Answers to frequently asked questions about hair transplant surgery.
Q: I’ve read some information on your website about donor area scarring from FUT and FUE. Since I wear my hair longer in the back, I am not really concerned about that. But what about the recipient area where my hair is thin? Are any scars visible in the recipient area after a hair transplant? How long after a hair transplant will you be able to see redness, marks, or scars on the top of my scalp? — A.N., Chicago, IL
A: The marks and redness from a hair transplant should fade in about 10 days, although there is significant patient to patient variability. The tiny recipient sites that we use prevent visible scarring, pitting, or other surface irregularities as a result of the procedure.
Q: I had an FUE hair transplant three weeks ago and some of my existing non-transplanted hair has fallen out. I was a Norwood 3V, but now I look more like a 4 or 5 without the hair that used to help cover up my thinning area. Am I destined to look balder for the next few months? When can I expect to look like before? — T.M., New Haven, CT
A: You are describing shedding that is pretty typical following a hair transplant. The hair which is shed generally grows back together with the transplanted hair beginning at about three months. You should expect hair that is shaved for the FUE procedure to grow back right away at the normal rate of 1/2mm per day.
The shedding (also called shock hair loss) doesn’t mean permanent damage to the hair follicles. What it refers to is a physiological, or normal, response to trauma to the scalp which is caused by the hair restoration procedure. In general, only miniaturized hair (the hair that is affected by androgens and that has begun to decrease in diameter) is shed after a transplant. This hair would be lost in the near term anyway. Existing healthy hair is unlikely to shed, but if it were to shed, you could expect it to grow back as the transplanted hair grows in.
Q: Is it harmful if I do not rinse or wash my recipient area for 5 to 7 days after the hair transplant? — T.E., Yonkers, NY
A: The purpose of showering the day after the procedure is to remove scabs and dried blood. This will allow for quicker healing, less inflammation (redness), and a reduced incidence of infection. It will also shorten the time post-op where the procedure might be detectable. In our practice, patients are instructed to start showering and gently washing the recipient area the day after the surgery. The first day after surgery the patient will shower three times, and for the remainder of the week, showering will be twice daily. When showering, patients can clean the transplanted area with a special medicated shampoo that is gentle on grafts. The follicular unit grafts are made to fit snugly into the recipient sites and will not be dislodged in the shower, as long as the patient washes gently.
Q: Does minoxidil play any role in the survival of the grafts after a Neograft/FUE procedure?
A: When a doctor performs a hair transplant, the hair should be taken from the permanent zone so, by definition, that hair is not affected by medication (i.e. does not need to be maintained by either minoxidil or finasteride). If the doctors using Neograft are suggesting that minoxidil increases survival, then they are probably harvesting hair outside the permanent zone. To clarify, I use the ARTAS robotic system for our FUE procedures, not Neograft, as the former is a far more accurate device for harvesting.
Can I Have a Hair Transplant if I Have a Scar in My Donor Area? If So, Which Do You Recommend, FUT or FUE?
Q: I have a diagonal scar in the middle of my donor area that I got during a childhood accident and I am concerned that it will limit my options for hair restoration. Will this type of scar prevent me from having either FUT or FUE? Do you recommend one or the other?
A: Traumatic scars in the donor area do not preclude us from performing a hair transplant. With an FUT/strip procedure, we can remove all or part of the scar when we excise the donor strip. In Robotic FUE, the ARTAS Robot can be programmed to avoid a scar during harvesting. In either procedure, we can improve the appearance of the scar by implanting follicular unit grafts directly into the scar tissue. The hairs will grow permanently in the scar, just like ones we implant in the recipient area, and the scar will become harder to detect.
It is important to note that transplanted hair will not grow in a thickened scar. If your scar is thickened, the doctor can thin it out (soften it) with injections of cortisone. They are usually repeated at 4-6 week intervals in advance of the procedure. The number of injection sessions required depends upon the thickness of the scar and your individual response to the medication.
The presence of a traumatic scar should generally not determine which type of transplant you have. That should be decided in consultation with your physician based on factors such as how much volume you need, how you intend to style your hair, how short you would like to keep it, how soon you need to return to strenuous physical activity, and other general considerations for a hair transplant.
We recently posted photos from a patient who had a robotic hair transplant with a scar in his donor area. The photos include images of his donor area (with scar) before his procedure, immediately after robotic graft harvesting and 11 days post-op. View this patient’s before after photos.
Q: I am an MMA fighter and I want to get a hair transplant. How long do I have to be out of commission and which type of procedure should I have, FUE or FUT? — J.A., Columbus, OH
A: With any type of hair transplant it takes 10 days for the transplanted grafts to be permanently fixed in place. The difference between FUE and FUT is in the limitations of activity due to the donor area. With FUE one would need to abstain from MMA for the same 10 days it takes the recipient area to heal (the grappling component of Mixed Marshal Arts is the most stressful on the scalp). With FUT, however, one would need at least three months for the linear donor scar to heal before one could resume contact sports like MMA.
Q: What is the problem with transplanting the crown too early? — P.L., Newark, NJ
A: If a person’s hair loss continues –- which is almost always the case -– the crown will expand and leave the transplanted area isolated, i.e. looking like a pony-tail. The surgeon can perform additional hair transplant procedures to re-connect the transplanted area to the fringe, but this is a large area that can require a lot of hair, and it is often impossible to determine when a person is young if the donor supply will be adequate. View the full post to see a photo of a patient who had an early hair transplant to his crown.
Q: It seems that some doctors offer only FUT and others only FUE. What is your opinion on that?
A: Both FUT and FUE are excellent techniques, but have different indications. To deliver the best care for our patients, hair restoration physicians should have expertise in both procedures, and they should offer both in their practices.
The main advantage of FUT is that it typically (but not always) gives the highest yield of hair. Therefore, when the patient’s primary goal is to achieve maximum fullness, FUT should be performed. There are many well described reasons for this, including the precision of stereo-microscopic dissection and the ability to efficiently harvest from a more select area of the donor zone, but these are beyond the scope of this brief commentary.
The main advantage of FUE is no linear scar. Therefore, when the patient’s primary goal is to be able to wear his hair very short, FUE should be performed. FUE is also indicated when there is an increased risk of a widened scar or when scalp laxity does not permit a strip excision. The patient may sometimes chose FUE simply to avoid the stigma of a linear donor scar.
There are situations in which both procedures are useful in the same patient. For example, FUT may first be used to maximize yield, but then, after several sessions, the scalp may become too tight to continue to perform FUT, or the donor scar may become wider than anticipated. In the former case, the physician can switch to FUE to obtain additional grafts; in the latter case FUE may be used to camouflage the scar of the FUT procedure.
It is tempting to see the world in black and white, and it is easiest to learn and train one’s staff in just one hair transplant technique — but medicine is never so simple. Developments over the past twenty years have given us two excellent hair restoration procedures. We should offer our patients both.
Q: I’m a 42 year old African-American woman and I’m losing hair on the crown of my head. Would I be a good candidate for a hair transplant?
A: Hair loss in the crown of an African American female can have several different etiologies, so the first thing to do is to make the right diagnosis. The most common causes of hair loss are androgenic alopecia (AGA) and scarring alopecia, also called ‘Central Centrifugal Cicatricial Alopecia,’ or CCCA. A biopsy is often useful to differentiate these two causes of hair loss when the diagnosis is unclear. A biopsy can also identify other, but less common, causes of crown hair loss.
Patients with central centrifugal cicatricial (scarring) alopecia are generally not candidates for a hair transplant procedure since the body may reject the transplanted hair. This condition is better treated with oral and injectable anti-inflammatory medications.
We recommend waiting at least 10 days before playing any contact sport, like football, as transplanted grafts could be dislodged if vigorously rubbed.
While the first session of a hair transplant is designed to stand on its own, there are several reasons why one would want a second hair transplant.
Q: I heard FUE is a scarless surgery. Is this true using any of the current FUE methods (ARTAS® robot, Neograft, manual FUE)?
A: All hair transplant procedures, follicular unit transplantation (FUT) and follicular unit extraction (FUE), leave scars. FUT produces a linear scar at the back of the scalp that may be visible if you keep your hair short. FUE, on the other hand, leaves small dot scars at the back of the scalp that are not visible if you keep your hair short. These tiny scars will happen regardless of which FUE method is used, i.e., ARTAS robot, SAFE system, Neograft, or manual FUE. Some physicians who use the Neograft method advertise that there is no scarring involved when using the Neograft; however, this is not true: however, this is not true: there is some scarring associated with all FUE methods that increases with the total number of grafts harvested.
Q: I have a significant amount of hair loss. Can a hair transplant make me look exactly the way I did before I lost my hair?
A: In most cases, the answer is no. All surgical hair restoration procedures move hair – they cannot create new hair. Specifically, surgical hair transplantation takes existing hair from the donor area (located in the back and on the sides of the scalp) and moves (transplants) them to the part of the scalp that has lost hair. It is usually the case that there is not enough hair in one’s donor area to replace all lost hair. That said, in persons with extensive hair loss, the restoration can often produce a dramatic improvement in one’s appearance.
Q: My hair is thinning, but I’ve been told I have too much existing hair to warrant a hair transplant. I heard that transplanting new hair into my thinned areas will lead to a loss of existing hair follicles. I was told to delay a hair transplant procedure until my density has further decreased. Is this true?
A: It is possible that you simply don’t need a hair transplant at this time one. If you have early thinning, it may be best treated with medication, or not at all. As you age, we will have a better idea of your thinning pattern and, at that time, a hair transplant may be more appropriate.
A hair transplant does not cause loss of hair follicles in the recipient area. The procedure may cause a temporary “shock” loss of the hair. Shock hair loss is a physiologic response to the trauma to the scalp which is caused by a hair transplant. Hair that is healthy is going to come back after some period of time – generally 6 months. Hair that may be near the end of its lifespan may not return. When a hair transplant is performed at the proper time, in the proper candidate, shock hair loss should just be an incidental issue.
Q: I’ve heard that healing after a hair transplant requires stitches. How long will they stay in?
A: In a follicular unit hair transplant, the surgeon removes a thin strip of scalp from the patient’s donor area that supplies the follicular unit grafts for the hair transplant. After the strip is removed we use either sutures (stitches) or staples to close the wound. We now close most wounds in the donor area with staples, rather than sutures, because we have found that staples cause less injury to the remaining hair follicles compared to sutures; therefore, more hair will be available for future hair restoration sessions. See Why We Changed from Sutures to Staples in FUT Hair Transplants.
Q: I know Dr. Bernstein is one of the leading hair restoration surgeons in the country but what about his medical assistants? How experienced are the hair restoration technicians that help him during surgery?
A: My medical assistants and technicians are full time employees, and many of them have worked closely with me for many years; in fact, many of them have been with me since the inception of FUT, the procedure I pioneered way back in 1995. I do not hire, nor have I ever hired, per diem technicians.
All my hair restoration technicians are highly skilled and experienced in stereo-microscopic dissection and follicular unit graft placement. Even with Robotic FUE, being highly skilled and experienced in stereo-microscopic dissection is important since every graft that the robot harvests is examined, counted, and, when necessary, trimmed to ensure they are of the highest quality before being implanted into the scalp.
Because of the intense in-house training of our staff, we have received national accreditation from the “Accreditation Association for Ambulatory Health Care” (AAAHC/Accreditation Association) for maintaining rigorous standards in patient care.
Read more about how we train our surgical staff.
Q: I received radiation therapy to my scalp two years ago to treat a brain tumor. I lost my hair during treatment and it has not grown back. The doctors said that this treatment might result in permanent hair loss. Is a hair transplant a viable option after radiation treatment?
A: Unlike chemotherapy which generally causes a reversible shedding of hair (called anagen effluvium), radiation therapy can cause both reversible shedding and the permanent loss of hair follicles (scarring alopecia). Hair can be successfully transplanted into these scarred areas – but there must be enough donor hair to do so. If the radiotherapy was localized, a hair transplant procedure is often quite effective – although several procedures may be required to achieve adequate coverage of the irradiated areas.
Q: At one time, I was told my donor area was not sufficient for an FUT hair transplant procedure. Does this also mean I’m not qualified for a FUE procedure either?
A: Great question. You are not giving me quite enough information to answer your question specifically, so I will answer in more general terms. If your donor hair supply was not good enough to do FUT (i.e. you have too little donor hair and too much bald area to cover) then most likely you will not be a candidate for FUE either, since both procedures require, and use up, donor hair. That said, if don’t need that much donor hair, but the nature of your donor area is such that a linear FUT scar might be visible then FUE might be useful.
An example would be the case in which a person has limited hair loss in the front of his scalp, has relatively low donor density, and wants to keep his hair on the short sides. In this case, FUT would not be appropriate as you might see the line scar, but we might be able to harvest enough hair through FUE to make the procedure cosmetically worthwhile. Remember, with low density neither procedure will yield that much hair to be used in the recipient area.
Another example is an Asian whose hair emerges perpendicular from the scalp so that a line incision is difficult to hide, i.e. the hair will not lie naturally over it. A third example is where the patient’s scalp is very tight. In this case, the donor density might be adequate, but it would just be hard to access it using a strip FUT procedure. In this case, FUE would also be appropriate.
From these situations, one can see that the decision to perform FUE vs FUT, or even a hair transplant at all, can be quite nuanced and requires a careful evaluation by a hair restoration surgeon with expertise in both procedures.
Q: Can you do a hair transplant using someone else’s hair?
A: Unfortunately, this is not possible because your body would reject the hair transplant without the use of immunosuppressive drugs. The problem with immune suppressants is that they will lower your natural immune response, increasing your susceptibility to infections and even cancer, and you’ll have to take them for the rest of your life.
A transplant using someone else’s hair is also not desirable for aesthetic reasons. There’s the style of the hair, its texture, thickness, color, etc. Trying to find the perfect donor whose hair would complement and flatter your particular features and blend in with your remaining hair would be a significant, if not impossible, challenge. It would be possible, however, to transplant the hair from one identical twin to another, but most likely if one went bald, so would the other.
Q: For patients who intend to keep their hair parted on the left side, do you follow any rule of making the left side more dense then the right or is it distributed evenly?
A: On a first hair transplant procedure, I generally place the sites/grafts symmetrically, even if a patient combs his hair to one side. The reason is that the person may change his styling after the procedure and I like to have the first hair transplant symmetrical for maximum flexibility. An exception would be a person with limited donor reserves. In this case, weighting on the part side is appropriate in the first procedure. Once the first hair transplant grows in and the person decides how he wants to wear his hair long-term a second transplant can be weighted to accommodate this. Weighting can be done in one, or both, of two ways: 1) by placing the sites closer together on the part side or 2) by placing slightly larger follicular units on the part side.
If a person decides to comb his hair back, then forward weighting is used. For greater details on this, please see some of my publications where I address the aesthetics of hair transplantation:
Q: I am having a facelift next month and also want to have a hair transplant soon after. How long should I wait between procedures?
A: Although it would be possible to do a hair transplant as soon as a week after a face or brow lift, ideally one should wait at least three months between procedures for the following reasons: 1) there will be less tension in the donor area and, therefore, it will be possible to harvest more grafts, 2) if there is any shedding from the facelift it will make the planning of the hair transplant more difficult, 3) it will leave the option of adding hair, in or around, any problematic surgical scars, and 4) will provide the ability to add hair to any area of thinning that might result from the facelift.
Q: I notice that some patients end up with hair that seems to stand straight up while others have hair that flows to one side or the other. Does the angle at which you place the follicles in the scalp ultimately determine how the hair will lie? Is there some artistic talent needed when placing these follicles so that patients end up with hair that lies flat or sticks straight up? What determines this? Do we have control over it?
A: Great question. You are correct, the angle of the recipient sites largely determines the hair direction. Hair should be planted the way it grows (i.e., in a forward and horizontal direction at the frontal hairline.) It is extremely important that it is transplanted that way to look natural. The body will alter the angle a bit as it heals, usually elevating it slightly and re-creating any prior wave (yes, waves are determined by the scalp, rather than by the hair follicles per se). In a properly performed hair transplant, a straight-up appearance should be due to grooming, it should not have been a result of the actual procedure. Hair should never be transplanted perpendicular to the scalp. I discussed these important concepts way back in my 1997 paper “The Aesthetics of Follicular Transplantation“.
Q: I have seen through forums that a hair transplant gives severe shock loss in the donor zone (especially behind ears) after the surgery. Doctors say it is temporary and can last about six months or more. Frankly, do you believe in this? Will the donor shocked hair recover?
A: It depends if you are speaking about follicular unit hair transplantation using strip harvesting (FUT) or Follicular Unit Extraction (FUE). With FUT, it is extremely uncommon to have any shock hair loss in the donor area. This could occur if the hair transplant procedure was done improperly, i.e. the donor area was closed too tightly. In this case, some hair loss may be permanent. This is one of the reasons that very large hair transplant sessions are unwise. Shock hair loss in FUE is more common, but is generally not significant and should eventually recover completely.
That said, some shock hair loss in the recipient area is quite common with either hair restoration procedure (FUT or FUE). This is particularly the case if there is a lot of existing miniaturized hair (hair that is starting to thin) in the transplanted area.
Q: I’ve noticed from the chatter on blogs, that it is not uncommon for men to go through multiple FUE procedures over 10+ year time-frame. It seems to be that after the initial FUE procedure to address moderate hair loss, the patient continues their natural balding to where they must undergo another FUE procedure in order to get back to their desired look. I’m almost 33 and while I take Propecia, my hair loss has been very gradual since I was about 26. I still have what many would consider a full head of hair, although very thin and with noticeable loss at my temples and crown. I’d always thought that a hair transplant would be a “1 and done” procedure, and now I’m concerned that if I do an FUE procedure now to replace what’s been already lost, I’ll just have to revisit a subsequent FUE down the line. Are ongoing FUEs simply part of the hair maintenance that a patient needs to accept about hair restoration process?
Q: If I have no linear scar and I can exercise right away, why would you ever recommend FUT instead of FUE?
A: I advise FUT because the grafts are of better quality (less transaction and more support tissue surrounding the follicle) and because more hair can be obtained from the mid-portion of the permanent zone –- which is where the hair is the best quality and most permanent. For the majority of patients a linear scar buried in the donor hair is not an issue. Each patient has to weigh the pros and cons of each procedure when making a decision.
A: I think that both procedures are excellent, which is why I do them both. My recommendations are determined by the individual patient. His or her age, desire to wear hair cut very short, athletic activities, donor density and miniaturization, extent of hair loss, and potential future balding are all important aspects in the decision process.
Q: Is the recovery time a lot longer with FUT compared to FUE?
A: Cosmetically, the recovery for FUT is actually shorter, since the back and sides do not need to be shaved and the longer hair can completely cover the donor incision immediately after the Follicular Unit Transplant procedure. In large Follicular Unit Extraction procedures, the entire back and sides of the scalp need to be clipped very close to the scalp. It can take up to 2 or 3 weeks for the hair to grow long enough to completely camouflage the harvested area. Once the healing is complete and any redness has subsided, the hair can be cut shorter.
A: The recipient area in both procedures is visible for up to 10 days. The donor area in FUT is generally not visible immediately after the procedure. In FUE, the donor area must be shaved, so that will be visible for up to two weeks (the time it takes for the hair to grow in).
Q: I am currently 8 days post op. I started to massage my hair in the shower to get rid of the scabs. When I was done I looked in the mirror and saw two of my transplanted hairs were slightly bleeding but still intact. What does that mean? Did I lose the grafts?
A: If they bleed, but were not dislodged (i.e. did not come out), they should grow fine. Just be gentle for the next week. Generally, when follicular unit transplantation is performed with tiny sites (19-21 gauge needles) the grafts are permanent at 10 days. Since I did not perform your procedure and am not familiar with the technique your doctor actually used, I would give it the extra few days.
Q: At about six days post op, I started to notice hairs on the tips of my fingers as I rubbed off my scabs. Additionally, if I tugged on the hairs lightly, they would immediately come out without any resistance. I did notice the small bulb at the end of the hair. My question is: is it not recommended to remove these hairs that have separated from the follicle? Should I just allow them to fall out on their own, or does it matter at all? Can pulling hairs out at 10 days post op effect growth differently than individuals who allow the hairs to fall out naturally?
A: At 10 days it should usually not make a difference, but I would still just let the hair fall out naturally when you shampoo. If there are any crusts (scabs) on the hair they are cosmetically bothersome, they can be gently scrubbed off in the shower at 10 days when very tiny recipient sites are used and you should wait slightly longer if larger sites were used. Since I don’t know the technique or site size used in your procedure, I would wait a full two weeks to be certain the grafts are permanent.
Q: I was told that I have low hair density in the donor area. Would multiple hair transplant procedures improve the results of my hair restoration? — J.G., Hoboken, NJ
A: Yes, but subsequent procedures would be smaller and there is a point of diminishing returns where additional procedures would yield so little hair that they would not be practical. There is a finite donor supply and once this is tapped, no more hair transplants are possible, regardless when one uses FUT or FUE.
Q: What are the chances of the donor scarring being visible long-term in FUT compared to FUE?
A: Both FUT and FUE produce donor scarring; FUT, in the form of a line and FUE in the shape of small, round dots. With FUT hair transplantation, the line is placed in the mid-portion of the permanent zone, whereas in FUE the dots are scattered all over the donor area.
If a patient becomes extensively bald (i.e. the donor fringe becomes very narrow), the line of FUT will generally still remain hidden, whereas the dots of FUE will be seen above the fringe of hair. In the less likely scenario of the donor hair actually thinning significantly, both the line (of FUT) and the dots (of FUE) may become visible.
Q: What is the most common cause of necrosis (death of tissue) in the recipient area?
A: Recipient site necrosis is one of the worst complications of a hair transplant and results in skin ulceration and scarring. Usually it is caused by a combination of a few or many factors. Each by itself should not present a risk. Read on for the list of risk factors.
Q: I am so confused reading about FUT and FUE on all the blogs. Can you please tell me which is better, FUT or FUE? — M.T., East Brunswick, NJ
A: FUT (via strip) will give the best cosmetic results (more volume) since the grafts are of better quality (when using microscopic dissection, there is less transection and more surrounding tissue to protect the grafts) and better graft selection (the grafts can all be harvested from the mid-portion of the permanent zone).
In contrast, in FUE you need approximately 5 times the area. Because of this large donor area requirement, some of the hair must be harvested from fringe areas and thus the hair will be less stable genetically.
Q: Dr. Bernstein, can you please comment on leg and body hair transplants?
A: I’ve tried the technique in the past but have been dissatisfied with the results. Scalp hair, unlike the rest of the body, has multiple hairs rising out of each follicle. With leg and body hair, you have only one hair per follicle, not follicular units of multiple hairs. Leg hair is also very fine. It might thicken up a little bit after it is transplanted, but not enough to be clinically useful. In men you want full thickness hair, so fine hair can make it look like it is miniaturizing, as it does when you’re losing it.
Q: Can shock loss be eliminated by using special surgical techniques?
A: Although there have been no scientific studies proving this, shock hair loss can most likely be minimized by keeping the recipient sites parallel to the hair follicles, by not creating a transplanted density too great in areas of existing hair, and by using minimal epinephrine (adrenaline) in the anesthetic. We implement all of these techniques. Finasteride may also decrease shock hair loss, or at least help any (miniaturized) hair that is lost to re-grow. That said, some shock hair loss from a hair transplant is unavoidable regardless of the technique as it is a normal physiologic response to stress.
Q: If I wanted a second procedure what is the typical time that I should wait after the first hair transplant? — P.L, Queens, NY
Q: I am 24 years old and just starting to thin. I was told by another doctor that it was too early to have a hair transplant, but the hair on the back and sides of my scalp seems really thick. Shouldn’t I have a hair transplant now, just in case I am not a candidate in the future? — A.S., Cherry Hill, NJ
A: The most important criteria in determining who will be a candidate for a hair transplant is the presence of sufficient permanent donor hair. When hair loss is early, it is often hard for the doctor to determine this, since early on the donor area can appear very stable. It is not until the front and/or top of the scalp has significant thinning that the donor area may also show thinning. Therefore, it is only at this time that the stability of the donor area can adequately be assessed.
Q: What does the hair transplantation process do to your existing hair? — R.V., London, UK
A: When we perform hair transplant surgery, we transplant into an area that is either bald or has some existing hair. The hair that is existing is undergoing a process called miniaturization. What this means is that the hairs are continuing to decrease in size – both in diameter and in length. When we perform a hair transplant, we don’t transplant around the existing miniaturized hair on your scalp, we transplant through it. And the reason why we do that is because the miniaturized hair, the fine hair that is being affected by DHT, is eventually going to disappear, so you don’t want there to be any gaps.
Q: Can I tell before I start to bald if I will be a candidate for a hair transplant.
A: Usually not. The main reason one is either a candidate or not is the stability (permanency) of the hair in the back and sides of ones scalp – the donor area. Since the top of the scalp usually thins first, if the top has not started to thin, the donor area will always appear to be OK. It is only when you have significant thinning on the front or top of your scalp can we actually begin to assess the stability of the donor area with any degree of accuracy.
Q: There is a famous hair transplant out there, Vice President, Joe Biden. How come it looks so unnatural? — W.S., Los Angeles, CA
A: With Joe Biden’s hair transplant a number of errors were made. Some were unavoidable due to the older technology and some were just poor planning. He had a hair transplant consisting mainly of large plugs because that was the way hair transplants were performed many years ago. But many of those plugs have now been fixed.
The persistent (but avoidable) problem is that Vice President Biden has a low, broad hairline. But when you see a low broad hairline one expects to see the rest of head to be covered with hair. But he didn’t have enough donor hair to accomplish this. With better planning, the hairline would have been more receded at the temples, producing a more natural, balanced look.
Q: I hear you leave staples in sometimes up to three weeks after a hair transplant. Why do you leave staples in that long? – M.C., Boca Raton, FL
A: My reason for leaving some staples in longer is that the tensile strength of the wound continues to increase (significantly) during the first three week period after surgery — actually, it will continue to gain strength for up to one year post-op. To give the wound the best chance to heal, on average, I take out alternating staples at 10 days and the remaining staples at 20 days.
Q: I am considering a hair transplant and would like to have the procedure and not be overly obvious about it. What are my options in hiding or concealing any redness after a week or so after the hair restoration? — R.T., Manhattan, NY
A: There are a number of factors that can make a hair transplant obvious in the post-op period. These include the redness that you are asking about, but also crusting and swelling.
Redness after hair restoration surgery is easily camouflaged with ordinary make-up. At one week post-op, the grafts are pretty secure, so that make-up can be applied and then gently washed off at the end of the day. Since the recipient wounds are well healed by one week, using make-up does not increase the risk of infection. At 10 days after the hair transplant, the grafts are permanent and cannot be dislodged, therefore, at this time the makeup can be removed without any special precautions.
Usually, residual crusting (scabbing) presents more of a cosmetic problem than redness, but can be minimized with meticulous post-op care. Crusts form when the blood or serum that oozes from recipient sites after the procedure dries on the scalp. Although it is relatively easy to prevent scabs from forming with frequent washing of the scalp after the surgery, once the scabs harden they are difficult to remove without dislodging the grafts.
Q: I am about 3 months post-op after my hair restoration procedure. I have noticed some hair shedding in the frontal part of my scalp. I have continued both Propecia and Minoxidil. Is there anything I can do and should I be concerned? — M.B., Chicago, IL
A: Shedding of some of the patient’s existing hair in, and around, the area of a hair transplant is a relatively common occurrence after a hair transplant and should not be a cause of concern. The mechanism appears to be a normal response of the body to the stress of the hair restoration surgery -– i.e., site creation, adrenaline in the anesthetic etc. Some doctors claim that their hair transplant techniques are so “impeccable” that their patients do not experience shedding. This is a false claim. Although using very small recipient sites and limiting the use of epinephrine may mitigate shedding somewhat, shedding is a normal part of the hair transplant process and the risk is unavoidable.
Q: How do you make the recipient sites in a hair transplant? — N.P., New Delhi, India
A: I make the recipient sites using 19-, 20-, 21- and 22-gauge needles. The higher the number, the finer the needle. The hairline is done with a 21-gauge, which is really very tiny. Eyebrow sites are created with a 22-. When one draws blood in a routine blood test, an 18-g needle is used and, of course, there are no residual marks. The instruments we use are significantly finer than this.
Q: If a person is graying on the top and sides and you do a hair transplant from the back, will the top look darker after the hair restoration? — W.C., Houston, TX
A: The hair is taken from the back and sides of the scalp and the follicular units, once dissected from the donor strip, are randomly inserted into the recipient area. That way, the color of the harvested hair will be mixed and will match perfectly.
Usually, people’s hair is lighter on the top because of the sun, so when you move the hair from the back and sides to the top, it will actually lighten to match the surrounding hair, if it didn’t match already.
Q: How are grafts distributed in a hair transplant? Are they distributed evenly? — B.V., Jersey City, NJ
A: Actually, we don’t make the transplanted hair evenly distributed. It is usually front weighted, so that the hair restoration will look most full when looking at the person head on.
Q: I am considering having a hair transplant. Does my hair need to be cut? — I.S., New York, NY
A: In all hair transplant procedures, we are able to transplant into areas of existing hair without it having to be cut. The question of whether hair needs to be cut in the donor area depends upon the way the donor hair is obtained (harvested).
With a Follicular Unit Hair Transplant procedure using single strip harvesting method (FUT), only the strip of hair that is removed needs to be cut. When the procedure is finished, the hair above the incision lays down over the sutured area and it becomes undetectable.
In Follicular Unit Extraction (FUE), particularly in sessions over 600 grafts, large areas of the donor area must be clipped short (to about 1-2mm in length) in order to obtain enough donor hair.
Q: Can I sleep as I normally do after a hair transplant? — G.C., Los Angeles, CA
A: We ask that you sleep on your back, with your head elevated on a few pillows. By raising your head, the pillows decrease any swelling that normally occurs after the hair transplant. We also use a small injection of cortisone given in the arm to help decrease swelling.
Q: After my hair transplant procedure I had some shock loss, and then after about 4 1/2 to 7 months I had tremendous growth — really thick. I was amazed actually. Now, at 8 months it has thinned again, quite a lot compared to the growth I had before. I just wondered if this was a normal growth pattern and whether further growth could be expected? — N.T., Brooklyn, NY
A: This is not the most common situation, but should not be a cause for concern. The newly transplanted hairs are initially synchronous when they first grow in — i.e. they tend to all grow in around the same time (with some variability). This is in contrast to normal hair, where every hair is on its own independent cycle. Sometimes the newly transplanted hair will shed at one time before the cycles of each hair become more varied asynchronous.
Q: I heard that it is possible to transplant body hair to the scalp. Does it leave any scarring? — V.P., Cherry Hill, NJ
A: Unfortunately, it does leave scarring. And since the hair is generally of poor quality, it is usually not worth the trade-off. View the full post to see an example of the typical scarring seen in a BHT procedure.
Q: Is it correct that the hair transplant surgery lasts about eight hours or if there is a range, what is that generally? — M.R., Montclair, NJ
A: The range is about 5 to 8 hours. For a completely bald person, it would be in the higher range. Keep in mind that the person is just relaxing, watching TV or dozing off. The time goes by quickly for the patient. Since there is no general anesthesia, there is no medical risk for this relatively long procedure.
To review the procedure in more detail, please visit our Overview of FUT Hair Transplant Procedure section; which includes details for before, during, and after the hair transplant. View the Overview of FUE Hair Transplant Procedure section for details on the follicular unit extraction procedure.
Q: Is transplanted hair the same length as existing hair?
A: The hair is first clipped to about 1-mm before it is transplanted. The transplanted hair will look like stubble for the first few weeks after the hair restoration procedure. It is then shed and the newly transplanted follicles go into a resting phase for about two months.
Q: I recently saw an episode of the Rachel Ray Show where her guest, Dr. Anthony Youn, said that the Neograft machine for Follicular Unit Extraction is painless and uses a vacuum rather than surgery to remove the grafts. Can this be true?
A: Follicular Unit Extraction (FUE) using the Neograft machine is not painless and, while it does not produce a linear scar, it is surgery and there is significant scarring in the form of thousands of tiny holes that heal with round white marks.
Q: I had a hair transplant about a month ago and I had scabs and some dead skin until day 16 or 17. Will that endanger the growth of the hair restoration procedure?
A: No, it will not. If follicular units were used for the hair transplant, the grafts should be permanent at 10 days. After this time, you can scrub as much as you need to get the scabs off.
Q: I had a hair transplant 10 days ago and I lost some hair that looks like the hair fell out at the root.
A: When there is shedding after a hair transplant, it is the hair that is lost, not the follicle that contains the growth center (the follicle eventually produces the new hair).
Since the “hair” usually consists of a hair shaft and the inner and outer root sheaths, which creates a little bulb at the end of the hair, it looks like the hair is “falling out at the root.” Do not be concerned as this is not the growth center.
Q: I have been reading about hair transplantation and I have a question concerning FUT (strip-harvesting). I understand, in this method, a strip is excised from the back of the scalp, the wound then closed. I wonder, then, is not the overall surface of the scalp reduced in this procedure? After two or three procedures, especially, (or even after one large session) will not a patient’s hairline also be shifted? That is, the front hairline would move back by the amount of scalp excised, or, more likely, the “rear hairline” (which ends at the back of the neck) must certainly be “moved upward.” At least, this is how I imagine it would be. Is my logic flawed? I’ve been trying to understand this in researching the procedure, but the point still evades me.
A: The hair bearing area is much more distensible (stretchable) than the bald area and just stretches out after the procedure. As a result, the density of the hair in the donor area will decrease with each hair transplant session, but the position of the upper and lower margins of the donor area don’t move much – if at all. As a result, the major limitation of how much donor hair can be removed is the decreasing hair density, rather than a decrease in the size of the donor area.
Q: I understand that seeing the result of a hair transplant is a process – what can I expect?
A: It generally takes a year to see the full results of a hair transplant. Growth usually begins around 2 1/2 to 3 months and at 6-8 months the hair transplant starts to become comb-able.
Over the course of a year, the hair will gain in thickness and in length and may also change in character. During this time, hair will often become silkier, less kinky or take on a wave, depending upon the original characteristics of the patient’s hair.
In subsequent hair restoration procedures, growth can be slower.
Q: If you transplant grafts in between the thinned out areas, is there a risk of cutting previously normal roots, even if one is cautious?
A: Healthy hair can be temporarily shocked from a hair transplant and then shed (the process is called telogen effluvium) but it will not be permanently damaged.
Any healthy hair that is lost in this shedding process should re-grow.
Q: At what level of thinning should the hair transplant be done?
A: A hair transplant should be considered in an area of thinning when:
- The area has not responded to medical therapy (finasteride 1mg a day orally and minoxidil 5% topically for one year).
- The thinning is significant enough that it can’t be disguised with simple grooming (i.e. is a cosmetic problem even when the hair is combed well).
Other factors that are important include:
- the age of the patient
- the donor supply
- whether the thinning is in the front of the scalp or in the crown
Bizymoms.com, the premier work-at-home community on the Internet with more than 5 million visitors per year, has interviewed Dr. Robert M. Bernstein in order to answer readers’ common questions about hair restoration and hair loss.
Q: When can patients go in the sun after a hair transplant?
A: Following a hair transplant, patients should protect their scalps from the sun for about a month.
This does not mean one needs to stay indoors. It just means that after a hair restoration surgery you should wear a hat or a good sunscreen when outdoors.
Sunburns on the scalp should be avoided, not just for persons having a hair transplant, but for everyone.
Q: Do patients need to wear a bandage after the surgery and for how long?
A: In a properly performed follicular unit hair transplant, the patient can remove any bandages the day after the procedure and gently shower/shampoo the transplanted area. The bandages do not need to be reapplied. The reason the dressing can be removed so soon is that follicular unit grafts fit into tiny needle-size incisions that heal in just one day.
Q: If you have already had a hair transplant, once cloning becomes available, will you be able to transplant the cloned hair into the first transplant’s scar on the back of the head? I like to wear my hair short, especially in the summer, and also would feel more comfortable knowing there is no scar in my head.
A: Yes, as long as the scar is not thickened, cloned hair should grow just as normally transplanted hair would and would be a great way to address any residual scarring from the procedure.
Q: I never kept my hair really long, what length can I wear my hair after a hair transplant to hide that I had a procedure?
A: Hair transplants, whether using the strip method to harvest the donor hair or by extracting individual follicular units one-by-one directly from the scalp, will leave some scarring. If the hair is long enough so that the underlying scalp is not visible, these scars will not be seen.
The quality and density of a person’s donor hair will affect this coverage and determine how short a person may keep his hair. In some cases the back and sides can be cut to a few millimeters, in others it would need to be kept longer. Since there is no scarring in the recipient area (the front and top of the scalp where the grafts are placed) the hair in these areas may be kept at any length.
Q: It has been over a month after my hair transplant procedure and I am starting to get nervous. When can I expect to see some growth?
A: Transplanted hair begins to grow, on average, about 10 weeks after the procedure, although this number can vary. Hair tends to grow in waves and occasionally some new hair may start to grow as long as a year after your procedure. In general, growth is a bit slower with each hair transplant procedure, although the reason for this is not fully understood.
Q: Why does a hair transplant grow – why doesn’t the transplanted hair fall out?
A: Hair transplants work because hair removed from the permanent zone in the back and sides of the scalp continues to grow when transplanted to the balding area in the front or top of one’s head. The reason is that the genetic predisposition for hair to fall out resides in the hair follicle itself, rather than in the scalp. This predisposition is an inherited sensitivity to the effects of DHT, which causes affected hair to decrease in diameter and in length and eventually disappear – a process called “miniaturization.” When DHT resistant hair from the back of the scalp is transplanted to the top, it will continue to be resistant to DHT in its new location and grow normally.
Q: Could you accept easing of the very strict definition of FUT, which you published about 15 years ago? Could you agree to use mixture of single FU and double FU under the name of FUT?
A: One would never want grafts larger than the largest original follicular units or the results will not look natural. The artificially large grafts will stand out in relatively thin surroundings. If one were to try to fix this by transplanting the doubled FUs very close together (over one or more sessions) one risks running out of grafts for other areas of the scalp. In other words, you can’t fool mother nature.
Q: Can the crown be transplanted first instead of frontal area? Why is the crown the last choice? Any reasons behind it?
A: The crown can be transplanted first in patients who have very good donor reserves (i.e., high density and good scalp laxity). Otherwise, after a hair restoration procedure to the crown you may not be left with enough hair to complete the front and top if those areas were to bald.
Cosmetically, the front and top are much more important to restore than the back. A careful examination by a trained hair restoration surgeon can tell how much donor hair there is available for a hair transplant.
Note from Dr. Bernstein: This article, by my colleague Dr. Rassman, is such important reading for anyone considering a hair transplant, that I felt it should be posted here in its entirety.
Areas of Unethical Behavior Practiced Today
William Rassman, MD, Los Angeles, California
I am disturbed that there is a rise in unethical practices in the hair transplant community. Although many of these practices have been around amongst a small handful of physicians, the recent recession has clearly increased their numbers. Each of us can see evidence of these practices as patients come into our offices and tell us about their experiences. When a patient comes to me and is clearly the victim of unethical behavior I can only react by telling the patient the truth about what my fellow physician has done to them. We have no obligation to protect those doctors in our ranks who practice unethically, so maybe the way we respond is to become a patient advocate, one on one, for each patient so victimized.
Q: I have had a hair transplant done in the hairline of 1,000 or so FUE grafts. However, as the hair sheds, under natural light the recipient skin seems bumpy with incisions and holes that are noticeable. Do these tend to go away with time once they have healed?
A: If a follicular unit transplant is performed properly (using either extraction or a strip) there should be no bumps or surface irregularities. When the hair restoration is totally healed, the recipient area should be appear as normal looking skin.
Q: It’s a question that greatly concerns me because I’m investigating getting a transplant sometime next year. I’m 28 and thought I started balding at 26, but photographic evidence suggests it had started somewhere around age 24. I’m roughly a Class 2 now, and thanks to finasteride, I’ve stayed almost exactly where I was at 26 with some improvement (not really cosmetically significant though). However, I am convinced I have some crown and top of the scalp thinning too, but not to a visible degree.
These people getting these miraculous jobs from Canada – it is a trick, right? They can’t honestly expect to be able to get away with what they’ve done over the course of their entire lives, can they?
A: I think you have better insights into hair loss than many hair transplant surgeons. ABI was the “rare” patient who seems to be a stable Class 3. I made that judgment due to: almost no miniaturization at the border of his Class 3 recession, no crown miniaturization, and his unusual family history. He had several older family members who stayed at Class 3 their whole lives.
Q: I wanted you to determine if I would be a candidate for FUE (to camouflage a scar). After reading through your vastly informative website, I had become aware that the Fox test is necessary to determine patient viability for FUE. When I mentioned the test, I believe I heard you say it was unnecessary. Unfortunately, I can’t help but think there was miscommunication between us, as your letter states that I should schedule a Fox test if I am considering FUE. Please confirm if a Fox test is, in fact, necessary.
A: I perform FOX tests on all patients when I am considering a FUE hair transplant. I do not routinely perform FOX tests before repairs (or on eyebrow transplants) where the number of grafts is relatively small.
The purpose of FUE is to identify those patients in whom FUE is inefficient — i.e. there is a greater than average risk of damage during the harvest. If this is the case, I would not perform the hair transplant since even slight inefficiencies create a significant problem when thousands of grafts are transplanted.
Q: I have been told a number of different ways to massage my scalp. What do you suggest?
A: We have found that the most successful technique is to perform the exercises: once a day, for at least 15 minutes, and using three different hand positions.
Q: How far into the scalp are the grafts placed and is the follicle far enough into the scalp that it will not be damaged? I have heard that the critical time to not touch your scalp is the first 2-3 weeks after the procedure.
A: The growth part of the follicle is 3-4mm into the scalp. Grafts can be dislodged the first 10 days, so you need to be careful not to scrub your scalp during this period. After that, the grafts are permanent. At 2-3 weeks they can’t be dislodged, even by vigorous scrubbing.
Q: When can patients resume physical training?
A: Moderate exercise may be resumed two days after the hair transplant.
The main limitation is to avoid putting direct pressure on the donor area and to avoid stretching the back of the scalp (neck flexion) as this will increase the chance of stretching the donor scar after a strip procedure.
There is no such limitation with follicular unit extraction (FUE). However, in general, contact sports should be avoided for at least 10 days with FUE and a month after a strip procedure.
Q: When can I wash my hair after a hair restoration procedure?
A: If a follicular unit hair transplant is performed so that there is a “snug fit” between the graft and the incision into which it is placed, the grafts are reasonably secure the day after the procedure.
At this time, gently washing with lightly flowing water and a patting (rather than rubbing) motion is permitted. Vigorous rubbing, however, will dislodge the grafts.
Over the course of the week the grafts become more secure, and at 10 days post-op they are permanent. At this time, normal scrubbing of the scalp is permitted.
Q: I have read that you can get pimples/ingrown hairs after 3-5 months post op. Is it ok if you pop or scratch these areas?
A: It is common to get small pimples that begin to erupt 2-3 months post-op. These are due to newly growing hairs trying to work their way through the skin. The pimples are transient and should be left to resolve on their own.
If they persist, you should see your doctor. Persistent inflamed pimples can be treated with antibiotics and may occasionally need to be drained.
Q: I had a facelift about a year ago and the skin on the sides by my temples is really bare. It makes the scar a little obvious too. Can you transplant hair just at the temples to cover the scar?
A: Hair loss in the temple area following a facelift is relatively common and can be treated with a hair transplant. If there is scar tissue, the hair restoration will generally require more than one session.
Q: I have heard of body hair transplants as an option being considered by some patients. Do you think that could be an option for me as my donor area isn’t able to provide the hair that I need?
A: With body hair transplants, the hair quality is poor and there can be a significant amount of scarring where the hair is harvested, so we are not recommending it at this time.
Q: Is it more important to do scalp exercises before the first procedure or the second?
A: When the scalp is tight, it can be useful for either the first or the second hair transplant.
Keep in mind, however, that the scalp will naturally stretch between hair transplant procedures, so that if exercises were not needed for the first procedure, they will generally not be needed for the second.
In our practice, we generally wait one year between hair restoration sessions so that we can see the full cosmetic impact of the first procedure and give the scalp laxity a chance to return to normal on its own.
In addition, there is a risk that active massage after the first procedure may widen the donor scar. Therefore, before considering massage before a second hair transplant, make sure that enough time has elapsed between procedures so that stretching of the scar will not be a be a problem.
Q: I just started to lose my hair but it’s just in one spot, like a circle on the left side of my head. Do you ever do a hair transplant just into a bald spot and not the whole head?
A: It is possible to have a hair restoration procedure into a single bald spot. However, it would be most beneficial to first determine the cause of the condition.
Bald spots caused by alopecia areata (an autoimmune disease) are best treated with injections of steroids into the scalp, rather than with a hair transplant. In fact, the transplanted hair can be rejected in patients with this condition.
Q: Hi! I wanted to ask if after a hair restoration surgery the transplanted hair will eventually fall out? Because the surgery is to restore hair mainly for people with genetic hair loss which results from DHT, won’t the DHT make the new follicles implanted fall out as well?
A: Hair loss is due to the action of DHT (a byproduct of testosterone) on hair follicles that cause them to shrink and eventually disappear (the process is called miniaturization). The follicles on the back and sides of the scalp are not sensitive to DHT and therefore don’t bald (miniaturize).
When you transplant hair from the back and sides to the bald area on the front or top of the scalp the hair follicles maintain their original characteristics (their resistance to DHT) and therefore they will continue to grow.
Q: How long should I do scalp exercises before the procedure?
A: To get the most benefit from scalp exercises, one should stretch vigorously on a regular basis for at least eight weeks prior to your hair restoration procedure. However, this will vary based upon the individual and upon how much the laxity needs to be increased.
Please remember that for the majority of patients scalp exercises are not necessary.
Q: What’s the story with Joe Biden’s hair? A: Joe Biden — former Senator from Delaware and now the Vice President of the United States — apparently had a hair transplant many years ago using the older hair restoration techniques. This included not only transplanting hair in large plugs (corn rows), but using them to […]
Q: Heard you were on Oprah with a hair transplant patient of yours. Is this true? A: Yes. Oprah wanted to know if hair transplants really worked, so I was asked to be on The Oprah Winfrey Show to explain the latest in hair restoration techniques. They showed a film of me performing a follicular […]
Q: I am scheduled to have a hair transplant next month and wonder if I should do scalp exercises before the procedure?
A: For the majority of patients, scalp exercises are not necessary.
The scalp in the donor area has a fair amount of redundancy. With a properly planned hair transplant, the donor area will close relatively easily.
If a patient’s scalp is particularly tight, or if a very large session is planned (even in the face of an average scalp), vigorous scalp exercises are useful in increasing laxity.
The advantage of stretching one’s scalp prior to surgery is that it allows the doctor to remove a slightly wider strip and it decreases tension on the closure so the person will heal with a potentially finer scar.
Q: In which procedure do you generally more of a change, the first or the second?
A: The answer depends upon the patient’s baldness. If they are very bald, the first session will be the most noticeable, since going from no hair to hair is much more dramatic than going from some hair to more hair. In addition, if someone is very bald, the first session is generally the largest, with less hair being transplanted in the second.
Q: I am interested in a hair transplant, but am turned off by the apparent side effects of follow up Propecia. Could herbs serve the purpose of Propecia? Regarding laser treatments, do they work on their own, or do you need drugs to supplement? Can laser damage in some cases, rather than benefit? It seems odd that laser therapy has been undertaken in Europe for 10 years, yet there are no published studies on the results. Might this be because it doesn’t work in the longer term?
A: Finasteride is the best medication. Herbs are not particularly effective for hair loss. You should consider trying finasteride.
If you are in the 2% group that has side effects with Propecia, just stop taking the medication. If you do not experience side effects, then there is no problem taking the medication long-term. Hair transplant surgery doesn’t prevent the progression of hair loss. That is why it is used in conjunction with medication.
Q: Can a hair transplant be done using the hair which has fallen out?
A: A hair transplant is really a misnomer, since it is the follicle (or root) that is transplanted not the hair itself – although the transplanted follicle usually contains a hair.
Hair, like fingernails, are dead and cannot grow once detached from the root.
Q: I had a follicular unit hair transplant performed by another doctor that was scheduled for 2,500 grafts and I ended up paying for exactly that amount. I was supposed to be paying per graft, so it seems strange that it came out to be exactly 2,500? How do I know what I really got?
A: This is a question that should be addressed to the doctor that operated on you.
If a doctor is charging by the graft, then you should know exactly how many grafts you are receiving. It is possible that he/she hit the number (2500) exactly on the head, but statistically that is extremely unlikely.
Q: How soon after the hair transplant procedure do I have to get the staples taken out? — T.J., Fort Lee, NJ
A: We remove every other staple at 10 days post-op. The remaining staples are generally removed at 20 days post-op. This varies based upon the patients scalp laxity and the width of the donor strip.
Q: Can health savings account dollars be used for a hair transplant procedure?
A: Generally yes, but I would check with your individual state and personal plan.
Q: Is it necessary to take medications before, during, or after the hair transplant? Will these medications affect pregnancy?
A: It is not necessary to take any medication for a hair transplant other than the local anesthesia used during the procedure.
Although I would not have a hair transplant during pregnancy, the procedure will have no effect on future ones.
Q: Are state taxes applicable for hair restoration procedures?
A: There are no taxes on cosmetic procedures performed in New York State.
Some states do have taxes. In New Jersey, for example, there is a cosmetic surgery tax of 6%, but not in NY.
Q: I am 25 year old who just started going bald. My doctor confirmed that I have pattern baldness and put me on Propecia and Rogaine. I don’t want to go bald at any age. So, instead of prolonging the process for 5-10 years and then having a HT, isn’t it easier to let the hair loss continue and then have a HT, so, that I can save the money on drugs for years.
A: It is far better to keep your own hair. Keeping your own hair will generally look fuller than a hair transplant, since a hair transplant just re-distributes existing hair (until hair cloning techniques are available).
The medications (i.e. finasteride and minoxidil) are relatively cheap if you get the generic forms.
Q: I would be so grateful if you could give me some idea on how the quality of the hair that is transplanted is affected by its new ‘home’ and the native neighboring hair.
Is it likely all the hair that is going to be able to come back to life with Propecia will also mature fully eventually? At the moment there is a big visual difference between the front section and rest of hair. (I understand hair count per cm2 may differ more drastically- I’m thinking here just of the hair shaft thickness.) Also, when I have hair transplants – as I intend to when Propecia has done all it can – will the hairs from the back of my head (thick) stay that thick regardless or will they take on the properties of the new surrounding hair?
A: Hair that responds to Propecia doesn’t always regain the full character of the original hair, so the area may still look thin.
The transplanted hair, however, will look like the original hair and maintain, over time, the same character as the hair in the donor area (where it came from).
Q: I am Hispanic and I have thick, black coarse wavy hair. Do you transplant Hispanics and are there any difficulties in performing hair transplants in them? A: Yes, we treat Hispanic patients. There are no specific issues unique to Hispanics when performing hair restoration procedures. However, things to consider are: Hispanics have a slightly […]
Q: Do you currently prefer sutures or staples to close the donor area? — O.C., Dallas, TX
A: Staples, because they conserve more hair.
A: You can fly home the second day after the procedure. We usually remove staples 10 and 20 days post-op. Patients that travel can have this done in their home town. We provide instructions and a staple remover that is easy for any health care professional to use. There should be no other reason to return to the office other than an optional one-year follow up.
Q: My first hair transplant was a breeze. Will a second procedure be any different than the first?
A: Generally in a second procedure, a patient can expect less swelling post-up although the reason for this is not known.
There will also generally be less shedding in the second hair transplant session since the weak miniaturized hair that will be shed is often lost in the first session and the previously transplanted hair is generally more resistant to shedding.
Q: After the day of the procedure, I could see what appeared as white specks on top of my scalp. Some are sticking out above the scalp more than others. I was wondering if the entire follicular unit should be at the level of the scalp. Is it normal for some part of it to be above the scalp? (I did not receive the procedure from you.)
A: It is normal for the grafts to be a little elevated and you should expect them to flatten as they heal.
The effect may be exaggerated in the shower as the grafts become hydrated, but they should settle down soon after you dry off.
Q: I am 26 years old, have had two successful hair transplants, but am still losing hair in the crown area. The doctor I have worked with told me that he does not do crown work on anyone until they are at least 40 (due to lack of donor area). I have very thick hair and the transplanted area looks as if nothing was lost. Would you do work on someone my age in their crown area if they have enough donor hair?
A: Although I am hesitant to start with the crown when transplanting a younger person, if you have good coverage on the front and top of your scalp from the first two sessions then extending the hair transplant into your crown may be reasonable. It depends upon your remaining donor supply and an assessment of how bald you will become. I would need to examine you.
If it is likely that you will progress only to a Norwood Class 6, then transplanting your crown can be considered. If you will progress to a Class 7 then you should not since, in the long term, hair that was placed in the crown might be better used for other purposes, such as connecting the transplanted top to receding sides.
Q: It had been 5 months since my hair transplant. I only see minimal growth of maybe a few hundred fine hairs. My transplant consisted of 2,217 grafts. Could you give me your opinion if this is normal or is it a failed hair transplant?
A: It is too early to tell. Hair grows in very gradually with great variability from person to person.
Some patients only have a little fuzz at five months and then have great growth by one year.
You really need to wait the full 12 months to evaluate the success of the hair restoration.
Q: I have seen some incredible photos on some websites. In some cases, they seem too good to be true. Are they real?
A: Evaluating results is more complicated than simply looking at photos – even if they are un-retouched and not studio shots.
For example, if 4,000 grafts were used to make a young person’s hair line look very dense, you might say that was a spectacular result. However, if he only has a total of 6,000 follicular units in his donor area (the average), then he is going to have many problems as he continues to bald, since there will be only 2,000 grafts left for the rest of his head.
Q: I was looking at the hair transplant photos on the Bernstein Medical website. I noticed that you and the NHI website have some of the same pictures. Did you both perform surgeries on these people?
A: All of the patients that appear on the Bernstein Medical website were operated on by me personally. My own staff assisted me in these procedures.
I worked with Dr. Rassman at NHI from 1995 to 2004. Photos of patients that I operated on during this period may therefore also appear on the NHI website.
Q: I recently had a follicular unit extraction procedure of 320 grafts to fix an old strip scar. The donor area where the FUE’s were taken looks very diffuse – worse than the original scar ever was, it looks horrible. My doctor said this was just shock loss. Have you seen that happen where the donor area gets all diffuse from shock? If not, have you seen it where the FUE’s are taken in an illogical pattern resulting in new scarring that is noticeable?
A: You can have shedding in the donor area from an FUE procedure, although it is not common. In FUE, the hair must be taken from the permanent zone and if there is too much wastage in the extraction process, too large an area may be needed to obtain the hair. This can leave a thin look even without shock loss (shedding).
Q: I had my first hair transplant of 1100 grafts five months ago. The hair has been growing in well and I am very satisfied with the progress, but the new growth appears to occur in different cycles. Some of the hair never fell out and started growing within weeks. At around three months, a lot more started to grow, and now there seems to be even more growth of new hair coming in its finer stages. Is it normal for transplanted hair to begin growing at different times? Why does some hair come in looking thick and other hair start off finer and then gradually thicken up?
A: You are describing accurately how hair grows after a hair transplant. After the hair restoration procedure, the transplanted stubble is shed and the hair goes into a dormant phase. Several months later, growth begins as fine, vellus hair that thickens over time. The hair usually does not have its original thickness right away.
Typically, growth occurs in waves so that initially some areas will have more hair than others. Over the course of a year the cycles will even out and the hair will thicken to its final diameter.
Q: I have had thinning eyebrows since my early twenties (I am now 32) and they have gotten to the point that I can’t make them look good with mascara anymore. I am considering an eyebrow hair transplant, how is it different from other hair transplants?
A: Eyebrow hair restoration procedures are similar to hair transplants to the scalp in that the hair, once transplanted, is permanent. They differ both in the techniques used to perform them and in the results.
Will Hair Transplant Grow Slower in Crown than Front of Scalp and Will Hair Grow More Slowly After Second Transplant?
Q: I had my second hair restoration procedure nearly 5 months back. New hair in the front part of the head is growing well, but the crown is growing slow. Is this common? Also does the new hair grow more slowly after second hair transplant procedure?
A: Yes, it is typical for hair in the crown to grow more slowly than the front and top of the scalp and the second procedure generally grows more slowly than the first.
Q: I had a hair transplant 4 days ago and am feeling itchy in the area where I have my grafts. When can I start massaging the area?
A: You can massage at 10 days post-op, as the grafts are firmly in place by this time, but I would not scratch the area for several weeks more, if at all.
Itching can be lessened by applying hydrocortisone 1% ointment to the area twice a day and by taking Benadryl 25mg every 4 to 6 hours (may cause drowsiness). Both medications can be obtained over-the-counter without a prescription.
Q: I had my hair transplant done 10 days back, I was a regular smoker (8-10) cigarettes every day from last 10 years. I have stopped smoking from the day of my surgery, how long should I stop smoking after surgery?
A: I would wait a minimum of 10 days, but the longer the better. The nicotine in the smoke constricts blood vessels and decreases the oxygen to the tissues and the carbon dioxide in smoke displaces the oxygen. Both chemicals retard healing.
Q: Five days after my hair transplant I shampooed, rubbing the transplanted area vigorously using my finger tips and all the scabs fell off. Is it possible I have dislodged some of the grafts even though they didn’t bleed? If there was no bleeding, is it enough to assume all the new transplanted follicles stayed in place??
A: At five days after a hair transplant the grafts are pretty secure, but still can be dislodged.
However, if there was no bleeding, it is unlikely that you lost any grafts.
Q: I am in my early 20’s and I was told my hair loss pattern is a Norwood Class 6, on its way to becoming a Class 7. My hair is brown in color and medium to coarse and I was told I have high density in my donor area. Although I was told I could have hair transplants, do you think that I should based upon what I have told you?
A: The main concern I would have is that when someone is already a Class 6 by their early 20’s, he may eventually be left with only a very thin see-through fringe as he ages. A high donor density now does not ensure that this will not occur – and coarse hair at 22 does not ensure that it will not become fine over time.
What Are Differences Between Follicular Unit Transplantation, Follicular Unit Extraction, and Ultra-refined FUHT?
Q: What is the difference between the following ways of doing hair transplants: Follicular Unit Transplantation (FUT), Ultra-refined FUHT, and Follicular Unit Extraction (FUE)?
In brief, with FUT, follicular units are obtained from the microscopic dissection of a donor strip that has been removed from the back of the scalp. In FUE, the doctor attempts to remove intact follicular units directly from the scalp via a small round instrument called a punch.
Ultra Refined FUHT (Follicular Unit Hair Transplantation) is term that Pat Hennessey uses on his Hair Transplant Network. It refers to using very tiny recipient sites, carefully dissected follicular unit grafts, and large hair transplant sessions in FUHT procedures.
Q: I recall that you wrote an article about Monocryl for the donor closure in hair transplants. Why are you now using staples? — R.S., Park Slope, NY
A: I have been using staples in almost all of our follicular unit hair transplants since the beginning of 2006. Continue reading for the detailed explanation as to why I made the switch from sutures to staples.
Q: Some surgeons are doing hair transplants using 5,000 to 6,000 grafts in a single surgery. Looking at the cases in your photo gallery, it seems like your hair transplants involve many fewer grafts per surgery. Do you do such large graft numbers in a single hair restoration procedure? A: The goal in surgical hair […]
Q: Can you please comment on the use of sutures verses staples in hair restoration procedures?
A: Sutures are great on non-hair bearing skin and allow perfect approximation of the wound edges, but on the scalp they can cause damage to hair follicles below the skin’s surface. The reason is that a running (continuous) suture traps hair follicles and when the skin swells (as it normally does after hair transplants) the trapped follicles can strangulate and die.
Q: Hi, I am a 21 year old male experiencing the first signs of hair loss as of late. I looked at your before and after pictures of hair transplant patients and honestly right now I have a lot more hair than the patients, even in the after photos. By no means do I intend to criticize your work at all, but I noticed that they still had a receding hairline. I myself am an artist and pay close attention to detail. What I want out of a hair transplantation procedure is to basically have the full head of hair that I had even before puberty. Is it possible for this to be done?
A: Your concerns and goals, although understandable, are impossible to achieve through hair transplantation and is exactly the reason why we don’t perform hair transplants in young persons.
Surgical hair restoration can never give you your original density back since we are just redistributing a smaller amount of hair.
In addition, your original hairline should not be restored since a transplanted hairline is permanent and will not evolve naturally as you age. A mature hairline must be built into the design of the first hair restoration procedure, regardless of a patient’s age.
Q: Can you give me an idea of the average width of a donor strip, i.e. the actual width taken from the back of your scalp for a hair transplant?
A: The average donor strip is 1cm wide, although this will vary depending on the patient’s scalp laxity, density, and the number of grafts desired for the hair restoration.
The length also depends on the number of grafts needed. We average 90-100 follicular unit grafts per cm2 of donor tissue (that is the density of follicular units in an average person).
Q: Could you tell me in case there is an infection at the donor area following a hair transplant, will it prevent the hair to grow after healing if the donor area closed by Trichophytic Closure? What are the problems which may the infection cause?
A: Infection may cause the donor incision to heal more slowly or with a widened scar after a hair transplant. It may affect any closure, Trichophytic or not.
The risk of infection after a hair restoration procedure is made worse by a tight closure, but not necessarily a Trichophytic closure, unless too much skin was removed at the edges leaving the dermis (deeper part of the skin) exposed.
Q: In my first hair transplantation procedure, I wanted to be as conservative as possible and focus on thickening the thinning hair on top of my head and lowering the hairline minimally. Is it still possible to lower the hairline further in a second hair restoration procedure? Is there an “ideal” time period for a second hair transplant after the first?
A: It is possible to lower the hairline with a second hair transplant, but the doctor must be certain that you have enough donor hair so that the transplanted pattern will look natural long-term.
Unless there is some pressing reason that you had to have a second session sooner, I would wait a minimum of 10-12 months between hair restoration procedures so that you can see the full cosmetic impact of the first session.
As a hair transplant matures and thickens, the hairline will look lower as the eye doesn’t see as far into the scalp.
Q: I had a follicular unit hair transplant 5 days ago and my scalp is very scabby. Is there something that I can do to make it look better?
A: Before you go to bed, take a long shower and shampoo during the shower for at least 5 minutes, with a very thorough rinsing. As soon as you get out of the shower, while your hair is still wet, put on a shower or bathing cap that will hold in the moisture. Sleep in this cap and then take a long shower/shampoo when you awake. This will remove some or all of the crusts. The process should be repeated each night until all the crusting is gone.
Q: I have had a minor facelift operation and have lost a bit of hair. Have you heard of this before? The areas around the scars are the most effected. What treatments are best for this?
A: Hair loss after a brow, or face lift, is quite common. If it is cosmetically bothersome, a localized hair transplant can correct the problem.
The hair can be transplanted directly into the scar (if the scar is flat) and into any surrounding areas of thinning. The complete correction may take more than one hair restoration session.
Q: I went to a hair transplant doctor for a consultation for my hair loss and he said that it was not that important to use microscopes for hair transplants. I had heard that it was. What’s the deal? A: It is extremely important to use microscopes when performing hair transplants. It is the only […]
Q: I had hair transplant surgery 10 days ago and have since developed what looks like big, dry flakes in the transplant area. How long does it take for the grafts to root, and is it okay that some of the grafts fall out when brushing my hair back carefully at this point? Also, the area that was worked on has not fallen out yet, so should I shave this area before the new hair comes in or should this be a natural process?
A: Grafts are generally permanent 9 days following a follicular unit hair transplant procedure, so you may shampoo the flakes off at this time. If larger grafts were placed (with correspondingly larger recipient sites), the grafts will be subject to being lost for a slightly longer period of time. After 9 days, you may shave or clip the hair in the transplanted area if you like, but this will not affect the success of the hair restoration one way or the other.
Q: I know that I can’t get all of my hair back, but what can I realistically expect from the best hair transplants?
A: You can expect the follicular unit hair transplant procedure to be perfectly natural, that the hair restoration will be completed in one or two sessions and you should anticipate a quick and easy post-op course.
The amount of coverage and density will depend upon your Norwood (balding) class, your donor reserves and your hair characteristics.
Q: Why should a doctor measure miniaturization in the donor area before recommending a hair transplant?
A: Normally, the donor area contains hairs of very uniform diameter (called terminal hairs). In androgenetic hair loss, the action of DHT causes some of these terminal hairs to decrease in diameter and in length until they eventually disappear (a process referred to as “miniaturization”). These changes are seen initially as thinning and eventually lead to complete baldness in the involved areas.
These changes affect the areas that normally bald in genetic hair loss, namely the front and top of the scalp and the crown. However, miniaturization can also affect the donor or permanent regions of the scalp (where the hair is taken from during a hair transplant). If the donor area shows thinning, particularly when a person is young, then a hair transplant will not be successful because the transplanted hair would continue to thin in the new area and eventually disappear. It is important to realize that just because hair is transplanted to another area, that doesn’t make it permanent – it must have been permanent in the area of the scalp it initially came from.
Q: I am considering having an FUE procedure and have heard the phrases topping, capping, and tethering as part of the procedure. What do all these terms mean?
A: These are all terms that refer to the types of injury that can occur to grafts during a follicular unit extraction procedure.
In FUE, a sharp instrument (or sharp instrument followed by a blunt one) is used to separate follicular units from the surrounding donor tissue. Forceps are then used to remove the follicular units from the scalp.
Topping occurs in the first step when the doctor accidentally cuts off the top of the graft so that the remainder of the graft cannot be removed.
Capping occurs when the doctor grabs a graft with forceps and the top of the graft (the epidermis and upper dermis) pulls off, leaving the rest of the graft behind.
Tethering occurs when the bottom of the graft is still attached to the deeper tissues after the first step causing the follicular unit to pull apart during extraction.
Q: I am a patient of yours who had a hair transplantation procedure done mostly in the crown area and in the front about seven months ago. The hair is just starting to come in nicely and is starting to fill in the bald spots. Yesterday I carelessly banged the top of my head against a beam in my attic and cut a nice gash in, you guessed it, a transplanted area. I’d say that the cut is about a good inch. My wife works for a doctor who is certified in facial plastic surgery and I had him suture up the gash. He did not cut any hair, but it took 4 stitches to close the wound. I’m worried about the impact on the transplanted area. Just when it was starting to come in nice I now have a bald spot that I suspect is going to stay as a result of the accident. Please advise.
A: There is not much you can do at this time. Depending upon the doctor’s suturing techniques; you may or may not have permanent hair loss from the trauma and subsequent suturing. The problem is that if the sutures are placed too far from the wound edge they can strangulate hair follicles, particularly if there is any swelling. Hair loss may be temporary, but if it is permanent, it should be minimal. Additional grafts can be added at your next hair restoration procedure to cover any area of hair loss and the scar from the injury, if it is visible.
Q I had a friend that had to wear a turban-like bandage on his head for a week after his hair transplant, but his procedure was a number of years ago. What is the post-op dressing like now and how soon can you shower after a hair transplant procedure?
A: Patients leave the office after the surgical hair restoration wearing only a tennis band wrap and a surgeon’s cap (that can be worn under a baseball cap).
The morning following the hair transplantation, the dressing can be removed and no further dressings or bandages need to be used.
The day following hair transplant surgery I suggest patients to take 3 or 4 showers to remove the crusting as it forms. The crusts are removed by gently shampooing with a copper-peptide based product. After the 1st day following the procedure, the crusts no longer form and showering/shampooing can be decreased to twice a day; morning and night.
After the first week, showering once a day is fine.
Q: I have curly hair with thinning on top and strong, but less curly hair on the sides and back. My hairline is receding, but it is really the area on top I am concerned about. Does hair replacement work with curly hair and will it match? A: Yes, curly hair grows as well after […]
Q: Dr. Bernstein, is a follicular unit hair transplant, the way you perform it, very painful?
A: We perform our hair transplant procedures using long-acting, local anesthesia, so after the initial injections, the patient doesn’t experience any pain or discomfort.
The local anesthesia (a combination of Lidocaine and Marcaine) lasts about 4-5 hours. For long sessions, we give additional anesthesia before the first wears off.
Q: Dear Dr. Bernstein, a full head of hair averages ~100 FU/cm2. To achieve the appearance of fullness with a hair transplant 50% is required. In one of your articles you say that you recommend 25 FU / cm2 to your patients. Is that the density per one session or the final one? If that […]
Q: Hair transplantation sounds like a really time-consuming procedure. How long does the hair transplant actually take?
A: An average hair transplant, that involves the movement of 1,500 to 2,500 grafts, can take a team of up to six people, five to eight hours.
Surgical hair restoration is a very time-consuming, labor intensive process, where every aspect of the surgery must be precisely controlled to get maximum growth and an optimum cosmetic result.
Q: Dr. Bernstein, I remember Senator William Proxmire. He was one of the first sort of high-profile people who had a hair transplant probably, what, thirty years ago, and to be honest with you, it wasn’t all that great. It looked kind of funny. Have we made any progress in the last twenty-five, thirty years?
A: When hair transplant surgery was first developed in the late 1950s, early 1960s, everybody was so ecstatic that it grew – that one could actually move hair from the back of the head to the top, and it would grow – that no one really considered either the long-term implications or the aesthetic aspects of the procedure. And the fact that the hair grew is actually a problem because it never went away when it was transplanted poorly.
Over the years the grafts have gotten smaller and smaller. So where in the ’60s and ’70s they were the size of pencil erasers, they gradually decreased in size until doctors were performing hair transplants using just a few hairs at a time. The major breakthrough came in the mid 1990s when we realized that hair doesn’t grow individually but grows in little tiny groups and these groups are called follicular units.
In modern hair transplant surgery (which began in 1995) hair is taken from the back of the scalp and moved to the front and top of the scalp in these individual groups of one to four hairs.
In this way the results can completely mimic the way hair grows in nature.
See the Follicular Unit Transplant (FUT) section for more information.
Q: How does a hair transplant prevent hair loss?
A: It doesn’t. Surgical hair restoration does just what it says. It restores hair to an area where the hair has been lost (by borrowing it from an area of greater density that is less important cosmetically, such as the back of the scalp).
To prevent, or slow down, further balding one would need to receive treatment with hair loss medication such as finasteride (Propecia).
Q: I had a hair transplant of over 600 grafts using Follicular Unit Extraction (FUE) to my frontal hairline and the frontal part of my scalp. The procedure was done less than a year ago by another doctor. Since then I have had persistent pimples and redness in the area that the grafts were placed. Also, the surface of the skin in the area is irregular.
A: One of the causes of having pimples and redness following Follicular Unit Extraction may be buried hair fragments and there are significantly more hair fragments generated with the two-step FUE technique than with the three-step method.
In the three-step procedure, we use blunt dissection which minimizes transection (cutting of hair follicles) and thus reduces the incidence of hair fragments. See the Three-Step FUE page at the Bernstein Medical – Center for Hair Restoration website.
Q: It is my understanding that as a person loses his or her hair, the skin of the scalp undergoes a number of changes, namely there is a loss of fat, an increase in cellular atrophy, and of course the dreaded perifollicular fibrosis (now that’s a mouthful). It seems to me that these changes, in particular the fibrotic scarring, are the main obstacles in the way of regrowth, and the reason Propecia does not work for extensively bald men. What can be done about this demon we call fibrosis? Can it be slowed, stopped, prevented, reversed? If we could somehow counteract collagen formation, wouldn’t our baldness problems be solved for good? If a bald scalp is atrophic, how does it have the capacity to hold a whole new head of transplanted hair? Is there a limitation to the number of hairs we can transplant (outside of donor limitations)?
A: The findings that you are describing are well documented; however, it is not clear if these changes are the cause of the hair loss or are the result of having lost one’s hair. Most likely, the DHT causes the hair follicles to miniaturize and eventually disappear. This, in turn, causes the scalp to thin and lose its abundant blood supply (whose purpose is to nourish the follicles). The changes in the scalp are also affected by normal aging, which causes alterations in connective tissue including the breakdown of collagen and other components of the skin. The changes seen with aging are greatly accelerated by chronic sun exposure.
Q: I have heard that staples are uncomfortable after the hair transplant, why do doctors use them?
A: Staples are used for two main reasons.
The first is that being made of stainless steel; they don’t react with the skin and, therefore, cause little inflammation.
The second is that, unlike sutures which are used with a continuous spiral stitch, each staple is separate and this causes minimal interruption to the blood supply.
Q: Is there ever an age where you are too old for a hair transplant? A: One can be too young for surgical hair restoration, but not too old (as long as one is in good health medically). Older people generally make excellent candidates for hair transplantation since their expectations are generally more realistic and […]
Q: What can be done if I want to have a hair transplant and my scalp is very tight from prior surgeries?
A: Follicular Unit Extraction is ideal in very tight scalps, provided that there is enough hair to extract without leaving the donor area too thin and provided that the follicles are not too distorted from the scarring.
With strip harvesting, undermining techniques may be helpful to close the wound edges once the strip is removed.
Q: I am interested in FUT. How do you figure out how large a strip to use for the hair restoration when transplanting all follicular units?
A: The length of the donor strip incision is determined by the number of follicular unit grafts required for the hair restoration.
There are slightly less than 100 follicular units/cm2, so if a 1cm wide strip is used, a hair restoration procedure requiring 1800 grafts would need a strip that measured slightly more than 18cm in length.
Q: I am trying to have my donor scar repaired after a 1000 graft hair transplant. I was told the FUE’s placed into the scar would conceal it enough to shave my head? I would like to shave my head completely bald with a razor.
A: In general, after a scar correction with follicular unit extraction you can clip your hair very short, but not shave your head. If you shaved your hair completely bald, you would generally see a vague outline of the linear scar as well as the small scars from FUE.
Q I had a hair transplant 15 months ago at a well known clinic in Manhattan. There were about 1000 grafts transplanted in the front hair line. At this point I am upset with my results. My guess is that only about 50 new hairs have grown. My question is what would cause this to happen? It seems to me that the hair transplant took longer than expected and my grafts died before they were placed! Please help!
A There are many factors that can contribute to poor growth during the hair restoration process including grafts that are left out of the holding solution too long or kept under the microscope for a prolonged period of time where they dry out.
Grafts can be injured in the dissection process or can be traumatized during the placing – if they are grasped too tightly or manipulated too much.
Q: I have heard that the hair for a hair transplant is taken from the back and sides of the scalp. Where exactly is the best place to remove the hair from?
A: You are correct. The best place to put the donor incision is in the mid-part of the permanent zone located in the back of the scalp. As more hair is needed the incision is extended towards the sides.
Q: Why are strips used so much in a hair transplant when there is now Follicular Unit Extraction (FUE)?
A: Strip harvesting is used in the majority of hair transplant procedures because it allows the surgeon the ability to perform hair transplant sessions using large numbers of grafts while minimizing injury to the patient’s hair follicles.
This is possible because once a strip is removed from the back of the scalp, the tissue can be placed under a stereomicroscope where dissection is accomplished using direct visualization of the follicular units. This allows the grafts to be dissected with minimal trauma.
Q: I am 22 and want to go for hair transplantation. I want hair restoration surgery now because I have a concern about my donor area that it might diminish if I postponed my transplantation. Could this be the case?
A: The logic is not correct. Having a hair transplant at an early age does not protect the donor supply.
If your donor area diminishes over time, then the transplanted grafts will fall out as well. Hair does not become permanent just because is moved in a hair transplant. It is never any better than the hair in the area where it came from.
The longer you wait – i.e. the older you are when a hair transplant is performed – the more information we will have about the stability of your donor area and this will allow for optimal planning of the hair restoration.
Q: I have read that some doctors perform something called a trichophytic closure. What is this?
A: A trichophytic closure is a way to minimize the appearance of the donor scar in a hair transplant using a strip incision.
The technique entails cutting the off the top of one of the wound edges and suturing it so that the hair from that edge grows through the scar. Either wound edge can be trimmed in the technique, but removing part of the upper edge is most common.
Q: I have read about something called “tumescent anesthesia” but didn’t understand what it is. What exactly is it? A: Tumescent techniques were first popularized in liposuction surgery where large quantities of fluid containing adrenalin were injected into the person’s fat layer to decrease bleeding before the fat was literally sucked out of the body. […]
A: In general, FUT will give you more hair since, in FUT, the best hair from the mid-portion of the permanent zone of the scalp (also called the “sweet spot”) can be utilized in the hair transplant.
With FUE, since only the hair follicles are extracted and not the surrounding bald skin, if too much hair is removed, the donor area will begin to look thin as hair is removed. This will limit the amount of hair that can be harvested.
Although in FUE additional areas of the scalp can be utilized to some degree, this will generally not compensate for the inability to access all of the hair in the mid-permanent zone and the total amount available for the hair restoration will be less.
Q: Should I cut my hair prior to the hair transplant?
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.
Q: What exactly is compression in a hair transplant?
A: Compression refers to the visible tufting of grafts due to the contraction of the grafts from the normal elasticity of skin around it, after it has been inserted into the recipient site.
Compression is most commonly seen when minigrafts are used in the hair restoration (minigrafts contain more than four hairs each).
Follicular units don’t show visible compression, since they are already naturally compact. However, if more than one follicular unit is placed into the same site, it can exhibit this phenomenon.
Q: What is your opinion on having a hair transplant to restore the hairline and then wearing a hair system behind it to regain the appearance of a full head of hair? K.Y. – Hackensack, New Jersey A: It is my personal feeling that one should not use a hair transplant to supplement a hair […]
Q: I understand that even if you have multiple hair transplants you will only be left with one scar in the donor area.
A: If the closure is performed 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: Is it possible to do a hair transplant using follicular unit extraction without shaving the donor area?
A: In follicular unit extraction, the area that is extracted is clipped to about 1-mm in length. However, if the session is not too large, then the clipped area can be long and thin so that the patient’s existing hair will cover it. The person’s hair should be left long for the procedure.
How Many Hair Transplant Grafts Will Give Best Results and Do Megasessions Yield Best Cosmetic Benefit?
Q: There is such a big deal made on the chats about people getting Megasessions of over 4000 grafts per session. When I look at the pictures on your website, the results look great, but I am surprised that not many grafts were used compared to what is being talked about. A: My goal is […]
Will Hair Transplant be Detectable Immediately After Surgery and What is Typical Appearance Post-op?
Q: Is it possible to have a hair transplant that is totally undetectable immediately following surgery?
A: Not unless a person has a fair amount of existing hair that can cover the transplanted area.
Although surgical hair restoration 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 detectable 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 the section on the Bernstein Medical – Center for Hair Restoration website entitled After Your Hair Restoration for more details. Also see the Instructions After Your Hair Restoration Surgery page regarding the normal post-op course following a hair transplant.
Q: Can hair be transplanted from one person to another?
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.
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: After a strip procedure, will the scalps laxity return to normal and how long after the hair transplant does it take?
A: The scalp regains most of its laxity in the first eight months following the hair transplant, but it will continue to loosen slightly after that.
Q: Is it possible to tell me roughly how many grafts would be left from donor area if one had a hair transplant of 2,500 grafts and had a density of around 2.0? G.H. – New York, NY
A: How much hair can be harvested in total depends upon a number of factors besides donor density. These include: scalp laxity, hair characteristics (such as hair shaft diameter, color and wave), and the actual dimensions of the permanent zone.
Every person is different, so all of these factors would need to be taken into account to determine the total number of grafts that would be available for the hair restoration.
Q: I have had some grafts implanted into a donor scar. How long does it take to see the final result?
A: In normal scalps, growth is generally complete by 10-12 months. Grafts placed in scar tissue may often take longer to grow.
Q: What causes graft popping during a hair transplant? 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 […]
Q: Can hair transplants grow in scars?
A: Grafts will grow in scar tissue as long as the scar is not thickened. However, they cannot be placed as close together as in normal scalp because of decreased blood flow. When performing a hair transplant into scar tissue, it is often necessary to perform the hair restoration in multiple sessions to allow the area to gradually re-vascularize (allow the blood supply to return).
Q: Why can donor hair become frizzy and dry once transplanted?
A: Frizzing and kinkiness is a temporary phenomenon that is part of the normal healing process after a follicular unit hair transplant.
During the healing process, the new collagen that forms around the grafts can alter their growth. Over time, usually within a year, this collagen matures and the hair quality usually returns to normal.
If grafts have been excessively traumatized or grafts larger than follicular units have been used, these changes are more likely to be permanent.
Q: Is it true that smoking is bad for a hair transplant and why?
A: Smoking causes constriction of blood vessels and decreased blood flow to the scalp, predominantly due to its nicotine content. Also, 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.
Q: Will the shock of a hair transplant make me lose my existing healthy hair and is it permanent?
A: In general, only miniaturized hair (the hair that is affected by androgens and that has begun to decrease in diameter) is shed after a transplant. This hair would be lost in the near term anyway.
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?
A: The follicles are firmly fixed in the scalp 10 days following the hair transplant. 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 you may shower and shampoo your scalp as you normally did before the procedure without any risk of losing grafts.
Q: I have had some surgical procedures on my head that left a fair amount of scar tissue. Can hair grow there? Is it a more difficult procedure? Are there any complications? A: Transplanted hair will grow in scar tissue as long as the tissue is not thickened. Thickened scar tissue can be flattened with […]
Q: I have had 4 hair transplants with strips taken out for a total of 2600 grafts over 15 years. The last one was 1,650 grafts. My doc says my donor site is good for a few more but I think it has been probably stretched to its max. Is it believable that the skin can be stretched to such extremes safely?
A: The scalp is very resilient to stretching, particularly in those with a loose scalp to begin with. After removing a strip, the laxity often returns to normal or very close to it within 6 months to a year.
The problem with multiple hair transplant procedures is not only that scalp laxity may decrease, but that the donor density decreases as well. If too much hair is harvested, the donor area may eventually appear too thin. This may happen with either Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE).
Therefore, it is important the doctor not only assess the scalp laxity, but the residual donor density.
Q: When a second hair transplant is performed, should there be a second incision or should it be incorporated into the first?
A: It is a very common practice to make a second separate scar in the second hair restoration procedure. This is done to maximize the hair in the second session, and it is technically the easiest to perform. 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.
Q: Will I be unconscious during the hair transplant procedure and do you use general anesthesia?
A: All of the surgical hair restoration procedures at Bernstein Medical 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.
Q: Why does a hair transplant work? A: Hair transplantation works because hair taken from the permanent zone in the back and sides of the scalp maintains its original characteristics when transplanted to a new place in the balding area in the top of the head. This property of hair is called “donor dominance” and […]
Q: I have a scar on the top of my head the size of a quarter from an old injury. I would like hair to grow back on the bald spot. Can a hair transplant re-grow hair on the spot and not have any scar on my head at all?
A: Traumatic scars are readily treated with follicular unit hair transplantation. The hair generally grows quite well in scar tissue as long as the scar is not thickened (hypertrophic). Several sessions are usually required. Although the hair restoration can make the bald area undetectable, the underlying scar tissue will still be there.
Q: What is “shock fall out”?
A: Shedding after a hair transplant 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 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 restoration 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.
Q: When harvesting donor hair, how does the surgeon know when to stop? A: The patient must first decide the shortest length he/she is comfortable wearing his/her hair. Donor hair can be removed — whether through Follicular Unit Transplantation (FUT) or Follicular Unit Extraction (FUE) — as long as, at this length, the back and […]
Q: I have a bald patch on my scalp diagnosed as DLE, can this be corrected with a hair transplant? A: DLE or discoid lupus erythematosus is a type of autoimmune disease where the body produces an inflammatory reaction to components of the skin, causing it to scar and lose hair. The skin in the […]
Q: This is my second hair transplant and is seems like it is growing more slowly than my first. Is this normal?
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 transplant to grow in fully and to give a chance for any hair that was shed to regrow.
Q: What is graft compression?
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.
Q: If I had a hair transplant using Follicular Unit Transplantation, how many grafts would be in a 15cm by 1cm donor strip, on average? A: In a person with average donor density there are approximately 100 follicular units per square centimeter. A 15cm long strip would have slightly less than 1500 grafts due to […]
Q: Can you shave your scalp after a hair transplant with FUE without noticing scarring in the donor area?
A: Although there is no line scar in follicular unit extraction, 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: I have developed a rather large, hard lump beneath the skin at the base of my scalp in the donor area that I first noticed this about two or three weeks after my hair transplant. What is this?
A: You are describing an enlarged lymph node, a condition commonly seen as a normal part of the post-op course following hair transplants.
This is a normal part of healing in response to the surgery. It will resolve on its own in about 3-6 months. It doesn’t require any treatment and it should not be a cause for concern.
Q: Should you perform a hair transplant on a crown that is just starting to thin?
A: A “thin” crown should first be treated with Propecia, as it may thicken the hair to a cosmetically acceptable degree without the need for surgery. If Propecia is ineffective in restoring enough hair, then surgical hair restoration can be considered.
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?
A: Each day following the 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 surgery, it is almost invariably associated with a small amount of bleeding.
For details on how to care for a hair transplant, visit the Instructions After Your Hair Restoration Surgery page on the Bernstein Medical – Center for Hair Restoration website.
Q: When a donor strip is taken out during a hair transplant and separated under the microscope, you can read on the internet that there is a wastage of grafts (about 15%), because of those unseen telogen hairs. What do you think about that and how does it affect the hair restoration?
A: The Telogen phase of the hair cycle is about 3 months long and about 12% of follicles are in this phase at any one time. It is speculated that the follicles may be empty for perhaps 1/2 that time (this number may vary significantly between people). Therefore, approximately 6% of the hair follicles may be in telogen at any one time.
Q: Can you get your original density back with a hair transplant?
A: Although the cosmetic benefit can be dramatic, a hair transplant only “moves” rather than creates new hair. In surgical hair restoration, 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.
Q: I’ll be traveling from New York to Cincinnati the week after my hair transplant. Will I be able to get through airport security if I have staples?
A: Yes. Although the staples that we use to close the donor area after hair transplant or restoration procedures are made of stainless steel, they are too small to be picked up by metal detectors.
I generally prefer staples, as they are superior to sutures in preserving donor hair.
Q: What is Follicular Unit Transplantation and how is it different from Follicular Unit Extraction?
A: Follicular Unit Hair Transplantation, called FUT for short, is a procedure where hair is transplanted in the naturally occurring groups of one to four hair follicles. These individual groups of hair, or units, 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. There is no linear scar. There is, however, scarring 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.
Q: Do you ever see poor growth from a hair transplant?
A: The situations where I have encountered poor growth are:
1) When hair is transplanted to areas of skin that has been thickened due to the prior placement of larger grafts or plugs (this is called “hyperfibrotic thickening”). Removal of the larger grafts can somewhat ameliorate this problem.
2) When hair is transplanted into a thickened scar.
3) When a hair transplant is performed into an area of severe chronic sun damage. In this case, a very modest number of grafts should be used in the first session and if these grow well, additional grafts can be added in a subsequent session.
Q: What are your recommendations for wearing a hairpiece following a hair transplant?
A: First, some clarification. It is OK to wear a “hair piece” (one that is attached to the hair with clips or to the scalp with tape) so that it can be removed each night, but NOT a “hair system” (that is woven to existing hair or glued to the scalp and must be removed by the salon).
Patients should wait a week before they resume wearing their hairpiece, although some patients use it as soon as two days later (but keep it on for very short periods of time).
Q: My hair is fine. Is that a problem for a hair transplant?
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: Is it possible to use the strip technique with the extraction technique together? If so, would that hide the scar enough for me to wear my hair really short?
A: The combination of Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) used the way you are suggesting does make sense and is actually how I originally envisioned the two procedures to work together.
The camouflage of the donor scar will probably never be necessary, but if it is desired, it should be postponed until after the last FUT procedure. FUE will make it possible for most people to wear their hair very short.
Q: Can you use beard hair for a hair transplant using Follicular Unit Extraction?
A: It is possible to use beard hair for a hair transplant, 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. Let’s explore these differences in turn.
Q: If my hair is just starting to thin, when should l have my first hair transplant?
A: It is best to wait until at least 25 before considering hair restoration surgery, although there are exceptions. The most important thing is to wait until you have hair loss that is a cosmetic problem. A hair transplant is a treatment for hair loss – it should not be used as a prevention. When hair loss is just starting, medical therapy is generally a better choice than surgery as it can both regrow hair and prevent future loss.
Q: If someone doesn’t have enough donor hair, do you ever perform a hair transplant using FUE, using donor hair from outside the permanent hair zone?
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: Does dense packing hurt grafts?
A: There is no absolute answer to this question. In a hair transplant, 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 transplant surgeon 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: 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.
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 sessions.
Q: If a second hair transplant is performed before the first had a chance to grow could the second procedure destroy the follicles from the first?
A: Hair from the second hair transplant session would not damage the follicles transplanted in the first session, even if follicular unit grafts were transplanted in exactly the same spot as in the first session.
The reason to wait until the hair grows in, however, is so that you can better plan the subsequent hair restoration procedure. If two follicular units are placed on top of each other or very close together, you will essentially be creating a mini-graft and the results will not look natural.