Drugs & Other Treatments

With the development of drugs specific for treating hair loss, medications play a significant role in both the management and prevention of baldness. This page reviews the two FDA approved medications for hair loss, Propecia and Rogaine, as well as GraftCyte, a substance that promotes wound healing:


Minoxidil (Rogaine)


An oral medication called minoxidil (Loniten) has been available for a number of years for the treatment of high blood pressure, but because of its serious side effects on the heart and general circulation, it is only indicated when the patient has been unsuccessfully treated with the maximum doses of a combination of a water pill plus two other hypertensive drugs. In addition, because of the serious side effects, such as fluid retention and heart failure, minoxidil is only to be used when the high blood pressure causes actual symptoms or causes damage to the patient’s internal organs such as the kidneys.

It was noted that these patients who were taking minoxidil began growing hair in unusual areas of the body, like the forehead and the backs of the hands. It was thought that applying minoxidil directly to a bald scalp might cause hair growth in this area as well. If this hair growth occurred without the other side effects of the medication, it might be useful in healthy balding men. It was then shown that when a topical solution of minoxidil was applied to bald scalps, some men did indeed regrow some hair in the area where it was applied.

Rogaine is the brand name for the topically applied minoxidil solution originally trademarked by Upjohn. It can now be purchased over-the-counter without a prescription in either 2% or 5% concentrations. It appears that the 5% is approximately 50% more effective than 2% solution. The greatest benefit from the medication is seen from 5 months to 2 years, with gradual decrease in effectiveness after that.

Although the mechanism by which minoxidil stimulates hair growth is not known, it probably works by prolonging the hair follicle growth cycle (increases the length of anagen). The effect of the medication is to increases the quality of the hair by increasing the diameter and length of miniaturized (fine) hair. It does not grow hair in areas that are bald.

Rogaine Use in WomenThe early studies with minoxidil were on balding men, but it appears that minoxidil may actually be more effective in women. This is probably because women usually exhibit a more diffuse type of hair loss so that areas thin rather than become totally bald. Thus, there is still hair present for minoxidil to “work on”. As with men, minoxidil is only modestly effective in restoring one’s hair and it does not seem to work in older, post-menopausal women.Although the 5% solution seems to be more effective, it is also stickier due to it’s higher propylene glycol content (the 2% solution contains more alcohol). This makes it impractical for many women to use during the day. As a compromise, it is advised that women use the 2% alcohol based solution in the AM and the stronger 5% propylene based solution in the PM.Side effects from minoxidil are also slightly different in women than in men. Women seem to be a little more sensitive to the medication and have an increased risk of developing contact dermatitis. A more significant local reaction is the development of facial hirsuitism. The development of facial hair slowly resolves when the medication is discontinued but can be a real nuisance when it occurs. Carefully trying to avoid the medication dripping down onto the temples and forehead seems to reduce but not totally prevent this problem from occurring.Some women appear to get light-headed or hypotensive (develop low blood pressure) when using the medication, but the exact incidence and significance of this is unclear.

The controlled studies on minoxidil showed that it grows hair in the vertex (back part) of a man’s scalp, and it probably works to a small degree in other parts of the scalp as well, although only in areas that still have some hair. In addition, it was not shown to regrow hair in the front part of a bald scalp (where the effects of balding are most obvious).

It appears that minoxidil’s effects may only be temporary. Since testosterone is always present in the blood stream, the hormone eventually overcomes the effects of the minoxidil so that with time, men using minoxidil continue to bald, although at a somewhat slower rate. The concomitant use of minoxidil and Propecia (see next section) may partially circumvent this problem and there is evidence that in some cases these drugs may act synergistically.

Prior to trying minoxidil, you should know that even if it is going to work for you, it may take 6-12 months before you see any results. In addition, unless the medication is used consistently twice a day, it will not be of any benefit. For most men, minoxidil does not grow any significant amount of new hair. The action of minoxidil is to thicken already existing hair that is miniaturized (thinned from genetic balding) and most patients who do grow hair, grow only short, thin fuzz.

The majority of patients who see an effect from minoxidil, see only a delay or decrease in the rate of hair loss. This is the most difficult effect to measure scientifically. For many men, the effects are first noticed when they stop using the medication. Once the drug is stopped, the previous pattern of hair loss resumes, and any effects are lost within two to three months, even if the medication had been used for many years. This same limitation applies to other drugs used for hair loss.

Many patients are attracted to minoxidil because of its seeming lower cost compared to other methods of hair replacement. But, because the effects of minoxidil are temporary, the lifetime cost of using minoxidil can be more expensive than the cost of hairpieces or surgical treatments for hair loss. Some doctors recommend minoxidil before and after hair transplantation to decrease or prevent the temporary loss of hair that sometimes occurs with newly placed grafts, but this theory has not been proven.

Minoxidil has been prescribed in conjunction with other medications such as topical retinoic acid (Retin-A) to increase its topical penetration. These medications can greatly increase the systemic absorption of minoxidil and may increase the risk of potential side effects including severe scalp irritation. The prescribing information of Upjohn specifically states “Rogaine should not be used in conjunction with other topical agents including topical corticosteroids, retinoids, and petrolatum or agents that are known to enhance cutaneous drug absorption.” In addition, Retin-A often causes significant skin irritation when used alone and in conjunction with minoxidil. The prescribing instructions clearly state “because absorption of minoxidil may be increased and the risk of side effects may become greater…you should not use Rogaine if your scalp becomes irritated or is sunburned.”

A problem unique to patients using the combined mixture of minoxidil/Retin-A occurs when scalp irritation begins and the patient is afraid to stop the Retin-A since this would also mean discontinuation of the minoxidil (and the risk of subsequent hair loss). These patients often continue the mixture in spite of the development of severe scalp irritation. This can result in infection, scarring and permanent hair loss.

Although it seems that the topical preparation of minoxidil is innocuous, the long-term safety is not known. As with many medications, the clinical trials with minoxidil were performed over a very limited time frame. Since the medication must be continued for years, there may be potential long-term problems that we are presently unaware of.

Finasteride (Propecia)


For frequently asked questions about Propecia (Finasteride), please read our FAQ.

Finasteride is an oral medication, manufactured by Merck, which blocks the conversion of testosterone to dihydrotestosterone (DHT), the form of the hormone that causes male pattern baldness. It does this by inhibiting the action of the type II 5-alpha reductase enzyme that is present in higher concentration in and around, the hair follicles of balding men with androgenetic alopecia.

The medication causes a significant drop in both scalp and blood levels of DHT. Its effectiveness is felt to be related to both of these factors. In patients taking finasteride 1-mg/day, serum DHT levels decreased by 68.4%. Serum testosterone levels actually increased by 9.1% but remained within the normal range.

Finasteride was originally marketed for use in prostate enlargement in men over 50 (the prostate also has the type II enzyme). This medication, in a 5-mg per day dose, is marketed under the name Proscar. In the treatment of prostate problems, finasteride has produced breast tenderness and breast enlargement. It has also caused impotence and decreased sexual interest in a small number of men taking the drug.

In January 1998 the FDA approved finasteride 1-mg/day (Propecia) for the treatment of male pattern alopecia. The phase III human trials, using the 1-mg dose, involved 1,553 men, ages 18 to 41, with Class II Vertex, III Vertex, IV or V balding patterns, i.e. men with mild to moderate hair loss. After two years, results showed that 83% of the men taking finasteride either kept their hair or grew more. Seventeen percent continued to lose hair on the medication. In the vertex (crown), 31% showed moderate improvement and 5% showed great improvement. In the front, only 4% showed moderate improvement and none showed great improvement.

Hair counts showed a gain of 86 hairs in a one-inch circle at the end of one year. These hairs were significantly larger than the fine, miniaturized hair seen in balding, but it is not clear if they all assumed the full weight and diameter of the patient’s original hair. As a comparison, hair transplantation can add significantly more density in a single session, and this number can be increased in subsequent sessions. In addition, transplanted hair has the full weight and diameter of the patient’s original hair and, of course, is permanent.

  • Sexual Dysfunction Although uncommon, there can be side effects of finasteride at the 1-mg/day dose. These include decreased libido (1.8%), impotence (1.3%), and decreased volume of ejaculate (1.2%). It is important to note that there was a small incidence of these problems in the control group as well. Altogether, 3.8% of men taking finasteride 1mg experienced some form of sexual dysfunction verses 2.1% in men treated with placebo (a sugar pill). Most reported cases of sexual dysfunction occurred soon after the medication was begun, but there have been reports of sexual dysfunction that have occurred at later time points. The sexual side effects were reversible in all men who discontinued therapy and in 58% of those who chose to continue treatment. When the medication was stopped, side effects generally went away within weeks, but occasionally took longer.If sexual side effects occur, they generally begin well before finasteride has had a chance to have visible effects on hair growth. Therefore, men who experience side effects can discontinue the Propecia at this time without the risk of hair loss due to stopping the medication. It is important to remember that when finasteride (or minoxidil) is discontinued, you only lose the hair that was gained or preserved by the medication, not more. In effect, you return to the level of balding where you would have been if you had never used the drugs in the first place.
  • Gynecomastia Adverse reactions related to the breast, including breast tenderness or enlargement (gynecomastia), occurred in 0.4% of men taking finasteride 1-mg (Propecia), but this was no greater than in the control group (those who did not take the medication).In patients on the 5-mg dose (Proscar), the time of onset of breast enlargement ranged from two weeks to 2½ years. In these patients, 80% showed partial or complete resolution when the drug was stopped, and 20% experienced no change.The mechanism of breast enlargement (gynecomastia) in patients taking finasteride may be due to its ability to block the conversion of testosterone to DHT. This, in turn, may cause more testosterone to be converted to estrogen, with estrogen then stimulating breast tissue. There have been a few cases of breast cancer in patients on the 5-mg dose, but a causative relationship with finasteride has not been established.
  • Effects on PSA Finasteride causes an approximate 1/3 decrease in serum PSA (prostate specific antigen) in normal men (from 0.78ng/ml to 0.52 ng/ml). It may also blunt the rise of PSA levels in patients with prostate enlargement and in patients who have developed prostate cancer.Since PSA is used as a screening test for the development of prostate cancer (the most common type of non-skin cancer in men), there is a concern that the use of Propecia may interfere with the detection of this disease. It is important that your personal physician is aware that you are taking finasteride so that he can take into account any effects that finasteride may have on your PSA. It is possible that the long-term use of Propecia may actually decrease the incidence of prostate disease, but this has not yet been confirmed in scientific studies.
  • Teratogenecity in Females Finasteride is contraindicated for use in women of childbearing age since birth defects in males can occur if significant amounts of the drug are absorbed into the body during fetal development. It is advised that crushed tablets not be handled by pregnant women out of concern that they may cause harm to the male fetus. However, to our knowledge, there has not been a single reported case of birth defects caused by women handling broken or crushed finasteride tablets. The concern of handling crushed tablets seems to revolve around the FDA policy of assuming maximal possible absorption of the full concentration of the medication during any contact.There is no evidence that exposure of pregnant women through semen is a risk to the human fetus, but for those patients who wish to limit any potential contact of finasteride to their partners during pregnancy, condoms can be worn once conception has occurred.
  • Use in Post-Menopausal Women Merck recently carried out a study to evaluate the efficacy of finasteride in post-menopausal women. After one year there was no significant hair growth and, as a result, the study was terminated. It is possible that the low DHT levels observed in postmenopausal women are responsible for the lack of significant response to finasteride. The safety profile for the use of finasteride in post-menopausal women has not been established. See Related Article
  • Long-Term Benefits and Risks The effects of finasteride are confined to areas of the scalp that are thinning, but where there is still some hair present. It does not seem to grow hair in areas that are completely bald. Therefore, the major benefit of finasteride seems to be in its ability to slow down or halt hair loss, or regrow hair in parts of the scalp that are thin. The long-term ability of finasteride to maintain one’s hair is unknown. Results generally peak around one year and then are stable in the second year or decrease very slightly.The benefits of finasteride will stop if the medication is discontinued. Over the 2-6 months following discontinuation, the hair loss pattern will generally return to the state that it would have been if the medication had never been used.It is important to understand that FDA approval of a medication does not mean that all the long-term risks are known. The small, but nevertheless real, incidence of adverse reactions seen with finasteride underscores the fact that its actions are not entirely specific. Only long-term experience with the medication will be able to determine all of its potential effects.
  • Propecia and Hair Transplantation Propecia (finasteride) has shown to be a useful adjunct to surgical hair restoration for a number of reasons.

    • Propecia works best in the younger patient who may not yet be a candidate for hair transplantation.
    • Propecia is less effective in the front part of the scalp, the area where surgical hair restoration can offer the greatest cosmetic improvement.
    • Propecia can regrow, or stabilize hair loss, in the back part of the scalp where hair transplantation may not always be indicated.
    • If Propecia is shown to be safe and effective in the long-term, it will allow the hair restoration surgeon the ability of creating more density in the cosmetically most important areas (such as the front part of the scalp), since keeping reserves for future hair loss in other areas will be less of a concern.
  • Patient Monitoring Men age 40 or over, should consult their regular physician or urologist before beginning Propecia (finasteride 1mg). If you are age 40, or over, and are of African descent and/or have a family history of prostate disease, it is recommended that you be evaluated yearly. If you have no family history of prostate problems and are not of African descent, yearly prostate examinations should begin at age 50. This may include a rectal examination, a baseline PSA, and other tests that your examining physician feels are appropriate.

Dutasteride (Avodart)


Dutasteride Available for the Treatment of Prostate Enlargement


Avodart Improves Symptoms and Reduces Risk of Acute Urinary Retention and the Need for BPH-Related Surgery in Men with an Enlarged Prostate

London – October 9 2002 – The U.S. Food and Drug Administration (FDA) today approved a supplemental new drug application for Avodart® (dutasteride), manufactured by GlaxoSmithKline (GSK), for the treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate. This new medicine for these patients will improve urinary symptoms, reduce risk of acute urinary retention (AUR) and reduce the risk of the need for BPH-related surgery.

Dutasteride, a second-generation 5 alpha-reductase inhibitor, is the first and only medicine to inhibit both the type 1 and type 2 enzymes responsible for the conversion of testosterone to DHT (dihydrotestosterone), the primary cause of prostate growth. Dutasteride’s dual inhibition decreases levels of DHT by 90 percent at two weeks and 93 percent at two years.

By reducing DHT levels, dutasteride reduces the size of an enlarged prostate. This reduction in prostate volume was seen as early as one month with reductions continuing through treatment. Shrinking the enlarged prostate relieves urinary obstruction and improves urinary flow. Dutasteride also improves urinary symptoms and reduces the risk of AUR (the sudden complete inability to urinate) and BPH-related surgery, two potential long-term serious consequences of BPH. The pivotal phase III study data were published in this month’s edition of the journal Urology.1

“With dutasteride, we now have a medicine that reduces the production of DHT by more than 90 percent, helping to shrink the prostate,” said Claus Roehrborn, MD, a principal trial investigator and professor and chairman of the Department of Urology at the University of Texas Southwestern Medical Center in Dallas, Texas. “By taking dutasteride, patients can improve urinary symptoms and reduce their risk of suffering from acute urinary retention – where you suddenly can’t urinate at all – or needing BPH-related prostate surgery.”

Dutasteride was approved by the Swedish regulatory authority (MPA) on July 24th 2002. It will be marketed in Sweden by the trade name Avolve. The MPA agreed to act as the Reference Member State for the Mutual Recognition procedure within Europe and GSK plan to market the drug in all major European markets once approvals are finalized during 2003. The European trade name (Avolve) is to be confirmed.

Background on BPH

  • BPH is one of the most common health problems in older men.2 BPH often begins after age 50 and can progress and worsen as men age. More than half of men over age 60 experience BPH,3 and by age 80, nearly 80 percent of men have the disease.3,4 In the United States alone, 375,000 hospital stays each year involve a diagnosis of BPH.5
  • BPH is a progressive disease in which the prostate gland surrounding the urethra enlarges.6 As it grows, the prostate obstructs the urethra, the tube through which urine flows, causing urinary difficulties. BPH symptoms interfere with normal activities and reduce the sense of well being.7 Symptoms of BPH vary, but the most common involve urinary problems, such as a hesitant, interrupted weak stream; urgency and leaking or dribbling; and more frequent urination, especially at night.5 In severe cases, the bladder and the kidney may become damaged.5
  • An enlarged prostate can continue to increase in size and may in severe cases lead to AUR and the need for BPH-related surgery.6 A 60-year-old man with a 20-year life expectancy has a 23 percent risk of developing acute urinary retention.8 Among men 60 years or older, with prostatic enlargement and obstructive symptoms, the 20-year probability of needing BPH-related surgery is 39 percent.9
  • To diagnose BPH, a physician will discuss urinary symptoms with a patient and conduct a digital rectal exam. A physician may also use a simple blood test that measures a protein called “prostate-specific antigen,” or PSA. PSA is produced by the prostate, and an increase in levels is associated with prostate growth.6 While PSA is primarily used as a screening tool for prostate cancer, it can also be used to determine prostate enlargement.

Clinical Trial Results

  • Dutasteride was investigated in three large, well-controlled multi-center studies involving 4,325 men aged 50 and above with a serum PSA level 1.5 ng/mL and 10 ng/mL, and BPH diagnosed by medical history and physical examination, including enlarged prostate (greater than or equal to 30 cc) and BPH symptoms that were moderate to severe according to the American Urological Association Symptom Index.
  • Data from these two-year clinical trials demonstrated that treatment with dutasteride (0.5 mg once daily) reduced the risk of both AUR and BPH-related surgical intervention relative to placebo, improved BPH-related symptoms, decreased prostate volume, and increased maximum urinary flow rates.
  • Dutasteride should not be used in women and children. Women who are pregnant or may become pregnant should not handle dutasteride because of possibility of absorption of dutasteride and subsequent potential risk to a male fetus.
  • Men treated with dutasteride should not donate blood until at least six months after their final dose to prevent giving dutasteride to a pregnant woman through a blood transfusion. Men with an allergic reaction to dutasteride or its ingredients should not take it. Men with liver disease should talk to their doctor before taking dutasteride.
  • Clinical trials of dutasteride showed that it was generally well tolerated. Most side effects were mild or moderate and generally went away while on treatment in both the dutasteride and placebo groups.
  • Drug-related side effects during the first six months were as follows: impotence (4.7 percent vs. 1.7 percent for placebo), decreased libido (3 percent vs. 1.4 percent), breast tenderness and breast enlargement (gynecomastia; 0.5 percent vs. 0.2 percent) and ejaculation disorders (1.4 percent vs. 0.5 percent).
  • The incidence of most drug-related sexual adverse events decreased with duration of treatment. The incidence of drug-related breast tenderness and breast enlargement remained constant over the treatment period. Ejaculate volume may be decreased in some patients with continued treatment. This decrease did not appear to interfere with normal sexual function.
  • Dutasteride will reduce the amount of PSA measured in the blood. A physician will be aware of this effect and can still use PSA to detect prostate cancer.
  • Although improvement in urinary symptoms was seen in some patients by three months, a therapeutic trial of at least six months is usually necessary to assess whether a beneficial response in symptom relief is achieved with dutasteride.


  1. Roehrborn CG, Nickel C, Hoefner K, Andriole G. Efficacy and safety of a dual inhibitor of 5 alpha reductase type 1 and 2 (dutasteride) in men with benign prostatic hyperplasia. Urol. 2002;60:434-441
  2. Meigs JB, Barry MJ, Giovannucci E, Rimm EB, Stampfer MJ, Kawachi I. Incidence rates and risk factors for acute urinary retention: the health professionals followup study. J Urol 1999; 162:376-382.
  3. American Foundation for Urologic Disease (AFUD). What is the Prostate and What Does it Do? http://www.afud.org.
  4. Marcelli M, Cunningham, GR. Hormonal signaling in prostatic hyperplasia and neuroplasia. J Clin Endocrin Metab 1999; 84(10):3463-3468.
  5. National Institute for Diabetes and Digestive and Kidney Diseases (NIDDK). Prostate Enlargement: Benign Prostatic Hyperplasia. June 2002. http://www.niddk.nih.gov/health/urology/pubs/prostate/index.htm.
  6. Anderson JB, Roehrborn CG, Schalken JA, Emberton M. The progression of benign prostatic hyperplasia: examining the evidence and determining the risk. Eur Urol 2001; 39: 390-399.
  7. Girman CJ, Epstein RS, Jacobsen SJ, Guess HA, Panser LA, Oesterling JE, Lieber MM. Natural history of prostatism: impact of urinary symptoms on quality of life in 2115 randomly selected community men. Urol 1994; 44:825-831.
  8. Jacobsen SJ, Jacobsen DJ, Girman CJ et al. Natural history of prostatism: risk factors for acute urinary retention. J Urol 1997; 158: 481-487.
  9. Arrighi HM, Metter EJ, Guess HA, Fozzard JL. Natural history of benign prostatic hyperplasia and risk of prostatectomy: The Baltimore Longitudinal Study of Aging. Urol (supplement) 1991; 38(1):4-8.



GraftCyte is a new product containing copper-peptide manufactured by ProCyte Corporation, that has been shown to facilitate wound healing in well controlled scientific studies. Our clinical experience with these products has been the same.

We supply GraftCyte shampoo to our patients as part of their routine post-operative care. In addition, our patients have the option of using a more intensive 7-day course with a variety of products containing copper-peptide. We do not routinely use the 7-day course of GraftCyte in our practice since we have found that GraftCyte has not offered any significant benefit in Follicular Unit Transplantation where the very small wounds already permit extremely rapid healing.

There has been speculation that copper-peptide solutions may also hasten the growth of newly transplanted hair. This later claim has not yet been proven and, at this point in time, we do not prescribe GraftCyte for this purpose. We do, however, strongly recommend its use for wound healing.

The following copper-peptide products are recommended for post-op care:

  • GraftCyte Moist Dressing Packets
  • GraftCyte Post-surgical Shampoo
  • GraftCyte Post-surgical Conditioner
  • GraftCyte Concentrated Spray
  • GraftCyte Iamin-hydrating Gel

The protocol that we use at NHI is as follows:

Moist Dressings -7 foiled packages of three sheets each

  • The first dressings (three sheets) will be applied after your procedure before you leave the office.
  • The dressings should be placed to cover the entire grafted area using occasional gentle pressure to keep the area saturated. Apply all three sheets to the transplanted area.
  • For best results leave the dressings in place 30 to 60 minutes.
  • Apply dressings twice per day, AM and PM for the following three days, until all packets are used up.

Concentrated Spray – 1 bottle

  • Beginning the day after surgery, spray the transplanted area liberally every hour or two in order to keep the transplanted area moist. This should be continued even after the dressings are stopped.
  • Use a minimum of 15 spays per application and 5-10 applications per day. Use until the bottle is finished.

Post-surgical Shampoo and Conditioner – 1 bottle each

  • Use the GraftCyte shampoo and conditioner in place of other shampoos.
  • Use shampoo and conditioner every day until the shampoo and conditioner are completely used up.
  • When GraftCyte shampoo and conditioner are used up, resume your regular shampoo.

Iamin-hydrating Gel – 1 tube

  • Apply a continuous layer to the entire suture line 3 times a day (AM, after work, PM).
  • Use this in place of the other ointments for the suture line, as discussed in your post-operative instructions.
  • When you shower, shampoo out any existing gel from previous applications.


Other treatments

Hair Cloning

The thought of being able to culture hair follicles and have an unlimited donor supply has been a long-time dream of patients with hair loss and hair restoration surgeons alike. The obstacles, however, have seemed enormous since the hair follicle is a very complex structure of skin cells, blood vessels, nerves, muscles, and glands. (As an analogy, culturing a hair follicle would be more like culturing an entire eyeball rather than just the cells of the cornea.) Now there is hope that not only is cloning possible, but that this hair may not even need to be your own.

Dr. Colin Jahoda, a British scientist recently reported that he took dermal sheath cells (cells from the lowest part of the hair follicle) from his own scalp and transplanted them into his wife’s forearm. These implanted cells then stimulated his wife’s skin to grow new hair. The hair was analyzed by Dr. Angela Christiano at Columbia University in New York and was show to be composed of cells with Dr. Jahoda’s XY chromosomes at the bottom and his wife’s XX chromosomes at the top.

This clever experiment shows that the hair follicle’s dermal sheaths cells are one of the bodies “immune privileged” organs, enabling them to be transplanted from one person to another without rejection. More importantly, this study suggests that all one might need to do is to transplant these “inducer” cells to stimulate new hair growth, rather than having to transplant the entire follicle itself. The great significance, for those that are balding, is that these cells may some day be cultured in the lab, to produce a potentially unlimited supply of hair.

Although, this was just one preliminary study, the work provides a clear direction for further cloning research and gives considerable hope that the technology may be available in the not too distant future. Stay tuned!

Tissue Expansion

Tissue expansion is a technique in which the skin is stretched beyond its usual limits to cover an adjacent bald area of scalp. It is most commonly used in conjunction with scalp reductions or lifts, but may also be used with flaps.

Tissue expansion is a relatively aggressive procedure and many question its appropriateness in treating androgenetic alopecia (common baldness). On the other hand, it is an invaluable technique for repairing burns and other injuries to the scalp when hair loss is associated with scarring.

In order to work, tissue expansion relies on two recently described properties of skin, Mechanical Creep and Biological Creep. Mechanical Creep is the stretching of skin that is due to tension applied over minutes to hours. The stretching is usually performed intra-operatively and is due to collagen re-alignment, displacement of fluids, fragmenting of elastic fibers and recruitment of adjacent skin. In contrast, Biological Creep involves the stretching due to tension over weeks to months. The mechanism of this is new tissue growth as well as recruitment of adjacent skin.

There are two types of tissue expansion, Volumetric and Non-Volumetric. In Volumetric Expansion, a balloon is placed under the scalp and gradually inflated, stretching the skin over weeks to months. This “balloon expansion” is very effective, but is generally too disfiguring for treating male pattern baldness. It’s use is usually limited to treating hair loss associated with injuries or congenital defects.

Non-volumetric tissue expansion, also called “scalp extension”, can be used in combination with a scalp reduction for treating male pattern baldness. The most popular type is the Frechet Extender which is a thin sheet of bioplastic that is placed under the skin through an incision. As it is stretched, its hooks are attached onto the undersurface of the scalp in two different areas. They are left in place for approximately 4 weeks during which time the skin stretches and buckles up. The redundant bald scalp is then excised in a subsequent surgical procedure. An intermediate type of device, designed by Martin Unger, is the PATE (Prolonged Acute Tissue Expansion) which can be used intra-operatively.

Cosmetic Camouflage




  • Toppik Keratin from wool Contact: Spencer Forest Labs, Westport Conn. 06880 Tel: 800-416-3325
  • Hair Magic Rayon


  • Couvre Sesame seed emulsion Inexpensive Comes in a tube Contact: Spencer Forest Labs, Westport Conn. 06880 Tel: 800-416-3325

Powder Cakes

  • Derm Match Inexpensive Good for local areas Applied with wet sponge applicator Contact: Tel: 1-800-826-2824 dermmatch.com


  • Fullmore Most expensive
  • ProThik

Hair Systems

A detailed discussion of hair systems, including hairpieces, wigs, and toupees, is beyond the scope of this web site. You may refer to The Patients Guide to Hair Restoration for more information.

The important point to make is that hair systems in men are “high-maintenance”. They require frequent, periodic visits to the “center” to adjust or re-attach the appliance and often require the patient to keep a spare. They, of course, will wear out over a few years and need to be replaced. The long-term costs generally far exceed those of surgical hair restoration.

Because hair systems are not your own hair they always present a psychological concern that they will be detected. This becomes magnified in close “social” situations. They are also difficult to keep clean and are often hot and uncomfortable to wear.

The major problems of hair systems are related to the way they are attached. In women, a wig can be loosely clipped to the surrounding hair and be removed at night, causing few problems. However, in those people who want to wear their hair system during sports or other physical activity, this form of attachment is not secure enough. In addition, men often have less hair to attach the system to, and they tend to wear their hair shorter, so they must use other means of attachment.

Attaching the hairpiece with adhesive tape is a simple method, but it leaves a sticky residue and can loosen with sweating and rigorous activity. To have a really secure attachment, the system must be either tied to the surrounding hair, weaved through a mesh network, or attached with glue or another type of bonding. Since these can’t easily be removed, they produce constant traction on the patient’s natural hair and cause a form of hair loss called Traction Alopecia. When this is superimposed on the natural balding process, the final result may be difficult to repair.

The use of hair systems or artificial fibers that are sewn into the scalp are outlawed in most states in the U.S. However, they are still popular in many countries, including Japan. The following patient wore a sew-on hair system for many years and developed the scarring that is often seen when foreign materials are imbedded into the scalp. Fortunately, this patient still had an adequate donor supply and was amenable to correction using Follicular Unit Transplantation.

Low Laser Light Therapy (LLLT)

Background on Laser and Theory of Proposed Benefits

For the Laser to become a medical device for benefiting the person with hair loss from genetic causes, the devices that are being promoted must prove that they are safe for use and that they are effective to meet the claims of those who promote it. It is critical for the consumer to know that what he is buying (either a service or a device) does what he has bargained for and does not expose him/her to any undo risks. There have been a great deal of claims for benefit of these laser hair devices along with proposed mechanisms of action. The purpose of this document is to review the information that is available (substantiated and unsubstantiated) so that you, the reader, can judge whether or not Laser treatment for hair loss is appropriate for your situation.

The Low Laser Therapy (LLT) for hair loss is claimed to work by supplying energy to the body in the form of non-thermal photons of light. The technology is further claimed that in the right application, the body is able to absorb this external energy on a cellular level and transform light energy into chemical energy, which the body then uses to accelerate the normal healing rate of tissue for a wide range of ailments. .

For the body to be able to absorb and transform the energy, certain parameters need to be defined such as treatment time, wavelength of the light energy, dosage, etc.. with the various techniques.

For a Laser, the wavelength of light is extremely important, since the wavelength ultimately decides the penetration depth in the target tissue. Red light from a 670 nm continues-wave is claimed to be less well absorbed in blood, which is also red, so the penetration rate is much greater than from other hair lasers closer to the red spectrum (632,8 nm, 635 nm 650 nm etc.) Since wavelengths from 670 to 690 nm support the redox processes (oxidization processes) it is believed that the 670nm wavelengths show better efficacy in therapeutics than lower wave length lasers such as the He-Ne-lasers (632,8 rim) etc. Low-energy visible light (LEVL) has been shown, in some studies, to stimulate certain cell functions. This is called “photobiostimulation” and has been used over the last three decades for treating a range of conditions, including soft tissue injuries, severe wounds, chronic pain, and more. Although the mechanism of photobiostimulative processes is still being debated, in order to interact with the living cell, light has to be absorbed by intracellular chromophores. In a search for the chromophores responsible for photobiostimulation, endogenous porphyrins, mitochondrial and membranal cytochromes, and flavoproteins were found to be favorable candidates. The above-mentioned chromophores are photosensitizers that generate reactive oxygen species (ROS) following irradiation. As the cellular redox state has a key role in maintaining the viability of the cell, changes in reactive oxygenation may play a significant role in cell activation. There is suggestive evidence demonstrating various ROS and antioxidants are produced following LEVL illumination. There are suggestions that the change in the cellular redox state plays an important role in maintaining cellular activities and leads to photobiostimulative processes

In the field of photochemistry, the light must be absorbed before photochemistry can occur. This is a very simple but powerful concept for this field and as such, is basic to the ‘laws’ of the science. Of the lasers in the visible region 670nm laser is considered to provide superior absorption (penetration). In 1993 a study on rat schwann cells demonstrated the variations between 670, 780 and 830 nanometer absorption. The highest absorptions were exhibited at 670 nm and the lowest at 830 nm. However there is clinical evidence that in contrast to other wavelengths, the 830 nm laser light produces specific beneficial biological reactions that are not produced by other wavelengths. Because the scalp skin is thin, the deep penetration of the 830 nm wave length may be too deep to get the full benefits to the rather superficial hair follicles and is therefore not needed for hair therapeutics. Today, the wavelengths most commonly used for therapeutic purposes are 632,8 run, 635 nm, 650 nm, 660 nm, 670 nm, 780 nm, 820 nm, 830 nm, 904 nm (GaAs lasers). Except for GaAs, all these lasers usually produce a continuous beam but some may also be pulsed. The infrared lasers, invisible to the eye, are more suitable for muscle therapy (deep penetration) and are not used in hair loss therapy because the penetration depth is not needed. With these lasers, eye protection is needed and these devices are considered Class IIIb devices by the FDA. (Visible light ranges from: 400 nm (violet) – 700 nm (red) Infrared light: Above the 700nm Infrared light, the light is invisible.

For hair applications, the first and most significant condition in choosing laser wavelength is depth penetration, which should be sufficient to target hair bulbs typically resting at a 5-6 mm depth.

Visible red light, at a wavelength of 660 nanometers (run -1 nanometer is equal to one billionth of a meter), penetrates tissue to a depth of about 8-10 mm so the entire hair organ will be covered to a depth just beyond the hair bulb. Visible red light also can theoritically be effective in the entire scalp and might include; wounds, cuts, scars, folliculitis, etc… Higher Infrared light in the non-visible area will penetrate to a depth of about 30-40 mm and therefore might make it effective in the treatment of joints, deep muscle, etc… (areas of application which are used today).

Lasers can operate in two modes: (1) either continuous-wave (cw) or (2) pulsed operation modes. The biological responses of the same cells to pulsed and continuous-wave (CW) light of the same wavelength, average intensity, and dose can vary.

Supporters for pulsed LLLT produce the following arguments for why pulsed might be better:

  • It is believed that pulsed LLLT can stimulate tissue repair and regeneration
  • It is believed that pulses stimulate cell, activity. Theory suggests that rapid pulsing of LLT starts to simulate a continuous beam.
  • It is believed that pulsed LLLT can regulate biological rhythms or cycles
  • It is believed that pulsed light produces deeper penetration compared to continuous wave. More science is needed to define and prove such claims.
  • It is believed that pulsed LLLT has an anti-imflamatory effect.
  • It is believed that when both pulsed light is used in combination with the visible infrared red light spectrum, it might have value for various hair treatments which are becoming the focus of marketing and research activities today.

There are two ways to create the pulsations:

  1. By turning the lasers on / off mechanically
  2. By transfer the light in specific patterns through internally moving parts to the administration device. The laser diodes can be fixed within a hood and by moving band shaped fields of light repeatedly over the area a pulsating stimulation of the hair follicles of the skin can be simulated. One of the commercial systems available today, Laser Hair Care, uses this proprietary approach and this company believes that this increases the stimulatory effect of LLLT on the scalp and hair.

The goal of LLLT is to increase the circulation of blood to the follicle area and to stimulate the hair organ (nerves, muscles and growth centers of the hair follicle). The effects of such LLLT to stimulated, enhance or speed up the normal life and production cycle of the exposed hair follicles is presently being studied and will fast become the science by which this technology will judged.

When dosing LLLT (often referred to as “fluence”), the energy is measured in J (joules), the area in cm2, and, consequently, the dose in J/cm2. To induce an optimal effect, the exposure dose has a lower and upper limit. The optimum theoretical dose probably lies somewhere in the middle. It is believed that repeated doses, given at intervals, induce stronger effects than the same total dose given in one treatment and as such, the treatment effect is cumulative. This would mean that repeated doses with a suitable, relatively short interval might give an added response. Fluences between 0.24 – 1.0 J/cm2 on one hand and 3 – 4 J/cm2 on the other hand, may be more favorable for different conditions.

I have obtained access to the Laser Hair Care device which produces 108 Joule in 15 minutes spread over a density between 0.12 – 1.09 J/cm2/15 minutes (10.8 J/cm2/15 minutes). In a scalp blood microcirculation study done with the Laser Hair Care device in 1996, Pontinen demonstrated that the Laser Hair Care (60 mW) fluencies increased blood flow while He-Ne laser 0.01 J/cm2 had no effect. The same study demonstrated that light emitting diodes (LED) with fluences between 0.68 – 1.36 J/cm2 (112.5 mW) produced Vasoconstriction* (reduced blood flow). Some believe that an increase in blood supply will parallel an increase in the demand for blood supply and as hair is amongst the highest metabolic organs in the body, the presumption that the demand for blood and oxygen from the hair organ is driving the higher blood supply reported in this and other similar studies. Speculation for interested third parties need science to back this assumption up with better studies that show the relationship between the size and mass of the sum of the hair organs when compared with pre-treatment metrics.

The power, watt or milliwatt, of a laser determines how much energy is initially delivered to the tissue surface and along with the wavelength, the power at any given depth of penetration. Energy density (Joules / entimeter2) is equal to the power of the laser in watts multiplied by the treatment time in seconds, divided by the surface area irradiated in square centimeters. Laser light has the unique properties of monochromaticity, (a single wavelength), coherence (travels in a straight line), and defined location (concentrated beam). Amongst the questions needed to be better understood is the effects of LLLT on the cells, namely: Do cells exposed to LLLT convert the energy into chemical energy and can they use that energy for repair, regeneration, or growth stimulation?

I will be writing more and offering reviews of a variety of scientific papers on the use of LLLT in the near future.

(Published Aug 10, 2005)


Not recommended

The following page contains techniques that are not recommended, but published here educational purposes: