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Hair Replacement Surgery, Hair Transplantation in Women

Author: Mark E Krugman, MD, Assistant Professor of Plastic Surgery and Clinical Professor of Otolaryngology-Head and Neck Surgery, University of California at Irvine School of Medicine
Contributor Information and Disclosures

Updated: Feb 4, 2008

Introduction

One of the most rapidly growing segments of hair transplantation is hair transplantation in women. Surgical hair restoration was developed for and has traditionally been used in males. Newer techniques are more adaptable to females.

History of the Procedure

Although reports appeared in the medical literature of hair transplantation in the 19th and early 20th centuries, Normal Orentreich, a New York dermatologist, is credited with being the "father" of modern hair transplantation. Orentreich described the principle of "donor dominance" in 1952. Simply stated, the hair retains the characteristics from where it is taken and does not take on new characteristics from where it is placed.

Orentreich used 4-mm punches to perform his first surgeries. Indeed, larger punch grafts were the standard method of hair transplantation until the mid 1980s. Strip grafts and transposition flaps were developed in the 1970s and early 1980s. None of these techniques was applicable to women, who often had thinning behind the hairline. In the mid 1980s, various individuals began using smaller grafts in larger numbers. Currently, grafts as small as a single hair are used. These techniques, which yield more natural results, have been adapted and modified to treat women.

Problem

According to the International Society of Hair Restoration Surgery, hair loss affects 21 million women in the United States, with varying impact on their psychological, social, and emotional well-being. Hair loss in men can be socially acceptable. Many consider men with baldness, such as Michael Jordan, Yul Brenner, Kojak, and Jean Luc Picard of Star Trek, to be quite virile. Conversely, society does not accept thinning of hair or baldness in women. Women with hair loss often find it more difficult to share their feelings about hair loss with loved ones or friends or even their physicians.

Etiology

The most common cause of hair loss in women is androgenetic alopecia. Unlike androgenetic alopecia in men, women tend to have diffuse thinning, often sparing the frontal and occipital regions.

Differentiating androgenetic alopecia in women from other causes of alopecia is important. A positive family history usually accompanies androgenetic alopecia. Increased sensitivity to androgen with normal serum hormone levels is present. The pattern usually preserves the frontal hairline. Miniaturized hairs with varying lengths and diameters are present.

Androgenetic alopecia must be differentiated from androgen excess disorders, which are often the result of adrenal, ovarian, or pituitary tumors or disorders.¹ Be suspicious of androgen excess if the following are present: hirsutism, menstrual disorders, cystic acne, galactorrhea, virilization with temporal recession, lowering of voice, increase in muscle mass (especially the shoulder girdle), and infertility. The workup is best performed by an endocrinologist or gynecological endocrinologist.

Rapidly thinning hair may suggest telogenic effluvium or endocrinopathies. Telogenic effluvium is best treated with minoxidil. Telogenic effluvium may be an acute generalized hair loss over the scalp, such as that occurring with stress, anesthesia, or childbirth. Hair regrowth usually occurs 4-12 months later. Chronic telogenic effluvium occurs more slowly and may be confused with androgenetic alopecia. Unlike the latter, chronic telogenic effluvium is not usually revealed in family history.

Hair loss in women can be caused by numerous sources, such as hypothyroidism, various medications, systemic disorders, trauma (eg, surgical trauma, burn alopecia), and infections. Telogenic effluvium and androgenetic alopecia can coexist, with an episode of telogenic effluvium unmasking coexistent androgenetic alopecia.

Scarring alopecia of unknown etiology is best evaluated by biopsy and dermatologic workup.

The other large group of women presenting for hair transplantation are those with postsurgical scarring. These are usually patients who have undergone browlifts and facelifts.

Interest in eyebrow and eyelash transplantation has recently increased. The use of micrografting techniques with microscopes employed for graft cutting has greatly improved these techniques. Eyebrow alopecia may result from plucking, trauma, or inherited thinning. Eyelash alopecia may also be traumatic, inherited, or caused by compulsive pulling or plucking.

Presentation

The technique used in women differs from that used in men.² To prevent telogenic effluvium of the existing hairs, the use of minoxidil 2% for 2 weeks preoperatively and resuming 5-7 days postoperatively is increasing in popularity. Larger grafts behind the hairline are necessary to create increased density. The author prefers the 0.5 X 2.5-mm slot graft, which contains 5-7 hairs. The author routinely uses 3.5X loupe magnification to avoid injury to existing hairs. The grafts are cut using stereo microscopes.

To perform hair transplantations in the eyebrow, a pattern must first be made by the patient, surgeon, or esthetician. Eyebrow and eyelash transplantation require a great deal of maintenance. Brow hairs must be trained with gels or waxes, and eyelashes must be curled. Both must be trimmed and shaped.

Case studies

• Case 1 - A 61-year-old patient with androgenic alopecia
  • Before (frontal): See Image 1.
  • After (frontal): See Image 2.
• Case 2 - A 38-year-old patient after browlift and tattooing (elsewhere)
  • Before: See Image 3.
  • After: See Image 4.
• Case 3 - A 52-year-old patient after browlift and facelift (elsewhere)
  • Before: See Image 5.
  • After: See Image 6.
• Case 4 - A 52-year-old patient with controlled hypothyroidism
  • Before: See Image 7.
  • After: See Image 8.

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