Dr Asim Shahmalak’s guide to hair transplantation

Crown Clinic’s hair transplant surgeon Asim Shahmalak writes for some of the most prestigious medical journals in the world.

He recently wrote a 2,500 word guide to hair transplantation for PMFA– a medical journal for doctors working in plastic surgery. Here are some of the highlights:

Early developments

Modern hair transplant techniques were first developed in Japan in the 1930s, where surgeons used grafts to help restore eyebrow and eyelashes as well as the scalp hair of burns victims. It did not develop as a treatment for male pattern baldness until the 1950s when dermatologist Dr Norman Orentreich planted the first grafts in balding areas.

Techniques progressed from there and follicular unit transplantation (FUT), also known as strip harvesting, became the first popular method of hair transplantation.

FUT is where a strip of hair is surgically removed from the back or side of the scalp and follicular unit grafts (one to four hairs) are extracted and replanted in the balding area by the surgeon, using very small micro blades or fine needles. The main drawback with this method is that a scar is left in the donor area, which is visible if the patient likes to wear his or her hair short.

Early FUT procedures in the 1980s had mixed success. Patients could be left with plug-like doll’s hair, with several hairs sprouting together in unsightly individual clumps. However, techniques for replanting donor hair have improved, creating a much more natural blend with existing natural hair. Techniques for planting new hair evolved over time as surgeons became more experienced at performing the operation and shared knowledge at big conferences such as the International Society of Hair Restoration Surgery (ISHRS) Live Surgical Workshop in Orlando, Florida.

FUE and its development over the last 10 years

A different hair transplantation method, follicular unit extraction (FUE), was first developed as a technique in the 1990s by Australian physician Dr Ray Wood and his sister Dr Angela Campbell. They felt that cutting out a big patch of skin to harvest the donor hair was unnecessarily traumatic so developed a new technique where the follicular units were taken one-by-one, directly from the donor area, with fine needles. Early FUE techniques were fairly unsophisticated and there was noticeable scarring from punch grafts used to the remove the donor hair, which ranged in diameter from 1.5mm to 2mm. However, more recently, these punches have become much smaller – 0.6-1mm in diameter – meaning the scarring is almost indiscernible to the naked eye. The equipment improved and manufacturers were able to develop more sophisticated punches that limited scarring.

Modern day FUE treatments involve removing individual follicular unit grafts, containing one to four hairs, under local anaesthetic using tiny punches. The grafts are replanted in the donor area using a fine needle, typically over the course of one day. Most surgeons are able to transplant up to 4000 grafts in a single day, though operations commonly involve between 1500 and 3000 grafts. FUE is much more time-consuming than FUT and therefore it is more expensive – costing approximately 50% more per procedure.

Over the last five years FUT has been superseded as the most popular method for treating baldness in men and women by FUE. The fact that several high profile celebrities have had hair transplants using the FUE method could explain the rise in patients seeking this treatment. This shift in the preferences of patients has been apparent at Crown Clinic. Five years ago, 80% of my patients opted for FUT and 20% for FUE; now, it is the complete opposite, with 80% opting for FUE.

The main advantage over strip harvesting is that the scarring with FUE is minimal. Due to the smaller punch holes developed over the last five years, the scarring is barely visible two weeks after the operation. For the first few days, a patient has red pinpricks in the areas of the scalp used for harvesting but these fade. All incisions and cuts leave a scar, but an FUE scar is barely visible to the naked eye because each FUE scar shrinks to less than 0.5mm. I have also noticed a surge in men wanting to wear their hair short around the back and sides of the scalp – and this style favours FUE over FUT.

Patient selection

Hair transplantation is the only permanent long-term solution for baldness. Anyone who has experienced permanent hair loss may be a candidate for hair restoration surgery including men and women with pattern baldness. We do not operate on patients under the age of 25 – largely because it difficult to establish how a patient’s baldness will progress before that age. People seek transplants for a number of reasons but the most popular is to restore or change the shape of their hairline. People with areas of scarring from injuries such as burns from an accident may also be suitable for a transplant.

Patients may require more than one hair transplant procedure to cover the bald areas of their scalp. If a patient has experienced substantial hair loss it may not be possible to cover the balding areas in a single procedure. While the transplanted hair is permanent, patients may continue to lose their natural hair after a procedure because hair loss is a continual process. All men have a permanent ‘horse shoe’ of hair around the back and sides of their scalp which remains even if they suffer from severe male pattern baldness. This horseshoe is from where the donor hair is harvested. It is possible to do several procedures on most patients without the donor area thinning noticeably.

Case studies

FUE patients at Crown Clinic include the model Calum Best, presenter of Homes Under The Hammer Martin Roberts, Gogglebox star Chris Steed and the football pundit Didi Hamann.

The TV doctor Chris Jessen has had two FUT transplants with our surgeon Dr Shahmalak.


As with any surgery, there can occasionally be complications such as an infection, which can usually be remedied with antibiotics. Also, there is a chance that the new follicles become ingrown hairs, leading to cysts, though this complication is rare. These ingrown hairs need to be removed and the cysts burst. With all hair transplant procedures there is a transection rate – recording the number of grafts that fail to take hold in the donor area. Transection rates for FUT and FUE vary between clinics. A low transection rate is a good sign of quality because it reflects the expertise of the surgeon in placing the grafts. The gold standard for the FUE transection rate is 5%. The more skilled the surgeon, the lower the transection rate. It is very difficult to find average figures because clearly if a surgeon has a poor transection rate, they do not want this fact advertised.

Side-effects and postoperative care

The patient will need a week to recover from the transplant. It is recommended that they sleep slightly upright with several pillows for the first few days after a procedure to stop them damaging the new hair. The patient should wear a buttoned-up shirt for a week or so afterwards, because removing a t-shirt or jumper after a procedure can displace the transplanted hair.

In the first two weeks after a transplant, nearly all the transplanted hair falls out due to the trauma of being moved to a new location on the scalp. This is known as ‘shock loss’ and is only temporary [15]. Between eight and 12 weeks later, the new hair will begin to grow from the transplanted follicles. The new growth will progress over the next six to nine months but it can be a year before a hair transplant can be shown off to its full effect.