Hair Transplants: What You Want To Know
Hair transplants have become increasingly popular as a solution for certain types of hair loss. A hair transplant, or restoration, is a surgical procedure where a dermatological surgeon first extracts hair, from the patient's head, or donor site, to be transplanted, according to WebMD. Then, the surgeon relocates those hairs in the balding area.
Primary candidates for hair restoration surgery are individuals who have a sufficient amount of genetically pure hair for a transplant to their hair loss region, the International Society for Hair Restoration Surgery indicated. These typically include men who've suffered from male pattern baldness for five or more years or whose hair loss has progressed to a Norwood class 3, the earliest stage of balding where hair is receding at the front and corners, or progressed to a higher level, the American Hair Loss Association noted. Others are men and women who've had hair loss as a result of trauma, burns or cosmetic procedures like facelifts.
Evolution Of Hair Transplants
The first hair restoration procedures were done on burn victims by a Japanese dermatologist, Dr. Okuda, in the late 1930s, WebMD reported. In 1943, Dr. Tamura, another Japanese dermatologist, used a revised version of Dr. Okuda's technique and transplanted scalp hair to replace lost pubic hair in women. Information about these procedures, however, didn't reach the Western world until decades later.
In 1952, Dr. Norman Orentreich performed the first U.S. hair transplant for male pattern baldness, yet the medical community criticized and rejected the notion, Bernstein Medical explained. Orentreich introduced the concept of "donor dominance" to explain that healthy hair taken from the back or sides of the scalp and
transplanted to the balding area on the top of the head would grow as it if hadn't been moved. In 1959, Oreintreich successfully published a paper on his technique, which involved taking large grafts, about 4 mm in diameter, or about the size of a pencil eraser (versus today's 1 mm, or half the size of a matchstick head). The outcomes tended to look unnatural and many times were tragic, per the AHLA. Consequently, hair transplants earned a poor reputation.
His large-graft technique, known as plugs, was used throughout the 1970s, according to Bernstein Medical. In 1982, mini-grafts, or smaller grafts taken from a strip of donor tissue, were introduced. This evolved to micro-grafts, the use of very small grafts of one to two hairs. A combination of the two -- mini grafts used on the mid-scalp and micro grafts around the hairline -- then became the norm, as it provided a more natural appearance. This procedure dominated the field until the mid-1990s when the technique became further refined.
Today's gold standard of hair transplants emerged after Drs. Robert Bernstein (of Bernstein Medical in New York) and William Rassman (of New Hair Institute, in Los Angeles) introduced the Follicular Unit Transplant (FUT) technique in 1995. Finally, the medical community could provide a surgical hair loss solution that produced natural-looking results with which patients were thrilled. In 2002, Bernstein and Rassman took hair transplants to yet another level with another technique for harvesting donor hair, Follicular Unit Extraction (FUE).
Hair restoration surgeons perform both FUT and FUE today, although FUT is most common, the ISHRS noted. Why one is chosen over the over depends on various factors, including the patient's cause and type of hair loss, likelihood of progression, chosen hair length, scarring considerations, cost and more. Not all hair restoration surgeons offer both FUT and FUE.
The Transplant Procedure
The first part of a hair transplant plant is procuring the follicular units (each one contains one to four hairs, nerves, muscles, oil glands, blood vessels and connective tissue), or grafts, to be moved to the balding areas. One of the two modern techniques, FUT and FUE, is used.
The original method, FUT, involves cutting out a strip of skin, typically from ear to ear, from the donor site and then harvesting the follicular units (FUs) to be relocated from that swath. The surgeon then sutures or staples the excised area closed. With FUE, the newer, more time-intensive, expensive technique, the surgeon removes each FU from the donor area individually. They make numerous, tiny holes across the donor area and extract one FU through each of those holes.
As for how many grafts are needed, about a 3-inch-square area requires about 500 to 600 standard grafts, noted the American Hair Loss Council.
Regardless of which grafting procedure a patient chooses, the subsequent transplant process of the harvested FUs is the same. With the FUs selected and ready for transfer, the surgeon prepares the recipient site for the final step -- placing the hair grafts in the balding scalp region, according to WebMD. The surgeon cleans and injects the area with local anesthetic to numb it. With the patient awake, they create tiny slits or holes in the scalp with a needle or scalpel, then gingerly insert the hair grafts into them.
Procedure Length, Recovery
The procedure length depends on the extent of the individual's hair loss and, therefore, the number of grafts needed, along with the FU extraction technique chosen. FUTs take anywhere from four to eight hours, about five to six on average, WebMD indicated. FUEs take about one to two hours more, and longer procedures may be done in two sessions on consecutive days, Bernstein Medical noted.
Patients don't feel pain during the procedure, only a little discomfort during the local anesthetic shots, per the ISHRS. Typically, they spend the procedure time chatting, watching television or movies or listening to music.
After the surgery, patients typically wear a dressing on their head for two days, WebMD explained. During that time, they may have mild scalp soreness or tenderness, which could require pain medications for a short time. Subsequently, the scalp becomes tender to the touch for about seven to 10 more days. Other side effects include swelling that may extend down to the eyes. Scabs, or crusting, forms throughout the donor area and takes about four to 10 days to clear up. According to Bernstein Medical, scalp tightness eases over the ensuing eight months and even more so after. Patients rarely have permanent tightness.
A baseball-type cap can be worn any time after the surgery. Most patients can return to work within two to five days after their transplant, although a realistic recovery period is about a week, according to the AHLA.
Bleeding and infection can occur, but are rare. Scarring at the donor site may be minimal or more significant, depending on a patient's genetic predisposition. A temporary numbness can happen due to the routine cutting of nerves during the procedure, however, feeling usually returns within a few months. Permanent numbness could result if a surgeon accidentally transects the main nerve branches.
Temporary loss of the surrounding hair -- shock loss -- also is possible. This normal bodily reaction to the surgery occurs in about 10 to 15 percent of male patients, per the ISHRS, and almost all female patients, the AHLA explained. If the hair remains undamaged from the procedure, it will begin to grow again a few months afterward. If damaged from the transplant, the hair may not regrow. Transplanted FUs could die, resulting in no hair growth. Also, the final outcome could appear unnatural if the procedure was performed badly.
To achieve their desired results, hair transplant patients may require more than one restoration surgery, especially those wanting great fullness (usually women) and those who continue to experience hair loss and want to maintain coverage. Sometimes, the hairline needs to be adjusted forward or back to appear age appropriate. People with thinner hair may need more sessions for their transplanted area to look denser. Other considerations for additional transplants are the scalp area treated, the number and thickness of grafts originally used, the projected hair loss rate and the amount of donor hair available. Men oftentimes can achieve the result they want in one session whereas women oftentimes require two or more, said Dr. Sara Wasserbauer, a Walnut Creek, Calif.-based, hair restoration surgeon.
When To Expect New Hair
New hair starts growing in the transplanted area between three and six months after the procedure, per Wasserbauer. When exactly depends on the patient's health and hair. Fine-haired people, for instance, will see growth later than earlier. In slow-healing diabetics, for example, it could take closer to six months. According to the ISHRS, the new hair will grow about one-inch per month.
How The Results Look
Once a patient's hair grows in the transplanted area, the appearance looks natural, if the procedure was performed by a skilled, experienced and qualified surgeon, Wasserbauer emphasized. Such a surgeon can even recreate or eliminate hair characteristics that existed before hair loss and surgery. These include cowlicks, widow's peaks, hair whorls and a natural part. How a patient's hairs grow out depends on how the surgeon made the scalp slits for the FUs.
Can People Tell?
Wasserbauer explained that immediately following the hair transplant, patients may or may not look like they've had something done to their head. It all depends on how their body responds. Fair-skinned people may appear slightly pink. Swelling might be obvious on some people, not on others. Scabs over the grafts may be visible or not (existing hair may or may not cover them). Patients who undergo FUE can, for some days, look like they have road rash on their scalp from all the extraction holes -- about 10 days' worth of hair growth covers that.
After those initial transplant side effects disappear, people won't suspect a patient's had anything done if they were a good surgical candidate and, again, if an expert hair restoration surgeon did the procedure.
The Results Are Permanent
Except in a few, odd cases, the results of hair transplant surgery are permanent, Wasserbauer explained. This is because the harvested hair is genetically resistant to male and female pattern baldness. Just as a patient won't lose the genetically pristine hair from the back of their head, they won't lose the new genetically perfect hair in their transplanted areas. The transplant won't ever need any maintenance by the patient or their surgeon over time.
Hair Transplant Costs
The cost of a hair transplant depends on several factors, including the technique used, the surgeon's skill level, the patient's needs and goals, and the geographical region and type of facility where the procedure is done, according to the DermHair Clinic. Hair type, hair loss type and extent of balding also influence price. Because FUE is much more labor intensive and time consuming, it costs quite a bit more than FUT, oftentimes double, per the ISHRS.
Surgeons typically charge in one of three ways: by the graft (one rate across the board), by the graft (on a sliding scale) and by the session.
By-the-graft rates typically range from $3 to $8, with $4 to $5 being the average, according to Dr. Gregory Pistone, a Pennsylvania and New Jersey hair restoration surgeon.
For example, DermHair Clinic, in Beverly Hills and Redondo Beach, Calif., charges $8 per graft.
Bernstein Medical charges $7 per graft for FUTs and $11 per graft for FUEs.
Sliding scale fee schedules may vary per physician. The cost per graft tends to decrease as the number of needed grafts increases. Hasson & Wong, in Seattle, Wash., for instance, charge $5 per graft up to 2,000 grafts and then $3 per graft thereafter.
Dr. Shapiro's Hair Institute, in Delray Beach, Fla., charges $3 per graft up to 1,000; $2.75 per graft from 1,200 to 1,500; $2.50 per graft for 1,600 to 1,900; and $2 per graft for 2,200 to 2,800 -- all for FUT grafts. FUE grafts cost between $5 and $6 apiece.
New Hair Institute charges different rates per surgeon: for FUT, Dr. Pak's fees are $6 per graft for the first 2,500, then $2.50; Dr. Rassman's fees are $8 per graft for the first 2,500, then $2.50.
Dr. Bradley Wolf, in Cincinnati, Ohio, charges between $3.83 (for 3,001-plus grafts) and $25 (for only 100 grafts) per FUT graft and between $7 and $12 per FUE graft. Within the ranges are several levels.
In the flat-fee scenario, a hair restoration clinic might charge, for instance, a straight $5,000 for 1,800 grafts, according to DermHair Clinic.
These charges translate into a total procedure cost that can run anywhere from $2,500 to $4,000 for less extensive hair loss and between $15,000 and $20,000 for much greater hair loss.
Using the statistic that a 3-inch-square area of hair loss needs about 600 standard grafts and assuming a patient's bald spot is twice that size, they'd need about 1,200 grafts. A transplant using FUT would cost roughly $3,600 at the low end ($3 per graft) and $9,500 at the high end ($8 per graft). Again, FUE would cost more.