Hair restoration

Reviewed By: Mary Ellen Luchetti, M.D., AAD Kimberly Bazar, M.D., AAD

About hair restoration Hair restoration is the general term for the numerous methods of restoring hair to areas that are balding. Some patients may benefit from medications designed to slow or stop hair loss (e.g., minoxidil, finasteride). However, surgical hair restoration is more effective for most patients. In some cases, a combination of medication and surgery is used to achieve the best results. Hair restoration is performed to restore portions of hair to a person who has experienced hair loss, usually due to heredity. It may also be performed to restore hair lost because of injury (e.g., burns) or disease (e.g., alopecia areata). Regardless of the success of the method used for hair restoration, it is important to note that a patient will never have the same degree of coverage prior to the beginning of hair loss. However, hair regrowth from medication or surgical techniques may give a fuller appearance and minimize the appearance of thin or bald areas. Hair has long been recognized as an important characteristic of a person’s physical appearance. In addition to other physical features (e.g., size, body frame), hair may influence socioeconomic status and occupation, and it distinguishes facial features (“frame the face”). Men and women who experience abnormal hair loss (alopecia) often undergo hair restoration to restore hair to areas where it has been lost. Although treatment is not usually necessary, patients who are emotionally impacted by hair loss may benefit from seeking treatment. Patients with mild-to-moderate pattern hair loss (androgenetic alopecia) are often good candidates for hair restoration using medication. Currently, minoxidil and finasteride are the only two medications approved for hair loss by the U.S. Food and Drug Administration (FDA), and finasteride is only approved for use in men. Each works to slow or reverse the shrinking of hair follicles (tiny, tubular structure in the skin through which hair grows) by interfering with the conversion of the hormone testosterone into dihydrotestosterone, the androgen (male sex hormone) that causes pattern hair loss. However, these medications do not work for everyone. Furthermore, any hair that grows as a result of their use usually occurs gradually over a period of several months or years. Hair usually grows in pairs, though it may grow in groups of up to five or more. Understanding these hair growth patterns has helped lead to significant improvements in surgical hair restoration. Hair density following a transplant procedure often appears natural, and scarring is typically minimal and unnoticeable. The most commonly utilized surgical hair restoration technique is hair transplantation. It involves transplanting healthy follicles from another site of the scalp (donor site) to a bald or thinning area. All surgical techniques use existing hair from the patient. The purpose of these techniques is to blend hair in the most efficient and natural way possible. Criteria used to determine if a candidate is qualified for surgical hair restoration include: Degree of baldness. Perhaps the most important criteria for selecting a candidate. Individuals with baldness in the front portion of the scalp as opposed to the top of the head are preferable as candidates. Age. It is generally more difficult to gauge the amount of hair loss patients younger than age 25 will experience. As a result, the preferred candidate is usually age 25 or older. Hair shaft caliber. Individuals with thick hair shafts achieve greater coverage than those with thinner hair. Very small increases in the volume of hair diameter can make a tremendous difference in surface area coverage. Donor hair. Hair at the donor site must be dense enough for transplanting and sufficient in quantity to conceal the removed portions. Hair color. Individuals with hair that is red, blonde or “salt and pepper” colored tend to be preferred to those with black hair. People with black hair may still receive hair transplants, but require a grafting method that transplants only one or two hairs per follicle. Lifestyle issues and patient expectations of hair restoration also factor heavily into the type of treatment chosen. For example, men with pattern hair loss that begins in the late teens or early 20s (premature male pattern baldness) may have unrealistic expectations of hair restoration surgery and do not typically make good candidates for surgical hair restoration. Because balding will likely continue to progress following surgery in the surrounding areas of the scalp, an unnatural or patchy appearance will probably develop. Furthermore, patients with this condition require an unusually large amount of donor follicles, making scarring at donor sites particularly difficult to conceal. It is important to note that women with female pattern hair loss lose hair in different patterns than men. Mild forms of this condition are often only noticeable as a minor widening of the central hair part, whereas severe forms may appear as severe thinning across most of the scalp (diffuse unpatterned hair loss). In general, women in either category make poor candidates for transplantation. Female patients that are ideal candidates for hair restoration have high hair density in the donor site with thinning or hair loss largely confined to the front of the scalp. Hair transplant patients may also take medications to slow or stop further hair loss both before and after hair restoration surgery. This typically results in less donor site harvesting, less hair loss over time and a more natural overall appearance. Not all forms of hair loss can be treated with hair restoration. Patients who are poor candidates for medical treatment may effectively disguise their hair loss with wigs, hairpieces and weaves. In some cases, hairstyle changes can also help disguise the condition. However, these methods do not slow or stop the progression of further hair loss. Types and differences of hair restoration Patients with mild-to-moderate pattern hair loss (androgenetic alopecia) are often good candidates for hair restoration using medication. The effectiveness of medication in restoring hair growth also depends on the cause of hair loss and the patient’s response to treatment. Some patients experience hair regrowth or a slowing or stopping of hair loss. However, others receive no benefit from the use of these drugs. The following medications are approved by the U.S. Food and Drug Administration (FDA) to regrow hair: Minoxidil (Rogaine). An-over-the-counter topical liquid or foam designed to regrow hair and/or stop hair loss associated with androgenetic alopecia and alopecia areata (patchy baldness). Applied to the scalp twice a day, it is available in both a 2 percent and a 5 percent solution. Some evidence suggests the 5 percent solution may be more effective at treating cases of pattern hair loss, particularly in men. However, the 5 percent solution may cause side effects in women (e.g., facial hair growth) and is only specifically approved for use in men. Applied twice daily to the scalp, the use of minoxidil may produce longer, thicker hairs by reversing, stopping or slowing the shrinking of hair follicles (tiny, tubular structures in the skin through which hair grows) associated with pattern hair loss. New hairs grown by minoxidil treatment may be thinner and shorter than previous hairs, though they are often produced in sufficient amounts to successfully blend with existing hair and at least partially cover bald spots. Minoxidil must be used continuously to remain effective, as any hair grown as a result of use usually falls out once treatment is stopped. Not all patients grow hair with minoxidil. When it is effective, it may take six months to a year for the drug to begin working. A physician may recommend discontinuing use of minoxidil if no results or minimal results are achieved within about nine to 12 months. Finasteride (Propecia, Proscar). A prescription medication used to treat male androgenic alopecia. Taken daily in pill form, finasteride often slows the rate of hair loss and, in some cases, may initiate new hair growth. It works by inhibiting the conversion of the hormone testosterone into dihydrotestosterone (DHT), a hair follicle shrinking hormone that contributes to hair loss in men. Like minoxidil, any hair that is regrown or maintained while using finasteride is likely to fall out after the drug is discontinued. It may also take one year or longer before results are noticeable. Patients with mild alopecia areata may benefit from corticosteroid scalp injections and those with more extensive hair loss may require oral corticosteroids. Corticosteroids are a group of anti-inflammatory drugs similar to hormones produced by the body. Ointments and creams may also be used less frequently, though they tend to be less effective than corticosteroids. In addition, the medication anthralin may provide some benefit for patients with alopecia areata. Usually used to treat psoriasis (a chronic condition marked by frequent episodes where the skin becomes itchy and red and develops thick, dry, silvery scales), anthralin is a tar-like substance applied daily to the scalp for 20 to 60 minutes and then washed off. Anthralin may also be used along with other hair medications (e.g., minoxidil) for better results. Other treatments that may be used for alopecia areata include topical sensitizers (drugs that provoke an allergic reaction that eventually leads to hair growth) and phototherapy (controlled exposure to ultraviolet radiation). Patients who are not considered good candidates for medical hair restoration may benefit from hair restoration surgery. These popular treatment methods are often effective at creating a hairline that appears natural. However, hair restoration techniques have limited potential to transplant hair to areas other than hairlines. People with diffuse or extensively thinning hair across large areas of the scalp do not typically make good candidates. Recent technological improvements have helped create safer and easier hair restoration techniques than in years past. In some cases, a combination of techniques may be used to accomplish the best possible results. In addition to other factors (e.g., cause of hair loss, patient lifestyle), the patient’s extent and pattern of hair loss will determine which hair restoration surgery will be performed. The most commonly used surgical method of hair restoration is hair transplantation. It involves the removal of small pieces of hair-growing scalp (grafts) from a “donor site” (usually the lower back or sides of the scalp) and moving them to a bald or balding area. Multiple surgeries over an extended period may be necessary to achieve an appearance the patient feels is satisfactory, with each surgery usually separated by a healing time of several months. Hair color and texture may play a role in determining how much coverage is necessary. Light-colored or coarse hair typically covers better than hair that is fine or dark-colored. The number of hairs moved varies according to the type of grafting method utilized: Micro-graft. About one to two hairs. Mini-graft. About two to four hairs. Slit graft. Roughly four to 10 hairs each. Slit grafts are inserted into slits created in the scalp. Punch graft. Typically round-shaped and contain about 10 to15 hairs. Strip graft. About 30 to 40 hairs each. Strip grafts are done in sections that are long and thin. Different names or descriptions of grafting techniques may be used at different facilities. Nevertheless, all hair transplant procedures involve one or a combination of these grafting techniques. The use of mini-grafts or micro-grafts, particularly in more noticeable areas such as the hairline has become increasingly popular in recent years. Transplanting hair in small amounts creates an appearance that is more natural. Mini-grafts and micro-grafts tend to grow out like normal hair and are often undetectable. Larger grafts may be used for greater coverage behind the hairline, but may also be more noticeable. Other hair restoration surgeries include: Tissue expansion. Commonly used to treat burns and injuries that cause skin loss. A balloon-like device (tissue expander) is inserted beneath hair-growing scalp next to a bald area and inflated with salt water for several weeks. This causes the skin to expand, creating new skin cells. After skin beneath the hair has been adequately expanded, an additional procedure stretches the expanded skin over the bald area where it is stitched closed. Flap surgery. A section of bald scalp is removed and hair-growing scalp is stretched and sewn in its place, with hair growing to the edge of the incision. The size and placement of the flap depends on the individual patient. Flap surgery is designed to cover large areas of baldness, with one flap providing roughly the same coverage as several hundred punch grafts. In some cases, it may also be combined with other restoration surgeries (e.g., tissue expansion) to provide better coverage. Scalp reduction. Bald scalp is removed and sections of hair-growing scalp are pulled forward to fill in a bald crown area. Scalp reduction surgery may be used to cover areas at the top and back of the head, but is generally inappropriate for covering the frontal hairline. A section of bald scalp is first anesthetized (numbed) and then removed. The pattern of the scalp removed may vary according to the extent of baldness and the goals of the patient. The skin immediately surrounding the removed scalp is loosened, pulled together and closed with stitches. In some cases, medication may be used in conjunction with hair restoration surgery. Before hair restoration Prior to starting treatment, a physician will obtain the patient’s complete medical history, review any family history of hair loss and ask if prior attempts at hair restoration have been made. In addition, the physician will evaluate the patient’s hair loss patterns during a physical examination. An assessment of these factors will help determine the best available hair restoration method. If surgery is deemed appropriate for restoring lost hair, a physician will provide specific instructions (e.g., eating and drinking guidelines) about how to prepare beforehand. All medical conditions (e.g., high blood pressure, blood-clotting disorders), current medications (e.g., anticoagulants, aspirin) and lifestyle factors (e.g., smoking) that could potentially complicate treatment will need to be brought to the operating physician’s attention. Important concepts of hair restoration that will be discussed prior to surgery include: The ongoing nature of hair loss. Hair loss occurs throughout the lifetime of someone with the condition. This will need to be clearly understood by the patient prior to surgery. Framing of the face. The goal of hair restoration surgery is to deflect attention from the hairline and make the central face the focus of attention. Appearance. Modern hair replacement techniques should produce a look that does not seem odd or artificial. When performed correctly, hair restoration can put forth the illusion that no surgery has taken place. Similarly, the physician will determine which areas of hair loss the patient finds most troubling. Hairline. The creation of a permanent hairline must continue to be acceptable by the patient as they age. Rounded or youthful hairlines often look artificial later in life. In addition, the type of anesthesia (numbing agent) that will be used during hair restoration surgery and its effects may be discussed to alleviate patient concerns about pain and expected recovery time. The location of the procedure, the procedures to be used as well as the associated risks and costs will all need to be clearly explained by the physician well in advance. Transportation home for the patient after the procedure will also need to be arranged beforehand. During hair restoration Patients using medications as a means of hair restoration (e.g., minoxidil, finasteride) will need to apply the product daily as recommended by their physician to ensure the best possible results. Medications may or may not be successful in stopping hair loss and/or stimulating hair regrowth. When effective, improvement in appearance is generally noticeable within several months. Hair restoration surgeries are performed on an outpatient basis, usually under local anesthesia while the patient is awake. The patient may be placed under general anesthesia (asleep during the procedure) during more extensive surgeries. Patients under anesthesia will be insensitive to pain, although those under local anesthesia may feel pressure or a tugging sensation during the procedure. Hair transplantation involves the removal of small pieces of hair-growing scalp (grafts) from a donor site (usually the back or sides of the head) and implanting them in a bald or balding area. It is the most popular surgical hair restoration method. At the beginning of the surgery, the hair at the donor site will be trimmed short to facilitate easy access and removal of the skin. Both the recipient and donor sites are sterilized to help prevent infection. Different tools may be used depending on the size of the graft and where it is to be relocated. An average donor site rarely produces more than 100 follicles (tiny, tubular structures in the skin through which hair grows) per square centimeter. The size of the total area removed depends on hair density at the donor site. After grafts are removed from the donor site, they are then separated into smaller sections and transplanted into small holes or slits prepared in the scalp. Grafts are placed about one-eighth of an inch (approximately 30 millimeters) apart to maintain healthy circulation. Subsequent treatments with additional grafts may later be required to fill in any open spaces that remain or have since appeared. During the procedure, a saline (salt water) solution may be periodically injected into the scalp to help keep the skin strong and resilient. The donor site is then stitched shut, leaving a small scar that is usually covered by surrounding hair. The total process typically takes from five to 12 hours depending on the number of grafts taken and the number of staff required. Some differences in the technique may be incorporated for women who undergo hair transplantation. The use of minoxidil 2 percent may be advised for two weeks immediately before surgery and resumed five to seven days following the procedure. Larger grafts may be necessary behind the hairline to give a natural appearance. During a tissue expansion procedure, a balloon-shaped object called a tissue expander is placed beneath hair-growing scalp that borders a bald area. The tissue expander is then gradually inflated with salt water over a several week period during which time the patient can perform normal duties. This causes hair-growing skin to stretch and produce new hair-growing skin cells. When the tissue expander has stretched the skin sufficiently, an incision is made by a physician and the hair-growing scalp is stretched over the adjoining bald area and stitched closed. During a flap surgery, a section of bald scalp is first cut out. Then a section of adjoining, hair-growing scalp is lifted off the surface while it is still attached at one end. The hair-growing scalp is then stretched and sewn into place where the bald scalp was removed while remaining connected to its original blood supply at the other end. The size of the flap needed and the way it is placed will depend largely on the needs and expectations of the patient. During a scalp reduction, a portion of the scalp is removed. The skin surrounding the removed area is then loosened and sewn together with stitches. Scalp reductions provide coverage of bald areas at the top and back of the scalp. However, they are not effective for coverage of the frontal hairline. The size of incision may vary according to the extent of the procedure. Scalp may be removed in the shape of an inverted Y, U, pointed oval or other figure depending on the amount of coverage needed. After hair restoration Following hair restoration surgery, the scalp is cleansed, the “donor site” is typically covered with an adhesive bandage and the patient’s head is wrapped in a turban. The patient may be kept in the facility briefly after hair restoration surgery for monitoring before being accompanied home by a friend or relative. Bandages can usually be removed in about one day. Patients may resume wetting and washing hair approximately two days after surgery. If stitches have been used, they are typically removed about seven to 10 days afterward. The wound at the donor site is typically healed in a week to 10 days, leaving only a narrow scar. Infection may occur in rare cases. How quickly a patient is able to resume normal activities following surgical hair restoration depends upon the size and scope of the procedure, as well as the individual reaction and healing abilities of the patient. Any pain, tightness or throbbing experienced is usually temporary and manageable with over-the-counter medication (e.g., aspirin). Prescription pain medication may be needed during the first two days following the procedure. Swelling may develop two to three days after hair restoration surgery, and typically lasts three to 10 days, depending on its severity. Patients may also be advised to do the following: Avoid strenuous activity (e.g., exercise, sexual activity) for several days or weeks, as increased blood flow to the scalp may cause bleeding. Do not drink alcoholic beverages for at least two days following surgery. Sleep with the head elevated for the first one or two nights following surgery. After daily shampooing, apply antibiotic ointment to the graft and donor areas with a cotton swab or clean fingers. Do not pick or scratch scabs or crusts that may form at the transplant sites. They will naturally fall off within about two weeks. Wait at least two weeks before wearing a hairpiece. The operating physician may want to periodically check the scalp in the first month following surgery to make sure incisions are healing properly. It is not uncommon for “new” hair to fall out about six weeks after surgery. This is usually temporary, with hair growth resuming in approximately six weeks at the rate of about a half-inch (13 millimeters) per month. In some instances, follow-up procedures may be necessary after the incisions have healed. Blending or filling in the hairline using a combination of grafting techniques may be performed to create a more natural look if transplanted hairs do not grow or if hair loss progresses in other areas after surgery. Patients who have had a flap procedure performed may need to have small bumps of skin that remain visible on the scalp (“dog ears”) removed. A physician may prescribe the use of minoxidil or finasteride following hair restoration surgery to minimize further hair loss and ensure a patient’s new hairline retains a natural appearance. Patients using one or both of these drugs will need to continue their use indefinitely. Hair loss will most likely resume and any new hair grown as a result of these drugs will fall out once their use is discontinued. Potential risks and benefits of hair restoration The risks and benefits of hair restoration depend on the method used. When performed correctly, successful hair restoration can provide patients with hair that appears natural. Recent advances in hair transplantation make it possible for some patients to achieve this natural look in one session. Careful planning combined with the right candidate can produce lasting results. Recent advances in grafting technology have made surgical procedures much more effective and less noticeable, though they tend to be expensive and may be painful. Hair replacement surgery is usually safe when performed by a qualified physician. However, side effects can occur and may include: Nausea or vomiting caused by medication Postoperative bleeding or infection (rare) Excessive sweating (hyperhidrosis) Headache Numbness of the scalp Scarring Poor growth of grafts (transplanted tissue) Hair replacement surgery is not generally recommended for people without sufficient quantities of donor hair, such as men with premature pattern baldness (androgenetic alopecia) or extensive balding. Further progression of hair loss following surgery may result in a “patchy” appearance, particularly if new hair loss occurs next to patches of transplanted hair. Additional procedures may be required for some patients to achieve a look that is cosmetically acceptable. The medications minoxidil and finasteride are normally safe methods of hair restoration that cause only occasional minor side effects when used as directed (e.g., skin irritation). However, finasteride is not approved for use in women. In addition, women of child bearing age should not ingest or handle finasteride due to a risk of serious side effects in male fetuses. Continued use of finasteride and/or minoxidil may regrow hair and/or stop hair loss after several months in some individuals, though these medications do not work for everyone. Furthermore, any hair grown or maintained because of the medication is usually lost within several months after treatment stops.