Hair Loss and Hair Restoration

Hair restoration procedures and treatments can reverse the appearance of aging associated with hair loss and restore a more youthful look—for women, men and people of all racial and ethnic backgrounds. Dermatologists and dermatologic surgeons can help each patient with hair loss select an appropriate hair restoration treatment.

Reasons for Hair Loss
By far the most common reason for loss of scalp hair is androgenetic alopecia. About 50 million men in the U.S. have scalp hair loss due to male-pattern androgenetic alopecia (male-pattern baldness). More than 30 million women in the U.S. have scalp hair loss due to female-pattern baldness. Androgenetic alopecia is an inherited condition—that is, it "runs in the family."

Male and Female Patterns of Hair Loss
The typical hair-loss patterns of male-pattern and female-pattern androgenetic alopecia are somewhat different. In men the initial hair loss—perhaps as early as age 20 to 30—may be in the frontal and temple areas of the scalp. When hair loss begins early it tends to continue and become more severe—the "cue ball" pattern shown in this photo:

Severe male-pattern androgenetic alopecia.

 (Photos in this discussion are used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides)

Female-pattern androgenetic alopecia often appears a bit later in life than male-pattern androgenetic alopecia—age 25 to 45. About one in four women experience female-pattern androgenetic alopecia. A woman may notice increased hair loss in association with events that influence hormonal patterns: use of birth control pills, menstruation, pregnancy, and menopause. The hair-loss pattern of female-pattern androgenetic alopecia tends to be thinning of hair rather than complete loss of hair. Female hair loss is likely to begin in the center of the scalp rather than at the front and temples as seen in men. A typical pattern of hair loss in female-pattern androgenetic alopecia is shown in this photo:

Female-pattern androgenetic alopecia; thinning hair in the central part of the scalp.

The "cue ball" complete loss of hair that occurs in many men rarely occurs in women.

Male-pattern and female-pattern androgenetic alopecia are not only very common, they are very treatable. Both surgical and medical treatments have high rates of success. The medical treatments are more effective in treating crown hair loss than frontal hair loss.

Other Reasons for Hair Loss
Other causes of hair loss are not necessarily associated with aging but are rather due to disease and scalp injury. While they are much less common than androgenetic alopecia it may be important to know about them if your hair loss may be due to a cause other than androgenetic alopecia. Causes include various acute and chronic diseases, nutritional deficiency, medications, radiation, and improper hair treatments.

The common and most of the less common causes of hair loss can be treated successfully by a variety of hair restoration procedures.

Surgical Hair Restoration

Hair Transplantation
Hair transplantation is the best known method of surgical hair restoration and also the method of surgical hair restoration most often used to treat hair loss due to androgenetic alopecia. Sometimes hair transplantation is combined with other surgical techniques or medical treatment when deemed appropriate by the dermatologic surgeon.

Great refinements continue to be made in the techniques of hair transplantation. The emphasis of hair transplantation is on creating the most natural appearance possible by using techniques of single-hair grafts and micro- or mini-grafts that contain two to four hairs. With such techniques it is possible to create a hair density pattern and hairline that looks completely natural. The hair transplant "plugs" of multiple hairs are rarely if ever used today.

Donor hair for transplantation is taken from sites that have hair of the appropriate color and texture, such as hair found at the back of the neck. Transplanting is typically done in a series of sessions over a period of several months. The areas to be treated and the anticipated outcome are discussed between the patient and dermatologic surgeon before transplanting begins. Transplantation also is preceded by a medical and physical examination, and examination of the scalp to determine the cause of hair loss. While androgenetic alopecia is the most common cause, other causes need to be ruled out by scalp examination. Hair loss due to other causes may be treatable by transplantation, but the surgical approach may be somewhat varied.

Hair transplantation is effective in treating androgenetic alopecia in men and women of all racial and ethnic backgrounds. Some differences in hair color, texture and curl may require slight variations in transplantation technique or in placement of grafts. For example, East Asians have hair of lower overall density but greater individual hair thickness than Caucasians; although hair density is less than in Caucasians, the greater thickness of individual hairs in East Asians gives an appearance of luxuriantly dense hair growth. African-Americans have hair with more curl than the hair of Caucasians; as in the case of East Asians, the hair with more curl gives an appearance of greater hair density. Placement of grafts in hair transplantation takes these esthetic features into account.

Postoperative effects of hair transplantation are usually limited to mild to moderate discomfort, swelling and scab formation over graft sites.

Hair transplantation may have to be repeated later in life if there is progressive loss of hair due to androgenetic alopecia. This possibility may be discussed with the dermatologic surgeon during the initial consultation and examination.

Scalp Reduction
Scalp reduction is a procedure that surgically removes bald scalp and pulls up adjacent areas of full hair. It may be done prior to hair transplantation to reduce the size of the area to receive hair grafts. Scalp reduction is a surgical procedure that requires a trained and experienced dermatologic surgeon.

Scalp Flaps
Scalp flaps are surgically created to move a hair-bearing segment of scalp to a place where hair is needed. When a flap is moved from the donor site to the recipient area it is left attached to its nerve and blood supply until the graft "takes" in its new site. A flap grafting procedure can be an all-in-one operation—for example, in a single procedure it brings hair from a donor site on the scalp to recreate a hairline on a bald frontal scalp. Not everyone is a candidate for a scalp flap procedure. Patients are carefully selected and the procedure should be performed by a trained and experienced dermatologic surgeon.

References:
•  Unger WP (ed.). Hair Transplantation, 3^rd ed. New York: Marcel Dekker, Inc.; 1995.
•  Stough DB, Haber RS (eds.). Hair Replacement. Surgical and Medical. St. Louis: Mosby; 1996.

An educational program brought to you by the American Academy of Dermatology.