FULL TEXT RESTORE HAIR THICKNESS AND HAIRLINE 

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​CONTENT
​
I.     Hair Growth, Hair Loss, and Hair Loss Treatment 101
​       Hair Growth Stages and Hair Loss
       Types of Hair Loss
​       Hair Loss Treatment Options
​       Men and Women Hair Loss Differences 
​
​       II.    Oral Supplements and Drugs 
       III.   Topical Products
       IV.    Low Level Laser Therapy (LLLT) and LED Lamps 
       V.     Regenerative Medicine - PRP/PRFM Injections 
       VI.   Regenerative Medicine - SVF Injections
       VII.  Regenerative Medicine - nano-fat/ALMI
       VIII. Regenerative Medicine - Options Comparison 
       IX.   Microneedling or (possibly - at home) Dermaroller 
       X.    Microneedling with PRP or Growth Factors 
       XI.   Hair Transplant
       XII.  Hair Loss Prevention 
​       
​REFERENCES AND LITERATURE 

Hair Growth, Hair Loss and Hair Loss Treatment 101

Hair growth stages and hair loss
Mostly men, but women too, experience hair loss for a number of reasons - genes and aging, hormones, stress, environmental factors, alcohol consumption, auto-immune disorders, diet, and deficiency in vital nutrients necessary for the metabolism and hair growth.

There are three stages of hair growth: anagen, catagen, and telogen. 

​From the viewpoint of these three phases, hair thinning and loss of visible hair occurs when the anagen stage becomes shorter and/or less hair is in the anagen phase, and the hair follicles spend more time in a dormant phase, telogen.
​As the process progresses, the hair follicles miniaturize, hair becomes thinner, until the hair follicles die out.  ​
Hair Growth Phases: anagen, catagen, telogen
HAIR GROWTH STAGES
types of hair loss
Androgenetic Alopecia (AGA).
​In men, up to 95% of hair loss is caused by androgenetic (androgenic) alopecia. It results in what is typically known as the male pattern hair loss. Androgenetic alopecia affects women too, but typically results in the female pattern hair loss. It is estimated that in the USA alone, 50 million men and 30 million women are affected by the androgenetic alopecia. The direct cause of the androgenic alopecia is hormonal and some people are genetically predisposed to it. In androgenic alopecia, a by-product of the testosterone metabolism, dihydrotestosterone, leads to shrinking of the hair follicle. 

Telogen Effluvium (TE)
Telogen Effluvium (Malkud, 2015) is expressed as a diffuse hair thinning and is listed as the second most common reason for the hair loss treated by dermatologists. In reality this diffuse hair thinning is an external expression of various health issues and conditions. It can be caused by and accompany:
  • Postpartum effluvium (postpartum hair loss); 
  • Disease: typhoid, malaria, tuberculosis, HIV; 
  • Stress: emotional, from injury and surgery, crash diet, starvation, haemorrhage, difficult labor, severe febrile illness; 
  • Drugs: oral retinoids, oral contraceptives, antithyroid drugs, anticonvulsants, amphetamines, Captorpil, hypolipidemic drugs, beta blockers; 
  • Heavy metals in the body; 
  • Nutrient deficiency from improper diet;
  • Endocrine reasons: hypothyroidism, hyperthyroidism. 
You may be able able to trace the root cause reason of such hair loss by knowing that the dramatic hair loss from the TE occurs two - three months after the triggering event. 
Dermatologists consider TE fully reversible; this is the type of hair loss that can be treated with less invasive and dramatic measure and/or by addressing the root cause. 

Alopecia Areata. The other well known, but less common type of hair loss alopecia areata. This type of hair loss is an auto-immune disease where the body's immune system is attacking hair follicles. The hair loss happens in irregular patches of varying size.

Frontal Fibrosing Alopecia. 
Frontal Fibrosing Alopecia (FFA) is more rare than the other types of hair loss. It looks like a receding hairline, sometimes with bolding on the sides, and is frequently accompanied by minor scarring where the hair is being lost.
Sometimes FFA exhibits together with the androgenetic alopecia. FFA typically affects women over the age of 50. It is not common in men and younger women. The precise cause of FFA is unknown. 
Current studies show that 5-alpha-reductase inhibitors (for example, the oral drug Finasteride, see under Oral Supplements and Drugs), are currently the most effective treatment for FFA  (Vañó-Galván, 2014; Fertig, 2016). 

Modern Aesthetic Medicine offers a number of treatment options ranging anywhere on the spectrums of inexpensive and a heavy price tag, simple and invasive, possibly effective for some and those with proven results. Reasons for hair loss differ, and therefore it is not always possible to say which solution will prove effective.
It may be a good idea to start with supplements and/or topical products, and/or try addressing the root cause (for example, in case with TE), and if the results are not satisfactory, then move to more drastic treatments. 

As a general rule, the more advanced the hair loss stage is, the more radical treatment may be required. For non-invasive or minimally invasive treatments to work, there should still be hair follicles inside the scalp even though there may be no visible hair on the surface. Once the hair follicles completely die and disappear, the only way to bring the hair back to the area is a hair transplant. ​
Hair Loss treatment options
To reinstate what was covered above, hair loss may be caused by different reasons.
At a high level, there is –
  • A large number of conditions and events that result in hair loss and that are typically grouped under Telogen Effluvium (see the above section on the Types of Hair Loss). It is reversible and treatable, especially if the root cause is addressed;
  • Alopecia (hair loss) caused by genes, aging, metabolism, and/or hormones and also by unknown reasons - androgenetic alopecia, alopecia areata, frontal fibrosing alopecia. And in this case with deep biological reasons, the true hair loss treatment would mean treating the underlying causes, which are aging, hormones, metabolism, and possibly other related factors, which are not yet fully understood by science, and reversing those underlying reasons. Modern Western medicine does not have such capabilities. It is therefore more appropriate to speak of the hair loss management. Even speaking about the most effective and invasive 'treatment', hair transplantation, it does not stop the progression of the hair loss, and for this reason, many doctors would recommend a maintenance regiment such as periodic PRP injections, or an LLLT/LED, or continued use of minoxidil etc.

The hair loss treatment and management options available today include:
  • Separately purchased vitamins, minerals, nutrients, 
  • Multi-ingredient oral supplements,
  • Finasteride (oral drug),
  • Peppermint oil and lavender oil (topical application),
  • Minoxidil 2% to 10% (topical solution),
  • Multiple treatments with LLLT/LED (Low Level Laser Therapy/Light Emitting Diodes) devices,
  • Regenerative medicine: PRP/PRFM injections (platelet rich plasma/platelet rich fibrin matrix derived from patient's own blood),
  • Regenerative medicine: SVF injections (stromal vascular fraction derived from patients own fat tissue, alone or combined with fat),
  • nanofat injections or ALMI (autologous lipocyte micronized injections - patient's own micronized fat), 
  • microneedling or (possibly - at home) derma roller,
  • combination micro needling + PRP or micro needling + growth factors,  
  • hair transplantation,
  • possible: Chinese acupuncture.
men and women hair loss differences
Hair loss in men –   
Hair loss in women –
Picture
Female and Male Patterns of Hair Loss Typical for Androgenetic Alopecia, the most common type of hair loss

Oral Supplements and Drugs

Hair nutrient basics
In some cases, the hair loss reasons may be as basic as the lack of vital nutrients, particularly vitamins and minerals necessary for the hair growth. Among the critical ones for the hair growth are - 
  • Biotin, or Vitamin B7. Participates in important metabolic pathways for energy production; daily intake - 30 to 100 mcg for adults. Important for hair, skin, and nails;
  • Marine Omega-3, EPA and DHA. Their deficiency may be implicated in decreased hair growth. 1,250 - 2,500 mg combined EPA + DHA a day, preferably in a triglyceride form, from a manufacturer who tested the product for heavy metals and other toxins;
  • Zinc. Benefits hair follicle health and participates in collagen synthesis. 15 - 30 mg a day;
  • Vitamin C. It minimizes formation of dihydrotestosterone (DHT), a hormonal by-product of our metabolism that leads to hair loss. Vitamin C is also important for building collagen, and hence, hair growth; finally, it participates in the absorption of iron, which contributes to hair strength. 500 - 3,000 mg a day, preferably combined with rutin and bioflavonoids that are 'companions' of ascorbic acid (or its alternatives) in nature and support effectiveness of Vitamin C;
  • Iron. It carries oxygen to the roots of the hair. Recommended daily intake is 14 - 18 mg a day. 
  • ​Supplementing with collagen may also help hair growth.
All of those nutrients can be purchased and taken separately. Provided daily nutrient intake includes both food sources and supplements. For example, someone, whose diet includes 3 - 4 portions a week of wild-caught salmon, does not need supplementation with Omega-3. ​
Multi-ingredient hair growth supplements
There are three multi-ingredient supplements with clinical studies behind them that show an improvement in hair thickness and hair regrowth. Two of them are Nutrafol and Viviscal available on the US market. The third one is a Chinese herbal supplement BeauTop.

​​​Both Nutrafol and Viviscal contain marine collagen, biotin, and some amino acids. Apart from that, Nutrafol includes a range of vital nutrients, while Viviscal seems to be exerting its benefits primarily through their AminoMar Marine Complex. Overall, these two supplements target the deficiency in vital nutrients described in the Hair Nutrients Basics section above and also add additional natural compounds intended to promote hair growth.
There are no studies that compare effectiveness of Nutrafol to that of Viviscal.

BeauTop's ingredients are very different, so potentially it can be taken together with Nutrafol or Viviscal for better results.

With both Nutrafol and Viviscal, it takes three to six months to start seeing results.
Viviscal - 75% of women reported a decrease in the hair loss and some improvement in hair volume and thickness.
Nutrafol - 81% of women saw an improvement in hair growth and hair thickness. 
The type of hair loss that those women were experiencing was not specified. 

Given that majority of the male hair loss is caused by androgenic alopecia (that is the effects of a testosterone metabolite DHT on the hair follicle), on average these two supplements are likely to be more effective for women than for men. However, web-sites of both manufacturers feature men success stories with before and after treatment pictures.

​The third supplement, BeauTop (Sun Ten Laboratories), is different from the above two in the type of ingredients and mechanisms of action. BeauTop is considered a Chinese herbal remedy and has six ingredients:  Ginseng Radix, Astragali Radix, Angelicae Sinensis Radix, Ligustri Fructus, Rehmannia glutinosa and Eclipta prostrata Linn.
In a rodent study, BeauTop was found to be effective in "enhancing growth factors that regulate hair follicle life cycles, and promoting hair follicle activity" (Lee C-Y, 2018).

Its effectiveness for the treatment of androgenetic alopecia in humans was evaluated on 32 participants during a 6-months trial, twice-a-day supplementation, with the following results  (Lee C-Y, 2017) - 
- there was no improvement in 47.1 %,
- 52.9% of participants had an improvement: minimally improved - 5.9% patients; moderately improved - 29.4% patients; and significantly improved - 17.6% patients.

The studies on BeauTop can be found in the National Center for Biotechnology Information (USA), however, search engines bring no results in English on where the supplement can be purchased. 
supplement summary
​Oral Supplements - 
Advantages - relatively inexpensive ($50 - $80 a month); non-invasive; the nutrients in the supplements are beneficial for the health overall, not just for the scalp hair; no side effects; may be a good option to start with while searching for a more drastic hair loss solution and then switch to more drastic measures if the supplements do not work. 
Drawbacks - uncertain whether the treatment will be effective and to what extent; unlikely to produce satisfactory results in cases with a major hair loss especially if the causes are genetic, hormonal, or auto-immune.
FINASTERIDE - oral drug
Finasteride, sold in the USA under the brand name Propecia, works by decreasing production of DHT (dihydrotestosterone). DHT is a by-product of testosterone metabolism and leads to minituarization of hair follicles and hair loss. 
Finasteride has been approved by FDA since 1997 for the treatment of scalp hair loss caused by androgentic alopecia in men. 
Finasteride is relatively dose dependent. Studies were done on 0.01 mg, 0.2 mg, 1 mg, and 5 mg - 
  • 0.01 mg is ineffective;
  • 1 mg and 5 mg are significantly more effective than 0.2 mg;
  • there is no major difference between 1mg and 5 mg (Roberts JL, 1999).
​
Finasteride affects the entire body, not just the hair, and given the side effects from Finasteride, it is safer to use the lowest effective dose. That is why the typically prescribed dose for the androgenetic alopecia is 1 mg.

Effectiveness for the androgenetic alopecia - 
  • 66% of men with androgenetic alopecia (male pattern hair loss) treated with 1 mg/d of Finasteride for two years experienced an average of 16% improvement in hair growth;
  • 17% more did not experience an improvement, but did not have any additional hair loss;
  • for the 17 remaining % treatment with finasteride was not effective (Shapiro, 2003).
​
Effectiveness for the frontal fibrosing alopecia - in the largest study of FFA treatment, over 100 patients were treated,- The study also showed that 5-alpha-reductase inhibitors, which Finasteride is, are currently the most effective treatment for FFA. 

Finasteride side effects are very rare, but may include impotence, loss of interest in sex, trouble having an orgasm; abnormal ejaculation; swelling in hands or feet; swelling or tenderness in breasts; dizziness, weakness; headache.

Advantages - over 60% likelihood of some effectiveness for androgenic alopecia, 47% effectiveness for frontal fibrosin alopecia; non-invasive, relatively inexpensive ($50 - $100 a month). 
Drawbacks - a minor risk of side-effects; unlikely to produce dramatic hair regrowth.

Topical Products

minoxidil
Androgenetic Alopecia (AA), also known as the male pattern hair loss, appears to be the reason behind the hair loss in 95% of male hair loss cases and some 40 - 50% of hair loss in women. AA is caused by the impact of a testosterone by-product dihydrotestosterone (DHT) on hair follicles. It appears that DHT attaches to androgen receptors on hair follicles on the head leading to the miniaturization of follicles and shortening of the anagen, the hair growth phase. Treatments that block DHT may prevent or reverse hair loss caused by androgenetic alopecia (See also Finasteride).

Minoxidil is a a pyrimidine derivative (2,4-diamino- 6-piperidino-pyrimidine-3-oxide); it is an adenosine triphosphate (ATP)-sensitive potassium channel (KATP channel) opener. Minoxidil's mechanisms of action for the hair regrowth have not been precisely established; it is thought though to be a DHT blocker.
​Minoxidil has only been approved by FDA and demonstrated its effectiveness in peer-reviewed studies for the androgenetic alopecia (Badri, 2018). However, it may be somewhat effective for other types of hair loss too; off-label Minoxidil is also used for treatment of Alopecia Areata, alopecia induced by chemotherapy, before and after hair transplant to minimize hair loss, scarring alopecia, hereditary alopecia. 

Minoxidil is also sold under a brand name Rogaine. 

Minoxidil is applied topically on the scalp twice daily; the first results are visible after 8 weeks of treatment; the maximal results are reached after six to 12 months of treatment.
​
Minoxidil appears to be effective in hair regrowth in 40 to 50% of the cases of androgenetic alopecia.
  • One small scale study showed that 7 out of 16 participants (43%) with androgenetic alopecia experienced a moderate improvement in hair regrowth after 4 months of twice-a-day application of 5% Minoxidil foam (Hournaz H, 2016). An improvement and patient satisfaction was higher in those who continued to use the product for 6 months. 
  • The more advanced the hair loss, the stronger minoxidil concentration is required. The typical concentration recommended for women is 2% up to 5%; for men 5% and in some cases - 10%. 
  • The studies were only done with 1%, 2%, and 5% minoxidil concentrations.
  • In one study of 393 patients with androgenetic alopecia used either 2% or 5% Minoxidil for 48 weeks (Olsen EA, 2002). 5% Minoxidil was found to result in 45% more hair regrowth than 2% Minoxidil. 
  • There are no studies, only anecdotal evidence for the use of 10% Minoxidil. Given that Minoxidil has been shown to be dose dependent, it is possible that 10% may be more effective than 5% and it may be effective where the 5% solution did not produce the desired or significant results. The 10% minoxidil is not endorsed by FDA since it was not clinically tested.  ​

Advantages - relatively inexpensive; non-invasive; severe allergic reactions are rare.
Drawbacks  - many users of Minoxidil experience scalp itching; it requires a prolonged effort and discipline of twice-a-day application and that is the primary reason why many people cease the treatment (Mapar MA, 2007); unlikely to produce a dramatic cosmetically acceptable hair regrowth (Gupta, 2015). 
peppermint oil and lavender oil
Only rodent studies were conducted to evaluate effectiveness of Peppermint Oil and Lavender Oil for the hairloss treatment; both studies were done on female mice. 
The studies showed that these two oils were at least as effective as minoxidil in promoting hair regrowth - 
  • Peppermint oil (applied once a day, six days a week, for four weeks). At week 4, Peppermint Oil treated mice showed hair growth about 92%, whereas the 3% minoxidil group - about 55% (Young, 2014); 
  • Lavender oil (LO), 3% and 5%, (applied once a day, five days a week, for four weeks). At week 4, 3% LO group and 5% LO group showed 90% and 95% hair growth respectively, while 3% minoxidil produced 99.8% hair growth. All three treatments resulted in significantly increased number of hair follicles, deepened hair follicle depth, and thickened the dermal layer (Lee, 2016).

Assuming that the above oils are also effective for humans, it is not clear what type of hair loss they may help addressing. ​

Advantages - easy to use, inexpensive, no side effects, natural.
Drawbacks - the inconvenience of having one's head consistently covered with oil, requires a consistent diligence in application; the efficacy is unclear.
0.2% caffeine solution
A recent study (Dhurat R, 2018) compared effectiveness of 0.2% caffeine solution to that of 5% Minoxidil in treating androgenetic alopecia in males.
The caffeine liquid used was Alpecin Liquid by Dr. Kurt Wolff. 
​Over 200 men participated in the study.
The caffeine solution was applied twice a day for 6 months. 

The study established that the caffeine solution is almost as effective, with less side effects, as Minoxidil 5%.
The use of both products twice a day for 6 months resulted in approximately 10% more of hair in anagen phase, the active phase of hair follicle growth (a 20% improvement compared to the baseline). ​​

LLLT (Laser) and LED Lamps

LLLT - low level laser therapy
LLLT stands for Low Level Laser Therapy. 
Laser is a focused coherent light, the depth of penetration of which depends on the wavelength. Most studies investigating effects of LLLT on the hair growth have used wavelengths that range from 635 to 650 nm (Avci, 2014).

Arndt-Shultz law states that every substance with pharmaceutical, healing, or poisonous properties heals in small quantities, inhibits in moderate quantities, and kills in large quantities. Applied to the laser effect on hair, it means that large quantities of laser (high level) treatment leads to hair removal, while low level laser treatment leads to hair stimulation.

An LLLT treatment lasts between 20 and 60 minutes and consists of placing one's head under a laser emitting device. It can be done in a doctor's office or under a take-home helmet. Another option offered on the market is a laser hair-brush. The treatments are not painful.
Typically, a device needs to be used every other day for fix months to see the full results. The duration of use per session should not exceed that stated by the device manufacturer so that the laser dose is kept in the low, healing, range. 

A meta-analysis of 11 studies (Afifi, 2016) that included a total of 680 patients, consisting of 444 males and 236 females showed that after an LLLT treatment in cases with androgenetic alopecia:
  • in nine out of 11 studies, assessing hair count/hair density there were statistically significant improvements in both males and females;
  • in two out of four studies that also assessed hair thickness and strength, there was a significant improvement;
  • overall patient satisfaction was positive.

​For a sample treatment regiment see the following section on the combined LLLT and LED therapy.
​
Another review of the medical literature shows that the FDA-cleared LLLT devices are both safe and effective in patients with Male Pattern Hair Loss and Female Pattern Hair Loss who did not respond to or were not tolerant to standard treatments (Zarei, 2016). Though the optimum wavelength, coherence and dosimetric parameters remain to be determined (Avci, 2014).

There is also some evidence that LLLT may darken gray hair by increasing melanin production in the hair follicles. 

At the beginning of the treatment there may be some hair shedding. Noticeable changes begin after 2 months of consistent use; it takes up to 6 months to see the final results. 

​Advantages - non-invasive, safe - no side effects, likely to have results, less expensive than more invasive methods.
Drawbacks - requires discipline, and long-term use, not likely to have dramatic results; likely to require a one-time investment to purchase the device for at-home use.
LED and Combination lllt and led
LED therapy, just like laser, makes use of emitting light of a certain wavelength. However, LED light is more dispersed, less focused than the light from LLLT. And so it is softer, less damaging to the tissue, and for that very reason it is also generally not as effective as LLLT. 
LED has been used for a long time for the muscle injury treatment and it is well studied in this application. 
Its use in promoting hair growth is recent and only minimally studied. 

As of the time of this publication, there has been one study demonstrating effectiveness of the LED alone (without LLLT) on the proliferation of the human derma papilla cells and on the hair follicle growth. It was an in-vitro study (cultured cells in a tube, not on people). The study showed that the LED with the 660 nm wavelength was indeed effective and resulted in cell growth (Joo, 2017).
​There are no human studies on the LED alone effectiveness. 

​There are also studies demonstrating effectiveness of a combination LLLT-LED therapy for the the hair regrowth in androgenetic alopecia. 
This particular study used a combination LED red light and Low Level Laser (655 nm wavelength) to treat persons with androgenetic alopecia, used for 16 weeks, every other day (60 treatments total), for 25 minutes.
The device used was a bicycle-helmet like "TOPHAT655". 
  • In men, after the 16-week treatment course, the average increase in the hair count of the group actively treated with the device was 35% (Lanzafame, 2013);
  • In women, after the 16-week treatment course, the average increase in the hair count was 37% (Lanzafame, 2014).

It is, however, unclear whether any portion of that effect stems from the LED dispersed light in addition to the effects already achieved with the LLLT alone. 

Regenerative Medicine:  PRP - Platelet Rich Plasma 

PRP/prfm at a high level
Platelet-Rich Plasma (PRP) and Platelet-Rich Fibrin Matrix (PRFM) are both made mostly of patient's own blood.
Read here about what PRP and growth factors are.
PRP is currently used in the regenerative and sports medicine for wound and injury healing and tissue regeneration; in the face and skin rejuvenation; and it has been studied in the treatment of the hair loss (Maria-Angeliki, 2015), mostly for the androgenetic alopecia, and to a lesser extent - for the alopecia areata.
PRP and PRFM are very similar, but differ in the type of compounds added to the drawn blood to activate the growth factors. Likely, PRFM provides a longer sustained release of growth factors after its injection in the scalp and may be more effective in the treatment of hair loss. 

PRP treatments are relatively non-invasive and regarded as safe.
- The patient's own blood is drawn from the vein;
- Then a vial with the blood is spun in a centrifuge to separate red blood cells, white blood cells, and platelet poor plasma from the PRP - platelet-rich-plasma. The former are all discarded, and
- The remaining golden-color PRP liquid is activated with thrombin and calcium and is injected with a syringe in multiple spots in the treated area. The regenerative potential of PRP/PRFM depends on the degree of the growth factors release (Wiebrich, 2002; Eppley, 2004)
​
Concentration of the platelets in PRP is 3-7 times higher than in the whole blood. 10 ml of blood produce between 1.5 and 4 ml of PRP.

The better quality the blood, the more effective the treatment will be. For this reason it is recommended to eat a healthy diet prior to the treatment. ​

The cost is $500 - $1,200 per treatment, and a series of 3-4 treatments is recommended to achieve a significant result.
PRP effectiveness in hair loss treatment
PRP is thought to work by activating dormant hair follicles that are in the resting, telogen stage. 

All studies of the the PRP/PRFM treatments for the hair loss with a minimum of three sessions demonstrate its effectiveness and improvements that commence at 2-3 months after the treatment and continue improving even more up to 6 months after the treatment.
  • “ A significant reduction in hair loss was observed between first and fourth injection. Hair count increased from average number of 71 hair follicular units to 93 hair follicular units. Therefore, average mean gain is 22.09 follicular units per cm2. After the fourth session, the pull test was negative in 9 patients" (Khatu, 2014)
  • A review of 10 studies that used the minimum of 3 PRP sessions for the treatment of androgenetic alopecia showed positive “ therapeutic potential of PRP for the treatment of AGA. Among them, 6 studies demonstrated a statistically significant improvement following treatment with PRP using objective measures and 4 additional studies showed hair improvement (e.g., hair density, diameter) with PRP” (Cervantes, 2018)
  • Two more studies (one PRP treatment for women with AGA; two PRP treatments for men with AGA) showed no significant improvement (Cervantes, 2018).

​PRP/PRFM is a biological material, and its quality depends on the blood quality. Further, preparation of activated PRP/PRFM is not standardized across the medical aesthetics industry, for example the number of centrifugations, the compounds activating growth factors, concentration of the platelets in the injected product.
Therefore, the difference in the outcomes can be most likely attributed to the above factors, particularly to the differences in the PRP/PRFM preparation (Wiebrich, 2002; Eppley, 2004). 
Hypothetically, PRFM (platelet rich fibrin matrix) should be more effective than PRP. Also, to increase likelihood of effectiveness, consider consuming a healthy diet before the blood for the procedure is drawn. 

Just like any other non-surgical procedure, PRP/PRFM is only going to work in the places where hair follicles are still alive (even though there may be no visible hair on the skin surface). 
how the procedure is performed
  • Numbing/local anesthetic is typically applied to the treated area, because the injections are somewhat painful;
  • The patient's own blood is drawn from a vein into vials;
  • The vials with the drawn blood are spun in a centrifuge to separate red blood cells, white blood cells, and platelet poor plasma from the PRP - platelet-rich-plasma. Some PRP preparation techniques include two rounds of centrifugation;
  • PRP is left, everything else is discarded;  
  • The remaining golden-color PRP liquid is activated with, for example, thrombin or calcium chloride;all the above steps take 10 to 20 minutes; 
  • Numbing/local anesthetic is typically applied, because the injections are somewhat painful;
  • PRP/PRFM is injected with a syringe in multiple spots in the treated area.

Some results are typically visible even after one treatment (2 to 6 months after). However, a series of 3 - 4 treatments is typically recommended. 
Picture
Hair loss treatment with PRP injections
PRP for HAIRLOSS summary
  • Likely to be effective for different types of hair loss;
  • The cost is $500 - $1,200 per treatment, a series of 3 – 4 sessions is recommended bringing the total cost to $1,500 - $ 4,800 for the treatment course. The cost is the main drawback of the procedure;
  • All natural, no downtime (except for minor red spots), minimal discomfort when numbing is used;
  • Unlikely to work if hair has been completely gone in the treated area for years;
  • Often recommended as an annual or bi-annual maintenance after hair transplant to counteractive progressive hair loss;
  • Can be combined with microneedling. 

Regenerative Medicine: SVF - Stromal Vascular Fraction

SVF at a high level
SVF stands for Stromal Vascular Fraction and it is one of the newest frontiers of the regenerative medicine. It is essentially a stem cell therapy and it can be used in treating many degenerative health conditions including hair loss. 

Adipose tissue (fat) in our bodies contains up to 2,500 times more multi-potent adult stem cells than our bone marrow. SVF is an extract from the adipose tissue that contains those stem cells. Stem cells look for damaged tissue to repair it naturally. In case with the hair loss, stem cells from SVF rebuild and strengthen hair follicles.

In very simple terms, hair loss treatment with SVF consists of harvesting some of the patient's own fat with a syringe, processing it, and then injecting it in the scalp in multiple spots.

The reliable providers of SVF procedures in the USA can be found within Cell Surgical Network. 
SVF effectiveness in hair loss
​Clinical study results vary, but all show effectiveness in the hairless treatment - 
  • hair loss 3rd degree, one treatment with fat enriched with SVF, at 24 week (6 months) follow up an average of 23% increase in hair count (Perez Meza, 2017) vs. 14% average increase in patients treated with the injections of unprocessed fat;
  • hair loss due to alopecia areata, one treatment with SVF, at 6 months follow up an average of 40% increase in hair count and 30% increase in hair diameter (Rami, 2018).

By account of some MDs, they found PRP to be more effective in hair re-growth than SVF.
How the procedure is performed
Only a small volume of fat is required for the procedure and so it can be obtained even from a very slim person.

  • The fat is collected (aspirated) with a syringe. This mini-liposuction is done under local anesthesia and takes up to 20 minutes;
  • The harvested fat is processed in a sterile closed system to separate adult fat cells from the combination of stem cells and other helpful cells in fat. The processing includes incubation, centrifugation to concentrate and purify the stem cells, cleansing, and activation. The SFV is ready to be used in about 90 minutes;
  • A doctor injects SVF or SVF combined with unprocessed fat at a site that needs healing - in this case, in the patient's scalp. Scalp injections are painful, and so at least some kind of numbing or anesthesia is used.

That entire process takes up to 120 minutes.
what SVF is in detail
Stromal vascular fraction contains:
  • adipose Derived Stem/Stromal Cells (ADSCs). They are similar to the Mesenchymal Stem cells derived from the bone marrow in that they are multi-potent and can grow to become many different types of cells;
  • endothelial precursor cells (EPCs),
  • endothelial cells (ECs),
  • macrophages,
  • smooth muscle cells,
  • lymphocytes,
  • pericytes, and
  • pre-adipocytes – ‘baby’ fat cells that unlike adult fat cells mostly survive the fat transfer and will grow to become adult fat cells after they are transferred to the recipient site;
  • growth factors.
(Bora, 2017) ​

SVF is also used to treat arthritis, spine disease, knee, hip joint or shoulder pain, lupus, multiple sclerosis, muscular dystrophy, ALS, Parkinson’s disease and stroke recovery, autoimmune disorders.

Regenerative Medicine: nano-fat/ALMI

nano-fat at a high level and how the procedure is performed 
ALMI stands for Autologous Lipocyte Micronized Injections and is a branded variation of micronized fat injections (also known as nano-fat). 
To obtain micronized fat, the patient's own fat is harvested with a syringe; the procedure is performed under local anesthesia; the fat is micronized, sometimes PRP is added. The major difference with SVF is that the entire fat extract is used, not a concentrate of stem cells. 
The obtained all natural material is then injected in the recipient area that the patient wants to rejuvenate, in this case - the head. 
nano-fat effectiveness at hair loss
One study has been conducted with the results published at NCBI. 12 patients with androgenetic alopecia received a single injection of nano-fat (micronized fat). All 12 patients showed an improvement in the hair thickness 3 months following the procedure. The satisfaction satisfaction and hair thickness continued improving 6 months following the procedure (Vestita, 2017).

There is mostly anecdotal evidence (personal accounts) from doctors and patients who are satisfied with the results of nano fat treatment for hair regrowth, however, the effectiveness is not generally quantified. 

The precise effectiveness is unclear, but given the regenerative mechanisms, the effectiveness of SVF should approach that of PRP and SVF, and maybe even more effective if the micronized fat is combined with PRP. ​

PRP/PRFM vs SVF vs ALMI

Option comparison
All three options have been shown to be effective in treating thinning hair. All three use patient's own tissue.
  • PRP exerts its regenerative and healing properties primarily from the growth factors in blood. It is much easier to draw blood from the vein than to do a mini-liposuction even with just a syringe. The studies done on PRP for hair growth included a series of three treatments; on average, they produced an over 30% improvement. 
  • ALMI and SVF exert their regenerative and healing properties primarily from the adipose derived stem cells. If PRP is added to ALMI, it is both stems cells and growth factors. Harvesting fat is more complex and invasive than drawing blood. Formal studies are limited and the results were evaluated after one treatment. Despite limited available studies showing effectiveness of SVF, there is an informal opinion among practitioners of regenerative medicine that PRP is more effective than SVF for the hair loss treatment. On average, the improvement was 23%, however it is difficult to compare with PRP, because the RP studies used 3 - 4 treatments, and SVF studies used one treatment. 
  • The major difference between SVF injections and ALMI/nano-fat is fat processing. In ALMI it is micronized; in SVF it is cleansed of some of the adult fat cells and activated. Theoretically therefore, SVF should be more effective. There are not studies comparing ALMI and SVF. The only study published on SVF effectiveness used pure fat injections as a baseline and it showed 23% improvement with SVF vs 14% improvement with fat only.

Microneedling or Dermaroller

How microneedling and dermaroller work
Micro needles of a micro needling device (Dermapen, Skinpen etc) or a derma roller uniformly wound the skin, creating thousands of microscopic punctures. Those micro wounds trigger body's own, complex and self-guiding, healing mechanisms; they awake stem cells and activate growth factors. In plain terms and as applicable to hair loss treatment, those healing mechanisms use the healthy state of tissue as their target template. 
  • One study compared effects of 12 weekly micro needling (1.5 mm needle length derma-roller) treatment sessions plus 5% Minoxidil to the effects of 12 weeks of continuous use of 5% minoxidil only on patients with mild to moderate androgenetic alopecia. The mean change in hair count was significantly greater for the Microneedling group compared to the 5% Minoxidil group (91.4 vs 22.2 respectively). In the Microneedling group, 82% patients reported more than 50% improvement versus only 4.5% patients in the Minoxidil group. Patients unsatisfied with conventional therapy for AGA got good response with Micro needling treatment. (Dhurat R, 2013)
  • ​Another very small scale study used four weekly sessions and then bi-weekly sessions for five more months (a total of 15 sessions over a 6-months period). The improvement of between 50% and 75% was observed. At the 18 months follow up, the patients maintained the results observed at the time of the last micro-needling session (Dhurat R, 2015). 

Conclusion: Dermaroller along with Minoxidil treated group was statistically superior to Minoxidil treated group in promoting hair growth in men with AGA for all 3 primary efficacy measures of hair growth. Microneedling is a safe and a promising tool in hair stimulation and also is useful to treat hair loss refractory to Minoxidil therapy.

microneedling
dermaroller
Just like microneedling, dermaroller creates multiple punctures, wounds in the skin.

Using a dermaroller at home may be a suitable option for those with a very tight budget who want the effects similar to those of microneedling. However, it is important to understand that if a person is performing a medical procedure on their own, they need to know the aspects otherwise handled by a medical practitioner. 
  • ​To be effective for the hair re-growth (vs. skin rejuvenation, for example), the needles have to be at least 1.5 mm long;
  • Prior to the procedure, the scalp has to be disinfected. In a clinic it can be disinfected with betadine and saline, at home - potentially with medicinal alcohol. Dermaroller has to be disinfected too;
  • The rolling is performed vertically, horizontally, an diagonally until mild erythema (slight bleeding);
  • The entire procedure will take 20 to 30 minutes;
  • A series of 6 - 15 procedures is required to see a noticable improvment;
  • Patients who are already using Finasteride or Minoxidil are typically advised to continue with the treatment;
  • Minoxidil is not applied on the day of the procedure.

Microneedling with PRP or Growth Factors

what growth factors are
A growth factor is a naturally occurring signaling protein. Growth factors bind to specific receptors on the cell surface and are capable of promoting cellular growth, differentiation, and healing. Our blood contains a number of growth factors that when activated in PRP/PRFM are thought to be the primary mechanisms behind the regenerative properties of PRP. The use of PRP/PRFM for the hair loss treatment is covered here.
As we age, our own production of growth factors, including on the skin, slows down. 

Growth factors can also be derived from plants and/or grown in a laboratory Solutions with those bio-identical growth factors can be applied instead of PRP after micro needling.

The molecules of growth factors are too large to penetrate through the upper layers of the skin. That is why they are used in a combination with a procedure that punctures the skin thus allowing the growth factors to penetrate inside. 
how the procedure is performed
The procedure has two parts.
The microneedling or dermaroller procedure alone is described here. 
If growth factors are used, they come in a vial, and are applied topically either immediately before or immediately after the procedures. The solution penetrates inside the skin through the wounds. 
PRP/PRFM (Platelet Rich Plasma/Platelet Rich Fibrin Matrix) can be applied to the treated area either immediately before the micro needling passes or immediately after. The plasma penetrates inside the skin through the wounds. 
Alternatively, PRP/PRFM can be injected with a syringe.
It is possible that PRFM may be more effective than PRP.

effectiveness of microneedling with prp or growth factors
There have been no studies that compared effectiveness of microneedling combined with PRP or microneedling combined with growth to a baseline of micro needling alone or PRP injections alone. 
However, hypothetically this combination treatment should be more effective that either one of the two alone, because it combines the effect of their two regenerative mechanisms.

One study compared effectiveness of six once-a-month micro-needling with PRP treatments with daily 5% Minoxidil use to the effectiveness of 5% Minoxidil alone for the treatment of patients with androgenetic alopecia only (other types of hair loss were excluded).
50 patients total (25 in each of the two groups) were evaluated. They've experienced hair loss for 1 to 5 years and all were Grade III and Grade IV hair loss stage. 
Micro-needling was performed in the manner described under Microneedling and Dermaroller, Dermaroller section. It was followed by PRP injection 0.05 ml per 1 cm square.  
Results.
In the micro-needling with PRP + Minoxidil group:
0% - no improvement; 8% - mild improvement; 68% - moderate improvement' 24% - excellent improvement;
In the Minoxidil only group: 
12% - no improvement; 40% - mild improvement; 44% - moderate improvement; 4% - excellent improvement (Shah KB, 2017).

The cost per procedure may vary anywhere between $800 and $1,500 per session.
This may be a good option for those who see progressive hair thinning, however are not yet suffering from a complete hair loss in the treated area, who want to avoid the more invasive hair transplantation, yet have a generous budget for the treatment. 
The major downside is the cost. The major advantage is that the treatment is minimally invasive and natural.
As an option, derma rolling can be performed at home if the protocol is strictly followed, and growth factors may be applied topically immediately after the procedure. 

Hair Transplant 

Hair transplant basics
Hair Transplantation is considered a surgical procedure and it involves harvesting (removing) hair from the donor site and placing it at the recipient site.

Hair transplantation is the only method to place hair where it has never existed (the aesthetic hairline enhancement) or where the hair follicles are completely gone for years, and hence there is nothing to revive (no other, non-surgical, method is likely work). It is the last resort when other, non- or less invasive, methods did not produce satisfying results. 

Hair Transplantation is an art as much as it is a science, because the patient satisfaction depends on how the new hairline is designed and how the hair is placed at the recipient site.
Two major factors that may differ in a hair transplant procedure and affect satisfaction with the results are - 
1. How hair is removed - the traditional follicular unit transplant (FUT), also called a strip or a linear method vs follicular unit extraction (FUE);
2. How hair is placed - depends on the aesthetic and artistic sense and skills of a doctor.
HOW THE PROCEDURE IS PERFORMED
Hair harvesting/removal can be done two ways -

- The first, older, method is linear or strip or FUT (Follicular Unit Transplantation), where a strip of skin with the hair is removed and that entire strip is then cut into pieces, and the pieces are placed in the recipient site. The linear/FUT method is less expensive, has on average (not always) - lower customer satisfaction, leaves linear scars at the donor site.
​
- The newer method, FUE (follicular unit extraction) means removing from the donor site tiny pieces containing one hair follicle, and then those pieces are placed at the recipient site. 
​
FUE extraction can be done manually or with the use of robotics.
The FUE method is more expensive, but provides on average more aesthetically pleasing results (assuming the proper hair follicle placement) and leaves no visible scars at the donor site. ​
Two - three weeks after the procedure the originally transplanted hair falls out, but the new hair starts growing from the transplanted follicles in several months. 

Adhering to the post-surgical instructions is critical for the hair follicle survival. That includes avoiding smoking to allow neo vascularization, avoiding alcohol for at least five days after the procedure, not touching the recepient are for several days etc.

The advantage of the hair transplant procedure is that it is the most effective method to "create" hair where it is gone or has thinned. It is also the only method to place hair where it has never existed (the aesthetic hairline enhancement) or where the hair follicles are completely gone for years, and hence there is nothing to revive (no other, non-surgical, method would work).
The downsides of the hair transplantation regardless of the method are primarily the cost (between $3,000 up to 12,000) and the fact that the hair at the donor sites are not endless, while the hair loss is a progressive condition. Sometimes, two procedures are required to achieve fully satisfactory results because not all transplanted hair survives. It also takes months to see the final results, but that is the case with all hair treatment options. ​
Finally, to maintain results many doctors recommend continuing use of Minoxidil and/or annual PRP injection procedures. 
ROBOTICS ASSISSTED HAIR TRANSPLANTATION
The advantage of the robotics assisted hair-transplantation surgery with the FUE stems from how hair is removed from the donor site.
The robotics, for example, ARTAS and NeoGraft, allow removing hair follicles one-by-one in natural groupings of 1-4 hairs with a tiny pinch; thus, no sutures are required and no scars are left. ​

Hair Loss Prevention and Other Options

ALL THE OPTIONS
1. Some doctors recommend using 2% Minoxidil for the prevention of or for slowing down the onset of the androgenetic alopecia. This may be especially effective for those who are genetically predisposed to hair loss as they may judge by the hair loss patterns of their older male relatives. 

2. Along with the standard Western medicine and even wholistic and functional medicine, other fields of medicine exist that have been used effectively for centuries, for example Chinese medicine of acupuncture and herbal remedies. Solid scientific research on the effectiveness of either is sporadic and limited, and the objective of MAIPS is to provide reliable scientifically-based information. 

However, information on the hair loss treatment and prevention through non-western methods is still available, and we are including it here for the sake of completeness - 
  • In the realm of Chinese medicine, "liver creates life energy that feeds hair". What weakens liver leads to hair loss. Liver is particularly weakened by alcohol consumption. Liver support through healthy eating and supplements and minimizing alcohol consumption may possibly act as a hair loss prevention approach;
  • There is an open study to evaluate effectiveness of the acupuncture for the treatment of Alopecia Areata (Lee HW, 2015).
​
We are working on analyzing modern scientific research data on the effectiveness of acupuncture for the hair loss treatment and will include this information here later. 

Hair Loss Treatment References and Literature

FULL LIST with links
Afifi L, Maranda, EL, Zarei M, Delcanto, GM, et al. Low-level laser therapy as a treatment for androgenetic alopecia. [Published online ahead of print April 25, 2016]. Lasers Surg Med. doi:10.1002/lsm.22512.
https://www.ncbi.nlm.nih.gov/pubmed/27114071

Avci P, Gupta GK, Clark J, Wikonkal N, Hamblin MR. Low-Level Laser (Light) Therapy (LLLT) for Treatment of Hair Loss. Lasers in surgery and medicine. 2014;46(2):144-151. doi:10.1002/lsm.22170.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3944668/

Badri T, Kumar D D. Minoxidil. [Updated 2018 Jan 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.
​https://www.ncbi.nlm.nih.gov/books/NBK482378/

Bora P, Majumdar AS. Adipose tissue-derived stromal vascular fraction in regenerative medicine: a brief review on biology and translation. Stem Cell Research & Therapy. 2017;8:145. doi:10.1186/s13287-017-0598-y.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5472998/
​
Cervantes J, Perper M, Wong L, L, Eber A, E, Villasante Fricke A, C, Wikramanayake T, C, Jimenez J, J: Effectiveness of Platelet-Rich Plasma for Androgenetic Alopecia: A Review of the Literature. Skin Appendage Disord 2018;4:1-11. doi: 10.1159/000477671
https://www.karger.com/Article/FullText/477671#
​
Dhurat R, Sukesh M, Avhad G, Dandale A, Pal A, Pund P. A randomized evaluator blinded study of effect of microneedling in androgenetic alopecia: a pilot study. Int J Trichology. 2013;5(1):6-11.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3746236/

Dhurat R, Mathapati S. Response to Microneedling Treatment in Men with Androgenetic Alopecia Who Failed to Respond to Conventional Therapy. Indian J Dermatol. 2015;60(3):260-3.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458936/

​Dhurat R, Chitallia J, May TW, et al. An Open-Label Randomized Multicenter Study Assessing the Noninferiority of a Caffeine-Based Topical Liquid 0.2% versus Minoxidil 5% Solution in Male Androgenetic Alopecia. Skin Pharmacol Physiol. 2017;30(6):298-305.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5804833/

Eppley BL, Woodell JE, Higgins J. Platelet quantification and growth factor analysis from platelet-rich plasma: Implications for wound healing. Plast Reconstr Surg. 2004;114:1502–8. 
https://www.ncbi.nlm.nih.gov/pubmed/15509939

Fertig R, Tosti A. Frontal fibrosing alopecia treatment options. Intractable & Rare Diseases Research. 2016;5(4):314-315. doi:10.5582/irdr.2016.01065.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5116872/​

Gupta AK, Charrette A. Topical Minoxidil: Systematic Review and Meta-Analysis of Its Efficacy in Androgenetic Alopecia. Skinmed 2015 May-Jun;13(3):185-9. 
https://www.ncbi.nlm.nih.gov/pubmed/26380504 

Ji Young Oh , Min Ah Park, and Young Chul Kim. Toxicol. Res. Vol. 30, No. 4, pp. 297-304 (2014)
Peppermint oil promotes hair regrowth without toxic signs.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4289931/

Joo HJ, Jeong KH, Kim JE, Kang H. Various Wavelengths of Light-Emitting Diode Light Regulate the Proliferation of Human Dermal Papilla Cells and Hair Follicles via Wnt/β-Catenin and the Extracellular Signal-Regulated Kinase Pathways. Annals of Dermatology. 2017;29(6):747-754. doi:10.5021/ad.2017.29.6.747.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5705357/ 

Khatu SS, More YE, Gokhale NR, Chavhan DC, Bendsure N. Platelet-Rich Plasma in Androgenic Alopecia: Myth or an Effective Tool. Journal of Cutaneous and Aesthetic Surgery. 2014;7(2):107-110. doi:10.4103/0974-2077.138352.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4134641/

Kim W-S, Calderhead RG. Is light-emitting diode phototherapy (LED-LLLT) really effective? Laser Therapy. 2011;20(3):205-215. doi:10.5978/islsm.20.205. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3799034/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3799034/

Lanzafame RJ, Blanche RR, Bodian AB, Chiacchierini RP, Fernandez-Obregon A, Kazmirek ER. The growth of human scalp hair mediated by visible red light laser and LED sources in males. Lasers in Surgery and Medicine. 2013; Oct; 45(8):487-95. doi: 10.1002/lsm.22173
https://www.ncbi.nlm.nih.gov/pubmed/24078483 

Lanzafame RJ, Blanche RR, Chiacchierini RP, Kazmirek ER, Sklar JA. The growth of human scalp hair in females using visible red light laser and LED sources. Lasers in Surgery and Medicine. 2014;46(8):601-607. doi:10.1002/lsm.22277.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4265291/

Lee BH, Lee JS, Kim YC. Hair Growth-Promoting Effects of Lavender Oil in C57BL/6 Mice. Toxicological Research. 2016;32(2):103-108. doi:10.5487/TR.2016.32.2.103. 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4843973/

Lee C-Y, Wei C-C, Yu M-C, et al. Hair growth effect of traditional Chinese medicine BeauTop on androgenetic alopecia patients: A randomized double-blind placebo-controlled clinical trial. Experimental and Therapeutic Medicine. 2017;13(1):194-202. doi:10.3892/etm.2016.3935.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5245083/ ​

Lee C-Y, Yang C-Y, Lin C-C, Yu M-C, Sheu S-J, Kuan Y-H. Hair growth is promoted by BeauTop via expression of EGF and FGF-7. Molecular Medicine Reports. 2018;17(6):8047-8052. doi:10.3892/mmr.2018.8917.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5983978/​

Lee HW, Jun JH, Lee JA, Lim H-J, Lim H-S, Lee MS. Acupuncture for treating alopecia areata: a protocol of systematic review of randomised clinical trials. BMJ Open. 2015;5(10):e008841. doi:10.1136/bmjopen-2015-008841.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636638/

Malkud S. Telogen Effluvium: A Review. Journal of Clinical and Diagnostic Research : JCDR. 2015;9(9):WE01-WE03. doi:10.7860/JCDR/2015/15219.6492.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606321/

Maria-Angeliki G, Alexandros-Efstratios K, Dimitris R, Konstantinos K. Platelet-rich Plasma as a Potential Treatment for Noncicatricial Alopecias. International Journal of Trichology. 2015;7(2):54-63. doi:10.4103/0974-7753.160098. 
​https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4502475/

Olsen EA, Dunlap FE, Funicella T, Koperski JA, Swinehart JM, Tschen EH, et al. A randomized clinical trial of 5% topical minoxidil versus 2% topical minoxidil and placebo in the treatment of androgenetic alopecia in men. J Am Acad Dermatol. 2002;47:377–385.
https://www.ncbi.nlm.nih.gov/pubmed/12196747
​
Perez-Meza D, Ziering C, Sforza M, Krishnan G, Ball E, Daniels E. Hair follicle growth by stromal vascular fraction-enhanced adipose transplantation in baldness. Stem Cells and Cloning : Advances and Applications. 2017;10:1-10. doi:10.2147/SCCAA.S131431.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5506773/

Rami Anderi, Nehman Makdissy, Albert Azar, Francine Rizk, Aline Hamade Cellular therapy with human autologous adipose-derived adult cells of stromal vascular fraction for alopecia areata
Stem Cell Research & Therapy. 2018: 9:1 - 1
https://link.springer.com/article/10.1186/s13287-018-0889-y#enumeration

J.L. Roberts, V. Fiedler, J. Imperato-Mcginley, et al. Clinical dose ranging studies with finasteride, a type 2 5α-reductase inhibitor, in men with male pattern hair loss J Am Acad Dermatol, 41 (1999), pp. 555-563
https://www.ncbi.nlm.nih.gov/pubmed/10495375

Shah KB, Shah AN, Solanki RB, Raval RC. A Comparative Study of Microneedling with Platelet-rich Plasma Plus Topical Minoxidil (5%) and Topical Minoxidil (5%) Alone in Androgenetic Alopecia. Int J Trichology. 2017;9(1):14-18.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5514790/

Shapiro J, Kaufman D. Use of Finasteride in the Treatment of Men With Androgenetic Alopecia (Male Pattern Hair Loss). Journal of Investigative Dermatology Symposium Proceedings. 2003 Jun;8(1):20-3.
https://www.sciencedirect.com/science/article/pii/S0022202X15529357

Vañó-Galván S, Molina-Ruiz AM, Serrano-Falcón C, et al. Frontal fibrosing alopecia: A multicenter review of 355 patients. J Am Acad Dermatol. 2014; 70: 670-678.
https://www.ncbi.nlm.nih.gov/pubmed/24508293​

Vestita M, Filoni A, Bonamonte D, Elia R, Giudice G. Abstract: The Use of Nanofat in Androgenic Alopecia. a Prospective Blinded Study. Plastic and Reconstructive Surgery Global Open. 2017;5(9 Suppl):90. doi:10.1097/01.GOX.0000526293.77976.7f.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5636413/
​
Weibrich G, Kleis WK, Hafner G, Hitzler WE. Growth factor levels in platelet-rich plasma and correlations with donor age, sex, and platelet count. J Craniomaxillofac Surg. 2002;30:97–102. 
https://www.ncbi.nlm.nih.gov/pubmed/12069512
​
Zarei M, Wikramanayake TC et all Low level laser therapy and hair regrowth: an evidence-based review. Lasers Med Sci. 2016 Feb; 31(2):361-70 
https://www.ncbi.nlm.nih.gov/pubmed/26690359