HAIR TRANSPLANT SURGERY FOR THE MALE-TO-FEMALE TRANSSEXUAL 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 male-to-female. 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 MTF. 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.