Toppik on 16 December 2014

It’s easy to define a bad hair transplant:

If it’s obvious it’s a hair transplant, then it’s quite obviously a bad hair transplant.

We have all seen the tell-tale signs: the plugs of hair interspersed with big gaps of naked skin, hairlines so straight and uniform they look like a pleat on a military general’s pair of pants – not examples that anyone concerned about their appearance would be rushing out to emulate.

The Breakthrough

For years I looked for a hair transplant procedure that would provide me with results I could be absolutely proud of.

Patients seemed generally pleased with the results of the past. They knew the limitations of the larger plugs. They knew that hairlines had their limitations. They knew that at times their result would appear like a hair transplant. While to them the results were better than being bald, I wanted something better to offer them.

The breakthrough I had been looking for was presented to me at the annual International Society of Hair Restoration Surgery meeting in October 1994. An American hair transplant surgeon, Dr Bill Rassman, presented three patients who had undergone follicular unit grafting. He invited every doctor in the auditorium up onto the stage to view first-hand the results achievable with this new method he had devised.

I was amazed. The results were unbelievable, the best I had ever seen – hairlines that naturally recreated a gradual transition from forehead to hair-bearing skin. A midscalp without the large gaps between plugs. The wind could blow it all over the place and you would never know. You could climb straight out of the pool and be confident it looked natural.

This was what I had been looking for ever since I started performing hair transplants. Following the conference I was fortunate enough to be approached by two technicians who worked with Dr Rassman. They offered to come to my rooms and show me the technique that had been developed.

In December 1994 I switched over totally to follicular unit grafts. At that stage they were being cut without the aid of magnification. The danger with this method was that if the grafts were trimmed down too much, the vital sebaceous glands and other tissues that are an integral part of the graft could not be removed, effectively destroying the graft and resulting in low growth rates.

I have a good relationship with Dr David Seager in Toronto and knew that he was interested in this particular technique. He persuaded me to go to Canada and learn how to cut the grafts with the aid of a microscope. The benefit of the microscope is, of course, that you can see all the appendages of the follicular unit group and leave them intact. Ultimately, for the prospective patient this means they can be assured of very high growth rate – in excess of 95% in nearly all cases.

In 1998 I went back to Dr Seager and he performed a procedure on me in which 1,900 grafts were placed in my frontal area. Over the next few months this produced very good growth. It looks totally natural and requires no special maintenance other than washing, combing and cutting. Anyone who has a transplant will only need to have it cut by their normal hairdresser and can use any shampoo and conditioner.

This was what I had been searching for:

  • Natural-looking and growing hair that requires no special maintenance
  • The transfer of a large amount of hair in one procedure
  • Consistently high growth rates, in excess of 95%

The methods of hair transplantation that you will read about below have not been developed by me, but are the culmination of many years of work by a number of surgeons who have dedicated their practices to the field of hair transplantation.

Follicular Unit Grafting (FUG)

The Best Hair Transplant is the One You Never See

A normal head of hair is composed of a mass of hairs growing in follicular units, naturally occurring in groups of one, two, three and occasionally four hairs. These units are randomly but closely spaced and ultimately form what we know to be a natural-looking head of hair. The best hair transplant, then, the one that you never see, would mimic ‘nature’s way.’

This is the principle behind follicular unit grafting. Clusters of one, two, three and four-haired grafts occur naturally all over the scalp. After male pattern baldness sets in they are still growing this way from the donor area at the back of the scalp. With the benefit of hindsight it is now easy to see that, if that is the way they were growing and they obviously looked natural prior to any hair loss, the most natural appearance would be achieved by putting them back that way.

In the past, surgeons unaware of their existence or relevance ignored these follicular unit groups. Micro grafts quite often contained the same number of hairs as the follicular unit graft, but they were dissected with the naked eye. This dissection resulted in transection of the follicular unit, which damaged vital structures crucial to graft survival. As a result, growth rates of around 50% for micro grafts or follicular units cut without the aid of magnifications were not uncommon.

The introduction of the binocular stereoscopic dissecting microscope has made it possible for surgeons to see these follicular units and dissect them intact by sculpting around the glands and muscles and removing the excess skin. There are three distinct advantages from using the microscope:

We can see the follicles. The microscope allows us to see and sculpt around the hair follicles instead of cutting straight through them. Using the older, unmagnified methods, a large percentage of hairs were transected and as a result were generally discarded. This fact alone allows us to yield approximately 20% more grafts from the same sized donor area.

We can cut them better. Every growing hair on our heads is supported by sebaceous glands and dermal tissue. These appendages are a vital part of the hair factory, and if they are cut during the dissecting process their chances of survival can in some cases be halved. The microscope allows us to identify these structures and sculpt around them, leaving them intact. They are impossible to see accurately without the microscope. In addition, not only do we get more grafts, we also dramatically improve the growth rate of the grafts we have cut – by a further 20%.

We can preserve hair follicles invisible to the naked eye. At any point in time, approximately 10% to 15% of follicles are dormant in the Telogen phase, or their hair has failed to reach the surface of the skin. However, they are still viable and should not be discarded, but implanted as part of the transplant process. These follicles are invisible to the naked eye but with the microscope we can identify a good portion of them and potentially increase the yield by a further 5%.

The net effect of all these benefits can be shown in a comparison between micro grafts and follicular unit grafts. If an average micro graft procedure were ultimately to yield 2,000 growing hairs, an equivalent follicular unit graft would yield almost 2,300 growing hairs.

Standard micro graft procedure 2000

Plus hairs in Telogen phase (+5%) 200 2,200

Plus improved growth rate hairs (+20%) 440 2,640

Plus all available follicle hairs (20%) 528 3,168

As can be seen from the comparison, the cumulative effect of FUG using microscopic dissection over a standard micro graft procedure is a very big difference. You must also take into account those extra 1,168 hairs removed from the donor hair, which would have been lost as wastage in the older-style procedure.

Single Hair Grafting

Occasionally, I am asked by prospective patients whether I offer all-single hair grafting. It is pertinent to discuss this while we are on the subject of graft cutting.

The hair on your head doesn’t generally grow singly anywhere except on the front hairline. As such, there is no requirement to replace it singly anywhere except on the front hairline. When performing a FUG procedure, we will generally yield about 20% to 25% single hair reconstruction of the hairline, along with some of the two-haired grafts. The balance of two, three and four-haired grafts are used behind the hairline for a thicker appearance. This is all that is required for a natural result. To go through and break up follicular units into single hair grafts for placements anywhere other than the hairline would be tantamount to vandalism. The destruction of active, growing hair follicles would generally result in growth rates lower than 50%.

An all single hair grafting procedure is more labour intensive, more expensive, has lower growth rates, has lower density and does not mimic the way nature naturally grows hair.

Dense Packing

Dense packing is usually performed in conjunction with the mega-session (a single procedure resulting in the transfer of 1,500 to 3,500+ follicular unit grafts) and is used to plant grafts in extremely close proximity to one another. This is possible because the FUG method does not require the extraction of skin when making the recipient hole. Because of the very small nature of follicular unit grafts, grafts can be inserted into holes made with only a hypodermic needle, allowing us to leave intact the delicate blood supply to the scalp.

The dense packing method has required a slight change in procedure. When procedures were performed in the past, generally the doctor would go through and make up to 1,000 incisions for the grafts to then be placed by the technicians. The problem was that by the time the technicians got around to the job some hours later, the holes had all but healed up. This then required the use of a larger needle so that the hole was still sufficiently open to accept the graft when the technician got around to placing it. This was obviously more invasive to the scalp.

The ‘stick and plant’ technique involves the technician making the hole under the direction of the doctor and then inserting the graft immediately. Then a second hole is created and the graft is inserted into that, and so on. This allows for the use of a far smaller hypodermic needle, because the skin is not allowed to partially heal prior to the insertion of the graft. A smaller needle allows the grafts to be placed closer together and is far less invasive to the scalp.

This minor change allows us to implant nearly twice the number of grafts per square centimetre, ultimately creating a high density in a small area when required.

The Front Hairline

Without doubt the most critical aspect of any hair restoration surgery is the construction of a natural-looking front hairline. In the past, front hairlines with a symmetrical bell shape and plugs stretching across with an absolutely perfect and uniform spacing throughout were quite a common sight. When people talk about ‘doll’s hair’ and ‘rows of corn’ this image is invariably the one they are talking about.

As a general rule, when people build things they look for symmetry or order in the design. Hairlines created using this same philosophy resulted in the problems mentioned above. Nature, when it creates a hairline, is erratic and random, lacking symmetry close up but when seen from a distance appearing to have perfect symmetry. The challenge was how to create this irregular zone that appears so natural.

The most natural hairlines have a soft transition from the forehead through sparse fine hairs to the thicker, denser hairs approximately 1-1.5cm behind the front hairline.

With the development of the follicular unit graft we have also developed ways to implant the grafts in a shape, pattern, angulation, direction and density that is indicative of a completely natural hairline.

Shape refers to the overall curvature of the hairline, taking current and future hair loss and ageing into consideration.

Pattern refers to the distribution or final position of 1, 2 and 3 hair grafts.

Density refers to the number of grafts placed per square centimetre required to achieve a natural outcome. For example, a lower density is generally required in the temple region than is required right at the front of the hairline.

Angulation refers to the angle of implantation of the grafts in relation to the scalp. Commonly at the front hairline the angle of implantation is around 25% to 30% from the scalp, generally rising to 60% as we move towards the crown.

Direction refers to the direction of the implanted hair graft and whether it will point to the left or the right. Such a decision is based upon the way the individual has styled his hair in the past and how he intends to style it in the future.

The first 1.5-2cm of the hairline is constructed out of three distinct zones of varying densities and graft sizes. The use of these distinct zones allows us to produce natural results that defy detection as a transplanted hairline.

Your consulting doctor will, with your input, design a hairline for you that takes into account variables such as age, current and future hair loss, facial features, skin colour and hair type and colour.

Some doctors will design the hairline for you at the consultation stage, while others will do it prior to the procedure at the meeting before surgery commences. Either way is okay. Just ensure that you are happy with it prior to surgery commencing.


The basic facts about hair transplants:

  • A hair transplant involves taking hair-bearing skin from the back and sides of the scalp where it is plentiful and resistant to the effects of the male hormone. This hair-bearing skin is then implanted into areas at the front top and crown.
  • What has been moved is the follicle that grows the hair, so afterwards you will have a growing, regenerating result.
  • It is only possible to move around what you have left – it is not possible to transplant hair from other individuals.
  • Generally a section is removed from the back of the scalp in one piece and is then dissected into individual groups containing a number of hairs. These transferable groups are called grafts.
  • Transplanted hair will continue to grow in its new area for as long as it would have in the area it was taken from. If it was correctly taken from the rim of ‘lifetime’ hair at the back and sides of the scalp, it will last a lifetime.
  • Remaining original hair around the transplanted area will generally continue to recede and further procedures may be required at a later date. This is especially true for younger patients.

Variations in the result achieved occur because of:

  • 1. The size of the area to fill. Obviously a larger area will require more grafts to achieve the same density as a smaller area.
  • 2. The density of the donor area. A large number of hairs per square centimetre will yield a larger number of grafts for a given area.
  • 3. Scalp flexibility. If the patient has quite loose, flexible skin it is possible to remove a larger piece of skin, while leaving an acceptable amount of tension on the scalp.
  • 4. Hair type. Thick, strong hair with a large diameter shaft can make the final result appear considerably thicker than weak, fine hair.
  • 5. Hair and skin colour contrast. The best visual results are attained by individuals with either dark hair and dark skin, or fair hair and light skin. Dark hair with fair skin can be very challenging.

At the end of the day, you should always choose the solution that works best for your budget and your expectations. In many cases the cosmetic approach is the simplest and most effective. That's why companies like Toppik offer a money back guarantee on their hair thickening fibres. It's worth considering if you feel that a hair transplant is not a good fit. On the other hand, if you can afford a hair transplant and you like the idea of not having to apply hair products on a daily basis then perhaps a transplant is the best choice. In any case, be sure to make a fully informed decision.