If you’re looking for a permanent solution to your hair loss, you may want to consider a hair transplant

Today, it’s possible to have natural-looking results thanks to one key advance. Most surgeons now transplant the healthy hairs a few at a time. This eliminates the unnatural doll-like hair that patients saw in the 70s and 80s. Back then, sections of hair called hair plugs were placed in the thinning area. In time, the hair plugs became quite noticeable.  

Improvements in creating the hairline and placing the hairs in the thinning areas also help create natural-looking results. 

Thanks to these advances, the results can look so natural that a barber or stylist cannot tell you’ve had anything done

 Good candidate for a hair transplant

Men and women of all races can be good candidates for a hair transplant.

To be considered for a hair transplant, you need two things:

1. Enough healthy hair on your scalp that can be transplanted to the area that needs hair
2. The ability to grow hair on the thinning area of your scalp

During a consultation with a dermatologist, you can find out if you have both. A dermatologist will give you a thorough scalp exam.

To find out why you have hair loss, you may also need a blood test. This can check for things going on in your body that may be causing your hair loss. Some patients need a procedure called a scalp biopsy. Your dermatologist can quickly and easily take what is needed for the scalp biopsy during the consultation. 

If the exam and tests show that you are a good candidate for a hair transplant, your dermatologist can tell you what results you can expect. A full head of hair may be unrealistic, but a fuller head of hair can be the goal.

During a hair transplant

You can expect a hair transplant to take between four and eight hours. If you are having a large amount of hair transplanted, you may need to return for a few hours the next day. 

Most patients remain awake during the entire surgery and need only an anesthesia that makes the scalp numb. Some patients also take a mild sedative to help them relax. 

Hair transplant surgery usually lasts between 4 and 8 hours. The surgery begins with your dermatologist removing the healthy hairs. To give you natural-looking results, your dermatologist may remove the healthy hairs by either cutting a strip of skin with healthy hairs from your scalp or removing individual hairs. 

The second option takes a lot more time, but avoids leaving a long, narrow scar on your scalp. This can be beneficial if you prefer close-shaven haircuts like buzz cuts.  

Before the surgeon can transplant the hairs, technicians need to prep the removed hairs and the surgeon must get your scalp ready for the transplant. 

Depending on the number of hairs to be transplanted, two to three members of the hair transplant team may help place the healthy hairs into the area that needs hair. Once all the hairs have been transplanted, your scalp will be bandaged and you will be given instructions for at-home care

patients see results from a hair transplant

Most patients see results between six and nine months after surgery. For some patients, it takes 12 months. 

It’s important to know that between two and eight weeks after the surgery, the transplanted hair will fall out. This is normal. By the third month, the hair may look thinner than before you had the transplant. Again, this is normal

Like good health and youth, most of us take our locks for granted — that is, until they’re gone. For many people, a hair transplant can help bring back what looks like a full — or at least a fuller — head of hair.

If thinning up top or going bald really bothers you, the procedure can be one way to feel more confident about your looks. But first talk with your doctor about what you can expect during and after the surgery

Hair Transplant

It’s a type of surgery that moves hair you already have to fill an area with thin or no hair. Doctors have been doing these transplants in the U.S. since the 1950s, but techniques have changed a lot in recent years.

You usually have the procedure in the doctor’s office. First, the surgeon cleans your scalp and injects medicine to numb the back of your head. Your doctor will choose one of two methods for the transplant: follicular unit strip surgery (FUSS) or follicular unit extraction (FUE).

With FUSS, the surgeon removes a 6- to 10-inch strip of skin from the back of your head. They set it aside and sews the scalp closed. This area is immediately hidden by the hair around it.

Next, the surgeon’s team divides the strip of removed scalp into 500 to 2,000 tiny grafts, each with an individual hair or just a few hairs. The number and type of graft you get depends on your hair type, quality, color, and the size of the area where you’re getting the transplant.

If you’re getting the FUE procedure, the surgeon’s team will shave the back of your scalp. Then, the doctor will remove hair follicles one by one from there. The area heals with small dots, which your existing hair will cover.

After that point, both procedures are the same. After they prepare the grafts, the surgeon cleans and numbs the area where the hair will go, creates holes or slits with a scalpel or needle, and delicately places each graft in one of the holes. They’ll probably get help from other team members to plant the grafts, too.

Depending on the size of the transplant you’re getting, the process will take about 4 to 8 hours. You might need another procedure later on if you continue to lose hair or decide you want thicker hair.

Expectations and Recovery

After the surgery, your scalp may be very tender. You may need to take pain medications for several days. Your surgeon will have you wear bandages over your scalp for at least a day or two. They may also prescribe an antibiotic or an anti-inflammatory drug for you to take for several days. Most people are able to return to work 2 to 5 days after the operation.

Within 2 to 3 weeks after surgery, the transplanted hair will fall out, but you should start to notice new growth within a few months. Most people will see 60% of new hair growth after 6 to 9 months. Some surgeons prescribe the hair-growing drug minoxidil (Rogaine) to improve hair growth after transplantation, but it’s not clear how well it works.

Hair Transplant

A hair transplant is a procedure in which a plastic or dermatological surgeon moves hair to a bald area of the head. The surgeon usually moves hair from the back or side of the head to the front or top of the head.

different types of hair transplants

There are two types of transplant procedures: slit grafts and micrografts.

Slit grafts contain 4 to 10 hairs per graft. Micrografts contain 1 to 2 hairs per graft, depending on the amount of coverage needed.

During a hair transplant

After thoroughly cleaning your scalp, a surgeon uses a small needle to numb an area of your head with local anesthesia.

Two main techniques are used to obtain follicles for transplantation: FUT and FUE.

In follicular unit transplantation (FUT):

1. The surgeon will use a scalpel to cut out a strip of scalp skin from the back of the head. The incision is typically several inches long.
2. This is then closed with stitches.
3. The surgeon next separates the removed portion of scalp into small sections using a magnifying lens and sharp surgical knife. When implanted, these sections will help achieve natural-looking hair growth.

In follicular unit extraction (FUE) the hair follicles are cut out directly from the back of the head through hundreds to thousands of tiny punch incisions.

1. The surgeon makes tiny holes with a blade or needle in the area of your scalp that’s receiving the hair transplant. They gently place hairs in these holes.
2. During one treatment session, a surgeon may transplant hundreds or even thousands of hairs.
3. After, the graft, gauze, or bandages will cover your scalp for a few days.

A hair transplant session can take four hours or more. Your stitches will be removed about 10 days after surgery.

You may require up to three or four sessions to achieve the full head of hair you desire. Sessions occur several months apart to allow each transplant to fully heal.

long-term outlook

Typically, people who’ve had a hair transplant will continue to grow hair in the transplanted areas of the scalp.

The new hair may appear more or less dense depending on:

• scalp laxity, or how loose your scalp skin is
• density of follicles in the transplanted zone
• hair caliber or quality
• hair curl

Conclusion

A full head of hair for women of all ages is the cultural norm. Recent techniques for efficient donor hair harvest and meticulous preparation of hair grafts have allowed many women to be candidates for hair restoration surgery. The artistic creation of grafts of different size and the meticulous handling of these fragile transplants have enabled treatment of some women who might not have been candidates for surgery a few years ago. Still, careful patient selection for hair restoration surgery is essential

Surgical Hair Replacement

Hair transplant surgery involves removing small pieces of hair-bearing scalp grafts from a donor site and relocating them to a bald or thinning area

What are the steps of a hair transplant procedure?

Hair transplantation involves removing small punch grafts from the hair bearing scalp or a larger piece of this scalp from a donor area and cutting this into smaller pieces to use as grafts. These grafts are then relocating to a bald or thinning area of the scalp. The grafts created in this manner differ in size and shape. Round-shaped punch grafts usually contain about 10-15 hairs. The much smaller mini-graft contains about two to four hairs; and the micro-graft, one to two hairs. Slit grafts, which are inserted into slits created in the scalp, contain about four to 10 hairs each; strip grafts are long and thin and contain 30-40 hairs.

Generally, several surgical sessions may be needed to achieve satisfactory fullness, and a healing interval of several months is usually recommended between each session. It may take up to two years before you see the final result with a full transplant series. The amount of coverage you’ll need is partly dependent upon the color and texture of your hair. Coarse, gray or light-colored hair affords better coverage than fine, dark-colored hair. The number of large plugs transplanted in the first session varies with each individual, but the average is about 50. For mini-grafts or micro-grafts, the number can be up to 700 per session

Just before surgery, the “donor area” will be trimmed short so that the grafts can be easily accessed and removed. For punch grafts, your doctor may use a special tube-like instrument made of sharp carbon steel that punches the round graft out of the donor site so it can be replaced in the area to be covered—generally the frontal hairline. For other types of grafts, your doctor will use a scalpel to remove small sections of hair-bearing scalp, which will be divided into tiny sections and transplanted into tiny holes or slits within the scalp. When grafts are taken, your doctor may periodically inject small amounts of saline solution into the scalp to maintain proper skin strength. The donor site holes may be closed with stitches—for punch grafts, a single stitch may close each punch site; for other types of grafts, a small, straight-line scar will result. The stitches are usually concealed with the surrounding hair. To maintain healthy circulation in the scalp, the grafts are placed about one-eighth of an inch apart. In later sessions, the spaces between the plugs will be filled in with additional grafts. Your doctor will take great care in removing and placement of grafts to ensure that the transplanted hair will grow in a natural direction and that hair growth at the donor site is not adversely affected.

After the grafting session is complete, the scalp will be cleansed and covered with gauze. You may have to wear a pressure bandage for a day or two. Some doctors allow their patients to recover bandage-free.

Tissue Expansion

Another technique used in the treatment of baldness is called tissue expansion. Plastic surgeons are the leaders in tissue expansion, a procedure commonly used in reconstructive surgery to repair burn wounds and injuries with significant skin loss. Its application in hair transplant surgery has yielded dramatic results-significant coverage in a relatively short amount of time.

In this technique, a balloon-like device called a tissue expander is inserted beneath hair-bearing scalp that lies next to a bald area. The device is gradually inflated with salt water over a period of weeks, causing the skin to expand and grow new skin cells. This causes a bulge beneath the hair-bearing scalp, especially after several weeks.

When the skin beneath the hair has stretched enough-usually about two months after the first operation-another procedure is performed to bring the expanded skin over to cover the adjacent bald area. For more information about tissue expansion, ask your plastic surgeon for the American Society of Plastic Surgeons, Inc. brochure entitled, Tissue Expansion: Creating New Skin from Old.

Flap Surgery

Flap surgery on the scalp has been performed successfully for more than 20 years. This procedure is capable of quickly covering large areas of baldness and is customized for each individual patient. The size of the flap and its placement are largely dependent upon the patient’s goals and needs. One flap can do the work of 350 or more punch grafts.

A section of bald scalp is cut out and a flap of hair-bearing skin is lifted off the surface while still attached at one end. The hair-bearing flap is brought into its new position and sewn into place, while remaining “tethered” to its original blood supply. As you heal, you’ll notice that the scar is camouflaged—or at least obscured—by relocated hair, which grows to the very edge of the incision.

In recent years, plastic surgeons have made significant advances in flap techniques, combining flap surgery and scalp reduction for better coverage of the crown; or with tissue expansion, to provide better frontal coverage and a more natural hairline

Scalp Reduction

This technique is sometimes referred to as advancement flap surgery because sections of hair-bearing scalp are pulled forward or “advanced” to fill in a bald crown.

Scalp reduction is for coverage of bald areas at the top and back of the head. It’s not beneficial for coverage of the frontal hairline. After the scalp is injected with a local anesthetic, a segment of bald scalp is removed. The pattern of the section of removed scalp varies widely, depending on the patient’s goals. If a large amount of coverage is needed, doctors commonly remove a segment of scalp in an inverted Y-shape. Excisions may also be shaped like a U, a pointed oval or some other figure.

The skin surrounding the cut-out area is loosened and pulled, so that the sections of hair-bearing scalp can be brought together and closed with stitches. It’s likely that you’ll feel a strong tugging at this point, and occasional pain

Procedure Steps

Before: Hair transplant candidates should have some noticeable hair loss with healthy hair growth at the back and sides of the head to serve as donor areas

Step 1: A tube-like instrument punches round grafts from the donor site to be placed in the area where hair replacement is desired.

Step 2: A tube-like instrument punches round grafts from the donor site to be placed in the area where hair replacement is desired.

Step 3: When the skin beneath the hair has stretched enough, it is surgically placed over the bald area.

Step 4: During flap surgery, a section of bald scalp is cut out and a flap of hair-bearing skin is sewn into its place

Step 5: The patterns used in scalp reduction vary widely, yet all meet the goal of bringing hair and scalp together to cover bald areas

After: The results of hair transplant surgery can enhance your appearance and self-confidence.

Hair restoration is a highly sophisticated subspecialty that offers significant relief to patients with hair loss. An improved understanding of the aesthetics of hair loss and cosmetic hair restoration, hair anatomy and physiology, and the development of microvascular surgical instrumentation has revolutionized the approach to surgical hair restoration since the original description. Additional elements that contribute to the current state of the art in hair restoration include graft size, site creation, packing density, and medical control of hair loss. The results of hair restoration are natural in appearance and are provided with a very high level of patient satisfaction and safety. This aspect of cosmetic surgery is a very welcome addition to a traditional aesthetic practice and serves as a tremendous source for internal cross-referral. The future of hair restoration surgery is centered on minimal-incision surgery as well as cell-based therapies

Hair Restoration

Alopecia, the term for generic hair loss, involves a diminution of visible hair. There are numerous types of alopecia. The most common form of surgically treatable alopecia is androgenic alopecia (AGA). Throughout time, the presence of scalp hair has represented attributes of health, vigor, vitality, and strength. Accordingly, loss of hair in men (MAGA, or male pattern androgenic alopecia) and especially women (FPHL, or female pattern hair loss) can have significant psychosocial effects. The overwhelming majority of procedures for hair restoration are hair transplants, and the advent of microvascular surgical instrumentation as well as an improved understanding of the anatomy and physiology of hair loss has revolutionized the art of surgical hair restoration since the original description and early refinement

Anatomy, Genetics, and Physiology of Hair Loss

Androgenic alopecia is characterized by progressive visible thinning of scalp hair in genetically susceptible men and in some women. The current scientific data support the thesis that AGA is a polygenic trait. Significant associations have been reported with variant regions of the androgen receptor gene, which is located on the X chromosome. Epidemiologic surveys of AGA reveal the highest incidence in Caucasians, followed by Asians and then Africans, with the lowest incidence in Native American For the purpose of hair transplantation, the scalp may be divided into the frontal, midscalp, vertex, and temporal areas Hair thinning and subsequent shedding is due to gradual miniaturization of genetically marked hair follicles and represents shortening of the anagen (growth) phase of the hair follicle with an increase in the telogen/anagen ratio of the affected scalp. An understanding of the normal hair follicle life cycle is critically linked to an appreciation of the physiology of hair loss

In women, there is no consensus on whether hair loss is truly androgen dependent. Most women with FPHL do not have biochemical hyperandrogenism. In fact, some women without detectable circulating androgens may also develop FPHL, suggesting a possible role for non-androgen-dependent mechanisms. Based on this evidence, it seems appropriate to replace the term androgenic alopecia in women with the previously mentioned, more contemporary and scientifically descriptive term female pattern hair loss (FPHL), to include this recognized heterogeneity

Nonsurgical Options for Treating Hair Loss

General Evaluation

Young men and women are particularly distraught by the signs of hair loss. Low self-esteem and vulnerability to a fantasized outcome place this subset of patients at particular risk for quick decision making and unrealistic expectations. Managing these expectations and formulating a realistic surgical plan for patients with hair loss is a critical component to the long-term success of the procedure.

A fundamental concept that physicians and patients are advised to maintain during the evaluation and planning for HRS is that hair loss is progressive. The appearance of hair loss in the office during consultation is merely a snapshot along a continuum that began years earlier and will progress until death. Communication regarding the quality of the patient donor hair is also an additional essential component in managing expectations. The qualities of the hair that should be reviewed include curl, hair shaft diameter, color, texture, follicular unit density, and the telogen/anogen ratio of in situ donor hair. These aspects of the donor hair should be not only reviewed but also documented as a means to predict how well the transplanted hair will camouflage areas of scalp alopecia.

Hair Transplant Technique

As with any surgical procedure, the techniques of the operation will vary based on personal preference and clinical circumstances. Although the fundamental approach described herein is nearly universally applicable, the specific techniques do reflect most closely the methodology preferred by the lead author (JEV).

Anesthesia

Hair transplantation can be performed under local anesthesia alone or with supplemental sedation. The local anesthesia solution is a 40-mL mixture of 0.25% bupivacaine with 1:200 000 epinephrine + 20 mL 1.0% lidocaine with 1:200 000 epinephrine. This solution is used in the donor and recipient sites, and supplementation with additional bupivacaine 0.25% is performed in both regions of the scalp prior to discharge from the operating room. If conscious sedation is included with the procedure, the patient is premedicated with 1 to 2 mg PO aprazolam. In the operating room, an intravenous cocktail of ketamine 5 mg/mL, midazolam 0.5 mg/mL, and fentanyl 10 mcg/mL is titrated to achieve the desired level of sedation. All patients receiving any type of sedation are continuously monitored during the procedure with oximetry and receive supplemental nasal

Donor Site Harvest

In contemporary practice, follicular units can be obtained either through strip excision of the donor scalp with subsequent microscopic tissue dissection or by removal using a technique called follicular unit extraction (FUE)

Strip excision.

In preparation for the strip harvest, the selected area of donor hair is trimmed to 4- to 5-mm length and the patient is positioned in a lateral decubitus position. An ellipse of donor scalp is outlined, and following the administration of local anesthesia, tumescent saline solution is infiltrated. Tumescence in conjunction with precise knife blade angulation parallel to the hair shafts reduces follicle transection. Dissection level of the donor strip should be at the superficial fat to avoid injury to the occipital neurovascular bundle. The wound is closed in 2 layers, with an absorbable suture in the deep layer and a monofilament suture of choice at the level of the skin. Staples or dissolving sutures are also options

Follicular unit extraction.

Follicular unit extraction is an alternative method of donor harvest. This technique is essentially a refined “micropunch grafting” version of the older punch graft technique. Using the current technique of FUE, 1 FU is removed at a time. There are several techniques and instruments to perform FUE. These include manual, power-assisted, and automated methods. No matter which technique is employed, the net result is still the isolation and removal of a single FU  The remaining puncture is left to heal by secondary intention. Some hair transplant surgeons choose to employ FUE on a selective basis for small cases  , whereas others select this donor harvest technique for their larger sessions  The increased popularity of FUE has been linked to the development of power-assisted technology as well as a general trend toward minimally-invasive techniques. The indications, outcomes, and techniques for FUE as a donor harvest option are found elsewhere

Hairline Design and General Recipient Area

The first landmark that needs to be determined is the height of the anterior hairline (AHL) In most instances, the location of the most anterior, midfrontal portion of the hairline is between 7.5 and 9.5 cm above the glabella. The shape of the head, predicted future hair loss, and donor capacity are factors to consider in this creative decision. One must place the hairline in such a location that it will look natural as the patient matures and continues to lose hair.

If the temporal point is expected to recede, a higher hairline should be considered because a low hairline with a lost temporal point suggests a hairpiece. The temple point should be even or slightly posterior to the frontal hairline. Along with the aforementioned principles, a gently curving hairline should be created, with care taken to always maintain a significant frontal-temporal recession. Restoration of the temporal triangle is performed according to the personal preference of patient and surgeon.

The design should begin by ensuring the presence of a lateral hump . If the lateral hump is absent, this should be designed first. The lateral hump is the superior extension of the inferiorly directed hair of the temporoparietal fringe. The superior extent of this important landmark is even with or just medial to a line drawn vertically from the lateral canthus. This landmark is important because it represents the lateral extent of the AHL. The intersection of the lateral AHL and the lateral hump is the apex of the frontotemporal recession and should always be convex in a male AHL design

When a forelock pattern is created, the rear border should be located somewhere along the midscalp. Whether or not there is a plan to graft the vertex, the rear hairline should be constructed with an irregular border of small grafts. The lead author prefers to create a tapered posterior forelock pattern of trailing design that renders the crown less circular and mimics a natural variation on the balding process .A distribution of grafts recreating a natural whorl pattern can be constructed at the posterior aspect of the forelock. The crown area can be further grafted as indicated but should always be considered as an extension of the posterior forelock to maintain a natural distribution of hair

Conclusion of Procedure, Postoperative Care, and Emergence of Results

Hair transplants are lengthy procedures. A typical session of 1500 to 2500 grafts utilizing 4 assistants will last approximately 6 to 7 hours. The procedure is conducted using a clean technique with sterilized or disposable instruments. Postoperatively, the recipient sites and donor area are typically not bandaged, and perioperative antibiotics are not prescribed on a routine basis. Patient instructions include head elevation and icing of the forehead and donor area, along with analgesics. Aloe ointment administration to the grafted area and gentle shampooing in the shower should commence on postoperative day 2. Most of the recipient site eschars are gone by day 10, and donor sutures are removed on day 14. Although there are exceptions to the rule, most grafts enter a telogen phase for the first 3 months prior to entering their anagen phase. Full growth and evaluation of transplant results cannot reliably be assessed for 8 to 12 months following the procedure.