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Dr Russell Knudsen Hair Restoration by xxx Russell Knudsen MB BS FFMACCS 1800 685 399 internationaL societY oF Hair restoration surgerY isHrs Advancing the art and science of hair restoration. internationaL societY oF Hair restoration surgerY Finding a Hair restoration doctor WHo is rigHt For You Before choosing a physician for hair loss treatment these are the basic things you should know about 1. The physician s training and credentials 2. The physician s experience 3. The manner in which the physician practices 4. The comfort level you feel with the physician. You can determine the manner in which the physician practices by visiting the their office and clinic and you can find out if you feel comfortable with the physician in an initial consultation. It is in your own best interest to learn as much as you can before making a final decision on choosing a physician. While no amount of information can assure you of a satisfactory outcome of treatment the best outcome is likely to result from a good patient physician relationship founded upon 1. Trust in the physician based on your knowledge of the physician s training experience and competence 2. A compatible relationship with the physician. The ISHRS Find a Doctor site provides you with a list of physicians who have met requirements for ISHRS membership. The ISHRS does not imply or guarantee that a physician selected from this list will be compatible with you and will provide treatment that meets your expectations. It is important to do your research and find a physician with whom you feel comfortable and who is likely to meet your expectations. WHo We are The International Society of Hair Restoration Surgery (ISHRS) is a nonprofit medical association of more than 850 physicians specializing in hair loss. The ISHRS provides continuing education to physicians specializing in hair transplant and restoration surgery and gives the public the latest information on medical hair restoration and non-surgical treatment for hair loss. our Vision To establish the ISHRS as the leading unbiased authority in hair restoration surgery. our Mission To achieve excellence in patient outcomes by promoting member education international collegiality research ethics and public awareness. H a i r r e s t o r at i o n w w w. i s H r s . o r g 3 Male hair loss Russell Knudsen MB Bs FFMaCCs 4 H a i r r e s t o r at i o n w w w. i s H r s . o r g profile ABOUT DR KNUDSEN r russell Knudsen is an internationally recognised specialist in the field of hair restoration. With practices in Melbourne Canberra Brisbane New Zealand and a Head office in Sydney he has performed more than 5 000 transplant procedures over 28 years. Dr Knudsen is highly experienced and well regarded among his peers and in 2000 he won The Golden follicle Award for excellence and his contribution in this field. Dr Knudsen works solely in hair transplantation and is a past president of the international Society of Hair restoration Surgeons and is currently on its Board of Governors. He is past president of both the Australian Society of Hair restoration Surgeons and the Australasian College of Cosmetic Surgery. As well as being a past editor of Hair Transplant Forum International he has also contributed to numerous text books and journal articles and speaks regularly at the international hair transplant conferences. Dr Knudsen s commitment to his patients is reflected in his desire to give each individual expert advice on the best treatment option available for them. He acknowledges the greatest problem facing patients is navigating the often very confusing information relating to hair replacement options. The simple fact is that there is only one proven permanent method for getting your hair back and that s hair transplant surgery says Dr Knudsen. Contrary to widespread belief contemporary hair transplants do not look like plugs or doll-like rather they provide a natural-looking undetectable nomaintenance solution to hair loss and are yours to enjoy for a lifetime. Dr Knudsen s personal approach commitment artistic ability and specialist skill is evident in his many thousands of satisfied patients. D Russell and his wife Anne Russell and Anne with their sons Alexander (left) and Joel (right with his girlfriend Alice) H a i r r e s t o r at i o n w w w. i s H r s . o r g 5 diagnosis Hair Loss Diagnosis anD anaLysis efore recommending or performing a hair restoration procedure a hair restoration doctor will conduct a scalp examination to determine the cause of hair loss. if the examination indicates that hair loss may be due to a condition other than male or female pattern baldness the physician will seek the cause with other diagnostic measures. in some cases an underlying condition may have to be treated before hair restoration is undertaken. B 6 H a i r r e s t o r at i o n w w w. i s H r s . o r g diagnosis Hair pull a hair pull is a diagnostic procedure used in virtually every patient with a complaint of unexplained hair loss to assess the presence or absence of any abnormalities in the hair growth cycle. about 25 to 50 hairs are removed from the scalp by a series of gentle hair pulls. normally only a few hairs are dislodged with each pull. When more are removed the possibility of an abnormality of hair growth cycling is indicated. The ends of the pulled-out hairs may be examined under a microscope to evaluate the condition of the hair shaft and the bulb (the end of the hair shaft extracted from the hair follicle). Variations of the hair pull are the phototrichogram and hair window Phototrichogram hairs are clipped or shaved in an area of the scalp and consecutive photographs taken over a period of 3 to 5 days to determine the pattern of hair growth. Hair window hairs are clipped or shaved in an area of the scalp and hair growth is evaluated over the next 3 to 30 days. abnormalities of hair growth cycling is a relatively uncommon cause of hair loss but may occur at any age. Underlying causes of these abnormalities include thyroid hormone imbalance nutritional deficiencies side effects of certain drugs anemia and other systemic illness and psychological stress. Scalp biopsy a biopsy of the scalp is usually performed only if additional information is needed to evaluate the mechanism of hair loss inside the hair follicle. Biopsy is not necessary in the great majority of patients evaluated for hair loss and hair restoration. Hair shaft evaluation if a hair shaft abnormality or infection is suspected the hair shafts removed from the scalp by hair pull are examined under a microscope. Hair shaft abnormalities and fungal bacterial or viral infection can be responsible for hair loss associated with hair breakage hair shedding and hair that is unruly. Hair analysis Hair analysis is a laboratory test performed if a hair shaft abnormality needs to be assessed for 1. altered hair-protein profile due to an inherited abnormality or 2. drug ingestion or heavy metal contamination. Hair analysis is ordered by a hair specialist physician only to determine the cause and mechanism of a hair shaft abnormality. The test has no value for the diagnosis of systemic disease or nutritional status contrary to claims by non-physician hair analysis specialists . Fortunately most persons seeking hair restoration in the Us are among the 80 million men and women who have male and female pattern hair loss a condition simple to diagnose and easy to treat. Extensive diagnostic workups for these easily recognized conditions are usually not necessary. There are other causes of hair loss however and it is essential that the cause of hair loss be evaluated before hair restoration is undertaken. H a i r r e s t o r at i o n w w w. i s H r s . o r g 7 Male hair loss maLe Hair Loss 8 H a i r r e s t o r at i o n w w w. i s H r s . o r g & Pattern BaLdness Male hair loss I The hair shafts in male pattern baldness become progressively miniaturized over time t is estimated that 35 million men in the United states are affected by male pattern baldness or androgenetic alopecia. andro refers to the androgens (testosterone dihydrotestosterone) necessary to produce malepattern hair loss (MPhl). Genetic refers to the inherited gene necessary for MPhl to occur. in men who develop male pattern baldness the hair loss may begin any time after puberty when blood levels of androgens rise. The first change is usually recession in the temporal areas which is seen in 96 percent of mature Caucasian males including those men not destined to progress to further hair loss. hamilton and later Norwood have classified the patterns of male pattern baldness (see illustration over page). although the density of hair in a given pattern of loss tends to diminish with age there is no way to predict what pattern of hair loss a young man with early male pattern baldness will eventually assume. in general those who begin losing hair in the second decade are those in whom the hair loss will be the most severe. in some men initial male-pattern hair loss may be delayed until the late third to fourth decade. it is generally recognized that men in their 20s have a 20 percent incidence of male pattern baldness in their 30s a 30 per cent incidence of male pattern baldness in their 40s a 40 per cent incidence of male pattern baldness etc. Using these numbers one can see that a male in his 90s has a 90 percent chance of having some degree of male pattern baldness. hamilton first noted that androgens (testosterone dihydrotestosterone) are necessary for the development of male pattern baldness. The amount of androgens present does not need to be greater than normal for male pattern baldness to occur. if androgens are present in normal amounts and the gene for hair loss is present male pattern hair loss will occur. axillary (under arm) and pubic hair are dependent on testosterone for growth. Beard growth and male pattern hair loss are dependent on dihydrotestosterone (DhT). Testosterone is converted to DhT by the enzyme 5-alpha-reductase. Finasteride acts by blocking this enzyme and decreasing the amount of DhT. receptors exist on cells that bind androgens. These receptors have the greatest affinity for DhT followed by testosterone estrogen and progesterone. after binding to the receptor DhT goes into the cell and interacts with the nucleus of the cell altering the production of protein by the DNa in the nucleus of the cell. Ultimately growth of the hair follicle ceases. The hair growth cycle is affected in that the percentage of hairs in the growth phase (anagen) and the duration of the growth phase diminish resulting in shorter hairs. More hairs are in the resting state (telogen) and these hairs are much more subject to loss with the daily trauma of combing and washing. The hair shafts in male pattern baldness become progressively miniaturized over time smaller in diameter and length. in men with male pattern baldness all the hairs in an affected area may eventually (but not necessarily) become involved in the process and may with time cover the region with fine (vellus) hair. Pigment (colour) production is also terminated with miniaturisation so the fine hair becomes lighter in colour. The lighter colour miniaturized hairs cause the area to first appear thin. involved areas in men can completely lose all follicles over time. Male pattern baldness is an inherited condition and the gene can be inherited from either the mother or father s side. There is a common myth that inheritance is only from the mother s side. This is not true. H a i r r e s t o r at i o n w w w. t r e at H a i r l o s s . c o m . a u 9 male hair loss is only from the mother s side. This is not true. in summary male pattern hair loss (androgenetic alopecia) is an inherited condition manifested when androgens are present in normal amounts. The gene can be inherited from the mother or father s side. The onset rate and severity of hair loss are unpredictable. The severity increases with age and if the condition is present it will be progressive and relentless. hair loss in men is likely to occur primarily between late teenage years and age 40-50 in a generally recognisable male-pattern baldness known as androgenetic alopecia. men with male-pattern hair loss may have an expectation of hair loss if they have male relatives who lost hair in a recognisably male pattern. THE HAMILTON NORWOOD CHART 10 H a i r r e s t o r at i o n w w w. i s H r s . o r g MAlE HAIR loSS When Young Men Lose hair Before age 21 B ecause hair loss is generally unexpected before age 21 it can be a shock for a young man 15 to 20 years old to discover he is losing hair. The first sign likely to occur is thinning in the temporal area of the frontal hairline above the eyebrows on either side of the widow s peak . This can result in the appearance of a high forehead. The young man may also begin to notice excess shedding when he combs brushes showers or shampoos his hair. If the young man s father mother uncles or older brothers have pattern hair loss he may not be surprised to see that the family baldness trait has been passed along to him. Nevertheless he most definitely will not be pleased to see the inherited trait appear so early. Hair loss before age 21 can be very disturbing for a young man even if he expects to eventually undergo hair loss. At this psychologically and emotionally vulnerable time in his life it can leave him feeling disfigured less attractive socially and hindered in the job market. He can be an easy target for expensive but ineffective miracle cures advertised in print media on TV and on the internet. What should a very young man experiencing hair loss do A good first step is a consultation with a physician hair restoration specialist who is a member of the International Society of Hair Restoration Surgery (ISHRS) who is skilled and experienced and importantly follows ethical guidelines. Ethical considerations are especially important when the patient is vulnerable distressed and not yet an adult. The minor with hair loss should not be pushed into any decisions regarding hair restoration especially surgery and should be educated and counseled against making any hasty decisions that may not be in his best interest. The first advice a physician hair restoration specialist might give a minor with hair loss is Don t panic. I understand. Male pattern hair loss is a common inherited condition and it is normal to be bothered by it. We can almost certainly find a way to manage it by making decisions tailored to your individual needs. When the patient is a minor the physician hair restoration specialist must insist that a parent or legal guardian be involved in the decision-making. Inclusion of a parent or legal guardian resolves questions of legal responsibility and gives H a i r r e s t o r at i o n w w w. i s H r s . o r g 11 male hair loss the patient support in making informed decisions. Close parental support is important in the success of any treatment recommended to a minor. No recommendations for treatment will be made until the physician hair restoration specialist has determined the cause of hair loss. While male pattern hair loss is the most common reason for hair loss in men there are many other causes that need to be considered and ruled out. hasty treatment before a diagnosis is established may be ineffective and could be counter-productive. What treatment is a physician hair restoration specialist likely to recommend While male pattern hair loss is the most common reason for hair loss in men there are many other causes that need to be considered and ruled out The physician s first goal is to educate the patient with regard to the cause progression and long-term ramifications of hair loss as well as any treatment for hair loss. Because hair transplantation has high public acceptance as a successful method of hair restoration the young man may consider it his first option for treatment. however most leading physician hair restoration specialists do not consider hair transplantation a good option for most men under age 21 because among other reasons The pattern and progression of hair loss has usually not been fully revealed at this early age hair transplantation performed this early may be less than desirable later in life when the pattern and progression of hair loss has been more fully revealed it is difficult to design a surgical procedure that will look natural and appropriate for the rest of the patient s life once hair transplantation is begun future surgeries are required to maintain a natural appearance Unfortunate results of hair transplantation performed too early may have to be surgically corrected later even with parental guidance it is difficult for a minor to make informed adult decisions regarding elective surgery. an interim option often recommended by leading physician hair restoration specialists is non-surgical treatment with minoxidil and finasteride the only hair restoration medications approved by the Us Food and Drug administration and scientifically proven to successfully treat hair loss. slowing the progression of hair loss before and after age 21 improves the opportunity for successful hair transplantation later. in selected cases a physician hair restoration specialist may perform a small forelock transplant to provide immediate improvement in the patient s temporal frontal hairline. 12 H a i r r e s t o r at i o n w w w. t r e at H a i r L o s s . C o M . a U male hair loss Hair TransplanTaTion afTEr agE 50 Excellent results are the rule in older patients older men with hair loss can be confident that age in itself does not exclude them from having hair transplantation. men are seldom too old to consider hair transplantation as a treatment for hair loss. men 50 years old and older can usually expect excellent results from firsttime hair transplantation. excellent results are common in men age 70 and older who decide to have hair transplantation later in life. When is the time right for hair transplantation male pattern hair loss can begin at any age from adolescence to the 40s and 50s. some men choose to seek treatment early and maintain a regimen of treatment for as long as progressive hair loss continues. early and continued treatment by a physician hair restoration specialist helps a man maintain a cosmetically pleasing appearance. hair loss that begins late in life or changing circumstances in a man s life may make hair restoration desirable or even a necessity after age 50. it is not unusual in today s globalized economy for example for a man to find it necessary to change employment or even careers at age 50 or older. societal emphasis on youthfulness may encourage a man to maintain an appearance as youthful-looking as his wife s. some men may decide they just want to lose the look of a balding man. in any of these instances hair restoration will contribute to the appearance that a man wishes to present. When the older man decides to seek hair transplantation The 50 man who seeks first-time hair transplantation should have a number of points to discuss with his physician hair restoration specialist. hair transplantation should aim to produce age-appropriate correction of hair loss. most older men will have modest goals for hair restoration they will not aim to achieve the full-hair look of a 20-year-old man but rather to improve the cosmetic deficiency of baldness. Goals for hair restoration must be frankly discussed and agreed upon between the patient and the physician hair restoration specialist. The amount of donor hair available on the patient s scalp will be an important factor in determining what hair restoration goals are achievable. a limited amount of donor hair will necessarily limit the number of hair grafts available for transplantation to balding areas of the scalp. For some older men first-time hair transplantation may be their only hair transplantation if progressive hair loss continues to diminish the patient s supply of donor hair. however the patient may feel that results of a one-time hair transplantation will accomplish the goal he wishes to achieve. H a i r r e s t o r at i o n w w w. i s H r s . o r g 13 male hair loss a very limited supply of donor hair may lead the physician hair restoration specialist to recommend against hair transplantation. if a good outcome is unlikely the patient should accept the physician s recommendation against having the procedure. The patient should be confident the physician believes a good result is possible. a modest but usually achievable hair transplantation goal for older men is restoration of a frontal hairline and strategic placement of a limited number of grafts behind the hairline to provide an aesthetic appearance of fullness . This strategy takes advantage of the inability of the human eye to discern a difference between 50 percent density and 100 percent density in scalp hair. The less is more strategy is one used with a high rate of success by skilled physician hair restoration specialists. The patient and physician must discuss all options and agree on a mutually acceptable goal for hair transplantation. Physical limitations and hair transplantation in older men a man aged 55 or older may have some chronic medical conditions that need to be taken into account prior to a surgical procedure such as hair transplantation. such conditions seldom pose a serious risk taking account of them reduces potential risk. The physician hair restoration specialist is a fully trained physician who can take such conditions into account and consult professionally with the patient s other physicians if necessary. it is very important for the patient to tell the physician hair restoration specialist about any medical conditions and about all medications he is currently taking or has recently taken. most medical conditions pose little risk if the conditions are recognized and appropriate precautions taken in the approach to hair transplantation. For a patient with a chronic heart condition for example hair transplantation may be carried out in two or more shorter sessions to avoid the potential stress of a longer single session. medical conditions that may indicate the need for precautions include heart disease high blood pressure diabetes and bleeding disorders. medications that may indicate the need for precautions include warfarin and aspirin that reduce the ability of blood to form clots. Realistic goals for hair transplantation in the older man Physician hair restoration specialists have generally found older men to have realistic expectations for the outcome of hair transplantation. The man aged 55 or older will rarely expect to reverse the effects of decades of hair loss. hair restoration that relieves the cosmetic impairment of baldness is usually considered very satisfactory. The older man with minimal hair loss may wish to achieve hair transplantation results comparable to those realized in younger men. Whether or not this goal is achievable should be discussed with the physician hair restoration specialist after the physician has the results of scalp examination and other tests as may be necessary. The degree of hair loss the amount and quality of donor hair and anticipated future hair loss are points to discuss with the physician hair restoration specialist in regard to achievable goals for hair transplantation. 14 H a i r r e s t o r at i o n w w w. t r e at H a i r l o s s . c o m . a u male hair loss LOss and THe Hair ance Of aging appear O ne of the most common reasons for men and women to consider hair transplantation is to overcome what they perceive to be an ageinappropriate appearance. They don t want to appear older than their calendar age or appear older than they wish to appear. The reasons to avoid age-inappropriate appearance can be personal workrelated or a combination of both. in both personal and work environments a prematurely aged appearance can substantially influence one s self-regard and interpersonal and work-related relationships. age is objectively measured in years but the appearance of age is assessed subjectively. it is often the subjective assessment by others that counts the most in one s personal and professional life. When a person firsts meets someone whether in the workplace or social environments they quickly make judgments regarding the person s age. along with this assessment they may make some judgments regarding what may be called age-related values a person who appears to be uncaring in their presentation of self to the world is seen as lacking vigor and self-regard. in contrast a person who presents an aura of youthfulness or agelessness even if obviously advanced in years is likely to be viewed in positive terms. While there is often negative criticism of the emphasis on youthfulness the positive flip side of being youth oriented is a perception of commitment to health and psychological as well as physical wellbeing. Commitment to these positive values is seen as personal and individual and judged as a positive in interpersonal relations. The interpersonal effects of hair loss hair loss can have a potent negative effect in overall assessment of age and age-related values. hair loss in a younger person can contribute to an appearance of premature aging. hair loss at any age can detract from overall appearance. in some circumstances hair loss may be the dominant factor in how a person is assessed. overall appearance figures prominently in the way potential clients and customers and employers view persons to whom they must give their trust. an initial interview can be skewed if the attention of the client customer or employer is focused on an apparent defect in the person s appearance. The perception of hair loss as a cosmetic defect influences the way in which both men and women may be assessed but it is often a detriment to women more than to men. The bald man may benefit from the mr Big image of the powerful bald-headed man. There is no such image from which women may benefit thinning hair is an age-related cosmetic detriment for women no matter what age it occurs. H a i r r e s t o r at i o n w w w. i s H r s . o r g 15 hair restoration HaiR RestoRation Medications a suMMaRy at a Glance 16 H a i r r e s t o r at i o n w w w. i s H r s . o r g hair restoration ou notice that you are beginning to lose hair and you want to halt or reverse hair loss if you can. one of your options is a medical approach to hair restoration using one of the medications that are offered with a claim to stop loss of hair and stimulate hair regrowth. But which one Choosing a hair restoration medication can appear to be a forbidding task. Dozens are advertised on the internet and in magazines or other print media. some are herbal some are all natural some are pharmaceutical agents and most are proven effective . What criteria should you use to choose among all of the products offered the gold standard for making a choice is approval of a product by the Us Food and Drug administration (FDa) for use in treating hair loss. approval of a product by the FDa for treatment of hair loss means that the product has been rigorously tested for safety and efficacy in clinical trials that meet FDa standards for study design number of persons enrolled in the trials and statistical analysis of study data. When your criterion for product choice is FDa approval your choice is made clear. Just two products have been approved for halting hair loss and stimulating hair regrowth minoxidil a topical agent available over-the-counter and finasteride a drug taken by mouth available only by prescription in the United states. a third drug dutasteride is in clinical trials. similar to finasteride in action it has been approved in europe for use in hair restoration and is sometimes prescribed off-label for that purpose in the Us. the most effective use of hair restoration medication is under the supervision of a physician hair restoration specialist. treatment of hair loss by medical or surgical means is best carried out after the reason for hair loss is correctly diagnosed. For some persons medical hair restoration is most effective when carried out in conjunction with hair transplantation or other surgical means of hair restoration. Y The gold standard is approval of a product by the FDA for use in treating hair loss. This means the product has been rigorously tested for safety and efficacy in clinical trials that meet FDA standards H a i r r e s t o r at i o n w w w. t r e at H a i r l o s s . c o m . a u 17 HAIR ReSTORATIOn xxx xxx t nOw abOu Ok S nt thingS t MEDicatiOn MpOrta n SOME i rEStOratiO hair -apprOvED FDa Minoxidil Topical applied to the scalp as a liquid or foam. Minoxidil is offered in 2 percent and 5 percent concentrations. The 5 percent concentration was developed for treatment of male-pattern hair loss but studies have shown that women also can benefit from the 5 percent formula. Over the counter Generic minoxidil is also offered under a variety of trade names it may also be an ingredient in an over-the-counter product. mode of action How minoxidil acts to slow hair loss and stimulate hair regrowth is not well understood. Minoxidil was first developed as an oral medication to lower blood pressure by dilating blood vessels. Its activity in stimulating hair growth was noted as a side effect. The side effect of hair growth became the basis for development of the hair restoration product Rogaine. Whether minoxidil s effect in dilating blood vessels contributes to its effect on hair growth is not known. Studies have shown that minoxidil slows or halts hair loss and promotes hair regrowth in both men and women at both 2 percent and 5 percent formulations. Positive response to minoxidil therapy (reduced hair loss and or hair regrowth) has been noted in from less than 50 percent to more than 80 percent of persons treated in various studies. Positive response is lost if minoxidil therapy is discontinued. Minoxidil is more effective when applied to defined areas of hair loss and less effective when applied to large areas of hair loss. An itchy scalp is the most common side effect of minoxidil therapy. Accidental application of minoxidil to the face can result in growth of unwanted facial hair. Repeated large applications of minoxidil have been associated with a drop in blood pressure in a few reported cases. Studies have shown minoxidil slows or halts hair loss and promotes hair regrowth in both men and women Finasteride Finasteride is an orally administered medication for male pattern hair loss (MPHL). It is the only specific MPHL treatment approved by the US Food and Drug Administration for prescription by a physician. Several years of investigation and use by more than a million patients show that finasteride has long-term effectiveness and safety in treating MPHL in men of all ages and all ethnic backgrounds. Finasteride is sometimes used alone or in combination with minoxidil to complement hair transplantation. Finasteride is not recommended for use in women. 18 H a i r r e s t o r at i o n w w w. t r e at H a i r l o s s . c o m . a u hair restoration Finasteride s effects in slowing hair loss and stimulating new hair growth work best for early to moderate degrees of hair loss. Men with extensive hair loss are unlikely to experience much regrowth with finasteride these men are better candidates for hair transplantation or other surgical approach to hair restoration. Finasteride is most effective in stimulating hair regrowth over the crown of the scalp. it is less effective in stimulating regrowth at the front of the scalp where hair loss is commonly called a receding hairline . Physician hair restoration specialists may prescribe finasteride to prevent further hair loss by the patient and carry out hair transplantation to provide coverage at the frontal hairline. How it works Finasteride works at the molecular level to halt hair loss and stimulate new hair growth. it is a medication that selectively inhibits the activity of an enzyme that converts the male hormone testosterone into a form that is active in hair follicles. androgenic ( male ) hormones such as testosterone have multiple effects in the body including actions in the skin hair follicles and prostate gland. hair follicles and sebaceous (oil-producing) glands in the skin are particularly responsive to androgenic hormones. testosterone is the most potent of the androgenic hormones. its actions on hair follicles skin and prostate tissue is not direct however. these tissues are responsive to a form of testosterone called dihydrotestosterone (Dht) testosterone is converted to Dht by the enzyme 5-alpha-reductase. Finasteride acts by inhibiting the action of 5-alpha-reductase and thus inhibiting the conversion of testosterone into Dht. investigators over a number of years found that 5-alpha-reductase occurs in two forms identified as type i and type ii and that finasteride is effective in inhibition of type ii. type i of the enzyme predominates in sebaceous glands. type ii occurs most abundantly in hair follicles and prostate tissue. investigators found that Men with normal to high levels of type ii of the enzyme (and thus normal to high levels of Dht) are more likely to develop MPhL and benign enlargement of the prostate gland men with low levels of type ii enzyme (and thus low levels of Dht) are less likely to develop MPhL and benign enlargement of the prostate and thus inhibition of type ii 5-alpha-reductase could lower levels of Dht in hair follicles and prostate tissue and decrease the likelihood for development of MPhL and benign prostate enlargement. Finasteride an agent that inhibits the activity of type ii alpha-reductase and thus lowers the level of Dht in target cells was first developed more than a decade ago to treat benign prostate enlargement. Prescribed at a dose of 5mg a day it is used in treatment of benign prostate enlargement in men. Following the lead of finasteride s effectiveness in treating benign prostate enlargement investigators studied its use in treating MPhL. these studies confirmed that at a dose of 1mg per day finasteride is effective in treating MPhL in some but not all men. Finasteride for treatment of hair loss should be prescribed only after examination by a physician hair restoration specialist. it is not approved for use in women and particularly in women who are pregnant. the drug has potential for interfering with sexual development of a foetus. Finasteride has long-term effectiveness and safety in treating MphL in men of all ages and all ethnic backgrounds H a i r r e s t o r at i o n w w w. t r e at H a i r l o s s . c o m . a u 19 SURGERy Hair TransplanT surgery for Hair resToraTion H air transplantation is an operation that takes hair from the back of the head and moves it to the area of hair loss. The fringe (back and sides) of hair on a balding scalp is known as donor dominant hair which is the hair that will continue to grow throughout the life of most men. The transplantation of this hair to a bald area does not change its ability to grow. Donor dominance is the scientific basis for the success of hair transplantation. Dr Okuda of Japan first described the use of transplanted hair to repair scarred eyelashes and eyebrows. Unfortunately the outbreak of World War II prevented his valuable discovery from reaching the rest of the world for two decades. Dr Norman Orentreich published the first widely read report on hair transplantation surgery in 1959 and the field of hair transplant surgery was born. Candidates for hair transplant surgery are those individuals with hair loss that have sufficient donor hair from the fringe of the scalp to transplant to the balding area. In the past many bald patients were not suitable candidates for hair transplant surgery but modern techniques have advanced the art of hair transplant surgery so that many more men are candidates. Hair transplantation surgery has improved in leaps and bounds over the past decade. The days of the plugs and corn rows are gone and the age of single hair- micro- and mini-grafting has arrived. Through the use of the these variable sized hair grafts along with new and improved instrumentation the accomplished hair transplantation surgeons can create a natural hair appearance that is appropriate for each individual patient. Single hair-grafts have the finest and softest appearance. Although they do not provide much density they do provide the critical soft hairline that is the transition to thicker hair. Reconstructing a new hairline is a skill requiring surgical as well as artistic expertise. It is critically important to get it right the first time and thus requires considerable forethought and planning. Examining the hairline of a nonbalding person will show the presence of numerous single hairs in the very frontal hairline. Micrografts are small grafts containing 2 to 3 hairs that are placed behind the hairline to provide a gradually increasing hair density. Lastly minigrafts contain 4 or more hairs and are placed well behind the hairline so that the single hair and micrografts can blend naturally into the density provided by these larger grafts. 20 H a i r r e s t o r at i o n w w w. i s H r s . o r g surgery There is different terminology and techniques used by many IsHrs surgeons. This is because IsHrs surgeons are innovators and are on the cutting edge of hair transplant surgery. New techniques naturally give rise to new terms. Although there are variations in the techniques of individual surgeons the combination use of these grafting techniques provide the most natural and pleasing results. Modern hair transplantation surgery is comfortable predictable and the results are pleasing to most patients. Hair loss however is a life-long process. Most men will develop male pattern baldness (due to male hormones) until approximately 40 to 45 years of age. After that the aging process thins the entire head of hair. Progressive hair loss or the desire for more density will require more transplant procedures. Modern techniques however allow hair transplant surgery specialists to transplant a larger number of grafts greatly reducing the number of procedures needed to complete the result. comparison between strip harvesting and follicular unit extraction a fair and balanced view Ten years ago the use of follicular unit extraction (Fue) was advocated as an alternative to traditional strip harvesting of the donor tissue. The use of the technique has been slow to be accepted as a new standard. Many physicians have in fact tried the technique but with markedly varying success. The recent promotion of mechanical devices and powered follicular extraction devices has sparked renewed interest and controversy regarding this method of harvesting. A great deal of discussion by physicians ancillary personnel and the general public has occurred on the internet and multiple media sources about the value of Fue versus strip harvesting and vice versa. sadly many of the claims of superiority of the newer technique seem more related to marketing and self-promotion rather than a clear scientific evaluation. This article discusses advantages and disadvantages of both techniques to provide a more accurate and balanced view of the two approaches. the donor area and scar formation strip harvesting produces a linear scar. The appearance of the donor strip scar can be a significant concern for patients who wish to wear their hair very short. The vast majority of patients who undergo strip harvesting have minimal scars that are easily concealed by the hair above the scar. And in many instances the scar may not be evident at all except on careful inspection. There are however some patients who have scars that have widened and there are also patients who have several scars from multiple procedures. In some instances the apparent widened appearance of a scar may actually be due to damage to follicles along the incision line during harvesting rather than true scarring. Judicious planning on the part of the surgeon can largely diminish the problems associated with strip scars. By limiting the width of the strip to be taken and avoiding tension on the wound the surgeon can minimize the donor scar. To avoid multiple scars many physicians who use strip harvesting employ a single scar technique even if multiple procedures are performed. By utilizing careful dissection along the incision line damage to hair follicles can be diminished. The use of the trichophytic method of closure for strip harvesting can also be extremely helpful in improving the appearance of the strip harvest scar. As noted above closing under minimal or no tension can help to avoid the widening of a scar. This allows hair to camouflage the scar and the hair growing through It is critically important to get it right the first time and thus requires considerable planning H a i r r e s t o r at i o n w w w. i s H r s . o r g 21 surgery Modern techniques allow hair transplant surgery specialists to transplant a larger number of grafts greatly reducing the number of procedures needed to complete the result 22 H a i r r e s t o r at i o n w w w. i s H r s . o r g the scar can limit the stretching. Avoiding damage to the hair follicles along the incision lines is crucial in preventing the appearance of a prominent scar. some physicians advocate the use of a layered closure and undermining as techniques to minimize scars. Other surgeons feel that undermining and layered closures do not seem to alter the healing except in situations where tension is a problem. There are patients such as those with ehlers Danlos syndrome who because of alterations in collagen deposition are prone to widened scars and poor wound healing. There is little that can be done to prevent such scars in these patients. The circular scars produced by Fue may suffer the same fate and be stretched in these patients. The primary rationale for the use of Fue is that a linear scar is avoided. several proponents of Fue market the procedure as a technique that does not involve cutting is less invasive and does not result in scars (ie scarless ). While a linear scar is not created with Fue circular scars are created. The length of incision is greater with Fue than with strip harvesting. Cutting is clearly involved when using a punch. Although a linear scar is not produced with Fue scars are created and evidenced by virtue of the fact that hypopigmented or hyperpigmented dots may be visible when the hair is cut very short. These dots may be a scar reaction or actual post-inflammatory pigment changes particularly in darker skinned individuals. Also the human eye may pick up spaces where follicular units are missing in the normal pattern. The depth of the incisions with Fue is usually shallower as compared to strip harvesting. The punch depth is to the level of the fat or at the fat-dermis junction. With strip harvesting the depth of incision is into the fat. some physicians cut to the deeper fat or just above the fascia. When using Fue it is important to recognize that as more and more grafts are harvested the area may appear moth eaten. If grafts are taken too close together there may be an appearance of a scar. In some patients as large numbers of grafts are removed there can be a clear demarcation between the areas that have been harvested and areas left alone. This is opposed to the strip technique where hair of similar density is brought back together at the suture line. Opponents of strip harvesting would note that if hair does not grow well in a strip scar and the scar widens the scar might be apparent if the hair above it is short or otherwise thin. some promoters of Fue have stated that nerves and veins are not cut. This claim is untrue. By entering the skin with the punch arteries veins and nerves are cut. It is important to point out that with Fue the patient s hair usually must be trimmed quite short for harvesting. This is the case especially when large numbers of grafts are required. A way to avoid trimming all of the donor hair is to set up rows of short hair between rows of long hair. The short hair grafts can be harvested within the existing long hair. But again this is only suitable when relatively small numbers of grafts are needed. graft survival Debate exists as to the rate of survival regarding Fue versus strip grafts. There is some concern that because the Fue grafts may have very little tissue surrounding them that they are less likely to survive. such grafts are more prone to dehydration which has been shown to be a major cause of diminished graft survival. The lack of perifollicular tissue is often a result of pulling on the graft to remove it. Because there is added manipulation in trying to remove a graft this may also contribute to diminished survival. surgery sometimes the ends of the bulbs are splayed or unusually far apart. This makes the bulbs more susceptible to trauma as a result of increased graft manipulation during implantation. As of this time there are not adequate studies to compare survival rates. Clearly there are patients who have undergone the Fue procedure and have excellent results. some physicians might argue that less successful results may be due to technical surgical skill rather than the nature of the more fragile graft created with Fue. With Fue there is a greater chance of transection of hairs as compared with strip harvesting and this could result in poor growth or lack of growth depending on the level of transection. The rates of transection seem to vary widely with Fue. Conversely with strip harvesting grafts may be damaged in making the initial skin incisions and subsequent dissection of the tissue but this is considered minimal. The use of the microscope for dissection of the donor strip should limit transection rates to 1 to 2 percent. grafts created with strip harvesting generally have a greater amount of surrounding tissue and fat. This may decrease the chance of dehydration and allow for greater leeway in manipulation of the grafts during placing and hence better graft survival. Placing of grafts When manual placement of grafts is utilized there is no difference in regard to the technique of placement of strip harvested or Fue harvested grafts. There may be some concern about the fragility of the Fue grafts and the fact they may be more susceptible to drying and over-manipulation. When a machine that uses pneumatic pressure is used it is the contention of the manufacturer distributor that the machine places the graft with less manipulation. some surgeons who have used the machine have indicated that the graft-placing capability of the machine is limited at times and not always reliable. Perfectly harvested grafts may be damaged during the placement phase and fail to grow. Trauma and graft drying are well known factors that may occur in inexperienced hands and will effect graft survival. regardless of how grafts are harvested there is a considerable amount of artistry and technical expertise necessary to place them to produce an excellent or even acceptable result. The surgeon must be able to create an aesthetic blueprint for graft placement determining the distribution of 1 2 and 3 hair grafts. Hairline design is obviously important as is the grafting plan over the rest of the scalp. The experienced hair surgeon will create gradients of density to achieve natural looking results with adequate density. The incisions must also be made at the H a i r r e s t o r at i o n w w w. i s H r s . o r g 23 xxx xxx proper angle and direction. Even single hair grafts will look unnatural if placed at the wrong angle. technical expertise A somewhat different skill set is required for FUE harvesting. The surgeon must be able to align the small punch correctly find the right depth and adjust the punch to account for changes in direction of the hair. The primary concern with FUE is the rate of transection. That is if the hairs in a follicular unit are transected they are less likely to grow. This is in part dependent on the level of transection. The reports from physicians performing FUE indicate that the rate of transection is higher than with strip harvesting. As noted above the physician must be able to adjust the punch to account for change in hair direction. Patients with curly or very wavy hair may be difficult to treat when FUE is used. In comparison strip harvesting is suitable for all types of hair. The use of the blunt punch can be helpful in harvesting curly or wavy hair with the FUE technique. number of grafts per session In general most physicians who perform FUE are not able to do as many grafts in a single session as can be done with strip harvesting. With strip harvesting sessions of 2000 to 3000 grafts are very common and some physicians frequently perform sessions in excess of 4000 grafts. There are however exceptions and some physicians routinely performing motorized FUE report similar in excess of 2000 grafts. Unfortunately the rates of graft transection in these larger FUE sessions have not been studied or reported. Cost The cost of FUE is usually significantly more than that for strip harvesting on a per graft basis. The costs may exceed double the price of strip harvesting. Body hair FUE can be very useful for harvesting body hair. In such situations the majority of follicular units are single hairs. Evidence of the surgery is often visible as hypo or hyperpigmented dots in these non-scalp donor areas. FUe into scars FUE can be used to try to camouflage linear donor scars. This is considered by many hair restoration surgeons to be another excellent use of the technique. Some surgeons have suggested that a combination of strip harvesting and FUE is the optimal use of the techniques. increased donor supply Advocates of FUE have stated that FUE expands the donor area in the scalp. With FUE the surgeon can harvest in the nape of the neck more easily as well as the areas superior and more anterior to the ear. This apparent advantage is somewhat negated because the area can become moth eaten in appearance as more and more grafts are obtained. In addition going into the nape of the neck area or high onto the scalp can be a problem later in life for the patient as some men lose hair in this area as a result of male pattern hair loss. Complications Some of the surgeons who prefer FUE feel that patients experience less pain and there is a shorter recovery time. There is little data to support this view. One 24 H a i r r e s t o r at i o n w w w. i s H r s . o r g surgery would need to compare the pain associated with comparable numbers of grafts harvested per session. For instance one would want to compare 1000 grafts harvested with strip vs the same number harvested with the Fue technique. The fact that pain is very subjective complicates such studies. Telogen effluvium can occur in the donor area with Fue or strip harvesting but this is uncommon. Infection is a very rare complication with hair restoration surgery. Dehiscence with strip harvesting can occur but this is quite rare and would be associated with surgical error. similarly necrosis of tissue should not occur unless the area harvested is too wide and or closed under excessive tension. This could also occur if the arterial supply was already compromised. Patients may complain of altered sensation but this can occur with strip harvesting or Fue as small nerves are cut in both procedures. A complication specific to Fue harvesting is the burying of grafts. This happens when the punch pushes the graft into the subcutaneous tissue. The grafts can be difficult to recover and can lead to a foreign body reaction and cyst formation. Hypertrophic scars and keloids should also be rare with Fue or strip harvesting. If patients have a predilection for keloids making punch excision will not limit such scar formation. summary strip harvesting and Fue are both acceptable techniques for harvesting donor grafts. each technique has advantages and disadvantages. On a cost-benefit ratio strip harvesting would seem to provide the most cost effective procedure. Fue is well suited for patients who insist on not having a linear scar. It may be an excellent choice for young patients seeking small procedures. Fue may be the ideal choice for harvesting trunk leg and arm hair and it is an excellent way to camouflage strip scars. No matter the technique employed the surgeon must be well versed in the technical and aesthetic components of performing the surgery in order to produce consistently good results. A single course or training session on one aspect of the hair restoration procedure such as harvesting is inadequate training for a physician to learn how to perform hair restoration procedures. The surgeon must acquire a sense of the aesthetic and technical components of the procedure. He or she must be able to develop a plan for patients with various clinical scenarios and know when to refer to a surgeon with more expertise. The goal of hair restoration seems simple enough namely to move hair from one part of the scalp to the other. However any experienced physician will tell you how complex this is. One of the most important concepts the physician must appreciate is that hair loss is progressive and that any restoration plan must be made with this in mind. When a patient comes to the physician with a given stage of hair loss the physician must be able to assess the donor area for hair density and quality calculate the number of grafts needed give the patient a reasonable expectation for what the result will be and plan this result with the possibility of future hair loss in mind. The physician must be able to discuss the pros and cons of medical treatments designed to stop or slow future hair loss such as oral finasteride and topical minoxidil. All of these elements require considerable training and expertise to implement for each patient. successful graft harvesting is only one small component of surgical hair restoration. Without attention to all of the other aspects there is a very real possibility of a bad outcome. Finally the incision of skin and tissue whether using instruments that create a linear or circular incision is legally considered surgery and should only be performed by a licensed physician with adequate training and expertise in hair restoration. H a i r r e s t o r at i o n w w w. i s H r s . o r g 25 risks Hair estoration r surgerY risk Factors Y ou may think of surgical hair restoration as minor surgery compared with major procedures such a hip replacement or organ transplantation. While those and other major surgical procedures are long complex operations hair restoration surgery is not major surgery and has proven to be very safe. However as with all surgical procedures the more risk factors a patient has the greater the possibility for postoperative complications. risk factors are those that increase a patient s risk for harm. some risk factors are associated with the surgical procedure while others are associated with the patient. Patient risk factors important in surgical hair restoration are those that increase risk for postoperative infection excessive bleeding and delayed healing. The hair restoration surgeon will determine risk factors based on the information given by the patient prior to any surgical procedure. some important risk factors the physician will want to know about include Tobacco use especially long-term cigarette smoking Alcohol abuse or heavy drinking Obesity Malnutrition including bulimia and anorexia Use of immunosuppressive drugs including corticosteroids and chemotherapy Use of herbal supplements immunosuppressive disease eg HiV-AiDs Diabetes or other chronic metabolic disease Chronic disease of the heart liver kidneys lungs or gastrointestinal system Chronic or recurrent skin infections such as boils Chronic or recurrent bacterial or viral infections Medications that decrease the ability of the blood to clot such as antiinflammatory drugs Conditions that require antibiotics prohylaxis such as artificial joints or valves. A prospective candidate for surgical hair restoration should answer questions about risk factors as fully as possible. For the patient s own safety it is essential for the physician to know in advance if there are risk factors that increase the possibility for postoperative complications--even if risk factors such as tobacco or alcohol use are somewhat embarrassing for the patient to discuss. The presence of risk factors will rarely deny a hair restoration procedure to the patient but the physician will be aware of the possibility of complications associated with the risk factors. 26 H a i r r e s t o r at i o n w w w. i s H r s . o r g products air Loss H iracLe & M cures he philosopher George santayana said skepticism is the chastity of the intellect. the showman p t Barnum said there s a sucker born every minute. the philosopher and the showman both said basically the same thing a healthy skepticism protects you from being suckered by an unverified claim. Advances in surgical and microsurgical technique over the past 50 years make surgical treatment of hair loss a possibility for many of the millions of Americans. Advances in understanding of the biochemistry and physiology of hair growth and hair loss make medical treatment of hair loss a scientifically documented reality for the first time in history. Efficacy of surgical and FdA-approved medical treatment is confirmed in clinical trials. scientifically confirmed success of surgical and medical hair restoration is a phenomenon of recent decades. undocumented claims of miracle cures for hair loss have been with us for much longer at least since the days of the patent medicine salesmen of the 19th century. How can you sort out the undocumented claims of miracle cures for hair loss from the scientifically documented facts about hair restoration We hope the following explanation can help you make informed decisions about treatment for hair loss. T How can you determine if the products will do what they claim one way is to accept the claims at face value purchase the products and try them. the other way is to approach the claims with a healthy skepticism H a i r r e s t o r at i o n w w w. i s H r s . o r g 27 PRODUCTS What you want to see is documented proof that the product has been tested in clinical trials and approved by the FDA and apply some truth-of-claims tests to determine if a product appears to be what the seller promises Do claims use words such as miraculous amazing sensational scientific breakthrough or developed by doctors These are classic Snake Oil claims and your skepticism should go into high gear. Any product claim that asks for your 100 percent gullibility should be suspect. What proof of product effectiveness is offered If the only proof is anecdotal eg a testimonial that I used Product X and had a full head of hair in 30 days be skeptical. So-called testimonials are not scientifically valid proof of effectiveness. What you want to see is documented proof that the product has been tested in clinical trials and approved by the US Food and Drug Administration (FDA) for use as indicated in product packaging. Has the product been approved by the FDA A product that stimulates the growth of hair is a product with a potent physiologic effect. What you should want to know is 1) does the product actually stimulate hair growth in a majority of persons who use it and 2) if so does it do so safely with minimal side effects FDA approval assures you that both product effectiveness and product safety have been rigorously investigated in clinical trials. Has the product been tested in FDA-approved clinical trials Clinical trials are 1) medical investigative studies in which human beings are the test subjects and 2) required by the FDA for the approval of a new drug or new uses of an existing drug. Before clinical trials are undertaken a product has usually been studied in laboratory tests and in animals to determine mechanism of action efficacy and safety. There are several types of clinical trials but the gold standard for unbiased study results is the randomized double-blind controlled trial (RCT). In the RCT study subjects are randomly assigned to a study group or control group and neither the investigators nor the study subjects and controls know who is receiving the treatment under investigation and who is receiving placebo (a non-drug with no physiologic effect a sugar pill ). Thus RCTs are double blind both investigators and study subjects are blinded regarding who is receiving the investigative drug and who is receiving placebo. Interestingly in the clinical trials of FDA-approved finasteride and minoxidil a significant percentage of people receiving placebo reported new hair growth even though careful measurements and photographs showed that no new hair had been grown. This demonstration of wishful thinking indicates the value of blinded studies that eliminate bias a tendency to see what you want to see. It is important to keep this in mind when evaluating glowing anecdotal reports of effectiveness from people who used non-FDA approved remedies. RCTs are also designed to assure that the number of people being studied will yield a statistically meaningful result. Product effectiveness and product safety are two parameters always investigated in clinical trials. Pharmaceutical firms sponsor RCTs to gather the data necessary to win FDA approval for a new drug 28 H a i r r e s t o r at i o n w w w. i s H r s . o r g products or new uses for an existing drug. FdA rules specify conditions under which the clinical trials are conducted. the studies are conducted by recognized medical investigators in hospitals and medical centers or by physicians in private offices independent of any involvement by the firm paying for the trials. If a product wins FdA approval it must be marketed within FdA guidelines and claims cannot exceed the findings of clinical trials. As of June 2001 two hair-restoration agents have been approved by the FdA--finasteride and minoxidil. Does product advertising include the listing of any side effects associated with use of the product FdA-approved clinical trials include study of product safety and side effects. It would be unusual to find that a product with a potent physiologic effect such as stimulating hair growth had no side effects. While side effects may be minimal and may be experienced by relatively small numbers of people prospective users of the product should be aware of the potential for side effects. If product advertising fails to mention side effects or claims no side effects be skeptical. Is a medical examination recommended before use of the product While inherited tendency for hair loss is the most common cause of baldness in the us there are other causes that may require medical treatment prior to hair restoration. surgical or non-surgical hair restoration should not be undertaken prior to examination by a physician specializing in hair loss and restoration. Be skeptical of a product claim that 1) omits recommendation for use under medical supervision or 2) says you can use the product without medical supervision. Miracle cures for hair loss typically have little or no scientific basis for their claims and no controlled trials of safety and efficacy. on the other hand are science-based medical treatments for male and female pattern baldness that have shown promise in limited studies but to date have not been proven safe and or effective in large controlled trials acceptable for FdA approval. some of these over-the-counter treatments are potential candidates for future approval by the FdA. claims of effectiveness for these treatments usually cannot be documented by reference to clinical trials claims are more likely to be anecdotal. If product advertising fails to mention side effects or claims no side effects be skeptical Is the product a hair thickener rather than a hair restorer read the product marketing information carefully to be sure you understand the claims. some products are capable of making temporary chemical changes in hair that thicken each hair strand and create an effect of a fuller head of hair . Hair thickeners do not stimulate hair growth but they may produce a temporary cosmetic improvement in thinning hair. A IsHrs physician can counsel you regarding the use of a hair thickener to complement hair restoration. the best way to judge hair restoration product claims is on the basis of objective criteria such as the results of FdA-approved clinical trials and subsequent FdA approval. consultation with a hair restoration doctor is the best first step when you are considering hair restoration. H a i r r e s t o r at i o n w w w. t r e at H a i r l o s s . c o m . a u 29 feMale hair loss femaLe 30 H a i r r e s t o r at i o n w w w. i s H r s . o r g Hair Loss & Pattern BaLdness feMale hair loss T The underlying cause of female pattern baldness is believed to be related to production of androgenetic (male) hormones he most common type of hair loss in women is female androgenetic alopecia (female pattern baldness). it occurs in about 20 percent of american women overall. in one study of 1 008 Caucasian women female androgenetic alopecia was found in 3 percent of women aged 20-29 years 16-17 percent of women aged 30-49 years 23-25 percent of women aged 50-69 years 28 percent of women aged 70-79 years 32 percent of women aged 80-89 years. [Norwood oT. incidence of female androgenetic alopecia (female pattern baldness). Dermatol surg 2001 27 53-54.]. The statistics reflect the increased incidence of female androgenetic alopecia during and after menopause. The underlying cause of female androgenetic alopecia is believed to be related to production of androgenetic (male) hormones and the effect of androgenetic hormones on the hair follicle the same underlying cause responsible for male androgenetic alopecia (male pattern baldness). The pattern of hair loss in female androgenetic alopecia has some distinctive features that differentiate it from male-pattern hair loss. in general there are three patterns of hair loss in female androgenetic alopecia grade i Thinning hair on the central scalp (top of the head). grade ii Thinning hair and patches of greater scalp hair loss. grade iii Male-pattern alopecia with hair loss at the front of the scalp to mid-scalp. however it is very rare to see complete male-pattern cue-ball baldness in a woman. female hair loss occurs in more than one pattern. if you are a woman with loss of scalp hair you should seek professional advice from a physician hair restoration specialist. in most cases female hair loss can be effectively treated. if you are a woman who has started to lose scalp hair you are not alone if You are unpleasantly surprised by the hair loss You don t understand why you are losing hair. The patterns of hair loss in women are not as easily recognizable as those in men. Unlike hair loss in men female scalp hair loss may commonly begin at any age through 50 or later may not have any obvious hereditary association and may not occur in a recognizable female-pattern alopecia of diffuse thinning over the top of the scalp. a woman who notices the beginning of hair loss may not be sure if the loss is going to be temporary or permanent--for example if there has been a recent event such as pregnancy or illness that may be associated with temporary hair thinning. if you are a woman worried about loss of scalp hair you should consult a physician hair restoration specialist for an evaluation and diagnosis. selfdiagnosis is often ineffective. Women tend to have less obvious patterns of hair loss than men and non-pattern types of hair loss are more frequent in women than in men. H a i r r e s t o r at i o n w w w. i s H r s . o r g 31 female hair loss Women tend to have less obvious patterns of hair loss than men and non-pattern types of hair loss are more frequent in women than in men Non-pattern causes of hair loss in women in women more often than in men hair loss may be due to conditions other than androgenetic alopecia. some of the most common of these causes are Trichotillomania compulsive hair pulling. hair loss due to trichotillomania is typically patchy as compulsive hair pullers tend to concentrate the pulling in selected areas. hair loss due to this cause cannot be treated effectively until the psychological or emotional reasons for trichotillomania are effectively addressed. alopecia areata a possibly autoimmune disorder that causes patchy hair loss that can range from diffuse thinning to extensive areas of baldness with islands of retained hair. medical examination is necessary to establish a diagnosis. Triangular alopecia loss of hair in the temporal areas that sometimes begins in childhood. hair loss may be complete or a few fine thin-diameter hairs may remain. The cause of triangular alopecia is not known but the condition can be treated medically or surgically. scarring alopecia hair loss due to scarring of the scalp area. scarring alopecia typically involves the top of the scalp and occurs predominantly in women. The condition frequently occurs in african-american women and is believed to be associated with persistent tight braiding or cornrowing of scalp hair. a form of scarring alopecia also may occur in postmenopausal women associated with inflammation of hair follicles and subsequent scarring. Telogen effluvium a common type of hair loss caused when a large percentage of scalp hairs are shifted into shedding phase. The causes of telogen effluvium may be hormonal nutritional drug-associated or stress-associated. loose-anagen syndrome a condition occurring primarily in fair-haired persons in which scalp hair sits loosely in hair follicles and is easily extracted by combing or pulling. The condition may appear in childhood and may improve as the person ages. 32 H a i r r e s t o r at i o n w w w. i s H r s . o r g female hair loss Hair Loss in Women and its effect on QuaLity of Life H air loss can have a dismaying or even devastating influence on a woman s quality of life not least because hair loss is often wrongly considered a less significant psychological and emotional problem for women than it is for men. Too often a woman s hair loss is not taken seriously by family and friends or even by a woman s personal physician. While hair loss itself can present psychological and emotional problems for a woman failure of others to recognize the seriousness of these problems may contribute additionally to psychological and emotional effects that can range from decreased self-esteem to anxiety and depression. in women hair loss is likely to be diffuse a thinning rather than the typical male-pattern monk s tonsure or cue-ball hair loss. The less-apparent diffuseness of typical hair loss in women may account in some degree for the underestimation of its importance in a woman s life. many people do not commonly think of hair loss as a female problem. scalp examination may not be part of a regular physical examination by a woman s personal physician and thus the subject of hair loss may not arise unless the woman mentions it as a concern. many women may be embarrassed to bring up the subject to their personal physicians. a personal physician who recognizes hair loss as a psychological or emotional concern for the woman can refer the woman to a physician hair restoration specialist for consultation and diagnosis. H a i r r e s t o r at i o n w w w. i s H r s . o r g 33 female hair loss Treatment should be considered when hair loss influences the woman s quality of life hundreds of women with hair loss were interviewed using a validated questionnaire as described by David h Kingsley PhD at an international meeting of the ishrs. Women responding to the questionnaire reported Loss of self-esteem i feel other people are always looking at my hair i constantly compare my hair loss to others i feel unattractive or undesirable as a result of my hair loss. anxiety and depression losing my hair has been the most disturbing event of my life i constantly worry about my hair loss. social dysfunction i go out less because of my hair loss i feel my hair loss is affecting my career my hair loss has limited my sexual activity. Loss of control i am constantly seeking advice about my hair loss. Lack of support friends and family don t take my hair loss seriously or underestimate its importance to me. hair loss in a woman may also be overlooked as a normal phenomenon. Gradual hair loss is often associated with aging. Temporary hair loss is often associated with pregnancy. Very often women have pattern hair loss that runs in the family . hair loss in a woman should never be considered normal however the cause should be pursued until a diagnosis is established. of the many causes of hair loss in women only a few such as aging hormonal changes associated with pregnancy and hereditary pattern hair loss may be considered normal . Treatment is available for hair loss due to these normal conditions and treatment should be considered when hair loss influences the woman s quality of life. other potential causes of hair loss in women require medical treatment. These include cystic ovaries hypothyroidism autoimmune disease chemotherapy psychological or physical stress and dietary deficiencies. Prescription drugs that commonly cause hair loss include beta-blockers coumadin anti-depressants and others. medications may need to be changed or dosages adjusted due to hair loss. Damage to hair and scalp caused by tight braiding corn-rowing or chemicals used in hair styling are causes of hair loss that require change in lifestyle. Compulsive hair-pulling a condition called trichotillomania that can cause unusual patterns of hair loss may require psychological counseling. if hair loss causes psychological or emotional problems for a woman it should always be taken seriously by family friends and the woman s personal physician. Dr Kingsley an authority on emotional and psychological problems associated with hair loss recommended that primary care physicians who treat women 1. Take the time to do a scalp examination and bring up the topic of hair loss even if the woman has not mentioned it 2. Take the time to discuss how the patient feels about her hair loss and fully answer all questions from the patient 3. Conduct the diagnostic examinations and tests necessary to establish a diagnosis when necessary or refer the patient to a physician hair restoration specialist for diagnostic tests and 4. refer the patient to a physician hair restoration specialist for effective treatment options. hair transplantation is one of the options that may be considered. 34 H a i r r e s t o r at i o n w w w. i s H r s . o r g female hair loss planTs ir Trans Ha re For a en Too Wom air transplantation is not just for men with hair loss. it is a treatment for women too. modern techniques of hair transplantation are successful in treating typically diffuse female-pattern hair loss as well as the more familiar forms of male-pattern hair loss. a woman who becomes concerned about hair loss can discuss this option with her physician hair restoration specialist. in general hair transplantation is likely to result in a more satisfying outcome for a woman when there is adequate donor hair for successful transplantation. a less satisfying outcome is more likely when transplantation is a last ditch treatment for advanced hair loss when donor hair is in short supply. [Unger WP Unger rh. hair transplantation an important but often forgotten treatment for female pattern hair loss. J amer acad Dermatol 2003 49 853-860]. H H a i r r e s t o r at i o n w w w. i s H r s . o r g 35 female hair loss Realistic expectations for hair transplantation Whenever hair transplantation is considered a woman and her physician should agree prior to treatment on realistic expectations for treatment outcome. a realistic expectation is to achieve a significant increase in hair density satisfactory for hair styling and overall cosmetic appearance. an unrealistic expectation is refusal to be satisfied with any result less than complete restoration of pre-thinning hair density. female-pattern hair loss like male-pattern hair loss is progressive and relentless. a woman with female-pattern hair loss who wants to maintain the same hair density throughout her life may consult her physician hair restoration specialist about wigs or hair additions. No currently available surgical or non-surgical treatment can cure female-pattern hair loss. There is no treatment that cures pattern hair loss in the way that antibiotics cure infection. The purpose of surgical and nonsurgical treatments is to mitigate the cosmetic effects of progressive pattern hair loss. The onset of female-pattern hair loss female-pattern hair loss can begin at any age from the 20s onward. The most common ages of onset are the 30s and 50s. onset is often insidious a few more hairs than usual in the comb or hair brush recognition of places where hair is no longer dense enough to conceal bare scalp. over time the loss of hair will evolve into one of the typical patterns of female-pattern hair loss. a woman who is concerned about thinning hair should first find out if female-pattern hair loss in the cause. examination by a physician hair restoration specialist will assure a correct diagnosis and confirm or rule out any causes that may require medical treatment. establishing the cause of a woman s hair loss should not be a guessing game. The physician hair restoration specialist will present options for treatment based upon 1. The correct diagnosis and 2. The woman s wishes regarding time cost and desired outcome of treatment. hair transplantation may or may not be an acceptable option recommended by the physician hair restoration specialist. it is important however that hair transplantation is now considered an option available to a woman. it should not be overlooked as a treatment only for men. it should not be dismissed because pluggy hair grafts were often produced by older transplantation techniques. modern hair transplantation techniques using mini-grafts micrografts single-hair grafts and follicular unit grafts produce results that meet the most stringent standards for naturalness of appearance. hair transplantation may be reserved as an option to consider later after a trial of minoxidil to slow hair loss and stimulate hair regrowth. minoxidil is also frequently used in conjunction with hair transplantation to enhance hair density in transplanted areas of the scalp. 36 H a i r r e s t o r at i o n w w w. t r e at H a i r l o s s . c o m . a u causes Other air LOss h Causes H a i r r e s t o r at i o n w w w. i s H r s . o r g 37 causes e oTHer poSSible Here Are Som r your HAir loSS cAuSeS fo Alopecia areata alopecia areata (aa) is a recurrent disease which can cause hair loss in any hair-bearing area. The most common type of alopecia areata presents as round or oval patches of hair loss most noticeably on the scalp or in the eyebrows. The hair usually grows back within 6 months to one year. Most patients will suffer episodes of hair loss in the same area in the future. Those who develop round or oval areas of hair loss can progress to loss of all scalp hair (alopecia totalis). The cause of alopecia areata is unknown but commonly thought to be an autoimmune disorder (the body does not recognize the hair follicles and attacks them). stress and anxiety are frequently blamed by patients as the cause of their hair loss. The most common treatment is with steroids (cortisone is one form) either topically or by injection. The outcome of treatment is good when the alopecia areata process is present less than one year it is poor especially in adults if the disease has been present for longer periods of time. Minoxidil can help to regrow hair. surgical treatment of this disorder is not recommended. If you have questions concerning alopecia areata please contact an IsHRs physician. Alopecia areata commonly presents as round or oval patches of hair loss most noticeably on the scalp or eyebrows Traction alopecia Traction alopecia is caused by chronic traction (pulling) on the hair follicle and is seen most commonly in african-american females associated with tight braiding or cornrow hair styles. It is generally present along the hairline. Men who attach hairpieces to their existing hair can experience this type of permanent hair loss if the hairpiece is attached in the same location over a long period of time. Trichotillomania is a traction alopecia related to a compulsive disorder caused when patients pull on and pluck hairs often creating bizarre patterns of hair loss. In long term case of trichotillomania permanent hair loss can occur. Scarring alopecia Hair loss due to scarring of the scalp is called scarring alopecia. scarring can be due to a variety of causes. Traction alopecia over a period of time may lead to scarring and permanent hair loss. Trichotillomania (compulsive hair-plucking) can cause permanent scalp scarring over time. Injury to the scalp caused by physical trauma or burns may leave permanent scars and permanent hair loss. Diseases that may cause permanent hair loss due to scalp scarring include 1) the autoimmune conditions lupus erythematosus and scleroderma and 2) bacterial infections such as folliculitis fungal infections and viral infections such as shingles (herpes zoster). 38 H a i r r e s t o r at i o n w w w. t r e at H a i r l o s s . c o m . a u causes Trichotillomania Trichotillomania is the name given to habitual compulsive plucking of hair from the scalp or other hair-bearing areas of the body. Over time continual plucking of scalp hair will result in a hairless area a bald spot. Long-term trichotillomania can result in permanent damage to scalp skin and to scarring alopecia. It is not known whether trichotillomania should be classified as a habit or as obsessive-compulsive behavior. In its mildest form trichotillomania is a habitual plucking of hair while a person reads or watches television. In its more severe forms trichotillomania has a ritualistic pattern and the hair-plucking may be conducted in front of a mirror. The person with trichotillomania often has guilt feelings about his or her odd behavior and will attempt to conceal it. Over time continual plucking of scalp hair will result in a hairless area a bald spot Triangular alopecia The cause of triangular alopecia is not known but the condition can often be treated medically or surgically. The characteristic pattern of hair loss in triangular alopecia is thinning or complete loss of hair in the scalp area around the temples. If hair loss is not complete the remaining hairs are often miniaturized fine-textured hairs of thin diameter. Triangular alopecia sometimes begins in childhood with unexplained hair loss in the temporal areas of the scalp. Telogen effluvium Telogen effluvium is the name given to hair loss that is caused when a large percentage of scalp hair follicles are shifted into the telogen or shedding phase of hair growth. The cause of this abnormally timed telogen phase may be hormonal nutritional drug-related or associated with stress. Loose-anagen syndrome Loose-anagen syndrome occurs most frequently in fair-haired persons. During the anagen (growth) cycle of hair scalp hairs sit so loosely in the follicles from which they grow that they can be easily extracted by combing or brushing. The condition may appear in childhood and gradually improve or disappear over time. H a i r r e s t o r at i o n w w w. i s H r s . o r g 39 FAQs estions about Common Qu Here are Some common queStionS and tHeir anSwerS concerning Hair loSS and Hair tranSplantS. what causes hair loss air restoration H The most common cause of hair loss is inheritance. Men and women inherit the gene for hair loss from either or both parents. Men are most commonly affected by the inherited gene as the hormone testosterone activates the genetic program causing loss of hair follicles. Currently there is no known method of stopping this type of hair loss. The age of onset extent and rate of hair loss vary from person to person. severe illness malnutrition or vitamin deficiency can accelerate this process. When applied incorrectly permanent hair color and chemical relaxers damage the hair and follicle to the extent that hair loss can be permanent. Causes of hair loss do not include wearing a hat excessive shampooing lack of blood flow or clogged pores. Do hair transplants really work Yes. The transplanted hair is removed from one area of the body (donor site) and transferred to another (recipient site). The transferred tissue is not rejected as it is not foreign tissue. The transplanted hair maintains its own characteristics color texture growth rate and curl after transplantation and regrowth. The vitality of the grafted follicle is maintained by the rich blood supply to the scalp. Originally large circular grafts containing 15 to 20 hairs were transplanted resulting in noticeable and unnatural results. Over years instruments and techniques have been developed that allow us to achieve truly natural results by transplanting small grafts very close together. We have found that hair grows from the scalp in groups of one two and three hair follicles. We transfer these groups of follicles after eliminating the excess surrounding fatty tissue. This allows the grafts to be placed closer together resulting in a denser and more natural result. 40 H a i r r e s t o r at i o n w w w. i s H r s . o r g FAQS what can be expected after hair restoration surgery The post-operative course will depend on adherence to the instructions given after surgery. Small scabs will form on the scalp at the graft sites. Generally speaking these scabs disappear in 4 to 7 days. Shampooing can be resumed 24 hours after surgery. The suture (stitch) used in the donor area is undetectable as it is completely covered by your existing hair. An appointment will be made for the suture to be removed one week after surgery. It is advisable to take at least two days off work after surgery. A baseball type cap can be worn at anytime after surgery. Patients should avoid strenuous physical activity for at least five days after surgery. Typically the grafted hair will shed in 2 to 4 weeks. New growth will begin in 3 to 4 months and length will increase approximately half an inch per month. are hair transplants painful Most people are surprised at how little pain there is during the procedure. Some discomfort is to be expected as the anesthetic is injected into the scalp. Once the skin is anesthetized there is no pain. If the numbing medicine wears off during the course of the procedure more is injected to re-anesthetize the area. what will it look like after the procedure The grafts form small scabs in the days after the procedure. If one has enough surrounding hair these scabs can be camouflaged with creative styling. If not the small scabs may be visible but do not attract much attention. By keeping the scalp moist the scabs usually come off in about a week or so. when can i go back to work Depending on the type of procedure you have done and the type of work you do it is often possible to go back to work the next day. Your hair restoration surgeon will discuss this with you during the consultation. are hair transplants expensive Hair transplantation is more expensive than a hair piece or some alternative treatments. However considering that the results are permanent most people consider it a good investment in their future happiness. How many sessions will be required The number of the sessions will depend on 1) the area of scalp treated 2) the number and size of grafts used 3) the density which the patient desires and 4) the individual characteristics of the patient eg coarse hair will provide a more dense look than fine hair. The estimate of the number of sessions can be discussed during the consultation with your surgeon. what is the specialization of hair restoration surgery The field of hair restoration surgery (HRS) is made up of physicians from many backgrounds including dermatology plastic surgery general surgery family practice ENT and many others. Unfortunately training in HRS in the typical residency is rarely at the same level as is performed today. That is why postgraduate education in HRS is so important and why the ISHRS is so paramount today in educating those physicians wishing to practice this specialty. In addition ISHRS offers post-residency fellowship training positions in several centers around the world. H a i r r e s t o r at i o n w w w. i s H r s . o r g 41 hair transplantation Before & after photos Gallery BEFORE AFTER hair transplant surgery by Dr Knudsen using 2 614 grafts BEFORE AFTER hair transplant surgery by Dr Knudsen using 2 614 grafts 42 H a i r r e s t o r at i o n w w w. i s H r s . o r g gallery BEFORE AFTER hair transplant surgery by Dr Knudsen using 2 484 grafts BEFORE AFTER hair transplant surgery by Dr Knudsen using 2 484 grafts H a i r r e s t o r at i o n w w w. i s H r s . o r g 43 Gallery BEFORE AFTER hair transplant surgery by Dr Knudsen using 2 604 grafts BEFORE AFTER hair transplant surgery by Dr Knudsen using 2 604 grafts 44 H a i r r e s t o r at i o n w w w. i s H r s . o r g gallery BEFORE AFTER hair transplant surgery by Dr Knudsen using 4 071 grafts BEFORE AFTER hair transplant surgery by Dr Knudsen using 4 071 grafts H a i r r e s t o r at i o n w w w. i s H r s . o r g 45 Gallery 46 H a i r r e s t o r at i o n w w w. i s H r s . o r g BEFORE AFTER hair transplant surgery by Dr Knudsen using 3 300 grafts gallery BEFORE AFTER hair transplant surgery by Dr Knudsen using 813 grafts H a i r r e s t o r at i o n w w w. i s H r s . o r g 47 gallery BEFORE AFTER hair transplant surgery by Dr Knudsen using 2 122 grafts H a i r r e s t o r at i o n w w w. i s H r s . o r g 49 Gallery 48 H a i r r e s t o r at i o n w w w. i s H r s . o r g BEFORE AFTER hair transplant surgery by Dr Knudsen using 2 088 grafts patient brochure t BrOcHure patien Medical & Surgical OptiOnS tO reStOre & Maintain Scalp Hair What causes scalp hair loss there are many causes for hair loss in men or women. however in the overwhelming majority of males with hair loss the cause is hereditary androgenetic alopecia more commonly known as male pattern baldness . the presence of the hormone dihydrotestosterone (Dht) in a genetically susceptible man is necessary for this problem to occur. Similarly for females most patients presenting with hair loss have hereditary female pattern hair loss. this condition is still being researched but the hormone influences on hereditary hair loss in females may be different from those in males. Some of the less common causes of hair loss which are reversible with treatment include thyroid disease iron deficiency high fever surgery or general anesthesia crash diets childbirth and certain medications. there are also certain dermatologic scalp disorders that can result in temporary or permanent hair loss such as lupus lichen planopilaris and alopecia areata. Many myths abound regarding this topic hair loss is not caused by poor circulation clogged hair follicles frequent shampooing the wearing of hats or helmets or the presence of mites. it is also important to remember that most adults lose approximately 75 to 125 hairs from their scalps every day due to the natural process whereby some hairs go into a dormant state (telogen) and others come out of this state and begin to sprout a new hair (anagen). as long as the process remains balanced the number of hairs on the scalp remains constant. one other minor factor in hair loss is stress which is thought to accelerate already genetically programmed hair loss. however it probably does not cause hair loss by itself without the necessary genes and hormones. the tendency for male and female pattern hair loss is genetically inherited from either side of the family and begins to develop after puberty. hair on the scalp that is genetically susceptible to androgenetic alopecia (generally the front and top of the scalp) starts to shrink in its shaft diameter and potential length during each 3 to 5 year life cycle until it eventually disappears. the hair on the back and sides of most men s scalps is usually genetically permanent hair which is destined to remain for that man s lifetime. 50 H a i r r e s t o r at i o n w w w. i s H r s . o r g patient brochure What can be done about male pattern hair loss people with thinning hair now have more options available to them than ever before. hair restoration surgery offers a permanent living solution to lost scalp hair. effective medical treatments are now offered in the form of a pill (finasteride) and a topical liquid (minoxidil). they require life-long treatment to maintain their effect. cosmetic enhancers include colored creams sprays and powders that when applied to the thinning scalp help to camouflage thinning areas as long as there is still some hair present in the area. they do not treat the hair loss process. hairpieces are a non-surgical means to restore hair by covering bald areas of the scalp. there is a large variety of means for attaching these. the most common are glue adhesives weave attachment and clips. Surgical Modern techniques of surgical hair transplantation can restore lost hair and replace or re-shape your hairline with your own natural growing hair which needs no more care than the ordinary washing styling and trimming you have always done. transplantation can be done today so well that often a barber or stylist cannot even tell that grafts have been placed. hair transplantation involves removing permanent hair-bearing skin from the back and or sides of the scalp (donor area). then using magnification the tissue is dissected into follicular unit grafts (containing 1 to 4 hairs) and multi-follicular unit grafts (containing 3 to 6 hairs each). these small grafts are then meticulously planted into the bald or thinning area of the scalp (recipient area) so as not to injure any follicles already existing in the area and at the same exact angle as the other hairs present. the creation of very small follicular unit grafts has enabled the hair surgeon to create very natural feathered hairlines which do not have the abrupt pluggy look that was commonly seen in hair transplants of years past. Some surgeons prefer to transplant exclusively with follicular unit grafts while others feel that placing the multi-follicular unit grafts into the central areas of the scalp allows them to better create central density. Depending on the degree of balding in the frontal mid-scalp and vertex (crown) areas usually 2 to 3 procedures are performed with the number of grafts used varying tremendously based on the area of potential alopecia the patient s safe donor supply the textural characteristics of the patient s hair whether or not multi-follicular unit grafts are used in addition to follicular unit grafts and the specific goals of the patient. hair transplant surgery today is remarkably well tolerated. Within 24 hours small crusts will form on each graft that are then shed in approximately 4 to 14 days. the grafted hairs will often start to grow by 10 to 16 weeks after the procedure and will continue to grow for most if not all of one s life. (as men and women age in many there is a slight loss of hair density all over the head which would naturally also affect the transplanted hairs.) H a i r r e s t o r at i o n w w w. i s H r s . o r g 51 patient brochure who can benefit from hair restoration surgery anyone who has experienced permanent hair loss may be a candidate for hair restoration surgery including Men with male pattern baldness Women with female pattern hair loss Men or women who want to restore or change the shape of their hairline people with areas of scarring from injuries or scarring skin diseases and also patients who experienced some hair loss after surgery such as face lift procedures people who want to thicken or restore eyebrows eyelashes and beards Men and women who want hair in an area where they have little or no hair. what happens during a hair transplant procedure hair transplantation surgery is considered to be minor out-patient surgery . hair transplant procedures can take from 3 to 8 hours and are usually performed using local anesthesia on an out-patient basis often with some supplemental oral or iV medication for sedation. patients are often awake but feel very relaxed because of the effect of the sedative. there is typically little discomfort during the surgical procedure. the donor areas where the grafts have been harvested are usually closed with sutures or surgical staples except in the Follicular unit extraction technique which does not require surgical closure. these are usually removed in 7 to 14 days. Dissolvable sutures may occasionally be used in order to eliminate the need for you to return for suture removal. the recipient sites where the grafts are placed on top are essentially small superficial needle holes or slits in the skin of the scalp. the surgeon should be willing to discuss with you the pros and cons of the various methods of both donor harvesting and transplanting the grafts. at the end of the procedure either a very light dressing is applied or in many cases the doctor will have you stay for brief observation and then allow you to leave with no dressing whatsoever. at the conclusion of the procedure the surgeon usually checks the final placement of the grafts and the doctor or an assistant then explains the postoperative instructions which are usually supplied in written form as well. what happens after hair transplant surgery hair transplantation is a very safe relatively minor surgical procedure. Significant complications are extremely rare. there is usually little or no discomfort in the grafted area. Most patients feel some tightness in the donor area for 1 to 2 days and are prescribed a mild analgesic to help cope with this. patients may be asked to use moist compresses or sprays and to sleep in a semi-upright position for 2 to 3 days following the procedure to minimize swelling and bruising. Small crusts may form on each graft and these can usually be camouflaged by any existing hair that can be combed over the recipient area or with camouflage products such as DermMatch couvre or toppik. these crusts will flake off by 5 to 14 days after the surgery the smaller follicular unit scabs often falling off at around 4 to 6 days and the multi-follicular unit scabs taking longer. the transplanted hair seen growing out of the scalp may initially be shed however the roots remain and will be dormant for 10 to 14 weeks at which time 52 H a i r r e s t o r at i o n w w w. i s H r s . o r g patient brochure the new hairs will all begin to grow. numbness that may occur in the donor or recipient area usually disappears within 2 to 8 months following surgery. as stated above complications are rare. Minor inflammation can occasionally occur around a newly transplanted hair follicle similar to an infected ingrown hair or pimple and usually responds to simple warm compresses. the scar that occurs in the donor scalp as a result of the removal of donor skin is usually quite narrow and can be easily hidden by the surrounding hair. the graft sites in the recipient frontal area heal with almost no visible scarring and are covered by the transplanted hair. a minority of patients may experience mild swelling in the forehead area for a few days following surgery. it typically appears around the third post-operative day and goes away after 3 to 4 days. infection in either the donor or recipient area is extremely rare. Many patients experience a small area of numbness above the donor scar and in the rear central scalp that gradually disappears after a few months. when should i start treatment Most doctors today recommend beginning medical treatment of significant hair loss as soon as the problem has been identified. even if a patient decides to proceed with surgical hair restoration medical treatment may slow or prevent additional hair loss in the future. patients may have hair restoration surgery at any age after the early 20s but the decision for any given patient may be different depending on a number of factors. the vast majority of patients have their first procedure while they are not yet completely bald so that they can use existing hair to help camouflage the procedure. however because hair loss tends to be both gradual and progressive it is often unwise to start surgical treatment in a patient who is too young. Medical treatments such as finasteride and minoxidil are usually recommended for men with hair loss to help preserve or partially reverse thinning hair in the rear crown and in the area on top. hair transplants can be used to fill in the front hairline and thicken the front half of the scalp and medical treatments can be used to maintain hair behind the transplants and to possibly enhance the long-term results of hair restoration surgery. Your hair restoration surgeon will work with you to design an individualized plan to fulfill your specific needs. Surgical options include Scalp reduction and FlapsSurgical options Scalp reduction and FlapsSurgical options Scalp reduction and Flaps Surgical options Scalp reduction and FlapsSurgical options Scalp reduction and Flaps. a scalp reduction is a surgical procedure that removes a portion of the bald skin usually in the rear crown area and the mid-scalp on top. a flap procedure is one in which a flap of hair-bearing scalp is removed from the side and back of the scalp while attached in the temple area where it derives its blood supply and this narrow tail of tissue is then swung around and sutured in place along the front hair line. these two procedures are performed only infrequently in this new era of large sessions of small grafts. For patients with the right kind of scalps and hair loss patterns the pros and cons of these procedures can be discussed with a surgeon trained in these techniques. Most doctors recommend beginning medical treatment of significant hair loss as soon as the problem has been identified H a i r r e s t o r at i o n w w w. i s H r s . o r g 53 patient brochure How do i know if i am a good candidate for hair restoration surgery the elements a doctor assesses to determine whether a candidate is a good subject for surgical hair restoration include such things as the patient s general state of health the hair s texture fine or coarse the contrast between the patient s hair color and skin color the density ie the number of hair follicles per square inch of the hair in the donor area the size of the area to be covered the size of the area of donor hair whether or not previous grafting procedures have been done and the patient s goals and expectations. Making an accurate diagnosis and making treatment recommendations require an examination by a doctor and a frank discussion of possibilities between the patient and the doctor. the doctor should also give the patient a realistic estimate of the total cost of the planned procedure or procedures. the patient must understand that transplantation redistributes existing hair follicles and cannot create new hair follicles. Medical what are the current medical treatments available Finasteride an oral medication available by prescription only has been introduced to the market in the past decade. Finasteride is approved only for use by men. through scientific studies it has been shown to re-grow hair in a significant number of men and stop hair loss in an even higher percentage. Finasteride works by decreasing the formation of Dht a hormone responsible in large part for male pattern hair loss while not reducing testosterone the overall male hormone responsible for masculinity. therefore any side effects that may involve male sexual function are mild and occur in less than 2 percent of all patients. Finasteride has been available for over 10 years and has been shown to be safe and effective. Finasteride works best for early or moderate hair loss but it may also help patients with more advanced hair loss to preserve their remaining hair and its use is suggested by hair restoration surgeons as an effective medication to slow down or reverse male pattern hair loss in many men. it is often used as a complementary treatment for hair transplant patients. topical minoxidil has been around for over 15 years and is helpful in slowing down hair loss but less effective in helping new hair to grow. a higher concentration (5 percent solution) of minoxidil is now available for men and has been shown to be more effective than the 2 percent solution. Five percent minoxidil solution is generally not recommended for use by women because it may stimulate the growth of facial hair and also because at least one study suggests that it is not more effective than the 2 percent in females. both finasteride and minoxidil must be used on a continual basis in order to sustain results if discontinued the process of balding resumes. these medications may not work for everyone but they have a proven track record that shows a significant benefit to many people. in addition combination treatment with minoxidil solution and finasteride may provide added benefit for men with androgenetic alopecia. 54 H a i r r e s t o r at i o n w w w. t r e at H a i r l o s s . c o m . a u Russell Knudsen MB BS FFMACCS 1800 685 399 SYDNEY Level 2 45a Bay Street Double Bay NSW 2028 02 9363 9308 BRISBANE 7 50 Sherwood Road Toowong QLD 4066 1800 685 399 CANBERRA Deakin Chambers 1 14 Hannah Place Deakin ACT 2600 02 6282 8587 MELBOURNE Stanhill Suite 203 34 Queens Road Melbourne VIC 3004 03 9867 6255 AUCKLAND 7 Morgan Street Newmarket Auckland NZ 0800 424 728 Russell Knudsen MB BS FFMACCS 1800 685 399