The Patient with Minimal Hair Loss: Planning and Decision-Making

23 The Patient with Minimal Hair Loss: Planning and Decision-Making

Marc R. Avram and Robert Finney

Summary

This chapter discusses the approach to the patient with early androgenetic alopecia and the role that hair transplant surgery can have in this cohort. As with all patients, setting expectations during the consult and appropriate patient selection are the keys to successful cosmetic outcomes. Age, pattern, gender, donor density, and hair caliber are all factors that can affect whether a patient is a candidate for hair surgery. Given the progressive nature of pattern hair loss, despite having minimal hair loss, a conservative surgery should be planned if a patient pursues hair transplantation. This will help ensure a good long-term cosmetic result.

Keywords: minimal hair loss hair transplantation hair surgery androgenetic alopecia pattern hair loss

Key Points

•Medical therapy should be emphasized in all patients with minimal hair loss.

•Transplanting the vertex should be avoided in the majority of patients with minimal hair loss.

•The best surgical candidates with minimal hair loss are older patients with stabilization of hair loss on medical therapy.

23.1 The Consult

The approach to a patient with minimal hair loss, like with any hair loss patient, begins with the consult. It is important to take a complete medical and hair loss history from the patient. This includes an inquiry as to the onset, course, and treatments tried for hair loss, as well as history of skin conditions involving the scalp. Medical conditions such as thyroid disease or iron-deficiency anemia can cause or accelerate hair loss. Further questioning regarding family history, diet, significant weight loss, and review of systems is important.

23.2 The Physical Exam

A clinical exam should be performed to rule out inflammatory or infectious etiologies. It is important to establish a clinical diagnosis for each patient before considering medical or surgical therapy for their hair loss. The exam should be performed by a dermatologist or hair loss expert comfortable with diagnosing and treating medical and surgical hair loss. If the hair transplant surgeon is not comfortable assessing medical aspects of hair loss, the patient should be referred to a colleague to assess and treat the hair loss medically prior to any attempted surgical correction if appropriate.

23.3 Medical Therapy

If the history, clinical exam, and/or studies point toward male pattern or female pattern hair loss, then it is imperative to discuss medical therapy prior to any surgical options. This is especially important in patients with minimal hair loss. This subset of patients have the most to benefit from medical therapy and with early intervention; they may not only delay further hair loss but also have higher rates of regrowth than patients with a more advanced pattern on the same therapy. With respect to medical therapy, the main focus of discussion should revolve around therapies with the most evidence of efficacy, including minoxidil, finasteride, low-level light therapy, and platelet-rich plasma (PRP). Topical minoxidil is safe for use in both men and women. Given that it is available over the counter, has minimal side effects, and has studies proving stabilization of hair loss even up to 2 years out, this is a medication that should be offered to all patients entering a hair transplant clinic.1 Oral finasteride is another option that is effective for men with pattern hair loss, including a study that has shown stabilization of hair loss at 5-year follow-up.²^,³ Patients with minimal hair loss, especially if younger, may be hesitant to commit to this medicine after being counseled about the low, but real risk of sexual side effects and the extremely low risk of post-finasteride syndrome.²^,⁴ Finasteride is Food and Drug Administration approved for males only and is not to be used in women of child-bearing potential. It has been used off-label with some success in postmenopausal females.⁵ Low-level laser light therapy is another treatment option to discuss with patients. The data is not as strong and a more modest benefit should be counseled, but studies have shown promising effects and thus this therapy warrants discussion.⁶^,⁷ In addition, PRP is an emerging treatment option that has shown promise and should be offered to both men and women with pattern alopecia, especially those who have failed other more proven treatments or who have contraindications.⁸ It is thought that many of these treatments can be synergistic and a combination approach can be used. As compliance is key with all of these treatments, guiding the patient toward the therapy or therapies that they will be most likely to use is important. It is also important to counsel that all therapies should be given a minimum of 6 to 9 months prior to judging their efficacy. Having the patient follow-up at the 6-month period to assess compliance and results can encourage adherence to the protocol and provide encouragement.

23.4 When to Consider Hair Transplantation

The final part of the consult in a patient with minimal hair loss can be focused on hair transplantation. It is vital that patients understand transplantation will not stop their underlying hair loss. The net perceived density of a transplant equals the amount transplanted minus their ongoing hair loss. Patients should understand that effective medical therapy will allow the maximum cosmetic impact from a hair transplant surgery. As a physician, we should also assume a patient may decide in the future to stop their medical therapy and their hair loss will resume. A patient who initially undergoes a hair transplant during the early stages of the pattern alopecia may return for subsequent surgeries at a much more advanced stage of hair loss. Thus, physicians must plan surgery with both the short- and long-term cosmetic impact of ongoing hair loss in mind. It is imperative for physicians to explain to patients that there are a limited number of follicular units that are considered “safe” in their donor area and there are not enough to transplant the entire frontal, midscalp, and vertex with an acceptable density over time.⁹ Given the progressive nature of androgenetic alopecia, when planning a hair transplant procedure, the surgeon has to assume that most patients will eventually progress to the later stages of their respective Norwood or Ludwig scales and thus the possibility of a full restoration is not realistic. This may not hold true in certain scenarios such as elderly patients with minimal hair loss who may never reach advanced patterns or patients stabilized for many years on medical therapy, who plan to continue that therapy indefinitely. From a cosmetic standpoint, the hairline and frontal scalp are the most important and cosmetically safe areas of the scalp to transplant and thus much of the donor area should be reserved for restoration exclusively in the frontal two-thirds of the scalp for men and women. The hairline and areas where grafts will be placed should be mapped out and discussed with the patient prior to the procedure with a marking pen. It is important to be cognizant of potential future hair loss when planning the hairline. Although patients frequently request inappropriately low hairlines that carry a high long-term cosmetic risk, the surgeon should counsel and plan for a receded hairline, which will help keep cosmetic balance with continued pattern alopecia occurring at the temples and posterior hairline. Transplanting only the central vertex region carries a steep cosmetic risk, given that over time a patient’s posterior hairline will continue to recede leaving transplanted hair separated from the posterior hairline by exposed scalp, almost with a donut appearance (Fig. 23.1).