Bernstein Medical - Center for Hair Restoration - Appearance After Hair Transplant
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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.

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A recently published study ((Bater KL, Ishii M, Joseph A, Su P, Nellis J, Ishii LE. Perception of Hair Transplant for Androgenetic Alopecia. JAMA Facial Plast Surg. 2016 Aug 25. doi: 10.1001/jamafacial.2016.0546.)) is the first to measure the perceived benefit of hair transplantation on a patient’s age, attractiveness, successfulness, and approachability – key factors that play an important role in workplace and social success. The pilot study, published in the Journal of the American Medical Association Facial Plastic Surgery, found that hair transplant recipients were perceived by others to be 3.6 years younger following their hair restoration surgery. The data indicate that the person’s attractiveness, successfulness, and approachability also showed statistically significant positive changes as a result of hair restoration surgery.

Background

Half of men over 40 experience hair loss. This may be associated with significant adverse psychological effects including reduced self-esteem and self-confidence, plus the social consequences that follow. Prior studies have shown that men who are balding are rated poorly when it comes to attractiveness, likability, and personal and career success. ((Wells PA, Willmoth T, Russell RJ. Does fortune favor the bald? psychological correlates of hair loss in males. Br J Psychol. 1995; 86(pt3):337-344.)), ((Cash TF. Losing hair, losing points? the effects of male pattern baldness on social impression formation. J Appl Soc Psychol. 1990;20(2):154-167.)) This perception motivates men to seek hair restoration in order to improve how they are viewed by others. The new study attempted to quantify, for both patients and their surgeons, the actual benefit of hair transplant surgery on these key perceptions.

Methods

The randomized, controlled study involved 122 participants — 47.5% men, 51.6% women — each of whom were shown a series of 13 sets of before and after hair transplant photos. Of the photo sets, seven showed men before and then after a hair transplant of approximately 1,200 follicular unit grafts. The control group were of men who did not have a hair transplant or any facial cosmetic surgery. Each participant was asked to rate how much younger the “after” photograph appeared, on a scale of 1-10 years. For the other metrics — attractiveness, successfulness, and approachability — the participants used a slider bar to indicate a positive or negative change.

Results

On age, the data showed a range of about one year younger to about six years younger for the “after” photos, for an average of 3.6 years younger in people who had a transplant. The “after” photos for the control group were perceived to be an average of 1.1 years younger, confirming that the post-transplant group appeared younger than the control group. On attractiveness, successfulness, and approachability, study participants rated the “after” photos with scores of 58.5, 57.1, and 59.2, respectively. This amounts to a 17% improvement in attractiveness, 14.2% improvement in successfulness, and an 18.4% improvement in approachability.

Summary

Since the first hair transplants in the 1950s we have observed that surgical hair restoration can significantly improve one’s appearance. Now, for the first time, we have concrete data that shows the extent of the change of perception in the person’s age, attractiveness, successfulness, and approachability that is caused by the hair restoration procedure. This pilot study should be encouraging for prospective patients, as the purpose of hair restoration is not only to improve one’s own self-image, but to improve appearance, attractiveness, and successfulness to other people as well. This study shows that this effect exists in a way that is both measurable and statistically significant.

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Q: How can I better understand how I will look after my hair transplant before I actually do the procedure? — E.M. ~ Wantagh, N.Y.

A: A key part of a hair loss evaluation is for the doctor to manage the patient’s expectations for possible benefits from both medication and surgery. The way we decide how to plan a hair transplant is through a careful history and examination, demarcating the extent of the hair transplant on the patient’s actual head and photographing it. When showing other photo results to patients, it is important to not only show before and after photos of the recipient area but also of the donor area; how the back of the head looks immediately after the procedure, at post-op intervals, and at different hair lengths. Most importantly, one should point out that every patient is different so that a picture of another person does not necessarily represent what you might achieve.

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Q: I’ve heard that using Propecia and/or Rogaine is a good idea after having a hair transplant, but are they mandatory? — B.M., Short Hill, N.J.

A: Neither finasteride (brand name: Propecia) nor minoxidil (brand name: Rogaine) will have any effect on transplanted hair. That said, while you don’t need them to protect your transplanted hair, you will likely have original hair interspersed among your transplanted hair that will continue to thin and fall out over time. This vulnerable hair can be protected by finasteride which has been shown to reduce future hair loss significantly; additionally, you can add Rogaine for extra benefit.

However, with Propecia, you should only use it if you can commit to it long-term because it takes up to a full year to see any effect. With Rogaine, you should only use it if you can commit to using it continually and regularly – you should not stop and start it.

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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? — V.S., Fairfield, C.T.

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.

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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? — H.B., Fort Lauderdale, F.L.

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“.

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Q: Is the recovery time a lot longer with FUT compared to FUE? — C.W., Chicago, I.L.

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.

For strenuous physical activity, however, the recovery is longer with FUT due to the linear incision. This is a major reason why professional athletes or very physically active people prefer FUE. However, many business professionals prefer FUT hair transplantation as there is significantly less down time from work (for the cosmetic reasons discussed above).

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Q: How long are FUT and FUE visible after the procedures? — S.V., Weston, C.T.

A: The recipient area is visible after both procedures 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).

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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.

Fortunately, if a hair transplant is performed using all follicular units, the recipient sites (the holes that the grafts are placed into) are so small that any oozing stops within a day. Therefore, frequent shampooing the day after the hair transplant procedure will prevent the scabs from forming and make the transplant less obvious. Preventing the scabs from forming in the first place will have the added advantage of decreasing the post-operative redness. However, if the scabs do form and adhere to the hair, one should wait a full 10 days before scrubbing them off, to insure that the grafts are not dislodged. Again, at ten days post-op the grafts are permanent.

Swelling (the medical term is edema) is another cosmetic problem that can appear in the post-op period after hair transplants. It can be significant in about 25% of patients. It begins at the hairline, descends onto the forehead, and then settles onto the bridge of the nose and around the eyes, before it finally disappears. The entire process takes a few days to a week. The incidence, degree and duration of swelling can be significantly decreased if the hair transplant surgeon adds cortisone to the anesthetic solution used to numb the scalp. An injection of cortisone in the arm (or oral prednisone) is also useful in decreasing the chance of post-op edema. Sleeping with the head elevated for several days following the hair restoration procedure can also help prevent any significant swelling.

Finally, the patient’s existing hair is very useful in hiding any tell-tale signs of a hair transplant in the post-op period. The doctor should be experienced at working through existing hair, so the hair restoration procedure can be performed without the need to cut the patient’s hair (if that is the person’s preference). Longer hair on the back and sides will camouflage the donor incision and hair on the top of the scalp will mask redness and residual crusting. Hair combed forward can also minimize the visibility of any facial swelling, if it should occur.

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Q: Is transplanted hair the same length as existing hair? — G.E., Buckinghamshire, UK

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.

At about 10 weeks after the hair transplant, the follicles will gradually start to produce new hair. They start out as fine hair and then gradually increase in thickness and in length. The process takes about 6 months, with full growth about one year after the hair restoration procedure.

For a more detailed overview of what to watch for in the days, weeks, and months after a hair transplant, view our After Hair Transplant Surgery page.

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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? — D.F., Chappaqua, N.Y.

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.

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Q: I would like to have the donor area from an old hair transplant repaired so it does not show the scar when I cut my hair shorter. What are my options?

A: Widened scars can be improved in two ways: they can be re-excised to make the scar finer, or hair can be placed into the scar to make it less visible.

Excising a scar works best when the original incision was closed with poor surgical techniques. In this case, using better closure methods can improve the scar. When the scar is the result of a person being a naturally “poor healer,” a wide scar will be the result – regardless of how the incision was closed.

I often approach the problem by excising a small area first, to see if I can decrease the width of the scar. If so, I would then proceed to excise the rest of the scar. If not, I would obtain hair using follicular unit extraction (FUE) — extracting hair in follicular units directly form the scalp — and place this hair into the scar. The hair placed in the scar can also be obtained from the edges of a partially excised scar.

If a wide scar that is thickened (called a hypertrophic scar) is also excised, it will usually reoccur and may result in an even worse scar. Because of this, thick scars should be flattened with injections of cortisone prior to removing. This will decrease the chance of a recurrence.

Flattening the scar is also important to permit the growth of newly transplanted follicular unit grafts.

For more on this topic, please see the page on Fixing Scars.

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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? — S.S., Glencoe, I.L.

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.

With FUE it is important to sort out the grafts under a microscope, to make sure that all of the grafts placed at the hairline are 1-hair grafts and that the larger grafts are place behind the hairline. They should not be planted without first being sorted under a microscope.

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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.) — T.C., London, U.K.

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.

As long as the grafts were no larger than follicular units and the graft sites no larger than the size of a 19g needle, there should be no permanent marks.

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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? — L.D., Miami, F.L.

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.

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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? — E.R., Bushwick, N.Y.

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.

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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? — B.V., Richmond, U.K.

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.

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Q: I know that I can’t get all of my hair back, but what can I realistically expect from the best hair transplants? — S.A., Santa Monica, C.A.

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.

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Q: Is it possible to have a hair transplant that is totally undetectable immediately following surgery? — G.F., Stamford, C.T.

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.

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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? — B.M., Upper East Side, NYC

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.

We advise waiting at least 8 months between sessions with 10-12 months being ideal so that the grafts of the second session can be evenly distributed among the grafts of the first.

The extra few months not only allow the surgeon to identify all of the previously transplanted grafts, but enables him to get a sense of the “look” of the first session (i.e. the wave, the density, and how the patient will ultimately want to comb his newly transplanted hair). This is very useful in guiding the placement of grafts in the second session to maximize its cosmetic benefit.

Read more about a second transplant
See before after hair transplant photos of patients who had a second procedure

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