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Hair Transplantation For Men With Advance Degrees of Hair Loss
By Jeffrey S. Epstein, MD

The Problem
Clinical Examples

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 satisfaction.

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 results.

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.
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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 results.

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 surgery.

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.
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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 of MPB.

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.
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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 follicles.
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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 density centrally.

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.
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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 temporal hairs.
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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 the transplantation.

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 hair restoration.

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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1. Hamilton, J.B. Patterned loss of hair in man: types and incidence. Ann. NY Acad Sci. 53:708-728, 1951.
2. Norwood O.T. Alopecia: Classification and Incidence. In: D.B. Stough, R.S. Haber (Eds.) Hair Replacement, Surgical and Medical. St. Louis, Missouri: Mosby-Year Book, Inc., 1996.
3. Norwood, O.T. Male pattern baldness: classification and incidence. South. Med. J. 68:1359-1365, 1975
4. DeVillez R.L. Pathophysiology of Androgenic Alopecia. In: D.B. Stough, R.S. Haber (Eds.) Hair Replacement, Surgical and Medical. St. Louis, Missouri: Mosby-Year Book, Inc., 1996
5. Bernstein, R.M., Rassman W.R. The logic of follicular unit transplantation. Derm. Clinics 17:277-295, 1999.
6. Rassman, W.R., Carson, S. Micrografting in extensive quantities: the ideal hair restoration procedure. Dermatol. Surg. 21:306-311, 1995.
7. Limmer, B.L. The density issue in hair transplantation. Dermatol. Surg. 23:747-750, 1997.
8. Headington, J.T. Transverse microscopic anatomy of the human scalp: a basis for a morphometric approach to disorders of the hair follicle. Arch. Dermatol. 120:449-456, 1984.
9. Bernstein, R.M., Rassman, W.R., Seager, D., et al. Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatol. Surg. 24:957-963, 1998.
10. Bernstein, R.M., Rassman, W.R.. Dissecting microscope versus magnifying loupes with transillumination in the preparation of follicular unit grafts: a bilateral controlled study. Dermatol. Surg. 8:875-880, 1998.
11. Swerdloff, J., Kabaker, S. Donor site harvest, graft yield estimation, and recipient site preparation for follicular-unit hair transplantation. Arch. Facial Plast. Surg. 1:49-52, 1999.
12. Beehner, M.L. A frontal forelock/central density framework for hair transplantation. Dermatol. Surg. 23:807-815, 1997.
13. Beehner, M.L. The frontal forelock. Hair Transplant Forum International 5(1):1-5, 1995.
14. Knudsen, R. Patterns of coverage: uniform versus graded density. Dermatol. Surg. 23:767-769, 1997.
15. Marritt, E., Dzubow, L. The isolated frontal forelock. Dermatol. Surg. 21:523-538, 1995.
16. Schell, R.J., Stough, D.B. Cadre' de cheveux. Am. J. Cosmetic Surg. 12:317-319,1995.
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