There are many different surgical techniques to correct androgenetic alopecia and it is important that our patients understand the risks and benefits of each and make an informed decision.

Hair transplants have evolved dramatically since Dr. Norman Orentriech, a Dermatologist, first developed the surgical procedure in 1959. Dermatologists have made huge strides over the past several years, creating hair transplant techniques that are undetectable and look completely natural. Please follow this link for a detailed description of Hair Transplants.

Scalp reduction is a technique where a portion of the bald scalp is surgically removed and the hair-bearing scalp is stretched over that area. In theory it sounds logical, however in reality it is highly illogical. There are some downsides to scalp reduction surgery:

It has a higher complication rate than hair transplants.

It leaves a scar in the balding area, which usually necessitates 2-3 hair transplants to hid. (It would be more logical to do 2-3 hair transplants in the first place instead and avoid the complications of scalp reductions.

Many times the scalp stretches back, which leaves the patient with the same amount of bald scalp and a visible scar that can be difficult to mitigate.

When a patient has a limited “hair bank,” it is far more important to use that “hair bank” to create a frontal forelock to frame the patients face. Unfortunately, scalp reductions only reduce the bald scalp in the vertex and on the sides of the patient’s scalp. Scalp reduction often does a patient a disservice by using most of the “hair bank.” Eventually, the patient will need this “hair bank” (that will no longer be available) to frame the face.

Dr. McAndrews no longer performs scalp reductions because he believes that there is no discernable benefit when compared to current hair transplant techniques.

There are several different techniques used to create scalp flaps. Scalp flaps were developed to shift hair from the sides and back of the scalp to the balding front of the scalp. These methods address the issue of using the limited “hair bank” to frame the face, unfortunately they are fraught with complications and produce an unnatural look:

It is a very complex procedure that is performed in stages over several weeks.

The complication rate is much higher than that of a hair transplant and potentially devastating (i.e.- necrosis or tissue death, of the whole scalp flap).

It usually looks quite unnatural.

It usually crosses over the frontal -temporal triangle (an area that is naturally bald in most men) creating a very unnatural look, resulting because the face is not framed correctly in relation to the hairline.

The hairs along the hairline are directed in the wrong direction, creating an unnatural look (usually hairs on the hairline naturally point forward, in the flap all the hair along the hairline is usually directed sideways.

The flap creates an unnaturally dense look right on the hairline.

The flap creates a scar in front of the hairline, which now needs to be hidden with hair transplants. (Why not just have a hair transplant instead?).

It is an inefficient use of the “hair bank.” Dermatologic studies have shown that the naked eye cannot distinguish the difference between a scalp that has 50% hair density versus 100% hair density. The flap method shifts a large portion of the “hair bank” to the frontal hairline at 100% density. A Hair Transplant could have used this same donor area and spread it over twice the area as the flap at a 50% hair density, with the appearance of the same density to the naked eye.

For all the above reasons, Dr. McAndrews will not perform scalp flaps.

Approximately half of the surgeries performed by Dr. McAndrews are corrective surgery. In the right surgical hands, a bad (pluggy) hair transplant can be corrected. The reason the traditional plugs stand out is because of the contrast in density between the plug and the surrounding existing density. As the patient continues to bald with aging, the density contrast increases and the plugs stand out even more. In order to make the plugs blend in, the corrective hair transplant surgeon needs to increase the density in the surrounding area with follicular unit grafts. When the surrounding density is increased to 50% density the plugs, at 100%, become unnoticeable. If a patient has 30% density surrounding the big plugs, then the hair transplant surgeon will need to increase the density by another 20% in order to make plugs look natural. Many times even density less than 50% is sufficient to hide the plugs (30%-40% is usually adequate).

Grafts are in the correct location (i.e.- conservatively placed in the frontal forelock) but are “pluggy” in appearance.

If donor supply (i.e.- good genetic hair from the sides and back of the scalp) is “abundant” — The hair transplant surgeon can harvest the abundant good genetic hair from the “hair bank” and place follicular unit grafts in front of, and around the plugs to make the contrast go away.

If the donor supply is “limited” — The hair transplant surgeon will need to remove plugs which are 100% density, dissect them into follicular unit grafts under the microscope, and the then re-transplant them in the same area at an evenly, distributed lower density.

In the extreme, the transplant surgeon will need to remove the grafts and the patient will have to settle being naturally bald. Unfortunately, some scarring will remain where the grafts were removed.

The other option is to remove the grafts and settle being naturally bald with some scarring where the grafts were removed.2. When the frontal hairline is designed too low or the plugs are on the forehead, the plugs need to be removed, dissected under a microscope, and placed in a more appropriate area (i.e.- frontal forelock) with even distribution of the density. Trying to hide the plugs with follicular unit grafts will hide the plugs, but create an even more unnaturally low hairline. The plugs can be removed individually or in a linear strip which creates a small scar — Dr. McAndrews has never had a patient that would rather have the plug instead of the scar.

If the patient has extensive baldness and does not want further hair transplants — The plugs should be removed and patient will be left with a bald vertex with mild scarring.If the patient has extensive baldness and very little donor hair, but desires to keep the grafts — The grafts should be removed, dissected under the microscope into follicular unit grafts, and place into the frontal forelock leaving the vertex bald.

If the patient has moderate balding and desires to have further hair transplants, but does not have the donor bank to fill in all the balding area — The plugs should be removed, dissected under the microscope into follicular unit grafts, and re-transplanted in the same area in a natural-appearing, evenly distributed with lower density.

If the patient is older, has mild balding, and has an immense amount of hair in his donor area — The follicular unit grafts could be placed in between the plugs to reduce the contrast.