Hair Transplant Surgery: What To Look For In A Surgeon

WebMD Medical Reference from the American Hair Loss Association

The specialty of hair transplant surgery has undergone profound changes over the past 5 years—and not all for the better. Social media, radio, television, and traditional print media market to the vulnerable hair loss consumer a more risk-free, guaranteed product as opposed to the highly specialized cosmetic surgical procedure it is. This article is intended to steer you in a more honest direction so you know for what to look in a hair transplant surgeon.

While there have been notable technological advancements, like robotic-assisted surgery,  suction-assisted follicular extraction, and semi-automated graft implantation, these advancements, according to recognized hair transplant specialists, have, at best, a minimal impact on improving the surgical outcomes and/or the lives of hair transplant patients. Also, all surgical instruments are user-dependent and, if unskilled, poorly trained practitioners use them, the potential to cause significant, permanent disfigurement is very real. In today’s fast-growing, brand-driven, multi-billion-dollar hair transplant industry, patients must do their due diligence to make informed decisions so they choose a qualified hair transplant surgeon. 

Performing state-of-the-art hair transplant surgery requires a team effort. In the traditional follicular unit transplant harvesting technique (FUT), which now accounts for less than 30% of all hair transplant surgeries worldwide, the surgeon removes donor tissue from the back of a patient’s scalp using a scalpel, sutures (or staples) the area closed, and then hands the tissue to his or her technicians to dissect into individual follicular units known as grafts. A team of technicians, under the guidance of the surgeon, places these grafts. This team effort makes it possible to place thousands of grafts in a single day.          

Since its introduction in the early 2000’s, the Follicular Unit Extraction (FUE) harvesting technique has slowly become the procedure of choice by most patients and in turn by most practitioners since the procedure is generally less invasive. However, because it is labor intensive, many physicians delegate more surgical responsibilities to their staff, including dissection and removal of grafts from the scalp, thereby making it even more critical that prospective patients not only understand how to choose a surgeon and their team but are also fully aware of who (physician or assistant) is performing which aspects of the procedure. 

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The only clear advantage of the FUE technique is that a scalpel is not used to harvest the donor tissue and hair follicles. No stitches are required; no linear scar is left behind. FUE also minimizes possible complications, including temporary or, in rare instances, permanent numbness or lack of sensation on the treated donor area of the scalp because donor hair is harvested using small diameter surgical punches, dissecting and removing one graft at a time. This results in tiny punctate (round) wounds that can heal on their own within days as opposed to a single, long wound that requires surgical closure. 

While FUE can be fantastic, since the technique is minimally invasive, it is only one small part of hair transplant surgery, with much of the final result depending on proper patient selection, hairline design, recipient site creation, proper handling and surgical refinement of individual hair grafts, and many other critical steps to ensure both graft survival and a natural aesthetic. The point: Do your research! Today’s marketing of hair transplant surgery tends to leave out the most critical aspects of the procedure, focusing only on the type of harvesting or surgical device being offered. Many consumers are misled, told the procedure is somehow scarless or, worse, not even surgery. When in fact there is no such thing as scarless hair transplant surgery. Discuss all pros and cons of the procedure with a qualified hair transplant surgeon during your surgical consultation. 

To begin your search, you might contact the International Alliance of Hair Restoration Surgeons (iahrs.org), a consumer organization that selectively screens skilled and ethical hair transplant surgeons. The IAHRS does not offer an open membership policy to doctors practicing hair transplantation and is the only society that recognizes that all surgeons and surgical teams are not equal in skill and technique.

Next, ask prospective surgeons how long they have worked with their teams. Historically, larger clinics have a much higher staff turnover rate, so going to an individual practitioner or group usually is best. However, since introducing turnkey FUE harvesting devices (which consequently introduced the per-diem, traveling tech model whereas surgical technicians are hired via a smartphone app or tech agencies among other ways), more than ever before, you must know who your technicians are, if they work full-time for the surgeon, and what their experience and duties are during your hair transplant surgery.
  
Be sure to do the following:

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1. Ask your hair transplant doctor for a minimum of 10 sets of before-and-after photos of previous patients—taken at the same angle, with the same background, and in the same lighting, clearly showing the hairline as well as the mid-anterior scalp (the top area between the hairline and crown). This ensures there are no discrepancies when looking at individual cases, allowing you to adequately and truthfully compare the transformations. Also ask for photographs of donor scars (both FUE and FUT) on the back of the scalp after hair-bearing tissue is removed for transplantation. Unfortunately, in today’s market, images or videos presented to you, the prospective patient, are not always of patients of the physician with whom you are consulting. Sometimes, a product manufacturer supplies them for marketing purposes. Ask if these examples are actually patients of the practice with which you are consulting.  

2. Request the names and phone numbers of at least six patients whom you can contact to discuss their experiences with the physician and staff. And, if possible, speak with two physicians who previously used this surgeon and team.

3. Meet patients who have similar hair and skin characteristics as you, so you see the results for yourself and assess the hair transplant physician's ability to provide you with a realistic and beneficial outcome.

4. Ask if the following questions if the hair transplant doctor or hair transplant group you are considering claims to be performing either or both follicular unit extraction (FUE) or follicular unit hair transplantation (FUT):

For FUT:
1. Are the grafts microscopically dissected?
2. Do all the technicians use stereo-microscopes?
3. How long have the technicians been using microscopes to dissect follicular units?
4. How many stereo-microscopes are used during a procedure?
5. Does your hair transplant doctor use a single-bladed knife to excise the donor strip? (The answer must be "yes.")

For FUE:
1. How many FUE procedures has the physician performed?
2. Who performs the dissection of the FUE grafts—the surgeon or the technicians? If the surgery is technician-driven, find out the technicians’ qualifications and if they are full-time employees or work on a per-diem basis. (Full time is preferred.) Depending on the state or province, the legality of technicians to perform that aspect of the surgery varies. In some manipulatives, the legality of technicians cutting or scoring the skin to dissect and remove tissue is questionable.
3. Are the FUE grafts examined and refined under a microscope before implantation? This is a critical step to ensure a natural result; often newer FUE-only practices do not do this. 
4. Have any complaints been filed against the hair transplant doctor or hair transplant group? Contact your state medical board for details.

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It is important to note hair transplant surgery is real surgery. While the vast majority of hair transplant clinics offer free, no-obligation online or in-person consultations to attract potential patients, do not be dissuaded to consult with a surgeon who charges a consultation fee. In most cases, the surgical evaluation will be more thorough and performed by a physician, not an unlicensed consultant more concerned with selling you a procedure. If you are a good candidate for surgical intervention, consultation fees are normally deducted from the cost of surgery. 

The American Hair Loss Association recognizes that a handful of top hair transplant surgeons offer free consultations in order to compete in this new, commoditized market. However, it is recommended that prospective patients include consultation fees in their surgical budgets so they fully do their due diligence when seeking out the best surgeon for their particular needs. Paying for a consult with a top surgeon is how almost every other medical specialty operates; the same should apply to hair transplant surgery.

WebMD Medical Reference from the American Hair Loss Association Reviewed by Paul J. McAndrews, MD on July 18, 2019
© American Hair Loss Association. All rights reserved.

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