Why use Graphs that have 3 or more hairs?

[THINinHOUSTON]

I can understand 2 hair graphs and obviously 1 hair graphs. But with limited donor hair available it seems you would want to separate and spread out the 3 and certainly the 4 hair follicle graphs? wouldn't it be ideal to have all 1 or 2 hair graphs?

[THINinHOUSTON]

I can understand 2 hair graphs and obviously 1 hair graphs. But with limited donor hair available it seems you would want to separate and spread out the 3 and certainly the 4 hair follicle graphs? wouldn't it be ideal to have all 1 or 2 hair graphs?

[notgoing2gobald]

TIH,

 

single and double hair grafts are often spoken about w/a sense of superiority when compared to multi-hair grafts and rightly so; BUT such discussion is confined to the context of modern ht('s) methods in comparison to the old "plug-look"....this distinction is made *ONLY* w/respect to the hair line, as this is where multiple hair grafts stand out, giving it an unnatural "pluggy" look. Splitting naturally occurring multi-hair grafts in *all* other areas (apart from the hair line) would be a zero sum game, much like asking if you value a $100 bill more than five $20 bills; the total quantity is equivalent just as the total hair quantity would be equivalent in the graft scenario.

 

Having said that, given the advent of lateral slits and the "shinling-effect" which are used to create the illusion of an exponential amount of greater coverage and density, I have personally wondered if single hair grafts used over the entire scalp in conjunction w/these techniques can afford better density and coverage in the hands of the proper surgeon; but this is both a speculation on my part, AND something which I have never heard any other input on.

[chucky]

Good question,i would like to here any docs comments on this.

[something]

just to note, the use of lateral slits is benefical when there are more then one hair in the graft. one hair grafts do not benefit from lateral slits...

 

the "shingling effect" happens essential becuase of the multi hairs in the graft and how they lay horizontally, instead of in a line vertically.

 

you will not get the appearence of more density if you cut every graft into a single, in fact, it would appear less dense. you are not born with all singles, why would it make sense to do that?

[Bill - Seemiller]

THINinHOUSTON,

 

Great question.

 

In my opinion, it's beneficial to excise and transplant the hairs as they occur naturally, which are in follicular unit families typically consisting of 1-4 hairs.

 

It's all about strategic placement of the grafts. Splitting follicular unit grafts into all 1s and 2s won't necessarily be superior or inferior since the number of hairs will inevitably be the same. As long as they are placed well, the end result will be a natural one.

 

A few potential problems I see with creating all smaller grafts:

 

1. Using smaller grafts will also mean more incisions will have to be created and may cause additional scalp trauma which could increase the risk of shock loss to the native hairs.

 

2. Pricing: Turning a 3000 follicular unit graft session into a 5000 smaller graft session of 1 and 2 haired grafts will inevitably be a lot more expensive.

 

Just my thoughts.

 

Bill

[Dr. Timothy Carman]

THINinHOUSTON-

That is an excellent question. As Bill has pointed out, hair occurs naturally on the scalp in what are termed "follicular units". These are groups of individual hair follicles that average two hairs per follicular unit. They can vary, therefore, from a "group" of only a single follicle, or two, three, or four follicles. As pointed out, one typically only utilizes one hair grafts for hairline reconstructions, but within regions where there is no specific need such as this, two, three and four hair grafts are completely acceptable, and are utilized commonly. There are situations where a graft which is comprised of TWO follicular units, called a "DFU" (di-follicular unit) are also appropriate to be utilized. An example of a location where "combination grafting" (referring to the use of intermixed follicular unit grafts and DFU's) are used with excellent results is the frontal forelock area and the midportion of the scalp directly behind it. To appreciate the rationale for this, one needs to consider the following.

In general, the limitation to packing in density (measured as the # of grafts per square cm) is the blood supply of the scalp itself. It has been demonstrated that a density of 40grafts per square cm will give near 100% graft survival, all other things being equal. It has also been observed that when grafting at higher densities than this, the survival rates of the grafts decreases. So, while it may be technically possible to make and place 60 grafts per square cm, the survival rate is in the low 90-93% range. So in essence, above 40/cm2 one is simply "throwing away" perfectly good grafts. It has to do with the 40 little stab wounds one makes, and the available blood supply to nourish those follicles. Now, in the case of the area above, the FF area and immediately behind, one may be able to place more hair mass using combination grafting as follows: The DFU's, being slightly larger than a single follicular unit graft, require a slightly larger recipient site accordingly. Yet we found you can "cheat" a little, making some of those 40 stab wounds DFU sites. Still 40 sites, but some of those sites (the DFU's) have double the hairs (on average) that the follicular unit sites have. This way, one can move more hair mass per unit area utilizing combination grafting than simple all follicular unit grafting alone. In our practice we have found that this technique yields excellent results.

Good question, I hope this explanation, long-winded though it may be, helps.

 

Timothy Carman, MD

[Jotronic]

Dr. Carman,

 

The problem I find with most "studies" is that they are not actually studies in the true sense of the word when apllied to hair transplantation. These "exercises" as I prefer to call them are usually performed on only one patient whereas a proper study would be carried out on many patients.

 

Secondly, these exercises are performed by practitioners that have not had experience in dense packing, in this case, above 40 grafts per cm2 therefore any result they get is limited only to their ability and experience which is limited to none.

 

I have no problem with physicians and clinics operating within their own parameters of comfort but the hair transplant industry is hardly an industry where one exercise by one clinic is necessarily relevant to that of another. I think studies that are less exciting, like those of storage solutions, etc., are more in line to give a larger scope of possibilities than those that have tried to support or refute dense packing and/or megasessions. Therefore, your comment about throwing away grafts when planting above 40 per cm2 must be qualified by stating that this is in your practice or the practice of those that conducted said "studies".

[Dr. Timothy Carman]

Jotronic-

 

Thank you for your comment. The information which I passed on to the forum members is qualified as follows; those figures and results were presented at the Annual International Society of Hair Restoration Surgeons (ISHRS) Meeting and was based on longitudinal investigations involving a sizeable group of patients (I apologize that I don't have a recollection of the exact number) not just an anecdotal patient or two, and it was performed by physicians well known in our practice community to have the expertise and skill to conduct techniques involving dense packing. That said, I agree that there can be a wide variability in what individual practitioners report regarding this phenomena.

Also, please bear in mind the context in which my remarks are made. I was speaking in broad generalities (the exception proves "the rule") in order to communicate to the original poster the rationale behind the use/benefits of larger grafts (including DFU's) in general. I do appreciate your observations, however.

 

Timothy Carman, MD

[THINinHOUSTON]

Thanks for the tips guys!! So in these Mega sessions of 5000 and more does the surgeon takes the graphs with 3 or more and split them up to get to 5000 right? Certainty they dont get 5000 graphs/units out do they?

[notgoing2gobald]

DInG'---dInG'---DING'!!!!

 

A'

 

Let's get

 

*ready*

 

toooOOooOOO------

 

ruuUuUmMMmBbBlLeEeEEEEEE!!!!

[Jotronic]

Dr. Carman,

 

I appreciate your follow-up post. I am familiar with the studies you mention and if I recollect properly these individuals of which you speak are exactly the same types that do not perform dense packing sessions, or megasessions or both, on a regular basis. The vast majority of those in the ISHRS do not and cannot dense pack as you mentioned and have for many years looked upon the mere prospect of doing so with disdain. To be able to perform these sessions one needs to work slowly and carefully. This takes several years and cannot nor should not be attempted for any reason other than the desire to do so properly.

 

I can certainly appreciate the indication of such studies but they cannot simply be thought of, executed, then have the data be considered valid if the proper experience to perform the studies to begin with is absent. This is not a slam on any one clinic or doctor. I am trying to simply get the point across to the readers that not every clinic in the ISHRS is the same, far from it as I'm sure you'd agree, and that different clinics have different ways of doing things. Most clinics are still performing sessions that max out at 2500 or 3000 grafts but other clinics are consistently cranking out 4000 to 5000 graft sessions on a weekly and even daily basis (where called for). And for dense packing, the same applies.

 

 

ThininHouston,

 

"Certainty they dont get 5000 graphs/units out do they?"

 

I cannot speak for other clinics but since we do these sessions on a regular basis I can say that the grafts are intact follicular units. There are occasions where some singles are made from larger grafts but this is in order to insure that enough singles are used for the appropriate area. One would think that a large 4500 graft session would yield enough singles naturally, which is usually the case, but there are cases where extra singles are necessary for increased naturalness in specific areas but this is not to artificially inflate numbers. It is for true "ultra-refined" follicular unit grafting for the most natural result for the patient and all of the better clinics utilize this method.