Frequently Asked Questions : Hair Transplant

What causes hair loss ?

The most common cause of hair loss is heredity. Men and women inherit the gene for hair loss from either or both parents. In men, the hormone dihydrotestosterone causes a gradual miniaturization and eventual loss of hair follicles that are genetically susceptible. The mechanism of female pattern hair loss is not clearly known. The age of onset, extent, and rate of hair loss vary from person to person. Men and women exhibit hereditary hair loss differently. Severe illness, medications, malnutrition, or vitamin deficiency can accelerate this process. When applied incorrectly, permanent hair color and chemical relaxers damage the hair and follicle to the extent that hair loss can be permanent. Causes of hair loss do not include wearing a hat, excessive shampooing, lack of blood flow, or clogged pores.

Do hair transplants really work ?

Yes. The transplanted hair is removed from one area of the body (donor site) and transferred to another (recipient site). The transferred tissue is not "rejected" as it is not foreign tissue. The transplanted hair maintains its own characteristics; color, texture, growth rate, and curl, after transplantation and regrowth. The vitality of the grafted follicle is maintained by the rich blood supply to the scalp. Originally many years ago, large circular grafts (commonly called 'plugs') containing 15-20 hairs were transplanted resulting in noticeably unnatural results. Over years, instruments and techniques have been developed that allow hair transplant surgeons to achieve truly natural results by transplanting large numbers of small grafts very close together. We have found that hair grows from the scalp in groups of one, two, or three (and rarely, four) hair follicles, called "follicular units." We can transfer these groups of follicles, called "follicular unit grafts," after eliminating the excess surrounding tissue. This allows the grafts to be placed closer together resulting in a denser and more natural result. A significant amount of artistry is also needed in order to recreate the natural patterns of hair growth.

Is an undetectable hair transplant possible ?

Yes. Today's highly trained and up-to-date surgeons, using a combination of artistry and technology, can recreate hairlines and crown coverage in a manner that truly defies detection. Progressing beyond the old style 'plug-type' transplants has been possible using advanced techniques which allow the transplantation of large numbers of small grafts. An appreciation for the natural shape and patterns of hair growth allows surgeons to create wavy, randomized hairlines that look natural.

What can be expected after hair restoration surgery ?

The post-operative course will depend on adherence to the instructions given after surgery. Small scabs will form on the scalp at the graft sites. Generally speaking, these scabs disappear in 4-10 days. Shampooing can be resumed 24 hours after surgery. The suture (stitch) used in the donor area is undetectable immediately after surgery as it is completely covered by your existing hair. Some surgeons use absorbable stitches which are dissolved by the body, other surgeons may use skin staples. If the suture is non-absorbable, an appointment will be made for the suture to be removed approximately one week after surgery. It is advisable to take at least two days off work after surgery. A baseball type cap can be worn at anytime after surgery. Patients should avoid strenuous physical activity for at least five days after surgery. Typically the grafted hair will shed in 2-4 weeks. New growth will begin in 3-4 months and length will increase approximately 1/2 inch per month.

Are hair transplants painful ?

Most people are surprised at how little pain there is during a hair transplant procedure today. Some discomfort is to be expected as the anesthetic is injected into the scalp. Once the skin is anesthetized, there is no pain. If the numbing medicine wears off during the course of the procedure, more is injected to re-anesthetize the area. Advances in local anesthetic and the way it is applied allow for a comfortable and relaxing procedure. Most patients watch movies, listen to music or nap during their procedure.

What will it look like after the procedure ?

The grafts form small scabs in the days after the procedure. If one has enough surrounding hair, these scabs can be camouflaged with creative styling. If not, the small scabs may be visible but do not attract much attention. By keeping the scalp moist, the scabs usually come off in about a week or so.

When can I go back to work ?

Depending on the type of procedure you have done and the type of work you do, it is often possible to go back to work the next day. your hair restoration surgeon will discuss this with you during the consultation.

Are hair transplants expensive ?

Despite the initial cost of the procedure, hair transplantation can be less expensive than an artificial hairpiece over the long run. Considering that the results are permanent, most people consider it a good investment in their future happiness.

How many sessions will be required ?

The number of the sessions will depend on the 1) area of scalp treated 2) the number and size of grafts used 3) the density which you desires and 4) the individual characteristics of you, e.g. coarse hair will provide a more dense look than fine hair. The estimate of the number of sessions can be discussed during the consultation with your surgeon.

After using Propecia® (finasteride) for a prolonged period, would cessation of use of the drug result in the same sudden rapid hair loss off all hairs that would have been lost without the use of the drug, like suddenly stopping use of Rogaine® (minoxidil) ?

The hair would be lost until the point where an individual would have been without treatment. However, the hair loss is not sudden and will take several months to a year after stopping the medication. That is why missing a day or two of treatment, although not recommended, is generally not detrimental.

What are the possible harmful effects of Propecia and Rogaine? Especially in regards to women handling Propecia and/or a man taking the drug while trying to have a baby? Can the man cease taking the drug until he has fertilized a child ?

There are no known harmful effects of either medication when used as directed by the manufacturer. Follow all package instructions. Propecia could be potentially harmful to a developing male fetus in a pregnant woman if a significant amount of the medication entered her body over time. This would require her to ingest the medication, so she should not handle broken or crushed tablets. The amounts of the medication in a male's semen have been studied and found to be insignificant. The man can certainly cease treatment during conception efforts, but this is not necessary.

Is Propecia less effective in different races ? Asian vs. Caucasian ? Is it less effective for frontal vs. coronal pattern hair loss ?

There has not been any noted difference in ethnic groups. Propecia is most effective in crown hair loss. It is less effective in frontal loss. It has not been shown to be effective in the temples (sides of head forward of the ears).

Is hair transplantation/hair restoration surgery a subspecialty of dermatology, and is it done as a fellowship post-residency ?

The field of hair restoration surgery (HRS) is made up of physicians from many backgrounds including dermatology, plastic surgery, general surgery, family practice, ENT, and many others. Unfortunately, training in HRS in the typical residency is rarely at the same level as is performed today. That is why post-graduate education in HRS is so important and why the ISHRS is so important today in educating those physicians wishing to practice this specialty. In addition, ISHRS offers post-residency fellowship training positions in several centers around the world.

Does the stuff advertised on TV work such as Rogaine ?

There are some items such as Rogaine that can be useful in some patients. Since my involvement in the treatment of baldness is primarily surgical, I don't really have much experience with those treatments. I have certainly seen friends and some patients who have improved with the regular use of Rogaine.

How does a hair transplant work ? What exactly is done, and how time intensive is it ?

Hair transplantation can be quite time intensive. Depending on the amount of hair that needs to be transplanted, it often takes several operative sessions, and these must be placed at least 6 to 8 months apart. We can move hair in very thin strips or we can use plugs containing 10 or 15 hairs per plug, but these techniques are much less popular than they once were. They often produce an artificial look that can be detected by others on casual inspection. Now it is much more common to do much smaller unit transplants. In other words, we may transplant single hair follicles or small groups such as 2 or 3 hair follicles in a single group and it is not uncommon to transfer between 750 and 1,500 hair follicles at a single session. Some surgeons are able to transfer up to 2000 or even more follicles in a single session. When one transplants hair, it is quite common for the hair shaft in that follicle to fall out. The transplanted hair follicles often go into a resting phase before they begin to produce new hair. It often takes up to a year following the hair transplantation to see the full result of the procedure. If necessary, one can then go back and provide more individually placed hair transplants to fill the small gaps that exist after the initial procedure. Technically, during the procedure, if one attempts to place the graft too close to the one just previously placed, the first graft begins to pop out as one attempts to insert the second. One usually has to place the grafts about 1/8 inch apart. This is not as dense as normal hair so it is often necessary to go back 8 months to a year later and place more follicles between those originally transplanted.

It is estimated that perhaps 20 percent of women will experience some degree of hair loss. It can be related to some underlying illness or perhaps to hormonal change after menopause. Usually, it is a general thinning of hair rather than losing hair over a specific patch such as is more common in men. Although hair transplantation is less commonly done in females, there is certainly no reason why you could not consider transplantation if there is enough donor hair. Sometimes, you can make the hair loss worse if you constantly pick at a spot where you are losing hair, so you should try to be careful about that.

Is there a medical explanation as to why so many more men experience balding than women? It has to be one of the most disproportionate problems ?

Hair loss is obviously much more common in males than in women. This is related to genetic factors and to hormonal influences. It is therefore much more common that men seek some type of treatment for their baldness.

How much does the transplant cost ?

The costs for treatment of baldness will vary greatly from one treatment center or surgeon to another. The costs will also vary depending upon the type of treatment necessary. When doing micrograft and minigraft transplants such as we have described earlier, the number of hairs transplanted will certainly be a major determinate of the cost. This procedure is very time consuming and detail oriented work. There are other techniques for treating baldness, which can include procedures known as scalp reduction. In scalp reduction, the surgeon will remove portions of the bald scalp and will then advance the hair bearing skin toward the central area. This will have a different fee structure than micro or minigrafts transplantation. There is also the possibility that tissue expansion might be useful as a treatment technique. In this procedure, one makes an incision and inserts small balloons. These special balloons can then be injected with saline solution over repeated office visits, and they will slowly expand the hair-bearing scalp. Then the surgeon can remove an area of baldness and advance the expanded hair-bearing scalp into the defect. This technique is very commonly used in cases where patients have had severe burn injuries to the scalp and in these cases micro-transplants would not achieve you's goal. Each of these techniques will ge priced differently and each surgeon is free to chose his own pricing structure so I cannot say what a surgical treatment for baldness will cost without knowing what must be done.

Where does the hair come from that is transplanted? Does the transplanted hair eventually grow on its own and "spread" ?

The hair that is transplanted usually comes from the back of the head or the side of the head of you having the transplant. Unless you have an identical twin with extra hair to donate, you must serve as your own donor. The hair follicle that is transplanted, should it survive the transplant, will produce hair in its new location. The hair follicles will not divide and multiple to produce several hairs in its new location. So, in that sense, the hair that is transplanted will not "spread".

Are there certain types of hair that do better with transplants than others ?

It is really important to sit down with the surgeon and to have a complete evaluation to determine whether you are a good candidate for hair transplantation. The hair color, the texture of the hair such as whether it is straight or curly, all these things can affect the outcome in a significant way. Patients with lighter blonde type hair generally have a better result than patients with fine, straight, black hair. The curly hair often appears fuller once it begins to grow again than straight hair. you must have a great enough density of donor hair to allow us to harvest up to 1000 hair follicles and not be so thin that the harvest site becomes visible. There will always be a scar at the harvest site, but if it is covered by hair it will not be visible.

What causes baldness ? Are there any preventive measures one can take ?

There are many myths about baldness. Baldness often is blamed on poor circulation of the scalp, vitamin deficiencies have been blamed for baldness, wearing a hat or not wearing a hat, and basically all of these myths have been shown to be false. you can't always just look at your mother's father and determine whether you are at risk. Within families, some brothers may have male pattern baldness and others may continue to have a thick head of hair. There have been suggestions that use of steroids can affect baldness. Probably there is a simple inherent genetic trait that determines whether you will lose hair or not and to what extent that will occur. I think that use of some of the legitimate drug company products may delay the need for transplantation. But I am not sure their use can prevent progressive baldness in some patients.

My Hairdresser is selling me nioxin products that claim to be follicle boosters. Are these effective or just a gimmick, as they are very expensive? And they sell pills too that claim to restore your hair. Any comment ?

I have no knowledge about Nioxin products. I really can't comment on their effectiveness because I have not seen any scientific studies on these products.

I have moderate receding hairline and very curly hair. What would my prognosis be for successful transplant and what kind of dollar figure can I expect to pay ?

Without an examination, it is hard to predict the prognosis regarding the moderate receding hairline and very curly hairline. Assuming there was adequate donor site, it is likely that your situation could be significantly improved. I can't quote you a dollar figure for such treatment, but most surgeons will be able to name a precise figure for their procedure after they have examined you in order to develop their treatment plan.

Should a person wash their hair everyday, every other day, or doesn't it affect the chance of baldness ?

Many people wash their hair on a daily basis and do not experience significant hair loss. I think that so long as neglect of scalp cleanliness does not produce some kind of infection of the scalp, that hair washing probably has little effect on baldness.

So the mother's father thing doesn't stand true ?

The myth that one can look at the mother's father is not borne out for everyone. Certainly, it does show that there is a genetic possibility for baldness. It is much more difficult to estimate the probability based on that single fact.

What are potential risks from hair transplantation ?

This procedure, if we are talking about mini grafts, is usually done in an office setting or outpatient surgery setting and is most commonly done under topical anesthesia which simply involves injection of local anesthetic like that used by the dentist. One risk of any such procedure would be the small possibility of an allergic reaction to the anesthetic used. Qualified physicians will have the proper equipment and training to deal with this type of risk. The other risks associated with any surgical procedure including hair transplantation would be the possibility of infection or significant bleeding. This is usually easily controlled by properly trained plastic surgeons. There is the possibility of visible scars where the hair is harvested at the side or back of the head. This is especially true if you experiences ongoing significant hair loss. This is why the surgeon will spend some time trying to learn about the pattern and rate of hair loss in each individual patient. There is always a risk that some of the individual hair follicles transplanted will not "take". In this case, the hair follicles will not survive and hair will not grow from that particular transplant. If, for some reason, a significant number of individual transplants fail, then the operation will fall short of the desired goal. As we said earlier, it is often necessary to do two or three sessions in order to achieve enough hair density to meet you's goal. If you continues to have progressive loss when one has placed a new graft in thin hair, there may come a rather patchy looking endpoint. In that case, it is sometimes necessary to perform yet another mini grafts transplant.

How does one find out who is reputable and the respective cost structure for individual transplant centers ?

I think one has to check with others that may have sought treatment. One should ask a lot of questions about the level of experience and what particular training the transplant surgeon has. If at all possible, it is good to talk with some patients that have been treated in the past by an individual surgeon. Finally, one should meet and feel comfortable with the treating surgeon, and certainly you should discuss the cost structure with the surgeon at that point. There may be young surgeons who have recently completed an excellent training program, so their relative lack of numbers of patients treated should not completely deter you from considering them for the procedure if they can answer your questions and if you feel comfortable with him.

Why are you continuing to evade the question regarding cost ?

I have "evaded" the question of cost because there is no particular standard. Different surgeons have different practice costs, which they must cover. The business of hair transplantation is relatively competitive and individual surgeons are not shy about stating what their procedure costs once they have seen what needs to be done in an individual patient. Without an examination, It is not possible to quote a price on a patient.

What type of specialist should one seek out for this procedure ?

Since our own specialty is plastic surgery, we are somewhat prejudiced in favor of plastic surgeons. There are individuals with other specialty training background that do good hair transplant procedures. In general, we think that the plastic surgeon is more likely to be able to use mini grafts, tissue expansion, flap advancement, and scalp reduction techniques to accomplish you's goals. I think that having many techniques available increases the likelihood that one can meet you's expectations.

Are there any over-the-counter treatments for balding ?

There is, I think, a never-ending supply of over the counter treatments for baldness. I am not aware of any that have undergone scientific testing to show their effectiveness.

If there are no further questions I will ask Dr. Khanna for his closing statement?

People seek treatment for hair loss to improve their self-esteem. There are many factors that influence the outcome in our attempt to correct baldness by surgical approaches. It is important to choose your surgeon and to be clear with the surgeon about your goals. It is important for the surgeon to attempt to relate to you the extent to which he or she feels the goal can be met. The recent advances into the mini graft approach have produced much better results than were available in the past with the larger plug hair replacements. Many patients do experience a restoration of self-esteem and confidence following hair replacement therapy. Briefly, if there are symptoms of itching, there may be some type of scalp problem that could be addressed by medical treatment. I would really advise someone with this situation see a dermatologist to see if there is a correctable skin problem. Once it has been established that there is not a treatable problem, or once a treatable problem has been corrected, some mini grafts or other hair replacement technique might still successfully treat the thinning of the hair.

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