Hair transplant surgery for hair restoration

Hair transplantation is an operation that takes hair from the back of the head and moves it to the area of hair loss. The fringe (back and sides) of hair on a balding scalp is known as donor dominant hair, which is the hair that will continue to grow throughout the life of most men and women. The transplantation of this hair to a bald area does not change its ability to grow. Donor dominance is the scientific basis for the success of hair transplantation.

Candidates for hair transplant surgery are those individuals with hair loss that have sufficient donor hair from the fringe of the scalp to transplant to the balding area. In the past, many bald patients were not suitable candidates for hair transplant surgery but modern techniques have advanced the art of hair transplant surgery so that many more men and women are candidates. Hair transplantation surgery has improved in leaps and bounds over the past decade. The days of the “plugs and corn rows” are gone and the age of single hair-, micro-, and mini- grafting has arrived.

Through the use of the these variable sized hair grafts along with new and improved instrumentation, the accomplished hair transplantation surgeons can create a natural hair appearance that is appropriate for each individual patient. Single hair-grafts have the finest and softest appearance. Although they do not provide much density, they do provide the critical soft hairline that is the transition to thicker hair. Reconstructing a new hairline is a skill requiring surgical as well as artistic skill. It is critically important to get it right the first time and thus requires considerable forethought and planning.

Examining the hairline of a non-balding person will show the presence of numerous single hairs in the very frontal hairline. Micro-grafts are small grafts containing 2-3 hairs that are placed behind the hairline to provide a gradually increasing hair density.

Lastly, mini-grafts contain 4 or more hairs are placed well behind the hairline so that the single hair and micro-grafts can blend naturally into the density provided by these larger grafts. There is different terminology and techniques used by many surgeons. This is because surgeons are innovators and are on the cutting edge of hair transplant surgery. New techniques naturally give rise to new terms. Although there are variations in the techniques of individual surgeons, the combination use of these grafting techniques provide the most natural and pleasing results.

The side-effects of hair transplantation surgery are relatively minor consisting of mild pain and discomfort after the operation, swelling which may move down to the eyes, and the formation of scabs over the grafts which take approximately one week to resolve. Serious problems of bleeding, scarring, and infection are rare. Modern hair transplantation surgery is comfortable, predictable, and the results are pleasing to most patients.

Hair loss, however, is a life long process and most men will develop male pattern baldness (due to male hormones) until approximately 40-45 years of age. After that, the aging process thins the entire head of hair. Progressive hair loss or the desire for more density will require more transplant procedures. Modern techniques, however, allow hair transplant surgery specialists of transplant larger number of grafts, greatly reducing the number of procedures needed to complete the result.

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Male hair loss & pattern baldness in men

Male pattern baldness or androgenetic alopecia. “Andro” refers to the androgens (testosterone, dihydrotestosterone) necessary to produce male-pattern hair loss (MPHL). “Genetic” refers to the inherited gene necessary for MPHL to occur. In men who develop male pattern baldness the hair loss may begin any time after puberty when blood levels of androgens rise.

The first change is usually recession in the temporal areas, which is seen in 96 percent of mature Caucasian males, including those men not destined to progress to further hair loss.

Hamilton and later Norwood have classified the patterns of male pattern baldness (see illustration). Although the density of hair in a given pattern of loss tends to diminish with age, there is no way to predict what pattern of hair loss a young man with early male pattern baldness will eventually assume.

In general, those who begin losing hair in the second decade are those in whom the hair loss will be the most severe. In some men, initial male-pattern hair loss may be delayed until the late third to fourth decade.

It is generally recognized that men in their 20’s have a 20 percent incidence of male pattern baldness, in their 30’s a 30 percent incidence of male pattern baldness, in their 40’s a 40 percent incidence of male pattern baldness, etc. Using these numbers one can see that a male in his 90’s has a 90 percent chance of having some degree of male pattern baldness.

Male pattern baldness is an inherited condition and the gene can be inherited from either the mother or father’s side. There is a common myth that inheritance is only from the mother’s side. This is not true. In summary, male pattern hair loss (Androgenetic Alopecia) is an inherited condition manifested when androgens are present in normal amounts.

The gene can be inherited from the mother or father’s side. The onset, rate, and severity of hair loss are unpredictable. The severity increases with age and if the condition is present it will be progressive and relentless. Hair loss in men is likely to occur primarily between late teen-age years and age 40-50, in a generally recognizable “male-pattern” baldness known as androgenetic alopecia. Men with male-pattern hair loss may have an expectation of hair loss if they have male relatives who lost hair in a recognizably male pattern.

Female hair loss & pattern baldness in women

Female hair loss occurs in more than one pattern. If you are a woman with loss of scalp hair, you should seek professional advice from a physician hair restoration specialist. In most cases, female hair loss can be effectively treated. If you are a woman who has started to lose scalp hair, you are not alone.

The patterns of hair loss in women are not as easily recognizable as those in men. Unlike hair loss in men, female scalp hair loss may commonly begin at any age through 50 or later, may not have any obvious hereditary association, and may not occur in a recognizable “female-pattern alopecia” of diffuse thinning over the top of the scalp.

A woman who notices the beginning of hair loss may not be sure if the loss is going to be temporary or permanent—for example, if there has been a recent event such as pregnancy or illness that may be associated with temporary hair thinning. If you are a woman who is worried about loss of scalp hair, you should consult a hair restoration specialist for an evaluation and diagnosis.

Diagnosis of hair loss in a woman should be made by a trained and experienced doctor.In women as in men, the most likely cause of scalp hair loss is androgenetic alopecia—an inherited sensitivity to the effects of androgens (male hormones) on scalp hair follicles. However, women with hair loss due to this cause usually do not develop true baldness in the patterns that occur in men—for example, women rarely develop the “cue-ball” appearance often seen in male-pattern androgenetic alopecia. Patterns of female androgenetic alopecia can vary considerably in appearance. Patterns that may occur include:

• Diffuse thinning of hair over the entire scalp, often with more noticeable thinning toward the back of the scalp.

• Diffuse thinning over the entire scalp, with more noticeable thinning toward the front of the scalp but not involving the frontal hairline.

• Diffuse thinning over the entire scalp, with more noticeable thinning toward the front of the scalp, involving and sometimes breaching the frontal hairline.

Other hair loss causes

Alopecia Areata

Alopecia areata (AA) is a recurrent disease, which can cause hairloss in any hair-bearing area. The most common type of alopecia areata presents as round or oval patches of hair loss most noticeably on the scalp or in the eyebrows. The hair usually grows back within 6 months to one year. Most patients will suffer episodes of hair loss in the same area in the future. Those who develop round or oval areas of hair loss can progress to loss of all scalp hair (alopecia totalis).

The cause of alopecia areata is unknown but commonly thought to be an autoimmune disorder (the body does not recognize the hair follicles and attacks them). Stress and anxiety are frequently blamed by patients as the cause of their hair loss. The most common treatment is with steroids (cortisone is one form) either topically or by injection.

The outcome of treatment is good when the alopecia areata process is present less than one year and poor, especially in adults, if the disease has been present for longer periods of time. Minoxidil (Rogaine®) can help to regrow hair. Surgical treatment of this disorder is not recommended. If you have questions concerning Alopecia areata, please contact an ISHRS physician.

Traction Alopecia

Traction alopecia is caused by chronic traction (pulling) on the hair follicle and is seen most commonly in African-American females associated with tight braiding or cornrow hair styles. It is generally present along the hairline. Men who attach hairpieces to their existing hair can experience this type of permanent hairloss if the hairpiece is attached in the same location over a long period of time.Trichotillomania is a traction alopecia related to a compulsive disorder caused when patients pull on and pluck hairs, often creating bizarre patterns of hairloss. In long term case of trichotillomania, permanent hairloss can occur.

Scarring Alopecia

Hair loss due to scarring of the scalp is called scarring alopecia. Scarring can be due to a variety of causes. Traction alopecia over a period of time may lead to scarring and permanent hair loss. Trichotillomania (compulsive hair-plucking) can cause permanent scalp scarring over time. Injury to the scalp caused by physical trauma or burns may leave permanent scars and permanent hair loss.

Diseases that may cause permanent hair loss due to scalp scarring include (1) the autoimmune conditions lupus erythematosus and scleroderma, and (2) bacterial infections such as folliculitis, fungal infections, and viral infections such as shingles (herpes zoster).

Trichotillomania

Trichotillomania is the name given to habitual, compulsive plucking of hair from the scalp or other hair-bearing areas of the body. Over time, continual plucking of scalp hair will result in a hairless area-a bald spot. Long-term trichotillomania can result in permanent damage to scalp skin and to scarring alopecia. It is not known whether trichotillomania should be classified as a habit or as obsessive-compulsive behavior. In its mildest form, trichotillomania is a habitual plucking of hair while a person reads or watches television. In its more severe forms, trichotillomania has a ritualistic pattern and the hair-plucking may be conducted in front of a mirror. The person with trichotillomania often has guilt feelings about his or her “odd” behavior and will attempt to conceal it.

Triangular Alopecia

The cause of triangular alopecia is not known, but the condition can often be treated medically or surgically. The characteristic pattern of hair loss in triangular alopecia is thinning or complete loss of hair in the scalp area around the temples. If hair loss is not complete, the remaining hairs are often “miniaturized”-fine-textured hairs of thin diameter.

Triangular alopecia sometimes begins in childhood with unexplained hair loss in the temporal areas of the scalp. Telogen Effluvium Telogen effluvium is the name given to hair loss that is caused when a large percentage of scalp hair follicles are shifted into the telogen or ”shedding phase” of hair growth. The cause of this abnormally timed telogen phase may be hormonal, nutritional, drug-related or associated with stress.

Loose-Anagen Syndrome

Loose-anagen syndrome occurs most frequently in fair-haired persons. During the anagen (growth) cycle of hair, scalp hairs sit so loosely in the follicles from which they grow that they can be easily extracted by combing or brushing. The condition may appear in childhood and gradually improve or disappear over time.

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Common questions about treatment

Here are some common questions and their answers concerning hair loss and hair transplants:

What causes hair loss?

The most common cause of hair loss is heredity. Men and women inherit the gene for hair loss from either or both parents. In men, the hormone dihydrotestosterone causes a gradual miniaturization and eventual loss of hair follicles that are genetically susceptible. The mechanism of female pattern hair loss is not clearly known. The age of onset, extent, and rate of hair loss vary from person to person. Men and women exhibit hereditary hair loss differently.

Severe illness, medications, malnutrition, or vitamin deficiency can accelerate this process. When applied incorrectly, permanent hair color and chemical relaxers damage the hair and follicle to the extent that hair loss can be permanent. Causes of hair loss do not include wearing a hat, excessive shampooing, lack of blood flow, or clogged pores.

Do hair transplants really work?

Yes. The transplanted hair is removed from one area of the body (donor site) and transferred to another (recipient site). The transferred tissue is not “rejected” as it is not foreign tissue. The transplanted hair maintains its own characteristics; color, texture, growth rate, and curl, after transplantation and regrowth. The vitality of the grafted follicle is maintained by the rich blood supply to the scalp.

Originally many years ago, large circular grafts (commonly called ’plugs’) containing 15-20 hairs were transplanted resulting in noticeably unnatural results. Over years, instruments and techniques have been developed that allow hair transplant surgeons to achieve truly natural results by transplanting large numbers of small grafts very close together. We have found that hair grows from the scalp in groups of one, two, or three (and rarely, four) hair follicles, called ”follicular units.” We can transfer these groups of follicles, called ”follicular unit grafts,” after eliminating the excess surrounding tissue. This allows the grafts to be placed closer together resulting in a denser and more natural result. A significant amount of artistry is also needed in order to recreate the natural patterns of hair growth.

Is an undetectable hair transplant possible?

Yes. Today’s highly trained and up-to-date surgeons, using a combination of artistry and technology, can recreate hairlines and crown coverage in a manner that truly defies detection. Progressing beyond the old style ‘plug-type’ transplants has been possible using advanced techniques which allow the transplantation of large numbers of small grafts. An appreciation for the natural shape and patterns of hair growth allows surgeons to create wavy, randomized hairlines that look natural.

What can be expected after hair restoration surgery?

The post-operative course will depend on adherence to the instructions given after surgery. Small scabs will form on the scalp at the graft sites. Generally speaking, these scabs disappear in 4-10 days. Shampooing can be resumed 24 hours after surgery.

The suture (stitch) used in the donor area is undetectable immediately after surgery as it is completely covered by your existing hair. Some surgeons use absorbable stitches which are dissolved by the body, other surgeons may use skin staples. If the suture is non-absorbable, an appointment will be made for the suture to be removed approximately one week after surgery.

It is advisable to take at least two days off work after surgery. A baseball type cap can be worn at anytime after surgery. Patients should avoid strenuous physical activity for at least five days after surgery. Typically the grafted hair will shed in 2-4 weeks. New growth will begin in 3-4 months and length will increase approximately 1/2 inch per month.

Are hair transplants painful?

Most people are surprised at how little pain there is during a hair transplant procedure today. Some discomfort is to be expected as the anesthetic is injected into the scalp. Once the skin is anesthetized, there is no pain. If the numbing medicine wears off during the course of the procedure, more is injected to re-anesthetize the area. Advances n local anesthetic and the way it is applied allow for a comfortable and relaxing procedure. Most patients watch movies, listen to music or nap during their procedure.

What will it look like after the procedure?

The grafts form small scabs in the days after the procedure. If one has enough surrounding hair, these scabs can be camouflaged with creative styling. If not, the small scabs may be visible but do not attract much attention. By keeping the scalp moist, the scabs usually come off in about a week or so.

When can I go back to work?

Depending on the type of procedure you have done and the type of work you do, it is often possible to go back to work the next day. Your hair restoration surgeon will discuss this with you during the consultation.

Are hair transplants expensive?

Despite the initial cost of the procedure, hair transplantation can be less expensive than an artificial hairpiece over the long run. Considering that the results are permanent, most people consider it a good investment in their future happiness.

How many sessions will be required?

The number of the sessions will depend on the 1) area of scalp treated 2) the number and size of grafts used 3) the density which the patient desires and 4) the individual characteristics of the patient, e.g. coarse hair will provide a more dense look than fine hair. The estimate of the number of sessions can be discussed during the consultation with your surgeon.

Is hair transplantation/hair restoration surgery a subspecialty of dermatology, and is it done as a fellowship post-residency?

The field of hair restoration surgery (HRS) is made up of physicians

from many backgrounds including dermatology, plastic surgery, general surgery, family practice, ENT, and many others.