What are hair transplantations?
Hair transplantation is a procedure in which hair is removed from permanent hair-bearing regions in the rim hair of balding individuals (the “donor” area) and transferred to bald or balding areas of the scalp (the “recipient” area). After initially falling out, the transplanted hair regrows and will continue to grow in the new area for as long as it would have grown in the area from which it was taken. It also has the same color and other characteristics as the hair in the donor area from which it was taken.
Usually, only one of the following three areas can be treated during any session: the frontal area extending from the hairline to a line drawn more or less vertically from the ears; the mid-scalp area extending from that point to the point on the scalp where the head changes from being more or less horizontal to the ground to a more vertical orientation; and the vertex area or “crown,” which is the balding area furthest back on the scalp.
How are hair transplantations performed?
Most hairs emerge from the scalp in groups of two or three hairs. Approximately 15 percent of hairs emerge as single hairs and another approximately 15 percent in groups of four or five hairs. These small groupings of hairs are called Follicular Groups or Follicular Units (FU). FUs are the building blocks of most modern hair transplanting. They are typically obtained by sectioning, with the aid of a 6X-10X magnifying “stereomicroscope,” an 8mm to 10mm wide strip of skin that is excised from the donor area. The most important advantage of transplanting exclusively with Follicular Unit Transplanting (FUT) is that a single session in an area that is bald or destined to become bald will result in a perfectly natural appearance. The donor site is sutured closed leaving only a narrow scar when the wound is completely healed in seven to 10 days. The donor scar also is usually excised within any subsequent transplant donor strip(s), so only a single scar is present in the donor area no matter how many transplants are carried out.
Small incisions are made in the recipient area using either small bore needles or blades. The angle and direction of the incisions mimic that of the hair that was originally present in the area. Once the grafts have been prepared, they are carefully transferred into those sites. Usually all of the transplanted hairs will initially fall out within a period of two to three weeks. Approximately, two to three months later, they regrow in the recipient area.
Hair transplanting is most commonly performed for Male Pattern Baldness (MPB) and Female Pattern Hair Loss (FPHL). However, it also can be used to produce hair in scarring secondary to surgery, trauma or burns. A relatively new technique referred to as Follicular Unit Extraction (FUE) skips the removal of a strip from the donor area. A small, round punch similar to a small cookie cutter is used to excise each individual FU directly from the donor area. It has the advantage of avoiding the production of a linear scar in the donor area but is more time-consuming, expensive and more likely to result in injury of the FUs. Nevertheless, it is advantageous for some patients (e.g., those who have very tight scalps or who have a tendency to healing with bad scars). It may also prove to be an effective way of removing hair from the body and transferring it to the scalp. FUE is not recommended at this time for routine hair transplanting by most practitioners because of the drawbacks noted earlier.
Although most hair transplanting today is carried out using only individual FUs, there are some advantages in using grafts containing more than one FU in some individuals. Transplanting with grafts that are larger than a FU requires multiple sessions in the same area to produce adequate naturalness; however, one can achieve greater hair density than is possible with FUT.
What to expect after the procedure
Initially, there are small crusts on the recipient sites. These fall off usually within three to 10 days. Post-operative pain is nearly always completely controllable with relatively mild pain killers such as Tylenol 3, Vicodin or Percocet. Such pain killers are usually necessary only for the first one or two nights after the procedure. Temporary mild-to-moderate swelling of the forehead usually occurs approximately two to three days after the operation and lasts for three to seven days. Approximately one out of every 50 patients has no swelling and one out of every 50 patients has severe swelling that may cause “black eyes” that last for seven to 10 days.
Complications that can occur
As with any surgical procedure, there can be post-operative bleeding or infection, but both of these are extremely rare occurrences and are easily controlled. If the grafts are not handled properly, if too many are transferred in a single session or if the grafts are planted too densely, an unacceptable percentage of the transplanted hairs may not grow. If reasonable numbers of grafts and reasonable graft density is employed, hair survival should be between 90 and 100 percent. There are other complications that can occur, but they are even less frequent than the preceding ones and virtually all of them are easily treated.
Questions to ask your dermatologic surgeon
Ask how many procedures he/she has carried out and over how many years. What medical training has he/she had and to what medical educational organizations does he/she belong? Most serious hair restoration surgeons belong to the International Society of Hair Restoration Surgery. The American Board of Hair Restoration Surgery certifies those who have passed oral and written exams designed to evaluate safety and (to a lesser extent) aesthetics. Ask whether the surgeon excises the donor strip and whether he/she makes all the recipient sites or whether other members of the surgical team carry out these aspects of the procedure. Ask who inserts the grafts. Ask to see before-and-after photographs of many patients. The photographs should always show the patient before and after treatment with their head in the same position, at the same distance and with the same lighting. Close-up photographs of the hairline after transplanting are also important to see.
For more information and referrals
For more information on skin conditions and treatments, along with a list of ASDS members in your state, please visit the Find a dermatologic surgeon section of our website.