Greg Williams, plastic surgeon and hair transplant surgeon talks about the impact of hair loss and what you can do about it.
Hair loss occurs for a variety of reason and for both men and women it can have a huge psychological impact, and for many people their distress levels have risen with lockdown and the rise in zoom-style meetings where you are looking at yourself for extended periods.
Dr Greg Williams says it isn’t always easy to get the right advice on what to do about hair loss. It’s a complicated are and there are multiple types of hair loss with varying causes. Often GPs and dermatologists aren’t experts in it, he says, unless they specialise in hair loss.
Dr Williams suggests finding a good trichologist or dermatologist, adding the British Hair and Nail Society as a good starting point in your search.
A good diagnosis is crucial for determining the best treatment for you.
Types of hair loss
Dr Williams says there are two types fo hair loss – scarring and non scarring alopecia – the medical term for hair loss. Scarring alopecia can be divided again into primary or secondary. Examples of secondary hair loss include hair loss from burns or surgery.
“The follicles are damaged and they aren’t going to come back,” he says.
Primary alopecia is often caused by our autoimmune system which starts to attack the follicles and there’s a lot of inflammation.
“It can be in some cases reversible or you can stop the progression,” he says. “A non-scarring version which can be reversible in some circumstances is Alopecia Areata.
“For me, as a hair transplant surgeon, there are some conditions that are suitable for hair transplants and some that are not.”
Ones that fall into the suitable category for transplant surgery are:
- Male Pattern Hair Loss and Female Pattern Hair Loss
- Traction alopecia
- Secondary scarring alopecia from scars or burns
- Congenital conditions like temporal triangular alopecia
Alopecia Areata is not suitable, nor is Frontal Fibrosing Alopecia, a condition that is becoming increasingly common, especially in menopausal women. It is thought to be a variation of Lichen Planopilaris and the rise in cases may be related to genetic, hormonal or environmental factors – but there is much that is unknown about it.
It is characterised by the hairline receding across the scalp and often there may also be thinning of the eyebrows. While it mainly affects white menopausal women, it can affect men too and people of all ethnic backgrounds.
“I rarely saw it at all a couple of years ago but now I’m seeing a couple of cases a week,” Dr Williams says.
Early diagnosis is vital to help stop its progression.
Male vs Female Pattern Hair Loss
These are completely different things, Williams says.
“Male pattern hair loss is usually very straight forward, easy to diagnose and has a limited range of treatment options. Topical minoxidil and oral finasteride are pretty much the only two FDA approved and in the UK licensed treatments for hair loss,” he says.
“For women there are so many different things you have to look at,” he says. “I won’t see them until there’s been a battery of test done and a full medical history. Often I’ll ask them to see a dermatologist before they come and see me because female hair loss can be affected by hormones, nutrition, stress – so many different things can cause and influence female pattern hair loss.”
“For something that is so common, we know very little about it. We used to call it androgenic hair loss but we’ve moved away from that unless we’re talking about Poly Ovarian Cyst Syndrome (POCS) where there may be an androgenic component. But we think that female hair loss is influenced by female hormones, but we just don’t know all that much about it.”
Often women say they notice their hair loss on the peri-menopause stage – but Williams says it may actually start much earlier, in the 20-30’s.
Hair loss has different patterns – there’s hair loss in an oval behind the hair line and hair loss around the temples and the start of the hair line. The latter is very common and is one of the easiest things to treat with hair transplant surgery, he says.
Traction Alopecia
This is often caused by braids or pony tails that are too tight or caps or head dresses that rub on an area as well as hair straighteners, weaves and extensions.
It’s often seen of the sides of the head but can also happen at the back of the head.
“It often affects black women, but can also people like ballerinas or athletes who pull their hair back and Sikhs who wear a turban. It’s a really satisfying one to treat, but if the area is wide it may have to be done in steps,” he says. “If it’s caught early enough the hair may grow back but if it’s left the hair may be lost forever.”
Having realistic expectations about what can be achieved in terms of regrowth is important.
Restoring eyebrows
Knowing the reason why eyebrows are thinning is important.
Thyroid function may affect them and you need to rule out the Frontal Fibrosing Alopecia, but, Williams says, “the most common reason for thinning eyebrows is that they’ve been plucked too often when thinner eyebrows were trendy.”
“Now it’s all the rage to have thick eyebrows, but again managing expectations is important. We take the hair from the back of the scalp and it means that you’ll be having to trim the hair every 7-10 days depending on the growth rate.”
Eyelash extensions are a no-no, according to Williams, as they may cause you to lose your eye lashes permanently.
Excessively pulling your hair out could see you developing bald patches too. Again, early treatment is important.
Do Supplements Work?
Collagen supplements?
“I’ve always been a ‘doubting Thomas’ about collagen supplements as it just broken down in the stomach into protein in the same ways as meat or beans.”
Hair growth supplements?
“You go down the aisle [in various shops] and there are rows of beautifully packaged products all saying they’re backed by clinical data, but the only FDA approved ones are minoxidil and finasteride. When you dissect the studies behind the claims made about these supplements you can often punch holes in them.”
The things he says that are important for hair growth are:
- Vitamin D
- Zinc
- Biotin
- Iron.
But, if your levels are normal you don’t need to take a supplement.
Things that might help some people are:
Low level light treatments, but he says we don’t know is which light lengths or types are best. “I wouldn’t waste time going into salons and paying good money for it.”
Many home devices say their FDA approved but that just means they’re approved for safety not efficacy, he adds.
Platelet Rich Plasma – the jury is still out, he says. It’s based on the theory that the growth factors in the blood that are extracted and re-injected into your hair stimulate growth, but at the moment there isn’t solid evidence to support it, he says.
The same goes for other stem cell/growth factor solutions, he says. At the moment we just don’t have enough evidence to say if they work or not, and if the do, it may be the injecting, stamping or microneedling that is responsible for any benefits rather than the product stem cell, growth factor or mesotherapy product that’s applied, he says.
Gene-based technology – In the future, however, he does see a role for genetic testing which would then allow tailored or bespoke growth factor treatments for each individual – but that’s a little way off. Hair rejuvenation and a cure for hair loss is something to look forward too, he hopes.
Types of Surgery
There are two types of surgery FUE and FUT. FUE stands for follicular unit extraction and FUT is follicular unit transplantation.
Williams explains that hair grows in little units with a one to three of fours hairs in each units. There are two ways of extracting these, he says – “drilling them out, which leaves a little hole which in turn leaves a number of little scars. Men can still wear their hair in a short style with this.”
The other technique involves taking a strip of scalp and is what he calls ‘strip FUT’. “The downside of this is that it leaves a scar, so it’s better suited for women or transgender women who’d generally want to wear their hair longer.”
There is also a recovery time and the area may need to be shaved.
The advantage of a strip FUT procedure is that you can get more hairs to transplant. It is also quicker.
There is, however, a bias these days, toward FUE where the individual follicles are harvested from the back of the head.
FUE is more time consuming but there is no surgery, scar or recovery time.
It’s vital to consider the future before you have a transplant, he says. Starting too young may mean that you continue losing hair later and you may have to employ a variety of treatments and techniques to help keep your hair.
As he says, a hair transplant does stop hair loss, it fills in gaps. A good assessment and counselling about future implications is essential.
You can find Dr Williams at the Farjo Institute here: https://www.farjo.com/staff/dr-greg-williams/
