Women and Hair Transplants – A New Relationship

Introduction: For many years, men were the primary beneficiaries of hair transplantation. However, with the development of more refined techniques, there are now many applications of hair transplantation in women, including the treatment of female pattern hair loss, hairline advancement, eyebrow and eyelash restoration, and the repair of the sequelae of certain plastic surgery procedures. Whereas not more than six or seven years ago seeing women in consultation about hair concerns was rather unrewarding, I now eagerly look forward to treating women due to the tools and experience I now have to successfully help them. Today, women make up over 20% of my patients, and this number continues to steadily rise.

What’s New in Hair Transplantation for Women?

What’s new for women is what has been evolving for the past seven years, to allow for many more successful applications of hair transplantation. Follicular unit grafting, now the state-of-the-art technique, has evolved during this time period to become the technique of choice, capable of creating the most natural appearing results. Of particular benefit to women is that these tiny follicular unit grafts are able to be placed into similarly tiny-sized incisions, expanding the applications to such refined areas as the eyebrows, and permitting the placement of donor hairs between existing hairs in areas of thinning.

Follicular unit grafting involves the microscopic dissection of grafts that consist of just the follicular unit- the hair bearing portion of the scalp. Within each follicular unit are one to four, most commonly two, terminal hairs, and supporting elements, typically wrapped in a fine adventitial sheath. Under slightly magnified visualization (or really good eyesight), these follicular units can be seen at the surface of the scalp as tiny bundlels of a few hairs all emerging as a group. To obtain these follicular units, the donor tissue is removed as a single strip typically ten to 14 mm in width, the defect then sutured closed primarily. From the donor strip, the microscope permits the dissecting away of all non-hair bearing tissue, leaving just these tiny individual follicular units. The microscopic nature of these follicular units allow for them to be placed into similarly sized tiny recipient site incisions. These incisions measure 0.5 to 0.9 mm in size, depending upon the location of the transplant and the number of hairs contained in the graft.

To successfully perform these procedures which can consist of as many as 2600 or more grafts, a team is needed. In my practice, 11 hair transplant technicians assist me. Each one has her/his own binocular microscope, and certain areas of expertise in the process. While some specialize in placing grafts, others in the dividing up of the large donor strip into individual slivers, all assistants participate in the dissecting process. Taking care to maintain the grafts in a moist environment, they are kept in chilled saline in Petri dishes each containing the same sized grafts, awaiting placement into recipient sites. Because of the importance of the recipient site in determining the pattern, direction, angle, and distribution of transplanted hairs, these incisions are all made by me. For the past two years, we have cut our own recipient site blades, cut to the exact size needed. To assure proper recipient site size, such that the grafts atraumatically but snugly fit into the sites, proper size is confirmed early on by test planting some grafts. Once the proper sizes are determined, all of the recipient sites in an area are made, then the grafts can be placed. Then, later on in the case, to achieve greater density, more recipient sites can then be made between the already placed grafts.

These procedures typically take 3 to 5 hours to perform. Afterwards, no bandages are applied, and the patient may begin hair washing on the second day. Growth of the transplanted hairs typically begins by 3 months, with full density reached at 8 to 12 months, depending upon the rate of hair growth. In the future, if desired, an additional procedure can be performed to increase density or provide a greater amount of coverage.

WHAT ARE WE TREATING

Female Pattern Hair Loss

Affecting as many as 10% of all women, female pattern hair loss is, like its male counterpart, a genetic process. As such, it is progressive, starting in women as young as their late teens, but much more commonly affecting women peri- or post-menopausal. A variety of conditions can accelerate the hair loss, but almost always there is some genetic component as the basis of the process. Some of these more common conditions include poor nutrition (often associated with special diets), anemia, and hypothyroidism.

Female pattern baldness (FPB) occurs along several different patterns, the most common consisting of diffuse thinning along the top and upper sides and back of the head, often sparing the frontal hairline.(1) In this classic FPB pattern, the hair loss is divided into 3 stages according to the Ludwig classification scheme, with stage 1 consisting of mild hair loss, with stage 3 extensive hair loss.(2) However, while this classification scheme is useful from an academic standpoint in its description of the degree of hair loss, it does not have much efficacy in assessing the degree of improvement that can be expected, and therefore help in counseling the patient. This is because the two most important predictors of success- or disappointment- are the density of the donor area, and the pattern (diffuse thinning versus patchiness) of hair loss in the recipient area(s). By density of the donor area, I am referring primarily to the presence of hairs of thick caliber as the most important predictor of success, and secondarily to hairs that grow closely together (dense concentration). By type of hair loss in the recipient area, the most important feature that determines success is a pattern of hair loss characterized by patchiness- large areas of non-hair bearing skin between the existing hairs- and of secondary importance the presence of hairs that are of normal to above normal caliber. The worst candidates are those with fine donor hairs (no matter the concentration of these hairs) and recipient areas characterized by diffuse thinning without large spaces between existing hairs into which large numbers of grafts can be inserted. To help deal with these variables, I have developed a simple classification scheme, where the caliber of the hairs and the degree of patchiness between these hairs are rated on a 1 to 5 scale (with 3 the average) for both the recipient and donor site areas. So, for example, a great candidate for a transplant procedure would be a woman who has, most importantly, a donor area hair caliber of 4/5 or greater, and a recipient area patchiness of 3/5 or greater.

When transplanting women with female pattern baldness, the finite supply of donor hairs limits the amount of coverage that can be obtained. While most women would like to have all the thinning areas treated, the work should be concentrated in those areas where it will provide the maximum benefit. Most commonly, these areas are the frontal region just behind and up to the hairline, and along the part line. For the best results, the procedure should maximize the number of hairs transplanted while minimizing the trauma to the existing hairs. This is usually best accomplished by the placing of two or three follicular unit grafts (for a total of, on average, three to five hairs) into each recipient site- except along the hairline where only a single graft containing one or two hairs is placed to assure a natural appearance. Patients can be assured that the growth of several hairs from a single recipient site will in no way give an unnatural “transplanted” appearance, because they are used to fill in areas between existing hairs.

In the typical case, 1000 to 1200 grafts (or around 2400 hairs) are transplanted. The recipient sites are slits made by blades 0.6 mm typically up to 0.9 mm in size- very tiny but a major boost in avoiding trauma to surrounding hairs. The grafts are carefully placed into the incisions, keeping them moist to maximize hair growth. To minimize ischemic shock to the existing hairs, the local anesthetic contains a low concentration of epinephrine, generally less than 1:200,000. To further minimize the loss of hairs due to shock, and to accelerate the regrowth of the transplanted hairs, the patient starts at 2-weeks post procedure the daily application of minoxidil 2%. With this regimen, the hairs can be expected to start growing at 2 ½ months, rather than the typical 4 months

The Sequelae of Prior Plastic Surgery, and Advancing Overly High Hairlines

Another common condition in women effectively treated with hair transplants is the alopecic scarring and hairline distortion associated with prior plastic surgery. The most common types of distortion are hair thinning and loss in the superior temporal region, and.the loss of the sideburns from rhytidectomy incisions that extend superiorly into the upper temporal region, thus pulling the temporal tuft along this superior vector.(3,4) While this incision design helps to improve ptosis of the lateral eyebrow, it can result in hairline distortion. Another distortion is the excessive elevation of the frontal hairline associated with coronal browlift incisions in patients with pre-existing high foreheads.(5) Meanwhile, alopecic scarring most commonly occurs along the frontal and temporal incisions of browlifts, and the occipital incisions of rhytidectomy. The goal of hair transplantation in these cases is to restore hair growth in the scarred and thinned out areas, and to recreate the normal anatomy of the temporal tufts and the frontal and temporal hairline.

The management of scarring from prior facial cosmetic surgery usually includes the restoration of the sideburn and other areas of distortions, and the repair of alopecic scarring. Aesthetic restoration of the sideburn begins with the recognition of its natural appearance in terms of location, direction of hair growth, and feathered look. Of particular importance are the superior to inferior, anterior to posterior direction of hair growth, and the fineness of the hairs, especially along the anterior and inferior borders. Areas of scarring, typically located in areas surrounded by hair, should be transplanted with larger grafts, so that even if there is less than the expected 90 percent of hair growth in the scar tissue, there still is the potential for sufficient coverage.

Lowering overly high hairlines is effectively treated by one of two different procedures. The most common technique in my hands is hair grafting. In a typical case, 1700 to as many as 2600 grafts are closely placed to fill in the pre-existing hairline (so as to maximize density) and in front of the frontal hairline to lower it as desired. Attention must be paid to the direction of the existing hairs, with many recipient sites needing to be placed at varying angles and directions, including following cowlicks, to assure naturalness.

The other procedure for hairline advancement is the surgical technique, in which a sufficiently flexible mobile hairline is advanced forward into the forehead, removing excess forehead skin then approximating with a trichophytic closure technique to assure hair growth through the scar. In some patients, a browlift can be combined with the hairline advancement procedure if the brows are ptotic. Furthermore, in those patients with quite tight scalps, scalp expansion can be used to enhance the amount of hairline advancement achievable.

Eyebrow and Eyelash Restoration

No procedure has benefited more from the technical advancements in hair grafting than eyebrow and eyelash restoration. These hairs not only play an important role in facial aesthetics, they also help to protect the eyes. These procedures are effective for restoring density, or to completely restore the normal anatomy, for both cosmetic and reconstructive indications. Etiology of hair loss in these areas are numerous: voluntary plucking when tapered fine eyebrows were in fashion, or involuntary plucking (trichotillomania); genetics; alopecia areata and other dermatologic conditions; medical conditions such as hypothyroidism; and trauma. When due to trauma, the absence of hair is made more noticeable because of the typical hypopigmentation of the skin. While important to identify any potentially treatable etiologies so as to slow down or stop the further progression of hair loss, nearly all patients with an absence or thinness of the eyebrows or eyelashes can be successfully treated with transplants.

Prior permanent makeup is not a contraindication to having the procedure- however, with the eyebrows, the presence of the tattoo may largely determine the position of the new eyebrows. However, I have had excellent results, in the occasional case where the tattooed eyebrow were placed in a significantly unaesthetic position, with the complete excision of the tattoo and primary closure of the fine line scar, which is then concealed with a subsequent eyebrow transplant procedure. In terms of indications, the best candidates are those with a slight curl to their donor hairs, so that the curl can be harnessed to assist in the desired direction of growth. For African Americans, I have only performed eyebrow, not eyelash transplants, and have had nice results with patients in this ethnic group. Because the hairs usually come from the scalp (I have performed several procedures using leg or big toe hair), they will need to be trimmed monthly. Sometimes the application of hair gel may also be of benefit to control the direction of hair growth..

For eyebrow restoration, most patients have a procedure ranges from 250 to 300 grafts per side- however, I have transplanted as many as 375 grafts into a single eyebrow. Typically, of the hairs transplanted, 70% will grow, and of these hairs that grow, 10 to 15% of them will grow in an aberrant direction (either too vertical or not flat enough to the skin) despite being planted in an aesthetic direction. These “rogue” hairs can be either cut short or simply plucked out, and for my patients, have not been enough of a deterrent to having the transplant.

The grafts are dissected under binocular microscopic visualization. The majority consist of single hairs, but two hair grafts are used for patients with medium to finer hairs to achieve greater density when desired, especially in the central aspect of the body. Recipient site creation is the essential aesthetic step. In the medial-most aspect of the brow, the hairs tend to grow vertically. The hairs then rapidly change from a vertical to a horizontal direction of growth as one proceeds laterally, with the hairs cross-hatching in the middle section, enhancing the density. In addition to the vertical and horizontal axes, the angle of the recipient sites should be as shallow to the skin as possible to allow for the hairs to grow in a flat position relative to the forehead, avoiding their growing or sticking “out”. The recipient sites are made using blades cut to 0.5 mm in size, with a 0.6 mm blade required in those occasional patients with extremely thick hairs. These tiny blades have several advantages: they allow for the closest possible placement of the hairs to each other; they minimize the risk of damage to already existing hairs; and, they allow for greater control of the direction and angle of hair growth

For eyelash restoration, I have to date limited all but one of my cases to the upper eyelid. In my one case of lower eyelid transplanting, a good outcome was achieved with a procedure of approximately 15 grafts to the lower eyelid to provide at least a minimum amount of growth. The technique of eyelash transplanting is completely different than for any other area. Rather than trimming the donor hairs quite short and inserting them into recipient sites, with the eyelash transplant, the donor hairs (which are left long) are first threaded onto a curved needle, which is then placed into the upper eyelid at or just below the superior tarsal crease to emerge at the lid margin- pulling through the donor hair. The hairs are pulled such that the follicle rests inside the skin. These curved needles can avoid trauma to any existing eyelash hair, and create a desirable slight curvature to the hairs. In any case, curling of the hairs- along with monthly trimming- is to be expected.

Discussion

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 transplantation for the treatment of female pattern hair loss, it is the author’s experience that, when appropriate candidates, these patients are very happy. For many, 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.

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. The percentage of “take” of the transplanted hairs is reduced, sometimes by as much as a third (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 four hair grafts where it is hoped that two or three 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, anemia, 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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2. Ludwig E. Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex. Br. J. Dermatol. 97:247-254, 1977.

3. Brennan HG, Toft KM, Dunham BP, Goode RL, Koch RJ. Prevention and correction of temporal hair loss in rhytidectomy. Plast. Reconstr. Surg. 104:2219-2225,1999.

4. Holcomb JD, McCullough EG. Trichophytic incisional approaches to upper facial rejuvenation. Arch. Facial Plast. Surg. 3:48-53,2001

5. Leonard RT. Hair transplantation in patients following cosmetic facial surgery. Cosm. Dermatol. 33-35, May 2001.

6. Headington JT. Transverse microscopic anatomy of the human scalp. Arch. Dermatol. 120:449-456, 1984.

7. Bernstein RM, Rassman WR, Seager D, et al. Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatol. Surg. 24:957-963, 1998.

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