Hair Transplantation for Men

Marc R. Avram

The goal of hair transplantation is to establish an aesthetically appropriate frontal hairline to frame the face. From the 1960s into the late 1990s, ten to twenty-five 3- to 4-mm hair grafts were the mainstay of hair transplantation, despite the fact that hair naturally grows in the scalp in bundles of 1 to 4 hair follicles. The 10 to 25 hair grafts looked unnatural because they were unnatural. Today, surgeons and their surgical assistants meticulously harvest the natural 1–4 hair-follicular groupings from donor hair and implant them in the recipient region. This technique consistently creates natural-appearing hair (Fig. 31-1A,B). Contemporary hair transplantation requires a highly skilled transplant team. A skilled team is created by having enthusiastic, dedicated members train more than 6 to 12 months to develop skills necessary to create grafts and place them in recipient sites. The surgeon and team work together to accurately and efficiently harvest the donor hair, create a large number of natural 1–4 grafts, create recipient sites, and place the grafts into these sites. This chapter will provide an overview of appropriate candidate selection, the role of medication with surgery, donor harvesting techniques, graft creation, hairline design, and graft placement for consistently natural transplanted hair in men. Hair transplantation procedures are indeed performed in men of darker racial ethnic groups, including Asians, Hispanics, Africans, and African Americans. Techniques are similar for Asians, Hispanics, and Caucasians. However, the unique morphological features of Afrocentric hair require special considerations for hair transplantation, as discussed in this chapter and in Chapter 30.

The Consult

Male pattern hair loss is an involuntary change in a man’s appearance. It affects 50% of men by age 50.¹ The involuntary change in physical appearance is a source of stress for many men. Unfortunately, many believe there is nothing that can be done to halt or reverse their hair loss. In fact, the vast majority of men could halt or reverse their hair loss via safe medical and/or surgical options. A consultation for male pattern hair loss is vital to create the appropriate treatment plan for each individual.

Medical Therapy

The introduction of minoxidil and finasteride as effective treatment options for hair loss have provided physicians with new tools to treat hair loss²^,³ (Table 31-1). Both medications are more effective for patients with earlier stages of hair loss and are an excellent treatment option for patients losing hair but who are not candidates for surgery. For patients who are candidates for surgery, continuing medical treatment will often help increase the density of transplanted hair by slowing down the rate of loss of existing hair and increasing the caliber of existing and transplanted hair. In addition, these medications may help reduce a postsurgical telogen effluvium and maintain donor density.⁴

There are a variety of supplements and products advertised on the Internet and television that purport to stop and reverse male pattern hair loss. The majority are herbal and vitamin supplements. Good nutrition is important for hair growth. The vast majority of men receive more-than-adequate nutrition for normal hair growth, and supplements are not needed. The problem is a genetic, not a nutritional, one. Some men, in their zeal to treat their hair loss, take megadoses of vitamins that have a counterproductive effect and promote further hair loss. Minoxidil and finasteride are the only two medications that have demonstrated through studies to have a consistently positive impact on male pattern hair loss.

Surgery

A hair transplant is an outpatient procedure performed under local anesthesia. The average procedure takes 3 to 4 hours. The majority of the time is used to create an average of 1,000 to 1,500 1–4 hair grafts, produce recipient sites, and place the grafts. Patients resume normal activities immediately, with a restriction on heavy exercise for 3 to 7 days after surgery. If there is pain after the procedure, it occurs during
the day of the procedure, and a mild pain medication is adequate for relief. The day after the procedure, patients should feel no discomfort. Typically, the only physical evidence of the procedure is the perifollicular crusting that remains 6 to 8 days and in some patients edema in the forehead for 2 to 3 days. Most patients return to work 2 to 3 days after the procedure without any negative cosmetic impact.

Figure 31-1 Before hair transplant (A) and after 800 1–3 hair grafts (B).

Table 31-1 FDA-approved medical therapy: comparison of the only two FDA approved medications for male pattern hair loss

	Finasteride	Minoxidil
Mechanism of action	5-alpha reductase type II inhibitor Blocks the conversion of testosterone to dihydrotestosterone	Unknown
Key to success	Emphasize maintenance over regrowth of hair Compliance for at least 6–8 months to see a benefit	Emphasize maintenance over regrowth of hair Compliance 6–8 months to see a benefit
Side effects	2% of men experience sexual dysfunction. Reversible within days if discontinued. No allergic reactions, blood monitoring, or drug interactions. Women should never handle or take medication.	Dryness and pruritus of the scalp. Rare allergic reaction.
Clinical onset of action	6–8 months	6–8 months
Dose	1 mg once daily with or without food	2–4 drops 1–2 times daily to frontal and vertex of scalp

All patients undergoing hair transplantation should expect natural-appearing transplanted hair. During the consult, realistic expectations need to be created for short- and long-term density from a hair transplant. All skin types and hair colors are candidates for surgery. The physical exam includes evaluating the donor density and caliber of the hair follicle which will help determine the expected density from the procedure. Patients with below-average donor density and fine-caliber hair will have natural but thin transplanted hair. Those with above-average density with wide-caliber hair follicles can expect greater perceived density. The density of transplanted hair will be affected by the rate of hair loss and/or postsurgery telogen effluvium. Patients with a lot of remaining hair but rapid loss of hair may even have less hair 12 months after surgery. The extent and rate of hair loss varies from person to person. During the consult, the surgeon must emphasize
the ongoing nature of hair loss with or without surgery. Despite recent 5-year studies confirming the long-term benefit from these medications, it is vital that surgeons still apply the same criteria for candidate selection and hairline design in patients with successful medical treatment.

Patients should be aware of a permanent scar in the donor region from the harvesting of hair for the transplant. For the majority of patients, the scar does not create any physical or cosmetic concern. Some patients that may shave their hair or wear it closely cropped to the scalp should be aware the scar will be visible before the procedure is performed. Explaining the ongoing loss of hair with or without transplantation, role of medications, permanent donor scar, realistic density based on hair caliber, and long-term hair loss will help create realistic expectations for patients. If a patient does not have a realistic expectation for what a transplant can and cannot achieve in the short and long term, the surgery should not be performed.

Figure 31-2 Donor ellipse harvesting.

Donor Region

The limiting factor in hair transplantation is the amount of hair available in the donor scalp of patients. From the 1960s into the 1990s, steel punches measuring from 3 to 4 mm in diameter were used to harvest donor tissue from the posterior scalp. This resulted in extensive scarring over the posterior scalp and an inefficient use of valuable donor hair. In the mid-1990s, multibladed knives were popularized as an easy method to obtain elliptical strips that were easily dissected into smaller follicular units.⁵

Only gold members can continue reading. Log In or Register to continue