Hair Transplant Q&A
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Q: My hair is fine. Is that a problem for a hair transplant? W.S., – Manhattan
A: Fine hair will give a thinner look than thicker hair, but will look completely natural. Thin hair doesn't prevent one from having surgical hair restoration, providing your donor density and scalp laxity are adequate. These would need to be measured.
Q: This is my second hair transplant surgery and it seems like it is growing more slowly than my first. Is this normal? H.S.,– Brooklyn, New York
A: It is common for a second hair transplant to take a bit longer to grow than the first, so this should be expected. It is also possible that there is some shedding from the procedure, or a continuation of your genetic hair loss. Propecia may be helpful in this regard. It is important to wait at least a year for the hair transplant to grow in fully and to give a chance for any hair that was shed to regrow.
Q: I had a hair transplant two weeks ago and I just started noticing that some grafts were in my baseball cap at the end of the day. Am I losing the transplant and what can I do to keep this from happening? Z.K. – New York, N.Y.
A: The follicles are firmly fixed in the scalp 10 days following the hair restoration surgery. Hair is shed from the follicle beginning the second week after the procedure. This is perfectly normal and does not represent any loss of grafts. What you are seeing is the root sheath that is shed along with the hair shaft. This looks like a little bulb, but is not the growth part of the follicle and should not be a cause for concern. Two weeks following the hair transplant surgery you may shower and shampoo your scalp as you normally did before the procedure without any risk of losing grafts.
Q: Should I cut my hair prior to the hair transplantation? GK, – Long Island, N.Y.
A: It is easier for the hair transplant surgeon and his team to work when the existing hair in the area to be transplanted is cut short, but a skilled surgeon can work well in either situation. Most experienced surgeons are used to working without cutting the hair in the recipient area, since so few patients want their hair to be cut – particularly in New York.
The main advantage of having a closely clipped scalp is that one has better visibility and therefore the hair replacement procedure moves along faster. This has little bearing in moderately sized sessions, but becomes very important in sessions over 2,400 grafts, when working through existing hair can make the duration of the hair transplantation procedure excessively long. Of course, the disadvantage of clipping the hair is that it is more difficult to “hide” the procedure.
I prefer for the patient to arrive the morning of the scheduled hair restoration surgery with his/her hair having some length so that I can better see the demarcation of the area of thinning. Once the area is marked, the hair can be clipped to the appropriate length in the OR. Although hair transplants will be more visible post-op if the hair is clipped short, it is much easier for the scalp to be kept free of crusts.
It is important to differentiate between a closely clipped scalp, which is an advantage, and a shaved head, which makes performing the hair transplant surgery more difficult. When there is some existing hair, the distribution and angle of the original hair is easy to discern and this allows the new grafts to be placed in a direction that follows the existing hair and in a distribution that complements that hair.
Q: How are recipient sites made during a hair transplant? L.F. – Manhattan, New York
A: At Bernstein Medical, we use a series of custom made, ultra-fine blades to create recipient sites for hair transplants. The blades differ in size by only one tenth of a millimeter and range from 0.6mm for one-hair follicular units to 1.2mm for 4-hair follicular units. At the start of the hair replacement procedure, the different size follicular units are fitted to specific site sizes to determine exactly the best size instrument to use for each graft. By custom fitting the sites to the grafts, healing is incredibly fast and patients are able to gently shampoo their scalp the day following the procedure. All recipient sites are made using lateral slits, as these give the most full, natural coverage.
Q: How did Follicular Unit Transplantation and Follicular Unit Extraction get their names? L.G. – Long Island City, New York
A: The first paper on Follicular Unit Hair Transplantation was published by Dr. Bernstein and Rassman in 1995 in the International Journal of Aesthetic and Restorative Surgery. The title of the paper used the abbreviated name Follicular Transplantation. The longer name “Follicular Unit Transplantation” was formalized by Bernstein et. Al. in the paper “Standardizing the classification and description of follicular unit transplantation and mini-micrografting techniques.” This paper appeared in Dermatologic Surgery in 1998. Follicular Unit Extraction derived its name from Rassman and Bernstein’s publication “Follicular Unit Extraction: Minimally invasive surgery for hair transplantation” that appeared in Dermatologic Surgery in 2002.
Q: If my hair is just starting to thin, when should l have my first hair transplant? J.K. - New York City
A: It is best to wait until at least twenty-five before considering surgical hair restoration, although there are exceptions. The most important thing is to wait until you have hair loss that is a cosmetic problem. Hair transplants are a treatment for hair loss – they should not be used as a prevention; that is what medications are for. Some hair loss in the temples is normal for a person in their mid- to late 20s as this represents the progression to a normal mature adult hairline. The hair loss needs to be significant before you should contemplate surgery. This issue is detailed in the publication Follicular Transplantation: Patient Evaluation and Surgical Planning.
Q: After a strip procedure, will the scalps laxity return to normal and how long after the hair transplant does it take? L.L. from Queens, NY
A: Following hair transplantation, the scalp regains most of its laxity in the first eight months, but it will continue to loosen slightly after that. It is interesting that if the scalp is tight prior to hair replacement surgery, the scalp is less likely to have its full laxity return than in patients who had loose scalps to begin with. With average or loose scalps, there is usually no difference. However, over time, the patient rarely, if ever, notices any permanent tightness, unless aggressive procedures have been performed or procedures such as scalp reductions and lifts.
Q: Can you get your original density back with a hair transplant? A.J. – New York, NY
A: Although the cosmetic benefit can be dramatic, a hair transplant only “moves” rather than creates new hair. In hair restoration surgery, a limited amount of hair from the donor area is transplanted to a much larger area in the front and top of the scalp, so that we can never reach the original density. Achieving a cosmetically appropriate density in the front part of the scalp (which is around 1/3 to ½ of the original) generally takes two sessions and is the goal of most hair replacement surgery. Lower densities are used towards the back of the scalp.
Q: I understand that even if you have multiple hair transplants you will only be left with one scar in the donor area. A.J – New York City
A: If the closure is performed by the hair transplant surgeon without tension, each procedure should result in the same fine scar. The best-placed incision is in the mid-portion of the permanent donor area. Since there is only one mid-point, there is one best position for the scar. All incisions should lie on this plane leaving one scar.
Q: Can you perform a hair transplant into scar tissue? A.H. – Rockland County, New York
A: Yes, hair grows in scar tissue, but not quite as well as in normal tissue. The scar is not as elastic as normal tissue so the grafts are at slightly higher risk of being dislodged; therefore, more care must be taken to protect the grafted area after the hair transplant surgery. In addition, the blood supply in scar tissue is less than in normal tissue, so that area should not be transplanted as densely and the hair replacement should be performed over multiple hair transplantation sessions. Finally, grafts do not grow well in thickened scars. If a scar can be thinned using injections of cortisone, it may improve the chance that the transplanted hair will grow.
Q: I have not seen any research in the medical literature that indicates to me that cloning is close at hand. Am I missing something? GL – New York, NY
A: Possibly the most interesting work related to cloning hair was done by Colon Jahoda in England. Jahoda's work is significant because he identified an inducer cell i.e. fibroblasts in the outer portion of the hair follicle (the outer root sheath) that can stimulate the skin to produce new hair. It is well known that fibroblasts, unlike many other tissue cells, are relatively easy to culture. Theoretically, a patient's fibroblasts could be removed from the sheaths of just a few follicles and then cultured to produce thousands of follicles. These fibroblasts could then be injected back into the scalp to induce thousands of new hair follicles to grow. In the study fibroblasts from a man were injected into the forearm of genetically unrelated women. The cross-gender aspect of his experiment has received much publicity and is of potentially great importance to burn victims etc., but has little relevance to hair transplant procedures for male pattern baldness, as patients would probably benefit most from using their own cultured fibroblasts to achieve the best match. So far this important single study has not been reproduced.
Q: What is graft compression? J.J. – Brooklyn, New York
A: Graft compression refers to a tufted look resulting from the contraction of grafts caused by the normally elastic skin that contracts around the graft as the hair transplant heals. This was a common occurrence with mini-micrografting where 5 or more hairs from two or more follicular units were placed into one recipient site. With follicular unit hair transplantation, follicular units won’t show visible compression since they are already naturally compact. One reason why FU’s are valuable in a transplant is that they are compact enough to fit into a very small site. It is important, however to “customize” the site size to the size of the graft so the fit is just perfect. This speeds up healing, enables the patient to shampoo the day after the hair restoration surgery, and enhances graft growth.
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Q: What is Follicular Unit Transplantation and how is it different from Follicular Unit Extraction? J.B. – New York, NY
A: Follicular Unit Hair Transplantation, called FUT for short, is a procedure where hair is transplanted in the naturally occurring groups of 1-4 hair follicles. During this type of hair transplant, these individual units, or groups of hair, are dissected from a single donor strip using a stereo-microscope. The area where the donor strip was removed is sutured closed, generally leaving a thin, fine, line scar. In Follicular Unit Extraction, or FUE, the individual units are removed directly from the back or sides of the scalp, through a small round instrument called a punch, so that there is no linear scar. There is, however, scaring from the removal of each follicle. Although the scars of FUE are tiny and round, the total amount of scarring is actually more than in FUT. In addition, since in FUE, the bald skin around each follicular unit is not removed, the total amount of hair that can be removed in FUE is substantially less than in FUT. This is because if one were to remove all the hair in an area, it would be bald. In FUT, the intervening bald tissue is removed along with the follicles in the strip. The pros and cons of each surgical hair restoration procedure can be found at the end of the section entitled Follicular Unit Extraction.
Q: What are your thoughts on performing hair transplants to the crown first? P.K. – Staten Island, N. Y.
A: It depends upon the person’s age, how bald he is likely to become, and the donor supply. As a general rule, the crown should not be transplanted in a younger person (under 30) as the extent of his balding is hard to predict and crown thinning at this age often suggests that the person will become at least a Norwood 6. If a person has enough donor hair, i.e. good donor density and scalp laxity, so that coverage of the entire bald area can be accomplished if the patient becomes a Norwood class 6 (and it is unlikely that he will become a Class 7) then transplanting the crown before the front is reasonable. If a person has a family history of baldness limited to the crown, even at an advanced age, and the person in question is following this pattern, then earlier treatment of the crown may be considered. Lastly, if you do treat the crown in a younger person, or in whom the extent of hair loss is uncertain, the crown should be transplanted with light coverage only so that just a limited amount of hair will be used up in this area and there will be enough left over for the cosmetically more important top and front of the scalp. For a complete review of this topic please read: Follicular Transplantation: Patient Evaluation and Surgical Planning. Dermatol Surg 1997; 23: 771-84. A copy in PDF format can be downloaded at our Medical Publications page.
Q: Does dense packing hurt grafts? G.B. – NYC, New York
A: There is no absolute answer to this question. In hair transplants, dense packing has a risk of decreasing yield if there is a significant amount of photo damage to the scalp (which alters the blood supply) and if there is a tendency for the grafts to pop (this is difficult to predict pre-operatively). Very closely spaced grafts exacerbates the popping and exposes the grafts to desiccation (drying), hypoxia (lack of oxygen) and mechanical trauma from the necessary re-insertion. That said, the skill of the hair restoration doctor and placing team, the size of the recipient sites, and the way the grafts are dissected and trimmed all play important roles in determining graft survival in dense packing.
Q: When harvesting donor hair, how does the hair transplant surgeon know when to stop? B.A. – New York City
A: First, the hair transplantation patient must decide the shortest length he/she is comfortable wearing his/her hair. Additional hair can be removed, whether through FUT or FUE, as long as, at this length, the back and sides do not look too thin (i.e. do not have a transparent look) and the scalp and donor scars are not visible. The surgeon needs to use his judgment when harvesting, so that this endpoint is not crossed. Additionally, the surgeon must anticipate that the caliber of hair in the donor area will decrease slightly over time as a normal course of events.
Q: Is it possible to have a hair transplant that is totally undetectable immediately following surgery? M.Z. – New York, N.Y.
A: Not unless a person has a fair amount of existing hair that can cover the transplanted area. Although surgical hair replacement techniques have improved dramatically over the past ten years, and wounds are so small that patients may shower the morning following the procedure, a hair transplant will be detectible for the first week. During this period, there may be some swelling that settles down on the forehead and some crusting and some residual redness. Please visit our section entitled After Your Hair Restoration for more details on the normal post-op course following a hair transplantation.
Q: When a second hair transplant is performed, should there be a second incision or should it be incorporated into the first? J.B. – Bronx, New York
A: It is a very common practice to make a second separate scar in the second hair replacement procedure. This is done to maximize the hair in the second session and is the easiest technically to do. If you incorporate the old scar in the new incision, there will obviously be less hair. As long as the upper incision is still in the permanent zone, the hair quality will be good. That said, in my practice I almost always use only one scar during hair transplants that I perform. The subsequent procedure would incorporate the first and extend the scar to one side or the other (or both). I generally use the old scar as one edge of the new strip so that there is only one incision into virgin scalp (rather than two). There are a number of reasons for this hair transplant surgery technique.
1. The hair will always be taken from the mid-portion of the permanent zone, so we utilize the thickest, most stable hair.
2. A line scar in this location is generally the least visible and most easily camouflaged with the persons existing hair.
3. One avoids making a scar too low that increases the risk of widening the scar.
4. One scar will be easier to camouflage with FUE (if this is ever necessary).
Q: What is “shock fall out”? J.S – New York, NY
A: Shedding after a hair replacement procedure is also referred to by the very ominous sounding term “shock fall out.” The correct medical term is "effluvium" which literally means shedding. It is usually the miniaturized hair i.e. the hair that is at the end of its lifespan due to genetic balding that is most likely to be shed. Less likely, some healthy hair will be shed, but this should re-grow. Interestingly, if hair transplants are spaced less than one year apart, one often notices some shedding of the hair from the first transplant, but this hair grows back completely. For most patients, effluvium is not a major issue and should not be a cause for concern.
Typically, when shedding occurs, a patient looks a little thinner during the several month period following the transplant, before the transplanted hair has started to grow. The thinning is often more noticeable to the patient than to others. Shedding is generally noted as a thinning, rather than of "masses of hair falling out," as the term "shock fall out" erroneously suggests.
In general, the more miniaturization one has and the more rapid the hair loss, the more likely shedding will be from the hair replacement surgery. Young, actively balding patients would be at the greatest risk. Older patients with stable hair loss would have the least risk. In either situation, since miniaturized hair is eventually going to be lost, the effluvium has no long-term effect on the outcome of the procedure.
It is important to differentiate the phenomena described above from shedding of the hair in the graft. This shedding is an almost universal characteristic of a hair transplantation procecure and occurs because during a hair transplant a graft is temporarily stripped of its blood supply. As a response to this insult, the graft sheds its hair. This shedding is generally noted beginning a week following the procedure and can continue for up to six weeks. A very small percentage of patients do not shed and the transplanted hair continues to grow. In others, the transplanted hair remains on the scalp for months until a new hair pushes it out. Whether a patient sheds or not has no bearing on the ultimate outcome of the surgical hair restoration.
There are a number of ways to minimize the effects of post-operative shedding: the first is using medication, the second is timing the transplant properly, and the third is performing a procedure using a sufficient number of grafts.
• Medication
Finasteride 1mg reverses or halts the miniaturization process in many individuals and is thus the logical way to decrease the risk of shedding following hair transplantation. Although many physicians have had the clinical impression that this assumption is correct, there has been no controlled studies to date that prove this.
• Timing and the size of the hair transplants
It is important to wait until a patient is ready to have a hair transplant, and then to perform one of sufficient size so that if there is some shedding, the procedure will more than compensate for it - and thus be worthwhile. A problem that patients often run into is that they present to their doctor with early hair loss but with a significant amount of miniaturization. The hair restoration doctor performs a small procedure and it does not even compensate either for potential shedding or for progression of the hair loss. The result is that the patient is thinner (or more bald) than he was before the procedure. The doctor rarely blames the problem on the fact that the hair replacement procedure was too small or that the miniaturization was not taken into account, but only that the patient continued to bald. The better solution is to treat early hair loss with medication, but once you make a decision to begin hair restoration surgery, have a procedure large enough to make a significant cosmetic improvement.
As a final point, it is a fallacy that some doctors’ techniques are so impeccable that they can avoid effluvium or those “small” procedures will avoid shedding. Of course, bad techniques and rough handling will maximize effluvium, but effluvium is what hair naturally does when the scalp is stressed and it is stressed during a hair transplant from the anesthetic mixture and the recipient site creation. It is important to note that it cannot be totally prevented. Despite claims to the contrary, Follicular Unit Extraction has no bearing on this process as it is a harvesting rather than a placing technique.
In sum, the best way to deal with effluvium is to treat with Finasteride when hair loss is early, perform a hair transplant only when indicated and finally, to perform a hair transplantation procedure with skill and to use a sufficient number of grafts.
Q: Can you use beard hair for a hair transplant using Follicular Unit Extraction? A.H. – Rochester, New York
A: It is possible to use beard hair for hair transplants, but there are three main differences between harvesting from the donor area and harvesting from the beard that should be taken into account. These are: 1) scarring 2) ease of extraction and 3) hair quality.
In FUE, although there is no linear scar, there are small white round scars from where the hair is harvested. Normally these marks are hidden in the donor area and are not visible, even if the hair is clipped very short. However, if the scalp is shaven, these marks will become visible. When the beard is used as the donor source for the hair transplant, the patient must continue to wear a beard after the restoration, even if it is tightly cropped, or the faint white marks will show. The tiny round scars from FUE will generally be visible on a clean shaven face. As each person heals differently, we would perform a test before doing the actual hair replacement procedure to make sure the marks from the extraction are not noticeable at the length that the person wants to wear his beard.
FUE performed on beard hair also differs from the scalp because of the greater laxity of facial skin. This makes extraction with minimal transection more difficult in some cases. A test prior to the hair transplant is particularly important in beard FUE so that the ease of extraction may be determined in advance.
Third, beard hair is coarser than scalp hair. Although the hair seems to take on some of the characteristics of the original hair in the transplanted area, this change is not complete, making beard hair an imperfect substitute for scalp hair. A solution to the problem is to use beard hair behind the hairline for volume and scalp donor hair at the hairline for naturalness.
Q: Should one stay on Propecia after a hair transplant? L.D. – New York City
A: Yes. Although there is some overlap, medication and surgery do two different things. Surgery (a hair transplant) is most useful to replace hair that has already been lost. Medication (finasteride) prevents further loss. Surgical hair restoration does nothing to prevent the progression of genetic balding and medication cannot grow hair in areas that are completely devoid of hair. Therefore, one should use hair transplantation surgery to restore hair in areas that medication won’t work, but use medication to retard the further hair loss.
Q: Can you shave your scalp after a hair transplant with FUE without noticing scarring in the donor area? T.C. – New York, NY
A: Although there is no line scar in FUE there are tiny round ones. You can clip your hair very short after FUE; however, shaving your head will make the very fine white scarring visible.
Q: Is it true that smoking is bad for hair transplants and why? D.I. – Queens, New York
A: Smoking causes constriction of blood vessels and decreased blood flow to the scalp, predominantly due to its nicotine content. In addition, the carbon monoxide in smoke decreases the oxygen carrying capacity of the blood. These factors both contribute to poor wound healing after a hair transplant and can increase the chance of a wound infection and scarring. Smoking may also contribute to poor hair growth.
The harmful effects of smoking wear off slowly after one stops. Particularly in chronic smokers, one is at risk to poor healing even after smoking is stopped for weeks or even months. Although it is not known exactly how long one should avoid smoking before and after a hair transplant surgery, a common recommendation is to abstain from 1 week prior to surgery to 2 weeks after the hair transplantation procedure.
Q: How do you know if you have lost any grafts after a hair transplant and how long after the hair transplant can you still lose them? G.H. – New York, NY
A: Each day following the surgical hair restoration, the transplanted grafts become more fixed in the scalp and the hairs in the grafts become more dissociated (loose). At nine days post-op, the grafts are fixed firmly in the scalp – it has essentially become part of the scalp in the new area and can’t be dislodged. The hair, however, has totally separated from the follicle by this time, so that it can easily be pulled out without dislodging the remainder of the follicle that contains the growth center. When this hair is pulled out (or is naturally shed) one often sees a tiny bulb at the end. This is the root sheath of the hair and not the growth center. This is normal and is not a lost graft. If a graft is lost, an event that may occur within the first 3-4 days following hair replacement surgery, it is almost invariably associated with a small amount of bleeding. For details on how to care for the hair transplant visit: After Your Hair Restoration.
Q: Can hair be transplanted from one person to another? Y.R. – New York City
A: A hair transplant between individuals can only be performed on identical twins, since they are genetically the same. In all other cases, including non-identical siblings, the transplanted hair will be rejected. We are often asked how it is that one can perform kidney transplants from one person to another, but not hair transplants. The reason is that the skin is more antigenic than a kidney i.e. it is more likely to be rejected. The reason is complex, but this makes sense considering that the skin is the first line of defense against foreign organisms.
Q: What causes graft popping during a hair transplantation? A.B. – Long Island, New York
A: Popping, or the tendency for grafts to elevate after they have been placed into the recipient area, is caused by a number of factors including: packing the grafts too closely, particularly when they are placed on a very acute (sharp) angle with the skin, rough placing techniques, bleeding, poor fit between the graft and recipient site, and the natural characteristics of the patient’s skin, including the elasticity and stickiness of wound edges. The problem with popping is that it exposes grafts to drying (while they are elevated on the skin surface) and trauma (when they have to be re-inserted).
The judgment and experience of the hair transplant surgeon is extremely important in minimizing popping. It is important that the surgeon customize the site size to the different size follicular unit grafts and to test the recipient sites as they are made, to make sure that the “fit” is perfect. Although it is important to place grafts close together, to get the best cosmetic result possible, over packing of the grafts risks popping and other factors (such as overwhelming the blood supply) that may lead to poor growth. In the end, maximum growth of the transplanted hair should be the primary goal.
Q: I am twenty and think that I am starting to thin. I am also experiencing a slight tingling in my scalp. Are these related? J.R. – Chelsea, New York City
A: Most likely. Early androgenetic alopecia can be associated with a slight tingling or slight tenderness of the scalp. You should see a dermatologist for evaluation and, if you have early male pattern baldness, consider starting finasteride (Propecia).
Q: After bad hair restoration surgery, can you use lasers or electrolysis to remove the transplanted hair? G.A. – New York, NY
A: Electrolysis does not work well, because the follicular anatomy is distorted and it is too difficult to insert the needle in the right position. Lasers will work as well with transplanted hair as it will with normal hair but, in either case, it takes multiple treatments. The disadvantage of both procedures is that they destroy the hair that is removed and they do nothing to improve the appearance of the underlying skin (which is often scarred and made more visible when the hair is gone). Graft excision, on the other hand, allows the hair to be reused and can often improve the appearance of the underlying skin.
Q: If someone doesn’t have enough donor hair, do you ever perform hair transplants using FUE, using donor hair from outside the permanent hair zone? Y.L – Manhattan, New York
A: No. If hair was taken from outside the permanent zone, as the surrounding hair continued to bald, the scars from FUE, although small, would become visible. In addition, the transplanted hair would not be permanent, and over time, would eventually fall out.
Q: Will I be unconscious during the hair transplant procedure and do you use general anesthesia? W.S. – New York, NY
A: All of the surgical hair restoration procedures at Bernstein Medical's New York Hair Transplant Center are performed under local anesthesia. The fact that general anesthesia is not needed is what makes hair transplant procedures – even though they are long – very safe. Patients are given a sedative to help them relax, but they are not put to sleep. Most patients watch TV, see movies or just chat during the procedure.
To read more Q & A’s with Dr. Bernstein or to view questions by category, visit our hair transplant Blog. If you are interested in Hair Restoration in New York City, schedule a consultation with Dr. Bernstein.
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