Male pattern baldness (androgenetic alopecia) is a progressive disease that worsens with aging. The cosmetic, medical, and surgical treatments have evolved greatly over the last several years. Unfortunately, there is still no perfect solution in the treatment of hair loss. Nonetheless, today’s hair transplantation procedures are far superior, and should be undetectable.

Unfortunately, there are limitations to today’s hair transplantation technology. The most significant limitation is that each patient only has a fixed amount of good genetic hair on the sides and the back of the scalp available for transfer to the balding areas.

  1. With the limitations in mind, we as physicians need to focus on 3 very important areas when performing a hair transplant:When performing hair transplants, we need to ensure the highest percent of grafts survive procedure and continue to grow after the transplant.The worst thing a hair transplant surgeon can do is waste part of the very limited "hair bank" of a balding patient. Poor survival can be secondary to:
    • poor hair transplant technique,
    • improperly trained hair transplant physicians or unlicensed technicians, or
    • automating the FUE or FUT hair transplant process.Hair transplant surgeons should avoid those techniques and technologies that damage or decrease the viable hair in the “hair bank.” Beware of many of the automated FUE devices
  2. We need to use the very limited donor hair wisely when performing hair transplants.
    The utmost focus should be to use up as little of the “hair bank” as possible during the hair transplant. The focus should be about making the patient happy and not about how many hair grafts the doctor can transfer as quick as possible during a single session. (Haste makes waste).

Aesthetically, the most important area to have hair is the frontal forelock because it frames the patient’s face and maintains a youthful appearance (Figure A).

Having hair in the frontal forelock with a balding vertex is a natural balding pattern. In an extensively balding young male, the limited amount of good genetic hair should be reserved for transplant to the frontal forelock and the mid-forelock. The hair in the frontal forelock is typically the last hair to miniaturize during the balding process. This can present a dilemma in a young patient experiencing androgenetic alopecia because many times he desires to use his limited amount of good genetic hair to solve his acute problem (i.e. – his vertex or the fronto-temporal triangle balding).

Transplanting into the vertex will solve the immediate problem for this balding male. For the next several years, this patient will be happy with his newly acquire hair in the vertex. However, when his existing hair in his frontal forelock and mid-forelock miniaturizes, leaving him with a very unaesthetic result, he might regret the decision to transplant his limited good genetic hair to his vertex. Unfortunately, at this point the patient will not have enough good genetic hair to create a natural balding pattern in the more important frontal and mid forelock areas. The original procedure solved an acute problem in the vertex, but in the long term it limited the patient’s ability to have further transplants. (Figures B, C, D)


Figure B             Figure C              Figure D

Transplanting hair in the vertex of a young male is not a wise use of the very limited good genetic hair and it is prudent to refrain from such transplants. Patients with such issues should be placed on the medical therapies, Propecia (finasteride) or Minoxidil.

Before puberty many men do not have fronto-temporal triangles (Figure E), but by the age of 25 the overwhelming majority of men have developed these triangles (Figure F). It is a very natural balding pattern as men age. However, it can be very disconcerting for the young male, because it is usually the first sign of balding.


Figure E              Figure F

Hair transplant surgeons should also refrain from transplanting hair into the fronto-temporal triangles because it will eventually create a very unaesthetic and unnatural balding pattern. An immature hairline will not naturally frame the face of on aging and balding man. As shown in Figure G, the patient began to lose hair in the fronto-temporal triangles. Figure H shows that hair has been replaced through hair transplants. Figure I shows how those grafts will not look natural as the patient ages and the hair loss continues to progress.


Figure G          Figure H             Figure I

The donor area (i.e. – the hair bank) along the sides and back of the scalp has a very limited amount of good genetic hair. It has been reported in the literature that there is 125 cm2 of good donor area in the average male . If half the donor area can be removed without it being noticeable , this would yield approximately 6250 follicular unit grafts if the density in the donor area is 100 follicular units/cm2 . However for many men this number is awfully optimistic since other reports in the literature state there are approximately 80 follicular units per cm2 in the donor area.

In my practice, the average male has 200 cm2 to many times over 300 cm2 of balding scalp. In order to cover this area at 50% density (i.e. – 50 follicular units/cm2) with all follicular unit grafts, it would take 10,000 to over 15,000 follicular unit grafts to achieve this goal. This would decimate “Hair Bank” 2-3 times over. These numbers exemplify the striking limitation the hair transplant field has and stresses the importance of the medical of therapy.

      3. We need the help from medical forms of therapy

The below scenario exemplifies the need of assistance from the medical therapies for hair loss. If a patient with 30% density of hair came to a hair transplant surgeon with the desire to create a look like he had a full head of hair, the hair transplant surgeon would need to add approximately 20% density. ( Studies have shown that the human eye cannot tell a person is balding until the person has lost over 50% of his density . Therefore we only need to achieve approximately 50% to achieve a full head of hair.)

The patient’s goal could probably be attained; however with the progressive nature of male pattern baldness, the patient’s goal eventually could not be maintained. The average male experiencing male pattern baldness loses approximately 4% density a year , so after 5 years his 30% existing density will now be at 10% and the transplanted 20% density will probably still be there— therefore he is back to where we started 5 years ago at 30% density.

The hair transplant surgeons’ biggest nemesis is the progressive nature of male pattern baldness and for many men we cannot keep up with nature.

Before a Hair Transplant After a Hair Transplant 5 Years Later – After a Hair Transplant on a patient NOT on Propecia
30% Existing Hair Density 30% Existing Hair + 20% Transplanted Hair = 50% Density 10% Remaining from the Existing Hair + 20% Transplanted Hair = 30%