The Procedure, Step by Step: What Is Actually Done to Coiled Hair

Written by the AfroHairClinicTurkey editorial team, drawing on the clinical experience of our medical team · Last updated September 25, 2026 · How we write and check this

On this page 9 sections
  1. What has to be settled before the room
  2. Extraction: the step where coiled hair changes the tool
  3. Punch size: a disagreement we are not going to hide
  4. What the donor area looks like afterwards
  5. Density: why the target is lower, and why that is a plan rather than a compromise
  6. The first year: what the hair actually does
  7. What can go wrong, and how often it has been counted
  8. What is not decided on the day
  9. If You Want This Looked At

This page is about the operation itself: what is actually done to Afro-textured hair on the day, in what order, and which decision at each step is different because the hair is coiled. It is not the page about whether you should have one — that question has its own pages, linked where they belong below.

Most of what is written about hair transplants describes a procedure performed on straight hair and then adds a sentence about “curly hair”. The sequence below is the same operation everyone else performs. What changes is narrower than the marketing suggests and wider than the footnote does, and the difference sits almost entirely in two steps: how the graft comes out, and how densely it goes back in.

What has to be settled before the room

None of the following is a surgical decision, and all of it changes the surgery:

  • Which hair loss this is. Traction, CCCA, androgenetic, or more than one at once — telling the causes apart comes first, because two of them can make a transplant fail for reasons no surgeon can out-operate.
  • Whether the disease is quiet. A that is still active is not a candidate on the day it is still active.
  • What the can actually give. It is finite and it does not grow back — the donor density explorer shows that trade-off without a sales pitch attached, and what a graft number actually buys explains why the headline figure is the least useful part of a quote.
  • Where the hairline goes. The hairline decision is the one that cannot be undone later, and it is a decision about your face, not a template.

If you have not been asked about all four, you have been quoted for an operation rather than assessed for one. The questions worth asking first are listed separately.

Extraction: the step where coiled hair changes the tool

A follicular unit is removed with a small cylindrical punch. In tightly curled hair the follicle does not run straight down from the skin — it continues to curve beneath it, so a tool aimed along the visible hair shaft can cut across the part it cannot see. That cut is called , and it is the thing the whole step is organised around. The shape being aimed at is specific: in tightly curled hair the follicle sits curved beneath the skin rather than straight, with a bent, golf-club-shaped bulb and an asymmetric root sheath.[1,2]

Two cross-sections of scalp side by side. On the left a straight follicle runs down from the skin and a punch outline surrounds it completely. On the right the follicle emerges at an angle and curves beneath the skin; the punch outline, drawn along the visible shaft, crosses the curved part, and that crossing is marked.STRAIGHTthe punch contains the whole rootTIGHTLY CURLEDthe wall meets the root it cannot seedashed outline = the punch, aimed along the visible shaft
Figure A. Why the tool is the question on this step. The punch is aimed along the part of the hair anyone can see; in tightly curled hair the root carries on turning underneath. Schematic; not a patient, not to scale.[1,2]

Punch geometry is the lever surgeons have used against it: shapes that keep the cutting edge away from the follicle beneath the skin have been reported to reduce transection.[3] The clearest demonstration is small but direct — in a case series of 18 patients with tightly curled hair, conventional rotary punches either failed outright or produced excessive transection in eight of them, while a curved non-rotary punch kept transection below 5 percent.[4]

Two things are worth holding alongside that, because the industry usually publishes only the first half.

  • Transection is not an Afro-hair problem; it is a feature of the technique. A study of 42 patients undergoing conventional excision with a 1 mm punch found transection in 6.3–7.4 percent of grafts.[5] The question is not whether it happens but what it is kept to.
  • Curl is not the main variable. In a retrospective series of 64 patients of African descent, the mean transection rate was 3–6 percent, and scalp thickness and firmness affected it more than hair curliness did.[6] A clinic that explains everything by your curl pattern is describing a simpler operation than the one it is performing.

Punch size: a disagreement we are not going to hide

There is an unresolved conflict in the published work, and it is directly about skin like yours. The largest published series of in patients of African descent used 18 and 19 gauge punches throughout — nominally about 1.1 to 1.3 mm. A 2026 complications review lists punches over 1 mm as a risk factor for donor-site hypopigmentation in darker skin phototypes, and recommends 0.8 to 0.9 mm. No published work reconciles the two.[6,7]

We are not going to resolve it on a web page either. What we can tell you is that it is a real question to put to whoever is holding the punch: what diameter do you use on this skin, and what are you trading away when you choose it? A clinic that has not thought about it will answer with a brand name.

A millimetre scale from 0.6 to 1.4. One band covers 0.8 to 0.9 and is labelled as the range a 2026 complications review recommends for darker skin phototypes. A second band covers 1.1 to 1.3 and is labelled as the range used throughout the largest published series in patients of African descent. The space between the two bands is labelled: no published work reconciles them.PUNCH DIAMETER, MILLIMETRES0.8–0.9recommended for darker skin phototypes (2026 review)1.1–1.3used throughout the largest Afro-descent series (18–19 gauge)above 1.0 listed as a risk factorfor donor-site hypopigmentation0.60.81.01.21.4nothing published bridges this
Figure B. Two published positions on the same tool, for the same skin, with no study reconciling them. This is the question worth putting to whoever is holding the punch. Schematic; not to scale.[6,7]

What the donor area looks like afterwards

Excision is not scarless, and the way it heals is not the same on every skin. Each punch takes the follicular melanocytes out with the graft, and the wound can heal as a small pale dot — reported as more visible in darker skin phototypes and with short hairstyles. The review that documents this grades it common but gives no incidence figure.[7,8]

That last clause is the honest part: common, but nobody has published how common. If you wear your hair very short at the back, this is the sentence on this page to take to your .

Density: why the target is lower, and why that is a plan rather than a compromise

Scalp biopsies from 22 African American and 12 white patients found total hair density significantly lower in the African American group.[9] Planning to a lower follicular density is therefore not a clinic cutting corners; it is the operation matching the scalp it is working on.

The practice of packing more units into a square centimetre in one sitting has its own limits, and they are stated by its own proponents: two of them describe dense packing as desirable in principle but say that not all patients are suitable and that it is not possible to achieve in certain patients — giving coarse or curly hair as the example.[10] Ask what density is being planned and why. A number given before anyone has looked at your donor area is a sales figure.

There is also a harder reason than anatomy to keep the number honest. The current review of recipient-site necrosis lists its technical risk factors as dense packing above 50 follicular units per square centimetre, sessions above 3,500 to 4,000 grafts, deep or overlapping slits, excessive tumescence and high epinephrine concentrations.[7,11] Those are the settings a clinic chooses, not features of your scalp — which is why “how many grafts in one sitting” is a safety question before it is a value-for-money one.

The first year: what the hair actually does

Transplanted hair falls out before it grows. That is expected, and the shape of it has been measured: in 11 men, grafts placed into tattooed templates were counted over the first year — 47.3 percent of follicular units present at one month and 57.4 percent at three months, while 92.0 percent of the transplanted hairs were present at six months and 90.4 percent at twelve. About half of the transplanted hairs fell out in the first month.[12]

A chart in two panels separated by a labelled divider. The left panel plots follicular units present at one month, 47.3 percent, and at three months, 57.4 percent. The right panel plots transplanted hairs present at six months, 92.0 percent, and at twelve months, 90.4 percent. The divider is labelled: different measure, not the same line.0%25%50%75%100%FOLLICULAR UNITS PRESENT47.3%57.4%1 month3 monthsdifferent measure — not the same lineTRANSPLANTED HAIRS PRESENT92.0%90.4%6 months12 months
Figure C. The first year as the one series that counted it reported it — in 11 men, not on Afro-textured hair. The two panels are two different measures, which is why they are not joined: the early figures count follicular units, the later ones count hairs. Reading across the gap as a single recovery curve is the mistake this figure exists to prevent.[12]

That series was not , and we are not going to present it as though it were. It is the shape of the first year as anyone has measured it. What happens after it is a separate question with its own evidence, and the hair you already had can shed too — shock loss is its own page because it surprises people who were never told.

What can go wrong, and how often it has been counted

Every clinic’s page has a risks paragraph. Almost none of them carries a number, because the numbers are unflattering and they are not required. Here are four that have been counted, with what each one was counted in.

Redness that does not settle

In a multicentre retrospective cohort of 1,090 patients, persistent redness around the grafts was mild in 16.33 percent, moderate in 5.14 percent and severe in 0.92 percent. Patients who had it shed more hair shafts and had lower graft survival; folliculitis was a significant risk factor, with an odds ratio of 6.061 for the mild form; and an untimely first post-operative wash was associated with the moderate and severe forms.[13] That last clause is the one to notice, because the first wash is something a clinic schedules.

Folliculitis in the recipient area

In a retrospective comparison of 27 patients who developed it and 28 who did not, onset ranged from 2 days to 6 months after surgery, with a mean of about six weeks. The lesions were mostly pustules, healed without scarring regardless of how they were managed, did not affect graft growth, and were not associated with patient characteristics or the .[14] Alarming to find, and on this evidence not a threat to the result.

Recipient-site necrosis

Rare, and the one on this list that ends the result rather than delaying it. In the largest published series — 18 patients seen after excision performed elsewhere — the commonest risk factors were smoking in 66.7 percent, then hypertension and diabetes; all had had a single session averaging 3,899 follicular units; and scarring and graft failure occurred in every patient.[7,11] If you smoke, this is the paragraph to raise before the one about price.

Hair that grows back with a different texture

In 980 women who had hairline-lowering surgery, transplanted hair grew back kinky or severely curly in 38 of them — 3.9 percent. In 36 the change appeared around four months after surgery, and in two at six to eight months, where growth was obstructed by existing hair.[15] That series is not Afro-textured hair and the procedure is not this one, which is exactly why it is worth knowing that a texture change after transplantation has been documented at all.

Two further things have their own pages because they are their own subjects: the hair you already had can shed after surgery (shock loss), and raised scarring is a separate risk profile on darker skin (keloids and hair transplants). If a result has already gone wrong, cobblestoning, pitting and repair covers what can and cannot be corrected.

What is not decided on the day

Three things get decided before anyone books, not in the chair: whether this is the right operation for the , what the donor area can afford across a lifetime rather than one session, and where the hairline sits. A clinic that settles all three in the same conversation as the price is settling them for its own convenience.

Everything stated above is sourced below. What we can and cannot yet prove about this clinic — including the parts still waiting on documents — is on the verification page, and the terms used here are defined in the glossary.

If You Want This Looked At

Send photos of your hairline, your crown and the back of your head. You will get an assessment with the reasoning attached, and no figure before someone has actually looked — which is the position this site takes everywhere, not a stalling tactic.

Ask about your case →

If you would rather work something out on your own first, the hair pattern assessment is a guided set of questions that nobody at this clinic sees, and the Afro Hair Lab holds the rest of the interactive tools.

Clinical references

  1. Thibaut S, Gaillard O, Bouhanna P, Cannell DW, Bernard BA. Human hair shape is programmed from the bulb. Br J Dermatol. 2005;152(4):632-8. view source →
  2. Thibaut S, Barbarat P, Leroy F, Bernard BA. Human hair keratin network and curvature. Int J Dermatol. 2007;46 Suppl 1:7-10. view source →
  3. Gupta AK, Bruce A, Trivellini R, Dua K, Mohebi P, True RH, et al. Innovations hair restoration surgeons have made to adapt to the challenges of follicular unit excision. Journal of cosmetic dermatology. 2020;19(8):1883-1891. view source →
  4. Umar S. Comparative Study of a Novel Tool for Follicular Unit Extraction for Individuals with Afro-textured Hair. Plastic and reconstructive surgery. Global open. 2016;4(9):e1069. view source →
  5. Park JH, You SH. Various Types of Minor Trauma to Hair Follicles During Follicular Unit Extraction for Hair Transplantation. Plastic and reconstructive surgery. Global open. 2017;5(3):e1260. view source →
  6. Umar S, Khanna R, Lohlun B, Maldonado JC, Zollinger M, Osei-Tutu A, et al. Follicular Unit Excision in Patients of African Descent: A Skin-Responsive Technique. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.]. 2023;49(10):949-955. view source →
  7. Romera de Blas C, Vega Díez D, Ricart Vayá JM, Gómez Zubiaur A. Complications in follicular unit excision hair transplantation. Frontiers in Medicine. 2026. doi:10.3389/fmed.2026.1750989 view source →
  8. Adotama P, Papac N, Alexis A, Wysong A, Collins L. Common dermatologic procedures and the complications unique to skin of color. Dermatologic Surgery. 2021. doi:10.1097/DSS.0000000000002813 view source →
  9. Sperling LC. Hair density in African Americans. Archives of dermatology. 1999;135(6):656-8. view source →
  10. Farjo B, Farjo N. Dense packing: surgical indications and technical considerations. Facial Plast Surg Clin North Am. 2013;21(3):431-436. view source →
  11. Ceran F. Recipient Site Necrosis After Follicular Unit Excision Technique For Hair Transplantation: Evaluation of 18 Patients. Aesthet Plast Surg. 2024;48(19):3735-3740. view source →
  12. Lee SJ, Lee HJ, Hwang SJ, et al. Evaluation of survival rate after follicular unit transplantation using the KNU implanter. Dermatol Surg. 2001;27(8):716-720. view source →
  13. Zhang J, Zhao Y, Zhang J, et al. Risk Factors and Hazards of Recipient-Area Perifollicular Erythema After Hair Transplantation: A Multicenter Retrospective Cohort Study. Aesthet Plast Surg. 2024;48(15):2771-2777. view source →
  14. Bunagan MJ, Pathomvanich D, Laorwong K. Recipient area folliculitis after follicular-unit transplantation: characterization of clinical features and analysis of associated factors. Dermatol Surg. 2010;36(7):1161-1165. view source →
  15. Park JH, Kim N, Manonukul K. Post-Hair Transplantation Complication: Kinky or Severely Curly Hair. J Craniofac Surg. 2024;35(2):e146-e150. view source →

References are checked on the dates recorded in our evidence library. If a source has been superseded, tell us and we will update it.