Balding is a progressive phenomenon affecting more than the 60% of the male human population.
Androgenic alopecia (AGA) represents the main cause of balding. It is a complex medical condition as different factors have been recognized as involved in hair growth.
At puberty, androgens affect hair growth in a paradoxical way depending on body site. Androgens stimulate vellus hairs to form terminal hairs in the armpit and pubis in both sexes and on the chest and lower face in men. At the same time androgens inhibit the hair growth in patterned distribution in the scalp of genetically predisposed people.
The mode of inheritance is not understood as yet. It has been proved that alterations of genes located on the chromosome X, 20 and 3 are associated with androgenic alopecia. The involvment of chromosome X confirms the maternal influence in the inheritance of the alopecia.
Several studies have confirmed a correlation between coronary heart disease and AGA. Early onset of AGA seems to be a risk factor for early onset of coronary heart disease.
In a prospective study of 250 white men aged 35 to 65 hypertension was strongly associated to AGA.
Both prostatic hyperplasia and AGA are androgenic-dependent disorders and their asociation has been confirmed in many studies. Instead it is still controversial the relation between AGA and the risk of develop prostate cancer.
The upper part of the scalp, from the frontal line backward to the crown, is the area affected by androgenic alopecia. The inferior part of the hair bearing scalp, including the occipital area (posteriorly) and the temporal area (laterally), is instead not affected by the action of androgens and the hairs growing in this area of the scalp will survive for a lifetime. This resistance to androgens is a "dominant" characteristic of hairs from the occipital area which is maintained also after their transplant in a different area of the body.
These hairs represent the ideal donor in hair restoration surgery.
To treat the crown, follicular units including 3 or more hairs will be used to recreate appropriate density. A natural result is achieved by recreating the natural twisting-orientation of the hair, typical of this area.
The frontal hairline (fronto-parietal or fronto-temporal areas) represents the most important aesthetic unit and the main target of the most of the procedures in male hair restoration surgery. The frontal line is designed according to patient wishes but also according to the personal risk of progression of the balding process. A "defensive" approach in the design of the frontal hairline will guarantee a natural looking result also after progression of the alopecia. As shown in the picture, the design marked on the left forehead is an unrealistic expectation of the patient while following the marking on the right hand side a natural result has been achieved in a young patient with androgenic alopecia. This condition can be treated by both FUT or FUE.
The fronto-temporal recession is often the first area of hairloss which causes a modification of the anterior hairline into a triangular – or spiky – shape. This condition is treated by use of follicle grafts including 1, 2 and 3 hairs, reproducing a natural looking hairline. This solution can be achieved by both FUT or FUE.
Complete alopecia represents the last stage of AGA and is a condition requiring accurate assessment and management according to quality of tissues, amount of donor hairs available for grafting, hair style desired and patient expectations. When appropriate a scalp reduction can reduce the extension of the area of alopecia and reduce the number of hair required to complete the treatment. In any case the management of this condition requires more surgical sessions. Complete alopecia can be treated with an association of FUT and FUE.
Triangular alopecia is congenital condition which becomes more evident anytime from birth up to 5 years of age. Is characterised by a patch of bald skin or bearing only vellus hair in the temopral region and might assume a triangular shape.
This is a form of non-cicatricial alopecia and the affected skin is otherwise completely healthy. This condition is not progressive and patients affected are generally very good candidate for surgical solutions in form of hair transplant or scalp reduction.
The incidence of this form of alopecia is very low, affecting about 0.1% of the general population.
The cause of this condition is not known, but a report of a father and his son with triangular alopecia is suggesting a genetic link.