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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:
- Hair transplants don’t address the underlying conditions of a balding a scalp
- Hair transplants don’t stop the process of pattern hair loss
- Transplanted follicles may eventually miniaturize too
- 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.
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.
Rob English is a researcher, medical editor, and the founder of perfecthairhealth.com. He acts as a peer reviewer for scholarly journals and has published four peer-reviewed papers on androgenic alopecia. He writes regularly about the science behind hair loss (and hair growth). Feel free to browse his long-form articles and publications throughout this site.