Toppik on 15 December 2014

Of all the procedures or treatments a person could consider to correct or compensate for their hair loss, the surgical alternative carries with it the most risk. In my opinion, hair restoration is one of the most demanding of all the cosmetic procedures available today. The specialist skill and artistry are learnt over many years of trial and error, and cannot be practised part time.

Some years ago I made the decision to practise hair transplant surgery full time and it is a decision I have never regretted. I do not believe the results I am achieving today would be possible if I had been juggling my time between hair transplantation and other cosmetic procedures.

There are two important factors in a technically successful hair transplant procedure:

Technical Competence: The doctor performing the procedure must have an intimate knowledge of the best procedures for natural looking hair with, at the very least, a very high growth rate. He or she will also require the latest equipment and staff, with up-to-date training.

Artistic Considerations: A surgeon must have a good aesthetic eye in order to design a procedure that suits the individual’s current and future age, current and future hair loss, facial structure, hair colour and type, and so on.

With these two factors taken into consideration, a doctor can produce a technically successful procedure. But ultimately the doctor is not the judge of the success or failure of a procedure. The doctor didn’t pay for it, nor did they endure an operation for it, nor do they have to wear it for the rest of their life. The patient is the final judge of the success of the procedure.

A Successful Procedure Always Begins at the Consultation Stage

I could be the best hair transplant surgeon in the world and consistently produce the best results in the world. Yet every procedure I perform could be a failure in the eyes of my patients if I gave them unreasonable expectations of what is achievable.

The consultation is an opportunity for the patient to find out about the doctor and the procedure, but just as importantly it is an opportunity for the doctor to assess the patient’s expectations and decide whether those expectations are realistic. There is quite clearly a right and a wrong time to adjust a client’s expectations of what is realistic and achievable. The right time is prior to the client committing himself to the procedure. Quite clearly then, the wrong time is any time after this commitment has been made, particularly after the procedure has been performed.

If during your consultation you are not asked enough questions to accurately gauge your expectations, you will most likely be dissatisfied with the results. How can any doctor fulfil your expectations if he or she does not first find out what they are?

My advice to you is the same as it is to those people that come to my clinic for a consultation. As a potential client, you should look around and review the various options available to you. If you decide a hair transplant is the method best suited to your lifestyle and expected outcomes, you should see a number of doctors who offer this service. Listen to their methods and weigh up the pros and cons of the surgical plans and advice offered to you. When it comes time to make your decision, you will do so armed with all the facts, and you will have given yourself the very best chance of achieving the aims you set out to achieve.

The answer to who should perform your procedure will be found when you can confidently answer the following question:

Which doctor or clinic understands what I am trying to achieve, and has a method or procedure that can achieve it?

The History of the Hair Transplant

Dr Okuda, a Japanese dermatologist, performed the first recorded attempts of hair transplantation on humans. In 1939 he reported in Japanese dermatological journals his results from treating various burns victims by transplanting plugs of hair from the permanent hair zone into burnt scar tissue on top of the scalp, eyebrow and moustache regions.

Dr Okuda never mentioned treating male or female pattern hair loss and it is unlikely that he realised the potential of his work. His reports never made it outside Japan and he was killed during WWII.

Dr Norman Orentreich of New York, completely unaware of Dr Okuda’s previous work, described a similar procedure he had performed in 1959. Dr Orentreich is considered to be the father of the modern hair transplant because he realised the application of the procedure in the treatment of baldness, and also because he recognised the importance of donor dominance.

Donor Dominance

The success of any hair transplant procedure is dependent upon the incidence of donor dominance. Simply stated, this is the phenomenon whereby hair-bearing skin taken from the permanent zone at the back and sides of the scalp and transferred to the balding areas at the front, top and crown will retain its original programming (or resistance to the effects of the male hormone) and will grow hair and continue to grow hair for as long as it would have in its original position.

Since those early days in New York, the science and art of hair transplantation has evolved to become the most commonly performed procedure on men in Australia today. To fully explain the advancements that have been made, it is necessary to look back at how the procedures were performed.

Different Graft Sizes

Previously, grafts were classified as plug grafts, mini grafts and micro grafts. Each graft was an improvement on its predecessor, but none could actually mimic nature and regrettably all three are still used by some doctors today.

Plug grafts are those large plugs of hair that produce objectionable results – many potential patients refer to them as the ‘doll’s hair’ look. The grafts themselves are approximately 3-4mm in diameter and contain 15-20 hairs. Due to the relatively large size of the grafts, a hole needs to be cored out of the recipient area to place the graft into. These recipient holes remove valuable blood supply to the scalp. Due to these blood flow considerations, a maximum of 100 grafts could be performed in one sitting. More importantly, the plugs had to be placed 3-4mm apart, compounding the unnaturalness of the appearance, particularly in the front hairline.

Mini grafts were the next progression, containing from four to eight hairs. They have a diameter of between 1.5 and 2.5mm. They also require a recipient hole to be inserted and result in similar problems to the punch graft, albeit to a lesser degree.

Micro grafts were a significant step forward, containing one to four hairs and ranged in size from 1 to 1.5mm in diameter. Whilst they have a size that allows for a natural looking appearance, they also have a very low growth rate.

The inherent flaw in micro grafts is that the natural grouping of follicles is ignored and split up, damaging vital anatomic structures. This results in a growth rate of around 50 per cent or less of the hair that was originally taken from the donor. This invariably results in a sparse final result and a waste of the precious resources from the donor area.

Scalp Reductions

Scalp reductions were developed in the late 1970s as an adjunct to hair transplantation. They involve removing the section of scalp suffering from hair loss and utilising the available stretch in the skin to pull the thicker hair from the sides up to the top of the scalp.

The original scalp reductions involved removing a section of skin with an elliptical shape similar to that of an Aussie Rules football. This would result in a central scar running from the forehead to the crown. Various other shapes have been devised in the hope of producing a less noticeable scar. Problems with this procedure are as follows:

Unnatural Hair Direction: This procedure can result in the patient having a central scar through the top of the head and the hair growing out of it on either side at right angles.

Accelerated Hair Loss: Trauma to the scalp can result in post-operative hair loss in the joining site.

Stretchback: Due to the tension on the scalp, it is not uncommon for the central scar to widen, in some cases by 2-3cm.

Difficulty Correcting: Subsequent thinning of the donor area may make such procedures difficult to correct with the latest follicular unit grafting. The donor area will have a lower yield because of the reduced elasticity of the skin.

The author of The Bald Truth, Spencer David Kobren, sums up the opinion of most patients who have had a scalp reduction: scalp reductions are barbaric and disfiguring. The bald part of the crown is literally cut away and the edges are sewn together, bringing the hair-bearing scalp from either side to meet in the middle.

In some cases, a hideous scar results that makes the top of your head look like your buttocks. The scalp reduction scar is sitting in the middle of an area in which scalp is often seen, resembling the ‘crack’ between the two cheeks you sit on.


This procedure is about shifting large slabs of hair-bearing skin in one piece. It involves removing a section of bald scalp, generally in the front hairline region. A section of hair-bearing scalp, generally from the side just above the ear, is then cut away on three sides in a corresponding shape. The remaining side of the flap is left attached to nourish it. The flap is then rotated into position on the front hairline of the scalp. The donor site is then sutured together, with the attached section forming a lumpy ‘knot.’ Small grafts can then be placed into the scar tissue in the front hairline in an attempt to make it look natural.

This procedure has a number of potential problems:

Necrosis of the flap because the flap is relying to a large extent on the relatively small connected corner of tissue for ongoing nourishment in the early stages of healing. If this fails to adequately supply the flap with nutrients, it will die in whole or in part, leaving the patient horribly disfigured.

A Heavy brow: An excess of skin can result in the patient having Neanderthal eyebrows protruding from the scalp.

Unnatural hair direction: Generally a flap will result in the patient having hair growing back at an angle of 45 degrees.

Scarring: A linear scar running the full length of the front of the hairline. However, this can generally be disguised by using smaller grafts placed in front of the flap.


Hair transplantation provides a lasting solution to hair loss because of the incidence of ‘donor dominance.’

The consultation is a critical time for the patient and the doctor to assess the client’s expectations of the procedure and to determine the likelihood of achieving these expectations. To reiterate, ‘a successful procedure always begins at the consultation stage.’

Over the last thirty years progressively smaller grafts have been used in hair transplantation, each with their own inherent problems.

Scalp reductions and flaps are outmoded technology and have no place in the 21st century. The natural results achievable with follicular unit grafting have further highlighted the limitations of these ‘older style’ procedures.