- Hair Transplant Overview
- Transplant Growth Timeline
- Frontal Hairline Techniques
- High Density Graft Arrangement
- Lateral Slit Technique
- Donor Harvesting – Strip Method
- FUE – Folicular Unit Extraction
- Graft Preparation
- Trichophytic Closure Technique
- Graft Placement
- Transgender Hair Restoration
Hair Transplant Overview
Modern hair transplantation is a sophisticated, refined process of moving hair from one part of the body (usually the back of the scalp where there is an abundance of donor hair) to an area where it is lacking (alopecia). Since the 1950’s, hair has been successfully transplanted from the back of the scalp to the other areas of the scalp. The technique has evolved into an ultra-refined process of harvesting the hair, preparing the individual follicular units, and delicately transplanting the hair to the desired site. At the Gabel Hair Restoration Center, Dr. Gabel and his team specializes in treating men and women who are looking to maintain and restore their living, growing hair utilizing the most modern, up to date hair transplant techniques.
Follicular Unit Transplantation (FUT) is a surgical procedure where natural occurring bundles of hair, called follicular units, are transplanted from the donor area to the area of alopecia, or recipient area. The follicular units are the most natural way that hair exits the scalp. Follicular units bundles may contain 1, 2, 3, or more hairs. When transplanted, the follicular units are then arranged in the most natural pattern: the frontal hairline will receive the single hair units for a soft hairline, and the central area of the scalp will have the larger 3 or 4 hair follicular units to give a denser appearance.
In the FUT procedure, Dr. Gabel and the patient will review the surgical plan and draw out the area to be transplanted. In the procedure room, the back of the scalp will be numbed, and he will remove a thin strip of tissue. The tissue is then examined and the individual follicular units are separated using precise stereo-microscopic dissection techniques. While this is occurring, Dr. Gabel will make the small openings in the scalp in the recipient site where the grafts will be inserted.
In contrast to FUT, Follicular Unit Extraction (FUE) is a technique where the individual follicular units are extracted one-by-one from the scalp. In this procedure, instead of making an incision and removing a strip of scalp, a round scalpel punch is used to make a circular incision around the follicular units allowing them to be extracted one-by-one. The follicular units are then examined under the high-powered microscope and trimmed as needed. They are then placed into the recipient sites that Dr. Gabel has created. There are several reasons to perform FUE on a patient, the most common being the ability for patients to cut their hair very short without visualizing a linear scar in the donor area. Dr. Gabel has tremendous experience with the FUE technique and has been performing it longer then any physician or group in the Northwest.
Ultimately, the most important goal of the procedure is to produce a natural result that satisfies the goals and expectations of the patient.
Hair Transplant Growth Timeline
Day 0: Day of hair transplant. The day starts early for Dr. Gabel and his patients. Depending upon the size and location of the transplant, the procedure can last from 3 hours to over 8 hours. When patients are finished, Dr. Gabel will review exactly how to care for the grafts until the following morning when the patient returns to have their transplants examined and their hair washed. Dr. Gabel will prescribe an antibiotic and pain medication to help with the postoperative recovery after the procedure.
Days 1 – 5: The first 2 weeks following a hair transplant are the most critical. Dr. Gabel provides his patients with detailed instruction booklets on exactly how to care for the newly transplanted grafts. During the first 5 days, patients will experience swelling of the forehead and at the back of the head, which is the donor area. The skin may also look red at the areas where all the tiny incisions were made for the newly transplanted hairs. This redness usually resolves after the first week or 2. After only a few days, the donor area is no longer tender.
Days 6 – 10: At this point, patients no longer experience any swelling and the redness should only be faint or completely gone. For each follicular unit transplanted, a “crust” will form which is the attached skin layer drying out. During this time, Dr. Gabel will have his patients gently remove the crusts by thoroughly soaking the grafts, and then gently rubbing them with a finger. By day 10, all the crusting should be gone and the transplanted hairs will appear like a “crew-cut” haircut. Lastly, around day 10, the sutures or staples will be removed.
Week 2 – 3: The transplanted hairs will start to shed at this point, and by the end of the 3rd/4th week, most will be gone. This is a normal part of the healing process and is totally expected. The newly transplanted hairs go through a shedding process as the actual hair shaft is released, but the actual follicular unit and bulb are totally intact starting to grow a new hair shaft. This is part of the normal hair cycle.
End of Month 1 – Month 2: The hair follicles have entered into the resting phase of their cycle. The length of the resting phase can vary before they start to grow again. At this stage, patients will appear exactly as they did prior to surgery with regards to the amount of hair present. At this time, patients are able to style and color their hair as they desire.
Months 2 – 4: The new hairs should start coming out. For some patients, their transplanted hairs start growing early in the timeline; for others, they start growing later. Patients will see the new transplants, but they will be thin at this stage as they begin to emerge from the scalp. Most of the native hair will be growing back at this time. The donor area is healing and any redness at the donor site will resolve.
Months 5 – 9: Patients will start to see a considerable amount of hair emerging from the scalp. The hairs are thinner; many of the transplanted hairs will be over 3 inches or longer and is able to be groomed. Toward the end of this period, the hair will show textural changes and start to thicken up. At 6 months, Dr. Gabel will see the patient in follow up. The donor area will be completely healed at this point.
1 Year: Patients have achieved about 80% of the growth of the transplanted hairs. Most of the hairs will have emerged from the scalp. Patients may notice that the hairs have a little “curvature” to them. This is from the micro-scarring that is at the recipient sites. This resolves and the hair takes on its native appearance over the next year.
2 Years: The final appearance from the hair transplant is appreciated at this point. For some patients, they achieve the full appearance by 1 year; others will take longer for the hairs to emerge and increase their density and thickness. Additionally, as the hair grows longer, that provides a fuller appearance since the volume of hair is increased at the transplanted area.
Photographs to Illustrate Growth Timeline
To illustrate the actual growth, the patient below patient had a hair transplant on September 3, 2014, with Dr. Gabel at his Portland hair hair restoration office. The patient had significant hair loss in the frontal aspect of her hairline and frontotemporal angles. She desired to redefine her hairline and increase the hair density at the angles. The following series of photos shows the time-line of growth.
10 Days After hair Transplant
Here are the 10 day suture removal photos from her hair transplant with Dr. Gabel. I tried to attach these to the original post, but I was not able to edit the original post.
As seen, the hairs are all growing which indicates to me that the transplanted hairs are all viable. When patients come back for the suture/staple removal at 10 days, I point this out to them because in a short time, over the next 3 weeks, most of the transplanted hairs will fall out. Some patients become concerned about the hairs falling out so I refer them to these photos that show all the transplanted hairs growing. Also at this time, there is a small amount of exudate or crusting that should be almost gone. All patients will develop some type of exudate and it is important that they follow their physician’s postoperative instructions for proper care in the postoperative period.
2-Months After hair Transplant
These are the 2-month photographs of her progress. As shown, the transplanted hairs have all released and shed. This is normal and expected at this stage. The hairs that are transplanted go through a temporary “shock” period where the actual hair shaft is released. The hair now starts growing a new hair shaft and we will start seeing that in the next few months.
3-Months After hair Transplant
These are the 3-month postoperative photographs showing that the hairs are now starting to grow in. This patient had 3439 follicular unit grafts transplanted at our Portland Hair Transplant Center. Her hair is matted down as she was wearing a hat all day long prior to coming into the office for her photographs. The hair is just stating to come out, and as expected, it is thin and space. This should change over the next few months as more of the hairs start to grow, and the hair shafts begin to thicken.
Frontal Hairline Techniques
The frontal hairline is arguably the most important area of a hair transplant. It ultimately defines and frames the face. It is the most visible portion of a hair transplant, and patients deserve to have a natural appearance to the hairline. Tremendous variations exist in facial features, and creating a natural hairline not only requires superb technical skills, but also an artistic approach is essential to meet patient’s high expectations. It is critically important that the hairline design meet the needs and desires of the patient today, but also has a natural appearance as he or she ages.
Hairline designs differ from patient to patient based on many factors including the patient’s sex, physical characteristics (facial size, shape), hair color/density, ethnicity, and patient’s individual desires. For example, some patients desire a straight hairline, while others would deep frontotemporal recessions because of their facial features. Ultimately, the design of the new frontal hairline will be accomplished after extensive discussions between the patient and Dr. Gabel.
The most important aspect of creating a hairline is to make it appear as natural as possible. This is accomplished first by designing the most appropriate hairline for the patient. When meeting with Dr. Gabel, a thorough discussion on hairline design will be done to develop a design that both meets the goals of the patient, and is natural appearing. The hairline should be symmetrical between the left and right sides, but also some irregularity needs to be incorporated which gives a natural appearance.
From a technical point of view, the hairline is created exclusively utilizing single follicular unit grafts. In the most frontal portion of the hairline, Dr. Gabel picks out the thinnest single unit grafts, and as the hairline progresses to posteriorly, the thicker single unit follicular grafts are utilized. Additionally, the hairline should not be straight – this is a sign of a bad transplant. The hairline should have irregularities which is natural.
As the hairline progresses to the middle of the scalp, the density also changes. Dr. Gabel will employ an artistic flair to the frontal hairline by producing a gradient effect to the hairline where the frontal hairline has less density, and the posterior hairline progressively gets more dense. Again, this creates the most natural appearance to a hairline.
High Density Graft Arrangement
A successful hair transplant depends upon many factors, and one of the most important qualities of a successful transplant is the ability to achieve adequate follicular unit density with the procedure. In patients who have a sufficient amount of donor hair, if the follicular unit grafts are transplanted utilizing high density graft placement techniques, the results are more natural and virtually undetectable.
To understand the concept of density, one must have some basic knowledge of the scalp. In a human scalp, the average density of hair is around 100 – 125 follicular units in a square centimeter (cm2). Since each follicular unit varies in the number of hairs, studies have shown that about 160 – 250 hairs are present per cm2. When an individual starts to notice their hair loss, they have lost approximately 50% of the hairs in that area. Even with modern surgical techniques, surgeons are not able to recreate natural hair densities of 125 follicular units/cm2. Fortunately, in order to achieve a cosmetically excellent result, surgeons don’t need to transplant hair at natural densities, but they need to be able to transplant the grafts in a high enough density so it appears as full as possible.
At the Gabel Hair Restoration Center, Dr. Gabel utilizes several techniques to achieve high density graft placement. First of all, Dr. Gabel and his team utilize high powered stereo-microscopes to meticulously dissect the grafts from the scalp tissue. This allow allows him to place more follicular unit grafts in a given area. If a follicular unit has not been properly trimmed by an experienced hair restoration technician, then high density graft placement is impossible. Each of his team members have had extensive training and experience with the stereo-microscopes that meets Dr. Gabel’s high standards for follicular unit preparation.
Secondly, in order to place as many grafts as possible in a given area, Dr. Gabel utilizes custom sized cut blades which are tailored to an individual’s follicular unit size. Individual follicular units and grafts vary in size from person to person. Therefore, in order to create an opening in the skin to fit an individuals follicular unit grafts, Dr. Gabel will measure the dimensions of the grafts, and make a blade that perfectly matches the graft size for the specific follicular unit, and avoid unnecessary trauma to the skin and minimizes disruption of the local blood supply. Also, if Dr. Gabel is placing grafts between existing hairs, a custom cut blade allows him to blend the new grafts in a way to achieve higher densities and a more natural result.
There are several different methods to create the openings in the scalp which are used by Dr. Gabel, he predominately utilizes the lateral slit technique to create higher densities with the hair transplant, which ultimately achieves a more natural result. The lateral slit technique, also known as the coronal technique, allows Dr. Gabel have have more control and to place more follicular units in a given space then any other technique. It also allows more control of how the grafts exit the scalp, which is especially important in the frontal hairline where an acute angle is necessary.
Megassessions is a term that describes transplanting a large amount of hair, greater then 3,000 grafts, and not uncommonly over 5,000 grafts, in one sitting. Overall, the more hair that can be transplanted in one session translates to a significant time savings and overall cost saving for the patient. This technique requires a large, organized, and experienced staff with the ability to process such a large number of grafts and place them at the same time. Currently, there are very few surgeons who have the ability to transplant more then 2000-2500 grafts in a single session. In patients that are good candidates for a megasession, the results can be very dramatic because it has the ability to cover a larger area of the scalp in one sitting.
Before and after photographs demonstrating a hair transplant greater than 3000 grafts in one procedure to the frontal hairline and midscalp.
Dr. Gabel and his dedicated hair restoration team have the technical skills and experience to accomplish these large procedures for which he has been performing for many years. Recently, Dr. Gabel edited a textbook and wrote an article specifically on the topic of megasessions.
Lateral Slit Technique
Recipient sites refer to the precise location where the prepared follicular units are placed. Recipient sites are made by making small incisions to exactly fit the size of the patient’s follicular units. Dr. Gabel prefers to create lateral slits (also called coronal or horizontal slits) vs perpendicular slits as lateral slits have the advantage giving the maximum degree of control of the direction that the hairs will grow and also the precise angle that they grow out of the skin.
The lateral slit technique allows Dr. Gabel to provide maximal density and coverage, as the hairs tend to fan out over the surface of the scalp in a layering effect giving the illusion of higher density, and ultimately a more natural appearance. The perpendicular technique (also referred as the sagittal technique) can result the hairs to stick up giving an unnatural appearance.
The angle that the hair exits the scalp is absolutely critical in achieving a natural appearing result. In the frontal hairline and the central crown areas, the hairs exit the scalp in a very acute angle. In the mid-scalp region, the hairs exit the scalp in a forward angle, but not as acute. Utilizing the lateral slit technique, Dr. Gabel is able to specifically create an opening for the follicular units at the exact angle for the particular area that is being transplanted.
In order to make the lateral slits, Dr. Gabel will make custom cut blades that exactly fit the follicular units of the patient. Follicular units vary in size from the small single hair follicular units to larger 4 or 5-haired units. After the follicular units are prepared, Dr. Gabel will measure each size follicular unit and make a custom cut blade for the various sized grafts. Utilizing this method allows Dr. Gabel to precisely match the follicular unit graft to the size of the slit opening. Since the sized opening is precisely fitted, Dr. Gabel is able to make more openings in a given space maximizing graft density and ultimately a more natural result. Additionally, healing is also improved because the grafts will fit perfectly into the recipient sites maximizing oxygenation, promoting faster healing, and increasing graft survival.
Donor Harvesting – Strip Method
In follicular unit transplantation, the follicular units grafts are essentially moved from one area of the body with an abundant supply of hair (donor) to the area lacking hair (recipient area). Utilizing the strip method in hair restoration surgery, which maximizes yield and minimizing scarring, Dr. Gabel will remove the donor tissue from the back of the head in a single thin strip. The donor hair is usually in the back of the head where the density is the highest and those hairs have the best long-term stability.
The strip method is preformed by precisely examining the donor hair for the best hairs for the particular area to be transplanted. Once this is marked out, the hairs are trimmed to a length of approximately 8 mm. Dr. Gabel prefers the hairs to be a little longer so he is able to see the curve of the hairs, which is important when placing the grafts. The area that was marked out is numbed, and Dr. Gabel removes the strip of tissue. The donor area is then closed with either sutures or staples depending upon the specifics of the case.
Dr. Gabel and his team at the Gabel Center will provide detailed instructions on the care of the incision after surgery. About 10 days after surgery, the sutures will be removed which is essentially painless. Occasionally, Dr. Gabel will use absorbable sutures that do not need to be removed. The donor area will heal over the next several weeks resulting in a fine line scar.
Donor Harvesting – Follicular Unit Extracting (FUE)
Follicular Unit Extraction (FUE) is a method of extracting or removing the donor hair for hair transplantation. Small, circular punches are used to make a round incision in the skin around the follicular unit, separating it from the surrounding tissue. The follicular unit graft is then extracted or harvested from the scalp, leaving a small opening, which quickly heals. This process is repeated until Dr. Gabel has harvested enough follicular unit grafts to complete the planned procedure. The FUE method is different from the strip method as the FUE extraction sites heal in a random pattern of circular scars, which is easier to hide in those patients who prefer to keep their hair very short.
In FUE, various instruments are utilized to extract the grafts from manual hand-held devices, electrical rotary instruments, and most recently, and automated robotic devices. Currently, Dr. Gabel utilizes a variety of instruments, and tailors the device to use to maximize survivability of the transplanted hairs.
Since FUE does not leave a linear scar, this procedure may be more appropriate for patients who want to cut their hair very short in the donor area. It can also be utilized for those patients who have had prior strip procedures to harvest more hair. It also allows the surgeon to harvest hair from other areas of the body such as the beard or chest. Lastly, in those patients who have had prior surgery, they may have enlarged scars in the donor area, which can be camouflaged by placing FUE grafts into it.
In FUE, the donor area of the scalp is trimmed to 2 – 3 mm in length. Utilizing high-powered magnifying glasses, Dr. Gabel is able to visualize the exact angle and direction that the hairs exit the scalp. Depending upon the sized of the graft, Dr. Gabel will use a FUE punch ranging from 0.8 mm to 1.2 mm to harvest the grafts. After the incision is made, the grafts are gently removed and examined under the microscope to verify the quality of the extraction and remove any excess skin. The grafts are then placed into the slits with micro-forceps.
Follicular Unit Extraction requires a highly skilled and experienced surgeon to perform the technique successfully. Each graft must be extracted in the center of a very small 1.0 mm punch to avoid transecting and damaging the graft. In the Northwest, Dr. Gabel has the most experience in FUE as he has been performing this since 2006 when the FUE method was in its infancy.
One of the most important stages of follicular unit transplantation is the preparation of the grafts. When the grafts are prepared, it is vital that the entire follicular unit is kept intact, as this will maximize the survivability and growth of the hairs. The intact follicular units also provide for the most fullness to a result as they contain the most hairs per graft. In order to prepare the grafts correctly, Dr. Gabel has a team of highly trained and experienced assistants to carefully perform this vital function.
Once the donor hair is harvested from the scalp, the strip is immediately bathed in specialized holding solution called HypoThermsol, which has been scientifically shown to optimize graft survivability. The average donor strip is approximately 1.5 cm wide and a variable length depending upon the number of follicular units needed for the case. There are approximately 70 – 100 follicular units per square cm of donor tissue, which varies widely between areas of the scalp, and between patients. Therefore, if Dr. Gabel is performing a 2,000-graft case, the donor strip will be approximately 1.5 cm wide and 13 cm long.
Stereomicroscopes are utilized to “sliver” and subdivide the donor strip into small wafers of tissue. The microscopes are needed to divide the tissue at the exact point at the spaces between the follicular units and avoiding any transection or damage to the grafts. This results in wafers of hair bearing tissue with multiple follicular units. Next, one of our highly experienced assistance will subdivide the wafer of tissue into the native follicular unit grafts. Each wafer will contain follicular graft of all sizes, which are then sorted into like grafts. The grafts are stored in HypoThermsol at a specific temperature, which assures maximum survival until they are placed into the recipient sites.
Trichophytic Closure Technique
The tricophytic closure technique is a surgical method to improve camouflaging the linear scar in follicular unit transplantation. In the strip method of extracting the donor hair, a small strip of skin is removed from the back of the scalp. Normally, the surrounding hair easily covers the scar. For patients who keep their hair very short, the resulting donor scar may be visible.
The tricophytic closure technique is performed after the strip is removed. The result is two skin edges that need to be approximated and sutured together. Dr. Gabel will remove a small, beveled sliver of skin that contains trimmed hairs. The edges are then sutured together in the normal fashion. The result allows the trimmed hair at the edge of the incision to grow directly through the scar during the healing phase. This can significantly approve the appearance of the donor scar by camouflaging the scar.
The final stage of a hair restoration procedure is the actual placement of the grafts into the recipient area of the scalp, which Dr. Gabel performs. Once the donor hairs are properly trimmed using stereo-microscopes, they are categorized into the 1-hair, 2-hair, 3-hair, and 4-hair follicular units. The follicular units are held in a specialized solution called HypoThermosol biopreservative which has shown to increase the survivability of the grafts. They are also maintained at an appropriate temperature around 8¬degrees Celcius, which has also been shown scientifically to improve the longevity of the follicular units.
Dr. Gabel and his staff at the Gabel Center use specialized loupe magnification that has been custom fit for each of his staff that place the grafts. This high magnification allows Dr. Gabel and his placing team to easily visualize the grafts for proper grasping, and to also easily visualize the graft openings for a smooth, non-traumatic insertion of the graft. If the grafts are damaged during placement, they may not grow. Although most hair restoration physicians do not place grafts, Dr. Gabel always is involved throughout the entire procedure placing graft with his highly trained and experienced staff. They also each use specialized, 0.12 mm tipped forceps which allows them to be absolutely precise on handling the grafts, and non-traumatically placing the grafts into the sites.
In the frontal hairline, the thinner 1-haired follicular unit grafts are placed, followed by the thicker 1-haired follicular unit grafts. Approximately 1-cm behind the hairline, the 2-haired follicular units are place, and in the central tuft, the larger 3-hair/4-hair follicular units are placed. This technique allows the hairline to develop in a gradient fashion, which is ultimately gives the most natural appearance to the frontal hairline, and gives the greatest appearance of density for the scalp.
Graft placement is a surgical technique that must be carried out with extreme precision and accuracy to achieve the best results. It requires an individual with years of experience to do it correctly or risk graft damage and poor growth. Dr. Gabel personally places grafts on each of his patients.
Transgender Hair Restoration
Dr. Gabel is actively writing content for this section.
Eyebrow transplantation surgery is growing in popularity among men and women. While the most common cause of eyebrow hair loss is over-plucking, it may also be due to scarring, electrolysis or laser hair removal. During the eyebrow transplantation procedure, modern follicular unit technology enhances or restores the eyebrows permanently with natural and undetectable results.
This aesthetic outpatient procedure takes place over a few short hours in the Gabel Hair Restoration Center’s custom-built surgery suite and is performed under local anesthesia. Donor hair is selected carefully from elsewhere on the head to mimic the characteristics of the native eyebrows. Single hair units are then dissected under high magnification stereoscopic microscopes by trained technicians and transplanted by the surgeon into tiny recipient sites along the brow line. The eyebrows are one of the most expressive facial features and can convey a variety of emotions. Considerable attention to detail must be given to the placement, angle, and direction of hair growth to aesthetically frame the eyes and give symmetry to the face to create a natural appearing eyebrow.
As with any medical procedure, it is important that the patient discuss his or her goals directly with the physician who will conduct the procedure and is confident in the surgeon’s credentials. During a personal consultation with Dr. Steven Gabel, the eyebrow transplantation procedure and the postoperative expectations and guidance are thoroughly discussed. To help guide the patient through the postoperative stage, detailed instructions are provided. Slight redness and swelling at the transplanted site are not uncommon immediately following the procedure, and discomfort is usually minimal. In fact, many patients return to work the following day. The recipient areas on the brow line form small crusts that last for five to ten days. Once these crusts fall off, all signs of the procedure are virtually undetectable. The relocated hairs will begin to shed after two weeks but will re-grow permanently in approximately three months. The new eyebrows will require periodic trimming, and a full cosmetic result can be expected after twelve months.
Dr. Gabel is actively writing content for this section.