Summary

Hair restoration involves moving hair from one body area to another for cosmetic improvement. The latest advances in the field, such as smaller grafts, follicular unit extraction or FUE, and novel pain reduction methods, make hair restoration treatment successful, safer, and more comfortable. Hair transplantation is most used for male pattern baldness. The second most common use is to treat female pattern baldness. An increasing number of women do not experience recession but wish to advance their hairline forward because of the congenital high hairline, traction alopecia, or previous facial cosmetic surgery. There are several key differences to note about the appearance of the male verse female hairline. It has been previously reported that the male hairline is typically 7 to 8 cm above the glabella and 5 to 7 cm in women.

Besides, a variety of conditions can be successfully treated with hair transplantation, such as scalp scarring, facial scars due to trauma or surgery, and hair loss due to traction can be repaired with hair transplantation. Finally, hair transplantation can be successfully used to restore hair to the eyebrows, eyelashes, beard, mustache, or goatee area; and even in areas of the body, such as the pubis or chest. The PRP and growth factors are used pre-operatively, intra-operatively, or post-operatively. The scalp where hairs are transplanted decreases bleeding, and bruising accelerates healing and reduces shock hair loss. The injection of nanofat or enriched microfat is performed subcutaneously above the galea and in proximity to the hair bulb, which is the region where stem cells exist.

Your Consultation at MSI

All men and most women who have androgenic or inherited pattern baldness can be treated with hair transplantation. As in all other elective cosmetic surgeries, hair transplantation’s essential patient choice criterion is the individual’s motivation. Results of hair transplantation are usually most dramatic when the procedure is performed on individuals with advanced degrees of hair loss. In general, the higher the degree of hair loss, the more significant number of grafts transplanted. As with any surgical procedure, counseling before hair-restoration surgery is critical.

Patients require education to make informed decisions about this elective procedure, i.e., whether to undergo it and, if so, which processes. Because hair restoration is cosmetic surgery, discussing patients’ areas of concern, explaining treatment options, and supplying a realistic picture of expected results. Individuals must be motivated to undergo hair transplantation.

Honest and thorough preprocedural consultation is a crucial part of the process. Prof Moawad conducts a formal psychological evaluation by lengthy questionnaires and examinations. The consultation helps ensure the patient is mature enough to decide to undergo the planned procedure. A prospective patient who has realistic motivations and expectations before the procedure is likely to be happy after the procedure.

Poor medical health is a potential contraindication for elective surgery of any kind. Individuals cannot be taking anticoagulants (e.g., warfarin, aspirin) before the procedure. Good surgical judgment must be exercised when one considers surgery in individuals with potentially complicating medical conditions. Age is not a medical contraindication, as these procedures have been performed on men in their late 70s. However, ensure that such patients provide medical clearance from their internist.

No single hair-loss condition calls for more conservatism in judgment than premature male pattern baldness. Teenagers and men in their early 20s are particularly self-conscious about hair loss because most of their peers still have full heads of hair. These young men often hold unrealistic expectations, wanting a youthful hairline that will not be appropriate as they age. Worse, early surgical correction uses many donor hairs, which will be sparse in the future, potentially resulting in an unnatural look and a disappointed patient. In general, attempt to delay the procedure in individuals in their 20s or younger. When counseling young men about hair loss, it is recommended to use a conservative approach to give patients time to consider hair transplantation.

Physical Examination

Upon the initial patient evaluation, the physician must first determine the etiology of the patient’s hair loss. Only after first ruling out (1) systemic causes such as thyroid abnormalities, polycystic ovarian syndrome, or iron-deficiency anemia; (2) dermatologic causes that may be treated medically; (3) and telogen effluvium (temporary hair loss that resolves over a few months), should a surgical approach to hair loss be considered. Hair transplantation may not be the most effective therapy for some medical causes of hair loss; it exacerbates the condition in some instances.

Therefore, workup to rule out other treatable causes of hair loss is essential, especially in women, in whom non-genetic etiologies for hair loss are more common than in men. Male pattern baldness follows a classic pattern best illustrated by using the Norwood Classification System, which ranges from type 1 (minimal frontotemporal recession) to type 7 (loss of all but a small rim of hair). Types 2-6 categorize the typical progression of hair loss.

The clinical presentation in women differs from that of men. In women, hair loss along the hairline is typically spared, with thinning throughout the top and upper sides of the head being more diffuse in women than in men. A patient is considered a candidate for hair transplant as long as their donor area (both current and projected) can yield a sufficient number of hair follicles to adequately address the projected recipient area.

A family history of hair loss in parents should be investigated and compared with standardized scales of hair loss in women and men (e.g., Norwood Pattern, Ludwig Pattern). Young patients (in their 20s) with a limited hair density in their donor area coupled with a projected Norwood Type VII or more significant hair loss, for example, will almost certainly not have an adequate number of permanent “fringe” hair follicle reserve to address the future recipient area and often cannot be considered candidates for the procedure. Appropriately aligning patient and physician expectations are critical during the initial evaluation and consultation.

Understanding the limits of a patient’s donor hair reserves, hair characteristics, goals, and motivation for undergoing hair transplantation can best help evaluate and articulate a projected outcome. Establishing this mutual understanding is one of the most effective ways to increase overall patient satisfaction. Helpful screening technology that enables quantitative microscopic donor area measurements (e.g., folliscope) aids physicians in patient candidacy evaluation by helping to discern between terminal and vellus (or miniaturized) hairs.

Young patients who possess more than 20% miniaturized hairs within their safe donor area may not ultimately benefit from the procedure because, over time, the transplanted hairs may not persist. Staging alopecia into both pattern and degree of severity can be accomplished through the Hamilton classification. Patients with Hamilton patterns I and II have very early limited alopecia requiring minimal treatment if accepted as candidates. Conversely, patients with patterns VI and VII may no longer be candidates for the surgery since their alopecia is extensive. The very best candidates fall into patterns IV to V, which produce the best, most natural results.

Do I need Lab Tests?

When healing or bleeding characteristics are concerns, consider performing screening blood tests, including tests of the following: CBC count with plateletsProthrombin time (PT), Activated partial thromboplastin time (aPTT). Further testing (e.g., chemical profile) is occasionally performed as the patient’s medical condition dictates. In female patients, an extensive workup is indicated to rule out potentially treatable causes of hair loss. Include tests of the following: CBC count, Total iron and ferritin, Thyroid function tests and thyroid-stimulating hormone, Total and free testosterone, Dehydroepiandrosterone (DHEA) sulfate, in cases of irregular menses. Further testing (e.g., ECG) is occasionally performed as the patient’s medical condition dictates. It also may be prudent to screen for antibodies to HIV hepatitis B and C.

What are the Risks of Hair Transplant?

When performed correctly, the results of hair transplantation are virtually undetectable. However, complications can arise from errors of technique, poor planning, and unpredictable patient factors. As with any surgery, hair transplantation poses risks. Excessive bleeding due to undiagnosed coagulation disorders or secondary to medications can be bothersome at the least and (in rare cases) life-threatening at the worst. Infections and anesthesia problems are two other potentials, although unlikely, complications. Complications more unique to the hair transplantation procedure are rare but can occur. Scarring of the donor site can include hypertrophic scar formation due to excessive tension and even a tendency toward keloid formation. Alopecic scar formation can result from excessively tight suture placement or hair follicle cauterization. Scarring of the recipient site is common if large-size grafts are placed. Such scarring included ridging, cobblestone, and skin hypopigmentation.

Weak hair growth can occur and is dependent primarily on technique. Graft desiccation, rough grafts, and inadequate graft preparation can result in limited hair growth. Lack of growth must be distinguished from delayed hair growth because transplanted hairs occasionally require 12 months to grow.

Telogen effluvium or loss of original hair in transplanted areas, usually an avoidable condition, can result from poor circulation or accidental trauma to existing hair follicles, thus producing a first early thinning of hair ranging from mild to mild cosmetically disturbing. Hairs usually return in 1-2 months, but this can be a difficult situation.

Errors of technique and poor planning are preventable but occur all too often. The most common of these technical errors, which result in a transplanted appearance, is extensive grafts and unaesthetic hairline design.

The importance of using 1- and 2-hair grafts, placed in the proper direction to create an irregular hairline of gradually increasing density as the surgeon goes ahead centrally, cannot be overstated. Failure to anticipate future hair loss in planning hairline restoration can result in an unnatural appearance as the patient ages. One of the most common problems can be the development of large bald areas between the lateral aspects of the parietal hairline and the temporal peaks caused by the recession of the temporal regions. Transplanting the crown in a young individual who eventually develops excessive baldness can result in a circular area of transplanted hair surrounded by a rim of bald scalp. I can dramatically improve undesirable hair transplantation results by using several reparative techniques.  However, the goal of hair-transplant surgeons should be the prevention of adverse outcomes.

Follicular unit extraction has a quicker patient recovery time and significantly lower post-operative discomfort than follicular unit transplantation (FUT). FUE supplies an alternative to FUT when the scalp is too tight for a strip excision and enables a hair transplant surgeon to harvest more delicate hair from the nape to be used in the hairline or for eyebrows. However, with FUE, the follicles are harvested from a much greater donor zone area than FUT, estimated to be eight times greater than traditional strip excision, so it requires patients to have hairs trimmed in a much larger donor area.  As a result, the hair in the lower and upper parts of the donor area, where the grafts were taken from, may be thin, making the donor scars visible. Follicles harvested from borderline areas of the donor region may not be indeed “permanent,” so that over time, you may lose the transplanted hair. The most abundant follicular unit graft yield is lower than FUT and may result in greater follicular transection (damage). The scarring and distortion of the donor scalp from FUE makes subsequent sessions more complicated, and grafts are more fragile and subject to trauma. They often lack the protective dermis and fat of microscopically dissected grafts, which ultimately may result in weak growth. Buried grafts can occur during the blunt phase of the three-step technique when the graft is pushed into fat and must be removed through a small incision. FUE can also be more expensive and take longer to perform than FUT, so grafts are usually out of the body longer, risking sub-optimal growth, says Prof Moawad.

The survival of follicular units upon extraction from the scalp is one of the critical variables of successful hair transplantation. If follicular units are transected in the extraction process, they will likely not survive the transplant, and the hair transplant will fail, says Prof. Moawad. While FUT procures using strip-harvesting of follicular units typically guarantees many non-transected follicular units, FUE procedures can, and often do, transect grafts, making them useless in a transplant. Significant efforts have been made to reduce the rate of transection in FUE procedures.

The surgeon’s skill and team and the type of instrumentation used are significant factors in the ultimate yield and viability of the follicular units. Graft survival is also affected by time out of the scalp and exposure to air (especially in vacuum extraction devices). Different methods have been proposed to improve graft survival affected by these factors by removing capture devices and adding/increasing time on ice. Many of the first downsides of FUE by manual approach have been minimized by introducing newer motorized and computerized devices. No scientific research data have shown FUT vs. FUE viability superiority, says Prof Moawad.

All men and most women who have androgenic or inherited pattern baldness can be treated with hair transplantation. As in all other elective cosmetic surgeries, the essential patient choice criterion in hair transplantation is the individual’s motivation. Results of hair transplantation are usually most dramatic when the procedure is performed on individuals with advanced degrees of hair loss. In general, the higher the degree of hair loss, the more significant the number of grafts transplanted. As with any surgical procedure, counseling before hair-restoration surgery is critical. Patients require education to make informed decisions about this elective procedure, i.e., whether to undergo it and, if so, which processes. Because hair restoration is cosmetic surgery, discussing patients’ areas of concern, explaining treatment options, and supplying a realistic picture of expected results is essential. Individuals must be motivated to undergo hair transplantation.

Prof Moawad conducts a formal psychological evaluation by lengthy questionnaires and examinations. The consultation helps ensure the patient is mature enough to decide to undergo the planned procedure. A prospective patient who has realistic motivations and expectations before the procedure is likely to be happy after the procedure. Honest and thorough pre-treatment consultation is a crucial part of the process. Poor medical health is a potential contraindication for elective surgery of any kind. Individuals cannot take anticoagulants (e.g., warfarin, aspirin) before the procedure. Good surgical judgment must be exercised when one considers surgery in individuals with potentially complicating medical conditions. Age is not a medical contraindication, as these procedures have been performed on men in their late 70s. However, ensure that such patients provide medical clearance from their internist.

No single hair-loss condition calls for more conservatism in judgment than premature male pattern baldness. Teenagers and men in their early 20s are particularly self-conscious about hair loss because most of their peers still have full heads of hair. These young men often hold unrealistic expectations, wanting a youthful hairline that will not be appropriate as they age. Worse, early surgical repair uses many donor hairs, which will be sparse in the future, potentially resulting in an unnatural look and a disappointed patient. In general, attempt to delay the procedure in individuals in their 20s or younger. When counseling young men about hair loss, it is recommended to use a conservative approach to give patients time to consider hair transplantation. If the patient and surgeon agree on transplantation, restore a high hairline, and encourage the patient to use minoxidil or finasteride for the crown region. In the future, as effective medical therapies that end or slow male pattern baldness progression become available, a less conservative approach can be taken.

Upon the initial patient evaluation, the physician must first determine the etiology of the patient’s hair loss. Only after first ruling out (1) systemic causes such as thyroid abnormalities, polycystic ovarian syndrome, or iron-deficiency anemia; (2) dermatologic causes that may be treated medically; (3) and telogen effluvium (temporary hair loss that resolves over a few months’ time), should a surgical approach to hair loss be considered. Hair transplantation may not be the most effective therapy for any medical causes of hair loss; in some instances, it exacerbates the condition. Therefore, workup to rule out other treatable causes of hair loss is essential, especially in women, in whom non-genetic etiologies for hair loss are more common than in men. Male pattern baldness follows a classic pattern that is best illustrated by using the Norwood Classification System, which ranges from type 1 (minimal frontotemporal recession) to type 7 (loss of all but a small rim of hair). Types 2-6 categorize the typical progression of hair loss. The clinical presentation in women differs from that of men. In women, hair loss along the hairline is typically spared, with thinning throughout the top and upper sides of the head are more diffuse in women than in men. Both men and women may be deemed candidates for hair restoration surgery as long as their donor area (both current and projected) are able to yield a sufficient number of hair follicles to address the projected recipient area adequately (a calculation termed “donor to recipient area ratio”). A family history of hair loss in both the maternal and paternal branches should be investigated and compared with standardized scales of hair loss in women and men (e.g., Norwood Pattern, Ludwig Pattern). Young patients (in their 20s) with a limited hair density in their donor area linked with a projected Norwood Type VII or more significant hair loss, for example, will almost certainly not have an adequate number of permanent “fringe” hair follicle reserve to address the future recipient area and often cannot be considered candidates for the procedure. Appropriately aligning patient and physician expectations are critical during the initial evaluation and consultation.
Understanding the limits of a patient’s donor hair reserves, their hair characteristics, and their goals and motivation for undergoing hair transplantation can best help evaluate and articulate a projected outcome. Establishing this mutual understanding is one of the most effective ways to increase overall patient satisfaction. Helpful screening technology that enables quantitative microscopic donor area measurements (e.g., folliscope) aids physicians in patient candidacy evaluation by helping to discern between terminal and vellus (or miniaturized) hairs. Young patients who possess more than 20% miniaturized hairs within their safe donor area may not ultimately benefit from the procedure because, over time, the transplanted hairs may not persist. Staging alopecia into both pattern and degree of severity can be accomplished through the Hamilton classification. Patients with Hamilton patterns I and II have very early limited alopecia requiring minimal treatment if accepted as candidates. Conversely, patients with patterns VI and VII may no longer be candidates for the surgery since their alopecia is so extensive. The very best candidates fall into models IV to V, which produce the best, most natural results.

Hair Transplant Surgery (FUE & FUT )  of Curly Afrocentric Hair (Egyptian Hair)

Although the biochemical composition of hair is similar among racial and ethnic groups, the hair structure between them varies, and individuals with curly hair pose specific challenges and special considerations when a surgical choice for alopecia is considered. Hair restoration in this population should, therefore, be approached with knowledge on the clinical characteristics of curly hair, hair grooming techniques that may influence the management, unique indications for the procedure, surgical instrumentation used, and the complications that may arise.

There are several critical differences between female and male hairlines. Understanding such differences and following specific guidelines will help Prof. Moawad to obtain beautiful and natural-appearing results. Patient choice, especially when attempting to treat female pattern androgenic hair loss, is critical. At least a minimal donor site density is necessary to achieve acceptable results. In many of these patients, a second procedure to achieve more density is performed, typically 12 or more months later.

Results vary from patient to patient, depending on factors such as; age, overall health & nutrition, and genetics. In general, usually over a 3 to 4-week interval, patients should be able to see improvements in skin texture, complexion, and tone. These improvements can continue for up to a year. Patients may need three separate sessions, two weeks-one month apart. Another session must keep improving each year. As part of our commitment to ultramodern care, PRP is provided with the hair transplant procedure for any patient who desires or is appropriate for it. Furthermore, the addition to the scalp of PRP can thicken thinning hairs and help reawaken dormant hairs. PRP is offered as a stand-alone procedure as a treatment for male and female pattern hair loss, where it is occasionally useful in slowing down shedding or progressive hair loss. Prof. Moawad can answer any questions you have about this therapy. Moawad Skin Institute (MSI) is offering and performing the latest in cosmetic enhancements and is now providing PRP therapy to our patients. We are excited to continue to strive at the forefront of the most advanced esthetic technology. Surgical hair restoration is the procedure of choice for restoring hair. The concept behind all forms of hair restoration is a redistribution of hair rather than the addition of new hair. Three hair-restoration procedures have traditionally been available: hair grafting, bald scalp reductions, and scalp-flap surgery. Today, hair grafting accounts for more than 99% of the methods performed. Hair grafting has a high success rate with a low incidence of complications; it is presented in the outpatient setting with little surgical preparation or specialized setup, and (most important) patient acceptance is high. Hair graft, the most common hair-restoration procedure, can be performed by using different techniques. From the early 1990s until recently, transplanting with micro-graft (1-2 hairs), often combined with mini-grafts (3-5 hairs), was considered state of the art. Today, most surgeons consider follicular-unit grafting the definitive procedure. Transplanting only follicular units and dissecting away all non–hair-bearing tissue can offer several advantages. These follicular-unit grafts can be placed into tiny recipient sites, allowing for dense packing and reducing post-procedure crusting. The requirement for careful dissection reduces the accidental transection rate and therefore minimizes the depletion of good hair follicles, a benefit that potentially maximizes hair yield from a strip of donor’s hairs. Finally, because hairs are transplanted following their natural growth in these tiny follicular units, the results are virtually undetectable. The follicular units can be obtained by either the strip technique (follicular unit grafting of follicular unit strip surgery) or single extraction (follicular unit extraction). Follicular unit extraction is preferred for younger men and those who wish to shave their heads because it avoids making a linear donor site scar. The technique used in women differs from that used in men. To prevent telogen effluvium of the existing hairs, the use of minoxidil 2% for 2 weeks pre-operatively and resuming 5-7 days post-operatively,  is increasing in popularity. Larger grafts behind the hairline are necessary to create increased density, using the 0.5 X 2.5-mm slot graft, which contains 5-7 hairs, and routine use of 3.5X loupe magnification to avoid injury to existing hairs.

• To perform hair transplantations in the eyebrow, a pattern must first be made by the patient, surgeon, or esthetician. Eyebrow and eyelash transplantation requires a great deal of maintenance. I must train brow hairs with gels or waxes, and I must curl eyelashes. Both must be trimmed and shaped. The use of donor trichophytic closure techniques can decrease the visibility of donor scars.
• Facial hair transplant procedures are best performed using follicular unit grafting, using minor recipient sites into which the surgeon and his team can insert grafts.
• Angulation is the most critical step in achieving aesthetic results, making recipient sites at as shallow an angle to the face as possible.
• In the beard, the “danger zone” where bumps can occasionally form is in a vertical central column extending inferiorly from the lower lip to the entire chin mound.
• Eyelash transplantation should be performed only if the patient fully understands the potential risks. Follicular unit extraction can be a practical alternative to the strip follicular unit graft technique for patients who shave their heads.
• The realistic goal of eyebrow and eyelash procedures is not perfection but a significant improvement.

FUE harvesting of grafts causes “pit” scarring small, round, and typically white scars in the patient’s donor area where the grafts have been removed. FUE scarring differs from strip harvesting in that the latter procedure produces a linear scar in the donor area where the strip of skin was removed. The pit scarring from FUE and linear scar from strip harvesting are often problematic to detect when hair in the donor area is at an average length and a skilled surgeon performs the extraction. While the outcome of the healing process, and thus the appearance of scar tissue, depends on several variables (including the type of extraction, the skill of the surgeon, and, in strip harvesting, the method of wound closure), in both FUE and FUT short cropped hair or a shaved head will typically reveal some scarring.

The PRP and growth factors are used pre-operatively, intra-operatively, or post-operatively. Added to the scalp where hairs are transplanted, it decreases bleeding and bruising, accelerate healing, and reduces shock hair loss. Clinically,  patients look better sooner after the procedure. Furthermore, it is speeding up and increasing the percentage of transplanted hair growth. Healing in the donor site incision heals better and faster.  PRP does seem to be effective. While it is still too early to tell just how effective it is for all patients, there is a good likelihood that PRP will become part of the standard of care of hair restoration surgery.

In 2010 fat was injected in a woman who showed a marked improvement in hair growth using adipocyte-derived stem and regenerative knows SVF for alopecia. Presently, no approach using enzymatically digested SVF is approved in the United States. In Europe, SVF can be used to treat alopecia in men and women. Mechanically dissociated SVF, nanofat, and PRP alone or combined with Fat transfers have been used to treat alopecia. In aesthetics, the lower-priced, more comfortable deployments, providing they achieve near similar results, will make the most sense. Patients with earlier stage hair loss are the best candidates. Combination treatments are the standard, and most patients are put on topical medications before and after treatment. In our clinic, during facial rejuvenation, if a man or woman has mild to moderate hair loss, nanofat with mSVF or SVF enriched fat obtained from mechanical dissociation or a combination of both are used in conjunction with microfat if the patient selects this approach. The injection of nanofat or SVF enriched microfat is performed subcutaneously above the galea and in proximity to the hair bulb, the region where stem cells exist. An 18 to 19-gauge cannula is used for grafting. The fat is injected retrograde in a radial and crisscrossing fashion.