When discussing hair loss and associated treatments, it is important that patients understand first of all, there are many causes of hair loss some are reversible, others are not. Hair loss can be divided into two general categories, scarring and non-scarring, and also several subcategories.
The scarring types of hair loss have origins either within the body (intrinsic causes) or external causes (extrinsic causes). The intrinsic types are believed to be related to inflammation of the scalp and hair follicles with symptoms such as itching, burning, scalp redness and patchy hair loss. Although they represent a small percentage of patients with hair loss, patients suspected of having a scarring alopecia should be seen and evaluated by a dermatologist. Diagnostic tests such as a biopsy, as well as other treatments, may be covered by insurance. They are considered a medical condition (some with autoimmune origins) and may affect disorders in other systems in the body and not just the hair. During its active phase, hair loss is ongoing and these patients are not appropriate candidates for hair restoration surgery. The medical therapies necessary to treat inflammatory and scarring alopecia are different than extrinsic causes of scarring.
When scarring is caused by trauma or external injury to the hair and scalp (traction from pony tails, hair extensions, corn rows, flat ironing, burns or chemicals), once the trauma has been eliminated and the scalp has healed, areas of hair loss can often be addressed with either hair transplantation or in some cases, scalp flaps. The latter requires particular surgical training and expertise and while flaps are more invasive, sometimes they are the best option. This underscores the need for a doctor to know the various types of hairloss and options for both medical and surgical treatment in order to inform the patient as to the best option to suit their needs and goals.
The most common non-scarring alopecia that is seen, as well as the most common reason for patients seeking surgery, is caused by genetic hair loss. This is known as male pattern hair loss or androgenetic alopecia (AGA). This can be relatively easy to diagnose in men who appear to have thinning or hair loss in a patterned distribution that involves the front and vertex or crown areas of the scalp. Such a pattern may not exist in women, or may be more diffuse, making the diagnosis more challenging since there are many causes of diffuse thinning.
Androgens refer to a category of hormones commonly associated with male characteristics that include testosterone and dihydrotestosterone (DHT). Even though androgens are thought of as male hormones, women also have androgens. In fact, skin and hair follicles are endocrine organs themselves, and can produce these hormones and use them inside the cell. When this occurs, they are not measurable with normal blood tests. This discovery was only made in the last decade so a doctor who is not a specialist in skin and hair may not yet be aware of this! Women still have less of the androgen hormones than men but the difference in androgen production between the genders is less than what has been believed in the past.
Androgens, or specifically dihydrotestosterone (DHT), impacts the hair follicle and causes it to stop producing hair in genetically predisposed people. This can happen over the course of one growth cycle or over the course of several growth cycles. At one point in time, doctors used to think that hair loss was genetically inherited only from the mother’s side. Doctors now know that both mom and dad can contribute genes and chromosomes that cause patterned hair loss in men and women. Interestingly, however, it is believed that the gatekeeper for this process is the androgen receptor gene which is on the X chromosome (from the mother). This gene interacts with other genes and other chromosomes to determine whether or not a person loses hair in their teens, 20s, 30s and so forth. This combination of genes also determines whether or not that pattern is a mild amount of hairline recession versus frontal or crown hair loss or a larger combination of both. Furthermore, evidence from twin studies suggests there are factors related to diet, lifestyle, or environment that may impact genetics to accelerate a genetic predisposition. These are known as epigenetic factors.
There are also other non-scarring causes of increased shedding and hair loss that specialists need to be familiar with in order to properly diagnose and treat a patient. Alopecia areata is an autoimmune process which causes patchy areas of hair loss that can be made worse by surgery. Areas of alopecia areata often resolve on their own in 6 months or they may require a little bit of steroid injection therapy. More severe cases may require aggressive immune suppression. Operating on patients with active alopecia areata has contributed to full blown alopecia totalis (all hairs on the head falling out!) which is a good reason to make sure the doctor knows how to recognize it and avoid operating on it when in its active phase!
Another non-scarring alopecia is caused by a condition called telogen effluvium. Every hair on the head goes through a growth cycle that consists of 3 phases called Anagen, Catagen and Telogen. The anagen phase is the active growth phase, and lasts from 2-6 years. Telogen is the rest phase of the hair growth cycle. Hairs can be pushed into their rest phase by a number of factors causing an abrupt cessation of the growth cycle and sudden increased shedding. Some of the causes of telogen effluvium include stress, illness, high fever, hormonal imbalance like thyroid disease, testosterone excess, elevated prolactin levels or (in women) estrogen suppression. Also, nutritional disturbances such as zinc deficiency, vitamin D deficiency and magnesium or selenium deficiency can contribute to hair shedding and thinning. When these factors are recognized and dealt with, hair may often regrow and surgery is not necessary. This again shows the importance of proper diagnosis and treatment of reversible causes of hair loss. In cases where there is underlying AGA, hairloss caused by these treatable conditions may accelerate an underlying genetic predisposition so that all of the hair loss in a case of telogen effluvium may not grow back even after the cause has been treated.
The key to proper treatment is, first and foremost, a proper diagnosis. Appropriate patient selection is critical for all forms of surgery and this is also true for hair restoration surgery.
There are different considerations that need to be kept in mind when making a treatment plan as previously noted. However, for the most common cause of hair loss, AGA, there are 2 FDA approved therapies which include topical minoxidil (Rogaine) and oral finasteride (Propecia/Proscar). Timing of starting medication is a critical determinant of successful response for many patients. For example, patients in the earliest phases of hair loss may have a lot of vellus hairs that are in the miniaturization process related to male pattern hair loss or androgenetic alopecia (AGA). These patients are most likely to be highly responsive to medications such as finasteride or topical Rogaine than patients who have already progressed to bare scalp. Topical Minoxidil (Rogaine) in select patients can take a miniaturized hair follicle and turn it back into a terminal hair follicle, but there are limitations to how much of that it can do. Once a hair miniaturizes smaller than a certain point, it will not be brought back by medical therapy. The best time to approach treatment of hair loss for androgenetic alopecia or male pattern hair loss is in the earliest phases. None of the medications listed above will repopulate lost hair follicles.
Topical minoxidil is a therapy that requires commitment. About 25 years ago, when the only FDA approved treatment for hair loss was a topical 2% minoxidil solution, the success rates were considerably lower. Visible response rates were in the neighborhood of 40-50% of patients. When topical minoxidil was approved as a 5% foam applied to both men and women, there was an increased percentage of patient responders. However, one of the reasons there are non-responders is the fact that minoxidil must be converted to its active form (minoxidil sulfate) inside the hair follicle. This requires an enzyme called sulfotransferase. Patients produce different amounts of that enzyme in their hair follicles. Therefore, some patients who do not produce sufficient amount of sulfotransferase will not be able to convert minoxidil into its active form and cannot respond to its hair growth promoting properties.
Topical Minoxidil has been labeled as inconvenient for some men because it has to be applied twice a day, every day. Women can apply the 5% foam once a day at night before they go to bed. However, there are a significant number of patients who complain about scalp redness, itchiness and allergic reactions. These problems have been reduced with the foam. Some patients will develop something called hypertrichosis or facial hair if they absorb a sufficient concentration into the blood stream. This is more likely to occur with a higher concentration.
Oral finasteride has a much higher level of compliance for the patients who choose to use it. It is a lot easier to just take a pill. It is a very flexible medication meaning that if a patient takes it most of the time, they will continue to get the benefits from it. Studies indicate a response rate of 85-90% of men will stabilize their hair loss and, according to the Merck studies, about 66% will have visible regrowth. Missing a day here or there does not seem to impact its ability to help preserve hair follicles. Patients must be aware that despite a small percentage of patients who report side effects, the vast majority of men who use it tolerate it well. It continues to receive FDA approval as a safe and effective treatment for hair loss in androgenetic alopecia.
Aside from cosmetic options such as wigs, hair systems or scalp colorants, the only way to treat areas where hair loss has already occurred is with surgery and hair transplantation.
Follicular unit is a term used in the hair restoration field, to refer to the naturally occurring hair bundles on the scalp. Hair bundles contain 1-4 hairs and are the unit important in donor harvesting as well as graft creation and placement. If those naturally occurring hair bundles are taken from the back and sides where the hairs are genetically more permanent, they maintain that characteristic wherever they are implanted. Depending on the extent of patterned hair loss destined to occur in a given patient, the “safe zone” for hairs that will be permanent throughout life can vary in size. This means that young men who are destined for more extensive hair loss may have a much smaller safe zone at age 45 than is noticeable at age 25. Caution and expertise are needed to avoid redistributing non-permanent hairs. The redistributed hair can recreate natural appearing coverage. However, it is important to understand that surgeons are typically dealing with a much smaller numbers of hairs than what nature originally gave the patient.
Donor harvesting refers to the surgical technique used to remove hair from the permanent hair bearing areas of the scalp in preparation for redistributing them to areas of hair loss. There are two methods of donor harvesting. One is called follicular unit extraction which involves the removal of individual follicular units by incising them with a small micro punch and then gently tugging or extracting them from the underlying fatty tissue. This produces individual grafts which will be reimplanted to areas of hair loss and also produces a diffuse distribution of small micro holes in the scalp that are open at the end of surgery and heal into a small round dot of scar on the scalp. These dots are very easy to camouflage even with short hair styles.
The other method involves removing a full thickness strip of hair with the follicles to be dissected into individual grafts using microscopes. The follicular unit grafts will then also be reimplanted into the area of hair loss. The difference with the strip is that all of the hair and skin is taken out by doing a full thickness excision of a strip of hair from the back and sides of the head. This excision is closed with sutures and leaves a linear scar. This technique was designed to take advantage of the high density of hairs in what is considered to be the safe zone or the hairs that are typically predetermined to be permanent hairs.
Patients who are trying to learn about their options for hair restoration surgery need to understand that Follicular unit extraction (FUE) is a method of donor harvesting and does not refer to the technique used to implant the grafts. FUT (follicular unit transplantation) is something of a misnomer because every technique used today for hair restoration involves the use of follicular unit grafts for transplantation. Nevertheless, FUT has been coined as the acronym to refer to the donor harvesting method of strip removal with microdissection
Patients may decide on a particular donor harvesting method based on a desire to wear their hair nearly shaved while others prefer the strip option in order to insure a high density of grafts from the “safest zone” of permanent hairs.
All surgical procedures include risks of infection, bleeding and scarring. The risks of infection or serious bleeding for hair transplantation techniques are less than 1% for appropriately selected patients. Scarring occurs with all surgeries but some patients have a greater risk for certain types of scarring.
Experienced hair restoration specialists have some concerns about the FUE procedure being performed on younger males (especially in the hands of inexperienced practitioners). These patients, if not stabilized on medical therapy, may very well progress to more extensive patterns of hair loss. It is disadvantageous for them to have hairs extracted from fringe areas of their donor hair (the very top or the very bottom). Responsible FUE doctors will try and avoid areas they think are likely to become non-permanent over the course of time. Inexperienced personnel may focus on obtaining the planned number of grafts and not on the permanence of the grafts.
The potential for progressive hair loss in patients with androgenetic alopecia is always a point of consideration for patients under the care of a hair restoration specialist. Finasteride and minoxidil may help mitigate or stabilize hair loss progression but this is not guaranteed. However, it is not known whether or not a given patient will stay on finasteride or whether these medications will be effective 10 or 15 years after surgery. Hair loss progression, to some degree, should be considered in any plan for hair restoration.
It is important for patients to contemplate not just what happens in the donor area but what happens in the recipient area where the grafts are placed! When patients come in with a small amount of hair loss in their hairline and they decide to recontour and fill in the frontal areas of hair loss, they need to commit to some type of medical stabilization with medication. If they do not take medication they will most likely need to plan on further surgery in the future to maintain their cosmetic appearance. Choosing a doctor who plans for the future is a key element in hair transplant surgery.
Recovery time for graft healing is approximately 3-5 days in order to allow a blood supply to grow into the new grafts. The grafts are very fragile to external trauma during this time and patients should plan to be relaxed to allow time to heal. By that point, a patient can feel confident that no casual brushing against their scalp will dislodge the grafts. The skin is healed over the top and the grafts are settled in place. By 7 days after surgery, they are healed in place and normal activities can be resumed.
The recovery time for the FUE donor harvesting technique is 5-7 days. Since a patient has thousands of small micro holes on their head after a follicular unit extraction procedure, it takes time for those holes to fill in and is somewhat variable from person to person.
The difference for the FUT/strip type of donor harvesting procedure is that the stiches are taken out one week after surgery. Although the incision is sufficiently well healed to remove the stitches, patients have only a fraction of the normal tensile strength of the skin so they should avoid exercises or activities that directly pull on the incision while they are healing.
Patients need to do their research and make sure their doctor is properly trained and legally licensed. A serious problem in the field has been spreading globally in recent years. The work that hair restoration specialists have performed in order to create remarkable surgical results has been misappropriated by some unlicensed people who do not have full knowledge, education or experience to make medical decisions or perform surgery. Currently the unlicensed practice of medicine and hair restoration surgery is occurring. Some doctors with really excellent credentials are purchasing medical devices and then delegating the surgery to a technician. In some cases, the patient sees a glossy advertisement and is attracted to a doctor because they have excellent credentials. However, they are not operated on by the doctor. Patients are paying good money to see a doctor and deserve to be operated on by a licensed medical practitioner. The International Society of Hair Restoration Surgery (ISHRS) is actively supporting policies to encourage doctors to not inappropriately delegate surgery to unlicensed medical assistants. The ISHRS is also encouraging lawmakers and regulators to protect patients from this unsafe and unfair practice. Hair restoration surgery in well trained and experienced hands is safe and effective. Patients should ask their doctor who will be performing their surgery, and be sure it is the doctor!
Written by Cosmetic Town Editorial Team- MA
Based on an exclusive interview with Sharon Keene, MD in Tucson, AZ