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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 amount of coverage attained from a hair transplant is a result of the number of hairs transplanted that actually grow. Follicular unit grafting (FUG), with single donor strip harvesting and microscopic sectioning of the donor material, is probably the most effective technique for assuring maximal hair growth (see Figure 1). FUG recognizes the aesthetic advantages of keeping intact the natural bundles of hairs as they grow in the scalp.(8,9) Each follicular unit graft consists of 1 to 4 hairs, and relies upon microscopic dissection for accuracy. Removing the donor strip in a single strip, versus multi-bladed excision, produces the least amount of blind cutting of the material, reserving the sectioning to be performed under the microscope. Careful dissection of each graft, performed by a team of experienced assistants, minimizes accidental transection of hair follicles, and allows for the preservation of a small cuff of supportive and protective tissue around the follicles.(8,10) It is the author's experience that an additional 20% or more of grafts are obtained from the same sized donor strip using the follicular unit microscopic technique versus the traditional basic magnification or no magnification technique. These findings have been confirmed in the literature by other investigators.(10)

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.

Designing the area to be transplanted in individuals with advanced degrees of hair loss is not merely the creation of a very high, receded hairline. For most men, the goal is to maximize the appearance of coverage while not compromising naturalness in appearance. The prominent frontal forelock, a pattern that exists naturally, serves as the template for the majority of hair restorations in individuals with advanced MPB. The frontal forelock consists of hairs growing in the central-anterior region of the scalp, bordered laterally by frontotemporal recessions. While other patterns can be designed, the frontal forelock represents the most efficient utilization of available donor hairs. A relatively small number of hairs, provided in as few as 800 to 1000 grafts, can strategically create the appearance of maximum hair coverage, and aesthetically frame the face. More extensive coverage, and/or greater density, can be achieved with the transplanting of more grafts. It is not uncommon to transplant 1600 to 1800, and as many as 2400 grafts, in a single procedure. Additional procedures can further supplement the coverage.

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.

From January 1999, to October 2001, the author performed 368 hair transplant procedures, on patients with an age range of 18 to 78 years old, and a mean age of 44 years. Of the 322 procedures performed on men, approximately 20% were on individuals presenting with, or at risk for developing advanced MPB. Uniformly, results were excellent, and patient satisfaction high.
The following case examples illustrate the approach taken with these patients.
Case 1 (see Figure 3)
47 year old Hamilton-Norwood Class 6. The patient's advanced degree of hair loss and low donor density limit the amount of coverage that is possible. Before and after at 8 months show the results of a single procedure of 1930 follicular units transplanted in the region of the frontal forelock with creation of temporal horns.
Case 2 (see Figure 4)
50 year old Hamilton-Norwood Class 7. Before and after show the results of 3800 follicular unit grafts transplanted over 2 procedures.
Case 3 (see Figure 5)
58 year old Hamilton-Norwood Class 7. Very fine hairs limit the amount of density that can be achieved with transplanting. Before and after 6 months show the results of a single procedure of 2,150 follicular unit grafts. In this case, the forelock was left isolated from the temporal hairs.



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