Hair Restoration

Androgenic Alopecia or Male Pattern Hair Loss (MPHL) is responsible for the vast majority of balding in men. While there are many possible reasons people lose their hair, including serious disease, reaction to certain medications, and in rare cases extremely stressful events, most hair loss in men (over 90%) can be blamed on heredity.

What MPHL sufferers are actually inheriting are hair follicles with a genetic sensitivity to Dihydrotestosterone (DHT). The number and location of these susceptible hairs is determined by inherited genetics from both or either parents. Hair follicles that are sensitive to DHT begin to miniaturise, shortening the lifespan of each hair follicle affected. The hair follicle has a life cycle. In simple terms, this cycle consists of a growing phase and a resting phase. Before hair loss sets in, the growing phase lasts up to seven years and the resting phase lasts three to four months. Genetic hair loss causes the life cycle phases to go in reverse (i.e. the growing phase becomes shorter and shorter and the resting phase longer). Eventually, these affected follicles stop producing hair that is visible.

MPHL is generally characterised by the onset of a receding hairline and thinning crown. Hairs in these areas but also in the temples and mid-anterior scalp appear to be the most sensitive to DHT. This pattern eventually progresses into more extensive baldness throughout the entire top of the scalp, leaving only a rim or horseshoe pattern of hair remaining. For some men even this remaining rim of hair can be affected by DHT.

DHT is a derivative or by-product of testosterone. Testosterone converts to DHT with the aid of the enzyme Type II 5-alpha-reductase, which is held in the hair follicles oil glands. While the entire genetic process of MPHL is not completely understood, scientists do know that DHT shrinks hair follicles, and that when DHT is suppressed, hair follicles continue to thrive. Hair follicles that are sensitive to DHT must be exposed to the hormone for a prolonged period of time in order for the affected follicle to complete the miniaturisation process. Today, with proper intervention this process can be slowed or even stopped if caught early enough.

Typical MPHL is usually diagnosed based on the appearance and pattern of the hair loss, along with a detailed medical history, including questions about the prevalence of hair loss in the patients family. An experienced medical hair loss expert will often examine the scalp under magnification (preferably with a device called a densitometer or folliscope), in order to assess the degree of miniaturisation process of the hair follicles. This assessment can be very important when recommending the proper course of treatment.

FINASTERIDE

Finasteride is the generic name for the brand name drugs Pro scar (5mg Finasteride) and Propecia (1mg Finasteride). Finasteride was originally developed as a drug to treat enlarged prostate glands. During the trials on men with prostate problems an intriguing side effect of hair growth was observed.

Finasteride works due to its ability to specifically inhibit Type II 5-alpha-reductase, the enzyme that converts testosterone into a more potent androgen dihydro testosterone (DHT).

1 mg of Finasteride taken daily can effectively lower DHT levels by as much as 60%. It is DHT that shrinks or miniaturises the hair follicle, which eventually leads to baldness. This 60% reduction in DHT has been proven to stop the progression of hair loss in 86% of men taking the drug during clinical trials. 65% of trial participants experienced what was considered a substantial increase in hair growth.

MINOXIDIL

Minoxidil (Reginae) was the first drug approved for the treatment of MPHL. For many years, Minoxidil, in pill form, was widely used to treat high blood pressure. Just like with Finasteride, researchers discovered a very interesting side effect of the drug. People taking the medication were growing hair in unexpected places like on their cheeks and the back of their hands, some even grew hair on their foreheads.

Some enterprising researchers had the idea that applying Minoxidil topically, directly on the scalp, might grow hair in balding areas. They found it did this to varying degrees depending on the extent of the hair loss.

While Minoxidil has been clinically proven to slow the progression of hair loss and regrow some hair, most informed experts see it as a relatively marginally effective drug in the fight against hair loss. Since Minoxidil has no effect on the hormonal process of hair loss its positive effects are likely to be temporary but might be a useful option for men who do not want to take Finasteride.

Hair loss in women isn’t always as straightforward as it is in most men. In men about 90 percent of all cases are caused by hereditary Male Pattern Hair Loss. In women, however, hair loss can be triggered by a multitude of conditions and circumstances. As a result, not only might it take some time for her to pluck up the courage to discuss the issue with her doctor, but it may take even longer for her to get specialised medical advice and accurate diagnosis.

Alopecia is the medical term for excessive or abnormal hair loss but there are different kinds of alopecia. The cause may be as simple as having a gene that makes women susceptible or it may be due to one of the dermatological causes of hair loss such as Alopecia Area-ta. However it may be more complex as there are a whole host of diseases and nutritional reasons why hair starts to fall out or stops growing. Hair loss may also be a symptom of a short-term event such as stress, pregnancy, and the taking of certain medications. In these situations, hair will often (though not always) grow back when the event has passed. Substances, including hormones, medications, and diseases can cause a change in hair growth, shedding phases and in their durations. When this happens, synchronous growth and shedding occur. Once the cause is dealt with, many times hairs will go back to their pattern of growth and shedding, and the hair loss problem stops. Unfortunately, for some women, hair loss becomes a life long struggle.

ANDROGENETIC ALOPECIA

The hormonal process of testosterone converting to Dihydrotestosterone (DHT), which then harms hair follicles, happens in both men and women. Under normal conditions, women have a minute fraction of the level of testosterone that men have, but even a lower level can cause DHT- triggered hair loss in women. And certainly if the levels of testosterone rise, DHT can be even more of a problem. Those levels can rise and still be within what doctors consider normal on a blood test, even though they are high enough to cause a problem. Furthermore, the levels may not rise at all but still be a problem if the body chemistry is overly sensitive to even its regular levels of chemicals, including hormones.

Since hormones operate in the healthiest manner when they are in a delicate balance, the androgens, as male hormones are called, do not need to be raised to trigger a problem. Their counterpart female hormones, when lowered, give an edge to these androgens, such as DHT. Such an imbalance can also cause problems, including hair loss.

The majority of women with Androgenic Alopecia have diffuse thinning on all areas of the scalp. Androgenic Alopecia in women is due to the action of androgens, male hormones that are typically present in only small amounts. Androgenic alopecia can be caused by a variety of factors related to the actions of hormones, including, ovarian cysts, the taking of high androgen index birth control pills, pregnancy, and menopause. Heredity plays a major factor in the disease.

ANAGEN EFFLUVIUM

Anagen Effluvium occurs after any insult to the hair follicle that impairs its mitotic or metabolic activity. This hair loss is commonly associated with chemotherapy. Since chemotherapy targets bodys rapidly dividing cancer cells, bodys other rapidly dividing cells such as hair follicles in the Anagen (growing) phase, are also greatly affected. Soon after chemotherapy begins approximately 90 percent or more of the hairs can fall out while still in the Anagen phase.

The characteristic finding in Anagen Effluvium is the tapered fracture of the hair shafts. The hair shaft narrows as a result of damage to the matrix. Eventually, the shaft fractures at the site of narrowing and causes the loss of hair.

TELOGEN EFFLUVIUM

When the body goes through something traumatic like child birth, malnutrition, a severe infection, major surgery, or extreme stress, many of the 90 percent or so of the hair in the Anagen (growing) phase or Catagen (resting) phase can shift all at once into the Telogen (shedding) phase. About 6 weeks to three month after the stressful event is usually when the phenomenon called Telogen Effluvium can begin. It is possible to lose handful of hair at time when in full-blown Telogen Effluvium. For most who suffer with this condition, complete remission is probable as long as severely stressful events can be avoided. For some women however, Telogen Effluvium is a mysterious chronic disorder and can persist for months or even years without any true understanding of any triggering factors or stressors.

TRACTION ALOPECIA

This condition is caused by localized trauma to the hair follicles from tight hairstyles that pull at hair over time. If the condition is detected early enough, the hair will re-grow. Braiding, cornrows, tight ponytails, and extensions are the most common styling causes.

ORAL CONTRACEPTIVES

Millions of women are prescribed the pill each year, but very few are aware that oral contraceptives are a common trigger of hair loss for many who use them. The pill suppresses ovulation by the combined actions of the hormones oestrogen and progestin or in some cases progestin alone. Women who are predisposed to hormonal related hair loss or who are hypersensitive to the hormonal changes taking place in their bodies can experience hair loss to varying degrees while on the pill or more commonly, several weeks or months after stopping the pill.

There is often some investigation needed to first isolate the true cause before working on a treatment.

The first person you should turn to is your GP, who will need to take a detailed medical, drug and family history. Most likely you will need some blood tests: full blood count, glucose, serum ferritin (iron stores), thyroid hormones and, where relevant gestational hormone levels. Alternatively you may need to be referred to a dermatologist (skin specialist doctor) or a trichologist (hair & scalp specialist). 

Go to ‘Find a BAHRS member’ to locate a BAHRS Dermatologist member or BAHRS Trichologist member

The treatment you require then depends on the cause found for the hair loss.

In Follicular Unit Excision (FUE), a small circular punch is used to cut around each individual follicular unit. The skin incision dissects the tissue around the hair shaft and root allowing the whole graft to be removed. This process is repeated until the surgeon has achieved the desired number of grafts needed for the procedure.

For FUE, the back and sides of the head may need to be shaved. At the end of surgery there will be multiple small round wounds, each about a millimetre in diameter, which will heal without the need for sutures. These small round wounds will likely leave small round scars which will be visible if the hair is completely shaved. Hence FUE is not ‘scar-less’ surgery and should not be advertised as such.

Each surgeon will have their own preference in how they perform FUE. Some will carry out the technique manually and others will prefer using a motorised instrument which may be vacuum assisted. There is even a robotic device that can make the punch incisions under the direction and supervision of the doctor. There is no best option for FUE harvesting - rather it comes down to the preference of the surgeon, which method they are more comfortable with, and which gives the best results in their hands.

Benefits of FUE include less invasive procedure, no linear surgical scar, less post-operative pain, faster wound healing, possible to perform in very tight scalps, provides an option in patients who have stretched scars from previous Strip Follicular Unit Transplantation (Strip FUT), ability to wear shorter hairstyles compared to Strip FUT, other donor sites other than the scalp can be used.

However, it is important to consider the limitations of FUE when planning surgery which is primarily that, in most cases, less grafts can be extracted in one procedure, and over multiple procedures, compared to Strip FUT. There is also a higher risk that the hair follicles may be transected during the excision. Repeated procedures result in additional scars and over-harvesting can result in thinning out of the scalp donor zone. In order to harvest large numbers of grafts, it is likely the hair will need to be shaved which may not be desirable for some male, female and transgender patients.

A hair transplant surgeon should go through all these factors so that the patient can decide if FUE is the best treatment option for them.

In Strip Follicular Unit Transplantation (Strip FUT) a linear ellipse shaped incision is made to isolate a thin strip of skin and hair from the back and sides of the head. Staples or sutures are then used to close the wound in its place. The strip of scalp is then examined carefully under the microscope, where it can be dissected into follicular unit grafts ready for the implantation phase.

Unlike Follicular Unit Excision (FUE), hair on the back and the sides of the head can be kept long during the procedure allowing the wound to be kept discrete. On healing the wound leaves a linear scar which is usually well concealed when the hair above it is grown out.

Other benefits of Strip FUT include being able to harvest a large number of grafts in most cases compared with FUE, less transection during the harvesting when done skilfully, possibility to recycle the scar with subsequent surgery thereby not increasing the scarring with repeated procedures and better quality grafts in many cases compared with FUE.

Limitations of Strip FUT include the need for sutures or staples to close the surgical wound, more post-operative pain compared to FUE, a linear scar that requires the hair to be worn long enough to hide it, risk that the linear scar could widen and progressive tightening of the scalp and likely widening of scars with repeated procedures. 

A hair transplant surgeon should go through all these factors so the patient can decide if Strip FUT is the best treatment option for them.