The Difference Between Male and Female Pattern Hair Loss and Approaches to Hair Transplantation
This question was posed by a female hair loss sufferer seeking hair loss help on our hair restoration forum and answered by Dr. Michael Beehner of Saratoga Springs, NY who is one of our recommended hair restoration physicians. His professional answer is below.
Female Hair loss is a little different than in men, and the approach for transplanting hair is often different for most hair restoration physicians. In our practice, women make up about 15-20% of our hair transplant patients. I find that around 70% of the women who present for consultation are able to be offered hair transplantation. The two key requirements are sufficiently dense, high-quality donor hair AND realistic expecations.
First of all, hair loss is far more psychologically devasting for a woman than for a man. Part of their body self-image is to have a full head of hair. Many men look fine without hair on top and it doesn’t bother them at all.
Somewhere around 20% of women will eventually have significant hair thinning. Their rate of female hair loss, compared to the typical male who has hair loss, is much more gradual and over many years. There often are other females in the family history with similar hair loss. They also have a somewhat higher incidence of medical factors causing hair loss, which have to be carefully looked for before assuming it is hereditary “female pattern hair loss.” Scalp biopsies are done much more often in women. There are a few different patterns of baldness in women, but the commonest is for the front hairline hairs to be preserved and for there to be a general thinning all through the top, central area. This hair thinning often extends to the side areas of the scalp in the temples and above the ears. Fortunately, the majority of these women retain good hair density in the rear occipital region of their scalp, and this can be used for hair replacement surgery if there isn’t too much hair miniaturization present. Another common pattern, present mostly toward the front, is the “Christmas tree” pattern, which is loss down the front-center of the scalp. Women’s hair loss doesn’t seem to be that related to DHT’s presence as in men, and Propecia (finasteride) is not usually of benefit. We know women have higher concentrations of the enzyme aromatase in the front hairline area.
In transplanting hair in women, expectations are important. How they will style their hair later is a key factor. Normally the priorities have to be filling in the front-central “frontal core” area with hair so the front view of a woman is a “full” appearing one and the scalp can’t be seen through the hairs. Depending on which side or down the center that they intend to part their hair, this area will be transplanted more densely. These hairs will then be styled off to either side, which creates overlap and the illusion of hair density. Perming the hair is another option that works well to create a fuller appearance.
In transplanting hair in women, one of the key pieces of information that must be communicated and accepted by the hair restoration patient is that there is greater incidence of “shock loss” to native hairs present in the balding area being transplanted. I would say it occurs to some extent in 30-40% of the women we transplant. It is severe in only 5% and in the others it is mild or moderate. The majority of the shocked hairs will after a few months, regrow and contribute to the hairs present on top. But a lot of the more vulnerable hairs, especially the wispier ones on their last life-cycle, will not return. For many years we used multi-follicular unit small slit grafts in the center and follicular unit grafts all around. This gives a wonderful hair density result, but I am presently trying to determine if the larger slits in the middle have anything to do with the 30-40% incidence of shocking, and so we are now taking a two year period in which we are going to transplant most of our females with 2000-2500 follicular units, using a dense packed stick-and-place method in the front center for “instant density” there, and we will see if the density results and perhaps reduced incidence of shocking comes about. If not, I would return to my former way of transplanting, as it is more economical for the patient and gives very predictable hair density results. The good news is that as early as 5-6 months after the hair restoration procedure, the area transplanted has the strong donor hairs from the occipital area growing and appearing filled in.
Paradoxically, I find that the women who are very early in their hair loss and don’t actually appear that bad are the ones who are most sensitive to shocking and are much more distressed when it happens. The women with moderate to severe hair loss are almost always happy they went through with it, especially at the 15 month point after the second hair transplant session.
Mike Beehner, M.D.
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Bill
Associate Publisher of the Hair Transplant Network and the Hair Loss Learning Center
View my Hair Loss Weblog
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