These sections focus on the various surgical treatments for women with hair loss. To learn about diagnosing the causes of hair loss please see Hair Loss in Women.
Aesthetic Issues in Treating Women With Hair Loss
The treatment of women’s hair loss must be approached differently than men’s hair loss, as most women rarely lose all of the hair with hair loss. In fact, much of the hair remains, but the thickness of the hair shaft becomes smaller than normal hair and the density of each follicular unit reduces from the normal of 2 hairs per follicular unit to between 1 – 1.6 hairs per follicular unit. When this is combined with the finer hair, then the bulk of hair in each follicular unit is significantly reduced. This reduction of hair bulk from miniaturization and loss of individual hair follicles causes the hair to appear thinner, at times making the patient look sickly. Because a relatively large area can be subject to this thinning, it is important that hair is transplanted in areas where it is cosmetically most significant or where it can enhance a specific styling plan to increase the appearance of fullness. Unfortunately, the process discussed above occurs, at time, even in the area we call the donor area, which in 99% of men, is perfectly normal regardless of the degree of balding present. In women with this donor area looking like the rest of the hair, this makes them significantly different from men whose donor area has normal hair, normal hair bulk and no significant miniaturization. If women have such hair in what we call the donor area, they are not candidates for hair transplantation under any circumstances. Too many doctors transplant such women just for the surgical fees, and these women are never made better, and at time even made worse.
When the hair in this ‘donor area’ is reasonably unaffected by the disease process discussed above, then they might become candidates for hair transplantation. We generally confine the transplant process to a localized part of the scalp where balding is worst (such as behind the “frontal hairline” or “along the part”). When women have a dense, stable permanent zone and a loose scalp, it is possible to provide more coverage over the top of the scalp but far few women are able to get a significant benefit from a limited hair transplant.
Since hair transplantation in women generally involves placing hair into a part the scalp that is thin, but not completely bald, there is a risk that original hair in this area may be lost. This process is called “telogen effluvium” and is usually (but not always) reversible. In addition, if the donor area continues to thin, then the transplanted hair will also thin over time, since it came from the same area. For these reasons deciding when it is appropriate to perform transplantation for women can be difficult and requires the careful judgment of a very experienced and ethical physician.
Forehead reduction surgery for women with high foreheads has been popular since the late 1990s. Dr. Sheldon Kabaker in Oakland, California is a well-known and prominent surgeon who has offered female forehead reduction surgery for many years. The procedure sometimes requires the use of tissue expanders to drastically lower the hairline.
Since 2006, Dr. Gal Aharonov in Beverly Hills, California has been offering a slightly modified approach to the forehead reduction surgery. His method has gained great popularity all over the world. With third party review sites such as RealSelf, the hair transplant community is seeing a demand for women seeking an alternative to forehead reduction.
A forehead reduction procedure can present some potential problems such as the visibility of a scar along the hairline and the surgical limitations of creating an oval or rounded appearance. While most patients are generally happy with the drastic reduction in their forehead size, others are self-conscious about the scar. They do not wear their hair pulled back and sometimes used makeup as a cover up.
A hair transplant procedure is an alternative for women who do not want to undergo a forehead reduction surgery. A hair transplant involves harvesting donor hair from the back of the head to individually relocate single follicles to the front. The limitation of a hair transplant lies in the wait time required to see results. It can take six months to a year to see the full results of a hair transplant since the hairs need to grow out from the roots. The advantage of a hair transplant over a forehead reduction surgery is that the natural shape of the hairline is dictated by the artistry of the surgeon who creates the hairline when he implants the moved follicles.
Hairline lowering is achieved by using a technique known as Follicular Unit Strip Surgery and sometimes referred to as Follicular Unit Transplant (FUT). Follicular Unit Extraction (FUE) is usually not used since it requires shaving the back of the patient’s head; something few women will accept. There is no shaving involved in strip surgery and the incision around the donor area on the back of the head is covered by the patient’s hair. Even if the hair is wet or worn up, the incision line (or scar) is rarely or even ever noticed.
Follicular Unit Transplantation in Women
As in men, the exclusive use of naturally occurring, individual follicular units represent the ideal way to restore a woman’s hair. However, to successfully perform hair transplantation in women the surgeon must understand the subtle, but important aesthetic differences between the sexes.
Hair transplant surgeons generally have more experience with men, and some of this experience is not directly transferable to women. As with all processes, one must start with observation.
A normal female hairline is much different that of a man’s hairline. In men, the hair in the frontal hairline usually started 3/4 inch above the highest crease of the furrowed brow, while the woman’s normal hairline position lies at this point. The hair direction is different as in men, the hair points predominantly forward, with a change in direction only as one approaches the temples. A woman’s hairline is more often characterized by “whorls” and “licks” that give the frontal edge its interesting “character” and it does not point forward in its normal position but rather to the sides. These abrupt directional changes can be recreated, but it requires very fine instrumentation and meticulous attention to the depth, angle and spacing of the recipient sites in which the grafts are to be placed as well as a skill-set from a knowledgeable doctor.
In women, a “vellus blush” produced by finer hair, is often noted at the leading edge of the frontal hairline. In men, the aesthetic contribution of these vellus hairs is much less significant, if they are present at all. Therefore, using one-hair follicular units will often be sufficient to produce a natural appearing frontal edge of a man’s hairline (except in those with the coarsest hair). In women, however, finer hair is sometimes needed and this can be produced by removing the bulb (cutting off the bottom) of a normal terminal follicle. This will decrease the hair shaft diameter and make the appearance of the frontal hairline softer. It is also useful when transplanting the temples and restoring the eyebrows.
Some transplant surgeons feel that the nape of the neck, or just behind the ear, is a good source of this finer hair and they make the donor incision in these areas. I strongly advise against this practice because the incidence of unacceptable scarring is quite high and the hair in this location may not be permanent, since it is more subject to androgenetic and age related changes.
Another interesting characteristic of the female hairline is the higher occurrence of “Widow’s Peaks.” The Widow’s Peak is not simply a triangular dip at the midline, but a series of variations in the hairline that can add elegance and drama and is a remnant of the recession of the original child’s hairline upward, leaving a pointed tuft in the mid-line. In constructing a Widow’s Peak, the following should be noted: 1) the peak is often bounded on at least one side by a concave (rather than convex) hairline, 2) it is often slightly off center, 3) it is usually asymmetrical, and 3) the hair often points to the side rather than forward when present in women consistent with the direction of the juvenile hairline before it receded.
In contrast to the male hairline that normally recedes approximately 1/2 to 3/4 inch from the highest crease of the furrowed brow at the midline and 2-4 cm at the temples after puberty (even without any genetic balding), the female hairline tends to hug the upper brow crease (upper forehead wrinkle) throughout life. This gives the frontal presentation a more rounded look and a more complete frame to the face. But, in order for the hair to frame the face well, the subtle changes in hair direction must be reproduced exactly as it occurs is nature. This is a technical challenge since the hair direction shifts from being forward at the midline, to pointing backwards and downward at the temples, with the hair emerging almost perfectly flat to the surface of the skin.
Another technical challenge in transplanting women is that any bulkiness to the grafts will create unevenness in the skin. The skin of many women is so thin, especially in the region of the temples, that even one-hair follicular units must be trimmed closely with all the extraneous tissues removed. This, of course, can only be performed with precision, using the dissecting stereo-microscope. Unfortunately, many hair transplant surgeons do not understand the subtle techniques that must be employed when transplanting the temple peaks. Their results often have dimpling and small tufts of skin surrounding each graft making temple transplants very detectable unless everything was done perfectly at the time of the surgery.
Understanding the nuances of temple restoration is mandatory for doctors attempting hair transplantation to women, since, in contrast to men where the temples are rarely transplanted, in women it is almost always required. Whether the balding is from a face or brow lift, due to traction, or inherited, the temples are almost always involved.
A final characteristic of the female hairline is that it is extremely irregular and often asymmetric. The surgeon must fight his “natural instinct” to be well organized and orderly when determining the placement of the sites, as this will detract from the naturalness of the result. But, beauty in all living things is defined, in part, by their “symmetry.” This is an evolutionary marker signifying good health that is noted throughout the animal kingdom. The surgeon must, therefore, posses the artistic sense to strike just the right blend of asymmetry and balance, and of irregularity and perfection.
Restoration After Brow and Face-lifts
When performing repair work in women’s hairlines after a face or brow lift, the same aesthetic challenges present themselves with several additional issues. The first is that a significant amount of scar tissue is often present in the area to be transplanted. This has a decreased blood supply which places a limit on the density of grafts that can be placed in any one session. A second problem is that, after the lift, the hair direction may be altered from the original way that it grew. A third consideration is that hair placement may interfere with subsequent face-lifts so that the planning must be coordinated with the plastic surgeon if future facial surgery is planned. Fortunately, these women often have ample donor hair supply, making this type of surgery very successful.
The most common reasons for performing eyebrow restoration are the following:
- hair loss from many years of over-aggressive tweezing
- permanent eyebrow tattoos that don’t look natural
- skin conditions that cause permanent hair loss (Alopecia areata is the most common, but the doctor must be relatively certain that the condition is stable)
- scarring from surgery, burns or other injury
Restoring eyebrow hair is a rewarding endeavor, as this structure is so important to a person’s appearance, perhaps even more so than scalp hair. The secret to eyebrow transplantation (as in other types of hair restoration) is to closely observe nature. Unlike scalp hair, the eyebrows consist of only one-hair follicular units, so that if the source of hair is the larger follicular units obtained from the permanent zone in the back of the scalp, these units (of 2, 3, and 4-hairs) must be carefully split up into individual follicles under the microscope.
Replicating the unique directional changes of eyebrow hair is also critical to a successful restoration. The hair points upward in its medial aspect (near the nose) and then fans outwards as one moves towards the temples. However, the angles are not quite so simple. As one moves laterally (towards the temples), the hair in the upper half of the brow points to the side and down and the hair in the lower half points to the side and up. The upper and lower hairs interdigitate causing the central part of the eyebrow to slightly rise and form a gentle ridge which gives the eyebrow its unique shape. This interlocking also keeps the eyebrow hair orderly and “neat” in appearance. All of the eyebrow hair emerges from the skin at a very acute angle (almost flat), so the recipient sites must be made with the needle actually lying on the skin surface.
Just as the outer edge of the female hairline is often comprised of finer hair, so are the outer boarders of the eyebrows. In a sense, each eyebrow can be viewed as a cosmetic unit, just as the scalp, with transition zones of fine hair around much of the perimeter. As with the frontal hairline and temples, this fine hair may be replicated by removing or producing controlled, intentional damage to the bulb (cutting off part or all of the bottom) of a normal terminal follicle. The practice of using all fine hair for the eyebrows is incorrect since the eyebrows, like the scalp, require a central area of greater density, and bulk, and this is best accomplished with intact (but in this case individual) hair follicles. In all cases, multiple sessions are needed for a complete eyebrow restoration.