Female Pattern Hair Loss

By Author: James Bonenfant
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Affecting as many as 10% of all women, female pattern hair loss is, like its male counterpart, a genetic process. As such, it is progressive, starting in women as young as their late teens, but much more commonly affecting women peri- or post-menopausal. A variety of conditions can accelerate the hair loss, but almost always there is some genetic component as the basis of the process. Some of these more common conditions include poor nutrition (often associated with special diets), anemia, and hypothyroidism.

Female pattern baldness (FPB) occurs along several different patterns, the most common consisting of diffuse thinning along the top and upper sides and back of the head, often sparing the frontal hairline.(1) In this classic FPB pattern, the hair loss is divided into 3 stages according to the Ludwig classification scheme, with stage 1 consisting of mild hair loss, with stage 3 extensive hair loss.(2) However, while this classification scheme is useful from an academic standpoint in its description of the degree of hair loss, it does not have much efficacy in assessing the degree of improvement that can be expected, ...
... and therefore help in counseling the patient. This is because the two most important predictors of success- or disappointment- are the density of the donor area, and the pattern (diffuse thinning versus patchiness) of hair loss in the recipient area(s). By density of the donor area, I am referring primarily to the presence of hairs of thick caliber as the most important predictor of success, and secondarily to hairs that grow closely together (dense concentration). By type of hair loss in the recipient area, the most important feature that determines success is a pattern of hair loss characterized by patchiness- large areas of non-hair bearing skin between the existing hairs- and of secondary importance the presence of hairs that are of normal to above normal caliber. The worst candidates are those with fine donor hairs (no matter the concentration of these hairs) and recipient areas characterized by diffuse thinning without large spaces between existing hairs into which large numbers of grafts can be inserted. To help deal with these variables, I have developed a simple classification scheme, where the caliber of the hairs and the degree of patchiness between these hairs are rated on a 1 to 5 scale (with 3 the average) for both the recipient and donor site areas. So, for example, a great candidate for a transplant procedure would be a woman who has, most importantly, a donor area hair caliber of 4/5 or greater, and a recipient area patchiness of 3/5 or greater.

When transplanting women with female pattern baldness, the finite supply of donor hairs limits the amount of coverage that can be obtained. While most women would like to have all the thinning areas treated, the work should be concentrated in those areas where it will provide the maximum benefit. Most commonly, these areas are the frontal region just behind and up to the hairline, and along the part line. For the best results, the procedure should maximize the number of hairs transplanted while minimizing the trauma to the existing hairs. This is usually best accomplished by the placing of two or three follicular unit grafts (for a total of, on average, three to five hairs) into each recipient site- except along the hairline where only a single graft containing one or two hairs is placed to assure a natural appearance. Patients can be assured that the growth of several hairs from a single recipient site will in no way give an unnatural “transplanted” appearance, because they are used to fill in areas between existing hairs.

In the typical case, 1000 to 1200 grafts (or around 2400 hairs) are transplanted. The recipient sites are slits made by blades 0.6 mm typically up to 0.9 mm in size- very tiny but a major boost in avoiding trauma to surrounding hairs. The grafts are carefully placed into the incisions, keeping them moist to maximize hair growth. To minimize ischemic shock to the existing hairs, the local anesthetic contains a low concentration of epinephrine, generally less than 1:200,000. To further minimize the loss of hairs due to shock, and to accelerate the regrowth of the transplanted hairs, the patient starts at 2-weeks post procedure the daily application of minoxidil 2%. With this regimen, the hairs can be expected to start growing at 2 ½ months, rather than the typical 4 months.