Hair transplantation depends on the now, well established principle that transplanted hair follicles (roots moved from their original location to another area) behave as they did in their original site. For example, even in the most advanced cases of common, male pattern baldness (MPB), a horseshoe-shaped fringe of hair persists. Hair follicles moved from this hairy fringe (the donor area) to a bald or balding area on the same patient’s scalp (the recipient area) takes root and grows. Continuing hair growth in such transplants has been observed since 1958, and it is believed that it will continue for the individual’s lifetime.

Many less common types of hair loss, in addition to MPB, can be helped by this procedure. These include thinning hair in many women, scarring from prior injuries or surgery, and a number of diseases that sometimes cause hair loss. Currently, there are numerous options available to people seeking a surgical solution to their hair loss problem. The option or options best suited for you is a choice you should make after a discussion with your physician and after exploring the possibilities listed below

Micrografts, Follicular Units, Double and Triple Follicular Unit Grafts(DFU and TFU), Slot Grafts and Round Grafts

In modern hair transplanting, grafts are prepared from a strip of donor area skin that is sectioned under various types of magnification into whatever kind of graft or grafts that are required.


A strip of donor area

The donor site is sutured closed and produces a hairless scar that is usually only 0.1 to 0.5 mm wide. A small number of patients develop slightly wider scars because of their personal healing characteristics. The donor site can always be easily camouflaged, immediately after surgery, by combing the hair above it. Any resultant scar can also always be easily camouflaged in the same way.


(After 2 months) Scar in Donor area

The scar from any previous session is excised as part of the donor strip in any subsequent session so that usually only a single scar is present, regardless of the number of sessions that are carried out.(Sometimes two donor areas are used in order to obtain hair with different textures and colors.)

We employs five types of grafts. They are chosen on the basis of:

  1. ultimate density objectives of the patient
  2. the amount of persisting hair in the recipient area
  3. hair characteristics such as color, wave and curl
  4. the estimated long-term donor area/recipient area ratio.

Each of these types of grafts is described below with a summary of their advantages and disadvantages.They can broadly be categorized as grafts which contain:

  • a single “follicular unit” (FU)
  • grafts that contain two, three, or more FUs (multi-FU grafts).

A)Follicular Unit(FU):

We use the terms “follicular unit” “follicular group” and “micrograft” interchangeably. Most scalp hairs grow in small groups of two or three hairs, separated from adjacent groups by small areas of bald skin. Usually, 15–20% of hairs exit the scalp as single hair follicles and approximately the same percentage exit as groups of more than three follicles.


Donor tissue can be dissected into grafts that contain only one hair follicle or, alternately, one FU that as noted above, can contain two, three, or more hairs—as they naturally exist in the donor site. The empty skin between these groups is dissected away from the groups of hair and is discarded. The FUs are inserted into holes made in the recipient area, with small blades or ordinary hypodermic needles, such as those used to give intra-muscular injections or dental anesthesia. When FUs are the only type of graft used for hair transplanting, the technique is referred to as Follicular Unit Transplanting (FUT)

The main advantage of transplanting exclusively with FUs is that they produce the most even, natural-looking coverage. If the recipient area is totally or nearly hairless, the difference between transplanting with FUs, as opposed to grafts containing more than one FU (multi-FU grafts), is virtually always more natural looking when FUs are exclusively utilized (white hair and/or curly hair are sometimes exceptions to this general statement). Thus, a single session of FUT can “stand on its own” and look natural in an area that is bald or destined to become bald. As soon as one also employs multi-FU grafts, at least two sessions and sometimes three sessions will ultimately be necessary to produce results that look sufficiently natural to be undetectable except with very close inspection. As a corollary to the preceding, one can also choose to transplant larger proportions of the bald area with single sessions of FUT— for example, a single session to the frontal area and a single session to the mid-scalp—without having to worry about whether the treated areas will look natural after only one session.

Whether an area ultimately needs to be treated more than once with FUT can be decided upon after full growth of the first session has occurred (approximately one year after the transplant session); additional sessions are done only to create more hair density rather than because they are necessary to produce a more natural appearance. The decision as to whether one treats any area more than once should take into account the patient’s hair density objectives, the long-term donor/recipient area ratio, the proportion of the existing or evolving bald area the patient wants to treat, and the amount of money, as well as the time, the patient is prepared to expend in the pursuit of his/her goals. Another advantage of FUT is that small needles or blades are used to make the recipient sites. These sites can be created between any existing hair in a thinning area, so none of that hair is removed or injured if enough care and skill are employed making them. (Some temporary hair loss may occur because of temporary decreased blood supply but this usually affects no more than 10% to 20% of the hairs in the area and it is temporary.)

Because of the above noted advantages of FUT, a large number of Hair Restoration Surgeons (HRS) prefer to use only FUT in their practices and some have declared it the “gold standard” of transplanting. Unfortunately, however, as will be discussed below, there are some disadvantages to FUT that make it a less attractive way to treat some patients

The disadvantages of FUT are:

  1. Less hair density: Multiple sessions of FUT cannot produce the degree of hair density that can be produced by multiple sessions of a combination of FUs and multi-FU grafts (a single session of FUT can match—and even exceed—the hair density produced by a single session of “combination grafting”). This inability to produce high-hair density is due to two factors: a) individual FUs can never be transplanted as close together as they existed in the original donor area. Getting them even half as close as in the donor tissue requires two or more sessions in most offices. Thus, transplanting with FUs has never resulted in hair density comparable to the hair density within a multi-FU graft and, b) the spaces between multi-FU grafts allow for an equal number of grafts and hairs to be transplanted in a second or third session while that is not possible with the usual FU densities that are employed by most FUT practitioners—hence the higher hair density that can be achieved after multiple sessions of “combination” grafting vs. FUT. In brief, while we may attempt to put hair into the scalp the way nature did it—one FU at a time—we cannot ultimately get them nearly as close together as nature did.
  2. The hair in FUs is more susceptible to potentially lethal damage during graft preparation, storage, and insertion into the recipient area. This is because there is less “insulating” tissue around the hairs in an FU than hairs in a multi-FU graft. This results in the need for a large staff of highly trained technicians who must be constantly supervised and too frequently replaced as they move from one doctor’s office to another. Put differently, the need for staff “perfection” increases as the size of the graft decreases, with FU being the smallest and therefore most unforgiving type of graft. Nevertheless, although hairs in an FU can more easily be killed than hairs in a multi-FU graft, good quality control of office staff is possible and high-hair survival (90 to 100%) is therefore achievable—it is just more difficult to achieve.
  3. The smaller the graft the more of them that are necessary to transplant the same amount of hair—therefore the smaller the graft, the larger the staff and physician time that is required and the more expensive the procedure becomes. The cost factor of FUT can often be managed because a single session of FUT will look natural so the patient can, if necessary, only do one session or even spread treatments far enough apart to be affordable.
  4. Despite the disadvantages noted above, hairline zones and the “crown” in all patients are treated exclusively with FUs because of the superb naturalness they produce after only one session. In addition, as noted earlier, because it will produce naturalness in a single pass, it allows the patient the option of either treating the same area again, for more density, or “saving” those grafts for use elsewhere. Patients with totally bald recipient areas are strongly encouraged to do at least the first session with FUT for the same reasons. FUT also remains the best option for most (though not all) patients who can afford it. (See below.) This is because most patients do not require high hair density to be satisfied. Furthermore, they should not seek it because most patients do not have good enough long-term donor/recipient area ratios for dense coverage of large areas. Currently, approximately 60% of Dr. Vafaei’s patients choose FUT when they are shown photos of what can be expected from this approach and what can be expected from a mixture of FUs and multi-FU grafts.

B) Multi-FU Grafts

General comments:

The oft-repeated charge that using anything larger than an FU always results in noticeable plugginess is inaccurate and overly simplistic. “Plugginess” is not simply a function of graft size. Other factors play an important role in whether a graft might or might not be noticeable.

  1. The finer the hair texture, the larger the graft can be without looking pluggy.
  2. The less contrast between hair and skin color, the larger the graft can be without looking pluggy. Patients with white hair, for example, can have grafts with many hairs in them without looking at all pluggy). Those with salt and pepper, blonde, and light brown or red hair can also frequently use multi-FU grafts without fear of looking “pluggy”.
  3. The more curl or wave to the hair, the larger the graft that can be without looking “pluggy”,and
  4. The more persisting hair in the recipient area, the larger the graft can be without looking “pluggy”. Most of Dr. Vafaei’s patients come to him well before they are totally bald and therefore do not have to be concerned about the multi-FU grafts being noticeable.

What is true, however, is that even in ideal circumstances, very close inspection will always reveal less than the perfectly even coverage that is produced with FUT. Because of this, a single session of multi-FU grafts is rarely cosmetically acceptable. As noted earlier, a second and sometimes third session in the same area will ultimately be necessary to produce a satisfactory naturalness. On the other hand, as was also discussed earlier, more hair density can be created with multi-FU grafts and with greater safety to the hairs and less cost to the patient. As long as hair characteristics are suitable and additional sessions are carried out in a timely fashion—for example, keeping pace with hair loss in a recipient area that initially was not bald—no plugginess need ever be noticed. The result is that a majority of Dr. Vafaei’s patients still choose a combination of FUs and multi-FU grafts over FUT, in order to ultimately achieve more density (or sometimes because it is more cost-effective).

C) Double Follicular Units (DFU) and Triple Follicular Units (TFU)

These grafts consist of two FUs lined up one behind each other like soldiers in a row while TFU grafts contain three FUs aligned in a similar fashion. They are inserted into incisions made with ultra-sharp small blades. The finer the hair texture, the less skin/hair color contrast, the more hair curl or wave and the more persisting hair present in the recipient area, the more likely these will be used behind the hairline zone without being noticeable. As noted above, two or more sessions of these types of grafts produce greater hair density than the same number of FUT sessions and do so with more hair follicle safety and less cost. A session consisting of a mixture of FUs and DFUs (with or without TFUs) can also be followed by a second session of FUT or FUs and slot grafts or even small round grafts (see below); the latter two in order to produce even greater hair density, and greater follicle safety. It is important to repeat, however, that if DFUs, TFUs, or any other type of multi-FU grafts are used in the first session, at least one more session will be necessary at some point to create enough naturalness if the area is bald or destined to eventually become bald.

Just as with FUs, no existing hair in the recipient area is removed during the preparation of the recipient sites. These are made between the hairs with small blades. Because virtually all women with Female Pattern Hair Loss (FPHL) are not destined to lose all of their scalp hair, a mixture of FUs and DFUs/TFUs is usually used in hair transplanting in females. Keep in mind also that whether the patient is a male or female, FUT can be used for the first session and a mixture of FUs and DFUs/TFUs can be used in a second session (or vice versa). Once a session of FUT has been carried out, however, slot or round grafts cannot be employed without removing some of the previously transplanted hair.

D) Slot Grafts

Slot grafts are three FUs long and approximately two FUs wide. They typically contain 10 to 12 hairs and are inserted into “slots” created with a special “slot punch”. They are particularly suitable for patients who want substantial hair density and who have a sufficiently good long-term donor/recipient area ratio. Once again, good hair characteristics, for transplanting, such as low hair/skin color contrast, frizz, curl and existing recipient area hair, increase the likelihood that these larger grafts will not be noticeable behind a hairline zone of FUs (and usually a zone of DFUs or TFUs behind the area treated with FUs).

The disadvantages of slot grafts are:

  • unless hair characteristics are good for transplanting, and the recipient area is suitable, these grafts may be temporarily noticeable,
  • when they are used in an area that still retains some of its original hair—as they usually are—some of that hair is removed as the recipient sites are punched out. Hence, in the slot-grafted zone, there is less hair for the first three months after surgery than there was before the surgery. (No hair is removed in front of or behind the slot grafted area),
  • more hair is also used in the frontal area, and less hair is left in reserve for the treatment of other areas. Two of these potential drawbacks of slot grafts can obviously be avoided if they are only used in people who do have good hair characteristics and in those men who have and are likely to maintain a good ratio of donor hair to bald area. (Doing the first two sessions five to six months apart—before the previously transplanted hair gets long and coarse—is also helpful in avoiding temporary noticeably.) However, such individuals constitute a minority of patients seeking hair transplanting and thus this approach is used in only 10 to 15% of our patients. It is especially useful for middle aged or older men with salt and pepper or white hair.

E) Round Grafts

“Round” grafts are actually square grafts placed into holes made by round trephines or “punches” behind a zone of FUs and DFUs, TFUs and slot grafts. The punches usually have a 2 mm diameter, but occasionally larger punches are employed. Everything that has been discussed about slot grafts applies to the use of round grafts but even more so. The potential for hair density and hair follicle survival are increased, as are the problems that can occur and that must be avoided. Thus, only 10% of Dr. Unger’s patients are currently offered this option. Nevertheless, in properly selected patients, the results can be spectacular

Alopecia Reduction(AR)

is a relatively simple procedure that reduces the size of the balding area. This is ideal for patients whose supply of transplantable hair may not otherwise be sufficient to cover the entire balding area. Essentially, an Alopecia Reduction (AR) consists of the excision/removal of a portion of bald or balding area. The normal laxity of the scalp is used to close the resulting gap. A narrow scar is usually all that remains after the procedure. Within a few weeks, the scalp will become loose again and, often, the bald area may be further reduced by additional ARs.

If one wants to transplant all of the frontal, mid-scalp and crown areas, most patients are strongly recommended that an attempt be made to decrease the size of the bald area with one or more AR. ARs increase the probability of being able to transplant the whole (reduced) area before the supply of available donor grafts has been completely depleted. Notwithstanding the preceding, some patients have enough donor tissue to cover the whole bald without the need for ARs—especially if they are willing to lower their hair density objectives.

In addition, many patients who are seen for correction of aesthetically unsatisfactory prior hair transplanting can benefit from having untransplanted areas —or lightly transplanted areas—excised instead of transplanting them and using up already depleted donor reserves. (In the latter case, any excised “old” grafts can be re-used elsewhere.) This approach maximizes the number of grafts that are available for filling in and camouflaging the spaces between the older grafts. While AR may sound rather frightening or painful, it is, in fact, a relatively simple procedure. In most patients, it is no more uncomfortable than a transplant session.

Hair Cloning

Hair cloning is still in the experimental stages. Although the initial laboratory results are promising, it will probably be at least 5 to 10 years before such an option becomes available. The researchers are studying on what is popularly called “cloning” of hair but is more accurately called ‘cell therapy’. Cells are removed from a patient’s hair and millions of similar cells can be reproduced within several weeks. These cells, when injected into immune-compromised mice, almost always resulted in the growth of human hairs that lasted until the mice were very old. Two studies on human subjects have been conducted. The patients’ own culture-grown hair cells were injected into their scalps. In the first study, hair grew in only one of the 10 patients. In the second study, hair grew in three of 13 patients; however, the growth of hair at the treated sites was not as vigorous as it had been in the one responder in the first study. The procedure has been temporarily discontinued these studies because of legal problems with the funding. Hopefully, this problem will be resolved soon.

Laser-aided Hair Transplantation

This technique holds great promise. However, we concluded that the existing laser equipment cannot be counted upon to produce consistently superior results and there were some significant disadvantages associated with it. Despite advertisements and media reports that suggest laser transplanting produces superior results with less bleeding and pain, there is, in fact, no laser currently available that will produce these advantages, and less hair may grow in some patients. So we, for the time being, stopped doing laser hair transplants. Laser manufacturers are still working on producing a more satisfactory machine.