Hair transplantation is an elective procedure. However, regardless of a desire to have surgery, patients should meet a number of basic criteria that will determine if they are indeed surgical candidates.
Criteria to have surgical hair restoration:
- A diagnosis of androgenetic alopecia (common genetic hair loss) or another condition that is amenable to hair transplantation
- First explored medical therapy and, if appropriate, given adequate time to see a full response (generally one year)
- Sufficient hair loss that it affects their aesthetic appearance
- Adequate donor hair to satisfy current and future needs
- Realistic expectations on what surgical hair restoration can accomplish
For most patients, these basic guidelines will determine their candidacy for hair transplant surgery. However, for female and young male patients, determining candidacy is a more complicated matter.
Hair Transplantation in Young Patients
Some young people experiencing hair loss think that a single hair transplant will be the solution to their present and future balding. Wanting a quick and permanent solution, they begin the consult requesting a hair transplant even before the physician has had a chance to examine them and offer suggestions on the various treatment options. They often expect the surgery to restore their adolescent hairline and give them back their old density. Despite these requests, a hair transplant is not advised in patients younger than 25 for five main reasons:
- It is difficult (or impossible) for a physician to determine the boundaries of the permanent zone when a person is young
- It is difficult (or impossible) for a physician to determine if the donor area of a young person will be stable over time
- The earlier the hair loss begins, the more likely the baldness will become extensive (and perhaps too extensive to make a hair transplant worthwhile)
- A younger person’s expectations may be too high (with respect to desired density and position of the hairline)
- A younger person may not know how he may want to wear his hair in the future and any hair transplant (FUT or FUE) can produce donor scarring that may preclude that patient from wearing his hair very short
Boundaries of the permanent zone
The exact size and shape of the permanent zone is very difficult to determine in younger patients since miniaturization may begin at any age. Areas that looked stable in a patient in his twenties can have a vastly different appearance over time. This problem has become more acute with the increasing popularity of Follicular Unit Extraction (FUE). Since FUE generally requires five times the donor area of a traditional FUT/Strip procedure, delineating the extent of future baldness (particularly the upper demarcation of the donor area) is important to prevent the punctate scars of FUE becoming visible over time. In addition, FUE is generally the procedure of choice for younger patients.
Donor area stability
In most patients, the donor area is resistant to DHT over the long-term. Some patients, however, have a less common type of androgenetic alopecia called Diffuse Unpatterned Alopecia (DUPA). In patients with DUPA, the donor area is not stable and will thin over time. If a hair transplant is performed on a young patient that turns out to have DUPA, the transplanted hair will succumb to the effects of DHT and the cosmetic benefit of the surgery will be lost, i.e. the hair transplant will vanish. In addition, the hair in the donor area may thin to such a degree that the donor scars, normally covered by hair, may become visible – this is true for both the linear scar of FUT and the small round scars of FUE.
Unfortunately, there is no blood test for DUPA. DUPA is identified by miniaturization (shrinking of hair follicles in response to DHT) in the donor area, but this may be very difficult to detect in its early stages. Whether the donor area will be resistant to the miniaturizing effects of DHT over the long-term is a crucial question that might not be answerable at the time of the first examination.
Early hair loss as an indicator of extensive balding
The younger someone starts to lose their hair, the greater their chance of becoming extensively bald. Generally, with extensive hair loss there is not enough donor hair to transplant the entire bald area. While a young patient may be tempted to fill in their receding hairline or temples – the first areas to lose hair in patterned hair loss – doing so may actually make their appearance worse in the long term. For example, a low, transplanted hairline with an extensively bald top of the scalp is not an aesthetically pleasing look. Similarly, hair transplanted to the temples would stand in sharp contrast to an extensively bald scalp that might develop over time.
In patients younger than 25 years old, it is best to delay the decision to have surgery until a more complete picture of future hair loss can be determined. Preserving existing hair through medical therapy, finasteride (Propecia) and/or minoxidil (Rogaine) is the most reasonable course of action to consider until the hairline is mature.
A person first starting to lose his hair has crystal-clear memories of his original density and low, broad adolescent hairline, so it is reasonable that he expects a hair transplant to be able to return his hair to this state. Unfortunately, for most this is not possible – particularly in a young person who may become extensively bald. If a transplant is performed early, the person may continue to lose his hair, leaving the low, transplanted hairline with not enough hair to cover all the area behind it.
For a young person who loses a lot of hair, keeping one’s hair very short may be the best aesthetic option. However, this option may be lost once a hair transplant is performed since the scars in the donor area may be visible with very short hair (this is true for both FUT and FUE).
Often, there is not enough donor hair for a hair transplant to cover the entire scalp. An older patient who has had a hair transplant that restored hair to the front and the top of his scalp while leaving the crown bare can leave his hair a bit longer and have a very good aesthetic outcome, but this is rarely an acceptable look for a younger person. If a younger person cannot have his whole scalp covered, as he frequently desires, it is usually better to just keep his hair short and not accentuate the balding areas (esp. the crown). When that person gets older, and his expectations and needs change, a hair transplant may then be appropriate.
Although there may adequate donor hair to cover the thinning areas when a patient is young, often there is not enough donor hair to cover the entire bald area when hair loss becomes extensive – particularly the crown. To compensate for this, a patient who has had a hair transplant may wear their transplanted hair longer i.e., use hair in the mid-scalp to comb back over the crown. Another option, however, is to cut one’s hair very short, or shaven, to make the bald crown less obvious. This option will be gone after a hair transplant since any hair transplant (FUT or FUE) can produce scarring in the donor area. A young person may not know which future option he would prefer.
Hair Transplants in Women
Women’s hair loss most often presents as thinning over the entire scalp, rather than the classic pattern of balding seen in men. This “diffuse” hair loss is caused by different levels of DHT in the scalp compared to men and the interaction with another chemical called aromatase. Due to these hormonal differences, women may have an unstable donor area, and thus fewer women than men are candidates for hair transplant surgery.
Before hair transplantation is considered, female patients should have their donor density measured using a densitometer, to ensure it does not exhibit signs of thinning. It is also important that if the history suggests a cause of hair loss other than common baldness, comprehensive diagnostic testing to rule out underlying medical conditions, medications, and pregnancy should be performed. If the diagnosis is confirmed as androgenetic alopecia and the donor area appears stable, the female patient may be an excellent candidate for surgical hair restoration. However, if the donor area exhibits thinning (significant miniaturization), medical therapy is the most appropriate treatment.
Many, but not all, hair restoration physicians understand these complexities of diagnosis and treatment and exhibit adequate restraint in who they consider candidates for hair transplant surgery. For this reason, it is imperative that the prospective patient research their doctor of choice. Patients should make sure that the physician performs an adequate examination before offering surgical treatment. Younger patients should inquire about DUPA and consider the long-term ramifications of a permanent surgery. Women should have the diagnosis of androgenetic alopecia confirmed through densitometry and, when appropriate, seek comprehensive diagnostic testing to rule out non-androgenetic causes of hair loss.