Hair loss, also referred to as alopecia, can have a profound effect on your appearance, social function, and self-esteem. It may be caused by a medical disease process, trauma, or simply genetics. There are several medical treatment options available to slow or even stop the continued hair loss. Surgical transplantation of hair from one part of the scalp to another is an excellent treatment option for many that can restore your hairline to a fuller, more natural look. Many patients will get the most benefit from a combination of medical and surgical treatment.
For the vast majority of people the cause of hair loss is readily identifiable and related to hereditary changes in local hormone levels (androgenetic alopecia). There are, however, a wide variety of conditions that can cause hair loss in both men and women. Determining the precise cause of hair loss is critical prior to starting treatment, as the recommended treatment will vary based on the cause of hair loss.
Is a hereditary condition that causes hair loss in both men and women and is by far the most common cause of hair loss.
Is most commonly seen as round or oval patches of hair loss that can occur quite suddenly. The hair loss occurs as the body’s immune system attacks the hair follicles causing hair loss. The treatment outcome is best when the disease has been present less than one year, with prognosis decreasing with length of time of disease. First line treatment typically consists of steroids either topically, injected in the scalp, or orally. The steroids work to decrease the inflammation and if treated in time, normal hair growth may return.
This is hair loss caused by a sizeable number of hair follicles moving into the shedding phase. This may be caused by stress, medical illness or surgery, poor nutrition, hormones, or medications. The accelerated hair loss can occur weeks to months after the stressful event and is usually reversible once the stress has been alleviated.
This type of hair loss is caused by a small group of disorders that cause permanent hair loss due to replacement of the hair follicles by scar tissue. This type of hair loss is more commonly patchy with less defined borders than non-scarring types of hair loss. Several conditions may cause scarring alopecia including lupus, frontal fibrosing alopecia, lichen planopilaris, and folliculitis decalvans among others. A small scalp biopsy may be recommended to evaluate for these or other disorders based on the pattern of hair loss seen on examination.
Loose Anagen Syndrome
This is characterized by hair that is often lost during brushing or combing. During the growing phase of hair, the hair is very loosely held in the follicle, so the hairs are easily extracted. This is most common in fair-haired persons and can be seen in children. The condition may spontaneously improve for some children with age.
This is characterized by a triangular pattern of hair loss or thinning at the temples. It most often occurs in childhood related to failure of hair follicles to grow in a select area. This patch of bald skin can be surgically removed or treated with hair transplant.
This is hair loss caused by persistent traction on the scalp. This is often seen with hair styled in tight braids or cornrows. This may be reversible in the early stages if the traction is removed, but in later stages it may become permanent.
Is hair loss caused by a compulsive habit of plucking or pulling of hair. Eventually this plucking leads to permanent hair loss in that location, and over time may even result in damage to the skin.
Diagnosing hair loss requires a thorough history and a close examination of the hair and scalp along with evaluation of potential contributing medical conditions or family history. We often collaborate with our colleagues in Dermatology to determine the correct diagnosis and most appropriate treatment for your hair loss. Some amount of hair loss is normal, most people lose an average of 75 to 125 hairs each day as our hair goes through a normal cycle of growth and loss. This can temporarily increase during times of mental or physical stress, but when accelerated hair loss persists it may signify an underlying issue and should be carefully evaluated.
Normal Hair Growth
The hair that is seen sticking out of the scalp is only a small part of a larger structure called the follicular unit. Each follicular unit contains one to four individual hairs along with nutrient cells, stem cells, and glands producing natural oils or sweat. The normal hair growth cycle includes three distinct stages; growth, shedding, and rest. The growth phase is called “anagen” and is the predominant phase for most of the hairs on the head lasting two to eight years. This is followed by a two to four week period where the follicle begins to degrade called “catagen.” The final stage is called “telogen” and is a resting stage for the follicle which lasts two to four months. After this time the hair is shed and the process repeats. There are numerous factors that can alter this cycle or increase the ratio of hairs in the resting phase which contributes to overall hair loss.
Male Pattern Hair Loss
Male pattern (androgenetic alopecia) hair loss is a very common inherited condition affecting more than 35 million men in the United States alone. Hair loss becomes more common with increasing age and roughly 50 percent of men in their 50’s experiencing some amount of hair loss. There are various patterns of hair loss described by the Norwood classification. Early hair loss patterns tend to start with recession in the temple region and can also include loss of hair from the crown of the head. The most advanced hair loss preserves only a small ring of hair extending from above each ear around the back of the head. Generally speaking, the earlier hair loss begins the more severe it will become in the end, but there is no way to fully predict the final hair loss pattern for each man. Genetic and hormonal factors both play a role and a history of hair loss on either the mother or father’s side can increase the likelihood of genetic hair loss.
Female Pattern Hair Loss
Hair loss in females is more common than societally recognized with approximately 30 million females in the United States affected. There are many causes of hair loss in females, but the predominant cause is hereditary, androgenetic alopecia. The pattern of hair loss in females follows a different pattern than in men often consisting of generalized thinning of the hair starting from the central part and expanding outward. This is classified by the Ludwig scale.
There are several options available to medically treat hair loss. We work closely with our partners in Dermatology to diagnose and treat your hair loss. There are currently two FDA approved medications for the treatment of hair loss; Minoxidil (Rogaine®) and Finasteride (Propecia®). Other off-label treatment options include Dutasteride (Avodart®), platelet-rich plasma injections (PRP), and low level laser (light) therapy. Most medical treatments work best for the early stages or moderate hair loss. More advanced hair loss does not respond as well to medical treatment alone, but often medical treatments are combined with hair restoration surgery to optimize results.
Minoxidil (Rogaine®) was the first FDA approved treatment for hair loss. This is a topically applied medication placed on the scalp once or twice a day and is available over the counter without a prescription in either a foam or liquid formulation. This medication can help slow the process of hair loss and promote hair regrowth. Minoxidil is available in a 2 to 5 percent concentration. The 5 percent concentration is generally more effective than the 2 percent concentration but may also have more side effects. Minoxidil can cause a temporary itching or burning sensation to the scalp after application. Particularly in women, minoxidil can cause a temporary increase in hair loss that lasts two to four weeks, but this usually predicts a better result to treatment. Minoxidil can also cause an unwanted increase in the appearance of facial hair if accidently applied to the face.
Finasteride (Propecia®) works by blocking the enzyme 5-alpha-reductace. This enzyme converts testosterone to dihydrotestosterone (DHT) which is the substance primarily responsible for hair loss in androgenetic alopecia. By blocking DHT production, finasteride can help reduce the rate of hair loss and even promote hair regrowth. Finasteride does not reduce overall testosterone levels. This medication comes as a pill that is taken once a day and is only available by prescription. Finasteride has a long track record of effectiveness and safety across many studies. Like any medication, however, there are potential side effects of treatment to consider. In men these side effects may include a decrease in libido, erectile dysfunction, breast tissue enlargement and depression. Women who may become pregnant should not take finasteride due to known risk of birth defects when taking this medication.
Dutasteride (Avodart®) is FDA approved for the treatment of prostate enlargement and is undergoing trials for FDA approval for hair loss as well. The mechanism of action is similar to finasteride and also blocks the 5-alpha-reductase enzyme. While finasteride blocks Type II of the enzyme, dutasteride blocks both types I and II. Dutasteride is approved for the treatment of hair loss in Europe, and physicians in the U.S. may prescribe dutasteride as “off label” treatment for certain types of hair loss. The side effect profile is similar to finasteride.
Platelet Rich Plasma (PRP)
Platelets are a natural component of blood that play a role in clot formation and also supply many growth factors important in wound healing and the body’s natural response to injury. Platelet rich plasma (PRP) is a concentrated solution of platelets that is isolated from a small sample of an individual’s blood. PRP has gained wide popularity in the Orthopedics and sports medicine world for its ability to enhance wound healing and recovery following injury. Recently, PRP has been used in hair restoration to help improve wound healing and graft survival with some early positive results.
PRP is obtained from a small sample of blood drawn from the arm. This blood sample is then separated into a concentrated platelet component in a centrifuge to make PRP. The PRP can then be added to the hair grafts just before transplant to enhance survival or injected into the scalp to improve wound healing. Since PRP is isolated from an individual’s own blood, there is no risk of rejection to the product, but there is often some temporary redness and inflammation present around the site of PRP treatment since PRP works by inducing inflammation.
Although there have not been enough large studies yet to prove the effects of PRP for hair restoration, smaller studies have suggested its use may help improve graft survival of transplanted follicles and improve wound healing particularly in locations of previous scar or trauma. There are also some reports suggesting that PRP injections to the scalp without transplantation may help promote hair growth of previously dormant follicles.
Low Level Laser Treatment (LLLT)
A non-invasive treatment that may help combat hair loss either alone or in combination with other medical or surgical treatments is low level laser treatment. This treatment involves shining multiple low level lasers over the surface of the scalp. This light is absorbed by molecules within the hair follicles that are responsible for slowing hair loss and promoting regrowth. There are several devices that are FDA cleared for this treatment and many are used in the home setting two to three times per week. While the effects of LLLT have not been proven in large double-blind studies there is some evidence from clinical trials to suggest some efficacy for mild to moderate hair loss. The treatment is well tolerated with few reported side effects and may be recommended as an adjunct to other treatments by your surgeon.
Hair Line Design
One of the most critical aspects to a natural looking result is the design of the hairline. The directionality of the transplanted hair throughout your scalp determines how naturally your hair will lay and style. This is something your surgeon will discuss with you before your procedure. Hairlines are not simply a curvature following the forehead; there are many subtleties to the variance in the design. And, depending on your degree of hair loss, a full restoration to your hair may not be possible, so creating a hairline that mirrors natural changes is critical to a desirable result.
Follicular Unit Transplantation (FUT)
Follicular unit transplantation involves the removal of a portion of the hair bearing scalp most commonly from the lower back portion of the head. This portion of the scalp rarely ever loses its hair, and the transplanted hair normally maintains the loss pattern from the area it is taken from, making this location an ideal donor site. The portion of hair that is removed is then microscopically isolated into individual follicles, each containing on to four hairs, before being re-implanted into the area of the scalp that requires additional hair volume. This is a very time intensive process, usually taking anywhere from two t0 six hours. This procedure creates a linear scar along the back of the scalp, but does not require shaving of the head and the scar tends to be well hidden in the hair.
Follicular Unit Extraction (FUE)
Follicular unit extraction is a process that removes individual hair follicles one by one from the back of the head before implanting these follicles into the part of the scalp that is thinning. This is a specialized technique that requires the surgeon to identify each hair follicle to be removed, use a specialized machine to remove the follicle, and then create an incision for the hair follicle to be implanted into. FUE is a very time intensive process, with the average time taking between two to eight hours. This procedure does not create the linear scar along the back of the head as FUT does, however, the hair must be clipped short prior to the procedure in order to best isolate the follicular units.
At Your Visit
The goals of the initial consultation are to understand the cause and extent of your hair loss and develop a comprehensive treatment plan. You will meet with the surgeon directly who will perform a thorough evaluation of your current hair loss history, complete medical history, and careful examination. It is helpful to come prepared to discuss the timing and speed of your hair loss, family history of male or female hair loss, complete list of medications, and any previous hair loss treatment including over the counter remedies. Photographs that show your hair pattern at younger ages can also be helpful. The examination will involve careful inspection of your face and scalp along with magnified examination of your hair. Photographs of your scalp and hair will be taken as part of your medical record to track hair restoration during treatment. At times a biopsy of the scalp may be suggested to better understand the exact cause of your hair loss and referral to a Dermatologist may also be recommended based on these findings. Scalp biopsy is a simple procedure performed at the time of your visit that involves a small injection of anesthesia to the scalp followed by excision of a small group of hair follicles. The site may be closed with one or two sutures if needed.
After the evaluation has determined the cause and pattern of your hair loss, you and your surgeon will discuss your treatment goals and identify the best treatment options to achieve these goals. For some people this involves medical management, for others surgery is suggested, and for many the best results may come from a combination of medical and surgical treatment. Typically medical treatment is started first and treatment response is assessed prior to pursuing any surgical management.
The Day of Your Surgery
Hair restoration surgery is performed under local anesthesia in the office. Your surgeon will estimate the total time of your procedure, but be prepared to spend several hours in the office the day of your surgery. The morning of surgery you should eat a regular breakfast and take your regularly scheduled medications other than those specifically told to avoid by your surgeon. Typically medications that thin the blood are avoided for several days prior to surgery. Wear comfortable clothing the day of surgery. There will be an opportunity to take short breaks during the procedure for food or restroom needs as necessary.
The morning of your surgery you will meet again with the surgeon to review the treatment plan and answer any remaining questions. The planned areas for implantation will be marked on your scalp so both you and your surgeon agree on the overall treatment area and design. You will also meet the rest of the surgical staff including nurses and hair transplant technicians.
The procedure usually starts by removing the hair follicles from the donor area in the back of the scalp. Local anesthetic is injected to numb the area and once the numbing is effective there should not be any pain with follicle removal. The follicles are removed either as a strip of hair or individually with FUE depending on the exact surgical plan you and your surgeon selected. The follicles are then carefully prepared by the hair technicians under the microscope while the surgeon numbs the area of the scalp to receive the grafts. The surgeon will then make small incisions in your scalp that the hair follicles will sit in and the technicians will place the hair in these incisions along with the surgeon.
After the procedure you will not have a dressing over your scalp but will be given a spray bottle to use regularly to keep the scalp moist. You will be given prescriptions for medication for pain and swelling. You should have a friend or family member available to take you home and stay with you for the first day after the procedure.
During Your Recovery
After your procedure you will have some discomfort in the scalp that is usually easily controlled with the pain medication prescribed. You will be given a spray bottle to take home and will need to spray this on your scalp very frequently for the first several days after your procedure to keep the grafts moist and improve the chance of survival. If a strip of skin was removed from the back of your scalp, you will have an ointment to apply to the stitches in this area. You will have some swelling and possibly bruising to your scalp after the surgery, it is recommended to sleep with you head elevated for the first several days to help relieve this swelling. After 24 hours you may take a shower and gently shampoo your hair without scrubbing then pat your hair dry. You will continue to regularly use the spray bottle to keep the hair moist during the healing phase. Light activity is recommended immediately following the procedure, but this can be steadily advanced in the weeks after your surgery.
Expect to have a follow up visit with your surgeon several days after your procedure to assess the grafts and remove any sutures that are present. Your surgeon will discuss allowable timing for haircuts, coloring or resuming any topical hair medications such as Rogaine. It is normal for the transplanted hairs to fall out two to four weeks after the surgery. Do not be alarmed, this is expected. New hairs will begin to grow back three to four months after your surgery and will continue to grow in over the following six months. You will follow up with your surgeon regularly during the first year after your surgery to assess the response.