Hair Replacement Guide

A man undergoing hair transplant surgery.
There are several options for hair replacement if you don't want to live with the status quo. byakkaya / Getty Images

There was a time, not too long ago, when baldness was something you lived with if you were a man, and covered with a wig if you were a woman. (Doctors estimate that one in every five women will experience some sort of hair loss.) Then men, bothered by their receding hairlines, began to wear hairpieces and toupees -- some of which were so obviously fake that they became the butt of comedians' jokes.

Well, things have changed! Today, if you have thinning hair and don't want to live with the status quo, you probably have three basic options:


  • Sophisticated and virtually undetectable hair replacement systems (formerly known as wigs)
  • Medications and topical ointments that can retard hair loss and sometimes even cause new growth
  • Surgical procedures such as hair transplantation and scalp reduction

In this article, we'll look at what causes hair loss in the first place and how to deal with the psychological fallout that often accompanies it. We'll discuss how to choose the right plastic surgeon (these professionals have been performing certain hair replacement procedures for 35 years!), how to choose the right procedure and what to expect before and after surgery. We'll also look at medications and the latest in wigs and hair additions. A word of caution: There is no quick or sure-fire way to replace your dwindling follicles with a full, thick head of hair. So it's important that your expectations are realistic and that you exercise patience while you explore your options. Good luck!

Before we discuss the reasons for hair loss, let's do a quick review of how hair works. This should help our understanding when we begin to look at the different transplantation procedures. (See How Hair Coloring Works for more.)

Typical mammalian hair consists of the shaft, protruding above the skin, and the root, which is sunk in a follicle, or pit, beneath the skin surface. Except for a few growing cells at the base of the root, the hair is dead tissue and is composed of keratin and related proteins. The hair follicle is a tube-like pocket of the epidermis (see How Sunburns and Sun Tans Work) that encloses a small section of the dermis at its base. Human hair is formed by rapid divisions of cells at the base of the follicle. As the cells are pushed upward from the follicle's base, they harden and undergo pigmentation. (See How Cells Work.)

The hair on our scalps and in our eyebrows and eyelashes are different from other bodily hairs. Hair on the head grows a healthy half-inch (1.3 cm) per month, and long scalp hairs have an average life of three to five years. Most of us have between 100,000 and 150,000 hairs on our heads.




What causes hair loss?

Baldness is not caused by vitamin deficiencies, bad circulation or wearing hats.
Photodisc/Getty Images

If you grew up hearing that baldness is caused by vitamin deficiencies, poor circulation to the scalp or too much hat-wearing, you might be surprised to know that all of these theories have been disproved. Also untrue:

  • You can tell if you'll lose your hair by looking at your maternal grandfather and uncles - No.
  • Forty-year-old men who haven't lost their hair never will - No.
  • Brushing your hair 100 strokes each day makes your hair healthier - No.

Experts say that baldness, or alopecia, is primarily caused by a combination of aging, hormonal changes and family history of baldness (on either parent's side). There are generally two types of hair loss:


  • Anagen effluvium - Permanent hair loss caused by the destruction of hair follicles
  • Telogen effluvium - Temporary hair loss due to transitory damage to the follicles

Anagen effluvium is generally due to internally administered medications, such as chemotherapy agents, that poison the growing hair follicles. Telogen effluvium is due to an increased number of hair follicles entering the resting stage. The most common causes of telogen effluvium are:

  • Physical stress - Surgery, illness, anemia, rapid weight change
  • Emotional stress - Mental illness, death of a family member
  • Thyroid abnormalities
  • Medications - High doses of vitamin A (sometimes present in diet supplements), blood pressure medications, gout medications
  • Hormonal changes - Pregnancy, birth control pills, menopause
Androgenetic Alopecia

Up to 95 percent of permanent hair loss is due to androgenetic alopecia, a hereditary condition that affects millions of men, women and children. This condition is characterized by what we call pattern baldness. Male pattern baldness generally starts with a receding hairline at the front or thinning of the crown hair and gradually progresses until, in extreme cases, only a thin horseshoe-shaped rim of hair remains at the back and sides of the head. Female pattern baldness, which has received more attention in recent years, refers to general thinning of hair all over the scalp, usually beginning at around age 30 and becoming more noticeable after 40 and particularly after menopause.

Along with advancing age and an inherited tendency to bald early (a more complex link than researchers originally thought), androgenetic alopecia is sped up by an over-abundance of the male hormone dihydrotestosterone (DHT) within the hair follicle. DHT is a highly active form of testosterone, which influences certain aspects of masculine behavior, from aggression to sex drive.

Testosterone is converted to DHT by an enzyme called 5-alpha reductase, which is produced in the prostate, the scalp and various adrenal glands. Over time, DHT causes hair follicles to degrade and shortens their anagen, or active, phase.

Technically, the follicle is still alive and connected to a good blood supply (that's why it can nurture a transplanted follicle that is immune to the effects of DHT), but it will grow smaller and smaller. Some follicles will die, but most will simply shrink in size and produce weaker hairs. The progressively shorter anagen growing cycle means more hairs are shed and remaining hairs become so thin that they cannot survive daily wear and tear, experts say. Hairs in balding areas gradually change from long, coarse, thick, colored hairs into fine, unpigmented, fuzzy hairs.


Alopecia Treatments

Approximately 20 percent of alopecia areata cases are related to heredity.
Amos Morgan/Getty Images

The best treatment options for androgenetic alopecia include:

  • Learning to live with hair loss (talking to a professional counselor can help)
  • Using hair styles (a good cut can make a big difference) and cosmetic techniques to diffuse hair loss
  • Some combination of hair additions (wigs, extensions) and hair replacement surgery

Many people with this disorder also use minoxidil, the only FDA-approved medication for safe and effective treatment of both male and female pattern hair loss. Generally, minoxidil, available in both oral (by prescription) and topical (over-the-counter) forms, is more effective at retarding hair loss than at stimulating growth, but many people say they experience both.


Alopecia Areata

According to the American Hair Loss Council, alopecia areata also affects (to some degree) millions of men, women and children. This non-scarring, inflammatory condition is usually temporary -- it's experienced in episodes by almost 90 percent of those who have it. Alopecia areata is generally thought to be an autoimmune disease in which cells from an individual's own immune system mistakenly prevent hair follicles from producing hair fiber. In many cases, the body will use its own management system to reverse the problem in time. However, those affected even temporarily by the disease can experience low self-esteem and depression and may need help from their families and friends.

The National Alopecia Areata Foundation says that approximately 20 percent of alopecia areata cases are related to heredity, as opposed to androgenic alopecia, in which heredity plays a more prominent role.

There is no diagnostic test for alopecia areata, but an experienced dermatologist can usually identify it. (For a more definitive diagnosis, doctors sometimes need to take a small skin biopsy for microscopic examination.) The disorder causes patchy hair loss, often appearing as small, smooth patches on different areas of the scalp (or, occasionally, on other parts of the body). These patches can appear suddenly, sometimes within 24 hours, and some people report feeling tingling and/or pain at the site. Other types of alopecia areata include:

  • Alopecia totalis - An advanced form of alopecia areata that results in total hair loss of the scalp
  • Alopecia universalis - Another form of advanced alopecia areata that causes hair loss over the entire body
  • Traction alopecia - Hair loss caused by physical stress and tension on the hair, such as prolonged use of hair weaving or braiding ("Corn rows" or braids done too tightly on weak hair can cause permanent hair loss.)

We'll take a look at treatment options for alopecia areata in the next section.­


Treatment for Alopecia Areata

Unfortunately, hair transplants do not work on alopecia areata because it's what doctors call recipient dominant, meaning patches have no potential for hair growth.
Digital Vision/Getty Images

There is no cure for alopecia areata, but its patchiness responds to medical treatment to varying degrees (less effectively in cases of alopecia totalis and universalis). Unfortunately, hair transplants do not work on alopecia areata because it's what doctors call "recipient dominant." In other words, the bald patch, which would receive transplanted hair, provides no potential for hair growth.

Patients whose conditions don't respond to medical treatment might want to explore the use of wigs (some insurance companies pay for these -- contact the American Hair Loss Council for a list of companies that do) or hair coverings such as turbans or scarves. Because of the unpredictability of alopecia areata, experts suggest that you avoid covering a patchy area with small hair additions. This is because the hair piece might be useless to you within a few weeks due to further advancement of the alopecia. A dermatologist can best tell you when your condition has stabilized -- at that time, more options might be available to you.


Experts suggest that parents support their child's choice when it comes to purchasing a wig or prosthesis for the child. Putting pressure on the child to wear a wig can send the wrong message and make the child feel self-conscious about the way he or she looks. There are support groups across the country for people of all ages. Contact the National Alopecia Areata Foundation to find a group in your area.

Chemotherapy-Related Hair Loss

As we mentioned earlier, chemotherapy is the administration of drugs that are poisonous to rapidly reproducing cancer cells (see How Cancer Works). Cancer cells are some of the most rapidly reproducing cells in the body (see How Cells Work). Other cells, such as those that contribute to the formation of hair shafts and nails, also reproduce quickly. So while chemotherapy drugs preferentially destroy cancer cells, the drugs also can destroy cells responsible for normal growth of hair and nails. That's why cancer patients sometimes shed their hair and nails during treatment. No hair growth stimulants, shampoos, conditioners or other cosmetic treatments can prevent or retard the hair loss. The good news is that once chemotherapy is completed, the hair usually grows back within six months to a year.


Drugs and Ointments

Pharmaceutical hair restoration treatments use manufactured chemical substances to affect the structure or function of the hair follicles in an effort to stop hair loss and promote hair growth. Some hair loss medications work by causing hair follicles that have shrunk or shut down to enlarge and grow hair again. Hair restoration medications are used to treat both sudden, temporary hair loss and chronic hair loss that starts slowly and becomes progressively more extreme over time.

These medications may be applied to the skin, taken by mouth or injected, and they include both prescription and non-prescription drugs. Prescription drugs are typically powerful and have the potential for some serious undesirable side effects if not used as directed and for their intended purpose.


Over-the-counter medications, like prescription drugs, contain active ingredients that affect the body's structure or function in order to treat a medical condition. These medications are intended for conditions that do not generally require skilled medical diagnosis. They are usually less powerful than prescription drugs and less likely to cause harmful side effects.


Minoxidil (the generic name) is in a class of drugs called hair growth stimulants. Oral minoxidil, a prescription drug originally used to treat high blood pressure, was found to increase body hair growth in the majority of patients taking it daily.

This led to the development of topical minoxidil, sold over-the-counter and marketed in its 2 percent form under the brand name HealthGuard (Bausch & Lomb Pharmaceuticals), and in its 5 percent form under the brand name Rogaine (Pharmacia & Upjohn). These formulas have been shown to stimulate hair growth in men with pattern baldness. In women, these ointments can help increase growth in the forehead area, according to manufacturers.

Pregnant or nursing women should avoid minoxidil in either form and be cautioned that the use of extra-strength formulas are not designed for women and can cause facial hair growth and other problems.

Minoxidil is what pharmacists call dose-dependent. This means that treatment must be continued in order to maintain or increase hair growth benefits. Regular-strength Rogaine must applied on a dry scalp at least twice daily (and left in place for at least four hours) and for at least four months to see results. Extra strength formulas work much more quickly (in about 45 days), manufacturers say.

Oral minoxidil can cause a fall in blood pressure, an increase in the heart rate, and weight gain (fluid retention). An increase in the absorption of topical minoxidil from the scalp can occur in users with inflamed or abnormal scalps and can lead to the same side effects as those of the oral minoxidil. This means that people with heart failure or major coronary heart disease should avoid the drug in either form, and those with high blood pressure should consult their doctors. In addition, topical minoxidil should not be used with other ointments or topical creams. Skin side effects might include irritation, itching, hives, swelling and sensitivity.

We'll take a look at some other medications in the next section.


Finasteride and Other Medications

Finasteride, a prescription drug marketed in a 1-mg tablet as Propecia (Merck Pharmaceutical), was approved by the FDA in 1998 for the treatment of androgenetic alopecia. (Finasteride, in a 5-mg tablet, was manufactured and marketed earlier as Proscar, which is still used to treat prostrate abnormalities.)

Propecia works by decreasing the concentration of the male hormone DHT (see previous page) by about 60 percent in people taking one tablet per day. Since finasteride inhibits this hormone, which is a key factor in the miniaturization of scalp hair follicles, this allows for a reversal of the balding process. Results are usually seen in about three months, and this drug is also dose-dependent. Generally, finasteride is not beneficial in the treatment of female pattern baldness.


Some researchers say that a combination of minoxidil and finasteride provides hair growth that is superior to that resulting from the use of either single drug. Talk to your doctor about this. Side effects that have been attributed to finasteride include decreased libido and groin aches.

Other Medications

Other less familiar options include using Retin-A (brand name, Ortho Pharmaceutical) alone and in combination with minoxidil to treat male pattern baldness. It is thought that the combination works because the increased absorption caused by Retin-A increases the amount of minoxidil reaching the hair follicle cells. (Since Retin-A is degraded by strong light, you should only use it at night. If you're using a combination formula, wear a hat or stay in the shade.)

Xandrox solutions, which are alternatives to Rogaine, come in formulas with varying amounts of minoxidil, Retin-A and azelaic acids. Ask your doctor or pharmacist to help you choose the right formula.

Over-the-Counter Products

If the shampoo bottles marked "for thicker hair" grab your attention in the store, you might want to think again before tossing one into your cart. According to the FDA, none of the shampoos or hair products that claim to give you thicker, fuller hair can actually do that. What these products do, instead, is to create the appearance of greater fullness by plumping up hair follicles.

There's another interesting product on the market -- make-up that colors your scalp the same color as your hair. It's cheap, it's fast and it's safe. (Manufacturers say it won't run when wet but easily washes off with normal shampooing.) You can't create a frontal hair line with this product, but if you can't afford surgery or a new wig, why not check it out?


Wigs and Hairpieces

For thousands of years, wigs have been called wigs. Today, wigs are called many different things, and they've come a long way in terms of offering a more natural appearance. Temporary usage of hair additions while undergoing lengthy hair transplant sessions is becoming more popular among men and women who don't want to advertise their work-in-progress, especially since many transplants take one or two years to complete.

­A non-surgical hair addition is any external hair-bearing device added to existing hair or scalp to give the appearance of a fuller head of hair. In this category are hair weaves, hair extensions, hairpieces, toupees, non-surgical hair replacements and partial hair prostheses. Devices may consist of human hair, synthetic fiber or a combination of both.


Partial hair additions -- now more popular than wigs -- are attached in a variety of ways. All techniques use either the existing hair or the skin as anchor sites. Weaving, fusion, bonding and cabling generally describe the techniques used to attach the new hair to the existing hair. All are used to provide more security for the active lifestyle, and they are all dependent on the growing existing hair and therefore must be reattached or tightened as the existing hair grows. (Techniques that stress your existing hair, such as weaves, can cause permanent damage if done incorrectly or on an inappropriate candidate. Even temporary clips attached too tightly can cause permanent hair loss.)

Techniques that use the skin as the anchor site include adhesives such as two-sided tapes and water-proof liquids. Most adhesives are safe, but it's a good idea to have your dermatologist do a patch test to check for skin allergies.

If your hair loss is due to illness or chemotherapy or physical abnormalities, these devices are your best solution (you should probably opt for a full wig). Many large hair replacement centers as well as many small salons offer this service.

On the down side, these hair systems are high maintenance and can be, in the long run, more expensive than the other options we've discussed. (Depending on materials and design, the price can range from $750 to $2,500 and up for a quality custom-made hair addition.) Although insurance generally does not cover male or female pattern hair loss, it may cover the cost of a hair addition when hair loss is caused by disease or other abnormalities.

And the expenses don't stop there. First, you will always need two hairpieces -- one that you wear and one that is being re-styled. Soon (usually in about a year to 18 months), you will need to replace both. Although human hair is used, it is constantly being dyed, brushed and permed to match your hair. After a while, just like your own hair, each hair strand breaks or becomes over-processed and the material it is attached to starts breaking down from the constant reattachment. You will also have to visit the hair center every four to six weeks to have your hair trimmed and have the piece reattached and blended.

The industry is seeing a growing number of people using wigs and hair systems to cover the results of a bad hair transplant, and to combine partial transplantation with a partial hair addition. The Hair Loss Council offers this example: An individual with severe baldness who wants to wear his hair straight back may opt for a transplanted hairline only (due to lack of donor hair available). Behind the newly transplanted front hairline, this person might have a hair addition designed so that he can now comb his own hair straight back.


Hair Transplantation

Hair transplantation is the No. 1 cosmetic procedure performed on men today.
Jose Gil/Dreamstime

Hair transplantation involves removing small pieces of hair-bearing scalp grafts, or plugs, from a donor site (often from the thick hair on the sides and back of the head) and relocating them to a bald or thinning area.

Before we examine specific hair replacement techniques, let's look at the history of hair transplantation. Historians say that the hair restoration field probably had its roots in the 1930s in Japan, where experiments focused on taking skin, hair and roots from one area of the body and moving them to areas of the body disfigured by accidents and war injuries.


In the 1950s, American dermatologist Norman Orentreich published articles on how hairy skin can be moved from one area to a bald area and actually take the genetics with it. Contrary to what most people believed, Orentreich was able to prove the theory of donor dominance, which says that hair, when moved, will continue to grow as it would have in its original site. (That's why the permanent, "lifetime" hair on the sides and back of the head are often used as donor sites in transplants.) He is credited with being the first to come up with the idea of using transplantation to replace the hair that a balding person is losing.

According to Dr. Stephen Cotlar, hair transplantation ranks as the number one cosmetic procedure performed on men today. The reason for the transplant explosion of the past six or seven years is that the results gained from the procedure are so much better than they once were. And the results are better because techniques have been improved. However, Cotlar says, the basic concept of hair transplantation is pretty much the same as when it was first performed. The major difference in hair transplantation today is related to graft, or plug, size.

Someone whose transplants were done by a doctor using the older technique can be easily identified by the "garden patch" appearance of his hair. These larger grafts were the standard until about a decade ago, when transplant surgeons looked critically at their work and the correlation between their results and graft size. They decided that smaller grafts would provide better results, because smaller grafts contain fewer hairs and, therefore, less clumping (of transplanted hairs), which is responsible for that characteristic sprout-like look. That began the era of mini-grafts and micro-grafts. Let's look more closely at these as we learn how hair transplantation works.


The Hair Transplantation Procedure

In hair transplantation, pieces of hair-bearing scalp are taken from the sides and back of the head and re-planted in holes in the bald area.

As we mentioned earlier, hair transplantation involves removing small pieces of hair-bearing scalp from a donor site and relocating them to holes or slits in a bald or thinning area, usually on the top of the scalp. Modern techniques in hair grafting (the most recently performed method of transplantation) is performed by many physicians and in many clinics throughout the world. No new hair is added during this procedure -- hair and skin are simply relocated. Grafts vary in size and shape:

  • Punch grafts - Round grafts that usually contain about 10 to 15 hairs
  • Mini-grafts - Much smaller grafts containing 2 to 4 hairs
  • Micro-graft - Tiny grafts containing 1 to 2 hairs
  • Slit grafts - Thin grafts that contain about 4 to 10 hairs each
  • Strip grafts - Long, thin grafts containing 30 to 40 hairs

Several surgical sessions may be needed to achieve more fullness, and a healing interval of several months is usually recommended between sessions. It may take up to two years before you see the final results of the transplant series.


The amount of coverage you need is partly dependent on the color and texture of your hair. Coarse, gray or light-colored hair offers better coverage than fine, dark-colored hair. The number of large plugs transplanted in the first session varies with each individual, but the average is about 50. For mini-grafts or micro-grafts, the number can be up to 700 per session (more about the new megasessions later).

Just before surgery, the donor area will be trimmed short so that the grafts can be easily removed. The graft donor and recipient areas are treated with a local anesthetic similar to that used by dentists. If your surgeon is making punch grafts, he or she may use a special tube-like instrument made of sharp carbon steel for punching the round graft out of the donor site. (The doctor will be very careful in removing and placing grafts to ensure that the transplanted hair will grow in a natural direction and that hair growth at the donor site is not negatively affected.)

For other types of grafts, your doctor will use a scalpel to remove small sections of hairy scalp, which will be divided into tiny sections and transplanted into tiny holes or slits within the scalp. When grafts are taken, your doctor may periodically inject small amounts of saline solution into the scalp to maintain proper skin strength.

The donor site holes may be closed with stitches (a single stitch may close each punch site). When other types of grafts are used, a small, straight-line scar will result. The stitches are usually concealed with the surrounding hair. To maintain healthy circulation in the scalp, the grafts are placed about one-eighth of an inch (3 mm) apart. In later sessions, the spaces between the plugs will be filled in with additional grafts.

After the grafting session is complete, your scalp will be cleansed and covered with gauze. Some doctors require patients to wear pressure bandages for a day or two, while others allow their patients to recover bandage-free.



Now that smaller grafts represent the standard in hair transplantation, the only major controversy in the field today is staged restoration versus megasessions. Traditionally, surgical hair restoration has been staged (planned) in multiple surgical sessions. A typical session might average between 150 and 300 grafts. The sessions are spaced three to four months apart. Depending on the patient's degree of balding, four or more sessions might be scheduled. Using staged sessions, it can take up to two years or so before the full effects of the transplant can be seen.

Recently, there has been a trend toward placing more grafts per session -- as many as 3,000! Technically, surgeons say, megasessions are more demanding and allow a slimmer margin for error. They are lengthy and require more staff. For example, a large session of 2,000 grafts or more may take over eight hours and require up to four or five assistants. In most cases, the physician will remove the pieces of hair-bearing scalp and then close the resulting wound. He then hands the donor hair to the assistants, who are responsible for both preparing the grafts for transplantation and placing them (usually the doctor will make the holes where the grafts are to be placed).


Proponents of the megasession say its appeal is that it requires fewer surgeries to achieve hair restoration in a shorter period of time. Since many physicians charge less per graft when larger numbers are placed, there may also be financial advantages to this option. If a person is traveling out of town to have his surgery performed, he probably would want to have as few sessions as possible.

Doctors who are opposed to megasessions say that in the very large megasessions where grafts are packed very close together, the overall graft survival is not as good. They also say that, since hair loss is an ongoing process, planning multiple smaller sessions allows more flexibility for the future. Even in the case of megasessions, a repeat procedure is often necessary for getting the best results.

We'll take a closer look at some of the other different types of surgical procedures for hair replacement in the following sections.


Other Surgical Techniques

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.

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.


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.

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.

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

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.

Scalp Expansion and Extension

Scalp expansion and scalp extension are done to accommodate scalp reductions when the scalp is too tight. Expansion is also used to prepare individuals for flap surgeries.

Tissue Expansion

Plastic surgeons are the leaders in tissue expansion, a procedure commonly used in reconstructive surgery to repair burn wounds and injuries with significant skin loss. Its use in hair replacement surgery has generated dramatic results -- significant coverage in a relatively short amount of time.

In this technique, a balloon-like device called a tissue expander is inserted beneath hair-bearing scalp that is next to a bald area. The device is gradually inflated with salt water over a period of weeks, causing the skin to expand and grow new skin cells. This causes a bulge beneath the hair-bearing scalp, especially after several weeks.

When the skin beneath the hair has stretched enough -- usually about two months after the first operation -- another procedure is performed to bring the expanded skin over to cover the adjacent bald area.

Laser Surgery

Lasers were first used in hair transplantation in 1992. Results were variable (in some instances, the use of strong continuous beam lasers caused traumatic injuries) and the procedure remains controversial today.

Newer, safer technology has been developed and approved by the FDA, especially in the area of pulsating lasers (see How Tattoo Removal Works). However, laser surgery still isn't a mainstream hair replacement option. In this procedure, the laser's light beam is rapidly pulsed up to hundreds of times per second. This avoids heat buildup and preserves the vascular layers of the scalp.

Laser recipient sites are generally holes ranging in size from 0.3 to 0.8 millimeters. (Some surgeons prefer to use strip grafts -- again, doctors disagree on this subject.) Small amounts of bald tissue are removed with each pulse of the laser. This prevents any compression of the newly placed grafts. After all the recipient sites are made, a small probe is used to enter the scalp's vascular layer -- a procedure that must take place without damaging the vascular layer's components.

As with conventional transplant surgery, local anesthetic is used, preceded by an analgesic cream that helps to reduce the injection's sting. The donor area is then harvested using simple scalpel techniques (the laser doesn't do the job here). After the donor grafts or strips have been removed, the area is sealed with an infrared coagulation device and then closed with sutures. Sutures are removed in 10 days in most cases.

How Do I Find the Right Surgeon?

Hair replacement surgery can improve your appearance and boost your self-confidence, but the results won't necessarily measure up to your ideal. Before you decide to have surgery, think carefully about your expectations and discuss them with your surgeon. It's important to understand that all hair replacement techniques use your existing hair. The goal of surgery is to find the most efficient uses for that hair. (As we mentioned earlier, if you have alopecia areata, you're not a candidate for hair transplantation.)

In general, hair replacement candidates must have healthy hair growth at the back and sides of the head to serve as donor areas. Donor areas are the places on the head from which grafts and flaps are taken. Other factors such as hair color, texture and waviness or curliness may also affect the outcome. There are several techniques used in hair replacement surgery. Sometimes, surgeons use two or more of these to achieve the best results.

The first thing to do if you're concerned about hair loss or baldness is to see a qualified dermatologist, dermatologic surgeon or plastic surgeon to determine the cause of your hair loss. This will eliminate certain replacement strategies. Then, you'll need the help of an experienced surgeon to decide which procedure will work best for you.

Ask your family doctor, city, county or state medical agencies, your hair stylist or the local Better Business Bureau for names of qualified surgeons. (You can also check with some of the major hair replacement and hair loss organizations listed at right.) It's best if your surgeon lives and works in your community, since several sessions are generally required and in case of complications following surgery. (This can also be beneficial because you can talk to your chosen surgeon's previous patients.)

It's also a good idea to inquire whether a surgeon holds membership in any of the well-known professional organizations, such as the American Society of Plastic Surgeons, the American Academy of Cosmetic Surgery, the American Academy of Facial Plastic and Reconstructive Surgery or the American Society of Dermatologic Surgery.

In addition to your surgeon's credibility, you should be able to trust him or her. There are always people who will do surgery that you request even if your chances of good results are slim. That's why some experts say the number of transplant candidates a surgeon has turned away (because they were inappropriate candidates) says more about the surgeon than the number of procedures he or she has done.

How Do I Know Which Procedure is Right for Me?

One transplantation veteran compares getting hair replacement surgery to doing a major remodeling job on your home. These considerations hold true for both "projects":

  • It is a major, expensive project that requires commitment.
  • It is something that you definitely want done right the first time around.
  • Although you would, naturally, like the job done in as short a time as possible, what you want more is quality.

One big difference between hair replacement surgery and a home remodeling project is that an unsatisfactory construction job is easier to redo than a poor surgical job. After all, the available hair that can be transplanted is limited. Once it's gone, it's gone.

Again, if you're considering hair replacement surgery, it's important to understand that you will never have the coverage you had prior to your hair loss, but surgery may camouflage the thin areas and give you more fullness. (If you have very little hair, surgeons may see you as a poor candidate for replacement surgery.)

No matter which surgical procedure you choose, it's important to know these facts about hair replacement surgery:

  • Hair replacement surgery is normally safe when performed by a qualified, experienced physician.
  • Since individuals vary in their physical reactions and healing abilities, and the outcome is never completely predictable, every surgical procedure contains some element of uncertainty and risk.
  • As with any surgery, infection may occur.
  • In transplant procedures, there is a chance that some of the grafts won't "take." (Although it is normal for the hair contained within the plugs to fall out before establishing regrowth in its new location, sometimes the skin plug dies and surgery must be repeated.)
  • When hair loss progresses after surgery, an unnatural, patchy look may result -- especially if the newly placed hair lies next to patches of hair that continue to thin out. If this happens, additional surgery may be required.
Planning Your Surgery

Remember, hair replacement surgery is an individualized treatment. To make sure that every surgical option is available to you, find a doctor who has experience performing all types of replacement techniques -- not just one procedure that he or she claims can take care of your hair loss problem.

In your first meeting, your surgeon will evaluate your hair growth and loss, review your family history of hair loss and ask about any previous hair replacement surgery. Your surgeon will also ask you about your lifestyle and discuss your expectations and goals for surgery. Medical conditions that could cause problems during or after surgery, such as uncontrolled high blood pressure, blood-clotting problems or the tendency to form excessive scars, should also be checked by your doctor. Be sure to tell your surgeon if you smoke or are taking any drugs or medications, especially aspirin or other drugs that affect clotting.

Once you and your surgeon have agreed on the best surgery for you, your doctor will explain anesthesia, where the surgery will take place (usually in your surgeon's office or in an outpatient clinic) and the risks and costs involved. Now's not the time to be shy -- ask lots of questions! Make sure you understand which procedures will be used and how long each will take. The number of sessions required depends on the individual patient, the extent of baldness and the number of grafts done at each session.

Be sure to find out if your doctor does megasessions -- single sessions in which up to 3,000 grafts are done at once -- or uses more traditional short sessions with fewer implants. This is a hot topic of debate in the hair replacement industry. The length of each session depends on the amount of surgery performed. Typical sessions are two to three hours.

It's also a good idea to ask your doctor to give you an idea (don't hold him/her to it!) of what you will look like after the procedure or, in the case of grafts, after each stage of treatment.

Preparing for Surgery

Your surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and taking and avoiding certain vitamins and medications. By following these instructions, you will help ensure that your surgery goes smoothly. If you smoke, it's especially important to stop at least a week or two before surgery; smoking inhibits blood flow to the skin and can interfere with healing.

Preliminary blood tests will be taken. You should wash your hair the evening before or the morning of the session. Don't bother to get your hair cut before your session. Surgeons say the donor sites are easier to conceal just after surgery if the surrounding hair is moderately long.

You should arrange for someone to drive you home after surgery (rarely is a hospital stay required). Plan to take it easy for a couple of days and arrange for help if you think you'll need it.

What can I expect after hair replacement surgery?

You may experience some pain or discomfort, but doctors say this will be mild and will respond to pain medication. Most surgeons will ask that you refrain from wearing a wig or hairpiece for at least two weeks after surgery.

What's tougher than that, hair transplant veterans say, is being patient. Patience is necessary since it will take some time for you to see the full results of your surgery. Due to the manipulation involved, the hairs in the larger grafts usually are shed. Regrowth typically begins in two to six months. Hairs in smaller grafts often continue to grow immediately after surgery. They will grow as if they were still in their original, non-balding location.

You'll also need to be realistic -- you can't really expect a "full head" of hair. Your surgery has simply redistributed the hair that remains on your scalp to the best cosmetic advantage. Occasionally, a few grafts may produce a reduced number of hairs, but almost all will produce hair.

It takes several weeks for the grafts to become firmly anchored, so be very careful with your hair grooming. Gentle shampooing may be done daily, if necessary, beginning three days after the procedure. A very mild, non-medicated shampoo should be used for the first few weeks.

How soon you get back to your normal schedule depends on the length, complexity and type of surgery you've had. You may feel well enough to go back to work and resume normal, light activity after several days.

How much does this surgery cost?

Cost can vary from $4,000 for a lesser degree of hair loss to over $20,000 for more extensive hair loss. The cost depends on the amount of surgery required -- this means that flap, scalp reduction and tissue expansion procedures will cost more. (Some surgeons claim that the cost of hair replacement surgery is hardly more than the cost, maintenance and replacement of a good hairpiece.)

You may need a surgical touch-up procedure to create more natural-looking results after your incisions have healed. Sometimes, this involves blending, a filling-in of the hairline using a combination of mini-grafts, micro-grafts or slit grafts. Or, if you've had a flap procedure, a small bump called a "dog ear" may remain visible on the scalp. Your doctor can surgically remove this after complete healing has occurred. Generally, it's best to anticipate that you will need a touch-up procedure. Your surgeon can usually predict how extensive your follow-up surgery is likely to be -- and how much it will cost.

Usually, your medical insurance will not cover these procedures. Check with your insurance company regarding reimbursement. Many surgeons will set up payment plans, and there are even companies that specialize in loans for hair replacement surgery!

When you consider your expenses, don't forget to factor in your travel expenses if you have to go out of town to see your doctor.

New Research in Hair Replacement

According to researchers at a small biotechnology company called AntiCancer, Inc., it may soon be possible to resuscitate gray hair and recover follicles that have gone dormant. These researchers, who work primarily to develop new diagnostic and therapeutic models for treating cancer, are growing various types of cancer cells on artificial sponge-gel matrices as part of this research.

When they tried to grow normal human skin on the gel matrices, they were surprised to see that not only did the cells grow, but they also produced hair! Having done that, they began to screen for molecules that might modify hair growth. Working along these lines, the researchers found that liposomes (synthetic microscopic phospholipid spheres) could be used to selectively and efficiently target molecules to the follicle cells.

They have now reported the successful delivery of plasmid DNA coding for the lacZ gene to mouse skin cells. "We were able to selectively target the lacZ reporter gene to the hair follicles of mice after topical application of the gene entrapped in liposomes. These results demonstrate that highly selective, safe gene therapy for the hair process is feasible," said Dr. Robert Hoffman, founder and president of AntiCancer, Inc. He believes the findings have laid the groundwork for the treatment of baldness or for methods of artificial darkening of hair that has turned gray with age, using a very safe and relatively straightforward procedure. Researchers at the National Institutes of Health find this work encouraging. Stay tuned!

If you'd like to read more about hair loss and replacement, check out the Bald Man's Home Page -- it's one of the best around! Now that you're better informed, you'll be able to work with your doctor to make the right decision about your hair loss.

One last thought: What's on the inside really does mean more than what's on the outside. And there are still bald men who wear their smooth pates proudly -- check out the Bald Headed Men of America Web site!

For lots more information on hair replacement and related topics, check out the links on the next page.