Management of Alopecia

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Chapter 6 Management of Alopecia

With current techniques, hair transplants can look totally natural and without signs that a procedure has been performed. 1 Hair transplantation has, however, a poor reputation because so many patients in the past have had less than acceptable results. 2 Scalp reconstruction with flaps and excisions and the use of tissue expanders for male patients with genetic hair loss are now rarely used except in the management of difficult secondary cases. 3–20


With current techniques, hair transplants can look totally natural and without signs that a procedure has been performed.1 Hair transplantation has, however, a poor reputation because so many patients in the past have had less than acceptable results.2 Scalp reconstruction with flaps and excisions and the use of tissue expanders for male patients with genetic hair loss are now rarely used except in the management of difficult secondary cases.320

Improvements in results in the past 15 years are due to the work of many in the field, and in particular, Dr Carlos Uebel from Brazil,21,22 who was one of the first to popularize the use of small natural-appearing grafts in large numbers performed at a single session. Today, rather than transferring a few hundred grafts at each session requiring numerous procedures, it is not unusual to transfer 1500, 2000, and even 3000 grafts in a single session.

Importance of Type of Graft and Design of a Natural Hairline

A discussion of transplantation usually refers to micro or mini grafts.23 Current nomenclature uses the term follicular grafts,2426 which are clusters of one to three hairs that emerge from the scalp as a unit. Grafts often used to contain 10, 20, and even 40 hairs per each graft, so creating an unnatural appearance (Fig. 6.1A&B), and the hairline was often poorly designed. A successful and aesthetically pleasing hair restoration is as demanding as any other aesthetic facial procedure.

The frontotemporal recession is an important component of creating a mature natural hairline in males.27 This anatomic landmark is formed by the junction of two lines, consisting of the frontal and temporal hairlines, which converge in an acute angle. It is critical in creating a natural-appearing male hair transplant to maintain this normal frontotemporal recession. In hair restorations where the frontotemporal angle is not created, the patient frequently has an un-natural result, creating either a feminine or immature male hairline.

Other important components of a natural hairline include the transition anteriorly from fine to thicker hair with increasing density, and a significant degree of irregularity along the hairline margin. Normal hairlines should not appear straight and regular. Perfectly straight hairlines are characteristic of unnatural-appearing hair transplants. Unsatisfactory results with hair transplants usually demonstrate a fundamental lack of knowledge of these critical points required to create a natural-appearing hairline.28


Most patients seeking hair restoration due to genetic hair loss are male. Approximately 15% of patients who have primary alopecia in my current practice are women and demonstrate typical genetic pattern hair loss. The other main group of patients have had previous hair transplantation with poor results;2931 these patients are more difficult to treat and fall into two groups:

One of the main indications in women is secondary or traumatic alopecia after procedures such as facelifts or forehead lifts. In these patients hair loss results from excessive tension or undermining of the hair follicle.32 Such women are ideal for hair transplantation because scars or abnormally high hairlines can be readily corrected. The most common area needing hair transplantation is probably the temporal and preauricular area.

Male Androgenic Alopecia

In most men, hair loss is related to androgenic alopecia. This form of alopecia is a response to androgens, which reduce the rate of hair growth as well as the diameter of the hair shaft.33 Also, the growth phase of hair referred to as anagen is shortened. It is believed that testosterone is converted by the enzyme 5-alpha reductase to dihydrotestosterone (DHT),34 which targets the hair and causes genetic hair loss. In most men with hair loss, the hair follicles in the frontal and crown regions appear to be most susceptible to DHT, leading to androgenic alopecia. In most patients, 30–50% of the hair has been lost before it becomes apparent. As the average normal head has 100 000–150 000 hairs, a significant amount of hair loss is necessary before it becomes apparent.

Female Hair Loss

Female hair loss is frequently more diffuse, and many women are not good candidates for hair restoration because of a lack of good donor hair.35 However, a subgroup of women present with hair loss similar to androgenic alopecia36 and usually have good hair density in the lateral and posterior areas of the scalp. Many of these women have a history compatible with that seen in male pattern hair loss and report many family members with either thin hair or balding scalps.

Unlike male pattern hair loss of the genetic form, women with genetic hair loss tend to maintain a low frontal hairline with an anterior margin of hair (Fig. 6.2A&B). This is very different from men where there is progressive elevation of the frontal hairline and increasing temporal recession over time. Women, however, frequently maintain a frontal hairline for life, and this factor requires hair transplantation to be performed, beginning from the frontal hairline and continuing posteriorly to fill in the defect.

Most women who present with hair loss are not candidates for hair transplantation because the hair loss is usually caused by a metabolic disorder, autoimmune disease or other factors.

Patient Selection

One factor that makes hair restoration unique compared to other areas of aesthetic surgery is the unpredictability of future hair loss. Evaluation and prognosis of male pattern hair loss can be difficult. It is critical to take into consideration not only the family history, but also the patient’s age. Patients in their early 20s often have a significant amount of unpredictable future hair loss, and it is important to explain the possible effects of hair transplantation at too early an age:

As in all areas of aesthetic surgery, realistic expectations of what can be accomplished with hair restoration are important.

Because hair loss is progressive, it is often better to wait until the third and fourth decades before considering transplantation. Also, as a young patient ages, there may also be recession of the hairline.

Another factor that must be carefully considered is hair transplantation of the occipital region. If the patient is relatively young or destined to have significant hair loss in the occipital area, overtransplantation centrally in the occipital area can lead to a bizarre appearance as he ages. Typically, there is hair loss in a coronal pattern around the area of transplantation, which leads to a halo of baldness. This will require further procedures to maintain a reasonable appearance. It is therefore important to evaluate the patient’s future hair loss based upon their hair characteristic and family history.

Preoperative History and Considerations

Hair normally passes through three cycles (Fig. 6.3A&B).37

Approximately 10% of hair is in the telogen phase at any one period. Therefore, most individuals with 100 000 or more hairs tend not to notice hair loss during the telogen phase. However, in the patient who has already lost a significant amount of hair, the telogen phase may be far more important.

After a hair transplant the hair transferred goes into a 3–4-month resting phase. It is important to inform patients that it will therefore take months to see the final result because of the delayed hair growth after transplantation.

Hair Type

An important component of the initial patient evaluation includes an assessment of hair type. This includes the color, texture, density, and curling or straightness of the hair.

Goals of Transplantation

On initial consultation, certain variables must be considered to assist the patient in making the appropriate decision and to set realistic goals concerning hair transplantation.


It is important that the patient understands that the goal is to create a hairline that is harmonious with their facial characteristics and to create balance. One term that is frequently used is facial framing (Fig. 6.6A&B). This creates a more balanced appearance in the anatomic components of the face. Typically, the face can be divided into equal thirds, but in a patient who has a receding hairline, the eyes appear to have a more centralized appearance; creating a lower hairline produces better balance by framing the facial characteristics.

Patients in their 20s and 30s often dislike their bald appearance, not only because of the hair loss but also because they often look years or decades older than their actual age. Framing of the face improves the appearance, making the individual appear years younger.

During the consultation, it is useful to draw the proposed transplantation pattern on the patient’s scalp and to allow the patient to see it (i.e. the most appropriate hairline) in a mirror. Patients given a marking pen will frequently draw the hairline in a relatively low position, which is usually not appropriate because a relatively youthful hairline now may lead to problems and dissatisfaction later. A demonstration of the Norwood classification allows patients to understand the normal nature of androgenic alopecia as hair recedes. A natural hairline will age appropriately with the patient as temporal recession and elevation in the frontal hairline progresses. For most patients the frontal hairline should be at least 8–10 cm above the glabella (Fig. 6.7A&B).

Special Cases

Isolated frontal forelock

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