Balding is a deeply personal and emotional process that 85% of men around the world will experience at some point in their lives. 70%  of men will have experienced hair loss by the age of 35. Male pattern baldness accounts for 95% of cases worldwide and is the most common form of hair loss. The stages of male pattern baldness are noticeable and predictable – it starts with hair loss at the temples and thinning hairs at the crown. Over time, these two areas will form a receding M-shaped hairline. An O-shaped bald spot at the back of the head will then follow and together, both areas will combine into a U-shaped horseshoe balding pattern.

Like Thanos, male pattern baldness is inevitable.  It’s a genetic condition that’s passed down and typically emerges between the ages of 25 and  35. For some men, male pattern baldness starts as early as the late teens. The Hamilton Norwood scale is a measurement system used by doctors to classify the stages of male pattern baldness. In my early twenties, I  was at Stage 2. After college, I did no favors to my hairline as a new grad, working late nights and weekends at the office to climb up the corporate ladder. By my mid-20s, I had reached Stage 3. Now in my late twenties and approaching Stage 4, I was confronted with three options. One, I  could do nothing, see balding as a way of life, and learn to live with hair loss. Two,  I could actively embrace the inevitable,   proactively shave my head, and go bald by choice. Three, I could fight back and restore my hair loss through prostheses, medication, and/or surgery just like Elon Musk, Gordon Ramsay, Wayne Rooney, Tom Hanks, Nicholas Cage, Ben  Affleck, Drew Brees, and Antonio Conte did.

With so many possible treatments with different degrees of effectiveness and cost, hair loss is a global billion-dollar market with ties not just to big pharmaceuticals, but also to the medical tourism of developed countries like Turkey and South Korea. The reality is that there’s only so much one can learn through financials and headlines. The best way to truly understand a business is to experience it yourself and as someone who started balding in their early twenties, there’s no better candidate to be a test subject, patient, and consumer of the hair loss industry than me.

In this article, we’ll navigate the business of balding, the different treatments available, and the companies behind those solutions, all through my own personal experience and transformation from medication to hair transplant at a  prestigious clinic in South Korea.

When it comes to balding, the easiest treatment is a prosthesis. Wigs and hairpieces are non-invasive, low-risk solutions. Toupees are the most popular choice of a prosthesis for male pattern baldness. While wigs cover the entirety of one’s head,  toupees are customized hairpieces that cover only the specific areas of hair loss. With wigs, you can buy and wear one off the shelf, but toupees by design must be fitted properly to match your scalp, forehead, and hair. A toupee can cost from $20 to thousands of dollars. The more convincing and natural a toupee looks, the more expensive it will be. The global hair prosthesis industry is a  low-value six-billion dollar market. China is the world’s largest producer, supplying 70% of the world’s wigs, hairpieces, hair extensions,   and toupees. 70% of wigs and hairpieces produced in China every year are exported to the United   States, Europe, and Africa – the three markets with the largest demand for hair prostheses.

Henan Rebecca is the largest producer of wigs and toupees in the world and was the first ever hair prosthesis company to go public on the Shanghai Stock Exchange in 2003.   Henan Rebecca is a timely demonstration of the unsustainable expansion and radical diversification that is so popular with today’s  Chinese companies. In less than two decades, the company has gone from just manufacturing wigs and toupees to also managing 4-star hotels, developing high-rises, buying an entire mountain and converting it into a tourist destination, operating luxury resorts, managing private high schools, mining gold in Laos, running amusement parks, supplying water to municipalities, processing sewage,   and providing public transportation. With so many different businesses wrapped into one company, Henan Rebecca’s finances don’t provide a clean look into the business of hair prostheses.

Common sense would indicate that such a massive business expansion could not have been funded by just selling wigs and hairpieces. A cleaner example would be the Hong Kong-based Evergreen Products, which is the 5th largest producer of hair prostheses in the world. The company has three business lines, wigs and toupees, hair extensions, and Halloween costumes. If you ever wondered where those crappy costumes at Spirit with the outdated branding and models come from, they likely came from Evergreen. The US alone accounts for 90% of Evergreen’s annual revenue while wigs and toupees contribute   85% of the company’s overall top line. While  Evergreen’s wig business has grown over the years with decent 20% gross margins, toupees make up an insignificantly small slice of the pie. In the past 5 years, male consumers and toupees have never been mentioned in any company strategy, presentation or report. While social acceptance has improved, toupees remain unpopular and niche for balding men. While production is concentrated in a  few overseas suppliers like Evergreen, the actual salons, and retailers who fit and sell toupees to end users are mostly local small businesses. These independent stylists and mom-and-pops are the ones who bear the cost of marketing, customizing, fitting, educating,  and evangelizing toupees to male customers.

Toupees are a difficult product where procurement requires personalization and trust. Sellers have to build trust, address the psychological barriers and cost concerns, and customize toupees with customers one at a time in order to close a sale. While I could order a $20 toupee from  Amazon or a $5 toupee from Aliexpress, it’s obvious how unrealistic these cheap hairpieces are. The higher-end toupees in the $200-800 range stand up better to the eye test, but the effort needed to size, fit, glue, style, and maintain just seemed troublesome and illogical. Toupees have to be regularly maintained as the glue sticking to your scalp will wear off over time. At least once a month, you have to shave your scalp, apply new glue, spray special products to reduce odors, and re-apply the entire toupee to keep hygiene and maintain the illusion.

While there are salons that can do this for you for the price of a high-end haircut, these maintenance costs quickly add up.   A toupee, conceptually, is only valuable if it’s convincing to others. It’s a temporary solution and half measure that disguises your baldness to the people around you, but it doesn’t actually change the reality that you’re balding. And at some point, whether it’s once a night or once a month, I have to take the toupee off. Ultimately, I would rather be balding out in the open than constantly worry about maintaining an illusion or being caught wearing fake hair.  My goal was to find a permanent and sustainable solution to my baldness, not illusions.

The next treatment I explored was medication. There are  only two proven drugs for hair loss – finasteride   and minoxidil. Finasteride is a tablet that  you take every day to slow down hair loss.   In the simplest abstraction, there’s an enzyme  in your body that converts testosterone into DHT.   DHT is the hormone that directly causes hair loss.  Finasteride blocks the actions of that enzyme,   which lowers your body’s production of DHT, and  then significantly slows the rate at which you   lose hair. Fundamentally, finasteride is a  preventative measure. It slows baldness but   doesn’t stop it entirely. It also doesn’t  restore hair that’s already been lost.   Finasteride was invented by the American  pharmaceutical giant Merck in 1993 and to this   day is the most clinically effective drug against  male pattern baldness. Finasteride is just one of   many blockbuster drugs in Merck’s portfolio. In  2020, Merck boasted six drugs that each surpassed   over $1 billion dollars in annual sales – the top  four being Keytruda, a cancer treatment with sales   of $14.3 billion dollars, the second was Januvia,  a medicine for type 2 diabetes with $5.3 billion   dollars, the third was an HPV vaccine with $3.9  billion dollars, and the fourth being a chickenpox   vaccine with $1.9 billion in sales. These days, finasteride is a widely available   generic prescription as Merck’s patent on  the drug expired back in 2013. But in the   20 years from 1994 to 2013 when Merck’s patent was  valid, the company held a complete monopoly over   hair loss medication. While Merck didn’t break  out their product sales by medication until 2006,   we can see that finasteride’s sales were healthy,  contributing nearly $500M every year. Keep in mind   that you have to take finasteride every day for as  long as you don’t want to go bald. While you can   always lower the dosage or frequency, people  on finasteride are generally on it for life.   It’s remarkable that this single drug with almost  half a billion dollars in annual sales accounted   for no more than 2% of Merck’s annual revenue over  its 20 years of exclusivity. It’s a demonstration   of how dominant Merck’s pharmaceutical  portfolio is that not even finasteride   at the height of its monopoly was ever one of  the company’s top 5 best selling drugs.   One theory I have as to why finasteride didn’t  sell as much for Merck has to do with the U.S   healthcare system. American health insurance  companies like Aetna, Cigna, and Anthem don’t   consider alopecia, hair loss, or male pattern  baldness as a medical condition. As a result,   consumers have to bear the entire cost of any  medication or treatment for balding themselves.   During Merck’s monopoly in the mid 2000’s, a  30-day supply of finasteride cost at least $90.   Nowadays, a 90-day supply of  finasteride costs me less than $30.   The second reason for finasteride’s commercial  underperformance relative to other drugs   in Merck’s portfolio has to do with its  troubling side effects and dark history.   With lower testosterone in your body, finasteride  introduces potential side effects like decreased   libido, erectile dysfunction, impotence, and  male infertility. While Merck insists that   finasteride is safe and that these side effects  only ever appeared in less than 4% of patients,   the reality is that even 1% chance of decreased  libido and impotence is still 1% too high for many   men. This potential gamble on your masculinity for  the sake of appearance is why finasteride remains   so controversial. There’s no shortage of horror  stories from men who experienced the side effects   and had difficulty shaking them off  even after stopping the medication.   There’s also many success stories from  men on finasteride who downplay the side   effects and insist that the bad experiences are  exaggerations, fear mongering, or placebo.   In 2016, hundreds of men who took  finasteride filed lawsuits against Merck,   alleging that the pharmaceutical giant knowingly  hid these side effects to keep sales up.   They accused Merck of bringing an unsafe  drug to market and manipulating trial   data to downplay the risks. Merck ended up  settling most of these lawsuits out of court   with hush money payments of $5,000 to $10,000  while successfully sealing all clinical data,   dispositions, and confidential information away  from public records. This was a win for Merck   and another timeless demonstration of the  immoral behavior, shady cover-ups, and the   pay-your-way-out-of-trouble corporate capitalism  that big pharmaceutical companies thrive in.   These days, there are less than 25 lawsuits  pending against Merk. The individuals and   families behind these lawsuits have organized  themselves into the Post Finasteride Syndrome   Foundation – a nonprofit dedicated to exposing  all the internal secrets that Merck has buried   over the years about the drug. Given that Merck  spends at least $10M every year on lobbying,   which by the way, is only the amount found in  public records, and the American healthcare   system doesn’t recognize balding as a real  medical condition, it’s no surprise these   lawsuits have been stuck in limbo for years and  remain low on the list of FDA priorities.   When I pressed my dermatologist on the risks of  finasteride, she unsurprisingly downplayed the   side effects, claiming none of her patients  ever experienced any. In the same breath,   she tried to sell me non-FDA approved “natural”  herbal supplements that she claimed were just   as effective as finasteride. Putting aside my  dermatologist’s shilling, questionable morals,   and Merck’s unethical behavior, I eventually took  the plunge on finasteride after being on the fence   for weeks. Elon Musk, Gordon Ramsay, and the  many other celebrities who went from bald domes   to full heads of hair are on finasteride. If these  billionaires couldn’t figure out a better, safer,   anti-balding medication for themselves,  then at least I take some comfort knowing   this is the best boat available today and  that we’re all riding in it together.   My experience 4 months in on finasteride  has been a net positive. My hair loss has   significantly slowed. Before finasteride,  anytime I ran my fingers through my hair,   my palms would be covered with clumps of hair  falling out. On finasteride, this same motion   only removes a few individual strands. As for  side effects, there’s no change in my libido   nor have I experienced impotence. But it does  take more conscious effort for me to get in the   room in the bedroom. As an unexpected positive, I  no longer wake up with the same aggressive energy   or raging masculine temper that I used to have in  my mid twenties. Perhaps this is placebo, but I’m   tempted to chalk it up to the lower testosterone  in my system. While the first few days on   finasteride were a little nerve-wracking, I’ve  gotten more comfortable with it over time. Like   many others, I’ve experimented with reducing doses  to find the right balance for myself between hair   loss prevention and lower testosterone. The other anti-balding drug is minoxidil or more   commonly known as Rogaine. It’s a medication that  you apply to your scalp every day through foam   or ointment in order to stimulate hair growth.  However, minoxidil’s effectiveness is modest at   best. Since minoxidil is a local treatment for  your scalp, it doesn’t target the hormones in   your body that directly cause hair loss the same  way finasteride does. While some men opt for both   finasteride and minoxidil as a comprehensive  solution to hair loss, I personally have only   stuck to finasteride. My perspective is that  it’s easier to maintain hair than to regrow it.   Finasteride is a guaranteed preventative  measure while minoxidil is an inconclusive   reactive measure where hair regrowth is not  guaranteed, it takes months to see results,   and is yet another drug where as soon as you stop  taking it, everything goes away. Having already   signed onto one lifelong drug with finasteride,  I’ve been hesitant to add another to the list.   Surgery is the last treatment option and is  widely considered to be the most effective,   long-lasting, yet invasive and expensive  solution for male pattern baldness.   Hair transplants are by definition invasive  surgeries, meaning there’s a puncturing   of the skin, open wounds, and a recovery period  involved. With finasteride and minoxidil,   progress is noticeable only after months  of continuous use and comes with risks.   In comparison, a one-time 4-10 hour hair  transplant in exchange for a clearly defined,   visible, immediate, and improved end state  is a great ROI compared to prosthesis or   medication. And as someone in their late twenties,  I wanted to tackle my male pattern baldness   as early as possible and had plenty of healthy  hairs at the back of my head for a transplant.   Hair transplants are simple procedures. A surgeon  relocates healthy hair from the areas of your head   where you have lots of hair (typically the back  or sides) to the areas where you don’t have hair.   It takes 6-12 months for the newly planted hair  follicles to grow fully and not every hair that’s   transplanted will survive the journey. A hair  transplant in its simplest form is a permanent   rearrangement of the hair on your head. While  it’s possible to do a hair transplant at any age   and stage, it’s generally recommended to do one as  early as possible as there is a greater number of   hair follicles that can be extracted. There are  two types of hair transplants, FUE and FUT. The   only difference between the two is how the hair is  extracted and harvested from the donor area.   FUT stands for follicular unit transportation. The  surgeon cuts out an entire piece of your scalp,   closes the incision with stitches, and then  separates that piece of scalp into smaller pieces   called grafts. Grafts contain 1-4 hairs, their  follicles, along with the surrounding skin tissue   that provides the nourishment for those hairs to  grow. The surgeon will then make small holes in   your bald recipient areas and insert the grafts  one at a time. FUT is the most traditional form   of hair transplants and can take 10-20 hours,  depending on the number of grafts. A hair   transplant can involve anywhere from 600 to 5,000  grafts depending on the health of the donor area,   severity of the hair loss, and size of the  recipient areas. FUT results in slightly higher   yield but is more invasive, requires a longer  recovery period, and leaves permanent scarring.   FUE, the other type of hair transplant, stands  for follicular unit extraction. Instead of   transporting a piece of your scalp, a surgeon  meticulously extracts hair follicles one at a time   from your donor area. The harvested grafts are  then planted one by one into the recipient areas.   FUE is the more popular form of hair transplant  as it’s easier, less invasive, faster, and more   affordable. FUE surgeries can be completed in 4-8  hours with no scars or stitches involved.   While I never wanted to take finasteride,  the drug is required for successful,   long-lasting hair transplants. A hair transplant  restores hair in bald areas but it doesn’t do   anything for your existing hair. If you got  a hair transplant but didn’t slow down your   hair loss through finasteride, you would  end up with a tale of two heads. In the   front you would have healthy hair growing  out but in the back you would be balding,   shedding, and losing hair, like Moses  parting the seas on your scalp.   Getting a hair transplant in the West is  expensive. Reputable clinics in the United   States and Canada can cost anywhere between  $10,000 to $25,000 for a single hair transplant.   While one has the freedom to stop and start  medication whenever they want, hair transplants   are generally one-and-done surgeries. There’s  a finite amount of hairs that can be harvested   as the hairs that are extracted from the donor  areas will never grow back. While the surgical   methods and tools are consistent around the world,  hair transplants are more art than science. It   takes skill and experience to transplant hairs in  a natural manner and construct new hairlines that   align with one’s facial features. How the new  hairs are specifically arranged is critical to   the final result. A bad hair transplant can lead  to infections, inconsistent growth, unconvincing   appearances, and poor survival rate. As the less invasive and more cost-efficient   procedure, I settled on FUE for my hair transplant  and began looking overseas. Shelling out $10,000   to $25,000 upfront for a hair transplant in  the US was out of my budget. Because of how   cost prohibitive hair transplants are in the West,  I had open concerns on how much experience these   doctors would have when they only perform at  most a handful of surgeries every month. Turkey,   Mexico, and Spain came up as popular medical  tourism destinations for hair transplants that   cost only $2,000 to $5,000. Many clinics in these  countries advertised all-in-one packages where   they would take care of not only the surgery,  but also the hotel, itinerary, transportation,   translator, and even drop you off for your  flight back to the US 24 hours after the surgery.   While these were convenient, what I was really  after was a highly skilled surgeon with a great   track record and whose customers were locals and  not Americans looking to save a quick buck.   South Korea is the cosmetic surgery capital  of the world. In this land of K-pop, K-dramas,   and Parasite, cosmetic surgery is a way of  life. The country performs over 1 million   cosmetic surgeries every year and has the highest  per capita rate of cosmetic surgery in the world   with 14 out of every 1000 Koreans going under the  knife every year. The beauty ideals and standards   in South Korea are so high that it’s normal  for celebrities, singers, and other public   figures there to undergo multiple surgeries as  early as their teenage years. A friend of mine who   grew up in Korea offered me the name of several  clinics that many locals considered to be the best   in the country. One of them was Dr. Kim Kyung-bok  of Moment Clinic, a celebrated surgeon who rose   to local prominence after having performed  successful hair transplants for celebrities.   Dr. Kim was so popular that there was a  waiting list for his new clinic in Gangnam.   Gangnam is the wealthiest neighborhood in  the country and known as the Beverly Hills   of South Korea with the highest concentration of  cosmetic surgery clinics in its 15-mile borders.   Dr. Kim and Moment Clinic is so oriented  for local Koreans that they don’t actually   have any English speaking staff on hand. For every  conversation I had with his clinic over KaKaoTalk,   which is Korea’s Messenger, I had to use  Google Translate. While I went through virtual   consultations with multiple clinics and doctors in  Korea, it was Dr. Kim’s professionalism, detail,   local demand, and his body of work that sealed  the deal for me. His local interviews and case   studies on YouTube suggested to me that this was  someone who really cared about their craft and   quality of work – not just a paycheck. I flew out to Korea in mid July for my hair   transplant with Dr. Kim. As a first time visitor  to South Korea, I was blown away with the maturity   and government sponsorship behind its medical  tourism. When you land at Incheon and walk   towards Arrivals, the largest booth at the center  of the airport is not a generic Information Desk,   but rather a Medical Tourism Support Center.  There’s staff who can speak English, Chinese,   Japanese, and Vietnamese all hired by the Korean  government to facilitate medical tourists like me.   Walking through Gangnam to Moment Clinic on the  day of my surgery was equally eye-opening. In just   four blocks from the subway station, I passed  nearly 20 different plastic surgery clinics,   doctor offices, and pharmacies – each with  signs in Korea promoting their services   and success stories. As requested, I  had hired a local translator for $20   an hour who could walk me through the  consultation, contract, and surgery.   Located on the sixth floor of a building,  Moment Clinic was clean, modern, new,   and sophisticated. As I expected, Dr. Kim  was a gracious, soft-spoken, and kind man.   While he spoke little English, he made  every effort to communicate his approach,   detail, and vision – using a pen to draw out my  new proposed hairlines and the exact areas he   felt would be most effective. Looking back, as a  very nervous American in a foreign country, I am   most grateful for Dr. Kim’s empathy as he would  regularly pause to listen and hear my feedback.   At one point, he even redrew the lines during  consultation after I shared some suggestions.   Surgery began right after consultation. As they put in my IV, I was an anxious mess,   shaking on the operating table. Hair  transplants rely on local anesthesia   so I was awake and conscious the entire time.  It was an exercise of patience for me, lying   down without moving for roughly five hours while  he and his staff of five nurses operated on me.   Even though Dr. Kim didn’t see many foreigners,  he intentionally played an American radio   station during the surgery so I could feel  comfortable. What amazes me to this day was the   staff discipline during my five hours of hair  transplant. Beyond one or two words here and   there, the room was completely silent. There was  no chatter – just 6 hours of silent concentration   and surgical noises. The whole time my face was  covered with an eye mask, so at no point did I see   or feel anything. Extraction took about 3.5 hours  and implementation took another 2.5 hours.   For around 4,300 grafts, my total cost for this  hair transplant came to $5,500 which was payable   with Visa. Looking back at my progress to date  – while my new hair won’t fully grow out for   another 3-6 months, I’ve been overjoyed with the  early results. My hair transplant with Dr. Kim   and the Moment Clinic has been a genuinely  wonderful and life-changing experience.   Wisdom teeth removal in my book is far more  painful than a hair transplant. My plan is   to revisit Dr. Kim after a year for a touch-up  surgery to further lower my hairline once the   hair follicles in my donor area fully heal. In full transparency, I wasn’t compensated or   given any discount to talk about Dr. Kim and  Moment Clinic. The price I paid for my surgery   was the same price that everyone else pays. For most men, hair transplants are a question of who,   rather than how and finding a trustworthy  clinic overseas is not an easy task.   For me, I was extremely fortunate to have a Korean  friend whose recommendations I trusted deeply   and could cut through all the tourist traps and  shady doctors. For those who are interested,   I’ve included a contact email for Dr. Kim and  his clinic in the description along with his   YouTube channel and website. You can follow  the same process I did – reach out over email,   include some photos of your head, and  they’ll provide you with a proposal, quote,   and availability. Like me, you would need to  organize your own accommodations, translator, and   travel but those are small and manageable costs  to pay for the quality of service offered.   Researching this episode and experiencing  the business of balding brought me around   the world and back from dermatologist offices  to pharmacies and to South Korea. Feeling and   having hair in areas where I used to be bald is a magical feeling that’s hard to put into words.

For once, I actually look like someone in their mid to late twenties, and for that – I am thankful.


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