Over the past 22 years, the time I have been fortunate to practice in the field, few plastic surgery procedures have evolved as extensively in terms of overall success and aesthetic outcomes as surgical hair restoration. Driven by the collective, usually collaborative and at times competitive, efforts of the leaders in the field, in spite of (or perhaps as a result of) their various backgrounds ranging from dermatology, emergency medicine, cardiology, urology, family practice, and, of course, plastic and facial plastic surgery, surgical hair restoration has earned its position as a true plastic surgical procedure.

Prior to the relatively rapid evolution of aesthetic hair transplant techniques starting in the early 1990s, there was an almost 30-year period in which hair transplantation was essentially limited to the simple production of cornrows or doll’s hair configurations. This started with Norman Orentreich’s 1959 explanation of donor dominance and posited how transplanted hairs maintain their genetic basis to continue growing, no matter where transplanted, whether on the bald scalp, face, chest, or anywhere on the body. Unfortunately, these plug grafts were 3 and 4 mm in diameter, contained 15 to 20 hairs, and produced rather unnatural results. Appearances could be somewhat improved when the hair was held together with gel or creatively styled. Using Donald Trump-like hairstyles, these 4-mm plugs could, to the benefit of some patients of more creative surgeons, create a more natural appearance when they were divided in half or even quarters before transplanting.

Because of the relative shortcomings of plug grafting, even after the development of subdividing these larger grafts, alternative hair restoration techniques were developed. Scalp flaps and bald scalp reductions became viable and reasonable alternatives in comparison to plug grafting. The temporoparietooccipital scalp flap, also called the Juri or Fleming-Mayer flap, involved the rotation of a 3- to 4-cm wide by 25- to 30-cm long flap of scalp from the side and back of the head into the hairline. These flaps created an unsurpassed density of hair along the anterior hairline. However, a constellation of new aesthetic problems was created, not only due to the usual posterior direction of hair growth, and that occurred where there was further progression of hair loss. Bald scalp reductions were enthusiastically embraced for their ability to reduce the size of the bald scalp, especially along the crown, but at the price of frequent scar widening, stretch-back, thinning along the sides of the scalp, and misdirection of hair growth. Perhaps the most important downside of this technique is its namesake: bald scalp reduction. In the end the bald scalp is not eliminated, and with progressive hair loss, the bald area eventually returns and possibly to even greater dimension. The only surgical procedure that has retained its usefulness is the surgical hairline advancement, or forehead reduction surgery. In the appropriate patient with a stable hairline and very good scalp laxity, the entire hairline can be brought forward by 3 to as much as 5 cm, permitting the shortening of the height of the forehead. As shown in Figure 32.1, female patients tend to be the most appropriate, as they are much less likely to lose hair in the future, something that makes the procedure contraindicated in most men.

In the early 1990s, with the advent of micro- and minigrafting, hair transplantation became the preferred technique of surgical hair restoration. Through a combined placement of minigrafts (3 to 6 hairs) and micrografts (1 or 2 hairs) along the anterior hairline, a reasonable cosmetic result could be achieved. Procedures of
500 to 1,200 grafts were the standard of care for nearly the next 10 years. Heavy marketing by several corporate chains further defined the understanding of hair transplantation and hair transplantation evolved into one of the most commonly performed plastic surgical procedures.

Follicular unit grafting (FUG) was developed in the late 1990s and transformed hair restoration into a true aesthetic procedure capable of consistently creating natural-appearing results. FUG involves the transplanting of as many as 2,000 to 3,000 or more grafts in a single procedure. Each graft contains a single follicular unit, which is the natural grouping of hairs in the scalp, and is composed of one to four hairs. As described below, the grafts are dissected out under microscopic visualization from a single donor strip obtained from the back and sometimes sides of the head. The grafts are then placed one at a time into recipient sites made in areas where hair is desired. The other technique outlined in this chapter is follicular unit extraction (FUE). This is a more recently introduced procedure in which the hair grafts containing a single follicular unit are obtained not from a donor strip but rather by their individual extraction using 0.9- to 1-mm punches. The FUE approach is a more labor-intensive technique but confers the advantage over FUG with the absence of a linear donor site scar. As a result, this technique allows patients to cut their hair as short as they wish since camouflage is unnecessary.

Both FUG and FUE are based on the original principle of donor dominance in hair growth. Each approach uses hair from more permanent/stable regions of hair growth for the treatment of the balding scalp and other areas devoid of hair.

Appropriate expectations must be established, and this is the most important in determining patient candidacy for a procedure. Additionally, it is important to anticipate for the progression of hair loss. This first means taking a family history and learning of the patient’s hair loss progression up to that point and then explaining the progressive nature of hair loss. Younger men, particularly those under the age of 30, must realize that lowering of the hairline and/or filling in of the frontotemporal recessions, as well as filling in of any crown loss, may not make sense as the donor supply could eventually be depleted, making it not possible to further fill in areas of loss in the future. For most young men, filling in of the frontal forelock may be the best and most appropriate procedure. Also, particularly in the younger male patient, for a number of reasons (the greater risk of widened donor site scars, the potential for the desire to shave his head in the future), but ultimately in any man who does not have to ever worry about cutting his hair short, FUE is the preferable technique to FUG.

In women, in addition to taking a thorough family and personal history, inclusion of questions about hormonal and nutritional health is essential. Blood testing should include thyroid function tests, total iron, ferritin, total and free testosterone, and DHEA-sulfate if there is a history of abnormal menses. Trichotillomania should be considered when the pattern of hair loss is atypical. A biopsy of the scalp may be necessary in the differentiation of androgenic alopecia (female pattern hair loss) from alopecia areata, telogen effluvium, and a variety of scarring alopecias including lichen planopilaris. The density of hairs in the donor area and the caliber of these hairs, as well as the color contrast between the scalp and hairs, are of particular importance in determining candidacy for a transplant procedure in women. For most women, it is not possible to completely fill in all areas of thinning; therefore, it must be explained that only those areas of greatest cosmetic importance can be restored and that the degree of improvement is better in cases of thick donor hairs and lower color contrast between the scalp and these hairs. Also, in women, there is a greater risk than in men of shock hair loss right after a transplant, particularly in cases of hair loss characterized by diffuse thinning and miniaturization versus when the hair loss is more patchy, the latter a situation more appropriate for hair grafting.

Usually, the FUE procedure is not indicated in women because of the need for shaving a large area of scalp for the procedure, except in the case of a woman who wants to avoid altogether any linear donor site scar. As it is, one of the key challenges in women is obtaining a sufficient amount of donor hairs, a challenge made greater by the use of the FUE technique. Other indications for hair procedures in women in particular include eyebrow restoration (a procedure also done in men), filling in of lost sideburns or of scarring from prior plastic surgery, and advancement of the overly high hairline. There are two techniques for advancing the hairline, the more common of which is hair grafting, the other the surgical hairline advancement procedure, a single-stage technique where the entire frontal hairline is advanced and the forehead shortened through a hairline incision, as discussed in the prior section. In the highly motivated patient with an immobile scalp, tissue expanders can be used to advance the hairline as desired.

Generally, while a medical evaluation is not indicated, options in medical therapy should be presented. Finasteride, a 5-alpha reductase blocker that prevents the conversion of testosterone into dihydrotestosterone, the hormone that causes miniaturization and eventual loss of the hair, is only to be used in men. Other therapies include minoxidil 5% and laser light therapy, the latter which can be particularly effective in slowing down or stopping altogether shedding and in some cases cause partial reversal of the miniaturization that can be seen in male and female pattern hair loss.