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Author: Jeffrey S. Epstein, M.D., FACS
Clinical Professor, University of Miami
Private Practice, Miami, FL
305.666.6708 (fax)
[email protected]

Send all reprint requests to Dr. Epstein: 6280 Sunset Drive, Suite 504, Miami, FL 33143

Originally presented as a poster, AAFPRS Annual Meeting, Denver, CO, September 2001. To be presented at the AAFPRS International Meeting, New York, NY, May, 2002.

Word Count: 3176

The role of hair restoration in men is well established. In women, the procedure is much less common, but has a definite role in both the management of female pattern hair loss and the repair of alopecic scarring and hairline distortion as a result of prior facial plastic surgery. When performing hair restoration in women, there are differences in technique from that used in men, so as to consistently achieve excellent results and minimize complications.

Over the past 3 years, the author has performed 86 hair transplant procedures on women. The majority of these cases were for female pattern hair loss. The techniques utilized, and typical results are presented. When performed properly for the proper indications, hair restoration is an effective procedure with a very high level of patient satisfaction.

While over 95% of all hair transplants are performed on men, women are candidates, and do undergo, hair transplants for the treatment of several conditions. Hair loss in women in the majority of cases is, like in men, genetic in origin, and progressive. The current train of thought regarding female pattern baldness (FPB) is that it occurs along several different patterns, the most common consisting of diffuse thinning along the top and upper sides and back of the head, often sparing the frontal hairline.(1) This, the classic FPB pattern, is divided into 3 stages according to the Ludwig classification scheme, with stage 1 consisting of mild hair loss, with stage 3 extensive hair loss.(2) In patients with stage 1 and most cases of stage 2 classic FPB, as well as those with some of the less common patterns, there usually is sufficient hair density in the donor region (mid-occipital region) to make restoration at least somewhat effective at restoring density to the thinner areas. Women with stage 3 FPB are usually advised not to undergo the procedure, but rather to consider the purchase of a hairpiece or hair system.

The other condition in women effectively treated with hair transplants is the alopecic scarring and hairline distortion associated with prior plastic surgery. The most common type of distortion is the loss of the sideburns caused by those rhytidectomy incisions that extend superiorly, rather than horizontally, from the upper aspect of the ear, thus pulling the temporal tuft along this superior vector.(3,4) While this incision design is superior for dealing with the lateral brow region, the hairline distortion it often produces can cause significant hair styling difficulties. Another type of distortion is the excessive elevation of the frontal hairline associated with coronal browlift incisions in patients with pre-existing high foreheads.(5) Alopecic scarring, meanwhile, most commonly occurs along the frontal and temporal incisions of browlifts, and the occipital incisions of rhytidectomy. Finally, representing a combination of hairline distortion and scarring is the loss of hair in the superior temporal region anterior to certain rhytidectomy and most browlifting incisions that is due to tension vectors in a superior-posterior direction and inadvertent transection of the superficial temporal artery. The goal of hair restoration in these cases is to restore hair growth in the scarred and thinned out areas, and to recreate the normal anatomy of the temporal tufts and the frontal and temporal hairline.

There are a variety of hair restoration techniques, which basically differ according to graft size and the technique of graft preparation. Over the past 3 years, the technique of follicular unit grafting (FUG) has largely become accepted as the technique of choice for the majority of hair restorations. This technique requires the microscopic dissection of the donor material into grafts each containing a single follicular unit. The follicular unit consists of 1 to 4, most commonly 2 or 3 hairs, in a single bundle, with the sebaceous gland elements and other supporting tissue, surrounded by an adventitial sheath.(6) This is the way the hair on the scalp grows naturally, and theoretically, by keeping the follicular unit intact, the pattern of hair growth has the potential to be virtually completely natural. Microscopic dissection is required for FUG, in order to assure the integrity of the unit, and to allow the dissecting away from the graft of as much non-hair bearing scalp skin as possible.(7)

Because of its technical difficulty, requiring a team of trained assistants to dissect as many as several thousand grafts in a single procedure, the majority of hair transplant surgeons do not perform FUG, but rather the conventional technique of micro/minigrafting (MM), also called mini/micrografting. Using accepted terminology, the micrograft contains 1 or 2 hairs, while the minigraft contains 3 to 6 hairs.(8) Dissection of these micrografts and minigrafts is performed under direct or magnified visualization. MM does not respect the integrity of the follicular unit, rather grafts are dissected out according to the numbers of hairs per graft that are required for the restoration. For example, the surgeon will request that a donor strip be divided into a certain number of 1 and 2 hair micrografts, and certain numbers of small minigrafts of 3 and 4 hairs and , perhaps, larger minigrafts of 5 and 6 hairs. With this technique, no effort is made to remove the excess non-hair bearing tissue, therefore grafts are larger than their follicular unit graft counterparts that contain the same number of hairs.

While it is beyond the scope of this paper to discuss the advantages of FUG versus MM, several distinctions can be made. MM is a simpler technique, enabling the procedure to proceed quicker with fewer assistants. In addition, some surgeons feel that MM affords them the ability to achieve a greater hair density. While technically more difficult to create, the smaller grafts of FUG allow for closer placing of grafts for increased hair density, minimal to no scarring of the recipient scalp, less trauma to already existing hairs in the area transplanted, and up to a 20% greater yield of hairs from a given sized donor strip.

The Technique: Treatment of Female Pattern Baldness


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