An enhancement of a technique originally developed in South America, the flap procedure is said to produce, in a relatively short period of time, a more natural, dense mop of hair than the punch grafting transplant. However, it is technically a more demanding procedure than grafting and has a higher risk of complications.

The flap procedure is ideal for patients with a receding hairline but sufficient hair at the back or sides. The surgeon cuts a flap of hair-bearing scalp, about 2 to 3 cm. in width, and rotates and slots it into an adjacent bald area (from which surface tissue has correspondingly been removed), leaving one end of the flap still connected to the scalp. Either one long flap from a single side of the scalp can be transposed to form a new hairline, or two bilateral flaps can be incised from opposite sides of the scalp and transposed to the front.

If necessary, a second flap procedure can be performed to provide hair coverage in the area just behind the first. Or, punch grafting and micro-grafting can be carried out following the initial scalp flap. An experienced surgeon can even transpose three flaps from the back of the head to fill a bald spot, following scalp extension and scalp reduction.

A lax scalp is best suited for this procedure, but the tissue expansion method (also used in scalp reductions) can get around this problem, or a temporary skin graft can be used.

Since balding is progressive and its pattern, even in MPB, often unpredictable, this method is best reserved for hair loss limited to the frontal area if a single flap operation is carried out; this leaves a second hair-bearing flap available in case of further balding.

Although, following the surgery, there is generally an amount of temporary hair loss (as hairs in the growing phase shift into the shedding phase), the hair coverage obtained with scalp flaps is by and large maintained in terms of extent and density.

However, balding continues in the areas outside the flaps; it can be managed by brushing back the hair at the front, or by having a secondary "filling-out" surgery, whether grafting or scalp reduction or another flap.

Scarring at the donor site may sometimes occur in the long term if, for instance ,it has been closed under tension; the problem can usually be prevented by excision during the early post-operative period. In smokers, those suffering from high blood pressure, or others with poor circulation, complications like tissue death are a possible risk.

Despite its cosmetically excellent and long-lasting results, the flap technique is often unsuitable because it does not always happen that an area containing enough hair is immediately adjacent to a completely bald area.

An enhancement of a technique originally developed in South America, the flap procedure is said to produce, in a relatively short period of time, a more natural, dense mop of hair than the punch grafting transplant. However, it is technically a more demanding procedure than grafting and has a higher risk of complications.

The flap procedure is ideal for patients with a receding hairline but sufficient hair at the back or sides. The surgeon cuts a flap of hair-bearing scalp, about 2 to 3 cm. in width, and rotates and slots it into an adjacent bald area (from which surface tissue has correspondingly been removed), leaving one end of the flap still connected to the scalp. Either one long flap from a single side of the scalp can be transposed to form a new hairline, or two bilateral flaps can be incised from opposite sides of the scalp and transposed to the front.

If necessary, a second flap procedure can be performed to provide hair coverage in the area just behind the first. Or, punch grafting and micro-grafting can be carried out following the initial scalp flap. An experienced surgeon can even transpose three flaps from the back of the head to fill a bald spot, following scalp extension and scalp reduction.

A lax scalp is best suited for this procedure, but the tissue expansion method (also used in scalp reductions) can get around this problem, or a temporary skin graft can be used.

Since balding is progressive and its pattern, even in MPB, often unpredictable, this method is best reserved for hair loss limited to the frontal area if a single flap operation is carried out; this leaves a second hair-bearing flap available in case of further balding.

Although, following the surgery, there is generally an amount of temporary hair loss (as hairs in the growing phase shift into the shedding phase), the hair coverage obtained with scalp flaps is by and large maintained in terms of extent and density.

However, balding continues in the areas outside the flaps; it can be managed by brushing back the hair at the front, or by having a secondary "filling-out" surgery, whether grafting or scalp reduction or another flap.

Scarring at the donor site may sometimes occur in the long term if, for instance ,it has been closed under tension; the problem can usually be prevented by excision during the early post-operative period. In smokers, those suffering from high blood pressure, or others with poor circulation, complications like tissue death are a possible risk.

Despite its cosmetically excellent and long-lasting results, the flap technique is often unsuitable because it does not always happen that an area containing enough hair is immediately adjacent to a completely bald area.

This method is used when there are such large areas of baldness at the front and crown that donor grafts would not be in sufficient supply. It is the ideal method for getting rid of the fairly common circular patch at the top back of the head. But success with this technique is more difficult to achieve than with grafting.

Scalp reduction involves progressively reducing the area of bald scalp. Essentially, the surgeon excises a section of bald scalp, either in the shape of an ellipse or a 'U' that follows the symmetry of the bald spot, or a modified 'S' if the bald area is not expansive enough to allow the U-shaped cut. The area excised should ideally not be more than one & half inches across at its widest point (to avoid too much tension on the stitches) and not more than four inches long. The edges of the cut section are then sutured together, thereby pulling the hair-bearing areas of the scalp closer and reducing the width of baldness. This cut-and close-up process is repeated over three to five sessions at intervals of three months each (during which time the skin stretches to some extent again). At the end of this time, the hair-bearing areas should have finally met, achieving cosmetically acceptable results. "Finishing touches" are generally provided through the use of micro-grafts over the last line of incision. (If for any reason the scalp reduction series is discontinued midway, you are likely to be left with a visible scar at the point of the last suturing).

It is common for surgeons today to precede a scalp reduction by first stretching the hair-bearing area of the scalp. This can be done in one of two ways: One is by inserting tissue expanders (silastic balloons that are gradually injected with saline) under the scalp skin. This is carried out over a period of about two-and-a-half months and has the effect of swelling the hair-bearing section to about twice its normal size; you'll have to put up temporarily with the unsightly bulge that results from this expansion process.

he second method used nowadays to stretch the scalp is known as "scalp extension" rather than "scalp expansion" ; it avoids the deformation of the scalp that results from expansion. This method makes use of a device known as the Frechet extender, named after its creator, Dr Patrick Frechet, a pioneer in the field of surgical baldness treatments. The device consists of a thin sheet of elastic silicone fitted with a row of titanium hooks at each end. Under anaesthesia, one row of hooks is attached to a deep-lying layer of the scalp just about 1 cm outside the margin of the bald scalp. The sheet is then stretched across, and the other row of hooks attached at the opposite end of the bald patch (again just about a centimetre within the hair-bearing area). The hair-bearing areas are thus put under constant tension, which has the effect of stretching them, while at the same time compressing the area of baldness that lies in between. Left in for a month to three months, the extender allows the easier removal (through scalp reduction) of 7 to 17 cm-wide areas of baldness. The scalp extension procedure may be repeated from two to four times, depending on how much baldness needs to be treated. Also, two extenders can be placed side by side to increase the area of scalp stretched, and therefore the area of scalp to be excised. But the pain is significantly more, requiring much stronger analgesics.

Patients with firm scalps can also be candidates for scalp extension, but the degree of stretching obtained is about one-third less than with softer scalps.

Bleeding during the surgical insertion of the extender, or the formation of scar tissue causes adhesions, to some extent compromising the efficacy of the extender. Dr Frechet therefore recommends the use of the elliptical incision when the extender is used, since bleeding is less, than with the 'U' shape cut.

Compared to hair transplantation, scalp reduction is more painful in the post-surgery period, even more so if the Frechet extender has been used.

The ideal patient for a scalp reduction is someone over age 50 whose inherited pattern of hair loss is known and therefore predictable; ideally, also, he should have minimal hair loss in the frontal area. His scalp skin should be of at least moderate thickness; this thickness is a more important consideration in scalp reduction than the elasticity of the scalp skin.

Younger patients with extensive balding - that is, in both, the frontal and the crown areas - are not ideal candidates for scalp reductions. Nor are those younger patients who may show hair loss in only the crown area, but who have a family history of baldness in both, crown and frontal areas.

Controversy continues to surround the scalp reduction procedure. Its advocates argue that when the scalp has an extensive area of baldness, donor hair for grafts may not be in plentiful supply ("The more you need, the less you have," as one surgeon observes), and in this case, they say, scalp reduction is the only option.

Scalp reductions also offer the advantage that the coverage obtained is the maximum possible with any surgical method.

Those who are opposed to the procedure however also have valid objections, including the following:

One, baldness is a progressive condition, and as people age, they tend to worry more about hair loss in the frontal [hairline] area than at the top [the crown].

Also, while scalp reductions do provide coverage, the procedure also accelerates hair loss in already-thinning areas of the scalp, as well as reduced density of hair growth all over the scalp because of the stretching and re-distribution of its area. While this does not occur to the extent that it becomes a cosmetic disaster, it does mean that fewer hairs are available in the donor area for grafting, if and when this may be required.

To avoid these pitfalls, while at the same time exploiting the potential of scalp reductions, some surgeons have suggested a modified approach combining scalp reduction with grafting, when the baldness extends across the front and crown of the scalp. In such extensive baldness, there may not be sufficient donor hair to provide full coverage for the bald area. On the other hand, carrying out several scalp reductions over such a wide area will risk not only thinning of hair, but also unsightly depressions or bumps on the scalp, or a non-cosmetic scarring. Combining the two, it is suggested, could achieve optimum results - the best of both methods.

Advocates of this approach suggest that grafting in the front and mid-crown areas be carried out first. The advantage is that this produces an immediately visible cosmetic result since it "frames" the patient's face, making the hair loss less obvious and providing a major psychological boost. If, for some reason, the patient decides to stop treatment midway, the most visible aspects of his balding will have been corrected. Carrying out the grafting first also avoids the thinning of donor areas, that would have resulted, had scalp reduction been the initial step.

After the grafts have produced coverage in about 60 per cent of the frontal and mid-crown regions, the remaining area of baldness can then be tackled through scalp reduction.

Certain risks and potential complications are common to all types of surgical treatments of baldness:

• If anaesthesia has not been adequate, has not been administered at the correct depth, or has been injected too rapidly, the patient can suffer from discomforts ranging from numbness to tingling in the donor and recipient areas, even from significant pain.
• A surgeon who is less skilled or less careful than he ought to be can destroy hair follicles by excising too deeply in the donor area or by paying insufficient attention to the proper angle/direction of the donor hairs. This is especially important in older persons in whom the skin and fat layers of the scalp may have thinned; it is equally important for patients coming for their second surgery session, who do not have "virgin" scalps.
• Another risk of excising the donor strip too deep is cutting the occipital artery or its branches which run in the scalp, causing bleeding which will require to be stopped by suturing the blood vessel or by electro-cautery. Both these can be challenging tasks if the surgeon blindly nicks the artery or its branches in particular areas where the blood tends to pool very quickly.
• The follicular bulbs may be injured during closure of the donor site if the surgeon has not carried out suturing with only very superficial "bites". These bulbs lie very shallowly in the fat layer, just below the lower skin layer of the scalp.
• The deep-lying layer of connective tissue in the scalp (known as the scalp's "danger space") can allow large amounts of blood to collect - because of the loose tissue here - causing hematomas (blood clots) to form.
• Also, infection introduced in the connective tissue area can travel along veins and may spread to the meninges - making it important for the surgeon to thoroughly cleanse this area with an anti-bacterial solution before he starts suturing it.
• Because the scalp is an extremely vascular area, in rare instances (about 0.02 per cent of cases), arteriovenous fistulas may form in the donor or recipient area. (They form as a transected arteriole and venule join together while healing). These fistulas make their presence felt as pulsating lesions, often accompanied by pain.The problem may well resolve itself with time; if it does not settle down within about six months, more aggressive treatments may be called for; thes include such as steroid injections into the lesions, surgery to suture the skin at the site of the lesion or even to remove the fistula completely (though heavy bleeding may be expected in the last approach).

This is one of the oldest approaches in the surgical treatment of baldness, and the techniques and tools of hair transplantation have been continuously honed and refined over the last three decades. The concept is simple: to transfer hair along with its roots [follicles], from an area where it is growing densely to an area of baldness. Even in MPB, the area at the back of the scalp is spared the effects of genetic baldness, and although it, too, is affected by the normal process of aging, the latter loss takes place only very slowly, so that hair growth in this area retains its density the longest. This, then, is the area that is traditionally harvested for its hair, the so-called donor region. The bald area into which donor hair is implanted is known as the recipient area. There are at least three different kinds of grafts that can be used to achieve this:

• Full-thickness grafts: The surgeon cuts out a number of small strips of hair-bearing tissue [around 1/4 inch in width] from the back of the scalp, making sure to include the follicles . Cutting away corresponding strips of tissue from the bald area, he transplants the hair grafts into these slots and sutures them in place, The donor slots at the back are also sutured. Around 40 to 60 strips can be transplanted with this method. However, the full-thickness graft method has today been largely superseded by other, more effective grafting techniques.
• Punch grafts: The surgeon uses a device to punch out tiny cylinders of hair-bearing tissue from the donor site after first trimming the hair in this area. Today's super-sharp punches allow the surgeon to create hundreds of holes at speed just by tapping the punch on the surface of the scalp. These plugs of hair are then inserted into cylindrical holes punched out by the same device in the bald area. The hair-bearing cylinders "take root", so to say, and start growing in their new location.

  Since hairs grow out of the scalp at varying angles, punching out donor plugs always results in the injury and loss of some hairs in the plugs. The extent of such damaged [ or "transected" ] hair depends on the skill and care of the surgeon: by aligning the cutting punch exactly parallel with the angle of the donor hair, he can maximise the number of viable hairs in each plug.

  Another aid to cutting down avoidable hair loss is the use of a tumescent solution during surgery so as to raise the scalp above the skull and to partially erect the [trimmed] hair. This enables the donor scalp to stay firm and blanched. Finally, chemicals injected pre-surgically into the area avoid the free-flowing blood that would impair visibility during the procedure.

  In general, punch grafting is suitable only for small patches of bald area, such as those resulting from scarring. If you avail of it to restore a receding hairline in the early stages of MPB, you should be aware that the balding process itself will continue in the untreated areas according to its pre-determined genetic pattern. On the other hand, when MPB is well advanced, say, upto the crown, it is probably unwise to use up a large amount of hair from the donor area - a precious and limited resource - in carrying out punch grafting for the entire area of baldness.

  To give a "finished" look to a section treated with punch grafts, surgeons today carry out a supplemental procedure called micro-grafting; this involves transplanting grafts of one or two hairs into the spaces between the punch grafts. This is particularly useful in creating a new hairline: the natural human hairline consists of singly-growing hairs.

Today, the laser can be used to create a slit while at the same time removing tissue at the recipient site, thus speeding up the process. The surgeon has virtually complete control over the bleeding, allowing for greater ease of operation. The downside of course is that as the laser removes tissue it also seals tiny blood vessels. This results in poorer blood circulation to the recipient area, which can compromise the survival or optimal growth of the new grafts.

Increasingly, hair transplantation techniques have evolved to the stage where surgeons are using hundreds of smaller grafts rather than a smaller number of big-sized plugs. This enables them to produce acceptable cosmetic improvements in a shorter time. For the patient it is a psychological boost, besides cutting down on practical problems such as the disruptions in daily life that result from several surgeries.

There are other advantages to doing larger graft sessions. Each time grafts are harvested, fibrosis [formation of scar tissue ] in the donor area causes the destruction of some hairs adjacent to the wound site. Those hairs adjacent to the suture that do survive are often distorted, and more difficult to harvest in subsequent sessions.

Also, virgin scalp has normal collagen and normal blood flow and one should take advantage of these optimal conditions by maximizing the amount of grafting carried out in the initial session.

By avoiding repeated violations of the same recipient area, the surgeon also lessens the physical trauma to this area - including the fibrosis and dermal changes that make successive surgical procedures more difficult to perform. The distortion produced by fibrosis means, for instance, that implanted hairs growing at a particular angle above the skin may not be at the same angle below the skin. This makes it difficult to perform future grafts close to existing ones for fear of damaging the hair below whose angle of growth is an unknown entity.

Nudging along the trend toward mega-sessions is the technique in which the surgeon incises, not plugs, but strips of donor hair. Using a multi-bladed knife, about half a dozen narrow strips, each about 20 cm in length, can be cut at a time. Then, from these strips the surgeon can select micro grafts of single hairs, two-three hair clusters or bigger groupings according to the needs of the bald area. In the hands of a surgeon who has gained mastery in the harvesting of such donor strips, the risk of transected hairs is also minimized using this method.

• Follicular Transplantation: Why transplant skin along with the hair when all you need is the hair or, more precisely, the living part of hair - the follicle - that lies below the scalp? This is the thinking behind the newest trend in Transplant Country. With the exception of the hairline area, human hair does not generally grow singly, but emerges from the scalp in groupings of two, three or more hairs, each grouping being termed a "follicular unit". The spaces of bare scalp in between these groupings are bigger than the space occupied by each grouping: This means that when donor plugs or donor strips are used as in punch grafts or micro-grafts, the surgeon will end up transplanting more bare scalp than hair. Transplanting only the follicular units will avoid this.

As many as 3,600 units can be transplanted in one session, going by the experience of surgeons thus far. This means earlier cosmetic benefits for the patient. It also means that in many cases one large session is quite sufficient to treat the entire area of baldness, thus bringing in all the benefits (mentioned earlier) of transplanting from and into virgin scalp. Several other benefits are claimed for follicular transplants:

• Transplanting follicles allows the surgeon to create in the balded area a pattern of coverage that is more natural-looking and aesthetically balanced than with punch or strip grafts. This is because the pattern of follicular grouping at the back of the scalp (the donor area), in terms of the proportion of 1, 2, 3, 4, 5 or 6-hair units, pretty much mirrors the pattern one might have expected in the recipient area if it had not balded. If you had mostly 2- and 3-hair units in the donor area, you would be having a hair density that is not too thin, yet not too luxuriant either. This, therefore, is the kind of "look" that the surgeon must try to reproduce in your balded area/s. To transplant units of mainly 4 or 5 hairs would make for an unnatural appearance; it would look equally unnatural if he transplanted units of mainly 1 or 2 hairs. Following the follicular pattern in your donor area, the surgeon can more precisely plan and design the restorative look that is right for you.
• When hair taken from the back of the scalp is transplanted to a balding area in the front, it needs to be positioned at the same 30-degree angle as it was growing at the back. Because of this angle of insertion, mechanical forces begin acting on the implant and continue doing so right through the healing phase. Their effect is to distort the alignment of the graft skin with the surrounding skin, resulting in some areas becoming settled, others becoming elevated - in effect, producing a cobblestone effect at the site of the graft. By avoiding the transplant of any skin, follicular implantation simply bypasses this problem.
• The incision required for a follicular insertion is so small (1 mm ) and the unit placed so compactly within this slit that the body's natural glue, "fibrin", secures it snugly, minimizing coagulation of blood as well as tissue death [necrosis], and speeding healing.
• Because the surgical incision is smaller, follicular transplantation greatly minimizes the fibrosis that occurs during the healing process which impedes blood flow to the area and prevents the grafts from "taking" uniformly.

Each punch, large slit or ultra-pulsed incision made carries the risk of cutting or sealing off blood vessels, which increases fibrosis. By using a "needle-like" knife with a 1-mm blade, follicular transplantation produces minimal trauma, so that a blood vessel that might be pierced would immediately re-seal.

• The bigger the transplanted unit, the greater the risk of the graft being deprived of oxygen (which reaches the hair follicle by simple diffusion). The smaller follicular graft minimizes this risk too, avoiding the "doughnuting" seen with larger implants.