Is Today's Hair Transplant Going
To Look Good Tomorrow
J. McAndrews, MD
medical and surgical treatments for androgenetic alopecia
have improved greatly over the recent years; however
there is still no perfect treatment. Today, one should
not be able to notice who has had, or who has not had,
a hair transplant. However, there is still a big limitation
to hair transplants: there is a limited amount of good
genetic hair that can be transferred from the sides
and back of the scalp to the "balding" top
of the scalp. As hair transplant surgeons we are just
"glorified farmers", transferring the good
genetic seed from the sides of the scalp to the balding
The cruel irony to hair transplants is the person I
can help the most is the person with the most hair and
the person I can help the least (and out of necessity
I need to be the most conservative) is the person with
the least hair. This is because I may have 10 acres
of land to cover and only 4 acres of seed (these numbers
don't add up) (Figure A).
the most important area to have hair is the frontal
forelock because it frames the patients face and maintains
a youthful appearance (Figure B). The hair in the frontal
forelock is typically the last hair to go during the
balding process. Therefore, if you only have 4 acres
of seed but 10 acres of land, the patient has to make
a tough decision on where to use this seed. Aesthetically
the answer is simple: If a young patient has a significant
amount of balding, this limited amount of good genetic
hair should be reserved for the frontal forelock and
the mid-forelock since this is where the hair is most
aesthetically important. It also recreates a natural
balding look. Unfortunately, many young men experiencing
androgenetic alopecia have tendency to focus only on
the acute problem and ignore the "big picture".
We must focus on the limitations to hair transplants,
1) Be realistic about what we can accomplish,
2) Enlist the help of other treatment options (i.e.
- Propecia and Rogaine)
3) Be critical of every technique or technology used
to ensure that the highest percent of grafts survive
4) Use the donor area (grafts) wisely (i.e. - place
the grafts in an area that will stand the test of time
and will always look natural)
of the worst hair transplants are the result of the
doctor not placing the grafts wisely so that it looks
natural for a lifetime. As hair transplant surgeons
we need to resist the temptation of solving the patient's
immediate problem, if long term this will eventually
become a cosmetic detriment. The Hippocratic Oath clearly
states "First of all, do no Harm". Unfortunately
with hair transplants the harm may not be noticeable
until years later. As physicians we always have to be
the patient's advocate.
When we are performing hair transplants, especially
on young patients, we must have the foresight 20, 30,
40 years down the line to envision the progressive balding
process, and how it will relate to prior hair transplants
performed. Many times we are trying to solve the patient's
acute problem without envisioning what the cosmetic
implications will be 20 to 30 years down the line.
Usually the first signs of balding in men are in the
fronto-temporal triangle and the vertex. The following
are 2 scenarios we see in young men.
The patient has vertex balding (Figure C- his acute
problem) which he wants filled in. The doctor submits
to the patient's wishes and transplants "3 of his
4 acres of his good genetic seed" to the vertex.
When this grows in the patient will be quite happy for
the next several years (Figure D). Unfortunately, this
happiness probably will not last when he continues to
recede in his frontal forelock and mid-forelock. If
the patient does not have enough "good genetic
seed" remaining to transplant in the frontal forelock
and mid-forelock, this transplant will not stand the
test of time (because it does not follow the natural
balding pattern in males) and will look very unnatural
(Figure E). The doctor solved an acute problem for this
patient, but long term has created a huge cosmetic detriment
for this patient.
it is prudent to refrain from transplanting hair to
the vertex in young men, and instead place them on Propecia
or other medical therapies. The vertex is where Propecia
works the best. In the vertex, 66% of men at 2 years
were doing better than they were before starting treatment.
In the vertex, 90% of men who were taking Propecia for
5 years were doing as good, if not better than they
were before starting treatment.
The Fronto-temporal triangle scenario-
puberty many men do not have fronto-temporal triangles
(Figure F), but by the age of 25 the overwhelming majority
of men have developed these triangles (Figure G). It
is a very natural bald area in the aging face. However,
it can be very disconcerting for the young male because
it is usually the first sign of balding.
patient with a maturing frontal hairline and fronto-temporal
triangles (Figure H) wants the hairline he had when
he was 18 years old. The doctor submits to the patient's
wishes and transplants his good genetic seed to the
fronto-temporal triangles. When this grows in the patient
is going to be quite happy for the next several years
(Figure I). Unfortunately, this hair transplant has
created 2 problems-
1) Since the property line was moved farther down the
patient has 13 acres of land to cover, instead of 10
acres of land to cover. However, I still only have 4
acres of seed in which to work. With time, the patient
will become quite unhappy because it will eventually
look unnatural (Figure J), especially if he runs out
of hair to transplant.
A hairline was created that is quite natural for a teenager
and also a person in their twenties. This hairline is
permanent and will always stay as an immature hairline.
As the patient ages this hairline will become progressively
more unnatural because it does not properly frame the
face of an aging man.
is another example of an acute problem being solved
for a patient, but long term a huge cosmetic detriment
was created for the patient.
In summary, we need to be very conservative in our approach
treating the balding male, have the foresight to understand
the implications of solving the acute problem, and the
integrity to do what's right for the patient (even if
it's against his immediate wishes).