Hair Transplant Basics

Understanding the Scalp

A scalp may be divided roughly into two separate areas.

1. The area susceptible to balding - Commonly in the front hairline, crown or top of head
2. The area not susceptible to balding - The horseshoe fringe of hair left behind on the back of a bald man’s scalp is the area from which hair can be safely donated. Hair transplanted from here will not be susceptible to balding even when it is placed right in the middle of the bald scalp. This new hair maintains the same characteristics of the hair left behind in the donor area no matter where it is transplanted to the scalp.

Harvesting Donor Hair

Multiple methods may be used to harvest this donor hair. In the early days of hair transplantation, the hair was removed in 4 mm plugs about the size of a pencil eraser. Multiple plugs were removed simultaneously and the area was allowed to heal in by itself. Although the healing areas were messy the first week because of the weeping from the open wound, the areas tended to heal well. The primary problem was the cobblestone scar pattern left behind.

This led to the idea of excising strips of tissue rather than plugs. The open area left by the strip was more easily sutured together. As the grafts that were transplanted became smaller, physicians began to use multi-bladed scalpels to produce multiple, thin strips facilitating the quick dissection of grafts. Now, since the advent of follicular unit transplantation, many hair surgeons will remove the strip with a single scalpel blade in order to minimize the transection of the follicular units.

The Recipient Area

In regards to the recipient area, during the early days of hair transplantation, the 4 mm plug removed from the back of the scalp was then simply implanted intact into the balding area in the front of the scalp. This certainly gave volume to the thinning hair but at the unacceptable price of extreme “plugginess” as the remainder of the preexisting hair eventually disappeared. Grafts were gradually down-sized to quartered 4 mm plugs and then to minigrafts containing 3 to 10 hairs each. This certainly reduces the harshness of the “plugginess”, but by no means does it remove the problem entirely. Instead of fewer, big plugs, there are numerous small plugs. Micrografts were developed to hide this “plugginess” in the hairline. Micrografts consist of 1 to 2 hairs dissected without magnification and without regard to the follicular units. These are a tremendous aid in helping to disguise the artificiality of minigraft hairlines.

Follicular unit transplantation was the next major milestone in hair transplantation. A follicular unit is the natural unit hair grows in on the scalp. If the scalp is shaved and magnified, the follicular units are evident as the 1 to 4 hair groupings exiting the scalp from single points. Each individual follicular unit has a single root system. Follicular unit transplantation is defined as the dissection underneath a microscope of the individual follicular units followed by the implantation of these single units into the balding area. Emphasis is placed on not disturbing the root systems while dissecting the 1 to 4 hair grafts. A microscope is required for the adequate visualization necessary to avoid transection of the follicular unit root system. Since these 1 to 4 hair grafts are transferred individually, there should be no “plugginess”.

The recipient site in the front or top of the scalp must be prepared to accept the various forms of grafts. The recipient site for the 4 mm plugs was simply a similar-sized hole created with a punch. A punch is a small, circular, cookie-cutter type knife that creates tiny, circular holes in the skin. The recipient sites for minigrafts are made with either scalpel blade incisions or small 1.5 to 2.0 mm punches. Lasers have been utilized to create recipient sites for minigrafts to no great advantage, but certainly at greater costs. The recipient sites for follicular units are simply made by inserting small needles into the scalp to create tiny holes.

Implanting the Grafts

The implanting of the grafts is considered the most technically difficult portion of the procedure. As the grafts have become smaller, the skill required to gently insert them with a fine pair of forceps (tweezer-like instruments) has greatly increased. These grafts must be grasped and inserted without traumatizing the tissue, or poor growth is risked. This gentleness combined with the close-spacing of the grafts makes a planter with good hands, patience, and a sense of perfectionism, critical.

Very few hair transplants are performed by the physician alone. With the advent of minigrafts, and then, especially, follicular units, the amount of work required to prepare and implant the grafts has increased logarithmically. Surgeons working alone would only be able to perform small follicular unit transplantation sessions. Most surgeons plan the procedure, perform the excision and repair, and then oversee a team of technicians who dissect the grafts and then implant them.

After the Transplant

After the transplant is completed, bandaging of the head is usually unnecessary. On occasion, if a patient is oozing a little from the donor area, a bandage will be applied like a headband for several hours. Patients leave wearing a baseball cap to hide what has been done.

The transplanted hair shaft typically falls out during the first month after surgery. The root system is still present just as if the hair had been plucked. The new hair starts to grow in three to five months. This transplanted hair is now permanent hair not susceptible to the progressive nature of male pattern baldness. This hair may thin out when the patient reaches seventy to eighty years of age, but this is a general thinning known as senile alopecia which causes hair over the entire scalp to begin to disappear. Otherwise, the new hair is permanent. The transplanted hair occasionally grows in a little kinky and coarse during the first year, but it will ultimately appear just like the hair in the donor area. It will grow and need to be cut probably more frequently then any surrounding miniaturized preexisting hair. It can be coloured  and styled any way the patient likes.

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