Hair thickening due to hair loss and thinning is a concern for a large part of the male population—and not only men. Learn more about hair thickening as a way of addressing hair loss.
Hair Thickening: Basic Concepts
- In many cases, the hair transplant surgeon is asked to implant follicular units (FUs) into areas with thinning hair in order to enhance the appearance of coverage.
- Transplanting follicular units into these areas is a major challenge for the surgeon and their team, since a fundamental principle of modern hair transplantation techniques is that every viable and aesthetically important follicle in the recipient area must be preserved.
- Beyond using the least traumatic technique possible, the surgeon must be able to determine whether there is truly enough “vital space” to implant additional FUs—or whether the procedure would ultimately cause such damage to existing follicles that the final result appears even thinner than before.
Most of the time, individuals seeking transplantation present with typical hair loss and want to cover fully bald areas. However, there is also a significant group of patients who come to the surgeon with diffuse thinning (such as DUPA), others with early-stage hair loss who have sparse but not bald areas, as well as women with hair loss presenting with diffuse thinning. These patients often believe that with the so-called “hair thickening” technique, follicular units can simply be transplanted between their thinning hairs to restore density. Since there are visible gaps between the hairs on the surface, they assume that grafts can easily be placed into those spaces to make the hair look denser.
In reality, what patients with hair loss imagine as being “so simple” is actually one of the greatest challenges of modern hair transplantation, because the risk of causing irreversible damage to existing follicles in the recipient area is significant. The contribution of these remaining follicles in achieving the best possible cosmetic result is critical, and they must be “protected” at all costs. In today’s era, with effective medical treatments against hair loss, it is especially important that not a single follicle in the recipient area is harmed during transplantation. For this reason, meticulous care is required whenever operating in a recipient area that still contains terminal or intermediate follicles.
Thinning and… Hair Thickening
What patients describe as “thinning” essentially means that they can see their scalp through the remaining hair. The cosmetic effect of thinning, without any clearly bald areas, is due to some combination of the following factors:
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Follicular density remains almost stable—that is, the average number of FUs/cm² stays at about 100 FUs/cm².
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Calculated density may decrease—meaning some follicular units now contain fewer terminal hairs than before, resulting in a lower hair density, i.e., fewer terminal hairs per cm².
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Hair mass decreases significantly—that is, the sum of the cross-sectional areas of the hairs per cm²—since some hairs have miniaturized.
Parameters 1 + 2 are related to pure hair loss (shedding), while factor 3 is associated with what is commonly called thinning. Overall, in these individuals, the number of follicular units remains stable, the number of hairs decreases only slightly, but the hairs become significantly finer—leading to a noticeable reduction in cosmetic coverage.
When can we place FUs between existing hairs
In every thinning area of the recipient zone, the three parameters mentioned earlier differ in value, and based on these, the decision is made whether or not to place grafts, as well as their exact arrangement and density. A certain minimum hair density is required for hair transplantation to be performed safely while also providing a cosmetically significant improvement that is visible to the patient. In general, the following principles must be observed:
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Each FU transplanted into the recipient area must have a minimum “vital space” relative to pre-existing FUs.
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Each pre-existing FU in the recipient area must also maintain a minimum “vital space” relative to the transplanted FUs.
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This “vital space” should be at least >1 mm around the notional center of each FU.
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Hair transplantation procedures must avoid damaging existing terminal and intermediate follicles; vellus follicles may be disregarded and used only as guides for angle, orientation, and direction of graft placement.
To operate on an area without damaging existing follicles, the existing density in that area should be <25 terminal or intermediate FUs/cm², so that both the old and the new follicles can maintain their vital space.
This vital space must measure at least ≥1 mm around any intermediate or terminal follicle.
If one attempts to place 20 FUs/cm² in an area that already has 40 FUs/cm², but those consist of thinner (intermediate) hairs due to miniaturization, the result will be:
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A large number of intermediate follicles will be destroyed.
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The transplanted follicles will grow normally.
Outcome: An area that previously had dense but fine hair will now have fewer but thicker hairs. However, the loss of the old, thinner hairs may be so severe that the patient ends up with less visible coverage than before surgery. Moreover, those intermediate follicles might have responded to medical treatment, allowing the patient to postpone transplantation for many years or undergo a smaller procedure.
Unfortunately, this is a very common issue in cases handled by inexperienced surgeons, leading patients who suffer these results to justifiably criticize the doctor and, unfairly, the entire field of hair transplantation.
It must be emphasized that the “hair thickening” technique requires significant expertise and should not be attempted by inexperienced surgeons. Before discussing techniques for “preserving” pre-existing follicles in the donor area, it must first be ensured that the recipient area has been correctly diagnosed, i.e., that its density is <25 FUs/cm².
The most important factor to ensure in every case is the atraumatic placement of grafts into the recipient area. The Proscope® HR2 video-microscope is the best value-for-money tool for surgeons to assess hair characteristics in the recipient zone. It can capture images at very high resolution (1600×1200 pixels) and includes measurement software that can determine hair shaft diameter—so the surgeon knows exactly what percentage of follicles are terminal and intermediate, since, as noted, vellus follicles are not considered in the evaluation.
Hair Thickening: Techniques for Better Survival of Pre-existing Follicles in the Recipient Area
In addition to preserving the necessary “peripheral vital space,” the follicles remaining in the recipient area must be protected from:
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Direct injury caused by the tool used to create recipient sites
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Damage to the subcutaneous microvascular network caused by the instrument
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General trauma to the recipient area, which can trigger the release of inflammatory molecules (“stress factors”) in the follicular microenvironment
As early as 2001, Brandy published his technique for creating recipient sites in areas with pre-existing follicles. His method required magnification of ×2.5–3.5 and strong Xenon lighting, and consistently demonstrated significantly higher follicle survival and a markedly lower rate of telogen effluvium. Brandy noted that magnification at ×2.5–3.5 naturally encourages more delicate handling of grafts, and should always be combined with strong Xenon lighting. Today, this approach is widely adopted by conscientious hair transplant surgeons.
Additional technical measures to protect pre-existing follicles include:
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Extreme care to place recipient sites between existing hairs, without damaging them
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Using the smallest possible recipient site tools, preferably micro-blades
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Creating shallow (<3–3.5 mm) and narrow (<1 mm) sites to protect the deeper vascular network
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Aligning recipient sites with the angle and direction of pre-existing hairs
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Maintaining low density (<20 FUs/cm²) and transplanting a small number of grafts per session to minimize postoperative edema, reduce inflammatory factor release, and ensure adequate nutritional support for the area
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Using abundant tumescent anesthesia containing methylprednisolone or triamcinolone
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Employing low concentrations of anesthetic and adrenaline (1:200,000–1:600,000), though opinions differ on the necessity of this parameter
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Trimming the recipient area to a length of 1–2 mm to better visualize the angle and direction of existing hairs
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The use of Minoxidil and Finasteride before and after hair transplantation has been reported to reduce recipient area hair loss post-surgery
With these techniques, it is possible to “densify” the recipient area safely. However, patients must always be informed of the limitations of hair thickening as well as the potential for unpredictable complications, which—despite excellent surgical technique—may still result in an appearance of greater thinning compared to the preoperative state.
Written by Dr. Konstantinos Anastassakis
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