How to know if a hair transplant has failed

It can be difficult to distinguish between the normal healing process and the early signs of a failed hair transplant. While patience is required to see the final hair transplant results, certain red flags can indicate that the procedure was unsuccessful or negligently performed.

Key indicators of hair transplant failure include poor or non-existent hair growth after a year, an unnatural or "pluggy" hairline, excessive scarring in the donor or recipient area, and signs of chronic infection or inflammation. If you are concerned about your hair transplant results, it's crucial to understand what an unsuccessful surgical outcome looks like.

1. Poor or no hair growth

The most obvious sign of a failed hair transplant is a lack of hair growth. After a hair transplant procedure, it is normal for the transplanted hairs to fall out in a phase known as "shock loss." However, new, permanent hair growth should begin to appear within 3-6 months, with more significant results visible after 12-18 months.

Signs of a signs of hair transplant failure related to hair growth include:

• Minimal growth: if, after 12 months, you see very little new hair, it suggests a high rate of graft failure. The transplanted hair follicles may have been damaged during the hair transplant operation or failed to receive adequate blood supply.
• Patchy and uneven hair growth: a successful hair transplant should result in even, consistent density. An unsuccessful hair transplant may lead to patchy areas or a sparse appearance, indicating that many of the hair grafts did not survive. This poor hair growth can be a direct result of poor surgical technique.
• Excessive graft shedding: while initial shock loss is expected, if your transplanted hair continues to shed excessively months after the procedure without new hair growing in its place, it may be a sign of poor graft survival.

A lack of substantial hair growth after one year is a clear indicator of a failed hair transplant, and you should seek a professional opinion.

2. Unnatural hairline and hair direction

A key goal of hair restoration surgery is to create a result that looks entirely natural. An inexperienced surgeon may fail to achieve this, leading to an artificial appearance that is a hallmark of a substandard procedure.

An unnatural hairline can be caused by several negligent acts:

• Incorrect hairline design: a natural hairline is soft, slightly irregular and age-appropriate.A hairline that is too asymmetric may be a sign of a negligently performed hair transplant.
• Unnatural hair direction: an experienced surgeon meticulously places each hair follicle at an angle that mimics natural growth patterns. When hairs are implanted at the wrong angle, they can stick straight out or grow in the wrong direction, creating an unnatural look. This unnatural hair direction is a tell-tale sign of a poorly performed hair transplant.
• A "pluggy" or "doll's hair" appearance: this occurs when a surgeon implants grafts containing multiple hair follicles at the very front of the hairline, instead of the single-follicle grafts required for a soft, natural transition. This outdated or improper surgical technique results in a clumpy, doll-like appearance.

3. Excessive or visible scarring

While any surgical procedure will leave some scarring, a successful hair transplant should result in minimal, well-concealed scars. Excessive or highly visible scarring is another sign of a failed hair transplant, often stemming from an inexperienced surgeon or poor post-operative care.

• Wide scars from follicular unit transplant (FUT): an FUT procedure involves removing a strip of scalp from the donor site, which is then sutured closed. If closed improperly or with too much tension, it can result in a wide, noticeable linear scar that is difficult to hide.
• "Moth-eaten" donor area from follicular unit extraction (FUE): in an FUE hair transplant, individual hair follicles are extracted from the donor area. If the hair transplant doctor is inexperienced and "overharvests" the donor area - taking too many grafts from one concentrated spot - it can lead to patchy, bald spots or a thinned-out appearance. This is a sign of poor donor area management.
• Keloid or raised scars: in the recipient area, improper implantation, incisions that are too large or poor healing can lead to raised scars or a cobblestone texture that prevents the transplanted hair from looking natural.

4. Persistent scalp issues and infections

The healing process after a hair transplant surgery involves some temporary redness, swelling and scabbing. However, if these issues persist or worsen, they can indicate serious complications that may lead to hair transplant failure.

• Prolonged redness and swelling: if redness and swelling last for more than a few weeks, it could be a sign of a chronic inflammatory reaction or one of the first signs of a scalp infection.
• Infection: though rare (occurring in less than 1% of cases), an infection is a serious complication. Symptoms include severe pain, pus or yellowish discharge, excessive swelling, and fever. An infection can damage or destroy healthy hair follicles and transplanted grafts, leading to poor graft survival and permanent scarring. A surgeon's failure to maintain a sterile environment or provide adequate aftercare instructions can constitute negligence.
• Necrosis:in rare cases, the blood supply to the scalp tissue can be compromised, leading to tissue death (necrosis). This may indicate negligence and can result in significant scarring and permanent hair loss in the affected area.

Why do hair transplants fail?

Hair transplant failures can happen for two primary reasons: surgical negligence or inherent risks and patient-related factors. It is vital to understand the difference, as outcomes resulting from a surgeon's failure to provide a reasonable standard of care may be grounds for a claim.

Failures due to surgical negligence

Many failed hair transplants are the result of the hair transplant clinic or surgeon not meeting their duty of care. An inexperienced surgeon or an unqualified hair transplant team can significantly increase the risk of an unsuccessful surgical outcome. Common examples of negligence can occur at every stage of the process.

Prior to surgery:

• Inadequate pre-operative assessment: a competent surgeon will thoroughly assess your type of hair loss (e.g., male pattern baldness, female pattern baldness, alopecia areata), the quality and quantity of your donor hair, and your overall health to determine if you are a suitable candidate for a hair transplant. Proceeding with a hair transplant procedure on an unsuitable candidate can lead to failure.

During surgery:

• Poor surgical technique: this is the leading cause of failed hair transplants. It includes everything from creating an unnatural hairline to placing hair grafts at the wrong depth or angle, which can compromise their survival. Improper surgical techniques are a clear sign of an unqualified practitioner.
• Overharvesting the donor area: an inexperienced surgeon might remove too many hair follicles from the donor site, causing permanent thinning or bald patches.
• Improper graft handling: hair follicles are incredibly delicate. If the hair transplant team leaves them outside the body for too long, fails to store them in the correct solution, or physically damages them during extraction or implantation, the grafts will not survive.
• Delegating to unqualified technicians: critical aspects of a hair transplant, such as making excisions and incisions, must be performed by a qualified hair transplant doctor. Some clinics cut costs by delegating these tasks to unlicensed technicians, leading to poor results and failed hair transplants.

After surgery:

• Inadequate aftercare and follow-up: a surgeon’s duty of care extends beyond the procedure itself. This includes providing clear post-operative instructions to prevent infection and ensure proper healing. A failure to provide this guidance, or a failure to recognise and treat complications like an infection during follow-up appointments, can constitute negligence.

Inherent risks and patient factors

Not all unsuccessful hair transplant outcomes are due to negligence. Some are related to the inherent risks of any surgical procedure or the patient's physiology:

• Pre-existing medical conditions: certain underlying conditions, like Lichen Planopilaris (LPP) or other scarring alopecias, can cause the body's immune system to attack hair follicles, which may lead to the rejection of transplanted hair.
• Poor post-operative care: the success of a hair transplant also depends on the patient. Failing to follow the aftercare instructions provided by the hair transplant clinic can damage the newly transplanted grafts and compromise the final hair transplant result.
• Insufficient donor hair: some individuals with advanced hair loss may not have enough healthy donor hair to achieve their desired density. While this should be identified by the surgeon beforehand, it is a limiting factor for hair transplant success.
• Shock loss: the trauma of surgery can cause temporary shedding of existing hair around the transplanted areas. While this hair usually regrows, in some cases, it can be permanent.