The Upper Third in Facial Gender Confirmation Surgery: Forehead and Hairline

ORIGINAL ARTICLE

Luis Capitań, MD, PhD, Daniel Simon, DMD, Carlos Bailoń, MD, Rau´l J. Bellinga, MD, FEBOMS, Javier Gutie´rrez-Santamarıá, MD, FEBOMS, Thiago Teno´rio, MD, and Fermıń Capitań-Canãdas, PhD

introduction of new materials for use in cranioplasty (i.e., hydroxy- Abstract: The upper third of the face contains 2 features that are apatite, polyetheretherketone, etc). particularly important for facial gender recognition: the frontona- However, and despite the importance of the hairline in the soorbital region and the hairline. The supraorbital ridge, which recognition of facial gender,16 few authors have studied the treat- determines the position and exposure of the eyebrows, is almost ment of the frontonasoorbital complex and the hairline together. In invariably more developed in the male than in the female. Surgical 2009, Shams and Motamedi described a surgical hairline lowering 4 modification of the frontonasoorbital complex, considered a stan- procedure in a trans female patient for the first time. Since then, dard procedure in facial feminization, is reliable and predictable, only 1 scientific publication has proposed an alternative hairline treatment technique: forehead reconstruction and simultaneous hair and also delivers satisfactory results that are stable over time. transplant (SHT).17 A prototypical male hairline has an M-shaped pattern compared This article provides an update on our forehead reconstruction to the more rounded shape often seen in female hairlines. Femini- technique.9 It also gives a bibliographic review of the evolution of zation of the hairline requires minimizing the temples as well as surgical techniques to feminize the forehead and treat the hairline rounding out the overall shape, optimizing hair density, and occa- (See supplemental digital content, Table 1-SDC, http://links.lww.- sionally changing the height of the hairline. com/SCS/A543), and compares surgical hairline lowering to a This article provides an update on our forehead reconstruction hair transplant. technique and our experience in the treatment of hairline redefinition. METHODS

Key Words: Facial feminization surgery, facial gender Study Design Between August 2008 and September 2018 (122 months), we confirmation surgery, forehead reconstruction, hairline, hairline treated a total of 1049 trans female patients for forehead recon- lowering surgery, simultaneous hair transplant struction, with the average patient age being 39.4 (range 18–73). Of (J Craniofac Surg 2019;30: 1393–1398) these patients, 129 (12.30%) were only operated on for forehead reconstruction. The remaining 920 patients (87.70%) also under- orehead recontouring or reconstruction is the surgical procedure went 1 or several of the following surgical feminization procedures: F most described in the scientific literature for Facial Gender SHT and/or deferred hair transplant (DHT), hairline lowering Confirmation Surgery (FGCS).1–15 Over the past few decades, new surgery (HLS), rhinoplasty, malarplasty, lip lift, lower jaw contour- diagnostic tools have been introduced, such as computed tomogra- ing, or Adam’s apple contouring. phy (CT) scan with 3D reconstruction, and numerous modifications With specific regard to hairline treatment, 287 patients of the have been made to improve the technique: recontouring the areas total number (27.36%) underwent SHT, 77 patients (7.34%) HLS, adjacent to the supraorbital ridge (forehead surface, frontomalar and 22 patients (2.09%) DHT. buttresses, orbital ridges, and frontonasal transition), the use Hair transplants were performed using the follicular unit (FU) strip surgery technique in either simultaneous or deferred trans- of osteosynthesis materials (titanium screws, microplates, and 18 meshes), the use of anchor systems for the scalp, and the plants. All of the patients who received a hair transplant had clinical alopecic stabilization resulting from the hormone treatment associated with their gender transition beginning at least 1 year before their operation.19 As previously described,17 a modified From the FACIALTEAM Surgical Group, HC Marbella International coronal approach at the temporoparietal level (anterior) was the Hospital, Marbella, Ma´laga, Spain. technique of choice for patients with Hamilton-Norwood type I, II, Received March 29, 2019. 2 Accepted for publication April 18, 2019. and III, good hair density (>60 FU/cm ), and a clinical and der- Address correspondence and reprint requests to Luis Capita´n, MD, PhD, matoscopic absence of miniaturization. A modified coronal FACIALTEAM Surgical Group, HC Marbella International Hospital, approach at the temporoparietooccipital level (posterior) was the Ventura del Mar 11, 29660 Marbella, Ma´laga, Spain; technique of choice for patients with Hamilton-Norwood type III E-mail: [email protected] and IV, temporoparietal hair density below 50 FU/cm2, and the The authors report no conflicts of interest. clinical or dermatoscopic presence of miniaturization in the Supplemental digital contents are available for this article. Direct URL temporoparietal region. citations appear in the printed text and are provided in the HTML and From August 2008 to October 2014, all patients underwent PDF versions of this article on the journal’s Web site (www.jcraniofa- preoperative and postoperative teleradiography and a cephalometric cialsurgery.com). Copyright # 2019 by Mutaz B. Habal, MD study. Since November 2014, all patients have undergone a preop- ISSN: 1049-2275 erative and postoperative CT scan with 3D reconstruction (SOMA- DOI: 10.1097/SCS.0000000000005640 TOM Emotion CT, Siemens, Munich, Germany). Pre-, intra- and

The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 1393 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Capita´netal The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 postoperative imaging was obtained for each patient, always using the same camera (Canon EOS 550D EF-S, Canon, Tokyo, Japan) and following the same protocol and parameters. In September 2016, 3D photography (VECTRA H1 3D Imaging System, Canfield Scientific, NJ) was incorporated. 3D photographs were taken during both the pre- and post-operative period. In all cases, general anesthesia was used, and surgeries that also included jaw procedures used nasotracheal intubation at that time. The results and images that appear in this article belong to patients who have given their express consent for their image to be published in scientific publications in compliance with current personal data protection regulations.

ANATOMICAL AND CLINICAL CONSIDERATIONS When approaching the upper facial third in trans female patients, both the anatomy of the frontonasoorbital region and the overall FIGURE 1. Forehead reconstruction approaches. (Left) Modified coronal condition of the hairline—format, height and hair density— should approach at the temporoparietal level (anterior). (Right) Modified coronal be considered as a unit.17 approach at the temporoparietooccipital level (posterior). The frontonasoorbital region encompasses the forehead surface, the frontal bossing (the most prominent region of the frontal area) coronal approach (anterior or posterior) is used in approximately and the supraorbital ridge, the frontomalar buttresses, the temporal 93% of our patients (Fig. 1), regardless of whether or not they ridges, and the frontonasal transition. The supraorbital ridge, which receive an SHT. The design of the pericranial flap and its careful determines the position of the eyebrows, is almost invariably more 20 detachment, preventing tears or perforations, is fundamental to developed in the male than in the female. Typically, all of the guarantee the correct isolation of the entire surgical site, especially areas are more pronounced and have greater bone volume in the in the reconstructed sinus area. It is essential to identify and expose male than in the female skeleton. the key anatomical areas, which will serve as a reference point when Regardless of gender, the hairline has a series of intrinsic the time comes to plan the bone remodeling and subsequent characteristics: reconstruction. The working field is exposed, taking into account The first 2 or 3 rows of hair that comprise the hairline are the identification and preservation of the supraorbital arteries, made up of FUs with only 1 hair, followed by FUs with 2 veins, and nerves. hairs. This makes the hairline unique with respect to the rest In cases where there is some projection of the upper forehead of the hair.21 region, an upper forehead setback procedure can be done before the The hairline itself is naturally irregular, with randomly osteotomy of the anterior wall of the frontal sinus. The aim is to distributed hairs.22 make this area as leveled as possible with the insertion of the nasal There is vast variability in the format of the hairline,23 which bones into the forehead. After the bone shaving, the retropositioning is, moreover, usually conditioned by hormone phenomena needed across the entire frontoorbital ridge will become quite related to gender.24 In the absence of these phenomena, the evident (Fig. 2). hairline is usually stable over time. However, changes in hair The sequence continues designing the osteotomy of the anterior morphology, density, and the like can appear over the years as wall of the frontal sinus. This must take into consideration the a natural consequence of the physiological phenomena anterior wall’s maximum projection, its thickness, the sinus length of aging. (cranial-caudal and lateral), the location and characteristics of the In terms of gender, the male hairline tends to have an M-shaped posterior wall of the sinus, the frontonasal angle, the location of the pattern with recessions at the temples.25 The hairline of women orbits with respect to the sinus, the intrasinus clinical situation, and usually has a rounded shape,26 their hair is not normally affected by the possible absence of a sinus. Most of these anatomical and alopecia and, proportionally, the hairline implantation is higher in functional considerations must be analyzed before surgery using a the center than with men.17 CT study (Fig. 3). After the osteotomy, the next step is recontouring and setback of the frontoorbital region, using the following reference points for the FOREHEAD RECONSTRUCTION bone shaving: the 2 frontomalar buttresses, the insertion of the nasal AND HAIRLINE REDEFINITION bones into the forehead, the orbital ridges, both temporal ridges, and the upper forehead region (with or without prior setback). With Forehead Reconstruction Surgical Technique foreheads that are especially square-shaped or have marked tem- Forehead reconstruction is one of the key procedures in facial poral ridges, correct exposure and shaving is essential in these areas. feminization. It completely modifies the frontonasoorbital anatomy If a rhinoplasty is included in the treatment plan and when the nose and helps to soften and feminize the patient’s expression. The insertion to the forehead is too high or projected, a conical burr is surgical plan is devised to open the frontonasal angle; achieve an used to lower the frontonasal transition to the optimal and desired adequate backward position of the entire forehead, including the position, which will mark the level of the osteotomy or rasping of anterior wall of the frontal sinus, while maintaining a harmonic the new bony nasal dorsum during the subsequent rhinoplasty.27 rounded shape; recontour the superior part of the orbit; and obtain a After completing the bone recontouring, work begins on repo- proper position of the eyebrows in relation to the new supraorbital sitioning the anterior wall of the sinus and fixing it using osteo- ridge. synthesis material. This may vary substantially from 1 case to This article describes new developments with regard to the another according to the sinus characteristics (Fig. 4 and Fig. 5). technique published by our group in 2014.9 At this time, a modified During this surgical step, properly sealing the sinus is of particular

1394 # 2019 Mutaz B. Habal, MD Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 Facial Gender Confirmation Surgery

FIGURE 4. Before and after surgical photos of a forehead reconstruction. Upper views. (Above) Reconstruction with micro screws and plates. (Below) Reconstruction with micro screws and titanium mesh.

Simultaneous Hair Transplant Technique This technique consists of taking advantage of the strip of scalp obtained during the modified coronal approach (anterior or posterior) used to access the frontal region, harvesting the hair follicles from the strip, and grafting them after the forehead reconstruction is done.17 Since it was published in 2017, the technique has undergone very few changes. Choosing the correct donor site based on hair density and absence of the phenomena of androgenetic alopecia and follicular miniaturization continues to be especially important. Additionally, attention must be paid to the transplant design in the hairline region in terms of the areas to cover and the drawing of the new hairline. This design must be marked before the forehead surgery so that it is not distorted by surgical manipulation.

FIGURE 2. Upper forehead setback. (Above) Pre-setback. (Center) Transition RESULTS detail between the area with and without setback, delineated by a black line. The average follow-up time with the patients included in this Note that the upper setback should not be carried out over the frontal sinus. publication was 58 months, with the interval ranging from 6 to (Below) Post-setback. 122 months. concern, especially in the lower region or closer to the nasoorbital Forehead Reconstruction ridge, as is using the correct material to reinforce all the areas with All the drainage devices could be removed between 24 and obvious bone gaps, which have become excessively weakened after 48 hours after surgery. shaving or perforated. The vast majority of the patients reported slight to moderate The final surgical steps include suturing the pericranial flap, paresthesia in the forehead and scalp region, with spontaneous placing the anchor devices (Endotine Forehead-mini device, Coapt resolution beginning 3 months after surgery. A total of 43 patients Systems Inc., Palo Alto, CA) to reposition the eyebrows in cases (4.10%) required surgical drainage of a coronal hematoma in the where this is required, and closing the surgical approach. first 24 hours after surgery. One patient had a cerebrospinal fluid The sequence in Figure 6 gives a step-by-step description of the forehead reconstruction technique proposed by our team.

FIGURE 5. Before and after surgical photos of a forehead reconstruction. Lateral FIGURE 3. Diagnostic tool for preoperative planning: CT study with 3D views. (Above) Reconstruction with micro screws and plates. (Below) reconstruction. Note the cranial-caudal and lateral length of the frontal sinus. Reconstruction with micro screws and titanium mesh.

# 2019 Mutaz B. Habal, MD 1395 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Capita´netal The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019

FIGURE 7. Clinical case before and after facial gender confirmation surgery. Procedures done: forehead reconstruction and simultaneous hair transplant; rhinoplasty; lower jaw contouring; Adam’s apple contouring.

FIGURE 6. Step-by-step sequence of forehead reconstruction. (A) Modified coronal approach, with elimination of the strip of scalp. (B) Pericranial flap until the supraorbital ridge and both frontomalar buttresses are reached. (C) Upper forehead setback. (D) Osteotomy of the anterior wall of the frontal sinus. The anterior wall is preserved in saline solution during skull recontouring. (E) Sculpture of the entire frontonasoorbital complex. (F) Readaptation of the frontal sinus ridges for subsequent attachment of the osteotomized anterior wall. (G) Stable fixation of the anterior wall of the frontal sinus. (H) Orbital opening. (I) Pericranial flap suture and placement of resorbable anchors (Endotine Forehead-mini device, Coapt Systems Inc., Palo Alto, CA) to correctly reposition the eyebrows over the new bone structure. (J) Surgical approach closure. fistula that resolved spontaneously after applying posture measures. One patient developed sinus problems 2 months after surgery that did not respond to conservative measures, antibiotherapy, or endoscopic treatment, requiring open surgery to clean the sinus and repermeabilize the frontonasal duct. One patient required a second operation to repair reabsorption in the orbitofrontal region that left a clinically visible defect.

Simultaneous Hair Transplant FIGURE 8. Clinical case before and after facial gender confirmation surgery. Of the 287 patients who underwent forehead reconstruction Procedures done: forehead reconstruction and simultaneous hair transplant; and SHT procedures, an anterior coronal approach was used with rhinoplasty.

1396 # 2019 Mutaz B. Habal, MD Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019 Facial Gender Confirmation Surgery

thick bony septum. Raffaini et al include a brow lift and lateral canthal upper repositioning.12 With particular regard to repositioning the eyebrows, we agree with the author that a coronal approach provides greater predictability and correct handling of the symme- try. This allows for precise, simultaneous control in the placement of both eyebrows and also respects their natural arch. Controlling the eyebrows through a hairline approach can be less predictable and more subject to possible asymmetries since the positioning of each eyebrow is done separately. Moreover, as sutures are required, the result may be some loss of the eyebrow arch and/or unnatural, unharmonious formats. Altman carries out the 3 techniques proposed by Ousterhout; the difference lies in the use of bone cement instead of methylmetha- crylate onlay implants for the augmentation cranioplasty (Group II patients).13 However, alloplastic reconstruction in any area of the body can produce complications, including infection, fractures, or the formation of a seroma.28 Salgado et al do an endoscopic brow reduction in patients with an anterior table thickness greater than 5 mm when HLS is not needed.14 In our point of view, an endoscopic approach is significantly limited with regard to being able to expose and work on the entire forehead complex, especially in some of the key anatomical areas cited, which can generate suboptimal results. Additionally, in the event of perforation or excessive weakening of the anterior wall of the sinus, this approach leaves no option to seal the sinus or reconstruct it using osteosynthesis material. Villepelet et al, the last group to date to describe their FIGURE 9. Clinical case before and after facial gender confirmation surgery. Procedures done: forehead reconstruction and simultaneous hair transplant; surgical technique, propose performing the forehead remodeling lower jaw contouring; Adam’s apple contouring. with simple burring or with an eggshell technique, where the anterior wall is weakened by burring and then caved, preserving the integrity of the mucosa.15 They also perform a lateral cantho- 174 (60.63%), and a posterior coronal approach was used with 113 pexy. In our opinion, with techniques that involve the sinus, one of (39.37%). the objectives should be to respect its functionality, guaranteeing The average number of FUs per strip was 1508 Æ 300, or some correct sealing in the region whenever possible. In more complex 3468 hairs. Clinical evaluation 12 months after surgery showed cases where the anterior wall of the sinus cannot be completely adequate density in the transplanted site (45 to 50 FU/cm2 on sealed after bone recontouring, we advocate the use of reconstruc- average) and in the donor site (70 to 80 FU/cm2 on average). tion material to guarantee the anatomical preservation of the sinus The most commonly seen complications were the presence of region. In secondary cases where the anterior wall is completely excessive scabbing in the recipient site (due to poorly hydrated missing due to reabsorption, the use of autologous bone grafts is grafts or because the patient had a condition like seborrheic of interest. dermatitis), light bleeding, or folliculitis. 5 patients developed skin Focusing on the hairline, in 2009, Shams and Motamedi argued necrosis in a small part of the recipient site, resulting in poor that it could be lowered to give amorefeminineappearance, transplant growth in the affected area. describing the first HLS in a trans female patient.4 In his 2011 Figures 7–9 show different preoperative and postoperative work, Spiegel concludes that the shape of the hairline plays a results. significant role in determining gender: ‘‘A receding or thinning hairline is distinctly masculine and may serve to skew observers to DISCUSSION judging the area as masculine even in the face of feminine eye- The forehead reconstruction technique has been widely described in brows and glabellar bone shape.’’6 His technique consists of the scientific literature and it is the FGCS surgical procedure with advancing (when necessary) and feminizing the hairline with the highest number of publications to date. In 2016, Morrison et al reduction of the temporal recession typical of the male pattern. did a comprehensive literature search of the Medline, PubMed, and Cho and Jin reach the frontonasoorbital region through a coronal EMBASE databases for studies published through October 2014 approach with a trichophytic incision 4 to 5 mm posterior to the with multiple search terms related to facial feminization.28 Specifi- hairline, following the natural undulations and slightly beveled cally, regarding forehead reconstruction, they reviewed the devel- (458), so that the hair would grow through the distal flap.8 Table 1 opment of the technique from the publication by Ousterhout in 1987 (SDC, http://links.lww.com/SCS/A543) describes the evolution of to the article published by our surgical group in 2014.1,9 the forehead reconstruction technique and hairline treatment in Since 2014, several authors have published articles about their the bibliography. experience with forehead reconstruction, presenting modifications In 2017, we published a forehead reconstruction and SHT to the technique. Bachelet et al use a piezoelectric scalpel for the technique as the only alternative to HLS at that time.17 In our osteotomy of the anterior wall of the frontal sinus.10 We believe that experience, HLS, which has been proposed by several authors, has a the vast majority of osteotomy cases can be safely and predictably series of disadvantages compared to hair transplantation. As noted, done using a standard reciprocating saw. The use of piezosurgery is there is a significant difference between the general format of the highly indicated for osteotomies on solid sinuses to prevent male (M-shaped) and female (rounded) hairlines. Using different unwanted fractures or perforations in the posterior sinus wall. techniques, surgical lowering can try to eliminate alopecic areas Likewise, its use might be of interest when freeing the supraorbital like recessions, but the consequence—something frequently nerve in the event that its emergence is very high or when it has a observed by our group in redoing patients—is the presence of

# 2019 Mutaz B. Habal, MD 1397 Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Capita´netal The Journal of Craniofacial Surgery Volume 30, Number 5, July 2019

visible scar tissue and the complete loss of the naturalness of 10. Bachelet JT, Souchere B, Mojallal A, et al. Facial feminization the hairline. surgery—upper third. Ann Chir Plast Esthet 2016;61:877–881 Based on the classification of hairline types in trans women 11. Balaji SM. Facial feminization—surgical modification for Indian, described in 2017,17 we believe that HLS is contraindicated for European and African faces. Ann Maxillofac Surg 2016;6:210–213 patients with normal height and rounded format hairlines (Type I, 12. Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: 22%). In hairlines with normal height and receding side temples patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg 2016;137:438–448 (Type II, 43%), HLS usually achieves greater lowering in the 13. Altman K. Forehead reduction and orbital contouring in facial central portion, since the side areas, which have a different degree feminization surgery for transgender females. Br J Oral Maxillofac Surg of recession, do not descend to the same level. As a result, there is 2018;56:192–197 some risk that the forehead will be excessively short in the middle 14. Salgado CJ, AlQattan H, Nugent A, et al. Feminizing the face: region after surgical lowering. For patients with rounded and combination of frontal bone reduction and reduction rhinoplasty. naturally high hairlines (Type III, 4%), HLS may be indicated. Case Rep Surg 2018;2018:1947807 HLS and SHT can be considered for high hairlines with receding 15. Villepelet A, Jafari A, Baujat B. Fronto-orbital feminization technique. side temples (Type IV, 21%), which can be complemented with a A surgical strategy using fronto-orbital burring with or without eggshell DHT in a second session. Finally, for hairlines that are undefined technique to optimize the risk/benefit ratio. Eur Ann Otorhinolaryngol Head Neck Dis 2018;135:353–356 due to advanced alopecia (Type V, 10%), we prefer SHT followed 16. Capitań L, Simon D. Facial Feminization Surgery: A Global Approach. by a DHT or to leave it untreated. In: Salgado C, Monstrey S, Djordjevic M, eds. Gender Affirmation: One of the main risks associated with HLS is the possibility that Medical and Surgical Perspectives. New York, NY: Thieme Medical 29 it will leave a visible scar in a highly exposed location. At times, if Publisher, Inc; 2016:3–30 the surgical wound was closed with tension, the scar can be 17. Capitań L, Simon D, Meyer T, et al. Facial feminization surgery: considerably wide.30 simultaneous hair transplant during forehead reconstruction. Plast In conclusion, we believe that the forehead region and hairline Reconstr Surg 2017;139:573–584 are key elements in the feminization of the upper facial third. 18. Rousso DE, Presti PM. Follicular unit transplantation. Facial Plast Surg Frontonasoorbital recontouring with frontal sinus osteotomy and 2008;24:381–388 19. Giltay EJ, Gooren LJ. Effects of sex steroid deprivation/administration setback offers satisfactory and safe results regardless of the anat- on hair growth and skin sebum production in transsexual males and omy of the frontal region, even in patients with complete agenesis 31 females. J Clin Endocrinol Metab 2000;85:2913–2921 of the frontal sinus. Furthermore, SHT is a safe and effective 20. Capitań L, Simon D, Capitań-Canãdas F. Facial Feminization Surgery alternative for treating the hairline. and Facial Gender Confirmation Surgery. In: Cecile, Ferrando, eds. Comprehensive Care of the Transgender Patient. 1st ed. New York, NY: Elsevier; 2019:55–73 ACKNOWLEDGMENTS 21. Shapiro R. Principles of creating a natural hairline. In: Unger WP, The authors thank their team, families, and patients. Shapiro R, Unger R, Unger M, eds. Hairline Transplantation. 5th ed. London, UK: Informa Healthcare; 2011:374–381 22. Knudsen RG. Hairline-design: Strategies and techniques. In: Lam S, ed. REFERENCES Hair Transplant 360. Vol. 3. 1st ed. New Delhi, India: Jaypee Brothers 1. Ousterhout DK. Feminization of the forehead: contour changing to Medical Publishers; 2014:5–21 improve female aesthetics. Plast Reconstr Surg 1987;79:701–713 23. Rassman WR, Pak JP, Kim J. Phenotype of normal hairline maturation. 2. Habal MB. Aesthetics of feminizing the male face by craniofacial Facial Plast Surg Clin North Am 2013;21:317–324 contouring of the facial bones. Aesthetic Plast Surg 1990;14:143–150 24. Randall VA. Hormonal regulation of hair follicles exhibits a biological 3. Becking AG, Tuinzing DB, Hage JJ, et al. Transgender feminization of paradox. Semin Cell Dev Biol 2007;18:274–285 the facial skeleton. Clin Plast Surg 2007;34:557–564 25. Norwood OT. Male pattern baldness: classification and incidence. South 4. 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