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New York Times

"How you doing, Tom?" asked Dr. Anthony DiBiase, a Manhattan surgeon, in
the midst of jabbing a lancet 1,130 times into the balding head of Tom
Raybek. "You O.K.?"

"Yep," said Mr. Raybek, as mellow and relaxed on a mild tranquilizer and
topical anesthetic as if he were getting a haircut, which was pretty
much the opposite of what he was getting.

At the age of 58, Mr. Raybek, a ski lodge owner from Killington, Vt.,
had agreed to undergo hair transplantation at no charge in exchange for
allowing his image to be used by Dr. DiBiase's employer, Bosley Inc., in
"before" and "after" photographs.

This, however, was "during," and it was not pretty. Tiny beads of blood
welled up as Dr. DiBiase's hand jabbed up and down as rhythmically as a
sewing machine, making three or four minuscule punctures every second.
Two medical assistants standing nearby counted off every puncture, so
that they would add up precisely to the number of follicles that had
already been "harvested" from the back of Mr. Raybek's head earlier in
the morning. In the afternoon, the medical assistants would spend nearly
three hours using tweezers to plant the individual follicles into the
holes.

"Pretty amazing, isn't it?" Dr. DiBiase said, standing back to admire
his handiwork, like a farmer gazing out on a newly planted field of
wheat.

With little fanfare, the science of hair restoration has in the last few
years undergone vast changes. Hair plugs, infamous for their artificial
appearance, are becoming a thing of the past, as scientists refine
techniques of transplanting individual hair follicles rather than
circular scoops of skin, giving the hair a more natural look. At least
one new hair-growth drug is in the pipeline. The cloning of individual
hair cells is only a decade away, experts say - an advance that, by
providing an unlimited source of replacement hair, could give even the
baldest head a luxuriant thatch, while at the same time making hair
transplantation surgery safer.

The market for such developments is sizeable. The Food and Drug
Administration estimates that some 40 million men and 20 million women
experience hair loss. Sales of Propecia, one of the most popular
hair-growth potions, totaled $111 million in the United States in 2003
alone, up 13 percent from 2002. Close to 32,000 hair transplants, 88
percent of them in men, were performed in this country last year,
according to the American Society of Plastic Surgeons, up from 29,000 in
2002. With the typical transplant running upward of $10 per follicle,
and the average procedure involving about 1,000 follicles, that
translates into nearly a third of a billion dollars.

The field's advances have not done away with bad hair jokes: A running
gag in the recent film "Hellboy" revolved around the doll's hair look of
a character's hair plugs.

"The big problem we've had to overcome is 30 years of plugs," conceded
Dr. Bobby Limmer, a dermatologist in San Antonio and the developer of
individual follicle transplants. "You mention hair transplantation to
the guy on the street, and the first image that's going to come to him
is the plug."

But the evolving medical science has come a long way since 1981, when a
Boston lawyer named John Kerry, not yet a political figure, represented
16 men whose heads had been surgically implanted with carpet fibers.

"They were badly, badly infected, and in most cases large parts of their
scalps had to be excised," recalled Roanne Sragow, then Mr. Kerry's law
partner and now the first justice of the Cambridge District Court. "It
was pretty gruesome."

Hair transplantation has been possible since 1952, when Norman
Orentreich, a dermatologist at New York University, figured out how to
transplant circular scoops of follicle-rich skin stolen from the back of
the head. The result was tiny tufts rising up like so many islands of
hair amidst a barren sea of baldness. This effect was especially
unfortunate at the hairline, where the hair plugs were plainly visible.

Even five years ago, experts say, plugs remained the hair replacement
technique of choice; they are still used by some, particularly on the
crown, where the doll's hair effect is not as visible.

But on Oct. 21, 1988, Dr. Limmer made hair restoration history by
transplanting follicular units, naturally occurring groups of one to
five follicles that are sown over the bald area in an evenly irregular
pattern that is indistinguishable from naturally growing hair.

Derived from the Latin word follis, for bag, the hair follicle is the
complex pouch-like structure from which grows hair, ground out like so
much sausage and composed primarily of the same dead keratin that makes
up nails. Normally each follicle goes through a five-year cycle of
growth and rest, with about 90 percent growing hair at any one time,
averaging about six inches per year.

Baldness begins when, in the presence of dihydrotestosterone, or DHT, a
byproduct of the male hormone testosterone, the growth cycle of
genetically susceptible follicles on the crown and temples gradually
speeds up to as little as 60 days. Newly growing hair never gets a
chance to mature, and eventually the worn-out follicles die. Hair on the
back of the head remains in place, however, because it is not
genetically susceptible to the ravages of DHT.

When surgeons first realized they could transplant hair from the back to
the front, they thought the follicles could only survive when
transplanted in swaths, like strips of sod on a new lawn. But slowly
they succeeded in transplanting smaller and smaller sections, until Dr.
Limmer, who said he has given lectures sponsored by Merck but does not
receive research financing from the industry, proved that an individual
follicle, like a single miniature tulip bulb, could be transplanted and
grow normal hair.

Like any surgery, hair transplantation is not without risks: Serious
complications are rare, doctors say, but minor ones occur in one-half to
one percent of cases. But the results have made the procedure far more
appealing, and surgeons say it now attracts the Hollywood elite,
although not, one may surmise, Bruce Willis or Ron Howard.

"How many movie stars have I transplanted?" said Dr. Jon Gaffney, a
plastic surgeon in Beverly Hills who recently became a partner in Hair
Club. "Over a dozen."

But, Dr. Gaffney said, he cannot name names.

"Men in general are pretty close-mouthed about any cosmetic surgery," he
said. "Women will share their surgeons with their friends. The ladies
are all waiting back home to see how it went. But some men, they don't
tell they wives, their mothers, their best friends, their brothers."

The only men who seem eager to talk about their transplants to anyone
who asks - or even to those who don't - are the ones in the transplant
business. Twice in the first minute on the telephone, Mike Smith, vice
president of marketing for Hair Club, the nationwide network of hair
replacement clinics, told a reporter that he was "also a client."

The man who coined that catch phrase of the 1970's ("I'm not only the
president, I'm also a client") is the founder of Hair Club, Sy Sperling.
Although he sold the company a few years ago, he is glad, he says, that
the company has recently begun offering transplants in addition to its
stock in trade, hairpieces.

"I never wanted to do transplants, because they always had that doll's
hair look," said Mr. Sperling, 62, reached at his oceanside home near
Boca Raton, Fla. "But today there's so much new technology, it looks
absolutely fantastic."

He added: "I would do one myself at this point, but I can't. I don't
have enough density to work with. If you try to cover a whole football
field with a little bit of sod, it's not going to work."

But Mr. Sperling said he would be the first to sign up if a technique
for cloning hair cells was available.

"That I would do in a second," he said.

Scientists are, in fact, studying how to isolate follicular stem cells,
nudge them into proliferating in a test tube, and then implant them back
into the head of the man or woman from whom they were originally taken.
Those stem cells, in turn, create follicles and hairs. In March,
researchers, led by George Cotsarelis, director of the University of
Pennsylvania's hair and scalp clinic, reported in the journal Nature
Biotechnology that the process had been successful in mice.

"It was pretty amazing, because not only did they make hair follicles,
they also made epidermis and sebaceous glands - the oil glands that
cause acne," Dr. Cotsarelis said.

He said at least three biotechnology companies are trying to develop the
technique in humans and he estimated that it could become commercially
available within a decade.

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