Hair transplantation or scalp shifting is very helpful in MTF's who have considerable, but not excessive, hair balding. There are many ways to improve the female hair pattern. It may require major procedures like a scalp flap, but more often plugs, or small grafts (either macro or micro), are preferable. Scalp reductions are useful in some individuals. On other occasions, tissue expansion can be very helpful for improving the hairline. There are, however, some individuals where baldness is so extensive that there is no choice but to use a hairpiece. Like all of the procedures described in this brochure, individualization is a must. Obviously, the results will depend upon the individual's basic hair appearance, combined with the results from hormones and associated surgical techniques.

Best Candidates for Hairline Correction

In males the hairline is often higher than in females and usually has receded corners above the temples that give it an “M” shape. The hairline can be moved forwards and given a more rounded shape either with a procedure called a “scalp advance” where the scalp is lifted and repositioned or with hair transplantation. Hair transplants can also be used to thicken up hair that has been thinned by male pattern baldness. If too much hair has been lost, it will not be possible to correct hairline problems.

Preparing for Hairline Correction

You will have been given a set of instructions to follow before your surgery. These may vary according to the type of procedure, e.g. follicular unit transplantation (FUT) but whatever form they take they must be adhered to.

They may include the following:

• Stop smoking at least 24 hours before surgery. Smoking can affect wound healing and also affects your recovery so stop or if you are unable to then put it temporarily on hold until after your surgery.
• Do not have alcohol in the three days before your surgery. It is better if you have your last alcoholic drink a week before your surgery.
• Don’t have a hair cut before your surgery. It is important to let the donor area grow so that there is enough for the transplant. Plus it will cover the stitches following your surgery.
• Massage your scalp about a month or two weeks before your surgery. Do this for a minimum of 10 minutes per day or a maximum of 30 minutes if possible. This will help to soften the skin and improve the skin tone. It will also get the blood flowing in that area.
• You will have to take medication such as Minoxidil (trade names Regaine, Rogaine) before surgery although this depends upon the degree of hair loss. This may not be required if the surgery is confined to the vertex (crown) of your head. You may be advised to take antibiotics beforehand to prevent the risk of infection. These may also be prescribed after the operation.
• If you are over a certain age, for example 45 and above then some clinics may ask you to undergo tests such as an ECG beforehand. You may also have a blood test.
• Stop taking aspirin or any anti-inflammatory medication two weeks before your surgery.
• Avoid taking anti-depressants, beta-blockers and blood thinning drugs two weeks before surgery. Your surgeon will provide you with a list of what medications you can and cannot take beforehand.
• Stop taking any multivitamin/mineral supplements or herbal supplements such as Gingko Biloba two weeks before surgery.

Hair Transplant Surgery Overview

air transplant surgery is a popular form of treatment for hair loss which results in healthy, natural looking hair. It is possible to end up with a full head of hair but this will be influenced by your genetics, balding pattern and the progression of this hair loss.

The more advanced the hair loss the less chance there is of achieving a full head of hair as there will not be enough donor hair to use for grafting.

It is important to remember that many people who undergo this procedure are happy with the results. Hair transplant surgery has been around for longer than we think, in fact since the 1950’s and has come a long way since then.

Hair Transplant Methods Include:

• Follicular unit transplantation (FUT)
• Follicular unit extraction (FUE)
• Micrografts and Minigrafts
• Scalp flap and scalp reduction
• Direct hair transplantation
• Hair ‘plugs’

Scalp flap and scalp reduction surgery tend to be viewed as outdated or having too many side effects. This means that the patient has to undergo corrective treatment which is not an ideal state of affairs.

Micro and minigrafts are techniques in which strips of skin containing hair follicles are removed from the donor area of the scalp and then inserted into the recipient (bald area) area of the scalp. A micrograft usually contains a couple of hairs and a minigraft around 3 to 4 hairs.

Hair ‘plugs’ are circular grafts containing follicles which were inserted into the scalp in a series of ‘corn rows’. This resulted in the patient having bunches of hair stuck on the top of their head in an unnatural looking manner. The hair looks bristly and in ‘clumps’ rather than an exact placement.

If you mention a hair transplant to someone then nine times out of ten they will think of this ‘corn row’ image. Many people still assume that a hair transplant will give them unnatural looking hair that resembles a doll’s hair or sticks up in frizzy bunches. But hair transplant surgery has come a long way since then.

The technology has advanced to what is now considered to be the ‘gold standard’ of hair transplant surgery – follicular unit transplantation (FUT) and follicular unit extraction (FUE).

These techniques involve removing these naturally occurring units from the donor area and inserting these in the bald area of your scalp. What happens is that these follicles grow hair in the same way as they did in the donor area which results in natural looking hair. It is almost impossible to tell the difference between donor hair and hair which has grown in the recipient area using follicular unit transplantation.

Follicular Unit Transplantation (FUT)

This is a procedure in which small clusters of hairs or 'follicular units' are removed from the donor area of hair (the fringe of hair around your head) in a strip, and inserted into the recipient area (the bald area of your head). These are naturally occurring units which if transplanted well, will replicate this natural growth in the recipient area of the scalp.

In other words, there will not be any unsightly clumps or corn rows of hairs as seen in older techniques. These grafts are very small and can be inserted into tiny recipient areas on the scalp.

This is a minimally invasive procedure with a brief recovery period and few complications. However, it takes a great deal of experience and skill on the part of the surgeon which is acquired, only after years of practice.

The difference between this and follicular unit extraction (FUE) is that FUT involves removing a strip of follicular units via microscopic dissection; whereas FUE involves removing the actual follicular units directly from the donor site.

Follicular Unit

Our hair grows in tiny groups, anywhere between 1 and 4 hairs in a group. These groups consist of the hair itself and the follicle: a sac-like structure beneath the scalp which produces and nourishes new hair growth. There are groups or units which consist of just a single hair but most of these contain two to three hairs. A person with thicker hair will have follicular units with four hairs. These are small independent units which can be damaged during surgery which may result in poor hair growth. So it is important that they are removed carefully.

This means a long and intensive procedure but the effects are generally worth it!

Before follicular hair transplants, surgeons often used a method in which large grafts of hairs were removed, usually in groups of 3 to 8 hairs. One problem with this method is that the follicular units could be damaged or broken up which would then affect hair growth.

But this isn't a problem with follicular hair transplantation which enables implanted units to remain the same as when they were in the donor area.

FUT Procedure

This involves placing the follicular units in the following manner:

• Places single hair units at the front of your hairline
• Places 2 hair units behind the hairline
• Places 3 hair units behind the 2 hair units
• Then places 4 hair units behind the 3 hair units

This will produce a natural looking appearance and the right amount of hair density without the risk of 'plugginess'. Plugginess occurs when groups of hair are arranged in corn rows or tufts which often look like the hair seen on a child's doll.

You will have an initial consultation with the surgeon to discuss all aspects of the procedure. This includes a frank and honest discussion about what you can expect and whether this is likely to meet your expectations. If you are satisfied with this meeting then it's a case of arranging a date for your surgery. Your surgeon will give you a set of 'pre-operative' instructions to follow which include stopping smoking (if you are a smoker), stopping any medications such as aspirin and anti-inflammatory drugs and massaging your scalp.

The surgery itself is performed under a local anaesthetic. The hair in the area where the units will be removed will be trimmed to enable easier access.

The surgeon will then inject a local anaesthetic into the donor area of your scalp which will numb the area. He/she will then remove or extract these hairs one by one. This is done in a particular pattern known as a 'spread arrangement' so that it is difficult to tell which hairs have been removed.

Your surgeon will use a microscope whilst doing so to prevent the risk of damage to the hair follicles. These units are removed in strips for micro-dissection (under a microscope) before implantation. The strip is removed from the centre of the donor area which enables him/her to obtain a large amount for transplanting.

He or she will then inject an anaesthetic into the recipient area (bald area of your scalp) and will use a specially designed 'micro-needle'to insert the follicular units into the scalp. These hairs will then grow as per usual.

NOTE: A maximum of 4,000 hairs can be transplanted in a single session.

The surgeon will use staples or stitches to close the incision made in the donor area.

You may require several sessions to achieve the look you want which will depend upon the type of hair loss and the amount of coverage you require.

On the other hand you may be lucky and get the result you want just in the one session.

Once the anaesthetic wears off you may experience some soreness, swelling and discomfort. Take painkillers if necessary.

You will have been given a set of 'post-operative' instructions which include advice on looking after the treated area, washing your hair and new hair growth.

Follicular Unit Extraction (FUE)

This is the name given to a new method of hair transplantation in which individual follicular units are removed from the donor site. This means that these follicles will remain in the same state and will grow as normal in the recipient site.

Note: the donor site is the name given to the band of hair around the head which lies just above the ears. This is a common feature of male pattern baldness.

Basically, FUE is part of the Follicular Unit Transplantation (FUT) method in which hair is harvested in small groups (units) and inserted into the bald area of the scalp (the recipient area).

The advantage of this method is that there is no need for the surgeon to make a long incision in the donor area. He or she uses a small micro needle which 'punches' a tiny incision around the hair follicle before extraction.

This is an ideal method of surgery for patients who like to have short hair. So if you have a short, cropped hair style then this surgery is for you.

It is also recommended for patients who have a tight scalp or have previously undergone the 'strip' method but with little success.

It sounds very similar to follicular unit transplant (FUT) surgery but the main difference between the two is in the way the donor hair is obtained.

FUT involves removing the follicular units in strips which are then dissected under a microscope. These units are then inserted into the recipient area.

But with FUE, the follicular units are taken directly from the donor area and then inserted into the recipient area.

Things to consider with FUE

There are a few things to think about in regard to the way the follicular units are obtained or 'harvested' as this does impact upon the procedure. These include:

• The number of grafts in a session
• The damage (transaction) rate to the follicular units
• How the follicular units are distributed
• The total number of follicular units
• The aftercare

You may undergo a 'FOX test' during the initial stage of surgery in order to assess the level of potential damage to the hair follicles. FOX stands for 'ease of extraction'.

There are patients who respond better than others to unit extraction and it is important to check to see if you are likely to be one of them. If this is the case then you need to consider whether to stick with the FUT procedure which will not damage the hair follicles or to go with FUE but risk follicle damage.

Remember: damaged hair follicles will affect the growth of new hair. This can reduce the amount (density) of new hair and the coverage of your bald area.

If you have chosen FUT then you can still undergo the FOX test in case you require further surgery and/or may need FUE some time in the future.

What this procedure can do is to hide the signs of a previous hair transplant surgery. So if you have undergone a hair transplant before but via an older method such as a micro/mini graft then this tends to leave a long, linear scar on the back of your head. FUE can disguise this scar.

The Follicular Unit Extraction (FUE) Procedure

The process is very much the same in that you will be given an injection of a local anaesthetic into the donor area which then freezes that area. You may be also be given a sedative as well.

The surgeon will use a microscope and a slender instrument (micro-needle) which makes a small circular incision around the follicular unit. He or she is then able to remove or extract the unit. This means no long, linear scar or stitches.

The follicular units are removed, one by one in a time consuming procedure. This also makes it rather expensive as well.

The recipient area (bald area of the scalp) is injected with a local anaesthetic in order to be ready for the follicular units. These units are then inserted into the recipient area. A maximum of 800 follicular units are transplanted in a single session. This means that it cannot be completed in the one session and you will have to undergo three or four sessions to achieve the result you want.

Another difference between this and FUT is that body hair can be sued for transplantation. But these are not of the same quality as the donor hair and don't always work as well.

FUE does result in great looking hair although there is no difference in the end result between this and FUT.

Advantages of FUE

The advantages of this procedure include:

• No linear scar
• Don't need staples or stitches
• Good choice of procedure for patients with short hair
• Good option for patients with previous scarring or a tight scalp
• Can use body hair
• Good choice if a limited number of grafts are required
• Quick healing time
• Minimal discomfort after surgery
• Less downtime/able to resume normal activities and exercise quickly

Disadvantages of FUE

Every procedure has its advantages and disadvantages and hair transplantation is no different.

The disadvantages of this procedure include:

• Time consuming procedure
• Costs more than FUT
• Risk of damage to the follicular units
• Limited supply of donor hair as some hair must be left to cover the rest of that area
• Small scars may obstruct nearby follicular units which can be problematic if further sessions are required
• Less hair density than with FUT
• Not enough suitable candidates for unit extraction than with FUT
• May be difficult to achieve an 'even spread' of units
• More than session is needed
• If body hair is used then this is unlikely to be permanent
• Risk of the hair graft being pulled off when extracted

After FUE you may experience soreness, swelling and some discomfort around your scalp but this ease within a week.

No surgery is 100% risk free but the chances of this happening with FUE are extremely rare. Any complications which do occur will include infection, bleeding, poor wound healing or a poor results but this tends to be rare.

Recovery from FUE is quick, in fact, quicker than with any other procedure so you can expect your scalp to be fully healed within a week after surgery.

It usually takes around a year for a full head of hair to have grown.

Micrografting

This is a type of hair transplant surgery in which a small drill (electric punch) is used to remove hair grafts from the donor hair (the fringe of hair around the back of the head) which are then inserted into the recipient area (bald area of the scalp).

The problem with this is that it left large circular scars on the back of the head and often unsightly looking 'corn rows'or tufts of newly grown hair on the scalp. However this has been largely replaced with the following graft preparation method:

• An incision is made in the donor area
• A thin strip of skin, complete with hair follicles, is removed from the donor area
• This strip of skin is divided into several smaller grafts
• The grafts are inserted into the recipient area

Difference Between Micro and Mini Graft

• A micrograft contains 1 to 2 hairs
• A minigraft contains 3 to 4 hairs

This method has become less popular due to follicular unit transplantation (FUT) and/or follicular unit extraction (FUE) but is still available.

Micrografting will insert larger grafts at the back of the scalp and progressively smaller grafts towards the front to give a natural looking appearance. Minigrafts are usually inserted in the centre of the scalp.

The Micrograft Procedure

Your surgeon will have given you a set of instructions on what to do before and after your surgery. These include massaging your scalp beforehand and stopping certain medications such as beta-blockers or anti-inflammatory drugs.

On the day of your surgery you will be given a local anaesthetic to help numb the donor area. This can be painful although the surgeon may freeze the area beforehand with a special spray and/or give you a mild sedative.

The surgeon makes a linear incision in the donor area (the back of your head) and removes a thin, horizontal strip of skin which contains follicular units.

He/she will close this incision using staples or stitches.

This strip contains numerous hair follicles and is cut up into smaller grafts. These are either micro or mini grafts.

He or she will anaesthetise your scalp before making a series of small circular holes using a micro-needle (or micro blade). These are very tiny 1mm incisions so there is unlikely to be any bleeding. They are made in a definite way so that space is left between each incision and in a pattern which conforms to the way your hair naturally grows.

The grafts are then inserted into the scalp via micro tweezers or an 'implanter pen'. They are fully inserted into the incisions, about a few millimetres in depth.

This procedure can take from two to eight hours depending on the number of grafts to be inserted. The surgeon will place this so that larger grafts are surrounded by smaller grafts to give a natural look.

This is preferable to the old large scale grafts or 'plugs'which resulted in a 'toothbrush' effect on the scalp.

It can be but the degree of pain will vary between patients. The most painful part is usually the local anaesthetic but many patients find that the procedure itself is painful.

You can also expect some discomfort in the form of bruising and/or swelling around the forehead after surgery but applying an ice pack will help.

The swelling can be noticeable so it can be a good idea to take time off work until it has eased.

Recovery After Hair Transplant

You will be given a set of post-surgery instructions to follow on the day of your operation.

It is a good idea to book some time off from work following this surgery. Your head will be sore and swollen and there will probably be some pain so allow yourself time to recover from this and to let the treated site heal.

Try and arrange this before you go for your operation.

As regards the hair transplant surgery this depends upon which method will be used. There is more than one technique for transplanting hair and these are discussed individually in our hair transplant surgery methods section.

Each method includes a description of the procedure, the benefits and the risks.

Once the anaesthetic has worn off – which is usually 3 to 4 hours after surgery then you will experience some pain and discomfort. There may be some minor swelling and soreness of your scalp but painkillers such as paracetamol can help.

When You Return Home

Any swelling or bruising around your hairline will ease after a few days. It is also a good idea to take a few days off from work to allow this bruising and swelling to subside.

If a bandage was applied to your scalp at the time of surgery then this will be removed although many surgeons prefer not to apply a dressing to the treated area.

Your scalp will be pink and feel ‘tight’ or itchy but this completely normal. The areas of your scalp where the donor hairs have been implanted will have crusted or formed small scabs which will fall off a few days later.

What you will also find is that once this has happened it will be followed by your newly transplanted hair. This hair will be shed but don’t worry; this is a normal reaction to the transplant known as ‘thermal shock’.

Thermal shock is where intense heat is applied to a hair follicle which destroys that follicle. However this doesn’t affect the actual stem cells which were transplanted at the same time so new hair will grow. What happens is that some of the follicles and grafted hairs fall out but the stem cells remain. These enable new hair follicles to grow.

The transplanted hair grafts will start to grow new hair which then follows the normal growth/loss cycle. This will occur after three months or so.

Hair Transplant Post Operative Care

You will also be given advice about washing and shampooing your scalp, using antibiotics and returning to the clinic for the removal of stitches (if applicable). So what will this advice consist of?

This is likely to take the form of a set of instructions, given to you by your surgeon which must be followed.

These instructions will include some or all of the following:

• Have someone drive you home after your surgery as you will have been given a sedative before surgery to help you relax. This takes time to wear off and during that time it is dangerous to drive or perform a complicated or dangerous task.
• If you have undergone a micro graft then a compression bandage will have been wrapped around your head, similar to a turban. This must remain in place for a day and kept clean and dry. Most hair transplant surgery doesn’t involve a bandage but all forms of surgery involve stitches. These may be the dissolvable variety but if not then you will need to return to the clinic in two weeks time to have them removed.
• For your first night home after surgery, sleep in a semi-upright position and use a couple of pillows to elevate your head. Do this for the first three days after your surgery. Do NOT touch or pick at the newly grafted areas. There may be some itching or soreness but it is important that you do not touch these. If you pick or rub them then they will fall out before they have had a chance to grow new hair.
• Do not drink alcohol for the first 48 hours after surgery. If you are a smoker then don’t resume this until a month later. Smoking can interrupt blood flow to the hair follicles which is vital for new growth. It is even better if you can give up. If you want to give up smoking but don’t know where to start then visit our stopping smoking guide.
• You may be given a special lotion in the form of a spray to use at home. This contains a ‘growth factor’ which is designed to encourage the growth of new hair. Spray this onto the areas where you had new hair grafted and do this until it is used up. You will have to do this every 30 minutes on the first day following your surgery.
• You will be able to wash and shampoo your hair a couple of days after surgery. This will remove any dead skin but more importantly, will clean the scabs which will have formed around the grafted hairs. This prevents the scabs from damaging these follicles and stopping new hair growth.
• This must be repeated on a daily basis for the first week after surgery. Use a balanced shampoo and work this into the donor hair and the grafted areas of your scalp. It’s a good idea to hand wash your hair for the first few days and then do this under a shower as per usual. The donor hair area (the fringe of hair around your head and just above your ears) must be kept clean to prevent crusts forming which can impede scarring.
• You can use an ice pack to reduce any swelling or bleeding during this first week but do NOT place this onto the grafted area. Place it either on your forehead or at the back of your head.
• If you play sport or exercise then avoid this for the first week after surgery. Try to avoid leaning forward or blowing your nose violently.
• The clinic will give you antibiotics in the form of a cream. This needs to be applied to any scarring twice a day in the first week. This cream will help to prevent any infection.
• If you have non-dissolvable stitches then these will be taken out fourteen days after surgery.
• Avoid sun exposure or using a sunbed whilst your scalp is still pink and swollen. Wear a hat if you have to go out in the sun.

If you experience any severe pain, bleeding or infection then contact your surgeon immediately. It usually takes around 3 to 4 months for new hair to grow although it can sometimes take up to 6 months. It’s a case of being patient and allowing your new hair grafts to spring into action.

Possible Hair Transplant Risks

The decision to have hair transplant surgery is extremely personal and you’ll have to decide if the benefits will achieve your goals and if the risks of breast implant safety and potential complications are acceptable. You will also need to review the techniques and options benifits.

FUT Complications and Risks Include:

• Poor/slow hair growth: may be as a result of damage to the follicles.
• Infection: this is extremely rare as antibiotics are prescribed before and after surgery.
• Noticeable scarring: the surgeon will try and place the incision in an appropriate part of the donor area so that it difficult to see.
• Poor wound healing: genetics can play a part in this and some people do heal more quickly than others.
• Changes in the pigmentation of the skin: there is a risk of hyperpigmentation (darkening) to the skin although this is very rare.