PST 017: Male Hair Loss — Read the Transcript
Welcome to Plastic Surgery Talk with Dr Steven Mulholland, brought to you by SpaMedica in Toronto, Canada and welcome to our podcast series. Today our podcast is on the ever popular, the number one most popular procedure for men, hair restoration, specifically follicular unit extraction and transplantation. We get asked a lot by our male held hair transplant patients like, what is the cause? Why am I losing my hair? And there’s a lot of urban myths. I know Dr Mulholland, I wore my hockey helmet too tight, or I didn’t wash my hair enough or I wear a baseball cap too much or I got too much sun or not enough sun. There’s a lot of urban myths, old wives tales, around hair loss. In truth, I’ve been doing hair restoration for 20 years and we know the basic science of why it happens.
It has nothing to do with how you looked after your hair. It doesn’t matter what kind of shampoo you use, how often you wash or didn’t wash, whether you swam in a chlorinated pool or you wore a hockey helmet too much. It comes down to your DNA, what you inherited from your parents. And it comes down to a little enzyme that lives down in the hair bulb. And if you have this enzyme, it can break down circulating testosterone effectively. If you have a weak enzyme, this five Alpha reductase, if it’s weak, which is a genetic curse, it can’t break down testosterone properly and end up a buildup of a toxic metabolite called DHT, dihydrotestosterone.
That DHT hammers away over the decades at your bulbs and sometimes in very young men in their twenties, late teens, sometimes in your thirties, sometimes in your forties, that plays out with that constant assault on the bulb by DHT of your bulb turning off the light and going home and dying and your hair shaft falls out.
And so, if you look at the treatments for male pattern hair loss there, they’re really centered around early treatment of elevated levels of DHT. And so how do we do that? Well, we can increase blood flow to the scalp. So one of the early treatments with early loss, especially for the crown at the top of the back of the scalp, is the treatment of increased blood flow in products like Minoxidil, which is a vasodilator, a topical applied foam or solution that vasodilates, increases the blood flow, into the hair and washes away some of the DHT and brings nutrients to follicles that are being assaulted by that building up DHT because of the weak enzyme you inherited, the five Alpha reductase.
Another strategy to increase blood flow and oxidative phosphorylation is to have red light, so the use of low level light therapy to stimulate the bulbs while they’re being assaulted while they’re being attacked by this DHT. And so you see low level light therapy in my office and plastic surgery and hair transplant offices with strong wattage. And then you have low level of wattage at home with the skull caps and the light caps that you can purchase, and even things like a light comb, so light, low level light therapy, Minoxidil for vasodilation.
One of the most common and successful treatments has been PRP or platelet rich plasma. We take a little blood sample, we spin it down into little growth factors and little stem cells, and we take those factors and we inject them right into your scalp, right into the areas of thinning. And it will help turn on and activate some dormant follicles. It’ll help make healthier more robust looking hair while it’s getting assaulted by the DHT. So all these tactics and strategies, PRP, low level light therapy, topical vasodilation, can be supplemented by topical nutrients shampoos, copper peptides and other things to help topically in the shampoo. But all these strategies only delay the inevitable. Eventually, if you have the genetic curse for enough five Alpha reductase deficiency, you will go bald.
George Costanza, Friar Tuck, the entire oval bald. The only way to significantly delay that inevitability is the last nonsurgical option. And that is the use of testosterone blockade. Testosterone we make in our testes, that then circulates, it gets to the scalp, can’t get broken down, gets built up to 5 Alpha … to DHT, because of the five Alpha reductase deficiency, we’re going to get more of this DHT unless we cut off the supply of testosterone. And that’s what finasteride does. Finasteride is a testosterone blocker. We cut off the supply of this hormone, Finasteride, from the testicle. You don’t get as much circulating, you don’t get as much DHt, you don’t lose the hair. So hormone blockade with drugs like finasteride and those Propecia, there’s many names for this chemical, but they block the producing testosterone.
The problem is there are side effects to the production and block of testosterone, loss of libido, male Gynecomastia, and sometimes even a more aggressive version of prostate cancer. So you want to screen your prostate very carefully if you go on androgen blockade. Those are all the nonsurgical options. And at SpaMedica, we offer all of them or advice on all of them. We have a very busy PRP program for female and male pattern hair loss. We have a great 15 percent minoxidil solution that we dispense. And we have very strong and effective low level light red and green light therapy.
However, at a certain time in that balding pattern, at a certain loss of density or frontal hairline or crowning, your best option is going to be transplantation. So what are the surgical options for thinning hair, male pattern hair loss, or even female pattern hair loss? It’s important to note that females can also get thinning. They tend not to go bald like men. They don’t go Friar Tuck, no hair on the top of my head, bald, but they get embarrassing thinning, thinning in the frontal area of their scalp where you have visible hair and wind and water are their worst enemy.
And so, the solution for serious and significant female pattern hair loss and typical male pattern hair loss, males tend to thin in the parking lots at the front and at the back and then they tend to unite in the middle and you get full on significant loss of hair. The final surgical solution is going to be hair transplantation. You can divide those options into two types: Old School, old fashioned, not done so much anymore strip techniques where there’s a significant cut at the back of the scalp, a two centimeter wide, 13 centimeter long strip of hair is removed, staple staple, staple. Your cut has to heal. It’s tender, it’s hypersensitive and you have a scar forever. And then those graphs are taken under the microscope by technicians and cut and divided and chopped into little graphs and inserted. That’s stripped technique, not done much anymore because it’s been replaced by automated and robotic rotatory punch harvest.
The hairs are taken one at a time in little families through little rotatory robotic or automated rotatory punches that are point nine millimeters in diameter, less than a millimeter, so tiny little holes are created in harvesting these follicle units, hence, the name FUE stands for follicular unit extraction. There are two popular devices in the marketplace. At SpaMedica, we have both of them: Robotic, which is the artist’s system of a rotatory punch; and then semi automated, which is Neo graft.
We’ve been doing FUE the longest in Canada, well over 10 years with automated robotic techniques and have by far the most experience accumulated in making awesome looking hair through this technique. And so what’s the best surgical solution? We shave a little patch at the back of your head. We harvest in a nonsurgical fashion, under local anesthesia, the number of little follicle units we need. And that hair will grow. And within a week, you can’t even tell that it was harvested. Your hair, yes, has to be a bit shorter. You can grow your hair longer at the back. So women have it easy. They can hide their donor site.
And the donor site’s always the back of the scalp, low down in that sort of nuchal ridge region at the back of the scalp where that Friar Tuck zone or George Costanza hair, where you never lose it, that’s where we take it from. And then of course, a lot of the artistry of a great result is the design and execution of a great frontal hairline and densification. So after we’ve harvested the hair, we spend the next few hours implanting the hair. We create hairline if needed. We fill in areas of loss of density, like the forloch, the middle scalp or the crown, and we always strive to have a plan.
And every five to eight years, we may need to do re implantation to ensure you never actually become the bald guy or the excessively thinning woman. We restore your hairline to keep the density and over the 20 years we might do four or five sessions so that you know you always are that guy with nice natural, thick, luxurious hair. And we do it by stealing from the back and taking it to the front. Men and women always ask, “Well, what happens to the hair from the back that you took it? Does it regrow back there?”
No, it never regrows again. But you have more than enough hair that we can steal from the back as long as we spread it out geometrically and effectively. If we spread it out and we harvest and then we implant it in the front, you’ll never notice the loss of hair in the back. We can steal up to 12,000 follicle units over multiple sessions and you’ll never notice the loss of density the back. So the back … Why is it preserved? Why don’t you lose the hair at the back? That’s a common question. It turns out that the DNA of those follicles are different than at the front.
At the front, the genetic code, that comes from your mum’s lineage or father’s lineage for baldness, codes for a bad enzyme, five Alpha reductase, on the hairs at the top of your head. At the back and the side, the temples, and at the back, your follicles have tons of five Alpha reductase, awesome enzyme. It breaks down testosterone to usable bite size morsels, and you never get any DHT back there. So we have our hair loss resistance zones. Those are our donor sites for transplantation. Many patients ask, “Okay, if you’re taking the hair from the back where it’s healthy and we put it into an unhealthy bed, why don’t those hairs we’ve transplanted just die?”
The answer lies in the cause. If we review what we talked about, it is the bulb, not the scalp that’s the problem. The scalp is perfectly healthy. It’s the bulbs that were unhealthy. They had an unhealthy level of DHT because they have a bad enzyme, five Alpha reductase. But if we take that healthy hair from the back and put it into the balding scalp, the bulb that we transplant has a healthy enzyme. It can break down all the testosterone in the world and so it lives happily ever after in the new recipient site, where the hair had fallen out, because it’s DNA is different. It’s got lots of five Alpha reductase.
So if you have all these nonsurgical options, PRP, low level light therapy, topical Minoxidil, Propecia, finasteride, and then you have FUE hair restoration surgery, how do you decide surgical versus nonsurgical? Well, one is the stage of your hair loss, male or female pattern hair loss. If you have advanced hair loss with significant thinning and a lot of visible scalp, generally the nonsurgical techniques will not be very successful. A lot of your follicles are permanently dead and deceased and can’t be resuscitated with the nonsurgical techniques. And so surgical techniques are best for advanced hair pattern loss.
Gender. Female pattern hair loss versus male. In general, females are not necessarily dependent upon testosterone and five Alpha reductase. And they respond much more effectively to nonsurgical techniques such as the increased blood flow from minoxidil. They respond very, very well to PRP, platelet rich plasma, low level light therapy. So if you’re a female with modest female pattern hair loss, we tend to always start with a nonsurgical because sometimes the results are quite impressive with no surgery at all. Also, a female’s hair is much more sensitive to physical trauma and the shock of the transplant process, and sometimes the shock of the transplant process can stimulate further hair loss, sort of like some women who have a fever or get sick or have a baby or stress, hair falls out in great clumps because it’s sensitive to what’s called shock hair or telogen effluvium.
So we will often start with nonsurgical techniques in female pattern hair loss, get their her thicker and tougher through our nonsurgical techniques before we do FUE. And then of course a young men with early stage hair loss who might be anxious to start transplantation, we want to see the hair pattern loss evolve a bit more, not over treat the crown when you knew you have to save most of your graphs for a loss at the front. And we’ll often start younger men with early pattern hair loss on the nonsurgical techniques, and then those that have contraindications to surgery, those that are medically unwell, perhaps they have a medical diseases such advanced diabetes or they’re smokers or they have a physical disability or illness that precludes our ability to harvest and implant, they’d be a good candidate for medical treatment.
And so medical treatment has its role. But usually the most effective treatment for advanced hair loss in men and women is going to be FUE transplantation. If we look at the results of what we can achieve through FUE first non surgically, I think in the properly selected patient that is early male or female pattern hair loss, we can have a noticeable increase in density through the use of our nonsurgical techniques. We can minimize the risk of telogen effluvium or shock hair if that patient proceeds into hair restoration surgery and that we can prolong the progression of their hair pattern loss with nonsurgical techniques, but usually the hair restoration and gain is modest to minimal the more advanced to hair loss is with nonsurgical.
On the surgical side, if we have a properly staged surgical plan, executed effectively, we can expect very luxurious restoration of density, a very significant and natural looking frontal hairline, and that if we apply our SpaMedica hair restoration artistry, it should look like you have a natural head of hair for the rest of your life. That has become the new paradigm of expectation, a very natural, never been bald, never gonna get bald, result through FUE hair restoration. How long do these nonsurgical and surgical techniques last and is there a maintenance? Well, first of all, for nonsurgical, it is not a one time shot. You’re using these techniques and strategies to break the cycle of five Alpha reductase and rising levels of DHT. So you have a series of PRP treatments, you have low level light therapy, you might you be using minoxidil and maybe Propecia, and you need to come back for intermittent maintenance throughout the year, usually once every three or four months. Or else, if you don’t, the five alpha reductase will continue to build up DHT. And the DHT will start to with assault the follicle with all the other positive influences of our nonsurgical techniques.
So once you begin the nonsurgical program, it is ongoing and persistent and consistent in maintenance, because without maintenance you don’t overcome that DHT pattern loss chemical fate. On the surgical side, every time you transplant hair into that scalp and it lives, and over 92 percent of the graphs will live, that hair, successful hair growth is permanent. It is not gonna fall out. It comes from the preferred zone, the fringe hair at the back of your head called the occiput or the side. So it’s a permanent result, you need nothing to maintain that hair.
However, remember, if you’re implanting it in and around hair that has not been transplanted, it is subject, the non transplanted hair at the top of your head, to ongoing loss. So you may need ongoing subsequent treatments to add hair where you’ve lost hair. You may need ongoing subsequent nonsurgical techniques and strategies like Propecia, PRP, low level light therapy, Minoxidil, to delay the loss of hair that hasn’t been transplanted. But the transplanted hair itself, when it lives and survives, is permanent. So thank you very much for joining us, Dr Steven Mulholland here at Plastic Surgery Talk for another one of our very popular podcasts. If you have found this podcast interesting and engaging and informative, everything you needed to know about FUE and non surgical techniques for hair restoration, please share this podcast on your social media channels and we look forward to seeing you again at Plastic Surgery Talk.