The Long-Term Viability of Transplanted Hair

Hair transplantation is one of the most enduring and successful procedures in both cosmetic and restorative surgery. When we think of making a person or a patient look their very best, it is only natural for a full head of healthy hair to come to mind. The need to restore hair volume is one of the first things medical and aesthetic procedures have been used for, predating nearly every other cosmetic surgery. But when millions of grafts are relocated over the span of many hours, we have a responsibility to think about these procedures in the context of a human lifespan. Hair transplantation for permanent, long-term aesthetic or reconstructive improvement does not have to involve any kind of short-cuts, and indeed, a certain skepticism about untested claims in this field is warranted. We’re dealing with the face and crown of a human being; nothing could be more important than it looks and functions over a lifetime.

In order to get to that lifetime guarantee of aesthetic benefit, it’s useful to start with a brief review of the simple but critical biological facts upon which modern hair transplantation was built. I call this the Theory of Hair Graft Evolution, because without a patient’s total and unconditional acceptance and understanding of the single concept that is “donor dominance”, all of the technical advances that have happened over the last 50 years are for naught. Put simply, donor dominance is the underlying biological truth upon which the multi-decade viability of transplanted hair grafts is based. This means that transplanted hair can be grafted from the back of the scalp to the front or top of the scalp with a guarantee of not only short-term aesthetic success, but a high degree of certainty of longer-term natural and healthy re-growth and retention. This same biological reason is what allows transplants to be routinely and consistently successful across all medical practitioners who adhere to basic and obvious common-sense principles. In other words, for all of the extremely valuable technical advances that have happened to the field of hair transplantation in recent years, from the way grafts are extracted, to the way they’re handled and processed in the operating room, to the way they’re precisely implanted, to the way they’re post-operatively cared for and maintained, there is one extremely important foundational reason why hair transplants not only work, but can last for decades. The Theory of Hair Graft Evolution begins with a single, very important and very simple truth: The relocated graft knows no different fate than that of its donor site of origin, genetically “programmed” for the same 20-30+ year lifespan of a non-transplanted graft in that donor area.

Put a little more simply: there is an area of the scalp that is not genetically programmed to go bald. The strongest examples of this DHT-resistant permanent zone are classically the band of hair around the back and sides of the head that typically forms a horseshoe pattern of DHT-resistant hair. For this reason, grafts from this area, when extracted with the utmost care and respect, and then precisely placed with exquisite accuracy in a careful, planned strategy to reinforce or even out a natural, thinning hairline or to fill in a sparse area of scalp, will survive and function for the lifetime of the patient in the same way that they would have if they had never been moved. It’s a miracle of biological science: the little “ball” that is the hair graft is moved across the crown of the head from one genetically predetermined life-course, but maintains its original genetic programming and “identity”, so to speak. There is no guarantee that the exact, detailed pattern of your lost hair will “grow back” precisely as it was or ever was, but there is a 100% guarantee that a single graft can be successfully relocated and will continue to cycle and grow for a human lifetime. If you do not understand and accept this, it is time to stop reading this and call a completely different hair surgeon.

If we imagine the history of hair transplantation over the past several decades, the visual evidence of technical progress is dramatic. Open-extraction “plug” transplants are a distant memory for a reason: in the hands of a highly trained and experienced surgeon, modern FUE and FUT grafts are significantly smaller, more numerous, and refined than ever before in the history of the specialty. In a procedure that takes place over 5-10 hours, and with the patient in an operating room instead of in a spa or hotel, there is a tremendous amount of responsibility and expectation on the surgeon and his team. Both FUE and FUT can be used to great effect. In my practice, both options are available, and a patient’s total choice of surgeon and long-term relationship with a hair restoration team should always be a factor when determining whether to use one extraction method or the other. In both cases, and for a surgeon who has chosen to practice 100% graft transplant methods, the unit of work is the same: follicular units of 1-4 hairs that are biologically “packaged” as discrete functional units by nature herself. As we understand more and more about the natural characteristics of the hair graft as a discrete and transferable unit of tissue, a cascade of improved longevity, patient satisfaction, and even potential applications follow. A delicate and specific handling protocol is mandatory for each and every graft to maximize the total number of transplanted hairs that survive over the long-term. From the moment they are plucked from the scalp, each individual graft must be kept alive and intact in a cryo-preservation solution in order to maintain graft viability until they can be returned to a nourishing blood supply through microscopic, perfect slits in the scalp. Rapid revascularization and normal, natural hair cycling post-operatively is the final critical step in providing your patients with their crowning achievement: a natural-looking, permanent solution for healthy, long-term hair growth. (NOTE: This will be the target audience of my upcoming book on advanced hair restoration medicine.)

In the first several months after the procedure, transplanted grafts “settle in” and re-establish a new natural shedding and growth cycle. I will briefly mention just a few key points of this because it is important to understand that the transplanted hair has, for all intents and purposes, healed and reconnected to all of the normal functioning systems of the scalp as native hair follicles and shafts do. The hair growth cycle can be broken down into three distinct phases. Growth, or anagen, is the period of time that a follicle is visibly creating and pushing new hair shaft up and out of the scalp. Catagen is the very brief time during which a follicle “rests”. Telogen, or “shedding phase”, is the period of time in which anagen or catagen follicles naturally fall out, allowing for the production of new, “younger” hairs to start a new growth cycle. The average time in these respective phases for scalp hair is 2-7 years (anagen), a few weeks (catagen), and around 3 months (telogen). Over 90% of a healthy scalp is actively growing at any given moment. The total shedding is, in effect, a planned and nearly invisible balancing of numbers in an elaborate and dynamic system. A new transplant is no different: each one of the thousands of individual grafts goes through these same three phases. As a graft is placed, however, it goes into a kind of dormancy, or telogen rest, that results in initial shedding, usually within 2-8 weeks post-operatively. This is normal and expected, and when a patient is first experiencing significant shedding of his new hair, the anxiety about graft failure is understandable. A 30-50% loss of new grafts after several months is also normal and is no reason for concern. After 3-4 months, new hairs will begin to grow from the transplanted grafts, entering their new cycle in their new home. For the most part, by a year post-op, total hair loss due to graft failure is well under 10% in the hands of a reputable surgeon who understands and values patient education as well as total long-term hair restoration.

From this, it is important to transition to the basic understanding of what makes a patient’s result look “natural” over the long-term. Remembering the concept of donor dominance is key here as well. Each follicular unit graft is genetically hardwired, so to speak, to cycle in its own, independent way over the course of a lifetime, and while the exact period of time spent in each growth phase is not 100% identical between individual grafts, there is a great deal of synchronicity at first. As it turns out, the greatest “trial by fire” for a brand-new transplant is simply time itself. It takes, on average, about 12-18 months for the newly implanted grafts to truly begin to re-synchronize into their normal growth and shedding cycles. The more careful and patient a surgeon and his team are in the earliest stages, the more “future-proof” a transplant result will be. A perfectly placed graft will, in a healthy scalp and genetic situation, “fade away” over time into the complex and seemingly natural pattern that you are all trying to create and maintain for patients. That is what makes a transplant appear non-shedding: we expect to lose some native hairs and have those be replaced by new ones; we don’t expect to lose as many total hairs, but for those we do lose to be replaced by healthy new grafts. For most patients with a typical harvest and implant, the ratio of new transplanted hairs to native hairs will settle into a new balance over time that reflects the original density of the donor area. There is no reason to expect that a patient will experience a similar and complete shedding process several years or even decades after the procedure, or to attempt to reconstruct a similar precise hairline shape and placement in exactly the same position.

This, in my opinion, is the point at which the planning for an excellent and truly long-lasting, natural-looking transplant result is most apparent. In most medical cases, the principles and technique of hair restoration have been honed to such a point over the past several decades that “competency” is a given. This is also the reason why I make a point of offering total choice of FUE or FUT options for hair restoration in the office, because either or both can provide excellent transplants when done with high technical proficiency. However, there are many subtle reasons for considering a patient’s total hair growth profile over the full timeline of his adult life in this respect. If we return to the basic biologic fact of donor dominance, we understand the short and medium-term results of a hair transplant to be “pretty much guaranteed” if the surgeon has proper skill and expertise. But the single biggest challenge to the long-term (20-30+) viability of a hair transplant is the progressive nature of Androgenetic Alopecia, also known as (male or female) pattern hair loss. It is therefore up to a surgeon’s experience and wisdom in planning to “future-proof” an excellent transplant as much as possible. The most effective way to do this is to not over-harvest, to respect the “permanent” donor zone (which is not truly permanent for all patients, unfortunately, as some men experience a thinning “donor area collapse” in their later decades, too), and to not over-distribute a one-time, finite resource of grafts to areas of a scalp that may well need more in the future than are being used for today. This is, to a large extent, a kind of personalized geometric and art-historical art/science. What looks good at age 30 is often an obvious giveaway at age 50 or 70.

It’s important to re-emphasize here, as we move towards the conclusion of this essay, that all of this added and future-proofing implies a certain conservatism in technique that is good practice no matter what a patient’s specific situation is. Placing too much tension on an outer table FUT strip, over-harvesting with FUE in a way that leaves the donor area with a noticeable loss of density, over-filling the frontal zone with no plan for the crown and mid-scalp, etc are all ways of creating what I have found to be the two most common long-term patient aesthetic complaints: unwanted visible scarring, and depletion of the patient’s supply of total donor grafts. A low, unobtrusive FUT strip closure with proper tension and contour of the scalp to leave a virtually invisible linear scar (if a patient will ever be able to see his own head in that way) is a cornerstone of FUT in our office, as is extremely conservative density (higher number of grafts with lower number of follicular units), again, to future-proof an excellent transplant as much as possible. A full and complete patient consultation will include a thorough and long-term examination of a patient’s total hair profile, which includes both native and donor characteristics. With time, thinning may also begin to occur in the back and sides of the scalp in certain patients, making an otherwise “perfectly executed” but high-graft-count single-session hair transplant suddenly look much more obvious to both patient and surgeon. Future needs for more surgery to “top off” an existing transplant are, of course, better met when there is still plenty of healthy donor area available. A conservative hairline and soft, mature framing around the sides and back of the head are perhaps the simplest ways to be future-proof in most medical cases. There are always exceptions, of course, but in the aggregate, long-term planning is the very definition of good medicine.

As a natural continuation of this last point, it is important to remind ourselves that hair transplantation is, among other things, about treating an organ of the body, in this case the scalp and hair, that is sensitive and responsive to the general health of an individual. As it is with other cells and tissues in the body, nutrition, general and local stress, and more specific and acute health events can have an impact. Hair transplantation, however, is in the majority of cases a permanent, “fix it and forget it” solution because it is designed to be so. (A scalp massage with well-trained hands to ensure gentle handling and post-op maintenance is recommended, as this will provide a number of benefits to graft health as well as the general head-neck region.) However, systemic health issues such as pronounced nutritional or endocrine deficiencies or hypothyroidism can have an impact on the entire scalp. This is one of the reasons that there is also a strong medical arm to hair restoration in our practice: the use of medications like finasteride and/or minoxidil are helpful not only in the short and medium-term slowing of or even reversal of miniaturization of non-transplanted hairs, but also over the very long term in reducing the number and severity of second surgeries and by a factor of three or more in the number of grafts used in performing those surgeries. The former allows the patient to retain the scalp density he had prior to the transplant longer, and both reduce and delay a cascade of effects that occur in the native hair follicles as they lose density. This can be the single biggest reason for a patient to choose one surgeon over another, and any surgeon who will not work with their patients both before and after the procedure in this way is not a surgeon with your or their own patients’ long-term best interests at heart.

In summary, it is important to focus on long-term results from all angles when it comes to permanent, effective hair restoration. In terms of technique, planning, and expectation-setting, a good surgeon knows that the basic and simple reason that hair transplantation works at all is the miracle of donor dominance. The small “package” that is a hair graft knows only one fate when transplanted: that of its donor area of origin. There is no way around this, and the absolute criticality of this understanding to the health of the patient and his own total experience with your practice cannot be overstated. However, a lifetime of careful and conscientious hair growth can take place “on top of” and in fact be significantly enhanced by that basic fact. The most common source of long-term aesthetic problems for patients is, in my opinion, an improperly set expectation, and this has almost nothing to do with the graft itself and everything to do with the surgeon. A natural, patient-specific and designed result that is framed conservatively to leave room for inevitable age-related thinning is more durable over time than a hairline with an artificially high or not age-appropriate hair density, and a large, mid-scalp and crown fill is much more immediately obvious and obvious-looking years down the road than a strategic, conservative crown and mid-scalp session to address thinning that may or may not require treatment in the future. In the “interstitial years”, the natural and healthy scalp maintenance of patients who choose their surgeon with the long-term in mind begins with a properly set expectation by an experienced, highly qualified surgeon and his team.