Hair Replacement Surgery
Hair replacement surgery involves acquiring a strip
of hair-bearing scalp from the back of the head, dividing
them into several hundred smaller grafts and then inserting
these grafts into tiny slits in the scalp. The key factor
in hair replacement is the presence of donor hair on
the side or the back scalp, which is then used to replace
hair where loss has occurred. Total baldness makes replacement
surgery impossible. Hair quality is another factor.
Hair that is light in color and course in texture produce
a look of greater density than fine or dark hair.
For patients looking for alternatives to hair transplants,
many doctors now offer scalp flaps and scalp reductions
to produce a new, natural-looking head of hair. Of all
hair restoration procedures, scalp flaps move the greatest
amount of hair in the shortest amount of time. As with
hair transplants, scalp flap surgery involves removing
hair from a section of the scalp where hair follicles
are abundant and transferring some of those to the balding
However, instead of cutting the section of hair into
smaller grafts and then inserting them into thinning
areas, scalp flap surgery is performed by moving the
entire strip to a completely bald section of the head.
The hair then continues to grow, in its new location,
at the same rate of growth as the previous location.
It will not thin or die unless hair in the area it came
from also thins or dies. Scalp flaps are sometimes performed
in combination with hair transplants for a more natural
look, or with scalp reduction, to more effectively cover
a large bald area.
Because of significant surgical advances with improved
results, interest in hair replacement has increased
significantly during the past decade.
Hair loss affects both men and women of all ages. Some
people begin to lose hair in their twenties. Frequent
shampooing, poor circulation, wearing hats or any other
personal habits are not factors that cause hair loss.
For men, heredity is the major factor in hair loss.
For women, hormonal changes, including those that occur
in menopause, are mainly responsible for female "pattern
changes," which include thinning and loss. Accidents,
burns, and disease can also trigger hair loss. It is
important to understand that you will never have the
coverage you had prior to your hair loss, but surgery
may camouflage the thin areas and give you more fullness.
Hair replacement surgery can enhance your appearance
and your self-confidence.
How is hair replacement surgery performed?
Hair transplantation involves removing small pieces
of hair bearing scalp grafts from a donor site and relocating
them to a bald or thinning area. Grafts differ by size
and shape. Round-shaped punch grafts usually contain
about 10-15 hairs. The much smaller mini-graft contains
about two to four hairs; and the micro-graft, one to
two hairs. Slit grafts, which are inserted into slits
created in the scalp, contain about four to10 hairs
each; strip grafts are long and thin and contain 30-40
Transplant techniques, such as punch grafts, mini-grafts,
micro-grafts, slit grafts, and strip grafts are generally
performed on patients who desire a more modest change
in hair fullness. Flaps, tissue-expansion and scalp-reduction
are procedures that are usually more appropriate for
patients who desire a more dramatic change.
Generally, several surgical sessions may be needed
to achieve satisfactory fullness-and a healing interval
of several months is usually recommended between each
session. It may take up to two years before you see
the final result with a full transplant series. The
amount of coverage you'll need is partly dependent upon
the color and texture of your hair. Coarse, gray or
light-colored hair affords better coverage than fine,
dark-colored hair. The number of large plugs transplanted
in the first session varies with each individual, but
the average is about 50. For mini-grafts or micro-grafts,
the number can be up to 700 per session.
Just before surgery, the "donor area" will
be trimmed short so that the grafts can be easily accessed
and removed. For punch grafts, your doctor may use a
special tube-like instrument made of sharp carbon steel
that punches the round graft out of the donor site so
it can be replaced in the area to be covered-generally
the frontal hairline. For other types of grafts, your
doctor will use a scalpel to remove small sections of
hair-bearing scalp, which will be divided into tiny
sections and transplanted into tiny holes or slits within
the scalp. When grafts are taken, your doctor may periodically
inject small amounts of saline solution into the scalp
to maintain proper skin strength. The donor site holes
may be closed with stitches-for punch grafts, a single
stitch may close each punch site; for other types of
grafts, a small, straight-line scar will result. The
stitches are usually concealed with the surrounding
To maintain healthy circulation in the scalp, the grafts
are placed about one-eighth of an inch apart. In later
sessions, the spaces between the plugs will be filled
in with additional grafts. Your doctor will take great
care in removing and placement of grafts to ensure that
the transplanted hair will grow in a natural direction
and that hair growth at the donor site is not adversely
affected. After the grafting session is complete, the
scalp will be cleansed and covered with gauze. You may
have to wear a pressure bandage for a day or two. Some
doctors allow their patients to recover bandage-free.
Plastic surgeons are the leaders in tissue expansion,
a procedure commonly used in reconstructive surgery
to repair burn wounds and injuries with significant
skin loss. Its application in hair replacement surgery
has yielded dramatic results-significant coverage in
a relatively short amount of time. In this technique,
a balloon-like device called a tissue expander is inserted
beneath hair-bearing scalp that lies next to a bald
area. The device is gradually inflated with salt water
over a period of weeks, causing the skin to expand and
grow new skin cells. This causes a bulge beneath the
hair-bearing scalp, especially after several weeks.
When the skin beneath the hair has stretched enough-usually
about two months after the first operation-another procedure
is performed to bring the expanded skin over to cover
the adjacent bald area.
Flap surgery on the scalp has been performed successfully
for more than 20 years. This procedure is capable of
quickly covering large areas of baldness and is customized
for each individual patient. The size of the flap and
its placement are largely dependent upon the patient's
goals and needs. One flap can do the work of 350 or
more punch grafts.
A section of bald scalp is cut out and a flap of hair-bearing
skin is lifted off the surface while still attached
at one end. The hair-bearing flap is brought into its
new position and sewn into place, while remaining "tethered"
to its original blood supply.
As you heal, you'll notice that the scar is camouflaged-or
at least obscured-by relocated hair, which grows to
the very edge of the incision.
In recent years, plastic surgeons have made significant
advances in flap techniques, combining flap surgery
and scalp reduction for better coverage of the crown;
or with tissue expansion, to provide better frontal
coverage and a more natural hairline.
This technique is sometimes referred to as advancement
flap surgery because sections of hair-bearing scalp
are pulled forward or "advanced" to fill in
a bald crown.
Scalp reduction is for coverage of bald areas at the
top and back of the head. It's not beneficial for coverage
of the frontal hairline. After the scalp is injected
with a local anesthetic, a segment of bald scalp is
removed. The pattern of the section of removed scalp
varies widely, depending on the patient's goals. If
a large amount of coverage is needed, doctors commonly
remove a segment of scalp in an inverted Y-shape. Excisions
may also be shaped like a U, a pointed oval, or some
The skin surrounding the cutout area is loosened and
pulled, so that the sections of hair-bearing scalp can
be brought together and closed with stitches. It's likely
that you'll feel a strong tugging at this point, and
How long does a hair replacement
Most doctors perform more than one session of transplanting
to achieve the best results. Each transplanting session
takes between two and four hours, depending on the extent
of the treatment.
What type of anesthesia is used?
Hair replacement surgery, regardless of the technique
is used, is usually performed using a local anesthesia
along with sedation to make you relaxed and comfortable.
Your scalp will be insensitive to pain, but you may
be aware of some tugging or pressure.
General anesthesia may be used for more complex cases
involving tissue expansion or flaps. If general anesthesia
is used, you'll sleep through the procedure.
Where is the procedure performed?
Hair replacement surgery is usually performed in a
physician's office-based facility or in an outpatient
surgery center. Rarely does it require a hospital stay.
A hair transplant can be done in an outpatient surgery
center or in an office surgical suite. Most hair transplants
are performed under local anesthesia (like that used
by dentists) combined with a sedative to make you drowsy.
You'll be awake but relaxed, and although you may feel
some tugging and mild discomfort, you won't feel any
When can I return home and resume
You should arrange for someone to drive you home after
your surgery. Plan to take it easy for a day or two
after the procedure and arrange for assistance if you
think you'll need it.
How do I prepare for hair replacement
During your initial consultation, your surgeon will
discuss the changes that you would like to make to your
appearance. Since the appearance of your hair is a matter
of personal perception and preference, you will need
to discuss your concerns in detail so your surgeon can
determine the appropriate alternatives. You also should
make arrangements ahead of time for someone to drive
you to and from your procedure and to assist you with
your daily activities during your recovery period.
Prior to your surgical procedure, the surgeon will
perform a complete health history and physical. Knowledge
of your allergies, medications and previous surgeries
should be brought to your surgeon's attention at this
time. Specific instructions to assist you in preparing
for this procedure will be given to you after the health
history and physical is complete. Depending on your
individual health status, the instructions may include
guidelines regarding your diet, alcohol intake, smoking
and which medications to take or avoid. Your experience
will be much smoother if you remain compliant with your
What precautions are necessary during
How you feel after surgery depends on the extent and
complexity of the procedure. Any aching, excessive tightness,
or throbbing can be controlled with pain medication
prescribed by your physician.
If bandages are used, they will usually be removed
one day later. You may gently wash your hair within
two days following surgery. Any stitches will be removed
in a week to 10 days. Be sure to discuss the possibility
of swelling, bruising, and drainage with your surgeon.
Because strenuous activity increases blood flow to
the scalp and may cause your transplants or incisions
to bleed, you may be instructed to avoid vigorous exercise
and contact sports for at least three weeks. Some doctors
also advise that sexual activity be avoided for at least
10 days after surgery.
To make sure that your incisions are healing properly,
your doctor will probably want to see you several times
during the first month after surgery. It's important
that you carefully follow any advice you receive at
these follow-up visits.
What are the possible complications
after hair replacement surgery?
Hair replacement surgery is normally safe when performed
by a qualified, experienced physician. Still, individuals
vary greatly in their physical reactions and healing
abilities, and the outcome is never completely predictable.
As in any surgical procedure, infection may occur.
Excessive bleeding and/or wide scars, sometimes called
"stretch-back" scars caused by tension may
result from some scalp-reduction procedures.
In transplant procedures, there is a risk that some
of the grafts won't "take." Although it is
normal for the hair contained within the plugs to fall
out before establishing re-growth in its new location,
sometimes the skin plug dies and surgery must be repeated.
At times, patients with plug grafts will notice small
bumps on the scalp that form at the transplant sites.
These areas can usually be camouflaged with surrounding
When hair loss progresses after surgery, an unnatural,
"patchy" look may result-especially if the
newly-placed hair lies next to patches of hair that
continue to thin out. If this happens, additional surgery
may be required. It is always important to be informed
about the possible complications before any surgery.
Be sure to discuss any concerns you may have with your
What results can I expect after hair
How soon you resume your normal routine depends on
the length, complexity and type of surgery you've had.
You may feel well enough to go back to work and resume
normal, light activity after several days.
Many patients who have had transplants (plugs or other
grafts) are dismayed to find that their "new"
hair falls out within six weeks after surgery. Remember,
this condition is normal and almost always temporary.
After hair falls out, it will take another five to six
weeks before hair growth resumes. You can expect about
a half-inch of growth per month.
You may need a surgical "touch-up" procedure
to create more natural-looking results after your incisions
have healed. Sometimes, this involves blending, a filling-in
of the hairline using a combination of mini-grafts,
micro-grafts, or slit grafts. Or, if you've had a flap
procedure, a small bump called a "dog ear"
may remain visible on the scalp. Your doctor can surgically
remove this after complete healing has occurred.
In general, it's best to anticipate that you will need
a touch-up procedure. Your surgeon can usually predict
how extensive your follow-up surgery is likely to be.
Choosing the right surgeon
To obtain further information regarding ear surgery,
we advise you to consult with a qualified and experienced
board-certified plastic surgeon. Regardless of the type
of procedure you are considering, it is crucial to choose
the right surgeon for your individual goals. To receive
a complimentary consultation with a specialist in your
area, simply fill out our Online
Referral Form or call Toll