Hair transplantation is a minor surgical procedure confined to the skin. Hair transplantation is performed under local anesthesia and is a safe procedure with few complications. Hair transplant patients are administered local anesthesia in a nearly imperceptible process. The new Septocaine anesthetic with vibratory muting is used. Patients are given a small dose of oral Valium prior to surgery for its calming effect. It also counteracts the agitation some patients have from the anesthetic. Patients should feel absolutely nothing during the procedure. Local anesthesia, when properly done, is 100% effective.

Process of Hair Transplantation at Pacific Hair Institute
The process and methods used for hair transplantation vary amongst physicians. Pacific Hair Institute Physicians, (including the author for 38 years), have developed certain techniques which they feel to be the best. The following are the steps in the author’s hair transplant process:

1. The first thing to do when you present to the office for a hair transplantation is to go through the paperwork with your physician, including the postop instructions so that you have a thorough understanding of what is going to happen. This includes deciding what prescriptions you would like after the procedure, sending a copy of your medical insurance card to the drugstore along with the prescriptions for delivery later in the day and, of course, reviewing the consent form and settling your
account.

2. The second step is to review what old photographs you have brought with you, and design the hairline. The doctor will take considerable time working with you to come up with the perfect hairline design that will please you the most. This is done by drawing with eyebrow pencil on your forehead where you would like to see the hairline, and then reviewing with a mirror. Adjustments are then made until perfect.

3. Since the hair transplant process is done in a comfortable chair similar to an airplane first-class chair, in a reclining position, you will need to pick out a couple of movies from the selection at the office (or decide you will read a book, listen to music, watch satellite TV, or bring your own movies). The procedure rooms have large plasma screens for your entertainment.

4. The next step is to take a small amount of preop medication such an antibiotic and Valium, which will relax you and counteract the agitative effects of the anesthetic you will receive. Time is then allowed for the preop medications to begin working.

5. The next step is for the doctor to select the proper donor area, which will provide a sufficient number of grafts for your proposed transplant. Note that the number of grafts required have already been worked out at your previous consultation. Please remember that it is important to have a thorough consultation with your hair transplantation physician at least one week prior to the actual surgery. In this way, a
complete history can be taken, you can be taken off whatever medicines you might be on which might cause difficulties in the transplants (such as bleeding from aspirin), and the design and measurements of the area of balding can be taken so that the number of grafts can be projected. Do not expect to have a consultation and a hair transplant on the same day, as this is not a practical or prudent idea.

6. Once the selected donor area for the strip harvest has been shaved and painted with Betadine or other antiseptic, your physician will anesthetize the area. In the author’s offices, this is done with four to six nerve blocks along the length of the donor area where the principal nerves lie. A vibrator is used to block the feeling while a very small injection is placed. After that, several minutes elapse while the injections
soak in to the nerve areas, thus anesthetizing the donor area. Once the donor area is asleep, a little additional anesthesia is put in, another 10 minutes or so are allowed to elapse, and the donor area is ready for harvesting.

7. The next step is to place the patient in a prone position (on stomach) on the operating chair which has now been made flat, with the headrest to hold the forehead. Once you are in a comfortable position, the donor process can begin. If the donor strip is just on the back of the head, the harvesting will be done with your head centered, but if back and both sides are necessary, the doctor will turn the head to one side and harvest the right side and back first. Once this has been harvested and sewn up with a careful plastic closure (which will result in a very small scar), the head is rotated to the other side and the left side is harvested. All of this takes about half an hour. There is absolutely no discomfort or feeling as the process goes on because the area has already been 100% anesthetized. There is also not any significant bleeding because the infrared cautery is used to eliminate any bleeders that are encountered. Once all bleeders have been eliminated, the dry field is sutured. If there was a previous donor scar, it is removed. In cases of severe widened old scarring from transplants done in other offices, your doctor can remove those widened older scars as part of the new strip, thus resulting in much less scarring when done. Of course, when removing old scars, it is not possible to harvest as many grafts. The secret to success for small scars in donor harvesting is a long but narrow strip being removed, and closed under no tension. A short but wide strip will almost always result in a widened scar, thus the design of the actual strip layout is, as in the hairline, extremely important.

8. Once the donor has been harvested, the strip will go to the cutting area where it will be dissected into follicular unit grafts under microscopic and high-power magnification. Two to six well-trained surgical technicians will perform this cutting task, depending on how large the case is. For example, a case of about 2000 grafts would probably require three technicians. The dissection process will take one to two hours. During this time, lunch will be ordered in for you and the staff. You will select what you wish to eat from a variety of menus, and have about a one and one-half hour hiatus before additional procedures are done. During this time, you can walk around, watch television, go to the restroom, or whatever you wish to do.

9. After your hiatus, your physician will place anesthesia in the hairline design (which you have previously drawn out working with the physician). Again, the vibrator will be used to block the feeling while the anesthesia is put in, in about four spots to block the front of the head. Note that once the donor area and the hairline and front of the head are blocked, you have a ring block going all the way around the head. This ring block will completely block all the feeling in the top of the head. Once in a great while there is a small perforator nerve that comes through the skull to the center or top of the head. This is taken care of by the anti-swelling solution.

10. Once the anesthesia is fully instilled and the recipient area is anesthetized, the physician will instill the anti-swelling solution. This consists of an anti-inflammatory steroid, a small amount of local anesthetic, and in some cases, a small amount of epinephrine. This will puff up the scalp for a few minutes. After the anti-swelling solution has been absorbed, it is time to make the recipient sites.

11. Using high-power magnification, your hair transplant surgeon will next make the recipient sites using custom-cut blades of 0.6 mm to 1.2 mm in size. While he does this, an assistant will count using a special electronic counter. Obviously one must have the same number of recipient sites as grafts. The final graft count will be determined at the end of the dissection process, and if there are extra grafts, as there usually are, the physician will make extra recipient sites to receive them. The recipient sites are made by the physician in a precise pattern, which will determine the direction that the hair grows out (once it begins growing). This is an extremely important part of the process, as the hair direction is constantly turning on the top of the head. The author has seen some hair transplants where inexperienced physicians placed all of the hairs pointing forward, and this will result in an unnatural appearance. Hair direction must match up in one corner of the hairline with the existing hairs on the side of the head and gradually rotate to match up with the hair direction on the other corner on the other side of the head. Similarly, the hair in the whorl (back of the head) must follow the original radial pattern, or a newly-created radial pattern in cases of severe and complete baldness. It usually takes about an hour for the hair transplant physician to make all of the recipient sites in a typical case of 2000-3000 grafts. As the recipient sites are being made with one hand, the surgeon is placing pressure on the other areas previously done to control bleeding. It is not necessary to cut the hair short, as the left hand can move the hairs out of the way as the right hand makes the recipient sites. It is important that the surgeon be ambidextrous for this process.

12. Following the surgeon’s making of the recipient incisions, it is time for the installation of the grafts. The surgical techs have been cutting the grafts for about two to three hours now, and they should be about finished. Having placed hundreds of thousands of grafts each, they are now ready to install the grafts with one person working in the back of the head, and two others working on the right and left sides. Simultaneously working as described, the surgical techs, under the supervision of the surgeon, can install 2000-3000 grafts in about 2-3 hours. Of note is that a soft scalp can have its grafts installed more quickly than a firm scalp, and there are other variables.

13. Once all the grafts are in place and adjusted to the proper position, (which is slightly puffy and not completely flat), the doctor will review the overall placement and review the postop instructions. The postop instructions will also be put on the plasma screen in front of you for your review.