Hair Transplant Surgery - The Art of Hair Transplant Surgery

What is a truly natural hair transplant result?

A truly natural result is one which cannot be identified, under any circumstances, even looking up-close, running your hand through your hair, wet hair, unbrushed, etc. ... in other words, just like someone who has never undergone hair transplant surgery. We usually say that a natural hair transplant is one that even your hair stylist won’t recognize.

Upon ending the scab phase (around 10-15 days post-surgery), our patients report that people who see them think they are taking “some type of medication to stimulate hair growth.” Questions and comments typically made are, “What’s going on? Are you taking medication? You look like you have more hair.” But they never say that they can tell that the person has undergone a hair transplant; it is up to the patient to reveal that information.

Patient before and 3 months after surgery (beginning phase of hair growth)

So how can one obtain an absolutely natural hair transplant result? As it is our intention to imitate nature to the greatest extent possible, refer to the example below: this is a person who has not undergone hair transplant surgery and, after, how to imitate this natural distribution. In the example of the non-operated individual who has a full head of hair, the impression one has is that density and volume are “immediate” and that the first line of hair is straight.

However, if we look closer, we will see that this is not really true. We can see that density only begins after the fourth or fifth line of hair, as the first lines of hair have lower density. This occurs because follicular units in this region are composed primarily of one hair each. Starting around the fourth or fifth line, density increases because the follicular units have 2 or 3 hairs each.

If we look even closer, we see that the design of the first lines is not straight as one would imagine, but rather in a triangular pattern. The outer triangles are less dense and made up of single hairs while the internal triangles are denser with follicular units containing 2 hairs.

Finally, we see that the front hairs are finer than the rest, providing a feathery characteristic to the front lines. One also notes that these hairs are distributed in an irregular pattern, angled in different directions in a random manner, because nature is erratic, not symmetric and calculated.

Therefor, how can we imitate nature?

Hairline: made up of the first lines of hairs, it is responsible for providing a natural appearance to a hair transplant.

The surgeon’s greatest challenge is to create an absolutely natural hairline.
This being the case, to imitate nature to the greatest extent possible, the first four to five front lines must be created hair by hair (only single hairs) and the density must begin to increase only starting at the fifth or sixth line, upon which 2-hair follicular units are placed creating an effect of gradual density, so called degradé.

In addition, as we previously demonstrated, the hairline cannot be created as a straight line, but rather the pre-existing design must be maintained to best imitate nature, as well as not alter the individual’s physiognomy (physical appearance of the face).

Observe that the design was maintained

For the front lines, as stated before, 1-hair follicular units should be used, but we must separate the finest of these single hairs from the others. These finest hairs, which we call ultrafines, are those that create the feathery appearance of the front lines found in nature.

Patient operated by other surgeon; and after repair surgery utilizing ultrafines

Deciding on the best design to adopt

The design is very important because the contours of the hair mold the face; therefore, the new design that will be adopted does not depend only on scientific knowledge, but also on an aesthetic and artistic sense.
Michelangelo, at the time he planned to sculpt the statue of David, divided the face into thirds (upper, middle and lower) and defined that in men, as well as women, the distance between the frontal hairline and the glabella (region between the eyebrows), should be equal to this same point until the bottom of the nose, which in turn should be equal to the distance from the bottom of the nose to the chin.

Aesthetic division of the face and hairline according to Michelangelo

*Celebrities shown here for illustrative purposes only

In the case of hair transplants, however, we do not have a sufficient donor area to bring the hairline so low.

To create a new design, we must then take into consideration, besides the type of face and forehead, the background of family members prone to hair loss (in the case of young patients, less than 35 years old). In other words, we must evaluate the donor area x recipient area balance.

In more advanced cases of hair loss, however, this is easy. Determining the correct balance between the donor area and recipient area in a young patient just beginning the hair loss process is quite difficult, but crucial, as the strategy must be created based on a realistic future balance. In other words when considering a 20-year-old patient we must know what his hair loss will be at age 30, 40 and 50.

*Celebrities shown here for illustrative purposes only

This is possible by way of microscopic analysis, analysis of the genealogical tree, and mainly by surgeon experience.

If the donor area x recipient area balance is negative, that is very little donor area and an extensive bald area, we do not have any other alternative than to reduce the transplanted area utilizing a design with a higher temporal recess.

*Celebrities shown here for illustrative purposes only

Or making a higher hairline

Because, as we have said before: “It is far more aesthetic to have a smaller, but denser area, than a larger, but thinner area of coverage.”

As you can observe, it is not necessary to bring the hairline low or without temporal recession, as many attractive “leading men” have a more mature hairline with temporal recession or high foreheads. Take a look at the example of this television actor, Luke Perry (best known for his role on Beverly Hills, 90210). Notice that even young, but with a high forehead, he looks better without the baseball cap, demonstrating that even with a higher frontline an aesthetic appearance can be preserved.

In the case of patients who have hair and only wish to reduce the temporal recession, or to increase density, we should maintain the existing design. In the case of lowering the frontal hairline, we should utilize a design that previously existed.

In patients with higher degrees of hair loss, however, we must create a new design.

Angle of the hairs

The angle of the hairs in relation to the scalp should be consistent with the hairs that still exist, or those that had previously existed in that region, in order to obtain a natural result, including cowlicks or the spiral pattern of hair growth at the crown. When the DA x RA balance is negative, however, we usually increase their inclination. The more inclined they are against the scalp the greater the appearance of volume in the final result due to the “Venetian Blind Effect”: one hair lies against another just as the blinds close against each other. (See published paper presented by Dr. Ruston - Blind Effect.) See the simulation below of the same number of hairs transplanted in different angles of inclination to the scalp.

Hair Distribution – Optimizing Each Session

We opt to distribute the grafts over a greater area in the first session. That is, we treat the greatest area possible, giving the impression that medication is being taken for hair growth, and not that the patient has undergone a hair transplant. We do not agree with the strategy to treat section by section, which many other hair transplant surgeons adopt.

before after 1st session after 2nd session

The human being works with proportionality of shapes. If we work on a specific area by treating, for example, first the front and middle, leaving the crown for a later session, the crown will appear balder in contrast with the other areas. It will drive the patient to seek a new procedure to improve the result, in addition to making it more obvious that a hair transplant was performed as the hairs do not naturally/suddenly appear in a single area.
See the two examples below. On the left, the patient underwent a hair transplant performed by Dr. Ruston and the optimization criterion was used. The patient was submitted to two surgeries with an interval of nine months between each procedure. Note that with each surgery the patient became “less bald” and in an absolutely natural manner. However with the case on the right, the patient who received a transplant by a different professional, subsequently corrected by Dr. Ruston, one can observe that only part of the bald area was transplanted in the first session, which resulted in an artificial and awkward aspect. The appearance normalized only after our intervention. It would have been better had the patient’s bald area been treated with a sparser distribution in the first place.

*Repair Case: Patient operated by other professional (center pic)
and after correction by Ruston Clinic (right pic)

*It is important that we make clear that naturalness is not dependent on the number of hairs transplanted. Of course, the higher the number of hairs, the greater the volume will be, but the final result will not necessarily be more natural or aesthetic. The case on the right is fuller, but not more natural, because no one can say that the patient on the left underwent a hair transplant, even having had a low number of FUs transplanted.

Fine Hairs 1830 FUs (2% FU3)	Thick hairs 2850 FUs (15% FU3)

Think about this: If you were bald and required 30,000 hairs to correct your baldness, but could only put 100 hairs in your bald area, would you refuse? Probably not. So imagine 1000 hairs: Wouldn’t that be better than 100? In other words, the greater the number of hairs, the less bald you will become and in a way that is 100% natural as long as a correct distribution of these hairs is followed.

See the example below of a corrective case performed by our clinic.
In the “Before” photo, one can see an example of the criterion stated above not being followed. Upon applying this criterion in the repair case (“After” Photo), the result is that of a scalp with less hair, however with a more natural appearance.

In other words, transplanting 100 hairs with an aesthetic notion of distribution and an appropriate technique is better than transplanting 5000 hairs in an unaesthetic/unnatural design, leaving obvious tufts, damaging the donor area, causing patient trauma, and unjustifiably making a bad name for hair transplantation. We have received many doctors, from all over the world, who would like to learn the technique we use in our clinic. We suggest that they always opt for the first policy, trying to go for a natural appearance with high forehead and/or accentuated corners, even if the fewer hairs result in initial low density. After all, the ability to transplant with greater density and volume may come in time as the surgeon’s skill develops and the surgical team grows, with no negative impact on the naturalness of the results and/or the donor area.

The competent professional, able to produce natural results, is one who, besides being concerned about the issues discussed above, will combine: theoretical and practical knowledge, skilled hands, aesthetic sense, a large, qualified and skilled team, and attention to some little details that will always make an enormous difference.

* Remember that only some of these details were mentioned here. (See Message from Dr. Ruston)

But our message is: The naturalness of the result is what matters most, more than the number of hairs transplanted.

The idea is to make the patient the “least bald” possible after each session, in a way that is 100% natural. See some of our RESULTS.