#43–Alan Bauman, M.D.: The science of male and female hair restoration—how to protect & restore hair

1. 0:00 – 0:04

   Intro

   1. PAPeter Attia0:00

      [instrumental music]

2. 0:04 – 8:27

   Why the Podcast Is Listener-Supported and Introducing Dr. Alan Bauman

   1. PAPeter Attia0:04

      Hey everyone, welcome to The Peter Attia Drive. I'm your host, Peter Attia. 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 on today's episode and other topics at peterattiamd.com. [instrumental music] Hey everybody. Welcome to this week's episode of The Drive. I'd like to take a couple of minutes to talk about why we don't run ads on this podcast and why instead we've chosen to rely entirely on listener support. If you're listening to this, you probably already know, but the two things I care most about professionally are how to live longer and how to live better. I have a complete fascination and obsession with this topic. I practice it professionally and I've seen firsthand how access to information is basically all people need to make better decisions and improve the quality of their lives. Curating and sharing this knowledge is not easy, and even before starting the podcast, that became clear to me. The sheer volume of material published in this space is overwhelming. I'm fortunate to have a great team that helps me continue learning and sharing this information with you. To take one example, our show notes are in a league of their own. In fact, we now have a full-time person that is dedicated to producing those, and the feedback has mirrored this. So all of this raises a natural question. How will we continue to fund the work necessary to support this? As you probably know, the tried and true way to do this is to sell ads. But after a lot of contemplation, that model just doesn't feel right to me for a few reasons. Now, the first and most important of these is trust. I'm not sure how you can trust me if I'm telling you about something when you know I'm being paid by the company that makes it to tell you about it. Another reason selling ads doesn't feel right to me is because I, I, I just know myself. I have a really hard time advocating for something that I'm not absolutely nuts for. So if I don't feel that way about something, I don't know how I can talk about it enthusiastically. So instead of selling ads, I've chosen to do what a handful of others have proved can work over time, and that is to create a subscriber support model for my audience. This keeps my relationship with you both simple and honest. If you value what I'm doing, you can become a member and support us at whatever level works for you. In exchange, you'll get the benefits above and beyond what's available for free. It's that simple. It's my goal to ensure that no matter what level you choose to support us at, you will get back more than you give. So for example, members will receive full access to the exclusive show notes, including other things that we plan to build upon, such as the downloadable transcripts for each episode. These are useful beyond just the podcast, especially given the technical nature of many of our shows. Members also get exclusive access to listen to and participate in the regular Ask Me Anything episodes. That means asking questions directly into the AMA portal and also getting to hear these podcasts when they come out. Lastly, and this is something I'm really excited about, I want my supporters to get the best deals possible on the products that I love. And as I said, we're not taking ad dollars from anyone. But instead what I'd like to do is work with companies who make the products that I already love and would already talk about for free and have them pass savings on to you. Again, the podcast will remain free to all, but my hope is that many of you will find enough value in, one, the podcast itself, and two, the additional content exclusive for members to support us at a level that makes sense for you. I want to thank you for taking a moment to listen to this. If you learn from and find value in the content I produce, please consider supporting us directly by signing up for a monthly subscription. My guest this week is Dr. Alan Bauman, a hair transplant surgeon who is one of the few people who is actually board 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 transplants are 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, as I learned, 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, 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, uh, there, 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 Bauman. [upbeat music] Hey, Alan, thanks for making time today.

   2. ABAlan Bauman7:32

      Peter, thanks for having me. This is great.

   3. PAPeter Attia7:34

      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. 'Cause unfortunately, a lot of times, you know, a patient will go and see somebody, and the outcome for anything, you know, 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 know, y- you gotta talk to him. He's your kind of guy. You're gonna, you're gonna, you're gonna connect." And I was like, "Of course, yeah. I mean, I'm happy to learn." And, and so the first thing that amazed me when we spoke was that you trained as a general surgeon.

   4. ABAlan Bauman8:26

      Correct.

3. 8:27 – 15:59

   Training and Board Certification in Hair Restoration

   1. PAPeter Attia8:27

      And I, I don't know why I didn't, or I, 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, a complete residency in general surgery?

   2. ABAlan Bauman8:36

      Well, there are many general surgeons in the field of hair transplant surgery, but I would say years ago it was mostly dermatologists.

   3. PAPeter Attia8:44

      Mm-hmm.

   4. ABAlan Bauman8:44

      But hair transplant is kind of a potpourri 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 one, you know, ones that you would see, dermatologists, surgeons, vascular surgeons, things like that, who have made a transition maybe from a previous type of practice into hair transplantation.

   5. PAPeter Attia9:07

      And is there a, like, a, a board certification for hair transplant the way there is for general surgery or thoracic surgery?

   6. ABAlan Bauman9:13

      So the American Board of Hair Restoration Surgery is not recognized right now yet by the ABMS, which is, um, you know, the American Board of Medical Specialties, so it's kind of in its primordial stage. When, uh, 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, uh, with a dead end because I would never become board certified, and they were very, very nervous about my interest in hair transplantation back in the early 1990s.

   7. PAPeter Attia9:42

      But now it has a certificate in the way that-

   8. ABAlan Bauman9:44

      Absolutely

   9. PAPeter Attia9:45

      ... transplantation or surgical oncology, which are not board-certified specialties, are still certificate specialties.

   10. ABAlan Bauman9:50

       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 specialty. It's all I do. All I've done for well over twenty years is hair transplantation, so to prepare for that was an exciting time. It's rigorous. Written exam, oral exam.

   11. PAPeter Attia10:16

       And you guys go through that every five years, or how often do you recert?

   12. ABAlan Bauman10:19

       Oh, God, the recertification. You know what? I, I, I know. No, I just did my recertification, and I should know. It's probably like-

   13. PAPeter Attia10:24

       [laughs]

   14. ABAlan Bauman10:24

       ... eight or ten years or something like that.

   15. PAPeter Attia10:26

       So what, what got you interested in the space? 'Cause you're-- it sounds like you're not... Again, I don't know if it's the exception or 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?

   16. ABAlan Bauman10:41

       Right. So 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, in surgery, and he kind of took a liking to me, and I, I-- he said, "Hey, if you're gonna go to medical school, you're gonna be-"

   17. PAPeter Attia11:02

       Did, did you do residency in New York?

   18. ABAlan Bauman11:03

       Beth Israel and Mount Sinai is where I did my general surgery. But this is way back when I was a teenager. He said, "Hey, if, 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, you know, I went to go see him, and he was a plastic surgeon, and that was the first time I ever saw surgery. 'Cause back in the 1990s-- this, 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, uh, I remember being there at Beth Israel, getting dropped off in the lobby and looking over his shoulder in the OR. You know, he-- we-- dressed me in scrubs, whatever. "Stand here. Don't touch anything blue." I guess the security wasn't so great. But, uh, you know, I was looking over his 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, uh, from there, you know, it was years and years of just shadowing him and, and being mentored off and on, vacation times and things like that. And I pursued general surgery through, you know, my interest in going that route through plas- to get to plastic and reconstructive work.

   19. PAPeter Attia12:01

       Yeah, because back in that day, I mean, today there's a combined plastics track where you can do three of general and three of plastics, but, uh, presumably when you went through it, it... And even when I went through training, those were the exception. Uh, most of them were still doing five years of general surgery plus two years of plastics, right?

   20. ABAlan Bauman12:16

       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, but coordinated with one of the hospitals where he was an 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, it was kind of interesting, and I, I felt like I had a, 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 h- his passion for the artistry, and getting the results taught me a lot. He was a little OCD, which is great. That's exactly what you want in a surgeon.

   21. PAPeter Attia13:01

       Yeah, I think, I think you want that in your engineers-

   22. ABAlan Bauman13:03

       Yeah

   23. PAPeter Attia13:03

       ... your accountants, and your surgeons.

   24. ABAlan Bauman13:05

       For sure. So I remember, uh, just being ecstatic just 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 pluggy 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 his scalp, going, "Where... You know, do you mind if I ask 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.

   25. PAPeter Attia14:15

       What year was this?

   26. ABAlan Bauman14:16

       This was in the mid-1990s.

   27. PAPeter Attia14:18

       And what year-

   28. ABAlan Bauman14:18

       So this was nin-

   29. PAPeter Attia14:19

       ... were you in your training?

   30. ABAlan Bauman14:20

       So I was in my second year of general surgery, or the end of my first year 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. 'Cause, 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, you know, a lot of things kind of struck me that way, but it was, 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, "Hmm, 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.
4. 15:59 – 22:40

   How Common Hair Loss Is and What Counts as Premature

   1. PAPeter Attia15:59

      So how common is it, uh, I guess both in men and women? Let's start with that.

   2. ABAlan Bauman16:04

      So hair loss is super common. Almost 100 million Americans are suffering from some s- some form of hair loss, and we know now it could be as close to 80 million men and, uh, 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 hairlines, loss of volume, loss of coverage of their scalp, and it's a, it's a big concern for many, although very much undertreated.

   3. PAPeter Attia16:31

      And i- 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?

   4. ABAlan Bauman16:48

      Well, first of all, everybody cares about hair, don't they? I don't under- Right? Well, I don't understand the question.

   5. PAPeter Attia16:51

      [laughs]

   6. ABAlan Bauman16:53

      No, but certainly-

   7. PAPeter Attia16:53

      Yeah, perhaps, right?

   8. ABAlan Bauman16:54

      No, but certainly it varies, because, you know, you could be a young guy in your 20s losing your hair and, 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 be focused on that hair loss. And remember that in men, it's socially acceptable. I'm looking at your bare scalp. You shave down to, uh, number zero or two or one or, you know, with a, with a trimmer, maybe that you shave once, uh, every other day perhaps.

   9. PAPeter Attia17:25

      Once a week.

   10. ABAlan Bauman17:26

       So okay. So there you go. But the point is, is that in women, there's no socially acceptable option for female hair loss, and so it can be much more devastating, for sure.

   11. PAPeter Attia17:36

       Yeah.

   12. ABAlan Bauman17:36

       Even though it's easier to cover in women. So there's, is a lot of nuance there. Women can lose, you know, 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.

   13. PAPeter Attia17:58

       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, the other is not. Of course, that's not what you mean. You mean evenly distributed across their head, half the density. You know, you, you... every two follicles become one. That's pretty easy to mask the longer the hair is, right?

   14. ABAlan Bauman18:16

       Right. And of course, m- you know, female pattern hair loss happens in a very specific pattern. Behind the hairline, that's where that density loss can occur. So it's not equally d- it's very rarely equally distributed, and the same in men. There's a very specific pattern that you can see basically progressing from across the room. But it's a, 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. And if you lose 50% of that, that's roughly the break point between coverage and, you know, maybe some see-through to the scalp. Does that make sense?

   15. PAPeter Attia18:54

       It, it certainly does, yeah. So you alluded to something I guess I hadn't even really thought about, which was, you know, someone losing their hair very young. So is there a definition for premature hair loss? Like, 'cause you hear that expression thrown 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?

   16. ABAlan Bauman19:15

       No. That, that doesn't make any sense.

   17. PAPeter Attia19:16

       Sort of a bogus term.

   18. ABAlan Bauman19:17

       It, it, premature is, uh, 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 in their 20s. Some people go gray in their 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, you know, when we see young men, I mean, hair loss can start any time 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.

   19. PAPeter Attia19:51

       That's a quick heuristic with percentage by decade?

   20. ABAlan Bauman19:53

       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.

   21. PAPeter Attia20:03

       And this is predominantly more in boys than girls, though.

   22. ABAlan Bauman20:06

       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, it's more multifactorial. You, we can see other things that are affecting the hair loss process. You know, women are just more complicated, man.

   23. PAPeter Attia20:18

       Yeah. Yeah.

   24. ABAlan Bauman20:19

       You know?

   25. PAPeter Attia20:20

       They, they, they do have that luxury. So like-

   26. ABAlan Bauman20:23

       So what, what happens?

   27. PAPeter Attia20:24

       Yeah. Yeah. Well-

   28. ABAlan Bauman20:24

       Here's what happens

   29. PAPeter Attia20:25

       ... you, you mentioned for a moment ago, like, that, uh, that if you're graying, that's genetically determined. How much is hair loss genetically determined?

   30. ABAlan Bauman20:31

       In men, it's, you know, 99%, 98, 99% 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, right? 'Cause again, those are the physical properties. And then hair styling, of course. So if you're a 20-year-old guy and you're 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 guys in the group. Four or five friends, they all look like they got pretty much full heads of hair, and, 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, there's, they don't want to be rushed into having to accept the fact that they're gonna look older than their stated age.
5. 22:40 – 26:17

   Female Hair Loss, Pregnancy and the Hair Cycle

   1. PAPeter Attia22:40

      Now talk to me a little bit about what's going on with women, because I am aware of this only in that, uh, 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 a step back, I certainly remember watching my wife go through pregnancy, right, where her hair would get very, very thick. You have a baby.

   2. ABAlan Bauman23:08

      Yes.

   3. PAPeter Attia23:08

      A lot of that hair falls out, and then it just kind of all grows back to normal. So, uh, putting that aside for a moment-

   4. ABAlan Bauman23:13

      Right

   5. PAPeter Attia23:13

      ... which is, it must be clearly driven by hormones.

   6. ABAlan Bauman23:16

      Hormones, of course. So the amount of follicles that are in anagen when you're in pregnancy is a much higher percentage. So anagen's the growth phase. You're gonna have more follicles staying in anagen, a longer time in anagen. So your hair will be thicker and fuller during that time in your pregnancy. And then when the hormones crash back down after childbirth, then those ratios go back to normal. And a shedding phase, an effluvium or telogen effluvium, can occur in about 6 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, 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."

   7. PAPeter Attia24:05

      And the other thing I hear women say a lot is the thickness was never the same after. So it's l- 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.

   8. ABAlan Bauman24:21

      Yes.

   9. PAPeter Attia24:21

      And, you know, I've heard women say a lot, "You know, after my third kid, like, my hair is so thin."

   10. ABAlan Bauman24:28

       Mm-hmm.

   11. PAPeter Attia24:28

       And they're referring to the actual hair itself.

   12. ABAlan Bauman24:30

       Right. 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.

   13. PAPeter Attia24:44

       Mm-hmm.

   14. ABAlan Bauman24:44

       So that's, that could be the sheer numbers of hairs that are growing at any given time, giving you, let's just call it 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, with a scrunchie or whatever or a rubber band, and it, 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 have t- I can turn it three times."

   15. PAPeter Attia25:07

       Mm.

   16. ABAlan Bauman25:08

       Meaning they, they need another wrap around.

   17. PAPeter Attia25:09

       That's a, that's a, that's an interesting litmus test I would have never thought about.

   18. ABAlan Bauman25:12

       Yeah, for sure. So, um, and of course, now in the, 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.

   19. PAPeter Attia25:29

       [laughs]

   20. ABAlan Bauman25:29

       But we may be going, uh, ahead of ourselves in terms of diagnosis and, and treatments and such. But there are ways to measure that. When someone says, "I have less hair," or, "I have thin hair," we need to figure out what exactly does 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, maybe let's call it 84, 85%. But all of a sudden, if you s- do something to switch that per- those percentages, then you're gonna get a thinner head of hair, meaning that there's less trees in the forest, perhaps.

6. 26:17 – 33:23

   DHT, Finasteride, Minoxidil and the Early History of Treatments

   1. PAPeter Attia26:17

      So going back to the males for a moment, which is pretty strongly genetically linked, as you said.

   2. ABAlan Bauman26:23

      Sure.

   3. PAPeter Attia26:23

      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 into DHT. Is that the only hormone that's playing a role, or is that just the one that we have a treatment for?

   4. ABAlan Bauman26:47

      Well, w- that is the primary trigger according to the data that we see right now, and, and the, 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.

   5. PAPeter Attia27:16

      Does that mean that, again, as a thought experiment-

   6. ABAlan Bauman27:19

      Yes

   7. PAPeter Attia27:19

      ... 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?

   8. ABAlan Bauman27:34

      Well, there's alwa- a- 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 someone on a finasteride or even dutasteride, 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. So-

   9. PAPeter Attia27:59

      And these things are not without their side effects. I mean-

   10. ABAlan Bauman28:02

       True

   11. PAPeter Attia28:02

       ... a subset of men experience sexual side effects with them. And I mean, I think the literature in, 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 around-

   12. ABAlan Bauman28:18

       Right. So I can, I can tell you how that's been explained to us as-

   13. PAPeter Attia28:20

       Yeah, yeah

   14. ABAlan Bauman28:20

       ... hair surgeons by the urologists that were involved in some of those studies. For example, finasteride, five milligrams, is, m- you know, one of the more prominent treatments for BPH, benign prostatic hypertrophy, a large prostate. You put somebody on five milligrams of finasteride, their regular prostate tissue shrinks.

   15. PAPeter Attia28:37

       Mm-hmm.

   16. ABAlan Bauman28:38

       And so that's likely what's happening also at a one 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-

   17. PAPeter Attia28:50

       Mm-hmm

   18. ABAlan Bauman28:51

       ... some high-grade cancer or cancerous 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.

   19. PAPeter Attia29:06

       Yeah, yeah.

   20. ABAlan Bauman29:06

       And, and, and that can, that ... I, I don't know if I'm explaining it correctly, but that-

   21. PAPeter Attia29:08

       No, no, that makes sense

   22. ABAlan Bauman29:09

       ... you know, 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 cancerous. And of course, you know, thank God people don't die of prostate cancer. It's, you know, it's a v- it's a very slow-moving thing. Obviously, there's very good survivability, uh, if you should be diagnosed. But the point is, 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 be high-grade. And, you know, high-grade cancers in prostate are very, very rare, so doesn't take much to skew the numbers from, like, let's call it, and I don't, don't quote me, but let's call it a quarter percent to, you know, three quarters of a percent. You know, all of a sudden it doubled.

   23. PAPeter Attia29:46

       Yeah.

   24. ABAlan Bauman29:46

       You know? Could be just a couple of biopsies to throw it off.

   25. PAPeter Attia29:49

       So, you know, you talked about finasteride, which of course is the, uh, generic name. Proscar is the five milligram formulation of that, and Propecia is the one milligram formulation, correct?

   26. ABAlan Bauman30:00

       Correct. Which are both now off patent, obviously, you know, as y- as you know.

   27. PAPeter Attia30:04

       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."

   28. ABAlan Bauman30:14

       I will tell you that Merck knew from the get-go that it was gonna 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 the 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 one milligram dose in 1998.

   29. PAPeter Attia30:37

       Got it.

   30. ABAlan Bauman30:38

       So it's not s- it was not serendipitous as minoxidil 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 finasteride came about.
7. 33:23 – 37:50

   Women, Androgens, PCOS and the Point of No Return

   1. PAPeter Attia33:23

      Going back to just close the loop on the pathophysiology in the women who... Uh, uh, so n- and again, uh, 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 sta- starts to say, you know, "My hair's getting thinner." And, 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 her 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.

   2. ABAlan Bauman33:56

      Yeah, her DHT levels could be very low, but she can also be androgen sensitive, so there is about a 50% success rate when you apply finasteride in post-menopausal women with hair loss.

   3. PAPeter Attia34:07

      When you say apply, you mean don't take it orally?

   4. ABAlan Bauman34:09

      Orally.

   5. PAPeter Attia34:09

      Oh, I, I thought that it was completely contraindicated in women.

   6. ABAlan Bauman34:12

      Well, w- women of childbearing age. It can be used off-label in post-menopausal women because the risk is to a developing male fetus.

   7. PAPeter Attia34:19

      Yeah.

   8. ABAlan Bauman34:19

      And f- that's the main issue, 'cause, you know, DHT 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 wanna w- 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 were in these clinical trials with female pattern hair loss, post-menopausal, 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 androgen sensitivity that could be driving it. And, you know, if you think about, for example, the most common hormone abnormality of women of childbearing age with PCOS, what are the things that kind of roll together in, uh, PCOS syndrome? There's acne, there's hirsutism, hair growth on the face, and, uh, acne, did I say that? And, uh, and hair loss. And so those are the, what do tho- all of those have in common?

   9. PAPeter Attia35:28

      They're all androgen processes.

   10. ABAlan Bauman35:30

       Correct. So, so there, it is a, there is a common androgen connection.

   11. PAPeter Attia35:34

       So do young women with PCOS also experience hair loss?

   12. ABAlan Bauman35:37

       Yeah, it's devastatingly bad.

   13. PAPeter Attia35:38

       God, I, I just, I didn't realize that.

   14. ABAlan Bauman35:40

       Yeah. It can be devastatingly bad.

   15. PAPeter Attia35:42

       Mm.

   16. ABAlan Bauman35:42

       Very common in PCOS. A lot of our PCOS-

   17. PAPeter Attia35:44

       And you're stuck because they'd probably respond to a 5-alpha reductase inhibitor, but they're in childbearing years, so you couldn't use it.

   18. ABAlan Bauman35:51

       Correct. They're under treatment typically to improve their fertility.

   19. PAPeter Attia35:54

       Yeah.

   20. ABAlan Bauman35:55

       So it's a delicate dance. You know, so we're left with other non-androgen modalities, and so that would be minoxidil to dir- directly stimulate the scalp, maybe low-level laser therapy to impart energy to the hair follicles, maybe injectable treatments like PRP and so forth.

   21. PAPeter Attia36:11

       Do those women in particular, these young women with PCOS, can their hair loss be restored, or is it permanent?

   22. ABAlan Bauman36:17

       Well, that's a trick question because-

   23. PAPeter Attia36:19

       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?

   24. ABAlan Bauman36:27

       It's tricky. So here's the thing. If you can normalize their hormones, uh, 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. Vellus 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, uh, whatever kind of hair loss you have, male, female, the idea is that you got to take action soon to protect the functioning of the follicles before there's that point of no return.

   25. PAPeter Attia37:26

       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, uh, uh, 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.

   26. ABAlan Bauman37:49

       Correct.

8. 37:50 – 45:38

   Snake Oils, Biotin and Early Prevention

   1. PAPeter Attia37:50

      Just briefly, what are some of the top three, top five snake oil things that were being peddled out there to people?

   2. ABAlan Bauman37:57

      Oh, gosh. Well, that... We'd 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, the same that would help for hair growth.

   3. PAPeter Attia38:06

      Yeah, like when you... I feel like when you, when you look at old magazines, like, there's always ads for, exactly, like some tonic or some, some ridiculous chemical that you couldn't-

   4. ABAlan Bauman38:16

      Dr. John's whatever, you know what I mean?

   5. PAPeter Attia38:17

      Yeah, yeah, yeah.

   6. ABAlan Bauman38:17

      You know? And there's always, like, a picture of a-

   7. PAPeter Attia38:19

      [laughs]

   8. ABAlan Bauman38:19

      ... you know, hair, a woman with a beautiful long head of hair. And so, you know, what happened was is that then, I guess it was, you know, it was Johnson & Johnson or whoever it was that had Rogaine was then able to say, you know, "You can't advertise hair growth from that kind of, you know, lavender oil extract because we have FDA approval for that now." So that was the method that kind of started to clear out the industry, if you will, moving some of those literally oil treatments, to- tonics and so forth that had no clinical efficacy whatsoever out of the market. Because now y- if in order to advertise hair growth, you had to have that FDA clearance. You had to have that FDA approval behind you.

   9. PAPeter Attia39:02

      So, and 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 wor- I've been on this and it hasn't been working," or, "What do you think about this?"

   10. ABAlan Bauman39:18

       Well, th- you know, there, there is a long list, but, you know, here's the thing. You have to be careful because, you know, people say, "Oh, well, you know, Rogaine didn't work for me." But remember we said earlier on that m- men-

   11. PAPeter Attia39:27

       Yeah, application matters

   12. ABAlan Bauman39:28

       ... application makes a big difference, compliance. Most people, they pick up a bottle of Rogaine. They, they're lackadaisical 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 get... They don't know that it's working. So it, a lot of it is expectations too.

   13. PAPeter Attia39:43

       Sure.

   14. ABAlan Bauman39:43

       So, right? So, you know, people say, "Well, I got it ro... Yeah, that Rogaine 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 y- you're trying to water your lawn with a watering can, when really what you needed was a sprinkler system. You needed a different type of delivery system.

   15. PAPeter Attia40:06

       Mm-hmm.

   16. ABAlan Bauman40:06

       So the, you know, w- we kind of get into trouble sometimes saying, well, you know, that... People thought that 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, and obviously they were all proven wrong by the exha- exhaustive studies that have been done now and all of the FDA clearances, which prove not only safety, but certainly hair growth. And, uh, we've seen patient after patient in that 20 years. So-

   17. PAPeter Attia40:30

       But what about, like, bi- like biotin and things that you see people taking, like these tablets or these makeshift things? They're like-

   18. ABAlan Bauman40:37

       Right. So biotin-

   19. PAPeter Attia40:37

       New York, New York is full of doctors who, um... I just know this 'cause I, when you do an intake with your patient-

   20. ABAlan Bauman40:42

       Mm

   21. PAPeter Attia40:42

       ... 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, you know, I'm obviously familiar with some of them, like finasteride, dutasteride, but I mean, biotin. What is biotin?

   22. ABAlan Bauman40:53

       Well, you have to know, you 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 hoof issues, and a lot of that science is real- is out there. You know, you can, you can put a horse on a high dose biotin and their hoofs improve, and that would be important if you're, you know, raising Thoroughbreds, for example, because a h- a hoof problem in a valuable racehorse is a big issue. So there's no question that, that there's a lot of science and data out there. It's less, honestly, in humans. There are less data out there. But, you know, if you put patients on biotin, a high dose, let's say 10,000 micrograms, nine times out of 10, they'll tell you their nails are getting stronger, and we know that you can do hair tensile strength studies and pu- you know, str- 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 [laughs] or male pattern hair loss problem to any substantial amount. It may make the hairs that you have stronger, but it's gonna need to be coupled with some other effective treatment, and that's where layering these kinds of therapeutic interventions are really, really important.

   23. PAPeter Attia42:00

       So have you ever had a patient come to you and say-

   24. ABAlan Bauman42:03

       With a bag of vitamins? [laughs]

   25. PAPeter Attia42:05

       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?"

   26. ABAlan Bauman42:29

       Well, a lot of my patients come to me with that exact question and concern. Many of my patients who we've transplanted or treated with other therapeutic interventions will bring in their teenage sons or daughters and say, "Listen, I, you know, 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, um, just like probably they paid for braces. So, uh, you know, they're concerned about keeping their, their child's hair intact, or at least as long as it possibly can. So we'll perform some evaluations and measurements. So if 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 trichometers to do hair bundle measurements. We'll look at the areas that are permanent, for example, in the back of the scalp, and we'll measure that and see what is their maximum hair mass index. That's the, 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.

   27. PAPeter Attia44:07

       Because you're sure that it's not just 20% less genetically.

   28. ABAlan Bauman44:12

       Correct. It should be the same. You know, 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 AOK. Now, a lot of those patients are, you know, [laughs] early teenage years maybe, or women who have hair loss problems, a different type of here- not necessarily a hereditary hair loss problem, some other issue.

   29. PAPeter Attia44:29

       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, 'cause sometimes you'll see, like, you know, like Ronald Reagan, even at the end of his age-

   30. ABAlan Bauman44:41

       Right
9. 45:38 – 50:58

   Medications, Dermatologists and Finding a Specialist

   1. PAPeter Attia45:38

      So what are these risk reduction techniques that, or what, what, what do you recommend for, uh, to patients in that s- in that situation?

   2. ABAlan Bauman45:47

      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, uh, 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, either 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.

   3. PAPeter Attia46:22

      Oh, I didn't realize that. And, and is it always negative, I'm assuming?

   4. ABAlan Bauman46:25

      Yeah, for sure.

   5. PAPeter Attia46:25

      So what were they again? So blood pressure.

   6. ABAlan Bauman46:27

      So blood, uh, yeah, antihypertensives.

   7. PAPeter Attia46:29

      Anti-lipid.

   8. ABAlan Bauman46:30

      Right. Uh, cholesterol m- modulating medica- medications.

   9. PAPeter Attia46:32

      And is there a particular type? Is it SSRIs, or is there a particular type of... You, you were a little vague in your description of that.

   10. ABAlan Bauman46:38

       Yeah. I would, I would say it's just in general anything that, that decreases the blood, that's being used to decrease the blood pressure. I can't say if it's only SSRIs, but, uh, as a general rule, if they're on some kind of blood pressure medication, typically they can correlate. If you ask them, uh, uh, pointed questions, you can, you can sometimes see at the time that they started that medication that there is some effect on their hair.

   11. PAPeter Attia47:00

       Now, how many of those things are sort of hypotheses you have versus documented facts? Is any, is that... I didn't, I didn't, I guess, I mean, uh, not that I'm in this literature-

   12. ABAlan Bauman47:06

       Yeah

   13. PAPeter Attia47:06

       ... but I didn't know any of those things, actually. I didn't realize that hair loss was a side effect of those meds.

   14. ABAlan Bauman47:11

       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," fill in the blank, you know, cholesterol medication, "that's when I really started to notice my hair changed." And, you know, when women tell you that their hair has changed, unlike many dermatologists out there, we believe them, very much so. They're-

   15. PAPeter Attia47:31

       You're gonna upset the dermatologists. Why, why don't dermatologists believe them?

   16. ABAlan Bauman47:35

       Well, the general feedback from most of my patients is that they've been around, that unfortunately they've been around the block to a number of different physicians, maybe endocrinologist, dermatologist, their 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 an over-the-counter Rogaine 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 you s- as we've talked about, looks like th- 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, it's a sweeping comment that I've made. I wouldn't say it is 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 that 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, you know, we're, we're here, we're, we're lopping off cancer growths over here. You know, that's what we do. And so you got all your hair. You know, your, your hair looks fine."

   17. PAPeter Attia48:45

       Are there-

   18. ABAlan Bauman48:45

       "I'll see you later."

   19. PAPeter Attia48:45

       ... 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're ask- y- you might as well be asking your radiologist that question, right?

   20. ABAlan Bauman49:08

       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 regimen and keeping a patient compliant with it. So it's just kind of like a doorknob conversation for them, and they're, they don't have the time to do it, honestly. I mean, a hair c- a good, strong hair loss consult in my office takes at least an hour typically. Patients usually will spend about an hour and a half in my office when they come in for a consultation. Y- you're not gonna spend an hour and a half with your local derm.

   21. PAPeter Attia49:43

       No.

   22. ABAlan Bauman49:43

       Certainly. You know, they're gonna do a quick exam, you know, look for some funky mole, and then kind of send you on your way. So they're, 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.

   23. PAPeter Attia49:56

       So, 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-

   24. ABAlan Bauman50:03

       Find a specialist

   25. PAPeter Attia50:04

       ... find someone who's gonna do a b- bunch of measurements. You want to make as many objective measurements as possible.

   26. ABAlan Bauman50:08

       Absolutely. Well, 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, whether it's genetic testing to look at androgen sensitivity in that post-menopausal women. I mean, a lot of derms don't, just don't have access to some of that stuff.

   27. PAPeter Attia50:26

       And what, so what were the tests again? You do a test of tensile strength, you do density, and then you... What, what sounded really interesting was the comparison density test, right? Where you do density in a region where there's never gonna be hair loss, make that your control, and then look at the crown.

   28. ABAlan Bauman50:39

       Yeah, crown or frontal and temporal areas.

   29. PAPeter Attia50:41

       Yeah.

   30. ABAlan Bauman50:41

       Or 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, you know, we've ta- spent a lot of time talking about hereditary hair loss, but there are many other types of hair loss. So, you know, figuring out what's going on in each of these different areas, you know, requires someone to look at the scalp and see what's happening.

10. 50:58 – 57:25

    Scalp Health, Shampoo and Conditioner

    1. PAPeter Attia50:58

       How, how many times do you look at the scalp and you see something completely unrelated like, you know, a fungal infection that can completely be treated and ameliorate the whole situation?

    2. ABAlan Bauman51:07

       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, you know, 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, the dandruff, if you will, uh, treatment protocols of, of zinc, pyrithione zinc, and some other treatment protocols for malassezia, the, uh, the yeast overgrowths 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, on hair growth. So we know that today. That's, that scalp health is important. So the, the soil in the forest needs to kind of be fertile, and if it's really inflamed or there's inflammation g- you know, if there's inflammation going on, that can definitely shut down the follicle and impair hair growth. So that's important to l- to look at that.

    3. PAPeter Attia51:59

       I- if somebody has dandruff, do we have a sense of how much that's increasing their risk of hair loss?

    4. ABAlan Bauman52:05

       So dandruff is kind of a nonspecific symptom, right? So flakes, right? But 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. So, you know, that's a whole nother deep discussion on trichology, 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, 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 you, should you shampoo? What's the right shampoo for you? And that's not sometimes a simple question to answer, especially if you've ever... Well, maybe for you it is, but- [laughs] Uh, but, uh, 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.

    5. PAPeter Attia53:01

       Yeah. Do you have any takeaways on what people should be doing? Are there any do's and don'ts with shampoos and conditioners?

    6. ABAlan Bauman53:06

       So I think the best thing... Well, of course, the do's and don'ts. So, uh, shampoos 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 gonna strip out a lot of the natural oils of the scalp and also of the hair, and a conditioner 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, shampoo is not gonna cure your hair loss. So when you asked, circling back, about some snake oil type treatments, there's no one shampoo that's gonna fix your hair loss situation. But again, you have to understand, if we can, if we can rectify some imbalance at the level of the scalp and reduce inflammation or tackle a-

    7. PAPeter Attia53:53

       Mm-hmm

    8. ABAlan Bauman53:53

       ... a, a fungal overgrowth, and we're gonna im- 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, you know, sometimes that's the right time to do it. But I guess the point is, is that Finding the right shampoo and conditioner, uh, 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, you know, and debris that you need to wash out of your hair on a regular basis?

    9. PAPeter Attia54:34

       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?

    10. ABAlan Bauman54:50

        Well, there are just some general guidelines, right? If, so if your hair is kind of long and curly, for example, uh, let's call it even kinky or, or Afro type hair, then you need like durable conditioning. You need conditioners 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 those, those are some general guidelines, I guess.

    11. PAPeter Attia55:20

        I, I remember when my daughter was little, and I would give her a bath. I don't know why. This might have been just a total wives' tale, but I remember that I was told shampoo is more important than the scalp, conditioner more important than... So you would start the shampoo at the head and work out to the ends, and then when I would con- put the conditioner in her hair, I would start at the ends and work up. Is that total nonsense?

    12. ABAlan Bauman55:39

        No, it makes some sense because the ends of the hair are the ones that are typically the driest. It's, it's been around the longest. The hair doesn't self-repair. It's a keratin fiber, right, that your body has produced. It's not alive. So, uh, when the fiber is long, it means it's been around a long time. And so the tips of the hair is the part where you're going to see a fraying of the hair, right? It's the part that looks the driest. It was the part that's been-- had the most exposure to UV radiation and everything else, the 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's starting to peel up. The ends are starting to split and fray. And if that continues, obviously, then that's-- then it 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, the hair breakage, literally that they've, they've stressed out the fiber so much that the fibers are actually breaking.

    13. PAPeter Attia56:41

        Mm.

    14. ABAlan Bauman56:41

        And we see that with harsh chemical treatments time and time again, or the new trends for flat ironing and such, you know, where you put the hot ceramic flat iron 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, you should condition the hair itself rather than the scalp. But don't forget that sometimes the scalp needs a little love, too, and we have a bunch of different types of products that are for exfoliation and for moisturization and anti-inflammatories and things like that. I mean, obviously, if you have a severe psoriasis issue, we need to get those flakes out of there, and we need to treat that psoriasis. You know, that's a bigger bit of business than just trying to like, "Well, what kind of shampoo should I buy at the supermarket?" You know?

    15. PAPeter Attia57:24

        Right. Right.

11. 57:25 – 1:10:54

    Treatment Buckets: Laser, Compounded Minoxidil and Inflammation

    1. PAPeter Attia57:25

       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, you know, we've talked a little bit about systemic treatment, so something that you take, like a pill, where it's going to act, you know, across your whole body, but you reap some benefit in, in the hair follicle. And then we've talked a little bit about topical as well, like, y-you know, minoxidil. I don't know if we would consider laser also topical, but maybe that could be considered something topical.

    2. ABAlan Bauman57:53

       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.

    3. PAPeter Attia58:02

       Okay.

    4. ABAlan Bauman58:02

       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, 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, for example.

    5. PAPeter Attia58:29

       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 stepwise. Obviously, you could do them together, but...

    6. ABAlan Bauman58:41

       Well, 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, ninety percent success rate, very low incidence of side effects. So for men, that's-

    7. PAPeter Attia58:51

       So for a guy, we're almost always going to consider that.

    8. ABAlan Bauman58:55

       Correct.

    9. PAPeter Attia58:55

       Okay.

    10. ABAlan Bauman58:55

        We're going to talk about that first.

    11. PAPeter Attia58:56

        Yep.

    12. ABAlan Bauman58:57

        Now, they may say, "Hey, no way. I want to-- I don't want to do anything that's going to lower my DHT level," and they may have heard or read about side effects.

    13. PAPeter Attia59:02

        Or they have side effects. Yeah, yeah.

    14. ABAlan Bauman59:03

        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, eighty two F is a way to get around that. So that would be for men. Let's try to at least address-

    15. PAPeter Attia59:20

        Yeah, yeah

    16. ABAlan Bauman59:20

        ... 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 women are of childbearing age, we're not even thinking about finasteride for them. We're going to be looking at laser light topicals as kind of the first types of therapies and maybe PRP.

    17. PAPeter Attia59:38

        So talk to me about why does laser work.

    18. ABAlan Bauman59:40

        Why does it work or how does it work? Laser works by imparting energy to the follicle. So we know now photobiomodulation is a very serious science. Uh, Dr. Michael Hamblin did much of the lion's share of the research at Wellman Center for Photomedicine, uh, here in, uh, Mass General at Harvard. He described, and this is, you know, going back now almost fifteen 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 the electron transport chain in the mitochondrial membrane at the cytochrome c oxidase. And y-what you get is a hyperpolarization of that mitochondrial membrane. And 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.

    19. PAPeter Attia1:00:36

        Do we know that in people who are losing their hair There's a deficiency in ATP production at the follicle?

    20. ABAlan Bauman1:00:42

        No.

    21. PAPeter Attia1:00:42

        Or is this something that we're doing to override whatever it is that's potentially causing the issue?

    22. ABAlan Bauman1:00:46

        We're trying to override it, and it's the same thing with minoxidil. When you apply a topical medication like minoxidil, you know that it has nothing to do with DHT, 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.

    23. PAPeter Attia1:01:01

        What is the mechan- I forgot. It's, uh, it's so funny. I've never seen a patient take minoxidil for blood pressure, and yet I sort of remember t- studying this in USMLE Part 1.

    24. ABAlan Bauman1:01:11

        It's a potassium-

    25. PAPeter Attia1:01:11

        What is the actual mechanism?

    26. ABAlan Bauman1:01:12

        Yeah, it's a potassium channel opener.

    27. PAPeter Attia1:01:14

        Okay. And so what is that doing to the follicle?

    28. ABAlan Bauman1:01:17

        So that's a great question, and, uh, probably beyond my pay grade, but there are some, many physicians, col- great colleagues of mine in the UK who have kind of, uh, figured all of that out, and I can provide that research for you. But essentially what minoxidil does is it keeps the follicle in the growing phase. So remember we talked about the anagen, which is the growing phase, and then of course the catagen, telogen, those are the resting degeneration phase, phases of the hair follicle. And we know that in a certain area of scalp, there's gonna 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, those-

    29. PAPeter Attia1:02:00

        Mm-hmm

    30. ABAlan Bauman1:02:00

        ... ratios change, and the hairs spend less time in a growing phase. So the anagen 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.
12. 1:10:54 – 1:27:30

    How PRP Works and Why Patient Selection Matters

    1. PAPeter Attia1:10:54

       So let's talk about PRP. You alluded to it.

    2. ABAlan Bauman1:10:57

       Oh, so you'd asked me how often you would do it. So the CapillusRx-

    3. PAPeter Attia1:10:59

       Oh, yeah, yeah

    4. ABAlan Bauman1:11:00

       ... is six minutes a day, but there are other devices like the laser cap, which was 20 minutes every other day.

    5. PAPeter Attia1:11:05

       Got it.

    6. ABAlan Bauman1:11:05

       So, you know.

    7. PAPeter Attia1:11:06

       But it sounds like you can be doing something else. Like-

    8. ABAlan Bauman1:11:09

       Yeah. You could be on-

    9. PAPeter Attia1:11:10

       ... the, the harder thing seems to me like the minoxidil, 'cause you have, you have to apply it twice a day.

    10. ABAlan Bauman1:11:14

        Yes. So, you know, sometimes, for example, you know, with busy college students, kids just starting a job, and so forth, they may have difficulty applying something to their scalp twice a day. They're living in the dorms and whatnot, that may be difficult. So, you know, we may do something more like laser or PRP for them. Uh, might be easier for them to be compliant with that.

    11. PAPeter Attia1:11:31

        Although it sounds like it's harder to walk around with a laser cap in a dorm room than...

    12. ABAlan Bauman1:11:34

        No, 'cause it's c- it's covered by a baseball cap.

    13. PAPeter Attia1:11:36

        Oh, literally a baseball cap?

    14. ABAlan Bauman1:11:37

        Literally, uh, it fits underneath a baseball cap.

    15. PAPeter Attia1:11:40

        Geez. [laughs] Wow, okay. I can't wait to link to a picture of one of these.

    16. ABAlan Bauman1:11:46

        See, so, you know... Well, later on when we go down to the expo, you'll have a chance to see, uh-

    17. PAPeter Attia1:11:50

        I'll stick it under my hat

    18. ABAlan Bauman1:11:51

        ... some of the links. Yeah.

    19. PAPeter Attia1:11:52

        Okay. You alluded to PRP. Now, you know, in, in, in, say, the world of orthopedics where PRP is used quite often, I think the jury's still out on the efficacy. I, 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 in when and, you know, who... Patient selection, basically, for lack of a better word.

    20. ABAlan Bauman1:12:21

        For sure. Because think about it. If, um, 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 gonna do the job, what do you think that success rate's gonna be? Probably not pretty good.

    21. PAPeter Attia1:12:35

        Yeah.

    22. ABAlan Bauman1:12:36

        So, you know, you can't come into a baldness clinic with total hair loss and think that a PRP is gonna solve the problem. That's not gonna 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 if it's cartilage or something else, you know, that's not gonna be gently fixed by a little bit of regenerative medicine, uh, you know, they're gonna need surgery for that. And that, and PRP may not necessarily solve that issue.

    23. PAPeter Attia1:13:01

        Yeah.

    24. ABAlan Bauman1:13:01

        So I think patient selection is a big, is a big concern, and as it is in hair loss and many other, you know, worlds of medicine.

    25. PAPeter Attia1:13:08

        So how... 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, 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.

    26. ABAlan Bauman1:13:25

        Correct. So, well, you're not wasting time and money if you have ongoing progressive hair loss, right? But you may not reach your goal with PRP, but it may help mitigate future loss, just like the use of minoxidil and laser is not gonna bring back that receding hairline, but it's gonna keep it from receding further-

    27. PAPeter Attia1:13:42

        Yeah. Yeah

    28. ABAlan Bauman1:13:42

        ... or faster.

    29. PAPeter Attia1:13:43

        Fair, fair point. Yeah.

    30. ABAlan Bauman1:13:44

        Okay?
13. 1:27:30 – 1:38:38

    From Plugs to FUE: How Hair Transplant Techniques Evolved

    1. PAPeter Attia1:27:30

       Let's get to the meat of it, which is the, the transplant. So how do you think about-

    2. ABAlan Bauman1:27:36

       What, you don't wanna know how long the PRP lasts in my hands?

    3. PAPeter Attia1:27:39

       Okay, yeah.

    4. ABAlan Bauman1:27:39

       Come on, this is really important. 'Cause most dermatologists are spinning test tubes. They're getting a two to three times concentrate. They're not getting seven to eight 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. What, 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.

    5. PAPeter Attia1:28:22

       And what's the percentage of patients that are not responding?

    6. ABAlan Bauman1:28:25

       Well, everybody responds to some degree. The question is, are they responding where they want? So if someone comes in with a receding hairline, they say, "Hey, uh, Doc, I really want PRP here at the receding hairline," if they're hoping for some regrowth, chances are that they're not gonna get too much action there. Because why? We talked about that, that there's just-

    7. PAPeter Attia1:28:42

       Yeah, we're past-

    8. ABAlan Bauman1:28:42

       ... less follicles-

    9. PAPeter Attia1:28:43

       Yeah

    10. ABAlan Bauman1:28:43

        ... 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. And that's pretty typical.

    11. PAPeter Attia1:28:57

        And when, and when they're leaving, obviously you're putting them on the regimen that is medical, topical, plus or minus laser.

    12. ABAlan Bauman1:29:03

        Could be any of the above or just one.

    13. PAPeter Attia1:29:06

        Wow.

    14. ABAlan Bauman1:29:06

        And, and many patients are doing monotherapy to start. They don't want to do two, three, or four different things. And then other patients come in, and they wanna 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, their, you know, their desire to, you know... and, and their goals, honestly. Some patients come in, they say, "You know what? If I just stay the same as I am right now, I'm pretty happy-

    15. PAPeter Attia1:29:29

        Yeah

    16. ABAlan Bauman1:29:29

        ... the way I am right now. If I stayed the same, I would be cool." And so they're-- we make a plan for that. But then there are other patients that say, "Hey, you know, we gotta, we wanna turn the clock back," and that's where the transplant comes in.

    17. PAPeter Attia1:29:39

        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?

    18. ABAlan Bauman1:29:57

        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, is our priority, and we have a, a patient-centered practice. So it becomes very, very clear after spending the time with the patient. For the patient under... The patient knows what they're gonna need, essentially. So they may say, "Well, hey, you know what? I, I, I think I'm probably gonna need a hair transplant. Now is not the right time. Maybe it's gonna 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, you know, I really wanna fix this hairline with PRP and laser," I mean, I have to be honest with them and tell, and show them with the microscope, "Look, man, we can wish and we can hope, and that's okay, but, you know, wishing and hoping is not a strategy."

    19. PAPeter Attia1:30:41

        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, 'cause I didn't think much was special in Toronto.

    20. ABAlan Bauman1:30:51

        So what was happening-

    21. PAPeter Attia1:30:51

        Other than the Shouldice clinic for hernia repair.

    22. ABAlan Bauman1:30:54

        Interesting. Okay.

    23. PAPeter Attia1:30:55

        That's very special.

    24. ABAlan Bauman1:30:56

        Yeah, for sure. So, um, things that were happening in the early, in the, I would say, the mid-1990s, were that surg- hair transplant surgeons were learning to use single follicle implants, meaning that instead of a plug or a punch or four millimeter biopsy of skin, they were cutting down and dissecting or getting down to literally a, 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 it was Dr. Seeger at the time, is the g- is the surgeon that, uh, was doing that work. So he's since passed on. But, um, uh, he was doing that work with, uh, 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. And 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 l- you know, larger, what they called micro minigrafts, let's say, or those punch grafts to create the density.

    25. PAPeter Attia1:32:31

        Two comments there.

    26. ABAlan Bauman1:32:32

        Yeah.

    27. PAPeter Attia1:32:32

        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, and 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, with or without a microscope? I'm just talking purely from the standpoint of patients. Like, how many years does that take?

    28. ABAlan Bauman1:33:00

        No, no, no, it doesn't take years. Um, you know-

    29. PAPeter Attia1:33:02

        I mean, I'm being facetious.

    30. ABAlan Bauman1:33:03

        No, I understand.
14. 1:38:38 – 1:44:00

    Graft Numbers, Beard Donors and Transplants in Women

    1. PAPeter Attia1:38:38

       So if you had a patient and you were, I don't know if you'd do this, but if you were gonna dedicate the entire day to that patient, like it was a one, you know, quote, unquote, "a big case of the day"-

    2. ABAlan Bauman1:38:46

       Mm-hmm

    3. PAPeter Attia1:38:46

       ... how many follicular units-

    4. ABAlan Bauman1:38:48

       Grafts

    5. PAPeter Attia1:38:48

       ... can you harvest and implant?

    6. ABAlan Bauman1:38:50

       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, our harvest rates and our harvest qu- uh, quality is much, much more improved than trying to do a marathon, you know, 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, uh, let's call it around 3,500 to 4,000 grafts over two days, and that's with a wide shave all the way around, provided that they have the hair to do it.

    7. PAPeter Attia1:39:27

       Mm-hmm.

    8. ABAlan Bauman1:39:28

       You know, and there are exceptions. I mean, we've done 5,000 grafts on some guys, and you know, sometimes we try to get 3,000, and we just can't even do it.

    9. PAPeter Attia1:39:34

       What is the greatest number of grafts you've implanted on a patient? And I'll ask it two ways.

    10. ABAlan Bauman1:39:40

        Mm-hmm.

    11. PAPeter Attia1:39:40

        One, harvesting only from their head.

    12. ABAlan Bauman1:39:42

        Mm-hmm.

    13. PAPeter Attia1:39:43

        And two, harvesting from other sites on the body, which I'd never even heard of until you mentioned this a couple, uh, maybe six months ago. We were talking about this, and you mentioned that in one of these patients, you'd actually harvested something from his beard.

    14. ABAlan Bauman1:39:55

        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? Um, and I'm not afraid to, to correct those cases and to, you know, update those cases into the latest and greatest possible situation that they could have. So top numbers, well, you know, my dad comes to mind. He had almost 8,000 grafts. He was totally bald before we started. Most guys who are totally bald up the top, meaning that they only have the hair on the sides and the back-

    15. PAPeter Attia1:40:28

        Mm-hmm

    16. ABAlan Bauman1:40:29

        ... most of them will need somewhere around 6 to 9,000 grafts to kind of fill up the zones.

    17. PAPeter Attia1:40:35

        And do you have, if someone is that bald, do they have enough donor site on the hair, on the remainder hair?

    18. ABAlan Bauman1:40:40

        Most of the time, if they've never been harvested, they do. But if they've had some less, 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.

    19. PAPeter Attia1:40:53

        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?

    20. ABAlan Bauman1:41:01

        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 at the frontal hairline, typically. It's gonna be used as filler.

    21. PAPeter Attia1:41:16

        It's filler in the back, yeah.

    22. ABAlan Bauman1:41:17

        Yeah, and it works really well. It grows like crazy.

    23. PAPeter Attia1:41:18

        And body hair seems less, much less thick and robust than hair hair. I mean, scalp hair, right?

    24. ABAlan Bauman1:41:24

        Again, everybody's different. I mean, if you are a person with very, very thin, fine hair on your scalp, you may find that the other hair, body hair is a better, thicker-

    25. PAPeter Attia1:41:33

        Yeah, yeah

    26. ABAlan Bauman1:41:33

        ... coarser caliber. But the problem is, and this is just a general idea, that as you get farther away from the scalp, the follicles spend less time in the growing phase. So again, we're going back to this anagen, catagen, telogen issue.

    27. PAPeter Attia1:41:45

        Sure, sure. The body hair-

    28. ABAlan Bauman1:41:46

        So-

    29. PAPeter Attia1:41:46

        ... doesn't really grow. I mean, it's...

    30. ABAlan Bauman1:41:48

        So it spends less time in anagen, but it also, out of, let's say, 10 follicles from the body, the chest, maybe only 5 of them are growing at any given time. So it's kind of like hiring part-time workers [laughs] in your factory, you know? You've put, you've hired 10 people, but only 5 of them are showing up a day.
15. 1:44:00 – 1:52:57

    Risks, Realistic Expectations and Donor Dominance

    1. PAPeter Attia1:44:00

       So what are the biggest risks of this procedure, besides the obvious risks that we talk about in every surgery, bleeding, infection, et cetera? Or, you know, uh, is there anything that is unique to this surgical procedure as far as a risk?

    2. ABAlan Bauman1:44:13

       Sure. Well, bleeding infection are extremely rare, thank goodness. Even though we're making thousands of little tiny sites in the scalp, not only the harvesting and implantation part-

    3. PAPeter Attia1:44:19

       Yeah, it's a privileged site

    4. ABAlan Bauman1:44:20

       ... bleeding is not an issue. Isn't-- Bleeding is not an issue. I mean, just like if you cut yourself shaving or you get a paper cut, you know, in 20, 30 seconds, you stop. Um, infection, your worst infection typically with a hair transplant might be a pimple, to be honest. And you-- maybe most people have one or two, and we call it, you know, could be around the time when the hairs start 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 know, one out of every 20 or 30 patients that has more than, you know, 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, of the procedure itself, because we can recreate something with artistic bent. You know, 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 normal and 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 and orientation that's required for recreating a crown area. But really the risk comes to that you're 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 ten out of ten, and the reality is that it's going to always be a five out of ten, 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 h-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 hairpiece and all that. The transplants that he has, if you look at him today, even fifteen years later after his procedures, it looks like he has a full head of hair, but it's an 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.

    5. PAPeter Attia1:46:41

       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, you're not going to be a great candidate."

    6. ABAlan Bauman1:47:15

       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 lackadaisical 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 the 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 and partnership with what we do and what we recommend. I can tell you what kind of therapies and treatments and such that are going to get-- keep your hair growing strong, but you have to do that work.

    7. PAPeter Attia1:47:58

       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-

    8. ABAlan Bauman1:48:04

       Yeah

    9. PAPeter Attia1:48:05

       ... 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?

    10. ABAlan Bauman1:48:23

        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 and the back of the scalp, which are virtually immune to the effects of DHT, most guys with a total baldness problem never l- 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, a dent into that.

    11. PAPeter Attia1:48:56

        Hmm.

    12. ABAlan Bauman1:48:56

        So in these few and far between cases, we believe that there is some recipient area control. And, 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.

    13. PAPeter Attia1:49:12

        Mm-hmm.

    14. ABAlan Bauman1:49:12

        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 spent in the growing phase. It tracked the antigen, the long, 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, or back of 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, right? 'Cause it's maybe not necessarily all androgen dependent, that we say that those hairs are relatively permanent.

    15. PAPeter Attia1:49:54

        Has anyone ever, ever done the experiment where you take a, a hair and implant it in an area that has zero hair, like the palm or-

    16. ABAlan Bauman1:50:01

        Of course, yes. In fact, I did that for someone. Have you ever heard of Nolz from YouTube?

    17. PAPeter Attia1:50:05

        No.

    18. ABAlan Bauman1:50:06

        So Nolz 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.

    19. PAPeter Attia1:50:20

        Wow. So th- that is, from a, just from a pure biology standpoint, that is really amazing.

    20. ABAlan Bauman1:50:26

        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.

    21. PAPeter Attia1:50:40

        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, I mean, look, I don't think about this obviously very much, but it would just, 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.

    22. ABAlan Bauman1:51:04

        No. Anywhere that you have a blood flow, it will grow.

    23. PAPeter Attia1:51:07

        Hmm.

    24. ABAlan Bauman1:51:08

        Because all it needs is energy. It needs the oxygen. It needs the nutrients. The hair follicle, you, 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.

    25. PAPeter Attia1:51:35

        [laughs] That's incredible.

    26. ABAlan Bauman1:51:37

        The hair follicle cell population, the population of cells within the hair follicle are among the most highest ly m- highest metabolically active cell populations in your body. It's one of the reasons why chemotherapy knocks them out-

    27. PAPeter Attia1:51:48

        Yeah

    28. ABAlan Bauman1:51:48

        ... as well as the lining of your gut-

    29. PAPeter Attia1:51:49

        Mm-hmm

    30. ABAlan Bauman1:51:49

        ... and your bone marrow, right? I mean, if your 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.
16. 1:52:57 – 1:55:56

    How Fast the Field Has Moved and Closing Thoughts

    1. PAPeter Attia1:52:57

       Well, Alan, this is super interesting. I suspect that there are gonna 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, I'm actually surprised at how often, you know, 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 in what seems like a decade and a half, basically.

    2. ABAlan Bauman1:53:30

       Yeah. I mean, it's, 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 follicular unit extraction, to the use of cellular therapy, you know, PRP and, and other things like low level laser therapy and compounded medications to attack the hair follicle and from all sides in 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.

    3. PAPeter Attia1:54:17

       Well, Alan, thank you very much. I appreciate the, um, the input, and I hope that, uh, anyone listening to this who's had some questions about this has, has got some of those answered.

    4. ABAlan Bauman1:54:26

       Great. Well, great to be here with you. [upbeat music]

    5. PAPeter Attia1:54:29

       You can find all of this information and more at peterattiamd.com/podcast. There you'll find the show notes, readings, and links related to this episode. You can also find my blog at peterattiamd.com. Maybe the simplest thing to do is to sign up for my subjectively non-lame once a week email where I'll update you on what I've been up to, the most interesting papers I've read, and all things related to longevity, science, performance, sleep, et cetera. On social, you can find me on Twitter, Instagram, and Facebook, all with the ID peterattiamd. But usually Twitter is the best way to reach me to share your questions and comments. Now for the obligatory disclaimer, this podcast is for general informational purposes only and does not constitute the practice of medicine, nursing, or other professional healthcare services, including the giving of medical advice. And note, no doctor-patient relationship is formed. The use of this information and the materials linked to the podcast is at the user's own risk. The content of this podcast is not intended to be a substitute for professional medical advice, diagnoses, or treatment. Users should not disregard or delay in obtaining medical advice for any medical condition they have and should seek the assistance of their healthcare professionals for any such conditions. Lastly, and perhaps most importantly, I take conflicts of interest very seriously. For all of my disclosures, the companies I invest in and/or advise, please visit peterattiamd.com/about. [upbeat music]

Episode duration: 1:55:56