This article covers how to manage patients with extensive hair loss in whom complete, dense coverage is not possible. In addition to discussing planning a transplant pattern for already bald men, I discuss a conservative approach for recognizing and transplanting younger patients who have telltale warning signs that may evolve to extensive hair loss. For both groups, a variant of a frontal forelock-type pattern is usually the best course to follow.
Key points
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The male patient with a very large area of alopecia relative to the amount of donor hair is best served with a frontal forelock approach, in which front-central density is emphasized along with a gradient of diminishing hair density to the sides and back of the central forelock area.
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All young men should be transplanted in a manner that assumes and prepares for the “worst-case-scenario” in order to avoid creating an unnatural appearance later in life for the patient.
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The lateral gaps off to the side of the forelock can be transplanted using a “hump” concept, which brings the lateral fringe up to the projected “crease” line area, or it can simply be filled in with a “mirror image” approach using sparely spaced FU grafts.
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The vertex area is virtually ignored in most of these very bald patients, since the overriding priority is the frontal and midscalp regions.
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I recommend using the “oval” forelock pattern for the patients with the worst degree of alopecia. For those in whom there is a moderate amount of donor hair and a bi-itemporal width of 12–14cm, I recommend using the “shield” forelock whenever possible.
Introduction
A fair number of the men who consult a hair surgeon have such a large area of alopecia that filling in the entire region or even the entire top plane of hair loss is impossible. Because the area of baldness is large, the corresponding donor area is necessarily reduced. Because the chief surgical goal for these patients with extensive alopecia is to frame the face and have the final result appear natural, the best way (in my opinion) to accomplish this is to create gradients of density, such that the final distribution of hair captures a stage of hair loss that people naturally see in men of that age, namely, that of a frontal forelock. In this article I describe a couple of approaches that can be taken, in which a modest amount of donor hair is used to create the effect of much more hair having been placed on the head and in an area that strongly creates a framing of the face.
Another equally important group of men are those younger patients in their 20s and early 30s who have various clues in their physical examination and history to indicate they might go on to extensive alopecia in the future.
I describe in detail my 2 favorite forelock patterns, the shield forelock ( Fig. 1 ) and the oval forelock ( Fig. 2 ). In addition, I briefly discuss a third pattern, the rounded arrowhead pattern ( Fig. 3 ), which I use rarely.
For the small group of female patients who have extensive balding, the same principles apply, namely the priority of creating front-central density. In women, the useable donor area is often confined to the occipital region. A magnified examination of this occipital hair is key in determining if hair transplantation is likely to be successful for a given patient. If there is some degree of miniaturization in these hairs, then sometimes it is futile to even begin hair transplantation. Often, a nonsurgical hairpiece is a better solution to achieving the look of a full head of hair. When these women with extensive hair loss are transplanted, usually a single styling pattern is agreed on, and the transplants are preferentially placed where they can be styled to create the best visual density of hair.
Introduction
A fair number of the men who consult a hair surgeon have such a large area of alopecia that filling in the entire region or even the entire top plane of hair loss is impossible. Because the area of baldness is large, the corresponding donor area is necessarily reduced. Because the chief surgical goal for these patients with extensive alopecia is to frame the face and have the final result appear natural, the best way (in my opinion) to accomplish this is to create gradients of density, such that the final distribution of hair captures a stage of hair loss that people naturally see in men of that age, namely, that of a frontal forelock. In this article I describe a couple of approaches that can be taken, in which a modest amount of donor hair is used to create the effect of much more hair having been placed on the head and in an area that strongly creates a framing of the face.
Another equally important group of men are those younger patients in their 20s and early 30s who have various clues in their physical examination and history to indicate they might go on to extensive alopecia in the future.
I describe in detail my 2 favorite forelock patterns, the shield forelock ( Fig. 1 ) and the oval forelock ( Fig. 2 ). In addition, I briefly discuss a third pattern, the rounded arrowhead pattern ( Fig. 3 ), which I use rarely.
For the small group of female patients who have extensive balding, the same principles apply, namely the priority of creating front-central density. In women, the useable donor area is often confined to the occipital region. A magnified examination of this occipital hair is key in determining if hair transplantation is likely to be successful for a given patient. If there is some degree of miniaturization in these hairs, then sometimes it is futile to even begin hair transplantation. Often, a nonsurgical hairpiece is a better solution to achieving the look of a full head of hair. When these women with extensive hair loss are transplanted, usually a single styling pattern is agreed on, and the transplants are preferentially placed where they can be styled to create the best visual density of hair.
The consultation and initial patient evaluation
Everything begins with the consultation. That is when the all-important rapport and sense of mutual trust are established between doctor and patient. Also, the surgeon’s examination of a patient’s scalp with fingers, eyes, and high magnification is invaluable for deciding that person’s candidacy for hair replacement surgery. The face-to-face encounter at a consultation is also invaluable for evaluating a patient’s level of maturity and whether or not his or her expectations are realistic or not. The use of a high-magnification examination of a patient’s scalp enables surgeons to precisely gauge the degree of miniaturization present and the average number of hairs per follicular unit (FU) in the donor area. It is also a great teaching tool for explaining to patients that the strong, terminal hairs seen in the donor area are moved to the recipient area, where patients can see the high percentage of thinner, miniaturized hairs. Most importantly, during the course of the consultation, there is an exchange concerning a patient’s wishes and desires for more hair, and this is balanced with the surgeon’s realistic assessment of what is possible and best for that patient. The ideal result from the consultation occurs when patient and surgeon leave the encounter with the same expectations for what the hair transplant process can achieve.
The Younger Man
As noted in the introduction, even though this article deals with what to do with patients with advanced hair loss patterns, I think it is necessary to include in this discussion those young men who have warning signs in their family history and in the physical examination pointing toward possible extensive balding later in life ( Fig. 4 ). Among these signs are the following:
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Large area of miniaturization already
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Family history of Norwood class VII male relatives
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Whisker hair above the ear
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Indistinct fringes with extensive miniaturization in the upper inch of the side fringe
