Is bigger really better in a hair transplant session?

[Pat - Community Publisher]

We've all seen the headline grabbing posts and eye popping photos for the huge single sessions of 3,500 to 5,000 grafts. All things equal - who wouldn't want to get faster and more dramatic results sooner? Well, if all things were truly equal I would absolutely agree.

 

But like many things that sound almost too good to be true there is often a catch. While I believe that the creation of smaller and less invasive incisions that enable dense packing (when appropriate) are important advances (see our new Recent Advances section), I'm concerned about the potential dangers of huge sessions that are being promoted agressively online.

 

I believe, as do many very responsible physicians, that these huge sessions may in fact not be in a patient's long term best interest for a number of reasons.

 

Some of the potential medical issues that patients need to consider:

 

1) Are large sessions of 3,500 to 5,000 grafts potentially masking lower growth rates?

 

2) Are the graft counts really comparing apples to apples or are the new huge follicular unit sessions actually using "sub follicular unit" (less hairs per graft than standard follicular unit grafts) that therefore give a deceptively high graft count? Ultimately, it is the amount of hairs that are relocated and how they are arranged that determines the appearance of density ??“ not the graft count.

 

3) Are these huge follicular unit cases potentially taking too much donor tissue from the donor area in one particular session thus increasing the danger of scarring?

 

4) Are young patients in particular in danger of depleting their limited donor area by dense packing their receding hairlines too aggressively, thus not enabling them to achieve an optimal long term distribution of transplanted hairs?

 

The fundamental question that many leading physicians are asking about these huge mega mega sessions is ??“ are such large cases really in the long term best interest of the patient?

 

Based on all the information I have been exposed to, I believe that in experienced hands surgeons using the newest ultra refined procedures can and do achieve good growth rates when dense packing.

 

However, I question whether sessions ranging from 3,500 to 5,000 grafts will ultimately yield less actual growing hairs in the balding areas than if the patient moved the same number of limited donor hairs in two sessions.

 

I welcome input on this topic from both patients and physicians.

 

Pat

[Ailene]

The number of grafts that is best will vary from person to person. It depends on the area to be transplanted, the amount of existing hair, the hair characteristics (coarseness, curl, etc.), the blood supply in the skin (prior surgery, scarring, etc.), and of course the preferences and budget of the patient. Ideally the procedure is planned so as to leave follicles in the donor area for future usage. We often talk people out of doing the crown until the front is finished because people often stop caring about the crown when they have a natural hairline and dense frontal growth. One of our colleagues once wisely commented that the best procedure is the smallest procedure that satisfies the patient.

 

Ailene Watts

[gillenator]

I would like to add that age and yes even race can play an important factor in determining a restoration plan. The symmetrical shape and size of the skull should also be considered especially when designing the hairline, with consideration to the level of density in various recipient areas especially the front forelock. Flatter hairlines and obviously lower hairlines use more grafts.

 

I am also a BIG proponent of evaluation of donor potential including isolated extraction methods BEFORE any decisions are made. Equal consideration given to the overall potential of genetic loss based on family history. Let's say for example a 32 year old male in a Norwood 4 class with potential to progress to class 6 and even 7, has less than average density with an estimated harvestable potential of 4,000 to 5,000 grafts. And lets also add that he has been on Propecia for 2 years with good stabilization in the vertex and crown although there is definite loss that did take place in the crown before he started Propecia. The patient further states that all areas of loss bother him and does not like the 5x5cm bald spot in his crown. He is happy that Propecia seems to have prevented the loss in his crown from spreading out.

 

Should a patient like this go for the maximum session of 4,000 to 5,000 grafts and just get it over with? Interesting question is it not?

 

Possibly a more conservative or better yet, methodical approach would be better for a patient with this profile. And yet the patient may want to do a mega-session of 4,000 grafts or whatever can be excised in one sitting. This is not untypical especially in today's environment.

 

The biggest problem I have is the lack of documentation on yields. What happens if this same patient talks his doctor into doing the 4,000 grafts and for some reason the yield is poor or less than was expected. But there is little to no donor left and possibly this patient feels regretful about the whole thing.

 

Yet if he approached it more conservatively let's say with 1700 in front and another 300 in the crown to dispell the bald surface look but instead produce a thinning look, there would still be future donor to use for adding density later. And since hairloss is progressive there would be some reserve for the front considering he is only 32 years old. If his hairloss ends up to be less than expected, he will save some money in his lifetime. But if there were less than expected yields, that would provide him with the option of not continuing and again save money.

 

Would it be wise to approach restoration aggresively or methodically approach it to evaluate both yield and future loss togethor? Certainly alot to think about.

[r20926]

I had a 3759 FU mega-session and my results really are great and life changing. Pat, I would have to disagree with your post and opinion on megasssions.

[Skywalker]

Assuming that you are satisfied your chosen doctor is up to the job (and this is where doing your research comes in) then in my opinion yes, bigger is clearly better. Artistry is obviously critical but there is at least some truth in the saying

"It is all about the numbers".

[Dr. Paul Rose]

I think that Pat raises interesting and important points. There is no doubt that sessions these large sessions can be done and patients can have excellent results.

Important factors to consider include;

1.Knowing the surface area to be covered and the proposed density.4000 grafts over 100 sq cm works out to 40 FU per sq cm. 4000 grafts over 200 sq cm such as in a type 6 pattern is 20 FU per sq cm (1/4 to 1/5 of normal density).

2.As pointed out by Ailene hair characterisitics, age and pattern of baldness are likewise important to know

3. Survivability of grafts. A session of 5000 grafts may look good over 100 sq cm even if 4000 grafts grow, but 1/5 would have been lost. We do not have reliable survivability studies at higher densities of 45+ grafts

4 There is increasingly more concern about the donor scar. To obtain almost 4000 grafts in a person with average density of perhpas 80 FU/sq cm, a strip of 50 sq cm would be required. Such a strip might be 2cm x 25cm. A patient would have to have fairly good scalp mobility to obtain such a strip and provide a low tension closure.There are certainly patients with this type of scalp laxity but I don onot think this is the majority of patients..

5.If something were to happen to a patient causing loss of grafts then perhaps a significant amount of the available donor would be wasted. Granted this would be exceptionally rare. I know of an instance of a patient who had to undergo a sugical procedure involving general anesthesia shortly after the hair repalcement procedure and had less than optimal growth.In a subsequent session he had excellent growth

6.Additonal sessions. Even after doing such large sessions the patient may still find that the density desired requires one or more additional procedures.

7.There is some concern about the patient's ability to tolerate the procedure in terms of length of time.If the area to be transplanted is fairly void of hair the procedure could go quickly. If there is a considerable amount of hair the procedure can be more difficult and take longer.In such instances it is probably imperative that the patient allow the physician to trim the hair sufficiently to allow for ease of palcement.

8. Extremely large sessions may commit the physician to going into portions of the scalp that may not be in the patients best interest. this would of course depend on age, family history, patterns etc

9. It is important to know the ration of one hair, two hair, three hair, four hair FUs etc to get a better undrstanding of the toal mass of hair being transferred. For instance if there is an exceedingly high number of single hairs density may still be a problem. The point is there are many variabel to considre not simply graft numbers.

10. Ultimately the question may be more about ways to achieve high density rather than simply high total numbers of grafts.

 

 

Paul T Rose, MD

612 965 4247

813 259 9889

getfithairs.com

[r20926]

Dr. Rose,

 

You make some valid points...

 

My only question is how do you explain the day in and day out consistent results of certain HT clinics that perform mega-sessions (3000 to 5000 FU's) on a daily basis.

 

And I might add that these clinics can back up those results with proof.

 

You have numerous patients walking around, who post their results on these forums with outstanding HT's who have had mega-sessions.

 

If there "might" be certain problems with mega-sessions, then how do you explain all of these HT patients who have had mega-sessions, I being one of them, with outstanding results with absolutely no complications?

[Robert_]

r20926,

 

I don't think that there is any argument to the fact that if you move enough hair there will be dramatic results. However, much of the concern lies in the notion that perhaps precious donor hair may be getting wasted on such sessions. True, much of it grows but with limited donor hair you want as high a yield as humanly possible. This involves careful planning and a degree of caution and judgement.

 

It is the yield factor that is the concern for me. If I were to get a 5,000 FU transplant I would want as close to 5,000 FU's to grow; not an impressive looking 4,000 with 1,000 gone to waste.

 

-Robert

[r20926]

Robert,

 

Here's a question:

 

Would you rather have five surgeries of 1000 FU's and hope that 4000 grow?

 

Or

 

One surgery of 5000 FU's and 4000 grow?

 

How do you know that a smaller surgery would yield a higher percentage of FU's that grow in comparison to a larger surgery?

 

I had 3759 FU's planted and most of them if not all of them have grown successfully.

 

I think it comes down to the ability of the Doctor, there staff, and the patient when you are talking about yield. There are no guarantees with surgery no matter how many FU's are planted.

 

It is just a fact that some Doctors are better then others and there results prove it, no matter how many FU's are planted.

 

It seems like excuses are being made for Doctors who perform smaller surgeries because they can not keep up with the big boys who perform successful mega-sessions day in and day out.

 

When I see a thread like this started which cast doubts on mega-sessions, there seems to be an underlying issue then just mega-sessions are bad.

 

Remember the poster boy on www.regrowhair.com and the GQ ad (aka FutzyHead, Dave N.) well he had not one but two sessions which were considered mega-sessions at the time of the procedures, you cannot have him as your poster boy but then start a thread that cast doubts on the procedure that made him your poster boy. Let's be honest here and give the forum readers what they want, good information about the HT industry.

[Bill - Seemiller]

This is an interesting topic indeed. My doctor for example, Dr. Katz is more on the conservative side and only does 1600 max at a time...and one of his beliefs is simply what has been stated here...that doing too many grafts at once could "potentially" (

 

Bill

[Robert_]

Originally posted by r20926:

Robert,

 

Here's a question:

 

Would you rather have five surgeries of 1000 FU's and hope that 4000 grow?

 

Or

 

One surgery of 5000 FU's and 4000 grow?

 

I think that since I've had already had a session of 2,300 with great success I would just finish up with 2,700.

 

How do you know that a smaller surgery would yield a higher percentage of FU's that grow in comparison to a larger surgery?

 

I don't. That is exactly what this discussion is about. The concern is there.

 

I had 3759 FU's planted and most of them if not all of them have grown successfully.

 

Awesome. Happy growin' to ya.

 

I think it comes down to the ability of the Doctor, there staff, and the patient when you are talking about yield. There are no guarantees with surgery no matter how many FU's are planted.

 

The surgical procedure always comes down to the skill of the physician. I have never said anything to the contrary of that.

 

It is just a fact that some Doctors are better then others and there results prove it, no matter how many FU's are planted.

 

True again.

 

It seems like excuses are being made for Doctors who perform smaller surgeries because they can not keep up with the big boys who perform successful mega-sessions day in and day out.

 

This is where you are wrong. Noone is trying to cast doubt on anything. You entered a discussion on the topic of survivability of high numbers of follicular units and you're taking it as an attack on physicians and thinking that there is some sort of conspiracy against megasessions. This is not true at all. I have seen dozens of threads on this same issue on every hair loss forum but once I enter as a forum moderator with an opinion, or Pat enters as publisher with an opinion, or a physician enters with an opinion then it becomes some sort of grand conspiracy. Since when am I not allowed to give my opinion in a discussion without being accused of making excuses for, well, whoever you think I am making excuses for?

 

Let's be honest here and give the forum readers what they want, good information about the HT industry.

 

...and you are saying that I am giving false information? Go back and reread my posts. Heck, go back and reread ALL of my posts. You tell me one instance where I have tried to mislead anyone in any statement.

 

I enjoy a healthy discussion just as much or more than the next guy but I don't care for you insenuating that I have some underlying agenda.

 

Oh, and by the way, your posting priveldges were revoked once under the username "Pandther." I find it interesting that you would think that you could come back a few months later under a different registration email and that I would not notice.

 

-Robert

[Dr. Paul Rose]

Dear R20926

 

I appreciate your comments

 

I stated at the beginning of my response that these sessions can be done and there are some physicians who have patients who are thrilled with the results.

 

 

My points were to acknowledge that there are some concerns about performing these extremely large sessions.Like many things in HT surgery sometimes we may have to wait years to find out the full effects of various techniques.

 

I would also suggest that in the current medical legal climate the "might be" questions can come back and bite.As an example if someone were to have a particularly poor donor scar after a 5000 graft mega sessions, could the patient allege that the scar was a result of taking an excision that was not the current standard of care? Likewise what a if patient had particularly poor growth could the patient suggest that such procedures were not the standard of care? I do not know.

 

I also like to think that hair restoration surgery needs to continue to take on a more scientific approach to things. It seems prudent to make small jumps and have the science to back it up. I think it is reasonable to try to obtain survival data on grafts based on density of implantation, total numbers of grafts placed over an area, time in solution prior to implantation etc.I also realize that obtianing such dat is very difficult.

 

 

Your enthusiasm for your results obviously makes a great case for doing 4000 graft sessions and as more of these cases are done I imagine we will collect more data to assess risks and results. I think that it is important to realize that not every patient is going to be a good candidate based on health considerations and other factors.

 

Paul T. Rose, MD

612 965 4247

813 259 9889

getfithairs.com

[Smoothy]

Pat and Dr. Rose, excellent responses. It is a personal judgement call, but from a person who has had multiple procedures over 15 yrs, I would rather repeat my multiple procedures rather than 1 large mega session to have more FU survive as well as further hairloss progression in later years. If one, uses 4-5K donor grafts in let say the hairline, temple and frontal core/mid scalp then 10 yrs later looses all his vertex and crown-- that would look pretty weird and noticable-- if you took that same 4-5K grafts in 2-3 different sessions then the surgeon can adapt to the hairloss within those 10 yrs to look natural-- "the zone" method would be applied better.

If I had to do it over, I would do the same rather than a mega session and use a majority of my donor at one time.

Just from personal experience,,, the only down side is donor scarring, which today, surgeon extract from the same scar rather than staggered extractions with multiple scars that they did in the early 90's.

Personal preference.

[Ailene]

This debate is one that is discussed at the conference each year. To date the data presented is inconclusive. I feel this is what Dr. Rose is trying to point out.

 

I will repeat myself and state that if you line up ten docs and give them the same patient you will get ten different scenarios. They may be close but still different.

 

It is a fact that the first time you go into a given area or zone is always the best. The vascularity has not been compromised and therefore everything is at it's best. But, the variable factors do exist, patient complience, smoking, techniques used in harvesting, and the time the surgery takes to name a few; do take their tole.

 

Like Dr. Rose, Dr. Cooley prefers to have consistant results. This does not mean that we do not implement new technique but that we do it slowly so we can observe the results and feel confident we are providing the best serice and patient care.

 

We do large sessions of 2500 to 3000 all the time. It totally depends on the patient. They must be good candidates for larger sessions. Another thing to concider is how much existing hair is involved. We do not often see shock loss any longer, with the microscope use and small instruments but if they were too densly packed this could be one of those factors.

 

Ailene

[Hairbegood]

Dr. Rose, thank you for chiming in. In my research I've not seen many doctors participate except to showcase their resultsso your participation is commendable.

 

This thread is more confusing than helpful though. You stated that more studies were needed for such large sessions. Are there studies that support the use of sessions of 2500 to 3000 grafts? 2000 to 2500 grafts? The reason why I'm asking is because the Bosley office that I had a consultation with stated that performing sessions over 1200 to 1500 grafts is a bad idea. The grafts will not grow as well and there will be a lot of waste. This was by the doctor not the consultant. 2500 grafts were recommended to me in two sessions. I was classified as a NW6.

 

Now I'm sure you feel confident in your procedures which if I remember tend to be in the 2000 to 3000 graft range. Why do you feel these are safe? Trust me I'd rather get more in one session if it is safe but I'm sure you can see why I'd be a little eneasy about it about since this topic has been raised.

 

Thank you for your time. Also, can I send photos your email address listed below for an opinin?

[Pat - Community Publisher]

I remember when I did my first "mega session" of almost 1,500 grafts 7 or 8 years ago. At that time, many physicians were resisting such big sessions based on reservations about the growth rate. As an enthusiastic patient I also scoffed at such conservativism.

 

Now we find ourselves debating whether these 1,500 graft sessions are too small and whether sessions of 4,000 plus are too big.

 

Then as now, I believe that a patient's session size should be determined by what is optimal for the patient not what is most convenient for the clinic.

 

Big ultra refined follicular unit sessions have once again stretched the limits of what can be done. I believe that today a truly state of the art clinic should have the skill, staff, and technique to dense pack grafts into very small minimally invasive incisions and in large sessions ranging as high as 3,000 to 4,000 grafts - when appropriate.

 

Such highly demanding surgeries should only be attempted by clinics that are at a very high level of skill and experience or the growth rates for such large sessions will indeed be very poor.

 

The bar has been raised and some have stepped up to the challenge and progressed with it and some have not. Many continue to provide decent results without having adopted these newest ultra refined techniques. But I think they will find themselves continuing to loose ground and patients, especially online, if they don't adapt and evolve.

 

The new Coalition since March 1st is now exclusively made up of those physicians who we believe have successfully risen to this challenge. The standards for surgical excellence have moved higher and so have our standards for the information we present to hair loss sufferers regarding procedures and physicians.

 

I do not think the comparison today is between one session of 4,000 grafts or four sessions of 1,000 grafts. Rather, I see the comparison that most patients must weigh as choosing between doing sessions of 2,500 to 3,500 follicular unit grafts (not sub follicular grafts) or pushing for the outer limit of 4,000 to 5,000 grafts in a session, which could too heavily tax both the donor area and the scalp's ability to support new hair growth in one session.

 

If I were once again a first time class 5a bald man I'd opt for a couple sessions ranging from 2,500 to 3,500 follicular units each for a total of 5,000 to 7,000 follicular unit grafts. This would provide a drastic improvement with adequate cosmetic density, while not over stressing or depleting the donor area ??“ thus still leaving some viable donor hairs in reserve for a future tune up.

[Skywalker]

We already have doctors producing almost monotonously good and consistent results doing strip HT's in the 4000 to 6000 graft range. The results look fantastic. I am not a fan of strip as I think FUE is the best way to go (assuming the funds are available) but even so these results cannot be denied and if some can do this I see no advantage in doing multiple small sessions - the results speak for themselves.

[Pat - Community Publisher]

Skywalker,

 

First, we need to be sure we are comparing apples to apples when we count grafts, especially when comparing naturally occurring 1, 2, 3 and 4 hair grafts to sub follicular unit grafts in which the 2, 3 and 4 hair grafts are divided into smaller grafts.

 

Thus the graft counts with sub follicular unit grafting may sound more impressive (4,000 to 6,000 "grafts") but the actual number of hairs moved is often no more than a some what smaller natural follicular unit graft case.

 

Thus a patient doing a state of the art all follicular unit session of 3,000 follicular unit grafts may in fact end up with more growing hairs in their recipient area than the patient doing the impressive sounding 4,000 plus case of sub follicular unit grafting.

 

The ultimate limiting factor in hair transplantation is that only so many bald resistant follicles can be safely relocated to the balding areas in a given surgical session.

 

If more donor tissue is excised then the risk of closing the donor area under increased tension goes up. Also as more grafts are placed in the recipient area the risk of lower growth rates increases. These lower growth rates can potentially be masked by the large size of the sessions.

 

Thus there is no magic scalpel. The real question comes down to what is the optimal number of hairs that can and should be safely transplanted for a particular person in one session.

 

For most patients with average donor density and elasticity, going beyond 3,500 natural 1, 2, 3 and 4 hair grafts (not sub follicular unit grafts) has the potential to over tax both the donor area and recipient area.

 

Personally, based on what I've experienced and seen over the past 7 years I think sessions of 2,500 to 3,500 (natural follicular unit grafts) are the optimal value and safest route for most patients with extensive baldness.

[Smoothy]

Dido Pat,

YOu hit the topic on the head.. I think there are many doctors out there who take 100% natural FU and "split" them to get additional grafts to implant-- like taking 250 2-hair bulbs and spliting to 500 1-hair grafts which is done somewhat but I believe many take advantage of this to get make additional money and to claim to "regularly conduct 4-5K megasessions"??????

[Guest]

I would like a doctor from the California area to please contact me about this matter, as I am definitely getting this procedure done in December 2005 or January 2006.

 

Thanks, and feel free to call me at 818-516-0570, if that is more convenient.

 

Michael

[troy]

Well today i had a very good conversation with Matt Zupan from Shapiro. I will say Matt is very pasionate about his work, and does seem to care about what they do and his role in helping people. One thing I applaud Matt for is does try to educate people rather than sell them. We went into a long disscussion these on jumbo sessions, I will sum it up this way. Everyone has a limited donor supply, this is a non changing factor. We all want to cosmetically hit our personal goal asap. So what is the quickest route? This is now where people will make choices they feel that suites them and what clinic can deliver the patients wants. 1. Be conservative, and go 2500, watch future hairloss and have a plan to address as our hair loss changes, maybe not get to our goals as fast, or 2. Role the dice and go big or go home. with out much of a back up plan for future hairloss. I find myself some where in the middle. We have all heard the painful disfiguring stories of regret from people on this forum and that scares me. I think the final answer will not prevail untill 5 years from now and we can hear the stories of the jumbo sesions and what has happened as they have lost more hair. I do think given peoples post on here the market does call for bigger sessions, and will probally end in the 3000-3500 average range, given a person wants to be aggresive. Sometimes you can only pioneer and industry so far untill you have exhausted it completley, and we have to say "1 step forward 2 steps back". At some point this indutry will change significantly and hair mulitiplication or someother thing will revolutionize things and we will hear of super jumbo session as the sessions will no be predicated on a limited donor supply. just my 2 cents

[Pat - Community Publisher]

Mike,

 

When done right hair transplant surgery is virtually a miracle. But choosing a truly outstanding surgeon is critical.

 

To view surgeons recommended in California, click here. Personally I think Dr. Jim DeYarman does the most refined and impressive ultra refined follicular unit surgery in California.

 

Best wishes for a great result.

[Bill - Seemiller]

As an FYI: there do seem to be a number of surgeons, that do large megasessions that do not divide into sub-follicular unit grafts. I'm not arguing that the concern doesn't have merit, but seemingly there are ethical doctors out there who are pushing the envelope for better hair restoration, and some do an excellent job from what I've seen, at least in pictures.

 

Bill