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!
