WHAT IS NORMAL?
- The hairline typically begins four finger breadths above the eyebrows.
- There are "recessions", bald areas as the hairline moves from the midline. These create the "part" in the hair. These recessions line up with the corner of the eyes in their deepest parts.
- Hair density is thick enough to prevent seeing the scalp.
- The hairline itself is irregularly, irregular. It does not form a perfectly straight line. The hair blends into denser areas.
COMMENT: Personal preference has a lot to do with hair design. Older men may feel more comfortable with a receded hairline and thinner hair. Younger patients may request a lower hairline.
Wet your hair with alcohol to see where it is truly dense. For hair surgeons, the question is not just what you look like today but five and ten years from now. The approach to a receded hairline is very different if the hair behind it is also thin. We look to see if the typical male pattern baldness is expected. Your doctor will then choose a procedure that won't leave you with an island of hair plugs five years from now.
Was your mother's father (maternal grandfather) bald? If so, you will probably loose more.
Are you over fifty? If you haven't lost your hair by now, you're probably Okay.
Place four fingers on your eyebrows and see where your hairline begins. This divides your face by thirds.
HOW MUCH CAN BE IMPROVED?
Your doctor can't create hair from thin air.
Hair plugs and flaps come from the side or back of the head. If there is dense growth, your head can usually be completely recovered.
The ratio between the amount of bald skin and hair bearing skin is the most important. The fact that the bald area has absolutely no hair is not important.
What do you want? If you simply want some density in the bald areas this is easier and requires less procedures than complete restoration. If you have dense hair along the sides, anything is possible.
OPTIONS AND ALTERNATIVES
THINNING HAIR AND MEDICAL PROBLEMS
Both men and women have problems with hair loss. In men, the problem often can begin at an early age and is inherited through the individual's maternal grandfather (mother's father). Male pattern baldness usually begins with loss in the front and can progress through stages until the entire mid-section of the head is bald.
The treatment of baldness depends on the doctor's and patient's ability to guess at what the natural outcome of the baldness will be. For instance, correcting a hair line at the front edge may prove an embarrassment a few years later if progressive baldness has left a small island of hair plugs. The doctor and the patient must plan on the inevitable future in regards to hair loss.
Many underlying diseases can cause hair loss, particularly when it occurs in inappropriate places like facial hair or body hair. If there is any question that the problem may be caused by a special health problem, a medical evaluation is appropriate. Diseases such as thyroid imbalances and bacterial infections in the skin commonly cause hair loss that is easily reversible and it would be a pity to miss a quick cure.
Unfortunately, the most common situation is hereditary, male pattern baldness. This usually begins with thinning of the hair. Essentially the hair follicle becomes dormant and will no longer respond. Hairs that stop growing with age are sensitive to a particular form of testosterone but this information doesn't help.
On a practical level, there are many products on the market that can assist with thinning of hair. There are potions, lotions, and restoratives, many that simply act by cleaning out the hair follicle which stimulates hair growth, to the extent that even plain alcohol can stimulate hair growth. Under careful scrutiny, you should be aware that 40% improvement in hair growth is expected for any medicine that you try, no matter what it is.
Some medicines that will stimulate hair growth for thinning hair are definitely valuable. Minoxidil, was actually stumbled upon as an oral medication to treat cancer. Although its side effects were unacceptable, it produced dramatic hair growth in many patients.
When Minoxidil is applied to the skin, its effectiveness is not nearly as dramatic or predictable as it was in a pill form. In several studies, Minoxidil has been shown to be no more effective than placebo; and in the vast majority of cases, where some effect was attributed to the medicine, this effect was a moderate thickening of areas with hair, but little growth in truly bald places. The amount of growth obtained from Minoxidil would never match the density of hair generated by a session of hair transplants.
When hair density is significantly reduced or hair is completely lost in an area, present medicines cannot restore new hair. Some people don't choose to do anything but for those who wish to restore their hair, here are the common options.
One should be aware that hair pieces have improved dramatically and now are made with very carefully matched hair and may even be held in place with stitches. These custom hair pieces are sold at hair replacement centers and may work well for the person who does not mind frequent hair maintenance and realizes that the system will eventually degenerate. When stitches are placed in the scalp to hold down a hair piece, scars can form from the traction of these sutures and can create a problem in the future if the hair piece is not worn.
To some extent, the degree and area of baldness dictates the possibilities. On one end of the spectrum, patients who are severely bald are not surgery candidates and can only choose a hairpiece of some kind.
What is exciting about treating hair loss is the great variety of new surgical options that can restore a natural hair line and a full head of hair in the motivated patient. The simplest, time-honored, and safest has been hair plugs.
In the past, a three millimeter round punch was used to remove a plug from the hair-bearing rear of the scalp and place it in the bald area. In each session, several hundred plugs would be transferred in rows and subsequent sessions would then fill in the spaces in between.
This process has been fine-tuned over recent years with the advent of the MINIGRAFTS and MICROGRAFTS. Minigrafts and micrografts are smaller slices of the same hair plug that contain fewer hairs. THEREFORE, THEY ARE SIMPLY SMALLER HAIR PLUGS.
A MINIGRAFT is made by dividing a 3- or 4-millimeter plug into fourths to make smaller plugs with about 6 or 7 hairs each.
A MICROGRAFT is made by actually slicing one or two hair follicles from the edge of a plug. This is delicate and time-consuming work.
In a typical session, the doctor may harvest about 200 to 400 plugs of various sizes and place these into the bald areas. A session will take about four or five hours total. Usually transplants will remain dormant for a few months and then begin to grow. After about six or eight months, the results are fairly clear. In subsequent sessions, the doctor will then fill in the spaces between these grafts.
Some doctors have assembled large teams of assistants and arrange for sessions with 1000 minigrafts and micrografts. The sessions lasts seven or eight hours but they can get light coverage over the entire head in one session. Unfortunately, they still never achieve dense hair growth with this technique but they reduce the need for many repeated sessions.
By intermixing minigrafts and micrografts with the larger plugs, in many cases a truly natural hair line can be achieved. Each doctor who performs hair plugs may offer a different formula for hair restoration. Usually the formula depends on the individual's degree and pattern of hair loss as well as the ability to pay for the services.
Remember that doctors can't create hair out of thin air! There may be a limit to donor areas in some patients or other restrictions.
The second category of hair transplant procedures are called HAIR FLAPS. These procedures involve transferring a large piece of hair-bearing skin to a bald area.
One common flap was designed by a doctor named Juri in Brazil about twenty years ago. The Juri Flap comes from the side of the scalp and is rotated to create a thick hair line. Later, a second flap from the opposite side can be taken as needed to fill in the back area of baldness. Eventually, the bald skin can be removed to completely cover the head with thick, permanent hair! Ultimately, this produces a dramatic restoration of hair! The donor area usually closes with a thin hidden scar.
The skin flap is usually an inch or two wide and seven or eight inches long, but can be adjusted in size depending on the area that needs coverage. The main step in the procedure, the rotation of the flap, requires a recovery period that is equivalent to a facelift. Associated with the rotation of the flap may be several small surgeries.
Afterwards it may be valuable to improve the hairline and fill in several corners using micro- and minigrafts but in these cases only small numbers of grafts are needed. The other type of flap comes from the thick hair in the back of the head and involves raising an artery in the front of the scalp. This is a very delicate procedure and usually requires the patient to spend a few days in the hospital to recover. Usually, a strip of hair-bearing skin that is approximately two inches wide is removed from the back of the head and brought to the front with the blood vessel that supply the blood to the skin being re-sewn to blood vessels in the front of the head. Again touch up procedures may be required to produce a truly natural hair line. The advantage of this procedure is that it is one surgical step and avoids several smaller touch up procedures of the Juri flap from the side of the head.
PLUGS VERSUS FLAPS
The doctors who do
plugs, including the minigrafts and micrografts, often feel that the hair
after a flap surgery looks too dense and the hairline is unnatural.
Likewise, the doctors who do flaps feel that plugs are sparse and unnatural. The advantage of the flaps is that they provide thick hair with NORMAL DENSITY IN ONE STEP. The average hair flap is the equivalent of 2000 micrografts, a density that can rarely be achieved with plugs, only after many sessions.
Each procedure has its inconveniences and costs, and each patient must judge these for themselves. Flaps are surgery and have a more significant recovery at the time of the procedure. Plugs are more of an ongoing process but carry less risk and time off work.
The bald area of scalp may be reduced (cut out) to help reduce the amount of area that needs coverage. Overall, the results of routine scalp reduction have been disappointing. Although the removal of 2 or 3 cm. of bald skin in a loose scalp may be successfully accomplished, this may create a noticeable scar after the area has healed and the overall impression of baldness remains. A phenomenon known as a STRETCH BACK, in which eventually the bald skin stretches to again take back the same dimensions, is fairly common.
Some doctors routinely combine scalp reductions to their graft sessions. Be aware that the before and after pictures they show you are their best ones.
Several doctors offer a procedure known as scalp lifting, where a large area of skin on the back of the neck is freed up and pulled superiorly. This can dramatically improve the results compared to a routine scalp reduction. In terms of the hair-bearing flap that may be used to cover the bald head, this procedure can produce the most dramatic and long-lasting results, unequaled by anything that can be done with transplants or scalp reductions.
Another procedure that is in the plastic surgeon's bag of tricks is SCALP EXPANSION. In this case, a balloon is placed underneath the area of skin with hair and gradually filled up with water to stretch the skin. The balloon is filled over about 10 weeks and looks like a big tumor in the head by the end of the process! However, a large area of bald skin can be removed and comfortably replaced by the expanded skin. The hair density is reduced, but usually not noticeably.
There are several advantages to expansion. The recovery after surgery is not as bad as a regular flap, because the skin has already been prepared. There is little risk of hair loss for the same reason. The entire donor area of the scalp can be utilized in one procedure to reduce bald skin, whereas other flaps only cover part of the scalp or require several steps.
WHAT TECHNIQUE IS FOR ME?
Plan for the future! If hair plugs are placed in the front of someone who eventually loses their hairline, the result may be very disappointing and revisions may be necessary.
In regards to the hair result you want, there is no one absolute choice either. Older patients tend to prefer the relatively thinner hair line produced by plugs compare to flaps and some people consider the hair line produced by flaps too dense and likewise unnatural. Younger patients who want thick hair for a lifetime, tend to enjoy flaps more.
The state of the donor site (the place where the grafts are coming from) is a critical consideration for any technique. No surgeon can create hair that is not there. If the sides of the head are thin, a flap from that area is not possible, leaving plugs as the only choice. If the bald area is a relatively small portion of the scalp, many techniques may produce an adequate result.
Some patients prefer the gradual restoration of hair produced by multiple plug sessions to the relatively startling restoration of hair that occurs immediately with flap surgery. On the other hand, some patients prefer the thick, dense hair that is generated in a single step with flap surgery that cannot be matched with plugs. After plugs are placed, they routinely lose the hair for several months before it re-grows so don't be surprised about this. Keep in mind that scalp reduction surgery that fails may leave scars in the scalp that can be difficult to deal with.
Do not be swayed by the very extensive marketing that occurs amongst hair surgeons. Choose a technique that is right for you. If you can't decide, wear a hair piece until you are sure! Be sure that you are not happy with the status quo and you want to do something before going for consultations.
Especially in the early sessions, the grafts tend to have a "row of corn" look. Later, your doctor can fill in the spaces. Minigrafts and micrografts may help resolve this as well.
LOSS OF GRAFTS
Only some percent of the grafts will grow, usually close to 90% or 95%.
Although the surgeon tries to set the direction of the plug when they insert it, the graft is still placed in an ill-fitting pocket and may not cooperate.
CHANGE IN HAIR TEXTURE
Many transplant surgeons remark that the hair that regrows from plugs often doesn't have the same texture and quality of the donor site. No one knows exactly why.
A grafted hairline may be two sharp or thick.
- LOOKS FAKE/TOO DENSE
Wherever the scalp is cut, it will leave a scar. With good technique, these scars can be very fine. The incision may be designed so that hair grows through the scar.
- DENSE HAIRLINE
The sharp edge of the flap may produce an "edge of the forest" that looks fake.
- POOR DIRECTION
Depending on the flap design, the hair direction may not be ideal. Ask your doctor.
- FLAP DEATH
Severe death of the flap, where all is lost, is rare if precautions are taken. It is manageable if it occurs, so don't panic. It will necessitate additional surgery and you'll be wearing a baseball cap for a while.
Hair flaps are surgical procedures that carry these common risks.