Hair restoration for men and women should involve both the latest in surgical methods and the newest medical treatment options in order to prevent further hair loss and to perhaps bring back some recently lost hair.

Many times, a surgeon corrects a patient with alopecia (baldness) but fails to inform the patient of what can be done medically.

Alopecia is a function of balding genes times the amount of DHT (dihydrotestosterone).

For example, A = B x DHT, in which A (alopecia, or the degree of baldness) equals B (balding genes) multiplied by DHT (amount).

In men, the treatment is Propecia (finasteride). It lowers DHT by 65% and stops balding in 85% of men by blocking 5-alpha reductase Type II, which is found in the prostate.

For the 15% of men who do not respond well to Propecia, switching to Avodart (dutasteride) will almost certainly stop their loss by lowering DHT 90%, because Avodart blocks both Type I and Type II 5-alpha reductase. Skin and hair contain Type I, and the prostate contains Type II.

In women, I believe all of the patients with androgenetic alopecia (AGA) should be treated as if they have polycystic ovarian syndrome.

In premenopausal women, YAZ (drospirenone and ethinyl estradiol) plus an additional 50 mg to 100 mg of spironolactone is my standard therapy because it blocks the androgen receptor site.

In postmenopausal women, the same dosage of spironolactone (as tolerated) and, sometimes, even dutasteride blocks the DHT formed by 5-alpha reductase Type I, found in skin and hair.

Anything that will block DHT production or block DHT at the androgen receptor site will help prevent male pattern baldness (MPB) or AGA.

Hippocrates attributed hair loss to hot-blooded men burning out their hair roots, noting in his Aphorisms that eunuchs do not go bald.

With the advent of the trichophytic closure, the donor incision line is nearly invisible. The natural “see-through” look improves on the old brick-wall hairline that resulted from punch grafts.

To address his own receding hairline, Hippocrates tried everything he could think of short of castration—from salad dressing to pigeon droppings.

Although the father of modern medicine was on the right track, it wasn’t until the 1940s that Dr James B. Hamilton proved that testosterone was involved in hair loss.

We now know that DHT is responsible for balding, and that Propecia is FDA-approved to suppress DHT for MPB.

Historically, hair restoration was the most effective aesthetic surgery for men until the popularity of botulinum toxin Type A, liposuction, and laser-based treatments.

Restoring hair after it has fallen out is a delicate process that has seen quite a boom recently—the procedure reportedly receives a very high rate of patent satisfaction.

Therefore, with surgical techniques becoming more refined, and with results that are increasingly consistent and natural-looking, hair restoration is enjoying renewed popularity among male Baby Boomers who must face the genetic inevitability of a balding head.

First performed by Dr Shoji Okuda in Japan in the 1930s, hair-restoration surgery took many forms during the 20th century.

Full-sized grafts (done elsewhere) in 1971 have remained at the hairline while hair on top of the head has receded by 1987. Ten years after the first of several sessions of corrective follicular unit micrografts.

From punch grafts to scalp lift and flap surgery to scalp reductions to mini-grafts, the procedures have finally evolved to the follicular unit graft.

It has been more than 50 years since Dr Norman Orentreich offered hair transplants in New York City, where he started the technique of 4-mm punch grafts that was the standard for 35 years.

Dr Bob Limmer found he could dissect out follicular units from a donor strip of scalp taken from the back of the head. His findings were published in 1992, and that has set the new standard for follicular unit transplants (FUTs).

Limmer used dissecting microscopes to tease out follicular unit grafts consisting of one to four hairs. The standard at the time was to take a 4-mm punch graft consisting of up to 10 hairs and insert the graft into a 3.5-mm receptor site in the balding area. Both skin and fat were transplanted along with the hair.

Due to the nature of this procedure, it was necessary to do four to five sessions of 50 to 100 grafts at 2- to 3-month intervals.

The patient had to commit to nearly 1 year of treatments and a series of surgeries, all the while walking around with his head looking like it should be cordoned off with yellow tape as “under construction.”

Today, refinements in equipment and technique have made the old punch grafts with their telltale “doll’s hair” look a thing of the past.


Over the years, the problems associated with handling the grafts have been studied and reduced to the point where we now approach more than 95% survivability of the hairs seen in the new grafts.

This is partially because 10% of the hairs are in catagen-telogen phase and are hard to see or count at the onset, but are transplanted with other hairs in a follicular unit.

In my practice, we routinely do 1,000 to 3,000 follicular unit grafts, with an average of 2.2 hairs per graft, in one session lasting 4 to 8 hours.

The grafts heal in 4 to 5 days, and in a week to 10 days they are difficult to detect. Within a few months, the hair has gone through another growth cycle and the patient has a natural “see-through” look, as opposed to the old brick-wall hairline that resulted from punch grafts.

The most significant refinement of this micrografting technique is the preservation of the naturally occurring clusters of hair follicles during grafting preparation.

A 78-year-old woman with female pattern hair loss before hair-restoration surgery. The same woman, 2 years after follicular unit micrografting.

These natural clusters are seen as single hairs, two hairs, and even three and four hairs coming out of a single pore. Within the skin, these follicular units of two or more hairs are bound together by collagen fibers.

With the new FUT procedure, the medical assistants preparing the grafts identify and cut around each unit and discard the skin between the follicular units.

This very labor-intensive process requires a trained team to produce these grafts and to aid in their placement.

Finally, the follicular unit grafts are placed into tiny slits made in the scalp using a miniature scalpel, which cuts to a depth of 5 mm and is only 0.8 mm to 1 mm wide.

The slits are only 1 mm apart and are made in a slightly irregular, staggered manner to avoid creating a pattern of rows.

The method of follicular unit grafts described above is commonly referred to as FUTs, which are harvested from the back and sides of the head as a donor strip about 1 cm wide and long enough to provide the number of grafts needed.

This donor strip is then sliced into “slivers” one or two follicular units wide (about 2 mm). This method is by far the most efficient and most commonly performed hair-restoration procedure.


With the advent of the trichophytic closure, popularized by Dr Mario Marzzola of Australia, the donor incision line is nearly invisible.

A 2.5-mm wedge is cut off the superior wound edge. When closed, the hairs that were cut at the superior edge grow through the scar, making it difficult to see even with a short haircut.

The popular buzz cut hairstyle led many patients to ask for a method that leaves little or no scarring.

The trichophytic closure comes close to fulfilling this desire. And a new technique of preparing grafts, the follicular unit extraction (FUE), has been promoted as being a method that leaves no scar.

The popular technique uses .75-mm to 1-mm-diameter skin punches to remove one follicular unit, up to three hairs, from any donor site on the body.

As a result, moving body hair to the scalp is now being done fairly often.

For instance, in 1992 I was the first to put pubic hair on the head. In 1994, after the same patient had a facelift, I moved 1,200 beard hairs to his head.

This was presented at a 1999 meeting of the International Society of Hair Restoration Surgery.

At that time, the technique I used was the FUT method, in which the hairs were taken from donor strips of skin. This process is now being done via FUEs.

At the 2007 ISHRS meeting, a patient was presented with 11,000 body hairs moved by FUE to create a full but short hairstyle of 1-inch-long body hair.

During a FUT procedure, by the time I have made the incision at the recipient bald site using magnifying loupes—in order to make, perhaps, 2,500 slits 1 mm apart—my team of surgical assistants has cut enough grafts to begin placement.

The technique I use for placement of grafts is to hold a smooth, curved micro Forester forceps in one hand, dilating the opening of the slit to prepare for the placement of the follicular unit graft; and then, while holding a straight forceps in the other hand, I would place the micrograft into the opening.

Once inserted into the slit using the straight forceps, I hold the graft near its base and drag it down to the base of the slit. In 4 to 6 months, the hair will grow and fill in the area.

The trichophytic closure is something that plastic surgeons use on the frontal hairline when doing scalp-advancement brow lifts to allow the hair to grow through the scar.

The newer, smaller blades allow for closer placement of the hairs in the recipient sites—some patients who were told they would need two procedures a few years ago can now get by with one. Many still need two or more sessions, though.

See also “Giving Hair Another Chance” by Bernard P. Nusbaum, MD in the April 2007 issue of PSP.

Women are becoming more aware that they can have transplants to thicken their hair, because we can place the single follicular units between existing hairs without damaging them.

In the 38 years that I have been doing hair transplants, the current results in restored hairlines are remarkable due to greatly improved techniques.

Patient satisfaction, which has historically been quite high, has become something more akin to patient exhilaration. As a professional, nothing satisfies me so much as seeing the joy on a patient’s face when he comes back for a checkup, beaming, and says, “Doctor, I can hardly believe it, but I’m growing new hair!”

With these new advances in the microdissection of hair follicles, which gives us FUTs or harvesting FUEs from anywhere on the patient’s body, we now can do transplants on both men and women in hitherto unforeseen ways, such as:

  1. To thicken thinning hair, especially in women, by increasing the density by adding hair in-between existing hairs;
  2. Adding FUEs from one part of the scalp and placing them into a linear scar, thus allowing a patient to have a shaved head and not show a scar;
  3. Correcting an eyebrow, mustache, or beard using scalp hair;
  4. Taking beard hair and moving it to the scalp, which is more common; and,
  5. In general, an increased ability to take hair from anywhere on the patient’s body and place it anywhere else, with very little aesthetic downside.

Peter Panagotacos, MD, is a board-certified dermatologist specializing in hair restoration. He practices in San Francisco, is on the clinical faculty at the University of California in San Francisco, and heads the dermatology section at St Mary’s Medical Center. He also is a fellow of the American Academy of Dermatology as well as a member of the International Society of Hair Restoration Surgery, the International Society for Dermatologic Surgery, and the American Society for Dermatology Surgery. He can be reached at (415) 922-3344.