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aesthetic hair medicine

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Male pattern baldness results from the progressive loss of hair in “privileged” areas: vertex (top of the skull), temples and forehead (fronto-temporal gulfs).

Beginning baldness is difficult to define and classify, because normality does not exist. In my opinion, it is the visual impression of the hair that prevails because the density and the number of hairs per cm2 vary considerably in a normal subject (from 200 to 400 hairs per cm2).

Hair is made up of two parts:

– an external stem which is its visible part;

– an internal root which corresponds to its part implanted obliquely in the scalp. Its deep end is swollen into a bulb and hollowed out with a papilla. At this level, stem cells allow constant regeneration of the hair, theoretically, throughout life. Normally, hair falls and then grows back according to a hair cycle that lasts about 3 years. The microscopic analysis of the hair, called trichogram, makes it possible to distinguish three phases of development:

– anagen, growth;

– pre-hair loss telognene;

– catogenic, fall;

– and finally, dystrophic hair.

Classically, it seems that a normal fall corresponds to the loss of 50 to 100 hairs per day, which seems to me a little too important.

The hair grows back an average of 0.35 to 0.45 mm per day. From the age of 30, the percentage of hair in the anagen phase, which is 80%, begins to decrease and the hair then tends to thin out. Baldness usually develops gradually.

It respects the hair of the parieto-occipital crown or hippocratic crown. This crown is measured between the upper edge of the upper implantation of the ear and the upper hairy end of the crown.

Baldness mainly affects men. Classically, it would most often be of andro-genetic origin by anomaly of the hair root receptors for male hormones and by family genetic predisposition. In fact, little is known and the etiological treatment remains to be discovered. On the other hand, its psychological impact is well known and always present, even among men who attach little importance to their appearance. Perhaps the effect of gravity intervenes, which slowly sends us back to the ground? Be that as it may, few men escape the trauma, more or less revealed, caused by this fall, even if, ultimately, too few men consult.

The goal of treatment is to transfer crown hair that will never fall out, in the form of grafts or shreds, to the bald or hairless areas that define baldness.

Some clinical elements seem important to me to know:

– the bald surface compared to the hairy surface: the surface of the normal scalp is 600 to 700 cm2. The surgery still gives satisfactory results up to a third of the bald surface, that is to say approximately 10 cm in width by 20 cm in length;

– the suppleness of the scalp: very variable depending on the patient, it is very difficult to quantify and is always greater in the vertical direction than in the horizontal direction;

– the quality of the hairs: their density depends on their thickness which is variable, from 0.5 to 1 mm, and on their number, normally from 100 to 400 per cm2. The hair may be sparse (100 to 200 hairs per cm2); very sparse (50 to 100 hairs per cm2), or hairless (less than 50 hairs per cm2).

The hair

physical examination


It is complete, specifying:

– age, tare, medical and surgical history concerning in particular prior hair implantation sessions which can make certain types of surgical intervention impossible;

– possible drug intake;

– date of the beginning of the fall, its intensity, its evolution? How much hair is there in the morning on the pillow or after the bath?;

– family history of baldness : father, grandfather, brother;

– hair washing habits: frequency and type of shampoo used? Possibly hair lotion possibly used?

Physical examination

It is always full.

On the scalp, the baldness is precisely measured and photographed. The color of the hair, its thickness, its density as well as its curly or stiff aspect are noted.

The crown is measured and studied in the same way.

The laxity of the scalp in the vertical and horizontal direction is specified.
The trichogram, which is the microscopic study of hair, does not seem to me to be of major interest and can even be psychologically destabilizing.

The real motivation and the psychological ground of the patient must be evaluated, the social integration and the family life known.

A complete biological assessment is necessary.

In addition to the dosage of cholesterol and glycaemia, the hormonal assessment, from the age of 45, is also judicious to prescribe. It makes it possible to evaluate the intensity of andropause and the fall of male hormones, the decline of which does not seem to be correlated with a cessation of hair loss.

The prostate check-up may be necessary, in particular the dosage of PSA.

From the age of 40, a cardiovascular assessment is appropriate.

Finally, it should also be remembered, on the sidelines of this question of hair, that a colonoscopy must be performed from the age of 50 and repeated regularly, colon cancer remaining the most common cancer in men.

The hair

the treatment


These grafts are in fact grafts composed of scalp,

each consisting of skin, hair bulbs and subcutaneous fat. They take the form of cylinders, 3 or 4 mm in diameter, which are punched. Elsewhere, the sample is finer, follicular, containing one, two, or even three bulbs at most. The number of hairs in each graft is therefore very variable: from 1 to 15 depending on the diameter of the punch which, in my opinion, should not exceed 4 mm. The sample is taken from the hippocratic crown whose hair, less sensitive to male hormones, never falls out. The sample is parallel to the direction of the hair.

The samples are spaced 5 mm apart and left in controlled healing or sutured. Elsewhere, a horizontal strip 1.5 to 2 cm high and 15 cm long is taken from the crown behind the ear and then sutured in 2 planes. The grafts are then taken from this strip.

These grafts are implanted in the hairless zone in two ways: either by means of punches of a diameter slightly smaller than that used during the taking and following a direction adapted to the usual growth of the hair, in the zone considered, or, for the follicular implants, by puncture with a scalpel and dilation by dilators. The transplanted hair falls in three weeks and begins to grow back around the third month. The next session is possible six months after the first.

The effectiveness of grafts depends on their covering power, i.e. the quality of the crown hair (black or curly hair covering better than blond hair), their density per cm2 and their diameter .

The closer you get to the anterior hairy edge, the finer the size of the implanted grafts must be to end, on the visible anterior frontal edge and on the gulfs, with a band of very fine follicular grafts (1,2 or 3 bulbs per graft) : the resulting look will be natural.
It is necessary to preserve the shape of the frontal gulfs and never try to fill them in a more or less rectilinear way.

It is also necessary to avoid scar enlargement in the areas where the graft is taken, especially in blondes, and to anticipate hair loss so that the grafts are well taken from the areas where the hair will never fall.

Finally, taking grafts often contraindicates any other type of surgical treatment for baldness.

Tonsural reduction

It is a question of reducing baldness by exeresis of strips of glabrous skin which are replaced by hairy skin. Several forms of tonsural excision are theoretically possible. For my part, I prefer the anteroposterior longitudinal fusiform resection, curving inwards in the occipital region. Three operating times, two on one side and one on the other, are most often necessary. The result is variable depending on the laxity of the scalp. A very lax scalp allows excision of 2 to 3 cm in width at each operation. I perform a very wide detachment on the hairy side, below the galea, and I carefully section the galea longitudinally as well as its external bone attachment point, gestures that increase skin laxity.

On the hairless side, a few millimeters of detachment are enough. The closure is performed firmly using an original technique of abutment flap in 2 planes avoiding widening of the scar.

The implantation of the hair in whirlwind in the posterior zone requires complementary cutaneous plasties of transposition in order to mask the posterior scar.
The results of these tonsural reductions are usually excellent.

Tissue expansion

It consists of expanding the scalp using one or more inflatable prostheses, which are placed under the galea and gradually inflated. This is an excellent method in the event of cicatricial alopecia in burn patients, but in a normally busy patient, the 2 to 3 months of inflation and the resulting deformation of the scalp make this technique unsuitable, with some exceptions.

Skin expanders are devices that are placed under the skin and stretch it, via hooks. Their aim would be to increase the theoretically possible width of the excisions, during, for example, a tonsural reduction. They are little used because they require additional installation time with all the septic risks inherent in the implantation under the skin of a foreign material, especially since their effectiveness still seems to have to be demonstrated more precisely.


The initial goal of scalp flaps is to recreate an anterior, partial or total frontal hairline.

If the hair is worn long, then it covers the baldness backwards which can also be filled with grafts, other flaps or with tonsural reductions

The JC Dardour flap seems to me the best suited. The hairy skin is taken from the temporal region, in front of the ear. The 3.5 cm wide pedicle is superior then it descends 10 to 15 cm, vertically, while narrowing. Its lower point curves forward and widens.

The one-stage picking and the final direction of the forward hair implantation are convincing arguments. On the other hand, if it is executed bilaterally, the direction of the hair does not harmonize. Its indication must therefore be unilateral, following the curvature of the frontal gulf and providing for a very fine hair graft over a few millimeters in front of its anterior scar.
The result is all the more flattering when the scalp is lax, allowing tension-free and invisible closure of the grip area, in front of the ear. Some authors have associated this flap with the cervico-facial lift, which seems to me an interesting idea, in order to make best use of the excess hairy skin usually resected in the temporal region during any cervico-facial lift.


They vary according to:

– the patient's age and wishes;

– the evolution, the type and the surface of the baldness;

– the quality of the remaining hair: diameter, density and color.

In any case, some hygiene rules, some of which are very personal, subjective and unproven, are in my opinion important:

– daily shampoo without rubbing or traumatizing the hair, but gently massaging the scalp;

– use of mild shampoo for frequent use, avoiding specialized shampoos such as anti-hair loss, oily hair, dry hair;

– change the brand of shampoo with each wash ;

– avoid brushings which dry out and traumatize the hair, dust, caps that are too tight, sun exposure;

– regularly moisturize the hair as well as possible thanks to a thermal water spray;

– adapt the length of the hair to its ability to grow and always call on a hairdresser or hairdresser who will know how to best take advantage of the remaining hair, harmonizing the cut with the shape of the face.

Certain medical treatments can be attempted:

– vitamin B6 (Cystine B6 Bailleul or Bepanthène) in tablets and as a course of four to six weeks, or even intramuscular injection of vitamin B6 (Bepanthène) at the rate of three times a week over 6 weeks, the courses being renewed twice a year. Often vitamin B6 is associated with vitamin H (Biotin) at the same rate and also intramuscularly.

– minoxidil in lotion can be effective and stop hair loss, while tending to grease the hair. Its success condemns the patient to lifelong treatment;

– Finasteride (Propecia) can also be tried. Its effectiveness is sometimes remarkable, even on hair regrowth, but after a year of treatment. It should be noted that some have noticed a decrease in libido, which, in my experience, is rare and seems above all to be psychological;

– finally, I personally and subjectively think that treatment with DHEA, in mature patients, in the presence of a low and confirmed blood level of male hormones, can also be attempted, even if it may seem contradictory to increase the rate of male hormone in terms of hair loss, the prostate balance must be normal.

When these hygiene measures are respected and medical treatments are insufficient, a surgical treatment plan for baldness may be considered. For me it is the following:

– iterative tonsural reduction: two to three operations each spaced about 3 months apart;

– then, anterior grafts becoming thinner and thinner near the frontal hairline in order to avoid the appearance of “doll's hair”;

– sometimes, a unilateral temporal flap can be judicious , but always embedded in grafts because an unmasked anterior frontal scar is, in my opinion, always visible and unnatural.


There is not one technique to treat baldness, but many surgical techniques. “Specialized hair dermatology” is therefore to be avoided. Some doctors only do grafts, which is insufficient on two counts:

– firstly, on certain types of hair , particularly blond hair, grafts alone will never give satisfactory results. Indeed, how with at most 5,000 transplanted hairs can we effectively compensate for an average baldness corresponding to a loss of 50,000 hairs?

– the taking of grafts in an uncontrolled way condemns certain possibilities of later surgery. Technique and tactics are the two key words to succeed in satisfying the controlled desires of the patient.


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