Non-surgical options

There are a number of non-surgical options available for hair restoration. False eyelashes, eyebrow prostheses, wigs and hair replacement systems can all simulate a normal appearance but need to be removed periodically. Makeup and camouflage can also recreate a natural appearance, especially to eyebrow and beard alopecia, but thinning scalp hair can be made to look fuller and thicker using scalp dyes and microfibres. A more permanent solution can be achieved with micro-pigmentation tattooing and, although this is well established for eyebrow replacement, it is now gaining popularity in men who wish to shave their heads and have the appearance of stubble with a more youthful hairline.

There are a very limited number of medications approved for use in hair loss. Bimatoprost is a prostaglandin analogue that is approved to treat eyelash hypotrichosis, and there is some limited anecdotal evidence that it can also improve eyebrow hair growth. Prostaglandin analogues might therefore be useful for treating scalp alopecia in the future, but currently there are only two medications that are approved for scalp hair loss.

Minoxidil

Minoxidil is used topically in both men and women and comes in different strengths. It is recommended that women use the 2% preparation as higher concentrations can cause the side-effect of unwanted facial hair growth. The 5% preparation is recommended for men and can be applied as a solution or foam. The majority of men using topical minoxidil are likely to see a slowing down or cessation of their hair loss, and a small minority will see some regrowth, although this is likely to just be soft downy hair. There might be an initial shedding of hair before the hair growth cycle stabilises and the risk of this does put some men off. Results in women are less predictable, but for a problem with very limited therapeutic choices it is a relatively inexpensive option with few side-effects. However, users need to be aware that a long-term commitment to daily use is required and results would likely not be noticed for at least 6 months. Its mechanism of action is not entirely clear, but it has been shown to have an action on potassium channels.

Finasteride

Figure 2 Follicular unit extraction (FUE) donor

Figure 2 Follicular unit extraction (FUE) donor

Finasteride is an oral drug that is only approved for men with hair loss as there is a risk of birth defects in women who ingest or absorb the drug. Levels of the drug in semen are insignificant and do not pose a risk of birth defects during fertilisation.

Finasteride is often prescribed to women ‘off licence’ if they are on a form of birth control or are post-menopausal. Up to 90% of men using finasteride at a 1 mg per day dose will see a benefit in terms of slowing down of hair loss2, and a small percentage will see significant regrowth. The mechanism of action is a blockade of the type 2 5α‑reductase enzyme that converts testosterone to dihydrotestosterone (DHT), which is the hormone responsible for male pattern hair loss. DHT only acts on those hairs with suitable receptors for it, which is why, in men with MPHL, there are some areas of the scalp in which the hair is lost owing to the presence of DHT receptors (hairline, mid-scalp and crown), but on the sides and back of the head the hair is not affected. Dutasteride, which is a type 1 and type 2 5α-reductase enzyme inhibitor, might be more effective in slowing down hair loss but is not currently licensed as a treatment for hair loss owing to the increased incidence of side‑effects.

Low-level light therapy (LLLT) is used in many medical specialties and hair restoration is no exception. Although the mechanism of action is not certain, it is thought to work by stimulating the mitochondria and ultimately increase protein production within the cell and increase the quality of hairs. Its effect is probably not dissimilar to that of minoxidil, however, there are few adequate studies looking at its efficacy3.

Hair transplant surgery

Hair transplantations were initially performed by the Japanese in the 1930s and published in their medical literature. However, early techniques developed there did not become known in the West as a result of the Second World War. The modern methods of hair transplantation, known as the strip technique and the follicular unit extraction (FUE) technique, have been refined from those early pioneers in the field, although the fundamentals of the procedures remain much the same. Older techniques such as scalp flaps and scalp reduction surgery are no longer considered to have a role in male pattern hair loss treatment.

Strip procedure

Figure 3 Eyebrow hair transplant (A) before, and (B) after

Figure 3 Eyebrow hair transplant (A) before, and (B) after

In the strip procedure, an ellipse of hair-bearing skin is removed from the safe donor zone in the parietal and occipital scalp and the resulting wound is sutured or stapled leaving a linear scar. Typically this scar is a few millimetres wide and as long as required depending on the number of grafts needed, but usually not more than about 32 cm. With an average density of 80–100 grafts per cm2, a strip of 30 cm x 1.5 cm might be expected to yield at least 3500 grafts. Hairs grow naturally on the scalp either singly or in groups of two, three or four hairs known as follicular units. A hair transplant involving 3500 grafts would be expected to move approximately 7700 hairs to the recipient area. The design of a hair transplant takes into account the different size grafts. For instance, single hair grafts are placed in the hairline to achieve a soft and natural appearance, double hair grafts are placed behind these, and triple/quadruple hair grafts are placed further back where the objective is to maximise density. The recipient sites are either made using blades or hypodermic needles into which the grafts are inserted with forceps, or the grafts are inserted using implanters that have a sharp needle to make the incision and a plunger which pushes the graft into the hole after which the needle is withdrawn.