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The following are excerpts from the Question and Answer segments of Dr. Bernstein’s Open House Seminars.



HAIR TRANSPLANT SEMINAR: PART 2

Hair Transplants in Women

Attendee: I went to two dermatologists and they told me that I am perfectly healthy, but I was told that I had hormonal hair loss related to aging. What is your experience with hair transplants in women? I see mostly men in the audience!

Dr. Bernstein: Although both men and women have hormonal hair loss, the mechanism in each is different. In the typical pattern of hair loss in men, the follicles in the front and top of the scalp are sensitive to the hormone DHT (produced by the action of the enzyme 5-alpha reductase on testosterone). Over time, DHT causes the affected follicles to become smaller and to eventually disappear. This process is called miniaturization and it occurs in a specific pattern involving the front and top of the scalp. That is why it is called “patterned” hair loss. The back and the sides of the scalp are generally not affected in hereditary “or androgenetic” baldness.

With hair loss in women, the more characteristic pattern is a diffuse type hair loss, which means there is thinning all over. This pattern in women results from the combined effects of two different enzyme systems. One is the DHT pathway that is similar to men. However, women also have an enzyme called aromatase that contributes to their hair loss. Men do not have this enzyme. It is felt that aromatase is at least partly responsible for why a woman’s pattern of baldness is different from a man’s. It is part of the reason that women’s hair will thin all over rather than have thinning just on the front and top of the scalp, with the hair on the back and sides being permanent.

There are a number of implications to this. First, when you thin evenly all over, it usually looks OK until there is a very dramatic amount of hair loss. Usually women complain of decreased hair volume, but they do not actually have bald spots, so people do not notice. Women typically feel much worse about their hair loss than others can appreciate, because changes in volume are often noted by the actual person who is thinning way before it is noticeable to others.

With respect to treatment, what surgical hair restoration does, is to move hair from an area of good density to an area where there is very little. It redistributes hair. Hair transplant surgeons do not actually create new hair (this is cloning) we just move the hair from the back and/or sides of the scalp to the front and top. So, if your hair is thin, but evenly distributed, you really cannot benefit from moving it around.

In this woman, we see that the top is barely thinning, but so are the back and sites, so there is little to gain by moving hair from the back to the top. This difference in the balding pattern is unfortunately the main reason why more men are candidates for hair restoration surgery than are women.

Another reason that women with diffuse hair loss are generally not good candidates for hair transplants is that, in the area of thinning, the hair is undergoing the process of miniaturization. This miniaturized hair can be subject to being shed from the surgery. Now, in a man who is already bald in a specific region of the scalp, we do not really care very much. However, if you have a lot of hair in that area and we are putting just a little bit in, the risk of losing miniaturized hair can outweigh the benefit of what we may be transplanting during the hair transplant.

The third reason, which is the most important, is that in women, the donor area, because it is also thinning, will continue to thin even after you move it. Just because one performs a surgical hair restoration, it does not make that hair permanent if it was not permanent in the donor area. The hair is no better than the area that it comes from.

Therefore, if you have a woman, who is thinning all over and you take hair that may not be permanent over the long term, and put this hair into an area that already has hair; you have risk in both places. You have the risk of shedding because you are putting new hair into an area that already has a lot of hair and you have the risk that the hair you are putting it in may not be permanent. In a man, with patterned hair loss, you have neither of those risks. The donor area is relatively permanent and we are usually putting it into an area that does not have very much hair.

So, when are women candidates for a hair transplant? They are candidates when their hair loss is patterned. When they have a relatively localized area of thinning and a stable donor area.

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