The International Society of Hair Restoration Surgery (ISHRS) publishes photography guidelines that set the benchmark for how hair transplant results should be documented. Clinics that follow these standards produce before and after photos you can actually trust. Clinics that ignore them produce marketing material designed to sell, not inform. This guide covers the full framework so you can tell the difference.
This content is for informational purposes only and does not constitute medical advice.
The ISHRS Photography Standard
The ISHRS recommends a standardized clinical photography protocol for documenting hair restoration outcomes. While not legally binding, adherence to this protocol signals that a clinic prioritizes evidence-based documentation over marketing aesthetics.
Core Requirements
The standard covers five areas:
- Camera and lens specifications. Consistent focal length (typically 85-105mm portrait lens) to avoid barrel distortion that changes apparent head shape and hair density.
- Fixed camera position. A tripod-mounted camera at a set distance from the patient, used identically for before and after shots.
- Lighting protocol. Standardized overhead lighting that reveals scalp visibility consistently. The same lighting setup must be used for both sessions.
- Background. A neutral, solid-color background (typically light blue or gray) in all photos.
- Patient positioning. Defined head angles and positions documented with reference marks or guides.
Required Photo Angles
A complete clinical documentation set includes these standard views:
| View | Purpose |
|---|---|
| Frontal (straight on) | Hairline shape, temple recession, frontal density |
| Left profile (90 degrees) | Left temple recession, temporal point |
| Right profile (90 degrees) | Right temple recession, temporal point |
| Left oblique (45 degrees) | Three-quarter view showing hairline contour |
| Right oblique (45 degrees) | Three-quarter view showing hairline contour |
| Vertex (top-down) | Crown coverage, vertex thinning pattern |
| Occipital (back of head) | Donor area condition, scar assessment |
A clinic showing only frontal photos is hiding information. Without the vertex view, you cannot assess crown density. Without the occipital view, you cannot evaluate donor area depletion.
Why Standards Matter for Patients
The Comparison Problem
Without standardized photography, two photos of the same patient taken minutes apart can look dramatically different. Consider these variables:
- Overhead vs. side lighting changes visible scalp area by 20-40%
- Wet vs. dry hair makes density appear 30-50% different
- Camera zoom level affects apparent density and coverage
- Head tilt of just 10 degrees can hide or reveal recession
When a clinic uses one set of variables for the "before" shot and different variables for the "after," the comparison is misleading even if no digital editing occurs.
The Selection Bias Problem
Even with standardized photography, clinics choose which cases to display. Industry standards do not require showing every result. The most transparent clinics address this by:
- Showing cases across a range of Norwood stages (2 through 6 or 7)
- Including average results alongside their best outcomes
- Disclosing their total procedure volume alongside their gallery size
- Publishing revision rates
Documentation Standards Beyond Photography
Case Data Requirements
The ISHRS recommends that each documented case include:
- Patient Norwood stage at the time of the procedure
- Total graft count placed during the session
- Procedure type (FUE, FUT, or DHI)
- Graft source (scalp, body hair, or combination)
- Adjunct treatments used (finasteride, minoxidil, PRP, or none)
- Timeline between before and after photos (minimum 12 months recommended)
- Surgeon identification confirming who performed the procedure
Why Adjunct Treatment Disclosure Matters
A before and after comparison that fails to mention concurrent medication use is incomplete. Finasteride halts further loss in 80-90% of users and promotes regrowth in 65%. Minoxidil produces moderate regrowth in 40-60%. PRP therapy increases hair density by 30-40% in clinical studies.
If a patient used finasteride for 12 months alongside their transplant, the "after" photo reflects both the surgical and pharmaceutical results. Without disclosure, the surgery appears more effective than it was in isolation.
Procedure-Specific Standards
FUE Documentation
FUE (Follicular Unit Extraction) is the most commonly advertised procedure. Documentation standards for FUE include:
- Punch size used (typically 0.7-1.0mm)
- Number of grafts extracted vs. grafts placed (transection rate)
- Donor area photos showing extraction pattern and dot scar visibility
- Maximum single-session capacity is 5,000 grafts with 90-95% survival
FUT Documentation
FUT (Follicular Unit Transplantation) documentation should show:
- Strip dimensions and closure technique
- Linear scar visibility at various hair lengths
- Microscopic dissection quality metrics
- Maximum single-session capacity is 4,000 grafts with 90-95% survival
DHI Documentation
DHI (Direct Hair Implantation) requires:
- Choi pen needle specifications
- Implantation density per square centimeter
- Comparison of angles achieved vs. natural hair growth direction
- Maximum single-session capacity is 3,500 grafts with 90-95% survival
How to Audit a Clinic's Gallery Against Standards
Use this checklist when evaluating any clinic's before and after gallery:
Photography Quality Checklist
- Same lighting setup in before and after photos
- Same camera distance and angle
- Same background
- Same hair styling (dry, unstyled in both)
- Multiple angles shown (frontal, profile, vertex, occipital)
- No visible retouching or filters
Case Documentation Checklist
- Norwood stage identified
- Graft count disclosed
- Procedure type specified (FUE, FUT, or DHI)
- Time between photos stated (12+ months)
- Adjunct treatments noted
- Surgeon identified
Gallery Integrity Checklist
- Cases shown across multiple Norwood stages
- Range of outcomes shown (not just best cases)
- Total procedure volume disclosed
- Revision rate available on request
- Patient references available
Regional Variations in Standards Compliance
Standards adherence varies significantly by region:
| Region | Cost Per Graft | Standards Compliance |
|---|---|---|
| USA | $4.00 - $6.00 | Generally high; advertising regulations enforced |
| UK | $3.00 - $5.00 | High; regulated by ASA and GMC standards |
| Europe | $2.50 - $4.50 | Varies by country; Germany and Spain tend to be strict |
| Turkey | $1.00 - $2.00 | Highly variable; top clinics meet ISHRS standards, budget clinics may not |
| India | $0.50 - $1.50 | Variable; accredited hospitals tend to comply |
| South Korea | $3.00 - $5.00 | Generally high; strong regulatory framework |
Higher cost does not guarantee standards compliance, and lower cost does not mean non-compliance. The determining factor is the surgeon's commitment to documentation integrity, not the regional price point.
What Patients Should Demand
As a patient, you have the right to ask for:
- Standardized before and after photos that meet ISHRS photography guidelines
- Complete case documentation including Norwood stage, graft count, procedure type, and adjunct treatments
- A range of outcomes beyond the clinic's best cases
- Contact with previous patients at a similar Norwood stage to yours
- Written procedure details before committing to a date
Clinics that refuse these requests are prioritizing sales over patient outcomes. A surgeon confident in their results welcomes scrutiny.
Graft Needs by Norwood Stage
When evaluating documented cases, match them to the standard graft ranges:
| Norwood Stage | Description | Grafts Needed |
|---|---|---|
| Stage 2 | Slight recession at temples | 800 - 1,500 |
| Stage 3 | Deep temple recession, M-shape | 1,500 - 2,200 |
| Stage 3V | Temple recession with vertex thinning | 2,000 - 2,800 |
| Stage 4 | Further recession, enlarged vertex area | 2,500 - 3,500 |
| Stage 5 | Front and vertex separation narrowing | 3,000 - 4,500 |
| Stage 6 | Bridge between areas lost | 4,000 - 6,000 |
| Stage 7 | Most extensive loss pattern | 5,500 - 7,500 |
A case labeled "3,500 grafts" on a Norwood 2 patient is inconsistent with standard practice. A case showing "1,000 grafts" on a Norwood 5 patient will produce thin, unsatisfying coverage. Cross-referencing the gallery with these ranges helps identify realistic vs. exaggerated claims.
Start With Your Own Assessment
Before evaluating any clinic's gallery against industry standards, determine your own Norwood classification and graft estimate. This gives you a concrete benchmark for filtering relevant cases. Use the free AI analysis at myhairline.ai/analyze to get your Norwood stage, graft range, and cost estimate in under 60 seconds. No account required, no data stored.