22 The Young Patient: Planning and Decision-Making

Robin Unger

Summary

Hair transplant surgery in young men is a challenging project. It is often easier to deny the surgery; however, they are in a stage of life in which their hair loss significantly affects their self-esteem and hence their social interactions at a crucial period. Understandably, these men want a more youthful look, and this often means that they want the temple recessions filled and a dense hairline. This should not be attempted, as the donor hair supply will not be able to provide sufficient hair. A few men who do maintain a low straight hairline have very dense hair posterior to that line—and men who develop early male pattern baldness can only hope for a long-term goal of the look of a man with early thinning. The future areas of loss should be treated as part of any surgery and adjunctive medical therapy should be prescribed when not contraindicated in order to help slow down that future loss. The issue of transplanting in young women is equally challenging; however, if the area of concern is one that is likely to remain of great aesthetic importance, the decision is less difficult.

This topic of hair transplantation in young patients has been debated extensively in the field of hair restoration.1 There are surgeons who set a lower age limit based on their experience and there are those who readily operate. The rationale for applying an age limit is based on the frequent occurrence of young men treated surgically without a strong consideration of the long-term progression of their male pattern baldness (MPB) including hairlines placed too low and too dense, no transplantation of grafts into areas of future loss, and grafts placed into the middle of a thinning vertex that will expand greatly over time.

There are other surgeons who advocate considering each patient on an individual basis in order to make the right decision. This always includes a surgical plan that has a strong emphasis on the future evolution of MPB or female pattern hair loss (FPHL).²

When a young person, male or female, presents to a hair restoration surgeon with early onset of alopecia, they are understandably very distraught. This is an extremely important period in their lives and the hair loss is rendering them feeling a lack of confidence when they present themselves in the world. They want a solution and they want it quickly. It may be “easiest” to play it safe and not operate on the patient, but surgery may greatly improve the patient’s quality of life and if performed with long term planning it produces excellent results.

22.2 Adjunctive Nonsurgical Treatments

The physician should first rule out any medical condition, which may contribute to hair loss.³ Chapter 7, 8, and 9 of this book deals with the topic in great detail. Basic blood tests should be ordered and evaluated. For men, this may include Fe, vitamin B12, vitamin D, testosterone, prolactin, thyroid-stimulating hormone (TSH), T3, and T4. For women, the tests are a little more involved as conditions such as androgen excess should be evaluated. They include testosterone, dehydroepiandrosterone, Fe, vitamin D, vitamin B12, prolactin, TSH, T3, T4, and referral to a gynecologist if polycystic ovarian syndrome is suspected.⁴ Obviously, if any abnormalities are found, these must be addressed first.

It is important to start these patients on some sort of medical treatment to slow down the alopecia (finasteride, minoxidil, other hormone modulation).5 It is also important to remember that none of these provides a lifetime cure or complete cessation of the development of MPB or FPHL—and therefore it should not alter the long-term surgery plan. The most innocuous treatment is to start with topical minoxidil.⁶ The side effects are minimal, if any, and there is excellent clinical evidence that minoxidil slows down the miniaturization process. It is important to educate the patients and explain that even if something is done surgically to replace hair that has already been lost, medical treatment is still necessary to slow down the ongoing loss. Finasteride and dutasteride are other options, approved for male pattern hair loss.^7,8 Most physicians feel quite comfortable prescribing this for young men (after puberty). This author agrees, but recommends that a baseline sperm analysis be performed to be certain the patient is starting with a normal sperm count. Although considered “extreme” by some other hair restoration surgeons, there is evidence that men who begin with low sperm counts may have a further drop in counts after starting finasteride.⁹ Patients seen in infertility centers who are on finasteride do see a rise in counts after cessation of the drug—but often they remain below normal levels. For both the patient’s peace of mind and future family building, and for the physician’s protection, this author feels that a baseline sperm analysis is a wise test to perform before starting finasteride.

Regarding the prescription of finasteride for young women, this author thinks it is usually unadvisable. There are women with androgen excess who may benefit; however, the potential risks of taking a medication long term which has not been tested (nor approved) for female patients needs to be seriously considered. A low androgen index birth control spironolactone is generally a safer choice for those practicing in the United States. Outside of the United States, cyproterone acetate is an excellent choice for young women with androgen excess syndromes. In addition, higher dose minoxidil (up to 15%) may be helpful in women who did not respond to 5% minoxidil and is generally well tolerated.¹⁰

The rise in hair restoration surgeons offering platelet-rich plasma (PRP) opens another option for the treatment of young patients with alopecia, albeit one with limited published clinical evidence.^11,12 Anecdotal reports and experience of physicians vary widely on this procedure—which also is not standardized across hair restoration centers. It most certainly is an option to be presented to young patients, but it should be done honestly and clearly. This can be offered to patients who have already tried the proven medical therapies without great success, or have had unwanted side effects from those treatments. It may help slow down or reverse some of the loss in some patients. The author has found it more helpful in young women as compared to young men, in general. The reason for this is unclear, but in most of the cases when it was performed on young men, they were undergoing very rapid hair loss and unable to tolerate finasteride; the PRP is more than likely an insufficient tool to combat a process primarily caused by hormonal changes.

Finally, various camouflage techniques can be suggested to make the patient a little more comfortable while waiting to see the effectiveness of medical treatment or to treat areas that cannot realistically be covered with surgery. For example, temporary scalp micropigmentation is a good choice for a young patient who still has light hair coverage in the vertex. The vertex should almost never be treated in a young patient, but both young men and women may be bothered by the amount of scalp seen through the hair in the crown. The temporary tattoos last several years and therefore will not potentially leave the patient in the future with a completely alopecic area that has visible tattooed dots or worse small dots that have spread and coalesced into a single block of color—that may or may not continue to match the patient’s hair color.

Hair transplantation is an option for young patients, but the patients should not rush into a surgical procedure without careful consideration. Only a surgeon with extensive experience should attempt these procedures. Knowledge of the family history of patterned hair loss of the patient is extremely important. Regardless of that history (or in its absence), the best approach is to assume the patient will evolve into one of the very severe patterns of alopecia in the future. The young person should be informed that the surgical plan is based on the possibility of this severe progression. Many young people are much more focused on the short term; the physician’s role is to emphasize that the long-term plan is more important.

22.3 Surgical Planning in Young Men

When young men are actually considering something as serious as surgical correction of their MPB, it is an indicator of how important this issue is for them. It is a time in their lives where appearance is so important to overall confidence—when they are interviewing for jobs, looking for a potential life partner—and lack of confidence can significantly alter the course of their life.

Related posts:

Methods and Techniques to Study Hair Cell Survival Hair Transplantation: The Promise of Cell Therapy OSHA, Laboratory Screening, and Office-Based Surgery The Patient with Minimal Hair Loss: Planning and Decision-Making Introduction and Definition of Follicular Unit Excision “Temporary” Scalp Micropigmentation (Trichopigmentation)

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