- Best Results12 months+
- Treatment Recovery7 days
- Procedure Time2 hours
- Skin SpecialistDavin Lim
- Duration of ResultsStudies still ongoing
- AnaestheticLocal + Blocks
- Back to Work1-2 days
Frontal Fibrosing Alopecia - FUE Transplantation
Frontal fibrosing alopecia is a common form of hair loss seen in post-menopausal women. As the name suggests it affects the frontal hairline & eyebrows. Management is medical. FUE or follicular unit extraction hair transplantation can be considered if FFA is not progressive. A two-year cooling off period is recommended.
FactsFacts On FUE Hair Transplants for FFA
- FUE hair transplantation can replace hair loss in frontal fibrosing alopecia
- Your condition should be dormant for at least two years before consideration of FUE
- The frontal & temporal scalp can be treated as can the eyebrows
- FUE for frontal hair loss has a higher success rate compared to eyebrow transplantation
- The use of pulsed anti-inflammatory creams can be useful
- Medical follow up is essential for best results
What are the guidelines for hair transplantation in FFA?
The current consensus by dermatologists is that patients should be in remission for at least 2 years before considering FUE or eyebrow transplantation. Refer to the para below for a guideline.
How do I know if FFA is in remission?
There are five ways dermatologists ascertain FFA remission.
Firstly, clinical examination of classically involved areas of the brow & frontal scalp. FFA can be classed as quiescent if there is an absence of redness & perifollicular scale (scaling around the hair follicle).
Secondly dermatoscopic examination can aid in diagnosing scarring, with further magnification to exclude activity around remaining hair follicles.
Thirdly symptoms are absent in cases of remission; namely no itch or burning.
Fourth, serial photography with magnification or a trichogram can confirm the static density of remaining follicles
Fifth, histological analysis (biopsy) – rarely required, but useful in cases of doubt.
What happens if you undertake FUE if FFA is still active?
Chances are you will waste your time, effort and money. Transferring good, healthy hair follicles in a potentially hostile recipient area will most likely result in death of the hair follicle. As one has a limited number of hair follicles, this is not a sensible option.
This is why every patient should have at least a 2-year remission prior to FUE. The flipside is that having a longer remission period (e.g 10 years), does not equate to improved outcomes. More studies in the next decade will provide a clearer picture.
What are test spot FUEs & why do I encourage them?
Test spots can give an indication of probable graft survival. This involves transplanting a limited number of grafts (usually between 50 to 100) to the margins of the temples & frontal scalp. Eyebrow hair can also be transplanted. It can take up to 12 months for full growth.
Test spots are only a guide as to the probable survival rate of grafts. Viability at one year means you have a higher chance of success compared to complete failure. The flipside is that if FFA reactivates, transplanted hair follicle survival may be compromised. This is why I always work closely with a medical dermatologist to ensure you have the best chances of graft survival.
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What is the success rate of FUE hair transplants for FFA?
50-85% at the one-year mark, depending on the studies. In total there are only a handful of good studies as FUE hair transplantation for FFA is relatively new (less than 10 years old). The best studies show around 85% retention at 6 years, the worse outcomes are 50% at one year. The common take home message in all studies is that FFA should be quiescent for at least 2 years.
FUE hair transplantation in the context of FFA is not a guaranteed treatment for FFA. The survival of grafts depends on your immune system.
Can we achieve normal density with hair grafts?
Unlikely. This is based upon blood perfusion of the areas of scarring. We do not aim for absolute coverage as blood supply to the affected areas is compromised due to scarring. A conservative density is between 40-50% of normal.
There are other ways to help improve the illusion of hair density including scalp micropigmentation & importantly a good hair stylist.
Where do I take the hairs from?
The most common donor area is the back of the scalp (occipital area). In the majority of cases FFA does not affect this area, however in the minority of patients associated lichen planopilaris may affect the scalp globally. If this is the case, you are not a good candidate for FUE.
Patients with diffuse female pattern baldness are also poor candidates for hair transplantation as this reduces hair density in the donor area. Be guided by your dermatologist as to the correct treatment for your pattern of FFA.
How is FUE for FFA performed?
The most common way I perform this procedure is with a limited strip shave technique to the donor area as I only require limited numbers of hair follicles.
A strip of hair approximately 1.5 to 2 inches is shaved the day of the procedure. This means the donor site is not visible as it is hidden by hair above the strip. Local anaesthetic is injected & harvesting begins. Depending on the extent of hair loss, I typically harvest between 600 to 800 units. For cases of eyebrow FUE transplantation, one unit follicles are chosen.
The recipient areas are numbed with blocks & implantation begins. I use a variety of implanters including slit Nokor needles. This procedure takes between 2-5 hours, depending on complexity.
How long does it take to see the results?
Best results are seen 9 to 14 months after the hair transplant. Yes, FUE transplantation is a marathon. In some cases I wait nearly a year before ascertaining the viability of test patches.
Can eyebrows be treated?
Yes, FUE can be employed to treat eyebrows. The long -term survival rate (5 years and beyond) is thought to be less compared to scalp FUE.
Brow transplantation requires approximately 180 -280 single follicular units harvested from the posterior scalp. As with normal FUE, disease remission of a minimum of 2 years is mandatory. The one-year survival rate is around 80%. Newer pulsed immunosuppressives with PRP may extend the survival period. We will have more of an idea in the next decade.
I also perform test spots in some cases of brow transplantation.
Should you be on medical treatments if you are undergoing hair transplantation?
Ideally, yes. If your FFA is active, you will benefit from medical intervention. Your dermatologist will prescribe you one of the following medications-
Topically: minoxidil, anti-inflammatory medications including CS, tacrolimus or pimecrolimus. In some cases they will perform dilute steroid injections.
Orally: minoxidil, hydroxychloroquine, pulsed CS anti-inflammatory tablets, & antihormone tablets (to treat incidental androgenetic alopecia).
For the highest success rate in FUE transplants, I refer patients to medical dermatologists post operatively to ensure your FFA does not reactivate.
Disclaimer: I am a procedural dermatologist, I do not treat or prescribe any medications. Be guided by your medical dermatologist for treatment strategies.
How is post operative care different from normal FUE?
Post-operative care is paramount to increase the chances of graft survival. Clear instructions will be provided post operatively.
In most cases I work with a medical dermatologist to monitor the status of FFA. We employ a combination of low level laser therapy coupled with topical immunosuppressants in a rotational manner. This stimulates hair growth & reduces local inflammation respectively.
What are the risks & side effects of FUE hair transplantation?
In the context of FFA, the most important risk is losing hair grafts due to disease activity or inflammation. FUE transplantation for baldness has a viability of 90-95% at 12 months. In contrast, FFA hair follicle viability ranges from 50-85% at 12 months.
Other side effects include-
- Patchy growth of hair (related to hair loss)
- Graft rejection early in the course
- Failure of graft to grow – moderate timeline
- Scarring at recipient site (as the bed is already compromised with scar tissue)
- White dots from the donor site & at the reception site
*Close clinical follow up can reduce, but not eliminate side effects. Do not consider FUE transplant if your FFA is active.
What is the evidence for lasers & low level light therapy?
Over the past 5 years there have been many reports of lasers helping with regrowth.
The most promising laser is the fractional 1927 thulium wavelength. There are other reports of CO2, erbium, 1550 & numerous other wavelengths.
1927 thulium laser sessions are performed every 1-2 weeks, for 8-12 sessions. They can provide demonstrable hair growth in most, but not all patients. Lasers are best used as adjunctive therapy & not monotherapy.
How much is a FUE hair transplant for frontal fibrosing alopecia?
This treatment is partially covered under Medicare. A rebate applies.
Cost will vary depending on the number of hair follicles transplanted. In some cases I elect to perform a test patch prior to full transplantation.
Davin’s Viewpoint on FUE transplants for Frontal Fibrosing Alopecia
FFA is more common than what the papers state. For the most part, this condition is progressive up to the point of hair loss confined to the eyebrows, frontal & temporal scalp areas. Interestingly complete loss of follicular units also occur on the face (Sun T, Lim DS, 2021).
Medical intervention early is the best treatment – this goes for all forms of hair loss. Your dermatologist can prescribe lotions, injections & tablets. Early management reduces inflammation that kills the follicle.
FUE for FFA is relatively new (just over a decade old). The studies show good to excellent results (50 to 80+% uptake) at 1 year. Eyebrow transplants have excellent results initially, however permanence is questionable. My advice to patients is that transplants should NOT be undertaken if there are any signs or symptoms of inflammation. For the highest chances of graft survival, medical follow up by a dermatologist is mandatory.
Another caveat is that the typical age group of FFA patients (postmenopausal women) will have incidental female patten baldness, realistically one in five. Early medical management will decrease hair fall in this group. This is why follow up by a hair expert is so important.
Disclaimer: I do not get involved in medical management of any hair loss conditions. My work is strictly procedural. Cutis has two hair experts who are dermatologists.
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