Pierre Bouhanna describes the available techniques to treat female alopecia effectively

Interest in the reversal of baldness has been enhanced by a precise multifactorial classification of female androgenetic alopecia (FAGA) in selected patients.

The diversity of hair transplant techniques allows for a definitive aesthetic solution for most hair alopecia. The indications consider a range of parameters of the thinning hair (aetiology, location, and evolution) and the specificity of each patient such as age, sex, ethnic origin, and self-motivation for pursuing a hair transplant.

The follicular unit for long hair (FUL) and conventional segmentation (follicular unit transplantation — FUT) techniques provide a natural result due to the fine implantation of 1–4 hairs at a time, during one session of 1000 to 3000 hairs. The follicular unit excision (FUE) is less suitable for female alopecia with low donor area density and for those who don’t agree to have their scalp shaved before treatment.

Whichever method is used by the surgeon, simple postoperative care is followed by definitive hair regrowth. Combining hair transplantation and hair medical treatments (minoxidil, anti-androgens) improves the result and postoperative evolution.

Objective measurement of female alopecia using a digital camera

A digital phototrichogram¹ or a trichoscan® (Figure 1) enables an objective measurement of hair growth parameters such as density, calibre, and number of miniaturised and terminal hairs. It is possible to determine the precise hair quantity available for the transplantation session.

The multifactorial classification (Bouhanna)² is also used at this stage, comprising of a range of hair and scalp parameters evaluated and computerised:

• bald and hairy areas
• scalp thickness and laxity
• hair density
• hair colour.

The multifactorial classification provides a better assessment of each female’s baldness for the simplest and most precise medical and surgical therapies.

Hair transplantation for female alopecia

Surgical procedures are currently used daily to provide a definitive aesthetic correction of alopecia. All the methods described in this article are not only for the treatment of female pattern baldness but also for alopecia caused by traumatic injury, second and third-degree burns, post-radiotherapy for a brain tumour, and African-American traction alopecia.

The choice of follicular unit transplantation technique will depend on the degree and location of the alopecia, and the degree of the donor area density, as well as the age and ethnic considerations of the patient.

Most hair transplant procedures are performed on an out-patient basis, using local anaesthesia (anaesthetising cream and nerve blocks). Follicular unit micrografting is a procedure during which 1000 to 3000 hairs are redistributed into the thinning or balding areas.

Once harvested from the donor area, hair follicles are microscopically dissected into grafts (FUL) or extracted or excised with a hand or a power micro-punch (FUE). Each micrograft contains a single ‘follicular-unit’ consisting of between one and four hair follicles. FUE or FUL are then carefully implanted into the bald or thinning recipient areas. The hair transplant session is usually completed in approximately 2–4 hours.

The almost painless surgery and the simple post-operative care allows few discomforts for the patient. Some itching and swelling can occur but is generally mild. Regular physical activities can be resumed immediately, and the first shampoo can be administered one day after the procedure. Crusting and scabbing of the transplanted areas are hidden by the long hair and lasts for approximately 10–12 days. The transplanted hair falls out in two weeks and generally begins to grow in about 3 months. Transplanted hair lives and grows indefinitely. The hair can be styled in any way the person desires.

The techniques

The unshaven follicular unit for long hair technique (FUL)

It has been many years since the author developed the follicular unit long hair technique (FUL)³. The hair on the scalp is not shaved like in the conventional FUT technique, but the resulting process is almost the same. For the patient, the advantages of this procedure are numerous. The donor area is not shaved so the suture on the donor area is not visible and the long hair hides the scabs of the recipient area.

For the surgeon, the benefits of this procedure include a better evaluation of the orientation and the obliquity of transplanted hairs. In the author’s opinion, the only disadvantage is for the female patients who routinely shave their scalp, and the fine linear scar may be visible.

A strip with long hair is harvested (10–30 cm long and 1–1.5 cm wide) and the donor area is closed with running suture or staples. The scar will be very fine, linear, horizontal and almost undetectable. The strip with long hair is then segmented under stereomicroscope into follicular units (1–4 hairs).

The follicular unit excision technique (FUE)

In the follicular unit excision (FUE) technique⁴ (Figure 2), the patient’s hairs are shaved throughout the donor area. FUE aims to harvest intact follicular units from the donor area by hand or using power micro punches (0.8–1 mm), introduced at a depth of 2–5 mm. In case of low donor area density, 500–1000 hairs can be transplanted in one session.

The conventional follicular unit technique (FUT)

The traditional follicular unit technique (FUT) is a procedure of strip harvesting similar to that of the FUL technique. The only difference is that the hairs are previously shaved.

Other techniques include automatic and robotic hair transplantation, such as Neograft®-Artas®, although FUE excision has a limited indication for the treatment of FAGA; and the unshaven FUE, in some cases of FAGA with a suitable donor area density, it is possible to extract the FUE without any prior shaving.

Indications

Female androgenetic alopecia

The evolution of female baldness and FAGA is evaluated according to the Ludwig classification⁵ or can be done more precisely with the multifactorial classification².

The three Ludwig stages are (Figure 3):

• Stage 1: moderate thinning of the vertex
• Stage 2: more significant thinning with a persistence of the frontal, anterior fringe
• Stage 3: nearly complete baldness of the fronto-occipital area.

The combined treatment with 2% minoxidil lotion, hormonal therapy, intradermal PRP injection (platelet rich plasma)⁶ and FUL are increasingly indicated. The oldest patient to receive this hair transplant treatment in the author’s experience was 83 years old.

African-American definitive traction alopecia

Repeated tractions of hair with brushing, straightening and braids, for example, are more frequently seen in African-American patients (Figure 5). They determine a definitive frontotemporal occipital alopecia. FUL hair transplant is indicated 6 months after stopping the traction⁷.

Post-radiotherapy alopecia

FUL hair transplant can efficiently treat definitive alopecia after radiotherapy for a brain tumour (Figure 6).

Post-chemotherapy alopecia

In some cases of breast cancer, the hormonal therapy after the chemotherapy can induce female androgenetic pattern alopecia which can be treated by FUL hair transplant (Figure 7).

Conclusion

The newest follicular unit transplantation techniques such as FUE (Follicular Unit Excision) and FUL (Follicular Unit for Long hair) provide a definitively aesthetic and natural looking hair restoration for the majority female alopecia patients. This treatment can be combined with various medical procedures and PRP injections⁸.