The number of hair transplants being done has exploded in recent years becoming a billion-dollar business. While the procedure was previously reserved for specialized doctors, the expansion of the market has also led to additional providers with low-cost offers fighting for the market share.
However, the principle that only properly trained licensed and officially supervised doctors can perform the surgery seems to have lost importance, mainly because patients are not aware that this should be the case.
Cheap hair transplant surgery done by unlicensed technicians is advertised on the internet and because of the low price, lures the unsuspecting individual.
In addition to the unethical nature of the offer, there are also considerable medical risks that exist with these providers. The low price, at first glance, can quickly be reversed if problems arise from the hair transplant surgery.
A clear distinction should be made between a low price due to lower living costs, and a „budget offer“ due to simply cutting corners in certain aspects of the operation.
There are a whole host of issues that are seen with illegal or unethical clinics such as:
- Not making it clear who the operating doctor is
- Allowing non-doctors to make surgical planning decisions including the method of donor hair harvesting, the number of hairs/grafts to be transplanted, and the transplant design including the hairline
- Advertising the presence of an experienced doctor during surgery when there is none
- Fake before-and-after photos, either created with an image processing program or stolen from a reputable doctor.
- Multiple surgeries are carried out in the same room or only separated by a curtain in disregard of infection control principles
- The personnel, including any doctors who may be present, are not professionally qualified or trained sufficiently in hair restoration
- The doctor is only present for a short time or not at all during the operation
This list is by far not complete and the public is often not even aware of what kind of problems may arise in this type of clinic.
It must also be explicitly mentioned that some doctors contribute to this problem by violating their procedures and duties as prescribed by medical ethics and legal regulations. For example, they place the medical tasks in the hands of other people who do not have the necessary medical training. Or the premises do not have the appropriate conditions for performing such an operation.
Why did hair transplantation become so popular and what contributed to the development of a black market?
The popularity of hair restoration surgery has emerged in large part due to the innovation and research by physician members of the ISHRS who over a period of decades, developed and refined a surgical technique known as follicular unit transplantation.
Originally, this was a strip of skin that was carefully dissected by a team of technicians after removal from the scalp. It was harvested from the areas of the head with the greatest density at the back and sides of the head that are least affected by genetic hair loss.
To do this, it was necessary to handle the scalpel safely and to know the basics of a medical operation. The scar resulting from this method limited the wearing of short hair. This procedure became widespread and more and more doctors trained large groups of technicians to assist them in the operation.
Individual doctors subsequently allowed their technicians to at least perform the insertion of the hairs independently, even if this is actually a medical activity by making an incision in the scalp. Even though this was and is illegal, it laid the foundation for independent work by non-physician assistants or technicians.
However, the presence of the doctor was still necessary for the performance of the removal and scar closure, which was no longer necessary, at least technically, due to the development of follicular unit excision (FUE).
How has the development of FUE (follicular unit excision) stimulated the black market for hair transplants?
Almost ten years ago, the new technique of FUE began to gain popularity. Round cylindrical punches of measuring 0.8mm to 1.5mm were used to extract individual follicular units or groups of hair. In 2020 experienced clinics will use FUE punches that are less than 1mm in diameter.
The FUE process usually involves thousands of small circular wounds where the hair grafts have been removed from the safe donor zone. This results in small white dot scarring. The scar size depends on the punch size, the skill of the person extracting them, and the patient’s individual healing characteristics.
Even though it is a minimally invasive technique, the fact that cuts are being made in the scalp and the large affected surface area means that this is certainly ‘surgery’. The necessity to anesthetize large areas of the scalp, the careful extraction pattern needed, different skin and hair structures take a great deal of expertise to perform this operation safely and with consistently good results.
The comparatively simple execution of this procedure has made it possible for non-physicians, sometimes completely without supervision by a physician to attempt this procedure. It is unclear how these technicians are trained, and what their abilities are.
Why should patients worry about this when surgery is cheaper on the black market?
Patients should be aware of what they are losing and what they are risking. Black market surgery is not a simple discount. Medical care and medical risks are very different from buying shoes or sunglasses, for example. These items are replaceable, and if the quality is not up to standard, there is no long term consequence.
On the other hand, a bad hair transplant has the risk of minor or major damage, sometimes life-threatening consequences. Of course, a technician without the expensive education at a medical school and clinical training can offer cheaper. However, in return, they lack the knowledge to select suitable patients or to offer other alternative medical procedures. It should be noted that there have been a few patients around the world who have actually died after undergoing hair transplant surgery where the care has been substandard.
Due to the mostly non-existent supervision by the authorities, there is no security regarding the acting persons or the premises. Things such as the necessary disinfecting and medical hygiene can be ignored. Patients are sometimes so close together so that basic hygiene regulations are not observed and there is a risk of cross-contamination. Likewise, in most cases, medical insurance is probably missing.
If something does not work as planned, black market providers lack medical experience on how to solve these problems. At best, they may offer free surgery. Would you risk another failed procedure and wasted donor grafts?
Why don’t regulators do anything about the dangerous black market?
The International Society of Hair Restoration Surgeons (ISHRS) regularly informs regulators around the world of the problems faced with hair restoration but is not responsible for creating and monitoring the rules in these countries.
Ultimately, control is always dependent on the level of supervision by the relevant authorities.
Regardless of this, there is an increasing number of complaints from patients against doctors and clinics who have improperly delegated hair transplantation tasks to technicians. This has led to lawsuits being filed against the doctors by the patients.
How can patients recognise they are considering using a black market clinic?
A lot is promised on the Internet, which makes it difficult to control and find out what is true or untrue. It`s always important to have medical qualifications checked, this can be done by contacting the local supervisory medical authority. However, this can be difficult in some countries.
Furthermore, one can check with the ISHRS via their database whether the doctor is a member of this association.
If they are not a member you should ask for proof of education and training. Here is a small list of points to help you choose a clinic or a doctor
- Find out about the doctor’s training, especially about their experience in the field of hair restoration surgery.
- Ask them to confirm that only they or another doctor can perform the medical procedures for anesthesia, incisions, and the excision of grafts from the scalp.
- The design of the hairline and the recipient areas should be done by the doctor
- It is always helpful to have information about how many operations are performed simultaneously by the doctor under their supervision. The more patients a doctor has per day, the more likely it is that the operation will be performed by a non-physician member of staff.
What are the risks for patients who undergo surgery in black market clinics?
There is a wide range of risks, some of which are listed below:
- Donor area overharvesting: the excessive thinning of the donor area with extensive scarring is a regular feature of low-cost clinics that offer transplants of “as much hair as possible” at an all-inclusive price.
- Necrosis of the donor area: an excessive number of holes too close together can cut off the blood supply to the remaining skin, resulting in dead skin that scars without hair
Poor hair growth: Hair is fragile and there are many reasons that can trigger insufficient regrowth.
- Necrosis of the recipient area: similar to the donor area, an excessive number of incisions can cut off the blood supply and lead to dead tissue in the recipient area
- Unnatural results: an optimal appearance requires a lot of experience in designing attractive hairlines. For technicians in and outside of established clinics, this does not matter, as the price is the main consideration here.
- Infection: the large area wound requires excellent hygienic conditions, if these are not maintained, infections of the skin or even the entire body can occur.
- Death: even if the procedure itself has a very low risk of complications, the local anaesthetic, for example, can lead to cardiac problems and ultimately death. Even if this is very rare, medical experience is extremely helpful in such a situation.
For more information on the ISHRS Public Awareness campaign please visit: https://fightthefight.ishrs.org/