Dr Sotirios Foutsizoglou discusses the benefits, limitations and controversy associated with performing hair restoration surgery on younger patients
For years, hair transplant surgeons have debated whether young balding individuals could be candidates for a hair restoration procedure, and the effects of Follicular Unit Extraction (FUE) and Follicular Unit Transplantation (FUT) on their donor zone. The problem lies in that it is very difficult, if not impossible, to identify the safe, permanent donor area when a person is young. In fact, at a young age, it is not always possible to determine with certainty if any of one’s hair will be permanent or what the ultimate quality of that hair will be.1 But what constitutes a ‘young’ patient? As a general rule, when treating androgenetic alopecia, most surgeons consider 25 to be the minimum age for hair transplant surgery. Before this age the evaluation of the alopecic patient, made usually by a thorough medical history, family history, and detailed physical examination, complemented by selective laboratory investigations and densitometry, used to measure hair miniaturisation, proves very hard to predict the pattern of female or male baldness and the degree of ultimate hair loss. Patterned hair loss, the most common type of hair loss affecting men and women, is characterised by a process of progressive hair miniaturisation whereby large, pigmented, terminal hairs are replaced by fine colourless vellus hairs.2 Androgens play an important role in this process of miniaturisation, hence the reason both male pattern hair loss (MPHL) and female pattern hair loss (FPHL) are collectively referred to as androgenic or androgenetic alopecia. In patterned hair loss there is a gradually shortening anagen phase resulting in affected hairs becoming shorter and finer. The recession observed in androgenetic alopecia follows a pattern and therefore the degree of hair loss is somehow predictable, allowing hair transplant surgeons to assess and plan treatments accordingly. In men, this condition preferentially affects hair on the superior and anterior temporal areas of the scalp, whereas in women it more commonly presents in a diffuse pattern in the crown, with or without sparing of the frontal fringe. Patients who go bald at a very young age (i.e. under the age of 25 years) are prone to developing more extensive and occasionally non-pattern hair loss than those who thin later in life. Diffuse un-patterned alopecia (DUPA) is a contraindication for hair restoration surgery as the instability of the donor area increases the risk of scarring becoming visible (whether it is the linear scar of FUT or the small, round scars of FUE). The simple solution would then be to not operate on younger patients. However, no one likes losing his or her hair and it is particularly upsetting when it occurs in the second or third decade of life. Visible thinning in teens and early twenties often progresses to advanced alopecia by the end of their third decade. This can cause great personal stress, especially due to the fact that the majority of their peers maintain the appearance of a full head of hair.
Arbitrarily not transplanting these patients, because of their age, could be considered unfair. Every case is different and should be judged on its merits. Some doctors may argue that conservative surgery would be less harmful to these young hair loss sufferers than condemning them to many years of low esteem.3 Their argument is based on the fact that a large majority of men who will eventually develop type VI male pattern baldness (MPB) will still have long-term donor-recipient area ratio that is adequate to transplant a cosmetically acceptable density of hair. Interestingly, FPHL is less difficult to predict in younger patients. We know from experience that while frontal female hairlines frequently become more sparse with time, they are never entirely lost.4 Therefore it is safer to transplant posterior to the hairline. In addition, women tend to maintain fairly good density in the occipital scalp, so their surrounding hair can easily cover whatever donor area scars may result from hair transplantation surgery.5 Notwithstanding the above, it cannot be overly emphasised that the hair restoration surgeon should, ideally, take a conservative approach with women, and men in particular, in their early 20s, especially if they have Norwood Types III-vertex, IV, or V MPB (Fig. 1). It is wise to assume that a younger male patient will probably progress to at least a Norwood Type V balding pattern and plan accordingly. Ominous signs in a young hair loss sufferer that point to the possibility of a very advanced stage of alopecia (i.e. Norwood Type VII), which is an absolute contraindication to surgery are the following:6
A father or maternal grandfather with a Norwood Type VII pattern or worse
The presence of whisker hair, around the ears
The absence of dense fringe hair
The presence of diffuse non-pattern (or un-patterned) alopecia presenting as rapidly progressive, generalised thinning at a young age
Repeatedly higher than average miniaturised hairs in potential donor areas
MPB beginning in teenage years
Patient JB is a 30-year old male complaining of progressive hair loss and a visible donor scar. He had two hair transplant procedures at ages 21 and 22. At the time, he was told he was a good candidate for surgery. Following his procedures he was started on finasteride and minoxidil. In spite of a hair transplant and medical therapy, the patient’s hair continued to thin. Within a few years, his donor scar became obvious, presenting a cosmetic problem far greater than his hair loss. On physical examination, JB had a persistent frontal hairline, generalised thinning, and a readily visibly donor scar. Densitometry revealed a donor density of 1.2 follicular units /mm2 and 90% donor miniaturisation consistent with a diagnosis of diffuse unpatterned alopecia (DUPA) which is a contraindication to hair restoration surgery (Fig. 2). Current surgical options for this patient remain extremely limited, as there is no permanent zone to harvest hair. Scar revision surgery may improve but will not eliminate his existing scar. Scalp micro-pigmentation can be discussed, but will give only partial cosmetic improvement.
The age at which to perform a hair transplant procedure on a young man or woman has been a controversial topic for decades. The decision making process, as to whether surgical hair restoration is appropriate for the presenting young patient, should include being on the lookout for certain red flags that could influence the physician’s evaluation. A thorough understanding of the pathophysiology of hair loss, the limitations of hair restoration surgery, its risks and benefits, as well as short- and longterm consequences can help establish whether or not a young patient is an appropriate candidate for a hair transplant procedure.
As with all patients, young patients must have realistic expectations as to the ongoing nature of their hair loss
Establishing a proper diagnosis is indispensable in determining prognosis and making treatment decisions. The case study young man could have been spared a failed hair transplant procedure and an unsightly donor scar if DUPA was diagnosed in the first place. Transplantation provides consistently natural results and if a patient understands the long-term cosmetic limitations of hair transplantation, all patients are potential candidates for surgery. Transplanting or not transplanting based on arbitrary age limits is unfair to patients, and has little or no medical basis.3 As with all patients, young patients must have realistic expectations as to the ongoing nature of their hair loss, the limited amount of donor hair available, and how this will impact the future cosmetic appearance and extent of their transplanted areas. Although no rigid age limit should exist with regards to hair restoration surgery, in my opinion, no matter what the cause of the hair loss problem may be, targeted pharmacotherapy, following a pertinent diagnosis, is the best initial choice for all patients under the age of 25. For instance, the combination of finasteride and minoxidil can slow down, and to some extent, prevent the progression of androgenetic alopecia into an advanced stage. Thus it gives patients time to think about their options and to adjust to the fact that, regardless of surgical or medical treatment, they will never have a full head of hair or the low hairline that they once had.1
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