Female pattern loss is usually diffuse rather than receding, which is why it is described by the Ludwig scale rather than Norwood. Candidacy for surgery depends less on the pattern than on whether the donor area at the back and sides is stable, because diffuse loss often affects it as well.
What the Ludwig scale describes
Ludwig classifies female pattern loss by widening of the central parting with a preserved frontal hairline โ the opposite emphasis to Norwood, which tracks a receding hairline and crown. Grades run from mild widening to extensive thinning across the top of the scalp.
| Grade | Typical appearance |
|---|---|
| I | Noticeable widening of the central parting; frontal hairline intact |
| II | More obvious widening; scalp visible through the top |
| III | Diffuse thinning across the top; hairline usually still present |
A preserved hairline is the point that distinguishes it clinically. Loss that includes a receding female hairline, or that is patchy, sudden or accompanied by scaling, is a different problem and needs a different assessment.
Why candidacy is decided at the back
Transplantation depends on moving follicles that will not be lost. In male pattern loss the back and sides are usually reliably stable. In diffuse female loss they frequently are not โ the thinning extends into the donor area, and grafts taken from there will thin in their new position too.
This is why donor assessment, including density measurement and often trichoscopy, does more to decide candidacy than the Ludwig grade does. A grade II with a stable donor may be a better candidate than a grade I whose donor is also thinning.
Causes that are not pattern loss
- Telogen effluvium after illness, childbirth, surgery or significant weight loss
- Thyroid disease and iron deficiency
- Traction from tight or repeated styling, often at the hairline
- Alopecia areata and scarring alopecias, which need medical treatment first
Several of these are reversible, and several would make surgery inappropriate until treated. This is why investigation comes before any surgical discussion โ the range of causes is set out under hair loss in women.
Where surgery does fit
Common indications in women include a stable, well-defined area โ a hairline lowered or reshaped, temples rebuilt after traction loss, or a scar treated โ rather than diffuse thinning across the whole top. Non-surgical options are often the first line, covered under non-surgical treatment and PRP.