There are many types of scarring alopecias (scarring hair loss) like lichen planopilaris, discoid lupus erythematosis, etc. This article will not try to review all the many types of histologic (tissue) diagnoses but to explain what goes through my head as a hair-transplant surgeon when encountering various scarring alopecias for possible hair restoration.

When I am evaluating a person for possible hair restoration, I am always concerned with the possibility of a scarring alopecia that could negatively impact my transplant result now or in the future. I carefully evaluate the scalp for any signs of abnormalities that may hint at this likelihood. If the scalp looks particularly shiny without pores this can be a telltale sign. Also, redness and inflammation in the area may indicate something as mild as psoriasis or hint at something more ominous like a scarring alopecia. Since I am not a dermatologist if I have even a remote suspicion of a possible scarring alopecia, I will send it to a qualified dermatologist for a scalp biopsy. Without a biopsy, even the most experienced dermatologist can be wrong if a scarring alopecia is suspected.

It is important that if a surgery is planned that the patient’s condition be completely burned out. My minimum criterion is at least 2 years of biopsy-proven time that there is not active disease. However, this still does not guarantee that the disease will not come back. In cases of just tissue scarring from trauma for example, this is obviously not a concern. However, a case of lichen planopilaris for example may flare up again in the future causing transplanted grafts to fall out over time.

There are two principal concerns that I have if someone has been diagnosed with a scarring alopecia. The first concern is will the transplanted grafts take and grow. If there is any concern a surgeon can transplant a few “test grafts” to see if the grafts will grow in the scarred bed of tissue. However, even if they do grow, this is no guarantee that the rest will grow. The second biggest concern, as mentioned before, is whether the disease that caused the scarring alopecia will reactivate in the future causing all of the transplanted hairs to fall out again. This is why the minimum of a 2-year period of burn out is typically advisable if still not longer. Sometimes a transplant can look good for a few years then fall completely out when the condition of scarring alopecia returns. For an experienced hair transplant surgeon, teamwork with an equally qualified dermatologist is a must when treating patients with scarring alopecia.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To learn more about scarring alopecias, hair loss disorders, or to schedule a consultation please call 972-312-8105, or visit for more info. To ask Dr Lam a question please visit our hair loss forum.