Dr. Mir Shahnawaz
Androgenetic alopecia (AGA) – the most common etiology of hair loss wherein androgenetic effects, namely testosterone and dihydrotestosterone (DHT), the growth cycle (the anagen to telogen ratio decreases).
Hallmark characteristics of AGA include thinning and subsequent miniaturization of terminal hairs to vellus hairs.Indeed, non-surgical modalities exist which may halt the progression of androgenic alopecia and even help grow new hairs (i.e., minoxidil, finasteride, dutasteride, platelet-rich plasma therapy). However, recent advancements in surgical hair restoration have made hair transplantation (HT) an increasingly effective, safe, and reliable way for hair restoration.The ability to provide very natural-looking results has encouraged larger number of balding men and women to opt for this surgical solution.
Hair transplantation is based on the ‘theory of donor dominance in androgenic alopecia.’ If a graft is taken from an area destined to be permanently hair-bearing and transplanted to an area suffering from male patterns baldness, it will, after an initial period of effluvium, grow hair in its new site as long as it would have at its original site. This is the scientific basis of hair transplantation surgery.
Donor area refers to the non-alopecic areas (not influenced by androgenic alopecia) where donor terminal hairs can be harvested for implantation. The safe donor site of the scalp lies in the mid-occipital region between the upper and lower occipital protuberances. If needed, the submental region, chest and other parts of the body may be used as donor sites, though data regarding efficacy is limited and the hair characteristics can be very different from scalp.
Identifying appropriate candidates for hair transplantation includes an evaluation of the following:
1. Diagnosis: Diagnosing androgenic alopecia is relatively straightforward and based upon the characteristic pattern of associated hair loss (Norwood for males, Ludwig for females), the miniaturization and depigmentation of hairs, and the lack of clinical inflammation.
2. Age: The HT surgeon should only operate on patients older than 25 years of age because future hair loss pattern is less predictable and expectations are generally more unrealistic in patients younger than 25 years old.
3. Hair Caliber: Patients with thicker hair diameter in donor area can be expected to obtain much denser coverage (better aesthetic results) versus patients with thin-caliber hair.
4. Donor Hair Density: Patients whose scalp donor sites have greater than 80 FUs per squared cm are excellent candidates. Those with donor hair density less than 40 FUs per squared cm are considered poor candidates for HT, and the clinician needs to set patient expectations accordingly.
5. Degree and Pattern of Baldness: Patients hoping to correct frontal baldness can expect the most dramatic results in appearance, and thus represent great candidates. Grafting only the scalp vertex should be avoided if possible, as this not only consumes potential future donor grafts but also may cause a “doughnut” appearance as hair loss progression continues. The surgeon must reiterate that concentrating grafts in the frontal scalp will provide the maximum long-term density and minimal aesthetic risk.
6. Patient expectations: Patients with realistic expectations and a history of compliance with hair loss medications/treatments (i.e., minoxidil, finasteride, platelet-rich plasma) represent ideal candidates. Lastly, multiple hair transplantation sessions may be needed to achieve the desired results.
7. Hair & skin colour: The contrast between the hair and the skin colour, is also an important factor that affect the result. The lesser the contrast between the donor hair and the skin, the better is the result.
Types of hair-transplant techniques
Two types of hair transplantation techniques predominate, including the follicular unit transplantation (FUT) and follicular unit extraction (FUE) techniques. Currently, FUE represents the more common approach due to its potential advantages over FUT, which include:
(a) Less post operative pain
(b) Less post operative healing time
(c) More number of grafts are harvestable
(d) Non- scalp Follicular units can be also be harvested (eg from chest, submental area etc)
On the contrary, FUT may be preferable to FUE given FUT’s reported advantages, which include shorter operative period, less learning curve and lesser and less chances of graft transection. Still, controversy remains as to which hair transplantation procedure is superior, however the astute hair transplantation surgeon should be knowledgeable of the nuances of each.
Direct hair implant
DHI (Direct Hair Implantation) hair transplantation technique is a further development of FUE hair transplant. It is is carried out with special ‘pen implanters’ which provide better control over the graft placement (angles and depth of the planted grafts) and highest graft survival rates than other techniques.
Red flags for hair transplant
Certain “red flags” for HT where one should refrain or judiciously opt for surgical hair restoration would include:
- Unrealistic expectations
- Mental illness
- Donor site miniaturization
- Unusual hair loss pattern
- Excessive shedding
- Unexplained Scalp inflammation
- Unexplained scarring
- Scalp or skin pain, burning, pruritus
Complications of hair transplant
In general, complications after hair transplantation are rare, given the vigorous blood-supply to the scalp, which allows for quick healing and low rates of infection. Nevertheless, potential complications include edema (5%), bleeding (0.5%), folliculitis, numbness of the scalp (mostly temporary).
Apart from these, an uncommon but concerning complication is Telogen Effluvium which is characterized by shedding of native hairs at the donor or recipient site. This “shock”loss, likely a result of stress and microtrauma sustained during HT, is transient. Patients should receive reassurance that the majority of the hairs shed will return at 3 to 4 months.
Sequel of hair transplant
The transplanted hair shafts start to shed off two to three weeks after the surgery, but the hair roots remain and go into a resting phase. New hair start growing about three months after the procedure. It usually takes eight to twelve months to appreciate the full result of a hair transplant surgery.
Recent advances in technology have made hair replacement surgery a viable option for many people but we must utilize this technique prudently. One must avoid shabby clinics and centres with un-qualified people who lure the patients by offering huge discounts just to grab more patients.
There is a very thin line between designing an aesthtically natural hair line and devastating the hair-restoration procedure altogether. When performing hair transplantation, an expert advice , proper patient evaluation and execution of a comprehensive treatment plan can produce safe, reliable, and satisfactory outcomes.