Hair Transplantation: Textbook for Estheticians (1999)
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Robert M. Bernstein, MD, New York, NY
William R. Rassman, MD, Los Angeles, CA

Milady’s Standard Textbook for Professional Estheticians, 8th Ed. New York, Delmar Publishers, 1999.


There has been a revolution in the field of hair restoration surgery that began in the early 1990’s. This is the result of new technology which has given the doctor the ability to transplant very large numbers of small grafts at one time. Although first hair transplants for baldness were performed in this country in 1952, the results of the hair restoration process were quite unsatisfactory for many years. The “pluggy” or “cornrow look” that people commonly associate with a hair transplant were the results of surgery performed during this period. With the latest hair transplant techniques, these poor results are a thing of the past. If performed properly, the modern hair transplantation can produce results that are totally indistinguishable from one’s existing hair.

Hair transplantation is an out-patient surgical procedure that can only be performed by a licensed physician who should have specific training and experience in this field. All hair transplants are based upon the principle that there is a permanent zone of hair in the back and sides of the scalp that is unaffected by genetic balding (also called androgenetic alopecia). In fact, this term actually explains what balding is. Andro… means that some hair is subject to the affects of male hormones called androgens (more specifically testosterone), which causes the affected hair to shrink in size and eventually die. “Genetic” means that the tendency for a person’s follicles to be affected is due to inherited or genetic factors rather than external situations, such as diet or shampoos. Finally, alopecia, is the medical term for hair loss.

Fortunately, in the “permanent zone,” the follicles are not affected by these hormones. Because this property resides in the hair follicle itself, rather than in the skin, the hair will retain its healthy characteristics regardless of where it is moved. Therefore, hair that is transplanted from the permanent zone in the back of the scalp to the bald area in front of the scalp will continue to grow. This trait, called “donor dominance,” was originally described in a famous paper published in 1959 by the dermatologist, Dr. Normal Orentreich.

It is interesting to note that most women do not bald in the typical male pattern but lose hair diffusely and would, therefore, not benefit from a hair transplant. The 10 percent of women that do bald in the typical “male pattern” (i.e., that have relatively thick donor hair with thin or absent hair in the front of the scalp), can be good candidates for this procedure.

When the first hair transplants were performed, it was thought that the challenge would be to make the hair grow. Now we know that the hair grows very well. Far more effort is devoted to removing unwanted hair than to replacing lost hair and as everyone who has gone through electrolysis knows, it is very hard to destroy healthy hair follicles. Since hair transplantation is permanent, the real challenge is to transplant the hair in a way that will look natural your entire lifetime. Unfortunately, severe hair loss can affect some people at as very young age (late teens to early 20’s), and for these people, proper long-term planning is especially important.

Although the younger patient may be anxious to do something right away, it may be better to postpone hair restoration surgery to a later date when the extent of the patient’s hair loss can be better determined, since hair loss is continuous, it is very important for the patient to have very realistic expectations of what a hair transplant can and cannot achieve. This is accomplished through a careful examination and a detailed discussion with an experienced physician.

The follicular unit hair transplant procedure itself is very straightforward. After the patient’s skin is numbed with a local anesthetic, a long thing strip of skin is removed from the donor area in the back (and sometimes sides) of the scalp. The donor area is then sutured closed, leaving a fine scar that will be well hidden in the surrounding hair. Next, a team of specially trained assistants helps the doctor dissect out the hair follicles (which grow in very small groups of 1 to 4 hairs, called follicular units) from the surrounding skin. The physician then makes tiny slits (sites) with a special instrument (that looks like a small needle) in the front, top, and sometimes crown of the scalp. It is very important that these sites are at the exact angle that the patient’s original hair grew, because this will determine how the transplanted hair will also grow. It is also important that the hairline be placed in a natural position and not too far forward, because it must look good for many years to come. In addition, the sites must be made in a very random [pattern, because this is how hair grows in nature. Once the sites are made, the individual follicular implants are placed in the recipient sites with the smallest (containing single hairs) at the frontal hairline, and those of two, three, and four hairs behind them.

Using the most modern hair transplantation techniques, where an entire bald area can often be covered in a single session, the procedure can take from 5 to 10 hours, depending upon how many grafts are needed. In an average session, 1500 tiny grafts would be transplanted, but this can range from as little as 400 to over 3,000 if someone is very bald and has a good supply of donor hair. During the hair restoration procedure, while the team works on his or her scalp, the patient rests comfortably in a reclining chair and can watch TV, eat, and take breaks to stretch or walk around. After the hair transplant, the patient leaves the office without bandages and is instructed to gently shampoo his or her hair the following morning and in a few days can go about all normal activities.

The transplanted hair generally falls out within a month after surgery, leaving behind the healthy, transplanted hair follicles and a completely normal looking scalp. The follicles will begin to produce new hair in about 3 to 4 months, but it often takes a year to see the full results of the hair transplant. During this time, not only will new hair crop up, but each hair will increase in thickness and in length.

New techniques can also repair the cosmetic problems produced by the larger grafts that had been used in the past. Plugs can often be camouflaged by placing a zone of very fine 1 and 2 hair grafts in front of them. In some situations, where the plugs have been placed too far forward, or in the wrong direction, they may need to be surgically removed.

The amount of hair transplanted will depend not only on the patient’s needs (i.e., how bald he or she is), but upon how much donor hair that can be safely moved. This is limited by the density (how much hair per square inch there is in the donor area) and the looseness of the scalp. How the patient will ultimately look after the hair restoration will not only depend upon how much hair was transplanted, but upon hair characteristics such as diameter, color, and wave. The patient’s satisfaction with the hair transplant is a combination of all these factors but, in addition, will ultimately rely upon how realistic his or her expectations were and if these expectations were reasonably met. Proper physician counseling and careful planning is always the best assurance for success in hair transplantation as in all cosmetic procedures.

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