Published Article Excerpts of: Hair Transplant Surgery by M. E. Tessler Originally published in "Recent Advances in Plastic Surgery", Vol. 5 Introduction Who Should Be Transplanted And When? Physical characteristics The donor area Treating 'early baldness' Conclusion Introduction Hair replacement surgery is one of the most rapidly evolving areas of cosmetic surgery. Greater numbers of balding men and women are opting for a surgical solution. Hair replacement meetings and seminars enroll record numbers of attendees because of an increasing demand by surgeons to learn the specialty. This is largely attributable to the recent advances in technology, specifically follicular unit transplantation. The concept of utilizing smaller grafts in hair replacement surgery has reached a new plateau. Initially, one- and two-hair grafts were used to soften the hairline consisting of larger round grafts. The intention was to develop a softer, less regular hairline that more closely mimicked that which occurs naturally. Patient resistance to the 'pluggy' or 'doll's hair' look, even if it only occurred in the early stages of the process, has inspired the development of new technique to make hair transplants less conspicuous, less embarrassing, and more gradual in change. The use follicular unit graphs are acknowledged as the most successful method for achieving these goals. Back to top Who Should Be Transplanted And When? If the extent and rate of hair loss were totally predictable at any age, one could easily establish a surgical plan. The surgeon would know how much donor area is available and how large the bald area is destined to be; unfortunately, we are not afforded this luxury. Hair loss is an ongoing process that continues throughout one's lifetime. Some people have accelerated loss at age 20 or 30 and others experience their greatest loss at age 40 or 50. It is this unpredictability that makes hair replacement such a challenge. It takes many years of experience to make an informed estimation of future hair loss and even then one can be wrong. The surgeon must look for the early signs of advanced baldness and proceed with caution in patients who display them. These signs include: sparse, curly or wooly hair above the ears; advanced thinning in the anterior temples and lower occipital area; much greater than average shorter, finer hairs throughout the donor area. It is relatively easy to develop a plan for a 50- or 60-year-old man whose hair loss has progressed and whose desires and expectations are very realistic. The most difficult challenge lies in evaluating the younger person (Norwood et al 1993a) whose hair loss is at an early stage and who wants to maintain or regain a very youthful hairline or to fill in a thinning crown. When a low, youthful hairline is surgically developed, it remains permanent. Then, as further loss occurs over the years, a very unaesthetic, unnatural appearance results. Many of these people should be discouraged from beginning hair replacement too soon. If they are obsessed with the idea of gaining more hair, then a temporary solution such as a hairpiece should be recommended. Then, as they get older, and the hair loss continues, surgery may be an acceptable alternative. Many young men will accept a higher hairline, or postpone any surgery if they truly understand the long-term ramifications of being too aggressive and placing or filling in the hairline too low. Although one may hear some young men say: 'Get me to age 30 and I'm married, I won't care what I look like', the truth is that both he and you will care. However, it should not be concluded that hair transplants (HT) should not be performed on young patients. The significant psychological impact on young men cannot be ignored (Cash 1992). If something can be done - taking into consideration future loss and long-term aesthetic considerations - then it should be. In the earlier stages of frontal hair loss, thickening can be accomplished if the hairline that is developed is high enough to look good even in later life (Norwood 1992c). If hair loss is more advanced, or if significant loss is anticipated, an option is to transplant only the front half of the head, leaving the crown untouched or covered with a hairpiece. Another option is the use of Propecia ® which has been successful in stopping hair loss in a significant percentage of patients. As long as there is sufficient donor area to accomplish the desired goals, and the person has no medical contraindications to surgery, the process may begin. Back to top Physical Characteristics When deciding what approach to take, one must consider the physical characteristics of skin colour, hair colour, hair texture, curl, and the density and size of the donor area. The greater the contrast between the skin and hair colour, the more noticeable is the presence of hair loss or thinning. Grey or salt-and-pepper coloured hair reveals the least contrast. Blond or red hair also has less contrast with the underlying skin. These characteristics should be considered when deciding subsequent hair-styling, including whether the patient should part the hair from one side, comb it straight back, or present a naturally curly appearance. Back to top The Donor Area The donor area varies tremendously from patient to patient. Some have large, dense donor areas and others have small donor areas of very low density. Age is a major factor, but individual variations occur even in young patients. The size and density of the donor area is important in the short and long term planning in the hair replacement process. Back to top Treating 'early baldness' A very important and complex issue is the transplanting of the patient who has moderate thinning. I discuss with the patient the need for more surgery to be performed in the future to replace the hair that will fall out with the advancement of male pattern baldness. When I begin to transplant such a patient, I develop a hairline which I estimate will look good on its own when the nearby non-transplanted hair falls out. Back to top Conclusion Recent advances in technology have made surgical hair replacement viable option for many more people. But, as physicians and surgeons, we must utilize this technology prudently. A great amount of care must be taken when making the decision to use these technique on prospective patients. Learning and feeling comfortable performing the different methods available can be achieved in a relatively short period of time. The ability to develop a surgical plan based on the patient's present situation and balanced with the likely prospect of further hair loss is an art that takes considerable experience and an abiding concern for the patient's appearance many years in the future. Consider the following: Having hair is great. Being bald isn't as great, but at least it looks natural. Having poor hair replacement surgery is much worse than being bald. Back to top Overview | Who Is A Candidate? | Techniques | Before & After | Women | Scars Published Articles | Success Stories | FAQ | Our Staff | Contact Us © Copyright 1997 - 2006 Martin E. Tessler, M.D. All Rights Reserved. Designed by Media Genesis