Many of the other blog articles have touched upon various elements of quality control that lead to excellent surgical outcomes. What I would like to do is to talk more globally about problems that I see that make a hair transplant result look fake when looking closely at the work. Unfortunately, the public thinks that there are only two conditions that lead to fake results: too big a graft (called a plug) and too straight or malpositioned a hairline. Although these are two very big no-nos that can lead to bad results, there are a host of subtle problems that lead to an overall bad result especially when multiple sins are committed.

Correction of previously bad hair transplant work: hair angles are too perpendicular, grafts are too large, temples do not match, and the hairline design is too straight.

One of the most common mistakes that I see performed is that hairs that are transplanted too perpendicularly to the scalp in the frontal hairline. First of all, hairs simply do not grow that way. Second, they do not create favorable density in that arrangement. Third, the insertion point of the graft to the skin is grossly visible making the graft look grafty even when the graft is a single hair. For all of these reasons graft placement is crucial, I place my graft angles at 10 to 30 degrees relative to the scalp whereas 70 to 90 degrees simply just looks bad.

Also, grafts can sometimes look like grafts when they are placed too far apart from one another no matter how small they are. That is why I densely pack them together so that you cannot see them, blurring the whole lot out. The number one thing that I see at hair-transplant meetings that is a dead giveaway that something surgically was done is that few hairs were used to cover too wide an area of the baldness leading to single little tufts of hairs populating a widely bald scalp. This does not look natural and that is a big reason why I do not transplant the crown and the front of the scalp at the same time in 90% or more of the cases.

The next problem is how the hairs are shingled, i.e., how they are layered next to each other. I notice when I teach junior surgeons at the course that I run in St. Louis that they tend to make recipient sites in a radial fashion, i.e., their hand arches in a circle around the head mimicking the shape of the round head. Grafts should not be placed in this fashion because not only is visual density compromised when all of the grafts are splayed open apart like an open book but because the result does not resemble how hair naturally grows on the head. Somehow this radial orientation of grafts just looks off to the casual viewer.

The next set of problems occurs due to bad hair-transplant technician work. When hair grafts do not fit into the recipient site, the grafts can either be chocked off and not grow or be compressed into a tuft of hair resembling a plug. Conversely, if the recipient site is too big and hair follicles fall into the hole the graft can show dimpling at the skin, another sign of artificiality. My team is trained to check for graft-to-site fit carefully with me before I begin to make my recipient sites and also they check that the right graft fits into the right sites as they progress. Assistants can also damage hairs during insertion. If the grafts are placed with too much trauma, they will either not grow or will grow out kinky like pubic hair. Finally, if grafts are placed too high relative to the surrounding skin, the result can be a bumpy, cobblestone appearance or it may not grow out at all. If the grafts are placed too deep relative to the surrounding tissue, they can either grow out as a cyst or show a dimpling pattern on the skin. If grafts are inadvertently stacked one on top of another, this can also lead to cyst formation due to buried, or piggy backed, grafts. This is why having quality assistants is so important to creating the best results possible for any given hair transplant procedure.

Other issues of poor quality control relate to the surgeon’s bad design work. For example, grafts that are too big placed into the wrong area can look fake. Or, as mentioned, if grafts are angled and directed poorly they can either have unnatural looking results or compromise density. All of these myriad elements that go into a quality hair-transplant result, my team and I manage consistently in every single hair transplant procedure to attain consistently high-quality results.

Samuel M. Lam, MD, FACS, a board certified hair transplant surgeon in Dallas, Texas. To schedule a hair transplant consultation please call 972-312-8105, or visit for more info. To ask Dr Lam a question please visit our hair transplant forum.