Frontal fibrosing alopecia (FFA) is a scarring hair loss condition that progressively moves the frontal hairline backward, and hair transplant suitability depends entirely on whether the disease has become inactive. Misdiagnosis of hair loss type leads to the wrong treatment plan in roughly 28% of cases, making accurate identification of FFA the essential first step before considering any surgical option.
This content is for informational purposes only and does not constitute medical advice. Always consult a board-certified dermatologist before pursuing any treatment for FFA.
What Makes FFA Different from Pattern Hair Loss
FFA belongs to the family of cicatricial (scarring) alopecias. Unlike androgenetic alopecia (male or female pattern hair loss), FFA permanently destroys the hair follicle through lymphocytic inflammation. Once a follicle is scarred, no medication or procedure can regenerate it.
Key differences at a glance:
| Feature | FFA (Scarring) | Androgenetic Alopecia (Non-Scarring) |
|---|---|---|
| Follicle destruction | Permanent | Miniaturization, not destruction |
| Typical pattern | Band-like frontal recession | Temple recession, vertex thinning |
| Scalp appearance | Pale, smooth, no follicular openings | Normal skin texture with fine hairs |
| Biopsy finding | Perifollicular fibrosis, inflammation | Miniaturized follicles |
| Reversibility | No (once scarred) | Partially (with medication) |
FFA most commonly affects postmenopausal women, though premenopausal women and men can also develop it. The hairline recedes in a band-like pattern, and eyebrow loss is present in more than 80% of cases.
Hair Transplant Suitability Criteria for FFA
A hair transplant is not automatically ruled out for FFA patients, but the criteria are strict. Surgeons who specialize in scarring alopecia typically require all of the following before proceeding.
1. Disease Inactivity for 12 to 24 Months
The single most important criterion is documented disease stability. This means:
- No further hairline recession over at least 12 months (many surgeons prefer 24 months)
- Stable clinical photographs taken at regular intervals
- Dermoscopy showing no perifollicular erythema or scaling
- A scalp biopsy confirming absent or minimal active inflammation
2. Adequate Donor Supply
FFA can sometimes affect the donor area (occipital scalp). If the donor region shows signs of inflammation or thinning, graft survival drops significantly. A standard FUE procedure achieves 90% to 95% graft survival in healthy donor tissue, but that rate falls when the donor area itself is compromised.
3. Realistic Expectations
Even with stable disease, there is a documented risk that FFA can reactivate and attack transplanted grafts. Published case series report graft survival rates ranging from 50% to 85% in FFA patients, compared to 90% to 95% in standard androgenetic alopecia transplants.
Risks of Transplanting into FFA
Proceeding with transplant surgery while FFA remains active or partially controlled carries several risks:
- Graft loss: Active inflammation can destroy transplanted follicles within months
- Disease flare: Surgical trauma may trigger a koebnerization response, worsening the condition
- Wasted resources: FUE procedures cost $4 to $6 per graft in the USA and $3 to $5 per graft in the UK, making a failed transplant a significant financial loss
- Scarring at donor site: Extraction from an inflamed donor area can produce visible scarring without the benefit of successful hair growth at the recipient site
Diagnostic Steps Before Any Decision
Before discussing transplant candidacy, confirm the diagnosis and disease status:
- Scalp biopsy: The gold standard for FFA diagnosis, showing perifollicular lymphocytic infiltrate and fibrosis
- Dermoscopy: Look for loss of follicular openings, perifollicular erythema, and tubular perifollicular casts
- Serial photography: Document the hairline every 3 to 6 months to track stability
- Blood work: Check hormone levels, thyroid function, and inflammatory markers to rule out overlapping conditions
If you are unsure whether your hair loss pattern is FFA or androgenetic alopecia, an AI-powered hair assessment can help you identify your current pattern and guide your next conversation with a specialist. Start with a free analysis at myhairline.ai to understand your baseline before booking a clinical consultation.
When to Revisit the Transplant Conversation
If your dermatologist confirms that FFA has been stable for at least 12 to 24 months and your donor area is healthy, a consultation with a transplant surgeon experienced in scarring alopecia is the next step. Ask specifically about their experience with FFA patients, their graft survival data, and whether they recommend continued immunosuppressive therapy after the procedure.
For a deeper look at all available treatment approaches, see our frontal fibrosing alopecia overview. If you want to evaluate whether your overall pattern supports hair transplant candidacy, start with a free assessment at myhairline.ai/analyze.