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June 15, 2004
Does He or Doesn't He? It's Harder to Tell
By DAN HURLEY
''How you doing, Tom?'' asked Dr. Anthony DiBiase, a Manhattan surgeon, in the midst of jabbing a lancet 1,130 times into the balding head of Tom Rabeck. ''You O.K.?''
''Yep,'' said Mr. Rabeck, as mellow and relaxed on a mild tranquilizer and topical anesthetic as if he were getting a haircut, which was pretty much the opposite of what he was getting....''Pretty amazing, isn't it?'' Dr. DiBiase said, standing back to admire his handiwork, like a farmer gazing out on a newly planted field of wheat.
With little fanfare, the science of hair restoration has in the last few years undergone vast changes. Hair plugs, infamous for their artificial appearance, are becoming a thing of the past, as scientists refine techniques of transplanting individual hair follicles rather than circular scoops of skin, giving the hair a more natural look. At least one new hair-growth drug is in the pipeline. The cloning of individual hair cells is only a decade away, experts say -- an advance that, by providing an unlimited source of replacement hair, could give even the baldest head a luxuriant thatch, while at the same time making hair transplantation surgery safer.
The market for such developments is sizeable. The Food and Drug Administration estimates that some 40 million men and 20 million women experience hair loss. Sales of Propecia, one of the most popular hair-growth potions, totaled $111 million in the United States in 2003 alone, up 13 percent from 2002. Close to 32,000 hair transplants, 88 percent of them in men, were performed in this country last year, according to the American Society of Plastic Surgeons, up from 29,000 in 2002. With the typical transplant running upward of $10 per follicle, and the average procedure involving about 1,000 follicles, that translates into nearly a third of a billion dollars. The field's advances have not done away with bad hair jokes: A running gag in the recent film ''Hellboy'' revolved around the doll's hair look of a character's hair plugs.
''The big problem we've had to overcome is 30 years of plugs,'' conceded Dr. Bobby Limmer, a dermatologist in San Antonio and the developer of individual follicle transplants. ''You mention hair transplantation to the guy on the street, and the first image that's going to come to him is the plug.''
But the evolving medical science has come a long way since 1981, when a Boston lawyer named John Kerry, not yet a political figure, represented 16 men whose heads had been surgically implanted with carpet fibers.
''They were badly, badly infected, and in most cases large parts of their scalps had to be excised,'' recalled Roanne Sragow, then Mr. Kerry's law partner and now the first justice of the Cambridge District Court. ''It was pretty gruesome.''
Hair transplantation has been possible since 1952, when Norman Orentreich, a dermatologist at New York University, figured out how to transplant circular scoops of follicle-rich skin stolen from the back of the head. The result was tiny tufts rising up like so many islands of hair amidst a barren sea of baldness. This effect was especially unfortunate at the hairline, where the hair plugs were plainly visible. ...
But on Oct. 21, 1988, Dr. Limmer made hair restoration history by transplanting follicular units, naturally occurring groups of one to five follicles that are sown over the bald area in an evenly irregular pattern that is indistinguishable from naturally growing hair.
Derived from the Latin word follis, for bag, the hair follicle is the complex pouch-like structure from which grows hair, ground out like so much sausage and composed primarily of the same dead keratin that makes up nails. Normally each follicle goes through a five-year cycle of growth and rest, with about 90 percent growing hair at any one time, averaging about six inches per year.
Baldness begins when, in the presence of dihydrotestosterone, or DHT, a byproduct of the male hormone testosterone, the growth cycle of genetically susceptible follicles on the crown and temples gradually speeds up to as little as 60 days. Newly growing hair never gets a chance to mature, and eventually the worn-out follicles die. Hair on the back of the head remains in place, however, because it is not genetically susceptible to the ravages of DHT.
When surgeons first realized they could transplant hair from the back to the front, they thought the follicles could only survive when transplanted in swaths, like strips of sod on a new lawn. But slowly they succeeded in transplanting smaller and smaller sections, until Dr. Limmer, who said he has given lectures sponsored by Merck but does not receive research financing from the industry, proved that an individual follicle, like a single miniature tulip bulb, could be transplanted and grow normal hair. ...
Scientists are, in fact, studying how to isolate follicular stem cells, nudge them into proliferating in a test tube, and then implant them back into the head of the man or woman from whom they were originally taken. Those stem cells, in turn, create follicles and hairs. ...
Also on the horizon is a promising drug called dutasteride, being tested by Merck for its hair-growing ability. Like Propecia, dutasteride was originally approved to treat benign prostatic hyperplasia, an enlargement of the prostate gland, by blocking DHT. But because Propecia blocks only one of the two types of DHT and dutasteride blocks both, doctors expect it will work even better, and some are already cautiously giving it to their hair-loss patients when other medical therapies have failed. A spokesman for Merck said the company has not yet decided how far it will go in studying dutaseride as a hair-loss remedy, but the company is preparing the results of a study for publication in a medical journal.
In the meanwhile, Propecia and Rogaine, the two medications already approved for treatment of hair loss remain the foundation of any treatment plan for both men and women, even those who opt for surgery. ''In the old days, we had to plan for extended hair loss,'' Dr. Gaffney said. ''Surgery was like rearranging the deck chairs on the Titanic. Now we can hold the line with agents that, together, will have a 90 percent response rate.''
Mr. Rabeck had been using one such product, minoxidil, for years by the time he arrived at the Bosley offices on Park Avenue wearing a golf hat at 7:30 a.m. on a Friday in mid-May. As a team of five registered nurses, medical assistants and clinical assistants scurried about, he watched the news on television while Dr. DiBiase drew lines on the top of his head with a Maybelline eye shadow pencil, to show where the follicles would be placed. Petri dishes sat on the counter nearby labeled, ''Rabeck, Tom, Rm. 5.'' ...
Using magnifying glasses to see and surgical knives to manipulate the tissue, they identified each follicle by a tiny black dot, barely visible to the naked eye and smaller than the period at the end of this sentence. From the dots trailed even tinier shafts resembling the tails of minnows or sperm. For the next two hours, as they separated the follicles into mushy little piles, the assistants labored like factory workers.
Although they had hoped to come up with 1,200 follicles, they were 70 short when they finished at 11:10 a.m., a deficit Dr. DiBiase judged to be cosmetically insignificant. He made the tiny incisions into Mr. Rabeck's head, and by noon the team was inserting the follicles into the holes. Near the hairline they used single or double follicles, to recreate the gradual, feathered-in look of a natural hairline. Farther back they used three- and four-follicular units. By 2:30 p.m. they were done.
Reached three days later by cell phone as he drove home to Vermont, Mr. Rabeck said the only difficulty he had encountered so far was a bit of itchiness. Aside from some redness, nothing on his head looked different to the casual observer, he said, with even the scar hidden by hair. Now all that remained was to wait a couple months for the follicles to begin producing thin baby hair that would look increasingly thick and dark within six months. Maybe then he could ditch the golf hat.
Copyright 2004 by The New York Times Co. Reprinted with permission.
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