Case 15: Surgical Hair Restoration: Men vs. Women - Bernstein Medical - Center for Hair Restoration
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June 27th, 2023

A 50-year-old husband and wife came together for a consultation. They were both diagnosed with androgenetic alopecia and had questions about their diagnoses and possible surgical treatment.

Question 1: What is the incidence of androgenetic alopecia in men vs. women in a middle age 50-year-old individual?

  1. Men 80% and women 20%
  2. Men 50% and women 40%
  3. Men 30% and women 30%
  4. Men 20% and women 80%

Answer B. Men 50% and women 40%. By 50 years of age, approximately half of all males will have androgenetic alopecia. In women, androgenic alopecia is also common but typically occurs later in life than in men. It affects around 40% of women by the age of fifty. A good rule of thumb with males is that each age is approximately what percentage of the patient has androgenetic alopecia (i.e., about 20% of 20-year-old male patients have androgenetic alopecia and about 60 % of 60-year-old male patients will have androgenetic alopecia). It is important to note that the severity of androgenetic alopecia will vary greatly depending on the individual’s genetic predisposition.

Question 2: What is an appropriate minimum age for transplanting in men and women?

  1. Men 20 years old and women 20 years old
  2. Men 20 years old and women 25 years old
  3. Men 25 years old and women 20 years old
  4. Men 25 years old and women 25 years old

Answer D. In our practice, have a minimum age of 25. In general, we want to avoid transplantation too early as we do not have enough information regarding how the patient’s hair loss will progress, nor can we assess the donor area’s long-term stability. In addition, older patients have more realistic expectations regarding the hair restoration (especially with respect to hairline placement and density) and, as one gets older, having some thinning is more socially acceptable.

Question 3: What is true about androgenetic alopecia in men and women?

  1. Men and women experience hair loss in basically the same way, with little real difference in pattern.
  2. Female androgenetic alopecia often leads to completely bald areas, like male androgenetic alopecia.
  3. Male pattern baldness typically starts with a receding hairline at the temples and thinning crown, while female pattern hair loss is characterized by diffuse thinning on the top of the scalp.

Answer C. In men, the typical pattern of androgenetic alopecia begins with a receding hairline and thinning at the crown of the head, eventually leading to partial or complete baldness. It is important to note that other patterns exist, including the anterior, vertex, and diffuse patterns. Women with androgenic alopecia typically experience diffuse hair thinning on the frontal/top of the head. Women can exhibit a patterned distribution where most of the thinning occurs on the front and top of the scalp with relative sparing of the back and sides, but this pattern is less common.

Question 4: How does the diffuse thinning in women affect hair transplant decisions? (Indicate all that apply)

  1. Men are often better candidates for hair transplants than women.
  2. Transplanting patients with diffuse hair thinning are more prone to shock loss after the transplant.
  3. Women are often better candidates for hair transplants than men.
  4. The donor area in women is generally more stable than in men.

Answers A and B. Hair transplantation is better for treating patterned hair loss (with localized areas of very little or no hair) rather than diffuse thinning. Patterned hair loss is more commonly seen in male androgenetic alopecia. However, if a woman presents with patterned hair loss, surgery can be very successful. Diffuse hair loss is more commonly seen in women. Diffuse thinning is generally best treated medically. The main reason why patients with diffuse thinning are generally not good candidates for surgery is that there is no permanent area to harvest the hair.

In addition, by definition, thin areas have high degrees of miniaturization. The reason why diffuse thinning (areas of high miniaturization) should be treated medically, rather than surgery, is because medical treatment can act on the all the miniaturized hair to help reverse the process, whereas surgery may actually cause them to be lost.

Question 5: How does transplanting a hairline differ in men and women? (Indicate all that apply)

  1. Men’s hairlines are generally more rounded.
  2. Women’s hairlines are generally more rounded.
  3. Mens hairline have more prominent temporal peaks.
  4. There is no difference in this regard.

Answer B and C. Women generally have a rounded hairline. Men generally have more prominent and pointed temporal peaks than women, but both sexes may have them to some degree.

Question 6: How does sex affect the decision to recommend follicular unit transplantation (FUT) or follicular unit extraction (FUE)?

    In general, women are often better candidates for FUT than FUE.

  1. In general, men are often better candidates for FUE than FUT.
  2. In general, men and women are equally good candidates for FUE and FUT.

Answer A. Generally, FUT yields better quality grafts and thus better growth than FUE. This is because, with the FUT procedure, the grafts are visualized microscopically, and we can ensure the necessary support structures are part of the graft. The main limitation of FUT is the donor area’s linear scar, which precludes one from wearing short hair on the back and sides. Since this is rarely a problem for women, they should take advantage of FUT’s better yield. FUE requires a broadly shaved area over which to harvest; this volume loss is extreme for a female patient. In men, the decision is more nuanced as having the option to wear their hair short may be more important than maximizing yield.

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