Hair Restoration for Men

I am losing my hair.  How common is this?

Loss or thinning of hair is a common complaint amongst men.  In fact, it is not unusual to have patients complain of hair loss as early as 20 years of age. Approximately 2 out of 3 men experience hair loss to the degree that they would consider medical or surgical treatment.

I am losing my hair.  How common is this?

Loss or thinning of hair is a common complaint amongst men.  In fact, it is not unusual to have patients complain of hair loss as early as 20 years of age. Approximately 2 out of 3 men experience hair loss to the degree that they would consider medical or surgical treatment.

What causes hair loss in men?

The most common cause of hair loss in men is a process called Androgenic Alopecia, which means Male Pattern Baldness.  The reason for this name is that the cause of this pattern of baldness is the interaction of testosterone (typically associated as a male hormone) with the hair cells in the forehead and temple regions.  In some men who are genetically prone to this type of hair loss, the hair cells in the forehead and temple region will begin to thin and fall resulting in hair loss.  This type of hair loss is entirely genetic in origin and the extent of loss is determined by the pattern seen in the family.

How much more hair loss should I expect?

The natural progression of hair loss in men has been classified in seven stages by Dr. Norwood.  Class I is normal hair with no loss or thinning while class VII is the horseshoe hair loss pattern seen in some men.  It is important to realize that about 30% of men will progress to class VII hair loss pattern and that typically the best predictor of hair loss is the pattern seen in of ones male family members such as father or grandfathers.

Some of the other causes of hair loss can be classified as infectious such as tinea capitis (fungal infection of the scalp), autoimmune (immune system attacks the hair follicles) such as alopecia areata or traumatic such as seen after surgery or burns.  Each of these conditions are treated differently and thus would need to be appropriately diagnosed.

Norwood Classifications

Class I: This group is considered to have no thinning or loss of hair and thus does not require any treatment.  Early hair loss in this stage can be slowed or reversed with topical or oral medications.

Class II: This group begins to have some hair loss along the frontal temporal area.  Oral or topical medications can slow or even reverse some of the hair loss in this stage.  Some individuals, depending on age, family history, pattern of hair loss, and quality of the hair, can benefit from hair transplantation procedures.

Class III: The hair loss along the frontal temporal area is increased in this group and some thinning or loss of hair along the vertex or crown of the scalp can be noted.  Again depending on age, family history, pattern of hair loss and quality of the hair, these individuals can be candidates for hair transplantation.

Class IV: This group has significant recession of the frontal temporal hairline with increase loss of hair in the vertex region resulting in the “bald spot” appearance.  At this stage several options including surgical and artificial hair restoration could be utilized to gain improvement in appearance.  This will again depend on age, family history, pattern of hair loss and quality of the hair.

Class V: This group has further recession of the frontal and temporal hairline as well as increase in the balding of the vertex.  There might be a thin island of hair between the two regions but this will quickly recede and a connection between the two regions will appear resulting in the early horseshoe pattern of hair loss.  Some individuals can benefit from artificial hair restoration.  For most, surgical hair restoration in form of grafting can be very beneficial.  Other procedures such as flaps and scalp reduction could be combined to achieve optimal results.  Again this will depend on age, family history, pattern of hair loss and quality of the hair.

Class VI: This group has very severe hair loss with balding of the frontal and vertex region.  Most in this group can benefit from artificial hair restoration in form of a hairpiece.  Some can undergo surgical restoration with combination of flaps, grafts and scalp reduction procedures.

Class VII: The individuals in this group have significant loss of hair and only a thin band of hair remains in a horseshoe pattern.  Surgical hair restoration is not an option in this group while artificial hair restoration in the form of a hairpiece is the best tool available today.

What are the indications for hair transplantation?

The indications for this procedure are thinning of the hair, hair loss or hair loss due to injury.

What does hair transplantation accomplish?

This procedure redistributes the hair from the back of the head to the balding areas.

What is the recovery time associated with this procedure?

Typically it takes about one week before one can return to normal work.

Is everyone a candidate for hair transplantation?

Most people will be a candidate for hair transplantation, however, several factors need to be considered. These factors include but are not limited to age, pattern of baldness, family history and general health. This can be decided after a consultation with a hair transplant surgeon.

hair transplantation

Background:  It has long been known that the hair on the scalp that is oriented along a horseshoe pattern responds differently to the genetic factors and hormones that cause balding. As such if these hairs were transplanted over the areas of hair loss, they could retain this property and continue to grow.  This is the basis behind hair transplantation procedures.

Procedure: A strip of hair is usually removed from a donor site behind the head where hair cells are resistant to effects of hormones.  This area is then closed with sutures.  The strip of hair is then cut down to individual one, two or three hair follicular units.  This is careful work performed under magnification.  These follicular units are then transplanted in the skin of the balding area.

The most important part of the procedure is the planning of the implantation.  In order to obtain a natural hairline it is pivotal that the direction of the hairline, number of hairs transplanted and the orientation of the hairs are planned carefully.  The actual hairline on the scalp is not a line as one would think.  Instead it is a transition zone from the skin of the forehead to the scalp.  The hairs grow in a random pattern and become increasingly dense as one moves backwards on the scalp.  This natural random pattern and transition zone should be preserved, otherwise, the results would appear as though it was operated or fake.

The procedure is typically done as an outpatient procedure under mild sedation with local anesthesia.  The patient is asked to wash their hair the night before the procedure as well as the morning of.  Once adequately sedated, the donor hair is obtained as previously stated and the surgical team begins to divide the hair follicles.  They are then transplanted in the area of the balding scalp and once done covered with a turbine like dressing.  The dressing is changed the morning after surgery.

Recovery: Following the procedure, starting the next day and for the next 10 days the hair can be cleaned using hydrogen peroxide and allowing water to run over the area.  Patients are asked to sleep on their backs and with their head elevated for 2 weeks.  It is expected that by about 8 weeks after the procedure the newly transplanted hairs would have completely fallen off.  This is a normal progression of hair transplantation as the roots of the hairs remain in the scalp and new hair growth begins at about 3-4 months after the procedure.  This will continue and the full results are seen at about 6-8 months after the procedure. Hair transplantation can also be performed for scars as the result of injury, surgery or burns and is a great tool for camouflaging unsightly scars over the scalp or eyebrows.

Long Term Results:  The transplanted hair will continue to grow similar to normal hair and the results are permanent in most individuals. Depending on the amount of balding, follow up procedures might be necessary to increase the volume.  Typically this can be done anytime after 4 months has passed from the previous transplantation.  This will allow adequate blood supply to have reached the hair cells that were transplanted.

Scalp Reduction

Scalp Reduction:  For those men with class IV, V or even VI balding pattern, scalp reduction can result in significant decrease in the amount of balding.  This procedure can either eliminate the balding spot entirely or in a serial fashion, decrease the amount of balding so that fewer hair grafts would be needed to cover the spot and achieve a dense natural look.  The procedure is performed under local anesthesia or twilight sedation and superficial layer of the balding skin is removed.  The incision is then closed with sutures.  Area is cleansed with hydrogen peroxide 4-5 times a day and patients can wash their hair with non-irritating shampoo the next day.  Sutures are removed on day 8.  Combing or brushing of the area should be avoided in order not to disturb the incision.

Flaps:  Flaps are able to improve hair loss by being able to rotate a hair bearing skin over an area of baldness. The process is typically an outpatient procedure under twilight or general sedation.  Tissue from hair bearing parts of the scalp is then rotated in such a way not to distort the remaining hair and to fill the bald areas of the scalp.  Tissue clips are then used to close the incisions.  A drain is placed under the flap.  The drain is typically removed the next day and the clips are removed in 8-10 days.  Ice packs are applied to the area for 72 hours.  Patient sleeps with head elevated for 10-14 days.  Incision lines are cleaned with peroxide 4-5 times a day and patient can wash their hair with non-irritating shampoo the day after the procedure.  Combing or brushing of the area should be avoided in order not to disturb the incision.  Occasionally, a repeat or bilateral procedure is needed to cover the entire balding region.

Artificial Hair Restoration

Artificial Hair Restoration:  Artificial hairpieces (aka wigs, toupee) have been around for centuries.  The original hairpieces were glued or taped to the scalp resulting in easy dislodgement and embarrassment.  Today’s hairpieces utilize other mechanisms to attach to the scalp.  Some are connected via surgical wire or hooks.  These have increase risk of infection and some have been banned for use due to complications associated with them.  Others are connected via weaving of the hairpiece to the remainder of the natural hair that exists on the scalp.  This can result in further loss of hair due to tension that is being placed on the existing hair by the weaving process.

Water activities present a unique challenge to artificial hair restoration.  Although most hairpieces will remain on the scalp during water activity, exposure to water furthers the wear and tear of the hairpiece and decreases its lifetime.  If one is considering artificial hairpieces it is important to take into account the cost of the hairpiece as well as the cost of the maintenance that is associated with it.  Most likely two hairpieces would be needed in order to utilize one while the other is being serviced.  Essentially the cost of purchasing and maintaining a natural appearing hairpiece can match or by far exceed that of surgical hair restoration procedures.

Medications:  Several herbal, over the counter and prescription medications exist for management of hair loss.  The herbal or “natural” medications might work in some instances; however, their efficacy and side effect profile is not thoroughly researched, as would be the case with other medications.  In most cases the actual results are not similar to the advertised results.  FDA approved over the counter and prescription medications are available for medical management of hair loss.

For the most part, individuals who will benefit from these types of treatment are younger individuals who have noticed new onset of balding or thinning of the hair but have not lost any significant amount of their hair.  In these cases topical medications can help cease further hair loss while oral medications can cause re-growth of some of the lost hair.  These medications do carry limitations.  Once on this medication, it must be continued for life or any improvement would quickly dissipate once the medication is terminated.  Further more, the oral medications available are not approved for use in females.  Males with pregnant partners are asked to refrain from using these oral medications and pregnant females are cautioned against handling of these medications.