Management of Alopecia

Chapter 6 Management of Alopecia

With current techniques, hair transplants can look totally natural and without signs that a procedure has been performed. ¹ Hair transplantation has, however, a poor reputation because so many patients in the past have had less than acceptable results. ² Scalp reconstruction with flaps and excisions and the use of tissue expanders for male patients with genetic hair loss are now rarely used except in the management of difficult secondary cases. ^3–20

Summary

1. A follicular graft refers to the transfer of clusters of one to three hair follicles emerging as a unit.

2. It is important to maintain the acute ‘frontotemporal’ angle on a male.

3. The natural hairline is not straight and follicles should be placed in an irregular fashion.

4. The natural hair is inclined forward in the frontal area, caudally and posteriorly in the temporal area, and posteriorly in the occipital area.

5. Male pattern baldness is the consequence of testosterone conversion to dihydrotestosterone (DHT) through an enzymatic action mediated by 5-alpha reductase, which targets the hair follicle.

6. The number of hair follicles in the donor area is 150–400/cm².

7. In most patients, the frontal hairline should be 8–10 cm cephalad to the glabella.

8. The harvested follicle unit should include the shaft, the follicle, and a small amount of fat.

9. The most common complication of the hair transplant is the development of inclusion cysts, which are commonly related to placement of the hair follicle too deeply.

10. The best indication for the excision and scalp advancement technique is to eliminate the site of a previously placed poor hair transplant.

Introduction

With current techniques, hair transplants can look totally natural and without signs that a procedure has been performed.¹ Hair transplantation has, however, a poor reputation because so many patients in the past have had less than acceptable results.² Scalp reconstruction with flaps and excisions and the use of tissue expanders for male patients with genetic hair loss are now rarely used except in the management of difficult secondary cases.³^–²⁰

Improvements in results in the past 15 years are due to the work of many in the field, and in particular, Dr Carlos Uebel from Brazil,^21,²² who was one of the first to popularize the use of small natural-appearing grafts in large numbers performed at a single session. Today, rather than transferring a few hundred grafts at each session requiring numerous procedures, it is not unusual to transfer 1500, 2000, and even 3000 grafts in a single session.

Importance of Type of Graft and Design of a Natural Hairline

A discussion of transplantation usually refers to micro or mini grafts.²³ Current nomenclature uses the term follicular grafts,²⁴^–²⁶ which are clusters of one to three hairs that emerge from the scalp as a unit. Grafts often used to contain 10, 20, and even 40 hairs per each graft, so creating an unnatural appearance (Fig. 6.1A&B), and the hairline was often poorly designed. A successful and aesthetically pleasing hair restoration is as demanding as any other aesthetic facial procedure.

Fig. 6.1 Unsatisfactory hair transplants. A, Patient who had hair transplantation 20 years previously. The large plug grafts and hairline that is too straight create an unnatural result. B, Due to the natural progression of hair loss, the plug grafts placed 20 years previously are several centimeters in front of the receding hairline.

The frontotemporal recession is an important component of creating a mature natural hairline in males.²⁷ This anatomic landmark is formed by the junction of two lines, consisting of the frontal and temporal hairlines, which converge in an acute angle. It is critical in creating a natural-appearing male hair transplant to maintain this normal frontotemporal recession. In hair restorations where the frontotemporal angle is not created, the patient frequently has an un-natural result, creating either a feminine or immature male hairline.

Other important components of a natural hairline include the transition anteriorly from fine to thicker hair with increasing density, and a significant degree of irregularity along the hairline margin. Normal hairlines should not appear straight and regular. Perfectly straight hairlines are characteristic of unnatural-appearing hair transplants. Unsatisfactory results with hair transplants usually demonstrate a fundamental lack of knowledge of these critical points required to create a natural-appearing hairline.²⁸

Indications

Most patients seeking hair restoration due to genetic hair loss are male. Approximately 15% of patients who have primary alopecia in my current practice are women and demonstrate typical genetic pattern hair loss. The other main group of patients have had previous hair transplantation with poor results;²⁹^–³¹ these patients are more difficult to treat and fall into two groups:

• those who have been treated with unnatural large plug grafts;

• those in whom the hairline was poorly designed at the time of the original procedure (they are the most difficult to treat).

Most women with hair loss may not be good candidates for hair transplants and may suffer from metabolic autoimmune disorders

One of the main indications in women is secondary or traumatic alopecia after procedures such as facelifts or forehead lifts. In these patients hair loss results from excessive tension or undermining of the hair follicle.³² Such women are ideal for hair transplantation because scars or abnormally high hairlines can be readily corrected. The most common area needing hair transplantation is probably the temporal and preauricular area.

Male Androgenic Alopecia

In most men, hair loss is related to androgenic alopecia. This form of alopecia is a response to androgens, which reduce the rate of hair growth as well as the diameter of the hair shaft.³³ Also, the growth phase of hair referred to as anagen is shortened. It is believed that testosterone is converted by the enzyme 5-alpha reductase to dihydrotestosterone (DHT),³⁴ which targets the hair and causes genetic hair loss. In most men with hair loss, the hair follicles in the frontal and crown regions appear to be most susceptible to DHT, leading to androgenic alopecia. In most patients, 30–50% of the hair has been lost before it becomes apparent. As the average normal head has 100 000–150 000 hairs, a significant amount of hair loss is necessary before it becomes apparent.

Female Hair Loss

Female hair loss is frequently more diffuse, and many women are not good candidates for hair restoration because of a lack of good donor hair.³⁵ However, a subgroup of women present with hair loss similar to androgenic alopecia³⁶ and usually have good hair density in the lateral and posterior areas of the scalp. Many of these women have a history compatible with that seen in male pattern hair loss and report many family members with either thin hair or balding scalps.

Unlike male pattern hair loss of the genetic form, women with genetic hair loss tend to maintain a low frontal hairline with an anterior margin of hair (Fig. 6.2A&B). This is very different from men where there is progressive elevation of the frontal hairline and increasing temporal recession over time. Women, however, frequently maintain a frontal hairline for life, and this factor requires hair transplantation to be performed, beginning from the frontal hairline and continuing posteriorly to fill in the defect.