The Technique: Treatment of Female Pattern Baldness

When transplanting women with female pattern baldness, the limited supply of donor hairs limits the amount of coverage that can be obtained. While most patients would like to have all the thinning areas treated, the hairs should be transplanted into those areas where they will provide the maximum benefit. Most commonly, these areas are the anterior/mid top of the scalp posterior to and sometimes up to the frontal hairline, and along the area where the hair is parted. It is critical to assess the donor region to make sure that enough hair is present to make the procedure worthwhile.

For the best results, the procedure should maximize the number of hairs transplanted while minimizing the trauma to the existing hairs. This is usually best accomplished by the transplanting of grafts containing 3 to 6 hairs, except along the hairline where smaller grafts of 1 or 2 hairs that contain a single follicular unit are placed to assure a natural appearance. Patients need to be assured that the larger grafts of 3 to 6 hairs do not result in a "transplanted" appearance, because they are used to fill in areas between existing hairs. While these grafts are bigger than classic follicular unit grafts, they are still prepared using single-strip harvesting and microscopic dissection to minimize inadvertent damage (and therefore loss) of the donor hairs.

In the typical case, 600 to 800 grafts (or around 2500 hairs) are transplanted. The recipient sites are slits made by a 3.5 mm or smaller blade carefully placed between existing hairs so as to minimize accidental transection of or damage to the follicles. SpearPoint blades (Ellis Instruments, Madison, New Jersey) in sizes from 1.5 mm to 4.5 mm, and the smaller SharpPoint blades (Ellis Instruments) in sizes of 15, 22.5, 30, and 45 degrees, are appropriate for making the recipient sites for the larger and smaller grafts, respectively.

The grafts are placed atraumatically into the incisions. Careful handling, along with keeping them moist, minimizes damage and insures good growth. To minimize ischemic shock to the existing hairs, the local anesthetic contains a low concentration of epinephrine, generally less than 1:200,000. To further minimize the loss of hairs due to shock, and to accelerate the regrowth of the transplanted hairs, the patient restarts at 1-week post procedure the daily application of minoxidil 2% (usually they will have already used the minoxidil in the weeks leading up to the procedure to help stimulate additional hair growth, stopping its use 3 days prior to reduce the risk of significant bleeding). With this regimen, the hairs can be expected to start growing at 2 ½ months, rather than the typical 4 months

The Technique: Treatment of Hairline Distortion and Alopecic Scarring from Prior Facial Cosmetic Surgery
The management of scarring from prior facial cosmetic surgery usually includes the restoration of the sideburn and other areas of distortions, and the repair of alopecic scarring. Aesthetic restoration of the sideburn begins with the recognition of its natural appearance in terms of location, direction of hair growth, and feathered look. Of particular importance are the superior to inferior, anterior to posterior direction of hair growth, and the fineness of the hairs, especially along the anterior and inferior borders. Areas of scarring, typically located in areas surrounded by hair, should be transplanted with larger grafts, so that even if there is less than the expected 90 percent of hair growth in the scar tissue, there still is the potential for sufficient coverage.

The technique of choice in these cases is follicular unit grafting. This procedure provides the 3 and 4 hair grafts for filling in areas of scarring, the 2 and 3 hair grafts for augmenting density along the upper temporal and posterior sideburn regions, and the finest 1 and occasionally 2 hair grafts for sideburn restoration and feathering along the leading edge of the restoration. In certain cases, where the finest single hair grafts are desired, purposeful transection of the follicle, leaving the hair shaft including its bulge region intact, can result in finer hair growth.

In the technique of follicular unit grafting, the donor hairs are removed as a single strip and the site closed primarily with a running 3-0 Prolene suture. A 10 cm-squared donor strip (1 cm in width by 10 cm in length) will typically provide 600 to 800 follicular unit grafts, which is more than adequate to meet the minimal need for the 150 to 200 grafts for each sideburn and the additional 75 to 100 grafts for each upper temporal region. Because donor density varies significantly among patients, the size of the donor strip is adjusted according to the density as well as the number of grafts that are needed. If needed, additional donor material can be harvested during the procedure.

A team of assistants using the binocular microscope dissects the grafts. While the grafts are being cut, the surgeon makes the recipient sites. A number of instruments are available for this step. It is the author's choice to make these recipient sites as tiny slits with SharpPoint blades (Ellis Instruments). After being made, the recipient sites are filled with their correspondingly sized grafts.

No bandages are applied, and the patient may begin hair washing on the second day. Growth of the transplanted hairs typically begins by 3 months, after which, if desired, an additional procedure can be performed to increase density.

Results
Over the past 3 years, 86 hair transplant procedures have been performed on 61 women. Of the 86 procedures, 59 were performed exclusively for the treatment of female pattern hair loss, 21 were performed exclusively for the repair of hairline distortion and/or alopecic scarring from prior facial cosmetic surgery, and 6 were performed for both indications. Patient age ranged from 25 years to 78 years, with a mean of 52 years.

For the treatment of female pattern hair loss, the number of grafts ranged from 75 to 1250, with the overwhelming percentage of patients (51 out of 59) receiving 600 to 800 grafts. Hair growth was consistent in all cases, and patient satisfaction extremely high. A case example is presented.
Case 1 (see Figure 1)
34-year-old female with an advanced hair loss pattern concentrated in the anterior and mid-scalp region. She was treated with a single procedure of 475 grafts, 80 containing 1to 3 hairs placed along the hairline and 395 containing 4 to 8 hairs placed further posterior.

For the repair of scarring and hairline distortion from prior cosmetic surgery, the number of grafts ranged from 250 to 1500, with the majority of patients (16 out of 21) receiving 650 to 750 grafts. The most common indication for surgery was the restitution of a normal sideburn, with less common indications including, in descending order of frequency, alopecic scarring along a temporal vertical incision, hair thinning along the upper temporal region anterior to a browlift or extended rhytidectomy incision, alopecic scarring along an occipital rhytidectomy incision, and frontal hairline recession and/or alopecic scarring from a browlift incision. Hair growth was rapid, in some cases beginning as soon as 10 weeks post-operatively, and patient satisfaction extremely high. Case examples are presented.
Case 2 (see Figure 2)
57 year old female, 9 years status-post rhytidectomy with loss of the temporal tufts and thinning with recession of the upper temporal region and lateral frontal hairline. A total of 1050 grafts were transplanted: 375 follicular unit grafts of 1 and 2 hairs to restore the sideburns, and 675 grafts consisting of 2 to 4 hair follicular units to restore density to the upper temporal and lateral frontal regions.
Case 3 (see Figure 3)
59 year old female, 5 years status-post rhytidectomy with loss of temporal tufts, and significant scarring of the upper temporal and occipital regions. 1000 follicular unit grafts containing 1 to 3 hairs were transplanted: 350 to restore the sideburns, and 650 into the temporal and occipital scars.
Case 4 (see Figure 4)
69 year old female, 2 years status-post rhytidectomy and coronal browlift, with significant recession of the entire hairline, loss of temporal tufts, and thinning of the upper temporal region. A total of 1400 follicular unit grafts containing 1 to 3 hairs were transplanted: 300 to restore the sideburns, 800 to advance the frontal and upper temporal hairlines, and 300 to restore density to the upper temporal and lateral frontal regions.

Continued on page 3

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