32. Hair Transplantation
There are many patients that can benefit from hair transplantation, not only men (male pattern baldness) but also females with androgenic alopecia and iatrogenic alopecia, i.e., postrhytidectomy hair loss.
Additionally, there are many examples of reconstructive situations that may benefit from hair transplantation, including eyebrows, eyelashes, moustache and beard, after burns, and after accidents or tumor removal.
With the latest technology in hair transplantation we have today, we cannot make new hair, but rather we can only redistribute the patient’s own hair roots. Suitable candidates have a favorable ratio of supply and density of the donor area as it compares to the size of the area that needs to be transplanted (the “supply and demand” factor).
Definition of Problem
Alopecia: Hair loss resulting from a diminution of visible hair 1 , 2
Three phases of hair growth: Anagen, catagen, and telogen (Fig. 32-1)
Anagen: Active growth
Catagen: Degradation phase
Telogen: Resting phase
Thinning and baldness develop when anagen phase shortens and telogen phase is prolonged. 2
Goals of Treatment
Provide a Natural Look
Hair growing in a natural and consistent direction with a natural appearance
In adult males a natural and mature hairline, with some degree of frontotemporal recession, and the absence of this recession on the female patient
Absence of detectable scarring
Indications
Androgenic alopecia in males and females
Secondary scarring alopecia (postsurgical, burns, radiotherapy-induced, traumatic injuries, postfungal infection scarring)
Congenital hair loss
Contraindications
Chronic lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia, classic pseudopelade of Brocq, folliculitis decalvans, central centrifugal cicatricial alopecia
Preoperative Evaluation
Norwood Classification System for Male Pattern Baldness
Type I: Minimal or no hairline recession at the frontotemporal areas
Type II: Symmetrical triangular frontotemporal recessions extend posteriorly no more than 2 cm anterior to the coronal plane drawn between the external auditory canals
Type III: Symmetrical triangular frontotemporal recessions extend posteriorly more than 2 cm
Type III vertex: Primarily vertex hair loss; may be accompanied by frontotemporal recession that conforms to type III guidelines
Type IV: Sparse or absent vertex hair with more severe frontotemporal recession; areas separated by a band of moderately dense hair that extends across the top of the head
Type V: Same as type IV, but more severe hair loss; band of hair narrower and more sparse
Type VI: Absent band, and two areas interconnect
Type VII: Most severe form; only a narrow horseshoe-shaped band of fine, sparse hair
Type a variants: Applies to 3% of cases in which baldness starts at the anterior hairline without a peninsula of hair and advances in a posterior direction
Ludwig Classification System for Female Pattern Baldness
Grade I: Mild hair loss
Grade II: Moderate hair loss
Grade III: Severe hair loss
Other Considerations
Normal hair density: 140-220 hairs/cm2
Need only 70-110 hairs/cm2 for normal-appearing density
Senior Author Tip:
This can usually be accomplished in two sessions (sometimes three, depending on the thickness and type of hair).
Male pattern baldness 1 , 2 , 8
When we do 2500 grafts, each graft having one, two, three, or four hairs per graft, this equates to somewhere about 5000-6000 hairs in a single session, so double that in two sessions or about 10,000-12,000 hairs in two sessions (see Fig. 32-5). 1 , 2
Donor site dominance
Concept that hair will retain growth characteristics of donor site
Best donor sites are occipital and temporal
Straight versus curly hair 1
Natural results are easier to obtain using curly hair in a single session.
Hair color 1
Dark hair on light skin tone may require more sessions to mask the contrast and create the optimal appearance of hair fullness.
Age 1
For patients <23 years of age, a trial of medical treatment (e.g., minoxidil [Rogaine] or finasteride [Propecia]) is recommended because of incipient baldness.
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