The natural history of balding is simply
the way it first presents or appears, the different ways
it progresses, and how it affects the different regions
of the head. We consider it vital that anyone with common
balding become familiar with these concepts. If you can
become as conversant as possible with the different balding
patterns, and can learn to compare and contrast your own
hair loss with these known patterns, you will become a
more informed patient. You will ask better questions,
understand the answers in more depth, and be more likely
to take care of the hair that you do have. Also, if you
choose a medical or surgical hair restoration treatment,
you will most likely have appropriate expectations, and
be more apt to follow the doctor’s instructions
about post-operative care or taking your medications.
In the beginning, we are born with varying amounts of
soft, fine baby hair, which is vellus in nature. As we
grow, much of our hair becomes the more robust terminal
type. It may change in pigmentation, often becoming darker,
and it may acquire a curl or wave, and may become coarser.
After puberty, we see what we call the adolescent hairline.
This type of hairline may only persist for a few years,
and is characterized by its low, fairly flat spread across
the forehead. This looks great on teenagers, but this
is rarely found on mature adults, even in their twenties.
As men progress through their twenties, given that there
is no balding, the hairline assumes the "mature"
look, with slight frontal-temporal recessions, which impart
a concave appearance to the hair line on each side, with
a lower peak in the middle. This is analogous to the number
"II" Classification on the Norwood scale (fig.
3). This is the most well known of several systems for
classifying degrees of baldness, and was developed by
Dr. O’Tar Norwood. This is a very useful scale for
identifying one’s own current degree of hair loss
in a way that is acknowledged and understood by physicians
in the field of hair loss treatment.
This "mature" hairline is not considered balding;
the Norwood III is considered the first evidence of balding
in androgenetic alopecia (male pattern baldness). In studying
the Norwood charts, we see that usually the most advanced
balding is known as a class VII, and that there are also
Type "A" variants in which the forelock in the
middle tends to recede along with the fronto-temporal
areas, and in which there is be less overt crown loss
than in the regular III, IV, and V patterns.
Figure 3
So there may be front-to-back hair loss, or hair loss
beginning in front and at the crown simultaneously, or
sometimes isolated vertex or crown loss (the "bald
spot"). These patterns are often overlapping and
not as clear-cut as in the drawings on the chart, but
they are an adequate and useful guide. It is important
to understand that a person may be a III at age 25, but
have progressed to a V or VI by age 35. Anyone considering
surgical hair restoration needs to understand the unpredictable
nature of the balding process; if further loss is not
planned for, then what may be a nice cosmetic effect at
one age can become a cosmetic nightmare ten years down
the road. We will devote an entire, later section to just
this kind of strategic planning.
A word about women’s hair loss: women can experience
a Norwood type of hair loss pattern. More often, however,
they experience a relative sparing and preservation of
the frontal hairline, but have diffuse thinning on the
top of the scalp. There is also a classification system
for women known as the Ludwig Classification (figure 4).
Figure 4
Sometimes women are candidates for surgical hair restoration
due to balding, and at times have lost hair due to other
cosmetic procedures, like face-lifting. This hair loss
is often around the hairline or ears, and can be remedied.
Women may also experience "traction alopecia",
which is caused by the chronic tugging force of tight
braids or pigtails. This type of loss is also amenable
to transplantation.
We have attempted here to stress the relative unpredictability
of "pattern" baldness. This must be reemphasized.
Often, young men seek hair transplantation and have desires
or illusions about how they would like to appear. These
may or may not be feasible. Certainly, when one is 25,
it may be hard to care about one’s appearance at
45, but this must be factored into the equation. The recent
memory of the low, adolescent hairline burns brightly
in the mind of a young man, but a really good hair transplant
procedure should always give the patient results that
can be "worn" for a lifetime, and always appear
appropriate for that individual’s age and head shape.
This is where the attention of an experienced, well-trained,
aesthetically sensitive hair restoration surgeon makes
all the difference in the world.
