Natural Hair Transplantation

The Hair Transplant Procedure

The most common hair transplant procedure involves taking small strips of scalp containing hair follicles from the donor area, usually at the sides or back of the head. These strips are then divided into several hundred smaller grafts. The surgeon relocates these grafts containing skin, follicle, and hair to tiny holes in the balding area by using microsurgical instruments or lasers.

Hair transplantation is a minor outpatient surgery that simply relocates existing hair follicles from the donor site to the balding area. The procedure first begins with the surgeon removing a donor strip from the donor site, which is often located on the back or side of the scalp. The donor strip is further cut into 3 sizes of grafts — the micro graft, the follicular unit, and the bi-follicular unit. The grafts are inserted into pre-cut micro slits that are strategically designed to aesthetically improve the density of your existing hair, lower the hairline, and fill in balding areas.

A typical hair transplant procedure is about 3 to 5 hours long depending on the number of grafts desired. The procedure is performed by a team of professionals consisting of one surgeon and 4 to 5 surgical technicians

It is easy for those with a full head of hair to say it’s vain to want hair. It is a biological and genetic reality that humans naturally prefer youthful looks. Baldness makes you look older exaggerating existing facial aging. Male pattern baldness is the cause of the vast majority of cases of hair loss. Don’t believe old wives’ tales about poor circulation, wearing hats or using the wrong hair products. The simple fact is the hair loss is a genetic reality for many men and women.

Hair Transplantation Surgery (HTS) is an excellent option for treatment of hereditary hair loss in many men and women. A consultation with Dr ali Vafaei is recommended to discuss the specifics of your case and decide whether it’s a good treatment for you or not. We guarantee 95% of hair grafts will grow into permanent hair. The major advantages of hair transplant surgery are that there are no expenses or maintainence required after the procedure. So that means you won’t have to spend money on creams, lotions, special shampoos, prescription medications or chemicals. You don’t have to endure the inconvenience and loss of time involved in remembering to take pills, rub special lotions into your head or having hair pieces serviced and maintained.

It’s the most natural solution to hair loss as its your hair growing. After you’ve had the procedure and your hair is growing in areas in which you previously experienced hair loss no-one will know you’ve ever had anything done unless you choose to tell them. Hair transplant surgery is the natural solution to hair loss.

1. An overview of hair transplants
2. The history of hair transplants
3. Hair transplant restoration costs
4. Finding a good hair transplant surgeon or hair transplant clinic
5. Preparing for an interview with a hair transplant surgeon
6. A summary of what to expect in your interview
7. Being rejected as unsuitable for a hair transplant.
8. Pre hair transplant operation guidelines and procedures
9. Pre operation guidelines and procedures
10. Planning the hair transplant donor site
11. Isolating the hair transplant grafts ready for implantation
12. Hair transplant recipient site preparation and implantation
13. Post hair transplant operation care
14. Scalp laxity and scalp reduction suitability
15. Hair transplants in women
16. Eyebrow reconstruction with hair transplants
17. Pubic hair reconstruction with hair transplants
18. Hair cloning by bisection as a new hair transplantation technique
19. Hair cloning by cell culture as a new hair transplantation technique
20. Followup Hair Restoration Procedures

An overview of hair transplants

1A) Introduction

Hair transplants are currently the only effective “cure” for androgenetic alopecia. Put simply, the procedure redistributes the remaining hair on a person’s scalp to cover any bald regions. We know that the hair follicles at the back of the head between the ears are not affected by androgenetic alopecia whereas the hair on the top of our heads is affected and can be lost to varying degrees. With hair transplantation, the hair not affected by androgenetic alopecia is taken from the back of the scalp and placed on the top.

It is a simple enough principle and it can provide superb, undetectable results when done well. Hair transplantation has had a lot of bad publicity because until recently the techniques involved were rather crude and results did not look natural. When hair transplantation was first developed, surgeons would use a large punch biopsy to take clumps of hair follicles from the back and then place then on the top in rows. The problem was that the clumps of hair follicles looked very artificial and were difficult to style and manage because the hair follicles were not oriented properly. Today however, the surgical procedure has been refined to the degree that a good dermatological surgeon will leave the patient with a completely natural looking result. Improvements have come from the way the hair follicles are obtained from the donor area and how they are implanted in the bald regions.

Both men and women can be suitable for hair transplantation. Most frequently hair transplants are conducted on people with androgenetic alopecia but hair transplantation can also be an option for people who have lost hair through a congenital defect, scarring alopecia, or alopecia after burns or other injuries. The transplant procedure need not be limited to the scalp. For example, some people have eyebrow transplantations.

1B) Why do hair transplants work?

The pattern of baldness in men is very distinctive and usually limited to the top and front of the scalp. These hair follicles have miniaturized and changed from terminal follicles into vellus hair follicles under the influence of androgens such as testosterone and dihydrotestosterone. As described elsewhere on this web site, not all hair follicles are the same. Some hair follicles are sensitive to androgens, but others are not. It so happens that hair follicles on the top of the scalp are made from cells that have androgen receptors on their cell surface. When these receptors are bound by androgen hormone molecules it triggers the cells to change their activity. In scalp hair follicles the cells are told to slow down and stop proliferating and this results in the hair follicle becoming smaller, producing a finer hair at a slower rate of growth. The hair cycle of these follicles also becomes shorter.

However, other hair follicles on the scalp at the sides and back of the head are not androgen sensitive. The cells that make up these hair follicles have far fewer androgen receptors. They are much less androgen sensitive and effectively take no notice of testosterone and dihydrotestosterone. These hair follicles continue to grow at a normal rate for a healthy terminal hair follicle regardless of the androgen concentration in the body.

This means that the hair follicles that are androgen insensitive can be moved from the back of the scalp and transplanted on to the top of the scalp to replace androgen sensitive vellus hair follicles. The transplanted hair follicles from the back of the scalp will keep their androgen insensitivity property in their new position as they are still composed of the same cells that have few or no androgen receptors. These cells will not change even in their new position. The result is that these transplanted hair follicles will continue to grow as healthy terminal hair follicles for the rest of your life.

1C) The preliminary consultation

When you first approach a dermatology clinic about a hair transplant procedure remember you are the consumer and make sure that you get the information you want. Typically you will first meet with the dermatologist to decide whether you are suitable for transplantation. Some people have too much hair loss and/or poor donor areas. This makes them unsuitable hair transplantation – they would not be satisfied with the result. The dermatologist will ask you what you are looking for in a hair transplantation. Remember regaining that full, thick coat of hair that you had as a teenager is not a practical option. You are only redistributing your hair follicles to gain a more cosmetically acceptable effect, no new hair follicles are being made in the process. The hair follicles you have can only be spread so thin before the result would be unacceptable! Make sure you see the dermatologist who will be conducting the procedure and not a technician or sales agent, and make sure you feel comfortable in the hands of this dermatologist.

The hair line will be discussed with you in some detail. The dermatologist will outline with a marker the optimal line across the front of the scalp that will define the edge of the hair line into which grafts will be put later. An important point here, many people ask for hair lines that are too low. Do not ask for a low hairline on your forehead. The hairline you had as a child or teenager looked great at that age but it is inappropriate for an adult. Almost all male adults have a higher hairline than they had as a teenager regardless of whether they have pattern baldness or not. Remember you can always have the hairline lowered in a later operation, but it is extremely difficult and sometimes impossible raise a hair line after the transplantation has been completed. Also remember that the higher the hair line the less bald scalp the grafts will have to cover. Larger areas of bald scalp mean the transplants will be spread more thinly.

Depending on how much hair loss you already have and the size of your donor area, the dermatologist will recommend a number of procedures. Note that most transplants involve more than one surgical procedure. Only so much can be done in one surgical session. You may end up having anywhere from one to six sessions with time in between for your scalp to recover. The entire process may take several months or years to complete.

After deciding the optimum procedure, you will inevitably be involved in the nitty gritty of negotiating a price for the operation. Different dermatologists use different pricing structures. Some will charge a set fee per graft others will set a price per procedure. Make sure you find out all the clauses and extra charges. When the charges are per graft be sure to find out how many grafts will be involved in your procedure. You may be charged separately for the dermatologist’s time and the nurses’ or technicians’ time. You may also be charged a separate fee for using the surgery room where the procedure is conducted. Whatever happens make sure you are satisfied that you are in safe hands. A bad hair transplant is very difficult to correct once it is done.

1D) How is a typical hair transplant conducted?

Different dermatologists may have slightly different approaches to the hair transplant technique, but here is an overview that covers the general approach that the majority of hair transplant surgeons use. A hair transplant will often take an entire day to complete. In the morning you will consult with the dermatological surgeon who will be performing and directing the operation. He/she will discuss the operation with you and recap on the procedure that should have been explained to you previously. Many hair transplant surgeons will take photographs of your scalp to show the before and after changes from the hair transplant.

In the operation room you will be examined and the optimum donor area of hair follicles will be identified. This area will be shaved so that the dermatologist can see what he/she is doing. A local anaesthetic and/or scalp freezing agent will be used to numb the donor area. The dermatologist will then use a special scalpel to cut a strip of hair follicles from the donor area. The scalpel used may have two or three (sometiems more) parallel blades with a fixed width between them. The scalpel blades are inserted at an angle similar to the angle that the hair follicles are growing at so as to avoid cutting through any hair follicles. Cutting the bulbs off hair follicles renders them impossible to successfully transplant. This scalpel is used to cut the donor skin in a thin strip with equal distance between the top and bottom cuts. This makes suturing of the wound and healing quicker and easier. Most surgeons take a long, thin strip of skin almost from ear to ear and full of hair follicles. The wound is then cauterized and sutured up to heal of its own accord. Because the strip of skin is long and thin it only leaves a small, narrow scar that is hidden by the hair growing immediately above it.

The strip of skin is then processed. Processing can involve several different methods depending on what result the dermatologist and patient require. Sometimes lines of four or five hair follicles are cut from the donor strip. Or the strip may be cut into hair follicles in clumps of two three or four and even single hair follicles may be isolated for transplantation. The most recent development in hair transplantation is micro dissecting and implnating the hair follicles in their natural units. Hair follicles naturally cluster in clumps of 1-4 follicles. By transplanting these natural clusters a much more natural result can be produced. The processing of the donor skin involves several trained technicians and can take a couple of hours to complete depending on how big the donor skin strip is. The grafts are arranged in dishes with pads saturated in sterile saline ready for transplanting to the scalp. This part of the procedure is what makes hair transplants so expensive to perform!

When processing of the donor strip is nearing completion your scalp is prepared to receive the grafts. Depending on how the hair follicles are being processed the surgeons may use a needle, punch biopsy, or cut thin lines with a scalpel. The hair line as previously marked is the first area to be prepared. The surgeon will use a scalp punch to make very small holes in the skin. The grafts are then placed into these holes. In a typical transplantation, small grafts consisting of just one or two hair follicles are used to define the new hairline. Gradually the hair transplant srugeon and his/her assistants will work backwards from the hair line over the top of the scalp making holes and inserting grafts. Larger grafts of two, three, four, or five hair follicles may be used behind the hair line to “fill in”.

Eventually the grafting procedure is completed. Some hair transplant surgeons prefer to bandage the scalp, others don’t. In either event the surgeon should advise you in some detail on how to take care of the implants. Clearly you cannot wash your scalp for the first few days as you may wash out the grafts! You will probably be required to return to the clinic for regular check ups on the progress of your hair transplant and at some point the sutures will be removed from the donor area.

1E) Do’s and don’ts of hair transplantation

Hair transplantation is a blossoming area of dermatology. There are many clinics around the world that exclusively focus on hair transplant treatment and little else. Unfortunately, because hair transplantation is so profitable there are some incompetent commercially oriented clinics that do poor quality transplants and even dangerous transplantations. Any dermatologist can attend a course that lasts a few days and leave supposedly fully qualified to conduct hair transplants.

If you are considering the hair transplant option do make sure you investigate the clinic and the hair transplant surgeon who will be conducting the procedure. You will be paying a lot of money and will have to live with the result for the rest of your life so make sure that you find an experienced dermatologist working in a clinic with a good, long term track record!

Do find a dermatologist recommended by a professional non-profit organization such as the American Hair Loss Council, the American Academy of Facial Plastic and Reconstructive Surgery, or similar organizations in other countries.

Do seek personal recommendations from people who have already had hair transplantations. You can ask them about their experience and judge how good their transplant looks. If you don’t know anyone with a hair transplant call several transplant clinics you are interested in and ask them for names of previous patients you can contact to ask about their transplants and see the result.

Do speak to the dermatologist who will carry out the procedure and not to a salesperson when deciding what type of transplant to have and finding out what the procedure will involve.

Do shop around and contact several clinics. The cost of transplantation procedures varies considerably and price is not necessarily a reflection of quality. Because hair transplantation is now so commercialized, many clinics charge what they think the market will bear in their region. A hair transplant in Los Angeles will cost more than a transplant in Boston which will in turn costs more than a transplant in Vancouver, Canada (consider the exchange rate). Even within local areas the cost of a procedure can vary depending on the prestige of the clinic, how much they spend on advertising, what cable television channels they get etc. The cost can range from $3,000 US dollars to $20,000 depending on what level of surgery is involved and what clinic you go to for the operation.

Do ask about the different grafting methods available and which one is best for you. Different degrees and patterns of hair loss require different transplant techniques. Ask how much experience the dermatologist has with the particular technique you want done and make sure you are satisfied with the reply.

Do realize that the more hair loss you have the longer the procedure will take and it may mean having several operations spanning several months to years before you and your dermatologist are truly satisfied with the result.

Do realize that transplant surgery is generally considered a cosmetic treatment and as such will not be paid for by medical insurance or a national health service. Hair transplantation may be covered by medical insurance or state health bodies if the cause of hair loss was due to a clinical disease or the result of an accident, injury, and/or burns.

Don’t ask for a low hairline on your forehead. The hairline you had as a child or teenager looked great at that age. It looks inappropriate and even ridiculous in an adult. All adults have a higher hairline than they had as a teenager regardless of whether they have androgenetic alopecia or not. Remember you can always have the hairline lowered in a later operation, but it is extremely difficult and often impossible to remove hair grafts without scarring once they have been put in.

Don’t assume that a prestigious dermatologist is capable of conducting hair transplants. A dermatologist may have built his/her reputation in other areas of dermatology and may actually have very little experience of transplantation.

Don’t part with your money until you have all your questions answered to your satisfaction and you are absolutely convinced that hair transplantation is right for you!

2A) The history of hair transplants

The idea of transplanting hair has been around for a long time. Animal and bird studies involving the transplantation of hair follicles or feathers were conducted by several doctors in the early to mid 1800s. However, these studies were not specifically directed at the development of a treatment for hair loss. The first to make the connection between hair transplantation and a treatment for alopecia was one Dom Unger who stated “tunc calvities res rara erit” or “then baldness will be a rare thing”. A student of Unger, Johann Friedrich Dieffenbach, published a dissertation in Wurzburg, Germany in 1822 in which he reported what is probably the first hair transplant in humans. Using a needle, he made holes in his own arm and inserted 6 scalp hair follicles. Of these 2 dried up and fell out, 2 were expelled due to an inflammatory reaction, but 2 became fixed and continued to grow. So follicular unit transplantation is actually a technique that is over 180 years old! In subsequent experiments, he improved his transplantation technique and even started transplanting hair follicles to replace eyelashes. However, while Dieffenbach, a highly skilled surgeon, was able to conduct such procedures with the relatively crude surgical instruments of the day, other surgeons were unable to repeat his success in hair transplantation. Research on hair transplantation did not progress and new developments were not seen until 100 years after Dieffenbach’s work.

The focus for hair transplantation development moved to Japan. Sasagawa in 1930 reported on a hair shaft insertion to treat hair loss, probably the first study that intentionally focused on the development of a surgical procedure to treat scalp alopecia. In 1939, Okuda described the use of small full thickness autografts of hair bearing skin for the correction of alopecia of the scalp, eyebrow and mustache areas. In 1943, Tamura, reported the reconstruction of the female pubic escutcheon by grafting single hairs. However, because of the Second World War, and the fact that the reports from Sasagawa, Okuda, and Tamura were published in Japanese dermatology journals, the reports were not generally read outside of Japan. In 1953 Fujita reported the eyebrow reconstruction in leprosy patients by hair grafting. He also reported punch hair grafting in which a free skin graft with hairs was divided into small pieces, each containing two to three or four hairs, using a scalpel or a pair of scissors. These pieces were inserted separately into many holes, which were prepared in the recipient site utilizing a thick injection needle or a slender scalpel. Ths approach is very similar to the modern method of hair transplantation, but Fujita’s work was not widely recongnised outside of Japan until many years later when in 1976 Fujita wrote a chapter on his work and and other studies in Japan for a book published in the USA.

It was not until the technique of hair transplantation was published in the English language that the technique really took off. In 1950, Barsky reported on the treatment of an individual with a scarring alopecia by implanting small grafts of hair bearing skin. In 1959, Norman Orentreich published a key paper describing the theory of donor dominance in hair follicle transplantation. Orentreich developed a punch grafting technique of hair transplantation and conducted an experiment on 52 volunteers with androgenetic alopecia. He took four full thickness punch grafts of skin form each volunteer, two were of bald scalp skin, and two were taken from adjacent, normal hair bearing skin. The grafts were then moved one hole so that one graft of bald skin was grafted to an area of bald scalp while the other bald scalp graft was placed in a hole in a hair bearing area. Similarly with the two hair bearing punch grafts, one was grafted to a hair bearing area and the other was grafted into a bald skin area. By observing what happened to the punch grafts, Orentreich concluded that the hair follicles in bald skin failed to regrow normal terminal hair even when they transplanted to a terminal hair bearing area. Equally, normal terminal hair bearing punch grafts continued to grow even when grafted to an area of bald skin. This proved the principle of donor dominance, that hair follicles from a hair bearing region could be transplanted to a bald region and would continue to grow – the transplanted follicles kept the characteristics of the hair follicles in the area from which they were taken, and continued to grow when transplanted to an area of miniaturized hair follicles in bald skin. This study finally proved that hair transplants could be used to treat androgenetic alopecia. Orentreich soon had many disciples in America and Europe and word quickly spread about this wonderful new technique. By 1970 the technique was being performed by small numbers of dedicated practitioners in many different countries.

Until about 1975 Orentreich’s 4mm size cut or punch graft method remained the basic procedure, but the large punch graft approach resulted in a rather “pluggy” result. Initially, the grafts were simply placed in holes in the skin and granulated tissue was allowed to form around the grafts. Gradually it was learnt that suturing these large grafts into place would promote improved wound healing (Carreirao 1978; Pierce 1979). The hair follicles grew in the grafted clumps and this gave a look similar to a doll’s head with tufts of hair sprouting out from bald skin. Large graft plugs can be quite effective when filling in bald areas behind the hair line, but large graft plugs in the hair line are very obvious when you see them. The desirability of using smaller punch grafts was clear to most surgeons using the punch graft technique and some surgeons did attmept to use smaller grafts. But, although studies were conducted in an effort to improve the technique and make a more natural looking transplantation, it took 30 years before a refinined technique with minigrafts was developed.

In the years after Orentreich’s study several improvements were made that enabled the minigrafting technique to be developed. The punch graft tools used in the 1960s were not as sharp as the ones used today. The first improvement in punch graft tools was a mechanised punch that rotated like a drill and could be used to quickly make punch grafts and holes and made for nice clean edges to the graft and less damage to the hair follicles (Tezel 1969). The problem however, was that the rotating drill-like punch produced aspirates of airborne blood particles as it cut the grafts. This was soon recognised as a potential infectious hazard for the surgeon and nurses. The mechanized punch graft tool gradually disappeared from the hair transplant clinic with three new developments, though a few were still using it well into the mid 1980s (Alt 1984).

This is an old photograph taken of an individual who underwent 4mm punch biopsy grafting to treat androgenetic aloepcia. The photo was taken a few weeks after the operation when the new hair was just beginning to grow. As you can see, the punch grafting technique resulted in a very unnatural hair line. However, modern hair transplant techniques have come a long way and give a very natural looking result.

In the mid 1970s Dr Richard Shiell introduced hand punch graft tools with hardened carbonized steel blades that were sharper and stayed sharper for longer reducing the need for mechanized punches. At about the same time, injection of saline into the donor area was found to increase turgidity and enhanced the ability to cut the donor skin quickly and easily with less damage to the donor graft skin (Frankel 1975). Also, there was a gradual move away from using punches to harvest the donor grafts towards using scalpels to cut strips of skin.

Vallis introduced the now very popular method of donor graft harvesting using a multibladed knife. He used a scalpel with two blades a fixed distance apart to cut the donor strip of skin from the back of the scalp (Vallis 1964). Today, around 70% of hair transplant surgeons use a scalpel with 2, 3 and even up to 9 blades to cut the donor skin. Vallis actually grafted the strips of donor skin in their entirity along with smaller punch grafts as his preferred method of transplantation (Vallis 1982). However, this form of strip grafting did not become popular and most surgeons moved to cutting square donor grafts from the long donor strips prepared with multi-blade scalpels (eg Coiffman 1987).

Smaller grafts were introduced by dissecting the traditional 4 mm plugs and squares into halves or quarters using a scalpel. The idea was first introduced in the 1970s but it took another 10 years for the approach to become widely used (Orentreich 1970; Stough 1986; Lucas 1988). Mini and micrografts were introduced by Emanuel Marritt and and Rolf Nordström with Marrit using minigrafts for eyelash transplantation (Marritt 1980; Nordström 1981). This produced a much less tufted appearance in the finished result. These grafts still had up to 8 hairs however and could still appear quite tufted when working with coarse black donor hair. Further subdivision of the grafts into smaller pieces containing 2-4 hairs was made popular by Uebel, Bradshaw, Stough and Brandy (Bradshaw 1988; Stough 1991; Uebel 1991). While these refined techniques gave a much more natural look hair transplant result, the techniques were much more labor intensive. A grater number of smaller grafts had to be implanted to transfer the same number of hair follicles as with the old, large punch graft approach. At this time the cost of transplantion rose significantly as more people were required to process and implant the grafts. By 1990 the typical hair transplant procedure involved about 12 work hours for hair transplant team and on average 1000 small grafts were transplanted.

The number of work hours per hair transplant procedure increased to 40 in the 1990s as further refined techniques increased the average number of grafts implanted per session to 3000. In 1994 Bob Limmer introduced the method of dissecting the grafts under stereoscopic dissecting microscopes (Limmer 1994). Limmer recognized that normal scalp terminal hair follicles grow in groupings of 1-4, referred to by hair transplant surgeons as “follicular units”. Limmer developed the methodology of follicular unit transplantation where the donor strip of hair follicles was microdissected by a team of technicians into natural follicular units. Implanting hair folliciles in their natural clusters gave a much more natural looking result. Single hair follicular units could be used to make the hair line while larger follicular units of 3-4 hair follicles could be used to fill in behind the hair line.

Follicular unit transplantation (FUT) was soon taken up by several big names in the hair transplant world including Rassmann, Bernstein, Seager, Norwood, and several others (Berstein 1997; Berstein 1998; Stough 1999; Unger 2000; Epstein 2003). When properly performed, follicular unit transplantation consistently and predictably produces the most natural-appearing hair restorations. Unfortunately, while the develpoment of follicular unit transplantion gives a superior result, the technical skills required, the large numbers of people involved in the procedure, and the subsequent expense to the hair transplant surgeon in training and paying the salary for such a large staff, has meant that follicular unit transplantion is still not used in many clinics.

3A) Cost per graft of cost per procedure

Hair transplant restorations are not cheap whichever way you look at it, but this is a permanent procedure. When you consider how much money that can be spent on drug treatments for baldness, calculating costs for a hair transplant compared to costs for drug treatment over several years, a hair transplant may turn out cheaper! If you use drugs to combat hair loss, then a cost comparison with a hair transplant may be a useful exercise to do.

The costs of a hair transplant can vary enormously from clinic to clinic. Someone with androgenetic alopecia might expect to see a minimum cost of $2,000 US dollars for a hair transplant. The average price for a hair transplant in North America is probably around $5,000. But a hair transplant may cost $10,000, $20,000 and even more!

There are two basic approaches used by hair transplant clinics to determine the total cost of a hair transplant; cost per follicular unit implanted, and cost per procedure. The cost per unit can range from anywhere between $3 to $12 US dollars in North America although the average is probably around $6. But what is a follicular unit? In follicular unit hair transplantation, a donor strip of skin is dissected into units of one to 4 hair follicles. The one and two hair follicle units are used to build the hair line, the larger units are used to fill in behind. But of course different people have different needs in terms of the number of follicular units required. It is not possible to exactly how many follicular units will be transplanted in advance of the procedure. Only when the donor strip of skin has been dissected into follicular units will the surgeon know exactly how many units are available for implantation. Because of this, determining the exact cost of a hair transplant going by the number of units implanted is difficult. To make costs clearer to the patient, many clinics go with the simpler approach of cost per surgical procedure with a ball park figure for the number of hair follicles to be transplanted in the procedure. Which costing approach is best is open to debate – though most of the surgeons I have met calculate cost per surgical hair restoration procedure.

The primary advantage of costing a hair transplant per unit is probably in advertising. $6 per unit sounds a lot more digestable than $5,000! I’m waiting to see advertisements for $5.99 a unit or buy 5 get one free. You just know it’s going to happen one day ….

3B) Evaluating hair transplant quality by price

Some people equate price to quality. Certainly if a hair transplant cost is unusually low you should be suspicious, but a $5,000 hair transplant may be just as good as a $10,000 transplant. The cost difference may come about because: 1) The surgeon has a well known name in hair transplantation and demand for his / her skills is high so he / she can charge a higher price. 2) Heavy advertising budgets. If the clinic is paying a lot in advertising to get you in the door, they will be incorporating that cost into your bill. 3) Sumptuous surroundings. A large attractive clinic costs a more to maintain than a plain office. 4) A high number of assistants, receptionists and other employees in a clinic will also increase the costs. 5) The local market. An affluent local market for hair transplants will usually result in higher charges from the local hair transplant clinics. It costs more to get a hair transplant in Los Angeles, California than it does in St Paul, Minnesota. 6) Demand versus supply in the local market. If there are a lot of hair restoration clinics looking for business and only a limited number of patients then hair transplant prices usually come down. Over the last 10 years prices have dropped (in real terms after considering inflation) as more hair restoration clinics have been launched. 7) Finally, charges may increase if you need a procedure that is not standard. A hair transplant for androgenetic alopecia is standard, but a transplant for a burns injury or for transplanting the eyebrows may be relatively expensive because there are fewer clinics capable of doing these kinds of transplantation techniques and because the expertise required to ensure a good hair transplant is higher than normal.

Overall then, the cost of a hair transplant is not a good indicator of quality. If price is a consideration for you, think about reducing costs by travelling to a clinic outside your own region. Some people even go overseas to Europe to get a cheaper hair transplant.

4A) Finding a good transplant surgeon

Finding a good hair transplant surgeon can be (and should be) hard work. A hair transplant is a serious undertaking. It is a surgical procedure with all the risks that entails. It is expensive. It is a procedure that will take a long time and multiple surgical sessions to complete, and the end rest is something permanent that you will have to live with. So you are looking for a hair transplant surgeon with lots of experience, who trained professionally and learnt from other experienced transplant surgeons, who can give you a quality, natural looking hair transplant, for a reasonable price. Frankly, not all hair transplant surgeons are equal and some are just cowboys. You might think that to be qualified to do a hair transplant you need a particular qualification. In fact, you don’t need any qualification other than a standard MD degree. General practitioners can set themselves up as hair transplant surgeons without any additional qualifications – they don’t even need to see a transplant procedure. As a result there are “transplant cowboys” out there who may claim to be able to do a hair transplant procedure but in reality their experience and expertise is extremely limited. They may not give you a “good” hair transplant. To be fair, there are relatively few cowboys around, most hair transplant surgeons learnt the procedures from other, experienced surgeons and they usually attend conferences and workshops to keep up to date on all the latest procedures. But because of the lack of regulation in the hair transplant industry, you do need to be careful about who you choose to conduct your hair transplant. This section of keratin.com will give you some ideas of how to find a good surgeon, the kinds of procedures available, and what to expect if you decide to get a hair transplant.

4B) Sorting the good from the bad(Questions to ask yourself about your prospective hair transplant surgeon and clinic)

Before and during your contact with your prospective hair transplant surgeon and clinic, you need to look for signs and signals that this surgeon and clinic is capable of providing you with a quality result – a natural looking hair transplant. Unfortunately there are a number of clinics and surgeons out there that do poor quality work. A bad hair transplant is very difficult to fix – it is much better to get a good hair transplant first time around. Before, during and after the clinic interview there are some questions to ask yourself privately to try and reduce the risk of getting a hair transplant from a cowboy surgeon.

1. How did you find out about the clinic and the surgeon? In the yellow pages or by personal recommendation? A personal recommendation by someone who has already had a transplant from the clinic / surgeon you are considering is best. Then you can see the results of their work and you can ask the person who had the hair transplant about their experience as a patient. If you don’t have a friend or colleague who can give you a recommendation, it’s okay to start with an advertisement or even the yellow pages, but you need to do more footwork to find out whether the surgeon / clinic is good.
2. How long has the clinic / surgeon been in business? If the clinic / surgeon has been around for a few years it suggests they must have a regular stream of (presumably satisfied) customers to stay in business.
3. What reputation does the surgeon / clinic have? These days with the availability of powerful search engines on the internet it is fairly easy to find out other peoples’ opinions of the clinic / surgeon involved (start with google.com – still the best search engine out there in my opinion). Just type in their name and see what comes up.
4. What reputation does the clinic / surgeon have in the business and legal arena? You could check with the better business bureau or equivalent in your area and check for any lawsuits brought against the clinic / surgeon. Often this can be done online. Contact your state medical board to see if any complaints have been filed against your hair transplant doctor or hair transplant clinic.
5. What qualifications does the surgeon have? Is he/she a member of a professional organization specifically for the hair transplant profession? There are a few professional organizations (eg. In North America – The International Society of Hair Restoration Surgeons (ISHRS)) that attempt to improve hair transplant standards and ensure members do quality work. Membership of these organizations is not a guarantee that the surgeon is good, but it helps.
6. In your contact with the clinic what is your general impression? Is the clinic in its own physical location or is it run from the back office of a general practice? Many hair transplant and cosmetic surgery clinics are in standalone buildings, others may be attached to larger dermatology clinics, each of which is valid. But some “clinics” are run by renting time in a surgery to do the operation and the only physical location may be a rented office not connected to a medical establishment. These small operations with a limited or no permanent location give cause for concern. They are harder to monitor and more difficult to contact if things go wrong.
7. What is your impression in the interview? Does the surgeon sounds like he / she knows what they are talking about? Do they show pictures of their own work? Do they explain the risks as well as the benefits of hair transplantation?
8. Do you feel some personal compatibility with the surgeon? You will be having a relatively intimate, albeit professional, relationship with this individual over a period of time if you have multiple hair transplant sessions. You need to feel comfortable with who you are dealing with.
9. How pressured do you feel to sign up for the hair transplant? If you feel unduly pressured it is better to walk away. Give yourself time to think about it. You can always sign up later or find a different clinic. Clinics and surgeons that push hard to get you to sign up may be losing sight of their professional conduct requirements – to put the patient before profit.
10. Prior to the surgery, did you actually meet with the surgeon who will oversee the transplant? Or did you just interview with a representative consultant, a nurse, or a technician? You should expect to see the surgeon at least once prior to the actual surgery. It is fairly normal to have your first interview with a representative who just explains the basics and talks about costs, but at some point prior to the surgery taking place you must interview with the surgeon conducting the hair transplant, and have them design a specific transplant approach for your particular hair loss situation. This interview should be quite in depth, not a brief “hello”. The surgeon should expalain the procedure to you in detail and explain risks involved. If you don’t see the surgeon before the procedure, or get only limited information, walk away from this clinic.
11. Who will actually conduct the surgical procedure? It is not necessarily going to be the surgeon who will conduct the procedure form start to finish. Hair transplants usually involve quite a lot of people. There are usually several technicians and a couple of nurses in addition to the surgeon. The technicians will look after the processing of the donor skin to isolate the hair follicles ready for transplantation. The nurses will look after you in general, get the surgical instruments ready, and maybe give you the anesthetic injections. The nurses may also actually do some of the hair follicle implantation. This is okay, but you should expect the surgeon to be there to oversee what is going on. Almost always, the surgeon him/herself will deal with the most important parts of the procedure. The removal of the donor skin is very important and needs to be done by the surgeon. Implanting the hair line should also be done by the surgeon. But filling in behind the hair line may be done by nurses under the surgeon’s guidance. There are a lot of hair follicles to transplant to cover a large area of skin so with two people working either side of the head you can get the implantation done in half the time. This is important as the longer the hair follicles sit around in saline the slower they will recover and start growing hair once they are implanted. Although nurses may do some of the hair follicle implanting, you should expect the surgeon to be present or in close proximity so they can be called upon during the procedure. If the surgeon is not going to be present and the procedure is to be done entirely by nurses or technicians, this is cause for concern.
12. Is your hair transplant surgeon’s practice dedicated solely to surgical hair restoration? And if not, what percentage of his/her practice is? How many hair transplant operations does the surgeon conduct in a week/month/year? Some clinics and surgeons are exclusively focused on hair transplantation, they do nothing else. This is another indicator that the clinic and surgeon have extensive experience in hair transplantation. Other surgeons divide their time between hair transplantation and other clinical duties. This is not unusual, especially if the dermatologist works at an academic institution or is in public health. In many countries such as Canada and the UK, it is not unusual for a hair transplant surgeon to have a job in the state health program consulting with outpatients, but to also work part time in a private hair transplant clinic. However, you should expect your surgeon to be conducting hair transplants on a regular basis averaging at least one a week and preferably more.

The above is not a comprehensive list of questions to consider, but it will help get you started.

5A) The interview basics and interview preparations

The interview with your prospective hair transplant surgeon is a key step in obtaining a hair transplant. The interview will allow you to obtain information about hair transplantation in general, your hair transplant in particular, and about the transplant surgeon who will be conducting the procedure. This is your opportunity to obtain answers to all the questions you may have about your hair transplant. Your objective is to obtain as much information as possible to satisfy yourself that this surgeon and clinic can do the job well. After all, a hair transplant is an operation, something that involves personal risk, and quite a lot of money, for a result that will be very difficult to fix if a mistake is made. Don’t sign on the dotted line until you are absolutely sure that a hair transplant is right for you and that you feel you are in safe hands with the surgeon you are interviewing. Remember you are in control. You are doing as much interviewing as being interviewed. If you still have doubts at the end of the interview, or are feeling pressured to make a decision there and then – walk away. You can always contact the clinic later or find another clinic and surgeon that you feel more comfortable with.

Interviews can cause anxiety, but you need to be as relaxed as possible. The more relaxed you are the more likely you will be able to take in what the surgeon is saying, to understand the information, and to ask pertinent questions. If it helps, take a family member or friend with you. Most surgeons are quite happy for you to have a friend in the interview with you. They can give you moral support, they may feel less anxiety and be able to view the proceedings more objectively, and they may ask some questions that you won’t think of. An interview will take at least 30 minutes, often one hour, and for some, particularly if you need reassurance, it may take up to 2 hours. If the surgeon has other appointments then he/she may ask you to come back at a later time to complete the interview. Don’t take this personally or in a negative manner, the surgeon needs to spend as much time interviewing with other prospective hair transplantees as they do with you.

While the interview is for you to obtain lots of information and have your questions answered, the surgeon also has objectives in the interview with you. He/she needs to provide you with information about the different hair transplant procedures used in the clinic (there are many and most clinics use more than one depending on the particular nature of your hair loss) and to identify the particular procedure most appropriate for your hair loss pattern. More details of what to expect are given elsewhere in this section of the web site. You might be given this information verbally or it might be in the form of a printed booklet. Ideally you want both so that you can ask questions when the procedures are being described to you during the interview and you have a summary sheet to keep and read later – because you won’t remember everything that is said in the interview. Before the interview think about what questions you have for the surgeon. Write them down and take them with you to the interview.

The surgeon will probably outline a short term and a long term plan. Hair transplants are not a quick fix. It often takes a couple of years with multiple surgical procedures to get a good result. There will be multiple steps and a lot of planning to achieve the final result. The long term plan actually extends over your entire lifetime. Whatever hair transplant you get, you have to live with it for the rest of your life. A hair line that might look good in your 30s is not going to look right in your 70s. The plan to design your hair transplant hair line needs to take into account not only how it will look at your age now, but how it will look as you grow older. Usually there needs to be a compromise in what hair line you want in your 30s and the appropriate hair line when you are older. Be realistic in your expectations and remember the surgeon has a lot more experience with creating natural hair lines than you do. Similarly, the eventual end stage extent of your hair loss has to be taken into account when developing a long term plan for you. You only have so many hair follicles in the donor area at the back of the scalp so they need to be used judiciously. Predicting future hair loss is difficult, but it must be taken into account so that some hair follicles can be left in the donor area for use in the future. Before the interview take some time to think about what you want from the hair transplant, but remember that there are limits to what the surgeon can do. While you may have an indeal result in mind, be flexible and recognise your ideal hair transplant result may not be possible.

5B) A summary of preparations to make for your interview

This is by no means a comprehensive list so check with the transplant clinic in advance and see what they want you to bring to the interview.

1. Make sure to write out a list of questions to ask. If you try to remember them all you will probably forget some. Write them down so you have all your questions ready.
2. Write out a list of any medications you are on. Take the drug packaging (most drugs usually come with a datasheet) with you in case the surgeon needs to know more details. Also include any alternative health medications (herbs etc.). Sometimes drugs and herbs can interact with the anaesthetics or antibiotics used in hair transplantation, so the surgeon needs to know what you are using.
3. Take with you any information regarding your hair loss. If you have had a diagnosis from a dermatologist, or have been prescribed drugs for your hair loss, make sure to bring a copy of the details with you.
4. Take any details of recent blood test results with you. Usually you have to take a blood test in advance of a hair transplant for things like HIV and Hepatitis C, and also to determine your health. If you have had a blood test for other reasons, the surgeon may use this and waive the requirement to get a separate blood test done specifically for the hair transplant.
5. Take the contact details for your doctor and dentist to the clinic. Most hair transplant clinics contact your doctor and dentist after the initial interview to confirm your health status and make sure you have not forgotten to tell them something important in your medical history!

Each clinic and surgeon has their own preferred interview method, but below is a generalised list of elements a typical interview would include.

1. The surgeon will ask you about your general health to make sure you are healthy enough to undergo an operation. Be honest with the surgeon and give all the information you can. Don’t withhold information because you might think the surgeon may refuse to give you a hair transplant. Bald may be bad, but dead is an untreatable diagnosis. In fact very few medical conditions prohibit hair transplantation. Even hypertension, once it is under control with drugs, does not stop a hair transplant from being conducted. But the surgeon does need this information in advance so that special care arrangements can be made for the hair transplant surgery. You will be asked about heart, liver, kidney and other organ diseases; whether you have diabetes, ulcers, hypertension, bleeding disorders, epilepsy, and fainting spells. You will be asked about any allergies and whether you have had adverse reactions to any drugs. You will be asked to take a blood test if you have not had one done recently (within the last 1-2 years). The surgeon should review the risks involved in hair transplant surgery based on your health situation.
2. The surgeon will examine your hair loss. They will be looking for the typical indicators of pattern baldness, scarring alopecia, or whatever hair loss condition you have. As part of the examination your scalp will be examined by hand. The surgeon is looking at the color, hair texture and coarseness, hair calibre, hair curl, and density. They will look at both the alopecia affected areas and at the donor area to gauge how much hair your have available for transplantation and how much bald skin needs to be covered. The surgeon will be judging the eventual end stage extent of hair loss he/she expects you to reach in the future as well as the actual hair loss you have today.
3. You will be asked about the history of your hair loss. When it started, how quickly it has progressed. You will also be asked about any hair loss history in your family. The surgeon will probably want to know how much hair loss your father and grandfathers had (or mothers and grandmothers for women).
4. The surgeon may show you a chart showing different degrees of hair loss. There are several different classifications in use – see the androgenetic alopecia section of this web site for the different classification systems. The surgeon may ask you to classify how much hair loss you think you have as well as judging you hair loss extent for him / her self.
5. In some of the fancy clinics, the surgeons take a picture of you and scan it into a computer. Then using software they change your appearance to show how much hair loss you might have in the future and then to show what they think you might look like with a hair transplant. However, the validity of these software programs is open to question. The programs may make hair loss seem far worse than it is or will be and can also give you an overly optimistic view of what can be achieved with a hair transplant. Most good surgeons do not use these software programs – they seem more of a sales pitch tool than a tool to provide you with really useful and accurate information.
6. The surgeon should give you a brief review of the different hair transplant techniques and then describe in more detail the one he/she prefers and believes is suitable for you. They might ask you how much you know about hair transplants to judge how much detail they need to give you. If you have questions – ask. The surgeon may show you photographs before and after hair transplants to show you what is achievable. They can also use the photos to explain how different transplant procedures are used for different hair loss presentations and on different areas of the scalp. Ideally the pictures you are shown are of patients the surgeon he / she has worked on. Ask them to make sure this is correct and the surgeon isn’t showing you pictures of work done by someone else – this is especially relevant in hair transplant chains where more than one clinic or surgeon goes under the same brand name. The pictures will give you an idea of the quality to expect from the surgeon. Make sure you like what you see. The surgeon may well show you pictures of patients from other clinics and surgeons, but here the objective is to show you the many different hair loss presentations – and possibly to match one to your particular hair loss presentation – so you can see the various results achievable for different hair loss situations. The surgeon may not have pictures of a hair transplant that is similar to what he/she predicts for you, especially if you have an unusual hair loss presentation, and so he/she may have to resort to showing you what to expect using another surgeon’s pictures. However, the surgeon should make it clear to you what is his work and what is someone else’s work.
7. The surgeon will outline what he/she feels is the most appropriate plan for your hair transplant. As part of this many surgeons often use a grease pencil to draw in a hair line on your scalp. Almost always the patient thinks the hair line drawn is too high. It may well be higher than normal, but remember you only have so many hair follicles that can be transplanted and you have to be realistic as to what is achievable. Also remember that the hair will hang over somewhat so the hairs growing from the hair line will be lower than the actual hair line (where the hair follicles will be implanted). Some patients may ask for a hair line that is way to low – a child’s hair line. These look fine on a child but for an adult a child’s hair line looks very odd. Hair that is implanted too low is very difficult to get rid of and usually requires laser hair removal or electrolysis. At least if a hair line is implanted too high you can undergo another transplant procedure to lower it later. The surgeon will discuss the hair line with you and might redraw it depending on your wishes, but remember there are limits to what a transplant surgeon can do and that the hair line you think you need may not be possible or appropriate.
8. With the hair line determined, the surgeon will discuss the lateral boundaries and filling in behind the hair line and whether or not the vertex needs attention. When determining what areas need attention the surgeon will be considering the future hair yet to be lost as well as your current hair loss state. If the surgeon does not address the issue of future hair loss then you may be in a situation of “chasing” the progressing alopecia in future years with another hair transplant. As a result, the surgeon may suggest transplanting to areas that are thinning but not yet bald as well as transplanting truly bald areas so as to reduce or avoid the need for future hair transplant procedures.
9. Eventually you should reach an agreement on how the hair transplant should look. The surgeon may take pictures of the grease marks on your scalp as a record of what was agreed and to review with you on the day of the first surgery.
10. The surgeon will probably explain in more detail what you should expect with your first transplant session and the effects immediately afterwards. These details are listed elsewhere on in this section of the web site.
11. The surgeon will then probably explain the long term planning. You may need multiple surgical sessions to achieve the hair transplant plan you have agreed upon. These multiple sessions, the time between sessions, and what to expect from the results of each session will be explained to you. Rather than spread hair transplanted hair follicles throughout the area to be treated at each session, hair transplant surgeons will concentrate on one area in the first session, usually the hair line, and then work on a different area in the next session (behind the hair line, the vertex, etc). Gradually a full transplant is built up with multiple transplant sessions. How many hair transplant sessions you need depends on the size of the alopecia area to be covered and the particular transplant technique the surgeon will use.
12. At the end of the interview, make sure you have asked all the questions you wanted answers to!

Unfortunately in some cowboy clinics the only objective in the interview is to get you to pay up and the clinic representatives may tell you whatever they think you want to hear and agree to whatever you demand to get your signature on a check. “The customer is always right” or “give the punters what they want” are ideals that many in the commercial world live and die by. But when it comes to your health and safety the customer is always right approach is not always in the best long term interests of you the customer. Do you really know what the best hair transplant technique is? Are your expectations for a hair transplant realistic? Do you understand the risks of the procedure? Is a hair transplant really the right treatment approach for you kind of hair loss? If the hair transplant technique is not the right one for your needs, or the result is not what you were expecting, it is too late to do much about it. If you are disappointed with a hair transplant, taking a clinic to court may be an option, but an expensive one, and the damage has already been done and will be difficult to fix. It is much better that you get the right advice first time around, even if the advice is that you should not have a hair transplant. A surgeon should have your best interests at heart, and a good surgeon will actually tell you if he / she finds that you are not suitable for a hair transplant.

A good consultant in a reputable hair transplant clinic will take the interview several steps beyond just giving you information. A good surgeon will try and gauge your motivation for having the hair transplant done and will find out how realistic your expectations are for the hair transplant procedure. If a good surgeon thinks you are not particularly motivated or you have unrealistic expectations, he / she will actually recommend that you do not have a hair transplant at that time. Some people are not really sure that they really want a hair transplant when they interview a clinic. Because a hair transplant is a significant financial and health undertaking, it is better such people are given more time to think about it. If you are not really sure about a hair transplant, a surgeon may suggest you wait and think about it some more. You can always contact the clinic later if you do decide a hair transplant is right for you.

Other people are wildly over optimistic about what a hair transplant will do for them (and their sex life even). Some people can get very emotional about their hair loss, they want it fixed at any cost and they want an immediate and perfect result. Hair transplants don’t work that way. Most hair transplants involve multiple surgical sessions over many months. It can take a couple of years before an acceptable hair growth is achieved. A good hair transplant can look quite natural, but it will never give you the hair density you had as a child. Sometimes because the number of donor hair follicles are limited and the area to cover is large, the surgeon has to resort to giving you a higher hairline than normal or making the hair at the front hairline more dense so that you can grow the hair long to cover thinner areas on top. Some people get very disappointed when they find this is the case and that there are limits to what can be done with hair transplantation techniques. When they get a hair transplant that is not as they had hoped, they get depressed and they may decide to sue the surgeon. For these people, it is better in the longer term that they do not receive a hair transplant, better for them, better for the surgeon too.

Some forms of hair loss are simply not suitable for hair transplantation. A hair transplant for a condition like telogen effluvium or alopecia areata would just not work. The transplanted hair follicles would be just as susceptible to hair loss as all the other hair follicles. While hair transplantation is possible for most people with pattern baldness, not everyone is a good candidate. People with extensive hair loss may not have enough hair follicles in the donor area at the back of the scalp for a hair transplant to give a cosmetically acceptable result. Others may be in the early stages of pattern baldness development with only limited areas of hair loss. Whilst the surgeon could give you a hair transplant, this would not stop more hair from falling out later on. So a hair transplant in the early stages of androgenetic alopecia development may fix the problem for a while, as the baldness continues to expand, so you would be left with “islands” of transplanted follicles surrounded by a sea of bald skin. If the interviewing surgeon believes this is the situation for you they may suggest you try drug treatments for now and come back in a few years for a hair transplant.

Finally you might be rejected because, while you may be a suitable candidate for a hair transplant, and your expectations of the transplant procedure are realistic, the surgeon does not have the required knowledge and experience in the particular technique needed for your hair loss presentation. This situation is most often encountered by those with scarring alopecia or those who need hair transplants to the eyebrows, lashes, beard, or pubic regions. Most hair transplant clinics are geared to people with pattern baldness, they may not have the knowledge to do a good hair transplant job for people who have a condition other than androgenetic alopecia. In these situations, a clinic may refer you to a specialist, a plastic surgeon with experience in corrective surgery. If you know you need a hair transplant that is different from the standard procedure, it may be best to seek out plastic surgeons with experience in treating the particular form of hair loss that you have and avoid the routine hair transplant clinics altogether.

To be turned down for a transplant may seem harsh at the time, but it is almost always in your long term interests. If you find the surgeon has recommended that you do not have a hair transplant you need to ask yourself why. If it is that your particular hair loss presentation is not suitable for transplanting then you may need to consider other treatment approaches. If the technique you need is not something a particular surgeon can do, find another who can. But if the issues are more emotional, you are not sure you really want a transplant, or the surgeon felt your demands were unrealistic, then you may have a lot of thinking to do. In both cases, gathering information about hair transplants and then weighing up the pros and cons of a transplant in an objective way may help you come to a conclusion.

8A) Take a test for HIV and hepatitis and have a general medical examination

If you have committed to getting a hair transplant there are few things that need to be done in preparation. Usually your transplant consultant will explain this to you, but here is a general summary of what to expect prior to your hair transplantation.

Most hair transplant clinics will expect you to take a blood test prior to the procedure. This is not so much for your benefit but to protect the surgeon, nurses, and anyone else who will be involved with your transplant. Hair transplants involve taking tissue (skin), dissecting it, and then implanting it to you. Each of these steps involves needles and scalpels and the possibility of the surgeon and nurses cutting or injecting themselves with a scalpel or needle contaminated with your blood is a very real possibility. Whilst these risks can never be completely avoided in any surgical operation, most clinics seek to avoid exposure of their employees to the risk by having prospective hair transplant recipients take a blood test. At the very least HIV and Hepatitis C is tested for. There may be tests for other infectious agents as well. You might need to arrange a test with your family doctor or the clinic may conduct the test themselves. Usually the test results are anonymous – the blood samples tested don’t carry your name, just a reference number that is given to you.

In the event that you are positive for an infectious agent it need not stop you from having a hair transplant. The clinic, surgeon, and nurses may take extra precautions like using double gloves and being extra careful with needles and scalpels.

The blood test may also include an examination of bleeding/blood clotting time, and a blood platelet count. A urinalysis may also be required to look for diabetes and other diseases. The hair transplant clinic will also probably want you to get a full medical check up to make sure you are generally healthy enough to undergo a surgical procedure.

8B) Grow your hair before the hair transplant

You should grow your hair fairly long over the donor site at the back of the scalp. The hair should be about 5cm long or more. This hair can then be combed over the donor site immediately after surgery so that the wound and the sutures are not visible. At the time of taking the donor skin and hair follicles, the surgeon or nurse will clean the donor area with antiseptic and use hair clips to hold the long hair out of the way. On completion of the surgery the hair clips are taken out and with some careful combing you can immediately hide the donor area. In a couple of weeks the wound will have fully healed and the sutures will be removed. The remaining scar should be virtually invisible except with close examination. At this time you can get you hair cut to a shorter hair style if you wish. Though, you should remember that there will always be a very fine scar line on the donor area so a close clipped or shaved scalp back is not suitable (unless you are not bothered of course). When you go to get your hair cut after surgery make sure that your hairstylist understands the situation and does not cut the hair too short. It is probably best to avoid having the hair cut at all in the 3 weeks prior to surgery so that you can be sure you have some long hair ready to comb over the donor site.

In addition to growing the hair long around the donor area, you can also grow your hair long to comb over the recipient site. For the first few days your head will be bandaged to help the transplanted hair follicles heal into the skin. Once the bandage is taken off though you will have a large area of still bald skin, your scalp will probably be somewhat red and inflamed, and the implants will be fairly obvious and a bit “crusty”. The inflammation should subside in a few days and the hair follicles will be fully healed in a couple of weeks. Eventually the hair will grow, though it may take 6 months from the surgery before you get a really good hair growth. Until that time you may want to comb long hair from the sides over the implantation site. If so, make sure you grow your hair long before the hair transplant procedure is done so it is ready to be arranged over the hair implantation site as soon as the bandages come off.

8C) Avoid drugs that may complicate the hair transplant

Medication prior and during surgery is a significant issue. You should inform your surgeon in advance of any medications you are taking including herbal and other alternative medicines. There are several classes of drugs that are known to increase bleeding. Aspirin will reduce the ability of blood to clot and should be avoided. Any anti coagulant drugs like warfarin can create significant problems with blood clotting. St John’s Wort increases drug metabolism which may reduce the effectiveness of anaesthetics. You should avoid alcohol for 10-14 days prior to surgery. It is believed that alcohol can increase the rate of bleeding. Although there is little hard proof of this, it has been shown that alcohol can affect the bleeding time after an injury (eg Hillbom 1985) so it may be best to play on the safe side. Vitamin E, vitamin E derivative drugs, and even foods with high vitamin E content (most green vegetables, eggs and products containing eggs like mayonnaise, most vegetable oils, etc) may prolong bleeding, particularly in those with a vitamin K deficiency (Corrigan 1974; Kappus 1992), and should be avoided prior to surgery. Niacin, and several of the vitamin Bs, can also increase bleeding. In contrast, vitamin K improves blood clotting speed. Fro women some of the older oral contraceptives with high estrogen content can reduce blood clotting. If you are using minoxidil to treat your hair growth you will be asked to stop using it until after surgery as minoxidil is a blood vessel vasodilator as well as a hair growth promoter. There are many other potential issues with drugs and surgery too numerous to list here. Make sure you talk to the clinic and give them a complete list of all the drugs, herbs, and supplements you are taking. They should then advise you on what you should not take prior to surgery.

If you are a smoker you may be asked to stop smoking a week prior to hair transplantation. Some surgeons believe that smoking (nicotine and carbon monoxide) reduce blood clotting speed. However, the scientific evidence to support this view is conflicting and in fact some studies have suggested smoking actually improves the rate of blood clotting (eg Ring 1983). However, there are other studies that suggest smoking can reduce hair growth (Trueb 2003) and given the general health implications of smoking, having a hair transplant may be a good occasion to quit smoking and start a new, more healthy, more hairy life!

9A) One to two months before the hair transplant

This is not intended as a comprehensive guide and each clinic has its own particular preferences so check with the clinic conducting your hair transplant to find out the all the guidelines you need to follow.

1. Grow you hair long ready to comb over the donor and recipient sites once the bandages come off.
2. Talk to the clinic about potential drug interactions and find out what drugs, herbs, vitamins, and foods you should avoid or keep to a minimum in the month before surgery.
3. Find out the time your procedure will start and the approximate time it will end. The exact time the hair transplant will be complete cannot be guaranteed. Most transplants start early in the morning and take a full day to complete. Make sure to avoid arranging appointments etc around the time of the procedure. Leave some days after the procedure free so that you can get your bandages and sutures removed as and when required. You might have this done at the transplant clinic or it may be done by your family doctor. Find out which and make the appointments for bandage and suture removal.
4. If you do not live close to the clinic make arrangements to travel and book a hotel room. Many clinics have special deals with hotels nearby and can arrange a place for you to stay. They might also arrange airline flights for you too. You should stay for at least one day after the procedure so the surgeon can follow up with you.

9B) One to two weeks before surgery

1. Stop drinking alcohol.
2. Possibly stop smoking.
3. Stop taking any drugs known to reduce blood coagulation (but consult with your doctor and hair transplant surgeon first).
4. Do not have permanent waves, hair coloring, or hair relaxing procedures.
5. Buy some bags of frozen peas or similar that you can apply to your scalp as a cold compress after the hair transplant.

9C) One to two days prior to the hair transplantation

1. Don’t party all night – gets lots of sleep. If you take sleeping pills check with the clinic in advance that the type of pills you use are okay and won’t interfere with the drugs used in the hair transplantation.
2. Wash you hair with an antiseptic / antibacterial soap / shampoo each day for the two days prior to the hair transplant. There are several over the counter products available. The hair transplant clinic should advise you of the best one to use. Do not use Nizoral shampoo as it can interfere with some antibiotics. You may be given antibiotics to reduce the risk of infection in the hair transplant procedure.
3. Travel to the clinic where the transplant is to be done if you are not living nearby.
4. Arrange for taxis or for someone to drive you to and from the clinic before and after the operation. The drugs involved will likely impair your ability to drive so you should avoid this. Make sure you can get to the clinic on time for the start of your operation. Check the route and the time it takes to get to the clinic.

9D) On the day of hair transplant surgery

1. Wash your hair with an antiseptic / antibacterial soap / shampoo. It is probably worth taking a shower too!
2. Have a normal breakfast. It may be best to avoid caffeine so you are as relaxed as possible for the procedure. If you are a liquids only breakfast person you should eat something.
3. Take antibiotics if they are prescribed by the clinic.
4. Wear clothes that can be removed without pulling them over your head. Ie. wear a shirt with a button or zip front, don’t wear a T shirt or sweater. After the surgery you will probably (a few clinics do not bandage the scalp) have a big bandage on your head and you do not want to dislodge the bandaging as you remove your clothes. Wear loose, comfortable clothes as you will be in the clinic for a long time and may be asked to lie or sit in various positions for the donor and recipient procedures.
5. Prior to the procedure, go to the lavatory – I’m not kidding! There will be long periods when you have to lie / sit still for removing the donor area and for implanting the hair follicles. You can’t go for a leak half way through.

10A) Size of donor area and tissue to be collected

This page refers to the procedure generally used for patients with androgenetic alopecia. The procedure will vary somewhat depending on the personal preference of the surgeon, and will vary even more if you have a form of alopecia other than androgenetic alopecia that is being surgically restored.

Planning the donor site is just as important is planning the hair implant recipient site in hair restoration. The donor area has to be preserved as much as possible, you don’t want an irregular shaped occipital scalp hair growth or a large scar from the removal of the donor hair follicles. The primary issue for the hair transplant surgeon in planning the donor site is how big it is and how much skin should be taken to provide enough hair follicles for the transplant session. Not all donor sites are the same size in hair transplant patients. Some men and women have quite large areas of occipital scalp where the hair follicles remain unaffected by androgenetic alopecia. In other patients, the androgenetic alopecia has spread far back on the scalp and the occipital scalp hair growth area is relatively small. In addition, there are some people in whom their androgenetic alopecia is so extensive that the hair follicles on the occipital scalp are also affected to some extent and the hairs are finer and thinner than would be expected. If the donor area is too small or the area is affected by androgenetic alopecia then the individual may not be a suitable candidate for hair restoration.

Some experience is required on the part of the hair transplant surgeon to correctly define the area of donor hair on the occipital area that is unaffected by androgenetic alopecia. It is important to get it right as transplanting hair follicles that are androgen responsive will lead to transplanted hair follicles miniaturizing in response to the androgen hormones. Also, the surgeon must leave enough hair behind after removing the donor hair follicles to ensure a natural look to the occipital hair line. It is generally believed that the “safe” area of potential donor hair follicles resistant to androgenetic alopecia is in the area from the lower hairline at the back of the neck, up to an imaginary line running around the back of the head about 2cm above the openings of the ears. This defines the maximum extent of the potential donor area for all but a few individuals. However, when actually removing the donor skin, the surgeon must leave margins above and below the removed hair follicles. The surgeon also has to take into account the possibility that the patient may need more hair restoration procedures in the future. Bearing these limitations in mind the surgeon will identify an area of skin to remove.

10B) Preparing the occipital scalp for donor skin removal

At the start of the procedure, you, as a patient, will be dressed in a surgical gown, or at least you will be asked to cover your upper body and around your neck in a disposable apron. You will be positioned face down on an operating table with your head on a prone pillow – it has a hole in the middle for your face to go into so you can breathe! The area of skin at the back of your head will be sterilized with one or more solutions swabbed over the skin and hair. The long hair that you have hopefully been growing to use later to cover over the sutures, will be combed out of the way and held in place with hair clips. The area of skin from which the donor hair follicles will be cut, will be shaved with clippers or cut with scissors so that the long hair doesn’t get in the way of cutting the skin and later when the skin is microdissected to obtain the hair follicles. The hair is not completely removed down to the skin surface, about 2mm of hair is left above the skin surface so that the surgeon can see where the hair follicles are when he cuts the donor skin. The skin is swabbed again to get rid of the loose, cut hair and to repeat the sterilization. Usually the solution is iodine (Betadine) or chlorhexidine (especially if you are allergic to iodine).

To prepare the skin ready for cutting, your skin will be injected with a saline solution and then a local anaesthetic or alternatively you may receive both saline and anaesthetic as a mixed solution. The intention of the saline is to increase tumescence in the skin that is, to make the skin relatively hard. This makes it easier to cut with a scalpel and ensures nice clean edges to the cut skin which makes healing of the wound quicker. It also spreads the hair follicles apart so they are easier to see and to cut between with the scalpel blade. The local injections can be painful, although the pain should be brief until the local anaesthetic takes effect. To overcome the brief pain during injection of the saline and local anaesthetic, some surgeons offer the option of a partial systemic anaesthetic like nitrous oxide. You usually administer this to yourself, by breathing it through a mask you apply to your mouth as and when you feel you need it, during the injection of saline and local anaesthetic. You should remain awake throughout the procedure. The breathable anaesthetic is only used until the local injected anaesthetic takes hold.

10C) Method of donor tissue collection

The next step is for the surgeon to actually cut the donor skin area. Most hair transplant surgeons currently (as of 2004) use a multi bladed knife to remove a strip of skin from the occipital scalp. The distance between the blades and the length of cut determines the size of the skin area that is removed. The multi bladed knife can be resized to change the distance between the blades. The surgeon will determine how much skin is needed and position the blades of the knife appropriately. The scalpel blades are inserted into the skin at one side of the head at an angle such that the blades are parallel to the hair follicles in the skin. The surgeon can predict how angled the hair follicles are in the skin by observing the angle of hair growth coming from the hair follicles. The cut is relatively quick in the hands of an experienced surgeon. It can take less than 30 seconds. However, it can take longer if you are one of the few individuals in whom the angle of the hair follicles changes across the scalp. Then the surgeon has to go more slowly and carefully to ensure he/she does not cut into the hair follicles.

The surgeon will then cut across the skin to make the strip of donor hair follicles. If you have already had one or more procedures done, the surgeon will cut the strip of skin just next to where the previous strip of skin was cut. The surgeon will cut the new strip of donor skin such that it also just cuts out the scar left from the previous operation. In this way, the surgeon can ensure that, regardless of how many implant procedures you have, you only ever have one scar on the occipital scalp. Just how much skin is removed depends on the size of the recipient area that needs to be implanted and the density of your hair follicles. Roughly speaking, the density of hairs in the donor region of the scalp typically ranges from 70 to 120 follicular units per square centimeter, with a median of 80. Therefore, in the typical patient, a 20-cm2 donor strip (20 cm in length by 1 cm in width) would be required for a 1600-graft procedure.

The strips are then cut away from the scalp. Usually, the surgeon or nurse will pull gently on one end of the donor strip with forceps and as the skin is lifted up above the remaining scalp skin, a pair of surgical scissors will be used to cut underneath the hair follicles to release the skin strip from the scalp. This is then put into a saline solution in a plastic dish in an ice bucket. This is taken away for further processing to make the grafts ready for implanting. What is left is a usually a narrow elliptical hole in the occipital scalp skin. If there is bleeding from some of the larger blood vessels, they may be cauterized. The wound is then sutured (sewed) together, often with a single running stitch. Some hair transplant surgeons use biodegradeable sutures that eventually fall out. Most however, use normal sutures that need to be taken out by a doctor at a later date. It will take a while until the grafts have been dissected ready for implantation. During this time you will probably be free to sit up and read or watch a video.

The donor strip of skin is then taken to a preparation room. Here the skin is dissected into grafts ready for implantation. In modern clinics the donor skin is dissected by a team of highly trained assistants. There can be three to five, and sometimes even seven or eight, technicians dissecting the skin simultaneously. Arguably the best, hair transplant clinics have their technicians divide up the donor skin using stereo dissecting microscopes.

Using the binocular microscope, the assistants subdivide the single strip into thin slivers 2 to 3 follicular units wide. These individual slivers are then further dissected into individual follicular units. The tissue is handled with fine forceps and cut with small scalpels. The tissue is held with forceps on one side, the scalpel is angled parallel to the angle of the hair follicles, and the skin is cut to the side of a follicular unit. If the technicians see significantly damaged hair follicles or hair follicle missing a bulb, they will cut these away from the follicular units and discard them. They cut off much of the non hair bearing scalp skin around the hair follicles. The smaller the follicular unit the quicker and better it will heal into the skin once it is implanted. It is also less likely to leave a visible scar. The grafts, separated by numbers of hairs, are kept in chilled saline until the time of implantation, separated by hair number. The mean number of hairs per graft is 2.2 to 2.3, so most grafts contain 2 or 3 hairs. Follicular units of ones and twos will be used towards the front to make the hair line, while follicular units of three and four hair follicles will be used to fill in behind the implanted hair line. (see figure below)

To be fair to those surgeons that do not have their technicians use microscopes when they cut up the donor skin into grafts, some studies have shown that implanted hair follicles can grow even after sustaining mild to moderate damage and that sometimes cutting the hair follicles in two can actually lead to two hair follicles being produced from one! The issue is how much damage a hair follicle can sustain before it becomes so damaged that it cannot grow. Those follicles from which more than a third of the lower follicle and bulb region have been cut will not grow. In light of this, dissecting hair follicles under a microscope is probably the safest way to ensure that the dissected hair follicles are healthy and will survive and grow after implantation. One study that compared implanted hair follicles that had been dissected with microscopes or loupes suggested microscope use increased the hair yield by as much as 20% (Berstein 1998).

Dissecting the hair follicles under a microscope also enables a relatively new development in hair restoration to take place – follicular unit grafting. Hair follicles often grow in natural clusters of twos, threes, and fours. Using the stereo dissecting microscope, the hair follicles in the donor skin can be divided into their natural “follicular units” and implanted in these units. This makes for a much more natural looking transplant result. So in short, microscopic dissection results in grafts that are smaller and contain a minimum amount of scalp skin. These grafts can be placed into smaller recipient sites, and this theoretically allows for a greater hair density, faster healing, and less trauma to any existing hairs in the implant recipient area. In addition, transplanting grafts with a limited amount of skin around them minimizes any changes in pigmentation and texture of the recipient scalp skin. So with the donor skin now dissected into follicular units the next part of the procedure, the implantation, can begin.

Above is a typical stereo microdissecting microscope set up for dissecting hair follicles. The box to the left is a cold light supply, the light is guided through optical fibers in the flexible metal arms that are positioned either side of the microscope to feed light onto the dissecting dish under the microscope.

To be fair to those surgeons that do not have their technicians use microscopes when they cut up the donor skin into grafts, some studies have shown that implanted hair follicles can grow even after sustaining mild to moderate damage and that sometimes cutting the hair follicles in two can actually lead to two hair follicles being produced from one! The issue is how much damage a hair follicle can sustain before it becomes so damaged that it cannot grow. Those follicles from which more than a third of the lower follicle and bulb region have been cut will not grow. In light of this, dissecting hair follicles under a microscope is probably the safest way to ensure that the dissected hair follicles are healthy and will survive and grow after implantation. One study that compared implanted hair follicles that had been dissected with microscopes or loupes suggested microscope use increased the hair yield by as much as 20% (Berstein 1998).

Dissecting the hair follicles under a microscope also enables a relatively new development in hair restoration to take place – follicular unit grafting. Hair follicles often grow in natural clusters of twos, threes, and fours. Using the stereo dissecting microscope, the hair follicles in the donor skin can be divided into their natural “follicular units” and implanted in these units. This makes for a much more natural looking transplant result. So in short, microscopic dissection results in grafts that are smaller and contain a minimum amount of scalp skin. These grafts can be placed into smaller recipient sites, and this theoretically allows for a greater hair density, faster healing, and less trauma to any existing hairs in the implant recipient area. In addition, transplanting grafts with a limited amount of skin around them minimizes any changes in pigmentation and texture of the recipient scalp skin. So with the donor skin now dissected into follicular units the next part of the procedure, the implantation, can begin.

12A) Implant site preparation

To prepare you, the hair transplant patient, for receiving the graft implants, you will be asked to sit in a surgical chair or in a semi supine position on a surgery table. There are arguments about which position is more comfortable and which leads to fewer complications with the procedure. So far no clear winner has emerged. The advantage of the semi supine position is that it reduces the chances of fainting or dizziness during the procedure. This can happen before the anesthesia is injected into the implant area, but rarely happens once the anesthesia takes effect. On the other hand, a sitting position reduces the amount of bleeding when the grafts are being implanted. The vertex (front and top of the scalp) has a high density of blood vessels in it. When the skin is cut on the scalp it can bleed quite a lot. A sitting position helps drain blood away from the scalp and in so doing reduces the amount of blood that bleeds from the implant wounds. Some surgeons may arrange for you to lie down for the initial anesthetic injection and then have you sit in a chair for the implant procedure to get the best of both approaches.

12B) The hair line

The area of skin for implantation is sterilized by swabbing with an antimicrobial solution. Anesthetic is injected locally in the area of skin ready for implantation. Once the anesthetic has taken effect, the implantation procedure can begin. For those with classic androgenetic alopecia in a male pattern and recession of the frontal hair line, the hair line is the first problem to be addressed. The surgeon, rather than any assistants, should be the one to make the incisions for the graft implants that will form the hair line. In general the surgeon will also be the one that fills the hair line incisions with grafts, although sometimes a nurse will do it. The hair line is the most important part of any hair restoration procedure. This will determine whether the result looks natural or artificial. For the hair line to look as natural as possible, the surgeon must make the line reasonably bilaterally symmetrical although perfect bilateral symmetry of the implanted hair line is unlikely. The hair line needs to adjusted on each side depending on the shape of the face – particularly if your face is not very symmetrical! When the hair follicles are actually implanted, only the small one, and occasionally two, hair follicle unit grafts are implanted into the hair line. They may not be in an exact line as, if you look at a natural hair line, there are always a few odd follicles out of line. A very slight “wiggle” in the hair line makes it look just that much more natural.

12C) Making the incisions and inserting the hair follicles

Different hair transplant doctors have different personal preferences for how they make the incisions into the skin ready to receive the hair follicle grafts. Some use needles of 16-18 gauge – which is pretty small. Others use small scalpels and make little slits in the skin into which the implants can be squeezed. A few hair transplant surgeons still use punch biopsies, although punch biopsies are only made as small as 2mm which is, for the most part, too large for the modern practice of follicular unit implantation. There are also some special implantation devices available that some surgeons use. Regardless, the objective is to make nice clean, small wounds ready to receive the hair follicle implants. The hair follicle units are then pushed into the small wounds using watchmaker’s forceps. Because the follicular units are so small and there are often many of them to implant, there are usually two nurses working on either side of the head to speed up the implantation process. Time is important, the longer the hair follicle grafts are lying in cold saline the longer they are away from nutrients in the blood that they need to grow. This is probably why it takes so long for transplanted hair follicles to grow after a procedure. The hair follicles have been starved and that usually sends them into a state of suspended animation (telogen). Once the grafts are healed in and they start receiving food via the blood again, so the hair follicles can repair themselves, rearrange themselves and start growing hair.

12D) Pattern of implantation

The pattern of incisions and hair follicle implantation is very important for ensuring a natural looking result. Hair follicles grow at an angle over the scalp and the angle changes depending on what area of the scalp you look at. For most people, though not everyone, the hair on the top of the scalp grows in a clockwise whorl pattern with the center of the whorl at the vertex. For this reason, if there is a parting it is usually on the left hand side of the scalp. It is much harder to part hair on the right and have the hair lay flat. Because of this whorl pattern, the surgeon will similarly arrange the implanted hair to match this natural hair growth whorl. The hairs will be implanted into the skin at an angle consistent with any remaining hair and pointing in a direction that follows the whorl pattern. The parting is also an important consideration for the surgeon. He/she may implant hair follicle units at a slightly higher density around the natural parting than on the opposite side of the scalp. This will help give the parting a normal looking hair follicle density.

Whilst the ideal is to give you a normal hair density in a natural growth pattern over the entire bald area, the limitations on how many donor hair follicles you have and the size of the recipient area to cover will modify the nature of the implantation. If there aren’t enough hair follicles to transplant, then the surgeon may implant more towards the front of the head than the back so that the hair can be grown longer and combed back to cover the thinner areas behind. The surgeon must also modify the implantation when there is more than one surgical procedure in the complete hair restoration. If subsequent transplant sessions are expected, then the implanted follicles may be more spread out than would be expected with just one implantation procedure. The surgeon is leaving room for hair follicles to be implanted in the next session in between the grafts implanted in the current session. This means the total hair restoration is built up over multiple session, and until the final session is done, it is not possible to determine just how natural (or not) the transplant looks.

Eventually all the grafts should be implanted and the basic procedure is complete.

13A) Bandages

There seem to be three basic approaches to care after a hair implantation procedure is complete. Traditionally, the individual had a bandage applied to the scalp to cover the implant wound area. The patient would then be sent home and returned to the clinic the day after to have the bandages removed and the implants examined. The alternative is to apply saline soaked gauze to the implant area and bandage it. The patient stays in the hair transplant clinic like this for a few hours before the patient is unbandaged and sent home. In each of these scenarios several layers of gauze are applied over the implantation site and then a long bandage is wound around the head to hold the gauze in place. The bandage applies some pressure to the scalp skin to help reduce any potential bleeding. More recently though, especially since the development of micrografting and follicular unit grafting, patients are not having their scalp bandaged at all. To use or not to use bandages after an implantation procedure is a topic of hot discussion among hair transplant surgeons. Some do some don’t and whether or not you have a bandage applied to your scalp will depend largely on the personal preference of the surgeon.

There are advantages and disadvantages to a scalp bandage. The obvious advantage is the bandage protects the implants while they heal into the scalp and any blood that bleeds out will be soaked up. The disadvantage is that the bandage “marks” the individual as having had surgery. However, at most the bandage only stays on for 24-48 hours and can be readily hidden by wearing a hat or cap when in public. The better answer may be to put aside the first two days after surgery and just to stay at home until the bandages come off. Depending on which approach is used, bandage or no bandage, the clinic should give you the relevant advice on what to do for the next 24 hours until they see you again – usually the next day.

13B) Keeping the follicles in place

The implants most susceptible to falling out are the ones implanted last in the procedure, but the transplanted hair follicles almost always stay in place of their own accord. The little bleeding at the edges of the incision wound cut for the graft help to “glue” the graft in place. By the time the hair implantation procedure is complete, those follicles implanted first in the hair line are pretty much fixed in place by this blood glue. Of course this is exactly what blood is supposed to do. By bleeding the blood is exposed to air. This activates a cascade of events in the blood that results in blood coagulation. This is to seal an open wound and close it as quickly as possible. It also activates the formation of fibrin that builds up a meshwork in the wound site. This helps glue the wound together and provides a scaffold on which cells from the edges of a wound can grow into the wound and heal it. With larger wounds it takes longer for the blood to clot and seal the wound and it takes longer for the wound to heal over. With micrografting and follicular unit grafting each individual wound is so small that the blood can clot in a couple of minutes and the wound starts to heal within a few hours.

Never the less, you should be extremely gentle with all of the grafts for the first 24-48 hours after implantation. It is very rare for grafts to fall out. If they do and they don’t look dried out, it may be possible to just pop them straight back in if you are still in the clinic. If they fall out after you have left the clinic it is unlikely much can be done to save the grafts. However, you could try to put the grafts in a saline solution (salt water mixture), keep it cool at about 4-8 degrees centigrade and call the clinic to see if they can put the graft back in – it may be possible, but there are no guarantees it will be successful. Again though, a graft falling out is an extremely rare event. The biggest issue in the first 24 hours after a hair transplant is probably how best to sleep without disturbing the implants. The clinic should be able to advise on what they think is best depending on whether your head is bandaged or not. People may sleep in a sitting position for the first night and maybe longer, so that the head does not come into contact with a pillow. In general, you will not wash your scalp for the first 24 hours, indeed avoid touching it at all. Usually you do not wash the scalp with shampoo for the first 3 days after the operation. Your scalp will be cleaned at your next clinic appointment.

13C) The first 72 hours post surgery

About 8 hours after the implantation procedure the local anesthetic injection will start to wear off. This is when you, as a hair transplant recipient, will experience most discomfort. Most often the pain is in the donor area rather than the recipient area as the donor area is, in effect, a much bigger wound. In many clinics you will be sent home after the procedure with a few acetaminophen and codeine tablets or their equivalent. This is usually quite enough to keep the pain to a minimum, but you should expect some discomfort. You might also be given some sleeping pills to use for the first couple of days. After 24 hours the pain should more or less disappear. If not, then you need to contact the clinic. Prolonged pain may suggest an infection has entered one or more of the wound sites. The clinic needs to deal with this quickly.

A rather crusty looking scalp is to be expected for the first 24-48 hours. It is of no concern, it happens to everyone undergoing a hair transplant. However, if you continue to bleed some hours after the procedure and certainly after 24 hours, then the clinic will probably apply a compression bandage that you wear for another 24 hours until the bleeding subsides. If this is the case you will be called back to the clinic the next day to have the bandage removed. The objective is to have the bandage on for as little time as possible. The grafts heal quicker if they are exposed to the air. Most clinics give patients an antibiotic solution or cream to gently apply over the donor and recipient areas for the next few days. Further crusting is likely in the next three days, but you should not wash your hair with shampoo until after the third day.

In general, you will be called back to the clinic the day after the procedure. The surgeon will examine the wound site and the grafts to make sure they are all in place, correctly orientated, and that they have not been pushed in too deeply as this can cause problems with healing. The area is usually fairly crusty and bloody. It is usually washed gently with a sterile solution using cotton tipped swabs and gauze pads. The hair may then actually be shampooed very gently in the clinic, combed, and dried. With this done, usually the grafts are pretty well hidden unless you look closely. You will not be given another bandage unless you still have some bleeding. A loose fitting cap or hat may be the answer if you want to stop anyone from seeing the new hair transplants in the first three days or so. Try to find a hat with holes in it to avoid heat build up under the hat. However, a hat or cap is only to be used when absolutely necessary. You grafts will heal much quicker and better if they are open to the air, but avoid getting sunburnt as this will hinder the healing process.

13D) 72 hours plus post surgery

Most patients develop some swelling 1-4 days after the operation. This can last for a week or so. In a few cases the swelling can become very bad such that the individual is unable to open their eyes properly. Sleeping in a sitting position or sleeping at a 45 degree angle can help reduce the swelling. A bag of frozen peas or similar applied to the swelling can also help reduce it. The frozen peas/ice should not be directly applied to the implants, rather apply it to your forehead. In the first 1-2 weeks there is an increased chance of infection. You should minimize this by avoiding dirty environments and polluted air as much as possible. Don’t go swimming in public pools or dirty water for at least two weeks after the implant procedure. Your clinic should give you an antiseptic/antibiotic solution or cream to apply to the donor and recipient areas to help limit the chances of infection.

Most clinics suggest you can start washing your hair gently after three days. Normally it is better (more gentle) to do the washing in a sink rather than under the shower head. It also helps to soak the crusting a little with the water before shampooing to help dissolve the crusts. After gentle washing, allow your hair to air dry. Avoid hair dryers and especially hot hair dryers. If you do any exercise or live in a hot climate where you perspire a lot then you need to wash your hair as soon as possible after sweating. Bacteria grow in moist conditions so sweating increases the chances of developing an infection. Most clinics suggest washing your hair every day so that the crusting can be removed fairly quickly. Consult with your clinic for their particular hair care recommendations.

13E) 7 days plus post surgery

Most clinics use permanent sutures that will need to be removed form the donor site. Usually, an appointment is used 7 to 10 days after the surgical procedure for their removal. You can go to the hair transplant clinic or, if you live far away, your family doctor may do the suture removal.

The crusting over and around the grafts should start to fall of 1-3 weeks after the procedure. Crusts will separate from the grafts more quickly if they are kept moist. There are different ways to do this and your clinic will tell you their preferred method. Some will give you a saline solution to use, others provide things like vitamin E containing oils. These are applied to the skin before gently washing the scalp with shampoo.

The transplanted hair follicles will usually shed their hair from 2-6 weeks after the hair implantation. The transplantation procedure involved cutting off their nutritional supply for a few hours. This shock to the hair follicle usually sends then into a telogen resting state. The hair fibers the follicles were growing gets shed over the subsequent few weeks after the surgery. It is almost inevitable and there isn’t much you can do about it. New hair growth will begin to be visible from about 10 weeks after surgery. Not all grafts will begin growing hair at the same time so don’t worry if the initial hair growth looks a bit patchy. This is normal. As hair only grows at a rate of at most 0.35mm a day, it will take time for the hair to grow long enough for you to comb and style it properly. By 6 months after the surgery the hair should be growing well enough for you to gauge the result of the transplant, though it will be 9 months after the surgery before the full effect will be realised. The hair fiber that initially grows in the first few months may be duller and more fizzy than normal. However, the follicles should settle down and start making better quality hair fiber by 14 months after the procedure.

To help things along and speed up the hair regrowth process, some hair transplant surgeons advise on applying minoxidil form the third day after the transplant. This is a direct hair growth stimulant so it should speed up the hair follicle recovery. However, some people are allergic to the ingredients in most minoxidil formulations so it is not for everyone. Your clinic should advise.

Scalp reduction is one method of surgically treating baldness used by a minority of plastic surgeons. In essence it simply involves cutting out the bald skin, pulling the hair bearing sides of the wound together and sewing it shut. It is a very quick method of removing bald areas on the scalp. However, for this to be done successfully there needs to be enough laxity in the skin for the sides of the wound to be pulled together.

In the planning of a scalp reduction the surgeon needs to examine the skin properties for its laxity, or moveability. A few people have very tense scalps, the skin cannot be stretched or moved much. These individuals cannot undergo a scalp reduction as the surgeon would be unable to pull the sides of the wound together to sew it closed. At the other end of the spectrum there are a few people who have very lax, moveable skin. These people can readily undergo scalp reduction.

To get a rough idea of scalp skin laxity is pretty easy. Simply pinch the bald area of skin in the center of the bald spot with you fingers and see how much skin you can squeeze between your fingers. If you can actually pull skin up and away from the scalp then you have a very lax scalp skin and scalp reduction could be an option for you. However, most people can’t actually pull much skin away from the scalp with their fingers, but they can squeeze the skin between their fingers. A scalp reduction is possible, but as the skin is not so lax the surgeon can only cut out a limited amount of skin in each procedure. However, you can undergo multiple procedures over time. So the surgeon may remove just 2-3 cm of skin in the first procedure and then another 2-3cm in a second procedure. In the clinic, one method used by some surgeons to determine suitability for sclap reduction is to place two small dots with a felt tip pen on either side of the scalp, across the bald area of skin, with a measured distance of 10cm apart. The skin between the dots is pushed together using thumbs and index fingers. With the skin squeezed together the distance between the dots is measured again. As a rough rule, whatever the width of skin is between the dots when they are squeezed together is about one half the amount of skin that can be cut out over 2-3 scalp reduction procedures (Bosley 1980).

Using this approach with the two dots 10cm apart and pressed together, the degree of scalp laxity, and so suitability for undergoing scalp reduction, has been classified into five categories.

Category 1 – the skin is compressible by 0.5cm or less.

Category 2 – the skin is compressible by 0.5cm – 1.0cm.

Category 3 – the skin is compressible by 1.0-1.5cm.

Category 4 – the skin is compressible by 1.5-2.0cm.

Category 5 – the skin is compressible by more than 2.0cm.

People in category 1 are not suitable for scalp reduction and those in category 2 may not be suitable. Category 3 defines the degree of scalp laxity that the vast majority of people have. A width of up to 3 cm can be removed in scalp reduction procedures in these people. People in categories 4 and 5 have relatively lax skin. A width of 5cm and maybe more can be removed from those individuals in category 5 with very lax skin.

For those in category 3 where rather more than 3 cm width of skin needs to be removed it is possible to increase the amount of skin that can be removed by using skin expansion of extension. Most often this is accomplished by inserting a silicone balloon under the skin and filling gradually over several weeks with saline. This stretches the skin and so when the balloon is removed and the scalp reduction is done the stretched skin can be easily pulled together. Depending on the nature and duration of the skin expansion or extension 20-50% more skin can be removed in a scalp reduction compared to scalp reduction without skin expansion/extension (Stough 1995). However, this approach is not popular as it involves the individual having a visible lump on their scalps for several weeks prior to the scalp reduction.

Through this web site I get asked by women quite regularly whether it is possible for them to get a hair transplant. The answer is yes within certain limits. Advertising from hair transplant clinics is almost exclusively pitched at men. This is probably because androgenetic alopecia is much more common in men than women. Despite the lack of advertising directly to women, under some circumstances women can be suitable for a hair transplant.

In general, for a woman to be a candidate for a hair transplant, the type of hair loss needs to be one or more of; androgenetic alopecia, scarring alopecia (only after it has “burnt out”), traction alopecia, alopecia due to cosmetic surgery gone wrong, trauma from an accident, or a need to cosmetically correct an issue such as a lack of eyebrow hair growth. In these forms of alopecia the hair loss is more or less permanent, but the hair loss is not expected to expand beyond a defined area of skin that the surgeon can actually see or predict as with progressive androgenetic alopecia. These forms of alopecia can be treated by removing the affected area and/or by transplanting the affected area. In short, the same types of alopecia treated using hair transplants in men can also be treated in the approximately the same way in women. Similarly as for men, the same limitations of suitability for hair transplantation apply to women. The primary limiting issue is whether the female candidate for a hair transplant has a good donor area from which to take the hair follicles. Read the other pages of this web site section for more details – most of the pages apply equally to both men and women who are considering a hair transplant. However there are perhaps a few issues specific to women that need a brief statement.

For most women affected by androgenetic alopecia, a mild diffuse hair loss develops. While the extent of the hair loss can be quite limited, the expectations of our modern society are for women to have nothing less than a full head of hair. This is an impossible ideal for many women to obtain given that around 50% of the female population will be affected by some form of hair loss during their lives with up to 40% of that figure accounted for by androgenetic alopecia. Yet the expectation of full head of hair in women prevails. The psychosocial impact of hair loss for women is significant and proven in a number of studies (Cash, 1999; Cash, 1993). Ideally the attitudes of society would change to admit the reality that hair loss affects the majority of the population. However, this seems unlikely anytime soon and for a woman with androgenetic alopecia the quickest method to relieve the pressure of society and its views on body image is a hair transplant.

The extreme body images values that our society holds for women and their scalp hair can create a significant problem for the hair transplant surgeon. Many women seeking a hair transplant are expecting to regain nothing less than a normal scalp hair density, but in many instances, this is not possible. Hair transplants just redistribute the hair follicles you already have, transplantation does not create new hair follicles. So while hair density can be improved on the top of the scalp, how close you get to a normal scalp hair density depends on the extent of the alopecia and the donor hair area. A large area of alopecia to be covered, or a limited hair follicle donor area, will mean that a normal scalp hair density is not possible. Because many women enter the hair transplant clinic with such high expectations, a surgeon may spend a significant amount of time counselling, reassuring, and explaining the limitations of hair transplantation to a prospective female patient.

Women with the classic androgenetic alopecia presentation with diffuse hair loss may find they are not suitable candidates for hair transplantation. While the diffuse hair loss of androgenetic alopecia is most often primarily on the top of the scalp, it can be quite extensive for some such that the back of the scalp, the donor area, is also partially affected. The smaller the donor area at the back of the scalp, the fewer hair follicles available for transplantation to the top and front of the scalp. This is also an issue for some men, but it is a more common problem in women with a diffuse hair loss presentation. When the donor area is limited, a hair transplant can be conducted if there is some compromise on the anticipated result. For example, transplanted hair follicles can be concentrated towards the front of the scalp and the hair grown long to be brushed over the thinner vertex. Whilst there are limits to what a hair transplant can do, a transplant can yield a natural result with a density that is cosmetically acceptable.

Women do have some advantages over men when it comes to hair transplantation. As androgenetic alopecia is usually a diffuse hair loss, it is relatively easy to fill in over the scalp with transplanted hair follicles to give a nice even density of very natural looking hair – because it is partially natural hair! Most women with androgenetic alopecia maintain their hair line (although a few do have hair line recession). This is a significant advantage compared to men who generally have a hair line recession with androgenetic alopecia development. The hair line is the most visible and most noticeable part of the scalp hair. It is also the most difficult part to reconstruct with a hair transplant. Some expertise is required on the part of the surgeon to get a hair line to look natural. It is much easier to transplant follicles behind a hair line to fill in and increase density than it is to create the hair line from scratch.

We generally take them for granted, but they are very important pieces of facial equipment. The eyebrows play an important role in conveying human emotions such as anger, sadness, happiness and surprise. Eyebrows and eyelashes make an important contribution to facial symmetry and presentation of self to others. A person without eyebrows and/or eyelashes may feel very self-conscious about his/her appearance. Transplantation or reconstructive surgery can often restore eyebrows and eyelashes.

We only really notice just how important eyebrows are when they are missing. Partial or complete loss of eyebrows may produce varying degrees of facial disfigurement, easily recognized by onlookers and much to the annoyance of the affected individuals. Although female patients are prepared to sacrifice eyebrow tissue for the sake of fashion, males on the whole prefer their eyebrows thick and full.

Eyebrows and eyelashes are lost in a variety of ways:

1)Physical trauma—e.g., auto accident, thermal, chemical or electrical burns, 2)Systemic or local disease that causes loss of eyebrow and/or eyelashes, 3)Congenital inability to grow eyebrows and/or eyelashes, 4)Plucking (to reshape the eyebrow) that results in permanent loss of eyebrows, 5)Self-inflicted obsessive plucking or eyebrows and/or eyelashes (trichotillomania), 6)Medical or surgical treatments that result in eyebrow or eyelash loss—e.g., radiation therapy, chemotherapy, surgical removal of tumor.

The cause of eyebrow/eyelash loss is evaluated in medical history and examination prior to consideration of hair restoration:

Systemic or local disease that causes hair loss must be under control to assure that hair restoration can succeed.Obsessive-compulsive plucking (trichotillomania) must be treated to assure that restored hair will not be plucked out.Trauma, burns or surgery may have resulted in formation of scar tissue; reconstructive surgery may be necessary before eyebrow/eyelash restoration. The degree of eyebrow loss may vary from complete to partial; the degree of loss may be a consideration in selection of the restoration procedure.

Some patients have no eyebrow/eyelash loss, but seek eyebrow/ eyelash enhancement for cosmetic reasons.

Some instances of eyebrow loss are not suitable for transplantation such as eyebrow loss through alopecia areata, alopecia induced by certain toxins (particularly thallium – a rat poison) which can cause the loss of the outer third of the eyebrows (called hertegoeths sign). For alopecia areata and many other forms of inflammatory alopecia, any transplanted hair follicles would also come under inflammatory cell attack, so a hair transplant would not help. A similar issue would occur with toxin induced eyebrow loss, the transplanted hair follicles would be affected by the toxins. Most forms of eyebrow loss that cannot be treated with a hair transplant are reversible hair loss conditions and they can be treated in other ways. Inflammation induced eyebrow loss is usually treated with topical creams or local injections of corticosteroids. Toxin induced alopecia is preferably treated by avoiding the toxins!

However, other forms of eyebrow loss can be treated quite successfully with an eyebrow transplant. The earliest hair transplant micrografts were applied to the eyebrow more than 30 years before their application to the scalp became the standard of care. Eyebrow transplants may be conducted because the individual has received an injury to the area and permanent destruction of the eyebrow hair follicles. Burns patients may benefit from an eyebrow transplant. People with facial injuries from car accidents often undergo reconstructive surgery, first to replace the damaged eyeball socket and then to replace the lost eyebrow follicles using a hair transplant. Others may have minor defects only affecting part of the eyebrow. Basal cell carcinomas (a slow growing form of skin cancer) can develop in the eyebrow area. They usually have to be surgically removed in a process called Mohs surgery. Because the basal cell carcinoma is often closely associated with adjacent hair follicles (at least some basal cell carcinomas are actually outgrowths from hair follicles) the follicles have to be cut out too. This leaves an area of scarred skin with no follicles and this can be successfully treated with a hair transplant.

Some people opt for an eyebrow transplant for cosmetic reasons. They may have been born with thin brows or virtually no eyebrows and want to improve the definition around their eyes. Limited eyebrow growth is particularly common in some far East Asian populations. Some individuals may destroy their eyebrow follicles through repeated plucking. Cosmetically, thin eyebrows were in vogue through the 1970s and some women repeatedly plucked their eyebrows to get “the look”. But fashion is fickle and today greater eyebrow definition is de rigeur. Unfortunately, eyebrow follicles are relatively easy to damage (compared to scalp or beard follicles for example) and repeated plucking can cause so much damage that the eyebrow follicles are unable to regrow. Others may be affected by trichotillomania, a compulsive repeated hair plucking. Some focus on the eyebrows. If they can overcome their trichotillomania, then an eyebrow transplant may replace the destroyed hair follicles.

16A) Eyebrow Hair Restoration

An eyebrow transplant is a relatively complex procedure. It requires some experience on the part of the surgeon to get the transplant to look natural. The hair of an eyebrow is thinner, has complicated directional changes, has an acute angle between the skin and hair shaft, a smaller diameter, slower growth, as well as changes in orientation over the brow area. When grafting eyebrows in small target areas of hair in the medial brow portion, surgeons must be concerned about the upward direction of natural hair growth. Mid and lateral brow follicles grow with central convergence in a flat direction almost parallel to the skin. Special consideration must be paid in order to maintain eyebrow symmetry and to avoid distortion of the hairline. All these factors have to be considered when implanting the hair. A standard hair transplant surgeon may not have the experience to make an eyebrow transplant look natural. A good hair transplant surgeon would refer such a patient to a plastic reconstructive surgeon with the ability to do a good job. Better still, if you need an eyebrow transplant, seek out reconstructive surgeons and approach them directly.

Sometimes, if there is only a small area of the eyebrow that needs attention, the surgeon may just redistribute the eyebrow hairs from elsewhere. This is most often done by cutting out the affected eyebrow portion and then moving the rest of the eyebrow inward to close the site. Sometimes though, there are too few or no eyebrow hair follicles left so this option is not available. In these cases, hair is taken from elsewhere on the head. Some surgeons have used the small hairs from around the ears to reconstruct eyebrows with some success. Others take the hair follicles from the back of the scalp, as with standard scalp hair transplants. They may just take the finer hairs for transplantation to the eyebrow. Still others take a thin strip of skin and hair follicles from the scalp and graft this to form the new eyebrow. Which approach is used depends in part on the nature of the eyebrow loss (whether it is from burns, injuries, or repeated plucking) and also on the personal preference of the surgeon. In the medical literature it is clear there are two schools, one proposing flaps as generally the best method to reconstruct eyebrows and the other proposing implantation of hair follicles in ones and twos over the brow area. A few surgeons are using an approach combining the two methods. Transplanted strips of scalp skin can give the eyebrows an overly dense appearance. In theory, the method of transplanting individual hairs should give the most natural result. However, this is a time consuming and technically challenging approach and it only works well in the hands of an experienced surgeon.

Whether the scalp hairs are transplanted individually or as larger graft flaps, the transplanted scalp hair follicles retain their scalp growth characteristics so they grow for several years and at a fast rate (0.35mm a day) unlike eyebrow follicles that grow relatively slowly (approx. 0.1mm a day) and each growth period lasts 3-6 months. Because of this, if scalp hair follicles are transplanted to the eyebrows, the eyebrows will require regular trimming to keep them in shape.

16B) Eyelash Hair Restoration

Transplantation is the only procedure used to restore eyelash hair. This is a very specialized procedure that is performed by just a few surgeons. As is the case for eyebrows, donor hair for transplantation must be finer rather than coarser. All grafts are single hairs meticulously placed into the lid. As few as six hairs per lid may be adequate to create a natural effect.

Itching is a common and troublesome postoperative complication. If the patient gives in to temptation and scratches, there is risk for dislodging the hair grafts and initiating infection. Eyeglasses may be worn to deter scratching. The dermatologist can prescribe medications to relieve itching. Training of transplanted hairs into eyelash conformation is accomplished by use of lash oil and an eyelash curler.

A total lack of hair growth in the pubic area in adults is a rare entity usually associated with a genetic anomaly in the affected individual. There are many genetic conditions that have an absence of body hair, including pubic hair, as one of the symptoms – too many to mention here. Most of these conditions are very rare and of the many physical and mental retardation symptoms involved, a lack of pubic hair is often the least of the affected individual’s concerns.

However, there are other non-genetic causes of pubic hair hypotrichosis (a lack of pubic hair growth) or pubic hair alopecia (hair loss through disease). Some individuals grow a normal pubic hair density at puberty, but may find alopecia develops later in adulthood. The most common causes of pubic hair loss include alopecia areata and telogen effluvium (see elsewhere on this web site for details). In these cases where and active process is involved in the hair loss, hair transplantation to the pubic area would not be successful. The transplanted hair will also be affected by the underlying process that is causing the hair loss. In the case of alopecia areata and telogen effluvium affecting the pubic hair, the best approach is to treat the alopecia areata or telogen effluvium. If treatment is successful, the affected pubic hair follicles should regrow. For those over 65 years of age there may be a general thinning of pubic hair. Hair growth slows down in the elderly and this may become apparent as a diffuse hair loss most noticeable on the scalp, but underarm hair and pubic hair may also be lost. Hair transplantation might be successful in this situation, but it is very rare for such a procedure to be conducted.

A disruption of hormone production prepuberty, particularly pituitary insufficiency, may result in a lack of pubic hair growth through puberty and well into adulthood. A hysterectomy or bilateral oopherectomy may be done prepuberty due to abnormal bleeding and this can also result in a lack of pubic hair growth in adulthood. In these cases it may be possible to graft hair from the scalp to the pubic region, though hormone supplementation is typically the preferred treatment approach.

There are situations where pubic hair transplantation is possible and successful. Most often, hair transplantation to the pubic area is needed to repair a burns injury or because the individual has inherited genes that infer a relative lack of pubic hair growth. In East Asian countries, it is a common practice for prostitutes shave their pubic hair. Because of this, many Asian men and women traditionally associate a lack of pubic hair with lack of “moral values”. As a result, the cultural pressure to have a thick crop of pubic hair is high in some Asian countries. Unfortunately, many ethnic groups in East Asia have a genetic constitution that codes for a relative lack of body hair growth as compared to Caucasians and they have only limited pubic terminal hair. Whilst both men and women in these ethnic groups have a lack of pubic hair growth, the social pressure is mostly focused on women. Some women suffer psychologic distress and have a low self-esteem due to a lack of pubic hair growth. This “condition” may cause them shame and decrease their chances of attaining a happy and successful marriage due to the potential husbands’ suspicious ideas. For Japanese women it can also be an issue in public baths and hot springs where nude bathing is acceptable, but “morally questionable” patrons are barred. Correction of this “problem” can be achieved either by hair transplantation or sometimes by grafting larger sections of skin containing hair to the region of the pubis.

There are two approaches to transplanting hair to the pubic region, either by grafting mini and micrografts consisting of 1-4 hair follicles each, or grafting a flap of scalp skin. Each approach has advantages and drawbacks. With mini and micrografts, to transplant the entire pubic area usually takes more than one grafting sessions with intervals of about 2 months in between each session. With the time needed to let the hair regrow after grafting, it can take a year before the end result can be seen. However, if the procedure is done carefully, the result can look reasonably natural with an appropriate hair density. Grafting a large flap of hair bearing skin to the pubic area is a much quicker process, but the result is more likely to look unnatural. Pubic hair is much more sparsely distributed than scalp hair, so a scalp hair graft can look unnaturally dense. This can be remedied partially by using tissue expansion under the scalp skin to be transplanted before surgery to stretch out and reduce the density of the skin to be grafted. Alternatively, epilation by electrolysis can be used a couple of months after grafting to decrease the hair density and contour the hair bearing area to a more acceptable shape. The more common approach is the mini-micrografting technique. It takes longer, but the result is more natural.

The transplanted scalp skin hair follicles retain their scalp skin hair growth characteristics, although at least one report has suggested that the recipient transplanted skin areas’ properties may modify the transplanted hair follicles to a degree. However, it is common for scalp hair transplanted to the pubic area to look less kinked than natural pubic hair. Some kinking is apparent because the contact/friction with underwear probably creates some physical damage to the hair. The transplanted hair also grows more quickly than natural pubic hair and grows for a longer time period in each hair growth cycle. As a result, regular trimming of the transplanted hair is required.

Some dermatologists are touting “hair cloning” as the future of hair transplantation, but few people actually know what it is. At its most basic, hair cloning involves taking one hair follicle from a donor and multiplying it in a laboratory to make several hair follicles. There are two main forms of hair cloning under development for use in the transplant clinic, both of which have already been used experimentally on humans. One involves purely surgical techniques the other involves cell culture. Here, the surgical technique is explained.

Hair cloning by multiplication involves taking a hair follicle by standard hair transplant surgery techniques and then cutting the hair into two (and maybe more) pieces. So if a typical hair transplant involves implanting 3000 hair follicles, by bisecting the hair follicles into two and implnating the upper hair follicles and the lower hair follicle portions seperately, you could get 6000 hair follicles growing while only 3000 hair follicles were taken fro mthe donor skin area. To get this method of hair cloning to work, a technician must have a fine eye, steady hands, and good micro dissection equipment. It is very easy to cut the hair follicle in such a way that it does not have enough cells to be able to regenerate. Hair follicles can be quite sensitive once they are isolated from the skin so any surgical manipulation can severely damage them. The technician has to have considerable experience in dividing the hair follicles with the minimum of disruption to keep them viable.

For a hair follicle cloned in this way to be viable as a transplant, it must contain dermal papilla cells or cells capable of regenerating a dermal papilla, and keratinocytes that make hair fiber. Animal research has shown that for a single hair follicle to be made into two hair follicles, the original hair follicle must be dissected such that the cut only removes the lower one third of the hair follicle. If this is done correctly and the upper and lower parts of the follicle are implanted into skin, then the upper two thirds of the hair follicle will regenerate a brand new hair bulb and the lower third of the hair follicle will regenerate the missing upper two thirds of the hair follicle. However, if the hair follicle is cut so that the upper portion of the hair follicle has less than two thirds of the tissue remaining and the lower hair follicle gets more than a third of the tissue, the lower hair follicle piece will grow, but the upper hair follicle piece is no longer able to regenerate a new hair bulb. So, if the hair follicles are not bisected correctly, you may end up with no “new” hair follicles to implant.

Even if the hair follicles are correctly dissected, there are still several potential problems with the results of the technique that need to be overcome before the method can be made routinely available. For example, the thickness of the hair fiber produced by a hair follicle is directly proportional to the size of the dermal papilla and number of cells contained in it. By cutting a donor hair follicle in two or more parts the effective number of cells and size of dermal papilla might be reduced. After transplantation it is possible that the hair produced by the clones is much finer than the hair produced by the original hair follicle. However, some transplant sepcialists have suggested that these fine hairs can put to good use to create finer hair lines (Swinehart 2001). So while hair multiplication may not be good for filling large bald areas of skin, they could be good for creating more natural hairlines.

Dermal papilla cells are the driving force behind each hair follicle. These cells sit as a little ball at the root of a follicle and send out chemical signals that control cell growth in the rest of the follicle. It has been known since the late 1960s that these cells could be isolated and transplanted into skin with no hair follicles and the dermal papilla cells would promote the formation of a brand new hair follicle.

In the mid 1980s it was shown that dermal papilla cells could be isolated and grown in culture, to make more of them, and then implanted into the skin to make new hair follicles. By culturing the cells, dermal papilla from just a few donor hair follicles could be grown into enough cells for implantation to induce many new follicles – hair cloning.

More recently in 1999, researchers, led by Colin Jahoda at Durham University in Britain, took cells at the bottom of hair follicles from Jahoda’s own scalp and from a colleague’s. These cells from the dermal papilla were then transplanted into the forearm of Jahoda’s wife, Amanda Reynolds. Within five weeks, the transplanted tissue – no bigger than the head of a pin – made a total of five fully grown hairs in Amanda’s arm. This simple experiment shows the potential of being able to induce new hair follicles in human skin.

Even more interesting from the scientific point of view is that the hair follicles were made in a woman using cells derived from a man. Normally the foreign cells would be rejected by the recipient. But the scientists suspect the cells taken from the base of follicle may have some type of immune privilege which allows them to mix with foreign cells. So instead of being rejected by the woman’s immune system, the male cells interacted with her cells to create new follicles. So it may be possible to use dermal papilla cells from one human source to induce hair follicles in another individual without the cells being rejected as foreign.

The new work suggests the possibility of a quick hair cloning procedure with the creation of new hair in just about anyone. The cells could be removed from a person’s own scalp or, if that person cannot produce good quality cells, they could be collected from someone else. They could then be multiplied through laboratory culture before being transplanted.

It is not yet clear whether such newly grown hair will last, grow at the correct angle, or satisfy other requirements for a cosmetically acceptable treatment. The microsurgery used in the experiment is complex, time consuming, and expensive right now. However, it could potentially be developed into a relatively simple procedure. The greatest problem facing developers will be to work out how to get the new hairs to all grow at an appropriate angle to line up with the natural hair follicles on our scalps. To do this will require that we understand much more about the gene expression involved in the induction of new hair follicles and what genes tell the hair to grow in a certain direction.

There is also the possibility that injecting cells that can induce new hair follicles might also induce tumor development and skin cancer in a few people. Such concerns will have to be addressed before the treatment method becomes available to the general public.

20A) Determining the Need For Subsequent Sessions

Surgical hair restoration is a permanent solution for male or female pattern baldness (androgenetic alopecia). Often patients require a second procedure or series of procedures for the following reasons:

1. Hair continues to be lost due to androgenetic alopecia and a follow-up procedure or series of procedures is necessary to maintain the desired hair coverage.
2. Hair transplants done many years ago did not use the refined techniques available today, and revision of the original procedure may be desirable to achieve a more natural look.
3. The patient desires greater density in the area previously treated.
4. The position of the hairline may need to be adjusted forward or backward in order to be “age appropriate.

Patients may have their personal reasons for seeking a second hair restoration procedure. It is imperative to discuss these reasons, in full, with a hair restoration surgeon to be certain that what is desired from a second procedure can be accomplished surgically and aesthetically.

20B) Progressive Hair Loss Due to Androgenetic Alopecia

Androgenetic alopecia (male and female pattern hair loss) is an inherited, progressive condition. It is also an unpredictably progressive condition.

For example, while male pattern androgenetic alopecia may be present as “monk tonsure” central hair loss in a man and his brothers, the man’s son may have androgenetic alopecia in a different and more rapidly progressive hair-loss pattern than his father and uncles. In this hypothetical but not uncommon case, the son’s hair loss may have started when he was in his 20s and been rapidly progressive whereas his father’s hair loss started later in life and was slowly progressive. The son may have greater than 50% hair loss by age 30 while his father still has only central hair loss at age 50+. Although androgenetic alopecia is inherited there can be wide variation in the way the genetic predisposition is expressed in family members.

When hair loss begins early in life due to androgenetic alopecia, as in this example case of the young man, early consultation with a physician hair restoration specialist should be considered. Early hair loss due to androgenetic alopecia can be an indication that hair loss will progress rapidly and will continue until most hair is lost. A hair restoration doctor may recommend a hair restoration program that conserves existing hair with a hair restoration drug approved by the FDA.

An experienced hair restoration doctor is able to anticipate future hair loss, and place transplanted hair into those areas to create a reserve against future hair loss. On the other hand, surgical hair restoration procedures may be required after the original procedure due to progressive and unpredictable hair loss. A potential problem over the years of treatment is the possibility that androgenetic alopecia will outpace efforts to restore hair, and at some point there might not be enough donor hair available for transplantation. The surgeon will be able to anticipate the patients’ need for subsequent procedures, and custom design the long-term treatment plan accordingly.

This is a critical issue that should be discussed by the patient with the physician hair restoration specialist in planning a comprehensive approach to long-term hair restoration.

In women, subsequent hair restoration procedures may be necessary due to increased hair loss from pregnancy and menopause. A medical and scalp examination by a physician hair restoration specialist helps to determine if and when subsequent procedures are required.

20C) Hair Transplants Done Many Years Ago Can Be Revised and Made More Natural by Today’s Techniques

Hair transplants have been available as a treatment for androgenetic alopecia for about four decades. The instruments and techniques were those of that time. Over the next 40+ years, and especially within the past 10 years, both instruments and techniques were refined. The unit of transplanted hair evolved from the “plug,” or standard graft, of numerous follicles to micrografts of 1 to 4 hairs. Techniques were improved for harvesting donor hair, minimizing the amount of tissue removed from a donor site. The emphasis in developing new instruments and transplantation techniques is to improve the naturalness of hair restoration by transplantation.

Hair transplants done many years ago using the “plug” technique do not appear as natural as transplants done today. The older transplanted hair often has an uneven or clumpy hair distribution—the “rows of corn” look sometimes associated with older hair transplants. A problem with older hair transplants is that they may look like transplants. Most of these older hair transplants can be revised using today’s techniques to create a natural look.

A hair restoration doctor will examine the patient’s scalp to determine an optimal approach to revision of the older transplant. A number of approaches are available, but the approach to revision must be suitable to the needs of the patient and to the outcome on which the patient and physician agree. In some instances an optimal approach might be to place micrografts or single-hair grafts irregularly throughout the “corn rows” to create a more natural pattern of hair density. In other instances it might be most effective to remove portions of the older transplant before inserting new micrografts or single-hair grafts. Follicles and hairs removed from the old transplant may, if they are in good condition, be separated into micrografts or single-hair grafts for re-transplantation.

Revision requires close cooperation and consultation between the patient and the physician. The physician may sometimes advise against an outcome the patient desires, either on technical or esthetic grounds. For example, a fair-skinned person with dark, coarse hair who expresses a desire for greater hair density may be advised that greater hair density could result in a “bushy” look. On the other hand, a fair-skinned person with light red hair may need greater hair density in order to achieve acceptable scalp coverage. The physician hair restoration specialist has training and experience on which the patient should rely. The patient should understand that revision of an older transplant often requires several transplant sessions. Older transplants sometimes resulted in uneven (“cobblestone”) areas of scalp, or scars around donor sites. Many of these skin defects can be revised or eliminated by minor surgical procedures.

20D) Hairline Revisions May be Desirable As a Patient Ages

A man who loses a great deal of hair in his 20s and 30s due to androgenetic alopecia may want to retain a “young” look after surgical hair restoration. This has, in some instances, induced a patient to request a relatively low placement of his hairline in the forehead-temple area. As the man ages he may come to consider this lower frontotemplar hairline to be inappropriate to his age. Hairline revision is accomplished by a surgical procedure that must be suited to the needs of the patient. It should be performed by an experienced hair restoration surgeon. Procedures that may be considered include:

1)scalp reduction to elevate the hairline, and 2)scalp reduction plus removal of several rows of transplanted hair from the hairline; a cosmetic surgical procedure called a forehead lift to elevate the forehead; and, surgical excision of hair from the hairline

These or other procedures may be recommended by the physician hair restoration specialist, depending on the surgical and aesthetic considerations and the patient’s wishes for outcome.