Hair loss sounds innocuous enough, like middle-aged spread or crow's-feet, something to tut-tut about and put down to passing years. But for many who look in the mirror one morning and realize that a thinning crown has turned into a glaring bald spot, the discovery can be a shock. That's why more and more men-and many women-are taking advantage of the latest in hair transplantation techniques.

According to Dr. Joseph Greco of The Center for Sight, who has written and lectured about hair transplants for years, 19 out of every 20 men suffer from hair loss at some point in their lives, and a sizeable number of those seek out hair transplant experts to fix the problem. "It's the No. 1 cosmetic surgery in males today," says Greco.

But surgery is not the only option, and selecting the best solution from the extensive menu of choices can be confusing. Type "hair loss" on an Internet search engine, and a dizzying number of links pops up.

Hair loss has spawned a $3-billion-a-year industry, says Dr. Brett Hirsch, a Sarasota osteopathic doctor who has 15 years of cosmetic work under his belt and has done about 4,000 hair transplant surgeries. It's an industry that touts everything from herbal remedies (whose efficacy is unproven) to $800 "laser combs" to restore scalp circulation on late-night infomercials and online banner ads. "Hair loss is a very emotional problem; so, very often, we have these companies feeding on the fact that people will do anything," says Hirsch.

A dermatologist is often the best first contact, advises Dr. Bobby Limmer, president of the International Society of Hair Restoration Surgery, an organization that numbers more than 700 hair transplant specialists across the world. "If you're thinking about hair restoration, ask the doctor to give nine or 10 patient references," says Limmer, a San Antonio dermatologist. "Call them and visit them and see them in person."

Limmer's Web site and the site of the American Academy of Dermatology are excellent starting sources for researching hair loss and can direct patients to doctors in their area. Seek out a doctor who specializes in hair loss or has intensive experience with hair transplant surgery.

Once you've done that, the next step is to determine the reasons for the hair loss. There are a surprising number and variety of factors to consider, ranging from hormone levels and medications to hereditary patterns and nutrition. A common cause of hair loss in women is hormonal imbalance caused by a recent pregnancy, menopause or a sudden cessation in taking oral contraceptives. While mere stress is rarely the primary cause of hair loss-other hoary chestnuts include wearing hats, and dirt and sweat-some sort of trauma, such as years of using damaging chemicals on your hair or radiation treatment for cancer, can cause hair to fall out.

Nutrition can also affect the health of hair; those on rigid diets with not enough protein might find their hair thinning. Lack of iron can also cause hair loss, which is why women who suffer from heavy menstrual periods might find their hair thinning. Medical conditions like hypo- and hyperthyroidism can also contribute, as can severe and prolonged fever and flu.

Lately, doctors also have been seeing a more modern cause of hair loss in women: More and more women are asking for treatment to rectify uneven hairlines caused by plastic surgery, to cover up scars and to reinstate follicles damaged during a face lift.

However, the most common cause of hair loss is still old-fashioned hereditary balding, also known as typical male-pattern baldness. According to information from the American Academy of Dermatology, our hair goes through different resting and growing phases. About 10 percent of our hair is in the resting phase at any given time. Then it is shed and replaced by a new hair from the same follicle. The presence of a hormone called DHT affects the process: Some people's follicles are simply genetically predisposed to soak up an inordinate amount of DHT, causing hair to go into longer and longer resting phases.

Treatments can be non-surgical or surgical. Although many drugs claim to stop hair loss, the only two FDA-approved, proven treatments are Propecia and Rogaine. Propecia is an oral medication, effective in men only, that comes in the form of a pill taken every day. Both men and women can use Rogaine, or monoxidil as it's also known. Rogaine is a topical cream applied directly to the scalp to stimulate hair growth. Doctors can suggest taking one or both together. Although local doctors say they hear few complaints about side effects, Rogaine can cause itching and redness of the scalp; and a small number-fewer than one percent-of people who take Propecia complain about decreased sexual desire.

"The problem with both," says Hirsch, "is when you stop, you'll go back to where you started." Hence, the increasing popularity of hair transplant surgery as a permanent, one-time solution.

"Advances in hair technology over the last five to 10 years are heading toward making transplants look natural," says Hirsch. "A great hair transplant is one where someone is walking down the street and you will not know that they've had one done. The No. 1 thing we're fighting is the old view of people's uncles and grandfathers who had hair transplants done 20 years ago and had cornrows growing out of their head."

Although cutting-edge, hair transplant surgery is not a recent discovery, explains Greco, who has been active in the field for 20 years. The first transplant of individual hairs took place in 1943 when a doctor in Japan discovered how to replant eyebrows and eyelashes in patients who had lost them. World War II prevented the progress and dissemination of that research. It wasn't until the 1950s that a New York City dermatologist began working with transplanting hair grafts from the back of the head-where follicles are genetically predisposed to always produce hair-to the front of the head. The problem was that those grafts were about 4 millimeters in diameter, creating an unattractive and unnatural cornrow look.

It was not until the 1980s that researchers learned how to transplant individual hairs into holes the size of a pinprick in the front of the head. And that research, explains Seattle-based cosmetic surgeon Dr. Tony Mangubat, is what provided the basis for hair transplant surgery as we know it today.

Here's how it works. Hair grows in bundles of one, two, three or four hairs. The doctor removes a strip of skin from the back of the head and sutures the cut closed. Then, from that strip of skin, he will either transplant a bundle of hair to the front of the head, or transplant individual hairs. Opinions vary as to which produces the most natural look, but Mangubat says that to the layman's eye, the two are virtually indistinguishable. In both cases, technicians use high-powered microscopes to slice the samples into the individual units.

As with all surgeries, the patient has to summon a level of trust in the surgeon. In this case, they also have to expect their surgeon to have an artist's eye, as it is the surgeon who will recreate the hairline, making sure it is age-appropriate and attractive. Hairs are angled in the same way they would grow naturally, and a detail-oriented surgeon will plant the finer hairs in front to create that natural fringe of "baby hair." The key, says Mangubat, is to match the technique to the candidate.

The operation takes four to five hours under local anesthesia, and patients are usually fully conscious during the whole procedure. In Hirsch's office, they can even watch videos and listen to CDs. Afterward, Hirsch says patients might feel a tightness in the back of the head where the donor area was sutured shut, and a sunburnt feeling or swelling on the top where the new follicles have been implanted. This usually does not last more than a day, and then the little red raised bumps of the transplant scab over and disappear within seven to 12 days. It does take some patience, though, to see the final results, because the hair takes anywhere from three to six months to grow in.

Hirsch now sees as many as five people a week in his office for surgery; about 75 percent of the patients who consult him come back and get the surgery done, he says. At Center for Sight, Greco uses soluble sutures to sew up the donor area in the back of the head, because his clients often fly in from all around the world and want to be able to fly back home the day after surgery.

What's surprising is the range of people who are choosing the procedure, which can cost from $3,000 to $7,000 a session (a heavily balding person may need two or three sessions for a thick head of hair; lightly balding people might be able to do it in one session). Doctors are seeing patients as young as 19 and as old as nearly 80 looking for fuller heads of hair to enhance self-confidence and self-esteem. Greco is also a board member of Hair Angels, a non-profit agency that provides pro-bono transplants to people who have lost their hair in traumatic ways, such as through fires or radiation therapy.

"The emotional stability of someone on a daily basis translates to their daily enjoyment of life," Hirsch says. "And cosmetic surgery is booming. It's at a point where it's become acceptable for men to do something about it; it's not the stigma it was 15 years ago. Some of these guys, they'll get hair and look 10 years younger, partly because of confidence; it shows."

And prospects for thick and healthy hair are even brighter in the future. Greco says cloning and genetic engineering will begin to make an impact on the industry in about 10 years by creating an inexhaustible supply of hair. Thanks to a free flow of information and research among practitioners in the field, the area of hair transplantation is honing in daily on what really works, Mangubat says. 

SIDEBAR

Why Hair Loss Happens 

The most common cause of hair loss is typical genetic male pattern balding, but there are several other causes to watch out for: 

o Birth control pills

Some types of birth control pills can cause women to lose hair, but usually only if they have a genetic inclination to do so. Sometimes when a woman stops using her birth control pills she may notice hair falling out about two or three months later for about six months. This usually stops by itself. 

o Illness

Hair loss often occurs in people who have a severe chronic illness, especially if they have just had major surgery. Hair loss can also occur a few weeks after a high fever or a bad infection, but corrects itself. Fungus infections of the scalp result in redness and swelling as well as hair loss, but are usually easily treated. 

o Diet

What you eat may have an effect on the health of your hair. A lack of protein can cause hair to switch into resting mode, which means that a large amount will then fall out about three months later. Iron intake also has an effect; this can be remedied with iron pills. Very high concentrations of vitamin A can also cause hair to shed. 

o Medications

If your hair is thinning, take a closer look at your medicine cabinet. Hair loss is a side effect of many medications, including a few that treat gout, depression and blood problems. Many people also lose almost all their hair because of cancer treatments, though it does usually grow back afterwards. 

o Hair pulling

Also called trichotillomania, this is a psychological problem where children and adults pull out hair from their scalp, eyebrows and lashes. Sometimes it's just a bad habit, and children especially can be talked out of it; but it can also be a sign of more serious mental problems and stress. 

Source: American Academy of Dermatology