Most men at Norwood 5 are good candidates for hair transplant surgery, provided they have adequate donor density (60+ follicular units per cm2), stable general health, and realistic expectations about achieving 30 to 50% of original density rather than full restoration.
The Five Candidacy Criteria at Norwood 5
Surgeons evaluate Norwood 5 patients across five dimensions before recommending surgery. Meeting all five substantially increases the likelihood of a satisfying result.
1. Donor Area Density and Supply
The donor area (the horseshoe-shaped band of permanent hair along the sides and back of the head) must have enough follicular units to supply 3,000 to 4,500 grafts without visible thinning.
| Donor Density | Candidacy Level |
|---|---|
| 80+ FU/cm2 | Excellent candidate, full graft count available |
| 60-79 FU/cm2 | Good candidate, graft count may need conservative planning |
| 40-59 FU/cm2 | Marginal candidate, limited graft count, careful discussion needed |
| Below 40 FU/cm2 | Poor candidate, transplant not recommended |
The safe extraction limit is 45% of the donor area. Extracting beyond this threshold creates visible thinning in the donor zone, which trades one cosmetic problem for another. At Norwood 5, a surgeon must confirm that your donor area can supply the needed grafts while staying well within this limit.
2. Hair Characteristics
Certain hair traits produce better visual coverage per graft:
- Hair caliber: Coarse or medium-thickness hair covers more scalp area than fine hair. Patients with fine, straight hair may need more grafts for the same visual result
- Hair color vs. skin color: Low contrast between hair and skin (e.g., blond hair on fair skin, dark hair on dark skin) creates a perception of greater density
- Curl and wave: Curly or wavy hair provides more coverage per graft because each strand occupies more space
- Hairs per graft: The average is 2.2 hairs per follicular unit. Higher averages (2.5+) produce better results with fewer grafts
3. General Health Status
Hair transplant surgery is performed under local anesthesia with optional sedation. While it is less invasive than many surgical procedures, certain health conditions affect candidacy:
Conditions that require clearance or management before surgery:
- Diabetes (uncontrolled blood sugar impairs healing)
- Hypertension (must be controlled before the procedure)
- Blood clotting disorders (bleeding risk during extraction and implantation)
- Autoimmune conditions affecting the scalp
Conditions that may disqualify:
- Active alopecia areata or alopecia universalis (autoimmune hair loss that can attack transplanted grafts)
- Active scalp infections or severe dermatitis
- Uncontrolled bleeding disorders
- Certain immunosuppressive therapy regimens
4. Psychological Readiness and Expectations
This is where many Norwood 5 consultations go wrong. Surgeons report that unrealistic expectations are the single most common reason for post-surgical dissatisfaction, not poor surgical technique.
Realistic expectations at Norwood 5:
- A natural-looking frontal hairline and moderate mid-scalp density
- 30-50% of the density you had before hair loss
- The ability to style hair in a way that looks fuller and frames your face
- A result that ages gracefully as native hair continues to thin (with medication support)
Unrealistic expectations at Norwood 5:
- A return to your hair at age 20
- Thick, full coverage across the entire scalp from a single session
- Permanent results without ongoing medical therapy to protect native hair
5. Commitment to Post-Surgical Maintenance
Transplanted hair is permanent (it comes from DHT-resistant donor follicles), but the native hair surrounding the transplant zone is not. Without medical therapy:
- Native hair continues to thin over the following years
- The contrast between transplanted and native hair becomes increasingly visible
- The result looks less natural over time
The standard post-surgical protocol includes finasteride (1mg daily, halts loss in 80-90% of men, 65% regrowth, 2-4% sexual side effects) and minoxidil (5% topical, 40-60% moderate regrowth, onset at 4-6 months). Patients unwilling to consider either medication should discuss this honestly with their surgeon, as it directly affects long-term result quality.
Who Should Not Get a Transplant at Norwood 5
Certain situations make surgery inadvisable:
- Active diffuse thinning in the donor area: If the donor zone itself is miniaturizing, transplanted grafts may not be truly permanent. A trichoscopy exam can detect donor miniaturization
- Extremely low donor density: Below 40 FU/cm2, extraction leaves visible gaps that cannot be concealed
- Unstable hair loss pattern: If you have rapidly progressed from Norwood 4 to 5 within the last 12 months, most surgeons recommend stabilizing with finasteride for 6 to 12 months before operating
- Body dysmorphic disorder (BDD): Patients with BDD may never be satisfied with surgical results regardless of outcome quality. Ethical surgeons screen for this condition
Alternative Pathways If Surgery Is Not Right
If you do not meet the candidacy criteria, the following options remain:
- Medical therapy only: Finasteride plus minoxidil can stabilize loss and produce modest regrowth even at Norwood 5
- Scalp micropigmentation (SMP): A cosmetic tattoo that creates the appearance of a closely shaved head. Effective at all Norwood stages
- Hair systems: Modern hair replacement systems are virtually undetectable and provide immediate full coverage
- PRP therapy: $500-$2,000 per session, 30-40% density increase in areas with miniaturized but living follicles
Get Your Candidacy Assessment
A preliminary assessment of your donor area and Norwood stage can help you determine whether a surgical consultation is worthwhile. Upload a photo at myhairline.ai/analyze for a free AI-powered analysis of your hair loss pattern, estimated graft count, and treatment recommendations.