combining medical and surgical treatments
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Combining medical and surgical treatments

Androgenetic alopecia known as male pattern baldness is caused due to thinning of hair follicles eventually resulting in its fall out. This is genetically inherited and affects men predominantly and a few women in the age group of 18-40. In this condition the male hormone testosterone is converted by the enzyme 5-alpha reductase into dihydrotestosterone which is absorbed by the hair follicles resulting in thinning of hair and eventually its loss.

The enzyme 5 alpha reductase is seen in different amounts in the scalp. In younger patients with pattern baldness, the amount of 5 alpha reductase and the androgen receptor sites are more in the front or fore lock region as compared to the back of the head. And another enzyme called cytochrome P450 aromatase is seen to be less in the fore lock region. The growth pattern of the transplanted hair depends on the presence or absence of these enzymes in the scalp.

Pattern baldness is classified as Hamilton – Norwood types ranging from Type I to VIII for men and Ludwig type ranging from type I to IV for women based mainly on the pattern of hair loss and its progression. Both these classification are being extensively used for determining balding patterns. There is another classification called as the dynamic multifactorial classification which evaluates a patient for size of balding areas, thickness and laxity of the scalp, hair parameters such as density, thickness of shaft and hair, color and growth patterns. This classification is an integrated approach and is helpful in evaluating patients individually for further procedures.

In the recent years, medication has been suggested for alleviating early onset of hair loss. Two most useful medicines have been finasteride and minoxidil. Men are prescribed 1 mg finasteride daily for ingestion while 2-5 % minoxidil is prescribed for external application. Women are administered 2% minoxidil and finasteride is not prescribed. Use of these two medicines in combination or separately have resulted in hair stabilization within a month and regrowth of hairs within 2-3 months. Within a year, most patients regained their scalp coverage. These medicines are to be used only when the hairs have thinned or started thinning. No effects were seen in totally bald areas. Also the treatment has to be continuous in order that the hairs remain in active growth phase. When they are discontinued, the thinning patterns set in within 6 months to a year.

When medication is not feasible, the next best alternative is to go in for hair transplant. Minimicrografts or follicular unit transplants are the best methods used in the recent years. It is a 5 step procedure involving expertise.

1. The patient is screened for all scalp and hair related parameters.
2. Local anesthesia is given to numb all nerve endings to minimize pain.
3. Donor hair is obtained from the back of the head and the area sutured with absorbable sutures to minimize scarring.
4. The donor hair is sectioned into follicular unit grafts for transplantation.
5. Keeping in mind the orientation of the hairs in each of the transplantable areas, the follicular unit grafts are inserted in small incisions all over the bald scalp using a jeweler’s forceps.

About 3000 such grafts can be planted in one sitting and the aesthetics of the fore lock region maintained using finer hairs to create the original hair line. Ideally a patient who has undergone this procedure is able to resume his normal activities 24 - 48 hours after the procedure. The transplanted hairs experience a fall out 15 days after the transplant but hair growth resumes normally 2- 4 months later.

The patients have to be evaluated before the hair transplant procedure for age, emotional stability, and alternate methods such as use of finasteride and minoxidil and ethnic background. All these are to be considered for optimum results and to the satisfaction of the individual involved. Most often patients are subjected to a combination of both medication and small range minimicrografts and this combination therapy seems to work better than the most recently evolving laser therapy.

Combining medical and surgical treatments references

  • Bouhanna P. Androgenetic alopecia: combining medical and surgical treatments. Dermatol Surg. 2003 Nov;29(11):1130-4. PMID: 14641340
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