Female hair fall cause, Medical treatment & Hair Transplant. Tips for female hair Transplant

1. Female Hair Transplant
Dr Sumit Agrawal
Plastic, Cosmetic & Hair Transplant Surgeon
HARLEYS CLINIC, Mumbai
Zulekha Hospital, DUBAI

2. Causes of Hair loss
• Androgenetic alopecia (FPHL) is the most common cause of permanent hair
loss in women as it is in men.
Other common causes :
• Alopecia areata
• Telogen effluvium (acute /Chronic)- unusually accelerated hair loss that
may have hormonal, nutritional, drug-associated or stress-associated
causes.
• Traction alopecia- as may occur with tight braiding or corn-rowing of hair.
• Post traumatic- burns/ stitches scar
• Trichotillomania
• Loose Anagen syndrome
• Scarring Alopecia- Frontal fibrosing Alopecia

3. Indications of Hair transplant
• Female pattern hair loss is the most frequent indication for hair
transplant in women.
• Non-pattern indications are Traction Alopecia ,post traumatic hair
loss, high forehead.

4. Female pattern Hair loss
• FPHL is a gradual onset, slowly progressive nonscarring alopecia,
which can be seen any time after menarche, but is most common in
females after the age of 40 years.
• It results from a progressive reduction of Anagen phase in successive
hair cycle time leading to miniaturization of hair follicles.
• These changes are mediated through interaction between
androgens, their receptors and enzymes like 5a reductase and p450
aromatase.

5. Female Pattern Hair Loss (FPHL)
• Three different patterns of FPHL have been described.
1. Diffuse central thinning (Ludwig type)
2. Frontal accentuation (Olsen type)
3. Frontotemporal recession/vertex loss (male pattern/Hamilton type)

6. LUDWIG SCALE
• The diffuse hair loss is concentrated
over frontoparietal region leading to
thinning over central scalp with intact
frontal hair line .
• Ludwig graded it into three stages
depending upon whether the central
thinning is mild (stage I), moderate
(stage II), or severe, that is, near-
complete baldness of the crown (stage
III).

7. OLSEN SCALE
• Thinning and widening of the central part
of the scalp with breach of frontal
hairline, Chrismas-tree pattern.

8. Male pattern (Hamilton)
• It leads to recession of frontotemporal hairline
and/or thinning at vertex.

9. Etiology of FPHL
• 1.Genetic Predisposition,
• 2. Androgen excess,
• Ovarian cause- Polycystic ovarian syndrome
• - Other ovarian tumor
• 3. Adrenal cause - Congenital adrenal hyperplasia (androgenital
syndrome)
- Tumor Adrenal adenoma Carcinoma.

10. HISTORY
• Age of onset & progression
• Family History
• H/o diet pattern, weight loss, Iron deficiency anemia.
• Medical H/o Thyroid, AKT, Chemotherapy
• Enviromental factors like Smoking, Stress
• Gynaecological H/o- menstrual cycles, menopause, OCPs

11. GENERAL EXAMINATION
• Signs of Hyper androgenism like Hirsuitism, Acne, Acanthosis
nigricans
LOCAL EXAMINATION
• Presence of miniaturized/vellus hairs (short thin hairs <3 cm and a
shaft diameter of .03 mm) at the frontoparietal region
• Frontotemporal recession.

12. HAIR PULL TEST
• is usually negative.
• Shedding may or may not be present, and if present, is mild and
never profound as noticed in TE/CTE.
DERMOSCOPY
• Hair shaft diameter diversity(HDD) >20% has been reported to be an
early sign of female pattern hair loss.
• Peripilar halos and atrophy can also be seen during dermoscopy in a
few patients

13. HORMONAL SCREENING to rule out any underlying cause for
androgen excess
• free and total Testosterone
• DHEAS, LH, FSH
• T3, T4, TSH
• Prolactin
• Ultrasound for ovaries and adrenal glands

14. • SCALP BIOPSY reveals significant reduction of terminal to vellus hair
ratio. The T:V ratio is reduced from a normal of 8:1 to 3:1 in FPHL and
any ratio <4:1 is diagnostic of FPHL.
• Perifollicular infiltrate, fibroses, and follicular streamers may also be
seen.
• GLOBAL PHOTOGRAPHY

15. Medical Management
• Topical Minoxidil 2%
• Anti Androgens (cautious use in fertile age group)
Spironolactone 100-200mg
Finasteride 5mg
Flutamide
Oral Contraceptives
• Mutivitamins
• Ketoconazole shampoo

16. Hair Transplant in FPHL vs MPB
• Female pattern hair loss is less precisely defined compared to MPHL
& often difficult to differentiate from other entities such as CTE.
• Its multifactorial and many causes may coexist in same patient.
• FPHL is difficult to manage medically and future progression is
common.
• Underlying conditions such as PCOD, may ensure progression of the
disease.
• FPHL rarely causes total balding in localized area and causes diffuse
thinning.

17. • Individual Follicular units don’t disappear: Non uniform (1-2) hairs
within the unit decrease. making it technically difficult to plant grafts
between the hair.
• Shock loss is more common.
• Results are often more delayed
• Donor area is often not very gud.
• Trimming hairs in donor area is daunting for a woman.

18. Good Candidates
• Women having significant thinning
• Medical management has reached a plateau
• Compliant to continue medical treatment after Transplant
• Good donor area with long term potential
• Realistic expectations
• Post traumatic /Traction Alopecia
• Women with high hairline / wide forehead

19. Poor candidates
• Women with diffuse thinning including the Occipital area.
• Not compliant to Medical Treatment
• Unrealistic expectations
• Dysmorphophobia !

20. Counselling
• More then 1session of counselling
• Preferred hairstyle/ parting area
• Serial photographs
• Apprehensions about the pain
• Apprehensions about trimming the hair in Donor area

21. Shock Loss (Telogen effluvium)
• Post operative shock loss may happen 4-6 weeks after the procedure.
• The hair shedding is temporary and, they regrow around the same
time as transplanted hairs.
Before 3mo. Post op

22. Surgical planning
• Typical session is around 1500-2000 Grafts.
• Megasessions rarely required
• More tedious, so takes longer time
• Patience & precision are key

23. Donor area harvesting (FUE/ FUT)

24. Technical tips
• Pre made slits/ stick & place
• Coronal slits/ sagittal slits
• Limited use of Adrenaline !
• Wetting the hairs & separating them by comb is helpful.
• Anterior hair line is made of 1-2 hair grafts, while 2-3 hair units are
used in back.

25. Coverage Planning
• In diffuse pattern of hair loss,
grafting has to be prioritized in the
parting area and in the central
forelock, behind the hairline.
*Dr Samuel Lam

26. Female Hair line
• The low-positioned (compared with men)
and rounded female hairline frames the
female face and adds youth, beauty, and
femininity to a woman’s face.

27. Female vs Male hair line
• The hairline should be rounded downwards at the fronto temporal
corners.
• Hairline is relatively straight and has fewer ‘sentinel hairs’ that
protrude out.
• The hairs rotate from a point centered typically just off of midline on
one side and cascade obliquely down the temple area, known as
‘cowlick’
• There can be ‘lateral mounds’ which are small protrusions of hairline
in the outer portion of the hairline

28. Post operative care
• is quiet similar to that in Men
• Head bath after 3 days

29. Early (Stage 1) in young female
FUT(Strip) 1000 Grafts

30. Moderate(Stage 2) in 60yr+ female
FUE done 1200 Grafts
After
Before

31. Severe (Stage 3) in 60yr+ female
FUE 1500 Grafts
Before After

32. FrontoTemporal recession in a young female
FUE done 900 Grafts
Before After

33. Before After

34. Fronto temporal recession in young female
FUT (strip) done 1400 Grafts
Before After

35. After
Before

36. High Forehead in a 50yr+ female
FUE done 1400 Grafts
Before After

37. MTF Transgender
previous H/o Frontal hair line lowering surgery
FUT( Strip) 1100 Grafts
After
Before

38. Camouflage
• The psychological impact of FPHL may also be reduced by cosmetic
products (Concealers) that improve the appearance of the hair.
• These agents work to minimize hair fibre breakage, improve hair
volume or conceal visible bald scalp.
• Scalp Micro Pigmentation (SMP)

39. THANK YOU