Attempts to medically manage MPB are nothing new. Hippocrates, in about 400 bc, prescribed several concoctions composed of animal and plant products to treat baldness.

Ideally, the medical treatment of AGA should be directed against dihydrotestosterone (DHT), the active agent involved in MPB. Finasteride (Propecia), which has been used for years to manage prostate hypertrophy, was approved by the U.S. Food and Drug Administration (FDA) for the treatment of MPB in 1997. Finasteride is a competitive and specific inhibitor of type II 5a-reductase, an intracellular enzyme that converts the androgen testosterone into DHT. Two distinct 5a-reductase isozymes are found in humans. The type II 5a-reductase isozyme is primarily found in the prostate, seminal vesicles, epididymides, and hair follicles. Finasteride has no affinity for androgen receptors but works by blocking the peripheral conversion of testosterone to DHT. Using the recommended dose of 1 mg/d, finasteride produces statistically significant increased hair counts in men with mild-to-moderate degrees of AGA. Systemic therapy that reduces or interferes with androgen levels enough to stop hair loss has the potential to reduce libido and sexual potency, making this form of treatment unacceptable to some men. Drug-related sexual adverse experiences resulting in discontinuation of therapy have been reported in 1.2% of patients on finasteride versus 0.9% of patients on placebo (3,4). Finasteride is not indicated for woman and children.

Minoxidil (Rogaine) was the first drug approved by the FDA for the medical management of MPB. This drug, which traditionally had been used to treat resistant hypertension, was noted to occasionally produce hypertrichosis as a side effect of oral therapy in adults. Minoxidil functions as a potassium channel opener and vasodilator. Currently, the dosages available are 2% and 5% formulations. In men, the 5% minoxidil solution demonstrates a significant advantage over treatment with the 2% solution (5). The mechanism by which minoxidil works to stimulate hair growth remains unclear. In addition, minoxidil does not have any known effect on the production, excretion, or interactions of human androgens. Most, if not all,
hair transplant surgeons recommend the use of minoxidil and/or finasteride to the majority of their patients (6).

In hair restoration, men constitute more than 90% of the patients seeking treatment. As techniques in surgical management continue to improve and public awareness of high patient satisfaction increases, however, there are increasing numbers of women undergoing treatment for hair loss. The approach to female pattern hair loss is much different than MPB, as only 10% of women have an androgenic hair-loss pattern. Therefore, the overwhelming majority of women have hair loss for variety of other reasons, such as hormonal and autoimmune.

The workup involves recognizing the enormous psychological toll hair loss takes on a woman and using appropriate sensitivity when treating women with hair loss. Referral to an endocrinologist is usually part of the workup. Minoxidil 2% solution has been effective in treating female pattern hair loss. Increased dosages of 5% minoxidil have caused unacceptable rates of facial hypertrichosis to occur. Finasteride has not been shown to have benefit in women. Surgical hair restoration remains the only permanent treatment for hair loss in women. The same principles of adequate donor area and advanced transplantation techniques lead to better outcomes (8).

Because most patients require multiple procedures, an adequate comfort level is essential to maintaining motivation for completion of the entire restoration process. Local anesthesia is sufficient for most hair-restoration procedures, but general anesthesia is occasionally necessary for extensive scalp reductions or flap procedures.

A preoperative sedative is commonly given before the injection of local anesthesia. Regional frontal, occipital, and temporal nerve blocks using 1% lidocaine with 1:100,000 epinephrine are performed before performing a wide-field, circumferential scalp block. This technique anesthetizes the entire hair-bearing scalp.

Okuda (9), a Japanese dermatologist, is generally regarded as the first to describe the successful use of full-thickness hair-bearing autografts for correcting alopecia of the scalp, eyebrow, and mustache areas. Hair transplantation using punch grafts was introduced in the United States in 1959 by Orentreich (10). He coined the term donor dominance to describe the fact that autografts maintain characteristics of the donor tissue when transplanted into other regions of the body. Patients followed for more than 30 years continue to demonstrate persistent hair growth following punch-graft hair transplantation (11).