Hair transplant surgeon Dr Greg Williams provides an overview of the causes of hair loss in Afro-textured hair and treatment methods available.
Hair loss in African-Caribbean hair types is a condition that affects both male and female patients and treatment differs from Caucasian, Asian and other hair textures. All hair is made up of the same proteins and layers; for example, a medulla, cortex, and cuticle.1 However, Afro-textured hair has a significant curl both above the surface of the skin and below the skin, compared to the follicles in straight Caucasian and Asian hair.2 Hair restoration is becoming increasingly popular, and Afro-textured hair presents special challenges both in diagnosis and treatment.
Types of hair loss in patients with Afro-textured hair
Caucasian men are four times more likely than men with Afro-textured hair to develop premature balding. However, whilst male pattern hair loss (MPHL), medically known as androgenetic alopecia, is not as prevalent in men from African descent as in Caucasian men, it is still common.3 A 2005 study found that, out of 98 male volunteers of African descent, 22% showed indications of androgenetic alopecia.4 Alopecia in women with Afro-textured hair is often misdiagnosed. Whilst female pattern hair loss (FPHL) certainly exists, it can be confused with the very common central centrifugal cicatricial alopecia (CCCA), which typically starts in the mid-scalp or crown and spreads outwards.5
Frontal hair loss in these patients is also very common as a result of long-term styling with tight hairstyles and braids. This concern is known as traction alopecia (TA) and should be differentiated from frontal fibrosing alopecia (FFA), which affects the hair margin on the front of the scalp.6 The true prevalence of TA in women with Afro-textured hair is unknown, but some studies suggest that it affects around one-third of women from African descent who wear various tight and potentially damaging hairstyles for an extended time period.7 Both CCCA and FFA are inflammatory scarring alopecias, which occur due to inflammation and eradication of the hair follicles.6 Whilst FPHL and TA are well suited to surgical hair restoration (Figure 1), CCCA and FFA are generally not indicated for hair transplantation as the inflammation that attacks and destroys native hair would do the same to transplanted hair.8
Although the specific cause of these alopecias is largely unknown, both genetic and environmental factors are suspected to contribute towards it.9 Many women with this hair type straighten and relax their hair with heat or chemicals, which causes damage at the hair shaft and often contributes to their hair loss, placing them at high risk of alopecia.9 It is worth discussing in your pre-operative consultation what their hair styling choices will be post-procedure in order to avoid damaging the transplanted hair.
If female patients with Afro-textured hair are requesting eyebrow transplants, practitioners should make them aware that if scalp hairs are used, then the hair curl will not replicate their straighter, naturally occurring eyebrow hairs. In patients where hair loss is thought to be from an inflammatory dermatological condition, biopsies will aid in making a definitive diagnosis and treatment should be managed by a dermatologist with specific expertise in this area.
Harvesting follicles for transplantation
There are two methods of harvesting donor follicles in a hair transplant:
The strip follicular unit transplant (strip FUT) technique involves cutting out an ellipse of scalp from the back and/or sides of the head, leaving a linear scar.10
The follicular unit excision (FUE) technique involves excising individual follicular units with one of a variety of tools, such as manual punches, automated drills, or robotic devices, and leaves small round scars wherever follicular units are extracted from.11
Whilst the surgical skills used in harvesting strip FUT donor hair in Caucasian and Asian patients are the same as those required to harvest Afro-textured hair, there is significantly greater difficulty extracting curly or kinky hair compared to extracting straight donor hair by the FUE method.12 All FUE surgeons will have a follicle transection rate threshold that they accept; this is the number of hairs that are damaged during the extraction process.13 There is no defined or accepted rate and each surgeon decides what he or she is comfortable with. However, to stay under this threshold in Afro-textured hair it might be necessary to use a larger diameter punch.
I find that a narrow diameter punch can slide over a straight hair, however to avoid a coiled hair being transected, in my experience a larger diameter punch is needed to successfully slide over a coiled hair which has a wider cross section. The downside of a larger punch is a larger round scar, a longer time to heal, and an increased risk of the FUE scar becoming hypertrophic (thickened and raised) in deeper complexions (Figure 2).14 This can also occur in strip FUT scars and these can even develop into keloid scars which progressively grow and can be very unsightly.14
In addition, both strip FUT and FUE recipient site incisions need to be larger when performing a hair transplant on Afro-textured hair to accommodate larger diameter follicular unit grafts. On the other hand, because of the curly nature of the hair, in my experience much less density is required to create the illusion of thick hair when the hair is allowed to grow long.
Whilst trends in male hairstyles vary from decade to decade, I have noticed that male patients with Afro-textured hair are currently tending to wear it in shorter styles. This means that it is difficult to hide even a good quality linear Strip FUT scar which is soft, flat, 1-2mm wide and the same colour as the surrounding skin, so FUE is often the preferred method of harvesting hair. As many women tend to wear their hair at a longer length, Strip FUT may be the preferable method for harvesting hair, since the donor scar can be hidden and the donor zones, which are typically the back and/or sides of the head, do not need to be shaved.
Limitation in donor hair availability in women may require large recipient areas to be covered in multiple surgeries. It is better to focus optimal hair density in smaller areas than to spread out available follicles over a wide area, so you can treat one area well before moving on to another. There is a density limitation that can be achieved in each procedure as one hair transplant cannot reproduce the density of natural hair.15 Therefore, repeated surgery of between two to three procedures may also be required in both men and women to increase hair density if short hairstyles are preferred, as the benefit of a hair transplant is usually optimised by longer hair length. There are often cultural differences in hairline preference and, in my experience, many men with Afro-textured hair request a lower position with a more rounded and angular-shaped temporal recessions (Figure 3).
Both MPHL and FPHL tend to be progressive conditions and therefore medical treatments, such as topical minoxidil and oral finasteride in men, and topical minoxidil in women (discussed in more detail in a previous article I wrote for Aesthetics),16 should be considered. Many men and women of African descent are genetically predisposed to hypertension and oral minoxidil can also be considered as an off-licence treatment for hair loss in these patients.16,17 There are also non-surgical treatments, such as low level light therapy and platelet-rich plasma, that could be considered. However, it should be noted that there is currently little research based evidence for efficacy with these treatments and this must be clearly outlined to patients who present for the treatment of hair loss. They can then use this information to decide whether or not to undergo these treatments to see if they work for their indications. In male patients with MPHL, scalp micropigmentation to simulate hair stubble in balding areas and shaving the surrounding hair completely offers an excellent alternative to surgical hair restoration (see Figure 4).
Male and female pattern hair loss are well suited to hair transplantation but inflammatory conditions are usually not. Prevention is always better than cure. Whilst there is increasing awareness of the cause of TA, braiding is a common method of styling and managing Afro-textured hair. The tradition of braiding hair in styles that are too tight, and can cause TA, continues to be passed from generation to generation. However, there are now websites and lobby groups encouraging women with Afro-textured hair to wear it in its natural curl pattern instead of in potentially damaging relaxed and tightly braided styles. Despite hair transplant surgery gaining increasing popularity amongst men, I find that there is still limited awareness that hair transplant surgery can be an excellent option for restoring lost hair for women as well.
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