Dr. Paul Shapiro

Bill You are correct that only a portion of the hairs should be DFU's. As I already mentioned, 10% to 20% of the hairs are used to make DFU's. The actual number depends on the size of the case, the donor density, etc. I have used from 150 to 400 DFU's in different cases. It just depends on the case. In most cases I don't even know exactly how many DFU's I will use until the strip is taken out. I will then save a portion of the strip for DFU's. When the cutting starts the technicians can give me an estimate of the number of FU's I will get from the strip and the percentage of 1,2,3,and ,,4 FU's the stirp will yield. Based on this information I then decide on if I will use DFU's and how many. Then density and distance we place the DFU's vary from patient to patient. I have never actually measured how many mm is between each DFU that I place. I would say on the average I place about 10 DFU's/sqcm. What is important is that the DFU's are not transplanted alone, but with FU's around them. Depending on how many FU's I plan to place around each DFU and if I plan to use 2, 3 or 4 hair FU's around the DFU also determines how far apart I will place the DFU's. I hope this answers your questions and sorry I can not give you a more exact answer. And I understand your concern about a pluggy look but I can't give you any more exact answers then the ones above. What I can say is that the proof of a good result using DFU's is in the pudding. We will follow Reversethecurse's progress and see how his transplant looks. And as I said DFU's are not for everyone. Many patients ask the exact same questions you ask, and if in the end they are still concerned about a pluggy look with DFU's I will only use FU's in their transplants. Either way the patients will end up with excellent results. There are some cases I believe that DFU's are so superior I will insist on using them. For example a man with very white hair, a good, dense donor, and a large central core to cover. But in many cases the difference between a surgery with or without DFU's is not big enough to make me be insistent on using one method or the other, even if I believe the DFU's would give a better illusion of density. Dr. Paul

Gorpy I am sure Pat would not mind me disclosing that his hair is actually very white but he dyes his hair. This leads me into mentioning another reason why we use DFU's. In patients with very white or grey hair it is very difficult to see the hair bulbs. Hair transplant doctors have tried various methods of dying the follicles to make them stand out and these methods help a little but it is still difficult to see the bulbs. Thus the chance of transecting a bulb of even cutting and unseen bulb out of the FU is possible. When we cut a DFU we know we are not cutting any of the hair bulbs between the two FU's. Even the best hair transplant technicians most likely will cut off bulbs in white hair patients. We believe by using DFU's we avoid some of that problem It may only mean saving 50 hair follicles, but every hair follicle counts. Secondly, we do use DFU's in patients with darker hair. Pat's hair color is a dark brown and his texture is not fine, but not thick. DFU's can be used in patients like Pat if used correctly. Pat has already had a number of hair transplant surgeries and we know all the hair in his central core is transplanted hair. Thus we have a good base to put the DFU's between By placing DFU's between the transplanted hair we can get the desity effect I spoke about earlier without any unnaturalness. There are cases we even use DFU's in dark hair patients. It depends on the individual case. But in general we use them on patients who have fine light colored hair with little contrast between the hair and the skin. You may be a candidate for DFU's and I am sure Dr. Keen will be glad to discuss the pros and cons of DFU's in your case with you. Dr. Paul

Hi Bill and Happy Thanksgiving to All Billerso, I always welcome any questions and devils advocate questions are always welcome because they are the ones that make me think the hardest. I would like to answer your question # 2 first. Strategic positioning is important in how we create the illusion of density in hair transplantation surgery whether we use FU's or DFU's I also believe the number of hairs in a graft does make a difference in how much light it can block. We can never place two 1 Hair FU grafts as close together as they are in a 2 Hair FU. In a 2 Hair FU the hairs can fan out and will block more light the two separate one hair FU grafts. Does that make sense? Thus I do believe that five 2 Hair FU grafts if placed correctly can block out more light then ten 1 Hair FU grafts. This principal of blocking light is the basis of how we plan a hair transplant. Sometimes we want the maximum light blocked as in the central core while other times we may not want as much light blocked as in the hairline. We believe it is better to have larger 3 and 4 hair FU's in the central core then using 2 and 1 hair FU's there even if we ended up with the exact same number of hairs. DFU's are just an extension of this principal. Most physicians agree that larger grafts block more light, but the problem is that large grafts can also look pluggy. DFU's are a larger graft that if used correctly can give a greater appearance of density without looking pluggy. So using DFU's is not exactly 6 in one half a dozen in another. But I do have to be careful in how I use DFU's. They only work well in the central core area, and should be only 10 to 20 percent of the total grafts used in a surgery. Only certain patients are good candidates for DFU's. This leads me to the answer of your first question, who is a good candidate for DFU's in a hair transplant surgery. The ideal person to use DFU's is one who has thin, white or light blond hair and when there is little contrast between a patients hair and scalp color. In these patients a FU with one hair hardly has any effect. DFU's with 6 hairs in these patients almost never look pluggy. On the other side of the spectrum, patients with dark, coarse, hair are not good candidates for DFU's. In these patients DFU's could look pluggy, however there still may be some cases in which DFU's might be used in these patients. Many patients fall somewhere in the spectrum of an ideal patient and a risky patient for using DFU's. For example, Reversesthecurse, has fine, straight, hair which makes him a good candidate for DFU's. But his hair color is light brown, not white. In my assessment there was not a very large contrast between his hair color and his scalp color making him a good candidate for DFU's. When using DFU's I also have to consider what area of the head I am going to transplant and how many grafts I will use for the procedure. DFU's are not useful when I am transplanting the hairline, temporal peaks, and crown or in patients who have a lot of hair in the central core area.. Also I don't use DFU's if I am doing a small case of less then 2,000 FU's because I will need the natural distribution of 1,2,3, and 4 hair FU's normally found in the donor strip. DFU's do now work well in patients with poor donor density because the yield of FU's will be low and the space between the FU's are too large to make a good DFU. Using the above criteria, I would say that in my practice 5%-10% of the patients are ideal candidates for DFU's. Another 5%-10% are good candidates for DFU's. I know I stated that I do DFU's in about 2% of my patients. I was just stating a number off the top of my head. When I went back and reviewed my charts I use DFU's in about 10% of my patients. Sorry for that error. I guess I use them more often then I thought. I most likely could use them in a greater percentage of patients, but there are many patients who insist on FU grafting only. They are afraid that DFU's will give them a pluggy look and in those patients I would not force them to use DFU's because regardless of whether I use DFU's of not I will get good results. Using either method the hairtranplant will look natural and full, but in certain patients I believe using DFU's will give a greater illusion of density in the central core.

Hi This is Dr. Paul Shapiro and this is my first post in the hair transplant forum. It is a great forum and I would like to thank Reversethecurse for posting his web blog. I am sorry it took me a week to post this explanation of DFU's (Double Follicular Units) but as I have typed up my responses I realize how difficult it is to explain this concept in words. After you have read my explanation if any of you have any further questions please feel free to email me at pshapiromd@shapiromedical.com or call our office. As you all may know I am Dr. Ron Shapiro's brother and I have been working with him for the past six years. In those six years I have gone to most of the IHRS meetings, and I have visited many of the well know hair transplant doctors to observe their surgeries. In those six years I have seen many changes in hair transplantation. When I first trained I was using #15 sharp points to make my incisions and a session of 2,000 FU's (Follicular Units) was considered a large session. Now we cut our own blades down to .6 mm for the one hair follicular units grafts and many of our session consist of 2,000 FU's and it is common for out sessions to go up to 3,000 FU's. As the sessions have become larger and the blades have become smaller the use of DFU's have largely been ignored. At Shapiro Medical Group we believe that DFU's have place in hair transplantation. In certain patients DFU's can be used to give a greater appearance of density in the central core area when compared to using the same number of FU's alone. When used correctly DFU's are undetectable and have a completely natural look. Also, DFU's give us the potential to achieve higher densities with fewer total grafts. We only use DFU's in patients who have more advanced hair loss so this technique is only appropriate for men who have a baldness of class 4 or greater. I would like to thank B Spot for his summary of DFU's as it is a complicated concept. What he has described is what we would call follicular families not DFU's. The terminology of what to call certain type of grafts is confusing and many physicians get confused about the terminology. . I would describe a DFU as a highly refined micro graft. Using the microscope, we are able see follicular units that are close to each other and can cut them into DFU's On the average these DFU's have 6 hairs in them and if they are trimmed well there is very little epithelial tissue on the sides of the graft. The DFU's can be so small as to fit into incisions cut with 1.1 or 1.2 mm size blades. But often I have to use larger blades to make the incisions. DFU's are never used alone, I always place FU's between each DFU. Using DFU's I believe we can create a greater illusion of density using the same number of hairs then if we use FU's alone. Going back to the basics in Hair Transplantation we always have to remember that all men have a limited donor supply and that most men prior to balding had a hair density of 100 FU/sqcm. In men who have type 4 to 6 balding we rarely have enough donor hair to cover the balding area with even 40 FU/sqcm. In all transplants one of our goals is use a density of 20 to 40 FU/sqcm to create the same effect as if one had 100 FU/sqcm. A more detailed discussion density can be found on the Forums Educational pages or on the Shapiro Medical Groups website in the consult resource pages. When someone's hair starts to thin we notice the thinning because we can see the scalp under the hair. Prior to this ones hair is thick enough to block the light going to the scalp. The contrast between our hair and the scalp is the main reason we notice that our hair is thinning.. The more light that gets through to our scalp, the greater contrast we can see. If you can imagine a DFU with its 6 hairs fanning with 2 to 3 hair FU's around it you can see the potential to block more light then just 2 and 3 hair FU's alone. How we place the DFU's and FU's are critical to get this effect. DFU's are only appropriate in certain patients with the right type of hair characteristics. They work will in patients with fine, straight, hair that is lighter in color. If a patient s has course, dark hair, there is the potential for the DFU's to look pluggy Also DFU's should never be used near the hairline. DFU's do give us the potential for achieving a higher density in the central core then using FU's alone. As B spot mentioned the space between the two follicular units in a DFU is much closer then we can normally place hair. But since we have a limited donor supply of hair to work with we are usually placing the same amount of hair in the central core area whether we use DFU's of FU's alone. We are mainly using the DFU's to create a greater illusion of density. An added benefit to using DFU's is that I can move more hair using less incisions in less time. On average a DFU has 6 hairs. I usually use 200 DFU's in a case which would mean I am moving 1,200 hairs. It would take 400 three hair FU's and 600 two hair FU's to move the same amount of hair. I do believe the sooner we get the hair from the donor strip to the scalp the better it is. I am not saying that this time saving is the reason for doing DFU's but just an added benefit. Our large sessions are taking 6 to 8 hours and just cutting of an hour is easier on the patient. In summary I believe that in a select group of patients, DFU's s have their usefulness. In these patients DFU's can give better "coverage" then FU's alone by creating a greater illusion of density. At present I would say that 2% of my patients are candidates for DFU's. In the vast majority of my surgeries I use only FU's and my incisions are made with .6 to 1mm blade. I hope this helps explain DFU's and why I use them. It will be great to see Reversethecurse transplant as he progresses.

Message from Paul Shapiro, MD: Hi to all on the hair transplant network. I am sorry for any confusion I may have caused and would like to introduce myself. I am Paul Shapiro, MD (please call me Dr. Paul) and I am Ron Shapiro MD's younger brother. I have been a medical doctor since 1986. Prior to working with my brother I have worked in medicine specializing in Pain Management, Rehabilitation Medicine, and as a Family Doctor. I am board certified with the American Academy of Family Medicine and a Diplomate of American Academy of Pain Management. I have been following Ron's career and attending hair transplant conferences since 1995, but seriously decided to learn hair restoration surgery six years ago after moving to Minneapolis. In the past five years I have gone through intensive training, first observing Ron and his staff, next assisting with surgeries, then performing surgeries with Ron's or Dr. Rose's supervision, and finally performing surgeries on my own. I have been performing solo surgeries for the past two years. In addition to my training at Shapiro Medical Group, Ron has arranged for me to visit and observe a number of well respected hair transplant surgeons such as Victor Hassan, Jerry Cooley, and Ed Epstein. I am privileged to have such good teachers as my brother and Dr. Paul Rose. I love doing the surgeries and feel that the quality of my work is comparable to any doctors who have done surgery at Shapiro Medical Group. As many of you know, besides Dr. Paul Rose, Dr. Sharon Keen and Dr. Glen Charles have worked at Shapiro Medical Group. Due to Dr. Ron Shapiro's reputation and his busy lecturing schedule, his surgery schedule is usually full up to three months ahead of time, thus it is more difficult to schedule a surgery with him. Since I do not have any teaching obligations and do not attend as many medical meetings, my schedule is more open then my brothers. For these reasons we have a different pricing schedule for surgeries done by myself then Ron. Our pricing schedule gives patients more options while still offering them the quality of work that is a standard at Shapiro Medical Group. It will always been our policy to let the patient decide which doctor will perform their surgery and a patient can always choose to have their surgery done by my brother. I am not mentioned on our web site because we are in the process of re-writing our web site and it should be completed in the next month. At that time I will be able to post some photographs of my work on the web site. I hope this response clarifies your questions and concerns. If anyone ever wants to ask me any questions my email is pshapiromd@shapiromedical .com. Paul V. Shapiro, MD