I am 24 years old and have experienced acute balding since age 16. I’m about a Norwood 5, and am serious about the transplant solution. However, I’ve always been turned off by the resulting “smily face” scar left on the back of the head which eliminates any possibility of a short haircut. You see, I’ve shaved my head with a zero guard since age 19 and enjoy the look. I would love to have a more masculine hairline, especially at the “point” near the temples which has disappeared, but am afraid of the scarring. Is the new FUE technique my dream come true and viable solution for those of us who prefer a shaved head? How much scarring is left?

FUE is the best hair transplant harvesting technique to address your concerns. If you elect to do an FUE, the costs will be slightly higher, but the ‘line’ scar you were worried about with the strip surgery will not be present.  Scarring is ‘punctate’ (dot-like rather than ‘line-like’).  You can see many of our FUE patients at our monthly open house. The picture on the left is the actual FUE wounds while the picture on the right is just 5 days later.  As you can see, with a shaved head, there is no evidence of any scarring on this patient after 1000 grafts were done.

This is a photo of a female patient who had a hair line lowering and rounding hair transplant surgery. This is sometimes known as forehead reduction surgery.

hair line lowering results

female hair line lowering before after photo


This patient did not like her square high forehead with receded corners.  She thought her hair line looked too masculine.  She considered a forehead reduction surgery to lower the hair line.  However, she was worried about the hair line incision scar.  She also wanted the hair line corners to be more rounded in appearance which a forehead reduction surgery could not achieve.


Forehead reduction surgery for women with a high forehead has been popular since the late 1990s.  Dr Sheldon Kabaker  in Oakland California is a well known and prominent surgeon who has been offering female forehead reduction surgery for many years.  It sometimes requires the use of tissue expanders to drastically lower one’s hair line.   Since 2006 Dr. Gal Aharonov in Beverly Hills California has been offering a slightly modified approach to the forehead reduction surgery.  His method has gained great popularity from all over the world.  With third party review sites such as RealSelf.com, the hair transplant community saw a demand for women seeking an alternative to forehead reduction.  Potential problems of a forehead reduction surgery were the visibility of a scar along the hair line, and the limitations of creating an oval or rounded appearance.  While patients were happy with the drastic reduction in their forehead size, some were self conscious about their scar and would not wear their hair pulled back.  They addressed this with make up and sometimes a limited hair transplant procedure.

HAIR TRANSPLANT for hair line lowering:

An alternative for those women who did not want to undergo a forehead reduction surgery was a standard hair transplant procedure.  Hair transplant procedure involves harvesting donor hair from the back of the head to individually relocate single follicles to the front.  The limitations of a hair transplant procedure was that the results were not instantaneous. The transplanted hairs need to grow out from its roots. The advantage was a natural shaped hair line dictated by the artistry of the doctor creating the hair line.  There was no scarring along the hair line.

The results for this hair line lowering patient were achieved using Follicular Unit Strip Surgery (strip surgery) sometimes referred as Follicular Unit Transplant (FUT).   If Follicular Unit Extraction (FUE) method was used, it would have required shaving the back of the patient’s head.  This is something few women would accept. There is no shaving involved with the strip surgery and the incision around the donor area (back of head) is covered by the patient’s hair.  Even with the hair wet or hair up, the incision line (scar) will rarely, if ever be noticed.  This incision may be an issue for men who keep their hair very short.

scar of FUE versus Strip

FUE vs Strip scar on the day of surgery

If the incision is an issue for a patient, the alternative method of harvesting hair is known as Follicular Unit Extraction (FUE).  FUE harvesting is carried out manually by a highly trained surgeon or with an aid of the ARTAS robotic FUE instrument.  There are other machines available such as Dr. Harris’s SAFE system or the NeoGraft machine you may have seen advertised in airline magazines.  FUE method of donor hair harvesting may seem attractive for many patients because it is heavily marketed and advertised as a “no scar” surgery.  This is NOT an accurate statement and is shunned by doctors since FUE does leave thousands of permanent round scars.  Many patients have their FUE scars as well as strip scars camouflaged with Scalp MicroPigmentation.

FUE scar fixed with SMP

Moth Eaten appearance of a FUE scar Before and After SMP

This reinforces the fact that the latest technology and fancy robots are not always the best choice. For most women, a small linear scar on the back of their head may be a better option than shaving their head for thousands of FUE “dot” scars.  Think of a C-section scar under long hair vs a moth eaten appearance on the back of a shaved head.

Can I have a Scalp Micropigmentation (SMP) and later a hair transplant surgery? What if I want to grow out my hair as well? I don’t want to always keep my hair shaved.

You ask a great question! We have been combining SMP with hair transplant surgeries using FUE or Strip FUT. After all we are a medical practice that specialize in all aspect of hair restoration!

This patient came to us with a old hair transplant surgery scar. He had a strip FUT surgery which didn’t really give him a full head of hair and he just gave up with the idea of having a full head of hair. But he had the strip scar which he couldn’t hide when he decided to cut his hair short. So he went to local doctor for FUE to the strip scar. As we tell all our patients, FUE to the strip scar doesn’t really give perfect results when you are looking to shave your head. So he ended up with MORE SCAR, many ‘punctate scars’ from the FUE surgery. Needless to say he was angry and was very skeptical when he came to see us. We didn’t blame him. He didn’t trust any doctors at this point. Although Dr. Pak thought he would be a great candidate for the SMP procedure, he actually turned him down because the patient’s expectations seemed unrealistic with a bad attitude.

Eventually, the patient came back for another consultation and even saw other SMP patients in person at our monthly Open House Seminars (where prospective patients can meet with former patients and see an actual SMP or Hair Transplant surgery taking place).

This patient eventually had SMP to the entire scalp and covered his FUE scar and strip scar with great results. In the process he came to know and befriend Dr. Pak to trust his work. So after about a year he came back to Dr. Pak for a FUE procedure (about 1500 graft) to add density to the top and soften (corrective surgery) his front hair line from the old transplant work.

While the FUE transplant didn’t give him the full density, the SMP provided a cosmetic benefit to provide a look of fullness. Now he has the option to shave or grow his hair out long.

Old FUE and FUT Strip Scar addressed with SMP Scalp Micropigmenation

Old FUE and FUT Strip Scar addressed with SMP Scalp Micropigmenation

SMP Scalp Micropigment for a shaved look

SMP Scalp Micropigment for a shaved look

SMP Scalp Micropigment with FUE Hair Transplant for Fullness for Long Hair

SMP Scalp Micropigment with FUE Hair Transplant for Fullness for Long Hair


I had a hair transplant “FUE” 8 days ago. I can still see the holes in the donor area. Do you know how long is the average healing time for the scars? Should I worry? Also, do you know of any products that will help the skin recover?

Thanks a lot for your time!

The tiny holes in the back of the head that are created from a follicular unit extraction (FUE) procedure should disappear very shortly. What you may be seeing are scabs, not the holes, and this requires a vigorous shampooing technique to get rid of the scabbing.

Your surgeon should’ve provided you with aftercare instructions that explained how to wash your donor and recipient area.

Tags: fue, follicular unit extraction, hair transplant, hairloss, hair loss

Dr. Russell Knudsen (from Australia) wrote in informative article in this months “Hair Transplant Forum International”. Clearly, the ability to harvest the donor area with FUE will be more restrictive in individuals who have more extensive balding patterns (Class 5, 6 and 7 patterns of balding). The donor area around the sides and back of the head reflect 25% of the original total hair count on the head (I call it my 25% rule). If one targets somewhere between half or 2/3rds of the follicular units found in the donor area, as the maximum safe yield for FUE over time, then for Caucasians with average hair density (100,000 hairs on their head or 50,000 follicular units in the permanent zone) might be able to safely harvest as much as between 6,250 (half) or 8,250 (2/3rds) from the 12,500 follicular units in the permanent zone (25% rule).

In those individuals with higher densities than 100,000 hairs on their head, the harvestable follicular unit numbers may safely go higher, while in the typical Asian, for example with lower hair densities (80,000 hairs on their head or 40,000 follicular units), the donor area would contain only 10,000 follicular units. With half of the Asian’s 10,000 follicular units harvested, that leaves 5,000 follicular units behind (this reflects a calculation of 25% of the birth hair follicular unit numbers which are permanent). I believe that extracting between one out of every two follicular units from the permanent zone may be pushing the limit on people with low density hair.

There may be reasonable limits for a typical Asian based upon hair density (we calculate hair density on every patient undergoing hair transplant surgery). To complicate matters, Asian follicular unit hair counts average less than two hairs per follicular unit, so to get out an average of two hair FUE grafts, it takes more follicular units to yield an average of two hair FUE grafts. Asians (or Caucasians with low hair density) who have a high number of FUEs will, in my opinion, be thin looking around the back and sides of the head. I have seen some Asians with significant track marks from the punch scars created by FUE, particularly when the harvesting numbers are high and the remaining donor hair is significantly lessened.

Many doctors are taking hair from the non-permanent area to give the patient the benefits of more hair in the transplant; however, this may spell disaster for the patient who develops more extensive balding (suggested by Dr. Knudsen). Hair taken from the non-permanent area will be lost with aging and/or advancement of the balding patterns. Over zealous FUE beyond the permanent zone, has long term consequences for some patients and they must be warned. I have seen some patients who’s balding had accelerated from multiple FUE procedures and have loss hair in areas where FUE grafts were taken while leaving visible scars.

I want to raise blood supply issues here as I have seen one patient already who had received 6700 FUE grafts in two sessions and lost more hair in the permanent zone than was removed by the surgeon during the FUE. I actually counted the grafts and the hairs on the head and had done density studies on him before another surgeon did surgery on him. When FUE numbers are pushed, this patient’s findings suggested vascular compromise may have occurred impacting the remaining hair in the donor area. I have heard, second hand, that at the last ISHRS meeting some cases of necrosis have appeared in the donor area when too many FUEs were done, possibly too close together. I don’t believe we really understanding the complications of large FUE sessions, or that doctors are not reporting their complications out of fear of professional ridicule and/or malpractice risks, all of which may become a factor in the long term future of this surgery. As we do many FUE cases in our practice, we are not anti-FUE; however, aggressive FUE megasessions in the wrong hands could be a problem.

In conclusion, “do FUE surgeries change donor area planning”, the answer is YES. FUE will impact long term planning and may impact strip surgery in future surgeries. Low density donor areas, resulting from FUE, make for less donor hair for a strip surgery, which will only make any scarring more visible as the hair is cut short.

I’m really interested in the scalp micro pigments / SMP and I’ve reviewed the results of SMP on your sites along with some of your competitors. There’s clear differences in the results, even on your site alone. How do you explain these differences?

How do you deal with scarring from previous surgeries of the transplant variety and can SMP do a good job covering it up for everyone with such scars?

I’m going to reference a couple patients found on our SMP Photo Gallery and explain why the results are so different and so obvious…

Patient 20 is the ideal patient result with a scar from a previous hair transplant. The scar was flat and uniform and was the result of a single surgical procedure with bad healing which caused the scar to stretch. The surgeon who did this patient did nothing wrong. When we did the SMP, we worked on a uniform scar surface, there were no divots or elevated areas on the scar, so the process worked perfectly. Contrary to what you see, the scar is still there and just as big as before, and if you ran you finger over it you would feel what you can not see.

Patient 51 had great results as well with the old drilled holes in his scalp from the old fashioned (now abandoned) surgical procedure called Open Donor Technique. He also had a strip surgery which accounted for the horizontal scar. The skin on the Open Donor Wounds turned out to be relatively flat, so the pigment was taken up well and uniformly, providing great results; however, the horizontal scar from the strip procedure was elevated and even though the skin took the pigment very well, the elevated scar could be soon.

These patients shaved their head for the procedure. They may have intended to grow out their hair and if they did, Patient 51 would have no obvious scar seen; however, Patient 20 would have to be careful, because the invisible scar would not grow any hair while the scalp above and below the scar would grow hair. This would be seen in the transition of early growth of the hair above and below the scar. When the hair is long enough, it will not be a problem because his hair stylist will account for the absence of hair from the scar.

We don’t always shave the head. As a matter of fact, we don’t shave the entire scalp in the area we work much of the time. That becomes a choice of the patient.

Finally, SMP is not real hair. SMP is applied under the skin, like a tattoo. It cannot possibly remove, erase, or make scars completely invisible. We do our best to blend in the scar and make it look less obvious, but the scar will always be there and will be noticed in certain lighting and at certain viewing angles. The goal is for the casual observer to not notice the scar.

Tags: scarring, scar, hair transplant, hairloss, hair loss, smp, scalp micro pigment, pigmentation

Its pretty interesting to see that you are investigating this whole ACELL thing. I was kinda wondering one day if you would be one of the DOCs to have this Acell cross your mind. I just ran into this whole page doing a daily Google study on Acell and the usual Hair loss deal and saw that yeah you are thinking about it. Good to see.

Would it make sense to use Acell injections/Powder in the donor area after a strip or FUE procedure as well as Acell into the transplant area such as the frontal hairline area, etc? I have read that it helps the wounds heal faster and the scar feels better when healed With ACell then if healed naturally. IF you said that you saw that it had value in the scar area after a strip procedure. Would it then also have the same value in the transplanted area where it would cause the tiny pin holes after the hair follicle is grafted to heal faster and be less present? As well as help heal the tiny holes after a FUE procedure in the donor area where the follicle was removed. In theory In the long run, would it show almost no scaring anywhere after any type of transplant. Weather its a strip or fue?

I know all the hype is about cloning this and that and plucked hairs growing everywhere. but in the sense where it promotes rapid healing and helps the scar look/feel more natural or show almost no scarring at all. IS that not a great value to the whole hair transplant community?

There are a bunch of cases where grafts that were installed were driven into deep and look like indents after all is done and healed. Im speaking from my own experience from a procedure. Those little bastards are ugly so would that Acell bacon compound help that case as well?

So ACell alone without FRP or whatever they call it for faster healing and better cosmetic scar results seem like a very realistic and valuable thing

Things in life like this interest me. Especially When i read about things that come out like Acell and other medical devices that could potentially help people with hair loss and hair surgery

ACellIt it generally thought that ACell will help the healing process deep in the wound and possibly reduce the superficial scarring, thereby making better wounds. There is circumstantial evidence for this in our practice, but this is more conjecture than science. I have not seen that ACell has helped the graft healing or made it grow better.

In our practice we have been using ACell for donor wound for over 3 years in most of our patients on a daily basis. Subjectively, the donor wound does look better with less tactile feel of a scar, so it may have some use in reducing keloid formation. Some patients came back for repeat surgeries and the old ACell scar seem to look better, but it was not a drastic improvement. Note that this is just a subjective observation from both the patient and doctor. ACell did not really have a reduction in the overall scar width and it does not make the scar any smaller in our observation. In one or two cases, the patient (who had prior non-ACell surgeries) thought it made the scarring worse. Even I (Dr. Rassman) had ACell put in my donor wound for strip surgery, but it made no difference in scarring compared to prior surgeries. ACell does not promote faster healing in our experience.

We also used ACell in many years ago in graft growth and even possible replication in recipient area. We submitted and applied for research approval with the medical board and conducted studies with Dr. Bernstein in New York. In the end, it didn’t work. The claims were false. To date, no one was able to replicate the claims of hair regeneration. Simply put, it was a publicity hype for the hair transplant world.

Tags: acell, hair multiplication, hair cloning, hair transplant, wound healing

My 8 year old son has a big scar on his head from one ear to the other due to head operation. Can hair grow on on that area? What are his options? Thanks

I don’t know what kind of procedure was done, but usually scar tissue won’t regrow hair on its own. Hair transplants into scars from surgery work well. If the scar is narrow enough, Scalp MicroPigmentation (SMP) would probably work. The two in combination will certainly solve the detectability issue.

Tags: hair transplant, child, scarring

This patient had one Scalp MicroPigmentation (SMP) treatment on his hair transplant scar. The AFTER video was taken immediately after SMP, so you can see some redness on the scalp, which will go away in a day or two.


In general, SMP to a scalp scar takes two to three sessions. The patient above will come back in one week to make sure everything blends in. The redness you see in this patient is due to the fact that it was taken immediately after it was done and there was a little bleeding present. He will be able to shave his head or keep his hair long without worrying about the scar. For more information you can visit scalpmicropigmentation.com or email us at hairdoc@newhair.com. You can include a photo of yourself for a consultation. The most common questions asked about SMP can be found here.

Tags: smp, scalp micropigmentation, scarring, hair transplant, hairloss, hair loss

Does having good laxity prevent large scars ? I see a lot of people with small scars, and a lot of people with large scars where the situation is so bad that many are implanting beard hair to cover those scars. I’m thinking about getting a second hair transplant, but I am afraid after the second transplant I might get a big scar which is hard to cover up. The doctor said I have above average laxity, but below average density. My density again is only 60 grafts per square centimeter. Can you give me some information about what causes a bad scar ?

Generally, people with very high laxity (loose scalp) may have a higher incidence of scars than those whose scalp is tight; however, the looser it is the more grafts can be extracted with any given hair density.

Scalp scars can be very easily treated, if they occur, with Scalp MicroPigmentation (SMP). An example patient can be seen here.

Tags: scarring, scars, hair transplant, hair restoraton

Hi Doc,
I have been following your blog closely & am really grateful to you for all your help. I had a FUE surgery done 2 years ago but now I wish I hadn’t. Basically I have a big bald spot & after reading the articles should have had strip. Now my problem is I dont like to have my hair long as its thin & doesn’t look good. Wearing them short as I do now exposes the donor & the recipient areas..By short I mean buzz. I dont shave my head.

What do you suggest i should do? Please help as I am losing my self confidence & getting depressed.

When there are large follicular unit extraction (FUE) sessions done on a patient with low density hair, it will show thinning in the donor area and a leave the patient with a more see-through back of the head. We have treated many FUE patients with Scalp MicroPigmentation (SMP) in the donor area to add some contrast to the skin. It also works wonders on the recipient area, making the hair look fuller in both locations.

Take a look at the site SMP site and see the many patients who have been treated with this modality. Particularly, look at this patient below, which shows a before and after treatment for FUE scars. This patient and many more can be found in our SMP gallery.


Tags: fue, follicular unit extraction, smp, scalp micropigmentation, scarring

Hi Guys, great blog. With regards to hair transplantation, I understand that there will be a scarring of some type in the donor area. My question is, with regards to the recipient area, once the grafts have initially dropped out, are there scars in the recipient area where the grafts were placed?


There is always scarring with any cut on the skin, but the visibility of the scarring depend on not only the surgeon’s skills, but also the individual.

The recipient area can usually appear red (in a fair group of people) for several weeks, but most patients will show no visible scarring in the recipient area after about 1 to 3 weeks.

Tags: hair transplant, hairloss, hair loss, scarring

We received some Scalp MicroPigmentation (SMP) questions:

1) The results pictures on the website all seem to show everyone with shaved heads. Should I expect the ability to cut my hair that short after the procedure and not have the scar visible? or are those atypical, “best case” scenarios? I know there will always be some irregularity but the pictures show it being very difficult to discern. This isn’t a make it/break it question. I’d be happy to cut my hair down to 1/8″ without the scar visible. I just want to make sure my expectations are in line with reality.

2) Must I shave my head for the procedure itself?

3) If I do have my head shaved and I expose the SMP’d scar to the sun, will it fade?

4) Is the SMP permanent? Permanent as in, I do this once (the 3 sessions) and it lasts for 50+ years? Or is there an expected life span for the SMP?

1. The photos on the SMP website show most people shaved, because that is what makes the scar blend in with the stubble of hair and the flat pigment of SMP underneath your skin.

Keep in mind, if you get SMP for a scar, it is not hair and that there will be a “step” in the hair where there is a scar. SMP will only make the scalp darker so you wont notice the white line. If you keep your hair 1/8 inch long you may see the step of where the hair starts and ends. Most patients shave or buzz their hair around the scar with an electric shaver set at zero guard or they keep their hair long enough to cover the invisible scar. Everyone is different in their degree of how they hide the scar, but you must remember that you will always still have a scar. SMP only helps hide it to most casual observers. No matter how good we get your SMP, you will always notice the scar in certain lighting and certain angles… and you will notice it more because you know how to look for it.

2. You don’t have to shave, but if you are ever going to shave later it will help us blend it in better. We work with longer hair all the time (this is not an issue). It is when we finish the job with long hair and later you decide to shave it, you will notice some areas that don’t look perfectly blended in. So if you are ever going to shave it, we recommend you have SMP done with the area shaved, because that is how we get it almost perfect. If you are never going to shave, then it is not an issue.

3. SMP will fade with or without sun. UV light makes it fade a bit more, but it won’t erase. If you ever need a touch-up in the future because you think it has faded too much, the fee is $300.

4. SMP is permanent just like a tattoo is permanent, though you may want a touch-up in the years to come. In our experience over the last 4+ years, most people do not return for touch-ups. When we follow up with our SMP clients, we find that most say it has not faded to a degree to warrant a touch-up.

We’ve answered many more SMP questions on our FAQ.

Tags: scalp micropigmentation, smp, pigment, hairloss, hair loss, scarring

When I was little I had an operation which resulted in a huge scar on my head. I cover it with my hair and am forced to keep it long enough to conceal it. Unfortunately for me I have hair loss in my family. Im 22 now with no signs of hair loss. I am scared to death that I will have my scar showing for everyone to see. Any suggestions?

Without knowing more details about your scalp scar (where it is on the head, how wide it is, how long it is, etc), it’s tough to offer any suggestions. If you have no hair loss at this point, that’s a good thing. Cross your fingers that you don’t have genetic male pattern baldness down the line, as it can skip generations. If you start noticing signs of hair loss, then you should see a doctor to get a treatment plan together. Until that happens, there’s no preventive treatment to use.

As for the possibility that your scar could show in the future, you could see a hair transplant doctor for options on how to disguise it (if it becomes noticeable).

Tags: surgical scar, scalp scar, hairloss, hair loss, hair transplant

Dr Rassman,have you heard of Dr Carlos Wesley’s Pilofocus no scar procedure? I watched the video it looks pretty amazing. I am curious what you think.

This was presented at this past October’s ISHRS meeting. Essentially, the procedure gets the hair from under the scalp with an endoscope. Although he was short on details, I would imagine that the scalp is lifted up with a gas (carbon dioxide) and then the hair follicles are plucked from below. If it looks/sounds too good to be true, then it is. We have no pictures or scientific material to base the claims that this is a valid procedure and I would imagine it would be very difficult and time consuming. A lot of work for very few hairs.

There is no such thing as scar-less surgery in the real world. Since I started offering Scalp MicroPigmentation (SMP), I have treated many Follicular Unit Extraction (FUE) patients who thought (and were told by their doctor) that their FUE surgery is “scar-less”. Even FUE produces some tiny scarring.

Tags: pilofocus, hair transplant, surgery, hair replacement, scarring