A Hairloss Evaluation System to Enhance Patient Selection for Alopecia-Reducing Surgery

BACKGROUND. The author presents an evaluation system that helps optimize the chances of achieving good results with alopecia-reducing procedures.

METHODS. Twenty criteria are scrutinized by the hair restoration surgeon during the initial evaluation and given a score of one to five. The scores are added together and divided by 20. A patient with a score greater than four is considered a good candidate for alopecia reduction in most cases.

RESULTS. This evaluation method has significantly decreased the number of patients undergoing alopecia-reducing procedures while helping the author achieve consistently good results. CONCLUSION. An evaluation system is presented that helps determine who is a good candidate for alopecia reduction and who is a poor candidate. This selection technique has helped the author achieve more consistently good results by eliminating poor and borderline candidates.

IN RECENT years, some cosmetic hair restoration surgeons have written about their disillusionment with alopecia-reducing procedures,^1-3 (Figure 1). Indeed, some problems can and do develop from alopecia reductions. But before hair restoration surgeons accept all of these negative philosophies, it is extremely important to ponder in one's own mind whether lifting is truly a viable option. In my own practice, I have seen alopecia-reducing procedures be a godsend for properly chosen patients.

Figure 1. The four basic design types of alopecia reduction: A) midline reduction; B) Mercedes reduction C) paramedian reduction; and D) circumferential reduction

From my 21 years of experience performing every type of hair restoration procedure (ie, conventional punch grafting, mini-micrografting, follicular unit grafting, scalp reduction [undermining to the nuchal line], scalp lifting [undermining to the hairline of the nape], tissue expansion, scalp extension, and rotational flaps), I can tell the reader with full confidence that every procedure (from follicular unit grafting of the forelock to performing a full restoration with alopecia reduction) can result in unpleasant aesthetics. It is indeed a reality that most full-time hair restoration surgeons could easily write an extremely negative dissertation on every type of hair restoration procedure, each filled with unsightly photographs from beginning to end. This negative approach, however, does nothing to educate the reader about how to develop the judgment to prevent poor results.

I, for one, have made more misjudgments about alopecia-reducing procedures than I wish to admit. In the future I probably will continue to make errors, but the longer I practice, the fewer they become. This decline in judgmental errors is in part due to experience, but is also due to an evaluation system that I have developed to circumvent the potential problems that may develop from alopecia reduction. Because of this system, I now perform far fewer alopecia reduction procedures that I did years ago, but when the procedure is performed, the results are consistently excellent. This evaluation system consists of 20 criteria (Table 1), which can easily be incorporated into the hair restoration surgeon's practice and will most certainly help reduce the number of poor results that can occur from improper patient selection.

Table 1. An Evaluation System to Enhance Patient Selection for Alopecia Reducing Surgery.

To help the reader incorporate this evaluation system into his/her practice, I will scrutinize each category independently and discuss its relationship to obtaining a good result with scalp reductions. How I rate each category will also be discussed.

AGE

Younger patients will usually not appreciate a significant improvement in cosmesis because frank baldness has not yet set in.

Patients in this age group have been found, in our practice, to generally heal with wider hypertrophic scars. This observation was also made by Webster et al.,⁴ who felt that younger patients get more exuberant scars secondary to more active collagen synthesis.

It is more difficult to predict the extent of baldness. The baldness will probably be quite extensive in the future.

The expectations are extremely high.

Patients less than 30 years of age would therefore be evaluated as poor candidates for alopecia reduction. I would rate the age group 30-35 years as below average for the same reasons as mentioned above. Ages 35-45 years would be average. Ages 45-50 years are above average, and anyone more than 50 years old is considered excellent. It is my opinion that if the scalp is thoroughly soaked with alcohol on a patient more than 30 years of age, a fairly good idea of future hair loss can be determined if one vigorously searches for it. This is because even in the very early stages of pattern baldness, before the actual miniaturization of the hair follicle occurs, significant changes in the hair shaft are evident. These changes include a decreased shaft diameter, less pigment, a frayed cuticle layer of the hair shaft, and a tendency for the hair to split at its ends. These microscopic changes become more evident when the hair is wet, and in most patients more than 30 years of age, a line of demarcation starts to appear at the donor dominant fringe. If the surgeon is uncertain, he/she should assume that the progression is going to be slightly worse than predicted. Another approach is to "wait and see" how the hair loss evolves over the ensuing years, since there is a small subset of patients who start developing male pattern baldness later in life.

Poor <30 years of age
Below average 30-35 years of age
Average 36-45 years of age
Above average 46-50 years of age
Excellent >50 years of age

Donor Fringe Width (One Side Measured Superior to the Ear)
This category indicates the amount of donor hair available for alopecia reduction. The wider the donor fringe, the better the results with lifting procedures. As is well known, when one attempts to totally eliminate the baldness on a patient with very extensive baldness, there ensues a "parting of the Red Sea" effect (Figure 2C). This occurs because as one moves away from the midline, the hair gradually begins to point 90 degrees away from the sagittal suture. It therefore becomes obvious that an individual with 5 cm of donor fringe (measured immediately above the ear) will develop severe divergence at the midline if several alopecia reductions are performed. Because of this reality, a measurement of less than 5 cm of donor fringe would be scored as poor. The markers are as follows:

Poor <5 cm
Below average 5.0-5.9 cm
Average 6.0-7.9 cm
Above average 8.0-10.0 cm
Excellent >10.0 cm

Bald Width (Measured at Ear Level)
It is obvious that if the donor fringe is narrow, the bald width will be inversely wide. It has been my experience that if a patient has only 8 cm of baldness at the vertex, alopecia reduction will very effectively treat that problem with a minimal effect on hair direction. As this number increases, the chances of creating a diverging effect of the hair at the midline goes up proportionately.

Poor >18.0 cm
Below average 15.0-18.0 cm
Average 12.0-14.9 cm Above average 8.0-11.9 cm Excellent <8.0 cm

2X Donor Fringe Width:Bald Width Ratio (Measured at Ear Level)
Once the donor fringe and bald widths are determined, one can determine a donor fringe width:bald width ratio. The donor fringe width is multiplied by two and is compared to the bald width. From the information of the two previous categories, the following ratios can easily be determined and have, indeed, been found to be commensurate with the quality of the candidate:

Poor 1:2
Below average 1:1.5
Average 1:1
Above average 2:1.5
Excellent 2:1

Figure 2. A) Patient with extensive baldness before a circumferential scalp lift. B) After one circumferential scalp lift and before a scalp reduction. C) After the scalp reduction, the baldness is eliminated, however, there is a slot with hair divergence. A 7 cm long 3 cm wide transposition flap is scribed and later performed. Follicular units will be derived from the bottom triangular-shaped area of the excision and transplanted to the front. D) One transposition flap 3 months after the procedure. E) Same patient from the oblique view before a circumferential scalp lift. F) Same patient after a circumferential scalp lift and before a scalp reduction. G) After two alopecia-reducing procedures and two sessions of follicular unit grafting. Notice how the patient can part through intact scalp due to the lifting procedures.

Donor Fringe Width (Measured at the Midposterior Head)
Many extensively bald patients who present for hair restoration surgery will have relatively wide donor fringes above the ear, but small donor fringe widths at the midposterior head. This latter circumstance is not especially favorable because these patients will tend to form a slot with diverging hair at the back of the head after scalp reduction surgery. This statement has even been found to be true (although less severe) when the posterior scalp is significantly elevated 4-6 cm with scalp lifting (Figure 2A-C). There is, however, a saving grace. With the recent introduction of transposition flaps^5-7 for the correction of slot formation (Figure 3), one can easily change the diverging hair direction to normal very quickly, effectively, and aesthetically (Figure 2C-G). These flaps also place the scar on top of the head, where it is much less obvious. The crucial factor with these flaps is that they must be taken from an area where the surgeon feels relatively confident that future hair loss is not going to occur. In the worst-case scenario, if future hair loss does occur in the flap, follicular unit grafting can be performed into the thinning area. The rating system that I use to determine this characteristic of midposterior donor fringe width is as follows:

Poor <6.0 cm
Below 6.0-7.9 cm
Average 8.0-9.9 cm
Above average 10.0-12.0 cm
Excellent >12.0 cm

	Figure 3. A) Divergence of the hair after consecutive scalp reductions. B) Transposition flap scribed. C) After transposition, hair is in a natural direction.

Donor Hair Shaft Diameter (Above the Nuchal Line)
When one compares a patient with poor hair density and very thick hair shafts to an individual with poor hair density and very fine hair shafts, it should be apparent that the former would be able to undergo more scalp reductions before obvious thinning would occur. This relationship exists because thicker hair shafts afford more coverage than fine shafts, which in turn allows for more aggressive alopecia reduction. To scrutinize this characteristic, a 30X microscopic evaluation is performed to evaluate hair shaft diameter.

Poor Fine; less than 36 µm in diameter
Below average Semifine; 37-53 µm in diameter
Average Average coarseness; 54-70 V Lm in diameter
Above average Semicoarse; 71-84 µm in diameter
Excellent Coarse; >84 µm in diameter

Degree of Curl
The shape of the hair is an extremely important factor when evaluating patients for any type of restoration surgery. It is well known to those who perform this kind of surgery that patients with curly hair achieve some of the best results in hair restoration. This reality exists because of the fact that curly hair overlaps upon itself, in effect doubling the density. As the hair becomes straighter, this doubling effect goes down proportionately. It is also important to point out that when fine whisker hair is present in the areas of the nape and periauricular areas (Figure 4), a red flag should go up because these patients usually progress to a very extensive type of alopecia.

Poor Whisker
Below average Straight
Average Slight wave
Above average Strong wave
Excellent Curly

Figure 4. If whisker is present in the periauricular and nape areas, great caution should be used before engaging in scalp reduction surgery. Also notice the wide pericircular space. This is not a good characteristic prior to scalp reduction because the space will increase, causing a severe defect.

Hair Density (Above the Nuchal Line)
As previously stated, the greater the hair density, the more the scalp can be stretched without significantly affecting cosmesis. It should also be obvious that if the donor fringe is narrow and the scalp needs to be lifted a greater distance; the density will be decreased proportionately. This is just one example of why as many factors as possible should be evaluated before making a determination as to whether or not a patient is a candidate for alopecia reduction.

One can evaluate hair density above the nuchal ridge with the use of a 30X microscopic evaluation. After microscopic evaluation, the following numbers can be used as guidelines:

Poor <75 hairs/cm2
Below average 75-125 hairs/cm2
Average 126-175 hairs/cm2
Above average 176-225 hairs/cm2
Excellent >225 hairs/cm2

Scalp Laxity
When performing alopecia-reducing procedures, the degree of scalp laxity will always come into play. Although this factor is important, it has become less critical for the complete elimination of posterior baldness because of the advent of scalp extension and scalp expansion. It must, however, be carefully evaluated because of the "widening effect" that poor scalp laxity seems to exert on the final scar. Why there is a tendency for the scar to broaden on patients with tight scalp is unclear, but it is my opinion that it may be due to the reality that more tension is usually present at the wound edges upon surgical closure, and to the realization that the skin edges tend to not approximate well due to the stiffness of the tissues, even when the closure is under no tension. In order to determine whether or not good scalp laxity is present, I grasp the scalp at the donor fringes and move my hands medially as far as possible. I then measure the distance that my hands have traveled during the testing maneuver. Rippling of the scalp is not weighed into this equation because thin scalps tend to ripple more than thick scalps, which creates an illusion of greater scalp laxity. To help me determine what is good scalp laxity and what is not, the following guidelines have been formulated:

Poor Hands move <1.0 cm medially on testing
Below average Hands move 1.0-2.0 cm medially on testing
Average Hands move 2.1-3.0 cm medially on testing
Above average Hands move 3.1-4.0 cm medially on testing
Excellent Hands move >4.0 cm medially on testing

Hair/Skin Color Contrast
Like curliness, light-colored hair on white skin and or black hair on black skin almost always ensures that a good result will ensue. This correlation exists because light scalp does not project through light hair and dark scalp does not likewise project through dark hair. Conversely, a light scalp projects significantly through dark hair, making the patient appear balder than he or she may actually be. Therefore those patients with gray, blonde, red, or light brown hair on white skin are considered favorable and those with dark brown or black hair on white skin are unfavorable. As previously alluded to, those with black hair on black skin are also considered favorable. Although these inverse relationships need to be adjusted by the evaluator due to the wide variety of skin tones and hair color, the following guidelines can be used as a baseline:

Poor Black hair on white skin, white hair on black skin
Below average Dark brown hair on white skin
Average Light brown hair on white skin
Above average Blonde, red, salt-and-pepper hair on white skin
Excellent Gray hair on white skin, black hair on black skin

Donor Hair Styling Capability
As previously discussed, one of the most difficult tasks in alopecia reduction is to prevent hair divergence at the midline. This task is especially difficult in those patients who have stiff hair that does not move against its normal flow. This characteristic equates to poor hair manageability. To determine whether or not the patient undergoing evaluation will do well after alopecia reduction, I part the hair with a comb in the region where the part will exist after the alopecia reductions are complete. If the hair does not easily fall into the desired location, the patient may have some difficulty with styling postoperatively. On the other hand, those patients who have soft hair that holds its new position will do very well. As previously alluded to, transposition flaps to correct slot formation make this characteristic less important than it was years ago, but it still must be evaluated on each patient.

Poor Hair combs +1 against normal direction
Average Hair combs +3 against normal direction
Excellent Hair combs +5 against normal direction

Hair Loss Delineation
The ability to determine the anterior, posterior, and lateral end points of the pattern baldness is extremely important to the long-term results of the patient. This characteristic correlates inversely with age, but must be evaluated separately because some patients will occasionally delineate their hair loss pattern very early in their lives. Once again, the hair must be thoroughly soaked with water or alcohol to get a sense of where the patient is likely to progress. Some surgeons, who claim that it is impossible to roughly predict the future pattern on any patient, will, of course, score everyone as poor, and that is fine if that is the philosophy of that particular surgeon.

Poor Unsure of the hair loss pattern
Average Somewhat sure of the hair loss pattern
Excellent Sure of the hair loss pattern

Figure 5. A patient with thin hair in the area below the nuchal line will not do well with alopecia reduction. With scalp lifting, the nape scalp will thin; with scalp reduction, the nape hair will be exposed.

Figure 6. A) Patient before midline scalp reduction. B) Same patient after two midline scalp reductions. C) After two sessions of follicular unit hair transplantation to the vertex and scar. This approach of two midline scalp reductions followed by follicular unit grafting is the approach that the author believes will become the procedure of choice for most properly selected patients with crown baldness. D) Same patient before surgery on oblique view. E) Same patient after two scalp reductions and two follicular unit grafting sessions. Notice how the patient can part through intact scalp due to the lifting procedures.

Nape Hair Density (Below the Nuchal Line)
This category pertains primarily to scalp lifting (undermining to the hairline of the nape), but it can also have ramifications specific to scalp reduction (undermining to the nuchal line). Because it has been demonstrated statistically by the author that scalp lifting induces approximately 60% of its stretch from below the nuchal line, it is logical that scalp lifting would significantly reduce the density of the nape hair on a patient who is already thin in that region (Figures 5 and 6). This nape hair evaluation can also be pertinent to patients undergoing scalp reduction because a thinner density of the hair above the nuchal line may expose an already thin nape. As alluded to previously, a 30x microscopic evaluation can be performed on the scalp (Figure 7).

Poor <75 hairs/cm2
Below average 75-125 hairs/cm2
Average 126-175 hairs/cm2
Above average 175-225 hairs/cm2
Excellent >225 hairs/cm2

Figure 7. A 30X microscopic evaluation can give the surgeon critical information about hair density and shaft diameter. The photograph demonstrates a 0.5 cm2 space. The number of hairs on the screen are multiplied by two to determine the hairs per cm2.

Nape Hair Shaft Diameter (Below the Nuchal Line)
As the hair shaft diameter is important above the nuchal line, so it is below the nuchal line. Because the hair can differ in the nape, it is crucial to perform a 30X microscopic evaluation of this area separate from the hair above the nuchal line. The same criteria are utilized and are as follows:

Poor Fine or whisker; <36 p m in diameter
Below average Semifine; 37-53 V Lm in diameter
Average Average; 54-70 µm in diameter
Above average Semicoarse; 71-84 µm in diameter
Excellent Coarse; >84 µm in diameter

Periauricular Space (Between the Hairline and Helix Base)
Because all reducing procedures lift the skin around the ear, it is critical to evaluate the space between the superior attachment of the helix of the ear and the periauricular hairline. If this space is wide, even before alopecia reduction, it will certainly become much more evident postoperatively and possibly turn into a cosmetic difficulty (Figure 4). If a problem does exist postoperatively, this area can easily be micrografted to re-create a very natural reconstitution of the hairline. Another approach is to excise some of the periauricular skin and pull down the adjacent hair. The following have been found to be appropriate criteria to help evaluate the characteristic:

Poor >2.0 cm space
Below average 1.5-2.0 cm space
Average 1.0-1.4 cm space
Above average 0.5-0.9 cm space
Excellent <0.5 cm space
Healing Potential

As with any cosmetic surgical procedure, it is extremely important to take a thorough history of the healing abilities of the patient. In addition, it is a good idea to evaluate previous scars from former surgeries or sutured lacerations, although it is well known by cosmetic surgeons that a hypertrophic scar in one area may not guarantee that a problem with scar formation will develop in another. The combination of these evaluations will help make a determination as to how the patient will heal postoperatively. If the patient has no history of previous surgeries or sutured lacerations, I usually use age as my criteria. As previously alluded to, the younger the patient the greater the tendency to heal with a wider, hypertrophic scar.

Poor History of previous keloid (>5 mm)
Below average History of hypertrophic scar (25 mm)
Average History of average width scar (1-2 mm)
Above average History of narrow, but perceptible scar (1 mm)
Excellent History of imperceptible scar (<1 mm)

Expectations
It is well known to those who perform cosmetic surgery that the expectation of the patient is one of the most important factors implicated in the success or failure of an operation. It is therefore the duty of the evaluator to determine as accurately as possible what the expectations of the patient are. This can be done in three ways: (1) by simply asking the patient how he/ she envisions the result will be; (2) having the patient bring in a photograph of how he/she visualizes the final result; and (3) performing computer imaging. We also have a question on the patient history form that asks if he/she realizes that there is a possibility that cosmetic surgery may not give them exactly what they are looking for. If the expectation level cannot be determined after these steps, the instincts of the evaluator must be followed.

Poor Totally unrealistic
Below average Somewhat unrealistic
Average Not sure
Above average Somewhat realistic
Excellent Totally realistic

Emotional Stability
It is also well known to cosmetic surgeons that the emotional stability of the patient can make or break the postoperative course. There is no magic in making this determination, but I have found a psychological screening test (Surgeon's Insight, Torrance, CA; 3103702633) to be extremely invaluable. This test is evaluated by a psychologist who scores an Oxford Capacity Test in three categories relating to cosmetic surgery: (1) roller coaster index; (2) trouble index; and (3) threat index. Each index is scored by the psychologist using the following scale:

Poor <2.0 on Surgeon's Insight Test
Below average 2.5 on Surgeon's Insight Test
Average 3.0 on Surgeon's Insight Test Above average 3.5 on Surgeon's Insight Test
Excellent 4.0 on Surgeon's Insight Test

Understanding
If, after consulting with a patient for 30 minutes you feel that he/she does not grasp the concepts, it would be prudent in most cases not to perform surgery on this patient. I have found through the years that patients who are the most satisfied postoperatively are those who understand (1) how the surgery is performed; (2) that they will not look like they did when they were 16 years of age; (3) that there may be a scar that may require a cover cream and styling; (4) that the baldness may progress somewhat if an accurate prediction was not made postoperatively; (5) that there may be some numbness postoperatively; and (6) that it takes multiple procedures to obtain a final result. If there is a strong sense that this information is not "connecting" with the patient, I usually do not perform the surgery. I have found that no matter how great the result, these patients never quite grasp the fact that there is a trade-off with all cosmetic surgery.

Poor

Has no comprehension of the procedure

Average

Has some comprehension of the procedure

Excellent

Has full comprehension of the procedure

Motivation
Motivation, and more specifically proper motivation, is more crucial to hair replacement surgery than it is to any other cosmetic surgical procedure because it requires multiple procedures. If a patient states with full confidence that he/she is determined to follow the procedures through to the end, a positive signal has been sent. If on the other hand, the patient says that he/she can only afford one or two procedures and/or doesn't seem overly determined to follow through, a negative signal should be perceived. Besides plain motivation, proper motivation must be determined. Why is the patient seeking surgery? Is it because he/she thinks it will fix his/her marriage? Do they think that their love life will suddenly improve? If the answers to these kinds of questions are yes, the surgeon should consider these as warning signs and should avoid performing surgery on these patients.

Another method to find highly motivated patients is to give them the consent form at the initial evaluation. If a patient is highly motivated, this will usually not deter them.

DISCUSSION

As previously alluded to, the trend in hair restoration surgery has moved far to the side of pure follicular unit transplantation for both the front half of the balding scalp and the crown. This trend will most certainly continue for the front half of the head. But it is my prediction that in the next decade there will be an increasingly judicious use of alopecia reduction in properly selected patients for treatment of the crown. The reasons that alopecia reduction will gradually take on a more prominent role for the treatment of vertex balding are due to the following negative aspects of follicular unit hair transplantation:

The results of exclusive follicular unit transplantation to the vertex usually result in a thin appearance.

Exclusive follicular unit transplantation to the vertex uses up a great many follicular units without achieving thick density in most cases.

Follicular unit transplantation is extremely time consuming, taking 6-8 hours.

Follicular unit transplantation is extremely expensive to perform due to the time and staffing requirements.

Alopecia reduction on the other hand has the following advantages:

The procedure takes approximately 30 minutes to perform.

The procedure requires only one other staff person.

The procedure achieves maximum density because the scalp isn't broken down into follicular units and then replanted (a process that will always cause some loss of hair).

The technique for crown restoration that I believe will be the approach of choice over the next decade for most cosmetic surgeons will be that of utilizing one to two midline scalp reductions⁸ with or without extenders⁹ followed by sessions of follicular unit hair transplantation (Figure 6). For those patients desiring maximum density, it is necessary to bring patients to full closure with either serial circumferential scalp reductions¹⁰ or scalp-lifting¹¹ procedures followed by transpositional flaps in combination with follicular unit hair transplantation.⁷ Candidates for the latter approach should be deemed excellent in almost every category discussed in the evaluation system presented in this article.

In regard to the utilization of this aforementioned evaluation system, it is essential that each of its 20 criteria (Table 1) be reviewed and given a score. Of course, as the system becomes more second nature to the surgeon, this actual scoring will not be as essential. When scoring each criteria, a 5 should be given for excellent, a 4 for above average, a 3 for average, a 2 for below average, and a 1 for poor. These 20 numbers should then be added together and divided by 20. If the resultant number is 4 or above, the patient should be deemed a good candidate for scalp reduction in most cases. When performing a full closure technique with circumferential scalp reduction or scalp lifting followed by transposition flaps, a score of 4.5 or greater is recommended. It is my general recommendation that alopecia reduction should not be performed if the patient averages less than 4. Of course, clinical discretion will be the final determining factor of whether or not a patient is a suitable candidate.

It has been my experience that since using this evaluation system, the number of alopecia procedures that I perform has dramatically decreased, while the results have become consistently excellent.

CONCLUSION

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