You may have heard that the process is very painful. But with the proper technique in the application of anesthesia, it does not have to be a painful process at all. It all depends on how the surgeon applies the anesthesia, and our office uses the least painful process available for the comfort of our patients.

For any hair transplantation procedure, every surgeon uses either a nerve-blocking process or local anesthesia (general anesthesia is never used in this case).

Any pain at all during our procedure would be during the initial needle injection. Our office uses NHT Anesthesia Method to reduce even this small pain. The anesthetic is warmed to reduce reaction time, the skin is pre-numbed before each localized shot and the finest gauge needle (30 gauge) is used to minimize this pain. Initially, the patient is given a sedative through an IV medication. This sedative puts the patient into a relaxed “twilight state” to minimize any pain there might be from the subsequent injections. The tumescent technique is used for prolonging the anesthesia time.

Most patients have informed us that the process was less painful than a routine trip to the dentist. In addition, the day after the hair transplant process, 50% of our patients do not require any pain relievers at all, and the other 50% will take a pain reliever for only one or two days until the discomfort is gone.

We feel that our procedures are much less painful in comparison to many other clinics. The only disadvantage to this “twilight state” anesthesia is that the patient will not be able to drive on the day of the surgery. However, should the patient forego the “twilight state” anesthesia and opt instead for a local anesthetic, he/she will be able to drive on that day.

Postoperative Pain Management and Sleep Aid

The patient signs a consent form for surgery.
Antibiotics are given to prepare for surgery.
The area for transplantation is confirmed and the new hairline design is drawn onto the scalp.
Photo documentation.
The patient enters the operating room and changes into surgery clothes.
The patient sits, relaxes, and listens to music while the heart rate, blood pressure, and oxygen saturation are carefully monitored.
It will take our surgical team about four hours to perform a 20cm2 donor size surgery, five to six hours for a 35 cm2 session. Each patient receives the full attention of our staff.
The patient is given local anesthesia with or without a mild sedative intravenously.
Hair is taped up in the back to allow access to the selected area of the hair-bearing donor scalp. A thin strip of the permanent hair along the lower back of the scalp is used. Afterward, this thin scar will be easily hidden underneath the surrounding permanent hair.
Using a very fine 30 gauge needle, the scalp is anesthetized. Once the scalp is numbed, the surgery is virtually painless as the nerves are blocked.
After the fine strips of hair are removed from the back of the scalp, the technicians divide them into the predetermined sizes of grafts using a video visualizer or a stereoscope.
The back of the scalp is sutured by the surgeon. This scar will barely be detectable in a few months and will be completely hidden by hair growth.
The grafts are now ready to be transplanted into the “recipient” area. Mini-slits are made for the modified follicular grafts (2 to 4 hairs) while 19 gauge needle holes are made for the single follicular unit (1 to 2 hairs.) We are able to accomplish several thousand hair grafts in one session.
The patient is then served snacks and is offered a selection of movies to watch after the slits are made according to the design.
After the short break, two to four surgical technicians begin implanting the grafts. This part of the procedure can last between 2 to 4 hours.
After all, grafts have been completed and checked, the donor and recipient areas are cleaned and the donor area only is bandaged. The patient is given a list of post-operative instructions and medications. If I.V. sedation is used, the patient must not drive home him/herself. It will be necessary to arrange for transportation home prior to arrival at the clinic.

Pre-Operation Instructions

For the first twenty-four hours, there will be a strip of bandage around the head. After that, you will be able to remove the bandage and shampoo your hair. If you have the surgery done on the hairline, the small scabs will remain for seven to ten days. You may want to cover the area with a cap. If you have partial hair, it is much easier to cover up the area, or you can use a camouflage product.

When the small scabs fall off after seven to ten days, the implanted area will be pink, and the skin slightly shiny which is usually a similar color to the surrounding normal skin. After approximately four to six weeks, the areas where the grafts were transplanted are barely visible.

Pre-existing hair around or adjacent to the transplanted grafts may shed, giving a thinner look, but will begin to grow back within a few months. This temporary thinning of pre-existing hair is called Telogen Effluvia. Unfortunately, there is a time lag between this increased thinning of pre-existing hair and re-growth of transplanted hair, so do not be alarmed if this happens.

If you have a completely bald area, it may take two or three surgeries to cover. If you have an area partially covered with hair, it may take only one surgery to fill in the area. Our goal is to restore about twenty-five percent to thirty-five percent of the donor’s original density in each surgery. After two surgeries, the density is at about fifty to seventy percent which is often adequate coverage to satisfy the patient. The time between each session is usually four to six months in order to see how the hair is growing out and to provide more equal distribution.

Hair roots are very tough and can tolerate surgery or any irritation to the scalp. We know this because we can see how difficult it is for people to remove unwanted hair. A hair can be plucked out hundreds of times and just keeps growing back. The actual physical trauma of cutting the scalp, when inserting the donor grafts, can cut the shafts and/or damage some hair follicles. But more significant is the interruption to the pre-existing hair’s blood supply which is enough to cause the shedding of this pre-existing hair.
This is temporary as most of the hairs lost will grow back after a few months.

We first have to measure the total area of coverage. Based on the total area of coverage then we can decide the size of the donor area that should be harvested. The sequence is very important.

Measure the Area of Coverage

Please keep in mind that the scalp is in 3 dimensions so it is very difficult to calculate with 100% accuracy, but we only need an approximation.

Discuss with the patient to find out his desired coverage area, and draw the area directly on his scalp with a “China Marker” (or a black eyebrow pencil).

Apply the transparent sheet (plastic food wrap) over the scalp.

Trace the coverage area on a transparent sheet.

Place the transparent sheet over the specially designed graphic paper* to count the number of small squares. (Each small square =1 cm2). By doing this, you can estimate the approximate coverage area in centimeters squared easily.

Take a digital photo of the scalp with the mark; keep it on file for future reference.

Photocopy the transparent sheet and keep it in the patient’s chart. (When the patient comes back for surgery, compare the coverage area to make sure it is exactly the same as measured during consultation.)

Decide the Size of Donor Area

From our experience, 90% of our patients are satisfied with a 50% to 70% donor site density. Of course, this depends on the patient’s hair color/texture, skin color, the contrast between skin and hair color, and the patient’s age. Accordingly, we have to make some adjustments.

For the average person, we assume 50% to 70% donor site density gives adequate coverage.

If the patient has lost his/her hair completely by the time of surgery, we suggest having two surgeries done at 30% density per session. For example, if the bald area is 100cm2, to achieve 30% density we will need to harvest 30 cm2 of donor area in each session.

 There are some minor, temporary complications:

Pink Skin on Graft Area
The implanted area will be pink, and the skin slightly shiny. It may last from two weeks to eight weeks then return to normal.

Temporary Thinning of Pre-Existing Hair
After the surgery, it is normal for some pre-existing hair to thin. The pre-existing hair will return to normal in full condition within a few months after the surgery.

Bleeding
Some bleeding is normal and will stop with simple pressure. Persistent bleeding occurs in about one in a few hundred cases. Additional stitching is rarely required.

Pain
Pain is usually fairly minimal and lasts only a few days. 50% of our patients do not require any pain relievers, and the others take Tylenol for a few days.

Numbness
Some transient numbness is inevitable and usually lasts from three to eighteen weeks. It is rarely bothersome or long-lasting.

Hiccups
Hiccups may occur after surgery. The cause is not well known. The incidence of this complication is about 5%. It usually lasts several hours to several days. If left untreated, the hiccups may interfere when you eat and sleep, but there is a medication that the doctor can prescribe to ease the hiccups.

Itching
Some itching commonly occurs but is rarely troublesome and lasts only a few days. Shampooing the hair daily will help the discomfort.

Swelling
There is some swelling in nearly all cases. It affects the forehead and the area around the eyes and lasts two to five days, being maximal on the fourth day. In about one in fifty cases, a “black eye” develops.

Infection
This happens in one in several thousand cases and is easily cured with antibiotics. We will provide you with antibiotics prior to and after the procedure to prevent this from happening.

Scarring
Keloid scarring occurs only in pre-disposed individuals, and even more rarely (1/1000 cases) has this keloid scarring been hypertrophy to the point of “ridging.”

Cysts
One or more cysts may occur in the recipient area. They usually disappear by themselves after a few weeks. They are not usually more than 2 or 3 mm in diameter, i.e., the size of small pimples.

Please note that the slits are made by hand. Therefore, it is impossible to insert them exactly the same distance to each other. NHT has calculated the graft per cm2 and estimated the distance between two grafts by using the following formulas:
Grafts per cm2 = number of grafts transplanted / area of transplant
Distance of grafts per mm = length/number of grafts

The length and width of the hair transplant recipient area are measured. The number of grafts is counted and inserted into the slits in the transplant area.
Here is an example:
NHT’s calculation shows that this eyebrow transplant has 92 grafts per cm2 (555grafts in 6 cm2) and approximately 0.8 mm between each graft (110 mm for 125 grafts in one row.)

During ISHRS meeting in September 2006, Dr. Jerry Wang was asked about the estimated transplanted hair growth rate in his mega session presentation. His answer was “I don’t know.” He has an honest and straightforward answer.
To answer this question, one needs to answer the following two questions:

How could anyone count thousands of hairs in the recipient area?
How do you distinguish the growth versus the original hair in this area?
Honestly, no one could answer these two questions in a scientifically acceptable methodology. Approximately ten years ago, NHT started to conduct such tasks in eyebrow hair restoration surgery. Eyebrow hair restoration is chosen for the reason that it simplifies the parameters, such as:

The hair-transplanted area is bordered by “no hair” zones. Hence, one can easily count the total number of hairs in the recipient area after the surgery.
The shapes of the original and the transplanted hair are different. Hence, the transplanted hair can be distinguished from the original hair.

NHT used a 0.8 mm slit and the growth rate was about 75%. Later the slit was changed to 0.9 mm, and it resulted in a growth rate of 83%. Recently, NHT switched to a 1.0 mm slit, which results in a growth rate of about 92%.

Dr. Jeffrey Epstein published an article regarding eyebrow transplants on page 121, Forum July/August 2006. He calculated a growth rate of 70%. We guess that the lower growth rate is due to a smaller slit size of 0.5 to 0.6 mm, which results in damages of FU during the graft insertion. The facts tell us that even too small of incisions can reduce the damage of microcirculation but increase the difficulty of insertion, leading to a slower growth rate. And to achieve the best growth rate is our final goal.
Please also keep in mind that the growth rate for hair transplants on the scalp should be more than eyebrow transplants. This is because it is easier to transplant hairs onto the scalp.

There are a number of reasons why many surgeons today use only SFU for hair transplants. Exclusively using SFU for hair transplants provides a more even “look” and fewer scabs immediately after surgery. As an additional benefit, surgeons can pack SFU more densely than modified follicular units.

However, there are three concerns:

1. Higher telogen (resting) stage hair loss due to the process of thin graft preparation
2. Poorer growth rates when using thin grafts compared to “chubby” grafts
3. Cost to the patient is almost double when using SFUs only

Humans typically shed 60 to 100 hairs per day. These telogen stage hairs, or resting hairs, amount to 10% to 15% of our total hair at any given time. After about three months, the hairs re-grow and start the natural process over again. Telogen stage hairs are of concern for hair transplants because they are effectively invisible. In the process of preparing an SFU, the technician must trim off the tissue next to the SFU grafts possibly discarding the invisible hair inside the tissue. 10% to 15% of hair may be lost in this trimming process.

Dr. Seager, Dr. Beener, Dr. Beeher, Dr. Reed, and Dr. Raposio each conducted studies to compare the results of chubby and thin grafts. These studies found that growth rates for chubby grafts’ are 20% to 51% faster than the thin grafts. So far we haven’t heard any report indicating that the thin graft’s growth rates are better.

The cost associated with a hair transplant surgery is also an important issue. We work hard to earn our incomes – why should we waste it if we have a more affordable alternative to achieve our goal.

For example, here is a cost estimate for a typical SFU-only hair transplant for a hypothetical patient.

Assumes:

A recipient area of 80 cm2
A donor size of 40 cm2 is needed for a 50% transplanted density
The donor area contains about 100 FUs in one cm2
Total grafts needed are around 4000 SFUs
The total cost is around $20,000 at $5 per graft
In reality, this surgery would likely cost much more than this estimate; in this calculation, we didn’t take into consideration potential hair loss during surgery or the growth rate.
Remember that hair loss is a lifelong process. A patient needs to receive touch-up hair transplants once in a while to maintain a good “look”. Over the longer term, the exclusive use of SFUs adds up to quite a sum!

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