How a Modern Hair Transplant is Performed
                     How a Modern Hair 
Transplant is 
Performed
Dr. Blake Bloxham 
Feller & Bloxham Medical, PC 
What is a “Modern” Hair Transplant? 
• Today’s hair transplant is very 
different from the “plug” procedures 
of yesteryears. A modern hair 
transplant is known as Follicular Unit 
Transplantation, because the 
procedure involves the removal and 
re-implantation of follicular unit 
groupings – the natural units follicles 
grow in. 
• By removing only true follicular units 
and implanting these into the bald and 
thinning regions -- typically in large 
numbers and densely packed together 
when appropriate – a modern hair 
transplant can be extremely natural. 
How is a Modern Hair Transplant 
Performed?
• A modern hair transplant can be broken down into several steps: 
• 1) Surgical Planning 
• 2) Donor tissue harvesting 
• 3) Implantation of follicular unit grafts into the recipient area 
Surgical Planning 
• Surgical Planning refers to both defining the parameters of the safe area for harvesting in the donor region and 
demarcating and designing the areas where the new grafts will be placed – IE new hairline design. 
• Donor Area Planning: It is imperative that only dihydrotestosterone (DHT) resistant follicles from the “safe zone” be used 
in hair transplant surgery. Follicles from outside this zone may thin and “fall out” over time. The donor harvesting area 
must be carefully demarcated to fall safely within this region. 
• Although several models exist, most agree that the safe donor begins in the occipital region at the nuchal ridge/occipital 
protuberance and extends superiorly approximately 6cm; this area extends in the same fashion across the 
parietal/temporal scalp up to the pre-auricular area. During some Follicular Unit Excision (FUE) cases (to be discussed 
under “Donor Harvesting”), doctors will take from “safer” areas in the donor region in specific patients (older, less active 
androgenic alopecia, limited loss in general, limited family history of loss, etc) as long as these patients consent and 
understand that the grafts from these areas are still not as resistant to future loss as those taken from the true safe donor: 
Surgical Planning 
• Recipient Area Planning: 
• Planning in the recipient plays a crucial role in the 
overall result. This planning includes: designing new 
hairlines, rebuilding temporal regions, 
reconstruction of the natural “whorl” pattern in the 
crown/vertex, etc. 
• Education, experience, and a conservative, “long-
term” approach is crucial for creating natural 
results which will age well and look appropriate at 
all times. 
Donor Tissue Harvesting 
• Modern Follicular Unit Transplantation can be performed via two 
different harvesting methods: 
• Follicular Unit Strip Surgery – also known as “FUSS,” “FUT,” and 
“Strip Surgery”
•  Follicular Unit Excision – also known as “FUE” or “Follicular Unit 
Extraction”
Follicular Unit Strip Surgery 
• During an FUSS procedure, a small strip of hair-bearing skin is demarcated in the safe donor region. The area 
is trimmed, cleaned (chlorhexidine, iodine, alcohol, etc), and numbed with local anesthetic (typically 2% 
lidocaine with differing amounts of epinephrine). The strip is then excised with a scalpel, and then 
immediately closed with sutures or staples – which can be done in a variety of ways including multiple layer 
closures and even in a “trichophytic” manner where hair is encouraged to grow through the resulting scar 
itself. 
• The “strip” is then handed to highly skilled and experienced surgical technicians who will carefully dissect 
the tissue down into individual follicular units under high-powered stereoscopic microscopes. 
• The FUSS procedure leaves behind a linear incision line scar in the donor area. 
• Strip harvesting must be performed by the physician. 
Follicular Unit Excision 
• During an FUE harvest, small dermal punch-like tools are used to carefully score around individual follicular units – after 
cleaning and trimming. These tools are very small; typically anywhere from 0.7mm to up 1.3mm (though tools this large 
are now less common). The tool may be a manual punch powered only by the doctor’s hand or may be attached to a 
motorized tool – wherein a motor provides the rotation or oscillation of the punch. There are various devices which 
partially automate the process, and even some robotic devices controlled via software. The punches themselves can also 
be sharp, dull, or a “hybrid” of a sharp and dull punch. 
• Once the follicular unit is scored, forceps are used to grasp and apply traction to free the follicular unit from the 
surrounding tissue. 
• Typically, these units are placed under the same stereoscopic microscopes and examined for quality. Some clinics also 
slightly trim the grafts to remove any excess tissue. 
• Despite how the procedure is sometimes marketed online, FUE is a surgical procedure which does leave scars in the donor 
area. The resulting scars are small, punctuate, hypopigmented “dots,” which can be very subtle. 
• FUE harvesting must be performed by the physician. 
“FUT vs. FUE” 
• There is much debate online today over which technique is “best.” 
The reality is that each technique has its benefits and limitations, and 
patients should be evaluated individually and appropriate 
recommendations made. 
• There is much discussion about this topic online, and we encourage 
interested parties to research further. 
• What the ISHRS agrees is not debatable, however, is that donor 
harvesting in both FUE and FUT is scalp surgery and should only be 
performed by experienced, licensed professionals – most typically 
physicians. Delegating this task is illegal in most US states. 
Graft Implantation 
• The final step of a modern hair transplant involves implanting the 
follicular unit grafts into the “recipient” area – IE the bald and 
thinning regions previously demarcated. 
• Grafts are typically implanted one of two ways: into pre-made 
recipient “sites” or in conjunction with recipient site creation using 
implanter devices. 
Graft Implantation 
• During placement into pre-made recipient sites, the process starts 
by the physician numbing the recipient region. This is typically 
done via a ring block or a supraorbital/supratrochlear block (done 
with the same local anesthesia used for the donor region). 
• After the area is numb, the physician will make recipient incisions 
or “sites” using either a blade (typically a small, custom-cut flat 
blade) or a needle. These sites are made in specific directions, 
angles, and densities in order to create a natural result. 
• After the recipient sites are created, surgical technicians carefully 
“place” each follicular unit graft into each slit. 
• Most commonly, the technicians will use jeweler’s forceps 
(typically “curved”) and needles to carefully and expertly place 
grafts. However, implanter devices can be used as well. These 
implanter devices are typically open bore sharp or dull needles 
attached to a loading port. The grafts will be loaded into the port, 
the needle will be inserted into the slit, and the graft will be 
slipped through the needle and into the slit. Some devices even 
have a spring-loaded action to push the graft. The device will then 
be removed – leaving the graft in place -- and will be reloaded for 
the next slit. 
Graft Implantation 
• Graft placement can also be done via 
simultaneous slit creation and graft placement 
using implanter devices. 
• These devices are the “spring-loaded,” sharp 
needle type discussed in the previous slide. 
• The implanted pen is “loaded” with graft and 
handed to the physician. The physician will 
determine where he/she wants the graft to be, 
and use the sharp needle to make the recipient 
incision. The doctor will then push the plunger, 
which slides the graft into the site that was just 
made. The device is then removed, the graft 
remains placed, and the implanter is re-loaded 
with another graft. 
• Once all grafts are “placed,” the case is complete 
and the patient is discharged (usually with a brief 
course of antibiotics and pain medication) to rest, 
recover, and wait for the new hair to grow 
starting 3 months later. 
How a Modern Hair Transplant is 
Performed
•Arguably one of the most 
important aspects of a 
modern hair transplant is 
that it is performed by an 
experienced, licensed 
physician. Procedures 
where surgical 
responsibilities are being 
delegated to non-licensed 
personnel are wrong, 
illegal, and severely 
hurting patients. Hair 
transplantation is scalp 
SURGERY, and should be 
treated as such. 
•ISHRS statement on 
Qualifications for Scalp 
Surgery: 
•The position of the 
International Society of Hair 
Restoration Surgery is that 
any procedure involving a 
skin incision for the purpose 
of tissue removal from the 
scalp or body, or to prepare 
the scalp or body to receive 
tissue, (e.g., incising the 
FUE graft, excising the 
donor strip, creating 
recipient sites) by any 
means, including robotics, 
is a surgical procedure. 
Such procedures must be 
performed by a properly 
trained and licensed 
physician. All FUE 
harvesting tools, including 
robotic devices, are 
considered extensions of 
the hand of the operator, 
and as such, all operators 
of these devices must be 
physicians.
•Physicians who perform 
hair restoration surgery 
must possess the 
education, training, and 
current competency in the 
field of hair restoration 
surgery.
•The ISHRS believes the 
following aspects of hair 
restoration surgery should 
only be performed by a 
licensed physician:
•Preoperative diagnostic 
evaluation
•Surgery planning
•Surgery execution 
including: Donor hair 
harvesting, Hairline design, 
Recipient site creation, and 
Management of other 
patient medical issues and 
possible adverse reactions
•Post-operative care
•The ISHRS believes it is 
unethical for an individual 
to travel to a state and/or 
country in which he or she 
is not licensed and perform 
the surgical aspects of hair 
restoration.
•The ISHRS also believes it is 
unethical for a doctor to 
train an individual to 
perform surgery who is not 
an accredited health 
professional licensed to do 
so.