Surgical Treatment of Pattern Baldness

For some people who are already experiencing mild to severe progressive baldness, pharmacological treatments (i.e. Finasteride or Minoxidil) and/or other alternatives (Platelet-rich Plasma preparations) are not enough to induce sufficient hair growth to visibly improve their overall appearance or positively affect their quality of life. These individuals may benefit from hair transplantation because it creates a more permanent solution to hair loss with more dense hair in balding areas and it can be performed in the later stages of AGA.

In a randomized controlled experiment, it was determined that those who underwent hair transplantation as a treatment forAandrogenetic Alopecia were perceived as younger, more attractive, more successful and more approachable, compared to their appearance before the hair transplant, by unbiased observers. In addition, hair transplantation’s are not as complicated or as unsafe as once perceived.

There are many highly qualified surgeons with reputable track records of success in the field in many areas of the world including Canada. Before deciding if hair transplantation is the right decision for your specific condition it is important to speak to a hair transplant expert directly while self-educating yourself on all aspects of the procedure.

Treatment of Androgenetic Alopecia with Hair Systems

Two well-practiced harvesting techniques are follicular unit transplantation and follicular unit extraction. Follicular unit transplantation (FUT), strip surgery or strip harvesting has been the “tried and true” preference of hair transplant surgeons since its inception in 1995.

Hair transplant surgeons are well-acquainted with the procedure and the possible complications. The method involves making incisions to the back of the head along the SDA to remove a piece of donor hair scalp. The process is accompanied by anesthetics to dull pain and rarely do complications arise as long as experienced and knowledgeable practitioners perform the entire procedure. The surgeon then sutures the resulting linear wound by at the edges of the incision. Technicians view the individual hair follicles or units using magnification and special lighting.

Surgical dissecting tools are used to dissect the hair follicles with precision. The other harvesting method of follicular unit extraction (FUE) does not involve excision of a strip and instead small (~1 mm) hollow metal tubes called punches are used to pierce the skin and tissue around a follicular unit to directly pull the hair(s) from the scalp. This process also uses local anesthetics so pain is masked. The resulting hair grafts from both procedures are then carefully implanted into tiny incisions in the recipient hair areas in an aesthetically pleasing manner using implantation tools. FUE surgeons who are well-practiced and knowledgeable about the procedure produce successful hair transplants similar to FUT.

Hair transplant surgeons will typically prefer one procedure over the other; however, most recognize the usefulness of both. Thus it is critical to understand the characteristics that define both options, since they can both be used for different situations. One way to do this is by examining the features of each procedure with certain categories from the viewpoint of the practitioner and the patient.


  • Medical Risks – Both procedures risk infection of the scalp and hair follicles, such as folliculitis. In rare instances, temporary numbness of the donor area may also occur after either procedure. A strip harvesting patient may have to rest longer compared after the procedure compared to an FUE patient. Temporary post-operative telogen effluvium, also known as hair shedding, caused by the physiological trauma of hair transplantation has been reported.

  • Scarring – There is a similar risk of scarring for both procedures. This is more obvious for FUT as the excision creates a linear scar along the back of the scalp. Depending on the healing nature of the patient and other factors such as the surgical technique used to close the wound this can appear quite striking, especially for those who choose to wear shorter hair. FUE scars are quite small and spread out over the donor area, so their appearance is hidden with long and short hairstyles.

  • Donor Depletion – For a successful hair transplant, surgeons attempt to maximize hair restoration, and also minimize the amount of the hair removed from the safe donor area or SDA. Strips should be limited in size and location on the scalp, and individual FUE grafts should be limited in number and focused within the SDA to avoid this phenomenon. Patient circumstances may allow for deviations from this strategy with respect to FUE; however, a knowledgeable physician must base this on a long-term hair restoration strategy. In addition, multiple hair transplants can deplete the donor zone further so physicians must devise long-term plans based on patient needs and hair attributes when considering hair transplantation.

  • Transaction Rates – When hair follicles or groups of follicles termed follicular units are excised from the scalp, they are called grafts. Graft excision requires expert surgical skill. In either procedure, accidental cutting of the hair shaft can lead to grafts that are essentially wasted, as they are unlikely to survive after being implanted in the recipient donor site. Hair transplant surgeons aim for low transaction rates, a measure of how many extracted grafts are accidentally cut. Strip transaction rates are typically lower than FUE because the technicians can remove hair follicles from the donor strip without the limitations of it being attached to the patient. They use three-dimensional microscopes, specific lighting and surgical tools to select and excise grafts, allowing for enhanced accuracy.

  • Grafts – Hair transplant experts usually agree that the number of grafts per comparable sessions of these two harvesting procedures is greater with strip surgery, although this is based on several variables. There are also different physical properties belonging to grafts from strip surgery and FUE. It is not known if these differences affect their survival and growth in the recipient site. Grafts excised from the strip contain more tissue around the follicles compared to grafts punched from the scalp. In practice, grafts excised from FUE must be handled delicately as they are susceptible to dehydration and breakage due to lack of supporting tissue.

  • Donor Area Shaving – Strip surgery can be performed on a patient with any length of hair. Only the area marked for strip excision must be shaved. FUE often requires full shaving of the head, particularly if an extensive transplant is scheduled. A technique called the unshaven method provides an option to those patients wanting to keep their hair long but choose the FUE procedure. Only sections where FUE is to be performed are shaved while the remainder of the hair is kept long.

  • Combination strip/FUE – For a large amount of grafts (i.e. for a situation where the patient has severe hair loss and extended bald areas), a combination of strip and FUE may benefit situation. As the technique suggests, strip surgery is performed in addition to FUE on either side of the strip. This procedure can maximize the number of grafts produced per comparable session; however, you will need to find an experienced surgeon who can perform this technique well as it has its own challenges.

  • FUE Considerations – The FUE procedure has its own challenges and benefits. FUE can be used to supply donor hair from non-scalp regions such as beard and torso hair, which is particularly useful for those with diminished donor hair. FUE is also best to repair unsuccessful hair transplants or other hair restoration procedures. It can also be used to strategically camouflage scars, including strip scars. The challenges of FUE are largely due to lack of knowledge and talent of the practitioner and incorrect selection or use of specific FUE instruments. It should also be noted that FUE is a difficult technique to learn and can be demanding of the expert’s time and physical ability.