Making Informed Choices (About a Life-Long Decision)

Deciding to use medical and/or surgical hair restoration techniques is indeed a life-long choice. At least with the medicines available today, continued use is required to maintain the benefits. Surgery, whether it is scalp reduction, flaps, older styles of transplantation, or state of the art follicular unit transplantation, will produce results, for better or for worse, which will persist for a lifetime. Therefore, this is a decision to be entered into thoughtfully, reasonably and with a working knowledge of the procedures and of the possible pitfalls. To assist you in this informed decision-making is the major purpose of this manuscript.

So let us revisit for a moment some of the salient points that have been made thus far. First of all, there is the significance of hair itself. Hair, or its absence, has been historically, and continues to be, of singular importance, culturally and individually. Like it or not, hair and hair styling speak volumes about our tastes, our station in life, and our attitudes. Hair loss may have a powerful affect on how we are seen and potentially how we feel about ourselves. Although some may see this as indicative of a current cultural vanity or superficiality, an interest in, if not an obsession with hair has existed for millennia.

We have learned that hair grows as thick, strong terminal hairs and also as soft, fine vellus hairs; also important is the concept of the stages of growth: anagen (active), catagen (transitional) and telogen (resting). We now recognize that hair is grouped together as "follicular units" of one, two, three, or more terminal hairs, along with vital supportive structures. Transplanting these single follicular units is recognized as the state of the art in current hair restoration surgery.

Remember that the cause of balding in men and in women is most often what we term androgenetic alopecia: this simply means that, in someone genetically predisposed, the effects of androgenic hormones (especially dihydrotestosterone, or DHT) over time lead to the process of miniaturization. It is this miniaturizing of the normally robust terminal hairs that leads to the condition we define as baldness, or thinning. The fine, short, less pigmented (vellus) hairs that remain are inadequate to provide the scalp coverage necessary to block light. It is this light shining on the scalp that causes the appearance of balding. In addition, the anagen, or growth phase of the hair, becomes progressively shorter, until eventually the hairs are lost for good. It is important to note, that at this point our current medications for hair loss will no longer be of assistance in preserving hair. These drugs are only useful in slowing or reversing the miniaturization process.

Useful tools for patients and physicians in staging the balding process are the Norwood and Ludwig classifications. These are "typical" patterns of male and female hair loss, respectively, but are only guidelines. They allow us to "speak the same language" when discussing balding patterns. Remember, however, that it is difficult or impossible to accurately predict the eventual progression of hair loss in any individual. Thus, it is usually crucial, especially in younger men, to assume that the pattern will at some point progress to its ultimate conclusion (in other words, to a Class VII, or complete baldness). This awareness is also invaluable in helping the hair transplant candidate develop realistic goals for hair restoration, so that the result can stand the tests of time and of continued hair loss. A true value is achieved if the surgical product is aesthetically appropriate not only at an earlier age, but also as the person continues to age.

There exist various medical, surgical and prosthetic remedies for hair loss. No one method is right for everyone. Wigs, or "hair systems", for example, may be the only option for the individual with very advanced balding and minimal donor hair available. These hair systems are manufactured in a wide variety of styles and attachment modes; they may be cheaply mass-produced, or custom made, with great care and a correspondingly high price. Many people think that a hairpiece or weave will be much less expensive than surgical hair transplantation. On further consideration, however, we realize the following: hair transplantation is naturally growing hair that persists for life, and may possibly require a single procedure only. Hairpieces, on the other hand, wear out and must be periodically replaced. In addition, two must usually be purchased, and regular maintenance is a feature of almost every type of hair system. The fees for this routine maintenance add up, and over the lifetime of the individual, can entail more financial investment than a surgical procedure! There are also some types of systems that may actually accelerate the process of hair loss.

There are as many "cures" and treatments for hair loss in the marketplace as there are entrepreneurs. Unfortunately, despite all the testimonials and "before and after" photos, none of them have been shown to work. Non-drug therapies are not under the aegis of the Food and Drug Administration (FDA), and therefore can make claims that may not be based on controlled scientific trials. Drugs, however, are required to pass rigorous testing for safety and effectiveness under the auspices of the FDA, and we currently have two such agents available: minoxidil (Rogaine) and finasteride (Propecia). These drugs will not re-grow hair where none exists, but they may slow or even reverse the miniaturization of terminal hairs in some people.

Like any drug, these two medications may cause side effects, although at this point they are both felt to be fairly safe. One drawback to their use is that the benefits are reversible. In other words, any advantage gained from using the drugs is lost with in a few months of stopping the medications. Also, they do not work for everyone, and their effects are generally more pronounced in the back of the head, rather than in the frontal or hairline area, which is usually more cosmetically important than the crown.

The art of surgical hair restoration has been widely practiced in the United States for about four decades, but it could be said that many of the major innovations in the field have largely taken place only during the past ten years. Throughout the decade of the 1990’s, older, more invasive procedures such as flaps, scalp lifts, and scalp reductions were abandoned by many. At the same time, cutting-edge hair surgeons began advocating follicular unit transplantation as the state of the art, along with its associated techniques of single strip donor harvesting, stereomicroscopic graft dissection, and, often, large sessions of a thousand or more grafts. A desire to preserve as much of the precious donor hair as possible for the future led to a new focus on the donor area; also, the development of new techniques for decreasing trauma to the recipient sites produced quicker healing, and less postoperative "detectability".

We have discussed at length the different regions of the scalp, and their varying importance in terms of the hair restoration process. The hairline and frontal area are usually of paramount consideration, because of the aesthetic impact of "framing the face". The crown, on the other hand, may be of somewhat less significance, as well as being an area that may consume vast quantities of donor hair for a minimal cosmetic impact. Again, the importance of long term planning cannot be overstated. The patient’s hair density, hair characteristics (color, curl, caliber), age, degree and type of hair loss, previous procedures, potential for "shock loss" (telogen effluvium), and budget all play a role in determining the eventual outcome of the transplant.

Another oft-neglected topic is the suitability of women for hair transplant surgery. Interestingly, although a large percentage of the balding population is female, only a small, albeit growing, number of the hair transplants performed yearly involve women. The reasons for this are varied. Many women have no idea that they may be candidates. Also, women’s hair loss is often more diagnostically complex than men’s, and a number of other disease processes may need to be ruled out. Be that as it may, we do know that hair loss may be even more emotionally devastating for women than it is for men.

Also significant, for either gender, is the decision to have a second or subsequent procedure. These can be undertaken for a variety of reasons. One is to refine or lower the hairline, and another is to increase fullness or density. Crown restoration is also a consideration. An often-unforeseeable occurrence is simply the progression of the patient’s hair loss; this may happen rapidly, or advance slowly over years or decades.

The concept of long term planning will be an obvious priority to the kind of surgeon you will want to work with. As we have stated before, technical expertise is mandatory, but is not enough. Your hair transplant surgeon must also have the aesthetic, visionary, and ethical qualities to help you make the correct, sober and realistic decisions that will be necessary for an optimal outcome. Does he discuss with you the cosmetic impact of planned procedures? Is there a concern not only for the immediate future, but also for the transplant you will be wearing for life? Is he willing to tell you what you may not want to hear about your hair characteristics, donor density, pattern of balding, and other factors which must be taken into account? And does he have the courage to postpone your surgery, or even refuse it, if that is truly in your best interests?

These are questions that will cast a light on the moral, technical, and artistic character traits of the person in whom you are placing your trust. These decisions are not always easy ones. Ask the questions, but also learn to trust your instincts, or your "gut" feelings. If you respect your physician’s character and motives, then allow him to counsel you. He will help you come to a reasonable conclusion. Remember, as you go forward with your plan, that a sense of trust will alleviate your anxiety about the surgery, as well as improving your level of confidence. Taking such a step toward boosting your self-esteem and refining your image is most ideally undertaken with poise, enthusiasm, and great optimism. Indeed, the hair transplant experience could be the most profound step you ever take in advancing your physical appearance and emotional wellbeing. Enjoy it!