Is the hair transplant surgery painful?
A: 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 a 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 zone” 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 zone” anesthesia is that the patient will not be able to drive on the day of the surgery. However, should the patient forego the “twilight zone” anesthesia and opt instead for a local anesthetic, he/she will be able to drive on that day.

What is a typical hair transplant surgery day like?
A:
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 hair-bearing donor scalp. A thin strip of the permanent hair along the lower back of the scalp is used. Afterwards, 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.
What steps should I take before the surgery?
A: Pre-Operation Instructions

The following is preparation before the surgery:

Allow hair at the sides and the back of the head to grow at least one inch long to allow concealment of donor area once the procedure is completed.

To have the best scar and widest donor size possible, we strongly recommend you to do the Scalp Stretch Exercise twice a day, ten minutes each time.

​5 days

 before the surgery:
·        No Rogaine, Minoxidil or other chemicals on your head

·        No ​anticoagulant (blood thinner)

·        No Aspirin (acetylsalicylic acid – A.S.A.) or anti-inflammatory medications that contain Aspirin.
·        No Vitamin E
·        No Ginkgo Biloba
·        No Herbal Supplement

1 day before:   
·        No Alcohol

·        Arrange transportation or hotel if you want to have I.V. sedation in addition to local anesthesia.  It is safe to drive home with local anesthesia.

On surgery day:
Wash your hair in the morning (no hair spray)

Take a shower.
​H​ave a light meal before coming to the office.

Please wear comfortable clothes with button-down shirt.

Please arrange a ride for pick up if you choose to receive IV sedation. We will not put you out completely, just a twilight state. We will give your ride a 1 hour notice.
How will the surgery affect me when I return to work the following day?
A: 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.

How many sessions of surgery will I need?
A: 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.
How long does it take the transplanted hair to grow out long enough to fill in the balding area?
A: Usually it takes four to six months for the hair to grow out, and after that it will grow about half an inch per month which is the same rate as the donor hair. Initial hair quality is usually very fine, softer in texture like baby hair and then it becomes coarser over time. Sometimes the initial hair is curlier, then straightens in about one year. The color of the initial hair may also be darker. It may be lightened by the sun later.
How long will the transplanted hair continue to grow?
A: Typically male pattern baldness affects the frontal or vertex area of the scalp, while not affecting the sides and the back of the scalp. The hairs on the back of the head are genetically programmed to be life permanent. The transplanted hair comes from the hair on the back of the head, and will retain all of the characteristics as those hairs, including being practically life long lasting. Therefore, it is reasonably safe to say that the results of hair transplantation should continue to grow for the rest of your life.
Can hair transplantation affect the rest of my hair?
A: 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.
How are the donor site areas determined?
A:

We first have to measure the total area of coverage. Based from the total area of coverage then we can decide the size of 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 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 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, contrast between skin and hair color and 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 each 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.

What are the side effects or complications?
A: 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.

How close and how many grafts can NHT transplant in one cm2?
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 are 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.)

What is NHT’s transplanted hair growth rate?
During ISHRS meeting in September 2006, Dr. Jerry Wang was asked about the estimated transplanted hair growth rate in his megasession 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 the 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 damage of microcirculation but increase the difficulty of insertion, leading to a lower 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.

Exclusive use of single follicular units (SFU) seems to be the current norm, why does NHT insist on using mixed sized grafts?
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 the process of thin graft preparation
2. Poorer growth rates when using thin grafts compared to “chubby” grafts
3. Cost to 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 needed for a 50% transplanted density
Donor area contains about 100 FUs in one cm2
Total grafts needed are around 4000 SFUs
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 life long 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!

For more information about this topic, please review this study we
conducted couple years ago.

Comparison Study between the Follicular Unit and Modified-Follicular Unit on a Single Patient
Patient’s progress photos updated every month.

Does NHT concern about the possible pluggy look due to larger grafts size of modified follicular unit (up to 4 hairs in one graft)?
No at all, NHT has prepared a 30-minute DVD video to answer this question. In the DVD, you will see the details of the hair transplant results. The patient’s recipient area is combed, so that this area is exposed and scrutinized. The DVD includes several patients that had a hair transplant 10 years ago. At that time, graft sizes went up to 8 hairs per graft. If you would like to view the detail on dvd, please e-mail or call us for free copy.
If you are interested in this theory please read:
Surgical Correction of ‘Plugginess’ in Hair Transplants
Published on Hair Transplant Forum International
January/February 2006 Volume 16, Number 1
Given the same donor size, less number of grafts will be produced with larger graft size. If only SFU are used, it will result in almost double amount of grafts compare to modified FU for hair transplant. In another words, it will increase NHT double income. Why doesn’t NHT follow the trend?
NHT has the knowledge, skills and experience in performing hair transplants with only SFU or Ultra Fine grafts. However, NHT’s experience with these procedures indicate that there are drawbacks, as mentioned before in the SFU hair transplant, NHT takes hair transplantation very seriously and enjoys each time a patient comes back just to say hello. We just can’t let them down.

We will present “One Week in NHT”, to show you some of our patients that came to visit our clinic from December 1 to December 8, 2006.

Do you have enough staffs to perform 5,000 grafts per session?
Yes, if the patient’s scalp is loose enough. NHT currently has five skilled technicians with combined hair transplant experience of more than 60 years. Each technician can cut 400 to 500 grafts per hour, regardless of how many technicians are available for inserting grafts, as it is limited by the working space. Typically, three technicians start to work around the patient’s head. It is then reduced to two and finally only one technician can work to finish up the job. It is harder to cut modified FU than the SFU due to the complexity involved in selecting two FU with four hairs maximum. As placing SFU is the easiest one to do. Because it is so small, it always fits the slit easily.
Is there any person is contradicting to use whole SFU?
Yes, for patients with curly hair or white hair, we especially do not recommend the practice of using only single follicular units. The reason for this is that curly hair is not only curly on the outside, but even the hair stem within the tissue is curly (photo). It is extremely difficult to avoid damage to these grafts. The more one cuts the strip, the more damage one will make. White colored hair poses a different problem because it is extremely hard to see even under the microscope. The reason for this is that white hair is the same color as the tissue. Just like writing with black ink on black paper, no matter how much you enlarge a white hair in the donor strip, it will still be very difficult to see. Even under the microscope, white hair is not clearly visible. Therefore, the more grafts that you cut from a curly donor strip or white donor strip, the more risk of damage you will incur. But, the result of them always looks very natural even used modified FU only.
What is NHT's philosophy for hairline design?
We believe that one’s hairline should be designed according to one’s preference. In general, a hairline design shall take into consideration the shape of one’s face. For instance, most Caucasians have longer and narrower faces, therefore, longer and narrower hairlines shall be considered. In addition, a flatter hairline may suit a square face better, such as most Asians’ faces.
We also recommend that the center of hairline should be at least 1.5 cm higher than the highest wrinkle in the face.

But every human being is unique, everyone has a different preference. A few people prefer to have lower and flatter hairlines. Adults are mature enough to drink, vote, and serve a jury. Why can’t they decide what kind of hairline they want? In situations where there isn’t complete agreement we will give our advice repeatedly, but also respect the decision that the patient has the right to have what they want. As long as the patient feels great about his/her hairline, we won’t pressure anyone with our standard.

Will NHT perform hair transplant with all SFUs? If so, what are the conditions?
Yes, we also perform hair transplant with all SFUs. Our main consideration is whether the patient has sufficient donor hair in the expected life span. If he has ample donor hair, we will then perform an all SFU hair transplant with this patient. However, if a patient has a large bald area and minimum donor hair available, or a young patient whose hair loss pattern is uncertain, we recommend NHT’s mixed size graft approach. A mixed size graft approach will reduce the chance of removing hair in the “resting phase” between follicular units. Therefore, it is expected to have a higher growth rate in the mixed size graft approach. We judge each patient’s situation on a case by case basis, and provide recommendations accordingly.