Hair Transplant 101

The history of hair transplants goes back to the early 19th century when it was used for reconstructive purposes only. The procedure gained mass popularity in the 20th century with the introduction of the punch technique and its cosmetic use for treatment of male patterned baldness. The advances in hair transplant technology have grown to the point that the procedure is now the most common cosmetic surgery among men. In 2014, the International Society of Hair Restoration Surgery reported that 397,048 procedures were performed in 2014 which was an increase of 28% over 2012.

How Do Hair Transplants Work?

Typically, male and female patterned baldness begins when the hair shafts start to thin. The decrease in the size of the hair shafts is a process known as miniaturization. Once this process progresses, most of the hair become invisible and the level of baldness on a person becomes obvious to the average person. Although hair loss medications can slow down the process of hair loss, the only solution to treat obvious balding is a hair transplant. Simply put, a hair transplant moves better quality hair from one area to restore the balding sections of another area.

Hair transplant techniques involve the harvesting of hair follicles from donor areas where hair is not prone to baldness. The donor area is normally located in the back or sides of the head in typical male patterned baldness although hair can be taken from other parts of the body such as the beard, torso and extremities. The hair grafts should be harvested and transplanted in naturally occurring follicular units in order to restore the balding area. The follicular units help to create the most natural looking hairline.

Follicular Unit Concept

Follicular Units of hair on scalp

Follicular units of scalp hair shows the natural grouping of hair follicles.

Hair follicles generally don’t grow individually. They bundle in groups of 1-4 hair follicles. These groupings are usually held together with a collagen band and they have their own oil grand, nerve and small vessel. Follicular units are the way hair grows in nature and that is why transplanting hair in their native follicular units can create the most natural look.

Hair transplants were initially done through removing pieces of hair bearing skin and implanting them into the balding areas. This procedure was known as “plug surgery”. Old hair transplantations resulted in a dull look to the head which could be easily detectable from a normal head of hair. Hair transplants have improved in the last few decades as doctors have moved toward transplanting smaller groups of hair known as minigrafts or micrografts. Follicular Unit Transplants are recognized as the most recent refinement in hair restoration.

Harvesting Hair

Human Hair follicular unit graft

Follicular Unit Grafts

Follicular unit transplant is considered the gold standard of modern hair restoration and the hair is usually harvested through two main methods. Choosing one of the two types of harvesting has to do with the preferences of the patient as well as how they plan to wear their hair in the donor area. The type of procedure undertaken affects the number of grafts that can be harvested in any one session and the cost of hair transplant:

  1. Follicular Unit Extraction (FUE) – This technique is performed when a doctor individually harvests follicular units or individual hair grafts from the donor area through microscopic techniques. In this method, hair is removed without the need to make a linear incision on the scalp thus it does not leave a linear scar. Overall, FUE is known as a less invasive procedure than the strip method since the follicular grafts are removed one at a time without the need to cut, suture or staple the scalp. FUE allows patients to keep a short hairstyle in the back since there won’t be a linear scar on the donor area. The disadvantage of FUE is that a smaller number of grafts can be harvested in each session and it costs more than the traditional strip method.
  2. Strip (FUT) – This technique involves the transplanting of hair units in their natural grouping via a strip method. Follicular units have one to four hair follicles that are wrapped by protein sheaths made up of collagen with an adjoining oil gland. During strip FUT, the doctor removes a strip of skin from the donor area and uses stereoscopic magnification to harvest hair grafts for transplantation in their natural direction. On average, strip FUT takes 6-9 hours to perform.

Once the hair is removed from the donor area, it is processed and counted before their implantation in the balding areas. Hair grafts are usually kept in a specific holding solution at a certain temperature.

Implanting Grafts

Graft Implantation during Hair Transplant

Implantation of Follicular Unit Grafts

Either before or after harvesting, and also preparing the grafts, the surgeon makes tiny incisions in the bald area where the follicular units will be transplanted. The follicular units are then inserted into the incisions and distributed in such a way that the balding areas will be covered in a natural looking manner. The transplanted hair creates the appearance of a hairline that will be undetectable to the average eye.

The process of implanting the follicular units is very meticulous and it should be performed under a microscope or with magnifying loupes by an experienced surgical staff. Special care needs to be taken to prevent damaging the reproductive part of the grafts where the hair stem cells reside.
Transplanted hair follicles become part of the new skin within a few days after implantation.

Which Areas Are Treated by Hair Transplant

While the common perception is that a hair transplant can only treat the scalp, hair can be transplanted on any part of the skin. For example, if patients never had any hair in an area such as the beard, hair can be transplanted to the beard area to give them the facial hair they have always desired. Some areas on the body where hair can be transplanted include:

  • Scalp hair restoration in typical male patterned baldness in men and women
  • Eyebrow transplant
  • Beard and mustache restoration
  • Hairline lowering
  • Body hair transplant on areas such as the chest and pubic area

After the Procedure

After the grafts have been placed in the scalp, the patient will see some stubble as well as some scabbing in the transplanted area that will heal rapidly. The transplanted hair will begin to fall out after a few weeks as the hair goes into a resting phase. However, there is no need to worry. After several months, the hair follicles enter another growth phase and they start to grow as small hair. This baby hair continues to become longer and thicker to the point that it becomes normal mature hair.

Unlike the original follicles in the balding area, the hair that is transplanted is not influenced by the same biological triggers that cause baldness. The transplanted area will produce and grow hair just as it did in the donor area. After completion of the hair growth, transplanted hair does not require any particular care when it is established in the new area of skin.

Designing Hairline before hair transplnat

Before Hair Transplant: Consultation to design hairline to fit facial proportions

After Hair Transplant

Day 1 After Hair Transplant: Patients come to our office for hair wash

9 Months post hair transplant

9 Months After Hair Transplant: Patients should expect to see full results

What to do After Hair Transplant

Once the hair transplant has been performed, there are still many steps patients need to follow in order to attain good results. While each doctor might differ a little bit in his follow-up treatment, here are some of the general steps that need to be followed:

  • How to wash your hair post-transplant – The first few days patients wash their hair after a hair transplant are crucial in maintaining the delicate work performed by the doctor. Patients should visit their doctor to wash their hair for the first time following surgery in order to be shown the proper way to wash it without disturbing the new grafts.
  • What to expect after Hair Transplant – The overall recovery period following a FUT is 6 to 8 months. In that time, patients need to take steps to care for their transplanted hair properly and also protect their scalp from the sun and other outside influences. Recovery after FUE procedure is usually smoother with minimal to no pain after the procedure. Also, there is no linear scar on the donor area.

Results

Patients need to follow the post-op instructions from their doctor in order to facilitate the results that should last a lifetime. The surgeon will inform patients what to expect after their procedure depending on the location of balding and the number and type of grafts that were used. Early results are seen within the first 3 to 4 months but most patients should expect to see their full results in six to twelve months.

  • Before-FUE Pt 2
    After-FUE Pt 2
    BeforeFUE Pt 2After

Male pattern baldness is usually a progressive condition so there might be more hair loss and a need for one or more procedures in the future for some people. Patient who are prone to advanced stages of hair loss can slow down the process by taking finasteride or minoxidil. Both of these medications help maintain the native hair of the patient.

Complications

It’s important to remember that a hair transplant is a skin level procedure. As such, patients generally see minimal complications following their surgery. The following is a list of complications patients should be aware of:

  • Post-operative hiccups
  • Swelling of areas near the transplanted hair such as the scalp and forehead
  • Itching
  • Hair thinning, AKA “shock loss“, which is a side effect where patients lose their native hair after hair transplant due to the stress of the procedure
  • Folliculitis – These are pimple-like skin lesions that can be seen in the transplanted area
  • Scaring in strip procedures – In FUE procedures, scars are small and scattered and they are usually not detectable even if the patient shaves his head

If you have any questions or concerns about the above complications, talk to your doctor before making the final decision of which transplant procedure to undergo.