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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