By 2032, the hair restoration industry will be valued at $30 billion.1 Rapid growth and the constant onset of technological advances fuel the need and desire for males and females to regain what they have lost. Nonsurgical interventions are up, and surgery is down, with about 149,000 hair restoration procedures done in the U.S. and Canada in 2022.2,3
Dermatologist and founder of M Beauty Clinic, Tess Mauricio, MD (San Diego and Beverly Hills, Calif.) reported that more female and even younger patients are seeking nonsurgical hair restoration treatments. “Many experience telogen effluvium from Ozempic, COVID infections, post-pandemic stress and chronic extensions,” she explained. Part of the uptick in the normalization of female-centric treatments for hair loss is due to social media. “Female patients experience more shame and psychological stress with hair loss. In the past, these patients hid the condition or camouflaged it rather than seek treatment for it.”
Causes of Hair Loss
Hair loss manifests for different reasons in male and female patients. Males are genetically predisposed to male-pattern baldness. Illness, hormonal changes, medication, a poor diet and stress can cause hair loss in both sexes. “Overuse of hair styling products and regimens, and hormonal imbalances from pregnancy, polycystic ovary syndrome (PCOS) and menopause, can lead to hair loss in women,” said Suvina Attavar, MD, a board-certified dermatologist in Bangalore, Karnataka, India. Other triggers include pollution and natural aging, affecting hair quality, quantity and density. “Males experience receding hairlines and vertex thinning, whereas females have diffuse thinning throughout the scalp or a widening of the midline partition and bi-temporal recession.”
According to Artur Diaz-Carandell, MD, an aesthetic surgeon in Barcelona, Spain, women are more concerned with hair loss than ever for several reasons. “Changing beauty standards place a strong emphasis on a full head of hair. Hair is associated with femininity and youth, which pressures women to maintain thick, healthy hair. We see that a big frontal area is no longer tolerated for most women.”
An accurate medical diagnosis by a physician is necessary to determine the root cause of hair loss before piecing together a plan. Dr. Mauricio takes a complete medical history and asks patients if their primary care doctor has ruled out thyroid disease, anemia, nutritional deficiencies, hormonal issues, or autoimmune diseases. Similarly, Dr. Attavar runs blood investigations for serum ferritin, thyroid profile, vitamins B12 and D, and hormonal assay. Dr. Mauricio also examines the scalp to rule out infection, scarring alopecia, and inflammatory scalp conditions. When necessary, she performs a scalp biopsy to examine the hair follicles.
Treatment Options to Restore Lost Hair
When patients experience hair loss, the typical response is to intervene with a myriad of solutions. Board-certified hair restoration surgeon and plastic surgeon, Robert Dorfman, MD (New York City, N.Y.), shared that in his experience, traditionally, patients waited until they had advanced hair loss before seeking intervention. “Now, more patients are taking preventative measures to stop their hair from falling out to avoid a big operation.” Younger patients opt for hair restoration intervention in their late 20s, a shift from the trend of patients in their 30s to 50s.
Naturally, hair loss patients seek efficacy when undergoing any hair restoration protocol or procedure. Typically, female patients prefer nonsurgical options used in tandem with medications. “This may include hormonal therapy, with caution in women of childbearing age when prescribing minoxidil and finasteride,” Dr. Attavar noted.
Besides a patient’s sex, other factors to consider are the stage of hair loss and the patient’s expectations. Dr. Dorfman explained that for more advanced-stage balding patients, nonsurgical treatments are unlikely to be effective alone, but are best when started early or preventatively. “It is essential to listen to patients and determine if they want to improve their hairline, density, or thickness to find the proper treatment.”
Supplements, Topicals and Medications
Hair supplements remain a popular way for patients to mitigate progressive hair thinning. While some find them beneficial, others believe them to be less effective. “Unfortunately, the hair loss industry has been plagued by ‘snake oil’ remedies,” Dr. Dorfman shared. “By the time patients come to me, nearly all of them have tried the popular hair loss supplements and vitamins and are disappointed by the lack of results. Hair loss vitamins can sometimes be beneficial, but likely, a vitamin alone will not do much to cure or treat hair loss. However, I recently discovered a supplement, Phyllotex (Zivmas LLC), with promising evidence for treating hair loss.”
Patients seeking hair growth supplements should consider ingredients with some evidence of effectiveness. Dr. Diaz-Carandell suggests looking for biotin, zinc, iron (if a deficiency exists), vitamins, niacin, collagen, marine extracts and saw palmetto. “Patients should always consult a healthcare professional for personalized guidance, as the efficacy of supplements can vary among individuals, and addressing underlying causes is crucial.”
Topical medications that include finasteride, dutasteride and minoxidil are mainstays in a comprehensive hair loss restoration plan. “I have seen excellent improvement with topical treatments in early stages of hair loss while advanced cases require a multimodality approach to target different pathways of hair loss and regrowth,” Dr. Attavar mentioned. “Minoxidil is the gold standard topical for hair loss. Other effective ones include aminexil, redensyl, procapil, capixyl, caffeine, tretinoin, azelaic acid and rosemary oil.” There are also newer FDA-approved drugs, such as ritlecitinib and baricitinib, to treat severe alopecia areata by blocking inflammatory signals that cause hair loss. A hair restoration drug in development for men is FOL-005, which features the protein osteopontin, believed to stimulate hair growth via injections and topical application.4,5
When considering oral medications, especially for female hair loss patients or those experiencing initial signs of hair thinning, physicians are quick to consider age, too. “Female patients of childbearing age should not start on finasteride due to possible birth defects, and oral minoxidil can lead to hair growth all over,” Dr. Dorfman shared. “I always discuss this possibility with my patients and few females are interested in taking it. However, male patients are often unphased about increased body hair growth.”
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Nonsurgical Solutions
Nonsurgical solutions can help slow hair loss and promote some regrowth; however, Dr. Attavar emphasized the importance of consistent use and incorporation of other modalities to see results.
Microneedling remains a popular treatment for reinstating hair growth, and many physicians now couple it with exosomes to help repair and restore the hair. Dr. Diaz-Carandell says non-invasive exosomes are extracellular vesicles involved in cell communication, homeostasis, differentiation and organogenesis, and play a central role in hair morphogenesis and regeneration with use for alopecia. “Exosomes may stimulate hair growth by providing growth factors and reducing inflammation in the scalp,” he noted.
Dr. Mauricio is also seeing great, quick results from microneedling with exosomes. “It is important to note, at this time there are no FDAapproved exosomes for scalp injections, so I use topical exosomes and apply them with microneedling.”
An effective topical exosome is the AnteAGE MDX Exosomes from AnteAGE MD (Irvine, Calif.), which offer a distinct blend of exosomes derived from bone marrow stem cells and Wharton’s Jelly umbilical cells, making them an exceptional resource for regenerative purposes. Bone marrow stem cells are extensively researched and possess potent antiinflammatory properties, while Wharton’s Jelly umbilical cells, derived from physiologically younger tissue, exhibit significant proliferation and extracellular matrix production (collagen and elastin). This combination presents an optimal array of regenerative proteins, making it an ideal choice for enhancing aesthetic treatments aimed at combatting aging.
In the context of promoting new hair growth, these exosomes activate dormant hair follicles, transitioning them from a resting (telogen) to a growth (anagen) phase. This involves two crucial components. First, the activation of stem cells, providing them with the necessary elements for hair production. Second, the involvement of active stem cells and growth factors that stimulate the hair follicles, fostering an overall environment of equilibrium and improving tissue health for optimal growth.
Other protocols that garner better results include platelet-rich plasma (PRP) injections and microneedling combined with oral supplements, oral and topical minoxidil, or at-home laser treatments and finasteride. Dr. Attavar also integrates topical minoxidil with azelaic acid, tretinoin, procapil, or capixyl for added benefits. “Minoxidil with PRP is the most common combination treatment and addresses multiple factors contributing to hair loss for faster and more noticeable results.”
In-office low-level laser therapy (LLLT) also plays a role in hair restoration. Dr. DiazCarandell explains that LLLT stimulates hair follicles and improves circulation, helping to reduce inflammation and keep the hair in the anagen phase of growth. “While these treatments are generally safe, their effectiveness varies. Ongoing research may lead to improved laser technologies in the future.”
Dr. Dorfman favors the 1927 nm laser to help increase hair growth and recommends three treatment sessions spaced one month apart. “I keep the laser on a low setting (anything too aggressive can result in damage), and after the treatment, massage in a topical growth factor. I have seen incredible results with this combination, both in mine and my patient’s hair.”
KeraLase from SkinQRI (Lincolnshire, Ill.) is a pioneering hair rejuvenation procedure that combines cutting-edge LaseMD Ultra technology from Lutronic (Billerica, Mass.) with a potent KeraFactorMD serum, effectively tackling a range of common hair-related concerns. This non-invasive treatment is meticulously designed to stimulate hair restoration, bolster hair thickness, and enhance overall hair health. KeraLase’s unique efficacy hinges on its distinctive method. It offers a safe and convenient option for individuals struggling with hair loss, thinning, or general hair health issues. It is suitable for both men and women across all hair and skin types. It can be a valuable complement to a comprehensive hair care routine, assisting individuals in regaining confidence and achieving fuller, more vibrant hair. However, it is important to note that individual results may vary, and it is advisable to consult with a qualified healthcare professional before embarking on this treatment.
Providers use the LaseMD Ultra to prepare the scalp for optimal absorption of the KeraFactorMD serum, thereby promoting cell regeneration in the scalp and facilitating the delivery of essential growth factors. Lastly, red light therapy is employed to activate the serum, targeting dihydrotestosterone (DHT) on the scalp, improving circulation and reducing inflammation. This process is virtually painless and has no downtime.
Additional treatments that originally gained traction for their skin rejuvenating capabilities are making their way onto the scalp to help with hair growth. According to Dr. Mauricio, adipose-derived stem cell treatments are effective for patients who want a natural, nontransplant solution. “We are one of the pioneers of this treatment,” she noted. First, she uses fat harvested under local anesthesia, sized to nanofat. “Then, the stromal vascular fraction (SVF) is injected into the scalp, and PRP follows. This introduces adipose-derived stem cells to the area in addition to growth factors from PRP.” Research using stem cells for hair growth is ongoing and may become more widely available in the coming years.
Polydioxanone (PDO) threads are also being used for more than their original intent.6 Dr. Dorfman says the absorbable synthetic sutures stimulate endogenous collagen production, resulting in hair regrowth. “These threads stimulate new blood vessel formation, which nourishes the scalp and supports hair growth. We can inject PRP or platelet-rich fibrin (PRF) into the threaded areas, which may potentiate regrowth. Clinical trials are currently underway to compare PDO threads as a stand-alone treatment versus with the addition of PRP.” Some physicians turn to scalp micropigmentation (SMP) to camouflage excessive scalp show. While SMP is performed more on men or small areas of hair thinning on or near the crown, Dr. Mauricio explains that it creates the illusion of fullness without the messy application of spray-on pigments. The most natural results are achieved by placing the pigment in the crown or behind the hairline.
Hair Restoration Surgery
Surgery is still the gold standard for restoring lost hair because it is permanent and effective, but recovery time exists. Dr. Attavar said that even though surgical options – best when nonsurgical treatments do not produce satisfactory results – are more invasive, they provide natural-looking hair.
Two popular techniques exist: follicular unit extraction (FUE), which produces no linear scar, and follicular unit transplant (FUT), which leaves a strip scar and the artificial ‘plugged’ look. “FUE has become the preferred method for hair transplantation over FUT,” Dr. Diaz-Carandall stated. “FUE, which is the best solution for patients with significant hair loss, can also be done on women, but the approach is often different from that of men, with more focus on creating a feminine hairline and natural-looking results.”
When designing the hairline, physicians should consider a patient’s facial proportions to achieve an aesthetically appealing result. “We also consider future hair loss to ensure the results look natural as the patient ages,” Dr. Attavar noted. “If the hairline looks younger than the patient’s age, it can draw unwanted attention and appear artificial.”
Minimally invasive surgery involves extracting hair follicle units from a donor site and transplanting them into a recipient site manually or robotically to recreate the patient’s hairline. Dr. Mauricio uses Neograft (Venus Concept) in her practice, “which harvests individual hair follicles and transplants them for a natural look. There is about one week of downtime, and it takes six months to one year for the transplanted hairs to fully grow. The procedure is life-changing for the right patient.”
Dr. Diaz-Carandell added that the use of robotic systems for hair transplantation, like the ARTAS system (Venus Concept), has become more prevalent.
Vision Medical, Inc. and Smart Solutions RX (Glen Mills, Pa.) are partners and leading manufacturers that develop medical devices and aesthetic hair regeneration products for medical markets worldwide, including ingestible, topical, laser light therapies, regenerative and surgical solutions. The SmartGraft® FUE Hair Restoration System features a closed canister system for storage to keep harvested grafts chilled, hydrated and robust. This storage system also eliminates exposure to outside air, creating optimal graft preservation, significant reduction in extraction times, and providing donor grafts the best possible chance of regrowth for better patient outcome.
Melissa Morrison Toyos, MD, an ophthalmologist and aesthetic medicine expert with six clinics across Tenn., Miss. and N.Y., calls SmartGraft the cherry on top of her hair restoration program. “The refrigerated cannisters retain and shower grafts inside the machine to protect them from the desiccation stress of the in-line vacuum of earlier technologies. This, along with the ability to boost efficacy by treating the harvested grafts with growth factors and exosomes, were the main determinants in our choice of machine. SmartGraft stands out in two common patient scenarios: those whose tenuous hair situation requires that every last graft be viable to achieve the results they want – although no one getting a transplant has any hair to spare – and in the very natural results that a lot of my patients in the entertainment industry require,” she shared.
“My patients come to the SmartGraft decision a few different ways. Many want the simplicity of receiving up to 3,000 grafts in a single-day, inoffice procedure to accomplish their hair goals and others pursue SmartGraft if they are unsatisfied after using non-invasive or minimally invasive options. The design of the SmartGraft helps us deliver superior outcomes with greater graft yields, no linear scar and results that are so natural after 90 days even your hairdresser cannot tell the difference.”
Even though FUE does not require stitches or a large scar, the transplanted hairs result in tiny punctate scars, Dr. Attavar shared. “Success rates for hair transplant procedures are generally high,” she indicated. To garner the best results, a proper hair protocol that includes medication, in-office treatments, high-quality shampoos and conditioners should be incorporated along with the transplantation surgery.
Even after a hair transplantation procedure, Dr. Mauricio recommends PRP in order to maintain the results, retain the hair and minimize progressive hair loss over time.
The Future of Hair Restoration
While no magic bullet exists to treat hair loss, the advent of innovative and effective nonsurgical solutions, as well as gene therapies to prevent progressing hair loss, may one day create less of a need for hair restoration surgeries. While hair cloning is still far out on the horizon, Dr. Dorfman says as medical-grade skincare continues to flourish, it may present more opportunities for medical-grade haircare. “I think medical-grade haircare will be the next biggest revolution in haircare worldwide,” he concluded.
References:
1. Future Market Insights Global and Consulting Pvt. Ltd. (2023, October 3). Hair restoration market route to US$ 30.8 billion, propelled by remarkable 18.2% CAGR by 2032 – FMI projection. GlobeNewswire News Room. https://www. globenewswire.com/news-release/2023/10/03/2753640/0/ en/Hair-Restoration-Market-Route-to-US-30-8-BillionPropelled-by-Remarkable-18-2-CAGR-by-2032-FMIProjection.html#:~:text=03%2C%202023%20(GLOBE%20 NEWSWIRE),expected%20from%202022%20to%202032
2. Mejia, R., & Sideris, K. (2022). 2022 practice census shows impact of covid-19 pandemic on hair restoration. International Society of Hair Restoration Surgery, 32(4), 136–136. https:// doi.org/10.33589/32.4.136
3. Hair transplant statistics (updated 2023). Wimpole Clinic. (n.d.). https://wimpoleclinic.com/blog/ hair-transplant-statistics-2022/
4. Runnsjö, A., Liljedahl, S., Sagna, D., Ekblad, M., & Alenfall, J. (2022). A novel Microparticle based formulation for topical delivery of FOL-005, a small peptide. Journal of Pharmaceutical Sciences, 111(5), 1309–1317. https://doi. org/10.1016/j.xphs.2022.01.009
5. Mandowara, K., & Satija, B. (2023, June 23). US FDA approves Pfizer’s hair loss drug. Reuters. https://www. reuters.com/business/healthcare-pharmaceuticals/ us-fda-approves-pfizers-hair-loss-drug-2023-06-23/
6. Metwalli M, Khattab FM, Mandour S. Monofilament threads in treatment of female hair loss. J Dermatolog Treat. 2021 Aug;32(5):521-525. doi: 10.1080/09546634.2019.1682499. Epub 2020 Mar 3. PMID: 31619089.
Talebzadeh AT, Talebzadeh N. Stem Cell Applications in Human Hair Growth: A Literature Review. Cureus. 2023 Apr 11;15(4):e37439. doi: 10.7759/cureus.37439. PMID: 37181955; PMCID: PMC10174680.
Staff, E. (2022, May 3). Dramatic reduction in number of Hair Transplant Surg. to achieve desired results: ISHRS survey. ISHRS. https://ishrs.org/ishrs-2022-practice-census-results/
Shimizu, Y., Ntege, E. H., Sunami, H., & Inoue, Y. (2022). Regenerative Medicine Strategies for hair growth and regeneration: A narrative review of literature. Regenerative Therapy, 21, 527–539. https://doi.org/10.1016/j. reth.2022.10.005
Natarelli N, Gahoonia N, Sivamani RK. Integrative and Mechanistic Approach to the Hair Growth Cycle and Hair Loss. Journal of Clinical Medicine. 2023; 12(3):893. https://doi.org/10.3390/jcm12030893
