Options for Men Losing Their Hair

As men age they tend to lose their hair. There are many options for men who want to reverse hair loss. In this post we’ll take a look at “Microplugs.”

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Microplugs permit improvement in coverage and the establishment of a more natural looking hairline. The surgeon produces these transplants by halving or quartering plugs of 3.0-4.5 mm. While a normal 4-mm graft holds 12-18 hairs, the microplug holds about 4 hairs. The surgeon may transplant as many as 200 microplugs in a session, inserting them in stab wounds made with a No. 15 scalpel. These are generally reserved for filling in the anterior hairline to avoid a tufty appearance, but the entire anterior border can be created with microplugs. Coverage may be slightly more expensive with micrografts than with 4-mm grafts.

Complications are uncommon with punch grafting. If transplanted plugs are taken from a site that eventually loses hair, the transplanted plugs also will lose their hair. The most common complaint of patients who have had punch grafting is tuftiness. The surgeon corrects this by placing more grafts or, if the problem is due to elevation of plugs, by shaving the elevated plugs flush with the skin. When the shaved plugs heal, the hair will regrow properly.

Patients who are not satisfied with punch grafting results are most often those who have not chosen to go back for more transplants to fill in between tufts. About 5% of patients may be disappointed in the coverage they achieve even with closely spaced transplants.

Punch grafting is effective for patients scarred by burns and those whose hairlines have been displaced by face-lift surgery. Punch grafts aren’t used to correct patches of baldness due to scarring disease processes such as discoid lupus erythematosus or lichen planopilaris because there is no way to predict whether an uninvolved donor site might be affected by the disease after the transplant. Transplants performed to cover burn scars are reimbursable by third-party payers under the category of reconstructive surgery.

Hair Loss

Scalp reduction is used as an adjunct to punch grafting in patients who have extensive balding on the crown of the head and who have fairly flaccid scalps. With the patient sedated and anesthetized locally, or occasionally generally, the surgeon excises an ellipse, crescent, or Y of scalp and undermines the scalp surrounding the excision; some undermine all the way to the ears. Subcutaneous tissues are closed with absorbable sutures and the skin with metal staples, thus shrinking the bald area and reducing the number of punch grafts needed. Each scalp reduction can remove a strip of tissue about 2-5 cm (about 1-2 in) wide and u0-15 cm (4-6 in) long.

No matter how extensive the skin removal, there is a 20%-50% stretchback. This return of flexibility is helpful in patients with extensive baldness as it allows removal of more bald scalp in repeat procedures. Each reduction costs approximately $1,500.

Often, the anterior part of the scalp is first transplanted with punch grafts placed slightly lower than the desired hairline. Then the scalp reduction is done, raising the new hairline to its intended level, and the rest of the bald area is filled in with punch grafts. Alternatively, scalp reduction may precede punch grafting.

Reduced Testosterone Levels with Age

The pronounced variation in serum testosterone levels between men together with the small number of men studied (especially younger than 30 or older than 70 years) may explain why some investigators did not find a major reduction in testosterone concentrations with age. Also, the failure to recognize that the circadian variability of testosterone levels observed in young men with peak levels occurring in the morning is lost in elderly men may explain why investigators who obtained blood specimens during the afternoon did not find a meaningful decline in testosterone concentrations.

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Testicular function and, in particular, testosterone production are affected by a number of external factors, such as illness (with its associated stress response), medications, psychological state, obesity, exercise, socio-economic condition (malnutrition associated with poor elderly), and life-style (alcohol or drug abuse). The presence of these factors may contribute to the notable variation in serum testosterone levels in both young and elderly men and a more pronounced age-related decline in testosterone concentrations observed in some studies. It is worth emphasizing, however, that substantially decreased testosterone levels have also been reported in carefully screened, exceptionally healthy elderly compared with young men. Because complicating conditions such as illness occur more often in elderly than in young men, serum testosterone levels in the general population of elderly men may be more profoundly suppressed than those in highly selected healthy older men.

Concomitant with the decline in serum testosterone levels, aging is associated with functional changes in a number of androgen-dependent body tissues. These include an age-related decline in sexual interest and function (including diminished libido and erectile function), a reduction in muscle mass and strength, a decrease in bone mass and an increase in fractures (osteoporosis), mood changes (including a decrease in the feeling of well-being and vigor), and alterations in sleep quality (reduced stage 3 and 4 and rapid-eye-movement sleep). These alterations contribute substantially to a functional decline in elderly men and are associated with considerable morbidity and a reduced quality of life. Because these changes occur in androgen target tissues, it is possible that the age-related decline in serum testosterone concentrations may contribute to reduced function.

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In this issue of the journal, Swerdloff and Wang present an interesting and timely overview of the potential physiologic importance of reduced serum androgen levels in elderly men. The known effects of severe androgen deficiency on psychosexual function, bone mass, and muscle mass and strength and of testosterone treatment in young hypogonadal men provide a rationale for the hypothesis that declining serum testosterone levels contribute to age-related physiologic alterations and a functional decline in these tissues.

Although severe androgen deficiency in elderly men probably results in physiologic changes similar to those found in young hypogonadal men, formal studies comparing the effects of severe androgen deficiency and responses to testosterone therapy in elderly compared with young hypogonadal men have not been done. Moreover, the physiologic importance of less severe degrees of androgen deficiency as observed in many elderly men remains unclear. In part, this is due to a generally poor understanding of the physiologic effects and mechanisms of the action of androgens on specific body functions and physiologic processes in both young and elderly men. It is likely that the dose-response effects of testosterone therapy will differ for different androgen-dependent physiologic processes. Furthermore, the role of active metabolites of testosterone (estradiol and dihydrotestosterone) and androgen-dependent anabolic hormones (such as growth hormone and insulinlike growth factor-I [IGF-I]) in mediating the actions of testosterone on specific target sites has not been clarified in either young or elderly men.