An update on hair-restoration surgery

Throughout history, the presence of scalp hair has played an important role as a representation of prestige, power, and status. Sampson derived his strength from long, flowing hair; Julius Caesar created the earliest known hairpiece by using a wreath of leaves to frame his face because he was bald; even today, in the British courts, thick, flowing wigs of hair are used as a part of the authoritarian uniform.

In society today, hair remains a symbol of health, fitness, vitality, and youth. Because the presence or loss of hair is genetic and beyond one’s control, alopecia (the medical term for hair loss), often represents an uncontrollable loss of these sought-after qualities. Thus, surgical hair restoration in men and women is a tremendous boost to self-esteem.

The first hair transplants were performed by Dieffenbach in 1822. In the 1950s, Orientreich performed hair transplants from the “permanent hair” in the occipital region to bald areas in the front of the scalp, and thereafter described the concept of “donor dominance.” This landmark concept describes the current thinking that hair in the occipital area is under different genetic and hormonal control than the follicles in the front of the scalp.

In the past 10 years, hair-restoration surgery has become a highly sophisticated cosmetic surgical subspecialty. Today, more than 95% of all surgical hair-restoration procedures performed are hair transplants. The primary reasons for this are advances in equipment and hair-grafting techniques, an improved understanding of the progressive nature of hair loss, and the availability of new medical treatments.

The consultation with a prospective patient seeking hair restoration is an educational process that requires thorough explanation of a topic with which many are not familiar. As with any cosmetic surgery procedure, a healthy patient whose goals and expectations are realistic sets the stage for a successful procedure.


The current fundamentals of contemporary hair-restoration surgery are summarized below. Observance of these principles has helped to boost the success of the procedures and enthusiasm among patients and surgeons. The three fundamental principles of hair-restoration surgery are the following:

1) No new hair is created. Until hair cloning becomes a reality, hair-restoration surgeons do not create new hair; they only redistribute it to a location where it will produce the greatest impact.

2) Hair loss is progressive. A patient may present for an initial consultation at age 25 with a certain amount of hair loss; however, he (or she) will almost certainly develop more hair loss as time goes by. A successful surgical hair-restoration plan for that patient must therefore take into account both the anticipated hair supply and the hair demand of each individual patient.

3) Procedures must stand the test of time. This fundamental principle is a logical extension of the first two. The surgical result must look natural and provide adequate restoration in the few years following the procedure; as well as 20 and 30 years later, when hair loss has progressed.

In applying these principles, surgeons must use meticulous technique and attention to detail. Newer techniques using microscope dissection of thousands of hair grafts, millimeter-size recipient sites, microvascular instrumentation for implantation, and a large staff utilizing these techniques to efficiently complete the procedure require a level of commitment and quality control that is surprisingly rigorous to those unfamiliar with contemporary hair-restoration.

State-of-the-art techniques in hair transplantation result in a restoration of hair that is almost always undetectable as a surgical creation. A natural appearance is the goal of follicular unit transplantation. A follicular unit is the natural grouping of individual hairs in vivo. While some hairs exist as single follicular units in the temporal and occipital donor area, most hairs exist as bundles of two to four hairs per follicular unit (Figures 1 and 2). Removal and preparation of individual donor follicular units and their implantation into areas of alopecia recreates the most natural appearance possible (Fig­­ure 3, page 38).

The details of room setup, hairline and distribution design, donor harvest, anesthesia, equipment, and postoperative care are beyond the scope of this review. You are directed to the references at the conclusion of this article. Briefly, the procedures are almost always performed under local anesthesia. In about half of the cases, an oral sedative is provided.

Examples in Men

The average transplant session lasts 3–4 hours, and typically 800–1,200 grafts are placed in a single session. Most men between the ages of 21 and 50 are also encouraged to consider the option of using oral finasteride as a medical adjunct to slow or stop the progression of male-pattern hair loss. Women are not candidates for finasteride use.

Following the transplantation procedure, grafts enter a resting phase (telogen) for the next 3 months. This is followed by the growth (anagen) phase, after 5 months of which it is possible to assess the results of the transplant procedure. Hair transplantation is an exceedingly reliable and safe operation. Growth rates are approximately 85–90% based on hair counts at 12 months. In my 13 years of performing hair transplants, I have seen an incidence of 3% donor wound complications. These include widening of the scar, scar pain, ingrown hairs, and scar separation. There have been no scalp infections, but there has been a 5%–8% incidence of inclusion cysts in the recipient area.

Examples in Women

Hair loss in women usually falls into two surgically correctable categories: androgic (hormonal) and iatrogenic alopecia. The Ludwig classification for female hair loss describes a typical hormonally mediated pattern loss that is different than that usually seen in men. Because the hairline in women is usually well-preserved, this challenging zone does not typically need to be created surgically. In this case, larger grafts cut to a desired size and containing up to five to eight hairs can be placed behind the existing camouflage of natural frontal hair. This provides increased density while maintaining a natural appearance. When the hairline does need to be recreated in women, follicular unit grafting is performed.

Only about 30% of women with typical female-pattern hair loss are candidates for a transplant. This is because many women’s donor density is very sparse. In general, if a woman’s donor density is less than 1.5 follicular unit per cm2, she will not have a satisfactory result. In addition, women have a greater likelihood of in situ hair loss as a result of the transplant. In some cases, the surrounding hair loss is true telogen and by definition will return within 3–5 months. In other cases, the fine vellus and fragile hairs in the recipient area will never return. The candidates for hair-restoration surgery need to be selected and counseled carefully.

Iatrogenic alopecia can occur in the crown or temporal area following other surgical procedures such as rhytidectomy and brow lifts. Eyebrow reconstruction with hair transplantation can be performed with a high degree of success as well.

Corrective Cases

Most procedures performed using older techniques of plug hair transplantation are not aesthetically acceptable by today’s standards. This is especially true in the face of progressive baldness and the resulting separation of the previous transplants from the receding hairline. The majority of patients who have had the old plug techniques performed are concerned with a straight, “pluggy,” or corn-row appearance of grafts; or the malposition of their anterior hairline. In the majority of patients, a clinically significant improvement in appearance can be achieved after one corrective procedure. However, it is the general rule that two or more staged operations are needed to maximally improve the results of previous hair-restoration procedures.

Patients who have an unnatural hair appearance as a result of outdated transplant procedures often bear the physical and emotional scars of the transplant experience and harbor a distrust for the field of hair-restoration surgery. The challenge for the hair restoration surgeon is to provide a level of expertise and honesty to these patients to restore their appearance and self-confidence.

The details of developing a surgical plan for correcting an abnormal hairline and ugly round plugs is complex, and you are referred to the references cited below. Factors such as the patient’s goals, the feasibility of matching expectations with results, the donor supply, the patient’s age and predicted future hair loss, the recipient scalp scarring, the level of the existing “pluggy” hairline, and the quality and intensity of the existing plugs are some, but not all, of the preoperative assessments needed to formulate a surgical approach. The fundamental principle in correcting the abnormal appearance of previous plug hair transplants is to remove the plugs, recycle those plugs into individual hair grafts, and redistribute the hair at the hairline and elsewhere to create a soft and natural appearance.


State-of-the-art hair-restoration surgery has evolved to a high level because of advances in technology; the improved understanding of the normal, progressive nature of hair loss; and the dedication of many hair-restoration surgeons who have developed the techniques illustrated in this article. Future advances to look forward to in this exciting field include hair cloning and improvements in graft storage solutions to accelerate the onset of graft growth following the transplant procedure.

Creating a hairline and restoring frontal scalp hair volume can be as rejuvenating and uplifting as any contemporary cosmetic surgical procedure available today. Most men will experience some degree of hairline thinning and elevation as they age. In some social circles, this feature can be interpreted as a symbol of maturity and wisdom. For most men (and women), however, hair loss is at best a suboptimal situation.

For men and women, restoration of scalp hair using contemporary techniques not only improves facial balance and harmony, but it strongly boosts self-esteem. For those patients who have had older plug techniques, correcting these unsightly outcomes is tremendously rewarding. Although not covered in this article, reconstruction of hair-bearing areas injured following trauma, burns, and extirpative surgery can be exceptionally gratifying as well.

For more details on this topic, you are referred to the general references and the International Society for Hair Restoration Surgery (ISHRS), which can be reached at (800) 444-2737. n

James E. Vogel, MD, FACS, is an assistant professor in the Division of Plastic Surgery at The Johns Hopkins School of Medicine and Hospital in Baltimore. He can be reached at (410) 484-8860.


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