Transplantation In Women: Treating Female Pattern Hair
Loss and Reparing The Distoration and Scarring From
Prior Cosmetic Surgery
S. Epstein, MD
Author: Jeffrey S. Epstein, M.D., F.A.C.S.
Clinical Professor, University of Miami
Private Practice, Miami, FL
Send all reprint requests to Dr. Epstein: 6280 Sunset
Drive, Suite 504, Miami, FL 33143
Originally presented as a poster, AAFPRS Annual
Meeting, Denver, CO, September 2001. To be presented
at the AAFPRS International Meeting, New York, NY, May,
The role of hair transplantation in men is well established.
In women, the procedure is much less common, but has
a definite role in both the management of female pattern
hair loss and the repair of alopecic scarring and hairline
distortion as a result of prior facial plastic surgery.
When performing hair transplantation in women, there
are differences in technique from that used in men,
so as to consistently achieve excellent results and
Over the past 3 years, the author has performed 86
hair transplant procedures on women. The majority of
these cases were for female pattern hair loss. The techniques
utilized, and typical results are presented. When performed
properly for the proper indications, hair transplantation
is an effective procedure with a very high level of
While over 95% of all hair transplants are performed
on men, women are candidates, and do undergo, hair transplants
for the treatment of several conditions. Hair loss in
women in the majority of cases is, like in men, genetic
in origin, and progressive. The current train of thought
regarding female pattern baldness (FPB) is that it occurs
along several different patterns, the most common consisting
of diffuse thinning along the top and upper sides and
back of the head, often sparing the frontal hairline.(1)
This, the classic FPB pattern, is divided into 3 stages
according to the Ludwig classification scheme, with
stage 1 consisting of mild hair loss, with stage 3 extensive
hair loss.(2) In patients with stage 1 and most cases
of stage 2 classic FPB, as well as those with some of
the less common patterns, there usually is sufficient
hair density in the donor region (mid-occipital region)
to make transplantation at least somewhat effective
at restoring density to the thinner areas. Women with
stage 3 FPB are usually advised not to undergo the procedure,
but rather to consider the purchase of a hairpiece or
The other condition in women effectively treated with
hair transplants is the alopecic scarring and hairline
distortion associated with prior plastic surgery. The
most common type of distortion is the loss of the sideburns
caused by those rhytidectomy incisions that extend superiorly,
rather than horizontally, from the upper aspect of the
ear, thus pulling the temporal tuft along this superior
vector.(3,4) While this incision design is superior
for dealing with the lateral brow region, the hairline
distortion it often produces can cause significant hair
styling difficulties. Another type of distortion is
the excessive elevation of the frontal hairline associated
with coronal browlift incisions in patients with pre-existing
high foreheads.(5) Alopecic scarring, meanwhile, most
commonly occurs along the frontal and temporal incisions
of browlifts, and the occipital incisions of rhytidectomy.
Finally, representing a combination of hairline distortion
and scarring is the loss of hair in the superior temporal
region anterior to certain rhytidectomy and most browlifting
incisions that is due to tension vectors in a superior-posterior
direction and inadvertent transection of the superficial
temporal artery. The goal of hair transplantation in
these cases is to restore hair growth in the scarred
and thinned out areas, and to recreate the normal anatomy
of the temporal tufts and the frontal and temporal hairline.
There are a variety of hair transplantation techniques,
which basically differ according to graft size and the
technique of graft preparation. Over the past 3 years,
the technique of follicular unit grafting (FUG) has
largely become accepted as the technique of choice for
the majority of hair restorations. This technique requires
the microscopic dissection of the donor material into
grafts each containing a single follicular unit. The
follicular unit consists of 1 to 4, most commonly 2
or 3 hairs, in a single bundle, with the sebaceous gland
elements and other supporting tissue, surrounded by
an adventitial sheath.(6) This is the way the hair on
the scalp grows naturally, and theoretically, by keeping
the follicular unit intact, the pattern of hair growth
has the potential to be virtually completely natural.
Microscopic dissection is required for FUG, in order
to assure the integrity of the unit, and to allow the
dissecting away from the graft of as much non-hair bearing
scalp skin as possible.(7)
Because of its technical difficulty, requiring a team
of trained assistants to dissect as many as several
thousand grafts in a single procedure, the majority
of hair transplant surgeons do not perform FUG, but
rather the conventional technique of micro/minigrafting
(MM), also called mini/micrografting. Using accepted
terminology, the micrograft contains 1 or 2 hairs, while
the minigraft contains 3 to 6 hairs.(8) Dissection of
these micrografts and minigrafts is performed under
direct or magnified visualization. MM does not respect
the integrity of the follicular unit, rather grafts
are dissected out according to the numbers of hairs
per graft that are required for the restoration. For
example, the surgeon will request that a donor strip
be divided into a certain number of 1 and 2 hair micrografts,
and certain numbers of small minigrafts of 3 and 4 hairs
and , perhaps, larger minigrafts of 5 and 6 hairs. With
this technique, no effort is made to remove the excess
non-hair bearing tissue, therefore grafts are larger
than their follicular unit graft counterparts that contain
the same number of hairs.
While it is beyond the scope of this paper to discuss
the advantages of FUG versus MM, several distinctions
can be made. MM is a simpler technique, enabling the
procedure to proceed quicker with fewer assistants.
In addition, some surgeons feel that MM affords them
the ability to achieve a greater hair density. While
technically more difficult to create, the smaller grafts
of FUG allow for closer placing of grafts for increased
hair density, minimal to no scarring of the recipient
scalp, less trauma to already existing hairs in the
area transplanted, and up to a 20% greater yield of
hairs from a given sized donor strip.
The Technique: Treatment
of Female Pattern Baldness
When transplanting women with female pattern baldness,
the limited supply of donor hairs limits the amount
of coverage that can be obtained. While most patients
would like to have all the thinning areas treated, the
hairs should be transplanted into those areas where
they will provide the maximum benefit. Most commonly,
these areas are the anterior/mid top of the scalp posterior
to and sometimes up to the frontal hairline, and along
the area where the hair is parted. It is critical to
assess the donor region to make sure that enough hair
is present to make the procedure worthwhile.
For the best results, the procedure should maximize
the number of hairs transplanted while minimizing the
trauma to the existing hairs. This is usually best accomplished
by the transplanting of grafts containing 3 to 6 hairs,
except along the hairline where smaller grafts of 1
or 2 hairs that contain a single follicular unit are
placed to assure a natural appearance. Patients need
to be assured that the larger grafts of 3 to 6 hairs
do not result in a "transplanted" appearance,
because they are used to fill in areas between existing
hairs. While these grafts are bigger than classic follicular
unit grafts, they are still prepared using single-strip
harvesting and microscopic dissection to minimize inadvertent
damage (and therefore loss) of the donor hairs.
In the typical case, 600 to 800 grafts (or around 2500
hairs) are transplanted. The recipient sites are slits
made by a 3.5 mm or smaller blade carefully placed between
existing hairs so as to minimize accidental transection
of or damage to the follicles. SpearPoint blades (Ellis
Instruments, Madison, New Jersey) in sizes from 1.5
mm to 4.5 mm, and the smaller SharpPoint blades (Ellis
Instruments) in sizes of 15, 22.5, 30, and 45 degrees,
are appropriate for making the recipient sites for the
larger and smaller grafts, respectively.
The grafts are placed atraumatically into the incisions.
Careful handling, along with keeping them moist, minimizes
damage and insures good growth. To minimize ischemic
shock to the existing hairs, the local anesthetic contains
a low concentration of epinephrine, generally less than
1:200,000. To further minimize the loss of hairs due
to shock, and to accelerate the regrowth of the transplanted
hairs, the patient restarts at 1-week post procedure
the daily application of minoxidil 2% (usually they
will have already used the minoxidil in the weeks leading
up to the procedure to help stimulate additional hair
growth, stopping its use 3 days prior to reduce the
risk of significant bleeding). With this regimen, the
hairs can be expected to start growing at 2 ½
months, rather than the typical 4 months
The Technique: Treatment of Hairline Distortion and
Alopecic Scarring from Prior Facial Cosmetic Surgery
The management of scarring from prior facial cosmetic
surgery usually includes the restoration of the sideburn
and other areas of distortions, and the repair of alopecic
scarring. Aesthetic restoration of the sideburn begins
with the recognition of its natural appearance in terms
of location, direction of hair growth, and feathered
look. Of particular importance are the superior to inferior,
anterior to posterior direction of hair growth, and
the fineness of the hairs, especially along the anterior
and inferior borders. Areas of scarring, typically located
in areas surrounded by hair, should be transplanted
with larger grafts, so that even if there is less than
the expected 90 percent of hair growth in the scar tissue,
there still is the potential for sufficient coverage.
The technique of choice in these cases is follicular
unit grafting. This procedure provides the 3 and 4 hair
grafts for filling in areas of scarring, the 2 and 3
hair grafts for augmenting density along the upper temporal
and posterior sideburn regions, and the finest 1 and
occasionally 2 hair grafts for sideburn restoration
and feathering along the leading edge of the restoration.
In certain cases, where the finest single hair grafts
are desired, purposeful transection of the follicle,
leaving the hair shaft including its bulge region intact,
can result in finer hair growth.
In the technique of follicular unit grafting, the donor
hairs are removed as a single strip and the site closed
primarily with a running 3-0 Prolene suture. A 10 cm-squared
donor strip (1 cm in width by 10 cm in length) will
typically provide 600 to 800 follicular unit grafts,
which is more than adequate to meet the minimal need
for the 150 to 200 grafts for each sideburn and the
additional 75 to 100 grafts for each upper temporal
region. Because donor density varies significantly among
patients, the size of the donor strip is adjusted according
to the density as well as the number of grafts that
are needed. If needed, additional donor material can
be harvested during the procedure.
A team of assistants using the binocular microscope
dissects the grafts. While the grafts are being cut,
the surgeon makes the recipient sites. A number of instruments
are available for this step. It is the author's choice
to make these recipient sites as tiny slits with SharpPoint
blades (Ellis Instruments). After being made, the recipient
sites are filled with their correspondingly sized grafts.
No bandages are applied, and the patient may begin
hair washing on the second day. Growth of the transplanted
hairs typically begins by 3 months, after which, if
desired, an additional procedure can be performed to
Over the past 3 years, 86 hair transplant procedures
have been performed on 61 women. Of the 86 procedures,
59 were performed exclusively for the treatment of female
pattern hair loss, 21 were performed exclusively for
the repair of hairline distortion and/or alopecic scarring
from prior facial cosmetic surgery, and 6 were performed
for both indications. Patient age ranged from 25 years
to 78 years, with a mean of 52 years.
For the treatment of female pattern hair loss, the
number of grafts ranged from 75 to 1250, with the overwhelming
percentage of patients (51 out of 59) receiving 600
to 800 grafts. Hair growth was consistent in all cases,
and patient satisfaction extremely high. A case example
Case 1 (see Figure 1)
34-year-old female with an advanced hair loss pattern
concentrated in the anterior and mid-scalp region. She
was treated with a single procedure of 475 grafts, 80
containing 1to 3 hairs placed along the hairline and
395 containing 4 to 8 hairs placed further posterior.
For the repair of scarring and hairline distortion
from prior cosmetic surgery, the number of grafts ranged
from 250 to 1500, with the majority of patients (16
out of 21) receiving 650 to 750 grafts. The most common
indication for surgery was the restitution of a normal
sideburn, with less common indications including, in
descending order of frequency, alopecic scarring along
a temporal vertical incision, hair thinning along the
upper temporal region anterior to a browlift or extended
rhytidectomy incision, alopecic scarring along an occipital
rhytidectomy incision, and frontal hairline recession
and/or alopecic scarring from a browlift incision. Hair
growth was rapid, in some cases beginning as soon as
10 weeks post-operatively, and patient satisfaction
extremely high. Case examples are presented.
Case 2 (see Figure 2)
57 year old female, 9 years status-post rhytidectomy
with loss of the temporal tufts and thinning with recession
of the upper temporal region and lateral frontal hairline.
A total of 1050 grafts were transplanted: 375 follicular
unit grafts of 1 and 2 hairs to restore the sideburns,
and 675 grafts consisting of 2 to 4 hair follicular
units to restore density to the upper temporal and lateral
Case 3 (see Figure 3)
59 year old female, 5 years status-post rhytidectomy
with loss of temporal tufts, and significant scarring
of the upper temporal and occipital regions. 1000 follicular
unit grafts containing 1 to 3 hairs were transplanted:
350 to restore the sideburns, and 650 into the temporal
and occipital scars.
Case 4 (see Figure 4)
69 year old female, 2 years status-post rhytidectomy
and coronal browlift, with significant recession of
the entire hairline, loss of temporal tufts, and thinning
of the upper temporal region. A total of 1400 follicular
unit grafts containing 1 to 3 hairs were transplanted:
300 to restore the sideburns, 800 to advance the frontal
and upper temporal hairlines, and 300 to restore density
to the upper temporal and lateral frontal regions.
The role of hair transplantation in women is becoming
more recognized as an option in the treatment of a variety
of hair loss conditions. Women are increasingly learning
that they can benefit, as do men, from the newer techniques
in surgical hair restoration. While there are certain
inherent limitations in the results of hair transplantation
for the treatment of female pattern hair loss, it is
the author's experience that, when they are appropriate
candidates, these patients are amongst the happiest.
For many of these women, the results of a relatively
small number of hairs transplanted strategically into
areas of maximum benefit, can restore confidence, and
avoid the need for the wearing of a hairpiece or hair
Several types of female pattern hair loss have been
described in the literature. From a therapeutic perspective,
it is necessary to divide these many patterns into two
general patterns: diffuse thinning, and thinning concentrated
along the top of the head similar to male pattern hair
loss. Because the second pattern tends to have a better
donor hair density, it is more suitable for treatment
with hair transplantation. Divided into 3 stages, those
with stage 1 and most cases of stage 2 have sufficient
donor density to provide sufficient hair to make transplantation
worthwhile. In addition, those with the diffuse thinning
pattern can usually benefit from hair transplantation,
although not as impressively.
Hair transplantation for pattern hair loss in women
is not merely the same procedure as performed in men.
As discussed in the technique section, certain precautions
must be taken to minimize iatrogenic hair loss in the
recipient region, which seems to occur much more frequently
in women. Precautions include using local anesthetics
that do not contain epinephrine, and minimizing of the
number of recipient site incisions and using larger
grafts so as to achieve a maximal increase in hairs
per graft placed. Patients with moderate to advanced
patterns are advised on the probable need for a second,
and perhaps additional procedures. Even in cases where
satisfactory density was achieved after one procedure,
the progressive nature of pattern hair loss usually
makes necessary the performance of an additional procedure
in the future.
The treatment of hairline distortion from prior cosmetic
surgery utilizes smaller follicular unit grafts than
the larger grafts for treating female pattern hair loss.
The most challenging area to restore is the lost sideburn.
In no other part of the scalp are the hairs as fine,
or the direction of growth so distinct and critical
for natural appearing results. However, when properly
performed, patient satisfaction with what was otherwise
a successful facelift procedure can be restored.
Other techniques have been described for sideburn restoration,
including transposition flaps (3,9) and micro-minigrafting.(10)
While it does restore the sideburn, the flap procedure
results in an unnatural dense appearance, can create
further alopecic scarring of the adjacent donor site,
and does nothing to restore any thinning or posterior
hairline displacement of the temporal region. Micro/minigrafting
procedures are an improvement over flap repair, but
tend to result in a less than natural "grafted"
appearance with detectable grafts and hypopigmented
scarring of the skin around the grafts.
Follicular unit grafting is the natural evolution of
the micro/minigrafting procedure. All grafts are dissected
out using the microscope or other form of magnification,
and contain a single follicular unit. The follicular
unit is the natural bundling of hairs as they grow in
the scalp. This technique is the author's procedure
of choice for nearly every hair restoration procedure
he performs, because the results are the most natural
in appearance and recipient scarring is minimal to non-existent.
For the most part, hairline distortion is a preventable
event with rhytidectomy. With secondary and tertiary
procedures, or when significant upper and mid-upper
facial rejuvenation is sought, hairline distortion becomes
more difficult to prevent. The "traditional"
rhytidectomy incision extends from the supra-auricular
crease through the temporal region in a mostly vertical
direction, displacing the entire temporal hairline,
including the sideburn, superiorly and posteriorly.
Alternate incisions, such as one that extends mostly
horizontally from the supra-auricular crease through
the upper aspect of the sideburn (peritemporal trichophytic)
can minimize hairline distortion. Beveling of incisions,
so that follicles are preserved along the leading edge
of the incision, minimizes scarring.
When transplanting into scar tissue, hair growth can
often be compromised. This is probably because the decreased
blood supply is not able to support the growth of transplanted
hair follicles. It is the author's experience, as well
as that of others in the literature, that transplanted
hairs will indeed grow in the scar.(11) The percentage
of "take" of the transplanted hairs is reduced,
sometimes by as much as 50% (this versus the greater
than 90% growth rate of hairs transplanted into normal
non-scarred tissue). To compensate for the reduced percentage
of hairs that will grow, the author transplants 4 hair
grafts where it is hoped that 2 or 3 hairs will actually
grow. It is also important that recipient sites be made
slightly larger and/or deeper, so as to promote bleeding
and potentially enhance the neo-vascularization of the
While this paper has focused upon the surgical treatments
for hair loss, it is important to remember the role
of the medical work-up for female pattern hair loss.
While very unusual, hair loss in women can be due to
a number of medical causes, including elevated levels
of testosterone, hypothyroidism, nutritional factors,
and post-pregnancy hormonal changes. In the female presenting
with pattern hair loss, in addition to taking a thorough
history and examination, several lab tests are conducted,
including thyroid function, total testosterone, and
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