Management of Alopecia

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Chapter 6 Management of Alopecia

Jack Fisher

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

Summary

1. A follicular graft refers to the transfer of clusters of one to three hair follicles emerging as a unit.
2. It is important to maintain the acute ‘frontotemporal’ angle on a male.
3. The natural hairline is not straight and follicles should be placed in an irregular fashion.
4. The natural hair is inclined forward in the frontal area, caudally and posteriorly in the temporal area, and posteriorly in the occipital area.
5. Male pattern baldness is the consequence of testosterone conversion to dihydrotestosterone (DHT) through an enzymatic action mediated by 5-alpha reductase, which targets the hair follicle.
6. The number of hair follicles in the donor area is 150–400/cm2.
7. In most patients, the frontal hairline should be 8–10 cm cephalad to the glabella.
8. The harvested follicle unit should include the shaft, the follicle, and a small amount of fat.
9. The most common complication of the hair transplant is the development of inclusion cysts, which are commonly related to placement of the hair follicle too deeply.
10. The best indication for the excision and scalp advancement technique is to eliminate the site of a previously placed poor hair transplant.

Introduction

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

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,24–26 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.

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Fig. 6.1 Unsatisfactory hair transplants. A, Patient who had hair transplantation 20 years previously. The large plug grafts and hairline that is too straight create an unnatural result. B, Due to the natural progression of hair loss, the plug grafts placed 20 years previously are several centimeters in front of the receding hairline.

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

Indications

• Primary alopecia:

• genetic hair loss (85% are men)

• Previous hair transplantation:

• to remedy unnatural large plug grafts
• to improve hairline

• Secondary or traumatic alopecia:

• after procedures such as facelifts or forehead lifts

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;29–31 these patients are more difficult to treat and fall into two groups:

• those who have been treated with unnatural large plug grafts;
• those in whom the hairline was poorly designed at the time of the original procedure (they are the most difficult to treat).

Most women with hair loss may not be good candidates for hair transplants and may suffer from metabolic autoimmune disorders

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.

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Fig. 6.2 Female genetic-pattern hair loss: appearances before and after transplantation. A, Pre-transplantation. typical female hair loss pattern in 47-year woman, demonstrating maintenance of a frontal hairline fringe. B, Appearance 1 year after second session of transplantation with a total of 2000 grafts. The grafting began at the anterior hairline.

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:

• young patients often have the desire to create juvenile hairlines, which will be inappropriate as they age and cause problems;
• patients who have hair transplants too young, especially if the temporal recession is filled in, may be destined to wearing a hair piece as a result of progressive hair loss.

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

Hair transplants to the existing hairline at a young age may cause significant undesirable patterns after the patient loses more hair at a later age.

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

• Anagen is the growth phase. During this phase the follicular cells are actively reproducing. This growth phase lasts 2–5 years, and most of the hair is in this active phase.
• Catagen is the regression phase and lasts 2–3 weeks.
• Telogen is the final phase of hair growth and lasts approximately 3–4 months. During this phase, follicles are inactive and hair growth stops.
image

Fig. 6.3 Hair. A, Cycles of growth. B, Anatomy.

After the hair is transplanted, it goes into a telogenic phase for a period of 3–4 months. The patient should be informed about this.

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.

Classification of Alopecia

The major classification of alopecia used by most physicians today is the Norwood classification, which is a modification of Hamilton’s original description (Fig. 6.4).38 There are many other classifications, but most divide baldness into six to seven primary groups, with sub-groups included.39,40 These classifications can be useful, but most patients do not fit into a single specific classification or hair loss type exactly.

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Fig. 6.4 Norwood classification of hair loss.

Ludwig has described a system for classifying androgenic alopecia in women.41

All techniques that attempt to classify hair loss have limitations and can only be used as guidelines, but can be useful tools in planning a hair restoration.

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.

• The hair shafts are often thinner in fair skinned individuals and thicker in Asians and Africans. Thin hair gives less coverage, whereas thick hair gives greater coverage.
• Wavy hair has an oval appearance on cross-section under the microscope, whereas straight hair demonstrates a round appearance. In patients with curly hair, it is possible to get greater density or the appearance of greater density with fewer transplants because curly hair gives greater coverage of the scalp. Straight hair does not create as much density for coverage of the scalp.
• Hair density in a patient with male pattern or androgenic alopecia rapidly drops off with age and hair loss. Transplantation of large unnatural grafts containing 20–60 hairs looks unnatural in these patients because hair normally emerges from a single orifice as one to three hairs, and occasionally, four. A graft that has been transplanted with 20–60 hairs violates the basic principal of normal hair growth.
• The angle at which the hair exits the normal scalp varies. In the normal frontal area, the hair is angled slightly forward, while in the temporal area, it is angled slightly downward and backward, and in the posterior scalp, it is angled downward toward the neck. If the hair is put in at an unnatural angle, it will be obvious.
• In people with light hair and light scalps, or people with dark hair and dark scalps, a relatively moderate amount of hair in these patients may give adequate coverage. However, more hair may need to be transplanted to give a satisfactory result in patients who have dark hair with light scalps or patients with light hair and dark scalps, because of the greater color contrast. Variegated hair color, such as salt and pepper, gives a slightly more natural result because it creates irregularity based upon color variation (Fig. 6.5A&B).
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Fig. 6.5 Appearances before and after transplantation. A, 52-year-old with salt and pepper colored hair (Norwood classification V). B, Result after 2550 grafts. The variegated color of the hair enhances the naturalness of the result. The greater the amount of gray hair, the less the color contrast between hair and scalp.

The less the color contrast between the hair and skin, the better the results.

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.

• Family history is useful, especially on the maternal side, but hair patterns are determined by a multifactorial inheritance. A strong history of hair loss among brothers, uncles, and grandfathers provides some ability to predict future hair loss.
• Another key factor is the availability of the donor hair. Patients may have only minimal hair loss but if they have little donor hair, the procedure and the final results can be limited. On the other hand, a patient with extensive hair loss who has extremely thick donor hair may be an excellent candidate for hair transplantation. The amount of hair in the donor area is quite variable and often ranges from 150 to 400 hairs/cm2. The patient’s with greater hair density are more able to have future multiple procedures to continue transplantation as hair loss progresses. However, a conservative approach is necessary for the patient with limited donor hair, especially if the patient is relatively young.
• One of the most difficult areas to deal with is the occipital region if a halo of alopecia develops around previous transplants. Many therefore prefer not to be aggressive in transplanting younger patients in the occipital area until the area of hair loss is well demarcated or established. One method to reduce problems is to transplant only in the anterior area of occipital hair loss to limit the number of grafts required. Patients may elect to fill in the occipital area provided they understand the significance of this decision and that it will lead to the need for further grafting as hair loss progresses.

Hairline

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.

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Fig. 6.6 Appearances before and after transplantation. A, A high forehead with temporal recession distorts the facial components, creating the illusion that the eyes are centrally located on the vertical plane. B, Transplantation of the anterior hairline and temporal areas create enhanced facial framing. Although the hairline has been lowered only 15 mm, there is a better aesthetic balance.

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.

Taking a family history and explaining to the patient what can be realistically accomplished with hair transplantation is important in achieving a successful outcome.

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).

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Fig. 6.7 Appearances before and after transplantation. A, Patient has Norwood III hair loss pattern. B, Result after 3200 follicular grafts in two sessions. The new hairline is 9 cm above the glabella. Also, an acute frontotemporal angle is maintained.

Appropriate angulation

It is critical when the hairs are transplanted to create the appropriate angulation in the different areas of the scalp. The frontal area should have slight anterior angulation, while the temporal area should have a slightly downward and posterior appearance. Creating angulation in any area of the hair restoration that is too oblique can produce an unnatural or inappropriate appearance.

The angulation of the grafts is extremely important in achieving a natural outcome.

Special Cases

Isolated frontal forelock

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