1. style and fashion
2. beauty
3. hair care

Understanding and Management of Female
Pattern Alopecia
Matt Leavitt, D.O.1
ABSTRACT
Female pattern hair loss is devastating to many of the 21 million U.S. women who
suffer from it. It is essential to differentiate female pattern hair loss from other types of hair
loss to ensure appropriate treatment. Through use of follicular units, follicular families, and
follicular pairing between existing hair follicles, natural-looking results can be achieved in
women. Hair transplants create the benefit of increasing density and providing options for
hair styling and can be combined with medications, devices, and styling aids such as
minoxidil, low-level laser therapy, and topical powder makeup, respectively.
KEYWORDS: Women, female pattern hair loss, hair transplant, alopecia,
follicular unit
A
n estimated 30 million women in the U.S.,
currently experience some form of hair loss, including
female pattern hair loss (FPHL), and hair loss triggered
by hormonal changes, medications or diseases such as
thyroid conditions and anemia, chemically related
alopecia, traction alopecia, and so forth. These forms
can mimic each other, masking the true cause of the
problem. Male pattern alopecia can be diagnosed readily. Conversely, there are many different conditions
that can contribute to hair loss in women, and certain
key factors may be overlooked, leading to incorrect
diagnosis. A comprehensive medical history specific
to the many factors in hair loss for women is essential
to ensure appropriate diagnosis and possible medical
testing. The correct diagnosis is essential to determine
the right treatment for each individual patient.
Once an accurate diagnosis has been made,
there are still many elements that must be evaluated
to establish an appropriate treatment plan. Treatment
options range from nonmedical to medical and surgical, and potentially a combination of any of these
modalities.
The article will provide information on the
following key factors in treating a female hair loss
patient:
1
Facial Plast Surg 2008;24:414–427. Copyright # 2008 by Thieme
Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA. Tel: +1(212) 584-4662.
DOI 10.1055/s-0028-1102905. ISSN 0736-6825.
Medical Hair Restoration, Maitland, Florida.
Address for correspondence and reprint requests: Matt Leavitt,
D.O., 120 International Parkway, Suite 240, Orlando, FL 32746
(e-mail: [email protected]).
Hair Restoration; Guest Editor, Daniel E. Rousso, M.D., F.A.C.S.
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Profile and psychological impact.
Etiology and most common causes of female hair loss.
Female pattern history and consultation.
Female pattern examination and tests.
Assessment for hair transplantation.
Specifics for the surgical procedure.
Other treatment options.
PROFILE AND PSYCHOLOGICAL IMPACT
Hair loss in females may be even more devastating
psychologically than it may be for males. Cultural
influences and societal norms dictate, influence, and
emphasize the importance of hair: it is a gauge of gender,
age, socioeconomic level, and, especially for women, a
personal statement. Currently, approximately 21 million
women in the United States have some degree of FPHL;
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FEMALE PATTERN ALOPECIA/LEAVITT
that number is increasing rapidly as the Baby Boom
population ages.
Male pattern hair loss and/or total baldness is
acceptable for men in society. However, this is not true
for women. This is perhaps best demonstrated by the fact
there are no female role models who have significant hair
loss. Graying or balding in women is not perceived as
‘‘distinguished’’; the assumption is aging or disease.
In 1993, one of the first studies dealing with the
psychological impact reported 70% of women versus
25% of men expressed high levels of distress with their
hair loss situation.
Approximately half of all females seen for hair loss
stated that they were dissatisfied with the initial contact
they had with their physicians. This was attributable to
the fact that they felt patronized and had been dismissed
as too worrisome, depressed, having marital or sexual
problems, or deemed ‘‘lucky’’ to have as much hair as they
did. Forty-three percent of the doctors advised their
patients to wait before taking any further action; of the
more ‘‘aggressive’’ physicians, 10% suggested vitamins.
Patients were often dismissed altogether as most of
the standard tests performed for their hair loss produced results considered to be within ‘‘normal’’ ranges.
Frequently, the women were prescribed treatment with
antidepressants (Table 1).
Twenty percent of females with hair loss seek
advice from their primary care physician, 47% see a
dermatologist or cosmetic surgeon, 39% see a general
or family practitioner, and 1% see an obstetrician/
gynecologist.
Women are skillful at camouflaging hair loss with
creative styles. As a result, their loss is usually obscured
because they retain the frontal hairline (85% of the
patients). Therefore, it is often difficult for a physician
to recognize hair loss in these patients. Females must
lose more than 50% of their hair before it is visible or
noticeable by others. Because it is a sensitive issue for
most female patients, physicians frequently wait for their
patient to raise the topic. Once this discussion occurs, it
is important for the physician treat the patient’s concerns
seriously and with respect.
Once hair loss becomes a problem for a patient, it
affects them daily. Initially, the patient may develop an
elaborate routine and methods to conceal the problem.
However, it is a short-term ‘‘fix,’’ and she will often
withdraw from social and professional settings as the
condition worsens. Many times, there is a denial factor
involved; the patient believes that the hair loss is temporary and will improve once her stress factors subside. It
frequently takes a great deal of time, and a deteriorating
situation, for the patient to speak to a physician.
After the patient has decided to seek advice from a
physician, it is critical that a relationship based on trust
be developed. In this consultation, the doctor must
establish that he understands the patient’s concerns
and what she may expect from available treatments.
This discussion requires sensitivity, compassion, and
time to allow the patient to express her needs and
feelings with dignity. It is necessary that the staff is
empathetic and conscious of the patient’s needs for
privacy and understanding.
ETIOLOGY OF HAIR LOSS IN WOMEN
There are three primary types of hair loss, all of which
are nonscarring and that account for more than 90% of
all female hair loss: FPHL, telogen effluvium, and
alopecia areata (Figs. 1–3).
Table 2 details the incidence of all forms of female
hair loss. In contrast, Table 3 lists what women believe
causes their hair loss.
The two greatest mimics of FPHL are telogen
effluvium and diffuse alopecia areata. Before any treatment approach can be determined, it is fundamental to
rule out any of the causes of telogen effluvium, diffuse
alopecia areata, and the scarring forms of alopecia.
Table 4 details several contributing factors that can
lead to hair loss in women.
The scarring alopecias can stem from diseases such
as lupus erythematosus to trauma and can be more easily
differentiated from the nonscarring alopecias (Table 5).
Telogen effluvium is a form of nonscarring alopecia characterized by diffuse hair shedding, often with
an acute onset. Hair often appears dull in these patients.
Telogen effluvium is generally more visible and has a
Table 1 Women’s Degrees of Concern about Hair Loss:
A Survey of 2000 + Households
Extremely concerned
19%
Somewhat concerned
24%
Slightly concerned
Not at all concerned
28%
29%
Figure 1 Female pattern hair loss (FPHL).
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FACIAL PLASTIC SURGERY/VOLUME 24, NUMBER 4
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Table 2 Incidence of All Forms of Female Hair Loss
Androgenetic alopecia (FPHL)
68.8% of patients
Diffuse alopecia (may be telogen
11.3% of patients
effluvium)
Alopecia areata
9.9% of patients
Cicatricial alopecia (many causes)
4.9% of patients
Trichotillomania
1.3% of patients
Trauma, traction
Other
1.1% of patients
2.7% of patients
Source: David Whiting, M.D.
Table 3 A Survey of 300 Females Experiencing Hair
Loss
Belief of Cause of Hair Loss
Percentage
Permanents, excessive coloring
20%
and bleaching, overprocessing
Figure 2 Telogen effluvium.
more rapid progression of hair loss than does FPHL.
Telogen hairs increase from 10 to 30 to 50%, and 150 to
700 hairs are lost per day. Hairs are easy to comb out.
Telogen effluvium lags the inciting event by approximately 3 months. In most cases, the condition corrects
within 5 to 18 months; 90% of all cases correct without
intervention. The best treatment is elimination or control of the cause.
Telogen effluvium can originate from a wide
range of issues, among which are stress, disease, drugs,
and illness (Table 6).
Alopecia areata affects 2% of the population. It
presents as spotty, patchy, or circular areas of hair loss or
can be seen as breakage/clumps of lost hair. In its diffuse
form, it mimics telogen effluvium and FPHL (Fig. 3). Its
most severe form is alopecia totalis (all scalp hair is lost)
Serious illness, medications
17%
Hereditary
14%
Age
14%
Stress, nerves
Pregnancy, childbirth
11%
10%
Note: Some women suggested more than one cause.
or universalis (the total loss of hair: scalp, body,
eyebrows, etc.). The condition is an immunologic disorder that can be triggered by stress. It most frequently
occurs in the 20- to 30-year-old population; however,
25% of reported cases present in the 40 + age group.
Regrowth of the hair usually occurs, and the condition
can resolve on its own. However, recurrence can be
expected. The condition is marked by an ‘‘exclamation
point’’ hair when plucked.
FPHL is characterized by a family history (may be
difficult to pinpoint), a slow onset, slow progression, and
a generally stable rate of loss. FPHL has no age predictor. It may present as early as puberty or as late as age
40 years. The peaks of onset are the third and fifth
decades: 25% of women aged 35 to 40 years, and an
estimated 50% of women after age 40 years, show signs
Table 4 Alopecia May Be Related to Any of Several
Factors
Figure 3 Alopecia areata (diffuse).
Trauma
Diet
Genetic/hereditary factors
Psychological abnormalities
Drugs
Primary hair or scalp disorders
Structural hair defects
Congenital hair abnormalities
Systemic diseases
Infection
Hormonal
Endocrine-related
Neoplastic disorders
Chemical and physical agents
Emotional stress
Physiologic stress
Androgenetic alopecia
Alopecia areata
Source: Dr. Maria Hordinsky; added to by Dr. Matt Leavitt.
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FEMALE PATTERN ALOPECIA/LEAVITT
Table 5 Scarring Alopecias
Central centrifugal scarring
Collagen vascular
alopecia (CCSA)
disease
Pseudopelade of Brocq
– lupus
Dissecting colitis
Traction
Folliculitis keloidalis nuchae
Sarcoid
Lichen planopilaris
Radiation
Trauma
Neoplasm
Infections
of hair loss or thinning. Those who have earlier onset
tend to develop more severe hair loss.
An estimated 20% of females with FPHL have an
easily identifiable family history of hair loss. FPHL is
identifiable in several ways. Typically, hair loss occurs
from the root of the follicle. Miniaturization, characterized by finer, smaller, slower growing, less pigmented
hairs, is present. Thinning is more common than areas of
noticeable hair loss and may present with a ratio of less
than four terminal hairs to one miniaturized hair. The
hairline and temple are mostly maintained; it is the part
in the hair (center part) that is usually the first visibly
noticeable area (Fig. 4).
The algorithm (Fig. 5) details three categories of
hair loss, their potential triggers, and possible diagnoses.
CONSULTATION
Hair loss is unforgiving for women. Frustration, depression, and fear are all underlying psychological issues for
this patient, and the patient requires a great deal of
reassurance and understanding.
A female patient generally presents herself differently from her male counterpart. Aside from the emotional issues, she usually has several carefully prepared,
organized, and well thought-out questions about her
specific hair loss needs. Her approach is methodical, and
she will expect a logical explanation for her situation.
Table 6 Causes of Telogen Effluvium
Acute stress (hemorrhage)
Drugs
Childbirth (postpartum)
– Allopurinol
Chronic systemic illness
– Clofibrate (Atromid-S)
Cancer
– Cocaine
Leukemia
– Warfarin (Coumadin)
Hodgkin’s disease
Tuberculosis
– Heparin
– Oral contraceptives
Cirrhosis
– Propylthiouracil
Crash dieting
Febrile illness
Chronic iron deficiency
Lobar pneumonia
Psychogenic stress
Pertussis
Scarlet fever
Influenza
(From Olsen E. Disorders of hair growth: diagnosis and treatment,
New York: McGraw Hill; 1994).
Figure 4 Example of FPHL.
During the consultation and examination, it is necessary
to look for a possible association between the hair loss
and other conditions. These range from disease (such as
lupus or a thyroid condition), reaction to certain drugs
(i.e., birth control pills or b-blockers), and/or a relationship between symptoms such as an infection or stress.
Unusual diets, family hair loss history, any episodes of
high fever, diabetes, Hodgkin’s disease, illnesses, vitamin
usage, and kidney or liver problems are questioned. The
tests are crucial in diagnosing any structural hair defects,
possible hair or scalp disorders, or evaluating any trauma.
A thorough, detailed questionnaire is a key in
obtaining essential patient history regarding hair loss
(Table 7). Questions should cover a broad range of topics
including family history of hair loss, illnesses, hair-care
habits, medications, emotional stresses, and recent
surgeries.
A family history for female pattern is helpful but
not essential because of the difficulty some individuals
have with pinpointing a family member with hair loss.
Remember slow onset and progression are common
characteristics of FPHL, and the rate of loss is generally
stable and from the root.
EXAMINATION AND TESTS
Examination most commonly shows that the patient will
maintain her hairline (85%) and the temples area (90%).
The majority will follow a Ludwig pattern with widening of the part. Miniaturization will be present as finer,
smaller, slower growing, less pigmented hairs. Thinning
is more likely than areas of complete hair loss. The ratio
of terminal hairs to miniaturized hairs is less than 4 to 1.
There are two hair loss charts designed specifically
for evaluating female hair loss that are used in the
examination. The Ludwig Classification, developed in
1977 by Dr. Erich Ludwig, defined three stages of hair
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Figure 5 Appearance of hair loss and possible etiologies.
loss (Fig. 6): I, II, and III (with III indicating the most
advanced hair loss). Stage I reveals hair beginning to
thin on the crown while the frontal hairline remains
preserved. In stage II, the crown continues to thin, and
the hair loss has advanced and is quite noticeable to
others. Stage III is full baldness in the crown area with
an increased number of shorter and thinner hairs. The
frontal hairline is not preserved, and hairstyling cannot
hide the loss as it is too great. Some Ludwig stage II and
all Ludwig stage III patients are not candidates for
surgery.
The Savin Female Density scale (Fig. 7) was
developed in the early 1980s. It is based on a scale of
1 through 7, with 7 representing the lowest density. This
scale shows hair that is lost diffusely over the entire scalp.
This is the most typical hair loss pattern for females.
The examination should include hair color, texture, diameter, and damage to the hair, as well as
observation for signs of erythema, scale, pustules, medications and/or drug use, and evaluation of the degree
and density of hair loss. Several tests will also likely need
to be ordered. Photographs should also be taken for
documentation purposes. A series of photos showing
many different angles and hair parts should be taken
with the hair wet and dry.
Although all workups should be individualized,
the following lab work and tests are standard for patients
with alopecia. Approximately 90% of the lab work and
tests will not provide a definitive answer; however, the
results will be useful for evaluation and interpretation of
the underlying cause of hair loss. ‘‘Normal’’ ranges do not
negate the fact that hair loss exists; it simply means that
finding the reason will be more difficult.
The laboratory workup should consist of routine
chemistry studies, complete blood count (CBC) with
differential, a urinalysis, a serologic test for syphilis, and
tests for thyroid function (TSH, T4). Additional useful
and helpful tests are free testosterone levels, and sex
hormone binding globulin (SHBG), dehydroepiandrosterone sulfate (DHEAS), androstenedione, luteinizing
hormone (LH), follicle-stimulating hormone (FSH),
and prolactin counts. Useful, too, are serum iron, total
iron-binding capacity, and ferritin levels. An abnormal
endocrinopathy reading can suggest that the hair loss is
the male pattern type.
Tests
DAILY HAIR LOSS TEST
This test is performed by the patient daily for 1 week.
Hairs that fall out during the day are counted, including
those lost in the bathroom, on pillows, and in brushes
and combs. The hairs that are presented for examination
are analyzed to determine the anagen-telogen ratio.
HAIR PULL TEST
This test is performed to determine degree and stage of
loss. A section of 8 to 10 hairs from various parts of the
base of the scalp are pulled outward to the ends of the
hair. One to two hairs is an acceptable number for being
detached or lost. Avoid doing this test on a patient after a
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FEMALE PATTERN ALOPECIA/LEAVITT
Table 7 Patient Information and History Form for Hair
Loss*
Hair
Table 7 (Continued )
List any medication that you take along with duration
and dosage.
What area or areas of hair loss are you experiencing?
What is the main problem (itching, scaling, thinning areas, etc.)?
List all vitamins and supplements you take and the duration
and amounts.
Have you previously been affected by any type of hair loss?
If so, explain.
List any surgeries, anesthesia, or hospital admissions.
When did this particular hair loss begin?
period. Have you gone through menopause?
Are you tired excessively?
Does anyone in your family have hair loss? What is the amount,
age of onset, and relationship to you? Be specific.
Is there anything unusual about your period? Describe your
Have you ever had, or do you currently have, any ovarian cysts?
Has the hair loss increased, decreased, or stayed the same?
Have you ever been pregnant?
How many hairs are you losing daily?
Do you have any children? How many?
Do you feel that you have been shedding excessive numbers
Were there any complications prepartum and postpartum?
of hair?
Do you feel that your scalp hair is slowly thinning out over
When were you last pregnant, and when did you last deliver?
the top without losing excessive numbers of hairs daily?
Do you take birth control pills? For how long and what brand?
Be specific.
Which did you notice first, shedding or thinning?
Are you losing hair from the entire scalp, or is it more noticeable
on the top?
Did you lose any hair after childbirth?
Have you changed jobs, moved, married, had a death in the
family, or had any life changes in the year prior to hair loss?
Has the appearance changed, straight to curly?
Have you had surgery or general anesthesia in the past year?
Are any of the hairs short and without color (pigment)?
Have you had a prolonged high fever within the past 6 months?
Where do you mainly lose them (tub, sink, brush or comb, etc.)?
Do your hairs come out at the root or break off, or both?
Are you bothered by being too hot or too cold?
Do you have symptoms (i.e., itching, scaling, etc.)?
Do you pull and/or twist your hair?
weight changed?
Are you a vegetarian? Do you eat red meat?
Has your hairline or temporal area receded?
Have you ever had chemotherapy or radiation treatments?
Have you noticed the middle part in your hair widening?
Does the hair seem dull, brittle, or uncombable?
Has anyone other than you noticed or mentioned your
hair loss?
Have there been any changes in your nails, skin, teeth,
Have you dieted within the past 8 to 12 months? Has your
When?
Have you ever been exposed to any animals or persons with
hair loss diseases?
*Developed by Dr. Paul Cotteril, with additions by Dr. Matt Leavitt.
or mouth?
Do you sweat normally?
Does hair loss affect your daily routine (more time spent
styling, less social contact)?
Does hair loss affect you emotionally (feel less attractive,
lower self-esteem)?
Hair Care
How often do you shampoo? List all products used on your hair.
Did you shampoo today?
Have you changed your hairstyle recently or within the past
6 months?
Do you wear a fall or use hair extensions?
recent shampoo as it may alter the number of lost hairs.
If four to six hairs are removed by this method, the test
indicates active shedding. The hairs are examined under
a light microscope to inspect for broken hair (chemical or
heat damage), dystrophic hair (seen with congenital hair
abnormalities), or for intact telogen hair. This test has
significance for patients with alopecia areata—a positive
hair pull test suggests that hair loss may be progressing to
the entire scalp.
Do you braid, plait, tease, or wear a bun or ponytail? How often?
Do you use relaxers, pomades, or straighteners?
HAIR MOUNT
Do you perm, color, dye, or bleach your hair? How often and
with what products?
This is a microscopic examination of the hair shaft to
observe hair shaft abnormalities. The type of hair,
texture, color, length, and condition (dry, oily, or brittle)
is observed in addition to noting if hairs are broken. If
broken hairs are visible, it may be attributable to hair
shaft fragility from chemicals such as shampoos, dyes,
heat, or sunlight, which can weaken the shaft’s disulfide
bonds. Fungal scalp infections can be identified using
this method. This test is useful in identifying various
congenital hair disorders, hair breakage, hair shaft
fragility, and fungal or bacterial infections.
Do you use hot or sponge rollers, hot combs? How often?
Do you use rubber bands, hairpins, or other hair ornaments?
Do you blow-dry your hair?
Medical
List any health problems that you have or have had. Be specific.
Do you have any history of diabetes, anemia, iron deficiency,
thyroid or glandular disease?
Have you donated blood in the past 3 years? How many times?
List any high fevers or drug allergies.
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2008
Figure 7 The Savin Female Density scale.
Figure 6 Ludwig scale for female hair loss: stage I, stage
II, and stage III.
MICROSCOPIC TRICHOGRAM
This is a microscopic examination of the hair bulb.
Several hairs from the affected area are pulled and
examined to compare the anagen-telogen relationship,
as well as hair shaft diameters. If hair bulbs are excessively clubbed, have a smaller than normal hair shaft
diameter, and pigment is limited, then the hair is
dystrophic or abnormal. Chemotherapy can be a cause
of this condition.
obtain a vertical and horizontal biopsy in FPHL. It will
reveal a decreased number of terminal hairs with a
proportional increase in vellus hairs. The test can also
ascertain the presence of seborrhea, psoriasis, alopecia
areata, and lupus.
Evaluating this total medical information should
result in a diagnosis for the patient (Fig. 8). As previously stated, photo documentation is an integral part of
the medical record for hair loss patients and should be
repeated periodically.
SCALP BIOPSY
A scalp biopsy is warranted in many cases using very
small (4 to 5 mm) sites on the scalp. It is preferable to
Treatment Options
Figure 9 indicates the treatment options for FPHL.
Figure 8 Physician’s hair loss examination form. (Source: Dr. Matt Leavitt.)
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FEMALE PATTERN ALOPECIA/LEAVITT
Figure 9 FPHL treatment options.
PATIENT ASSESSMENT FOR HAIR
TRANSPLANTATION
Traditional Ludwig stage I and II females are the most
common candidates for hair transplantation (Fig. 5);
however, other patterns may also exist (Table 8).
Some women may present with male pattern
baldness or other problems that would benefit from a
surgical procedure (Table 9; Figs. 10–13).
The majority of women who are candidates for
surgery require increasing the density in a thinning area
versus creating a hairline or transplanting a bald area. It
is rare for a woman with FPHL to progress to complete
baldness. A thorough examination is critical in determining if enough donor hair exists to meet the patient’s
expectations both at the time of consultation and in the
future. Women are generally creative with styling hair
and, therefore, transplantation to localized areas may
have a tremendous positive impact. It is essential to
ask the patient regarding current and possible future
hairstyles.
Donor Area Assessment
Donor hair availability and density are the case-limiting
factors in determining if a woman can have surgery. The
progressive diffuse loss of hair in female patients in
traditional areas of donor harvesting compared with
that in male patients makes the decision to determine
if a female is a candidate extremely difficult. The key
elements in assessing the donor area for the female
patient are similar to those for men. Specifically, it is
necessary to evaluate several aspects of the donor area.
The individual’s inherent hair characteristics, which
include color, texture, scalp to skin contrast, and level
of curl, factor into the surgical design strategy for the
patient. Hair that has curl will provide more coverage
and look thicker with fewer grafts than will fine, straight
Table 9 Female Pattern Hair Loss
Hereditary changes in the hairline
Traumatic alopecia
Cosmetic indications
Table 8 Patient Assessment for Hair Transplantation
Scars
Extent and pattern of loss
Eyebrows/pubic region
Ludwig classification (stage I, II, III)
Childhood burns
Bitemporal recession
Cosmetically nonsatisfying operations
Diffuse loss of discrete areas
Frontal accentuation (‘‘Christmas tree’’ pattern)
Increased awareness of the difference in male and female
hairlines among patients undergoing gender reassignment
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Figure 10 Hair transplant patient (left, before; right, after).
This woman was a Ludwig stage I patient with classic
‘‘Christmas tree’’ pattern.
Figure 12 Hair transplant patient (left, before; right, after)
demonstrating an example of traction alopecia.
hair. Similarly, coverage can be achieved with a lesser
amount of grafts if the hair color is close to the scalp
color rather than hair that contrasts highly with scalp
color (i.e., dark hair and light skin). However, darker
hair will create the appearance of more hair volume (i.e.,
brown vs. gray hair or white hair).
The key assessment to determine candidacy is
donor density follicular unit/cm2 to recipient density
follicular unit2. If the donor density is substantially better
than the recipient density and sufficient donor area is
available, the patient has the opportunity for excellent
improvement. Another essential component is scalp elasticity. Donor density should be measured with a densitometer, whereas scalp elasticity can be measured with the
Mayer-Pauls Caliper (A-Z Surgical, Hauppauge, NY).
Before selecting the donor (single strip), ask if the
patient ever wears her hair up in the back. Midoccipital is
the most common area to take the strip; if the patient
wears her hair up, it is important to take the strip
superior enough to allow for this style.
Figure 11 Hair transplant patient (left, before; right, after).
The patient had an unusual pattern of hair loss. Notice
recession in the temporal areas.
Figure 13 Hair transplant patient (left, before; right, after).
The patient had had radiation therapy, which destroyed the
follicles.
Recipient Area
Examination of the recipient area should focus on the
degree of miniaturization, diameter of existing hairs,
pigment loss, decrease in density, and examination of the
total area of miniaturization cm2. The progressive and
unpredictable nature of FPHL is a huge obstacle in an
accurate assessment of future hair loss. In addition,
medical therapies such as minoxidil will have widely
variable benefit in female patients.
The other major concern in transplantation of the
female patient is the propensity for postoperative shock,
which is a combination of telogen effluvium and some
anagen effluvium. Similar to the difficulty in predicting
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FEMALE PATTERN ALOPECIA/LEAVITT
future hair loss, it is not possible to know which patients
will be most adversely affected by this effluvium. It is
therefore mandatory to discuss this risk and present
a worst-case scenario with all prospective patients. However, do realize that severe telogen, and anagen, effluvium from a hair transplant does not occur in a majority
of women. If it does occur, it does so as early as the
immediate postoperative period and up to 3 months
postoperatively. By 6 to 12 months, the hair has grown
back completely. I have personally found that shock loss
cannot be overemphasized because of the devastation a
patient may feel when it occurs.
Additional Assessment
The most common complaint from the prospective
FPHL patient is the ‘‘see-through’’ appearance of the
frontal area of the scalp. Given the fact that donor hair is
usually the greatest limiting factor, a frank discussion is
required with the patient to make certain that they
understand that donor hair could ultimately not be
available to treat future areas of loss. Ask the patient
which areas are her priorities for treatment. There
are two benefits to narrowing the areas of treatment.
(1) Women are accustomed to styling their hair, and
placement of grafts in strategic areas may give the
illusion of good overall coverage. (2) Donor conservation, more donor available for future needs: Remember,
the long-term potential donor-recipient area ratio
along with whether or not the patient has realistic
expectations are the determining factor for hair transplant candidacy.
Time and patience are required when determining
the patient’s expectations. Most women will not be able
to achieve dense hair in all thinning areas with transplantation. Fortunately, most women are realistic
enough to understand this fact. Reasonable density in
chosen areas is often possible and usually acceptable.
Women who say they do not want to see any scalp
are poor candidates because of the unrealistic nature
of this goal. Documentation with multiple pictures
(with different angles and hairstyles) is an essential
tool for evaluating these patients preoperatively and for
postoperative results.
In summary, the hair transplant surgical concerns
for transplantation of female patients are unpredictability of future loss especially in the donor zone, anagen and
telogen effluvium related to a hair transplant, and diffuse
thinning without baldness in which it may be difficult to
transplant enough density.
SURGICAL PROCEDURES
Most aspects of the surgical process are the same for men
and women. We will concentrate on some of the subtle
differences.
Preoperative Events
The diagnosis of FPHL needs to be validated as previously described in this article before deciding if the
patient should undergo a surgical consultation. For
example, treatment of telogen effluvium is completely
different and medical in nature versus the potential need
for surgical treatment with FPHL patients. I recommend that female patients start on minoxidil 2% or 5%
ideally 3 months before surgery. Minoxidil may have the
secondary benefit of helping prevent or lessen telogen
effluvium. Minoxidil will be discussed in more detail
later. During the preoperative consult, we use a mirror to
have a patient prioritize treatment areas and also to show
the location of the donor area.
Because female patients have more hair in the
recipient area than do Norwood stage V and VI male
patients and hair is also often longer, blood may be
difficult to remove postoperatively and cause hair to
become unbearably tangled. We have found that leaving
conditioner in the hair is helpful in avoiding this problem. Frequent rinsing of recipient hair is also advisable.
Donor Area/Suturing Anesthesia
Instrumentation and anesthesia of the donor hair are the
same for men and women except for the occasional use of
less epinephrine in the lidocaine and tumescence in the
recipient area. Similar to male patients, donor hair is
selected based on density, caliber, color, and curl. If the
patient states that they use a hairstyle where their hair is
pulled up, a more superior occipital location is chosen.
Many FPHL patients have thinning into the parietal
scalp, and therefore the occipital hair is often most dense
and hence most used. Parietal hair may be cautiously used
as a donor location if family history and examination give
comfort regarding future loss. Temple hair is not used.
An incision that courses between the left and
right postauricular area is most common. Density and
elasticity of tissue determine the number of grafts
available. Typically, we are able to harvest between
1000 and 1800 grafts in this area. A densitometer and
Mayer-Pauls Caliper are used to obtain objective measurements of density and elasticity. FPHL patients are
always advised that future surgery is needed. Future hair
loss and patient expectations regarding density typically
dictate more surgery. Location of donor area for the first
surgery is planned in a way that allows the second
surgical incision to ellipse the first surgical incision.
Maintaining one scar allows donor area to be camouflaged easier and also enhances the ease of future surgery
planning. The donor incisions are typically closed in two
layers as prophylaxis against widening. The subcutaneous and subcuticular space is closed with a 4-0 monofilament absorbable suture and a continuous horizontal
mattress stitch below the papilla. This successfully closes
the dead space, removes all tension from the skin, and
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approximates wound edges. Skin is closed with either
3-0 or 4-0 nylon in continuous closure. It is sutured with
very superficial skin bites that are placed very close
together. In the author’s 20 + years of performing
surgery on female patients, I have observed that the
scalp epidermis and dermis is typically thinner and the
subcutaneous fat is less fibrous. The practical application
of this observation is the increased importance of
using subcutaneous/subcuticular sutures in addition to
suturing skin.
Recipient Area/Graft Preparation
Characteristics of the type of female pattern patient
dictates the type of graft used. Female patients typically
do not have areas of complete loss but instead are
thinning, and most female patients have maintenance
of the hairline and temples. The goal is to increase
density. Because donor hair is usually not sufficient to
keep up with all areas of present and future loss, it is
critical to transplant those areas that will allow the
patient to get the best coverage in the most visible areas.
Priority areas are often just behind the hairline and in the
part (versus in the central vertex area).
Net increase in density is equal to the hairs gained
less hairs lost. Therefore, magnification is critical when
making recipient sites to avoid damage to existing hair.
The sites must be made at exactly the same angle and
direction to prevent injury to existing hair. The angle is
generally less acute than what is typically performed in
hairlines or in patients with complete loss. It is also
critical to maintain hemostasis for clear visualization of
existing hair. Typically 1-, 2-, 3-, and 4-hair follicular
units are placed in incisions of 0.7 mm to 1.3 mm.
Follicular pairing, a technique that places more than one
Figure 14 Two whole follicular units.
Figure 15 Placement of follicular pairing.
follicular unit in the same site, may be used to increase
density. For example, a one-hair follicular unit may be
paired with a three-hair follicular unit in the same site.
There is little risk of an unnatural result because this
technique is not used in the hairline and there is usually
plenty of surrounding hair (Figs. 14 and 15).
Follicular families are similarly used to create
more density, for example, if a two-hair follicular
unit is adjacent to a one-hair follicular unit, the graft
can be prepared as a graft with three hairs. In the author’s
practice, I typically transplant a density of 20 to
35 follicular units per cm2 in female patients. I have
found that dense-packed cases have been more predisposed to significant telogen effluvium; of course, exceptions do exist (Fig. 16).
Figure 16 Follicular unit and follicular family.
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FEMALE PATTERN ALOPECIA/LEAVITT
Figure 17 Hair transplant patient (right, before; left, after) demonstrating an example of FPHL.
Postoperative telogen and anagen effluvium are
the greatest concern. Preoperative treatment with minoxidil 2% or 5% along with meticulous surgical technique and avoiding dense packing have been most helpful
in our practice. In addition, we are much more judicious
in the amount and frequency of tumescence with epinephrine. An effort is made to use a tumescent solution
containing epinephrine only one time in the recipient
area; because of this, close coordination of the timing of
these injections with placement of grafts is necessary.
Postoperative Care
Female patients are brought back for hair washes on
postoperative day 1. This ensures that all grafts are
sitting in the correct position and that surrounding
hair is clean and that the donor is also free of blood. It
is essential to make sure patients restart their minoxidil
treatment within 1 week after surgery. Low-level laser
therapy (LLLT) is also recommended. Many studies
extol the benefits of LLLT for wound-healing and pain
management. It is the author’s experience that it also
helps postoperatively in hair transplants. Specifically, I
have seen a decrease in the amount of crusts, erythema,
and edema.
Graftcyte, (Procyte/Photomedex, Redmond, WA)
a copper peptide wound-healing solution, is also recommended to reduce the postoperative sequelae of crusting
and erythema. Styling may be more difficult postoperatively, and subsequent frustration and anxiety are not
uncommon for female patients. Slightly changing the
part is helpful in camouflaging. A topical camouflaging
agent such as Topik powder (Spencer Forest, Westport,
CT) is extremely useful and recommended for those
patients who still have difficulty hiding their surgery or
hair loss. Topik should not be applied immediately
Figure 18 Female hair transplant patient (right, before; left, after) demonstrating an example of male pattern hair loss.
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postoperatively; 5 days is our earliest recommended time
for application.
The anxiety of postoperative telogen effluvium is
significant for female patients, even when they know it
may occur and that it will resolve. Follow-up appointments at 2 weeks, 3 months, 6 months, and 9 months are
scheduled to provide contact with patients where they
may be examined and reassured that they are doing fine.
A video microscope that provides 50 magnification
and projects the image of the scalp examination on
a television screen is very helpful and reassuring to
patients. They are able to clearly see the new grafts
that are coming in and also the improvement in density.
They are also able to visualize improvement in the
pigment and caliber of new hairs as opposed to miniaturized hairs (Figs. 17 and 18).
of telogen hair to anagen, and prolongation of the
anagen phase. Side effects were minor, consisting primarily of contact or irritant dermatitis in 6% of patients
with 5% minoxidil topical solution and in 2% of patients
with 2% topical minoxidil. Facial hypertrichosis occurred
in 3 to 5% of women using the 2% minoxidil solution.
The 5% minoxidil group tends to have a higher incidence of hypertrichosis.
Minoxidil 2% or 5% is recommended at the time
of the initial hair loss consultation. It is recommended in
our practice that application be stopped 5 days prior to
surgery and restarted 2 to 7 days after surgery, or as soon
as tolerated. In addition to the benefits mentioned above,
use of minoxidil appears to delay the shedding seen after
hair transplant surgery and may shorten the period for
grafted hairs to regrow. Some potential suggestions for
application:
OTHER TREATMENT OPTIONS
As recently as 20 years ago, there was virtually no
medical path on which women with FPHL could
venture. It frequently remained untreated by physicians
because they had few, if any, solutions for this specific
type of hair loss. The factors that produce FPHL are not
completely understood, and it is clear that more
than dihydrotestosterone (DHT) is involved. There are
thousands of nonmedical ‘‘cures’’: lotions, potions, herbs,
home remedies, and concoctions for hair loss, some of
which defy all believability. If any of these were truly
effective, reproducible medical studies would validate
their claims.
Currently, there is only one FDA-approved medication for FPHL or thinning hair in women that can
claim regrowth. In 1988, minoxidil 2% was approved for
treatment of male pattern hair loss after studies demonstrated statistically significant improvement in hair
counts and an excellent safety profile. In 1992, 2%
minoxidil was approved for use in women. In 1996, 2%
minoxidil was approved as an over-the-counter (OTC)
medication for men and women with pattern hair loss. In
1997, the FDA approved 5% minoxidil as an OTC
medication without initially approving the formulation
as a prescription product. A more cosmetically elegant
form of minoxidil, Rogaine Foam (Johnson & Johnson,
Morris Plains, NJ), was recently released in 2007.
Patients who have switched to the foam have been
more compliant in both consistency and duration of use.
Minoxidil is considered to be a nonspecific biologic response modifier with an unknown mechanism of
action in hair growth. It appears to act directly on viable,
suboptimally functional follicles as a potassium channel
agonist. In women, minoxidil 2% solution increased
hair counts by 29% and hair weights by 42% compared
with –2.6% and 1.9% for control over a 32-week test
period. Benefits of treatment include enlargement of
miniaturized follicles (increase in diameter), conversion
Remember foam
Apply Rogaine Topical Solution (Johnson & Johnson,
Morris Plains, NJ) twice daily.
Towel dry or blow dry hair before application.
Apply Rogaine Topical Solution directly onto scalp.
Wash hands after application.
Apply 5 minutes before using styling aids.
Do not shampoo or swim for 4 hours after application.
Let solution dry before going to bed.
The other group of medications that helps women
with hereditary hair loss is called antiandrogens. The
goal of antiandrogens is the deliberate interference with
androgens (male hormones) in the body to help alter the
course of hair loss. The failure of finasteride to provide
clinical benefit to most women with FPHL reinforces
the belief that FPHL is not solely DHT dependent.
Women who have hair loss secondary to excess androgens may benefit. It is important to emphasize to female
patients that finasteride is prohibited in any female who
may potentially become pregnant because it might cause
abnormalities of the external genitalia of a male fetus. In
some cases, doctors do prescribe the drug off-label for
postmenopausal women in the treatment of FPHL.
Cyproterone acetate is another potent antiandrogen. It works by competing with DHT for androgen
receptor binding. It has been approved in Europe and
has been shown to benefit women with FPHL, women
with hair loss and high ferritin levels or clinical evidence
of hyperandrogenism, including acne, hirsutism, menstrual irregularities, and a high body mass index. Potential side effects include menstrual irregularities, weight
gain, breast tenderness, loss of libido, and the potential
feminization of a male fetus. The latter side effect
requires concomitant use of oral contraceptives. Birth
control pills that contain small amounts of cyproterone
acetate are Diane and Dianette (Bayer AG, Pittsburgh,
PA), (but are not available in the United States).
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FEMALE PATTERN ALOPECIA/LEAVITT
Spironolactone is approved in the United States
as a medication for high blood pressure. As an off-label
drug, it is commonly used to treat alopecia and hirsutism
in females. It is believed to work in arresting hair loss by
interfering with testosterone synthesis or its production
and by suppressing the 5a reductase activity. It also
increases peripheral conversion of testosterone to estradiol (female estrogens are believed to extend the
anagen phase and provide protection against hair loss).
It competes with DHT for the androgen receptor and
may decrease androgen production of male hormones. In
a few small clinical trials, hair growth was not seen, but
the trials did show that spironolactone might slow down
hair loss. If doses above 100 mg a day are taken, uterine
bleeding can be a side effect, and there may be a possible
risk of developing breast cancer. Spironolactone may also
cause abnormal fetal development, so a form of birth
control is also recommended when taking this drug.
Although not approved by the FDA specifically for use
as an antiandrogen, it is widely administered for this
purpose and must be carefully supervised.
Another option for FPHL patients is LLLT,
which has been used for numerous medical conditions
for the past 40 years. More recently, this decade has seen a
focus on LLLT and hair loss, specifically regarding its
applications for hair growth/maintenance. There are two
types of devices, hood and hand-held, which deliver
energy to the scalp. This energy is absorbed by the cells
to stimulate them. Several studies have shown the effectiveness of these lasers in wound healing, pain management, and reduction of inflammation; currently there are
several studies under way for hair growth and maintenance. The first FDA-approved device for hair growth in
men was the Hairmax Lasercomb (Hairmax LaserComb
Manufacturer, Boca Raton, FL), (hand-held) in 2007.
The author’s practice has found this therapy to be
a valuable tool for some female hair loss patients. We
have recently begun to treat female patients with the
device. It has also been effective in many female hair
transplant patients in terms of more rapid wound healing
and decreased erythema. It appears to have a beneficial
effect on decreasing telogen effluvium after transplantation in some hair transplant patients. Currently, we have
been receiving feedback from patients regarding an
increased manageability and thicker ‘‘feel’’ to their hair,
as well as a deepening of their hair color. The Hairmax
Lasercomb has an application before the FDA for
clearance for hair growth and safety in females.
CONCLUSION
FPHL is devastating to many of the 21 million U.S.
women who suffer from it. It is essential to differentiate
FPHL from other types of hair loss to ensure appropriate
treatment. Through use of follicular units, follicular
families, and follicular pairing between existing hair
follicles, natural-looking results can be achieved in
women. Hair transplants create the benefit of increasing
density and providing options for hairstyling and can be
combined with medications, devices, and styling aids
such as minoxidil, LLLT, and topical powder makeup,
respectively. Although hair restoration surgery is time
consuming, it is extremely gratifying. As a physician, I
have experienced great joy in seeing what a difference it
can make in a woman’s life.
ACKNOWLEDGMENTS
I would like to acknowledge my personal assistant and
right hand, Valarie Montalbano, for all her assistance
with this article. Valarie has worked with me for 17 years,
and much of my success is credited to her. I would also
like to acknowledge my family: my wife, Judye, and my
children, Lauren, age 18, Adam, 17, and Danielle, 13.
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