Discussion

The role of hair restoration in women is becoming more recognized as an option in the treatment of a variety of hair loss conditions. Women are increasingly learning that they can benefit, as do men, from the newer techniques in surgical hair restoration. While there are certain inherent limitations in the results of hair restoration for the treatment of female pattern hair loss, it is the author's experience that, when they are appropriate candidates, these patients are amongst the happiest. For many of these women, the results of a relatively small number of hairs transplanted strategically into areas of maximum benefit, can restore confidence, and avoid the need for the wearing of a hairpiece or hair system.

Several types of female pattern hair loss have been described in the literature. From a therapeutic perspective, it is necessary to divide these many patterns into two general patterns: diffuse thinning, and thinning concentrated along the top of the head similar to male pattern hair loss. Because the second pattern tends to have a better donor hair density, it is more suitable for treatment with hair restoration. Divided into 3 stages, those with stage 1 and most cases of stage 2 have sufficient donor density to provide sufficient hair to make restoration worthwhile. In addition, those with the diffuse thinning pattern can usually benefit from hair restoration, although not as impressively.

Hair restoration for pattern hair loss in women is not merely the same procedure as performed in men. As discussed in the technique section, certain precautions must be taken to minimize iatrogenic hair loss in the recipient region, which seems to occur much more frequently in women. Precautions include using local anesthetics that do not contain epinephrine, and minimizing of the number of recipient site incisions and using larger grafts so as to achieve a maximal increase in hairs per graft placed. Patients with moderate to advanced patterns are advised on the probable need for a second, and perhaps additional procedures. Even in cases where satisfactory density was achieved after one procedure, the progressive nature of pattern hair loss usually makes necessary the performance of an additional procedure in the future.

The treatment of hairline distortion from prior cosmetic surgery utilizes smaller follicular unit grafts than the larger grafts for treating female pattern hair loss. The most challenging area to restore is the lost sideburn. In no other part of the scalp are the hairs as fine, or the direction of growth so distinct and critical for natural appearing results. However, when properly performed, patient satisfaction with what was otherwise a successful facelift procedure can be restored.

Other techniques have been described for sideburn restoration, including transposition flaps (3,9) and micro-minigrafting.(10) While it does restore the sideburn, the flap procedure results in an unnatural dense appearance, can create further alopecic scarring of the adjacent donor site, and does nothing to restore any thinning or posterior hairline displacement of the temporal region. Micro/minigrafting procedures are an improvement over flap repair, but tend to result in a less than natural "grafted" appearance with detectable grafts and hypopigmented scarring of the skin around the grafts.

Follicular unit grafting is the natural evolution of the micro/minigrafting procedure. All grafts are dissected out using the microscope or other form of magnification, and contain a single follicular unit. The follicular unit is the natural bundling of hairs as they grow in the scalp. This technique is the author's procedure of choice for nearly every hair restoration procedure he performs, because the results are the most natural in appearance and recipient scarring is minimal to non-existent.

For the most part, hairline distortion is a preventable event with rhytidectomy. With secondary and tertiary procedures, or when significant upper and mid-upper facial rejuvenation is sought, hairline distortion becomes more difficult to prevent. The "traditional" rhytidectomy incision extends from the supra-auricular crease through the temporal region in a mostly vertical direction, displacing the entire temporal hairline, including the sideburn, superiorly and posteriorly. Alternate incisions, such as one that extends mostly horizontally from the supra-auricular crease through the upper aspect of the sideburn (peritemporal trichophytic) can minimize hairline distortion. Beveling of incisions, so that follicles are preserved along the leading edge of the incision, minimizes scarring.

When transplanting into scar tissue, hair growth can often be compromised. This is probably because the decreased blood supply is not able to support the growth of transplanted hair follicles. It is the author's experience, as well as that of others in the literature, that transplanted hairs will indeed grow in the scar.(11) The percentage of "take" of the transplanted hairs is reduced, sometimes by as much as 50% (this versus the greater than 90% growth rate of hairs transplanted into normal non-scarred tissue). To compensate for the reduced percentage of hairs that will grow, the author transplants 4 hair grafts where it is hoped that 2 or 3 hairs will actually grow. It is also important that recipient sites be made slightly larger and/or deeper, so as to promote bleeding and potentially enhance the neo-vascularization of the graft hairs.

While this paper has focused upon the surgical treatments for hair loss, it is important to remember the role of the medical work-up for female pattern hair loss. While very unusual, hair loss in women can be due to a number of medical causes, including elevated levels of testosterone, hypothyroidism, nutritional factors, and post-pregnancy hormonal changes. In the female presenting with pattern hair loss, in addition to taking a thorough history and examination, several lab tests are conducted, including thyroid function, total testosterone, and DHEA-sulfate.

REFERENCES
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11. Barrera A. The use of micrografts and minigrafts for the treatment of burn alopecia. Plast. Reconstr. Surg. 103:581-584, 1999.

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