HAIR TRANSPLANT
CONSULTATION SINCE 2004

HAIR TRANSPLANT Facts and Information

Andreas Krämer Hair4life

ABOUT THE AUTHOR

ANDREAS KRÄMER

Hair loss sufferer, consultant since 2004, co-author of the book “Hair Transplantation Guidebook” by Alliance4Hair, founder of Propatient with lawyer Chr. Bomke, co-founder of the HTTC training center for doctors. Known from SWR, SAT 1, ZDF, Spiegel and many others.About Us

Fuller hair with an hair transplantation

Celebrities like Elon Mask, Wayne Ronney, Robbie Williams have already done it, as have many other women and men, a hair transplant for hair loss. Medication and hair loss remedies can slow down hair loss or, in the best case, even stop it, but to grow hair again on bald areas, this is only offered by a hair transplant.

However, transplantation is a special procedure and should only be carried out by specialists with sufficient know-how and experience. Please read the following information on how a transplantation works, for whom it is suitable and how the procedure is carried out.

Information on the basic principle: How does A transplantation work?

Hair transplant is the transplantation of “own hair” and, in other words, the surgical redistribution of “hair roots, which are insensitive to male hormones (DHT), to previously bald areas. Transplanted to these previously bald areas, this insensitivity to the harmful male hormones (dihydrotestosterone) remains – and this is the principle of the surgery – and the redistributed hair follicles continue to grow there for life. In principle, it is only a redistribution of one’s own hair (transplanting hair from other people is not possible!).

The Donor area for hair transplantation
Donor area

Typically, men who have male pattern baldness will still have a permanent band of hair surrounding the sides and the back of their head.

One often notices that bald people usually always keep a permanent rim of hair surrounding the sides and the back of their head. Due to predisposition (heredity) of the gene information and under the influence of male hormones, certain hair roots can be damaged so that the hair falls out (hereditary hair loss). Usually, “receding hairline” forms first, then the “hairline”, the “top of the head” and the “crown area” at the back of the head are also affected. These changes can also occur in women. Other hair roots (beard and body hair, hair crown) are insensitive to male hormone and therefore never fall out.

This knowledge is used by taking insensitive hair roots from the donor area and inserting them into bald areas. There they continue to grow normally for the rest of the patient’s life (see additional information) and produce healthy hair that can be washed, blow-dried, colored or permed as normal.

Donor area: Here the hair follicles are removed for the hair restoration surgery and transplanted into bald areas
Donor area/Rim of hair: Here the hair follicles are removed for the hair restoration surgery and transplanted into bald areas

Statistics: Why do hair loss sufferers underwent transplantation? What is the motivation?

Statistics: Why do Hair loss suffers underwent a hair transplant
Hair restoration surgery statistics: Source ISHRS 2020 Practice Census Results

For many men and women, this is one of the biggest concerns. We are talking about hair loss, which is obviously visible to the outside world and which is a no-go par excellence for many. What is the motivation of hair loss sufferers to underwent hair restoration surgery?

According to ISHRS1, 37% of all patients underwent surgery in 2019 to have a better chance of finding a partner and social dating in general. 34.7% of patients underwent a transplantation solely for professional and career reasons.

Definition

“Hair transplantation (hair restoration) is a redistribution of hair. Hair roots are transplanted from hormone-insensitive areas (donor area) to previously bald areas or between existing hair for hair thickening/filling. The aim is to redistribute the hair follicles so skilfully and aesthetically that the result is as maximum as possible and thus brings the maximum possible aesthetic improvement. The hair available for salvage, i.e. the harvesting area, is only available in limited quantities and must last a lifetime. For this reason, the responsible surgeon always plans for the necessary safety reserves so that further progressive hair loss can be corrected by further operations that may be required.


Statistics: Information on the number of hair surgeries performed worldwide

STATISTICS: INFORMATION ON THE NUMBER OF HAIR SURGERIES PERFORMED WORLDWIDE
Statistics: Source ISHRS 2020 Practice Census Results

According to ISHRS, approximately 735,312 hair transplants were performed worldwide in 2019 and 106,949 of these were performed in Europe!1


Statistics: What is the average age of patients who UNDERGOING TRANSPLANTATION?

Hair transplant Statistic: What is the average age of patients who undergoing hair restoration surgery
Statistics – Source ISHRS 2020 Practice Census Results

According to ISHRS1, the main patients for hair transplantation among your federation-affiliated physicians are 26-35 year olds at 45.2% and continue to be 36-45-year-olds at 42.2%. At the age of 46-60, only 8.6 % still opt for a transplant.

FACTS about the theory of donor dominance – How long does a transplant last? Important additional information about the permanence of the result and scientific basis

The concept of hair transplant is based on the theory of donor dominance in androgenetic hair loss. When a graft is taken from an area destined to bear hair permanently and transplanted into an area suffering from male pattern baldness, it will, after an initial period of effluvium on grow hair in its new place for the same length of time as would have been the case in its original place. This is the scientific basis of hair transplantation.2

It must be mentioned that the rim of hair can “thin out” with age and at a higher age, especially with a high degree of baldness such as NW 6. In such cases, the result of the hair transplantation also becomes “thinner” with age

By the way, it is suspected that the active ingredient finasteride (read about finasteride to stop hair loss and treat it with medication) could also be beneficial after a hair transplant and can stop or at least weaken this process.

For whom is a Surgery an option?

Hair transplant can be performed on women and men (women please read the women’s chapter).

However, it is PRINCIPALLY important that only hereditary hair loss is present and that the donor area is still in good condition!

In women, hair transplantation is possible if there is alopecia androgenetic hair loss (AGA) of the male type with receding hairline and of the female type with a middle parting light pattern according to Ludwig.3

If pathological hair loss is present, transplantation cannot be performed in the vast majority of cases. In the case of Alopecia Areata (circular hair loss), only if there are only small hairless areas and there has been no hair loss for at least 1 year after therapy4

If there are cases of Norwood 7 in the family (see Norwood scale), hair restoration should also not be considered, as in these cases often (there are exceptions, but rare) only a very limited area of donor hair is available, which does not allow aesthetically satisfactory thickening in the case of pronounced, extensive balding.

Statistics: What is the proportion of Hair Restoration Surgeries performed by women and men?

Statistics: source ISHRS 2020 Practice Census Results

According to ISHRS, of all hair surgery procedures performed in 2019, 84.2% men and 15.8% women performed a transplantation1

Information on the limited donor area, further hair loss and careful planning

However, there are only limited hair follicles available for “redistribution” in the donor area. Therefore, it is absolutely important to choose a trustworthy, reputable and experienced surgeon for hair transplantation. This surgeon will plan carefully and also include any interventions that may be necessary at a later date, in case the hair loss should progress in other areas and a further transplantation of the patient’s own hair should be required for follow-up care.


FACTS about the additional option of BHT: Transplantation of body hair with Follicular Unit Extraction in case of poor donor hair

As mentioned above, hair transplantation is normally not possible if there is not enough donor hair available. But thanks to the modern FUE (Follicular Unit Extraction) procedure, it is even possible today to transplant body hair, i.e. to take hair from the body as donor hair, from the back, from the chest, from the arms and legs as well as from the beard

Dr. Sanusi Umar from Los Angeles, USA informs in the article of Researchgate5 about his experience of the surgery on 122 patients and concludes that FUE with the use of body hair can be an effective option for a selected group of patients who have good hair on the body and who suffer from severe hair loss, large bald areas and do not have enough donor grafts in the normal donor area.

Methods and method comparison

Currently, there are two techniques of hair transplantation that have become the latest standard over the last few years. They differ mainly in the method of harvesting. See the table below for more information (the table scrolls left and right depending on your screen resolution)

Method comparisonFUT strip techniqueFUE hair transplantation
Harvesting the grafts/follicular unitsIn the FUT technique, the hair follicles are removed from the back of the head in a strip of skin and prepared for distribution under a microscope. By surgically removing a complete strip of skin, 2000 to 4000 grafts (or significantly more, depending on the elasticity of the scalp) can be harvested at once. The resulting wound at the back of the head is then surgically closedWith the FUE technique (single extraction) the hair roots are taken individually from the donor area, isolated into grafts with 1-4/5 hair follicles, and transplanted into the thinned out areas. Since hair roots are taken one by one, this method requires more time
Duration of the extractionDepending on the number of grafts, 30 minutes to 1 hourDepending on the number of grafts and depending on the clinic and whether they are harvested manually or with a micromotor, only a few hours or spread over several days
Maximum number of grafts in one sessionDepending on the elasticity of the scalp, the density of the hair and the size of the hairline, and also depending on the experience and size of the team of technicians, 4000-5000 grafts or even considerably more (but considerably less frequently)Depending on the size and density of the rim of hair, up to 4000 grafts or even more, but usually spread over 2-3 days by renowned hair surgeons
Suitable for whom?People with good scalp elasticity and people who like their hair to be over 1.2 – 1.5 cm long at the level of the scar in the hairline. Also for those who have a great need for donor hair and those who do not like to be shaved in the crown of the hairFor lovers of short haircuts who, for example, like to have their hair 1-3 mm short in the crown
AnaesthesiaLocal anaesthesia always where the work is being doneLocal anaesthesia always where the work is being done
ScarsAfter a strip surgery, a linear scar is created. The extent of the scar, the width and thickness of the scar depends on the number of grafts taken, the closure technique, the know-how and experience of the doctor, and the elasticity of the scalp, as well as the healing behaviour/scar tendency of the patient. If performed professionally and by experienced doctors and with good prerequisites of the patient, scars of only 1-3 mm can remain, which still allows for quite short haircuts.After an FUE, small, fine, round scars develop which, however, can hardly be seen by the human eye if the hair is expertly removed. The size and visibility of the scars are strongly dependent on the know-how and experience of the doctor, as well as the type and size of the removal instruments used. Are the grafts removed manually or with a micro motor? If the latter, with a micromotor from which manufacturer and with which punch sizes?
Risk/risks Donor area: Wider scar which makes it necessary to wear the hair in the band of hair long. Also the risk of prolonged tightness and numbness

Reception area: With both methods poor growth rate unnatural hairline, thick grafts, toilet brush effect, cobblestoning, and pitting
Donor area: Decimated hair crown and “overharvesting”, moth-eaten and football field appearance. As a result, this not only brings visual and aesthetic damage but also ruins the graft reserves in the donor area, with no options for the future.

Recipient area: Poor growth rate unnatural hairline, thick grafts, toilet brush effect, cobblestoning and pitting with both methods

When is sport possible again after hair restoration?After the surgery no sport should be done for at least 14 days and fitness training should ideally be avoided for 2-3 months. The risk increases so that the scar expands and a wider scar developsAfter an FUE, you can start doing some sports such as light jogging and cycling after only 10 days
Temporary ShocklossBoth methods! Applies to compaction (but can also occur in adjacent areas of 1-3 cm next to the grafted area):

When hair is transplanted into areas that are still hairy, the stress of the operation, the anesthetic, etc. can cause existing hair follicles to go dormant, which means that for 3-5 months after the transplant you may look slightly worse than before the operation. Temporary shock loss, however, is only “temporary” and after 3-5 months the situation will gradually improve, when the growth of new hair will also slowly start
Both methods! Applies to compaction (but can also occur in adjacent areas of 1-3 cm next to the transplanted area):

If the hair is still growing, the stress of the operation, the anesthesia, etc. can cause existing hair follicles to fall into a resting phase, which means that for 3-5 months after the transplant you may look somewhat worse than before the operation. Temporary shock loss, however, is only “temporary” and after 3-5 months the situation will gradually improve as the new hair slowly starts to grow.
Permanent ShocklossBoth methods! Applies in case of compaction (but can also occur in adjacent areas of 1-3 cm next to the transplanted area)

If the hair is still growing, the stress of the operation, the anesthesia, etc. can cause existing hair to fall into the resting phase, with the result that 1. for 3-5 months after the hair transplantation you look slightly worse than before the operation (as with temporary shock loss), but 2. in the case of permanent shock loss, the hair is so traumatized by the stress of the surgery, the anesthesia etc. that they are damaged forever. The risk is all the higher the thinner the existing hair has already become due to hereditary hair loss. Unfortunately, it is not possible to predict how sensitive hair that has already become thinner is and whether it will survive the operation or not.
Both methods! Applies to thickening (but can also occur in adjacent areas of 1-3 cm next to the transplanted area)

If hair is thickened in areas that still have hair, the stress of the operation, the anesthetic, etc. can cause existing hair to fall into a resting phase, which means that 1. for 3-5 months after the hair transplantation, one looks somewhat worse than before the surgery (as with temporary shock loss), but 2. in the case of permanent shock loss, however, the hair is so traumatized by the stress of the surgery, the anesthetic etc. that they are damaged forever. The risk is all the higher the thinner the existing hair has already become due to hereditary hair loss. Unfortunately, it is not possible to predict how sensitive hair that has already become thinner is and whether it will survive the operation or not.
Is shaving required for the transplant?No at the back of the head and no in the area to be transplanted. However, depending on the hair situation, a hair surgeon may recommend shaving in the reception areaThe back of the head: Usually yes and the area to be transplanted is usually yes too. However, there are now some hair surgeons who at least do without a shave in the recipient area and only shave in the hairline. In the hairline, either a strip shave or a GJ cut can be performed (depending on the number of grafts). In the meantime, there is also an FUE without any shaving, the Unshaven FUE variant without shaving in the receiving area plus no shaving in the harvesting area. However, this method is expensive and is only performed by very few hair surgeons
Social fitness after hair transplantationDepending on the shave, a 14-day leave of absence is generally recommendedDepending on the shave, a 14-day holiday is generally recommended. If there is still enough remaining hair and if this is not shortened and thus the cover for the resulting traces after the hair transplantation (redness/crusting) is possible, then possibly a social fitness of less than one week or is it even possible to go back to work one day after the operation without anyone being able to recognize a surgical intervention (for example, possibly possible when transplanting a smaller number of grafts into the receding hairline)
Hair transplantation: Comparison of methods

Statistics: How many patients choose the FUE technique and how many patients choose the FUT strip technique?

STATISTICS ABOUT THE HAIR TRANSPLANT METHOD: HOW MANY PATIENTS CHOOSE THE FUE TECHNIQUE AND HOW MANY PATIENTS CHOOSE THE FUT STRIP TECHNIQUE?
Statistics: Source ISHRS 2020 Practice Census Results

According to ISHRS, of all hair transplants performed in 2019, a total of 66% of patients opted for transplantation using the FUE technique and 29.8% of patients opted for a FUT strip technique1


How much does hair restoration surgery cost?

How much does a hair transplant cost, NW Table: Assessment of the hair situation before hair restoration surgery
NW Table: Assessment of the hair situation before hair restoration surgery

For all those interested, it is important to know what one has to spend financially for such a special surgical procedure as a hair transplant. What a hair transplantation costs is always strongly dependent on the respective situation. Which status according to the NW table has one already achieved and which status would one like to achieve with the hair transplantation? How much area has to be planted therefore strongly determines how many grafts are needed for the hair restoration.

For large bald areas such as NW 6, 7000-8000 grafts can be needed quickly and the cost of hair transplantation can range from 14,000 – 40,000 Euros depending on the doctor. For small areas such as only receding hairline like NW 2, only 1000 – 1500 grafts may be needed and the eventual cost of hair transplantation is only 2000 – 5000 or 3000 – 7,500 Euros.

Read more details about hair transplant prices here.

Hair transplantation and other frequently asked questions and answers

When will the transplanted hair/grafts start to grow: Time curve after hair transplantation
Time curve after hair transplantation: Start of growth of the inserted hair follicles

The importance of follicular units for hairlines

Info on the natural bundling of hair = follicular units and its importance in hair transplantation

Follicular Units: The importance of follicular units for hair restoration
Follicular Units: The importance of follicular units

Over the years it has been discovered that hair does not grow individually but in natural bundles, the follicular units (FU’s). These follicular units usually contain between 1 – 4 hair follicles.

Follicular Units: Modern hair transplant techniques use only follicular units
Follicular Units: Modern hair transplant techniques use only follicular units

If you take a closer look at natural hairlines with a microscope, you will notice that there is a very high proportion of follicular units (FU’s) with 1 hair follicle.

This is one of the reasons why earlier hairlines often looked unnatural after a hair transplant, because, for example, with mini/micro-grafts, sometimes up to 7 hair follicles were transplanted in one graft

In modern hair restoration, however, only follicular units are transplanted, which, as mentioned above, usually contain 1 – 4 hair follicles. In the hairline, 1 follicular unit (follicular unit with 1 hair follicle) is preferred and in areas behind this, 2, 3, and 4 follicular units are also transplanted.


Survey among ISHRS surgeons – Which celebrity/star/actor has the best hair situation: Brad Pitt, Chris Hemsworth, Rai Malek, or Gerhard Butler?

Statistic: Which Celebrity has the best hair situation
Statistics: Source ISHRS 2020 Practice Census Results

Among ISHRS doctors, 53.9% thought Brad Pitt had the best hair situation, followed by Chris Hemsworth at 30.3%, and trailing behind were Gerard Butler and Rami Malek1


FACTS regarding a hairline as natural as possible through a hair transplant: No multiple follicular units (multis) in the front line

However, since follicular units (FU’s) can also contain multiple hair follicles, care should be taken to avoid inserting units (FU’s) with multiple hair into the hairline, even with a hair transplant using the FUE and FUT methods. In this case, the insertion of follicular units would also lead to unattractive results in a hair transplantation of a hairline.

Likewise, the hair surgeon should pay attention to the correct direction of growth during hair transplant and front grafts should not be placed in “rows and rows” (straight), but in accordance with nature in alternating, irregular densities or arrangements.

Example 1: Conservative approach, low density

Successful and natural result of a transplantation Example 1 - from the front
Successful and natural result of a transplantation Example 1 – from the front
Successful and natural result of a hair restoration Example 1 - from the left
Successful and natural result of a hair restoration Example 1 – from the left
Exclusively single hair grafts in the front row: Example of a successful hair transplantation with a natural result - Example 1 close up
Exclusively single hair grafts in the front row: Example of a successful hair transplantation with a natural result – Example 1 close up

Example 2: Aggressive APPROACH, higher density (Dense Packing)

Example 2 of a successful natural hairline with "Dense Packing" trough hair transplantation - from the front
Example 2 of a successful natural hairline with “Dense Packing” – from the front

Facts about “Dense Packing”: If the grafts are transplanted very densely on a square cm area, this is called Dense Packing. Read here more about Dense Packing.

Example 3 of a natural and successful restoration result: Thickening and filling of the receding FRONT

Example 4 of an unnatural RESULT IN THE FRONT with thick multigrafts and wrong growth direction, with subsequent repair/repair

Example 3: Unsuccessful example of hair transplantation shown in the picture above, with wrong growth direction and thick grafts (multiple hair grafts) and below the result after correction
Example 3: Unsuccessful example of hair transplantation shown in the picture above, with wrong growth direction and thick grafts (multiple hair grafts) and below the result after correction

Hair Restoration Surgery and the expectations of the result: Thin and straight hair achieve less visual effect than thick curly hair

In the collaborative article “Hair Restoration Surgery: The State of the Art”7 by Dr. Francisco Jimenez, Dr. John Cole, Dr. Sharon Ann Keene, Dr. James A Harris, Dr. Alfonso Barrera, and Dr. Paul T Rose, it is stated about the expectations of the result that it cannot be stressed enough to the patient that it is the donor’s own characteristics that determine the visual fullness of the result. For example, patients with a thick hair shaft (>80 microns) are better candidates for an autologous hair transplant than those with thin hair (<60 microns). Even when such characteristics have high transplanted densities per sq cm (>40 FU/cm2), individuals with fine, straight hair often have a more “translucent” result compared to those with thick and curly hair which may even have been transplanted at a lower density. In addition, patients with low follicular density (1-2 FU) will have a sparser result with an autologous hair transplant than patients with higher follicular density (3-5 FU).

FOLLICULAR DENSITY HAS AN IMPACT ON THE RESULT THAT IS SIGNIFICANT! THE SAME NUMBER OF GRAFTS DOES NOT CORRESPOND TO THE SAME NUMBER OF TRANSPLANTED HAIR, WITH EXAMPLE

As described above, modern hair transplantation techniques involve the transplantation of so-called follicular units. A follicular unit consists of 1 – 4 hair follicles. In the article “Hair Restoration Surgery: The State of the Art“7 it is described again that the follicular density has a great influence on the result. We would like to illustrate this briefly with an example (the table can be scrolled to the left and right depending on the screen resolution):

Hair transplant in patient AHair transplant in patient B
Transplanted number of grafts/FU’s 3500Transplanted number of grafts/FU’s 3500
Follicle density per FU = 1.5 hair folliclesFollicle density per FUE = 2.5 hair follicles
Total number of follicles transplanted = 5250Total number of follicles transplanted = 8750
Comparison of the total number of hair transplanted in a hair transplant in patient A with patient B with the same number of grafts

Patient A receives a total of 3500 fewer hair than Patient B, which ultimately affects the visual result of the hair transplant!

Before and after examples

Some more before and after examples of successful hair transplant can be found on our Instagram channel and also on the before and after pictures subpage.


Sources/References/Author

1 ISHRS Practice Census Results Published 2020
2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2825128/
3 https://www.haarerkrankungen.de/therapie/alopeciaandrogenetica_w_lichtungsmuster.htm
4 https://www.haarerkrankungen.de/therapie/haartransplantation_indikationen.htm
5 https://www.researchgate.net/publication/303690534_Body_Hair_Transplant_by_Follicular_Unit_Extraction_My_Experience_With_122_Patients
6https://www.researchgate.net/publication/233738772_Hair_Restoration_Surgery_The_State_of_the_Art

Author:
Andreas Krämer and Hairforlife expert editorial team