Hairtransplantation in transsexual Patients with male to female Transformation
 
Dr. Ursula Halsner
(Germany)

ESHRS Journal. Volume 4 - Number 1. Spring 2004.

We feel observed and unsure of ourselves if our appearance is not corresponding with our personal or social norms. Especially transsexual man who cannot identify themselves with their biological sex suffer from their unloved gender appearance and seek for help in cosmetic surgery. Male pattern baldness is particularly distressing because it points out the very attribute that the individual is to deny namely masculinity. Therefore hairtransplantation is more and more asked by genetically male transsexuals for creation of a female hairline, coverage of a receding hairline and new hair in the crown area.
 
Hairtransplantation male to female transsexuals is seldom reported in publications ( e.g. Shiell R., Stough, D.). But transsexual people with hair-problems represent a collective that should not be underestimated. In our patient data of approximately 7.000 patients 7 patients with male to female transsexuality asked for surgery (1: 1.000). This is much more than the estimated number of transsexuals in the average population (1 :40.000). The treatment of this group of patients requires not only much experience in the field of hair restoration surgery but also the willingness to concern with the physical and psychical unity of these patients.
 
Transsexuality is defined as:

• A strong and persistent crossgender identification
• Persistent discomfort with his or her assigned natal sex and its associated gender role
• Absence of any physical intersex conditions
• Clinically significant distress or impairment of social and occupational functioning

For differential diagnosis it is important to stress the differences between transsexuality and other gender related disorders such as:

• Temporary or partial disturbance of gender identification especially in young adults
• Transvestism (when men wish to wear female dresses but do not like to change the biological sex)
• Homosexuality
• Psychosis (schizophrenia) with disturbance of the personal identity

To start therapy transsexual men first must undergo the real life test and live for 2 years the social life of females. During this time accompanied by psychotherapy they normally start with hormonal therapy and at least seek cosmetic surgery for a variety of feminizing procedures.
 
Feminizing hormonal therapy leads to less greasy skin and hair. Slow down of progressing male pattern baldness and improvement of texture and thickness of scalp hair is also possible. Sometimes recently lost hair is growing back.
 
Nevertheless it is important to take into account that the number of androgen sensitive receptors has not changed with this therapy. There still exist a minimal risk of progressive androgenetic alopecia under feminizing hormonal therapy. Therefore very often the adjuvant therapy with finasteride is recommended. For hair restoration surgery it is therefore important to remember the well defined male donor area for harvesting the grafts.
 
Before starting the procedure the following questions should be answered:

• Does the patient want to look truly female?
• Do we have realistic patient's expectation?
• How far has baldness progressed; is hairtransplantation really satisfying?
• Which Donor Area is to our disposal?

Two main recipient areas are mostly asked for transplantation: the receding hairline (Fig. 1 and 2) and the crown area.

Figure 1	Figure 2

For both creating a female hairline and coverage of the crown area follicular units, mini -and micrografts are cut according to hair quality, color and structure. For insertion both holes and slit techniques are applied according to hair density and diameter of the grafts. Two achieve best density often two or three operations are recommended. (Fig. 3 and 4)

Figure 3	Figure 4

Transsexual patients need a lot of empathy. We should accept this situation and help them on their way to a new identity of body and soul.

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