Hair Transplant Surgery: Ethnic Differences Matter




Hair transplant surgery is such a delicate surgery, with so many variations, that consideration of ethnicity can make all the difference in the success of a surgery. Aside from the many technical aspects that differ, Dr. Robert M. Bernstein, M.D., F.A.A.D., clinical professor of dermatology at the College of Physicians and Surgeons of Columbia University and hair transplant surgeon and director of Bernstein Medical Hair Restoration, also in New York City, explains that racial differences have an effect on all phases of the procedure, including the original diagnosis, any complications, the finished design and future aesthetic considerations that may arise because of racial differences in hair follicle and growth pattern, hair density and hair diameter.

Dr. Bernstein explains that the hair density — the number of hairs per square inch — differs among ethnicities. Caucasians have the highest, followed by Asians, and Africans have the lowest density. Both Africans and Caucasians have thinner hair diameters, while Asians have a coarse, thicker hair diameter, which takes up more space. The average amount of hairs contained in each follicular unit also varies, as hairs typically grow in groupings of one to four hairs per follicle. Asians have groupings of one to two hairs per follicle, while Africans have three and Caucasians have anywhere from two to four hairs per follicle. In addition, the straightness or kinkiness of the hair makes a big difference in the final results. African hair is the kinkiest and finest, while Asian is the straightest and coarsest, with Caucasian hair falling somewhere in between depending on the client. Asians look as if they have more hair because of its thickness, and the kinkiness of African hair also makes it look thick, although it is actually very fine. Below, Bernstein explains how these variations affect the stages and decisions involved in a hair transplant surgery.

Diagnosis is an important part of hair transplant surgery strategy

The main differences in diagnoses of hair loss disorder occur between male and female causes for hair loss. But aside from those differences, some diagnoses are a little more racially determined. For example, traction alopecia is seen mainly in African-American women who wear tightly braided hairstyles that cause hair loss between braided sections or around the hairline, which can recede. Another form of “traumatic” hair loss in predominantly black women stems from constant heated styling close to the scalp and irritating chemical processes; this is called central centrifugal cicatricial alopecia (CCCA). Both of these diseases are typically reversible if the woman stops her damaging hair practices; therefore, surgery wouldn’t be necessary. But if the hair loss was permanent in those areas (as determined by a scalp biopsy), she would be a very good candidate for hair transplant surgery because of the health of donor hair areas not affected by the trauma. Bernstein stresses that the diagnosis is the all-important first step in determining your surgery strategy because it concludes whether you have enough healthy donor hair to achieve the desired result.

The hair transplant surgery procedure

In terms of the technical aspects of the hair transplant procedure, Bernstein explains that there are two ways to harvest the grafts. One method is to take a long, thin strip and dissect follicular units; the other process, called follicular unit extraction, involves extracting each follicular unit separately under a microscope. In Caucasians both procedures are straightforward, but in Africans there is a huge difference because the follicular units are curved under the skin, unlike in Caucasians or Asians. Harvesting the follicular units is easiest in Asians because the hair is coarse and stiff. Strip harvesting usually gets a better yield, no matter what the ethnicity; but the procedure, no matter what the race, must always be done with a skilled surgical team.

The hair transplant surgery design

There are many differences, both cultural and physical, that affect the final design of the hair transplant. Asians, particularly Indians, in contrast to Caucasians, like to have broad, flat hairlines because they are especially concerned about frontal hair for their wedding ceremonies and this broader hairline requires more hair. “Often we weight it more in front and less in back, which is especially important depending on the amount of healthy donor hair they have,” says Bernstein. In Caucasians, on the other hand, a little hair recession at the temples is perfectly acceptable, so surgeons can transplant and cover over a little, depending, again, on the amount of healthy donor hair available on the back and sides. Africans, however, can’t use the comb-over method, because their hair does not lie flat and is kinky and fine, so the design is much less forgiving. “In comparison with Asians and Caucasians, Africans are less likely to be good candidates for hair transplant surgery unless they have good donor density to cover all bald or thinning spots,” explains Bernstein.

Complications of hair transplant surgery

There are some other racial differences that can cause complications in the final outcome of the procedure, and clients need to be aware of them, advises Bernstein. Also, a personal history of skin and scarring tendencies should always be discussed. In Africans there is a greater incidence of keloids, or raised, thickened scars. They also don’t have as much scalp flexibility to excise a strip of donor hair, and they run the risk of greater scarring, when compared with Caucasians. Asians don’t have the propensity for thickened scars but can have a stretch scar or a visible incision scar because their hair grows more perpendicular to the scalp, so that when it is cut short, the scalp is more visible — it becomes transparent and does not hide the scar. Luckily, notes Bernstein, the recipient areas usually show no scarring at all, no matter what the ethnicity.

Final aesthetics of your hair transplant procedure

“One final style issue all hair transplant recipients need to be aware of is that to avoid visible scars, they generally will not be able to wear their new hair cut close to the scalp — and that goes for any race,” cautions Dr. Bernstein. “In addition, we try never to make a judgment on a person’s future hair loss when the patient is too young — we try to wait until he or she is at least age 30 or so to determine a pattern of balding. We want to be sure there is a very good chance of having limited future hair loss and that donor areas are stable and healthy, usually at the sides and back of the head.”

The bottom line on hair transplant surgery

Patients need to be aware of ethnic and racial differences and be sure to choose a skilled hair transplant surgical team that has experience with exactly their type of hair. Ask questions, ask for referrals and request before-and-after photos just to be sure.