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The Hair Transplant Procedure
1) The basics of hair transplantation: The hair on the sides and back of the head are generally immune to the negative effects of the hormone DHT, and thus are not prone to miniaturization and balding. This is why bald men nearly always keep a horseshoe shaped area of hair despite losing their hair on the top of their heads. Hair transplantation is a process by which hair is removed from a small area in the back of the head and subsequently placed in the thinning or bald areas of the head. Once moved to the new location, these hair follicles maintain their original characteristics, and continue to grow indefinitely. The procedure is performed in the doctor’s office under a local anesthetic, and lasts between 4-7 hours. Patients generally watch television or simply just sleep through the procedure.
The technique of hair transplantation is not new. Hair transplants have been around since the 1950’s, in which 20-30 large 4mm “plugs” were harvested from areas in the back and sides of the head and placed on the top. Unfortunately, these “plugs” were just that. They gave the appearance of “cornrows,” or “doll’s hair,” as they created very dense areas of 35-40 hairs surrounded by the balding areas. Over the next several decades, these plugs got smaller in size, but nevertheless, were still plugs and still were cosmetically noticeable. By the late 1980s and early 1990s, micrografting and minigrafting began to replace the larger grafting techniques. In these procedures, grafts of 1-5 hair follicles (2-12 hairs) are transplanted. These methods create a vastly improved cosmetic appearance over the prior methods. However, they are still noticeable to the naked eye upon close inspection, as they are more dense than the surrounding areas. The only way to truly recreate the hairline in an undetectable fashion is to transplant the individual follicles, as they occur in nature. Thus, the follicular unit hair transplant procedure.
In the late 1990s, the follicular unit hair transplant procedure emerged to become the most cosmetically appealing method of transplantation. By this method, the donor hair from the back and sides of the head is dissected into its simplest form under stereo microscopic guidance. Under these microscopes, the tissue is completely divided into its component single follicles, with the excess tissue being removed. This provides individual follicles (each consisting of 1-4 hairs) to be transplanted to the balding areas in the most naturally occurring way. Even upon close inspection of a well performed follicular unit hair transplantation, one cannot tell that the procedure has been done.
The merits of follicular unit transplantation are obvious by examination of their improved cosmetic results. Unfortunately, many physicians continue to rely on micrografting and minigrafting procedures. This is mainly because such procedures are technically easier and faster to perform, allowing physicians to perform multiple procedures in a single day. Furthermore, the follicular unit procedure has higher associated costs, such as the high tech microscopes and staff training. However, those physicians who elect to use follicular unit grafting feel the results are worth the added training and longer procedure duration.
1) The consult: At Ross Cosmetic Medical Group, your consultation is free. Upon arrival for your appointment, you will sit down with Dr. Ross and discuss your hair loss characteristics and Norwood hair loss classification (see figure). This will help you determine what your options are so you can make the best choices on how to treat your hair loss. Many people find on their consultation day that the follicular unit hair transplantation is the best option for them, while others choose to treat their hair loss with medicines, or simply wait and see what happens down the road without intervention. We feel it is in everyone’s best interest to be well informed before any type of treatment is begun. Whatever you may choose, your initial visit with the doctor is free of charge.
2) Prior to the procedure: Once you have determined that a follicular unit hair transplant is right for you, it is important to communicate to the physician what medicines you are taking (if any). This is so the doctor can be aware of any possible adverse effects of the medicines, such as prolonged bleeding time or decreased wound healing. The day prior to your procedure, you should refrain from drinking alcohol, as this has a tendency to thin the blood. Also, you should try to get a good night of sleep.
3) Procedure day: The morning of the procedure, you should eat a small breakfast, and come to the office around 9:30 am. You will then meet with the doctor to again discuss exactly what you would like done during the procedure. This is also a great opportunity to ask any new questions you may have come up with since your last visit. Next, the doctor will begin to outline your new hairline, and present it to you for your approval. You will sign the surgical consent form, and have a few “before” photographs taken. Then you will be given a sedative (valium) to help calm you and allow you to rest during the procedure.
After washing your hair and shaving the small donor area in the back of your head, the doctor will escort you into the procedure room. It is here where you will receive your new head of hair. First, you will have local anesthetic (lidocaine) injected into the donor area in the back. This is usually considered to be the worst part of the procedure, very similar to the injections received at the dentist’s office (some people relate it to a bee sting). Next, the donor area will be removed as a single piece of tissue (many physicians use a different technique in which the donor area is removed in several small strips, thus saving time under the microscope, but leading to increased follicle transection and damage to the hair follicles). Patient vital signs including oxygen saturation are continuously monitored throughout the donor tissue harvesting. Following the removal of the donor area, you will have the incision closed and be moved to a reclining chair for the remainder of the procedure.
Once in the recliner, you will be given a list of movies you may watch. As you watch your movie (or fall asleep), the doctor will numb the area with local anesthetic, and proceed to make the recipient sites for the hair to be transplanted. Sites are very small, and usually made with a tiny needle point. Considerable skill is required during this part of the procedure, as the sites must be made at the correct depth, angle, and position in order to maximize the cosmetic results. While the doctor makes the sites for the new hair, his technicians will diligently proceed to dissect the donor area under the microscopes into the follicular units. Tissue is kept in a chilled saline solution at all times to ensure maximal survival of the grafts. Following dissection and recipient site formation, the doctor and technicians place the grafts using very fine-tipped jewelers forceps. Careful to create an undetectable hairline, the staff places the 1- and 2-haired follicles closest to the front, and 3- and 4-haired follicles several millimeters back.
During the procedure, you and the staff will take a short break to eat lunch (and bathroom breaks are offered). Afterwards, you will have a small bandage applied to the donor area. This looks similar to a headband and is to be worn overnight. The area at the top of the head does not require a dressing, however, a lubricating ointment will be applied to keep it moist. Before leaving, you will be given a shot to reduce swelling, and be given four medicines you will take for a few days. These include an antibiotic, lasix (a water pill- also to reduce swelling), potassium (replaces that lost using lasix), and vicodin (a pain pill- although most patients do not require these). The doctor will carefully review which medicines to take and when, as well as what to do when you leave the office. He will also provide you with his cellular phone number to call for any concerns.
4) Afterwards: You are requested to sleep with your head elevated on pillows for four nights following the procedure. This helps prevent any swelling which may occur. The day following your procedure, you have the option of returning to the office for a hair wash and to review any new questions which arise. You may shower and gently shampoo your head in the days which follow. 7-14 days after the procedure, you will return to the office to have your stitches or skin staples removed and again address any concerns you may have. By this time, there should be no trace you had a hair transplant unless your brush aside the hair in the back and hunt for the small scar (by 2-3 days after the procedure most of the very small scabs which form on the recipient area should have vanished). Three months later, you are requested to return to the office to monitor your progress. At your six month checkup, your newly growing hair should be evidenced and you should begin to enjoy your “after” photographs.
While occasionally patients retain the newly transplanted hairs, in most patients these hairs fall out 2-3 weeks following transplantation. They remain dormant for a few months as they heal and become integrated into the surrounding tissue. Usually 3-4 months after transplantation, they begin to grow in normally. At first fine, they gradually become thicker, stronger and longer. Occasionally a few months after the transplant, patients experience a slight loss of hair in the sights surrounding the transplanted hairs. This is normal. The process is called telogen effluvium and the lost hairs usually begin to regrow 6-8 months following their loss. By one year following the procedure, most, if not all of the transplanted hair and hair lost by telogen effluvium should be growing and nearly all of the resulting increased density of hair and cosmetic improvement visible.
5) Fees and financing: Many physicians offer a stair-stepped fee plan, in which per-graft costs are reduced for very large “megasessions.” Prices for smaller sessions range from $8-$10 per graft and are lowered to the $6-$8 range for larger sessions. At Ross Cosmetic Medical Group, fees are fixed at a very reasonable $3 per graft. A minimum 400 grafts per session is required, and costs $1200. For 1000 follicular unit grafts (estimated 2200 hairs), the fee is $3000. Financing may be available upon request on the day of consultation. Also, a travel reimbursement of up to 10% of the procedure cost is available for airline travel to and from San Diego for the procedure.
