| The
Treatment of Female Pattern Hair Loss and Other Applications
of Surgical Hair Restoration in Women
By Jeffrey
S. Epstein, MD
• Synopsis
• Introduction
• Etiology of Hair Loss in
Women
• The Work-Up and Consultation
• Treatment Options -Non Surgical
• Treatment Option
- Surgery
• Surgical Technique
• The Procedure
• Final Thoughts
SYNOPSIS:
In the specialty of surgical hair restoration, men comprise
over 90% of the patients treated. However, in the last
few years, the number of women undergoing the procedure
has increased significantly. The reasons for this growth
are many, and include the increase in public awareness
of the efficacy of hair transplantation from such sources
as the media, the internet, advertising, and word of
mouth. More importantly, advances in technique have
significantly improved results, increasing the confidence
level in women to undergo the procedure, and in hair
transplant specialists to offer it.
INTRODUCTION:
In the specialty of surgical hair restoration, men comprise
over 90% of the patients treated. However, in the last
few years, the number of women undergoing the procedure
has increased significantly. The reasons for this growth
are many, and include the increase in public awareness
of the efficacy of hair transplantation from such sources
as the media, the internet, advertising, and word of
mouth. More importantly, advances in technique have
significantly improved results, increasing the confidence
level in women to undergo the procedure, and in hair
transplant specialists to offer it.
ETIOLOGY
OF HAIR LOSS IN WOMEN:
As in men, the overwhelming majority of cases of hair
loss in women are genetic in origin. Female pattern
androgenic hair loss occurs in approximately 10% of
women. The onset can be as early as the late 20s to
early 30s, with steady progression most commonly accelerating
with menopause. There are several classification schemes
applied to describe the degree of hair loss. The scheme
used most often, the Ludwig Classification, describes
the most common pattern: diffuse thinning along the
top and upper sides and back of the head, often sparing
the frontal hairline.(1) Hair loss in women can also
follow several other patterns that have been described
in the literature. Diffuse thinning can often be a variant
of Ludwig Class 3, but in some cases displays no preference
for the top of the head, instead involving the entire
scalp. Another pattern involves the central aspect of
the hairline and extends posteriorly in a triangular
shape.
Hair loss in women can be due to a variety of other
causes. While it is beyond the scope of this article
to review all of them, several of the most common will
be discussed. Hormonal alterations or abnormalities,
such as hypothyroidism, pregnancy and menopause, can
be associated with diffuse hair thinning, and must be
ruled out and treated as indicated. Traction alopecia,
more common in African-American women, occurs due to
excessive pulling of hair from hair weaves or hair systems.
This is a slow, gradual process that often develops
over a period of years. Trichotillomania, an obsessive-compulsive
disorder characterized by incessant hair pulling, can
result in patches of baldness. More common in women,
it usually begins in adolescence, and can involve all
hair-bearing areas and not just the scalp. Once the
psychological aspect is controlled, hair transplantation
can restore permanent hair growth. Elevated body temperature
that occurs with a fever, nutritional deficiencies (i.e.
iron) from unhealthy dieting or other physiological
abnormalities, chemotherapy, and infection can all cause
hair loss, most of which is temporary and reverses itself
with resolution of the underlying problem or condition.
Alopecia areata, an autoimmune-like disorder, results
in patchy areas of hair loss that with time usually
resolves
A variety of pathologies cause the scarring alopecias.
This group includes lichen planopilaris and discoid
lupus.(2) Alopecic scarring and hairline distortion
from prior plastic surgery is a common complaint from
women presenting for surgical hair restoration. The
most frequent manifestations are the absence of sideburns
from rhytidectomy, and visible alopecic scarring along
browlift and rhytidectomy incisions.(3) Other hair sequelae
that are a result of prior surgery include abnormal
hairline elevation from certain browlift approaches,
and the diffuse thinning of the upper temporal region
anterior to certain rhytidectomy and browlift incisions.(4)
The approach to rhytidectomy that seems to cause the
most hair problems is that which incorporates incisions
that extend from the upper aspect of the ear in a superior,
rather than horizontal and anterior, direction. While
this approach is more effective in treating lateral
brow ptosis, it can result in excessive elevation of
the sideburns. This approach is also associated with
diffuse thinning of the upper temporal region, especially
in that area anterior to the incision. This hairline
distortion and thinning seems to be due both to vectors
of tension in a superior-posterior direction, and to
inadvertent transection of the superficial temporal
artery. All of these sequelae of prior plastic surgery
can be effectively treated with hair transplantation.(5)
This procedure is capable of restoring hair growth in
the areas of thinning and scarring, as well as recreating
the normal anatomy of the receded hairline.
Finally, hair transplantation can be used to restore
or reinforce hair growth in other parts of the body.
(Please refer to another article in this issue of Clinics)
The most common of these areas is the eyebrows, where
it is not uncommon to see poor density and/or very limited
areas of coverage associated with a history of hair
plucking or repeated electrolysis in the past. Because
the donor area for these transplants is the scalp, the
transplanted hairs continue to grow and require once
or twice monthly trimming.
THE WORK-UP AND
CONSULTATION:
The first step in the approach to women with hair loss
is to be sensitive to the enormous psychological toll
it inflicts. While men with hair loss can be insecure
or sometimes depressed, in women the impact can be devastating.
Often times these women have already gotten some “advice”
from family or hair dressers, some of which may have
merit, but often is incorrect. The consultation provides
the practitioner the opportunity to listen to and educate
the patient, and to present a plan of treatment.
Female pattern hair loss is basically a diagnosis of
elimination. First, all medically known causes of hair
loss need to be considered and evaluated, so as to eliminate
any medically treatable problem, as well as to assess
the prospective success of hair transplantation. Often
times, even if a medical condition is diagnosed, it
may be superimposed upon a case of genetic hair loss.
The work-up of the female patient with hair loss starts
with a comprehensive, directed history. Some of the
more important events/issues to discern are: family
history of hair loss, medications, diet, menstrual cycle
and pregnancy history, diet, illnesses, stress, and
hormonal alterations. It is also key to discern whether
the patient has had slow progressive thinning, versus
acute shedding- the latter is more typical for telogen
effluvium, where some insulting event typically three
or four months earlier causes a rapid loss of hair.
A review of medications is important, because oral contraceptives,
the statins for hypercholesterolemia, coumadin, and
beta blockers can cause hair loss. Physical examination
focuses upon scalp and hair abnormalities, including
the pattern of hair loss, but also examining other parts
of the body for signs of hormonal alterations. A hair
pull test assesses not only whether there is breakage
of hairs versus hairs pulling out from the follicles,
but also the degree of acute hair loss.
Work-up typically consists of several blood tests, including
CBC, thyroid function tests, ferritin and iron, VDRL,
ANA, DHEA-sulfate and total testosterone levels.(6)
Women with regular menses and no infertility or hirsutism
are unlikely to have androgen excess, therefore testosterone
and DHEA levels are not indicted in these cases.(7)
A scalp biopsy is often indicated, as it can differentiate
alopecia areata and telogen effluvium from female pattern
androgenic alopecia.(8) A smooth scalp devoid of pores
is suggestive of a cicatricial alopecia, and an indication
for a scalp biopsy. Assuming no etiology is detected,
the presumptive diagnosis becomes female pattern hair
loss. Once the diagnostic work-up is completed, treatment
options are then presented.
TREATMENT
OPTIONS - NON SURGICAL
After the diagnostic workup, any treatable abnormalities
and other potential etiologies need to be addressed.
Referral to an endocrinologist for hypothyroidism or
other endocrinologic abnormality, or to a hematologist
for anemia or low ferritin, is prudent. Patients need
to be counseled about proper dieting if a nutritional
abnormality is suspected as a contributing cause. Women
with post-stress telogen effluvium, such as results
after pregnancy or high fever, are reassured that return
of normal hair growth can be expected within several
months after the event.
Cases of traction alopecia must be first managed by
the complete cessation of the application of hair weaves.
In addition to hair additions that by their securing
to hair causes some alopecia, hair pieces or systems
worn for prolonged periods of time, sometimes days or
even weeks at a time, seem to further hamper hair growth
in general. Therefore, women are advised of the vicious
cycle that hairpieces incur- the hairpiece exacerbates
hair loss, while the further hair loss makes the patient
more reliant upon the hairpiece. In women that undergo
a hair transplant procedure, for the first 3 months
the wearing of a hair system must be minimized so as
to not interfere with the regrowth of transplanted hairs.
In nearly all cases of hair loss in women, regardless
of the etiology, several treatments or interventions
are recommended. If not already used on a regular basis,
all women are advised to begin minoxidil 2% (although
many women tolerate the stronger 5% concentration which
is approved for use in men), the only medication to
have received FDA approval for the treatment of hair
loss in women. A topical medication, several drops are
applied to areas of thinning twice a day. Six to 12
months are required before significant results can be
detected, and once started, the medication must be continued
in order to maintain results. Side effects are minimal,
most commonly scalp pruritis. Another side effect occasionally
seen in women is facial hypertrichosis, which is reversible
upon stopping the drug. Minoxidil 5%, designed for men,
can be used off label in women with greater efficacy
than the 2% formulation (9), but anecdotally has a greater
incidence of facial hair growth as a secondary effect
Finasteride 1 mg (Propecia®) is the other medication
with FDA approval for the treatment of hair loss, but
only in men. In pregnant women, there is a risk of androgenization
of the fetus in utero. Furthermore, in post-menopausal
women, in whom this risk is not relevant, no benefit
has been shown by finasteride in treating hair loss.
While minoxidil is the only FDA-approved medical treatment,
a variety of products are promoted for the treatment
of hair loss in women, as well as in men. Some of these
anecdotally are effective, while others such as scalp
massages and other stimulatory treatments offer little
if any scientific benefit. I advise my patients as to
all the therapies available, allowing the patient to
make her decision about which, if any, products to use.
Shampoos such as the Nioxin® products (which are
promoted as enhancing hair growth despite no scientific
evidence in support of this claim) seem to work by volumizing,
making the hair appear thicker. Other shampoos, such
as Nizoral® and Head and Shoulders®, used on
a once or twice weekly basis, may help slow down hair
loss by interfering with the formation of or binding
to the hair follicle of dihydrotestosterone, the hormone
that at least in men is attributed to be a contributing
cause of androgenic hair loss. Certain nutritional supplements
may help promote healthy hair growth. These include
biotin and zinc, and are available in most commercial
vitamins designed for thinning hair.
TREATMENT
OPTION - SURGERY
Surgical hair restoration remains the only permanent
treatment for hair loss in men and women. Note that
it is not a cure, for it does not stop the process from
progressing. Rather, it treats the manifestations, restoring
hair growth in areas experiencing thinning and/or frank
hair loss. For over 50 years, starting with the use
of large plug grafts 4 mm in diameter, the concept behind
hair transplantation has remained the same- the transferring
(or transplanting) of more permanent hairs from the
back and side of the head to areas of thinning. The
phenomenon of donor dominance assures that, once transplanted,
the hairs will retain their ability to continually grow
as if they were still in their original location.
Most types of hair loss in women are appropriately treated
with hair transplantation. The most important criteria
include an adequate donor area, appropriate motivation
with reasonable expectations, and the absence of any
medical conditions that would put the patient’s
health or success of the procedure at risk. In addition,
with certain etiologies of hair loss, such as alopecia
areata as well as some infectious and scarring conditions,
it is necessary to assure that the “process”
that caused the hair loss has stabilized, without any
evidence of still being “active”. With certain
etiologies of hair loss, such as hypothyroidism, correction
of the medically treatable condition is unlikely to
result in hair regrowth, only stabilization of the progression
of the loss, while with other etiologies, such as nutritional
deficiencies, their correction is likely to result in
a return to near-normal hair density. Patients are counseled
as to the almost certain need to perform hair transplant
surgery in those conditions where no hair regrowth is
expected.
SURGICAL
TECHNIQUE
The biggest challenge in hair transplantation has been
the attainment of undetectable results. This has largely
been accomplished through the use of smaller and smaller
grafts to mimic the way hair grows naturally in the
scalp. When looking closely at the scalp and the pattern
of hair growth, it becomes readily apparent that hair
grows out in little bundles of 1 to 4 (most commonly
2 or 3) hairs. These bundles, called follicular units,
also contain a tiny muscle, the arrector pilli, and
a glandular component, surrounded by a fine adventitial
sheath.(10) For most cases of hair transplantation,
natural appearances are achieved through the transplanting
of these follicular units, which are best dissected
out under the microscope.
There are exceptions to the concept that superior results
are only attained through the transplanting exclusively
of follicular unit grafts. One group in particular in
whom the exception applies is some women with female
pattern hair loss. Transplanting with grafts containing
3 to as many as 5 or 6 hairs, depending upon hair color
and other characteristics, balances the goals of maximizing
density, minimizing traumatic loss of hair from the
procedure, and maintaining a natural undetectable appearance
in these women. The rationale behind these larger grafts
is that, for every graft placed, an incision needs to
be made- an incision that has the potential for causing
iatrogenic hair loss due to the proximity to surrounding
hairs. If a single graft containing 4 or 5 hairs can
be placed in an incision that is only minimally larger
than that required for a 2 or 3 hair graft, then the
maximum benefit in terms of increasing hair density
can be achieved with the minimum risk of surrounding
iatrogenic hair loss. In order to reap the benefits
of traditional follicular unit grafts (minimal non-hair
bearing skin, smaller size, and minimal accidental transection
of hairs during the dissection process), dissecting
is still performed under the microscope.
While some follicular units naturally contain 3 or 4
hairs, the majority contain 2 hairs. By combining 2
follicular units, forming a follicular unit “family”,
it is possible to create many grafts containing 3 to
6 hairs. These larger grafts are not placed along the
hairline (where, similar to in men, 1 and 2 hair grafts
are used), but rather in areas of thinning between already
existing hairs.
Not all women are appropriate for transplanting with
follicular unit “families”. In particular,
women with high donor density, dark colored hair, or
hair shafts of wide diameter are at risk for developing
a “transplanted” appearance if grafts larger
than single follicular units are used. Women undergoing
transplantation to restore receded hairlines and/or
absent temporal tufts (sideburns) that often are the
result of prior rhytidectomy or browlifting are also
in this group. Because of the visibility of these areas
due to their leading-edge position and the lack of existing
hairs to blend in with the transplants, it is necessary
to use pure follicular unit grafts, with only 1 and
occasionally 2 hair grafts placed along the anterior-most
edge. In addition, hair transplantation of the eyebrow
is best accomplished with the use of all 1 and 2 hair
grafts. However, these are the minority of cases.
THE PROCEDURE
Procedures are performed under oral sedation in an operating
room using a sterile set-up. Patients are typically
given 10 mg each of diazepam and Ambien® (zolpidem
tartrate), which provides a nice combination of relaxation
and some degree of amnesia. Marking out of the areas
to be transplanted is performed in accordance to what
was discussed in the consultation.
During the initial consultation, I always try to determine
the exact areas of hair loss with which the patient
is concerned, and present a plan to best restore hair
into those areas. In general, because the supply of
donor hairs is limited, and it is expected that the
patient will likely desire or require additional procedure(s)
in the future, my goal is to achieve the appearance
of the greatest amount of hair coverage within the patient’s
anticipated hairstyle. Women with hair loss usually
are quite adept at creative hair styling in order to
maximize the appearance of hair coverage- adding hairs
into the most critical areas can go a long way towards
further enhancing this appearance. For example, placing
additional hairs along the anterior hairline and part
region in a woman in whom the hair is brushed back and
away from the part will provide more coverage than if
the hairs were instead placed primarily in the middle
of the scalp.
Once marked out, the patient is brought into the procedure
room where anesthesia is injected into both the recipient
and donor areas of the scalp. To make this step as pain-free
as possible, neck massaging is performed simultaneously
with administration of anesthesia by a computerized
injection system called The Wand® (Milestone Scientific
Inc., Livingston, NJ). By injecting the anesthesia at
a flow rate at or just below the threshold of detection,
The Wand® eliminates most if not all of the discomfort.
By injecting along the pathways of the nerves that provide
sensation to the recipient and donor regions, anesthesia
can be attained with a very small amount of agent- typically
no more than 8 to 10 cc- thus reducing the incidence
of post-procedure edema. Furthermore, to reduce the
traumatic telogen effluvium to which female patients
are particularly susceptible, I avoid the injection
of epinephrine into the recipient areas.
Once the scalp has been prepped and draped sterile,
the donor tissue is excised as a single fusiform-shaped
strip using a number 15 scalpel blade. To facilitate
the removal of the donor strip and control hemostatis,
tumescence with a dilute epinephrine solution is first
applied to the donor tissue. The donor region is located
along the back and occasionally the sides of the scalp,
usually at the level of the top of the ears, where the
hair typically has the greatest density and the resultant
donor site scar will heal the best. The size of the
donor strip depends upon the number of grafts to be
transplanted. For example, a procedure of 800 to 900
3 and 4 hair grafts would typically require a donor
strip 15 cm-squared in size- 1 cm in width (a width
that results in minimal scar formation) by 15 cm in
length. Closure of the donor site is performed with
a single row of simple running 3-0 polypropylene (Prolene;
Ethicon Inc, Sommerville NJ) suture.
Once harvested, the donor strip is then turned over
to the assistants. Under binocular microscopic visualization,
the assistants dissect from the strip the individual
grafts. This is a demanding process, requiring careful
dissection so as to not transect follicles while excising
the maximum amount of non-hair bearing scalp tissue.
Because in women the goal is to achieve the maximum
increase in density, most of the grafts, with the exception
of those that are to be placed along the anterior hairline,
contain 3 to 5 hairs. Because of their pronounced visibility,
only 1 and 2 hair grafts typically are placed along
the hairline.
Simultaneous with graft dissection, the recipient sites
are made. This is, I feel, the single most critical
step in the procedure, due to the import the direction,
location, and pattern of graft recipient sites play
in determining the final appearance. Therefore, I make
all recipient sites, not leaving them to be performed
by my assistants. For the making of recipient sites,
tiny slits are made using microblades as small as 0.7
mm up to 1.6 mm in size. Typically, grafts of 2, 3,
4, and 5 hairs fit nicely into recipient sites 0.9,
1.1, 1.3, and 1.4 mm in size. These recipient sites
are carefully made between existing hairs, in a direction
parallel to the surrounding hairs so as to avoid accidental
transection. The depth of the recipient sites is 2 to
5 mm, depending on the length of the follicles.
When performing hair restoration for the treatment of
scars, absent sideburns, and other sequelae of plastic
surgery, the procedure varies somewhat. For example,
when reconstructing the sideburns or the anterior temporal
and frontal hairline, special attention must be paid
to proper recipient site direction, and the use of the
finest 1-hair grafts when cosmetically desirable. (Figure
1) Another case, transplanting into scars, requires
a different approach. In these cases, as the goal is
to maximize hair growth so as to provide the most coverage,
larger grafts are used. Typically, 3 to 5 hair grafts
are implanted as it is expected that one-quarter to
one-third of the hairs will not grow in the fibrotic,
less vascular scar tissue.
For graft placement, jewelers’ forceps, atraumatically
grabbing the fat around the base of the hairs, are used.
So as to minimize “pit” formation, characterized
by a small depression of the skin around a contracted
group of hairs from a graft, a small cuff of skin from
the graft is left sticking above the surface of the
surrounding scalp. With the inevitable contracture of
the graft that takes place in the healing phase, the
surrounding skin will still remain at or just above
the surface of the scalp, preventing pitting.
Once all grafts are implanted, the scalp is cleaned,
and the hair is combed so as to check for any trapped
hairs under the grafts. No bandages are used, and the
patient is discharged home. Medications include an antibiotic,
prednisone to reduce edema, and a mild analgesic. Patients
also use a copper-containing saline spray called GraftCyte®
(Procyte Corp., Redmond,WA), which seems to accelerate
healing. Most patients return to the office the next
day for hair washing, after which gentle hair washing
may be resumed. Sutures are removed on the 8th to 10th
day, at which point most of the crusts are gone or should
be rubbed off.
Regrowth of transplanted hair is expected at 3 to 4
months. This interval can be shortened by as much as
6 weeks by the regular application of minoxidil to the
transplanted scalp starting the 10th day after the procedure.
Hair tinting or coloring may be resumed 3 weeks post-procedure.
Patients are advised that it can take as long as 12
months before the final results are apparent. Many female
patients undergo a second procedure, sometimes as soon
as 6 months later, to achieve more density and/or especially
after several years to replace those original hairs
that fall out due to the progression of female pattern
hair loss.
Case Examples
Figure 2: 55 year old female, before and 7 months after
a single procedure of 660 grafts for the treatment of
female pattern hair loss.
Figure 3: 58 year old female, who desired repair of
scarring and hairline distortion secondary to prior
rhytidectomy with browlift, as well as to restore density
to thinning areas along the sides of the scalp. She
is shown before and 8 months after a single procedure
of 750 grafts, of which 375 were used to restore the
sideburns.
FINAL THOUGHTS
Hair transplantation is a viable option for women with
hair loss and hair distortion from many different etiologies.
Microscopic dissection, which provides smaller grafts,
has led to improved results in these cases. An empathetic
approach, coupled with conservative utilization of the
usually limited supply of hair, can result in satisfied
patients.
Patient selection, especially when attempting to treat
female pattern androgenic hair loss, is critical. At
least a minimal donor site density is necessary to achieve
acceptable results. In many of these cases, a second
procedure to achieve more density is performed typically
12 or more months later.
In addition to careful patient selection, several additional
steps are critical for assuring more successful outcomes.
Special precautions, such as avoiding the use of epinephrine
in the anesthetic solution, and performing a relatively
limited number of grafts that are each implanted into
carefully created recipient sites, are helpful in achieving
success.
Finally, the role of the medical workup and, if indicated
and accepted, the importance of medical adjunctive therapy
cannot be understated. Hopefully over the next several
years, new medications will help supplement the results
achieved surgically.
REFERENCES
Legends for Figures
1. Illustration of the technique of sideburn restoration.
Note that the direction of the grafts is primarily inferior
along the superior region, then becomes more horizontal/posterior
in the inferior region.
2. Patient before (A), and after (B) a single procedure
of 660 grafts for the treatment of female pattern hair
loss.
3. Patient before (A) and after (B) a single procedure
of 750 grafts to restore the normal hair pattern after
rhytidectomy.
References
1. Ludwig E. Classification of the types of androgenetic
alopecia (common baldness) occurring in the female sex.
Br J Dermatol 97(3):247-254, 1977.
2. Sperling LC. A new look at scarring alopecia. Arch
Dermatol. 2000;136:225-232.
3. Brennan HG, Toft KM, Dunham BP, Goode RL, Koch RJ.
Prevention and correction of temporal hair loss in rhytidectomy.
Plast Reconstr Surg. 1999;104:2219-2225.
4. Leonard RT. Hair transplantation in patients following
cosmetic facial surgery. Cosmet Dermatol. May 2001:33-35.
5. Epstein JS. Hair transplantation in women. Treating
female pattern baldness and repairing distortion and
scarring from prior cosmetic surgery. Arch Facial Plast
Surg. 2003;5:121-126.
6. Chartier MB, Hoss DM, Grant-Kels JM. Approach to
the adult female patient with diffuse nonscarring alopecia.
J Am Acad Dermatol 2002;47:809-818.
7. Price VH. Treatment of hair loss. N Engl J Med 1999;341:964-973.
8. Chartier MB, Hoss DM, Grant-Kels JM. Approach to
the adult female patient with diffuse nonscarring alopecia.
J Am Acad Dermatol 2002;47:809-818.
9. Lucky AW, Pacquadio DJ, Ditre CM, et al. A randomized,
placebo-controlled trial of 5% and 2% topical minoxidil
solutions in the treatment of androgenetic alopecia
in females. J Am Acad Dermatol. In press.
10. Headington JT. Transverse microscopic anatomy of
the human scalp. Arch Dermatol. 1984;120:449-456.
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