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Surgical Treatments for Hair Loss

Surgical treatments for hair loss are all procedures that move active, hair-producing follicles from one site on the scalp to another site where follicles are inactive or minimally active. The surgical procedures for hair restoration are:

  • Hair transplantation
  • Alopecia reduction plus scalp extension (Frechet extension)
  • Scalp expansion (also called scalp extension)
  • Hair-bearing flap transfer

Hair Transplantation
Surgical restoration of scalp hair by means of hair transplantation has been available as a hair loss treatment for more than 50 years. The first attempts to transfer scalp hair were made more than 150 years ago; surgical technology was not far enough advanced to follow up on these first experiments.

The beginnings of hair transplantation in the U.S. in modern times were the successful procedures carried out by Dr. Norman Orentreich in the 1950s. Dr. Orentreich, a dermatologist, is credited as the originator of successful hair transplantation. Over following decades hair transplantation techniques were refined, resulting in improved results and decreased risk for complications. Japanese surgeons first accomplished successful hair transplantation in the 1930s, but their work was not widely known outside of Japan.

In its first years of development, success in hair transplantation was judged by success in restoring hair coverage to areas of hair loss. Surgical techniques emphasized removing "plugs" of hair-bearing tissue from a donor area on the scalp to a recipient area. Cosmetic results were often relatively crude by today's standards; the hair transplants of 50 years ago were often described as having a "pluggy" look.

Hair transplantation today stresses the "natural" look. The goal of the hair transplant surgeon and the patient is to achieve an outcome that has the cosmetic appearance and texture of "natural" non-transplanted hair. This result is usually achievable due to better understanding of scalp and hair biology, refined surgical techniques, and ever-improving surgical instruments.

Key to achievement of natural-appearing results is the size of the grafts placed in the recipient sites. The plug graft of past decades often contained from 5 and up to 15 hair follicles. Today, the transplant surgeon works with mini-grafts of 3 to 5 hair follicles, micro-grafts of 2 or 3 follicles, single-hair grafts, and follicular unit grafts. The smaller grafts permit more refined surgical artistry in creating natural hair density and natural-ness in cosmetically sensitive areas such as the hairline.

The follicular unit graft-a recent surgical development-is the outcome of anatomical research that revealed the pattern of hair follicle growth on the scalp. The research found that scalp hair follicles do not grow evenly across the scalp like wheat in a wheat field, but rather in clumps of 1 to 5 follicles that grow like islands in a sea.

For extensive and detailed information about hair transplantation techniques, procedures, outcomes, risks for complications, and postoperative recovery, visit the ISHRS website under Surgical Hair Restoration for Hair Loss.

Alopecia Reduction
The goal of alopecia reduction is to surgically remove "bald" scalp skin in areas of hair loss, and pull adjoining hair-bearing scalp skin together to close the wound and eliminate the bald spot. Alopecia reduction is sometimes combined with hair transplantation and medical hair restoration to achieve an optimal cosmetic outcome. The selection of alopecia reduction as a hair restoration procedure is based on factors that include extent of hair loss, likelihood of continued and progressive hair loss, physical characteristics of the patient's scalp, wishes of the patient for cosmetic result, and risk for complications.

Scalp Expansion and Alopecia Reduction
Scalp expansion is a technical modification of alopecia reduction. A balloon-type device is placed under the scalp and slowly inflated or expanded over a period of several weeks to create a "dome" or "bubble" of stretched scalp skin. A series of surgical procedures is then performed to (1) reduce the area of hair loss by alopecia reduction surgery, (2) perform any necessary ancillary procedures to achieve complete alopecia reduction, (3) remove the scalp expansion device, and (4) complete closure of hair-bearing scalp to achieve complete alopecia reduction. Selection of scalp expansion as a hair restoration procedure requires consideration of the same factors as for alopecia reduction.

Scalp Flap Transfer
Flap procedures are used in both cosmetic and reconstructive surgery. In reconstructive surgery, flaps of skin and underlying tissues are used to correct defects caused by trauma or by congenital anomalies. In cosmetic surgery, flaps are used to achieve a cosmetic result when this surgical approach is most likely to achieve the optimal result.

In treatment of hair loss, a flap of hair-bearing scalp tissue is surgically raised from underlying tissue and transferred to a hair-loss site that has been prepared to receive it. The survival of the transferred flap is dependent upon the vitality of the flap's continued connection to arteriovenous blood supply and nerves. The flap may have an attached pedicle of tissue that connects the flap to its blood and nerve supply. A "free flap" is cut loose from its blood and nerve supply, and reattached by microscopic surgery to blood vessels and nerves at the recipient site.

The success of hair transplantation in achieving natural-appearing results has made it the most widely used surgical procedure for hair restoration. Flap procedures and alopecia reduction are used less frequently, but for some patients they may achieve the most desirable results.

Find additional and detailed information about surgical hair restoration, visit the ISHRS website under Surgical Hair Restoration for Hair Loss.