The Peter Attia Drive - #43 - Alan Bauman, M.D.： The science of male and female hair restoration - how to protect, enhance, and restore the appearance and health of the hair and scalp

00:00:00.000 Hey everyone, welcome to the Peter Atiyah drive. I'm your host, Peter Atiyah. The drive

00:00:10.880 is a result of my hunger for optimizing performance, health, longevity, critical thinking, along

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00:04:12.080 My guest this week is Dr. Alan Bauman, a hair transplant surgeon who is one of the few people

00:04:17.780 who is actually board certified in hair transplantation. There are lots of hair transplant surgeons out

00:04:22.260 there, but Alan is one of the very few who's actually board certified. And I've gotten to know

00:04:25.740 Alan very well because one of my patients, actually two of my patients went to him for procedures a couple of

00:04:32.040 years ago. I was sort of blown away by the results because the best hair transplants are the ones where

00:04:37.780 after the fact, you have no clue that the patient had a hair transplant, got to know him better and

00:04:42.620 was impressed immediately by how open he was to all of my questions. And believe me, there were a lot

00:04:49.320 of questions before I refer one of my patients to another physician, especially a physician who's going

00:04:54.880 to do a procedure on them. I want to be able to vet the heck out of them. And I want to understand

00:04:59.420 how they're doing what they're doing. And internally we put together summaries of the stuff that we

00:05:06.400 learned. And Alan was so gracious in his ability to share his data, share his insights, acknowledge

00:05:12.420 what he didn't know that over the past couple of years, I've sent more and more patients to him who

00:05:17.180 have inquired about both surgical and non-surgical solutions to hair loss. And this is of course true

00:05:22.100 for both men and women. So at some point I said, Alan, we need to sit down and talk about this. And Alan is

00:05:27.260 of course, one of the experts in the world on this topic. He's treated over 20,000 patients. He's done

00:05:33.960 over 8,000 hair transplants. The thing about this that's interesting is you come to learn as I, as I

00:05:39.500 learned that this is a problem that both men and women think about. And so in this episode, we talk

00:05:44.540 about what hair loss looks like in both men and women. And it turns out that pretty much nobody goes

00:05:50.640 through their life without some change in their hair pattern. Now for men, I think it's a little

00:05:56.680 more obvious. We see the results of hair loss, but of course, any woman who's been pregnant knows that

00:06:01.100 just there and then she's going to experience a dramatic change in her pattern of both gaining

00:06:06.340 hair and then losing hair post-pregnancy. But of course, for many women, this changes as they get

00:06:10.900 older and once they go through menopause. And I think most women aren't aware of some of the solutions

00:06:16.520 that exist maybe as much as men are. So we talk in great detail about what the non-surgical or

00:06:21.940 non-invasive approaches are. And there turned out to be many more than I had ever understood or even

00:06:27.480 appreciated. And I think Alan does a great job of explaining those. And then of course, there are many

00:06:32.820 invasive things such as PRP that would be even pre-surgical. And then of course, within the surgical

00:06:38.700 side of hair restoration, like anything, I suppose there are many different techniques and they have

00:06:44.660 advantages, disadvantages. And Alan does a great job here of explaining the method that he has chosen

00:06:50.980 and why I think it certainly seems to produce unbelievable results in the cases that I've

00:06:56.800 seen. This is an episode that has been, I've been asked about a lot in social media. So this is a great

00:07:01.280 example of bugging the heck out of me over social media for topics that you want to hear about. And

00:07:06.760 both men and women have said, please interview somebody who's an expert on hair restoration. And so

00:07:12.820 with that said, please continue to ask about things that you're interested in hearing about. And

00:07:18.720 hopefully I'll be able to continue to find exceptional people with whom to bring expertise

00:07:23.280 to you. So without further delay, please enjoy my conversation with Dr. Alan Bauman.

00:07:30.760 Hey Alan, thanks for making time today.

00:07:32.700 Peter, thanks for having me. This is great.

00:07:34.200 Yeah, well, we met actually through a patient because I mean, a lot of the doctors that I know who are doing

00:07:42.260 really cool stuff I'm somehow finding on my own, but perhaps just as often actually, now that I think

00:07:48.160 about it, I come to meet somebody through the work they've done with one of my patients. And then that

00:07:53.300 takes me down the rabbit hole. Because unfortunately, a lot of times, you know, a patient will go and see

00:07:57.640 somebody and the outcome for anything, you know, whether it be a colonoscopy or whatever, it's not what

00:08:02.340 you want. But in particular, the patient that saw you had such a great outcome. And because you're in

00:08:07.740 Florida, where I just don't really have much of a network, I was intrigued by the outcome. And the

00:08:13.260 patient insisted that I speak with you. You know, he was like, you know, you got to talk to him. He's

00:08:17.760 your kind of guy. You're going to, you're going to, you're going to connect. And I was like, of course,

00:08:20.960 yeah, I mean, I'm happy to learn. And, and so the first thing that amazed me when we spoke was that

00:08:25.240 you trained as a general surgeon. Correct. And I don't know why I didn't, or I don't know why I

00:08:30.640 thought that would be so unusual. Is that common for people who are doing hair transplantation to have

00:08:34.700 done a complete residency in general surgery? Well, there are many general surgeons in the

00:08:38.800 field of hair transplant surgery, but I would say years ago, it was mostly dermatologists,

00:08:44.420 but hair transplant is kind of a potpourri of all different types of areas of medicine. I mean,

00:08:50.700 we have people in the field who are psychiatrists, urologists, as well as the commons, you know,

00:08:57.500 ones that you would see dermatologist surgeons, vascular surgeons, things like that, who have made a

00:09:01.920 transition maybe from a previous type of practice into hair transplantation.

00:09:07.380 And is there a, like a board certification for hair transplant the way there is for

00:09:11.540 general surgery or thoracic surgery? So the American board of hair restoration surgery is not recognized

00:09:16.980 right now yet by the ABMS, which is, you know, the American board of medical specialties. So it's

00:09:22.100 kind of in its primordial stage. When I first got interested in hair transplantation, there wasn't even a

00:09:27.520 board certification test anywhere on the horizon. And so of course my parents thought that I was

00:09:33.280 going down a deep rabbit hole, maybe with a dead end because I would never become board certified.

00:09:37.140 And they were very, very nervous about my interest in hair transplantation back in the early 1990s.

00:09:42.660 But now it has a certificate in the way that transplantation or surgical oncology,

00:09:47.020 which are not board certified specialties are still certificates.

00:09:50.220 Right. Even restorative dentistry has these types of boards. And so it's a rigorous process,

00:09:54.600 one that was a lot of fun to go through, to be honest, because before that, you know, I never

00:10:00.440 took a test that was specifically geared to my primary specialty. It's all I do, all I've done

00:10:07.120 for well over 20 years is hair transplantation. So to prepare for that was an exciting time.

00:10:13.300 It's rigorous, written exam, oral exam.

00:10:16.380 And you guys go through that every five years or how often do you recert?

00:10:19.180 Oh God, the recertification, you know, I don't know. No, I just did my recertification. I should

00:10:23.220 know. It's probably like eight or 10 years or something like that.

00:10:26.160 So what got you interested in the space? Because it sounds like you're not,

00:10:31.120 again, I don't know if it's the exception of the rule, but you went into surgery to do this.

00:10:35.960 Whereas, as you pointed out, there are a number of people who come to this probably as a second

00:10:39.620 career in surgery, right?

00:10:41.520 Right. So I kind of fell into it almost by accident. My first love was plastic surgery,

00:10:46.040 constructive surgery. My first mentor was a plastic surgeon, pretty prominent plastic surgeon on the

00:10:51.320 Upper East Side of Manhattan. And he was close friends of the family. His kids were my age.

00:10:55.780 They had no interest in surgery. And he kind of took a liking to me. And I, he said, hey,

00:11:00.040 if you're going to go to medical school, you're going to be-

00:11:02.000 Did you do residency in New York?

00:11:03.440 Beth Israel and Mount Sinai is where I did my general surgery. But this is way back when I

00:11:07.360 was a teenager. He said, hey, if you're thinking about going into medicine, you should come and watch

00:11:11.200 me operate. And I was like, well, I don't know what kind of operation he does. But, you know,

00:11:14.700 I went to go see him and he was a plastic surgeon. And that was the first time I ever saw surgery

00:11:18.320 because back in the 1990s, this was in the 80s, no YouTube, no discovery channel. I mean,

00:11:24.500 I didn't really know what surgery was, to be honest, as a teenager. And I remember being there

00:11:29.480 at Beth Israel, getting dropped off in the lobby and looking over his shoulder in the OR, you know,

00:11:33.860 he dressed me in scrubs, whatever, stand here, don't touch anything blue. I guess the security

00:11:38.220 wasn't so great. But, you know, I was looking over his shoulder and he was doing his procedures

00:11:41.660 and I was blown away. I was like, this is what I want to do. I want to do surgery.

00:11:45.960 And from there, you know, it was years and years of just shadowing him and being mentored,

00:11:52.440 often on vacation times and things like that. And I pursued general surgery through, you know,

00:11:57.800 my interest in going that route to get to plastic and reconstructive work.

00:12:01.240 Yeah, because back in that day, I mean, today there's a combined plastics track where you can

00:12:05.680 do three of general and three of plastics. But presumably when you went through it, and even

00:12:10.140 when I went through training, those were the exception. Most of them were still doing five years

00:12:14.600 general surgery plus two years of plastics, right?

00:12:16.860 Right. And that's just what I figured I would be doing. I did an externship while I was in medical

00:12:20.920 school that happened to be, not happened to be, but coordinated with one of the hospitals where

00:12:25.460 he was in attending. So I got some very, very close mentorship there. I was doing things with him

00:12:30.460 in medical school that he wasn't letting his fellows do in rotation in the hospital. So it was kind

00:12:35.860 of interesting. I felt like I had a nice leg up. I got to watch him interact with patients in his

00:12:41.120 practice as well as see him operate. And he really was an amazing teacher and a great mentor of mine

00:12:46.260 and really changed the course of my whole life really into the surgical end of medicine. And

00:12:51.720 seeing how he dealt with patients, seeing his passion for the artistry and getting the results

00:12:56.520 taught me a lot. He was a low CD, which is great. That's exactly what you want in a surgeon.

00:13:01.560 Yeah. I think you want that in your engineers, your accountants, and your surgeons.

00:13:05.620 For sure.

00:13:06.000 So I remember just being ecstatic. Just every time we were together, it was like,

00:13:10.380 what are we seeing next? And so I always thought that plastic and reconstructive surgery,

00:13:14.180 that's kind of where I was headed. And it really wasn't until I met a patient who had had a hair

00:13:18.260 transplant, did I even consider looking at hair transplant surgery as a potential procedure that

00:13:25.240 I would even want to perform. I thought it was all painful or pluggy looking. Like why would anybody

00:13:29.400 ever want to have a hair transplant? It was just totally out of sight, out of mind. And when I met this

00:13:33.720 patient and I couldn't tell that he had had a hair transplant, I was basically blown away. I was

00:13:39.580 like, well, we need, let's talk about this for a minute. And of course he was getting something else

00:13:42.820 done at that day. And I was the good resident doing the intake forms and the paperwork. And he was

00:13:48.080 telling me about why he flew here or there to get his hair transplanted. And he was a layman. He told

00:13:53.840 me all about what he knew about the procedure. And I'm looking at his scalp. Do you mind if I ask you,

00:14:00.100 where did you get this procedure done? You know, where did you have this procedure? And he said,

00:14:03.620 oh, up over there in Canada or something like that. And I said, no, where on your scalp? He's

00:14:07.260 like, well, right here at the hairline. And so he started to explain to me in layman's terms,

00:14:11.600 the use of single follicles, I mean, individual hairs.

00:14:15.040 What year was this?

00:14:16.000 This was in the mid 1990s.

00:14:18.040 And what year were you in your training?

00:14:19.900 So I was in my second year of general surgery or the end of my first year of general surgery.

00:14:24.500 I was thinking to myself just after that conversation, because he was so ecstatic about it. And it was

00:14:29.240 really something I never thought about before. And it was kind of unusual that the result was

00:14:34.960 totally different than what I expected. Because, you know, as a general surgery resident, you think

00:14:38.140 you know a lot, you know, you think you know everything. And first of all, why would he have

00:14:41.080 gone to Toronto to have the procedure done when everything is here in New York, you know, which

00:14:45.100 is where I was trained. So, you know, a lot of things kind of struck me that way. But it was,

00:14:49.420 it was exciting. And to see that, and to see that it could be done in a way that was totally

00:14:54.480 unexpected to me. And of course, I'd watched my dad go through his hair loss process. So

00:14:58.620 immediately, I'm thinking, maybe my dad should look into this. And I thought then also, well,

00:15:03.320 if this is that good, maybe I should look into it and perhaps learn how to do it so I could add

00:15:07.860 it to my future practice later on down the line. And so that started me on the path to like looking

00:15:13.780 into hair restoration, hair transplantation as something maybe I would consider doing.

00:15:18.960 Well, I want to come back to that because I want to know about the genesis of the surgical

00:15:24.580 perfection. I mean, to me, one of the fun things about surgery is kind of understanding how

00:15:29.360 operations evolve. You know, I chose the residency program I chose because of its proficiency in doing

00:15:34.720 this Whipple procedure. And so you would go in there, you would learn everything about how barbaric

00:15:39.900 that procedure once was and how over years of being perfected in surgical technique, even the type

00:15:46.820 of suture that was used, the mortality of that could fall from 50% to, you know, 0.3%.

00:15:52.240 So I want to, I want to actually come back to this, but I guess I want to take a step way back

00:15:57.360 and just talk about hair loss in general. So how common is it, uh, I guess, both in men and women

00:16:02.860 to start with that. So hair loss is super common. Almost a hundred million Americans are suffering

00:16:07.540 from some, some form of hair loss. And we know now it could be as close to 80 million men and even 46

00:16:14.660 million women out there who are struggling with the hair loss process. So there's a lot of people out

00:16:19.520 there who are experiencing hair thinning. They may be experiencing receding hairlines, loss of volume,

00:16:25.520 loss of coverage of their scalp. And it's a, it's a big concern for many, although very much

00:16:30.720 undertreated. And is there data on how many people care? I mean, or what percentage of men with hair

00:16:37.360 loss care versus what percentage of women? Like, is it naive to assume that this is even though a

00:16:43.520 smaller problem by numbers in women, that it might create more distress in women?

00:16:48.020 Well, first of all, everybody cares about hair, don't they? I don't know. I don't understand

00:16:51.140 the question. No, but certainly it varies because, you know, you could be a young guy in your twenties

00:16:58.940 losing your hair and, and be really devastated by it. Or you could be someone who has a slower

00:17:03.700 hair loss problem with the exact same amount of hair loss, but at a much older age. And you may be

00:17:08.720 at a different place in time where you may not necessarily be focused on that hair loss.

00:17:12.840 And remember that in men, it's socially acceptable. I'm looking at your bare scalp to shave down to

00:17:18.720 a number zero or two or one, or, you know, with a, with a trimmer, maybe that you shave once every

00:17:24.380 other day, perhaps once a week. So, okay. So there you go. But the point is, is that in women,

00:17:29.500 there's no socially acceptable option for female hair loss. And so it can be much more devastating

00:17:35.760 for sure. Even though it's easier to cover in women. So there's, is a lot of nuance there. Women

00:17:41.480 can lose, you know, half their hair and you would look at them across the room and think that they

00:17:46.260 have a full head of hair. And that's how the physical optics of hair fibers work. Meaning that

00:17:51.260 you can lose 50% of your density and from across the room, the coverage will be pretty much the

00:17:57.320 same. Okay. Well, that's really interesting, right? Because yeah, some people listening to this

00:18:01.640 might say, or get a mental image of somebody loses half their hair, like one half of their head is

00:18:06.080 bald. The other is not, of course, that's not what you mean. You mean evenly distributed across

00:18:09.840 their head, half the density, you know, you, you, every two follicles become one. That's pretty easy

00:18:14.560 to mask the longer the hair is right. Right. And of course, you know, female pattern hair loss happens

00:18:19.280 in a very specific pattern behind the hairline. That's where that density loss can occur. So it's not

00:18:24.060 equally, it's very rarely equally distributed and same in men. There's a very specific pattern that you can see

00:18:29.700 basically progressing from across the room, but it's a, it's a commonly accepted knowledge point

00:18:35.860 that you can, and we see it obviously every day in the office that you can lose 50% of the hair mass.

00:18:40.860 So that might be a number that's a combination of the density and the diameter of the hair.

00:18:45.300 If you lose 50% of that, that's roughly the break point between coverage and, you know,

00:18:50.680 maybe some see-through to the scalp. Does that make sense?

00:18:54.020 It certainly does. Yeah. So you alluded to something, I guess I hadn't even really thought about,

00:18:57.880 which was, you know, someone losing their hair very young. So is there a definition

00:19:02.520 for premature hair loss? Like, cause you hear that expression thrown out there, but does it mean like

00:19:07.300 everybody to the age of X is supposed to have perfectly normal hair volume and anything,

00:19:12.960 anyone that loses hair below that it's quote unquote premature?

00:19:15.520 No, that doesn't make any sense. Sort of a bogus term.

00:19:17.520 Premature is in the eye of the beholder. Obviously, if you think that you're prematurely losing your hair,

00:19:22.340 just like prematurely gray, right? So there's a spectrum. Some people go gray in their

00:19:26.040 twenties. Some people go gray in their eighties. Some people never go gray. So how quickly you go

00:19:30.800 gray is genetically predetermined. If 70 is the new 50, then maybe you don't want to be gray at

00:19:37.000 70. So hair loss is very much the same thing. But, you know, when we see young men, I mean,

00:19:42.480 hair loss can start anytime after puberty, right? 20% of men in their twenties, 30% of men in their

00:19:46.940 thirties, 40% of men in their forties have visible signs of hair loss.

00:19:51.100 That's a quick heuristic with percentage by decade.

00:19:53.580 Yes. Pretty darn close. And so what does that mean? Remember I said that you can lose half

00:19:57.500 your hair by the time it's noticeable to the naked eye. So immediately after puberty, that's when

00:20:02.380 hair loss starts. And this is predominantly more in boys than girls though. Correct. We were talking

00:20:07.020 about male pattern hair loss, right? When I give you those numbers. So the female hair loss,

00:20:10.620 typically it's a little bit later on and there's, it's more multifactorial. We can see other things

00:20:14.660 that are affecting the hair loss process. You know, women are just more complicated, man.

00:20:18.520 Yeah. Yeah. They, they do have that luxury. So like, yeah, you mentioned for a moment ago,

00:20:25.840 like that, uh, that if you're graying, that's genetically determined. How much is hair loss

00:20:30.020 genetically determined?

00:20:31.120 In men it's 99%, 98, 99% is genetically determined. How quickly it's noticeable to the naked eye,

00:20:38.060 where it progresses to somewhat of the pattern, you know, is it more loss in the front versus the

00:20:42.860 crown? You know, there's some variations there genetically. Of course there's 200 genes that regulate

00:20:47.720 hair. And that would include color, curl, texture, and all of those play a role in terms of coverage,

00:20:54.720 right? Cause again, those are the physical properties and then hairstyling, of course.

00:20:59.040 So if you're a 20 year old guy and you know, with your friends hanging out in the bar on a Friday night

00:21:04.120 and you are experiencing some recession of the hairline, you may be one out of your group of

00:21:09.340 friends that's having some significant male pattern hair loss. So for you, that's premature.

00:21:13.520 You're looking at the rest of the guys in the group, four or five friends. They all look like

00:21:17.260 they got pretty much full heads of hair and you don't. So that can cause a lot of stress and

00:21:21.700 anxiety. I think in this day and age, you know, Instagram age or however you want to call it,

00:21:26.400 people want to look good and feel good. And they don't, there's, they don't want to be rushed into

00:21:30.380 having to accept the fact that they're going to look older than their stated age.

00:21:35.940 And I didn't realize that there were 200 genes that played a role in hair.

00:21:40.000 I never counted them, but that's what they said.

00:21:41.540 No, no, no, no. Directional. Yeah. So it's not a simple, if your dad or your mom's dad or something

00:21:48.760 like you, I've heard these things that say that that's the direction it tracks. It sounds like

00:21:52.440 you're, that's not the case.

00:21:53.560 Right. So X link mom's dad should tell you whether you're going to go bald or not. That's really not

00:21:57.900 the case anymore. We know that there's other factors that come from both sides of the family.

00:22:02.540 You know, the genetic components that play a role in all those factors that I mentioned,

00:22:06.920 you know, the, the color, the quality, the hair and so forth and speed at which the hair loss occurs

00:22:11.040 and the patterns and so forth. And I have friends who are brothers who one has total hair loss and

00:22:16.560 the other looks like he's got the thickest head of hair I've ever seen in my life.

00:22:20.020 And maybe one's good at football and the other good at math, you know? And so everybody,

00:22:22.960 that's how genetics work. It can skip siblings. It's recessive gene. So it could skip generations,

00:22:28.380 you know, or it can be a wipeout. I mean, I have the grandfather bringing in,

00:22:32.460 or the dad's bringing in the grandfather and then the kids come in and, you know,

00:22:35.800 and it's like a whole family affair because the, you know, the force runs strong in that family,

00:22:39.940 if you know what I mean. Now talk to me a little bit about what's going on with women,

00:22:43.040 because I am aware of this only in that, you know, I've taken care of more and more women over

00:22:48.020 the past few years. I realized that it's sort of like you say, like, I don't even notice it,

00:22:53.160 but they notice it. Right. And they'll say, you know, do you think that this hormone is right in me

00:22:58.660 or this hormone or taking a step back? I certainly remember watching my wife go through pregnancy,

00:23:04.480 right? Where her hair would get very, very thick. You have a baby, a lot of that hair falls out,

00:23:09.700 and then it just kind of all grows back to normal. So putting that aside for a moment,

00:23:13.380 which is, it must be clearly driven by hormones. Hormones, of course. So the amount of follicles

00:23:17.580 that are in antigen when you're in pregnancy is a much higher percentage. So antigen is the growth

00:23:22.800 phase. You're going to have more follicles staying in antigen, longer time in antigen. So

00:23:26.720 your hair will be thicker and fuller during that time of your pregnancy. And then when the hormones

00:23:30.440 crash back down after childbirth, then those ratios go back to normal. And a shedding phase,

00:23:37.040 an effluvium or telogen effluvium can occur in about six to 12 weeks. But if you're prone to

00:23:43.500 female pattern hair loss, sometimes you don't necessarily recover from that dramatic effluvium.

00:23:51.880 So you shouldn't just say, oh, well, it's just pregnancy shedding and that's it. Because sometimes

00:23:56.760 women come in and they say, look, I had my kid three years ago. My hair never rebounded from that

00:24:02.220 situation. It changed right after that. And the other thing I hear women say a lot

00:24:07.720 is the thickness was never the same after. So it's, they don't, I mean, I don't know that

00:24:13.000 that one of us, meaning me or the patient is skilled enough to assess follicular density,

00:24:18.420 but thickness is very easy for the patient to accept. And, you know, I've heard women say a lot,

00:24:22.780 you know, after my third kid, like my hair is so thin and they're referring to the actual hair

00:24:30.240 itself. Right. Well, they could be referring to the hair fiber diameter and that can change just

00:24:35.160 with age. Honestly, it gets thinner with time, but it could also be that they feel like their whole head

00:24:40.780 of hair is not as thick as it was. And that would be a volume issue. So that could be the sheer numbers

00:24:46.180 of hairs that are growing at any given time, giving you what's just call it the ponytail volume.

00:24:50.980 You know, a lot of women will say, you know, when I was in my twenties, I put my ponytail in the,

00:24:56.260 you know, with a scrunchie or whatever, or a rubber band. And it, I could just, I turned it two times

00:25:00.640 and boom, that was it. It was like a, you know, a horse's tail. And now here I am 10, 15 years later,

00:25:05.480 and I have, I can turn it three times, meaning that they need another wrap.

00:25:09.880 That's an interesting litmus test I would have never thought about.

00:25:12.540 Yeah, for sure. So, um, and of course now in the, in the office, we have scientific methods,

00:25:17.040 ways, devices, tools that can actually quantify different areas of the scalp and give us literally

00:25:23.360 cross-sectional bundle measurements of scientific ponytails. And we can go back to the same area

00:25:28.440 again and again, but we may be going ahead of ourselves in terms of diagnosis and treatments

00:25:32.940 and such, but there are ways to measure that. When someone says, I have less hair or I have thin hair,

00:25:38.880 we need to figure out what exactly does that, what are they saying when they talk about that symptom?

00:25:43.240 Because shedding is also another confusing symptom. People say, oh, I have shedding.

00:25:48.060 Well, shedding happens every day. Hair follicles turn on and turn off. Hair follicles will grow for

00:25:54.040 five to seven years, a long, strong hair, and then turn off, rest for 90 days. And then the cycle

00:25:59.340 begins again. And a certain percentage of hair follicles are in that growing phase. Let's call it

00:26:03.880 84, 85%. But all of a sudden, if you do something to switch that, those percentages, then you're going to

00:26:12.200 get a thinner head of hair, meaning that there's less trees in the forest perhaps.

00:26:17.580 So going back to the males for a moment, which is pretty strongly genetically linked, as you said,

00:26:22.680 my overly simplistic view of the problem is dihydrotestosterone is a hormone that will

00:26:29.400 precipitate this in a genetically susceptible individual, which is why two of the most popular

00:26:34.980 systemic agents to mitigate male pattern baldness block the enzyme that turns testosterone into DHT.

00:26:41.420 Is that the only hormone that's playing a role? Or is that just the one that we have a treatment for?

00:26:47.680 Well, that is the primary trigger, according to the data that we see right now. And the data is very

00:26:53.640 clear. If you put someone on finasteride, about a milligram a day, they have a 90% chance of looking

00:26:59.780 the same or better into the long run. Long run for pharmaceutical clinical trials, you know,

00:27:04.700 is about five years. It's not infinity, but it's five years. And that tells you that, you know,

00:27:08.620 we're pretty close to, that's a pretty safe bet that DHT is the bad guy, you know, responsible for

00:27:14.700 a lot of follicular homicide out there. Does that mean that, again, as a thought experiment,

00:27:19.580 I don't think it would ever make sense to do this. If the moment a boy went through puberty,

00:27:24.320 he was put on finasteride, are you suggesting that there may not, like that might be enough

00:27:29.720 to mitigate baldness, at least in men, because I think in women, it probably is different, correct?

00:27:33.800 Well, there's always, and the answer is complicated. Yes, I think that would help in

00:27:38.140 a huge percentage. I'm not advocating that, of course. But remember that even if you put someone

00:27:42.880 on a finasteride or even dutasteride, which is a stronger DHT blocking agent, right, blocking

00:27:47.400 both pathways to DHT, you still squeak by with a little bit of DHT. So there is still some of that

00:27:54.680 happening in the body, even with those strong pharmaceutical blockades.

00:27:59.500 And these things are not without their side effects. I mean, some set of men experience

00:28:03.640 sexual side effects with them. And I mean, I think the literature in the prostate land is still

00:28:10.820 very confusing about lower rates of prostate cancer, but potentially higher grade when it strikes and

00:28:16.960 all of this confusion. So I can tell you how that's been explained to us as hair surgeons by the

00:28:22.140 urologists that were involved in some of those studies. For example, finasteride, five milligrams is,

00:28:27.460 you know, one of the more prominent treatments for BPH, benign prostatic hypertrophy, a large

00:28:31.900 prostate. You put somebody on five milligrams of finasteride, their regular prostate tissue shrinks.

00:28:37.680 And so that's likely what's happening also at a one milligram dose. And so what happens if the

00:28:43.380 normal prostate tissue is shrinking and you go to biopsy that tissue, you may be more likely to find

00:28:50.100 some high grade cancer or cancerous material in there just because the normal tissue is less

00:28:57.460 voluminous. So that's why not everybody in the world gets a prostate biopsy, but everybody in a

00:29:03.240 clinical trial does. So that can skew the numbers. And that can, I don't know if I'm explaining

00:29:08.340 correctly, but that's one of the ways it's been explained to us in the world of hair restoration

00:29:12.920 surgery, that you're not causing the prostate to become cancerous. And of course, you know,

00:29:17.820 thank God people don't die of prostate cancer. It's, you know, it's a, it's a very slow moving

00:29:21.900 thing. Obviously there's a very good survivability, uh, if you should be diagnosed, but the point is,

00:29:28.060 is that you're shrinking that good, healthy tissue. And then you're more likely to find

00:29:31.600 something on the biopsy and that more likely to be high grade and, you know, high grade cancers in

00:29:35.800 prostate are very, very rare. So it doesn't take much to skew the numbers from like, let's call it,

00:29:40.940 and I don't, don't quote me, but let's call it a quarter percent to, you know, three quarters of a

00:29:44.640 percent, you know, all of a sudden it doubled, you know, it could be just a couple of biopsies

00:29:48.640 to throw it off. So, you know, you talked about finasteride, which of course is the generic name.

00:29:54.360 Proscar is the five milligram formulation of that. And Propecia is the one milligram formulation,

00:30:00.220 correct? Correct. Which are both now off patent, obviously, you know, as you know.

00:30:04.800 Were they developed in parallel or was it first a BPH drug? And then they noticed,

00:30:08.760 hey guys, hair is falling out less. Oh, we don't need to use as much of this. Let's create a new drug.

00:30:14.260 I will tell you that Merck knew from the get-go that it was going to be a hair loss drug.

00:30:19.880 They also knew about the effect on the prostate. They went after the prostate indication first,

00:30:24.920 got that FDA approval, and then did the, and had safety studies and such done for that,

00:30:30.340 and then pursued the hair loss indication after. And it was FDA approved for hair loss as a one

00:30:35.900 milligram dose in 1998. Got it.

00:30:38.020 So, it's not, it was not serendipitous as minoxidil was. And some people confuse those

00:30:43.520 two stories. Like, oh, this prostate drug, you know, they figured out it grew hair. No, no,

00:30:48.060 that's not the way finasteride came out.

00:30:50.160 Wasn't minoxidil, at least systemically, a blood pressure drug?

00:30:54.540 Yes. So, I think back in the 70s, minoxidil was administered for hypertension. And it was,

00:30:59.860 I think it was people who were on dialysis, honestly, that were being noted to be on this drug for

00:31:04.080 long periods of time. And the people running those clinics were seeing patients on minoxidil,

00:31:10.800 oral minoxidil, and they're literally growing hair on their knuckles almost, you know, and seeing hair

00:31:15.120 growth in other places. And that's how they, and it wasn't really that great of a blood pressure

00:31:19.620 drug, minoxidil. And so, that's when they decided to move it into a topical. One man's side effect is

00:31:25.660 another man's indication, right?

00:31:27.940 Yeah, yeah, for sure. The story of Viagra, not quite as elegant, but similar.

00:31:32.360 Yeah. So, we'll come back to minoxidil because it's topical. And that's what Rogaine is by brand

00:31:38.080 name?

00:31:38.440 Correct. So, Rogaine was the first drug. Rogaine was a minoxidil formulation with propylene glycol,

00:31:44.560 and that was the first FDA-approved medication for hair loss. So, that is an important data point

00:31:49.640 in the history of hair loss. You know, when we write the history books, that really started

00:31:54.080 hair loss as something that we can treat and the beginning of the end, if you will, of a snake oil era.

00:32:01.400 So, Rogaine is purchased over the counter, correct?

00:32:04.120 Correct. So, today, Rogaine's available in a number of different formulations over the counter. You can

00:32:07.940 get 2% or 5% solutions or foam versions. There's generic versions all over the place. But the problem

00:32:16.000 is, is that most of those are very, very irritating to the scalp. They can be very greasy or gooey.

00:32:21.920 The foam versions, if you have any kind of hair on your head whatsoever, can be very difficult to

00:32:26.160 apply to get into the scalp. So, those formulations have some issues. And that's why Rogaine, if you

00:32:32.960 will, or over-the-counter minoxidil is consistently ranked as the most disappointing hair loss treatment

00:32:38.200 ever by Consumer Reports. They had a big report on that a number of years ago. And the reason is

00:32:43.140 because it's very difficult to use. So, I would say about 15 years ago, we started looking at

00:32:49.320 compounding pharmacies to really help us make a better minoxidil. Could we create a minoxidil that

00:32:55.520 was penetrating better, easier to use, less irritating to the scalp, take advantage of some

00:32:59.980 of the other knowledge that we have about the hair loss process, like inflammation and so forth.

00:33:05.140 What can we do to potentiate or accelerate the movement of minoxidil across the epithelium into the

00:33:11.600 location of the follicles where we need it the most? You know, and that's where we came up with

00:33:15.520 some of these more sophisticated formulations, like 82M and 82F and so forth.

00:33:20.200 All right. Well, I want to come back to that as well, because that sounds super interesting.

00:33:23.180 Going back to just close the loop on the pathophysiology in the women who, and again,

00:33:29.380 separating it from sort of the pregnancy cycle, you know, you have a woman who 20 years after or 10

00:33:35.040 years after having her last child starts to say, you know, my hair is getting thinner. And it's to

00:33:41.060 the point where she's noticed that either just based on the volume of hair coming out in the

00:33:45.020 shower, brushing her hair on a pill or whatever, and, or even just able to visually see the

00:33:49.480 difference. What do we think is driving that? Acknowledging that it's going to be more complicated

00:33:53.960 than just her DHT, which is probably very low. Yeah. Her DHT levels could be very low,

00:33:58.460 but she can also be androgen sensitive. So there is about a 50% success rate when you apply finasteride

00:34:04.920 in post-menopausal women with hair loss. When you say apply, you mean don't take it orally?

00:34:09.340 Orally. Oh, I thought that it was completely contraindicated in women.

00:34:12.380 Well, women of childbearing age, it can be used off label in post-menopausal women because the

00:34:17.120 risk is to a developing male fetus. And that's the main issue because, you know, DHT in a developing

00:34:22.360 male fetus is the driver that makes men look like men for lack of a better way to explain. So, you

00:34:28.460 know, we would never want to use finasteride in women of childbearing age, and it's not FDA approved

00:34:33.840 at all in women. And for those reasons in particular, and, but we do know that there are some studies

00:34:40.820 out there that showed that 50% of women who are in these clinical trials with female pattern hair

00:34:46.120 loss post-menopausal, right? No risk to a developing male fetus at all. We're treated with finasteride

00:34:51.100 and they got some response from it. So their DHT may be a driver in some of those patients. So

00:34:57.600 what androgen sensitivity is something that is, I mean, we don't know the incidence, but let's say

00:35:03.720 50% of women with hair loss have some degree of androgen sensitivity that could be driving it.

00:35:08.640 And, you know, if you think about, for example, the most common hormone abnormality of women of

00:35:13.520 childbearing age with PCOS, what are the things that kind of roll together in PCOS syndrome? There's

00:35:19.220 acne, there's hirsutism, hair growth on the face, and acne, did I say that? And, and hair loss. And so

00:35:25.540 those are the, what are the, all of those have in common? They're all androgen processes. Correct. So,

00:35:30.240 so there, it is, there is a common androgen connection. So do young women with PCOS also experience hair

00:35:36.840 loss? Yeah. It's devastatingly bad. God, I just, I didn't realize that. Yeah. It can be

00:35:41.220 devastatingly bad. Very common in PCOS. A lot of our- And you're stuck because they'd probably

00:35:46.300 respond to a 5-alpha reductase inhibitor, but they're in childbearing years, so you couldn't

00:35:50.760 use it. Correct. They're under treatment typically to improve their fertility. Yeah. So it's a delicate

00:35:56.460 dance, you know, so we're left with other non-androgen modalities. And so that would be

00:36:01.780 minoxidil to directly stimulate the scalp, maybe low-level laser therapy to impart energy to

00:36:06.820 the hair follicles, maybe injectable treatments like PRP and so forth.

00:36:10.920 Do those women in particular, these young women with PCOS, can their hair loss be restored or is

00:36:16.700 it permanent? Well, that's a trick question because- Meaning if you resolve the PCOS, you know,

00:36:21.780 you can treat them and they can bear children and such. Will they also regain the hair that they lost?

00:36:27.220 It's tricky. So here's the thing. If you can normalize their hormones, many of their hair loss

00:36:31.340 symptoms improve slightly. But remember that once the follicle is, let's call it just damaged beyond

00:36:36.300 repair, miniaturized down to a certain level, it reaches a point of no return. So the terminal hair

00:36:43.020 is a good, healthy oak tree in the forest. That's the, your best, best quality hair is a terminal

00:36:48.600 hair. Velous hair is the type of hair you have on the top part of your cheek. It's invisible. It's

00:36:53.440 less than two millimeters long. It doesn't have any pigment to it. And it's very thin in terms of its

00:36:58.040 diameter. So if a follicle was producing a terminal hair and then it miniaturizes all the way down to now

00:37:03.860 creating a vellus hair, you're out of luck. Meaning that there's nothing that we know of,

00:37:09.080 that I know of, that's going to revive that follicle and get it to regain any kind of significant

00:37:15.040 amount of growth. So whatever kind of hair loss you have, male, female, the idea is that you got

00:37:20.940 to take action soon to protect the functioning of the follicles before there's that point of no

00:37:25.580 return. That makes sense. You alluded to Rogaine being the first drug or topical agent that actually

00:37:33.840 had clinical efficacy, which therefore I think you described it very nicely as the beginning of the

00:37:41.820 end of snake oil, not the end, but at least the first shot across the bow that this could be a

00:37:47.800 legitimate industry. Correct. Just briefly, what are some of the top three, top five snake oil

00:37:54.680 things that were being peddled out there to people? Oh gosh. Well, we'd have to go back to

00:37:58.920 the history books, but you know, there were all kinds of tonics and such that were promoted through

00:38:04.720 advertising and so forth. Yeah. Like when you, I feel like when you, when you look at old magazines,

00:38:08.760 like there's always ads for exactly like some tonic or some, some ridiculous chemical that you

00:38:15.720 could Dr. Johns, whatever, you know what I mean? You know, and there's always like a picture of a,

00:38:19.540 you know, hair, woman with a beautiful long head of hair. And so, you know, what happened was,

00:38:25.200 is that then I guess it was, you know, it was Johnson and Johnson or whoever it was that had

00:38:28.980 Rogaine was then able to say, you know, you can't advertise hair growth from that kind of, you know,

00:38:36.060 lavender oil extract because we have FDA approval for that now. So that was the method that kind of

00:38:42.360 started to clear out the industry, if you will, moving some of those literally oil treatments,

00:38:48.680 top tonics and so forth that had no clinical efficacy whatsoever out of the market. Because

00:38:53.780 now if you, in order to advertise hair growth, you had to have that FDA clearance. You had to have

00:39:00.220 that FDA approval behind you. So, and we don't have to do an exhaustive list now, but I would love

00:39:05.180 to list to an exhaustive link in the show notes, but what are some of the snake oils you're seeing

00:39:11.640 out there today that people come to you saying, you know, I've been where I've been on this and

00:39:15.260 it hasn't been working? Or what do you think about this? Well, you know, there, there is a long list,

00:39:19.960 but you know, here's the thing you have to be careful because, you know, people say, oh, well,

00:39:22.960 you know, Rogaine didn't work for me, but remember we said earlier on that. Yeah. Application matters.

00:39:28.560 Application makes a big difference. Compliance. Most people, they pick up a bottle of Rogaine. They,

00:39:32.960 they're lackadaisical about it. They don't do it twice a day. They can't get it on their scalp. They have

00:39:37.140 some kind of irritation. They get, they don't know that it's working. So a lot of it is expectations

00:39:42.400 too. So, right. So, you know, people say, well, yeah, yeah, that Rogaine didn't work or, you know,

00:39:46.860 this handheld laser that I bought back in, you know, 1999, you know, it was supposed to grow hair,

00:39:52.540 but it doesn't. But well, the problem with, for example, that small little handheld laser is just

00:39:58.660 that you're trying to water your lawn with a watering can when really what you needed was a

00:40:03.320 sprinkler system. You needed a different type of delivery system. So that, you know, we kind of

00:40:08.000 get into trouble sometimes saying, well, you know, that people thought that laser was a bogus

00:40:12.700 treatment. Even my colleagues for many, many years thought that low-level laser therapy had no

00:40:17.320 influence on the hair follicle. And obviously they were all proven wrong by the exhaustive studies

00:40:22.200 that have been done now and all of the FDA clearances, which prove not only safety, but certainly

00:40:27.360 hair growth. And we've seen patient after patient. And what about like biotin and things that you see

00:40:33.080 people taking like these tablets or these makeshift things? New York is full of doctors who,

00:40:40.060 I just know this because when you do an intake with your patient, you find out all the medications

00:40:43.540 they're taking. And there's like all these cocktails of pills that they're taking for hair growth. And

00:40:47.920 I'm, you know, I'm obviously familiar with some of them like finasteride, dutasteride, but

00:40:52.020 I mean, biotin, what is biotin? Well, you have to know, you know, what they actually do.

00:40:56.360 Biotin has been shown to improve keratin production, not only in the animal kingdom,

00:40:59.700 because it's used in horses who have hoof issues. And a lot of that science is real,

00:41:03.860 is out there. You know, you can, you can put a horse on a high dose biotin and their hoofs

00:41:08.440 improve. And that would be important if you're, you know, raising thoroughbreds, for example,

00:41:12.120 because a hoof problem in a valuable racehorse is a big issue. So there's no question that there's a

00:41:19.860 lot of science and data out there. It's less, honestly, in humans, there are less data out there.

00:41:24.700 But, you know, if you put patients on biotin, a high dose, let's say 10,000 micrograms,

00:41:28.940 nine times out of 10, they'll tell you their nails are getting stronger. And we know that you can do

00:41:34.060 hair tensile strength studies and pull, you know, literally stretch and pull on those hairs and see

00:41:38.580 the strength improve. But remember that that's not going to improve your female pattern hair loss or

00:41:44.660 male pattern hair loss problem to any substantial amount. It may make the hairs that you have stronger,

00:41:50.860 but it's going to need to be coupled with some other effective treatment. And that's where layering

00:41:56.920 these kinds of therapeutic interventions are really, really important.

00:42:00.620 So have you ever had a patient come to you and say-

00:42:03.560 With a bag of vitamins?

00:42:04.940 No, no. Have you ever had a patient come to you and say, I'm 25 years old and everyone in my family

00:42:10.760 has lost their hair, you know, when they're in their forties. I'm, and it's male or female,

00:42:15.360 by the way. So feel free to answer the question differently. Is there anything I can do

00:42:19.240 preventatively, even though now my hair is still seemingly perfectly normal, but it look, if,

00:42:25.720 if history repeats itself in 15 years, I'm going to be losing it or it's going to be thinning.

00:42:29.400 Well, a lot of my patients come to me with that exact question and concern. Many of my

00:42:34.000 patients who we've transplanted or treated with other therapeutic interventions will bring in

00:42:38.160 their teenage sons or daughters and say, listen, you know, I got measured too late. Can you measure my

00:42:45.580 son or daughter? They're going off to college. They're going to grad school. Let's get them

00:42:49.180 measured and let's see what's going on. And then the son or daughter may or may not have a concern

00:42:52.520 very often. It's the parents, um, just like probably they paid for braces. So, uh, you know,

00:42:57.880 they're concerned about keeping their, their child's hair intact, or at least as long as it

00:43:01.900 possibly can. So we'll perform some evaluations and measurements. So we, we know that there's a

00:43:06.700 hair loss risk in the family. The father's a hair transplant patient, obviously, or something

00:43:10.860 like that. We'll use the trichometers to do hair bundle measurements. We'll look at the areas

00:43:16.480 that are permanent, for example, in the back of the scalp. And we'll measure that and see what is

00:43:20.700 their maximum hair mass index. That's the, that's the term that we use for the number that is a

00:43:26.960 combined measurement of the diameter and the density in a given area of scalp. And then we'll

00:43:31.160 compare that area to an area that might be at risk, like the crown area or the frontal zone or in the

00:43:36.300 temples. And so it's normal to see a little bit less in the temple areas, but when you're going through

00:43:42.240 puberty, your hair mass is essentially all the same over the entire top of your scalp. So I can

00:43:47.880 pick up if they have a tendency towards hair loss very, very early on, way before it's noticeable to

00:43:54.580 the naked eye. They may not, young man may not even have a receding hairline. And we can tell by

00:43:59.860 measuring the instruments are so sensitive, we can tell already he's got maybe a, let's call it a 20%

00:44:05.400 loss in that frontal zone. Because you're sure that it's not just 20% less genetically.

00:44:11.940 Correct. It should be the same. You know, these areas are the same. I have patients that come in

00:44:16.520 and they get measured and they are the same. All of the areas measure A-OK. Now, a lot of those

00:44:21.540 patients are, you know, early teenage years, maybe, or women who have hair loss problems,

00:44:26.020 a different type of, not necessarily a hereditary hair loss problem, some other issue.

00:44:29.660 Is hair loss sort of like atherosclerosis where, you know, if you lived long enough,

00:44:33.860 everybody would get atherosclerosis. Is this one of those things where if you, you know,

00:44:37.620 because sometimes you'll see like, you know, like Ronald Reagan, even at the end of his age,

00:44:41.020 he looked like he had this thick mane of hair. If you did that high fidelity testing on him,

00:44:46.520 would you suspect you would have detected differences?

00:44:48.900 I'm sure. Yeah, I'm sure. I'm sure that it's not the same.

00:44:52.400 If someone figured out a way for people to live to be 500, everyone's eventually going to lose their

00:44:56.860 hair if they don't take some.

00:44:58.320 I think so. I mean, you know, there are a few exceptions. I have a friend of mine from New York. He's in the

00:45:03.160 music business and, you know, he's on the admin side, the managerial side. And man, he's got the

00:45:07.940 hairline that he had when he was a teenager. It literally goes straight across his head and it

00:45:13.060 has not budged. It has not moved and has not, I don't know what the exact density is. He doesn't

00:45:18.400 let his hair grow out. It's basically kind of like a buzz cut, but you can see that hairline straight

00:45:22.620 across. Now he, now I've come across tens of thousands, hundreds of thousands of people in my

00:45:26.960 life so far and I've never seen anybody else like him. So I don't know if it's a hundred percent true,

00:45:32.760 but I would guess that it is something like that where over time you will see some kind of thinning.

00:45:38.500 So what are these risk reduction techniques that, or what, what would you recommend for

00:45:44.000 to patients in that, in that situation?

00:45:46.980 Well, of course, in those early stages for men, sometimes the first visit to the doctor is their

00:45:52.240 visit to the hair doctor, honestly. And there may not be any other medical conditions that we can

00:45:58.280 necessarily pick up at that time that require, you know, drastic intervention. But if we switch

00:46:03.720 gears for a moment and look at a little bit of an older age category, either male or female, when they

00:46:07.780 start being on at the age where they're taking medications for blood pressure or cholesterol,

00:46:11.860 or they're on some mood modulators, those are some top, those are like the top three types of

00:46:18.980 medications that can really impact hair quality.

00:46:22.620 Oh, I didn't realize that. And is it always negative, I'm assuming?

00:46:25.040 Yeah, for sure.

00:46:25.520 So what were they again? So blood pressure.

00:46:27.240 So blood, yeah, antihypertensives.

00:46:29.640 Anti-lipid.

00:46:30.680 Right. Cholesterol modulating medications.

00:46:32.580 And is there a particular type, is it SSRIs or is there a particular type of,

00:46:36.660 you were a little vague in your description of that?

00:46:38.660 Yeah, I would say it's just in general, anything that decreases the blood that's being used to decrease

00:46:43.640 the blood pressure. I can't say if it's only SSRIs, but it's a general rule. If they're on

00:46:47.880 some kind of blood pressure medication, typically they can correlate. If you ask them pointed

00:46:53.640 questions, you can sometimes see at the time that they started that medication, that there is some

00:46:59.300 effect on their hair.

00:47:00.080 Now, how many of those things are sort of hypotheses you have versus documented facts?

00:47:04.180 Is that, I guess, I mean, not that I'm in this literature, but I didn't know any of those things,

00:47:07.720 actually. I didn't realize that hair loss was a side effect of those meds.

00:47:10.980 Well, it's just been so clear. I mean, I've treated about 20,000 patients and many patients say,

00:47:14.880 you know what? When I started that medication a year ago, fill in the blank, you know,

00:47:19.240 cholesterol medication, that's when I really started to notice my hair changed. And, you know,

00:47:24.940 when women tell you that their hair has changed, unlike many dermatologists out there, we believe

00:47:29.340 them. Very much so.

00:47:31.620 You're going to upset the dermatologist. Why don't dermatologists believe them?

00:47:35.080 Well, the general feedback from most of my patients is that they've been around,

00:47:40.840 unfortunately, they've been around the block to a number of different physicians,

00:47:43.240 maybe endocrinologists, dermatologists, their primary doctor, family doctor, whomever,

00:47:47.020 doing all sorts of blood tests, looking for why their hair is thinning. And no one has ever even

00:47:50.920 looked at their scalp, measured their hair, or talked to them about potential treatment options.

00:47:57.400 Except maybe an over-the-counter Rogaine bottle on the way out the door. Here, catch.

00:48:02.520 So a lot of dermatologists have a certain bias where they look at the woman who, as we've talked about,

00:48:07.960 looks like she's got a full head of hair and say, well, you're not dying of cancer, so you're okay.

00:48:11.320 And so this is not, I wouldn't say, it's a sweeping comment that I've made. I wouldn't say

00:48:16.480 it as appropriate for every single dermatologist out there. And I think that many derms are starting

00:48:20.740 to wake up to the fact that hair loss is important, something important to treat, and that it can be

00:48:27.580 devastating for many men and women who are experiencing it. So my heart goes out to them

00:48:32.160 if they've been to a dermatologist or several and kind of been ushered out the door saying, well,

00:48:37.620 you know, we're, we're here, we're, we're lopping off cancer growths over here. You know,

00:48:41.840 that's what we do. And so you got all your hair, you know, your, your hair looks fine.

00:48:45.360 Are there dermatologists in high volume places like New York and Florida that would be doing

00:48:49.480 what you're doing, which is they're taking a sort of either surgical or non-surgical approach,

00:48:54.600 but basically doing pure hair restoration. Like it sounds to me like one of the problems in that

00:48:58.960 scenario is, you know, if you're seeing a dermatologist who's mostly interested in skin cancer,

00:49:04.280 it's like you're asking, you might as well be asking your radiologist that question, right?

00:49:08.560 Yeah. Well, unfortunately, dermatologists often hold themselves out as experts in skin and hair,

00:49:14.860 but yet they have little ability to diagnose the hair loss process. They have no interest in

00:49:21.440 measuring or monitoring or prescribing even a treatment regimen and keeping a patient compliant

00:49:25.980 with it. So it's just kind of like a doorknob conversation for them. And they're,

00:49:30.060 they don't have the time to do it, honestly. I mean, a hair, a good, strong hair loss consult in my

00:49:33.960 office takes at least an hour. Typically patients usually spend about an hour and a half in my

00:49:38.340 office when they come in for a consultation, you're not going to spend an hour and a half with

00:49:42.500 your local derm. Certainly, you know, they're going to do a quick exam, you know, look for some funky

00:49:46.740 mole and then kind of send you on your way. So they don't have an hour to spend with you. So I think

00:49:50.920 it's part of it is that those practices are just not simply set up to treat hair loss.

00:49:56.860 So, so I mean, the takeaway is, I guess, if you're, if you go to see a doctor about a concern you have

00:50:02.640 on hair loss, find a specialist, find someone who's going to do a bunch of measurements. You

00:50:06.580 want to make as many objective measurements as possible. Absolutely. We'll find somebody who

00:50:10.080 does it full time. That's their area of expertise and specialty. And yes, who has those tools at

00:50:15.700 their disposal to measure and monitor and figure out what's going on or whether it's genetic testing

00:50:20.100 to look at androgen sensitivity and that post-menopausal women. I mean, a lot of derms

00:50:24.340 don't just don't have access to some of that stuff. And what, so what were the tests again? You do a test

00:50:28.260 of tensile strength, you do density and then you, what, what sounded really interesting was the

00:50:32.560 comparison density test, right? Where you do density in a region where there's never going

00:50:36.240 to be hair loss, make that your control and then look at the crown. Yeah. Crown or frontal and

00:50:40.520 temporal areas or anywhere really that the thinning is occurring. You know, you have to look at the

00:50:44.340 scalp and you have to see is the skin tone normal. And, you know, we've spent a lot of time talking

00:50:48.060 about hereditary hair loss, but there are many other types of hair loss. So, you know, figuring out

00:50:52.100 what's going on in each of these different areas, you know, requires someone to look at the scalp and see

00:50:57.700 what's happening. How many times do you look at the scalp and you see something completely unrelated,

00:51:01.780 like, you know, a fungal infection that can completely be treated and ameliorate the whole

00:51:06.720 situation? Quite often, actually. And one of the things that we've learned, I say I've learned over

00:51:10.780 the past maybe five to seven years is the impact on scalp health to hair growth. And, you know, we had

00:51:17.340 kind of an inkling that maybe this was important, but there is some good data out there, journal articles

00:51:22.480 and such that talk about, especially coming out of like the dandruff, if you will, treatment protocols

00:51:28.420 of zinc, pyrethione zinc, and some other treatment protocols for malathesia, the yeast overgrowths that

00:51:34.840 you get in the scalp that show that if the inflammation and the overactivity of those populations are out of

00:51:40.580 control, then you can get a detrimental effect on hair growth. So, we know that today, that scalp health is

00:51:47.140 important. So, the soil in the forest needs to kind of be fertile. And if it's really inflamed or there's

00:51:52.500 inflammation, you know, if there's inflammation going on, that can definitely shut down the follicle and impair

00:51:57.820 hair growth. So, that's important to look at that.

00:52:00.060 If somebody has dandruff, do we have a sense of how much that's increasing their risk of hair loss?

00:52:05.040 So, dandruff is kind of a nonspecific symptom, right? So, flakes, right? But flakes could be thick and yellow.

00:52:12.340 They can be small and white. Your scalp could be oily and dandruffy. They could be dry and flaky.

00:52:20.520 So, you know, that's a whole nother deep discussion on trichology, which is the study of the chemistry

00:52:25.460 of the scalp, essentially, where we look at scalp pH levels, moisture levels, sebum levels,

00:52:31.300 and really try to assess what's the right protocol of scalp care. Just like you would do that,

00:52:37.580 an esthetician might do that for your face, for your skin of your face. Well, we want to treat the

00:52:41.960 scalp in that same kind of way. Figure out, well, what's the right protocol? How often should you

00:52:46.480 shampoo? What's the right shampoo for you? And that's not sometimes a simple question to answer,

00:52:52.100 especially if you ever, well, maybe for you it is. But if you walk down the shampoo aisle in any

00:52:57.000 supermarket, you see that there's thousands of choices, right? So, there's got to be some

00:53:00.180 confusion there.

00:53:00.840 Yeah. Do you have any takeaways on what people should be doing? Are there any do's and don'ts

00:53:05.000 with shampoos and conditioners?

00:53:06.640 So, I think the best thing, well, of course, the do's and don'ts. So, shampoos and conditioners,

00:53:10.880 if you have any length of hair, you should always follow your shampoo with a conditioner. Shampoo is

00:53:14.780 like a degreasing, essentially. It's a cleanser. And if you shampoo in a harsh way or with a strong

00:53:20.420 surfactant, let's call it, then you're going to strip out a lot of the natural oils of the scalp

00:53:25.000 and also of the hair. And a conditioner replaces those natural moisturization of the hair. So,

00:53:30.880 it's kind of important to do both of those things. But there's a huge spectrum of different

00:53:34.940 types of shampoos. First of all, shampoo is not going to cure your hair loss. So, when you ask,

00:53:38.500 circling back about some snake oil type treatments, there's no one shampoo that's going to fix your

00:53:44.100 hair loss situation. But again, you have to understand if we can rectify some imbalance

00:53:49.700 at the level of the scalp and reduce inflammation or tackle a fungal overgrowth, and we're going to

00:53:55.640 start to improve some things. And if we have some ingredients that maybe we want to apply in the

00:53:59.720 shower while the scalp is kind of steamed, if you will, you know, sometimes that's the right time to

00:54:04.460 do it. But I guess the point is, is that finding the right shampoo and conditioner regimen for you

00:54:12.020 has to do with some of the variables that I just mentioned, the scalp pH level, moisture level,

00:54:16.980 oil level. What's your natural sebum production? What does your hair care regimen look like? Does

00:54:21.220 it require a lot of product or hairspray or things like that that need to be rinsed and washed out?

00:54:26.520 Are you in a dirty environment? Do you live in the city where there's smoke and toxins and things like

00:54:30.340 that, you know, and debris that you need to wash out of your hair on a regular basis?

00:54:34.720 So how does somebody, I mean, given that I don't think about this problem,

00:54:37.700 how does somebody who does think about this problem find out? I mean, is this something where

00:54:41.340 they, you can go to a website where there's like a, you know, if you fit these criteria,

00:54:47.500 this is the shampoo conditioner combo you should use?

00:54:50.460 Well, there are just some general guidelines, right? If so, if your hair is kind of long and curly,

00:54:54.600 for example, let's call it even kinky or Afro type hair, then you need like durable conditioning.

00:55:00.240 You need conditioners that kind of stick around for a while. If your hair is on the other end of

00:55:04.260 the spectrum, let's just call it like thin and kind of limp, then you need very, very light

00:55:10.380 conditioners. And you want to make sure you're using shampoo that strips out a lot of that oil

00:55:14.080 so that you get some weightlessness to the hair in order to style it. So those are some general

00:55:19.300 guidelines. I remember when my daughter was little and I would give her a bath. I don't know what,

00:55:24.200 this might've been just a total wives tale, but I remember that I was told shampoo is more

00:55:29.340 important in the scalp conditioner, more important. So you would start the shampoo at the head and

00:55:34.020 work out to the ends. And then when I would put the conditioner in her hair, I would start at the

00:55:37.820 ends and work up. Is that total nonsense? No, it makes some sense because the ends of the hair

00:55:42.220 are the ones that are typically the driest. It's, it's been around the longest. The hair doesn't

00:55:46.180 self-repair. It's a keratin fiber, right? That your body has produced. It's not alive. So when the fiber

00:55:52.420 is long, that means it's been around a long time. And so the tips of the hair is the part where

00:55:57.480 you're going to see a fraying of the hair, right? It's the part that looks the driest. It's the part

00:56:01.140 that's been had the most exposure to UV radiation and everything else, a heat, or if you've done a

00:56:05.880 Brazilian blowout or some other straightening treatment or curling treatment or coloring

00:56:09.580 treatment, the part that's received the most amount of abuse is the tips. And so the tips of the hair

00:56:15.560 are typically the ones that look the unhealthiest and feel the unhealthiest. They may be rough. The

00:56:20.900 cuticle starting to peel up. The ends are starting to split and fray. And if that continues,

00:56:25.840 obviously then that's, then it could lead to hair breakage, which can actually is a very common

00:56:30.240 problem for hair loss in women or trigger of hair loss in women, the hair breakage. Literally that

00:56:35.880 they've, they've stressed out the fiber so much that the fibers are actually breaking. And we see that

00:56:41.540 with harsh chemical treatments time and time again, or the new trends for flat ironing and such, you know,

00:56:46.380 where you put the hot ceramic flat iron again and again and again and again and again on your hair to

00:56:51.300 straighten it to straighten out the curl. And so that application of heat and or other products

00:56:56.880 can degrade the hair fiber. So you should condition the hair itself rather than the scalp, but don't

00:57:02.880 forget that sometimes the scalp needs a little love too. And we have a bunch of different types of

00:57:06.860 products that are for exfoliation and for moisturization and inflammatories and things like

00:57:12.660 that. I mean, obviously if you have a severe psoriasis issue, we need to get those flakes out of

00:57:17.580 there and we need to treat that psoriasis, you know, that's a bigger bit of business than just

00:57:21.320 trying to like, well, what kind of shampoo should I buy at the supermarket? Right. So once we get to

00:57:26.360 treatment, when I think about this, I kind of create four buckets. So I don't know if this is

00:57:31.440 right or wrong, but, you know, we've talked a little bit about systemic treatment. So something

00:57:35.760 that you take like a pill where it's going to act, you know, across your whole body, but you reap some

00:57:41.200 benefit in the hair follicle. And then we've talked a little bit about topical as well, like,

00:57:46.200 you know, minoxidil. I don't know if we would consider laser also topical, but maybe that could

00:57:51.660 be considered something topical. Well, let's talk about, for example, putting oral and topical

00:57:56.800 medications or pharmaceuticals in one bucket. And then let's talk about non-chemical therapies in

00:58:01.160 another. Okay. So our non-chemical therapies would be laser and or PRP. And so a lot of times during a

00:58:08.720 consultation process, we're looking to try to institute something that's going to help someone's hair

00:58:13.420 loss issue. And they may say, you know what, I just don't want the risk of side effects of this

00:58:17.620 drug. I don't want to apply this medication into my body. And I can certainly understand that they

00:58:21.900 may want to try something that's non-chemical, whether it's a real or perceived value of less

00:58:26.960 side effects. Laser has no side effects. Oh, I see. So you think of laser PRP topical as

00:58:34.540 maybe something you would try even before you go systemic. I mean, for a patient who wants to be

00:58:39.480 step-wise, obviously you could do them together, but. Well, for men and for women, it's going to

00:58:43.540 be different. So for men, we talked about the fact that finasteride knocks out the DHT level

00:58:47.460 and that's the primary treatment. It's a strong treatment, 90% success rate, very low incidence

00:58:51.480 of side effects. So for a guy, we're almost always going to consider that.

00:58:55.360 Correct. We're going to talk about that first. Now they may say, hey, no way, I don't want to do

00:58:59.320 anything that's going to lower my DHT level. And they may have heard or read about side effects.

00:59:03.380 They may have side effects. So there's ways to get around side effects, changing timing of the dose,

00:59:07.180 frequency of the dose, the amount of the dose, moving that finasteride from an oral treatment

00:59:12.320 to a topical with a prescription product like 82F is a way to get around that. So that would be for

00:59:17.200 men. Let's try to at least address the DHT issue first. And if we're not going to go that route,

00:59:23.100 then let's choose from the other tools in the toolbox. Now for women, because DHT is not the

00:59:29.100 issue most of women are of childbearing age, we're not even thinking about finasteride for them.

00:59:32.560 We're going to be looking at laser light topicals as kind of the first types of therapies and maybe

00:59:37.680 PRP. So talk to me about why does laser work? Why does it work? Or how does it work? Laser

00:59:42.360 works by imparting energy to the follicle. So we know now photobiomodulation is a very serious

00:59:48.220 science. Dr. Michael Hamblin did much of the lion's share of the research at Wellman Center for

00:59:53.060 Photomedicine here in Mass General at Harvard. He described, and this is going back now almost 15 years

01:00:00.040 or more, the mechanism of action of low-level laser therapy, how and where the photons of light

01:00:05.220 in specific wavelengths are accepted at the level of the electron transport chain in the mitochondrial

01:00:10.240 membrane, cytochrome C oxidase. And what you get is a hyperpolarization of that mitochondrial membrane.

01:00:16.280 And if you remember back from basic science that those ions flowing back and forth into and out of

01:00:21.100 the mitochondria is really what generates ATP for kind of a simple way to think about it. ATP is the energy

01:00:26.320 center within the cell. And if you can charge up those energy centers, if you can make those

01:00:30.320 mitochondria kind of fire up and produce a lot of fuel, you end up getting a better, stronger,

01:00:35.480 healthier hair growth. Do we know that in people who are losing their hair, there's a deficiency in

01:00:40.620 ATP production at the follicle? No. Or is this something that we're doing to override whatever

01:00:44.700 it is that's potentially causing the issue? We're trying to override it. And it's the same thing with

01:00:48.740 minoxidil. When you apply a topical medication like minoxidil, you know that it has nothing to do with

01:00:53.280 DHT, but you're basically pushing that gas pedal all the way down to the floor, trying to push that

01:00:58.920 follicle into the best possible growth. What is the mechanism? I forgot. It's so funny. I've never

01:01:04.540 seen a patient take minoxidil for blood pressure. And yet I sort of remember studying this in USMLE

01:01:10.520 part one. What is the actual mechanism? Yeah, it's a potassium channel opener.

01:01:14.200 Okay. And so what is that doing to the follicle?

01:01:17.240 Cool. So that's a great question and probably beyond my pay grade, but there are some many

01:01:22.180 physicians, great colleagues of mine in the UK who have kind of figured all of that out and I can

01:01:27.240 provide that research for you. But essentially what minoxidil does is it keeps the follicle in

01:01:31.900 the growing phase. So remember we talked about the antigen, which is the growing phase. And then of

01:01:36.720 course the catagentilogen, those are the resting degeneration phases of the hair follicle.

01:01:40.720 And we know that in a certain area of scalp, there's going to be about 84, 85% of the hairs

01:01:47.220 in a healthy area, 84, 85% of the hairs are in a growing phase. But as you get to a male pattern

01:01:53.000 hair loss or female pattern hair loss situation, many, many more follicles are in a resting phase

01:01:58.100 than in a growing phase before those ratios change and the hairs spend less time in a growing phase.

01:02:05.400 So the antigen phase starts to shorten. So that's one of the reasons why if you have someone with

01:02:10.540 thinning hair, whether it be male pattern hair loss in the hairline or female pattern hair loss,

01:02:14.660 let's say in the frontal zone right behind the hairline, typically you can make a part with your

01:02:19.100 comb and you can see these very, very short kind of spiky hairs. That is indicative of

01:02:25.900 miniaturization. And if you look at the microscopic level, you'll see even shorter, thinner, weaker,

01:02:31.360 wispier hairs than that. So what happens is that when you put somebody on minoxidil,

01:02:37.380 resting follicles start to kick into action and grow. So you're going to start to produce more

01:02:42.620 fiber. So fewer spikes, more of the long guys. Right. And the guys who are already growing that

01:02:49.000 may want to turn off too soon are kept in the growing phase. So those, the antigens can be

01:02:54.380 delayed, meaning that the antigen is going to keep going. And we also know that the longer you keep

01:03:00.220 a follicle in antigen, the thicker, the fiber becomes over time. So there's literally fewer

01:03:06.800 exits at the cellular level in the, in the matrix at the base of the follicle near the dermal papilla,

01:03:11.520 the cellular material continues to aggregate in that area and almost like swell essentially to,

01:03:17.240 as long as you keep it in the antigen phase, you actually get a thicker hair follicle over time

01:03:21.220 and a thicker fiber as a result of that. So your question was, how does minoxidil work? It decreases

01:03:26.720 the amount of follicles that are in that resting phase, keep them in the growing phase. And so

01:03:31.120 you're going to get better, thicker, stronger, healthier hair from those follicles that could

01:03:35.180 be rejuvenated, that are not too far gone. Yeah. Okay. That was the next question I was

01:03:39.000 going to ask you. Thank you. So let's go back to something you alluded to earlier, which is most

01:03:45.060 physicians, this is one thing I know about hair loss. Most physicians I've spoken with have said what

01:03:50.160 you said earlier, which is you don't want to buy minoxidil off the shelf. You should have it

01:03:54.840 compounded. Correct. What? I didn't realize that there was foams and I didn't know what the exact

01:04:01.280 issues were. So that's obviously one issue you're trying to overcome is create a different viscosity

01:04:05.960 that makes it easier to reach the scalp. But what are the other agents that they typically add

01:04:10.220 to minoxidil to make it more efficacious? So tretinoin, retin-A. Retin-A. Yep. Is excellent

01:04:16.160 to mix with minoxidil. Wait, wouldn't that also aggravate the scalp? Usually not. If the percentage is

01:04:21.060 a 0.025% that we're working with, you're not going to get an aggravation, but there's a lot

01:04:25.620 of good clinical data that shows that the combination of minoxidil plus tretinoin improves

01:04:31.260 the hair growth. So there's some basic science that describes the increased penetration. And then

01:04:36.900 there's also on the results and increased hair density and hair growth that you get from combining

01:04:41.920 minoxidil and retin-A. In, for example, the formula 82M product, which is our most powerful,

01:04:48.280 most popular treatment, most easily compliant version of minoxidil. It's a prescription

01:04:53.840 compound, obviously. You're going to have also a tiny little bit of flucinilone in there. So it's

01:04:58.440 a little anti-inflammatory. I'm not familiar with that.

01:05:01.880 It's a steroid anti-inflammatory. Oh, yeah. That's one that you would put on your skin if you've had

01:05:06.560 like a rash or something like that. Yeah, it's very common in the dermatological world. There's

01:05:10.880 basically a whiff of that in the 82M formula. So even, you know, inflammation is such a big

01:05:17.260 topic on this podcast. It comes up in every disease. I would not have thought it was going

01:05:22.580 to come up in hair loss. So I was part of a study in the University of Miami where they looked at

01:05:27.400 the microinflammation at the level of the hair follicle. We donated a number of follicles

01:05:31.860 from hair transplant patients from donor zones and recipient zones and such. And what they determined

01:05:37.580 is that there is an inflammasome, which is this mediator of inflammation that was discovered and

01:05:43.740 elucidated through some of that research. So there is microinflammation. It's very well-known

01:05:48.280 male pattern, female pattern hair loss. There is a lot of microinflammation at the level of the

01:05:52.180 follicle. So we think that maybe not only could the flucinilone that's in the 82M be making it more

01:06:00.480 tolerable to the scalp. Certainly people can have dermatitis from just about anything. You know,

01:06:06.140 you can put a piece of scotch tape on your head and have dermatitis from it. So maybe it's keeping

01:06:10.340 the scalp a little bit healthier in that way, but also addressing that microinflammation right at

01:06:14.940 the level of the follicle and shutting that down a bit. And that also helps us out in understanding

01:06:20.180 that there's some microinflammation also helps us understand some of the more nutraceutical

01:06:24.520 ingredients that we see. It also helps us understand maybe how some of our sophisticated

01:06:28.420 PRP creation techniques may improve hair follicle function. Once you understand that there is some bit

01:06:33.880 of inflammation going on, it kind of opens the door to some other modalities of treatment.

01:06:37.800 So we've established that for most guys, a combination of 5-alpha reductase inhibition

01:06:45.360 plus this type of a compounded topical minoxidil plus or minus the laser to hit. And it's so funny.

01:06:52.800 I'm totally familiar with that technology for some of the experimental use that's going on with

01:06:57.900 Alzheimer's disease for the exact same reason. It's hitting cytochrome C oxidase. By the way,

01:07:02.720 they're also using methylene blue, which is a cytochrome C oxidase activator as well.

01:07:07.800 But I'm guessing putting minoxidil, methylene blue on the scalp isn't going to be a great idea

01:07:12.440 because you're going to have to, for every time you apply it, you'll have to spend an hour washing

01:07:17.620 your skin to get the blue off.

01:07:19.620 Yeah. I don't know how that would work so well.

01:07:22.140 So that sounds like a pretty interesting regimen.

01:07:24.140 Unless you're coming here to Vegas to be part of the blue man group.

01:07:26.320 Yeah. I saw a woman in the airport today that had that going on. So she would be fine,

01:07:30.640 but she looked like she had great hair. So I don't think she needs it. For women,

01:07:33.480 you've got those two options, which is the same compounded minoxidil. You don't have to make a

01:07:38.000 different formulation for women.

01:07:39.180 We do not make a different formulation. AD2M works very, very well in our female patients.

01:07:43.200 Plus the laser.

01:07:44.220 Yes. They may use the laser. Plus or minus, they may or may not use low level laser therapy.

01:07:49.800 You know, one of the good things about the AD2M product just for the women specifically is that

01:07:53.840 it has a little bit of a skin conditioner and a hair conditioner in it. One of the main complaints

01:07:58.220 with over-the-counter Rogaine is that it just makes the hair nasty. It just makes it greasy and gooey

01:08:03.220 and basically unmanageable and stylable. And so the AD2M product goes on very, very clean and dry.

01:08:08.640 And we teach also how to apply it so that it's most active effect at the level of the scalp. And

01:08:13.660 you really don't get it on your hair. How do you, uh, yeah, yeah. I've never really understood that.

01:08:18.200 How do you apply it to, I mean, if someone's in the early stages of hair loss, or if it's a woman who

01:08:24.660 barely has hair loss, how do you actually get it on the scalp?

01:08:28.100 Yeah. And it's a tricky bit of business. And if you're using a Rogaine foam version,

01:08:31.060 then forget about it. Most of it is not getting on the scalp. And that's part of the reason why

01:08:34.840 a foam is not necessarily such a great option for women. But what we do is we teach how to part the

01:08:40.320 hair. The bottle of the AD2M comes in has a, an applicator tip. So you actually put the tip of

01:08:46.360 the bottle directly onto the scalp when you apply it. So you're, you're kind of parting the hair

01:08:51.500 and you're directing the application directly onto the scalp. So it may sound complicated,

01:08:56.940 but literally once you know how to do it, it takes you 90 seconds twice a day, every day.

01:09:00.800 And that's the other piece of the puzzle. Most people who buy minoxidil over the counter

01:09:04.480 think that once a day is going to do the job. And that very, very rarely has any substantial effect

01:09:09.960 on hair growth whatsoever. And what is the requirement of the laser? How often does that need to be done?

01:09:14.860 So that depends on the type of laser that you have, because the laser energy that comes out of these

01:09:19.820 different devices could be intermittent, meaning that there's a duty cycle to the laser, right?

01:09:24.600 How much time the laser spends on or off during any given minute of therapy and also how the lasers

01:09:30.840 are kind of designed into the device to shine onto the scalp. Is it something where it's a spot treatment

01:09:36.360 that you have to move around? Like years ago, we had the laser comb and you had to like move it all

01:09:41.120 the way around your head every five seconds, pretty laborious. Today, the laser cap or cap therapy

01:09:47.900 devices just sit on your scalp like a baseball hat and the battery pack clips to your belt or sticks

01:09:53.800 in your pocket. And you could be done in as little as six minutes. And you do that once a day or twice

01:09:58.160 a day? So that would be, well, different devices have different recommendations. So let's just start

01:10:03.840 with the best of the best. You know, the Kapilis RX is really the top device. It's a physician only

01:10:08.620 device. It has 312 diodes, which is a lot. When you say physician only, meaning you have to be in

01:10:13.280 a physician's office to use it? No, it's only prescribed and dispensed by physicians. You're

01:10:18.460 not going to get it like over the counter. You're not going to get it. You can't buy it on Amazon or

01:10:21.920 Costco. I mean, unless it's through the pharmacy. Not the 312. It's the RX device. How much does one

01:10:28.180 of these things cost? So the RX is $3,500. Wow. But what do you say? Wow. I don't know. I guess I

01:10:34.180 just think that's a lot of money. Well, actually laser therapy is your least expensive treatment over

01:10:38.460 time. I guess because there's one cost and that's it. Correct. They last for 10 to 15 years. I have many

01:10:42.740 patients using the same laser caps that they did from 10 or 15 years ago. All they've done is swapped

01:10:47.220 out a battery. Yeah, when you put it that way, it's a buck a day. Yeah. And no side effects,

01:10:51.700 non-chemical. You know, it's a great investment. So let's talk about PRP. You alluded to it.

01:10:57.600 You did ask me how often you would do it. So the Kapilis RX is six minutes a day, but there are other

01:11:01.460 devices like the laser cap, which was 20 minutes every other day. Got it. So, you know. But it sounds

01:11:07.320 like you can be doing something else. Like the harder thing seems to me like the minoxidil because you

01:11:12.540 have to apply it twice a day. Yes. So, you know, sometimes, for example, you know,

01:11:16.600 we have busy college students, kids just starting a job and so forth. They may have difficulty

01:11:20.660 applying something to their scalp twice a day. They're living in the dorms and whatnot. That

01:11:24.100 may be difficult. So, you know, we may do something more like laser or PRP for them.

01:11:28.880 Might be easier for them to be compliant with that. Although it sounds like it's harder to walk

01:11:32.560 around with a laser cap in a dorm room than... No, because it's covered by a baseball cap.

01:11:36.480 Oh, literally a baseball cap. Literally. It fits underneath a baseball cap.

01:11:40.040 Jeez. Wow. Okay. I can't wait to link to a picture of one of this.

01:11:46.060 See. So, you know, well, later on when we go down to the expo, you'll have a chance to see...

01:11:50.320 I'll stick it under my hat. Okay. You alluded to PRP. Now, you know, in say the world of orthopedics,

01:11:58.280 where PRP is used quite often, I think the jury's still out on the efficacy. I think most orthopedic

01:12:04.400 surgeons I speak with believe there probably is some efficacy to PRP, though it obviously

01:12:09.760 seems to be dependent on two things. The technique used to basically create the formulation

01:12:16.420 and the clinical judgment and when and, you know, patient selection, basically, for lack of a better

01:12:20.940 word. For sure. Because think about it. If we relate it to the hair follicle for a moment,

01:12:25.620 if the follicle is dead and gone and you're hoping that your laser minoxidil PRP regimen is

01:12:31.100 going to do the job, what do you think that success rate's going to be? Probably not pretty

01:12:35.300 good. So, you know, you can't come into a baldness clinic with total hair loss and think that a PRP

01:12:41.100 is going to solve the problem. That's not going to work. And so, I would imagine orthopedics is

01:12:44.820 pretty much the same. If you have someone who needs surgery because there's some severe depletion

01:12:50.420 of whatever, I don't know, if it's a cartilage or something else, you know, that's not going to be

01:12:53.320 gently fixed by a little bit of regenerative medicine, you know, they're going to need surgery for

01:12:57.580 that. And that PRP may not necessarily solve that issue. So, I think patient selection is a big

01:13:02.820 concern and as it is in hair loss and many other, you know, worlds of medicine.

01:13:08.260 So, I mean, you sort of alluded to it, which is there's probably a sweet spot, right? Where

01:13:13.120 someone who's not experiencing any loss but is trying to be prophylactic, that's way too early.

01:13:19.400 And someone who's already experienced the death of the follicle, you're basically,

01:13:23.160 you know, wasting time and money.

01:13:24.540 Correct. So, well, you're not wasting time and money if you have ongoing progressive hair loss,

01:13:29.680 right? But you may not reach your goal with PRP, but it may help mitigate future loss.

01:13:35.400 Just like the use of minoxidil and laser is not going to bring back that receding hairline,

01:13:40.400 but it's going to keep it from receding further or faster.

01:13:43.560 Fair point. Yeah.

01:13:44.420 Okay. So, combination therapy, there's again, thinking about what we do in practice every single

01:13:49.000 day in my office is part of the process is to prevent loss of the follicle function and enhance

01:13:55.400 whatever follicles you have. And then the other piece of the puzzle is to restore density to those

01:14:01.300 areas which are too far gone. So, PRP has a role in that, right? A PRP has a role in preventing the

01:14:08.280 loss of that follicle function. It enhances those follicles that are weak, kind of like what minoxidil or

01:14:14.100 laser might do for up to a point, right? And we would need to use that over time.

01:14:20.800 So, tell the folks listening how PRP works. I realize I'm sort of taking it for granted that

01:14:25.180 people know what PRP stands for, what it is, how you harvest. Can you spend a minute just explaining

01:14:29.580 if someone comes into your office and you decide that they're a good candidate for PRP,

01:14:34.440 tell me what the process is.

01:14:35.660 PRP stands for platelet-rich plasma. And platelet-rich plasma is an autologous treatment.

01:14:40.340 That means it's derived from your own blood. So, in the office, we're going to take a sample of

01:14:44.740 your blood and we're going to spin it in a centrifuge, which essentially separates the

01:14:49.240 formed components in the blood. So, red blood cells weigh much more than platelets do, right?

01:14:55.180 Blood cells. And so, when you spin a sample of the blood, you can then separate the blood

01:15:00.220 components based on their mass, based on their weight. And the reason why we want to do that

01:15:05.360 is that platelets contain very powerful ingredients called growth factors and cytokines. And their

01:15:11.400 platelets are responsible for not only clotting blood, like we've all learned in grade school,

01:15:15.880 but platelets are responsible for tissue regeneration and repair. They're like the

01:15:20.340 orchestrators of repair in the body. If you get a paper cut, platelets come to clot the blood,

01:15:24.800 and then they also orchestrate the repair of the skin in that area. They're the first thing that

01:15:28.420 kind of happens. Platelets get activated by that injury. They release these powerful growth factors,

01:15:34.240 which may call into action wound healing cells. It may call into action or recruit stem cells into

01:15:40.760 the area. They may then trigger other functions in the body, like increasing new blood vessel

01:15:46.740 formation and so forth. But what does all this have to do with hair? So, what we found is that

01:15:51.220 anything that helps out with wound healing tends to have a nice positive effect on hair growth.

01:15:56.520 And so, PRP was started, this dates back maybe 15 years ago, PRP into the scalp, at least in our

01:16:04.000 clinic, we were using it as a wound healing treatment in conjunction with hair transplantation.

01:16:09.620 And we, because I'm, remember, I'm a born and raised general surgeon. We know that anytime you

01:16:13.420 want to cut the skin, you want to heal it. And so, hey, by the way, low-level laser therapy does that

01:16:17.920 too. But PRP was one of the first indications was for wound healing for chronic ulcers and to

01:16:23.740 accelerate healing in diabetics and so forth. So, as a wound healing treatment, PRP works really,

01:16:29.460 really well. And it was around this time, some of our physicians were also noticing that when they

01:16:34.260 applied PRP for wound healing, they were also reporting some improved hair growth. And at first,

01:16:40.280 I think many of my colleagues were very skeptical about these early reports, but we were using PRP

01:16:45.620 as a wound healing adjunct. I figured if we can get our patients healed a little bit more quickly,

01:16:49.160 that would be a good thing. Less downtime. We'd get them back into their regular team more quickly

01:16:53.400 after a hair transplant. But we were noticing it as well. We were seeing this improvement

01:16:57.580 in hair growth. Let me ask a silly question, perhaps. Presumably, you were using it on the

01:17:03.540 donor sites because that's where the incisions are made or were you using it on the recipient site?

01:17:08.460 Both. I see. Okay. Makes sense. Yeah. We were using it in both areas. The recipient zones,

01:17:13.580 obviously, the ones that were pretty much more visible at that time in, let's just call it on 2007,

01:17:19.780 2006. And that's really when we got started with PRP. And our colleagues were also noticing that,

01:17:25.220 as I said before, that there were some improvements in hair growth. And so we started to apply it a

01:17:30.260 little bit more aggressively in some of these patients and applying it into other areas of

01:17:33.860 the scalp that maybe we weren't transplanting. And lo and behold, colleagues and myself included,

01:17:39.680 were noticing that there were some improvements in the thickness and the caliber and the length of

01:17:45.320 some of these miniaturized hairs. What size needle do you use to inject it?

01:17:49.360 So I use a 27 gauge half inch. Is it painful?

01:17:53.400 No, PRP is not painful because we use a complete local anesthetic block. So we're going to block

01:17:58.360 the entire area that we're going to treat. People say, well, of course, once the local

01:18:03.120 anesthetic is in place, you won't feel anything on your scalp. Obviously, that's how we do a hair

01:18:06.280 transplant. People often say, oh my God, it's so painful. Like even if you put the local anesthetic

01:18:10.340 in, that's going to be painful. No, it's not. We have a Pronox device. It's nitrous oxide delivery

01:18:15.460 system. It's on demand. If you want to take a couple of puffs on the nitrous, usually makes

01:18:20.380 it a hundred percent painless. And to be honest, nine out of 10 patients say that it was dreamy

01:18:24.560 when they had their treatment done. So PRP should not be painful.

01:18:27.920 So that's a good point for people to know.

01:18:29.580 Should not.

01:18:29.960 Yeah. I'm amazed you can get it out of a 27 gauge needle. Like I thought it would have been

01:18:35.300 too viscous to come out of that.

01:18:36.960 No, platelets are tiny. Platelets are super duper tiny. I mean, we can look up the exact

01:18:41.440 measurement, but-

01:18:42.920 Yeah. Come to think of it, they are.

01:18:44.000 I mean, they're extremely small.

01:18:45.660 Yeah.

01:18:46.260 Yeah.

01:18:46.640 It's basically part of plasma.

01:18:47.820 Yeah. But platelets are cell fragments that are smaller than red blood cells.

01:18:51.100 Yeah.

01:18:51.560 So they're extremely tiny.

01:18:53.220 And just as a directional number, not that you're counting, when someone comes for a

01:18:58.260 quote unquote standard PRP therapy, how many actual injections do you think they require

01:19:03.620 in a typical treatment?

01:19:04.780 So most patients want to know how many needles are you going to hit me with, doc?

01:19:09.020 Yeah, exactly.

01:19:09.800 So that's always the question. Of course, as I said, with local anesthetic applied appropriately,

01:19:14.960 applied painlessly, you will feel none of my PRP going in. So you will feel none of the

01:19:21.760 700 injections that are required.

01:19:23.460 Well, no, I wasn't asking from a pain standpoint, more from a bleeding standpoint.

01:19:27.460 No, but for your listeners, they need to know that they're not going to feel any of the 700 very,

01:19:32.480 very tiny injections.

01:19:33.540 How long does that take you?

01:19:34.740 It takes only about 10 minutes.

01:19:36.580 Wait, wait, wait. How can you do 700 injections in 10 minutes?

01:19:39.580 Well, actually my nurse practitioner and I tag team the scalp. And so we do,

01:19:42.840 you know, half and half. So, but you know, my thumb is pretty strong.

01:19:45.900 Wow. Each injection gets how much volume?

01:19:49.200 A tenth of a CC. It's pretty quick.

01:19:51.700 Wow.

01:19:52.100 To be honest. I mean, the whole treatment procedure in the office is about an hour

01:19:55.300 start to finish. And most of that is honestly the preparation time of the PRP.

01:19:59.580 I have patients who are being treated in New York. So they haven't, they're not patients that

01:20:03.500 you take care of, of mine who have had excellent results with PRP. And I know obviously our mutual

01:20:09.020 patients have as well. And we've talked quite a bit about it. Is it your expectation once you've

01:20:15.940 decided or, you know, once like obviously the persons that, you know, they're seeing in New York,

01:20:20.480 I mean, there's lots of good people out there, but once you're in the hands of someone who has a

01:20:24.140 really good set of patient criteria selection, are you pretty optimistic that PRP is going to move the

01:20:29.020 needle?

01:20:29.320 Oh yeah. I mean, PRP works well.

01:20:31.380 How often does one need to be treated that way?

01:20:33.820 Well, that's a great question. So everyone's a little bit different in terms of the power and

01:20:37.320 strength of their PRP. Remember, this is not coming out of a bottle. This is coming out of

01:20:40.760 your vein. So if you come to my clinic and you have 150,000 platelets per microliter,

01:20:45.720 you may have a different platelet concentration than somebody has a 250,000.

01:20:49.580 So stop your aspirin before you show up.

01:20:51.960 Well, it is a smart idea, but remember that if you believe that the aspirin is simply just

01:20:57.120 delaying the activation of the platelets, I mean, as a surgeon, you know, that all bleeding stops.

01:21:02.580 So, you know, eventually the platelets get activated. So, you know, I'm not so sure that

01:21:07.680 that's such an important, you know, hard rule.

01:21:09.000 So remember how we used to give all those patients a ton of aspirin after splenectomies

01:21:13.260 and stuff like that when they were getting these sort of the macrocytic, or maybe it was the shape

01:21:17.520 of the platelets that was changing. I don't remember if it was the number of the shape, but okay.

01:21:21.040 I don't remember, but I'm not so, uh, you don't worry, you don't worry too much about that.

01:21:25.120 I don't, I really don't. I really don't. I want to know that I'm getting a good platelet

01:21:30.600 concentrate. So I'll do a CBC at the bedside. I have a Coulter counter in the office. Unlike

01:21:36.000 most physicians, I have the devices, a Beckman Coulter counter, and we'll do a CBC on the whole

01:21:42.560 blood that comes right out of the vein immediately, right there, right before we do any kind of spin

01:21:46.580 after we do our, let's just call it a proprietary protocol of spinning and separation and

01:21:51.640 concentration of the platelets. Uh, we'll do a final count on that. We'll use a couple of

01:21:56.760 microliters, not much to get a final platelet count on what exactly we're going to be injecting.

01:22:01.160 So I can tell you, if you come into my clinic, exactly how many platelets we're going to be

01:22:06.160 injecting for you. And I think that over the years, having done about 4,000 PRP injections,

01:22:11.660 I feel like we have a very, very good handle on how platelet count affects the outcome.

01:22:19.060 So we're working on that data right now. Wow. Something as simple as someone shows up with

01:22:23.280 150,000 versus 400,000, presumably the more that they show up with, the better.

01:22:28.240 Yes. And there's some good journal articles that describe the effect of platelet concentrate on

01:22:33.600 these biologic processes that we're interested in. So physiologically, we know that there's a dose

01:22:38.480 curve. As you increase the concentration of platelets, for example, on, um, neovascularization,

01:22:44.320 there is a dose dependent upward curve on that. So the higher the platelet concentration,

01:22:49.200 the more neovascularization you're going to get. Now there's a biphasic dose curve on stem cell

01:22:54.380 mobilization. So as you go up on, uh, the number of platelet concentrates, there's a kind of a sweet

01:22:59.700 spot that occurs. And then if you go over that amount, then it starts to dip downwards. So what exactly

01:23:06.140 is that concentration in both of those studies that I just said, what, what is that concentration

01:23:11.620 supposed to be? And according to that data, it says somewhere between 1.4, 1.5 million platelets

01:23:17.680 per microliter is that is where that sweet spot exists. And what we're trying to show in the office

01:23:23.280 is that that correlates also at the bedside to the clinical response.

01:23:28.140 And I, I mean, I assume you're gathering those data. You've done 4,000 of these. So you have your

01:23:32.440 own prospective series. Yes. So what I can tell you is that I think that there's a strong correlation

01:23:36.860 between the amount of platelets that you come to the table with and the amount that we can

01:23:41.420 concentrate. So obviously we have to maybe make some adjustments in our protocol if you are kind

01:23:46.440 of low on platelets, but you know, again, there's some other things that we may not necessarily be

01:23:50.940 taking into account. Everybody has a different size and shape of platelets. Let's say your platelets

01:23:54.620 are low, but they're very big. We don't know what exactly do those platelets contain. But again,

01:24:00.700 there's some data in the clinical literature where we can correlate growth factor concentrations

01:24:05.880 with platelet counts pretty well. This sounds to me like it's something that's still in its infancy

01:24:11.240 where- It is. Absolutely. I mean, that sounds like the crudest of all metrics and it's probably

01:24:15.860 an oversimplification for what's really going on. And, you know, hopefully in 10 years you have

01:24:21.280 a different assay than just something as blunt as the CBC, right? You can measure some cytokine or you

01:24:27.540 can measure some other functional property of the platelet that probably matters a heck of a lot

01:24:31.900 more than the number. Right. I mean, look, eventually maybe there'll be a bedside PCR where

01:24:36.520 we can figure out exactly what exactly those growth factors are that are doing their job, you know,

01:24:41.280 inside. But the other thing that I've learned over the years of doing those thousands and thousands of

01:24:46.080 PRP treatments for nearly 10 years is the importance of the white blood cells. So the monocytes

01:24:52.040 are a very, very important component. I think they're underappreciated in,

01:24:55.780 not only in the literature in terms of what they do in the body, but especially in PRP.

01:25:01.380 And I'm a very strong proponent of the importance of monocytes in the final PRP. And we say that our

01:25:08.460 PRP is monocyte rich. And I don't think that that's really a term that's caught on yet, but I think that

01:25:13.660 it will. And monocyte rich PRP- Wait, so you can, obviously it's easy to pull the platelets out,

01:25:19.380 but when you're looking at leukocytes versus monocytes versus eosinophils, you have a sensitive

01:25:26.060 enough centrifuge to get that band? So the way that we've been able to do that is through a dual spin

01:25:31.380 process. So the dual spin process, for lack of a better way to explain it, the first spin is kind

01:25:38.220 of a gentle spin to take off the red blood cells. We don't want red blood cells in our PRP. Red blood

01:25:43.780 cells in the skin are extremely inflammatory. When those red blood cells lice, the heme is

01:25:49.520 extremely inflammatory and there's a lot of- Makes sense. Yeah, the iron would be devastating.

01:25:53.740 It's really bad. So we don't want that in the skin if we can avoid it. So I prefer to have PRP

01:25:58.780 that has less than 1% hematocrit. So the PRP may look pink in the syringe, but it's a very,

01:26:04.100 very small amount of red blood cells. Now, of course, when you're trying to decant the platelets,

01:26:08.580 decant the Buffy coat, you're right up against those red blood cells. So the first spin takes off

01:26:15.200 the layer of red blood cells and leaves us with a plasma, which contains the platelets. So the

01:26:24.400 plasma-based spin, which is the second spin, then essentially pushes the platelets to the bottom.

01:26:30.300 So we've captured this maximum number of platelets. We can take off the platelet-poor plasma to as much

01:26:36.200 as we would like, leaving us within a reconstituted amount of whatever we choose,

01:26:40.960 concentration and volume of PRP. So that process, that dual spin process, and I haven't found another

01:26:48.160 one that has been able to duplicate this, consistently removes the red blood cells,

01:26:54.540 consistently gives me a very high concentrate of platelets, and consistently gives me this bump or

01:27:00.320 boost in monocytes. And remind me about how many tubes of blood are you actually drawing out for the

01:27:05.320 full treatment? We take 60 cc's on the treatment. Okay. So 60 cc's concentrates down to about seven

01:27:10.980 and a half cc's of PRP. Wow. That's incredible. And how many hours does it take? What do you mean?

01:27:17.960 It takes... From the time you do that first prick of blood until you're injecting... It takes less

01:27:22.320 than an hour. They're walking out the door in an hour. They're out the door in an hour, man.

01:27:27.080 I obviously know very little about this specialty. Yeah. So when you come in, you'll see.

01:27:30.320 Okay. Let's get to the meat of it, which is the transplant. So how do you think about...

01:27:36.180 You don't want to know how long the PRP lasts in my hands? Okay. Yeah.

01:27:39.640 Come on. This is really important because most dermatologists are spinning test tubes. They're

01:27:43.380 getting all two to three times concentrate. They're not getting seven to eight times

01:27:46.820 on the platelets. They're missing all the monocytes. And besides all of that,

01:27:50.300 they're booking their patients for every other month or every month treatment.

01:27:53.260 So the treatments that I just described to you that we do, that proprietary protocol is

01:27:58.900 essentially about once a year. And so people say, well, you could claim five years. You could

01:28:04.120 claim six months. How do you know? Well, we know because we measure. So we know that 90% of our

01:28:08.880 patients get a positive response from the PRP that lasts about 10 to 14 months. And that there's a

01:28:14.840 small percentage of patients, maybe 5% that need it more often than that. And then I have another small

01:28:19.420 cohort of patients that can get away with it almost every two years and that's it.

01:28:22.500 And what's the percentage of patients that are not responding?

01:28:25.220 Well, everybody responds to some degree. The question is, are they responding where they want?

01:28:29.500 So if someone comes in with a receding hairline, they say, hey, doc, I really want PRP here at the

01:28:33.560 receding hairline. If they're hoping for some regrowth, chances are that they're not going to get

01:28:38.440 too much action there because why? We talked about that, that there's just less follicles in that area.

01:28:44.500 There's not enough trees in the garden, so to speak, or plants in the garden when we go to

01:28:48.220 fertilize. But the other zones that they didn't even realize were thinning,

01:28:52.000 we're going to get a 20 to 50% boost in volume in many of those areas.

01:28:57.200 And that's pretty typical.

01:28:57.720 And when they're leaving, obviously you're putting them on the regimen that is medical,

01:29:02.060 topical, plus or minus laser.

01:29:03.820 Could be any of the above or just one.

01:29:06.260 And many patients are doing monotherapy to start.

01:29:08.640 They don't want to do two, three to four different things.

01:29:11.180 And then other patients come in and they want to do kitchen sink approach.

01:29:14.140 So it varies. It varies on their motivation, sometimes the beauty budget,

01:29:17.860 sometimes it's just their time, effort, and energy involved, their, you know, their desire

01:29:22.300 to, you know, and their goals. Honestly, some patients come in, they say, you know what,

01:29:25.760 if I just stayed the same as I am right now, I'm pretty happy the way I am right now. If I stayed

01:29:30.500 the same, I would be cool. And so they may make a plan for that. But then there are other patients

01:29:35.260 that say, hey, you know, we got it. We want to turn the clock back. And that's where the transplant

01:29:38.880 comes in.

01:29:39.360 So is it more often the case that the patient says something to you that makes you say transplant

01:29:47.400 is really the only option here? Or is that generally the inevitable path for most people

01:29:54.420 once they start going down the treatment?

01:29:56.980 Well, I think we're so clear about what these treatments do that the patients will typically

01:30:00.780 say, hey, you know, in order to accomplish what I want to accomplish, it sounds like we need

01:30:04.260 to transplant. So it's very much patient driven process. My patient, you know, is our

01:30:08.560 priority. And we have a patient centered practice. So it becomes very, very clear after

01:30:13.280 spending the time with the patient for the patient, the patient knows what they're going

01:30:18.380 to need, essentially. So they may say, well, hey, you know what, I think I'm probably going

01:30:22.920 to need a hair transplant. It's now is not the right time. Maybe it's going to be next

01:30:25.580 year. Let's see what we can get with the non-invasive therapies. And I'm cool with that.

01:30:29.780 But if somebody comes in and says, hey, you know, I really want to fix this hairline with

01:30:32.700 PRP and laser. I mean, I have to be honest with them and tell and show them with the

01:30:36.260 microscope. Look, man, we can wish and we can hope and that's okay. But, you know, wishing

01:30:40.380 and hoping is not a strategy.

01:30:41.940 So let's go back to that first patient that you saw who had gone up to Toronto. Where did

01:30:45.860 they go? What was special in Toronto? Having grown up there, I'm curious because I didn't

01:30:49.280 think much was special in Toronto.

01:30:50.780 So what was happening?

01:30:51.560 Other than the Scholdeis Clinic for hernia repair.

01:30:54.600 Interesting.

01:30:55.080 That's very special.

01:30:55.980 Yeah, for sure. So things that were happening in the early, I would say the mid-1990s were

01:31:00.740 that hair transplant surgeons were learning to use single follicle implants, meaning that

01:31:06.140 instead of a plug or a punch or four millimeter biopsy of skin, they were cutting down and dissecting

01:31:12.960 or getting down to literally a one hair follicle graft. And what that enables you to do, if you

01:31:20.420 angle and orient that appropriately in the right position in the scalp, is to create a result

01:31:25.980 that looks like mother nature made it, make it look natural. It's soft. So you can't put them

01:31:31.520 in a row. You can't put them perpendicularly in the skin. You have to angle them, but there are

01:31:37.340 ways to work with single follicle implants to make your end result look a hundred percent

01:31:43.140 undetectable. And that is why that gentleman traveled from New York to Toronto because there

01:31:50.800 was a gentleman up there who was having, doing that work. And it was Dr. Seeger at the time

01:31:54.500 is the surgeon that was doing that work. So he's since passed on, but he was doing that

01:32:00.400 work with a linear harvesting. So that was the old style strip harvest and using microscopic

01:32:05.000 magnification to dissect the hair follicles and then implant them in a way that would make

01:32:10.920 the end result look natural. And it seems like, well, why wasn't everybody doing that? Well,

01:32:16.020 not every surgeon was using microscopes. Not every surgeon was using tiny grafts. They were using

01:32:23.260 either, you know, larger, what they called micro mini grafts, let's say, or those punch grafts to

01:32:30.320 create the density. Two comments there. The first is, so they were still doing a linear graft, which

01:32:36.720 means that these patients were having hair taken out with a big scar and presumably in the back of

01:32:42.680 their head. So that's a comment. And then the question is, how in God's name do you take a strip of

01:32:50.520 hair out of the back and isolated by follicle with or without a microscope? I'm just talking purely

01:32:56.420 from the standpoint of patients. Like how many years does that take? No, no, no. It doesn't take

01:33:01.840 years. I mean, I'm being facetious, but no, I understand. So there's a lot of labor, right? So

01:33:06.080 my training and my training happened in the 1990s there. We took linear harvests on patients and we

01:33:12.540 moved two to 3000 grafts in a single day for those patients. And I did that early on in my practice as

01:33:17.760 well from a linear harvest. And the way that we did it was with labor. We had surgical technicians

01:33:22.820 working two, three, four, five at a time under backlights or microscope, stereoscopic magnification,

01:33:31.920 literally doing the bench work to process that tissue. But this is all done sterilely.

01:33:37.800 It's done aseptically. Yeah. Okay. So you can't sterilize the scalp. It's a common knowledge. Good

01:33:43.500 news. The scalp is very much immune to a severe infection. It's just, we're built that way,

01:33:48.160 much like the face. So you said two to 3000 you could harvest and it's grafts. And would that be

01:33:53.520 like one strip that would be what, how many centimeters long and how wide? So the single

01:33:58.500 strip could be, you know, depending on the size of the case could be 10 to 20 centimeters long and a

01:34:04.400 centimeter wide. Wow. So it's going to go from ear to ear, essentially around the back of your scalp.

01:34:09.300 And unfortunately for many of those patients, they ended up with some wide scars, even with techniques

01:34:16.200 like I helped pioneer back with the linear harvesting trichophytic techniques, where we would

01:34:20.700 actually overlap the closures to get hair to grow through the scar. There's still a scar and the scar

01:34:25.820 has not as much hair. It's a little bit smooth. Sometimes it has a different type of color, right?

01:34:31.160 Than regular skin. So even with short haircuts, hairs growing through the scar can still be a scar

01:34:36.460 that can be disfiguring. And so I'm sure you remember in the field of general surgery,

01:34:41.840 there was a paradigm shift from open gallbladders to laparoscopic. So that was happening in the

01:34:48.820 mid 1990s. So I was very much attuned to changes in surgical technique and surgical paradigms.

01:34:54.980 And when FUE, follicular unit extraction started to become kind of a chatter on the internet, there were

01:35:01.480 some guys in Australia doing it and a few people here around the US. I wanted to really try to do

01:35:08.280 that procedure and perfect it. And so that led me down the road to adopt FUE, follicular unit extraction

01:35:15.380 at a very, very early stage of the game.

01:35:18.580 So I did my-

01:35:19.080 Describe how that works.

01:35:20.180 So follicular unit extraction is the use of a very, very tiny punch. Let's call it about a

01:35:25.640 millimeter. In the early days, we used disposable punches that were sharp, that were used for punch

01:35:29.620 biopsies. But these were very, very small items, smaller than the tip of a ballpoint pen, typically,

01:35:35.140 to harvest the individual follicular units. So those are the groups of one, two, or three hairs each

01:35:40.440 out of the scalp. So the graft comes out of the scalp basically ready and without a scalpel and

01:35:46.900 without stitches. Now in the early days, it was very difficult. I designed the first manual hand-turned

01:35:53.940 instrument available to physicians to be able to do this procedure. It was called the Bauman Mindex.

01:35:58.460 And we were doing these procedures in a very, very slow way. They weren't very efficient. They weren't

01:36:04.980 very accurate. But what we learned through many, many years of time on tissue, applying this kind

01:36:10.920 of technique, eventually we got to a point where it became a viable procedure.

01:36:15.000 And is the harvest scar such that it doesn't even require a closure?

01:36:20.240 Correct.

01:36:20.460 Or do you still need a stitch?

01:36:21.080 No, it's less than a millimeter. It closes up 50% in 24 hours and the skin is totally clean

01:36:27.620 within another day or two. Really what you would, the only thing that you would see like on a shaved

01:36:31.780 scalp is if you had, think of your, the head of hair like a five o'clock shadow is that you would

01:36:37.080 see a little bit less shadow in those areas. There's no visible linear scar. So now you could move a lot

01:36:43.560 of hair and not leave someone with a disfiguring scar in the back of their scalp. It gives them much

01:36:48.900 more flexibility in hairstyling.

01:36:50.660 Is it safe to say today that nobody is still doing large scars? Because even if I open up the

01:36:55.780 magazines on the airplanes, you, I mean, I feel like once it's in the airplane magazine, it's no

01:37:01.300 longer inside baseball. You know, they have the picture of the guy standing, like you're looking

01:37:05.480 at two guys from a head behind and there's the scar and there's the no scar. Is it safe to say like

01:37:10.240 no one is having that type of a harvest any longer?

01:37:12.740 No, it's actually not true at all. Many of the large national clinics that you see on late night

01:37:18.500 infomercials still do linear harvesting. And many of my colleagues here in the U S still

01:37:24.260 prefer to do a linear harvest than FUE.

01:37:28.460 So I want you to play skeptic devil's advocate for a moment. Why are they still doing it? What

01:37:34.400 is, what are they saying is better about that approach than the approach you just described

01:37:38.160 of single follicular extraction?

01:37:40.120 Well, you know, probably some surgeons, uh, that are kind of stubborn.

01:37:43.200 Yeah, but I would like, I'd like to think that in something where aesthetics play such a role,

01:37:48.660 it seems like kind of a no brainer. There must be some other explanation other than like,

01:37:53.360 put it this way. If I'm a patient and I'm going to see somebody who's about to do a huge linear

01:37:58.580 scar on my scalp. And I say to that person, why are you still doing it this way? When the pictures

01:38:05.040 in the airplane magazine say, I should not have a scar.

01:38:07.640 They're going to say, Oh, well, we get a lot more hair this way. It's a lot more efficient.

01:38:12.160 I don't have to buy any expensive equipment to do this. I don't have to learn any new skills.

01:38:17.340 It seems like it's much less efficient because, well, I guess it depends how you define efficiency.

01:38:22.740 You can have, you have more hands involved, but presumably it can take less time. Is that

01:38:26.860 what they mean by more efficient?

01:38:28.220 It definitely would take less time. If you're doing a 3000, 4000 graft procedure in your office

01:38:33.360 with a strip and you have enough staff, that could be much quicker than an FUE procedure for sure.

01:38:38.060 So if you had a patient and you were, I don't know if you'd do this, but if you were going to

01:38:42.000 dedicate the entire day to that patient, like it was a one, you know, quote unquote, a big case of

01:38:45.920 the day, how many follicular units can you harvest and implant?

01:38:50.000 So we've done very, very large cases all in a single day, but today we would really prefer to do

01:38:55.680 anything over 2000 grafts in two consecutive days. We find it a lot more comfortable for the patient.

01:39:01.200 It's a lot more comfortable in the office for the staff and our, our harvest rates and our harvest

01:39:06.620 quality is much, much more improved than trying to do a marathon, you know, into the evening type

01:39:12.160 of session. So most of our patients, if they're going to do a large maximum, as much as possible

01:39:17.300 procedure, they're going to get a, let's call it around 3,500 to 4,000 grafts over two days.

01:39:23.680 And that's with a wide shave all the way around, provided that they have the hair to do it.

01:39:27.540 You know, and there are exceptions. I mean, we've done 5,000 grafts on some guys and,

01:39:31.700 you know, sometimes we try to get 3,000 and we just can't even do it.

01:39:34.620 What is the greatest number of grafts you've implanted on a patient?

01:39:38.600 And I'll ask it two ways. One, harvesting only from their head and two, harvesting from other

01:39:45.320 sites on the body, which I'd never even heard of until you mentioned this a couple, maybe six

01:39:50.120 months ago, we were talking about this and you mentioned that in one of these patients,

01:39:53.100 you'd actually harvested something from his beard.

01:39:54.780 Oh yeah. We actually do quite a bit of beard harvesting these days. Many of our patients have

01:39:59.480 old style scar tissue from either procedures that I did back in the early days, you know,

01:40:04.340 in the early two thousands, when we were still doing half of our work with the linear harvest

01:40:07.960 technique, you know, and I'm not afraid to correct those cases and to, you know, update those cases

01:40:13.760 into the latest and greatest possible situation that they could have. So top numbers. Well, you know,

01:40:19.620 my dad comes to mind, he had almost 8,000 grafts. He was totally bald before we started.

01:40:23.220 Most guys who are totally bald up the top, meaning that they only have the hair around the sides and

01:40:28.320 the back. Most of them will need somewhere around six to 9,000 grafts to kind of fill up the zones.

01:40:35.140 And do you have, if someone is that bald, do they have enough donor site on the, on the remainder

01:40:40.280 hair? Most of the time, if they've never been harvested, they do. But if they've had some less

01:40:44.860 efficient harvesting techniques, then we may have to go to other places. As you say, alternative sources

01:40:49.580 of donor, like the beard or the body hair to satisfy that.

01:40:52.860 And I've never really thought about it, but my beard hair, actually, it seems about the same

01:40:57.740 thickness as my hair, but I don't know. Is beard hair thicker than hair?

01:41:01.400 Yes, usually it is, but everybody's different. So some people have thicker beard hair than their

01:41:05.200 scalp. Some people have thinner beard hair than their scalp. Some people have curlier,

01:41:09.040 coarser hair on their beard. It seems to be most common. So we're not going to put your beard at

01:41:13.020 the frontal hairline. Typically it's going to be used as filler in the back.

01:41:16.960 Yeah. And it works really well. And body hair seems less, much less thick and robust than hair

01:41:23.080 hair. I mean, scalp hair, right? Again, everybody's different. I mean, if you are a person with very,

01:41:28.140 very thin, fine hair on your scalp, you may find that the other hair, body hair is a better, thicker,

01:41:33.600 coarser caliber. But the problem is, and this is just a general idea, that as you get farther away

01:41:38.640 from the scalp, the follicles spend less time in the growing phase. So again, we're going back to

01:41:43.320 this antigen, catagen, telogen. Sure, sure. The body hair doesn't really grow. I mean, it's-

01:41:48.460 So it spends less time in antigen, but it also, out of, let's say, 10 follicles from the body,

01:41:53.880 the chest, maybe only five of them are growing at any given time. So it's kind of like hiring

01:41:58.360 part-time workers in your factory. You've hired 10 people, but only five of them are showing up a day.

01:42:04.740 That's not so good.

01:42:05.960 So the beard is pretty good there for a male.

01:42:07.840 It's really good for a male. It kind of solves a lot of problems. Beard is good to fill in the

01:42:12.360 scar too, sometimes.

01:42:14.080 Oh yeah, that makes sense. Now for women, is this-

01:42:18.180 Yeah, the beard's not going to work.

01:42:18.980 Yeah, no. This strikes me as a much easier problem in women because you have generally far less

01:42:25.180 volume to cover and far greater ability to cover up donor sites, right?

01:42:30.400 So women pose different problems than the men. You know, if you want to do a large session on a man,

01:42:36.080 you can say to most guys, hey, can we, you know, give you a pretty short haircut? And they'll be

01:42:40.340 like, yeah, okay, no problem. I may not love that haircut, but I'll do it. For women, that's not

01:42:44.820 really going to work. So if you need to move a lot of hair for a female patient, it needs to be done

01:42:49.060 in steps and stages. So there's a couple of ways to approach the donor area in women that would be

01:42:53.640 like shaving a tiny little stripe. So a little horizontal area where we're going to take the

01:42:57.400 individual follicles from, right? Because we're not going to cut a strip. We're going to take the

01:43:00.900 individual follicles that way. Or we may trim a couple of hairs here, let's say one out of every

01:43:06.600 10 or 20 hairs, and then go after those hair follicles the next day. So there's no shaving

01:43:11.400 whatsoever. Nice way to handle that. But, you know, you'd be surprised how many women have receding

01:43:16.680 hairlines, like their temples really with female pattern hair loss really go back as they age 55,

01:43:22.120 65 years old. They can start to lose that feminine shape to the hairline. It can really start to move

01:43:28.400 backwards. And that's the most common area that we transplant in women is the temples part of the

01:43:34.940 hairline. A lot of women want to move their hairline. They're not happy with the size and the shape of

01:43:39.820 their forehead. They want a hairline lowering procedure that doesn't involve cutting with a

01:43:44.380 scalpel or stitches or a prolonged recovery or risk of invasive surgery. And it's very easy to do

01:43:51.300 transplantation to fix a high hairline and to bring the hairline down into what da Vinci would call the

01:43:57.400 golden ratio, which is one third, one third, one third. So what are the biggest risks of this

01:44:02.820 procedure besides the obvious risks that we talk about in every surgery, bleeding, infection, et

01:44:07.540 cetera, or, you know, uh, is there anything that is unique to this surgical procedure as far as a

01:44:12.700 risk? Sure. Well, bleeding infection, extremely rare. Thank goodness. Even though we're making

01:44:15.940 thousands of little tiny sites in the scalp, not only the harvesting and implantation part,

01:44:19.820 it's a privilege. Bleeding is not an issue. Bleeding is not an issue. I mean, just like if you cut

01:44:23.800 yourself shaving or you got a paper cut, you know, in 20, 30 seconds, you stop, um, infection,

01:44:28.880 your worst infection typically with a hair transplant might be a pimple to be honest.

01:44:33.140 And you, maybe most people have one or two and we call it, you know, could be around the time when

01:44:37.080 the hairs start to kick in like an ingrown hair, you kind of have to pop it like a pimple, release

01:44:40.920 the hair that may be caught at the level of the scalp. And it's pretty rare, maybe like, you know,

01:44:46.000 one out of every 20 or 30 patients that has more than, you know, a half a dozen pimples or

01:44:51.040 something where it needs something more significant in terms of wound care to kind of release those

01:44:56.400 hair follicles. Maybe they have curly hair or something like that. But I would say the main

01:45:00.320 concern for hair is not the physical attributes of the, of the procedure itself, because we can

01:45:06.540 recreate something with artistic bent. You know, we apply an artistic approach to the shape of the

01:45:11.720 hairline, the angle, the orientation and position of the hairs, the variation in terms of hair density

01:45:17.540 to make it look normal and natural, not a wall of hair, straight density across the hairline,

01:45:22.660 the shape that builds into the sides, the temples, the temporal point on the side of the scalp,

01:45:27.660 the angle and orientation that's required for recreating a crown area. But really the risk comes

01:45:32.740 to that you're simply not happy with the result. And so again, it all comes down to the consultation

01:45:38.980 process. What exactly are you expecting out of this procedure? And have we gone over exactly what we

01:45:45.500 believe we can achieve? Because if I tell you, you're going to be a 10 out of 10. And the reality

01:45:51.640 is that it's going to always be a five out of 10, then I've promised you the wrong thing. And you will

01:45:57.000 be forever unhappy with that. So we have to be very, very clear about what's possible and what's

01:46:02.360 not. I can't put back a full head of dense hair for you, but I can make you look like you have a full

01:46:09.360 head of hair. You know, and I go back to my dad, for example, total, total baldness for two decades,

01:46:13.920 wore a hair piece and all that. The transplants that he has, if you look at him today, even 15

01:46:19.200 years later after his procedures, it looks like he has a full head of hair, but it's an illusion.

01:46:24.960 It looks like he's got full coverage. You see the frame of his face. You see that Da Vinci golden

01:46:29.880 ratio. He looks 20 years younger than when he had his procedure, but he never will have that density

01:46:36.480 that he had as a teenager until we can figure out how to clone these babies.

01:46:41.060 That makes a lot of sense. And I guess that as your practice continues to grow,

01:46:46.980 one of the greatest things that each patient is providing as a gift to a subsequent patient is a

01:46:52.480 before and after photo that gives you a bigger and bigger database to show patients more closely,

01:46:58.100 I suspect what they can expect based on where they are, because you've got just a greater basis from

01:47:04.200 which you can say, look, I've got 27 patients who look almost identical to what you looked like.

01:47:08.980 Here's the range of outcomes. And if you're not comfortable with that range,

01:47:13.460 you're not going to be a great candidate.

01:47:15.220 Correct. So after 8,000 surgeries, I can tell you with very, very good confidence what's possible

01:47:21.380 and what's not and what it will take to get there. And if the patient is all in and he's going to

01:47:26.760 protect the existing hair, we know that that's going to add a lot of great benefit to the end result.

01:47:31.040 If he's lackadaisical and he's losing other hair while we're transplanting this area,

01:47:35.740 other areas are being lost, that's going to be a much tougher battle. So it's very much a team

01:47:40.300 approach. And my patients become very much the drivers of the bus, so to speak, because in order

01:47:45.680 to get the best results, there has to be a good amount of buy-in and partnership with what we do

01:47:50.740 and what we recommend. I can tell you what kind of therapies and treatments and such that are going

01:47:55.080 to keep your hair growing strong, but you have to do that work. When you take a hair off the side of

01:48:00.060 the head or the back of the head in an area as a donor hair and hair that was never going to fall

01:48:04.380 out and you put that hair back on the top, is it susceptible to its nature or its nurture? In other

01:48:12.960 words, is it now susceptible to the DHT forces that took out the hair that it's replacing or does it bring

01:48:20.640 with it its genetic pattern from its donor site? So the whole basis of the field of hair transplant

01:48:25.920 surgery is based on the concept of donor dominance. So that would mean, and again, it's the theory,

01:48:32.340 right, of donor dominance, meaning that the hair follicles from the sides and the back of the scalp,

01:48:36.200 which are virtually immune to the effects of DHT, most guys with a total baldness problem never

01:48:41.860 ever lose that hair, that it will grow, live and grow forever in its new location. There are,

01:48:48.040 I would say, very small numbers of scientific reports that kind of put a dent into that.

01:48:56.580 So in these few and far between cases, we believe that there is some recipient area control. And the

01:49:04.320 way that I would explain that to patients is if, remember we said how long the follicles stay in the

01:49:08.860 growth phase has a lot to do with where those follicles come from. Well, one of our more prominent

01:49:13.800 researchers and colleagues in the field took a hair follicle from one place on his body and put it

01:49:18.840 into another place and then move that follicle someplace else and track those lengths of time

01:49:23.120 that it's spent in the growing phase. It tracked the antigen, the long, the growth phase. And so what

01:49:28.600 you would expect initially is that wherever you took it from, like let's say the chest, it grew for an

01:49:32.720 inch and that's it. You put it in the back of your arm should grow or back of your hand, it should

01:49:36.340 grow for an inch. Well, it didn't, it grew differently in those different locations. So there is some local

01:49:41.520 effect. So what we do say, and especially true for women where sometimes they can have a more

01:49:46.480 diffuse hair loss problem, right? Cause it's maybe not necessarily all androgen dependent that we say

01:49:52.340 that those hairs are relatively permanent. Has anyone ever done the experiment where you take a

01:49:56.600 hair and implant it in an area that has zero hair, like the palm or. Of course. Yes. In fact,

01:50:02.300 I did that for someone. Have you ever heard of Naltz from YouTube? No. So Naltz from YouTube is a

01:50:08.100 prankster. I'm sure he wouldn't be upset with me sharing with you and your listeners that

01:50:12.540 he had some hair follicles implanted into the palm of his hand during his last hair transplant

01:50:18.180 procedure. And it grew fine. Wow. So that is from a, just from a pure biology standpoint,

01:50:24.400 that is really amazing. No, it's not because listen, the hair follicle is an organ. It's a

01:50:29.420 self-determining organ. If you have a scar, which doesn't make any hair on its own, you can cut that

01:50:34.240 scar. It's going to bleed, right? You throw a hair follicle in there. It will survive. It will

01:50:39.080 grow. It will thrive. It will demand more blood flow. But there must be something very unique

01:50:42.900 about parts of our body that don't grow any hair that, I don't know, I guess, I mean, look, I don't

01:50:49.260 think about this obviously very much, but it would just, it just strikes me as counterintuitive. If this

01:50:53.460 were an exam and you asked me that question, I would guess that if you implanted the most robust hair

01:50:59.360 into an area that otherwise would never grow hair, it wouldn't have the fertile enough soil to

01:51:03.740 promote it. No. Anywhere that you have a blood flow, it will grow because all it needs is energy.

01:51:10.520 It needs the oxygen. It needs the nutrients, the hair follicle. If you have a non-healing wound on

01:51:16.460 the side of your leg, a diabetic ulcer, you can implant follicles into that area. And those follicles

01:51:22.320 are so metabolically active that they will actually secrete the growth factors, demand more blood flow,

01:51:27.200 and vascular neogenesis will occur. And wound healing will be accelerated and enhanced by

01:51:32.600 placing hair follicles into that non-healing wound. That's incredible.

01:51:37.500 The hair follicle cell population, the population of cells within the hair follicle are among the

01:51:41.820 most highest metabolically active cell populations in your body. It's one of the reasons why chemotherapy

01:51:47.040 knocks them out as well as the lining of your gut and your bone marrow, right? I mean, if you've got

01:51:51.420 your bone, your hair, those are some of the most highly metabolic and metabolically active

01:51:56.080 cell populations that we have. And so they continue to work and grind away to grow on your head,

01:52:03.600 a full head of hair, right? 150,000 hair follicles will produce somewhere around 1500 feet of hair a

01:52:10.860 day. That's interesting. Did you say how many, how many hairs on the head? So you're born with about

01:52:14.680 100 to 150,000. And it's amazing that you said you could take someone who is completely bald and

01:52:21.000 through very strategic placement using only 10,000 hairs, say.

01:52:27.120 No, I said 10,000 grafts.

01:52:29.160 Ah, graft could be two to three hairs.

01:52:30.800 Correct.

01:52:31.280 Got it. Okay.

01:52:33.220 Because, you know, again, we're not going to recapitulate a teenager hairline, you know,

01:52:36.940 age appropriate matters, right? So the recession of the hairline, that's going to look normal and

01:52:41.080 natural. That's where some of the nuances, right? And the discussion between our patients who are maybe

01:52:46.220 in their 20s who want to look like they did in their teenage years versus patients who may be a

01:52:50.680 little bit more mature in their 30s or 40s. So the idea is to design something that looks normal and

01:52:55.300 natural as they go through the process.

01:52:56.980 Well, Alan, this is super interesting. I suspect that there are going to be a lot of people who

01:53:01.600 listen to this who are going to potentially revisit assumptions that they've had on this entire

01:53:06.780 topic. I'm actually surprised at how often, you know, a patient asks me a question about this.

01:53:14.600 And obviously, I just don't know much. I mean, all I've learned over the years is to find people

01:53:20.420 like you who I can send them to. But I think what surprised me the most in this discussion is how

01:53:25.980 far this field has come in what seems like a decade and a half, basically.

01:53:30.800 Yeah. I mean, it's incredible. This is the most fast-moving field. I mean, it's incredible how quickly

01:53:36.840 things have changed in hair transplantation from, you know, whether it be linear harvesting to

01:53:41.120 follicular unit extraction to the use of cellular therapy, you know, PRP and other things like low

01:53:48.280 level laser therapy and compounded medications to attack the hair follicle and from all sides

01:53:52.860 and all different ways and all different modalities to help our patients really grow better hair and

01:53:58.060 look great and feel great. I mean, that's what it's all about, right? It comes down to the emotion.

01:54:01.720 When you look in the mirror and you see that hairline growing back in, you know, patient after

01:54:06.480 patient, they say, this is amazing. This is a miracle. This is like, I never thought I would see my

01:54:10.440 hairline again. I never thought I'd cover that bald spot except with a hat. I mean,

01:54:14.800 that's the exciting thing that keeps me going every day.

01:54:17.400 Well, Alan, thank you very much. I appreciate the input and I hope that anyone listening to this

01:54:22.160 who's had some questions about this has got some of those answered.

01:54:25.820 Great. Well, great to be here with you.

01:54:29.500 You can find all of this information and more at peteratiamd.com forward slash podcast.

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01:55:47.820 please visit peteratiamd.com forward slash about.

The Peter Attia Drive - March 04, 2019

#43 - Alan Bauman, M.D.： The science of male and female hair restoration - how to protect, enhance, and restore the appearance and health of the hair and scalp

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