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Macrene Alexiades-Armenakas, MD

Clinician, Researcher, Entrepreneur

Plus:Employee Selection

Laser Vein Treatment

July/August 2013 $5.00Volume 9, Number 4

medestheticsmagazine.com

NEW

WHAT’S

Removal Plumes?

in Hair Restoration

LURKINGin Laser Hair

ADVANCES

20 JULY/AUGUST 2013 | MedEsthetics

By Cindi Myers

Growing Innovations abound in the field of hair restoration.

THE ART AND SCIENCE of hair restoration has

come a long way from fake-looking plugs and obviously

unnatural hairlines. Today, physicians can off er

many patients permanent, natural-looking solutions

to thinning or lost hair, and new discoveries and

technologies off er the promise of even more options in

the future. For the professional who wants to expand a

dermatology or plastic surgery practice, hair restoration

off ers variety, challenges and the potential to serve a

large population. “Hair loss aff ects so many people,” says

James Harris, MD, medical director of the Hair Sciences

Center of Colorado (hsccolorado.com). “If you look at

men in their 50s and 60s, probably 50% to 60% of them

have this condition, and it eff ects many more women

than you think.”

In addition to hair-replacement surgery, practices can

off er patients a variety of products and technologies

developed to treat thinning hair and help clients

maintain the hair they have. For many patients, multiple

therapies will off er the best results.

Possibilities

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Medications To Treat Hair Loss

Minoxidil, sold under the brand name Rogaine (McNEIL-

PPC, rogaine.com), was the fi rst topical preparation

approved by the FDA for regrowing hair. Available fi rst

as a prescription product, minoxidil is now available

in a variety of over-the-counter preparations. For his

patients, Alan J. Bauman, MD, of Bauman Medical (bau-

manmedical.com) prefers a compounded formulation,

Formula82M, which contains not only minoxidil, but also

anti-infl ammatory Retin-A. “It’s dryer and easier to use

than the over the counter products,” he says. “It isn’t

messy or greasy, and it has a very, very powerful effect

on hair growth.”

Finasteride—an oral medication sold under the brand

names Propecia (Merck & Co., propecia.com) and Pros-

car— was approved by the FDA in 1992 for the treatment

of benign prostatic hyperplasia (BPH). In 1997 fi nasteride

received approval for male pattern baldness. It works by

blocking the production of 5a-dihydrotestosterone (DHT)

and reducing androgen activity in the scalp. Because

fi nasteride can cause birth defects, it is not approved for

use in women of child-bearing age. Dutasteride, brand

name Avodart (GlaxoSmithKline, avodart.com), is another

drug used to treat BPH that some doctors use off-label for

treating male pattern hair loss.

In addition to medications, practices can offer powders,

sprays and shampoos to thicken existing hair. Dr. Bauman

was involved in clinical trials for Pantene’s Age Defy line of

products and recommends these to his patients. He also

offers a proprietary hair care line, Bauman MD, which

includes therapeutic shampoos with active ingredients

including caffeine.

The doctors interviewed for this article also stress the

importance of nutrition to their patients. “In a screening

process for hair loss in men and women, you want to look

at things like poor nutrition,” says Dr. Bauman. “Diet plays

a big role. Crash dieting can cause hair loss. Young men

taking creatine supplements can unknowingly increase their

DHT and knock their hair out.” Nutrition supplements such

as Viviscal Professional (viviscal.com) and Appearex Biotin

(appearex.com) offer patients another way to boost their

intake of nutrients important for healthy hair.

Laser Options

Low-level laser therapy (LLLT) can help thicken existing

hair, and is an easy, pain-free therapy for patients. Like

topicals, it requires regular, ongoing treatment. “We use

the laser alone or in conjunction with topical therapies,”

says Craig Ziering, MD, of Ziering Worldwide (ziering-

medical.com). “And for our surgical patients, we have

them come in for two weeks after surgery to have laser

therapy. This decreases shedding, speeds up hair growth

and helps speed up the results of the surgery.”

The Hair Loss Control Clinic (hlcconline.com) offers

practices a turn-key program to offer hair restoration. Their

products include in-offi ce low-level laser devices as well as

supplements, scalp treatments and home use laser combs.

Sunetics International (Sunetics.com) also offers a variety of

in-offi ce and home use LLLT devices.

While these treatments have traditionally been offered

in-offi ce, there is a growing variety of LLLT devices that

allow patients to administer the treatments to themselves at

home. Laser combs, including the HairMax (hairmax.com)

and the Ultimate II Laser from HLCC, have been avail-

able for several years, but the doctors interviewed for this

article were most excited about the LaserCap (lasercap.us).

“Instead of having to come into the offi ce and sit under this

big device, the technology has enabled the same delivery

system as a big in-offi ce laser dome that is battery operated

and fi ts under a baseball cap,” says Dr. Bauman. Patients

wear the cap for 30 minutes every other day while driving

to work, watching TV or relaxing.

Surgical Interventions

Though laser treatments, and topical and oral medications

can help thicken hair and produce new growth in areas

of thinning hair, the gold standard for restoring hair to a

bald pate is hair transplant surgery. New technologies and

approaches have revolutionized the results surgeons are

able to achieve. “It’s not the procedure it was 25 years

ago,” says Dr. Harris. “Some of the surgical techniques we

have now, 99% of the time when someone has had a hair

transplant, you can’t tell by looking at them.”

The primary surgical technique involves taking a strip

GROWING POSSIBILITIES

The ARTAS Robotic system allows for faster, more precise harvesting of individual hair grafts.

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from the donor site—usually the back of the head—and

cutting it into individual grafts under the microscope. The

surgeon then implants these individual grafts of one, two or

three hairs into the bald areas of the scalp, in a pattern that

mimics natural hair growth. Over the next year these grafts

begin producing hair that blends in with existing hair.

Follicular Unit Extraction (FUE) harvests very small sam-

ples of hair—as small as one to four follicles at a time—with

a micropunch method. This eliminates the horizontal scar

at the back of the head that’s produced by strip surgery.

Initially, grafts harvested with this method had a high failure

rate. “One problem was that when using a sharp punch

you can damage a lot of the follicles, because the follicles

underneath the surface of the skin, their direction and

confi guration, don’t always match with the hair that’s com-

ing out of the skin,” explains Dr. Harris. In an attempt not

to damage the follicles, surgeons using the original punch

technique would penetrate only 2mm to 2.5mm, resulting

in more bruising and trauma.

Dr. Harris developed the SAFE system for FUE, which

uses a blunt-tipped dissection device powered by a small

motor. The SAFE system extracts hair follicles at a depth

of 4mm. “This allows us to separate those follicles a little

bit better and makes it easier to get the grafts out of the

skin,” he explains. The system also speeds up the extraction

process. “We’ve been using the motorized version of the

SAFE system for around 3½ years now, and it’s allowed us

to speed up the process,” Dr. Harris says. “If the conditions

are right I can dissect maybe a thousand grafts an hour by

hand.” A typical transplant might involve from 1,000 to

3,000 or more grafts.

Dr. Bauman and Richard Chaffoo, MD, FACS, use the

Neograft (neograft.com), a rotating, mechanical punch aid-

ed by suction to extract individual hair grafts. “The Neograft

system harvests up to 600 grafts per hour,” says Dr. Chaf-

foo. “There are no sutures and the graft sites heal within a

week of transplant surgery leaving no visible scar, allowing

patients to wear their hair quite short.” He uses the device

to restore receding hairlines, reconstruct eyebrows and

camoufl age existing scars.

The latest innovation in FUE is the ARTAS Robotic

System (Restoration Robotics, restorationrobotics.com),

which takes the physical act of harvesting grafts out of the

doctor’s hands and turns it over to a robot. The robot aids

in mapping the grafts, then performs the procedure quickly

and automatically, under the supervision of the physician.

“The robot has defi nitely brought in a new way for doc-

tors who want to provide this procedure to be involved,”

says Dr. Harris. “When you do it by hand, it’s a fairly taxing,

time-consuming process, removing grafts one at a time.

It requires some training to do. You need excellent vision

and eye-hand coordination. Frankly, not all physicians want

or are interested in investing the months and years that it

takes to learn this. For them, acquiring a robot would be an

excellent option. With a couple of days of training, they can

extract grafts at a very rapid rate, of very high quality.”

Once the grafts are harvested, no robot as yet will

implant them for the physician. That takes skill, and a

signifi cant bit of artistry. “The most important part is not

really the tool or the technique,” says Dr. Bauman. “It’s

how we recreate a natural-looking hairline and density by

mimicking the natural patterns of hair growth. It’s not just

‘close your eyes and plant the hair.’ Every single follicle

has to be angled in the right orientation and positioned

to get the right-looking result.” He estimates he spent

10,000 hours developing the necessary skill.

Treatments for Women

Traditional advertisements for hair restoration have tar-

geted men. From famous actors to sports stars, bald men

are everywhere, so it’s a common and familiar condition.

But one of the fastest growing patient populations for hair

loss clinics is women.

Dr. Ziering estimates that about 50% of the patients he

sees are women, and about 20% of his surgical patients

are women. “We also do eyebrow replacement surgery

and about 75% of those patients are women.”

While many men face androgen-related male-pattern

hair loss, there’s no one mechanism responsible for

the majority of women’s hair loss. “Some of the treat-

ments that men use, such as Propecia, may not work for

women,” says Dr. Harris. Hair loss in women may be due

GROWING POSSIBILITIES

24 JULY/AUGUST 2013 | MedEsthetics

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Before After

Hair transplant surgery results have improved dramatically with new devices that aid in harvesting grafts. This patient underwent surgery using the Neograft system.

In a screening process

for hair loss in men and

women, you want to look at

things like poor nutr ition.

continued on page 27