To DFU, or not To DFU.....

[thanatopsis_awry]

I've noticed numerous docs like to employ a few hundred DFU's, particularly when working on the crown/vertex. It makes sense that this would be a boon towards increased density.

 

What are the downsides, though? And if you are a proponent of selective DFUs, are virtually all cases of crown/vertex work a good fit to utilize DFUs?

 

The most immediate concern would be "naturalness", but I've seen it stated that when blending in to the crown region this concern is nullefied.

[thanatopsis_awry]

I've noticed numerous docs like to employ a few hundred DFU's, particularly when working on the crown/vertex. It makes sense that this would be a boon towards increased density.

 

What are the downsides, though? And if you are a proponent of selective DFUs, are virtually all cases of crown/vertex work a good fit to utilize DFUs?

 

The most immediate concern would be "naturalness", but I've seen it stated that when blending in to the crown region this concern is nullefied.

[Bill - Seemiller]

Thanatopsis,

 

Great topic.

 

Personally, I happen to be a fan of all follicular unit grafting however, Dr. Paul Shapiro and a few others have made compelling cases with photos that using a small number of DFUs in certain candidates might help aid the illusion of hair density.

 

In my opinion, DFUs must be used in small quantities in the vertex or crown area in patients and good surrounding hair density (either natural or transplanted follicular units). Otherwise, they may appear "pluggy".

 

Another concern I have, is using too many DFUs may limit a patient's hair length and styling. Cutting their hair too short may result in an unnatural look in these areas.

 

If DFUs have been placed around natural hair that is later lost, a patient may feel more pressed to get another hair transplant not only to add more density, but to camouflage the double follicular units.

 

It will be interesting to see what others have to say about this important topic.

 

Thanks for bring it up.

 

Best wishes,

 

Bill

[thanatopsis_awry]

I agree; and you've raised some very logical points that I hadn't considered prior.

 

Shame some docs/reps/et.al. won't drop a note w/ their thoughts. I too think it is an important topic that prospective patients should have a solid idea about.

[the B spot]

Instead of opinion or misinformation, I'll be posting some facts when Dr. Shapiro gets back to me Thana.

 

Talk to you later,

Jason

[Dr. Timothy Carman]

This is a great area for discussion-good thread.

In our experience DFU's are an excellent way to increase hair mass while decreasing (or keeping the same)the number of recipient sites/cm2. As with any surgical technique, "one size does not fit all" (here referring to choice of techniques, not the literal meaning of "size" as it relates to recipient characteristics), and the indication for their use in our practice is fairly specific.

In our practice we will sometimes utilize a technique called combination grafting, wherein DFU's are interspersed between FU grafts. Utilizing the combination grafting approach will mitigate the long-term possibility brought up by Bill wherein loss of native hair surrounding these grafts may lead to a look that reveals hair exiting the scalp that appear quite healthy, but spread far enough apart as to possibly not appear natural on close inspection. I would not go so far as to say they would look "pluggy", as that term denotes (to me) an extreme situation wherein a single graft contains 7- 8 FU's, traditionally seen in transplants pre 1970's (give or take a few years).

I cannot obviously speak for other surgeons, however in our practice the use of DFU's in the crown or vertex is not an appropriate placement choice for these grafts.

We utilize DFU's (via combination grafting techniques) almost exclusively for increasing the hair mass of the posterior Frontal Forelock and "central core" areas. The cosmetic result of the judicious use of these grafts is one that addresses an observation made by many patients following reconstruction of the hairline, FF, temples and central core areas; "lack of density in the middle of my scalp so that the light shines through and I can see my scalp". My personal observations of the evolution of the hair restoration procedure includes remembering a time when, because it was so exciting/amazing that individual follicles could survive when grafted as single units, that it was believed that cutting everything down to ones and two's would look the most natural. My opinion of that result is that it does not/did not. To me it gave the appearance that the hair was "airbrushed" on, and it lacked a certain natural heterogeneity and density that naturally occurring hair possessed. We have since evolved from that practice, and for good reason. For me, one of the artistic challenges of this procedure is to develop techniques that not only provide real density, but create an additional "optical density" in the face of a limited supply of materials (donor grafts) and a large® surface area to cover.

What ARE the indications, or better, when does it work best? One example is where the patients donor hair is fine with low skin to hair colour contrast, such as blonde, red or grey hair. In these patients, even grafting at the upper limits/cm2 (so as to maintain >97% survival) the look will still look a bit thin and "styling dependent" when only FU grafts are used. It is (to me) one of the "tip-off's" that a transplant has taken place when I see a uniform density from side to side across the posterior frontal forelock and central core areas. In nature that area is usually more dense than the hair which surrounds it bilaterally. In selected cases this technique (combination grafting) addresses this issue quite nicely, and the cosmetic result IMHO is excellent. Dr Vance Elliott brought in three or four of his patients to our ISHRS conference a few years back, and it was difficult for most of the surgeons on close inspection to decipher which patients had DFU's and which did not! And again, the cosmetic result, when used appropriately is, IMHO again, superior to that density obtained using solely FU grafts.

There's my note w/thoughts and observations-

Always a good topic!!

[Bill - Seemiller]

Dr. Carman,

 

I read your post with great interest, especially after you stated that in your experience, the crown and vertex are not optimal for the placement of DFUs. I know other clinics feel they are better used in these rear areas to help re-create the illusion of density, assuming they are placed in between and around enough natural hair or follicular unit grafts to minimize the unnatural appearance under close inspection.

 

I agree with you that there is no "one size fits all" hair transplant approach however, I do believe some techniques are outdated and can make a hair transplant appear less natural. i also believe there are different "correct" approaches for the same patient which is often why surgeons have contrasting opinions that often confuses a patient who consults with more than one first-rate physician.

 

In my opinion, it's much more important to look at the long term hair restoration strategy than a single surgery. In most cases, even though a short term surgical plan may look different between surgeons for the same patient, the long term plans often are a pretty close match.

 

Best wishes,

 

Bill

[Smoothy]

This technique is basically what they called in the 90's mini/micro grafts (but now more refined with disection of bundle hairs). Before FU they used mini/micro and before that the traditional plugs.

Like Fal said, this is good in the middle core/vertex and crown as it give more fuller look but you DO NOT want this in the hairline or temple regions and few if not any in the frontal core because it can give appearance of smomewhat of pluggyness depending on placement. I had some of these in my frontal core from HT in 90's that looked OK but not natural--Dr Shapiro did his magic and everything looks 100% natural.

 

SMOOTHY

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