Although many technical advances have been made in the field of surgical hair restoration over the past decade, particularly with the widespread adoption of follicular transplantation, many problems remain. The majority revolve around doctors recommending surgery for patients who are not good candidates. The most common reasons that patients should not proceed with surgery are that they are too young and that their hair loss pattern is too unpredictable. Young persons also have expectations that are typically too high – often demanding the density and hairline of a teenager. Many people who are in the early stages of hair loss should simply be treated with medications, rather than being rushed to go under the knife. And some patients are just not mature enough to make level-headed decisions when their problem is so emotional.
In general, the younger the patient, the more cautious the practitioner should be to operate, particularly if the patient has a family history of Norwood Class VII hair loss or diffuse un-patterned alopecia.
Problems also occur when the doctor fails to adequately evaluate the patient’s donor hair supply and then does not have enough hair to accomplish the patient’s goals. Careful measurement of a patient’s density and other scalp characteristics will allow the surgeon to know exactly how much hair is available for transplantation and enable him/her to design a pattern for the restoration that can be achieved within those constraints.
In all of these situations, spending a little extra time listening to the patient’s concerns, examining the patient more carefully, and then recommending a treatment plan that is consistent with what actually can be accomplished, will go a long way towards having satisfied patients. Unfortunately, scientific advances will improve only the technical aspects of the hair restoration process and will do little to ensure that the procedure will be performed with the right planning or on the appropriate patient.
Five-year View
The improvement in surgical techniques that have enabled an ever-increasing number of grafts to be placed into ever smaller recipient sites had nearly reached their limit and the limitations of the donor supply remain the major constraint for patients getting back a full head of hair. Despite the great initial enthusiasm of follicular unit extraction, a technique where hair can be harvested directly from the donor scalp (or even the body) without a linear scar, this procedure has added relatively little towards increasing the patient’s total hair supply available for a transplant. The breakthrough will come when the donor supply can be expanded through cloning. Although some recent progress had been made in this area (particularly in animal models) the ability to clone human hair is at least 5 to 10 years away.
Key Issues
1. The greatest mistake a doctor can make when treating a patient with hair loss is to perform a hair transplant on a person that is too young, as expectations are generally very high and the pattern of future hair loss unpredictable.
2. Chronic sun exposure over one’s lifetime has a much more significant negative impact on the outcome of the hair transplant than peri-operative sun exposure.
3. A bleeding diathesis, significant enough to impact the surgery, can be generally picked up in the patient’s history; however, OTC medications often go unreported (such as non-steroidal) and should be asked for specifically.
4. Depression is possibly the most common psychiatric disorder encountered in patients seeking hair transplantation, but it is also a common symptom of those persons experiencing hair loss. The doctor must differentiate between a reasonable emotional response to balding and a depression that requires psychiatric counseling.
5. In performing a hair transplant, the physician must balance the patient’s present and future needs for hair with the present and future availability of the donor supply. It is well known that one’s balding pattern progresses over time. What is less appreciated is that the donor zone may change as well.
6. The patient’s donor supply depends upon several factors including the physical dimensions of the permanent zone, scalp laxity, donor density, hair characteristics, and most importantly, the degree of miniaturization in the donor area – since this is a window into the future stability of the donor supply.
7. Patients with very loose scalps often heal with widened donor scars.
8. One should never assume that a person’s hair loss is stable. Hair loss tends to progress over time. Even patients who show a good response to finasteride will eventually lose more hair.
9. The position of the normal adult male hairline is approximately 1.5 cm above the upper brow crease. Avoid placing the newly transplanted hairline at the adolescent position, rather than one appropriate for an adult.
10. A way to avoid having a hair transplant with a look that is too thin is to limit the extent of coverage to the front and mid-scalp until an adequate donor supply and a limited balding pattern can be reasonably assured – an assurance that can only come after the patient ages. Until that time, it is best to avoid adding coverage to the crown.
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