Procedure
How does a hair transplant actually work?
Every step from assessment to first wash: what it's for, who does it, and what it's actually like.
Written by Sedef Özdemir · Content Specialist
Reviewed by Dr. Muhammet, Anatomist; Hair Transplant Specialist
Last medically reviewed: 13 August 2026
Source quality
Based primarily on clinical guidelines and peer-reviewed literature. Commercial sources are used only for labelled price observations. Where the evidence is limited or outcomes vary by individual, we say so in the text rather than stating a single number.
See our full source hierarchy →The ten steps, in order
Most of these steps are the same regardless of technique. Only two, marked below, are where FUE and DHI actually diverge.
Diagnosis and history
Confirm the type and stability of hair loss before anything else is planned.
This step exists to rule out causes a transplant can't fix, telogen effluvium, active alopecia areata, thyroid or hormonal issues, before any surgical planning starts. Norwood staging (or Ludwig/Savin staging for diffuse female-pattern cases) is recorded here as the baseline the rest of the plan is built around.
Who: The reviewing clinician
Patient experience: A conversation and scalp examination. No procedure happens yet.
Donor and recipient measurements
Measure donor density and the size of the area that needs coverage.
Donor density is typically measured in follicular units per square centimetre using trichoscopy (a magnified, often digital, scan of the scalp), which also reveals how many of those units are single-, double-, or triple-hair grafts, information the later distribution plan depends on. The recipient area is measured in total square centimetres, since graft count is ultimately a function of area multiplied by planned density, not a number picked in isolation.
Who: Clinician or surgical planner
Patient experience: The scalp is examined and measured, sometimes with trichoscopy.
Hairline and distribution plan
Decide where the hairline sits and how grafts are distributed across zones.
A natural hairline is never a smooth arc: it's built with irregular micro-density, single-hair grafts placed with deliberately randomised spacing along the frontal edge, with density increasing as the design moves back. For patients with early-stage loss, hairline height is usually planned conservatively, higher than a patient might initially want, specifically because the underlying pattern loss often continues, and a hairline set too low today can look disconnected from a design that has to account for further recession years later.
Who: Surgeon, with patient input
Patient experience: The hairline is marked while sitting upright, so it can be seen and approved beforehand.
Trimming, preparation and local anaesthesia
Prepare the scalp and numb both the donor and recipient areas.
A lidocaine-based local anaesthetic, usually combined with epinephrine to reduce bleeding and prolong numbing, is injected first into the donor area and later into the recipient area once that stage begins. Some clinics use a tumescent technique, infiltrating saline into the donor scalp beforehand to firm the tissue, which can make extraction cleaner and reduce bleeding.
Who: Surgical team
Patient experience: Some or all of the head may be trimmed. The anaesthetic injections are typically the main discomfort of the day, and brief.
Donor harvesting
Extract individual follicular units from the donor area.
Each follicular unit is extracted with a fine hollow punch, typically 0.7–1.0mm in diameter, aligned to the follicle's subsurface angle by feel. This is the step where transection (accidentally severing a follicle) can occur if the punch angle is misjudged, which is why extraction pace is a poor proxy for quality and why experienced teams work at a consistent, unhurried rhythm rather than racing through the donor area.
Who: Surgeon or trained technician, depending on the clinic
Patient experience: Lying face down or on the side for an extended period. Generally no pain once numb, some pressure.
Graft sorting, hydration and storage
Sort grafts by follicular unit size and keep them hydrated and viable outside the body.
Grafts are sorted under magnification into single-, double-, and triple-hair units and kept in a chilled holding solution, since prolonged time outside the body measurably reduces graft survival. This sorting is what allows the distribution plan to actually be executed: single-hair units are reserved for the hairline, denser multi-hair units for areas where visual bulk matters more than micro-level naturalness.
Who: Technician team, working in parallel with extraction
Patient experience: Happens off to the side. Nothing is felt directly during this step.
Recipient-site creation and/or implanter placement
Create the openings, or place grafts directly, in a way that determines final density, angle and direction.
Site angle is matched to the natural direction of surrounding hair, and site depth is judged carefully: too shallow risks the graft failing to establish blood supply, too deep risks a raised, uneven healed texture. Achievable density is generally limited by local blood supply rather than by how tightly sites can physically be spaced, common targets are roughly 35–45 grafts per square centimetre at the hairline and somewhat less further back.
Who: Surgeon for the technical decisions, team for execution
Patient experience: Usually the longest part of the day, lying face up.
FUE / DHI: This is the step where FUE and DHI genuinely diverge: FUE creates recipient sites first and places grafts into them afterward, while DHI loads grafts into an implanter pen and places them directly, without a separate site-creation step.
Graft placement
Insert each graft into its site, matching the planned angle and direction.
Who: Surgical team
Patient experience: Continues directly from the previous step.
FUE / DHI: In FUE, placement usually follows site creation with forceps. In DHI, placement happens in the same motion as the implanter insertion.
Final inspection and dressing
Check density and coverage against the plan, then bandage or dress the treated areas.
Who: Surgeon performs the final check
Patient experience: Short, mostly waiting.
Immediate aftercare and first wash
Give aftercare instructions and, depending on the clinic's protocol, perform or explain the first wash.
Sleeping semi-upright for the first several nights is standard advice, aimed at limiting swelling that can otherwise migrate toward the forehead and eyes. First washes typically follow a specific low-pressure protocol using a diluted, clinic-provided solution rather than a normal shower, since dislodging a freshly placed graft in the first days is one of the few genuinely avoidable risks to the final result.
Who: Aftercare team or nurse
Patient experience: Instructions on sleeping position, medication, and what to expect over the coming days.
How a graft count actually gets calculated
A quoted graft number isn't a round figure picked to sound impressive, it's the output of a calculation: recipient area (in square centimetres) multiplied by a target density (grafts per square centimetre), adjusted for how much of that area can realistically be covered given donor supply. Target density itself varies by zone: the hairline is typically planned around 35–45 grafts per square centimetre using mostly single-hair units, while the mid-scalp and crown, where visual bulk matters more than micro-level naturalness, are often planned somewhat less densely using two- and three-hair units to cover more area per graft. This is also why two patients with the same Norwood stage can be quoted meaningfully different graft counts: the actual recipient area and donor density measured on their own scalp, not the stage label, drives the number.
Where to read more
Compare FUE and DHI in more detail, see how the plan behind these steps actually gets built, or check what recovery looks like afterward.