Alopecia and baldness Are hair transplants always possible?

Loss of density, a receding hairline or more complex forms of alopecia: hair transplants are often seen as a miracle solution. Yet not every situation can be treated with a hair transplant. Under what conditions is it an option, and does it guarantee a natural, lasting result? MonacoSanté keeps you informed.

Alopecia, baldness, trichotillomania: what are we talking about?

In everyday language, the terms "alopecia" and "baldness" are often confused. It is worth remembering that alopecia is a generic term covering any form of hair loss, whether localised, diffuse, temporary or permanent. Baldness, meanwhile, refers to one specific form: androgenetic alopecia. This condition is hereditary and hormonal in origin. It affects around 75% of men and between 40% and 50% of women after the menopause. In men, thinning follows a classic pattern, with a receding hairline, deepening at the temples and thinning at the crown. In women, hair loss mainly shows up as central thinning along the parting, forming what is known as a "Christmas tree" pattern.

Is a transplant the solution?

This distinction matters, because each hair condition calls for a different approach. The question, "can I have a transplant?", cannot therefore be given an automatic answer. Several criteria need to be met. "It is purely an aesthetic solution to hair loss, not a curative one", explains Dr Enrica Segond, co-founder of La Clinique Monte-Carlo and a plastic surgeon. "The procedure restores a denser appearance by redistributing existing follicles, but it does not necessarily stop the progression of alopecia", adds her colleague Dr Cecilia Marcacci, medical director and hair transplant surgeon. So while a transplant is an excellent option for restoring hair density, both doctors point out that it is not a cure for hair loss itself. "It is feasible in almost 90% of cases in men. For women, it is different, because unfortunately the donor area is often affected too."

Key conditions before considering surgery

The two specialists identify four essential criteria before recommending a transplant. The first is the density and quality of the healthy donor area, located at the back of the head, in the occipital region, and on the sides, in the temporal regions. The success of a transplant depends significantly on preserving this area. Follicles are harvested there in limited quantities: once removed, they do not grow back at that spot. The follicular reserve must therefore be assessed precisely, in particular through specialised examinations such as trichoscopy, a non-invasive examination of the scalp. Second, the extent of the area to be treated needs to be considered. In cases of advanced baldness the ratio between the available donor area and the surface to be covered may prove insufficient. Third, it is absolutely essential that the alopecia is stable. "Transplanting during an active phase, without treatment to slow the hair loss, leads to an unsatisfactory result in the long run. Even though hair loss in men can start when testosterone levels begin to rise, between the ages of 14 and 16, it is best not to carry out a transplant before the age of 25", confirms Dr Marcacci. The fourth criterion concerns the patient's expectations. "It is not a miracle. A thorough consultation should make clear what is medically achievable", the specialist insists. A pre-operative appointment should determine this precisely, taking into account facial morphology, available density and the likely progression of the alopecia.

When is a transplant contraindicated or impossible?

There are several clinical situations in which hair transplantation is strongly discouraged or simply not possible, particularly in cases of autoimmune and inflammatory alopecia. "Conditions such as lichen planopilaris, lupus, alopecia areata or frontal fibrosing and scarring alopecia are major contraindications. Whenever an alopecia has a persistent underlying cause, a transplant is out of the question. If the disease is still active, the immune system would attack the transplanted follicles in exactly the same way", explains Dr Cecilia Marcacci. Another absolute contraindication is trichotillomania, a disorder that first and foremost requires psychological support, as it drives the person to compulsively pull out their own hair, producing a very specific form of alopecia. "As long as the behavioural cause has not been addressed, no transplant can be considered, since the grafts risk being pulled out. What is more, repeated pulling causes chronic inflammation of the hair bulb, which can progress to irreversible scarring alopecia", warns Dr Enrica Segond. More generally, people with active cancer, severe uncontrolled diabetes or those on immunosuppressant treatment, are excluded from any surgical procedure.

In women, a more complex indication

Hair transplantation is not reserved for men, but the indications in women are often more delicate. In some forms of female alopecia, the donor area itself may be affected by thinning and may not provide enough healthy follicles. A transplant can therefore only be considered in certain situations, following a thorough assessment. Women also consult for other hair-related issues, linked in particular to changes in the hair fibre, hormonal fluctuations or certain nutritional factors. "We can offer them blood tests to check for nutritional deficiencies, because hair sometimes suffers as a result of certain diets, eating patterns, or following weight loss", explains Dr Segond. In these situations, correcting deficiencies, or medical and regenerative treatments, may then be the preferred approach.

Diagnosis and therapeutic alternatives

Faced with the growing trend for low-cost medical trips abroad, particularly to Turkey, the surgeons warn of the risks of over-harvesting and poorly designed and positioned implants, which can permanently damage a patient's hair capital. "It is very important to see a specialist experienced in transplants, one who will tell you honestly what can and cannot be done. A diagnosis and lifelong support are essential", says Dr Segond. When a transplant is not possible or is premature, regenerative medicine alternatives can be offered to stimulate dormant follicles, such as needle-free mesotherapy, LED light therapy, growth factor therapies or targeted supplements. Personalised follow-up makes it possible to tailor care to each situation, slow the progression of certain forms of alopecia as much as possible, and preserve the hair over the long term. When it comes to hair transplantation, the right question is therefore not just "is it possible?", but rather "is it right for me, today and in the years to come?".