Chapter 4: Why hair transplantation is not recommended for fibrosis areas of the scalp

“Director, perhaps because I’ve been losing hair for so long, my scalp has become hard. Can I plant hair here too?”

Patients who are considering hair transplantation as their last hope for hair loss treatment, especially those whose hair loss has progressed to an advanced stage, often receive this question. Just by touching it, it feels hard and inelastic, different from a healthy scalp. This is a sign that ‘scalp fibrosis’ is likely to have progressed. And unfortunately, I do not hastily recommend hair transplantation for this type of scalp. The reason is because of the fundamental environmental problems of the scalp, which are directly related to the success rate of transplantation.

1. What is scalp fibrosis?

Scalp fibrosis refers to a phenomenon in which our scalp loses its original soft and flexible characteristics and becomes hard due to an abnormally large number of collagen fibers accumulating. It is easy to understand if you think of this as a condition very similar to hard 'scar tissue' that occurs when the skin heals after a deep wound. A healthy scalp is rich in blood vessels and is like fertile soil where hair follicles can take root while receiving sufficient space and nutrients. However, the scalp with advanced fibrosis is like barren land where moisture and nutrients have dried up and hardened like a stone. Even if a seed called a hair follicle is planted, the environment has become difficult for it to take root and grow properly.

2. Why and how does scalp fibrosis occur?

There are several main reasons why the scalp develops this hard scar tissue-like appearance.

• Long-standing chronic inflammation:A typical example is when inflammatory diseases such as seborrheic dermatitis, atopic dermatitis, and severe folliculitis are left untreated for a long time. As the inflammation and recovery process repeats, our body produces collagen fibers to heal the wound. [cite: 1165] However, if this process continues chronically, collagen is excessively produced and accumulates in a disorderly manner, eventually hardening the entire scalp tissue.
• Old hereditary hair loss:Even when male/female pattern hair loss progresses over a long period of time, over 10 or 20 years, it is accompanied by fibrosis. When hair follicles gradually become smaller and disappear due to the influence of hair loss genes, the empty space where the hair follicles once were is gradually replaced by fibrous tissue. Additionally, as hair disappears, blood circulation in the scalp decreases overall and the skin becomes thinner, losing elasticity and becoming hard.
• Trauma and other factors:Localized fibrosis can also occur due to burns on the head, scarring from healing deep wounds, or certain skin diseases (e.g. cicatricial alopecia).

3. Seeds cannot grow in poor soil: Why transplantation is not recommended for fibrotic scalp

So why is hair transplant not recommended for such a hardened scalp? The reason is clear.

First, the survival rate, or ‘engraftment rate,’ of transplanted hair follicles is significantly low.The most important factor that determines the success of hair transplantation is ‘blood circulation’. Newly transplanted hair follicles can survive and produce new hair only if they receive oxygen and nutrients from surrounding microcirculation. However, the fibrotic scalp has a very poor blood supply due to the dense collagen tissue compressing the blood vessels. Transplanting hair follicles into this ‘barren land’ is like sowing seeds in a desert without water or nutrients. The transplanted hair follicles do not receive even the minimum nutrients necessary for survival, and eventually most of them become necrotic and fall out. This is the most fundamental reason why it is difficult to obtain satisfactory results even when transplantation is performed with high costs and time.

Second, the procedure itself is difficult and may produce unnatural results.Technically, a fibrosed scalp is unfavorable for transplantation. Not only is it difficult to create holes (slits) in the hard scalp for the hair follicles to enter, but it is also difficult to plant them at exactly the desired depth and angle. This can increase the rate of hair follicle damage, and even if some hair follicles succeed in engraftment, hair growing on hard skin may not blend in with the surrounding hair and give an unnatural feel.

Third, there is a risk of worsening the condition.Microscopic wounds and inflammatory reactions that occur during the hair transplant process may irritate already hypersensitive fibrous tissue, worsening inflammation and further promoting fibrosis.

Therefore, rather than rushing for a hair transplant, I recommend that patients with scalp fibrosis first treat scalp inflammation and improve blood circulation to soften the hardened scalp. This is because the seed of hair transplantation can take root successfully only after the soil called the scalp is first made healthy.