There are several techniques that can be used alone or in combination. Transplant techniques, such as punch grafts, mini-grafts, micro-grafts, slit grafts and strip grafts, are generally performed on patients who desire more modest changes in hair fullness.

Flaps, tissue-expansion and scalp-reduction are usually more appropriate for patients who desire a more dramatic change. (General anesthesia is often necessary to allow patients to sleep through these more extensive surgical procedures.) Let's look at these more closely.

Flaps
How would you like to wake up tomorrow with a full-grown frontal hair line of your own natural hair? Well, this is the only procedure that offers such a possibility.

In this 20-year-old procedure, a much larger portion of hair-bearing skin -- basically a flap -- is transferred from the sides or back of the head to the balding area. The size of the flap and its placement depend on the patient's needs. The hair-bearing flap (which can take the place of around 350 punch grafts) is brought into its new position and sewn into place, still attached on one end to its original blood supply. As healing occurs, the scar will be hidden by relocated hair, which grows to the very edge of the incision.

A large flap of hair-bearing skin, taken from the back or sides of the head to the bald area, can take the place of several hundred punch grafts.

Although flaps transfer the greatest amount of hair in the shortest amount of time, the surgery is more extensive and your doctor must have very specific training and experience. This treatment requires general anesthesia, and it leaves scars both above and below the flap. Also, the angle of hair growth may be the same as it was on the side of your head, which may look strange.

In recent years, plastic surgeons have made significant advances in flap techniques, combining flap surgery with scalp reduction for better coverage of the crown, or with tissue expansion to provide better frontal coverage and a more natural hairline.

Scalp Reduction
What if you could just remove the skin in the bald area on the back of your head and pull the two sides of (hair-bearing) skin together? Scalp reduction, which has become pretty common, is sometimes referred to as "advancement flap surgery" because sections of hair-bearing scalp are pulled forward or advanced to fill in a bald crown (it's not useful for covering the frontal hairline).

After the scalp is injected with a local anesthetic, a segment of bald scalp is removed. The pattern of the segment varies widely, depending on the patient. If a large amount of coverage is needed, doctors commonly remove a segment of scalp in an inverted Y-shape. Excisions may also be shaped like a U, a pointed oval or some other figure.

In scalp reduction surgery, a segment of bald scalp is actually removed and the surrounding skin pulled together and sutured.

The skin surrounding the cut-out area is loosened and pulled, so that the sections of hair-bearing scalp can be brought together and closed with stitches. Doctors say you will probably feel a strong pulling at this point and possibly some pain. Usually, multiple scalp reductions are done; their success depends on the laxity of the scalp and the degree of hair loss as well as the patient's age. Almost all scalp reductions are done with a combination of either flaps or grafts.

Disadvantages to this procedure are that multiple surgeries are usually required as the skin on most heads is not elastic enough to remove more than a few square inches of scalp at a time. The procedures may go on for months, and the pain and healing cycles are present after each session. Scars may be very noticeable between procedures and the skin on your head may feel very tight for a long time.

We'll take a look at scalp expansion techniques in the next section.