Surgical Treatments for Hair Loss

History of Hair Loss Surgery

As early as the 1930’s, Japanese physicians were successfully harvesting and grafting multiple and single hairs into other areas of the body, including the scalp, face, and pubic region. The reports of these procedures were written in Japanese; this, together with the onset of World War Two, insured that the Western world remained in the dark until the late 1950’s.

In 1959, New York dermatologist Norman Orentreich reported hair-bearing scalp autografts (from the same person) that were successfully transplanted from the back of the head to the balding front and top. Thus the concept of "donor dominance" was introduced, and the discipline of hair restoration surgery in the West was born.

Donor dominance is the central functional principle of hair transplant surgery. What this means is this: if one harvests hair follicles from the "permanent zone" of the scalp, and transplants it to the balding areas, the donor hair characteristics will predominate. In other words, since this donor hair is genetically programmed not to respond to the male hormone DHT by becoming miniaturized, it will continue to grow and thrive even though its location is now in a balding "zone".

Evolving Aesthetics of Hair Transplantation

For the first 20 to 25 years of hair transplantation, 3-4mm (millimeter) round, "plug" grafts were the standard units generally placed in balding areas. These were felt to be the optimal size grafts in terms of density (hairs per square mm) and in terms of blood flow (nourishment) to the tissues of the graft. In other words, these grafts, with 12 to 20 hairs each, could achieve high density in the recipient (balding) area; also, bigger grafts would be easier to move, but re-establishing their blood flow, especially toward the center of the grafts, would be tricky. Later, this was found to be a problem even with these standard grafts, and sometimes the hairs in the very center of the graft would die, leading to the appearance of a hole in the middle, hence the term "donutting".

Other cosmetic problems were soon recognized. Often, a raised area at the base of the graft led to the aptly named "cobblestoning" effect. Probably the most widely recognized negative effect is the so-called "doll’s hair" "toothbrush" or "cornrow" appearance. This results from a dense, round graft set in the midst of bald scalp; the effect is worsened by the fact that, as the graft heals in place, scarring causes it to contract. This increases the density (compresses the hairs into a bundle) even more, to a level not found anywhere on the head, therefore appearing unnatural. When these round grafts were placed at the frontal hairline, they often appeared as an inhumanly straight, regular row, which is not the way hairs grow in nature. Furthermore, if the patient’s balding progressed, these grafts stood out even more, to the point of becoming a cosmetic nightmare. Also, if the hair behind the grafts was lost, there developed an unnatural look further back in the scalp; this appears as a posterior, or "rear" hairline.

In addition, the normal, natural direction of hair growth was not honored. Hair from the crown up to the front grows in a generally forward direction; there is a "whorl", or circular effect at the crown, and at the temples the hair abruptly changes to a downward, and then backward, direction. Often the large grafts pointed up at right angles regardless of location, which added to the less than natural appearance, and could severely limit styling options.

From a logistical standpoint, grafting with standard plugs could be a nightmare. Usually, these were done in small sessions of 20 to 50 grafts at a time; then sessions were repeated after a period of time. This might require 4 or 5 sessions to "complete" the work; if financial, health, job, or other circumstances supervened, the work might not be finished, leaving the patient in an embarrassing state of incompleteness. Moreover, if baldness progressed, the rear or side margins of the plugs could then be seen by the casual observer.

Finally, using large, round grafts is an extremely inefficient use of the donor hair supply. Much hair is left in the scarred spaces between the circular holes in the donor area. The punch tool must be held perfectly parallel to the angle at which the hair emerges from the scalp; otherwise, many of the hair follicles at the edges of the graft will be transected, or cut in two. This destroys the hair, or, at the very least damages its ability to grow and thrive. Making the punch tools smaller failed to solve the problem the problem of transection; with a smaller graft, an even higher percentage of hairs per graft could be damaged. Likewise, when 4mm grafts were "quartered" or otherwise divided into smaller grafts, this required further trauma and manipulation with resultant follicular damage or destruction.

Many men were happy just to have hair again, and never complained about these cosmetic conundrums, or were aware of the technical limitations. However, certain creative surgeons begin to move toward a higher aesthetic ideal. In the early 1980’s, hair restoration specialists began utilizing minigrafts and micrografts. We define minigrafts as containing 5-10 hairs, and being between 1 and 2.5mm in diameter. Micrografts are smaller still: 1 to 1.5mm, with 1 to 3 hairs. Follicular unit grafts are the naturally occurring growth units of hair, and will be discussed in great detail in subsequent sections.

What were the benefits of these smaller grafts? For one thing, they could be used to "soften" the hairline. The hairline is naturally a feathered, indistinct, and variable entity; it is not abrupt, extremely dense, or regular. Usually, the first row or two of the hairline are single hairs, a "transition zone" between the hairless forehead and the hair-covered scalp. Also, the line is not straight at all, but irregular. Placing these small grafts at the hairline, in front of the larger, round grafts, gave a more pleasing, natural look, especially with the hair swept back or diagonally to the side.

Despite this and other benefits of using mini- and micro-grafting techniques, there was still a major downside (and still is today, as some hair transplant surgeons stubbornly cling to the old but familiar ways). Minigrafts can still produce the artificially high, local density leading to the doll’s hair look; they have a tendency to appear "pluggy". Also, grafting large areas with micrografts often can give a "see-through" or excessively thinned look. The reason for this is quite important to understand; although a 2 hair follicular unit and a 2 hair micrograft contain the same number of hairs, the devil is in the details; the major detail is in the way they are cut. Follicular units are dissected out intact, using a microscope, and thus have the minimal amount of tissue present to support the hairs. Conversely, micrografts are cut without regard for the follicular unit structure; a 2 or a 3 hair micrograft may contain hairs from as many as 2 or 3 separate follicular units! As such, they contain much more tissue than corresponding follicular units, require larger recipient incisions, or even holes, and cannot be placed as closely together. Healing takes longer with these excess tissue-containing grafts, and their larger incisions, and it may be that breaking up the fundamental unit of hair growth inhibits the very survival of the grafts themselves.

Scalp Flaps

Plastic surgeons have developed methods of advancing hair-bearing "flaps" of tissue from one area of the scalp to another. For example, a strip of scalp from the non-bald temple might be freed up, and rotated forward to the bald frontal hairline. A small area of the flap is left attached in order to preserve the blood supply of the tissue. Unfortunately, sometimes the blood circulation is compromised, leading to tissue necrosis, or death of part of the flap. This can cause visible scarring, as well as loss of the hair (!) from that portion of the flap.

The benefit of flap procedures is that one has an instant "growth" of mature, full-length hair in the previously bald area. There is nothing subtle or gradual here! This may be a social liability if one desires privacy regarding the surgery.

This is major surgery, requiring a hospital operating room. Bleeding and infection are other possible complications. Also, there is a cosmetic downside. A hairline constructed with a flap is likely to be unnaturally straight and overly dense, unlike the natural "feathered" transition zone found in a natural or surgically well-constructed hairline. The inevitable scar at the leading edge of the flap may also be apparent to the observer. Also, there may be thinning or balding scalp behind the flap, which requires camouflage. Alterations from the normal direction of hair growth can appear nothing short of bizarre. Thus we see little benefit and abundant potential for negative outcomes with flap procedures.

Scalp Reductions

This group of procedures are collectively known as alopecia reductions, baldness reductions, male pattern reductions, and by other names. The basic premise is, that by excising, or cutting out, a segment of bald scalp, the baldness is reduced. This provides an immediate and relatively dramatic improvement in the balding appearance, and the added benefit of less area needing to be grafted. This would limit the strain on the patient’s finite "donor reserves", meaning the hair available from the permanent zone that can be harvested for grafting. This may seem intuitively obvious at first glance, but consider this: when scalp is removed from the crown area and the top of the head, the sides and back are pulled up in order to approximate the wound and suture it closed. The effect this can have on the donor hair in the back and sides of the head is to decrease the density of this hair.

Other problems that slowly became evident included the phenomenon of stretchback, whereby the natural elastic properties of the scalp skin overcame the tension element of the scalp reduction, and some or all of the benefit would be lost. Hair loss may be accelerated by scalp reductions, in the opinion of some hair surgeons; we definitely know that "shock loss", or effluvium, can occur around the incision. Some of this shock loss hair may or may not grow back, largely depending on its state of miniaturization.

Scarring is one of the most significant complications seen after scalp reduction. There are a number of incisional patterns that surgeons use: the midline ellipse, Mercedes star, Z-plasty, and lazy-S. The end result of any of these will be a scar in the shape of the sutured wound. This scar may be more or less noticeable depending, in part, on whether there is continued balding in the area, or how closely adjacent to the scar dense hair is found. The fact of the matter is that the patient’s donor density and scalp laxity can be reduced by the procedure. These are two of the determinants of the amount of donor "reserves" remaining. If they are reduced enough, there may not be enough hair left to graft over the scar if it is, or becomes, obvious to the casual observer. This is a major cosmetic problem.

While scalp reductions are often done as series of two or three, some surgeons will substitute for the series by doing one large procedure. This is known as a scalp lift or hair lift. It requires general anesthesia, and essentially undermines the scalp down to the ears and down to the neck. Then, the loose scalp is pulled up, the balding area removed and the wound edges stitched together. It is also standard procedure to ligate, or tie off, the major arteries to the back of the head, called the occipital arteries. Usually, the occipital nerves are sacrificed in the bargain, leading to significant and long lasting scalp numbness.

There are also various types of scalp expanders, both inflatable and spring-type. Both types are surgically implanted, and are designed to stretch the scalp prior to the reduction surgery. Their effects are variable, and although some surgeons seem to do well with their use, many of the same potential drawbacks of scalp reductions may occur.

Two other well-known cosmetic deformities resulting merit mention here. One is the loss of normal hair direction, often manifesting as the "parting of the Red Sea" phenomenon. This occurs because when the scalp is pulled up from the sides, and then becomes situated on top of the head, its hair will still emerge at its native angle. In short, it may appear to stick out to the sides from the midline in an unnatural way, like the biblical parting of the Red Sea. Another is the "posterior slot" formation, which also occurs as the result of scalp reduction surgeries. This "slot" appears as vertical scar running down the crown of the head, with the adjacent hair angled out flatly. This is a very obvious deformity; there is a flap surgery designed just to correct this problem (!), but it is complex and not performed well by many surgeons.

We feel that scalp reduction procedures generally have a very high risk to benefit ratio. As such, we would rarely recommend these surgeries, except in certain selected patients with the ideal hair and scalp characteristics, of the optimal age, and who are highly motivated. With all other factors considered, properly performed follicular unit transplantation (FUT) can produce natural, undetectable results, without cosmetic deformity, in patients who are candidates for this procedure. In the next section, we will discuss, at length, FUT, why and how it is done, the rationale for, and history of, its development, and its potential drawbacks.