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Am Fam Physician. 1999;60(9):2508-2510

to the editor: I read with interest the article entitled “Medical Treatment for Balding in Men.”1 While the title aptly describes the article's content and its focus on medical therapies, I was disappointed that it almost completely ignored surgical options.

Surgical solutions for androgenetic alopecia include autografts, flaps and lifts, scalp reduction and scalp extenders. The ideal candidate for autograft is a man with dense hair on the sides or back of his head. Micro, mini or standard grafting (ranging from three to 100 hairs per graft) are successful in many cases, especially in frontotemporal balding areas that have not been amenable to medical therapy.

The average cost of grafting is $50 per plug, multiplied by an average of 300 plugs per case, or approximately $15,000. While this may seem expensive, it compares favorably with the 30- to 40-year lifetime costs of a daily dosage of full-strength minoxidil and/or finasteride. Moreover, beyond the inherent small risk of surgery, no long-term side effects are evident.

Modern plastic surgery involves the advanced techniques of scalp lifts and flaps, scalp reduction and scalp extenders. These surgical treatments have met with great success and resulted in good cosmetic results.

I would also like to point out that the U.S. Food and Drug Administration's original label approval for finasteride was contingent on its use with Neutrogena T/Gel shampoo, which adds to the total costs of treatment. A full discussion of all potential treatments (medical and surgical) for male pattern baldness is indicated for our patients.

in reply: Although our article1 focused on the medical treatments of male pattern baldness, Dr. Elgert rightly points out that surgery is also an option.

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