Assessing Hair Loss

The first step in making a rational assessment of the extent of your hair loss, is to compare your present hairline with the hairline on a photograph taken a few years ago. This will give you an approximate idea of how much hair loss has occurred and the rapidity of the process. The unknown factor for most men is the extent of hair loss in the crown area. Looking in a mirror is one way to appraise the loss at the back of your head. The best way to accurately assess the hair loss in this area is to have a friend take a Polaroid photo of the back of your head. For an accurate reading, the picture must be taken with a flash. Another way is to ask your barber or hairdresser.

Knowing something about your father, grandfather, and brothers hair loss pattern may suggest what will happen to you. You may not follow one of their patterns, but the probability is that you might well follow in that direction. Look at the patterns of hair loss on this page below and make that judgment.

A visit to a physician who specializes in hair restoration is a worthwhile step. A thorough history and examination of the scalp can reveal the extent and trend of the hair loss process. With the use of the Hair Densitometer, a special magnifying apparatus invented and patented by Dr. William Rassman, and with a special instrument which can measure hair bulk (the actual volume of hair), the physician can measure the actual degree of hair loss in various areas of the scalp. This has the advantage of establishing a baseline from which the hair loss can be graded over time. If you decide to treat the process with minoxidil, a repeat examination in 6-12 months may show the effectiveness of the treatment. Careful assessment of the hair loss process is critical to accurate prediction of the rate and extent of hair loss. I have seen young men who have no evidence of any hair loss, yet their are convinced that they are losing hair and when we measure the hair bulk in different areas of the head, with almost 100% accuracy, we can validate or reject this premise regardless of what we see as the eye can not tell a loss of as much as 30% of the hair in any particular area of the head. As this often changes over time, these tests show a general direction of hair loss and a skilled doctor can project just what hair loss pattern you might develop.

The scientific way to assess your degree of baldness is to compare your pattern with the standard patterns described by Dr. O’Tar Norwood (below). They depict the most common configurations of male pattern baldness. There are seven grades of hair loss in the main series and five grades of a variation called the “A” series. Comparing your own front and back with these diagrams can tell you where you stand now. Discussion with a knowledgeable physician can give you some idea of what is likely to be in your future based upon an examination of you in his office.

Norwood Classes Explained

In 1975, a dermatologist and hair transplant surgeon, Dr. O’Tar Norwood, building upon the earlier work of Hamilton, developed a classification of male pattern hair loss that is widely used today.

He divided androgenetic hair loss in men into two common patterns: the Regular Type, characterized by hair loss that begins in two different areas (at the temples and in the crown) and that gradually merge into one; and the less common Type ‘a’, that is characterized by “front-to-back” hair loss. Hair loss that is not genetic in origin usually follows a different pattern.

Some women also lose hair according to the pattern described by Norwood, but more commonly have a diffuse (thin all over), rather than patterned variety (please see Hair Loss in Women). Pattern balding does occur in women, but they do not develop the patterns described by Norwood. The Norwood patterns shown below, do not progress from 2, to 3, to 4, to 5, to 6 and finally to 7. They are actually lost in those patterns gradually, from the onset in most men. If you father has a Class 7 pattern, he developed it most probably, by the age of 26, never going though the other patterns shown on below.

Hair loss tends to progress over the years, although the rate can vary dramatically from person to person and the rate of loss can vary significantly over time. For example, a man may lose hair rapidly in his early 40’s and then stabilize for many years, not showing a significant amount of additional hair loss until his 60’s. People who become extensively bald usually, but not always, show most of their hair loss in their 20’s.

In general, the pattern of one’s hair loss follows the specific type first presented. For example, a person who begins as a Class 3 usually evolves into a Class 4, then possibly a Class 5, etc.. On a thorough examination by a good doctor, the bulk measurements, regardless of what shows by the naked eye, will show loss of bulk in the Class 5 pattern despite the reality that what you see is a Class 3 pattern. A Class 3a pattern may become a Class 4a and then a Class 5a pattern, but again, the bulk measurements will mostly show some early hair loss in the entire Class 5a pattern. Rarely, a Class 2 may thin diffusely and directly evolve into a Class 6 or 7 but he is probably a teenager who has not yet developed the cardinal signs of loss of hair bulk, or on very rare occasions, he may develop a process called Diffuse Un-Patterned Alopecia (DUPA) which will impact the entire hair baring scalp. This last group of patients must be diagnosed and never transplanted, unfortunately this diagnosis is rarely made by hair transplant doctors who go on to transplant these patients on the belief that they can fix the balding, when in fact, they never fix anybody with this condition (DUPA) and frequently doom these patients to a hellish life of hair loss deformities.

Look over the following diagrams and their explanations to see if you can recognize your pattern or the pattern of hair loss of any male member of your father’s or mother’s side of the family. The patterns you see in your older relatives may become your pattern since heredity plays an important role in androgenetic baldness. It is important to note the age at which the family member reached a specific pattern. For example, if your father is totally bald, but lost all of his hair in his twenties, and you are 35 with only a Class 4a pattern (for example), his extensive hair loss pattern has little relevance to predicting your future loss.

Once you have identified your Norwood Class, view our photo galleries to view before and after photos of actual NHI patients.

Regular Norwood Classes

1Type I• No recession
• “Adolescent” or “Juvenile” hairline
2Type II• Temporal recession < 1″
• Mild recession along frontal hairline
• “Mature” hairline
3Type III• Further frontal recession
• Deeper recession at corners
• Earliest stage of balding
3vType III• Hairloss predominantly in vertex (crown)
• Frontal hairline recession may be present
4Type IV• Further frontal hair loss and temporal recession
• Enlargement of vertex (crown)
• Solid band of hair across top separating front from vertex
5Type V• Frontal and temporal areas enlarge further
• Band separating the two areas becomes narrower and sparser
6Type VI• Frontal and vertex balding areas merge into one and increase in size
7Type VII• Narrow horseshoe band of hair
• Low hairline in the back
• Hair in permanent zone may be sparse

Type A Variant Norwood Classes

• Frontal recession keeps advancing backwards
• Single area of balding
• Eventual extent of balding tends to be more limited than in Regular classes
2aType IIa• Entire frontal hairline recedes
3aType IIIa
4aType IVa• Hair loss moves past this “mid-coronal” line
5aType Va• Hair loss extends towards the vertex
• Back part of bald area is narrower than in the regular Norwood VI

How Much Hair Do I Need?

Norwood ClassFollicular UnitsTotal Units With Crown*
31000-1500 +** –
3 Vertex1500-2500+1100-1300+
3A1300-1600+
41100-2000+1500-1800+
4A1500-2500+
52000-3000+1900-2500+
5A2200-3000+
62000-4000+2800-5000+
74000-8000+

Over the past few years, we have tried to put a number on the amount of hair and grafts any given person might need. As we have gained experience, we have found that our patients want more hair than we had believed. At NHI, patient procedures are planned to ensure natural looking results after each session. However, some of our patients elect to undergo further sessions to further enhance their appearance. A recurring question is how much hair does NHI recommend? The number of grafts recommended is highly dependent on information our doctors would gather during a private consultation with you, as well as the characteristics of the hair-coarseness, texture, etc. The total number of follicular units generally transplanted in the first session for specific Norwood classifications are listed (left). In general, the higher the donor density, the greater the number of hairs each follicular unit will contain and the more hair that can be transplanted in a single session. With low donor density, little scalp laxity or poor hair characteristics, these numbers may not be achievable

The number of grafts that can be harvested for any individual is limited by the laxity of the scalp (for FUE-Strip Surgery) and the density of the hair (for both Strip Surgery and FUE Surgery). In some individuals, it will be impossible to safely move 5000 or more grafts over the individual’s lifetime, while in other individuals, the number of grafts can reach significantly above 7000 to possibly as high as over 10,000 as we have done in a small number of patients who were very bald. At seminars around the country, we frequently present patients who have received 5000-6000 grafts for their reconstruction so that prospective patients can learn what can be accomplished with persistence and tenacity.