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

Episode Date: March 4, 2019

In this episode, Alan Bauman, certified hair transplantation surgeon and hair restoration expert, discusses both male and female pattern hair loss, the science behind what drives it, and what that tells us about prevention and restoration. Having treated over 20,000 patients, Alan shares his invaluable insights into what works and what doesn’t in terms of the non-surgical treatment options. We also go into great detail about the more invasive approaches like PRP, and of course, hair transplantation, a procedure which Alan has refined over the years into a proprietary method that seems to produce unbelievable results. Additionally, Alan provides tips for maintaining scalp health, which is vital for hair growth, as well as the importance of choosing a hair specialist who has the tools, expertise, and patience to develop a compassionate and encompassing approach to hair restoration.    We discuss: Alan’s unique path, and how he became interested in hair transplantation [7:15]; The prevalence of hair loss, types of hair loss, and the different patterns in men vs. women [15:45]; The role of genetics in hair loss, and when does it start [19:00]; Female hair loss: the role of hormones, pregnancy related hair loss, and what it means to have thinning and shedding [22:30]; Primary drivers of male hair loss, finasteride as a treatment, and the potential side effects [26:15]; Common treatments - Proscar, Propecia, Rogaine, and more - how they all came about and what you need to know [29:45]; Primary drivers of female hair loss, potential treatments, and the different types of hair follicles [33:15]; What are some of the unproven/snake oil methods of hair treatments being pushed to the public? [37:15]; Preventative steps to take if you’re worried about future hair loss [42:00]; Medications that may negatively affect hair quality [45:30]; The importance of seeing a hair specialist [47:15]; Impact of scalp health and inflammation on hair growth, how to pick and apply shampoo and conditioner, and how to avoid and treat hair breakage [50:15]; Treatment options - finasteride, minoxidil, laser caps - how they work and what you need to know [57:15]; PRP treatment: How it works, details of the procedure, and Alan’s proprietary protocol [1:11:45]; The hair transplant procedure [1:29:30]; Risks involved with a hair transplant procedure [1:44:00]; Is a donor hair susceptible to the forces of the implant site that caused the hair loss? Can a hair follicle grow anywhere on the body? [1:47:45]; Age appropriate procedures, how far the field has come, and why Alan loves his work [1:51:45]; and More. Learn more at www.PeterAttiaMD.com Connect with Peter on Facebook | Twitter | Instagram.

Hey everyone, welcome to the Peter Atia Drive. I'm your host, Peter Atia. The drive is a result of my hunger for optimizing performance, health, longevity, critical thinking, along with a few other obsessions along the way. I've spent the last several years working with some of the most successful top performing individuals in the world, and this podcast is my attempt to synthesize what I've learned along the way to help you live a higher quality, more fulfilling life. If you enjoy this podcast, you can find more information

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My guess this week is Dr. Alan Bauman, a hair transplant surgeon who is one of the few people who is actually bored, certified in hair transplantation. There are lots of hair transplant surgeons out there, but Alan is one of the very few who's actually board certified and I've gotten to know Alan very well because one of my patients, actually two of my patients went to him for procedures a couple of years ago I was sort of blown away by the results because the best hair transplant so the ones where after the fact you have no clue that the patient had a hair transplant got to know him better and was impressed immediately by how open he was to all of my questions and believe me, there were a lot of questions. Before I refer one of my patients to another physician, especially a physician who's going

to do a procedure on them, I want to be able to vet the heck out of them and I want to understand how they're doing what they're doing. And internally, we put together summaries of the stuff that we learned, and Alan was so gracious in his ability to share his data, share his insights, acknowledge what he didn't know, that over the past couple of years, I've sent more and more patients to him

who have inquired about both surgical and non-surgical solutions to hair loss. And this is, of course, true for both men and women. So at some point, I said, Alan, we need to sit down and talk about this. And Alan is of course one of the experts in the world on this topic. He's treated over 20,000 patients. He's done over 8,000 hair transplants. The thing about this that's interesting is you come to learn as I learn that this is a problem that both men and women think about. And so in this episode, we talk about what hair loss looks like in both men and women.

And it turns out that pretty much nobody goes through their life without some change in their hair pattern. Now for men, I think it's a little more obvious we see the results of hair loss, but of course, any woman who's been pregnant knows that just there and then she's going to experience a dramatic change in her pattern of both gaining hair and then losing hair post pregnancy. But of course, for many women, this changes as they get older and once they go through menopause. And I think most women aren't aware of some of the solutions that exist, maybe as much as men are. So we talk in great detail about what the non-surgical or non-invasive approaches are. And there are there turn out to be many more than I had ever understood or even appreciated.

And I think Alan does a great job of explaining those. And then, of course, there are many invasive things, such as PRP, that would be even pre-surgical. And then, of course, within the surgical side of hair restoration, like anything, I suppose, there are many different techniques and they have advantages, disadvantages, and Alan does a great job here of explaining the method that he has chosen and why I think it certainly seems to produce unbelievable results in the cases that I've seen. This is an episode that has been, I've been asked about a lot in social media, so this is a great example of bugging the heck out of me over social media for topics that you want to hear about. And both men and women have said, please interview somebody who's an expert on hair restoration. And so with that said, please continue to

ask about things that you're interested in hearing about. And hopefully I'll be able to continue to find exceptional people with whom to bring expertise to you. So without further delay, please enjoy my conversation with Dr. Alan Bommett. Hey, Alan, thanks for making time today. Peter, thanks for having me. This is great. Yeah, well, we met actually through a patient

because I mean, a lot of the doctors that I know who are doing really cool stuff, I'm somehow finding on my own, but perhaps just as often, actually, now that I think about it, I come to meet somebody through the work they've done with one of my patients, and then that takes me down the rabbit hole. Because unfortunately, a lot of times,

a patient will go and see somebody in the outcome for anything, whether it be a colonoscopy or whatever, it's not what you want, but in particular, the patient that saw you had such a great outcome. And because you're in Florida where I just don't really have much of a network, I was intrigued by the outcome.

And the patient insisted that I speak with you. You know, he was like, you gotta talk to him. He's your kind of guy. You're gonna connect. And I was like, of course, yeah, I mean, I have to learn. And so the first thing that amazed me when we spoke was that you trained as a general surgeon.

Correct. And I don't know why I didn't, or I don't know why I thought that would be so unusual. Is that common for people who are doing hair transplantation to have done a complete residency in general surgery? Well, there are many general surgeons in the field of hair transplant surgery, but I would say years ago was mostly dermatologists. But hair transplant is kind of a popery of all different types of areas of medicine. I mean, we have people in the field who are psychiatrists, urologists, as well as the commons, you know, ones that you would see,

dermatologist surgeons, vascular surgeons, things like that, who have made a transition, maybe from a previous type of practice into hair transplantation. And is there a board certification for hair transplant the way there is for general surgery or thoracic surgery? So the American Board of Hair Restoration Surgery is not recognized right now yet by the ABMS, which is the American Board of Medical Specialties. So it's kind of in its primordial stage when I first got interested in hair transplantation, there wasn't even a board certification test

anywhere on the horizon. And so of course, my parents thought that I was going down a deep rabbit hole maybe with a dead end because I've never become board certified and they were very, very nervous about my interest in hair transplantation back in the early 1990s. But now it has a certificate in the way that transplantation or surgical oncology, which are not

board certified specialties, are still certificates. Right, even restorative dentistry has these types of boards. And so it's a rigorous process, one that was a lot of fun to go through, to be honest, because before that, you know, I never took a test that was specifically geared to my primary specialties, all I do, all I've done for well over 20 years, is hair transplantation.

So to prepare for that was an exciting time. It's rigorous written exam or exam. And you guys go through that every five years or how often do you research? Oh, the recertification, you know, I know, no, I just did my recertification and I should know. It's probably like eight or 10 years or something like that. So what got you interested in the space?

Because it sounds like you're not, I don't know if it's the exception of the rule, but you went into surgery to do this. Whereas as you pointed out, there are a number of people who come to this probably as a second career in surgery, right? Right. I kind of fell into it almost by accident. My first love was plastic surgery, reconstructive surgery. My first mentor was a plastic surgeon,

pretty prominent plastic surgeon on the Upper East Side of Manhattan. And he was close friends of the family. His kids were my age. They had no interest in surgery. And he kind of took a liking to me. And I, he said, hey, if you're going to go to medical school, you're going to be-

Did you do residency in New York? Beth Israel and Mount Sinai is where I did my journal surgery. But this is way back when I was a teenager. He said, hey, if you're going to go to medical school, you're going to be- Did you do residency in New York? Beth Israel and Mount Sinai is where I did my journal surgery, but this is way back when I was a teenager. He said, hey, if you're thinking about going into medicine, you should come and watch me operate. And I was like, well, I don't know what kind of operation he does. But I went to go see him, and he was a plastic surgeon, and that was the first time I ever saw surgery,

because back in the 1999, this was in the 80s, no YouTube, no Discovery Channel. I mean, I didn't really know what surgery was, to be honest, as a teenager. And I remember being there at Beth Israel, getting dropped off in the lobby and looking over shoulder in the OR, you know, he would dress me and scrubs whatever stand here, don't touch anything blue. I guess the security wasn't so great, but you know, I was looking over shoulder and he was doing his procedures. And I was blown away. I was like, this is what I want to do. I want to do surgery. And from there, you know, it was years and years of just shadowing him and being mentored, often on vacation times and things like that.

And I pursued general surgery through, you know, my interest in going that route to get to plastic and reconstructed work. Yeah, because back in that day, I mean, today there's a combined plastic track where you can do three of general and three of plastics, but presumably when you went through it, and even when I went through training, those were the exception. Most of them were still doing five years of general surgery plus two years of plastics, right? Right.

And that's just what I figured I would be doing. I did an externship while I was in medical school that happened to be, not happened to be be coordinated with one of the hospitals where he was in attending. So I got some very, very close mentorship there. I was doing things with him in medical school that he wasn't letting his fellows do in rotation in the hospital. So it was kind of interesting. I felt like I had a nice leg up. I got to watch him interact with patients in his practice as well as see him operate.

And he really was an amazing teacher and a great mentor of mine and really changed the course of my whole life really into the surgical end of medicine and seeing how he dealt with patients, seeing his passion for the artistry and getting the results taught me a lot. He was a low CD, which is great.

That's exactly what you want in a surgeon. Yeah, I think you want that in your engineers, your accountants and your surgeons. For sure. So I remember just being ecstatic, just the every time we were together, you know, it was like, what are we seeing next? And so I always thought that plastic and reconstructive surgery,

that's kind of where I was headed. And it really wasn't until I met a patient who had had a hair transplant, did I even consider looking at hair transplant surgery as a potential procedure that I would even want to perform. I thought it was all painful or pluggie-looking. Like, why would anybody ever want to have a hair transplant? I just, it was just totally out of sight out of mind. And when I, when I met this patient and I couldn't tell that he had had a hair transplant, I was basically blown away. I was like, well, we need, let's talk about this for a minute, you know? And of course, he was getting

something else done at that day, and I was the good resident doing the intake forms and the paperwork. And he was telling me about why he flew here or there to get his hair transplanted, and he was a layman. He told me all about, you know, what he knew about the procedure, and I'm looking at a scalp. You know, if you might have asked you, where did you get this procedure done?

You know, where did you have this procedure? And he said, oh, up over there in Canada or something like that. And I said, no, where on your scalp? He's like, well, right here at the hairline. And so he started to explain to me in layman's terms, the use of single follicles, I mean, individual hairs. What year was this? This was in the mid 1990s.

And what year was it? So you were in your training. So I was in my second year of general surgery, or the end of my first year of general surgery. I was thinking to myself just after that conversation because he was so ecstatic about it and it was really something I never thought about before and it was kind of unusual that the result

was totally different than what I expected because you know as a general surgery resident you think you know a lot, you know, you think you know everything. And first of all, why would he have gone to Toronto to have the procedure done when everything is here in New York, you know, which is where I was trained. So a lot of things kind of struck me that way, but it was exciting and to see that,

and to see that it could be done in a way that was totally unexpected to me. And of course, I'd watched my dad go through his hair loss process, so immediately I'm thinking, maybe my dad should look into this. And I thought then also, well, if this is that good, maybe I should look into it and perhaps learn how to do it, so I could add it to my future practice

later on down the line. And so that started me on the path to like looking into hair restoration, hair transplantation as something maybe I would consider doing. Well, I wanna come back to that because I wanna know about the genesis of the surgical perfection. I mean, to me, one of the fun things about surgery is kind of understanding how operations

evolve. You know, I chose the residency program. I chose because of its proficiency in doing this Whipple procedure. And so you would go in there. You would learn everything about how barbaric that procedure once was and how over years of being perfected in surgical technique, even the type of suture that was used, the mortality of that could fall from 50% to 0.3%. So I want to actually come back to this, but I guess I want to take a step way back and just talk about hair loss in general.

So how common is it, I guess, both in men and women to start with that? So hair loss is super common. Almost 100 million Americans are suffering from some form of hair loss. And we know now it could be as close to 80 million men, and even 46 million women out there who are struggling with the hair loss process. So, there's a lot of people out there

who are experiencing hair thinning. They may be experiencing receding hair lines, loss of volume, loss of coverage of their scalp, and it's a big concern for many, although very much under-treated. And is there data on how many people care? I mean, or what percentage of men with hair loss care versus what percentage of women, like, is it naive to assume that this is even though a smaller problem by numbers in women that it might create more distress in women? Well, first of all, everybody cares about hair, don't they? I don't know. I don't understand the question.

No, that's perhaps, right? No, but certainly it varies because you know, you could be a young guy in your 20s losing your hair and be really devastated by it. Or you could be someone who has a slower hair loss problem with the exact same amount of hair loss, but at a much older age, and you may be at a different place in time where you may not necessarily focus on that hair loss. And remember that in men, it's socially acceptable. I'm looking at your bare scalp, you shave down to number zero or two or one or, you know, with a trimmer, maybe that you shave once every other day perhaps. One so we can. Okay, so there you go. But the point is that in women there's no socially acceptable option

for female hair loss. And so it can be much more devastating for sure. Even though it's easier to cover in women. So there's a lot of nuance there. Women can lose half their hair and you would look at them across the room and think that they have a full head of hair. And that's how the physical optics of hair fibers work, meaning that you can lose 50% of your density, and from across the room, the coverage will be pretty much the same. Okay, well, that's really interesting, right? Because yeah, some people listening to this might say, or get a mental image of somebody

loses half their hair, like one half of their head is bald. There's not, of course, that's not what you mean. You mean evenly distributed across their head, half the density, you know, you, every two follicles become one, that's pretty easy to mask the longer the hair is, right? Right. And of course, you know,

female pattern hair loss happens in a very specific pattern behind the hairline. That's where that density loss kind of curve. So it's not equally, it's very rarely equally distributed. And same in men, there's a very specific pattern that you can see basically progressing from across the room. But it's a commonly accepted knowledge point that you can, and we see it obviously every day in the office, that you can lose 50% of the hair mass.

So that might be a number that's a combination of the density and the diameter of the hair. If you lose 50% of that, that's roughly the break point between coverage and maybe some see-through to the scalp. Does that make sense? It certainly does, yeah. So you alluded to something I guess I hadn't even really thought about, which was someone losing their hair very young.

So is there a definition for premature hair loss? Because you hear that expression, throw it out there, but does it mean like everybody to the age of X is supposed to have perfectly normal hair volume and anything, anyone that loses hair below that, it's quote unquote premature. No, that's a main reason. It's premature is in the eye of the beholder. Obviously, if you think that you're prematurely losing your hair, just like prematurely gray, right? So there's a spectrum. Some people go gray and they're 20.

Some people go gray and they're 80s. Some people never go gray. So how quickly you go gray is genetically predetermined. If 70 is the new 50, then maybe you don't want to be gray at 70. So hair loss is very much the same thing. But when we see young men, I mean, a hair loss can start anytime after puberty, right? 20% of men in their 20s, 30% of men in their 30s, 40% of men in their 40s have visible signs of hair loss.

That's a quick heuristic with percentage by decade. Yes, pretty darn close. And so what does that mean? Remember, I said that you can lose half your hair by the time it's noticeable to the naked eye. So immediately after puberty, that's when hair loss starts. And this is predominantly more in boys than girls though. Correct.

We were talking about male pattern hair loss, right? When I give you those numbers. So the female hair loss typically it's a little bit later on. And there's more multifactorial. We can see other things that are affecting the hair loss process. You know, women are just more complicated, man. Yeah. They do have that luxury.

So what happens? Yeah, you mentioned for a moment ago, like that if you're graying, that's genetically determined. How much is hair loss genetically determined? And men, it's 99%, 98% is genetically determined. How quickly it's noticeable to the naked eye where it progresses to, somewhat of the pattern, you know, is it more loss in the front versus the crown, you know, there's some variations there genetically.

Of course, there's 200 genes that regulate hair, and that would include color, curl, texture, and all of those play a role in terms of coverage, because again, those are the physical properties. Then hair styling, of course. If you're a 20-year-old guy and you're with your friends hanging out on the bar on a Friday night and you are experiencing some recession of the hairl know, with your friends hanging out in the bar on a Friday night, and you are experiencing some recession of the hairline, you may be one out of your group of friends that's having some significant male pattern hair loss. So for you, that's premature.

You're looking at the rest of the guy, you're in the group. Four or five friends, they all look like they got pretty much full heads of hair, and you don't. So that can cause a lot of stress and anxiety. I think in this day and age, you know, Instagram age or however you want to call it, people want to look good and feel good. And they don't want to be rushed into having to accept the fact that they're going to look older than their state of age.

And I didn't realize there were 200 genes that played a role in hair. I never counted them, but that's what they said. No, no, no, no, it's a lot. Directionally, yeah. So it's not a simple, if you're dad or your mom's dad or something like you, I've heard these things that say that that's the direction it tracks. It sounds like that's not the case.

Right, so ex-link, mom's dad should tell you whether you're going to go ball or not. That's really not the case anymore. We know that there's other factors that come from both sides of the family, you know, the genetic components that play a role in all those factors that I mentioned, you know, the color, the quality, the hair, and so forth, and the speed at which the hair loss occurs, and the patterns, and so forth. And I have friends who are brothers, who one has total hair loss, and the other looks like, he's got the thickest head of hair I've ever seen in my life. And maybe one's good if up all, and the other good if math, you know.

And so everybody, that's how genetics work. It can skip siblings. It's recessive gene so it could skip generations You know or can be a wipe out I mean I have the grandfather bringing in or the dads bringing in the grandfather and then the kids come in and you know And it's like a whole family affair because the you know the force runs strong in that family if you know what I mean Now talk to me a little bit about what's going on with women because I am aware of this only in that, you know, I've taken care of more and more women

over the past few years. I realize that it's sort of like you say, like I don't even notice it, but they notice it, right? And they'll say, you know, do you think that this hormone is right in me or this hormone or taking us back? I certainly remember watching my wife go through pregnancy, right, where her hair would get very, very thick.

You have a baby. A lot of that hair falls out, and then it just kind of all grows back to normal. So putting that aside for a moment, which is, it must be clearly driven by hormones. Of course. So the amount of follicles that are in antigen when you're in pregnancy is a much higher percentage. So antigen is the growth phase. You're going to have more follicles staying in antigen longer time in antigen.

So, your hair will be thicker and fuller during that time in pregnancy. And then when the hormones crash back down after childbirth, then those ratios go back to normal. And a shedding phase and a fluveum, or tealogen, a fluveum can occur in about six to 12 weeks. But if you're prone to female pattern hair loss, sometimes you don't necessarily recover

from that dramatic effluvium. So you shouldn't just say, oh, well, it's just pregnancy shedding and that's it. Because sometimes women come in and they say, look, I had my kid three years ago, my hair never rebounded from that situation. It changed right after that. And the other thing I hear women say a lot is the thickness was never the same after.

So it's they don't I mean, I don't know that that one of us, meaning me or the patient is skilled enough to assess follicular density, but thickness is very easy for the patient to accept. And you know, I've heard women say a lot, after my third kid, my hair is so thin. And they're referring to the actual hair itself. Well, they could be referring to the hair fiber diameter. And that can change just with age, honestly. It gets thinner with time.

But it could also be that they feel like their whole head of hair is not as thick as it was. And that would be a volume issue. So that could be the sheer numbers of hairs that are growing at any given time, giving you what's just called the ponytail volume. You know, a lot of women will say, you know, when I was in my 20s,

I put my ponytail in the, you know, it was scrunchier or whatever or rubber band. And I could just, I turned it two times and boom, that was it. It was like a, you know, a horse's tail. And now here I am 10, 15 years later, and I can turn it three times, meaning that need another route. That's an interesting litmus test I would have never thought about.

Yeah, for sure. Of course, now in the office, we have scientific methods, ways, devices, tools that can actually quantify different areas of the scalp and give us literally cross-sectional bundle measurements of scientific ponytails, and we can go back to the same area again and again, but we may be going ahead of ourselves in terms of diagnosis and treatments and such, but there are ways to measure that. When someone says, I have less hair, I have thin hair, we need to figure out what exactly that is that, what are they saying when they talk about that symptom?

Because shedding is also another confusing symptom. People say, oh, I have shedding. Well, shedding happens every day. Hair follicles turn on and turn off. Hair follicles will grow for five to seven years, a long strong hair, and then turn off, rest for 90 days, and then the cycle begins again. And a certain percentage of hair follicles

are in that growing phase, and it's called 84% or 85%. But all of a sudden, if you do something to switch those percentages, then you're going to get a thinner head of hair, meaning that there's less trees in the forest, perhaps. So, going back to the males for a moment, which is pretty strongly genetically linked, as you said. My overly simplistic view of the problem is dihydrotestosterone is a hormone that will precipitate this in a genetically susceptible individual, which is why two of the most popular systemic agents to mitigate male pattern baldness block the enzyme that turns testosterone to DHT. Is that the only hormone that's playing a role or is that just the one that we

have a treatment for? Well, that is the primary trigger according to the data that we see right now, and the data is very clear. If you put someone on finasteride about a milligram a day, they have a 90% chance of looking the same or better into the long run. Long run for pharmaceutical clinical trials, you know, is about five years, it's not infinity, but it's five years and that tells you that, you know, we're pretty close to, that's a pretty safe bet that DHT is the bad guy, you know, responsible for a lot of

follicular homicide out there. Does that mean that, I get it as a thought experiment, I don't think it would ever make sense to do this. If the moment a boy went through puberty, he was put on finasteride, are you suggesting that there may not, like that might be enough to mitigate baldness, at least in men, because I think in women it probably is different, correct? Well, there's always, and the answer is complicated. Yes, I think that would help in a huge percentage.

I'm not advocating that, of course, but remember that even if you put some on a finasteride or even due to astray, which is a stronger DHT blocking agent, right? Blocking both pathways to DHT, you still squeak by with a little bit of DHT. So there is still some of that happening in the body, even with those strong pharmaceutical blockades. And these things are not without their side effects. I mean, some side of men experience sexual side effects with them. And I mean, I think the literature in the prostate land is still very confusing about lower rates of prostate cancer, but potentially higher grade when it strikes

and all of this confusion. So I can tell you how that's been explained to us as care surgeons by the urologists that were involved in some of those studies. For example, finasteride, 5 milligrams is one of the more prominent treatments for BPH, benign, prosthetic, hypertrophy, or the large prostate. You put somebody on 5 milligrams of finasteride, the regular prostate tissue shrinks. And so that's likely what's happening also at 1 milligram dose. And so what happens if the normal prostate tissue is shrinking and you go to biopsy that tissue, you may be more likely to find some hygric cancer or cancer or material

in there just because the normal tissue is less voluminous. So that's why not everybody in the world gets a prostate biopsy but everybody in a clinical trial does. So that can skew the numbers. And that can, I don't know if I'm explaining great with that. No, that makes sense. That's one of the ways it's been explained to us in the world of hair restoration surgery, that you're not causing the prostate to become cancer. So of course, thank God people don't die a prostate cancer. It's a very slow moving thing. obviously, there's a very good survivability if you should be diagnosed. But the point is that you're shrinking that good healthy tissue, and then you're more

likely to find something on the biopsy and that more likely to be high grade. And high grade cancers in prostate are very, very rare. So it doesn't take much to skew the numbers from like, let's call it, and I don't quote me, but let's call it a quarter percent to three quarters of a percent You know all of a sudden it doubled. Yeah, you know could be just a couple of biopsies to throw it off So, you know you talked about finasteride, which of course is the generic name Prost-Carr is the 5 milligram formulation of that and Propecia is the 1 milligram formulation correct correct, which are both now off patent obviously

You know as you know were they developed in parallel or was it first a BPH drug and then they noticed, hey guys, hair is falling out less. Oh, we don't need to use as much of this. Let's create a new drug. I will tell you that Merck knew from the get-go that it was going to be a hair loss drug. They also knew about the effect on the prostate. They went after the prostate indication first, got that FDA approval, and then did the, and had safety studies and such done for that, and then pursued the hair loss indication after. And it was FDA approved for hair loss as a 1 milligram dose in 1998. So it's not, it was not serendipitous as Menoxidil was. And some people confuse those two stories like, oh, this prostate drug,

you know, they figured out it grew hair. No, no, that's not the way Phenastride came out. Wasn't Menoxidil at least systemically a blood pressure drug? Yes. So I think back in the 70s, Menoxidil was administered for hypertension. And it was, I think it was people who were on dialysis, honestly, that were being noted to be on this drug for a long, you know a long periods of time. And the people running those clinics were seeing patients on minoxidil, oral minoxidil, and they're literally growing hair on their knuckles almost,

and seeing hair growth in other places. And that's how they, and it wasn't really that great of a blood pressure drug, minoxidil. And so that's when they decided to move and into a topical. One man's side effect is another man's indication, right? Yeah, yeah, for sure. The story of Viagra, not quite as elegant but similar. So we'll

come back to my doxodil because it's topical and that's what Rogaine is by brand name. Correct. So Rogaine was the first, Rogaine was a manoxidil formulation with propylene glycol and that was the first FDA approved medication for hair loss. So that is an important data point in the history of hair loss. You know, when we write the history books, that really started hair loss as something that we can treat and the beginning of the end, if you will, of a snake oil era. So Rogaine is purchased over the counter, correct?

So today Rogaine's available in a number of different formulations over the counter. You can get 2% or 5% solutions or foam versions. There's generic versions all over the place. But, the problem is that most of those are very, very irritating to the scalp. They can be very greasy or gooey. The foam versions, if you have any kind of hair on your head, whatsoever, can be very difficult to gooey. The foam versions, if you have any kind of hair on your head whatsoever, can be very difficult

to apply to get into the scalp. So those formulations have some issues. And that's why Rogaine, if you will, or over-the-counter monocetyl is consistently ranked as the most disappointing hair loss treatment ever by consumer reports. They had a big report on that a number of years ago. And the reason is because it's very difficult to use. So, I would say about 15 years ago, we started looking at compounding pharmacies to really help us make a better manoxidil. Could we create a manoxidil that was penetrating better, easier to use, less irritating to the scalp, take advantage of some of the other knowledge that we have about the

hair loss process, like inflammation and so forth. What could we do to potentiate or accelerate the movement of monocytel across the epithelium into the location of the follicles where we needed the most? And that's where we came up with some of these more sophisticated formulations like 82M and 82F and so forth. All right. Well, I want to come back to that as well, because that sounds super interesting. Going back to just close the loop on the pathophysiology and the women who, so, and again, separating

it from sort of the pregnancy cycle, you know, you have a woman who 20 years after or 10 years after having her last child starts to say, you know, my hair is getting thinner. And it's to the point where she's noticed it either just based on the volume of hair coming out in the shower, brushing her hair on a pillow, whatever, and or even just able to visually see the difference. What do we think is driving that, acknowledging that it's going to be more complicated than just her DHT, which is probably very low. Yeah, her DHT levels could be very low, but she can also be Android and sensitive. So there is about a 50% success rate when you apply finasteride and postmenopausal women with hair loss.

When you say apply, you mean don't take it orally. Orally. Oh, I thought that it was completely contraindicated in women. Well, women of childbearing age. It can be used off label and postmenopausal women because the risk is to a developing male fetus. Yeah. And that's the main issue because, you know, D-H-T in a developing male fetus is the driver that makes men look like men for lack of a better way to explain. So, you know, we would never want to use finasteride in women of childbearing age, and it's not FDA-approved at all in women, and for those reasons, in particular. And but we do know that there are some studies out there that showed that 50% of women who

are in these clinical trials with female pattern hair loss postmenopausal, right, no risk to a developing male fetus at all, were treated with finasteride and they got some response from it. So their DHT may be a driver in some of those patients. So what Androgen Sensitivity is something that is, I mean, we don't know the incidence, but let's say 50% of women with hair loss have some degree of antigen sensitivity that could be driving it. And if you think about, for example, the most common hormone abnormality of women of childbearing age, PCOS, what are the things that kind of roll together in the PCOS syndrome?

There's acne, there's here's satisome, hair growth on the face, and acne, did I say that? And hair loss. And so, and acne, did I say that, and hair loss. And so those, what are all those having common? They're all Androgen processes. Correct. So there is a common Androgen connection. So do young women with PCOS also experience hair loss?

Yeah, it's devastatingly bad. I just, I didn't realize that. Yeah, it can be devastatingly bad. Very common in PCOS. A lot of our... And you're stuck because they'd probably respond to a five-valve or reductase inhibitor, Yeah, it can be devastatingly bad. Very common in PCO. So a lot of our... And you're stuck because they'd probably respond to a five-valve reductase inhibitor, but they're in childbearing years, so you couldn't use it.

Correct. They're under treatment, typically, to improve their fertility. So it's a delicate dance. So we're left with other non-androgen modalities, and so that would be Menoxidil to directly stimulate the scalp, maybe level laser therapy to impart energy to the hair follicles Maybe injectable treatments like PRP and so forth. Do those women in particular these young women with PCOS can their hair loss be restored or is it permanent? Well, that's a trick question because... Meaning if you resolve the PCOS, you know, you can treat them and they can bear children and such.

Will they also regain the hair that they lost? resolve the PCOS, you can treat them and they can bear children and such. Will they also regain the hair that they lost? It's tricky. So, here's the thing. If you can normalize the hormones, many of their hair loss symptoms improve slightly, but remember that once the follicle is, let's call it just damaged, beyond repair, miniaturized down to a certain level, it reaches a point of no return. So the terminal hair is a good, healthy, oak tree in the forest.

That's the, your best, best quality hair is a terminal hair. Velis hair is the type of hair you have on the top part of your cheek. It's invisible. It's less than two millimeters long. It doesn't have any pigment to it. And it's very thin in terms of its diameter. So if a follicle was producing a terminal hair and then it miniaturizes all the way down to now creating a vellus hair, you're out of luck, meaning that there's nothing that we know of, that I know of, that's going to revive that follicle and get it to regain any kind of significant amount of growth. So whatever kind of hair loss you have, male, female, the idea is that you've got to take action

soon to protect the functioning of the follicles before there's that point in overturn. That makes sense. You alluded to Rogaine being the first drug or topical agent that actually had clinical efficacy, which therefore I think you described it very nicely as the beginning of the end of snake oil, not the end, but at least the first shot across the bow that this could be a legitimate industry. Correct. Just briefly, what are some of the top three, top five snake oil things that were being petdled out there to people? Oh gosh, well, we have to go back to the history books, but you know, there were all kinds

of tonics and such that were promoted through advertising and so forth. Yeah, like when you, I feel like when you look at old magazines, like there's always ads for exactly like some tonic or some, some ridiculous chemical that you could. Dr. John's whatever, you know, I mean, you know, and there's always like a picture of a, you know, hair as a woman with a beautiful long head of hair. So what happened was that then, I guess it was Johnson and Johnson or whoever it was that had Rogaine was then able to say, you can't advertise hair growth from that kind of lavender oil extract because we have FDA approval for that now. That was the method that started to clear out the industry, if you will, moving

some of those literally oil treatments, tonics and so forth that had no clinical efficacy whatsoever out of the market. Because now, if you're in order to advertise hair growth, you had to have that FDA clearance. You had to have that FDA approval behind you. So we don't have to do an exhaustive list now, but I would love to list to an exhaustive link in the show notes. But what are some of the snake oils you're seeing out there today that people come to you saying, you know, I've been, where I've been on this and it hasn't been working or what

do you think about this? Well, you know, there's a long list, but you know, here's the thing. You have to be careful because, you know, people say, oh, well, you know, Rogan didn't work for me. But remember we said earlier on that application matter. Application makes a big difference, compliance. Most people, they pick up a bottle of Rogan, they relax a day's ago about it, they don't do it twice a day, they can't get it on their scalp, they have some kind of irritation, they don't know that it's working.

So a lot of it is expectations too, so right, so you know, people say, well, yeah, that rogans didn't work or you know, this handheld laser that I bought back in, you know, 1999, you know, it was supposed to grow hair, but it doesn't. But well, the problem with, for example, that small little handheld laser is just that you're trying to water your lawn or the watering can when really what you needed was a sprinkler system. You needed a different type of delivery system. So we kind of get into trouble sometimes and say, well, people thought laser was a bogus treatment. Even my colleagues for many, many years thought that low level laser therapy had no influence on the hair follicle.

Obviously they were all proven wrong by the exhaustive studies that have been done now and all of the FDA clearances which prove not only safety but certainly hair growth. And we've seen patient after patient and that. But what about like biotin and things that you see people taking like these tablets or these makeshift things? So by it.

New York is full of doctors who, I just know this because when you do an intake with your patient, you find out all the medications they're taking and there's like all these cocktails of pills that they're taking for hair growth. And I'm obviously familiar with some of them, like finasteride, dutastoid, but I mean, biotin. What is biotin? Well, you have to know what they actually do.

Biotin has been shown to improve keratin production, not only in the animal kingdom, because it's used in horses who have hoofed issues. And a lot of that science is out there. You know, you can put a horse on a high-dose biotin who have hoofed issues. And a lot of that science is out there. You can put a horse on a high dose biotin and their hoofs improve. And that would be important if you're raising thoroughbreds, for example, because a hoof problem in a valuable race horse is a big issue.

So there's no question that there's a lot of science and data out there. It's less honestly in humans. There's less data out there. But if you put patients on biotin, a high dose, let's say 10,000 micrograms, nine times at a 10, they'll tell you their nails are getting stronger. We know that you can do hair tensile strength studies and literally stretch and pull on those hairs and see the strength improve.

But remember that that's not going to improve your female pattern, hair loss or male pattern hair loss problem to any substantial amount. It may make the hairs that you have stronger, but it's going to need to be coupled with some other effective treatment. That's where layering these kinds of therapeutic interventions are really, really important. So, have you ever had a patient come to you and say... With a bag of vitamins? No, no. Have you ever had a patient come to you and say with a bag of vitamins? No, no. Have you ever had a patient come to you and say I'm 25 years old and

Everyone in my family has lost their hair, you know when they're in their 40s. I'm and it's male or female by the way So feel free to answer the question differently. Is there anything I can do preventatively even though now my hair is still seemingly perfectly normal But it look if if history repeats itself in 15 years, I'm gonna be losing it or it's gonna be thinning. Well, a lot of my patients come to me with that exact question and concern. Many of my patients who we've transplanted

are treated with other therapeutic interventions. We'll bring in their teenage sons or daughters and say, listen, I got measured too late. Can you measure my son or daughter? They're going off to college, they're going to grad school. Let's get them measured and let's see what's going on. And then the son or daughter may or may not have a concern. Very often it's the parents, just like probably they paid for braces.

So they're concerned about keeping their child's hair intact, or at least as long as it possibly can. So we'll perform some evaluations and measurements. So we know that there's a hair loss risk in the family. The father's a hair transplant patient obviously or something like that. We'll use the tricometers to do hair bundle measurements. We'll look at the areas that are permanent, for example, in the back of the scalp. We'll measure that.

And see, what is their maximum hair mass index? That's the term that we use for the number that is a combined measurement of the diameter and the density in a given area of scalp. And then we'll compare that area to an area that might be at risk, like the crown area, or the frontal zone, or in the temples. And so it's normal to see a little bit less in the temple areas.

But when you're going through puberty, your hair mass is essentially all the same over the entire top of your scalp. So I can pick up if they have a tendency towards hair loss very, very early on, way before it's noticeable to the naked eye. They may not, young man may not even have a receding hairline. And we can tell by measuring the instruments are so sensitive, we can tell already he's got maybe a, let's call it a 20% loss in that frontal zone.

Because you're sure that it's not just 20% less genetically. Correct. It should be the same. These areas are the same. I have patients that come in and they get measured and they are the same. All of the areas measure A okay. Now a lot of those patients are really teenage years maybe,

or women who have hair loss problems, a different type of not necessarily a hereditary hair loss problem, some other issue. Is hair loss sort of like atherosclerosis, where, you know, if you lived long enough, everybody would get atherosclerosis? Is this one of those things where if you, you know, because sometimes you'll see like,

you know, like Ronald Reagan, even at the end of his age, he looked like he had this thick mane of hair. If you did that high fidelity testing on him, would you suspect you would have detected differences? I'm sure. Yeah, I'm sure that. I'm sure that if someone figured it out a way for people to live to be 500, everyone's

eventually going to lose their hair if they don't take some. I think so. I mean, there are a few exceptions. I have a friend of mine from New York. He's in the music business and he's on the admin side, the managerial side and man He's got the hairline that he had when he was a teenager literally goes straight across his head and It has not budged. It has not moved and has not I don't know what the exact density is He doesn't let his hair grow out. It's basically kind of like a buzz cut

But you can see that hairline straight across now. He now I've come across Hundreds of thousands of thousands of people in my life so far, and I've never seen anybody else like him. So I don't know if it's 100% true, but I would guess that it is something like that where over time you will see some kind of thinning. So what are these risk reduction techniques that, or what would you recommend for risk reduction techniques that, or what would you recommend for to patients in that situation? Well, of course, in those early stages, for men, sometimes the first visit to the doctor is their visit to the hair doctor, honestly, and there may not be any other medical conditions that we can necessarily pick up at that time that require, you know, drastic intervention. But if we switch gears for a moment and look at a little bit of an older age category,

their male or female, when they start being on at the age where they're taking medications for blood pressure or cholesterol, or they're on some mood modulators, those are some top, those are like the top three types of medications that can really impact hair quality. I didn't realize that. And is it always negative? I'm assuming? Yeah, for sure. So what were they again? So blood pressure? So blood anti-hypertensives? Anti-lippid. Right. Clestrol-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular-modular in general, anything that decreases the blood, that's being used to decrease the blood pressure. I can't say if it's only SSRIs, but it's a general rule. If they're on some kind of blood pressure and medication, typically they can correlate. If you ask them a point of questions, you can sometimes see at the time that they started that medication that there is some effect on their hair.

Now, how many of those things are sort of hypotheses you have versus documented facts? Is that, I guess, I mean, I'm not that I'm in this literature, but I didn't know any of those things. Actually, I didn't realize that hair loss was a side effect of those meds. Well, it's just been so clear. I mean, I've treated about 20,000 patients, and many patients say, you know what? When I started that medication a year ago, feeling the blank, cholesterol medication, that's when I really started to notice my hair changed.

And when women tell you that their hair has changed, unlike many dermatologists out there, we believe them very much so. You're going to upset the dermatologist. Why don't dermatologists believe them? Well, the general feedback from most of my patients is that they've been, unfortunately, they've been around the block to a number of different physicians, maybe endocrinologists, dermatologists, the primary doctor, family doctor, whomever, doing all sorts of blood tests, looking for why their hair is thinning, and no one has ever even looked at their scalp, measured their

hair, or talked to them about potential treatment options, except maybe a little bit of the counter-rogene bottle on the way out the door, here, catch. So a lot of dermatologists have a certain bias where they look at the woman who, as we've talked about, looks like she's got a full head of hair and say, well, you're not dying of cancer, so you're okay. And so this is not, I wouldn't say, it's a sweeping comment that I've made. I wouldn't say it's appropriate for every single dermatologist out there. And I think that many derms are starting to wake up to the fact that hair loss is important, something important

to treat, and then it can be devastating for many men and women who are experiencing it. So my heart goes out to them if they've been to a dermatologist or several, and kind of been ushered out the door, saying, well, we're here, we're lopping off cancer growths over here. That's what we do. And so you got all your hair. Your hair looks fine.

Are the dermatologists in high volume places like New York and Florida that would be doing what you're doing, which is they're taking a sort of either surgical or non-surgical approach, but basically doing pure hair restoration. Like it sounds to me like one of the problems in that scenario is, you know, if you're seeing a dermatologist who's mostly interested in skin cancer, it's like you skin cancer, you might as well be asking your radiologist that question, right? Yeah, well, unfortunately, dermatologists often hold themselves out as experts in skin and hair, but yet they have little ability to diagnose the hair loss process.

They have no interest in measuring or monitoring or prescribing even a treatment of regimen and keeping a patient compliant with it. So it's just kind of like a doorknob conversation for them and they don't have the time to do it, honestly. I mean, a good strong hair loss consult in my office takes at least an hour, typically patients usually spend about an hour and a half in my office when they come in for consultation. You're not going to spend an hour and a half with your local dorm. Certainly, you know, they're going to do a quick exam, you know, look for some funky

mole and then kind of send you on your way. So they don't have an hour to spend with you. So I think it's part of it is that those practices are just not simply set up to treat hair loss. So I mean, the takeaway is, I guess, if you're, if you go to see a doctor about a concern you have on hair loss, find a specialist. Find someone who's going to do a bunch of measurements. You want to make as many objective measurements as possible. Absolutely. We'll find somebody who does it full time. That's their area of expertise and specialty.

And yes, who has those tools at their disposal? To measure and monitor and figure out what's going on, or whether it's genetic testing, to look at antigen sensitivity and that postmenopausal women. I mean, a lot of germs don't have access to some of that stuff. And so what were the tests again? You do a test of tensile strength. You do density. And then what sounded really interesting was the comparison density test, right? Where you do density in a region where there's never going to be hair loss.

Make that your control and then look at the crown. Yeah, crown or frontal and temporal areas are anywhere really that the thinning is occurring. You know, you have to look at the scalp and you have to see is the skin tone normal. And we've spent a lot of time talking about hereditary hair loss, but there are many other types of hair loss.

So figuring out what's going on in each of these different areas requires someone to look at the scalp and see what's happening. How many times do you look at the scalp and you see something completely unrelated, like a fungal infection that can completely be treated and emulate the whole situation? Quite often, actually.

And one of the things that we've learned, I say I've learned over the past maybe five to seven years, is the impact on scalp health to hair growth. And we had kind of an inkling that maybe this was important, but there is some good data out there, journal articles and such that talk about, especially coming out of like the dandruff, if you will, treatment protocols of zinc, pure thion zinc and some other treatment protocols for the malthezia, the yeast overgrowth, that you get in the scalp that show that,

if the inflammation and the overactivity of those populations are out of control, then you can get a detrimental effect on hair growth. So we know that today, that scalp health is important. So the soil in the forest are out of control, then you can get a detrimental effect on hair growth. We know that today, that scalp health is important. The soil in the forest needs to be fertile, and if it's really inflamed or there's inflammation going on, that can definitely shut down the follicle and impair hair growth. That's important to look at that.

If somebody has dandruff, do we have a sense of how much that's increasing their risk of hair loss? Dandruff is a non-specific symptom. So flakes. Flakes could be thick and yellow. They can be small and white. Your scalp could be oily in dandruffy. They could be dry and flaky.

That's a whole other deep discussion on tricology, which is the study of the chemistry of the scalp, essentially, where we look at scalp pH levels, moisture levels, sebum levels, and really try to assess what's the right protocol of scalp care. Just like you would do that, an esthetician might do that for your face, for your skin of your face, well, we want to treat the scalp in that same kind of way. Figure out, well, what's the right protocol? How often should you shampoo? What's the right shampoo for you? And that's not sometimes a simple question to answer, especially if you ever, well, maybe for you it is, but if you walk down the shampoo aisle in any supermarket, you see that there's

thousands of choices, right? So there's got to be some confusion there. Yeah, do you have any takeaways on what people should be doing? Are there any do's and don'ts with shampoo and conditioners? So I think the best thing, well, of course, the do's and don'ts. So shampoo's and conditioners, if you have any length of hair, you should always follow your shampoo with a conditioner. Shampoo is like a degreaser, essentially. It's a cleanser.

And if you shampoo in a harsh way or with a strong surfactant, let's call it, then you're going to strip out a lot of the natural oils of the scalp and also of the hair in a condition of replaces those natural moisturization of the hair. So it's kind of important to do both of those things, but there's a huge spectrum of different types of shampoos. First of all, a shampoo is not going to cure your hair loss. So when you ask circling back about some snake oil type treatments, there's no one shampoo that's going to fix your hair loss situation.

But, again, you have to understand if we can rectify some imbalance at the level of the scalp and reduce inflammation or tackle a fungal overgrowth, and we're going to start to improve some things. And if we have some ingredients that maybe we want to apply in the shower while the scalp is kind of steamed, if you will, sometimes that's the right time to do it. But I guess the point is, is that finding the right shampoo and conditioner regimen for you has to do with some of the variables that I just mentioned, the scalp pH level, moisture level, oil level. What's your natural sebum production?

What does your hair care regimen look like? Does it require a lot of product or hairspray or things like that that need to be rinsed and washed out? Are you in a dirty environment? Do you live in the city where there's smoke and toxins and things like that? And debris that you need to wash out of your hair on a regular basis? So how does somebody, I mean, given that I don't think about this problem, how does somebody who does think about this problem find out? I mean, is this something where they, you can go to a website where there's like a, you know, if you fit these criteria, this is the shampoo conditioner combo you should use?

Well, there are just some general guidelines, right? So if your hair is kind of long and curly, for example, let's call it even kinky or afro type hair, then you need like durable conditioning. You need conditions that kind of stick around for a while. If your hair is on the other end of the spectrum, let's just call it like thin and kind of limp, then you need very, very light conditioners. And you want to make sure you're using shampoo that strips out a lot of that oil so that you get some weightlessness to the hair in order to style it. So there's some general guidelines.

I remember when my daughter was little and I would give her a bath. I don't know what this might have been, just a total wives tale. But I remember that I was told shampoo is more important in the scalp, conditioner more important. So you would start the shampoo at the head and work out to the ends and then when I would put the conditioner in her hair, I would start at the ends and work up. Is that total nonsense? No, it makes some sense because the ends of the hair are the ones that are typically the dryest. It's been around the longest. The hair doesn't self-repair. It's a keratin fiber that your body has produced.

It's not alive. When the fiber is long, it means it's been around a long time. The tips of the hair is the part where you're going to see a fraying of the hair. The part that looks the dryest, it's the part that's been had the most exposure to UV radiation and everything else. A heat or if you've done a Brazilian blowout or some other straightening treatment or curling treatment or coloring treatment, the part that's received the most amount of abuse is the tips. And so the tips of the hair are typically the ones that look the unhealthiest

and feel the unhealthiest. They may be rough. The cuticle is starting to peel up. The ends are starting to split and fray. And if that continues, obviously, then that's, then you could lead to hair breakage, which can actually is a very common problem for hair loss in women, or trigger of hair loss in women, the hair breakage, literally that they've stressed out the fiber so much that the fibers are actually breaking. And we see that with harsh chemical treatments time and time again, or the new trends for flat ironing and such.

You know, we've put the hot ceramic flat iron again and again and again and again and again and again on your hair to straighten it, to straighten out the curl. And so that application of heat and or other products can degrade the hair fiber. So you should condition the hair itself rather than the scalp, but don't forget that sometimes the scalp needs a little love too. We have a bunch of different types of products that are for exfoliation and for moisturization and inflammatory and things like that. Obviously, if you have a severe psoriasis issue, we need to get those flakes out of there and we need to treat that psoriasis. That's a bigger bit of business than just trying to like, well, what kind of shampoo should I buy at the supermarket?

That's a bigger bit of business than just trying to like, well, what kind of shampoo should I buy at the supermarket? Right. So once we get to treatment, when I think about this, I kind of create four buckets. So I don't know if this is right or wrong, but we've talked a little bit about systemic treatments. So something that you take like a pill where it's going to act across your whole body, but you reap some benefit in the hair follicle. And then we've talked a little bit about topical as well, like, you know, minoxidil. I don't know if we would consider laser also topical, but maybe that could be considered something topical.

Well, let's talk about, for example, putting oral and topical medications or pharmaceuticals in one bucket, and then let's talk about non-chemical therapies in another. Okay. So our non-chemical therapies would be laser and or PRP. And so, a lot of times during a consultation process, we're looking to try to institute something that's going to help someone's hair loss issue. And they may say, you know what, I just don't want the risk of side effects of this drug. I don't want to apply this medication into my body.

And I can certainly understand that they may want to try something that's non-chemical, whether it's a real or perceived value of less side effects, laser has no side effects. Oh, I see. So you think of laser PRP topical as maybe something you would try even before you go systemic. I mean, for a patient who wants to be step wise, obviously you could do them together. Well, for men and for women, it's going to be different. So for men, we talked about the fact that finasteride knocks out the DHT level, and that's the primary treatment.

It's a strong treatment, 90% success rate, very low in supply effects. So for a guy, we're almost always going to consider that. Correct. We're going to talk about that first. Now, they may say, hey, no way. I don't want to do anything that's going to lower my DHT level, and they may have heard a red side effects. They have side effects.

They may have side effects. So there's ways to get around side effects, changing timing of the dose, frequency of the dose, the amount of the dose, moving that finasteride from an oral treatment to a topical with a prescription product, like 82F is a way to get around that. So that would be for men, let's try to at least address the DHT issue first. And if we're not going to go that route, then let's choose from the other tools in the toolbox. Now, for women, because DHT is not the issue most for women or of childbearing age,

we're not even thinking about finasterites for them, we're going to be looking at laser light topicals as kind of the first types of therapies and maybe PRP. So talk to me about why does laser work? Why does it work? Or how does laser works by imparting energy to the follicle. So we know now, photobio-modulation is a very serious science. Dr. Michael Hamlin did much of the lion's share of the research at Wilman Center for

Photomedicine here in Mass General at Harvard. He described, and this is going back now almost 15 years or more, the mechanism of action of low-level laser therapy. How and where the photons of light in specific wavelengths are accepted at the level of electron transport chain in the mitochondrial membrane, cytochrome sioxidase, and what you get is a hyperpolarization of that mitochondrial membrane. If you remember back from basic science that those ions flowing back and forth into and out of the mitochondria is really what generates ATP for kind of a simple way to think about

it. ATP is the energy center within the cell and if you can charge up those energy centers if you can make those mitochondria kind of fire up and produce a lot of fuel you end up getting a better stronger healthier hair growth. Do we know that in people who are losing their hair there's a deficiency in ATP production at the follicle? No. Or is this something that we're doing to override whatever it is that's potentially causing the issue? We're trying to override it, and it's the same thing with menoxidil. When you apply a topical medication like menoxidil, you know that it has nothing to do with

the HT, but you're basically pushing that gas pedal all the way down to the floor, trying to push that follicle into the best possible growth. What is the mechanism? I forgot. It's so funny. I've never seen a patient take monocetyl for blood pressure, and yet I sort of remember studying this in USMLE Part One.

What is the actual mech and is that? Yeah, it's a potassium channel over there. Okay, and so what is that doing to the follicle? So that's a great question, and probably beyond my pay grade, but there are some many physicians, great colleagues of mine in the UK who have kind of figured all of that out and I can provide that research for you, but essentially what Menoxidil does is it keeps the follicle in the growing phase. So remember we talked about the antigen, which is the growing phase, and then of course

the catagen-tealigen, those are the resting degeneration phases of the hair follicle. And we know that in a certain area of scalp there's going to be about 84, 85% of the hair follicle. And we know that in a certain area of scalp, there's going to be about 84, 85% of the hairs in a healthy area, 84, 85% of the hairs are in a growing phase. But as you get to a male pattern hair loss or female pattern hair loss situation, many, many more follicles are in a resting phase than in a growing phase before those ratios change. And the hairs spend less time in a growing phase. So the antigen phase starts to shorten.

So that's one of the reasons why if you have someone with thinning hair, whether it be male pattern hair loss in the hairline or female pattern hair loss, let's say in the frontal zone right behind the hairline, typically you can make a part with your comb, and you can see these very, very short, kind of spiky hairs. That is indicative of miniaturization. If you look at the microscopic level, you'll see even shorter, thinner, weaker, whisperer hairs than that.

So what happens is that when you put somebody on monoxidil, resting follicles start to kick into action and grow. So you're going to start to produce more fiber. So fewer spikes, more of the long guys. Right. And the guys who are already growing that may want to turn off too soon are kept in the growing phase. So those, the antigen is going to be delayed, meaning that the antigen is going to keep going. And we also know that the longer you keep a follicle in antigen, the thicker the fiber becomes over time.

So there's literally fewer exits at the cellular level in the matrix, at the base of the follicle near the dermal papilla. The cellular material continues to aggregate in that area and almost like swell essentially as long as you keep it in antigen phase, you actually get a thicker hair follicle over time and a thicker fiber as a result of that. So your question was, how does menoxidil work? It decreases the amount of follicles that are in that resting phase, keep them in the growing phase.

And so you're going to get better, thicker, stronger, healthier hair from those follicles that could be rejuvenated that are not too far gone. Yeah, okay. That was the next question I was going to ask you. Thank you. So let's go back to something you alluded to earlier, which is most physicians, this is one thing I know about hair loss. Most physicians I've spoken with have said what you said earlier, which is you don't want

to buy manoxidil off the shelf, you should have it compounded. Correct. What? I didn't realize that there was foams and I didn't know what the exact issues were. So, that's obviously one issue you're trying to overcome is create a different viscosity that makes it easier to reach the scalp. But what are the other agents that they typically add to Monoxidil to make it more efficacious? So Tretenoan, right now?

Tretene? Yeah, is excellent. Wait, does Monoxidil make it so that it doesn't... Wouldn't that also aggravate the scalp? Usually not. At the percentages, 0.025 percent that we're working with, you're not going to get an aggravation, but there's a lot of good clinical data

that shows that the combination of monocytoplus tretenone improves the hair growth. So there's some basic science that describes the increased penetration, and then there's also on the results and increased hair density and hair growth that you get from combining monocyn and retinate. In, for example, the formula 82M product, which is our most powerful, most popular treatment,

most easily compliant version of menoxidil, it's a prescription compound, obviously. You're going to have also a tiny little bit of flusinolone in there, so it's an anti-inflammatory. What is a metroidar with that? It's a steroid anti-inflammatory. Oh, yeah, that's one that you would put on your skin if you've had like a rash or something like that. Yeah, that's very common in the dermatological world. There's basically a whiff of that in the 82M formula.

So even inflammation is such a big topic on this podcast. It comes up in every disease. I would not have thought it was going to come up in hair loss. So I was part of a study in the University of Miami where they looked at the microinflammation at the level of the hair follicle. We donated a number of follicles from hair transplant patients, from donor zones and recipient zones and such. And what they determined is that there is an inflammatory zone which is this mediator

of inflammation that was discovered and elucidated through some of that research. So there is microinflammation, it's very well known male pattern, female pattern hair loss, there is a lot of microinflammation at the level of the follicle. So we think that maybe not only could the flusinoleon that's in the 82M be making it more tolerable to the scalp, certainly people can have dermatitis from it just about anything. You can put a piece of Scotch tape on Certainly people can have dermatitis from it just about

anything. You can put a piece of scotch tape on your head and have dermatitis from it. So maybe it's keeping the scalp a little bit healthier in that way, but also addressing that microinflammation right at the level of the follicle and shutting that down a bit. And that also helps us out in understanding that there's some microinflammation also helps us understand some of the more nutraceutical ingredients that we see it also helps us understand maybe how some of our sophisticated PRP creation techniques may improve hair follicle function once you understand that there is some bit of inflammation going on it kind of opens the door to some other modalities of treatment so we've established that for most guys a combination of five alpha reductase inhibition plus this type of a compounded

topical monoxidil plus or minus the laser to hit, and it's so funny. I'm totally familiar with that technology for some of the experimental use that's going on with Alzheimer's disease for the exact same reason. It's hitting cytochrome C oxidase. By the way, they're also using methylene blue, which is a cytochrome C oxidase activator as well. But I'm guessing putting my noxitol, methylene blue on the scalp isn't going to be a great idea because you're going to have to, for every time you apply it, you'll have to spend

an hour washing your skin to get the blue off. Yeah, I don't know how that would work so well. So that sounds like a pretty interesting regimen. Unless you're coming here to Vegas to be part of the Blue Man Group. Yeah, I saw a woman in the airport today that had that going on. So she would be fine. But she looks like she had great hair. So I think she needs it.

For women, you've got those two options, which is the same compounded menoxidil. You don't have to make a different formulation for women. We do not make a different formulation. 82M works very, very well in our female patients. Plus the laser. Yes, they may use the laser. May, plus or minus, they may or may not use low-level laser therapy.

You know, one of the good things about the 82M product just for the women specifically is that it has a little bit of a skin conditioner and a hair conditioner in it. One of the main complaints with over-the-counter-rogane is that it just makes the hair nasty. It just makes it greasy and gooey and basically unmanageable and styleable. And so the 82M product goes on very, very clean and dry and we teach also how to apply it so that it's most active effect at the level of the scalp. And you really don't get it on your hair.

How do you, yeah, yeah, I've never really understood that. 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 barely has hair loss, how do you actually get it on the scalp? Yeah, and it's a tricky bit of business. And if you're using a Rogaine foam version, then forget about it. Most of it is not getting on the scalp, and that's part of the reason why a foam is

not necessarily such a great option for women. But what we do is we teach how to part the hair. The bottle of the 82M comes in has an applicator tip, so you actually put the tip of the bottle directly onto the scalp when you apply it. So you're kind of parting the hair and you're directing the application directly onto the scalp. So it may sound complicated, but literally once you know how to do it, it takes you 90 seconds, twice a day every day. And that's the other piece of the puzzle. Most people who buy an oxytel over the counter think that once a day is going to do the job and

that very, very rarely has any substantial effect on hair growth whatsoever. And what is the requirement of the laser? How often does that need to be done? So that depends on the type of laser that you have because the laser energy that comes out of these different devices could be intermittent, meaning that there's a duty cycle to the laser, right? How much time the laser spends on or off during any given minute of therapy? And also how the lasers are kind of designed into the device to shine onto the scalp. Is it something where it's a spot treatment that you have to move around? Like years ago, we had the laser comb and you had to like move it all the way around

your head every five seconds. Pretty laborious. Today, the laser cap or cap therapy devices just sit on your scalp like a baseball hat. And the battery pack clips to your belt or sticks in your pocket and you could be done in as little as six minutes. And you do that once a day or twice a day. So that would be, well, different devices have different recommendations. So let's just start with the best of the best. The Kapililas RX is really the top device. It's a physician only device. It has 312 diodes Which is a lot when you say physician only meaning you have to be in the physician's office to use it

No, it's only prescription only oh I got I physicians You're not gonna get it like over the counter. You're not gonna get it You can't buy it on Amazon or Costco. I mean unless through it's through the pharmacy. Not the three, not the three 12. Okay, RX device. How much does one of these things cost? So the RX is $3,500? Wow. But what do you say, wow?

I don't know, I guess I just, this is all like a lot. Well, actually, laser therapy is your least expensive treatment over time. I guess because there's one cost and that's it. Correct, they last for 10 to 15 years. I have many patients using the same laser caps that they did from 10 years, 15 years ago. All they've done is swapped out about it. Yeah, when you put it that way, it's a. Correct. They last for 10 to 15 years. I've many patients using the same laser caps that they did from 10

Your 15 years ago. All they've done is swapped out about it. Yeah, when you put it that way. It's a bucket day Yeah, and no side effects non-chemical. Yeah, it's a great investment. So Let's talk about PRP you alluded to it. You asked me how often you do it. So the capital is correct six minutes a day But there are other devices like the laser cap, which was 20 minutes every other day. Got it. So, you know, it sounds like you can be doing something else. Like, yeah, the harder thing seems to me like the manoxidil, because you have to apply it twice a day.

Yes. So, you know, sometimes, for example, you know, we busy college students, kids just starting a job, and so forth, they may have difficulty applying something there to their scalp twice a day, they're living in the dorms and whatnot. That may be difficult. So we may do something more like laser or PRP for them, might be easier for them to be compliant with that. Although, it sounds like it's harder to walk around with a laser cap in the dorm room than... No, because it's covered by a baseball cap.

Oh, literally a baseball cap. It fits underneath a baseball cap. Geez. Wow, okay. I can't wait to link to a picture of one of this. See, so, you know, well, later on when we go down to the expo, you'll have a chance to see, uh, I'll speak it under my hat. Okay, you alluded to PRP. Now, you know, in, in, say, the world of orthopedics where PRP is used quite often, I think the jury's still out on the

efficacy. I think most orthopedic surgeons I speak with believe there probably is some efficacy to PRP, though it obviously seems to be dependent on two things. The technique used to basically create the formulation and the clinical judgment and when in, you know, who, patient selection basically for lack of a better word. For sure. Because think about it if we relate it to the hair follicle for a moment, if the follicle is dead and gone and you're hoping that your laser, minoxidil, PRP regimen is going to do the job, what do you think that success rate is going to be?

Probably not pretty good. So you can't come into a baldness clinic with total hair loss and think that a PRP is going to solve the problem. It's not going to work. And so I would imagine orthopedics is pretty much the same. If you have someone who needs surgery, because there's some severe depletion of whatever, I don't know, it's cartilage or something else, that's not going to be gently fixed by a little bit of regenerative medicine, they're going to need surgery for that.

And that PRP may not necessarily solve that issue. So I think patient selection is a big concern and as it is in hair loss and many other worlds of medicine. So I mean you've sort of alluded to it which is there's probably a sweet spot right where someone who's not experiencing any loss but is trying to be prophylactic. That's way too early and someone who's already experienced the death of the follicle you're basically you know wasting time and money. Correct. So well you're basically wasting time and money. Correct. Well, you're not wasting time and money if you have ongoing progressive hair loss, right? You may not reach your goal with PRP, but it may help mitigate future loss.

Just like the use of Menoxidil and laser is not going to bring back that receding hairline, but it's going to keep it from receding further or faster. Fair point. Yeah. So combination therapy, there's, again, thinking about what we do in practice every single day in my office is part of the process is to prevent loss of the follicle function and enhance whatever follicles you have. And then the other piece of the puzzle is to restore density to those areas which are

too far gone. So PRP has a role in that, right? PRP has a role in preventing the loss of that follicle function. It enhances those follicles that are weak, kind of like what Menoxidil or laser might do, up to a point, right? And we would need to use that over time. So tell the folks listening how PRP works.

I realize I'm sort of taking it for granted. The people know what PRP stands for, what it is, how you harvest. Can you spend a minute just explaining if someone comes in your office and you decide that they're a good candidate for PRP? Tell me what the process is. PRP stands for platelet rich plasma. And platelet rich plasma is an autologous treatment that means it's derived from your own blood.

So in the office, we're going to take a sample of your blood and we're going to spin it in a centrifuge, which essentially separates the formed components in the blood. So red blood cells were way much more than platelets do or blood cells. And so when you spin a sample of the blood, you can then separate the blood components based on their mass, based on their weight. And the reason why we want to do that is that platelets contain very powerful ingredients called growth factors and cytokines. And their platelets are responsible for not only clotting blood, like we've all learned in grade school, but platelets are responsible for tissue regeneration and repair. They're like the orchestrators of repair in the body.

If you get a paper cut, platelets come to clot blood, and then they also orchestrate the repair of the skin in that area, they're the first thing that kind of happens. Plate let's get activated by that injury. They release these powerful growth factors, which may call into action wound healing cells, it may call into action or recruit stem cells into the area. They may then trigger other functions in the body, like increasing

a new blood vessel formation and so forth. But what does all this have to do with hair? So what we found is that anything that helps out with wound healing tends to have a nice positive effect on hair growth. And so PRP was started, the states back maybe 15 years ago, PRP into the scalp, at least in our clinic, we were using it as a wound healing treatment in conjunction with hair transplantation. Because I'm a born and raised general surgeon, we know that anytime you want to cut the skin, you want to heal it. So, hey, by the way, low-level

laser therapy does that too. But PRP, one of the first indications was for wound healing for chronic ulcers and to accelerate healing in diabetics and so forth. So as a wound healing treatment, PRP works really, really well. And it was around this time, some of our physicians were also noticing that when they applied PRP for wound healing, they were also reporting some improved hair growth. And at first, I think many of my colleagues were very skeptical about these early reports, but we were using PRP as wound healing. I jumped, I figured if we can get our patients healed a little bit more quickly, that would

be a good thing. Less downtime. Get them back into their regular team more quickly after a hair transplant, but we were noticing it as well. We were seeing this improvement in hair growth. Let me ask you silly question, perhaps. Presumably, you were using it on the donor sites because that's where the incisions are made or where you're using it on the recipient site. Both. I see. Okay, makes sense. Yeah, we're using it in both areas. The recipient zones, obviously, the ones that were

pretty much more visible at that time. And let's just call it on 2007, 2006. And that's when really when we got started with PRP. And colleagues were also noticing that as I said before that There were some improvements in hair growth and so we started to apply it a little bit more aggressively in some of these patients and applying it into other areas of the scalp that maybe we weren't Transplanting and lo and behold colleagues and myself included were noticing that there were some improvements in the thickness and the caliber and the length of some of these miniaturized hairs. What size needled you used to inject it? So I use a 27 gauge half inch to inject the ERP?

No, PRP is not painful because we use a complete local anesthetic block. So we're going to block the entire area that we're going to treat. People say, well, of course, once the local anesthetic is in place, you won't feel anything on your scalp. That's how we do a hair transplant. People often say, oh my god course, once the local anesthetic is in place, you won't feel anything on your scalp obviously. That's how we do a hair transplant. People often say, oh my God, it's so painful. Like, even if you put the local anesthetic in, that's going to be painful. No, it's not.

We have a pro-Nox device, it's nitrous oxide delivery system. It's on demand. If you want to take a couple of puffs on the nitrous, usually makes it 100% painless. And to be honest, 9 out of 10 patients say that it was dreamy when they had their treatment done. So I'm actually just not be painful. That's a good point for people to know. Should not.

Yeah. I'm amazed you can get it out of a 27 gauge needle. Like I thought it would have been too viscous to come out of that. No, platelets are tiny. Platelets are super duper tiny. Hmm. I mean, we can look up the exact measurement, but I'm not even expecting this. Yeah, come to think of it there.

I mean, they're extremely small. Yeah measurement, but I'm not even thinking about that. Yeah, I kind of think of it there. They're extremely small. Yeah. Yeah, basically, they're smaller. They're quite smaller. Yeah, but platelets are self-ragments that are smaller than red blood cells. Yeah. So they're extremely tiny. And just as a directional number, not that you're counting, when someone comes for a quote

unquote standard PRP therapy, how many actual injections do you think they require in a typical treatment? So most patients want to know how many needles are you going to hit me with, Jack? Yeah, exactly. So that's always the question. Of course, as I said, with local anesthetic applied appropriately, applied painlessly, you will feel none of my PRP going in. So you will feel none of the 700 injections that are required. Well, no,, I wasn't asking from a pain standpoint or from a bleeding standpoint. No, but for your listeners, they need to know that they're not going to feel any of the 700 very, very tiny injections. How long does that take you?

It takes only about 10 minutes. Where? How can you do 700 injections in 10 minutes? Well, actually, my nurse practitioner and I tag team the scalpel. So we do, you know, half and half. So, but, you know but my thumb is pretty strong. Wow. Each injection gets how much volume?

A tenth of a CC. It's pretty quick. Wow. To be honest, I mean, the whole treatment procedure in the office is about an hour. Start to finish. And most of that is honestly the preparation time of the PRP.

I have patients who are being treated in New York, so they're not patients that you take care of, I've mine, who have had excellent results with PRP. And I know obviously our mutual patients have as well. And we've talked quite a bit about it. Is it your expectation once you've decided or once like obviously the persons that you know they're seeing in New York? I mean there's lots of good people out there. But once you're in the hands of someone who has a really good set of patient criteria selection, are you pretty optimistic that PRP is going to move the needle?

Oh, yeah. I mean, PRP works well. How often does one need to be treated that way? Well, that's a great question. So everyone's a little bit different in terms of the power and strength of their PRP. Remember, this is not coming out of a bottle. This is coming out of your vein. So if you come to my clinic and you have 150,000 platelets per microleader, you have a different platelet concentration that somebody has 250,000. So stop your aspirin before you show up. Well, it is a smart idea.

But remember that if you believe that the aspirin is simply just delaying the activation of the platelets, I mean, as a surgeon, you know that all bleeding stops. So eventually the platelets get activated. So, maybe you know, I'm not so sure that that's such an important problem. So, we, remember how we used to give all those patients a ton of aspirin after splenectomies and stuff like that when they were getting these sort of macrosidic,

or maybe it was the shape of the platelets that was changing. I don't remember if it was the number of the shape, but okay. I don't remember. Yeah, yeah. But I'm not so, you don't work too much about that. I really don't. I really don't.

I want to know that I'm getting a good platelet concentrate, so I'll do a CBC at the bedside. I have a colter counter in the office. Unlike most physicians, I have the devices, a Beckman colter counter, and we'll do a CBC on the whole blood that comes right out of the vein immediately right there, right before we do any kind of spin. After we do our, this is called a proprietary protocol of spinning and separation and concentration of the platelets, we'll do a final count on that. We'll use a couple of microleaders, not much, to get a final platelet count on what exactly we're going to be injecting.

So I can tell you, if you come into my clinic, exactly how many platelets we're going to be injecting. So I can tell you if you come into my clinic exactly how many platelets we're going to be injecting for you. And I think that over the years having done about 4,000 PRP injections, I feel like we have a very, very good handle on how platelet count affects the outcome. So we're working on that. Wow, something as simple as someone shows up with 150,000 versus 400,000, presumably the more that they show up with, the better. Yes, and there's some good journal articles that describe the effect of platelet concentrate on these biologic processes that we're interested in. Physiologically, we know that there's a dose curve.

As you increase the concentration of platelets, for example, on neovascularization, there is a dose dependent upward curve on that. So the higher the platelet concentration, the more neovascularization you're going to get. Now, there's a biphasec dose curve on stem cell mobilization. So as you go up on the number of platelet concentrates, there's a kind of a sweet spot that occurs. And then if you go over that amount, then it starts to dip downwards. So what exactly is that concentration? In both of those studies that I just said, what is that concentration supposed to be? According to that data, it says somewhere between 1.4, 1.5 million platelets per microleader

is where that sweet spot exists. What we're trying to show in the office is that that correlates also at the bedside to the clinical response. And I mean, I assume you're gathering those data. You've done 4,000 of these. So you have your own prospective series? Yes. So what I can tell you is that I think that there's a strong correlation between the amount of platelets that you come to the table with and the amount that we can concentrate. So obviously we have to maybe make some adjustments in our protocol if you are kind of low on platelets.

But, you know, again, there's some of the things that we may not necessarily be taking into account. Everybody has a different size and shape of platelets. It let's say your platelets are low, but they're very big. We don't know what exactly do those platelets contain. But again, there's some data in the clinical literature where we can correlate growth factor concentrations with platelet counts.

Pretty well. This sounds to me like it's something that's still in its infancy where it's absolutely. I mean, that sounds like the crudest of all metrics, and it's probably an oversimplification for what's really going on. And, you know, hopefully in 10 years you have a different assay than just something as blunt as the CBC, right? You can measure some cytokine or you can measure some other functional property of the platelet.

It probably matters a heck of a lot more than the number. Right. I mean, look, eventually, maybe there'll be a bedside PCR, or we can figure out exactly what exactly those growth factors are that are doing their job, you know, inside. But the other thing that I've learned over the years of doing those thousands and thousands of PRP treatments for nearly 10 years is the importance of the white blood cells. So the monocytes are a very, very important component. I think they're underappreciated in not only in the literature in terms of what they do

in the body, but especially in PRP. And I'm a very strong proponent of the importance of monocytes in the final PRP. And I'm a very strong proponent of the importance of monocytes in the final PRP. And we say that our PRP is monocyte rich. And I don't think that that's really a term that's caught on yet, but I think that it will. And monocyte rich PRP. Wait, so you can, obviously it's easy to pull the platelets out, but when you're looking at leukocytes versus monocytes versus ES ESYNFILZ, you have a sensitive enough centrifuge to get that band. So the way that we've been able to do that

is through a dual spin process. So the dual spin process, for lack of a better way to explain it, the first spin is kind of a gentle spin to take off the red blood cells. We don't want red blood cells in our PRP. Red blood cells in the skin are extremely inflammatory. When those red blood cells. We don't want red blood cells in our PRP. Red blood cells in the skin are extremely inflammatory. When those red blood cells lice, the hem is extremely inflammatory, and there's a lot of chazy iron.

It's really bad. So we don't want that in the skin if we can avoid it. So I prefer to have PRP that has less than 1% hematocrit. So the PRP may look pink in the syringe, but it's a very, very small amount of red blood cells. Now, of course, when you're trying to decant the platelets, right, to can't the buffy coat, you're right up against those red blood cells. So the first spin takes off a layer of red blood cells and leaves us with a plasma, which contains the platelets. So the plasma-based spin, which is the second spin, then essentially pushes the platelets to the bottom. So we've captured this maximum number of platelets.

We can take off the platelet poor plasma to as much as we would like, leaving us with then a reconstituted amount of whatever we choose, concentration and volume of PRP. So that process, that dual spin process, and I haven't found another one that has been able to duplicate this, consistently removes the red blood cells,

consistently gives me a very high concentrate of platelets, and consistently gives me this bump or boost in monocytes. And remind me about how many tubes of blood are you actually drawing out for the full treatment? We take 60 cc's on the treatment. Okay. So 60 cc's concentrates down to about seven and a half cc's of PRP. Wow. I think incredible. And how many hours does it take? What do you mean? Takes.

From the time you do that first prick of blood until you're in direct. It takes just an hour. They're walking out the door in an hour. They're out the door an hour, man. I obviously know very little about this. Yeah, so when you come in, you'll see. Let's get to the meat of it, which is the transplant. So how do you think about? Well, you don't want to know how long the PRP lasts in my hands. Okay, yeah.

Come on, this is really important, because most dermatologists are spinning test tubes. They're getting all two-3 times concentrate. They're not getting 7-8 times. On the platelets, they're missing all the monocytes and besides all of that, they're booking their patients for every other month or every month treatment. So the treatments that I just described to you that we do, that proprietary protocol, is essentially about once a year. And so people say, well, you know, you could claim five years, you could claim six months,

how do you know? Well, we know because we measure. So we know that 90% of our patients get a positive response from the PRP that lasts about 10 to 14 months. And that there's a small percentage of patients, maybe 5% that need it more often than that. And then I have another small cohort of patients that can get away with it almost every two years. And that's it. And what's the percentage of patients that are not responding? Well, everybody responds to some degree. The question is, is they responding where they want? So, if someone comes in with a receding hairline, they say,

hey, Doc, I really want PRP here at the receding hairline. If they're hoping for some regrowth, chances are that they're not going to get too much action there. Because why? We talked about that, that there's just less chemicals. Yeah, we're pastoral. In that area, there's not enough trees in the garden, so to speak, when we, or plants in the garden,

when we go to fertilize. But the other zones that they didn't even realize were thinning, we're gonna get a 20 to 50% boost in volume in many of those areas. That's pretty simple. And when they're leaving, obviously, you're putting them on the regimen that is medical, topical, plus or minus laser.

Could be any of the above or just one. When many patients are doing monotherapy to start, they don't want to do two, three, they're four different things. And then other patients come in and they want to do kitchen sink approach. So it varies. It varies on their motivation. Sometimes the beauty budget, sometimes it's just their time effort and energy involved. They're, you know, they're desire to, you know, and their goals.

Honestly, some patients come in. They say, you know what, if I just stayed the same as I am right now, I'm pretty happy the way I am right now, if I stayed the same, I would be cool. And so they may make a plan for that. But then there are other patients that say, hey, you know, we got it, we want to turn the clock back. And that's where the transplant comes in. So is it more often the case that the patient says something to you that makes you say transplant

is really the only option here? Or is that generally the inevitable path for most people once they start going down the treatment? Well, I think we're so clear about what these treatments do that the patients will typically say, hey, you know, in order to accomplish what I want to accomplish, it sounds like we need to transplant. So it's very much patient-driven process. My patient, you know, in order to accomplish what I want to accomplish, it sounds like we need to transplant. So, it's very much patient-driven process. My patient, you know, is our priority.

We have a patient-centered practice. So it becomes very, very clear after spending the time with the patient for the patient knows what they're going to need, essentially. So they may say, hey, you know what, I think I'm probably getting any hair transplant. It's now is not the right time. Maybe it's going to be next year. Let's see what we can get with the non-invasive therapies. And I'm cool with that. But if somebody comes in and says, hey,

I really want to fix this hairline with PRP and laser. I mean, I have to be honest with them and show them with the microscope. Look, man, we can wish and we can hope. And that's OK. But wishing and hoping is not a strategy. So let's go back to that first patient that you saw who had gone up to Toronto.

Where did they go? What was special in Toronto? Having grown up there, I'm curious because I didn't think much was special in Toronto. So what was happening? Other than the Sholdyze clinic for hernia repair. Interesting. That's very special.

Yeah, for sure. So things that were happening in the early, I would say the mid-1990s were that hair transplant surgeons were learning to use single follicle implants, meaning that instead of a plug or a punch or 4mm biopsy of skin, they were cutting down and dissecting or getting down to literally a one-hair follicle graft. And what that enables you to do, if you angle and orient that appropriately in the right position in the scalp, is to create a result that looks like Mother Nature made it,

make it look natural, it's soft. So you can't put them in a row, you can't put them perpendicularly in the skin, you have to angle them, but there are ways to work with single follicle implants to make your end result look 100% undetectable. And that is why that gentleman traveled from New York to Toronto because there was a gentleman up there

who was having, doing that work, and his Dr. Seager at the time is the surgeon that was doing that work since he's since passed on, but he was doing that work with linear harvesting. So that was the old-style strip harvest and using microscopic magnification to dissect the hair follicles, and then implant them in a way that would make the end result look natural. It seems like, well, why wasn't everybody doing that?

Well, not every surgeon was using microscopes, not every surgeon was using tiny grafts. They were using either larger, what they call call micro-minigrafts, let's say, or those punch grafts to create the density. Two comments there. The first is, so they were still doing a linear graft, which means that these patients were having hair taken out with a big scar, presumably in the back of their head. So that's a comment. And then the question is, how in God's name do you take a strip of hair out of the back and isolate it by follicle, whether or without a microscope?

I'm just talking purely from the standpoint of patients. Like how many years does that take? I don't know. It doesn't take years. I mean, I'm being facetious, but I understand. So there's a lot of labor, right? So my training, and my training happened in the 1990s there, we took linear harvests on patients,

and we moved to 3,000 grafts in a single day for those patients, and I did that early on in my practice as well from a linear harvest, and the way that we did it was with labor. We had surgical technicians working two, three, four, five at a time under back lights or microscope, stereoscopic magnification, literally doing the bench work to process that tissue. But this is all done sterile. It's done aseptically. Yeah. Okay, so you can't sterilize the scalp. It's a common knowledge. Good good news the scalp is very much immune to severe infection It's just we're built that way much like the face so you said two to three thousand you could harvest and it's graphs

And would that be like one strip that would be what how many centimeters long and how long? So as the single strip could be you know depending on the size of the case could be 10 to 20 centimeters long and a centimeter wide wow So it's gonna go from ear to ear essentially around the size of the case, could be 10 to 20 centimeters long and a centimeter wide. Wow. So it's gonna go from ear to ear, essentially, around the back of your scalp. And unfortunately, for many of those patients, they ended up with some wide scars.

Even with techniques, like I helped pioneer back with the linear harvesting, trichofitic techniques, where we would actually overlap the closures to get hair to grow through the scar. There's still a scar, and a scar has not as much hair. It's a little bit smooth. Sometimes it has a different type of color, right?

Then regular skin. So even with short haircuts, hairs growing through the scar can still be a scar that can be disfiguring. And so, I'm sure you remember in the field of general surgery, there was a paradigm shift from open gallbladders to laparoscopic. So that was happening in the mid of general surgery there was a paradigm shift from open gallbladders

to laparoscopic. So that was happening in the mid-1990s. So I was very much attuned to changes in surgical technique and surgical paradigms. And when FUE, follicular unit extraction, started to become kind of a chatter on the internet. There were some guys in Australia doing it, and a few people here on the US, I wanted to really try to do that procedure and perfect it. And so that led me down the road to adopt FUE, follicular unit extraction at a very, very early stage of the game. So I did my best. So I did my best. So I did my best. So follicular unit extraction is the use of a very, very tiny punch, let's call it about a millimeter.

In the early days, we used disposable punches that were sharp, that were used for punch biopsies, but these were very, very small items, smaller than the tip of a ballpoint pen, typically, to harvest the individual follicular units. So, those are the groups of one, two, or three hairs each, out of the scalp. So, the graft comes out of the scalp basically ready and without a scalpel and without stitches. Now in the early days it was very difficult. I designed the first manual hand turned instrument available to physicians to be able to do this procedure. It was called the Boundmon Mindex and we were doing these procedures in a very, very slow way. They weren't very

efficient. They weren't very accurate, they weren't very accurate, but what we learned through many, many years of time on tissue, applying this kind of technique, eventually, we got to a point where it became a viable procedure. And is the harvest scar such that it doesn't even require a closure or do you still need a stitch? No, it's less than a millimeter. It closes up 50% in 24 hours

and the skin is totally clean within another day or two. Really, the only thing that you would see on a shaved scalp is if you had, think of the head of hair like five o'clock shadows that you would see a little bit less shadow in those areas. There's no visible linear scar. So now you could move a lot of hair and not leave someone with a disfiguring scar in the back of their scalp because it's a much more flexibility in hair styling. Is it safe to say today that nobody is still doing large scars? Because even if I open up the magazines on the airplanes, I mean I feel like once it's in the airplane magazine it's no longer inside baseball. You know they

have the picture of the guy standing there. You're looking at two guys from ahead behind and there's the scar and there's the no scar. Is it safe to say like no one is having that type of a harvest any longer? No, it's actually not true at all. Many of the large national clinics that you see on late-night infomercials still do linear harvesting. And many of my colleagues here in the US still prefer to do a linear harvest than FUE. So I want you to play skeptic devil's advocate for a moment. Why are they still doing it? What are they saying is better about that approach than the approach you just described of single follicular extraction? Well, you know, probably some surgeons that are kind of stubborn. Yeah, but I would like to think that in something where aesthetics play such a role, it seems

like kind of a no-brainer. There must be some other explanation other than, like, put it this way, if I'm a patient and I'm going to see somebody who's about to do a huge linear scar on my scalp, and I say to that person, why are you still doing it this way when the pictures in the airplane magazine say I should not have a scar? Oh, they're going to say, oh, well, we get a lot more hair this way. It's a lot more efficient. I don't have to buy any expensive equipment to do this. I don't have to learn any new skills.

It seems like it's much less efficient because, well, I guess it depends how you define efficiency. You can have you have more hands involved, but presumably it can take less time. Is that what they mean by more efficient? It definitely would take less time. If you're doing a 3000, 4000 graft procedure in your office with a strip and you have enough staff, that could be much quicker than an FE procedure for sure. So if you had a patient and you were, I don't know if you'd do this, but if you were going to dedicate the entire day to that patient, like it was a one, quote unquote, a big case of the day.

How many flaky units can you harvest and implant? So we've done very, very large cases all in a single day, but today we would really prefer to do anything over 2,000 grafts in two consecutive days. We find it a lot more comfortable for the patient. It's a lot more comfortable in the office for the staff and our harvest rates and our harvest quality is much, much more improved than trying to do a marathon into the evening type of session. So most of our patients, if they're gonna do a large

maximum as much as possible procedure, they're gonna get, let's call it around 3,500 to 4,000 graphs over two days. And that's with a wide shave all the way around, provided that they have the hair to do it. They're exceptions. I mean, we've done 5,000 grafts on some guys, and sometimes we try to get 3,000

and we just can't even do it. What is the greatest number of grafts you've implanted on a patient? And I'll ask it two ways. One, harvesting only from their head, and two, harvesting from other sites on the body, which I'd never even heard of until you mentioned this a couple, maybe six months ago. We were talking about this, and you mentioned that in one of these patients, you'd actually

harvest it something from his beard. Oh, yeah. We actually do quite a bit of beard harvesting these days. Many of our patients have old-style scar tissue from either procedures that I did back in the early days, you know, in the early 2000s, when we were still doing half of our work with the linear harvest technique, you know, and I'm not afraid to correct those cases and to, you know, update those cases into the latest and greatest possible situation that they could have. So top number as well, you know, my dad comes to mind.

He had almost 8,000 graphs. He was totally bald before we started. Most guys who were totally bald up the top, meaning that they only have the hair on the sides and the back. Most of them will need somewhere around 6 to 9,000 grafts to kind of fill up the zones. Do you have, if someone is that bald, do they have enough donor site on the remainder hair? Most of the time, if they've never been harvested, they do. But if they've had some less efficient harvesting techniques, then we may have to go to other places, as

you say, alternative sources of donor, like the beard or the body hair to satisfy that. And I've never really thought about it, but my beard hair... Actually, it seems about the same thickness as my hair, but I don't know. Is beard hair thicker than hair? Yes, usually it is, but everybody's different. So some people have thicker beard hair than their scalp. Some people have thinner beard hair than their scalp. Some people have curlier, coarser hair on their beard. It seems to be most common. So we're not gonna put your beard

in the frontal hairline typically. It's gonna be used as filler. It's filler in the back, yeah. And it works really well. And body hair seems much less thick and robust than hair hair. I mean scalp hair, right? Again, everybody's different. I mean, if you are person with very, very thin fine hair

on your scalp, you may find that the other hair, body hair is a better thicker, or so caliber, but the problem is, and this is just a general idea, that as you get farther away from the scalp, the follicle spend less time in the growing phase. So again, we're going back to this antigen, catigen, tealigen, and... Sure, sure, The body here doesn't really grow. I mean, it's so it spends less time in antigen, but it also out of let's say 10 follicles from the body, the chest, maybe only five of them are

growing in any given time. So it's kind of like hiring part-time workers in your factory. You know, you've put you've hired 10 people, but only five of them are showing up a day. You know, that's not so good. So the beard is pretty good there for a male. You know, it's really good for a male. Yeah, yeah, cause the beard solves a lot of problems. Beard is good to fill in the scar too sometimes. Oh yeah, that makes sense. Now, for women, is this beard's not gonna work?

Yeah, no. This strikes me as a much easier problem in women because you have generally far less volume to cover and far greater ability to cover up donor sites, right? So women pose different problems than the men. If you wanna do a large session on a man, you can say to most guys, hey, can we give you a pretty short haircut?

And they'll be like, yeah, okay, no problem. I may not love that haircut, but I'll do it. For women, that's not really gonna work. So if you need to move a lot of hair for a female patient, it needs to be done in steps and stages. So there's a couple of ways to approach the donor area in women that would be like shaving a tiny little stripe, so a little horizontal area

where we're gonna take the individual follicles from, right, because we're not gonna cut a strip, we're gonna take the individual follicles that way. Or we may trim a couple of hairs here, let's say one out of every 10 or 20 hairs, and then go after those hair follicles the next day. So there's no shaving whatsoever. Nice way to handle that. But you know, you'd be surprised how many women have receding hairlines, like their temples

really with female pattern hair loss, really go back as they age 55, 65 years old. They can start to lose that feminine shape to the hairline. You can really start to move backwards. That's the most common area that we transplant in women is the temples, part of the hairline. A lot of women want to move their hairline. They're not happy with the size and the shape of their forehead. They want a hairline lowering procedure that doesn't involve cutting with a scalpel or stitches or a prolonged recovery or risk of invasive surgery. And it's very easy to do transplantation to fix a high hairline and to bring the hairline

down into what Divent you would call the gold and ratio, which is one third, one third, one third. So what are the biggest risks of this procedure? Besides the obvious risks that we talk about in every surgery, bleeding, infection, etc. Or, you know, is there anything that is unique to this surgical procedure as far as a risk? Sure. Well, bleeding infection extremely rare, thank goodness, even though we're making thousands of little tiny sites in the scalp, not only the harvesting and implantation part,

it's a pretty exciting. Yeah, it's a pretty exciting. Bleeding is not an issue. I mean, just like if you cut yourself shaving or you got a paper cut, you know, in 20, 30 seconds you stop. Infection, your worst infection, typically, with a hair transplant, might be a pimple to be honest. And maybe most people have one or two, and we call it, you know, it could be around the

time when the hair starts to kick in, like an ingrown hair. You kind of have to pop it like a pimple, release the hair that may be caught at the level of the scalp. And it's pretty rare, maybe, like, you maybe like one out of every 20 or 30 patients that has more than a half a dozen pimples or something where it needs something more significant in terms of wound care to kind of release those hair follicles. Maybe they have curly hair or something like that. But I would say the main concern for hair is not the physical attributes of the procedure itself, because

we can recreate something with artistic bent. We apply an artistic approach to the shape of the hairline, the angle, the orientation and position of the hairs, the variation in terms of hair density to make it look normally natural, not a wall of hair, straight density across the hairline, the shape that builds into the sides, the temples, the temporal point on the side of the scalp, the angle orientation that's required for recreating a crown area. But really, the risk comes to simply not happy with the result.

And so, again, it all comes down to the consultation process. What exactly are you expecting out of this procedure? And have we gone over exactly what we believe we can achieve? Because if I tell you you're going to be a 10 out of 10 and the reality is that it's going to always be a 5 out of 10, then I've promised you the wrong thing and you will be forever unhappy with that. So we have to be very, very clear about what's possible

and what's 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 head of hair. You know, and I go back to my dad, for example, total, total baldness for two decades, wore a hair piece and all that. The transplants that he has, if you look at him today, even 15 years later after his procedures, it looks like he has a full head of hair, but it's in illusion. It looks like he's got full coverage. You see the frame of his face. You see that Da Vinci golden ratio. He looks 20 years younger than when he had his procedure, but he never will have that

density that he had as a teenager until we can figure out how to clone these babies. That makes a lot of sense, and I guess that as your practice continues to grow, one of the greatest things that each patient is providing as a gift to a subsequent patient is a before and after photo that gives you a bigger and bigger database to show patients more closely, I suspect, what they can expect based on where they are. Because you've got just a greater basis from which you can say, look, I've got 27 patients who look almost identical to what you looked like. Here's the range of outcomes. And if you're not comfortable with that range, you're not going to be a great candidate. Correct. So after 8,000 surgeries, I can tell you with very, very good confidence, what's possible

and what's not, and what it will take to get there. And if the patient is all in and he's going to protect the existing hair, we know that that's going to add a lot of great benefit to the end result. If he's lack sedasical and he's losing other hair while we're transplanting this area, other areas are being lost, that's going to be a much tougher battle. So it's very much a team approach. And my patients become very much drivers of the bus, so to speak, because in order to get the best results, there has to be a good amount of buy-in in partnership

with what we do and what we recommend. I can tell you what kind of therapies and treatments and such that'll get, keep your hair growing strong, but you have to do that work. When you take a hair off the side of the head or the back of the head in an area as a donor hair, and hair that was never going to fall out. And you put that hair back on the top. Is it susceptible to its nature or its nurture? In other words, is it now susceptible to the DHT forces that took out the hair that it's

replacing or does it bring with it its genetic pattern from its donor site? So the whole basis of the field of hair transplant surgery is based on the concept of donor dominance. So that would mean, and again, it's the theory, right, of donor dominance, meaning that the hair follicles from the sides in the back of the scalp, which are virtually immune to the effects of DHT, most guys with a total baldness problem never ever lose that hair, that it will grow, live and grow forever in its new location. There are, I would say, very small numbers of scientific reports that kind of put a dent

into that. So in these few and far between cases, we believe that there is some recipient area control. And the way that I would explain that to patients is if, remember we said, how long the follicles stay in the growth phase has a lot to do with where those follicles come from. Well, one of our more prominent researchers and colleagues in the field took a hair follicle from one place on his body

and put it into another place, and then moved that follicle someplace else and tracked those lengths of time that it's spent in the growing phase. it tracked the antigen, the growth phase. And so what you would expect initially is that wherever you took it from, like let's say the chest, it grew for an inch

and that's it, you put it in the back of your arm, it should grow for your hand, it should grow for an inch, well it didn't, it grew differently in those different locations. So there is some local effect. So what we do say, and especially true for women, where sometimes they can have a more diffuse hair loss problem, because it's maybe not necessarily all antigen dependent,

that we say that those hairs are relatively permanent. Is there anyone ever done any experiment where you take a hair and implant it in an area that has zero hair like the palm or... Of course. Yes. In fact, I did that for someone. Have you ever heard of NALTS from YouTube? No? So knalts from YouTube is a prankster. I'm sure he wouldn't be upset with me sharing with you and your listeners that he had some hair follicles implanted

into the palm of his hand during his last hair transplant procedure. And it grew fine. Wow. So that is from just from a pure biology standpoint, that is really amazing. No, it's not because, listen, the hair follicle is an organ, it's a self-determining organ. If you have a scar, which doesn't make any hair on its own, you can cut that scar. It's gonna bleed, right? You throw a hair follicle in there, it will survive,

it will grow, it will thrive. It will demand more blood flow. But there must be something very unique about parts of our body that don't grow any hair that, I don't know, I guess, I mean, I don't think about this obviously very much, but it just strikes me as counterintuitive. If this were an exam and you asked me that question, I would guess that if you implanted the most robust hair into an area that otherwise would never grow hair, it wouldn't have the

fertile enough soil to promote it. No. Anywhere that you have a blood flow, it will grow. Because all it needs is energy. It needs the oxygen, it needs the nutrients, the hair follicle. If you have a non-healing wound on the side of your leg, you have diabetic ulcer, you can implant follicles into that area,

and those follicles are so metabolically active that they will actually secrete the growth factors, demand more blood flow, and vascular neogenesis will occur, and wound healing will be accelerated and enhanced by placing hair follicles into that non-healing wound. That's incredible. The hair follicle cell population, the population of cells within the hair follicle are among the most highest, metabolically active cell populations in your body.

It's one of the reasons why chemotherapy knocks them out as well as the lining of your gut and bone marrow, right? I mean, if you gut your bone, your hair, those are some of the most highly metabolic and metabolically active cell populations that we have. And so they continue to work and grind away to grow on your head, a full head of hair, right? 150,000 hair follicles will produce somewhere around 1,500 feet of hair a day. That's interesting. Did you say how many hairs on the head?

So you're born with about 100 to 150,000. And it's amazing that you said you could take someone who is completely bald and through very strategic placement using only 10,000 hairs, say... No, I said 10,000 grafts. Graph could be two to three hairs. Correct. Got it. Okay.

Because again, we're not going to recapitulate a teenager hairline. Age appropriate matters, right? So the recession of the hairline, that's going to look normal and natural. That's where some of the nuances, right, and the discussion between our patients who are maybe in their 20s who want to look like they did in their teenage years, versus patients who are maybe a little bit more mature in their 30s, 40s.

So the idea is to design something that looks normal and natural as they go through the process. Well, Alan, this is super interesting. I suspect that there are going to be a lot of people who listen to this who are going to potentially revisit assumptions that they've had on this entire topic. I'm actually surprised at how often a patient asks me a question about this, and obviously I just don't know much. I mean, all I've learned over the years is to find people like you, who I can send them to,

but I think what surprised me the most in this discussion is how far this field has come and what seems like a decade and a half, basically. Yeah, I mean, it's incredible. This is the most fast moving field. I mean, it's incredible how quickly things have changed in hair transplantation from, you know, whether it be linear harvesting to a molecular unit extraction, to the use of cellular therapy, you know, PRP and other things like low-level laser therapy and compound of medications to attack the hair follicle and from all sides and all different ways and all different modalities to help our patients really grow better hair and look great and feel great. I mean, that's what it's all about, right?

It comes down to the emotion. When you look in the mirror and you see that hairline growing back in, you know, patient after patient, they say, this is amazing. This is a miracle. This is like, I never thought I would see my hairline again. I never thought I'd cover that bald spot except with a hat. I mean, that's the exciting thing that keeps me going every day. Well, Alan, thank you very much. I appreciate the input and I hope that anyone listening to this who's had some questions about this has got some of those answered. Great, well great to be here with you.

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