Women, unlike their male counterparts are less likely to frustrate the hair transplanting surgeon by shaving their head as a cure for alopecia. For them, a healthy head of hair is an essential part of their attractiveness. In 2003, women had 87 percent of cosmetic procedures. According to the American Society for Aesthetic Plastic Surgery (ASAPS) (2), the number of procedures performed on women was nearly 7.2 million, an increase of 16 percent from 2002. The top five surgical cosmetic procedures for women in 2003 were: liposuction (322,975 and 84 percent of liposuction total); breast augmentation (280,401); eyelid surgery (216,829 and 81 percent of total); breast reduction (147,173); and rhinoplasty (119,047 and 69 percent of total). The number of surgical procedures for women increased 11 percent overall from 2002. Noticeably absent from their statistics are those for hair transplantation. I predict that in less than five years they will be tracking hair transplantation as well as injection therapy of unsightly varicose veins.

Incidence

The incidence of female alopecia increases with age, and in women fifty years and older, some thirty percent have hair loss, to the extent that they can no longer camouflage it with creative styling.

Non-surgical treatment is limited in women. Finasteride has no clinical efficacy and the only FDA recognized pharmacological therapy, minoxidil, promotes moderate to dense hair regrowth in 26% of men and 20% of women who use it twice daily. Results can take six to twenty-four months to become visible and the effects are greatest in the crown area. Another promising but unproven technology is the LaserComb which applies "low-level Laser therapy" and requires twice weekly application.

Patient Classification

Women who suffer a particular pattern of hair loss as described by Ludwig (3) or Vogel (4) do not need to undergo a barrage of testing. When in doubt one should refer the patient to an Endocrinologist. Initial standard testing would include a full blood count, ferritin and thyroid studies, Hormonal studies may be indicated. Most women with non-scarring alopecia have no evidence of abnormal androgen production. A scalp biopsy may be necessary to complete the diagnosis. (5)

There are three types of female alopecia that are suitable for treatment. The first is the type described by Ludwig (3) that is different from male pattern alopecia in that there is thinning in the frontal and crown vertex area with preservation of the frontal hairline (3). A sub-type of this first pattern is associated with diffuse thinning which includes the potential donor sites of the occiput and parietal scalp. This subset is not suitable for surgery.

The second type is characterized by a fronto-temporal recession typically seen in the early stages of male pattern alopecia Stages II and III (6) and the third type is the one so commonly associated with the results of a previous facelift and brow lift in which the side-burn and temporal and frontal hair line have been pulled posterior.

Evaluation

In order to evaluate the patient, first rule out any likely medical problems and elicit any history of prior transplant surgery. Examine the occipital scalp for the texture of the hair and its density as well as the mobility of the scalp. If density appears low, a densitometer reading can be obtained to confirm the clinical impression. I do not usually perform a measurements with a hair densitometer (Ellis Instruments, Madison, NJ) until the day of surgery when I count the number of hair follicles per high power field and multiply by eight to obtain the density of follicular units per square centimetre which provides a guide to the length of the donor strip to be harvested. The ideal patient will have follicular units consisting of 2-3 hairs. 10 units are counted and the average calculated. If the average is less than 1.5, transplanting will provide only thin coverage. Thick wavy hair is better than fine straight hair. The less colour contrast between scalp and hair the better the coverage. Obviously women can change their hair colour more easily than men, so this again is an advantage in their management.

Technique

The surgical technique is similar to men. The surgery is performed under local anesthesia alone, with oral anxiolyics such as lorazepam or with intravenous sedation. Many Plastic Surgeons have an accredited Surgical Center which offers many advantages over the non-accredited facilities used by many hair transplant surgeons. I think that one of the missions of the International Society of Hair Restoration Surgery should be to mandate accreditation of all facilities performing hair transplantation by a state recognized association such as the American Society for Accreditation of Ambulatory Surgical Facilities, the Accreditation Association for Ambulatory Health Care or Medicare.

Donor Site

The donor strip is harvested either in the prone or the seated position. I prefer the prone position taking the donor strip using a Persona number 10 blade, angled to the same inclination as the hair follicles, being careful to preserve the base of the hair follicles and avoid injury to underlying posterior occipital artery and nerve, by the use of injection tumescence. Closure is performed with deep absorbable 3-0 polyglactic acid suture and running 4-0 chromic catgut to skin. The harvested strip is then "diced" into individual hair follicles known as follicular units as well as larger grouping known as mini-grafts depending on the individual requirements of the patient. Preparation of the grafts is done by under a microscope or with the use of loupes and with the aid of good lighting and an ergonomic seating position. The counter-top is set at approximately 40" from the floor.

Recipient site

The patient with fronto-temporal recession as well as the patient with recession of the temporal and frontal hair secondary to prior surgery will require follicular unit grafts almost exclusively. This is in contrast to the Ludwig distribution where a significant number of larger grafts are required to give density behind the hair line. One essential difference in the planning is that the mature male pattern hairline is typically placed at 8.5 to 9.0 centimetres above the superior level of the eyebrows and at the junction of the vertical and horizontal portion of the skull whereas in women, the aesthetic hairline is one to two centimetres below this point, and on the anterior vertical face of the skull as illustrated so beautifully by Raphael, Virgin in the Meadow, 1503-6, Kunsthistoriches Museum, Vienna (7)

Also unlike the correction of male pattern alopecia, a temporal "alley" is not preserved but instead a concerted attempt is made to obliterate it, since this is one of the stigmata of fronto-temporal alopecia in the female. The surgeon is not expecting further recession posterior and lateral and should plan to fill the triangular temporal "alley". (See Figure 1 and 2)

To reduce the possibility of hair loss from surgery and minimize trauma, a 126-Minde knife (AtoZ Instruments) is used for the anterior grafts. A P91 or a punch or slot knife is used for larger grafts posterior. The female scalp is thinner than the male scalp and the slits should also be made at a shallower lever 2.0 mm - 3.0 mm instead of 4.0 mm. Recipient slits are placed at an angle of 30 degrees in a fan like pattern in the frontal region and posterior. Creation of an irregular hairline is mandatory with a few wild hairs placed anterior to the grafted line. Sideburns recipient sites should be placed at a 30-degree angle to the scalp and in a posterior and inferior direction. A minimum of 300 follicular units are necessary for recreation of an anterior hairline and often as much as a thousand may be used for the anterior hairline, temporal and sideburn area combined, with an additional 60-70 mini grafts for both temporal alleys, more posteriorly.

In the case of loss according the Ludwig pattern involving the vertex and crown, 2-300 mini-grafts are placed into 2.5 mm holes created with a skin punch. Punches can also be used to remove alopecic scalp without grafting. It is recommended to use smaller grafts with Asians to avoid a pluggy look. African Americans have textured hair, which provides excellent coverage. Larger sized grafts may be used.

Conclusion

Cosmetic surgeons are well positioned to treat hair transplantation in women. They already have a patient base that is interested in cosmetic surgery.

Even if they choose not to perform this type of surgery, an understanding of the condition and the treatment options, will help them to advise their patients and plan facelift and brow lift incisions with minimal risk of hair loss.

Conventional wisdom is that a hair transplant surgeon should do no other cosmetic procedures, but a varied cosmetic practice may guarantee longevity and success as well as patient recognition. The skill of a trained surgeon and the availability of an accredited surgical center are also beneficial to the patient.

Illustrations

Figure 1a. 59 year old female with history of post-facelift and brow lift alopecia (as seen in Elizabethan era
and exemplified in Interior with a woman peeling apples, 1663, Pieter de Hooch, Wallace collection (8)
Indicated for correction of frontal and temporal hairlines. 900 follicular unit grafts were used to recreate the hairline and 68 mini-grafts for the temporal recesses.

Left to right top row: Preoperative view, plan of surgery, same patient 5 days after surgery combined with an
endoscopic removal of corrugator supercilii and facelift. Left to right bottom row: lateral view.

Figure 1b. Frontal view before, and 5 days after surgery

Figure 1c. Lateral view before, and 5 days after surgery

Figure 2a. 45 year old female with history of fronto-temporal alopecia: oblique view above and frontal view
below.

Figure 2 b. frontal views: preoperative above, operative plan below, 1000 follicular unit grafts placed.

References

1. Marzola, M., Hair Transplant Forum International, Vol. 14, No. 1, p.2
2. 2003 ASAPS Statistics - 8.3 Million Cosmetic Procedures: American Society for Aesthetic Plastic Surgery
Reports 20 Percent Increase. http://www.surgery.org/press/news-release.php?iid=325
3. Ludwig, E., Classification of the types of androgenetic alopecia (common baldness) occurring in the female sex, Br J Dermatol 97:247-254, 1977
4. Vogel, J.E., Hair transplantation in Women: A practical New Classification System and Review of Technique, Aesthetic Surgery Journal Aesthetic Surgery Journal
May/June 2002 o Volume 22 o Number 3 o p247 to p259
5. Griffin, E.I., The Treatment of Female Pattern Alopecia by Hair Transplantation pp.210-218, in Hair
Replacement, Ed. Stough, D.B., Mosby 1996.
6. Norwood, O.T., Male pattern baldness: classification and incidence, South med J 68(11): 1359-1365, 1975
7. Raphael, Virgin in the Meadow, 1503-6, Kunsthistoriches Museum, Vienna, in. Gombrich, E.H. The Story of
Art, p.34 16th Ed. Phaidon Press1995
8. Interior with a woman peeling apples, 1663, Pieter de Hooch, Wallace collection, in. Gombrich, E.H. The
Story of Art, p.19 16th Ed. Phaidon Press1995

Appendix A

Evaluation form

Significant Medical History: Anaemia, Thyroid, Hormonal Problems

Lab tests: Full Blood Count, Ferritin, Thyroid Functions Tests, Hormone Assays

Referral: PMD, Endocrinologist

Pre-operative prescriptions: Arnica, Aquamephyton, Medrol Dose-Pack, Keflex, Erythromycin, Lorazepam,
other Medications / Allergies

Recipient Site exam

Scalp Colour __ / African American / Asian / Mediterranean / Caucasian

Type of Hair loss:

Ludwig: discrete - vertex / crown /
Ludwig: diffuse - unsuitable
Vogel: - fronto-temporal alopecia
Post-surgical: - sideburns / frontal / temporal

Hair restoration plan

Frontal hairline follicular units number ___________ estimate 500
Temporal hairline follicular units number ___________ estimate 150
Sideburn follicular units number ___________ estimate 150

Other sites

Eyebrow follicular units number ___________ estimate
Crown follicular units number ___________ estimate 200
Vertex mini-grafts 5-6 hairs 2.5 mm holes estimate 200-300

Total mini grafts ______
Total follicular units ______

Donor Site Exam

Previous Harvest Y/N
Hair Colour
Texture Fine/Coarse/ Medium
Density Good/ Bad/ Average
Interfollicular distance Good/ Bad/ Average
Laxity Good/ Bad/ Average
Hair Diameter Good/ Bad/ Average
Wave Good/ Bad/ Average
Scalp camouflage rating 1-5