Dr. Paul Shapiro

Yes I did mean FU's not hairs. Sorry for the confusion. I need to change the titles of the slides. Where ever the slide said hairs I did mean to put FU's. It is only within the last two years we have started to take detail photos of patient's donors and recipient sites and we only started to do this consistently within the last year. One of the reasons I started to take these detailed photos is because we did not have very good documentation on what we were doing during our surgeries. And I wanted to know in more detail exactly what I was doing in a surgery. I also was interested in documenting the average donor densities since that seemed to be a constant question. So unfortunately I can't give you an accurate answer to your question. I would say that very few patients qualify for the extra dense packing. I would guess that 1%-5% of our patients qualify for extra dense packing. We end up planting grafts at densities of 40 to 50 FU/sqcm in many of our patients, but I can't give you a percentage. In some patients we only pack at these densities behind the hairline, especially in the central core area but in some patients we do pack this densely in the hairline. As I take more photographs during surgery I will be able to answer this question more accurately. Remember 20% of the male population will be a Norwood type V to VI by the time they are 60, and 10% will be a Norwood type VII. So in patients who are too young to tell how they may progress or in patients in which we have a lot of evidence they may progress to a Norwood type V or greater we tend to pack more in the 30 to 40 FU/sqcm densities. The densities we pack at also depend on the cosmetic goals of the individual patients. Some patients don't care too much about their balding crowns and would rather look denser from the front, while others are very concerned about their crown loss. The difference in each patient's goals will affect the density in which we make our incisions. I hope this is helpful Dr. Paul

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)

Avolat Dr. Beehner made some very good points I would just like to add a few more comments. Even though you have had a medical work up there are a few more points that may be helpful. Sometimes sub-clinical Iron Deficiency Anemia or Sub-Clinical Thyroid problems can cause hair loss. I suggest that all young women with significant hair loss go to an endocrinologist to have a complete thyroid panel done and also to consider going on spironolactone as Dr. Beehner mentioned. Also, did your PCP take lab test for Iron Deficiency Anemia? There is a lab test called the Ferritin level. Some women will have normal Iron levels and with low normal Ferritin levels. The Ferritin level is reported as normal even when it is as low as 30. I suggest that all young women experiencing hair loss have a Ferritin level of greater the 70. If your level is less then 70 you should take Iron supplements until it is above 70. After all medical causes have been ruled out and/or treated hair transplant surgery may be an option for you. But as Dr. Beehner pointed out it is very important to have realistic expectations and to know what a hair transplant can accomplish for a female patient with female pattern hair loss. Women tend to have a lower donor density and a smaller safe donor area to take hair from then men. So it is very unusual to get a session greater then 2,500 grafts in a female patient and as Dr. Beehner pointed out it is not unusual to get sessions of 1,600 to 2,200. Also most women with genetic hair loss have very fine hair. When using such fine we get better results when combining Multi Unit Grafts (MFU) with Follicular Unit Grafts (FU) Not all donor hair has the right density and quality to use MFU's but if you decide to get a hair transplant I would suggest you go to a doctor who is skilled in both FU and MFU grafting. It is almost impossible to cover the total area of hair loss so there is not any see through scalp in women with female pattern hair loss. So as Dr. Beehner pointed out the goal of the transplant should be to get enough hair so that the patient can style her hair to better cover up the scalp, and/or to have less areas of see through scalp. As Dr. Beehner mentioned this often times takes two hair transplants. With these realistic expectations transplants can be very helpful in the female patient. I have included a few photos of female patients in which I would consider the transplant successful. As you can see in the top views, there is still see through scalp, but all the patients were very satisfied with there results. Each photo has the before on the left and a one year after photo on the right. Both patients have had only one hair transplant and could benifit from a second one. This patient has siginificant female pattern hair loss: Top View, Before, at 6 months, and at 14 months Front View This patient has moderate female pattern hair loss: Top view Front View I hope this is helpful Dr. Paul Shapiro

MIAI This patient already had an old procedure using Multi Follicular Unit Grafts (MFU) so he is not a candidate for DFU's. There are many type of Multi Follicular Unit Grafts and Double Follicular Unit Grafts (DFU) are just one type of MFU. Dr. Ron Shapiro wrote a good post on graft terminology which helps explain the different types of grafts. Here is the link. http://www.regrowhair.com/hair...t-graft-terminology/. As I have pointed out, by using DFU's correctly in the appropriate patients I believe I get a better illusion of density with the same total number of hairs without sacrificing naturalness. Unfortunately this patient had larger MFU's which did not look natural, especially when placed in the hairline. Being a repair case I needed to place individual FU's between his old MFU's to give him a natural look. As you can see by proper placement of the FU's the pluggy MFU's blend in and he has a natural looking hairline. If he cut his hair short the hairline might still look somewhat pluggy. As long as he keeps his hair over 1 to 2 inches long it will look very natural. For many older men keeping the hair with this type of styling is not a problem. One factor to consider before having a hair transplant is what type of hair style is acceptable for the patient. It is difficult to talk about density in this patient because of his previous surgery. I do not have his old surgical history from his previous surgeon. That surgery was done many years ago. Also, in repair cases I focus on planting the FU's strategically between the old MFU's in order to hide them and do not focus on how many FU'sq.cm I plant. But in answer to your density question, there are many factors that go into determining what density I plan to plant in a case. The densities I plant can be anywhere from 25 to 80 FU/sq.cm. Some cases are appropriate for dense packing which I consider from 40 to 60 Follicular Units/sqcm. And there are the very rare cases in which I will plant at what I call super dense packing at densities between 60 to 80 FU/sq.cm. But in many cases it is more appropriate to plant at densities between 30 to 40 FU/sq cm. And if I am doing a person who is Norwood type 6 or 7 I many plant at densities between 25 and 35 FU/sqcm just to give a good frontal forelock pattern. The patients age, health status, degree of balding, family history, donor density, response to medication, hair caliber and quality, all are factored in when I decide what density to plant in a hair transplant surgery. I hope this answer is helpful Dr. Paul Shapiro

This 38 yr old male had a previous surgery which resulted in an unatural hairline. I used only one and 2 hair FU's to go slightly in front and between his old transplant to give him a natural hairline.

This 54 year old male had a surgery done about 10 years ago. He came in wanting a more natural hairline and better density. Here are his 6 month post operative photos. He is very pleased with his results and should get more density as the new hair coninues to grow over the next 6 months. His graft count was as follows: 1 Hair FU 679 # Hairs 679 2 Hair FU 1290 # Hairs 2580 3 Hair FU 470 # Hairs 1410 4 Hair FU 74 # Hairs 286 Total FU 2513 Total 4965

This 67 year old male had about 120 sq cm area he wanted to cover. He had average donor but a tight donor area. This restricted the width of the donor excision. He has fine, white/grey hair which he dyes. His type of hair made him a perfect candidate for DFU's. I took out a 1.5 cm wide x 29.5 cm long strip. This yielded 3,329 FU's, 250 DFU's for a total of 3579 Grafts and 8340 Hairs. I have circled the area where the DFU's were placed and I believe I got a greater illusion of density using the same amount of hair using the combination of DFU and FU's then if I used FU's only. To cover the area we wanted to cover I averaged 30-35 FU/ sq.cm. If I had not used DFU's I don't think the central core would look as thick. And with his type of hiar the DFU's look completely natural. At his 6 month follow up visit he has the coverage I would expect at 30 to 35 FU/sq.cm.. He is still a bit see through in the back 2/3d area but is very happy with his results. He also should expect more growth at in the next 6 months. His graft count is as follows 1 Hair FU - 567 #Hairs 567 2 Hair FU - 1912 #Hairs 3824 3 Hair FU - 701 #Hairs 2103 4 Hair FU - 1 49 #Hairs 596 4-6 Hair DFU - 250 #Hairs 1250 Total Grafts 3579 Total Hairs 8340 Since there are 2 FU in each DFU if you add another 250 grafts to the graft total the equivalent FU count would be 3829. Pre op and 6 month post op comparison Front view

This 35 year old female patient has the classic female pattern balding in the 'Christmas Tree' pattern. The thinning starts behind the hairline and goes back in a triangular pattern, with the widest part of the thinning (the base of the Christmas Tree) behind the hairline. I believe this patient is a good example in which we can achieve superior results using DFU's and FU's in combination as compared to using only FU's. Most women with this type of hair loss have very fine hair. Even their FU's with four hairs do not have much hair volume. Using DFU's in these patients look completely natural and adds a great deal of density to the central core area. You can see how the area where DFU's were used the hair looks very dense. Because of her hair styling the photos are not an exact comparison, but give a good idea of what a hair transplant can accomplish in this type of female patient. Since this transplant is only 6 months out she should continue to have some more hair growth. Her hair graft count is as follows: 1 Hair FU 707 Hairs - 707 2 Hair FU 894 Hairs - 1788 3 Hair FU 116 Hairs - 348 4 Hair FU 20 Hairs - 80 4-6 Hair DFU 200 Hairs - 1,000 Total Grafts 1937 Total Hairs - 3923 In summary I do believe that being able to use DFU's are a valuable tool when performing transplants in the Female population.

TC17: Usually when I consult with a young patient who has significant hair loss I like to wait a few years before doing a surgery. I always wet their hair to see how much thinning is in the temporal hump area and the lower crown area. The worse the temporal hump area and the crown area are, the more likely they will become a type 7. I like to follow how they respond to medications, and how their hair loss progresses over time, including the miniaturization that is seen. Using all this information and the patient's family history I then make my estimate if I think they are going to become a type 6 or type 7. But of course this prediction is not an exact science. I do not have all your information and there is a possibility you may progress to a Norwood type 7. I just did not mention that in my post. Then, if I go ahead with surgery I do plan the first surgery as if they may become a type 6 or type 7 using all the information I have. If I fell strongly that a patient may become a Norwood type 7 I may be a bit more conservative in their first surgery. My goal in the first surgery would be to devise a pattern that would look natural even if the patient progresses to a type 6 or 7, leaving enough donor hair to build up the temporal humps if necessary and still be able to hide any donor scar. I take into consideration that a second surgery down the road is a likely possibility. Many young patients when seeing this type of plan think it is too conservative. For some patients they may just opt out of having any surgery and decide to keep their hair short. Or after discussing the risk and benefits of a surgery I may be a bit more aggressive as long as the patient if fully educated in the risk they are taking. I hope this is helpful Dr. Paul ShapiroI

From what you describe I would consider you to have significant balding. If I was to plan a hair transplant surgery on you I would plan it as if you may become a Norwood 6. That would mean keeping the hairline at least 8 cm above the glabella and not bringing out the temporal angles too much. Of course this is all without seeing you and in any surgery the plan would have to frame the patients face nicely and end up with a good cosmetic effect. Also, when I see a patient like you I discuss with them how we can not exactly predict the future. And sometimes I am more or less aggressive depending on each patients goals, family history, how their donor looks today, their response to medications. Dr.Paul

This is a very good thread and has brought up a lot of good issues. It is important to remember that balding is a complex multi-genetic trait, and the balding genes are expressed very differently in each individual. What age these 'balding genes' turn on, the rate of balding, and how sever the balding will be is difficult to predict early on. Your family history and how much hair loss you have in your 20's is a guide to future hair loss, but not a predictor. The only thing I can say for sure is that if someone has significant balding in their early 20's they are likely on their way to be a Norwood type 6 or 7. But the opposite is not true. I have seen many patients in which their hair loss did not start until they were in their 30's, some do become a Norwood type 6 or 7 and some do not. I come from a family of 4 boys (my poor mom). Two of us have a full head of hair and two have significant balding. Secondly, I do think that it is very rare to find someone who will have 10,000 FU donor grafts over a lifetime. If my memory servers me correctly I have seen only a few patients posted on the HTN who have had 9,000 to 10,000 grafts total. I am concerned that to get so many grafts we may push the limits of taking hair from the safe donor area. I have seen some transplants in which to get such a large amount of donor hair, the donor is taken from outside the 'safe' donor area. Not only is there a potential to see the scar, but there is the potential that this is not permanent hair. So the hair that is transplanted may fall out like all the other hair with male pattern balding. I have spoken privately to some on the HTN about this. These hair transplant patients say they are aware of the risk they are taking, and would rather look good today and take a chance on tomorrow. This is a personal choice for each patient to make, but I do think the risk/benefit ratio should be made clear prior to the surgery so each patient can make an educated decision. I do like to point out that we are living longer, and the US divorce rate is over 50% so there is a good chance a lot of us will be single in our 50 or 60's and back on the dating seen. I also like to point out that we can get a very good cosmetic look with less grafts then a lot of the HTN patients seem to think they need. Please look at my post 'How Many Grafts are Needed in a Hair Transplant'. http://hair-restoration-info.c...66060861&m=615103223 Third is an issue that is hardly mentioned on the Hair Transplant Network. As we age our safe donor area does lose hair and becomes less dense. I have not seen any good studies on this phenomenon but there is a general consensus in the hair transplant medical community that this does happen. I have notice that most of my older patients have less donor density then my younger patients. I believe this is a process of aging just like we get wrinkles in our skin due to less collagen in our skin. This thinning does not seem to be hormone related like the hair loss in male pattern baldness because the donor area never becomes completely bald like in male pattern baldness, but just thins out. If there is a hormonal component to this thinning of the donor area it is different then the male pattern balding process. The amount of thinning varies with each individual. So if you your donor density is 90 FU/sq.cm when you are 20 it may thin out to 80FU/sq.cm when you are 50. So I don't think one can count on having the same donor density thought out ones lifetime. I hope this information is helpful. Dr. Paul Shapiro

I just wrote a post on how many grafts are needed in a transplant you may find helpful. http://hair-restoration-info.c...66060861&m=615103223 You could be a hairline case or a front 1/2 case if you are willing to cut your hair short. One thing you don't want to do is to lower your hairline too low or dense pack in the hairline not knowing your future hair loss. Being on propecia is an important adjunct to any surgery because it can prevent future thinning. If you definitely don't want to be on propecia you should approach your first hair transplant very conservatively. I hope this is helpful Dr. Paul Shapiro

I just wrote a post on how many grafts are needed in a tranplant which may be helpful for you to read. http://hair-restoration-info.c...66060861&m=615103223 If your dad is a Norwood 7 you do have to be more on the conservative side. Just do enough to fill in the temporal corners and reinforce your hairline for now. That should take between 1,000 and 1,500 grafts. And in your case since it is hairline work, any clinic would cut down your 3 and 4 hair grafts to make only one and two hair grafts so you won't be using up much of your donor. Being on Finasteride helps but it won't guarantee any more hair loss. It can lose its efficacy in some patients and unfortunately we can't predict in which patietns this happens. You should consult with more then one clinic. Most clinics will do free consults and if the clinic is not in your area they will do the consult over the telephone. I hope this is helpful Dr. Paul Shapiro

I just wrote an post on how many grafts are needed in a transplant which has a section on graft survival. you may want to look at that http://hair-restoration-info.c...75108723#475108723Dr. Paul Shapiro

This female patient had the typical high hairline, and male pattern recession seen after menopause. These results are 11 months out. Most female patients take at least 18 months to see the final results of their hair transplant so I expect to see even more thickening over the next 6 months. The graft count was as follows: 1 hair FU 813 Hairs 813 2 hair FU 1485 Hairs 2970 3 hairFU 404 Hairs 1212 4 hair FU 19 Hairs 19 Toatl FU 2721 Total Hairs 5071 Below is a close up of her post op hairline at 11 months:

The survival studies I mentioned have only been done on the strip method. I think it would be useful to do some survival studies on FUE cases. When we extract the follicles by the FUE method they do not have as much tissue around them and to me they do seem more fragile then the grafts from the strip method. Thus I think it is wise to keep the cases smaller when doing FUE to ensure good graft survival. If a patient has little or no hair, using the strip method, we usually can finish a 3,500 to 4,000 case covering the front 2/3's within 8 hrs. If the patient has hair and chooses not to cut it short, then the number of grafts we plant will be less. We have not done a strip case over two days because if we get a yield of 4,000 we can usually finish the case within 8 hours. If a patient came in who was a type 6 or 7 and had a great donor we might consider doing a 5,000 to 6,000 case over 2 days but that has never come up. If that happened I am not sure how we would do the pricing. So far the largest FUE case we have done is 2,000 over 3 days (we probably could have finished that case in 2 days). Most of our FUE cases have been in the 1,500 range and it was over 2 days. Each patient is different but we can extract 800 to 1,000 follicles in a day using the FUE method. We want to see how these cases grow out before trying larger cases. I have seen some FUE cases where to get large number of hairs it looks like the doctors are going outside the safe donor area. As long as the patient knows that there is a risk that hair may not be permanent then that is ok. Also I have not seen many FUE cases over 2,000 where the results have been very good. When doing a FUE case we charge the same regardless of how many days the case takes. I hope this answer is helpful Dr. Paul Shapiro

The question you ask is a good one. And as you pointed out there are many variables that may make the results different for each patient. Taking that into consideration I would say that in the 'average patient' using 6,000 to 7,000 grafts we can achieve a cosmetically pleasing result over the entire scalp. In the average Norwood type 5 or 6 the amount of total scalp needed to be covered is about 200 sq.cm. With 6,000 grafts we can recreate a mature hairline, create good density in the central core and get good coverage of the crown. In many patients the area of bald crown is so large that our goal is to shrink the crown but not completely cover the crown. This gives a cosmetically pleasing result because the hair in the upper crown falls down over the rest of the crown and the crown no longer looks bald. I also find that a lot of my patients in their second surgery decide to bring the hairline and temporal corners down a bit and chose not to have as much density in the crown. Here is an example of an 'average' patient who had a total of 5,797 Grafts to cover his top and crown. A patient of mine, Baxter, recently posted his results from his 6 month follow after his second surgery: http://hair-restoration-info.c...=588102092#588102092 He is a good example of a patient with a large surface area to cover and a large crown. He had a total of 6,076 grafts and I covered about 250 sq.cm of scalp. The photos of the second surgery are only 6 months out and I expect to see more crown coverage at his one year follow up, but this should give you a feeling of what can be accomplished using 6000 grafts in a patient with a large surface area to cover. In Baxter's case I used 400 DFU's in his central core and each DFU is like two FU's so this case is the equivalent of a 6400 FU case. I hope this answer is helpful DR. Paul Shapiro

aWidowsPeak Many FUE procedures take more then one day because we can not get the number of grafts to complete the procedure in one day. The numbing medications we use are Lidocaine and Marcaine and should have no effect on the graft survival. These medications affect the way sodium is transported in the nerve fibers which stops the transmission of the pain nerve conduction. They do not affect the blood vessels which supply oxygen to the new grafts. There is a small amount of epinephrine in these numbing medications and epinephrine does cause the blood vessels to constrict. But we inject one half centimeter in front of the area that we are transplanting into, This small amount of epinephrine should not effect graft survival or the blood flow to the new grafts. At present we think we can harvest more donor using the strip method then using only FUE. But exactly how much that translates into number of grafts we have yet to determine. Dr. Ron wrote a good article on the advantages and disadvantages of FUE: http://www.regrowhair.com/hair...transplant-surgery/, which might be helpful to read. The donor area that has the permanent hair and thus is safe to harvest is the same regardless of which procedure we use. And both procedures leave a scar and we still have to leave enough hair in the donor area to cover the scar of the FUE or Strip procedure. In most patients the center of the donor has the best density. Using the strip method we believe we can harvest more of that area and still leave enough permanent hair to completely hide the scar. I hope this answers your question, Dr. Paul shapiro

mmhc I am glad you enjoyed the post Thanks for pointing out the typographical errors. I will change them Dr. Paul

Annieg: You may find this previous post on Female Hair Transplants Helpful: http://hair-restoration-info.c...4&a=tpc&f=3466060861 It is very important that you fist have a good medical work up to make sure there are no medical treatments needed. Many hair transplant doctors have seen that that treating borderline iron deficiency anemia or borderline thyroid problems can help hair loss. Dr. Robin Unger is also in NY city and has a large female hair transplant practice. It is always good to get multiple consults prior to doing a hair transplants. Dr. Paul

UD The question you ask does not have a straight forward answer. There are many factors that go into deciding how many grafts are 'needed' for a hair transplant. I just posted a topic on 'How Many Grafts Are 'Needed' For a Hair Transplant Surgery'? in the open hair loss topics: http://hair-restoration-info.c...66060861/m/615103223 This post might be helpful for you to read. There are many factors that need to be considered in deciding how many grafts are needed for each patient's hair transplant. A hair transplant doctor needs to take into consideration the following factors: will you allow you hair to be cut short, your age, your goals, your donor density, the sq.cm area of the scalp we are transplanting into, your hair caliber, your family history of hair loss, your response to medical treatment, your personal health history, and as our cases go longer and get larger the risk benefit ratio that is acceptable to you. At Shapiro Medical Group we do have general guidelines which I have 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. I do believe it is beneficial to do a session in which the grafts can be planted within 6 hours of being out of the body and try to limit the total time of surgery to 8 hours or less. I suggest you have consults done at more then one of the clinics listed in this web sites recommended physicians. Most clinics do the consults for free and can do them over telephone if you do not live in the area. Then you should go with the clinic you feel the most comfortable with. I hope this information is helpful. Dr. Paul Shapiro

How Many Grafts Are 'Needed' For a Hair Transplant Surgery? Recently Jana posted photographs of my patient Brad Becker: http://hair-restoration-info.c...21087683/m/918102092 This post elicited a common response that we get when we post a Shapiro Medical Group patient on the HTN web site. The response usually states how good the case looks considering the small number of grafts we use. Here are a few recent quotes on the HTN about SMG patients: 'This is great result for only 2500 grafts' http://hair-restoration-info.c...=104101501#104101501 'Amazing coverage for the number of grafts Janna.' http://hair-restoration-info.c...21087683/m/606101362 'janna,a very pleasing result with relatively few grafts(considering the area covered)' http://hair-restoration-info.c...21087683/m/158100281 'Wow, Janna! Those results for the # of grafts are amazing, they really are' http://hair-restoration-info.c...051020473#7051020473 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

Hdude46 You could have chronic TE and that would be one diagnosis that should be looked into. We do have the ability to do skin biopsies and order blood work at a local laboratory, but we prefer to have potential hair transplant patients see a dermatologist and endocrinologist where they live for such work ups. Then if you require ongoing medical treatment you have a local doctor to work with. I will pm you and would be happy to discuss your situation in more detail with you. It is important that you have a proper work up before considering hair transplant surgery. If you have a treatable condition, it should be treated and stabilized prior to considering a hair transplant. Dr. Paul Shapiro

Sole_man: At Shapiro Medical Group we do hair transplant with or without shaving the head. In both cases you will get excellent results, but if we shave the head we can plant more hair at greater densities. When doing a megasession of 3,000 grafts or more, or in cases in which we plan to do dense packing, I think it is important to be able to shave the head. Our goal in these megasessions is to get the patients total hair density (the patients native hair plus the hair we transplant) up to at least 40 FU sq.cm and in some cases we even get their total hair density up to 60 FU sq.cm. If I we are going to plant hair at these densities I believe it is important to shave the head in order to avoid transection of existing hair and get the high densities desired. I tell patients that we can perform a surgery with or without shaving the head, but that we can pack more densely and the amount of hair we transplant will be greater if we can shave the head. In general I use the following guidelines: In transplanting the frontal 1/3, if the patient has existing hair and will not allow us to shave the head I will transplant 1,500 FU. If the patient has little hair or allows us to shave the transplanted area I can transplant 2,000 to 2,500 FU. In transplanting the frontal 1/2, if the patient has existing hair and will not allow us to shave the head I will transplant 2,000 FU. If the patient has little hair or allows us to shave the transplanted area I can transplant 2,500 to 3,000 FU. In transplanting the frontal 2/3, if the patient has existing hair and will not allow us to shave the head I will transplant 2,500 FU. If the patient has little hair or allows us to shave the transplanted area I can transplant 3,000 to 4,000 FU. Of course this is just a guideline and the numbers varies depending on donor, quality of hair, patients health status, patients goals, etc??¦ In summary, what I tell patients is that we can do a lot in one session without shaving ones head, but the remarkable dense packing one sees on the internet can only be done with shaving the head. So it is up to the patient to decide which way they want to go. Some patients can not shave their head and we can still get very good results. But if they want to get the maximum density possible and the biggest bang for the buck it is better to shave the head. I hope this information is helpful Dr. Paul Shapior

Even in the crown/vertex area or hairline mid scalp alone? I've heard quite the opposite from a leading clinic who have been prescribing it for 10+ years. We also have patient who have been on propecia for 10 year and for some it seems to continue to be 100% effective, for others it starts to lose its efficacy. Unfortunately we don't have any good studies to know the percentage of men in which propecia stops to work or the percentage of men it continues to work for. And most likely there are many men who even if they are having some hair loss, propecia still retards the rate of hair loss. What I do think is important is to not count on propecia to halt all hair loss, especially if you are young. So I would still be conservative in a young patient regardless of if they are on propecia or not. Now if 10 years down the road that patient choses to have a second surgery and has not had any progession in their balding on propeica, I would plan a different surgery then if they continued to progress even on propecia. Dr. Paul Shapiro