Is Today's Hair Transplant Going To Look Good Tomorrow
By Paul J. McAndrews, MD

The 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 areas.
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).

Fig. A	Fig. B

Aesthetically, 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, and-
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 and grow.
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)

Many 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 Vertex Scenario-
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.

Fig. C	Fig. D	Fig. E

Therefore, 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-

Before 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.

) Fig. F	Fig. G

A 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.

Fig. H	Fig. I	Fig. J

2) 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.

This 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).