Background

Hair loss occurs in more than 60% of men and in approximately 10% of women.

Although a lack of scalp hair can potentially increase the risk of actinic damage and skin cancer,

male and female pattern baldness are conditions that are, with few exceptions, treated electively.

Balding is a major concern for many, and surgery to treat hair loss (ie, hair transplantation)

is the most common cosmetic surgery procedure performed on men today.

Yet, the market for hair transplantation is dwarfed by the immense market for products that treat hair

loss without surgery. These products, which include shampoos, hair-care cosmetics, scalp massagers,

laser combs, and many more, have no proven efficacy except for their ability to temporarily increase

the volume of existing hair, resulting in a denser appearance than before.

Exceptions are the two medications the US Food and Drug Administration (FDA) approved:

minoxidil (Rogaine, available over the counter in the United States) and finasteride (Propecia,

available by prescription only for men), which have limited but definite benefit.

Interest in hair transplantation

will probably increase as knowledge that most modern

hair-transplantation techniques can create virtually undetectable restoration spreads, as shown below.

To this day, hair transplantation remains the treatment of choice for most patients with hair loss.

One of the most rapidly growing segments of hair transplantation is hair transplantation in women.

Surgical hair restoration was developed for and has traditionally been used in males.

Newer techniques are more adaptable to females.

Hair transplantation is used to treat various forms and degrees of permanent alopecia in both men and women.

Intact hair follicles may be harvested from within the safe donor area (SDA) of a patient’s scalp

by either follicular unit strip surgery (FUSS) or follicular unit extraction (FUE); each harvesting method has

unique advantages and disadvantages. The refinement of follicular unit transplanting

over the last decade has led to markedly improved hair survival and natural-appearing results

Problem

Some say, “A bad hair day is better than a no hair day.” For millions of individuals, hair loss is a

major problem associated with loss of self-esteem, insecurity, and even depression.

Hair loss can range from early thinning or hairline recession to complete loss of hair along the top

and upper sides of the head.

A full head of hair contains approximately 100,000 hairs.

(People with red or blonde hair have somewhat more than this.)

The loss of up to 30% of the number that was present during the peak of adolescence that occurs

by middle age is part of the normal aging process. For thinning to become cosmetically

noticeable, at least 50% of the hairs must have fallen out in a particular area. Loss of a smaller percentage

than this generally does not result in the cosmetic appearance of hair loss. In addition to the

loss of the number of hairs, the hair loss process causes individual hairs to thin,

which further contributes to the appearance of hair loss.

The Norwood Classification System recognizes and categorizes the typical sequence of the

hair loss process in men. [6] Early in the process (types 1-3), the hairline recedes,

typically led by frontotemporal recessions. In the latter stages (types 4-7), progression

of hair loss at the vertex (crown) gradually meets and joins the progressive hairline recession,

resulting in varying sizes (in both coronal and sagittal dimensions)

of the confluent vertex with frontotemporal regions of baldness.

For women, the development of androgenic alopecia is classified into three stages.

The typical pattern of hair loss in women is progressive diffuse thinning in an oval area along the top of the scalp.

Hair loss along the hairline is usually spared.

During the 1990s, leaders in hair transplantation debated several topics.

Out of the debates emerged several commonly (though not unanimously) accepted truths.

First is the superiority of

hair grafting versus bald-scalp reduction and scalp-flap surgery in almost all situations.

Second is the inferiority of lasers to conventional cutting devices to form the recipient site.

Third is the acceptance of large-session micrografting, also termed the megasession,

in which 2000 or more grafts can be transplanted safely in a single procedure.

Nearly all hair-transplant specialists agree on the superiority of follicular-unit micrografting over traditional

micrografting and minigrafting. Although follicular-unit micrografting is technically more demanding

and time-consuming than other procedures, it yields superior results in terms of creating a

natural appearance because hairs are transplanted as they grow naturally in the scalp.

The procedure also enables dense graft placement when desired because individual grafts are small

and thereby permitted small recipient sites and closer spacing. In addition, follicular-unit grafting reduces

accidental transection of hair follicles during the graft-dissection process because dissection

is performed under microscope visualization; therefore, wastage of valuable donor hairs can be reduced.

The future of hair restoration

is exciting, primarily because of medical advances. Improved effectiveness

of control of hair loss coupled with minimization of adverse effects result from the use of 5-alpha reductase

inhibitors that are specific for the hair follicle or from the use of medications that work by alternate pathways.

In addition, gene therapy may have future application in hair loss treatment.

The genes that cause alopecia can be located and potentially replaced with genetic

sequences not associated with hair loss.

Hair cloning (technically cell multiplication)

may offer the surgeon a virtually unlimited supply of donor hairs.

By cloning multiple copies of just a few donor hairs, patients with even extensive hair loss can expect complete

scalp coverage, all with minimal donor-site morbidity. Most likely, follicle stem cells will

multiply then

injected into areas of thinning to initiate the regrowth of hairs. Candidates for hair cloning include those with

advanced hair loss and those with scarring or poor supplies of potential donor hairs because of burn injury or

previous poorly performed hair transplantations.

Mechanization of the hair-transplantation process is perhaps the only way to improve the process of follicular-unit

transplantation. Instruments capable of rapidly and accurately dissecting the grafts and atraumatically placing the

grafts will speed the process and reduce reliance upon assistants. However, hair transplantation will remain an

aesthetic procedure that requires a skilled surgeon to create natural-appearing results.

According to the International Society of Hair Restoration Surgery,

hair loss affects 21 million women in the United States, with varying impact on their psychological,

social, and emotional well-being. Hair loss in men can

be socially acceptable, and, in fact, deemed attractive or alluring. Conversely, society generally has less acceptance

of thinning of hair or baldness in women. Women with hair loss often find it more difficult to share their feelings

about hair loss with loved ones or friends or even their physicians.

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