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Introduction
Hair transplants are currently the only effective “cure” for
androgenetic alopecia. Put simply, the procedure redistributes
the remaining hair on a person’s scalp to cover any bald regions.
We know that the hair follicles at the back of the head between
the ears are not affected by androgenetic alopecia whereas the
hair on the top of our heads is affected and can be lost to varying
degrees. With hair transplantation, the hair not affected by androgenetic
alopecia is taken from the back of the scalp and placed on the
top.
It is a simple enough principle and it can provide superb, undetectable
results when done well. Hair transplantation has had a lot of bad
publicity because until recently the techniques involved were rather
crude and results did not look natural. When hair transplantation
was first developed, surgeons would use a large punch biopsy to
take clumps of hair follicles from the back and then place then
on the top in rows. The problem was that the clumps of hair follicles
looked very artificial and were difficult to style and manage because
the hair follicles were not oriented properly. Today however, the
surgical procedure has been refined to the degree that a good dermatological
surgeon will leave the patient with a completely natural looking
result. Improvements have come from the way the hair follicles
are obtained from the donor area and how they are implanted in
the bald regions.
Both men and women can be suitable for hair transplantation.
Most frequently hair transplants are conducted on people with androgenetic
alopecia but hair transplantation can also be an option for people
who have lost hair through a congenital defect, scarring alopecia,
or alopecia after burns or other injuries. The transplant procedure
need not be limited to the scalp. For example, some people have
eyebrow transplantations.
Why
do hair transplants work?
The pattern of baldness in men is very distinctive and usually
limited to the top and front of the scalp. These hair follicles
have miniaturized and changed from terminal follicles into vellus
hair follicles under the influence of androgens such as testosterone
and dihydrotestosterone. As described elsewhere on this web site,
not all hair follicles are the same. Some hair follicles are sensitive
to androgens, but others are not. It so happens that hair follicles
on the top of the scalp are made from cells that have androgen
receptors on their cell surface. When these receptors are bound
by androgen hormone molecules it triggers the cells to change their
activity. In scalp hair follicles the cells are told to slow down
and stop proliferating and this results in the hair follicle becoming
smaller, producing a finer hair at a slower rate of growth. The
hair cycle of these follicles also becomes shorter.
However, other hair follicles on the scalp at the sides and back
of the head are not androgen sensitive. The cells that make up
these hair follicles have far fewer androgen receptors. They are
much less androgen sensitive and effectively take no notice of
testosterone and dihydrotestosterone. These hair follicles continue
to grow at a normal rate for a healthy terminal hair follicle regardless
of the androgen concentration in the body.
This means that the hair follicles that are androgen insensitive
can be moved from the back of the scalp and transplanted on to
the top of the scalp to replace androgen sensitive vellus hair
follicles. The transplanted hair follicles from the back of the
scalp will keep their androgen insensitivity property in their
new position as they are still composed of the same cells that
have few or no androgen receptors. These cells will not change
even in their new position. The result is that these transplanted
hair follicles will continue to grow as healthy terminal hair follicles
for the rest of your life.
The
preliminary consultation
When you first approach a dermatology clinic about a hair transplant
procedure remember you are the consumer and make sure that you
get the information you want. Typically you will first meet with
the dermatologist to decide whether you are suitable for transplantation.
Some people have too much hair loss and/or poor donor areas. This
makes them unsuitable hair transplantation - they would not be
satisfied with the result. The dermatologist will ask you what
you are looking for in a hair transplantation. Remember regaining
that full, thick coat of hair that you had as a teenager is not
a practical option. You are only redistributing your hair follicles
to gain a more cosmetically acceptable effect, no new hair follicles
are being made in the process. The hair follicles you have can
only be spread so thin before the result would be unacceptable!
Make sure you see the dermatologist who will be conducting the
procedure and not a technician or sales agent, and make sure you
feel comfortable in the hands of this dermatologist.
The hair line will be discussed with you in some detail. The dermatologist
will outline with a marker the optimal line across the front of
the scalp that will define the edge of the hair line into which
grafts will be put later. An important point here, many people
ask for hair lines that are too low. Do not ask for a low hairline
on your forehead. The hairline you had as a child or teenager looked
great at that age but it is inappropriate for an adult. Almost
all male adults have a higher hairline than they had as a teenager
regardless of whether they have pattern baldness or not. Remember
you can always have the hairline lowered in a later operation,
but it is extremely difficult and sometimes impossible raise a
hair line after the transplantation has been completed. Also remember
that the higher the hair line the less bald scalp the grafts will
have to cover. Larger areas of bald scalp mean the transplants
will be spread more thinly.
Depending on how much hair loss you already have and the size
of your donor area, the dermatologist will recommend a number of
procedures. Note that most transplants involve more than one surgical
procedure. Only so much can be done in one surgical session. You
may end up having anywhere from one to six sessions with time in
between for your scalp to recover. The entire process may take
several months or years to complete.
After deciding the optimum procedure, you will inevitably be
involved in the nitty gritty of negotiating a price for the operation.
Different dermatologists use different pricing structures. Some
will charge a set fee per graft others will set a price per procedure.
Make sure you find out all the clauses and extra charges. When
the charges are per graft be sure to find out how many grafts will
be involved in your procedure. You may be charged separately for
the dermatologist’s time and the nurses’ or technicians’ time.
You may also be charged a separate fee for using the surgery room
where the procedure is conducted. Whatever happens make sure you
are satisfied that you are in safe hands. A bad hair transplant
is very difficult to correct once it is done.
How
is a typical hair transplant conducted?
Different dermatologists may have slightly different approaches
to the hair transplant technique, but here is an overview that
covers the general approach that the majority of hair transplant
surgeons use. A hair transplant will often take an entire day to
complete. In the morning you will consult with the dermatological
surgeon who will be performing and directing the operation. He/she
will discuss the operation with you and recap on the procedure
that should have been explained to you previously. Many hair transplant
surgeons will take photographs of your scalp to show the before
and after changes from the hair transplant.
In the operation room you will be examined and the optimum donor
area of hair follicles will be identified. This area will be shaved
so that the dermatologist can see what he/she is doing. A local
anaesthetic and/or scalp freezing agent will be used to numb the
donor area. The dermatologist will then use a special scalpel to
cut a strip of hair follicles from the donor area. The scalpel
used may have two or three (sometiems more) parallel blades with
a fixed width between them. The scalpel blades are inserted at
an angle similar to the angle that the hair follicles are growing
at so as to avoid cutting through any hair follicles. Cutting the
bulbs off hair follicles renders them impossible to successfully
transplant. This scalpel is used to cut the donor skin in a thin
strip with equal distance between the top and bottom cuts. This
makes suturing of the wound and healing quicker and easier. Most
surgeons take a long, thin strip of skin almost from ear to ear
and full of hair follicles. The wound is then cauterized and sutured
up to heal of its own accord. Because the strip of skin is long
and thin it only leaves a small, narrow scar that is hidden by
the hair growing immediately above it.
The strip of skin is then processed. Processing can involve several
different methods depending on what result the dermatologist and
patient require. Sometimes lines of four or five hair follicles
are cut from the donor strip. Or the strip may be cut into hair
follicles in clumps of two three or four and even single hair follicles
may be isolated for transplantation. The most recent development
in hair transplantation is micro dissecting and implnating the
hair follicles in their natural units. Hair follicles naturally
cluster in clumps of 1-4 follicles. By transplanting these natural
clusters a much more natural result can be produced. The processing
of the donor skin involves several trained technicians and can
take a couple of hours to complete depending on how big the donor
skin strip is. The grafts are arranged in dishes with pads saturated
in sterile saline ready for transplanting to the scalp. This part
of the procedure is what makes hair transplants so expensive to
perform!
When processing of the donor strip is nearing completion your
scalp is prepared to receive the grafts. Depending on how the hair
follicles are being processed the surgeons may use a needle, punch
biopsy, or cut thin lines with a scalpel. The hair line as previously
marked is the first area to be prepared. The surgeon will use a
scalp punch to make very small holes in the skin. The grafts are
then placed into these holes. In a typical transplantation, small
grafts consisting of just one or two hair follicles are used to
define the new hairline. Gradually the hair transplant srugeon
and his/her assistants will work backwards from the hair line over
the top of the scalp making holes and inserting grafts. Larger
grafts of two, three, four, or five hair follicles may be used
behind the hair line to “fill in”.
Eventually the grafting procedure is completed. Some hair transplant
surgeons prefer to bandage the scalp, others don't. In either event
the surgeon should advise you in some detail on how to take care
of the implants. Clearly you cannot wash your scalp for the first
few days as you may wash out the grafts! You will probably be required
to return to the clinic for regular check ups on the progress of
your hair transplant and at some point the sutures will be removed
from the donor area.
Do’s
and don’ts of hair transplantation
Hair transplantation is a blossoming area of dermatology. There
are many clinics around the world that exclusively focus on hair
transplant treatment and little else. Unfortunately, because hair
transplantation is so profitable there are some incompetent commercially
oriented clinics that do poor quality transplants and even dangerous
transplantations. Any dermatologist can attend a course that lasts
a few days and leave supposedly fully qualified to conduct hair
transplants.
- If you are considering the hair transplant option do make sure
you investigate the clinic and the hair transplant surgeon who
will be conducting the procedure. You will be paying a lot of
money and will have to live with the result for the rest of your
life so make sure that you find an experienced dermatologist
working in a clinic with a good, long term track record!
- Do find a dermatologist recommended by a professional non-profit
organization such as the American Hair Loss Council, the American
Academy of Facial Plastic and Reconstructive Surgery, or similar
organizations in other countries.
- Do seek personal recommendations from people who have already
had hair transplantations. You can ask them about their experience
and judge how good their transplant looks. If you don't know
anyone with a hair transplant call several transplant clinics
you are interested in and ask them for names of previous patients
you can contact to ask about their transplants and see the result.
- Do speak to the dermatologist who will carry out the procedure
and not to a salesperson when deciding what type of transplant
to have and finding out what the procedure will involve.
- Do shop around and contact several clinics. The cost of transplantation
procedures varies considerably and price is not necessarily a
reflection of quality. Because hair transplantation is now so
commercialized, many clinics charge what they think the market
will bear in their region. A hair transplant in Los Angeles will
cost more than a transplant in Boston which will in turn costs
more than a transplant in Vancouver, Canada (consider the exchange
rate). Even within local areas the cost of a procedure can vary
depending on the prestige of the clinic, how much they spend
on advertising, what cable television channels they get etc.
The cost can range from $3,000 US dollars to $20,000 depending
on what level of surgery is involved and what clinic you go to
for the operation.
- Do ask about the different grafting methods available and which
one is best for you. Different degrees and patterns of hair loss
require different transplant techniques. Ask how much experience
the dermatologist has with the particular technique you want
done and make sure you are satisfied with the reply.
- Do realize that the more hair loss you have the longer the
procedure will take and it may mean having several operations
spanning several months to years before you and your dermatologist
are truly satisfied with the result.
- Do realize that transplant surgery is generally considered
a cosmetic treatment and as such will not be paid for by medical
insurance or a national health service. Hair transplantation
may be covered by medical insurance or state health bodies if
the cause of hair loss was due to a clinical disease or the result
of an accident, injury, and/or burns.
- Don’t ask for a low hairline on your forehead. The hairline
you had as a child or teenager looked great at that age. It looks
inappropriate and even ridiculous in an adult. All adults have
a higher hairline than they had as a teenager regardless of whether
they have androgenetic alopecia or not. Remember you can always
have the hairline lowered in a later operation, but it is extremely
difficult and often impossible to remove hair grafts without
scarring once they have been put in.
- Don’t assume that a prestigious dermatologist is capable
of conducting hair transplants. A dermatologist may have built
his/her reputation in other areas of dermatology and may actually
have very little experience of transplantation.
- Don’t part with your money until you have all your questions
answered to your satisfaction and you are absolutely convinced
that hair transplantation is right for you!
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