Hair Transplants for Men with Advanced Hair Loss
DIAGNOSING THE PROBLEM, COUNSELING THE PATIENT: PREPARING TO MINIMIZE DEMAND
As with most plastic surgery procedures, proper diagnosis and good communication between doctor and patient are the first, and perhaps most important steps. Patient concerns, expectations, and understanding must be evaluated with respect to the findings on examination. Further, the patient must be educated as to the progressive nature of MPB.
Expectations are usually in proportion to the degree of hair loss and the age of the patient. For example, the man in his 50s with a Hamilton-Norwood Class 6 pattern would probably be accepting of a conservative hair restoration, happy to have any amount of natural appearing hair on top of his head. On the other hand, the 22 year old with a Hamilton-Norwood Class 2 pattern is seeking to have a hairline similar to that of his peers, most of whom have a full head of hair. Such a hairline design is achievable at the early state of hair loss, but would look to some degree unnatural in the future with the expected progression of hair loss. Sequelae could include a hairline that is too low for the patient's age, and an unnatural pattern because of not enough donor hairs available for further transplanting to fill in areas that progressively lost hair.
THE TECHNIQUE: MAXIMIZING SUPPLY
Proper handling of the grafts after dissection is critical for hair growth. Desiccation is felt to be the most common cause of poor growth, therefore grafts must be kept moist and chilled during the entire time.(10) Grafts must also be handled delicately to avoid damaging the follicles.
THE AESTHETICS: MINIMIZING DEMAND, MAXIMIZING APPEARANCES
Frontal forelock design involves the concentrated placement of grafts in the central anterior scalp. To minimize the appearance of abruptness, all of the borders (anterior, lateral, and posterior) are feathered-in by irregularly placing 1 and, if appropriate, 2 hair grafts (see Figure 2). Proceeding from peripheral to central in all directions, follicular unit grafts containing 2 to 4 hairs apiece are placed progressively closer together to increase density centrally.
A number of variations exist with the frontal forelock design. Most commonly, the forelock is semi-oval in shape, with a rounded convex anterior border and concave posterior border. The location of the anterior-most hairline is individualized for the patient. Most commonly this is at the point where the vertical forehead curves into the horizontal scalp, typically located nine to ten cm above the nasion (root of the nose). The anterior hairline can be rounded, or, alternatively, more triangular in shape, resulting in a more "severe" appearance. By creating a widow's peak at the central aspect of the frontal hairline, if so desired by the patient, a small number of hairs can create the appearance of an even lower hairline. The sagittal axis of the forelock is usually longer than the coronal axis, but this can vary depending upon the morphology and shape of the face and skull. Hair coverage can be extended further posteriorly by transplanting 1 and 2 hair follicular unit grafts into the area.
Probably the greatest variety in design is whether the forelock is isolated or connected to the temporal fringe. In cases where the temporal fringe is high (minimally receded), the forelock will naturally connect. However, in more advanced cases of MPB where there is significant caudal recession of the temporal fringe, the frontal forelock will be isolated.(11,12) In a number of cases, the surgeon can convert an isolated pattern into a connected pattern by transplanting 1 and 2 hair grafts cephalic to the superior border of the temporal fringe up to the lateral aspect of the forelock. These extensions, termed "temporal horns", can be created by transplanting as few as 50 to 150 grafts on each side. While they need only to be light in density, they can significantly improve appearances.
For any patient presenting with an early or intermediate degree of hair loss but at risk of advanced MPB, the guidelines of frontal forelock creation should also be followed. The restoration is designed as if the patient will eventually progress to an advanced stage of MPB. In these cases, the goal is the enhancement of density in the area of the central forelock, which in the future will eventually serve as the heart of the restoration.
Variations in hairline design allows for unlimited flexibility when performing hair restoration. While it is beyond the scope of this article to teach proper hairline design, it is important that the surgeon be well versed in the elements of what makes a hairline appear natural. The common factor in all natural appearing hair restorations, whether for limited or advanced hair loss, is the creation of an irregular, broken line hairline composed of 1 and occasionally 2 hair grafts. Subtleties, such as the direction in which the hair grows, and the angle from which the hair emerges from the scalp, can have a profound effect on the overall aesthetic appearances.
Designing the Hairline | Female
| Follicular Grafts |
Hairline Dr Shapiro |
The Hair Replacement Revolution |
Guidelines for Hair
| Hair Restoration for Men
with Advanced Hair Loss
Are Fullicular Units | How
FU Transplants Work | Corn
Row Correction | Hair Transplant