Female hair loss is a devastating issue for women that has only relatively recently been publicly acknowledged as a significant problem. Hair transplant surgery is extremely successful in correcting the most cosmetically problematic areas of alopecia. This article discusses the surgical technique of hair transplantation in women in detail, including pearls to reduce postoperative sequelae and planning strategies to ensure a high degree of patient satisfaction. A brief overview of some of the medical treatments found to be helpful in slowing or reversing female pattern hair loss is included, addressing the available hormonal and topical treatments.
Key points
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Female hair loss is a prevalent condition with a particularly devastating psychological impact.
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Hair transplantation is the only currently available option to provide a permanent and natural solution for female patients with alopecia.
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Surgery for female patients should be performed in strategic areas to produce the maximum cosmetic impact.
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Grafts containing 1 to 6 hairs can be used to create different zones of density.
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Female patients need to understand the postoperative sequelae and the evolution of female pattern hair loss to ensure a successful outcome.
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When appropriately treated, women are among the most grateful of all hair transplant patients.
Treatment goals
Unique to female hair transplantation is the advantage that female pattern hair loss (FPHL) does not usually cause complete alopecia in any area, rather the affected regions become thinner. Therefore, it is reasonable to focus hair transplant surgery in the most cosmetically significant regions as opposed to the surgical treatment of men that requires a more diffuse coverage of the affected areas that are, or will become over time, totally alopecic ( Fig. 1 ). The hair restoration surgeon (HRS) needs to examine patients and have an in-depth discussion to determine exactly which areas this might include. It is best to underestimate the area that can be addressed in a single surgery. The goal is increased density, in other words, patients will still be able to see their scalp, just less of it; this needs to be clearly understood. It is also advisable to review and prescribe medical treatments if applicable, which can help to stabilize or slow future hair loss and, in a minority of cases, may even help patients recover some density.
Treatment goals
Unique to female hair transplantation is the advantage that female pattern hair loss (FPHL) does not usually cause complete alopecia in any area, rather the affected regions become thinner. Therefore, it is reasonable to focus hair transplant surgery in the most cosmetically significant regions as opposed to the surgical treatment of men that requires a more diffuse coverage of the affected areas that are, or will become over time, totally alopecic ( Fig. 1 ). The hair restoration surgeon (HRS) needs to examine patients and have an in-depth discussion to determine exactly which areas this might include. It is best to underestimate the area that can be addressed in a single surgery. The goal is increased density, in other words, patients will still be able to see their scalp, just less of it; this needs to be clearly understood. It is also advisable to review and prescribe medical treatments if applicable, which can help to stabilize or slow future hair loss and, in a minority of cases, may even help patients recover some density.
The initial consultation
The first meeting with patients should begin with a thorough discussion of the family history of female hair loss and a pertinent medical history of the patients themselves. One of the most important medical issues to review in depth are hormonal disorders or recent changes, including some of the more common ones related to hair loss: polycystic ovarian syndrome, adding/stopping/changing birth control pills, perimenopause, menopause, postpartum hormone changes, thyroid abnormalities, and pituitary abnormalities. Diet changes and changes in medication should be looked at as possible reasons for telogen effluvium, and surgery should not be pursued if it is possible the hair loss may be temporary. In some female patients, the impetus for seeking help may be a recent telogen effluvium coupled with FPHL, in which case surgery should not be performed until regrowth of the recent temporary hair loss has occurred (usually 6 months after the resolution of the inciting event). The reason for this is that hairs in the donor area may have been affected by the temporary loss and would be dormant at the time of surgery; these dormant follicles would be discarded as part of the alopecic tissue between visible hairs, resulting in an unnecessary loss of precious donor hair.
In the author’s experience, there have been 2 conditions that warrant special mention with regard to female patients:
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Lichen planopilaris
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Alopecia areata incognita (AAI)
Lichen planopilaris is an autoimmune disorder that causes a scarring permanent alopecia; the author has noticed an increased frequency in patients, especially the frontal fibrosing variant. Many of these patients are unaware they have the condition and think they suffer from a particularly severe pattern of female hair loss affecting their hairline and temple regions. It is important to identify this condition, confirm quiescence, and educate patients regarding the recurrent nature of the disease and need for frequent monitoring by a dermatologist before attempting any surgical correction. This author has had great success in surgical correction of frontal fibrosing lichen planopilaris ( Fig. 2 ); however, it requires treating the recipient area as one would any other area of cicatricial alopecia and ensuring there is diligent postoperative follow-up.
The author has diagnosed a much greater number of patients with AAI in recent years. It is unclear whether this increased frequency is caused by better diagnostic tools or a true increase in incidence. This condition is particularly difficult to diagnose if patients have an underlying FPHL that is unmasked by the alopecia areata. It is very important to ask questions regarding the onset, duration, and course of hair loss; if patients report that the alopecia has occurred over a relatively short period of time, the physician should have a higher degree of suspicion. The dermatoscope is a tool that has been very helpful in diagnosing AAI. On examination with the dermatoscope, the physician should look for dystrophic or cadaverized or exclamation point hairs, small yellow dots within the ostium of both empty and hair bearing follicles, and areas of complete alopecia within intervening areas of thinning ( Fig. 3 ). Both the potential recipient and donor areas need to be examined and a biopsy performed if there is any question. Unfortunately, even biopsy results may be unclear. If there is any question remaining, this author prefers to try medical treatment. The treatment of choice for her patients is the use of 0.5% clobetasol cream under occlusion 5 nights weekly for 5 weeks, combined with morning application of 5% minoxidil for 3 months. Results are assessed at 3, 6, and 9 months.
Preoperative planning for female hair restoration
The most important aspect of preoperative planning in females is deciding the size and location of the area to be treated. The donor area should be carefully assessed to provide an estimate of the number of follicular units that can be harvested in one surgery as well as the total lifetime estimate of available donor hair. This assessment will help inform the surgeon’s decision regarding which area should be treated in the present surgery and which area or areas might be important to address in the future. Women’s long-term donor rim hair is generally less dense and shorter than that seen in men.
Determining Hair Transplant Candidate
There is a great diversity in opinions as to how many women are candidates for hair transplant surgery. The author thinks that the source of this range in perspectives is caused by the HRS’s assessment of the available donor hair versus the actual size of the area of thinning. If the HRS’ goal is to treat virtually all the areas affected by alopecia, then indeed a limited number of women would be good candidates. However, if the surgeon understands that certain areas of hair loss are much more important and increasing the density in those regions can make a very significant impact on the woman’s appearance and styling options, then many more women can greatly benefit from hair restoration surgery. The author has encountered many women who are, in reality, very marginal candidates in terms of the extent of thinning versus the available donor hair. However, treating the most cosmetically significant area allows these patients to style their hair strategically to cover other areas and avoid wearing a full wig, which is a result that makes a great impact in their lives ( Fig. 4 A ).
Styling Hair to Determine Areas for Transplant
It is helpful to try styling the hair in different ways (straight back, central part line, side part line, and so forth) to make the best choice regarding which area is indeed the most important cosmetically. The area to be treated should be outlined with a grease pencil, and photographs should be taken with the patients’ hair both wet and dry (see Fig. 4 B). These photographs should be reviewed with patients and adjusted if necessary to incorporate the patients’ goals, keeping in mind the donor limitations and likely future areas of concern. It is vitally important that patients understand that any grafts used in the current surgery will necessarily reduce the number available to address future areas of loss. Ideally, the most important region for the duration of the patients’ life should be addressed in the first surgery, and less important regions (such as the temple recessions) should be not be treated at all or treated with low density. Preferably, only more mature women with abundant donor hair and a limited region affected by alopecia should have areas of lesser importance addressed in a first surgery. To accept these limitations, the HRS needs to spend a great deal of time explaining to female patients the progressive nature of female hair loss, the relationship to the family history of FPHL, and life events that may cause an increase in the speed of hair loss in the future (very notably menopause).
Examining Female Hairline Design
Hairline design in women is quite complex. There are an endless number of variations; although it may be possible to describe some commonly occurring contours, this surgeon generally creates hairlines based on the individual’s unique contour. Many times this contour can be determined by following the miniaturized hairs still evident in the hairline; adding terminal hairs in the same distribution and pattern will create the most natural line. If the hairline is completely absent, an older photograph can direct the surgeon appropriately to create the hairline contour best suited for each patient. The only recurring theme is that the hairline should be very irregular, including both macroirregularities and microirregularities.
Determining Hair Transplantation Technique
Donor harvest via strip excision is the most commonly used technique for removing the donor in women; however, there are special situations when follicular unit extraction (FUE) may be of benefit. Specifically, appropriate candidates for FUE are women who have had a previous strip harvest and have areas of chronic paresthesia, those with very limited scalp laxity, and patients who have a history of poor healing. The disadvantages of FUE in women are similar to that in men, with one notable exception: women generally have longer hair and, thus, shaving of the donor area for harvest has a much greater impact and takes considerably longer to resolve completely. Additionally, women frequently have very limited donor hair reserves relative to their large areas affected by alopecia; therefore, it is important to be able to maximize the yield of grafts from the most permanent fringe of hair. The grafts tend to be more fragile and prone to damage, and studies on survival are limited. Furthermore, FUE requires that the extraction sites be surrounded by intact hair-bearing tissue; thus, only every third follicular unit (FU) can be removed. For these reasons, a strip harvest is usually preferred.
Laboratory Tests Before Hair Restoration
Basic laboratory tests include complete blood count, basic chemistry panel, hepatitis, and human immunodeficiency virus. Medical clearance is obtained when necessary. All patients are prescribed preoperative prophylactic antibiotics and given a list of foods and supplements to avoid. Patients taking anticoagulants for therapeutic reasons are told to continue their medications, whereas those taking baby aspirin as prophylaxis are told to discontinue; clopidogrel bisulfate (Plavix) is the one exception. Provided their cardiologist or neurologist approves of discontinuation for surgery, the patients are told to stop Plavix 5 days before surgery and resume 2 days postoperatively. All patients are advised to start a homeopathic regimen 2 weeks before surgery and continue for 2 weeks after surgery. The regimen includes arnica tablets, arnica gel postoperatively, bromelain, and vitamin C. Although the author does not have scientific proof of efficacy, experience has revealed that this regimen significantly reduces the incidence of postoperative bruising and edema, which is particularly important in female patients who have a greater tendency to bruise and swell in the forehead and temple areas.
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