Dr Greg Williams discusses the rise in hair transplants in younger men and how to successfully treat a receding hairline
Hair transplant surgery is becoming increasingly popular. This is likely to be due, in part, to society’s growing obsession with looks and appearance,1 as well as the regular revelations in the media by celebrities who have had the procedure. In the last 24 months there have been a number of men in their early twenties who are in the public eye and have addressed their temporo-parietal recession and hairlines with hair transplants. I believe that what is significantly different with this generation of men, is that they have been posting photographs of their immediate post-operative appearance on social media sites such as Twitter and Instagram, as is the norm for many Western millennials. There is cause for concern that, with the extensive celebrity following of some of these young public figures, the general male public will see this as an attractive and reasonable option.
There are many unscrupulous practitioners who will perform such surgery with short term rather than long term objectives in mind and, from my observations, this is particularly true of overseas clinics where surgery is generally offered on a cheap ‘fly in, have surgery, fly out’ basis. Whilst performing hair transplant surgery to temporo-parietal recessions in men under thirty might be reasonable in certain situations, there are several factors that should be carefully considered by both the patient and the doctor.
In adolescence, the typical juvenile male hairline is rounded and, during puberty, it starts to develop the hallmark of an adult male hairline which has temporo-parietal recessions. This might be self-limiting or be the start of progressive male pattern hair loss (MPHL) that might progress to complete baldness. The challenge for the hair transplant surgeon consulting a man in his twenties is to try and predict whether progressive hair loss is likely. Predictors include age of onset, rate of progression, family history on both the mother’s and father’s side of hair loss as well as the pattern of hair loss, and importantly, the presence of visible thinning in the forelock, mid-scalp and crown.2
In my opinion, patients with actively progressing hair loss in the hairline and temples should be counselled with regards to trying to stabilise their hair loss prior to embarking on hair transplantation. A hair transplant can take up to 18 months to achieve its full result and in a patient whose hairline is rapidly receding, by the time the transplanted hairs fully mature, the hairline may have receded behind them leaving gaps and requiring a further procedure almost immediately to maintain a natural appearance. Since any treatment aimed at stabilising hair loss is generally accepted to take at least six to 12 months before a judgement can be made on efficacy, at least this period of time should be given to young men in their twenties following an initial consultation, before considering performing a hair transplant.
Doing a hair transplant to the temporo-parietal recessions in a man whose hair loss is progressing is likely to result in an unhappy patient before too long. If hair loss continues despite therapeutic interventions, then it might be appropriate to delay hair transplantation until the likely extent of hair loss becomes apparent and an appropriate hairline can be planned. The hairline level and design that might be appropriate for a man who is going to progress to a very advanced degree of hair loss is likely to be very different from that desired and requested by a young man seeking to regain his youthful hairline.3
In my professional opinion, men under 30 who might be suitable for a hair transplant to the temples are those whose hairlines have been spontaneously stable for at least 12 months and who have no family history of advanced male pattern hair loss, or those whose hair loss has been convincingly stabilised with medical treatment.
There are effective, proven methods of slowing down hair loss, which include topical over the counter minoxidil and prescription-only oral finasteride medication. Less proven therapies include microneedling, mesotherapy, platelet rich plasma, low level light therapy and adipose- derived regenerative cell therapy. A hair transplant surgeon may offer these options to patients who have MPHL in an attempt to stabilise hair loss before a transplant.
If a hair transplant is deemed suitable for a patient, they must then decide which method of donor hair harvesting they would prefer – Strip Follicular Unit Transplantation (Strip FUT) which leaves a linear donor scar but yields larger number of follicular unit grafts, or Follicular Unit Excision (FUE) which leaves small round scars but usually requires the donor area to be shaved.4 For relatively small hair transplant surgery procedures, such as addressing temporo-parietal recessions, either technique is likely to yield sufficient grafts. However, the hair in the typical donor zone at the back and sides of the head needs to be worn long enough to cover a Strip FUT scar therefore, in my experience many young men opt for the FUE method so that they can retain the option of a very short haircut.
Follicular unit grafts utilise the fact that naturally occurring groups of hairs within the donor scalp contain one, two, three or four hairs. In the FUE technique the grafts are extracted individually, whereas in the Strip FUT technique the grafts are dissected from the excised strip of skin.4 In order to create a new natural hairline, incisions for single hair follicular unit grafts are made in an irregular pattern sometimes called a snail trail, with randomised ‘rogue’ hairs placed in front of the main hairline to simulate what occurs naturally. Two-hair grafts are placed behind the one-hair grafts and the larger hair groupings are placed further back where density is required but their more pluggy, coarser appearance can be hidden from an anterior view.
Hair transplant surgery (HTS) is one of two types of hair restoration surgery (HRS), the other being prosthetic hair fibre implantation (PHFI). PHFI should be reserved for patients who do not have any autologous donor hair and should only be considered after consultation with a hair transplant surgeon who offers both forms of HRS so the two options can be fairly assessed. There is no accredited training in HRS in the UK and no specific qualifications required, other than a General Medical Council licence. However, HRS must be performed in a Care Quality Commission (CQC)5 registered facility and the HRS service provider must itself be CQC registered, even if the surgery they offer is done elsewhere in a separate CQC-registered clinic. Advice on what to look out for is offered to patients from the British Association of Hair Restoration Surgery (BAHRS),7 which also offers support for those looking to have their hair transplant done overseas.6,7
Transplanted hairs in the hairline and temporo-parietal recessions are more ‘on show’ than transplanted hair elsewhere on the scalp and, therefore, it is absolutely critical that the surgeon’s technique creates a result where the transplanted hairs are indistinguishable from naturally occurring ones. This is dependent on the incision making process which determines the depth, direction, angle, geometry and density of the transplanted hairs. There is a physical limitation to the spacing of incisions which is usually less than the density of hair unaffected by MPHL; this incision spacing should be further reduced in diabetics and smokers to lessen the risk of skin necrosis. Patient expectations regarding transplant density must be managed to avoid disappointment in the thickness of their hair transplant result. A clear explanation should be given which clarifies that the hair transplant density will be less than their original hair density, but can be increased by repeating hair transplant procedures until a density satisfactory to the patient is achieved.
Health-related complications are rare and limited to infection, either in the form of folliculitis or cellulitis.8 Excessive bleeding should only be problematic in patients with a bleeding disorder or those on blood-thinning medication. Like with any surgical procedure, a full medical history should be taken prior to treatment to identify any contraindications to hair transplant surgery or precautions to be taken. Donor site scarring is usually described in relation to the Strip FUT donor but FUE over-harvesting can lead to extensive punctate scarring and associated donor zone hair depletion with an unnatural moth-eaten appearance.9 As expected, significant aesthetic morbidity can occur from incorrect and asymmetrical hairline design, improper hair growth exit angle and direction, poor density, and pitting or cobble- stoning at the hair base. In terms of technical success, I have found that 90% of transplanted hairs should be expected to grow.
During puberty there is a normal progression from a juvenile rounded hairline to a mature masculine hairline with temporo-parietal recessions. This can be self-limiting to a pre-determined genetically programmed hairline level. Conversely, male pattern hair loss is usually an ongoing dynamic process that continues over a lifetime to a predetermined genetically programmed end-point, the severity of which varies from person to person and is impossible to predict.
Men in their late teens and twenties who are seeing their hairline receding need to determine whether this is going to be self-limiting or progressive, and this can only be judged over a period of several years. In those patients where it is self-limiting, hair transplantation might be a reasonable option. For those patients where it is progressive, hair transplantation is not advisable. These patients should be counselled to either try to stabilise their hair loss with medical therapy or postpone having a hair transplant until the likely extent of their hair loss can be predicted and an appropriate hairline level and design determined.
1. Nuffield council on Bioethics, Cosmetic procedures: ethical issues, Appearance and Appearance ideals <http://nu eldbioethics.org/report/cosmetic-procedures-ethical-issues/appearance- appearance-ideals>
2. PLOS Genetics, Genetic prediction of male pattern baldness https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5308812/
3. Gupta, M., Mysore, V., (2016) Classifications of Patterned Hair Loss: A review, J Cutan Aesthet Surg pp3-12 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4812885/
4. Berstein Medical Centre for Hair Restoration, Logic of Follicular Unit Transplantation <https://www. bernsteinmedical.com/research/logic-of-follicular-unit-transplantation/>
5. Care Quality Commission, The scope of registration <http://www.cqc.org.uk/sites/default/ files/20151230_100001_Scope_of_registration_guidance_updated_March_2015_01.pdf>
6. British Association of Hair Restoration Surgery, BAHRS Advice to Patients On Factors to Beware of When Choosing a Hair Transplant Surgeon/Clinic, < http://www.bahrs.co.uk/wp-content/ uploads/2018/03/BAHRS-Advice-to-patients-on-factors-to-beware-of-when-choosing-a-hair-tr....pdf>
7. British Association of Hair Restoration Surgery, BAHRS Advice to Patients Considering Having Hair Transplant Surgery Abroad, <http://www.bahrs.co.uk/wp-content/uploads/2018/03/BAHRS-Advice-to- patients-considering-having-hair-transplant-surgery-abro....pdf>
8. The International Foundation For Dermatology, Management of Bacterial Infections of the Hair Follicles <http://www.ifd.org/protocols/bacterial-infections-of-the-hair-follicles>
9. International Society of Hair Restoration Surgery, Comparison Between Strip Harvesting and Follicular Unit Extraction: A Fair and Balanced View <http://www.ishrs.org/article/comparison-between-strip- harvesting-and-follicular-unit-extraction-fair-and-balanced-view>