However, in men still in their twenties and early thirties, the extent of possible further hair loss can be difficult to predict. Most men have enough donor hair, even into their sixties and beyond, to surgically treat at least the frontal scalp, which is the most important area cosmetically for maintaining the appearance of their actual age. Once the frame of the face is lost, the patient can look 5–10 years older than their apparent age. Since minoxidil and finasteride work best in the younger men with early ongoing hair loss and work best in the vertex regions, which is just the area where the physician should not place grafts, it is a good marriage of surgery and medication. Perform transplants to the frontal scalp and use medications to maintain vertex hair until such time that the front is fully transplanted and /or the thinning pattern is clearly established and it is safe to commit to a portion of the vertex.

The medical treatment of FPHL can also include the use of antiandrogens [14, 15] especially in women with documented elevation of male hormones. Spironolactone, at doses of 100–200 mg/day, has weak antiandrogenic properties that has been used with varying degrees of success to slow down the progression of FPHL. However, there can be the possibility of menstrual irregularities, hyperkalemia, and feminization of a male fetus requiring the necessity of ongoing monitoring and contraceptive measures. Other antiandrogens that have been tried include cyproterone acetate, estrogen and cimetidine. A study by Tosti [16], following premenopausal women with FPHL taking higher dosages of finasteride, 2.5 mg daily in combination with an oral contraceptive, showed that 62% of the group studied had improvement over their hair loss.

Women are also found, much more commonly than men, to have low serum iron and/or serum ferritin levels. It has been shown that improving a low ferritin level with an iron replacement such as ferrous gluconate can improve the benefits of daily minoxidil use and improve hair growth [17]. Additionally, vitamin supplements including biotin and folic acid may help.

13.5 Nonmedical Treatments

Low-level light lasers are being used to stimulate hair growth for MPB and FPHL and have been given approval by the FDA as being a safe device [18]. Currently, more third party studies need to be done in

order to show accurate efficacy. However, lasers are beginning to receive more widespread use as an adjunct treatment to surgery and medications for hair loss.

To aid in minimizing the contrast of thinning hair against a pale scalp and to give the appearance of fuller hair, camouflage agents can be used to good affect if there is still hair left in the thinning area. Colored hair sprays (ProTHIK: Aquila International Ltd), colored lotions (COUVRe: Spencer Forrest, Inc), fibers (Toppik: Spencer Forrest, Inc), and powders (DermMatch: DermMatch, Inc) are all available to men and women to achieve the visual impact of more scalp hair.

13.6 Preoperative Consultation

The consultation is the time when the physician determines if the patient is suitable for hair transplantation both physically and mentally. Extra time taken at the consultation is time well spent to determine if the patient’s expectations are appropriate. The young male and female patients are especially prone to having inappropriate expectations that the physician must determine and decide if they can be reset or decide if the patient is not appropriate for surgery at all.

The following are important items to be covered at the consultation:

1.History and physical: It is important to know the length of time that hair loss has occurred, patient’s age, family history of hair loss, medications that can contribute to hair loss, past and present illnesses, and allergies. The physician needs to make an educated guess as to the future potential thinning and possible worst case scenario. It is important that the patient be educated on not only what may be required now but also what might be required in the future.

2.Once MPB/FPHL is diagnosed, a full explanation of treatment options and adjuncts to hair restoration should be given. Proper medical therapy with minoxidil and finasteride to enhance surgery and maintain hair for a longer period of time should be stressed and incorporated into your treatment plan if possible.

3.For all patients, it is important to know the specific area the patient wants treated and what the physician assesses should be treated. For MPB, draw

a hairline on the scalp with a grease pencil for a focus of discussion. Generally speaking, for a younger male with MPB, concentrate on the frontal scalp only.

4.Photographs with any lines drawn on the scalp to indicate where grafts will be positioned should be taken at the time of consultation or immediately before surgery. Photographs can be invaluable at a later time when assessing the success of a transplant. Patients often forget what they looked like with hair loss and sometimes photos are your chief tool to convince the patient of a successful outcome.

5.Set the expectations of the potential short-term and long-term outcomes: If the patient has early thinning then one session may be appropriate, but as ongoing thinning of the preexisting hair occurs, a second and eventually a third session may be required. If there is complete baldness then stress the need for possibly up to three sessions depending on the density desired. It is essential that at consultation the potential need for further sessions in the future be discussed. Unlike many other cosmetic surgeries, hair restoration patients tend to have a long relationship with their physician often spanning decades. The physician should be cognoscente that what they say one day about the degree of hair loss and the number of sessions and grafts required could come back up for discussion years later.

6.The patient should understand that the end result will never achieve the density the patient had before the onset of thinning. In an otherwise bald area the result achieved can be that of early thinning.

7.Stress that different hair types and hair colors and scalp colors can lead to varying results. Hair characteristics should be assessed and documented. Patients with fine, wavy, salt and pepper hair with a lot of body and a lighter scalp will have a fuller look than patients with straight, black, thin, coarse hair, and a pale scalp.

8.Assess the density and amount of hair available in the donor area compared to the eventual size of the balding area and relay this information to the patient.

9.Emphasize that the limiting factor in hair restoration is the amount of permanent, limited, donor hair available.

10.The donor scar will be camouflaged as long as the hair in the donor region is not shaved off the scalp. There is a limitation as to how short the hair can be.

11.Go over the timing of important stages after a transplant: The crusts/scabs on each graft will have fallen off by 10–12 days. Patients are warned to expect that every hair in each transplanted graft will be shed and start to grow by 3 months. At 6 months there is a cosmetic benefit, but full maturity is not appreciated till after 12 months.

12.There can be significant postoperative effluvium of preexisting hair, primarily in women.

13. Have many representative photographs of your patients available for patients to see and discuss with you.

14. A thorough discussion of the complications and potential side effects must be provided and understood.

13.7 Female Considerations

Females that present with scalp hair loss often present with more complex assessment issues. FPHL, due to the generalized nature of thinning with maintenance of the frontal hairline, can be more of a diagnostic challenge [14]. The history and physical play a much more important role compared to their male counterpart. The chief causes for generalized hair loss that can mimic FPHL include acute telogen effluvium and less commonly chronic telogen effluvium and generalized alopecia areata. Acute telogen can occur from such things as child birth, high fever, general anesthetics, certain medications, rapid weight loss, and thyroid imbalances. It is important to determine the exact time of onset of the hair loss. Low ferritin/or iron levels, in addition to contributing to FPHL, can also contribute to telogen effluvium. Chronic telogen effluvium, usually presenting with no specific trigger, occurs usually in the 40–50 year-old age group. At the consultation, the physician should be looking for signs and symptoms of a testosterone excess syndrome that could be quickening or contributing to FPHL. Blood tests routinely indicated for women include a complete blood count, free thyroxine, serum thyroid stimulating hormone, serum iron, and serum ferritin. If there is a suspicion of testosterone excess, (lowering of the voice, rapid hair loss in the frontotemporal recessions, hirsutism, acne, and menstrual irregularities), then referral to a gynecologist or endocrinologist for appropriate workup are suggested. In addition to a hair pull test,