Special Topic

Aesthetic Surgery Journal

Continuing Medical Education Article 33(1) 128­–151
© 2013 The American Society for
Aesthetic Plastic Surgery, Inc.
Hair Restoration Surgery: The State of the Art Reprints and permission:
http://www​.sagepub.com/
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DOI: 10.1177/1090820X12468314
www.aestheticsurgeryjournal.com

James E. Vogel, MD; Francisco Jimenez, MD; John Cole, MD;

Sharon A. Keene, MD; James A. Harris, MD; Alfonso Barrera, MD;
and Paul T. Rose, MD, JD

Abstract
Hair restoration is a highly sophisticated subspecialty that offers significant relief to patients with hair loss. An improved understanding of the aesthetics of
hair loss and cosmetic hair restoration, hair anatomy and physiology, and the development of microvascular surgical instrumentation has revolutionized
the approach to surgical hair restoration since the original description. Additional elements that contribute to the current state of the art in hair restoration
include graft size, site creation, packing density, and medical control of hair loss. The results of hair restoration are natural in appearance and are provided
with a very high level of patient satisfaction and safety. This aspect of cosmetic surgery is a very welcome addition to a traditional aesthetic practice and
serves as a tremendous source for internal cross-referral. The future of hair restoration surgery is centered on minimal-incision surgery as well as cell-
based therapies.

Keywords
hair transplant, alopecia, follicular unit graft, hairline, CME

Accepted for publication September 28, 2012.

Alopecia, the term for generic hair loss, involves a diminu-
tion of visible hair. There are numerous types of alopecia.
The most common form of surgically treatable alopecia is
androgenic alopecia (AGA). Throughout time, the pres-
ence of scalp hair has represented attributes of health,
vigor, vitality, and strength. Accordingly, loss of hair in
men (MAGA, or male pattern androgenic alopecia) and
especially women (FPHL, or female pattern hair loss) can
have significant psychosocial effects. The overwhelming
majority of procedures for hair restoration are hair trans-
plants, and the advent of microvascular surgical instru-
mentation as well as an improved understanding of the
anatomy and physiology of hair loss has revolutionized
the art of surgical hair restoration since the original
description and early refinements.1-3
Anatomy, Genetics, and Physiology
of Hair Loss
have been reported with variant regions of the androgen
receptor gene, which is located on the X chromosome.
Epidemiologic surveys of AGA reveal the highest incidence
in Caucasians, followed by Asians and then Africans, with
the lowest incidence in Native Americans.4-8
For the purpose of hair transplantation, the scalp may
be divided into the frontal, midscalp, vertex, and temporal
areas (Figure 1A-C). Hair thinning and subsequent shed-
ding is due to gradual miniaturization of genetically
Dr Vogel is Associate Professor, Department of Plastic Surgery,
The Johns Hopkins Hospital and School of Medicine, Baltimore,
Maryland. Dr Jimenez is a hair restoration surgeon in private
practice in Canary Islands, Spain. Dr Cole is a hair restoration
surgeon in private practice in Alpharetta, Georgia. Dr Keene is a
hair restoration surgeon in private practice in Tucson, Arizona. Dr
Harris is a Plastic surgeon in private practice in Greenwich Village,
Colorado. Dr Barrerra is Clinical Assistant Professor of Plastic
Surgery, Baylor College of Medicine, Houston, Texas. Dr Rose is a
hair restoration surgeon in private practice in Coral Gables, Florida.

Androgenic alopecia is characterized by progressive visible Corresponding Author:

thinning of scalp hair in genetically susceptible men and Dr James E. Vogel, 4 Park Center Court, Owings Mills, MD 21117,
in some women. The current scientific data support the USA.
thesis that AGA is a polygenic trait. Significant associations E-mail: jamesevogel@comcast.net

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 Vogel et al 129

Figure 1.  Surgical anatomy of the scalp. (A) Frontal view emphasizing the level of the hairline, relationship to the temporal
triangle, and the lateral canthal line. (B) Profile view to illustrate the relationship between the lateral hump and lateral aspect
of the forelock. (C) Caudal view to illustrate the relationship with the lateral canthal line and lateral extent of the anterior
hairline.

marked hair follicles and represents shortening of the
anagen (growth) phase of the hair follicle with an increase
in the telogen/anagen ratio of the affected scalp. An
understanding of the normal hair follicle life cycle is criti-
cally linked to an appreciation of the physiology of hair
loss.9-14
Miniaturization results in the conversion of terminal
(large) hairs into smaller, barely visible, depigmented vel-
lus hairs (Figure 2).15 At the cellular level, follicle minia-
turization is thought to be caused by a reduction in dermal
papilla volume, as a consequence of a decrease in the
number of cells per papilla. Nonetheless, hair follicles are
still present and cycling, even in bald scalps.16,17 Although
testosterone is the major circulating androgen that causes
hair loss, to be maximally effective, it must first be con-
verted to dihydrotestosterone (DHT) by the enzyme
5α-reductase. The importance of DHT as an etiologic fac-
tor in male pattern hair loss is shown by the absence of
AGA in men with congenital deficiency of type II
5α-reductase and by varying amounts of hair regrowth in
men with MAGA treated with finasteride, a selective type
II 5α-reductase inhibitor.18 Balding scalp contains exces-
sive concentrations of 5α-reductase, DHT, and the DHT
androgen receptor. The action of DHT is mediated by
intracellular nuclear androgen receptors.19
In women, there is no consensus on whether hair loss
is truly androgen dependent. Most women with FPHL do
not have biochemical hyperandrogenism. In fact, some
women without detectable circulating androgens may also
develop FPHL, suggesting a possible role for non-andro-
gen-dependent mechanisms. Based on this evidence, it
seems appropriate to replace the term androgenic alopecia
in women with the previously mentioned, more contem-
porary and scientifically descriptive term female pattern
hair loss (FPHL), to include this recognized heterogene-
ity.4,6-8,19-26
On a macro level, the majority of human hair shafts
emerge from the scalp as single-, 2-, and 3-hair groupings
(Figure 3). The groupings are the visible superficial por-
tion of a distinctive histologic structure, known as the
follicular unit (FU). Present-day hair transplants almost
exclusively use follicular units as the transferred element

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 130 Aesthetic Surgery Journal 33(1)

Figure 2.  Progression of hair loss. In youth, testosterone is limited in concentration; however, during puberty and adulthood,
testosterone is converted to dihydrotestosterone (DHT). Exposure of susceptible hair follicles to DHT results in miniaturization
and ultimately hair loss. The enzyme 5α-reductase is responsible for the conversion of testosterone to DHT. Finasteride is an
oral medication that blocks this pathway and prevents hair loss.

diffuse central thinning over the midfrontal scalp, as

described and originally classified by Ludwig.36,37
Exceptions to these patterns occur. Some men will exhibit
a Ludwig pattern of loss, and some women will display a
typical Norwood pattern.

Nonsurgical Options for Treating

Figure 3.  Magnification view of in situ follicular units (FUs).
A 4-hair FU has been scored in preparation for a follicular
unit extraction (FUE) donor harvest.
of tissue, and thus the contemporary nomenclature for this
procedure is a follicular unit hair transplant (FUT).27-34
The clinically observed patterns of MAGA have been
well described by Norwood,35 after whom the most com-
mon classification system for this condition is named. On
the other hand, hair loss patterns in women are typically
characterized by maintenance of the anterior hairline and
Hair Loss
There are currently only 2 medications approved by the US
Food and Drug Administration (FDA) to promote hair
growth in the scalp. These medications are finasteride and
minoxidil. Other options for medications claiming to treat
hair loss are extensive but also of questionable value.38-40
Finasteride (Propecia; Merck & Co, Inc, Whitehouse
Station, New Jersey) is a medication that lowers DHT
through blockades to the 5α-reductase type 2 pathways
(Figure 2). In a prospective randomized study by the
manufacturer, finasteride was shown to reduce hair loss or
have positive effects related to hair growth in 90% of
patients, and the drug’s safety and efficacy have also been
reported by independent research.41 Propecia is FDA
approved for men only. The FDA only allows the manufac-
turer to make claims regarding growth in the vertex area
of the scalp, but many physicians have noted that this
medication has a global effect on the scalp hair.
Side effects reported with finasteride include a decrease
in libido, erectile dysfunction, testicular pain, and benign

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 Vogel et al 131
growth in the male breast. The side effects associated with
the drug generally disappear with discontinuation of finas-
teride. Some controversy exists regarding its relation to
breast and prostate cancer as well as the temporary nature
of sexual side effects.42,43
Minoxidil (Rogaine; McNeil-PPC, Inc, Morris Plains,
New Jersey) has been available since 1988 as a topical
medication indicated to treat hair loss. It has been used in
men and women. The mechanism of action is unclear, but
it is recognized that the vasodilatory effects of minoxidil
do not fully explain its positive action on hair growth.
Observed benefits include increased proliferation of der-
mal papillae cells, increased hair caliber, and diminished
telogen phase during the hair growth cycle.
Evaluation and Planning
Photography
Photography of the hair restoration surgery (HRS) result is
the principal measure by which results are objectively
documented. The use of lighting and standard positions
for hair photography has been described.44 The use of a
light gray or blue-colored background is recommended, so
that the top borders of dark hair will not blend into the
background. This background will also work for white and
blond hair.
General Evaluation
Young men and women are particularly distraught by the
signs of hair loss.45,46 Low self-esteem and vulnerability to
a fantasized outcome place this subset of patients at par-
ticular risk for quick decision making and unrealistic expec-
tations. Managing these expectations and formulating a
realistic surgical plan for patients with hair loss is a critical
component to the long-term success of the procedure.
A fundamental concept that physicians and patients are
advised to maintain during the evaluation and planning
for HRS is that hair loss is progressive. The appearance of
hair loss in the office during consultation is merely a snap-
shot along a continuum that began years earlier and will
progress until death. Communication regarding the quality
of the patient donor hair is also an additional essential
component in managing expectations. The qualities of the
hair that should be reviewed include curl, hair shaft diam-
eter, color, texture, follicular unit density, and the telogen/
anogen ratio of in situ donor hair. These aspects of the
donor hair should be not only reviewed but also docu-
mented as a means to predict how well the transplanted
hair will camouflage areas of scalp alopecia.
Lab tests for diagnosis are generally unnecessary in
men with typical pattern AGA. However, a differential
diagnosis for nonandrogenic causes for hair loss should be
maintained for consideration during the evaluation.47-50
Finally, most men younger than 60 years will also be
encouraged to consider the use of finasteride, 1 mg daily,
to reduce crown hair loss.
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In women, the pattern of hair loss with FPHL, espe-
cially in the early stages, can be mimicked by a variety of
other conditions. These include frontal fibrosing alopecia,
diffuse alopecia areata, and telogen efluvium (acute and
chronic).51-54 Women with bitemporal recessions, as seen
with male pattern baldness, should be screened for hor-
monal imbalances. Finally, women with typical FPHL in a
Ludwig pattern should be checked for iron deficiency as
well as thyroid function to rule out other causes of diffuse
hair loss.55
Recipient Area
The first step in assessing the recipient area is to deter-
mine where to place the grafts. A conservative and princi-
pled surgical plan for the recipient site is an initial forelock
distribution hair transplant. The forelock is the area
bounded anteriorly by the frontal hairline, posteriorly by
the anterior crown region, and laterally by the parietal
fringe (Figure 1). This is a commonly maintained, normal
distribution of hair seen in male patients with mild hair
loss. A forelock pattern hair transplant is initially planned
when there is anticipation of considerable future hair loss,
especially in a young patient. For the same reason, this
approach is also very appropriate for older patients who
present with extensive baldness and limited donor supply.
The rationale for this approach is that the distribution of
grafts in a forelock limits the requirements from the donor
supply. Creation of a forelock pattern also provides an
opportunity for a large, single-session procedure to achieve
the 2 fundamental goals of hair restoration surgery—
namely, to recreate a normal pattern of hair loss seen in
nature and to create a frame of hair for the face (Figure
4).56-58 The beauty of this conservative and safe surgical
approach is that this graft distribution can be expanded
posteriorly for additional crown coverage as desired.
Determining the number of grafts for the initial proce-
dure and over the lifetime of the patient is the next step in
recipient planning and evaluation. This assessment
depends on a number of factors. These include current
degree of baldness, donor hair characteristics, degree of
anticipated hair loss, patient’s goal for density and ulti-
mate coverage, technical expertise of the hair transplant
team, and financial considerations of the patient. A good
visual transplant result will be apparent with densities
between 25 and 40 FU/cm2. To put this into perspective,
in adult men with no “visible” hair loss, the typical den-
sity in the frontal hairline ranges between 38 and 78 FU/
cm2 (average 52 FU/cm2), whereas the average frontal
density of prepubertal males is approximately 80 to
100 FU/cm2.59
Donor Area
It cannot be overemphasized to the patient that his or her
own intrinsic donor hair characteristics will dictate the
fullness of the hair transplant result. Patients with a thick
 132 Aesthetic Surgery Journal 33(1)

Figure 4.  This 38-year-old man with male pattern hair loss requested hair restoration. He underwent a 2200–follicular unit forelock
transplant in 1 session and is shown intraoperatively in part A. (B, D) Preoperative views. (C, E) At 10 months postoperatively, the
patient’s face is framed with hair in a natural distribution. This result could be a stand-alone outcome or additional grafts could be
added for more coverage as desired.

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 Vogel et al 133
hair shaft (>80 microns) are better candidates than those
with narrow hair (<60 microns). Recently, a novel device
has been described to measure hair density and caliber.60
Even when transplanted densities are high (>40 FU/
cm2), individuals with fine, straight hair will have a more
“see-through” result compared with those with coarse,
curly, and large-caliber hair transplanted at a lower den-
sity. In addition, patients with low follicular density (1-2
hairs/FU) will have a more sparse result than those with
higher follicular density (3-5 hairs/FU).
In general, patients require a donor density of at least
40 FU/cm2 to be considered for transplants. A higher den-
sity donor supply is extremely advantageous. To accu-
rately assess the size of the donor strip, required
measurement of donor follicular unit density is performed
using one of several available specialized instruments
(hair densitometer, digital video camera, etc).61 Then the
size of the donor strip can be determined according to the
desired number of follicular units to be transplanted. The
region between the occipital protuberance and 1 cm above
the top of the ears is considered the “safest” physiological
place from which to harvest hair. In most patients, this
area is approximately 5 to 6 cm in width. The higher area
above the ear and below the occipital protuberance may
thin over time and should be avoided, as this hair may be
susceptible to future AGA.
In women with a diffuse pattern, the quality of the
donor hair is often less than ideal. Clinical judgment and
the objective criteria listed above are components with
which to determine suitability for the procedure.
Hair Transplant Technique
As with any surgical procedure, the techniques of the
operation will vary based on personal preference and
clinical circumstances. Although the fundamental
approach described herein is nearly universally applicable,
the specific techniques do reflect most closely the method-
ology preferred by the lead author (JEV).
Anesthesia
Hair transplantation can be performed under local anes-
thesia alone or with supplemental sedation. The local
anesthesia solution is a 40-mL mixture of 0.25% bupiv-
acaine with 1:200 000 epinephrine + 20 mL 1.0% lido-
caine with 1:200 000 epinephrine. This solution is used in
the donor and recipient sites, and supplementation with
additional bupivacaine 0.25% is performed in both regions
of the scalp prior to discharge from the operating room. If
conscious sedation is included with the procedure, the
patient is premedicated with 1 to 2 mg PO aprazolam. In
the operating room, an intravenous cocktail of ketamine
5 mg/mL, midazolam 0.5 mg/mL, and fentanyl 10 mcg/
mL is titrated to achieve the desired level of sedation. All
patients receiving any type of sedation are continuously
monitored during the procedure with oximetry and receive
supplemental nasal oxygen.
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Donor Site Harvest
In contemporary practice, follicular units can be obtained
either through strip excision of the donor scalp with
subsequent microscopic tissue dissection26-28 or by
removal using a technique called follicular unit extrac-
tion (FUE).62-69
Strip excision. In preparation for the strip harvest, the
selected area of donor hair is trimmed to 4- to 5-mm length
and the patient is positioned in a lateral decubitus posi-
tion. An ellipse of donor scalp is outlined, and following
the administration of local anesthesia, tumescent saline
solution is infiltrated. Tumescence in conjunction with pre-
cise knife blade angulation parallel to the hair shafts
reduces follicle transection. Dissection level of the donor
strip should be at the superficial fat to avoid injury to the
occipital neurovascular bundle. The wound is closed in
2 layers, with an absorbable suture in the deep layer and a
monofilament suture of choice at the level of the skin. Sta-
ples or dissolving sutures are also options.
Trichophytic closure. With the advent of shorter hair-
styles, there has been an increased interest in minimizing
(or maximally concealing) the donor scar. The trichophytic
closure has been described to promote scar camouflage by
allowing hair growth through the scar.70,71 After the first
layer of the donor wound is closed, the entire lower edge of
the incision epithelium is excised. The final running suture
is then completed, with care taken to avoid deep “bites” of
scalp that have the potential to damage underlying follicles
(Figures 5A-F and 6A-C). This important anatomic detail is
worth emphasizing to maximize the results with the tricho-
phytic closure technique. Deepithelization as well as suture
depth should not exceed 1 mm, to avoid injury to the follicle
“bulge” zone. Although the bulge was originally described
as the portion of the hair follicle to which the arector pili
(AP) muscle attaches, this important region has lately
attained significant interest because it is where follicular
epithelial stem cells have been identified.9 The bulge region
starts at a depth of approximately 1 mm and extends down
to 1.8 mm.29-31 Recently, a double-layer trichophytic closure
technique was described.72
Graft preparation. Once the donor tissue has been har-
vested using the strip excision method, the tissue is
immediately immersed in chilled isotonic saline or another
type of preferred “holding” solution. Graft preparation is per-
formed using stereomicroscopes and microsurgical
instrumentation. Initially, the donor strip is subsectioned into
slivers, each being 1 FU in width (approximately 1-2 mm).
Considerable skill and experience are required to avoid tran-
section of grafts during slivering and at the same time
maintaining an efficient pace of preparation. Each sliver is
then dissected into FU grafts (Figure 7). These grafts are
placed back into a holding solution until they are planted. It
is imperative that these grafts stay moist in order for them to
avoid desiccation.
Follicular unit extraction. Follicular unit extraction is an alter-
native method of donor harvest. This technique is essentially
a refined “micropunch grafting” version of the older punch
graft technique. Using the current technique of FUE, 1 FU is
 134 Aesthetic Surgery Journal 33(1)

Figure 5.  Donor site harvest and trichophytic closure technique. (A) Patient is shown in decubitus position with donor hair
shaved to 4 mm. (B) Excised donor strip. (C) The first of the 2-layer donor site closure is complete. (D, E) The intraoperative
technique is shown and illustrated, with deepithelization of the donor wound margin. (F) The final closure is shown, with
superficial bites of 1 mm. Superficial needle entry into the scalp is performed to avoid injury to the follicle “bulge” zone.

removed at a time. There are several techniques and instru- employed, the net result is still the isolation and removal of a
ments to perform FUE. These include manual, power-assisted, single FU (Figures 3 and 7). The remaining puncture is left to
and automated methods. No matter which technique is heal by secondary intention. Some hair transplant surgeons

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 Vogel et al 135

Figure 6.  A healed donor harvest site is shown after strip excision and closure with the trichophytic closure technique. (A)
Eight months postoperatively. (B) Diagram of healed donor scar following trichophytic closure. (C) Reexcision of the donor
scar shown in part A, illustrating hair growth through the initial closure site on tangential view of the specimen.

choose to employ FUE on a selective basis for small cases

(Figure 8), whereas others select this donor harvest tech-
nique for their larger sessions (Figure 9). The increased
popularity of FUE has been linked to the development of
power-assisted technology as well as a general trend toward
minimally-invasive techniques. The indications, outcomes,
and techniques for FUE as a donor harvest option are found
elsewhere.62-69
Follicular unit extraction comprises approximately 22%
of all hair restoration donor harvest procedures performed,
as reported in a worldwide poll of hair restoration sur-
geons.73 As with any emerging technology, there is debate
regarding this methodology. Controversy related to this
donor technique includes the idea that this method is a
return to earlier methods of punch harvesting, the specific
indications, the ideal harvesting tools (blunt vs sharp),
and the survival and growth of the grafts themselves as Figure 7.  Microscopic dissection of donor “sliver” and
compared with those obtained with strip harvesting. subdissected individual follicular units containing 1, 2, and
Depletion of donor density as well as overharvesting of 3 hairs.

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 136 Aesthetic Surgery Journal 33(1)

Figure 8.  Intraoperative view of small follicular unit extraction (FUE) donor harvest site. (A) Manual FUE harvest tool in use.
(B) FUE donor harvest completed. (C) Donor site 8 months after initial harvest.

Figure 9.  Large-session follicular unit extraction (FUE) donor harvest site. (A) Immediate intraoperative view upon
completion of approximately 2500 FUE harvest. (B) Same donor area, 1 week postoperatively.

hair vulnerable to AGA is also a concern with extensive interest and technical refinements. In fact, a novel robotic
FUE harvesting. However, increased acceptance and popu- automation of the FUE technique is in the developmental
larity of FUE are emerging as a result of evolving patient stage.74 Most hair restoration surgeons feel this donor

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 Vogel et al 137
technique is “here to stay,” and future refinements and
experience with FUE will solidify its indications.
Hairline Design and General Recipient Area
The first landmark that needs to be determined is the height
of the anterior hairline (AHL) (Figure 1). In most instances,
the location of the most anterior, midfrontal portion of the
hairline is between 7.5 and 9.5 cm above the glabella. The
shape of the head, predicted future hair loss, and donor
capacity are factors to consider in this creative decision. One
must place the hairline in such a location that it will look
natural as the patient matures and continues to lose hair.
If the temporal point is expected to recede, a higher
hairline should be considered because a low hairline with
a lost temporal point suggests a hairpiece. The temple
point should be even or slightly posterior to the frontal
hairline. Along with the aforementioned principles, a gen-
tly curving hairline should be created, with care taken to
always maintain a significant frontal-temporal recession.
Restoration of the temporal triangle is performed accord-
ing to the personal preference of patient and surgeon.
The design should begin by ensuring the presence of a
lateral hump (Figure 1). If the lateral hump is absent, this
should be designed first. The lateral hump is the superior
extension of the inferiorly directed hair of the temporopa-
rietal fringe. The superior extent of this important land-
mark is even with or just medial to a line drawn vertically
from the lateral canthus. This landmark is important
because it represents the lateral extent of the AHL. The
intersection of the lateral AHL and the lateral hump is the
apex of the frontotemporal recession and should always be
convex in a male AHL design (Figure 10).75-77
The single most important component to achieving a
natural appearance to the hair transplant is the creation of
an outstanding AHL (Figure 11). This is accomplished
through proper location and design of the hairline as well
as the use of large numbers of small grafts. The shape of
the frontal hairline should not be linear but should be
broken up with major irregularities (triangles and gaps).
The hairline should consist of a transition from the bald
forehead to a zone consisting of random placement of
single hair grafts from the softest hair available in donor
supply.78,79 Typically, these single hairs are taken from the
temporal donor fringe. Posterior to the single hair grafts
are FU containing 2 and 3 hairs with stronger physical
characteristics (Figure 12). Recreating a female hairline
requires a design that includes a more rounded temporal
infill and lower hairline than the one normally created for
men (Figures 13 and 14).80
When a forelock pattern is created, the rear border
should be located somewhere along the midscalp. Whether
or not there is a plan to graft the vertex, the rear hairline
should be constructed with an irregular border of small
grafts. The lead author prefers to create a tapered posterior
forelock pattern of trailing design that renders the crown
less circular and mimics a natural variation on the balding
process (Figure 15). A distribution of grafts recreating a
natural whorl pattern can be constructed at the posterior
aspect of the forelock. The crown area can be further
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grafted as indicated but should always be considered as an
extension of the posterior forelock to maintain a natural
distribution of hair (Figure 15).
Recipient Site Creation
There are numerous instruments and methods with which
to create a site in which a hair graft is placed. The funda-
mental principles that should underlie any technique
include matching the size of the individual recipient site
with the length and width of the patient’s FU. For example,
if short, single hair grafts are placed at the anterior hairline
in a thin scalp, a smaller and more shallow site is created
than would be required to accommodate a larger 3- to
4-hair FU placed in the thicker scalp. The most simple and
cost-effective instrument for recipient site creation is a
hypodermic needle. Needle sizes ranging from 23 to 18
gauge are typically used. A 19-gauge needle will produce a
1.1-mm slit that will accommodate the size of the majority
of FU of average density (Figure 16). Another popular
instrument for site creation is the sharp-point, 22.5-degree
or the “mindi” knife. These instruments, as well as micro-
scopes designed for hair restoration surgery, are available
through different vendors (Ellis Instruments, Madison, New
Jersey; Tiemann-Bernsco & A to Z Surgical, Hauppauge,
New York). Customized recipient blades can also be cut to
specific size from flat surgical prep blades using specialized
cutting devices. In some circumstances, a 0.8-mm to 1.5-mm
hole punch might be utilized as well.81
The angle of the recipient site should mimic the angles
of the nontransplanted, existing hair growth. When hair
is absent, a natural flow of hair is created. On most hair-
lines, the angle of graft site creation should be approxi-
mately 30 to 45 degrees anteriorly off the scalp. This
results in the illusion of more coverage as well as a natu-
ral angle. The hair on the left side of the hairline should
be angled anteriorly and toward the midline. As the hair
progresses to the right side, a switch should be made so
that the hair on the opposite side is angled toward the
midline. As mentioned above, a whorl is created at the
midpoint of the crown vertex area through a spiraling of
the angulation of recipient sites through a 360-degree
rotation (Figure 15).
Most patients will require a follicular density of approx-
imately 25 to 40 FU/cm2 for satisfactory coverage. However,
as mentioned above, the individual hair characteristics
play an important role in this regard. Although highly
variable between surgeons, the typical density of site
packing in a completely bald scalp is approximately 25 to
35 sites/cm2/hair transplant session. The density for opti-
mal site packing as well as the use of “skinny” (closely
trimmed) or “chubby” (containing more fat and sebaceous
tissue) grafts is controversial. The considerations in this
debate are based on limited reports of survival at different
densities, surgeon’s preference, and also the skill of the
transplant team.82-85
Graft Planting
As with site creation, numerous techniques and instru-
ments are available for graft placement. The different
 138 Aesthetic Surgery Journal 33(1)

Figure 10.  This 58-year-old man with male pattern alopecia who underwent a 2500-graft follicular unit hair transplant is
shown during immediate preoperative planning (A, C) and immediately postoperatively (B, D, E). Note the design of the
posterior forelock taper and fill of the temporal hump.

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 Vogel et al 139
Figure 11.  (A, C) This 63-year-old man with male pattern alopecia requested restoration of his anterior hairline. (B, D) Eight
months after receiving 3200 grafts in 2 sessions.
forceps used for planting are essentially adaptations of
those used in microvascular surgery. The fundamental
principles of this aspect of the procedure include gentle
grasping of the grafts, maintenance of graft hydration,
placement of grafts in the identical angle of site creation,
and also maintaining appropriate rotation of the natural
curvature of the hair graft. As with graft preparation, con-
siderable skill is required to perform this delicate task in
a repetitive, atraumatic, and efficient manner. Frequently,
several “planters” work simultaneously to complete the
procedure in an efficient manner. An experienced assis-
tant or physician can plant 200 to 300 grafts per hour.
Typically, the recipient sites are designed first and the
grafts are placed as a following step. However, another
technique known as the “stick-and-place” method incor-
porates both maneuvers in a sequential manner. The
“sticker” creates the site with a blade of choice, and the
“placer” inserts the graft immediately before the next slit
is developed.
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Conclusion of Procedure, Postoperative Care, and
Emergence of Results
Hair transplants are lengthy procedures. A typical session of
1500 to 2500 grafts utilizing 4 assistants will last approxi-
mately 6 to 7 hours. The procedure is conducted using a
clean technique with sterilized or disposable instruments.
Postoperatively, the recipient sites and donor area are typi-
cally not bandaged, and perioperative antibiotics are not
prescribed on a routine basis. Patient instructions include
head elevation and icing of the forehead and donor area,
along with analgesics. Aloe ointment administration to the
grafted area and gentle shampooing in the shower should
commence on postoperative day 2. Most of the recipient site
eschars are gone by day 10, and donor sutures are removed
on day 14. Although there are exceptions to the rule, most
grafts enter a telogen phase for the first 3 months prior to
entering their anagen phase. Full growth and evaluation of
transplant results cannot reliably be assessed for 8 to 12
months following the procedure (Figure 17).
 140 Aesthetic Surgery Journal 33(1)

Figure 12.  This 48-year-old man demonstrates the irregularity required for graft distribution at the anterior hairline. (A)
The patient is shown intraoperatively, after a single session of 2200 grafts. Note the distribution of grafts containing 1 and
2 hairs per follicular unit at the leading edge of the hairline and larger grafts posteriorly. (B) The patient’s hairline is shown
preoperatively. (C) Eight months after grafting, the irregularity and distribution of graft size clearly contribute to the natural
appearance of the patient’s transplanted hairline.

Special Considerations surgery, burns, radiation, trauma, and congenital deformi-

Body Hair as Donor
Body hair is useful to treat areas of hair loss when the
scalp donor area supply is near or at exhaustion. The
results of body hair transplants are impossible to predict
with certainty because of the intrinsic physical and short
life cycle characteristics of this type of hair. In general, the
beard is the best source of body hair because its intrinsic
life cycle and physical characteristics most closely resem-
ble that of scalp hair.86-89 Follicular unit extraction as a
donor technique is particularly well suited to the submen-
tal area when beard hair is harvested.
ties.90-93 Hair transplants do grow in scar as well as radi-
ated tissue; however, the survival rate is lower than in
noninjured recipient beds. Formal studies on this topic
have not been published (Figure 18).
In the case of hairline reconstruction for female-to-
male gender reassignment, androgen supplementation
and ensuing temporal recession or thinning is generally
all that is necessary. In male-to-female reassignment, the
hairline design includes a typical rounded temporal infill
and the lower hairline described earlier for restoring
FPHL (Figure 14).

Reconstructive Applications
Hair transplantation can have a significant role in correct-
ing alopecia associated with scars from previous aesthetic
Flaps/Scalp Reduction/Expanders
In contemporary practice, hair-bearing scalp flaps and
alopecia reductions for elective aesthetic hair restoration
surgery are primarily of historic interest. A comprehensive

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 Vogel et al 141
Figure 13.  (A, C) This 68-year-old woman with typical female pattern hair loss presented for hair restoration. (B, D) Eight
months after undergoing a second treatment session, for a total of 3300 total grafts.
review of the previous use of these techniques in the treat-
ment of AGA can be found in 2 studies.94,95 In some cases,
these procedures have resulted in an excellent outcome for
the patient. However, as a result of poorly designed surgi-
cal incisions as well as naive surgical planning in the face
of progressive hair loss, the long-term results of these
procedures have also resulted in exposed, unattractive
scars as well as misdirection of hair flow. The use of
scalp expanders, reductions, and flaps for reconstruction
of traumatic hair-bearing scalp defects remains well
entrenched in the scalp surgeon’s armamentarium.
Complications and Patient Safety
Fortunately, the incidence of complications in HRS is quite
low. Unfortunately, there are no published reports of sig-
nificant size detailing the frequency of complications in
large series. Nevertheless, the types of complications seen
have been well described and can be categorized into surgi-
cal and aesthetic complications. In contemporary practice,
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the incidence of primary surgical problems is estimated to
be less than 2% to 3% and includes bleeding, arteriovenous
fistula, cysts, pustules, infection, frontal necrosis, neurosen-
sory changes, and scarring.96 Primary aesthetic complica-
tions include poor growth of grafts, postsurgical effluvium,
and unnatural appearance. The incidence of poor growth
ranges from 0% to 25%, but this number is highly subjec-
tive. These complications and other patient safety concerns
have been reviewed in detail elsewhere.97
Surgical Complications
Folliculitis/Cysts/Pustules
A variety of cysts and pustules can present within the first
few weeks or months following a transplant. They can be
isolated or occur as clusters of diffuse lesions. The causes
are not clear. Theories include “ingrown” hair, foreign
body reactions, epithelium logged into slit sites during
recipient site creation, piggybacked grafts, and the “idio-
pathic” intrinsic properties of the host scalp. In the majority
 142 Aesthetic Surgery Journal 33(1)

Figure 14.  A female hairline design is shown in a 32-year-old genetic male, transgender patient seeking a feminine
appearance. (A) Preoperative markings are shown following healing of a previous forehead-lowering procedure by another
surgeon. (B) The patient is shown intraoperatively. (C, D) Eight months after a third treatment session and a total of
approximately 4700 grafts.

of cases, a pathogen cannot be cultured from the lesions,
but a secondary, uncultured bacterial agent cannot be
excluded as having a secondary role in pathogenesis. Oral
antibiotics, warm compresses, and unroofing of the cysts
are the mainstays of treatment.
keloid scarring is rare in the donor site and interestingly has
never been reported as occurring in the recipient area.
Reduction in donor density secondary to extensive punctate
scarring is a potential risk of FUE harvesting.

Neurosensory Complications Aesthetic Complications

A certain amount of pain, especially in the strip harvested
donor site, is to be expected. Occasionally, some patients
will experience severe pain in the donor site, requiring
prolonged periods of narcotics. Although some patients
report headaches following the transplant procedure, there
have been reports of a decrease in this symptom as well.
Neuralgias and hypoesthesia symptoms are uncommon
and almost always resolve within the first 6 to 8 months.
Neuromas have been rarely reported and are treated with
steroid injection or excision.
Scarring
Scarring in the donor area remains the primary concern, even
with modern strip harvesting techniques. The advent of the
trichophytic closure technique and the awareness of the
critical importance of avoiding tension in donor site closure
have reduced the incidence of donor scar complications. True
Poor Growth
It is unrealistic to expect 100% of grafts to survive.
Accurate measurement of growth requires precise hair
counts using magnification, scalp tattooing, and macro-
photography. Studies of this caliber are small in size and
very limited. However, most would agree that growth rates
less than 85% to 90% would be considered poor growth.
Causes for poor growth are numerous but generally focus
on follicular trauma and dehydration during the different
stages of the lengthy procedure. Some limited studies on
out-of-body time indicate that graft growth is not effected
until 6 to 8 hours following harvest.82,83 Different holding
solutions are being investigated to maximize graft integ-
rity. Other factors for poor growth include host factors
such as vascularity of scalp, smoking, and the presence of
scar tissue.

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 Vogel et al 143
Figure 15.  (A) This 43-year-old man with primary alopecia in the crown region presented for hair restoration. (B) Eight
months after posterior forelock grafting and creation of crown whorl pattern with approximately 2000 grafts.
Figure 16.  Relationship of size between 1-, 2-, and 3-hair
follicular unit grafts and the 19-gauge and 1.0-mm blades used
to create recipient sites. It is important to create recipient sites
with a depth and width that match the graft size.
Postsurgical Effluvium
Occasionally there can be a shedding of the in situ, non-
transplanted hair. This postsurgical shedding can be either
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an anagen or a telogen effluvium and typically takes place
2 to 6 weeks following the transplant procedure. This situ-
ation most frequently occurs in female patients with dif-
fuse pattern hair loss but can be seen in men as well. In
addition, effluvium can also be seen in the donor harvest
sites. Fortunately, the effluvium is usually temporary. In
some instances, the hair will grow back with a more
narrow caliber or not at all. To reduce the likelihood of efflu-
vium, the surgeon can minimize the number of recipient
sites, as well as their size, and also consider the use of
minoxodil (Rogaine) or finasteride (Propecia) during the
perioperative period.
Unachieved Patient Expectations
As in any type of aesthetic surgical procedure, the expecta-
tions of the patient need to be realistic. However, unique
for the hair restoration patient is the importance of appre-
ciating the progressive nature of nontransplanted hair loss
over time, the inherent qualities of their donor hair as a
source for scalp coverage, and their individual limitation
in donor supply.
Poor Cosmetic Appearance of the Transplant
The expected outcome using contemporary techniques of
hair transplantation is a result that is generally indistin-
guishable from the appearance of native scalp hair.
 144 Aesthetic Surgery Journal 33(1)

Figure 17.  (A, C, E) This 28-year-old man with male pattern alopecia presented for hair restoration. (B, D, F) Eight months
following a single session of hair grafting with 2500 grafts placed in a forelock distribution. Note the beneficial effect from
finasteride in the nontransplanted posterior crown region. The benefit to forelock grafting is that additional grafts can be
placed in the crown region if desired or the result can stand alone.

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 Vogel et al 145
Figure 18.  (A) This 28-year-old man presented for beard reconstruction after a burn injury and secondary chin reconstruction.
(B) Twelve months after placement of approximately 1000 grafts in 2 sessions. Reprinted with permission from Barrera A. The
use of micrografts and minigrafts in the aesthetic reconstruction of the face and scalp. Plast Reconstr Surg. 2003;112(3):883-890.
Unfortunately, older techniques as well as some poorly
performed recent transplants have not resulted in a natu-
ral appearance. As a consequence, there are a considerable
number of patients who bear the visual and psychological
burden of an unnatural hair transplant. A complete review
of these types of problems and their management was
published elsewhere.98-105
The most frequent type of cosmetic problems following
hair transplants are
1. Unsightly appearance of plugs
2. Wide scars in the donor area
3. A poorly designed hairline
4. Errors in surgical planning and inappropriate dis-
tribution of grafts at a young age, in which the
progressive nature of hair loss was not considered
All of the above cosmetic complications result in the
same fundamental problem for the patient: an unnatural
appearance to the scalp hair that yields a strange and
unnatural appearance. Patients are plagued with these
unnatural results, which become worse over time as their
surrounding hair recedes and thus further exposes the
original unnatural hair grafts. Understandably, these
patients are angry with the original surgeon and themselves
for submitting to the original transplant; they often wish
they could trade the unnatural appearance for simple bald-
ness. Correction of these tragic results is difficult and time-
consuming, requires a special relationship of trust between
the surgeon and patient, and often requires 3 or more surgi-
cal procedures. The techniques and approach for correction
of these challenging cases are beyond the scope of this cur-
rent review. The references cited in this section provide the
principles and fundamental techniques for restoring normalcy
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to a patient whose life has been undesirably transformed by
the initial hair transplant procedures (Figure 19).
The Future of Hair Transplantation
FUE
Currently, a minority of hair transplant surgeons provide
FUE for all patients. Most practices use FUE for selected
indications. However, the future direction appears to be
moving toward a greater interest in and application of
FUE. Improved instrumentation, automation, and an ever-
increasing interest in minimally-invasive techniques are
driving this trend.
Cell-Based Therapy
In the foreseeable future, hair restoration surgery will be
intermingled with some type of cell-based therapy. The
concept of the hair follicle as a mini-organ is recognized
by cell biologists pursuing hair replication research.
Biotech and basic research labs are currently investigating
pathways for hair induction, hair development, and hair
follicle regeneration. The results of this research will
undoubtedly make their appearance into clinical trials
and, theoretically, daily practice. It should be recalled that
androgenic alopecia is, at least in principle, a reversible
condition. Although the terminal hairs have become min-
iaturized beyond recognition by the naked eye, the same
hair follicles (with fully intact stem cell machinery) con-
tinue to be present in the balding scalp. The ultimate solu-
tion to finding a cure for androgenic alopecia would be
a product that is able to switch on the differentiation
mechanism from vellus to terminal hair. The ability to
 146 Aesthetic Surgery Journal 33(1)

Figure 19.  (A) The patient’s preoperative markings are shown prior to the first procedure. The dots indicate the location where
plugs are to be removed and recycled into new follicular unit grafts for immediate grafting. The irregular anterior hairline was also
marked for creation of a new leading edge hairline. Dome marking in the area of the lateral hump above the ears indicates planned
distribution of grafts to fill in bald “alleys” of scalp. (B, D, F) This 38-year-old man had previously undergone a hair transplant at
age 20 but was cosmetically dissatisfied with the appearance of his scalp. The patient had experienced progressive hair loss with
resulting exposure of previously transplanted 4-mm “plug” grafts. In addition, progressive hair loss above his ears resulted in “alleys”
of baldness. He desired correction of this unnatural appearance. (C, E, G) Eight months after the third procedure; all procedures
consisted of primary hair grafting from the occipital donor site, plug reduction, and recycling of 4-mm plug grafts. In total, the patient
underwent removal and recycling of approximately 252 four-mm previously grafted transplant “plugs” and 2000 follicular unit grafts
over a 2-year period. The patient was also maintained on finasteride oral medication.

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 Vogel et al 147

Figure 19. (continued)  (A) The patient’s preoperative markings are shown prior to the first procedure. The dots indicate the
location where plugs are to be removed and recycled into new follicular unit grafts for immediate grafting. The irregular anterior
hairline was also marked for creation of a new leading edge hairline. Dome marking in the area of the lateral hump above the ears
indicates planned distribution of grafts to fill in bald “alleys” of scalp. (B, D, F) This 38-year-old man had previously undergone a
hair transplant at age 20 but was cosmetically dissatisfied with the appearance of his scalp. The patient had experienced progressive
hair loss with resulting exposure of previously transplanted 4-mm “plug” grafts. In addition, progressive hair loss above his ears
resulted in “alleys” of baldness. He desired correction of this unnatural appearance. (C, E, G) Eight months after the third procedure;
all procedures consisted of primary hair grafting from the occipital donor site, plug reduction, and recycling of 4-mm plug grafts. In
total, the patient underwent removal and recycling of approximately 252 four-mm previously grafted transplant “plugs” and 2000
follicular unit grafts over a 2-year period. The patient was also maintained on finasteride oral medication.

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 148 Aesthetic Surgery Journal 33(1)
enhance hair graft growth and survival through the use of
platelet-derived growth factors is an additional area for
research and development.106
Cloning
Initial enthusiasm for replication of a single hair into thou-
sands of hairs suitable for transplantation has been tem-
pered by the difficulties of culturing and replicating hair in
vivo. Even when this biological task has been minimally
accomplished, the effective number of viable hairs created
as well as the subsequent delivery techniques into tissue
has been disappointing thus far.
Incorporating HRS Into Plastic Surgery
Practice
A traditional aesthetic surgery practice that includes hair
restoration surgery enjoys excellent internal marketing
opportunities and patient crossover between the 2 prac-
tices. For this and other reasons, HRS often piques the
interest of plastic surgeons. However, lack of exposure to
HRS in plastic surgery residency training renders this field
difficult to fully incorporate into practice. The fact is that
HRS is a “subspecialty” in itself and does not exclusively
reside within the domain of any one of the specialties
endorsed by the American Board of Medical Specialties
(ABMS). The International Society of Hair Restoration
Surgery is the largest organization dedicated to education
and training in HRS. Six- and 12-month fellowships in HRS
as well as annual educational meetings and local surgical
workshops are offered through this organization. Although
not recognized by the ABMS, the American Board of Hair
Restoration Surgery does offer an excellent educational cur-
riculum leading to certification. This later curriculum is a
particularly good educational track for a board-certified
plastic surgeon to expand his or her knowledge base in this
field. However, establishing a practice setup, training hair
transplant technicians and front office staff, and develop-
ing a marketing program in this subspecialty require a
disciplined and multifaceted, long-range business plan.
Conclusions
Hair restoration surgery has developed into a highly sophis-
ticated subspecialty that offers significant relief to patients
with hair loss. This aspect of cosmetic surgery is a very
welcome addition to a traditional aesthetic practice and
serves as a tremendous source for patient satisfaction and
internal cross-referral. The results of contemporary hair
restoration are natural, enduring, and are performed with a
very high level of patient safety. This degree of refinement
has been established through an improved understanding
of hair biology and physiology as well as the incorporation
of standard microsurgical techniques. The combination of
graft size, site creation, packing density, and selected donor
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hair are the key elements the hair restoration surgeon uti-
lizes to artistically craft the transplant. The future of HRS
and the treatments for alopecia are centered on minimal-
incision surgery as well as cell-based therapies.
Disclosures
The authors declared no potential conflicts of interest with respect
to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
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