Forehead Hair Transplants

The forehead is a visually conspicuous part of the face and frontal hair loss leading to a high forehead often leads to a significant change in appearance and personality.

Frontal baldness due to hairline recession is usually the first sign of androgenetic alopecia and the forehead hair transplant is a common cosmetic procedure in middle-aged men.

A high forehead is not always due to hair loss; a naturally large forehead can also create the impression of frontal baldness, both in men and women. For this, a hair transplant on the forehead is a treatment option and an alternative to forehead reduction surgery.

What is a forehead hair transplant?

Hair transplant as a mainstream cosmetic procedure was first introduced in the 1950s (See hair plugs). The techniques has since then evolved considerably in terms of modernization of equipment and improvements in results.

The modern technique of follicle unit transplant (FUT) was introduced in the 1990s and along with the newer modality, follicle unit extraction (FUE), is the current standard surgical technique for various types of hair transplant including forehead hair transplant. Apart from transplant, medical treatment for forehead hair loss is available, like Minoxidil and Finasteride, but their results are often short-lived and hair loss resumes in a large number of patients when the medications are stopped.

Planning for a forehead hair transplant begins with a discussion about the most appropriate hairline contour and the extent to which the forehead needs to be lowered. Of the two currently used surgical procedures FUE is the more common method used, in which hair follicles are extracted from the donor area and implanted into an already marked area on the frontal scalp and high forehead.

The back of the head is a common donor area as the hair there is relatively resistant to the actions of dihydrotestosterone (DHT), the hormone responsible for pattern balding and forehead hair loss. If FUT (follicular unit transplant) is used as a technique for the procedure, then a strip of scalp containing hair follicles, instead of individual follicles, is harvested from the donor area. This may lead to visible scarring of the donor area and is less commonly used nowadays.

Some centers have started using robotics for follicle extraction and implantation to improve precision and speed up the process. FUE, FUT (and DHI) for forehead hair transplants are specialized cosmetic procedures. A minimum skill set in surgery and cosmetics is required to perform them. Doctors trained to perform FUE, FUT or DHI usually have a background in plastic surgery and dermatology.

Characteristics of forehead hair loss

Frontal or forehead hair loss is common in men with androgenetic alopecia – the most common cause of baldness in men. It typically starts at the temples and progresses forward to affect the forehead and hairline.

Thinning of hair continues backward, meeting an area of hair loss at the crown to produce complete baldness. The extent of hair loss can be mapped out according to the Norwood scale, which uses grades hair into seven categories. Type I means minimal, frontal hair loss. Type 2 baldness refers to significant thinning of the forehead and frontal scalp. The most severe category is type VII, which means complete baldness with only a thin horseshoe-shaped strip of hair remaining on the back and sides of the head.  

The result of forehead hair loss is the appearance of a high forehead. This appearance can also be due to a naturally large forehead without any hair loss. Another condition causing a high forehead is the maturing hairline in which the hairline changes after puberty attaining a higher position and exposing more of the forehead and temples. This is a physiologic process and almost universal in men.

Androgenetic alopecia is also a common cause of hair loss in women but the pattern is different and typically does not result in frontal baldness but a general thinning of the hair, commonly manifested first as widening of the part line. Common causes of forehead hair loss in women include frontal fibrosing alopecia, traction alopecia, and alopecia areata. Frontal fibrosing alopecia affects post-menopausal women.

The hair loss in traction alopecia, as its name suggests, is due to repeated pulling of the hair mostly due to tight hairstyles. Alopecia areata is an inflammatory condition leading to the appearance of discrete bald patches in the scalp, eyebrows, and other hair-growing areas of the body. Other factors that might play a role in hair loss include a genetic predisposition to hair loss, smoking, and stress.

Procedure options

FUE, FUT, and DHI are the surgical procedures currently in use for various types of hair loss including forehead hair loss. FUE is the one more commonly used as it offers several advantages over FUT. DHI (direct hair implantation) is a modified version of FUE.

In FUE, individual follicles are harvested from the donor area, placed in a solution to avoid desiccation, and then implanted onto the recipient area. In DHI, harvesting and implantation are done simultaneously, obviating the need to store harvested follicles. DHI is a new procedure with good results. The disadvantages of DHI include its relative complexity and longer duration of the procedure.

Alternatives to forehead hair transplant include the use of platelet-rich plasma (PRP), micro-pigmentation, and forehead reduction surgery. When used alone the results of PRP are inferior to hair transplantation. However, many surgeons use PRP as an adjuvant to hair transplant to expedite the recovery process and promote healing. PRP is derived from a patient’s blood and injected into the scalp after the hair follicles are implanted. Micropigmentation is a non-surgical hair loss solution that involves tattooing dots in the scalp to create an illusion of fuller hair.

Considerations before undergoing a hair transplant procedure include follicle density of the donor area, hair color and texture, the contrast between skin and hair color, and suitability of the recipient area. Patients with hair loss due to an inflammatory condition may not be suitable candidates for hair transplant surgery. Curly or frizzy hair (Such as afro hair) may be difficult to work with during transplant but the results according to some surgeons are better than with straight hair.

Hair transplant procedures are not available on the NHS as they are cosmetic surgeries (1). For the same reason, they are usually not covered by private insurance firms either.

Transplant Vs forehead reduction surgery

Forehead-reduction surgery is an alternative to transplant for patients with frontal hair loss and a high forehead. The procedure involves surgically removing part of the forehead skin to lower a high forehead.

Its advantages, compared to hair transplant, are:

• On average, 2 cm lowering is achieved via the procedure, although as much as 5cm is possible (2). In comparison, covering a similar area would require implanting 7000 to 9000 follicle grafts.
• Like a hair transplant, the procedure can be performed under local anesthesia.
• With forehead reduction surgery (FRS), the results are immediately apparent after the procedure, while hair transplant takes 9-12 months for significant hair restoration.

Its comparative disadvantages include:

• The procedure requires a stable frontal hairline and mobile scalp. This excludes a large number of male patients since their hairline is often unstable due to persistent recession. The ideal candidates for FRS are females with a genetically high frontal hairline. Hair transplant, on the other hand, is suitable for a wider variety of hair loss patterns.
•  Forehead reduction surgery may leave a visible scar, which is uncommon with an FUE hair transplant.
• FRS may require a follow-up hair implantation to achieve the desired hairline, although the number of grafts required is significantly lower than those for hair-transplantation surgery.

Cost:

• In the UK, a forehead-reduction surgery costs on average GBP 7500 (3). The cost of hair transplantation ranges from GBP 1000 up to 30,000 depending on the extent of hair loss, type of procedure, and the transplant team. (1)

Donor area

A safe donor area is an area that is expected to be permanently covered with hair so that the follicles harvested from it will remain in the recipient area for a lifetime.

Hair at the back of the head is usually permanent as it is resistant to the effects of DHT – the hormone responsible for pattern-baldness. This is the most commonly used donation area for hair transplantation on the forehead and other areas of the scalp.

If hair cannot be harvested from the back of the head, other body areas like the beard, chest, and groin can be used as alternative donor sites. Implanting body hair to the forehead will require extra care and expertise on behalf of the surgeon to ensure that the hair blends well.

Cost

Depending on the extent of hair loss, a hair transplant can cost anywhere from GBP 1000 to 30,000. Most clinics charge per graft unit and may provide a graft calculator to provide a cost estimate.

Minor adjustment may require as little as 500 grafts while more extensive coverage from temple to temple can take 2000 or more grafts. On average, early frontal hair loss (Norwood scale 2) requiring 500-800 grafts will cost £ 1250 to £4000 in the UK.

In comparison, a similar transplant of 500- 800 grafts would cost in the range of £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

With rising medical costs, health tourism is becoming popular in Western countries. It is a particularly attractive option for elective procedures like forehead and other types of hair transplant which are not offered by the NHS.

Turkey is a popular health tourism destination with the quality of healthcare at par with many developed countries. For a hair transplant, there are many clinics in Turkey where expert surgeons use the modern FUE procedure. The cost of a forehead hair transplant in private clinics in the UK can be significantly higher than those offered in Turkey. When the combined costs of travel, hotel stay, and transplant procedure are considered, you can still save up to 70% on your hair restoration treatment in Turkey, compared to the UK.

While opting for a hair transplant procedure abroad, the logistics of staying in a foreign country, visa, and travel issues are important considerations. If you are employed, you will need to take leave from work which may not be counted as sick leave considering the cosmetic nature of the surgery. While the surgery at a local clinic will be a daycare procedure from which you can return to work quickly, travel abroad would mean significant off time. For extensive hair implantation, repeat sessions may be required, which would mean a lengthy stay abroad or repeat visits.

Risks and considerations

Preoperative Considerations:

• Forehead reduction surgery is an alternative to a forehead hair transplant and might be a more suitable option for some patients. Discuss with your surgeon the pros and cons of each before committing to either.
• Some patients who undergo a forehead hair transplant for frontal hair loss may experience thinning of the vertex later on and may require a second transplant to cover the vertex.
• Before graft harvesting and implantation, the hairline on the forehead is mapped out whose contour depends on the patient’s ethnicity, face structure, patient preference, and pattern of hair loss.

Risks:

• Infection: Both the donor and recipient areas are at the risk of getting infected. With modern hygienic standards, the risk of infection is low but not insignificant. Antibiotics are commonly used in the first few days to minimize the risk.
• FUT may occasionally lead to scarring of the donor area. The increasing use of FUE has reduced this complication.
• When body hair is used, its texture and color might be different than existing scalp hair.
• Short-term complications of forehead hair transplant include scalp edema, swelling, and allergic reaction that settle promptly with over-the-counter medications.
• Long-term complications include chronic folliculitis, cobble-stoning of the recipient area, and poor hair growth. 

Forehead hair transplant timeline

Booking Appointment: The first visit would be about assessing the adequacy of the donor area, estimating the number of grafts and the likely number of sessions the procedure will take.

Surgery: The procedure is done in sessions, with 3000 to 4000 grafts implanted per session. Each session lasts 4-5 hours. It is done under local anesthesia and usually, there is minimal pain during the process.

1-2 postoperative days: Swelling, tightness, and slight pain are common and would settle with pain medications.

First few weeks: Many patients experience itching, scalp dryness, and scabs during the first week. Don’t be alarmed, it is normal. Don’t pick the scabs and avoid scratching. The scabs will fall off spontaneously by the second week.

Recovery: It takes, on average, 9 to 12 months for the implanted hair to grow significantly.

Before and after pictures

This is a collection of before- and after-transplant pictures, of patients who underwent a forehead hair transplant.

1. Picture of a patient with a high forehead due to forehead hair loss
2. Picture of a patient whose hairline is mapped out before the procedure.
3. Picture of a patient immediately after the procedure. The recipient area may be swollen for the first couple of days.
4. 9 months post-implantation: After a successful FUE, the hair looks fuller with a marked lowering of the forehead.

Results and aftercare

1 Month after surgery: After FUE recovery is quick and the patient can return to work after a day or two. The implanted hair usually falls off by 3-4 weeks. It is normal and not a cause for concern. You can wash your hair with a mild shampoo but avoid direct application of water from a hose or shower. Massage gently avoiding excessive rinsing.

2-3 months: The implanted hair would have likely shed off by now and your forehead would look similar to how it was before transplant.

8-9 months: By now sufficient growth is achieved with the forehead appearing fuller.

1 year: Hair recovery is mostly complete by the end of 1 year. Good results are expected after FUE with up to 80% of the transplanted hair showing growth.

References:

1- https://www.nhs.uk/conditions/cosmetic-procedures/hair-transplant/

2 – https://pubmed.ncbi.nlm.nih.gov/32312507/