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 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-2000s, 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 a 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 are 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 pay-your-way-out-of-trouble corporate capitalism that big pharmaceutical companies thrive. 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 of 4 months 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 a 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 a 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 transplant 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, the severity of the hair loss, and the size of the recipient areas. FUT results in a 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 one wants, 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 a 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 about 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 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 toward 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 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 by 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 are 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 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 the consultation after I shared some suggestions. Surgery began right after the consultation. As they put in my IV, I was anxious, 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 who could cut through all the tourist traps and shady doctors.
For once, I actually look like someone in their mid to late twenties, and for that – I am thankful.
