All About Hair Transplantation

Hair Transplantation is a surgical procedure that should be performed with a multi-disciplinary clinical approach, considering the patient as a whole. The patient has to find a clinic that specializes in this field, follows up innovations in the world and brings them into the practice. The team should have excellent clinical knowledge of hair loss, be able to perform not only surgical but medical treatment as well.

At Istavita Clinic, our doctors asses the hair loss type of the patient, mark the areas that need treatment, and precisely plan the hair transplantation procedure. After arriving at the clinic on surgery day, the routine paperwork (complete consent form of surgery/local anesthesia) red and signed. After screening test for contagious diseases (HepB, HepC, HIV) carried out, these are mandatory tests needed for the patient and surgical team safety.

After paperwork and blood test done, doctors give our patients a detailed briefing regarding general aspects of hair transplantation, hair transplantation steps, details of the procedure, timeframe, factors that affect the success of the transplant on the patient side.

After all these preparations, the patient transferred to the operating room before the surgery starts, an individual on-to-one planning of the surgery done. During the evaluation, the type of hair loss determined, recipient, and donor areas marked. Before marking the recipient area for implantation, different criteria like skull anatomy, hair type, graft quality, graft density, and other factors are taken into consideration, and only after that new front hairline is drawn or the existing one sharpened.

Every factor is considered and evaluated, along with the expectations of the patient. Patients are informed about all possible outcomes and front hairline drawing done. During the planning, another essential decision taken regarding the surgery – will it be with a shave or without a shave. In without the shave option, only the donor area (back of the head) shaved for extraction. In an opposite decision of going with shave the whole heads hair is cut (shaved).

Before the surgery starts, all vital signs like BP, pulse, temperature, etc., are measured, recorded in the patient’s file, and doctor acknowledged.

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Hairline Design Criteria

For many years the hairline design of the patients was determined by Da Vinci’s golden ratio or according to criteria of various institutions. Nowadays, this approach is not actual anymore. A more scientific method and assessment used today, i.e., the patient’s age, skull anatomy, ethnic origin, and patients expectations, are critical points in the new hairline design. If the patients’ open area is extensive, most of the time, unfortunately, graft numbers are low as well. In this kind of case, a more conservative – high hairline should be considered. If the number of grafts is sufficient and the desired rate of closure can be achieved, a lower hairline can be drawn.

A new hairline should fit the patient’s face geometry. Caucasian, Asian, Afro faces have different facial lines, and they can be straight, oval, curved; that’s why the shape of the face is a crucial factor in determining the hairline. Under normal circumstances, the hairline should start 6.5-7.5 cm above the eyebrows.

Although the hairline needs to look good from the front, it should be evaluated through the “mirror test” to see its symmetry. The mirror test gives us a 3D view of the hairline, just like the patient sees it. For this reason, the hairline design should be decided with the patient.

The side view of the hairline is also essential. It should be slightly tilted upward and provide a natural outlook. If the patient is elderly, the temples (temporal region) should be even higher, and should link up in the area where the side hair and front hair meet.

Another factor to consider the hairline design is the forehead muscle anatomy, the muscle easily detected by raising the eyebrows of the patient. Evaluation of this muscle structure plays a vital role in creating a natural line, also by giving an idea regarding the previous hairline. The ideal planning is to start the hairline right above this muscle structure. Another auxiliary factor is the pictures of the patient before hair loss. Planning by evaluating all these variables is a challenging task. During the incisions/creating hair channels, a step of the surgery, the direction of hair growth is also taken into consideration, and the plan is implemented.

Steps of Hair Transplantation

The hair transplantation process consists of three steps. These are as follows; Extraction, Incisions (creating hair channels), and implantation. Hair transplantation carried out under the local anesthesia, which is numbing of the specific area of the scalp. Local anesthesia gives a patient a smooth, comfortable, and painless procedure. Hair transplantation surgery lasts 6-8 hours on average, and the local anesthesia process takes about 15 minutes. After local anesthesia administered, patients do not feel any pain. Local anesthesia is applied twice during the surgery; the first time before the extraction step, and the second time is before the incision step.

Extraction (Harvesting) Time: 1.5-2.5 Hrs. 1’st Local Anesthesia Applied

Incisions (Opening Channels) Time: 1-1.5 Hrs. 2’nd Local Anesthesia Applied

Implantation Time: 2.5-3.5 Hrs.

The total time needed for the surgery with all the preparations varies between 6-8 hours.

Extraction (Harvesting)

Extraction is the most challenging step of the surgery for patients, because they have to lie face down for about 2-3 hours. After the patient lies on the surgical chair, the donor area marked according to the hair loss pattern and hair structure. The first local anesthesia applied at this step of the surgery, after the admission of local anesthesia pain control performed, and we make sure that the patient does not feel any pain. After local anesthesia admitted, the next step – tumescent performed. Tumescent is done to decrease the blood flow across the scalp, thus minimizing the blood loss. Also, the tumescent prevents the damage of the vessels, nerves, and scalp tissue. Extraction is carried out via a micromotor with a different diameter (size) punch tips that differ from 0.70-1.00mm. The punches are individual for the patient and used only once. The punch size determined according to the hair thickness of the patient with control shots with different size punches.

The reason we are obsessed with the punch size is to ensure that the grafts removed as a whole tissue without transection and damage. Extraction is the most critical step in the hair transplantation surgery. The main target here is to keep the transection rate of the hair follicle under the 5%. By following the low transection rates, the planned number of grafts are acquired with the high quality and minimum damage, and the best possible result is significantly approached. During this procedure, the superior attention required. Each removed graft is dissected, counted, and evaluated by highly skilled surgical assistants trained by doctors. Doctors should control these transaction rates strictly. At Smile Hair Clinic, this process is meticulously monitored by supervisors and doctors. By doing so, the quality of the operation and the best possible outcomes secured.

Patients’ expectations are usually the maximum graft number possible. The critical point here is correct planning and detecting an approximate number of grafts. Even though you acquire a high number of grafts, the recipient area blood flow, and the ability of the blood flow to feed the grafts is also crucial. Over harvesting of the donor area in the hunt for the high numbers may lead to catastrophic results. Although patients’ expectations are the high number of grafts, the challenging point is to get the number that the patient needs without harming the donor area. In short, it is to evaluate the patient accurately and draw a treatment plan according to the patients’ expectations and his/her donor area capacity.

The number of grafts varies depending on several factors;

Donor area size

Donor area density

Ratio of single/multiple follicles

Ratio of thick/thin hairs

Donor area size ( ): Almost anything in the world can be explained with mathematics and physics, hair transplant as well. If these rules are taken into consideration, from two donor zones of the same density, more grafts acquired from a donor area of a bigger size. Sometimes the receding areas (crown area) of patients can proceed into the donor area. This hair loss pattern can be at the initial stages in young adults, and we have to consider it when marking the donor area. Our doctor can draw the donor area lower at the back. In this way, preventing the overlapping of the receding line with the extraction line and prevent unfavorable aesthetic results in the donor area. The main window of the donor area at the back of the head is the place where the best grafts with multiple and quality grafts can be harvested. The sides and ear zone of the donor area have a weaker blood supply, the grafts here are thinner and mostly with single hair follicles. That is why the extraction of the grafts should be performed carefully in this area. These delicate grafts with individual hair follicles are used in the front hairline.

Donor area density

Donor area density varies from person to person and is one of the most critical factors directly affecting the result of hair transplantation it is indicated as FU/ (Follicular Unit/Centimeter Square) of the scalp. A human being may have 40-110 FU/ , and an average is 60-80 FU/ . After measuring the area size, the total number of follicles calculated by multiplying these two variables (size*density). An estimate of the maximum number of grafts for extraction calculated from the total number of follicles. We can extract up to 30-40% of the total number of follicles from the donor area. The aim here is to decrease the intensity of the donor area to a level where it is not understood that extraction is performed and prevent extensive scar formation. Each follicle removed leaves a gap on the skin that varies according to the punch size used.

These holes are tiny, and the tissue heals fast with dot-like small scars. During the extraction step, these punch size holes should not be too close to each other; otherwise, adjacent holes conjoin with each other, resulting in significant wound areas that heal with scar formation. This situation causes the patient to have problems in the future, i.e., bad aesthetic outlook, dissatisfaction, etc. But some black-market clinics in search of the high number of grafts neglect this aspect. That is why it’s vital to avoid this kind of mistake during the surgery.

As we know, the extracted grafts do not grow back, and if later on, the patients will want to have another session, avoiding conjoined holes will increase the chance for the surgery. So, when we mention the maximum number of hair grafts, we mean the extraction of the highest possible number without extensive scar formation, damaging or depleting donor area, blood supply, etc. Patients with low density will have a smaller number of grafts during the extraction; likewise, the patients with high donor area density should be accurately evaluated as well. In high-density patients, the follicles are very close to each other, thus trying to acquire high numbers can lead to the conjoining of holes and scar formation, that is why it should be avoided. Following these simple rules will keep the donor area with minimal damage and maintain the donor reserve well for the possible future surgeries.

Ratio of single/multiple follicles

A healthy human with no hair loss has around 100.000 hairs on the body, and the majority of them located on the head. There are around 60.000-80.000 hair follicles on the head, and these follicles are packed as grafts – a combination of 1-5 follicles, appendages, and tissues. As an average, as a mathematical equation, we say that there are 2.2 Follicles per graft. So the patients with more multiple follicles per graft have better results with a lower number of grafts extracted. Single follicles used in the restoration of the front hairline. Whereas multiple follicles are used to cover the overall open areas and to give dense and natural look after the hair transplantation.

For this reason, it is crucial to acquire single follicles for the front hairline first, and then extract multiple grafts. Larger size punches used to get the grafts with numerous follicles. It is done to avoid damaging and transection of the grafts mentioned earlier during the extraction with small-sized punches (the same way different size blades used during the incision). Extracted grafts are set as singlets, doublets, etc., by surgical assistants and data recorded in the patient file.

Ratio of thick/thin hairs

Patients with thick hair can get a better result with fewer grafts. For this reason, thick hair in the donor area targeted during extraction. The patient should know that thin hair will give less dense results. The patients with thin hair who use their hair long may seem to have a good density, and it can be diverse them. There is a term called cumulative hair thickness, and it reflects the total thickness of the hairs extracted. With this in mind, patients with thicker hair will always have a better result in the recipient area. Again, it is crucial to acquire single follicles for the front hairline first and then extract multiple thick grafts to obtain the best possible result with a single session.

In conclusion, the maximum number should be harvested according to the anatomy, donor area size, density, and circulation status of the patients and should not exceed a specific amount. That is why the doctor should accurately mark the areas of donor area for extraction. It should be considered as a race, and acquiring a high number in one session should be avoided. A high number can make a patient happy at the beginning. Still, hair transplantation is not a matter of a year; 5-10-15-20 years should be considered. And the patient should be warned and educated by the doctor.

Incisions (Opening Channels)

Grafts acquired during extraction are separated and set according to the follicle numbers by surgical assistants. The first step during the incision step is evaluation of the height and width of the grafts for the correct blade choice. For the natural results, the frontside incisions should be opened under10-20 degrees angle. The angle increases as we go to the backside of the head, with being around 60-70 degrees at the top of the crown area.

At this step, the doctor should mimic the direction and angle of the patient’s hair. Along with the channel direction and degree, the length of the channel is also an essential factor in catching the natural view. The channels should be created vertically on the front side. The channels on the lateral sides of the head should be designed with horizontal to vertical gradient (more horizontal on the sides, more upright on the transition zones between frontside and lateral side)—a good guider for the angle and direction maybe the existing hair of the patient. Mimicking them also helps to catch the natural view. The width of the channel is a factor that directly affects the outcomes. The incision with interlocking patterns (close and in a row) will lead to a high-density area. The number of grafts that can be implanted per centimeter square differs depending on the thickness of the hair follicle. It varies from 60-70 FU/ .

If the patient doesn’t have a sufficient number of grafts to cover all the areas equally, the priority areas can be covered with high density, and the rest areas with the density of 20-25FU/ . The other important factor alongside with the direction and density is the depth of incisions (channels).

The incisions should not be very deep or shallow. Shallow channels will cause the graft not to get the necessary level of circulation, and due to the shallow recipient sites, the grafts can be bent by surgical assistants during the implantation, and it will result in non-growing hair. On the other hand, if the recipient sites are too deep, the blade can damage the epithelium and vessels – it is called Pitting. The follicular unit is placed too deep, as the wound heals, it becomes unnaturally concave. Before starting the incisions, the doctor should measure the recipient area with a ruler and calculate the surface area correctly. In this way, the grafts can be accurately distributed, and the doctor can plan the incisions successfully.

The hair transplant surgeon should inform the patient about the graft number extracted and explain the plan of distribution and double-check priority areas. Another critical point during recipient site creation is tumescent fluid (a unique solution of saline and adrenaline). Tumescent is injected under the skin to control the bleeding, stretch and raise the scalp over the fat pad during the incisions, thus helping to prevent punching out big vessels and nerves. After tumescent applied, the scalp is stretched, the surface area increased, and it helps the surgeon to open the incisions much more efficiently with a high density and less trauma to the tissue. At the end of the incision step doctor will check the front hairline, compare the sides, symmetry with the patient in the sitting position, and get final approval. After the patient approves the hairline, the recipient site creation is finished.

During hairline recipient site creation, it is vital to go with macro and micro irregularities. These irregularities after hair regrowth give a natural view to the hairline.


The grafts harvested from the patients’ donor area can wait up to 6 hours without any damage, to ensure this, the grafts should be stored in a particular solution and under specific temperature during the surgery. Control of these factors should be strictly provided when implantation begins. In this way, the viability of the grafts is maintained, and the quality of the hair transplantation process ensured. The surgical team who will be doing implantation must have extensive education, know the hair, scalp, and graft anatomy with all its appendages. They must be skilled in positioning the graft without causing trauma correctly. Even under the best conditions with all the nuances met perfectly, if the implantation step goes wrong, and a mistake made here, it may cause catastrophic results for the patient. We must avoid holding the graft at the root level, keeping it too tight to prevent possible trauma. In the process of lodging the graft into the channel, utmost attention should be paid to avoid it from bending and place it accurately. The grafts must be checked with a loop after the operation. The implanted grafts should be picked up randomly from different parts of the scalp to ensure that the planting was done correctly. It is another quality control step of the operation

After all these quality control steps, the surgery is finished. The patient is taken into the dressing room of the OR, donor area dressed, and banded. The bandage is applied on the forehead with the dressing. It is done for two reasons; 1) To make the dressing of the scalp stable, 2) To prevent the swelling from coming down the face due to the effect of gravity.

After the dressing and banding, the pictures of the patient are taken for archive and follow-ups. Then the patient is taken to the waiting lounge where he/she will meet the doctor for discharge.

Before the discharge, the doctor should warn the patient about the following points;

He/She is still under the effect of local anesthesia, for this reason, it is necessary to protect the head from traumas (especially when getting in and out of the car, passing somewhere and leaning)

Keeping the head in the upright position (Especially while using the phone, reading the book, while wearing the shoes).

Explaining how to sleep (The pillow and neck pillow are adjusted, the way they keep the neck and head in a single position and prevent trauma to new hair during the sleep)

Avoid salty foods for 1-2 days

Avoid Coffee and Cigarettes for the first few hours after the surgery

No alcohol intake for at least five days (until the medications are over)

Explain how to use medicines given in the first aid kit (antibiotics, pain killers, anti-inflammatory drugs)

Avoiding hot, sunny and dusty environment

Applying the massage in the forehead to reduce edema and apply ice if possible.

We rarely see pain in patients after the operation. Having to be careful during sleep to prevent damage to the grafts may cause not getting enough sleep at night, it is commonly seen among the patients. Also, discharge from the back of the head (donor area) may be seen, and this is the tumescent fluid injected under the skin. The dressing perfectly well absorbs most of the discharge, but every once in awhile, there may be some bloody marks over the pillow. Some patients misperception it as blood, but as mentioned above, it is tumescent fluid, and there is nothing to worry about. To avoid blood marks over the pillow clinic supply the patients with diapers to cover the pillow.

Local anesthesia aspects

Local anesthesia is the step most of the patients are worried and anxious about. Hair transplantation is a surgical procedure, and we frequently get questions regarding the pain and local anesthesia. After local anesthesia is applied, there is no pain for the patient. The patient may feel someone touching his/her head, and it’s a normal function of the body called proprioception. Patients may listen to music or watch the favorite shows after the local anesthesia with no problem during the surgery.

However, the local anesthesia process is a painful procedure. The pain during the procedure is not due to the needle sticks, but due to the chemical structure of the local anesthetics, they cause a burning feeling just after administration, which lasts for 5-7 seconds. Unfortunately, there is not much to do about this point. In the world today, there are dozens of local anesthetics, and all of them, with no exception, cause this burning sensation. Interestingly after the surgery in the feedbacks, most of the patients tell us that the procedure is not as painful as mentioned in the internet and forums.

Our patients undergo local anesthesia twice during the entire procedure, and the total duration of these two procedures is around 30 minutes. Considering that the surgery takes about 6-8 hours, this is not too much time.

In our clinic, we have two options for local anesthesia; 1) Classic local anesthesia with a needle, 2) Needle-free local anesthesia. There are pros and cons in both for both types. There is no negative impact on the course and outcomes of the surgery in neither of them.

Needle-free local anesthesia

Though the local anesthesia with the needle doesn’t cause too much pain, there may be people who have needle phobia or have a very low pain threshold. For this kind of patient, needle-free local anesthesia may be an option.

The needle-free local anesthesia method, which has started to be used in recent years in developed countries over the world, is one of the local anesthesia types. It minimizes the anxiety of patients and facilitates the working process of physicians.

Needle-free anesthesia is performed with high-tech devices in hair transplantation. These devices use the pressurized air to deliver/disperse the local anesthetic over the skin. Later on, the medication is absorbed and spread across the tissues. An important point here is that after the needle-free local anesthesia applied, needles are still used to refer tumescent and to make dose adjustment of local anesthetic throughout the surgery.

Needle-free local anesthesia is NOT a painless anesthesia

Hair transplantation is a big market. Unfortunately, some clinics introduce needle-free anesthesia as painless anesthesia, to take a step forward in this market and make the patients to choose their clinic.

As mentioned earlier in local anesthesia, pain isn’t caused by the application, but due to the chemical structure of the medication. For this reason, even though the needle-free anesthesia is less painful, it is not painless. Patients should not honor those who say otherwise when looking up for the hair transplant clinic.

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