance the hair restoration effects of minoxidil³, which may make the combination a much better hair replacement option.

Another Hair replacement option is the drug Finasteride

Finasteride, like saw palmetto also blocks the conversion of testosterone to DHT, and Finasteride is another medical treatment for baldness.

Finasteride is marketed under different brand names depending on its intended purpose; however, as a hair replacement option finasteride is sold as Propecia.

In clinical trials, finasteride has been shown to be effective at increasing hair growth (or regrowth) somewhat, but is best at halting further progression of hair loss. Propecia is an oral medication that must be taken every day for as long as hair growth is desired, presumably for the rest of the patient’s life. The package insert included with Propecia claims hair growth in three months but clinicians actually caution patients that they may need to wait for six to nine months to see an effect from this hair replacement option.

Of note, a more potent hair replacement medicine which is related to finasteride, and called dutasteride, may be even more effective.

This newer hair replacement option is not yet approved by the FDA for that purpose, but early scientific results are promising. Also being considered for their ability to halt baldness and regrow hair are the drugs ketaconazole and latanoprost. Ketaconazole is a drug used to treat fungal infections (of all things!) and latanoprost is a medication used to treat glaucoma and increased pressure within the eye. As you might imagine, these medications have been approved by the FDA for their original purpose but must be separately considered as hair replacement drugs (previously considered a side effect of these medications).

Hair Replacement Options : The Surgical Treatments

There are a lot of misconceptions about hair transplant surgery, mainly because those misconceptions were accurate conceptions a few years ago. Early hair transplant procedures left patients with a “doll’s hair” appearance in which each new group of hairs was surrounded by a large hairless border. Within the last several years, though, hair replacement option has advanced considerably as Drs. Lee and Minton note in a recent review on the subject.⁴

Hair Replacement Surgical Treatments Options: Follicular unit strip surgery or FUSS

While there still may be some other hair transplant procedures available, the gold standard surgical hair restoration procedure that has emerged is follicular unit strip surgery or FUSS. In follicular unit strip surgery, a single strip of hair is removed from a donor site on the scalp that does not undergo pattern baldness, usually the very back of the head at the neck. This harvested strip is usually about a half an inch wide and seven inches long. The follicular unit strip is then dissected into small individual units of a few hairs, perhaps as many as 2,000 follicular units. These individual units are then placed in prepared areas on the front of the scalp to form a new hairline. The tufts of one or a few hairs each are spaced as close as needed to achieve a good cosmetic result, but not so close that the tufts may not survive the transplant.

While the donor site—the forehead hairline looks quite good after the scalp heals, the strip of hair harvested during the FUSS procedure leaves a fairly large scar in the back of the head. If the recipient of the hair transplant prefers short hair, the scar can be quite noticeable and undesirable in some cases. Because of this less than ideal cosmetic result for the donor area, the latest advance in this hair replacement option was developed, namely follicular unit extraction or FUE.

In follicular unit extraction instead of dissecting out a large strip of donor hair, individual follicular units are cut from the donor area. These small dissected groups of hair follicles are then implanted in the scalp as would be done in a follicular unit strip surgery. This hair replacement option usually provides an excellent cosmetic appearance in the front of the head without large linear scars in the donor area. However, when a large number of follicular units are needed to create the new hair line using this hair replacement option, the donor has the potential to appear “moth eaten” or like Swiss cheese since instead of a large sutured line in the back of the head, hundreds of small circular patches of hair are missing.

Despite the respective limitations of the FUSS or FUE hair replacement options, these surgical hair transplantation methods have been quite popular because of the rapid and definitive results that they deliver. The major drawback to these surgical hair replacement options is the cost of the procedure. Hair transplant surgery can easily cost thousands of dollars if not more than ten thousand. One reason for this cost is the painstaking nature of this hair replacement option, especially in the FUE approach. Consider that follicular units of one to three hairs each need to be carefully dissected as to not damage the hair root. Also the placement of the follicles creating a new hairline requires a close-but-not-too-close distribution of transplanted follicular units. While the hair replacement option can be performed in a single day under local anesthesia, a complete procedure may take six to eight hours from start to finish. Given the delicate nature of the grafts, the art with which they need to be placed, and the time required of the surgeon it is not surprising that this hair replacement option can exceed ten thousand dollars, especially when this hair replacement option promises fast, excellent results.

Hair Replacement Options Revolve Around A Gentle Turf Battle

It becomes quite clear from reading the scientific literature on hair replacement options, that there is a rather stark distinction between dermatologists and plastic surgeons.

Dermatologists argue in favor of medical hair replacement options like minoxidil and finasteride and consider hair transplant surgery a secondary approach.

Plastic surgeons, on the other hand, promote hair replacement surgery as the primary type of hair replacement options, and treat medications as a supplement to the “true” hair replacement options of surgery.

What is interesting about this difference of perspective is that by comparing the writing from the two camps, you can make very informed decisions about the medical and surgical options, since the benefits are more loudly trumpeted by the proponents but the complications, side effects, and limitations are more clearly elucidated by the other group.

What you are left with is a virtual stalemate, however, since there are clear advantages and limitations in both hair replacement options / restorations - It becomes important to the patient, however, when that patient looks to a physician to help sort through the volumes of information on hair replacement. The advice that you receive from a dermatologist may be different than the advice you get from a surgeon on the topic.

Finally, since neither group puts much stock in non-medical hair replacement options, it is not always easy to get good information about these treatments. However, most of these treatments are, in fact, ineffective and if you are seriously trying to prevent further hair loss, it may be the best and cheapest long term approach to choose either the medical or surgical hair replacement options, or a combination of both.

Hair Replacement Options Reference List

(1) Prager N, Bickett K, French N, Marcovici G. A randomized, double-blind, placebo-controlled trial to determine the effectiveness of botanically derived inhibitors of 5-alpha-reductase in the treatment of androgenetic alopecia. J Altern Complement Med 2002;8:143-152.

(2) Satino JL, Markou M. Hair regrowth and increased hair tensile strength using the HairMax LaserComb for low-level laser therapy. Intl J Cosmet Surg Aesthet Dermatol 2003;5:113-7.

(3) Rogers NE, Avram MR. Medical treatments for male and female pattern hair loss. J Am Acad Dermatol 2008;59:547-566.

(4) Lee TS, Minton TJ. An update on hair restoration therapy. Curr Opin Otolaryngol Head Neck Surg 2009;17:287-294.

ABOUT THE AUTHOR: Michael T. Spako is an M.D. who chose to pursue a medical writing career instead of a doctors practice. I am pleased to have him as the principal writer for this hair replacement / hair restoration site, and look forward to his further contributions. Donald Urquhart, Psychologist, Editor.

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