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 ARTICLES

1.  HAIR LOSS ARTICLES

• Hair Loss Causes and Conditions   (By John P. Cole, MD)

• Hair Loss - Why?   (By Bradley Wolf, MD)

2.  HAIR TRANSPLANTATION ARTICLES

• Creating a Natural Hairline In One Session  (By Ron Shapiro, MD)

• Hair Transplantation In Women: Treating Female Pattern Hair Loss and Repairing The Distortion and Scarring From Prior Cosmetic Surgery (By Jeffrey S. Epstein, MD)

• Recreating The Crown Whorl    (By Robert H. True, MD)

   

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Hair Loss Causes and Conditions
By John P. Cole, MD

There are many causes of hair loss in men and women, including disease, nutritional deficiency, hormone imbalance, and stress. However, by far the most common cause is what is called adrogenetic alopecia. Alopecia is simply the medical term for hair loss. Androgenetic refers to the fact that both a genetic predisposition to balding, and the influence of androgens, or male hormones, play a part in this type of hair loss.
In fact, there is a third factor, which is the passage of time, or aging. In other words, in order for androgenetic alopecia to occur, there must be:

* a genetic propensity for balding
* the presence of androgens, or male hormones
* enough aging time to allow the first two factors to exert their influence on the hair follicles

Genetics

Genetics is not always simple, and such is the case with balding. Just the presence or absence of balding in one’s parents or grandparents, on either the mother’s or father’s side, is not necessarily predictive of one’s likelihood of balding. Certainly, if a man’s father is completely bald, and this man begins to rapidly lose hair in his early twenties, it’s a safe bet that he will develop extensive balding at some point. In short, it’s very hard to accurately predict who will go bald and how rapidly.

This inherent uncertainly about the progression of balding is of utmost importance in planning surgical hair restoration, as we will see in later sections. We must always plan for a "worst case scenario" in order to give patients the best possible results in the long term, as well as in the short term. Anything less is irresponsible.

Androgenic Hormones

All normal men and women produce "male" hormones. The most common of these are testosterone, androsteinedione, and dihydrotestosterone (DHT). Androgens are produced by the testicles and adrenals in men, and by the ovaries and adrenal glands in women. These hormones are quite important in both sexes, but occur in different concentrations, being much more predominant in males than in females. This, in part, is responsible for the typical differences between the genders.

It is the exposure of the hair follicles to DHT, in a genetically susceptible person, over a period of time, which leads to androgenetic alopecia, or male and female pattern baldness. How does this exposure to DHT occur?

In certain cells of the hair follicle, and in the sebaceous glands, there are high levels of an enzyme called 5-alpha-reductase. What this enzyme does is to convert testosterone, which is delivered to these areas by the blood, into DHT. This is important not only in understanding the mechanisms of balding, but also one medical treatment now available: Propecia (finasteride). What Propecia does is inhibit, or limit the activity of, this 5-alpha-reductase enzyme. Therefore, there is less conversion of testosterone to DHT, and lower levels of DHT are found in the follicle. In later sections, we will discuss this and other medical treatments in much greater detail.

Aging

There is no set age at which balding occurs. It is a process, and this is a simple, but oft-ignored fact. Like any process, it can be rapid or slow, it can begin toward the end of life or in the late teens, and it can progress in a predictably inexorable fashion, or it can stop and start, seemingly stabilize, and then begin again. Once we understand and accept this as a dynamic process, then we can better plan for the present and for the future in terms of how we treat it. This quest for understanding, which you have begun just by opening this book, will do more than all the despairing thoughts, hand-wringing, and self-pity, toward allowing a clear-eyed, rational, long term approach to the problem of hair loss.

So we now have looked at these three interdependent factors that play into the common types of balding. Again, they are: hormones, genetics, and Father Time. So what exactly does happen to the hair? Let’s take a look.

Assuming we have a genetically predisposed person, then as the follicles are continuously exposed to DHT, an interesting phenomenon occurs. Remember the anagen phase, or active growth phase of the hair? This phase becomes gradually briefer and briefer, and eventually the hair becomes finer and shorter, and less deeply colored. We call this "miniaturization" of hairs. This is also the point at which hair loss tends to first be noticed. It’s not that there are fewer hairs on the head, but that their caliber (cross-sectional area), color and length are so diminished that they no longer provide "coverage" for the scalp beneath. Light penetrates through to the shiny scalp, and this is perceived by the observer as "thinning" or balding.

Also, the ratio between hairs in the anagen phase and those in the telogen, or resting phase, is increased. This simply means that, at any given time, an increased number of hairs are in the telogen phase. These extra numbers of telogen hairs will be found in the susceptible zone for common balding, which is the front, top, and crown of the head. The so-called "permanent" zone, the familiar horseshoe-shaped wreath of hair around the back and sides, is unaffected by these changes. The telogen hairs are easily dislodged during washing, drying, or combing, and this is the second sign of balding: in addition to the apparent thinning seen with miniaturization, we begin to see larger numbers of hairs on the comb, the towel, the pillowcase, or in the bathroom drain. This can be quite traumatic, especially for the younger man or for women. In the next section, we will discuss the natural history of balding, that is, the way it first presents or appears, the different ways it progresses, and how it affects the different regions of the head.

For the sake of completeness, let’s briefly mention some of the other patterns of hair loss, if only to distinguish them from androgenetic alopecia (male and female pattern baldness). There is alopecia areata, where discrete patches of scalp go bald; triangular alopecia, which tend to occur in a triangular pattern in the temporal area; alopecia universalis, in which the entire body may be affected; and various "toxic" alopecias, including those following a severe illness, sometimes with high fever, or following pregnancy. Toxic alopecias may also occur with low thyroid and/or pituitary gland function, or following chemotherapy. The cicatricial (scarring) alopecias occur following tissue destruction and inflammation.

Also seen are the so-called diffuse alopecias (patterned and un patterned), in which there is widespread thinning that may affect the "permanent" zone as well as the areas vulnerable to balding. In any or all of these less common types of balding above, it may be necessary to have a complete physical and laboratory workup, possibly including scalp biopsy.

So again, the common types of balding are directly related to the presence of male hormones in a genetically predisposed person over time. This can occur in both men and women. The process involves progressive miniaturization of the terminal hairs, and diminished length of the active hair growth cycle. Now, let’s take a look at how this microscopic, cellular process is manifested on the head; we can call this the natural history of balding.   <Above>

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Hair Loss - Why?
By Bradley Wolf, MD

Though humans no longer make use of hair for protection, heat retention, or camouflage, it still remains a very important means by which individuals display and are recognized. Appropriate appearance and grooming are still very important in social organization and the human relationships.
The human body contains approximately five million hair follicles while the scalp (prior to any kind of hair loss) contains 100,000 - 150,000 hair follicles. Blondes have the greatest number of scalp follicles, followed by brunettes. Humans with red hair have the fewest number of scalp follicles. The normal growth rate of scalp hair is one-fourth to one-half inch per month.

THE NORMAL HAIR GROWTH CYCLE

It is important to understand the normal hair growth cycle to understand why hair loss occurs. The hair follicle is an anatomical structure which evolved to produce and extrude (push out) a hair shaft. Hair is made up of proteins called keratins. Human hair grows in a continuous cyclic pattern of growth and rest known as the "hair growth cycle". Three phases of the cycle exist: Anagen= growth phase; Catagen=degradation phase; Telogen= resting phase. Periods of growth (anagen) between two and eight years are followed by a brief period, two to four weeks, in which the follicle is almost totally degraded (catagen). The resting phase (telogen) then begins and lasts two to four months. Shedding of the hair occurs only after the next growth cycle (anagen) begins and a new hair shaft begins to emerge. On average 50-100 telogen hairs are shed every day. This is normal hair loss and accounts for the hair loss seen every day in the shower and with hair combing. These hairs will regrow. Not more than 10 percent of the follicles are in the resting phase (telogen) at any time. A variety of factors can affect the hair growth cycle and cause temporary or permanent hair loss (alopecia) including medication, radiation, chemotherapy, exposure to chemicals, hormonal and nutritional factors, thyroid disease, generalized or local skin disease, and stress.
Androgens (testosterone, dihydrotestosterone) are the most important control factors of human hair growth. Androgens must be present for the growth of beard, axillary (underarm), and pubic hair. Growth of scalp hair is NOT androgen-dependent but androgens are necessary for the development of male and female pattern hair loss.

MALE PATTERN HAIR LOSS (Androgenetic Alopecia)

It is estimated that 35 million men in the United States are affected by androgenetic alopecia. "Andro" refers to the androgens (testosterone, dihydrotestosterone) necessary to produce male-pattern hair loss (MPHL). "Genetic" refers to the inherited gene necessary for MPHL to occur. In men who develop MPHL the hair loss may begin any time after puberty when blood levels of androgens rise. The first change is usually recession in the temporal areas, which is seen in 96 percent of mature Caucasian males, including those men not destined to progress to further hair loss. Hamilton and later Norwood have classified the patterns of MPHL (See Norwood-Hamilton Scale). Although the density of hair in a given pattern of loss tends to diminish with age, there is no way to predict what pattern of hair loss a young man with early MPHL will eventually assume. In general, those who begin losing hair in the second decade are those in whom the hair loss will be the most severe. In some men, initial male-pattern hair loss may be delayed until the late third to fourth decade. It is generally recognized that men in their 20’s have a 20 percent incidence of MPHL, in their 30’s a 30 percent incidence of MPHL, in their 40’s a 40 percent incidence of MPLH, etc. Using these numbers one can see that a male in his 90’s has a 90 percent chance of having some degree of MPHL.
Hamilton first noted that androgens (testosterone, dihydrotestosterone) are necessary for the development of MPHL. The amount of androgens present does not need to be greater than normal for MPHL to occur. If androgens are present in normal amounts and the gene for hair loss is present, male pattern hair loss will occur. Axillary (under arm) and pubic hair are dependent on testosterone for growth. Beard growth and male pattern hair loss are dependent on dihydrotestosterone (DHT). Testosterone is converted to DHT by the enzyme, 5a -reductase. Finasteride (Propecia) acts by blocking this enzyme and decreasing the amount of DHT. Receptors exist on cells that bind androgens. These receptors have the greatest affinity for DHT followed by testosterone, estrogen, and progesterone. After binding to the receptor, DHT goes into the cell and interacts with the nucleus of the cell altering the production of protein by the DNA in the nucleus of the cell. Ultimately growth of the hair follicle ceases.
The hair growth cycle (see "The Normal Hair Growth Cycle") is affected in that the percentage of hairs in the growth phase (anagen) and the duration of the growth phase diminish resulting in shorter hairs. More hairs are in the resting state (telogen) and these hairs are much more subject to loss with the daily trauma of combing and washing. The hair shafts in MPHL become progressively miniaturized, smaller in diameter and length, with time. In men with MPHL all the hairs in an affected area may eventually (but not necessarily) become involved in the process and may with time cover the region with fine (vellus) hair. Pigment (color) production is also terminated with miniaturization so the fine hair becomes lighter in color. The lighter color, miniaturized hairs cause the area to first appear thin. Involved areas in men can completely lose all follicles over time. MPHL is an inherited condition and the gene can be inherited from either the mother or father’s side. There is a common myth that inheritance is only from the mother’s side. This is not true.

In summary, male pattern hair loss (Androgenetic Alopecia) is an inherited condition manifested when androgens are present in normal amounts. The gene can be inherited from the mother or father’s side. The onset, rate, and severity of hair loss are unpredictable. The severity increases with age and if the condition is present it will be progressive and relentless.

FEMALE PATTERN HAIR LOSS (Androgenetic Alopecia)

Female pattern hair loss (FPHL) differs from male pattern hair loss (MPHL) in the following ways. It is more likely to be noticed later than in men, in the late twenties through early forties. It is likely to be seen at times of hormonal change, i.e., use of birth control pills, after childbirth, around the time of menopause, and after menopause. Recession at the temples is less likely than in men and women tend to maintain the position of their hairlines. Like in men, the entire top of the scalp is the area of risk. In women there is generally a diffuse thinning throughout the area as opposed to thinning in the crown of men. Ludwig has classified hair loss in women into three classes. (See Ludwig Classification) The vast majority of women affected fall into the Ludwig I class.

In the United States it is estimated that 21 million women are affected by FPHL. The incidence in women has been reported to be as low as eight percent and as high as 87 percent. It does appear to be as common in women as in men. The hair loss in women becomes particularly notable in menopause.
Androgens are responsible for hair loss in women by the same mechanisms they cause hair loss in men. Women do produce small amounts of androgens by way of the ovaries and adrenal glands. Also prehormones are produced by the ovaries that are converted to androgens outside of the ovaries or adrenal glands. Women rarely experience total loss of hair in an area if the loss is due to FPHL. If they do they should be evaluated for an underlying pathological (disease) condition. In women, the process of miniaturization of the hair follicle is more random with some hair being unaffected. Normal thick hairs are mixed with finer, smaller diameter hairs. The end result is a visual decrease in density of hair rather than total loss of hair. The hair growth cycle is affected as in men. The growth phase (anagen) is shortened resulting in shorter hairs and the resting phase (telogen) is increased resulting in fewer hairs.

If the cause of hair loss is suspected to be abnormally elevated or decreased amounts of hormones the patient should undergo laboratory tests to measure hormone levels.    <Above>

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HAIR TRANSPLANTATION ARTICLES

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Creating a Natural Hairline In One Session
By Ron Shapiro, MD

INTRODUCTION

Creating a natural hairline is one of the most important elements of a successful hair transplant. Our ability to create naturalness has dramatically increased in recent years due to the development of more refined techniques. The "degree" of naturalness expected by patients has also increased along with our abilities. Today, patients expect an undetectable hairline that can stand on its own after one session; they will no longer tolerate an embarrassing grafty phase. This high "degree" of naturalness can be achieved using the techniques and the methods described below.

KEY CONCEPTS IN CREATING A NATURAL HAIRLINE

Use Specifically "Follicular Unit" Micrografts

Most physicians will say that only micrografts should be used in the hairline area. However this statement is not specific enough since all ‘micrografts’ are not the same. "Follicular unit" micrografts are the ultimate microgafts for the hairline area because they have specific characteristics that enable them to achieve the highest degree of naturalness on a consistent basis. Follicular unit micrografts are trimmed of as much excess tissue and epithelium as safely possible and are therefore smaller than untrimmed micrografts with equivalent numbers of hairs. Their small size enables them to be placed in tinier, less traumatic incisions closer together.

Additionally, the minimal amount of epithelium left on follicular unit's limits the potential for pitting, which can still occur when untrimmed micrografts, placed too deep.

Conceptualize A Larger Total Hairline Area

Most discussions about hairline focus only on the first .5-1 cm anterior border of the hairline, commonly referred to as the "transition zone". In contrast, I conceptualize the hairline as a larger, 2-4 cm area bridging the bald forehead to the mid frontal region. This larger area is divided into two smaller zones. The anterior portion, or" transition zone" should be soft and irregular. The posterior portion, or "defined zone" should be more defined and dense. Both these zones are important to the overall appearance of the hairline.

The "Transition Zone"

The transition zone, consisting of the first .5-1.5 cm of the hairline, should be irregular and ill defined. Only 1 hair follicular units should be used in this area. The greater the degree of hair loss the wider and more diffuse this "transition zone" should be, mimicking the pattern found when more sever hair loss occurs in nature. A natural tendency to "fill in the spaces" in this area must be overcome to prevent a too straight or solid appearing hairline. A systematic method that aids in accomplishing this goal is described later in the text.

The "Defined Zone"

The "defined zone" is a two to three cm wide area that sits directly behind the "transition zone". In this is the area the hairline should develop a higher degree of definition and density, yet still have the highest degree of naturalness under close examination. Concentrating 2-3 hair follicular units this area accomplishes both goals nicely. Density in the defined zone contributes to the illusion of a fuller looking hairline by limiting the distance that can be seen past the transition zone. It does this without placing hair directly in the transition zone thereby limiting the chance of creating too straight or solid an appearance.

Separate and Distribute Specific Size Follicular Units in Specific Locations

Separating and selectively placing 1, 2, and 3 hair follicular units allows us precise control over the distribution of hair density and naturalness. The transition zone should contain primarily 1 hair follicular units. Finer one hair grafts are separated and placed in the most anterior portion of this zone Larger 2-3 hair follicular units should be placed in the defined zone, concentrating the 3 hair follicular units in the mid central portion of this zone ( were the frontal tuft is usually located). Creating density in this frontal tuft area has a high aesthetic impact, contributing a greater illusion of density overall and mimicking a pattern commonly found in nature.

Use A Larger Number Of Follicular Unit Micrografts in the First Session

Sufficient numbers of micrografts should be placed in the first session to ensure that the hairline will be natural and have enough substance to stand on its own independent of further sessions. This effect begins to occur when micrografts are place an average of 1-2 mm apart (or about 20-30 micrografts per square cm). This calculates to be about 500-700 follicular units placed in the total hairline area ( combined transition zone and defined zone) during the first session. Higher degrees of dense packing (30-40 micrografts per square cm) are possible with today’s techniques but the temptation to place grafts this close together in the hairline zone should be resisted. Otherwise the hairline area could become denser than the central region and give an abnormal ring like effect when viewed from above. In nature the hairline zone is always less dense than the central region.

Do Not Place The Hairline Too Low

The hairline should be placed at a level appropriate for the severity of baldness. Standard rules for determining hairline placement have the potential of placing it too low, especially in patients with more severe degrees of hair loss. In these patients, raising the hairline by as much as 1-2 cm may be appropriate.

Preserve A Soft Frontal-Temporal Angle

The normal angle formed by the juncture of the frontal and temporal hairlines needs to be preserved. It should not be cut off or blunted. It should be soft and ill defined. The apex of this angle needs to be positioned further back in patients with more severe degree’s of hair loss. It is important to pay attention to the change in direction and elevation of grafts positioned around the apex of this angle.

TECHNIQUE

Planning And Drawing the Hairline Zones

Mark 3 important reference points: 1) The mid-anterior border of the hairline (point X),

and 2) Both frontal- temporal angles (points Y). The mid-anterior border of the hairline (point X) is about 8-10 cm above the glabella and usually at the point were the forehead changes from horizontal to vertical. The frontal-temporal angles (points Y) are located with the help of 2 reference point lines. Line 1 is a vertical line drawn from the lateral epicanthis. Line 2 is a vertical line about 1 cm in front of the auditory meatus. The intersection of these 2 lines is a good starting point for the apex of the frontal-temporal angle. These rules give good approximations for the location of these reference points but may need to be adjusted posteriorly or anteriorly depending on the severity of hair loss.

After the reference points are marked, draw 3 lines that demarcate the proposed "transition zone" and "defined zone" . Line A is the connection of the 3 points described above. It is the most anterior border of the transition zone. Check for symmetry of this line by using a mirror. Line B is drawn about .5-1 cm behind Line A. It is the anterior border of the defined zone. Line C is drawn about 2 –3 cm behind Line B. It is the posterior border of the define zone.

Mark off an area in the central part of the defined zone for the possible placement of 3 hair follicular units.

Making The Incisions

A key principle when creating an irregular, soft transition zone is to start with the defined zone and then move to the transition zone. First "marking" incisions are made along the anterior border of the hairline (Line A.) These incisions should be about 1 cm apart and slightly irregular. Placing some in front and some behind the line helps create the irregularity. These marks ensure you will not lose the position of the hairline and allows you to safely move to the anterior portion of the defined zone (Line B) Incisions in this zone are placed in a staggered pattern about 1-1.5mm apart creating organized disorder (Unger). When small grafts are placed this close together the eye does not recognize this as a pattern. This is preferable to random placement which can lead to skipped areas and uneven distribution of density.

After the "defined zone" has been established the following technique is used to methodically create a framework for the "transition zone". Incisions are made that create multiple triangular shaped bridges between the defined zone and the anterior border of the transition zone. The shape of each bridge resembles an elongated triangle and contains about 6-10 incisions. The tips of these triangles are the original marking incisions that were made on the anterior border of the "transition zone". The base of these triangles extends into the "defined zone". When this is finished a framework has been created for an irregular pattern in the transition zone. This pattern has been described as resembling the rays of a sun that become less intense as they radiate through the "transition zone". (Zupan)

After creating this framework artistic skills are used for fine-tuning. Several more passes are made through this "transition zone" filling in obvious spaces but keeping the same general pattern and being careful not to get rid of the irregularity.

Selective Placing

Grafts are cut under a microscope. The 1.2.3 hair grafts are separated into different petrie dishes to facilitate selective placing. In addition assistants are instructed to look for and isolate finer 1 hair grafts for the most anterior portion of the hairline (sentinel hairs). 1 hair grafts are used in the "transition zone". A shift is made to 2 hair grafts at the "defined zone". 3 hair grafts are used in the mid central portion of the "defined zone"(the frontal tuft area).

Frontal Temporal Angle

It is important to pay attention to the change in direction and elevation of grafts positioned around the apex of the frontal temporal angle. Incisions become more lateral and lie flatter. Incisions in the temporal point hairline should lie flat and have a more posterior direction.

Final "Stick and Place" Fine Tuning

About 100 grafts are usually saved for the end of the procedure to further fine-tune the hairline. Look at the hairline and "stick and place" these extra grafts at points where they are needed. One hair grafts are put in the transition zone if needed. If the transition zone is satisfactory then the one hair grafts are paired to create 2 hair grafts and placed in the defined zone. Once again it is best to concentrate more grafts in the frontal tuft region because density in this region is crucial to an aesthetically pleasing affect.

CONCLUSION

The principles and techniques outlined in this paper will help Physician meet the expectations of today’s patients. We can now establish a natural hairline during the first surgery that can stand on its own independent of further sessions. It is not enough to "just use micrografts". Proper selection and use of follicular units, combined with artistry and skill, provide us with the tools to follow natures lead in creating deliberately irregular, soft hairlines, while establishing the illusion of density. <Above>

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Hair Transplantation In Women

Treating Female Pattern Hair Loss and Reparing The Distoration and Scarring From Prior Cosmetic Surgery
By Jeffrey S. Epstein, MD
 

• Abstract:
• Introduction:
• The Technique
• Results
• Discussion
• References
 

Author: Jeffrey S. Epstein, M.D., F.A.C.S.
Clinical Professor, University of Miami
Private Practice, Miami, FL
305.666.1774
305.666.6708 (fax)
jsemd@foundhair.com

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, 2002.

Abstract:
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 minimize complications.

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 patient satisfaction.
 

Introduction:
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 hair system.

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.
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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 increase density.
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Results
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 is presented.
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 frontal regions.
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.
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Discussion
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 system.

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 graft hairs.

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 DHEA-sulfate.
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REFERENCES
1. Halsner UE, Lucas MF. New aspects in hair transplantation for females. Dermatol. Surg. 21:605-610, 1995.
2. Ludwig E. Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex. Br. J. Dermatol. 97:247-254, 1977.
3. Brennan HG, Toft KM, Dunham BP, Goode RL, Koch RJ. Prevention and correction of temporal hair loss in rhytidectomy. Plast. Reconstr. Surg. 104:2219-2225,1999.
4. Holcomb JD, McCullough EG. Trichophytic incisional approaches to upper facial rejuvenation. Arch. Facial Plast. Surg. 3:48-53,2001
5. Leonard RT. Hair transplantation in patients following cosmetic facial surgery. Cosm. Dermatol. 33-35, May 2001.
6. Headington JT. Transverse microscopic anatomy of the human scalp. Arch. Dermatol. 120:449-456, 1984.
7. Bernstein RM, Rassman WR, Seager D, et al. Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques. Dermatol. Surg. 24:957-963, 1998.
8. Stough DB, Bondar GL. The Knudsen nomenclature: standardizing terminology of graft sizes. Dermatol. Surg. 23:763-765, 1997.
9. Juri J, Juri C, deAntueno J. Reconstruction of the sideburn for alopecia after rhytidectomy. Plast. Reconstr. Surg. 57:304-308, 1976.
10. Barrera A. The use of micrografts and minigrafts for the correction of the postrhytidectomy lost sideburn. Plast. Reconstr. Surg. 102:2237-2240,1998.
11. Barrera A. The use of micrografts and minigrafts for the treatment of burn alopecia. Plast. Reconstr. Surg. 103:581-584, 1999.
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Recreating The Crown Whorl
By Robert H. True, MD

A great hair transplant can accomplished when the surgeon is able to appreciate and reproduce the subtle variations in the architecture of the hair on different parts of the scalp. Appropriately, much has been written about reconstruction of the hairline zone, as it is widely appreciated that this is critical to achieving a "natural" result. Although written about much less frequently, reconstruction of the crown whorl is of nearly equal cosmetic importance.

All people naturally have a whorl or cowlick in their hair on the crown of the head. The whorl is usually located off center to the right side, however there are many variations in location and some people even have two whorls.
The whorl is a spiral in which the hair direction changes 360°. The hair on the front of the scalp is generally oriented forward. The hair direction begins to turn toward one side on the mid portion of the scalp, and on the back (tonsure) the hair faces toward the rear. The whorl is the center of this critical change in hair direction. Its spiral actually extends to involve the majority of the crown of the scalp. For most patients the whorl is actually 4 to 5 inches in diameter.

Not only does the hair change direction 360° in the whorl, the angle at which the hair emerges from the scalp decreases. Thus, the hair does not stand straight up in the center. Rather, it lays flat along the curved contour of the crown. In some ways, reproducing the correct spiral angle while at the same time creating the appropriate "flatness" angle is more technically demanding for the surgeon than a hairline

Recreating the whorl is essential to treating crown baldness. A well constructed whorl is as much a credit to the surgeon's art as an elegant hairline. Both must be approached with equal finesse and have comparable cosmetic value.
The center of the whorl requires single hairs just like edge of the hairline. The receptor sites must properly rotate in the spiral and be properly angled across the curve of the scalp to make the hairs lie flat to the scalp.

Because it is rarely possible to reproduce high density in a crown restoration, it is critical to use only microscopically prepared single follicular unit grafts. Thus with lower density there will be no "plugginess" or unnatural appearance.
Some transplant surgeons will not treat the crown, arguing that the limited donor supply is best focused on the front. However, this is a necessity only for patients with an exceptionally limited donor supply. Most patients with advanced Class 5A to 6 baldness do have sufficient supply to treat some or the entire crown as long as the whorl is reconstructed. The whorl is necessary to produce the layering effect of hair upon hair required for cosmetic coverage.

The crown should not be treated without rebuilding the whorl. To do so would be like restoring the front without a hairline. I also believe that in cases where the doctor and patient make the decision to treat the front part of the balding pattern only, the result will look much better from the rear when the restoration has been carried back far enough that it includes the upper half of the whorl. When this is achieved, the hair drapes much better onto the crown.

Since the mid 1990's scalp reduction has fallen out of favor with hair transplant surgeons. One of the major problems with scalp reductions is that they change the hair direction in the crown, making the hair fall away from the middle of the crown. In other words, they eliminate the whorl. Moreover, it was very difficult to successfully recreate a whorl with transplants once reductions had been done. The center could not be placed in the correct location and the hair direction could not be matched to the remaining native hair on the margin of the scalp reduction.

Without scalp reductions, the size of the area remains large. However, because the native hair direction is reproduced in a carefully reconstructed whorl the cosmetic result is more natural and the coverage is comparable.

The decision about where to put the hair is one that needs to be explored thoroughly with each patient, It is possible to use up all of the donor hair in creating a very thick frontal restoration. At the other end of the spectrum the hair can be evenly distributed throughout the entire balding area in low to moderate density. Another choice is to treat the entire scalp, but place greater density in the front and top, lesser to the crown.

Special care must be taken when treating a young patient whose crown is just beginning to thin in the center. Further treatment will be needed as the balding progresses. Control can often be achieved with Propecia® and/or minoxidil preparations. However, even in these cases the surgeon has to anticipate future needs and make sure that an appropriate amount of the donor supply is retained to complete the crown restoration.

While some patients may choose partial restoration focused on the front and top only, those who want full head coverage or those who want the back edge of their frontal restoration to look natural, may achieve their goal in the hands of a transplant surgeon skilled in whorl reconstruction.  <Above>

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