enhanced patient selection for alopecia-reducing surgery
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Enhanced patient selection for alopecia-reducing surgery

For any hair surgeon, evaluating his patient for alopecia related surgery is a tedious one. In order to effectively identify a patient for such a procedure, Dr. Brandy has put for a series of evaluation points based on which a patient can be recommended for surgical procedure. His system of evaluation is based on his many years of experience as a hair surgeon and highlights 20 points each of which is then scaled from 1-5. The total scores divided by 20 would give the final score. When the final score is more than 4, the patient is recommended for further hair loss procedures.

Let’s find out what each of the evaluation points have to suggest.

1. Age – Patients below 30 years are considered very poor candidates for hair transplant mainly because the extent of baldness cannot be predicted and in most cases the probability of increase in hair loss as the patient ages is very high. When patients under 30 yrs were subjected to hair transplant it was found that their scalp showed visible ugly scars due to further hair loss that could not be predicted during the hair transplant. Those in age group 30-35 yrs had similar reasons and are classified as below average. Patients in 35-40 yrs are considered average as some pattern of baldness has set in.
From 30 yrs onwards, the pattern of baldness can be evident considering the size of the hair shaft, pigmentation of the scalp, fraying of cuticle layer at the shaft region and splitting of hair ends. All these can be observed by wetting the hair and studying them under a microscope. But the best bet always is to wait and watch as the actual balding pattern may differ from person to person and also the balding may be delayed for several years than expected.

2. Donor fringe width – This is the amount of donor hair available to cover the balding areas. The donor area is considered here as the area just above the ear. So if the width of donor hair is less than 5 cm it is scored as very poor while a score of 10 cm is considered excellent. The measurements falling in the range of 5-10 cm is considered below average, average and above average accordingly.

3. Bald width – This is related to the donor fringe width. If the donor fringe width is narrow, then the bald width will be wide and vice versa. So lesser the bald width better results with hair transplant procedures. A bald width of 8 cm brings out the best results while one as large as 18 cm will obviously be poorer.

4. Donor fringe width and bald width ratio – The ratio of donor fringe width and bald width is found by multiplying donor fringe width by 2 and comparing it with bald width. A ratio of 1:2 is poor, 1:1 average and 2:1 excellent, with intermittent scores being below and above average.

5. Donor fringe width at middle of the head – Patients having a smaller donor fringe width at the middle of the head are more likely to have cosmetic problems when there is progress in the hair loss. Patients usually get an area of scalp without hair after the corrective surgery has been performed. Techniques such as transposition flaps are used to correct this fault. But a better evaluation can avoid unnecessary expenditure. Fringe width of less than 6 cm is very poor while that of above 12 cm is excellent in the 5 point scale.

6. Donor hair shaft diameter – The shaft diameter is a yard stick in predicting hair loss patterns. When studied under a microscope, the shaft size can be classified as fine, semi-fine, average, semi-coarse and coarse depending on the diameter size of the shaft. Fine hair obviously means early thinning down and poor quality while coarse hair relates to strong and late thinning. Also thicker shafts always result in more coverage as compared to thinner shafts which is why they are preferred by hair transplant surgeons.

7. Degree of curl – A person with curly hair is at an advantage because when he undergoes a hair transplant the hairs overlap to give more body and fullness to the final result. So a hair surgeon considers curly hair excellent for hair transplant and the points slope down proportionately with the extent of straightness of the hair. Patients with whisker type of hair are the most likely candidates for total baldness.

8. Hair density above the nuchal line – Hair density when studied under a microscope reveals the number of hairs present in a square cm area. Higher the number of hairs per square cm, better the final result.

9. Scalp laxity – After the surgery, the sutures area expands in some patients revealing ugly scars. This depends on the elasticity of the scalp and has nothing to do with the thickness or thinness of the scalp. This can be evaluated by pinching the scalp and running over the hand on the scalp in the region just above the ear. A hair surgeon can determine effectively the scalps laxity by experience. If the movement can be extended beyond 4 cm then the scalp is considered excellent and below 1 cm as poor.

10. Hair and skin color contrast – The authors experience is that light color skin matches with light color hair while dark skin goes well with dark hair. One of the most logical explanations for the above observation is the perception of the scalp after the hair transplant. A light skin with dark hair gives the feeling that the patient is still bald although he may not be. Hence a basic guideline proposed is black hair on white skin or white hair on black skin is a poor transplant cosmetically. Gray hair on white skin and black hair on black skin is the best. Shades of brown, blond read and pepper gray fall in the intermediate range. However, this depends largely on the patient’s race and his hair growth patterns.

11. Donor hair styling capability – After the hair transplant a patient must be able to comb his hair with partition as he had done before hair loss. So in order to find if the patient’s original styling would be retained after surgery, the author suggests parting the hair with a comb and study the fall of hair. If the partitioned hair holds in place then there are excellent chances of him retaining his styling pattern. Otherwise some corrective measures like transposition flaps have to be done.

12. Hair loss delineation – This is done by soaking the hair with water or alcohol and ruffling it. By doing so a hair surgeon can predict to a certain extent the probable pattern of hair loss. When the pattern is unpredictable, the patient may not be considered for hair transplant. When the pattern is detectable to a certain extent he is an average contender. But when the pattern has set in and is easily predicted, he is an excellent choice for hair transplant.

13. Nape hair density below the nuchal line – This evaluation is particularly useful when single scar technique procedure is followed. The hair density projects the visual appeal of the nape region. If the nape region has thin hair then less density nuchal region will make it look thinner. Ideally 225 hairs and above per square cm of area is considered excellent and below 75 hairs as poor.

14. Nape hair shaft diameter – The same criteria used in evaluating donor hair shaft diameter is employed here. The nape region always differs from person to person.

15. Periauricular space – This is the space between the ear and the hair line. This criterion is very important while retaining the hairline. If the space is small well below 0.5 cm there is no need for additional coverage to retain normal hairline. But if the space is more than 2 cm, it becomes necessary to fill up the gaps to restore normalcy.

16. Healing potential – If the patient has had any other surgery prior to hair transplant, the scars are studied for healing patterns. If the scar is more than 5 mm thick then he patient is a poor candidate for healing. Patients with less than 1 mm scar are the best and fast healing ones. Otherwise age is the main factor for consideration. Younger patient always heal with wider scars.

17. Expectations – It is obvious that a patient undergoing hair transplant will be anxious to know what the final outcome would be. The hair surgeon explains the possibilities and what he can deliver under the given circumstances. Depending on the reactions from the patient, a hair surgeon can expect a certain kind of co-operation from his patient. A highly realistic patient who understands the procedural advantageous and disadvantageous is an excellent candidate to work with.

18. Emotional stability – To find out the emotional well being of a patient, a psychology test called the surgeons insight test is carried out. The cosmetic procedures largely depend on the emotional well being of a patient both before and after the transplants. The success and failure rates depend on this aspect too.

19. Understanding – When a doctor explains the facts to the patient, he must be in a position to understand the outcome of the transplant. If he does not, it is a waste to help such patients because however good the surgeon might have performed his task, there is always an element of doubt that it could have been performed better.

20. Motivation – A patient should have the determination to go through the complete procedure given to understand the time and different procedures he may have to undergo. Patients who hint at feelings such as their life may turn better over night are not suitable according to Dr. Brandy for any of the cosmetic surgeries.

In the author’s opinion, this 20 point evaluation may come handy to hair transplant surgeons in minimizing the number of patients treated for alopecia and obtain consistently excellent results.


Enhanced patient selection for alopecia-reducing surgery references

  • Brandy DA. An evaluation system to enhance patient selection for alopecia-reducing surgery. Dermatol Surg. 2002 Sep;28(9):808-16. PMID: 12269874
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