Introduction
A successful hair transplant depends on the appropriate selection of patients by the
surgeon. Not every balding person is a candidate for hair restoration. Missed diagnoses
can lead to poor surgical outcomes.
The most common indication for hair transplantation in both men and women is patterned
alopecia. Patterned alopecia incudes male pattern hair loss (MPHL), which is also
known as androgenic alopecia (AGA), and female pattern hair loss (FPHL). [Fig. 1] shows the widely used Norwood–Hamilton classification of MPHL and [Fig. 2] shows the Ludwig classification of FPHL.[1]
[2] A minority of women will have frontotemporal hair loss in patterns similar to the
Norwood–Hamilton patterns.
Fig. 1 Norwood classification of male pattern hair loss (MPHL).
Fig. 2 Ludwig classification of female pattern hair loss (FPHL).
The majority of patients with pattern hair loss, at some point in the course of their
condition, will be candidates for transplantation. A hair transplant can be performed
for any person with sufficient hair loss, good donor area hair, a healthy scalp, in
good general health, and who has reasonable expectations.[3] When the hair transplant is done by a well-qualified, trained, and experienced surgeon,
results are natural and enduring.
Diagnosis and Determining Surgical Candidacy
The key to identifying and excluding patients with PHL, who are not candidates for
hair transplantation, is being able to perform a competent and thorough general medical
and scalp-specific history and examination. A hair surgeon must be fully trained and
experienced in performing this evaluation. It is relatively easy to identify many
cases of poor candidacy, but some of these cases are subtle and can be missed without
detailed and knowledgeable evaluation.
Essential questions to determine candidacy
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Is there a pattern to the hair loss?
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Is there greater than 50% hair loss in any part of the scalp?
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Does the scalp appear healthy?
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What is the quality and quantity of hair in the donor region?
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Is the hair loss unstable?
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Does the patient have realistic expectations?
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Are there any medical or dermatologic conditions that could interfere with the surgery?
Caveats to Avoid Misdiagnosis
For all patients:
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Take a thorough general medical history.
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Take a thorough hair loss-specific history.
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Examine the entire scalp, both donor and recipient areas of both the hair and the
scalp. In men, examine the nonscalp donor areas of the beard and body.
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Routinely use dermoscopy/densitometry.
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Have a high index of suspicion—get consultations/biopsies if anything unusual.
In each consultation, get a thorough current and past medical history to identify
any conditions that could be contributing to hair loss or which could impact on surgery.
A detailed history of the development and character of the hair loss must be obtained.
When did the hair loss start? Is it now stable or worsening slowly or rapidly? Is
there a family history of hair loss; if so, who and what patterns? What treatments
have been used? Diagnoses by other doctors who were consulted.
Examine the entire scalp thoroughly. This means combing through the whole scalp while
looking at the condition of the scalp and quality and density of the hair. During
this examination, pay attention to miniaturization of hair (which is the hallmark
of PHL), variations in density, scaling or redness of the scalp, and loss of follicular
ostia and shininess. Is there gross evidence of hair loss? Note the degree of loss
for each location. Is the loss patchy? Diffuse?
Routinely use dermoscopy/densitometry in both the recipient and donor areas to determine
density and the degree of miniaturization, percentage of loss density, and further
characterize any scalp findings.
Hair of 60 to 65 microns is considered fine hair, 65- 80 microns is considered medium
hair, and greater than 80 microns is considered coarse hair. Less than 60 follicular
units (FUs)/cm2 in the donor region is considered low density.
If this examination shows only findings consistent with PHL, if the donor area is
of good density and condition, and if the there are areas of sufficiently developed
balding, hair transplantation can be undertaken.
On the other hand, if there are scalp findings or unusual patterns of hair loss and/or
miniaturization in the donor area, further evaluation is needed before undertaking
transplantation. This means possible biopsy and dermatology consultation.
Contraindications to Transplantation in Patterned Hair Loss
While there are few absolute contraindications to hair restoration surgery, there
are several relative contraindications.
Avoid Performing Hair Transplant Surgery in These Eight Patient Categories
1. Diffuse unpatterned alopecia
It is essential to identify patients who do not have a patterned alopecia, but rather
they have a diffuse unpatterned alopecia (DUPA). The key aspect in making this differentiation
is that the miniaturization and loss of density is not confined to the top of the
head, but also involves the temporal, parietal, and occipital scalp ([Fig. 3]). The concept of donor dominance is at the heart of hair transplantation. To produce
an enduring result with hair transplantation, the donor follicles must be taken from
the portion of the scalp which is spared by the pattern of alopecia and commonly referred
to as the safe donor area. If there is no such donor area, as in DUPA, transplantation
will not be successful and should not be performed. The loss of density and miniaturization
in many cases of DUPA is readily evident upon gross inspection. But in earlier stages
of the condition, magnified scalp examination with dermoscopy or trichoscopy is necessary
to identify excess miniaturization. Diagnosis can be confirmed by scalp biopsies taken
from the sides or back of the head as well as the top of the scalp. Medications are
the treatment of choice for DUPA and not surgery. The degree of miniaturization that
defines DUPA is not fully defined. Dr. Jose Lorenzo has suggested greater than 15%
is a warning sign (personal communication). Devroye has suggested the threshold of
35% as an absolute contraindication to surgery.[3] Anything in between is certainly cause for caution.[4]
[5]
[6]
Fig. 3 Patient with diffuse unpatterned alopecia (DUPA) (Courtesy of Seema Garg).
Diffuse Patterned Alopecia
DPA is to be differentiated from DUPA. In DPA, the hair loss does follow a pattern
and is confined to the top of the head, but the thinning is present throughout the
entire pattern rather than focused on specific regions, as in the Norwood patterns
([Fig. 4]). Those with DPA are potential candidates for hair transplantation.
Fig. 4 Patient with diffuse patterned alopecia (DPA) (Courtesy of Seema Garg).
2. Cicatricial Alopecias
CAs may mimic PHL or may occur along with PHL. Hair transplantation is not indicated
with active CAs, as not only is there a high risk of failure but hair transplant surgery
can also exacerbate the disease. Cicatricial alopecias include lichen plano pilaris
(LPP), CCCA, discoid lupus erythematosus (DLE), and others.[7]
[8] In scalp examination, look for patchy hair loss, redness around the base of hair
follicles as they exit the skin, loss of follicular ostia, shininess of the skin,
scarring of the scalp, or hair loss without miniaturization ([Fig. 5]). There can be underlying PHL and superimposed CA. These lesions can occur anywhere
throughout the scalp—recipient and donor areas. In the presence of any of these signs,
dermoscopy and scalp biopsy are indicated before proceeding with hair transplantation.
Although controversial, hair transplantation may be undertaken when the CA is burned
out, no active disease for two or more years, or biopsy confirmed. Yield may be suboptimal
due to the scarring, and results may be only temporary.
Fig. 5 Patient with cicatricial alopecia (CA) (Courtesy of Seema Garg).
3. Alopecia areata
An autoimmune variant that affects hair follicles, AA may coexist with PHL. Patchy
hair loss may occur anywhere in the scalp, beard, or body hair[9] ([Fig. 6]). Detection of such a patch or multiple patches necessitates a high index of suspicion
and should be followed by dermoscopy, biopsy, and possible dermatology referral. Hair
transplant is contraindicated in the presence of active AA, even if there is also
PHL. Surgery may precipitate a recurrence and the transplanted hair may be affected
by AA. If there has been no active disease for an extended period (2 or more years),
the risk with hair transplant is diminished but not eliminated.
Fig. 6 Patient with alopecia areata (AA) (Courtesy of Seema Garg).
4. Patients with unstable hair loss
It is essential during the initial consultation that the practitioner develop an assessment
of the stability of the patient's condition. If the history indicates that the condition
has not been changing or accelerating recently, and if there is not a high degree
of miniaturization in the area to be transplanted (less than 15%), it is safe to proceed
with surgery. On the other hand, if the history indicates rapid deterioration and
progression and the recipient area has greater than 15% miniaturization, it is better
to initiate medical therapy for 6 to 12 months to stabilize the patient before proceeding
with surgery. A patient with a high degree of miniaturization in the recipient area
is at high risk of experiencing shock loss with transplantation that may be permanent.[10] Patients who experience this kind of hair loss from the surgery are likely to be
unhappy and feel that the surgery has made them worse rather than better. A total
of 6 to 12 months of medical therapy with finasteride, minoxidil, low-level laser
therapy (LLLT), and platelet-rich plasma (PRP) is likely to reverse some of the miniaturization
and lessen the impact of shock loss secondary to the surgery.
5. Patients with insufficient hair loss
Most patients with PHL will present with some of the areas of the top of the head
with readily visible loss of hair density and the scalp showing through the hair.
In these areas, over 50% of the native hair density has been lost. This is generally
held as the threshold at which hair transplantation can be performed without risking
damage to the native hair in the recipient area. Some patients will present without
any areas of the scalp showing such thinning. Nevertheless, closer examination with
trichoscopy will reveal the presence of PHL and miniaturization. Such patients are
not yet candidates for hair transplantation. Rather, medical therapy is indicated
along with ongoing monitoring until such time that loss of hair density reaches the
threshold for transplantation.
6. Beware the young patient!
Surgeons must be particularly cautious when dealing with young male patients in their
late teens to early 20s.[11]
[12] Often when PHL develops at such a young age, it is both rapidly progressive and
emotionally devastating to the patient. When these patients present for the consultation,
there is often a sense of urgency on the part of the patient and sometimes his parents
to “fix” the problem, and they come to the office convinced that getting a hair transplant
is what will resolve the situation. In many instances, their hairline has receded.
This recession may have converted their juvenile low and flat hairline to the level
of a normal adult male hairline. They show you a picture of their favorite pop star
with a very thick head of hair and a low, flat hairline and squared-off temples, declaring
that this is what they want. Or they may have a balding vertex and want it restored
to the original density. These patients often have very unstable hair loss, and they
are undergoing rapid progression of their balding. Most will, without intervention,
end up with Norwood class 5–6 balding by age 30, if not before. While tempting to
the surgeon, performing a hair transplant at this early stage is the wrong way to
treat these young patients. Giving the patient that low flat hairline and/or overutilizing
donor supply to make the vertex hair thick will jeopardize the future for these patients
and come back to haunt both them and the surgeon.
Proper care for these patients means that the surgeon will spend time explaining the
progressive nature of the balding process and the need for ongoing treatment throughout
adulthood. Medical treatment will be recommended with the goal being stabilizing the
progression of balding and perhaps restoring some lost density prior to performing
a hair transplant. This means deferring consideration of hair transplanting for at
least a year. During that year, the patient should be seen two to four times to monitor
medical therapy effects and side effects, with the goal of helping the patient get
the best results. It is essential that the patient be fully informed about the medications
prescribed and understand that effects take months to develop fully.
Some patients will reject medical therapy and insist on transplantation. Rather than
bowing to this pressure, the best course for the surgeon is not to do the surgery
but to invite the patient to get further consultations with reputable and ethical
surgeons and to return for a second consultation. Without medical therapy, it is probable
that these patients will be chasing their progressing balding with a series of surgeries
until their donor supply, their doctor, and they are exhausted and unsatisfied.
7. The patient with unrealistic expectations
Apropos the discussion above of the pitfalls of transplanting in young patients, there
also lies the issue of examining the problem of the patient with unrealistic expectations.
The patient who is showing you the picture of their favorite pop star, movie star,
or professional athlete typically has unrealistic expectations. Our goal with transplantation
is not to create a superdensity as great or greater than the prebalding level. Rather,
we aim for cosmetic density that creates the appearance of density without actually
restoring or surpassing the original density. A patient who expects to see no scalp
at all after transplantation is going to be very difficult to satisfy. At the same
time, a patient who expects that there will be “zero” scarring after surgery will
be equally at risk for dissatisfaction. It is the surgeon's responsibility to be able
to educate the patient with reasonable expectations and be convinced that they understand
and accept these limitations. If not, proceeding with surgery can be risky and problematic.
8. Patients with psychological disorders
The most complex psychological disorder is BDD. These patients will often present
with very trivial defects, sometimes not even evident to the examining surgeon. They
will report a fixation of this defect, constantly looking in the mirror and believing
that others are aware of the defect and staring because of it. It is a mistake to
transplant these patients. They are at high risk of being dissatisfied, seeking a
never-ending stream of “corrective” surgeries and also being litigious. They may not
readily accept a refusal to perform surgery, and they may not accept recommended psychological
counseling.
Another risky patient to transplant is the patient with trichotillomania, an obsessive-compulsive
disorder of incessant hair pulling and plucking. A patient may have this coexisting
with PHL, or they may produce a balding pattern that mimics pattern hair loss ([Fig. 7]).
Fig. 7 Patient with trichotillomania (Courtesy of Seema Garg).
Inquiring about hair pulling needs to be a routine part of the consultation, as does
an examination of the balding area for broken hairs. Sometimes patients will deny
hair pulling, making diagnosis more challenging. Trichotillomania is not an absolute
contraindication to hair transplantation, but transplantation should be deferred,
pending psychological treatment and stabilization.
Anxiety and/or depression are not contraindications and transplantation may help in
treating these conditions. It is important for the surgeon to support the patient
in receiving psychological treatment for these disorders in conjunction with hair
loss treatment.
Proceed with Caution
Patients with Medical Conditions that Complicate Surgery
Patients who smoke regularly are at risk of having poor yield from their hair transplant
because of the vascular effects of smoking. The best situation is for the patient
to completely stop smoking a month or two before the transplant and not resume smoking
afterward. If this is not possible, then cessation 3 weeks before and after can reduce
the risks. But if the patient cannot or will not do either of these, the best course
is to not perform surgery. If surgery is performed on a smoker, without cessation,
he/she should give written acknowledgment of being informed that the result may be
suboptimal.
Patients with long-standing diabetes with microvascular damage or patients with extensive
solar damage to the scalp are also at risk of suboptimal yield and should be so advised
prior to surgery. Perhaps, the best course for these patients is to do smaller treatments
with somewhat lower density.
Other patients with chronic medical conditions such as hypertension, heart disease,
diabetes, excessive alcohol use, immune deficiency, anticoagulation, and others can
undergo hair transplantation if these conditions are fully recognized and managed
before and during surgery.
Relatively Poor Candidacy
Some patients will have poor quality or limited donor hair, making them relatively
poor candidates for surgery, particularly if they have advanced balding. They will
be able to only cover a part of the balding area (usually frontal forelock) and achieve
lower density of coverage. This does not mean that they cannot have surgery, but that
they must be aware of and accept the limitations of what can be achieved ([Fig. 8]).
Fig. 8 Poor Candidates for hair transplantation.
