Hair Transplantation in Black Patients

90 Hair Transplantation in Black Patients

Ahmed Adel Noreldin

Summary

The traditional terms for hair in black people are various (curly, kinky, Afro, etc.), but perhaps the most appropriate term is “highly textured” hair (HTH). This hair can actually be present in people of many backgrounds, but this chapter focuses on black patients. This HTH has better coverage capacity than straight hair, yet its harvesting is more challenging as compared to straight hair, because hair shaft transection is more difficult to avoid and occurs with greater frequency. The hair transplant surgeon has to be aware that the curliness often continues from top to bottom of the hair follicle including the root. Therefore, extra care should be given to donor harvesting in order to ensure preservation of intact follicles. There are certain tips and practice recommendations for harvesting the follicular units from the donor area with both strip technique and follicular unit excision method. In both cases, an experienced surgeon leading a dedicated team of assistants is essential to a good outcome in harvesting hair follicles from patients with HTH.

Keywords: hair transplant highly textured hair curly hair recommendations for FUE in black patients strip recommendations for black patients folliculitis

Key Points

•Evaluate carefully the direction of hair shaft preoperatively in black patients.

•Do not give much promise preoperatively about the number of follicles you are going to extract; rather concentrate on the degree of coverage that can be achieved.

•If the initial testing proves poor yield of follicular unit extraction (FUE) do not hesitate to shift to follicular unit transplantation (FUT).

•It is worthy to take ample time in both extraction and implantation.

90.1 Introduction

Hair characteristics and styles vary among different cultures and ethnic groups, playing a significant role in their lives, often conveying important conceptions of gender, class, personality, and beauty.1 This is especially true for people of African descent, due to the unique nature and texture of their hair.² In African people, hair is intensely symbolic. Its meaning is integrated into their culture and daily life and serves as a method of self-expression.³

In the past, aesthetic plastic surgery was viewed in the black community as something that “white people” did as well as a waste of money and a sign of vanity. However, at present more and more black men and women feel more open toward enhancing their physical appearance, and hair restoration is not an exception. While there are no data detailing the exact percentage of black patients undergoing hair transplantation today, many practitioners have reported seeing an increasing demand from this population in their practice.⁴

The older plug technique did not have a reliable success rate among the black population.⁵ The introduction of follicular unit transplantation (FUT) in the 1990s resulted in higher success rates and a more natural appearance, which in turn increased the demand from people of black ethnicity. The demand for hair transplant treatments increased even more after the follicular unit extraction (FUE)technique was introduced in the early 2000s due to the popularity of very short hair cuts in the majority of black males and the concern over visible donor scarring.

90.2 Characteristics of Hair

The morphological characteristics of hair, such as curl, caliber, and density, can be very loosely categorized along racial origins and ethnic groups. For example, Asian hair is typically straight, thick, and round in cross-section; Caucasian hair is usually straight, medium in caliber, and oval in cross-section; and black hair is tightly coiled, lower in caliber, and elliptical in cross-section (Fig. 90.1).

Fig. 90.1 Illustrations of racial variations in hair. (a) White race: the hair is slightly curved with medium-thick hair shaft. (b) Black race: slightly flattened, ribbon like, and medium-thick hair shaft. (c) Asiatic race: more straight and thick hair shaft.

The hair of black patients has unique characteristics that have both advantages and disadvantages when it comes to hair styling, hair health, and hair restoration surgery. The traditional terms for hair in black people are various and include curly, kinky, Afro, etc., but perhaps the most appropriate term is “highly textured” hair (HTH). This HTH has better coverage capacity than straight hair, yet its harvesting is more challenging as compared to straight hair, because hair shaft transection is more difficult to avoid and occurs with greater frequency. This hair can actually be present in people of many backgrounds, but this chapter focuses on black patients. In this chapter, we will use the term HTH when referring to the properties of hair in black patients, which will be described in more detail later.

90.2.1 Curl

The shape and curl of hair is thought to reflect variations in cross-linking in the cortex that develops during the molding of the hair shaft. Genetic differences in metabolism and skin structure are involved in determining these differences.5 Black patients have HTH. The degree of curl can range from a moderate curl to a very tightly coiled curl. The HTH of black people is prone to dryness, and the cuticle weathers more rapidly than that of other hair phenotypes. This dryness is proportionate to the degree of curliness, which hinders the distribution of the sebum produced by the scalp. As a consequence, the hair is more vulnerable to physical damage and breakage during grooming and requires particular attention to moisturization. The common practice of hair straightening contributes to the hair and scalp damage seen in this population. Repetitive treatments to straighten the HTH often require the use of toxic chemical hair relaxers and/or intensive heat, up to 400 degrees. These treatments expose these patients to scalp burns and to variable degrees of hair loss.⁶

The major benefit of a high degree of curl is that a given amount of hair covers more surface area and creates a greater illusion of fullness than straight hair. On the other hand, with extreme curl, the hair shaft enters the skin horizontally and continues to curl below the skin, on a path and to a degree that cannot be predicted from the surface (Fig. 90.2). This, along with a tendency for greater splay in black hair, increases the risk of transection during donor harvesting for both FUT and FUE (Fig. 90.3). This is the disadvantage of extreme curl.

Fig. 90.2 (a) Straight hair follicle. (b) Curly hair follicle.(Reproduced with permission of Belal Kamel.)

Fig. 90.3 Hair follicles from a black patient with curly hair showing curls and splaying at the base.

90.2.2 Color Contrast between Hair and Scalp

The colors of hair and skin vary considerably in people who are considered “black,” from lighter brown to darker black.⁵ Black hair on dark skin has a low color contrast and, along with the HTH, the benefit of the low contrast is an increased illusion of fullness with a given amount of hair. The downside of decreased color contrast is a greater difficulty visualizing incisional sites, making both visualizing your pattern and placing grafts more difficult. The use of recipient site staining and/or cross-polarization to help visualize recipient sites may be particularly helpful in these patients

90.2.3 Hair Density and Hair Caliber

The density of hair in blacks is significantly lower than that of Caucasians (~60–65 vs. ~80–100 FU/cm², respectively).⁷ The caliber of hair in blacks is also lower than that of other ethnicities. Hair shaft diameter averaged 60 to 65 µg in blacks versus 70 to 75µg in Caucasians and closer to 100 µg in East Asians. These characteristics of low density and low caliber make it more difficult to achieve an illusion of density and have to be taken into consideration when planning a hair restoration procedure in black patients. However, good results can often be achieved because the high curl and low color contrast mentioned earlier decrease the incisional density needed to meet patient expectation of fullness. Some feel only about 50% of the incisional density (compared to other ethnicities) is needed to produce good coverage.

90.3 Evaluation and Concerns

Most black male patients’ major complaint is classic pattern androgenic alopecia. The goal is usually rebuilding the frontal hairline and improving coverage. The situation in black females can be more complex. They often present with hair loss due to traction alopecia (TA), which causes frontotemporal recession (Fig. 90.4). This is related to long-term use of styling tools or tight braiding. In its early stages, it responds well to conservative measures like minoxidil and proper patient education. Another not uncommon complaint in black females is the end stage of central centrifugal cicatricial alopecia (CCCA; Fig. 90.5) or frontal fibrosing alopecia (FFA; Fig. 90.6). The end stage of CCCA usually leaves a centrifugal clearing of the involved area. It should be confirmed that the recipient area is not actively inflamed before carrying out hair transplantation, and even then, the decision to do hair transplants is controversial. Experienced surgeons feel that surgery can be attempted after 2 years of disease quiescence, and with continued monitoring. If in doubt, a biopsy is useful⁸^,⁹ (see Chapter 76).