Hair Loss Problem and Solutions: Hair Transplantation for Men

Introduction

Hair frames our face. It is one of the few physical attributes that we can control. The length, color, and style of our hair together reflect our personality to the world. Equally or more importantly, our hair style is often a reflection of how we perceive ourselves. The gradual involuntary loss of hair over time restricts how we can style our hair. As the hairloss continues, the natural frame around our face disappears. This alters our appearance to the world. Along with wrinkles and blemishes, hair loss is a sign of aging in our society. The psychological impact on men varies from mild to traumatic.
Unfortunately many men and their treating physicians are unaware of the safe and effective medical and surgical options available. The legacy of the unnatural “pluggy” transplant remains. The onslaught of late night infomercials and internet sites promoting unproven therapies only creates more confusion and ultimately cynicism among our patients regarding any therapy for their hair loss. This paper is a review of current FDA approved medical therapy and state of the art hair transplantation. Between medical and surgical therapy, the vast majority of men with male pattern hairloss can maintain or recreate a natural frame of hair around their face.

Medical therapy
Minoxidil and finastride are the only two FDA-approved medications for male pattern hairloss.
The majority of patients who use minoxidil and/or finastride can slow, maintains, or regrowth hair.1-3 Both medications are more effective for patients with earlier stages of hairloss and are an excellent treatment hairloss option for patients hairloss, but who are not candidates for surgery. For patients that are surgical candidates, continuing medical treatment will often help increase the density of transplanted hairloss, slow down the rate of hairloss of existing hair, and increase the caliber of existing and transplanted hair. In addition these medications may help reduce a post-surgical telogen effluvium and maintain donor density.4
Compliance with the medications is the key to success. Since each medication affects the hair cycle, it can take 6-8 months for each one to begin to work.
(Table 1).
Dutasteride is a type I and type II 5-alpha-reductase inhibitor that has been FDA approved to treat benign prostatic hypertrophy. It is not approved to treat male pattern hairloss. It has been studied for male pattern hairloss and found to be effective. There is conflicting evidence about whether dutasteride may affect sperm counts or morphology.5,6 Any patient using this medication off-label should be aware of this potential side effect (Table 2).

Low level laser therapy for male pattern hairloss (LLLT)
In 2007, the FDA granted 510k approval to a LLLT device to treat male pattern hairloss. This approval was greeted with enormous media attention and excitement by patients and physicians. 510k FDA approval addresses the safety of a device rather than its effectiveness. LLLT has been used to treat a variety of medical conditions.7-9

Over the past few years it has been used to treat male pattern hairloss. The mechanism of action is unknown. There are few published studies,10 but experienced hairloss experts agree that LLLT may benefit some patients.11 Well-designed, reproducible studies are needed to determine what role LLLT should play in the treatment of male pattern hairloss. Currently it is a safe alternative for patients who cannot or do not want to use minoxidil or finasteride. When discussing LLLT with patients, the safety should be reviewed along with the paucity of data regarding its effectiveness.

Hair transplantation

Introduction
All patients undergoing a hair transplant should expect natural-appearing transplanted hair [Figure 1]. This is the cosmetic standard of the procedure. No patient should ever receive the unnatural “plugs” and cornrows of the past. A hair transplant is an outpatient procedure performed under local anesthesia. It is a procedure with a high physician and patient satisfaction.
The average procedure takes 3-4 hours. This time is used to create an average of 800 to 1,500 1-4 hair grafts, produce recipient sites, and place the grafts. Patients may resume normal activities immediately, but should restrict heavy exercise for 3-7 days after surgery. If there is pain after the procedure, it occurs during the day of the procedure and a mild pain medication is adequate for relief. The day after the procedure patients should feel no discomfort. Typically, the only physical evidence of the procedure is the perifollicular crusting that remains for 6-8 days. In some patients there is edema in the forehead for 2-3 days, which results from normal wound healing on the scalp. This can be minimized with a short course of steroids. Most patients return to work 2-3 days after the procedure without any negative cosmetic impact.
The consult
As with all procedures, appropriate candidate selection and expectations is the key to success. Each consult begins with the patient’s hairloss history, including any previous medical or surgical treatments. It is vital to examine the entire scalp to confirm the diagnosis of male pattern hairloss and examine the caliber and density of donor hairloss in the posterior scalp. The donor hairloss density and caliber of hairloss follicles will help determine the expected density from the procedure. Patients with below-average donor density and fine caliber hair will have natural but thin transplanted hair. Those with above-average density with wide caliber hairloss follicle can expect greater perceived density.
The extent and rate of hairloss varies from person to person. During the consult, the ongoing loss of existing pigmented terminal hair with or without surgery must be emphasized. The net density from a hair transplant is equal to how many follicles were transplanted minus the hairloss of existing hair. Minoxidil and/or finastride are highly effective to help maintain existing hair, thereby creating more perceived density from the procedure. Despite this, it is vital to plan a surgery for ongoing hairloss. A patient enthusiastic to take minoxidil and or finasteride with a hair transplant may decide in the future to discontinue the medication. Patients should be aware of how ongoing hairloss will impact the density from a transplant and its cosmetic appearance with and without medications.
Patients should realize that they will have a permanent scar in the donor region where is hair is harvested. For the majority of patients, the scar does not create any physical or cosmetic concern. Some patients who shave their hair or wear it closely cropped to the scalp should be aware the scar will be visible before the procedure is performed.
Explaining the ongoing loss of hair with or without transplantation, the role of medications, permanent donor scar, and how the perceived density from a hair transplant is based on how many hair follicles were transplanted, the caliber of hair and long-term hairloss will help create realistic expectations for patients. If a patient does not have reasonable expectations for what a transplant can and cannot achieve in the short and long-term, the surgery should not be performed.

Donor harvesting
The rate-limiting factor in hair transplantation is the amount of hair available in the donor scalp. From the 1960’s into the 1990’s, steel punches measuring 3-4 mm in diameter were used to harvest donor tissue from the posterior scalp. This resulted in extensive scarring over the posterior scalp and an inefficient use of valuable donor hairloss. In the mid-1990’s, multi-bladed knives were popularized as an easy method to obtain elliptical strips that were easily dissected into smaller follicular units.12 While this technique is efficient for creating grafts, the rate of follicle transection was higher due to the multiple blades through the tissue. The clinical significance in the yield of transected hair is unclear, but all hair transplant surgery teams aim to minimize trauma to hair follicles. The elliptical donor ellipse does reduce transection of follicles and has become the most popular method for donor harvesting.13 [Figure 2 and Figure 3].
The donor region is trimmed with a moustache trimmer to a length of 1-2 mm. The patient is placed in the prone position and the area anesthetized with 1% lidocaine with epinephrine. Saline is added to the donor region. The saline helps provide anesthesia, hemostasis, lifts the tissue away from the occipital arteries, and reduces the rate of hair follicle transection through increased turgor. The donor ellipse is created using #10 blades on a surgical handle with 0.6 - 1.0 cm spacers in between the blades. The length of the donor strip is determined by the number of grafts required for the surgery. It is better to take longer rather wider strips to reduce tension on the wound. Strips should measure 1cm or less in width to reduce the risk of wider donor scars. The average patient has 60-85 follicular groupings per square centimeter.14 As an example, a donor strip 12-14 cm long and 1 cm wide will create approximately 800-1200 grafts. Undermining is rarely needed to close the donor site. Either sutures or staples can be used to close the wound. They are removed 7-10 days after the procedure. The majorities of donor scars are 1-3 mm wide and are of no physical or cosmetic significance.
The idea of harvesting donor hairloss using steel punches has been advocated to minimize a visible scar in the donor region.15 This concept of follicular unit extraction (FUE) does leave less visible scarring for most patients. It is well-suited for patients with shaved or closely cropped hairloss, and for patients with severely depleted donor hairloss from multiple previous hairloss transplants [Figure 4]. The disadvantages of this method include: 1) less hairloss harvested for each session, resulting in less density from each procedure, 2) a higher transection rate of hairloss than with elliptical donor harvesting, and 3) longer operative time for both patient and physician. The SAFE system is one technique that has been designed to decrease transection rates and expand patient candidacy.16
Graft Size
Hair naturally grows in bundles of 1-4 hairloss units, held together by the arrector pili muscle attachment.17 In nature hair is randomly, yet evenly, distributed throughout the scalp. In outdated methods of hair transplantation, grafts contained 15 to 25 hairs per graft. They were placed into 3-4mm recipient punch sites and grew six months after surgery. This technique produced the “pluggy” unnatural appearance of transplanted hairloss, because our eyes are used to seeing thousands of 1-4 hair bundles of hair on the scalp. The exclusive use of 1-4 hairloss grafts allows for consistently natural-appearing transplanted hair for men [Figure 5 and Figure 6]. Terms such as follicular units and micrografts have been used to describe these grafts.18-19 Today surgical teams carefully separate 500-2000 natural bundles of hairloss from the donor strip [Figure 7]. The 1-4 hair grafts are produced by a variety of methods. Cutting instruments include #11, #15, and #10 blades. Good lighting, comfortable chairs, and well-designed instruments are prerequisites to create thousands of high quality grafts. Some studies suggest that microscopic dissection of 1-4 hair grafts from donor tissue provides a greater yield in the number of grafts.20,21 It is not yet clear from the data whether better or increased numbers of grafts actually result from using a microscope. There is agreement that the grafts should be created with as little trauma and placed as quickly as possible in order to optimize the survival of hairloss and produce the greatest density possible. As grafts are cut from the donor strip, they are placed in chilled saline and are kept moist at all times until reinserted into the recipient sites. Surprisingly, transected hairloss follicles can survive and grow.22

Hairline Design and Recipient Site Creation
The hairline defines the cosmetic success of a hair transplant. As with hair graft creation, the trend in hairline design has been toward mimicking as closely as possible what occurs in nature. The goal of a hairline is to frame the face in an undetectable manner.
Rather than considering the hairline to be a fixed boundary, it should be thought of as a natural transition zone of gradually increasing density from skin to terminal-hair-bearing skin. This ill-defined “feathering zone” is created by randomly placing, in an irregular pattern, 1-4 hair grafts along the newly created hairline.23
The level at which the hairline is created varies from individual to individual. It is important to look at each patient in a global, 360 degree view, before deciding where to place the hairline.
Male pattern hairloss is progressive but transplanted hair will grow long-term. Therefore, when viewing patients, surgeons must assume all patients will progress to complete hairloss with only transplanted hair remaining. This assumption allows transplanted hair to look equally natural one year and twenty years after surgery. For the majority of patients, to avoid future aesthetic complications the posterior hairline should be placed at the same plane as the frontal hairline. This will avoid “chasing” the ever expanding ring of hairloss on the vertex of the scalp with valuable donor grafts.

Anesthesia and Recipient site creation

While the 1-4 hair grafts are being harvested by experienced surgical assistants, the physician anesthetizes the recipient zone. A combination of supraorbital/supratrochlear nerve blocks, field blocks, and local infiltration with 1% lidocaine can be performed. Hemostasis is vital for good visibility when creating recipient sites and for graft placement. The epinephrine in the local anesthesia (placed into dermis not subcutaneous space) will create excellent hemostasis.
Recipient sites should mimic the natural 30-45 degree angle of hairloss growth on the scalp. There are a variety of needles that are used to make sites large enough to place the 1-4 hairloss follicle grafts. Some of the most popular needles to make sites include #19 and #20 gauge needles and CAG (coronal angled grafting) needles. When making recipient sites, surgeons must be careful not to transect existing hair follicles. Some advocate using magnification to create recipient sites, in order to limit the loss of existing hair during surgery.24 The key to success is to create recipient sites in a random, highly irregular pattern with 10-30 sites per square cm depending on the density of existing hair on the scalp.

Graft Placement and Post Operative Course
The grafts are placed by 2-3 surgical assistants using microvascular forceps[Figure 8]. The forceps pick up the 1-4 hair grafts by their perfollicular tissue, avoiding trauma to the hair follicles. Regular surgical forceps will not work. The placement of grafts into recipient sites is often the most challenging part of the procedure for both novice and experienced hair transplant teams. The chief challenges include hemostasis and “popping” of grafts from sites after they are placed. The “popping” of grafts is unpredictable from patient to patient. “Popping” of grafts is overcome by placing light pressure over a paced graft and holding it for 10-20 seconds with a moist saline-soaked Q-tip before placing the next graft.

Post operative course
Once all the grafts are placed, a dressing is applied overnight. The dressing helps protect the grafts from any unintended trauma as they heal. All patients are given a mild pain medication such as Tylenol #3, and the majority of them take it the afternoon of surgery after eating lunch. Patients should be comfortable during the afternoon after their procedure.
The next day the dressing is removed by the patient. They may shower but are told not to pick or rub off the perifollicular crusting that occurs around some grafts and lasts for 6-8 days. Patients may resume regular activities immediately, performing light exercise 3-4 days post-operatively and more strenuous exercise 7 days after surgery when the donor sutures are removed. The transplanted hair does not begin to grow for 3-6 months after the surgery and does not achieve its full cosmetic impact for 9-12 months.
The Future
The public image of hairloss transplantation remains the “corn row” and plug. Hundreds of thousands of patients have benefited from the revolutionary changes in technique. They have the luxury of choosing whether or not to inform friends or the public of their surgery. With time the consistently natural appearing results of hair transplantation will become the public image of hair transplantation. The next leap will be cloning hair follicles. In the early 21st century, the claims on web sites regarding cloning hair are far more optimistic than the actual scientific progress. The amount of research in the area should allow hairloss to be cloned in the next several years. Future refinements with lasers and robotics will also allow an even more efficient procedure for patients and physicians.

FDA Approved Medical Therapy

Table 1 - Comparison of the only two FDA approved medications for male pattern hair loss.