Hair Loss: Procedures to Avoid

Be aware that many physicians in this country and abroad perform outdated and even dangerous hair restoration techniques.

One reason is economics. To perform state-of-the art follicular unit hair transplantation, a physician or group has to revamp the infrastructure of their practice. They have to hire and train a full-time staff of technicians, purchase binocular stereomicroscopes, and most likely expand the size of their facilities.

The time needed to perform a quality hair restoration procedure can take any where from five to 10 hours -- an entire work day. This is much longer than the older, less-demanding techniques. Also, there's a learning curve involved in converting a practice. It usually takes several months for a physician and staff to learn to perform these newer techniques in an efficient manner.

For these reasons, some physicians offer the following procedures but we advise you to avoid them.

Flap and Free-Form Flap

A flap of hair bearing skin is moved from the side of the scalp to the front hairline by cutting it on three sides, but not separating it from its blood supply or severing it completely from the scalp. The procedure is major surgery and is performed in a hospital.

A flap is one inch wide and approximately three to seven inches long. It has to be twisted for the hair-bearing side of the flap to end up facing outward from the head once it is shifted over and stitched into the surgically removed balding area. An unsightly "knot" will always form where the flap has to be twisted.

Another type of flap known as the free-form flap is created when all four sides are cut and the flap is completely removed from the donor area so that its new position in the balding area can be set in a direction of natural growth. This is not a procedure recommended for men or women with common androgenetic alopecia and should be reserved for severely disfigured patients such as burn or accident victims.

Other serious problems with these procedures can include:

  • Necrosis, the chance of a partial or complete death of the flap, leaving a bad scar.
  • Hair always grows in the opposite direction of a normal hairline. Normally, hair in the hairline grows forward. In this case the direction is completely reversed, which makes hair difficult to style naturally.
  • Infection
  • Permanent shock loss (loss of some or much of existing hair caused by the trauma of the procedure) and extreme scarring in the donor area
  • Loosened skin in the forehead develops and hangs over the brow, giving a Frankenstein-like or Neanderthal appearance.
  • Absence of hair behind the newly created frontal hairline.
  • Poor positioning of the flap (this is extremely common)
  • The front hairline scar has to be re-grafted to hide a scar.
  • Integrity of the scalp is compromised. The normal shape or position of the scalp on the scull is altered; in some cases so severely that the patient's ears move out of normal position or the nape of the neck is pulled onto the back of the scalp.

Linear or Line Grafts

A three- to four-mm linear strip of donor hair is removed from the side or back of the head and instead of dividing the strip into follicular unit grafts, the entire strip or large parts of it are transplanted.

Since this large graft can't be placed in tiny recipient sites, a trench must be surgically cut into the bald area and the large graft is placed into the trench. As hair grows, it looks like a manmade line of hair that is not cosmetically acceptable.

Round or Square Grafts

These are the original, standard, out-of-date pluggy-looking grafts. Each three- to five-mm graft is made with a hole punch device, resulting in a plug of hair about the size of a pencil eraser. Whether round or square, these large grafts are too large and do not resemble the way hair grows naturally from the head.

When transplanted, because the grafts are so large and therefore compromise the blood supply, hair in the middle of the graft often does not grow, leaving the patient with a doughnut effect. These large grafts are responsible for what looks like doll hair -- a pluggy look of islands of hair in an ocean, as they are now described. Cobble-stoning, a common scalp deformity in hair restoration patients, is caused by this procedure.

Even the more recently developed smaller version of the grafts -- the mini grafts and micro grafts -- can give a less-than-natural appearance, which is why transplants should be made up of naturally occurring grafts called follicular units comprised of one to four hairs.

Scalp Reduction

Also known as alopecia reduction (AR), galeoplasty (GP), or male pattern reduction (MPR), scalp reductions can result in an unattractive appearance. Performed in the doctor's office under local anesthesia, the bald part of the scalp at the top or crown of the head is cut away, and the edges of the nearby hair bearing skin are sewn together, bringing the hair-bearing scalp from either side to meet in the middle. In some cases a scar results, commonly know as a "dog ear" scar.

Scalp reduction problems also include:

  • Accelerated hair loss, more than the natural course your hair would take. This hair loss can occur within just weeks or months and often doesn't return.
  • An unnatural appearance because the direction of hair growth is altered.
  • Infection
  • Hemorrhaging and hematoma (blood pooling)
  • Stretch back, a problem in almost 100% of scalp reduction cases. The stretched part of the hair-bearing scalp that has been stitched together loses its tightness and stretches out partially or totally, leaving a visible bald area created by the stretching. The dog ear scar is not only unattractive; it is extremely difficult to repair.
  • Suture reaction, in which the stitches in the deep layers below the skin can cause pain and swelling. The body can reject the sutures, causing holes in the scalp at the suture sites.
  • Loss of hair for future transplants. Scalp reductions do not preserve hair for later use, as some physicians may try to claim. The same wreath of permanent hair is stretched to cover the wider area in the crown, thereby thinning the permanent hair that would normally be used as donor hair for transplantation.

Hair Lifts

This is a more radical form of scalp reduction. Dissection or loosening of the scalp skin is done at a level below the major arteries of the scalp. The procedure may leave parts of your head permanently numb.

Unlike other scalp reductions, this is major surgery, which requires hospitalization and general anesthesia. It leaves visible scars around the ears, and additional hair loss is often a result.

Published on March 1, 2010