What is a hair transplant?

Hair transplant surgery involves the surgical transfer of hair follicles from a donor area (where there is hair growth) to a recipient area (the area which you wish to cover). Modern hair transplant techniques involve follicular unit grafting. A follicular unit is the natural grouping of hairs with most hairs grouped as 2, 3, or 4 hairs in a close bunch. There will also be some single hairs that grow on their own. Hair transplant surgeons try to keep the natural groupings together and move them surgically by two main techniques.

1. Strip Follicular Unit Transplantation (Strip FUT) also known as Linear Strip Excision

Strip FUT involves the removal of a strip of hair bearing scalp from the back of the head then stitching or stapling the wound closed. The hair length above the surgery site will hide it whilst it heals leaving a scar which is usually 2-3 mm in width. The strip of skin and hair is then dissected under microscopes to isolate the follicular units.

2. Follicular Unit Excision (FUE)

Follicular unit excision (FUE) is a process of meticulously coring out each grouping with a small punch. Usually with this technique the back of the head needs to be shaved. When the scalp heals there are small dot scars that are left behind.

With both techniques, once the follicular unit grafts are prepared, they are then inserted into a small incision made in the bald area. The surgeon will normally place 20-40 of these grafts in each square centimetre of bald scalp. The procedure is usually done as a day case under local anaesthetic.

Prosthetic hair fibre implantation

Prosthetic hair fibre implantation uses synthetic hair fibres rather than your own hair from a donor site. Synthetic hair fibres can be implanted in the skin to simulate natural hair coverage. Unlike transplanted hair, these artificial hair fibres do not grow, tend to fall out over time, and need to be kept clean to avoid getting infected. The fibres should only be inserted by a hair transplant surgeon. Although legal in the UK, the synthetic hairs can cause significant scarring and most hair transplant surgeons do not advocate their use for this reason.

Can all type of hair loss be treated with hair transplant surgery?

There are many causes of hair loss, not all of which are suitable for hair transplant surgery. Getting an accurate diagnosis from a doctor who specialises in hair loss conditions is the first step. When to have a hair transplant for genetic male or female hair loss is dependent on a large number of factors that will be discussed with patients in depth by an ethical hair transplant surgeon. The majority of male patients who undergo hair transplantation surgery have androgenetic alopecia, sometimes referred to as male pattern hair loss. The exact cause of the majority of female pattern hair loss is not known although a small percentage will be due to an excess of male hormones. Hair transplant surgery can also restore hair in cases of traction alopecia and some other types of non-genetic hair loss. 

If alopecia areata is diagnosed there are only certain situations where hair surgery is recommended, and this is when there are small discrete patches that have remained unchanged for several years. For most people alopecia areata is a condition that comes and goes and changes location on the scalp or elsewhere on the body. Because it can’t be determined where the permanent hair is going to be, surgery is only an option if the condition is stable and unlikely to extend further. If the hair loss is on-going then trying to stabilise the loss with medical or non-surgical treatments might be the initial advice given. There is a hair density limitation that can be achieved per procedure so patients should clarify with the doctor what this will be. Of course, when someone loses all the hair on their head (alopecia totalis or alopecia universalis) there is no available donor hair. Hair can only be used from another person if they are an identical twin.

How successful is hair transplant surgery?

In a completely bald area with one operation, hair transplant surgeons can achieve about 30% of the original density so some patients may require 2 operations to achieve a thicker look. If hair loss is due to genetics, then the result should be long lasting. In other situations, if hair is lost due to a medical condition such as alopecia areata, then transplantation cannot be guaranteed as the disease process can recur at any time. But for some patients even a temporary return to ‘normal’ hair is acceptable. It is really important to speak to the surgeon about what outcome you might expect before having surgery so you can make an informed decision of whether hair transplant surgery is right for you and likely to lead to an outcome you feel happy with.

What can I expect from my clinician?

Patients should expect to be treated professionally and for their best interests to be prioritised over commercial gain. Both hair transplant surgery and prosthetic hair fibre implantation are considered forms of hair restoration surgery. The Cosmetic Practice Standards Authority (CPSA) has developed standards for both of these procedures which can be found here.

The British Association of Hair Restoration Surgeons has professional standards that its members are expected to adhere to which can be viewed here.

What do I need to be aware of?

Hair transplant surgery is becoming increasingly popular in the UK, but the sector lacks regulation. Anyone seeking surgical hair restoration should do their research very carefully before having it done.

Things to look out for

• Beware of clinic websites that do not clearly list the names of the doctors along with their qualifications and experience. Many clinics say something like ‘all our doctors are GMC registered and are amongst the best in the UK’.
• Non-medical advisors should not make surgical planning decisions e.g., the donor hair harvesting method, the hair transplant design, or the number of follicular unit grafts/hairs required.
• Only doctors should make incisions in the skin including for Follicular Unit Excision (FUE). Patients should ask the doctor at the time of the initial consultation who will be making the FUE incisions and then confirm this at the time of surgery.
• All hair transplant clinics in England should be registered with the Care Quality Commission (CQC) and all facilities where the surgery is done should also be registered. All hair transplant clinics in the devolved nations should similarly be registered with the relevant regulatory bodies.
• Hair transplant clinics should not advertise financial inducements - these include discounts. In general, very cheap offers will likely reflect a lower quality of surgery.

Further advice on factors to beware of when choosing a hair transplant surgeon/clinic can be found on the British Association of Hair Restoration Surgery (BAHRS) website here.

For those patients seeking less expensive alternatives in health tourism destinations, additional advice can be found here.

Alopecia UK would like to thank Dr Greg Williams and Dr Nilofer Farjo of the Farjo Hair Institute for providing this information.