The Case Against A Hair Transplant

Read time: 10 minutes

Considering A Hair Transplant?

If your hair is thinning, it’s tempting to consider a hair transplant as a means to course-correct. And you might find yourself more enticed when walking into a hair restoration office and seeing patients’ results. It’s true that some hair restorations surgeons are incredibly talented – capable of upping their patients one or two Norwood notches in a series of procedures. But is a hair transplant worth a $10,000+ price tag?

When I was diagnosed with pattern hair loss in 2007, my answer was, “Yes.” I wanted to reverse my hair loss at any cost. But unfortunately, I wasn’t in a financial position to afford a transplant. Now nearly a decade later, I’m no longer convinced the transplant route is the best path forward. Beyond the costs of the procedure, there are a few things you should know before jumping in.

This article discusses how hair transplants work, options to consider before getting one, and if you’re getting one, how to best prepare your scalp for a successful transplant.

Hair Transplant Basics

A hair transplant is a surgical procedure that moves hair follicles from non-balding sites to balding sites. If you’ve ever noticed, men tend to bald in a horseshoe-shaped pattern. The hair on the tops of their heads tends to disappear, while the hair on the sides, back, and nape of the neck mostly remain for life.

A hair transplant surgeon usually takes hair follicles from the back and nape of the neck (the “donor” site) and moves them to balding regions of the scalp (the “recipient” site). In some cases, hair transplant surgeons will even take body or facial hair and move it to the scalp – though this practice is much less common.

Are Hair Transplants Successful?

It depends on how you define the term “success.”

How do I define success? A reversal of pattern hair loss. An arrest of future thinning and recession, along with the thickening and regrowth of previously vellus and dormant hair follicles.

How do hair transplant surgeons define success? Reorganizing our healthy hair follicles to cosmetically cover our pattern hair loss. This means moving thick hairs from the back of your head to thinning areas in the front, creating the appearance of a younger hairline and healthier head of hair.

What’s the difference?

To me, success means regrowth – or reactivating our dormant follicles (the hairs that have disappeared). To hair transplant surgeons, success means cosmetically covering up the symptoms of that condition.

Hair Transplants Don’t Stop Hair Loss Progression – They Merely Mask It

There’s nothing wrong with wanting to cosmetically hide hair loss. And some hair transplant surgeons are impressive hair architects. The right surgeon can make your vertex look thicker. The right surgeon can make your hairline look years younger. But let’s make one thing clear:

Hair transplants do not stop the process of androgenic alopecia. Even after a hair transplant, the surrounding hair in your recipient site is still going to get thinner. This presents a challenge to surgeons: how do you create a natural-looking hairline while also anticipating the pattern of future hair loss, so that five years later when a patient has further thinning, their transplanted hairs don’t stick out like a sore thumb?

This is especially challenging because according to most hair transplant surgeons, “donor hairs” from the back of your head will never thin. They’ll stay in place forever. But digging into the research, is this actually true?

Is It True That Transplanted Hairs Never Thin?

Contrary to popular belief – healthy hair follicles transplanted into thinning or balding regions can eventually thin too.

This is known as “Donor Dominance” – the observation that transplanted hairs eventually take on the look of the hairs near which they’re transplanted. If those hairs happen to be thinning, your transplanted hairs will likely also miniaturize (albeit at a slower pace).

This is contrary to what most people read online and what most surgeons say. Typically you’ll hear that hairs transplanted from the back of the head are “immune” from androgenic alopecia and never miniaturize.

Then Why Do People Say That Transplanted Hairs Never Thin?

This assumption – that transplanted hairs never thin – arose from the first few decades of hair transplantation research.

Over fifty years ago, researchers published a study highlighting an attempted hair transplant. Scientists took thick healthy hairs from non-bald regions in the back of the scalp and transplanted them to balding regions. These hairs continued to grow normally for the duration of the study, and so scientists concluded that these hairs would continue to grow in perpetuity because they were protected, for reasons unknown, from male pattern baldness (MPB).

Following studies showed similar results. During each study’s duration, most hair follicles that survived transplantation tended not to miniaturize.

The key term here is study duration. The majority of these studies ranged from six months to three years. Is that long enough to gauge whether transplanted hair is thinning? Let’s look at our end points.

It takes infants over half a decade to grow hair. It takes adults multiple decades to lose hair. So a three year observation period probably isn’t long enough to say whether transplanted hairs are forever protected from MPB. In fact, basing my opinion off of anecdotes, I think the opposite is true – that transplanted hairs do thin.

I’ve provided email and video support to dozens of hair transplant recipients. Of the ones who received a transplant five to ten years ago, nearly all of them claim most of their transplanted hairs have already fallen out. I also have a friend with a hair transplant who’s experiencing the same thing. That’s not very encouraging.

So the studies conflict with the anecdotes – or at least the anecdotes I’ve been told. My guess is that this discrepancy exists due to too-short study durations. But I’ve also read surgeons say this could be caused from transplanting follicles from too close to the vertex – thereby transplanting hairs already susceptible to baldness.

Why Do Many Hair Transplant Recipients Report Their Transplanted Hairs Are Thinning Years After Surgery?

The reason why isn’t yet 100% clear. But based on the evidence, my theory is this:

Healthy donor hairs are transplanted into balding regions of the scalp. And if you’ve read other articles on this site, you know that balding scalp regions have elevated tissue DHT, fibrosis, calcification, excess sebum/dandruff build-up, collagen remodeling, a fused galea, and a host of other symptoms stemming from chronic, localized inflammation.

These conditions starve the follicles of nutrients and proper blood flow. This results in follicle miniaturization, and over a series of hair cycles, baldness.

These scalp conditions tend to precede hair loss. They kick start the balding process. But the process in which hairs miniaturize still takes decades.

By that same logic, if you transplant thick healthy hair follicle units into balding regions, it might also take decades for those transplanted follicles to thin from reduced nutrient and blood supply. These hairs eventually miniaturize too, but since they’re starting out thick and healthy, it takes a long time.

Do All Transplanted Hairs Survive The Surgery?

Some studies suggest that with the right surgeon, 90% survival rates for follicles is common.

But it’s hard to say just how factual this is. Just read this quote from the following hair transplant review:

“Micrograft survival rates in hair transplantation have been frequently described in private conversations by hair transplant doctors as variable at best. References in medical literature may grossly underestimate the prevalence and magnitude of poor growth. This is probably because most hair transplant surgeons are concerned that publication of a significant incidence of poor growth would reflect negatively on their practice.”

Hair transplant surgeons are often the authors of studies on hair transplant efficacy. Interestingly, I’ve never found a study tracking hair transplant survival rates 10+ years down the line (if you find one, I’d love to read it). This is why I tend to default to the anecdotes from transplant recipients. The surgery is a short-term gain but not a long-term solution.

On top of that, surgeons also know that androgenic alopecia continues after a hair transplant. This is why most ask their patients to start taking Finasteride and Minoxidil post-surgery. They know that more thinning will make the transplanted hairs look out-of-place. Some surgeons even mandate massages weeks prior to surgery (sound familiar?) to increase scalp elasticity and improve transplanted follicle survival rates.

Summarizing The Downsides

Hair transplants can be cosmetically beneficial, but keep in mind the following:

  1. Hair transplants don’t address the underlying conditions of a balding a scalp
  2. Hair transplants don’t stop the process of pattern hair loss
  3. Transplanted follicles may eventually miniaturize too
  4. Micrograft survival rates – the percent of hairs that survive being transplanted from a healthy region to a balding region – are variable at best

Knowing this, can we improve hair transplant success rates – both in maintaining existing hair and improving the odds of a high follicle survival rate?

Improving Your Odds For A Successful Hair Transplant

I think it’s necessary to first do everything possible to address the underlying conditions of a balding scalp – calcification, fibrosis, scalp inelasticity, reduced blood flow, reduced nutrient supply, decreased subcutaneous fat, and any inflammatory-related symptoms. So how do we do this:

#1: Massaging Pre-Surgery

Surgeons who mandate massages prior to surgery are getting it right, though they’d do an even better job by telling their patients to massage for a full year instead of two-three weeks. There’s evidence to suggest aggressive massaging benefits most (and maybe all) of the conditions affecting a balding scalp. There’s even evidence that hard massages can thicken existing hair and regrow dormant follicles, the mechanisms of which – wound healing, angiogenesis, and gene upregulation. – are still being uncovered.

#2: Dermarolling Pre-Surgery

Beyond massaging, surgeons might also benefit their patients by mandating dermarolling sessions for months leading up to surgery. Like massaging, dermarolling seems to promote hair regrowth through similar mechanisms – angiogenesis (the formation of new blood vessels), wounding / healing, the downregulation of calcification inducers, increased blood flow, and thereby better oxygen and nutrient supply to dormant and miniaturizing follicles.

My guess is that either of these mechanical stimulation exercises would position transplant recipients for better micrograft survival rates, and some thickening or regrowth of natural hair – even before they walk in for their operation. And by arresting hair loss through these natural means, you’re also making your surgeon’s job a lot easier. Why? If you can stop the progression of your hair loss before and after your surgery, your surgeon can think less about crafting a transplant around your future thinning, and more on making the surgery look good.

Final Thoughts

Personally, I feel that hair transplants should be a last resort. Many people have seen significant regrowth through natural means such as mechanical stimulation (massages and dermarolling) – especially in conjunction with dietary and lifestyle changes. Why not try those for a year and postpone the $10,000 cost of a hair transplant? The worst case scenario: if you later decide to get a hair transplant, you’ve already likely helped to reverse the scalp conditions (fibrosis and calcification) which precede hair loss. And that means you’ll probably have a better transplant.

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Stop Googling "How To Regrow Hair" Until 3AM

Instead, just sign up for my 10-day course on natural hair recovery.

You'll get access to my before-after photos, the science behind the DHT paradox, hair loss mistakes to avoid, reader-submitted photos, and more.

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14 Comments

  • Nicholas

    Reply Reply October 21, 2016

    Great article Rob, thanks again for the info you’re sharing!

    I wanted to ask you a question on your method: what about the success rate? Are there any failures or people not satisfied with the results (after a reasonable time spent massaging)?

    • Rob

      Reply Reply October 23, 2016

      Hey Nicholas! I’m not sure what the exact success rate is. The challenge is that not everyone who gets the book tries the regimen, and not everyone who tries the regimen contacts me (or keeps in contact with me). Based on everyone who’s stayed in contact with me, the majority report thickening and some regrowth (with the degree varying), some people report just a stop in hair loss, and about 5-10% report no change in their thinning. My goal is to get that number to 0% (which is why I released the new book – to make the techniques clearer, update everyone on the new literature, and highlight the practices of the best responders). So I’m hoping to have more information for you in the coming months.

      Best,
      Rob

  • Alex

    Reply Reply October 22, 2016

    What do you mean by a fused galea? Can you explain further ?

    • Rob

      Reply Reply October 23, 2016

      Hey Alex,

      You can read more information about the galea fusion theory here:

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4639964/

      I’m currently writing an article about all the theories of the galea’s involvement in hair loss. That will give you a much clearer understanding of the potential mechanisms at play (and be more helpful than the link I just sent you). I’ll let you know when it’s ready.

      Best,
      Rob

  • Alex

    Reply Reply October 24, 2016

    Is the galea supposed to slide freely on the scalp bones?

    • Rob

      Reply Reply November 1, 2016

      Hey Alex – in general, the skin above the galea should be as elastic as the skin at the sides of the scalp. You can test this just by touching someone’s scalp who isn’t thinning or balding. There’s generally equal elasticity – with very little difference between the sides and top.

      Also, the article about the galea is now finished. Just as a heads up, it’s very technical:

      https://perfecthairhealth.com/the-leading-theories-of-pattern-hair-loss/

  • Nadester

    Reply Reply November 3, 2016

    About the Detumesence therapy study:-

    How can you take that study seriously??
    It might have given an idea as for the pattern, but “Grease trapped inside” and all is just a very amateurish way to write a study.

    Also can this method of yours surely STOP hair loss at its track??

    • Rob

      Reply Reply November 3, 2016

      Hey Nadester,

      It’s important never to weight any study too seriously, at least until there’s a body of independent research supporting it. In the case of the DT study, there are definitely some translation mishaps, plus results that – according to the literature – are otherwise unprecedented.

      So I hear where you’re coming from. The reason why I support the DT study is because 1) it’s one of the things that worked for me, 2) it’s a free therapy, and 3) its results are now supported by a handful of other studies connected to the fields of mechanotherapy. These are covered in the book, but to highlight just a few:

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4740347/
      http://www.jwatch.org/jd201111100000001/2011/11/10/growing-hair-with-botox

      There are also a handful of studies now showing wounding/healing’s effects on hair regrowth – mostly concentrated around dermarolling. Wounding/healing is also another component of the massages. So for these reasons, it’s hard for me not to take the DT study seriously. The best part is that these studies also show sustained regrowth 18+ months after stopping treatment. So unlike conventional treatments, regrowth achieved from mechanical stimulation appears to be much more permanent and independent of lifelong drug use (minoxidil, finasteride, etc.).

      As far as stopping hair loss in its tracks–

      There are no guarantees in life. The same is true for hair loss. In the above comments, I wrote about my perceptions of these protocols’ efficacies. In general, I think these regimens are more effective, longer lasting, and less dangerous than conventional treatments. They’re also much easier on your wallet (there are no supplements, surgeries, drugs, shampoos, topicals, etc. to keep buying).

      Best,
      Rob

  • Ralph

    Reply Reply November 7, 2016

    What about the role hormones and amino acids play in hair growth?
    Isn’t there a relationship between thyroid dysfunction and hair loss. I read that Arginine deficiency can also affect hair growth.

  • sharose

    Reply Reply December 4, 2016

    Hey Roab!

    Actually I want to know about oiling the hair and scalp. I oil my hair daily with massage and I have not been using any shampoo and conditioner for 3 or 4 weeks.

    It was good in starting, no hairfall, but now since last 4 or 4 days, I have not used any oil and hair becomong greasy and even with more hair fall.

    I take shower daily but its not helping. Can you help me out of this horrible condition.

    • Rob

      Reply Reply December 5, 2016

      Hey Sharose – I’m not sure I understand your question. Are you applying topical oils to your hair and not shampooing? In general, it’s harder to wash out hair gels and oils like coconut, olive oil, etc. in the absence of shampoo (which is why I don’t use gels or oils).

  • Alan

    Reply Reply May 29, 2017

    Hi Rob, I bought your book a while back. I read in there about dermarolling. I remember you said you can do it up to once a week with a 1.5mm. Is this enough time for the skin to heal? Some websites say to wait 4-6 weeks in between sessions. What is your take on this? I won’t want to risk damaging my skin or anything, but I trust your opinion and knowledge. Thank you! 🙂

    Btw, I started the massage routine but my fingers started hurting, so I took a break. I started it back up and I seem to be getting results! Small hairs are sprouting. Oh, and I don’t know if this is a thing or not, but I’m getting some small acne randomly from massaging, and it only has happened when I would be frequently massaging my head. Is this from the release of sebum or dht? I am not a person who ever has acne and this seems to have started only when I started massaging.

    Thanks again!

    • Rob

      Reply Reply May 30, 2017

      Congrats on the regrowth Alan! That’s great to hear.

      In human studies showing regrowth from dermarolling, a 1.5 mm used once weekly was what achieved results (with some studies switching to a once-every-fourteen-days regimen after the first few months). These studies, along with reader anecdotes, is where I build my recommendations.

      The acne is commonly reported, and is usually the result of the acute inflammation generated during the massages. It’s more common in those with oily skin, which suggests that the inflammation + sebum have some sort of interaction with each other. This is easily course-correctable! Just take a few days off and the problem should dissipate. And when you return to the massages, just decrease intensity to evoke less irritation (and acne).

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