What Is a Hair Transplant?
A hair transplant is a minor Surgical Hair Restoration where healthy areas of skin, hair, and roots are transplanted from the sides or back of the head (the donor area) to bald or balding areas of the scalp of the same person (the recipient area). The transplanted hair will generally continue to grow permanently because it is taken from an area where the hair roots were never programmed to fall out. The hair transplant graft always retains the same characteristics as it did prior to the procedure. It will even turn gray as you age.
In the past the areas from which the hair had been taken were allowed to remain open and heal naturally, creating a pegboard effect in the donor area. Today’s donor areas are sutured closed and healed with thin scars in most cases.
Donor areas are chosen to match as best as possible the type of hair that should grow in the area being transplanted. For example, hairline hair is generally taken from the lower sides where the hair is finer and will help feather the front.
Does It Hurt?
The answer is – it depends on your doctor’s technique and skill in numbing along with your own tolerance for any pain.
Patients are given the option for Nitrous Oxide (laughing gas) while the local anesthesia is applied. This is usually the only discomfort you will feel during the procedure and lasts only a few minutes. At The New York Hair Loss Center, we use a computer-assisted anesthesia delivery system that dramatically reduces any patient discomfort that may arise in the first few minutes of surgery. Once numb, you will hear funny noises (the scalp conducts sound) but will feel no pain. Long-acting anesthesia really helps to prevent the wear-off ache and makes the transplant very comfortable at night.
When Will the Hair Grow?
All scalp hair grows in a growing phase (anagen) and in a resting phase (telogen). Every hair on our heads replaces itself every six years. Think of the resting phase as a three-month hibernation cycle where the follicle is alive under the skin but there is no cosmetic hair produced. After its three-month dormancy, the follicle once again produces a new cosmetic hair.
Certain factors will throw growing hair prematurely into a resting phase. Any type of minor trauma, such as surgery, will fool the follicle into an early three-month resting cycle. This is no different than moving a flowering plant from one soil area to another. The plant roots survive, but the flower may not.
Transplanting hair temporarily interrupts blood supply and thus will cause the growing hair to shed. As such it’s not unusual for patients to call frantically telling me that the transplant didn’t work because the hair fell out. In fact, the hair only temporarily falls out and the root remains in a three-month resting phase. The new hair then begins to grow and will resume its old genetically programmed cycle.
And no, they don’t all fall out every six years.
The smaller (or narrower) transplant grafts will grow quicker because they heal faster. But this is only thin frontal hair and the patient should assume then the best is yet to come. So to answer the question directly – new hair growth will start in two to four months in general. For some reason, it starts quicker in the front than in the back (crown), and the more transplant sessions you have, the longer it takes for the subsequent transplanted hair to begin growing.
Do hair transplants work?
Hair restoration products are much more likely to succeed than over-the-counter hair restoration products. However, there are several things you should know about hair transplants: Around 10 to 80 percent of the transplanted hair will grow back in 3 to 4 months, according to Trusted Source. The transplanted hair will thin with time just as regular hair does. Although a 2016 study in Trusted Source discovered that plasma therapy may help up to 75 percent of the transplanted hairs regrow hair, it doesn’t work for everyone. Hair transplants don’t work for everybody. If you’re losing hair or balding naturally or have lost hair as a result of an accident, a hair transplant might be able to restore it. A hair transplant procedure is usually done using your existing hair, so it isn’t as suitable for treating people with widespread thinning and baldness, chemotherapy or other medications, or thick scalp scars resulting from the injury.
How is a hair transplant performed?
Simply put, a hair transplant moves hair from a location where you don’t have hair to a spot where you do. Typically, hair is removed from the back of your head, but it can also be removed from other areas of your body. Before the operation begins, your surgeon sterilizes the region where the hair will be taken and anesthetizes it with a local anesthetic. You may also request to be sedated in order to remain asleep throughout the procedure. Two transplant techniques are used, FUT and FUE.
What Was a Plug?
A plug is a circular hair transplant graft taken from a donor area (usually made by using a power tool) and transplanted to a prepared circular site on the top of the balding scalp.
It’s called a plug because a slightly larger graft is “plugged” into a smaller bald site, which can cause a thick, tufted result. Since the plugs are slightly separated from one another, the result was the often described cornrow effect. Different size circular “plugs” were inserted between the prior healed or growing ones, but there was always a small space between the grafts making them noticeable, especially in dark-haired patients with contrasting light-colored skin.
Generally, plugs were very large in diameter and would contain fifteen to twenty hairs. The typical procedure would require three or four visits of about one hundred plugs each in a very bald gentleman.
Hair was usually styled to the side to cover the hairline and any of the plugs in the center of the bald area which were always spaced further apart than those on the hairline or frontal region. In the past patients were told, “Look it’s not perfect, but at least you have hair.”
There were two schools of thought in the past. Some doctors believed that only twenty to thirty plugs should be transplanted in each (of multiple) sessions. Others felt that larger sessions were better for the patient and the result because circulation, and therefore, subsequent growth lessened with multiple procedures.
What Are Slit Graft Transplants?
Slits grafts were the first real attempt at avoiding the plug look. In essence, they were simple cuts made in the bald area into which we inserted small strips of hairs and their roots. The problem, of course, is that no bald tissue is removed and thus, like trying to lay too much carpet in a room, you will eventually get buckling (or in some cases pitting) to accommodate the extra tissue. This is called the carpet effect. When a person has only thinning hair (as in female pattern hair loss) slit grafts can be useful because they add hair without removing the surrounding thinner hair. But let me emphasize that if an area is balding significantly, slit grafts can look worse than the old plugs because they can look like little tufts or hair coming from beneath the surface of the scalp.
What Are Single-hair Transplants and Mega sessions?
Single-hair transplanting is the attempt to once again avoid “plugs” and thereby create a natural result. In this procedure, large numbers of single-hair grafts, sometimes even several thousand, are made from strips of hair removed from one’s donor area and are individually inserted into the top of the scalp. These mega sessions can take up to twelve hours each. The benefit of this type of session is that the result looks natural, but as several patients have asked me, “Where’s the hair?”
Mega sessions usually create a thin result, and often, the patient is fooled into believing that one giant session will solve their whole problem.
What About the Donor Area?
Well, years ago, surgeons let the donor area close on its own, leaving small white scars where the hair was removed.
This pegboard effect could only be noticed if you lifted the hair in the donor area or if the hair was shaved closely. By the late 80s, surgeons started closing the donor area with sutures. This seemed to work because everyone has more skin than they need in the back of the head and suturing it closed seemed easy. The problems began with the big sessions where wide strips of hair were removed. In these cases, the closure was under tension, and the results were wide scars that we later had to revise.
Most doctors today know that too wide a strip of a donor’s hair is a problem and thus would rather take a donor strip that’s longer and thinner. By doing this, we are reducing the tension on the wound and allowing it to heal rapidly and with the thinnest of scar lines.
Will the Doctor Remove the Old Scars from the Donor Area?
Another valuable question to ask when interviewing a physician who may perform your procedure is, does he remove the old scars? By this, I mean that a good physician will usually incorporate the scar of the precious donor area in the very corner of the next donor strip he removes. By doing this, when your transplant sessions are finished, you should wind up with only one thin scar in the donor area.
What if I Had Previous Transplants and My Donor Area Was Taken the Old Way?
Even if your donor area was plucked thoroughly and left with circles or no hair, we can now harvest (the medical term for removing) strips of the donor. We simply use good hair and discard the scars. We then cleanly sew the donor area back together and the result usually looks as good if not better than before you took the strip. The trick, once again, is long and narrow when removing the donor strips.
Is the Procedure Safe?
Part of interviewing your prospective doctor should include questions about instruments and sterility. Your doctor should have a hospital-type autoclave (sterilizer) and should have special disposal systems for medical waste.
The doctor and his technical staff should all have current Federal Occupational Safety Hazard Association (OSHA) certification and training.
A hair transplant is a clean procedure (hair can’t be sterilized) but all instruments must be! Ask for a tour of your doctor’s lab and ask to speak to one or several of his assistants. Do not be shy here! We all want hair, but we want it safely.
Now we use a form of laser technology to seal bleeding vessels in the donor area and then suture the area closed. This virtually eliminates the problem.
The recipient area rarely has any bleeding unless an accident occurs, and bleeding here is easily controllable with pressure.
The scalp rarely gets infected. Old military manuals (circa the 1950s and 60s) will advise medics that they don’t even need gloves to sew up or treat scalp injuries. This is because the scalp has such a good blood supply that the body’s defenses easily prevent infection from setting in. Today, doctors all wear gloves as protection for both the patient and the physician.
Infection after a hair transplant is rare. We always place patients on preventative antibiotics after treating them and have them return for a follow-up in seven to ten days. We encourage them to call with questions and if in doubt, bring them into the office for a checkup.
Placing aside bleeding and infection, a poor result can be the biggest risk in hair transplantation. The most common problems that I see are as follows.
Lack of Density
In their quest for a more natural result, many doctors have swung the pendulum too far and have decided to use only micrografting. This may be suitable for those who are looking for a thin, yet more natural result, but it can be devastating for those who expected a good amount of hair and wound up paying thousands for a “see-through” look. Fortunately, lack of density is usually treatable.
This is usually the product of old transplant procedures or inexperience. It generally involves doctors forgetting that hairlines don’t go from desert to forest. We all have a little buffer zone and this is what makes the hairline look natural. Because of new technology, this is an easy correction.
One of the big complications with the old plugs was the elevation of the individual grafts (actual bumps). This occurred because the grafts were always a bit larger than the receptor sites and thus they would not fit flush. Instead, they would bulge like a cobblestone street. People with prior transplants with bumpiness can be helped now.
Hair that has been transplanted may not always grow with the same texture as the area from which it has been taken. This was especially true during the “plug” era where larger circular plugs of hair and their roots were placed into sites that were narrower in diameter. This acted to squeeze the tissue tighter and caused the resulting hairs to grow frizzy. Much of this problem stopped when grafts stopped being condensed into smaller sites.
This was definitely a function of the old round plugs. Some patients would develop a thin white circular area. Although this did not matter as much in areas of the scalp hidden by hair, it did matter when it occurred along the hairline.
Today’s transplanted grafts rarely have this problem. In the case of prior ones which do, single-hair grafting or linear grafting through the white borders effectively eliminates the problem.
Misdirected Hair Grafts
Hair grows in specific directions on the front and vertex (crown) of the head. It is vital that transplanted hair grafts be directed to follow these directions.
Transplanted Grafts Spaced Too Far Apart
One of the biggest mistakes of the inexperienced transplant surgeon is placing the transplanted hair grafts far apart in an effort to cover more area. This is a real problem because once a fair number of grafts are placed in a bald area, the patient is committed to finishing the transplant in that area. Now we run into the problem of filling in the in-between areas to make them look acceptable and this can be a devastating task.
So if you are fairly bald, concentrate on finishing the front half first. This way you are assured of a completed result in that area rather than a half-complete job over the whole bald scalp.
You can’t transplant a tree by breaking off a branch and sticking it in the soil. Similarly, you can’t transplant hair by moving the shafts and not the roots – they won’t grow.
The most common cause of poor growth is technique. If a doctor removes the donor area properly, he should have taken the hairs out at the proper angles to preserve the roots. If he ignores the fact that hair grows at different angles from the scalp and that the roots are parallel to the shafts of hair, he can transect the roots causing little or no hair growth.
Having the grafts placed too close together can also cause poor growth. Blood supply initially feeds the grafts and promotes growth, but too many grafts in too small an area can decrease the hair yield per graft. This can also happen when a patient has transplant sessions very close together, not allowing enough time for healing and proper return of the blood supply.
Does the Transplant Hair Always Take and for How Long Will It Last?
This question is as common as “Does it hurt?” The answer is, if done properly by an experienced physician, it will generally always take and will grow for the rest of your life plus two weeks (hair and nails grow for two weeks after we depart). Remember, the hair lasts as long on the same person in the new area as it did where it came from. So if the donor area was selected properly, it will continue to grow in the previously bald sites.
Who Is a Candidate for Hair Transplant Surgery?
When I talk with a prospective patient I often investigate the following.
- What are his concerns about his hair loss?
- What are his expectations?
This is important because a person with a good donor area and a reasonable amount of hair loss may be a bad candidate if he expects unrealistic results.
A good candidate is someone who is realistic about his goals based on his existing pattern of hair loss and remaining hair density. He or she understands that it will take time for the hair to grow and is willing to undergo several sessions if necessary to achieve the desired result. Hair transplantation is an art as well as a science, and art takes time and work. If the patient is young, a good candidate will allow the hairline to be a bit higher (in case of extensive baldness occurring in later years) and will understand that future sessions may be needed if further hair loss occurs. The doctor and the patient are a team. Both should be patient and available to work together to achieve the desired result. Knowing this makes for a good candidate.
Are My Activities Restricted Before My Hair Transplant?
Prior to having a transplant, there are several general precautions that most doctors will take. Further specifics are usually given prior to the transplant procedure. Typical preoperative instructions include the following.
- Do not get a haircut prior to a transplant because any trimming required will be done by the hair transplant technician. If the hair is cut too close, the doctor may not be able to determine where to put the transplants. Also, shampoo your hair well as close to the hair transplant time as possible. Even though we will place an antiseptic on the ear, it’s nicer to start with a clean scalp.
- Eat a good meal during the day, but do not eat or drink anything within one hour prior to the scheduled transplant. This is because hungry people are more nervous. The one-hour period not to eat is to prevent nausea during nitrous oxide anesthesia.
- Do not exercise twenty-four hours prior to transplant. Exercise tends to raise blood pressure temporarily. This usually increases the chance of bleeding during the procedure.
- Wear a shirt which buttons rather than a pullover as your head may have a small dressing. If you have a hairpiece, you will not be able to wear it until the second day.
- It is important that no alcoholic consumption takes place within forty-eight hours of transplant surgery. Alcohol interferes with your blood platelets and slows down the clotting process.
- Do not take any aspirin or aspirin-containing products for the same reason you shouldn’t drink alcohol.
- Don’t forget to write down your questions for the doctor before the procedure. This is because nervousness may make you forget to have your concerns answered at the time. Write the answers down so you will remember them.
Are My Activities Restricted After My Hair Transplant?
The biggest restrictions after a transplant involve no heavy physical activity for five to seven days. This is usually the most contested instruction, as most people feel fine after the procedure. Nevertheless, the first place that gets robbed of circulation when you’re active is the skin and scalp. Blood gets diverted to the muscles; blood pressure rises, and people bang their transplanted area. Any surgery, even minor, requires rest afterward, this is no different.
Don’t drink alcohol or take aspirin for forty-eight hours for the same reason as before.
Postoperative medicines are prescribed, and in some cases, such as with tetracycline and/or minoxidil with Retin A, they can restrict your ability to go out in direct sunlight.
Do not pick at the scabs – let them fall off. Extreme care must be exerted so that your comb or brush does not catch on the scabs during the healing process. You may shampoo your hair on the third day. While shampooing, use only your fingertips. Vitamin E oil can be applied at night to help promote healing after two weeks.
You can generally return to work in two or three days, but if the work requires heavy lifting, accommodations should be made.
In my experience, at the end of seven to ten days, there are no further restrictions. The patients can resume all their prior activities in full. Now begins the waiting game, but rest assured, if your procedure was performed by a competent surgeon and you’ve followed his instructions, your hair will grow.