I recently met someone who revealed to me that he had had a hair transplant. I examined his hairline up close and could see no evidence of this (beyond a full head of blond hair). To my eyes, the transplant was undetectable. And who carried on this expert work? None other than Miami-based hair restoration expert, Dr. Jeffrey Epstein.
Intrigued, I contacted Dr. Epstein to find out about advancements in the field of hair transplants. Subsequently, I spoke with one of the pre-eminent hair restoration surgeons in the Pacific Northwest, Dr. Steven Gabel. And, I also reached out to internationally-recognized hair surgeon Dr. Parsa Mohebi in California.
What I discovered should give hope to anyone considering a hair transplant for there are several procedures and techniques that go a long way towards achieving abundant, natural-looking results on the scalp and even on the face, with minimal downtime for both, men and women.
The key, of course, is finding a doctor with plenty of experience and a keen sense of artistry.
One of the most exciting recent advances is body-to-scalp transplants whereby hair can be harvested from virtually any part of the body for use on the scalp.
Dr. Epstein is one of a handful of surgeons who routinely harvest hairs from the chest, back and beard for this purpose. Beard hair, with it more reliable regrowth rate, is the non-scalp hair of choice. “In the past 3 or 4 years, I’ve started doing FUE [Follicular Unit Extraction] supplementing scalp hairs with beard hairs. This way, we can extend an individual’s donor supply,” explains Dr. Epstein. The hairs are extracted from below the chin, so it doesn’t even show.
This procedure is of enormous benefit to those who are either in an advanced stage of baldness or those who’ve had prior transplants and are running out of donor hair. If a patient only has a rim of hair around the scalp – that rim can provide 3,000 – 4,000 grafts, explains Dr. Mohebi.
That’s sufficient to create a hairline, but it’s not enough to fill in the crown area. This is where beard hair can provide a substantial advantage because the bottom of the chin and neck area can supply a further 2,000 – 3,000 grafts. A thick beard isn’t even a necessity. An “average” beard will suffice. “In many cases, that’s enough to restore the entire crown area,” according to Dr. Mohebi.
And how does beard hair look on the scalp? Very good. That’s because of something not yet fully understood called “recipient site influence” explains Dr. Gabel, which means that the beard hair begins to mimic scalp hair.
Over time, it will thin out and continue to grow as scalp hair. To be sure, differences will remain — beard hair will always be a little thicker and it comes in single strands as opposed to groups of 2 or 3 like scalp hair, but, when used as filler behind the hair line, “It’s essentially undetectable to the untrained eye. It just looks like natural scalp hair,” says Dr. Gabel.
It also works in reverse, with scalp-to-beard transplants potentially showing very good results for those who desire a thicker beard.
In this case, there’s “recipient site influence” too, with the donor hairs, usually sourced from the scalp, eventually behaving like beard hair. They can be shaved or trimmed as desired. When appropriate, beard hairs are also harvested from below the jawline.
Also growing in popularity in the field of hair restoration is eyebrow transplants, reports Dr. Epstein, revealing that this procedure is particularly sought after by patients who’ve overplucked their eyebrows or have scarring.
Because scalp hair is used in this instance, “the only downside is that the patient needs to trim the hair,” explains Dr. Epstein, who performs about 4 to 5 of these procedures per week and has done about 1,400 altogether using meticulous techniques that involve making the smallest possible recipient sites positioned to mimic the hair’s natural growth.
An added challenge with this procedure, adds Dr. Gabel, is finding the best hairs. “You want to find a hair that’s not too thick, nor too thin and has a curve to it because when you put the hairs into the eyebrow area, it has to be perfect,” explains Dr. Gabel. “It has to follow the exact direction of the eyebrow hair and it also has to have a nice curvature in order to mimic the most natural state. This is a complex procedure and you really want to go to someone with a lot of experience.”
Hairline Lowering Surgery
Another procedure increasingly in demand is hairline lowering surgery.
That’s for patients, particularly women, who were born with high hairlines and are seeking to have them brought down. “In a single surgical procedure that takes 90 minutes, I can advance the entire frontal hairline by as much as an inch or more,” says Dr. Epstein. The incision is made right along the hairline. It’s designed so that hairs actually grow through the scar. In most cases, the results are undetectable or minimally detectable and they are instantaneous. “Literally, the next day, the patient has a lower hairline.”
Another advantage, according to Dr. Epstein, is that the density, in most cases, exceeds the results that can be achieved with a hair transplant. Men are not usually good candidates for this procedure because if they have frontal thinning, there’s no hairline to bring down. “But for women, it can be very attractive,” says Dr. Epstein.
Cutting edge methods, such as allowing hair to grow through incisions, is one of the driving forces behind the proliferation of these types of procedures and the achievement of natural-looking results. “One of the most important aspects of hair restoration is the improvement of the tools that we’re able to use. And with an experienced doctor, people are able to get amazing results with the latest techniques,” says Dr. Mohebi. “The art of performing hair transplants has evolved to the point where the results are almost undetectable from a natural full head of hair.”
Follicular Unit Extraction (FUE)
Take FUE, a procedure whereby individual hair follicular units are removed one at a time from the donor area and transplanted into the balding areas of the scalp. Contrast this to the more traditional method called Follicular Unit Transplantation (FUT) which involves removing a strip of hair from the back of the head, closing the surgical wound and then extracting the follicular grafts microscopically before implanting them into the scalp.
There are pros and cons to both. Although FUT leaves the patient with a linear scar across the back of the head, it generally produces a larger number of grafts per session, meaning that FUT can cover a large balding area in only one session in most cases. The tiny extraction scars left by FUE, on the other hand, are virtually undetectable.
Nonetheless, “rarely do I do the strip anymore,” says Dr. Epstein. There’s really no indication for doing strip except on the occasional woman who will never cut her hair short. But because the yields are so good, the regrowth rates are so good, I will do FUE on nearly every single one of my patients.”
Besides technique, an added reason for the current general preference for FUE is superior instrumentation. Punches, for example, the devices used to extract the hair grafts, are better at maximizing the survivability of transplanted hairs. “Years and years ago, when we first started this, we had more basic punches but now, we have all sorts of computerized models to help us with the harvesting, with the extractions and also the technology of the punches itself is advancing,” reveals Dr. Gabel. “We have all sorts of different punches to accomplish the goals for hair restoration and for harvesting hairs.”
The “no shave FUE” and “long hair FUE” are a case in point. One of the big limitations of FUE is that most doctors shave the entire scalp, explains Dr. Epstein. But it’s not necessary to do that. It’s now possible to just trim the donor hair while leaving the surrounding hair intact. “It’s more time consuming and therefore somewhat more expensive, but we’re able to harvest the hair from the back and sides of the head without having to shave the head. Patients have hair the next day and look really presentable,” says Dr. Epstein.
It’s also possible to preserve the original length of the donor hair. “There are specialized FUE punches with a notch to accommodate the hair and when the FUE punch oscillates, it does not cut the hair. By using this technique, the donor hair remains long, but each individual hair graft is short.”
“I had a patient that had an important Board meeting two days after surgery and it was essentially undetectable,” adds Dr. Gabel of long hair FUE.
Implantation devices have come a long way, too. Dr. Mohebi invented his own called, naturally, the “Mohebi Implanter.” “When we do hair transplants, we have to remove hairs and then put them in the balding area. This process is usually tedious and time consuming and a very important portion of it is how we place the grafts in the holes,” explains Dr, Mohebi.
Often times, hair restoration centers perform “forceps placement” where grafts are grabbed by the sensitive bulb and pushed into the premade sites. By contrast, Dr. Mohebi’s implanter allows for a gentler loading of the graft.
There’s no grabbing and holding, as there is with forceps. The device’s diminutive size also allows for one-handed placement. Why is this important? Because it makes room for another technician in the small amount of real estate around a patient’s head. So now, two technicians are implanting the grafts instead of one.
This cuts down significantly on the amount of time a graft, which is live tissue, spends outside the head, increasing its viability. “In traditional methods,’ explains Dr. Mohebi, some of the grafts were sitting out of the body for 6-8 hours at a time.
With this implanter and with my method of making the incisions and determining the direction of the hair at the beginning of the day, we are cutting down the out-of-body time for the grafts to something around 5-30 minutes.”
As exciting as the field of hair transplantation is currently, the future is even more promising. Hair multiplication — sometimes mistakenly called hair cloning — is on the (distant) horizon. This entails the harvesting of a few hairs from the donor area and then multiplying them in a lab, creating thousands of hairs from just one bulb. “That would be a solution to almost everything, well, hair related anyway,” enthuses Dr. Mohebi. But, this multiplication is at least a decade away. In the meantime, procedures delivering enviable, natural-looking results abound.