Transplantation For Men With Advance Degrees of Hair
S. Epstein, MD
Presented: September 7, 2001, at the Annual Meeting
of the American Academy of Facial Plastic and Reconstructive
Surgery, Denver, Colorado
In the field of surgical hair restoration, there is
probably no greater challenge than treating the individual
with advanced male pattern hair loss. Recent developments
in follicular unit grafting and recognition of the natural
appearance of the transplanted frontal forelock have
now made it possible to obtain excellent, undetectable
results in these patients.
Over a two year period, the onset correlating with the
time when the author began to use the technique of follicular
unit grafting, 61 of 322 (20%) hair transplant procedures
performed for male pattern hair loss were on men with,
or at high risk of developing, advanced male pattern
hair loss. Uniformly, the creation of some type of frontal
forelock provided excellent results and high patient
The concept of the frontal forelock is not new. Developments
in aesthetic principles, enhanced understanding of its
applicability, and the applied advantages of follicular
unit grafting allow for the first time, truly undetectable
There is perhaps no greater challenge in surgical hair
restoration than treating the individual with advanced
male pattern hair loss. Fortunately, in probably no
other area in the field of hair restoration have advancements
in technique and changes in approach led to such a great
improvement in results when treating such individuals.
In men with advanced hair loss, the donor hair supply
is far exceeded by the amount required to cover the
balding areas. That is the irony in hair restoration:
the greater the need, the less the supply.
The approach to restoring hair to such individuals
is waged along several fronts. The first front is maximum
utilization of available donor supply through advances
in technique. Follicular unit grafting, by minimizing
the inadvertent damage or loss of existing follicles,
preserves the greatest amount of donor hairs. The second
front is conservation of demand through refinements
in the aesthetics of hair transplantation. The designing
of a conservative hairline, often limited to a central
forelock that is acceptable to the patient, dramatically
improves the results from those of patterns that have
been used in the past. The final front is recognition
of the patient's situation as challenging from a supply/demand
perspective. Such recognition is easy in the patient
presenting with an advanced degree of hair loss (i.e.
a Hamilton-Norwood Class 6 or 7 pattern), but is more
difficult with the younger patient presenting with an
early hair loss pattern at risk to progress to a much
more advanced pattern in the future.
Over 60% of all men experience some degree of cosmetically
noticeable hair loss by age 50.(1,2) The Hamilton-Norwood
scheme classifies male pattern baldness (MPB) into 7
stages, with some flexibility to account for variations
in the classic patterns.(3) Because MPB is progressive
with age, most men will advance several stages over
the course of a lifetime.
It is possible to predict with some accuracy whether
an individual will progress to an advanced hair loss
pattern. Predictive factors include the onset of MPB
at a young age (mid-20s and earlier), a strong family
history of baldness, and extensive hair thinning along
the back and sides of the head and the superior temporal
tufts at presentation.
Little can be done medically to slow down the hair
loss process. Genetically determined, MPB can be affected
only by reducing the body's production, or the hair
follicle's uptake, of dihydrotestosterone, the hormone
shown to induce the miniaturization and eventual death
of the hair follicle.(4) The only medications approved
for the treatment of hair loss are finasteride (Propecia®)
and minoxidil (Rogaine®). Both slow down hair loss
in less than two-thirds of men, and induce new hair
growth in a much smaller percentage. These results are
for the crown region; results for areas more anterior
in the scalp are significantly poorer. The medications
are temporary, and must be taken continuously to maintain
The average head contains 100,000 hairs at peak density,
with approximately 25% of these hairs located in the
"permanent" donor area.(5) As many as 50%
(or 12,500) of the 25,000 hairs within the donor region
are available for transplanting, meaning that they can
be harvested and the donor site closed without resulting
in scarring or abnormal lack of adequate density.(6)
The Hamilton-Norwood Class 2 patient has lost 10% to
20% of total scalp hairs, but still has as many as 12,000
hairs in the donor region available for transplantation
(to "replace" a loss of a similar number of
hairs). The Class 6 patient, on the other hand, has
lost 70% to 80% of total hairs, and has 6,000 to 8,000
hairs available for transplantation (to "replace"
a loss of more than 70,000 hairs). These 2 examples
illustrate the demand/supply challenge in hair restoration
While an explanation is beyond the scope of this analysis,
the appearance of normal hair coverage can be achieved
by transplanting to just 50% of original density.(7)
In the case of the Class 6 patient, the 6,000 to 8,000
available donor hairs can therefore adequately fill
in an area once covered by 12,000 to 16,000 hairs, which
is approximately 20 to 25% of the total area of hair
loss. Therefore, complete scalp coverage in individuals
with advanced hair loss is not achievable, and a plan
must be in place so as to attain the best result of
the hair transplant.
DIAGNOSING THE PROBLEM,
COUNSELING THE PATIENT: PREPARING TO MINIMIZE DEMAND
As with most plastic surgery procedures, proper diagnosis
and good communication between doctor and patient are
the first, and perhaps most important steps. Patient
concerns, expectations, and understanding must be evaluated
with respect to the findings on examination. Further,
the patient must be educated as to the progressive nature
Expectations are usually in proportion to the degree
of hair loss and the age of the patient. For example,
the man in his 50s with a Hamilton-Norwood Class 6 pattern
would probably be accepting of a conservative hair restoration,
happy to have any amount of natural appearing hair on
top of his head. On the other hand, the 22 year old
with a Hamilton-Norwood Class 2 pattern is seeking to
have a hairline similar to that of his peers, most of
whom have a full head of hair. Such a hairline design
is achievable at the early state of hair loss, but would
look to some degree unnatural in the future with the
expected progression of hair loss. Sequelae could include
a hairline that is too low for the patient's age, and
an unnatural pattern because of not enough donor hairs
available for further transplanting to fill in areas
that progressively lost hair.
THE TECHNIQUE: MAXIMIZING
The amount of coverage attained from a hair transplant
is a result of the number of hairs transplanted that
actually grow. Follicular unit grafting (FUG), with
single donor strip harvesting and microscopic sectioning
of the donor material, is probably the most effective
technique for assuring maximal hair growth (see Figure
1). FUG recognizes the aesthetic advantages of keeping
intact the natural bundles of hairs as they grow in
the scalp.(8,9) Each follicular unit graft consists
of 1 to 4 hairs, and relies upon microscopic dissection
for accuracy. Removing the donor strip in a single strip,
versus multi-bladed excision, produces the least amount
of blind cutting of the material, reserving the sectioning
to be performed under the microscope. Careful dissection
of each graft, performed by a team of experienced assistants,
minimizes accidental transection of hair follicles,
and allows for the preservation of a small cuff of supportive
and protective tissue around the follicles.(8,10) It
is the author's experience that an additional 20% or
more of grafts are obtained from the same sized donor
strip using the follicular unit microscopic technique
versus the traditional basic magnification or no magnification
technique. These findings have been confirmed in the
literature by other investigators.(10)
Proper handling of the grafts after dissection is critical
for hair growth. Desiccation is felt to be the most
common cause of poor growth, therefore grafts must be
kept moist and chilled during the entire time.(10) Grafts
must also be handled delicately to avoid damaging the
THE AESTHETICS: MINIMIZING
DEMAND, MAXIMIZING APPEARANCES
Designing the area to be transplanted in individuals
with advanced degrees of hair loss is not merely the
creation of a very high, receded hairline. For most
men, the goal is to maximize the appearance of coverage
while not compromising naturalness in appearance. The
prominent frontal forelock, a pattern that exists naturally,
serves as the template for the majority of hair restorations
in individuals with advanced MPB. The frontal forelock
consists of hairs growing in the central-anterior region
of the scalp, bordered laterally by frontotemporal recessions.
While other patterns can be designed, the frontal forelock
represents the most efficient utilization of available
donor hairs. A relatively small number of hairs, provided
in as few as 800 to 1000 grafts, can strategically create
the appearance of maximum hair coverage, and aesthetically
frame the face. More extensive coverage, and/or greater
density, can be achieved with the transplanting of more
grafts. It is not uncommon to transplant 1600 to 1800,
and as many as 2400 grafts, in a single procedure. Additional
procedures can further supplement the coverage.
Frontal forelock design involves the concentrated placement
of grafts in the central anterior scalp. To minimize
the appearance of abruptness, all of the borders (anterior,
lateral, and posterior) are feathered-in by irregularly
placing 1 and, if appropriate, 2 hair grafts (see Figure
2). Proceeding from peripheral to central in all directions,
follicular unit grafts containing 2 to 4 hairs apiece
are placed progressively closer together to increase
A number of variations exist with the frontal forelock
design. Most commonly, the forelock is semi-oval in
shape, with a rounded convex anterior border and concave
posterior border. The location of the anterior-most
hairline is individualized for the patient. Most commonly
this is at the point where the vertical forehead curves
into the horizontal scalp, typically located nine to
ten cm above the nasion (root of the nose). The anterior
hairline can be rounded, or, alternatively, more triangular
in shape, resulting in a more "severe" appearance.
By creating a widow's peak at the central aspect of
the frontal hairline, if so desired by the patient,
a small number of hairs can create the appearance of
an even lower hairline. The sagittal axis of the forelock
is usually longer than the coronal axis, but this can
vary depending upon the morphology and shape of the
face and skull. Hair coverage can be extended further
posteriorly by transplanting 1 and 2 hair follicular
unit grafts into the area.
Probably the greatest variety in design is whether
the forelock is isolated or connected to the temporal
fringe. In cases where the temporal fringe is high (minimally
receded), the forelock will naturally connect. However,
in more advanced cases of MPB where there is significant
caudal recession of the temporal fringe, the frontal
forelock will be isolated.(11,12) In a number of cases,
the surgeon can convert an isolated pattern into a connected
pattern by transplanting 1 and 2 hair grafts cephalic
to the superior border of the temporal fringe up to
the lateral aspect of the forelock. These extensions,
termed "temporal horns", can be created by
transplanting as few as 50 to 150 grafts on each side.
While they need only to be light in density, they can
significantly improve appearances.
For any patient presenting with an early or intermediate
degree of hair loss but at risk of advanced MPB, the
guidelines of frontal forelock creation should also
be followed. The restoration is designed as if the patient
will eventually progress to an advanced stage of MPB.
In these cases, the goal is the enhancement of density
in the area of the central forelock, which in the future
will eventually serve as the heart of the restoration.
Variations in hairline design allows for unlimited
flexibility when performing hair restoration. While
it is beyond the scope of this article to teach proper
hairline design, it is important that the surgeon be
well versed in the elements of what makes a hairline
appear natural. The common factor in all natural appearing
hair restorations, whether for limited or advanced hair
loss, is the creation of an irregular, broken line hairline
composed of 1 and occasionally 2 hair grafts. Subtleties,
such as the direction in which the hair grows, and the
angle from which the hair emerges from the scalp, can
have a profound effect on the overall aesthetic appearances.
From January 1999, to October 2001, the author performed
368 hair transplant procedures, on patients with an
age range of 18 to 78 years old, and a mean age of 44
years. Of the 322 procedures performed on men, approximately
20% were on individuals presenting with, or at risk
for developing advanced MPB. Uniformly, results were
excellent, and patient satisfaction high.
The following case examples illustrate the approach
taken with these patients.
Case 1 (see Figure 3)
47 year old Hamilton-Norwood Class 6. The patient's
advanced degree of hair loss and low donor density limit
the amount of coverage that is possible. Before and
after at 8 months show the results of a single procedure
of 1930 follicular units transplanted in the region
of the frontal forelock with creation of temporal horns.
Case 2 (see Figure 4)
50 year old Hamilton-Norwood Class 7. Before and after
show the results of 3800 follicular unit grafts transplanted
over 2 procedures.
Case 3 (see Figure 5)
58 year old Hamilton-Norwood Class 7. Very fine hairs
limit the amount of density that can be achieved with
transplanting. Before and after 6 months show the results
of a single procedure of 2,150 follicular unit grafts.
In this case, the forelock was left isolated from the
The frontal forelock concept was first popularized in
the early-1990s by the work of Beehner, Marritt, Stough,
and others.(13-16) Recognizing both the progessive nature
of hair loss, and the need to provide hair transplantation
to men already with or at risk for developing advanced
hair loss, the frontal forelock was proposed as a natural-appearing
solution. What is truly amazing is the ability of some
of these pioneers to achieve reasonably natural-appearing
results using traditional micrografts and minigrafts
Today, follicular unit grafting offers hair transplant
surgeons several distinct advantages over traditional
micro/minigrafting. In addition to the fact that hairs
are preserved in their naturally occurring bundles,
what is especially relevant to the ongoing discussion
is the maximal preservation of donor hairs by microscopic
dissection. The additional 20% or more hairs can go
a long way towards providing more coverage. Other advantages
of follicular unit grafting are conferred by the smaller
size of the grafts compared to traditional micro/minigrafts.
The grafts require smaller recipient sites, which can
be placed closer together for greater density, and which
result in minimal to no scarring. Follicular unit grafting,
however, is merely a technique and not a guarantee of
a good result. Success, as measured by the ability to
create undetectability, naturalness, and the appearance
of reasonable density, is dependent upon the planning,
the aesthetic designing, and the proper executing of
A number of different forelock patterns have been presented
in the literature.(12,15) What they all have in common
is a soft transition zone (created by the irregular
placement of all 1, and occasionally 2, hair grafts)
along the periphery, and the progressive increase in
density as one proceeds centrally (once created by minigrafts
with 3 to 6 or more hairs, now created with the close
placement of 2 to 4 hair follicular unit grafts). The
illustration and case presentations serve as examples,
illustrating the key fundamentals of frontal forelock
design. Much like the design of any hairline, considerations
must account for the individual patient's facial morphology,
expectations, and hair quality.
The majority of men who undergo the frontal forelock
procedure have sufficient cephalic temporal hairlines
to connect to the transplanted hairs. However, in certain
individuals, recession of the temporal horns requires
deciding whether to create an isolated, or a connected
frontal fringe. It is the author's experience that the
majority of men prefer a connected forelock. A relatively
small number of 1 and 2 hair grafts can be judiciously
applied to build up the temporal horns to the level
of the forelock. Key to aesthetics is placing these
grafts at an acute angle to the scalp in order that
they grow in an inferior direction. However, in certain
individuals, the natural direction of growth is in a
more superior or anterior direction.
While the forelock design as presented is specifically
for use in men with advanced hair loss, the concepts
put forth are applicable to virtually all hair transplants.
Until a truly effective medical "cure" for
hair loss, such as gene therapy or a new medication,
becomes available, almost every individual must be viewed
as being at risk for progressing to an advanced degree
of hair loss. Adhering to the concepts of conservative
hairline design and maximizing density in the central
forelock can prevent cosmetic problems in the future.
Of course, following a conservative course requires
educating the patient. Perhaps the greatest challenge
in treating these patients lies not in the actual procedure
but in the counseling process, and getting the patient,
especially the young patient at high risk for developing
advanced baldness, to willingly agree to undergo a conservative
The price of not adhering to a conservative transplantation
course in the young patient can be an unnatural appearance
in the future, if the progression of hair loss occurs
as expected. Possible features of the unnatural appearance,
which are almost all due to the exhaustion of hairs
for further transplanting, depend upon how the transplantation
was performed. Inadequate density, with "see-through"
hair, can result if all 1 to 3 hair grafts were widely
distributed along the entire top of the head. An abnormally
low and dense hairline, sharply contrasting with the
remaining thin fringe hair, can result if the hairline
was solidly filled in and positioned according to the
desired features of a young man, not that of a more
"appropriate" older man. On the other hand,
if in the young individual there is minimal progression
of hair loss in the future, defying expectations, nothing
has been lost. The conservatively created frontal forelock
can be extended laterally, posteriorly, even anteriorly,
by the transplanting of hairs that proved to be permanent,
withstanding the test of time.
Corresponding author: Jeffrey Epstein, M.D., 6280 Sunset
Drive, Suite 504, Miami, FL 33143
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