What Are the Steps to Performing a Hair Transplant

Anyone looking into getting a hair transplant should be aware of how the process works before proceeding with the surgery for hair loss. Although complicated and requiring a lot of surgical skill, the hair transplant has a clear and logical process starting with an initial consultation and finishing with the recipient having their full results. Below you will find an all-inclusive guide that outlines the hair transplant process from when you first meet with your surgeon to when you see your final results. The procedures for Follicular Unit Transplantation (FUT) and Follicular Unit Extraction (FUE) have unique processes, and the guide will show you where they differ.

Planning Phase and Pre-Operative Assessment

Even though the surgery is the most recognized part of the transplant process, it actually starts long before surgery occurs. The first step, and perhaps the most important step, is the pre-operative assessment and planning stage. During this stage, the surgeon will do a comprehensive review of the patient’s scalp and hair, as well as how much hair loss has occurred. The patient’s medical history, medications, history of hair loss, and donor location—the place on the scalp where the hair is harvested—will all be thoroughly examined. The donor area is generally the back and sides of the head where the hair doesn’t typically fall out. Knowing the available grafts will determine how many grafts can be obtained without making the donor area too thin.

The determination of how many grafts can be obtained is something that is very important to this planning phase as it will ultimately determine what result a patient can realistically achieve. The next step of the planning phase is the design of the hairline and recipient site. To help ensure that the patient receives a natural and age-appropriate hairline, the surgeon will consider such things as the patient’s facial proportions, the patient’s pre-operative hair and the patient’s expected future hair loss. A hairline that is well-planned doesn’t consist of a straight line. Instead, it generally starts with finer, single-hair grafts in front for the softest transition, and then larger (multiple) unit grafts behind it to create density. The architect of your new hairline—your surgeon—uses this planning stage to set realistic expectations, and you’ll talk with them about what you can expect based on your own donor supply and pattern of hair loss. For example, someone with advanced hair loss (Norwood V–VII) could expect to need 4,000–5,000+ grafts, and will probably get the best result from one larger FUT session. We’ll also finalize the harvesting technique (FUT, FUE, or a combination) that will best meet your needs and goals for your lifestyle.

Getting Ready for the Procedure

A number of procedures will be followed on the day of the procedure to get you ready and provide a hygienic, safe setting.

First, the surgical team will thoroughly clean and sterilize your scalp. If you are having an FUE procedure, your donor area will usually be shaved so that your surgeon can clearly see individual follicular units using the punch tool. If you want to keep your FUE surgery private, there are choices for “shaveless” or “long-hair” procedures. For FUT, your surgeon will trim only a small strip of hair in the donor area, and because the surrounding hairs will be long enough to cover the sutured wound, only minimal trimming will be needed.

Once your scalp has been prepped, your surgeon will inject local anesthetic into your donor and recipient areas so that you won’t be able to feel anything during the surgery. You will be awake during the procedure, although we may provide you with an oral tranquilizer to make it easier for you to relax. Pain associated with receiving anesthetic injections is often reported as the most difficult part of the process, much like the pain when having injections during dental work. After anesthesia has taken full effect, your surgeon will draw the patient’s hairline and recipient area for final patient approval. The Aesthetician will also take pictures for your medical record as well.

Donor Follicle Harvest Phase

Following the administration of the anesthetic, the major phase of donor follicle harvesting takes place via either the FUT method (strip harvesting) or FUE method (individual follicular unit harvesting).

FUT (Strip Harvesting)

For FUT (strip harvesting), a strip of tissue will be surgically removed from the back of the scalp (donor site). This strip is typically 0.5 cm–1.5 centimeters wide × 30 centimeters long, depending on how many grafts you are getting. A scalpel is used to make several parallel incisions, with the incision angle appropriately parallel to the angle of the naturally growing hair (to reduce damage). Any incisions made to the scalp during your FUT procedure will then be closed with either stitches or staples via an Aesthetician technique called “trichophytic closure.” This means that the hair will grow through the donor scar and therefore lessen the visibility of that scar as time goes by. In this case, as the donor scalp is closed immediately after the strip of tissue is removed, the patient will not have any prolonged open donor sites while preparing the grafts.

FUE (Individual Follicular Unit Harvesting)

For FUE (individual follicular unit harvesting), a small (0.8 mm–1.1 mm diameter) punch harvesting tool will be used to remove each individual donor follicular unit from the scalp. Each follicular unit (donor follicle) is isolated and harvested from the scalp as a separate transaction.

Both strip and extraction methods require the follicles to be prepared prior to placement in the recipient site. In the case of follicular unit transplantation (FUT), the excised strip of tissue is given to a group of technicians and they dissect the strip into individual follicular units (grafts) that contain between 1 and 4 hair follicles using high-powered stereo-microscopes to establish the integrity of the graft and to maximize the success of the graft. In the case of follicular unit extraction (FUE), the extracted grafts are collected directly from the patient and are subsequently prepared, sorted, and stored in a chilled holding solution (commonly isotonic saline) to keep the grafts hydrated and viable until placed in the recipient area. Studies have shown that the mortality rate of a graft will increase from 9% after 2 hours in non-physiologic condition to 54% after 48 hours in non-physiologic condition, so minimizing the time the grafts spend outside of the body is extremely important.

Creating the Recipient Sites

The surgeon creates the recipient sites in the bald regions of the patient’s head shortly after the preparation of the grafts for transplantation is complete. For this purpose, the surgeon uses either fine hypodermic needles, chisel-type blades, or sapphire blades to incise the scalp. The creation of recipient sites should be done in an artistic fashion with regard to their angle, dimension, and density to achieve a natural appearance of the hair growth pattern of the individual. Grafts with one hair are generally placed in the front to form a soft and natural edge to the hairline, with those grafts having 3–4 hairs being placed behind them to produce density. The skill and judgment of the surgeon in this step is of the utmost importance, as it will set the tone for how the finished hair transplant will look.

The Implantation of Grafts into Recipient Sites and Postoperative Care

Graft Implantation

The implantation of the grafts that have been prepared is the last step in the surgical process. The implantation of the grafts is highly technical and time-consuming; as such, a high degree of skill and precision is required to do this properly. The technicians or surgeon carefully pick up each graft with fine-tipped forceps, taking care to avoid damaging the delicate follicular bulb, and then place them into the pre-made incisions of the scalp. The use of specialized techniques such as Direct Hair Implantation (DHI) allows the grafts to be placed in the pre-made incision while creating the incision at the same time, thus allowing for less handling of the grafts, which results in higher survival rates of grafts. A single FUT can produce as many as 3,000–5,000 grafts in just one procedure, which makes FUT very effective in extensive cases. The method of FUE is often used for smaller cases and when a high degree of accuracy is needed. After all the grafts have been placed, the scalp is cleaned gently, and either a light bandage, dressing, or both may be applied to the donor area.

Postoperative Care and Recovery Timeline

Immediate postoperative care is extremely important for a successful overall outcome of the hair transplant procedure. Patients usually receive detailed instructions for care following their procedures. Sleep with your head elevated for at least the first few nights to minimize swelling, do not touch or disturb the transplanted area, and begin a gentle hair washing regimen as directed by the surgeon (generally starting as soon as one day post-operative). Patients typically experience minimal discomfort that can be controlled by the prescribed analgesic medication. Patients generally return to light desk work within several days of surgery.

The recovery of hair transplants typically progresses through several predictable stages of healing as follows:

• Mild swelling in the forehead area for the first several days.
• The formation of small rough crusts or scabs on the recipient sites that will peel off around the second week.
• The transient shedding of transplanted hairs (known as shock loss) that occurs 2–4 weeks after surgery.

The actual growth of hair will begin to be visible at approximately 3–6 months after surgery; however, the complete density of the hair will not typically be seen for approximately 9–12 months after the hair transplant procedure.

Are You Ready to Take The Next Step?

An experienced physician and a proper strategy are vital to having a successful hair transplant procedure done. The staff members at Powell Medical Center can guide you through the best approach for your balding pattern and your future plans about your hair restoration. Make an appointment for consultation immediately to start your journey towards regaining confidence in yourself and achieving permanent, natural-looking results.