Guidelines For Hair Transplantation
in The Young Patient
The young man who is losing his
hair is a challenge to the hair transplant surgeon.
He is often extremely distressed about his follicular
future and the initial consultation must balance the
patient's emotions with the reality of his hair loss.
Some surgeons may deal with this situation by adhering
to a minimum age policy. "I won't operate on anyone
under 25." But should there really be a minimum
age? With the transformation of hair transplantation
into a microsurgical procedure and the availability
of effective medical treatments for hair loss, we now
have the opportunity to more confidently treat this
Consider the young patient under 25 years old. There
are advantages to working with these patients. They
are highly motivated, generally healthy individuals
who are rarely on medication. Many of these patients
are devastated by the early loss of their hair and we
have the opportunity to restore their confidence, and
self-esteem as well as their hair. With early surgical
intervention the surgeon can keep up with the patient's
hair loss and he will never look bald. Futhermore, most
of these patients still have some existing hair, which
makes the surgery easier to camouflage.
There are also potential hazards when transplanting
this younger age group, that need to be addressed in
detail during the initial consultation. Their expectations
are very high and sometimes unreasonable. They want
their hairlines where it was when they were 15 and they
invariably want more density than is technically possible.
Often their decision to have surgery is an impulsive
one. These young men are experiencing their first encounter
with the aging process and many of them are not emotionally
or intellectually able to deal with it. The patient
must understand that once beginning hair transplantation,
it is a lifetime commitment because they may need additional
surgeries to keep up with their hair loss. But the most
difficult issue of all is the estimation of future hair
loss. The progression of androgenetic alopecia must
never be underestimated. Failure to do so can lead to
a cosmetic disaster.
For a successful end result, the surgeon must be cautious
and conservative in long term planning. Examination
of male parents and siblings and evaluation of family
photographs can be very helpful in predicting the ultimate
pattern of loss. This is a challenging group, but they
should not be denied access to hair transplantation,
solely because of their age.
The following guidelines are recommended to
achieve a successful surgical result when transplanting
patients under 25 years of age.
•Place the hairline higher than where the patient
wants. Follow the rule of thirds and then push the patient
to accept an even higher hairline. Hairlines should
not be less than 8 cm above the mid glabella line. Preferably
it should be at least 9 cm. A higher hairline conserves
donor hair. Every centimeter higher saves hundreds of
hairs that may be needed in later years. Also, by reducing
the area to be transplanted, greater density can be
achieved with the same amount of donor hair.
•As the patient ages, a higher hairline will
only look more natural. If this issue reaches an impasse
after all of this has been explained, which it often
does, the patient should be advised that the hairline
can always be lowered during subsequent procedures.
Always try to buy time. Raising the hairline is extremely
difficult and it is usually cosmetically unacceptable.
•Avoid transplanting the vertex because of the
difficulty in accurately estimating future hair loss.
By starting in the frontal area, and continuing back
as hair loss progresses, the patient will always have
enough donor hair to adequately cover these areas in
the future. If the vertex is transplanted at this early
age, there is a risk of depleting the donor hair that
will be needed later. Without the necessary donor hair,
the patient can end up with islands of hair that are
not connected or insufficient density in the frontal
•Use caution when transplanting temporal angles.
In the old days, many surgeons avoided transplanting
temporal angles because of unsightly results with full
size grafts or large minigrafts. Now, cosmetically acceptable
results can be achieved using follicular units and maintaining
a slightly receded concave hairline. Because the temporal
fringe naturally flattens as one ages, avoid creating
a permanent temporal point that is too far anterior
which will look inappropriate in the future.
•Start the patient on medical therapy. Finasteride
with or without minoxidil has the potential to significantly
reduce future hair loss and may even promote growth
particularly in the vertex. The new 5-year data on Finasteride
shows that 66% of treated patients have significantly
more hair in the vertex than when they started. The
effectiveness of both of these drugs in the vertex is
another reason to delay transplanting in this area.
By preventing or reducing the potential for further
hair loss, the surgeon has a much greater margin of
•Look for clinical clues that may portend the
development of extensive future hair loss (type VII).
The presence of "whisker hair" and poor temporal
density are signs that suggest an early onset of potentially
significant baldness. Norwood first described whisker
hair as short curly hairs that are found above the ears
that have characteristics of beard hair. He suggested
a correlation between significant future baldness and
the presence of these hairs.
When examining the young patient the temporal density
should be carefully determined. Early significant thinning
in this area may also be a sign of impending follicular
•Select the safest donor areas. The mid-occipital
area should be selected for the initial procedures because
it is the least likely to thin over time. Subsequently
the donor area can be expanded inferiorly and superiorly
as determined by the pattern of hair loss. The temporal
donor sites should be saved for later years because
the future density of these sites is less predictable.
Defer scheduling surgery during the first consultation.
Resist the temptation. Have the patient return for a
second consultation, preferably in 6 months. Although
this may be a difficult business decision, I believe
that this is the most appropriate medical decision for
this age group. You will be able to weed out any emotionally
impulsive or psychologically unstable individuals who
would be unsuitable for surgery. By deferring the surgery,
the surgeon will then be able to evaluate how rapidly
the hair loss is progressing and how well any medical
treatment might be working. By proceeding in this manner,
the groundwork for a positive-long-term relationship
and a successful surgical experience will be in place.
With the latest advances in microsurgical techniques
and the availability of effective medical therapy for
hair loss, we should reconsider the concept of a minimum
age and be more confident treating a younger patient
population. By following these recommended guidelines,
the surgeon should be able to avoid cosmetically unacceptable
results in the future.