The ultimate hair transplant technique has to respect the only remaining limitation to the surgical treatment for hair loss, as each patient has a fixed amount of good genetic hair from the sides and back of their scalp that can be used to transplant in the balding area.

It is of paramount importance that the hair transplant surgeon is entirely focused on ensuring every transplanted graft survives and grows. Any technique or procedure that ultimately increases the percentage of survival of the transplanted hair should be used. Conversely, any technique or procedure that decreases survival must not be used.

The techniques that maximize survival of the grafts during the hair transplant are as follows:


Any physician can legally perform hair transplants, even if they have little or no training. It is of utmost importance that any doctor performing hair transplants should have formal training under the strict guidance of a residency or fellowship program. Taking a weekend course on hair transplants or “on the job” hair transplant training at one of the big hair transplant clinics is inadequate.

Over the past several years there are many untrained doctors that have purchased automated FUE devices trying to bring increased revenue into their practices. Since they are untrained and don’t want to waste their time doing the hair transplant (time is money), they have unlicensed technicians perform the surgery. A physician that bought a Neograft, Smartgraft, Artas, or other FUE device and then allows an unlicensed technician to use it is entirely wrong, unethical, and illegal. Most patients are unaware the doctor is allowing an unlicensed technician to “perform surgery without a license”- this is a criminal offense that could cause both the doctor and technician to serve jail time. Patients are also unaware that this unlicensed technician is absolutely creating permeant scars into the scalp with this FUE device and can create damage to the patient that will last a lifetime. I fail to see the quality in performing the hair transplant in this style and believe the doctor should have prior training and then actually do the hair transplant surgery.


Typically, a hair transplant lasts four to seven hours, therefore, if the hair transplant physician is going to be involved in every step of the hair transplant process he can perform only one hair transplant procedure a day.


Hair does not just come out of the scalp individually, one by one, but actually grows naturally in groups of one to four hairs with a fibrous sheath surrounding them.

Since that is how God designed everyone’s scalp, that is how we do a hair transplant. We perform hair transplants with the single hair groups on the hairline and the natural groups of three and four hairs farther behind for density. The benefit of performing the hair transplant with the individual “natural hair groupings” is the completely natural look we achieve and a higher survival rate of the transplanted grafts.

To try to obtain a natural look, many doctors now perform transplants with what is called “single hair micro grafts or ultrafine micrografts.” They separate the “natural hair groupings” into single-unit hair grafts and transplant the hairs individually. By separating the natural groupings of hair, the transplant surgeon is going against nature. A study published in the Journal of Dermatologic Surgery showed that the survival and quality of these grafts markedly decreases when separated out of the natural hair groupings. The best alternative is to mimic the pattern as God designed it, instead of trying to change it.

 (Single Hair Micro-grafts)


The stereoscopic microscope is the most important innovation in hair transplants. The “natural hair groups” must be preserved intact during dissection to insure increased survival and growth. Many doctors dissect with the naked eye or with minimal magnification. The vast majority of doctors marketing FUE hair transplants NEVER use this vitally important stereoscopic microscope. That leads to increase transection and destruction of the hair. When dissecting the donor hair without the stereoscopic microscope it is nearly impossible to ensure that the “natural hair groupings” will remain intact.

One of the major down sides to FUE hair transplants is it makes the stereoscopic microscope less useful. With any device (Neograft, Smartgraft, Artas, or other motorized/manual tool) used to surgically excise the donor tissue in the FUE hair transplant, the doctor does not know if he transected the follicular unit until after the graft is removed and the damage to the follicular unit is already done. Again, this increased transection rate of the follicular unit decreases the survival of the very limited donor hair.

For a balding man seeking a transplant, his most precious commodity is his donatable “hair bank.” The use of the “stereoscopic microscope” to dissect the grafts enables fully visualization of each and every individual “natural hair grouping.” By using the “stereoscopic microscope” the trauma to the surrounding hair is greatly reduced and our patients receive superior quality grafts with a much higher incidence of survival. I can now achieve survival rates of 95 to 100 percent, as compared to other techniques where the survival rate is much less. The “stereoscopic microscope” is still useful in FUE hair transplants because it enables us to trim excess skin away from the hair follicle, therefore, smaller incisions can be made, which enables us to pack the grafts closer together to give a denser, more natural look. Using the stereoscopic microscope after excising the donor tissue with FUE is also valuable to verify the size of the graft in order to avoid placing bigger grafts on the hairline (avoiding an unnatural look).


The design of the hairline is crucial to the overall look of naturalness. A physician could use all the latest techniques and technology but still create an unnatural looking hair transplant because they do not understand the aesthetics of a natural human hairline. An unlicensed technician most definitely will do this.

There are five critical areas of concern when creating an aesthetically natural hairline and frontal forelock. Dr. McAndrews authored the chapter about hairline design in the preeminent text book on hair transplants.

  1. The anterior (or central) starting point of the frontal hairline:

    Many hair transplant surgeons (or their unlicensed technicians) place the hairline too low on the forehead, which will never look natural as the patient ages. Particularly with younger hair transplant patients who have more extensive baldness. The hair transplant surgeon needs to create a more conservative pattern that will look natural now and twenty years from now.
  2. The lateral frontal hairline:

    Many hair transplant surgeons (or their unlicensed technicians) design too wide of a frontal hairline that creates the look of an unnatural comb-over or hairpiece.
  3. The angle of the hair exiting the scalp:

    The angle of the hair gets more acute at the more anterior (frontal) part of the hairline. Many hair transplant surgeons (or their unlicensed technicians) create the incision so the hair comes out perpendicular to the scalp, which is not aesthetically pleasing and does not cover the scalp as well. This also looks unnatural since your hair would not normally grow in this direction.
  4. The irregularity of the frontal hairline:The human hairline is naturally very irregular. It is a common mistake of hair transplant surgeons to make the hairline too symmetrical and too linear. The human eye is naturally drawn to lines, which will draw unnecessary attention to the hairline and make the patient self-conscious. An irregular hairline is natural and does not draw attention to it
  5. Direction of the incision:

    Follicular Units

    Coronal Incision.

    Sagittal Incision.

    The hairs in a follicular unit typically sit side by side when looking at hair from front to back. This is a cosmetic benefit because the hairs are in a row instead of lined up behind one another, which gives a thicker cosmetic result. Therefore, the incision with the needle should be placed with the long axis going from ear to ear (coronal incision) versus from front to back (sagittal incision).

    Since hairline design is so important to the overall result, it is vitally important that your hair transplant surgeon has been properly and formally trained in the art of hair restorations. Never let an untrained doctor or an unlicensed technician design your hairline. Call the state medical board and the local authorities if the doctor allowed the unlicensed technician to design your hairline or use the automated FUE device.