During the first consultation, the patient’s goal of the procedure needs to be discussed. A thorough physical evaluation will need to be performed and an explanation of the surgical options available. The physician must understand the patient’s motivations and expectations regarding hairrestoration surgery. Patients who seem emotionally labile may require a psychiatric assessment to evaluate their true motivations, but most patients requesting hair replacement do not have emotional problems; they simply would prefer not to be bald.
Several factors determine what procedure, if any, is appropriate for restoring an alopecic scalp. It is not uncommon for the patient to expect more than can be accomplished with the donor area available. The major reason for rejecting a patient is an inadequate supply of donor hair relative to the patient’s final goals.
The ideal patient is one with enough donor hair to completely fill all current or potential areas of alopecia. The younger the patient, the more conservative the physician must be in estimating the donor hair present and establishing a long-term treatment plan. An accurate assessment of the donor area is required to prevent moving follicles at risk for future alopecia into cosmetically important areas on the scalp, because any future hair loss in those transplanted follicles will result in exposed scars over the scalp. In younger patients whose final hair-loss patterns cannot be determined, the physician should try to delay hair restoration until the physician is secure with the availability of donor hair.
TABLE 196.2 TREATMENT—ANDROGENETIC ALOPECIA
Follicular unit grafts
Low-density donor hair may be a contraindication to hair transplantation. Patients with fewer than 40 follicular units/cm2 tend to be poor candidates for hair transplantation, unless they are willing to accept very thin hair density from the transplantation procedures. Age is not a contraindication to hair transplantation. Older patients generally have well-established patterns of alopecia that allow a more reliable assessment of the donor area.
Hair color, skin color, and hair texture are important factors in surgical hair restoration. A sharp contrast between the hair and the skin may result in an unnaturalappearing hairline. This is especially true if transplantation is performed with grafts that contain more than one follicle unit. The best hair colors for surgical hair restoration in light-skinned patients are white, salt-and-pepper, and blond. Patients with dark skin and dark hair and those with wiry hair generally are good candidates for hair restoration. Naturally curly hair appears thicker than straight hair, thereby enhancing the results of most hair-replacement procedures.
The most important goal of hair-replacement surgery is to restore aesthetic balance to the face by recreating a natural, age-appropriate frontal hairline and part (7
). The surgically restored hair should be easy to maintain and should not require extraordinary hairstyles for camouflage.
The mature male hairline usually demonstrates distinct triangular regions bilaterally at the junction of the frontal and the temporal hair (Fig. 196.1
). These frontotemporal triangles are formed by progressive recession of the frontal hairline superiorly and the temporal hairline posteriorly.
A natural frontal hairline is convex, with the central portion positioned slightly inferior to the frontotemporal triangle region. The most anterior portion of the hairline is placed approximately 7 to 10 cm superior to the glabella. The apex of the frontotemporal triangle marks the lateral aspect of a natural hairline. Regardless of the extent of hairline recession, the apex is designed to fall on a vertical line drawn upward from the lateral canthus of the eye. Because the temporal hairline intersects the lateral extent of the frontal hairline, advanced temporal recessions require a more posterior frontal hairline. Any attempt to fill a large frontotemporal triangle as a means of compensating for
advanced temporal recessions will result in an unnatural hairline and part. Modern follicular unit grafting techniques can be used to recreate the temporal hairline in those patients with a low-lying superior temporal fringe.
Figure 196.1 The frontotemporal triangle (BCD) is defined by the frontal and the temporal hairlines. When planning surgical restoration of the frontal hairline, the apex of the triangle is designed to fall on a vertical line (AA‘) that intersects the lateral canthus.