Guidlines for Hair Restoration in the Young Patient
S. Cohen, MD
Associate Clinical Professor -Yale University School of Medicine
The young man who is losing his hair is a challenge to the hair restoration
surgeon. He is often extremely distressed about his follicular future
and the initial consultation must balance the patient's emotions with
the reality of his hair loss. Some surgeons may deal with this situation
by adhering to a minimum age policy. "I won't operate on anyone under
25." But should there really be a minimum age? With the transformation
of hair restoration into a microsurgical procedure and the availability
of effective medical treatments for hair loss, we now have the opportunity
to more confidently treat this age group.
Consider the young patient under 25 years old. There are advantages to
working with these patients. They are highly motivated, generally healthy
individuals who are rarely on medication. Many of these patients are devastated
by the early loss of their hair and we have the opportunity to restore
their confidence, and self-esteem as well as their hair. With early surgical
intervention the surgeon can keep up with the patient's hair loss and
he will never look bald. Futhermore, most of these patients still have
some existing hair, which makes the surgery easier to camouflage.
There are also potential hazards when transplanting this younger age
group, that need to be addressed in detail during the initial consultation.
Their expectations are very high and sometimes unreasonable. They want
their hairlines where it was when they were 15 and they invariably want
more density than is technically possible.
Often their decision to have surgery is an impulsive one. These young
men are experiencing their first encounter with the aging process and
many of them are not emotionally or intellectually able to deal with it.
The patient must understand that once beginning hair restoration,
it is a lifetime commitment because they may need additional surgeries
to keep up with their hair loss. But the most difficult issue of all is
the estimation of future hair loss. The progression of androgenetic alopecia
must never be underestimated. Failure to do so can lead to a cosmetic
For a successful end result, the surgeon must be cautious and conservative
in long term planning. Examination of male parents and siblings and evaluation
of family photographs can be very helpful in predicting the ultimate pattern
of loss. This is a challenging group, but they should not be denied access
to hair restoration, solely because of their age.
The following guidelines are recommended to achieve a successful surgical
result when transplanting patients under 25 years of age.
- Place the hairline higher than where the patient wants. Follow the
rule of thirds and then push the patient to accept an even higher
Hairlines should not be less than 8 cm above the mid glabella line.
Preferably it should be at least 9 cm. A higher hairline conserves
hair. Every centimeter higher saves hundreds of hairs that may be needed
in later years. Also, by reducing the area to be restored, greater
density can be achieved with the same amount of donor hair.
As the patient ages, a higher hairline will only look more natural.
If this issue reaches an impasse after all of this has been explained,
which it often does, the patient should be advised that the hairline
can always be lowered during subsequent procedures. Always try to buy
time. Raising the hairline is extremely difficult and it is usually
- Avoid restoration in the vertex because of the difficulty in
accurately estimating future hair loss. By starting in the frontal
back as hair loss progresses, the patient will always have enough
hair to adequately cover these areas in the future. If the vertex is
restored at this early age, there is a risk of depleting the donor
hair that will be needed later. Without the necessary donor hair, the
patient can end up with islands of hair that are not connected or
density in the frontal scalp.
- Use caution when performing restoration at temporal
angles. In the old days, many surgeons avoided restoring temporal
results with full size grafts or large minigrafts. Now, cosmetically
acceptable results can be achieved using follicular units and maintaining
a slightly receded concave hairline. Because the temporal fringe naturally
flattens as one ages, avoid creating a permanent temporal point that
is too far anterior which will look inappropriate in the future.
- Start the patient on medical therapy. Finasteride with or without
minoxidil has the potential to significantly reduce future hair loss
and may even promote growth particularly in the vertex. The new 5-year
data on Finasteride shows that 66% of treated patients have significantly
more hair in the vertex than when they started. The effectiveness of
both of these drugs in the vertex is another reason to delay transplanting
in this area. By preventing or reducing the potential for further hair
loss, the surgeon has a much greater margin of safety.
- Look for clinical clues that may portend the development of extensive
future hair loss (type VII). The presence of "whisker hair"
and poor temporal density are signs that suggest an early onset of potentially
significant baldness. Norwood first described whisker hair as short
curly hairs that are found above the ears that have characteristics
of beard hair. He suggested a correlation between significant future
baldness and the presence of these hairs.
When examining the young patient the temporal density should be carefully
determined. Early significant thinning in this area may also be a sign
of impending follicular disaster.
- Select the safest donor areas. The mid-occipital area should be
selected for the initial restoration procedures because it is the
least likely to thin over
time. Subsequently the donor area can be expanded inferiorly and superiorly
as determined by the pattern of hair loss. The temporal donor sites
should be saved for later years because the future density of these
sites is less predictable.
- Defer scheduling surgery during the first consultation. Resist the
temptation. Have the patient return for a second consultation, preferably
in 6 months. Although this may be a difficult business decision, I believe
that this is the most appropriate medical decision for this age group.
You will be able to weed out any emotionally impulsive or psychologically
unstable individuals who would be unsuitable for surgery.
By deferring the surgery, the surgeon will then be able to evaluate
how rapidly the hair loss is progressing and how well any medical treatment
might be working. By proceeding in this manner, the groundwork for a
positive-long-term relationship and a successful surgical experience
will be in place.
With the latest advances in microsurgical techniques and the availability
of effective medical therapy for hair loss, we should reconsider the concept
of a minimum age and be more confident treating a younger patient population.
By following these recommended guidelines, the surgeon should be able
to avoid cosmetically unacceptable results in the future.
Hair Loss information
on this site has been contributed by hair loss specialists
and surgeons who have years of experience in the field of hair