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

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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