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How Many Grafts Are “Needed”

Paul Shapiro MD

Paul Shapiro MD

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#1
How Many Grafts Are €œNeeded € For a Hair Transplant Surgery?

We've seen common responses when posting Shapiro Medical Group patients on different ht forums. They usually state how good the case looks considering the small number of grafts we use. Here are a few examples I'm referring to:


€œThis is great result for only 2500 grafts €

€œAmazing coverage for the number of grafts Janna. €

€œjanna, a very pleasing result with relatively few grafts(considering the area covered) €

€œWow, Janna! Those results for the # of grafts are amazing, they really are €

These comments suggest that there may be a misconception on the number of grafts needed to accomplish a patient €™s hair transplant goals. I like to think that we use the appropriate amount of grafts for each case taking into consideration the patients goals, donor density, hair caliber, age, degree of balding, family history, response to medical treatment, and the risk/benefit ratio as the cases get larger and go longer.
I would like to point out a few reasons why surgeries using less grafts may lead to the same or very similar results to transplants using greater number of grafts.
1) Each patient has a threshold level of hair density in which their hair will look full under most conditions. Once this threshold is reached as we increase the hair density we get only minimal esthetic improvement. For example let €™s say a certain patient needs 2,000 FU to reach this threshold level for the area being transplanted. If we transplant 2,500 FU in this area the esthetic improvement will be very similar to planting 2,000 FU. Thus the results of the two transplants could look similar even though in one surgery 500 more FU were planted.
2) We often are transplanting into areas in which there is existing hair in the early stages of thinning. In most of these cases I need to plant 20 to 30 FU/sqcm in these areas to get an excellent cosmetic look. With proper magnification I can plant 30 to 40 FUsqcm in these areas but usually chose not to. I find that in most cases these extra grafts do not yield a significant denser look. Some argue that if we can plant more hair in an area then why don €™t we do it as a preventative measure. The possible advantage of this preventative philosophy is that as a patient loses his native hair he still has more transplanted hair and will not need another hair transplant? The disadvantage of dense packing in areas of pre-existing hair is that there is an increased risk of transection and shock loss which could damage existing hair. I am not sure the advantage outweighs the disadvantages of this preventative philosophy. Especially because in my experience if a patient does have progressive hair loss they will still want another transplant to achieve their goals and we will not have saved them another hair transplant.

3) All patients have a different percentage of 1,2,3,and 4 hair FU €™s. There are studies which show that the number of 4 hair FUs can vary from 5% to 20% of the total graft count. It is difficult to compare surgeries without knowing the exact number of 1,2,3, and 4 hair FUs which allows us to calculate the number of hairs transplanted.
There is some discretion when cutting FUs. The photo below is a close up of a patient €™s donor hair. The area circled in Black is a 3 hair FU that could not be split. But as you can see the area circled in Red can be cut many ways.


At SMG we do believe that the larger 4 and 3 hair FUs give a greater illusion of density in the central core area and thus try to get as many 3 and 4 hair FU unless we are doing a hairline case or the patient has coarse dark hair. There is the possibility that our results look similar to some of the larger cases one sees on the internet because even though we are transplanting less total grafts we are transplanting more hair per graft. Also, by placing the maximum amount of 3 and 4 hair FUs in the central core area we believe we get a greater illusion of density even if we are using the exact same number of total hairs without compromising the naturalness.

If we can achieve the same cosmetic results using fewer grafts I believe there are some potential benefits to the patient. Here are some advantages I can think of:
1) Never lose sight of the basic principle of hair transplant surgery that we are using a limited donor supply to cover a potentially expanding balding area of the scalp. If we can get the same or similar results using fewer grafts, we have more grafts left over for future hair transplants if needed.
2) We strive to get the best graft survival when doing a hair transplant surgery. To maximize graft survival we protect them from dehydration by placing them in physiologic holding solution on ice, use tiny micro blades to limit the amount of vascular trauma to the scalp, and use gentle placing techniques. Most published studies show that even under ideal conditions we do not get 100% graft survival. I still have concerns about surgeries in which the grafts are out of the body for greater then 6 hours. Graft survival decreases the longer the grafts are out of the body. The most commonly sited study shows that after 4 hours graft survival decreases to 95%, after 6 hours graft survival decreases to 90%, and then graft survival continues to decrease by 2% for every additional hour they are out of the body. Also, as the cases go longer there is the possibility of staff fatigue resulting in less careful graft cutting and placing which could decrease graft survival. Taking into consideration that there is the potential for less graft survival as the cases become larger and go longer, I believe there is an advantage to keeping surgeries to the size where the placing can be completed within 4 to 6 hours.
A point I would like to make about graft survival is that we can not accurately measure graft survival in the clinical setting. The published studies on graft survival are done on completely bald scalp, in one centimeter square boxes that are tattooed onto the scalp, and the hair is planted as soon as it is cut. Even in these studies we usually do not get 100% graft survival. The graft survival ranges from 90% to 100%. Taking these studies into consideration no clinic can say they get 100% graft survival. My educated guess is that most good clinics get about 95% graft survival.
In general we judge our hair transplant results by the way the outcome looks. Since in clinical practice we can €™t accurately measure graft survival, as the sessions get larger we need to decide when the potential risk for decrease graft survival outweighs the benefit of a large session. Here is a hypothetical example to point out the potential risk. Let €™s say 4,000 and 5,000 grafts are planted in the exact same area. Now let €™s say the 4,000 transplant yields 95% graft survival and the 5,000 graft transplant yields 85% graft survival. That leaves us 3,800 and 4,200 grafts respectively. The 5,000 graft transplant will still look better then the 4,000 graft transplant even though there is less graft survival. I am not saying this is what happens, but since we can not accurately measure graft survival in our clinical practice the doctor and patient need to decide when this potential risk outweighs the benefits of a large megassesion.
3) Another advantage of keeping the surgery as short as possible is that there is decrease risk of medical side effects. Most patients tolerate the surgery fine, but there are some patients who get nausea, irretraceable hiccups, back /neck pain, or difficulty in keeping the surgical area numb. In my experience I find these side effects are more common during long surgeries. When a patient has these side effects it makes the planting more difficult and can affect graft survival.
4) As the surgeries increase in time, there is the possibility of Deep Vein Thrombosis (DVT). DVT is blood clot in the deep veins in the leg. Prolonged immobilization is one of the risk factors for DVT. A study showed that travelers who are greater then 50 years old have a 10% chance of developing asymptomatic DVT €™s on airplane flights that last longer then 8 hours. Lancet May 12,2001;357:1485-9 These asymptomatic DVT €™s usually do not cause any medical problems. But very rarely they can lead to a blood clot in the lung called a Pulmonary Embolism, which is a medical emergency and needs hospitalization. I had such an occurrence on a 45 year old male whose surgery lasted over 8 hours. (I published this case in the Hair Transplant Forum International) Like I said this is a very rare occurrence, but the possibility increases as we increase the length of surgery. When does this risk of DVT outweigh the cosmetic benefits of a prolonged cosmetic surgery?
At Shapiro Medical Group we do have general guidelines for the number of grafts we will transplant into different areas of the scalp. The guidelines are printed in the table below. These general guidelines are good for the average patient but sometimes our sessions will go larger and sometimes smaller then in these guidelines.



In summary, how many grafts are needed to get excellent results varies for each patient depending on many factors. But I do believe that if we can get the same or similar results using less grafts there are some advantages. We have less chance of using up limited donor supply that may be needed in future surgeries, potentially increase our graft survival, and limit potential medical risk as much as possible.
Paul Shapiro, MD
 
Bigmac

Bigmac

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#2
Thanks Dr Paul for a very interesting post.

Its good to hear the philosophical approach SMG utilise with each individual patient they see.

Also the DVT part explaining how you look at possible side effects to the patient sitting for extended lengths of time is something which is usually only talked about when its connected to air travel.

Thanks again.

bm.


 
bullitnut

bullitnut

4 awesome repairs with SMG
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#3
I agree this post is fantastic the summary Dr Paul used below says it all imo:-

(In summary, how many grafts are needed to get excellent results varies for each patient depending on many factors. But I do believe that if we can get the same or similar results using less grafts there are some advantages. We have less chance of using up limited donor supply that may be needed in future surgeries, potentially increase our graft survival, and limit potential medical risk as much as possible.
Paul Shapiro, MD)

It shows on many different levels the extensive thought and preperation behind a procedure at SMG, its obvious that ultimately its all about the patients best interest which is just how it should be and is great to see. The DVT bit is not something ive seen on ANY forum before though so its great to know you guys have procedures and are prepared to deal with DVT'S, i applaud you Dr Paul for your dedication to the patients welfare great post ¬b`
 
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Bigmac

Bigmac

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#4
Watching a program earlier about DVT,has anyone heard of this happening with a HT patient.
 
U

UK Chap

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#5
Dr Shapiro

In your opinion what do you consider a safe limit when dense packing a hairline?, some results i have seen have been packed in at density`s of 70+/cm2.Have you dense packed any hairlines above the stated 55/cm2 in your post?, if so could you post some examples.

Best regards Chappers.
 
Paul Shapiro MD

Paul Shapiro MD

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#6
UK Chap

You ask a good question. The answer is not straight forward. I just recently wrote an article pointing out that there are patients in which dense packing the hairline at a density of 70+FU/sqcm. is appropriate, but the patient should meet certain criteria. Here is a copy of the article:



Here are few examples of patients in which I believe dense packing in the hairline area is appropriate. I consider planting at densities between 40- 60FU/sqcm as dense packing. There are patients in whom I will plant at densities from 60-80 FU/sqcm, but they are the rare exceptions and need to be perfect candidates for what I would call super dense packing.
In order for me to feel comfortable dense packing the hairline I think the following criteria need to be met:
1) The patient must be at least 30 years of age
2) The patent should have a family history that suggest his balding will not progress furhter then a Norwood type IV.
3) The donor area has to have at least an average density of 80/FU/sqcm
4) The donor area has to have good laxity
5) The hair behind the hairline should have no or little evidence of miniaturization.
6) The crown should have no or little evidence of hair loss or miniaturization.

At SMG we have a camera which can take close up photographs of a 1 sq.cm area of the skin which allows us to get a measurement of donor density and the density of our incisions. That is how we can get an accurate measurement of density. As you can see, to get an accurate count the existing hair has to buzzed. We rarely take postoperative density photographs because most post op patients do not want to buzz their new hair. Even it the patient did buzz his hair it is difficult to tell previous existing hair from transplanted hair in post operative photos. That is one of the reasons it is so difficult to do accurate post operative density studies. These cases were both done within the last month so I do not have 6 month results. I will post them when they return for their follow up visits.

Case #1 I packed at a density of 60-80 FU/sq cm. He had all the criteria for a case in which I feel comfortable packing at super high densities. He is a 33 year old male with no family history of hair loss more than a Norwood type IV. He has great donor density of greater then 100 FU/sqcm., and no miniaturization or hair loss behind his hair line. He also had no evidence of hair loss or miniaturization in his crown. I must stress we do not get many patients like this. But he is a good candidate for super dense packing. The photographs show my incisions ranged from 60 -80 FU/sq.cm. A total of 2164 FU €™s were planted.
Below are photographs showing his donor density, the density of my incisions, and day of surgery photos: (in the photos where the title is Hairs/sq.cm., it should read FU's sq.cm)

DONOR DENSITY


INCISION DENSITY


DAY OF SURGERY PHOTO, (before and after comparison)


Case #2 I packed at densities of 40-50 FU/sqcm. He represents the more typical patient I see in which I feel comfortable doing dense packing. He is a 38 year old male with most of the males in his family not progressing to greater then a Norwood type IV, but he did have an uncle who had Norwood type V hair loss. His donor density was not as good as case #1 and there was some evidence of miniaturization in his central core and crown areas.

DONOR DENSITY


INCISION DENSITY



DAY OF SURGERY PHOTO, (before and after comparison)








Unfortunately when it comes to hair transplants fate can be cruel. Most of the patients we chose to dense pack do not have significant male pattern balding. They are usually men who will not progress to more then a Norwood type III or IV, have thick hair behind the balding area and want to keep a thick young looking hairline. This is not possible in patients who have male pattern balding who are destined to become Norwood type V or greater.



In summary we do dense pack the hairline at densities of 70+FU/sqcm., but these patients need to be picked carefully. I have seen patients posted on the internet who have had dense packing procedures done but are too young to accurately predict future balding. I have also seen patients in which donor hair has been harvested from outside the safe donor area to get large sessions with dense packing. I believe we may be doing these patients a disservice because as the age we may have used up valuable donor they may have chosen to use in other areas of their scalp and may not be happy with their look when they are in their 60 €™s. But if we pick our patients carefully dense packing at 70+ can be a great procedure and produce great results.



I hope this answer is helpful



Dr. Paul
 
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U

UK Chap

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#7
Thankyou Dr Shapiro for a very thorough and insightful reply to my questions.

Best regards Chappers
 
Bigmac

Bigmac

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#8
Hi Dr Paul

On the following diagram how much thinning of native hair would the patient have before they move into the Little or no hair category.

Thanks bm.





 
Paul Shapiro MD

Paul Shapiro MD

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#9
Bigmac



That table is assuming the patient is not willing to cut their hair short. So if the patient is not willing to cut his hair short then I consider densities of under 20FU/sqcm into the little or no hair category.



If one willing to cut ones hair short then even native densities of 30 to40 FU/sqcm I can sometimes



That is one of the advantages of cutting ones hair short.



Dr. Paul
 
Bigmac

Bigmac

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#10
Thanks Dr Paul for explaining that.

Can i ask if you have any idea roughly what percentage of patients dont want to be shaved down for their HT as this was one of my worst fears.

Thanks bm.