Patient consultation, examination, and selection are crucial for successful outcomes in hair restoration surgery. The hair restoration surgeon must take a holistic approach in identifying those patients who are and who are not candidates for surgery. In this article, an overview of the consultation, pertinent physical examination features relating to patient candidacy, and several treatment paradigms are discussed. Additionally, those findings that may lead to poor results and conditions that are contraindications to hair restoration surgery are reviewed.
Key points
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Hair restoration physicians must determine which patients are appropriate candidates for successful hair transplantation and understand the physical characteristics that may lead to less than optimal results.
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Hair restoration physicians must be cautious in selecting a young patient to transplant because these patients often desire aggressive restoration patterns in the setting of an unpredictable future of hair loss.
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Hair loss is progressive and can be unpredictable at any age.
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A thorough preoperative evaluation is essential to exclude those patients with conditions that are contraindications to hair restoration surgery and may require referral to a dermatologist.
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A detailed, long-term treatment plan must be prepared to ensure the patient’s goals coincide with the anticipated outcomes outlined by the physician.
Introduction
Male-pattern baldness (MPB), also known as androgenetic alopecia (AGA), is the most common cause of hair loss. In affected areas, genetically sensitive hair follicles exposed to normal levels of dihydrotestosterone (DHT) go through progressively shorter anagen (growth) phases. New generations of terminal hairs miniaturize, becoming shorter, finer, and lighter in color, and they conceal the scalp less. In its final phase, the terminal hairs transition into vellus hairs. Miniaturization may be gradual or can come in waves, and the course and extent of AGA are unpredictable. There is polygenic inheritance and variable penetrance, so family history alone is not predictive.
Hair transplantation involves relocating unaffected donor hair follicles to a recipient area of thinning or balding with the expectation that the transplanted follicles will continue to produce unaffected terminal hairs. Experts once believed that the donor area was separated from the recipient area by a well-demarcated line. That definition of MPB stated that a man established a pattern, balding occurred within the pattern, and the pattern did not change significantly after midlife. The inference was that the surgeon could predict the patient’s final pattern or the lowest line of demarcation when a man reached an age somewhere between 30 and 45. Unfortunately, we now know that terminal hair has the potential to progress to vellus hair decades beyond the initiation of the balding process. The clear line that once was presumed to be permanent is actually an indistinct line that can advance inferiorly in many more cases, and often at much later ages, than we once thought possible.
Introduction
Male-pattern baldness (MPB), also known as androgenetic alopecia (AGA), is the most common cause of hair loss. In affected areas, genetically sensitive hair follicles exposed to normal levels of dihydrotestosterone (DHT) go through progressively shorter anagen (growth) phases. New generations of terminal hairs miniaturize, becoming shorter, finer, and lighter in color, and they conceal the scalp less. In its final phase, the terminal hairs transition into vellus hairs. Miniaturization may be gradual or can come in waves, and the course and extent of AGA are unpredictable. There is polygenic inheritance and variable penetrance, so family history alone is not predictive.
Hair transplantation involves relocating unaffected donor hair follicles to a recipient area of thinning or balding with the expectation that the transplanted follicles will continue to produce unaffected terminal hairs. Experts once believed that the donor area was separated from the recipient area by a well-demarcated line. That definition of MPB stated that a man established a pattern, balding occurred within the pattern, and the pattern did not change significantly after midlife. The inference was that the surgeon could predict the patient’s final pattern or the lowest line of demarcation when a man reached an age somewhere between 30 and 45. Unfortunately, we now know that terminal hair has the potential to progress to vellus hair decades beyond the initiation of the balding process. The clear line that once was presumed to be permanent is actually an indistinct line that can advance inferiorly in many more cases, and often at much later ages, than we once thought possible.
Patient selection
With regard to devising a surgical protocol, MPB must be defined as an event that proceeds into the ages of 50s, 60s, and beyond. If MPB was a static process, the surgeon could easily choose a surgical procedure that would suit the patient for life. However, MPB is a dynamic process that can alter a patient’s eligibility for any given procedure depending on the stage of baldness ( Fig. 1 ). If, at age 30 years, the patient’s baldness is defined as class IV, the physician must consider the risk of the baldness progressing to class V, VI, or VII in later years. The physician must factor in the variable of progression and select an appropriate treatment based on the patient’s final pattern. If the surgeon would not perform a particular procedure on a 55-year-old man with class VI or VII baldness, he should not perform that same procedure on a 30-year-old man with class IV baldness because he may be the same patient 25 years later.
Patient Consultation
An in-depth consultation allows the patient to communicate their goals and desires for the hair restoration procedure. The surgeon must take into account the patient’s age, medical history, family history of alopecia, facial features, and hair characteristics (caliber, texture, color) that may have an effect on the final outcome. Young patients usually request a full head of hair even though future balding can make them poor surgical candidates for the procedures that are recommended. The surgeon must counsel young patients about their denial of how bald they will become and about any unrealistic fantasy of regaining a full head of hair. The fact is that hair transplantation does not create new hair; it only rearranges existing hair. The patient must understand his condition and the limitations of surgical restoration so that the surgeon can create an honest and logical treatment plan. Wherever possible, it is best to demonstrate before and after photographs of patients who faced similar limitations to show surgical candidates what results they can realistically expect.
Clinical Examination
Simple procedures can be used to uncover subtle signs and improve diagnosis. Some physicians advocate wetting the hair to determine the line of demarcation between permanent terminal hair and thinning vellus hair. Wetting the hair can help identify currently thinning hair but does not predict future thinning. What appears to be terminal hair on the wet head of a 30-year-old man is not guaranteed to be terminal hair when he is 40 or 50 years old. However, wetting the head is useful for communicating a treatment plan to the patient and helping the patient appreciate the significance of his future pattern.
Parting the hair in various areas may demonstrate differences in density or miniaturization. Because hair hangs down, parting is essential to assess the quality and density of donor hair. High-power magnification with a hand-held microscope camera, densitometer, or even loupe makes miniaturization, scarring, or hair abnormalities easier to see. Trimming hairs first can show miniaturized hairs that are normally hidden by longer terminal hairs. A pull test can be used to check for effluvium. Typically, a cluster of 30 to 40 hairs is grasped at the base then pulled slowly. If five or more telogen hairs are pulled out, it is considered a positive test, and surgery should be postponed until the cause of the hair loss is discovered. Simple mechanical devices are also available to measure hair volume to help detect subtle volume changes that develop before miniaturization may be noticed. Finally, a full-depth scalp biopsy can be submitted for histopathological diagnosis to help identify the cause of any suspected inflammatory or scarring hair loss condition.
Transplantation candidacy
Although most patients with hair loss are good candidates for hair replacement surgery (HRS), some are not. To identify noncandidates and nonideal candidates, the hair replacement surgeon must examine every prospective patient carefully and actively look for warnings or red flags ( Table 1 ).
The extent to which hair can be replaced on a given individual’s head depends on the following law of MPB: the balder a man is, the more grafts he will need to restore the bald area. The more grafts he needs, the fewer grafts he will have because of the inverse reciprocal relationship between the donor and recipient areas. Almost every man is a candidate for hair transplantation provided he accepts the limitations of surgery and understands the final hair loss pattern that will result. Even a patient with advanced class VII baldness can be a candidate if the donor supply is sufficient to meet his individual expectations.
Good Candidates
Good HRS candidates have realistic goals, stable and high-quality donor hair, and a recipient area that will support growth of the transplanted hair. They should have enough donor hair available in their lifetime to cover enough of the eventual balding or thinning pattern to maintain a natural hair (loss) pattern and to fulfill individual recipient-site density expectations.
Noncandidates
Unrealistic expectations
After the initial greeting, it is best to ask an open-ended question such as “What are your goals for your hair?” This simple question can help determine whether the patient has reasonable expectations related to the limitations of surgical restoration, the progressive nature of hair loss, and the finite nature of donor supply. Transplanted hairlines do not recede, but patients’ faces age. It is both impossible and undesirable to restore a patient’s hairline, density, and coverage to teenager levels. Young patients are particularly prone to excessive expectations because they compare themselves to their recent past and to their peers. Ironically, they need a more conservative plan than do older patients with a similar pattern of loss. Younger patients have a higher risk of extensive loss because they have more years of hair loss ahead and may have faster hair loss. Many young patients, but not all, do not have the maturity or foresight to temper their short-term expectations to achieve their best long-term goals.
Patients with depression, obsessive-compulsive disorder, or body dysmorphic disorder may be psychologically unable to be satisfied with any HRS results. Mental illness may also make the recovery period difficult to bear.
Donor hair issues
Some patients do not have a stable supply of donor hair. For example, diffuse unpatterned alopecia is an uncommon variation of AGA in which hair follicles in the traditional donor area are also sensitive to DHT and will miniaturize ( Fig. 2 ). Transplanting DHT-sensitive donor hairs can result in poor growth or later loss of transplanted hair. Donor scars can also become visible with progressive thinning in the donor area. Other examples of unstable donor hair include active alopecia areata, primary scarring alopecia, and active effluvium (see Table 1 ).
