Bald Spot Hair Transplants

Bald spots can appear on the scalp, beard, eyebrows, or other hairy-bearing areas of the body. The most common cause is alopecia areata, which can affect either sex and may occur at any age, though the majority of the cases (80%) appear before 40 years.

Other causes, which would be discussed in the coming sections, include trichotillomania, tinea capitis, nutritional deficiencies, and scarring alopecia, etc. 

Whether a bald spot hair transplant is the right option for a patient with patchy hair loss depends upon the underlying condition. In general, bald spots due to an inflammatory condition may not be amenable to a hair transplant.

What is a bald spot hair transplant?

Hair transplant is not a recommended treatment option for a large number of patients with bald spots due to them being caused by alopecia areata.

This is because the active disease follows a relapsing-remitting course where new patches of hair loss continue to appear at different locations while the older ones may spontaneously regress. Moreover, an active inflammatory process makes the skin unsuitable for engraftment.

The only patients with alopecia areata suitable for a bald spot hair transplant are those whose disease is “burnt out”. That is, the hairless patches are stable and don’t change for a long time. In patients with alopecia totalis (where the whole scalp is involved), not enough hair is left from which follicles can be harvested. In patients with scarring alopecia, excessive hardening and fibrosis of the skin make transplant a difficult treatment option, but it has been done successfully in many patients.

When considered a suitable option, hair transplant for bald spots involves harvesting hair follicles from a donor area and implanting them into hairless patches. The methods of hair transplant currently in use initially appeared in the 1990s, with FUT becoming a popular choice for hair transplant. In the early 2000s, FUE overtook FUT as the preferred procedure and remains so to date. Some centers have started using robotics for follicle extraction and implantation to improve precision and speed up the process.

Hair transplant is a specialized procedure, done by dermatologists or plastic surgeons certified in hair restoration surgery. To find out a qualified surgeon in your area you can check for surgeons registered with a national or international association of hair restoration surgeons, like BAHRS, IAHRS, etc. Hair transplant for bald spots is a relatively uncommon procedure and a discussion with your surgeon regarding his experience in patients with this type of hair loss is advised. 

Characteristics of bald spot hair loss

Hair loss on the scalp may be diffuse or limited to discrete patches, leading to the appearance of bald spots. Diffuse hair loss is commonly due to androgenetic alopecia or pattern baldness.

Several conditions can cause patchy hair loss and bald spots, the most well-known of which is alopecia areata. This is an autoimmune disorder, characterized by hairless patch(es) which is solitary in the majority of cases but can be more than one.  The patches are typically asymptomatic. Occasionally, there may be itching or a burning sensation in the affected area.

Apart from the scalp, bald spots can occur in the beard and eyebrows. Less commonly, the process may involve extensive areas, leading to complete scalp baldness (alopecia totalis) or the whole body (alopecia universalis). The bald spots are smooth, normal-colored or slightly reddened, with hair at the margins giving the appearance of exclamation marks, as they are tapered at the roots and thicken towards the ends.

Bald spots due to alopecia areata can not be mapped on the Norwood scale, as it does not fit the distribution of male-pattern hair loss. Instead, the pattern of hair loss is expressed as patchy, reticular, ophiasis, or sisaiphao pattern, and alopecia totalis/universalis – each term having a defined extent of hair loss.

Other conditions that can lead to bald spots include:

• Trichotillomania or hair-pulling disorder: It is a form of the psychiatric condition, obsessive-compulsive disorder, in which there is persistent and excessive pulling of one own’s hair, leading to the appearance of bald spots on the scalp.
• Ringworm (Tinea capitis): A fungal infection of the scalp with patchy hair loss. Hair growth usually resumes when the infection settles.
• Scarring alopecia: This is a broad term, describing patchy hair loss with fibrosis and atrophy of the skin tissue.
•  Androgenetic alopecia and Telogen Effluvium: These conditions lead to diffuse rather than patchy hair loss, like the alopecia totalis form of alopecia areata.

Procedure options

Medical options are preferred over surgical ones in patients with bald spots due to alopecia areata. Both topical and oral medications are available.

The therapeutic agents include steroids, other immunosuppressive drugs, and minoxidil. When the response to mediations is suboptimal, minimally invasive procedures like platelet-rich plasma (PRP), micro-needling and electroacupuncture may be tried. (3) Bald spots hair transplant is suitable for non-active disease, with permanent hairless patches.  When indicated, the surgical procedures commonly in use for a bald spot hair transplant include follicle unit extraction (FUE), follicle unit transplant (FUT), and direct hair implantation (DHI). FUE is the method most commonly used as it offers aesthetic advantages over FUT. DHI, a modified form of FUE, was recently introduced with promising results.  

Other treatment options:

• Platelet-rich plasma (PRP): It may be used alone to promote hair growth, or in combination with a hair transplant to expedite the healing process.
• Micropigmentation: Scalp micro-pigmentation is an aesthetic procedure in which pigmented dots are tattooed to the scalp. It is more commonly employed in extensive hair loss and hair thinning but may be useful to fill up bald spots.

On bald spots due to fungal infection (tinea capitis) hair restoration commonly occurs after treatment with anti-fungal medications like fluconazole. Tinea capitis is of two types: inflammatory and non-inflammatory. The inflammatory type occasionally leads to permanent bald spots, for which hair transplant may be considered, once the infection and inflammation are settles. Psychiatric consultation is required for a patient with bald spots due to trichotillomania.

As a general rule, hair loss due to inflammatory conditions is less amenable to treatment with hair transplant. Regarding hair types, some surgeons find curved and frizzy hair difficult to work with but the results may be better than those for straight hair.

Bald spots hair transplant is a cosmetic procedure and is not available on the NHS.

Donor area

Hair on the back of the head is resistant to the effects of DHT – the hormone responsible for male-pattern hair loss and usually the first choice for follicle harvesting. Surgeons often use the term ‘safe donor area’ to refer to this area.

If the bald spots happen to affect this area, an alternative donor area may need to be considered. This can either be from the scalp or the body. Body areas from which hair follicles can be harvested include the beard, chest, groin, etc. Implanting body hair to the scalp will require extra care and expertise on behalf of the surgeon to ensure that the hair blends well.

Cost

The cost of a hair transplant depends on the number of grafts that need to be implanted, which in turn depends on the number and extent of bald spots. A relatively small bald spot can be covered with 500 grafts, compared to 2000 -3000 grafts required for more extensive hair loss.

An average bald spot requiring 500-800 grafts will cost £ 1250 to 4000 in the UK, depending on the clinic. In comparison, a similar transplant would cost, on average, £800 to £1500 in Turkey. The average cost per graft is £ 2,5-5 in the UK and half as much in Turkey.

Surgery in the UK vs Turkey

Turkey is among the top destinations globally for health tourists. For those looking to cut costs on a procedure like bald-spot hair transplant which is not covered by the NHS or private insurance firms, it is an attractive option.

The advantages it offers compared to doing the surgery in the UK include:

• Affordability:  Cost per unit graft in clinics in Turkey can be 50% lower than the corresponding rates in the UK. If the number of grafts required is small, the total savings may not be particularly high when travel and hotel stay is considered. On the other hand, you can expect to save up to 70% in terms of total expenditure when there is extensive hair loss, compared to the UK.
• Quality of care: Turkey has one of the highest numbers of US accredited hospitals. (6) There are several clinics with qualified surgeons, experienced in hair transplant using FUE.

The downsides of opting for a hair transplant abroad include:

• Logistics: Travel and flight considerations can make the already anxious times of surgery more stressful. In addition, some people may find hotel stay, away from family and friends, uncomfortable. 
• Work-life considerations: Given the cosmetic nature of the procedure, some employers may not count the off-time as sick leave, which would be significantly longer when the procedure is done abroad.

Risks and considerations

Preoperative Considerations:

• Before embarking on a bald spot hair transplant procedure, the underlying condition which led to hair loss must be diagnosed. Hair transplant is not recommended for bald spots due to alopecia areata when there is an active disease, which means the procedure would be unsuitable in a large number of patients. Discuss in detail with your surgeon the suitability, expected outcomes, and alternative treatment options that might be more feasible.
• There is a high risk of graft rejection when hair fall is due to inflammatory conditions or there is significant scarring of the scalp tissue.
• In the case of alopecia totalis, there wouldn’t be a large enough hair-bearing area left on the scalp to serve as a donor area. Alternative treatment options may be considered in such cases.

Risks:

• Infection: As with all surgical procedures, there is a non-negligible risk of the donor and/or recipient area getting infected. Apart from proper surgical hygiene, good post-operative care and pre-emptive use of antibiotics help in minimizing the risk.
• If a transplant is done during active disease, new bald spots may continue to appear on different areas, and might even affect the implanted hair.
• Scalp edema and allergic reactions are common acute complications, which settle promptly with over-the-counter medications.
• Long-term complications include chronic folliculitis, cobble-stoning of the recipient area, and poor hair growth. 

Bald spot transplant timeline

Consultation: Look for a surgeon with expertise in bald-spot hair transplant. Discuss in detail whether a transplant is the right treatment option for your bald spots.

Before Surgery: Prior to the actual procedure, an assessment of the donor and recipient area will be done and a rough estimate of the number of grafts and the probable outcome will be communicated.

Surgery: FUE is a minimally invasive surgery. It is done under local anesthesia and usually, there is minimal pain.

After Surgery: Scalp dryness and itchiness are common during the first week and usually settle thereafter. You will receive specific instructions regarding sleeping and washing during the first month after the transplant.

Recovery: Complete hair restoration takes 9 months to 1 year.

Results and aftercare

1-2 Weeks: There might be slight pain and the scalp will appear swollen.  Over-the-counter pain medications are helpful. Scab formation is common during this time. Avoid scratching and picking scabs.

1 Month: The implanted hair usually falls off by 3-4 weeks. It is normal, the hair falls but the follicles remain, from which new hair grows. The hair can be washed. Baby shampoo should be used and excessive rinsing and direct application of shower hose should be avoided.

2-3 months: The implanted hair would have likely shed off by now and the bald spots would still be easily recognizable.

8-9 months: By 9 months, the hair has grown sufficiently to cover the bald spot, giving a fuller appearance to the head.

1 year: Hair recovery is mostly complete by the end of 1 year. The implanted hair can be styled and combed as usual.