Patient Education Booklet

• Tranquilizer
• Preparation of the Donor area`s hair
• Anesthesia
• Removing the hairs from Donor area
• Types of Grafts
• The Recipient Site
• Bandage
• After session
• Number of sessions required
• Final Results
• Repair of Unsatisfactory Prior Transplanting
• Confusing Claims
• Summary

The following is a summary of the procedure that is routinely given to you during HAIR TRANSPLANTATION SURGERY:

You are given a mild tranquilizer(usually Diazepam), usually orally, 1 hour befor session. This minimizes anxiety, reduces discomfort, and helps to prevent or decrease any side effects that might be caused by the anesthetic.

Hair in the donor area is clipped to a 2 mm length in one or two zones that are less than 12 mm wide, and a total of 18-22 Cm long. The hair above removed area is left long, so it can be combed over and completely camouflages the donor area immediately after the procedure.

Position of the patient

Donor area’s hair is cut & clipped

The donor area and the recipient area are anesthetized by injecting a local anesthetic with a very small gauge needle that is about the size of an acupuncture needle. In addition to using a small gauge needle, we reduce the sting when injecting the local anesthetic by neutralizing the pH of the anesthetic, which is normally stored in an acidic form. (The acidity is the main cause of the stinging one usually feels.) Nitrous oxide (laughing gas) may also be used simultaneously for particularly sensitive or nervous people. Anesthetizing the area is the only uncomfortable part of the session. Although it may be hard to believe, many patients have told us that the above technique usually causes less discomfort than a visit to their dentist.

In order to accommodate patients who prefer “no needle” procedures, we can use an instrument called a “dermajet”, which propels the anesthetic into the skin via pressure rather than a needle. Even though no needle is being used, such propulsion does cause a short-lived sting at each site. Most patients seem to find this method less satisfactory than the use of narrow gauge needles, but both options are available.

For patients who are particularly anxious about pain, an anesthetist can be called upon to administer a very short-lived and very safe general anesthetic, which induces sleep for 5 to 10 minutes during which all the potentially painful needles are given. It is, however, worthwhile emphasizing that this is rarely necessary as current techniques produce very little discomfort for the vast majority of patients.

After the local anesthetic has taken effect, A scalpel is used to cut narrow ‘strips’ or ‘ellipses’ of hair-bearing scalp from the donor areas and the wound is closed with sutures. (A similar method can also be used to remove scars in the donor area). This tissue is then divided into a variety of graft sizes.

Immediately after suturing Donor area(The site is compleletly invisible)

Removed strip

A fragment of removed strip

Many types of grafts are now used in the recipient area. Their advantages and disadvantages are discussed elsewhere in this website—see “Current Hair Transplant Options”. In general, the smaller the size of the graft used, the less noticeable treatment will be post-operatively and in between sessions. On the other hand, in general, the smaller the graft, the lower the density that can ultimately be achieved.

Follicular units ready for placing

In the terminology of hair transplantation, the recipient site is where hair is transplanted. It is the area of the scalp where hair follicles and the hair that grows from them are transplanted to correct hair loss. The hair follicles used for transplantation are harvested from the donor site, scalp areas at the side and back of the head where follicles are not influenced by the gene(s) responsible for male pattern hair loss. With minor exceptions, the donor site is the same for both male and female hair transplantation.

The purpose of hair transplantation is to restore aesthetic balance to a person’s appearance-a balance that is lost with balding of the scalp. Whether hair loss is confined to one area (for example, recession of the hairline or balding on top of the head) or over most of the scalp, the aesthetic balance of a person’s face is compromised. The hair loss area can become the feature that draws attention away from the face and dominates overall facial appearance.

Restoration of facial balance-restoration of appearance that pleases the patient-is a process that calls upon the surgical science of hair transplantation and the aesthetic artistry of the physician hair restoration specialist. The person with hair loss consults a physician hair restoration specialist because he/she is not pleased with the change in appearance created by hair loss. The physician hair restoration specialist listens to the patient’s wishes and concerns and interprets them in the context of:

1. the patient’s age, location of hair loss, degree of hair loss, progression of hair loss, and availability of donor hair
2. surgical techniques and procedures that could be used to address the patient’s wishes
3. how these techniques and procedures can be used to achieve the best aesthetic result given the patient’s age, characteristics of hair loss, and wishes of the patient including time and cost of hair transplantation.

The end result of transplantation should always be optimum aesthetic outcome for the patient as agreed upon between patient and physician. The patient should not be “sold” an approach to hair restoration. Rather, the patient and physician should agree on an approach and an anticipated outcome after full and honest discussion of (1) the patient’s wishes, (2) the physician’s recommendations, and (3) the patient’s concerns about the number of transplant sessions required, cost and potential complications.

Primary aesthetic concerns that must be addressed include:

A) The hairline:

A recreated hairline should be placed at an aesthetically correct position on the frontal scalp, be natural in appearance, be appropriate to the patient’s age, and be congruent with the appearance of other original or restored hair on the scalp. The skilled and experienced physician hair restoration specialist also takes into account how a recreated hairline will “age” as the patient ages. The hairline should remain appropriate to the patient’s age over a period of time; a hairline that looks natural when the patient is 28 should continue to appear natural when the patient is 48.

B) The part:

Unless the patient intends to habitually have a very short hair style such as a crew cut, he will usually comb his hair with a part. If he had a part before hair loss, he should have a part after hair restoration unless circumstances individual to the patient make this impossible. A natural-appearing part usually begins at a point where the frontal hairline curves inward and upward from the forehead. From the origin of the part at the frontal hairline to its termination at the center of the scalp, the placement, density and quality of hair on either side of the part should promote comb-styling and naturalness of appearance.

C) Natural appearance and ease of styling:

“Natural appearance” is the key phrase describing hair transplantation today. The type of donor hair selected, graft placement, size of grafts and overall transplant technique are selected to assure that transplanted hair is as “natural” in appearance as original hair and is amenable to styling as appropriate to the patient’s wishes.

Preoperative planning is directed toward achieving an optimum aesthetic result at the recipient site-a result that meets the expectations of the patient as agreed upon after full and frank discussion between patient and physician hair restoration specialist. Optimum aesthetic result is achieved by the physician hair restoration specialist’s skillful and experienced use of:

• knowledge of hair follicle biology and its application in the processes of hair transplantation
• the physical characteristics of hair (caliber, color, texture, curl) and how to use these characteristics to maximum aesthetic effect at the recipient site
• transplantation grafts ranging in size from single-hair to multiple hairs, and which types of graft are appropriate for use in the patient to achieve the optimum aesthetic result
• surgical techniques of donor hair removal, preservation of donor grafts between removal from donor site to implantation in the recipient site, preparation of scalp skin for graft implantation, and implantation of grafts at the correct depth and angle to assure survival and subsequent hair growth at the angle appropriate for natural appearance and ease of styling.

It is fortunate for both patient and physician that there are a variety of transplantation techniques available today, all of which can be used to produce natural results. Several techniques may be used in combination-for example, mini-grafts (5 hairs or more) where density is a primary objective, micro-grafts (cut to size with 1 to 4 hairs)and follicular unit grafts (natural groupings of 1 to 4 hairs) where finely defined effects are needed. The number of transplant sessions needed to accomplish the anticipated aesthetic outcome varies from patient to patient. Multiple sessions over a period of months may be recommended. This allows the physician hair restoration specialist to assess the outcome of each session and use this assessment to guide the choice of size, type and placement of grafts for following sessions to assure a final natural-looking appearance. For example, single-hair or micro-hair grafts of two or three follicles might be used to complete the natural-looking appearance of a given scalp area.

Incisions in bald area(Recipient site)

Fine insertion of a follicular unit

Grafs are inserted

Completion of hair transplantation in one densely-packed “mega-session” has recently been made possible by advances in surgical technique. However, one must understand that hair loss is an on-going condition-i.e., the patient may lose hair in the future. In such an event, more surgery may be required than is recommended at present. Mega-sessions should be carried out only by a skilled and experienced physician hair restoration specialist in selected patients. The choice of multiple sessions or mega-session should be individualized to the patient’s needs and wishes. The “best” choice is the one best for the individual patient.

Immediately after hair transplantation

Grafts are held in place by coagulated blood. To keep them secure and properly oriented, a turban-like bandage is usually applied after the operation and left in place overnight. The following day, the bandage is removed and the area is cleansed. If there is no more than the average amount of bleeding during surgery and you are willing to remain in the office for one or two hours after the procedure is completed, you can go home without a bandage. (Most patients seem to prefer the security of an overnight bandage). Whether or not a bandage is used, patients return the next day for follow-up cleansing, hair washing, and check-up.

A crust or scab forms over each graft shortly after the procedure, and remains attached for 5 to 14 days. (The smaller the graft, the faster the crust tends to fall off.) When the area is healed, the crusts separate from the scalp leaving a clean, pinkish area to indicate the site of each graft. Although these crusts are visible during the five-day to two-week healing period, many patients can camouflage them by combing the adjacent hair over the transplanted site. If a hairpiece is normally worn, it may be used to conceal the crusts after the first week (and should be worn as little as possible for an additional week). DFUs, TFUs, “slot” grafts and round minigrafts leave much less visible marks than standard round grafts, and are virtually undetectable within 7 to 10 days. The holes made for micrografts disappear within a few days to a week.

The hairs in the transplanted grafts are shed between the 2nd and 8th week after the procedure. Sometimes, they fall out attached to the separating crusts; occasionally they persist longer. Rarely, some of the transplanted follicles do not shed their hair at all, but continue to grow immediately after the procedure. With these exceptions, the grafts are usually bare until 10 to 14 weeks after the operation, during which time the follicles recuperate to produce new hair. A new generation of hair is usually visible at the surface of the scalp by the 12th week after transplanting, but this may occur slightly earlier, or up to eight weeks later in a few patients. These hairs grow at the same rate as they did in their original location (which is usually 1 Cm per month).

When a large area is transplanted, swelling of the forehead frequently occurs. While this swelling is usually mild and lasts only two to four days, it occasionally can be severe enough to cause a large amount of puffiness around the eyes. Approximately, 1 out of 50 patients have swelling bad enough to cause “black eyes”. Generally, the swelling begins two to three days after the procedure and is most noticeable after the first session. With subsequent treatments, it usually occurs in a milder form or not at all. In view of this, it’s advisable to schedule, if possible, a holiday to coincide with the 1st session. Please be assured that the swelling is ALWAYS temporary and has no harmful effect on the healing grafts. (An intra-muscular injection of a cortisone-type drug can be given at the time of the operation to help minimize swelling).

Contrary to what many patients have been told, the scalp (hairy or bald) has an excellent blood supply. A certain amount of bleeding during the transplant procedure is expected and is controlled simply by applying pressure. The donor area is stitched closed to produce better scars and to minimize bleeding. The stitches are normally removed 7 to 10 days later.

The nurses will wash your hair the day after surgery when any bandages are also removed. You should begin a bathing routine twice per day, beginning the second day after surgery, during which you soak your head for 10 minutes while gently massaging your scalp, and massage while shampooing your head for an additional 10 minutes. This accelerates the separation of crusts from the recipient area and any crusting in the donor area. Patients from out of town are required to stay in the city overnight after the transplant procedure. This allows us to remove the bandage and properly cleanse the area the day following surgery. Patients should not drive themselves home on the day of surgery because of the lingering effects of medications.

Ingrown hairs are, occasionally, a temporary problem, beginning 8-12 weeks after surgery. This is more often the case when DFU and TFU grafts are used or if the hair tends to be naturally curly. It is easily controlled, does not cause any permanent damage, and does not occur in a majority of patients.

A temporary decrease in scalp sensitivity is always noted after transplanting because nerves are cut as donor grafts are taken and recipient sites are prepared. Usually this will correct itself completely in 3 to 18 months as the nerves regenerate. Rarely, there may be a permanent slight degree of decreased sensitivity in one or more small areas.

Generally, the front third-to-half of a totally bald area can be completely finished in two to three sessions if only micrografts, DFU/TFU and/or slot grafts are being used, or three to three and a half sessions, if round grafts are also being employed. If you have the right hair characteristics, two sessions in a bald area may produce very nice cosmetic results, but patients who believe that they can have dense hair after only one or two sessions are being unrealistic. If round grafts are also being used, the 4th ‘half session’ is used to solidly fill the area started with round grafts. Even if the hair is wet or wind blown, no plugginess will be noticed. Sometimes this ‘half session’ can be done at the same time as the mid-scalp or crown is being treated rather than as a completely separate procedure. Or, it can be omitted because of high-hair density.

Transplant sessions may be done as far apart as the patient wishes. However, they are not done in any given area without a 5-6 week interval between the first 2 sessions, and an interval of 3-4 months or longer between the following sessions. If entirely separate areas are being transplanted at the same time (for example the front and the crown), sessions can be much closer. For example, the crown can be treated the day after the front. While the typical session done in our offices results in the transplantation of 1500 to 4000 hairs, the number of grafts that should be transplanted at 1 session and the frequency of transplant sessions depend on the size of the graft utilized and the characteristics of each individual.

It is becoming more common for patients to have 1 or 2 ‘early’ transplanting sessions before hair loss has reached an advanced stage. The benefit of these early sessions is fourfold: the remaining hair provides natural, immediate post-operative camouflage for the initial session; the transplanted hair (once it has grown) persists and provides additional coverage for any later sessions; sessions can be spaced farther apart, thus spreading the inconvenience and cost over a longer period of time; and, because there is no dramatic change from bald or nearly bald to hairy, the fact that a transplant is being done at all is less likely to be noticed by anyone.

In less than 10% of patients treated with FU and/or slit grafts, there may be some mild thinning involving the pre-existing hair of the recipient area within the first 2 to 3 weeks after a transplant. This thinning, if it occurs, is temporary and the hair will regrow slightly before or at the same time as the transplanted hair begins to sprout.

It is impossible to predict precisely how many hairs will appear in any given graft. At least 90%, and often 100%, survive transplanting. Not uncommonly, more hairs grow than were planted because some were in an invisible ‘resting phase’ when they were originally counted. After over 25,000 hair transplant sessions, we have never encountered a patient who failed to grow hair.

Within a few weeks, the colour and skin surface of the grafts has usually blended in perfectly with the surrounding scalp. In some patients, however, the grafts may be a shade lighter in colour until they are aged by sun exposure. The grafts are usually level with the surrounding scalp, but a few may be slightly elevated in less than 1% of patients. Such grafts can be flattened with an electric needle without interfering with hair growth. The final appearance is usually that of early thinning to ‘very early thinning’, which is not meant to imply ‘thin’ hair, but rather to convey the idea that you cannot expect to look like you did when you were a teenager.

As one ages, the rim hair from which the grafts were taken also gradually becomes less dense. Thus transplanted areas will also thin somewhat. However, they will never go bald again. In addition, as the hair goes grey with aging, it will look thicker, so any decreased density may or may not be noticeable. Because of this gradual thinning effect, you may want to transplant the area a little thicker to begin with. Or, alternatively, you may want to conserve some grafts for use in 15 to 20 years.

Most patients seen for repair of unsatisfactory prior transplanting are treated with a combination of: a) excision of part or all of any old large pluggy-looking grafts, b) creation of a new hairline constructed exclusively with FUs, c) the use of FUs and multi-FU grafts behind the new hairline zone. The type of graft chosen for any given area will depend on a large number of factors but the choice is based on which variety of graft will most rapidly correct noticeable plugginess. Usually at least two transplant sessions are necessary to create substantial improvement

Frequently, however, patients will want three or more treatments (if possible) because each session will result in more improvement in both the recipient and donor area. With regard to the latter, improvement of scarring in the donor area is often as important a goal as is improvement in the recipient area. As a result of the relatively new technique of strip harvesting, these goals are not incompatible. One can often excise two rows of wider scars with a zone of hair between them, thereby creating one narrow scar from two wide ones

Follicular Unit Extraction (FUE) is sometimes also used to obtain grafts without creating new linear scars. FUE involves the excision of single FUs from the donor area—one at a time—rather than the excision of a strip that must later be divided into different types of grafts. In most patients Dr. Unger sees, however, he prefers to remove old scars at the same time as he is obtaining more donor tissue and he likes to have the option of using multi-FU grafts as well as FUs.

The public is often confused by conflicting claims and counterclaims about exclusive “follicular unit” transplanting (FUT) in advertisements that can cost their sponsors millions of dollars annually. What follows is Dr. Vafaei’s view of what the scientific evidence, to-date, reveals.

If you feel you would be satisfied with light or moderate hair density, you may want to consider using only FUs for your transplanting. There are important advantages to such an approach. Some can be found in the section of this website that discusses the various “Types of Grafts”. In brief:

1. FUs cause the least damage to any existing hair in the recipient area.
2. FUs produce the least amount of post-operative crusting.
3. FUs generally grow somewhat faster than other types of grafts.
4. FUs produce absolutely no clumping or plugginess, and therefore produce remarkably natural looking results after even a single session in an area that is bald or destined to become bald.
5. Most patients will not have sufficient donor reserves to transplant the entire evolving bald area relatively densely; therefore, FUT provides the most flexibility in the distribution of the donor tissue that is available. This is because single sessions can be used in less cosmetically critical areas—such as the crown and still produce natural-looking results, while other areas can be treated more than once—for example, the frontal area—to create higher hair densities.

Transplanting an entire bald head in one “megasession” of even 3000 or more FUs will not result in what most people would call cosmetically acceptable hair density. On the other hand, when the area to be treated is relatively small, for example the front third or half of a typically sized area of MPB, such a session can produce very acceptable results

Only a small minority of hair transplant surgeons carry out “megasessions”. Why? There is very little difference in work or staff requirements between doing a 1500 graft session for each of two patients in a day or doing a 3000 graft session on a single patient. If anything, there is slightly more work and staff requirements if two patients are treated instead of one. It is also more convenient for patients to have a single session than several sessions to the same area, and it is, therefore, certainly more “saleable” to more patients. The answer to the question of why so few surgeons employ “megasessions” lies with differing opinions about patient safety and hair survival when such large sessions are utilized.

Megasessions of 3000 or more FUs typically involve 10 to 12+ hours of surgery. They are, therefore, more physically and emotionally stressful than more standard sized sessions. The increased risk associated with such long sessions can be minimized by careful monitoring of blood oxygen levels, blood pressure, and pulse rates, as well as continuous intravenous fluids and drugs. Most physicians, nevertheless, feel that the increased risks outweigh the benefits for what is, after all, a cosmetic procedure. The choice between patient convenience and safety seems to them to be properly weighed towards the latter.

“Dense packing” of 40, 50, or more FUs/cm2 in a single session does produce a greater hair density than using a graft density of 20 to 25 FUs/cm2. Thus, photos showing the results of such dense packing can be very impressive. There is, however, a substantial body of evidence suggesting that dense packing FUs results in reduced hair survival. There is a limited number of FUs available for transplanting and anything that might endanger their survival should be avoided.

The smaller the graft, the more easily it can be injured by technicians (as each hair is closer to the edge of the graft). Three thousand incisions in the scalp obviously will cut more blood vessels than 2000 or 1500 incisions. While most megasessions produce what appear to be adequate yields, a minority produces very little hair. It is likely that there are many patients between those two extremes who will grow hair, but less than they would have if a more conventional approach had been used. In a similar fashion, the current competition amongst some hair restoration surgeons to see who can transplant the most FUs/cm2 seems to be ignoring the vascular damage caused by high density FUs/cm2, and its effect on hair survival. For example, 50 FUs/cm2 requires a total length of 5 cm of incisions in each 1 cm2 box if the recipient sites are made with needles or blades that only create 1 mm long incisions. (An 18-g needle produces an incision that is approximately 1.2 mm long.) Making 5 cm of incisions in every 1 cm2 box of scalp tissue would intuitively lead one to expect massive vascular damage in that small area and consequently lower rates of hair survival than could be expected with less FUs/cm2. Yet some practitioners are suggesting even higher FUs/cm2 densities.

How then does one explain claims of 100% hair survival by proponents of megasessions and dense packing and photos of excellent looking results after only one or two sessions?

• The claims of 100% or more survival have been based on studies in which FUs have been inserted into holes made in small areas (1 cm2) that were surrounded by otherwise intact, untreated skin. This is not at all comparable to what actually happens during a typical transplant session in which thousands of additional incisions or holes are made, each one of which severs some blood vessels and thus reduces the blood supply to the recipient area, which in turn could reduce hair survival rates.
• Apparent hair density is not dependent only on the number of hairs/cm2. The less contrast between the hair and skin color, the more curl or wave, the more “frizziness” to the hair and the higher the hair caliber, the thicker or denser the hair will appear to be. An increase in hair shaft diameter of only 0.01 mm for example will increase hair volume by 36%.1 Thus, the impressive results seen in photos of selected patients by proponents of megasessions and dense packing are both possible and real. Nothing that has been said here should in any way be construed to mean that I believe intentional deception is being used by anyone. Even if 35% or more of the hair transplanted by a few proponents is dying, if enough hairs are transplanted densely enough the results may, in fact, look excellent after two sessions or, less commonly, after one session if the patient’s hair characteristics are particularly advantageous.

Given the fragility of the FU graft, FUT is obviously very dependent on perfect technique. Good hair survival is possible if technique and quality control of technicians are excellent. It should be recognized, however, that hair count studies are notoriously difficult to do, with results that may or may not be scientifically valid, and therefore it would appear to be wise to use micrografts/FUs without megasessions or “dense packing” whose intention is a completed result after a single session. “Dense packing”, if used, should also only be employed in limited areas until such a time as good hair survival rates in an entire recipient area (not, for example, a 1 cm2 box) are documented by independent evaluators.

In summary, patients are often anxious to have as much done as quickly as possible and are, therefore, anxious to believe that there is no intrinsic problem with megasessions and/or dense packing for quick results. However, increased risk and the possibility of lesser hair yield permanently should be weighed against the temporary convenience of a faster result.

In summary With the new techniques of hair transplanting, the hairline no longer appears as abrupt or dense as was the case with older traditional grafts. Micrografts create a very natural looking hairline. This enables patients to wear their hair in virtually any style including combing the hair straight back. Micrografts, DFU and TFU grafts create a more feathered, less tufty appearance, thus avoiding the ‘Barbie-doll’ look that sometimes is present with round grafts before the area has been densely transplanted. They also do not result in the removal of any existing hair in the recipient area and are, therefore, particularly advantageous for transplanting in patients with ‘early’ MPB or female pattern thinning. Most women, in fact, can now consistently expect cosmetically significant improvement whereas, as recently as 10 years ago, most women were not acceptable candidates for transplanting.

Current techniques have increased the proportion of patients who can be helped by transplanting while at the same time producing far more natural looking results than those of the past. These new techniques are also remarkably effective in helping to correct cosmetically poor results of older types of transplanting. New, more natural looking hairlines can be created in front of old pluggy ones while spaces between the older grafts are also filled.