Unfortunately many physicians in this country and
abroad are still performing outdated and dangerous
hair restoration techniques. The reasons are
simple--economics. In order to perform state
of the art follicular unit hair transplantation,
a physician or group has to completely revamp
the infrastructure of their practice. They would
have to hire and train a full time staff of
technicians, purchase binocular stereomicroscopes,
and most likely expand the size of their facilities.
The time needed to perform a state of the art
hair restoration procedure can take any where
from 5 to 10 hours ---an entire work day. This
is much longer than the older less demanding
techniques. Also remember that there’s
a learning curve involved in converting a practice.
It will usually take several months for a physician
and staff to learn to perform these newer techniques
in an efficient manner. They will be performing
far fewer procedures while working many more
hours. Time is money and most physicians who
choose to be in this field are not willing to
lose money. Many hair restoration surgeons believe
in the old adage” if it aint broke, don’t
fix it” and unfortunately for the unsuspecting
and trusting patient this attitude can be a
formula for disaster.
The following outdated and potentially dangerous
procedures should be avoided.
1 Flap/Hair Flap
A flap of hair bearing skin is moved from the
side of the scalp to the front hairline by cutting
it on three sides, thus not separating it from
it’s blood supply or severing it completely
from the scalp. The procedure is major surgery
and is performed in a hospital. A flap is one
inch wide and approximately three to seven inches
long. It has to be twisted in order for the
hair bearing side of the flap to end up facing
outward from the head once it shifted over and
stitched into the surgically removed balding
area. A unsightly “knot” will always
form where the flap has to be twisted. Other
serious problem include:
• Necrosis: A very real chance of partial
or complete death of the flap, leaving a horrific
• Hair always grows in the opposite direction
of a normal hairline.
• Permanent shock loss and extreme scaring
in the donor area
• Loosened skin in the forehead develops
and hangs over the brow, giving a Frankenstein
or Neanderthal appearance.
• Absence of hair behind the newly created
• Poor positioning of the flap (extremely
• The front hairline scar always has to
be re-grafted to hide a linear scar.
• Integrity of the scalp is always compromised.
A type of flap known as the free-form flap is
created when all fours side are cut and the
flap is completely removed from the donor area
so that it’s new position in the balding
area can be set in a direction of natural growth.
This is not a procedure recommended for men/women
with common androgenic alopecia and should be
reserved for severely disfigured patients such
as burn or accident victims.
If your hair restoration surgeon offers his
procedure for common hair loss, leave immediately.
2. Linear or Line Grafts
A 3-4mm linear strip of donor hair is removed
from the side or back of the head and instead
of dividing the strip into follicular unit grafts,
the entire strip or large parts of it or transplanted.
Since this large graft can’t be placed
in tiny recipient sites, a trench must be surgically
cut into the bald area and the large graft is
placed into the trench. As hair grows, it looks
like a completely man made line of hair that
is not cosmetically acceptable.
3. Round or Square Grafts
These are the original, standard, out of date
pluggy-looking grafts. Each 3-5mm graft is made
with a hole punch devise, resulting in a plug
of hair about the size of a pencil eraser. Whether
these large grafts are round or square, they
are too large and do not even remotely resemble
the way hair grows naturally from the head.
When transplanted, because the grafts are so
large and there fore compromise the blood supply,
hair in the middle of the graft often does not
grow, leaving the patient with a doughnut effect.
These large grafts are responsible for what
looks like doll hair-a pluggy look of islands
of hair in an ocean as they are no described.
Cobble-stoning which is a common scalp deformity
seen in hair restoration patients, is caused
by this procedure.
Even the more recently developed smaller version
of the grafts-the mini grafts and micro grafts-can
give a less than natural appearance, which is
why it is recommended that transplants should
be comprised of naturally occurring graft called
follicular units comprised of 1-4 hairs.
4. Scalp reduction
Also known as alopecia reduction(AR), galeoplasty
(GP), or male pattern reduction (MPR), scalp
reductions are barbaric and disfiguring. Performed
in the doctor’s office under local anesthesia,
the bald part of the scalp at the top or crown
of the head is literally cut away, and the edges
of the nearby hair bearing skin are sewn together,
bringing the hair-bearing scalp from either
side to meet in the middle. In some cases a
hideous scar results commonly know as a “dog
Scalp reduction problems also include:
• Accelerated hair loss, more than the
natural course your hair would take. This hair
loss can occur within only weeks or months and
often doesn’t return.
• Thinning of the scalp
• An unnatural appearance because the
direction of hair growth is altered.•
• Hemorrhaging and hematoma (blood pooling)
• Almost 100% of scalp reduction cases
end in stretch back, in which the stanched part
of the hair-bearing scalp that has been stitched
together loses its tightness and stretches out
partially or totally, leaving a visible scar-tissue
bald area created by the stretching, reveling
the dog ear scar which is extremely difficult
• Suture reaction, in which the stitches
in the deep layers below the skin can cause
pain and swelling. The body can reject the sutures,
causing holes in the scalp at the suture sites.
• Scalp reductions do not preserve hair
for use in future transplants, as some physicians
may try to claim. The same wreath of permanent
hair is stretched to cover the wider area in
the crown, thereby thinning the permanent hair
that would normally be used as donor hair for
t5. Hair lift
This is a more radical form of scalp reduction,
in which dissection or loosening of the scalp
skin is done at a level below the major arteries
of the scalp. To avoid damaging these blood
vessels, the nerves are cut and tied. This leaves
your head permanently numb. Unlike other scalp
reductions, this is major surgery, which requires
hospitalization and general anesthesia. It leaves
visible scars around the ears, and additional
hair loss is often a consequence of this ill-advised
6. Scalp Expanders
These are silicone balloons that are inserted
into pockets that are created between the inside
of your scalp and your skull in order to stretch
the skin on the scalp for future scalp reductions,
flaps or hair lift surgery. After incisions
heal, in several weeks, the balloons are gradually
inflated with a series of saline solution injections.
The head is blown up to two to three times its
normal size. This radical procedure is only
recommended in trauma cases when the patient
has received deep burns to the scalp. All forms
of scalp expansion except when use is trauma
cases are not recommended.
Reviewed by Paul J. McAndrews, MD