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Everything you need to know about hair restoration surgery

We asked hair loss surgeon and EV expert Dr Greg Williams to talk us through this increasingly popular procedure

Hair loss is normal, in fact we lose around 100 strands of hair a day. However, more than that and you’re veering into abnormal har loss that can lead to balding.
According to NHS figures, male pattern baldness is the most common type of hair loss for men, with around half of all men presenting with the condition by the age of 50 (it usually starts around the late twenties and early thirties). The NHS has estimated that eight million women in the UK also experience hair loss by the age of fifty.

Characterised by thinning at the crown and temples, androgenetic alopecia, aka female pattern hair loss is the most common form of hair loss in women.

But there are lots of other forms of hair loss, from traction alopecia caused by hairstyles which repeatedly pull on the hair and central centrifugal cicatricial alopecia, a condition that develops in the middle of the scalp and spreads outwards like a Christmas tree, to telogen effluvium, which occurs when large numbers of follicles on the scalp enter the resting phase of the hair growth cycle and the growth phase doesn’t begin.

The causes are also plentiful, from autoimmune conditions and hormonal issues to genetics, lifestyle, stress and scalp infections. But when it comes to treatments success varies greatly, which is why those who can afford it are opting to undergo hair transplant surgery. But what does this entail exactly? We asked EV expert and renowned hair transplant surgeon Dr Greg Williams to explain.

What is hair restoration surgery?

Hair transplant surgery replaces hair where it has been lost or introduces it to areas where it is desired. Both hair transplant surgery (where a patient’s own hair is used) and prosthetic hair fibre implantation (where a synthetic fibre is used) are considered forms of hair restoration surgery. And while it is becoming increasingly popular in the UK,  the sector lacks regulation.

How is it performed?

The principle behind hair transplant surgery is that hair is taken from one part of the body and transferred to another. There are two methods for harvesting the hair – Follicular Unit Excision (FUE) and Linear Strip Excision (often referred to as Strip Follicular Unit Transplantation or Strip FUT). One method is not better than the other, but they have different advantages and disadvantages.

The main disadvantage of the strip technique is that it is more invasive and more painful post procedure, takes longer to heal, and leaves a linear scar. However, in most patients, more hairs can be harvested safely with this method. The strip of harvested scalp is divided under microscopic magnification into the naturally occurring individual clusters of hairs called follicular units.

With the FUE method, these follicular units are instead removed individually, leaving small round holes that heal with circular scars that are about 1mm in diameter.

With this technique, the larger groupings of hairs can be preferentially harvested. Once the follicular units have been harvested, they are implanted in the recipient site. This can be done using forceps or dull implanter devices, inserting the hairs into pre-made incisions or using sharp implanters where the skin incision is made, followed immediately by the implantation of the follicular unit by depressing the plunger of the implanter device in the same way that is done with dull implanters.

While it is acceptable for non-doctor assistants to implant the grafts with forceps of dull implanters, only doctors should use sharp implanters.

Who makes the best candidate for hair restoration 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, as every case is unique.

Be aware that in order to make a definitive diagnosis, a biopsy might be required, and if the hair loss is ongoing, trying to stabilise it with medical or non-surgical treatments might be the initial course of action before surgery can be considered.

How does surgery differ between men and women? 

The techniques for harvesting and implanting hair in men and women are the same, but the way in which the hairline is ‘designed’ usually differs between men and women. The creation of female hairlines is an important part of transitioning for trans women too, and again, the techniques used are the same.

In terms of different hair types, are there any differences when it comes to transplant surgery?

Curly hair, of which Afro-textured will be the most tightly coiled, will be more difficult to harvest with the FUE method and there will often be a higher rate of accidental cutting or harming of the hair bulb. In general, a larger diameter punch will be required which will usually result in slightly larger round scars.

Is there any pre procedure prep?

Pre-operative instructions will vary from clinic to clinic, so patients should be clear what the doctor who is doing their surgery has recommended. Some medications or supplements might need to be stopped, alcohol might need to be avoided and there might be a preferred hair length.

What can patients expect post-surgery?

A modern hair transplant, when well planned and performed, should look completely natural. It should be difficult to differentiate the transplanted hairs from the native ones. However, if hair loss continues over time, the transplanted hairs might become isolated and might not look natural.

This is particularly true for hair transplants that just involve the hairline, temple recessions, or the crown. There is also a limit to depth of hair density that can be achieved per procedure, so patients should clarify with the doctor what this will be.

What should people look out for when choosing a hair transplant surgeon?

Patients seeking surgical hair restoration should do their research very carefully before having it done.

In particular, 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, i.e 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.

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

What is the cost?

The cost of a hair transplant will vary significantly between providers but is generally dependent on the number of follicular unit grafts/hairs that have been recommended.

Hair transplant clinics should not advertise financial inducements – these include discounts. In general, very cheap offers will likely reflect a lower quality of surgery.

Greg Williams, Hair Transplant Surgeon

I am a Plastic Surgeon with a full time practice in Hair Restoration Surgery. I spent just under a decade as an NHS...

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