a biopsy is often indicated to help differentiate FPHL from telogen effluvium, alopecia areata, or scarring inflammatory disorders. It is suggested when performing biopsies to do two 4 mm diameter biopsies and request for horizontal sectioning.

Just as important as making the diagnosis of FPHL is determining if the patient is suitable for transplantation and if their expectations are appropriate. Psychological studies have shown that women are much more upset by their hair loss [19]. Men can be satisfied with a thinning look from a frontal scalp transplant and may not desire to transplant the crown at all. Women may not be satisfied with any appearance of thinning at all. Additionally, since typical FPHL is that of generalized thinning and not total loss, once transplanted, there is less of a relative impact or change, when compared to adding hair to a bald male. It is much more important for the physician to take the extra time to assess and set the expectations with women. The physician needs to assess the extent of generalized thinning which can include the occipital potential donor region. Often the thinning area is too large, with too small a potential donor region. If transplantation is to be considered then it is better to settle with making a small area, such as just behind the frontal hairline, discretely thicker. Emphasize that there will still be some degree of seethrough to the scalp after treatment, but to a lesser degree. The female patient should be forewarned of the greater risk of postoperative telogen effluvium and the potential benefit of pretreating with minoxidil to help minimize this occurrence.

HIV, a complete blood count, and clotting profile. To minimize the chance of bleeding, patients are told to stop anticoagulants, alcohol, and acetylsalicylic acid products 1 week prior to surgery. Additionally, vitamin E. products and ginkgo biloba should also be stopped. If using minoxidil solution, do not apply an application on the day of surgery to minimize the vasodilatation effect on the local microvasculature. On the day of surgery some physicians advocate an antistaphylococcal antibiotic given 1 h preoperatively. Half an hour prior to surgery a mild tranquilizer or sedative, such as 10 mg p.o. valium or 1–2 mg sl ativan, can be given. At the time of the consultation if there is any indication of a preexisting medical risk, then consent for surgery from either the family doctor or cardiologist should first be obtained. The author suggests that an anesthetist be present for any patient that may have a preexisting medical risk or when intravenous sedation is required.

13.9 Surgical Planning

Hairline design and placement is of critical importance to the successful esthetic outcome of a hair transplant. It is one of the most difficult aspects of the procedure to master, and consequently the area where the most errors are made. The reader is referred to other sources for a thorough treatment of hairline planning [20–23]; however, certain principles should be described.

13.8 Preoperative Instructions

At the time of the initial consultation it is a good idea to advise the patient that they may require up to 1 week off work (Table 13.2). Up to 20% of patients may experience some degree of postoperative forehead swelling and / or facial edema. This can start 2–3 days after surgery and continue for another 2–3 days. Patients are also advised not to play any sports or perform any heavy physical exercise for 1 week postoperatively. The patient should also be warned about the potential visibility of the scabs in the recipient area. The patient is advised to keep the donor hair long enough to easily camouflage the sutures. Blood tests are to be ordered to include hepatitis B, hepatitis C,

13.9.1 Men with MPB

It is important to remember when planning a hairline in men that thinning is ongoing throughout life, and that there is a finite amount of hair available from the permanent donor fringe. There may not be enough hair to transplant both the frontal and crown regions. As such, for most men with MPB, it is generally prudent to treat the front one-third to half of the scalp and not treat the crown at all. Another option is to wait until such time as the front is completed before deciding if the patient is concerned with the crown and if there is adequate hair left to treat that area. It is also important to impress upon the patient with early

thinning, that even though one session may thicken and treat nicely the frontal scalp for now, a second and possibly third session may ultimately be required as thinning progresses, to yield the density that can be achieved with transplantation.

The scalp can be divided into several important zones (Fig. 13.5), with the three potentially treatable areas being the frontal region, mid-scalp, and vertex (crown).

When recreating a frontal hairline, a line is drawn from the midline anterior most point, or mid-frontal point (MFP). This point usually is placed 7– 11 cm

Frontotemporal corner (apex)

above the midglabellar line, at approximately where the forehead transitions from being vertical to sloping gradually posteriorly (Fig. 13.6). It is best to choose the MFP as superior as is acceptable to both patient and physician. A difficulty that can arise when, typically with the younger male, there is a strong remnant of the immature hairline present as a teenager, which can be as low as 4–6 cm above the midglabellar line. It can be very difficult for the patient to understand why the surgeon is placing a hairline 3 cm to even 6 cm higher than where the patient thinks it should be. This is a chief reason why many physicians wait till a patient is above 25 years of age to start surgery, when the patient is more mature, with better expectations, and the eventual thinning pattern becomes more evident. A curved line is then drawn from the MFP superiorly and laterally to the apex, the highest point of the frontotemporal recessions. As a guide, an imaginary line can be drawn vertically from the lateral epicanthus. The apex is placed at, or medial to, where this line intersects with a line drawn from the MFP. If the apex is placed too low or lateral, and as a consequence the frontotemporal recessions are filled in, this can lead to an unnatural appearance. Continue the line from the apex posteriorly, keeping

Fig. 13.5 Major zones and landmarks. The three transplantable zones are the frontal region, mid-scalp, and vertex. The midfrontal point (MFP) is the lowest anterior mid-point of the frontal hairline. The frontal hairline meets the temple at the apex (frontotemporal junction). The vertex transition point is where the horizontal scalp changes to the vertical, and is often the positioning of a posterior hairline when not committing to crown transplantation (Reprinted with permission from Berg and Cotterill [24]. Copyright Elsevier Limited 2009)

Fig. 13.6 The frontal hairline is designed by placing the MFP 7–11 cm above an imaginary line drawn horizontally across the glabella. A curved line is drawn from the MFP to meet with a line drawn vertically from the epicanthus, at the highest most point of the frontotemporal recession (apex) (Reprinted with permission from Berg and Cotterill [24]. Copyright Elsevier Limited 2009)

the line horizontal with the ground to define the part. A common mistake is to not identify lateral fringe areas of ongoing thinning. It is best to place some, “insurance” hair in the triangles for when the patient goes on to more advanced thinning, keeping in mind that eventual thinning in the parietal region usually ends up in a line often horizontal with the ground (Fig. 13.7).

In some patients, thinning progresses inferiorly into the temporoparietal fringe and recedes. A lateral hump can be created by incorporating the apex with the newly designed lateral hump (Fig. 13.8). The posterior

Fig. 13.7 Line CA indicates where transplants are often finished, without anticipating where future hair loss may extend to. Insurance hair should be placed to line CB so that the physician does not need to keep chasing an advancing, thinning triangle of continuing hair loss

border of the frontal region and mid-scalp region is finished frequently in a curved fashion to re-create a natural appearing posterior hairline when viewed from the back of the patient. When transplanting the frontal and mid-scalp regions the mid-portion of the posterior hairline should not go further than the vertex transition point (VTP). This is the point where the horizontal scalp changes to the vertical (Fig. 13.5). Beyond that point the hair direction begins to change as the hair in the crown begins to form a whorl from where the hair radiates out in a 360° pattern. The appearance of a head of hair, when viewed from the front of the patient is achieved if adequate transplantation is performed to the VTP. After that point any additional hair is not appreciated from the front.

There are a variety of hairline placement patterns depending on the age of the patient, nationality, extent of present and possible further thinning hair loss patterns and expectations. For the very bald or very young patient who may become very bald in the future, an isolated frontal forelock can be planned [25]. This is one of the safest ways to achieve a conservative hairline when there is the concern of present or future extreme limitations in the amount of donor hair relative to a significant balding area. Figure 13.9 demonstrates a frontal forelock in a young male that may go onto extensive hair loss in the future. There is the creation of a natural hairline pattern with an island of central density being created in the middle with less

Fig. 13.8 Creating a lateral hump in a lowered temporoparietal fringe allows the frontal hairline to be kept in a natural alignment

Fig. 13.9 Creation of a frontal forelock in a young male that may go on to extensive balding. The central oval zone is planted most densely with less density toward the fringe. This pattern is meant to stand on its own even if there is significant balding in the future