Hair Transplantation in South Asian Hair

89B Hair Transplantation in South Asian Hair

Venkataram Mysore, Sanjeev Vasa, and Manoj Khanna

Summary

Hair restoration in South Asian patients has certain specific features because of ethnic characteristics, cultural aspects, and attitudes. Recent economic liberalization, Internet, and globalization have led to changes in attitude and increase in hair transplantation.

Keywords: South Asian hair ethnic features

Key Points

•South Asian skin shows great variations in hair and skin characteristics, which impact the outcome in hair transplantation.

•Religious attitudes such as shaving the head and using a turban in Sikhs are important considerations.

•Hypopigmentation after follicular unit extraction (FUE) and wide scars after strip excision are common.

•Patients prefer a wider hairline design.

•Hair transplantation is emerging as an important method of treating vitiligo.

89B.1 Introduction

South Asian region includes India, Pakistan, Bangladesh, Sri Lanka, Bhutan, Nepal, and Maldives. This region is especially unique in that there is great ethnic variability—Caucasian, Dravidian, Mongoloid, Negroid, and others—all types are found, and a mixing over the centuries have led to great variations in hair characteristics.13

South Asian skulls are smaller than Caucasian skulls and Mongoloid skulls. In most Indian patients, maximum possible length in a strip is about 28 cm, with a range of 25 to 32 cm. It is rare to get more than 32 cm.

Androgenetic alopecia (AGA) in Indian patients is increasingly being seen—most hair restoration physicians believe that the incidence itself is on the rise. Onset appears to be at younger ages and the author has seen patients as young as 15 years presenting with AGA. Fifty-eight percent of the male population aged 30 to 50 years had AGA.¹⁴ Its grade increased with increase in age. Among males, 12.9% of the population had grades IV to VI, while 44.1% had grades I to III, in a study.¹¹ Basic and specific (BASP) classification seems more relevant, and suitable, but it is also more time-consuming to adapt in routine practice.¹⁵

The diffuse type is particularly important to consider when considering a patient for transplantation, as these patients are poor candidates for transplantation.¹⁶ Diabetes and hypertension (metabolic syndrome) are increasingly common in the Indian population.¹⁷

89B.2 Hair Characteristics

89B.2.1 Color

The combination of hair and skin color varies among Southern Asian patients:

•Fair skin and dark hair: This combination is seen in patients from northern parts of India and some patients in other parts of India. These individuals have a strong contrast between hair and skin color.

•Fair skin and lighter colored hair: This combination can be seen in patients of northern parts of India. Hairs merge against the background more easily.

•Dark skin and dark colored hair: This combination is seen in South Indian and Sri Lankanpatients. In these patients, contrast is minimal. The disadvantage is that slits, particularly in the preformed slits method, are often difficult to identify. Dyes such as methylene blue are useful to identify the slits.

89B.2.2 Caliber

Asian hair has been shown to be thicker than Caucasian hair, but the density per square centimeter is lower. It can be said that people from south India and Sri Lanka have thicker hairs than those from northern India. The average thickness of hairs in the author’s experience varies between 0.6 and 0.9 μm. Asian hair has more cuticle layers and wider cuticle cells than Caucasian hair, and the cuticular inclination of Asian hair is steeper and its cuticular interval is narrower than in Caucasian hair.¹⁸

89B.2.3 Curl

Most Indians have straight hairs. Curly hair to varying extent is seen in some patients in all regions. However, curliness, when present, is usually mild and is more a waviness than curliness.

89B.2.4 Density

Unpublished data show that density varies among patients widely. The average hair density per unit is about 2.2 to 2.4. Density can vary from area to area within the scalp. The average density in Indian patients¹⁹ is 88.8 follicular units (FUs)/cm² as determined by Tricho Scan.

89B.3 Customs and Religious Practices regarding Hair

There is one unique feature of the Indian society, which is the custom of arranged marriages, which is still a predominant system of marriage. This means that parents arrange brides for the young men, and baldness is a disqualification for such men!!!.

Sikh men constitute another important special group. These men, called sardars, grow their hair long and then tie their hair in a knot before covering tightly with a piece of cloth called pagdi. The hairs are often arranged with a gel and then pulled. This results in traction alopecia, which is seen not only in frontal areas (Fig. 89B.1), but also in temporal areas. Further, it is also seen in the lower part of the beard because people apply gel to tie the hair, which stretches it and then it causes alopecia. This is mainly seen under the chin, but even the right or the left submandibular region can be involved.