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Dr. Paul Shapiro, FUE Transplant, 1049 Grafts: Goal to bring down Frontal Temporal Angles.

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Paul Shapiro MD

Paul Shapiro MD

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Dr. Paul Shapiro, FUE Transplant, 1049 Grafts: Goal to bring down Frontal Temporal Angles.

This 28 year old Norwood type II male was bothered by the recession of his frontal-temporal angles. He did have some thinning throughout the front 2/3 of his scalp which is noticeable with his hair wet, but under most conditions this thinning did not bother him. He chose to do a FUE hair transplant just to bring down his frontal temporal angles. We chose a conservative hair line because of his age and potential for future hair loss. We transplanted a total of 1049 FU €™s. He recently came if for his 7 month follow up visit and is very happy with his results.



IMG]http://i288.photobucket.com/albums/ll194/paulshapiromd/Ryan%20Dancer/Slide1.jpg[/IMG]












 
D

dodger1

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#2
Great looking change! I too had weak temporal angles and hope to have similiar results at my 7 month mark! looks awesome bro! Great work Doctor Shapiro!
 
Nervousnelly

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#3
Nice. Pretty amazing what a difference it can make to restore the temples. Gives him appearance of no hairloss at all. You give a young man a little more confidence with not having to worry about his looks and it can dramatically affect his future potential in business.(Just a side note-ha ha)

NN


 
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karmenelec

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#4
Janna what density did Dr. Paul transplant at? How much more thickening do you expect at the 7 month mark? Well done as always..

 
Paul Shapiro MD

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Karmenelec

I did not do a density measurement in this case. From experience I know that a case like this will take about 1,000 FU to 1,200 FU. In general the area of a frontal temporal angle and the hairline on one side is about 12 to 15 sq.cm. I would say in this surgery I covered about 25 sq. cm. Since I used about 1,000 FU, I planted at an average density of 40 FU/sq.cm

In hairline work the density is not evenly dispersed. The hairline can be divided into two parts: The transition zone which incorporates the peaks and valleys and the defined zone which is the area behind the transition zone. Most likely the area of the defined zone had densities around 40-45 FU/sq.cm and the peaks and valleys had densities from 30- 35 FU/sq.cm.

This is about as aggressive I would be in a patient who is young, 28, and has the potential for future hair loss. He still has plenty of donor left if he needs future hair transplants.

I hope this is helpful

Dr. Paul
 
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karmenelec

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#6
But if the rule of thumb is that you can only achieve a natural look with a minimum of half one's density at the hairline, isn't 40 grafts too little? I have to say, I don't find these results all too impressive - especially looking at the right side of the patient's temple. Perhaps there will be more thickening in the coming months.
 
Bigmac

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#7
Where is this rule of thumb regarding density,can you provide a link for me.

Thanks bm.
 
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karmenelec

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#8
I'm sure Dr. Shapiro could confirm that old adage. Half the original density is the standard protocol -- although, googling those terms to prove my point, I came across this on H&W's site.


Hair restoration surgeons have long been taught that those patients who achieve 50% of original density will look the same as those with full density. So it would appear that transplanting anything over 50 follicular units per square centimeter would be unnecessary. The reality is that in our experience 50% of original density does not in any way look the same as full density.

But in any event, isn't the proof in the pics? I understand Dr. Paul didn't want to go aggressive, but it's clear that 40 grafts is not enough to create an illusion of density at the hairline. Just look at the right temple post-op.
 
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janna

janna

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#9
We know at 7 months post op, this patient has not received his full results. We like posting "still in progress" pictures to give others an idea of where a patient will likely be at various stages of their HT journey.

This patient who has approximately 40 grafts per cm2 at 7 months post op is right where he should be. The styling gel he likes to use is called Glue or has the word glue in the name. It gives the wet look, which can certainly make any density look less and it makes the hairline look a bit stark too. At this point, we are pleased the patient feels he is well on his way to achieving his goals.
 
Paul Shapiro MD

Paul Shapiro MD

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Karmenlec:

The amount of grafts needed to give a good illusion of density varies with each patient. What I have noticed is that each patient has a threshold level that when the density is greater than that threshold the hair looks dense. That can be 40 FU/sq.cm. in some patients and it can be up to 60FU/sq.cm. in other patients. A lot depends on the volume of the hair follicles. It is really the hair volume, not the graft density that is important. We can plant the exact same graft density in two patients and get very different result if their hair caliber is different. If one doubles the hair diameter, the volume is quadrupled. (This is because the area of a circle is pi times the radius squared).

At Shapiro Medical Group in most patients we plant at densities between 40 and 50 FU/sq.cm. We do this because of the issues of limited donor density and the fact that hair loss is a continual process through ones life. In some patients this gets us above the threshold and the hair looks very dense, in others it still looks see-through in some situations. Sometimes we will plant at higher densities but because of the issue of limited donor we have to be very careful in picking patients in which we can plant at higher densities. When planning a hair transplant if we don €™t take the issue of limited donor and future hair loss into consideration we could paint ourselves into a corner.

Take this patient as an example. He is only 28. It is impossible to predict his future balding. Suppose he progresses to a Norwood type 6. If I had planted his temporal corners at a density of 50 to 60 FU/sq.cm., and if his balding progresses to a Norwood type 6, most likely he will not have enough donor to cover the rest of the front half of his scalp at a density of 60 Fu/sq.cm. Thus he would have very dense temporal corners and less dense central core area. Cosmetically I don €™t think that would be look good.

Unfortunately we are limited by the patient €™s donor supply and the likelihood of future hair loss. I know that some doctors will plant at higher densities. I think there are some risks in these procedures unless the patient is picked very carefully. I have planted at densities of 60 FU/sq.cm. I only do high densities in patients with a great donor supply and no or very little evidence of miniaturization in the areas behind where I am transplanting. Also these patients should be at least in their 30 €™s, preferably, mid 30 €™s. Remember, a patient who is 30 now will only be 60 in 30 years. With most of us are living until 80 or 90 years old and there is still a lot of life after 60. And with the divorce rate being 50% at least half of us will be single again later in life. In twenty or thirty years from now we may see patients in which doctors have been aggressive in their hairline and/or temporal peaks and these patients may regret what was done. Also to get the high number of grafts needed to cover large areas of scalp at high densities we may be taking hair from areas that may not be in the traditionally safe donor area. There is a possibility that hair taken from these areas may not be permanent.

If we can still a get good cosmetic results with densities of 40 to 50 FU/sq.cm., I believe it is better to err on the side of caution. At these densities we still get a big cosmetic improvement and we are not at risk of using up the limited donor.

Below is an example of a patient who I dense packed 60 FU/sq.cm into the hairline. But he met the criteria I mentioned above. Not many of the patients I see meet these criteria. As you can see the density of his hair transplant does match the density behind the transplant. This patient was in his mid 30 €™s and had great donor and no miniaturization behind his hairline. The top photo is his before photo ( with the proposed new hairline drawn in red),the bottom photo is one year post op.








 
Nervousnelly

Nervousnelly

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#12
Paul Shapiro, MD wrote:
Karmenlec:

The amount of grafts needed to give a good illusion of density varies with each patient. What I have noticed is that each patient has a threshold level that when the density is greater than that threshold the hair looks dense. That can be 40 FU/sq.cm. in some patients and it can be up to 60FU/sq.cm. in other patients. A lot depends on the volume of the hair follicles. It is really the hair volume, not the graft density that is important. We can plant the exact same graft density in two patients and get very different result if their hair caliber is different. If one doubles the hair diameter, the volume is quadrupled. (This is because the area of a circle is pi times the radius squared).



Take this patient as an example. He is only 28. It is impossible to predict his future balding. Suppose he progresses to a Norwood type 6. If I had planted his temporal corners at a density of 50 to 60 FU/sq.cm., and if his balding progresses to a Norwood type 6, most likely he will not have enough donor to cover the rest of the front half of his scalp at a density of 60 Fu/sq.cm. Thus he would have very dense temporal corners and less dense central core area. Cosmetically I don €™t think that would be look good.


The above statement is dead on. There is so much more tought process that has to take place versus just placing as many grafts as possible so that the patient is happy for a couple of years. The future has to always be considered. Well done doc.



NN
 
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karmenelec

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#13
Thanks doc for the explanation. I do appreciate your point of view, but respectfully disagree. Seems to me that the hairline encompasses say, 25-30 cm2. So to add another 10 grafts per centimeter would be another 250-300 grafts. I think you'd agree that an extra 10 grafts per cm2 would make an appreciable cosmetic difference in the hairline, one that a younger patient would want. Indeed, it seems the hairline is what most patients tend to worry about the most. So you'd be using an extra 300 grafts to get the hairline from 50 to 60. That's 300 grafts less for the patient to have, say, in his crown if and when it balds in the future. Let's face it, an extra 300 grafts in the crown is borderline negligible, whereas in the hairline it's very useful. I do think it's possible - and I have seen cases - where you can fade 60 from the hairline down to 50 or 40 as you get further back on the head without it looking unnatural in the least.

Also, by the time the patient reaches the age where the crown starts to thin, he a) may not care as much, b) would have a natural look anyway because many people have a thin or bald crown and still have hair upfront. So this is where I think one should take the patient's wishes into account rather than insisting on such rigid principles. You speak of 30-60 years later -- at the risk of you rolling your eyes, I think it's safe to assume that, given the recent advances coming down the pike, it is unreasonable to suggest that the medicines/procedures we currently have will not be improved in the near future. Histogen/Aderans/Acell = a very reasonable and calculated risk in using more grafts on the hairline than 40-50.


 
Bigmac

Bigmac

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#14
Hi Karmenelec.

Thought i`d offer my opinion on this.

Everyone has the right to disagree and offer their opinion,thats what this forum is for to help educate people.

A hair transplant is all about creating a natural balance and illusion of thickness,some areas will require more density than others,this is true to create a pleasing result but there is no need to guild the lilly just because you can.A hair line has to be balanced with the surrounding hair and the person's natural characteristics,if a lower density can be placed and be sufficient to create a natural pleasing look then this is more than likely due to the hair blending well with the surrounding native hair.If say for example you are placing a higher density directly on the hair line than the surrounding hair then the balance is lost and regardless how natural looking the placement is made the hair line loses it's balance and becomes a focal point instead of just naturally framing the face.

Every patient is different and future loss has to be considered regardless of whats down the pike as these type of advancements have been promised for a long time.





 
Paul Shapiro MD

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#15
Karmenelec

I understand your point but I still disagree that planting at densities of 60FU/sq.cm in most patients is the appropriate thing to do. As you mentioned to get up to that density we may need to use 300 to 400 more grafts which in the scheme of things in not a lot of grafts. But using the extra 300 to 400 grafts is not my point. My concern is that the density that I plant at in the hairline then determines the density that needs to be planted later in a patient €™s life as his hair loss progresses. What I am saying is that if I plant at densities of 60 FU/sq.cm., in the hairline then I am committed to plant at the same densities or higher behind the hairline. So if I plant a hairline at the density of 60 FU/sq.cm in a 25 to 30 year old male and he then progresses to a Norwood type 6 or 7 he may not have enough donor to plant at densities behind the hairline that will be cosmetically pleasing unless you stick to just the front 1/3 of the head. And that can look very unnatural. Because if one plants at densities of 60 FU/sq.cm, in the hairline you need to plant at the same densities at least in the central core area and the frontal temporal angles or one will have a very thick hairline with less density behind it. That is not a pattern we see very often in nature.

If you look at the patient presented, he has evidence of hair loss and miniaturization in his front half and down to his crown. So I choose to plant at a density that will blend into his present hair and will continue to blend as his hair loss progresses. There is a good probability that he will lose most of his hair in the front ½ of his scalp and there is a possibility that he will continue to have hair loss in his crown even on medical treatment. This patient is very happy with his results at 6 months and still has 6 more months of growth. Planting at this density met his goals, and leaves us with greater flexibility for future hair transplants as his hair loss progresses.

You say: €œ I have seen cases - where you can fade 60 from the hairline down to 50 or 40 as you get further back on the head without it looking unnatural in the least. € I have not seen these examples and the general consensus in the Hair Transplant community is that this is not a natural look. The general consensus is that the central core area should have more density then the hairline. If you can point out cases in which the hairline is denser then the central core and frontal temporal angles I would appreciate it if you can send them my way.

You also say €œby the time the patient reaches the age where the crown starts to thin, he a) may not care as much, b) would have a natural look anyway because many people have a thin or bald crown and still have hair upfront. In men who are Norwood type 6 or 7 the area of balding on the crown can be 100 sq.cm and often it is completely bald. There are also cases in which the temporal humps are bald or thin which means there is even more surface area to cover. I see a lot of patients who are 50 and are Norwood type 6. They usually prefer to have greater coverage but less density so that the crown does not look like a shinny bald spot. Often I can shrink the crown, but not make it disappear. I think it is difficult for guys in their 20s to imagine how they would react in this situation. In all honesty I don €™t even know what I would think if I found myself in that situation. What I can say is that if we start out by planting at densities of 50 to 60FU/sq.cm then we have less choice in how to proceed with future hair transplants as the patient continues to have hair loss. We can always put more hair in the hairline and frontal 1/3 later in life if that is what a patient desires, but we cannot take it away.

As for the possibility of medical treatments:, for the last 10 years I have heard that there are new medical treatments on the horizon in the next few years but none of them have been good enough to use in clinical practice. There are some major obstacles to the treatments you mentioned. One is that the hair might grow, but it has to be hair with good characteristics. Secondly, there is the issue of safety. It takes many years of good clinical studies to make sure a treatment that we use are clinically safe. Thirdly, there is the question of making these treatments cost effective. They will most likely be much more expensive than traditional hair transplants if they become available. I am not saying that these treatments are not possible. But I would not base my present hair transplant surgeries on these treatments being clinically available any time soon.

I agree that we should not be completely rigid about our principles of hair transplant design. That is why I call them guidelines. But I do think that it is very important that each patient is well educated on the risk and benefits of a procedure. If after I think a patient is well educated, and I believe I will do no harm, I may be more aggressive then I originally planned.

I would just like to review some educational points.

1) Studies have shown that the average donor density is around 80 FU/sq.cm. Also on average the safe donor area is 25 cm long. The safe donor zone is 6cm. wide on average. We need to leave about half of the safe donor so that we can hide the scar. That gives us on average 3cm wide X 25 cm long X 80 FU/sq.cm., which equals about 6,000 FU to use over a patients €™ life time.

2) The front ½ scalp on a patient can average from 100 to 150sq.cm. If we plant at a density of 45 FU/sq.cm in the front half we need to use from 4,000 to 6,750 FU.

3) Studies show that after we plant at densities greater than 50 FU/sq.cm there is the potential for less graft survival.

4) Studies show that when we cut the grafts very skinny which we need to do to dense pack there is the potential for less survival then when we leave them chubby.

5) I have seen a lot of post where to get the large number of grafts needed to dense pack the front 2/3 of the scalp hair was taken from outside the traditional safe donor area. There is a potential that this hair is not permanent.

In conclusion I do think that there are some patients who are good candidates for dense packing in the hairline but we need to choose the patients carefully. I do believe that the risk of dense packing at densities greater than 50 FU/sq.cm., outweigh the benefits in the €œaverage € patient. I think there may be a tendency on the internet to push for higher densities because we all would like more density. But we need to consider the risk/benefit ration of doing these procedures. One of the problems is that we do not have the wisdom of time to see how these transplants will look in 20 or 30 years. So unless a patient has great donor density, little evidence of progressing to a Norwood type 6, and is over 30 years old I believe it is better to err on the side of caution.


 
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karmenelec

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#16
Dr. Paul, I gotta say, I think your points are all very good. I may disagree with a few of them but they do make sense. I suppose my points is, if some patients - rational, educated patients - want to assume the risks you've discussed, if they are within the bounds of reason, I believe an HT doc should allow them to do so. But I'll leave it at that. A healthy debate that I much appreciate.
 
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Pacman

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#17
An excellant thread. Fascinating to follow. I think this kind of healthy debate is what this forum is all about. Some very well thought out points raised on both sides which has helped to educate me at the very least.

Well done all ¬b`
 
the B spot

the B spot

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#18
I would like to point out that you can always go back and add later. While I certainly understand the desire for more hair, the fact is, hair transplantation is about achieving results using a minimum amount of grafts. Dr. Paul could have easily used another 5-600 grafts and produced a much more dramatic effect, but that would not be in the patients best interests long term (as Dr. Paul has expressed).

I really enjoy these discussions as it really shows such varied perspectives and I appreciate when they can be held with respect.

Take Care,
Jason
 
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karmenelec

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#19
Agreed, very educational discussion. I do have one follow-up point/question.

Dr. Paul, you stated that: "What I am saying is that if I plant at densities of 60 FU/sq.cm., in the hairline then I am committed to plant at the same densities or higher behind the hairline."

Is this really the case since, at the hairline you would presumably be using single hair grafts, whereas, once you get approx 1 cm deep, you can start using two hair units, then three/four hair units. So wouldn't you be able to transition from 60 cm2 to 50 or even 40 or less since you would be using multiple haired units -- ie. densities of 20 cm2 in the core that used three-haired units would amount to the same amount of hairs as the 60 single FU...

BSpot, let's face it, it's not that easy to simply come in for another procedure to add more density if the hairline is still a little sparse. Having to - all over again - deal with shaving the head, shockloss, healing the scar, facing your peers at home or at work with a red scalp for months, going through the doldrums, etc, simply because a doc refused to put in an extra 10 FUs at the hairline during the first procedure because he'd rather play it by ear and see how the first round turns out, well.... I for one would rather err on the other side of caution! But that's me. :)



 
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Paul Shapiro MD

Paul Shapiro MD

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#20
Karmenelec

You raise a good point. The terminology in hair transplant surgery has settled on talking about FU/sq.cm., but in fact, it is the amount of hairs/sq.cm. that is important to know. That is why at SMG when we cut our donor strip we count our 1,2,3, and 4 hair FU grafts. This enables us to give a graft count as well as a hair count with all our surgeries. Actually, what determines the outcome of a transplant is the volume of hair moved. So not only the number of hairs transplanted, but the diameter of the hair shaft is what determines the outcome. It is easier to talk about the number of grafts/sq.cm. planted, and that is how we usually present a case.

When planning a hair transplant surgery there are many factors we have to consider. One is that the average donor strip yields many more 1 and 2 hair FU €™s then 3 and 4 hair FU €™s. When an average donor strip is cut it usually divides into 1,2,3, and 4 hair FU €™s as follows: 1 hair FU-25%, 2 hair FU-50%, 3 hair FU-20% and 4 hair FU-5%. Because of this natural division of FUs we always get a lot more hair from the 1 and 2 hair FU grafts then the 3 and 4 hair FU grafts.

The chart below shows what how 6,000 FU €™s will divide into different graft size. I chose 6,000 FU €™s because in some patients that is their lifetime donor supply. Some patients have up to 8,000 FU €™s in their lifetime, but 6,000 is the average. I have noticed that some patients are getting up to 10,000 FU in their lifetime, but I am concerned that in these large cases some of the transplanted hair is removed outside the €œsafe € donor area and that this hair may not be permanent. Below is a table of what we would expect to get from 6,000 FU in an average person.



So as you can see we get 7,500 hairs form the 1 and 2 FU grafts and 4,800 hairs from the 3 and 4 FU grafts. We get 2,700 more hairs from the 1 and 2 hair FU €™s then the 3 and 4 hair FU €™s. It is correct that we can get the same density using less 3 and 4 hair FU grafts then 1 and 2 hair FU grafts, but we have fewer 3 and 4 hair FU grafts to use. Also we only like to use the one hair FU grafts in the hairline. After the hairline is complete we almost always have more 1 hair FU grafts left over. Usually we end up planting two or maybe three 1 hair FU grafts together to artificially make a 2 or 3 hair grafts.

We plant the 3 and 4 hair grafts in the central core area as you mentioned. Ideally we like to have the central core area be denser then the surrounding hair. That is what we normally see in nature and also the more light we block in the central core area, the denser the hair transplant looks overall. That is a basic principle of hair transplantation. But as you can see the amount of 3 and 4 hair grafts we get from a donor will be significantly less than the 1 and 2 hair grafts. So there is a limit to how many of these large grafts we will have to plant in the central core area.

Since we are talking about a hairline design and how planting at densities of 60FU/sq.cm will affect a hair transplant in the future I would like to review how I approach a hairline design. When I plan a hair transplant I use the method that my brother, Dr. Ron Shapiro taught me. It is the same method that can be found in the section he wrote on Hair Line Design in the textbook of Hair Transplantation, 4[suP]th[/suP] edition in which he is a co-editor. I believe it is the background for hair transplant design for many hair transplant doctors since Dr. Ron Shapiro has presented this method at numerous hair transplant, dermatology, and cosmetic surgery meetings over the past 15 years.

I was taught to look at the hairline as two separate zones. The front of the hairline is called the transition[/b] zone and behind it is the defined[/b] zone. Behind the hairline, in the center of the scalp, is an area called the central core. We always want the central core to have the greatest density in a hair transplant. Sometimes we extend the central core area into the center of the defined zone.

The transition[/b] zone is usually .5 to 1cm wide. In this zone only 1 hair FUs are used. This is also the zone in which there are peaks and valleys in an irregular pattern. This is what gives the hairline a natural look. It is very difficult to say what the actual density of FU €™s are planted in this zone is because there are areas of densely packed peaks surrounded by valleys in which no hair is planted. Also, the tip of the peaks are usually planted at a lesser density then the base of the peaks. I only use 1 hair FUs in this zone and the actual hair density will be less than in the defined zone. I want the peaks to look softer then the hair in the transition zone to give a natural looking hairline. In general I use 400 to 600 one hair FU €™s in the transition zone

Behind the transition zone is the defined[/b] zone which is usually 2 to 3 cm wide. This is the area of the hairline in which the incisions become denser and more defined. It is usually planted with 2 hair FU grafts. Sometimes 3 hair FU grafts are planted at the back of the defined zone. When we are referring to planting at densities of 60 FU/sq.cm we are usually referring to the defined zone. We want the central core area to be denser then the defined zone. Having density in the central core area gives the whole transplant a greater illusion of density. So if I plant the defined zone at 60 FU/sq.cm with 2 hair FU grafts, that gives me 120 hairs/sq.cm. I can plant the 3 and 4 hair FU grafts at a lesser density of 50FU/sq.cm and still get a greater actual hair density then the 60FU/sq.cm 2 hair grafts in the hairline. Since there are four times as many 3 hair FU grafts than 4 hair FU grafts that will give me a density of about 160 hairs/sq.cm. You are correct that we can plant the 3 and 4 hair follicular units at a lesser density, but we still have to plant them at a density that will give us more hairs/sq.cm then the defined zone. Remember that we get a lot more 2 and 1 hair FU €™s in a normal donor then 3 and 4 hair FU €™s. So we are limited in how many of these larger FU €™s we have to plant.



When I transplant a young patient (in their 20 €™s and early 30 €™s) I always plan the transplant as if they may progress to a Norwood type 6. Unfortunately we still have no good way of exactly predicting how a person €™s hair loss will progress. This is because male pattern balding is a complex, multi-genetic phenomena that we still don €™t completely understand. Studies show that about 25% of men will progress to a Norwood type 6 or 7 by the time they are 60. There are guidelines such as family history, the age when hair loss started, response to medications, which can help us predict future hair loss. But these are just guidelines and can be very unreliable in younger patients

Now I would like to review some basic principles that need to be taken into consideration when transplanting a patient who is a Norwood 6. In general the front 1/3 of the scalp is 70 sq.cm, the front ½ of the scalp is 100 sq.cm, the front 2/3 of the scalp is 130 sq.cm, and the total scalp (front ½ and crown) is 200sq.cm. The following photo shows you this as a diagram and how much density we can achieve in each area if we use 3,000grafts and 4,000 FU grafts. In general we can get between 3,000 and 4,000 grafts in a first surgery.








If a patient comes in significantly bald, such as a Norwood 6 they usually would like to cover at least the front ½ of the scalp. Most of these patients would rather cover the front 2/3 €™s of the scalp and sacrifice some density because they don €™t want such a large bald crown. But let €™s say we plan a surgery in which we are only covering the front ½ of scalp. When covering this area, besides the hairline and central core area there is usually an area above the temples that need to be covered. I call this area the Temporal trough. In general the 100 sq.cm of scalp divides as shown in the photo below.







Now that I have described the different areas of a scalp that need to be transplanted I will show that if we plan to transplant the defined zone of the hairline at a density of 60FU/sq.cm we will need 6,000 FU to cover the front ½ of the scalp. As I already mentioned, 6,000 FU is the maximum lifetime donor in many patients. Also, to cover this area with 6,000 grafts it will take 2 surgeries.

When I €œcrunch € the numbers you can see why I say we will need 6,000 FU units if we plant the hairline at a density of 60Fu/sq.cm. Below is the table of the graft distribution in a 6,000 graft case.



Let €™s say I use 600 one hair FU grafts in the transition zone and frontal-temporal angles. I will still have 900 one hair grafts left over. From the diagram of the scalp above you can see the defined zone of the hairline and temporal trough area takes up 50 sq.cms. These areas are planted with 2 hair FU grafts and I want to plant them at a density of 60FU/sq.cm. The 2 hair FU grafts number 3,000. If I divide 3,000 grafts by 50 sq.cm I get a density of 60 FU/sq.cm. or 120 hairs/sq.cm. So I have the exact number of 2 hair FU €™s that I need.

We still have the central core area to plant with the larger grafts. The central core area measures 40 sq.cm. I have 1,200 three hair grafts, 300 four hair grafts, and 900 one hair grafts left to use. To use the one hair grafts in the central core area I can put three of them together to make 3 hair FU grafts. That would give me the equivalent of an extra 300 three hair grafts. Adding 300 to the 1,200 three hair grafts I get 1,500 three hair grafts, plus 300 four hair grafts to yield 1,800 large grafts. If I divide 1,800 grafts by 40 sq.cm I get a density of 45 FU/sq.cm or 142 hairs/sq.cm. This gives me the exact number of large hair grafts for the central core area I need to have the central core area denser then the hairline defined zone.

So as you can see we will need to use 6,000 FU if we plant the hairline at a density of 60 FU/sq.cm. in a Norood type 6 patient with the goal of transplanting the front 1/2 of the scalp.


Let €™s return to the example of a younger patient in which we are only doing the hairline. Below is a photo of such patient.



As you can see in this transplant I transplanted the transition zone and only half of the defined zone. But if he is in his 20 €™s, he still has at least 40 years of active life in him. Most likely his balding will progress, but how much is impossible to predict. If he progresses to a Norwood 6 then I am possibly committing to using his entire available lifetime donor in the frontal ½ of the scalp. As I said earlier, in my experience most Norwood 6 patients would rather have at least the front 2/3 of the scalp transplanted. And they are willing to sacrifice some density to get this coverage. They just don €™t want to have such a large bald crown.

Now that I have €œcrunched € the numbers, I would like to make another point. From our experience most patients are happy when we plant the hairline defined zone at densities of 40-50 FU/sq.cm. I find that when a hairline is planted at this density and we gradually increase the density to the central core we get a very good cosmetic result. In the case I presented in this post, the patient is very happy at 7 months post op. And usually it takes one year for the transplanted hair to look its fullest. If I can get a result in which the patient is happy, using less grafts, then I will have more donor to use in the future. If he does progress to a Norwood type 6 or 7 I will be able to cover more scalp in future transplants.

As you can see there is a lot to consider in the planning of a hair transplant. If we had a crystal ball and could accurately predict a person €™s future balding it would make my job much easier. But I can €™t. If someone progresses to a Norwood 6 you can see there is a lot of area to cover even if we do not touch the crown. I agree that it is good to err on the side of caution, but we may not agree what it is best to be cautious about. You stress trying to accomplish the most with fewer surgeries which is a good goal. I think more in terms of what will happen if one progress to a Norwood type 6 or 7 and we run out of donor and paint ourselves into a corner. Both views are important to take into consideration, and as I stated earlier with good education the patient should be able to make the right choice for him as long as he understands the risk and benefits.

Once a young patient has a hair transplant he is most likely committed to future transplants, because most likely his balding will progress at some point. And since we don €™t know what the future will bring I think it is best to use an optimal amount of donor to get the best look possible while still saving valuable donor for future hair transplants. At SMG we find that a hairline density of 40 to 50 FU/sq.cm will usually accomplish this goal. Not all hair transplant doctors agree with us and that is what we are disagreeing on. With so many unknown variables to consider of course one will find that different doctors will have different approach and philosophies. That is why these web sites are valuable. They provide a way that potential patient can see different approach to the same situation and then decide which approach meets their goals for today and into the future.

 
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