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PART I
THE BACKGROUND

Chapter 1
The Business of Hair Loss

“You can fool all of the people all of the time . . .
if the advertising budget is big enough.”
—Ed Rollins, political advisor

The times have certainly changed for the field of hair replacement. Over the years, as cosmetic surgery has gained acceptance, the popularity of hair replacement has risen as well. It is a golden age for the entire field. In an industry that now grosses more than a billion dollars annually, the technological advances in all three branches—surgical, cosmetic, and pharmaceutical—are nothing less than astounding.
Although we are in the middle of the hair replacement’s technological and financial golden age, it is also the age of big business, multinational chains, and direct-market advertising. Along with this comes hair-transplant “counselors,” video sales pitches, and unwanted phone solicitation. To avoid industry fraud, misrepresentation, and, worst of all, disfigurement, anyone interested in hair replacement must become educated.
Never have more choices been available, and yet, never have more outrageous promises been made, directly impeding the consumer’s ability to choose among the many options. This chapter, therefore, is about realigning your attitude towards the field of hair replacement. It will help raise your awareness level of the misrepresentations and even dangers found within the industry. In other words, it will help you become a savvy consumer.
O’Tar Norwood, MD, a prominent hair-replacement surgeon from Oklahoma City and author of several textbooks, has cautioned that “[we] must be careful, ethical, and truthful. It is very easy to emphasize the positive things about a procedure and ignore, or de-emphasize the negative aspects. We must be very careful because it is very easy when dealing with hair and aesthetics to mislead an under-educated consumer.” This is an excellent reminder that applies to all three areas of the hair-replacement field. To ensure that you are not misled, this chapter will reveal some of the unsavory business practices that have permeated this field. Don’t worry, though, many ethical doctors and other hair-replacement professionals still exist. But an important first step in helping to identify the best in the field is learning to avoid those people, products, and practices that will not help you reach your goals.

Bad Business Practices
Business has always been a part of medicine. Even Hippocrates, the father of modern medicine who lived in ancient Greece, had to charge for procedures and sell tonics to cover his expenses. In the 1800s, traveling salesmen sold snake oils and tonics to anyone willing to hand over a few pennies, and even in the 1950s—a perceived golden age in America—there were unethical doctors and salesmen who conned people out of their money. What is most important to remember about those times is that the vast majority of doctors, salesmen, and others who dispensed medical information and services were relatively ethical. But some time in the early 1980s, the balance in the field of hair replacement changed, and the number of people trying to take advantage of hair clients grew, eventually appearing to constitute the majority in the field.
As this balance shifted, the profession of surgical hair replacement was transformed into a business, with the search for profits—not a search for healing—as the driving force. Unfortunately, the patient or client was transformed into a consumer. The difference between profession and business, patient and consumer is enormous. A patient seeks out a doctor for trustworthy advice on how to cure an ailment, and the doctor gives his opinion based on years of experience and training. The patient assumes that the physician places his well-being above all other considerations. A consumer, on the other hand, goes to a place of business and talks with a salesperson. The salesperson gives his biased opinion, hoping to sell another “widget,” whether or not the consumer needs it or wants it. The consumer understands the sales process and, therefore, approaches the relationship with caution. The biggest problem with the change from profession to business is that most people who have experienced hair loss don’t even realize the change has taken place.

Surgical Hair Replacement
The surgical branch of the hair-replacement field is the area in which the invasion of business tactics has had the most impact. This is largely because the consequences are so much greater. Losing money is certainly serious, but not more so than permanent scarring and disfigurement. Since the 1980s, over 50 percent of our patients have come to us in need of repair and reconstruction because of poor results from inferior transplant surgery. Many of these patients just wanted to look normal enough to be seen in public. This was truly sad, because their disfigurements could have been prevented.
Why are so many hair-replacement patients failing to get the results they want and expect? As you are about to see, there are a number of contributing factors.

Doctors Find You
In the 1970s, when the surgical hair-replacement field was still in its infancy, prospective patients usually asked their family general practitioner, a dermatologist, or even the local medical school for referrals of competent hair-replacement surgeons—in effect, an endorsement by a trusted source. Furthermore, because the referring parties had no vested financial interest in the outcome, they could give accurate, unbiased information to the best of their knowledge and expertise. With this initial recommendation, the patient then scheduled a consultation with the surgeon.
Today, without rules prohibiting medical advertising, to find a hair-replacement surgeon, one can simply log onto the Internet, scan the sports pages of the newspaper, or watch infomercials. Each of these avenues usually leads to the same place—an 800 number, from which the caller will receive a brochure and an “informational” video. These methods circumvent the traditional safeguards for finding a surgeon.
But the lack of safeguards doesn’t end there. Most people then go to consultations still expecting ethical, factual, and objective advice regarding the treatment of hair loss. However, many consultation offices have changed from straightforward sources of information into seductive showrooms—so cleverly designed and disguised that, to the trusting patient, they appear to be doctors’ offices. Ingrid Wagner-Smith, MBA, CMR, a hair-replacement technician from St. Louis, laments, “Unfortunately . . . the patient can no longer distinguish gimmick and hype from fact.”
Advertising, however, is now something of a necessary evil, because it is difficult for novice surgeons to get patients without advertising in some way. Traditionally, a doctor, at least in part, built up a practice through personal referrals. Satisfied patients were—and still are—a surgeon’s best and least expensive form of advertising. Unfortunately, these traditional methods take time to have any effect. Unlike other forms of cosmetic surgery, hair restoration can require one or two years for completion. So what does the novice hair-replacement surgeon do to establish a practice while waiting for his first patients’ hair to grow out? He advertises.
Of course, advertising can be responsible, ethical, and educational. It can create increased consumer awareness and healthy competition, which, in turn, can act as a force to improve technology, decrease fees, and increase the availability of state-of-the-art procedures. Unfortunately, some doctors and clinics take a different approach; they will use any gimmick or unrealistic promise to get new patients.

Promises That a Scalpel Can’t Keep
Russell Knudsen, MD, past President of both the International Society of Hair Replacement Surgery and the Australian Society of Hair Replacement Surgeons in Sydney, Australia, once warned, “Never let your mouth make promises that your scalpel can’t keep.” The fact is, however, that unethical hair-replacement surgeons do make promises that can’t be kept. They promise clients the complete return of all lost hair—as much hair as they want, as fast as they want it. Unfortunately, hair-replacement surgeons do not and cannot replace, restore, revive, or resuscitate dead and departed hair. They can only take permanently growing hair from the back and sides of a head and redistribute it over the bald areas on the top and front. No patient has one more hair on his head in his “after” picture than he did in his “before” picture. It just looks as if he does. His hair has been rearranged, not replaced.
While this fact may limit your expectations of the hair-replacement process, it does not mean that you can’t get great results. It just means that, contrary to what some doctors may promise, you can’t have it all.

The Rise of Multi-Center Clinics
Multi-center or chain clinics specializing in hair-replacement surgery have taken the place of many traditional doctors’ offices. It is difficult to say exactly what provides the impetus for such a trend, but it would be safe to assume that “profit” is a major force. Although these multi-center establishments can provide excellent results, they are not without certain inherent problems, which are presented in the following discussions.

Who Works in Multi-Center Clinics?
Many people assume that multi-center clinics are on the cutting edge of technology. Whether or not this is true, the clinic itself is not the issue. The two essential elements of surgery are always you and your surgeon. It is an individual doctor, not a clinic or institute, who operates on your head. So it is the surgeon who must have the competence to perform the procedure that you have chosen.
Of course, the clinic will try to convince you that its surgeons are all masters of their craft. But consider this: If a clinic is overflowing with such gifted, artistic, leading authorities, why are they working there? Typically, less experienced doctors work at these clinics, trying to gain experience without the stress of managing a private practice. And nothing is inherently wrong or even unethical about doctors working for other doctors. In some instances, a surgeon can spend more time conducting research or writing professional articles if someone else runs the business. However, this scenario is the exception rather than the rule.
Moreover, nothing is wrong with your choosing to go to a clinic for many reasons, including cost, convenience, and location. Some people do receive good, satisfying results from multi-center clinic surgeons. What’s critical, however, is to evaluate the clinic and its surgeons before making any commitments. The information found in this book will help guide you in this evaluation.

Who Pays the Overhead?
Inherent within any doctor’s practice are the ongoing responsibilities of managing personnel, patient records, office overhead, and bookkeeping. Any doctor who decides to expand his practice into a national chain will be responsible for vastly increased overhead. He will sign multiple leases and hire and train many new employees, including other doctors. Most important, he will significantly increase his advertising budget. Because these expenses are paid up front, they can become either a subtle or a not so subtle pressure to increase income.
In the largest nationally franchised institutes, the advertising budgets can be counted in the millions of dollars for a single year, sometimes exceeding $10 million according to the trade journal Ad Week. Remember, that’s $10 million in addition to the standard expenses, including doctors’ fees, nurses’ salaries, rent, supplies, and medications. So, by the time you walk through the door of the clinic, you are not viewed only as a patient, but also as an expense to be covered. The income to cover such monumental expenses comes from one place only—surgery performed on your head.
Doctors will acknowledge this potential conflict of interest, but many will counter with, “I can handle it.” Yet it is not easy to do so. Only one reason compels doctors to advertise—to increase their number of patients. The patient-consumer needs to be aware that there may be a direct correlation between the amount of advertising that a clinic does and the pressure that it may place on the patient to have surgery performed. The feeling that one is being pressured, coerced, or “sold” should be a warning sign that perhaps your best interest is not the top priority of the physician or clinic.

“Counselors” Replace Doctors
The expansion of the traditional doctor’s office into a multi-center clinic has given rise to another new development—the hair-replacement counselor. As the surgeon feels the pressure to earn more money to pay for increasing overhead, he must spend more of his time operating, thereby generating more income. From an economic perspective, his most valuable time is surgical time. As a result, others may be responsible for some of the tasks that have been traditionally performed by doctors, including the most time-consuming but also most important task: the consultation.
To solve the surgeon’s operating room-versus-consultation room dilemma, many clinics now use hair-replacement counselors. These “counselors” are often nothing more than salesmen in white lab coats, working on commission. Posing as qualified medical advisers, these “professionals” represent the doctor in consultations. They may even plan the new hairline, diagnose the future extent of baldness, and assess donor graft availability. Prospective patients should be aware that these counselors are not licensed in any field of medical practice to give out surgical recommendations of any kind. Only a surgeon is qualified to make such suggestions.
Ideally, the doctor and his patient, after proper discussion in search of a common but realistic goal, should form a strong and lasting bond. Unfortunately, such bonds are strikingly absent from many doctor-patient relationships, which have been reduced to consent forms and payment plans. The bond between a surgeon and patient cannot even begin to form when a counselor-salesman substitutes for the doctor during the consultation.
Substituting a counselor for a doctor is distressing enough, but it is only the first step toward an eroding doctor-patient relationship. In many cases, the patient first meets the doctor on the day of surgery, and often during the presurgical preparation. There’s a good chance that any patient who meets the surgeon on the day of the operation has not been made sufficiently aware of all treatment options, has not had the opportunity to understand the nature of his condition, and doesn’t have the proper expectations for the outcome of the surgery.
Assessing the skill and compassion of a surgeon is hard enough under the best of circumstances—and it’s nearly impossible to do immediately prior to surgery. Although in the final analysis, it doesn’t matter whether a surgeon is deliberate in his deceptions, or just plain naive and unaware of the ramifications of surgical hair replacement, the end result can be the same. Therefore, knowing your surgeon and his attitude towards surgery is vital in order to achieve a safe and satisfying result. It is a process that takes time.
Understanding the element of time is as important as understanding the surgery itself. Meeting your surgeon in the operating room for the first time is perfectly appropriate if you’ve just been in a car accident and suffered some serious trauma that needs immediate attention. Certainly, this would hardly be the time to ask for your surgeon’s credentials or to request a meeting with some of his other patients. Elective or cosmetic surgery, conversely, is, by definition, a choice. There should be no feeling of urgency.

Clinics Become Superstores
A number of hair-replacement clinics have become superstores. They offer all of the options—surgical, pharmaceutical, and cosmetic. These places claim that because they offer everything, they have no particular bias or goal other than giving clients complete satisfaction. Typically, however, they encourage surgery, since it is usually the most expensive option. Of course, a lifetime of hair additions can also be costly, but with surgery, the costs are paid immediately. These superstores typically suffer from all of the problems associated with surgical clinics, but because they offer hair additions and pharmaceutical treatments, they also have the problems associated with these branches of hair replacement.

Turnkey Operations
Once there was a time when marketing firms considered medical professions off-limits. Now, they specifically target doctors, especially those who are overburdened by managed care. The express intent of these marketing firms in the area of hair restoration is to “help” physicians establish new practices literally overnight. The setup is so complete that all the doctor has to do is “turn the key” and open the door to a brand new hair-replacement office—hence, the term “turnkey” marketing.
Dr. Robert Leonard, past President of the International Society of Hair Restoration Surgery and hair-replacement specialist in Cranston, Rhode Island, recounts a personal experience with just such a marketing firm. He recalls, “I spoke with [a] marketing professional who, for a fee, [would have] provided before and after photos of patients [whose surgery was not performed by me], provided advice on marketing a hair-restoration practice, training for office staff to properly answer the phones, [and] training me (sic) how to do hair-transplant surgery. I asked him how he could do something like this. [The marketing man] responded that he observed the ‘Masters,’ and therefore, could walk me through my first few surgeries.”
The marketer was literally offering Dr. Leonard a surgical hair-replacement franchise. Of course, this example represents the worst kind of abuse, but, unfortunately, it is not an isolated incident. And please don’t think that we are lost in a haze of nostalgia for a kinder, gentler America. We realize that all doctors are not created equal, but the traditional safeguards for the patient have eroded to the degree that editorials on medical ethics appear in hair-replacement journals with a frequency that almost rivals the articles on surgical techniques.
Dr. Leonard is responsible for the “Medico-Legal” section of The Hair Transplant Forum International. It offers articles on the ethical decisions that surgeons make every day. Until recently, it was unheard of to include a section on ethics in a medical journal.

Is Training Always Sufficient?
Would you get on a plane knowing that the pilot’s training consisted of a weekend seminar with a marketing consultant who had watched other pilots fly planes? Not unless someone held a gun to your head. Would you knowingly allow anyone to perform surgery on your head with the same kind of inadequate training? Of course not. Yet, in many cases, patients unwittingly allow surgeons who have had little or no training to operate on their heads.
Picture this scenario: Dr. X, who has been working in a hair-transplant clinic, feels that he has learned enough and is ready to open his own practice. He plans to leave in two weeks but has surgeries scheduled—one of which is yours—for the following two months. The clinic, or more specifically, its founding surgeon (who is also the CEO) now faces an ethical dilemma. Knowing that it will take several months to hire and train another doctor to replace Dr. X, does Dr. CEO inform you that Dr. X is leaving the clinic and that it will be necessary for you (and fifty other patients that were also scheduled for surgery with him) to have the surgery rescheduled? Or does he hire another doctor to step in immediately, regardless of his training, without notifying you? It may make perfect business sense for Dr. CEO to hire a replacement surgeon without informing the patients, but does it make professional sense?
Remember, this type of ethical dilemma can occur in any surgeon’s office, large or small. However, the bigger the business, the greater the chance of such problems occurring.

Rationalizations
Certainly, if a doctor behaved in the unethical, unprincipled ways we have just described, you would avoid choosing him as your surgeon. Unfortunately, most doctors with such intentions aren’t obvious, and they use subtle rationalizations to justify performing inappropriate procedures. These rationalizations typically fall into one of three major groups: 1) If I don’t do it, someone else will; 2) The patient made me do it; and 3) I’m not my brother’s keeper.

If I Don’t Do It, Someone Else Will
Kenneth Bushwach, MD, the author of a textbook on surgical hair replacement, gave a lecture in 1996 about the long-term complications of scalp-reduction surgery. Because of these problems, he spoke of his intent to discontinue performing this type of surgery. At the end of the lecture, a noted surgeon stood and said, “Ken, you have an established cosmetic surgery practice in Kansas City. You can afford not to do these procedures. But if you lived here, where we have so many more plastic surgeons doing hair replacements, you wouldn’t be able to turn patients away, because if you didn’t do the procedures, someone else would. So, it might as well be me who does them, especially since I do them better than everyone else.”
It is interesting to note that the offending doctor implicitly acknowledged that the procedures had inherent problems. Still, he rationalized that it was better to have a good surgeon perform a bad procedure rather than a bad surgeon. Although this may be true, it would be even better to have a good surgeon refuse to do a bad procedure regardless of the financial consequences to his practice.

The Patient Made Me Do It
If a woman went to a plastic surgeon and said that she’d like to have her ears attached backwards, would the surgeon do it just because she asked for it? Of course not. The surgeon would know full well that his reputation is at stake and he would never perform such an unnatural procedure. Yet somehow, when it comes to a man and his hair, many surgeons seem to abandon this very fundamental responsibility if it means losing a patient. They coyly claim, “The patient made me do it.”
The rationalizing surgeon can even set up his patient as a convenient scapegoat by asking him, “What would you like? Where would you like your grafts?” Such questions should raise suspicions immediately. Can you imagine being wheeled into the operating room for open heart surgery and the surgeon leaning down to ask, “Bill, during today’s surgery I will bypass the anterior descending artery, but as long as I’m in the neighborhood, do you want me to bypass the posterior coronary artery also?” The surgeon may ask for your cosmetic goals, but never for your “surgical plan.”

I Am Not My Brother’s Keeper
A distinguished hair surgeon approached Dr. Marritt at a surgical conference with one of his best-looking patients, a thirty-seven-year-old male. Dr. Marritt remarked, “This patient looks fabulous right now, but what about the fact that fifteen years from now, his head will look like a road map of exposed scars?” The doctor replied with all honesty, “I tell all my patients, nothing lasts forever. It’s their decision. I’m not my brother’s keeper.”
Such utter disrespect for the patient is often revealed by the work performed. The ethical surgeon will make decisions that are in the best long-term interest of his patients.

Cosmetic Hair Additions
The technology for making hair additions that look and feel real has made this a valuable option for anyone experiencing hair loss. Professionals working with cosmetic hair additions have always had more of a business focus than those involved in the other branches of hair replacement. This means that outrageous advertising and sales gimmicks occasionally make their way in the promotion of this business.

Swim, Shower, and Play?
Because it is true that you can get all the hair you want from hair additions, with certain exceptions that will be outlined in Chapter 4, the unethical hair-addition practitioner likes to use the “swim, shower, and play” tactic as an advertising tool. Almost every ad claims that you won’t have to sacrifice any part of your busy active life. The hair addition, giving you all the hair you want, will not only remain perfectly in place at all times, it will also look and feel like human hair under any and all conditions. Some advertisers will also promise that because of some revolutionary attachment method, no cleaning or maintenance is needed. And, of course, the price is so low they may as well be giving them away.
Such pie-in-the-sky promises are pure fantasy. Hair additions, although improving all the time, are still detectable under certain circumstances, such as close inspection and extremely high winds. Plus, all hair additions need maintenance and cleaning on a regular basis. Some of the higher-end additions require that you purchase two so that while one is on your head, the other can be in the “shop,” getting maintained. Moreover, even using human hair does not guarantee complete naturalness in feeling. Over time, human hair degrades from exposure to the elements. And although several new synthetic fibers feel totally natural, each one needs specific maintenance. In addition, the base of any hairpiece is made of a synthetic material that lies on the top of the head; and because it is not natural, it will not feel natural.
What are the consequences of believing the advertising hype? For the most part, you will be losing some money and, perhaps, a little dignity. However, some hair-addition attachment methods can cause permanent damage to the scalp if they are not handled correctly. The pros and cons of each type of attachment method are outlined in Chapter 4.

Hidden Costs
Many of the problems with surgical hair replacement are related to the withholding of information. The same is true of hair additions. What a hair-addition professional decides to tell you (or not tell you) will significantly affect the outcome of your purchase and your satisfaction with it. A lack of complete and proper information always leads to poor decisions.
One of the most common ways in which salesmen mislead customers is to hide costs in the fine print of a contract. Contracts should specify additional interest or payments, added maintenance charges, unusual fees for replacements or repairs, surcharges, and taxes. The person supplying your hair addition should be able to explain each and every cost that is stipulated in the contract. Ninety-nine percent of all hair-addition costs are based on three components: the hair itself, the base, and the method of attachment. (One exception—a new hair-addition process called Micro Point Link, discussed in Chapter 4—does not have a base.) Maintenance costs should also be factored in for normal wear and tear and the regular cleaning of additions. If you are charged for anything else, you’re getting ripped off.
Regardless of their potential drawbacks, cosmetic hair additions, which continue to improve, represent a viable option for hair loss. Whether they are used as permanent solutions or temporary hair replacements prior to surgery, hair additions serve a valuable purpose.
Pharmaceutical treatments
Like hair additions, the pharmaceutical treatment of hair loss also has a strong business focus. Most of the products that fall under this category are purposely designed to be used without a doctor’s supervision, and, therefore, do not need FDA approval. As a result, the question of ethical boundaries in the area of pharmaceuticals is not clear. A lack of proper information is another major problem with this branch of the hair-replacement field.

Promises, Promises
Advertisements for pharmaceutical treatments usually promise the painless, quick, and easy return of all your lost hair, regardless of age or amount of hair loss. A full-page ad in Sports Illustrated for extra-strength Rogaine roared, “Gentlemen, Start Your Follicles!” What made this ad so ingenious is that nothing is stated overtly. No actual promise is made, but the implication is clear: Extra-strength Rogaine will jump-start your hair growth like high-octane fuel runs a racecar. That’s a powerful message, but for the vast majority of men, it’s also a false message, as you will soon learn in Chapter 5.
At this time, only Rogaine and Propecia have FDA approval for safety and efficacy to combat hair loss. More important, no other pharmaceutical treatment is backed by any legitimate scientifically approved testing to effectively reverse, stop, or even slow the balding process. It may be disheartening to hear this, but it is the truth.
With that said, currently, there is no product, pill, lotion, potion, or vitamin supplement—including Rogaine and Propecia—that can permanently reverse and cure male pattern baldness. Any pharmaceutical product claiming that it can is lying—no ifs, ands, or buts. Maybe someday there will be a drug that cures baldness, but at this time, all claims of a “cure” are false.

Snake Oils
As with most things in life, simple solutions rarely apply to complex situations. Most so-called pharmaceutical remedies—referred to as “snake oils”—are based on the assumption that male pattern baldness is caused by a biological deficiency or imbalance. This imbalance may seem plausible to the layperson, but, in actuality, has no sound basis in medical fact. These snake-oil products or treatments raise consumer hope by claiming to reverse hair loss by correcting the imbalance. This, however, is impossible. (Chapter 3 explains the actual cause of male pattern baldness.)
Before there were surgical clinics, salons typically sold snake-oil products or treatments that were designed to combat baldness. Thriving infomercials continue to present erroneous causes of hair loss to keep a number of ineffectual treatments alive, including the following:
• Avoiding hats or any objects that cover the head tightly.
• Standing on one’s head periodically to increase blood flow to that area.
• Brushing the hair one hundred strokes daily for stimulation of the hair follicles.
• Washing with “special, scientifically formulated” shampoos and/or solutions—the exact ingredients of which are suspiciously kept secret.
• Using “special” topical creams or lotions to eliminate harmful bacteria from the scalp.
• Using electrical treatments to liquefy dead skin, dirt, and oil to dislodge them from the hair shaft.
• Taking daily vitamins and supplements.
• Using massage, heat lamps, and hot towels to dilate blood vessels in the head, which increases blood flow to the scalp.

As you can see, some of these “treatments” will cost the consumer nothing, while others can be very expensive. Most often, however, a combination of these snake-oil remedies is recommended. This usually means a trip to the hair salon for further unnecessary but costly treatments.

Why Is this happening?
It is difficult to say with complete confidence why such bad business practices have invaded the field of hair replacement. It appears that a combination of greed and declining standards have conspired to help the invasion. Our nation’s cultural shift from the 1970s to the 1980s also may have played a part. The 1970s was a decade of great change and social upheaval in America. It was a time of economic recession, the Vietnam War, the Watergate scandal, and such controversial court cases as Roe versus Wade. In stark contrast to the seventies, the eighties were a time of relative peace for Americans. The economy boomed. People felt rich and comfortable again.

Money to Spend, Money to Make
The seventies were over and there was money to be made. Expendable income became a new phrase in the American vocabulary. Luxury was in. The times had definitely changed for hair replacement. For cosmetic surgeons, it was the beginning of the financial golden age. While the intellectual elite was critical, saying that our obsession with appearance was damaging our culture, cosmetic surgery gained acceptance in ways never before imaginable. Once relegated to housewives trying to eliminate signs of aging, cosmetic surgery has expanded to include anyone and everyone, even men. But it wasn’t only the cosmetic surgeons who benefited. After its announcement for Rogaine in 1988, Upjohn saw its stock triple. Also, the growth in technology for cosmetic hair additions was driven largely by an increased concern for natural appearance, which directly coincided with the overall acceptance of cosmetic surgery.
Estimates vary, but the total earnings of the field—including those from surgical hair rearrangement, cosmetic additions, and pharmaceutical treatments—have grown to more than a billion dollars per year. The lure of money is a formidable adversary, which certainly explains why unethical hair-addition providers and other salespeople affiliated with the field have no incentive to change their bad business practices. Unfortunately, money is partially the incentive for many doctors as well.

Doctors and Voluntary Compliance
Why do some doctors choose an unethical path? Perhaps it is because they have little incentive to change. In addition to the money they can make, the system of medicine is set up in such a way that it almost discourages doctors from changing. The concept of voluntary compliance means that it is the individual doctor alone who decides which new ideas he will or will not incorporate into his own private practice. This depends on a doctor’s willingness to accept change and discard outmoded procedures. Accepting the scientific observations about male pattern baldness or a new surgical technique can be difficult even when supported by scientific evidence, because the evidence may be filtered through an emotional interaction between the patient and the doctor. Therefore, a doctor may prescribe inappropriate procedures because of his personal fear of aging, his own issues with baldness, or to maintain his position in the field of surgical hair rearrangement.
If, for example, a doctor develops a new surgical procedure, which, at the time, seems revolutionary, and becomes the world’s leading authority in this technique, he may acquire academic prestige and wealth as a result. He will undoubtedly develop an emotional attachment to “his procedure.” After years of building a reputation and an office empire, suddenly, long-term study and observation of his procedure reveals unsuspected complications. What seemed brilliant at one time is now exposed by objective scientific observation as not just mediocre but even damaging to the patient. The doctor faces a moral dilemma. Does he sacrifice his status and income in light of this new information? Who would want to start over at age fifty, learning new techniques, training new staff, and downsizing expenses and lifestyle?
More important, a surgeon in this position typically reacts from an emotional perspective and will not want to accept the death of a procedure that had once been so promising. Bruce Jafek, MD, a former department chair of Head and Neck Surgery at the University of Colorado said it like this, “In medicine, and surgery, you are always permitted to find new and interesting applications for an existing surgical procedure. You are never permitted to find fewer indications for an existing surgical procedure.” And so, the hair-replacement field is flooded with many bad business habits and practices.

Declining Standards
It seems pretty straightforward to say that our culture has relaxed its standards. Morals, values, whatever you want to call them, have definitely changed. When the first ads for lawyers appeared on television, there was a large and loud debate throughout the medical industry. Although the consensus was that advertising was not acceptable for doctors, sure enough, some doctors started to advertise. Today, medical advertising is accepted as the norm. Many medical school graduates are not even aware that physicians were once prohibited from advertising. And so standards change.
Ultimately, however, it makes no difference why bad business practices have overtaken the field of hair replacement. It is only important to recognize that it has happened, and that you have to plan accordingly to avoid them.

The Light at the End of the Tunnel
Is there a light at the end of the tunnel? The answer is a resounding yes. There are plenty of ethical doctors out there who do excellent work, enough so that every person reading this book will find one. Consider the motto of Robert Limmer, MD, a San Antonio dermatologist and hair-replacement surgeon: “The goal is what is best for the patient, not for the surgeon. Our role is to educate the patient on his options in a manner that reflects the highest levels of integrity as we all pledged to do when we became physicians.” These words perfectly describe what to look for in anyone providing information about hair-replacement options, whether a doctor, salesman, or hair professional.
So, can you find a light at the end of the tunnel? Can you find an ethical doctor or hair-addition provider with the aid of this book? It is not only possible, but guaranteed. Through heightened awareness, you can avoid bad business practices and learn to view advertisements with a healthy dose of skepticism. Caution should always be your watchword, but never more so than when dealing with big business and its single-minded focus on the bottom line, which is rarely in your best medical interest.

CONCLUSION
We have outlined how the field of hair replacement has changed, but haven’t discussed why this change has taken hold. In Chapter 2, “The Psychology of Baldness,” we will discuss how negative business practices dovetail perfectly with personal fears and anxiety about hair loss. “Psychology?” you ask. Yes. And once you understand the origin of your fears, you will be less vulnerable, less likely to succumb to any emotionally manipulative practices used by unethical doctors or salesmen.

Chapter 2

Excerpt(s) from THE HAIR REPLACEMENT REVOLUTION by James Harris, MD, and Emanuel Marritt, MD, Square One Publishers (c) 2003. Used by permission.

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