How Medical Conditions Can Affect Hair Transplant Success

Hair transplant has now become an art form of surgery. It can provide not only a hair, but the renewal of the spirit of living and restoring the beauty of our life. Success stories of highly visible personalities as well as aggressive marketing create a misleading perception that it’s just a simple and universal solution to any problem of hair loss, making one look several years younger and reversing the signs of time.

It is a highly deceptive perception and can have grave consequences.

Hair transplant is a procedure, the candidacy and success of which are determined by an extremely complex interaction of several underlying medical conditions. These can be a condition causing hair loss itself, systemic illnesses causing the inhibition of the body’s core mechanisms that provide healing and regeneration, and several others.

Medical diagnosis is not only a perfunctory medical formality, but the sine qua non of a safe, successful and a happy outcome.

In this article we explore a number of important medical conditions, which have a direct bearing on hair transplant. They have been grouped in categories affecting the donor supply, the viability of the recipient area, the body’s healing mechanisms and even the nature of the hair loss itself.

The Keystone to Success: The Donor Dominant Area

The entire concept of a modern hair transplant surgery is based on a principle called “donor dominance”. This is the concept that hairs, which are genetically resistant to DHT from the donor areas at the back and sides of the scalp, continue to be DHT-resistant when transplanted to the balding area. Thus, the very first and most important medical question relates to the stability and adequacy of this donor supply.

1. Androgenetic Alopecia (Pattern Hair Loss): The Prime Candidate

AGA is by far the most common cause for people seeking transplantation. However, it’s not just the present pattern and amount of hair loss that is important. The hair transplant surgeon, as a surgeon, must have the ability to predict the course of hair loss several decades into the future. This is done by extrapolating the age of the patient at which hair loss started, current severity, family history and other features. The objective is to place hair in a way that looks natural and replicates the patient’s genetically programmed male/female pattern. This hair should also age gracefully in the decades ahead, always maintaining a natural appearance. However, several conditions can mimic or coexist with AGA and muddy the waters.

2. Diffuse Unpatterned Alopecia (DUPA): An Absolute Contraindication

DUPA is by far the most important contraindication to hair transplant. This is a condition, which spares neither the recipient area, nor the “safe” donor area at the back and sides of the scalp. It causes a generalized thinning all over the scalp. The hair follicles in the donor area are genetically programmed to miniaturize and fall out in time. Harvesting follicles from an area which is programmed to become thin and fall out is asking for trouble. The transplanted hair in the recipient area will also start to miniaturize and fall out. The patient will lose all the transplanted grafts along with the native hair and will be left with a wasted resource (grafts, money and time) and a sub-par and patchy result. Thus, the recognition of DUPA, either by a trained eye, or by biopsy, is one of the first steps in screening a patient.

3. Cicatricial (Scarring) Alopecia: A Proceed-with-Extreme-Caution Zone

Scarring alopecias, such as Lichen Planopilaris (LPP), Frontal Fibrosing Alopecia (FFA), Central Centrifugal Cicatricial Alopecia (CCCA) and other such conditions, are a group of inflammatory disorders, which destroy hair follicles, replacing it with scar tissue. These conditions are active in nature.

The Koebner Phenomenon: Hair transplant involves making an injury to the scalp by punching thousands of recipient holes. In the setting of an existing scarring alopecia, this can lead to Koebner phenomenon, a classic phenomenon where an existing disease causes the appearance of new lesions on sites of trauma or injury.

The requirement of Quiescence: Even if the disease has been in complete remission (quiescent) for a period of 1-2 years (confirmed by a dermatologist), transplantation is still only a remote possibility and is fraught with a high risk of reactivation. The poor blood supply to scarred tissue also impacts the survival of the grafted hair.

Systemic Conditions: Saboteurs of the Patient’s Healing Machinery

Hair transplant is surgery, which makes wounds in the scalp. This in turn requires a normal, good healing response at a number of levels.

4. Uncontrolled Autoimmune Diseases

A group of illnesses like lupus, rheumatoid arthritis, scleroderma etc., are called autoimmune diseases because the body’s immune system is in overdrive and starts attacking its own tissues. The trauma of the transplant operation can potentially flare the underlying disease. Also, many of these patients are on medications, which dampen the body’s immunity (immunosuppressives like corticosteroids, methotrexate, etc.). While such medicines are necessary for control of the autoimmune disease, they also blunt the body’s resistance to infection, making the patient highly susceptible to post-operative folliculitis, and serious infections at the graft sites.

5. Bleeding and Coagulation Disorders

Illnesses like hemophilia, von Willebrand disease, etc., as well as medicines, which are known as blood thinners (anticoagulants like warfarin, clopidogrel, aspirin etc.) are a huge problem for a hair transplant. The procedure involves making thousands of small incisions in the scalp and uncontrolled bleeding can have several serious consequences.

Poor Visibility: The excessive bleeding into the wound area, which we call “operating field”, blurs the surgeon’s vision, making it impossible to see the tiny recipient holes that are punched in the scalp. Accurate placement of grafts in these holes is the key to a good aesthetic result. Loss of visibility thus jeopardizes the entire cosmetic goal of surgery.

Hematoma formation: A hematoma is a collection of blood under the skin. Hematomas, in addition to creating a hideous look, actually compress and occlude the small blood vessels supplying the recipient areas and the transplanted grafts, leading to death of the grafts.

Prolonged surgery and recovery: Excessive bleeding, both during and after surgery, not only prolongs the procedure, but results in more bruising and a more difficult recovery period.

While it is true that certain blood-thinning medications may be stopped a few days prior to surgery in select cases, as per the advice of a cardiologist or primary care physician, every patient is a risk/benefit ratio that has to be individually considered.

6. Poorly Controlled Cardiovascular and Metabolic Diseases

Diabetes Mellitus: Uncontrolled diabetes is a major risk factor for hair transplant surgery. Poorly controlled blood sugar levels damage the body’s blood vessels, impairing a process called “microcirculation”. This process is important for the survival of transplanted grafts, as the tiny blood vessels in microcirculation, supply oxygen and nutrients to the transplanted grafts and newly forming scalp wound. This has a marked effect on the survival of grafts, which will be much poorer in patients with uncontrolled diabetes. Also, a diabetic patient has a weakened immune system, making them more prone to infections and delaying healing.

Hypertension (High blood pressure): As with bleeding and coagulation disorders, uncontrolled high blood pressure also leads to excessive bleeding intra- and post-operatively. This also increases the risk of hematomas and poor graft take.

7. Thyroid Disorders

An underactive or overactive thyroid can cause diffuse hair loss (telogen effluvium). A hair transplant in a setting of unstable thyroid levels is an ill-advised thing to do. The hormonal imbalance, which causes the diffuse shedding of the patient’s own non-transplanted hair, will continue. The result will be highly unpredictable and rarely satisfactory. The thyroid levels must be in control and stable for a few months before a transplant is even considered.

Dermatological and Scalp Conditions

The immediate milieu of the scalp itself, must also be in a conducive condition to receive the transplanted grafts.

8. Chronic scalp infections and inflammatory conditions

Active scalp conditions like severe seborrheic dermatitis, psoriasis, or bacterial folliculitis create an inflammatory and infected milieu, which is completely inhospitable to hair grafts. Inflammation and infection both directly injure and damage the fragile newly implanted hair follicles, and also prevent the grafts from establishing a blood supply (vital for survival). All such conditions must be in complete control with topical or systemic treatment before surgery is considered.

9. Trichotillomania

A psychiatric disorder, which is characterized by compulsive urge to pull out one’s own hair. Transplanting hair into such a recipient area, only for it to be pulled out by the patient again, is clearly a nonsensical and unethical medical proposition. A hair transplant is strictly contraindicated till the underlying psychiatric disorder is well-controlled and the hair pulling behavior is stopped, after a prolonged period of time. Multidisciplinary psychiatric management, involving a psychiatrist or a psychologist is necessary in these patients.

The Subliminal Aspects: The Psychological and the Expectation of the Patient

Non-medical conditions related to the psychological makeup of the patient may also be of extreme importance.

10. Body Dysmorphic Disorder (BDD)

This is a mental health disorder, where a person becomes excessively preoccupied with some real or imagined flaw in their physical appearance that is either minor or unnoticeable to others. In BDD patients, hair loss will be such a physical feature. A patient with BDD, as a primary or secondary focus, is an extremely poor candidate for a hair transplant. The final aesthetic result, no matter how well done, will never be satisfactory to such a patient and can often actually make their anxiety and dissatisfaction worse. The ethical surgeon will screen for this and may refuse to operate on such patients, instead referring them for psychological support.

11. Unrealistic Expectations

A patient coming in for a hair transplant, who has expectations of a full and dense head of hair recreating what they had at the time of their high school graduation, despite having an advanced Norwood Class 6 or 7 type of pattern loss and a limited donor supply, is setting themselves up for a lifetime of psychological discontent. The medical and ethical responsibility of the surgeon and their team is to manage such expectations by clear and transparent counseling.

The Necessity of a Thorough Consultation and Diagnosis

This is by no means an exhaustive list. A wide range of medical conditions can complicate or contraindicate hair transplant. This is why a thorough and professional medical consultation with a detailed diagnosis is an absolute non-negotiable. An ethical and professional hair restoration clinic will:

Take a Detailed Medical History

Reviewing past and present illnesses, current medications, family history of hair loss and the patient’s own history of hair loss is an extremely important process.

Perform a Detailed Scalp Examination

A trained physician is able to check the donor area for calibre and density of hair using a densitometer, as well as look for evidence of miniaturization in the recipient area.

Order Blood Tests

Several standard blood tests can rule out a number of conditions, which can cause hair loss, like thyroid problems, anemia or hormonal imbalances.

Take a Scalp Biopsy

In doubtful cases, a scalp biopsy may be necessary to rule out scarring alopecia or any other disease process.

Require Clearance by a Specialist

Certain patients, who have a major systemic disease, may require clearance for surgery by their cardiologist, endocrinologist or dermatologist in the form of a simple written note.

A Collaborative Medical Process

Hair transplant is a wonderful, miraculous medical procedure, but it is not the panacea for all problems of hair loss. It is a procedure, which is very much intertwined with the patient’s medical health. The medical conditions, which we have listed above, in many ways define the scope of surgery and determine the boundaries of its technical feasibility, safety, and long-term success. The autoimmune patient, who’s body is likely to fight off the transplanted grafts as a foreign tissue; the poorly controlled diabetic, whose microcirculation cannot support the healing of the grafted hair; the patient with DUPA, who has no reliable stable donor area are all examples, where these conditions draw the line and determine the success or failure of hair transplantation.

The journey to a successful hair transplant therefore starts not in the OR, but in the consultation room. It begins with a partnership between a ethical, knowledgeable surgeon and a well-informed patient and can sometimes involve other medical specialists too. By screening and managing these underlying conditions, surgeons can not only help protect their patients from a poor outcome, but also ensure that the hair restoration journey is always a safe, healthy and happy experience.