1. At the beginning of each session, the patient is given a mild tranquilizer (Valium or Versed) either orally or intravenously. This minimizes anxiety, reduces discomfort, and helps to prevent or decrease any side effects that might be caused by the local anesthetic.
2. Hair in the donor area is clipped to a 2-mm length in a single zone that is less than 12 mm (1/2") wide, and 10- 25 cm (4-10") long. If the hair in the hair-bearing fringe has been left 1½-2" long, the hair above the donor site completely camouflages it immediately after the procedure.
3. The donor area and the recipient area are anesthetized using a very small gauge needle that is about the size of an acupuncture needle to inject a local anesthetic. To reduce any stinging sensation, in addition to using a small gauge needle, we prepare and use an anesthetic solution that is at an almost neutral pH, instead of "stock" anesthetics which are stored in an acidic form. (The acidity is the main cause of the stinging one usually feels with anesthetic injections). Anesthetizing the areas is the only uncomfortable part of the session and although it may be hard to believe, many patients have told us that the above technique usually causes less discomfort than a visit to their dentist.
4. After the anesthetic has taken effect, a scalpel is used to cut narrow (usually 8-10 mm [1/3 – 2/3 inch] ) "strips" or "ellipses" of hair-bearing scalp from the donor areas. A similar method can also be used to remove scar(s) from preceding scalp surgery or injury. This tissue is then divided into a variety of graft sizes. In subsequent transplant sessions, the scar from the preceding session(s) is excised as part of the new donor strip; it is therefore rare that more than one scar will be produced, regardless of the number of sessions that are undertaken.
5. Many types of grafts are now used in the recipient area. In general, the smaller the size of the graft used, the less noticeable treatment will be postoperatively and in between sessions, i.e. the more natural the result will appear after a single session. However, larger grafts are occasionally utilized if, a) high density is the ultimate goal, b) the patient is judged to have an unusually good long-term donor/recipient area ratio and c) the individual is prepared to undergo at least two sessions in the same area.

6. Grafts are held in place by coagulated blood. To keep them secure and properly oriented, a turban-like bandage is usually applied after the operation and left in place overnight. The following day, the bandage is removed and the area is cleansed. If you are having the front portion of your scalp transplanted, and if there is no more than the average amount of bleeding during surgery, and you are willing to remain in the office for 30 minutes after the procedure is completed, you can go home without a bandage. Most patients seem to prefer the security of an overnight bandage. Perhaps more importantly, every scientific study on wound healing, of which we are aware, has revealed better and faster healing if a wound is covered for the first 12 to 24 hours. Whether you have a bandage or not, you should still return the next day for follow-up cleansing, hair washing, and a check-up.

The balding scalp should be conceptualized as being composed of three areas: a "frontal" area that extends from the hairline to a line drawn more or less perpendicularly from the ears; a "mid-scalp" area that extends from the frontal area as far back as a point at which the top of the scalp changes from a more or less horizontal orientation to a more or less vertical orientation, and a "crown" or "vertex" area that extends from the mid-scalp area to the borders of the hair-bearing fringe at the back of the head (Fig. 12). Each of these areas is usually treated separately, so that three sessions will be required to transplant all three areas in a man with an average-sized bald area. In men with smaller than average-sized bald areas, two sessions may cover all three areas, while in men who have or might develop larger than average-sized bald areas, four or more sessions may be necessary to transplant the entire bald area (and that many sessions may not be available from the donor area). Fortunately, transplanting just the frontal and mid-scalp areas produces the appearance of hair from frontal and side views and this often can be accomplished with only two sessions. (Many men naturally keep their frontal and mid-scalp hair while losing only the crown hair, so there is nothing unnatural about a man who has only a bald crown.) (Figs. 5 and 13). In addition to transplanting the clearly thinning or bald areas, we also like to concomitantly treat any adjacent areas that still contain some hair, but that on wetting the hair, appear on close inspection to be destined to eventually lose that hair. By treating these evolving areas of hair loss at the same time as the more easily seen areas of loss, we hope to minimize the need to constantly chase an enlarging area of MPB with additional sessions (Figs. 13-14).

While the frontal area can be completed with a single session, if only FUs are being used, the same area will usually need two to three sessions to produce adequate naturalness if FUs and micro-slit grafts or slot grafts are being used, and as many as three to three and one-half sessions if round grafts are also being employed. As discussed before, these larger types of grafts can produce more hair density than sessions of exclusive FUs, but once grafts containing more than a single FU are used, at least two sessions will be necessary in that area to produce sufficient natural-looking results. As also noted before, the finer your hair texture, the curlier or frizzier your hair is, and the less contrast between the color of your hair and skin, the fewer the number of sessions that will be required to create natural-looking results.

Transplant sessions may be done as far apart as the patient wishes; however, they are not done in the same area without at least a four-month interval between the first two sessions, and an interval of at least six months between the following sessions. In fact, we nearly always use a six-month or longer interval between all sessions in order for patients to appreciate a reasonable amount of hair growth from a prior session before undergoing another one. While the typical session done in our office will result in the transplantation of 1500-2500 FU (3450-5750 hairs) or its equivalent, the number of grafts that should be transplanted at one session, and the frequency of transplant sessions depend on the size of the graft utilized and the characteristics of each individual's hair texture, caliber, wave, color, and density. More importantly, the size of the session depends on the patient's hair density, scalp laxity, and the circumference of the head. We will do the largest session that we feel can prudently be done, keeping in mind that the blood supply in the recipient area also limits the size of session which can be expected to consistently produce good growth.

It is becoming more common for patients to have one or two "early" transplanting sessions before hair loss has reached an advanced stage. The benefit of these "early" sessions is threefold: a) the remaining hair provides natural camouflage for the initial session—not only for the immediate post-surgical period but also for what might otherwise be some noticeability of grafts that are larger than an FU. (As long as additional sessions are done in pace with the loss of the original hair, grafts containing more than one FU can be no more noticeable than a single follicular unit—without very close inspection), b) the transplanted hair (once it has grown) will persist and provides additional coverage for any later sessions and, c) because of a) and b), sessions can be spaced farther apart, thus spreading the inconvenience and cost over a longer period of time.

In 10% to 20% of male patients, there may be some "shock loss" or mild thinning involving the pre-existing hair of the recipient area within the first two to three weeks after a transplant. In women, the incidence is unfortunately closer to 40% to 50%. This thinning (if it occurs) typically consists of the loss of 1–3 of every 10 hairs and is ALWAYS temporary; the hair will regrow at the same time as the transplanted hair begins to sprout or often earlier.

WHAT TO EXPECT AFTER EACH SESSION

A crust or "scab" will form over each graft shortly after the procedure (Fig. 18) and will remain attached for several to 14 days. The smaller the graft, the smaller the "scab" and the shorter this period will be. The FU sites lose their scabs within 4 to 7 days, while larger sites may retain their scabs for up to 14 days. When the area is completely healed, the crusts will separate from the scalp and fall off leaving a clean, slightly pinkish area to indicate the site of each graft (Fig. 15). Although these crusts are present during the one- to two-week healing period, many patients can camouflage them by combing the adjacent hair over the transplanted site (Fig. 16). If a hairpiece is normally worn, it may be used after the first week, keeping in mind that it should be worn as little as possible until all of the crusts or "scabs" are gone. The hairs in the transplanted grafts are shed between the second and eighth week after the procedure. Sometimes they fall out attached to the separating crusts; often they persist longer. Rarely, some of the transplanted follicles do not shed their hair at all, but continue to grow immediately after the procedure. With these exceptions, the grafts are usually bare for a period of 10 to 14 weeks after the operation, during which time the follicles recuperate and begin to produce new hair. A new generation of hair is usually visible at the surface of the scalp by the 12th week after transplanting, but this may occur slightly earlier, or up to eight weeks later in a few patients. These hairs grow at the same rate as they did in their original location (which is usually 1/2 inch per month). FUs commonly show regrowth two to four weeks earlier than larger types of grafts.

When a large area is transplanted, swelling of the forehead frequently occurs. While this swelling is usually mild and lasts only two to four days, it occasionally can be severe enough to cause a large amount of puffiness around the eyes and approximately one out of 50 patients has swelling bad enough to cause "black eyes". Generally, the swelling begins two to three days after the procedure and is most noticeable after the first session. With subsequent treatments, it usually occurs in a milder form or not at all. In view of this, if possible, it is advisable to schedule a holiday to coincide with the first session. The swelling is ALWAYS temporary and has no harmful effect on the healing grafts. An intramuscular injection of a cortisone-type drug is usually given at the time of the operation to help minimize swelling.

Contrary to what many patients have been told, the scalp (hairy or bald) has an excellent blood supply. A certain amount of bleeding during the transplant procedure is expected and is simply controlled by applying pressure. The donor area is stitched closed to produce better scars and to minimize bleeding. The stitches are normally removed seven to ten days later.

The nurses will wash your hair the day after surgery. You may gently shampoo on the second day after transplanting.

Patients from out of town are required to stay in town overnight after the transplant procedure, so that any bandage can be removed and the areas of surgery can be properly cleaned. They should not drive home themselves on the day of surgery because of the lingering effects of medications. Ingrown hairs are occasionally a temporary problem, beginning 8 to 12 weeks after surgery, especially when FUs and micro-slit grafts are used, and especially if the hair tends to be naturally curly. It is easily controlled, does not cause any permanent damage, and does not occur in a majority of patients.

A temporary decrease in scalp sensitivity is always noted after transplanting because nerves are cut as donor tissue is taken and recipient sites are prepared. Usually this will correct itself completely in 6 to 18 months as the nerves regenerate. Rarely, there may be increased sensitivity in a small area that can take more than 18 months before it disappears, or permanent decreased sensitivity in a small area.

FINAL RESULTS

It is impossible to predict precisely how many hairs will appear in any given graft but usually, at least 95% of them will survive transplanting. Not uncommonly, more hairs will grow than were planted because some were in an invisible "resting phase" when they were originally counted. After more than 30,000 hair transplant sessions, we have never encountered a patient who failed to grow enough hair to produce a substantial cosmetic improvement.

Within one to six months, the skin surface of the grafts has usually blended in perfectly with the surrounding scalp. In some patients, however, grafts that contain more than one FU may be a shade lighter in color until they are "aged" by sun exposure. The grafts are usually level with the surrounding scalp, but a few may be slightly elevated in less than 0.1% of patients. Such grafts can be flattened down with an electric needle without interfering with hair growth. A small number of grafts, rarely, may also be slightly depressed. Surrounding skin can be cauterized to correct this or the graft can be replaced with another one, while the original graft can be re-utilized elsewhere in the recipient area.

The final appearance is that of "early thinning", which is not meant to imply "thin" hair, but rather to convey the idea that you cannot expect to look like you did when you were a teenager.

As one ages, the rim hair from which the grafts were taken gradually becomes less dense. Thus, transplanted areas will also thin somewhat with the passage of time. However, they will never go bald again. In addition, as the hair goes grey with aging, it will look thicker, so any decreased hair density may or may not be noticeable. Because of this gradual thinning effect, you may want to transplant the area a little thicker to begin with, or alternately, you may want to conserve some grafts for use in 15 to 20 years, for example.