Sheldon S. Kabacker, M.D.

The author became familiar with the challenges of male pattern baldness for
the male-to-female transsexual through one of his patients seeking surgery to
lessen a male-pattern baldness situation and create a more feminized hairline.
In the past, a number of transsexual patients have sought this procedure. This
article was provided because of its great applicability to the needs of the

Two-thirds of all males are genetically predisposed to have a significant
balding pattern which may present itself in the late twenties, or even
earlier. The two-thirds figure is reached by the mid- or late-fifties in those
genetically predisposed to have male-pattern baldness. Even those men with
relatively full hairlines may have significantly deep recessions
characteristic of the male hairline. The female hairline is more full and
rounded; and although most women have some thinning and slight recession, a
full head of hair persists throughout the life of most females.

The male-to-female transsexual suffers the usual incidence of male pattern
baldness; however, the balding pattern pattern is quite often arrested by
hormone therapy and the sex reassignment surgery. Unfortunately, by the time
the medication and surgical intervention occurs a  significant amount of male
pattern baldness has resulted or is already a masculine hairline. Most MTFs
wear wigs to achieve maximum feminization.

An alternative to wearing a wig is one of the forms of hair transplantation,
which is selected by the individual, can provide a result adequate enough to
allow the individual to socialize and work without wearing a wig. Individuals
exhibiting male pattern baldness -can- have a hair transplant procedure
adequate to achieve feminization of the hairline.

The surgery for hair transplantation is almost thirty years old #as is sex
reassignment surgery$ and is widely practiced throughout the United States.
The most common procedure used is the PUNCH GRAFT METHOD wherein small,
circular plugs of the fringe hair are cut out with an instrument similar to a
small cookie cutter. These plugs, which contain skin and hair follicles, are
placed into recipient holes which are slightly smaller than the plug. The
recipient holes are placed on the top of the head, where the hair will grow
and recover balding areas. The plugs are usually slightly smaller then a
pencil eraser. At least four to five grafting sessions are necessary to fill
in any area and the grafting sessions can be done no more frequently than
three to six weeks apart. There is a "lag phase" of three months before hair
grows from the plugs transplanted by this method. Hair then continues to grow
at the rate of approximately one-half inch per month. The average

significantly bald individual will require between 300 and 500 grafts. (Each
plug is a "graft"). One must allow a two year period of growth for the hair to
be long enough for incorporation into feminine hair styles.

Most often the MTF patients with whom I have worked were not particularly good
candidates or were not desirous of having the Punch Graft Method, especially
because of their desire for long hair and a full feminine hairline sooner than
the two year period. Therefore I have incorporated the FLAP METHOD for the

The flap procedure, that I recommend, is a modification of the flap operation
devised by Doctor Jose Juri of Buenos Aires, Argentina. I have been using this
procedure for six years and have found it quite satisfactory for establishing
a full, dense frontal hairline. The long hair transferred from the sides
continues to grow and a lag phase, such as that occurring with the Punch Graft
Method, is not experienced. Therefore if you have, for example, twelve inch
long hair on the side it can be transferred to the top of the head and still
have twelve inches of length which will continue to grow. WHAT IS A FLAP? A
flap, in surgical terms, is a piece of full thickness skin detached from the
body on three sides, yet has a remaining attachment through which it receives
its blood supply and therefore manages to survive. To reconstruct the hairline
a flap of skin is designed along the side of the head to encompass a 4.0cm
width of the fringe and is made long enough to go completely across the front
hairline, which usually makes the flap approximately 24-28cm in length. The
hair on the side of the head (the fringe) in most men is genetically
predisposed to not grow bald. Therefore, if it is moved to any other part of
the body of the same individual it will continue to grow. The same principle
applies to the Punch Graft Method.

The Flap Method we perform for the MTF is done with one or two preliminary
procedures to redirect the blood supply. Two weeks later a relatively major
procedure is done wherein the flap is elevated; a cut made where the rounded,
feminine hairline will be created; the flap sewn into the desired hairline of
the scalp and the donor site closed by stretching the flesh of the scalp donor
site and neck so the resulting scar will be hidden by the hair above and below
it. Once healing takes place, minor adjustment procedures are usually
necessary. In the more advanced stages of baldness a second flap, from the
other side, can be placed behind the first flap three or four months after
healing has taken place.

Hair transplantation, either by the Punch Graft or Flap Method is a relatively
extensive and expensive undertaking. However, when successful, living and
growing hair is transferred to the bald areas of the scalp. With good hair
styling, many patients have been able to discard their wigs and hair pieces.

There are many doctors throughout the country who perform the Punch Graft
Method and obtain good results. However, there are few physicians performing
the Flap Method described in this article (or other flap procedures). It is
the opinion of this author that the flap procedure described is the treatment
of choice for the MTF. Information can be provided for those interested.

Dr. Kabaker
3324 Webster, Oakland, CA 94609.

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