HAIR TRANSPLANTING IN WOMEN Walter Unger
Female Pattern Hair Loss (FPHL) is far more common than is generally recognized by
physicians—including many dermatologists. There are three recognized general patterns of FPHL:
A caudal and centrifugal pattern described by Ludwig in which hair in the hairline is maintained,
though it may thin to varying degrees. In Venning’s and Dawber’s study of 564 women, 87% of
pre-menopausal women showed some degree of this pattern of hair loss.1
A “male” pattern of fronto-parietal loss. In his study of 214 women, Hamilton found that 79%
had at least Hamilton Type II MPB after puberty, while Type IV MPB occurred in 25% by age 50 years and 50% by age 60 years.2 Venning and Dawber found lower percentages in their larger
study, but even they reported Norwood-Hamilton Types II-IV MPB in 13% of their pre-
menopausal women and 37% of their post-menopausal women.
A “Christmas tree” pattern of loss, described by Olsen, which begins as a “widened part” but
evolves into a zone of hair loss that is widest anteriorly at the hairline and gradually narrows, with ragged borders, more posteriorly.3 In her study of 163 women “with obvious but not
severe patterned alopecia”, she found this pattern in 70% of them and believes it is more
common than Ludwig’s. (I agree with her.) Common to all of these patterns is the frequent
presence of small lacunae of total alopecia that are scattered in the areas of diffuse thinning.
These were first noted by the author in 1987 4 and their significance will be elaborated on later.
Thus, based on the above studies, if a woman looks for signs of thinning hair — and many women with a family history of female hair loss will be particularly alert for such a
development—approximately 80% of pre-menopausal women will find it! Furthermore, post-
menopausal women will not only find signs of hair loss but also will find it more frequently and
easily, or notice it without even trying to find it. Women presenting with FPHL should always be
screened with an appropriate history and physical examination. If there are any signs and/or
symptoms suggestive of a dermatologic or systemic cause, the patient should obviously be investigated appropriately or referred to someone for this purpose.
Modern hair transplanting techniques allow me to help a majority of the women I see in
consultation with FPHL.5, 6 The reasons for this are:
If one does not take donor strips that are too wide, and therefore avoids closing under tension,
a single fine scar is the usual result. If one also excises the scar from previous sessions as a component of all new donor strips, only a single fine scar is present in the donor area,
regardless of the number of sessions that are carried out. In the average patient that I see, two
to four sessions of 8 to 10 mm wide strips can be excised, with very little or no noticeable
thinning of the occipito-parietal areas. (Temporal areas are never harvested in females.) Thus,
there is no obvious cosmetic “price” to be paid in the donor area for the removal of this hair.
In the recipient area, I primarily use Follicular Units (FUs) and Double Follicular Units (DFUs) that are inserted into small incisions that are made between the existing hairs. If those incisions
are made at the correct angle and direction, no existing hair is excised or permanently
damaged. Therefore, there is always an increase of hair in the recipient site at no apparent
decrease of hair density in the donor area. One of the most important aspects of the latter
qualification—going at the correct direction and angle when recipient sites are being made—is that one must go slowly enough to discern hair direction and angle at each stage of the
procedure. This involves parting the hair many times, combing it this way and that, to get a
sense of the way the hair wants to fall and following those directions and angles. Typically, for
example, I will spend between 45 minutes and 75 minutes making 900 to 1000 sites in a hair-
bearing area. The need to go slowly and carefully cannot be over-emphasized. If your experience with transplanting into hair-bearing areas has been more negative than mine, I
believe you should reconsider the speed at which you are making your sites and perhaps your
results will be different. As with all skills, part of the results, of course, are related to innate
talent and part to experience and effort, but whether you have talent and experience or not,
unless you go slowly enough these advantages will be wasted. The small lacunae of atrichia, that have been noted earlier, are treated by excising them with an appropriately sized punch.
The sites are then filled with grafts that are usually 1.5 to 2.5 mm and that contain two to three
FUs. More details on the technique used to treat female patients can be found in two
The expectations of female patients must also be managed carefully. It is important to
emphasize that the goal is “thicker” hair not “thick” hair. Sometimes one can produce the appearance of great density, but this is unusual. On the other hand, a cosmetically significant
thickening can be anticipated. Secondly, it is important to advise the patient that because of a
limited donor area, only cosmetically more important areas can be treated. Increased hair
density in those areas, subsequent to transplanting, can then be used as part of styling that will
create the illusion of denser hair in areas that were not treated. Rather fortunately, women have far more options with regard to hairstyling than men and therefore the limitations noted above
can be better managed in women than in men.
It is very important to take many photographs pre-operatively, both with the hair dry and wet and
also with the hair parted in different ways to show the areas of thinning clearly and the areas
that you are going to treat. If your transplanting is good, it will be very difficult to demonstrate
to the patient the hair growing from the grafts postoperatively and these photographs will be reassuring both to you and your patient, making recriminations less likely.
There are several aspects of hair transplanting that present more problems in women than men
in addition to the limited donor areas that are available.
telogen/anagen effluvium both in the recipient area and the donor area is far more common in
females than in males. Patients should be strongly warned of this before surgery. Approximately
40 to 50% of my female patients experience telogen/anagen effluvium. During the consultation they are told that if they are not prepared to take the chance on this happening that they should
not proceed with surgery. At the same time, I reassure them that the hair loss is temporary loss
and if limited areas are treated, quite often one can use surrounding hairs to camouflage the
areas of effluvium until the hair grows back. One can also use a variety of products such as
Toppik to color the scalp until the hair grows back, thereby minimizing the cosmetic problem. Such agents can be used beginning approximately two weeks after surgery—which is usually
before the effluvium occurs. Applying a 3% solution of minoxidil twice daily for one week before
surgery and five weeks postoperatively also appears to decrease the incidence and severity of
When one is using Follicular Unit Transplanting (FUT), a density of 20 to 25 FUs/cm2 is the
maximum that I employ. My worst case of effluvium occurred in a female in whom I tried 30 to 35 FUs/cm2. I believe that many of the FU proponents who have had problems with
transplanting in hair-bearing areas, and in particular in women, may be having those problems
During the consultation it is important to stress that although most of the hair is growing three
months after surgery, it is usually five to six months before you really start to appreciate any improvement and one year before full results are seen. Often the cosmetic improvement begins
prior to five or six months after surgery, but if patients are being forewarned that it will be five or
six months before results are seen, they are less likely to become worried. Ideally, transplanting
should not be repeated in the same areas until at least 12 months after surgery, so that full
results can be properly evaluated. This may obviate the need for doing additional transplanting in those areas, thus leaving more grafts in reserve for treating other areas that either require it at
that time or may require it at a later date.
A growing number of my patients are women with FPHL. In my experience, most women inquiring about hair transplanting are acceptable candidates because of modern hair
transplanting techniques. Most of them can have between two and four sessions carried out
with 8 to 10 mm wide strips being taken from the donor area on each occasion. If expectations
are managed properly, and patients are informed of all potential drawbacks in advance of the
surgery, a substantial majority of them is very satisfied with their results—as are their hairstylists.
The latter often become an important source for new patients. REFERENCES
1.Venning VA., Dawber RPR., Patterned androgenetic alopecia in women. J Am Acad Dermatol, 18:1-73-7, 1988.
2.Hamilton JB. Patterned loss of hair in man: types and incidence. Ann NY Acad Sci, 53:708-
3.Olsen EA., Female Pattern Hair Loss. J Am Acad Dermatol, September 2001, part 2, 45: 2, 1-19.
4.Unger W., Hair Transplantation in Females. Hair Transplantation, Unger W., Nordstrom R.
(eds.) 2nd edition, Marcel Dekker Inc. New York 1987, p.299.
5. Unger W., Unger R., Hair Transplanting: An Important but Often Forgotten Treatment for Patterned Alopecia in Women, J Am Acad Dermatol, in press.
6.Unger W., Hair Transplanting in Women. Hair Transplantation, Unger W., Shapiro R., (eds.)
4th edition, Marcel Dekker Inc. New York 2003, Chapter 12, in press.
7.Uremia S., Umar SH., Li CH., Prevention of temporal alopecia following rhytidectomy: the
prophylactic use of minoxidil. A study of 60 patients. Dermatol Surg, 2002, Jan 28(1):66-74.
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