Compared to men, the causes of hair loss among women are more insidious and harder to diagnose. Thankfully, while minimally-invasive procedures such as hair transplants are available to counter the problem, more can be done to educate the public about them, says Dr Harold Ma from Freia Medical

(Q) What is a hair transplant?

(A) A hair transplant is a minimally invasive procedure that moves healthy hair follicles from an area of the head called the donor site to a bald or balding part of the body known as the recipient site. The donor site is usually the back of the head as it is rarely effected by male pattern baldness. The hair cover is very dense at the back so there is a good reserve of hair that can be used for transplantation.

Hair density refers to the number of hair follicles per square centimetre as opposed to hair thickness, which refers to the calibre or thickness of individual hair shafts. Although primarily used to treat male pattern baldness, transplants can also be used to increase the hair density of beards and sideburns for men, eyebrows for either gender or reshaping female hairlines. A hair transplant is also performed in gender reassignment patients to create a more feminine hairline, for example.

(Q) Why do women lose hair?

(A) The causes of hair loss are multiple, varied and it is not within the scope of this article to cover every cause in detail.

Female pattern baldness is genetic, although it is often aggravated by underlying conditions such as a thyroid disorder, iron deficiency (anaemia), hormonal imbalance (polycystic ovarian syndrome) and other nutritional deficiencies. Traction alopecia, a type of hair loss which occurs when the hair is pulled back too tightly over a long period of time could also occur for example, among ballerinas, competitive swimmers and Sikh men who wear their hair up in turbans.

Ageing and menopause can cause individual hair shafts to grow thinner so that even though the number of hair follicles per square centimetre (the density) of hair remains the same, it looks sparser because the individual shafts are thinner.

Telogen effluvium is a type of alopecia where there is generalised, widespread thinning of the hair, rather than specific bald patches. The hair feels thinner, but you’re unlikely to lose it all and your other body hair isn’t usually affected. Excessive stress, major surgery, post-pregnancy hormonal fluctuations can trigger telogen effluvium. Thankfully, this condition is usually self-limiting and with the right treatment, the hair volume and density can bounce back within months.

(Q) What are the techniques for hair transplant procedures and what are their pros and cons?

(A) There are two methods main methods for hair transplants: the older STRIP method and the more recently developed Follicular Unit Extraction (FUE) method which has now largely replaced STRIP.

The STRIP method requires the physician to make an incision at the back and sides of the scalp to obtain hair grafts. The scalp is then stitched together to close the wound. The grafts are spliced into individual units before they are transplanted in the bald or thinning areas of the head.

This method is by far the most invasive method of hair transplantation and inevitably leads to a linear scar. Prolonged pain, swelling and even a loss of sensation in the area where the strip was obtained can be encountered. This procedure also involves more downtime than the more modern Follicular Unit Extraction (FUE) where the hair follicles are harvested individually from the donor site and then transplanted likewise into the recipient site. There is no cutting or stitching. As such, the FUE method is less invasive than the STRIP method. This also means a much faster recovery and almost no pain.

The more advanced FUE process requires painstaking attention to detail and a level of skill that can only be acquired with a lot of practice to be successful. Depending on the area to be treated, this daytime procedure usually takes from four to six hours; typically including a meal break and rest for the patient.

The patient will first undergo a consultation with the physician who will determine suitability for the hair transplant procedure. This includes evaluating if the patient has a donor site filled with healthy, viable hair follicles.

On the day of the procedure, the donor site is trimmed short and the hair washed as part of the preparations. Prophylactic antibiotics, pain relief and anti-swelling medication are routinely prescribed to ensure a smooth and speedy recovery.

The physician will carefully harvest hair follicles from across the donor site under local anaesthesia. To preserve them, the hair follicles are stored in a holding solution at strictly-controlled temperatures which will keep them viable for about six hours. Speed is of the essence; as hair follicles are cut off from oxygen and blood supply after they are harvested, they must be replanted into the scalp as soon as possible.

As every harvested hair follicle is precious, the physician takes pains to ensure that every one of them is viable for transplant. Under a microscope, hair technicians inspect and tally the number of hair follicles harvested as part of the stringent hair transplant quality control. The physician will then mark out the recipient area where all of the harvested hair follicles will be transplanted. He makes little micro-incisions in the area, determining the angle, direction and density of the new hairs. This step is vital to create a natural and successful result.

The patient will have a short lunch break provided in the clinic. After lunch, the physician’s assistants will commence planting the hair follicles in the recipient area using precision instruments, ensuring that the direction, angle of growth of each harvested strand is placed optimally in the recipient site.

(Q) Is there any pain during or after the procedure?

(A) The procedure is done under only local anaesthesia. Apart from mild discomfort in the initial few moments, the entire hair transplant process is painless. Patients are routinely given post-procedure pain killers, although most do not need to take any. Some patients feel mild ache or itch as the wounds heal.

(Q) Is there any downtime?

(A) Patients normally need between five to 10 days of downtime, depending on the nature of work and social commitments. Most patients can work from home the very next day, and return to most activities after 1 week, including sports.

(Q) What is the success rate of hair transplant procedures?

(A) There are three factors that determine the success of hair transplant procedures – the availability of healthy, viable and abundant hair follicles at the back of the head, proper handling of hair follicles from harvest to implantation to ensure their viability, and finally the proper transplant of hair follicles to achieve the most natural angle, density and direction of hair growth. If any of these are compromised, the outcome of the hair transplant procedure will be affected, sometimes with disastrous long-lasting effects. We have encountered and repaired the results of suboptimal treatments that several of our patients had the misfortune to have undergone. The results of a good hair transplant should last a long time (10 to 15 years), if not a lifetime.

(Q) Are there any instances where the physician will not recommend a hair transplant to the patient?

(A) Suitability for a hair transplant depends on a few factors: The patient must have healthy and viable hair follicles in sufficient numbers for a hair transplant to be successful. Because there is a limited, finite donor hair density, it is very important to make every single transplanted hair count. The patient must not have too advanced a stage of male pattern baldness; if the bald area is too big there may not be enough hair available from the donor site to cover the thinning areas.

The physician will also subject all potential hair transplant patients for a pre-op screening blood test to ascertain that the patient is in good health and does not have any underlying issues that may affect the hair transplant, for example: (a) hormonal issues (b) nutritional deficiencies and anaemia or (c) thyroid disorders that could be causing hair loss.

In the case that the hair loss can be linked to any of these factors, these conditions must be treated first before considering a hair transplant. In some cases, a hair transplant can be avoided if the underlying cause is treated successfully.

Dr Harold Ma from Freia Medical

Dr Harold Ma from Freia Medical


Dr Harold Ma is the medical director of Freia Medical, founded in 2006. A medical graduate of National University of Singapore and a dermatology diploma holder from the prestigious University of Cardiff in Wales (United Kingdom), he is very passionate in the Follicular Unit Extraction (FUE) method as an effective way of permanently restoring hair. Over the years, he has honed his skills and trained an in-house hair restoration team to support him in performing hair transplant procedures that are considered world-class.