Fig.1
Approximately 15 to 20% of scalp hairs emerge from the scalp as single hairs; the majority of them however emerge in small groupings of two to five hairs. These “follicular groups” or “follicular units” (FU) are obtained for Follicular Unit Transplanting (FUT) by slicing the donor tissue, using a stereoscopic microscope, into the naturally occurring single hairs and small groupings.

Fig.2
Photo showing a patient before and nine months after treatment with 1947 FU in a single session using a density of approximately 30 FU/cm². This individual had ideal characteristics: wavy, medium coarse, slightly frizzy and dense hair.

Fig.3a
Before and nine months after a single session of 1644 FU using a density of approximately 30 FU/cm². The hair has been parted for critical evaluation. This individual had hair characteristics that were typical of a majority of patients seen for hair restoration surgery.

Fig.3b
A frontal view of the same patient shown in Fig. 3a nine months after treatment.

Fig.4a
A schematic drawing demonstrating the various zones of the head, the frontal area (F) running from the hairline zone to a line drawn more or less perpendicularly from the ears the mid-scalp area (M) from that point back to where the head changes its orientation from more or less parallel to the ground to more or less vertical, and the crown or “vertex” area (V) behind that area. Areas labeled FE, ME, and VE are zones that still contain hair but can be anticipated to lose that hair over the patient’s lifetime. These areas are in general best treated at the same time as the more obvious areas are transplanted, in order to avoid a constant chasing of an enlargeing bald area.

Fig.4b
A patient before treatment (top photo) and nine months after the second of two transplants; the first to the frontal area and the second to the mid-scalp area with a total of 3864 FU and a relatively low density of approximately 20 to 25 FU/cm².

Fig.4c
A frontal view of the same patient taken at the same time as Fig. 4b. Note that the hair appears thicker in this view than in Fig. 4b. Always look for comparable views in “before” and “after” photos.

Fig.5a
A before and after photo of an individual with fine, fluffy hair with generally typical hair characteristics but in this instance also having relatively light-colored hair. One session of 1504 FU at a density of approx. 30 FU/cm² was done in the frontal area and a similar session in the mid-scalp area nine months after the frontal area had been treated. Transplanting only as far back as the zone in which the head changes its orientation from more or less being parallel to the ground to more or less vertical to the ground produces the appearance of hair from both frontal and lateral views. Many patients choose to only treat this far back on the head, as the results are satisfactory to them and it can be accomplished in most individuals with only two sessions—one to the frontal area and one to the mid-scalp area.

Fig.5b
A frontal photo of the patient, taken at the same time as the “after” photo shown in Fig. 5a.

Fig.6a
A patient with apparently very limited hair loss in the fronto-temporal corners of his hairline.

Fig.6b
The same patient as shown in Fig. 6a nine months after his first transplant.

Fig.6c
The same patient as shown in Fig. 6a, and at the same time, which demonstrates that he had diffuse thinning through the entire frontal area and that the hair loss was not limited to only the hairline zone, as might at first have seemed to be the case.

Fig.6d
The same patient as shown in Fig.6c nine months after a session of 2211 FU. One does not have to wait until an area has experienced the loss of the majority of its hair before the area can actually be treated. However, the hair density shown above will not persist for the patient’s lifetime because it is a combination of the transplanted hair and the original hair in the recipient area at the time the surgery was carried out. As the patient loses his original hair, the hair density in the transplanted area will become more like that shown in the “after” photos in Fig. 4b and 4c by the time he would have looked like the “before” photo in Fig. 4b, (if he hadn’t in fact undergone transplanting).

Fig.7a
A patient before transplanting.

Fig.7b
Nine months after a single session of 2282 FU at an average density of approximately 30 FU/cm². This individual had very good characteristics for hair transplanting and represents a better than average result.

Fig.8a
A 41-year-old patient before transplanting in 1993.

Fig.8b
Nine months after a single session consisting of 315 FU at an average density of approximately 30 FU/cm², 268 double follicular units and 268 triple follicular units. The more persisting original hair in the recipient area, the finer the texture of your hair, and the less contrast between the color of your hair and skin, the less difference there is between the apparent naturalness of FUT and a combination of FU and micro-slit grafts. However, as the original hair is lost the results will not look as natural as FUT would have and therefore at least a second session in the same area will likely become necessary.

Fig.9a
A patient before transplanting.

Fig.9b
The same patient nine months after his second transplant consisting of a combination of FU, micro-slit grafts, and slot grafts. Note the absence of any noticeability of grafting. The less contrast between the color of your hair and skin and the more frizz or curl in your hair, the less difference there is between the apparent naturalness of FUT and a combination of FU and micro-slit grafts, or for that matter, even larger grafts such as the slot grafts used in this patient.

Fig.9c
A photo taken at the same time as that shown in Fig. 9b with the hair combed as normally worn. This combination of graft types is ideal for many patients with white hair who want maximum density and are willing to undergo at least two sessions to attain that goal.

Fig.10a
A 54-year-old patient before transplanting. He wanted maximum hair density and had an excellent long-term donor/recipient area ratio as well as very good hair characteristics for transplanting.

Fig.10b
One year after his second transplant consisting of a combination of FU, micro-slit grafts, and slot grafts. Less than 1% of our patients are eligible for this option and choose to proceed with this combination of grafting.

Fig.10c
A close-up of the hairline taken at the same time as the photo shown in Fig. 10b. On close examination, with the hair parted through the middle of the transplanted area, the zones treated with micro-slit grafts and slot grafts would not have as diffuse or natural coverage as that shown in the hairline zone which was treated exclusively with FU. On the other hand, more density was achieved than could have been created with two sessions of FUT, using acceptable FU densities.

Fig.11a
A patient before transplanting. He had excellent hair characteristics for transplanting, an exceptionally good long-term donor/recipient area ratio and an objective of maximum hair density. The patient decided to proceed with a combination of FU, micro-slit grafts, and round grafts. Less than 1% of our patients are eligible for this option and choose to proceed with this combination of grafting.

Fig.11b
Nine months after a small fourth session had been carried out in the frontal round grafted area. The hair has been parted for critical evaluation, revealing no plugginess in the area treated with round grafts.

Fig.11c
A photo taken at the same time as that in Fig. 11b but with the hair combed as normally worn.

Fig.11d
A photo taken as that shown in Fig. 11 b. I have never seen this type of density produced when only FU are used. On the other hand, it was necessary to undertake three and a half sessions to create that density and if he had stopped without completing the round grafted area during a fourth visit, if his hair had been parted and wet, there would have been some degree of plugginess noticeable. Very few patients require this sort of density to be satisfied and therefore very few need even to consider this option.

Fig.12
The Hamilton/Norwood classification of degrees of severity of Male Pattern Baldness with Type I the least severe and Type VII the most severe.

Fig.13a
A photo showing an individual before and nine months after his second transplant, one to the frontal area and one to the mid-scalp area after treatment with respectively 1923 and 1643 FU at an average density of 30 FU/cm². Note in the before photo that there is a hemispheric area above the temple area that we most often refer to as the supra-temporal hump. This area was treated at the same time as the more obvious areas of thinning more medial to it were transplanted.

Fig.13b
An intra-operative photo of the third session showing the same patient as in Fig. 13a with the recipient sites having been made for FU. In this third session we were able to go beyond the vertex transition zone but were unable to treat all of the bald area. In many individuals one can transplant the entire balding area in three sessions, one to the frontal area, one to the mid-scalp area, and one to the crown. Individuals who are destined to have, or who already have, areas that are larger than average however, may require four or even five sessions, if that amount of donor tissue is in fact available.

Fig.13c
A back view of the same patient just prior to a fourth hair transplant session. While in many patients three sessions (one in each of the frontal, midscalp, and "crown" areas) are sufficient to treat the entire bald area, if that area is larger than average or the donor hair density is lower than average, a fourth (or sometimes even a fifth) session may be necessary to achieve that coverage.

Fig.14a
A young man before transplanting. Note that the supra-temporal areas have been outlined and will be treated at the same time as the more obvious areas of thinning medial to it.

Fig.14b
Nine months after treatment with 2137 FU at an average density of 30 FU/cm².

Fig.15
The appearance of an essentially bald area transplanted exclusively with FU, the day after surgery.

Fig.16
The appearance of the recipient area one day after FUT in an individual whose recipient area still had a small amount of hair present. Even in bald recipient areas, the noticeability of the grafting is usually gone by seven to 10 days after surgery. The more hair still present in the recipient area, the less likely that FU grafts will be noticed even several days after the operation.

Fig.17a
A young man with severe (for his age) hair loss in the frontal area before transplanting.

Fig.17b
One year after a single session to the frontal area consisting of 2246 FU transplanted at an average density of approximately 30 FU/cm². The hair has been parted in the same area as it was in the before photo for critical evaluation.

Fig.17c
The same patient shown in Fig. 17a before his first session but with the hair wet with an antiseptic solution prior to the surgery. The photo demonstrates considerable hair loss in the mid-scalp area as well as in the frontal area. The mid-scalp was treated with 1998 FU at an average density of approximately 30 FU/cm² six months after the frontal area had been transplanted.

Fig.17d
19 months after the second session of FUT. This individual had very dense hair in his donor area. Primarily because of his age, the average number of hairs/FU was greater than the typical 2.3/FU, hence the denser than average results. As he gets older and the number of hairs/FU in the original donor tissue decreases, the recipient area hair density will also decrease. Younger patients should proceed with transplanting with more caution because of the greater uncertainty of the ultimate extent of hair loss in both recipient and original donor tissues. However, emotional factors must also be taken into account when a physician decides how long one should wait before starting transplanting in a young man.

Fig.18a
A female before transplanting.

Fig.18b
Nine months after a single session consisting of 379 FU and 36 double follicular unit grafts. The hair has been parted in a similar area to that shown in the before photo, for critical evaluation.

Fig.19a
Before transplanting.

Fig.19b
The same patient as shown in Fig. 19a one year after a single session to the frontal thinning area consisting of 619 FU and 193 double follicular unit grafts. This is an unusually good result because of excellent hair characteristics for transplanting.

Fig.20a
A female patient before transplanting with the hair wet to demonstrate the degree of thinning in the frontal area and part of the mid-scalp area.

Fig.20b
One year after a single session consisting of 262 FU and 300 double follicular unit grafts. Not all women are eligible for transplanting but a majority of them that we see in our offices are. Because of the limited donor area however, usually only the cosmetically most important areas can be treated. The hair in the thickened area is then used to camouflage areas that have not been treated. More information can be obtained on transplanting in female patients in an article published by Dr. Walter Unger and his daughter Dr. Robin Unger in the Journal of the American Academy of Dermatology (Vol. 49, Number 5, Nov. 2003), which can be accessed by returning to the main menu of this website.

Fig.21a
A female patient after a face-lift with a scar behind her ear.

Fig.21b
Nine months after a single session of transplanting to correct the scar shown in Fig. 21a.

Fig.21c
The same patient with a scar running along the temporal hairline and absence of sideburn hair after a face-lift. (A common hallmark of face-lifts.)

Fig.21d
The same patient six months after a transplant to the scar and the sideburn area. Scarred areas can be successfully transplanted whether they are caused by cosmetic surgery, trauma, or some skin diseases.

Fig.22
The above photo shows an intra-operative photo of a patient who had an unacceptable donor area scar in his left temple. A small punch has been used like a cookie cutter to punch out individual FU in the donor area, instead of excising a donor strip and dissecting it microscopically. The lower photo shows the results of the session without any visible scarring at the site of the FU extractions and with the FU that were transplanted into the scar completely concealing it six months after surgery. (In fact some of the FU were also used in areas of MPB at the same time.) The Follicular Unit Extraction (FUE) in this individual was done by another surgeon to whom I referred the patient.

Fig.23
This patient underwent FUE and was left with quite noticeable scars at the site of each of the extractions, as well as multiple purulent cysts. The noticeable scarring is the result of a combination of a larger than ideal sized punch having been used, the grafts having been taken too close together given the size of the punch and perhaps the healing characteristics of the patient. The cysts are the result of some transected FU having been driven underneath the skin at the time the extraction was being carried out. The photo should remind patients that FUE can be done well or badly just as any other form of surgery.

Fig.24a
The donor strip has been excised and the wound sutured. The hair has been combed upward so that we can see the sutured wound. When hair is combed over the sutures, it easily, and immediately after the operation, completely camouflages the donor site.

Fig.24b
The same wound shown in Fig. 24a, six months after the procedure. The vast majority of donor areas scars will be only 0.1 mm to 1.5 mm wide even after multiple sessions.

Fig.24c
As seen above, the donor scar of some patients will be a little wider than that shown in Fig. 24b.

Fig.24d
This photo was taken at the same time as that shown in Fig. 24c but the hair has been combed as normally worn. More than 95% of our patients have scars similar to that shown in Fig. 24b & c and can wear their hair as short as that shown above without the scar being noticeable. The other approximately 5% have an inherent tendency to heal with wider than average scars. However, because there is only one scar no matter how many sessions are carried out, and it runs through the densest rim hair, even these wider scars should be completely camouflaged by surrounding hair that is cut to a reasonable length.

Fig.25a
A patient with a relatively limited donor area, before transplanting. He had quite sparse hair in the lower part of his “permanent rim” and therefore had an extremely narrow potential donor area.

Fig.25b
Before and after two sessions of relatively low density FUT because the area to be treated was so large and the donor area resources relatively small.

Fig.25c
A frontal view before and after two sessions, one to the frontal area and one just behind it.

Fig.25d
The donor area after three sessions of transplanting had been carried out with the hair combed as normally worn in the upper photo. In the lower photo, the only scar present after the three sessions.

Fig.25e
A close-up of the scar after three sessions.

Fig.26a
A patient one day after his first transplant in 1995. The black crayon marks denote areas that we intended to excise with alopecia reductions at a later date.

Fig.26b
The same patient several months after his fifth transplant (and two alopecia reductions). The scene in the above photo really represents the results of hair growing after four sessions as the fifth session was only beginning to grow at the time this photo was taken.

Fig.26c
The patient’s donor area showing a relatively narrow zone of reasonably dense hair and quite sparse hair in the lower part of the “permanent rim” hair that was unsuitable for donor harvesting.

Fig.26d
The only scar that was present after five transplant sessions. The hair has been clipped so as to reveal it more clearly. Figs. 26c and 26d were photos taken just prior to a sixth session.

Fig.27
Another quite old photo done years ago (when sessions were smaller) just prior to a seventh strip being removed from the same area. The hair has been clipped in order to facilitate the harvesting of the next strip. Note that most of the scar is still quite narrow despite the preceding six sessions. It is a little wider to the right probably because of a higher closing tension at that site than in the majority of the length of the strip. It is commonly said that although a good scar can be obtained after a single or perhaps second strip harvest that the scars tend to get wider with each subsequent harvest. Figures 24 through 27 are intended to show that this is not necessarily so. The width of the donor scar is dependent on many factors and the number of sessions is only one of them; closing wound tension is more important by far.

Fig.28a
A patient seen approximately 15 years ago for correction of pluggy-looking hair transplanting carried out in another office. The hair in the grafts has been cut short just prior to the surgery.

Fig.28b
An intra-operative photo showing that portions of each of the larger grafts had been excised. At the same time as that was done, a combination of micrografting and micro-slit grafting was carried out in the same area.

Fig.28c
Nine months after the photo shown in Fig. 28b showing a far more natural distribution of hair because of the combination approach of excising portions of old grafts and adding new smaller ones.

Fig.29a
This 56-year-old gentleman had undergone hair transplanting 15 years prior to seeing me in 2002. He had fine-textured, reddish-to-blonde colored hair. The transplanted area was moderately pluggy-looking and would have appeared much worse had his hair not been so fine and relatively light-colored. The density in the transplanted area was also relatively low. In addition to the preceding, his MPB was obviously extending further laterally and he had lost all of the hair behind the transplanted zone. He was basically left with a pluggy-looking, unsatisfactory isolated frontal forelock, as is shown in the photo. I designed lateral “humps” for completion of the frontal-third of the area of MPB and a new hairline zone in front of the old one. The black crayon line delineates these objectives.

Fig.29b
The same patient shown in Fig. 29a nine months after first repair session that consisted of 1270 follicular units, 105 double follicular units, and twenty-one 2 mm² grafts.

Fig.30a
A patient before repair of transplanting done in another office. The areas to be treated are outlined in black grease pencil.

Fig.30b
The same patient shown in Fig. 30a, 10 months after his first frontal repair session (1973 FU).

Fig.30c
The same patient shown in Figs. 30a and b, 11 months after his second repair session (1361 FU), the latter behind the first one.

Fig.30d
A photo of a back view, taken at the same time as the photo in 30c.

Fig.31a
Many patients who come for repair of older-type transplanting have alternating rows of scars and hair in their donor area as shown in this schematic drawing with H denoting the hair-bearing sections and S the scar-bearing sections. A strip is excised that contains two rows of scar and one row of hair as shown in the drawing and the wound is sutured closed. One ends up with one scar instead of two. The single scar is in addition, far narrower than both of the two that have been excised. One also ends up with two rows of hair-bearing skin adjacent to each other. The result of this sort of repair harvesting is that a) one obtains additional hair from the hair-bearing section that was excised as part of the strip, and b) the donor area looks thicker rather than sparser despite the removal of additional hair because one is left with one finer scar instead of two, and just as importantly, there are two rows of hair adjacent to each other now.

Fig.31b
A clinical photo of a patient who demonstrates old methods of harvesting prior to repair.

Fig.31c
After a strip that has been excised that contains two rows of scar and one row of hair as demonstrated in the schematic drawing in Fig. 31a. Obviously, the donor area looks better after this harvest despite the removal of additional hair.

Fig.32a
A scar from an infection in the donor area during a preceding hair transplant done elsewhere. Many people believe that such scars cannot be improved upon by additional strip harvesting. This is not necessarily true.

Fig.32b
The same patient immediately after excision of the strip from the area shown in Fig. 32a. In such cases, it is particularly important a) to not close the wound with any tension whatsoever and b) that one border of the new incision should run through intact hair-bearing skin, thus supplying a better blood supply to the new wound.

Fig.32c
Six months after the photo in Fig. 32b showing that the scar has not become wider with the passage of time. The hair adjacent to the remainder of the scar has been clipped short just prior to another strip being removed in order to further improve the scarring.

Fig.33a
A patient who had been in a car accident and had severe scarring alopecia in the temple area.

Fig.33b
The same patient nine months after a single session of grafting into the temple area. Hair transplanting into scar-bearing tissue can produce substantial improvements. See also Fig. 21.