Hair Transplant Surgery – Pros & Cons

Depending on a number of critically important factors, hair transplant surgery can either be one of the best decisions you will ever make or among the worst. Today we’re going to discuss the pros and cons of surgical hair restoration, euphemistically called hair plugs or transplantation. In fact, the more accurate description is “autologous hair bearing skin transplantation”. This is because the actual procedure involves harvesting sections of skin from a hairy part of one’s scalp (donor) and moving it to a bald area (recipient) of the same person. Skin transplantation between anyone other than genetically-identical twins does not work.

The technique of moving hair bearing skin tissue grafts from one part of the scalp to another dates back at least 50 years. In the 1950’s a pioneering surgeon by the name of Dr. Norman Orentreich began to experiment with the idea on willing patients. Orentreich’s groundbreaking work demonstrated a concept that became known as donor dependence, or donor identity, that is to say that hair bearing skin grafts harvested from the zone of the scalp outside the pattern of loss continued to produce viable hair even though the grafts had been relocated into areas that had previously gone bald.

During the next two decades hair transplantation gradually evolved from a curiosity into a popular cosmetic procedure, primarily among balding men of late middle years. In the 1960’s and 1970’s practitioners including Dr. Emanuel Marritt in Colorado, Dr. Otar Norwood, Dr. Walter Unger showed that hair restoration could be feasible and cost effective. A standard of care was developed that, in experienced hands, allowed for reasonably consistent results.

At the time the most common technique involved the use of relatively large grafts (4mm — 5mm in diameter) that were removed individually from the donor site by round punches. This tended to leave the occipital scalp resembling a field of Swiss cheese and significantly limited the yield that was available for movement to the bald zones on top and in front of the patient’s scalp.

Over the course of multiple surgical sessions, grafts were placed into defects that had been created in the recipient zone (bald area) using slightly smaller punch tools. After healing the patient returned for follow up sessions where grafts were placed in and amongst the previous transplants. Because of the relative crudity of this technique, results were often quite apparent and the patient was left to walk around with a dolls hair like appearance, particularly noticeable at the frontal hair line, and especially on windy days. Such patients were usually quite limited in the manner they could style their hair and, because of the wasteful donor extraction method, many persons ran out of donor hair long before the process could be completed.

In the 1980’s hair restoration surgery gradually began to evolve from the use of larger punch grafts to smaller and smaller mini and micrografts. Minigrafts were used behind the hair line, while one and two hair micrografts were used to approximate a natural transition from forehead to hair. Donor site management also evolved from round punch extraction to strip harvesting — a far more efficient technique. Pioneers in this area were skilled surgical practitioners such as Dr. Dan Didocha, Dr. Martin Tessler, Dr. Robert Bernstein and others. The concept of creating a more natural appearance evolved still further in the 1990’s with the advent of follicular unit extraction (FUE), first proposed by the highly gifted Dr. Robert Bernstein, and described in the 1995 Bernstein and Rassman publication “Follicular Transplantation.”

The 1990’s also brought new tools into the mix, such as the introduction of binocular or ‘stereoscopic’ microdissection. Stereoscopic microdissection allowed the surgeon to clearly see where one hair follicle begins and another ends. As the 1990’s progressed, many transplant surgeons shifted away from the use of larger grafts in favor of one, two and three hair follicular units.

While highly useful in the hairline region, such ‘micrografts’ were not always optimal in recreating density behind the hairline. So even after multiple sessions, the final outcome of micrograft-only transplanted scalps tended to look thin and rather wispy. Perhaps of even greater concern, the dissection of a donor strip entirely into micrografts risked a significantly reduced conversion yield. Here’s why.

Let’s assume we are starting with two donor strips of hair bearing tissue from two similar patients. Two surgeons are each dissecting a single donor strip, but the first surgeon aims to dissect down into one and two hair micrografts alone, while the second surgeon dissects only enough micrografts to place in the hairline, leaving larger three, four, five and six hair grafts available for placement behind the hairline. At the beginning each donor strip contains 1,000 hairs. Both surgeons should theoretically end up with 1,000 viable hairs available for transplantation regardless of how the tissue was dissected. Unfortunately, the reality doesn’t quite work out that way.

Every time the donor tissue is cut the risk of transecting a follicle occurs. Transected hair follicles are known colloquially in the industry as Christmas trees — because they are hairs that lack viable roots. Basically, from a previously robust terminal structure, they either produce thin fine hair or none at all.

This is a problem for several reasons, but first and foremost, it is a problem because the act of hair transplantation does not ‘create’ new hair. The process simply relocates viable hair from the back of the scalp to the front.

And since there is a fixed supply of permanent donor hair which may not be sufficient to fill the area of demand, it is intrinsically counterproductive to reduce this limited supply via a technique know to engender relatively poor yield. The problem is solved by the careful use of FUE/micrografts in the recreated hairline and somewhat larger grafts behind the hairline. Refinement is thus achieved at the hairline with appropriate density behind the hairline zone. If either of these factors are missing from the equation the result is a dysaesthetic hair restoration. Either the outcome looks thin and fuzzy (micrografts only) or it looks doll-hair like (large grafts only). So now we can now begin to see why the size and strategic placement of each graft becomes a critically important consideration in hair transplant surgery.

Several other potential caveats to hair transplant surgery are graft compression, misdirection, misangulation, mishandled grafts and donor site damage. Graft compression occurs by trying to insert too large of a donor graft into too small of a recipient hole. If the donor graft is not carefully fitted to the recipient hole then the tissue and hair can literally get ‘squeezed together’.

To see how this works, extend the fingers from your left hand open and wrap the fingers from your right hand around the middle portion of your left hand. Just as your fingers get squeezed closer together, the hairs in a compressed graft end up closer together then they were intended by nature. This tufting lends an odd or unnatural appearance to the hair.

Misdirected grafts produce hair that ends up growing in a direction contrary to that which was intended. Again, this problem causes a weird, unnatural — and difficult to style — head of hair. Misangulation, somewhat similar to misdirection describes a misplaced graft that produces hair at an angle which does not correspond to the way scalp hair is supposed to grow. Again, the result is hair that just doesn’t look right no matter how it is combed.

Mishandling of grafts usually involves either transsecting a follicle (cutting off the root) or dessicating (allowing to dry out) the tissue. Graft mishandling typically occurs primarily in less than experienced surgical hands.

Donor site damage is metaphorically tantamount to decimating the entire Amazon rain forest in order to harvest a few dozen plants to use for decorating a neighborhood street. There are few things more aesthetically demoralizing then walking around with a partially-completed hair transplant — knowing that there isn’t enough donor hair available to finish the job because your donor site is exhausted.

Your donor hair is a precious resource. Treat it like solid gold. It’s all you’ve got and everything you’ve got to complete a process of surgical hair restoration. Don’t waste a single follicle.

So from all of this we can begin to appreciate some of the key pitfalls and risks of transplant surgery. As we see, the risks are principally aesthetic — meaning that the potential for damage is generally cosmetic, not medical. The scalp of most healthy people is extremely well vascularized and, in the setting of transplant surgery, scalp infection and/or other medically-relevant scalp complication is quite rare.

For those individuals considering transplant surgery it is crucial to equip oneself with good solid information. The internet is a good place to start. Visit trusted online resources. An excellent start would be a visit to the International Society of Hair Restoration Surgeons. Another reasonably objective resource is the hair transplant network. David Tse runs a highly educational website called Hairsite. There is always Medline which acts as a clearinghouse for all medical research, including surgical hair restoration. Those who publish on are often the highest caliber in their field.

Once you’ve gathered information from online resources you can move next to contacting the surgeon’s office itself. Take your time. Don’t let anyone talk you into surgery until you’re ready. Keep your money in your wallet and your donor hair behind your ears until you’re really prepared to commit both to the task at hand.

Talk to actual patients. If possible, visit with a restored patient or two in person. Many finished patients will not mind visiting with you if they’re happy with their outcome. Plan to have at least one personal consultation with each surgeon you’re considering. Don’t be afraid to travel. You needn’t go outside the United States for hair restoration. But if you live on the West Coast or East Coast you shouldn’t be limited to hair surgeons in your immediate vicinity. It’s your hair for goodness sake! Don’t let geography be a factor in the decision.

Ask each candidate surgeon pointed questions, such as: Can you show me pictures from patients who started with my degree of hair loss? How close to a full head of hair can I come? What will be the total cost for me to get there? Not just price per graft, or price per procedure, but the cost to get me from where I am now to where I want to be. How many surgeries are we talking about, and spread over what period of time? What is your policy for touch up work? What portion of your practice do you devote to corrective surgeries? Can I see photos of patients that you’ve corrected? These last two questions are highly useful because hair surgeons who are adept at correcting other people’s mistakes are generally less likely to blunder themselves.

There is a crucial take-home lesson from all of this. The single most important criterion in predicting a good outcome for hair transplant surgery is not the patient, but the surgeon. In surgical hair restoration, art is at least as important as science. You’ve access to genuine excellence in the hands of experts like Dr. Dan Didocha, Dr. Robert Bernstein, Dr. Bradley Wolf, Dr. Martin Tessler, Dr. Leonard Aronovitz and others. So for those seriously thinking about undergoing transplant surgery, the key is to arm yourself with knowledge first. Take your time. Be ‘patient’ before becoming anyone’s “patient”. Follow this advice and the odds are you will end up happier after your hair restoration then you are today.