Hair Transplant Surgery : Determining whether a hair transplant is an option, Figuring the costs, Finding a surgeon, Preparing yourself for all stages of the surgery Managing complications and Understanding results that may require repair

Hair Transplant Surgery
In This Chapter

Surgery can be a daunting prospect even when it’s medically necessary, so it’s no surprise that undergoing elective surgery
for a cosmetic procedure can be a little frightening. In this chapter, we cover all aspects of hair transplant surgery, starting with helping you to determine whether it’s a viable option for you. We walk you through the requirements and costs as well as help you find the right surgeon (not necessarily the one with the biggest ad in the phone book). We prepare you to visit possible surgeons and make sure you go in as an informed patient. You find out what you’ll face before, during, and after surgery, and we help you be realistic about the possible post-op complications and results that may send you back for additional transplants.
Are You a Candidate for Hair Transplant Surgery?
Do you really need a hair transplant? At first glance, this may seem like a silly question. But hair transplantation shouldn’t be your first thought when you start losing your hair. Most candidates for hair transplantation are men with male pattern balding, which takes years to develop. Young men who have just started losing their hair don’t know how far their hair loss may progress or how fast. Finding an extra hair or two in the sink or in your comb doesn’t mean you need a hair transplant tomorrow — or ever.
Not everyone who’s balding is a good candidate for hair transplantation. The best candidates for transplant are those who have the following:
Those who don’t qualify for a hair transplant
Among the people who probably aren’t good candidates for hair transplantations are
Those who may qualify and benefit from a hair transplant
A healthy area of donor hair is essential for a good hair transplant, so if you have that, you’re already in a good position for the procedure.
Men over age 30 with established male pattern baldness are often more deliberate than others about the decision to undergo hair transplant surgery. They’re more likely to have given the matter considerable thought, thoroughly researching the options and finding a doctor they trust. Sometimes a change in lifestyle precipitates the decision, such as a search for a new job, a divorce, or simply the financial ability to indulge themselves.
The best transplant patients are educated about their hair loss and set realistic expectations for the success of a transplant. They must learn, in advance, the realities of what a hair transplant can and can not do. You don’t have to go bald before you go the hair transplant route, but it’s best if you’re informed and mature.
Even if you have male pattern baldness, which could eventually be helped by transplant, hair loss at its earliest stage is best treated with medication. The use of medication may forestall a transplant for years.
Unfortunately, young people in a panic may fall prey to unscrupulous physicians whose practices are built on selling hair trans- plants to those in an emotionally fragile state. Men under 25 years old should think twice before they undergo a surgical solution and should ask themselves the following questions:
It’s the responsibility of the physician to make sure that an emotionally distraught patient is making informed choices and under- stands the long-term implications of any treatment option — especially surgery. With younger patients, it’s often prudent to slow down the decision-making process through multiple consultations, stressing the importance of drug therapy, and when appropriate, getting parents or other significant persons involved. Your doctor should allow you to reflect on the situation and the decisions involved — and should never rush to operate. Our rule of thumb for those considering a hair transplant is to delay the decision until they fully understand what it is all about. We tell every- one: A good decision today will be a good decision tomorrow.
Psychological Considerations for Hair Transplantation
Modern society is preoccupied with hair; it symbolizes youth, health, sexuality, and individual style in today’s culture. Throughout history, the presence or absence of hair has affected the way people are viewed. For example, during the Middle Ages, men who experienced poor health also had hair loss; as a result, society established biased opinions equating good health — and desirability — with a full head of hair. Unfortunately for some, that public opinion has proven to be pretty persistent.
Balding can make you feel like you’ve lost control. Hair is one of the few body parts that you can manipulate: You can grow it long, cut it off, wave it, dye it, or pull it back in a ponytail. But you can’t control when and how it grows naturally. Hair also serves as a form of self-expression, and as you start to lose it, you may become depressed and withdrawn. Men who lose their hair feel that they’ve lost control of the image they present to the world — and to themselves.
Hair loss isn’t just a physical change. It also has many less tangible effects, namely on your
There are plenty of studies of the psychological impact of balding but few studies have examined the psychological improvement after hair transplant surgery. Having seen the drastic changes in patient behavior and the high level of patient satisfaction following hair transplant procedures, we decided to take a look at data supplied by mail-in questionnaires we sent out after transplant surgery.
We selected 200 patients who had hair transplants within the previous one to three years for male pattern balding and sent them open-ended questionnaires that focused on eight major criteria. Included were questions on the general level of happiness, energy level, feeling of youthfulness, anxiety level, self confidence, outlook on one’s future, and impact on one’s sex life. We received 37 anonymous, voluntary responses (an 18.5 percent return rate), which we share in Appendix C. Patients described significant improvements in all eight criteria regardless of their stage of baldness and their ages.
In another attempt to compare psychological changes that patients experienced after surgery to address different stages of baldness, we divided patients into two groups (turn to Chapter 4 for an explanation of the Norwood classification system):
We observed the most significant difference between the groups in the two categories of sex life and career. Transplant had a greater impact on sex life and career in people who had less hair loss at the time of transplant compared to those who had more advanced stages of hair loss. These changes weren’t age-related.
Not surprisingly, patients who suffer the most from hair loss are the most likely to benefit psychologically. In early stages of hair loss, patients may be more aware of their condition and be more affected than men in the later stages of hair loss, especially if a patient’s hair loss occurs at an early age, when his social life is likely to be more active and more fragile.
Although each individual’s motives may vary, it’s understandable for people at any age to want to improve their appearance, and hair has a great impact in this regard. However, a decision to proceed with hair restoration should be made with a clear head, a specific objective, and as much factual information as possible in order to establish realistic expectations.
On the other hand, when hair loss becomes an obsession, it’s rare that either medical treatments or surgery satisfy the patient’s need for perfection. If the patient’s emotional reaction to his hair loss far exceeds the degree of hair loss, or if his expectations of treatment are more than can be achieved with existing technology, psycho- logical counseling may be in order.
Realistic expectations are critical before undergoing a surgical hair restoration procedure. Any transplant done in the face of unrealistic expectations is doomed to failure. Realistic expectations for a hair transplant should be based on proper education, emotional maturity, and the availability of adequate finances to undergo an assessment and a hair restoration surgery.
A final result that’s more than meets the eye
A patient of Dr. Rassman’s is 55 years old and one of the more powerful men in America. If you were in a room with 100 men, this successful businessman’s charisma would make him stand out. Powerful and brilliant men and women always surrounded him, but secretly, he felt insecure, not with his abilities but with his aging appearance, epitomized by his balding.
Although his wife appeared supportive of his transplant decision at the time, a few years after the surgery she came to visit Dr. Rassman and said, “I want to apologize to you.” The confused doctor asked, “Why do you want to apologize to me?”
She told him about a rift she and her husband had had about his getting the trans- plant. “I told him that he looked great and that hair wasn’t important. But my husband has his own mind, and after the only fight we had in our 27-year marriage, I agreed to go along with him. But I was secretly furious, and I came here today to apologize if I was rude. You see, after the transplant was done and his hair came back, the man I married also came back. I never realized that he could ever feel insecure about what I thought was this ridiculous, unimportant thing called hair. His insecurity was a secret he even kept from me. But when his hair came back, his personality became more open, and his joy of life was enhanced. I saw changes in his passion for life and for me. The contrast was remarkable. I was selfish to think that I knew how he felt, but I never realized how important hair could be. So, I am apologizing to you because I cannot apologize to him.”
Needless to say, Dr. Rassman was touched by her apology.
Having Enough Hair for a Transplant
Needing to cover a large balding area with a small supply of good, healthy donor hair can make the hair transplant option a “no-go.” Obviously, the larger your balding areas, the less donor hair you have. But you don’t need to restore your hair all the way to its original density to develop the appearance of fullness.
For example, uniformly pulling out every other hair (50 percent) from the head of a person with black, medium-weight hair and white skin won’t change the person’s appearance much at all. At 75 percent uniform hair loss, this person will start to show significant hair thinning, but it’s still disguisable with good styling techniques that layer the hair. In contrast, a blond with 75 percent hair loss may show no thinning because of the uniform color of the hair and the light-colored scalp. At 90 percent loss, the black-haired, white- skinned person will show severe thinning, whereas the blond- haired person with light skin color may lose up to 90 percent of his hair and still look reasonably full-haired. It’s not fair, we know!
There’s an art as well as a science to the hair transplant process. A good surgeon can achieve the illusion of fullness even when the need for hair follicles exceeds the supply. For example, it’s not unusual for the hair restoration surgeon to restore just one area of the bald scalp in a very bald person; putting hair in the front and leaving the crown thin or bald creates a natural-looking variation of a typical balding man who has only crown balding. Viewed from the front, the hair looks normal, whereas from the back the balding crown is visible.
People are born with varying numbers of hair on their heads, ranging from 60,000 to 150,000 hairs. If a man is born with 60,000 hairs and loses 70 percent of them, he would only have 15,000 hairs left, most of which would be needed to cover the areas around the side and back of the head where all of the good donor hair is found.
At the other extreme, a man born with 150,000 hairs who loses 75 percent would have 37,500 hairs on the side and back of his head. Redistributing 20,000 hairs may be enough to cover the entire balding head of a very bald man and make him appear as if he has a full head of hair.
Frontal hairline recession, the most common hair loss pattern, may result in a loss of between 2,000 and 18,000 hairs. Restoring enough hair to replace what’s been lost is relatively easy in these cases
Surgeons see less successful results from the standpoint of meeting the patient’s expectations when they have considerably fewer grafts to work with. Although the artistic distribution of 8,000 hairs (4,000 grafts) may produce the illusion of fullness, it’s a far greater (if not impossible) challenge to create enough fullness to meet any reasonable expectations of the patient if only 2,000 hairs (1,000 grafts) are available.
Planning for Possible Future Hair Loss
Unfortunately, hair loss doesn’t stop just because you’ve had a transplant, so any reconstruction work must take into account what may happen down the road. Your surgeon should develop a master plan to cover any future hair loss; the plan may include drugs like Propecia that slow or stop hair loss. Any master plan should address the following questions:
The master plan should include short-term and long-term
solutions. Hopefully, the worst-case plan will never be realized, but it’s critical to include this possibility in your understanding of your procedure.
If the surgeon doesn’t leave enough hair for the worst-case scenario, then sooner or later you’ll be up the creek without a paddle — and without hair, either.
The doctor’s honest description of possible future needs is crucial to your making an informed, smart decision.
Assessing the Costs
Hair transplant surgery is generally not covered by insurance because it’s considered a cosmetic procedure, and that means that the cost will come right out of your own pocket. And the price can be high, depending on how much area you want to cover and how much your surgeon charges.
Hair transplant surgeries are generally charged per graft, with a graft being one to four hair follicular units. The cost varies between $3 and $20 per graft. Most people focus on the per graft price, as this is how most doctors calculate their fee.
For many people, hair transplantation is limited by their financial constraints. That being said, it’s important to look at the long-run versus the short-run when selecting your surgical team. In the short-run, you may save a few hundred, even a few thousand, dollars by going with the least expensive doctor, but if the surgery is performed incorrectly, if the team isn’t experienced and loses grafts, or if the surgeon doesn’t have the experience or the artistry to place grafts properly, you may end up needing more surgery in the future and worse, you may have a botched job that can not be fixed. The buyer must realize from the beginning that a hair trans- plant is permanent and errors of design and good planning may not be correctable.
When discussing price, you need to compare apples to apples. One graft (or follicular unit) contains one, two, three, or sometimes four hairs. In general, one graft averages about two hairs. Some doctors add to the confusion by charging per hair to make the procedure appear less expensive (this is known as graft splitting). Just remember that 2,000 hairs is around the same as a 1,000-graft surgery.
Sometimes a doctor may make single hair grafts by splitting a two- hair graft so that he or she can transplant it to the frontal hairline. But splitting a four-hair graft into two two-hair grafts, or a two-hair graft into two one-hair grafts, just to push up the total number of grafts to make the fee appear like a bargain is the same as double- charging you. Sadly, this is quite a common practice.
Your doctor should be able to explain the exact number of cut grafts and how the numbers were calculated. Ask your doctor how the grafts are counted and to see the sheet that lists the numbers of grafts cut by each technician, because the accounting process of dissecting grafts is highly variable.
If graft splitting weren’t complicated enough, you also need to be aware of the “low-ball” sales technique when estimating the number of grafts needed. In this technique, the estimate of the work needed increases after the work has already begun. If your doctor’s initial estimate of how many grafts you need sounds low because you sense that he/she wants to make the sale, then you might assume the worst and do some good comparative shopping.
Although the overall cost of a hair transplant is an important factor in making your decision of whether to move forward with it, you also need to have an honest, competent doctor whom you can trust to act in your best interest. The good and bad news about hair transplantation is that it’s permanent. Unfortunately, the work of a poor surgeon will be with you for your entire life, so choosing the right doctor and practice is critical.
Choosing a Doctor
The most important factor in hair transplant surgery is choosing the right surgeon. You can have a wonderful plan for surgery, a great medical facility, and marvelous nurses, but if the surgeon doesn’t plan your reconstruction properly and then do a good job, the whole thing is for naught. Good planning in how the hair is to be trans- planted is as important as doing the technical components correctly.
Basically, what you’re looking for is a well-credentialed, caring, competent, artistic (cosmetic surgery is about 50 percent art) doctor whom you like and feel comfortable with. This section guides you through the task of finding a hair transplant surgeon who’s right for you and helps you prepare yourself for your office visits to make sure that you get all the information you need to make an informed selection.
Finding a doctor
The best place to start your search for a hair transplant doctor is with friends who have had transplants. Talk with them and look at the quality of their work.
If you don’t have a personal connection to someone who has had a transplant, start your search on the Internet. The International Society of Hair Restoration Surgery (www.ishrs.org) lists hundreds of doctors worldwide who work in the field. You also may want to enter “hair transplantation” along with your city and state in your favorite search engine, and explore the results.
Meeting for the first consultation
Going in for a surgical consultation is both exciting and a bit scary — don’t lose your head, though, in your excitement about regaining your hair.
Always meet with more than one doctor before making a decision. We also strongly suggest that you look at the Web sites of various doctors, both in and out of your area. The comprehensive nature of these sites will give you a feeling of just how good the doctor is at educating you and sharing his experience and his patient popu- lation with you.
This section walks you through what to expect at your first meet- ing, starting with these first steps:
1. The initial interviewer, who may or may not be the doctor, should provide you with basic information about the hair transplant procedure.
2. You’ll fill out a basic medical history form to determine your candidacy for having a surgical procedure.
3. Some assessment of your hair loss may be done, but only a physician or a specially qualified nurse practitioner or physician’s assistant may legally perform a physical examination and render an opinion.
4. A more knowledgeable interviewer may try to determine whether your expectations are realistic.
In some hair restoration practices, salespeople work at remote offices without a doctor present. These salespeople function independently in many ways and may even wear white coats, implying some medical expertise. If you visit a remote office staffed with salespeople, follow these suggestions:
� Ask whether the person you’re meeting with is a salesperson or doctor. Only a doctor can give you a diagnosis and assessment. A salesperson may be able to educate you on the process of hair restoration surgery — and that can be very useful — but he or she shouldn’t give a medical opinion.
� Make certain that salespeople don’t recommend any medical or surgical treatment. This includes the type of surgical procedures that would be used in your situation, the number of procedures, or the approximate cost of your restoration. Don’t accept recommendations without input from a qualified doctor.
� Don’t discuss your financial status with a salesperson. When
a physician is available in the office, the patient educator or
salesperson should call the doctor in to examine your hair and scalp, quantify the amount of donor hair you have, address your worst-case balding pattern, and then discuss your surgical options. When the doctor reviews costs with you, your cost shouldn’t depend upon what you can afford.
� The doctor should outline a master plan specifically for you that addresses future hair loss. If you can’t afford what you need to achieve your goals, ask the doctor whether modifying your goals is reasonable, and make sure you understand the implications of modifying your goals.
It’s always best to have the doctor do the entire consultation. During the consultation, a doctor should
� Educate you in the procedure.
� Take a history.
� Do the physical examination.
� Discuss your options.
� Estimate the number of surgeries it will take to achieve the desired result.
� Review all the costs involved.
Busier practices may offload some of these tasks to nurses or clerical people, which may be okay because some of these people will have more time to spend with you answering your questions than a doctor would, but nothing can replace the doctor’s advice. One well-known clinic takes the view that the doctor “just screws up the sale” and that it’s best to minimize patient-doctor contact. This view is clearly opposite to our thinking.
A good doctor needs to have a strong team behind him. You should expect physician extenders to be educated as nurses or certified physician assistants. Doing refined follicular unit transplantation, which is today’s standard of care, takes a team of 3 to 6 people working together for hours. So, the doctor’s team is almost as important as the doctor is. As the old cliché says, a chain is only as strong as its weakest link.
Asking the right questions
Like buying any big-ticket item, buying a hair transplant requires extensive research. A good buyer is an educated buyer, so take the time to do your homework.
First, be sure your doctor practices the standard of care, follicular unit transplantation, in which individual, naturally growing groups of hair are microscopically dissected and moved into the balding area in their anatomical intact units.
When you think you’re ready to sign on the dotted line, pause to consider the following questions:
� Did the doctor listen to you, give you enough time to voice concerns, and thoroughly explain the procedure and other options? Did he or she learn about you and your concerns, fears, goals, and economic situation? Did the doctor decide what you will need done to achieve your goals, and are you confident in that decision? Most people can tell almost immediately whether they trust or like the doctor if the doctor spends enough time with them.
� How much experience does the doctor have in the hair restoration field? How is the doctor regarded in the medical community?
� Did you receive documents that fully outline the proposed work? Memories often fail, so the more information that the doctor gives you in writing, the better the communication will be between you and your doctor. For example, did you receive an estimate reflecting the scope of the proposed work and its costs? Many times it takes more than one hair transplant to achieve a patient’s need. The patient has every right to know what is in store for him after the surgery. How many more surgeries will be required? The doctor should volunteer this information, but if not, ask about it.
� How does the doctor estimate the cost for a hair restoration procedure? Beware of low-balling — underestimating what you really need to achieve the desired results. Low-balling bids to make the sale isn’t an uncommon practice in many industries, but we’re talking about what you’ll look like for the rest of your life, so low-balling here can have a particularly dramatic effect.
� Are you being pressured by hard-sell tactics? Too many doc-
tors oversell, even though it’s unethical. Does the doctor keep
putting a salesperson between you? Salespeople may sell the doctor’s service like a used car. Note: Commission sales in this field are illegal in most states.
High-pressure sales tactics tell you a lot about the doctor and his or her integrity. Waiting at least a few days before deciding on a surgical procedure is never a mistake. We tell patients that a good decision today is a good decision tomorrow.
� Does the doctor innovate? Is he or she a leader or a follower?
All doctors don’t have to be innovators, provided that they
can deliver a quality service and have learned from the innovators and practice the standard of care. Some doctors misrepresent themselves to build up an image that they haven’t earned, such as claiming to be the inventors or pioneers of the surgeries that they offer. With the Internet as a resource, it’s relatively easy to verify such claims.
� Has the doctor been bombarded with legal problems? Is his or her medical legal record clean? Make sure that you have done your diligence by checking as many sources as you can to determine the history of the medical practice.
Look up the doctor or the medical group of your choice on your state’s medical board Web site before making a decision. (You can find a directory of state medical board contact information at www.fsmb.org/directory_smb.html.) State medical boards make available doctors’ records with regard to legal matters. You may be surprised at what you learn from the medical board search.
� Does the doctor or salesperson try to find out how much money you’re planning to spend before giving you an estimate for the proposed work? That’s a bad sign. The doctor’s first priority should be what is or isn’t on top of your head, not what’s in your wallet. You should never feel that a doctor is trying to pick your pocket!
Seeing results for yourself
Does your doctor offer patient references? Our office promotes a monthly interaction with our former patients for the purpose of educating prospective patients about the hair transplant process. We also allow prospective patients to speak to someone who’s having the transplant procedure and even watch the process.
You can get what you want
A 23-year-old patient had developed the nickname “Captain Forehead” when he first came to see me (Dr. Rassman). His hairline was very high and had receded back about 1 inch beyond his original mature hairline. His temple prominences were set back on his head, and he had the beginning of balding in the crown.
He used a photograph to show me what he wanted to achieve. He earned $9 per hour, had no savings, and had about $3,000 worth of credit card availability. I real- ized that his goals were well beyond his ability to pay not only for the first procedure he would need but for subsequent surgeries if his hair loss should progress, and I discouraged him from doing the surgery.
Six months later, he made an appointment with my colleague and got on the sur- gery schedule. I met him again the day after the surgery and was disappointed to find that he had gone forward with a transplant. To my surprise, I found out that this young man had moved out of his apartment and into his 1991 Dodge Omni (he was over 6 feet tall, so it must have been cozy!), where he had lived for the last 6 months. He saved his pennies, got a loan from his parents, and went to Mexico to purchase Propecia long before it was released in the United States. I was so impressed with his focus and dedication that I hired him and put him to work for me educating patients over the phone. This patient now cuts his hair short and no longer looks like Captain Forehead.
There’s no better way to evaluate a doctor’s work than to see it up close and in person. Good pictures are beneficial, but pictures can be altered or patients can be photographed in ways that really don’t reflect the whole truth. When you meet a patient, however, you can look at him or her from every angle! Ask your doctor for direct patient references.
It’s best if you can meet with someone who has had a transplant similar to the one you’re considering. If your doctor doesn’t promote face-to-face meetings, before and after pictures taken from every angle can help you evaluate his or her work.
Before the Surgery
Different doctors have different rules for what you should and shouldn’t do before surgery, so always follow your own doctor’s recommendations. The following are common recommendations:
� Ask if you can have anything at all to eat or drink before surgery.
� If you’re on aspirin or any blood thinner, stop taking it ten days prior to the surgery.
� Speak to your doctor about any medications you normally take, and get instructions about what you should and should- n’t take in the days before surgery and particularly on the morning of surgery.
� If you’re a diabetic on insulin, ask your doctor what to do with regard to your insulin use and your diet.
� Wear comfortable clothing that’s easy to remove.
� Ask about using an antibacterial soap on your hair and scalp the night before and the day of surgery. If the doctor wants you to use an antibacterial soap, be very careful not to get it in your eyes as it may be very irritating. If you accidentally get it in your eyes, rinse your eyes thoroughly with clear water until the burning subsides. Reducing the bacterial count in the hair follicles is best done with good washing before the surgery.
Review any paperwork you have before you head in for your surgery; this should include all the communications between the doctor’s office and you. You should have received a copy of the informed consent form that you have to sign on the morning of the surgery. This document defines what the surgeon intends to do, and most important, it defines the risks of the proposed surgery. You may have questions after reading through it, so jot them down to ask the doctor if anything is unclear.
When you meet with your doctor prior to the surgery, review the informed consent document with him or her. It’s not unusual for last- minute questions to come up; legal documents are often filled with every possible risk and can be overwhelming and scary to sign.
Ask your doctor what the plan will be if the actual number of grafts harvested exceeds or falls short of the estimate you’re paying for. For strip harvesting, this is a critical question because making the estimation is as much an art as a science. Donor densities vary by the exact anatomic location on the back and sides of your head, so estimates are frequently off by 5 to 10 percent. For FUE harvesting,
quantifying the grafts harvested is far more precise because hair groupings are removed one at a time. You can find explanations of these harvesting techniques in Chapter 12.
During the Surgery
Hair transplant surgery is usually performed under local anesthesia, so you’ll probably be awake (although somewhat sedated) during your procedure. Often pictures are taken of you prior to the surgery to document your starting point. The surgeon should draw your new hairline on your head; you should have had considerable input into the hairline design and location before this point, because once the hair goes in, it’s too late to change it!
The process of determining your new hairline is your last input into what the surgeon will do, so make sure that you’ve agreed not only on the hairline but also on the distribution of hair.
It is difficult to place a hairline and this process requires a friendly interplay between the surgeon and his patient. There are artistic considerations for the surgeon and there is often anxiety on the patient’s part because he must imagine that the hairline that is drawn in crayon, is just a line. The patient usually goes along with the surgeon’s suggestions on hairline placement but should voice concerns on location and balance.
After you sign all the legal papers, you’ll be given a sedative that should help you manage any anxiety you may have; many patients fall asleep within the first hour of the surgery. The procedure is performed under local anesthetics such as lidocaine or Marcaine injected to numb your scalp and some mild sedation to help the patient through the long surgery. Some doctors use a short-acting narcotic before the local anesthetics are started (like a twilight sedative), and some also add laughing gas to help you through the initial phase of the surgery, when there may be some pain. There should be no pain associated with a hair transplant procedure aside from some small mosquito bite-type shots during the initial administration of local anesthesia. The amount of sedation may be the choice of the doctor or the patient, and the depth of the sedation various with different clinics.
The entire procedure may take place in a surgical chair much like the chair at your dentist’s office. Some surgeons allow you to sit up, whereas others lie you flat. You’ll be awake, so you can interact with the doctor and staff or just relax — watching a movie, listening to music, or sleeping if you wish. The average surgery takes four to seven hours, depending upon the number of grafts performed and the size of the surgical team.
Most of our patients consider surgery day a great day because they feel good with so many people working on them and taking care of them, and they remain comfortable from the drugs they receive.
Because the day can be long, your procedure may include snacks and meals! In our practices, we serve good food, including shrimp cocktail and ice cream sundaes for dessert, all in the middle of a hair transplant procedure. That’s right — you can eat during surgery!
The Night and Morning after Surgery
One of the most common patient concerns after any surgery is what he or she will feel like afterward. What you experience after hair transplant surgery depends somewhat on which procedure you have, strip harvesting or FUE.
� Strip harvesting: As we explain in Chapter 12, single strip harvesting removes the donor tissue as a single strip or oval, and then technicians divide it into smaller sections using a dis- secting stereo-microscope to minimize damage to the follicles.
• Pain: When you leave the surgical office after a procedure involving strip harvesting, you shouldn’t feel any pain for about six hours. Doctors usually administer a long-acting anesthetic when you leave that keeps you pain-free for this period. When the anesthesia wears off, you may have a dull ache in the area where the donor strip was taken. About 95 percent of patients tolerate this discomfort well, but you’ll get narcotics in pill form to take home, and we strongly urge you to take one along with a sleep aid when you go to sleep so that you’re able to get some rest.
One out of every 200 to 300 patients experience considerable pain on the night of surgery, probably resulting from muscle spasms in the incision area. Your surgeon should give you enough pain medication for this rare occurrence, and you may want to put ice on the band- aged incision area for pain relief. Also, you should be given a travel-type neck pillow for properly positioning the head at home. The pain will usually subside by morning.
• Bandaging and bleeding: You’ll leave the office with
a 1-inch band wrapped around your head, like a tennis sweat band. This puts gentle pressure over the surgical wound, which sometimes bleeds slightly under this bandage. Some bleeding may occur because the long- acting anesthetics contain adrenaline, which constricts blood vessels. Generally, gentle pressure for about ten minutes usually stops any bleeding, but if there’s any excessive bleeding, be sure to call your doctor.
• Next day follow-up: Doctors generally like to see you the next morning to administer the first hair wash, which is done more aggressively than you may feel comfortable doing yourself. The goal is to clean off all blood and scabs; many patients walk out after the hair wash with minimal redness or indications that a hair trans- plant was done. The post-surgical hair wash by the surgical staff isn’t a necessity, but if you do it yourself, make sure you follow the washing instructions carefully. Your doctor may supply a video to make the process easier for you to understand and follow.
� Follicular unit extraction (FUE): In the FUE procedure, each follicular unit is removed one at a time. The wounds are less than 1mm each and they are not sutured as they are left open. The wounds swell and often close on their own in a day or two. If they crust, the scabs are very small. Bleeding is usually minimal and healing is very fast, usually in less than a week.
• Pain: The best part of an FUE is that there’s often no significant pain after the surgery. Patients receive pain medications, but these are rarely needed. The ache that occurs in strip harvesting procedures is rarely present.
• Bandaging and bleeding: The wounds from where the grafts were taken are left open and hidden under a base- ball hat or bandana. Significant bleeding rarely occurs because the wounds are so small. No bandages are used.
• Next day follow-up: Most patients have the option of revisiting the office so that the surgical staff can perform the first post-surgical hair wash, but it’s not a necessity following this type of harvesting.
Possible Complications of Hair Transplant Surgery
It’s important to remember that a hair transplant is a surgical procedure, and any surgical procedure carries some risks. The risks associated with a hair transplant are minimal, but they’re still worth some thought. In this section, we explain the possible complications and estimate their frequency.
We base the following estimations on our own experiences in our hair transplant practices over the years.
Anesthesia reactions
General anesthesia, in which you’re “put out,” is rarely used for hair transplant surgery. General anesthetics bring risks that are almost non-existent with local anesthetics, such as risk of death or stroke.
Local anesthetics with adrenaline may have effects on many of the body’s organ systems, including the heart. Following are some of these risks, along with the percentage of patients that typically experience them:
� Allergic reaction (less than 1 percent of patients)
� Irregular heartbeat (less than 1 percent of patients)
� Heart attack within one month after surgery (less than 0.001 percent of patients)
� Particular sensitivity to epinephrine in patients who use heart or blood pressure medications called beta-blockers (less than 1 percent of patients)
� Temporary light-headed episode as a nervous reaction to injections, causing a drop in blood pressure and possible fainting (less than 1 percent of patients)
This reaction is easily and relatively rapidly treated, most of the time by lying the patient flat and elevating the legs.
Wound healing
Surgical wounds take time to heal. After surgery, any of the follow- ing points may apply to your donor and recipient areas:
� Superficial crusting, pinkness, or redness of the recipient area may occur (less than 5 percent of patients), but these effects are usually temporary. In most patients, pinkness disappears in a few days.
� Some area of skin around the suture edges may crust, taking longer to heal (less than 5 percent of patients). A tight suture may cause such crusting.
� A stretched, widened scar is possible, as is a thickened or raised (hypertrophic) scar (less than 1 percent of patients).
Significant scarring is more likely to occur in people who have a history of hypertrophic scars elsewhere on the body (less than 25 percent of patients). True keloid scars (a tumorous type of growth that grows out of the wound and extends beyond the confines of the wound) are very rare in scalp incisions (less than 0.001 percent of patients).
� In areas of scar tissue, grafts may grow poorly or not at all.
� Temporary swelling, discoloration, or bruising (less than 5 percent of patients)
� Formation of a cyst at a graft site (less than 5 percent of patients). Most cysts will disappear on their own, a few may spontaneously pop and drain themselves, and a few may have to be lanced by a doctor or nurse. Cyst formation rarely impacts hair growth. Cysts are formed as remnants of the hair from a hair transplant remain in the surgical recipient site. The existence of such remnants in the recipient sites is very common but cyst formation is vary rare. Usually, any buried remnants are ‘attacked’ by the body’s defenses and dissolved.
� Ingrown or buried hairs (less than 5 percent of patients).
Ingrown hairs can be difficult to distinguish from buried
grafts. A graft that is placed too deeply in the scalp at the recipient site, may sink into the fatty dermis and form a cyst. Sometimes, the surgical staff may place one graft on top of another and this will add to cyst formation as well. Both of these problems may result from staff training inadequacies and problems with in-office quality control processes.
� Hematoma (localized blood clot) (less than 1 percent)
Pain
As the anesthesia wears off, if you had a strip harvesting procedure (see Chapter 12 for an explanation), you’ll experience a throbbing pain on the back of the scalp, but this can be managed with oral prescription pain medications such as Vicodin or Endocet. Some patients rely on these medications for the first few nights so that they can rest their heads in a comfortable position and sleep. During the day, most patients use over-the-counter pain relievers.
The pain shouldn’t disrupt your normal daily functions; most patients are able to return to their normal work activity in two to three days following hair transplant surgery.
Some patients experience pain from the sutures or staples used to close their wounds. Staples are more uncomfortable than sutures but may produce better long-term wound healing. When the staples or sutures are removed (10 to 20 days after surgery, depending on the doctor’s preference), most of the related pain goes away. A very small percentage of patients (less than 2 percent) have some discomfort in the wound for weeks or months after the surgery, but this discomfort usually subsides over time.
Numbness
Numbness of the scalp may occur due to necessary cutting of fine nerve fibers in the skin (less than 30 percent of patients). This is expected to gradually disappear over several months, but it’s possible that all the sensation may not return (less than 1 percent of patients). This is the consequence of strip harvesting and although it can happen with follicular unit extraction harvesting, it is far more rare.
In extremely rare circumstances, major sensory nerve injury may occur, resulting in long-term or possibly permanent numbness and/or pain in the scalp (less than 0.001 percent of patients).
Having more than one hair transplant procedure puts you at a higher risk of severing a major sensory nerve, which can produce a temporary or permanent sensory defect in the back of the head. Your surgeon’s experience is paramount in avoiding this complication. The risk of such damage with strip harvesting although very small, is greater than the same damage from FUE harvesting.
Swelling
A small number of patients experience post-surgical swelling in the forehead if their grafts were placed in the frontal area. In the past, swelling was a real problem for almost every hair transplant procedure, but the use of short-term, higher-dose steroids during and after the surgery has made the problem rarely significant. Applying ice packs or cold compresses to the forehead a few times a day may help reduce swelling.
If swelling occurs, it usually appears on the third or fourth day after surgery and lasts from one to two days at most. You shouldn’t feel any pain with the swelling. Most people with swelling look terrible but feel fine. Significant swelling occurs in a substantial number of patients who do not use large dose steroids and less than one out of 40 patients for those using steroids. When swelling
does occur, it ) usually drops down to the eyelids, possibly closing one eye on the third or fourth day (less than 1% of patients).
Infection
Although infection in hair transplantation is rare (less than 1 per- cent of patients), you’ll be given an antibiotic to reduce the possibility of infection at the beginning of the surgery. Your doctor may want you to use a special antibacterial soap the night before and the morning of surgery to help protect against infection, but washing with a good detergent shampoo may be just as effective.
The symptoms of infection may include:
� Swelling
� Redness
� Tenderness or pus at the surgical site
� Fever or chills
If you experience any of these symptoms, contact your doctor immediately.
Redness, swelling, and slight tenderness is to be expected for the first few days after the procedure. If the redness, swelling, or tenderness increases after the second day, you should speak with the doctor. Infection can occur at either the donor or the recipient site. Rarely, one or more grafts may become infected within the first two weeks following the surgery. Infected cysts in the recipient area may appear weeks after the surgery; they look like white pimples or redness around individual hairs. They may be associated with a yellow-colored crust and may be tender. If soaked with a warm compress, they usually drain a yellow fluid following the soaking. If these should occur with any frequency, you should con- tact the doctor’s office. Antibiotic treatment may be necessary if they become infected, spread to other areas, or don’t respond to warm compresses.
Almost everyone develops a few pimples in the recipient area at approximately one month following the surgery. These are either new hairs breaking through the skin or the old hair from the grafts being expelled by the body. They occasionally can be confused with a true infection, but pimples tend to resolve on their own in three or four days. As individual pimples resolve, new ones may crop up. You can treat them by applying a warm, moist washcloth at least twice a day for 10 to 15 minutes at a time (you may find it convenient to do this in the shower). If more than just a few pimples
develop at one time, or if the skin in a larger area becomes swollen, red, tender, and hot, you must see your doctor to find out if you have an infection and possibly get antibiotics if they’re necessary.
Ingrown hairs may cause a cyst to develop in the area of a graft. The cyst can develop over a graft that was placed several months earlier. Cysts appear as local swelling and redness, with or without tenderness. These cysts can be easily treated in the doctor’s office.
Preventing Hair Loss Acceleration: Shock Loss
The medical term for the very onerous-sounding shock loss is “effluvium,” which literally means “shedding.” Patients who experience shock loss usually notice it in the first one to four months after hair transplant surgery. Most of the hairs lost from post-surgical shock loss may never grow back, particularly in young balding men.
Hair loss after one to three months may be from a number of causes, including acceleration of the genetic process. Post-surgical hair loss in men is usually seen in the miniaturized hair, and it’s possible that some healthy non-miniaturized hair will be shed, but this should regrow. Rarely do patients shed hair from a prior trans- plant; however, when this occurs, previously transplanted hair that’s lost almost always grows back completely.
Rest assured there are things you and your doctor can do to minimize the effects of post-op shedding. Talk with your doctor about your risk for post-op shedding and ways you can reduce your chances of experiencing it, including the following:
� Use medication: The drug finasteride 1 mg (which goes by the name Propecia) appears to reverse, slow down, or halt the miniaturization process (when hair is at the end of its lifespan due to genetic balding) and is very effective at decreasing the risk of shedding following a transplant in most men.
� Time the transplant properly: If you’re experiencing early hair loss but with a significant amount of miniaturization, a minimal hair transplant won’t compensate either for potential shedding or for progression of the hair loss. The surgery will have a negative impact in that you may develop hair that appears thinner, or you may have more bald spots than before the procedure, which reflects the miniaturized hairs that have been lost.
� Use a sufficient number of grafts to offset any reasonable
expected hair loss: Your doctor can perform a transplant of sufficient size to more than compensate for some shedding.
It’s a fallacy that some doctors’ techniques are so impeccable that they can avoid effluvium altogether. Of course, bad techniques and rough handling maximize the risk of shedding, hair naturally sheds when the scalp is stressed, and it’s stressed during a transplant from the anesthetic mixture and the recipient site creation. Post-op shedding can’t be totally prevented.
Having Surgery to Repair Unsatisfactory Results
You have some important considerations to make when considering a repair surgery. Not all hair transplants end up with good results. The major cosmetic problems were caused by the older techniques used prior to the mid-1990s but poor techniques are not uncommon today. Most of the poor results seen today are primarily due to poorly planned or improperly executed hair restoration surgery. Many of these problems are interrelated, and patients needing repair work often have multiple problems to correct. Poor hair transplant work can not always be repaired.
Repairing many disastrous cases is a challenge, and you need to keep in mind that your doctor may not be able to fix everything that’s wrong. Partial improvement may still be a worthy endeavor when repairs are needed.
Before repairing a prior transplant, it’s important to first establish what aspects of the old transplant work bothers you most. For this, you must clearly express your concerns and priorities.
Some deformities of the transplant that bother your surgeon may be left untreated if they don’t necessarily bother you. Setting priorities at the outset will help ensure maximum patient satisfaction. Our most satisfied patients are those who walked around deformed from the old type of transplant work prior to our working with them. Gaining their trust after years of suffering is a major accomplishment by itself.
This section describes some potential problems that may have you heading back to your surgeon for repairs.
Grafts that are too large or look pluggy
Tens of thousands of patients who received the large graft hair transplant technique prior to the early 1990s have the classic doll’s head look that people think is what all hair transplants look like. Thankfully, this pluggy look shouldn’t occur with today’s trans- plant techniques.
Large plugs placed into a bald head contract in size. Assuming that all the hair survives the transplant, the density of these grafts will (theoretically) be higher than the normal density of the donor hair. So when they’re placed into a bald area, they become very detectable because of a pattern of excessive density within the larger grafts and empty spaces between them.
Most patients who have a significant amount of balding don’t have enough donor hair to both fill in the spaces between the plugs and cover all the area that needs to have hair. As a result, the surgeon is left with the dilemma of choosing between a pluggy look scattered over a large area or an uneven look, with very high density grafts in some areas and insufficient coverage in others. Often the patient is left with both problems!
When hair is distributed properly in a hair restoration procedure, the density shouldn’t exceed 50 percent of your original hair density. The average human scalp has at least a 100 percent visual redundancy, which means that the eye can’t perceive hair loss until it exceeds 50 percent of what was originally there. So there’s no logical reason to restore more than 50 percent of the original density, especially given that the balding patient has less total hair available. Hair from the old plugs can be removed and redistributed according to this rule or, if available, more hair can be taken from the permanent zone and distributed in and around the big plugs to camouflage them.
The pluggy look may also be tied to less density in the grafts than anticipated from the size of the harvested plug. Two of the most common causes are hair loss from poor harvesting techniques and hair loss caused by a phenomenon called doughnutting. In dough- nutting, the centers of grafts get insufficient oxygen following transplantation and so the follicles in the central portion of the grafts failed to survive. When part of the hairs around the circle also died, a crescent moon deformity results in hair growing only in part of the periphery of the grafts.
Grafts generally placed without great precision often pit, creating a deep hole in the scalp with hair growing out of it, or are raised above the scalp horizon creating some cobblestoning of the skin. Before better techniques were developed and perfected, these unattractive results were common.
Hairline problems
If your hairline isn’t placed in the correct position, you won’t have a natural look and are likely to seek another transplant to repair your results. Hairline problems fall into one of four categories:
� Hairline too far forward: If the hairline is placed too low, it may be impossible to fix. A common mistake of the inexperienced hair restoration surgeon is to restore the hairline to the adolescent rather than the normal adult position.
Unfortunately, this also occurs when the doctor is anxious to get the patient started with surgery rather than embarking on a more conservative (and more appropriate) non-surgical treatment. A low frontal hairline not only distorts your facial proportions, but also it sets expectations that are unsustain- able if the balding progresses. A low hairline also leaves the restoration looking unnatural and unbalanced as you age.
� Hairline too high: A high hairline looks abnormal, even if the grafts are follicular unit grafts with single hairs in the front. Locating a restored hairline requires artistry, and placing a frontal hairline too high is the most common mistake of the hair restoration surgeon.
� Hairline too broad: Although the adolescent hairline hugs the upper brow crease, the position of the normal adult male hair- line is approximately one fingerbreadth higher (1.5 cm above the upper brow crease at the midline).
� Hair pointing in the wrong direction: Your own hair direction must be followed exactly for any hope of the transplant looking natural. The only exception is the occasional swirl at the frontal hairline that most likely won’t be permanent.
The hair also must be placed pointing forward, toward the horizon in the front and slowly angled upward as it progresses back. Too many surgeons place the hair in a radial configuration, like the spokes of a bicycle, which is a most unnatural hair direction that never quite looks right. As hair approaches the crown, a swirl is appropriate to allow for changing directions.
The hair also shouldn’t be transplanted perpendicular to the scalp. Although patients are often unaware of the problem, this looks distinctly unnatural. In a properly performed hair
transplant, the hair is transplanted pointing forward and then when the hair is groomed to the side or back, the hair is bent, showing the curve of the hair shaft rather than the base.
Unrealistic area of attempted coverage
Hair is a limited resource, so distributing it properly is critical. In the hands of an ethical doctor, there’s no such thing as a preventive hair transplant. Areas where your hair still appears normal should not receive grafts. Many doctors transplant behind the targeted bald area in order to push their fees higher, but hair trans- plants placed in normal hair may do damage to that hair and, in many men, will accelerate the hair loss.
On the other hand, the first areas to bald — the crown and frontal hairline — should be transplanted cautiously, with an adequate amount of hair always reserved for future use. Critical areas such as the forelock and the area behind it will eventually require trans- plants. If your donor reserves are limited due to poor scalp laxity, low donor density, fine hair shaft diameter, or a host of other reasons, transplanting hair in other less critical areas should be postponed or avoided entirely.
A pattern that resembles two horns and a tail may result when doc- tors are too aggressive in transplanting the frontal hairline and crown in a young person. This can become a cosmetic nightmare for the patient if he experiences further balding and these regions can’t be connected due to inadequate donor reserves.
Ridging
Ridging doesn’t occur with the modern follicular unit transplant, but it’s a well-known abnormality of the older minigraft and larger graft techniques. Ridging is essentially an area of heaped up skin at the point where the plugs were placed into the frontal scalp. This extra tissue makes the transplanted area elevated to the degree that you can see a ridge in the scalp separating the forehead from the area behind. In some patients, ridging is made worse by a reaction of the surrounding tissue in response to the transplanted grafts. This phenomenon called hyperfibrotic scarring accentuates the abnormal contour of the transplanted area. Hyperfibrotic changes are rarely seen with very small grafts and haven’t been reported with follicular unit transplantation (FUT). (We explain FUT in Chapter 12.)
Scarring
Scarring occurs 100 percent of the time after hair transplant surgery, but if it can’t be seen or doesn’t impact hair growth, it’s not a problem. Scarring can occur in either the donor or the recipient areas. Donor area scarring is pretty much a given in patients whose hair is harvested by the strip harvesting technique, but it may be minimized by certain surgical techniques that can make them almost undetectable in most patients. However, keep in mind that some patients will always scar more than others. Scarring in the recipient area is very rare with modern techniques.
Having a scar removed later may result in another scar in the same place, although specialized surgical techniques may make cosmetic improvements. The degree of scarring after a first surgery where the wound measures more than 3 millimeters occurs in about 5 percent of patients. After a second surgery, this risk doubles. Scars of this size generally can’t be seen if the hair length in the back of the head is 1⁄3 inch or so.
Although the major effect of removing hair from the donor area is decreasing the amount of available hair for use elsewhere, when scarring is severe, the scar itself may become a cosmetic problem. This is most likely to occur when the scar is placed too high (in the non-permanent zone), is placed too low (near the nape of the neck or over the ear), is excessively wide in any location, or is raised and results in a hypertrophic scar or a keloid.
Transplanting hair into areas with severe scarring can cause graft elevation or depression, loss of grafts after the surgery, and poor hair growth. Mild scarring may result in subtle textural and visual irregularities in the skin around the grafts, distort the hair direction, and cause a change in quality of the hair shaft, all reducing the chance of a cosmetically satisfactory result.
Laser hair transplantation, more aptly termed laser site creation, represents the epitome of purposeless scarring. The laser is nothing more than a marketing gimmick; it’s basically a glorified punch that creates recipient holes or slits in the scalp by removing (vaporizing) tissue. Regardless of how little damage is done to surrounding tissue, the recipient tissue directly under the beam is totally destroyed. (The laser has the additional disadvantages of increased set-up time, greater cost, and potential eye hazards.) Laser operators lack the precise tactile and visual guidance to adjust for depth and angle when making sites on a curved scalp. Most important, the laser destroys tissue, produces third-degree burns, and unnecessarily increases the recipient wound size.
Hair wastage
Careful surgery and a good surgical team using modern microscopically controlled harvesting techniques produce minimal wastage. If your doctors don’t use microscopes, the wastage can be 20 to 40 percent of the total hair removed. If your surgeon uses a multi- bladed knife, the hair kill rate may be as high as 50 percent.
Wastage of donor hair from poor techniques leaves you with limited hair for future hair transplant surgeries. Hair wastage may be a result of
� Poor graft harvesting and dissection
� Improper graft storage and handling
� Keeping the grafts out of the body too long
� Packing the transplanted grafts too closely in the scalp
� Poor preoperative preparation
� Inadequate postoperative care
Literally every step of a poorly executed transplant may deplete your donor supply, and all the hair that’s lost is lost forever.
An interesting paradox occurs with the old punch-graft technique. When the procedure is done well, most of the donor hair is captured in each punch, but the growth of the grafts appears pluggy, which is a primary complaint from patients. When the procedure is performed poorly, more of the harvested follicles are cut and dam- aged. Transplanting these grafts decreases the pluggy look and contributes to a softer, more natural look, which initially makes patients happy. However, the poor growth is evidence that there will be problems with hair supply in the future and, ultimately, a worse cosmetic result.

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