A hair transplant is the only operation I know of where the patient routinely never meets the surgeon. That is not a figure of speech. In the clinics the International Society of Hair Restoration Surgery calls black market, there is no surgeon to meet.
Today is the sixth World Hair Transplant Repair Day. About a hundred ISHRS physicians around the world will do a corrective transplant for free for someone who got hurt that way. I am a member, and I read the society’s numbers this year with the feeling you get when a problem you thought was somewhere else turns out to be down the street. In the 2025 practice census, 59 percent of surveyed members said black-market clinics operate in their city. In 2021 it was 51 percent. One in ten repair cases those members did last year followed a black-market transplant, up from six in a hundred three years earlier.
The Thing That Gets Sold
What gets sold is a graft count and a price. Five thousand grafts, a package, a hotel, a flight. What does not get sold, because it cannot be, is a surgeon’s judgment about your scalp. I told Men’s Fitness last month that a price that is far too cheap often means a technician is operating, and I will stand by that line on any day of the year.
Here is what the judgment sounds like when it exists. This is me, in my own exam room, to a man who wears a high fade:
“So when people wear the hair short on the back, that’s where we get the hair from. So those are the follicles that we use to fill in the front. So one way to take them from the back is doing the FUE, which is the one by one, the neograft. We take them one by one, it heals in, and you don’t see any scars. The other one is doing a strip where I actually cut like a sliver of hair follicles or scalp, but it does leave a scar. So if you wear your hair short, you would see that long scar.”
And this is me saying no to a number, which is the sentence a package deal never contains:
“With the FUE, we can do maximum twenty-five hundred, sometimes twenty-eight hundred follicles.”
“Three thousand’s the limit, because more than that we really can’t get out of one strip.”
The donor area is a bank account. A surgeon tells you the balance. A clinic tells you what you want to hear and overdraws it, and the overdraft is permanent, because the hair that was pulled from the back of your head does not grow back there.
Technicians Are Not the Villain
I want to be fair about this, because the word “technician” gets thrown around as if it settled the argument. Trained technicians handle grafts in every serious hair practice, including mine:
“We do a minimum of a thousand grafts at a time, just because I bring the techs in from out of town, but that will fill in pretty nice.”
The difference is who they work for. In my practice they work under a surgeon who examined you, designed the hairline, chose the method, and will be the one looking at you at six months and a year. The ISHRS says it is a lifetime relationship, not a one-day transaction, and that is exactly the difference. The clinic’s relationship with you ends when the deposit clears.
What I See When It Went Wrong
The repairs come in a handful of shapes. A hairline drawn too low and too straight on a young man, which looks fine at 25 and strange at 40. Grafts placed in rows, so the front edge reads as a doll’s head. A donor area harvested until it is patchy, which is the one with the fewest options. A strip scar that was never warned about and sits above a short haircut.
Some of that I can fix. Grafts come out and go back in higher, single hairs go on the front edge, density gets added behind, a widened scar gets hair grafted into it. Two years after a strip transplant one of my own patients wanted more density, and the answer was simple:
“It looks good, but you can see that there’s a little bit of distance between them, because that’s the way we have to do it. So now we can go in between.”
Some of it I cannot fix, and the honest consult is the one that says so. A transplant moves hair; it does not make new hair. When the donor supply is spent, the plan is medication, a hair system, or scalp micropigmentation, and anyone who promises otherwise is selling the same thing that caused the problem.
What to Ask Before Anyone Touches Your Scalp
Who examined me, and is that the person who will operate? Who is designing the hairline? How many grafts does my donor area allow, not how many will you sell me? Whose license is on the consent, and can I check it with the medical board? Who sees me at a year?
A practice answers all five without flinching. The full checklist, the ISHRS definition, and what each kind of repair involves are on my surgical site. The practice’s version, with the PRP and exosome side of a repair, is on Southwest Plastic Surgery. The consult that decides strip or FUE is in my FUE read.
I am a double board-certified plastic surgeon, a Mayo Clinic fellowship alum, a Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center, and a member of the ISHRS. I also have a hair transplant of my own, done by strip. I know what the scar looks like, and I know what it is to wait a year to see whether it worked. I would not let someone I had never met do it to me.
Call the office at (915) 590-7900, text us at 1-866-814-0038, or book a consultation at agulloplasticsurgery.com/appointments.
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