We are born with an average of 100,000 hair follicles on the scalp. (Blondes have 20% more, redheads 20% less)
Each hair follicle on the scalp normally grows for 4-6 years (anagen phase) and then it goes through a resting phase (telogen) of approximately 4 months.
Your terminal hair follicles are under the influence of the inherited genes and hormones. When we age, the hair follicles that are susceptible to male pattern baldness will shorten their growth phase and slowly turn into miniatures of what they once were. So from thick long hairs, they turn into peach fuzz-like hairs. From an anagen phase of 4-6 years they may only grow for 3-6 months and so they are short and thin, like peach fuzz. Eventually they die (apotosis)

Diameter decreasing in size
However, only hair at the top and front of the scalp is susceptible to male pattern baldness. Hair on the sides and lower back of the scalp always stays. Most bald males have a fringe of hair. Some people call it the Friar’s Fringe.
When a patient first notices the hair loss, it is usually in the form of a receding hair line or that the hair on top of the head is not growing like before. It is much shorter and falls off sooner so that the top part does not grow longer than 3-4 inches. They soon see their scalp a lot more than before. Patients will also notice an increase in hair loss when shampooing or showering. The hair that had been falling off is called “telogen” hair and you can recognize telogen hair by the round bulb at the end. Normally, 15% of our hair goes through a telogen phase of 3-4 months. In male pattern baldness the percentage of telogen hair is much higher as the growth of each hair is so much shorter. As the hair miniaturizes, more skin is seen and this is generally accepted as balding.

Hamilton classifies male pattern baldness into eight subgroups and the diagram is shown here.

This involves the removal of hair from the back fringe where it constantly grows terminal hair to the top of the scalp where hair is gone. These hair roots will behave as they did in their original site. Continuing hair growth in these transplanted hairs has been observed since 1958 and it is believed that these grafts will grow for a lifetime.
Once the hair roots are removed from the fringe area, they are gone. However, on the back of your scalp, there are so many curtains of hair falling down that the loss is not evident. Harvested areas are sutured together to leave a fine scar line that is usually covered with the remaining hair curtains.
We cannot use donor hair roots from friends or relatives because the body’s immunological systems will reject them. Also artificial fibres cannot be used as they will cause infection and extreme scarring.
In Europe and Japan there are operators who are promoting these procedures. They are claiming that they have fewer problems with reactions. If you check with the American Hair Loss Council you will be informed otherwise. If physicians in the U.S.or Canada do this procedure they will lose their license to practice. The reason is that artificial fibres have caused deaths, severe infections and scarring.

It used to be impractical to transplant each individual hair. The individual root can easily be damaged and the harvesting is difficult. Needless to say, it is also very labour intensive.
However, we now call the transplant of one to two hairs micrografts. Small groups of hairs 3-5, are called minigrafts. This technique of mini and micrografts started a few years ago and the results of these smaller grafts have a lot of advantages. These grafts are small enough so that the hair lines do not have the “doll’s head” appearance. The doll’s head appearance only occurs with the large grafts of 4mm, 12-15 hairs, that were used at the beginning of hair transplants in the 1970’s.

Minigrafts are grafts that are cut from the strips harvested from the back of the head.
Large grafts contain five to six hairs and small grafts contain three to four hairs. The large grafts are usually placed in the 4th row inwards. This gives density to the hair. Small grafts are placed in the third and fourth rows or in between. This gives the hair near the hairline a much more natural appearance.

Micrografts are one hair or two hair grafts and are placed in the first two to three rows of the hairline.

This mimics a normal hairline

•Micrografts(•) are inserted into holes made by a syringe needle.
•Minigrafts (x,o) are inserted into slits if there is still existing hair at the recipient site or round small holes of 1.25mm to 2mm if there is bald skin. By punching out these little holes, bald skin is also removed.

In using minigrafts we use grafts of 3-5 hairs. This gives a more scattering effect. This natural appearance allows you to have only one session(if you desire) as the hair grows much more natural looking and without a clumping effect.

If your hair thins out even more in the future, you may have more grafts added in.

This method can be started for people who still have hair or are totally bald. If this procedure is done while thinning, we only make slits between the hairs to insert the grafts.

You can keep your existing hair on top until it is ready to fall. Small holes of 1.3-1.8 mm in diameter are made for the grafts in bald scalps. This also removes some bald skin and reduces the scalp surface area.
Smaller grafts take well and grow faster. I normally use micrografts in the front 2-3 lines to stimulate a natural hair line and minigrafts (3-5 hairs) on the rows behind to give density. The resultant transplant may not give you hair like when you were a teenager but it does turn the clock back a few years where the hair line is concerned.

You may have read about punch grafts. These were the standard 4mm grafts that we used to use before the onset of mini and micrografts. Each graft is harvested by a 4mm punch drill and then put into the front in a pattern that you see below.

However after 1 to 2 sessions you see tufts of hair growing and at certain angles it still looks like a doll’s head. I have abandoned this procedure since 1990. People who have started with punch grafts in previous years can still get their hair line refined by using micrografts in between punch sites and micrografts in front.

After transplanting the mini and micrografts, a crust or scab forms over each graft shortly after the procedure and remains attached to the graft for seven to fourteen days, after which it separates, leaving a clean pinkish area to indicate the site of the transplant. These crusts are plainly visible for one to three weeks following surgery, although in many patients they can be covered by combing your present hair from an adjacent area over the transplanted site. If a hairpiece is normally worn, it may be used after the first week to conceal the crusts but it should be worn as little as possible for an additional week.

When a large area is to be transplanted at one sitting, swelling of the forehead is a frequent occurrence. This swelling may be very slight and rarely severe, resulting in swelling around the eyes and even black eyes in approximately 1 out of 50 patients. The swelling usually begins approximately two to three days after the procedure and lasts for four to eight days. In view of this, it is advisable, if possible, to schedule a holiday to coincide with the first session. Generally this swelling is most noticeable after the first session and occurs on day 3 to day 5. This is not harmful but you may not want to schedule meetings during this time. Ice bags will help to decrease the swelling.

For each transplant session of mini or micrografts, 2 or 3 strips of hair-bearing skin are harvested from the back of the scalp. The area to be harvested is between the ears. Once the strips of skin are removed, this area will be sutured together. The strips are then divided into micro and minigrafts.

The area will heal leaving a straight line and because you have curtains of hair at the back the hair is not noticeable. Usually each strip will yield an average of 150-200 minigrafts or 400-600 micrografts. Patients with wide heads will yield more. Two to three strips make up a session. You can determine the amount that best suits you.

Usually for a totally bald scalp at the front it takes 9 to 11 strips to restore the appearance of hair. (Photographs are available at the office (11516 Jasper Avenue, Edmonton, AB) for you to judge the density). I advise doing the front first because you need hair to frame your face. Esthetically the front of the face is what your presentation is. People see the frame of your face, then your eyes.

The sessions may be done as far apart as the patient wishes, however they are not done in any given area any closer than three to four months between sessions. If entirely separate areas are being transplanted at the same time (i.e. the front and crown), sessions can be much closer together-the crown can be done one month later.

The hair shafts in the transplanted grafts may not grow immediately, but are shed between the second and eighth week after the procedure. Sometimes many of these hair shafts fall out attached to separated crusts and sometimes they persist longer. Even though the hair shaft is shed, the root will remain. Rarely one or two of the transplanted follicles may not shed its hair shaft at all but continue growing immediately after the procedure. With these exceptions, the follicles rest for a period of ten to twenty weeks after the operation, during which time the shafts are shed and the grafts are bare. A new generation of hair is seen on the surface usually during the twentieth week after transplanting, but this may occur slightly earlier in individual patients. These hairs grow at the same rate as they did in their original location.

2% or 5% Rogaine/Apogain (Minoxidil) is known to enhance hair growth in the transplanted hair follicles. You will be advised to use this twice a day starting on day three following the hair transplant.

Minoxidil retails at approximately $50.00 -$70.00 per month. You are expected to use this for at least 2-3 months after the transplant. This medication seems to deter transplanted hair shafts from falling out and it even stimulates the recovery of the hair shafts from the shock of transplantation. Dr. Liao likes to use liquid nitrogen on the transplanted areas monthly for four months following each transplant. This helps with the healing, prevents scarring and enables her to check on the transplanted hair to ensure that it is growing well.

This is the procedure we do in our office most of the time. We harvest 2-3 strips from the back of your head and the strips are divided into micro and minigrafts. The area where the strips are harvested will be sutured together and sutures will be removed in 14 days. The results are normally excellent cosmetically.

Each strip will yield 150-200 minigrafts or 400-600 micrografts. The selection, either holes or slits size, will depend on whether there is still hair on top. Slits are used between existing hairs to accommodate the grafts but if the skin is totally bald we prefer holes. Scars are not seen because the area involved is so small and once the hairs grow the area is covered. Micrografts (1-2 hairs) are put into needle created holes so it is not noticeable. (Again photos are available in the office).

The above sounds fairly simple technically but unless both the surgeon and technicians who divide the strip and insert the grafts are experienced there could be a lot of damage done. If the hair roots are cut, squeezed or dried during the procedure they will not grow and the whole procedure is wasted.

As a consumer you must be sure that whoever transplants your hair is technically proficient. The donor area is a limited resource. (This is the “Friar’s Fringe” at the back of your scalp). If the area scars up badly because of poor harvesting or healing, a lot of hairs will be destroyed. They will be gone forever. The destroyed hair could have been grafted to give you a much better cosmetic appearance and thickness in hair. This office has had to deal with some of these patients and unfortunately there is nothing I can do if the harvesting area has been destroyed. It is much more difficult to do corrective surgery than to do proper surgery. Make sure that whoever does your surgery is well experienced.

Number of Grafts
Some patients think that the more grafts they have the better looking they will be. If only micrografts are used 1-2 hairgrafts, then visualize an orchard of straight trees with a single trunk when you look through the orchard you can see for a long way. When you look at an orchard whose tree trunks are 2 or 3 together, you cannot see much distance through this because it is a lot more dense. That is the reason why for your face, it is best to put 2,3 or 4 hairgrafts behind the hairline, otherwise the look would be too thin.
So if you are going to transplant minigrafts of 3-5 hairs, you would only get one graft, compared with 3-4 micrografts. It is not the number of grafts that gives you the results; it is how many hairs which are strategically placed that will give you the right density.

Recipient Sites
For 1-2 hair grafts, the site is made with a 16-18 gauge needle. For minigrafts, the recipient site is made with slits or punches of 1.3, 1.5 or 1.75 mm sizes. If you have a lot of bald skin, it is best to take some of the bald skin out , which causes the surface area of the bald area to shrink.

If a patient does not have lots of donor hair, but has light skin and heals real well, small holes of 1–1.5mm could be made between grafts to minimize the bald surface areas as the area of baldness shrinks when these holes heal.

Putting large grafts of 3+ hairs into slits, may cause compression of the grafts, and therefore poor growth. But we do not punch out skin with hairs, and so the largest grafts for slits will be 3–4 hairs.

Sutures and Staples
A fine scar is very important to me as a surgeon. As a dermatologist, wound healings basic sciences are ingrained into the specialty. Strength in a wound is best after 21 days. If sutures are removed at 7 days and there is some movement on the scalp, i.e, lying on a pillow, the scar could split. Also the granulation (scar) tissue underneath would build up more to prevent the wound from breaking up. The more granulation tissue, the greater the scar.

To leave the sutures or staples in could help the wound to heal with little or no stress, so as to minimize scar tissue. Scar tissue could also choke roots of hair.

In subsequent transplants, we have to reharvest from the same area. Then it is best to cut the old scar out with each harvesting, so as to leave only one scar at any one time.

There was a patient of mine who had three transplants in the mid-1990’s and he shaved his head in 1997 because it was fashionable then. Luckily, he had only one scar across the back of his head and it resembled the normal crease that some men have. I was ever so happy that I had taken the trouble to have as fine a scar as possible, even when I did not anticipate a shaved head.

Some of us like to use staples. The reason is that staples are made of stainless steel, they are a lot more expensive than sutures, but they cause the least amount of reaction into the skin. The less the reaction, the less the amount of scar tissue, the better looking the scar.

Staples are not as comfortable as sutures, but if the scar line is very fine, even the hairdresser may not pick it up and short hair fashions or wet hair may not cause embarrassment.

If you do not want staples because of discomfort, we are happy to use sutures for you, as you are then making an informed decision.

Density
With mini and micrografts, hair transplants restore the look you had when your hair started to thin. Results vary from patient to patient. You were originally born with approximately 100,000 terminal hairs and with Male Pattern Baldness the hair loss may be 20%, 30%, 40%, 50% or as much as 80%.
By transplanting hair to restore a hair line and thinning hair it is as if we turn the clock back a few years. Hair transplantation cannot restore the amount of hair that you originally had but it gives you hair to frame your face. To quote one of my patients who had Hamilton VIII M.P.B. he wanted the transplant to “take the shine off the top”. Transplanted hair will be present for the rest of your life.
Scarring
The skin surface of the grafts usually blends in with the surrounding skin perfectly, after a period of four to six months. In some patients however, the grafts may be a shade lighter in colour until they are “aged by sun exposure”. The grafts are usually level with the surrounding scalp, but are occasionally slightly elevated, such grafts may be flattened down with an electric needle, without interfering with hair growth. This is necessary in only approximately one of every hundred patients.
Hairline
It is important not to give a patient a hair line of a 20 year old when they are near 40 years old. As we age, a too youthful hairline is out of place amongst our peers. You will also need a lot more grafts to cover the additional bald areas created by a lower hairline.
The front hair line is not perfect, as all hairs are coarse as opposed to normal hairlines, where the most forward hairs are very fine and gradually get coarser as one goes farther towards the back of the head. This is not seen if the hair is swept slightly forward and to one side as most men wear their hair. How good the hairline is depends on a number of factors, but most importantly on how fine and light your hair is. The finer and lighter coloured, the better the hairline. Now with the use of micrografts (1-2 hairs) the hairline is very natural as it mimics the original state except for coarseness. The next important factor is how experienced and skilled the hair transplant surgeon is.



1. The number of transplant grafts which should be placed at one session and the frequency of transplant sessions, depends on the characteristics of each individual case. They can be planned out in advance for each patient. Contrary to what many patients have been told, the scalp, hairy or bald, has an excellent blood supply. A certain amount of bleeding during the transplant procedure is expected and is controlled by simple pressure.
2. Hair should be washed the night before or morning of the procedure. The scalp may be shampooed on the third or fourth day after transplanting without vigorous massage.
3. Patients from out of town are required to stay in Edmonton overnight after the transplant procedure so the bandage can be removed and the area can be properly cleaned the next day.



Females are lucky that they have estrogen. This is the female hormone that their ovaries produce and this protects them from baldness.

Unfortunately females may also inherit the gene for male pattern baldness and as they age they may not be bald but their hair will thin out on the top. The older females grow, the lower the levels of estrogen and subsequently the hair will be thinner.

Rogaine/Apogain (Minoxidil) or low estrogen replacement are good medical therapies. However if the above does not seem to work we may consider hair transplantation. Unfortunately the women that benefit the most from this procedure are the ones that still have thick hair at the back of the scalp.
If the patient is thin all over however the donor site may be unsuitable.

Hair transplant surgery is permanent and you should investigate your choice of hair transplant surgeon. You cannot return the product if you are not satisfied. Should your donor site be damaged, you will not have sufficient hair to correct any defects.

Hair transplantation is both a craft and an art. As a consumer, you should be concerned about who your transplant surgeon is. You do not want an inexperienced surgeon learning his or her profession on your head. It takes many years for a surgeon to perfect his or her craft and a franchised company may or may not have experienced surgeons.

A lot of non-medical businesses now also have arrangements with a doctor to do transplants on a referral or fee splitting arrangement. If you are discussing treatment with one of these organizations ensure that you know who the physician is that will do the procedure, and also that the physician is available for complications and follow-up.

You should also question whether or not your surgeon is going to be available to you following hair transplantation surgery if you should need him or her. Follow up care is as important as the transplant itself in ensuring successful growth.

CHECK OUT DR. LIAO’S HAIR TRANSPLANT UPDATE PAGE
Ask to see photos of Dr. Liao’s work on previous patients.

For further information contact:

Dermatology & Hair Transplant Centre
11516 Jasper Avenue, Edmonton, Alberta, Canada T5K 0M8
Telephone 780.482.1548
E-Mail:jyliao@telusplanet.net