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Hair Transplant

Hair Transplant Surgery

Hair transplant surgery also known as Follicular Unit Transplantation (FUT) is the process of collecting donor hairs from other parts of the body not affected by hair loss (usually the back of the head, occipital region) and after preparing the individual hair follicles, planting them in the hair loss affected region.

Not every hair loss patient is a suitable candidate for this surgery. This is due to the fact that patients suffering from an inflammatory or auto-immune form of hair loss (such as Alopecia Areata for example) may not be a suitable candidate since the surgery can exacerbate the inflammation and lead to even further hair loss. This is why an accurate diagnosis of the patient’s hair loss type is crucial for identifying the right treatment option.     

The FUT process although straight forward, is a very meticulous and arduous procedure which requires a team of highly experienced staff and a skillful surgeon.

FUT done by less experienced surgeons will lead to scarring, unnatural looking hair line, lower follicle survival rate and an overall unsatisfactory outcome. This is why choosing the right surgeon is crucial for natural looking results. Dr. Nagai and his team have performed over 3000 procedures, making him one of the world’s most experienced surgeons. Dr. Nagai has developed and trademarked his transplantation technique called The Nagai Line-Slit Method.

Here we will elaborate the FUT procedure with the Nagai Method and discuss its advantages over the conventional FUT procedure done by the average hair transplant surgeons.

There are four stages in a hair transplant surgery: 

Extraction of donor hairs

Inserting pores into the recipient area for grafts

Graft preparation

Follicular Unit Transplantation (FUT)

Number of Grafts Required

Determining how many follicle grafts a patient needs for a satisfactory result is straight forward. A healthy scalp has an average hair density of 50 – 80 hair follicles per cm2. When dealing with a hair loss affected region that has a very low density or completely bald, a satisfactory result can be achieved with a density as low as 30 follicles per cm2. This density is optimal since it will minimize the damage to the skin as well as securing a high survival rate for transplanted hairs.

Calculating the number of follicle grafts needed is therefore very simple. In fact patients can attempt to estimate the number of grafts they need using a flexible ruler and a mirror.  Considering the AGA affected regions as seen here, the total area of the marked region is about 35 cm2.

Total number of grafts needed = 35 cm2 × 30 follicles / cm2 = 1050 follicles

the Nagai hair transplant method leads to a natural looking hair line design.

Donor Hair Collection Method

Donor hairs are collected from a part of the scalp (or body) that is not affected by hair loss. The hairs in the back of the scalp (Occipital region) are often considered the perfect option as they have similar thickness to the rest of the scalp and are not affected by hair loss.

There are two main extraction methods for Occipital donor hairs and they include FUE (Follicular Unit Extraction) which includes collecting the donor hair follicles individually using a punch needle and FUSS (Follicular Unit Strip Surgery) where a small section of the scalp containing the donor hairs is excised and sutured.

For patients with fine occipital hairs (either naturally or due a previous surgery), facial and body hairs can also be used as donors provided that the patient has sufficient hairs in these regions.

hair transplant method which involves includes collecting the donor hair follicles individually using a punch needle.

FUE

Follicular Unit Extraction which includes collecting the donor hair follicles individually using a punch needle

hair transplant method which involves removing a crescent shaped portion of the skin and suturing the excised site.

FUSS

Follicular Unit Strip Surgery where a small section of the scalp containing the donor hairs is excised and sutured

Facial and body hairs can also be used as donors if the patient has sufficient hairs in these regions.

Facial & Body Hair

For patients with fine occipital hairs, facial and body hairs can also be used as donors if the patient has sufficient hairs in these regions

Graft Preparation and Transplantation

The Nagai Method focuses on a tailored approach to hair transplant as no two hairlines are supposed to look similar. In order for the transplanted hairs to look natural, they must mimic the local pattern of natural hairs as well as match the individual patient`s facial structure which leads to a natural looking and elegant outcome.

One of the characteristics of AGA is an unclear hairline border. Since AGA often begins at the hair line, as it progresses it leaves a blurred and unclear hair line behind as seen in this patient.

An unclear hairline will lead to what is known as the lack of frame effect since a clear hair line will put an above frame to the face. This means that by rebuilding the hair line, we can drastically improve the overall facial expression as well. 

AGA progression leads to an unclear hair line border

Therefore, instead of lowering the hairline (as is done by many inexperienced hair loss surgeons) more attention should be paid to the overall facial shape to recreate the frame effect.

hairline reconstruction surgery will restore the frame boundaries of a natural hair line.

As a result, a natural looking hairline reconstruction should follow the following principles:

A natural looking hair line should be within the range of 7 – 10 cm from the Glabella (upper edges of the eyebrows).

Moreover, the male hair line has an M shaped design and to achieve that, the apex (the left and right end) should have an obtuse angle. On the other hand, a female hairline should follow a round shaped outline as is the natural feminine design.

In addition, some patients will also experience hair loss along temporal regions as well, giving an appearance of a wider forehead. This should be addressed with a few transplanted grafts (usually up to 100 grafts per side) to create the natural frame.

a natural looking hair transplant design.

Finally, special care must be given to the patient’s future hair loss progression as well. If the hair line is lowered beyond the mentioned range (as seen here at 5.5 cm from the Glabella), not only it will look unnatural, but also it will lead to an abnormal and strange looking pattern if the hair loss progresses as seen here.

transplanted hair line is too low leaving an unnatural look due to AGA progression.

Follicle Transplantation  

When it comes to transplanting the individual follicle grafts into the recipient site, there are two methods used by surgeons. These are the outdated hole slit method versus the more advanced line slit method.

Hole Slit Method

This method is the basic and outdated technique of transplanting the donor grafts which involves punching a hole in the recipient area and placing the grafts inside.

Although this method is very simple and straightforward (easing  the burden on the surgical team), it does not lead to a natural looking result and further reduces the follicle`s survival rate.

The main reasons for the inferior results achieved by this method is the fact that the holes created for the grafts are significantly larger than the follicles being planted inside. In fact, the smallest hole diameter used in this method is around 0.6 mm which is several times larger than the donor grafts, as seen here with a microscope.

hole slit method pores are significantly larger than the follicles resulting an unnatural hair transplant outcome.

This leads to unnatural, rugged looking transplanted hairs and unsatisfied patients. This can be seen here immediately post operation where the transplanted follicles take an octopus sucker like appearance.  

Moreover, post-surgery photos also reveal unsatisfying results as seen here.

hole slit hair transplantation method leads to an unnatural, rugged looking transplanted hairs and unsatisfied patients.
hole slit hair transplantation method leads to an unnatural, rugged looking transplanted hairs and unsatisfied patients.

Another reason for the unnatural looking results of the hole slit method, is the fact that transplanted follicles are not firmly placed in the skin. This comes back to the hole diameter being larger than the grafts making it impossible for the surgeon to control the growth direction of the transplanted hairs. This means that the transplanted grafts have room to be displaced, leading to them growing in random directions and therefore an unnatural looking result.

The larger hole diameter is also responsible for the lower follicle survival rate. The follicle`s post-op survival relies on its ability to absorb nutrients from the surrounding tissues until a new blood supply is formed for each individual graft. Vascularization for the new follicles will often take at least 48 hours to complete, meaning that the transplanted follicles must rely on blood plasma components existing in the surrounding tissues.  This is why the follicles that are placed firmly and tightly in the scalp (as in the line slit method) will have a higher survival rate in contrast to the loosely placed follicles in the hole slit method.

Despite the fact that this method is outdated and inefficient, many hair loss surgeons still use it in their practice due to its simplicity. Since the hole diameter is larger than the follicle, the surgeon can bypass the entire graft preparation phase and simply plant the follicle grafts. Therefore, the hole slit method requires very little skill and experience from the surgeon making it a very popular method among inept doctors.

Line Slit Method

In contrast to the hole slit method, the line slit method is a sophisticated and meticulous method of transplanting the grafts which requires a tremendous amount of experience and skill. This method involves making new hair pores in the recipient skin using micro blades in the shape of a linear cut. This method is far more arduous and burdensome than the hole slit method since each cut is made to match the size of the graft being planted. Moreover, since a linear cut is being made,, the surgeon can control the direction of the transplanted hair growth by adjusting the direction of the cut.  Although this method is more time consuming and laborious, it results in a more natural looking hairline with a higher follicle rate of survival.

Depending on the size of the individual donor graft, a different micro blade is used. Here are the 0.8 mm and the 0.9 mm micro blades with a width of 0.1 mm commonly used.

creating new hair transplant pores in the recipient skin using micro blades in the shape of a linear cut.
creating new hair transplant pores in the recipient skin using micro blades in the shape of a linear cut.

Cuts made by these blades are invisible to the naked eye. As seen here in this case, the donor area is prepared by making up to 1000 individual cuts using the 0.8 mm and the 0.9 mm micro blades for each of the 1000 donor grafts with respect to the individual graft size.

by mimicking the natural hair pattern, a hair transplant performed by Dr. Nagai will lead to a natural looking hair line.

As mentioned in the hole slit method, hair follicle survival relies on absorbing nutrients from the surrounding tissues within the first days of the surgery. Therefore, the transplanted follicle should be as tightly planted into the scalp as possible to maximize its survival. This is achieved with the line slit method through perfectly matching the micro blade size to the individual graft type and size as seen here.

the hair transplant grafts must be carefully prepared to perfectly match the microblade size

The total area of the punch hole created by the hole slit method (using the smallest diameter hole size of 0.6 mm) is about 0.28 mm2. That is about 3.5 times larger than the area created by the 0.8 mm micro blade with a thickness of 0.1 mm (an area of 0.08 mm2), meaning that the hair follicles are tightly packed in and as a result, the line slit method leads to a significantly higher follicle survival rate than the hole slit method.

The Nagai Line-Slit Method

The line slit method is common practice among experienced hair transplant surgeons. Despite its advantages, many surgeons still struggle to create natural looking results even with the line slit method. This is because most surgeons do not consider the unique growth pattern and flow angle of the hair follicles in the recipient region. The insertion direction of the micro blade will determine the growth angle and pattern of the transplanted hair. Unfortunately, most hair transplant surgeons only make vertical and horizontal cuts while performing a FUT operation. This leads to unnatural looking hair growth patterns as normal hairs rarely follow a horizontal or vertical growth angle.

Dr. Nagai can perform the hair transplant surgery with both hands making his results more natural.

By examining a healthy scalp hair under a microscope, it is clear that individual follicles often have unique growth angles. In fact, even hairs that are 1 cm apart will have a different growth pattern as seen here.

In order for a FUT procedure to lead to a natural looking result, the surgeon must try and mimic the natural growth angle and pattern of the local hairs. Examining the growth angle of the healthy hairs, we can see that they grow in a more unique diagonal angle (blue lines) rather than an abnormal looking artificial horizontal angle (while lines) or vertical angle (orange lines). This is why making horizontal and vertical cuts will look unnatural.

scalp hairs have a unique pattern which should be taken into account for a natural looking hair transplant.
scalp hairs have a unique pattern which should be taken into account for a natural looking hair transplant.

This is more obvious in the case of this FUT patient. The post-op picture clearly shows how unnatural a horizontal (blue lines) and a vertical (black lines) pattern would look like. The Nagai Method (white lines) on the other hand, perfectly mimic the appropriate growth angle and pattern of the local hairs which will lead to a more natural looking hairline.

The line slit method can lead to a more natural looking result if the surgeon adjusts the insertion direction of the micro blade. This allows for transplanting the grafts in specific directions, mirroring the neighboring follicle`s natural growth pattern. Hairs in different regions of the scalp grow with unique patterns and directions. The Nagai Method pays close attention to the local hair pattern and tries to replicate a similar outcome by adjusting the flow and angle of growth for each transplanted hair. Dr. Nagai is also ambidextrous which makes his results even more natural looking since this ability gives him more control to place a more precise incision on either side of the scalp using either hand.

Therefore, cuts made with the micro blades in The Nagai Method are neither horizontal nor vertical. They are made individually and diagonally to match the local pattern.

the Nagai hair transplant method leads to a natural looking hair line design.
the Nagai hair transplant method leads to a natural looking hair line design.

The white lines in this picture showcase the direction of the incisions made using the Nagai method. It is clear that the incisions perfectly mimic the local hairs growth pattern and will lead to a natural looking hairline.

the Nagai hair transplant method leads to a natural looking hair line design.

After the pores are created in the recipient area, comes the next step which is graft preparation.  In contrast to the hole slit method, the micro blades have created precise cuts in the recipient area. This means that the donor grafts must fit perfectly in each cut. Therefore, the grafts must be carefully prepared to perfectly match the blade size as seen here. 

the hair transplant grafts must be carefully prepared to perfectly match the microblade size

This is why Dr. Nagai and his team use the Mantis Stereo Microscope for graft splitting. This leads to a more precise and stable graft cutting while reducing fatigue.  

 

donor grafts are carefully examined and prepared individually for hair transplantation.
A single hair transplant graft prepared to be planted in a FUT
individual hair transplant grafts prepared to be planted.

Finally, the grafts are carefully and meticulously planted one by one in their appropriate pores with special care given to the handling of the hair bulb. An inexperienced team can lose several grafts during this procedure due to mishandling which can cause the bulb to break. This further emphasizes the importance of an experienced surgical team who can patiently plant every individual graft (often thousands) in place without causing graft loss.

individual hair transplant grafts prepared to be planted.
donor grafts are carefully being planted one by one.

The grafts are placed in their appropriate recipient area as seen here. Single hair grafts are placed near the hair line while multiple hair grafts are placed further back since this is the natural pattern in the scalp.

Single hair grafts are placed near the hair line while multiple hair grafts are placed further in a hair transplant.

Another advantage of The Nagai Method is the ability to extract and plant donor hairs even when the patient has long hair. This is often a major relief for many patients as they do not wish to shave their head before the operation in order to hide the scalp redness post-op. This is seen here where the grafts are planted in the patient`s hairline without the need to cut the patient`s hair short.

extent of hair loss is assed and the new hair line design is marked prior to the hair transplant.
after the hair transplant surgery, the new hair line looks completely natural and the patient is satisfied.

This video showcases Dr. Nagai`s FUE method as well as his microblade incision technique using both hands (ambidextrous handling of the microblade) on either side of the patient`s temples. Finally, it shows the surgical team carefully planting the donor grafts in place. 

The end result of The Nagai Method will look like this. This picture was taken immediately post-op after a 1030 graft FUT for restoring the patient’s hair line.

It is clear that the transplanted hairs look natural and they will lead to a hair line that will be indistinguishable to a healthy natural hair line. It is also important to note that the post-surgery bleeding is minimal and the recipient area will heal quickly as well.

the Nagai hair transplant method leads to a natural looking hair line design.

Have questions about this treatment, visit our FAQ page. You might find a detailed response there.

Have questions about this treatment, visit our FAQ page. You might find a detailed response there.

Review Our Case Studies

To see the results of The trademarked Nagai Line-Slit Method in restoring patient’s hair lines, review our case studies and read about other patients success stories. 

You are a good candidate for a hair transplant surgery treatment if:

 

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Are suffering from a form of hair loss not caused by chronic inflammation or an auto immune distorder

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Have sufficient donor hairs in the occipital region

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Or have sufficient body or facial donor hairs

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