The Consultation, Patient Expectations, and Patient Evaluation

Assessing the Extent of Baldness

Anticipating Short and Long-Term Hair Loss

When planning the hair transplant, always try and anticipate the patient’s worst case scenario. Although any hair loss is never really "predictable," one must still make an educated judgment as to what the future hair loss will most likely be so that rational short and long-term plans can be formulated.

In anticipating the patient’s long-term hair loss, we find three factors to be useful. Since the inheritance of male pattern baldness appears to be polygenic, it is impossible to make accurate judgments from the family history. In our own experience, we find that if a specific pattern of hair loss is recognizable in another family member that matches the patient’s own hair loss pattern and chronology, this can be useful in judging how rapidly the hair loss may progress and what the final pattern might be.

The second factor, the personal history may be of value once the patient has reached his late 20’s. When taking a history, it is important to ascertain not only when the hair loss began, but the present rate of loss. Even for the patient in his late 20’s, it is very hard to predict the future course when the present hair loss is in its early stages. The most difficult of all hair loss patterns to interpret is the Norwood Class III, as this patient has not yet "tipped his hat" as to the direction of future loss.

The third means of evaluating hair loss is to measure the degree of miniaturization in both the donor and recipient areas. Miniaturization is the progressive diminution of hair shaft size reflected in both the diameter and length, due to the genetically determined effects of aging and/or androgenic hormones on the terminal hair follicle. We find that miniaturized hairs normally represent no more than 20% of the terminal hair population. Because miniaturization is a relative measurement (comparing finer hair to the thickest hair), it takes substantial experience before this measurement can be useful to the individual clinician. In our experience, from examining and following, over 5,000 patients with the Hair Densitometer¹⁰, we have found that assessing the degree of miniaturization has useful predictive value when evaluating the risks of hair loss and in establishing hair loss patterns. A high degree of miniaturization in the upper portion of the donor area suggests that the donor fringe will contract over time. A high degree of miniaturization throughout the donor area indicates that all of the patient’s hair is unstable and that he is at risk to have diffuse unpatterned alopecia and of becoming extensively bald (see section on Diffuse Androgenetic Alopecia).

Miniaturization in the recipient area can often delineate which areas of the scalp are most likely to bald and which are stable, anticipating the patient’s future Norwood classification. In the very early stages of hair loss, increased miniaturization can anticipate future balding even before any loss is clinically apparent. Usually large numbers of hairs undergo miniaturization before any are actually lost. Therefore, even with clinically significantly thinning, the actual total number of hairs present in the balding area may be the same as the patient’s original hair counts. The percentage of terminal hairs, however, would be markedly diminished. For the most reliable prediction of the final hair loss pattern, the patient should be over the age of 30 and have had significant hair loss already, although this measurement is, of course, useful at any age.

As mentioned above, predicting future hair loss in the Class III patient is especially problematic. In contrast to the Class III Vertex patient, who we may reasonably expect will evolve into a Class V or VI (especially if there are Class V or VI family members), it is impossible to accurately predict if the Class III patient will stabilize and remain at this class or will become more extensively bald. However, a significant degree of miniaturization (>20%) measured in a young person across the top and crown, but sparing the bridge, would suggest the likely possibility of future progression to at least a Class IV or V (and possibly to a Norwood Class VI or VII pattern). Widespread areas of increased miniaturization throughout the front and top of the scalp indicate the development of either diffuse, patterned or unpatterned alopecia (see section on Diffuse Androgenetic Alopecia).

We feel that in predicting the short-term loss, the extent of miniaturization in the recipient area, as well as the rapidity of the loss, are important. In rapid hair loss, the degree of miniaturization in the balding area is well over 50%, and this can be easily determined with the densitometer. Often the reason a person seeks a consultation for hair loss is that there is some change in the "rate" of his hair loss. A patient who is gradually losing his hair is less likely to seek help than a patient who suddenly has an acceleration in the rate that he is losing hair. However, it is the very patient who is first seen while entering an accelerated stage of hair loss that is at greatest risk for being unhappy with the outcome of his surgery. Careful counseling to give him a clear understanding of the natural progression of his balding is critical in achieving realistic patient expectations. In treating patients with rapid hair loss (and adequate donor reserves), goals must be conservative and clearly defined before any surgery is attempted.

A history of diffuse, rapid hair loss, especially in a young patient, can be an ominous sign and may reflect an evolving Norwood VII pattern. This is often associated with a high degree of donor miniaturization, significant bitemporal recession, and the absence of the elevated triangular segment of hair in the parietal region that would define a Norwood Class VI. (The superior portion of the rim of Class VII patient, when viewed from the side, is flat, or slopes gently backwards. This is in contrast to the Class VI patient who, when viewed from the side, has an elevation, that has its peak just anterior to the ear and is the residual of the Class V bridge that separated the anterior and posterior portions of the scalp.) Occasionally, a young patient is seen with a complaint of loss of hair volume, but that clinically appears to be normal. If densitometry reveals a donor density in the range of 1.0 to 1.5 hairs/mm², with miniaturization in this area of 35% or greater, this patient has a high risk of being extensively bald with insufficient donor hair and, in our opinion, should generally not be transplanted.

Planning for an Effluvium and Progressive Hair Loss

The hair that is subject to being impacted by a telogen effluvium is usually miniaturized hair. Healthy terminal hair or hair from previous transplantation procedures, are much less likely to be affected. Each miniaturized hair is of smaller diameter and shorter length than the corresponding terminal hair and may not have great importance individually, but since these hairs often can be present in large numbers, they can have a substantial clinical impact. In later stages of hair loss, the balding area may be populated entirely by miniaturized hair.

Telogen effluvium is generally more significant during active stages of hair loss. This hair loss can be substantial in the young patient who is rapidly balding and whose recipient area is characterized by a high degree of miniaturization. When the effects of telogen effluvium are superimposed upon hair that is already near the end of its natural life span, this shed hair often does not return. Unless a significant amount of hair is transplanted in these individuals, the gain from the surgery may not be adequate to compensate for the loss due to the telogen effluvium. It is important to explain to the patient that when performing a transplant in the early stages of balding, large numbers of miniaturized hairs will be replaced by a relatively smaller number of healthy terminal hairs. Although the density can never reach that which was originally present, the overall clinical appearance may be improved, because these terminal hairs will have the size and luster of his original hair, and may produce a fuller cosmetic appearance. The major gains, however, will be to provide a permanent frame for the face and avoiding the problem of having to wait to become more bald in order to have a procedure. In the surgical planning, when a significant amount of miniaturization is present, the numbers of implants used should approach that which would have been planned if the area was totally devoid of hair.

It is important to note that it may not only be the actual trauma of making the sites that induces this effluvium, but the vasoconstrictive properties of the epinephrine and other factors may be contributory. In this regard, transplanting a small number of grafts may not offer any great protective advantage over transplanting large numbers. On the contrary, we feel that it is probably important to transplant enough hair to overwhelm any possible telogen effluvium that might occur so that the net effect of the transplant will be a positive one.

Assessing Donor Reserves

We find donor density and scalp laxity to be the key factors in determining the total donor reserves of the patient. The number of follicular units in the mid-portion of the donor area of a non-surgically treated, normal Caucasian male is 1 unit/mm². Thus, in the first procedure, the donor area should yield one follicular implant per mm² of scalp harvested if there is no wastage during the surgery. However, there will always be a fraction of the grafts lost from harvesting the strip and some loss from dissection of the individual units, depending upon the skill of the surgical team, which must be accounted for. In longer strips, as both the back and sides are accessed, the density will often decrease toward the temples. This must also be taken into account. In some individuals, the density can vary widely within a localized area. There will also be errors due to the visual limitations in identifying the hair, particularly in those patients with white hair. Telogen follicles, which represent about 10% of the total population, will not be visible with densitometry or under gross visualization (if the hair has been shed), but can be seen with the aid of the dissecting microscope.

Since the number of follicular units per unit area is constant, the donor density will tell us the average number of hairs per implant (i.e. it will tell us the quality of each implant). Thus, if a patient has a density of 2 hairs/mm², the donor area will contain one follicular unit per mm², and the implants will consist of an even mix of 1’s, 2’s, and 3’s, with the average being 2 hairs per implant. If a patient has a density of 2.3 hairs per/mm, there will still be one follicular unit /mm², so the same number of implants will be harvested per unit donor area, but now the implants will have an average of 2.3 hairs/mm² and consist of a mix of 1’s, a larger percentage of 2’s and 3’s, and even some 4 hair units.

If the scalp has been stretched from previous hair transplants, scalp reductions, or scalp lifts, the follicular units will be spaced further apart, and it will be necessary to actually measure the density of follicular units to accurately estimate the number of implants obtainable from the strip (as the density of follicular units will now be less than 1/mm²).

Donor scarring from previous surgeries will also have a significant impact on the ultimate donor yield. There will always be some loss of hair as a result of the actual scar produced by any donor harvest, no matter how perfectly executed. In addition, the angle of the surrounding hair in the immediate vicinity of the scar will be altered slightly so that there will be more transection in any subsequent harvest. This effect has been reduced, since the use of the multi-bladed knife has been abandoned by these authors and replaced by two parallel blades, with adjustable spacing, angled at 30^o. In addition, the use of tumescence in the subcutaneous fat, increases the margin of safety below the follicles when harvesting the implants. However, even with these improved techniques, the blades still may damage more hair follicles in scarred rather than virgin scalps, due to the altered angle of the remaining hair. Racial differences will also have a significant effect upon the number of implants that may be harvested per unit area.

A person can lose a substantial amount of his/her hair volume before any change is noticeable. When the hair is blonde or white, more hair can be lost before the thinning is evident. When the hair is black and the skin white, thinning may be evident even sooner. This loss in volume can either be due to actual loss of hair or due to the decreased volume of each individual shaft from miniaturization. In our experience, in a person with average density and average hair attributes, half of the donor area may be moved without a significant change in appearance. However, in a person whose normal donor density is 25% below average, (i.e. 1.5 hairs/mm² rather than 2.0 hairs/mm²) there would be a 50% decrease in moveable hair since the same fixed amount (1.0 hairs/mm²) must still remain for the donor area to look natural. As discussed above, the assessment of miniaturization (the progressive diminution of hair shaft size) must always be part of the evaluation. A high degree of miniaturization in the donor area can mean that a significant portion of the patient’s donor hair is unstable, and this must be accounted for in the long-term surgical planning.

While donor density was thought to be the critical factor in determining the patient’s ultimate donor supply, it appears that scalp laxity plays a much greater role in the total availability of donor hair than had been previously imagined. In a patient with a loose scalp, the harvesting of the donor strip merely removes some of the scalp redundancy and has little impact on the density. With a tight scalp, however, each procedure stretches the skin, producing a measurable decrease in the density (hairs/mm²). The full impact of a tight scalp is not usually appreciated at the first surgery, but on subsequent procedures the ability to produce a non-tension closure and to harvest a significant amount of hair (in the face of decreased density) can be severely compromised. In a patient with a scalp that is tighter than normal, the long-term goals must be scaled back to coincide with a more limited donor supply. The adverse effects on scalp laxity, as well as donor density, are among the many reasons why scalp reductions are not generally recommended.

The dimensions of the donor area are also very important. We measure the length of the donor region from 3 cm behind the temple hairline to the corresponding part on the other side. This distance should be at least 30 cm. If it is less, more conservative goals should be considered. As mentioned previously, recession at the temples can be a sign of extensive balding, and densitometry should be performed to assess the stability of the temple hairline position. The height of the permanent zone is equally important and this distance can vary markedly, even from one Norwood Class VII patient to another. Again, densitometry can measure the extent of miniaturization which is useful in assessing what the future dimensions of this region might be.

What Can Be Accomplished in The First Session?

Patient Expectations

In our experience, patient expectations are most often influenced by the patient’s age, stage of hair loss, and its rapidity. The young patient (those in their 20’s) with the memory of their adolescent hairline and density still clear in their minds, are also the ones most susceptible to rapid, significant hair loss and are the patients that need the most time in the education and planning process. Other factors include the person’s social situation (such as how he is perceived by significant others), and how he has been dealing with his hair loss (such as using a hair piece or the continuous wearing of a hat). It is incumbent upon the physician to educate the patient and set his expectations correctly, or the patient may never be satisfied.

The patient should not be led to believe that hair restoration surgery will restore what has been lost. In the ideal situation, hair restoration surgery should maintain the patient’s adult appearance and give him the same "look" as he would have had if he had simply "matured." The surgery should never attempt to restore the patient’s adolescent appearance. At a minimum, it can keep the patient from perceiving himself as being bald. In a patient who is distraught from extensive hair loss, this alone can be a significant accomplishment.

The young, rapidly balding patient poses perhaps the greatest challenge. Even an extensive procedure may not be able to compensate for the loss that can occur during the year it takes for the implants to fully grow. In this patient especially, understanding every aspect of the dynamic nature of the hair loss is critical. The progressive nature of balding, realistic hairline placement, the sparing of the crown, and the possible acceleration of loss from the surgery itself must be clearly explained. If the patient does not grasp each and every one of these ideas, it is better to postpone the surgery. Time is always on the physician’s side, since the progression of the patient’s hair loss will make each of these issues more tangible to the patient, simplifying the education process.

At the other end of the spectrum, the patient who has been bald for many years is much easier to satisfy since his expectations are generally reasonable, and modest amounts of hair will produce a marked change in his appearance. However, this same patient who has worn a hair piece for many years identifies with this look and is much more difficult to please. Like the very young patient, his reference point is a full head of hair. If this patient’s only goal is to be rid of the hair system, it is critical to determine the necessary amount of coverage that would be needed to accomplish this. If this has not been established beforehand, a transplant that might be perfect in every other respect, will be a total failure if the patient still feels compelled to wear his hair piece.

Different problems are presented by patients with more limited hair loss. The person who presents with recent progression from an adolescent hairline (Norwood Class I) to a mature hairline with natural recession at the temples (Class II), should not be transplanted. It should be explained that this evolution is normal and a flat hairline would look unnatural as he ages. In this patient, one should not attempt to "fill-in" the temples. It also may not be appropriate to transplant a young, early Class III patient. However, in an older Class III patient with stable hair loss, above average density, and without a familial history of significant balding, it would be appropriate to blunt the angles produced by the bitemporal recession, but not to eliminate it.

A final issue regarding expectations is related to the time frame in which the patient expects to see the results of his procedure. The normal follicular growth cycle is quite variable. In most patients, the majority of the transplanted hair begins to grow at about 3 to 4 months after surgery, with additional hair appearing over the next several months. In a small percentage of patients, the onset of growth of the bulk of the hair can be seen from 4 to 8 months or more, with additional new hair occasionally appearing up to 18 months after the transplant. Since newly transplanted hair will increase in diameter and in length, in this subset of patients, there may be continued cosmetic improvement for up to two years.

The Critical First Session

In our experience, for the majority of patients, establishing the frontal hairline is the single most important function of the first procedure. At the outset, the frontal hairline should be placed in its normal, mature position. The hairline in this location should frame the face and restore a balance to the patient’s facial proportions in a way that is appropriate for a mature individual. In our opinion, the common practice of creating a hairline significantly above the mature hairline position with the intention of lowering it in a subsequent procedure should be avoided. If the intent is to conserve hair in anticipation of a very limited donor supply, one could still maximize the cosmetic impact of the surgery by creating more bitemporal recession or not extending the transplant as far back toward the crown. However, the position of the mid-portion of the frontal hairline should not be compromised, as this defines the "look" of the individual. Creating a hairline too high (in the hope of conserving donor hair) only accentuates the patient’s baldness by enlarging the forehead and distorting the normal facial proportions .

The other major goal of the first session should be to provide coverage to the remaining bald scalp with the exception of the crown. Since the Norwood Class A patients, by definition, do not have hair loss extending into the crown, if possible, their entire bald area should be treated in the first session. The amount of hair needed to cover the front and top of the patient’s scalp will obviously vary depending upon the extent of baldness, but there should always be an attempt to cover these areas in the first session, even if the coverage is light. In general, areas of the scalp which already have adequate coverage should not be transplanted. Although the edges of the transplanted area should be blended into the hair bearing skin, too aggressive encroachment may accelerate hair loss and not offer any additional cosmetic benefit. The goal should not be to restore adolescent density, since this is neither necessary from a cosmetic standpoint nor (as we have discussed) mathematically reasonable. Patients desiring adolescent density should be treated the same as those desiring an adolescent hairline. They should be further educated rather than ushered off to surgery.

In general, crown coverage should not be a goal of the first session, but should be addressed after the cosmetically more important front and top have been adequately transplanted. Since the front and top of the scalp are a single cosmetic unit, the transplant may stop after this area has been treated. The patient can then evaluate for himself the adequacy of coverage from the first procedure, and if he desires more fullness or greater density, a second session can be used to supplement the area transplanted in the first. If crown coverage is attempted in the first session, the patient’s options will be much more limited, and the ability to produce an aesthetically balanced transplant might be permanently eliminated. An exception would be patients of Norwood Class III Vertex and Class IV, who are generally over the age of 30, have less risk of becoming extensively bald, and have good donor density and scalp laxity. In these situations, transplanting the crown in the first session can provide modest coverage to the area and will serve to camouflage a limited amount of further crown balding. What should be avoided in these patients is the risky practice of repeatedly transplanting hair into the crown to achieve a high degree of density, as this density can often not be supported as the balding progresses (see section Goals for the Second Section).

Beside the aesthetic issues which make the first session so important, there are many surgical advantages of working on a virgin scalp¹. In sum, implants can be placed more easily, more securely, and closer together into a normal scalp, since the blood supply and elasticity of the connective tissue are intact. In the donor area, maximum density and scalp mobility as well as the absence of scarring will facilitate a hairline closure. To take advantage of these factors, one should attempt to achieve, in the first session, as many of the patient’s goals as possible. In our opinion, what can safely be accomplished in one procedure is best done in one procedure, and should not be spread out over two or more.

When Should a Single Session Transplant be Considered?

As stated, we feel the main goals for the first session should be: 1) to provide a frame for the face, 2) to provide coverage to the front, and, when appropriate, the top and vertex of the scalp, 3) to have a totally natural appearance.

In general, for the physician to suggest to a patient that he might be satisfied with a single session, he should have relatively stable hair loss. This is especially important in the Norwood Class III, IIIa, IV, and V patients whose own hair contributes to the cosmetic appearance of the front of the scalp. In patients who have little frontal hair, the first procedure may successfully frame the face and provide coverage to the anterior portion of the scalp so that even with further balding, a second procedure would not be immediately necessary. For Norwood Class VI or VII patients in which the front and top of the scalp are adequately transplanted in the first procedure, satisfaction can be achieved in one session, because further expansion of the bald crown is relatively inconsequential. However, if coverage of the crown was attempted, then as the bald crown expands, the centrally transplanted grafts would become an isolated island of hair, and further surgery would be required.

A patient with lighter hair color will also have a greater chance of achieving his goals in one session as these colors reflect light and give the appearance of more hair. In addition, the low contrast with the underlying skin gives the illusion of more hair since the skin serves as a "filler" for the space between the hair shafts. In contrast, dark hair over light skin accentuates any spaces between the strands of hair. Salt and pepper hair works both by reflecting light and by creating another visual detail to detract from areas of sparseness. Certainly any patient who does not posses the genetic attributes of good hair color can easily change the color to complement the surgical procedure.

Wavy hair will generally provide better coverage than straight hair and is beneficial in the transplant. As with hair color, this can be manipulated after the surgery to improve the cosmetic impact of the transplant. Very curly hair, on the other hand can, on occasion, work to the patient’s disadvantage if complete coverage of the bald area is not anticipated. Very curly hair may increase the fullness of the transplanted area to such a degree that contrast with any remaining bald area may be accentuated. In addition, very curly hair transplanted to the front and top of the scalp may not be easily combed back to cover a bald crown.

The follicular density in the donor area will also impact the procedure. In patients with high density, there will be more hairs per follicular unit, and thus each implant will contain more hair. In patients with very high density, a significant proportion of implants containing 3 and 4 hairs each can be harvested from the donor area, giving a wonderfully full appearance, even from a single procedure.

Patients with hair of average or above-average diameter will have the best chance of success with one procedure. The cylinder of skin surrounding the follicular unit of a patient with coarse hair is roughly similar to a unit of fine hair, however, the volume of hair is vastly different. The diameter or "weight" of the patient’s hair is a huge variable. Whereas density may vary by a factor of 3 fold, hair weight may vary from patient to patient by many times that. Although it is much easier to quantify the density (number of hairs/mm²), rather than the weight of an individual hair, the latter is probably more significant to the outcome of the procedure. Those patients with early balding who have fine, dark hair of high density are very difficult to satisfy in a single session, since the transplanted hair is often viewed against the background of the patient’s thick terminal hair population that surrounds the bald area. By contrast, in a similar patient with coarser hair, satisfaction is more easily achieved in a single session.

Contrary to what one might expect, the extensively bald patient, even with low donor density, can often be very satisfied after one procedure. These patients often have very reasonable expectations and after being bald for many years are ecstatic to have hair framing their face, light coverage on top, and "something to comb." In order for expectations to be met in one session, the realities of the supply/demand situation must be taken into account. It is obvious that for individuals in the Norwood Class VI or VII pattern, only light to modest coverage can be achieved in a single session, since the area in need of hair will exceed the total donor supply by a factor of at least 6:1, even under ideal circumstances.

Finally, grooming patterns will also influence the success of a single procedure. Patients who plan to comb their hair to the side rather than straight back will have the appearance of much more fullness. Unfortunately, this hair style will not provide crown coverage. Many patients achieve the "best of both worlds" by combing their hair diagonally backwards.

The number of follicular unit grafts that we generally transplant in the first session is indicated in Table 1 below.

Table 1. First Follicular Unit Transplantation Session