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Hair Restoration for Men with Advanced Degrees of Hair Loss

Jeffrey S. Epstein, M.D., FACS
Miami, Florida

Clinical Voluntary Professor, University of Miami College of Medicine

Presented: September 7, 2001, at the Annual Meeting of the American Academy of Facial Plastic and Reconstructive Surgery, Denver, Colorado

ABSTRACT: In the field of surgical hair restoration, there is probably no greater challenge than treating the individual with advanced male pattern hair loss. Recent developments in follicular unit grafting and recognition of the natural appearance of the transplanted frontal forelock have now made it possible to obtain excellent, undetectable results in these patients.

Over a two year period, the onset correlating with the time when the author began to use the technique of follicular unit grafting, 61 of 322 (20%) hair transplant procedures performed for male pattern hair loss were on men with, or at high risk of developing, advanced male pattern hair loss. Uniformly, the creation of some type of frontal forelock provided excellent results and high patient satisfaction.

The concept of the frontal forelock is not new. Developments in aesthetic principles, enhanced understanding of its applicability, and the applied advantages of follicular unit grafting allow for the first time, truly undetectable results.

There is perhaps no greater challenge in surgical hair restoration than treating the individual with advanced male pattern hair loss. Fortunately, in probably no other area in the field of hair restoration have advancements in technique and changes in approach led to such a great improvement in results when treating such individuals. In men with advanced hair loss, the donor hair supply is far exceeded by the amount required to cover the balding areas. That is the irony in hair restoration: the greater the need, the less the supply.

The approach to restoring hair to such individuals is waged along several fronts. The first front is maximum utilization of available donor supply through advances in technique. Follicular unit grafting, by minimizing the inadvertent damage or loss of existing follicles, preserves the greatest amount of donor hairs. The second front is conservation of demand through refinements in the aesthetics of hair restoration. The designing of a conservative hairline, often limited to a central forelock that is acceptable to the patient, dramatically improves the results from those of patterns that have been used in the past. The final front is recognition of the patient's situation as challenging from a supply/demand perspective. Such recognition is easy in the patient presenting with an advanced degree of hair loss (i.e. a Hamilton-Norwood Class 6 or 7 pattern), but is more difficult with the younger patient presenting with an early hair loss pattern at risk to progress to a much more advanced pattern in the future.

Over 60% of all men experience some degree of cosmetically noticeable hair loss by age 50.(1,2) The Hamilton-Norwood scheme classifies male pattern baldness (MPB) into 7 stages, with some flexibility to account for variations in the classic patterns.(3) Because MPB is progressive with age, most men will advance several stages over the course of a lifetime.

It is possible to predict with some accuracy whether an individual will progress to an advanced hair loss pattern. Predictive factors include the onset of MPB at a young age (mid-20s and earlier), a strong family history of baldness, and extensive hair thinning along the back and sides of the head and the superior temporal tufts at presentation.

Little can be done medically to slow down the hair loss process. Genetically determined, MPB can be affected only by reducing the body's production, or the hair follicle's uptake, of dihydrotestosterone, the hormone shown to induce the miniaturization and eventual death of the hair follicle.(4) The only medications approved for the treatment of hair loss are finasteride (Propecia®) and minoxidil (Rogaine®). Both slow down hair loss in less than two-thirds of men, and induce new hair growth in a much smaller percentage. These results are for the crown region; results for areas more anterior in the scalp are significantly poorer. The medications are temporary, and must be taken continuously to maintain results.

The average head contains 100,000 hairs at peak density, with approximately 25% of these hairs located in the "permanent" donor area.(5) As many as 50% (or 12,500) of the 25,000 hairs within the donor region are available for transplanting, meaning that they can be harvested and the donor site closed without resulting in scarring or abnormal lack of adequate density.(6) The Hamilton-Norwood Class 2 patient has lost 10% to 20% of total scalp hairs, but still has as many as 12,000 hairs in the donor region available for restoration (to "replace" a loss of a similar number of hairs). The Class 6 patient, on the other hand, has lost 70% to 80% of total hairs, and has 6,000 to 8,000 hairs available for restoration (to "replace" a loss of more than 70,000 hairs). These 2 examples illustrate the demand/supply challenge in hair restoration surgery.

While an explanation is beyond the scope of this analysis, the appearance of normal hair coverage can be achieved by transplanting to just 50% of original density.(7) In the case of the Class 6 patient, the 6,000 to 8,000 available donor hairs can therefore adequately fill in an area once covered by 12,000 to 16,000 hairs, which is approximately 20 to 25% of the total area of hair loss. Therefore, complete scalp coverage in individuals with advanced hair loss is not achievable, and a plan must be in place so as to attain the best result of the hair transplant.

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