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: 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 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. 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 average 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.