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Procedure: Hair Restoration

Author: Lisa Ishii, MD FACS

Learn about hair transplants and laser hair restoration for the treatment of alopecia (hair loss) in men and women.

Hair Restoration

Hair Restoration

The appearance of our hair has a dramatic impact on the image we project to the world.  Though the social norms for hair differ for men and women, and between individuals who are young and old, its presence makes a statement about us.  Women and men alike invest significant amounts of time and money on hair care products, hair treatments, hair styling, and more recently even hair extensions and hair transplantation to optimize the appearance of their hair.  It is therefore not surprising that hair loss can be a devastating problem.

The medical term for hair loss is alopecia.  Hair loss is common in the general population, and affects almost equal numbers of men and women.  There are many different causes of hair loss, though the most common cause in men and women is pattern hair loss, also known as androgenetic alopecia.


Hair Loss in Men

The vast majority of hair loss in men is a result of male pattern hair loss.  Though it may have its onset in men in their teenage years, it is thought to affect approximately 20 % of men in their 20s.  Thereafter, the number of affected men increases 10 % by decade, with 30 % of men in their 30s affected, 40% in their 40’s affected, etc.  In general, the earlier the onset the worse the amount of hair loss.

Male pattern hair loss is understood fairly well.  It occurs in men who have inherited genes for hair loss.  The genes may come from the mother’s or father’s side of the family. Testosterone also plays a role, and that is why the medical term is androgenetic alopecia. Both factors, the genes and the testosterone product, have to be present for male pattern hair loss to occur.

The term “pattern hair loss” refers to the fact that the hair loss occurs in a typical pattern in men.  It usually starts with the temple portion of the hairline receding, followed by backward movement of the frontal hairline.  The hair on the top portion of the scalp, or crown, may also begin thinning around the same time.  The hair loss stages have been described by Norwood and consist of 7 different grades, with grades 1 and 2 actually representing normal hair.


Hair Loss in Women

While the majority of hair loss in women is also a result of female pattern hair loss, women are considerably more likely than men to suffer hair loss from other causes.  It is now thought that hair loss affects essentially the same number of women as men, though we have less data on the exact incidence.  It is thought that there are two main peaks of onset, the 20’s to 30’s and the 50’s to 60’s.  Unlike the pattern in men, the most common pattern of loss in women begins with diffuse thinning of the hair on the top of the scalp that gradually spreads to involve a larger area of increasingly thin hair.  Ludwig’s classification of hair loss in women describes 3 grades of loss, with grade one being the least severe.  Women usually maintain their frontal hairline but may experience widening of their hair part in a characteristic “Christmas tree” pattern.

We still do not understand exactly what causes female pattern hair loss.  Though some experts think the process is androgenetic alopecia, similar to the process that occurs in men, this has not been clearly shown.  Women have less circulating testosterone and do not respond to some of the anti-testosterone medicines as well as men. 

Other causes of hair loss to be considered in women include an underactive thyroid gland, low iron levels, and medical conditions that result in higher levels of testosterone, such as polycystic ovary syndrome (PCOS).  Women also lose hair after exposure to common medications, such as Coumadin (a blood thinner), ranitidine (Zantac), allopurinol (a gout medicine), or blood pressure medications.  Unless the history and clinical exam are absolutely consistent with female pattern hair loss most physicians will check thyroid hormone levels and iron levels to be sure those factors are not low.  If there are concerns for an excess testosterone state, such as irregular periods, problems with getting pregnant or facial hair growth, a more extensive workup may be performed.  Scalp biopsies are also useful in some situations to make a diagnosis.


Medical Treatment

The only FDA-approved medicine for pattern hair loss in women and men is minoxidil.  Finasteride is FDA approved for the treatment of pattern hair loss in men only.  Both medicines have been proven in large, well-designed studies to slow the progression of pattern hair loss.  

Minoxidil comes as a lotion or a foam and is commonly sold under the brand name Rogaine®.  It comes in 2 % strength and 5% strength.  The 2% strength is FDA approved for women, while both strengths are approved for men.  It is applied to the affected areas of the dry scalp on a twice daily basis.  Some patients experience mild itching and flaking of the skin.

Finasteride, a pill available only with a doctor’s prescription, is sold under the brand name Propecia®.  As noted above it is FDA approved only for men. It acts on the hormone that causes hair loss in men.

Spironolactone is another medication that has been given to women to treat hair loss for over 30 years though it is not FDA-approved for this.  It is a diuretic (“water pill”) that was originally used to treat patients for high blood pressure.  It was noted that women who took it experienced less hair shedding while they were taking it. It has few side effects and many women currently take it for hair loss, though it is not safe in pregnancy.


Laser Treatment

Low-level laser therapy has been described as a treatment for pattern hair loss.  Currently the data on its effectiveness for this is limited, with most studies showing very minimal change in hair loss or hair regrowth.  It may be effective for promoting healing in the early post-operative phase after hair transplantation. 


Hair Transplantation

Hair transplantation is currently the only treatment shown to effectively restore hair density.  It is performed for men and women with pattern hair loss, the hair loss that results from trauma and some medical types of hair loss.  First described in the 1950’s, the procedure has undergone extensive refinement over the years with modern day techniques established in the 1990’s.  Candidates for hair transplantation are men and women older than age 25.  The point at which a patient is no longer a candidate for the procedure depends on whether the patient no longer has enough “donor” hair on the back of the scalp to move to the thinning areas.  Theoretically there is no upper age limit.


If you examine normal scalp hair using magnification, you see randomly distributed bundles or groupings consisting of 1-4 hairs. Such bundles are called follicular units, again typically containing 1-4 hairs. The current standard of care for the hair transplantation procedure consists of creating grafts of individual follicular units. Natural looking results are achieved by transferring these follicular units to result in a normal appearing growth pattern.  This is as opposed to the larger “plugs” of the past, where large grafts of several hairs were moved from one area to another.  Current procedures may consist of the transfer of hundreds or thousands of these follicular units from the area on the back of the scalp, called the “donor” area, to the area where the hair is thinning.  Hair that is taken from the donor site and transplanted to the thinning site does not undergo pattern hair loss.


In the standard technique a strip of scalp is removed from the back of the scalp where there is typically plenty of remaining hair.  The area from which the skin is taken is sewn together again so that ultimately there is only a fine scar in that area.  There is no appreciable hair loss noticed from that location.  The strip of scalp is then prepared by technicians who use a microscope to cut out each follicular unit from the strip.  The size of the strip and the number of grafts depends on the size of the area that needs to be filled in. Generally the strip is 15 to 20 cm long and 1 cm wide. 


While the technicians are cutting the donor strip, the surgeon is typically making the small holes (recipient sites) where the grafts will be placed.  The recipient sites are usually made with either a fine needle or a special instrument designed to create the small holes.  The recipient sites are placed in the location where an increased density of hair is desired (the frontal hairline, crown, mid scalp e.g.) 


The grafts are then carefully placed into the recipient sites using a very fine instrument.  They fit snugly into the holes so no stitches are needed to hold them in place.  Patients keep their scalp dry for 24 hours and then begin washing gently on a daily basis thereafter.


The procedure typically takes place in a special procedure room designed by the surgeon for hair transplantation.  Many patients take an oral pain medication or an oral medication for relaxation, such as Valium, prior to the start of the procedure.  The back of the scalp and recipient area are made numb with local anesthesia to minimize pain.  Many patients take additional oral pain medication during the procedure. 


The length of the procedure depends on the number of grafts being transferred, but on average ranges from 4 to 6 hours.  Some patients develop swelling of their forehead after the surgery, particularly if grafts were placed in the frontal hairline.  Many patients plan on taking anywhere from a few days to a week or 10 days off from work or while they are healing.  The new hair sites typically have small scabs that fall off in a week or so.  The small scabs are relatively well hidden when there is surrounding hair to cover them.  Many patients find they need an oral pain medication for a few days after the procedure to ease the pain in the donor site area.


Patients typically notice hair growth in 3 to 4 months.  The transplanted hairs enter a resting phase after first being transplanted.  The new hairs begin to appear once the hairs cycle back into a growth phase.  The general expectation is that the vast majority, 95% or greater, of the bundles will grow hair in the new location.


The procedure has very few risks.  The scalp has such rich blood flow that infection is very unusual.  The resulting scar on the back of the scalp is typically well hidden by the remaining hair in the area. The scars in the area where the hair grafts are placed are typically not noticeable at all.  The one exception is for patients who may want to shave their head in the future.  Patients who decide to shave their head in the future may be bothered by the fact that their scar is no longer hidden by existing hair.



Men and women alike experience hair loss.  The most common cause of hair loss in men and women is pattern hair loss, though in some cases other causes should be considered.  While there are a few medicines that work to slow down hair loss, the only way to make thin areas have more hair is with hair transplantation.  Modern hair transplantation leads to natural-looking results that restore confidence and satisfaction for patients suffering from hair loss. 



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